Recent Advances in Pediatrics (Volume 17): Hot Topics Suraj Gupte
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Kangaroo Mother Care (KMC)1

Ashok Kumar, Sriparna Basu
 
INTRODUCTION
The term, kangaroo mother care (KMC), is derived from practices similar to marsupial care, in which the infant is kept warm in the maternal pouch and close to the breasts for unlimited feeding. KMC refers to skin-to-skin contact between a mother and her newborn. It ensures frequent and exclusive breastfeeding, provides tactile, kinesthetic, and vestibular stimulation and transmits heat from the mother's to the infant's body. It was proposed initially as an alternative to conventional neonatal care for low birth weight (LBW) infants. The term was first suggested in 1978 by Dr Edgar Rey in Bogotá, Colombia. It was developed initially as a way of compensating for the overcrowding and scarcity of resources in hospitals caring for low birthweight (LBW) infants.1, 2 KMC promotes physiological stability of newborns and enhances the parent-child bonding.
 
CLINICAL APPLICATIONS
KMC is an alternative to standard hospital care for low birthweight infants. Early and continuous skin-to-skin contact between the mother and her infant is the cornerstone of the practice, with breastfeeding and early discharge with careful ambulatory clinical follow-up. Three uses of KMC have been identified3:
  1. Where appropriate neonatal care facilities do not exist, KMC is proposed as the alternative to incubators in health facilities.
  2. Where all levels of neonatal care are readily accessible, early mother-infant skin-to-skin contact in health facilities can enhance the quality of mother-infant bonding and promote successful breastfeeding.
  3. Where technical and human resources are of a high standard but are insufficient to cope with the demand, KMC is provided mainly 2as outpatient care after a short in-hospital adaptation period, provided that the infant has overcome major neonatal problems and is eligible for minimal care.
 
MAIN COMPONENTS
  • Skin to skin contact: This component involves direct skin-to-skin contact of the newborn with the mother which can be started early and continued for prolonged periods of time.
  • Exclusive breastfeeding: Even most of the VLBW babies (birth weight < 1500 g) can be switched over early and adequately to exclusive breastfeeding. The mother should be explained that she can breast feed in the kangaroo position and that KMC actually makes breastfeeding easier. Furthermore, holding the baby near the breast stimulates milk production.
  • Early discharge and follow-up: KMC initiated in the hospital under supervision facilitates early discharge from the hospital and this practice should be continued at home. Babies discharged early on KMC should be followed up regularly to ensure a normal outcome.
 
BENEFITS
 
For the Baby
  1. Overall mortality: Survival for the preterm low birth weight infants was found to be remarkably better in the group where KMC was started early than the babies who were kept in the conventional method of care in the first 12 h and thereafter.4
  2. Better somatic growth: Different studies showed that infants cared for by KMC have a better daily weight gain (mean gain 3.6–15g/day more than those cared conventionally) during their hospital stay compared to their counterparts. Long-term follow-up studies showed better gain in length and better increase in head circumference at the corrected age of 1 year to a minimum of 0.5 cm.5
  3. Better behavioral pattern: Very low birthweight infants, while on KMC were found to have longer period of quiet sleep and lesser periods of crying.
  4. Better psychomotor development: When psychomotor development has been evaluated at 6 and 12 months of corrected age, it has been found that the overall scores are better than the controls.3
  5. Breastfeeding: Studies have shown that KMC results in increased breastfeeding rate as well as increased duration of breastfeeding. 3At the time of discharge exclusive breastfeeding rate is significantly higher in preterm very low birth weight infants who were on KMC. The practice has also been found to promote self-regulatory feeding behavior in preterms.6 The need for supplementation of breastfeeding becomes a minimum even for very low birthweight infants.
  6. Prevention of hypothermia: The risk of hypothermia is reduced by >90% when nursed by KMC rather than conventional care. Micro-ambient temperature is always higher during KMC than the average room temperature.7
  7. Infections: Overall frequency of infections, expressed as the number of infectious episodes and incidence density was found to be significantly less in newborns who were given KMC. They had lesser chances of development of nosocomial infections and a lesser need for inpatient care because of infections.3
  8. Reduced duration of hospital stay: KMC has reduced the total number of days spent in the hospital and diminished the overcrowding of the neonatal unit, which is a particular problem in hospitals in developing countries. Number of follow-up visits has increased significantly. The parents of KMC infants are more sensitive to the health care needs of their newborns and therefore demand more ambulatory health care which is always preferable to prolonged hospitalization if the outcome is equivalent.
  9. Phototherapy during KMC: It has been seen that KMC can be continued in low birthweight icteric infants safely and effectively using a fiberoptic phototherapy panel on their back.8
  10. Endocrinal effect: Better maturation of the pituitary-thyroid axis and adrenal function has been reported in preterm infants on KMC.9
  11. Other effects: Very low birth weight infants with frequent apneic episodes thrive better while on KMC. They have been found to have less apneic episodes with more regular breathing patterns and longer periods of alertness than those on conventional care.1 The incidences of readmission in infants who are given KMC at home is much lesser compared to their counterparts.
 
