Kangaroo Mother Care, home environment and father involvement in the first year of life: a randomized controlled study

Kangaroo mother care had a protective effect on the volume of brain structures in young adults born preterm

Aim

The protective effects of Kangaroo mother care (KMC) on the neurodevelopment of preterm infants are well established, but we do not know whether the benefits persist beyond infancy. Our aim was to determine whether providing KMC in infancy affected brain volumes in young adulthood.

Method

Standardised cognitive, memory and motor skills tests were used to determine the brain volumes of 20‐year‐old adults who had formed part of a randomised controlled trial of KMC versus incubator care. Multivariate analysis of brain volumes was conducted according to KMC exposure.

Results

The study comprised 178 adults born preterm: 97 had received KMC and 81 were incubator care controls. Bivariate analysis showed larger volumes of total grey matter, basal nuclei and cerebellum in those who had received KMC, and the white matter was better organised. This means that the volumes of the main brain structures associated with intelligence, attention, memory and coordination were larger in the KMC group. Multivariate lineal regression analysis demonstrated the direct relationship between brain volumes and duration of KMC, after controlling for potential confounders.

Conclusion

Our findings suggest that the neuroprotective effects of KMC for preterm infants persisted beyond childhood and improved their lifetime functionality and quality of life.

Barriers and Facilitators to Conducting Kangaroo Mother Care in Italian Neonatal Intensive Care Units

PURPOSE

This work aimed to investigate obstacles and facilitators for carrying out Kangaroo Mother Care (KMC) across Italian NICUs.

DESIGN AND METHODS

A survey that investigated Unit's characteristics, policies toward parents and KMC practice and policies was carried out. Data from 86 NICUs (80.4%) was collected. Descriptive statistics and Multiple Regression Models were computed.

RESULTS

Eighty-one NICUs provided KMC. These NICUs had a less restricted parental access policies (chi² = 7.373, p = .007). More than the 70% of the units did not have adequate facilities for parents. KMC daily length was positively predicted (R² = 0.18, F = 7.91, p = .001) by repeated sessions and documentation of KMC.

CONCLUSION

The implementation of KMC is characterized by different barriers and facilitators that determine the parent's possibility to provide KMC. Structural factors (e.g., adequate space and facilities) can support families in providing KMC. A unique result of this survey is that KMC documentation on medical records appears critical for improving its practice.

PRACTICE IMPLICATIONS

Although most of the Italian units provide KMC as a routine practice, improving its practical support would be beneficial to its implementation. A more formalized approach to KMC may strengthen staff habits to consider KMC like a standard care treatment.

Barriers for kangaroo mother care (KMC) acceptance, and practices in southern Ethiopia: a model for scaling up uptake and adherence using qualitative study

BACKGROUND

Globally, approximately 15 million babies are born preterm every year. Complications of prematurity are the leading cause of under-five mortality. There is overwhelming evidence from low, middle, and high-income countries supporting kangaroo mother care (KMC) as an effective strategy to prevent mortality in both preterm and low birth weight (LBW) babies. However, implementation and scale-up of KMC remains a challenge, especially in lowincome countries such as Ethiopia. This formative research study, part of a broader KMC implementation project in Southern Ethiopia, aimed to identify the barriers to KMC implementation and to devise a refined model to deliver KMC across the facility to community continuum.

METHODS

A formative research study was conducted in Southern Ethiopia using a qualitative explorative approach that involved both health service providers and community members. Twenty-fourin-depth interviewsand 14 focus group discussions were carried out with 144study participants. The study applied a grounded theory approach to identify,examine, analyse and extract emerging themes, and subsequently develop a model for KMC implementation.

RESULTS

Barriers to KMC practice included gaps in KMC knowledge, attitude and practices among parents of preterm and LBW babies;socioeconomic, cultural and structural factors; thecommunity's beliefs and valueswith respect to preterm and LBW babies;health professionals' acceptance of KMC as well as their motivation to implement practices; and shortage of supplies in health facilities.

CONCLUSIONS

Our study suggests a comprehensive approach with systematic interventions and support at maternal, family, community, facility and health care provider levels. We propose an implementation model that addresses this community to facility continuum.

Systematic review and meta-analysis suggest that the duration of Kangaroo mother care has a direct impact on neonatal growth

AIM

A 2016 Cochrane review showed that Kangaroo mother care (KMC) had a moderate impact on preterm growth, with high heterogeneity among studies. This systematic review and meta-analysis considered new evidence on KMC, particularly the duration.

