State of the art and recommendations. Kangaroo mother care: application in a high-tech environment

Since Kangaroo Mother Care (KMC) was developed in Colombia in the 1970s, two trends in clinical application emerged. In low-income settings, the original KMC modelis implemented. This consists of continuous (24 h/day; 7 days/week) and prolonged mother/parent-infant skin-to-skin contact; early discharge with the infant in the kangaroo position; (ideally) exclusive breastfeeding and, adequate follow up. In affluent settings, intermittent KMC with sessions of one or a few hours skin-to-skin contact for a limited period is common. As a result of the increasing evidence of the benefits of KMC for both infants and families in all intensive care settings, KMC in a high-tech environment was chosen as the topic for the first European Conference on KMC, and the clinical implementation of the KMC modelin all types of settings was discussed at the 7th International Workshop on KMC Kangaroo Mother Care protocols in high-tech Neonatal Intensive Care Units (NICU) should specify criteria for initiation, kangaroo position, transfer to/from KMC, transport in kangaroo position, kangaroo nutrition, parents'role, modification of the NICU environment, performance of care in KMC, and KMCin case of infant instability.

CONCLUSION

Implementation of the original KMC method, with continuous skin-to-skin contact whenever possible, is recommended for application in high-tech environments, although scientific evaluation should continue.

Towards universal Kangaroo Mother Care: recommendations and report from the First European conference and Seventh International Workshop on Kangaroo Mother Care

The hallmark of Kangaroo Mother Care (KMC) is the kangaroo position: the infant is cared for skin-to-skin vertically between the mother's breasts and below her clothes, 24 h/day, with father/substitute(s) participating as KMC providers. Intermittent KMC (for short periods once or a few times per day, for a variable number of days) is commonly employed in high-tech neonatal intensive care units. These two modalities should be regarded as a progressive adaptation of the mother-infant dyad, ideally towards continuous KMC, starting gradually and progressively with intermittent KMC. The other components in KMC are exclusive breastfeeding (ideally) and early discharge in kangaroo position with strict follow-up. Current evidence allows the following general statements about KMC in affluent and low-income settings: KMC enhances bonding and attachment; reduces maternal postpartum depression symptoms; enhances infant physiologic stability and reduces pain, increases parental sensitivity to infant cues; contributes to the establishment and longer duration of breastfeeding and has positive effects on infant development and infant/parent interaction. Therefore, intrapartum and postnatal care in all types of settings should adhere to a paradigm of nonseparation of infants and their mothers/families. Preterm/low-birth-weight infants should be regarded as extero-gestational foetuses needing skin-to-skin contact to promote maturation.

CONCLUSION

Kangaroo Mother Care should begin as soon as possible after birth, be applied as continuous skin-to-skin contact to the extent that this is possible and appropriate and continue for as long as appropriate.

State of the art and recommendations. Kangaroo mother care: application in a high-tech environment

Since Kangaroo Mother Care (KMC) was developed in Colombia in the 1970s, two trends in clinical application emerged. In low income settings, the original KMC model is implemented. This consists of continuous (24 h/day, 7 days/week) and prolonged mother/parent-infant skin-to-skin contact; early discharge with the infant in the kangaroo position; (ideally) exclusive breastfeeding; and, adequate follow-up. In affluent settings, intermittent KMC with sessions of one or a few hours skin-to-skin contact for a limited period is common. As a result of the increasing evidence of the benefits of KMC for both infants and families in all intensive care settings, KMC in a high-tech environment was chosen as the topic for the first European Conference on KMC, and the clinical implementation of the KMC model in all types of settings was discussed at the 7th International Workshop on KMC. Kangaroo Mother Care protocols in high-tech Neonatal Intensive Care Units (NICU) should specify criteria for initiation, kangaroo position, transfer to/from KMC, transport in kangaroo position, kangaroo nutrition, parents' role, modification of the NICU environment, performance of care in KMC, and KMC in case of infant instability.

CONCLUSION

Implementation of the original KMC method, with continuous skin-to-skin contact whenever possible, is recommended for application in high-tech environments, although scientific evaluation should continue.

