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Author manuscript
MCN Am J Matern Child Nurs. Author manuscript; available in PMC 2021 May 01.
A
ut Published in final edited form as:
MCN Am J Matern Child Nurs. 2020 ; 45(3): 163–168. doi:10.1097/NMC.0000000000000612.
ho
r
M
an Kangaroo Care for Hospitalized Infants with Congenital Heart
us Disease
cri
Amy Jo Lisanti, PhD, RN, CCNS, CCRN-K [Nurse Scientist – Clinical Nurse Specialist],
Cardiac Nursing and the Center for Pediatric Nursing Research and Evidence-Based Practice, Children’s
Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104

Alessandra Buoni, BSN, RN, CPN [Clinical Nurse],

A Neonatal Intensive Care Unit, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE 19803
ut
ho Megan Steigerwalt, BSN, RN [Clinical Nurse Expert],
r Cardiac Intensive Care Unit, Children’s Hospital of Philadelphia, Philadelphia, PA 19104
M Michelle Daly, BSN, RN, CCRN [Clinical Nurse],
an Cardiac Intensive Care Unit, Children’s Hospital of Philadelphia, Philadelphia, PA 19104
us
cri Stephanie McNelis, BSN, RN, CCRN [Cardiac Center Outreach and Referral Nurse
Manager],
Children’s Hospital of Philadelphia, Philadelphia, PA 19104

Diane L. Spatz, PhD, RN-BC, FAAN

Professor of Perinatal Nursing & The Helen M. Shearer Professor of Nutrition, University of
A Pennsylvania School of Nursing, Philadelphia, PA 19104, Nurse Scientist, Center for Pediatric Nursing
ut Research and Evidence-Based Practice, Children's Hospital of Philadelphia, Philadelphia, PA 19104
ho
r Abstract
M
Background: Kangaroo Care (KC), or skin-to-skin care, occurs when an infant is dressed in a
an
diaper and held to a parent’s bare chest. This form of holding has been shown to have many
us
benefits for hospitalized infants and has been shown to be a safe and feasible intervention to
cri
support infants with congenital heart disease. Despite known benefits, KC was not implemented
routinely and consistently in our cardiac center for infants with congenital heart disease. The
purpose of this project was to support use of KC as a nursing intervention for hospitalized infants
with congenital heart disease and their parents.

A Methods: A KC quality improvement committee formed to develop strategies to increase

ut frequency of KC, including the creation of a new nursing policy and procedure on KC for
ho infants, adaptation of the electronic health record to facilitate KC documentation, provide
r education, and promote translation of KC into practice through the cardiac center’s first
M Kangaroo-A-Thon.
an
us
cri lisanti@email.chop.edu.
Disclosures: The authors have no conflicts of interest to disclose
 Lisanti et al. Page 2

Results: Twenty-six nurses initiated KC 43 times with 14 patients over the eight-week period for
A the Kangaroo-A-Thon. No adverse events were reported as a result of infants being held by their
ut parents in KC.
ho Conclusion: Our local initiative provided preliminary evidence that KC can be safely
r integrated into standard care for hospitalized infants with congenital heart disease. Formal
M standards and procedures, along with creative initiatives such as a Kangaroo-A-Thon, can be a
an first step towards fostering the translation of KC into practice.
us
cri Keywords
infant; family; congenital heart disease; nursing

