PMK WHO.doc

8/14/2019 PMK WHO.doc

http://slidepdf.com/reader/full/pmk-whodoc 1/73

k a n g a r o o mother care

A p r a c t i c a I g u i d e



KANGAROO MOTHER CARE

Department of Reproductive Health and Research WorldHealth OrganizationGeneva



WHO Library Cataloguing-in-Publication Data

World I]ciilIII Organization.

Kangaroo mother cure ; a ractical guide!

" .In#ant cart - methud$ %&n#u r' curt - oryiini(alicm and

udmini$trattcm .)lii#em! Premature *." nlant! Lo+ birth! +eight ,.rea$t

#eeding ./uideline$ 0.1anual$ l.2itle

", 3 4 n & "56/55 I 74l !1 cla$$i#ication8 W, *"/9

: World Health Organization %//

All rights reserved. Publications of the World Health Organization can be obtained fromMarketing and Dissemination, World Health Organization, 2 Avenue A!!ia, "2""#eneva 2$, %&itzerland 'tel( )*" 22 $+" 2*$- fa( )*" 22 $+" */0$- email(

bookorders1&ho.int. 3e4uests for !ermission to re!roduce or translate WHO !ublications 5 &hether for sale or for noncommercial distribution 5 should be addressedto Publications, at the above address 'fa( )*" 22 $+" */- email(

!ermissions1&ho.int.

6he designations em!lo7ed and the !resentation of the material in this !ublication donot im!l7 the e!ression of an7 o!inion &hatsoever on the !art of the World HealthOrganization concerning the legal status of an7 countr7, territor7, cit7 or area or of itsauthorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines onma!s re!resent a!!roimate border lines for &hich there ma7 not 7et be full agreement.

6he mention of s!ecific com!anies or of certain manufacturers8 !roducts does not im!l7that the7 are endorsed or recommended b7 the World Health Organization in !referenceto others of a similar nature that are not mentioned. 9rrors and omissions ece!ted, thenames of !ro!rietar7 !roducts are distinguished b7 initial ca!ital letters.

mailto:[email protected]






6he World Health Organization does not &arrant that the information contained in this !ublication is com!lete and correct and shall not be liable for an7 damages incurred as aresult of its use.

Printed in :rance



2<L= O> CO42=42,

?LO,,<3@

<3=)I<2IO4,

". Introduction $

"." 6he !roblem 5 im!roving care and outcome for lo&5birth5&eight babies $".2 ;angaroo mother care 5 &hat it is and &h7 it matters /".< What is this document about= +".* Who is this document for= +".0 Ho& should this document be used= +

%. =Aidence ""

". Mortalit7 and morbidit7 "2".$ >reastfeeding and gro&th "<"./ 6hermal control and metabolism "*".+ Other effects "*"." 3esearch needs "0

. 3eBuirement$ "$

"."" %etting "$"."2 Polic7 "/"."< %taffing "/"."* Mother "+

"."0 :acilities, e4ui!ment and su!!lies "+"." :eeding babies 22"."$ Discharge and home care 2<

*. Practice guide 20

"."/ When to start ;M? 20"."+ @nitiating ;M? 2$".2 ;angaroo !osition 2$".2" ?aring for the bab7 in kangaroo !osition 2+".22 ength and duration of ;M? <".2< Monitoring bab78s condition <"

".2* :eeding <*".20 Monitoring gro&th *"".2 @nade4uate &eight gain *<".2$ Preventive treatment **".2/ %timulation **".2+ Discharge **".< ;M? at home and routine follo&5u! *

3=>=3=4C=, *$



<44==, 0"

".<" 3ecords and indicators 0"

".<2 >irth &eight and gestational age 0<".<< ?onstraints 0*

.+t-5.

2<L=,

".<* 6he effect of ;M? on breastfeeding "*".<0 Amount of milk 'or fluid needed !er da7 b7 birth &eight and age *".< A!!roimate amount of breast milk needed !er feed b7 birth &eight and age *".<$ Mean birth &eights &ith "th and +th !ercentiles b7 gestational age 0<".</ @m!lementing ;M? 0*

ILL',23<2IO4,

".<+ Holding the bab7 close to the chest 2".* ?arr7ing !ouches for ;M? babies 2"".*" Dressing the bab7 for ;M? 2"*a Positioning the bab7 for ;M? 2$*b >ab7 in ;M? !osition 2/*c Moving the bab7 in and out of the binder 2/0 %lee!ing and resting during ;M? <

: a t h e r 8 s turn for ;M? <"$ >reastfeeding in ;M? </ 6 u b e 5 f e e d i n g in ;M? *"

<3=)I<2IO4,

>W o& birth &eight;M? ;angaroo mother care3?6 3andomized controlled trial3D% 3es!irator7 distress s7ndrome

.+t-5.

?LO,,<3@

6erms in this glossar7 are listed under ke7 &ords in al!habetical order.

<ge

Chronological age8 age calculated from the date of birth.?e$tational age8 age or duration of the gestation, from the last menstrual !eriod to birth.Po$t-men$trual age8 gestational age !lus chronological age. irth

2erm birth8 deliver7 occurring bet&een <$ and *2 &eeks of gestationalage. Preterm birth8 deliver7 occurring before <$ &eeks of gestationalage. Po$t-term birth8 deliver7 occurring after *2 &eeks of gestationalage.



irth +eightLo+-birth-+eight in#ant8 infant &ith birth &eight lo&er than 20g 'u! to and including

2*++g, regardless of gestational age. )ery lo+-birth-+eight in#ant8 infant &ith birth&eight lo&er than "0g 'u! to and

including "*++g, regardless of gestational age. =Etremely lo+-birth-+eight in#ant8 infant&ith birth &eight lo&er than "g 'u! to and including +++g, regardless of gestational age.Different cut5off values are used in this guide since the7 are more useful for clinical

!ur!oses. ody temeratureHyothermia8 bod7 tem!erature belo& <.0B?.

?ro+thIntrauterine gro+th retardation8 im!aired gro&th of the foetus due to foetal disorders,maternal conditions 'e.g. maternal malnutrition or !lacental insufficienc7. 1ilF(#eeding

>oremilF8 breast milk initiall7 secreted during a breast feed.Hind milF8 breast milk remaining in the breast &hen the foremilk has been removed'hind

milk has a fat content and a mean caloric densit7 higher than foremilk. <lternatiAe #eedingmethod8 not breastfeeding but feeding the bab7 &ith e!ressed breast milk b7 cu! or tube-e!ressing breast milk directl7 into bab78s mouth. Preterm(#ull-term in#ant

Premature or reterm in#ant8 infant born before <$ &eeks of gestational age. Pretermin#ant aroriate #or ge$tational age 7<?<98 infant born !reterm &ith birth &eight bet&een the "th and the +th !ercentile for hisCher gestational age. Preterm

in#ant $mall #or ge$tational age 7,?<98 infant born !reterm &ith a birth &eight belo& the "th !ercentile for hisCher gestational age. >ull-term in#ant $mall #or

ge$tational age 7,?<98 infant born at term &ith birth &eight belo& the "th !ercentile for hisCher gestational age. ,mall baby8 in this guide, a bab7&ho is born !reterm &ith lo& birth &eight. ,table reterm or lo+-birth-+eight in#ant8a ne&born infant &hose vital functions 'breathing and circulation do not re4uire

continuous medical su!!ort and monitoring, and are not subect to ra!id and une!ecteddeterioration, regardless of intercurrent disease.

Note: Throughout this document babies are referred to by the personal pronoun "she" or

"he" in preference to the impersonal (and inaccurate!) "it". The choice of gender is

random.

.+t-5.



".

Introduction

+




1.1 The problem - improving care and outcome for low-birth-weight babies

%ome 2 million lo&5birth5&eight '>W babies are born each 7ear, because of either !reterm birth or im!aired !renatal gro&th, mostl7 in less develo!ed countries. 6he7

contribute substantiall7 to a high rate of neonatal mortalit7 &hose fre4uenc7 anddistribution corres!ond to those of !overt7.", 2 >W and !reterm birth are thus associated&ith high neonatal and infant mortalit7 and morbidit7.<, * Of the estimated * millionneonatal deaths, !reterm and >W babies re!resent more than a fifth. 0 6herefore, the careof such infants becomes a burden for health and social s7stems ever7&here.

@n affluent societies the main contributor to >W is !reterm birth. 6he rate has beendecreasing thanks to better socioeconomic conditions, lifest7les and nutrition, resulting inhealthier !regnancies, and to modern neonatal care technolog7 and highl7 s!ecialised andskilled health &orkers.

@n less develo!ed countries high rates of >W are due to !reterm birth and im!airedintrauterine gro&th, and their !revalence is decreasing slo&l7. %ince causes and

determinants remain largel7 unkno&n, effective interventions are limited. Moreover,modern technolog7 is either not available or cannot be used !ro!erl7, often due to theshortage of skilled staff. @ncubators, for instance, &here available, are often insufficient tomeet local needs or are not ade4uatel7 cleaned. Purchase of the e4ui!ment and s!are !arts, maintenance and re!airs are difficult and costl7- the !o&er su!!l7 is intermittent,so the e4ui!ment does not &ork !ro!erl7. Ender such circumstances good care of !retermand >W babies is difficult( h7!othermia and nosocomial infections are fre4uent,aggravating the !oor outcomes due to !rematurit7. :re4uentl7 and often unnecessaril7,incubators se!arate babies from their mothers, de!riving them of the necessar7 contact.

Enfortunatel7, there is no sim!le solution to this !roblem since the health of an infantis closel7 linked to the mother8s health and the care she receives in !regnanc7 andchildbirth.

:or man7 small !reterm infants, receiving !rolonged medical care is im!ortant.Ho&ever, kangaroo mother care ';M? is an effective &a7 to meet bab78s needs for&armth, breastfeeding, !rotection from infection, stimulation, safet7 and love.

"10



1.2 Kangaroo mother care - what it is and why it matters

;angaroo mother care is care of !reterm infants carried skin5to5skin &ith the mother. @t is a !o&erful, eas75to5use method to !romote the health and &ell5being of infants born !reterm as&ell as full5term. @ts ke7 features are(

❖ early, continuous and prolonged skin-to-skin contact beteen the mother and the baby

❖ eclusi#e breastfeeding (ideally)

❖ it is initiated in hospital and can be continued at home

❖ small babies can be discharged early

❖ mothers at home re$uire ade$uate support and follo-up

❖ it is a gentle, effecti#e method that a#oids the agitation routinely eperienced in a busy

ard

ith preterm infants.

@t &as first !resented b7 3e7 and Martinez, 5/

+ in >ogota, ?olombia, &here it &as develo!ed as an alternative to inade4uate andinsufficient incubator care for those !reterm ne&born infants &ho had overcome initial

!roblems and re4uired onl7 to feed and gro&. Almost t&o decades of im!lementation andresearch have made it clear that ;M? is more than an alternative to incubator care. @t has

been sho&n to be effective for thermal control, breastfeeding and bonding in all ne&borninfants, irres!ective of setting, &eight, gestational age, and clinical conditions. ",

Most !ublished e!erience and research concerning ;M? comes from health facilities,&here care &as initiated &ith the hel! of skilled health &orkers. Once a mother &as confidentin the care she gave her bab7, she continued it at home under guidance and &ith fre4uentvisits for s!ecialised follo&5u!.

9vidence of the effectiveness and safet7 of ;M? is available onl7 for !reterm infants&ithout medical !roblems, the so5called stabilised ne&born. 3esearch and e!erience sho&that(

❖ %&' is at least e$ui#alent to con#entional care (incubators), in terms of safety and

thermal

protection, if measured by mortality.

❖ %&', by facilitating breastfeeding, offers noticeable ad#antages in cases of se#ere

morbidity.

❖ %&' contributes to the humaniation of neonatal care and to better bonding beteen

mother

❖and baby in both lo and high-income countries.%&' is, in this respect, a modernmethod of care in any setting, e#en here epensi#e

technology and ade$uate care are a#ailable.

❖ %&' has ne#er been assessed in the home setting.

Ongoing research and observational studies are assessing the effective use of this method insituations &here neonatal intensive care or referral are not available, and &here health&orkers are !ro!erl7 trained. @n those settings ;M? before stabilisation ma7 re!resent the

best chance of health7 survival. ""

*,+

"*,

6his guide &ill therefore refer to ;M? initiated at a health facilit7 and continued at home

under the su!ervision of the health facilit7 'domiciliar7 ;M?. ;M? as described in thisdocument recommends continuous skin5to5skin contact ackno&ledging that it might not be

""



!ossible in all settings and under all circumstances. 6he !rinci!les and !ractice of ;M?outlined in this document are also valid for intermittent skin5to5skin contact, !rovidedade4uate care is offered to >W and !reterm ne&born infants &hen the7 are se!arated from

their mothers. %uch intermittent skin5to5skin contact has been sho&n to be beneficial,"0

" if

"2



".*2com!lemented b7 !ro!er incubator care. #uidance on skin5to5skin care ma7 be used forre&arming ne&born infants &ith h7!othermia or kee!ing them &arm during trans!ortation to

the referral facilit7.What is this document about?

6his document describes the ;M? method for care of stable !retermC>W infants 'i.e.those &ho can breath air and have no maor health !roblems &ho need thermal !rotection,ade4uate feeding, fre4uent observation, and !rotection from infection.

@t !rovides guidance on ho& to organize services at the referral hos!ital and on &hat isneeded to introduce and carr7 out ;M?, focusing on settings &here resources are limited.

9vidence for the recommendations is !rovided"$

"/ &henever !ossible. Ho&ever, for man7 statements, es!eciall7 those related to secondar7

!rocedures, sound evidence is not available as in man7 other fields of health care. @n these

cases, the tet re!orts the e!erience of health !rofessionals &ho have im!lemented ;M? for

man7 7ears, man7 of &hom carefull7 revised !revious versions of this document.

:or breastfeeding counselling and su!!ort, readers should refer to reastfeeding'ounselling: Training 'ourse - Trainers /uide.0 :or H@F and infant feeding, refer to 123and 2nfant 4eeding 'ounselling: Training 'ourse - Trainers /uide.

".*<Management of medical !roblems of small babies is not !art of this guide. :urtherguidelines can be found in tetbooks or the WHO document &anaging neborn problems.

guide for doctors, nurses and midi#es.Who is this document for?

6his tet has been !re!ared for health !rofessionals in charge of >W and !retermne&born infants in first referral hos!itals in settings &ith scarce resources.

@t is not &ritten for all !otential care !roviders. Practical instructions 'or !rotocols ada!tedto the categories of health &orkers available in different settings should be !re!ared locall7.

@t is also aimed at decision5makers and !lanners at national and local levels. 6he7 need tokno& &hether ;M? suits the needs of their health s7stems, &hether it is !ractical andfeasible, and &hat is re4uired to im!lement it successfull7.