Kangaroo Mother Care, home environment and father involvement in the first year of life: a randomized controlled study

AIMS

This study tested the hypothesis that Kangaroo Mother Care creates a climate in the family, which enhances infants' performance on the developmental quotient scale.

SETTING

The largest social security hospital in Colombia with a neonatal intensive care unit.

SUBJECTS

At 12 months of corrected age, 194 families in the Kangaroo Mother Care group and 144 families in the Traditional Care group were available for analysis.

INTERVENTIONS

Infants were kept 24 h/day in an upright position, in skin-to-skin contact until it was no longer tolerated by the infants. Babies in the Traditional Care were kept in incubators on the Minimal Care Unit until they satisfied the usual discharge criteria.

OUTCOME MEASURES

The Home Observation for Measurement of the Environment (HOME), Father Involvement and Developmental Quotient (Griffiths) scores.

RESULTS

1) Kangaroo mothers created a more stimulating context and a better caregiving environment than mothers in the Traditional Care group; 2) this environment was positively correlated to father involvement and 3) the family environment of male infants was most improved by Kangaroo Mother Care.

CONCLUSION

Kangaroo Mother Care has a positive impact on home environment. The results also suggest, first, that both parents should be involved as direct caregivers in the Kangaroo Mother Care procedure and secondly, that this intervention should be directed more specifically at infants who are more at risk at birth. The Kangaroo Mother Care intervention could be an excellent means to ensure parents' mature involvement in the future of their children.

Breast milk composition in a cohort of pre-term infants' mothers followed in an ambulatory programme in Colombia

OBJECTIVES

Describing preterm breast milk evolution and composition according to gestational age (GA) and postnatal age (PNA) in a cohort of mothers cared for in an ambulatory Kangaroo Mother Care Program (KMCP) in a developing country.

METHODS

A cohort involving 113 mothers who delivered 'healthy' preterms adequate for GA was assembled. Mothers received intensive breastfeeding support before discharge. Samples of both fore- and hind milk were obtained at entry into KMCP and weekly thereafter, until term. Composition was described according to PNA and postconceptional age (PCA).

RESULTS

Protein concentration varied inversely with both PCA and PNA. Fat concentration was consistently higher in hind milk than in fore milk samples of the same feed. Lactose increased steadily with PCA. Calcium/phosphorus ratios were stable, close to 2:1 and content of both was similar in samples of different PCA and PNA.

CONCLUSION

Minerals concentration could be inadequate for preterms. Protein concentration decreases steadily to mature milk levels by the third week of PNA, regardless of birth GA. Therefore, from the third week of PNA onwards, protein content could be insufficient to satisfy needs of preterms born at 32 weeks or less. Feeding hind milk could increase caloric density and fat intake to better meet preterms' nutritional needs.

Influence of feeding patterns and other factors on early somatic growth of healthy, preterm infants in home-based kangaroo mother care: a cohort study

OBJECTIVE

Breast-milk fortifiers recommended for premature infants are seldom available in developing countries. We describe the characteristics of growth in preterm infants under ambulatory Kangaroo Mother Care (KMC) who eventually required supplemental formula because of failure to thrive with exclusive breast feeding. We evaluated the relationship between growth indices at term, nutritional status of the infant at birth, and feeding pattern.

DESIGN

Prospective cohort study conducted in the Neonatal Unit at Clínica San Pedro Claver and the KMC program, an ambulatory clinic from the Clínica del Niño tertiary care clinics in Bogotá, Colombia. Included were 115 mothers and their 129 healthy, preterm infants. One hundred twenty-six (98.4%) infants were available for evaluation at term. Infant weights were monitored daily until they achieved 15 g/kg per day for 2 days and then weekly until term. Formula was offered only to infants who did not gain 15 g per kg per day for 3 consecutive days.

RESULTS

Sixty (47.6%) infants gained weight adequately with exclusive breast feeding. In 14 of those who needed supplements, adequate weight gain was achieved before reaching term and supplements could be stopped. The more immature infants required supplementation more frequently. With or without supplementation, infants with lower weight for gestational age at birth were less likely to achieve adequate weight by term.

