KMC Dr. behzad barekatain, MD Assistant professor of pediatrics, Neonatologist (faculty member of IUMS)

Kangaroo mother care – what is it and why it matters? Kangaroo mother care is care of infants carried skin-to-skin with the mother. It is a powerful, easy-to-use method to promote the health and well-being of infants born preterm as well as full-term.

Brief History of Kangaroo Mother Care • 1979 - It was first presented by Rey and Martinez, in Bogotá, Colombia, where it was developed as an alternative to inadequate and insufficient incubator care for those preterm newborn infants who had overcome initial problems and required only to feed and grow.

Circumstances at the hospital where they worked Large numbers of LBW & preterm infants delivered because of: Poor Ante Natal Care attendance High incidence of toxaemia of pregnancy, anaemia & infections Shortages of staff & inadequate equipment High infection & mortality rate because of overcrowding Large numbers of infants who were abandoned by their mothers

Maternal-infant skin-to-skin contact was introduced to stable LBW infants surviving the first few weeks of life Exclusive breast-feeding was encouraged As long as infants could feed and were gaining weight, they were discharged, regardless of weight This practice resulted in: Improved outcome for LBW infants Humanized general care of infants in hospital Decreased hospitalisation time Less overcrowding Less abandoned infants Improved staff moral

First reported by UNICEF, 1984 Intriguing & incredible survival of “kangaroo babies” unparalleled in medical literature Whitelaw (UK) visited Bogotá in 1985 1st description of KMC in English medical literature Continued KMC research - found many benefits

•In Oct 1991 in BOSTON / US preterm baby named “Stevene” was born with 24 w GA.He suffered from severe disease, he verged to death. At the end moments of his life, his mother ‘Dorothy’ hugged him and after several minutes his vital sign improved. She carried on embrace and ultimately his physiologic conditions reclaimed in 3th day. …………………… He discharged from hospital at age 4 month and he was named “The miracle baby “ in US.

• 2000 - Third International Workshop, Yogyakarta, Indonesia. • 1996 - First International Workshop, Trieste, Italy, hosted by Adreano Cattaneo and team. Noted over thirty different terms used, agreed to use KMC (Kangaroo Mother Care), defining the program of skin-to-skin contact, breastfeeding and early discharge. The term “K C” refers only to intervention “intrahospital maternal-infant skin-to-skin contact”. • 1998 - First International Conference on Kangaroo Care, Baltimore, Maryland, USA, arranged by Susan Ludington-Hoe • 1998 - Second International Workshop, Bogota, Colombia, arranged by Nathalie Charpak and team; focus on research and implementation. • 2000 - Third International Workshop, Yogyakarta, Indonesia. • Other visits to Bogotá followed Various forms of KMC practiced in many parts of the world Supported by WHO and many organizations as a life saving method of care

the biological basis of KMC Dr. Bergman, the superintendent of a maternity hospital in Mowbray, South Africa, an expert in the area of kangaroo mother offered the biologic aspect of KMC He pointed out that human infants were designed for continuous feeding and holding and our usual practice of separating mothers and babies is counter to our biological need for togetherness. The most stable and safe place for a baby to grow and thrive is against his mother's body. Dr Nils Bergman

The habitat is the physical area where a species lives The niche is how an organism “makes a living.” A niche will include the organism's role in the flow of energy through the ecosystem. An organism's niche also includes how the organism interacts with other organisms

In the uterine habitat, oxygenation is provided through the placenta and the cord, as well as warmth, nutrition and protection. Parturition (birth) represents a habitat transition. In the new habitat, the basic needs remain the same. Research over the last years provides strong support for the contention that four basic biological needs bring into being with skin to skin contact (habitat)

The correct habitat provides four basic biological needs: Oxygenation has been shown to improve on SSC. The breathing becomes regular and stable, and is coordinated with heart rate. Infants removed from incubators and placed in SSC show a rise in temperature and a dramatic drop in gluco-corticoids. (2) Nutrition (3) Warmth (4) Protection

When in the right habitat, newborns will respond with a “set sequence of behaviors” Newborn’s actions >>>>> maternal care taking responses (Rosenblatt, 1994) “Protest-despair response” occurs when newborns are not in right habitat

Human infants are the most immature of all mammals at birth Based on the rate of brain growth in human infants and the size of the average adult brain, we can assume human babies are born about twelve months early compared to other mammals. They need to complete their gestation on or near their mother. And it is another reason for biologic-based theory of KMC

another reason for biologic-based theory of KMC is different patterns of care in mammals Bergman explained four patterns that mammals follow when caring for their babies. The patterns are: Cache, which feeds about every 12 hours, (deer, rabbit) Nest, which feeds about every 4 hours, (dog, cat) Follow, which feeds about every 2 hours, (giraffe, cow) Carry, which feeds about every 30 minutes or nearly continuously, (apes, marsupials)

The composition (fat and protein ratio) of milk varies among mammals who follow each pattern. "Cache" mammals produce milk that is low in carbohydrates and high in fat and protein. "Carry" mammals (including humans) produce milk that is high in carbohydrates and low in fat and protein. This composition difference helps explain why kangaroo mother care is best for human babies although our society has tried to change the pattern. This societal change is counter to our biological design and potentially detrimental to the infant.