".** ow should this document be used?

;M? guidelines have to be ada!ted to s!ecific circumstances and available resources atnational or local level. 6his document can be used to develo! national and local !olicies,guidelines and !rotocols from &hich training material can be develo!ed. 6his documentcannot, as it stands, be used for training !ur!oses. Other training material and activities,es!eciall7 on breastfeeding su!!ort and counselling on H@F and infant feeding, are needed toac4uire all the necessar7 skills. We ho!e that !re5service institutions &ill include those skillsin their curricula.

.+t-*5

67

5

.

"<



KANGAROO MOTHER CAREKANGAROO MOTHER CARE



%.

=Aidence

"0




6his cha!ter revie&s the evidence on ;M?, from both develo!ing and develo!edcountries, &ith regard to the follo&ing outcomes( mortalit7 and morbidit7- breastfeedingand gro&th- thermal !rotection and metabolism, and other effects. 6he e!erience &ith;M? has been revie&ed b7 several authors,"2, "<, ", 2", 22 and in a s7stematic revie&.2< We

also !resent evidence on the acce!tabilit7 of the intervention for mothers and health5carestaff.

While revie&ing the evidence, regardless of the outcome, it became clear that it &asim!ortant to highlight t&o essential variables( time of initiation of ;M?, and dail7 andoverall duration of skin5to5skin contact.

6ime of initiation of ;M? in the studies under consideration varied from ust after birth to several da7s after birth. ate initiation means that the !retermC>W infantshave alread7 overcome the !eriod of maimum risk for their health.

ength of dail7 and overall duration of skin5to5skin contact also varied from minutes

'e.g. < minutes !er da7 on average to virtuall7 2* hours !er da7- from a fe& da7s toseveral &eeks. 6he longer the care, the stronger the !ossible direct and causal association bet&een ;M? and the outcome. :urthermore, &hen ;M? &as carried out over a long !eriod of time, care &as !redominantl7 !rovided b7 the mother rather than the nursingstaff or the conventional incubator.

%ome other variables that might have affected the outcome of ;M? are(

❖ the position in hich the baby as kept

❖ the changes in the type and mode of feeding

❖ the timing of discharge from the institution and the transition to home care

❖ condition at discharge

❖ the intensity of support and follo-up offered to mothers and families afterdischarge from the institution.

Man7 other factors 'e.g. social conditions, environment and health care, es!eciall7services offered for ;M? ma7 be associated &ith the !ositive effects observed in ;M?studies. @t is ver7 im!ortant to se!arate the effects of these factors from those derivingfrom ;M?. >elo&, in revie&ing the evidence, &e tr7 to address those additional factors.

Go !ublished stud7 on ;M? &as found in the contet of high H@F !revalence among

mothers.

"16



2.1 !ortality and morbidity

Clinical trial$

6hree !ublished randomized controlled trials '3?6 com!aring ;M? &ith conventionalcare &ere conducted in lo&5income countries.2*52 6he results sho&ed no difference in survival

bet&een the t&o grou!s. Almost all deaths in the three studies occurred before eligibilit7, i.e. before >W infants &ere stabilised and enrolled for research. @nfants &eighing less than2g &ere enrolled after an average !eriod of < 5"* da7s on conventional care, in urbanthird5level hos!itals. 6he ;M? infants sta7ed in hos!ital until the7 fulfilled the usual criteriafor discharge, as the control infants did, in t&o of the studies,2*, 2 &hile in the third stud7 the7&ere discharged earlier and subected to a strict ambulator7 follo&5u!. 20 6he follo&5u!

!eriods lasted one,2 si2* and t&elve months,20 res!ectivel7.

6he 3?6 carried out in 9cuador b7 %loan and collaborators sho&ed a lo&er rate of severe

illness among ;M? infants '0 than in the control grou! '"/.2*

6he sam!le size re4uiredfor that stud7 &as <0 subects !er grou! for a total of $ infants, but onl7 < babies &ererecruited. 3ecruitment, in fact, &as interru!ted &hen the difference in the rate of severeillness became a!!arent. 6he other controlled studies conducted in lo&5income countriesrevealed no significant difference in severe morbidit7, but found fe&er hos!ital infections andreadmissions in the ;M? grou!. ;ambarami and collaborators from Iimbab&e also re!ortedreduced hos!ital infections.2$ High5income countries re!ort no difference in morbidit7.Ho&ever, it is notable that no additional risk of infection seems to be associated &ith skin5to5skin contact.

Observational studies sho&ed that ;M? could hel! reduce mortalit7 and morbidit7 in !retermC>W infants. 3e7 and Martinez,2*52$

+ in their earl7 account, re!orted an increase in hos!ital survival from < to $ in infants

bet&een "g and "0g. Ho&ever, the inter!retation of their results is difficult becausenumerators, denominators and follo&5u! in the ;M? grou! &ere different from those in the

historical control grou!.2/ >ergman and Jurisoo, in another stud7 &ith an historical control

grou! conducted in a remote mission hos!ital &ithout incubator care in Iimbab&e,"* re!orted

an increase in hos!ital survival from " to 0 in infants &eighing less than "0g, and

from $ to + in those &eighing bet&een "0 to "+++g. %imilar results are re!orted from

a secondar7 hos!ital in nearb7 Mozambi4ue."0 6he difference in survival, ho&ever, ma7 be

due to some uncontrolled variables. 6he studies in Iimbab&e and Mozambi4ue, conducted in

hos!itals &ith ver7 limited resources, a!!lied ;M? ver7 earl7 on, &ell before >W and

!reterm infants &ere stabilized. @n the earl7 stud7 b7 3e7 and Martinez, ;M? &as a!!lied

later, after stabilization. @n both cases the skin5to5skin contact &as maintained virtuall7 2*

hours a da7.

"$



?har!ak and collaborators, in a t&o5cohort stud7 carried out in >ogota, ?olombia,2+ found a

crude death rate higher in the ;M? grou! 'relative risk K ".+- +0?@( , to 0./, but their

results reverted in favour of ;M? 'relative risk K .0, +0?@( .2 to ".2 after adustment for

birth &eight and gestational age. 6he differences, ho&ever, &ere not statisticall7 significant.6he t&o cohorts recruited in t&o third5level hos!itals, sho&ed man7 social and economic

differences. ;M? &as also a!!lied after stabilization and 2* hours a da7. @n a controlled but

not randomized trial carried out in a tertiar75care hos!ital in Iimbab&e, there &as a slight

difference in survival in favour of the ;M? infants, but this might have been due to

differences in feeding.Conclu$ion

On balance the evidence sho&s that although ;M? does not necessaril7 im!rove survival,it does not reduce it. After stabilization, there is no difference in survival bet&een ;M? andgood conventional care. 6he h7!othesis that ;M? might im!rove survival &hen a!!lied

before stabilization needs to be further e!lored &ith &ell5designed studies. @f such an effecton survival eists, it &ill be more evident and easier to demonstrate in the !oorest settings,&here mortalit7 is ver7 high.

As for morbidit7, &hile there is no strong evidence of a beneficial effect of ;M?, there isno evidence of it being harmful. @n addition to the little evidence alread7 !ublished, 2$

"*, "0 some !reliminar7 results on a small number of ne&born infants &ith mild res!irator7

distress seem to confirm that ver7 earl7 skin5to5skin contact might have a beneficial effect.< A

&ord of &arning about discharge( ;M? infants discharged during the cold season ma7 be

more susce!tible to severe illness, es!eciall7 lo&er res!irator7 tract infections, than those

discharged during the &arm season.<" A closer follo&5u! is needed in such cases.

@t should be noted that all the studies so far have taken !lace in &ell5e4ui!!ed hos!itals, 7et

arguabl7 the most significant im!act of ;M? &ill be felt in settings &ith limited resources.6here is an urgent need for further research in these settings. @n the meantime, it seems that&here !oor conventional care is available, ;M? offers a safe substitute, &ith little risk ofraised morbidit7 or mortalit7.

2.2 "reastfeeding and growth

rea$t#eeding

6&o randomized controlled trials and a cohort stud7 carried out in lo&5income countrieslooked at the effect of ;M? on breastfeeding. All three studies found that the method

increased the !revalence and duration of breastfeeding.20,

2,

2+

%i other studies conducted inhigh5income countries, &here skin5to5skin contact &as a!!lied late and onl7 for a limitedamount of time !er da7, also sho&ed a beneficial effect on breastfeeding.<25<$ 6he results of allthese studies are summarized in 6able ".

@t a!!ears that ;M? and skin5to5skin contact are beneficial for breastfeeding in settings&here it is less commonl7 used for !retermC>W infants, es!eciall7 if these are cared for inincubators and the !revailing feeding method is the bottle. Other studies have sho&n a

!ositive effect of skin5to5skin contact on breastfeeding. @t could therefore be e!ected that theearlier ;M? is begun and the earlier skin5to5skin contact is initiated, the greater the effect on

breastfeeding &ill be.

?ro+th

"/



6he t&o5cohort stud7 conducted in ?olombia2+ revealed slo&er

&eight gain in ;M? infants &hen com!ared &ith the control

grou!, but the t&o cohorts also sho&ed man7 social and

economic differences. @n the subse4uent 3?620 no difference ingro&th &as observed at one 7ear of age. @n another 3?6,2

;M? infants sho&ed a slightl7 larger dail7 &eight gain &hile

the7 &ere cared for in hos!ital, but in the overall !eriod of

stud7 their gro&th did not differ from that of the control grou!.

%imilar results in terms of dail7 &eight gain &ere observed in

Iimbab&e.Table 1. The effect of KMC on breastfeeding

Study

Author Year Ref. Outcome KMC Control

RCT

Charpak etal.

1994

29 art!al or e"clu#!$e %rea#tfeed!n& at'

1 month 9() *+), month# *-) (*)1 year 41) 2()

RCT

Charpak etal.

199*

2 art!al or e"clu#!$e %rea#tfeed!n& at (month#

+2) *)

RCT

Cattaneo etal.

199+

2, /"clu#!$e %rea#tfeed!n& at d!#char&e ++) *-)

Schm!dt etal.

19+,

(2 0a!ly $olume ,4-ml

4--ml

0a!ly feed# 12 9

h!tela etal. 19++ (( 3rea#tfeed!n& at , eek# ) 2+)

ahl%er& etal.

1992

(4 3rea#tfeed!n& at d!#char&e **) 42)

Syfrett et al. 199(

( 0a!ly feed# (4 eek# of &e#tat!onala&e5

12 12

3laymore63!er

199,

(, 3rea#tfeed!n& at' d!#char&e 9-) ,1)

et al. 1 month -) 11)7ur#t et al. 199

*(* 0a!ly $olume at 4 eek# ,4*

ml(-ml

/"clu#!$e %rea#tfeed!n& at d!#char&e (*) ,)

".*0 Thermal control and metabolism

%tudies carried out in lo&5income countries2$

2 sho& that !rolonged skin5to5skin contact bet&een the mother and her !retermC>Winfant, as in ;M?, !rovides effective thermal control and ma7 be associated &ith a reducedrisk of h7!othermia. :athers too can effectivel7 conserve heat in ne&born infants</ des!ite aninitial re!ort of &orse !erformance of males in thermal control.

Heart and res!irator7 rates, res!iration, o7genation, o7gen consum!tion, blood glucose,slee! !atterns and behaviour observed in !retermC>W infants held skin5to5skin tend to be

similar to or better than those observed in infants se!arated from their mothers. <+

*5*2 ?ontact bet&een mother and child has other effects also. :or instance, salivar7 cortisol, an

"+



indicator of !ossible stress, a!!ears to be lo&er in ne&born infants held skin5to5skin. *< 6his

observation is consistent &ith the re!orting of significantl7 more cr7ing in full5term health7

infants + minutes after birth**, *0 and in >W and !reterm infants at months<< of age &hen

the7 are se!arated from their mothers.

".* #ther effects

2



;angaroo care hel!s both infants and !arents. Mothers re!ort being significantl7 lessstressed during kangaroo care than &hen the bab7 is receiving conventional care. Mothers

!refer skin5to5skin contact to conventional care2 and re!ort an increased confidence, self5esteem, and feeling of fulfilment, also in high5income countries. 6he7 describe a sense of

em!o&erment, confidence and a feeling that the7 can do something !ositive for their !reterminfants in different settings and cultures.*5*+ :athers too said that the7 felt relaed,comfortable and contented &hile !roviding kangaroo care. ;M? thus em!o&ers mothers andincreases their confidence in handling and feeding their >W and !reterm infants. 6essierand collaborators, using data from the 3?6 conducted in ?olombia, concluded that ;M?should be encouraged as soon as !ossible after birth because it im!roves bonding and makesmothers feel more com!etent.;M? is acce!table to health5care staff, and the !resence ofmothers in the &ard does not seem to be a !roblem. Most health &orkers consider ;M?

beneficial. 6he7 ma7 think that conventional incubator care allo&s better monitoring of sick>W and !reterm infants, but the7 recognize that it increases the risk of hos!ital infectionsand it se!arates infants from their mothers. Health &orkers &ould !refer ;M? for their o&n

!retermC>W infant.

o&er ca!ital investment and recurrent costs is 7et another advantage of ;M? and could bring about some savings to hos!itals and health care s7stems in lo&5income countries.%avings ma7 result from reduced s!ending on fuel, electricit7, maintenance and re!air ofe4ui!ment0

2

2 as &ell as !ossible reduction in staffing costs, since mothers !rovide the greater !ro!ortion

of care. ?om!ared &ith conventional incubator care, 9cuador 2* has re!orted lo&er costs !er

infant, in !art associated &ith a reduced rate of readmission to hos!ital. 6his ma7 !artl7 be

due to a shorter length of hos!ital sta7 in ;M? infants, re!orted from both lo& 2052$ and high5

income countries.<<, <0, * ?a!ital and recurrent savings ma7 be more substantial in tertiar7 than

in first5referral and small facilities in lo&5income countries.

2.$ %esearch needs

More evidence of the advantages of ;M? over other methods of care is needed, !articularl7 on(

❖ the effecti#eness and safety of %&' before stabiliation, in settings ith #ery limited

resources

(i.e. ithout incubators and other epensi#e technologies)

❖ breastfeeding and feeding supplements in 89 infants less than +* eeks of

gestational age

❖ simpler and reliable methods for monitoring the ell-being of %&' infants, especially

breathing

and feeding

❖ %&' in 89 infants eighing less than 555g, and in neborn infants ho are

critically ill

❖ %&' in #ery special circumstances, e.g. in #ery cold climates or in refugee camps

❖ cultural and managerial barriers that may hinder the implementation of %&', and

inter#entions that may foster it, particularly in settings ith #ery limited resources

❖ the implementation of %&' for 89 and preterm infants deli#ered at home ithout the

help

of trained personnel and ithout the possibility of referral to the appropriate le#el of

care.

