|
Kangaroo mother care (KMC), also known as "kangaroo mother
method" or "skin-to-skin contact", has been proposed
as an alternative to conventional neonatal care for low birthweight
(LBW) infants. This method was developed and first implemented by
Edgar Rey Sanabria and Hector Martinez in 1979, at the Maternal
and Child Institute of Bogotá, Colombia, and it received
this name because it shares similarities to marsupial caregiving.
It was used for the early hospital discharge of LBW infants due
to a critical lack of incubators, cross infections, lack of technological
resources, early weaning, high neonatal mortality rates and infant
abandonment. The new home care program for LBW infants was based
on the following principles: a) early hospital discharge regardless
of weight provided that the infant has stable clinical conditions;
b) no use of formulas, only breastmilk; c) encouragement of early
skin-to-skin contact between mother and baby; the baby is positioned
on the mother's chest, and d) the baby is maintained in an upright
position. This initiative was supported by UNICEF, which widely
advertised the results of the study, especially with regard to the
reduction in mortality rates, to psychological benefits and low
cost ().
Despite the arguments over the benefits of KMC that arose from
the lack of comparison of preliminary results with the results obtained
from a control group, several European countries have adopted this
practice and the research carried out by them has confirmed most
of the initial results ().
In the last few decades, several health services have adopted KMC,
both in industrialized and developing countries, thus showing that
it is possible to adapt this practice to different contexts of access
to neonatal care technology.
The first experiments conducted in industrialized countries demonstrated
that KMC was safe in terms of physiological response of newborns
and that the method brought benefits regarding the breastfeeding
practice and decreased the number of hospitalizations, in addition
to reducing infant crying at six months of life ().
Two experiments carried out in developing countries showed that
KMC was safe in terms of mortality, and could reduce severe morbidity
and avoid hospital readmissions ().
In the mid-90s, a group of researchers and health professionals
from several countries, with expertise in KMC, met in Trieste, Italy,
to discuss the effectiveness, safety, applicability and acceptance
of this type of care given to LBW newborns in different places.
Based on previous studies and on the experiences reported in different
health services, the group concluded that KMC can potentially improve
the health and survival of LBW newborns, especially in those places
where resources are scarce. However, benefits to both mothers and
babies can be obtained in places where technology is available and,
in this case, it contributes to the humanization of neonatal care
and stronger mother-infant bonding ().
This review aims at showing the scientific evidence of the benefits
of KMC regarding breastfeeding, as well as its impact on infant
morbidity and mortality, and on psychoemotional and neurosensory
aspects.
KMC in Brazil
In Brazil, the first services to use KMC were Hospital Guilherme
Álvaro, in Santos, São Paulo (1992) and the Maternal
and Child Institute of Pernambuco - IMIP (1993). In 1997, the model
adopted by IMIP was acknowledged by the Fundação Getúlio
Vargas with the award of "Public Management and Citizenship,"
also receiving the Best Practice ()
award by the Brazilian Development Bank (BNDES). From then on, KMC
became considerably widespread in Brazil, having become a public
policy, as occurred in four other countries: Colombia, Indonesia,
Mozambique and Peru ().
In 2000, the Brazilian Ministry of Health approved the Humanized
Care for Low Birthweight Infants (KMC), recommending it and defining
the guidelines for its implementation in medical units accredited
with the Unified Health System (SUS). This policy proposes the use
of KMC in three stages, starting with neonatal units (neonatal intensive
care units - NICU and intermediate care units), being extended to
kangaroo care units (or kangaroo rooming-in facilities) and, after
hospital discharge, to outpatient clinics (domiciliary KMC). At
the first stage, parents are granted early and free access to the
NICU, mothers are encouraged to breastfeed and participate in baby
care, and skin-to-skin contact is encouraged as soon as the baby's
clinical conditions allow so. At the second stage, both mother and
baby stay in a rooming-in facility, where the kangaroo position
should be practiced for as long as possible. The eligibility criteria
for staying in this facility are maternal availability, mother's
ability to recognize situations that may put newborns at risk, and
ability to place the infant in the kangaroo position. On top of
that, infants must have achieved clinical stability, total enteral
nutrition, minimum weight of 1,250 g and a daily weight gain greater
than 15 g. The criteria for hospital discharge and transfer to the
third stage are: mother's self-assurance regarding baby care; motivation
and commitment towards using the method 24 hours a day; guarantee
of frequent visits to the health unit; minimum weight of 1,500 g;
infant receiving exclusive breastfeeding; appropriate weight gain
three days prior to hospital discharge; and agreement to seek the
original hospital unit at any time while at the third stage, which
usually ends when the infant reaches 2,500 g ().