METHOD

Databases were searched for papers published in English, French, Spanish and Portuguese up to 2017. Randomised controlled trials (RCT) of preterm or low birth weight infants were included if they compared growth between KMC and conventional care. Anthropometric measures were related to duration.

RESULTS

We identified 1368 papers, and 13 RCTs covering 743 KMC infants and 718 controls met the selection criteria. Infants held in KMC for at least 6 h/d gained more weight than the controls, with a mean difference of 8.99 g/d (95% confidence interval 8.14-9.84, I²  = 0%). This difference persisted between 2 and 6 h/d and disappeared with 2 hours or less. When we used g/kg/d, the weight gain was higher when the duration was at least 8 h/d. Only babies who received 6 h/d gained more length and head circumference.

CONCLUSIONS

The effect of the KMC on growth was directly related to the duration.

A complementary feeding and play intervention improves the home environment and mental development among toddlers in rural India

A cluster randomized trial design was used to test the efficacy of a behaviour change communication intervention on the quality of the home environment and infant development at 15 months of age. Children (n = 600) in rural South India were followed from 3 through 15 months of age. The control group (C group) received the standard of care, the complementary feeding group (CF group) received recommendations on complementary foods and the responsive complementary feeding and play group (RCF&P group) received recommendations on complementary foods plus skills on responsive feeding and play. The intervention was delivered in biweekly home visits to caregivers using flip charts. At postintervention, infants (n = 521) were assessed for development (Bayley-II scales) and their home environment was assessed (Home Observation for Measurement of the Environment [HOME] scale). Cluster adjusted analysis of variance showed no significant differences at baseline. The HOME score at 15 months differed by group, F(2, 38) = 6.41, P = 0.004; the CF and RCF&P groups had higher scores than the C group. Scores on subscales 'Opportunities for Variety in Daily Stimulation' and 'Caregiver Promotion of Child Development' (CPCD) were higher for the RCF&P group than for the C and CF groups. Mental development index (MDI) scores differed by group, F(2, 37) = 3.31, P = 0.04, with the RCF&P group showing higher scores than the C group (P < 0.04); no differences were noted in psychomotor development index (PDI) scores (P = 0.48). The subscales of HOME associated with MDI at 15 months were 'CPCD' and 'Cleanliness of Child' (R2 = 0.076). 'CPCD' was also associated with PDI (R2 = 0.039). A responsive complementary feeding and play intervention delivered through home visits benefitted children's mental development and caregiving environment at 15 months.

Parent-targeted postnatal educational interventions in low and middle-income countries: A scoping review and critical analysis

OBJECTIVES

To identify and map existing postnatal educational interventions targeting parents in low and middle-income countries. A secondary objective is to conduct a critical analysis of the strengths and limitations of the educational strategies used for parent-targeted postnatal education. Design & data sources: Using scoping review methodology, MedLine, CINAHL, and SCOPUS were searched in October 2017.

REVIEW METHODS

All studies published after 2000 reporting on educational interventions that targeted parents from the period of birth to 6 weeks postnatally in low and middle-income countries were included. Studies were excluded if they targeted healthcare professionals or were community interventions that spanned antenatal to postnatal care. Title, abstract and full-text screening was conducted by two reviewers.

RESULTS

We initially identified 9284 articles with 77 articles included after title, abstract and full-text screening. Most of the studies were quantitative (94%) with over half published after 2014. Most studies (61%) targeted a single newborn care education intervention, of which 75% targeted breastfeeding. Interventions used on average three different methods of implementation (e.g., verbal, written information, counselling). Interventions were provided in the hospital (76%), at home (23%), at a clinic/hospital (8%), and/or virtually through an eHealth intervention, including phone or text messages (12%). Maternal outcomes primarily included knowledge, self-efficacy, anxiety and stress while newborn outcomes primarily included exclusive breastfeeding, weight gain at follow-up, and morbidities. Positive changes were found to occur for reported maternal outcomes (89%) and newborn outcomes (56%).

