September/October 2003 JOGNN 579

PRINCIPLES & PRACTICE

Safe Criteria and Procedure for KangarooCare With Intubated Preterm InfantsSusan M. Ludington-Hoe, Carla Ferreira, Joan Swinth, Jennifer J. Ceccardi

Kangaroo care (KC) was safely conducted withmechanically ventilated infants who weighed less than600 grams and were less than 26 weeks gestation atbirth. These infants, ventilated for at least 24 hours atthe time of the first KC session, were considered stableon the ventilator at low settings (intermittent mandato-ry ventilation < 35 breaths per minute and FiO2 <50%), had stable vital signs, and were not on vaso-pressors. A protocol for implementation of KC withventilated infants that uses a standing transfer, withtwo staff members assisting to minimize the possibili-ty of extubation, is presented. Also discussed is thepositioning of the ventilator tubing during KC. Thisprotocol was implemented without any accidentalextubation throughout an experimental researchstudy. The criteria and protocol were compared tothose available in published reports and revealedmany similar elements, providing additional supportfor the recommended protocol. No adverse eventsoccurred with the criteria and protocol reported here,suggesting that they can be adopted for broader use.JOGNN, 32, 579–588; 2003. DOI: 10.1177/0884217503257618

Keywords: Skin-to-skin contact—Kangaroocare—Premature infants—Procedure—Ventilated

Accepted: December 2002

Kangaroo care (KC), otherwise known as skin-to-skin, chest-to-chest contact between the preterminfant and parent (usually the mother), is recom-mended for premature infants of 28 weeks postcon-ceptional age or higher in tertiary neonatal intensive-care units (NICU) (Cattaneo, Davanzo, Uxa, &Tamburlini, 1998). Many of these infants are offeredKC while mechanically ventilated (Franck, Bernal,

& Gale, 2002; Neu, 1999), but 59.3% of UnitedStates NICU nurse managers believe that intubatedinfants should not receive KC (Engler et al., 2002).The nurse managers cited the following as impedi-ments to the practice of KC: a lack of criteria forselection of infants, concern about its safety due tofear of extubation and stressing the infant, and thelengthy time involved for the nurse to completetransfer (Engler et al., 2002; Franck et al., 2002).Other suggested barriers are concerns about temper-ature control and nurses’ fear that something will gowrong and the nurse would be blamed for it(Drosten-Brooks, 1993), especially without writtenpolicy to support the practice of KC with intubatedpreterm infants (hereafter called KC-Vent).

Survey results from 215 of the 1,133 NICUs inthe United States showed that 30% of the units hadpolicies or procedures for holding premature infants(Franck et al., 2002), but the number of policies orprocedures that specifically addressed holding intu-bated infants was not reported. The purpose of thisarticle is to share the criteria for selection of infantsand the procedure developed and implemented in a3-year study of the effects of KC with mechanicallyventilated infants (Ludington, Ferreira, & Swinth,1999). These criteria and the procedure resulted insafe administration of KC to ventilated infants ofvarying weights and postnatal ages throughout the 3years of study. They meet the need for KC guidelinesto facilitate continuation of this program (McGrath& Brock, 2002).

Review of the Literature

Few publications about KC with intubatedinfants were found that provided data supporting or

contradicting caregivers’ concerns about infants’ physio-logical condition. Drosten-Brooks (1993) presented twocase studies showing that infants responded to KC-Ventwith increased quiet sleep and decreased oxygen require-ments during KC. The major focus of the article waspreparation of mothers, staff, and infants for the KCexperience to prevent infant overstimulation and neu-robehavioral decompensation. Gale, Franck, and Lund(1993) studied 25 intubated infants of varying weightsand postconceptional ages. In infants weighing 0.7 to 1.3kg, who were 28-33 weeks postconceptional age with adiagnosis of respiratory distress syndrome at time ofstudy and who received ad lib amounts (15 min to >20hours over one or more sessions) of KC, body tempera-ture did not drop but rose above that of the incubator. Inaddition, once an infant settled on the mother’s chest, hisor her oxygen saturation rose. Infants weighing less than1.2 kg or who were less than 30 weeks postconceptionalage tended to have 15-20 minutes of quiet comfort before“becoming wriggly.” Although one accidental extubationoccurred, this infant was returned to the incubator andwas re-intubated without complications. A step-by-stepprocedure was presented that included taping the endo-tracheal tube to the mother’s clothing to stabilize it, apractice that may have contributed to the extubation thatoccurred.

