Skin-to-skin care for infants on neonatal dialysis: practical pathways, safety evidence, and how NICUs can make kangaroo care work for medically complex newborns

Key Highlights
Introduction
Why skin-to-skin matters for medically complex neonates
Clinical challenges unique to infants with congenital kidney failure
How the iRainbow developmental care pathway enables safe skin-to-skin with devices
Aligning dialysis schedules and family visits: operational coordination that works
Safety evidence: mechanical complications and infection risk
Staffing, training, and workflow redesign
Parental experience, breastfeeding support, and psychosocial benefits
Infection control: balancing benefits and precautions
Measuring success: metrics, quality improvement, and reporting
Equity, policy, and resource considerations
Research gaps and priorities
Practical checklist for NICU teams adopting skin-to-skin for infants on dialysis
Implementation case study: operational lessons from a tertiary center (synthesized)
Closing perspective
FAQ

Key Highlights

Skin-to-skin care (kangaroo care) is a critical component of neurodevelopmental support in the NICU and can be delivered safely to medically complex infants, including those with congenital kidney failure who require neonatal dialysis, when structured protocols and interprofessional coordination are in place.
The iRainbow developmental care pathway provides explicit criteria and practical steps for safe transfers and skin-to-skin sessions in infants with endotracheal tubes, central venous catheters, and other lines; aligning dialysis schedules and visitation supports implementation without increasing mechanical or infectious complications in experienced units.
Scaling skin-to-skin for infants on peritoneal dialysis, intermittent hemodialysis, or prolonged intermittent renal replacement therapy requires attention to timing, staffing, device securement, parental preparation, and outcome monitoring—areas amenable to protocol-driven quality improvement and multicenter study.

Introduction

Skin-to-skin contact between parent and newborn produces measurable benefits for physiological stability, stress regulation, breastfeeding, and early attachment. Those benefits take on heightened importance for infants born with congenital kidney failure (CKF) who initiate dialysis in the neonatal period. These infants face multiple risk factors for adverse neurodevelopmental outcomes—chronic kidney disease itself, exposures related to dialysis, and often prematurity. Delivering developmentally supportive care while managing the technical demands of dialysis creates a clinical tension: how to protect fragile access lines and respiratory support devices while enabling parents to hold and bond with their infant.

A recent single-center study published in the Journal of Perinatology (Zhou et al., 2026) examined whether structured neurodevelopmental protocols could make skin-to-skin feasible and safe for these infants. The investigation built on established evidence that kangaroo care reduces stress and supports neurodevelopment in preterm infants and applied a formal care pathway—the iRainbow developmental care pathway—to infants on intermittent dialysis modalities (manual peritoneal dialysis, prolonged intermittent renal replacement therapy, and intermittent hemodialysis). The study framed the primary outcome as the proportion of infants receiving skin-to-skin care and set secondary outcomes to capture readiness, family visitation alignment, and the incidence of mechanical and infectious complications.

This article synthesizes the rationale, practical approaches, safety considerations, and implementation strategies for skin-to-skin care in infants undergoing neonatal dialysis. It draws from the study framework, established neonatal and kangaroo-care literature, implementation experience from tertiary centers, and operational lessons relevant to NICU teams, nephrology services, and parents.

Why this matters now

Survival of infants with CKF has improved; attention has shifted toward optimizing long-term neurodevelopment and parental well-being.
Standardized developmental care pathways are increasingly adopted in NICUs; integrating skin-to-skin for infants with devices can remove a barrier to equitable developmental care for medically complex newborns.
Practical, evidence-informed guidance makes implementation repeatable and measurable across centers.

What follows: explanation of the physiologic and developmental rationale, device-specific considerations, how the iRainbow pathway operationalizes safety, real-world coordination of dialysis and visitation, workforce and training needs, strategies for infection control and mechanical risk mitigation, and a roadmap for research and quality improvement.

