Kangaroo Care Does Not Adversely Affect Oxygenation of Babies Born Preterm

What Is the Main Idea?

Kangaroo care is a method that puts babies born preterm or newborns in skin-to-skin contact with their parents. In the open-access review article “Impact of Kangaroo Care on Premature Infants’ Oxygenation: Systematic Review”, published in the journal Neonatology, the authors analyze and discuss the combined findings of studies that have investigated the long-term physiological effects of kangaroo care on babies born preterm compared with standard incubator care.

What Else Can You Learn?

In this blog post, general care of preterm babies is discussed, along with the method of kangaroo care and its advantages.

What Does It Mean If a Baby Is Born Preterm?

A premature birth is one that takes place more than 3 weeks before the baby’s estimated due date (at 40 weeks), in other words, before the 37th week of pregnancy. Babies born between 34 and 36 completed weeks of pregnancy are classed as “late preterm”, those born between 32 and 34 weeks as “moderately preterm”, those born at less than 32 weeks as “very preterm” and those born at or before 25 weeks as “extremely preterm”. Premature birth usually means that a baby will need to be cared for in hospital for longer than a baby born at term, with the amount of time influenced by how early he or she is born. Depending on how much care the baby needs, he or she may be admitted to an intermediate-care nursery or a neonatal intensive care unit (NICU).

What Affects Whether a Baby Is Born Preterm?

There are some known risk factors associated with premature birth. These include: the mother having had a previous premature birth, or multiple miscarriages or abortions; an interval of less than 6 months between pregnancies; smoking cigarettes or using illicit drugs; some infections and chronic conditions; stressful life events, physical injury or trauma; and being under- or overweight before pregnancy. However, the specific cause is not often clear and many women who have a premature birth have no known risk factors.

How Can Being Born Prematurely Affect a Baby?

Although some babies born prematurely do not have any complications, generally speaking, the earlier a baby is born the greater the risk. Birth weight also plays an important role. Some complications that may be apparent at birth include breathing, heart and temperature control problems, and babies may also have issues related to metabolism, the blood and the immune system (particularly increased risk of infection). Longer term, they are at increased risk of complications including cerebral palsy, chronic health issues, vision, hearing and behavioural problems, and developmental delay. Because complications at birth can influence the development of longer-term issues, babies admitted to an NICU are closely monitored by the medical team and things such as the baby’s heart rate and oxygenation (oxygen levels inside the body) are frequently checked. They are also at increased risk of developing hypothermia if they have difficulty regulating their body temperature, so are usually cared for in incubators. This helps the baby maintain an optimum temperature and can also protect him or her from noises and direct light, which can cause stress.

What Is Kangaroo Care?

Although incubator care is very effective, kangaroo care is an important component in the care of babies born both prematurely and at term. Kangaroo care is described by the World Health Organization (WHO) as a method of care consisting of putting babies in skin-to-skin contact with their parents. Skin-to-skin contact is known to be effective for thermal control, breastfeeding and bonding, regardless of setting, weight, gestational age and clinical conditions, and is recommended for all newly born babies whether they are born preterm or not. In kangaroo care, the baby wears only a nappy or diaper (and often also a hat), and is placed in a flexed (fetal) position on the parent’s chest. The baby can be secured with a wrap that goes around the naked torso of the parent, ensuring that the baby is properly positioned and supported, or both parent and baby can be covered with a blanket, gown or clothing for warmth. Kangaroo care can even be given if the baby is attached to tubes or wires, as long as the parent stays close to the machines.

What Are the Advantages of Kangaroo Care?

The skin-to-skin contact of kangaroo care provides physiological and psychological warmth and bonding to both the parent and baby. Because the parent’s body temperature is stable, it regulates the temperature of a premature baby more smoothly than an incubator. Babies born preterm that receive kangaroo care also experience more normalized heart and respiratory rates, increased weight gain and fewer hospital-acquired infections. Other benefits include the promotion of frequent breastfeeding, improved sleep/wake cycle and cognitive development, decreased stress levels and positive effects on motor development. There are advantages for the parent as well, with kangaroo care helping to promote attachment and bonding, decrease parental anxiety, improve parental confidence, and promote increased milk production and breastfeeding success. However, to date, studies on the physiological stability of preterm babies during kangaroo care have reported conflicting results.

