As the practice seems to be winning the world over you can imagine that a headline entitled,
would get some attention. This article was sent to me by a colleague after being published last month on Yahoo news service. The claim is based on the experience of a hospital in Perth that has seen some cases of neonatal suffocation after mothers who were performing skin to skin care fell asleep and rolled onto their newborn. This “fad” they say is attributable as the cause of death. Before looking into whether there is any basis for such a claim it may be worth exploring whether Kangaroo Care (KC) otherwise known as Skin to Skin (STS) care is effective. The irony is not lost on me either that safety of Kangaroo Care is being challenged in Australia…
Is KC Effective in the NICU?
KC or is an ideal method of involving parents in the care of their premature infant. It fosters bonding between parents and their hospitalized infant, encourages the family to be with their child and thereby exposes them to other elements of neonatal care that they can take part in.
Before you reach the conclusion that KC only serves to enhance the parental experience it does so much more than that. The practice began in Bogota Columbia in 1979 in order to deal with a shortage of incubators and associated rampant hospital infections. The results of their intervention were dramatic and lead to the spread of this strategy worldwide. The person credited with helping to spread the word and establish KC as a standard of care in many NICUs is Nils Bergman and his story and commentary can be found here.
The effects of KC are dramatic and effective to reduce many important morbidities and conclusively has led to a reduction in death arguably the most important outcome. An analysis of effect has been the subject of several Cochrane Collaboration reviews with the most recent one being found here.
To summarize though, the use of KC or STS care has resulted in the following overall benefits to premature infants at discharge or 40 – 41 weeks’ postmenstrual age:
mortality (typical RR 0.68, 95% CI 0.48 to 0.96)
nosocomial infection/sepsis (typical RR 0.57, 95% CI 0.40 to 0.80)
hypothermia (typical RR 0.23, 95% CI 0.10 to 0.55)
KMC was found to increase some measures of infant growth, breastfeeding, and mother-infant attachment
To put this in perspective, medicine is littered with great medications that never achieved such impact as simply putting your child against your chest. This is another shining example of doing more with less. This is not to say that modern medicine and technology does not have its place in the NICU but KC is simply too powerful a strategy not to use and promote routinely in the NICU.
What About Term Infants?
Much has been written on the subject. A Pilot study in 2007 by Walters et al found benefits in newborn temperature, glycemic control and initiation of breastfeeding. Perhaps the strongest evidence for benefit comes from a cochrane review of the subject last updated in 2012.
This analysis included 34 RCTs with 2177 participants (mother-infant dyads). Breastfeeding at one to four months postbirth (13 trials; 702 participants) (risk ratio (RR) 1.27, 95% confidence interval (CI) 1.06 to 1.53, and SSC increased breastfeeding duration (seven trials; 324 participants) (mean difference (MD) 42.55 days, 95% CI -1.69 to 86.79) but the results did not quite reach statistical significance (P = 0.06). Late preterm infants had better cardio-respiratory stability with early SSC (one trial; 31 participants) (MD 2.88, 95% CI 0.53 to 5.23). Blood glucose 75 to 90 minutes following the birth was significantly higher in SSC infants (two trials, 94 infants) (MD 10.56 mg/dL, 95% CI 8.40 to 12.72).
Taken together there are benefits although the impact on breastfeeding rates in term infants show a strong trend while not reaching statistical significance. Importantly though in this large sample we don’t see any increase in mortality nor to my knowledge has there ever been a study to show an increase.
How do we deal with this claim from Australia then?
I think the problem with this claim is that KC is being blamed after a “root cause analysis” has come to the wrong conclusion. The problem is not KC but rather a lack of a “falls prevention” strategy on the postpartum units. Mothers after delivery are exhausted and may be on pain medication so as the saying goes “there is a time and a place”. As our hospital prepares for accreditation again, safety to prevent falls (including babies falling out of mom’s arms or in a similar vein mothers falling onto babies) is something that every hospital needs. Whether a mother is practicing KC, breastfeeding or simply holding her baby if a mother falls asleep while doing so there is a risk to the infant. If the hospital in this case has seen an increase in such cases of newborn deaths while performing KC then it is likely the hospitals lack of attention to minimizing risk in the postpartum period that is to blame and not KC itself. Certainly the evidence from rigorously done trials would not support this claim.
This hospital would do well to have a comprehensive plan to educate parents about the risks of fatigue, ensure bassinets are next to every bed to provide mothers with an easy transfer if they are tired. Certainly during the immediate period after delivery mothers, partners of mothers who have just delivered should be encouraged to be with them or advise the mothers if they are tired to put the baby down and rest. A little education could go a long way!
I think it is a cheap out to blame KC for such problems as it turns our attention away from the real issue and that is a lack of policy and education. So in the end I would like to state emphatically that…
No I don’t believe the “skin-to-skin fad” is to blame for an increase in deaths!