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Kangaroo Mother Care (or skin-to-skin care) is a method of caring for newborn infants. The infant is nursed between the mother’s bare breasts in direct contact with her skin. Kangaroo Mother Care (KMC) is particularly useful for nursing low birth weight infants (infants with a birth weight below 2500 g). KMC is a way of keeping mother and infant together.
It is often not easy to get KMC started in a hospital or clinic as both medical and nursing staff may think that KMC is dangerous and will result in more work and expense. Any new idea is difficult to introduce at first. A clear description of KMC, together with the advantages and safety must be presented to all the staff, including the senior management. Allow time for discussion where questions and fears can be raised. KMC will not be successful unless the staff are convinced that it can be done and will benefit mothers and infants.
It is very useful if a few of the staff can visit a hospital where KMC is being used successfully. Here they can see KMC at first hand. It would also help to invite a few staff members from another hospital, where KMC has been established, to present a talk on their experience.
KMC is a radical change from the traditional western model of caring for small infants. The main obstacles to the introduction of KMC are fixed ideas and attitudes. Introducing KMC into a service represents a major shift in the way infants are managed. All the staff must ‘buy in’ to this new method of mother and infant care or it will not be successful
The implementation of KMC depends on the following:
Every maternal and neonatal service should have both a Kangaroo Mother Care policy and a clear set of guidelines. Health care workers, managers, policy makers and funders need to be convinced that KMC offers better, more cost effective care.
All the staff must be encouraged and trained to help mothers provide Kangaroo Mother Care to their small infants.
The KMC policy is a written statement which gives the benefits of KMC and commits the service to implement and promote KMC. It does not have to be a long and complicated document. The KMC policy must be displayed for staff and patients to see.
KMC guidelines explain how KMC is implemented. Formal written protocols are needed in the guidelines. Copies of the guidelines must be freely available in hospitals and clinics where KMC is practiced.
It may be useful to get copies of the KMC policy and guidelines from another service where KMC is used successfully. These documents can guide the process of writing the KMC policy and guidelines in your service. KMC should be promoted as a safe, effective and affordable method of caring for newborn infants.
There are no fixed rules for KMC. Each hospital and clinic has their own preferences while each mother has her own likes and dislikes about KMC. However, it is important that the principles and guidelines are followed.
All members of the staff, including nurses, doctors and administrators. In order that KMC succeeds, the whole staff must support the idea and play a roll in writing the KMC policy and guidelines. Every mother should know about KMC. The general public should also know about KMC. In particular, the infant’s grandmothers needs to be educated to support KMC both in hospital and at home.
The practice of Kangaroo Mother Care should be supported and promoted by all members of the staff.
Many mothers have never heard about KMC and are afraid to give KMC, especially to small infants. Often mothers feel that their infant will receive better care in an incubator. Therefore, the benefits, safety and method of giving KMC must be explained to the mother. Once the community learns about KMC, many mothers will ask if they can also give KMC to their infants. The method, advantages and implications of KMC should be discussed with the mother as soon as a low birth weight infant is born. She needs to know that she may have to stay longer in hospital, give KMC when the infant is discharged home, and attend a follow up clinic.
It is important that the general public knows about and understands the benefits of KMC. The media has an important role to play in promoting KMC. The following can be used to inform the public about KMC:
Kangaroo Mother Care should be promoted among the general public.
From the start of antenatal care when KMC should be included as an important part of educating pregnant women. The best method of teaching women about KMC during the antenatal period is for them to see other mothers providing KMC for their infants. Videos can be shown at antenatal clinics and information sheets can be provided to inform pregnant women about KMC.
When small infants are first admitted to a newborn nursery for incubator care, their mothers must be told that they will need to provide intermittent KMC as soon as their infants are well enough. They will also need to give continuous KMC for a few days before their infants are discharged home.
All pregnant women should know about Kangaroo Mother Care.
This is a group of mothers who have themselves given their infants KMC. They are very effective in promoting KMC and helping other mothers to provide KMC. They can give KMC education at antenatal clinics or encourage and assist mothers to give KMC in the nursery or KMC ward. Members of the support group can also teach mothers how to express breast milk. This assistance can be of enormous help to the nursing staff, especially in hospitals and clinics where staffing is inadequate. While some helpers are voluntary, others may need to be paid a small fee. Even a few hours help each day will be very useful. Someone needs to be identified to start and manage a KMC support group.
Because these clinics will be involved in providing follow up care to mothers who are giving KMC to their small infants after discharge from hospital. Therefore, the clinic staff will also need information and training in KMC.
