Kangaroo Mother Care

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Dr Edgar Rey and Dr Hector Martinez of the Instituto. Materno Infantil in Bogota .... Cattaneo A, Davanzo R, Bergman N, Charpak N. Kangaroo mother care in low ...
Editorial

Kangaroo Mother Care Kangaroo Mother Care (KMC) was proposed in 1978 by Dr Edgar Rey and Dr Hector Martinez of the Instituto Materno Infantil in Bogota, Colombia.1 Their Maternity Unit at the San Juan de Dios Hospital was very large with 11 000 babies delivered annually, many high risk. KMC was proposed as a solution to the problems in the nursery of overcrowding, nosocomial infection, and high mortality and abandonment rates. The programme was aimed at infants who had overcome the difÆculties of early neonatal life when most mortality occurs. There was some initial confusion around the excellent mortality rates of the programme which were related to infants eligible to enter the programme and not to the overall perinatal or neonatal mortality rates of the unit.2 The issue of who is the study population and who is excluded remains important in evaluating studies on KMC as these can differ. UNICEF was quick to recognize its potential.3 In the 20 years since its conception KMC has evolved in different directions and its evidence base has broadened. Firstly the components of KMC have been more precisely deÆned. Following a two-cohort study that raised questions about early weight gain and neurodevelopment in the KMC infants,4 Charpak et al. modiÆed KMC for an open randomized controlled study.5 It had three components. (i) Kangaroo position–mothers were used as `incubators' with the infant kept 24 hours a day in strict upright position, in skin to skin contact, Ærmly attached to the mother's chest. Infants remained in the kangaroo position until they no longer accepted it by demonstrating discomfort, pushing out limbs, or crying and fussing when mothers tried to return them to the upright position. (ii) Kangaroo feeding–infants were breastfed regularly. Pre-term formula supplements were administered to guarantee adequate weight gain (20 g per day) if necessary. (iii) Kangaroo discharge–infants less than 2000 g at birth were discharged as soon as they overcame major adaptation problems to extra-uterine life, received proper treatment for infection or concomitant condition, could suckle and swallow properly, and achieved a positive weight gain regardless of actual weight or gestational age. Clearly access to the resources needed to fulÆl this study deÆnition is not available in many Ærst-level facilities in countries with very limited resources. A position paper produced by the participants of an international workshop on KMC in 1996 and published 192

q Oxford University Press 1999

in this Journal last year gives very helpful guidance on implementation of the intervention in Ærst-, second-, and third-level facilities in countries with very limited resources.6 The workshop participants produced a further consensus paper which clariÆed Æve critical requirements for the implementation of KMC irrespective of the setting and of the available resources.7 These are: ∑ information and support to mothers, including the issues of consent, replacement of mothers by other family members and the need for support after discharge ∑ training of health personnel ∑ skin to skin contact and thermal control ∑ breastfeeding ∑ discharge when (a) the infant is suckling on the breast and swallowing adequately and is gaining weight; (b) there is temperature instability in the kangaroo position; and (c) adequate follow-up. As KMC has evolved, different facets of the programme have attracted research in their own right. In particular, the skin to skin component has been adapted by high technology units in Europe and North America. Different outcomes have been measured: ∑ temperature control is at least as good as that provided by an incubator8±10 ∑ a reduction in apnoea and periodic respiration compared to control infants11 ∑ higher oxygenation levels and less oxygen desaturation12,13 ∑ no increase in oxygen consumption8,14 ∑ improved neurobehaviour10,11,15 ∑ no additional risk of infection16 ∑ increased production of breastmilk.17 It is interesting that paternal kangaroo care can improve the neonate status as well as maternal care.12 In an attempt to understand what dynamics underlie the premature infants' improved outcomes from skin to skin care Feldman and Eidelman suggest that the key may be the unique integration of the self-regulatory, minimal handling, tactile stimulation, and sensory enrichment perspectives within the setting of parent±infant physical contact.18 Some research groups in resource-poor countries have evaluated the in-patient kangaroo position and kangaroo feeding, also called Hospital KMC. Bergman and Jurisoo reported an observational study with a historical control group from a rural Zimbabwean hospital. There was a reduction in mortality in infants of less than 1500 g from 90 to 50 per cent and in infants weighing 1500 to 1999 g Journal of Tropical Pediatrics

