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British Medical Journal 13 November
2004. 329:1179-1181
Juan Gabriel Ruiz-Peláez,
professor1,
Nathalie Charpak, director2, Luis
Gabriel Cuervo, clinical editor3
Caring for low birthweight infants imposes a heavy burden on
poor countries. An effective healthcare technique developed in
1978 may offer a solution to this problem and additionally be of use
in wealthy countries too
Introduction
Each year about 20 million infants of low birth weight are
born worldwide, which imposes a heavy burden on healthcare and social
systems in developing countries.1
w1 Medical care of low birthweight infants is complex, demands
an expensive infrastructure and highly skilled staff, and is often a
very disruptive experience for families.2
w2 w3 w4 Premature babies in poorly resourced
settings often
end up in understaffed and ill equipped neonatal care units, that may
be turned into potentially deadly traps by a range of factors
colluding—for example, malfunctioning incubators, broken monitors,
overcrowding, nosocomial infections, etc.
In 1978 Edgar Rey, a Colombian paediatrician concerned with
the problems arising from a shortage of incubators and the impact
of
separating women from newborns in neonatal care units, developed Kangaroo
Mother Care (KMC),3
a healthcare technique for low birthweight infants that is at least
as effective as traditional care in a neonatal care unit.4
5
What does KMC entail?
In KMC, babies weighing 2000 g or less at birth and unable to
regulate
their body temperature remain with their mothers as incubators, main
source of stimulation, and feeding. Newborns are attached to mothers
and other carers' chests in skin to skin contact, wearing only a
nappy and a baby bonnet, and are kept upright 24 hours a day. Mothers
can share the role of provider of the kangaroo position with others,
especially the babies' fathers, without disrupting breastfeeding
routines. The carer should sleep in a semi-sitting position. The KMC
begins as soon as the baby no longer requires other support from the
neonatal care unit, although intermittent skin to skin contact has
been used in ventilated infants6
w5 w6 Exclusive breast feeding (plus
vitamins) is attempted,
and growth is closely monitored. Breast milk is fortified or formula
milks are added if infants are not thriving.7
Infants will reject permanent contact once they achieve regulation of
their body temperature, at a median age of 37 weeks after conception.4
8
KMC usually starts in hospital with an adaptation process.
During adaptation and after discharge, carers attend a day clinic
where they are trained, infants are monitored, and the carer enmeshes
in a social peer network. Care is thereafter provided at home
with
follow up visits as needed. KMC can be implemented in various facilities
at different levels of care.w8 It may be the best option
if neonatal care units are unavailable.9
w7 w8 If a neonatal care unit is available but overwhelmed by
demand, KMC allows rationalisation of resources by freeing up
incubators for sicker infants.8
10 w8
Even in well resourced neonatal care units, it still enhances bonding
between mother and infant and breast feeding.8
11
Does it work?
Evidence backs the effectiveness and safety of KMC in stable,
preterm
infants. In low birthweight infants weighing 2000 g or less, who are
unable to regulate their temperature, KMC is at least as safe and
effective as traditional care with incubators.12
An open randomised controlled trial in Bogotá, Colombia,
assessed
the long term clinical effects of KMC by randomising 746 low
birthweight infants.4
5
Follow up at the 12 months of age corrected for gestational age (93%
children) found that KMC had improved successful breastfeeding rates
and infections were milder in these children. Hospital stay was
reduced in "Kangaroo" newborns weighing 1500 g or less. A
non-significant reduction in mortality (3.1% v 5.5%; relative
risk 0.57, 95% confidence interval 0.17 to 1.18) and slight
improvements in developmental indices were found with KMC. The
investigators found no significant differences in physical growth
patterns or in the rates of cerebral palsy, failure to thrive, visual
problems, deafness, or hip dysplasia.5
Blind assessments of bonding between mother and infant by using
videos in a subsample of 488 mother-infant dyads found that bonding
improved markedly with KMC,13
as did neurodevelopmental evaluations in infants at higher risk.14
In developing countries, other studies of varying
methodological soundness have found similar results with regard to
infections.w9 w10 Studies in wealthy countries have not found
significant improvement in morbidity, but standard care has still
failed to outperform KMC. Current evidence indicates that KMC is at
least as good as standard care.1
12
KMC may not suit everyone and every circumstance. People
travelling long hours to attend the KMC clinic while caring for other
children may rather rely on care in hospital; harsh or risky
environments (such as extreme climates, floods, landmines, or
conflict areas) or dangerous traffic conditions may make it safer to
remain in hospital. Nevertheless, during the one year follow up in
the Bogotá study, no transport incidents between home and the
KMC clinic were reported.
