k

m o t h e r care

A practicaI

guide

KANGAROO MOTHER CARE Department of Reproductive Health and Research World Health Organization Geneva

WHO Library Cataloguing-in-Publication Data World I]ciilIII Organization. Kangaroo mother cure ; a ractical guide! " .In#ant cart - methud$ %&n#ur' curt - oryiini(alicm and udmini$trattcm .)lii#em! Premature *." nlant! Lo+ birth! +eight ,.-rea$t #eeding ../uideline$ 0.1anual$ l.2itle ", 3 4 n & "56/55 I 74l !1 cla$$i#ication8 W, *"/9

: World Health Organization %//; All rights reserved. Publications of the World Health Organization can be obtained from Marketing and Dissemination, World Health Organization, 2 Avenue A!!ia, "2"" #eneva 2$, %&itzerland 'tel( )*" 22 $+" 2*$,- fa.( )*" 22 $+" */0$- email( bookorders1&ho.int2. 3e4uests for !ermission to re!roduce or translate WHO !ublications 5 &hether for sale or for noncommercial distribution 5 should be addressed to Publications, at the above address 'fa.( )*" 22 $+" */ ,- email( !ermissions1&ho.int2. 6he designations em!lo7ed and the !resentation of the material in this !ublication do not im!l7 the e.!ression of an7 o!inion &hatsoever on the !art of the World Health Organization concerning the legal status of an7 countr7, territor7, cit7 or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on ma!s re!resent a!!ro.imate border lines for &hich there ma7 not 7et be full agreement. 6he mention of s!ecific com!anies or of certain manufacturers8 !roducts does not im!l7 that the7 are endorsed or recommended b7 the World Health Organization in !reference to others of a similar nature that are not mentioned. 9rrors and omissions e.ce!ted, the names of !ro!rietar7 !roducts are distinguished b7 initial ca!ital letters.

6he World Health Organization does not &arrant that the information contained in this !ublication is com!lete and correct and shall not be liable for an7 damages incurred as a result of its use. Printed in :rance

2<-L= O> CO42=42, ?LO,,<3@ <--3=)I<2IO4, ". "." ".2 ".< ".* ".0 %. "., ".$ "./ ".+ "." ;. "."" "."2 "."< "."* "."0 ".", "."$ *. "."/ "."+ ".2 ".2" ".22 ".2< ".2* ".20 ".2, ".2$ ".2/ ".2+ ".< Introduction 6he !roblem 5 im!roving care and outcome for lo&5birth5&eight babies ;angaroo mother care 5 &hat it is and &h7 it matters What is this document about= Who is this document for= Ho& should this document be used= =Aidence Mortalit7 and morbidit7 >reastfeeding and gro&th 6hermal control and metabolism Other effects 3esearch needs 3eBuirement$ %etting Polic7 %taffing Mother :acilities, e4ui!ment and su!!lies :eeding babies Discharge and home care Practice guide When to start ;M? @nitiating ;M? ;angaroo !osition ?aring for the bab7 in kangaroo !osition Aength and duration of ;M? Monitoring bab78s condition :eeding Monitoring gro&th @nade4uate &eight gain Preventive treatment %timulation Discharge ;M? at home and routine follo&5u! $ $ / + + + "" "2 "< "* "* "0 "$ "$ "/ "/ "+ "+ 22 2< 20 20 2$ 2$ 2+ < <" <* *" *< ** ** ** *, *$

3=>=3=4C=,

<44=C=, ".<" 3ecords and indicators ".<2 >irth &eight and gestational age ".<< ?onstraints .D+t-5. 2<-L=, ".<* ".<0 ".<, ".<$ ".</

0" 0" 0< 0*

6he effect of ;M? on breastfeeding "* Amount of milk 'or fluid2 needed !er da7 b7 birth &eight and age * A!!ro.imate amount of breast milk needed !er feed b7 birth &eight and age * Mean birth &eights &ith " th and + th !ercentiles b7 gestational age 0< @m!lementing ;M? 0*

ILL',23<2IO4, ".<+ Holding the bab7 close to the chest ".* ?arr7ing !ouches for ;M? babies ".*" Dressing the bab7 for ;M? *a Positioning the bab7 for ;M? *b >ab7 in ;M? !osition *c Moving the bab7 in and out of the binder 0 %lee!ing and resting during ;M? , : a t h e r 8 s turn for ;M? $ >reastfeeding in ;M? / 6 u b e 5 f e e d i n g in ;M? <--3=)I<2IO4, A>W ;M? 3?6 3D% Ao& birth &eight ;angaroo mother care 3andomized controlled trial 3es!irator7 distress s7ndrome .D+t-5. ?LO,,<3@ 6erms in this glossar7 are listed under ke7 &ords in al!habetical order. <ge Chronological age8 age calculated from the date of birth. ?e$tational age8 age or duration of the gestation, from the last menstrual !eriod to birth. Po$t-men$trual age8 gestational age !lus chronological age. -irth 2erm birth8 deliver7 occurring bet&een <$ and *2 &eeks of gestational age. Preterm birth8 deliver7 occurring before <$ &eeks of gestational age. Po$t-term birth8 deliver7 occurring after *2 &eeks of gestational age. 2 2" 2" 2$ 2/ 2/ < <" <, *"

-irth +eight Lo+-birth-+eight in#ant8 infant &ith birth &eight lo&er than 20 g 'u! to and including 2*++g2, regardless of gestational age. )ery lo+-birth-+eight in#ant8 infant &ith birth &eight lo&er than "0 g 'u! to and including "*++g2, regardless of gestational age. =Etremely lo+-birth-+eight in#ant8 infant &ith birth &eight lo&er than " g 'u! to and including +++g2, regardless of gestational age. Different cut5off values are used in this guide since the7 are more useful for clinical !ur!oses. -ody tem erature Hy othermia8 bod7 tem!erature belo& <,.0B?. ?ro+th Intrauterine gro+th retardation8 im!aired gro&th of the foetus due to foetal disorders, maternal conditions 'e.g. maternal malnutrition2 or !lacental insufficienc7. 1ilF(#eeding >oremilF8 breast milk initiall7 secreted during a breast feed. Hind milF8 breast milk remaining in the breast &hen the foremilk has been removed 'hind milk has a fat content and a mean caloric densit7 higher than foremilk2. <lternatiAe #eeding method8 not breastfeeding but feeding the bab7 &ith e.!ressed breast milk b7 cu! or tubee.!ressing breast milk directl7 into bab78s mouth. Preterm(#ull-term in#ant Premature or reterm in#ant8 infant born before <$ &eeks of gestational age. Preterm in#ant a ro riate #or ge$tational age 7<?<98 infant born !reterm &ith birth &eight bet&een the " th and the + th !ercentile for hisCher gestational age. Preterm in#ant $mall #or ge$tational age 7,?<98 infant born !reterm &ith a birth &eight belo& the " th !ercentile for hisCher gestational age. >ull-term in#ant $mall #or ge$tational age 7,?<98 infant born at term &ith birth &eight belo& the " th !ercentile for hisCher gestational age. ,mall baby8 in this guide, a bab7 &ho is born !reterm &ith lo& birth &eight. ,table reterm or lo+-birth-+eight in#ant8 a ne&born infant &hose vital functions 'breathing and circulation2 do not re4uire continuous medical su!!ort and monitoring, and are not subDect to ra!id and une.!ected deterioration, regardless of intercurrent disease. Note: Throughout this document babies are referred to by the personal pronoun "she" or "he" in preference to the impersonal (and inaccurate!) "it". The choice of gender is random.

.D+t-5.

KANGAROO MOTHER CARE

". Introduction

KANGAROO MOTHER CARE 1.1 The problem - improving care and outcome for low-birth-weight babies %ome 2 million lo&5birth5&eight 'A>W2 babies are born each 7ear, because of either !reterm birth or im!aired !renatal gro&th, mostl7 in less develo!ed countries. 6he7 contribute substantiall7 to a high rate of neonatal mortalit7 &hose fre4uenc7 and distribution corres!ond to those of !overt7.", 2 A>W and !reterm birth are thus associated &ith high neonatal and infant mortalit7 and morbidit7.<, * Of the estimated * million neonatal deaths, !reterm and A>W babies re!resent more than a fifth.0 6herefore, the care of such infants becomes a burden for health and social s7stems ever7&here. @n affluent societies the main contributor to A>W is !reterm birth. 6he rate has been decreasing thanks to better socioeconomic conditions, lifest7les and nutrition, resulting in healthier !regnancies, and to modern neonatal care technolog7 and highl7 s!ecialised and skilled health &orkers. @n less develo!ed countries high rates of A>W are due to !reterm birth and im!aired intrauterine gro&th, and their !revalence is decreasing slo&l7. %ince causes and determinants remain largel7 unkno&n, effective interventions are limited. Moreover, modern technolog7 is either not available or cannot be used !ro!erl7, often due to the shortage of skilled staff. @ncubators, for instance, &here available, are often insufficient to meet local needs or are not ade4uatel7 cleaned. Purchase of the e4ui!ment and s!are !arts, maintenance and re!airs are difficult and costl7- the !o&er su!!l7 is intermittent, so the e4ui!ment does not &ork !ro!erl7. Ender such circumstances good care of !reterm and A>W babies is difficult( h7!othermia and nosocomial infections are fre4uent, aggravating the !oor outcomes due to !rematurit7. :re4uentl7 and often unnecessaril7, incubators se!arate babies from their mothers, de!riving them of the necessar7 contact. Enfortunatel7, there is no sim!le solution to this !roblem since the health of an infant is closel7 linked to the mother8s health and the care she receives in !regnanc7 and childbirth. :or man7 small !reterm infants, receiving !rolonged medical care is im!ortant. Ho&ever, kangaroo mother care ';M?2 is an effective &a7 to meet bab78s needs for &armth, breastfeeding, !rotection from infection, stimulation, safet7 and love.

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1.2 Kangaroo mother care - what it is and why it matters ;angaroo mother care is care of !reterm infants carried skin5to5skin &ith the mother. @t is a !o&erful, eas75to5use method to !romote the health and &ell5being of infants born !reterm as &ell as full5term. @ts ke7 features are( early, continuous and prolonged skin-to-skin contact bet een the mother and the baby! e"clusi#e breastfeeding (ideally)! it is initiated in hospital and can be continued at home! small babies can be discharged early! mothers at home re$uire ade$uate support and follo -up! it is a gentle, effecti#e method that a#oids the agitation routinely e"perienced in a busy ard ith preterm infants. @t &as first !resented b7 3e7 and Martinez,,5/ + in >ogota, ?olombia, &here it &as develo!ed as an alternative to inade4uate and insufficient incubator care for those !reterm ne&born infants &ho had overcome initial !roblems and re4uired onl7 to feed and gro&. Almost t&o decades of im!lementation and research have made it clear that ;M? is more than an alternative to incubator care. @t has been sho&n to be effective for thermal control, breastfeeding and bonding in all ne&born infants, irres!ective of setting, &eight, gestational age, and clinical conditions." , Most !ublished e.!erience and research concerning ;M? comes from health facilities, &here care &as initiated &ith the hel! of skilled health &orkers. Once a mother &as confident in the care she gave her bab7, she continued it at home under guidance and &ith fre4uent visits for s!ecialised follo&5u!. 9vidence of the effectiveness and safet7 of ;M? is available onl7 for !reterm infants &ithout medical !roblems, the so5called stabilised ne&born. 3esearch and e.!erience sho& that( %&' is at least e$ui#alent to con#entional care (incubators), in terms of safety and thermal protection, if measured by mortality. %&', by facilitating breastfeeding, offers noticeable ad#antages in cases of se#ere morbidity. %&' contributes to the humani(ation of neonatal care and to better bonding bet een mother and baby in both lo and high-income countries.%&' is, in this respect, a modern method of care in any setting, e#en here e"pensi#e technology and ade$uate care are a#ailable. %&' has ne#er been assessed in the home setting. Ongoing research and observational studies are assessing the effective use of this method in situations &here neonatal intensive care or referral are not available, and &here health &orkers are !ro!erl7 trained. @n those settings ;M? before stabilisation ma7 re!resent the best chance of health7 survival. ""
)*,)+ "*,

6his guide &ill therefore refer to ;M? initiated at a health facilit7 and continued at home under the su!ervision of the health facilit7 'domiciliar7 ;M?2. ;M? as described in this document recommends continuous skin5to5skin contact ackno&ledging that it might not be ""

!ossible in all settings and under all circumstances. 6he !rinci!les and !ractice of ;M? outlined in this document are also valid for intermittent skin5to5skin contact, !rovided ade4uate care is offered to A>W and !reterm ne&born infants &hen the7 are se!arated from their mothers. %uch intermittent skin5to5skin contact has been sho&n to be beneficial,"0 ", if

"2

".*2com!lemented b7 !ro!er incubator care. #uidance on skin5to5skin care ma7 be used for re&arming ne&born infants &ith h7!othermia or kee!ing them &arm during trans!ortation to the referral facilit7.What is this document about? 6his document describes the ;M? method for care of stable !retermCA>W infants 'i.e. those &ho can breath air and have no maDor health !roblems2 &ho need thermal !rotection, ade4uate feeding, fre4uent observation, and !rotection from infection. @t !rovides guidance on ho& to organize services at the referral hos!ital and on &hat is needed to introduce and carr7 out ;M?, focusing on settings &here resources are limited. 9vidence for the recommendations is !rovided"$ &henever !ossible. Ho&ever, for man7 statements, es!eciall7 those related to secondar7 !rocedures, sound evidence is not available as in man7 other fields of health care. @n these cases, the te.t re!orts the e.!erience of health !rofessionals &ho have im!lemented ;M? for man7 7ears, man7 of &hom carefull7 revised !revious versions of this document.
"/

:or breastfeeding counselling and su!!ort, readers should refer to ,reastfeeding 'ounselling: - Training 'ourse - Trainer.s /uide.)0 :or H@F and infant feeding, refer to 123 and 2nfant 4eeding 'ounselling: - Training 'ourse - Trainer.s /uide. ".*<Management of medical !roblems of small babies is not !art of this guide. :urther guidelines can be found in te.tbooks or the WHO document &anaging ne born problems. guide for doctors, nurses and mid i#es.Who is this document for? 6his te.t has been !re!ared for health !rofessionals in charge of A>W and !reterm ne&born infants in first referral hos!itals in settings &ith scarce resources. @t is not &ritten for all !otential care !roviders. Practical instructions 'or !rotocols2 ada!ted to the categories of health &orkers available in different settings should be !re!ared locall7. @t is also aimed at decision5makers and !lanners at national and local levels. 6he7 need to kno& &hether ;M? suits the needs of their health s7stems, &hether it is !ractical and feasible, and &hat is re4uired to im!lement it successfull7. ".** ow should this document be used? ;M? guidelines have to be ada!ted to s!ecific circumstances and available resources at national or local level. 6his document can be used to develo! national and local !olicies, guidelines and !rotocols from &hich training material can be develo!ed. 6his document cannot, as it stands, be used for training !ur!oses. Other training material and activities, es!eciall7 on breastfeeding su!!ort and counselling on H@F and infant feeding, are needed to ac4uire all the necessar7 skills. We ho!e that !re5service institutions &ill include those skills in their curricula. .D+t-*5
67 5

