Kangaroo mother care: need of the day

Abstract

Each year approximately 20 million low birthweight babies are born globally. Prematurity is a leading cause of neonatal mortality in developing countries and results in 60%–80% of neonatal deaths. Neonatal mortality is the major contributor to under-5 mortality. According to Pakistan Demographic and Health Survey 2017–2018, neonatal mortality in Pakistan is 42 per 1000 live births and under-5 mortality is 74 per 1000 live births. One out of every 22 newborns dies in Pakistan, which is an alarming figure. Majority of these deaths are preventable. They can be prevented by well-trained midwives, safe delivery, early initiation of breast feeding within an hour after birth and skin-to-skin contact. Pakistan is among the top 10 countries with the highest number of preterm births and with limited resources to manage the burden. Kangaroo mother care (KMC) is a safe and economical alternative to provide preterm care in developing countries. In babies at gestational age less than 37 weeks or with neonatal weight less than 2.5 kg, skin-to-skin contact prevents hypothermia and infection. Neonatal mortality and morbidity can be reduced by providing preterm care through KMC. This case report is of a preterm baby who was delivered at 33 weeks of gestation with a weight of 1.3 kg and was saved by KMC in the paediatric department of Services Hospital in Lahore.

Background

The first 28 days of life of a neonate is the most crucial period for child survival, and in low birthweight babies (including both preterm and intrauterine growth retardation) this is exacerbated due to insufficient reserves and immature systems.¹ In low birthweight babies temperature regulation is difficult due to immature hypothalamus and limited brown fat, underdeveloped organs (especially lungs and intestine, leading to respiratory distress syndrome and necrotising enterocolitis), immature immune function and increased susceptibility to severe infections, making them vulnerable to problems associated with the transition to extrauterine life.² Globally, the risk of dying in the first 28 days after birth is 19 deaths per 1000 live births (UNICEF 2018³). The rate of neonatal mortality globally decreased from 37 per 1000 live births in 1990 to 19 per 1000 live births in 2016, but this is a slow decline as compared with under-5 mortality. There are disparities in data all over the world, but prematurity remains a leading cause of neonatal mortality.⁴

Of all early neonatal deaths that are not related to congenital malformations, 28% are due to preterm birth.⁵ These morbidities directly affect their families. Around 7% of global neonatal deaths occur in Pakistan, most of which are due to prematurity and its complications.⁶ Most of preterm births occur in developing countries.⁷ Newborn health has become a global and national public health priority, with attention given to child survival in the Millennium Development Goals.⁸ Newborn survival is a sensitive index in any health system.

Preterm birth is also responsible for loss of human potential by increasing neonatal morbidity.⁹ Many preterm babies who are saved by interventions develop significant morbidity, including neurodevelopment delay, learning deficiencies, visual disorders and long-term health problems.¹⁰ These morbidities directly affect their families. Care of low birthweight babies is expensive and requires specialised units. Effective interventions and modern technology are limited in developing countries, and there is shortage of skilled staff and incubators. Kangaroo mother care (KMC) is an effective and safe substitute to incubators in preterm infants and was first introduced by Rey and Martinez in 1978 in Bogota, Colombia.¹¹ The components of KMC are skin-to-skin contact, exclusive breast feeding and early discharge. KMC also improves maternal bonding and decreases the risk of nosocomial and respiratory tract infections and hypothermia.¹² It also helps in the improvement of sleep pattern and in the relief of colic.¹³

KMC is a cost-effective strategy to improve newborn survival. The KMC project was started in Services Hospital in Lahore in August 2016, both in the paediatric and gynaecology departments. Since then many babies have been saved. KMC improved neonatal outcome and decreased the burden on medical staff.

