Kangaroo Mother Care, an example to follow from developing countries
BMJ 2004; 329 doi: https://doi.org/10.1136/bmj.329.7475.1179 (Published 11 November 2004) Cite this as: BMJ 2004;329:1179All rapid responses
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Ruiz-Palaez et al describe the “Bogota experience” of Kangaroo Mother
Care, arising in a context of shortage of incubators, and define a
management programme involving a number of elements 1. The first of these
is maternal infant skin-to-skin contact starting after stabilisation in a
neonatal care unit. The second element is breastfeeding, preferably
exclusive. The third element described is early discharge after an
adaptation period, which can be delayed in the form of kangaroo wards,
with subsequent follow-up. As originally described by Drs Rey and
Martinez2, and with subsequent minor modifications, this method has indeed
been highly effective in many developing countries.
Marlow’s comment differentiates between the developing country
context and the use of KMC in Western settings: issues around bonding,
better breastfeeding, and shorter lengths of stay 3. Marlow does however
make an important point which deserves elaboration. There are a host of
effective interventions (some aggressive and interventionist, some more
natural) for which we have good evidence of efficacy, but there is a need
to elucidate “for the more complex interventions, which components are the
most effective”.
Kangaroo Mother Care is a generic definition of a model of newborn
care4, composed of a number of components or elements as described above,
and each of those elements have a range possible applications. It is not
one intervention , but a complex strategy. It is becoming generally
accepted that exclusive breastfeeding, though culturally uncommon, is the
optimal feeding method5, but context and circumstances determine a range
of feeding methods from near exclusive to mixed feeding to complete
artificial feeding6. Where long term outcomes are studied, it is essential
to control for feeding method, as it is now established that breastfeeding
duration directly impacts on cognitive and other neurodevelopment
outcomes7. Adaptation, discharge and followup (though important parts of
KMC)1 are highly context and resource dependent, and are unlikely to
directly impact on long term outcomes as do breastfeeding and skin-to-skin
contact.
Maternal-infant skin-to-skin contact (SSC), is the primary and
essential element of KMC. It has a number of important dimensions, each of
which may individually and critically influence the effectiveness of KMC
as a model of care. Initiation of SSC is the first, and possibly the most
important. In the developing world, the majority of premature newborns do
not have access to neonatal care units or incubators, and die before they
stabilise. KMC started after stabilisation as described by Ruiz-Pelaez et
al would not help such infants. Various reports have however shown the
safety of and potential to improve mortality by initiating SSC from birth,
or within the first hour of life, regardless of stabilisation8-11. A
recently published randomised controlled trial from a western setting
provides evidence that lowbirth weight infants stabilise better in SSC
than they do in incubators12. In the absence of incubators, this could
potentially save many lives.
Two other important time dimensions of SSC are dose and duration.
Even ten minutes per day of SSC can impact maternal breastfeeding
success13, but it does appear that for the infant, a minimum episode of 60
– 90 minutes is required to achieve physiological benefit14. Shorter
periods may in fact be disruptive to the infant’s state organisation.
However, continuous SSC is likely to be the optimum for the newborn, and
in particular for the neurodevelopment of the infant, see more below.
Continuous SSC may initially appear impossible in the interventionist and
technological milieus the western world has created in neonatal units, but
is easy, obvious and uncomplicated elsewhere.
Duration of SSC is obviously dependent on a variety of factors. In
many units term newborns may spend the first hour of life in SSC, before
being separated15;16. In many western settings SSC is encouraged for a
brief period prior to discharge. However from a neurodevelopmental
perspective, SSC is the salient stimulus for the development of the
amygdala-prefrontorbital tract, the first pathway for healthy right brain
development and subsequent mental health, and this develops up to the 48th
post-menstrual week17. It can be inferred therefore that KMC is not only
important for premature babies, but all newborns. Experience does confirm
that the infant will “reject permanent contact”1 in its own time, though
this varies greatly from infant to infant.
Hypothetically: the ideal or gold standard would be that SSC starts
from birth, is continuous 24 hours a day, and continues to 6 or 8 weeks
post-menstrual age. Anthropological studies show that the majority of
tropical hunter-gatherer societies, presumably behaving more naturally and
in tune with basic evolutionary and biological drives, abide by this gold
standard18.
A further important dimension of SSC relates to technique. A variety
of wrappers, ties and shirts have been described to empower and support
mothers to provide continuous SSC19. For shorter periods as described in
western settings, simple placement on mothers chest, covering with cloth,
and observations is adequate. An absolute requirement is that the infant
airway is continuously protected, until such a time that there is head
control. Continuous SSC is better achieved with techniques that give the
mother maximal freedom of movement. When applied to premature infants from
birth, the upright position is not always well tolerated: the infant is
best placed at an angle of 30 to 40 degrees from horizontal8.