CONCLUSIONS

Growth indices at term in premature infants were close to those expected for term infants born in Bogotá (between percentile 10 to percentile 25). Decision on formula supplementation of breast milk should be made not only based on birth weight or gestational age but on a careful monitoring of weight gain while the mother is receiving continuous support to enhance and maintain successful breast-feeding. Small-for-date premature infants thrive less well than other infants even with supplementation.

Ethical issues in research on control of the HIV/AIDS epidemic: report from a workshop of the world federation of scientists, Erice, Sicily, Italy, 22-24 August 2003

In research on control of the HIV/AIDS epidemic there are many ethical issues to be considered. The problem of personal autonomy versus the interest of society to prevent the spread of the disease in various settings makes it difficult to follow the regulations of the Declaration of Helsinki in all respects. This is particularly clear in the evaluation of trials aimed at preventing mother-to-child transmission of HIV. The interest of the child does not always conform to the policy of avoiding stigmatization of the mother. Programmes for the implementation of antiretroviral therapy and vaccine trials may differ in countries with different mean incomes of the inhabitants, and are also influenced by local patterns. For this reason, the Declaration of Helsinki should be changed in such a way that it conforms with the ways in which it may be possible to combat such a disastrous epidemic as that caused by HIV.

Predictional need for supplementing breastfeeding in preterm infants under Kangaroo Mother Care

It has been estimated that 95% of low-birthweight infants are born in developing countries. Nevertheless, most of the globally available resources are invested in developed countries, both for sophisticated, expensive technological care and for research focused on solving problems in scenarios in which access to expensive resources is available. Very little research on scientifically sound, economically accessible interventions reaches internationally recognized scientific journals. For instance, one accepted scientific dogma is that all premature infants must receive breast-milk fortifiers. Thus, healthcare workers consider that not offering fortification or supplementation to all preterm infants under 2000 g is unethical, as it denies them the proven benefits of this intervention. This approach oversimplifies the problem by assuming that infants under 2000 g are a homogeneous population, with similar needs and risks. The largest proportion of preterm survivors in developing countries comprises infants weighing > 1200 g, and their nutritional needs differ from those weighing < 1200 g, who represent a significantly smaller proportion. In developing countries, fortification of breast milk is seldom a feasible option. Even supplementing breast milk with formula implies an expense that cannot always be covered. In addition, many preterm infants (particularly those weighing > 1200 g) can grow properly on exclusive breastfeeding. In our experience, about 45% of infants under ambulatory Kangaroo Mother Care (KMC) thrive properly. The choice between giving and withholding supplementation for all preterm infants is not an ethical issue, because there is no choice. This was the justification for conducting the study reported here, which attempts to answer the question of how to identify, as early as possible, those premature infants who survive the early neonatal period and have no obvious risk factors for inadequate growth other than prematurity, but who are less likely to thrive with exclusive breastfeeding.

CONCLUSION

The answer to this question will allow us to use our meagre resources in the most reasonable way, as supplementing breast milk involves not only the direct cost of the formula but also that of training the mothers in techniques for feeding their infants without compromising breastfeeding or increasing the risk of infectious diseases.

A randomized, controlled trial of kangaroo mother care: results of follow-up at 1 year of corrected age

OBJECTIVE

To assess the effectiveness and safety of Kangaroo Mother Care (KMC) for infants of low birth weight.

METHODS

An open, randomized, controlled trial of a Colombian social security referral hospital was conducted. A total of 1084 consecutive infants who were born at </=2000 g were followed, and 746 newborns were randomized when eligible for minimal care, with 382 to KMC and 364 to "traditional" care. Information on vital status was available for 693 infants (93%) at 12 months of corrected age. KMC consisted of skin-to-skin contact on the mother's chest 24 hours/day, nearly exclusive breastfeeding, and early discharge, with close ambulatory monitoring. Control infants remained in incubators until the usual discharge criteria were met. Both groups were followed at term and at 3, 6, 9, and 12 months of corrected age. The main outcomes measured were morbidity, mortality, growth, development, breastfeeding, hospital stay, and sequelae.