Wallace and Ridpath-Parker (1993) reported clinicalobservations of several infants, one who was receiving KCwhile mechanically ventilated. The infant settled in com-fortably, fell asleep, and exhibited high oxygen saturationlevels. Neither criteria about the infants nor the procedurethat was followed were elucidated in this report. In anoth-er case study, an intubated newborn who was 27 days oldand weighed 894 g received synchronized intermittentmandatory ventilation (SIMV) at a rate of 12 breaths perminute while receiving 45 minutes of KC (Ludington-Hoe, Ferreira, & Goldstein, 1998). The infant respondedto KC with consistently high and stable oxygen saturationlevels, lower airway resistance, fewer apnea episodes, sta-ble temperature, and an increased percentage of quietsleep. Recommendations for the selection of infants toreceive KC-Vent were not included.

The effect of the standing or sitting transfer from incu-bator into and out of KC on the physiological and behav-ioral responses of 15 ventilated preterm infants was inves-tigated by Neu, Browne, and Vojir (2000). Each infantreceived one sitting transfer by nurse and one standingtransfer by parent (14 mothers, 1 father). Heart rate, oxy-gen saturation, and axillary temperature were recordedmanually for 30 minutes before and after transfer andduring 1 hour of KC. Axillary temperatures did notchange significantly before and during KC. Maximumheart rate increased outside of the normal range duringstanding and sitting transfers and was stable during KC.

Oxygen saturation was lower during transfer than duringKC, probably due to disconnection from the ventilator fortransfer, similar to what happens with typical nursing care

(Peters, 1992). Motor disorganization occurred withtransfer. The transfer procedure used in Neu et al.’s study(2000) was similar to the procedure reported here.

Smith (2001, 2002) studied 14 mechanically ventilatedinfants who had bronchopulmonary dysplasia (mean weightof 992 g and mean age 30.5 weeks postconceptional agewhen studied at a mean 34 days old). Each infant received2 hours of KC and 2 hours of incubator care. Infants’temperatures rose significantly and more than 0.1°C perhour during KC, leading the author to conclude that therewas an instability in temperature even though infantswere warmer than when in the incubator. The infants alsorequired a 14% higher concentration of oxygen to main-tain satisfactory oxygen saturation levels during KC ascompared to incubator values, possibly due to theirwarmer temperatures. This was not at all an unusual find-ing, however, given that all of the infants had bron-chopulmonary dysplasia. Criteria for infants in the studyincluded oral intubation, ventilation in the SIMV or inter-mittent mandatory ventilation mode, and settings “notnear extubation” (Smith, 2001, p. 31). More specific cri-teria and a procedure to be followed were not presented.

Smith’s findings contrast with those of a randomizedclinical trial of preterm infants (five in a control groupwho remained in incubators compared with six infantswho received 1 hour of KC-Vent each day for 1 to 4 con-secutive days beginning 24 hours after the onset of SIMV)who had heart rate, respiratory rate, oxygen saturation,and pulmonary functions measured each minute through-out three consecutive testing periods (1 hour pretest, 1hour for test, and 1 hour posttest) (Ludington et al.,1999). The mean gestational ages were 26.3 and 26.6weeks, and mean ages at testing were 29.0 weeks and28.4 weeks for the KC and control groups, respectively.KC infants demonstrated values similar to those of con-trol infants, and nurses often reduced oxygen concentra-tion by 10% over the course of 1 hour of KC-Vent to pre-vent overoxygenation. The criteria and procedures usedin that study are those that are being reported here.

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Because kangaroo care is being usedmore widely with infants receivingmechanical ventilation, guidelines

and a protocol are needed.

