Kangaroo care

Kangaroo care also called skin-to-skin contact, is a technique of newborn care where babies are kept chest-to-chest and skin-to-skin with a parent, typically their mother (occasionally their father).

A mother providing kangaroo care immediately following birth

Kangaroo care, named for the similarity to how certain marsupials carry their young, was initially developed in the 1970s to care for preterm infants in countries where incubators were either unavailable or unreliable. More recently, the term skin-to-skin care is also used to describe the technique of placing full-term newborns immediately after birth on the bare chest of their mother or father. There is evidence that it is effective in reducing infant mortality, the risk of hospital-acquired infection, increasing weight gain, increasing rates of breastfeeding, and other advantages for both mother and baby.

Medical uses

Originally babies who are eligible for kangaroo care included pre-term infants weighing less than 1,500 grams (3.3 lb), and breathing independently. Cardiopulmonary monitoring, oximetry, supplemental oxygen or nasal (continuous positive airway pressure) ventilation, intravenous infusions, and monitor leads do not prevent kangaroo care. In fact, babies who are in kangaroo care tend to be less prone to apnea and bradycardia and have stabilization of oxygen needs.[1][2]

During the early 1990s, the concept was advocated in North America for premature babies in NICU and later for full term babies. Research has been done in developed countries but there is a lag in implementation of kangaroo care due to ready access of incubators and technology.

Restrictions for eligibility to receive skin-to-skin contact are becoming fewer, the main constraint has probably been caregiver confidence and experience.

Evidence

In 2016 a Cochrane review, "Kangaroo mother care to reduce morbidity and mortality in low birthweight infants", was published bringing together data from 21 studies including 3042 low birth-weight babies (less than 1,500 grams (53 oz) at birth).[3] This review showed that babies receiving kangaroo care had a reduced risk of death, hospital-acquired infection, and low body temperature (hypothermia); was also associated with increased weight gain, growth in length, and rates of breastfeeding.[3]

A randomized controlled trial published in 2004 reported that babies born between 1200 and 2200g became physiologically stable in skin-to-skin contact starting from birth, compared to similar babies in incubators.[4] In another randomized controlled trial conducted in Ethiopia, survival improved when skin-to-skin contact was started before 6 hours of age.[5]

A further Cochrane review on "Early skin-to-skin contact for mothers and their healthy babies", updated in 2015, provides clinical support for the scientific rationale but looked at evidence for early skin-to-skin contact for healthy babies.[6] The available evidence showed that early skin-to-skin contact was associated with increased rates of breastfeeding, and some evidence of improved physiological outcomes (early stability of the heart rate and breathing) for the babies.[6]

While Kangaroo Mother Care generally implies care of low birth weight and preterm infants, skin-to-skin contact should be regarded as normal and basic for all newly born humans.[6] The original research by Thomson showed increased breastfeeding rates when skin-to-skin contact started at birth, and when early breastfeeding was encouraged every two hours.[7] Currently, the impact of skin-to-skin contact on breastfeeding is the scientific rationale for Step 4 of the Baby Friendly Hospital Initiative (BFHI), which requires help to "initiate breastfeeding within one hour of birth".

Benefits
A Mother providing Kangaroo care to a preterm baby

Pre-term and low-birth-weight infants

Kangaroo care "is an effective and safe alternative to conventional neonatal care for LBW infants, mainly in resource-limited countries."[3] Kangaroo Mother Care reduces mortality, and also morbidity in resource limited settings, though further studies are needed.

Kangaroo care arguably offers the most benefits for pre-term and low-birth-weight infants, who experience more normalized temperature, heart rate, and respiratory rate,[6][8] increased weight gain,[3][9] and fewer hospital-acquired infections.[3] Additionally, studies suggest that preterm infants who experience kangaroo care have improved cognitive development, decreased stress levels, reduced pain responses, normalized growth, and positive effects on motor development.[10][9][11][12][13][14] Kangaroo care also helps to improve sleep patterns of infants, and may be a good intervention for colic.[15] Earlier discharge from hospital is also a possible outcome[1] Finally, kangaroo care helps to promote frequent breastfeeding, and can enhance mother-infant bonding.[16] Evidence from a recent systematic review supports the use of kangaroo mother care as a substitute for conventional neonatal care in settings where resources are limited."[3]

For parents

Kangaroo care is beneficial for parents because it promotes attachment and bonding, improves parental confidence, and helps to promote increased milk production and breastfeeding success.[10][3][17][18]

