Rapid Responses to:

EDUCATION AND DEBATE: Juan Gabriel Ruiz-Peláez, Nathalie Charpak, and Luis Gabriel Cuervo Kangaroo Mother Care, an example to follow from developing countries BMJ 2004; 329: 1179-1181 [Full text]

Rapid Responses: Submit a response to this article

Rapid Responses published:

The Kangaroo Mother Care and the Instituto Materno Infantil

Javier H. Eslava-Schmalbach, Gaitán-Duarte, Hernando G.   (14 November 2004)

Kangaroo Mother Care: the importance of skin-to-skin contact.

Nils J Bergman   (24 November 2004)

Re: Kangaroo Mother Care: the importance of skin-to-skin contact.

Juan G Ruiz, Nathalie Charpak and Luis G. Cuervo   (2 December 2004)

The Kangaroo Mother Care and the Instituto Materno Infantil 14 November 2004
Javier H. Eslava-Schmalbach, School of Medicine Professor, Universidad Nacional de Colombia Bogotá, (1), Gaitán-Duarte, Hernando G. Send response to journal: Re: The Kangaroo Mother Care and the Instituto Materno Infantil	The Kangaroo Mother Care, which has been presented in the “Kangaroo Mother Care, an example to follow from developing countries” article 1, has saved thousand of lives of premature children. It is a case where natural warm from the mother overcome the available technological advancements at hospitalary level The first time when we heard and learnt about this health care approach was in the ends of 70’s at the Instituto Materno Infantil (IMI), when we were students at the Universidad Nacional de Colombia`s Medical School. In this place, Professor Edgar Rey showed us the advantages of carry on the premature child, over the incubator. At the IMI was originated and developed implemented for the first time the Kangaroo mother care The IMI, is a 60 years old institution. It is the biggest reference center for maternal and perinatal care located in Bogotá. There are many important researches in progress in it and it has participated as collaborative institution, in international investigations as the Magpie Trial, for instance 2. However nowadays the IMI is nearby to close its doors as result of the Health Sector Reform implemented since 1993 3. This reform has left without enough financial resources several institutions that have already been closed definitively. This is a special opportunity, to congratulate visible actors of Kangaroo Program, and to defend an invisible one, that it is going to be closed nearly. With it, it will be closed too, the Kangaroo Program for poor newborns of the city and of the country. May be, international scientific community should demand for the Colombian Government urgent decisions and measurements, addressed to achieve the survival of the IMI in order to maintain this University Hospital open for the life of a lot of more mothers and newborns in Colombia and overseas. References 1. Ruiz-Peláez J, Charpak, Natalie, Cuervo, Luis Gabriel. Kangaroo Mother Care, an example to follow from developing countries. BMJ 2004;329:1179-1181. 2. The Magpie Trial Collaborative Group. Do women with pre-eclampsia, and their babies, benefit from magnesium sulphate? The Magpie Trial: a randomised placebo controlled trial. Lancet 2002;359:1877-90. 3. República de Colombia Congreso de la República. Ley 100, 1993. Competing interests: None declared
Kangaroo Mother Care: the importance of skin-to-skin contact. 24 November 2004
Nils J Bergman, Senior Medical Superintendent Mowbray Maternity Hospital, Mowbray 7700, Cape Town, South Africa Send response to journal: Re: Kangaroo Mother Care: the importance of skin-to-skin contact.	Ruiz-Palaez et al describe the “Bogota experience” of Kangaroo Mother Care, arising in a context of shortage of incubators, and define a management programme involving a number of elements 1. The first of these is maternal infant skin-to-skin contact starting after stabilisation in a neonatal care unit. The second element is breastfeeding, preferably exclusive. The third element described is early discharge after an adaptation period, which can be delayed in the form of kangaroo wards, with subsequent follow-up. As originally described by Drs Rey and Martinez2, and with subsequent minor modifications, this method has indeed been highly effective in many developing countries. Marlow’s comment differentiates between the developing country context and the