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Fathers providing kangaroo care in neonatal intensive care units: a scoping review.

Authors:

Abstract

Background: Kangaroo care (KC) has been used widely in neonatal care to promote bonding/attachment and neurodevelopment for preterm and term infants. However, current literature suggests that research mainly focuses on infants’ and mothers’ experiences. The role of fathers in caring for their infant/child is changing and evolving in many countries around the globe yet little is known about fathers’ experiences of KC in neonatal units. This review, therefore, aims to scope the current evidence of father–infant KC (FKC) in neonatal intensive care units (NICUs). Research question: What impact does KC have on fathers when their baby is cared for in a NICU? Search method: A scoping review was conducted, guided by the Arksey & O’Malley (2005) framework. The data sources consisted of MEDLINE, Embase, the American Psychological Association (APA) PsycInfo, Emcare, Cochrane Database of Systematic Reviews (CDSR), Web of Science, Google Scholar, and ProQuest.The study inclusion criteria were: 1. studies involving fathers who had experience of KC with their baby while in NICUs and other neonatal care settings (such as Special Care Baby Nursery (SCBU), delivery/labour room, and postnatal ward); 2. literature published from 2000 to 2020; 3. primary studies including qualitative, quantitative, and mixed-methods studies; 4. studies published in English.Results: The total number of studies identified was 13. Seven studies were qualitative and six were quantitative. None were mixed-methods studies. Studies reported several positive KC benefits for fathers such as reduced stress, promotion of paternal role and enhanced father–infant bond. It was highlighted that KC could be time-consuming for fathers and challenging to practise when balancing work and family life commitments. Conclusion: This review provides evidence that KC practice has health and wellbeing benefits for fathers and infants in NICUs and other relevant neonatal care settings. The findings of this review support the justification to promote FKC in NICU environments and guide policies to include father involvement. Implementing FKC in NICU settings will assist fathers to care and connect with their baby. Further research is needed to explore how to facilitate and evaluate KC education for fathers from diverse backgrounds and cultures.
Fathers providing kangaroo care in neonatal
intensive care units: a scoping review
Qiuxia Dong1, Mary Steen, Diane Wepa
1Corresponding author
Date submitted: 6 September 2021. Date accepted: 25 January 2022. First published: 31 January 2022.
Background: Kangaroo care (KC) has been used widely in neonatal care to promote
bonding/attachment and neurodevelopment for preterm and term infants. However,
current literature suggests that research mainly focuses on infants’ and mothers’
experiences. The role of fathers in caring for their infant/child is changing and evolving in
many countries around the globe yet little is known about fathers’ experiences of KC in
neonatal units. This review, therefore, aims to scope the current evidence of father–infant
KC (PKC) in neonatal intensive care units (NICUs).
Research question: What impact does KC have on fathers when their baby is cared for
in an NICU?
Search method: A scoping review was conducted, guided by the Arksey & O’Malley (2005)
framework. The data sources consisted of MEDLINE, Embase, the American Psychological
Association (APA) PsycInfo, Emcare, Cochrane Database of Systematic Reviews (CDSR),
Web of Science, Google Scholar and ProQuest.
The study inclusion criteria were: 1. studies involving fathers who had experience of KC
with their baby while in NICUs and other neonatal care settings (such as Special Care Baby
Nursery (SCBU), delivery/labour room and postnatal ward); 2. literature published from
2000 to 2020; 3. primary studies including qualitative, quantitative, and mixed-methods
studies; 4. studies published in English.
Results: The total number of studies identied were 13. Seven studies were qualitative and
six were quantitative. None were mixed-methods studies. Studies reported several positive
KC benets for fathers such as reduced stress, promotion of paternal role and enhanced
father–infant bond. It was highlighted that KC could be time-consuming for fathers and
challenging to practise when balancing work and family life commitments.
Conclusion: This review provides evidence that KC practice has health and wellbeing
benets for fathers and infants in NICUs and other relevant neonatal care settings. The
ndings of this review support the justication to promote PKC in NICU environments, and
guide policies to include father involvement. Implementing PKC in NICU settings will assist
fathers to care and connect with their baby. Further research is needed to explore how to
facilitate and evaluate KC education for fathers from diverse backgrounds and cultures.
Keywords: kangaroo care, skin-to-skin, fathers, neonatal, NICU, Evidence Based Midwifery
Introduction
Kangaroo care (KC) is often referred to as skin-to-
skin or kangaroo mother care (KMC). KC refers to
a method of holding an infant, naked (except for a
diaper/nappy), in an upright and prone position, skin-
to-skin, on a caregiver’s bared chest (Conde-Agudelo
& Díaz-Rossello 2016, Chen et al 2017).
KC was originally introduced at the Instituto
Materno Infantil in Santa Fede Bogotá, Colombia in
1978. The initial reason KC was introduced in this
maternity unit was due to a shortage of incubators;
the lack of incubators led to a study being undertaken
at the hospital. Lower neonatal mortality rates and
increased weight gain for low birth weight (LBW)
babies (that is, babies weighing less than 2500gms,
regardless of gestational age) were reported compared
to newborns receiving conventional care in an
incubator (Whitelaw & Liestøl 1994).
The World Health Organization (WHO) reported
that KC was a cost-effective method of achieving
optimised health outcomes for premature and full-
term babies (WHO 2003). It was acknowledged that
ABSTRACT
Dong Q, Steen M, Wepa D (2022). Fathers providing kangaroo care in neonatal intensive care units: a scoping review.
Evidence Based Midwifery 20(2): 20-36
20The Royal College of Midwives, Evidence Based Midwifery 20(2): 20-36
KC is a fundamental method of achieving thermal
control for preterm and LBW infants (WHO 2015).
Additionally, KC has been shown to reduce neonate
infection rates and hospitalisation length and enhance
maternal–infant bonding (Conde-Agudelo & Díaz-
Rossello 2016).
Babies in NICUs experience stress from numerous
interventions and separation from their mothers
(Stevens et al 2011). KC has been reported as
a primary method for mothers and babies to
complete an integral physiological process following
childbirth, while providing nurturing care (Jesus
et al 2015). Mothers have been recognised as the
main KC provider by health professionals in the
NICU environment (Jesus et al 2015). In contrast,
fathers are often referred to as ‘bystanders’ in the
engagement of maternal and neonatal care (Steen et al
2012). However, due to some societal, economic, and
cultural changes, there has been a steady increase in
the father’s role in providing care to their infant/child
(Yogman et al 2016).
Research has provided evidence that fathers have
an innate biological connection to their infants
similar to mothers (Yogman et al 2016). This
intrinsic connection enables father–infant KC to be
implemented and is benecial during the separation
of mothers and infants (Shorey et al 2016), thus
promoting and increasing KC practice in fathers
(Jesus et al 2015). Additionally, PKC has been found
to be associated with increased paternal involvement
(Jesus et al 2015) and an enhanced paternal role
(Varela et al 2018). Moreover, PKC has been shown
to have the same effect as KMC on preterm and term
infants’ physiological stability (Shorey et al 2016).
Current literature on KC mainly investigates or
explores mother and infant practices and experiences.
There seems to be a lack of research exploring PKC
(Martel et al 2016) and therefore a clear justication
to undertake a scoping review of the literature.
A scoping review examines a broad topic to identify
its volume, nature, and characteristics by mapping
the related evidence with the relevant time, location,
and origin, and detecting possible research-based
gaps (Peters et al 2015). This type of review is
suited to explore a unique and complex question
when research appears limited for a specic topic.
Therefore, this review used a scoping review
framework to guide the review approach, to identify
relevant studies to answer the research question
and to collect evidence in accordance with inclusion
criteria that incorporated core elements of Population,
Concept, Context (PCC) in a wide range of databases
(Peters et al 2020).
This framework recommends that ndings are
mapped, synthesised, presented narratively and
summarised in tables. The clinical implications
associated with PKC will be reported. It is envisaged
that this review will provide evidence to support the
practice of PKC in NICUs.
The aim of this review is to examine the literature
relating to research exploring the views and
experiences of fathers providing KC to their babies
while they are being cared for in NICUs.
Methods
Protocol and registration
A protocol was developed to guide the undertaking
of this scoping review (Dong et al 2021); the scoping
review framework described by Arksey & O’Malley
(2005) was used. According to the international
prospective register of systematic reviews
administered by the University of York’s Centre for
Reviews and Dissemination (PROSPERO), scoping
reviews do not meet the eligibility to be registered in
the database (University of York Centre for Reviews
and Dissemination n.d.). Therefore, no registration
was required for this review.
Research question
What impact does KC have on fathers when their
baby is cared for in an NICU?
Eligibility criteria
In this review, the search strategy approach to nding
studies was sought by utilising the core components:
Population, Concept, Context (PCC). The inclusion
criteria were aligned with the PCC components to
guide the undertaking of this review (Peters et al
2020).