A 2017 study found that the psychological benefits of kangaroo care for parents of preterm infants are fairly extensive. Research shows that the use of kangaroo care is linked to lower parental anxiety levels. It was shown to decrease anxiety scores in both mothers and fathers, unrelated to parents’ marital status. Kangaroo care has also been shown to lead to greater confidence in parenting skills. Parents who used kangaroo care displayed higher confidence in their ability to care for their child. It has been shown to positively impact breastfeeding as well, with mothers producing larger amounts of milk for longer periods of time.[19]

For fathers

Both preterm and full term infants benefit from skin to skin contact (SSC) for the first few weeks of life with the baby's father as well. The new baby is familiar with the father's voice and it is believed that contact with the father helps the infant to stabilize and promotes father to infant bonding. If the infant's mother had a caesarean birth, the father can hold their baby in skin-to-skin contact while the mother recovers from the anesthetic.[20]

A 2016 study looked at international literature reviews of early (SSC) benefits for infants and fathers. Their findings for infants included:

  • Swedish and Germany reviews found that father SSC is as effective as mother SSC in raising a baby’s temperature and there is no difference between father and mother skin-to-skin on biophysical measures of the baby’s expenditure of energy.
  • A Swedish review found that babies experiencing father SSC had significantly higher blood glucose levels than babies who were placed in an incubator. A higher glucose level protects a baby from cold temperatures.
  • A Swedish review found that babies who experienced father SSC showed lower levels of salivary cortisol when handled, which indicates a lower stress response.
  • A Swedish review found tha babies receiving father SSC were more easily comforted and stopped crying more quickly than babies that had been separated from a parent.
  • A Swedish review found that pre-feeding behaviours, such as rooting and sucking, were less frequent among the infants who received father SSC. Infants receiving father SSC started breastfeeding a little later than those receiving SSC only from their mothers.[21]

Looking at the review, researchers found that SSC was of benefit to fathers as well. Their findings included:

  • An India study found that fathers who provided SSC to preterm infants exhibited more caring behaviours and developed a more sensitive approach to their infants.
  • A Colombia review found that after a pre-term birth, father SSC was linked to better cognitive development of the infant and more engagement by the father when the couple returned to their home.
  • Reviews done in the USA and Sweden showed that fathers who provided SSC felt less stress, were less anxious, and had a better relationship with the mother.
  • Reviews done in Denmark and Sweden found that father SSC, like mother SSC, promotes verbal interaction between infant and parent within minutes of the birth. The review also found that fathers who have experienced SSC participated more in infant care and felt more in control when handling unexpected situations.[22]

Following Caesarean section birth

Although WHO and UNICEF recommend that infants born by Caesarean section should also have skin-to-skin contact (SSC) as soon as the mother is alert and responsive, a 2014 review of medical literature found that many hospitals were not providing SSC following a C-section. Immediate SSC following a spinal or epidural anesthetic is possible because the mother remains alert; however, after a general anesthetic the father or other family member may provide SSC until the mother is able. [23]

It is known that during the hours of labor before a vaginal birth a woman's body begins to produce oxytocin which aids in the bonding process, and the authors believe that SSC can be of special importance following a C-section birth. Indeed, women reported that they felt that SSC had helped them to feel close to and bond with their infant. The review reported comments made by mothers such as "My baby calms down right away when I put him to my chest. I don't know if it's related to holding him skin‐to‐skin during the cesarean – but I think it is." Newborns were also found to cry less and relax quicker when they had SSC with their father as well. There is evidence that women who give birth by C-section are less likely to breastfeed and those that do have increased difficulties in establishing breastfeeding. However the review found that immediate or early SSC increased the likelihood of successful breastfeeding.[24]

Promotes breastfeeding
Infant nursing shortly after birth

According to some authorities there is a growing body of evidence that suggests that early skin-to-skin contact of mother and baby stimulates breast feeding behavior in the baby. Newborn infants who are immediately placed on their mother's skin have a natural instinct to latch on to the breast and start nursing, typically within one hour of being born. It is thought that immediate skin-to-skin contact provides a form of imprinting that makes subsequent feeding significantly easier. The World Health Organization reports that in addition to more successful breastfeeding, skin-to-skin contact between a mother and her newborn baby immediately after delivery also reduces crying, improves mother to infant interaction, and keeps baby warm. According to studies quoted by UNICEF, babies have been observed to naturally follow a unique process which leads to a first breastfeed. After birth, babies who are placed skin to skin on their mothers chest will:

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

Providing that there are no interruptions, all babies are said to follow this process and it is suggested that trying to rush the process or interruptions such as removing the baby to weigh or measure is counter-productive and may lead to problems at subsequent breastfeeds.[25]

For mothers with low milk supply, increasing skin-to-skin contact is recommended, as it promotes more frequent feeding and stimulates the milk ejection reflex, prompting the body to produce more milk.[26]

Pain control

Skin-to-skin contact is effective in reducing pain in infants during painful procedures. There appears to be no difference between mothers and others who provide skin-to-skin contact during medical treatments.[27][28]

For institutions

Kangaroo care often results in reduced hospital stays, reduced need for expensive healthcare technology, increased parental involvement and teaching opportunities, and better use of healthcare dollars.