For the Mother
  1. The mother's sense of competence is higher when she provides KMC to her baby especially when the intervention is started soon after birth (1 to 2 days).
  2. 4Mothers are less stressed during kangaroo care than when the baby is receiving incubator care. Mothers prefer skin-to-skin contact to conventional care and feed with more confidence, self-experience, and feeling of fulfillment. They describe a sense of empowerment, confidence and a satisfaction that they can do something positive for their preterm infants. They feel more relaxed, comfortable and better bonded with the baby while providing KMC.
  3. KMC improves maternal adaptation to having a fragile infant.
 
For the Community
  1. KMC does not require hospital staff other than for conventional care.
  2. KMC is acceptable to the mothers and the healthcare staff working in the hospital.
  3. KMC is cheap and can be used in hospitals with limited resources.
 
PHYSICAL, EMOTIONAL AND EDUCATIONAL SUPPORT IN KMC
The mother and the family need constant support from the nursing and medical staff. The KMC intervention sometimes produces negative feelings in the mothers. She feels more isolated. This is especially true for those whose infant spends a longer time in hospital. This may have occurred when the infant could not gain sufficient weight or suckle properly, had an infectious disease, or was sick in any way. These mothers may feel burdened with too many responsibilities in taking care of the infant and, consequently, feel overwhelmed and that they are not getting sufficient help from the hospital staff and family. This suggests that in such cases, we should add a social support to the KMC's usual components. The mother should be encouraged to ask for help if she is worried and the health personnel should be prepared to respond to her questions and anxieties. Sometimes, maternal sensitivity is moderately induced by the KMC intervention. In the long run this marked orientation toward the sick child might be the beginning of a continuing protective behavioral pattern observed frequently in the interaction between a mother and a sick child during the first years of life.
 
ELIGIBILITY CRITERIA
 
For Babies
All low birthweight babies are eligible for KMC. However, babies needing special care should be cared for according to conventional 5management and KMC should be started after the baby has become stable. Some guidelines for practicing KMC are:
  1. Birth weight >1800 g: If stable, can be started on KMC soon after birth.
  2. Weight 1200–1799 g: In such cases the delivery should take place in a well equipped facility, which could provide the early neonatal care required. If delivery occurs elsewhere, the baby should be transferred soon after birth preferably with the mother. One of the best ways of transporting small babies is keeping them in continuous skin-to-skin contact with the mother. It might take a week or more before KMC can be initiated
  3. Birth weight <1200 g or gestation <30 weeks: These babies benefit most from transfer before birth to an institution with neonatal intensive care facilities. It may take weeks before their condition allows initiation of KMC.
 
For Mothers
All mothers can provide KMC, irrespective of age, parity, education, culture and religion. KMC may be particularly beneficial for adolescent mothers and for those with social risk factors. The following points must be taken into consideration when counseling on KMC:
  1. Willingness: The mother must be willing to provide KMC
  2. Full-time availability to provide care: Other family members can offer intermittent skin-to-skin contact
  3. General health: If the mother has suffered from complications during pregnancy delivery or ill otherwise, she should recover before she can initiate KMC
  4. Being close to the baby: She should either be able to stay in hospital until discharge or return when her baby is ready for KMC
  5. Supportive family: She will need support to deal with other responsibilities at home
  6. Supportive community: This is particularly important when there are social, economic or family constraints.
 
METHODOLOGY
When baby is ready for KMC, arrange with the mother a time that is convenient for her and for her baby. The first session is important and requires time and undivided attention. Ask her to wear light, loose clothing. Use a private room, warm enough for the small baby. Encourage her to bring her husband or a companion of her choice if 6she wishes. It helps to lend support and reassurance. Followings are the steps to provide KMC:
  1. Mother wears a loose blouse or gown or wrap.
  2. Baby is undressed carefully, except for a napkin, cap and socks.
  3. Kangaroo positioning : The baby should be placed between the mother's breasts in an upright position. The head should be turned to one side and in a slightly extended position. This slightly extended head position keeps the airway open and allows eye-to-eye contact between the mother and the baby. Avoid both forward flexion and hyperextension of the head. The hips should be flexed and abducted in a “frog” position; the arms should also be flexed. Baby's abdomen should be somewhere at the level of the mother's epigastrium. This way baby has enough room for abdominal breathing. Mother's breathing stimulates the baby.
  4. Wrap the baby from outside with the mother's blouse/gown/wrap.
  5. Encourage the baby to suckle at breast as often as he wants, at least once in every 2 hours.
  6. Make sure the baby's trunk, palms and feet remain warm to touch.
 