Population
Fathers, including all age groups >18 years old,
from all geographical locations and all cultural
backgrounds were included. Infants included in this
review were referred to as neonates (that is, infants
under 28 days of age) from different geographical
areas with diverse cultural backgrounds. Babies who
were beyond the neonatal period were excluded.
Concept
The core concept examined by this review is the
experience of KC.
Context
The context of this review was mainly referred to as
NICUs. However, other relevant settings where PKC
might be practised were included, such as a Special
Care Baby Nursery (SCBU), delivery/labour room or
postnatal ward. =
The types of evidence searched
Given that little is known, or published, about PKC
the search timeframe was set from 2000 to 2020
(Peters et al 2020). The core content and type of
Dong Q, Steen M, Wepa D (2022). Fathers providing kangaroo care in neonatal intensive care units: a scoping review.
Evidence Based Midwifery 20(2): 20-36
21The Royal College of Midwives, Evidence Based Midwifery 20(2): 20-36
papers meeting the inclusion criteria associated with
the components of PCC were searched. Primary
studies using qualitative, quantitative, and mixed
methods were included. Only articles in English
were selected.
Information sources and search strategies
A wide range of literature searches was performed
in databases, registers, and some additional sources,
in October 2020. Databases involved MEDLINE,
Embase, the American Psychological Association
(APA), PsycInfo, Emcare. Registers include Cochrane
Central Register of Controlled Trials (CENTRAL)
and Clinical Trials.
The keywords and the Medical Subject Headings
(MeSH) terms used in MEDLINE are listed in
Table 1. The search strategy in MEDLINE is
provided as an example for replicability and
auditability (Peters et al 2020).
An additional search of grey literature was conducted.
The rst 200 articles (Bramer et al 2017) were
selected from Google Scholar under ‘Father kangaroo
care’. Theses and dissertations were searched in
the ProQuest platform. Other searches included
Web of Science, clinical guidelines, conference
abstracts, hand-searching through reference lists,
communication with peers or experts via media.
Study screen and selection
All the identied literature (n=1298) was exported
into the bibliographic software EndNote X9.0 and
duplicates were removed using the same software.
The duplicating process was double-checked by an
experienced librarian.
The initial selection was undertaken by screening
titles and abstracts with a second reviewer. The
further screening (n=38) was carried out by reading
the full text to obtain the articles which meet the
inclusion criteria. Clarications were sought with a
third reviewer to achieve consensus to nalise the
selected articles for the scoping review (n=13). The
search strategy is demonstrated using a PRISMA
2020 ow chart for transparency and reexivity
(Figure 1).
Data charting
Microsoft Excel software was used to record data
extracted from the 13 articles reporting a study
aligned with the research question. Data extraction
elds include author/s, year of publication, title of
publication, country of origin, type of study, aim/
objectives, methods, population and sample size,
setting, factors associated with PKC, impact of PKC,
limitations and strengths, clinical implications. Three
reviewers dened the extracted data, which are
shown in the Summary of included studies table
(see Supplementary information).
Results
A total of 13 studies met the inclusion criteria. Of
these, seven studies were reported to undertake
qualitative research (Fegran et al 2008, Blomqvist et
al 2012, Helth & Jarden 2013, Magee & Nurse 2014,
Jesus et al 2015, Olsson et al 2017, Günay & Coşkun
Şimşek 2021).
Five of the qualitative studies used a
phenomenological research approach (Fegran et al
2008, Blomqvist et al 2012, Helth & Jarden 2013,
Jesus et al 2015; Günay & Coşkun Şimşek 2021).
One qualitative study reported using a descriptive
approach (Olsson et al 2017) and the remaining study
was a case study (Magee & Nurse 2014).
Six studies were reported to conduct quantitative
research (Varela et al 2014, Mörelius et al 2015,
Cong et al 2015, Chen et al 2017, Varela et al 2018,
Dongre et al 2020). Quantitative studies included
ve experimental designs, two randomised controlled
trials (RCTs) (Mörelius et al 2015, Chen et al 2017),
one crossover study (Cong et al 2015), one quasi-
experimental study (Varela et al 2014), and one
pre- and post-observational study (Varela et al 2018).
No mixed methods studies were identied.
Figure 2 demonstrates an upward trend in the
number of studies undertaken on PKC between 2000
and 2020. Only one included study (Fegran et al
Dong Q, Steen M, Wepa D (2022). Fathers providing kangaroo care in neonatal intensive care units: a scoping review.
Evidence Based Midwifery 20(2): 20-36
Table 1. MEDLINE search strategy (literature search)
1. Fathers/
2. Father-Child Relations/
3. (father* or dad* or paternal* or parent*).ti,ab,kw.
4. 1 or 2 or 3
5. Infant, Newborn/
6. ((preterm or premature* or term or full term or low
birth weight or LBW or postnatal) adj4 (baby or babies or
neonatal* or infant$1)).ti,ab,kw.
7. 5 or 6
8. Kangaroo. Mother Care Method/
9. ((Kangaroo or Skin to Skin) adj5 (care or contact or
method)).ti,ab,kw.
10. 8 or 9
11. Intensive Care Units, Neonatal/
12. Postnatal Care/
13. Operating Rooms/
14. Nurseries, Hospital/
15. Delivery Rooms/
16. (NICU* or neonatal intensive care or neonatal care or
intensive care units or newborn icus or neonatal or
special baby care unit or SCBU or postnatal ward or
delivery room or labo?r ward or theatre or operating
room or recovery room or parenting room or birthing
center).ti,ab,kw.
17. 1 or 12 or 13 or 14 or 15 or 16
18. 4 and 7 and 10 and 17
19. Limit 18 to yr=“2000-2020”
22The Royal College of Midwives, Evidence Based Midwifery 20(2): 20-36
Dong Q, Steen M, Wepa D (2022). Fathers providing kangaroo care in neonatal intensive care units: a scoping review. Evidence Based Midwifery 20(2): 20-36
23The Royal College of Midwives, Evidence Based Midwifery 20(2): 20-36
Figure 1. PRISMA ow chart of the selected articles for scoping review Source: Adapted from Page et al (2021).
Included Screening Identification
Records screened
(n=378)
Records excluded**
(n=347)
Reports sought for retrieval
(n=31)
Reports not retrieved
(n=0)
Reports sought for retrieval
(n=8)
Reports not retrieved
(n=1)
Reports assessed for eligibility
(n=7) Reports excluded:
Reason: Non-English (n=3)
Reports assessed for eligibility
(n=31)
Reports excluded:
Reason 1: Commentary (n=1)
Reason 2: Reviews (n=3)
Reason 3: Proposal (n=2)
Reason 4: Non-English (n=2)
Reason 3: Uncompleted clinical
trial (n=3)
Reason 4: Wrong intervention
(n=11)
Studies included in review
(n=13)
Reports of included studies
(n=0)
Records identied from*:
Darabases (n=768)
Registers (n=99)
Records removed
before screening:
Duplicate records removed
(n=489)
Records marked as ineligible
by automation tools (n=0)
Records removed for other
reasons (n=0)
Records identied from:
Websites (n=200)
Organisations (n=216)
Theses and disertations (15)
Other searches (n=0)
Identification of studies via databases and registers Identification of studies via other methods
2008) was conducted between 2000 and 2009. Four
studies were published during the 2011–2014 period
(Blomqvist et al 2012, Helth & Jarden 2013, Magee
& Nurse 2014, Varela et al 2014). Eight studies were
published in the ve years from 2015–2020 (Cong
et al 2015, Jesus et al 2015, Mörelius et al 2015,
Chen et al 2017, Olsson et al 2017, Varela et al 2018,
Dongre et al 2020, Günay & Coşkun Şimşek 2021).
Figure 3 highlights the geographical distribution of
studies and demonstrates that northern European
countries conducted more studies for PKC.
Three studies were undertaken in Sweden, one in
the UK, one in Norway, and one in Denmark. Fewer
studies were conducted in the Mediterranean and
South East Asian regions: two in India, one in Turkey.
One study was conducted in a Far East Asian country:
Taiwan. Only one study was completed in Canada
and one in the United States of America (USA). None
have been undertaken in Australia.
The data relevant to factors associated with PKC
are detailed in the Factors associated with father KC
table (see Supplementary information) which shows
the length of KC, the facilities/aids for KC, and the
cultural and policy background.
In Sweden, single-family rooms with beds were
available in NICU settings. Parental leave and
allowance enabled fathers to spend more time
implementing KC. Blomqvist et al (2012) showed that
fathers had KC with their babies for up to 24 hours
a day, and 7–19.6 hours a day was reported in the
study by Mörelius et al (2015).
In regions where fathers had to manage most of the
family’s nancial responsibilities, KC duration was
between 15–90 minutes (Varela et al 2014, Cong et al
2015, Chen et al 2017, Varela et al 2018, Dongre et al
2020, Günay & Coşkun Şimşek 2021). The cot-side
chair provided for KC was reported in four studies
(Cong et al 2015, Chen et al 2017, Varela et al 2018,
Günay & Coşkun Şimşek 2021). However, three
studies did not report on the provision of this aid
(Helth & Jarden 2013, Magee & Nurse 2014, Jesus
et al 2015).
