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3

Principles of Kangaroo Mother Care

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Contents

Objectives

When you have completed this unit you should be able to:

Introduction to kangaroo mother care

3-1 What is Kangaroo Mother Care?

Kangaroo Mother Care (or skin-to-skin care), is a simple, easy method of caring for newborn infants where the mother uses her own body temperature to keep her infant warm. Kangaroo Mother Care (KMC) is particularly useful for nursing low birth weight infants (infants with a birth weight below 2500 g). KMC provides the infant with the basic needs for survival, i.e. mother’s warmth, stimulation, breast milk, love and protection. As 20 million low birth weight (LBW) infants are born each year worldwide, KMC has become a very important way of caring for these high risk infants. Unfortunately, attempts to lower the prevalence of low birth weight infants in poor countries has not been successful.

Note
KMC reminds one of the way mother kangaroos (and other marsupials) care for and keep their infants warm in a special pouch. The mother kangaroo carries her infant against her body both day and night. While in the pouch, the infant is warm, protected and able to suckle whenever it wants.

The word ‘mother’ was added to kangaroo mother care to emphasise the importance of the mother and her breast milk. As the word ‘kangaroo’ is foreign to many people in South Africa, it may be preferable to talk about skin-to-skin care instead. The Zulu word ‘ukugona’ (to hold or cuddle) has also been suggested.

3-2 Where did Kangaroo Mother Care start?

The idea of nursing an infant skin-to-skin against the mother’s bare breasts is not new and has probably been used for thousands of years. However, the idea was made popular in modern times by health care workers in Bogotá, the capital of Colombia in South America. From here it has been introduced into many developed and developing countries.

Note
Doctors Rey and Martinez first started KMC in Bogotá, Colombia during 1979 in response to a crisis with the large number of low birth weight infants, a shortage of staff and facilities, overcrowded nurseries and a high mortality from hospital infection.

3-3 Why is Kangaroo Mother Care natural?

Many animals give birth to young who are not immediately able to run and follow their mother. They have to be carried by the mother or hidden away while she looks for food and water. Humans and other primates (e.g. monkeys and baboons) carry their newborn infants, either in their arms or against their bodies. The infant is emotionally and physically programmed to remain constantly with the mother. As these infants are relatively immature when they are born, they need constant care for some time after delivery. In this position the infant grows and develops rapidly. KMC is therefore a ‘natural’ way of nursing a human infant. Many women want to keep their infants close to them. Using their own bodies to keep their infant warm gives many mothers a sense of satisfaction and pleasure.

Note
In hunter-gatherer societies and most non-western cultures, mothers demonstrated the ‘carry’ pattern of infant care. The infant is always with the mother and breastfeeds frequently. In contrast, many animals such as small antelope and hares, demonstrate the ‘nesting’ pattern of care, where the infants are hidden while the mother searches for food. In the artificial environment of western society, this latter pattern of infant care has become common. Infants are often left alone to sleep in a cot or pram. Many believe it is not the best pattern of caring for a human infant. KMC is a return to a natural method and often preferable to incubator care.

3-4 What are the components of Kangaroo Mother Care?

KMC consists of four components:

  1. Kangaroo position (skin to skin contact)
  2. Kangaroo nutrition
  3. Kangaroo support
  4. Kangaroo discharge

3-5 What is the kangaroo position?

Usually the infant is placed in an upright position against the mother’s bare chest and between her breasts. The infant is kept naked except for a nappy, socks and woollen cap. Both mother and infant are usually covered by a blanket or shirt. The kangaroo position is also called skin-to-skin contact, as much of the infant’s skin is in direct contact with the mother’s skin.

Note
The kangaroo position is regarded as the optimal habitat or place for newborn infants. In this place infants exhibit specific non-stress behaviour patterns such as ‘crawling’ towards the nipple and ‘self attachment’.

The kangaroo position is also known as skin-to-skin contact.

3-6 What is kangaroo nutrition?

Exclusively breast feeding on demand. With KMC, most infants are either breast fed or fed expressed breast milk by cup or nasogastric tube. Most small infants should be fed every two hours. One of the benefits of KMC is that these infants have easy access to their mother’s breasts.

3-7 What is the advantage of kangaroo nutrition?

With KMC, successful breast feeding is common and most infants are discharged home on breast feeds. The duration of breast feeding is also much longer. With KMC, many infants as immature as 30 weeks can begin breast feeding. KMC increases the volume of milk that a mother produces.