Introduction
A Kangaroo Care (KC), or skin-to-skin care, occurs when an infant is dressed in a diaper and
ut held to a parent’s bare chest. This form of holding has been shown to have many benefits for
ho hospitalized infants, including enhanced physiologic stability, increased weight gain,
r decreased length of stay, and decreased risk of hospital acquired infection (Gazzolo, Masetti,
M & Meli, 2000; Harrison & Brown, 2017; Moore, Bergman, Anderson, & Medley, 2016).
an Kangaroo care has also been shown to improve outcomes for mothers including decreased
us postpartum depression, increased maternal milk production, and improved parent-infant
cri attachment (Ludington-Hoe, 2011; Moore et al., 2016). The Children’s Hospital of
Philadelphia has a predominant strong human milk and breastfeeding culture which includes
KC as routine care in all units caring for infants (Martino, Wagner, Froh, Hanlon, & Spatz,
2015; Spatz, 2004; Spatz, 2018). There has had a procedure and instructional DVD in place
for skin-to-skin transfer of the intubated infant since 2005. Despite availability of resources
A and our hospital’s strong human milk and breastfeeding culture, routine KC was not
ut integrated into standard care for hospitalized infants with congenital heart disease (CHD) in
ho our cardiac center, which is composed of a cardiac intensive care unit (CICU) and a cardiac
r step-down unit (CCU). Research in our cardiac center has found almost all parents initiate
M pumping for their infants and the majority of infants receive human milk through a feeding
an tube or a bottle (Torowicz, Seelhorst, Froh, & Spatz, 2015). Experts have called for
us integration of family-centered, developmental care interventions, such as KC, into standard
cri care for infants with CHD (Harrison, 2019; Lisanti et al., 2019; Peterson, 2018; Torowicz,
Lisanti, Rim, & Medoff-Cooper, 2012). In a survey of 28 CICUs in North America, all sites
reported allowing infant holding during the infant’s CICU admission and 57% reported they
encouraged KC (Sood et al., 2016). Several pilot studies have established feasibility and
safety of KC as an intervention for infants with CHD after cardiac surgery (Gazzolo et al.,
A 2000; Harrison & Brown, 2017; Harrison & Ludington-Hoe, 2015). While emerging
ut evidence suggests KC promotes cognitive development and autonomic functioning of
ho infants with CHD (Harrison & Brown, 2017; Harrison, Chen, Stein, Brown, & Heathcock,
r 2019), we did not find published evidence of feasibility of unit-based integration of KC in
M cardiac centers.
an
us Infants born with critical CHD are often separated from their parents immediately after birth
cri to receive life-saving care in our CICU, including cardiac surgery in the first few days of
life

MCN Am J Matern Child Nurs. Author manuscript; available in PMC 2021 May 01.
 Lisanti et al. Page 3

(Lisanti, Golfenshtein, & Medoff-Cooper, 2017). A critical window is missed for early
A initiation of parental bonding and breastfeeding. Fragility of infants with CHD who need
ut surgery in the first few weeks of life requires intensive care in the pre and postoperative
ho periods, with the use of a multiple lines, tubes, wires, medications, interventions, and
r technologies (Lisanti et al., 2019). Intensity of care creates many barriers hindering initiation
M of KC between infants and parents (Sood et al., 2016). Nurses may not be comfortable
an identifying patients to safely implement KC at the bedside or understand the process or
us method to perform the intervention. Infant holding via KC may increase risk of
cri dislodgement of lines (Torowicz et al., 2012). Nurses in our cardiac center created holding
and mobility guidelines to support a more consistent and standard approach to infant holding
(Torowicz et al., 2012). The guidelines provide specific information about which lines, tubes
and wires are considered safe for infant holding in the cardiac center. Although our team
was able to demonstrate the safe holding of infants after cardiac surgery, we were unable to
A examine KC documentation in the electronic health record because no field existed for
ut nurses to enter these types of data. However, our team anecdotally witnessed much less
ho frequent KC after cardiac surgery than infant holding in the other units.
r In January, 2018, the lead author (AJL) launched a KC research project in our cardiac center
M
for infants undergoing cardiac surgery. This provided a unique opportunity to have the unit-
an
based nurse scientist partner with staff nurses to launch a separate quality improvement (QI)
us
initiative to address barriers, provide education, and foster increased translation of KC into
cri
practice in the cardiac center. Nurses from the CICU and CCU formed a KC QI committee
under the mentorship of the lead author to create strategies to support use of KC as a nursing
intervention for infants and their parents before and after cardiac surgery. The committee
met monthly, over six months, to launch the following initiatives:

A 1. Create an additional nursing policy and procedure on KC for infants with

ut a natural airway to provide more general guidelines for infants in the
ho cardiac center.
r 2. Adapt the electronic health record (EHR) to facilitate KC documentation.
M
an 3. Educate nurses about KC through formal group presentations and peer-to-
us peer, in-person education by members of the KC Committee.
cri 4. Encourage translation into practice through the cardiac center’s Kangaroo-A-
Thon, giving nurses a chance to win a prize basket for initiating and
documenting KC with an infant and parent.