The data related to clinical implications in the Factors
associated with father KC table (see Supplementary
information) demonstrate that ve studies reported
that staff educated fathers about KC (Blomqvist et al
2012, Magee & Nurse 2014, Jesus et al 2015, Chen
et al 2017, Günay & Coşkun Şimşek 2021). One
study (Blomqvist et al 2012) described a care plan
to promote and support fathers to provide KC. One
study (Fegran et al 2008) recommended mother’s
encouragement, and another study (Günay & Coşkun
Şimşek 2021) established policies to support PKC
practice. Interestingly, Varela et al (2014) reported
less KC practice in a single room than in the open
intensive care room.
Table 2 highlights which studies reported which
impacts of PKC, including enhancement of paternal
role and initiating and strengthening the father-infant
bond.
An important nding was that increasing fathers’
competence and affection was associated with a
reduction of paternal stress and anxiety. Additionally,
two studies (Jesus et al 2015, Olsson et al 2017)
reported that the father’s role was promoted as a
primary carer in certain circumstances, when the
mother was not available. Other ndings included
promoting the relationship between fathers and
mothers; Dongre et al (2020) also showed KC
to be an excellent opportunity to establish better
communication between fathers and NICU staff.
Collectively, these ndings indicate clear benets
associated with PKC. However, Olsson et al (2017)
reported that KC was an energy-draining practice,
and sometimes led to guilty feelings because of
spending less time with other siblings. Helth & Jarden
(2013) highlighted fathers’ conict between working
and spending time with the infant. However, Jesus
et al (2015) found that KC was a valuable learning
experience for fathers, and this was conrmed by
Olsson et al (2017).
Dong Q, Steen M, Wepa D (2022). Fathers providing kangaroo care in neonatal intensive care units: a scoping review.
Evidence Based Midwifery 20(2): 20-36
Figure 2. Publication year of the journals containing
selected studies
Figure 3. Geographical distribution of the selected studies
24The Royal College of Midwives, Evidence Based Midwifery 20(2): 20-36
Discussion
As far as the authors are aware, this is the rst
scoping review undertaken to search current literature
relating to fathers’ experiences of providing KC to
their baby in an NICU.
The 13 included studies for this review were
undertaken in various geographical regions. The
researchers acknowledge that clinical and cultural
neonatal variations in NICUs and other neonatal care
settings need to be considered. Fathers being involved in
their infant’s care will vary throughout the world and,
generally speaking, most societies continue to recognise
mothers as the primary caregiver. However, over the last
few decades, there has been increasing involvement and
caregiving by fathers (Steen et al 2012).
A specically designed website (www.familyincluded.
com) provides information on studies undertaken
around the globe where fathers and families are
being researched, and there appear to be several
benets when they are engaged in infant care. There
is also a useful website for fathers to access (www.
birthingdads.com.au).
Reecting on this review, it highlights that there has
been a growing interest in fathers’ experiences of
KC, mostly from northern European countries, but
some research has also been undertaken in North
America, Canada and in the Mediterranean, South
East and Far East Asian regions. Nevertheless, it has
been recommended that further research and studies
that involve more diverse backgrounds are required
(Magee & Nurse 2014).
The collective evidence from this review conrms
that there are health and wellbeing benets when
PKC is undertaken, and this conrms earlier ndings
reported in an integrative review by Shorey et al
(2016). These researchers concluded that PKC had
positive effects on understanding the father’s role,
promoting improved paternal interaction with infants
and reducing paternal stress.
Over the last few decades, fathers’ involvement in
childcare has been increasing and is associated with
the dual-income family structure that has evolved
from a transformation of the socio-economic
environment (Faris 2016). The responsibilities
pertaining to the father’s role include involvement
in childcare and inuencing the child’s physical and
mental development (Varela et al 2014, Yogman
et al 2016).
PKC can provide fathers with an opportunity to gain
caregiving skills and connect with their baby, which is
supported by Varela et al’s (2014) study conducted in
India. These researchers reported that fathers with KC
experiences showed a more empathetic and emotional
connection to their child. Fathers with a baby in an
NICU are at increased risk of developing anxiety
and depression (Givrad et al 2021): the practice of
KC may assist fathers to manage anxiety and stress
when caring for their newborn in an NICU (Magee &
Nurse 2014, Mörelius et al 2015, Olsson et al 2017).
Feeling competent as a father will also contribute
to fathers’ health and wellbeing (Fegran et al 2008,
Blomqvist et al 2012, Helth & Jarden 2013, Magee
& Nurse 2014, Varela et al 2014, Varela et al 2018,
Günay & Coşkun Şimşek 2021).
Adamsons & Johnson (2013) reported that positive
father involvement in a child’s upbringing may
enhance academic achievement, emotional wellbeing,
and social behaviours. Garnica-Torres et al (2021)
suggested that the attainment of fatherhood is
driven by men’s emotions and mental wellbeing.
PKC appears to assist fathers to review their views
about fatherhood and acts as a lived workshop
about becoming a father, as described by Olsson et
al (2017). This review found evidence to suggest that
PKC supported fathers in connecting and bonding
with their infants, which positively impacted fathers’
condence and self-esteem when engaging in their
baby’s care in an NICU environment.
These key ndings conrm research by Logan &
Dormire (2018) who conducted semi-structured
interviews with seven fathers about the experience of
caring for their premature babies in the rst weeks in
an NICU and reported that KC played a critical role
in connecting to their infant.
According to John Bowlby’s evolutionary concept of
attachment theory, infants seek proximity gures that
respond to their stress behaviours, such as crying,
to help them survive (McLeod 2017). By acting as
a caregiver, fathers could instinctively enable the
father–infant attachment to be established, and
Dong Q, Steen M, Wepa D (2022). Fathers providing kangaroo care in neonatal intensive care units: a scoping review.
Evidence Based Midwifery 20(2): 20-36
Table 2. Categories of impact of father KC on fathers by study
The impact of father KC on fathers Study
Initiating and strengthening father–
infant bond
S1, S2, S3, S6, S7, S9,
S11, S12
Enhancement of paternal role S1, S6, S7, S8, S9, S10,
S11, S12, S13
Feeling in control S9, S10, S11
Improvement of competence as a
father
S1, S6, S7, S8, S9, S12,
S13
Reduction of paternal stress or
anxiety
S1, S5, S6, S7, S11, S13
Aection S1, S2, S7, S8, S11
Better communication between
fathers and NICU sta
S5
Promotion of family relationships S2, S4, S5, S10
KC information availability S2, S11
Acting as a primary carer (motherly
role)
S1, S9
Energy-draining, feeling guilty
about other siblings at home
S1, S11
Conict between working and
spending time with their infant
S8
25The Royal College of Midwives, Evidence Based Midwifery 20(2): 20-36
then a reciprocal interaction between them might
be created. This physiological relationship between
fathers and infants was also illustrated by Bloch-
Salisbury et al (2014). They reported that premature
infants’ respiratory stability corresponded to the KC
providers’ cardiac rhythm during KC sessions and
babies were calmer.
Interestingly, bonding between fathers and babies
often occurs during pregnancy. Genesoni (2009)
found that fathers psychologically bonded to
their babies in the rst trimester of their partner’s
pregnancy. However, during the childbirth continuum,
fathers are often seen as a ‘bystander’ and receive
education and information ‘second-hand’ (Steen et
al 2012). Nevertheless, the NICU environment may
provide opportunities to promote the father–infant
bond and connection by supporting the practice
of PKC.
Theoretically, close touch between fathers and infants
through KC activates the hypothalamic-pituitary-
adrenal axis stress system to produce oxytocin, which
leads to decreased levels of cortisone, also referred
to as a stress predictor (Cong et al 2015). This
reduction in stress was clearly shown by Varela et
al (2018). These researchers collected saliva samples
from fathers and reported a signicant reduction
in cortisone level one-hour post-KC compared to
before and during KC. Interestingly, Cong et al (2015)
found similar results in their crossover study: fathers’
oxytocin level was raised after KC and maintained
at the same high level for 30 minutes after KC.
Hence, the stress-free advantage produced by KC
might act as a catalyst to enhance the paternal role,
as highlighted by Blomqvist et al (2012). Evidence
to support the promotion of PKC in NICU settings
appears to be emerging over the last decade.
In some circumstances if a mother is unavailable
as the result of a critical medical condition, such
as following an emergency caesarean section,
the father is available and can provide PKC. The
benets of PKC were also clearly shown in the case
study reported by Magee & Nurse (2014). These
researchers discussed how a bereaved father cared
for his premature daughter in the NICU when her
mother died nine days after giving birth. Therefore,
health professionals may advocate KC to fathers to
maximise the facilitation of KC.