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KANGAROO MOTHER CAREKANGAROO MOTHER CARE

%. =Aidence

"0

KANGAROO MOTHER CARE 6his cha!ter revie&s the evidence on ;M?, from both develo!ing and develo!ed countries, &ith regard to the follo&ing outcomes( mortalit7 and morbidit7- breastfeeding and gro&th- thermal !rotection and metabolism, and other effects. 6he e.!erience &ith ;M? has been revie&ed b7 several authors,"2, "<, ",, 2", 22 and in a s7stematic revie&.2< We also !resent evidence on the acce!tabilit7 of the intervention for mothers and health5care staff. While revie&ing the evidence, regardless of the outcome, it became clear that it &as im!ortant to highlight t&o essential variables( time of initiation of ;M?, and dail7 and overall duration of skin5to5skin contact. 6ime of initiation of ;M? in the studies under consideration varied from Dust after birth to several da7s after birth. Aate initiation means that the !retermCA>W infants have alread7 overcome the !eriod of ma.imum risk for their health. Aength of dail7 and overall duration of skin5to5skin contact also varied from minutes 'e.g. < minutes !er da7 on average2 to virtuall7 2* hours !er da7- from a fe& da7s to several &eeks. 6he longer the care, the stronger the !ossible direct and causal association bet&een ;M? and the outcome. :urthermore, &hen ;M? &as carried out over a long !eriod of time, care &as !redominantl7 !rovided b7 the mother rather than the nursing staff or the conventional incubator. %ome other variables that might have affected the outcome of ;M? are( the position in hich the baby as kept! the changes in the type and mode of feeding! the timing of discharge from the institution and the transition to home care! condition at discharge! the intensity of support and follo -up offered to mothers and families after discharge from the institution.

Man7 other factors 'e.g. social conditions, environment and health care, es!eciall7 services offered for ;M?2 ma7 be associated &ith the !ositive effects observed in ;M? studies. @t is ver7 im!ortant to se!arate the effects of these factors from those deriving from ;M?. >elo&, in revie&ing the evidence, &e tr7 to address those additional factors. Go !ublished stud7 on ;M? &as found in the conte.t of high H@F !revalence among mothers.

",16

2.1 !ortality and morbidity Clinical trial$ 6hree !ublished randomized controlled trials '3?62 com!aring ;M? &ith conventional care &ere conducted in lo&5income countries.2*52, 6he results sho&ed no difference in survival bet&een the t&o grou!s. Almost all deaths in the three studies occurred before eligibilit7, i.e. before A>W infants &ere stabilised and enrolled for research. @nfants &eighing less than 2 g &ere enrolled after an average !eriod of < 5"* da7s on conventional care, in urban third5level hos!itals. 6he ;M? infants sta7ed in hos!ital until the7 fulfilled the usual criteria for discharge, as the control infants did, in t&o of the studies,2*, 2, &hile in the third stud7 the7 &ere discharged earlier and subDected to a strict ambulator7 follo&5u!.20 6he follo&5u! !eriods lasted one,2, si.2* and t&elve months,20 res!ectivel7. 6he 3?6 carried out in 9cuador b7 %loan and collaborators sho&ed a lo&er rate of severe illness among ;M? infants '0H2 than in the control grou! '"/H2.2* 6he sam!le size re4uired for that stud7 &as <0 subDects !er grou! for a total of $ infants, but onl7 , < babies &ere recruited. 3ecruitment, in fact, &as interru!ted &hen the difference in the rate of severe illness became a!!arent. 6he other controlled studies conducted in lo&5income countries revealed no significant difference in severe morbidit7, but found fe&er hos!ital infections and readmissions in the ;M? grou!. ;ambarami and collaborators from Iimbab&e also re!orted reduced hos!ital infections.2$ High5income countries re!ort no difference in morbidit7. Ho&ever, it is notable that no additional risk of infection seems to be associated &ith skin5to5 skin contact. Observational studies sho&ed that ;M? could hel! reduce mortalit7 and morbidit7 in !retermCA>W infants. 3e7 and Martinez,2*52$ + in their earl7 account, re!orted an increase in hos!ital survival from < H to $ H in infants bet&een " g and "0 g. Ho&ever, the inter!retation of their results is difficult because numerators, denominators and follo&5u! in the ;M? grou! &ere different from those in the historical control grou!.2/ >ergman and Jurisoo, in another stud7 &ith an historical control grou! conducted in a remote mission hos!ital &ithout incubator care in Iimbab&e,"* re!orted an increase in hos!ital survival from " H to 0 H in infants &eighing less than "0 g, and from $ H to + H in those &eighing bet&een "0 to "+++g. %imilar results are re!orted from a secondar7 hos!ital in nearb7 Mozambi4ue."0 6he difference in survival, ho&ever, ma7 be due to some uncontrolled variables. 6he studies in Iimbab&e and Mozambi4ue, conducted in hos!itals &ith ver7 limited resources, a!!lied ;M? ver7 earl7 on, &ell before A>W and !reterm infants &ere stabilized. @n the earl7 stud7 b7 3e7 and Martinez, ;M? &as a!!lied later, after stabilization. @n both cases the skin5to5skin contact &as maintained virtuall7 2* hours a da7.

"$

?har!ak and collaborators, in a t&o5cohort stud7 carried out in >ogota, ?olombia,2+ found a crude death rate higher in the ;M? grou! 'relative risk K ".+- +0H?@( ,, to 0./2, but their results reverted in favour of ;M? 'relative risk K .0, +0H?@( .2 to ".22 after adDustment for birth &eight and gestational age. 6he differences, ho&ever, &ere not statisticall7 significant. 6he t&o cohorts recruited in t&o third5level hos!itals, sho&ed man7 social and economic differences. ;M? &as also a!!lied after stabilization and 2* hours a da7. @n a controlled but not randomized trial carried out in a tertiar75care hos!ital in Iimbab&e, there &as a slight difference in survival in favour of the ;M? infants, but this might have been due to differences in feeding.Conclu$ion On balance the evidence sho&s that although ;M? does not necessaril7 im!rove survival, it does not reduce it. After stabilization, there is no difference in survival bet&een ;M? and good conventional care. 6he h7!othesis that ;M? might im!rove survival &hen a!!lied before stabilization needs to be further e.!lored &ith &ell5designed studies. @f such an effect on survival e.ists, it &ill be more evident and easier to demonstrate in the !oorest settings, &here mortalit7 is ver7 high. As for morbidit7, &hile there is no strong evidence of a beneficial effect of ;M?, there is no evidence of it being harmful. @n addition to the little evidence alread7 !ublished,2$ "*, "0 some !reliminar7 results on a small number of ne&born infants &ith mild res!irator7 distress seem to confirm that ver7 earl7 skin5to5skin contact might have a beneficial effect.< A &ord of &arning about discharge( ;M? infants discharged during the cold season ma7 be more susce!tible to severe illness, es!eciall7 lo&er res!irator7 tract infections, than those discharged during the &arm season.<" A closer follo&5u! is needed in such cases. @t should be noted that all the studies so far have taken !lace in &ell5e4ui!!ed hos!itals, 7et arguabl7 the most significant im!act of ;M? &ill be felt in settings &ith limited resources. 6here is an urgent need for further research in these settings. @n the meantime, it seems that &here !oor conventional care is available, ;M? offers a safe substitute, &ith little risk of raised morbidit7 or mortalit7. 2.2 "reastfeeding and growth -rea$t#eeding 6&o randomized controlled trials and a cohort stud7 carried out in lo&5income countries looked at the effect of ;M? on breastfeeding. All three studies found that the method increased the !revalence and duration of breastfeeding.20, 2,, 2+ %i. other studies conducted in high5income countries, &here skin5to5skin contact &as a!!lied late and onl7 for a limited amount of time !er da7, also sho&ed a beneficial effect on breastfeeding.<25<$ 6he results of all these studies are summarized in 6able ". @t a!!ears that ;M? and skin5to5skin contact are beneficial for breastfeeding in settings &here it is less commonl7 used for !retermCA>W infants, es!eciall7 if these are cared for in incubators and the !revailing feeding method is the bottle. Other studies have sho&n a !ositive effect of skin5to5skin contact on breastfeeding. @t could therefore be e.!ected that the earlier ;M? is begun and the earlier skin5to5skin contact is initiated, the greater the effect on breastfeeding &ill be. ?ro+th

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Stu dy RC T

Author Charpak et al.

RC T RC T

Charpak et al. Cattaneo et al. Schm!dt et al. 1h!tela2 et al. 1ahl%er& et al. Syfrett et al. 3laymore6 3!er et al. 7ur#t et al.

6he t&o5cohort stud7 conducted in ?olombia2+ revealed slo&er &eight gain in ;M? infants &hen com!ared &ith the control grou!, but the t&o cohorts also sho&ed man7 social and economic differences. @n the subse4uent 3?620 no difference in gro&th &as observed at one 7ear of age. @n another 3?6,2, ;M? infants sho&ed a slightl7 larger dail7 &eight gain &hile the7 &ere cared for in hos!ital, but in the overall !eriod of stud7 their gro&th did not differ from that of the control grou!. %imilar results in terms of dail7 &eight gain &ere observed in Iimbab&e.Table 1. The effect of KMC on breastfeeding Year Ref. Outcome KMC Contr ol 199 29 art!al or e"clu#!$e %rea#tfeed!n& at' 4 1 month 9() *+) , month# *-) (*) 1 year 41) 2() 199 2. art!al or e"clu#!$e %rea#tfeed!n& at ( +2) *.) * month# 199 2, /"clu#!$e %rea#tfeed!n& at d!#char&e ++) *-) + 19+ (2 0a!ly $olume ,44-, ml ml 0a!ly feed# 12 9 19+ (( 3rea#tfeed!n& at , 2eek# ..) 2+) + 199 (4 3rea#tfeed!n& at d!#char&e **) 42) 2 199 (. 0a!ly feed# 4(4 2eek# of &e#tat!onal 12 12 ( a&e5 199 (, 3rea#tfeed!n& at' d!#char&e 9-) ,1) , 1 month .-) 11) 199 (* 0a!ly $olume at 4 2eek# ,4* .(* ml ml /"clu#!$e %rea#tfeed!n& at d!#char&e (*) ,)

".*0 Thermal control and metabolism %tudies carried out in lo&5income countries2$ sho& that !rolonged skin5to5skin contact bet&een the mother and her !retermCA>W infant, as in ;M?, !rovides effective thermal control and ma7 be associated &ith a reduced risk of h7!othermia. :athers too can effectivel7 conserve heat in ne&born infants</ des!ite an initial re!ort of &orse !erformance of males in thermal control. Heart and res!irator7 rates, res!iration, o.7genation, o.7gen consum!tion, blood glucose, slee! !atterns and behaviour observed in !retermCA>W infants held skin5to5skin tend to be similar to or better than those observed in infants se!arated from their mothers.<+ * 5*2 ?ontact bet&een mother and child has other effects also. :or instance, salivar7 cortisol, an
2,

"+

indicator of !ossible stress, a!!ears to be lo&er in ne&born infants held skin5to5skin.*< 6his observation is consistent &ith the re!orting of significantl7 more cr7ing in full5term health7 infants + minutes after birth**, *0 and in A>W and !reterm infants at , months<< of age &hen the7 are se!arated from their mothers. ".*, #ther effects

;angaroo care hel!s both infants and !arents. Mothers re!ort being significantl7 less stressed during kangaroo care than &hen the bab7 is receiving conventional care. Mothers !refer skin5to5skin contact to conventional care2, and re!ort an increased confidence, self5 esteem, and feeling of fulfilment, also in high5income countries. 6he7 describe a sense of em!o&erment, confidence and a feeling that the7 can do something !ositive for their !reterm infants in different settings and cultures.*,5*+ :athers too said that the7 felt rela.ed, comfortable and contented &hile !roviding kangaroo care. ;M? thus em!o&ers mothers and increases their confidence in handling and feeding their A>W and !reterm infants. 6essier and collaborators, using data from the 3?6 conducted in ?olombia, concluded that ;M? should be encouraged as soon as !ossible after birth because it im!roves bonding and makes mothers feel more com!etent.;M? is acce!table to health5care staff, and the !resence of mothers in the &ard does not seem to be a !roblem. Most health &orkers consider ;M? beneficial. 6he7 ma7 think that conventional incubator care allo&s better monitoring of sick A>W and !reterm infants, but the7 recognize that it increases the risk of hos!ital infections and it se!arates infants from their mothers. Health &orkers &ould !refer ;M? for their o&n !retermCA>W infant. Ao&er ca!ital investment and recurrent costs is 7et another advantage of ;M? and could bring about some savings to hos!itals and health care s7stems in lo&5income countries. %avings ma7 result from reduced s!ending on fuel, electricit7, maintenance and re!air of e4ui!ment0
2,

as &ell as !ossible reduction in staffing costs, since mothers !rovide the greater !ro!ortion of care. ?om!ared &ith conventional incubator care, 9cuador2* has re!orted lo&er costs !er infant, in !art associated &ith a reduced rate of readmission to hos!ital. 6his ma7 !artl7 be due to a shorter length of hos!ital sta7 in ;M? infants, re!orted from both lo& 2052$ and high5 income countries.<<, <0, *, ?a!ital and recurrent savings ma7 be more substantial in tertiar7 than in first5referral and small facilities in lo&5income countries.
2,

2.$ %esearch needs More evidence of the advantages of ;M? over other methods of care is needed, !articularl7 on( the effecti#eness and safety of %&' before stabili(ation, in settings ith #ery limited resources (i.e. ithout incubators and other e"pensi#e technologies)! breastfeeding and feeding supplements in 8,9 infants less than +* eeks of gestational age! simpler and reliable methods for monitoring the ell-being of %&' infants, especially breathing and feeding! %&' in 8,9 infants eighing less than )555g, and in ne born infants ho are critically ill! %&' in #ery special circumstances, e.g. in #ery cold climates or in refugee camps! cultural and managerial barriers that may hinder the implementation of %&', and inter#entions that may foster it, particularly in settings ith #ery limited resources! the implementation of %&' for 8,9 and preterm infants deli#ered at home ithout the help of trained personnel and ithout the possibility of referral to the appropriate le#el of care.