Support for KMC based on science and evidence It might seem a bit insulting to say mother is a place, but to the newborn brain she is first the safe place, and then becomes the safe person.” Mother’s smell, both from her body but also specifically from her breasts, fire specific pathways to the front of the brain. Smell also send signals directly to the AMYGDALA … which I call the “emotional processing unit” of the brain.

At the same time, direct skin-to-skin contact, specifically the deep pressure component of contact, sends messages to the same amygdala. The result is that another signal is fired by the amygdala to the “prefronto orbital cortex “. In this part of the brain is an activation centre for orientation. The CRITICAL PERIOD for this pathway to mature is 6-8 weeks. After this, it is eye-to-eye contact which is important for the next pathway building from here.

Babies’ brain development requires: *skin to skin contact & *eye to eye contact to form the right brain pathways. Depriving babies of this skin to skin care makes alternative stress pathways which can lead to ADD, colic, sleep disorders and etc

Why the title "Kangaroo Mother 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 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.

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.

HUMAN KANGAROO MOTHER CARE does the same for the premature! - Skin-to-skin contact - Breastfeeding - Protection

Healthy infants should be placed and remain in direct skin-to-skin contact with their mothers immediately after delivery until the first feeding is accomplished. Dry the infant, assign APGAR scores, and perform the initial physical assessment while the infant is with the mother. American Academy of Pediatrics, Section on Breastfeeding. Breastfeeding and the Use of Human Milk.Pediatrics 115(2), 496-506. The alert, healthy newborn infant is capable of latching on to a breast without specific assistances within the first hour after birth If infants were placed in KC immediately after delivery and remained there for at least 50 minutes they spontaneously crawled to the breast and start feeding 50 to 90 minutes after birth.

Initiation of Breastfeeding by Breast Crawl Dr.Ravari

KMC program and Its key features: *early, continuous and prolonged skin-to-skin contact between the mother and the baby; *exclusive breastfeeding (ideally);

The Components/Elements of KMC Kangaroo position Skin-to-skin on the mother’s chest Secured with a wrap Kangaroo nutrition Exclusive breastfeeding whenever possible Kangaroo discharge Mother continues KMC practice at home after discharge Kangaroo Support Health care staff provide support to the mother to take care of her infant in the hospital Family support of mother in practicing KMC at home

Diagram of KMC Components S U P P O R T I V E E N V I R O N M E N T Kangaroo Position Kangaroo Nutrition S U P P O R T I V E E N V I R O N M E N T Kangaroo Discharge

Kangaroo Position: maternal infant skin-to-skin contact between the baby front and the mother's chest. The more skin-to-skin, the better.  For comfort a small nappy is fine, and for warmth a cap may be used. Skin-to-skin contact should ideally start at birth, but is helpful at any time. It should ideally be continuous day and night, but even shorter periods are still helpful.

Kangaroo Nutrition: early and exclusive breastfeeding means that for an average mother, expressing from the breasts or direct suckling by the baby is all is needed. For very premature babies, supply of some essential nutrients may be indicated.

The benefits of kangaroo care to the baby include Stabilization of the baby's heart rate Improved (more regular) breathing pattern Improved oxygen saturation levels Gain in sleep time and Restful sleep More rapid weight gain Decreased crying More successful breastfeeding episodes Normal temperature

Possible reduced risk of sudden infant death (see www.infactcanada.ca( May be a good intervention for colic Possible positive effects in motor development of infants Reduced physiologic and behavioural pain responses Less nosocomial infection, severe illness, or lower respiratory tract disease Earlier hospital discharge

KMC babies are different! They breastfeed earlier, and more frequently. They grow faster and a ready to go home sooner. They have round heads, round wide awake eyes and know what is going on!

what are the benefits of Kangaroo Mother Care? Thermal control and metabolism Breastfeeding Protection Development and growth Other effects The benefits for all babies on KMC Early discharge Less morbidity and mortality ALL OF THESE ABOVE FACTORS ARE EVEN MORE IMPORTANT IF THE BABY IS BORN PREMATURE

The benefits of kangaroo care to the parents include Improved bonding, feelings of closeness with their babies Increased breast milk supply and increased duration of breastfeeding Increased ability to care for their babies Increased confidence that their babies are well cared for

The benefits of kangaroo care For community Less morbidity and mortality especially in developing countries Decreased use of financial resources Promotion of total family health.