CONCLUSIONS

Parent-targeted education varied in terms of educational topics covered, method and location of intervention, and outcomes examined. While the best strategies of implementing postnatal education interventions to parents in low and middle-income countries is yet to be determined, evidence suggests that current interventions had a positive impact on parents' outcomes using a combined approach. Further work is needed to evaluate the impact on newborn outcomes and to identify the most effective methods and timing of the interventions.

Effect of Kangaroo Mother Care on Successful Breastfeeding: A Systematic Review and Meta-Analysis of Randomised Controlled Trials

BACKGROUND & AIMS

Evaluating the effect of Kangaroo Mother Care (KMC) on breastfeeding success shows conflicting results. Regarding the importance of breastfeeding and uncertainties about its effect, this study intended to conduct a systematic review and meta-analysis of randomised controlled trials on the effect of KMC on success of breastfeeding.

METHODS

In this systematic review and meta-analysis study, required data were collected by searching the following keywords: breastfeeding, Breast-Feeding, "skin-to-skin", "Kangaroo Mother Care", randomized clinical trial. The following databases were searched: Google Scholar, PubMed, EMBASE, Scopus, and Cochrane Central Register of Controlled Trials. Two authors independently extracted the data. To estimate the Breast-Feeding outcome variables, CMA2 software was used. The risk of bias of studies was assessed with the criteria developed in the Cochrane Handbook.

RESULTS

Twenty articles were included. In the KMC and CNC groups, 1,432 and 1,410 neonates were examined. Breastfeeding success rate was higher in the KMC group within different time slots, however this difference was not statistically significant (RR=1.11(95CI, 0.93-1.34) and RR=1.13(95%CI, 0.92-1.34) based on the time slot and birth weight, respectively). The inter-groups differences in the mean scores of Infant Breast-Feeding Assessment Tool (IBFAT) were statistically significant (P<0.05). Breastfeeding was initiated very sooner in the KMC group, suggesting a statistically significant inter-groups difference -0.72(95%CI, from -0.92 to -0.53) (P<0.05). Majority of the studies had a high risk of bias.

CONCLUSION

Findings indicated a superiority of KMC over CNC in terms of breastfeeding success. Assessment of the complications and costs of KMC implementation is recommended.

Early father-infant skin-to-skin contact and its effect on the neurodevelopmental outcomes of moderately preterm infants in China: study protocol for a randomized controlled trial

BACKGROUND

Skin-to-skin contact (SSC) is an evidence-based intervention that benefits low birth weight /preterm infants. However, China's health institutional policy inhibits parents from visiting their baby in the neonatal intensive care unit (NICU). In addition, the Chinese traditional postpartum behavioral practice of confining women to home raises barriers to mother-infant contact. Thus, to shorten the duration of parent-infant separation, father-infant SSC is considered a possible alternative. This study determines whether it is safe to perform father-infant SSC in the NICU and investigates how paternal SSC affects outcomes compared with traditional care (TC) for moderately preterm infants.

METHODS/DESIGN

A randomized controlled trial will be used to investigate the effects of paternal-infant SSC in NICU wards in China. Preterm infants born at a gestational age in the range of 320-346 weeks with a birth weight > 1500 g will be eligible. A simple random sampling method will be used to allocate infants to the SSC group (n = 25) or the TC group (n = 25). After medical stability, infants in the SSC group will be provided SSC by fathers for one hour every day until discharged from hospital. The primary outcome is neurodevelopmental measures, specifically salivary cortisol and Premature Infant Pain Profile (PIPP) during hospitalization. At 40 weeks of corrected age, infants will be assessed using the Infant Neurological International Battery (INFANIB) and neuroimaging. Secondary outcomes include infants' physiological stability during SSC and throughout hospitalization and state observation at discharge. The fathers' mental health will be assessed with the State-Trait Anxiety Inventory (STAI) 1 day to 3 days after the infant's admission to the NICU and at discharge. Father-infant attachment will be evaluated at 4 and 6 months after the infants' discharge, measured by the Paternal Postnatal Attachment Scale (PPAS). Statistical analyses will be conducted using a two-sided significance level of 0.05.

DISCUSSION

The effects of paternal-infant SSC on moderately preterm infants will be assessed. The data gathered in this study may have important implications for medical practice and policy in the NICU regarding the care methods of premature infants in China.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ChiCTR-IOR-1701274 . Registered on 20 September 2017. Retrospectively registered.

