Baby-Friendly e-Newsletter : Baby Friendly Watch (Dec 2025)

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Date: 2025-12-29

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Discover how a neonatal unit’s quality improvement initiative enhanced the implementation of Kangaroo Care for preterm infants through updated guidelines, strengthened safety measures, and targeted staff training. This article shares how earlier and safer skin‑to‑skin care improved coverage, supported parent‑infant bonding, and contributed to better developmental outcomes for vulnerable newborns.

Please click here to download the PDF version of the whole article with images and the references. The preview is at the bottom of this webpage.

A Quality Improvement Project to Enhance Kangaroo Care for Preterm Infants:

Transforming the Neonatal Intensive Care

Ms. WONG Ka Yin

Nurse Consultant (Neonatal Care), Queen Mary Hospital

Introduction

Kangaroo Care (KC) is defined as the practice of holding an infant skin-to-skin with a caregiver. KC offers numerous benefits for both infants and parents, including reduced mortality and severe infection rates, decreased stress for infants and parents, increased parental confidence, lower rates of parental depression, shorter hospital stays, improved growth rates, enhanced maternal–infant attachment, and increased rates of breastfeeding at discharge as well as 1-month & 3-month follow-up. ^1-3,6,8,10

Kangaroo care is especially beneficial for low birth weight (LBW) and preterm infants. The World Health Organization (WHO)⁹ recommended KC as routine care for infants with a birth weight of ≤2000 g and it should be initiated as soon as possible after birth unless the infant is critically ill. However, global studies show that delayed initiation of KC is common, with a Cochrane review reporting the median age of initiation ranging from 3 to 24 days.^{2, 7}A 2023 WHO global position paper further emphasised that KC should be regarded as an essential standard of care for all preterm and LBW infants. ¹⁰ In addition, WHO and UNICEF’s Every Newborn action plan set a target for KC coverage to reach at least 50% of preterm or LBW infants by 2020 and 75% by 2025. ¹¹

Identifying the Practice Gap

A retrospective chart review conducted from July to September 2023 in the neonatal intensive care unit (NICU) at Queen Mary Hospital (QMH) revealed that KC coverage for preterm infants was only 41%, with a mean age of initiation of 28.1 days. To address this practice gap, a continuous quality improvement (CQI) project was launched to increase KC coverage and reduce the age of initiation for preterm infants in the QMH NICU.

CQI Project Implementation

A multidisciplinary workgroup consisting of doctors and nurses was formed to revise the KC guideline and to identify the root causes of delayed KC initiation for preterm infants. (See Figure 1: Reasons for delayed initiation of kangaroo care among preterm infants in the QMH NICU, please refer to the PDF version).

The team conducted a literature review to incorporate the most up-to-date evidence-based KC practices. Previously, preterm infants were eligible for KC only if they met specific criteria: body weight >1.2 kg, corrected gestational age ≥30 weeks, and were not on mechanical ventilation or without an umbilical catheter/arterial line.

The revised guideline now states that infants are eligible for KC when they are medically stable, with no reference to body weight or gestational age. A modified lateral kangaroo position (see Figure 2: Modified KC Lateral Position) is also introduced for infants with conditions such as umbilical catheters or stomas, who have difficulty with the conventional prone position (see Figure 3: Conventional KC Prone Position). Additionally, the updated guideline includes a category of infants requiring special consideration, such as those on mechanical ventilation. This group of vulnerable infants can still receive KC if their conditions are deemed suitable during daily ward rounds by medical and nursing staff.

(For Figures 2 & 3: please refer to the PDF version )

Addressing Safety Concerns

1. Prevention of intraventricular haemorrhage (IVH) in the first 72 hours of life

Preterm infants weighing less than 1.5 kg are at high risk of IVH, with most cases occurring within the first 72 hours of life. ⁴During this period, midline positioning and a minimal-handling approach should be adopted to help prevent IVH in this vulnerable group of infants. ⁵ Since the conventional KC position may cause jugular venous obstruction, potentially increasing IVH risk, the revised guideline stipulates that KC should be withheld during the first 72 hours for infants weighing less than 1.5 kg.