This project followed Squire 2.0 guidelines and did overlap, disrupt, or impact the KC
research study that was ongoing in the cardiac center during the same time frame (Ogrinc et
A al., 2016).
ut
ho
Method
r
s
M A nursing standard and procedure on KC was created in July of 2018 that added to the
an procedure and resources in place at the Children’s Hospital of Philadelphia (see Table 1).
us The procedure directly linked to the cardiac center’s holding guidelines to help nurses
cri
 Lisanti et al. Page 4

determine KC eligibility, safety considerations, and best practices for patients. The EHR
A was updated to include specific fields in the holding and positioning nursing flowsheets for
ut documentation of KC, including fields to note who participated in KC and for how long.
ho Nursing education on the new standard and EHR documentation was completed between
r August and September, 2018. Nurses were provided with slide presentations via email and
M in person, and just-in-time teaching was done at the bedside by members of the KC
an committee. The lead author modeled KC practice to the staff nurses as she personally
us facilitated KC between infants and mothers in the cardiac center through her separate KC
cri research project in the cardiac center. The unit-based nurse scientist oversaw KC
intervention occurring for her study and used this opportunity to teach staff nurses about
benefits of KC. This was an opportunity to reinforce to the nurses all of the policies and
procedures that are available on our internal website (Froh & Spatz, 2016).

A Kangaroo-A-Thon was initiated for eight weeks from October to November 2018 to
A promote the translation of KC into practice through an exciting and novel nursing
ut engagement strategy. The Kangaroo-A-Thon gave nurses from each unit a chance to win a
ho prize basket for initiating KC with their patient and parent and documenting it in the EHR.
r
Each time nurses in the units independently supported KC on their own (and not for the lead
M
author’s research), they could enter the unit’s raffle. The more times nurses initiated KC, the
an
greater their chances of winning. Education was repeated often and frequent emails were
us
sent reminding and encouraging nurses to participate. Members of the KC committee helped
cri
bedside nurses identify candidates for KC and provided just-in-time teaching for KC as
needed. Data were collected from the raffle to identify the number of nurses and patients
that participated in the Kangaroo-A-Thon and documentation was confirmed in the EHR.
After the conclusion of the Kangaroo-A-Thon, nurses who entered the raffle were
approached by members of the KC QI committee and asked an open-ended question about
A how they felt their experience was participating in the Kangaroo-A-Thon. Responses were
ut collated by the KC QI committee.
ho
r Safety is continuously monitored in our cardiac center through adverse event reporting.
M Adverse events are any unplanned event occurring with a patient, such as line or tube
an dislodgements. These events were monitored after the institution of the new policies as
us well as during the Kangaroo-A-Thon.
cri
Results of the Kangaroo-A-Thon
Twenty-six nurses initiated KC 43 times with 14 patients over the eight week period for the
Kangaroo-A-Thon (Table 2). Three patients were held in both the CICU and the CCU after
being transferred out of critical care. Kangaroo care was initiated more times on day shift
A (n=29) than on night shift (n=14). Kangaroo care was initiated more times in the CCU (n=
ut
28) than the CICU (n=15). No adverse events were reported as a result of infants being
ho
held by their parents in KC.
r
M Nurses who participated in the Kangaroo-A-Thon provided positive feedback. Nurse
an comments included “It was amazing to see how my patient’s vitals really did improve with
us skin-to-skin! My patient was a pre-operative critical coarctation who was having
cri
 Lisanti et al. Page 5