Case presentation

This is a case report of a baby girl delivered at 33 weeks of gestation with a birth weight of 1.3 kg. She is one of the triplets, with her two siblings weighing 600 g and 1100 g. All of them were transferred to the neonatal intensive care unit (NICU). Her two siblings expired in NICU due to respiratory distress syndrome, while the baby girl weighing 1.3 kg survived. The baby was managed in NICU for 4 days, where she was kept in the incubator and on intravenous fluids. She was active with good neonatal reflexes, but sucking was not well developed. The baby remained oxygen-dependent for 2 days, following which the oxygen was tapered off. On initial investigations, haemoglobin was 155 g/L, total leucocyte count was 9.5×10³ µL and platelet count was 320×10⁹/L.¹⁴ Nasogastric feeding was started on the second day. Repeat investigations after 48 hours revealed C reactive protein was 79.6 U/mL, haemoglobin was 135 g/L, total leucocyte count was 16.7 µL and platelet count was 216×10⁹/L. There was no growth on blood culture. However, taking into consideration the high C reaction protein, antibiotics were started. On day 4, the baby was stable; however, her weight had reduced from 1.3 kg to 1.13 kg. As the baby was stable, she was transferred to the KMC unit (figure 1), where breast feeding was started and she was kept in continuous skin-to-skin contact with her mother (at least 20 hours a day). Room temperature was kept at 25°C–28°C to prevent hypothermia and her temperature was maintained at 37°C. The couple and the family were counselled about the benefits of KMC and its components including breast feeding, hospital stay, criteria for discharge and follow-up.

Figure 1.

The baby is transferred to the kangaroo mother care ward.

On day 5, the baby developed jaundice and her serum total bilirubin was 14.3 mg/dL, during which phototherapy was started in KMC position. During phototherapy, the baby was kept in skin-to-skin contact with her mother. One day later, her bilirubin level dropped to 12.8 mg/dL, and 2 days later the level further reduced to 9.5 mg/dL. Phototherapy was discontinued. Gradually the mother feed was increased with tapering of nasogastric feed. During stay in the KMC unit, feeding and temperature were monitored 2 hourly and her weight gain was monitored daily. The mother was taught proper hand-washing technique and was advised to clean hands before touching the baby and before and after every feed. Chlorhexidine gel was applied to the site of the umbilical cord.

The baby was monitored by weekly measurement of head circumference and length to assess growth. On day 15, the baby was breast feeding every 2 hours for 20 min and she had gained weight to 1.5 kg. The criteria for discharge from the KMC unit were fulfilled, and counselling of the mother and family members was done to highlight the importance of continuing KMC at home. The mother had strong family support. The family members were encouraged to support the mother by keeping the baby in skin-to-skin contact with themselves for some time to provide opportunity for the mother to rest. The mother and the baby were discharged in a satisfactory condition (figure 2). The mother was advised exclusive breast feeding and skin-to-skin contact until her expected date of delivery, which was at 40 weeks, and to maintain regular follow-up.

Figure 2.

The baby is discharged from the kangaroo mother care ward.

The family lived in another province (Sindh) which was far, so they decided to stay in Lahore for 3 months to ensure follow-up. The follow-up plan was at 1 week, 1 month, 3 months and 6 months. At each follow-up, weight, length, temperature, head circumference, feeding status and general condition of the baby were evaluated. At 5 weeks postdischarge, skin-to-skin contact was stopped; the mother, however, continued to exclusively breast feed the baby. After 6 weeks eye examination was done by an ophthalmologist to rule out retinopathy of prematurity. At 3 months, hearing assessment and consultation by a neurologist for neurodevelopment were done. At 3 months the weight of the baby increased to 3.8 kg and the baby was doing well. Thereafter, the family went home to Sindh, and since then have maintained telephonic follow-up. The progress has been satisfactory. At 6 months of age, the baby’s weight was 5.8 kg and there were no issues (figure 3).

Figure 3.

Follow-up at 6 months.

Global health problem list

• Prematurity can lead to problems such as hypothermia, hypoglycaemia and infections.

• Problems in incubators and admissions to neonatal units can lead to decreased bonding between the baby and the mother, delayed initiation of breast feeding, problems in temperature regulation and infection.

Global health problem analysis

KMC is the care of newborns through continuous skin-to-skin contact to provide a thermo-neutral environment to the baby, done as a substitute to incubators. According to literature, thermal care can be provided through continuous skin-to-skin contact between the mother and her baby using a cloth or a binder to tie the baby with her in order to keep the baby warm and provide opportunity for exclusive breast feeding. The earliest report was published and results were shared in 1981 in Spanish and the term kangaroo mother care was used here for the first time. This term got the attention of 30 international researchers at a meeting convened by Dr Adriano Cattaneo and colleagues¹⁵ in November 1996 in Trieste, Italy, together with the WHO. Since then it has been practised in various countries. KMC was basically designed for developing and low-income countries. Recently, there has been a lot of emphasis on reducing neonatal mortality in developing as well as developed countries. Every 2 years, KMC workshops are conducted worldwide, and currently it is practised in various countries in America, Africa and Asia.