Silva ()
assessed the policies and routines defined by the Brazilian Ministry
of Health and found the following mainstays: (1) individualized
care, which is parent-centered (family-centered intervention); (2)
early skin-to-skin contact (appropriate and pleasant stimulation
with sensory integration); (3) control of light and sound (to avoid
aversive and inappropriate stimuli); (4) proper positioning (prevention
of future dystonias in preterm newborns); and (5) breastfeeding
(enhancing bonding and prevention of diseases in the first year
of life).
We may say that the development of kangaroo mother care in Brazil
was strongly influenced by the Colombian model, which served as
guidelines for the program (presence of the mother, skin-to-skin
contact, breastfeeding and chances of early hospital discharge)
and also by other experiences with preterm baby care, such as the
Newborn Individualized Development Care and Assessment Program (NIDCAP),
which is based on the synactive theory of development ().
According to this theory, the balance of a preterm baby's functioning
is established by five subsystems (autonomic, motor, states, attention/interaction
and self-regulatory) which are interconnected and interact with
each other. The disorganization of a subsystem overloads the others
and has a negative effect on the baby, while the organization of
a subsystem has a positive effect on the other systems, allowing
for equilibrium in the body.
The KMC used in Brazil can be considered to be a complex and comprehensive
intervention program, which takes into consideration the global
development of the baby and the environment in which he is reared.
Its objective is to humanize the care LBW newborns are provided
with and not to replace technology at NICUs ().
Scientific evidence of the role of KMC in
reducing infant morbidity and mortality
Since KMC was first described, it has been extensively studied (),
although there is a paucity of methodologically appropriate studies
for the analysis of its impact on morbidity and mortality.
A systematic review conducted by Cochrane Library, updated in February
2003, found only three studies comparing KMC with conventional neonatal
care which met the inclusion criteria, namely the random distribution
of babies weighing less than 2,500 g into the KMC or control group
().
The first study, carried out in a hospital in Ecuador (),
assessed the outcome of singleton babies weighing less than 2,000
g, who had not presented with severe congenital, respiratory, metabolic
or infectious disorders. A total of 140 babies were randomly assigned
to the KMC group and 160 to the control group. The babies in the
KMC group were submitted to skin-to-skin contact and were breastfed
on demand, while control individuals were kept in incubators or
in heated cribs and were breastfed at predefined schedules. The
second study, conducted in Colombia (),
analyzed babies weighing 2,000 g or less who did not present with
early congenital malformations or perinatal disorders, whose mother
or relative was available to take part in the program and had no
plans to leave Bogotá in the near future. Out of 777 newborns,
396 were randomly assigned to the KMC group, being submitted to
skin-to-skin contact 24 hours a day and receiving breastmilk on
a regular basis, although they were formula-fed whenever necessary.
The third study was carried out in three hospitals in Ethiopia,
Indonesia and Mexico (),
including newborns whose birthweight ranged from 1,000 to 1,999
g, without administration of oxygen and/or intravenous fluids, who
were able to feed and had no malformations. Of 463 babies, 178 were
excluded, and the number of newborns initially assigned to each
group is not known. Babies in the KMC group were submitted to continuous
skin-to-skin contact, night and day, including the time during which
their mothers were asleep.
The major findings of this review, which included 1,362 babies
and used standardized methods from the Cochrane Collaboration
for statistical analysis, were the following (the relative risks
and the respective confidence intervals are shown in parentheses):
- KMC was associated with reduction in nosocomial infection at
41 weeks of corrected gestational age (RR 0.49; 95%CI 0.25-0.93);
reduction in the incidence of severe diseases (RR 0.30; 95%CI 0.14-0.67);
and reduced incidence of lower respiratory tract infections during
the six-month follow-up (RR 0.37; 95%CI 0.15-0.89).
