Target Health Blog

Kangaroo Care

December 3, 2018

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Quiz
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The logo is for free use without modification, and is to celebrate, share, encourage kangaroo care globally.Graphic credit: By Kangaroo Care - Own work, CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=58141623

Kangaroo care (KC) or kangaroo mother care (KMC), sometimes called skin-to-skin care, is a technique of newborn care where babies are kept skin-to-skin with a parent, typically their 1) ___. It is most commonly used for low birth-weight preterm babies, who are more likely to suffer from hypothermia, while admitted to a neonatal unit to keep the baby warm and support early breastfeeding.

KC, has positive benefits for both infants and mothers, that persist after discharge from the NICU. When KC is implemented, there have been no reported detrimental effects on physiological stability for preterm infants as young as 26 weeks' gestation, including those on assisted ventilation. KC enables both mothers and 2) ___ to care for and nurture their fragile infant and promotes family health during a time of great stress. KC enhances breastfeeding and may contribute to improved neurodevelopmental outcome.

KC is named for the similarity to how certain marsupials carry their young, and was initially developed in the 1970s to care for preterm infants. There is evidence that it is effective in reducing both infant mortality and the risk of hospital-acquired infection, and increasing rates of breastfeeding and weight gain. KC seeks to provide restored closeness of the newborn with family members by placing the infant in direct skin-to-3) ___ contact with one of them. This ensures physiological and psychological warmth and bonding.

The parent's stable body temperature helps to regulate the neonate's temperature more smoothly than an 4) ___, and allows for readily accessible breastfeeding when the mother holds the baby this way. KC is not mutually exclusive from neonatal intensive-care units and (NICU) procedures. One recent survey found that 82% of neonatal intensive care units use kangaroo care in the United States today.

KMC is a broader package of care defined by the World Health Organization. KMC originally referred only to care of low birth weight and preterm infants, and is defined as a care strategy including three main components: kangaroo position, kangaroo nutrition and kangaroo discharge. Kangaroo position means direct skin-to-skin contact between mother and baby, but can include father, other family member or surrogate. The infant should be upright on the chest, and the airway secured with safe technique. Kangaroo nutrition implies exclusive breastfeeding, with additional support as required, but with the aim of achieving ultimately exclusive 5) ___. Kangaroo discharge requires that the infant is sent home early, meaning as soon as the mother is breastfeeding and able to provide all basic care herself.

History

Peter de Chateau in Sweden first described studies of "early contact" with mother and 6) ___ at birth in 1976. Klaus and Kennell did very similar work in the USA, more well known in the context of early maternal-infant bonding. The first reported use of the term "skin-to-skin contact" is by Thomson in 1979. Dr Rey and Dr Martinez published their results in 1981 in Spanish, and used the term Kangaroo Mother Method. This was brought to the attention of English speaking health professionals in an article by Whitelaw and Sleath in 1985. Gene Cranston Anderson and Susan Ludington were instrumental in introducing this to North America.

Scientific Rationale

In primates, early skin-to-skin contact is part of a universal reproductive behavior, and early separation is used as a research modality to test the harmful effects on early development. Research suggests that for all mammals, the maternal environment (or place of care) is the primary requirement for regulation of all physiological needs (homeostasis), 7) ____ absence leads to dysregulation and adaptation to adversity. In mainstream clinical medicine, KMC is used as an adjunct to advanced technology that requires maternal infant separation. However, skin-to-skin contact may have a better scientific rationale than the incubator. All other supportive technology can be provided as part of care to extremely low birth weight babies during skin-to-skin contact and appears to produce a better effect.

Based on the scientific rationale, it has been suggested that skin-to-skin contact should be initiated immediately, to avoid the harmful effects of separation. In terms of classification and proper defining for research purposes, the following aspects that categorize and define skin-to-skin contact have been proposed:

Initiation time, (minutes, hours from birth), ideal is zero separation.

Dose of skin-to-skin contact, (hours per day, or as percentage of day), ideal >90%.

Duration, (measured in days or weeks from birth), ideally until infant refuses.

The Procedure

Safe techniques should ensure that obstructive apnea cannot occur. Since the mother must be able to sleep to provide adequate care, it is mandatory to implement a technique that enables the airway to safely open, and close, while the infant is secured to the mother's bare chest using a garment. Various of these garments are described in the WHO guidelines.

Mother should be the primary provider of skin-to-skin contact, as only she can breastfeed. However, it is almost always necessary that father should also provide skin-to-skin contact to achieve adequate dose; other family members can also be used. Since skin-to-skin contact is basic to early bonding and attachment, it should probably not be done by hospital staff and other surrogates.

In KC, the baby wears only a small diaper and a hat and is placed in a flexed (fetal position) with maximum skin-to-skin contact on parent's chest. The baby is secured with a wrap that goes around the naked torso of the adult, providing the baby with proper support and positioning (maintain flexion), constant containment without pressure points or creases, and protection from air drafts (thermoregulation). If it is cold, the parent may wear a shirt or hospital gown with an opening to the front and a blanket over the wrap for the baby. The tight bundling is enough to stimulate the baby: vestibular stimulation from the parent's breathing and chest movement, auditory stimulation from the parent's voice and natural sounds of breathing and the heartbeat, touch by the skin of the parent, the wrap, and the natural tendency to hold the baby. All this stimulation is important for the baby's development.

