Introduction

Aim

The aim of this guideline is to provide all clinical staff with the benefits, criteria and procedure to promote and provide skin-to-skin care to infants and parents during admission effectively and safely.

Definition of terms 

Continuous Positive Airway Pressure (CPAP): may be delivered via Single Nasal Prong, Bi-Nasal Prong, or Nasal Mask

ETT: Endotracheal Tube

JET ventilation: A mode of ventilation which utilises an additional JET box to deliver pulsated ventilation at a high frequency.

Neopuff: Device used to administer air or oxygen flow with PEEP +/- PIP to neonates in an emergency.

Normothermia: An axillary temperature 36.5°C – 37.5°C

Skin-to-Skin (STS): Also known as kangaroo care refers to the method of holding an infant in an upright and prone position, skin-to-skin, on the parent’s chest for a period of time.  Clothing or blankets are wrapped around the infant to provide a secure kangaroo-like pouch.  

Assessment

Criteria

Skin-to-skin care should be promoted and provided to all haemodynamically stable infants, as well as to families of infants redirecting to palliative care. 

Contraindications

• High Frequency Ventilation via the Sensormedics Ventilator
  
• Infants who have had an acute or sudden deterioration in the past 24 hours
  
• Infants with chest or abdominal lesions (gastroschisis), wounds/drains/vacuum dressings and new stomas
  
• Infants with an umbilical arterial line insitu
  
• Infants within 48 hours of major surgery requiring ventilation
  
• Infants who are muscle relaxed
  
• Infants with parents who are diagnosed with a contact-contagious illness
  

Considerations

• The provision of STS care should be discussed by the medical and nursing team, at each baby’s bedside during the ward round.
  
• If there are concerns over the appropriateness of providing STS for an infant, please raise these concerns with your medical and nursing colleagues. 
  
• Umbilical venous lines are not a complete contraindication, however they should be assessed to be patent and secure prior to STS.
  
• A requirement for environmental humidity does not exclude a haemodynamically stable infant from participating in STS.  The potential increase in trans-epidermal water loss (TEWL) during STS is small and transpires to marginal clinical importance.
  
• Allow a minimum of 4 hours post extubation prior to STS to assess the infant’s stability.
  
• If respiratory support has recently been altered allow minimum of 2 hours to assess stability before commencing STS care. 
  
• Caution is to be taken to ensure safe management of peripheral arterial lines and central venous access devices while the infant is receiving STS.
  
• An infant under droplet or airborne transmission based precautions should be nursed in a single room with the door closed prior to coming out of an incubator for STS.
  
• Parents may initiate STS independently when their infant is stable, if the infant does  not require respiratory support and is without IV lines. Nursing staff may be required to assist with gathering equipment or guiding cardiorespiratory monitoring during the transfer.
  

Management

Equipment

• Comfortable and stable chair with arm rests and a high back
  
• Pillow
  
• If parents do not have a stretchy or button front top, provide a hospital gown to allow front opening
  
• Blankets and infant hat
  
• Tapes to secure respiratory support tubing
  
• Neopuff should be easily accessible and within reach of the infant during STS.
  
• Footstool (optional).
  
• Mirror
  
• Close curtains between rooms to provide privacy. Privacy screen may be required for shared rooms in High Dependency Unit in order to ensure culturally-sensitive care is achieved.
  
• Provide a quiet and calm environment.

Parent preparation

• Ensure parents are educated on the benefits of STS and the sequence of events in transferring the infant to and from their chest.
  
• STS should continue for a minimum of 60 minutes; parents should be advised to prepare and plan the timing to enable this. STS may continue for as long as the infant is stable, not requiring interventions and the parent is comfortable. 
  
• Ensure drinking water is close by.
  
• Offer to change the top clothes for an open-front hospital gown if top or shirt not suitable.  Ideally the mother should remove her bra for optimal skin-to-skin contact.
  
• Both parents should be offered the opportunity to provide STS.
  

Infant preparation

• Ensure infant is nursed only in a nappy.
  
• Add a woollen hat if infant is of low birth weight or has had previous temperature instability.
  
• Confirm patient monitoring alarms are of appropriate limits and audible.
  
• Ensure patency and security of intravenous lines and gavage tubes.
  
• Infant should be in supine position in their cot prior to transfer.
  
• If the infant is intubated, ensure the ETT is secure, check that breath sounds are equal and if required, suction the ETT prior to transfer. 
  
• If the infant usually requires an increase in oxygen during periods of handling, increase prior to initiating the transfer.
  
• Notify medical staff of STS timing if there were concerns over the infant’s stability.
  
• Drain condensation from respiratory support tubing prior to moving the infant.
  
• Lower cot side and place the chair close to the ventilator and infusion pumps.
  