Breastfeeding of preterm newborn infants following hospital discharge: follow-up during the first year of life

This paper aims to evaluate the prevalence of breastfeeding among premature infants following hospital discharge. Cohort (< 33 gestation weeks) followed up to 12 months (adjusted age).

VARIABLES

breastfeeding, anthropometric measurements, social and family information. The proportion of breastfeeding during follow-up was calculated. Survival analysis was conducted to estimate breastfeeding duration. In total, 242 of the 258 infants (93.7%) returned to follow-up; 170 (69.9%) at 6 months and 139 (57.2%) at 12 months (adjusted age). A history of miscarriages (27.5%), stillbirths (11.7%), neonatal deaths (9.5%) and preterm births (21.1%) was noted in 65.5% of women. At hospital discharge: 5.5% received exclusive breastfeeding, 65.8% breastfeeding and formula, 28.6% formula. At month 1, 81.3% received breastfeeding, decreasing to 68.5% at month 2, 62.4% at month 3, 48.1% at month 4 and 22.4% at month 6 (adjusted age). The median of breastfeeding duration was 4 months. Breastfeeding occurred up to four months adjusted age in almost half of the population. Despite the need to improve these rates, the results could reflect the profile of the Child-Friendly Hospital Initiative Unit. Maintaining breastfeeding amongst preterm infants following hospital discharge is still a challenge, for both mothers and health professionals.

Push or Carry? Pragmatic Opportunities for Language Development in Strollers vs. Backpacks

Strollers and backpacks are employed early, frequently and throughout the first year, with parents overwhelmingly using strollers. However, because these transport modalities put infants in different proximities to caregivers, postures, and states of alertness, their use may translate to different opportunities that are of developmental consequence, particularly with regard to language. We used GoPro technology in a within subjects counter-balanced design to measure dyadic vocalizations in strollers and backpacks with 7-to-11-month-old infants. Parent-infant dyads (N=36), who regularly used both transport modes took two 8-minute walks in their own neighborhoods using their own carriers while wearing lightweight head-mounted GoPros. There was significantly more parent speech, infant vocalizations, dyadic conversations and infant-initiated speech in backpacks, as well as more head motion consistent with visual scanning by infants. Backpacks appear to be a practical way to encourage more engaging, language-enriched developmental opportunities in the critical first year.

Parent participation in the neonatal intensive care unit: Predictors and relationships to neurobehavior and developmental outcomes

OBJECTIVE

To 1) define predictors of parent presence, any holding, holding in arms, and skin-to-skin care in the NICU and 2) investigate the relationships between parent participation and a) early neurobehavior and b) developmental outcomes at age 4 to 5years among preterm infants.

METHODS

Eighty-one preterm infants born ≤32weeks estimated gestational age were prospectively enrolled within one week of life in a level III-IV NICU. Parent (maternal and paternal) presence and holding (including holding in arms and skin-to-skin care) were tracked throughout NICU hospitalization. Neurobehavior at term equivalent age and development at 4 to 5years were determined using standardized assessments.

RESULTS

The median number of days per week parents were documented to be present over NICU hospitalization was 4.0 (IQR=2.4-5.8) days; days held per week 2.8 (IQR=1.4-4.3) days [holding in arms days per week was 2.2 (IQR=1.2-3.2) days and parent skin-to-skin care days per week was 0.2 (IQR=0.0-0.7) days]. More parent presence was observed among mothers who were Caucasian, married, older, or employed and among those who had fewer children, familial support and provided breast milk (p<0.05). More holding was observed in infants with fewer medical interventions (p<0.05) and among those who were Caucasian, had a father who was employed, had fewer children and family support (p<0.05). More parent holding in the NICU was related to better reflex development at term age (p=0.02). More parent skin-to-skin care was related to better infant reflexes (p=0.03) and less asymmetry (p=0.04) at term and better gross motor development (p=0.02) at 4-5years.

DISCUSSION

Social and medical factors appear to impact parent presence, holding, and skin-to-skin care in the NICU. Parent holding is related to better developmental outcomes, which highlights the importance of engaging families in the NICU.