RESULTS

Baseline variables were evenly distributed, except for weight at recruitment (KMC: 1678 g; control participants: 1713 g). The risk for death was lower among infants who were given KMC, although the difference was not significant (KMC: 11 [3.1%] of 339; control participants: 19 [5.5%] of 324; relative risk: 0.57; 95% confidence interval: 0.17-1.18). The growth index of head circumference was statistically significantly greater in the group given KMC, but the developmental indices of the 2 groups were similar. Infants who weighed </=1500 g at birth and were given KMC spent less time in the hospital than those who were given standard care. The number of infections was similar in the 2 groups, but the severity was less among infants who received KMC. More of these infants were breastfed until 3 months of corrected age.

CONCLUSION

These results support earlier findings of the beneficial effects of KMC on mortality and growth. Use of this technique would humanize the practice of neonatology, promote breastfeeding, and shorten the neonatal hospital stay without compromising survival, growth, or development.

Kangaroo mother care and the bonding hypothesis

BACKGROUND

Based on the general bonding hypothesis, it is suggested that kangaroo mother care (KMC) creates a climate in the family whereby parents become prone to sensitive caregiving. The general hypothesis is that skin-to-skin contact in the KMC group will build up a positive perception in the mothers and a state of readiness to detect and respond to infant's cues.

METHOD

The randomized controlled trial was conducted on a set of 488 infants weighing <2001 g, with 246 in the KMC group and 242 in the traditional care (TC) group. The design allows precise observation of the timing and duration of mother-infant contact, and takes into account the infant's health status at birth and the socioeconomic status of the parents. BONDING ASSESSMENT: Two series of outcomes are assessed as manifestations of a mother's attachment behavior. The first is the mother's feelings and perceptions of her premature birth experience, including her sense of competence, feelings of worry and stress, and perception of social support. The second outcome is derived from observations of the mother and child's responsivity to each other during breastfeeding at 41 weeks of gestational age.

INTERVENTIONS

KMC has three components. The first is the kangaroo position. Once the premature infant has adapted to extrauterine life and is able to breastfeed, he is positioned on the mother's chest, in a upright position, with direct skin-to-skin contact. The second component is kangaroo nutrition. Although breastfeeding is the prime source of nutrition, infants also may receive preterm formula whenever necessary and vitamin supplements. The third component is the clinical control; infants are monitored on a regular basis, daily until they are gaining at least 20 g per day. Afterward, weekly clinic visits are scheduled until term, which constitutes the ambulatory minimal neonatal care. In the TC group, infants are kept in incubators until they are able to self-regulate their temperature and are thriving (ie, have an appropriate weight gain). Infants are discharged according to current hospital practice, usually not before their weight is approximately 1700 g. Afterward, as with the KMC group, weekly clinic visits are scheduled until term.

RESULTS

We observed a change in the mothers' perception of her child, attributable to the skin-to-skin contact in the kangaroo-carrying position. This effect is related to a subjective "bonding effect" that may be understood readily by the empowering nature of the KMC intervention. Moreover, in stressful situations when the infant has to remain in the hospital longer, mothers practicing KMC feel more competent than do mothers in the TC group. This is what we call a resilience effect. In these stressful situations we also found a negative effect on the feelings of received support of mothers practicing KMC. We interpret this as an isolation effect. To thwart this deleterious effect, we would suggest adding social support as an integral component of KMC. The observations of the mothers' sensitive behavior did not show a definite bonding effect, but rather a resilience effect. This is attributable to the KMC intervention; mothers practicing KMC were more responsive to an at-risk infant whose development has been threatened by a longer hospital stay. Otherwise, we observed that the mothers (in both the KMC group and the TC group) had behavioral patterns that were adapted to the child's at-risk health status and to the precarious condition of some premature infants requiring intensive care. We conclude that the infant's health status may be a more prominent factor in explaining a mother's more sensitive behavior, which overshadows the kangaroo-carrying effect.

CONCLUSION

These results suggest that 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 the 40 weeks of gestational age. Thus, KMC should be viewed as a means of humanizing the process of g

Kangaroo mother versus traditional care for newborn infants </=2000 grams: a randomized, controlled trial

BACKGROUND

In 1978, kangaroo mother care (KMC) was proposed as a caring alternative for low birth weight (LBW) infants. We are reporting here early outcomes of a randomized, controlled trial comparing KMC to traditional care.