Nevertheless, this review detected some negative
impacts associated with PKC. Some fathers reported
that providing KC to their newborn baby was time-
consuming and it was perceived by some as an
energy-draining task (Blomqvist et al 2012, Helth
& Jarden 2013, Olsson et al 2017). The negativity
reported might be related to prolonged KC events
and nding time for KC from the father’s multiple
responsibilities: being a father and a supporter for
mother or an economic provider. One issue that
surfaced was that fathers’ involvement in providing
KC led to an imbalance between working and family
life (Helth & Jarden 2013, Garnica-Torres et al
2021). Another was that fathers felt guilty about
spending less time with other siblings at home when
providing KC for their newborn baby in the NICU
(Blomqvist et al 2012, Olsson et al 2017).
These negative impacts might be associated with
socio-cultural factors and variations in health policies
in different geographic areas. In some European
countries, where NICU facilities/aids included single
rooms with a bed and leisure equipment, parents
are well-supported to offer their infants KC for up
to 24 hours a day (Blomqvist et al 2012). Paternal
leave enables fathers to be available for KC provision
(Blomqvist et al 2012, Mörelius et al 2015). In
contrast, parental leave is not provided in some
countries, which impacted the availability of fathers.
This nding is consistent with the studies reported by
Garnica-Torres et al (2021) and Günay & Coşkun
Şimşek (2021).
Mixed reports of facilities/aids and support for
fathers to provide KC appears to be the current
situation. Comfortable chairs and single rooms might
help. Paid paternal leave could be advocated by the
local government to reduce the nancial burden
and create more opportunities for fathers’ to be
available. Negative outcomes might be circumvented
by designing a PKC care plan to support fathers who
wish to conduct KC with their infant (Blomqvist et
al 2012) and introducing a exible approach to the
length of time for which KC is provided. Care plans
for PKC may promote more positive experiences for
fathers while their infant is in a NICU setting and
address the negative aspects raised by some fathers.
As for clinical implementation, the ndings of this
review have demonstrated that PKC enhances couple
and family relationships (Cong et al 2015, Jesus et al
2015, Mörelius et al 2015, Dongre et al 2020) and
is therefore worthy of support for the practice. This
positive outcome on relationships may be explained
by a pattern of an interlinked inuence circle of
mother to child, child to father and father to mother,
where the father–child bond that emerges from the
involvement in PKC plays a pivotal role in linking
the relationship between family members (Lindsey
& Caldera 2006). The improved interaction reported
between fathers and nursing staff associated with
PKC (Dongre et al 2020) provides an opportunity
for nurses and midwives to understand the fathers’
perspective to help them communicate more
effectively. Improved communication with a father
will promote better engagement in their infant’s care
while in the NICU (Cong et al 2015).
Some studies mentioned education for PKC, and this
seems to have had a positive outcome on supporting
fathers to undertake the practice (Helth & Jarden
2013, Mörelius et al 2015, Chen et al 2017, Olsson et
al 2017, Günay & Coşkun Şimşek 2021). Therefore,
Dong Q, Steen M, Wepa D (2022). Fathers providing kangaroo care in neonatal intensive care units: a scoping review.
Evidence Based Midwifery 20(2): 20-36
26The Royal College of Midwives, Evidence Based Midwifery 20(2): 20-36
it appears that providing PKC education to fathers
before, or shortly after, admission of their infant to
an NICU would be advantageous. However, further
studies on educating and mentoring fathers to provide
KC in NICUs are required.
Strengths and limitations
A strength of this review is that a protocol was
developed, and rigorous steps were undertaken to
identify relevant quantitative and qualitative studies.
A scoping of the literature was undertaken and PKC
in NICU settings is a topic currently emerging as an
area of interest. However, the included studies were
limited to some countries and therefore, may not be
generalisable to a global population. A limitation
is that the reviewed articles were only written in
English, and therefore studies written in other
languages may have been missed.
Some quantitative studies’ sample sizes were small
and underpowered and further larger studies are
required. No longitudinal studies were reported, and
this is a limitation. Most qualitative studies used a
phenomenological approach and further studies may
benet from using an ethnographic design where
the NICU environment, staff and fathers may all be
considered and participate in the research. Mixed-
method studies may also contribute to providing
further evidence for PKC in NICU settings.
Conclusion
Research evidence to support PKC in NICU settings
is emerging and this review has provided and
consolidated current literature evidence by answering
the research question: what impact does KC have upon
fathers when their baby is cared for in an NICU?
This review has shown that there are health and
wellbeing benets for fathers and their babies when
PKC is undertaken in NICUs and other clinical
settings. The ndings from this review provide some
evidence to support the implementation of PKC in
NICUs and other clinical settings and will inform
policies and clinical practices in countries where
paternal involvement is evolving. Paid paternal
leave may reduce nancial burdens and create
more opportunities for fathers to be available to
provide PKC.
Adopting a exible approach strategy for the length
of time to provide PKC that meets individual father’s
and their baby’s needs may enhance the experience.
Care plans for PKC may promote more positive
experiences for fathers while their infant is in an
NICU setting and address the negative aspects raised
by some fathers.
Further research is needed about how, and what, to
provide to fathers in terms of KC education and the
evaluation of PKC care plans. Fathers from a wide
range of diverse backgrounds need to be included in
further research studies to enable an international
perspective to be investigated and explored in
more depth.
Acknowledgments
The authors acknowledge the support of Upeksha
Amarathunga and Natalie Dempster, librarians
respectively from the University of South Australia
and the Women’s and Children’s Hospital, Adelaide,
South Australia, who assisted with the database
searches. The authors are also grateful to Dr Trudi
Mannix for helpful comments when writing up
this review.
Conict of interest
The authors declare that they have no conict
of interest.
Funding
This research is being funded by an Australian
Government Research Training Program (RTP).
Authors
Corresponding author
Qiuxia Dong RN Dip(Nur), BMed(Nur), Master
Candidate, Neonatal Intensive Care Unit of Women’s
and Children’s Hospital, Adelaide, Australia. Masters by
Research student at the University of South Australia,
Australia. Email: qiuxia.dong@mymail.unisa.edu.au or
qiuxia.dong@gmail.com.
Co-authors
Professor Mary Steen PhD, RGN, RM, DipClinHyp, BHSc,
PGCRM, PG Dip HE, MCGI, Professor of Midwifery,
Dept of Nursing, Midwifery and Health, Faculty of
Health and Life Sciences, University of Northumbria,
United Kingdom; Adjunct Professor at University of South
Australia, Australia; Clinical & Health Sciences, University
of South Australia, Australia.
Dr Dianne Wepa PhD BSW, MPhil, Cert Adult Learning
& Teaching, Cert Clinical Supervision, PhD, AMHSW,
Associate Professor Mental Health, School of Nursing
& Healthcare Leadership, Faculty of Health Studies,
University of Bradford, United Kingdom; Adjunct research
fellow at University of South Australia, Australia; Clinical
& Health Sciences, University of South Australia, Australia.
Dong Q, Steen M, Wepa D (2022). Fathers providing kangaroo care in neonatal intensive care units: a scoping review.
Evidence Based Midwifery 20(2): 20-36
27The Royal College of Midwives, Evidence Based Midwifery 20(2): 20-36
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Dong Q, Steen M, Wepa D (2022). Fathers providing kangaroo care in neonatal intensive care units: a scoping review.
Evidence Based Midwifery 20(2): 20-36
29The Royal College of Midwives, Evidence Based Midwifery 20(2): 20-36
Dong Q, Steen M, Wepa D (2022). Fathers providing kangaroo care in neonatal intensive care units: a scoping review. Evidence Based Midwifery 20(2): 20-36
30The Royal College of Midwives, Evidence Based Midwifery 20(2): 20-36
Supplementary information
Summary of included studies
Author(s)/year/
country
Type of study Aim/objectives Methods Population and sample size Settings Fathers’ demographic
prole
S1 Blomqvist et al
2012, Sweden
Qualitative
descriptive study
- Phenomenology
To describe
fathers’
experiences of
providing KC to
their preterm
infant
Data collection: questionnaires
completed by fathers while their babies
were in hospital; individual semi-
structured interviews at four months ±
two weeks post-discharge; data analysis:
using qualitative content analysis
described by Grameheim & Lundman
(2004)
Inclusion criteria: fathers
whose babies were born at the
gestational age of 28 to 33 + 6
weeks and medically stable.