Note
Before KMC was introduced, it was believed that infants had to reach about 35 weeks gestation before they could suck and swallow adequately. However, with KMC it was noticed that many much more immature infants could be partially or completely breast fed.

Successful breastfeeding is promoted by kangaroo mother care.

3-8 What is kangaroo support?

This is the physical and emotional support which is given when KMC is practiced.

  1. Support must be given by the nursing and medical staff to the mother to assist and encourage her to provide KMC.
  2. The whole family should be informed about KMC. They may also need to be supported by the staff. In turn, the family should support the mother. The role of the father or partner is important in supporting the mother. The support of the mother-in-law is also helpful.
  3. The mother’s own mother has a very important role to play in helping her to give KMC.
  4. The community should also be told about the advantages of KMC. A supportive attitude by the community helps the mother to succeed with KMC.
  5. When introducing KMC into a hospital or clinic, the staff often also need support.

Without support, it is difficult to get mothers to give KMC successfully. Pregnant women should be informed and educated about KMC from their first antenatal visit.

3-9 What is kangaroo discharge?

With kangaroo discharge, the mother leaves the hospital with her infant in the kangaroo position and continues to provide KMC at home. This practice has many advantages both to the mother and her infant. Most low birth weight infants can be discharged home earlier if KMC is used. By reducing the time that these small infants stay in hospital, hospital costs and staffing can be reduced. Mothers can get home to their families sooner. However, with early discharge (kangaroo discharge), adequate follow-up care and support are essential.

Predischarge planning is important. Each mother should practice KMC while her infant is still in hospital. She should also make arrangements for her return home and emotionally prepare herself for KMC after discharge. The family must be told that the infant will be receiving KMC at home.

Low birth weight infants can be discharged home earlier with Kangaroo Mother Care.

3-10 Why is Kangaroo Mother Care so important for low birth weight infants?

KMC is particularly important when caring for low birth weight (LBW) infants in poor countries where there is often a high mortality rate in hospitals which cannot offer sophisticated care. These small infants often die of hypothermia (cold) or infection. Studies have shown that the number of low birth weight infants dying in hospitals without incubators can be dramatically reduced if KMC is introduced. Even in industrialised countries, the mortality rates can be reduced with KMC.

Conventional incubator care for low birth weight infants is often problematic in poor countries. Not only are there not enough incubators, but they are expensive, often not used correctly, are broken and cannot be repaired. They are not cleaned properly and the power supply is often unreliable.

Kangaroo Mother Care has reduced the mortality rate of small infants.

Note
Infants who are delivered before term often die as a result of being born too soon. With KMC, a mother is able to give her infant the protection, warmth and nutrition that she would have given if the pregnancy had continued and the infant was still a fetus. With KMC, the mother can complete the ‘gestation’ outside the uterus. Twenty million LBW are born worldwide annually. Of these 96% are born in poor countries where only 1% of the world’s incubators are available.

3-11 Can Kangaroo Mother Care be used for all infants?

KMC can be used in the majority of infants, whether they are born in hospital, a clinic or at home. While KMC is most important in low birth weight infants, infants of normal weight and gestational age can also benefit from KMC, especially in cold conditions.

While the principles of providing KMC are important, the details are not fixed and inflexible. The technique varies slightly between different countries and services. Mothers are also individuals who have their own ideas and preferences. The dress and customs in different communities also influences how KMC is given. What is important is for the whole community, but especially women, to understand the advantages of KMC and to support other women who are giving their infants KMC.

During antenatal care visits women should be told about KMC and allowed to decide whether they would like to give KMC to their infant.

3-12 When should kangaroo mother care be started?

If both mother and infant are well enough, KMC should be started immediately after birth once the infant is dried, examined and the cord cut. Many low birth weight infants can be given KMC from birth. Normal infants can also be given KMC for the first few hours after delivery to promote bonding, encourage breastfeeding and prevent hypothermia. Infants who are ill at birth should receive KMC once they have recovered and their clinical condition is stable. While a small infant is still unstable and being nursed in an incubator, the mother should be taught how to express her breasts so that the infant can be given breast milk as soon as possible. All women who choose to breastfeed, especially women giving KMC, should learn how to express breast milk.

Kangaroo Mother Care should be started as soon as possible after birth.

