Current Women's Health Reviews - Volume 7, Issue 3, 2011

The editor of the CWHR has the great pleasure to provide the readers and the medical community with an outstanding issue summarizing one of the most compelling interventions to save newborn lives in the world. This issue is being published at the same time that an updated review of the Cochrane Library provides evidence-based, conclusive support regarding the impact of the kangaroo mother care (KMC) intervention on neonatal survival [1]. The history of the development of KMC is well summarized by the editors of this issue, Drs. Ruiz and Charpak, exceptional pioneers and promoters of this intervention. In 1978, Edgar Rey [2] proposed and developed kangaroo mother care at Instituto Materno- Infantil in Santa Fe de Bogota, Colombia, as an alternative to the conventional contemporary method of care for low birth weight (LBW) infants. KMC was initially conceived to address a lack of incubators, high rates of nosocomial infections, and infant abandonment in the local hospital. The term KMC is derived from similarities to marsupial caregiving. The mothers are used as “incubators” to maintain the infants' body temperatures and to serve as the main source of food and stimulation for LBW infants until such time as they have matured enough to face extrauterine life in conditions similar to those born at term [1, 2]. Dr. Edgar Rey Sanabria passed away in 1992. From this original proposal, many studies have been conducted in low-middle- and high-income countries, all of which have concluded that KMC, when compared with conventional neonatal care, is associated with a reduction in neonatal mortality, severe infection/sepsis, hypothermia, and length of hospital stay, as well as with an increase in weight gain and exclusive or any breastfeeding [1]. Results shows consistency that neonatal deaths can be reduced by about 40% and that approximately 40 infants need to be treated to avoid one death. Kangaroo Mother Care should be widely and strongly recommended for use primarily in low- and middle-income countries. It is desirable to stimulate the creation of a leading KMC initiative advocating for the use of the intervention and providing support and training to those willing to implement it, thus building a repository of world experiences on the use of KMC and supporting, orienting, and stimulating research needed on this intervention. The spread of the use of this intervention at all levels of care would result in a significant impact on a reduction in global neonatal deaths.

THE PAST Kangaroo Mother Care (KMC) began sometime during 1978, at the Instituto Materno Infantil (IMI) one of the largest maternity facilities at that time, in Bogota, Colombia. Its creators, E. Rey and colleagues were confronting problems generated mainly by overcrowding at their Neonatal Care Unit (NCU). Despite that there were numerous beds and incubators, the demand greatly exceeded the available slots. Preterm infants frequently had to share incubators, and nurse and doctor-patient ratios were suboptimal. “Healthy” preterm infants, who had survived the neonatal and post-neonatal adaptation remained in incubators or heated cribs, until able to regulate temperature and therefore being eligible for discharge. Periodic outbreaks of nosocomial infection and necrotizing enerocolitis decimated these infants who had reached the stable growth period, were mainly bottlefed, and could not be discharged because their continued incubator need. Rey looked for a way of securing thermal stability and proper feeding outside the incubators and of the NCU. If that could be achieved, these infants could be discharged earlier, protecting them against nosocomial risks and easing the burden on the already insufficient neonatal beds. His solution was “natural”, simple and elegant: the stable preterm infant was placed in skin-to-skin contact on top of the mother's bare chest (under her clothes). In that way, the infant could regulate temperature, and had easy on demand access to breastfeeding. Once mother and infant were adapted to this position (the “kangaroo position”), they could be discharged home, and an incubator was freed to accommodate another infant. Mothers and infants needed follow-up in an outpatient clinic that was started in a small pre-fabricated house in the yard of the IMI, the “Casita Canguro” (Kangaroo little house). This eventually evolved into a kind of daytime hospital that substituted for the minimal care neonatal unit....

