KANGAROO MOTHER CARE Presentation summary

Benefits of kangaroo mother care is critical in care of preterm babies towards maintaining thermoregulation

1. Kangaroo Mother Care

2. Define Kangaroo Mother Care (KMC) Explain the benefits of KMC Outline the eligibility criteria for KMC Describe the elements of KMC Objectives 2

3. Introduction Definition: KMC is the care of preterm/LBW infants in continuous and prolonged skin-to-skin contact between a mother or her surrogate* and the preterm/ LBW infant. It should be done for at least 8–24 hours per day with support for exclusive breastfeeding or breast-milk feeding NB: Skin to skin contact after birth does not equate to KMC 3

4. Introduction Recommended for all infants weighing <2500g Should be initiated immediately after birth ( iKMC ), within 2 hrs, for all stable or unstable premature or LBW infants except those who are: Unable to breathe spontaneously after resuscitation are in shock need mechanical ventilation. 4

5. Introduction cont.…. For home deliveries, skin to skin contact should be initiated at home for all infants before and during referral to a health facility. All premature/LBW Infants, <2500g, should be on KMC during referral from primary health care facilities. 5

6. Why KMC? 40% reduction in mortality in LBW infants given KMC after stabilization compared to conventional care in hospitals Kangaroo Mother Care soon after birth ( iKMC ) has also been shown to improve neonatal survival by a further 25%, compared with Kangaroo Mother Care initiated after stabilization, and is is currently recommended . 1 .Conde-Agudelo A, Díaz-Rossello JL. Kangaroo Mother Care to reduce morbidity and mortality in low birthweight infants.  Cochrane Database Syst. Rev . 2016; 8: CD002771. [ PMC free article ] [ PubMed ] [ Google Scholar ] 2. WHO Immediate KMC Study Group, Arya S, Naburi H, Kawaza K, Newton S, Anyabolu CH, et al. Immediate ‘Kangaroo Mother Care’ and survival of infants with low birth weight. N Engl J Med. 2021;384(21):2028–38. [ PMC free article ] [ PubMed ] 6

7. Benefits of KMC Parasympathetic nervous system Baby absorbs food better Grows & gains weight faster Stable heart rate Stable breathing Less stressed Baby able to breastfeed sooner Better resistance against illnesses Better survival Skin to skin touch Oxytocin Faster wound healing, less inflammation Quiet and calm when awake Very little crying Warm breast skin temperature keeps baby warm Mother’s temperature responds to baby’s temparature Baby experiences less pain even during painful procedures Baby sleeps better Sleep cycles more organised Brain grows better Baby develops faster Does better at school Better relationship with one another and others Mother forms a loving bond with her baby with response from the baby 7

8. Benefits of KMC Mother/care giver Boost mothers confidence in caring for the newborn Improves bonding between mother and infant Empowers mothers to play an active role in their newborn’s care Promotes breast feeding which has benefits for both mother and baby Facility Significant cost-savings Less dependence on incubators Additional nursing staff not required (compared to incubator care) Shorter hospital stay Improved morale & quality of care Improved outcome 8

9. Basic Requirements for KMC Willing mother or surrogate. Eligible newborn. Stable/ unstable LBW infant with no contra indications. KMC bed/ reclining chair Wrap ( Lesso /Kanga) for baby Baby caps, socks, mittens diapers/ nappies KMC chair KMC wrap KMC wraps 9

10. Eligibility Criteria for KMC Baby factors All babies weighing <2500g should be initiated on KMC unless the infant is: Unable to breathe spontaneously after resuscitation, In shock Needs mechanical ventilation. Has congenital anomalies Maternal factors Willingness of the mother /surrogate If the mother is too sick, a surrogate can provide KMC 10

11. Eligibility for admission into KMC by level of Care Level 4, 5 & 6 hospitals All LBW babies below 2500g including those referred Level 3 facilities (Health Centers) All stable preterm and LBW babies weighing > 1500g should be started on KMC. Babies referred from higher level facilities to continue KMC . 11

12. Eligibility….. Level 2 Health Facilities (Dispensary) Start iKMC for all newborns less than 2500g then refer for assessment. Level 1 (Community Health Services) All newborn delivered at home should be referred to nearest health facility in skin to skin position. The babies discharged from health facility to continue KMC should be followed up. 12

13. Elements of KMC 13

14. The four elements of KMC 14

15. 1. KMC Position Dress the baby in socks, a diaper/nappy and a hat . Place the baby between the mother’s breasts chest to chest The head is turned to one side in a slightly extended position with the top of the binder being just under the baby’s ear. This keeps the airway open Allows eye-to-eye contact between the mother and the baby. Avoid flexion and hyperextension of the head The hips should be flexed and abducted in a “frog” position. The arms should also be flexed 15

