As evidence has been growing on the benefits of kangaroo care,1 the practice of skin-to-skin contact has spread through neonatal units and is being implemented in more patients, including extremely preterm newborns.2

Cardiorespiratory parameters are more stable during skin-to-skin contact.3,4 Studies in extremely preterm newborns have demonstrated the safety of skin-to-skin contact during mechanical ventilation,5 and one study conducted in term newborns that had undergone surgery found greater stability in cardiorespiratory parameters following extubation in infants that had been put in skin-to-skin contact with their parents.6

Since the kangaroo care approach facilitates physiological stability, we hypothesised that infants may tolerate extubation better during skin-to-skin contact with their parents compared to conventional extubation in the incubator. We developed a procedure for extubation during kangaroo care, and later performed a retrospective analysis of patients born preterm at less than 28 weeks’ gestational age that were electively extubated during skin-to-skin contact with their parents.

The procedure for extubation during skin-to-skin contact was based on the recommendations for the implementation of kangaroo care in mechanically ventilated infants,5 adding elements concerning extubation.

The procedure consisted of: controlling environmental stimuli (noise, lighting) during the entire process, transfer from incubator to skin-to-skin contact, preparation of all the necessary material and placement of the CPAP bonnet, skin-to-skin contact for as long as needed to attain physiological stability, followed by extubation and connection to CPAP.

The clinical assessment and monitoring were performed as they would have if extubation had taken place in the incubator, and the health care staff was prepared to transfer the patient back to the incubator in case of extubation failure, which was defined as inability to sustain adequate spontaneous ventilation and/or oxygenation.

The parents had been informed about the procedure and given consent.

We collected the data from the medical records of the patients, and analysed them retrospectively.

A total of 14 newborns were extubated during skin-to-skin contact in our unit between 2008 and 2012. Table 1 shows the characteristics of the patients. Their gestational ages ranged from 236/7 to 270/7 weeks, and their birth weights from 570 to 850g. The mean chronological age at the time of extubation was 32 days (14–46), the postmenstrual age ranged between 25 and 32 weeks, and the weight at the time of extubation ranged between 640 and 1430g.

All the neonates had been put in skin-to-skin contact with their parents before, and half of them had undergone at least one failed extubation attempt in the incubator.

Extubation was successful in 12 of the 14 neonates. The reason for extubation failure was croup in one neonate and hypoxia in the other. In these two cases, the patients were transferred back to their incubators and reintubated without complications.

No complications developed in association with the procedure, and parents expressed a high level of satisfaction.

One of the benefits of skin-to-skin contact is cardiorespiratory stability, even in recently extubated neonates. Thus, kangaroo-care extubation could be well tolerated, as our case series seems to suggest.

The procedure is no more complex than skin-to-skin contact in ventilated preterm newborns. As for extubation itself, the sole difference compared to conventional practice is the placement of the child.

The incorporation of family-centred care involves increased parental participation in care, which could include extubation during skin-to-skin contact. A high degree of cohesion between parents, the nursing staff and the neonatologist is essential when performing this procedure.

Some of the limitations of the study are the absence of a control group and its retrospective design. Furthermore, while parents did express high satisfaction with the method, we did not formally analyse its emotional impact.

In our experience, elective extubation during skin-to-skin contact in extremely preterm infants is a safe practice that is not associated to complications outside of those expected in extubation performed in the incubator, and could contribute to increased respiratory stability.

Considering the limitations of this study, further studies should be conducted to demonstrate the safety and benefits of this method before recommending it, as well as research on its emotional impact on the parents.