Kangaroo Mother care Method Science and Tenderness

1. Kangaroo Mother care MethodScience and Tenderness Module 1 • Introduction • Definitions and Epidemiology of Preterm and Low Birth Weight Infants • History of the Kangaroo Mother Care Method • Main interventions of the Kangaroo Mother Care Method

2. 1.1 Introduction

3. “The arrival of the new millennium is an excellent pretext to take a step back and assess what we are doing and the way in which things are becoming our own life projects. In our case, it refers to the care of the premature and/or low birth weight infant” Dr. N. Charpak and J.G. Ruiz 2012

4. Definitions • A preterm infant is born before achieving 37 weeks of gestation, or born 1 or 2 month before the due date • A Late/Mild/Near preterm (70% of all preterm infants) • Born prematurely between 34- 36 weeks of gestation • Born one month before the due date • A Very preterm infant (<5% of all preterm infants): • Born prematurely before 28 weeks of gestation • Born more than 2 months before the due date • A Low-Birth Weight (LBW) is weighing less than 2,500 g at birth • A Very Low-Birth Weight (VLBW) is weighting less 1,500g at birth

5. WHO definition of live birth • Live birth complete expulsion or extraction from its mother of a product of conception • Irrespective of the duration of the pregnancy which, after such separation, breathes or shows any other evidence of life - e.g. • beating of the heart, • pulsation of the umbilical cord or • definite movement of voluntary muscles - whether or not the umbilical cord has been cut or the placenta is attached • Each infant is considered alive

6. Intra uterine growth chart

7. 1.2 Development and Technologies

8. 1stTechnological progresses for preterm infants • Until the end of 19th century preterm infants were born and care for at home and either lived or died without medical care • 1880 :Dr. Tarnier invented the 1st incubator based on “chicken eggs "incubator • 1893 : Dr. Budin created 1st specific department to care for preterm infant in Paris • Using incubators method, Budin reduced the mortality rate for infants < 2000 g from 98 % to 23% • Budin recognized the importance of breast milk and the mother’s attachment to the child Dr. Budin, “the Nursling “ 1895

9. 20th Century progresses in developed countries • After1945: creation in most of developed countries of special wards for preterm infants isolated from parents • Late 1970’: creation of Newborn Intensive Care Units • 20% of infants never received parental visit while in NICU • .1980’: development of surfactant , improves ventilation • Increasing needs and use of monitoring and life support system • Stress from noise , light , painful procedures, reduced physical contact , separation from the mother , interference with breastfeeding opportunities • Surviving rate of <1,500g : 1960: 40% - 1980: ≈ 80% • Long term concerns : high proportion of disabilities

10. Evolution of Technology 2010 :NICU 1909 :Incubator

11. Management of Preterm or LBW infants in Developing countries • Few trained staffs and rare medical equipment : • Overcrowded wards • Overcrowded incubators • Deficient monitors • Frequent nosocomial infection • Unreliable electricity supply • Prematurity is responsible for 61% of early infant deaths and is the leading cause of death even in pregnancies near term

12. 1.3 Geography and epidemiology of Preterm and Low birth weight infants

13. Geography and Resources • 90 % of preterm and LBW are born in developing countries , but • 90% of funds on research for high risk infants (preterm and LBW) are spend in developed countries Newborns, regardless of their place of birth, must have the right to receive the best possible quality of care, from the biomedical technology, psychological, emotional and “human” perspectives It is essential to join  the best of both worlds

14. Epidemiology of preterm/LBW • Preterm and LBW infants represent a public health burden, especially in developing countries • 2007 UNICEF reported that every year: • > than 20 million of preterm or LBW are born • 17% of all births in developing countries • 7% of all births in industrialized countries • 60% of infantsbornaroundtheworldisnotweighed • Lackof comparable data makesitdifficulttoevaluateprogress • Data fromsomedevelopedcountries (UK, USA) show a dramaticriseoverthepast 20 years

15. Percentage of infants with birth weight < 2,500 g in some  regions (1999-2006)

16. Neonatal mortality and LBW • Every year, around 4 million children die before reaching 28 days of life ( neonatal period) • Low birth weight infants have 40 times more changes to dye before reaching one month of age compare to bigger ones

17. Infant Mortality and LBW Preterm /LBW birth accounted for 27% of infant mortality Improving neonatal survival is essential to reduce infant and children mortality

18. Global causes of child deaths Neonatal deaths = 41% Pie chart derived from data in Black RE, Cousens S, Johnson HL et al. in “Global, regional, and national causes of child mortality in 2008: a systemic analysis,” The Lancet, May 12, 2010.

