Barriers and Facilitators to Conducting Kangaroo Mother Care in Italian Neonatal Intensive Care Units

The NeoRoo mobile app: Initial design and prototyping of an Android-based digital health tool to support Kangaroo Mother Care in low/middle-income countries (LMICs)

Premature birth and neonatal mortality are significant global health challenges, with 15 million premature births annually and an estimated 2.5 million neonatal deaths. Approximately 90% of preterm births occur in low/middle income countries, particularly within the global regions of sub-Saharan Africa and South Asia. Neonatal hypothermia is a common and significant cause of morbidity and mortality among premature and low birth weight infants, particularly in low/middle-income countries where rates of premature delivery are high, and access to health workers, medical commodities, and other resources is limited. Kangaroo Mother Care/Skin-to-Skin care has been shown to significantly reduce the incidence of neonatal hypothermia and improve survival rates among premature infants, but there are significant barriers to its implementation, especially in low/middle-income countries (LMICs). The paper proposes the use of a multidisciplinary approach to develop an integrated mHealth solution to overcome the barriers and challenges to the implementation of Kangaroo Mother Care/Skin-to-skin care (KMC/STS) in LMICs. The innovation is an integrated mHealth platform that features a wearable biomedical device (NeoWarm) and an Android-based mobile application (NeoRoo) with customized user interfaces that are targeted specifically to parents/family stakeholders and healthcare providers, respectively. This publication describes the iterative, human-centered design and participatory development of a high-fidelity prototype of the NeoRoo mobile application. The aim of this study was to design and develop an initial ("A") version of the Android-based NeoRoo mobile app specifically to support the use case of KMC/STS in health facilities in Kenya. Key functions and features are highlighted. The proposed solution leverages the promise of digital health to overcome identified barriers and challenges to the implementation of KMC/STS in LMICs and aims to equip parents and healthcare providers of prematurely born infants with the tools and resources needed to improve the care provided to premature and low birthweight babies. It is hoped that, when implemented and scaled as part of a thoughtful, strategic, cross-disciplinary approach to reduction of global rates of neonatal mortality, NeoRoo will prove to be a useful tool within the toolkit of parents, health workers, and program implementors.

Early Skin-to-Skin Contact in Preterm Infants: Is It Safe? An Italian Experience

Background: Skin-to-skin contact (SSC) is one of the four components of kangaroo care (KC) and is also a valued alternative to incubators in low-income countries. SSC has also become a standard of care in high-income countries because of its short- and long-term benefits and its positive effect on infant growth and neurodevelopmental outcome. However, barriers in the implementation of SSC, especially with preterm infants, are common in NICUs because parents and health care professionals can perceive it as potentially risky for the clinical stability of preterm infants. Previous studies have assessed safety before and during SSC by monitoring vital parameters during short-time intervals. Aims: To demonstrate the safety of early SSC in preterm infants during at least 90 min intervals. Design: Prospective observational monocentric study. Methods: Preterm infants born between June 2018 and June 2020 with a gestational age of ≤33 weeks and a birth weight of <2000 g were monitored while performing an SSC session during the first three weeks of life. Infants with necrotizing enterocolitis, sepsis, and congenital malformations on mechanical ventilation or with more than five apneas in the hour before SSC were excluded. Continuous oxygen saturation (SaO2), heart rate (HR), and respiratory rate (RR) were registered during an SSC session and in the hour before. The minimum duration of an SSC session was 90 min. Information regarding postmenstrual age (PMA), body weight, respiratory support, presence of a central venous catheter and the onset of sepsis within 72 h after a session was collected. Two physicians, blinded to infant conditions and the period of analysis (before or during SSC), evaluated desaturation episodes (SaO2 < 85%, >15 s), bradycardia (HR < 100, >15 s) and apneas (pause in breathing > 20 s associated with desaturation and/or bradycardia). A Wilcoxon rank sum test was used for the statistical analysis. Results: In total, 83 episodes of SSC were analyzed for a total of 38 infants. The mean gestational age at birth was 29 weeks (range 23–33 weeks). Median PMA, days of life, and body weight at SSC were 31 weeks (range 25–34 weeks), 10 days (range 1–20 days), and 1131 g (range 631–2206 g), respectively. We found that 77% of infants were on respiratory support and 47% of them had a central venous catheter (umbilical or peripherally inserted central catheter) during SSC. The total duration of desaturation, bradycardia, and the number of apneas were not statistically different during the SSC session and the hour before. No catheter dislocation or ruptures were reported. Conclusions: These findings highlighted the safety of early SSC in preterm infants and the possibility of performing it in an intensive care setting in the first weeks of life. In addition, these findings should reassure health care professionals offering this practice as a standard of care. SSC plays a key role in the care of preterm infants due to its short- and long-term positive benefits, and it deserves to be increasingly offered to infants and their parents.