- Babies submitted to KMC had a larger daily weight gain (mean
difference of 3.6 g/day; 95%CI 0.8-6.4).
- Psychomotor development was similar in both groups at 12 months
of corrected age.
- No evidence regarding differences in infant mortality was found
when both groups were compared.
The authors in charge of the review conclude that, although KMC
seemingly reduces infant mortality, the evidence is still insufficient
to recommend the method as a routine practice, since some questions
about the methodology of the assays used reduce the reliability
of the findings. They also point out that more randomized, controlled
and well-designed trials should be carried out. On the other hand,
the same authors acknowledge that there are no reports on the deleterious
effects of KMC ().
Recently, a randomized controlled trial conducted in two hospitals
in South Africa revealed that babies who were submitted to skin-to-skin
contact had better outcomes with regard to physiological stabilization
compared to those babies who were kept in incubators ().
Evidence of the psychoemotional benefits
related to KMC
Separation of a baby from its family, especially from the mother,
determined by the baby's clinical conditions and by the rules of
conventional NICUs, may have a more negative effect than necessary
on mother and child bonding, which may affect the psychoemotional
development of this baby.
Some evidence exists that a close contact between the mother and
the preterm baby may have a positive influence on the relationship
of this baby with the world. The skin, the human body's largest
organ, receives sensory stimuli of different intensity and the skin-to-skin
contact, which in KMC implies the skin contact of body/chest between
the preterm baby and his mother, may cause several changes in the
bodies of both baby and mother. The well-known effect of the skin-to-skin
contact as a stimulus to the release of oxytocin apparently plays
a crucial role in the mother's behavior and seems to positively
affect her mood, thus facilitating her contact with the baby ().
In 1989, Affonso et al. (),
in a study involving 33 mothers who had skin-to-skin contact with
their preterm babies and a control group, observed a greater tendency
towards emotional stability in mothers submitted to this method.
They also reported a more intense feeling of reliability and competence
in these mothers compared with those mothers whose babies received
conventional care. Signs of establishment of an early mother and
child bonding and greater involvement of parents in baby care and
in the growth and development of their children was reported by
Charpak et al.()
and Reichert et al. ()
in other studies.
In a study involving 488 mothers of preterm babies, Tessier et
al. ()
observed that those submitted to KMC felt more competent and had
an increased perception of the baby's competences. Moreover, they
felt less stressed even when hospital stay was longer. Advantages
such as better relationship with the baby, with the health care
team, better acceptance of the care received by the baby at the
ICU and greater self-assurance in baby care were also reported by
the parents who participated in the Kangaroo Mother Care Program
by Rapisardi et al ().
These subjective feelings may be seen as positive indirect signs
of the establishment of a parent and child bonding favored by KMC
and could be positive signs of greater participation of parents
in baby care and stimulation, allowing them a more comprehensive
and more individualized care ().
On the other hand, prolonged separation of the baby from the mother
may have a negative effect on bonding. Klaus & Kennel ()
described prematurity and long hospital stay as risk factors for
developmental delay, child maltreatment and abuse by family members,
attributing the origin of these problems to the separation of the
baby from the mother. A prospective Australian study involving 353
babies weighing less than 1,000 g treated at conventional neonatal
units revealed, after the assessment of 167 cases, 80 infants with
confirmed maltreatment, which could not be related to deficiencies,
medical or perinatal causes, but which were mainly related to parental
factors ().