19. Causes of premature births or LBW infants • Premature delivery (before 37 week of gestation) • 50% of case is idiopathic • Intrauterine growth retardation • Maternal poor nutrition, including vitamin A, iron, folic acid and zinc deficiency • Maternal arterial hypertension • Multiple pregnancy ( twin, triplets) • Teenage pregnancy • Mother exposed to intensive workload. • Stress, anxiety and other psychological factors • Active and passive smoking • Acute and chronic infection during pregnancy: malaria, bacterial vaginitis

20. Efficientlowcostinterventionstodecreasemortality in LBW infants UNDP, in 2010 recognized the KMCM as an available tool to decrease IMR and to achieve the Millennium’s Goal 4

21. 1.3 History of the Kangaroo Mother Care Method

22. Kangaroo mother care Method Creation • In 1978, Dr. E Rey Sanabria , in Bogotá, Colombia conceived the KMCM to : • Solve the shortage of incubator • Reduce the separation of mothers and infants • Reduce the rate of abandonment • The key components of KMCM are : • Continued and prolonged skin-to-skin contact • Breastfeeding and • Early discharge • KMCM reinstalled mother in their role of principal care provider

23. Additional factors to the creation KMCM • High morbidity/mortality rates in hospitalized preterm and LBW infants • Frequent ++ nosocomial infections • An intimate conviction of the benefits of breast milk for hospitalized preterm and/or LBW infants • The conviction that the incubator’s warmth could be replaced by the warmth of the body of the infant’ mother • The observation of LBW infants who survived due to the care of mothers or grandmothers who placed them skin-to-skin on their laps. • The observation of the marsupial experience in nature

24. Reinforcement of Ambulatory KMC Program • Regardless of weight or gestational age, when a preterm /LBW infant is stableand needs only to be kept warm and fed, he is sent home : • The infant should stay day and night in skin-to-skin contact on his mother´s chest • The infant should be fed at will, and • The infant should be monitored through frequent ambulatory consultations • In 1979, Dr. Martinez and in 1982, Dr. Navarrete strengthen and systematized follow up visits • Conducting daily lectures for families (nutrition, stimulation) • Creating solidarity and warm humane feeling between families and health staff

25. Dissemination of KMCM • 1981: WHO conveyed the message several countries , many experts from poor and rich countries visited the program and start disseminating KMCM • 1980-1990: 1st evidence based researches on KMCM in Colombia and Europe (Impact on mortality, Role of skin to skin in thermal regulation) • 1993: written guidelines and methodology for KMC in hospital and follow up • 1994: Creation of the Kangaroo Foundation in Bogotá • led by pediatricians Dr. Charpak and Figueroa and epidemiologist Juan Gabriel Ruiz • 1997: “Practical Clinical Guide based on evidence for the optimal use of the Kangaroo Mother Care Method in the preterm and/or low birth weight infant”

26. Role of the Kangaroo foundation • To humanizes neonatal care • To continues the systematic scientific evaluation of the KMCM • To facilitates the transfer of knowledge on KMCM • To shares the results through publications • To train health professionals • To promotes around the world, a high-quality management of the high risk newborn in a humane, scientific, efficient manner, making rational use of cost and resources

27. KMCM specificities • KMCM was conceived and implemented initially in countries with few technical resources • Therefore , it was mistakenly considered the alternative for the “poor” • KMCM is already integrated in initiatives such as family-centered care or NIDCAP in many developed countries • KMCM is physiologically, humanly and emotionally appropriate for the newborn needs • KMCM for preterm infants is not against medical care based on technology, nor has been proposed as alternatives to it, they are allies

