Kangaroo Mother Care: Easing Baby's Transition into the World
Guelph ON Canada
From NEW BEGINNINGS, Vol. 24 No. 2, March-April 2007, pp. 52-55
My first grandchild, Sebastian, was born eight weeks early and had difficulty breathing. For several days he spent almost all his time in an incubator, attached to a respirator, while we watched him through the plastic walls, longing to touch and hold him. I went out and bought his mother a new-baby gift that was perhaps a little different than she had expected: several shirts in her size that buttoned down the front.
The minute Sebastian no longer needed help with his breathing, his mother understood the value of that gift. She tucked him inside her shirt, skin-to-skin, with the monitors still attached. He immediately snuggled into position and relaxed, his head against her chest, hearing her familiar voice and heartbeat, smelling her familiar scent, warm and safe next to her breasts.
Fortunately, Sebastian spent those first few days at a hospital where Kangaroo Mother Care (KMC) was encouraged, and the nurses supported his mother in keeping him close to her. But that changed when his breathing stabilized and he was transferred back to the hospital where he'd been born, where the staff was not as familiar with KMC.
What Is Kangaroo Mother Care?
Most health professionals who work with mothers and newborns are aware of "kangaroo mother care," or "kangaroo care" as it is often called. The actual practice varies tremendously from one hospital to another. In some places, KMC is seen as an adjunct to technological care of premature infants, something to be permitted for brief periods of time, and only when certain requirements are met. In others, it is the standard of care for all infants, both full-term and premature, and any technological assistance is provided in conjunction with KMC.
The essential components of KMC are simple, yet they provide a complex set of stimuli and create a rich environment for baby and mother. The work of Dr. Nils Bergman has confirmed the value of this approach and defined the elements crucial to its success (Bergman, Linley, and Fawcus 2004).
The first component is skin-to-skin contact between mother and baby, with the baby positioned upright against the mother's chest. The second component is exclusive breastfeeding, something that is readily facilitated by the skin-to-skin aspect of KMC. The third is no (or minimal) separation of mother and baby; any needed care for either person will be done while the baby and mother remain in contact. The final component is support: the mother receives the support she needs to continue providing for her baby's needs. Support includes whatever is needed for the medical, emotional, psychological, and physical well-being of mother and baby without separating them.
What Are the Benefits of KMC?
KMC was introduced to promote the survival of premature infants in situations where limited technology was available (Bergman and Jurisoo 1994), but ongoing research has shown that it is, in fact, a superior approach to caring for both premature and full-term infants. One area where KMC has significant impact is in encouraging and facilitating breastfeeding (Syfrett and Anderson 1993). In studies involving both premature and full-term babies, KMC increased the rates of breastfeeding initiation, exclusive breastfeeding at discharge, and breastfeeding duration. These benefits were observed even in studies where KMC was not fully implemented. In some, for example, the mothers were allowed to have their babies skin-to-skin for up to two hours each day, yet even these minimal changes from standard care with baby in an incubator often yielded significant results in terms of breastfeeding (Righard and Alade 1990).
Why does KMC lead to breastfeeding success? Research suggests several reasons:
- Mothers involved in KMC show more positive feelings toward their infants (Tessier et al. 1998). In some countries, large-scale implementation of KMC has led to lower rates of infant abandonment and abuse (Bergman and Jurisoo 1994). These affectionate, loving feelings toward the baby encourage the mother to initiate and continue breastfeeding.
- KMC facilitates frequent feeding (Whitelaw, Heisterkamp, and Sleath et al. 1998), an essential step to building milk production. With the baby always close by, the mother is able to pick up her child's earliest hunger cues and quickly offer the breast.
- The greater physiological stability provided by KMC means that the baby has more energy to devote to feeding at the breast. The mother's body, for example, is highly effective in maintaining the baby's temperature. If the baby is too warm, the temperature of the mother's skin will drop slightly; if the baby is too cool, the mother's temperature will rise. Many studies have shown that KMC is as effective or more effective at maintaining infant temperature as keeping the baby in an incubator. Babies in KMC also have better oxygenation, more stable heart rates, and fewer signs of stress than those who are cared for away from their mothers' bodies.
- Mothers with babies who were not yet developmentally ready to feed at the breast found they could pump larger amounts of milk when they were doing KMC, as compared to mothers whose babies were not in skin-to-skin contact with them (Anderson 1991).
- The mother's greater involvement in her baby's care while doing KMC helps the mother know her baby as an individual, to recognize signs of hunger, distress, and fatigue. Recognition of these cues are all important in managing breastfeeding, especially with a premature baby.
- KMC reinforces for the mother that she is important to her baby. In hospitals where mothers and babies are routinely separated, the mother is often given the impression that she is not only unimportant, but potentially dangerous to her child. This sense of being valued by the staff in her mothering role encourages the mother to breastfeed as a way to nourish and nurture her baby.
KMC Versus Incubators and Cribs
The baby in KMC is positioned vertically on the mother's chest. Dr. Christina Smillie, medical director of Breastfeeding Resources in Stratford, Connecticut, USA who uses "baby-led latching" when assisting breastfeeding dyads, suggests that this vertical position allows the baby to orient himself and prepare to seek out the breast. While in skin-to-skin contact with the mother, the baby hears her heartbeat and voice, much as he did in utero, smells her unique scent, and is able to position himself to look up at her face and make eye contact. Babies are hard-wired to breastfeed, and these stimuli create the environment that signals them to seek the breast and latch on.