use of KMC in Western settings: issues around bonding, better breastfeeding, and shorter lengths of stay 3. Marlow does however make an important point which deserves elaboration. There are a host of effective interventions (some aggressive and interventionist, some more natural) for which we have good evidence of efficacy, but there is a need to elucidate “for the more complex interventions, which components are the most effective”. Kangaroo Mother Care is a generic definition of a model of newborn care4, composed of a number of components or elements as described above, and each of those elements have a range possible applications. It is not one intervention , but a complex strategy. It is becoming generally accepted that exclusive breastfeeding, though culturally uncommon, is the optimal feeding method5, but context and circumstances determine a range of feeding methods from near exclusive to mixed feeding to complete artificial feeding6. Where long term outcomes are studied, it is essential to control for feeding method, as it is now established that breastfeeding duration directly impacts on cognitive and other neurodevelopment outcomes7. Adaptation, discharge and followup (though important parts of KMC)1 are highly context and resource dependent, and are unlikely to directly impact on long term outcomes as do breastfeeding and skin-to-skin contact. Maternal-infant skin-to-skin contact (SSC), is the primary and essential element of KMC. It has a number of important dimensions, each of which may individually and critically influence the effectiveness of KMC as a model of care. Initiation of SSC is the first, and possibly the most important. In the developing world, the majority of premature newborns do not have access to neonatal care units or incubators, and die before they stabilise. KMC started after stabilisation as described by Ruiz-Pelaez et al would not help such infants. Various reports have however shown the safety of and potential to improve mortality by initiating SSC from birth, or within the first hour of life, regardless of stabilisation8-11. A recently published randomised controlled trial from a western setting provides evidence that lowbirth weight infants stabilise better in SSC than they do in incubators12. In the absence of incubators, this could potentially save many lives. Two other important time dimensions of SSC are dose and duration. Even ten minutes per day of SSC can impact maternal breastfeeding success13, but it does appear that for the infant, a minimum episode of 60 – 90 minutes is required to achieve physiological benefit14. Shorter periods may in fact be disruptive to the infant’s state organisation. However, continuous SSC is likely to be the optimum for the newborn, and in particular for the neurodevelopment of the infant, see more below. Continuous SSC may initially appear impossible in the interventionist and technological milieus the western world has created in neonatal units, but is easy, obvious and uncomplicated elsewhere. Duration of SSC is obviously dependent on a variety of factors. In many units term newborns may spend the first hour of life in SSC, before being separated15;16. In many western settings SSC is encouraged for a brief period prior to discharge. However from a neurodevelopmental perspective, SSC is the salient stimulus for the development of the amygdala-prefrontorbital tract, the first pathway for healthy right brain development and subsequent mental health, and this develops up to the 48th post-menstrual week17. It can be inferred therefore that KMC is not only important for premature babies, but all newborns. Experience does confirm that the infant will “reject permanent contact”1 in its own time, though this varies greatly from infant to infant. Hypothetically: the ideal or gold standard would be that SSC starts from birth, is continuous 24 hours a day, and continues to 6 or 8 weeks post-menstrual age. Anthropological studies show that the majority of tropical hunter-gatherer societies, presumably behaving more naturally and in tune with basic evolutionary and biological drives, abide by this gold standard18. A further important dimension of SSC relates to technique. A variety of wrappers, ties and shirts have been described to empower and support mothers to provide