28. KMCM in the World • In South and Central America Early replications of KMCM program in several countries • In Europe and North America KMCM was implemented at different time of the life: • immediately after birth • in neonatal units KMCM was implemented for different duration : allowing the measurement of different effects and benefits in preterm and/or LBW infant, and even in full term babies. • In 1996 : 1st international KMCM Meeting in Italy • a nucleus of 36 expertsfrom 15 countriesonKMCM isconsolidated • ParticipantsfromAfrica, Asia, Europe, North America and South America

29. KMCM Implementation 2011

30. Kangaroo Care Definitions • The Kangaroo Mother Program- KMP is a set of organized activities/ interventions , with a properly trained and organized team of health care staff, within a defined physical and administrative structure • Kangaroo Mother Intervention – KMI consists in a series of components applied in an organized and systematic manner, following a method: The Kangaroo Mother Care Method • The Kangaroo Mother Care Method - KMCMis a protocol-based, standardized care system for preterm/LBW infants, based on skin-to-skin contact between infant and his mother. • It seeks to empower the mother, transferring the capacity and responsibility of being the primary caretakers of their child, satisfying their physical and emotional needs

31. KMCM Characteristics • Since 1978, the method changed, including modifications originated in practice and scientific researches • A reference scenario is defined, which characterizes the elements and circumstances of implementation of the KMCM • It contains the components considered fundamental in KMCM • Target population : preterm (<37 weeks gestational age) and/or LBW infants (< 2500 g) • as soon as it is possible and prudent to do so and if the child is able to tolerate it: having stable vital signs, no bradycardia, no hypoxemia when manipulated and not presenting primary apnea or, if present, apnea is controlled. • Kangaroo intervention does not replace neonatal care units, but rather complements health intervention performed on the newborn

32. Kangaroo Position: “Hallmark” of the KMCM • Reference definition of kangaroo position: The infant is placed almost naked (except hat, nappy and socks) in strict upright ventral position between the mother´s breast, in direct contact with her skin, under her clothes, 24 hours a day • The cloth support helps to prevent the child’s airway from being obstructed and developing obstructive apneas • The baby may be fed at any time, while and still in KP • Any other person (e.g. the father), can share the mother role, carrying the baby in KP • The provider must sleep in a semi-sitting position (30°) • The KP is maintained until the baby no longer tolerates it

33. Variations of the Kangaroo Position • The initiation of KP could be from few minutes after birth up to the time of hospital discharge, as soon as the preterm infant has been stabilized • Continuity of the position could be maintained 24 hours a day, or intermittently (alternating with incubator) for periods of minutes to few hours   • Duration of Kangaroo position could be followonly during hospitalization , others maintain KP after hospital discharge. It is definitely not possible to talk about Kangaroo Mother Care Method, if the baby is never placed in kangaroo position

34. Kangaroo Feeding and Nutrition strategy Three different periods are identified in the early life of preterm infant: • The transition period, from birth to day 7-10 is the adaptation to extra uterine life . During this time parenteral nutritional and/or adaptive strategies for enteral feeding are used   • The period of “stable growth” , from the end of the transition period to reaching full term, similar to the period of intra uterine growth which may have occurred if the newborn was not preterm . During this period, it is usually appropriate to use enteral feeding, predominantly oral • The post-discharge period, from term or hospital discharge to 1 year corrected age Reference definition of the Kangaroo Feeding and Nutrition Strategy • The kangaroo feeding strategy is for children during the ”stable growth period” • The child’s fundamental source of nutrition is the child’s own mother milk and it will be used whenever possible • Breast feeding may be done through direct suction or through extracted mother´s milk