To overcome transport problems, KMC has been delivered in
"Kangaroo wards," where mothers and infants stay for days
or weeks until they can be safely discharged home once frequent
monitoring is unnecessary. This is the standard way of delivering KMC
in several large facilities in both developing countries (for
example, Jose Fabella Hospital, Manila) and developed countries (for
example, Helsingborg Hospital, Sweden).
KMC may be unsuitable for carers with important mental,
cognitive, or behavioural problems. Some parents may feel intimidated
or overwhelmed by caring for a premature baby, but most parents
cope
well with the demands of KMC.4
13
15
w11 Most caregivers prefer skin to skin contact over
conventional care and find themselves empowered by KMC. Parental
sense of fulfilment and confidence are improved, and these
improvements are consistently found in affluent settings as well as
impoverished settings.1
5
12-13
w11 w12
Where has KMC been implemented and where else can it be
implemented?
The Bogotá experience has been replicated in other
places. KMC has now been embraced by Colombia's Ministry of Health,
and with variable uptake in other countries including Vietnam,
Brazil,
and South Africa. The Fundación Canguro trained a "second
generation" of KMC centres that now deliver KMC in large
healthcare centres in 25 developing countries: in Asia (including
Ukraine, India and South East Asian countries), Africa, and Latin America.w13
Different modalities of KMC (mainly kangaroo position and nutrition)
are currently used in many industrialised countries such as France,
Sweden, the United Kingdom, and the United States. A survey among
1133 hospitals providing neonatal intensive care in the United States
found that among the 669 (59%) hospitals that responded, 548 (82%)
used KMC.w14 The World Health Organization backed its uptake:
"Almost two decades of implementation and research have made
it
clear that KMC is more than an alternative to incubator care. It has
been shown to be effective for thermal control, breastfeeding and
bonding in all newborn infants, irrespective of setting, weight,
gestational age, and clinical conditions."1
Guidance on KMC implementation is available, including WHO
guidelines that can be downloaded free of charge.1
Other free information sources are also available.w13 w15 w16
Current evidence shows that KMC should be encouraged in
affluent settings; inertia and unfounded wariness are perhaps the
biggest hurdles to overcome to achieve this. Despite being developed
in a resource stricken setting, parents and healthcare providers
alike
have often expressed that they are happier with KMC than with
standard care, even in the well resourced settings.w8 w17-w19
Conclusion
KMC delivers ideal conditions for stable, low birthweight
infants to thrive, strengthens parental participation and
empowerment, and contributes to the healing process.5
13 w9
w20 Despite relying on simple interventions, KMC is a
scientifically sound, effective, and efficient alternative to
neonatal care units in many settings.12
It delivers high quality care at a fraction of the cost of usual
care,9
w7 w8 and improves satisfaction for consumers
and providers
alike. KMC should be implemented as early as possible; it prepares
the family and the environment for a successful discharge from
hospital, allowing parents to remain the main direct providers for
the physical and emotional needs of low birthweight infants in
affluent as well as impoverished environments. In impoverished
environments, the evidence shows that KMC may also reduce morbidity
and hospital stay. One of the main barriers for rolling out KMC may
be unfounded cautiousness, particularly among clinicians and policy
makers.