Note
A recent study has shown that very small infants who cry well at birth and do not have respiratory distress experience fewer problems during the first few hours of life if they are given KMC rather than standard incubator care.

Advantages of kangaroo mother care

3-13 What are the advantages of kangaroo mother care?

There are many advantages of KMC to:

  1. Mothers:
    • The mother’s confidence and bonding is encouraged. They feel less stressed.
    • Mothers are empowered to play an active role in their infant’s care.
    • Breast feeding is promoted.
    • Less neglect and abandonment.
  2. Fathers:
    • Fathers are able to play a far greater role in the care of their infants.
    • It improves bonding between fathers and infants, which is particularly important in countries with high rates of violence towards children.
  3. Infants:
    • Most low birth weight infants can be kept warm and stable with KMC.
    • Infants grow faster.
    • Serious infection is less common in the infant.
    • Less apnoea (stopping breathing).
  4. Health care providers:
    • Fewer staff and less equipment are needed in hospital nurseries.
    • Infants can be discharged home earlier.
    • It is cheaper.

KMC moves the mother back into the position where she can play a meaningful role in the care of her infant. KMC also enables her to choose breast feeding above formula feeding.

3-14 What are the disadvantages of separating mother and infant after birth?

KMC keeps the mother and infant together. If the infant is separated from its mother, it becomes stressed. This may be harmful. Only in modern times have women in western traditions been separated from their newborn infants who have been nursed alone in incubators or cots in hospital. This is the price that is often paid when small infants have to be moved to an intensive care unit. At home, many infants are again separated from their mothers when they are placed in cots, often in another room.

Note
Both human infants and young animals that are separated from their mothers after birth display the features of protest and despair. When prolonged, this stress response has been shown to be harmful. Many people believe this to be a cause of behavioural disorders. In contrast, infants receiving KMC exhibit a ‘vagal response’ which promotes growth and development and speeds up the adjustment from an intra-uterine to an extra-uterine existence. The mother and infant pair is often referred to as a ‘dyad’ to emphasise that they should be kept together.

Mothers and their infants should be kept together.

3-15 Is Kangaroo Mother Care safe?

Yes. Most small infants can be safely and efficiently nursed with KMC once their clinical condition is stable. Many scientific studies on human and animal infants have shown that KMC can be as safe as conventional incubator care for stable, small infants. The infant is kept warm, heart and respiratory rates are normal, there is less apnoea and bradycardia (slow heart rate) and fewer episodes of cyanosis (turning blue). It is important that KMC is demonstrated and supervised by staff trained in this method. Mothers should be taught what danger signs to look for (e.g. breathing difficulties or cyanosis).

Note
Many scientific studies have demonstrated that almost all measurements of wellbeing are better in infants receiving KMC when compared to infants nursed under overhead radiant heaters or in closed incubators. The infant’s skin and core temperatures remain within the physiological range with KMC. Survival rates are the same for infants receiving KMC or conventional incubator care once they are stabilised.

Very small infants, sick infants and infants with complications are best cared for in incubators where they can be closely monitored and treated. Once they are stable with normal vital signs and no major complications, they can be considered for KMC.

3-16 How does Kangaroo Mother Care keep the infant warm?

The temperature of the skin over the mother’s breasts warms the infant’s naked skin. This is a very effective way of both keeping an infant warm and of warming a cold infant. If the infant is cold the mother’s skin becomes warmer. When the infant becomes too hot, the mother’s skin cools down. In this way, the temperature of the infant receiving KMC is kept in a very narrow range (often with better control than an infant in a servocontrolled incubator). A woollen cap helps to keep the infant warm during KMC. In cold weather the infant can wear a cotton jacket which is open in front.

Note
The temperature of an infant receiving KMC is slightly higher than that of an infant in an incubator. With KMC, the mother’s skin temperature may rise as much as 2° C to keep the infant warm.

3-17 How does Kangaroo Mother Care reduce the risk of apnoea and bradycardia?

It is probably the constant temperature together with the mother’s movement, breathing and heart sounds that stimulate the infant and reduce apnoea and bradycardia. This is very different to the infant in a conventional closed incubator, which makes a constant sound and does not move. Infants in incubators cry more and then sleep deeply from exhaustion. Infants nursed by KMC also require less oxygen and have better oxygen saturation in their blood. They also sleep for longer.

