Work Group 2KMC in Low Resource setting

Members Adriano Cattaneo

Ochi IbeNancy Sloan

Hadi 　 PratomoJoseph de Graft Johnson

Evely ZimbaSuman Rao

Saluddin AhmedNagai Shuko

Zita de CalumeSteve Wall

THU 　 NGA NGUYENMUKESH GUPTA

Rationale for the group work • To respond to WHO’s needs to facilitate revision of KMC guidelines

– Originally composed in 1998-1999, published 2003,– Due to recent publication of standards for guidelines development in

the Lancet. – The new WHO guidelines will focus on what should be done for KMC,

universally. Other tools will have to be developed alongside the new guidelines on how to implement KMC in high and low tech settings, and at community level, and on how to use KMC for early child development. Tools will also be needed for advocacy, integration within health systems and services, training (pre- and in-service), monitoring and evaluation.

– This working group worked to provide ideas and experience on how to proceed with the development of the above guidelines and tools from the point of view of low income settings and communities

The topics the group discussed are:

• What is universally needed, e.g., position, feeding, follow-up, friendly environment

• How to implement at different levels, e.g., referral hospital, primary level, community

• Minimum Resources needed (requirements) for implementation

What is universally needed• Skin to Skin (kangaroo Position)

• The earlier after birth, the better (sensitive period in the first two hours of life; can be done later, but it will be increasingly difficult and less effective)

• In all full term healthy newborn infants (see the BFHI and other WHO documents, let alone the abundant literature; not to be discussed further)

• In all preterm and LBW newborn infants (likely positive effect on physiological stability; what is meant by “stable” newborn infant?)

• As continuous as possible (ideally day and night over 24 hours), intermittent STS being a lower quality alternative in case of prematurity if there is no alternative means of keeping baby warm) (but some STS is better than no STS, provided each session lasts at least an hour, and efforts are put in place to achieve continuous STS)

• For as long as possible (until spontaneous weaning off by the baby)• In the frontal position (oxytocin receptors), vertical or semi-reclined

(also at night), diaper or local surrogate only (keep mother and baby dry), head covered in cold climate (but allow STS)

• Skin to Skin (kangaroo Position)• STS needed also in hot wet climate (hypothermia frequent also

in these settings); if mothers complain, help them keep dry (change clothes, cool, ventilate, use shade, etc); if needed, allow few hours with light cotton cloth between mother and baby during hottest day hours; do not bath; dry clean the baby

• With appropriate containment (lycra band or other local culturally and economically acceptable material)

• Postioning technique must ensure the newborn has a patent airways

• Primarily by the mother, but father and other designated family members (limited number) can replace the mother when needed

• STS provides comfort and promotes attachment and parental bonding, with positive maternal and paternal reaction and involvement, as well as acceptance (mediated by oxytocin)

• STS and KMC promote good quality hospital neonatal care and NICU environment (humanization, mother and family centred care)

What is universally Needed (ii)Breastfeeding (BF)/Breastmilk

– All full term newborn infants immediately at the breast for first latch as soon as the baby is ready, without forcing to the nipple, allowing time as needed (see BHFI; not to be discussed further)

– All preterm and LBW newborn infants at the breast as early as possible, to stimulate lactation even if latching and sucking do not occur

– If the baby is unable to breastfeed (suck, swallow), start expressing colostrum and breastmilk as soon as possible and use to feed the baby (use clean syringe, teaspoon or other appropriate tool); avoid prelacteal feeds

– If unable to breastfeed and not fed properly, give some glucose solution in first 24-48 hours to avoid hypoglycemia

– Scheduled and/or semi-demand feeding needed in all preterm and LBW infants until exclusive breastfeeding is well established and adequate growth is observed

– In case of inadequate growth, try to increase breastmilk production, use hindmilk, use donor safe breastmilk is available; if no breastmilk available, use preterm formula (national guidelines and hospital protocols); BF support in preterm and LBW infants need health workers with special skills

– For HIV, follow national guidelines, no special KMC policy

What is universally Needed (iii)

• Universal (?free) access to effective health care for preterm and LBW infants, better if in a preterm/LBWI friendly hospital (certification like BFHI? With different grades of achievement to show that progress is rewarded?) with:

Steps to preterm/LBWI friendly hospital (certification like BFHI?

• Written KMC policy know to all staff and parents• Health workers (including auxiliaries) trained to implement policy• Information on KMC for all pregnant women• Adequate KMC routines for all preterm/LBWI• Adequate follow up (ambulatory or in continuity with health care

system) with established criteria (ability to suck and feed, gaining weight, no disease, parents prepared to KMC at home) as close as possible to home to improve compliance (frequency will depend on age and weight gain)

• Adequate links with family and community for social support• Better if all this is included in national policies and plans for essential

newborn care (pilot phase, assessment, identification of obstacles and problems, find solution, expansion, monitor process and results); follow technology assessment procedures, but keep in mind the behavioural component of KMC

• Essential if community-based KMC is implemented• Integrate with other components of maternal and child health

(antenatal care, care at childbirth, postnatal care, early childhood development)

What is universally Needed (iv)

– Social support and friendly environment:• Promote mother-to-mother support• Try to overcome physical and economic obstacles• Empower families and promote in neighbourhoods• Positive representation in mass media• National supportive legislation (maternity leave and

protection)

HOW TO IMPLEMENT AT DIFFERENT LEVELS, INCLUDING RESOURCES NEEDED AND ESSENTIAL REQUIREMENTS

Secondary and tertiary referral hospitals....i

• Necessary if you want to implement KMC at lower and community levels; a good programme at this level will facilitate extension