2"



6his last situation ma7 &ell be the most im!ortant current source of !erinatal and neonatalmortalit7 and morbidit7. 6he evidence about the benefits of ;M? for >W and !reterminfants relates to those born and assisted in health facilities or &ho can benefit from careful

follo&5u! at home, not to those delivered at home. ?lear scientific evidence is needed toestablish the safet7 and suitabilit7 of domiciliar7 ;M? for babies born at home. Ho&ever,there is no evidence that such care &ould be harmful or less safe than current !ractice. @tmight be reasonable, unless future research sho&ed that other methods of home care &eremore effective, to recommend ;M? for the home care of >W and !reterm infants born athome and &ho cannot be taken to hos!ital. ocal culture and local activities to im!rove birthcare at home should be taken into account if such a recommendation &ere issued.

.+t-5.

22




6he most im!ortant resources for ;M? are the mother, !ersonnel &ith s!ecial skills and asu!!ortive environment. 6he re4uirements described in this cha!ter are formulation of !olic7,organization of services and follo&5u!, e4ui!ment and su!!lies for mothers and babies, andskilled !roviders for the facilities. %ome common constraints faced &hen im!lementing;M?, and !ossible solutions, are discussed in Anne @@@.

Fer7 small ne&born infants and those &ith com!lications are best cared for in incubators&here the7 can receive the necessar7 attention and care. As soon as the general conditionim!roves and the bab7 no longer needs intensive medical care, but sim!l7 &armth, !rotectionfrom infections and ade4uate feeding to ensure gro&th, ;M? can be the method of choice.

&.1 'etting

;M? can be im!lemented in various facilities and at different levels of care. 6he mostcommon settings &here such care can be im!lemented, are described belo&(

1aternity #acilitie$

%mall maternit7 units &ith several deliveries !er da7, these facilities are usuall7 staffed b7skilled mid&ives but often have no doctors and lack s!ecial e4ui!ment 'incubators andradiant &armers and su!!lies 'o7gen, drugs and !reterm formula for the care of >W and

!reterm ne&born infants. @f !ossible, such infants are transferred to a higher level of care-other&ise the7 are ke!t &ith their mothers and discharged earl7 for home care. H7!othermia,infections, res!irator7 and feeding !roblems contribute to high mortalit7 rates among thoseinfants.

3e#erral ho$ital$

6his categor7 includes a &ide range of s!ecial care units in district and !rovincial hos!itals.A common feature is the availabilit7 of skilled !ersonnel 's!ecialized nurses and mid&ives,

!aediatricians, obstetricians, or at least e!erienced !h7sicians and basic e4ui!ment andsu!!lies for s!ecial neonatal care. Ho&ever, in realit7, staff and e4ui!ment are often in shortsu!!l7( com!etent !h7sicians ma7 be available a fe& hours !er da7 onl7, small ne&born

infants are ke!t in large nurseries or &ards, sometimes in contact &ith older !atients. Motherscannot sta7 &ith their infants and the7 have difficult7 establishing and maintaining

2*!



breastfeeding. Mortalit7 ma7 also be high for the same reasons. Abandonment ma7 be acommon !roblem.

20



6here is a range of institutions bet&een the t&o t7!es of facilit7 mentioned above, &hereskilled health &orkers can !rovide ;M?.

".*$ (olicy

@m!lementation of ;M? and its !rotocol &ill need to be facilitated b7 su!!ortive healthauthorities at all levels. 6hese include the hos!ital director and the !eo!le in charge of thehealth care s7stem at district, !rovincial and regional levels.

A national !olic7 ensures a coherent and effective integration of the !ractice &ithin !re5eisting structures of the health s7stem and education and training.

Preterm babies are best born in institutions that can !rovide the s!ecial medical carere4uired for managing their fre4uent com!lications. 6hus, &hen a !remature bab7 is e!ected,the mother should be transferred to such an institution before birth. @f this is not !ossible, ver7

small babies or small babies &ith !roblems should be transferred there as soon as !ossible.6he referral s7stem should be organized in such a &a7 as to guarantee the safet7 of the bab7.

Gational standards and !rotocols need to be develo!ed for the care of small babies,including those mentioned above, once the7 have overcome the initial !roblems. %tandardsmust include clear criteria for monitoring and evaluation. 6hese can best be develo!ed b7 thea!!ro!riate !rofessional grou!s &ith the !artici!ation of !arents. :urthermore, local !rotocols&ill be easier to im!lement if national !olicies and guidelines are clearl7 set out.

?ontinuous monitoring and regular evaluation according to established criteria &ill hel!im!rove !ractice and design, and carr7 out research that ma7 hel! refine the method.

9ach health facilit7 that im!lements ;M? should, in its turn, have a &ritten !olic7 andguidelines ada!ted to the local situation and culture. %uch !olicies and guidelines &ill be moreeffective if the7 are agreed on b7 consensus, involving all the staff, &here !ossible, indevelo!ing local !rotocols based on national or international guidelines. 6he !rotocol shouldcover ;M? as !resented here, and should, of course, include follo&5u!. @t could also becom!lemented b7 detailed instructions on general !roblems 'e.g. h7giene of staff andmothers or on !roblems commonl7 occurring in !reterm infants 'e.g. !revention andtreatment of infection. After the introduction of the ;M? !rotocol, monthl7 meetings &iththe staff &ill be useful to discuss and anal7se data and !roblems, and to im!rove the !rotocolif necessar7.

".*/ 'taffing

;M? does not re4uire an7 more staff than conventional care. 9isting staff 'doctors andnurses should have basic training in breastfeeding and ade4uate training in all as!ects of;M? as described belo&(

❖ hen and ho to initiate the %&' method

❖ ho to position the baby beteen and during feeds

❖ feeding 89 and preterm infants

❖ breastfeeding

❖ alternati#e feeding methods until breastfeeding becomes possible

❖in#ol#ing the mother in all aspects of her babys care, including monitoring #ital signsand

2



recogniing danger signs

❖ taking timely and appropriate action hen a problem is detected or the mother is

concerned

2$



❖ deciding on the discharge

❖ ability to encourage and support the mother and the family.

9ach institution should have a !rogramme of continuing education in the area of ;M? and breastfeeding. Gursing and medical schools should include ;M? in their curricula as soon as !ossible.

".*+ !other

3esearch and e!erience sho& that mothers like ;M? once the7 have become familiar&ith it. ;M? must therefore be discussed &ith the mother as soon as a !reterm bab7 is bornand offered to her as an alternative to the conventional methods &hen the bab7 is read7.%ince ;M? re4uires the continuous !resence of the mother, it &ould be hel!ful to e!lain toher the advantages of each method and discuss &ith her the !ossible o!tions regarding bab7

care. %he must have time and o!!ortunit7 to discuss the im!lications of ;M? &ith herfamil7, since this &ould re4uire her to sta7 longer in hos!ital, continue the method at homeand attend follo&5u! visits. @f obstacles arise, talk about them and tr7 to find solutions &iththe famil7 before abandoning ;M?. 6he mother must also be full7 su!!orted b7 the health&orkers to graduall7 take over the res!onsibilit7 for the care of her small bab7.

@n theor7 it is !ossible to full7 im!lement ;M? &ith a surrogate mother 'e.g. the grand5mother but this is difficult to accom!lish in !ractice.

".0 )acilities* e+uipment and supplies

;M? does not re4uire s!ecial facilities, but sim!le arrangements can make the mother8ssta7 more comfortable.

1otherG$ need$

6&o or four5bed rooms of reasonable size, &here mothers can sta7 da7 and night, live &iththe bab7, and share e!erience, su!!ort and com!anionshi!- at the same time the7 can have

!rivate visits &ithout disturbing the others. 6he rooms should be e4ui!!ed &ith comfortable beds and chairs for the mothers, if !ossible adustable or &ith enough !illo&s to maintain anu!right or semi5recumbent !osition for resting and slee!ing. ?urtains can hel! to ensure !ri5vac7 in a room &ith several beds. 6he rooms should be ke!t &arm for small babies '2252*B?. Mothers also need bathroom facilities &ith ta! &ater, soa! and to&els. 6he7 should

have nutritious meals and a !lace to eat &ith the bab7 in ;M? !osition. Another &arm,smaller room &ould be useful for individual &ork &ith mothers, discussion of !rivate andconfidential issues, and for reassessing babies. 6he &ard should have an o!en5door !olic7 forfathers and siblings.

Dail7 sho&er or &ashing is sufficient for maternal h7giene- strict hand5&ashing should beencouraged after using the toilet and changing the bab7. Mothers should have the o!!ortunit7to change or &ash clothes during their sta7 at the ;M? facilit7.

3ecreational, educational and even income5generating activities can be organized formothers during ;M? in order to !revent or reduce the inevitable frustrations of being a&a7

from home and in an institution. Goise levels should, ho&ever, be ke!t lo& during suchactivities to avoid disturbing the small babies. Mothers should also be allo&ed to move

2/



around freel7 during the da7 at the institution and, if !ossible, in the garden, !rovided the7res!ect the

2+



hos!ital schedules for !atient care and regularl7 feed their babies. 6he staff should use thelong !eriod in hos!ital 'and the fre4uent contacts after discharge to carr7 out othereducational activities on infant and maternal health.

Mothers should be discouraged from smoking &hile !roviding ;M? and su!!orted intheir anti5smoking efforts. Fisitors should not be allo&ed to smoke &here there are small

babies, and the measure should be reinforced if necessar7.

During the long sta7 at the facilit7 visits b7 fathers and other members of the famil7 should be allo&ed and encouraged. 6he7 can sometimes hel! the mother, re!lacing her for skin5to5skin contact &ith the bab7 so that she can get some rest.

Mothers, ho&ever, a!!reciate !rivac7 &hile breastfeeding, taking care of their !ersonal h7giene and during visits.

,lothing for the mother

6he mother can &ear &hatever she finds comfortable and &arm in the ambienttem!erature, !rovided the dress accommodates the bab7, i.e. kee!s him firml7 andcomfortabl7 in contact &ith her skin. %!ecial garments are not needed unless traditional onesare too tight.

The support binder

6his is the onl7 s!ecial item needed for ;M?. @t hel!s mothers hold their babies safel7close to their chest ':ig.". 6o begin &ith, use a soft !iece of fabric, about a meter s4uare,folded diagonall7 in t&o and secured &ith a safe knot or tucked u! under the mother8s arm!it.ater a carr7ing !ouch of mother8s choice ':ig. 2 can re!lace this cloth. All these o!tions

leave the mother &ith both hands free and allo& her to move around easil7 &hile carr7ing the bab7 skin5to5skin. %ome institutions !refer to !rovide their o&n t7!e of !ouch, shirt or band.

<



abyG$ need$

When bab7 receives continuous ;M?, he does not need an7 more clothing than an infantin conventional care. @f ;M? is not continuous, the bab7 can be !laced in a &arm bed andcovered &ith a blanket bet&een s!ells of ;M?.

,lothing for the baby

When the ambient tem!erature is 2252*B?, the bab7 is carried in kangaroo !osition naked,ece!t for the dia!er, a &arm hat and socks ':ig.<. When the tem!erature dro!s belo&22B?, bab7 should &ear a cotton, sleeveless shirt, o!en at the front to allo& the face, chest,abdomen, arms and legs to remain in skin5to5skin contact &ith the mother8s chest andabdomen. 6he mother then covers herself and the bab7 &ith her usual dress.

<"



Other eBuiment and $ulie$

6he7 are the same as for conventional care and are described belo& for convenience(

❖ a thermometer suitable for measuring body temperature don to +6 '❖ scales: ideally neonatal scales ith 5g inter#als should be used

❖ basic resuscitation e$uipment, and oygen here possible, should be a#ailable here

preterm

babies are cared for

❖ drugs for pre#enting and treating fre$uent problems of preterm neborn babies may

be added according to local protocols. ;pecial drugs are sometimes needed, but are

not recommended in this guide. Treatment of medical problems is not part of this

guide.

3ecord Feeing

9ach mother5bab7 !air needs a record sheet to note dail7 observations, information aboutfeeding and &eight, and instructions for monitoring the bab7 as &ell as s!ecific instructionsfor the mother. Accurate standard records are the ke7 to good individual care- accuratestandard indicators are the ke7 to sound !rogramme evaluation.

A register 'logbook contains basic information on all infants and t7!e of care received, and !rovides information for monitoring and !eriodic !rogramme evaluation. Anne @ includes aneam!le of the t7!e of record sheet that can be used for this !ur!ose and ada!ted to differentsettings. 6he data thus collected &ould also allo& for regular calculation 'e.g. 4uarterl7 andannuall7 of im!ortant indicators, listed also in Anne @.

&. )eeding babies

Mother8s milk is suited to bab78s needs, even if birth occurred before term or the bab7 issmall. >reast milk is thus the best food for !retermC>W infants and breastfeeding is the bestmethod of feeding.0", 02 Mother8s milk should al&a7s be considered a nutritional !riorit7 due tothe biological uni4ueness of the !reterm milk, &hich adusts itself to the bab78s gestationalage and re4uirements.

@n this guide onl7 mother8s milk is recommended for feeding her bab7. Although !asteurized breast milk from another &oman or the milk bank can be used, recommendationson !asteurization and milk banking are not included in this guide.

>reastfeeding !reterm and >W infants is a difficult task, and is almost im!ossible if thehos!ital and home environment are not su!!ortive of breastfeeding in general. 6he staff needto be kno&ledgeable about breastfeeding and alternative feeding methods, and skilled inhel!ing mothers to feed their term and normal &eight infants, before the7 can effectivel7 hel!mothers &ith >W babies.

6he ultimate goal is eclusive breastfeeding. ;M? facilitates the initiation andestablishment of breastfeeding in small infants. Ho&ever, man7 babies ma7 not breastfeed&ell at the beginning or not at all, and need alternative feeding methods. 6herefore the staffshould teach and hel! the mother to e!ress breast milk in order to !rovide milk for her bab7and to maintain lactation, to feed the bab7 b7 cu! and to assess the bab78s feeding. 6he7

should kno& ho& to assess the readiness of small babies for breastfeeding.

<2



Hand e!ression is the sim!lest &a7 to e!ress breast milk. @t needs no a!!liances, so a&oman can do it an7&here at an7 time. 9!ressing breast milk b7 hand is recommended anddescribed in this document.

Mothers need containers for e!ressed breast milk( a cu!, glass, ug or a &ide5mouthed ar.

Different kinds of breast !um!s can also be used for e!ressing breast milk(

❖ rubber bulb or syringe pumps

❖ mechanical or electrical pumps, either hand or foot operated.