2"

6his last situation ma7 &ell be the most im!ortant current source of !erinatal and neonatal mortalit7 and morbidit7. 6he evidence about the benefits of ;M? for A>W and !reterm infants relates to those born and assisted in health facilities or &ho can benefit from careful follo&5u! at home, not to those delivered at home. ?lear scientific evidence is needed to establish the safet7 and suitabilit7 of domiciliar7 ;M? for babies born at home. Ho&ever, there is no evidence that such care &ould be harmful or less safe than current !ractice. @t might be reasonable, unless future research sho&ed that other methods of home care &ere more effective, to recommend ;M? for the home care of A>W and !reterm infants born at home and &ho cannot be taken to hos!ital. Aocal culture and local activities to im!rove birth care at home should be taken into account if such a recommendation &ere issued.

.D+t-5.

22

KANGAROO MOTHER CARE

KANGAROO MOTHER CARE

6he most im!ortant resources for ;M? are the mother, !ersonnel &ith s!ecial skills and a su!!ortive environment. 6he re4uirements described in this cha!ter are formulation of !olic7, organization of services and follo&5u!, e4ui!ment and su!!lies for mothers and babies, and skilled !roviders for the facilities. %ome common constraints faced &hen im!lementing ;M?, and !ossible solutions, are discussed in Anne. @@@. Fer7 small ne&born infants and those &ith com!lications are best cared for in incubators &here the7 can receive the necessar7 attention and care. As soon as the general condition im!roves and the bab7 no longer needs intensive medical care, but sim!l7 &armth, !rotection from infections and ade4uate feeding to ensure gro&th, ;M? can be the method of choice. &.1 'etting ;M? can be im!lemented in various facilities and at different levels of care. 6he most common settings &here such care can be im!lemented, are described belo&( 1aternity #acilitie$ %mall maternit7 units &ith several deliveries !er da7, these facilities are usuall7 staffed b7 skilled mid&ives but often have no doctors and lack s!ecial e4ui!ment 'incubators and radiant &armers2 and su!!lies 'o.7gen, drugs and !reterm formula2 for the care of A>W and !reterm ne&born infants. @f !ossible, such infants are transferred to a higher level of careother&ise the7 are ke!t &ith their mothers and discharged earl7 for home care. H7!othermia, infections, res!irator7 and feeding !roblems contribute to high mortalit7 rates among those infants. 3e#erral ho$ ital$ 6his categor7 includes a &ide range of s!ecial care units in district and !rovincial hos!itals. A common feature is the availabilit7 of skilled !ersonnel 's!ecialized nurses and mid&ives, !aediatricians, obstetricians, or at least e.!erienced !h7sicians2 and basic e4ui!ment and su!!lies for s!ecial neonatal care. Ho&ever, in realit7, staff and e4ui!ment are often in short su!!l7( com!etent !h7sicians ma7 be available a fe& hours !er da7 onl7, small ne&born infants are ke!t in large nurseries or &ards, sometimes in contact &ith older !atients. Mothers cannot sta7 &ith their infants and the7 have difficult7 establishing and maintaining

2* !

breastfeeding. Mortalit7 ma7 also be high for the same reasons. Abandonment ma7 be a common !roblem.

20

6here is a range of institutions bet&een the t&o t7!es of facilit7 mentioned above, &here skilled health &orkers can !rovide ;M?. ".*$ (olicy @m!lementation of ;M? and its !rotocol &ill need to be facilitated b7 su!!ortive health authorities at all levels. 6hese include the hos!ital director and the !eo!le in charge of the health care s7stem at district, !rovincial and regional levels. A national !olic7 ensures a coherent and effective integration of the !ractice &ithin !re5 e.isting structures of the health s7stem and education and training. Preterm babies are best born in institutions that can !rovide the s!ecial medical care re4uired for managing their fre4uent com!lications. 6hus, &hen a !remature bab7 is e.!ected, the mother should be transferred to such an institution before birth. @f this is not !ossible, ver7 small babies or small babies &ith !roblems should be transferred there as soon as !ossible. 6he referral s7stem should be organized in such a &a7 as to guarantee the safet7 of the bab7. Gational standards and !rotocols need to be develo!ed for the care of small babies, including those mentioned above, once the7 have overcome the initial !roblems. %tandards must include clear criteria for monitoring and evaluation. 6hese can best be develo!ed b7 the a!!ro!riate !rofessional grou!s &ith the !artici!ation of !arents. :urthermore, local !rotocols &ill be easier to im!lement if national !olicies and guidelines are clearl7 set out. ?ontinuous monitoring and regular evaluation according to established criteria &ill hel! im!rove !ractice and design, and carr7 out research that ma7 hel! refine the method. 9ach health facilit7 that im!lements ;M? should, in its turn, have a &ritten !olic7 and guidelines ada!ted to the local situation and culture. %uch !olicies and guidelines &ill be more effective if the7 are agreed on b7 consensus, involving all the staff, &here !ossible, in develo!ing local !rotocols based on national or international guidelines. 6he !rotocol should cover ;M? as !resented here, and should, of course, include follo&5u!. @t could also be com!lemented b7 detailed instructions on general !roblems 'e.g. h7giene of staff and mothers2 or on !roblems commonl7 occurring in !reterm infants 'e.g. !revention and treatment of infection2. After the introduction of the ;M? !rotocol, monthl7 meetings &ith the staff &ill be useful to discuss and anal7se data and !roblems, and to im!rove the !rotocol if necessar7. ".*/ 'taffing ;M? does not re4uire an7 more staff than conventional care. 9.isting staff 'doctors and nurses2 should have basic training in breastfeeding and ade4uate training in all as!ects of ;M? as described belo&( hen and ho to initiate the %&' method! ho to position the baby bet een and during feeds! feeding 8,9 and preterm infants! breastfeeding! alternati#e feeding methods until breastfeeding becomes possible! in#ol#ing the mother in all aspects of her baby.s care, including monitoring #ital signs and

2,

recogni(ing danger signs! taking timely and appropriate action hen a problem is detected or the mother is concerned!

2$

deciding on the discharge! ability to encourage and support the mother and the family.

9ach institution should have a !rogramme of continuing education in the area of ;M? and breastfeeding. Gursing and medical schools should include ;M? in their curricula as soon as !ossible. ".*+ !other 3esearch and e.!erience sho& that mothers like ;M? once the7 have become familiar &ith it. ;M? must therefore be discussed &ith the mother as soon as a !reterm bab7 is born and offered to her as an alternative to the conventional methods &hen the bab7 is read7. %ince ;M? re4uires the continuous !resence of the mother, it &ould be hel!ful to e.!lain to her the advantages of each method and discuss &ith her the !ossible o!tions regarding bab7 care. %he must have time and o!!ortunit7 to discuss the im!lications of ;M? &ith her famil7, since this &ould re4uire her to sta7 longer in hos!ital, continue the method at home and attend follo&5u! visits. @f obstacles arise, talk about them and tr7 to find solutions &ith the famil7 before abandoning ;M?. 6he mother must also be full7 su!!orted b7 the health &orkers to graduall7 take over the res!onsibilit7 for the care of her small bab7. @n theor7 it is !ossible to full7 im!lement ;M? &ith a surrogate mother 'e.g. the grand5 mother2 but this is difficult to accom!lish in !ractice. ".0 )acilities* e+uipment and supplies ;M? does not re4uire s!ecial facilities, but sim!le arrangements can make the mother8s sta7 more comfortable. 1otherG$ need$ 6&o or four5bed rooms of reasonable size, &here mothers can sta7 da7 and night, live &ith the bab7, and share e.!erience, su!!ort and com!anionshi!- at the same time the7 can have !rivate visits &ithout disturbing the others. 6he rooms should be e4ui!!ed &ith comfortable beds and chairs for the mothers, if !ossible adDustable or &ith enough !illo&s to maintain an u!right or semi5recumbent !osition for resting and slee!ing. ?urtains can hel! to ensure !ri5 vac7 in a room &ith several beds. 6he rooms should be ke!t &arm for small babies '225 2*B?2. Mothers also need bathroom facilities &ith ta! &ater, soa! and to&els. 6he7 should have nutritious meals and a !lace to eat &ith the bab7 in ;M? !osition. Another &arm, smaller room &ould be useful for individual &ork &ith mothers, discussion of !rivate and confidential issues, and for reassessing babies. 6he &ard should have an o!en5door !olic7 for fathers and siblings. Dail7 sho&er or &ashing is sufficient for maternal h7giene- strict hand5&ashing should be encouraged after using the toilet and changing the bab7. Mothers should have the o!!ortunit7 to change or &ash clothes during their sta7 at the ;M? facilit7. 3ecreational, educational and even income5generating activities can be organized for mothers during ;M? in order to !revent or reduce the inevitable frustrations of being a&a7 from home and in an institution. Goise levels should, ho&ever, be ke!t lo& during such activities to avoid disturbing the small babies. Mothers should also be allo&ed to move

2/

around freel7 during the da7 at the institution and, if !ossible, in the garden, !rovided the7 res!ect the

2+

hos!ital schedules for !atient care and regularl7 feed their babies. 6he staff should use the long !eriod in hos!ital 'and the fre4uent contacts after discharge2 to carr7 out other educational activities on infant and maternal health. Mothers should be discouraged from smoking &hile !roviding ;M? and su!!orted in their anti5smoking efforts. Fisitors should not be allo&ed to smoke &here there are small babies, and the measure should be reinforced if necessar7. During the long sta7 at the facilit7 visits b7 fathers and other members of the famil7 should be allo&ed and encouraged. 6he7 can sometimes hel! the mother, re!lacing her for skin5to5 skin contact &ith the bab7 so that she can get some rest. Mothers, ho&ever, a!!reciate !rivac7 &hile breastfeeding, taking care of their !ersonal h7giene and during visits. ,lothing for the mother 6he mother can &ear &hatever she finds comfortable and &arm in the ambient tem!erature, !rovided the dress accommodates the bab7, i.e. kee!s him firml7 and comfortabl7 in contact &ith her skin. %!ecial garments are not needed unless traditional ones are too tight. The support binder 6his is the onl7 s!ecial item needed for ;M?. @t hel!s mothers hold their babies safel7 close to their chest ':ig."2. 6o begin &ith, use a soft !iece of fabric, about a meter s4uare, folded diagonall7 in t&o and secured &ith a safe knot or tucked u! under the mother8s arm!it. Aater a carr7ing !ouch of mother8s choice ':ig. 22 can re!lace this cloth. All these o!tions leave the mother &ith both hands free and allo& her to move around easil7 &hile carr7ing the bab7 skin5to5skin. %ome institutions !refer to !rovide their o&n t7!e of !ouch, shirt or band.

<

-abyG$ need$ When bab7 receives continuous ;M?, he does not need an7 more clothing than an infant in conventional care. @f ;M? is not continuous, the bab7 can be !laced in a &arm bed and covered &ith a blanket bet&een s!ells of ;M?. ,lothing for the baby When the ambient tem!erature is 2252*B?, the bab7 is carried in kangaroo !osition naked, e.ce!t for the dia!er, a &arm hat and socks ':ig.<2. When the tem!erature dro!s belo& 22B?, bab7 should &ear a cotton, sleeveless shirt, o!en at the front to allo& the face, chest, abdomen, arms and legs to remain in skin5to5skin contact &ith the mother8s chest and abdomen. 6he mother then covers herself and the bab7 &ith her usual dress.

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Other eBui ment and $u

lie$

6he7 are the same as for conventional care and are described belo& for convenience( a thermometer suitable for measuring body temperature do n to +6: '! scales: ideally neonatal scales ith )5g inter#als should be used! basic resuscitation e$uipment, and o"ygen here possible, should be a#ailable here preterm babies are cared for! drugs for pre#enting and treating fre$uent problems of preterm ne born babies may be added according to local protocols. ;pecial drugs are sometimes needed, but are not recommended in this guide. Treatment of medical problems is not part of this guide. 3ecord Fee ing 9ach mother5bab7 !air needs a record sheet to note dail7 observations, information about feeding and &eight, and instructions for monitoring the bab7 as &ell as s!ecific instructions for the mother. Accurate standard records are the ke7 to good individual care- accurate standard indicators are the ke7 to sound !rogramme evaluation. A register 'logbook2 contains basic information on all infants and t7!e of care received, and !rovides information for monitoring and !eriodic !rogramme evaluation. Anne. @ includes an e.am!le of the t7!e of record sheet that can be used for this !ur!ose and ada!ted to different settings. 6he data thus collected &ould also allo& for regular calculation 'e.g. 4uarterl7 and annuall72 of im!ortant indicators, listed also in Anne. @. &.- )eeding babies Mother8s milk is suited to bab78s needs, even if birth occurred before term or the bab7 is small. >reast milk is thus the best food for !retermCA>W infants and breastfeeding is the best method of feeding.0", 02 Mother8s milk should al&a7s be considered a nutritional !riorit7 due to the biological uni4ueness of the !reterm milk, &hich adDusts itself to the bab78s gestational age and re4uirements. @n this guide onl7 mother8s milk is recommended for feeding her bab7. Although !asteurized breast milk from another &oman or the milk bank can be used, recommendations on !asteurization and milk banking are not included in this guide. >reastfeeding !reterm and A>W infants is a difficult task, and is almost im!ossible if the hos!ital and home environment are not su!!ortive of breastfeeding in general. 6he staff need to be kno&ledgeable about breastfeeding and alternative feeding methods, and skilled in hel!ing mothers to feed their term and normal &eight infants, before the7 can effectivel7 hel! mothers &ith A>W babies. 6he ultimate goal is e.clusive breastfeeding. ;M? facilitates the initiation and establishment of breastfeeding in small infants. Ho&ever, man7 babies ma7 not breastfeed &ell at the beginning or not at all, and need alternative feeding methods. 6herefore the staff should teach and hel! the mother to e.!ress breast milk in order to !rovide milk for her bab7 and to maintain lactation, to feed the bab7 b7 cu! and to assess the bab78s feeding. 6he7 should kno& ho& to assess the readiness of small babies for breastfeeding.