The almost naked infant (wearing only a nappy and woollen cap) is placed between the mother’s bare breasts. If the room is cold, the infant can wear a cotton shirt, open in front. The infant is nursed upright, facing the mother with the arms and legs flexed in the frog position, under the mother’s shirt, blouse, T-shirt or dress. Keeping the infant upright helps to prevent vomiting. All mothers should be taught how to nurse their infant in the KMC position. The mother does not need to shower or wash her chest before giving KMC.
Figure 4-1: The almost naked infant is placed between the mother’s bare breasts.
It is important that the infant is kept warm and held securely. Holding the infant skin-to-skin, chest-to-chest against the mother will keep the infant warm. The mother should have her hands free and be able to walk around. A number of methods are used to keep the infant in place:
Special binders or carrying pouches are commercially available and can be helpful.
Figure 4-2: The infant is secured by the mother’s clothing, a blanket or towel or a special pouch or carrier.
No special equipment is needed to give Kangaroo Mother Care.
Most infants can be given KMC as long as they are stable with a normal skin temperature, heart rate and breathing rate. Both infants in cots and incubators can be given KMC. Even infants on ventilators can sometimes be given KMC provided that their condition allows this KMC has the most benefit in low birth weight infants. All low birth weight infants should routinely be offered KMC once they are stable.
Where there are no incubators, every very small infant can be given KMC. In these circumstances, KMC can dramatically reduce the mortality of low birth weight infants.
Severely ill infants who are going to die can also be given KMC (compassionate KMC). Many parents want to hug or hold their dying infant.
KMC should be given every time the parents visit (intermittent KMC). The mother should be encouraged to give KMC throughout the visit. Even if the visit is short, the infant will benefit from KMC. Some mothers spend most of the day in the nursery and can give KMC for hours at a time. Usually KMC is given for a short period to start with and then the time of the KMC becomes longer as the mother becomes more confident.
The mother needs to be shown how to remove the infant and how to put the infant back into the incubator safely. Once the mother is able to do this correctly, she can take the infant out and put it back by herself. It is important that the mother informs the nursing staff when she wants to give KMC. She must always wash her hands well before touching her infant.
It is important that the infant does not get cold. Before removing the infant, make sure that it is wearing a woollen cap and clean nappy. If the infant is receiving an intravenous infusion or has skin probes, be careful that they are not pulled loose.
It is best if the mother sits next to the cot or incubator in a comfortable chair. Once the infant is well and no longer needs ventilatory support, intravenous infusions (drips) and skin probes or electrodes, the mother may give KMC while walking about with the infant in the nursery.
No special facilities are needed. Comfortable chairs for the mother and partner are required. Simple plastic chairs are adequate. A refrigerator is helpful to store expressed breast milk. In a very crowded nursery, space must be created for parents to visit and give KMC.
This is usually not necessary if the infant’s temperature has been stable in the incubator.
As far as possible, give the infant its mother’s own milk. Exclusive breast feeding is by far the best for low birth weight infants. Some small infants will breastfeed while others will have to be fed expressed breast milk by nasogastric tube until they are mature enough to suck and swallow. Some mothers will choose to give formula feeds. Theses infants should be fed by cup rather than bottle.
Exclusive breast feeding is by far the best for low birth weight infants.
With encouragement, many small infants will take part or all of their feed from the breast. The mother should start to express her breasts from the day the infant is born. Until breastfeeding is established, the infant should be fed expressed breast milk by cup or nasogastric tube.
Often mothers have difficulty visiting their infants every day as they live far away and transport is expensive and infrequent. It is very helpful if these mothers can stay in or near the hospital on a 24 hour basis so that they can give intermittent KMC to their infants in the nursery.
This facility is often called a lodging ward. However, it is not a typical hospital ward as these mothers are well. It is one or more rooms where mothers can be given accommodation. Often the lodging ward is next to the nursery and KMC ward so that they can share facilities. The lodging ward needs to be supervised to ensure cleanliness and security but nursing is not required. Mothers in a lodging ward need a bed, somewhere to sit and relax, and a place to keep their clothes and belongings safely.
A lodging ward provides a mother with a place to stay so that she can be near her infant in the nursery at all times.
It is not expensive to accommodate mothers in a lodging ward. By providing breast milk and giving KMC, they reduce the hospital cost of caring for small infants. Without a lodger ward, many mothers would be discharged home and would not be able to afford the transport to visit their infants regularly.