6hese are !articularl7 convenient for &omen &ho e!ress breast milk several times a da7over a long !eriod. 6his is often the case &hen the bab7 is born long before term or re4uires

!rolonged intensive care 'for more on breast !um!s, see WHO breastfeeding counsellingcourse"+ .

?u!s, Go. 0 to Go. / :rench gauge feeding tubes and s7ringes are needed for feedinge!ressed breast milk or formula milk. Other tools such as dro!!ers, s7ringes and teas!oonshave been used instead of a cu!. 6raditional feeding devices, such as the L!aladaiL in @ndia,have been sho&n to be effective.0< A refrigerator also is needed for storing milk. 9cess breastmilk can be frozen.

Preterm formula must be available &hen breastfeeding is not ade4uate or for re!lacementfeeding.

Health &orkers must be familiar &ith local harmful cultural !ractices, such as refusal to

give colostrum or negative attitudes to&ards >W and !reterm infants 'Lthe7 are ugl7L orLthe7 &ill not surviveL. 6he7 should be trained to discuss such !ractices and attitudes &iththe mother and her famil7 and find &a7s to overcome them.

&. /ischarge and home care

Once the bab7 is feeding &ell, maintaining stable bod7 tem!erature in ;M? !osition andgaining &eight, mother and bab7 can go home. %ince most babies &ill still be !remature at thetime of discharge, regular follo&5u! b7 a skilled !rofessional close to mother8s home must beensured. :re4uenc7 of visits ma7 var7 from dail7 at the beginning, to &eekl7 and monthl7later. 6he better the follo&5u!, the earlier mother and bab7 can be discharged from the facilit7.

As a guide, services must !lan at least " visit for ever7 !reterm &eek. 6hose visits can also becarried out at home.

Mothers also need free access to health !rofessionals for an7 t7!e of counselling andsu!!ort related to the care of their small babies. 6here should be at least one home visit b7 a

!ublic health nurse to assess home conditions, home su!!ort and abilit7 to travel for follo&5u! visits.

@f !ossible, su!!ort grou!s in the communit7 should be involved in the home 'to !rovidesocial, !s7chological, and domestic &ork su!!ort. Mothers &ith !revious ;M? e!eriencecan be effective !roviders of this kind of communit7 assistance.

.+t-5.

<<



*.

Practice guide

<0




6his cha!ter describes ho& to !ractice kangaroo mother care in the institution &here asmall bab7 has been taken care of and &hen to begin. @t describes each com!onent(thermal !rotection through the correct !osition, feeding, observing the bab7, deciding&hen mother and bab7 can go home to continue ;M?, and the follo&5u! needed toensure ade4uate gro&th and to su!!ort the mother.

0.1 When to start K!,

When a small bab7 is born, com!lications can be e!ected 5 the more !reterm andsmall for gestational age the infant is, the more fre4uent the !roblems are. @nitial care forinfants &ith com!lications is !rovided according to national or institutional guidelines.;M? &ill have to be dela7ed until the medical conditions im!rove. When eactl7 ;M?can begin for those small babies must be udged individuall7, and full account should betaken of the condition and status of each bab7 and his mother. Ho&ever, the mother of asmall bab7 can be encouraged to ado!t ;M? ver7 earl7 on. 6he birth &eight ranges

belo& are given as a guide.

>abies &eighing "/g or more at birth 'gestational age <5<* &eeks or more ma7have some !rematurit75related !roblems, such as res!irator7 distress s7ndrome '3D%.6his ma7 raise serious concerns for a minorit7 of those infants, &ho &ill re4uire care ins!ecial units. @n most cases, ho&ever, ;M? can start soon after birth.

@n babies &ith birth &eight bet&een "2 and "$++g 'gestational age 2/5<2 &eeks, !rematurit75related !roblems such as res!irator7 distress s7ndrome '3D% and othercom!lications are fre4uent, and therefore re4uire some kind of s!ecial treatment initiall7.@n such cases the deliver7 should take !lace in a &ell e4ui!!ed facilit7, &hich could !rovide the care re4uired. %hould deliver7 take !lace else&here, the bab7 should be

transferred soon after birth, !referabl7 &ith the mother. One of the best &a7s oftrans!orting small babies is kee!ing them in continuous skin5to5skin contact &ith themother.",0* @t might take a &eek or more before ;M? can be initiated. Although earl7neonatal mortalit7 in this grou! is ver7 high, mostl7 due to com!lications, most babiessurvive and mothers could be encouraged to e!ress breast milk.

>abies &eighing less than "2g 'gestational age belo& < &eeks incur fre4uent andsevere !roblems due to !reterm birth( mortalit7 is ver7 high and onl7 a small !ro!ortionsurvive !rematurit75related !roblems. 6hese babies benefit most from transfer before birth to an institution &ith neonatal intensive care facilities. @t ma7 take &eeks beforetheir condition allo&s initiation of ;M?.

<"6



Geither birth &eight nor gestational age alone can reliabl7 !redict the risk ofcom!lications. 6able * in Anne @@ sho&s ho& much the mean, and the " th and the +th &eight !ercentiles, var7 b7 gestational age for a !o!ulation &ith mean birth &eight of<<0g.00 When eactl7 to initiate ;M? reall7 de!ends on the condition of the mother and the

bab7. 9ver7 mother should be told about the benefits of breastfeeding, encouraged and hel!edto e!ress breast milk from the first da7, to !rovide food for the bab7 and ensure lactation.

6he follo&ing criteria &ill hel! determine &hen to suggest that the mother ado!ts ;M?.

1other

All mothers can !rovide ;M?, irres!ective of age, !arit7, education, culture and religion.;M? ma7 be !articularl7 beneficial for adolescent mothers and for those &ith social riskfactors.

?arefull7 describe the various as!ects of this method to the mother( the !osition, feedingo!tions, care in the institution and at home, &hat she can do for the bab7 attached to her bod7and &hat she should avoid. 9!lain the advantages and the im!lications of such care for herand her bab7, and al&a7s give the reasons behind a recommendation. Ado!ting ;M? should

be the result of an informed decision and should not be !erceived as an obligation.

6he follo&ing !oints must be taken into consideration &hen counselling on ;M?(

❖ illingness: the mother must be illing to pro#ide %&'

❖ full-time a#ailability to pro#ide care: other family members can offer intermittent

skin-to-skin contact but they cannot breastfeed

❖ general health: if the mother suffered complications during pregnancy or deli#ery

or is otherise ill, she should reco#er before initiating %&'

❖ being close to the baby: she should either be able to stay in hospital until discharge or

return

hen her baby is ready for %&'

❖ supporti#e family: she ill need support to deal ith other responsibilities at home

❖ supporti#e community: this is particularly important hen there are social, economic

or family constraints.

@f the mother is a smoker, advise her on the im!ortance of sto!!ing smoking or refrainingfrom it in the room &here the bab7 is. 9!lain the danger of !assive smoking for herself,other famil7 members and small infants.

aby

Almost ever7 small bab7 can be cared for &ith ;M?. >abies &ith severe illness orre4uiring s!ecial treatment ma7 &ait until recover7 before full5time ;M? begins. During that

!eriod babies are treated according to national clinical guidelines.0 %hort ;M? sessions can begin during recover7 &hen bab7 still re4uires medical treatment '@F fluids, lo&concentration of additional o7gen. :or continuous ;M?, ho&ever, bab78s condition must

be stable- the bab7 must be breathing s!ontaneousl7 &ithout additional o7gen. 6he abilit7 tofeed 'to suck and s&allo& is not an essential re4uirement. ;M? can begin during tube5feeding. Once the bab7 begins recovering, discuss ;M? &ith the mother.

6hese general recommendations on starting ;M? should be ada!ted to the situation of the

<$



region, health s7stem, health facilit7, and individual. @n settings &ith limited resources and&hen referral is im!ossible, the decision on &hen to start ;M? during recover7 should be&eighed against the alternatives available for thermal control, feeding and res!irator7su!!ort.

</



".0" nitiating K!,

When bab7 is read7 for ;M?, arrange &ith the mother a time that is convenient for her andfor her bab7. 6he first session is im!ortant and re4uires time and undivided attention. Ask herto &ear light, loose clothing. Ese a !rivate room, &arm enough for the small bab7. 9ncourageher to bring her !artner or a com!anion of her choice if she so &ishes. @t hel!s to lend su!!ortand reassurance.

While the mother is holding her bab7, describe to her each ste! of ;M?, then demonstratethem and let her go through all the ste!s herself. Al&a7s e!lain &h7 each gesture isim!ortant and &hat it is good for. 9m!hasize that skin5to5skin contact is essential for kee!ingthe bab7 &arm and !rotecting him from illness.

".02 Kangaroo position

Place the bab7 bet&een the mother8s breasts in an u!right !osition, chest to chest 'as sho&n in

:ig. *a.%ecure him &ith the binder. 6he head, turned to one side, is in a slightl7 etended !osition.6he to! of the binder is ust under bab78s ear. 6his slightl7 etended head !osition kee!s theair&a7 o!en and allo&s e7e5to5e7e contact bet&een the mother and the bab7. Avoid bothfor&ard fleion and h7!eretension of the head. 6he hi!s should be fleed and etended in aLfrogL !osition- the arms should also be fleed. ':ig. *a

6ie the cloth firml7 enough so that &hen the mother stands u! the bab7 does not slide out.Make sure that the tight !art of the cloth is over the bab78s chest. >ab78s abdomen should not

be constricted and should be some&here at the level of the mother8s e!igastrium. 6his &a7

bab7 has enough room for abdominal breathing. Mother8s breathing stimulates the bab7 ':ig.*b.

<+



%ho& the mother ho& to move the bab7 in and out of the binder ':ig. *c. As the mothergets familiar &ith this techni4ue, her fear of hurting the bab7 &ill disa!!ear.

Moving the baby in and out of the binder:

m hold the baby with one hand placed behind the neck and on the back;m lightly support the lower part of the jawwith her thumb and fingers to prevent

the baby'shead from slipping down and blocking the airway when the

baby is in an upright position; m place the other hand under thebaby's buttocks.

*

)ig. 0c !oving the baby in and out of the binder



9!lain to the mother that she can breastfeed in kangaroo !osition and that ;M? actuall7makes breastfeeding easier. :urthermore, holding the bab7 near the breast stimulates milk

!roduction.

Mother can easil7 care for t&ins too( each bab7 is !laced on one side of her chest. %he ma7&ant to alternate the !osition. @nitiall7 she ma7 &ant to breastfeed one bab7 at a time, later

both babies can be fed at once &hile in kangaroo !osition.

After !ositioning the bab7 let mother rest &ith him. %ta7 &ith them and check bab78s !osition. 9!lain to the mother ho& to observe the bab7, &hat to look for. 9ncourage her tomove.

When introducing the mother to ;M? also talk to her about !ossible difficulties. :or sometime her life &ill revolve around the bab7 and this ma7 u!set her dail7 routine. Moreover, asmall bab7 at first might not feed &ell from the breast. During that !eriod she can e!ress

breast milk and give it to the bab7 &ith a cu! or other im!lements, but this &ill take longerthan breastfeeding.

9ncourage her to ask for hel! if she is &orried and be !re!ared to res!ond to her 4uestionsand anieties. Ans&er her 4uestions directl7 and honestl7 5 she needs to be a&are of thelimitations that ;M? ma7 !ut u!on her dail7 activities as &ell as the benefits it canundoubtedl7 bring to her bab7.

9!erience sho&s that most mothers are ver7 &illing to !rovide ;M?, es!eciall7 if the7can see other babies thriving. >7 sharing the same room for a long time, ;M? mothersechange information, o!inions and emotions, and develo! a sense of mutual su!!ort andsolidarit7. After a !eriod of im!otence and frustration during stabilization, the7 areem!o&ered as the main caretakers of their infants and reclaim their maternal role from thestaff.

0.0 ,aring for the baby in angaroo position

>abies can receive most of the necessar7 care, including feeding, &hile in kangaroo !osition. 6he7 need to be moved a&a7 from skin5to5skin contact onl7 for(

❖ changing diapers, hygiene and cord care and

❖ clinical assessment, according to hospital schedules or hen needed.

Dail7 bathing is not needed and is not recommended. @f local customs re4uire a dail7 bathand it cannot be avoided, it should be short and &arm 'about <$B?. 6he bab7 should bethoroughl7 dried immediatel7 after&ards, &ra!!ed in &arm clothes, and !ut back into the;M? !osition as soon as !ossible.

During the da7 the mother carr7ing a bab7 in the ;M? !osition can do &hatever she likes(she can &alk, stand, sit, or engage in different recreational, educational or income5generatingactivities. %uch activities can make her long sta7 in hos!ital less boring and more bearable.%he has to meet, ho&ever, a fe& basic re4uirements such as cleanliness and !ersonal h7giene'stress fre4uent hand5&ashing. %he should also ensure a 4uiet environment for her bab7 andfeed him regularl7.

*"



,leeing and re$ting

Mother &ill best slee! &ith the bab7 in kangaroo !osition in a reclined or semi5recumbent !osition, about "0 degrees from horizontal. 6his can be achieved &ith an adustable bed, if

available, or &ith several !illo&s on an ordinar7 bed ':ig.0. @t has been observed that this !osition ma7 decrease the risk of a!noea for the bab7.0$ @f the mother finds the semi5recumbent !osition uncomfortable, allo& her to slee! as she !refers, because the advantagesof ;M? are much greater than the risk of a!noea. %ome mothers !refer slee!ing on theirsides in a semi5reclined bed 'the angle makes slee!ing on the abdomen im!ossible, and ifthe bab7 is secured as described above there &ill be no risk of smothering.

A comfortable chair &ith adustable back ma7 be useful for resting during the da7.

0.$ 3ength and duration of K!,

Length

%kin5to5skin contact should start graduall7, &ith a smooth transition from conventionalcare to continuous ;M?. %essions that last less than minutes should, ho&ever, be avoided

because fre4uent changes are too stressful for the bab7. 6he length of skin5to5skin contactsgraduall7 increases to become as continuous as !ossible, da7 and night, interru!ted onl7 forchanging dia!ers, es!eciall7 &here no other means of thermal control are available.

When the mother needs to be a&a7 from her bab7, he can be &ell &ra!!ed u! and !lacedin a &arm cot, a&a7 from draughts, covered b7 a &arm blanket, or !laced under ana!!ro!riate &arming device, if available. During those breaks famil7 members 'father or

!artner, grandmother, etc., or a close friend, can also hel! caring for the bab7 in skin5to5skin

kangaroo !osition ':ig..