<2

Hand e.!ression is the sim!lest &a7 to e.!ress breast milk. @t needs no a!!liances, so a &oman can do it an7&here at an7 time. 9.!ressing breast milk b7 hand is recommended and described in this document. Mothers need containers for e.!ressed breast milk( a cu!, glass, Dug or a &ide5mouthed Dar. Different kinds of breast !um!s can also be used for e.!ressing breast milk( rubber bulb or syringe pumps! mechanical or electrical pumps, either hand or foot operated. 6hese are !articularl7 convenient for &omen &ho e.!ress breast milk several times a da7 over a long !eriod. 6his is often the case &hen the bab7 is born long before term or re4uires !rolonged intensive care 'for more on breast !um!s, see WHO breastfeeding counselling course"+ 2. ?u!s, Go. 0 to Go. / :rench gauge feeding tubes and s7ringes are needed for feeding e.!ressed breast milk or formula milk. Other tools such as dro!!ers, s7ringes and teas!oons have been used instead of a cu!. 6raditional feeding devices, such as the L!aladaiL in @ndia, have been sho&n to be effective.0< A refrigerator also is needed for storing milk. 9.cess breast milk can be frozen. Preterm formula must be available &hen breastfeeding is not ade4uate or for re!lacement feeding. Health &orkers must be familiar &ith local harmful cultural !ractices, such as refusal to give colostrum or negative attitudes to&ards A>W and !reterm infants 'Lthe7 are ugl7L or Lthe7 &ill not surviveL2. 6he7 should be trained to discuss such !ractices and attitudes &ith the mother and her famil7 and find &a7s to overcome them. &.. /ischarge and home care Once the bab7 is feeding &ell, maintaining stable bod7 tem!erature in ;M? !osition and gaining &eight, mother and bab7 can go home. %ince most babies &ill still be !remature at the time of discharge, regular follo&5u! b7 a skilled !rofessional close to mother8s home must be ensured. :re4uenc7 of visits ma7 var7 from dail7 at the beginning, to &eekl7 and monthl7 later. 6he better the follo&5u!, the earlier mother and bab7 can be discharged from the facilit7. As a guide, services must !lan at least " visit for ever7 !reterm &eek. 6hose visits can also be carried out at home. Mothers also need free access to health !rofessionals for an7 t7!e of counselling and su!!ort related to the care of their small babies. 6here should be at least one home visit b7 a !ublic health nurse to assess home conditions, home su!!ort and abilit7 to travel for follo&5 u! visits. @f !ossible, su!!ort grou!s in the communit7 should be involved in the home 'to !rovide social, !s7chological, and domestic &ork su!!ort2. Mothers &ith !revious ;M? e.!erience can be effective !roviders of this kind of communit7 assistance. .D+t-5. <<

KANGAROO MOTHER CAREKANGAROO MOTHER CARE

*. Practice guide

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KANGAROO MOTHER CARE 6his cha!ter describes ho& to !ractice kangaroo mother care in the institution &here a small bab7 has been taken care of and &hen to begin. @t describes each com!onent( thermal !rotection through the correct !osition, feeding, observing the bab7, deciding &hen mother and bab7 can go home to continue ;M?, and the follo&5u! needed to ensure ade4uate gro&th and to su!!ort the mother. 0.1 When to start K!, When a small bab7 is born, com!lications can be e.!ected 5 the more !reterm and small for gestational age the infant is, the more fre4uent the !roblems are. @nitial care for infants &ith com!lications is !rovided according to national or institutional guidelines. ;M? &ill have to be dela7ed until the medical conditions im!rove. When e.actl7 ;M? can begin for those small babies must be Dudged individuall7, and full account should be taken of the condition and status of each bab7 and his mother. Ho&ever, the mother of a small bab7 can be encouraged to ado!t ;M? ver7 earl7 on. 6he birth &eight ranges belo& are given as a guide. >abies &eighing "/ g or more at birth 'gestational age < 5<* &eeks or more2 ma7 have some !rematurit75related !roblems, such as res!irator7 distress s7ndrome '3D%2. 6his ma7 raise serious concerns for a minorit7 of those infants, &ho &ill re4uire care in s!ecial units. @n most cases, ho&ever, ;M? can start soon after birth. @n babies &ith birth &eight bet&een "2 and "$++g 'gestational age 2/5<2 &eeks2, !rematurit75related !roblems such as res!irator7 distress s7ndrome '3D%2 and other com!lications are fre4uent, and therefore re4uire some kind of s!ecial treatment initiall7. @n such cases the deliver7 should take !lace in a &ell e4ui!!ed facilit7, &hich could !rovide the care re4uired. %hould deliver7 take !lace else&here, the bab7 should be transferred soon after birth, !referabl7 &ith the mother. One of the best &a7s of trans!orting small babies is kee!ing them in continuous skin5to5skin contact &ith the mother." ,0* @t might take a &eek or more before ;M? can be initiated. Although earl7 neonatal mortalit7 in this grou! is ver7 high, mostl7 due to com!lications, most babies survive and mothers could be encouraged to e.!ress breast milk. >abies &eighing less than "2 g 'gestational age belo& < &eeks2 incur fre4uent and severe !roblems due to !reterm birth( mortalit7 is ver7 high and onl7 a small !ro!ortion survive !rematurit75related !roblems. 6hese babies benefit most from transfer before birth to an institution &ith neonatal intensive care facilities. @t ma7 take &eeks before their condition allo&s initiation of ;M?.

<,"6

Geither birth &eight nor gestational age alone can reliabl7 !redict the risk of com!lications. 6able * in Anne. @@ sho&s ho& much the mean, and the " th and the + th &eight !ercentiles, var7 b7 gestational age for a !o!ulation &ith mean birth &eight of <<0 g.00 When e.actl7 to initiate ;M? reall7 de!ends on the condition of the mother and the bab7. 9ver7 mother should be told about the benefits of breastfeeding, encouraged and hel!ed to e.!ress breast milk from the first da7, to !rovide food for the bab7 and ensure lactation. 6he follo&ing criteria &ill hel! determine &hen to suggest that the mother ado!ts ;M?. 1other All mothers can !rovide ;M?, irres!ective of age, !arit7, education, culture and religion. ;M? ma7 be !articularl7 beneficial for adolescent mothers and for those &ith social risk factors. ?arefull7 describe the various as!ects of this method to the mother( the !osition, feeding o!tions, care in the institution and at home, &hat she can do for the bab7 attached to her bod7 and &hat she should avoid. 9.!lain the advantages and the im!lications of such care for her and her bab7, and al&a7s give the reasons behind a recommendation. Ado!ting ;M? should be the result of an informed decision and should not be !erceived as an obligation. 6he follo&ing !oints must be taken into consideration &hen counselling on ;M?( illingness: the mother must be illing to pro#ide %&'! full-time a#ailability to pro#ide care: other family members can offer intermittent skin-to-skin contact but they cannot breastfeed! general health: if the mother suffered complications during pregnancy or deli#ery or is other ise ill, she should reco#er before initiating %&'! being close to the baby: she should either be able to stay in hospital until discharge or return hen her baby is ready for %&'! supporti#e family: she ill need support to deal ith other responsibilities at home! supporti#e community: this is particularly important hen there are social, economic or family constraints. @f the mother is a smoker, advise her on the im!ortance of sto!!ing smoking or refraining from it in the room &here the bab7 is. 9.!lain the danger of !assive smoking for herself, other famil7 members and small infants. -aby Almost ever7 small bab7 can be cared for &ith ;M?. >abies &ith severe illness or re4uiring s!ecial treatment ma7 &ait until recover7 before full5time ;M? begins. During that !eriod babies are treated according to national clinical guidelines.0, %hort ;M? sessions can begin during recover7 &hen bab7 still re4uires medical treatment '@F fluids, lo& concentration of additional o.7gen2. :or continuous ;M?, ho&ever, bab78s condition must be stable- the bab7 must be breathing s!ontaneousl7 &ithout additional o.7gen. 6he abilit7 to feed 'to suck and s&allo&2 is not an essential re4uirement. ;M? can begin during tube5 feeding. Once the bab7 begins recovering, discuss ;M? &ith the mother. 6hese general recommendations on starting ;M? should be ada!ted to the situation of the

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region, health s7stem, health facilit7, and individual. @n settings &ith limited resources and &hen referral is im!ossible, the decision on &hen to start ;M? during recover7 should be &eighed against the alternatives available for thermal control, feeding and res!irator7 su!!ort.

</

".0" 1nitiating K!, When bab7 is read7 for ;M?, arrange &ith the mother a time that is convenient for her and for her bab7. 6he first session is im!ortant and re4uires time and undivided attention. Ask her to &ear light, loose clothing. Ese a !rivate room, &arm enough for the small bab7. 9ncourage her to bring her !artner or a com!anion of her choice if she so &ishes. @t hel!s to lend su!!ort and reassurance. While the mother is holding her bab7, describe to her each ste! of ;M?, then demonstrate them and let her go through all the ste!s herself. Al&a7s e.!lain &h7 each gesture is im!ortant and &hat it is good for. 9m!hasize that skin5to5skin contact is essential for kee!ing the bab7 &arm and !rotecting him from illness. ".02 Kangaroo position Place the bab7 bet&een the mother8s breasts in an u!right !osition, chest to chest 'as sho&n in :ig. *a2. %ecure him &ith the binder. 6he head, turned to one side, is in a slightl7 e.tended !osition. 6he to! of the binder is Dust under bab78s ear. 6his slightl7 e.tended head !osition kee!s the air&a7 o!en and allo&s e7e5to5e7e contact bet&een the mother and the bab7. Avoid both for&ard fle.ion and h7!ere.tension of the head. 6he hi!s should be fle.ed and e.tended in a LfrogL !osition- the arms should also be fle.ed. ':ig. *a2 6ie the cloth firml7 enough so that &hen the mother stands u! the bab7 does not slide out. Make sure that the tight !art of the cloth is over the bab78s chest. >ab78s abdomen should not be constricted and should be some&here at the level of the mother8s e!igastrium. 6his &a7 bab7 has enough room for abdominal breathing. Mother8s breathing stimulates the bab7 ':ig. *b2.

<+

%ho& the mother ho& to move the bab7 in and out of the binder ':ig. *c2. As the mother gets familiar &ith this techni4ue, her fear of hurting the bab7 &ill disa!!ear. Moving the baby in and out of the binder: m hold the baby with one hand placed behind the neck and on the back; m lightly support the lower part of the jaw )ig. 0c !oving the baby in and out of the binder with her thumb and fingers to prevent the baby's head from slipping down and blocking the airway when the baby is in an upright position; m place the other hand under the baby's buttocks.

9.!lain to the mother that she can breastfeed in kangaroo !osition and that ;M? actuall7 makes breastfeeding easier. :urthermore, holding the bab7 near the breast stimulates milk !roduction. Mother can easil7 care for t&ins too( each bab7 is !laced on one side of her chest. %he ma7 &ant to alternate the !osition. @nitiall7 she ma7 &ant to breastfeed one bab7 at a time, later both babies can be fed at once &hile in kangaroo !osition. After !ositioning the bab7 let mother rest &ith him. %ta7 &ith them and check bab78s !osition. 9.!lain to the mother ho& to observe the bab7, &hat to look for. 9ncourage her to move. When introducing the mother to ;M? also talk to her about !ossible difficulties. :or some time her life &ill revolve around the bab7 and this ma7 u!set her dail7 routine. Moreover, a small bab7 at first might not feed &ell from the breast. During that !eriod she can e.!ress breast milk and give it to the bab7 &ith a cu! or other im!lements, but this &ill take longer than breastfeeding. 9ncourage her to ask for hel! if she is &orried and be !re!ared to res!ond to her 4uestions and an.ieties. Ans&er her 4uestions directl7 and honestl7 5 she needs to be a&are of the limitations that ;M? ma7 !ut u!on her dail7 activities as &ell as the benefits it can undoubtedl7 bring to her bab7. 9.!erience sho&s that most mothers are ver7 &illing to !rovide ;M?, es!eciall7 if the7 can see other babies thriving. >7 sharing the same room for a long time, ;M? mothers e.change information, o!inions and emotions, and develo! a sense of mutual su!!ort and solidarit7. After a !eriod of im!otence and frustration during stabilization, the7 are em!o&ered as the main caretakers of their infants and reclaim their maternal role from the staff. 0.0 ,aring for the baby in 2angaroo position >abies can receive most of the necessar7 care, including feeding, &hile in kangaroo !osition. 6he7 need to be moved a&a7 from skin5to5skin contact onl7 for( changing diapers, hygiene and cord care! and clinical assessment, according to hospital schedules or hen needed.

Dail7 bathing is not needed and is not recommended. @f local customs re4uire a dail7 bath and it cannot be avoided, it should be short and &arm 'about <$B?2. 6he bab7 should be thoroughl7 dried immediatel7 after&ards, &ra!!ed in &arm clothes, and !ut back into the ;M? !osition as soon as !ossible. During the da7 the mother carr7ing a bab7 in the ;M? !osition can do &hatever she likes( she can &alk, stand, sit, or engage in different recreational, educational or income5generating activities. %uch activities can make her long sta7 in hos!ital less boring and more bearable. %he has to meet, ho&ever, a fe& basic re4uirements such as cleanliness and !ersonal h7giene 'stress fre4uent hand5&ashing2. %he should also ensure a 4uiet environment for her bab7 and feed him regularl7.

*"

,lee ing and re$ting Mother &ill best slee! &ith the bab7 in kangaroo !osition in a reclined or semi5recumbent !osition, about "0 degrees from horizontal. 6his can be achieved &ith an adDustable bed, if available, or &ith several !illo&s on an ordinar7 bed ':ig.02. @t has been observed that this !osition ma7 decrease the risk of a!noea for the bab7.0$ @f the mother finds the semi5 recumbent !osition uncomfortable, allo& her to slee! as she !refers, because the advantages of ;M? are much greater than the risk of a!noea. %ome mothers !refer slee!ing on their sides in a semi5reclined bed 'the angle makes slee!ing on the abdomen im!ossible2, and if the bab7 is secured as described above there &ill be no risk of smothering. A comfortable chair &ith adDustable back ma7 be useful for resting during the da7. 0.$ 3ength and duration of K!, Length %kin5to5skin contact should start graduall7, &ith a smooth transition from conventional care to continuous ;M?. %essions that last less than , minutes should, ho&ever, be avoided because fre4uent changes are too stressful for the bab7. 6he length of skin5to5skin contacts graduall7 increases to become as continuous as !ossible, da7 and night, interru!ted onl7 for changing dia!ers, es!eciall7 &here no other means of thermal control are available. When the mother needs to be a&a7 from her bab7, he can be &ell &ra!!ed u! and !laced in a &arm cot, a&a7 from draughts, covered b7 a &arm blanket, or !laced under an a!!ro!riate &arming device, if available. During those breaks famil7 members 'father or !artner, grandmother, etc.2, or a close friend, can also hel! caring for the bab7 in skin5to5skin kangaroo !osition ':ig.,2.