Why skin-to-skin matters for medically complex neonates

Skin-to-skin contact, often called kangaroo mother care, originated as an alternative to incubators in resource-limited settings and evolved into a cornerstone of developmental care for preterm and critically ill newborns. Benefits extend across multiple domains:

Neurobehavioral development: Regular skin-to-skin is associated with improved self-regulation, state organization, and social engagement. Observational work shows dose-dependent relationships between the amount of skin-to-skin and neurodevelopmental outcomes at one year and beyond.
Physiological stabilization: Holding infants against a parent’s chest contributes to more stable heart rate, breathing patterns, and temperature regulation.
Stress response and pain modulation: Cortisol levels decrease during skin-to-skin sessions; behavioral indicators of pain and stress are reduced during minor procedures.
Lactation and feeding: Skin-to-skin contact supports breastfeeding initiation and maintenance through hormonal pathways that increase prolactin and oxytocin, and by facilitating maternal confidence and frequent chest-to-chest cues for feeding.
Parental mental health: Holding the infant reduces anxiety and improves parental attachment, which has downstream benefits for caregiving and adherence to complex home regimens.

For infants with CKF, these domains carry amplified importance. Chronic kidney disease in infancy affects growth, nutritional reserves, and brain development. Dialysis introduces additional physiologic stress and separates infants from routine parental contact. Maintaining breastmilk supply and early attachment may provide resilience that modifies long-term outcomes.

Evidence base specific to complex devices Concerns persist that lines and respiratory support might make transfers unsafe. Multiple studies in NICU populations with devices—including endotracheal tubes and central venous catheters—have found that structured skin-to-skin protocols do not increase unplanned extubations, line dislodgement requiring replacement, or bloodstream infections when multidisciplinary teams follow defined criteria and transfer processes. Those findings support offering skin-to-skin to carefully selected infants with devices, provided teams have the skills and systems to do so.

Clinical challenges unique to infants with congenital kidney failure

Infants with CKF face a combination of vulnerabilities that complicate routine interventions:

Vascular and peritoneal access: Central venous catheters (CVCs) and peritoneal dialysis catheters are lifelines. A dislodgement or contamination has immediate and high-consequence implications.
Hemodynamic fragility: Rapid shifts in fluid balance during or after dialysis can affect blood pressure and respiratory drive.
Respiratory supports: Many infants requiring neonatal dialysis are premature or have comorbid pulmonary disease, requiring endotracheal tubes, non-invasive supports, or oxygen supplementation.
Nutritional needs: Growth-preserving nutrition is complex; breastmilk offers immunologic and developmental advantages but sustaining supply is logistically challenging.
Family stress and logistics: Parents manage complicated schedules, learning sterile technique and follow-up regimens while coping with the emotional burden of critical illness.

Each of these domains requires targeted mitigation when planning skin-to-skin sessions.

Device-specific concerns and mitigations

Endotracheal tubes (ETT): Securement devices and two-person transfers reduce the risk of accidental extubation. The iRainbow pathway offers clear criteria for when infants with ETTs are eligible and defines roles during transfer.
CVCs and PD catheters: Securement, sterile dressings, and minimizing traction across the catheter tract are essential. Holding positions that avoid tension on the access site and using additional anchoring during transfers help.
Dialysis connections and tubing: For infants on intermittent dialysis, predictable “off-dialysis” windows can be scheduled. For continuous modalities, skin-to-skin may be limited to infants who are stable and whose tubing can be safely managed during a session.

Risk stratification must be individualized, combining objective readiness criteria with clinician judgment and informed parental consent.

How the iRainbow developmental care pathway enables safe skin-to-skin with devices

The iRainbow pathway provides structured, parent-focused criteria for developmental care, including when and how to perform skin-to-skin with critically ill infants. Key elements relevant to infants with CKF:

Eligibility criteria: Physiologic stability thresholds (heart rate, oxygen saturation range, respiratory support level), securement of devices, absence of active infection that contraindicates transfer, and staffing availability.
Device-specific protocols: Steps for securing and checking ETTs, CVCs, and PD catheters before transfer; required supplies at bedside; and contingency plans for emergent issues during holding.
Transfer choreography: Defined roles for the bedside nurse, a second nurse or clinician to stabilize devices, and a parent coach or team member who positions the parent and infant.
Documentation and communication: Standardized forms to record readiness checks, duration and frequency of skin-to-skin sessions, and any events or near-misses.
Family education: Simple, consistent instructions for parents on what to expect, how to hold, and signs to report immediately.

Implementation of iRainbow depends on multidisciplinary engagement: neonatology, nephrology, nursing, respiratory therapy, and allied professionals such as lactation consultants and physical therapists. The pathway’s emphasis on predictability and repeatable steps reduces variability and supports safety.

