Kangaroo mother care (KMC) was first devised in Colombia, 1978 as a means of strengthening the bond between mother and premature infant in a technologically deprived region. Following successful short term and long term results, the practice was proposed as a useful tool in the neonatal units of developed nations in 1985 and has since become one of the most researched and substantiated techniques for encouraging development in the premature infant (Whitelaw and Sleath, 1985). This paper aims to discuss the methodology behind KMC and the evidence for benefit in the neonatal unit. Based on this assessment recommendations for practice will be discussed.
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The essential component to KMC is the kangaroo position, in which the mother and infant engage in direct skin-to-skin contact, with the infant between the mothers breasts, under her clothes (Martinez et al., 1992). Initially this contact was recommended for 24 hours a day, with the father substituting for the mother if necessary at times (Nyqvist et al., 2010a). However, in more affluent settings an intermittent approach has been adopted, which involves contact several times a day and for a limited number of days. Rather than being considered a separate approach, intermittent KMC can be seen as part of a progression and may be more acceptable and practicable in a high tech neonatal unit, rather than the continuous approach.
The other components to KMC, which are less frequently cited, include breast feeding as the sole source of nutrition for the infant and early discharge from the neonatal unit/hospital. The proposed benefits of KMC include: physiological benefit to the infant; enhanced mother-infant bonding; the promotion of breast-feeding; and helping mothers cope with premature births (Nyqvist et al., 2010b).
Evidence for Benefit
A number of studies have assessed physiological parameters in both the infant and mother in order to determine the effectiveness of KMC compared with conventional care. These parameters include: sleep patterns; respiratory status; temperature and weight; and heart rate. Of these, infant temperature and weight seem to be most robustly affected by skin-to-skin contact. For example, KMC for a period of 1-2 hours increases the infant temperature by 1Â°C and those infants undergoing KMC suffer from hypo-/hyperthermia less so than control infants (Anderson, 1991; Cattaneo et al,, 1998). It is thought that KMC is at least as effective in temperature regulation as neonatal unit incubators (Bergmann et al., 2004). Daily weight gain has been shown to be increased in low birth weight infants (>2000g) undergoing KMC rather than conventional care which correlates with increased growth as determined by head circumference and length measurements (Suman et al., 2008).
KMC also appears to induce a rest state in infants, both a ‘quiet awake state’ and extended quiet sleep reflected in stable heart rate, breathing patterns and oxygen saturation levels (Charpak et al., 2005). Sleep is proposed to contribute to infant growth, weight gain and neurological development and therefore the calming effect of KMC may contribute towards those factors by providing more effective rest periods (Smith, 2007).
One of the main reasons for assessing physiological criteria is to improve the mortality outcome of premature infants. A Cochrane review in 2003, revealed a paucity of research demonstrating increased survival rates in infants receiving KMC (Conde-Agudeln and Belizan, 2003). One reason for this is that the majority of low birth weight infant mortality occurs prior to KMC commencing (the stabilisation period). Mortality data has been reviewed in developing nations and in general KMC results in improved rates of survival, however extrapolating this data in the context of advanced care units is difficult: other modes of care, such as intravenous fluids and medications have a huge survival impact and are given alongside KMC.
Regardless of the status of ‘pure’ mortality data there are strong indicators that KMC has survival benefits: nosocomial (hospital-acquired) infections occur less frequently in infants receiving KMC, with severe illness and respiratory disease levels also reduced at a 6 month follow up (Conde-Agudeln and Belizan, 2003). Infants are also more likely to initiate successful breastfeeding if they have received KMC, particularly if it is commenced as soon after birth as possible. In turn, this effect results in increased rates of exclusive breastfeeding on discharge from hospital (Moore et al., 2007). Whether or not these effects persist in the long term is debatable.
One of the main benefits of KMC is strengthening the bond between infant and mother, especially if the child is perceived as very fragile. It has been observed in the clinical setting, that close interaction (such as KMC and skin-to-skin contact) enhances the feelings of responsibility and parenting in the mother, leading to increased acceptance of maternalism and enhancement of the skills necessary to nurture the growth and development of the infant (Luddington, 1990). This is reflected in data suggesting that mothers who practiced KMC are less stressed than those who used conventional approaches, even after only 2 weeks of KMC. KMC mothers also perceive their child as ‘less difficult’ than the mothers in the control group (Tallandini and Scalembra, 2006). Another study extends these findings, by assessing depression scores in mothers 6 weeks post partum who had an experience in the neonatal intensive care unit. It concluded that scores were lower in those mothers who had practiced KMC (Nyqvist et al., 2010b).