A final dimension concerns the integration of SSC with “support”:
which ranges from psychological and social support to the “aggressive and
interventionist” technological support available in western settings. It
must be emphasised that SSC does not exclude technological support, rather
the KMC paradigm is one that places the maternal infant dyad in the centre
of care, to which is added whatever support is available as indicated.
This may require considerable modifications and adjustments to
infrastructure and equipment.
Thus, Marlow is correct that further research is needed; and this
should be done in western settings. This research should however focus on
“maternal-infant skin-to-skin contact”, and should address the dimensions
of time of initiation, dose, duration, technique and support. Unanswered
questions relate particularly to infant limits of gestational age and
weight, and to maternal tolerance. There is a little evidence of maternal
benefit in the literature20-24, but hypothetical arguments for lasting
positive impact exist25-28.
In terms of the importance of KMC for the developed world, the most
important aspect is almost certainly its impact on the neurodevelopment of
the premature infant. Improved survival of premature infants has been
achieved by providing thermal and cardiorespiratory support, with little
consideration for the premature’s brain. The quality of that survival can
however be compromised: it is accomplished through technological
interventions, resulting in prolonged maternal infant separation.
Separation results in infant “hyper-arousal dissociation behaviours”,
which when prolonged result in compensatory brain pathways, with permanent
adverse effects across the lifespan29;30. Schore reviews a body of
psychoneurobiological and psychiatric research with a neurodevelopmental
perspective29. For healthy (right) brain development, the newborn requires
the maternal milieu to provide essential salient stimuli, which sculpt the
final configuration of the brain26. Thus, Feldman et al report that
infants receiving SSC in the neonatal care unit had better perceptual-
cognitive and motor development at six months than controls.25
Anthropologists, with a different perspective of what constitutes “normal
care”, would interpret the same results by saying that premature infants
separated from their mothers have deleterious developmental outcomes.
KMC comes to readers in western settings with connotations of “nice
and cute”, and “appropriate for the developing world”. It is however, as
Ruiz-Pelaez et al propose, an example for the developed world to follow.
Maternal-infant skin-to-skin contact, provided from birth and
continuously, embodies and defines individualised neurodevelopmental care,
and should be regarded as a fundamental right of every newborn, premature
or otherwise. We should not surrender the technology we have mastered, but
we should ensure the humanisation of premature infant care, and restore
all mothers to their newborns31.
Dr Nils Bergman.
bergman@xsinet.co.za
Reference List
1. Ruiz-Palaez, J. G., Charpak, N., and Cuervo, L. G. Kangaroo
Mother Care, an example to follow from developing countries. BMJ
329(10.1136/BMJ.329.7475.1179), 1179-1181. 11-13-2004.
2. Rey SE,.Martinez GH. Maejo racional del nino prematuro.
Proceedings of the Conference 1 Curso de Medicina Fetal y Neonatal,
1981;Bogota, Colombia: Fundacion Vivar, 1983. (Spanish)..
3. Marlow, N. Family friendly care. BMJ 329, 1182-1182. 11-13-2004.
4. Cattaneo A, Davanzo R, Bergman N, Charpak N. Kangaroo mother care
in low-income countries. International Network in Kangaroo Mother Care.
J.Trop.Pediatr. 1998;44:279-82.
5. Heinig J,.Ishii K. Exclusive Breastfeeding: Isn't Some
Breastfeeding Good Enough? J.Hum.Lact. 2004;20:np.
6. Labbok M,.Krasovec K. Toward consistency in breastfeeding
definitions. Stud.Fam.Plann. 1990;21:226-30.
7. Oddy WH, Kendall GE, Blair E, De Klerk NH, Stanley FJ, Landau LI
et al. Breast feeding and cognitive development in childhood: a
prospective birth cohort study. Paediatr.Perinat.Epidemiol. 2003;17:81-90.
8. Bergman NJ,.Jurisoo LA. The 'kangaroo-method' for treating low
birth weight babies in a developing country. Trop.Doct. 1994;24:57-60.
9. Lincetto O, Nazir AI, Cattaneo A. Kangaroo mother care with
limited resources. J.Trop.Pediatr. 2000;46:293-5.
10. Ludington-Hoe SM, Anderson GC, Simpson S, Hollingsead A, Argote
LA, Rey H. Birth-related fatigue in 34-36-week preterm neonates: rapid
recovery with very early kangaroo (skin-to-skin) care.
J.Obstet.Gynecol.Neonatal Nurs. 1999;28:94-103.