*2

Duration When the mother and bab7 are comfortable, skin5to5skin contact continues for as long as !ossible, first at the institution, then at home. @t tends to be used until the bab7 reaches term 'gestational age around * &eeks2 or 20 g. Around that time the bab7 also outgro&s the need for ;M?. %he starts &riggling to sho& that she is uncomfortable, !ulls her limbs out, cries and fusses ever7 time the mother tries to !ut her back skin5to5skin. 6his is &hen it is safe to advise the mother to &ean the bab7 graduall7 from ;M?. >reastfeeding, of course, continues. Mother can return to skin5to5skin contact occasionall7, after giving the bab7 a bath, during cold nights, or &hen the bab7 needs comfort. ;M? at home is !articularl7 im!ortant in cold climates or during the cold season and could go on for longer. 0.- !onitoring baby4s condition 2em erature A &ell5fed bab7, in continuous skin5to5skin contact, can easil7 retain normal bod7 tem!erature 'bet&een <,.0B? and <$B?2 &hen in kangaroo !osition, if the ambient tem!erature is not lo&er than the recommended range. H7!othermia is rare in ;M? infants, but it can occur. Measuring bab78s bod7 tem!erature is still needed, but less fre4uentl7 than &hen the bab7 is not in the kangaroo !osition.

*<

When starting ;M?, measure a.illar7 tem!erature ever7 , hours until stable for three consecutive da7s. Aater measure onl7 t&ice dail7. @f the bod7 tem!erature is belo& <,.0B?, re&arm the bab7 immediatel7( cover the bab7 &ith a blanket and make sure that the mother is sta7ing in a &arm !lace. Measure the tem!erature an hour later and continue re&arming until &ithin the normal range. Also look for !ossible causes of h7!othermia in the bab7 'cold room, the bab7 &as not in ;M? !osition before measuring the tem!erature, the bab7 had a bath or has not been feeding &ell2. @f no obvious cause can be found and the bab7 continues to have difficult7 in maintaining normal bod7 tem!erature, or the tem!erature does not return to normal &ithin < hours, assess the bab7 for !ossible bacterial infection. @f an ordinar7 adult5t7!e thermometer does not record the tem!erature, assume there is moderate or severe h7!othermia and act accordingl7. Wa7s of identif7ing and treating h7!othermia are described in detail in another WHO document." 3e&arming can be carried out through skin5to5skin contact.

How to measure axillary temperature m Keep the baby warm throughout the procedure, either in skin-to-skin contact with the mother and properly covered, or well covered on a warm surface; m use a clean thermometer and shake it down to less than 3 ! "; m place the thermometer bulb high up in the middle of the a#illa; the skin of the a#illa must be in full contact with the bulb of the thermometer, with no air pockets between skin and bulb; m hold the infant's arm against the side of the chest gently; keep the thermometer in place for at least three minutes; m remove the thermometer and read the temperature; m avoid taking the rectal temperature since it is associated with a small but significant risk of rectal perforation.

Ob$erAing breathing and +ell-being 6he normal res!irator7 rate of an A>W and !reterm infant ranges bet&een < and , breaths !er minute, and breathing alternates &ith intervals of no breathing 'a!noea2. Ho&ever, if the intervals become too long '2 seconds or more2 and the bab78s li!s and face turn blue 'c7anosis2, his !ulse is abnormall7 lo& 'brad7cardia2 and he does not resume breathing s!ontaneousl7, act 4uickl7( there is a risk of brain damage. 6he smaller or more !remature the bab7 is, the longer and more fre4uent the s!ells of a!noea. As bab7 a!!roaches term, breathing becomes more regular and a!noea less fre4uent. 3esearch sho&s that skin5to5skin contact ma7 make breathing more regular in !reterm infants"$ *",0/ and ma7 reduce the incidence of a!noea. A!noea a!!earing late ma7 also indicate the beginning of an illness. 6he mother must be a&are of the risk of a!noea, be able to recognize it, intervene immediatel7 and seek hel! if she becomes concerned.

**

What to do in case of apnoea m $each the mother to observe the baby's breathing pattern and e#plain the normal variations; m e#plain what apnoea is and what effects it has on a baby; m demonstrate the effect of apnoea by asking the mother to hold her breath for a short time %less than &' seconds( and a long time %&' seconds or more(; m e#plain that if breathing stops for &' seconds or more, or baby becomes blue %blue lips and face(, this may be a sign of a serious disease; m teach her to stimulate the baby by lightly rubbing the back or head, and by rocking movements until the baby starts breathing again. )f baby is still not breathing, she should call staff; m always react immediately to a mother's call for help; m in case of prolonged apnoea, when breathing cannot be restarted through stimulation, resuscitate according to the hospital resuscitation guidelines; m if apnoeic spells become more fre*uent, e#amine the baby+ this may be an early sign of infection. $reat according to the institutional protocol.

Once the bab7 has recovered from the initial com!lications due to !reterm birth, is stable and is receiving ;M?, the risk of serious illness is small but significant. 6he onset of a serious illness in small babies is usuall7 subtle and is overlooked until the disease is advanced and difficult to treat. 6herefore it is im!ortant to recognize those subtle signs and give !rom!t treatment. 6each the mother to recognize danger signs and ask her to seek care &hen concerned. 6reat the condition according to the institutional guidelines.

Danger signs \i ,ifficulty breathing, chest in-drawing, grunting \i -reathing very fast or very slowly \i .re*uent and long spells of apnoea \i $he baby feels cold+ body temperature is below normal despite rewarming \i ,ifficulty feeding+ the baby does not wake up for feeds anymore, stops feeding or vomits \i "onvulsions \i ,iarrhoea \i /ellow skin

*0

3eassure the mother that there is no danger if the bab7( snee(es or has hiccups! passes soft stools after each feed! does not pass stools for *-+ days. 0.. )eeding >reastfeeding !reterm babies is a s!ecial challenge. :or the first fe& da7s a small bab7 ma7 not be able to take an7 oral feeds and ma7 need to be fed intravenousl7. During this !eriod the bab7 receives conventional care. Oral feeds should begin as soon as bab78s condition !ermits and the bab7 tolerates them. 6his is usuall7 around the time &hen bab7 can be !laced in kangaroo !osition. 6his hel!s the mother to !roduce breast milk, so it increases breastfeeding. >abies &ho are less than < to <2 &eeks gestational age usuall7 need to be fed through a naso5gastric tube, &hich can be used to give e.!ressed breast milk. 6he mother can let her bab7 suck her finger &hile he is having tube feeds. 6ube5feeding can be done &hen the bab7 is in kangaroo !osition. >abies bet&een < and <2 &eeks gestational age can take feeds from a small cu!. ?u! feeds can be given once or t&ice dail7 &hile a bab7 is still fed mostl7 through a naso5gastric tube. @f he takes cu! feeds &ell, tube5feeding can be reduced. :or cu!5feeding the bab7 is taken out of the kangaroo !osition, &ra!!ed in a &arm blanket and returned to the kangaroo !osition after the feed. Another &a7 to feed a bab7 at this stage is b7 e.!ressing milk directl7 into the bab78s mouth. 6his &a7 the bab7 does not need to be taken out from the kangaroo !osition. >abies of about <2 &eeks gestational age or more are able to start suckling on the breast. >ab7 ma7 onl7 root for the ni!!le and lick it at first, or he ma7 suckle a little. ?ontinue giving e.!ressed breast milk b7 cu! or tube, to make sure that the bab7 gets all that he needs. When a small bab7 starts to suckle effectivel7, he ma7 !ause during feeds 4uite often and for 4uite long !eriods. @t is im!ortant not to take him off the breast too 4uickl7. Aeave him on the breast so that he can suckle again &hen he is read7. He can continue for u! to an hour if necessar7. Offer a cu! feed after the breastfeed, or alternate breast and cu! feeds. Make sure that the bab7 suckles in a good !osition. #ood attachment ma7 make effective suckling !ossible at an earlier stage. >abies from about <* to <, &eeks gestational age or more can often take all that the7 need directl7 from the breast. Ho&ever, su!!lements from a cu! continue to be necessar7 occasionall7. During this initial !eriod the mother needs a lot of su!!ort and encouragement to establish and maintain lactation until the bab7 is read7 to breastfeed. Primi!arae, adolescent mothers, and mothers of ver7 small infants ma7 need even more encouragement, hel! and su!!ort during the institutional sta7 and later at home.

*,

Discuss breastfeeding with the mother m 0eassure her that she can breastfeed her small baby and she has enough milk; m e#plain that her milk is the best food for such a small baby. .eeding for him is even more important than for a big baby; m at the beginning a small baby does not feed as well as a big baby; he may tire easily and suck weakly at first suckle for shorter periods before resting -fall asleep during feeding -have long pauses after suckling, and feed longer -not always wake up for feeds; m e#plain that breastfeeding will become easier as baby becomes older and bigger; m help her place and attach the baby in the kangaroo position.

-rea$t#eeding 6he kangaroo !osition is ideal for breastfeeding. As soon as the bab7 sho&s signs of readiness for breastfeeding, b7 moving tongue and mouth, and interest in sucking 'e.g. fingers or mother8s skin2, hel! the mother to get into a breastfeeding !osition that ensures good attachment. 6o start breastfeeding choose a!!ro!riate time 5bab7 &hen the bab7 is &aking a slee!, or is alert to5skin and !osition. a&ake. :or Hel! the the first mother breastfeeds toand sit comfortabl7 take the inbab7 an out armless of the !ouch chair &ith and from &ra! the bab7 or dress in skin5 him the mother to better to demonstrate ensure good the !osition techni4ue. attachment. 6hen !ut the into the kangaroo !osition and ask Help the mother to position her baby m 1how the mother the correct position and attachment for breastfeeding; m show the mother how to hold her baby+ - hold the baby's head and body straight; - make the baby face her breast, the baby's nose opposite her nipple; - hold the baby's body close to her body; - support the baby's whole body, not just the neck and shoulders; m show the mother how to help her baby to attach+ - touch her baby's lips with her nipple; - wait until her baby's mouth is wide open; - move her baby *uickly onto her breast, aiming the infant's lower lip well below the nipple; m show the mother signs of good attachment+ - baby's chin is touching her breast; - his mouth is wide open; - his lower lip is turned out; - a larger area of the areola is visible above rather than below the baby's mouth; - sucks are slow and deep, sometimes pausing.

*$

Aet the bab7 suckle on the breast as long as he &ants. 6he bab7 ma7 feed &ith long !auses bet&een sucks. Do not interru!t the bab7 if he is still tr7ing. %mall babies need breastfeeding fre4uentl7, ever7 25< hours. @nitiall7 the7 ma7 not &ake u! for feeds and must be &akened. ?hanging the bab7 before the feed ma7 make him more alert. %ometimes it hel!s to e.!ress a little milk &ith each suck. @f the breast is engorged, encourage the mother to e.!ress a small amount of breast milk before starting breastfeedingthis &ill soften the ni!!le area and it &ill be easier for the bab7 to attach. 9ven if the bab7 is not 7et suckling &ell and long enough 'ver7 !reterm2, offer the breast first, and then use an a!!ro!riate alternative feeding method. Do &hatever &orks best in 7our setting( let the mother e.!ress breast milk into bab78s mouth or let her e.!ress breast milk and feed it to the bab7 b7 cu! or tube. Give special support to mothers who breastfeed twins m 0eassure the mother that she has enough breast milk for two babies; m e#plain to her that twins may take longer to establish breastfeeding since they are fre*uently born preterm and with low birth weight.

*/

Help the mother feed her twins m .eeding one baby at a time until breastfeeding is well established; m finding the best method for her twins+ if one is weaker, encourage her to make sure that the weaker twin gets enough milk. )f necessary, she can e#press milk for him and feed him by cup after initial breastfeeding; m alternating the side each baby is offered daily.

<lternatiAe #eeding method$ 6he bab7 can be fed b7 e.!ressing breast milk directl7 into his mouth or giving e.!ressed mother8s breast milk or a!!ro!riate formula b7 cu! or tube. 56pressing breast mil2 Hand e.!ression is the best &a7 to e.!ress breast milk. @t is less likel7 to carr7 infection than a !um!, and can be used b7 ever7 &oman at an7 time. A techni4ue to e.!ress milk effectivel7 is described in the WHO breastfeeding counselling course. %ho& the mother ho& to e.!ress breast milk and let her do it. Do not e.!ress her milk for her. 6o establish lactation and feed a small bab7 she should start e.!ressing milk on the first da7, &ithin si. hours of deliver7, if !ossible. %he should e.!ress as much as she can and as often as the bab7 &ould breastfeed. 6his means at least ever7 < hours, including during the night. 6o build u! her milk su!!l7, if it seems to be decreasing after a fe& &eeks, she should e.!ress her milk ver7 often for a fe& da7s 'ever7 hour2 and at least ever7 < hours during the night. Mothers often develo! their o&n st7le of hand e.!ression once the7 have learned the basic !rinci!les. %ome &ill e.!ress both breasts at the same time, leaning for&ard &ith a container bet&een their knees and !ausing ever7 fe& minutes to let the sinuses refill &ith breast milk. 9ver7 mother &ill find her o&n rh7thm, &hich is usuall7 slo& and regular. 9ncourage mothers to e.!ress breast milk their o&n &a7, !roviding it &orks for them. @f a mother is e.!ressing more milk than her small bab7 needs, let her e.!ress the second half of the milk from each breast into a different container. Aet her offer the second half of the e.!ressed breast milk first. 6his &a7 the bab7 gets more hind milk, &hich gives him the e.tra energ7 he needs and hel!s him gro& better. @f the mother can onl7 e.!ress ver7 small volumes at first, give &hatever she can !roduce to her bab7 and su!!lement &ith formula milk if necessar7. 9.!ressing breast milk takes time, !atience and for&ard !lanning. Ask the mother to start at least half an hour before the bab78s feed, irres!ective of the method used. @f !ossible, use freshl7 e.!ressed breast milk for the ne.t feed. @f there is more milk than the bab7 needs, it can be stored in a refrigerator for u! to */ hours at *B?.

*+

56pressing breast mil2 directly into baby4s mouth >reast milk can be e.!ressed directl7 into the bab78s mouth, but the mother should first become familiar &ith e.!ressing breast milk b7 hand. he baby can be fed while in !angaroo position m 2old the baby in skin-to-skin contact, the mouth close to the nipple; m wait until the baby is alert and opens mouth and eyes %very small babies may need light stimulation to be kept awake and alert(; m e#press a few drops of breast milk; m let the baby smell and lick the nipple, and open the mouth; m e#press breast milk into the baby's open mouth; m wait until baby swallows the milk; m repeat the procedure until the baby closes his mouth and will take no more breast milk even after stimulation; m ask the mother to repeat this operation every hour if the baby weighs less than 3&''g and every two hours if the baby weighs more than 3&''g; m be fle#ible at each feed, but check that the intake is ade*uate by measuring the daily weight gain.