Sample size: x 7
Level 3 NICUs at two
Swedish hospitals
Age range: 34 to 42
years old, 56.6% rst-
time fathers
S2 Jesus et al 2015,
Brazil
Qualitative
descriptive study
- Phenomenology
To identify
father’s
perceptions
about KC; to
explore how
nurses could
foster the father-
child relationship
Data collection: semi-structured
interviews through open and closed
questions; data analysis: using content
analysis
Inclusion criteria: fathers who
were 1) biological parents of
premature infants and/or low
birth weight; 2) Fathers over 18
years of age; 3) Experiencing
Kangaroo Care; 4) Interest
participate
Sample size: x6
Maternal hospitals
x 2, Brazil, no wards
specied
Not reported
S3 Chen et al 2017,
Taiwan
Quantitative
study - RCT
To observe the
eects of KC
on father-child
attachment
Pilot study performed: intervention
group ( = 3) control group ( = 3);
Data collection: computer program
generated a random stratied
allocation. Intervention group: KC
provided for at least 15 minutes/for the
rst three days of life; control group:
received standard care, KC provided
at fathers’ request; Both groups
received KC information on admission.
Data collection: instruments used:
Demographic Information Survey; Early
Childcare for Fathers, Nursing Pamphlet;
Father-Child Attachment Scale (FCAS)
developed by Yang & Chen (2001): self-
reported by fathers; Data analysis: SPSS
and Windows 20.0
Inclusion criteria: 1) new fathers;
2) older than 20 years old; 3) at
the hospital daily until discharge;
4) non-smokers; 5) not have
an alcohol addiction or be
diagnosed with a psychological
disorder; 6) signed an informed
consent agreement; 7) babies of
gestational age ≥ 37 weeks, stable
vital signs and no congenital
abnormalities or diseases. Sample
size: total n=83 participants:
intervention group (n=41) and
control group (n=42)
Postnatal ward in a
teaching hospital,
maternal clinic in
Taiwan
Age range: 34 to 42
years old, 56.6% rst-
time fathers, 50.6%
college education,
85.5% antenatal class
attendance
S4 Cong et al 2015,
USA
Quantitative
study - Crossover
study
To examine
oxytocin
mechanism in
modulating
parental stress
and anxiety
during M-KC
and paternal KC
(P-KC) with their
preterm infants
Data collection: the mother-father-
infant triad was assigned randomly by a
computer-program to study sequences:
M-KC on day 1 and P-KC on day 2 or vice
versa. Process: parents’ saliva collected
using a standard unstimulated passive
drool method and a validated visual-
analog scale (VAS) measuring anxiety
and self-reported at the end of the
period of pre-KC (10mins), during-KC
(30 mins) and post-KC (30 mins) phases.
Data collection: measurements: salivary
oxytocin assay, salivary cortisol, parental
anxiety; Data analysis: Using IBM SPSS
20.0 (Armonk, NY)
Used a convenience sampling
approach. Power analysis to
determine the sample size.
Inclusion criteria: parents were >
18 years old, with no depression
history, whose babies were the
gestational age of 30-34+6 weeks
@ the age of 3-10 days, cared for
in an incubator, NPO or on bolus
feeds. Sample size: 26 triads.
Sequence 1 (M-KC on day -1 and
P - KC on day - 2), n=14; Sequence
2 (P-KC on day -1 and M - KC on
day - 2), n=12; mothers: n=26;
fathers: n=19
A level IV NICU in
Connecticut, USA
68% of fathers were
white, 79% with higher
education, 53% had
KC experience before
study participation
S5 Dongre et al
2020, India
Quantitative
study -
Prospective
observational
study
To study stress
in fathers after
initiation of KC
Data collection: total study period:
6 months. Demographic details
collected. Likert type scale was rated by
participants before KC, Parental Stressor
Scale: neonatal intensive unit (PSS
NICU) were used to assess fathers’ stress
level in 5 aspects after KC X 3 on the
consecutive days; Data analysis: SPSS
software version 16, Wilcoxon signed
rank-sum test
Inclusion criteria: fathers with
no major medical and surgical
illnesses, whose babies were
at the gestational age of 28-35
weeks, birth weight < 1500 grams,
not ventilated, no congenital
abnormalities. Sample size: n =30
A tertiary level neonatal
unit, India
Mean age: 28.5 years
old; 63.2% of fathers
were lower-middle
socio-economic class
S6 Fegran et al
2008, Norway
Qualitative
- descriptive
Phenomenology
- hermeneutic
approach
To obtain
in-depth
knowledge
of, and to
compare parents’
individual
experiences of
the attachment
process
immediately
after a premature
birth.
Data collection: interviews with
mothers and fathers individually.
Interview length: 40 minutes. Interview
audiotaped. Demographic data
collected. Data analysis: NUD*IST
computer software ORS used.
A convenience sample of parents.
Inclusion criteria: Parents of
infants at the gestational age of
27 to 32 weeks, staying at the
same hospital with their infants
from birth until discharge. Sample
size: 6 parents
A 13-bed NICU in a
regional Norwegian
hospital
Age range: 27 - 59
years old
S7 Günay & Coşkun
Şimşek 2021,
Turkey
Qualitative
descriptive study
- Phenomenology
To investigate
the emotions
and experiences
of fathers in
Eastern Anatolia
region of Turkey
who experienced
KC in the NICU.
Data collection: face-to-face, audio-
taped, individual interviews were
conducted for 45-50 minutes at two
weeks after experiencing KC from
January to May 2019. Questions X 2,
open-ended. Data analysis: inductive
qualitative content analysis by
Graneheim & Lundman (2004)
Inclusion criteria: Fathers whose
babies were at the gestational age
of 27 to 36 weeks, birth weight
≥1000 grams, who visited their
babies regularly and experienced
KC. Sample size: fathers x 12
NICU in a training and
research hospital in the
Eastern Anatolia region
of Turkey
Mean age: 29.7 years
old; First-time fathers x
6; education: primary
to university; fathers x
5 from village
Dong Q, Steen M, Wepa D (2022). Fathers providing kangaroo care in neonatal intensive care units: a scoping review. Evidence Based Midwifery 20(2): 20-36
31The Royal College of Midwives, Evidence Based Midwifery 20(2): 20-36
S8 Helth & Jarden
2013, Denmark
Qualitative -
Phenomenology
- hermeneutic
approach
To explore
how fathers
of premature
infant’s
experience
and potentially
benet from
experiencing
KC during their
infants’ stay in
NICU.
Data collection: Semi-structured
interviews for 30-45 mins. Data analysis:
Theoretical framework by Kvale and
Brinkman (2009).
Inclusion criteria:1) Danish-
speaking fathers, 2) Infants at the
gestational age < 35 weeks, @
stable condition, 3) Admission to
the NICU > 1 week; Sample size:
Purposeful sampling, fathers x 5
Copenhagen University
Hospital, Hvidovre
Hospital, Denmark.
Age: range: 28-37 years
old, university degree
x 3, employed x 4,
student x1, all rst-time
fathers, twins X1
S9 Magee & Nurse
2014, UK
Case study -
Reective study -
Qualitative study
To explore
the nurse’s
role acting as
an eective
advocate for the
baby and the
role of the father
in the neonatal
unit
Data collection: reective study for a
case of a bereaved father who cared for
his premature daughter in the NICU;
Data analysis:Framework Guiding
Reective Activities by Borton’s model
(1970)
Father x 1, a bereavement father NICU x 1 in UK A father whose wife
passed away nine days
after birth of breast
cancer, carried family
commitments
S10 Mörelius et al
2015, Sweden
RCT -
Quantitative
study
To compare the
eects of almost
continuous KC
(CKC) on salivary
cortisol, parental
stress, parental
depression, and
breastfeeding
with standard KC
(SKC)
Data collection: Apr 2008-Apr 2012, An
RCT between two groups of parents;
one group experiencing KC and the
other experiencing SKC. Continuous
KC: almost 24 hours a day, baby stayed
with parents since birth. Standard
KC: separate from parents after
the birth of a baby. Measurements
were collected at discharge during
home-visit at CA of 1 and 4 months.
Medical data was collected from
the parents’ journal. Measurements
included: salivary cortisol, Swedish
Parenthood Stress Questionnaire (SPSQ)
Edinburgh Postnatal Depression Scale
(EPDS), Questions about health and
breastfeeding, Ainsworth’s Sensitivity
scale; Data analysis: statistical software
SPSS 20.0
Inclusion criteria: mothers -
healthy, procient in Swedish,
give birth to a single child who is
at the gestation age of 32 to 35
weeks; Sample size: families x 42,
CKC: 23, SKC: 19
Level 3 NICU x 1 and
Level 2 NICU x1, in
Sweden
Not reported
S11 Olsson et al
2017, Sweden
Qualitative
descriptive study
To describe
fathers’
experiences of
KC with their
premature infant.
Data collection: between January 2014
and June 2015, eligible fathers were
interviewed using a semi-structured
interview guide. Data analysis: direct
qualitative content analysis by Hsieh &
Shannon (2005)
Inclusion criteria: fathers of
preterm infants, had provided
KC for their infants on at least
one occasion. Sample size: a
purposeful sample. Fathers x 20
Neonatal units x 2 (one
in a county hospital,
the other in a university
hospital) in central
Sweden
Mean age: 32 years old.