Cleary, Spinner, Gibson, and Greenspan (1997) pro-vided the following guidance for KC with intubatedinfants: “Prolonged mechanical ventilation does not pre-clude skin-to-skin contact” (p. 459) if the following crite-ria are met: “>1000 grams, 26-36 weeks GA, <25 breathsper minute of mechanical respiratory support, <40% sup-plemental oxygen support, have intravenous and intra-arterial lines securely in place, and are considered stableby attending neonatologist” (p. 458). In general, most lit-erature supports the findings of infant physiological andbehavioral stability with modest cardiorespiratory andthermal improvements during KC-Vent and more activeparenting by mothers who practice KC with intubatedinfants.

In conclusion, several reports of experience or researchwith mechanically ventilated infants receiving KC werefound, but few provided detailed descriptions of selectioncriteria. Nonetheless, similarity in selection parametersbecame evident, yielding the following infant criteria thatwere used in a randomized controlled trial of KC withventilated preterm infants: more than 600 g birth weight,ventilated for at least 24 hours at time of the first KC ses-sion, on SIMV less than 35 breaths per minute, FiO2 lessthan 50% with stable vital signs, considered stable by theattending neonatologist, not on vasopressor medications,and do not have chest tubes (Ludington et al., 1999).Oxygen saturation level was not a limitation, and infantscould have broviac, umbilical, arterial, and intravenouslines that were well-secured. Infants who had apnea,bradycardia, or seizures, and those with substance abus-ing mothers, were excluded from the study because thesecharacteristics influenced the outcome measures. Theycould be included in the clinical use of KC-Vent on a case-by-case basis. These criteria broadened the populationbase of fragile preterm infants who could be offered KC-Vent and met the approval of neonatologists and the nurs-ing and respiratory staff and institutional review boardsfor study in five NICUs across the United States. None ofthe infants who met these criteria had to be removed fromKC-Vent before completion of data collection, and noaccidental extubations occurred. A summary table of allavailable criteria are presented in Table 1 to facilitatecomparisons and modification of the criteria for individ-ual units.

Procedural Elements

Procedures for KC-Vent were presented in two publi-cations (Cleary et al., 1997; Gale et al., 1993), and proce-dural elements were included in a third (Drosten-Brooks,1993). The published procedures included some contro-versial elements and did not include some of the safe-guards incorporated in our study (Ludington et al., 1999).These elements are explained below.

Head CapThe need for routine use of a head cap has not been

established. Even though 40% of body heat is lostthrough the exposed head in a full-term infant (Karlsson,1996), body heat loss has not occurred in KC in modernnurseries when there is sufficient covering across theinfant’s back. Some units prefer to use a head cap withinfants less than 1,000 g weight. A guideline that hasworked well in numerous studies (Ludington-Hoe &Swinth, 1996) and with ventilated infants is applicationof a head cap if abdominal or axillary temperature fallsbelow 36.0°C.

Covering Over InfantInfants can lose body heat by convection across the

surfaces of their bodies not in contact with maternal skinif insulation is inadequate. In all the literature availableon KC, only one study has reported a loss of body heat(Bosque, Brady, Affonso, & Wahlberg, 1995), and thiswas probably because mothers wore a variety of clothing,including cotton gauze blouses or loosely fitting cottonknit sweaters, as insulation while kangarooing. When amedium-weight velour blouse was worn by the mother ora receiving blanket folded in fourths was placed againstthe infant’s back, body heat loss did not occur, even dur-ing 3 consecutive hours of KC (Ludington-Hoe, 1995;Ludington-Hoe, Hadeed, & Anderson, 1991; Ludington-Hoe, Thompson, Swinth, Hadeed, & Anderson, 1994),when KC was begun immediately after birth (Anderson,Chiu, Pagliotti, & Dowling, 2000), or with intubatedinfants (Ludington-Hoe et al., 1998; Smith, 2001). Astandard receiving blanket folded in fourths provides 1.0clo heat resistance, a measurement of insulation providedby clothing equal to 0.25-inch (0.5 cm) thickness of wool,to prevent body heat loss. This insulation, in conjunctionwith the flow of heat from the mother to the infant dur-ing KC (Karlsson, 1996), ensures that even infants weigh-ing only 600 to 800 g will often become warmer, not cold-er, during KC.