continuous SSC19. For shorter periods as described in western settings, simple placement on mothers chest, covering with cloth, and observations is adequate. An absolute requirement is that the infant airway is continuously protected, until such a time that there is head control. Continuous SSC is better achieved with techniques that give the mother maximal freedom of movement. When applied to premature infants from birth, the upright position is not always well tolerated: the infant is best placed at an angle of 30 to 40 degrees from horizontal8. A final dimension concerns the integration of SSC with “support”: which ranges from psychological and social support to the “aggressive and interventionist” technological support available in western settings. It must be emphasised that SSC does not exclude technological support, rather the KMC paradigm is one that places the maternal infant dyad in the centre of care, to which is added whatever support is available as indicated. This may require considerable modifications and adjustments to infrastructure and equipment. Thus, Marlow is correct that further research is needed; and this should be done in western settings. This research should however focus on “maternal-infant skin-to-skin contact”, and should address the dimensions of time of initiation, dose, duration, technique and support. Unanswered questions relate particularly to infant limits of gestational age and weight, and to maternal tolerance. There is a little evidence of maternal benefit in the literature20-24, but hypothetical arguments for lasting positive impact exist25-28. In terms of the importance of KMC for the developed world, the most important aspect is almost certainly its impact on the neurodevelopment of the premature infant. Improved survival of premature infants has been achieved by providing thermal and cardiorespiratory support, with little consideration for the premature’s brain. The quality of that survival can however be compromised: it is accomplished through technological interventions, resulting in prolonged maternal infant separation. Separation results in infant “hyper-arousal dissociation behaviours”, which when prolonged result in compensatory brain pathways, with permanent adverse effects across the lifespan29;30. Schore reviews a body of psychoneurobiological and psychiatric research with a neurodevelopmental perspective29. For healthy (right) brain development, the newborn requires the maternal milieu to provide essential salient stimuli, which sculpt the final configuration of the brain26. Thus, Feldman et al report that infants receiving SSC in the neonatal care unit had better perceptual- cognitive and motor development at six months than controls.25 Anthropologists, with a different perspective of what constitutes “normal care”, would interpret the same results by saying that premature infants separated from their mothers have deleterious developmental outcomes. KMC comes to readers in western settings with connotations of “nice and cute”, and “appropriate for the developing world”. It is however, as Ruiz-Pelaez et al propose, an example for the developed world to follow. Maternal-infant skin-to-skin contact, provided from birth and continuously, embodies and defines individualised neurodevelopmental care, and should be regarded as a fundamental right of every newborn, premature or otherwise. We should not surrender the technology we have mastered, but we should ensure the humanisation of premature infant care, and restore all mothers to their newborns31. Dr Nils Bergman. bergman@xsinet.co.za Reference List 1. Ruiz-Palaez, J. G., Charpak, N., and Cuervo, L. G. Kangaroo Mother Care, an example to follow from developing countries. BMJ 329(10.1136/BMJ.329.7475.1179), 1179-1181. 11-13-2004. 2. Rey SE,.Martinez GH. Maejo racional del nino prematuro. Proceedings of the Conference 1 Curso de Medicina Fetal y Neonatal, 1981;Bogota, Colombia: Fundacion Vivar, 1983. (Spanish).. 3. Marlow, N. Family friendly care. BMJ 329, 1182-1182. 11-13-2004. 4. Cattaneo A, Davanzo R, Bergman N, Charpak N. Kangaroo mother care in low-income countries. International Network in Kangaroo Mother Care. J.Trop.Pediatr. 1998;44:279-82. 