Kangaroo Mother Care: An Argument for the Adoption of a Comprehensive KMC Program in U.S.

Hospitals

By Nathaniel B. Broyles

PSY 281 - Developmental Psychology I Prof. Elizabeth Geiling August 3, 2011

Kangaroo Mother Care (KMC) is a technique wherein newborns are carried directly against the skin of the mother. The practice was started in 1978 in Bogota (Colombia) in response to overcrowding and insufficient resources in neonatal intensive care units associated with high morbidity and mortality among low-birthweight infants. (Charpak, 514) It is practiced in low, middle, and high-income countries but is most prevalent in developing countries that do not have access to the same level of health care and medicine found in countries like the United States. It is primarily practiced because there is very little cost associated with its practice, which makes it affordable in a country where there may only be one trained medical doctor serving the needs of the equivalent of a mid-sized city in a more developed nation. Surprisingly, however, those infants who are getting by on KMC may be better off in some ways than those who are cared for in what we envision in America as normal.

Dr. Edgar Rey Sanabria founded the KMC practice in 1978 in order to address the critical lack of incubators, cross-infections, and infant abandonment at his hospital. The overcrowding and insufficient resources in Dr. Sanabrias neonatal intensive care unit led to a high morbidity and mortality rate among low-birthweight infants. The intervention that he developed involved continuous skin-to-skin care between infant and mother, exclusive breastfeeding, and early home discharge in the kangaroo position. (Charpak, 514)The theory behind KMC has its basis in neuroscience and operates on the premise that mother and infant are a dyad that should not be separated. Kangaroo refers to the means by which some marsupials care for their young, wherein the infant is kept warm in a maternal pouch and close to the breasts for unlimited feeding. (Ali, 156) Brain development in infants requires maternal sensory stimulation based on skin-to-skin contact and the incubator strips that stimulation away, leading to poorer brain development.

(Etika, 220) In many cases, incubator treatment is unnecessary for the health and survival of the infant but is still used as a matter of course.

Low-birthweight (LBW) infants are a major problem all over the world and not solely in less-developed countries. In developing countries, however, approximately 30% of all neonatal mortality is directly related to LBW. It has become common practice in hospitals around the world to treat LBW infants in incubators or with radiant warmers. In developing countries, these practices are often extremely difficult to implement due to the high costs of the equipment, difficulty in maintenance and repair of that equipment, unreliable power supply, and a lack of trained staff. (Ali, 156) It was an innovative and creative solution to a critical problem. The solution also had unexpected benefits that had researchers flocking to Bogota to learn this new technique.

Later testing to determine whether or not KMC was truly a viable alternative to what we think of as conventional care for LBW infants proved that, in many ways, KMC is a better alternative, provided that there are no other barriers than LBW for the infant to overcome. For instance, babies born prematurely would need more help than KMC can provide in order to develop physically enough that KMC becomes an option for care. When comparing conventional treatment of LBW infants with those receiving KMC, as was done from March 2006 to September 2007 in a randomized controlled trial (Ali, 159), the KMC infants demonstrated significantly higher weight gain during the course of their hospital stay. It is theorized that this is due to reduced energy requirements that the infant was able to direct towards growth. There was also a large reduction in respiratory rate and an increase in oxygen saturation in the infants

receiving KMC. Since both processes are gravity dependent, the upright position utilized in KMC practice seems likely to be a factor in explaining those results. Since placing an infant in skin-to-skin contact with their mother underneath a blouse or shirt inevitably creates an insulating effect, the KMC infants showed very few instances of hypothermia and a higher rectal temperature than those receiving conventional care. Incidences of infection were also significantly higher in the infants receiving more conventional care. (Ali, 160)

If the physical differences between LBW newborns receiving conventional care versus those being given KMC were not astounding enough, studies show that KMC has an effect on the neurobehavioral responses of infants. In fact, there is a significant difference in neurobehavioral development between infants receiving radiant warmer or incubator care and those receiving KMC. (Rebecca, 54) In one study, performed from June 30, 2008 through August 5, 2008, the physiological differences were observed through electronic thermometer and monitors. A Modified Brazelton Behavioral Assessment Scale was used to judge the neurobehavioral state of the infants. It should also be noted that this study was aimed at full-term newborns that were not classified as LBW. When observing the physiological state of both groups of infants, it was seen that both fell into what could be classed as normal parameters. It was in the neurobehavioral results that significant differences were found. The mean behavioral response score of the radiant warmer care infant was 5.6500 and the KMC infant mean was 5.9500. That is a differential that certainly cannot be ignored and explained away as an anomaly.