Technique
A woman holds her premature twin grandsons skin-to-skin. This position helps babies maintain the proper body temperature.

Kangaroo care seeks to provide restored closeness of the newborn with family members by placing the infant in direct skin-to-skin contact with one of them. This ensures physiological and psychological warmth and bonding. The parent's stable body temperature helps to regulate the neonate's temperature more smoothly than an incubator, and allows for readily accessible breastfeeding when the mother holds the baby this way.[10]

While this model of infant care is substantially different from the typical Western neonatal intensive-care unit procedures, the two are not mutually exclusive, and it is estimated that more than 200 neonatal intensive care units practice kangaroo care. One survey found that 82 percent of neonatal intensive care units use kangaroo care in the United States.

In kangaroo care, the baby wears only a small diaper and a hat and is placed in a flexed (fetal position) with maximum skin-to-skin contact on parent's chest. The baby is secured with a wrap that goes around the naked torso of the adult, providing the baby with proper support and positioning (maintain flexion), constant containment without pressure points or creases, and protecting from air drafts (thermoregulation). If it is cold, the parent may wear a shirt or hospital gown with an opening to the front and a blanket over the wrap for the baby.[29]

The tight bundling is enough to stimulate the baby: vestibular stimulation from the parent's breathing and chest movement, auditory stimulation from the parent's voice and natural sounds of breathing and the heartbeat, touch by the skin of the parent, the wrap, and the natural tendency to hold the baby. All this stimulation is important for the baby's development.

"Birth Kangaroo Care" places the baby in kangaroo care with the mother within one minute after birth and up to the first feeding. The American Academy of Pediatrics recommends this practice, with minimal disruption for babies that don't require life support. The baby's head must be dried immediately after birth and then the baby is placed with a hat on the mother's chest. Measurements, etc. are performed after the first feeding. According to the US Institute of Kangaroo Care, healthy babies should maintain skin-to-skin contact method for about 3 months so that both baby and mother are established in breastfeeding and have achieved physiological recovery from the birth process.

For premature babies, this method can be used continuously around the clock or for sessions of no less than one hour in duration (the length of one full sleep cycle.) It can be started as soon as the baby is stabilized, so it may be at birth or within hours, days, or weeks after birth.

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

Rationale

In primates, early skin-to-skin contact is part of a universal reproductive behaviour,[30] and early separation is used as a research modality to test the harmful effects on early development. Research suggests that for all mammals, the maternal environment (or place of care) is the primary requirement for regulation of all physiological needs (homeostasis),[31] maternal absence leads to dysregulation and adaptation to adversity.[32][33]

In mainstream clinical medicine, Kangaroo Mother Care is used as an adjunct to advanced technology that requires maternal infant separation.[34] However, skin-to-skin contact may have a better scientific rationale than the incubator. All other supportive technology can be provided as part of care to extremely low birth weight babies during skin-to-skin contact,[35] and appears to produce a better effect.[36]

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

  • Initiation time, (minutes, hours from birth), ideal is zero separation.
  • Dose of skin-to-skin contact, (hours per day, or as percentage of day), ideal >90%.
  • Duration, (measured in days or weeks from birth), ideally until infant refuses.

Safe technique should ensure that obstructive apnoea cannot occur. Since the mother must be able to sleep to provide adequate dose, this requires keeping the airway safely open, and close containment to mother's bare chest using a garment, various of these are described in the WHO guidelines.[37]

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

Terminology

Kangaroo Care is likely the most widely used term in the United States for skin-to-skin contact. Gene Cranston Anderson may have been the first to coin the term Kangaroo Care in the USA.[38] The defining feature of this is however for skin-to-skin contact, commonly abbreviated as SSC, also STS. This is used synonymously with "skin-to-skin care".[39][40] Dr Nils Bergman, one of the founders of the Kangaroo Mother Care Movement, argues that since skin-to-skin contact is a place of care, not a kind of care in itself, skin-to-skin contact should be the preferred term.[41]