6/20 fathers had more
than two children
Dong Q, Steen M, Wepa D (2022). Fathers providing kangaroo care in neonatal intensive care units: a scoping review. Evidence Based Midwifery 20(2): 20-36
32The Royal College of Midwives, Evidence Based Midwifery 20(2): 20-36
S12 Varela et al
2014, India
Quantitative
study - quasi-
experimental
design - a pilot
study
To evaluate the
impact of KC
on the sensitive
care that fathers
provided to
their premature
babies in 5
Kangaroo
Mother Care
programs in
India.
Data collection: socio-demographic
survey completed. The Kangaroo
position adherence survey was
conducted to assign participants into
two groups: intervention group (KC)
and control group (non-KC). Paternal
sensitive behaviour and perception
of paternal role assessed by two
people, using a Q-Sort methodology
during a 60-minute period of KC. Data
analysis: SPSS 17.0 for Windows, a non-
parametric statistical test: the Mann-
Whitney U, T-tests, and a Cohen’s d.
Inclusion criteria: fathers of
preterm infants. Intervention
group: n=14; Control group: n=23
Hospitals x 5 in India;
No details of clinical
setting/wards
Age range: 25-48 years
old. Education level:
up to high school.
Spouse: the majority
were classied as a
housewife and related
to both families.
Not all fathers were
procient in English;
for fathers who did not
speak English, a local
translator served as an
interpreter
S13 Varela et al
2018, Canada
Quantitative
study -
Pre- and Post-
investigation
To explore the
physiological
stress responses
of fathers during
their rst KC with
their new baby.
Data collection: salivary cortisol
measured from 6 saliva samples and
simultaneous blood pressure and heart
rate measured on arrival in the room,
immediately before starting KC, at 30
minutes and 60 minutes into KC, and 15
and 30 minutes after the end of KC. Data
analysis: SPSS statistics version 21.0
Inclusion criteria: fathers who
were in a relationship with the
infant’s mother, no anxiety or
depression, whose babies’ GA
was up to 33+3 weeks, medically
stable. Sample size: fathers x 49
The NICU of the
University Laval
Hospital Centre’s
pediatric department in
Quebec City, Canada
Mean age: 31 years old;
Mean education level:
14.1 years of education;
Mean working hours/
week: 43.3
Dong Q, Steen M, Wepa D (2022). Fathers providing kangaroo care in neonatal intensive care units: a scoping review. Evidence Based Midwifery 20(2): 20-36
33The Royal College of Midwives, Evidence Based Midwifery 20(2): 20-36
Factors associated with father KC
Factors associated with father KC Findings of impact of father KC on fathers Strengths and
limitations
Clinical
implications
KC frequency &
duration
KC facilities/aids Culture and
policies
KC
education
Forming and
strengthening
father–infant
bond
Enhancing
paternal
role
Decreasing
paternal
emotional and
physiological
stress
Promoting
relationship
between
fathers
and family
members
Negative
impacts
S1 Up to 24 hours/
day
Cot-side beds
or recliners plus
privacy screen;
Co-care rooms
containing beds
Parents
post-partum
allowance -
Parental leave
up to 480 days/
child + NICU
temporary
parental leave
Nil 3 3 3 Not
reported 3Adequate
sample size
used, rigour and
trustworthiness
achieved,
theoretical
saturation
achieved
Early KC education
needed. Father KC
could be initiated as
early as after birth.
Care plan would
help in increasing
the frequency of
Father KC
S2 Not reported Not reported Not reported Nil 3 3 3 Not
reported
Not
reported
No demographic
details of
participant.
Transparent data
collection and
analysis
Nurses can
promote Father KC
by explaining the
purpose of KC and
the benets of KC
to baby, father, and
mother
S3 Once a day. At
least 15-min
session
An armchair with
a footrest, a pillow
and a blanket,
private screen
provided
Traditional
women’s
connement
after birth;
workforce
limitations; KC
session provided
after 2 hours of
feeding and a
bath
KC
information
(pamphlets)
provided on
admission
3Not
reported
Not reported Not
reported
Not
reported
Workforce
limitations
stopped the
provision of
personalised
instruction to the
participants.
Father KC is
recommended
when mother is
not available. KC
education should
be started as early
as during childbirth
education and
antenatal period
S4 30-min session A La Fuma recliner
chair, a footrest, a
privacy screen, a
hospital gown, a
blanket
Study was
undertaken
at 1-3 pm,
between feeds,
after parent’s
lunch, and with
consideration
of the timing of
mother’s milk
expression
Not reported Not reported Not
reported 3 3 Not
reported
Small sample
size
Paternal touch
will contribute
to parenting
development
S5 90-min KC
episode for 3
consecutive days
Not reported Not reported The benets
and method
of KC were
taught by
a senior
registrar
Not reported Not
reported 3 3 3 Limited KC
application
length; No
consideration
about other
relevant paternal
stress stimuli,
e.g., nancial,
physical, and
social factors;
singleton
context, small
sample size
Not reported
S6 Not reported Not reported Not reported Not reported 3 3 3 Not
reported
Not
reported
The method
of collecting
demographics
was not
mentioned. A
small sample.
Triangulation of
data collection
Father KC was
promoted
by mothers’
encouragement
Dong Q, Steen M, Wepa D (2022). Fathers providing kangaroo care in neonatal intensive care units: a scoping review. Evidence Based Midwifery 20(2): 20-36
34The Royal College of Midwives, Evidence Based Midwifery 20(2): 20-36
S7 KC x 2/day for
15 days, each KC
lasted for 15 - 30
min
A comfortable chair
provided next to an
incubator
Turkish culture
requires men to
return to work
early due to the
traditional role
of the male in
this society, i.e.
nancial support
and limited role
in caring for
children
PowerPoint
presentation
+ A
handbook
about KC
process
3 3 3 Not
reported
Not
reported
Transparent data
collection and
analysis process
Health professionals
should encourage
father–infant
KC. The hospital
facilities/aids and
policies need to
be established to
facilitate father KC
S8 Not reported Not reported Not reported KC method
introduced
Not reported 3Not reported Not
reported 3Small sample
size. Credibility
was increased
by using direct
quotations.
Future studies on
the importance
of the father’s
presence in the
early infant’s life
Parents, nurses,
midwives, and
hospital services
need to recognise
that fathers can
participate equally
in parenthood
S9 KC practised
every second
day; KC duration
not mentioned.
Not reported Not reported Not reported 3 3 Not reported Not
reported
Not
reported
The ethical
approval was
unclear
No visiting
restriction for
NICUs. NICU
nurses/midwives
should give fathers
education in
advance about
the NICU father’s
experience
S10 SSC: 19.6 hours/
day; SC: 7.0
hours/day
Single rooms
equipped
with beds for
parents, medical
equipment.
KC accessories
provided such as
tube tops, scarves,
and blouses
KC is standard
care for both
parents in these
NICUs; the
Swedish health
care system
allows parents to
stay in the NICU
as long as they
can
KC method
was
introduced
before the
study. A
lesson was
given about
noticing and
responding
to their
preterm
baby’s signals
Not reported 3Not reported 3Not
reported
No comparison
with a baby who
has no KC from
parents as KC is
routine care in
their NICU
If both parents
engage after the
birth of preterm
infants, this can
strengthen the
relationship
between the
parents
Dong Q, Steen M, Wepa D (2022). Fathers providing kangaroo care in neonatal intensive care units: a scoping review. Evidence Based Midwifery 20(2): 20-36
35The Royal College of Midwives, Evidence Based Midwifery 20(2): 20-36
S11 Median times: 18
(4-80) min
Cot-side in the
intensive care
room with a private
screen; a bed in
the family rooms;
television
The Swedish
parental
allowance
system allows
fathers and
mothers to stay
with the infant
in the NICU
and provide
KC to him/her
while receiving
nancial
compensation
Information
about the
benets of
KC was given
by the NICU
sta
3 3 3 Not
reported 3Trustworthiness
(conrmability,
credibility,
transferability)
was achieved.
Triangulation of
data collection
methods
(interviewers X 2)
NICU sta need
to identify the
father’s individual
KC preference to
advocate equal
parenthood. Less
KC practised in
single rooms
than in the open
intensive care room
S12 1 hour/day for at
least 1 week.
Not reported The father is not
the primary carer
in India. Fathers
do not live with
mothers during
the rst months
after giving birth,
mothers live with
their mothers.
Many Indian
families have a
preference for
boys over girls.
Well-structured
KC programs
+ a pediatric
follow-up. KC
was provided
by fathers once
premature
infants had
adapted to
extra-uterine life
and were able to
breastfeed
Not reported 3 3 Not reported Not
reported
Not
reported
Small sample.
Language
interpretation
bias existed
during data
collection due to
using a language
translator.