Although originally intended as an alternative practice in lower income settings, it is clear that KMC can also be utilized to great effect in high-technology environments also. Where KMC

is practiced in those more wealthy areas, the more traditional treatment tends to be supplemented by KMC sessions of one to a few hours for intermittent periods. (Nyqvist, 812) Many of the same effects noted in those LBW infants whose mothers utilize KMC are found even in those babies fortunate enough to be born in a more high-tech environment and receive intermittent KMC. In addition to those positive effects previously mentioned, infants experience: a decrease in the pain response for painful procedures, lower infant cortisol, and physiological parameters tend to be more stable during transport when KMC is used by parents (even hospital staff if the childs parents give permission). (Nyqvist, 813)

Other common benefits of KMC are psychosocial in nature. For instance, when engaging in KMC there is a more rapid healing from parental crisis reactions after the birth of a pre-term or LBW baby. In addition, recovery post-partum depression in new mothers is increased over those mothers who engage only in more conventional care of their infants and feel less stress associated with their newborn. Even the intermittent KMC usually practiced in more affluent hospitals results in a higher breastfeeding rate, longer durations of breastfeeding, and a higher proportion of exclusive breastfeeding while in the hospital and through follow-up care. (Nyqvist, 813)

KMC is not relegated to the sole domain of mothers as it can be equally important, even beneficial, for the father to also engage in the skin-to-skin contact of KMC. The interaction of the father is especially beneficial once mother and infant have been discharged from the hospital and are in their home environment. Unlike the marsupials whose name we use to characterize this particular method of infant care, humans do not have a belly pouch to carry an infant around

in and so mothers will, inevitably, need help in order to provide continuous KMC. Although the father cannot breastfeed the infant, the skin-to-skin contact provides much the same benefit that would be received from the mother. In fact, studies show that the fathers involvement in more direct KMC carries with it a greater sensitivity by the father, a better perception of the child by the father, and an all-around better home environment. It is hypothesized that this sense of coresponsibility and greater involvement happens the first time that the carrying position is used. (Tessier, 1448) Fathers who engaged in more traditional care may also develop those same feelings but it is more likely that KMC fathers will form those deeper connections more quickly.

Whereas the more traditional high-tech care found in Western societies, and which have become the norm around the world, can often cost tens of thousands of dollars in equipment and training, the implementation of KMC has no such costs associated with it. In fact, the only costs associated with KMC is for the training of the hospital personnel who would be responsible for educating new mothers and fathers on how to properly implement their personal KMC program and, perhaps, some literature to be printed and distributed to those same parents. There would be tremendous cost savings for the parents, too. Buying formula can be extremely expensive but breastfeeding is, essentially, free. Caring for a newborn can be a financial burden with all of the associated costs but paying for something that nature provides should not be one of them.

In 2010, a proposal was made to revise the World Health Organizations practical guide to include updated information and extensive revision. That proposal includes an exhaustive argument for the WHO to strongly endorse more comprehensive KMC practice worldwide. (Nyqvist, 825) All of the available evidence supports KMC as not just an alternative treatment

for LBW infants in low-income areas of the world but as an important component infant development. While low-income hospitals may, out of necessity, have KMC as the totality of infant care, KMC has proven to be equally as effective in a high-tech environment. While it must be acknowledged that KMC cannot completely replace all of the neonatal care that infants deserve, especially when the treatments are available, KMC should be universally practiced and taught to mothers in every hospital around the world. The benefits of KMC are tangible and cannot be denied as advantageous both to the dyad of mother and infant but to the entire family unit as well.

Works Cited Ali, S., Sharma, J., Sharma, R., & Alam, S. (2009). Kangaroo Mother Care as compared to conventional care for low birth weight babies. Dicle Medical Journal / Dicle Tip Dergisi, 36(3), 155-160. Retrieved from EBSCOhost. Charpak, N., Ruiz, Juan G., Zupan, J., Cattaneo, A., Figueroa, Z., Tessier, R., Cristo., M., Anderson, G., Ludington, S., Mendoza, S., Mokhachane, M., Worku, B. (2005) Kangaroo Mother Care: 25 years after. Acta Paediatrica, 94(5), 514-522. Retrieved from EBSCOhost. Etika, R., Roeslani, R. D., Alasiry, E., Endyarni, B., & Bergman, N. J. (2009). "HUMANITY FIRST, TECHNOLOGY SECOND" REDUCING INFANT MORTALITY RATE WITH KANGAROO MOTHER CARE: PRACTICAL EVIDENCE FROM SOUTH AFRICA. Folia Medica Indonesiana, 45(3), 219-224. Retrieved from EBSCOhost. Rebecca, J., Nayak, S., & Paul, S. (2011). Comparison of Radiant Warmer Care and Kangaroo Mother Care Shortly after Birth on the Neurobehavioral Responses of the Newborn. Journal of South Asian Federation of Obstetrics & Gynecology, 3(1), 53-55. Retrieved from EBSCOhost. Nyqvist, K. H., Anderson, G. C., Bergman, N. N., Cattaneo, A. A., Charpak, N. N., Davanzo, R. R., & ... Widstrm, A. M. (2010). State of the art and recommendationsKangaroo mother care: application in a high-tech environment. Acta Paediatrica, 99(6), 812-819. doi:10.1111/j.16512227.2010.01794.x Nyqvist, K. H., Anderson, G. C., Bergman, N. N., Cattaneo, A. A., Charpak, N. N., Davanzo, R. R., & ... Widstrm, A. M. (2010). Towards universal Kangaroo Mother Care: recommendations and report from the First European conference and Seventh International Workshop on Kangaroo Mother Care. Acta Paediatrica, 99(6), 820-826. doi:10.1111/j.1651-2227.2010.01787.x Tessier, R. R., Charpak, N. N., Giron, M. M., Cristo, M. M., de Calume, Z. F., & Ruiz-Pelez, J. G. (2009). Kangaroo Mother Care, home environment and father involvement in the first year of life: a randomized controlled study. Acta Paediatrica, 98(9), 1444-1450. doi:10.1111/j.16512227.2009.01370.x