• Have written policy and train all staff to implement it; involve obstetricians, anesthesiologists, auxiliaries etc; a BFHI accreditation will facilitate KMC

• Let pregnant women and all hospital users know about the policy (appropriate written and pictorial materials)

• Essential equipment and supplies are needed: incubator, radiant warmer, oxygen and flowmeters, pulse oxymeter, CPAP, phototherapy, lab tests, drugs, micronutrients, i.v. fluids, facilities for expressed breastmilk, preterm formula, cups, feeding tubes, scales (10 g precision), refrigerator, etc; but also leisure room for mothers to socialize, read, chat, play, watch TV, knit, etc; involve fathers

Secondary and tertiary referral hospitals....ii

• Use available facilities and resources (rooms, staff, equipment, money, etc) and reallocate, rather than request new facilities and resources

• Ensure that KMC staff has the necessary skills to support BF in preterm/LBWI

• Ensure adequate follow up, ambulatory or at peripheral facilities depending on distance and circumstances (hence the need to train also health workers in lower level facilities), ensure continuity of care

• Keep good records and use database to assess quantity and quality of KMC, as well as outcomes

First level Hospitals (with admission policy)

• Clear criteria about which preterm/LBWI will be cared for at which level, so that only those appropriate for this level will remain here, or will be sent here after discharge from secondary or tertiary care unit

• Link with secondary/tertiary unit, but also with lower level health centres and facilities

• Have a written policy, inform and train all staff, inform all pregnant women and their families

• Have a minimal package of materials, equipment and supplies that will allow to care and monitor larger preterm/LBWI (or smaller preterm/LBWI discharged from secondary/tertiary units) for few days to monitor health and growth, before discharge home

• Be equipped, including trained staff, to deal with special breastfeeding support needed for KMC infants

• Keep good records

Other first level facilities• Differentiate care provided according to capability for

inpatient care, although limited, or not; for example: can cases of neonatal sepsis be treated or will they be referred to upper level facility?

• If no inpatient care, train staff to follow up (including outreach if necessary) preterm/LBWI discharged from upper levels or referred from CHW/V (see below)

• Weighing, monitoring growth, counseling, etc should be possible in these and upper level facilities, with appropriate equipment and supplies, including simple management and triage (staff must be trained for all this; make sure staff does not go beyond what they have been trained to do for preterm/LBWI)

• Keep simple records, ensure regular supervision, have simple pictorial instructional material (IMCI-like)

Community KMC• In settings where percentage of births assisted by

skilled attendants is low and unlikely to grow rapidly• Start simultaneously with KMC in health care facilities

(see above) and teaching institutions; do not use community KMC to delay access to quality health care services• For all newborn infants or only for preterm/LBW

(small) infants, depending on countries and circumstances (GA impossible to assess everywhere; BW impossible to get in most places; where scales are available, may only have colour-coded gross indication of weight categories; no accurate measures; colour-coded assessment of mid arm circumference may be an alternative)

Community KMC..contd 2• About 500-1500 (based on distances) population per

CHW/V (larger populations difficult to manage) with a comprehensive but not excessive and unmanageable number of tasks• Community sensitised with culturally adapted social

communication for behavioural change that creates a favourable environment (see recent Lancet paper by V. Kumar); integrate traditional birth attendants• Start with information for all pregnant women, with

appropriate instructions and pictorial material (1-2 visits in pregnancy), counselling materials and skills• Promote birth in preterm/LBW friendly hospital in case

of preterm labour and birth, or refer to hospital soon after birth (clear criteria for referral in training and instructions); use STS for transport, while maintaining BF

Community KMC..contd 3• Promote as early as possible STS (first 24 hours, maximum 48

hours) and as continuous as possible• Promote adequate personal hygiene for the mother who is

providing KMC• Ensure a CHW/V visit as soon as possible after birth (same timing);

then visit every two days in first week and for a total of five times in the first month; observe BF and give adequate support at every visit; promote scheduled and/or semi-demand feeding until baby sucks and feed well and good growth is confirmed

• Use simple checklists for both ante- and postnatal care, so that essential observation and advice is not missed; identify danger signs and refer accordingly

• Community (and even ambulatory or facility based) follow up after hospital discharge may be particularly difficult in peri-urban slum areas; special efforts needed

Community KMC..contd 4• If for all newborn infants, monitor adverse events

(unexpected and unexplained deaths reported in France and UK); the baby may be used to identify which needs STS beyond sensitive period: term babies will push away)

• Provided by community health workers or volunteers (CHW/V), male or female, paid or unpaid, employed by governments or NGOs, with a given educational level, depending on circumstances; credible in the community

• CHW/V appropriately trained: competency based courses of adequate duration (2-3 weeks?)

• CHW/V with essential equipment (scale? thermometer? drugs? mobile phone?) and simple records and adequate supervision to maintain or improve quality performance

Key take home messagesIntegrate KMC in to Essential newborn care• For sustainability• think about cost • plan accordingly (never as

stand alone KMC, but as part of comprehensive newborn care),

• Provide accurate information that survival may improve, but deaths will still occur, and that survivors may have a better life.

For advocacy

• Involve governments and donors, set up local partnerships

• Have “champion” to help sustain enthusiasm (and deal with anti champions)

• Award, certify, reward (as in BFHI or better)

• Present as part of comprehensive integrated ENC

• Get WHO and UNICEF support