Kangaroo Mother Care is a broader package of care defined by the World Health Organization. Kangaroo Mother Care originally referred only to care of low birth weight and preterm infants, and is defined as a care strategy including three main components: kangaroo position, kangaroo nutrition and kangaroo discharge. Kangaroo position means direct skin-to-skin contact between mother and baby, but can include father, other family member or surrogate. The infant should be upright on the chest, and the airway secured with safe technique. (The term Kangaroo Mother Care is commonly used to mean skin-to-skin contact, despite its definition from the WHO as including a broader strategy).[37] Kangaroo nutrition implies exclusive breastfeeding, with additional support as required but with the aim of achieving ultimately exclusive breastfeeding. Kangaroo discharge requires that the infant is sent home early, meaning as soon as the mother is breastfeeding and able to provide all basic care herself. In Colombia in 1985 this took place at weights around 1000g, with oxygen cylinders for home use; the reason was that overcrowding in their hospital meant that three babies in an incubator would result in potentially lethal cross-infections. An essential part of this is close follow-up, and access to daily visits.[42]

History

Peter de Chateau in Sweden first described studies of "early contact" with mother and baby at birth in 1976, articles do not describe specifically that this was skin-to-skin contact.[43] Klaus and Kennell did very similar work in the US, more well known in the context of early maternal-infant bonding. The first reported use of the term "skin-to-skin contact" is by Thomson in 1979[7] and quotes the work of de Chateau in its rationale. This is contemporary or even precedes the origins of Kangaroo Mother Care[44] in Bogota, Colombia.[40] This latter did however make the concept more widely known.

In 1978, due to increasing morbidity and mortality rates in the Instituto Materno Infantil NICU in Bogotá, Colombia, Dr. Edgar Rey Sanabria, Professor of Neonatology at Department of Paediatry - Universidad Nacional de Colombia, introduced a method to alleviate the shortage of caregivers and lack of resources. He suggested that mothers have continuous skin-to-skin contact with their low birth weight babies to keep them warm and to give exclusive breastfeeding as needed. This freed up overcrowded incubator space and care givers.

Another feature of kangaroo care was early discharge in the kangaroo position despite prematurity. It has proven successful in improving survival rates of premature and low birth weight newborns and in lowering the risks of nosocomial infection, severe illness, and lower respiratory tract disease. It also increased exclusive breastfeeding and for a longer duration and improved maternal satisfaction and confidence.[9]

Dr Rey and Dr Martinez published their results in 1981 in Spanish,[40] and used the term Kangaroo Mother Method. This was brought to the attention of English speaking health professionals in an article by Whitelaw and Sleath in 1985.[42] Gene Cranston Anderson and Susan Ludington were instrumental in introducing this to North America.

"Kangaroo Mother Care" as a term was first defined at a meeting of some 30 interested researchers, attending a meeting convened by Dr Adriano Cattaneo and colleagues in November 1996 in Trieste, Italy, together with the WHO represented by Dr Jelka Zupan.[45][46]

An International Network of Kangaroo Mother Care (INK) was convened at the Trieste meeting and has overseen workshops and conferences every two years. After Trieste, meetings were held in Bogota Colombia 1998, Yogyakarta Indonesia 2000, Cape Town South Africa 2002, Rio de Janeiro Brazil 2004, Cleveland USA 2006, Uppsala Sweden 2008, Quebec Canada 2010, Ahmedabad India 2012, and Kigali Rwanda 2014; the meeting in 2016 planned for Trieste Italy.

An informal steering committee coordinates these meetings: (alphabetically, current) Nils Bergman, Adriano Cattaneo, Nathalie Charpak, Kerstin Hedberg-Nyqvist, Ochi Ibe, Susan Ludington, Socorro Mendoza, Mantoa Mokrachane, Juan Gabriel Ruiz, Réjean Tessier, Rekha Udani.

Susan Ludington maintains a "KC BIB" (bibliography) on behalf of INK, endeavouring to be a complete inventory of any and all publications relevant to Kangaroo Mother Care. This is also broken down in an analysis of 120 charts, in which specific outcomes are collated.[47]

The International Kangaroo Care Awareness Day has been celebrated worldwide on May 15 since 2011. It is a day to increase awareness to enhance the practice of Kangaroo Care in NICUS, Post Partum, Labor and Delivery, and any hospital unit that has babies up to 3 months of age.

Society and culture

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

Controversy

The main controversy among proponents of Kangaroo Mother Care relates to eligibility to initiate kangaroo position: in the original Rey & Martinez model and as described in the WHO guidelines,[37] the infant should be stable to "tolerate skin-to-skin contact".[48][49] From a biological and neuroscience perspective, others argue that it is separation from mother that causes the instability.[50][51][52]

Regarding ‘kangaroo nutrition’ there is little controversy, with accumulating evidence for the benefits of breastfeeding as such,[53][54] and evidence that even preterm infants can exclusively breastfeed.[55][56]

Further controversy concerns the ‘early discharge’, which is defended by the Fundación Canguro, in Bogota, Colombia, and reported in evidence from a Cochrane review.[3]

See also

References
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