Infant PositionKC positioning, as the authors of this article practice it,

is a 40° upright incline with the infant prone on the moth-er’s chest. This KC position has been associated with aconsistently high oxygen saturation level and only a slightheart rate increase (Ludington-Hoe et al., 1994; Ludington-Hoe et al. 1998; Ludington-Hoe & Swinth, 1996). Theupright position, in general, reduces apnea incidence(Acolet, Sleath, & Whitelaw, 1989) and permits an opti-mal level of oxygenation, even shortly after the stressfultransfer period (Ludington-Hoe et al., 1998). A greaterincline is not needed nor recommended, because preterminfants tend to slip down and slouch, compressing thetrunk and increasing risk of obstructive apnea. The

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TABLE 1Procedural Issues for Kangaroo Care With Mechanically Ventilated Preterm Infants

Drosten-Brooks Gale et al. Cleary et al. Ludington-Hoe Neu et al. Smith(1993) (1993) (1997) et al. (1998) (2000) (2001)

# of infants reported 2 25 1 11 15 14IssueClothing on infant Not specified Diaper only Diaper Diaper only Diaper only DiaperInfant head cap Yes, if needed Only if < 1 kg Yes No No YesCovering over infant Blanket and/or Nothing Blanket Receiving blanket Blanket or cloth Receiving blanket

parent’s shirt folded in fourths diaperHeat lamps in Heat lamps if < 5 Heat lamp if temp Not specified Not specified Not specified Not specified

preparation days old < 36.0°CHeat lamp if 1st time

out of radiant warmer

Infant position Vertical/upright prone Vertical, prone Upright/vertical, Upright and prone Prone or sidelying Supineprone

Maternal clothing Front-opening shirt/ Front-opening shirt/ Blouse Cover gown open in Front-opening cover Front-opening blouse gown gown front gown over front or cover gown

opening shirt/blouseMaternal comfort Rocker/easy chair, Rocking chair, Comfortable chair Recliner, footrest Reclining chair Glider rocker, footrest

footstool, pillows footstool Maternal fluids as needed

Privacy Screens, quiet corner Not specified Screen Screen, if requested Screen ScreenLength of KC-Vent As long as infant Ad lib unless SaO2 2 hours Minimum 1 hour 60 minutes 2 hours

stable becomes unstableAs long as parent

desires One to two times

per day One or more hours

each timeParent advice Do not disturb infant SAMsa given addition- KC discussed, Same as Drosten- Instructed on transfer Keep hands on baby,

while sleeping al guidance and suggested ways of Brooks method, practiced but may hold over Do not stroke, rock, support holding per their the transfer once on blanket if more

talk to, give eye criteria a doll comfortablecontact if infant does not tolerate them

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FiO2 Before transfer Not specified Increased 10% Not specified Increased if infant Not specified Not specified before transfer required

Check patency of Auscultate lungs, Auscultate lungs Check for physical Auscultate lungs, Not specified Suction if necessaryairway/lungs be- suction if necessary occlusion by mater- suction if necessaryfore transfer nal breast tissue

Transfer into KC 2-3 nurses, gently 2 nurses, sit or stand Not specified 2-3 nurses, standing 1 nurse or 1 parent Investigator & nurse awaken infant first transfer with infant transfer with infant assisted mother with

in horizontal in KC position transferposition

Check patency of Auscultate Not specified Not specified Auscultate Not specified Not specifiedairway/lungs after transfer

Suctioning after Not specified Not specified Not specified As needed in KC Not specified As needed during KCtransfer

Vent tubing place- Secured by tape Secured by tape Not specified Not attached, draped Nurse disconnected Nurse disconnected ment over shoulder during transfer during transfer