Practical example of pathway steps (operational)

Pre-session check (15 minutes): bedside nurse confirms vital signs stable within defined ranges, securement of ETT/CVC/PD catheter, no scheduled procedures or dialysis in next hour, and parent availability.
Supplies and personnel: second nurse or clinician present, portable monitoring available, sterile dressings and extra securement materials at hand, and respiratory therapist on standby if on ventilator.
Transfer: coordinated lift with one clinician securing the airway and lines, the other supporting trunk and hips; parent positioned reclined with infant upright, kangaroo wrap available for secure hold.
Monitoring during session: continuous cardiopulmonary monitoring, regular inspection of access sites, and documentation of skin-to-skin start time and parent identity.
Post-session debrief: assess infant stability, inspect lines, and record session length and any complications.

This sequence is adaptable to specific unit workflows and to infants receiving intermittent dialysis where sessions can be planned.

Aligning dialysis schedules and family visits: operational coordination that works

Dialysis modalities in neonatal CKF introduce scheduling dimensions that can facilitate skin-to-skin if coordinated intentionally.

Types of dialysis and opportunities

Manual peritoneal dialysis (PD): Exchanges are intermittent and frequent but predictable. Many units can schedule PD exchanges around family visiting times to create windows suitable for skin-to-skin.
Prolonged intermittent renal replacement therapy (PIRRT): Sessions are longer than manual PD but still scheduled; teams can identify off-dialysis windows for holding.
Intermittent hemodialysis (iHD): Typically performed in defined blocks; infants are entirely off dialysis between sessions, offering clear opportunities for skin-to-skin.

Coordination strategies

Shared schedules: Maintain a unit-level calendar that overlays dialysis sessions with family visiting hours and planned developmental rounds. This single source of truth helps nurses, nephrologists, and families align.
Pre-visit huddles: A quick bedside or clinical huddle before family arrival clarifies whether the infant is ready and what supports are necessary.
Cross-training: Nephrology and dialysis staff familiar with transfer protocols reduce delays and friction when sessions are scheduled.
Flexibility: Families often juggle work, other children, and travel. Where possible, offer multiple short sessions rather than one long session, and prioritize equity so that families with constraints still receive opportunities.

Real-world vignette (illustrative) A unit coordinates PD exchanges around a mother’s weekday visits. The nephrology team adjusts the PD prescription to complete exchanges before a midday visit. The nursing team confirms readiness, and the mother holds the infant for two 30-minute skin-to-skin sessions. Lactation support educates on pumping timing and storing milk. The infant remains stable, and the mother reports increased milk volume over two weeks. This illustrative plan reflects how modest scheduling changes improve family-centered care without compromising dialysis efficacy.

Safety evidence: mechanical complications and infection risk

Safety remains a central concern when transferring infants with lines and respiratory devices for skin-to-skin. Two classes of harms dominate scrutiny: mechanical events (unplanned extubations, catheter dislodgements requiring replacement) and infectious events (central line–associated bloodstream infections, peritonitis).

Mechanical complications Large NICU cohorts that adopted structured skin-to-skin protocols report no increase in rates of unplanned extubation or line dislodgement when transfers follow standardized procedures and utilize two-person techniques. Key risk-reduction elements include:

Use of securement devices and redundant fixation for ETTs and CVCs.
Two-person transfers with clearly assigned roles.
Matching the holding position to minimize tension on lines.
Time-limited holding sessions when infants are on less stable support.

Infectious risks Evidence indicates that skin-to-skin contact does not increase bloodstream infection rates when sterile dressings remain intact and hand hygiene and infection control protocols are followed. For infants on PD, peritonitis risk depends on catheter care; holding may enhance breastfeeding-mediated immune benefits but requires strict attention to abdominal catheter waterproofing and avoiding pressure on exit sites.

Monitoring for safety signals Units implementing skin-to-skin for infants on dialysis should track specific process and outcome metrics:

Process metrics: proportion of eligible infants receiving skin-to-skin when parents visit, median session duration, and documentation completeness.
Safety outcomes: unplanned extubation rate, catheter dislodgement requiring replacement, bloodstream infection rate, and peritonitis incidence.
Balancing measures: any delay to scheduled dialysis or clinical procedures attributable to skin-to-skin.