A meta-analysis was conducted in 2010 where 15 studies were included, and it was concluded that KMC is associated with up to 51% reduction in cause-specific mortality.¹⁶ According to the latest recommendation of WHO, KMC is one of the cost-effective strategies to reduce preterm mortality, globally. Evidence of this recommendation is derived from multiple facility-based studies from different middle-income to low-income countries.¹⁷ Ongoing research and observational studies are assessing the effective use of this method in situations where neonatal intensive care units and referrals are not available. Acceptance of KMC is increasing worldwide due to its effectiveness. Continuous skin-to-skin contact for 20 hours or more is recommended. It can be practised by the mother, the father or other relatives. Mothers are advised to keep the baby in continuous skin-to-skin contact except when changing nappy or when they want to go to the washroom. She can sleep or take rest from KMC in a reclined or semirecumbent position, 44° horizontally.

Thermoregulation is a critical factor in newborn survival, as 30%–90% of sick children admitted to NICUs in hospitals of developing countries experience hypothermia.^{18 19} According to WHO hypothermia is defined as a core body temperature less than 36.5°C. Another study favoured the previous results showing that 89% of preterm babies admitted to NICU in Nigeria experienced hypothermia.^{19 20} Babies with hypothermia are at increased risk of dying due to complications such as intraventricular haemorrhage, respiratory distress, hypoglycaemia, coagulopathy and metabolic acidosis. Hypothermia increases the risk of neonatal death to more than three times the normal.^{20 21} Previously incubators were used to maintain body temperature of preterm babies. In low-income and middle-income countries, there is limited availability of incubators, which are expensive and difficult to maintain. The infection rates are also high due to overcrowding and reduced breastfeeding rates. Therefore, it is recommended that mothers can also help in thermoregulation. Evidence supports that infants who are nursed with KMC optimise their body temperature more efficiently (Kangaroo Mother Care Implementation Guide 2012).^{22 23} Studies have shown that infants nursed with KMC showed almost no fluctuation in body temperature, compared with babies treated in incubators, who have multiple fluctuations in body temperature.

KMC has significant positive psychological effects on the baby as well as the mother, and improves newborn bonding. With the baby being in close proximity to the mother, skin-to-skin contact proves to be an effective method that prevents distress routinely experienced in a busy preterm infant unit. KMC also improves physiological parameters, including heart rate, respiratory rate and oxygen saturation.^{21 24} It was observed that, following KMC sessions, the mean increase in body temperature was about 0.4°C, respiratory rate improved by 3 breaths per minute, heart rate by 5 beats per minute and oxygen saturation by 5%. The results of this study strengthen the belief that apart from improving weight gain KMC also helps in stabilising the babies. KMC also has psychological and other physiological impacts.

KMC aims to provide newborns the basic tools for survival, including the mother’s warmth, nutrition, protection and love. KMC can also play an important role in the promotion of breast feeding and can improve newborn survival. Multiple studies have proved that KMC is associated with improved rates of breast feeding. According to one study, KMC was associated with 4.1 times increase in breastfeeding rate.^{24 25} Further studies examining breastfeeding outcomes showed that daily volume of milk for babies managed by KMC was 640 mL vs 400 mL for babies managed in incubators.²⁶ Expressed breast milk can also be given by alternate methods including cup, spoon and nasogastric tube.