Summary points
·
Low birthweight infants are particularly vulnerable
to
the increased morbidity and mortality in overcrowded neonatal units
·
Kangaroo Mother Care (KMC), a technique developed in
Colombia
to deal with overcrowding of neonatal units, delivers ideal
conditions for low birthweight infants to thrive
·
The technique is welcomed by most parents and centres
where it has been made available
·
KMC is safe, works at a fraction of the
cost of an
incubator, reduces morbidity (in impoverished settings), improves
breastfeeding rates, improves bonding between mother and infant, and
increases satisfaction in parents and care providers
·
KMC has not been outperformed by standard care in any
evaluation and is deemed a sound, evidence based alternative to treat
premature babies in most settings
(references and further information
available at BMJ website)
High-tech western hospitals were failing premature babies by
making it difficult for mothers to breastfeed, a breastfeeding medicine expert
said. Professor Jane Morton is one of the world's first directors of
a department of Breastfeeding Medicine, at the Stanford University School of
Medicine in California. Speaking from the United States ahead of a visit to Australia
to speak to breastfeeding advocates, Prof Morton said her position should exist
at all big universities and hospitals.
"Over the last 10 years or so the research that shows the
benefits of breastmilk and the risks of formula, particularly for pre-term
babies, is stronger," Prof Morton said. "Yet when you have larger, more specialised, more
high-tech centres, we haven't programmed into our system the necessary
ingredients to support that vital contact between the mother and the baby. "With all the benefits that are increasingly evident you
wonder why there hasn't been a veritable stampede to try and redesign our
systems to better support breastfeeding under any and all circumstances."
The World Health Organisation (WHO) recommends that all babies
are fed only breast milk for their first six months, but in Australia only 32
per cent of babies are breastfed exclusively up to six months of age. Part of the problem was a tendency in western medicine to view
pregnancy as a medical condition, Prof Morton said. "Medical intervention begets medical intervention,"
she explained. "So if you induce a mother she's less likely to deliver
vaginally than if she went into labour on her own and if she has a caesarean
section then she's at higher risk for insufficient milk production and at birth
you're more likely to remove the baby from the mother while the mother's in a
recovery room. "Then maybe you eventually reunite the baby after he or
she has received a bottle or supplementation."
Studies have shown that a mother of a premature baby in an
incubator produces more breastmilk if she sits next to the baby than if she's in
another room, Prof Morton said. There's also proof that regular skin-to-skin contact achieved
by laying the baby between the mother's breasts - known as kangaroo care - makes
for a happier and healthier baby. "If you think about it, you wouldn't think of removing a
puppy from a new litter and every couple of hours returning it to the
mother," Prof Morton said. "In (animal) studies where they have interfered with the
intimacy of that relationship and a strong sense of the mother and baby and the
feel of the nipple in the mouth you run havoc with the suckling, and as mammals,
I don't think humans are any different."
British Medical Journal doi:10.1136/bmj.38131.675914.55
(published 18 June 2004)
Objective To determine the effect
of artificial teats (bottle and dummy) and cups on breast feeding in
preterm infants.
Design
Randomised controlled trial.
Setting Two large tertiary hospitals,
54
peripheral hospitals.
Participants 319 preterm infants (born
at
23-33 weeks' gestation) randomly assigned to one of four groups:
cup/no dummy (n=89), cup/dummy (n=72), bottle/no dummy (n=73),
bottle/dummy (n=85). Women with singleton or twin infants <34
weeks' gestation who wanted to breastfeed were eligible to
participate.
Interventions Cup or bottle feeding occurred
when
the mother was unable to be present to breast feed. Infants randomised
to the dummy groups received a dummy on entry into the trial.
Main outcome measures Full breast feeding (compared
with partial and none) and any breast feeding (compared with
none)
on discharge home. Secondary outcomes: prevalence of breast feeding
at three and six months after discharge and length of hospital stay.