The single-center study by Zhou and colleagues used similar outcomes to evaluate feasibility and safety. Those outcome domains create a common metric set for multicenter comparability.

Staffing, training, and workflow redesign

Delivering skin-to-skin safely to infants on neonatal dialysis requires workforce readiness and workflow redesign.

Nursing roles

Primary bedside nurse: performs readiness checks, secures lines for transfer, and monitors infant during holds.
Second clinician (nurse or respiratory therapist): stabilizes devices during transfer and supports parent positioning.
Float or runner: available to obtain supplies or provide emergent assistance when staffing constraints exist.

Interdisciplinary contributions

Nephrology team: adjusts dialysis timing as needed and provides guidance on catheter care.
Respiratory therapy: advises on ventilator settings and assists with ETT securement for transfers.
Lactation consultants: prepare and support parents to combine skin-to-skin with feeding plans.
Physical/occupational therapists: guide positioning and ergonomic supports to keep both infant and parent comfortable.

Training elements

Simulation practice: teams rehearse transfers of infants with lines and ETTs using manikins to build muscle memory and reduce anxiety.
Competency checklists: documented skills such as securing an ETT for transfer or anchoring a PD catheter.
Regular debriefs: weekly or monthly reviews of near-misses and successful sessions to refine processes.

Policy and documentation

Standardized consent language describing benefits and risks.
Electronic health record templates to document eligibility checks, transfer events, and any complications.
Protocols for rare but high-risk events, such as accidental extubation or sudden catheter leakage during hold.

Addressing staffing constraints Units with limited staffing can pilot skin-to-skin for infants with dialysis using time-limited sessions during predictable off-dialysis windows and prioritizing high-impact cases (e.g., infants whose parents travel long distances). Data from pilots support business cases for additional staffing or dedicated developmental care roles.

Parental experience, breastfeeding support, and psychosocial benefits

Parents of infants on dialysis face complex medical education, worry about infection risks, and concerns about bonding when infants remain in the NICU for prolonged periods. Skin-to-skin provides tangible experiences that support parental confidence.

Breastmilk and lactation

Kangaroo care stimulates milk production through hormonal pathways and increases opportunities for skin-to-skin signaling that aids latch development, even when direct breastfeeding is not immediately possible.
Lactation support should integrate skin-to-skin into pump schedules and explain how holding can boost supply and maintain milk production during prolonged hospitalizations.

Emotional and informational support

Structured counseling before first skin-to-skin sessions reduces anxiety. Clear instruction on positioning, signs of infant distress, and when to call for help empowers parents.
Peer support groups—connecting families whose infants receive neonatal dialysis—amplify morale and provide practical tips for balancing dialysis care with parental roles.

Practical guidance for parents (what to expect)

Dress in a button-down or loose shirt to facilitate chest-to-chest contact.
Expect staff to perform safety checks before every session.
Sessions may be short initially and increase as infant stability and parental confidence grows.
Ask questions about line securement and how to spot signs of access-site problems.

Real-world impact When parents feel safe and competent holding their infant, their participation in rounds, feeding plans, and post-discharge care improves. This involvement often translates to better adherence to complex home therapies and improved long-term outcomes.

Infection control: balancing benefits and precautions

Infection prevention is non-negotiable for infants with central lines and peritoneal catheters. Integrating skin-to-skin care requires robust infection control practices but does not inherently increase infection risk when those practices are followed.

Core precautions

Ensure dressings over catheter exit sites are intact and reinforced before transfer.
Use barrier methods (waterproof covers) over abdominal PD catheters when holding; avoid pressure on exit sites.
Strict hand hygiene for parents before contact; provide hand-sanitizing stations at every bed.
Consider transient limitations after invasive procedures or active infection until controlled.

Monitoring and rapid response

Inspect access sites before and after every session.
Record any redness, drainage, or increased leak; escalate promptly to nephrology and infection control teams.
Maintain low threshold for culture and antibiotics per unit protocols if infection suspected.

Evidence and surveillance Units should conduct ongoing surveillance for line-associated infections and compare rates before and after implementing skin-to-skin protocols. This real-world data, aggregated across centers, will refine risk estimates and best practices.

Measuring success: metrics, quality improvement, and reporting

A data-driven approach ensures that skin-to-skin for infants on dialysis remains safe, equitable, and beneficial.