"Birth Kangaroo Care" places the baby in kangaroo care with the mother within one minute after birth and up to the first feeding. The American Academy of Pediatrics recommends this practice, with minimal disruption for babies that don't require life support. The baby's head must be dried immediately after birth and then the baby is placed with a hat on the mother's chest. Measurements, etc. are performed after the first feeding. According to the US Institute of Kangaroo Care, healthy babies should maintain skin-to-skin contact method for about 3 months so that both baby and mother are established in breastfeeding and have achieved physiological recovery from the birth process. For premature babies, this method can be used continuously around the clock or for sessions of no less than one hour in duration (the length of one full sleep cycle.) It can be started as soon as the baby is stabilized, so it may be at birth or within hours, days, or weeks after birth.

Kangaroo care is different from the practice of babywearing. In KC, the adult and the baby are skin-to-skin and chest-to-chest, securing the position of the baby with a stretchy wrap, and it is practiced to provide developmental care to premature babies for 6 months and full-term newborns for 3 months. In babywearing the adult and the child are fully clothed, the child may be in the front or back of the adult, can be done with many different types of carriers and slings, and is commonly practiced with infants and toddlers.

The Literature

In 2016 a clinical review, "Kangaroo mother care to reduce morbidity and mortality in low birthweight infants", was published bringing together data from 21 studies including 3,042 low birth-weight babies (less than 1,500 grams (53 oz.) at birth). This review shows that babies provided kangaroo mother care have a reduced risk of death, hospital-acquired infection, and low body temperature (hypothermia); it is also associated with increased weight gain, growth in length, and rates of breastfeeding. Early skin-to-skin contact for mothers and their healthy babies", updated in 2015, provides clinical support for the scientific rationale but looks at evidence for early skin-to-skin contact for healthy babies. The available evidence shows that early skin-to-skin contact is associated with increased rates of breastfeeding, and some evidence of improved physiological outcomes (early stability of the heart rate and breathing) for the babies. Randomized controlled trials report that babies born between 1,200 and 2,200 g became physiologically stable in skin-to-skin contact starting from birth, compared to similar babies in incubators. Survival improved when skin-to-skin contact was started before 6 hours after 8) ___.

While KMC generally implies care of low birth weight and preterm infants, skin-to-skin contact should be regarded as normal and basic for all newly born humans. The original research by Thomson showed increased breastfeeding rates when skin-to-skin contact started at birth, and when early breastfeeding was encouraged every two hours. Currently, the impact of skin-to-skin contact on breastfeeding is the scientific rationale for Step 4 of the Baby Friendly Hospital Initiative (BFHI), which requires help to "initiate breastfeeding within one hour of birth". Originally babies who are eligible for KC include pre-term infants weighing less than 1,500 grams (3.3 lb.), and breathing independently. Cardiopulmonary monitoring, oximetry, supplemental oxygen or nasal (continuous positive airway pressure) 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.

Results

Skin-to-skin contact is effective in reducing pain in infants during painful procedures. There appears to be no difference between mothers and others who provide skin-to-skin contact during medical treatments. KC is beneficial for parents because it promotes attachment and bonding, improves parental confidence, and helps to promote increased milk production and breastfeeding success. A recent study found that the psychological benefits of KC for parents of preterm infants are fairly extensive.

Research shows that the use of KC is linked to lower parental anxiety levels. KC has also led to greater confidence in parenting skills. Parents who used KC displayed higher confidence in their ability to care for their child. KC has been shown to positively impact breastfeeding as well, with mothers producing larger amounts of 9) ___ for longer periods of time. Overall, KC has many important benefits for parents as well as infants. Fathers should be a part of KC. Both preterm and full term infants benefit from skin to skin contact for the first few weeks of life with the baby's father as well. The new baby is familiar with the father's voice and it is believed that contact with the father helps the infant to stabilize and promotes father to infant bonding. If the infant's mother had a caesarean birth, the father can hold their baby in skin-to-skin contact while the mother recovers from the anesthetic.

The World Health Organization reports that in addition to more successful breastfeeding, skin-to-skin contact between a mother and her newborn baby immediately after delivery also reduces crying, improves mother to infant interaction, and keeps baby warm. According to studies, babies have been observed to naturally follow a unique process which leads to a first breastfeed. After birth, babies who are placed skin to skin on their mother's chest will:

  1. Initially babies cry briefly - a very distinctive birth cry
  2. Then they will enter a stage of relaxation, recovering from the birth
  3. Then the baby will start to wake up
  4. Then begin to move, initially little movements, perhaps of the arms, shoulders and head
  5. As these movements increase the baby will actually start to crawl towards the breast
  6. Once the baby has found the breast and therefore the food source, there is a period of rest. Often this can be mistaken as the baby is not hungry or wanting to feed
  7. After resting, the baby will explore and get familiar with the breast, perhaps by nuzzling, smelling and licking before attaching

KC often results in reduced 10) ___ stays, reduced need for expensive healthcare technology, increased parental involvement and teaching opportunities, and better use of healthcare dollars. Overall, KC helps to reduce morbidity and mortality, improves parent satisfaction, provides opportunities for teaching during postnatal follow-up visits, and decreases hospital-associated costs.

The International KC Awareness Day is celebrated on May 15 since 2011. It is a day to increase awareness, education, and celebration to enhance the practice of KC globally. Healthcare professionals, parents, volunteers around the world show their support, in their own way, for improving KC practice to benefit babies, parents, and society at large.

ANSWERS

1) mother; 2) fathers; 3) skin; 4) incubator; 5) breastfeeding; 6) baby; 7) maternal; 8) birth; 9) milk; 10) hospital

10)

Extremely instructive video of neonatal incubator, and literally the survival importance of touching

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