(< 5 seconds) (< 20 seconds), then secured and clipped to mother’s blouse/ gown

Incubator temper- Temp probe on On air control to Temp probe on On air control to Not specified Air temp control modeature during KC- prevent cooling prevent cooling Vent Temp probe on

Cardiorespiratory, Continuously per Continuously per Routine vitals and For study routine Continuously 30 Routine vitals and temp-vitals, and satura- routine, temperature routine, temperature temperature before vitals and tempera- minutes before, erature within 15 tion monitoring every hour every hour KC and every 30 ture before KC & during KC, and 30 minutes of transfer

Watch for stress Watch for stress minutes then recorded every minutes after transfer.minute Temperature imme-

Watch monitor during diately before and clinical use of KC after KC

Discontinuation Not specified Not specified Yes Yes, check for Yes, self-extubation Yescriteria adaptation

Transfer into Standing 1 or 2 nurses standing, Not specified 2 or 3 nurses standing, 1 nurse or 1 parent Investigator & nurseincubator infant horizontal infant in KC position assisted mother with

transfer

aSubstance abusing mother.

incline is easily achieved with most recliners or loungechairs used in NICUs.

Maternal ComfortMany mothers of preterm infants will be moving

through the 6-week postpartum period while their infantsare hospitalized. During postpartum, women are prone tothrombosis development if they do not bear and shift

weight on their legs at least once every 90 minutes. Whenthe mothers are in a reclined position, their feet are sup-ported by the chair’s footrest or a footstool.

Mothers also need at least one cup of fluid every hourto prevent becoming overheated in the warm NICU envi-ronment and to provide adequate fluids for milk produc-tion. Maternal fluid needs may be even greater once KCbegins because milk production is enhanced with skin-to-skin contact (Durand et al., 1997; Hamelin & Ramachan-dran, 1993; Hurst, Valentine, Renfro, Burns, & Ferlic,1997; Tuomikoski-Koiranen, 1990).

If a mother senses her infant perspiring, the infant’stemperature should be checked to make sure he or she hasnot overheated. Gale and associates (1993) recommendthe use of a towel to ease the discomfort of perspiration,but reducing the clothing of the mother cannot be prac-ticed unless satisfactory insulation across the infant’s backis maintained.

Transfer Into KCThe transfer procedure is the greatest contributor to

infant heat loss and stress. Ludington-Hoe et al. (1994)recommended the placement of a receiving blanket foldedin fourths under the supine infant prior to transfer. Twotypes of transfer can be used with KC-Vent: standing orsitting. Standing transfer consists of the mother placingher hands under the receiving blanket on which the infantis lying. The assisting nurse or respiratory therapist thendisconnects the ventilator tubing from the endotrachealtube, and the mother lifts the infant directly to her barechest in one movement. The ventilator tubing is recon-nected, allowing the infant to receive several ventilatorbreaths. Then it is again disconnected while the mother isseated, at which time the tubing is reconnected and posi-tioned appropriately over the mother’s shoulder. Directlylifting the infant to the mother’s chest prior to movement tothe chair limits exposure of the infant’s skin to cooler air.

A sitting transfer is one in which the mother sits in thechair and has her infant handed to her by the nurse. Inthis transfer, a second nurse or the respiratory therapistdisconnects the ventilator tubing during the move of theinfant from bed to mother and reconnects the tubing assoon as the infant is placed on mother’s chest. Then theventilator tubing is positioned appropriately for the KCsession. For either transfer method, a third person may beneeded to assist with the lines (monitor, umbilical, periph-eral). The containment provided by a blanket duringtransfer and the mother’s warm body help to minimize thestress of being moved as the mother secures her seating.In the sitting transfer, the infant has a longer delay beforebeing contained and warmed by the maternal milieubetween her breasts. The 11-minute adaptation time for asitting transfer versus a 3-minute adaptation time for astanding transfer indicates that infants experience morestress with the sitting transfer technique (Ludington-Hoeet al., 1998). Thus, we recommend the standing transfer,which was used in the experimental study.