Results 303 infants (and 278 mothers) were included
in the intention to treat analysis. There were no significant
differences
for any of the study outcomes according to use of a dummy. Infants
randomised to cup feeds were more likely to be fully breast fed on
discharge home (odds ratio 1.73, 95% confidence interval 1.04 to
2.88, P=0.03), but had a longer length of stay (hazard ratio 0.71,
0.55 to 0.92, P=0.01).
Conclusions
Dummies do not affect breast
feeding in preterm infants. Cup feeding significantly increases the
likelihood that the baby will be fully breast fed at discharge home,
but has no effect on any breast feeding and increases the length of
hospital stay.
Originally published in the Dominion Post -
Wednesday
22nd September 2004
By Nikki
MacDonald
Overcrowded
and overstretched neonatal units are endangering sick babies, a new report
shows.
The Health
Ministry review of neonatal intensive care services shows New Zealand hospitals
are almost 20 beds short of the minimum number of level-three cots needed, based
on international benchmarks. Taking the upper recommended number, the service,
caring for the most premature babies, is more than 40 beds short.
The country's
six level-three neonatal intensive care units are often full, forcing stressful
and potentially dangerous transfers of pregnant mothers or very premature
babies.
A recent
British study found babies admitted to a full unit were 50 per cent more likely
to die than those in a half-full unit. The review
found occupancy here "well above recommended levels". On a significant
number of days each month, fewer than three cots were free nationwide.
Even with
planned expansions, New Zealand could still struggle to find enough cots and
staff to care for its sickest babies.
Demand for
neonatal intensive care has been growing, even as birth rates dropped, with more
older women having babies; better survival of premature babies and more multiple
births. However, doctors appear to be managing difficult conditions well, as New
Zealand has one of the highest survival rates for premature babies.
Despite the
grim statistics, reviewer and Health Ministry child and youth health chief
adviser Pat Tuohy believes the worst is over. "Already
we are starting to see new units being built around the country. Yes, there is
still going to be pressure for a short period of time. We are not out of the
woods yet but at least we can see the light."
However, some
concern existed that even the planned extensions would not be enough in some
areas. Based on latest birth figures, between 87 and 116 level-three cots were
needed now, according to international benchmarks. New Zealand now has just 66
cots nationally. Planned expansions would increase that to 86 within five years.
Overcrowding
is also a concern. The review found Wellington Hospital had up to 10 babies in
an area only big enough for four, according to American guidelines.
Dr Tuohy said
the Health Ministry would watch cot numbers closely and encourage district
health boards to improve flexibility and reduce low birth rates. However, beds
were only half the problem.
High occupancy
meant staff were getting burnt-out. Finding enough qualified staff was likely to
be the biggest challenge for neonatal ICU units when bed numbers pressure eased.
Wellington
neonatal ICU clinical leader Vaughan Richardson said the review highlighted
doctors' long-held concerns. Fortunately no baby had so far been seriously
affected by overcrowding, but infections spread faster in restricted space.
The hospital
planned to convert a storeroom to ease overcrowding. Bed numbers
were a constant and nationwide concern. The unit often cared for more than its
maximum of 34 level-three and level-two babies. About five babies or mothers a
month were transferred to other centres because of a bed or staff shortage.
Wellington's
new regional hospital should increase cot numbers to 40. The review called for
at least 43.
Premature births have reached epidemic proportions in Britain with 18,000
babies a year spending their first weeks in an incubator. But a pioneering
doctor claims keeping them apart from their mothers damages their development.