Breastfeeding Challenges and the Preterm Mother-Infant Dyad: A Conceptual Model

Breastfeeding is an experience that only a mother and her infant(s) can share. Infants who can feed from the breast receive not only the best nutrition but also, due to the close physical contact between mother and child, it is the optimal nurturance they can receive from their mother. When breastfeeding is trouble free, maternal well-being is uniquely heightened. However, breastfeeding remains a challenge for many mother-infant dyads and more so for those whose infants are born prematurely. This article introduces a conceptual model of the breastfeeding challenges facing preterm mother-infant dyads. It distinguishes between a maternal caregiving and an infant growth/development components. Within the maternal component, two primary elements are considered, that is, maternal behavioral and nutritional care. The two primary elements within the infant component include infant non-nutritional and nutritional growth/development. It is proposed that an improved understanding of the factors associated with these four elements and how they interplay with each other within individual dyads will facilitate the identification of the breastfeeding challenges facing these mother-infant entities. Due to the intimate relationships existing between a mother and her infant(s), it is further advanced that breastfeeding studies would be optimized if mother-infant pairs are studied as one entity rather than mother and infant separately. It is proposed that this conceptual model will assist health professionals develop personalized breastfeeding management plans for individual preterm mother-infant dyads, while furthering the development of evidence-based interventions to optimize their breastfeeding experiences.

Breaking down barriers: enabling care-by-parent in neonatal intensive care units in China

BACKGROUND

Denying parents access to their infant in the Neonatal Intensive Care Unit (NICU) is a standard practice in most hospitals across China. Visitation is not usually permitted or may be strictly limited, and NICU care for most neonates is provided by health-care professionals with little participation of the parents. An exception to this rule is the level 2 "Room-In" ward in Qilu Children's Hospital, Shandong University, where parents have 24-hour access to their infants and participate in providing care.

METHODS

This retrospective cohort study compared the outcomes of infants who were admitted to the NICU and remained there throughout their stay (NICU-NICU group, n=428), admitted to the NICU and then transferred to the Room-In ward (NICU-RIn group, n=1018), or admitted straight to the Room-In ward (RIn only group, n=629).

RESULTS

There were no significant differences in the rates of nosocomial infection, bronchopulmonary dysplasia, intraventricular hemorrhage, and retinopathy of prematurity between the NICU-NICU and NICU-RIn groups. The rate of necrotizing enterocolitis was significantly lower in the NICU-RIn group (P=0.04), while weight gain and duration of hospital stay were significantly higher (both P<0.001). Rates of adverse outcomes were lower in RIn-only infants due to their low severity of illness on admission.

CONCLUSIONS

Allowing parents access to their infant in the NICU is feasible and safe in China, and may result in improvements in infant outcomes. Further studies are required to generate stronger evidence that can inform changes to neonatal care in China.

Twenty-year Follow-up of Kangaroo Mother Care Versus Traditional Care

BACKGROUND AND OBJECTIVES

Kangaroo mother care (KMC) is a multifaceted intervention for preterm and low birth weight infants and their parents. Short- and mid-term benefits of KMC on survival, neurodevelopment, breastfeeding, and the quality of mother-infant bonding were documented in a randomized controlled trial (RCT) conducted in Colombia from 1993 to 1996. The aim of the present study was to evaluate the persistence of these results in young adulthood.

METHODS

From 2012 to 2014, a total of 494 (69%) of the 716 participants of the original RCT known to be alive were identified; 441 (62% of the participants in the original RCT) were re-enrolled, and results for the 264 participants weighing ≤1800 g at birth were analyzed. The KMC and control groups were compared for health status and neurologic, cognitive, and social functioning with the use of neuroimaging, neurophysiological, and behavioral tests.

RESULTS

The effects of KMC at 1 year on IQ and home environment were still present 20 years later in the most fragile individuals, and KMC parents were more protective and nurturing, reflected by reduced school absenteeism and reduced hyperactivity, aggressiveness, externalization, and socio-deviant conduct of young adults. Neuroimaging showed larger volume of the left caudate nucleus in the KMC group.

CONCLUSIONS

This study indicates that KMC had significant, long-lasting social and behavioral protective effects 20 years after the intervention. Coverage with this efficient and scientifically based health care intervention should be extended to the 18 million infants born each year who are candidates for the method.

Early skin-to-skin contact for mothers and their healthy newborn infants

BACKGROUND

Mother-infant separation post birth is common. In standard hospital care, newborn infants are held wrapped or dressed in their mother's arms, placed in open cribs or under radiant warmers. Skin-to-skin contact (SSC) begins ideally at birth and should last continually until the end of the first breastfeeding. SSC involves placing the dried, naked baby prone on the mother's bare chest, often covered with a warm blanket. According to mammalian neuroscience, the intimate contact inherent in this place (habitat) evokes neuro-behaviors ensuring fulfillment of basic biological needs. This time frame immediately post birth may represent a 'sensitive period' for programming future physiology and behavior.