Evidence of neurosensory benefits related
to KMC
Preterm babies are born in a period when the maturation process
is at full throttle, especially with regard to the maturation of
the brain and to the development of psychoemotional aspects. They
have their physiological maturation interrupted and are deprived
of an optimal intrauterine environment, which would offer them various
comprehensive sensory and motor experiences facilitated by the lack
of gravity. Their experiences would be defined by the mother's pace
and they would be reasonably protected against excessive external
stimuli. After birth, due to its immaturity, the extrauterine environment
is expected to a have a significant impact on their body. Brazelton
(),
in a careful study with babies, asserted that a preterm baby's nervous
system becomes more easily organized while in a calm environment
without excessive stimuli. Meyerhof ()
assessed preterm babies treated at a conventional neonatal unit,
using the Brazelton scale, which consists in observing the behavioral
response of newborns to different stimuli, and corroborated that
a less stressful environment has a positive effect on the baby's
maturation. Preterm babies who received conventional care, were
kept in an incubator, and were allowed to rest and sleep in certain
periods of the day, spent less time at the hospital, spent less
time in the incubator and less time on a nasogastric tube. These
babies also had a better control over behavioral states and autonomic
stability, therefore showing a better physiological and behavioral
stability.
By observing the physiological pattern during intrauterine life,
we note that the baby's experiences occur in a cyclic rhythm of
activity and are determined by the possibility to rest and sleep
whenever necessary, which, according to Korones (),
occurs in approximately 80% of the time. Mann et al. ()
regard sleep as a positive influence on the development of the brain.
On the other hand, an inappropriate extrauterine environment,
characterized by constant stress, excessive handling, sleep deprivation,
and excessive light and sound stimuli, results in effects that are
adverse to the proper development of the nervous system ()
and are risk factors for a normal development ().
The painful stimuli to which babies are exposed at the neonatal
unit are considered to be the major factors for stress and disorganization.
Recent studies have demonstrated that painful experiences in the
neonatal period may lead to abnormal global development of preterm
babies ().
Several neonatal intervention programs were devised based on studies
showing that the environment and the way in which preterm babies
are cared for may negatively interfere in their development. The
aim of these programs is to protect the babies and offer adequate
stimuli in order to minimize the effects of the intervention imposed
by the infant's organic needs. Some programs were developed and
adopted, using criteria such as decrease in light and sound stimuli
and proper positioning in the incubator in order to provide self-adaptation
and self-consolation, in addition to measures for pain management
and the possibility of rest and sleep periods. The results of these
studies confirm that babies treated as described above had better
results as to their global development even if assessed partially
().
Appropriate positioning alone may allow for self-adaptation and
proper maintenance of tone and self-consolation ().
Salles ()
evaluated 25 preterm babies treated at a neonatal unit that used
protective measures for the normal development of the central nervous
system (appropriate positioning in the incubator, attenuation of
excessive light and sound stimuli and establishment of skin-to-skin
contact including KMC) comparing them with a control group treated
at a conventional care unit. The Dubowitz scale was used in babies
with 40 weeks of corrected age. The group that received the protective
care showed significantly better results than the control group.
The combination of these protective measures with the presence
of parents at the neonatal unit, their participation in baby care
and skin-to-skin contact brought new perspectives to the positive
stimulation of babies ().
The presence of parents facilitates skin-to-skin contact, which,
in its turn, allows tactile proprioceptive stimulation and protects
against an overload of aversive stimuli, being an acceptable method
for the proper stimulation of the baby's neurobehavioral development
().
Preterm babies submitted to skin-to-skin contact showed a better
mental development and better results in motor tests (),
a significantly lower difference in the duration of crying and in
the consolability pattern ()
and longer sleep periods ().
Another impact on the development of a preterm baby is concerned
with the presence of transient neurological disorders mainly observed
in the muscle tone within the first year of life. The literature
shows rates between 36 and 83%, depending on birthweight and gestational
age ().
However, Silva ()
observed an incidence of only 27.1% of transient tone disorders
in one of the few Brazilian studies with a neurological follow-up
of preterm babies in the kangaroo care program. In this study, the
author assessed the neurological development of 70 preterm infants
submitted to KMC, using protective measures at the neonatal unit,
skin-to-skin contact and parental participation.
Evidence of benefits related to the breastfeeding
practice
An important mainstay of kangaroo mother care is breastfeeding
encouragement. Although evidence shows countless benefits of breastfeeding
for preterm babies (),
the prevalence of breastfeeding in this group is still quite low.