Monitoring the infant for 10 to 15 minutes followingtransfer permits an assessment for physiological disrup-tion and needed intervention. If physiological disruptionpersists 15 minutes after transfer, then KC-Vent shouldnot be conducted with this infant, as it suggests that thechange in chest wall mechanics secondary to the moreupright position and rhythmic movement of the maternalchest are not tolerated. Adaptation periods are recom-mended and should be considered part of any interven-tion with infants on mechanical ventilation.

Suctioning During KCTwo safeguards have been included in the procedure

recommended here. One is draining the vent circuit; thesecond is the periodic removal of secretions by suctioningduring KC. We regularly conducted these safeguardswithout an adverse effect on the infant nor distress to themother. In fact, infants tolerated suctioning during KCwith many fewer distress responses than commonly occurwith suctioning. For example, one infant who was suc-tioned during KC-Vent had no disruption of heart rate oroxygen saturation level, and within 2 minutes of beingplaced on the mother’s chest, went into the quiet sleepstate (Ludington-Hoe et al., 1998). One might anticipatethat a mother could be uncomfortable observing the suc-tioning procedure while holding the infant. But this wasnot observed. Instead, many mothers did not want thebaby moved for any procedure and preferred continuingKC-Vent throughout treatments (Ludington-Hoe, 1995).

Ventilator Tubing PlacementThe endotracheal tube is not attached to the parent’s

clothing, because attachment limits elasticity and flexibil-ity of the circuit, especially with sudden jerky movementsof the infant’s head. Instead, the ventilator circuit is

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The infant selection criteria and theprotocol described here were not

associated with any adverse events.

draped over the mother’s shoulder with adequate lengthof tubing. Accidental extubations did not occur in any ofthe studied infants.

Transfer Back to IncubatorTransfer back to the incubator was accomplished by

standing transfer. For transfer back, the ventilator tubingis supported by a staff member as the mother, maintain-ing the infant in KC position, moves to the front edge ofthe chair. The ventilator tubing is disconnected as shestands, then reconnected to give the infant severalbreaths. After these breaths, the tubing is disconnectedagain while the mother places the infant in the incubator,and then tubing is reconnected. Standing transfer back tothe incubator appeared to be much easier than standingtransfer into KC, for several reasons. First, mothersappeared to be more relaxed and confident in their abili-ty to handle and maneuver the fragile infant after givingKC-Vent. Second, the ventilator tubing, intravenous lines,and the infant’s leads are more accessible and more easilyorganized for transfer when the infant is in KC-Vent.Third, the infant is more relaxed and quiet after KC(Cleary et al., 1997; Ludington-Hoe et al., 1991; Ludington-Hoe et al., 1994). As little as 20 minutes of KC withnonventilated infants attenuates the preterm infant’sstress responses as measured by circulating levels of beta-endorphins (Mooncey, Giannkoupoulos, Glover, Acolet,& Modi, 1997), so the finding of relaxation following 45-60 minutes of KC is possible, even with intubation andtreatments (Tornhage, Serenius, Uvnas-Moberg, & Lind-berg, 1998). As a result, transfer to the incubator requiredless time. In turn, the transfer was tolerated with muchless physiological and behavioral disturbance to the infantbecause KC regulates stress reactivity (Bystrova et al.,2003; Weller & Feldman, 2003).

Discussion

Because of procedural differences reported in the liter-ature (see Table 1), a protocol for safe administration ofKC to ventilated infants was developed (see Table 2) andused as part of a study examining the effects of KC onmechanically ventilated preterm infants (Ludington-Hoeet al., 1998). No adverse physiological or behavioralevents or extubations occurred with this procedure. Allinfants tolerated KC-Vent well, did not appear to be agi-tated, and spent most of the time sleeping (Ludington etal., 1999).

A generic element of a safe KC-Vent experience is theuse of the standing transfer technique, first described byGale and associates (1993), and, as adapted, with place-ment of a blanket underneath and around the infant forlimb containment prior to lifting. The standing transferwas found to be less disruptive than sitting transfer toinfants’ physiological and behavioral organization. The

sitting transfer was tried on a pilot subject and took muchlonger to accomplish. Infant adaptation to sitting transferwas prolonged in comparison to adaptation to standingtransfer (Ludington-Hoe et al., 1998). The NICU stafflearned how to conduct the transfer quickly, becomingproficient and comfortable within two transfers.