35. Goals of Kangaroo Feeding /Nutrition strategy The goal is to reach through ideally exclusive breastfeeding a weight gain similar to the usual growth during the intra uterine life - 15 g/Kg/day until full term • If the goal is not reached • 1stidentify and correct conditions explaining inadequate weight gain • Initially supplement breastfeeding with 30% of daily needs • Then decrease supplement to reach 40 weeks with exclusive breastfeeding • Variations of the Kangaroo Mother Care Nutrition strategy In some case, infants are placed in the KP despite the fact that they cannot benefit of the kangaroo feeding strategy based on breast milk ,it is still a Kangaroo Mother Intervention, as the kangaroo position is implemented

36. Early Discharge A “kangaroo” child is eligible for ambulatory kangaroo care regardless of weight and gestational age when: • Kangaroo adaptation is achieved for mother and infant including kangaroo position and kangaroo nutrition • The child is able to coordinate sucking, swallowing and breathing • Some Kangaroo Mother Programs are discharging children fed through “gavage” or by alternative method by the mother after training • The family is willing and able to follow protocols, advices and follow up policy • The child and family have access to a systematic, rigorous and well established ambulatory management and kangaroo follow up The child is maintained in kangaroo position 24 hours a day, at home or in a “Kangaroo wing” until he rejects it

37. Ambulatory and High Risk Follow up • After discharge, children are controlled daily, until they reach a daily weight gain of 15 g/Kg/day • Then, weeklycontrols are conducted until reaching full term (40 weeks gestational age and 2,500 g) • Follow up care includes systematic prophylactic treatment such as anti-reflux and prophylaxis of primary apnea, and vitamins • During this follow up, ophthalmologic , audiometric and neurologic screenings are conducted, including a brain echography • Follow up program for high-risk newborns, is done at least until the child is 1 year old, corrected age

38. Objectives of the KMCM (1) • Humanized hospital and ambulatory care for preterm /LBW infants • Offer of specialized care, oriented on the quality of survival and the preservation of adequate brain development • Supported the development of attachment between the infant and his parents, as soon as possible after birth • Empowered through training mothers or caregivers by gradually transferring to them the ability and responsibility of being the baby´s caregivers, satisfying his physical and emotional needs • Timely detection and treatment of any sequels inherent to prematurity and low birth weight during high risk follow up (up to a minimum of one year corrected age)

39. Objectives of the KMCM (2) • Improved life prognosis, fostering an adequate physical, neurological and psycho social development of preterm and LBW infants • Exclusive breast feeding is promoted and protected, as much as possible • Contribution to the decrease of child abandonment and abuse KMCM is recognized an adequate clinical care alternative, when there is limited available capacity and technology, allowing for a rational use of human and technological resources

40. Different approaches to implement the KMCM • Taking into account specific expectations and the level of development, the KMCM may be used to achieve at once, 1or several goals. KMCM may be implemented in 3 different ways: • 1. As an complement to an incubator The most complete use of the KMCM achieving 2 objectives: • Optimizes the use of the available human and technological resource • Allows the infant to be with his mother as soon as possible This method is of special interest, to middle income countries with limited access to economic, technical and human resources and are concerned with the consequences of separating a mother from her infant

41. Different approaches to implement the KMCM 2. As a substitute to an incubator : • In countries with no incubators, the kangaroo method represents a survival possibility for LBW infants where there is no option different from the Kangaroo Mother Care Method for thermoregulation and nutrition of the low birth weight infant. • This way to implement the Kangaroo Mother Care Method is a transitional alternative • Developing countries, must insist on having adequate referral centers to receive these fragile children, aiming not just for their survival but for quality of these lives

42. Different approaches to implement the KMCM 3. To limit the separation between mother and child Where there is no limitation to access to high technology neonatal care • KMCM is introduced to foster the development of the maternal-infant bond and breast feeding • Changes including early mother-infant contact, kangaroo position when needed, joint accommodation, exclusive and frequent breast feeding and minimal contact with health care teams are introduced in maternity – neonatal wards around the world

43. Neonatology requires a change in the paradigm concerning the care of the LBW infant , regarding the participation and leading role of the parents in his care • The introduction of the Kangaroo Mother Care Method allows this change in the practice, as units must not only open their doors to parents but offer a holistic approach: integrating parents and transferring responsibility to them for caring for their baby during his treatment