National & International Endorsements Kangaroo care has been endorsed as the standard of care by: • American Academy of Pediatrics (AAP) • Academy of Breastfeeding Medicine (ABM) • World Health Organization (WHO) • Neonatal Resuscitation Program (NRP: by American Heart Association & AAP)

New AAP Guidelines: Healthy infants should be placed and remain in direct skin-to-skin contact with their mothers immediately after delivery until the first feeding is accomplished

WHO Recommendation “Given the importance of thermoregulation, skin to skin contact should be promoted and “kangaroo care” encouraged in the first 24 hours after birth.” This is a Grade A recommendation.

Academy of Breastfeeding Medicine Protocols, Peripartum breastfeeding management for the healthy mother and infant at term Academy of Breastfeeding Medicine Protocols, “The healthy newborn can be given directly to the mother for skin-to-skin contact until the first feeding is accomplished. The infant may be dried and assigned APGAR scores and the initial physical assessment performed as the infant is with the mother. Such contact provides the infant optimal physiologic stability, warmth, and opportunities for the first feeding. Delaying procedures such as weighing measuring and administering vitamin K and eye prophylaxis (up to an hour) enhances early parent-infant interaction.”

American Heart Association Neonatal Resuscitation Program (7th Ed.) Lesson 1 “for all normal newborns, skin to skin care can be used to provide routine resuscitation”

Ideal Kangaroo Care • Start as soon after birth as possible • Let the mother help stabilize her infant • Provide a comfortable, private milieu • Provide KC as long and as often as possible, even as the infant grows • Provide KC before, during, and after feedings • Let others KC if mother agrees

Technology is not an issue Ideal Kangaroo Care (cont) • Let mother & baby sleep together • Let perform KC even in intubated baby and never separate mother and baby, and ADD ON available technology Technology is not an issue

History of newborns experienced KMC

HILDA was born without problems, and started life with skin-to-skin contact. ....  And she did all the right things ...  

She comes home, and gets to know Dad ! Mum thinks Hilda prefers Dad's hairy chest than her own  ....    

But on the third day, she has JAUNDICE    And here she is having standard treatment: overhead lights, or a "biliblanket". And not enjoying it very much ....                   

  Luckily the night staff nurse understands Hilda's and Mum's needs, and she is confident and inventive .... Hilda settles happily, and maintains her vital signs well.

The biliblanket and the KangaCarrier can be combined, or the biliblanket just added to the resting kangaroo position.

And Hilda has continued to be well bonded and attached !!

Little baby Stohm is now four weeks old, and weighs 775 grams. A mother will often feel so helpless faced with a very premature baby being cared for in an incubator. This is important, newborns even of this age can hear and feel, and recognise mothers voice and smell. But the incubator is nevertheless a separation of mother and baby

Though Sharleen may feel helpless, there is one critical, vital, essential and important thing she can do: provide expressed breastmilk. There is NOTHING that can replace mother's own milk, and there is nothing that will provide better protection and better growth. Sharleen expresses comfortably by hand, and does so regularly at home to make sure there is always enough.

Stohm is placed in a flexed posture (frog position), and fits inside mother's shirt. Stohm's head is turned to the side, and is slightly extended. Notice how relaxed Stohm is. Sharleen has been giving skin-to-skin contact almost every day since birth. Stohm settles very quickly, not always the case after transfer

After a few minutes of being awake and alert, Stohm will settle down to sleep. the heart rate has been stable at around 150 beats per minute, and the oxygen saturation stable at 97%.

Thereafter Sharleen makes herself comfortable. She has spent many hours reading novels, but also encouraging the staff and other mothers.

Sharleen moves Stohm from the incubator onto her chest, standing close by and being careful with the tubes and the saturation monitor still attached to Stohm's foot.

Father Johnny is here doing skin-to-skin for the second time ever Father Johnny is here doing skin-to-skin for the second time ever. Sharleen can't come today, so Johnny has come during his extended lunch-break. Even an hour of skin-to-skin is good for a premature

The KangaCarrier is especially designed to make continuous KMC safe The KangaCarrier is especially designed to make continuous KMC safe. The wrapper fixes the baby to mother's chest, and goes underneath the ear.

The wrapper is tied firmly, tight enough to keep baby's head fixed to mother. The shirt comes on, and mother ties it firmly below the baby's flexed legs.

After tying below baby, mother is able to sit up and move about freely.

DISCHARGE DAY !!! 9th February 2002, Stohm is finally ready for discharge, weighing 1790g. Father and brother have come to collect! Sharleen and Stohm sign out through the security desk!

With Stohm secured inside the KangaCarrier, transport by car is quite safe. Mother Sharleen will wear her seat belt, but only the hip belt - and not the shoulder strap. Should there be a mishap (unlikely with father a traffic warden!) then the baby is secured safely, and at worst will end up between mothers legs.

1998 Bogotá Declaration Kangaroo Mother Care is a basic right of the newborn and should be an integral part of the management of low birth weight and full term infants in all settings at all levels of care and in all communities

Thanks for your attention