Nils Bergman tells Emily Wilson why the best place for an early baby is on its
mother's skin
In 1988 Nils Bergman, the son of two Swedish missionaries, began work as a
doctor at a remote mission hospital in south-west Zimbabwe. He was one of two
resident medics, and between them they were responsible for an operating
theatre, 106 hospital beds, 11 rural medical centres and the health of 200,000
people. Bergman's duties were varied, his interests likewise: for several years,
he was primarily concerned with the treatment of scorpion stings (the fourth
most common cause of inpatient admissions in the area). But he also developed an
interest in premature babies, and it is this that may one day make him famous.
There were no incubators at the Manama mission hospital, nor ventilators.
Care for premature babies involved hot-water bottles and cotton-wool blankets:
nine out of 10 died. One of Bergman's colleagues, a midwife named Sister Agneta
Jurisoo, had read about work on "kangaroo care" - skin-to-skin contact between
mother and premature baby - in Colombia. Why didn't they try it? Kangaroo care
was designed as therapy for babies who had already been stabilised, but in the
absence of better options, Bergman and Jurisoo took it as their starting point.
"We used mothers as incubators," says Bergman. "Flat out, full out. Instead
of using incubators to stabilise the baby, we used the mother." Mothers were
told to hold their babies to their skin day and night. Bergman's wife helped
design a shirt that would hold the baby in place; Bergman learned to make sure
the baby's airways stayed open by tying the infant's head in position with a
theatre towel. The team found, through trial and error, the best angle at which
mother and baby should lie in their hospital bed. They were soon saving small
babies - babies of just over 2lb at birth. The youngest they saved was born at
28 weeks. And the babies seemed peculiarly well in themselves, Bergman says. "I
saw babies that behaved in a way that was extremely different from what an
incubator baby looks like. It's so chalk and cheese, I sometimes jokingly say,
'This is a new species of premature baby.' They're aware, they're connected,
they grow."
With nothing more sophisticated than piped oxygen and antibiotics at their
disposal, there wasn't much they could do with babies born before 31 weeks'
gestation, Bergman says, but survival rates generally went up to 50%. That may
compare badly with near-100% survival rates for post-30-week babies in
state-of-the-art western units, but then survival, for Bergman, is a "surrogate
outcome". His work on kangaroo care in Zimbabwe, and since then in more
sophisticated circumstances in South Africa, has brought him to the conclusion
that incubators - ubiquitous in rich countries since the 1940s - have led
orthodox neonatal medicine up a blind alley. An entire raft of medical science
has been built around incubators - but they are a poor second best. "Mother's
skin, chest, is a far better place and safer place to stabilise a baby," he
says. It's the only place, he argues, where a premature baby's brain can develop
properly, where "wiring defects" can be avoided. "We are producing babies with
brain wiring of 70% but 100% survival and we're smiling, because we're saving
them. I'm saying: 'This is mediocrity'."
Premature births have reached epidemic proportions in Britain: around one in
eight babies are now born early - 80,000 a year. There are lots of reasons for
the rise: increasing numbers of older mothers, increasing numbers of younger
mothers, increasing numbers of multiple births (thanks to IVF) and advances in
antenatal medicine. People argue a lot about how far we should go with all this
- whether 22- or 23-week babies should be saved. What they don't argue about is
the core treatment that is doled out to these babies.
According to Rob Williams, chief executive of the premature baby charity
Bliss, of the British babies born early each year, around 18,000 receive the
full-on, hi-tech, alarm-heavy, floodlit incubator experience. Most of the rest
receive some sort of "special care" in a cot on a neo-natal ward. All are
separated from their mothers - that's the constant. Babies on one ward, mothers
on another, or even in a different hospital, as happened to Prince Andrew's
wife, Sophie. It's a separation that feels beyond awful for all directly
concerned. But parents are kept going by the knowledge that the horror is
unavoidable; that without it their child might die. In most units, parents are
encouraged to take their child out of its cot or incubator for so-called
kangaroo-care sessions - there's plenty of science showing that such contact is
good for both mother and baby - but it's very much an add-on, and if the baby's
not judged to be stable, the baby stays in its box.
