Increasing Rates of Kangaroo Care for Everyone

When it comes to changing our behaviors, we often have to take a hard, honest look at ourselves. It’s often uncomfortable and humbling, but it’s necessary for self-improvement. It’s the same for institutions. At Stanford Medicine Children’s Health, a team of neonatologists are tackling health equity—making sure every patient has the same opportunity to be healthy—especially when it comes to kangaroo care (holding your baby with your skin touching). Melissa Scala, MD, neonatologist with Stanford Medicine Children’s Health and the medical lead of the NEST (our small-baby NICU), led one of the first, and maybe the only, studies in the nation on the differences in kangaroo care for premature infants in the Neonatal Intensive Care Unit (NICU). What she and her colleagues found was a bit surprising, and it’s leading to sometimes uneasy, but real, change.

The study, titled “Disparities in Kangaroo Care for Premature Infants in the Neonatal Intensive Care Unit,” published in the Journal of Developmental and Behavioral Pediatrics in 2021, compared how often and for how long mothers spent in kangaroo care—or skin-to-skin time—with their babies, a practice known to have several benefits for babies, especially premature ones. For the study, mothers were divided into four groups, English speakers and non-English speakers and those with high socioeconomic status and low socioeconomic status.

“Our findings revealed disparities in the rate, frequency, and duration of kangaroo care in the NICU for moms who spoke a language other than English and who had a lower socioeconomic status,” Dr. Scala says.

While the study is groundbreaking for exploring inequities in kangaroo care, it reflects what’s happening in NICUs across the nation. For example, a recently published paper in the journal Pediatrics reviewed 566 studies on disparities in NICUs across the country and found that babies of nonwhite families did not receive equal treatment or have as good of outcomes as white babies.

The kangaroo-care study findings inspired change in our NICU at Stanford Medicine Children’s Health and motivated the neonatology team to explore ways to reduce differences in care, an effort led by neonatologist Sonia Bonifacio, MD. A few new and improved care practices are underway, including ones that promote kangaroo care more equally. Others are in the works.

“I’m a daughter of immigrants, and my parents relied on me to translate for them. When I see a mom who doesn’t speak English with fear in her eyes because she doesn’t understand what is happening with her baby, I see my mom staring back at me,” Dr. Bonifacio says. “We want our patient families to know that being able to ask questions is a right for everyone.”

To increase kangaroo care among lower-income and/or non-English-speaking families, Dr. Bonifacio started by setting a goal to increase access to interpreters within the NICU. While restrictions during the COVID-19 pandemic have limited in-person interpreters, the team is using phone and tablet interpreters to communicate health information to parents. Future goals including getting a dedicated interpreter in the NICU and Cardiovascular Intensive Care Unit (CVICU), and prompting nurses to always ask patients if they need an interpreter and then calling for interpreter services, which are available 24/7.

“Kangaroo care takes some extra effort in the NICU. There are breathing tubes and IVs to keep in place. Parents who advocate for themselves and who can easily communicate that they want to have skin-to-skin time are the ones who get it more frequently,” Dr. Scala says. “But the families who don’t speak English might not feel as confident or empowered to speak up. Providing equitable care doesn’t mean everyone gets the same care; it means that families who need extra support get the support that they need, and we meet them where they are.”

“For example,” Dr. Bonifacio adds, “if a parent has to work two jobs and the only time they can get to the NICU is at 10 p.m. to have kangaroo-care time with their baby, then that is when it needs to happen.”

Each day, neonatologists round on every single baby in the NICU, and they review key points of care. Recently, they’ve added a few new checkpoints to their list. These include, “Has the baby been held by their parents?” and “Has the family been updated on their baby’s status in their own language?” Another change that has taken place is adding a bilingual lactation nurse to the team. This not only promotes breastfeeding more equally but also promotes kangaroo care, because the two go hand in hand.

Besides these rounding questions, the team also checks for language barriers and social determinants of health, which are added to patient charts as risk factors, so that nurses know when families need extra care. It also helps families get more frequent support from the developmental care team. Developmental care is very important for keeping premature babies on track with their growth, development, and learning.

“It’s not always comfortable, and it takes bravery to recognize that we all have biases,” Dr. Bonifacio concludes. “Once we take a hard look at how our beliefs influence patient care, we can enact real change.”