Note
Studies have confirmed that the number of apnoea and bradycardia spells is less with KMC while the oxygen saturation and oxygen consumption are improved. Infants also have more quiet sleep with KMC. They sleep for longer but not so deeply.

3-18 How is breastfeeding promoted by Kangaroo Mother Care?

Many studies have confirmed that more women successfully breast feed for longer with KMC. Breast milk production is also better and more infants are discharged home fully breast fed if KMC is practiced. KMC promotes a feeling of wellbeing in the mother as she can see and touch her infant all the time. This stimulates milk production and helps with the let-down reflex. KMC is a very important benefit in many poor communities where breast feeding reduces the risk of infant death. It is important that the opportunity to feed is available continuously day and night.

Note
The secretion of both prolactin and oxytocin is inhibited when a mother is anxious, unhappy, worried and separated from her infant.

3-19 Do mothers have to breast feed if they give Kangaroo Mother Care?

No. If for some good reason the mother is unable to breast feed, or is advised not to breast feed, the kangaroo position can still be used. Some very small infants are fed expressed breast milk by nasogastric tube or cup while receiving KMC. Mothers can also give formula feeds while using the KMC position. If the infant is formula fed, the formula should preferably be given by cup rather than by bottle. Kangaroo nutrition (exclusive breast feeding) is, therefore, desirable but not essential for KMC.

3-20 Why does Kangaroo Mother Care improve a mother’s confidence?

By having her infant with her all the time, a mother giving KMC becomes both confident and competent in the way she handles her infant. Mothers prefer KMC as they feel more satisfied, relaxed and fulfilled by the experience. Mothers feel less anxious if their infant is with them.

Most women feel relaxed and happy giving KMC and do not find it stressful and exhausting. However, they need the support of the hospital staff and their families.

Note
KMC helps to restore a mother’s self esteem, which is often low after delivering a low birth weight infant.

3-21 Why do infants receiving Kangaroo Mother Care have fewer infections?

Low birth weight infants, cared for in incubators or cots in a newborn nursery, are at high risk of becoming colonised and infected by hospital bacteria which have become resistant to many antibiotics. In contrast, infants being given KMC tend to become colonised with the mother’s own skin bacteria. As the cells and antibodies in a woman’s breast milk are produced in response to her own bacteria, a mother’s breast milk is specifically protective against those bacteria, which colonise her infant (‘designer milk’). A number of studies have shown that infants receiving KMC have fewer serious infections, such as necrotising enterocolitis, than other infants who do not receive KMC. This is one of the main benefits of using KMC to care for small infants in both poor and wealthy countries. Therefore, KMC and breast milk act together to reduce infections.

Low birth weight infants receiving Kangaroo Mother Care have fewer serious infections.

3-22 How can Kangaroo Mother Care save money?

  1. Breast feeding saves the cost of buying formula.
  2. Fewer nurses are needed as the mother provides most of the care to her infant.
  3. Less hospital equipment, such as incubators, are required.
  4. With less infection, fewer infants have to be admitted for intensive or special care.
  5. Small infants can be discharged home sooner.

3-23 When can infants receiving Kangaroo Mother Care be discharged home?

Infants receiving KMC can be discharged home (kangaroo discharge) when all the following criteria are met:

  1. They are healthy and gaining weight (at least 20 g per day).
  2. They are breast feeding or cup feeding well.
  3. The mother is confident and able to manage her infant.
  4. Good follow-up care is arranged.

Weight and gestational age need not be used as strict criteria for KMC discharge. The maturity of the infant is more important, i.e. feeding well. The weight at which most infants receiving KMC are discharged home varies from one hospital to another. With KMC, infants can be discharged home much earlier than with conventional care. With early discharge from hospital, it is important that these infants are seen frequently at a follow up clinic for the first few weeks.

Note
With the use of KMC, many hospitals discharge their infants when their weight reaches between 1500 and 1700 g. These infants should be gaining at least 15 g/kg/day.

3-24 When is Kangaroo Mother Care for low birth weight infants useful in hospitals?

There are three circumstances when KMC is particularly useful in the care of low birth weight infants in hospital:

  1. In hospitals where no facilities are available to look after low birth weight infants. Here KMC is the only alternative if there is a lack of incubators and nurses.
  2. In hospitals where staffing and facilities are good but limited and not sufficient to care for all the low birth weight infants. KMC is then used instead of conventional incubator care.
  3. In hospitals with good and adequate staffing and facilities. Here KMC is used to promote bonding between mother and infant, reduce the risk of infection, promote breast feeding and shorten hospital stay.

