TEACHING ON KANGAROO MOTHER CARE
Description of kangaroo mother care
Kangaroo care seeks to provide restored closeness of the newborn with mother and/or father by placing the infant in direct skin-to-skin contact with one of them. This ensures physiological and psychological warmth and bonding. The kangaroo position provides ready access to nourishment. The mother's body responds to the needs of the infant directly, helping regulate temperature more smoothly than an incubator, her milk adjusts to the nutritional and immunological needs of her fragile infant, and the baby sleeps more soundly.
Historical notes on kangaroo care
· Mother kangaroo is a mammal (just like us), and feeds its baby milk like we do (or like we should!) from a nipple inside its pouch. The pouch covers the baby with skin, and this not only protects the very immature baby, but also provides it with a total environment which is essential for development. This includes warmth, food, comfort, stimulation, protection. The baby is CARRIED for all this time, without interruption !
When it is born, the kangaroo baby has no hair and is called a PINKY. It is the size of a peanut, yet must crawl into the pouch by itself. (This is a hand-reared orphan, a few months old) Once inside the pouch, the kangaroo baby latches on to a nipple, where it then remains attached, feeding on mother’s milk, non-stop, for months. (This pinky is being fed from a teat with the exact shape of a real one.) The pouch can close tightly to protect the baby, notice its legs protruding. | |
The baby will come out of the pouch for the first time when it is about a quarter of the mothers weight!! The joey can continue breastfeeding even when it is too big to fit in the pouch. When frightened, the joey does a forward somersault into mothers pouch.
HUMAN KANGAROO MOTHER CARE does the same for the premature!
- Skin-to-skin – CALOR – warmth.
- Breastfeeding – LECHE – milk.
- Protection – AMOR – love.
Most mammals have young which are born able to fend for themselves. The human baby is extremely immature compared to such mammals, which is also the case for kangaroos, and other “marsupials”.These similarities to marsupial care is why we call it Kangaroo Care. And so we prefer to call it Kangaroo Mother Care or KMC
But it is the MOTHER which is essential for the baby! For the human immature baby, the mother’s chest provides the essentials: warmth, breast milk, comfort, stimulation and protection.
Not all areas in the world have resources to provide technical intervention and health care workers for premature and low weight babies. In 1978, due to increasing morbidity and mortality rates in the Instituto Materno Infantil NICU in Bogotá, Colombia, Dr. Edgar Rey Sanabria, Professor of Neonatology at Department of Paediatry - Universidad Nacional de Colombia, introduced a method to alleviate the shortage of caregivers and lack of resources. He suggested that mothers have continuous skin-to-skin contact with their low birth weight babies to keep them warm and to give exclusive breastfeeding as they needed. This freed up overcrowded incubator space and care givers. Another feature of kangaroo care was early discharge in the kangaroo position despite prematurity. It has proven successful in improving survival rates of premature and low birth weight newborns and in lowering the risks of nosocomial infection, severe illness, and lower respiratory tract disease. It also increased exclusive breast feeding and for a longer duration and improved maternal satisfaction and confidence.
DEFINITION OF KMC (1990) MANAMA, ZIMBABWE
# Skin-to-skin contact from birth, continuous
# Breastmilk from birth & exclusive breastfeeding
# Psychological support to mother
Aspects of kangaroo care:
1) Kangaroo position - skin to skin contact.
2) Kangaroo nutrition – breast feeding.
3) Kangaroo discharge – home followup.
4) Kangaroo support – adjunct to techonology.
Indications for kangaroo care
Originally babies who were eligible for kangaroo care were pre-term infants, less than 1500 grams, and breathing on their own. Cardiopulmonary monitoring, oximetry, supplemental oxygen or nasal continuous positive airway pressure (CPAP) ventilation, intravenous infusions, and monitor leads do not prevent kangaroo care. In fact, babies who are in kangaroo care tend to be less prone to apnea and bradycardia and have stabilization of oxygen needs. (London, Ladewig, Ball & Bindler, 2006; Robles, 1995).