hypotension earlier in the morning. When doing skin-to-skin his blood pressure was as
A robust as it had been all day (CICU nurse). Nurses from the CCU offered these responses
ut The Kangaroo-a-Thon shed light on a tool we as nurses had in our back pockets all along.
ho Skin-to-skin is medicine our babies need to promote healing… I will definitely be using this
r tool in my everyday practice and I think in all the hustle and bustle of the hospital, it’s so
M important to take the time to nurture and cuddle an infant in need, in pain, or just in
an general to help them grow. And the Kangaroo-A-Thon promoted that skin-to-skin that all
us babies need.
cri
Discussion
This project describes our unit-based initiative to support KC for infants admitted to the
cardiac center for CHD who require cardiac surgery. Similar to recent studies on KC in
infants after cardiac surgery (Harrison & Brown, 2017; Harrison & Ludington-Hoe, 2015),
A the project found KC is safe and feasible in this patient population, but highlighted that
ut standards and procedures are needed to support translation of KC into practice in a cardiac
ho center. Nurses in the CCU had more opportunities to place patients in KC with their
r parents than in the CICU, most likely due to increased physiologic stability and less
M invasive lines present (Sood et al., 2016). In the CICU, infants are more often unstable
an hemodynamically and frequently have multiple tubes, lines, and wires present (Lisanti et
us al., 2019). Infants in our CICU are often in open bay-style rooms where parents are unable
cri to sleep overnight at the bedside. This may have contributed to KC occurring more
frequently on dayshift than nightshift.

Nurses who participated in the Kangaroo-A-Thon in both the CICU and CCU described
positive experiences. Although we did not directly measure patient outcomes or
A hemodynamic stability for this quality improvement project, nurses commented on the
ut physiologic benefits that they noticed while their patients were in KC and no adverse events
ho occurred. Nurses found the Kangaroo-A-Thon to be a helpful event to increase awareness of
r KC, the new standards and procedures, and to remind nurses in the cardiac center to
M promote KC between their neonatal patients and parents.
an
Our hospital has had a nurse researcher in lactation (senior author DLS) in place since 2001.
us
Nurses at Children’s Hospital of Philadelphia have the opportunity to take a two-day
cri
intensive course on human milk and breastfeeding, The Breastfeeding Resource Nurse
course (Spatz, Froh, Flynn-Roth, Barton, 2015), which addresses importance of KC for
critically ill infants. This model has published research outcomes on the impact of nurses
providing care to families including KC (Spatz et al., 2015). Breastfeeding Resource Nurses
articulated the importance of the course in empowering them to be able to provide evidence-
A based lactation care and support including the provision of KC. For nurses in the Neonatal
ut
Intensive Care Unit and the Special Delivery Unit, the Breastfeeding Resource Nurse course
ho
is mandatory. The cardiac center cares for pediatric patients across all age ranges from
r
infancy to young adults; which creates a unique challenge to ensure that all nurses have
M
expertise in mother-baby care, which is a main focus in the Neonatal Intensive Care Unit
an
and Special Delivery Unit. Both CICU and CCU nurses need to be adept at caring for a wide
us
range of populations; therefore, the orientation needs and priorities are different.
cri
 Lisanti et al. Page 6

This QI project was led by a unit-based nurse scientist (lead author). With the lead author
A conducting research in the cardiac center, it created a unique opportunity to re-engage
ut nurses about importance of KC. The study served as a catalyst for practice change in the
ho unit. The launch of the research study allowed the unit-based nurse scientist to engage staff
r nurses in a mentoring relationship. This led to the local QI initiative that facilitated unit-
M based procedure development, education, and grass-roots interventions. Hospital based
an nurse scientists who are embedded within a clinical practice setting are well-positioned to
us support reduction of the research-to-practice gap and enhance implementation of evidence-
cri based practice (Brant, 2015).