Bergman says this is topsy turvy. He thinks mothers and babies should only
ever be separated in extreme circumstances. "You want babies on their mother's
skin 24 hours, as the default setting," he says. Skin-to-skin contact provides
all the warmth a baby needs, and helps to regulate a baby's breathing, he says;
any extra help needed (such as oxygen, drips, monitors or a feeding tube)
shouldn't stop the baby being on the mother - just add the technology to the
mother-baby unit.
Only proximity to the mother can provide a baby with all the sensory
stimulation necessary for proper brain development, he goes on. When he talks
about "70% brain wiring", he is plucking figures from the air - he does not mean
to be taken literally. But if premature babies do only achieve 70% wiring, say,
what sort of things are going to be wrong with them? There's the obvious,
measurable stuff, he says - IQ and so on - and then there's the stuff that's
hard to measure. Such as? "Ability to relate."
He says: "The brain is complex. Layers on layers. It depends on timing, on a
complex glue of nature and nurture and sequence ... if something happens at this
point, it could make an aggressive child; if it happens at that point, it could
make a passive child." But what about the really little babies, the 24-weekers
the length of pencils? Bergman would argue that those babies need their mothers
more than most, if they're to have any chance of a good outcome. Can a child
ever recover, in his opinion, from the "insults", as he calls them, of
separation and incubator care? Does he think you can love it out of them
afterwards? "Yes I do," he says. "To an extent."
Bergman has done research on skin-to-skin versus incubators at Cape Town's
Mowbray maternity hospital, the first of its kind, and the first proper
controlled trial, he would argue, of incubators. It was a very small study,
involving just 33 babies, and lasted for only the first six hours of the babies'
lives, but it's interesting none the less. Bergman says 92% of the incubator
babies got into trouble at some point; enough to need a doctor to step in -
against only 17% of the skin-to-skin babies. The second group were "very much
more stable", he says.
Bergman is a religious man, and he is evangelistic about kangaroo care and
breastfeeding (and the perils of formula). The west prefers its scientists
rather more cool and dispassionate, but Bergman is no New Age flake. His
pioneering work in South Africa has had real impact: in some provinces,
round-the-clock kangaroo care is becoming standard. Bergman says a hospital in
Pretoria now has 40 or so "mother beds" on its neonatal ward - mothers on drips,
babies on oxygen, but together. Could it ever happen here?
"We're interested in funding more research into this sort of area," says Rob
Williams, at Bliss. "We're about to fund a study into kangaroo care in the UK
... but it wouldn't be instead [of incubators] but with." But he doesn't dismiss
Bergman's ideas of 24-hour kangaroo care out of hand - far from it. "This
reflects a lot of new thinking," he says.
Bergman, who is 50 and a father of three, was in Britain this week to address
Unicef UK's annual baby-friendly initiative conference. He was here to talk
about premature babies, but his interests remain wide - he talks about "the
biology of wellbeing", and has strong views on a wide range of parenting issues.
He thinks it's wrong to separate women from their full-term newborns, too, even
for short periods, and that separation is a key cause of low breastfeeding
rates. He thinks women should carry their babies everywhere for the first eight
months; that they should take them to work with them if necessary; that
workplaces should change dramatically to accommodate babies, and if they can't,
that women should be properly rewarded for staying at home. Bergman says that
babies can only cope with one change in their primary carer in the first year,
and that nurseries are not a suitable habitat for babies.
He gets shouted at a lot when he talks like this, he says, but he remains
unrepentant. "If it's damaging their babies, I have an obligation to tell them.
If society insists they damage their babies, they have a responsibility to tell
society where to go. Society can't change overnight, but it must know it has to
change. I'm a public health physician, woe to me if I don't tell you the truth"
· The full abstract of Bergman's kangaroo-care trial can be found at
www.babyfriendly.org.uk/pdfs/bergman_2005.pdf. For more information on his
work, visit
www.kangaroomothercare.com.
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