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EDITORIAL

from 30 to 10 per cent.19 This is the only study to date to show a reduction in mortality. Sloan et al. reported an open, randomized controlled trial in Quito, Ecuador.20 The study, randomized 140 infants to hospital-based KMC and 160 control infants were allocated to care in a minimal care unit. Enrolment was terminated early because severe morbidity was signiÆcantly less in the KMC group ( p < 0:02 at 2 months, p < 0:005 at 6 months of age). This paper has been criticized because of the number of the study population which were lost to follow-up.21 Recently more work from Zimbabwe has been published. This pilot study was conducted in a tertiary level hospital and found that the KMC group gained twice as much weight per day (20.8 vs 10.2 g, p à 0:0001), had a shorter hospital stay (16.6 vs 20.7 days, p à 0:0457), and had a better survival rate (0 vs 9 per cent).22 Finally a large randomized controlled trial of hospital based KMC in three tertiary hospitals has been reported. The trial took place in Addis Ababa (Ethiopia), Yogyakarta (Indonesia), and Merida (Mexico) over 1 year. KMC infants had signiÆcantly less hypothermia and were signiÆcantly more likely to be breastfeeding at discharge, these differences were most marked in Merida. KMC infants had a higher mean daily weight gain and were discharged earlier. KMC was found to be at least as safe as conventional methods of care and was found to be feasible in different settings, acceptable to mothers of different cultures, and less expensive.23 The Bogota research group alone have taken the complete KMC package and sought to evaluate its effect. An initial observational two cohort study was complicated by baseline differences between the cohorts. These were particularly apparent in socio-economic status and perinatal care. There was no statistical difference in mortality but the KMC group showed poorer growth in the Ærst 3 months and more developmental delay at 1 year.4 The confounding variables were addressed in the follow-up trial which was an open randomized controlled trial5 with the KMC principles deÆned as above. This study showed no signiÆcant difference in mortality. The growth of the KMC infants was similar to the controls. The KMC group had fewer nosocomial infections and a shorter hospital stay. The early discharge did not increase the readmission rate due to apnoea, hypoglycaemia, or aspiration. This study reported follow-up to 40±41 weeks post-conception age only. Research on KMC has progressed rapidly since the strategy was Ærst reported. It is important when reading the literature to be clear which aspect of KMC is being evaluated. The skin to skin facet investigated in the developed world has good evidence to show that it is physiologically safe. However, the long-term effects on neuropsychologic and emotional development need to be explored further. Hospital KMC or the use of kangaroo position and kangaroo feeding has a growing evidence base. It has only been shown to reduce mortality in one study with a historical control group, however it does not increase mortality either. It has been demonstrated to Journal of Tropical Pediatrics