9.!erience sho&s that mothers learn this method 4uickl7. Moreover, it has an advantage over other methods since no utensils are re4uired, thus ensuring good h7giene. @t is not !ossible, ho&ever, to assess the amount of milk given, es!eciall7 at the beginning, &hen it could be too small for the bab78s needs. Aater, it can be assumed to be ade4uate as long as the bab7 is gaining &eight 'see belo&2. 6he method has, ho&ever, not been assessed s7stematicall7 and com!ared to other methods. ,up-feeding ?u!s and other traditional utensils such as the L!aladaiL in @ndia"+
"+ 0< can be used to feed even ver7 small babies, as long as the7 s&allo& the milk.0+,, :or details of cu!5feeding techni4ues, see the WHO breastfeeding counselling course '!!. <* 5 <**2. Mothers can easil7 learn this techni4ue and feed their babies &ith ade4uate amounts of milk. ?u!5feeding !resents a fe& advantages over bottle5feeding since it does not interfere &ith suckling at the breast- a cu! is easil7 cleaned &ith soa! and &ater, if boiling is not !ossible, and enables the bab7 to control his o&n intake. At first, the mother ma7 !refer to take the bab7 out of the kangaroo !osition.

'yringe or dropper-feeding 6he techni4ue is similar to that for e.!ressing breast milk in bab78s mouth( measure the re4uired amount of breast milk in a cu! and !our it directl7 into the bab78s mouth &ith a regular or s!ecial s!oon, s7ringe or dro!!er. %ome more milk is given once the bab7 has s&allo&ed the given amount. %!oon5feeding takes longer than cu!5feeding and s!illage can be substantial. :eeding &ith s7ringes and dro!!ers is not faster than cu!5feeding. Moreover, s7ringes and dro!!ers are more difficult to clean and more e.!ensive.

"ottle-feeding 6his is the least !referred feeding method and is not recommended. @t ma7 hinder breathing and o.7genation"+ ,", ,2 and it interferes &ith suckling. >ottles and teats must be sterilized in institutions, and boiled at home. Tube-feeding 6ube5feeding is used &hen the bab7 cannot 7et s&allo&, or coordinate s&allo&ing and breathing, or tires too easil7 and does not get enough milk. While the health &orker inserts the tube and !re!ares the s7ringe or dro!!er, mother can let the bab7 suck her breast. 6he bab7 can be tube5fed in the kangaroo !osition.

How to insert a tube m $ake the baby out of the kangaroo position, wrap her in a warm cloth and place her on a warm surface; m insert the tube through the baby's mouth rather than the nose+ small babies breathe through the nose and the tube placed in the nostrils may obstruct breathing; m use 4o. to 4o. 5 .rench gauge short feeding tubes, depending on the si6e of the infant; m measure and mark the distance from the mouth to the ear and to the lower tip of the sternum on the tube with a felt pen; m pass the tube through the mouth into the stomach until the felt pen mark reaches the lips; baby's breathing should be normal with the tube in place; m secure the tube to the infant's face with a tape; m replace the tube every &7-8& hours. Keep it closed or pinched while removing it to avoid dripping fluid into the baby's throat.

How to prepare and use the syringe ,etermine the amount of milk for the feed %$able 3(; choose the corresponding si6e syringe; remove the piston from the syringe and discard it; attach the syringe to the tube; pour the re*uired amount of breast milk into the syringe; hold the syringe barrel above baby's stomach and let the milk flow by gravity; do not inject the milk; m observe the baby during feeding for any change in breathing and spilling; m when feeding is completed close off the tube with a spigot; m during tube-feeding baby can suck the breast or the mother's finger %.ig.5(. m m m m m m

0"

As soon as the bab7 sho&s signs of readiness for oral feeding 'breastfeeding or cu!, s!oon, s7ringe, or dro!!er5feeding2, feed at first once or t&ice a da7, &hile the bab7 is still mostl7 fed through a tube. #raduall7 reduce tube feeds and remove the tube &hen the bab7 takes at least three consecutive feeds of breast milk b7 cu!. Huantity and #reBuency :re4uenc7 of feeding &ill de!end on the 4uantit7 of milk the bab7 tolerates !er feed and the re4uired dail7 amount. As a guide, the amount !er feed for small ne&born !reterm babies should be steadil7 increased as follo&s( up to day 6 slo ly increase the total amount and the amount per feed, to help the ne born infant get used to enteral feeding! after day 6 steadily increase the $uantity to achie#e the amount re$uired for the baby.s age as indicated in Tables * and +! by day )< the baby should take *55ml=kg=day, hich is the amount re$uired for steady gro th. 6able < sho&s the a!!ro.imate amount and number of feeds re4uired as the bab7 gro&s older. Avoid overfeeding or feeding too ra!idl7 to lessen the risk of milk as!iration or abdominal distension. Fer7 small babies should be fed ever7 t&o hours, larger babies ever7 three hours. @f necessar7, &ake mother and bab7 during the da7 and night to ensure regular feeding. Table . A#o$nt of #il% &or fl$id' needed (er da) b) birth *eight and age 8eed 0ay 1 0ay 2 0ay ( 0ay 4 0ay . 0ay# ,6 0ay 14 e$ery 1( 2 ,+91-1112-61+- 1+-6 ml:k& ml:k& ml:k& ml:k& ml:k& ml:k& 2-hour# ml:k& ( hour# Table ". A((ro+i#ate a#o$nt of breast #il% needed (er feed b) birth *eight and age ;um%er 0ay 1 3!rth 0ay 2 0ay ( 0ay 4 0ay . 0ay# ,6 0ay 14 of feed# 2e!&ht 1( 1---& 12 . ml:k& * ml:k& + ml:k& 9 ml:k& 11161, 1* ml:k& ml:k& ml:k& 12.-& 12 , ml:k& + ml:k& 9 ml:k& 11 ml:k& 12 14619 21 ml:k& ml:k& ml:k& 1.--& + 12 1. 1* 19 21 2(6(( (. ml:k& ml:k& ml:k& ml:k& ml:k& ml:k& ml:k& 1*.-& + 14 1+ 222 24 2,642 4. ml:k& ml:k& ml:k& ml:k& ml:k& ml:k& ml:k& 2---& + 1. 22( 2. 2+ (-64. .ml:k& ml:k& ml:k& ml:k& ml:k& ml:k& ml:k&

3!rth 2e!&ht 1---6 1499& 91.--&

02

6ransition from an alternative feeding method to e.clusive breastfeeding ma7 occur earlier in larger babies and much later in ver7 small babies and ma7 take a &eek. 9ncourage mother to start breastfeeding as soon as the bab7 sho&s signs of readiness. At the beginning the bab7 ma7 not suckle long enough but even short sucking stimulates milk !roduction and hel!s the bab7 to L!racticeL. ;ee! reassuring the mother and hel!ing her &ith breastfeeding the bab7. As the bab7 gro&s, graduall7 re!lace scheduled feeding &ith feeding on demand.

0<

When the bab7 moves on to e.clusive breastfeeding and measuring the amount of milk intake is not !ossible, &eight gain remains the onl7 &a7 to assess &hether feeding is ade4uate. @f the mother is H@F5!ositive and chooses re!lacement feeding, suggest using cu!5feeding. :or further information on this issue, !lease refer to H@F and infant feeding counselling course.0.7 !onitoring growth Weight Weigh small babies dail7 and check &eight gain to assess first the ade4uac7 of fluid intake and then gro&th. %mall babies lose &eight at first, immediatel7 after birth( &eight loss of u! to " H in the first fe& da7s of life has been considered acce!table. After the initial &eight loss, ne&born babies &ill slo&l7 regain birth &eight, usuall7 bet&een $ and "* da7s after birth. After that babies should be gaining &eight, a little at the beginning, more later on. Go &eight loss is acce!table though after this initial !eriod. #ood &eight gain is considered a sign of good health, !oor &eight gain is a serious concern. 6here is no u!!er limit for &eight gain for breastfed infants, but the lo&er limit should be no less than "0gCkgCda7. "de#uate daily weight gain from the second wee! of life is$%g&!g&day' "pproximate weight gains for different post-menstrual ages are given below: &'g9day up to 3& weeks of post-menstrual age, corresponding appro#imately to 3 '-&''g9week; & g9day from 33 to 3: weeks of post-menstrual age, corresponding appro#imately to &''-& 'g9week; 3'g9day from 38 to 7' weeks of post-menstrual age, corresponding appro#imately to & '-3''g9week.

0*

6here are no universall7 acce!ted recommendations regarding fre4uenc7 of gro&th monitoring for A>W and !reterm infants. 6here is no universal reference chart for !lotting the !ostnatal &eight gain of those babies but intrauterine gro&th charts b7 &eek of gestation, &ith !ercentiles or standard deviations, are used instead. @t is not kno&n &hether an e.trauterine gro&th similar to the one the !reterm infant &ould have had in utero is an a!!ro!riate criterion for monitoring !ostnatal &eight gain. @t seems reasonable, ho&ever, to aim for a &eight of at least 20 g or more b7 the * 2 th &eek of !ost5menstrual age.

he following recommendations are based on experience m ;eigh babies once a day; more fre*uent weighing might upset the baby and be a cause of an#iety and concern for the mother. <nce the baby has started gaining weight, weigh every second day for a week and then once weekly until the baby has reached full term %7' weeks or & ''g(; m weigh the baby in the same way every time, i.e. naked, with the same calibrated scales %with 3'g intervals if possible(, placing a clean warm towel on the scales to avoid cooling the infant; m weigh the baby in a warm environment; m if you have a local weight chart showing the e#pected intrauterine growth, plot the weight on the graph to monitor growth.

#ro&th monitoring, es!eciall7 for dail7 &eight gain, re4uires accurate and !recise scales and a standardized &eighing techni4ue. %!ring scales are not !recise enough for fre4uent monitoring of &eight gain &hen &eight is lo&, and ma7 lead to &rong decisions. Analogue maternit7 hos!ital scales '&ith " g intervals2 are the best alternative. @f such accurate and !recise scales are not available, do not &eigh ;M? infants dail7 but rel7 on &eekl7 &eighing for gro&th monitoring. Weight is recorded on a &eight chart and &eight gain is assessed dail7 or &eekl7. Head circum#erence Measure head circumference &eekl7. Once bab7 is gaining &eight, head circumference &ill increase b7 bet&een .0 and "cm !er &eek. :or ade4uac7 of head gro&th refer to national anthro!ometric standards. <lternatiAe method$ #or monitoring gro+th Alternative methods, such as measuring bab78s length, and chest and arm circumference, are less useful for gro&th monitoring and are not recommended for the follo&ing reasons( length is less reliable than &eight. @t increases more slo&l7 and does not hel! to make decisions about feeding or illness surrogates, such as chest and arm circumference, have been !ro!osed to assess size at birth and as a tool to evaluate the need for s!ecial care.,<, ,* 6heir effectiveness for gro&th monitoring in A>W and !reterm infants has not 7et been assessed.

00

0.8 1nade+uate weight gain @f &eight gain is inade4uate for several da7s, first assess the feeding techni4ue, fre4uenc7, duration and schedule, and check that night feeds are given. Advise the mother to increase the fre4uenc7 of feeds or to feed on demand. 9ncourage her to drink fluids &hen thirst7. 6hen look for other conditions as !ossible reasons for !oor &eight gain( oral thrush ( hite patches in the mouth) can interfere ith feeding. Treat the baby by gi#ing her an oral suspension of nystatin ()55,555 2>=ml)! use a dropper to apply )ml in the oral mucosa and paint the mother.s nipples after each feed until the lesions heal. Treat for ? days! rhinitis is $uite disturbing for the baby because it interferes ith feeding. Nasal drops of normal saline solution in each nostril before each feed may help to relie#e nasal obstruction! urinary tract infection is a possible insidious cause. 2n#estigate if the baby fails to gro ithout ob#ious reasons. Treat according to national=local treatment guidelines! se#ere bacterial infection can initially manifest itself ith poor eight gain and poor feeding. 2f a pre#iously healthy baby becomes un ell and stops feeding, consider this as a serious danger sign. 2n#estigate for infection and treat according to national=local treatment guidelines.

Other causes of failure to gain &eight include !atent ductus arteriosus and other diseases that ma7 be difficult to diagnose in settings &ith scarce resources. 3efer the bab7 &ho fails to gain &eight after the e.clusion or treatment of the above common causes to a higher level of care, for further investigation and treatment. @f a mother8s breast milk su!!l7 is reduced and does not satisf7 bab78s needs, she must in5 crease it. 6his often ha!!ens &here there is a breastfeeding difficult7( bab7 is not suckling &ell, the mother has been a&a7 or sick and sto!!ed feeding her bab7 'on increasing breast milk and relactation see the WHO breastfeeding counselling course, !! <*/5<0/,"+ and the WHO document @elactation: - re#ie of e"perience and recommendations for practice ,0 2. 6his should be the first ste! before turning to other methods. Lactogogue$ Herbal teas obtained from sesame, fenugreek, fennel, cumin, basil and aniseed have not been !roven effective in increasing breast milk !roduction. >eer and other alcoholic drinks used in some cultures to increase lactation should be discouraged since alcohol in breast milk is dangerous for babies.,,, ,$ Dom!eridone can hel! increase milk su!!l7. @t could be used as a su!!ortive !rocedure and onl7 after all other effective methods for im!roving milk !roduction have been tried out. Al&a7s follo& national guidelines. @f des!ite all these efforts the bab7 is not gaining &eight, consider su!!lementing breastfeeding &ith !reterm formula, given b7 cu! after each feed. 6o !re!are formula milk follo& the instructions on the bo..

0,

Do not make im!ortant decisions about formula su!!lementation on the basis of dail7 &eight, since this is subDect to large variations. Onl7 &eight change over a fe& da7s, or &eekl7 &eight gain, is a good basis for such decisions.

0$

Discuss &ith the mother &hether this is a feasible, affordable and safe o!tion that &ill be available for several months. %ho& her ho& to !re!are it and give it safel7. :ollo& the instructions on the !ackage. 3eturn to e.clusive breastfeeding as soon as !ossible after the infant has gained &eight for some time. Monitor more closel7 the health and gro&th of small infants fed or su!!lemented &ith formula since the7 are more e.!osed than breastfed babies to infection and malnutrition. 6r7, if at all !ossible, not to discharge a small bab7 &ith formula su!!lements.