During the early 1990’s, the concept was advocated in North America for premature babies in NICU and later for full term babies. Research has been done in developed countries but there is a lag in implementation of kangaroo care due to ready access of incubators and technology.
when should mothers first be told about kangaroo mother care?
From the start of antenatal care, KMC should be included as an important part of educating pregnant women. The best method of teaching women about KMC during the antenatal period is for them to see other mothers providing KMC for their infants. Videos can be shown at antenatal clinics and information sheets can be provided to inform pregnant women about KMC.
All stable LBW babies are eligible for KMC. However, very sick babies needing special care should be cared under radiant warmer initially. KMC should be started after the baby is hemo -dynamically stable. Guidelines for practicing KMC include:
I. Birth weight >1800 g :These babies are generally stable at birth. Therefore, in most of them KMC can be initiated soon after birth.
II. Birth weight 1200-1799 g : Many babies of this group have significant problems in neonatal period. It might take a few days before KMC can be initiated. If such a baby is born in a place where neonatal care services are inadequate, he should be transferred to a proper facility immediately after birth, along with the mother/ family member. He should be transferred to a refferal hospital after initial stabilization and appropriate management, One of the best ways of transporting small babies is by keeping them in continuous skin-to-skin contact with the mother / family member during transport
III. Birth weight <1200 g :Frequently, these babies develop serious prerelated morbidity often starting soon after birth. They benefit the most from in-utero transfer to the institutions with neonatal intensive care facilities. It may take days to weeks before baby's condition allows initiation of KMC
2) Mother All mothers can provide KMC, irrespective of age, parity, education, culture and religion. The following points must be taken into consideration when counseling on KMC:
i. Willingness: The mother must be willing to provide KMC. Healthcare providers should counsel and motivate her. Once the mother realises the benefits of KMC for her baby, she will learn and undertake KMC.
ii. General health and nutrition: The mother should be free from serious illness to be able to provide KMC. She should receive adequate diet and supplements recommended by her physician.
iii. Hygiene: The mother should maintain good hygiene: daily bath/sponge, change of clothes, hand washing, short and clean finger nails.
iv. Supportive family: Apart from supporting the mother, family members should also be encouraged to provide KMC when mother wishes to take rest. Mother would need family's cooperation to deal with her conventional responsibilities of household chores till the baby requires KMC.
v. Supportive community: Community awareness about the benefits should be created. This is particularly important when there are social, economic or family constraints.
KMC can be started as soon as the baby is stable. Babies with severe illnesses or requiring special treatment should be managed according to the unit protocol. Short KMC sessions can be initiated during recovery with ongoing medical treatment (IV fluids, oxygen therapy). KMC can be provided while the baby is being fed via orogastric tube or on oxygen therapy.
• Skin-to-skin contact should start gradually in the nursery, with a smooth transition from conventional care to continuous KMC.
• Sessions that last less than one hour should be avoided because frequent handling may be stressful for the baby.
• The length of skin-to-skin contacts should be gradually increased up to 24 hours a day, interrupted only for changing diapers.
• When the baby does not require intensive care, she should be transferred to the post-natal ward where KMC should be continued.
THE METHOD OF KANGAROO MOTHER CARE
The almost naked infant (wearing only a nappy and woolen cap) is placed between the mother’s bare breasts. If the room is cold, the infant can wear a cotton shirt, open in front. The infant is nursed upright, facing the mother with the arms and legs flexed in the frog position, under the mother’s shirt, blouse, T-shirt or dress. Keeping the infant upright helps to prevent vomiting. All mothers should be taught how to nurse their infant in the KMC position. The mother does not need to shower or wash her chest before giving KMC. It is important that the infant is kept warm and held securely. Holding the infant skin-to-skin, chest-to chest against the mother will keep the infant warm. The mother should have her hands free and be able to walk around. A number of methods are used to keep the infant in place:
1. Usually the mother’s shirt or blouse is tucked into her belt or trousers to prevent the infant slipping out.
2. Sometimes a blanket or cotton towel can be tied around the mother as a binder to hold the infant firmly. The binder can be tied, pinned or tucked in to keep it in place. A shirt or blouse can be worn over the binder. A “boob-tube” is useful.