How Does Kangaroo Care Affect Oxygenation in Premature Babies?

Uncertainties regarding the effects of kangaroo care on oxygen saturation (the oxygen level in the blood) and “regional” cerebral oxygen saturation (i.e. relating to the brain) were investigated through a systematic review of research articles that assessed oxygenation, using pulse oximetry and near-infrared spectroscopy, during kangaroo care in NICUs. Pulse oximetry is non-invasive and pain-free, involves a clip-like device being placed on a body part such as a finger or ear lobe, and uses light to measure how much oxygen is in the blood. Near-infrared spectroscopy is also non-invasive and can continuously monitor regional oxygen saturation. This is important for babies born preterm because early detection of low cerebral oxygen saturation can prevent irreversible cerebral damage that can lead to cerebral palsy.

What Do the Results of the Systematic Review Show?

In total, the results of 25 research articles were analyzed, which documented data for 1,039 premature babies undergoing kangaroo care at three different study points: pre-, during and post-kangaroo care. Although the results of the systematic review cannot be extended to premature babies requiring critical care (described in the review as “unstable”), “stable” premature babies showed no significant differences in heart rate, oxygen saturation in the arteries (blood vessels that carry oxygen-rich blood away from the heart to the tissues of the body) or fractional oxygen extraction (the balance between oxygen supply and demand) compared with routine incubator care. Regional cerebral oxygen saturation also remained stable with a slight upward trend. Although most of the studies included in the review were observational (where participants are simply compared with placebo, no treatment or an alternative condition without randomization) and further studies are needed, the authors conclude that stable preterm babies receiving or not receiving respiratory support are as physiologically stable as those receiving routine incubator care.

Take-Home Message for Parents

Parents of babies born preterm can be reassured that the many benefits of kangaroo care in the NICU do not come at the cost of their baby being adequately oxygenated. Although more research is needed, there is no evidence that premature babies receiving kangaroo care are less physiologically stable than those that receive only routine incubator care.

Kidney Failure: How Peritoneal Dialysis Has Helped Reduce COVID-19 Infections

What Is the Main Idea?

Peritoneal dialysis (PD) enables people with kidney failure to conduct dialysis at home by themselves. During the COVID-19 pandemic, increased use of PD has helped to limit the spread of COVID-19 in this vulnerable patient population. In the open-access review article “Should More Patients with Kidney Failure Bring Treatment Home? What We Have Learned from COVID-19”, published in the journal Kidney Diseases, the authors analyze and discuss the utility of PD in the Asia Pacific region during the COVID-19 pandemic.

What Else Can You Learn?

In this blog post, kidney failure in general and the advantages and disadvantages of PD, particularly in relation to the COVID-19 pandemic, are discussed.

What Is Kidney Failure?

The kidneys do several important jobs in the body, including helping to control your blood pressure and make red blood cells, and removing waste products and extra water from your body to make urine. In chronic kidney disease (CKD), the kidneys no longer work as well as they should and are unable to remove waste products from your blood. As a result, too much fluid and waste products remain in the body, which can cause health problems such as heart disease, stroke and anemia. Although CKD can be a mild condition with no or few symptoms, around 1 in 50 patients can progress to a very serious form of CKD known as kidney failure, where kidney function drops to below 15% of normal.

How Is Kidney Failure Treated?