Xavier et al. (),
in a descriptive study on breastfeeding in babies weighing 2,500
g or less born at the Hospital das Clínicas de Ribeirão
Preto, state of São Paulo, Brazil, found that 13.5% had never
been breastfed and that only 38.5% were being breastfed at six months
of life. Lefebvre ()
observed that among Canadian babies weighing less than 2,500 g only
58% had been breastfed at birth, compared to 73% in the full-term
group. Among LBW infants, only 3% were discharged on exclusive breastfeeding
and 11% were never breastfed.
Hellbauer et al. (),
in South Africa, studied the factors that influence a mother's choice
regarding the form of feeding her baby after discharge from an NICU
and observed that, among other factors, LBW and prolonged hospital
stay had a negative effect on her decision to breastfeed. Bicalho-Mancini
et al. (),
in a study about the risk factors of not exclusively breastfeeding
LBW infants at an NICU in Belo Horizonte, state of Minas Gerais,
before and after the implementation of the Baby Friendly Hospital
Initiative, found that, although the rates of exclusive breastfeeding
at hospital discharge increased from 36% (before implementation)
to 54.7% (after implementation), these figures show the necessity
of other interventions in order to encourage the breastfeeding of
these babies. Boo (),
in Malaysia, with the aim of determining the breastfeeding rate
among babies weighing less than 1,500 g admitted to a high-risk
neonatal unit, observed that, despite breastfeeding incentive programs
adopted by the hospital, only 40.2% of these babies were being breastfed
at the time of hospital discharge.
On the other hand, studies carried out in settings where KMC is
used show that mothers who establish a skin-to-skin contact with
their preterm babies have a significantly higher milk production
compared to the control group . Furthermore, these studies revealed
that interruption of breastfeeding was more frequent among mothers
who were not submitted to this method ().
In a randomized controlled study conducted in Sweden with 71 preterm
babies weighing less than 1,500 g, Whitelaw et al. ()
found that babies submitted to KMC had a two times higher prevalence
of breastfeeding than the control group at six weeks of life (55
versus 28%). Ramanathan et al., in New Delhi,, India (),
found similar results in a study with 28 preterm babies, in which
the frequency of breastfeeding at six weeks of life amounted to
85.7% for babies submitted to KMC versus 42.8% for control individuals.
Charpak et al., in two studies carried out in Colombia (one in 1994
and the other one in 2001), revealed higher prevalences of breastfeeding
at 1, 6 and 12 months of life in babies submitted to KMC compared
with control individuals ().
In Brazil, Lima et al. ()
and Silva ()
found similar results for breastfeeding rates. At six months of
life, the prevalence rates of breastfeeding in these studies were
respectively 63 and 60.3% for babies submitted to KMC.
Conde-Agudelo et al. ()
have recently analyzed three randomized trials and concluded that
KMC was a protective factor for exclusive breastfeeding at hospital
discharge (RR 0.41; 95%CI 0.25-0.68).
Table 1 briefly summarizes some studies on the breastfeeding of
babies submitted to KMC.
Table 1 -
Studies that have analyzed KMC and the frequency of breastfeeding
Final remarks
KMC in Brazil takes into account the baby's continuous growth process
and introduces some possibilities to understand neonatal care in
a broader context, allowing the retrieval of physiological, psychological
and neurological information about human beings, considering the
individual as a whole. KMC provides data on neurological, psychological
and emotional development, therefore contributing to a care that
suits the needs of the baby and of his family.
This review provides evidence of the benefits of KMC, which were
certainly considered when this strategy was defined as a public
policy in Brazil. However, it is essential that the efficiency of
KMC in LBW infants in Brazil be further investigated. We should
not forget that KMC was proposed here to humanize the care given
to LBW infants, similarly to what occurs in industrialized countries,
and not to replace the existing technology at neonatal units. The
different contexts in which the method has been used should also
be considered by the studies, since Brazil is characterized by large
macroregional and microregional differences.
Recent Brazilian studies on the topic show the interest of researchers
in subjective aspects such as the perception of parents of preterm
babies about the KMC experience ()
and the influence of support networks on this practice ().
These studies on the acceptability and applicability of KMC are
crucial to provide valuable information and show us how to organize
KMC in our setting.
|
KMC
Help menu