16. KMC Position….. (f) Secure the baby on to the mother’s chest with a clean lesso , soft cloth or any of the other recommended KMC wrappers Secure the head Secure the buttocks Apply appropriate tightness (g) Put a blanket or a shawl on top for additional warmth (h) Instruct the mother to put on a top that is open at the front ( i ) Instruct the mother to keep the baby upright when walking or sitting (j) Advise the mother to have the baby in continuous skin-to-skin contact for 8 to 24 hours per day 16

17. Positioning the baby for Kangaroo Care 17

18. Sleeping and resting in KMC The mother will best sleep with the baby in kangaroo position in a reclined or semi- recumbent position, about 15 degrees from the horizontal plane . 18

19. 2. KMC Nutrition Mother’s own milk is the recommended feed for preterm and LBW infants Kangaroo position promotes breastfeeding while maintaining skin to skin contact Mothers should be assisted to correctly position and attach the baby during breastfeeding. The neonates who are unable to breastfeed, should be fed on EBM via NGT or cup. 19

20. Feeding while in KMC position Feeding via NGT in the KMC position Breastfeeding supported while in KMC position 20

21. Initiation and Maintenance of KMC Educate the mother on: KMC position Feeding options Care in the institution and at home Do’s and don’ts during KMC Advantages of KMC to her and her baby Adopting KMC should be the result of an informed decision. 21

22. Care of the baby during KMC a. Infection prevention: Wash hands Before and after feeding baby Before and after changing nappies After using the toilet As need arises 22

23. Care of the baby during KMC Infection prevention Clean or wipe baby daily (“head to toe”) Ensure the baby always wears clean diapers/nappies Ensure all cups and feeding utensils properly cleaned before and after use Controlled access to non-essential personnel and visitors Apply all other standard infection prevention measures 23

24. Care of the baby during KMC b. Cord care Apply 7.1% chlorhexidine digluconate gel to the cord immediately after cutting the cord Apply 7.1% chlorhexidine digluconate gel to the cord once daily for 7 days. For the preterm baby the single application after birth suffices NB. A wet cord is not a contraindication for KMC. 24

25. Care of the baby during KMC c. Clinical review Neonates should be reviewed daily during KMC Initiate supplements as per the guidelines ROP screening, hearing screening, aneamia of prematurity cranial ultrasound and bone biochemistry as indicated 25

26. Care of the baby during KMC d. Monitoring Monitor vital signs (respiratory rate, pulse rate, temperature) 3-hourly. Record feeds given as per the schedule used. Monitor growth by taking daily weight of the baby. Target a daily weight gain of at least 15g/kg/day after regaining birth weight. 26

27. Care of the baby during KMC Monitoring Birth weight is regained within 14 days after birth. If weight gain is not adequate assess possible causes Inadequate amount and frequency of feeds Inadequate skin to skin contact Signs of infection Take weekly head circumference and length Use the KMC daily score sheet to evaluate progress of the baby 27

28. KMC Daily Score Sheet KMC Daily Score Sheet Based on the Intra-hospital KMC Training Programme in Bogotá, Colombia Date                                      Name:     Breastfeeding: Started 24h KMC: Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day 8 Day 9 Day 10 Day 11 Day 12 Day 13 Day 14 Day 15 Day 16 Day 17 Day 18 Reg No:     Formula: ......../......./.......                                     Evaluation   Score   Weight                                        1 2 Remarks                                     Socio-economic support No help or support Occasional help or support Good support system                                       Mother’s milk production Expresses 0‑10 ml breast milk Expresses 10‑20 ml breast milk Expresses 20‑30 ml breast milk Must score 2 before discharge. N/A for formula                                     Positioning and latching baby onto breast Always needs assistance Occasionally needs assistance No assistance needed Not applicable for formula feeding                                     Baby’s ability to suckle at the breast / bottle Gets tired very quickly Gets tired infrequently Takes all feeds well                                       Confidence in handling baby i.e. feeding, bathing, changing Always needs assistance Occasionally needs assistance No assistance needed                                       Baby’s weight gain per day 0-10g 10-20g 20-30g Must score 1 or 2 for a few days before discharge                                     Confidence in administering vitamin and iron drops No confidence Some confidence Fully confident                                       Knowledge of KMC No knowledge Some knowledge Knowledgeable                                       Acceptance & application of KMC Does not accept or apply KMC method Partly accepts & applies KMC method Fully accepts and applies KMC method Applies KMC without having to be told                                     Confidence in caring for baby at home Does not feel sure or able Feels slightly unsure & unable Feels confident                                       TOTAL SCORE per day                                           28