This is a special room where mothers can room-in for a few days so that they can give continuous KMC to their infants under supervision both day and night. Most of these mothers are well and do not need nursing care or routine observations. Every effort must be made to make the KMC ward as homely as possible and not look like a typical hospital ward. Mothers are encouraged to wear their own clothes and walk around. The KMC ward should be close to the nursery if possible. Ideally, a door should link the KMC ward with the nursery so that help can be obtained if needed. Limited visiting is allowed in the KMC ward but the mothers’ privacy must be respected.
A ‘KMC ward’ enables the mother to give her infant Kangaroo Mother Care both day and night while being supervised by the staff.
At night most mothers prefer to sleep on their backs with the infant on their chest and their head and shoulders propped up with pillows into a semi-sitting position. Other mothers sleep on their side with the infant still in the KMC position.
A dedicated KMC ward provides a very valuable step between giving intermittent KMC in the nursery and giving continuous KMC at home. In a KMC ward mothers gain experience and confidence before going home with their infants. Mothers support, teach and encourage each other.
Cribs are not needed in a KMC ward as the infants are continuously with their mothers. However, plastic bassinettes are sometimes used to bath infants. The room temperature should be 22–24 °C.
Mothers should be able to give KMC during meals. Daily showering or washing is adequate. Mothers must wash their hands after going to the toilet. Facilities for washing clothes are needed.
Some facilities can be shared with the lodging ward. Mothers in the lodger ward can be encouraged and supported by meeting mothers in the KMC ward. In future all neonatal nurseries should be designed with both a KMC ward and a lodging ward nearby.
The following is recommended:
There should be no cots in the KMC ward. The mother can wrap up her infant and leave it on the bed when she goes to the toilet. If there is not enough space for chairs, mothers will have to sit on their beds, and have their meals in another room nearby.
It makes an enormous difference if the KMC ward is attractively painted, new curtains and bed covers are made, and posters or murals of KMC are put on the walls. Funding can usually be obtained from local charities.
A nurse is needed to supervise the mothers in the KMC ward. It helps that most mothers have already been trained in KMC before they reach the KMC ward. It is important to have a nurse who is experienced and enthusiastic about KMC. A professional nurse is preferable. However, a non-professional nurse can be used as the KMC ward supervisor. It is helpful but not essential to have a nurse in the KMC ward at night. If a nurse is not available, the KMC ward must be close to the nursery so that the mothers can call for help if needed. Usually a team of two or three nurses is needed to provide adequate day cover in a KMC ward. The nurse should have experience in caring for low birth weight infants and be able to recognise an ill infant.
Volunteers (lay helpers) are of great help in a KMC ward. They can encourage mothers, help them give KMC and teach them to express their breast milk if necessary. A kind, motherly person who has breast fed and given KMC to her own infant is an ideal helper. Many helpers only work one or two days a week, often in the mornings. Some helpers may need funds for transport or a small payment for their time.
Usually only well, thriving infants are admitted to the KMC ward. However, if infants below 1500 g or infants still being fed by nasogastric tube are admitted, then an experienced nurse is needed both day and night. Good cord care must not be forgotten.
The mother’s stay in a KMC ward provides an ideal opportunity for education. It is important that the nurses in the KMC ward are able to provide education, not only about giving KMC but also about other aspects of health. Talks, discussion groups, demonstrations and educational videos are used. Topics, which should be taught in the KMC ward, include:
The main problems in a KMC ward are boredom and frustration. Other than education, activities such as knitting woollen caps, reading magazines and arts or crafts should be encouraged. A radio and television set with a video or CD player are useful as are a kettle, toaster and microwave oven. Community groups can be invited to help with some of these activities. Smoking must not be allowed.
Teenagers are naturally rebellious and often do not easily accept any form of authority. An unhappy teenager may disrupt the normal routine in a KMC ward and they may require support and understanding from the staff. Weekends are often most difficult for teenagers who want to be with their friends. They may also be anxious about their boyfriend or partner.
Many mothers in both the lodger and KMC wards may need ‘time out’ to go home for a few days. This is important for women who have other children at home. Some may have spent weeks or months in hospital. While she is away, her infant will have to go back into an incubator in the nursery. Mothers rarely stay away for more than a few days as most have already formed a strong bond with their infant during intermittent KMC. It gives them time to prepare for the infant’s arrival at home.
When the mother is able and confident to care for her infant at home. The weight and gestational age of the infant are less important than its maturity. Usually the infant is discharged from the KMC ward when both mother and infant are ready.
