Kangaroo care worldwide: The human incubator.


Imagine a baby kangaroo, warm and snug as a bug in a rug in its pouch. This is the model for so-called “kangaroo mother care” (KMC). The key component of KMC is placing the infant in direct skin-to-skin contact with the mother on the mother’s chest (where the body is warmest), in an upright position underneath her clothes. How long the infant stays in that position is variable; the aim is for more than 18 hours a day, but this may differ depending on the stability of the infant and what other care he or she requires. In addition, KMC includes support for exclusive and early breast milk provision, a timely discharge from hospital and the appropriate follow-up care, but these components show significant global differences (1).
It started in Colombia

The first country to develop and scientifically investigate KMC for low-birth weight (LBW) infants was Colombia, approximately 30 years ago. Emerging evidence from the first studies on this subject pointed to benefits in regards to morbidity and mortality, so the South American country soon filed KMC under “good alternative to incubator care” and implemented the method in national guidelines.

Since then, the benefits have been corroborated by studies worldwide.

  • Three Cochrane meta-analyses have investigated KMC in LBW infants (in 2000, 2014 and 2016)
  • The 2014 study included 18 trials of continuous KMC initiated before postnatal day ten in infants with a birth weight < 2,500 g. It showed a significantly reduced mortality at discharge / 40-41 weeks (RR 0.60) and a decreased incidence of healthcare-related sepsis (0.45) and hypothermia (0.34), compared to conventional neonatal care, as well as some benefits regarding infant growth, breastfeeding and mother-infant attachment (2).
  • The 2016 analysis included 21 studies and investigated KMC in LBW infants after and before stabilization and in relatively stable LBW infants. In addition to the benefits of the 2014 paper, KMC was associated with an increase in weight, length and head circumference gain (mean difference 4.1 g/d, 0.21 cm/week and 0.14cm/week, respectively) (3).
  • These meta-analyses also demonstrated that KMC promotes colonization with maternal flora and is associated with lower rates of sepsis, necrotizing enterocolitis and pneumonia.
  • Several studies have shown improved motor development due to KMC, with infants scoring higher on Bayle motor scales at six, twelve, and 24 months than infants without KMC (4).
  • A 16-year follow-up of preterm infants who had been under 24/7 KMC from the time they came off oxygen support until an age of 28 days showed that these children had a similar brain motor connectivity as term-born infants and a better motor development than preterm infants without KMC (5).
  • A US-American study demonstrated that preterm babies had significantly fewer oxygen desaturation events and fewer bradycardia events per hour during KMC time versus time spent in an incubator (6).

According to a report on “Prematurity Treatment and Management”, achieving universal KMC coverage could potentially save an estimated 450,000 preterm newborns annually (7). In the light of these numbers, it would seem safe to assume that KMC would be catching on worldwide – but far from it: The current global coverage of KMC is less than one percent. This means a lot of work for a multi-stakeholder group of newborn health advocates who have proposed a worldwide goal of 50 percent coverage of KMC by the year 2020 (8).

So what is the current situation with KMC in various parts of the globe?

KMC in Africa

According to a 2014 World Health Organization (WHO) report, “Fulfilling the Health Agenda for Women and Children”, 44 percent of developing countries worldwide now have national policies in place that recommend KMC in facilities for LBW or preterm newborns, including Benin, Burkina Faso, Ethiopia, Mali and Malawi (9). However, in many cases the implementation is still limited, due to incomplete dissemination of KMC guidelines, inadequate financial resources, shortage of trained healthcare workers and poor availability of basic supplies, says a US-American report (10).

KMC in Asia

A recent report investigated KMC uptake and service coverage in India, Indonesia and the Philippines. The report suggests that progress is slow in these countries. Even though pioneers of KMC introduced it as early as the 1990s and even managed to establish it in a few individual hospitals, the idea failed to spread further in most areas. According to the report, there was an only “patchy uptake and expansion of KMC services” between the late 1990s and 2012 (11).

KMC in Europe

A Spanish study compared the policies and practices regarding parental involvement and the kangaroo care position in eight European countries (Belgium, Denmark, France, Italy, the Netherlands, Spain, Sweden and the UK). It found that holding babies in the kangaroo position is widespread in these countries; most have reclining chairs or a dedicated room for KMC (with Italy and Spain having the least). However, in the UK, France, Italy and Spain, many units have restrictions in place regarding frequency (KMC not routinely offered, only sometimes, only at the parents’ request) as well as clinical conditions that prevent the use of KMC, such as mechanical ventilation and the presence of umbilical lines. Also, in these countries, fathers are routinely offered KMC less frequently than mothers (12).

Generally, implementation in western countries has been slow, due to ready access to incubators and technology.

Mark the date: May 15

Since 2011, “Kangaroo Care Awareness Day” has been observed worldwide on May 15. This day aims to increase awareness and to enhance practice of kangaroo care in neonatal intensive care units, post-partum units, labor and delivery wards, and any hospital unit that has babies up to three months of age.
Sources:

  1. Chan GJ et al, Glob Health 2016;6:010701
  2. Conde-Agudelo A et al, Cochrane Database Syst Rev. 2014;4(4):CD002771
  3. Conde-Agudelo A et al, Cochrane Database Syst Rev. 2016;23(8):CD002771
  4. Barradas J et al J Pediatr (Rio J). 2006;82:475–480.
  5. Schneider C et al, Acta Paediatr. 2012;101:1045–1053.
  6. Mitchell AJ et al, J Neonatal Perinatal Med 2013;6:243-249
  7. Furdon SA, Prematurity Treatment and Management,
  8. http://emedicine.medscape.com/article/975909-treatment
  9. Engmann C et al, Lancet 2013;382:e26-7.
  10. http://www.countdown2015mnch.org/documents/2014Report/Countdown_to_2015-Fulfilling%20the%20Health_Agenda_for_Women_and_Children-The_2014_Report-Conference_Draft.pdf
  11. Vesel L et al, BMC Pregnancy Childbirth. 2015; 15(Suppl 2): S5.
  12. Bergh AM et al, BMC Int Health Hum Rights 2016;16:4
  13. Pallás-Alonso CR et al, Pediatr Crit Care Med 2012;13:568-577
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