• Assess to ensure that all respiratory support tubing, lines and monitoring cables will easily reach the chair prior to transfer.
  
• Arterial transducer may need to be repositioned prior to transfer and again once position is set to ensure correct level for monitoring.
  
• Disconnect skin temperature probe cables and set the cot to an appropriate air temperature to maintain the correct level of ambient heat while the infant is in STS.

Transfer

• At least two experienced nurses must be present for the transfer of an infant receiving respiratory support such as CPAP or invasive ventilation to STS.
  
• Support should be sought if a nursing staff member feels uncomfortable with the process of transferring to/from STS.
  
• Gently rouse the infant prior to initiating transfer or handling and respond to any cues of distress with containment.  Ensure that the handling required to move the infant from a horizontal to vertical position is slow and controlled.
  
• Infant should be positioned in their cot in a supine position prior to STS. 
  
• Take down the side of the cot where the parent is to be situated prior to seating the parent. 
  
• One nurse should support the infant, whilst at least one other supports the ETT and ventilator tubing, as well as monitoring cables and lines. Seek further support if required. 
  
• Infants on the JET ventilator will require a third nurse to support the JET box.
  
• Transfer the infant from the cot to the parent’s chest in a smooth and steady movement. Position the infant comfortably upright and prone with their legs and arms flexed and their head to one side.  Have the parent support the infant with one hand on the infants’ head and the other over the infant’s bottom.
  
• If the infant is on CPAP ensure prong or mask position is appropriate to not place additional pressure on the nares or septum and that the ventilator is delivering the correct pressure.
  
• If the infant is ventilated, ensure the ETT remains secure and without additional tension and that the ventilator is delivering the correct pressure.
  
• Secure respiratory support tubing by taping to the parents clothing at shoulder height, allowing for some movement of tubing as the baby moves their head.  The tubing can then pass over the back corner of the chair.
  
• Ensure infusion lines, gavage tubes and monitoring leads remain free from tension and are well secured.
  
• Wrap the parent’s shirt or gown around the infant to form the “pouch” and place a blanket over the infant’s back.
  

During skin-to-skin care

• If the infant is receiving respiratory support, the nurse should remain in the room for the duration of skin-to-skin care and regular assessments should be performed
  
• Allow the infant time to settle into STS.  Adjust oxygen as required, allowing for a 10% increase.  Ensure good head position is maintained and suction the airway as indicated.  If the oxygen requirement remains increased by greater than 10% despite the above interventions, the infant is displaying signs that they are not tolerating the procedure and should be returned to the cot.  Notify medical staff and ensure that the parents understand why STS was ceased on this occasion.
  
• Check the infant’s axillary temperature after 15 minutes of STS, add or remove hats or blankets as required and continue to monitor
  
• A mirror may be provided to allow the parents to see their infant’s face during STS.  Encourage parents to quietly talk, hum or sing to their infant.
  
• Feeding via gavage tube should continue, ensuring that at least 20 minutes passes after completion of the feed before further transfer.  If the infant is on continuous feeds, pause the infusion during transfers and restart after 10 minutes.
  
• Preterm infants less than 32 weeks corrected gestation are not yet able to coordinate effective breastfeeding, however if they are showing signs of interest in sucking, they may ‘nuzzle’ or suck non-nutritively on an empty breast.
  
• If infants greater than 32 weeks corrected gestation are not requiring CPAP or ventilation, and are awake and alert during STS, a breastfeed may be offered.  Assess signs of readiness to feed and discuss with the infant’s mother regarding rate of milk flow and breast fullness. 
• Adjustments should be made according to the infant’s ability and stage of feeding.
  

Completing skin-to-skin care

• STS should last at least 60 minutes.  Monitor the infant’s cues of restlessness as an indication that they wish to return to their cot
  
• As with the transfer into STS, ensure sufficient staff are present, and that the infant and tubing, lines and cables are safely supported during the transfer back into the cot.
  
• Reattach temperature probes and record an axillary temperature 15 minutes after returning to the cot.  Reengage servo control functions if the infant was previously requiring this thermoregulatory mode
  
• If breastfeeding or expressing, encourage maternal expression after she has partaken in STS, as a larger volume of milk may be obtained post STS
  
• Document the time and duration that the infant participated in STS, and the relevant observations and support throughout, including FiO2 and ventilation changes.
  

Companion Documents

Nursing Guidelines

• Neonatal thermoregulation guideline
  
• Environmental humidity for premature neonates
  
• Breastfeeding support and promotion

Evidence table

The evidence table for this guideline can be viewed here. 

Please remember to read the disclaimer. 

The review of this nursing guideline was coordinated by Sarah Gardner, Associate Nurse Unit Manager, Butterfly Ward, and approved by the Nursing Clinical Effectiveness Committee. Updated February 2023.