Key performance indicators (KPIs)

Percent of eligible infants who receive skin-to-skin when parents visit.
Median and mean duration of skin-to-skin sessions per infant per week.
Number and rate of mechanical complications: unplanned extubations, CVC or PD catheter dislodgements requiring replacement.
Central line–associated bloodstream infection (CLABSI) and PD peritonitis rates per 1,000 catheter-days.
Parent-reported outcomes: breastfeeding duration at discharge, measures of parental confidence and stress, qualitative feedback.
Long-term developmental follow-up metrics at 12 and 24 months corrected age.

Quality improvement methodology

Plan-Do-Study-Act (PDSA) cycles allow units to start small, measure, and rapidly iterate.
Root cause analyses of any adverse events to identify system fixes rather than individual blame.
Transparency in reporting and sharing lessons with other centers accelerates safe adoption.

Benchmarking and collaboration

Multicenter consortia can standardize outcome definitions to enable meta-analyses.
Registries that capture process metrics and safety outcomes would provide the statistical power to determine effect sizes for rare events.

Equity, policy, and resource considerations

Implementation must account for disparities in access to family-centered care and for resource variability across NICUs.

Equity considerations

Parents with limited visiting ability (work, distance, childcare obligations) are less likely to participate in skin-to-skin unless units offer flexible scheduling and support.
Translation services, transportation assistance, and social work involvement increase equitable access.
Units should track participation by socioeconomic indicators and proactively address gaps.

Policy implications

Hospital policies that recognize the importance of parental presence—flexible visiting hours and parking accommodations—facilitate more skin-to-skin exposure.
Reimbursement and staffing models that undervalue developmental care create barriers; administrators should view skin-to-skin as an investment in long-term outcomes.

Resource-limited settings

Even where dialysis resources are scarce, principles of securement, two-person transfers, and parent education can be adapted.
Low-cost securement strategies and basic simulation training improve safety.

Research gaps and priorities

The single-center evaluation frames feasibility and safety; additional evidence is needed to guide widespread adoption and optimization.

Priority research questions

What is the magnitude of neurodevelopmental benefit specifically attributable to skin-to-skin in infants with CKF compared with standard care?
Do skin-to-skin sessions influence rates of successful breastfeeding at discharge and at 6 and 12 months?
Which specific device-management strategies most effectively minimize mechanical risks during transfer?
How do different dialysis modalities and timing patterns modulate feasibility and safety?
What are parents’ qualitative experiences and how do these experiences influence long-term caregiving behavior?

Methodological considerations

Prospective multicenter cohorts with standardized outcome definitions will provide better estimates for rare complications.
Randomized trials would be challenging and ethically fraught where skin-to-skin is considered standard; stepped-wedge or cluster-randomized designs focusing on implementation elements may be feasible.
Mixed-methods studies that integrate parental-reported outcomes, nursing workflow metrics, and infection/mechanical outcomes will generate actionable insights.

Translating evidence to policy

National pediatric and neonatal societies should consider formal guidance that integrates device-specific checklists and staff competency requirements.
Accreditation and quality frameworks could include developmental care metrics for medically complex infants.

Practical checklist for NICU teams adopting skin-to-skin for infants on dialysis

A concise checklist that units can adapt:

Before session

Confirm infant stability: heart rate, oxygen saturation, respiratory settings within agreed ranges.
Inspect all lines and dressings; reinforce fixation if needed.
Verify no scheduled dialysis, imaging, or procedures within 60 minutes.
Ensure two trained staff are available for transfer.
Educate and prepare the parent for positioning and signs to report.

During transfer

Use two-person technique: one stabilizes airway and lines, the other supports body and limbs.
Avoid pulling on tubing or catheters; maintain slack and secure tubing to clinician as needed.
Position infant upright on parent’s chest with head turned to maintain airway patency.
Continue continuous monitoring and visual inspection of catheter sites.

After session

Inspect access sites and securement.
Document session duration, any events, and parent identity.
Debrief with parent and staff to capture near-misses or process improvements.

Contingency planning

Establish rapid-response roles for accidental extubation or catheter complication.
Have immediate access to sterile supplies and replacement lines as per unit policy.