29. Care of the baby during KMC e. Immunization Immunize all babies soon after birth, according to the National Immunization schedule and guidelines . N.B: Prematurity/low birth weight is not a contraindication for immunization. All babies should be immunized before discharge irrespective of the weight. 29

30. 3. KMC discharge and follow up Baby factors Continuous weight gain of at least 15g/kg per day for 3 consecutive days Has regained birth weight and has a minimum weight of 2000g Breastfeeding and/or feeding well by cup Overall condition is stable Stable babies between 2000-2500g can be initiated on KMC and be discharged to continue KMC at home Maternal factors Accepts KMC method and observed to be confident about caring for the baby. Able to breastfeed or express breast milk for feeding Willing to continue KMC at home Has support from the family to continue KMC Criteria for discharge from the KMC Unit 30

31. KMC discharge and follow up Follow up factors Availability and accessibility of health facility with KMC capacity. Ability of the mother to return to the health facility with KMC. Supportive family systems to encourage follow up and continuity of KMC Availability of a functional community unit for support. Criteria for discharge from the KMC Unit 31

32. Guidelines for follow-up After discharge from the facility KMC unit A baby weighing <2500g continues KMC at home. Follow up will be at the discharging facility / nearest health facility offering KMC. CHP continues routine newborn care follow up as below: A day after the scheduled follow up date at a health facility to check scheduled visit and reinforce any health messages. Conducts more frequent visits for a preterm baby. 32

33. Guidelines for follow-up Where there is no functional Community Unit Baby is followed up at the nearest health facility every week while on KMC until they attain a weight of 2500gms. Baby should be seen at the POPC monthly up to the age of 24 months. 33

34. Care during Follow up visits Assess and manage danger signs in the baby Assess for any breastfeeding challenges Assess immunization status Assess growth and development Reinforce KMC messages Address any concerns from the mother Practice FCC 34

35. Guidelines for discontinuation of KMC Discontinued when the baby attains 2500gms Ensure child continues with supplements (Vit D3, folate, calcium, phosphorus and iron) up to one year of age 35

36. Readmission to facility KMC Unit Readmit baby to hospital if: The baby gained less than 15g/kg/day in two consecutive weekly follow up visits The baby has not gained weight at all The baby has lost weight There is no one to continue providing KMC and baby is less than 2000g Has any danger signs 36

37. 4. Supportive Environment KMC is continued at home when mother and baby are discharged. For KMC at home to be successful, it requires the support from: Family members Health Care worker Community 37

38. Family Support Provide physical, spiritual, financial psychological and emotional support both at home and whilst in the KMC Unit A surrogate can provide KMC to allow the mother to relax Provide adequate nutritional support for the mother Support the mother to refrain from unhealthy habits like substance abuse, child neglect, etc. Encourage male involvement (fathers, partners) 38

39. Health care providers (facility and community based) Health care providers need to be updated on the knowledge, skills and competencies in KMC. Health care staff should: Oversee the medical care of newborns in KMC providing diagnosis and treatment. Collaborate with other healthcare professionals in the multidisciplinary team to ensure the well-being of infants Support families through the neonatal care journey. Lead inter-disciplinary and family meetings Confirm that mother is stable including mental status 39

40. Health care providers ctd … Explain to the mother the KMC concept, benefits and demonstrate how it is done Facilitate integration of family members Encourage formation of support groups including mother to mother pairing to support each other Support any issues that the mother may have Advocate for behaviour change in the community to minimize stigma on KMC 40

41. Community Support Promote facility-community linkage through CHPs Encourage acceptability of KMC by the community Behaviour Change Communication( BCC) Dispel myths and beliefs about the small babies: no name, has no future, Encourage male involvement Advocacy for KMC Supportive community environment 41

42. KMC Monitoring tools KMC Register Daily Score Sheet Preterm Growth Chart Monthly Summary Form 42

43. Challenges Strong beliefs in technology Apparent simplicity of KMC Cultural barriers Stigma Non adherence by mothers and health workers Inadequate infrastructure Can be tiring for the mother 43

44. Solutions for KMC challenges Surrogate can assist the mother Provide correct information about KMC Institutional support for KMC BCC for community Community sensitization and utilization of KMC champions at all levels Health worker supervision, mentorship, and regular feedback forums. Mother /caregiver to be offered regular psychosocial support by health workers and KMC champions. 44

45. KMC Video 45

46. Questions ? 46

47. KMC has been shown to reduce morbidity and mortality in preterm/LBW newborns Should be initiated immediately after birth for stable/unstable newborns< 2500g Family centered care is key in supporting KMC Summary 47