The survival rate of low birth weight infants given KMC is the same as that when conventional incubator care is provided.

3-25 Can the father also give Kangaroo Mother Care?

Yes. It is very important that the father also becomes involved in the care of the infant. This helps build a bond between the father and infant, and also helps the father support the mother in caring for their infant. In communities with a high rate of child abuse, KMC promises to improve the relationship between men and their children. This simple intervention may also improve the relationship between men and women in society.

Other family members, such as a sister or the grandmother, may also play an important role in giving KMC. They can give the mother a break to visit the bathroom or have some time for herself.

3-26 How is kangaroo support provided?

After the birth of an infant, the mother needs support in many different ways. KMC empowers the mother to meet all her infant’s needs. However, she in turn needs help:

  1. Emotional support: The mother needs encouragement if she is to give KMC successfully. Many young mothers with their first infant need an enormous amount of reassurance from family, friends and health professionals. KMC empowers mothers to meet all their infants’ needs.
  2. Physical support: During the first few weeks of KMC, nursing the infant takes up most of the mother’s time. Adequate rest and sleep are essential. Therefore, she needs support with household chores and managing the family.
  3. Educational support: It is important to give the mother the information she needs to understand the whole process of KMC and accept that KMC is important. She needs to be made aware of the many advantages of KMC. This makes the KMC experience more meaningful and increases the chances that she will give KMC successfully both in hospital and after discharge.

3-27 Why has Kangaroo Mother Care only been introduced recently?

Because health professionals believed that infants would develop problems, such as hypothermia, and apnoea, if they were taken out of the incubator too soon. Infection was also seen as a great risk if the mother handled her infant. Mothers were not viewed as capable of looking after a low birth weight infant. However, there are many reports of individual infants surviving with KMC after they had been refused standard incubator care because they were thought to be too small to survive.

3-28 Can Kangaroo Mother Care be used for transporting infants?

Yes. KMC is very useful in transporting small infant between clinics and hospital, especially if a transport incubator is not available. If the mother is not available, the ambulance staff can give KMC themselves.

Kangaroo Mother Care is a safe and effective method of transporting infants.

3-29 Is it safe to use Kangaroo Mother Care to warm up cold infants?

KMC is a very effective and safe method of warming infants with hypothermia (axillary temperature below 36.5° C). If an overhead heater or closed incubator is not available, KMC is the best method of warming cold infants. KMC has been shown to warm cold infants better than an incubator.

3-30 Should Kangaroo Mother Care be used in extremely small infants?

Infants that are extremely preterm and are not viable can also be given KMC. This ‘compassionate care’ of infants too small to survive is far better than simply leaving the infant to die in the labour ward or nursery. It helps the mother psychologically to come to terms with her bereavement.

3-31 What are the two types of Kangaroo Mother Care?

KMC can be given to small infants in two different ways:

  1. Intermittent KMC: This type of KMC is not given all the time but only when a mother visits her infant who is still being nursed in an incubator.
  2. Continuous KMC: With continuous KMC, the mother provides KMC all the time, both day and night.

3-32 When is intermittent kangaroo care used?

It is usually given to very small infants who are well but still need to spend most of the time in an incubator. During her visit in the nursery, the mother takes the infant out of the incubator and places the infant in the kangaroo position while she sits beside the incubator. This enables her to play an active part in the care of her infant while the infant is still in the nursery. Intermittent KMC can range from many hours per day to only once every few days. The length of time an infant spends in KMC can also vary from a few minutes to a few hours at a time. Even if the mother only gives KMC for 10 minutes during a visit, it is beneficial to her infant. Not only does this increase the infant’s weight gain but it also promotes breast feeding. Intermittent KMC allows the mother to learn and practice how to give KMC, which will help when the incubator is no longer needed and the infant is big enough for continuous KMC. It is important that nurses teach mothers how to provide KMC correctly.

Intermittent Kangaroo Mother Care in the nursery has many advantages for both mother and infant.

3-33 When is continuous Kangaroo Mother Care used?