Background: The Kangaroo Mother Care (KMC) method is a set of interventions for providing appropriate health care to preterm and/or low birth weight infants, based on the so-called kangaroo position (skin-to-skin contact). Since it was first described (Rey 1978) considerable variability has developed about: a) definition of the target population and of the therapeutic goals; b) time for starting skin-to-skin contact; c) continuity and duration of the kangaroo position, d) feeding strategies, and e) discharge and follow up policies. There is an urgent need to standardize the intervention, based on scientific evidence that supports its benefits and limitations. Objective: To develop a set of recommendations about the characterization and proper use of the different components of the Kangaroo Mother Care method, and to support each assertion with a systematic review of evidence. Design/Methods: A multidisciplinary group including experts in the field, heath care workers, users, parents of patients, and methodological and content experts worked between 2005 and 2007 in Javeriana University in Bogota. After defining terms and characterizing components of the intervention, a systematic review of published literature (Medline, Lilacs, hand searching and review of previously compiled bibliographies) was conducted to identify, appraise and summarize the evidence regarding the effects, risks, expected benefits and limitations of each component. Evidence based assertions were widely discussed until consensus with each statement was achieved, and then were evaluated by external peers experts in KMC method in developed countries. Results: Standardized definitions of Kangaroo Mother Care and its components, variants, target population, indications and precautions were produced. An evidence-based foundation for each component was developed, identifying the strength of the evidence, the knowledge gaps, the areas of controversy and the needs for further research. Conclusions: Although sound guidelines should be tailored to local needs and conditions (this particular exercise is focused in the Colombian situation), it is reasonable to expect that many of the recommendations and certainly most of the evidence appraised will be a useful input for guidelines development elsewhere.

A comprehensive review of the evidence documenting preterm infant physiologic responses to Kangaroo Care (KC - intermittent skin-to-skin contact) and Kangaroo Mother Care (KMC - 24/7 skin-to-skin contact) has been conducted. Kangaroo Care's effects on preterm infant heart rate, bradycardia, respiratory rate, apnea, oxygen saturation, cerebral oxygenation, supplemental oxygen needs, oxygen consumption, desaturation episodes, temperature, rewarming, blood glucose, serum bilirubin, cholecystokinin, gastrin, somatostatin, weight gain or change, sleep and crying, brain maturation and complexity, infection, stress, and pain are reviewed, as are KC's effects with congenital heart defect infants. Documented effects of KC on prevention and amelioration of maternal depression, swifter delivery of the placenta and involution, and decreased likelihood of postpartal anemia are presented. Guidelines based on dosage (duration and frequency) of KC are provided, as is a summary of actual and potential benefits of KC, including use at end-of-life. Kangaroo Care's role in moving to the new paradigms of non-separation of the infant and mother during hospitalization and parents as primary providers of neonatal care concludes the manuscript.

The slow progress, indeed the ineffectiveness, in checking the rise in preterm births is undoubtedly partly due to the inaccuracy of predictive models, our focus on curative interventions, and the dearth of prevention strategies in this public health sector. Moreover, results from meta-analyses of observational studies concluded that premature or low birth weight subjects have cognitive deficits, poorer academic performance, attention problems and are less socially competent than their full-term peers, and that these consequences have long lasting impacts on adolescence and adulthood. Can these effects be reversed? Could an intervention such as Kangaroo Mother Care reverse the short- and long-term negative effects of preterm birth? Recent interventions aimed at improving the intensive care unit environment have already shown positive effects on babies' physical growth, respiratory autonomy and length of hospitalization. The KMC program appears to act at a number of levels and in different time windows. In the very short term, it reduces length of hospitalization and exposure to the stressful intensive care unit environment. Since infants are carried by their parents, noise is reduced and absorbed by the latter's clothing and body. KMC allows parents to have early, close contact with their baby and at the same time strengthens the foundation for secure parentinfant bonding. Parents feel more positive and more confident regarding their preterm infant. They appear to accept the intervention and carry it out without any difficulty. The infants gain weight more rapidly, they breathe better, experience less apnea, maintain their body temperature better and have fewer iatrogenic problems due to long hospital stays. In the medium term (12 to 24 months), KMC appears to protect infants who are more fragile at birth. The latter obtain a higher developmental quotient (ranging from 10 to 13 points for the most fragile) than extremely preterm infants who receive traditional care and they benefit from a family environment (including father involvement) that is more dynamic and stimulating than fragile infants who did not receive KMC. However, a number of questions remain regarding the factors responsible for these changes. Given the current state of knowledge, the main hypotheses focus on the neurological changes that result from the intervention. This new neuroscientist approach we conduct in KMC proposes that different types of care can repair the brain to some extent at a critical age, that is, very early. The ancillary knowledge provided by neurophysiological studies on brain functioning should contribute to guide the medical and rehab interventions aimed at minimizing the long-term neurodevelopmental disability of children born preterm.