When the kidneys stop working, kidney replacement therapy in the form of dialysis or kidney transplant are needed so that the person can survive. Kidney failure treated in this way is called end-stage renal disease. If you have a kidney transplant, a healthy kidney from a donor is placed in your body to filter your blood. In contrast, dialysis is a procedure by which the blood is “cleaned”. There are two types of dialysis. In hemodialysis (HD), your blood leaves your body, goes through a filter in a machine and is returned to your body. HD is usually delivered in a healthcare setting. In contrast, peritoneal dialysis (PD) uses the lining of your abdomen, the peritoneum, to filter the waste and extra fluid from your body. A key difference between the two is that, once you have been trained, PD can be done at home, at work or while travelling without the help of another person. Home HD is possible, but you need the help of a partner and it is not available in all regions.

How Does Peritoneal Dialysis Work?

Before a patient can begin to use PD, they need an operation to insert a catheter, usually near the bellybutton. The catheter will carry the dialysate into and out of their abdomen. The patient then usually waits up to 1 month before starting PD to give the catheter site time to heal, and is trained how to use the equipment. Once PD begins, in each session, a cleansing fluid (called “dialysate”) flows through the catheter into part of the abdomen and stays there for a fixed period of time (called the “dwell time”), usually 4–6 hours. The dialysate contains dextrose, which helps to filter waste and extra fluid from tiny blood vessels in the peritoneum. At the end of the dwell time, the dialysate drains into a sterile collecting bag, taking the waste products and extra fluid with it. There are two main ways of conducting PD: continuous ambulatory PD, which uses gravity to move the fluid through the catheter and into and out of the abdomen, and continuous cycling PD, which uses a machine to perform multiple exchanges while you sleep at night. Your medical team will help you identify which PD method is best for you.

What Are the Advantages and Disadvantages of Peritoneal Dialysis?

Compared with in-center HD, the benefits of PD include:

  • greater lifestyle flexibility and independence, which can be especially important if you have to travel long distances to a dialysis unit;
  • a less restricted diet than if you receive HD, because PD is done more continuously than HD, so there is less build-up of potassium, sodium and fluid;
  • and the possibility of longer lasting residual kidney function.

However, PD might not be suitable for you if you have extensive surgical scarring in your abdomen, a hernia, limited ability to care for yourself or caregiving support, or inflammatory bowel disease or diverticulitis. It is also likely that people using PD will eventually have a decline in kidney function that will require HD or a kidney transplant.

How Has the COVID-19 Pandemic Affected the Treatment of People with Kidney Failure?

Patients with kidney failure, especially those receiving dialysis, are more susceptible to infections like COVID-19 than the general population and are at greater risk of severe disease or death when infected, partly because they are more likely to have other conditions that have been linked to severe COVID-19 (such as cardiovascular disease, diabetes, and cerebrovascular disease). Many patients experienced difficulties accessing HD during lockdowns, and those that could travel to a dialysis unit risked exposing themselves, their family and healthcare staff to COVID-19 infection. As a result, patients and healthcare providers have been encouraged to consider PD as a preferred option for kidney replacement therapy because home-based treatment prevents chains of transmission through in-center dialysis units, reduces the risk of exposure through travel, and helps to preserve hospital resources being stretched by this and possible future pandemics.

What Has Been the Effect of Increased Use of Peritoneal Dialysis during the Pandemic?

Evidence suggests that increased use of PD during the pandemic has had a beneficial effect. Survival and efficacy rates for patients undergoing PD are similar to those undergoing HD, and observational data from multiple countries have identified lower rates of COVID-19 infection in patients undergoing PD than those receiving in-center HD. In addition, fewer healthcare staff can support a larger number of patients through ongoing interaction using telehealth, although careful monitoring is required to ensure any negative effects are identified.

Take-Home Message for Patients

PD is currently underutilized, thought to be in part because of patient hesitancy, less frequent interaction with nephrologists and perceived lower levels of clinical oversight. However, if available, PD is an important treatment option that can protect patients with kidney failure from exposure to infection and may be worth their consideration in consultation with their clinical team.

Note: The authors of this paper make a declaration about grants, research support, consulting fees, lecture fees, etc. received from pharmaceutical companies. It is normal for authors to declare this in case it might be perceived as a conflict of interest. For more detail, see the Conflict of Interest Statement at the end of the paper.