OBJECTIVES

To assess the effects of immediate or early SSC for healthy newborn infants compared to standard contact on establishment and maintenance of breastfeeding and infant physiology.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (17 December 2015), made personal contact with trialists, consulted the bibliography on kangaroo mother care (KMC) maintained by Dr Susan Ludington, and reviewed reference lists of retrieved studies.

SELECTION CRITERIA

Randomized controlled trials that compared immediate or early SSC with usual hospital care.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. Quality of the evidence was assessed using the GRADE approach.

MAIN RESULTS

We included 46 trials with 3850 women and their infants; 38 trials with 3472 women and infants contributed data to our analyses. Trials took place in 21 countries, and most recruited small samples (just 12 trials randomized more than 100 women). Eight trials included women who had SSC after cesarean birth. All infants recruited to trials were healthy, and the majority were full term. Six trials studied late preterm infants (greater than 35 weeks' gestation). No included trial met all criteria for good quality with respect to methodology and reporting; no trial was successfully blinded, and all analyses were imprecise due to small sample size. Many analyses had statistical heterogeneity due to considerable differences between SSC and standard care control groups. Results for womenSSC women were more likely than women with standard contact to be breastfeeding at one to four months post birth, though there was some uncertainty in this estimate due to risks of bias in included trials (average risk ratio (RR) 1.24, 95% confidence interval (CI) 1.07 to 1.43; participants = 887; studies = 14; I² = 41%; GRADE: moderate quality). SSC women also breast fed their infants longer, though data were limited (mean difference (MD) 64 days, 95% CI 37.96 to 89.50; participants = 264; studies = six; GRADE:low quality); this result was from a sensitivity analysis excluding one trial contributing all of the heterogeneity in the primary analysis. SSC women were probably more likely to exclusively breast feed from hospital discharge to one month post birth and from six weeks to six months post birth, though both analyses had substantial heterogeneity (from discharge average RR 1.30, 95% CI 1.12 to 1.49; participants = 711; studies = six; I² = 44%; GRADE: moderate quality; from six weeks average RR 1.50, 95% CI 1.18 to 1.90; participants = 640; studies = seven; I² = 62%; GRADE: moderate quality).Women in the SCC group had higher mean scores for breastfeeding effectiveness, with moderate heterogeneity (IBFAT (Infant Breastfeeding Assessment Tool) score MD 2.28, 95% CI 1.41 to 3.15; participants = 384; studies = four; I² = 41%). SSC infants were more likely to breast feed successfully during their first feed, with high heterogeneity (average RR 1.32, 95% CI 1.04 to 1.67; participants = 575; studies = five; I² = 85%). Results for infantsSSC infants had higher SCRIP (stability of the cardio-respiratory system) scores overall, suggesting better stabilization on three physiological parameters. However, there were few infants, and the clinical significance of the test was unclear because trialists reported averages of multiple time points (standardized mean difference (SMD) 1.24, 95% CI 0.76 to 1.72; participants = 81; studies = two; GRADE low quality). SSC infants had higher blood glucose levels (MD 10.49, 95% CI 8.39 to 12.59; participants = 144; studies = three; GRADE: low quality), but similar temperature to infants in standard care (MD 0.30 degree Celcius (°C) 95% CI 0.13 °C to 0.47 °C; participants = 558; studies = six; I² = 88%; GRADE: low quality). Women and infants after cesarean birthWomen practicing SSC after cesarean birth were probably more likely to breast feed one to four months post birth and to breast feed successfully (IBFAT score), but analyses were based on just two trials and few women. Evidence was insufficient to determine whether SSC could improve breastfeeding at other times after cesarean. Single trials contributed to infant respiratory rate, maternal pain and maternal state anxiety with no power to detect group differences. SubgroupsWe found no differences for any outcome when we compared times of initiation (immediate less than 10 minutes post birth versus early 10 minutes or more post birth) or lengths of contact time (60 minutes or less contact versus more than 60 minutes contact).