The criteria and procedure reported here were devel-oped and carefully reviewed by authorities in the field ofneonatology (physicians and nurses) and neonatal pul-monology (physicians and respiratory therapists) toreflect reasonable clinical practice. These criteria arebroad enough to allow clinical discretion in application,and the procedure can be easily adapted to the individualinstitution’s concerns and requirements. The authors urgethe reader to appreciate that this procedure is not a hardand fast rule, but may require interpretation with discre-tion. “Any guideline should not be used rigidly so as toexclude the essence of discretion, namely a readiness todeal with each case on its own merits” (Cane, 1992, p. 411).

With the criteria and procedure developed here,adverse effects on the infant and mother were avoided.Although maternal apprehension and fear of somethinggoing wrong during KC-Vent have been reported (Neu,1999), use of a uniform procedure and careful selection of

appropriate infants might alleviate some of the concernmothers express when first conducting KC-Vent. Adher-ence to the criteria and procedure outlined above mightreassure health care workers of their ability to preventnegligence and injury during KC-Vent (Hurwitz, 1995).Through provision of these criteria and this procedure, itis hoped, such reluctance will diminish. If so, the practiceof KC-Vent may spread. Wider practice of KC-Vent canbe encouraged once randomized clinical trials of KC-Ventreveal the true nature of physiological and behavioral dif-ferences between infants who receive the KC-Vent andthose who do not, enlightening caregivers as to anyadvantages and disadvantages of the treatment.

In summary, literature sources were found that provid-ed guidelines for implementation of KC with mechanical-ly ventilated infants. The exact nature of the effects ofKC-Vent on cardiorespiratory, thermal, and behavioraloutcomes is equivocal and needs to be determined by fur-ther study. Concern over maintaining a patent airway

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The infant selection criteria and protocolcan be adopted by NICUs to allow closecontact between mother and infant who

is on ventilation.

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TABLE 2Safe Protocol for Kangaroo Care With Mechanically Ventilated Infants (KC-Vent)

Kangaroo Care is skin-to-skin contact between a preterm infant and a parent, usually mother, chest-to-chest in an upright proneposition. The infant is clad in a diaper and has a receiving blanket covering the infant’s back. The optimal chair for experiencingkangaroo care is a recliner. Mechanically ventilated infants are intubated or receiving nasal CPAP or oropharyngeal CPAP via a ven-tilator. The physician will be contacted for approval to kangaroo the infant and confirmation of infant’s hemodynamic stability.

Prior to transfer1. Record infant’s baseline ventilator parameters (SIMV/IMV, PIP, PEEP, FiO2) and hemodynamic (HR, RR, SaO2) and thermal

values (axillary temperature). These measures should be carefully monitored during KC-Vent to ascertain the infant’s toleranceof this intervention.

2. With support of a second person, place the infant in supine position. Note any significant changes in the infant or mechanicalventilator requirements.

3. Auscultate the infant’s chest for quality of breath sounds, suction the endotracheal tube, and change the infant’s diaper as nec-essary.

4. Suction infant if necessary and drain the vent circuit of condensation. The water condensed in the ventilator tubing will bedrained to decrease resistance and maintain flow (Bhutani & Abbasi, 1992).

5. Assess infant’s response to the above actions. Wait up to l5 minutes to allow for physiological adaptation to the above minis-trations. Adaptation is defined as all physiological parameters returning to baseline and staying there for 3 minutes. If adapta-tion has not occurred in 15 minutes, the infant is probably not stable enough to receive KC-Vent on that day.

6. Place a receiving blanket, folded in fourths, underneath the infant (or in the bed but easily accessible to the mother) so moth-er picks up her infant by placing her hands underneath the blanket and moving infant and blanket simultaneously.