2. Ensuring clinical stability and normothermia during KC

To prevent hypothermia in preterm infants during KC, several measures are implemented. For infants weighing less than 1 kg, a warm hat should be worn and an electric heater placed nearby. Following WHO recommendations⁹, binders are introduced to secure infants firmly to the caregiver’s chest, ensuring crucial skin-to-skin contact and helping to maintain temperature. (see Figure 4: A binder is used to secure the infant firmly to the caregiver’s chest, please refer to the PDF version). All nurses are trained to assist caregivers in using the binder. Additionally, a binder is routinely provided to parents of each preterm infant with a birth weight of less than 1.5 kg or a gestational age of less than 32 weeks during their first visit to the NICU. This measure aims to encourage parents to provide KC to their infants.

A new observation checklist for KC has been added to the clinical information system. Nurses must complete the checklist for each KC episode, documenting vital signs and temperature before and after each KC session, as well as recording temperature hourly during KC. The checklist includes a standardised list of interventions for managing hypothermia or hyperthermia, such as applying or removing warm blankets and adjusting the infant’s position. If hypothermia or hyperthermia is noted, the nurse must check the temperature every 15 minutes until it stabilises. Furthermore, the checklist specifies conditions that require suspension of KC, including:

Persistent hypothermia (Temperature ≤ 35.5 °C) despite interventions;
A requirement for fraction of inspired oxygen (FiO₂) of more than 10% above the baseline;
Vital signs that do not stabilise within 15 minutes of transfer to the caregiver’s chest.

3. Prevention of dislodgement of tubing/invasive lines during KC

As many nurses have reported that the fear of dislodging tubes or lines is one of the primary reasons for hesitating to assist caregivers with KC (see Figure 1, please refer to the PDF version), comprehensive small-group training sessions have been conducted for all nurses. These hands-on sessions help nurses master the technique of safely transferring infants from the incubator to the caregiver’s chest while securing ventilator tubing and invasive lines at the same time. in addition, a tubing and cable holder (Neogrip) has been introduced to help organise and secure tubes, cables, and invasive lines during KC, thereby preventing dislodgement. To ensure patient safety, all nurses are required to pass a competency assessment in assisting caregivers with KC.

Project Outcomes

Following the completion of nurse training and competency assessments, the updated KC guideline was implemented at the end of July 2024. Data collected two months post-implementation showed significant improvements. Before the intervention, the mean age at KC initiation for preterm infants was 28.1 days. This decreased to 12.8 days after project implementation, representing a 54.4% reduction. It was also encouraging to note that even an infant with a corrected gestational age of 29 weeks and a body weight of 870 g could undergo KC safely and successfully. KC coverage for preterm infants in the NICU increased from 41% to 70% after project implementation. No adverse events related to KC – such as unplanned extubation, dislodgement of invasive lines, or moderate / severe hypothermia during KC – were reported during the review period. In line with the revised guideline, no infant with a birth weight of less than 1.5 kg received KC during their first 72 hours of life.

Summary

In conclusion, this project successfully facilitated increased KC coverage for preterm infants in the NICU and earlier initiation of KC, allowing this vulnerable group to benefit from KC at a younger age. Going forward, several strategies can be explored to further improve KC coverage. For example, extending NICU visiting hours and enhancing the comfort of bedside chairs are practical steps that could encourage and enable caregivers to perform KC more frequently and for longer durations.

Views expressed in this article are the author’s and do not necessarily reflect the opinion or position of the BFHIHKA.

Editor-in-Chief: Dr Shirley Leung

Editorial Team: Mrs Francis Au, Ms Sally Wan, Ms Sing Chu, Dr Annie Fok, Ms Ivy Yiu, Ms Julia Yeung, Dr Ana Lee, Ms Tracy Ling, Ms Wong Ka Yin, Ms Lo Ka Yee

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