Implementation case study: operational lessons from a tertiary center (synthesized)

Several tertiary centers that integrated skin-to-skin for infants with devices report common success factors:

Early leadership alignment between neonatology and nephrology created predictable windows for skin-to-skin.
Simulation training reduced transfer time and anxiety.
Small initial pilots quantified safety and built staff confidence before broader rollout.
Inclusion of parents in protocol development improved acceptability and adherence.
Routine audits and transparent reporting maintained vigilance for infection and mechanical outcomes.

These lessons echo the acknowledgements from the Zhou et al. study team, which thanked clinicians who aligned dialysis schedules with family visitation to facilitate transfers.

Closing perspective

Delivering skin-to-skin care to infants with congenital kidney failure represents a convergence of family-centered developmental support and high-acuity clinical management. Structured pathways like iRainbow translate evidence into practical, repeatable workflows. When teams prioritize coordination, training, and robust monitoring, kangaroo care can become part of routine neurodevelopmental support for infants on neonatal dialysis—preserving early attachment, supporting breastfeeding, and potentially improving long-term outcomes without adding undue risk. Continued multicenter data collection and quality improvement efforts will sharpen best practices and ensure equitable access for all families facing the challenges of neonatal CKF.

FAQ

Q: Is skin-to-skin safe for infants who require neonatal dialysis? A: When teams follow structured protocols and objective readiness criteria, skin-to-skin can be performed safely in many infants receiving neonatal dialysis. Key safeguards include securement of lines and tubes, two-person transfers, continuous monitoring, and scheduling sessions during off-dialysis windows when possible. Units should track mechanical and infectious outcomes to confirm safety within their local context.

Q: Which infants with congenital kidney failure should not receive skin-to-skin? A: Contraindications include active hemodynamic instability, uncontrolled sepsis, recent unhealed surgical or access-site complications that preclude transfer, or any situation where the airway or access devices cannot be reliably secured. Decisions should be individualized and documented in the medical record.

Q: How do dialysis schedules affect opportunities for skin-to-skin? A: Intermittent modalities create predictable off-dialysis windows suitable for skin-to-skin. PD exchanges can sometimes be timed around visiting hours. For continuous therapies, skin-to-skin may be more limited but is still possible in selected stable infants with careful device management.

Q: Will holding the infant increase the risk of catheter-related infections? A: Available evidence suggests that with intact sterile dressings, proper hand hygiene, and avoidance of pressure or contamination of exit sites, skin-to-skin does not increase the rate of bloodstream infections or peritonitis. Ongoing surveillance and strict infection control practices are essential.

Q: How long should initial skin-to-skin sessions last? A: Start with short, supervised sessions (for example, 10–20 minutes) and extend duration as infant stability and parental comfort increase. Many units aim for multiple shorter sessions daily rather than a single prolonged session, particularly early in the course.

Q: What staff are required to perform a safe transfer? A: At minimum, the bedside nurse and one additional trained clinician (nurse or respiratory therapist) should be present for transfers involving lines or ETTs. Teams should have a documented contingency plan and rapid-response availability.

Q: How does skin-to-skin support breastfeeding when the mother cannot nurse directly? A: Kangaroo care stimulates lactation hormones and supports milk production even when direct breastfeeding is delayed. Pairing holding sessions with pumping schedules, lactation counseling, and provision of breastmilk storage supports is effective.

Q: What should units measure to ensure safe implementation? A: Track process measures (proportion of eligible infants receiving skin-to-skin, session duration) and outcome measures (unplanned extubation rate, catheter dislodgement requiring replacement, CLABSI and PD peritonitis rates). Include parent-reported outcomes related to breastfeeding and maternal confidence.

Q: Are there resources or templates for units that want to start a skin-to-skin program for infants with lines and dialysis? A: Developmental care pathways like iRainbow provide structured criteria and checklists. Units can adapt such pathways to local workflows, supplement with simulation training, and consult with pediatric nephrology and infection control teams to tailor protocols.

Q: What research is needed next? A: Prospective multicenter cohorts and implementation studies are needed to quantify neurodevelopmental benefits, breastfeeding outcomes, and rare adverse events. Standardized metrics will enable benchmarking and inform policy.

If you would like practical templates—checklists, transfer-role scripts, or a pilot PDSA plan that your unit can adopt—requesting those resources will allow tailored, actionable materials aligned to your staffing and clinical context.