KMC has general benefits for the mother, baby, family and health system. Benefits to mothers include early bonding, early exclusive breast feeding, more confidence and less depression. As mentioned previously, babies also benefit in the form of maintenance of body temperature at a minimum energy expenditure, stabilisation of heart rate and respiratory rate, early and exclusive breast feeding, and reduced risk of infections.²⁴ For the family there is increased involvement and increased equity in child healthcare. On the part of the paediatric staff and nursery, there are shorter stays and less burden. There is also reduced requirement for staff, and hence reduced burden on the health system. There is no need for additional resources, so a major health problem can be solved by minimum resources. In a similar fashion, in Kenya, KMC was implemented in 2016, where the average reduction in mortality was 52%. No extra staff were recruited, and only training and basic materials were provided by UNICEF.²⁷ In a study conducted in India, it was demonstrated that there was significant reduction in expenditures in the KMC group compared with the neonatal intensive care group. Around 33 800 rupees were saved, equivalent to $475, for each patient.^{27 28} KMC was basically designed for developing and low-income countries due to its cost-effectiveness, but now it is also being adopted in developed countries, which shows changing trends.^{18 29}

Another component of the KMC strategy is early discharge and prompt referral. Due to early discharge, the risk of nosocomial infections can be reduced significantly. There is evidence in favour of reduced risk of nosocomial infections in KMC units.¹² Infection prevention practices were ensured by medical staff, patients and the family. Hand hygiene recommendations were strictly followed. Cord care was mandatory as it may provide a portal of entry for infectious organisms. Cord care included applying 4% chlorhexidine gel on the cord according to the national protocol. The baby was given sponge baths until the cord fell off and the umbilicus was healed.

The KMC team at Services Hospital included professors of obstetrics and gynaecology and paediatrics, doctors, nurses, members of the infection control committee, and administrative staff. Since then 82 babies with weight less than 2.5 kg and gestational age less than 37 weeks with no danger signs have been admitted, and the results were encouraging. Out of 82 babies, 81 were saved. One baby became sick due to necrotising enterocolitis and was transferred to NICU, where he expired (table 1).

Table 1.

Outcome of KMC babies admitted in hospital

Preterm KMC babies	n=82	%
Discharged	81	98.7
Expired	1	1.3

KMC, kangaroo mother care.

Mothers were trained in checking the weight and temperature of the baby themselves; therefore, no extra staff nurse was recruited. The average duration of hospital stay in preterm babies was reduced (table 2).

Table 2.

Duration of hospital stay of KMC babies

Duration of stay in hospital (days)	Neonates (n)
1–3	12
3–7	56
7–14	14

KMC, kangaroo mother care.

To implement KMC in the hospital, there are six important phases:

1. Planning for KMC implementation.

2. Training for KMC practice.

3. Resource allocation.

4. Implementing KMC.

5. KMC routinely integrated in the basic newborn care.

6. KMC training centre.

KMC training programmes aimed at training health professionals who will be involved in taking care of preterm babies. Currently, Services Hospital is at phase 6 of the KMC implementation plan with KMC training centre in place. Eight hospitals of Punjab including the district headquarter hospital are implementing KMC services. Thirty-five workshops have been conducted and around 700 doctors and nurses trained in KMC. More work needs to be done on the role of community workers and on referral systems from districts.

There are many challenges faced in running KMC units. Despite continuous counselling, refusals among parents are seen. Maintaining infection-free environment is also challenging, and data collection and follow-up are difficult. Families living in far-flung areas that do not come for follow-up of their babies can be approached by community health workers, and proper training should be given to these community health workers. They should have knowledge of good antenatal care. At home they can check skin-to-skin contact, temperature of the baby and feeding problems. Records should be maintained. In case of signs of danger, referrals should be made. The baby should be transferred to an appropriate hospital in ambulance with the community health workers. Guidance on skin-to-skin care may be given to keep newborn infants with hypothermia warm.

Patient’s perspective.

I am very satisfied by this mode of treatment and I will recommend it to other mothers in my family and neighbourhood.

Learning points.

• In neonates at gestational age less than 37 weeks and with weight less than 2.5 kg, prolonged skin-to-skin contact and exclusive breast feeding save them from hypothermia and improve weight gain, leading to reduced mortality and morbidity.

• Kangaroo mother care (KMC) babies discharged from the hospital can benefit from community workers’ follow-up who have been trained to monitor KMC practices at home and to identify danger signs and help in the referral of the baby.

• KMC is a good alternative to expensive incubators in low-income and middle-income countries such as Pakistan.

• KMC is associated with decreased hospital stay and reduced treatment expenses, as expensive incubators can be replaced with mothers’ warmth.