AUTHORS' CONCLUSIONS

Evidence supports the use of SSC to promote breastfeeding. Studies with larger sample sizes are necessary to confirm physiological benefit for infants during transition to extra-uterine life and to establish possible dose-response effects and optimal initiation time. Methodological quality of trials remains problematic, and small trials reporting different outcomes with different scales and limited data limit our confidence in the benefits of SSC for infants. Our review included only healthy infants, which limits the range of physiological parameters observed and makes their interpretation difficult.

Kangaroo mother care to reduce morbidity and mortality in low birthweight infants

BACKGROUND

Kangaroo mother care (KMC), originally defined as skin-to-skin contact between a mother and her newborn, frequent and exclusive or nearly exclusive breastfeeding, and early discharge from hospital, has been proposed as an alternative to conventional neonatal care for low birthweight (LBW) infants.

OBJECTIVES

To determine whether evidence is available to support the use of KMC in LBW infants as an alternative to conventional neonatal care before or after the initial period of stabilization with conventional care, and to assess beneficial and adverse effects.

SEARCH METHODS

We used the standard search strategy of the Cochrane Neonatal Review Group. This included searches in CENTRAL (Cochrane Central Register of Controlled Trials; 2016, Issue 6), MEDLINE, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), LILACS (Latin American and Caribbean Health Science Information database), and POPLINE (Population Information Online) databases (all from inception to June 30, 2016), as well as the WHO (World Health Organization) Trial Registration Data Set (up to June 30, 2016). In addition, we searched the web page of the Kangaroo Foundation, conference and symposia proceedings on KMC, and Google Scholar.

SELECTION CRITERIA

Randomized controlled trials comparing KMC versus conventional neonatal care, or early-onset KMC versus late-onset KMC, in LBW infants.

DATA COLLECTION AND ANALYSIS

Data collection and analysis were performed according to the methods of the Cochrane Neonatal Review Group.

MAIN RESULTS

Twenty-one studies, including 3042 infants, fulfilled inclusion criteria. Nineteen studies evaluated KMC in LBW infants after stabilization, one evaluated KMC in LBW infants before stabilization, and one compared early-onset KMC with late-onset KMC in relatively stable LBW infants. Sixteen studies evaluated intermittent KMC, and five evaluated continuous KMC. KMC versus conventional neonatal care: At discharge or 40 to 41 weeks' postmenstrual age, KMC was associated with a statistically significant reduction in the risk of mortality (risk ratio [RR] 0.60, 95% confidence interval [CI] 0.39 to 0.92; eight trials, 1736 infants), nosocomial infection/sepsis (RR 0.35, 95% CI 0.22 to 0.54; five trials, 1239 infants), and hypothermia (RR 0.28, 95% CI 0.16 to 0.49; nine trials, 989 infants; moderate-quality evidence). At latest follow-up, KMC was associated with a significantly decreased risk of mortality (RR 0.67, 95% CI 0.48 to 0.95; 12 trials, 2293 infants; moderate-quality evidence) and severe infection/sepsis (RR 0.50, 95% CI 0.36 to 0.69; eight trials, 1463 infants; moderate-quality evidence). Moreover, KMC was found to increase weight gain (mean difference [MD] 4.1 g/d, 95% CI 2.3 to 5.9; 11 trials, 1198 infants; moderate-quality evidence), length gain (MD 0.21 cm/week, 95% CI 0.03 to 0.38; three trials, 377 infants) and head circumference gain (MD 0.14 cm/week, 95% CI 0.06 to 0.22; four trials, 495 infants) at latest follow-up, exclusive breastfeeding at discharge or 40 to 41 weeks' postmenstrual age (RR 1.16, 95% CI 1.07 to 1.25; six studies, 1453 mothers) and at one to three months' follow-up (RR 1.20, 95% CI 1.01 to 1.43; five studies, 600 mothers), any (exclusive or partial) breastfeeding at discharge or at 40 to 41 weeks' postmenstrual age (RR 1.20, 95% CI 1.07 to 1.34; 10 studies, 1696 mothers; moderate-quality evidence) and at one to three months' follow-up (RR 1.17, 95% CI 1.05 to 1.31; nine studies, 1394 mothers; low-quality evidence), and some measures of mother-infant attachment and home environment. No statistically significant differences were found between KMC infants and controls in Griffith quotients for psychomotor development at 12 months' corrected age (low-quality evidence). Sensitivity analysis suggested that inclusion of studies with high risk of bias did not affect the general direction of findings nor the size of the treatment effect for main outcomes. Early-onset KMC versus late-onset KMC in relatively stable infants: One trial compared early-onset continuous KMC (within 24 hours post birth) versus late-onset continuous KMC (after 24 hours post birth) in 73 relatively stable LBW infants. Investigators reported no significant differences between the two study groups in mortality, morbidity, severe infection, hypothermia, breastfeeding, and nutritional indicators. Early-onset KMC was associated with a statistically significant reduction in length of hospital stay (MD 0.9 days, 95% CI 0.6 to 1.2).