".0< 9nsure that the facilit7 follo&s the rules !rescribed b7 the 2nternational 'ode of &arketing of ,reast-milk ;ubstitutes, issued b7 WHO.(reventive treatment %mall babies are born &ithout sufficient stores of micronutrients. Preterm babies, irres!ective of &eight, should receive iron and folic acid su!!lementation from the second month of life until one 7ear of chronological age. 6he recommended dail7 dose of iron is 2mgCkg bod7 &eightCda7. m 9.!lain to the mother that( iron is essential for bab78s health and gro&th the bab7 needs to take iron regularl7( at the same time ever7 da7, after breastfeeding bab78s stools ma7 become darker, &hich is normal. m 9.!lore her concerns. ".0* 'timulation All infants need love and care to flourish, but ver7 !reterm babies need even more attention to be able to develo! normall7 since the7 have been de!rived of an ideal intrauterine environment for &eeks or even months. 6he7 are instead e.!osed to too much light, noise and !ainful stimuli during their initial care. ;M? is an ideal method since the bab7 is rocked and cuddled, and listens to the mother8s voice &hile she goes about her ever7da7 activities. :athers too can !rovide such an environment. Health &orkers have an im!ortant role to !la7 in encouraging mothers and fathers to e.!ress their emotions and love to their babies.

".00 Ho&ever, if the bab7 has other !roblems due to !reterm birth or its com!lications, additional treatment ma7 be necessar7. #uidance on such treatment can be found in standard te.tbooks or in the WHO manual &anaging ne born problems. - guide for doctors, nurses and mid i#es./ischarge Discharge means letting the mother and bab7 go home. 6heir o&n environment, ho&ever, could be ver7 different from the ;M? unit at the facilit7, &here the7 &ere surrounded b7 su!!ortive staff. 6he7 &ill continue to need su!!ort even though this &ill not have to be as intensive and fre4uent. 6he time of discharge ma7 therefore var7 de!ending on the size of the bab7, bed availabilit7, home conditions and accessibilit7 of follo&5u! care. Esuall7, a ;M? bab7 can be discharged from the hos!ital &hen the follo&ing criteria are met( the baby.s general health is good and there is no concurrent disease such as apnoea or infection! he is feeding ell, and is e"clusi#ely or predominantly breastfed! he is gaining eight (at least )6g=kg=day for at least three consecuti#e days)!

0/

 his temperature is stable in the %&' position ( ithin the normal range for at least three consecuti#e days)! the mother is confident in caring for the baby and is able to come regularly for follo up #isits. 6hese criteria are usuall7 met b7 the time the bab7 &eighs more than "0 g.

6he home environment is also ver7 im!ortant for the successful outcome of ;M?. 6he mother should go back to a &arm, smoke5free home and should have su!!ort for ever7da7 household tasks. Where there are no follo&5u! services and the hos!ital is far a&a7, mother and bab7 should be discharged later. @mmunize the bab7 according to national !olic7 and give enough ironCfolate tablets to last until the follo&5u! visit. :ill in the home5based bab78s record. 9nsure that the mother kno&s( ho to apply skin-to-skin contact until baby sho s signs of discomfort! ho to dress the baby, hen he is not in kangaroo position, to keep him arm at home! ho to bath the baby and keep him arm after the bath! ho to respond to baby.s needs such as increasing the duration of skin-to-skin contact if he has cold hands and feet or lo temperature at night! ho to breastfeed the baby during the day and night according to instructions! hen and here to return for follo -up #isits (schedule the first #isit and gi#e the mother ritten=pictorial instructions for the abo#e issues)! ho to recogni(e danger signs! here to seek care urgently if danger signs appear! hen to ean the baby from %&'. (he should return immediately to hospital) or go to another appropriate provider) if the baby: stops feeding, is not feeding well, or vomits; becomes restless and irritable, lethargic or unconscious; has fever %body temperature above 38. !"(; is cold %hypothermia - body temperature below 3:. !"( despite rewarming; has convulsions; has difficulty breathing; has diarrhoea; shows any other worrying sign.

6ell the mother that it is al&a7s better to seek hel!, if in doubt( &hen caring for small infants it is better to seek care too often than to disregard im!ortant s7m!toms. 9arl7 discharge becomes a goal for the mother as she gains confidence in her abilit7 to care

0+

for her bab7. A bab7 can be discharged earlier if the follo&ing criteria are met( ade$uate information on home care is gi#en at discharge to mothers and their families, preferably as ritten and pictorial instructions! mothers ha#e recei#ed instructions on danger signs, and kno hen and here to seek care.

0.1& K!, at home and routine follow-up 9nsure follo&5u! for the mother and the bab7, either at 7our facilit7 or &ith a skilled !rovider near the bab78s home. 6he smaller the bab7 is at discharge, the earlier and more fre4uent follo&5u! visits he &ill need. @f the bab7 is discharged in accordance &ith the above criteria, the follo&ing suggestions &ill be valid in most circumstances( t&o follo&5u! visits !er &eek until <$ &eeks of !ost5menstrual age one follo&5u! visit !er &eek after <$ &eeks. 6he content of the visit ma7 var7 according to mother8s and bab78s needs- check the follo&5 ing, ho&ever, at each follo&5u! visit( K1C Duration of skin5to5skin contact, !osition, clothing, bod7 tem!erature, su!!ort for the mother and the bab7. @s the bab7 sho&ing signs of intolerance= @s it time to &ean the bab7 from ;M? 'usuall7 at around * &eeks of !ost5menstrual age, or Dust before2= @f not, encourage the mother and famil7 to continue ;M? as much as !ossible. -rea$t#eeding @s it e.clusive= @f 7es, !raise the mother and encourage her to continue. @f not, advise her on ho& to increase breastfeeding and decrease su!!lements or other fluids. Ask and look for an7 !roblem and !rovide su!!ort. @f the bab7 is taking formula su!!lements or other foods, check their safet7 and ade4uac7- make sure that the famil7 has the necessar7 su!!l7. ?ro+th Weigh the bab7 and check &eight gain in the last !eriod. @f &eight gain is ade4uate, i.e. at least "0gCkgCda7 on average, !raise the mother. @f it is inade4uate, ask and look for !ossible !roblems, causes and solutions- these are generall7 related to feeding or illness. 6o check ade4uate dail7 &eight gain !lease refer to bo. on !age <$. Illne$$ Ask and look for an7 signs of illness, re!orted b7 the mother or not. Manage an7 illness according to 7our local !rotocols and guidelines. @n case of non5e.clusive breastfeeding, ask and look !articularl7 for signs of nutritional or digestive !roblems. Drug$ #ive a sufficient su!!l7 of drugs, if needed, to last until the ne.t follo&5u! visit. Immunization ?heck that the local immunization schedule is being follo&ed. 1otherG$ concern$ Ask the mother about an7 other !roblem, including !ersonal, household, and social !roblems. 6r7 to hel! her find the best solution for all of them. 4eEt #ollo+-u Ai$it Al&a7s schedule or confirm the ne.t visit. Do not miss the o!!ortunit7, if time allo&s, to check and advise on h7giene, and to reinforce the mother8s a&areness of danger signs that need !rom!t care. , ecial #ollo+-u Ai$it$ @f these are re4uired for other medical or somatic !roblems, encourage the mother to attend them and hel! her if needed. 3outine child care 9ncourage the mother to attend routine child care once the bab7 reaches 20 &eeks of !ost5menstrual age. ," g or *

3e#erence$

".0, 8o birth eight. - tabulation of a#ailable information. #eneva, World Health Organization, "++2 'WHOC M?HC+2.22. ".0$ de Onis M, >lossner M, Fillar J. Aevels and !atterns of intrauterine gro&th retardation in develo!ing countries. Auropean Bournal of 'linical Nutrition, "++/, 02'%u!!l."2(%05%"0. ".0/ Assential ne born care. @eport of a Technical 9orking /roup (Trieste *6-*0 -pril )00<). #eneva, World Health Organization, "++, 'WHOC:3HCM%MC+,."<2. ".0+ Ash&orth A. 9ffects of intrauterine gro&th retardation on mortalit7 and morbidit7 in infants and 7oung children. Auropean Bournal of 'linical Nutrition, "++/, 02'%u!!l."2(%<*5%*"discussion( %*"5*2. "., Murra7 ?JA, Ao!ez AD, eds. /lobal burden of disease: a comprehensi#e assessment of mortality and disability from diseases, inCuries and risk factors in )005 and proCected to *5*5. >oston, Harvard %chool of Public Health, "++, '#lobal burden of disease and inDuries series, vol. "2. ".," #ulmezoglu M, de Onis M, Fillar J. 9ffectiveness of interventions to !revent or treat im!aired fetal gro&th. Dbstetrical E /ynecological ;ur#ey, "++$, 02("<+5"*+. ".,2 ;ramer M%. %ocioeconomic determinants of intrauterine gro&th retardation. Auropean Bournal of 'linical Nutrition, "++/, 02'%u!!l."2(%2+5%<2- discussion( %<25<<. ".,< Mc?ormick M?. 6he contribution of lo& birth &eight to infant mortalit7 and childhood morbidit7. The Ne Angland Bournal of &edicine, "+/0, <"2(/25+ . ".,* 3e7 9%, Martinez H#. ManeDo racional del nino !rematuro. @n( Eniversidad Gacional, 'urso de &edicina 4etal, >ogota, Eniversidad Gacional, "+/<. ".,0 Thermal control of the ne born: - practical guide. Maternal Health and %afe Motherhood Programme. #eneva, World Health Organization, "++< 'WHOC:H9CM%MC+<.22. ".,, %hiau %H, Anderson #?. 3andomized controlled trial of kangaroo care &ith fullterm infants( effects on maternal an.iet7, breastmilk maturation, breast engorgement, and breast5feeding status. Pa!er !resented at the @nternational >reastfeeding ?onference, Australia8s >reastfeeding Association, %7dne7, October 2<520, "++$. ".,$ ?attaneo A, et al. 3ecommendations for the im!lementation of kangaroo mother care for lo& birth&eight infants. -cta Faediatrica, "++/, /$(** 5**0. ".,/ ?attaneo A, et al. ;angaroo mother care in lo&5income countries. Bournal of Tropical Fediatrics, "++/, **(2$+52/2. ".,+ >ergman GJ, Jurisoo AA. 6he Lkangaroo5methodL for treating lo& birth &eight babies in a develo!ing countr7. Tropical Goctor, "++*, 2*(0$5, . ".$ Aincetto O, Gazir A@, ?attaneo A. ;angaroo Mother ?are &ith limited resources. ,2

Bournal of Tropical Fediatrics, 2 , *,(2+<52+0. ".$" Anderson #?. ?urrent kno&ledge about skin5to5skin 'kangaroo2 care for !reterm infants. Bournal of Ferinatology, "++", ""(2",522,. ".$2 ?hristensson ;, et al. 3andomised stud7 of skin5to5skin versus incubator care for re&arming lo&5risk h7!othermic neonates. The 8ancet, "++/, <02("""0. ".$< %hekelle P#. ?linical guidelines( Develo!ing guidelines. ,ritish &edical Bournal, "+++, <"/(0+<50+,. ".$* ,reastfeeding counselling: - training course - Trainer.s guide. #eneva, World Health Organization, "++< 'WHOC?D3C+<.*2. Also available from EG@?9: 'EG@?9:CGE6C+<.22. ".$0 123 and infant feeding counselling: - training course - Trainer.s guide. #eneva, World Health Organization, 2 'WHOC:?HC?AHC .<2. Also available from EG@?9: 'EG@?9:CPDCGE6C 5*2 or EGA@D% 'EGA@D%C++.0/2.

,<

".$, ?har!ak G, 3uiz5Pelaez J#, :igueroa de ?alume I. ?urrent kno&ledge of kangaroo mother intervention. 'urrent Dpinion in Fediatrics, "++,, /(" /5""2. ".$$ Audington5Hoe %M, %&inth JM. Develo!mental as!ects of kangaroo care. Bournal of Dbstetric, /ynecologic, and Neonatal Nursing, "++,, 20(,+"5$ <. ".$/ ?onde5Agudelo A, Diaz53osello JA, >elizan JM. ;angaroo mother care to reduce morbidit7 and mortalit7 in lo& birth &eight infants. 'ochrane 8ibrary, @ssue 2, 2 2. ".$+ %loan GA, et al. ;angaroo mother method( randomised controlled trial of an alternative method of care for stabilised lo&5birth&eight infants. The 8ancet, "++*, <**($/25$/0. "./ ?har!ak G, et al. ;angaroo mother versus traditional care for ne&born infants N 2 grams( a randomized controlled trial. Fediatrics, "++$, " (,/25,//. "./" ?attaneo A, et al. ;angaroo mother care for lo& birth&eight infants( a randomised controlled trial in different settings. -cta Faediatrica, "++/, /$(+$,5+/0. "./2 ;ambarami 3A, ?hidede O, ;o&o D6. ;angaroo care versus incubator care in the management of &ell !reterm infants( a !ilot stud7. -nnals of Tropical Faediatrics, "++/, "/(/"5/,. "./< Whitela& A, %leath ;. M7th of marsu!ial mother( home care of ver7 lo& birth &eight infants in >ogota, ?olombia. The 8ancet, "+/0, "("2 ,5"2 /. "./* ?har!ak G, et al. ;angaroo5mother !rogramme( an alternative &a7 of caring for lo& birth &eight infants= One 7ear mortalit7 in a t&o5cohort stud7. Fediatrics, "++*, +*(/ *5/" . "./0 Anderson #?, et al. >irth5associated fatigue in <*5<, &eek !remature infants( ra!id recover7 &ith ver7 earl7 skin5to5skin 'kangaroo2 care. Bournal of Dbstetric, /ynecologic, and Neonatal Nursing, "+++, 2/(+*5" <. "./, Aincetto O, et al. @m!act of season and discharge &eight on com!lications and gro&th of kangaroo mother care treated lo& birth&eight infants in Mozambi4ue. -cta Faediatrica, "++/, /$(*<<5*<+. "./$ %chmidt 9, Wittreich #. ?are of the abnormal ne&born( a random controlled trial stud7 of the Lkangaroo methodL of care of lo& birth &eight ne&borns. @n( 'onsensus 'onference on -ppropriate Technology 4ollo ing ,irth, Trieste, ?-)) Dctober )0H7. WHO 3egional Office for 9uro!e. ".// Whitela& A, et al. %kin5to5skin contact for ver7 lo& birth &eight infants and their mothers. -rchi#es of Gisease in 'hildhood, "+//, ,<("<$$5"</". "./+ Wahlberg F, Affonso D, Persson >. A retros!ective, com!arative stud7 using the kangaroo method as a com!lement to the standard incubator care. Auropean Bournal of Fublic 1ealth, "++2, 2(<*5<$. ".+ %7frett 9>, et al. 9arl7 and virtuall7 continuous kangaroo care for lo&er5risk !reterm infants( effect on tem!erature, breast5feeding, su!!lementation and &eight. @n( Froceedings of the ,iennial 'onference of the 'ouncil of Nurse @esearchers. Washington, D?, American Gurses Association, "++<. ".+" >la7more5>ier JA, et al. ?om!arison of skin5to5skin contact &ith standard contact in lo& birth &eight infants &ho are breastfed. -rchi#es of Fediatrics E -dolescent &edicine, "++,, "0 ("2,05"2,+. ".+2 Hurst GM, et al. %kin5to5skin holding in the neonatal intensive care unit influences maternal milk volume. Bournal of Ferinatology, "++$, "$(2"<52"$. ,*