METHOD

An open randomized, controlled trial was conducted in a large tertiary care hospital. All newborn infants </=2000 g, surviving the neonatal period and being eligible for a minimal care unit, were included. A total of 1084 newborns </=2000 g were followed, and 746 were randomized-382 to KMC and 364 to traditional care. KMC infants were discharged after randomization, regardless of weight or gestational age. Infants spent 24 hours per day in an upright position, in skin-to-skin contact, and attached to the mother's chest. After randomization, control infants remained at the minimal care unit until meeting usual discharge criteria. Both groups are being followed up to 12 months of corrected age; 679 (90%) were available for evaluation when they reached term (40 to 41 weeks of postconceptional age). The present paper reports early outcomes (when reaching term) including mortality, infectious episodes, hospital stay after eligibility, and growth and feeding patterns.

RESULTS

Both study groups were similar regarding all baseline variables but weight at eligibility. The risk of dying was similar in both groups (relative risk = 0.59, 95% confidence interval 0.22-1. 6). There were no differences in growth indices. Nosocomial infections were more frequent in control infants. Hospital stay after eligibility was shorter in KMC, primarily for infants </=1800 g.

CONCLUSIONS

These results show that KMC is a safe approach to the care of clinically stable LBW infants. Our findings provide the necessary scientific support to a method that is already incorporated in the care of LBW infants at many hospitals around the world and at different levels of care.

Current knowledge of Kangaroo Mother Intervention

Kangaroo Mother Intervention (KMI) started in 1978 in Colombia as a way of dealing with overcrowding and scarcity of resources in hospitals caring for low birth weight infants. Currently the intervention comprises three components: kangaroo position (skin-to-skin contact), kangaroo nutrition (exclusive or nearly exclusive breast-feeding), and kangaroo discharge policies (early discharge in kangaroo position regardless of weight or gestational age). Different authors have adopted and adapted diverse components of the KMI to suit the particular needs of their parents. We discuss different modalities of kangaroo care reported in developed and in developing countries and also describe in some detail the components of the whole KMI program. In addition, results from a systematic review of kangaroo-related papers published in English between 1991 and 1995 are provided, together with a summary of current knowledge (evidence-based) and research needs.

Rey-Martinez Kangaroo Mother Program: an alternative way of caring for low birth weight infants? One year mortality in a two cohort study

OBJECTIVES

To assess the effectiveness and safety of the Kangaroo mother intervention (KMI).

DESIGN

Observational, analytic, prospective (two cohorts) study.

SETTING

Two large tertiary care obstetric hospitals, one offering "traditional" care and the other KMI.

PATIENTS

Newborn infants with birth weights < or = 2000 g, who survive the neonatal period and are eligible for an in-patient minimal care unit (MCU) (having overcome major adaptation problems to extra uterine life).

INTERVENTIONS

"Kangaroo infants" (KI) were discharged as soon as they were eligible for MCU, regardless of weight or gestational age. Infants were kept 24 hours a day in an upright position, in skin-to-skin contact and firmly attached to the mother's chest until the KMI was not tolerated anymore. Control babies (from the other facility) were kept in incubators at the MCU until they satisfied usual discharge criteria for the control hospital. Both groups were followed periodically up to the age of 1 year.

RESULTS

Three hundred thirty-two eligible infants were recruited, 162 at the Kangaroo hospital and 170 at the control hospital. KI came from a much lower socio-economic class and were more ill before eligibility. Relative risk of death was higher for KI (RR 1.9), although this figure was reversed after adjusting for weight at birth and gestational age (RR 0.5). KI grew less in the first 3 months and had a higher proportion of developmental delay at 1 year, and a multivariate analysis failed to control for the large baseline differences in socioeconomic levels and babies' health status between the two cohorts.

CONCLUSIONS

In spite of major baseline differences between studied cohorts, the survival of LBW infants in Bogotá is similar between the KMI and the "traditional care". Questions remain about quality of life, especially regarding weight gain and neurodevelopment, that may be answered by a Randomized Controlled Trial.