Significant benefits on infant host defense, sensory-neural development, gastrointestinal maturation, and some aspects of nutritional status are observed when preterm infants are fed with their mothers' own milk. A reduction in infection-related morbidity in human milk-fed preterm infants has been reported. Studies on neuro-developmental outcomes have reported significantly positive effects for human milk intake on mental and motor development. Human milk-fed infants also have decreased rates of rehospitalization following discharge. Hospital-based practices may contribute to increased rates of breast milk feeding for preterm infants for longer periods of time. There is quite a lot of information available on using KMC to promote maternal breastfeeding with the aim of increasing its frequency and duration in preterm infants. The positive effects of Kangaroo skin-to-skin contact on breastfeeding can be stated with some confidence. The provision of personal breastfeeding education and support by a skilled nurse as an integral part of the interventions is likely to increase the success of the intervention both in terms of breastfeeding outcomes and the acceptability of KMC. We should not therefore pass up the opportunity to introduce a low cost intervention such as KMC with consistently beneficial effects demonstrated.

Caring for preterm and low birth weight (LBW) newborns in neonatal care units (NCU) can overwhelm healthcare systems in both developed and developing countries. Ensuring intact survival and adequate growth until term gestation and/or appropriate size is reached before discharging a LBW to the home environment leads to overcrowding of NCUs. This system undoubtedly contributes to increased morbidity and mortality due to the acquisition of secondary infections. Integral to the Kangaroo Mother Care (KMC) intervention is the policy of “early discharge” to the care of the mother/family, maintaining the kangaroo position in the home environment, coupled with frequent follow-ups in specialty clinics. This policy however, has been challenged due to the risks of loss to follow-up and inability to track neonatal outcomes especially in resource-limited places where provisions for ambulatory care are not in place or if available, cannot be accessed. This paper reviews the best available evidence on benefits, risks and safety of early discharge of LBW infants weighing < 2000gm from settings with and without KMC. Whereas safety and risks post-discharge are similar in both settings, the benefits on exclusive breastfeeding rates at discharge up to 3 months thereafter, maternal-infant bonding and family involvement are clearly evident in KMC settings. Unpublished experience by the authors on this policy are also discussed. A practical guide for the implementation of the early discharge policy of the KMC intervention is outlined. The early discharge policy is contingent upon a systematic, operational outpatient follow-up program, the absence of which should motivate the KMC program coordinator to devise appropriate measures to ensure survival and safety of the LBW infant in KMC. A low-care /KMC ward or a “halfway house” have been utilized as alternatives to home discharge in areas where follow-up cannot be assured.

In addition to exerting positive physiological and social effects on preterm infants, the Kangaroo Mother Care method also provides these infants with stimulation, which is similar to the multisensorial stimulation which the fetus receives in utero. Still, in high tech NICUs the application of KMC is typically restricted to limited periods of parentinfant skin-to-skin contact. The aim of this article is to describe practical guidelines for KMC, 24 hours per day whenever possible, in a Swedish university NICU. The guidelines are based on the norm of parent-infant non-separation and infant care in the kangaroo position, continuously whenever possible, and were formulated based on observations and research of infants' and parents' responses during gradual implementation of components in the guidelines. Ideally, KMC is initiated and continues uninterrupted from birth in infants born at ≥ 32 weeks, also after a caesarean section; this is also possible at a gestational age of 28-31 weeks. For infants born at ≤ 27 weeks, intermittent periods of KMC can be introduced during the first week of life, based on individual assessment. The guidelines describe initiation, infant's and parent's positions, transport, transfer to/from the kangaroo position, continuous KMC, performance of nursing and medical procedures during KMC, KMC and infant instability, support of the parental role, and early discharge. Recommendation: KMC, continuous as far as possible, should be the norm for preterm infants also in high tech NICUs.