*2



Duration

When the mother and bab7 are comfortable, skin5to5skin contact continues for as long as !ossible, first at the institution, then at home. @t tends to be used until the bab7 reaches term'gestational age around * &eeks or 20g. Around that time the bab7 also outgro&s theneed for ;M?. %he starts &riggling to sho& that she is uncomfortable, !ulls her limbs out,cries and fusses ever7 time the mother tries to !ut her back skin5to5skin. 6his is &hen it issafe to advise the mother to &ean the bab7 graduall7 from ;M?. >reastfeeding, of course,continues. Mother can return to skin5to5skin contact occasionall7, after giving the bab7 a bath,during cold nights, or &hen the bab7 needs comfort.

;M? at home is !articularl7 im!ortant in cold climates or during the cold season and couldgo on for longer.

0. !onitoring baby4s condition

2emerature

A &ell5fed bab7, in continuous skin5to5skin contact, can easil7 retain normal bod7tem!erature 'bet&een <.0B? and <$B? &hen in kangaroo !osition, if the ambienttem!erature is not lo&er than the recommended range. H7!othermia is rare in ;M? infants,

but it can occur. Measuring bab78s bod7 tem!erature is still needed, but less fre4uentl7 than&hen the bab7 is not in the kangaroo !osition.

*<



When starting ;M?, measure aillar7 tem!erature ever7 hours until stable for threeconsecutive da7s. ater measure onl7 t&ice dail7. @f the bod7 tem!erature is belo& <.0B?,re&arm the bab7 immediatel7( cover the bab7 &ith a blanket and make sure that the mother

is sta7ing in a &arm !lace. Measure the tem!erature an hour later and continue re&arminguntil &ithin the normal range. Also look for !ossible causes of h7!othermia in the bab7'cold room, the bab7 &as not in ;M? !osition before measuring the tem!erature, the bab7had a bath or has not been feeding &ell. @f no obvious cause can be found and the bab7continues to have difficult7 in maintaining normal bod7 tem!erature, or the tem!eraturedoes not return to normal &ithin < hours, assess the bab7 for !ossible bacterial infection.

@f an ordinar7 adult5t7!e thermometer does not record the tem!erature, assume thereis moderate or severe h7!othermia and act accordingl7. Wa7s of identif7ing andtreating h7!othermia are described in detail in another WHO document." 3e&armingcan be carried out through skin5to5skin contact.

How to measure axillary temperature

m Keep the baby warm throughout the procedure, either in skin-to-skin contact with the motherand properly covered, or well covered on a warm surface;

m use a clean thermometer and shake it down to less than 3! ";m place the thermometer bulb high up in the middle of the a#illa; the skin of the a#illa must be

in full contact with the bulb of the thermometer, with no air pockets between skin and bulb;m hold the infant's arm against the side of the chest gently; keep the thermometer in

place for at least three minutes; m remove thethermometer and read the temperature;m avoid taking the rectal temperature since it is associated with a small but significant risk of

rectal perforation.

Ob$erAing breathing and +ell-being

6he normal res!irator7 rate of an >W and !reterm infant ranges bet&een < and breaths !er minute, and breathing alternates &ith intervals of no breathing 'a!noea.Ho&ever, if the intervals become too long '2 seconds or more and the bab78s li!s and face

turn blue 'c7anosis, his !ulse is abnormall7 lo& 'brad7cardia and he does not resume breathing s!ontaneousl7, act 4uickl7( there is a risk of brain damage. 6he smaller or more !remature the bab7 is, the longer and more fre4uent the s!ells of a!noea. As bab7a!!roaches term, breathing becomes more regular and a!noea less fre4uent. 3esearch sho&sthat skin5to5skin contact ma7 make breathing more regular in !reterm infants "$

*",0/ and ma7 reduce the incidence of a!noea. A!noea a!!earing late ma7 also indicate the

beginning of an illness.

6he mother must be a&are of the risk of a!noea, be able to recognize it, interveneimmediatel7 and seek hel! if she becomes concerned.

**



What to do in case of apnoea

m $each the mother to observe the baby's breathing pattern and e#plain the normal variations;m e#plain what apnoea is and what effects it has on a baby;m demonstrate the effect of apnoea by asking the mother to hold her breath for a short

time %less than & seconds( and a long time %& seconds or more(; m e#plain that ifbreathing stops for & seconds or more, or baby becomes blue %blue

lips and face(, this may be a sign of a serious disease; m teach her to stimulate the babyby lightly rubbing the back or head, and by rocking

movements until the baby starts breathing again. )f baby is still not breathing, sheshould call staff; m always react immediately to a

mother's call for help;

m in case of prolonged apnoea, when breathing cannot be restarted through stimulation,resuscitate according to the hospital resuscitation guidelines; m if apnoeic spells become

more fre*uent, e#amine the baby+ this may be an early signof infection. $reat according to the institutional protocol.

Once the bab7 has recovered from the initial com!lications due to !reterm birth, is stableand is receiving ;M?, the risk of serious illness is small but significant. 6he onset of aserious illness in small babies is usuall7 subtle and is overlooked until the disease is

advanced and difficult to treat. 6herefore it is im!ortant to recognize those subtle signs andgive !rom!t treatment. 6each the mother to recognize danger signs and ask her to seek care&hen concerned. 6reat the condition according to the institutional guidelines.

Danger signs

\i ifficulty breathing, chest in-drawing, grunting \ireathing very fast or very slowly \i re*uent andlong spells of apnoea

\i $he baby feels cold+ body temperature is below normal despite rewarming\i ifficulty feeding+ the baby does not wake up for feeds anymore, stops feeding or

vomits \i"onvulsions \iiarrhoea \i/ellow skin

*0



3eassure the mother that there is no danger if the bab7(

❖ sneees or has hiccups

❖ passes soft stools after each feed

❖ does not pass stools for *-+ days.

0. )eeding

>reastfeeding !reterm babies is a s!ecial challenge.

:or the first fe& da7s a small bab7 ma7 not be able to take an7 oral feeds and ma7 need to be fed intravenousl7. During this !eriod the bab7 receives conventional care.

Oral feeds should begin as soon as bab78s condition !ermits and the bab7 tolerates them.

6his is usuall7 around the time &hen bab7 can be !laced in kangaroo !osition. 6his hel!s themother to !roduce breast milk, so it increases breastfeeding.

>abies &ho are less than < to <2 &eeks gestational age usuall7 need to be fed through anaso5gastric tube, &hich can be used to give e!ressed breast milk. 6he mother can let her

bab7 suck her finger &hile he is having tube feeds. 6ube5feeding can be done &hen the bab7is in kangaroo !osition.

>abies bet&een < and <2 &eeks gestational age can take feeds from a small cu!. ?u!feeds can be given once or t&ice dail7 &hile a bab7 is still fed mostl7 through a naso5gastrictube. @f he takes cu! feeds &ell, tube5feeding can be reduced. :or cu!5feeding the bab7 istaken out of the kangaroo !osition, &ra!!ed in a &arm blanket and returned to the kangaroo

!osition after the feed. Another &a7 to feed a bab7 at this stage is b7 e!ressing milkdirectl7 into the bab78s mouth. 6his &a7 the bab7 does not need to be taken out from thekangaroo !osition.

>abies of about <2 &eeks gestational age or more are able to start suckling on the breast.>ab7 ma7 onl7 root for the ni!!le and lick it at first, or he ma7 suckle a little. ?ontinuegiving e!ressed breast milk b7 cu! or tube, to make sure that the bab7 gets all that he needs.

When a small bab7 starts to suckle effectivel7, he ma7 !ause during feeds 4uite often andfor 4uite long !eriods. @t is im!ortant not to take him off the breast too 4uickl7. eave him onthe breast so that he can suckle again &hen he is read7. He can continue for u! to an hour if

necessar7. Offer a cu! feed after the breastfeed, or alternate breast and cu! feeds.

Make sure that the bab7 suckles in a good !osition. #ood attachment ma7 make effectivesuckling !ossible at an earlier stage.

>abies from about <* to < &eeks gestational age or more can often take all that the7 needdirectl7 from the breast. Ho&ever, su!!lements from a cu! continue to be necessar7occasionall7.

During this initial !eriod the mother needs a lot of su!!ort and encouragement to establishand maintain lactation until the bab7 is read7 to breastfeed. Primi!arae, adolescent mothers,and mothers of ver7 small infants ma7 need even more encouragement, hel! and su!!ort

during the institutional sta7 and later at home.

*



Discuss breastfeeding with the mother

m 0eassure her that she can breastfeed her small baby and she has enough milk; m e#plain thather milk is the best food for such a small baby. eeding for him is even

more important than for a big baby; m at the beginning a small baby doesnot feed as well as a big baby; he may ❖ tire easily and suck weakly at first

❖ suckle for shorter periods before resting -fallasleep during feeding -have long pauses aftersuckling, and feed longer -not always wake up forfeeds;

m e#plain that breastfeeding will become easier as baby becomes older and bigger; m help her place and attach the baby in the kangaroo position.

rea$t#eeding

6he kangaroo !osition is ideal for breastfeeding. As soon as the bab7 sho&s signs ofreadiness for breastfeeding, b7 moving tongue and mouth, and interest in sucking 'e.g. fingersor mother8s skin, hel! the mother to get into a breastfeeding !osition that ensures goodattachment.

6o start breastfeeding choose a!!ro!riate time 5 &hen the bab7 is &aking from a slee!, or isalert and a&ake. Hel! the mother to sit comfortabl7 in an armless chair &ith the bab7 in skin5to5skin !osition. :or the first breastfeeds take the bab7 out of the !ouch and &ra! or dresshim to better demonstrate the techni4ue. 6hen !ut the bab7 into the kangaroo !osition and askthe mother to ensure good !osition and attachment.

Help the mother to position her baby m

1how the mother the correct position and attachment for breastfeeding;m show the mother how to hold her baby+

- hold the baby's head and body straight;- make the baby face her breast, the baby's nose opposite her nipple;- hold the baby's body close to her body;- support the baby's whole body, not just the neck and shoulders;

m show the mother how to help her baby to attach+- touch her baby's lips with her nipple;- wait until her baby's mouth is wide open;- move her baby *uickly onto her breast, aiming the infant's lower lip well below the nipple;

m show the mother signs of good attachment+- baby's chin is touching her breast;- his mouth is wide open;- his lower lip is turned out;- a larger area of the areola is visible above rather than below the baby's mouth;- sucks are slow and deep, sometimes pausing.

*$



et the bab7 suckle on the breast as long as he &ants. 6he bab7 ma7 feed &ith long !auses bet&een sucks. Do not interru!t the bab7 if he is still tr7ing.

%mall babies need breastfeeding fre4uentl7, ever7 25< hours. @nitiall7 the7 ma7 not &akeu! for feeds and must be &akened. ?hanging the bab7 before the feed ma7 make him morealert.

%ometimes it hel!s to e!ress a little milk &ith each suck. @f the breast is engorged,encourage the mother to e!ress a small amount of breast milk before starting breastfeeding-this &ill soften the ni!!le area and it &ill be easier for the bab7 to attach.

9ven if the bab7 is not 7et suckling &ell and long enough 'ver7 !reterm, offer the breastfirst, and then use an a!!ro!riate alternative feeding method. Do &hatever &orks best in 7oursetting( let the mother e!ress breast milk into bab78s mouth or let her e!ress breast milk andfeed it to the bab7 b7 cu! or tube.

Give special support to mothers who breastfeed twins

m0eassure the mother that she has enough breast milk for two babies; m e#plain toher that twins may take longer to establish breastfeeding since they are fre*uentlyborn preterm and with low birth weight.

*/



Help the mother feed her twins

m eeding one baby at a time until breastfeeding is well established; m finding the best methodfor her twins+ if one is weaker, encourage her to make sure

that the weaker twin gets enough milk. )f necessary, she can e#press milk for himand feed him by cup after initial breastfeeding; m

alternating the side each baby is offered daily.

<lternatiAe #eeding method$

6he bab7 can be fed b7 e!ressing breast milk directl7 into his mouth or giving e!ressedmother8s breast milk or a!!ro!riate formula b7 cu! or tube.

56pressing breast mil

Hand e!ression is the best &a7 to e!ress breast milk. @t is less likel7 to carr7 infectionthan a !um!, and can be used b7 ever7 &oman at an7 time. A techni4ue to e!ress milkeffectivel7 is described in the WHO breastfeeding counselling course.

%ho& the mother ho& to e!ress breast milk and let her do it. Do not e!ress her milk forher. 6o establish lactation and feed a small bab7 she should start e!ressing milk on the firstda7, &ithin si hours of deliver7, if !ossible. %he should e!ress as much as she can and asoften as the bab7 &ould breastfeed. 6his means at least ever7 < hours, including during the

night. 6o build u! her milk su!!l7, if it seems to be decreasing after a fe& &eeks, she shoulde!ress her milk ver7 often for a fe& da7s 'ever7 hour and at least ever7 < hours during thenight.

Mothers often develo! their o&n st7le of hand e!ression once the7 have learned the basic !rinci!les. %ome &ill e!ress both breasts at the same time, leaning for&ard &ith a container bet&een their knees and !ausing ever7 fe& minutes to let the sinuses refill &ith breast milk.9ver7 mother &ill find her o&n rh7thm, &hich is usuall7 slo& and regular. 9ncouragemothers to e!ress breast milk their o&n &a7, !roviding it &orks for them.

@f a mother is e!ressing more milk than her small bab7 needs, let her e!ress the secondhalf of the milk from each breast into a different container. et her offer the second half of thee!ressed breast milk first. 6his &a7 the bab7 gets more hind milk, &hich gives him the etraenerg7 he needs and hel!s him gro& better. @f the mother can onl7 e!ress ver7 smallvolumes at first, give &hatever she can !roduce to her bab7 and su!!lement &ith formulamilk if necessar7.

9!ressing breast milk takes time, !atience and for&ard !lanning. Ask the mother to start atleast half an hour before the bab78s feed, irres!ective of the method used. @f !ossible, usefreshl7 e!ressed breast milk for the net feed. @f there is more milk than the bab7 needs, itcan be stored in a refrigerator for u! to */ hours at *B?.

*+



56pressing breast mil directly into baby4s mouth

>reast milk can be e!ressed directl7 into the bab78s mouth, but the mother shouldfirst become familiar &ith e!ressing breast milk b7 hand.

he baby can be fed while in !angaroo position

m 2old the baby in skin-to-skin contact, the mouth close to the nipple; mwait until the baby isalert and opens mouth and eyes %very small babies may need

light stimulation to be kept awake and alert(; m e#press afew drops of breast milk; m let the baby smell and lick thenipple, and open the mouth; m e#press breast milk into thebaby's open mouth; mwait until baby swallows the milk;m repeat the procedure until the baby closes his mouth and will take no more breast milk even

after stimulation;m ask the mother to repeat this operation every hour if the baby weighs less than &g

and every two hours if the baby weighs more than &g; m be fle#ible at each feed, butcheck that the intake is ade*uate by measuring the daily

weight gain.