The following criteria should be met before the mother and infant are discharged from the KMC ward:
Care in the KMC ward should be seen as a step between discharge from the nursery and discharge home. Most mothers only need to spend a few days in the KMC ward unless their infant is very small. Infants are usually discharged home when they are 1500 g or more. Many KMC wards discharge their mothers when the infants reach 1800 g. Infants receiving KMC are often discharged a little later in the cold season. The better the follow up facilities, the sooner infants can be discharged home.
Some funding is needed to establish a KMC ward. Thereafter, there is a small cost to the hospital for running a KMC ward, as the mothers need food and bedding. Sometimes mothers may have to bring their own food and bedding. The KMC ward has to be cleaned and staff are needed to supervise the mothers. However, there is a great financial saving because:
A Kangaroo Care Mother ward makes a great financial saving for the hospital.
Similarly, it is cost efficient to run a lodging ward.
Many hospitals have obtained funding for their KMC ward from private institutions, charity groups and service organisations.
The word ambulatory means to ‘walk around’. Ambulatory KMC usually refers to the KMC which is given after the infant has been discharged home from the hospital or clinic. These mothers give home (or ambulatory) KMC throughout the day. Most work in the house (e.g. washing up) can be done while giving KMC. Mothers can give KMC while walking around in or near their homes. Ambulatory KMC should also be given when attending the clinic, visiting friends, on the bus or going shopping. Many low birth weight infants need KMC for days or weeks after they are discharged home. Mothers must be convinced of the benefits of KMC and committed to give KMC at home.
Ambulatory Kangaroo Mother Care is given when the mother and infant are both well and the mother is able to walk around with her infant.
Infants that still weigh less than 2000 g would benefit greatly from KMC at home. Some infants between 2000 g and 2500 g would also benefit from KMC, especially when it is cold.
Low birth weight infants can benefit from ambulatory Kangaroo Mother Care at home after discharge from hospital.
It is best to give ambulatory KMC all the time. It can be given while the mother performs most household duties. When she is not able to give ambulatory KMC, the infant should be given KMC by another responsible member of the household. KMC can be given outside the home when the mother goes shopping, catches a bus or train, or attends the local clinic.
As many of these infants are still small when they are discharged home, they should be seen regularly at the hospital or community based local clinic to check that the infant is well and the mother is managing. The infant’s weight must be measured to ensure that the infant is receiving adequate feeds and gaining weight. Failure to gain weight must always be carefully assessed. The clinic visit gives an opportunity to discuss KMC with the mother. Any problems can be identified and corrected.
The smaller the infant, the more frequently the infant should visit a clinic. Below 1500 g, daily checkups are needed. From 1500 g and above, three to four visits a week until 1800 g. Thereafter, weekly visits until the infant reaches 2500 g. These recommendations should be seen only as a guide, and will depend on the mother, on her family and support systems, on distances and ease of access to the clinic, and on how the infant is growing. More frequent follow up may be needed in the cold season.
Many mothers giving ambulatory KMC to small infants at home spend most of their day in the KMC room at the local clinic. Here the staff can support and supervise the mothers. Some facilities have a special KMC clinic. This may be a better option than keeping mothers and their infants in an overcrowded hospital.
Frequent follow up visits at a Kangaroo Mother Care clinic are essential for low birth weight infants getting Kangaroo Mother Care at home.
Infants usually decide for themselves when KMC can be stopped. As infants get older and their weight increases with more subcutaneous fat, they become hot and restless during KMC and try to climb out of the mother’s dress. Mothers of low birth weight infants should try to continue KMC until at least 2000 g is reached. By 2500 g, most infants no longer need KMC. However, these infants still need close contact with the mother, and breastfeeding. Keeping older infants on their mother’s back or in a sling is recommended.
Yes. Many stable newborn infants can be safely transported with KMC. This is a cheap and very effective method, as a transport incubator is not needed. If the infant is sick or unstable, it is still safer to use a transport incubator.
It is unacceptable for a small infant to arrive cold at a hospital because a transport incubator was not available when KMC could have been used. KMC can also be used to warm cold infants.
Usually the mother gives KMC. However, a nurse or member of the transport team can also give KMC if the mother is not well enough or is not moved with the infant. Even the father or grandmother could provide KMC during transport. Every effort must be made to keep the mother and infant together. Some KMC training is needed by the transport staff.