7. Position and prepare the chair to be used.

Transfer From Incubator to KC-Vent1. Have two or three staff members assist the mother in the transfer of the infant.2. Have mother stand at the side of the incubator/warmer while one staff member gathers all the infant’s lines on one side of the

infant.3. A second staff member is responsible for transferring and securing the ventilator tubing. (A third staff member may be needed

to assist the mother.)4. Disconnect the ventilator tubing from the ETT and have mother lift her infant and place prone on her chest in one movement.5. Reconnect the ventilator tubing, and have mother or staff member quickly secure the receiving blanket across the infant’s back

(if not already placed when mother picks up her infant as instructed in step 6 above).6. Disconnect the ventilator tubing and move mother backwards to recliner/chair, assisting her in sitting once she feels the reclin-

er against her calf. Reconnect ventilator tubing to ETT.7. Raise the footrest and reposition the infant, as needed, and make sure the infant is tucked in a slightly flexed or comfortable

position underneath the blanket. If infant is in fully flexed position, monitor for respiratory compromise and reflux.8. Drape the ETT circuit securely over the mother’s shoulder (be sure adequate circuit tubing length has been provided).9. Change the setting on the incubator/warmer to air control and set it at 33.0°C for duration of KC-Vent.

10. Monitor the infant’s condition every 10 minutes during KC-Vent. Allow KC-Vent for a minimum of 1 full hour if infant’s con-dition remains stable.

Transfer From KC-Vent Back to the Incubator1. Have one staff member assist the mother in moving to the front edge of the chair, a second staff member handle the lines, and

a third staff member disconnect the ventilator tubing.2. Assist the mother to a standing position, reconnect the ventilator tubing, and give the infant several ventilator breaths.3. Disconnect the ventilator tubing and replace the infant in the incubator/warming table in one movement.4. Reconnect the ventilator tubing and make sure all ventilator tubing is stabilized and all lines are placed securely within the incu-

bator/warming table.5. Document infant’s participation in and tolerance of KC-Vent.

Bhutani, V., & Abbasi, S. (1992). Evaluation of pulmonary function in the neonate. In Polin & Fox (Eds.), Fetal and neonatal physiology (Vol. 2,pp. 853-871). Philadelphia: W B Saunders.

throughout the KC-Vent session persists among clinicians.The criteria for infant selection and the procedure report-ed here were not associated with infant physiological orbehavioral compromise. Extubation did not occur. Theguidelines presented here may be used to support clini-cians in their efforts to adopt KC-Vent practice in theirNICUs.

Acknowledgments

This work was funded by NIH-NINR Grant #02251-04, AACN/Hewlett Packard Grant #N13614, andBlack/Marlens Productions, in loving memory of Anna.The authors thank Pryon and BICORE Corporations fortheir loan of equipment but are in no way related or obli-gated to these corporations.

REFERENCES

Acolet, D., Sleath, K., & Whitelaw, A. (1989). Oxygenation,heart rate, and temperature in very low birthweightinfants during skin-to-skin contact with their mothers.Acta Paediatrica Scandinavica, 78, 189-193.

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Susan M. Ludington-Hoe, CNM, PhD, FAAN, is a professorand Walters Chair of Pediatric Nursing, Case Western ReserveUniversity, Frances Payne Bolton School of Nursing, Cleve-land, OH.

Carla Ferreira, RCP, is a neonatal respiratory therapist in NewYork, NY.

Joan Swinth, RNC, BSN, is a neonatal staff nurse and the proj-ect director for kangaroo care research studies at Kadlec Med-ical Center in Richland, WA.

Jennifer J. Ceccardi, RN, BSN, is a recent graduate of FrancesPayne Bolton School of Nursing, Case Western Reserve Univer-sity, Cleveland, OH.

Address for correspondence: Susan M. Ludington-Hoe, CNM,PhD, FAAN, Case Western Reserve University, Frances PayneBolton School of Nursing, 10900 Euclid Ave., Room 322D,Cleveland, OH 44106-4904. E-mail: sml15@po.cwru.edu.

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