Limitations

This local project was conducted in one cardiac center, with a small sample, limiting
generalizability to other hospitals. We did not gather data on incidence of KC prior to the
A Kangaroo-A-Thon because of inability to extract data from charts, since a place for EHR
ut documentation did not exist. Therefore, results should be interpreted with caution because
ho they only reflect the amount of KC that occurred during the period of the Kangaroo-A-
r Thon. The small sample does not allow wide inferences about safety in infants with CHD
M before and after corrective surgery; however, our findings are consistent with other studies
an about safety of kangaroo care for newborns in general. More QI data are needed to
us determine whether the interventions for this project will support sustainable culture change
cri and increased frequency of KC in the cardiac center. We acknowledge that the ongoing
research project being conducted by the lead author most likely enhanced the educational
opportunities of staff and exposure of staff to KC. We cannot separate the impact of the
nurse-scientist’s study from the efforts of this QI project. However, we believe the
synergistic effect of a unit-based nurse scientist conducting research while modeling,
A mentoring, and supporting staff to lead a QI project is a novel model to support inquiry and
ut innovation in our current era.
ho
r Clinical Implications
M
an Our initiative provided preliminary evidence that KC can be safely integrated into standard
us care in cardiac centers that care for infants with CHD. More data with larger samples are
cri needed to confirm these results. Formal standards and procedures, combined with nursing
education and creative initiatives such as a Kangaroo-A-Thon, can foster translation of KC
into practice for this patient population. These standards and procedures can serve as an
example to other cardiac centers and provide additional evidence of feasibility of integrating
KC as a nursing care standard for infants with CHD. Future quality improvement initiatives
can also evaluate whether the consistent provision of KC according to standards improve
A
patient outcomes such as reducing hospital length of stay or rates of hospital-acquired
ut
infections, as has been shown in other neonatal populations. Experience of parents of infants
ho
with CHD as well as pediatric cardiac nurses caring for this fragile population should be
r
examined in future studies.
M
an
us
cri
 Lisanti et al. Page 7

Clinical Implications
A Kangaroo care has been shown to have many benefits and to improve outcomes for
ut hospitalized infants and their parents, thus for these fragile infants with congenital heart
ho disease, the therapy may be especially valuable.
r
M Even with multiple lines, tubes, wires, medications, and interventions, kangaroo care can be
an accomplished in the context of a clinical protocol and care guidelines.
us
We found kangaroo care to be a feasible intervention to support infants with congenital
cri
heart disease before and after cardiac surgery and their parents.

Development of formal standards and procedures for KC of infants with congenital heart
disease is essential to support translation of KC into practice in cardiac centers.

A Creative strategies to engage nurses, such as a Kangaroo-A-Thon, may be effective

ut to enhance awareness of KC as an intervention and increase its use in a cardiac
ho center.
r
M Funding:
an
us Dr. Lisanti was supported by NINR T32NR007100 as a Ruth L Kirschstein Postdoctoral Fellow at the University
of Pennsylvania school of nursing during this work. The Skin to Skin Holding study referred to in this manuscript
cri was funded by a grant to Dr. Lisanti from the American Nurses Foundation, Association of periOperative
Registered Nurses, and Stryker.

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r Harrison TM (2019). Improving neurodevelopment in infants with complex congenital heart
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 Lisanti et al. Page 9

Callouts
A benefits and to improve outcomes for hospitalized infants and their parents
ve many
ut to support infants with congenital
rvention • heart disease and their parents.
hodisease who need surgery in the first few weeks of life requires intensive care in the pre and postoperative periods, with use of a multiple lines,
al heart
• a kangaroo care committee to develop strategies to support use of kangaroo care as a nursing intervention
re unitr and a cardiac step-down unit formed
ombined
M with nursing education and creative initiatives such as a Kangaroo-A-Thon, can be a first step in the translation of kangaroo care into practice.
•
an
us
cri

A
ut •
ho
r
M
an
us
cri

A
ut
ho
r
M
an
us
cri

A
ut
ho
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 Lisanti et al. Page 10