Delays are avoided, as there is no need to wait for a transport incubator. This is particularly important when moving low birth weight infants to a level 2 or 3 hospital. It is also very useful when moving well low birth weight infants back to the referral hospital. This avoids many of the problems that commonly occur when arranging transport. KMC in a motor car or van is ideal for transferring well, low birth weight infants.
Kangaroo Mother Care can be used to transport infants.
KMC is usually given by the mother when transporting infants. She needs to be supervised by a member of the ambulance staff or an accompanying nurse. Usually the ambulance staff alone are able to supervise KMC during transport.
Yes. It is best if the mother sits in the back seat and wears a seat belt. Only the hip belt should be used. The seat belt should not be placed over the infant but between the mother and her infant. The infant can be tied to the mother’s chest with a towel. Make sure that the infant’s neck is not flexed as this may interfere with breathing.
A mother attending antenatal care says that she has read about KMC in a magazine and wants to know how this is done. The clinic staff are unable to help her as they have no experience of KMC.
All the staff members at the clinic should know about KMC. The staff who care for her at the antenatal clinic must give her the information that she needs. Giving information on KMC is an important part of antenatal care. Videos or CDs are a very useful way of teaching pregnant women about KMC.
Through the schools, radio and TV, newspapers and magazines, and health care facilities.
The grandmother. The whole family should support a mother giving KMC.
At the beginning of her pregnancy as soon as she starts antenatal care. There is a possibility that any pregnant woman might deliver preterm and need to give KMC to a small infant.
The mother of a 1500 g newborn infant visits the nursery. Her infant appears healthy and is being nursed in an incubator. The infant is still being fed by nasogastric tube. The nursery staff ask the mother whether she is willing to give KMC during the times that she visits her infant. They show her how to express her breast milk.
No. Most small infants can be given KMC, especially if they are healthy and stable.
For the whole of the time that she visits her infant. The more time she spends giving KMC the better.
It is important to encourage bonding between the infant and both parents. Therefore, the father should also have an opportunity to give KMC. This will also help him understand and support the mother when she gives KMC.
All that is needed is a comfortable chair. It is best if the mother is able to give KMC beside the incubator.
Because the infant needs expressed breast milk feeds as it is still too immature to suck. One of the most important skills that all mothers should learn is how to express their milk.
The matron of a maternity hospital calls a meeting of her staff. She is keen to start a KMC ward as the well baby nursery is grossly overcrowded. She asks how KMC can be given by mothers who are already living at the hospital to be near their infants. She also needs to know what equipment will be required and whether this will be very expensive.
Overcrowding is a very common problem in hospital nurseries. The overcrowding, with the resultant stress on the staff and high rate of infection, will be greatly improved if a KMC ward is started.
A space for the mothers to sleep, a living area where they can eat and relax, and toilets and showers.
A room will be needed where mothers and their infants can stay together. One of the rooms previously used for mothers of infants in the nursery could probably be converted into a KMC ward.
Simple beds, comfortable chairs, lockers for clothes, and tables and chair for meals.
An experienced and enthusiastic nurse will be needed to supervise the mothers. Staffing is far less than that required in a well baby nursery. However, staff need to have the skills necessary to teach and support KMC. Volunteers are also very useful to assist in a KMC ward.
Some funding will be required to start the KMC ward. Thereafter, the savings to the hospital will be greater than the running costs.
The young mother of a low birth weight infant gave intermittent KMC while visiting her infant in the nursery. Later she stayed with her infant for 5 days in a KMC ward. At discharge the infant was healthy, breast feeding well and gaining weight. The infant’s discharge weight was 1750 g. On the day after discharge she was asked to attend the local well baby clinic.
It is safe to discharge this infant provided that it is healthy, feeding well, gaining weight and receiving KMC.
All the time, both day and night. Someone else reliable can give KMC if the mother needs a break.
On the day after discharge and then three or four times a week until a weight of 1800 g is reached. Thereafter, weekly visits are usually adequate. With very small infants receiving ambulatory KMC at home, it is best for the mother and infant to visit the clinic every day so that the infant’s weight gain can be checked and the mother supported.
When the infant reaches 2500 g.
A mother is transferred to a level 2 hospital on the day after delivery for investigation of a heart murmur noted during labour. Her well 1700 g infant is not moved with her as the transport incubator is broken. She is very upset about being separated from her newborn infant.
They should not have been separated. The infant should have been moved with the mother.
The mother could have given KMC.
A nurse or ambulance driver or her partner or the grandmother could have given KMC on the way to hospital.