11. Ludington-Hoe SM, Anderson GC, Swinth JY, Thompson C, Hadeed AJ.
Randomized controlled trial of kangaroo care: cardiorespiratory and
thermal effects on healthy preterm infants. Neonatal Netw. 2004;23:39-48.
12. Bergman NJ, Linley LL, Fawcus SR. Randomized controlled trial of
skin-to-skin contact from birth versus conventional incubator for
physiological stabilization in 1200- to 2199-gram newborns. Acta Paediatr.
2004;93:779-85.
13. Hurst NM, Valentine CJ, Renfro L, Burns P, Ferlic L. Skin-to-
skin holding in the neonatal intensive care unit influences maternal milk
volume. J.Perinatol. 1997;17:213-7.
14. Modi N,.Glover V. Non-pharmacological reduction of
hypercortisolaemia in preterm infants. Infant Behaviour and Development
1998;21 April 1998:86.
15. Koepke JE,.Bigelow AE. Observations of Newborn Suckling
Behaviour. Infant Behaviour and Development 1997;20:93-8.
16. Righard L,.Alade MO. Effect of delivery room routines on success
of first breast-feed. Lancet 1990;336:1105-7.
17. Schore AN. Effects of a secure attachment relationship on right
brain development, affect regulation, and infant mental health. Infant
Mental Health Journal 2001;22:7-66.
18. Lozoff B,.Brittenham G. Infant care: cache or carry. J.Pediatr.
1979;95:478-83.
19. Department of Reproductive Health and Research, World Health
Organisation. Kangaroo mother care: a practical guide. (1st ed). 2004.
Geneva, WHO.
20. Affonso D, Bosque E, Wahlberg V, Brady JP. Reconciliation and
healing for mothers through skin-to-skin contact provided in an American
tertiary level intensive care nursery. Neonatal Netw. 1993;12:25-32.
21. Anderson GC. The mother and her newborn: mutual caregivers.
JOGN.Nurs. 1977;6:50-7.
22. Carlsson SG, Fagerberg H, Horneman G, Hwang CP, Larsson K,
Rodholm M et al. Effects of amount of contact between mother and child on
the mother's nursing behavior. Dev.Psychobiol. 1978;11:143-50.
23. Curry MA. Maternal attachment behavior and the mother's self-
concept: the effect of early skin-to-skin contact. Nurs.Res. 1982;31:73-8.
24. De Chateau P,.Wiberg B. Long-term effect on mother-infant
behaviour of extra contact during the first hour post partum. III. Follow-
up at one year. Scand.J.Soc.Med. 1984;12:91-103.
25. Feldman R, Eidelman AI, Sirota L, Weller A. Comparison of skin-
to-skin (kangaroo) and traditional care: parenting outcomes and preterm
infant development. Pediatrics 2002;110:16-26.
26. Hofer MA. Early relationships as regulators of infant physiology
and behaviour. Acta Paediatr. 1994;Suppl 397:9-18.
27. Keverne EB,.Kendrick KM. Maternal behaviour in sheep and its
neuroendocrine regulation. Acta Paediatr Suppl 1994;397:47-56.
28. Klaus MH, Jerauld R, Kreger NC, McAlpine W, Steffa M, Kennel JH.
Maternal attachment. Importance of the first post-partum days.
N.Engl.J.Med. 1972;286:460-3.
29. Schore AN. The effects of early relational trauma on right brain
development, affect regulation, and infant mental health. Infant Mental
Health Journal 2001;22:201-69.
30. Kjellmer I,.Winberg J. The neurobiology of infant-parent
interaction in the newborn: an introduction. Acta Paediatr Suppl
1994;397:1-2.
31. Levin A. Humane Neonatal Care Initiative. Acta Paediatr.
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Competing interests:
Author markets a shirt for facilitating continuous skin-to-skin contact.
Competing interests: No competing interests
The Kangaroo Mother Care, which has been presented in the “Kangaroo
Mother Care, an example to follow from developing countries” article 1,
has saved thousand of lives of premature children. It is a case where
natural warm from the mother overcome the available technological
advancements at hospitalary level
The first time when we heard and learnt about this health care
approach was in the ends of 70’s at the Instituto Materno Infantil (IMI),
when we were students at the Universidad Nacional de Colombia`s Medical
School. In this place, Professor Edgar Rey showed us the advantages of
carry on the premature child, over the incubator. At the IMI was
originated and developed implemented for the first time the Kangaroo
mother care
The IMI, is a 60 years old institution. It is the biggest reference
center for maternal and perinatal care located in Bogotá. There are many
important researches in progress in it and it has participated as
collaborative institution, in international investigations as the Magpie
Trial, for instance 2. However nowadays the IMI is nearby to close its
doors as result of the Health Sector Reform implemented since 1993 3.