".+< ?hristensson ;. :athers can effectivel7 achieve heat conservation in health7 ne&born infants. -cta Faediatrica,"++,, /0("<0*5"<, . ".+* Audington5Hoe %M, et al. %elected !h7siologic measures and behavior during !aternal skin contact &ith ?olombian !reterm infants. Bournal of Ge#elopmental Fhysiology, "++2, "/(22<5 2<2. ".+0 Acolet D, %leath ;, Whitela& A. O.7genation, heart rate and tem!erature in ver7 lo& birth &eight infants during skin5to5skin contact &ith their mothers. -cta Faediatrica ;candina#ica, "+/+, $/( "/+5"+<. ".+, de Aeeu& 3, et al. Ph7siologic effects of kangaroo care in ver7 small !reterm infants. ,iology of the Neonate, "++", 0+("*+5"00. ".+$ :ischer ?, et al. ?ardiores!irator7 stabilit7 of !remature bo7s and girls during kangaroo care. Aarly 1uman Ge#elopment, "++/, 02("*05"0<. ".+/ Anderson #?, Wood ?9, ?hang HP. %elf5regulator7 mothering vs. nurser7 routine care !ostbirth( effect on salivar7 cortisol and interactions &ith gender, feeding, and smoking. 2nfant ,eha#ior and Ge#elopment, "++/, 2"(2,*. ".++ ?hristensson ;, et al. 6em!erature, metabolic ada!tation and cr7ing in health7 full5 term ne&borns cared for skin5to5skin or in a cot. -cta Faediatrica, "++2, /"(*//5*+<. "." ?hristensson ;, et al. %e!aration distress call in the human infant in the absence of maternal bod7 contact. -cta Faediatrica, "++0, /*(*,/5*$<. "." " Affonso D, Wahlberg F, Persson >. 9.!loration of mother8s reactions to the kangaroo method of !re5 maturit7 care. Neonatal Net ork, "+/+, $(*<50".

,0

"." 2 Affonso D, et al. 3econciliation and healing for mothers through skin5to5skin contact !rovided in an American tertiar7 level intensive care nurser7. Neonatal Net ork, "++<,"2(205<2. "." < Aegault M, #oulet ?. ?om!arison of kangaroo and traditional methods of removing !reterm infants from incubators. Bournal of Dbstetric, /ynecologic, and Neonatal Nursing, "++0, 2*(0 "50 ,. "." * >ell 9H, #e7er J, Jones A. A structured intervention im!roves breast5feeding success for ill or !reterm infants. -merican Bournal of &aternal and 'hild Nursing, "++0, 2 (< +5<"*. "." 0 6essier 3, et al. ;angaroo mother care and the bonding h7!othesis. Fediatrics, "++/, " 2(<+ 5<+". "." , H7lander MA, %trobino DM, Dhaniredd7 3. Human milk feedings and infection among ver7 lo& birth &eight infants. Fediatrics, "++/, " 2(9</. "." $ %chanler 3J, %hulman 3J, Aau ?. :eeding strategies for !remature infants( beneficial outcomes of feeding fortified human milk versus !reterm formula. Fediatrics, "+++, " <(""0 5""0$. "." / Malhotra G, et al. A controlled trial of alternative methods of oral feeding in neonates. Aarly 1uman Ge#elopment, "+++, 0*(2+5</. "." + %ontheimer D, et al. Pitfalls in res!irator7 monitoring of !remature infants during kangaroo care. -rchi#es of Gisease in 'hildhood, "++0, $2(:""05""$. "."" Aubchenco AO, et al. @ntrauterine gro&th as estimated from live born birth &eight data at 2* to *2 &eeks of gestation. Fediatrics, "+,<, <2($+<5/ . ".""" &anaging ne born problems. - guide for doctors, nurses and mid i#es. #eneva, World Health Organization 'in !ress2. ".""2 Jenni O#, et al. 9ffect of nursing in the head elevated tilt !osition '"0 degrees2 on the incidence of brad7cardic and h7!o.emic e!isodes in !reterm infants. Fediatrics, "++$, " (,225,20. ".""< Audington5Hoe %M, Hadeed AJ, Anderson #?. Ph7siologic res!onses to skin5to5skin contact in hos!italized !remature infants. Bournal of Ferinatology, "++", ""("+52*. ".""* #u!ta A, ;hanna ;, ?hattree %. ?u! feeding( an alternative to bottle feeding in a neonatal intensive care unit. Bournal of Tropical Fediatrics, "+++, *0(" /5"" . ".""0 Aang %, Aa&rence ?J, Orme 3A. ?u! feeding( an alternative method of infant feeding. -rchi#es of Gisease in 'hildhood, "++*, $"(<,05<,+. "."", >ier J>, et al. >reast5feeding of ver7 lo& birth &eight infants. Bournal of Fediatrics, "++<, "2<( $$<5$$/. ".""$ Poets ?:, Aangner ME, >ohnhorst >. 9ffects of bottle feeding and t&o different methods of gavage feeding on o.7genation and breathing !atterns in !reterm infants. -cta Faediatrica, "++$, /,( *"+5*2<. ".""/ ,irth eight surrogates: The relationship bet een birth eight, arm and chest circumference. #eneva, World Health Organization, "+/$. ".""+ Diamond JD, et al. 6he relationshi! bet&een birth &eight and arm and chest circumference in 9g7!t. Bournal of Tropical Fediatrics, "++", <$(<2<5,. "."2 @elactation: - re#ie of e"perience and recommendations for practice. #eneva, World Health Organization, "++/ 'WHOC?H%C?AHC+/."*2. ,,

"."2" Mennella JA, #errish ?J. 9ffects of e.!osure to alcohol in mother8s milk on infant slee!. Fediatrics, "++/, " "(92. "."22 3osti A, et al. 6o.ic effects of a herbal tea mi.ture in t&o ne&borns. -cta Faediatrica, "++*, /<(,/<. "."2< 2nternational code of marketing of breast-milk substitutes. #eneva, World Health Organization, "+/" 'HA<*C"+/"C39?C", Anne. <2.

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KANGAROO MOTHER CAREKANGAROO MOTHER CARE

<nneEe$

I 3ecord$ and indicator$ ?linical records for hos!ital and follo&5u! care of small babies var7 from !lace to !lace and according to the level of care offered to A>W and !reterm infants. 9ssential information on ;M?, &hen this is !art of the care !rogramme, must also be recorded. 6he follo&ing additional information should be recorded dail7( :or the bab7 hos!ital record( &hen ;M? began 'date, &eight and age2 condition of the bab7 details on duration and fre4uenc7 of skin5to5skin contact &hether the mother is hos!italized or is coming from home !redominant feeding method observations about lactation and feeding dail7 &eight gain e!isodes of illness, other conditions or com!lications the drugs bab7 is receiving details on discharge( condition of the bab7, maternal readiness, conditions at home that make discharge !ossible- date, age, &eight and !ost5menstrual age at dischargefeeding method and instructions for follo&5u! '&here, &hen and ho& fre4uentl72. Mother should be given a discharge letter summarizing the course of hos!italization and instructions for home care, medication and follo&5u!. @t is also necessar7 to record &hether the bab7 &as transferred to another institution or died. 6he follo&5u! record should contain, besides the usual data on the bab7, the follo&ing information( &hen the bab7 &as first seen 'date, age, &eight and !ost5menstrual age2 feeding method dail7 duration of skin5to5skin contact5 a n 7 concerns mother ma7 have &hether bab7 has to be or has been readmitted to hos!ital &hen mother sto!!ed skin5to5skin contact 'date, age of the bab7, &eight, !ost5menstrual age, reasons for sto!!ing and feeding method at &eaning2 other im!ortant remarks. @f the follo&5u! care is !rovided at the facilit7 &here the bab7 &as hos!italized, the hos!ital record and the follo&5u! record should be a single document. @f this cannot be done, the t&o records must be linked b7 an identification number. 6he records can obviousl7 be used to develo! an electronic database. 6he follo&5u! record !resented in this anne. is derived from those used b7 ;M? !rogrammes in some countries.

,+

6hese data &ill !rovide basic information for dail7 bab7 care and !rocess and outcome indicators for !rogramme monitoring. When ;M? forms !art of a care !rogramme for small babies it is im!ortant to kno& the follo&ing( the number of small babies 'N2 g andCor N<* &eeks2 treated and the !ro!ortion receiving ;M? mean age at start of ;M? 'stratified b7 &eight and gestational age at birth, and &eight and !ost5menstrual age &hen starting2 t7!e of ;M? '!redominant or !artial2 mean duration of ;M? 'in da7s2 mean &eight gain during ;M? in institution and at home mean age of &eaning from ;M? 'stratified b7 &eight and gestational age at birth, and &eight and !ost5menstrual age &hen starting2 feeding method for babies at &eaning from ;M? 'e.clusivel7C!artl7 breastfed, or not breastfed2 !ro!ortion of babies needing hos!italization during home ;M? death rate during ;M?, at institution and at home.

II -irth +eight and ge$tational age At different gestational ages birth &eight can var7 b7 about one kilogram- at a given &eight babies can be of different gestational ages.

Table !. Mean birth *eights &g' *ith 10th and ,0th (ercentiles b) gestational age <e#tat!onal a&e Mean %!rth 2e!&ht 1- percent!le 9- percent!le 2+ 12-9-1.-29 1(.1--1,.(1.-11-1*.(1 1,.12-2--(2 1+-1(-2(.(( 2--1.-2.-(4 22.1*.2*.(. 2.-2--(--(, 2*.22.(2.(* (--24.(.-(+ (2-2,.(*-(9 ((.2+-(9-4(.-(--41-th th

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III Con$traint$ ;M? has been included in national guidelines for the care of A>W and !reterm infants, and successfull7 im!lemented in man7 countries. 9.!erience sho&s that the main !roblems, obstacles and constraints fall under four categories( !olic7, im!lementation, communication and feeding. %ome !ossible solutions are suggested in 6able 0.

Table -. .#(le#enting KMC Problems, obstacles and constraints Possible solutions /olic) = 0e$elopment of plan#? pol!c!e#? &u!del!ne#? = >ack of plan#? pol!c!e#? &u!del!ne#? protocol#? manual# protocol#? manual# = /#ta%l!#h!n& l!nk# 2!th m!n!#tr!e#? med!cal = >ack of !n#t!tut!onal? academ!c and #chool#? a&enc!e# and or&an!Aat!on#B ad$ocacy 2ork profe##!onal #upport = /#ta%l!#h!n& %a#!c? po#t6&raduate and !n6 = >ack of ade@uate tra!n!n& and #er$!ce cour#e# cont!nuou# educat!on = Cnte&rat!on 2!th e"!#t!n& pro&ramme# = R!#k of an !#olated and $ert!cal = Creat!on of local and re&!onal l!%rar!e#B l!nk# pro&ramme 2!th ma!n documentat!on centre# = oor acce## to e$!dence? l!terature and = ropo#!n& chan&e# to e"!#t!n& la2#? rule# and documentat!on re&ulat!on#B !n$ol$!n& mother# and fam!l!e# = >e&al pro%lem# 4e.&. KMC not !ncluded !n the !nter$ent!on# f!nanced %y the health care #y#tem5 .#(le#entation = Re#!#tance of mana&er#? adm!n!#trator# = Ade@uate !nformat!on on effect!$ene##? #afety? and health 2orker# fea#!%!l!ty and co#t = oor fac!l!t!e#? e@u!pment? #uppl!e#? = Cmpro$!n& #tructure and or&an!Aat!on? or&an!Aat!on? lack of t!me procurement of %a#!c e@u!pmentB en#ur!n& = Cultural pro%lem#' m!#&u!ded %el!ef#? #uppl!e# att!tude#? pract!ce# = Appropr!ate tra!n!n& and !nformat!on #trate&!e#? commun!ty part!c!pat!on = Apparent !n!t!al !ncrea#e of 2orkload = Cntroduc!n& chan&e# #tep6%y6#tep = Red!#tr!%ut!on of ta#k#? mult!d!#c!pl!nary = 1r!t!n& ne2 Do% de#cr!pt!on#? encoura&!n& team approach 2ork and fre@uent Do!nt re$!e2 of pro%lem# = 7o#p!tal and commun!ty #upport &roup# = Re#!#tance of mother# and fam!l!e# = <ather!n&? analy#!n& and d!#cu##!n& #tandard = >ack of mon!tor!n& and e$aluat!on data Co##$nication = Ade@uate !nformat!on !n the antenatal per!od = Mother# and fam!l!e# una2are of KMC and at the referral fac!l!ty = oor commun!cat!on and #upport !n = Cmpro$!n& commun!cat!on and #upport #k!ll# of ho#p!tal and dur!n& follo26up health 2orker# = Cnade@uate commun!ty and fam!ly = Commun!ty meet!n&#? ma## med!a? hot l!ne# #upport = 7o#t!l!ty of pol!t!c!an# and other health = Art!cle#? ne2#letter#? !ntere#t &roup#? profe##!onal# te#t!mon!e# 0eeding = >o2 rate of e"clu#!$e %rea#tfeed!n& after = Reduc!n& #eparat!on a# much a# po##!%leB lon& #eparat!on of !nfant# from mother# !mplementat!on of feed!n& &u!del!ne# = 0!ff!cult &ro2th mon!tor!n&? lack of = Accurate #cale#? appropr!ate &ro2th chart#? ade@uate #tandard# clear !n#truct!on# = Cnade@uate &ro2th de#p!te &ood = <ood #k!ll# for a##e##!n& %rea#tfeed!n& and

$2

!mplementat!on of %rea#tfeed!n& &u!del!ne# = 7!&h pre$alence of 7CE6po#!t!$e mother#

alternat!$e feed!n& method# = Eoluntary coun#ell!n& and te#t!n& of parent#B !nfant feed!n& coun#ell!n&? appropr!ate replacement feed!n& for preterm !nfant#B #afe alternat!$e# to %rea#t m!lkB pa#teur!#er#

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