5. Heinig J,.Ishii K. Exclusive Breastfeeding: Isn't Some Breastfeeding Good Enough? J.Hum.Lact. 2004;20:np. 6. Labbok M,.Krasovec K. Toward consistency in breastfeeding definitions. Stud.Fam.Plann. 1990;21:226-30. 7. Oddy WH, Kendall GE, Blair E, De Klerk NH, Stanley FJ, Landau LI et al. Breast feeding and cognitive development in childhood: a prospective birth cohort study. Paediatr.Perinat.Epidemiol. 2003;17:81-90. 8. Bergman NJ,.Jurisoo LA. The 'kangaroo-method' for treating low birth weight babies in a developing country. Trop.Doct. 1994;24:57-60. 9. Lincetto O, Nazir AI, Cattaneo A. Kangaroo mother care with limited resources. J.Trop.Pediatr. 2000;46:293-5. 10. Ludington-Hoe SM, Anderson GC, Simpson S, Hollingsead A, Argote LA, Rey H. Birth-related fatigue in 34-36-week preterm neonates: rapid recovery with very early kangaroo (skin-to-skin) care. J.Obstet.Gynecol.Neonatal Nurs. 1999;28:94-103. 11. Ludington-Hoe SM, Anderson GC, Swinth JY, Thompson C, Hadeed AJ. Randomized controlled trial of kangaroo care: cardiorespiratory and thermal effects on healthy preterm infants. Neonatal Netw. 2004;23:39-48. 12. Bergman NJ, Linley LL, Fawcus SR. Randomized controlled trial of skin-to-skin contact from birth versus conventional incubator for physiological stabilization in 1200- to 2199-gram newborns. Acta Paediatr. 2004;93:779-85. 13. Hurst NM, Valentine CJ, Renfro L, Burns P, Ferlic L. Skin-to- skin holding in the neonatal intensive care unit influences maternal milk volume. J.Perinatol. 1997;17:213-7. 14. Modi N,.Glover V. Non-pharmacological reduction of hypercortisolaemia in preterm infants. Infant Behaviour and Development 1998;21 April 1998:86. 15. Koepke JE,.Bigelow AE. Observations of Newborn Suckling Behaviour. Infant Behaviour and Development 1997;20:93-8. 16. Righard L,.Alade MO. Effect of delivery room routines on success of first breast-feed. Lancet 1990;336:1105-7. 17. Schore AN. Effects of a secure attachment relationship on right brain development, affect regulation, and infant mental health. Infant Mental Health Journal 2001;22:7-66. 18. Lozoff B,.Brittenham G. Infant care: cache or carry. J.Pediatr. 1979;95:478-83. 19. Department of Reproductive Health and Research, World Health Organisation. Kangaroo mother care: a practical guide. (1st ed). 2004. Geneva, WHO. 20. Affonso D, Bosque E, Wahlberg V, Brady JP. Reconciliation and healing for mothers through skin-to-skin contact provided in an American tertiary level intensive care nursery. Neonatal Netw. 1993;12:25-32. 21. Anderson GC. The mother and her newborn: mutual caregivers. JOGN.Nurs. 1977;6:50-7. 22. Carlsson SG, Fagerberg H, Horneman G, Hwang CP, Larsson K, Rodholm M et al. Effects of amount of contact between mother and child on the mother's nursing behavior. Dev.Psychobiol. 1978;11:143-50. 23. Curry MA. Maternal attachment behavior and the mother's self- concept: the effect of early skin-to-skin contact. Nurs.Res. 1982;31:73-8. 24. De Chateau P,.Wiberg B. Long-term effect on mother-infant behaviour of extra contact during the first hour post partum. III. Follow- up at one year. Scand.J.Soc.Med. 1984;12:91-103. 25. Feldman R, Eidelman AI, Sirota L, Weller A. Comparison of skin- to-skin (kangaroo) and traditional care: parenting outcomes and preterm infant development. Pediatrics 2002;110:16-26. 26. Hofer MA. Early relationships as regulators of infant physiology and behaviour. Acta Paediatr. 1994;Suppl 397:9-18. 27. Keverne EB,.Kendrick KM. Maternal behaviour in sheep and its neuroendocrine regulation. Acta Paediatr Suppl 1994;397:47-56. 28. Klaus MH, Jerauld R, Kreger NC, McAlpine W, Steffa M, Kennel JH. Maternal attachment. Importance of the first post-partum days. N.Engl.J.Med. 1972;286:460-3. 29. Schore AN. The effects of early relational trauma on right brain development, affect regulation, and infant mental health. Infant Mental Health Journal 2001;22:201-69. 30. Kjellmer I,.Winberg J. The neurobiology of infant-parent interaction in the newborn: an introduction. Acta Paediatr Suppl 1994;397:1-2. 31. Levin A. Humane Neonatal Care Initiative. Acta Paediatr. 1999;88:353-5. Competing interests: Author markets a shirt for facilitating continuous skin-to-skin contact.
Re: Kangaroo Mother Care: the importance of skin-to-skin contact. 2 December 2004