3. A special KMC top (a pouch) can be used but this is not essential. A KMC top looks like an open shirt with long tails. The shirt is pulled closed in front by crossing the tails. The tails are wrapped around the mother’s back and then tied fast in front. The tails support the infant.
4. In preterm infants it is important to make sure that the airway is never obstructed. The infant’s head should be turned to one side and slightly extended to keep the airway open. Do not allow the infant’s neck to be flexed or over extended. The top edge of the towel or binder should be just under the infant’s ear. It is best if small infants are kept upright between the mother’s breasts and not allowed to slip sideways.
5. If the mother is lying down, she and her infant should be kept at an angle of about 45° by raising the head of the hospital bed or be using a large pillow or a number of pillows or cushions. Special binders or carrying pouches are commercially available and can be helpful.
Typically in kangaroo care, the baby wears only a diaper and is tied in a head-up position to the mother’s bare chest with a strip of cloth in a manner that extends the baby’s head and neck to prevent apnea. The mother wears a shirt or hospital gown with opening to the front. The cloth wraps around and under the baby’s bottom to create flexion.
The tight bundling is enough for the mother’s breathing and chest movement to stimulate the baby’s breathing. Because of the close confines of being attached to his (her) mother’s chest, the baby is enclosed in a high carbon dioxide environment which also stimulates breathing. Fathers can also use the skin-to-skin contact method.
Beginning kangaroo care 30 minutes to 2 hours after birth seems to be the most effective time period for successful breastfeeding. Many advocates of natural birth encourage immediate skin-to-skin contact between mother and baby after birth, with minimal disruption. Babies must be kept warm and dry. This method can be used continuously around the clock or for short periods per day gradually increasing as tolerated for infants who are compromised by severe health problems. It can be started at birth or within hours, days, or webirth. Proponents of kangaroo care encourage maintaining skin-to-skin contact method for about six weeks so that both baby and mother are established in breastfeeding and have achieved physiological recovery from the birth process. (Mohrbacher & Stock, 2003; London et al., 2006)
The practice of babywearing is used by many parents of both preterm and full term newborns to facilitate kangaroo care. A variety of slings and other carriers may be used, some are designed specifically for neonates and the classic "upright between the breasts" positioning, and some are intended for a wider variety of positions and ages. Benefits of kangaroo care
- Enhanced attachment and bonding (Tessier et al., 1998)
- Increased milk volume, doubled rates of successful breastfeeding and increased duration of breastfeeding (Mohrbacher & Stock, 2003)
- Physiologically her breasts respond to her infant’s thermal needs (Ludington-Hoe et al., 2006)
- Resilience and feelings of confidence, competence, and satisfaction regarding baby care (Tessier et al., 1998; Conde-Agudelo, Diaz-Rossello, & Belizan, 2003; Kirsten, Bergman, & Hann, 2001)
For preterm and low birth weight infants
- Normal temperature, heart rate, and respiratory rate (Ludington-Hoe et al., 2005)
- Breast milk is readily available and accessible, and strengthens the infant's immune system
- The maternal contact causes a calming effect with decreased stress and rapid quiescence (McCain, Ludington-Hoe, Swinth, & Hadeed, 2005; Charpak et el., 2005)
- Reduced physiologic and behavioural pain responses (Ludington-Hoe, Hosseini, & Torowicz, 2005; Johnston et al., 2003)
- Increased weight gain (Charpak, Ruiz-Pelaez, & Figueroa, 2005)
- Enhanced mother-infant bonding (Dodd, 2005)
- Positive effects on infant’s cognitive development (Feldman, Eidelman, Sirota, & Weller, 2002)
- Less nosocomial infection, severe illness, or lower respiratory tract disease (Conde-Argudelo, Diaz-Rossello, & Belizan, 2003)
- Restful sleep (Ludington, Hosseini, & Torowicz, 2005);
- Earlier discharge (London et al., 2006)
- Possible reduced risk of sudden infant death (see www.infactcanada.ca)
- Normalized infant growth of premature infants (Charpak, Ruiz-Pelaez, & Figueroa, 2005)
- May be a good intervention for colic (Ellett, Bleah, & Parris, 2002)
- Possible positive effects in motor development of infants (Penalva & Schwartzman, 2006).