Triangulation
data collection
Father KC provides
opportunities for
fathers to increase
their paternal
role in a culture
where this is not
recognised. Fathers
did not display any
gender preference
S13 1 hour The room contained
less than six
incubators equipped
with comfortable
chairs
Fathers were
asked not
to consume
nicotine, caeine,
food, or drugs
for at least one
hour before their
arrival to the NICU
Not reported Not reported Not
reported 3Not
reported
Not
reported
No control group
were involved in
this study due
to the lack of
consensus from
the clinical team
Not reported
Dong Q, Steen M, Wepa D (2022). Fathers providing kangaroo care in neonatal intensive care units: a scoping review. Evidence Based Midwifery 20(2): 20-36
36The Royal College of Midwives, Evidence Based Midwifery 20(2): 20-36
Article
Full-text available
To explore fathers' views and experiences of providing Kangaroo Care (KC) to their baby cared for in a Neonatal Intensive Care Unit (NICU). Kangaroo Care has been known to improve the health outcome for preterm, low birth weight and medically vulnerable term infants and achieve the optimal perinatal health wellbeing for parents and infants. Historically, mothers are considered as the dominant KC providers, whereas fathers are spectators and have been overlooked. Little is known about the fathers' perspectives in providing KC in NICUs. Individual semi‐structured interviews were conducted with 10 fathers who delivered KC to their baby when in the NICU. Data were analysed using Braun and Clarke's six‐phase thematical framework. The Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist was followed to report this qualitative study. Fathers in this study identified they were passing a silent language of love and connecting with their baby by the act of KC in a challenging environment. Three themes emerged: ‘Positive psychological connection’, ‘Embracing father‐infant Kangaroo Care’ and ‘Challenges to father‐infant Kangaroo Care’. The findings of this study show KC enhances the bonding and attachment between fathers and infants. The conceptualisation of the paternal role in caregiving to a newborn is evolving as a contemporary practice. Further research is warranted to confirm or refute the study findings. Policies and facilities should be modified to include father–infant KC within the fields of neonatal care. It is important for nurses and other health professionals to support and enable fathers to give KC. Father–infant KC is recommended in neonatal care settings
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Objective: The objective of this paper is to describe the updated methodological guidance for conducting a JBI scoping review, with a focus on new updates to the approach and development of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (the PRISMA-ScR). Introduction: Scoping reviews are an increasingly common approach to informing decision-making and research based on the identification and examination of the literature on a given topic or issue. Scoping reviews draw on evidence from any research methodology and may also include evidence from non-research sources, such as policy. In this manner, scoping reviews provide a comprehensive overview to address broader review questions than traditionally more specific systematic reviews of effectiveness or qualitative evidence. The increasing popularity of scoping reviews has been accompanied by the development of a reporting guideline: the PRISMA-ScR. In 2014, the JBI Scoping Review Methodology Group developed guidance for scoping reviews that received minor updates in 2017 and was most recently updated in 2020. The updates reflect ongoing and substantial developments in approaches to scoping review conduct and reporting. As such, the JBI Scoping Review Methodology Group recognized the need to revise the guidance to align with the current state of knowledge and reporting standards in evidence synthesis. Methods: Between 2015 and 2020, the JBI Scoping Review Methodology Group expanded its membership; extensively reviewed the literature; engaged via annual face-to-face meetings, regular teleconferences, and email correspondence; sought advice from methodological experts; facilitated workshops; and presented at scientific conferences. This process led to updated guidance for scoping reviews published in the JBI Manual for Evidence Synthesis. The updated chapter was endorsed by JBI's International Scientific Committee in 2020. Results: The updated JBI guidance for scoping reviews includes additional guidance on several methodological issues, such as when a scoping review is (or is not) appropriate, and how to extract, analyze, and present results, and provides clarification for implications for practice and research. Furthermore, it is aligned with the PRISMA-ScR to ensure consistent reporting. Conclusions: The latest JBI guidance for scoping reviews provides up-to-date guidance that can be used by authors when conducting a scoping review. Furthermore, it aligns with the PRISMA-ScR, which can be used to report the conduct of a scoping review. A series of ongoing and future methodological projects identified by the JBI Scoping Review Methodology Group to further refine the methodology are planned.
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Background: Historically, the relationship between infant and mother in the neonatal intensive care unit (NICU) has been the main focus of parenting research, leaving a gap in the literature regarding the paternal experience. Purpose: The purpose of this study was to gain an understanding of the lived experience of fathering an infant born at less than 28 weeks' gestation admitted to a level III NICU. Methods: Seven fathers of premature infants (25-27 weeks' gestation) participated in a semistructured interview about the experience of becoming a father to a premature infant at least 1 to 2 weeks after the NICU admission. Data were collected in 2015. Findings: The primary themes identified were looking in, persevering, holding, and finding my way. Fathers in this study described feeling like an outsider in the NICU while learning to trust strangers, protect the mother and the child, and continue to work and provide for the family. Holding for the first time is pivotal in this journey, as the moment of solidifying the connection with the child. Implications for practice: The findings from this study bring awareness of the experiences of fathers during the NICU journey of having a premature infant. Nurses should encourage paternal participation and involvement, visitation, and facilitate kangaroo care opportunities early and often. Implications for research: The findings from this study allow nurses to better understand the paternal experience of having a premature infant born at less than 28 weeks. However, future research should continue to investigate the paternal experience with other gestational ages as well as the influence of stress of fathers during this experience.
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Aim: Premature birth is an extremely stressful experience. In 2013 to 2014 we explored the physiological stress responses of fathers during their first skin-to-skin contact with their new baby. Methods: We recruited 49 fathers whose partners had given birth to a premature baby of up to 33 weeks and three days. The study, in the neonatal intensive care unit (NICU) of a Quebec hospital, measured the physiological stress responses of the fathers before and after they first experienced skin-to-skin contact with their new baby. Cortisol levels and blood pressure were measured and a generalised estimating equation was used for the data analysis. Results: The fathers' cortisol levels decreased from 10.55 nmol/l, with a 95% confidence interval (95% CI) of 9.61-11.59 at the beginning of the experiment to 8.26 nmol/l (95% CI 7.51-9.07) after 75 minutes. Meanwhile, their systolic blood pressure decreased from 135.16 mmHg (95% CI 130-140) to 125.25 mmHg (95% CI 121-129). Conclusion: Fathers who held their baby in skin-to-skin contact for the first time showed a significant reduction in physiological stress responses. Our findings support hospital practices that enable fathers to experience their first intimate contact with their newborn infant in the NICU. This article is protected by copyright. All rights reserved.
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Background Within systematic reviews, when searching for relevant references, it is advisable to use multiple databases. However, searching databases is laborious and time-consuming, as syntax of search strategies are database specific. We aimed to determine the optimal combination of databases needed to conduct efficient searches in systematic reviews and whether the current practice in published reviews is appropriate. While previous studies determined the coverage of databases, we analyzed the actual retrieval from the original searches for systematic reviews. Methods Since May 2013, the first author prospectively recorded results from systematic review searches that he performed at his institution. PubMed was used to identify systematic reviews published using our search strategy results. For each published systematic review, we extracted the references of the included studies. Using the prospectively recorded results and the studies included in the publications, we calculated recall, precision, and number needed to read for single databases and databases in combination. We assessed the frequency at which databases and combinations would achieve varying levels of recall (i.e., 95%). For a sample of 200 recently published systematic reviews, we calculated how many had used enough databases to ensure 95% recall. Results A total of 58 published systematic reviews were included, totaling 1746 relevant references identified by our database searches, while 84 included references had been retrieved by other search methods. Sixteen percent of the included references (291 articles) were only found in a single database; Embase produced the most unique references (n = 132). The combination of Embase, MEDLINE, Web of Science Core Collection, and Google Scholar performed best, achieving an overall recall of 98.3 and 100% recall in 72% of systematic reviews. We estimate that 60% of published systematic reviews do not retrieve 95% of all available relevant references as many fail to search important databases. Other specialized databases, such as CINAHL or PsycINFO, add unique references to some reviews where the topic of the review is related to the focus of the database. Conclusions Optimal searches in systematic reviews should search at least Embase, MEDLINE, Web of Science, and Google Scholar as a minimum requirement to guarantee adequate and efficient coverage. Electronic supplementary material The online version of this article (10.1186/s13643-017-0644-y) contains supplementary material, which is available to authorized users.
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This study examines how skin-to-skin contact between father and newborn affects the attachment relationship. A randomized controlled trial was conducted at a regional teaching hospital and a maternity clinic in northern Taiwan. The study recruited 83 first-time fathers aged 20 years or older. By block randomization, participants were allocated to an experimental ( n=41 ) or a control ( n=42 ) group. With the exception of skin-to-skin contact (SSC), participants from each group received the same standard care. Both groups also received an Early Childcare for Fathers nursing pamphlet. During the first three days postpartum, the intervention group members were provided a daily SSC intervention with their respective infants. Each intervention session lasted at least 15 minutes in length. The outcome measure was the Father-Child Attachment Scale (FCAS). After adjusting for demographic data, the changes to the mean FCAS were found to be significantly higher in the intervention group than in the control group. We recommend that nurses and midwives use instructional leaflets and demonstrations during postpartum hospitalization, encouraging new fathers to take an active role in caring for their newborn in order to enhance father-neonate interactions and establish parental confidence. This trial is registered with clinical trial registration number NCT02886767 .