Juan G Ruiz, professor Universidad Javeriana and Fundación Canguro, Bogotá, Colombia, Nathalie Charpak and Luis G. Cuervo Send response to journal: Re: Re: Kangaroo Mother Care: the importance of skin-to-skin contact.	Dr. Bergmann’s detailed reaction to our paper raises several important issues. First, in his view, the main explanation for the benefits of the intervention lies on kangaroo position and exclusive breast feeding. We feel that it is appropriate not to underestimate the role of the phases of adaptation, early discharge and follow up. They are not circumstantial activities related to specific settings and conditioned by availability of resources: “adaptation” means adaptation of both mother and infant to kangaroo position (including tolerance, monitoring of physiological stability and weight gain); early discharge (to a kangaroo ward or to home) means discharge while in kangaroo position after having evidenced during adaptation that kangaroo position and nutrition have been well tolerated and do not jeopardise the infant; and “follow up” means monitoring the compliance with all the components of intervention as well as clinical outcomes, which is comparable to clinical daily follow up in a neonatal unit. We insist on early discharge with close follow up not only because of the obvious saving in hospital stay but for the documented beneficial effects on mothers-infants bonding and on the sense of competence self-esteem and sensitivity to infants needs, that have been demonstrated in a large RCT including all components1;2 and which has not been evidenced in developed countries in evaluations of isolated components of KMC. In response to Dr. Bergman’s opinion, we would like to remark that usually the effects of a complex intervention are not the simple sum of the effects of each individual component. A second issue that should be considered carefully is Dr. Bergmann’s statement: “A recently published randomised controlled trial from a western setting provides evidence that low birth weight infants stabilise better in SSC than they do in incubators. In the absence of incubators, this could potentially save many lives”, in based on a study conducted in South Africa. The paper reports results from a small sample of highly selected LBW infants showing a good thermal stabilization3. In Dr. Bergmann’s statement, stabilisation can be understood as overall stability, but we think that the evidence he provides refers properly to thermal stabilisation. The process of transition to extrauterine life includes many more critical adaptations that need physiological support. Suggesting that in environments where there are no incubators, Kangaroo Position is a good alternative to proper neonatal care could be unfair for either the LBWI or the professional health staff: in developing countries infants also need access to a number of specific interventions as needed, such as ventilatory support, pharmacologic interventions, etc. for survival. Demonstrating that kangaroo position helps reaching physiological stability should not have implications regarding the need to provide other interventions (ventilatory support, antibiotics, etc.) developed by Neonatology which have proven to make survival possible in many instances. We would like to highlight that KMC is an intervention that can complement and enhance appropriate neonatal care; it was not conceived as a substitute. Although it was not at all suggested by Dr. Bergsman’s comment, we are taking this opportunity to remark that it would be worrisome using KMC as an excuse for delaying the development of appropriate infrastructure and resources for caring for these fragile infants all over the world. Reference List (1) Tessier R, Cristo M, Velez S, Giron M, de Calume ZF, Ruiz-Palaez JG et al. Kangaroo mother care and the bonding hypothesis. Pediatrics 1998; 102(2):e17. (2) Tessier R, Cristo M, Nadeau L, Figueroa Z, Ruiz-Palaez JG, Charpak N. Kangaroo Mother Care: a method for protecting high-risk low birth weight and premature infants against developmental delay. Infant Behaviour and Development 2003; 26(3):384-397. (3) Bergman NJ, Linley LL, Fawcus SR. Randomized controlled trial of skin-to-skin contact from birth versus conventional incubator for physiological stabilization in. Acta Paediatr 2004; 93(6):779-785. Competing interests: We are the authors of the initial paper that motivated the comment