State-of-the-art Newborn Intensive Care Units (NICUs), instrumental in the survival of high-risk and everearlier- born preterm infants, often have costly human repercussions. The developmental sequelae of newborn intensive care are largely misunderstood. Developed countries eager to export their technologies must also transfer the knowledgebase that encompasses all high-risk and preterm infants' personhood as well as the neuro-essential importance of their parents. Without such understanding, the best medical care, while assuring survival jeopardizes infants' long-term potential and deprives parents of their critical role. Exchanging the womb for the NICU environment at a time of rapid brain growth compromises preterm infants' early development, which results in long-term physical and mental health problems and developmental disabilities. The Newborn Individualized Developmental Care and Assessment Program (NIDCAP) aims to prevent the iatrogenic sequelae of intensive care and to maintain the intimate connection between parent and infant, one expression of which is Kangaroo Mother Care. NIDCAP embeds the infant in the natural parent niche, avoids over-stimulation, stress, pain, and isolation while it supports self-regulation, competence, and goal orientation. Research demonstrates that NIDCAP improves brain development, functional competence, health, and life quality. It is cost effective, humane, and ethical, and promises to become the standard for all NICU care.

Objective: The objective of this study was to assess the feasibility, acceptability and outcome of Kangaroo Mother Care (KMC) on low birth weight (LBW) infants, including morbidity and mortality related to prematurity. Methods: A longitudinal study of preterm infants in KMC at the Gabriel Toure University Hospital (CHU), Bamako, Mali. Data collected in the KMC unit using hospital and ambulatory records. Data entered withEpiInfo and analyzed with SPSS12.0. Results: Mortality in preterm infants was very high (41.4%) before admission to the KMC unit. More than a third (30.7%) of the 480 surviving LBW infants during the study period were admitted to the KMC unit. The mean age of mothers was 25 years, with an average of three antenatal visits per mother. Deliveries had taken place mainly in community and district health centers. The mean gestational age at birth was 32.5 weeks for a mean birth weight of 1355 g. All babies and families admitted met the KMC eligibility criteria. The mean age at admission in the KMC unit was 9 days, with a mean weight of 1432 g, a mean height of 41 cm, and a mean head circumference of 29 cm. Somatic growth was satisfactory with a mean weight gain of 19 g per day during admission. The mean age of entry into the outpatient KMC program was 9.16 days (range: 2-32 days). The overall mortality of preterm infants admitted to the KMC program was 7.91%. Mortality among the preterm infants who remained in the neonatal unit was 51.1%. The KMC deaths occurred mostly between discharge from the KMC unit and 40 weeks of gestational age. The most common difficulties recorded after discharge were non-compliance with periodic visits, the occurrence of gastrointestinal, infectious or neurological complications, and failure to grow. Conclusions: The KMC program has been accepted by all mothers and families. Infants admitted to KMC showed a satisfactory growth. The overall mortality was lower among preterm infants in KMC unit compared to those cared in the neonatal unit.

Community-based Kangaroo Mother Care (CKMC) was designed to be initiated immediately after birth in very low-income settings where most births occur at home, access to clinical care is limited and newborn mortality rates are high. The objectives of CKMC are to prevent hypothermia, some respiratory conditions, diarrhea and improve newborn nutrition. In these settings, babies are seldom weighed at birth and newborn clinical assessment is rarely available, therefore CKMC is promoted for all babies. While KMC was successfully adapted for immediate postnatal communitybased application in the Bangladesh pilot study, subsequent weak training has produced token skin-to-skin care with little health, nutrition or survival potential. If rigorous evaluation proves the CKMC guidelines affordably produce adequate skin-to-skin care, their costs and effectiveness to improve health and survival should be assessed in randomized controlled trials that adhere to the guidelines. Regardless of its health and survival potential, some babies will require other care.