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Background: Parents and their preterm infants (born between 32-37 weeks of gestation) are often overlooked by the healthcare system. And very little attention is given to the relationship parents develop with their infants in the neonatal unit (NNU). Specifically, very few studies focused on fathers and how they establish a relationship with their infants. However, we know that the father-infant relationship is extremely important for their future social development and more. Purpose: This article presents the results of a qualitative study of the establishment of the father-premature infant relationship in an NNU. Methods/search strategy: The study's theoretical framework was Bell's model of the parent-infant relationship, which encompasses discovery, physical proximity, communication, involvement, and emotional attachment. Ten fathers of premature infants (gestational age: 32-37 weeks) participated in 2 semistructured interviews (1 individual and 1 "in situ," ie, at the infant's bedside) during the first week following the premature birth. Findings/results: The results confirm the emergence of different components of the relationship between fathers and their children from the first days of hospitalization in the NNU. The commitment component is the basis for the development of other components in the relationship with their children. Furthermore, involvement influences the deployment of emotional attachment, discovery, physical proximity, and communication toward premature infants. Similarly, the 5 themes of the model can be seen as forming a dynamic nexus in which each theme influences the others. Implications for practice: For neonatal nurses, this model of the early father-child relationship helps the understanding of the deployment of that relationship according to 5 components. Similarly, it provides awareness of the experiences of fathers so that nurses can be better equipped to support and individualize interventions tailored to their specific needs, thus helping them develop and sustain the relationship with their children. Implications for research: This study allows us to better understand fathers' experience regarding the establishment of the relationship to their premature infants born between 32 and 37 weeks of gestation. However, there is little understanding about the early paternal experience and more research on this dyad is necessary in neonatology.
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Premature and medically vulnerable infants experience early and sometimes prolonged separation from their parents, intrusive and unnatural environments, painful and distressing procedures, difficulties with physiological regulation, increased biological and neurological vulnerabilities, and grow up to have higher rates of neurocognitive and psychosocial difficulties. Parents of infants born prematurely or with medical vulnerabilities, in turn, experience significant distress and are a psychiatrically vulnerable population, with very high rates of depression, anxiety, and posttraumatic stress disorder. The combination of these factors cause significant challenges for some of these infants and parents in developing an early optimal relationship and connection. Given the critical importance of early relationships with main caregivers for infant mental health and long-term developmental outcomes, we review various targets of intervention to promote healthy infant and parent mental health and bonding thereby facilitating an optimal infant-parent relationship in the NICU population.
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The aim of this study was to investigate the emotions and experiences of fathers in Eastern Anatolia Region of Turkey who applied kangaroo care in the neonatal intensive care unit. This study applied the qualitative descriptive design. The study included 12 fathers at the NICU of a university hospital. The fathers practiced kangaroo care with their babies two times a day for 15 days. Content analysis was then conducted to determine the main themes and sub-themes of the interviews. Three main themes and six sub-themes emerged from the analysis: (1) Emotions of being a father (feeling that the baby belongs to own and feeling the warmth and scent of the baby); (2) Confidence in fathering roles (self-confidence and caring for the baby); and (3) Happiness in the new parent role (seeing the baby calm down, hugging the baby and touching the baby’s skin).
Article
Objective: The objective was to assess stress in fathers of preterm infants and use of "Kangaroo Father Care (KFC)" to mitigate it. Study design: Stress levels of 30 fathers of preterm infants admitted in the NICU were assessed using the parental stressor scale: neonatal intensive care unit (PSS: NICU) before and after three sessions of KFC. The data was analysed using Wilcoxon signed rank sum test. Result: There was a statistically significant reduction in stress levels after KFC (p = 0.006). Amongst all the four subscales, stress levels were found to be reduced in 'staff behaviour and communication' (p = 0.001) domain and 'baby looks and behaves' domain (p = 0.05). Conclusion: Fathers of preterm infants admitted in the NICU experience a lot of stress, which can adversely affect their mental health. Kangaroo care is very effective in reducing this paternal stress levels.
Article
Background: Kangaroo mother care (KMC), originally defined as skin-to-skin contact between a mother and her newborn, frequent and exclusive or nearly exclusive breastfeeding, and early discharge from hospital, has been proposed as an alternative to conventional neonatal care for low birthweight (LBW) infants. Objectives: To determine whether evidence is available to support the use of KMC in LBW infants as an alternative to conventional neonatal care before or after the initial period of stabilization with conventional care, and to assess beneficial and adverse effects. Search methods: We used the standard search strategy of the Cochrane Neonatal Review Group. This included searches in CENTRAL (Cochrane Central Register of Controlled Trials; 2016, Issue 6), MEDLINE, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), LILACS (Latin American and Caribbean Health Science Information database), and POPLINE (Population Information Online) databases (all from inception to June 30, 2016), as well as the WHO (World Health Organization) Trial Registration Data Set (up to June 30, 2016). In addition, we searched the web page of the Kangaroo Foundation, conference and symposia proceedings on KMC, and Google Scholar. Selection criteria: Randomized controlled trials comparing KMC versus conventional neonatal care, or early-onset KMC versus late-onset KMC, in LBW infants. Data collection and analysis: Data collection and analysis were performed according to the methods of the Cochrane Neonatal Review Group. Main results: Twenty-one studies, including 3042 infants, fulfilled inclusion criteria. Nineteen studies evaluated KMC in LBW infants after stabilization, one evaluated KMC in LBW infants before stabilization, and one compared early-onset KMC with late-onset KMC in relatively stable LBW infants. Sixteen studies evaluated intermittent KMC, and five evaluated continuous KMC. KMC versus conventional neonatal care: At discharge or 40 to 41 weeks' postmenstrual age, KMC was associated with a statistically significant reduction in the risk of mortality (risk ratio [RR] 0.60, 95% confidence interval [CI] 0.39 to 0.92; eight trials, 1736 infants), nosocomial infection/sepsis (RR 0.35, 95% CI 0.22 to 0.54; five trials, 1239 infants), and hypothermia (RR 0.28, 95% CI 0.16 to 0.49; nine trials, 989 infants; moderate-quality evidence). At latest follow-up, KMC was associated with a significantly decreased risk of mortality (RR 0.67, 95% CI 0.48 to 0.95; 12 trials, 2293 infants; moderate-quality evidence) and severe infection/sepsis (RR 0.50, 95% CI 0.36 to 0.69; eight trials, 1463 infants; moderate-quality evidence). Moreover, KMC was found to increase weight gain (mean difference [MD] 4.1 g/d, 95% CI 2.3 to 5.9; 11 trials, 1198 infants; moderate-quality evidence), length gain (MD 0.21 cm/week, 95% CI 0.03 to 0.38; three trials, 377 infants) and head circumference gain (MD 0.14 cm/week, 95% CI 0.06 to 0.22; four trials, 495 infants) at latest follow-up, exclusive breastfeeding at discharge or 40 to 41 weeks' postmenstrual age (RR 1.16, 95% CI 1.07 to 1.25; six studies, 1453 mothers) and at one to three months' follow-up (RR 1.20, 95% CI 1.01 to 1.43; five studies, 600 mothers), any (exclusive or partial) breastfeeding at discharge or at 40 to 41 weeks' postmenstrual age (RR 1.20, 95% CI 1.07 to 1.34; 10 studies, 1696 mothers; moderate-quality evidence) and at one to three months' follow-up (RR 1.17, 95% CI 1.05 to 1.31; nine studies, 1394 mothers; low-quality evidence), and some measures of mother-infant attachment and home environment. No statistically significant differences were found between KMC infants and controls in Griffith quotients for psychomotor development at 12 months' corrected age (low-quality evidence). Sensitivity analysis suggested that inclusion of studies with high risk of bias did not affect the general direction of findings nor the size of the treatment effect for main outcomes. Early-onset KMC versus late-onset KMC in relatively stable infants: One trial compared early-onset continuous KMC (within 24 hours post birth) versus late-onset continuous KMC (after 24 hours post birth) in 73 relatively stable LBW infants. Investigators reported no significant differences between the two study groups in mortality, morbidity, severe infection, hypothermia, breastfeeding, and nutritional indicators. Early-onset KMC was associated with a statistically significant reduction in length of hospital stay (MD 0.9 days, 95% CI 0.6 to 1.2). Authors' conclusions: Evidence from this updated review supports the use of KMC in LBW infants as an alternative to conventional neonatal care, mainly in resource-limited settings. Further information is required concerning the effectiveness and safety of early-onset continuous KMC in unstabilized or relatively stabilized LBW infants, as well as long-term neurodevelopmental outcomes and costs of care.