TIME OF INITIATION
KMC can be started as soon as the baby is stable and receiving oral feeds. Babies with severe illness or requiring special treatment must wait until recovery before KMC can be started. During that period babies are treated according to neonatal unit clinical guidelines. Short KMC sessions can be initiated during recovery with ongoing medical treatment (IV fluids, low concentration of additional oxygen). KMC can be started during oro-gastric feeding. Once the baby begins recovering the mother should be motivated to practice KMC.
 
DURATION
Skin-to-skin contact should start gradually, with a smooth transition from conventional care to continuous KMC. Sessions that last less than 60 minutes should, however, be avoided because frequent handling is too stressful for the baby. The length of skin-to-skin contacts gradually increased to become as prolonged as possible, day and night, interrupted only for changing diapers, especially where no other means of thermal control are available. When the mother needs to be away from her baby, other family members (father, grandmother etc.) can also help by caring for the baby in skin-to-skin kangaroo position.
7The mother can even sleep with the baby in kangaroo position in a reclined or semirecumbent position, about 15 degrees from horizontal. This can be achieved with an adjustable bed, if available, or with several pillows on an ordinary bed. It has been observed that this position may decrease the risk of apnea for the baby. Some mothers prefer sleeping on their sides in a semi reclined bed (the angle makes sleeping on the abdomen impossible), and if the baby is secured as described above there will be no risk of smothering. If the mother finds the semi-recumbent position uncomfortable, allow her to sleep as she prefers and she can continue KMC as much as possible. A comfortable chair with adjustable back may be useful for resting during the day.
 
DISCHARGE CRITERIA FOR A BABY WHO IS GETTING KMC
Usually, a KMC baby can be discharged from the hospital when the following criteria are met.
  1. The baby's general health is good and there is no concurrent disease such as apnea or infection.
  2. Baby is feeding well, and is exclusively or predominantly breastfed.
  3. Baby is gaining weight (at least 10–15 g/kg/day for at least three consecutive days)
  4. Baby's temperature is stable in the KMC position (within the normal range for at least three consecutive days)
  5. The mother is confident of caring her baby at home.

KEY LEARNING POINTS

  • Because of the shortage of equipments and staffs and the frequency of cross-infection in hospital, KMC is a valuable approach in developing countries for caring small fragile neonates.
  • It helps in reducing the length of hospital stay and decreases frequency of nosocomial infection.
  • Additional desirable components of the intervention are that it empowers families by giving them the responsibility and the tools for providing health care to their infants, encourages breastfeeding and even the quality of family-to-infant bonding.
  • All health professionals involved in caring for newborn infants, therefore, should consider using part or all of KMC to complement usual neonatal care. In particularly, KMC should be recognized as a means of humanizing such care.
  • KMC should be promoted actively and that mothers should be encouraged to use it as soon as possible during the intensive care period, up to 40 weeks’ gestational age.
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REFERENCES
  1. Charpak N, Ruiz-Pelaez JG, Figueroa de Calume Z Current knowledge of kangaroo mother intervention. Curr Opin Pediatr 1996; 8: 108–112.
  1. Doyle LW Kangaroo mother care. Lancet 1997; 350: 1721–1722.
  1. Charpak N, Ruiz-Pelaez JG, Figueroa de CZ, Charpak Y. Kangaroo mother versus traditional care for newborn infants ≥2000 grams: a randomized, controlled trial. Pediatr 1997; 100: 682–688.
  1. Worku B, Kassie A. Kangaroo mother care: a randomized controlled trial on effectiveness of early kangaroo mother care for the low birthweight infants in Addis Ababa, Ethiopia. J Trop Pediatr 2005; 51: 93–97.
  1. Conde-Agudelo A, Diaz-Rossello JL, Belizan JM. Kangaroo mother care to reduce morbidity and mortality in low birthweight infants. Cochrane Database Syst Rev 2003; CD002771.
  1. Chwo MJ, Anderson GC, Good M, Dowling DA, Shiau SH, Chu DM. A randomized controlled trial of early kangaroo care for preterm infants: effects on temperature, weight, behavior, and acuity. J Nurs Res 2002; 10: 129–142.
  1. Ibe OE, Austin T, Sullivan K, Fabanwo O, Disu E, Costello AM. A comparison of kangaroo mother care and conventional incubator care for thermal regulation of infants < 2000 g in Nigeria using continuous ambulatory temperature monitoring. Ann Trop Paediatr 2004; 24: 245–251.
  1. Ludington-Hoe SM, Swinth JY. Kangaroo mother care during phototherapy: effect on bilirubin profile. Neonatal Netw 2001; 20: 41–48.
  1. Weller A, Rozin A, Goldstein A, et al. Longitudinal assessment of pituitary-thyroid axis and adrenal function in preterm infants raised by kangaroo mother care. Horm Res. 2002; 57: 22–26.