9!erience sho&s that mothers learn this method 4uickl7. Moreover, it has an advantageover other methods since no utensils are re4uired, thus ensuring good h7giene. @t is not

!ossible, ho&ever, to assess the amount of milk given, es!eciall7 at the beginning, &hen itcould be too small for the bab78s needs. ater, it can be assumed to be ade4uate as long as the

bab7 is gaining &eight 'see belo&. 6he method has, ho&ever, not been assesseds7stematicall7 and com!ared to other methods.

,up-feeding

?u!s and other traditional utensils such as the L!aladaiL in @ndia "+

"+

0< can be used to feed even ver7 small babies, as long as the7 s&allo& the milk. 0+, :ordetails of cu!5feeding techni4ues, see the WHO breastfeeding counselling course '!!. <*5<**.

Mothers can easil7 learn this techni4ue and feed their babies &ith ade4uate amounts of

milk. ?u!5feeding !resents a fe& advantages over bottle5feeding since it does not interfere&ith suckling at the breast- a cu! is easil7 cleaned &ith soa! and &ater, if boiling is not !ossible, and enables the bab7 to control his o&n intake. At first, the mother ma7 !refer totake the bab7 out of the kangaroo !osition.

'yringe or dropper-feeding

6he techni4ue is similar to that for e!ressing breast milk in bab78s mouth( measure there4uired amount of breast milk in a cu! and !our it directl7 into the bab78s mouth &ith aregular or s!ecial s!oon, s7ringe or dro!!er. %ome more milk is given once the bab7 hass&allo&ed the given amount. %!oon5feeding takes longer than cu!5feeding and s!illage can

be substantial. :eeding &ith s7ringes and dro!!ers is not faster than cu!5feeding. Moreover,

s7ringes and dro!!ers are more difficult to clean and more e!ensive.

0



"ottle-feeding

6his is the least !referred feeding method and is not recommended. @t ma7 hinder breathing and o7genation"+

", 2 and it interferes &ith suckling. >ottles and teats must be sterilized in institutions, and boiled at home.

Tube-feeding

6ube5feeding is used &hen the bab7 cannot 7et s&allo&, or coordinate s&allo&ingand breathing, or tires too easil7 and does not get enough milk. While the health &orkerinserts the tube and !re!ares the s7ringe or dro!!er, mother can let the bab7 suck her

breast.

6he bab7 can be tube5fed in the kangaroo !osition.

How to insert a tube

m $ake the baby out of the kangaroo position, wrap her in a warm cloth and place her on awarm surface;

m insert the tube through the baby's mouth rather than the nose+ small babies breathe throughthe nose and the tube placed in the nostrils may obstruct breathing;

m use 4o. to 4o. 5 rench gauge short feeding tubes, depending on the si6e of the infant;mmeasure and mark the distance from the mouth to the ear and to the lower tip of the

sternum on the tube with a felt pen;m

pass the tube through the mouth into the stomachuntil the felt pen mark reaches thelips; baby's breathing should be normal with the tube in place; m

secure the tube to the infant's face with a tape;m replace the tube every &7-8& hours. Keep it closed or pinched while removing it to avoid

dripping fluid into the baby's throat.

How to prepare and use the syringe

m etermine the amount of milk for the feed %$able 3(;m choose the corresponding si6e syringe;m remove the piston from the syringe and discard it;m attach the syringe to the tube;m pour the re*uired amount of breast milk into the syringe;m hold the syringe barrel above baby's stomach and let the milk flow by gravity;

do not inject the milk;m observe the baby during feeding for any change in breathing and spilling;m when feeding is completed close off the tube with a spigot;

m during tube-feeding baby can suck the breast or the mother's finger %ig.5(.

0"



As soon as the bab7 sho&s signs of readiness for oral feeding 'breastfeeding or cu!, s!oon,s7ringe, or dro!!er5feeding, feed at first once or t&ice a da7, &hile the bab7 is still mostl7fed through a tube. #raduall7 reduce tube feeds and remove the tube &hen the bab7 takes at

least three consecutive feeds of breast milk b7 cu!.

uantity and #reBuency

:re4uenc7 of feeding &ill de!end on the 4uantit7 of milk the bab7 tolerates !er feed andthe re4uired dail7 amount. As a guide, the amount !er feed for small ne&born !reterm babiesshould be steadil7 increased as follo&s(

❖ up to day 6 sloly increase the total amount and the amount per feed, to help the

neborn infant get used to enteral feeding

❖ after day 6 steadily increase the $uantity to achie#e the amount re$uired for the

babys age as

indicated in Tables * and +❖ by day < the baby should take *55ml=kg=day, hich is the amount re$uired for steady

groth.

6able < sho&s the a!!roimate amount and number of feeds re4uired as the bab7 gro&solder. Avoid overfeeding or feeding too ra!idl7 to lessen the risk of milk as!iration orabdominal distension.

Fer7 small babies should be fed ever7 t&o hours, larger babies ever7 three hours. @fnecessar7, &ake mother and bab7 during the da7 and night to ensure regular feeding.

Table . A#o$nt of #il% &or fl$id' needed (er da) b) birth *eight and age3!rth

e!&ht8eede$ery

0ay 1 0ay 2 0ay ( 0ay 4 0ay 0ay# ,61(

0ay 14

1---61499&

1--&

2

hour#(

hour#

,-ml:k&

+-ml:k&

9-ml:k&

1--ml:k&

11-ml:k&

12-61+-ml:k&

1+-62--ml:k&

Table ". A((ro+i#ate a#o$nt of breast #il% needed (er feed b) birth *eight and age

3!rth e!&ht

;um%erof feed#

0ay 1 0ay 2 0ay ( 0ay 4 0ay 0ay# ,61(

0ay 14

1---& 12 ml:k& * ml:k& + ml:k& 9 ml:k& 1-ml:k&

1161,ml:k&

1*ml:k&

12-& 12 , ml:k& + ml:k& 9 ml:k& 11 ml:k& 12ml:k&

14619ml:k&

21ml:k&

1--& + 12ml:k&

1ml:k&

1*ml:k&

19ml:k&

21ml:k&

2(6((ml:k&

(ml:k&

1*-& + 14ml:k&

1+ml:k&

2-ml:k&

22ml:k&

24ml:k&

2,642ml:k&

4ml:k&

2---& + 1ml:k&

2-ml:k&

2(ml:k&

2ml:k&

2+ml:k&

(-64ml:k&

-ml:k&

02



6ransition from an alternative feeding method to eclusive breastfeeding ma7 occur earlierin larger babies and much later in ver7 small babies and ma7 take a &eek. 9ncourage motherto start breastfeeding as soon as the bab7 sho&s signs of readiness. At the beginning the bab7

ma7 not suckle long enough but even short sucking stimulates milk !roduction and hel!s the bab7 to L!racticeL. ;ee! reassuring the mother and hel!ing her &ith breastfeeding the bab7.As the bab7 gro&s, graduall7 re!lace scheduled feeding &ith feeding on demand.

0<



When the bab7 moves on to eclusive breastfeeding and measuring the amount of milkintake is not !ossible, &eight gain remains the onl7 &a7 to assess &hether feeding isade4uate.

@f the mother is H@F5!ositive and chooses re!lacement feeding, suggest using cu!5feeding.:or further information on this issue, !lease refer to H@F and infant feeding counselling

course.0.7 !onitoring

growth Weight

Weigh small babies dail7 and check &eight gain to assess first the ade4uac7 of fluid intakeand then gro&th. %mall babies lose &eight at first, immediatel7 after birth( &eight loss of u!to " in the first fe& da7s of life has been considered acce!table. After the initial &eightloss, ne&born babies &ill slo&l7 regain birth &eight, usuall7 bet&een $ and "* da7s after

birth. After that babies should be gaining &eight, a little at the beginning, more later on. Go

&eight loss is acce!table though after this initial !eriod. #ood &eight gain is considered asign of good health, !oor &eight gain is a serious concern. 6here is no u!!er limit for &eightgain for breastfed infants, but the lo&er limit should be no less than "0gCkgCda7.

"de#uate daily weight gain from the second wee!of life is$%g&!g&day' "pproximate weight gains fordifferent post-menstrual ages are given below:

❖ &g9day up to 3& weeks of post-menstrual age, corresponding appro#imately to -&g9week;

❖ &g9day from 33 to 3: weeks of post-menstrual age, corresponding appro#imately to &-&g9week;

❖3g9day from 38 to 7 weeks of post-menstrual age, corresponding appro#imately to &-3g9week.

0*



6here are no universall7 acce!ted recommendations regarding fre4uenc7 of gro&thmonitoring for >W and !reterm infants. 6here is no universal reference chart for !lottingthe !ostnatal &eight gain of those babies but intrauterine gro&th charts b7 &eek of gestation,

&ith !ercentiles or standard deviations, are used instead.

@t is not kno&n &hether an etrauterine gro&th similar to the one the !reterm infant &ouldhave had in utero is an a!!ro!riate criterion for monitoring !ostnatal &eight gain. @t seemsreasonable, ho&ever, to aim for a &eight of at least 20g or more b7 the *2

th &eek of !ost5menstrual age.

he following recommendations are based on experience

meigh babies once a day; more fre*uent weighing might upset the baby and be a cause of

an#iety and concern for the mother. <nce the baby has started gaining weight, weighevery second day for a week and then once weekly until the baby has reached full term%7 weeks or &g(;

mweigh the baby in the same way every time, i.e. naked, with the same calibrated scales %withg intervals if possible(, placing a clean warm towel on the scales to avoid cooling theinfant;

mweigh the baby in a warm environment;m if you have a local weight chart showing the e#pected intrauterine growth, plot the weight on

the graph to monitor growth.

#ro&th monitoring, es!eciall7 for dail7 &eight gain, re4uires accurate and !recise scalesand a standardized &eighing techni4ue. %!ring scales are not !recise enough for fre4uentmonitoring of &eight gain &hen &eight is lo&, and ma7 lead to &rong decisions. Analoguematernit7 hos!ital scales '&ith "g intervals are the best alternative. @f such accurate and

!recise scales are not available, do not &eigh ;M? infants dail7 but rel7 on &eekl7&eighing for gro&th monitoring. Weight is recorded on a &eight chart and &eight gain isassessed dail7 or &eekl7.

Head circum#erence

Measure head circumference &eekl7. Once bab7 is gaining &eight, head circumference&ill increase b7 bet&een .0 and "cm !er &eek. :or ade4uac7 of head gro&th refer tonational anthro!ometric standards.

<lternatiAe method$ #or monitoring gro+th

Alternative methods, such as measuring bab78s length, and chest and arm circumference,are less useful for gro&th monitoring and are not recommended for the follo&ing reasons(

❖ length is less reliable than &eight. @t increases more slo&l7 and does not hel! to make

decisions about feeding or illness-

❖ surrogates, such as chest and arm circumference, have been !ro!osed to assess size

at birth and as a tool to evaluate the need for s!ecial care.

<,

*

6heir effectiveness forgro&th monitoring in >W and !reterm infants has not 7et been assessed.

00



0.8 nade+uate weight gain

@f &eight gain is inade4uate for several da7s, first assess the feeding techni4ue, fre4uenc7,duration and schedule, and check that night feeds are given. Advise the mother to increase thefre4uenc7 of feeds or to feed on demand. 9ncourage her to drink fluids &hen thirst7.

6hen look for other conditions as !ossible reasons for !oor &eight gain(

❖ oral thrush (hite patches in the mouth) can interfere ith feeding. Treat the baby by

gi#ing her

an oral suspension of nystatin (55,555 2>=ml) use a dropper to apply ml in the oral

mucosa and paint the mothers nipples after each feed until the lesions heal. Treat for

? days

❖rhinitis is $uite disturbing for the baby because it interferes ith feeding. Nasal drops

of normal

saline solution in each nostril before each feed may help to relie#e nasal obstruction❖urinary tract infection is a possible insidious cause. 2n#estigate if the baby fails to gro

ithout

ob#ious reasons. Treat according to national=local treatment guidelines

❖ se#ere bacterial infection can initially manifest itself ith poor eight gain and poor

feeding.

2f a pre#iously healthy baby becomes unell and stops feeding, consider this as a

serious danger

sign. 2n#estigate for infection and treat according to national=local treatment

guidelines.

Other causes of failure to gain &eight include !atent ductus arteriosus and other diseasesthat ma7 be difficult to diagnose in settings &ith scarce resources. 3efer the bab7 &ho fails togain &eight after the eclusion or treatment of the above common causes to a higher level ofcare, for further investigation and treatment.

@f a mother8s breast milk su!!l7 is reduced and does not satisf7 bab78s needs, she must in5crease it. 6his often ha!!ens &here there is a breastfeeding difficult7( bab7 is not suckling&ell, the mother has been a&a7 or sick and sto!!ed feeding her bab7 'on increasing breastmilk and relactation see the WHO breastfeeding counselling course, !! <*/5<0/,"+ and theWHO document @elactation: re#ie of eperience and recommendations for practice 0 .6his should be the first ste! before turning to other methods.

Lactogogue$

Herbal teas obtained from sesame, fenugreek, fennel, cumin, basil and aniseed have not been !roven effective in increasing breast milk !roduction. >eer and other alcoholic drinksused in some cultures to increase lactation should be discouraged since alcohol in breast milkis dangerous for babies., $ Dom!eridone can hel! increase milk su!!l7. @t could be used as asu!!ortive !rocedure and onl7 after all other effective methods for im!roving milk !roductionhave been tried out. Al&a7s follo& national guidelines.

@f des!ite all these efforts the bab7 is not gaining &eight, consider su!!lementing breastfeeding &ith !reterm formula, given b7 cu! after each feed. 6o !re!are formula milkfollo& the instructions on the bo.

0



Do not make im!ortant decisions about formula su!!lementation on the basis of dail7&eight, since this is subect to large variations. Onl7 &eight change over a fe& da7s, or&eekl7 &eight gain, is a good basis for such decisions.

0$



Discuss &ith the mother &hether this is a feasible, affordable and safe o!tion that &ill beavailable for several months. %ho& her ho& to !re!are it and give it safel7. :ollo& theinstructions on the !ackage. 3eturn to eclusive breastfeeding as soon as !ossible after the

infant has gained &eight for some time. Monitor more closel7 the health and gro&th of smallinfants fed or su!!lemented &ith formula since the7 are more e!osed than breastfed babiesto infection and malnutrition. 6r7, if at all !ossible, not to discharge a small bab7 &ith formulasu!!lements.