Compare this to the baby who is isolated in an incubator or crib, hearing unfamiliar voices and mechanical sounds and smelling hospital disinfectants. At a time deemed appropriate by his caregivers, he is wrapped snugly in a blanket and brought to his mother to feed. He may be immediately placed in a nursing position, with no opportunity to see his mother's face or feel her skin. It is not surprising that often the baby doesn't seem to know what to do in this situation.
Many lactation consultants and others who work with new mothers have shared anecdotes about mothers who had not intended to breastfeed but who changed their minds after experiencing at least some elements of KMC.
In one case, a mother I was supporting through labor and birth had stated that she intended to bottle-feed. Immediately after the birth, her physician placed the baby on her chest, skin-to-skin, and told her it would be beneficial to the baby to have as much skin contact as possible. She stroked and talked to the baby affectionately, and after an hour or so, the baby moved toward his mother's breast and attempted to latch on. I was uncertain about how she would react, given her earlier determination to bottle-feed, but she smiled at her son and said, "I've changed my mind." She breastfed him for nine months.
Increasingly, research suggests that the use of KMC continuously from birth is the most appropriate approach for ensuring baby's health and survival. Many hospitals require that a premature baby spend time after birth in an incubator until stabilized, before being returned to the mother for KMC. However, one study found that premature babies who were skin-to-skin with their mothers from birth onward stabilized more quickly and more effectively than those in an incubator (Bergman, Linley, and Fawcus 2004).
In this study, premature infants with birth weights between 2.65 to 4.85 pounds (1200 grams and 2199 grams) were randomly assigned to receive either skin-to-skin care from birth or standard incubator care for six hours. An infant assigned to skin-to-skin care was secured to the mother's chest with a folded towel so as to fix the head and chest of the infant in a "sniffing" position, providing an optimal airway. The hips were flexed in a frog position. Otherwise the infants in both groups received identical care. All of the infants assigned to skin-to-skin care had perfect stabilization scores after five hours of skin-to-skin contact, compared with less than half of the infants assigned to incubator care.
Skin-to-skin contact for babies is valuable in many ways beyond facilitating breastfeeding. Studies have shown, for example, that skin-to-skin care is effective in preventing hypoglycemia, which is an abnormally low level of sugar in the blood, in newborns (Bergman, Linley, and Fawcus 2004). Since many breastfeeding newborns are supplemented because of concerns about hypoglycemia, this may also be important in maintaining exclusive breastfeeding. Skin-to-skin contact also reduces pain in infants undergoing procedures such as heel pricks, with better results than standard pain medications (Ludington-Hoe, Hosseini, and Torowicz 2005).
Bergman has described the mother's body as the baby's natural habitat (Bergman, Linley, and Fawcus 2004), and one of the most significant benefits of keeping mothers and babies together is that the baby finds this environment calming and relaxing. Babies in KMC have much lower levels of glucocorticoids than babies cared for out of maternal skin contact (Smillie 2006). Bergman states that when a baby is separated from his mother, there is an inborn, automatic, biological response, which is called "protest-despair." First, the baby cries and moves (as much as he can) to find his mother (the "protest"); when time goes on and his mother doesn't respond, his heart rate slows, his body temperature decreases, and he becomes less active (the "despair"). These responses lead to a delayed adaptation to the extra-uterine environment.
Positive Mother-Baby Relationships
Finally, whether or not the baby is breastfed, KMC helps to create more positive mother-baby relationships, and the benefits last long past the newborn period. One study found that KMC mothers were less likely to return to work during the first year after the baby's birth. While technology may succeed in keeping babies alive, KMC has the potential to help babies thrive. The enhanced mother-baby relationships and increased breastfeeding rates alone improve health outcomes of all kinds. There is strong evidence that KMC should be the standard, normal care for all babies, both full-term and premature, and that only when a baby is clearly in need of technology incompatible with KMC should other approaches such as placing the baby in an incubator be used.
When my grandson, Sebastian, was transferred back to the local hospital at a week old, my daughter-in-law was surprised to have the nursing staff tell her that it would be too stressful for the baby to continue with the Kangaroo Mother Care she'd been doing.
"Too stressful?" she asked. "Well, let's just see." Sebastian was already connected to monitors that traced his heart rate, his breathing, and his temperature on the computer. She settled him against her chest again and buttoned up the bottom of her shirt to keep him warm and secure. We watched the lines on the graph. His breathing became more regular, his temperature more stable, and the pattern of his heart beating less jagged and erratic.
The nurse looked, too, and didn't say a word. But no one suggested he be put back in the incubator, and from that day on, until Sebastian came home three weeks later, he spent much of the time enjoying KMC -- easing his transition into the world.
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Born a Year Too Early?
At an LLLI Conference in 2001, Dr. Nils Bergman, world renowned for his extensive experience with Kangaroo Mother Care, presented a session on KMC. He emphasized that the human mother and infant should be viewed as a pair, adding, "Breastfeeding's worst enemy is separation."
Anthropologists theorize humans appear to be born about one year "too early." For many mammals, brain size at birth is about 80 percent of adult size, whereas that of humans is about 25 percent. Humans don't achieve 80 percent of adult brain size until approximately 21 months gestational age, or 12 months postpartum. It has been suggested that the human newborn completes its gestational brain growth outside of the womb.
Therefore, the correct habitat for an infant to complete this growth process is in skin-to-skin contact with the mother, with breastfeeding providing the nutrition that is uniquely adapted to the needs of the human infant's "immaturity."
Dr. Bergman will be speaking at the 2007 LLLI Conference in Chicago, Illinois, USA this July. For more information, see www.llli.org.
Source: Albright, L. Kangaroo mother care: Restoring the original paradigm for infant care and breastfeeding. LEAVEN 2001; 37(5):106-07.