- Shorter hospital stay
- Advanced healthcare technology only used in addition to kangaroo care
- Different monitoring of infants
- More parental involvement, with greater opportunities for teaching and assessing
- Better use of healthcare dollars
- Less morbidity and mortality especially in developing countries
- Opportunities for teaching during pregnancy and follow-up in preparation for postnatal implementation
- Decreased use of financial resources
- Promotion of total family health.
A KANGAROO MOTHER CARE WARD (kangaroo care unit)
This is a special room where mothers can room-in for a few days so that they can give continuous KMC to their infants under supervision both day and night. Most of these mothers are well and do not need nursing care or routine observations. Every effort must be made to make the KMC ward as homely as possible and not look like a typical hospital ward. Mothers are encouraged to wear their own clothes and walk around. The KMC ward should be close to the nursery if possible. Ideally, a door should link the KMC ward with the nursery so that help can be obtained if needed. Limited visiting is allowed in the KMC ward but the mothers’ privacy must be respected.
The standard policy of the unit for discharge from the hospital should be followed. Generally the following criteria are accepted at most centers:
• Baby's general health is good and no evidence of infection
• Feeding well, and receiving exclusively or predominantly breast milk.
• Gaining weight (at least 15-20 gm/kg/day for at least three days)
• Maintaining body temperature satisfactorily for at least three consecutive days in room temperature.
• The mother and family members are confident to take care of the baby in KMC and should be asked to come for follow-up visits regularly.
Ambulatory Kangaroo Mother Care At Home
The word ambulatory means to “walk around”. Ambulatory KMC usually refers to the KMC which is given after the infant has been discharged home from the hospital or clinic. These mothers give home (or ambulatory) KMC throughout the day. Most work in the house (e.g. washing up) can be done while giving KMC. Mothers can give KMC while walking around in or near their homes. Ambulatory KMC should also be given when attending the clinic, visiting friends, on the bus or going shopping. Many low birth weight infants need KMC for days or weeks after they are discharged home. Mothers must be convinced of the benefits of KMC and committed to give KMC at home.
When should KMC be discontinued ?
When the mother and baby are comfortable, KMC is continued for as long as possible, at the institution & then at home. Often this is desirable until the baby's gestation reaches term or the weight is around 2500 g. She starts wriggling to show that she is uncomfortable, pulls her limbs out, cries and fusses every time the mother tries to put her back skin to skin. This is the time to wean the baby from KMC. Mothers can provide skin to skin contact occasionally after giving the baby a bath and during cold nights.
Research support has provided evidence that kangaroo care contributes to breastfeeding longer and more frequently; health and survival of premature infants; quiet alertness and deep sleep; less time in incubators; earlier discharge; less crying and distress; fewer illnesses; and fewer readmissions to hospital. There is evidence of better maternal milk supply; increased confidence of mothers; father’s participation and acceptance; and empowerment.
Promotion of kangaroo care
Given the benefits of the kangaroo care method on mothers, babies, families, hospitals, health care workers and society, it is essential that it be promoted and implemented on a wider scale in developed and developing countries (Kennell, 2006). Further research and studies must be done to provide quality information for evidence–based practice in mother-infant care.