".0< 9nsure that the facilit7 follo&s the rules !rescribed b7 the 2nternational 'ode of &arketing of reast-milk ;ubstitutes, issued b7 WHO. (reventive treatment

%mall babies are born &ithout sufficient stores of micronutrients. Preterm babies,irres!ective of &eight, should receive iron and folic acid su!!lementation from the secondmonth of life until one 7ear of chronological age. 6he recommended dail7 dose of iron is

2mgCkg bod7 &eightCda7.

m9!lain to the mother that(❖ iron is essential for bab78s health and gro&th-❖ the bab7 needs to take iron regularl7( at the same time ever7 da7, after breastfeeding-❖ bab78s stools ma7 become darker, &hich isnormal. m9!lore her concerns.

".0* 'timulation

All infants need love and care to flourish, but ver7 !reterm babies need even more attention

to be able to develo! normall7 since the7 have been de!rived of an ideal intrauterineenvironment for &eeks or even months. 6he7 are instead e!osed to too much light, noise and

!ainful stimuli during their initial care. ;M? is an ideal method since the bab7 is rocked andcuddled, and listens to the mother8s voice &hile she goes about her ever7da7 activities.:athers too can !rovide such an environment. Health &orkers have an im!ortant role to !la7in encouraging mothers and fathers to e!ress their emotions and love to their babies.

".00 Ho&ever, if the bab7 has other !roblems due to !reterm birth or its com!lications,additional treatment ma7 be necessar7. #uidance on such treatment can be found in standardtetbooks or in the WHO manual &anaging neborn problems. guide for doctors, nurses

and midi#es. /ischarge

Discharge means letting the mother and bab7 go home. 6heir o&n environment, ho&ever,could be ver7 different from the ;M? unit at the facilit7, &here the7 &ere surrounded b7su!!ortive staff. 6he7 &ill continue to need su!!ort even though this &ill not have to be asintensive and fre4uent. 6he time of discharge ma7 therefore var7 de!ending on the size of the

bab7, bed availabilit7, home conditions and accessibilit7 of follo&5u! care. Esuall7, a ;M? bab7 can be discharged from the hos!ital &hen the follo&ing criteria are met(

❖ the babys general health is good and there is no concurrent disease such as apnoea or

infection

❖he is feeding ell, and is eclusi#ely or predominantly breastfed

❖he is gaining eight (at least 6g=kg=day for at least three consecuti#e days)

0/



❖his temperature is stable in the %&' position (ithin the normal range for at least

three

consecuti#e days)

❖ the mother is confident in caring for the baby and is able to come regularly for follo-up #isits.

6hese criteria are usuall7 met b7 the time the bab7 &eighs more than "0g.

6he home environment is also ver7 im!ortant for the successful outcome of ;M?. 6hemother should go back to a &arm, smoke5free home and should have su!!ort for ever7da7household tasks.

Where there are no follo&5u! services and the hos!ital is far a&a7, mother and bab7 should be discharged later.

@mmunize the bab7 according to national !olic7 and give enough ironCfolate tablets to lastuntil the follo&5u! visit. :ill in the home5based bab78s record. 9nsure that the mother kno&s(

❖ ho to apply skin-to-skin contact until baby shos signs of discomfort

❖ ho to dress the baby, hen he is not in kangaroo position, to keep him arm at home

❖ ho to bath the baby and keep him arm after the bath

❖ho to respond to babys needs such as increasing the duration of skin-to-skin contact if

he has

cold hands and feet or lo temperature at night

❖ho to breastfeed the baby during the day and night according to instructions

❖hen and here to return for follo-up #isits (schedule the first #isit and gi#e the

mother ritten=pictorial instructions for the abo#e issues)

❖ho to recognie danger signs

❖here to seek care urgently if danger signs appear

❖hen to ean the baby from %&'.

(he should return immediately to hospital) or go toanother appropriate provider) if the baby:

❖ stops feeding, is not feeding well, or vomits;

❖ becomes restless and irritable, lethargic or unconscious;❖ has fever %body temperature above 38.!"(;❖ is cold %hypothermia - body temperature below 3:.!"( despite rewarming;❖ has convulsions;

❖ has difficulty breathing;❖ has diarrhoea;❖ shows any other worrying sign.

6ell the mother that it is al&a7s better to seek hel!, if in doubt( &hen caring for smallinfants it is better to seek care too often than to disregard im!ortant s7m!toms.

9arl7 discharge becomes a goal for the mother as she gains confidence in her abilit7 to care

0+



for her bab7. A bab7 can be discharged earlier if the follo&ing criteria are met(

❖ade$uate information on home care is gi#en at discharge to mothers and their families,

preferably

as ritten and pictorial instructions❖mothers ha#e recei#ed instructions on danger signs, and kno hen and here to seek

care.



0.1& K!, at home and routine follow-up

9nsure follo&5u! for the mother and the bab7, either at 7our facilit7 or &ith a skilled !rovider near the bab78s home. 6he smaller the bab7 is at discharge, the earlier and morefre4uent follo&5u! visits he &ill need. @f the bab7 is discharged in accordance &ith the abovecriteria, the follo&ing suggestions &ill be valid in most circumstances(❖ t&o follo&5u! visits !er &eek until <$ &eeks of !ost5menstrual age-❖ one follo&5u! visit !er &eek after <$ &eeks.

6he content of the visit ma7 var7 according to mother8s and bab78s needs- check the follo&5ing, ho&ever, at each follo&5u! visit(

K1CDuration of skin5to5skin contact, !osition, clothing, bod7 tem!erature, su!!ort for themother and the bab7. @s the bab7 sho&ing signs of intolerance= @s it time to &ean the bab7from ;M? 'usuall7 at around * &eeks of !ost5menstrual age, or ust before= @f not,

encourage the mother and famil7 to continue ;M? as much as !ossible.rea$t#eeding

@s it eclusive= @f 7es, !raise the mother and encourage her to continue. @f not, advise heron ho& to increase breastfeeding and decrease su!!lements or other fluids. Ask and lookfor an7 !roblem and !rovide su!!ort. @f the bab7 is taking formula su!!lements or otherfoods, check their safet7 and ade4uac7- make sure that the famil7 has the necessar7 su!!l7.

?ro+thWeigh the bab7 and check &eight gain in the last !eriod. @f &eight gain is ade4uate, i.e. atleast "0gCkgCda7 on average, !raise the mother. @f it is inade4uate, ask and look for !ossible

!roblems, causes and solutions- these are generall7 related to feeding or illness. 6o checkade4uate dail7 &eight gain !lease refer to bo on !age <$.

Illne$$Ask and look for an7 signs of illness, re!orted b7 the mother or not. Manage an7 illnessaccording to 7our local !rotocols and guidelines. @n case of non5eclusive breastfeeding,ask and look !articularl7 for signs of nutritional or digestive !roblems.

Drug$

#ive a sufficient su!!l7 of drugs, if needed, to last until the net follo&5u! visit.

Immunization

?heck that the local immunization schedule is being follo&ed.

1otherG$ concern$Ask the mother about an7 other !roblem, including !ersonal, household, and social

!roblems. 6r7 to hel! her find the best solution for all of them.

4eEt #ollo+-u Ai$itAl&a7s schedule or confirm the net visit. Do not miss the o!!ortunit7, if time allo&s, tocheck and advise on h7giene, and to reinforce the mother8s a&areness of danger signs thatneed !rom!t care.

,ecial #ollo+-u Ai$it$@f these are re4uired for other medical or somatic !roblems, encourage the mother to attendthem and hel! her if needed.

3outine child care

9ncourage the mother to attend routine child care once the bab7 reaches 20g or *&eeks of !ost5menstrual age.

"



3e#erence$

".0 8o birth eight. tabulation of a#ailable information. #eneva, World HealthOrganization, "++2 'WHOC

M?HC+2.2.".0$ de Onis M, >lossner M, Fillar J. evels and !atterns of intrauterine gro&th retardationin develo!ing

countries. Auropean Bournal of 'linical Nutrition, "++/, 02'%u!!l."(%05%"0.".0/ Assential neborn care. @eport of a Technical 9orking /roup (Trieste *6-*0 pril

00<). #eneva, WorldHealth Organization, "++ 'WHOC:3HCM%MC+."<.

".0+ Ash&orth A. 9ffects of intrauterine gro&th retardation on mortalit7 and morbidit7 ininfants and

7oung children. Auropean Bournal of 'linical Nutrition, "++/, 02'%u!!l."(%<*5%*"-discussion( %*"5*2.

". Murra7 ?J, o!ez AD, eds. /lobal burden of disease: a comprehensi#e assessmentof mortality and

disability from diseases, inCuries and risk factors in 005 and proCected to *5*5. >oston,Harvard %chool of Public Health, "++ '#lobal burden of disease and inuries series,vol. ".

"." #ulmezoglu M, de Onis M, Fillar J. 9ffectiveness of interventions to !revent or treatim!aired fetal

gro&th. Dbstetrical E /ynecological ;ur#ey, "++$, 02("<+5"*+.".2 ;ramer M%. %ocioeconomic determinants of intrauterine gro&th retardation.

Auropean Bournal of 'linical Nutrition, "++/, 02'%u!!l."(%2+5%<2- discussion( %<25<<.

".< Mc?ormick M?. 6he contribution of lo& birth &eight to infant mortalit7 andchildhood morbidit7.

The Ne Angland Bournal of &edicine, "+/0, <"2(/25+.".* 3e7 9%, Martinez H#. Maneo racional del nino !rematuro. @n( Eniversidad Gacional,'urso de

&edicina 4etal, >ogota, Eniversidad Gacional, "+/<.".0 Thermal control of the neborn: practical guide. Maternal Health and %afeMotherhood Programme.

#eneva, World Health Organization, "++< 'WHOC:H9CM%MC+<.2.

". %hiau %H, Anderson #?. 3andomized controlled trial of kangaroo care &ith fullterminfants( effectson maternal aniet7, breastmilk maturation, breast engorgement, and breast5feedingstatus. Pa!er !resented at the @nternational >reastfeeding ?onference, Australia8s>reastfeeding Association,%7dne7, October 2<520, "++$.

".$ ?attaneo A, et al. 3ecommendations for the im!lementation of kangaroo mother carefor lo& birth&eight

infants. cta Faediatrica, "++/, /$(**5**0."./ ?attaneo A, et al. ;angaroo mother care in lo&5income countries. Bournal of Tropical

Fediatrics, "++/,**(2$+52/2.

".+ >ergman GJ, Jurisoo A. 6he Lkangaroo5methodL for treating lo& birth &eight babies

in a develo!ingcountr7. Tropical Goctor, "++*, 2*(0$5.".$ incetto O, Gazir A@, ?attaneo A. ;angaroo Mother ?are &ith limited resources.

2



Bournal of Tropical Fediatrics, 2, *(2+<52+0.

".$" Anderson #?. ?urrent kno&ledge about skin5to5skin 'kangaroo care for !reterminfants. Bournal of

Ferinatology, "++", ""(2"522.".$2 ?hristensson ;, et al. 3andomised stud7 of skin5to5skin versus incubator care forre&arming lo&5risk

h7!othermic neonates. The 8ancet, "++/, <02("""0.".$< %hekelle P#. ?linical guidelines( Develo!ing guidelines. ritish &edical Bournal,"+++,

<"/(0+<50+.".$* reastfeeding counselling: training course - Trainers guide. #eneva, World Health

Organization,"++< 'WHOC?D3C+<.*. Also available from EG@?9: 'EG@?9:CGE6C+<.2.".$0 123 and infant feeding counselling: training course - Trainers guide. #eneva,World Health

Organization, 2 'WHOC:?HC?AHC.<. Also available from EG@?9:'EG@?9:CPDCGE6C 5* or EGA@D% 'EGA@D%C++.0/.

<



".$ ?har!ak G, 3uiz5Pelaez J#, :igueroa de ?alume I. ?urrent kno&ledge of kangaroomother

intervention. 'urrent Dpinion in Fediatrics, "++, /("/5""2.".$$ udington5Hoe %M, %&inth J. Develo!mental as!ects of kangaroo care. Bournal of

Dbstetric, /ynecologic,and Neonatal Nursing, "++, 20(+"5$<.

".$/ ?onde5Agudelo A, Diaz53osello J, >elizan JM. ;angaroo mother care to reducemorbidit7 and

mortalit7 in lo& birth &eight infants. 'ochrane 8ibrary, @ssue 2, 22.".$+ %loan G, et al. ;angaroo mother method( randomised controlled trial of analternative method of

care for stabilised lo&5birth&eight infants. The 8ancet, "++*, <**($/25$/0."./ ?har!ak G, et al. ;angaroo mother versus traditional care for ne&born infants N 2grams(

a randomized controlled trial. Fediatrics, "++$, "(/25//."./" ?attaneo A, et al. ;angaroo mother care for lo& birth&eight infants( a randomisedcontrolled trial in

different settings. cta Faediatrica, "++/, /$(+$5+/0."./2 ;ambarami 3A, ?hidede O, ;o&o D6. ;angaroo care versus incubator care in themanagement of

&ell !reterm infants( a !ilot stud7. nnals of Tropical Faediatrics, "++/, "/(/"5/."./< Whitela& A, %leath ;. M7th of marsu!ial mother( home care of ver7 lo& birth &eightinfants in >ogota,

?olombia. The 8ancet, "+/0, "("25"2/."./* ?har!ak G, et al. ;angaroo5mother !rogramme( an alternative &a7 of caring for lo&

birth &eightinfants= One 7ear mortalit7 in a t&o5cohort stud7. Fediatrics, "++*, +*(/*5/".

"./0 Anderson #?, et al. >irth5associated fatigue in <*5< &eek !remature infants( ra!idrecover7 &ith

ver7 earl7 skin5to5skin 'kangaroo care. Bournal of Dbstetric, /ynecologic, and

Neonatal Nursing, "+++, 2/(+*5"<."./ incetto O, et al. @m!act of season and discharge &eight on com!lications and gro&thof kangaroo

mother care treated lo& birth&eight infants in Mozambi4ue. cta Faediatrica, "++/,/$(*<<5*<+.

"./$ %chmidt 9, Wittreich #. ?are of the abnormal ne&born( a random controlled trialstud7 of the Lkangaroo

methodL of care of lo& birth &eight ne&borns. @n( 'onsensus 'onference on ppropriate Technology 4olloing irth, Trieste, ?- Dctober 0H7. WHO 3egionalOffice for 9uro!e.

".// Whitela& A, et al. %kin5to5skin contact for ver7 lo& birth &eight infants and theirmothers. rchi#es of

Gisease in 'hildhood, "+//, <("<$$5"</".

"./+ Wahlberg F, Affonso D, Persson >. A retros!ective, com!arative stud7 using thekangaroo method asa com!lement to the standard incubator care. Auropean Bournal of Fublic 1ealth, "++2,2(<*5<$.