It is usually used with low birth weight infants who are ready to be taken out of the incubator permanently. Some infants are only given continuous KMC when they are almost ready to be discharged home while some mothers provide KMC to their infants for many weeks before discharge. It is best given in a KMC ward but can also be used in a general postnatal ward. Mothers usually have experience from giving intermittent KMC before their start providing continuous KMC. This form of KMC should always be used for a small infant where there is no incubator available. Continuous KMC can also be practiced at home after small infants are discharged from hospital. In nurseries with very little equipment, even the smallest of infants receiving nasogastric tube feeds and oxygen can be given continuous KMC.

Intermittent KMC should be followed by continuous KMC as soon as possible.

3-34 What is a Kangaroo Mother Care ward?

This is a special ward where mothers and their infants are kept together so that KMC can be given all the time. Although supervised by the nursing staff, the mothers take responsibility for all their infant’s care. In a KMC ward, mothers support and learn from each other. A well managed KMC ward is of great benefit to a newborn nursery. A KMC ward provides a wonderful opportunity to also teach mothers about primary health care (immunisation, family planning, good nutrition).

3-35 Can infants receiving intensive care be given Kangaroo Mother Care?

As soon as infants are stable and no longer very ill, they can be given intermittent KMC, provided that they are monitored. Even infants receiving ventilation can sometimes be given intermittent KMC. Many stable infant receiving headbox oxygen can be safely placed in the KMC position and given oxygen by face mask or nasal cannulas.

3-36 Can infants be given Kangaroo Mother Care at home?

Yes. When small infants leave hospital, they should continue to receive KMC at home (home, ambulatory or domiciliary KMC) until they weigh at least 2000g. Intermittent KMC in the intensive care and high care nursery, followed by continuous KMC in the KMC ward, and finally KMC at home is an ongoing process. Many small infants born at home or in a clinic will thrive and survive with home KMC. Infants receiving KMC at home must be seen frequently at the local clinic to check that they are healthy and gaining weight. Clinics should have a KMC room where mothers can give KMC and breastfeed their infants.

3-37 Should mothers with HIV infection give Kangaroo Mother Care?

Yes. KMC is particularly important in these women, even if they decide not to breast feed. They can nurse their infant in the kangaroo position and give formula feeds by cup. KMC has many benefits to HIV exposed infants who are often low birth weight and at increased risk of bacterial infections. Many HIV positive women in rural areas may choose to exclusively breast feed their infants.

Kangaroo Mother Care can be used safely in HIV positive mothers.

Case study 1

During the antenatal period, a woman arranges to deliver in a primary care clinic where Kangaroo Mother Care (KMC) is encouraged. Her husband agrees with her choice and says that he also wants to help by giving KMC.

1. What is KMC?

KMC, or Kangaroo Mother Care, is a method of caring for an infant where the mother nurses her infant against her bare breasts. The infant, who usually only wears a woollen cap and a nappy, is kept upright, often with a towel, piece of cloth or binder. The mother wears a dress or shirt over the infant. This is known as the KMC position.

2. What is KMC nutrition?

Most infants who are nursed in the KMC position are breast fed. However, expressed breast milk can also be given by cup or nasogastric tube during KMC. Breast feeding is an important part of KMC and is referred to as KMC nutrition. However, a mother can still use the KMC position if she wants to formula feed rather than breast feed. This is important in some mothers who are HIV positive and have chosen to formula feed. If formula is given, a cup rather than a bottle should be used.

3. What is KMC support?

This is the help, encouragement and support provided to a mother by the father, family and community. This physical and emotional support helps a mother to successfully give KMC.

4. How can the father also give KMC?

The father and other members of the family or a friend can also give KMC. This is helpful when the mother goes to the bathroom or wants a little time alone. KMC promotes bonding between a father and his infant and should improve the later emotional relationship between a father and his child.

5. When should KMC be started?

It is best to start KMC immediately after the infant is born. Once the infant is dried, examined, and the cord is cut, it can be given to the mother to start KMC. Most healthy infants can be given KMC even if they are small at birth.

6. Which infants benefit most from KMC?

Low birth weight infants, who would otherwise have to be separated from their mother to be cared for in an incubator or crib in a nursery. This is particularly important in poor countries where incubators may not be available.

Case study 2

A young, primiparous woman delivers a healthy, active 36 week infant weighing 1800 g. The infant has good Apgar scores with no clinical problems. When the mothers asks to keep the infant with her and nurse the infant in the KMC position, the staff tell her that the infant is too small and must spend the first 12 hours in an incubator. The mother is transferred to the postnatal ward and does not see her infant until the following day.