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reduce hypothermia, improve weight gain, and breastfeeding rates at discharge. It also leads to early discharge, is cost effective, and acceptable to parents. The entire KMC package has been evaluated in one randomized controlled trial which was very encouraging but had a short follow-up period. The International Network on KMC (INK) established at the 1996 Trieste workshop has produced further research priorities. These include: (i) work on the effectiveness and safety of KMC as a means of stabilizing premature and low birthweight infants just after birth; (ii) further health system research on the application of KMC in different settings; (iii) KMC at birth for very low birthweight infants in Ærst- and second-level maternity units in settings with very limited resources; and (iv) KMC for home deliveries not assisted by trained personnel.7 D. E. Simkiss References 1. Rey ES, Martinez HG. Manejo racional del nino prematuro. In: Curso de Medicina Fetal. Universidad Nacional, Bogota, 1983. 2. Whitelaw A, Sleath K. Myth of the marsupial mother: home care of very low birth weight babies in Bogota, Colombia. Lancet 1985; ii: 1206±9. 3. Grant GP. State of the Worlds' Children. Oxford University Press, Oxford, 1984. 4. Charpak N, Ruiz Pelaez JG, Charpak Y. Rey±Martinez kangaroo mother program: an alternative way of caring for low birth weight infants? One year mortality in a two cohort study. Pediatrics 1994; 94: 804±10. 5. Charpak N, Ruiz-Pelaez JG. Figueroa de Calume Z, Charpak Y. Kangaroo mother versus traditional care for new-born infants < 2000 grams: a randomised, controlled trial. Pediatrics 1997; 100: 682±8. 6. Cattaneo A, Davanzo R, Bergman N, Charpak N. Kangaroo mother care in low income countries. J Trop Pediatr 1998; 44: 279±82. 7. Cattaneo A, Davanzo R, Uxa F, Tamburlini G. Recommendations for the implementation of Kangaroo Mother Care for low birth weight infants. Acta Paediatr 1998; 87: 440±5. 8. Acolet D, Sleath K, Whitelaw A. Oxygenation, heart rate and temperature in very low birth weight infants during skin to skin contact with their mothers. Acta Paediatr Scand 1989; 78: 189±93. 9. Bosque EM, Brady JP, Affonso DD et al. Physiologic measures of kangaroo versus incubator care in a tertiary level nursery. J Obstet Gynecol Neonatal Nurs 1995; 24: 219±26. 10. Ludington SM. Energy conservation during skin to skin contact between premature infants and their mothers. Heart Lung 1990; 19: 445±51. 11. Messiner PR, Todriguez S, Adams J et al. Effect of kangaroo care on sleep time for neonates. Pediatr Nurs 1997; 23: 408±14. 12. Bauer J, Sontheimer D, Fischer C et al. Metabolic rate and energy balance in very low birth weight infants during kangaroo holding by their mothers and fathers. J Pediatr 1996; 129: 608±11. 13. Legault M, Goulet C. Comparison of kangaroo and traditional methods of removing preterm infants from incubators. J Obstet Gynecol Neonatal Nurs 1995; 24: 501±6. 193

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14. Bauer K, Uhrig C, Sperling P et al. Body temperature and oxygen consumption during skin to skin (kangaroo) care in stable preterm infants weighing less than 1500 grams. J Pediatr 1997; 130: 240±4. 15. Ludington-Hoew SM, Swinth JY. Developmental aspects of kangaroo care. J Obstet Gynecol Neonatal Nurs 1996; 25: 691±703. 16. Anderson GC. Current knowledge about skin to skin (kangaroo) care for preterm infants. J Perinatal 1991; 11: 215±25. 17. Hurst N, Valentine C, Renfro L et al. Skin to skin holding in the neonatal intensive care unit inØuences maternal milk volume. J Perinatal 1997; 17: 213±17. 18. Feldman R, Eidelman A. Intervention programs for premature infants–how do they affect development? Clin Perinatol 1998; 25: 613±26.

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19. Bergman NJ, Jurisoo LA. The `Kangaroo method' for treating low birth weight babies in a developing country. Trop Doct 1994; 24: 57±60. 20. Sloan NL, Camacho LW, Rojas EP et al. Kangaroo mother method: randomised controlled trial of an alternative method of care for stabilised low birth weight infants. Lancet 1994; 344: 782±8. 21. Charpak N, Ruiz-Pelaez JG, Figueroa de Calume Z. Current knowledge of kangaroo mother intervention. Curr Opin Pediatr 1996; 6: 108±12. 22. Kambarami RA, Chidede O, Kowo DT. Kangaroo care versus incubator care in the management of well preterm infants–a pilot study. Ann Trop Paediatr 1998; 18: 81±6. 23. Cattaneo A, Davanzo R, Worku B et al. Kangaroo mother care for low birth weight infants: a randomised controlled trial in different settings. Acta Paediatr 1998; 87: 976±85.

Journal of Tropical Pediatrics

Vol. 45

August 1999