Table 1:

Kangaroo Care Procedure

A
ut Parent assisted
Transfer
• A method of transferring the infant if the parent is able to get in and out of the chair independently.
This is the preferred method for transfer.
ho Nurse Assisted
• A method of transferring the infant by the nurse lifting the infant from the sleep surface and handing
Transfer
r the infant to the parent (who is sitting in the chair).
M
Parent Assisted Parental Role Nurse Role
an Transfer
us Best Practices

cri Prepare
environment
• Perform hand hygiene • Perform hand hygiene
• Warm hands • Warm hands
• Have mother in just a gown, • Gather warm blankets
open towards the front
• Supply privacy screen
• Gather velcro HUGS to secure lines

A ICU safety • Infant can be fed during skin- • Ensure all lines are secured according to policy
ut considerations to- skin care and long enough to reach the parent

ho • Temporarily disconnect suction and/or

continuous feeds to allow for adequate length to
r reach the parent

M • Do not transfer immediately after bolus feed; rather

transfer prior to a feed or an hour after
an
• Note cm markings on umbilical lines and ensure
us the sutures are intact
cri
Delegate roles • Verbalize that the parent • Verbalize that the nurse is responsible for tubes
is responsible for infant and lines

• *Respiratory Therapist (RT) is responsible for

the endotracheal tube (ETT) throughout the
transfer.
Technique to • Place one hand underneath infant’s • Guide and instruct parent on how to scoop
A transfer infant to bottom and with the other hand cup patient from bed to chest
Kangaroo Care the infant’s head and shoulders
ut • Move parents’ chair as close to the infant’s
• Lean forward over the sleep sleep surface as possible
ho surface and gently lift the infant to
his/her chest • Guide all lines and tubing while parent transitions
r to the seated position
• Stand still to ensure the infant
M is stable before sitting • Ensure adequate slack on IV lines, feeding tubes,
an • Move to the chair and sit down
etc
*Assess the infant’s endotracheal tube and
us •
ventilator tubing and ensure the tube is secure.
cri Secure infant’s endotracheal tube to the parent’s
clothing.

While in Kangaroo • Allow for at least an hour • Reconnect any tubes/lines that were disconnected
Care to promote for ease and safety of transfer
thermoregulation
• Remain at or near the bedside for the duration of
the session to allow for continuous monitoring
A
ut Nurse Assisted
Transfer
Parental Role Nurse Role

ho Best Practices
r Prepare Same as above Same as above
environment
M
an
us
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 Lisanti et al. Page 11

ICU safety Same as above Same as above

considerations

Delegate roles • Parent is responsible for • Nurse is responsible for all lines and tubes. Ask a
A receiving the infant while sitting second nurse to assist, if needed.
in chair.
ut • *Respiratory Therapist responsible for ETT
ho
r Technique to • Parent prepares to receive • Place hand under the blanket and underneath
transfer infant into infant while sitting in chair the infant. With the other hand, support the
M KC infant’s head.
an • Gently lift the infant and place him/her on the
parent’s chest.
us
• Parent may cradle infant in arms first, and then
cri help parent reposition infant to place the infant’s
chest and stomach on the parent’s chest.

• *Assess the infant’s endotracheal tube and

ventilator tubing and ensure the tube is secure.
Secure infant’s endotracheal tube to the parent’s
clothing.

A While in Kangaroo Same as above Same as above

Care
ut
ho *
Intubated infants
r
M
an
us
cri

A
ut
ho
r
M
an
us
cri

A
ut
ho
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 Lisanti et al. Page 12

Table 2:

Kangaroo-A-Thon Participation
A
ut Kangaroo-A-Thon Participation CCU CICU Total

ho # Entries 28 15 43

r # Participating Nurses 17 9 26

M # Infants Placed in KC 9 8 17

an KC During Day Shift (0700 – 1900) 17 12 29

us KC During Night Shift (1900 – 0700) 11 3 14

cri

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M
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