1. Do you agree with the decision of the staff to place the infant in an incubator?

No. There appears to be no reason why the mother and infant should be separated and why she cannot give KMC to her infant.

2. What are the advantages of this infant staying with its mother?

Remaining with the mother from birth promotes bonding, increases the chances of successful breast feeding and reduces the risk of infection in the infant. It is also cheaper as extra staff and equipment are not needed. In addition, infants getting KMC can be discharged home sooner.

3. Is it not safer to observe this infant in an incubator in the nursery for a few hours?

No. With KMC the infant can be kept warm and breast feeding can be started. As this infant is healthy and active, there is no danger in giving KMC. The infant should only be moved into an incubator if there are abnormal signs such as cyanosis, respiratory distress or apnoea. Healthy, active infants should be given KMC.

4. Why is KMC a more natural method of caring for a newborn infant?

Most primates carry their infants against their bodies after birth. Similarly, many human mothers feel a great desire to keep their infants with them. Using their own bodies to keep their infant warm, gives mothers a sense of satisfaction and pleasure. Many mothers feel this is the normal and natural way to care for their infant.

5. Why do infants receiving KMC have fewer serious infections?

Because they are colonised with their mother’s bacteria rather than the dangerous bacteria often found in nurseries. Breast feeding also reduces the risk of infections. Therefore, KMC and the use of breast milk act together to prevent serious infections.

Case study 3

A mother visits her small, preterm infant who is nursed in an incubator. The infant weighs only 1200 g but is otherwise well and active. She sits beside the incubator and spends hours looking at and talking to her infant.

1. Would it be safe for her to take the infant out of the incubator and give it KMC?

Most well preterm infants who still need incubator care can be taken out of the incubator and given KMC during the time that the mother visits. This is known as intermittent KMC.

2. What are the benefits of intermittent KMC?

It promotes bonding and breast feeding and usually results in faster weight gain by the infant. Intermittent KMC allows the mother to play an active part in caring for her infant and helps to reduce the risk of infection.

3. Is it safe to give KMC in cold weather?

KMC is a very effective method of keeping an infant warm. If the infant’s skin temperature drops, the mother’s skin temperature increases to keep the infant warm.

4. What is continuous KMC?

Once an infant no longer needs to spend part of the time in an incubator, it can be given continuous KMC day and night. Continuous KMC is usually given in a KMC ward in the hospital until the mother and infant are discharged.

5. When can infants receiving KMC in hospital be discharged home?

Once they are healthy and gaining weight, breast or cup feeding well, the mother is confident and able to manage her infant, and follow up care is arranged. Weight and gestational are less important as criteria for discharging KMC infants home from hospital.

6. Can KMC be safely used to transport small infants?

Many small infants who are clinically well can be safely transported with KMC. This is especially useful when a transport incubator is not available. If the mother is not able to travel with the infant, a nurse or member of the ambulance crew can give KMC.

Case study 4

An HIV positive women delivers a healthy infant weighing 2300 g at term. She has read about kangaroo mother care and is keen to try but the nursing staff tell her that it is dangerous as she may transmit HIV to her infant, especially if she breast feeds. Therefore the infant is taken away from her after delivery and sent to an isolation nursery for formula feeding.

1. Is it dangerous for this mother to hold her infant in the kangaroo position after birth?

No. The mother and infant should not have been separated. Using the kangaroo position immediately after delivery is important as it promotes bonding. HIV cannot be transmitted by skin-to-skin contact between a mother and her infant.

2. Can KMC be used even if the mother does not breast feed?

Yes. Although there are four components to KMC, the infant and mother can still benefit from the kangaroo position, support and discharge even if she decides not to breast feed her infant.

3. Do you agree with the management of this infant?

No, as there is no indication to isolate the infant even if the mother does not breast feed. The question of feeding choices should have been discussed and decided upon during pregnancy. Some HIV infected mothers may choose to exclusively breast feed.

4. When should women be informed about the benefits of kangaroo mother care?

This should be an important part of antenatal education.

5. Are there problems with the term kangaroo mother care?

Although KMC is widely used some people would rather talk about skin-to-skin care. This however promotes the position and not the benefits of good nutrition, the emotional, physical and educational support and the early discharge.