This reform has left without enough financial resources several
institutions that have already been closed definitively.
This is a special opportunity, to congratulate visible actors of
Kangaroo Program, and to defend an invisible one, that it is going to be
closed nearly. With it, it will be closed too, the Kangaroo Program for
poor newborns of the city and of the country. May be, international
scientific community should demand for the Colombian Government urgent
decisions and measurements, addressed to achieve the survival of the IMI
in order to maintain this University Hospital open for the life of a lot
of more mothers and newborns in Colombia and overseas.
References
1. Ruiz-Peláez J, Charpak, Natalie, Cuervo, Luis Gabriel. Kangaroo
Mother Care, an example to follow from developing countries. BMJ
2004;329:1179-1181.
2. The Magpie Trial Collaborative Group. Do women with pre-eclampsia, and
their babies, benefit from magnesium sulphate? The Magpie Trial: a
randomised placebo controlled trial. Lancet 2002;359:1877-90.
3. República de Colombia Congreso de la República. Ley 100, 1993.
Competing interests:
None declared
Competing interests: No competing interests
Re: Kangaroo Mother Care: the importance of skin-to-skin contact.
Dr. Bergmann’s detailed reaction to our paper raises several
important issues.
First, in his view, the main explanation for the benefits of the
intervention lies on kangaroo position and exclusive breast feeding. We
feel that it is appropriate not to underestimate the role of the phases of
adaptation, early discharge and follow up. They are not circumstantial
activities related to specific settings and conditioned by availability of
resources: “adaptation” means adaptation of both mother and infant to
kangaroo position (including tolerance, monitoring of physiological
stability and weight gain); early discharge (to a kangaroo ward or to
home) means discharge while in kangaroo position after having evidenced
during adaptation that kangaroo position and nutrition have been well
tolerated and do not jeopardise the infant; and “follow up” means
monitoring the compliance with all the components of intervention as well
as clinical outcomes, which is comparable to clinical daily follow up in a
neonatal unit. We insist on early discharge with close follow up not only
because of the obvious saving in hospital stay but for the documented
beneficial effects on mothers-infants bonding and on the sense of
competence self-esteem and sensitivity to infants needs, that have been
demonstrated in a large RCT including all components1;2 and which has not
been evidenced in developed countries in evaluations of isolated
components of KMC. In response to Dr. Bergman’s opinion, we would like to
remark that usually the effects of a complex intervention are not the
simple sum of the effects of each individual component.
A second issue that should be considered carefully is Dr. Bergmann’s
statement: “A recently published randomised controlled trial from a
western setting provides evidence that low birth weight infants stabilise
better in SSC than they do in incubators. In the absence of incubators,
this could potentially save many lives”, in based on a study conducted in
South Africa. The paper reports results from a small sample of highly
selected LBW infants showing a good thermal stabilization3. In Dr.
Bergmann’s statement, stabilisation can be understood as overall
stability, but we think that the evidence he provides refers properly to
thermal stabilisation. The process of transition to extrauterine life
includes many more critical adaptations that need physiological support.
Suggesting that in environments where there are no incubators,
Kangaroo Position is a good alternative to proper neonatal care could be
unfair for either the LBWI or the professional health staff: in developing
countries infants also need access to a number of specific interventions
as needed, such as ventilatory support, pharmacologic interventions, etc.
for survival. Demonstrating that kangaroo position helps reaching
physiological stability should not have implications regarding the need to
provide other interventions (ventilatory support, antibiotics, etc.)
developed by Neonatology which have proven to make survival possible in
many instances.
We would like to highlight that KMC is an intervention that can
complement and enhance appropriate neonatal care; it was not conceived as
a substitute. Although it was not at all suggested by Dr. Bergsman’s
comment, we are taking this opportunity to remark that it would be
worrisome using KMC as an excuse for delaying the development of
appropriate infrastructure and resources for caring for these fragile
infants all over the world.
Reference List
(1) Tessier R, Cristo M, Velez S, Giron M, de Calume ZF, Ruiz-Palaez
JG et al. Kangaroo mother care and the bonding hypothesis. Pediatrics
1998; 102(2):e17.
(2) Tessier R, Cristo M, Nadeau L, Figueroa Z, Ruiz-Palaez JG,
Charpak N. Kangaroo Mother Care: a method for protecting high-risk low
birth weight and premature infants against developmental delay. Infant
Behaviour and Development 2003; 26(3):384-397.
(3) Bergman NJ, Linley LL, Fawcus SR. Randomized controlled trial of
skin-to-skin contact from birth versus conventional incubator for
physiological stabilization in. Acta Paediatr 2004; 93(6):779-785.
Competing interests:
We are the authors of the initial paper that motivated the comment
Competing interests: No competing interests