".+ %7frett 9>, et al. 9arl7 and virtuall7 continuous kangaroo care for lo&er5risk !reterminfants( effect on

tem!erature, breast5feeding, su!!lementation and &eight. @n( Froceedings of the iennial 'onference of the 'ouncil of Nurse @esearchers. Washington, D?, American Gurses Association, "++<.

".+" >la7more5>ier JA, et al. ?om!arison of skin5to5skin contact &ith standard contact inlo& birth &eight

infants &ho are breastfed. rchi#es of Fediatrics E dolescent &edicine, "++,"0("205"2+.

".+2 Hurst GM, et al. %kin5to5skin holding in the neonatal intensive care unit influencesmaternal milk

volume. Bournal of Ferinatology, "++$, "$(2"<52"$.

*



".+< ?hristensson ;. :athers can effectivel7 achieve heat conservation in health7 ne&borninfants. cta

Faediatrica,"++, /0("<0*5"<.".+* udington5Hoe %M, et al. %elected !h7siologic measures and behavior during !aternal

skin contact&ith ?olombian !reterm infants. Bournal of Ge#elopmental Fhysiology, "++2, "/(22<52<2.

".+0 Acolet D, %leath ;, Whitela& A. O7genation, heart rate and tem!erature in ver7 lo& birth &eight

infants during skin5to5skin contact &ith their mothers. cta Faediatrica ;candina#ica,"+/+, $/( "/+5"+<.

".+ de eeu& 3, et al. Ph7siologic effects of kangaroo care in ver7 small !reterm infants. iology of the

Neonate, "++", 0+("*+5"00.".+$ :ischer ?, et al. ?ardiores!irator7 stabilit7 of !remature bo7s and girls duringkangaroo care. Aarly

1uman Ge#elopment, "++/, 02("*05"0<.

".+/ Anderson #?, Wood ?9, ?hang HP. %elf5regulator7 mothering vs. nurser7 routinecare !ostbirth(

effect on salivar7 cortisol and interactions &ith gender, feeding, and smoking. 2nfant eha#ior and Ge#elopment, "++/, 2"(2*.

".++ ?hristensson ;, et al. 6em!erature, metabolic ada!tation and cr7ing in health7 full5term ne&borns

cared for skin5to5skin or in a cot. cta Faediatrica, "++2, /"(*//5*+<."." ?hristensson ;, et al. %e!aration distress call in the human infant in the absence ofmaternal bod7

contact. cta Faediatrica, "++0, /*(*/5*$<."."" Affonso D, Wahlberg F, Persson >. 9!loration of mother8s reactions to the kangaroomethod of !re5

maturit7 care. Neonatal Netork, "+/+, $(*<50".

0



"."2 Affonso D, et al. 3econciliation and healing for mothers through skin5to5skin contact !rovided in an

American tertiar7 level intensive care nurser7. Neonatal Netork, "++<,"2(205<2."."< egault M, #oulet ?. ?om!arison of kangaroo and traditional methods of removing

!reterm infantsfrom incubators. Bournal of Dbstetric, /ynecologic, and Neonatal Nursing, "++0,2*(0"50.

"."* >ell 9H, #e7er J, Jones . A structured intervention im!roves breast5feeding successfor ill or !reterm

infants. merican Bournal of &aternal and 'hild Nursing, "++0, 2(<+5<"*."."0 6essier 3, et al. ;angaroo mother care and the bonding h7!othesis. Fediatrics, "++/,"2(<+5<+"."." H7lander MA, %trobino DM, Dhaniredd7 3. Human milk feedings and infectionamong ver7 lo&

birth &eight infants. Fediatrics, "++/, "2(9</."."$ %chanler 3J, %hulman 3J, au ?. :eeding strategies for !remature infants( beneficialoutcomes of

feeding fortified human milk versus !reterm formula. Fediatrics, "+++, "<(""05""0$."."/ Malhotra G, et al. A controlled trial of alternative methods of oral feeding in neonates. Aarly 1uman

Ge#elopment, "+++, 0*(2+5</."."+ %ontheimer D, et al. Pitfalls in res!irator7 monitoring of !remature infants duringkangaroo care.

rchi#es of Gisease in 'hildhood, "++0, $2(:""05""$."."" ubchenco O, et al. @ntrauterine gro&th as estimated from live born birth &eightdata at 2* to *2

&eeks of gestation. Fediatrics, "+<, <2($+<5/.".""" &anaging neborn problems. guide for doctors, nurses and midi#es. #eneva,World Health

Organization 'in !ress.

".""2 Jenni O#, et al. 9ffect of nursing in the head elevated tilt !osition '"0 degrees on theincidence of brad7cardic and h7!oemic e!isodes in !reterm infants. Fediatrics, "++$, "(22520.

".""< udington5Hoe %M, Hadeed AJ, Anderson #?. Ph7siologic res!onses to skin5to5skincontact in

hos!italized !remature infants. Bournal of Ferinatology, "++", ""("+52*.".""* #u!ta A, ;hanna ;, ?hattree %. ?u! feeding( an alternative to bottle feeding in aneonatal intensive

care unit. Bournal of Tropical Fediatrics, "+++, *0("/5"".".""0 ang %, a&rence ?J, Orme 3. ?u! feeding( an alternative method of infantfeeding. rchi#es of

Gisease in 'hildhood, "++*, $"(<05<+."."" >ier J>, et al. >reast5feeding of ver7 lo& birth &eight infants. Bournal of Fediatrics,

"++<, "2<($$<5$$/.".""$ Poets ?:, angner ME, >ohnhorst >. 9ffects of bottle feeding and t&o differentmethods of gavage

feeding on o7genation and breathing !atterns in !reterm infants. cta Faediatrica,"++$, /(*"+5*2<.

".""/ irth eight surrogates: The relationship beteen birth eight, arm and chestcircumference. #eneva, World

Health Organization, "+/$.".""+ Diamond JD, et a l. 6he relationshi! bet&een birth &eight and arm and chestcircumference in 9g7!t.

Bournal of Tropical Fediatrics, "++", <$(<2<5."."2 @elactation: re#ie of eperience and recommendations for practice. #eneva,World Health Organization,

"++/ 'WHOC?H%C?AHC+/."*.



"."2" Mennella JA, #errish ?J. 9ffects of e!osure to alcohol in mother8s milk on infantslee!. Fediatrics,

"++/, ""(92."."22 3osti , et al. 6oic effects of a herbal tea miture in t&o ne&borns. cta

Faediatrica, "++*, /<(/<."."2< 2nternational code of marketing of breast-milk substitutes. #eneva, World HealthOrganization, "+/"

'HA<*C"+/"C39?C", Anne <.

$



<nneEe$

I 3ecord$ and indicator$

?linical records for hos!ital and follo&5u! care of small babies var7 from !lace to !laceand according to the level of care offered to >W and !reterm infants. 9ssential informationon ;M?, &hen this is !art of the care !rogramme, must also be recorded. 6he follo&ing

additional information should be recorded dail7(

❖:or the bab7 hos!ital record(❖&hen ;M? began 'date, &eight and age-❖ condition of the bab7-❖details on duration and fre4uenc7 of skin5to5skin contact-❖&hether the mother is hos!italized or is coming from home-❖ !redominant feeding method-❖observations about lactation and feeding-❖dail7 &eight gain-❖ e!isodes of illness, other conditions or com!lications-❖ the drugs bab7 is receiving-

❖details on discharge( condition of the bab7, maternal readiness, conditions at home thatmake discharge !ossible- date, age, &eight and !ost5menstrual age at discharge-feeding method and instructions for follo&5u! '&here, &hen and ho& fre4uentl7.

Mother should be given a discharge letter summarizing the course of hos!italization andinstructions for home care, medication and follo&5u!. @t is also necessar7 to record &hetherthe bab7 &as transferred to another institution or died.

❖6he follo&5u! record should contain, besides the usual data on the bab7, the follo&inginformation(

❖&hen the bab7 &as first seen 'date, age, &eight and !ost5menstrual age-

❖ feeding method-❖dail7 duration of skin5to5skin contact-5 a n 7 concerns mother ma7 have-❖&hether bab7 has to be or has been readmitted to hos!ital-❖&hen mother sto!!ed skin5to5skin contact 'date, age of the bab7, &eight, !ost5menstrual

age, reasons for sto!!ing and feeding method at &eaning-❖other im!ortant remarks.

@f the follo&5u! care is !rovided at the facilit7 &here the bab7 &as hos!italized, thehos!ital record and the follo&5u! record should be a single document. @f this cannot be done,the t&o records must be linked b7 an identification number. 6he records can obviousl7 beused to develo! an electronic database. 6he follo&5u! record !resented in this anne isderived from those used b7 ;M? !rogrammes in some countries.

+



6hese data &ill !rovide basic information for dail7 bab7 care and !rocess andoutcome indicators for !rogramme monitoring.

When ;M? forms !art of a care !rogramme for small babies it is im!ortant to kno&❖

the follo&ing(

❖ the number of small babies 'N2g andCor N<* &eeks treated and the !ro!ortionreceiving ;M?-

❖mean age at start of ;M? 'stratified b7 &eight and gestational age at birth, and &eightand !ost5menstrual age &hen starting-

❖ t7!e of ;M? '!redominant or !artial-❖mean duration of ;M? 'in da7s-❖mean &eight gain during ;M? in institution and at home-❖mean age of &eaning from ;M? 'stratified b7 &eight and gestational age at birth, and&eight

and !ost5menstrual age &hen starting-❖ feeding method for babies at &eaning from ;M? 'eclusivel7C!artl7 breastfed, or not

breastfed-❖ !ro!ortion of babies needing hos!italization during home ;M?-

❖death rate during ;M?, at institution and at home.

$



II irth +eight and ge$tational age

At different gestational ages birth &eight can var7 b7 about one kilogram- at a given

&eight babies can be of different gestational ages.

Table !. Mean birth *eights &g' *ith 10th and ,0th (ercentiles b) gestational age

<e#tat!onal a&e Mean %!rth e!&ht 1-th percent!le 9-th percent!le

2+ 12-- 9-- 1--29 1(- 1--- 1,-(- 1-- 11-- 1*-(1 1,- 12-- 2---(2 1+-- 1(-- 2(-

(( 2--- 1-- 2--(4 22- 1*- 2*-( 2-- 2--- (---(, 2*- 22- (2-(* (--- 24- (--(+ (2-- 2,- (*--(9 ((- 2+-- (9--4- (-- (--- 41--

$"



III Con$traint$

;M? has been included in national guidelines for the care of >W and !reterm infants,

and successfull7 im!lemented in man7 countries. 9!erience sho&s that the main !roblems,obstacles and constraints fall under four categories( !olic7, im!lementation, communicationand feeding. %ome !ossible solutions are suggested in 6able 0.

Table -. #(le#enting KMC

Problems, obstacles and

constraints

Possible solutions

/olic)

= >ack of plan#? pol!c!e#? &u!del!ne#?protocol#? manual#= >ack of !n#t!tut!onal? academ!c andprofe##!onal #upport= >ack of ade@uate tra!n!n& andcont!nuou# educat!on= R!#k of an !#olated and $ert!calpro&ramme= oor acce## to e$!dence? l!terature anddocumentat!on= >e&al pro%lem# e.&. KMC not !ncluded!n the !nter$ent!on# f!nanced %y the healthcare #y#tem5

= 0e$elopment of plan#? pol!c!e#? &u!del!ne#?

protocol#? manual#= /#ta%l!#h!n& l!nk# !th m!n!#tr!e#? med!cal#chool#? a&enc!e# and or&an!at!on#B ad$ocacy

ork= /#ta%l!#h!n& %a#!c? po#t6&raduate and !n6#er$!ce cour#e#= nte&rat!on !th e"!#t!n& pro&ramme#= Creat!on of local and re&!onal l!%rar!e#B l!nk# !th ma!n documentat!on centre#= ropo#!n& chan&e# to e"!#t!n& la#? rule# andre&ulat!on#B !n$ol$!n& mother# and fam!l!e#

#(le#entation= Re#!#tance of mana&er#? adm!n!#trator#and health orker#= oor fac!l!t!e#? e@u!pment? #uppl!e#?or&an!at!on? lack of t!me= Cultural pro%lem#' m!#&u!ded %el!ef#?att!tude#? pract!ce#= Apparent !n!t!al !ncrea#e of orkload= Red!#tr!%ut!on of ta#k#? mult!d!#c!pl!naryapproach= Re#!#tance of mother# and fam!l!e#= >ack of mon!tor!n& and e$aluat!on

= Ade@uate !nformat!on on effect!$ene##? #afety?fea#!%!l!ty and co#t= mpro$!n& #tructure and or&an!at!on?procurement of %a#!c e@u!pmentB en#ur!n&#uppl!e#

= Appropr!ate tra!n!n& and !nformat!on #trate&!e#?commun!ty part!c!pat!on

= ntroduc!n& chan&e# #tep6%y6#tep= r!t!n& ne Do% de#cr!pt!on#? encoura&!n& team ork and fre@uent Do!nt re$!e of pro%lem#= 7o#p!tal and commun!ty #upport &roup#= <ather!n&? analy#!n& and d!#cu##!n& #tandarddata

Co##$nication= Mother# and fam!l!e# unaare of KMC= oor commun!cat!on and #upport !nho#p!tal and dur!n& follo6up= nade@uate commun!ty and fam!ly#upport= 7o#t!l!ty of pol!t!c!an# and other healthprofe##!onal#

= Ade@uate !nformat!on !n the antenatal per!odand at the referral fac!l!ty

= mpro$!n& commun!cat!on and #upport #k!ll# ofhealth orker#= Commun!ty meet!n&#? ma## med!a? hot l!ne#= Art!cle#? ne#letter#? !ntere#t &roup#?te#t!mon!e#

eeding= >o rate of e"clu#!$e %rea#tfeed!n& afterlon& #eparat!on of !nfant# from mother#= 0!ff!cult &roth mon!tor!n&? lack of

ade@uate #tandard#= nade@uate &roth de#p!te &ood

= Reduc!n& #eparat!on a# much a# po##!%leB!mplementat!on of feed!n& &u!del!ne#

= Accurate #cale#? appropr!ate &roth chart#?

clear !n#truct!on#= <ood #k!ll# for a##e##!n& %rea#tfeed!n& and

$2



!mplementat!on of %rea#tfeed!n& &u!del!ne#= 7!&h pre$alence of 7E6po#!t!$e mother#

alternat!$e feed!n& method#= Eoluntary coun#ell!n& and te#t!n& of parent#B!nfant feed!n& coun#ell!n&? appropr!atereplacement feed!n& for preterm !nfant#B #afe

alternat!$e# to %rea#t m!lkB pa#teur!#er#

PMK WHO.doc

Documents

Transcript of PMK WHO.doc