Although these results are significant there is little quantitative data available regarding stress levels in mothers utilising KMC. One notable study evaluated salivary cortisol levels are found a significant reduction (32%) in mothers after practicing skin-to-skin contact in the neonatal intensive care unit, which correlates with subjective measurements of reduced stress (Morelius et al., 2005).
Interestingly, there seems to be emerging evidence suggesting that KMC benefits the family unit as a whole, rather than purely from the maternal perspective. In Colombia it was shown that KMC mothers created a home environment which provided more stimulation for the infant, with the level of stimulation increasing if the father became involved in the KMC process (Tessier et al., 2009).
Further benefits of KMC
Apart from the physiological benefits to the child and the development of a healthy bond between mother (or parents) and child, one must consider the role of KMC in reducing hospital stay, as well as the cost effectiveness of the technique in order for it to be practicable in the neonatal unit. As such, there is convincing data to suggest that KMC can effectively reduce the length of hospital stay and accordingly reduce the cost of that hospital visit. One study, by Cattaneo and colleagues showed that median hospital stay was reduced in the KMC group (11 days compared with 13 days in the conventional care group) and suggested that the total cost of treatment was approximately 50% less if KMC was utilised (Cattaneo et al., 1998). This is supported by an earlier study where it was observed that neonatal care costs were reduced in KMC infants. However, this study showed that hospital stay was two days greater in the KMC group than the control group (Sloan et al., 1994). Studies with larger numbers of infants are required to clarify this issue, taking into account the birth weights, gestational age and further parameters which may influence length of hospital stay.
Conclusion: Recommendations for Clinical Practice
In summary, evidence indicates that KMC is likely to be beneficial for premature infants in neonatal units by improving physiological parameters, strengthening the bond between mother and infant and increasing the uptake of breast feeding. Coupled with the perceived cost-effectiveness of the technique, it seems logical that KMC should be widely used in neonatal units.
In 2003, a Cochrane review on KMC in neonatal care concluded that there was not enough evidence to recommend KMC use in low birth weight infants, although it did appears to reduce severe infant mortality (Conde-Agudeln and Belizan, 2003). However, research conducted since then has included randomised control trials and more rigorous data collection prompting a reassessment of the clinical use of KMC. As such, in 2010 the ‘International Network on Kangaroo Mother Care’ released recommendations for the widespread use of KMC in neonatal units (Nyqvist et al., 2010a). The important aspects of this report is that mother and infants should be separated as little as possible, skin-to-skin contact should be used to promote infant maturation (ideally in the position adopted in KMC) and that KMC should be implemented as early as possible after birth.
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Essentially, there are three important areas which need to be addressed for the successful implication of KMC in clinical practice: appropriate maternal education; appropriate staff education (and maternal support); and provision of medical interventions in the context of KMC. Maternal education is paramount to the success of this initiative and therefore there should be an abundance of literature and experienced staff available to provide information about KMC. Clearly this requires highly trained staff who are able to teach the mother the correct way to hold the infant, facilitate KMC adherence as soon after delivery as possible, and provide sensitive support throughout the process. This level of expertise cannot be stressed enough, as studies have shown that despite an increased uptake of KMC and other developmental care pathways there is still a massive variation in effectiveness, based on the level of staff knowledge and experience (Hamilton and Redshaw, 2009).
The final aspect to consider is how KMC will work around existing medical interventions and protocols. Firstly, KMC should be considered the number one priority and separation of the infant and mother for medical procedures kept to an absolute minimum. Medical procedures should be instituted wherever possible with the infant in the KMC position. Of course, careful assessment of physiological parameters are still important and if deemed necessary may overrule the need for continuous KMC. In such cases, e.g. the infant requiring ventilatory support, attempts should be made to maximise infant-mother contact, as the value of KMC cannot be dismissed.
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