Benefits of Kangaroo Mother Care on the Physiological Stress Parameters of Preterm Infants and Mothers in Neonatal Intensive Care

It is well documented that the stress of separation of mother and baby can lead to short-term physiological instability as well as neurological, sociological or psychological consequences that may last a lifetime. Objective: The goal was to estimate the effect of kangaroo mother care (KMC) on physiological and biochemical parameters of preterm infant stress and maternal stress in neonatal intensive care. Methods: The investigation involved 112 preterm infants. Two groups were compared according to the mean duration of KMC during 12 days of study: the KMC group (mean duration more than 90 min daily) and the control group (less than 90 min). Results: Kangaroo mother care for more than 90 min on average per day in preterm infants is associated 12 days after the intervention with lower mean cortisol levels (p = 0.02), greater weight gain and less need for parenteral nutrition in preterm infants, as well as less postpartum depression (p = 0.02) and lower cortisol levels (p = 0.002) in the mothers of preterm infants. Conclusions: This study suggests that KMC can be used to improve the stress of preterm infants and their mothers, and that the greater weight gain observed in these preterm infants could contribute to a shorter average hospital stay and lower healthcare expenditure.

Barriers to Kangaroo Care in the NICU: A Qualitative Study Analyzing Parent Survey Responses

BACKGROUND

Despite its benefits, parents in the neonatal intensive care unit (NICU) face significant barriers to kangaroo care (KC). Clinician-reported barriers to KC include staff education, environment, and equipment among others; however, parent-perceived barriers are underexplored.

PURPOSE

To examine parental understanding of KC, parental perception of experiences with KC, and parental views on the key factors that help or hinder KC.

METHODS

This is an observational, mixed-methods study that used an author-developed survey to assess parental feelings, perceived importance, and barriers to KC. Likert scale responses were analyzed using descriptive statistics. Free-text responses were analyzed using thematic analysis. A comparison of results was made between parents receiving and not receiving infant mental health services.

RESULTS

Fifty (N = 50) parents completed surveys. Eighty percent of parents stated they wanted more information on KC. Common barriers to KC were reported by parents, such as issues with space/environment. The most frequently reported barrier when asked openly was fear of hurting their infant. Ninety-six percent of parents believed that KC helped their emotional well-being. Parents receiving mental health services reported more fear but results did not reach significance.

IMPLICATIONS FOR PRACTICE AND RESEARCH

The frequency with which factors are reported as important to parents may allow a prioritization of barriers to KC, which may help focus quality improvement initiatives. The results of this study underscore the vital role nurses play in supporting KC. Additional attention needs to be given to the mental health of NICU parents and its impact on care practices.

Studying the Experience of Care Through Latent Class Analysis: An Application to Italian Neonatal Intensive Care Units

Though many data on the experience of care of patients and caregivers are collected, they are rarely used to improve the quality of health care delivery. One of the main causes is the widespread struggle in interpreting and enhancing these data, requiring the introduction of new techniques to extract intelligible, meaningful, and actionable information. This research explores the potentiality of the latent class analysis (LCA) statistical model in studying experience data. A cross-sectional survey was administered to 482 parents of infants hospitalized in several Italian neonatal intensive care units. Through a 3-step LCA, four subgroups of parents with specific experience profiles, sociodemographic characteristics, and levels of satisfaction were identified. These were composed of parents who reported (1) a positive experience (36%), (2) problematic communication with unit staff (30%), (3) limited access to the unit and poor participation in their baby's care (26%), and (4) a negative experience (8%). Through its explorative segmentation, LCA can provide valuable information to design quality improvement interventions tailored to the specific needs and concerns of each subgroup.

Surveying family access: kangaroo mother care and breastfeeding policies across NICUs in Italy

BACKGROUND

Studies on the application of developmental care initiatives in Italian NICUs are rather scarce. We aimed to assess parental access to the NICUs and facilities offered to the family members and to test "the state of art" regarding kangaroo mother care (KMC) and breastfeeding policies in level III Italian NICUs.

METHODS

A questionnaire both in paper and in electronic format was sent to all 106 Italian level III NICUs; 86 NICUs (i.e., 80% of NICUs) were completed and returned. The collected data were analysed. In addition, a comparison between the 2017 survey results and those of two previous surveys conducted from 2001 to 2006 was performed.

RESULTS

In total, 53 NICUs (62%) reported 24-h open access for both parents (vs. 35% in 2001 and 32% in 2006). Parents were requested to temporarily leave the unit during shift changes, emergencies and medical rounds in 55 NICUs (64%). Some parental amenities, such as an armchair next to the crib (81 units (94%)), a room for pumping milk and a waiting room, were common, but others, such as family rooms (19 units (22%)) and adjoining accommodation (30 units (35%)), were not. KMC was practised in 81 (94%) units, but in 72 (62%), i.e., the majority of units, KMC was limited to specific times. In 11 (13%) NICUs, KMC was not offered to the father. The average duration of a KMC session, based on unit staff estimation, was longer in 24-h access NICUs than in limited-access NICUs. KMC documentation in medical records was reported in only 59% of questionnaires. Breastfeeding was successful in a small proportion of preterm infants staying in the NICU.

CONCLUSION

The number of 24-h access NICUs doubled over a period of 13 years. Some basic family facilities, such as a dedicated kitchen, rooms with dedicated beds and showers for the parents, remain uncommon. KMC and breastfeeding have become routine practices; however, the frequency and duration of KMC sessions reported by NICU professionals still do not meet the WHO recommendations.