AUTHORS' CONCLUSIONS

Evidence from this updated review supports the use of KMC in LBW infants as an alternative to conventional neonatal care, mainly in resource-limited settings. Further information is required concerning the effectiveness and safety of early-onset continuous KMC in unstabilized or relatively stabilized LBW infants, as well as long-term neurodevelopmental outcomes and costs of care.

Skin-to-skin contact by fathers and the impact on infant and paternal outcomes: an integrative review

OBJECTIVE

to summarise research evidence on the impact of father-infant skin-to-skin contact on infant and paternal outcomes.

DESIGN

an integrative literature review.

DATA SOURCES

PubMed, ScienceDirect, PsycINFO, and Cumulative Index to Nursing & Allied Health.

REVIEW METHODS

studies included were: (1) published in English between January 1995 to September 2015; (2) primary researches; and (3) focused on fathers providing skin-to-skin contact with their infants and its impact on infant and paternal outcomes. The Joanna Briggs Institute's Critical Appraisal Checklists were used to appraise the scientific rigour of the studies.

FINDINGS

twelve studies (10 quantitative and two qualitative) were included in this review. Father-infant skin-to-skin contact had positive impacts on infants' outcomes, including temperature and pain, bio-physiological markers, behavioural response, as well as paternal outcomes, which include parental role attainment, paternal interaction behaviour, and paternal stress and anxiety.

CONCLUSIONS

a father's involvement in providing skin-to-skin contact seems to be feasible and beneficial to both infants and fathers. However, there has been a scarcity of literature that exclusively examines fathers' involvement and perceptions related to skin-to-skin contact in the postpartum period. Future research should examine skin-to-skin contact by fathers and its associated benefits, as well as fathers' perceptions on father-infant SSC among varied populations.

IMPLICATIONS FOR PRACTICE

a father's involvement in providing skin-to-skin contact should be promoted during the postnatal period. Father-infant skin-to-skin contact is a valuable alternative, especially during the unavailability of mothers due to special circumstances, including medical emergencies and caesarean section.

Kangaroo Mother Care and Neonatal Outcomes: A Meta-analysis

CONTEXT

Kangaroo mother care (KMC) is an intervention aimed at improving outcomes among preterm and low birth weight newborns.

OBJECTIVE

Conduct a systematic review and meta-analysis estimating the association between KMC and neonatal outcomes.

DATA SOURCES

PubMed, Embase, Web of Science, Scopus, African Index Medicus (AIM), Latin American and Caribbean Health Sciences Information System (LILACS), Index Medicus for the Eastern Mediterranean Region (IMEMR), Index Medicus for the South-East Asian Region (IMSEAR), and Western Pacific Region Index Medicus (WPRIM).

STUDY SELECTION

We included randomized trials and observational studies through April 2014 examining the relationship between KMC and neonatal outcomes among infants of any birth weight or gestational age. Studies with <10 participants, lack of a comparison group without KMC, and those not reporting a quantitative association were excluded.

DATA EXTRACTION

Two reviewers extracted data on study design, risk of bias, KMC intervention, neonatal outcomes, relative risk (RR) or mean difference measures.

RESULTS

1035 studies were screened; 124 met inclusion criteria. Among LBW newborns, KMC compared to conventional care was associated with 36% lower mortality(RR 0.64; 95% [CI] 0.46, 0.89). KMC decreased risk of neonatal sepsis (RR 0.53, 95% CI 0.34, 0.83), hypothermia (RR 0.22; 95% CI 0.12, 0.41), hypoglycemia (RR 0.12; 95% CI 0.05, 0.32), and hospital readmission (RR 0.42; 95% CI 0.23, 0.76) and increased exclusive breastfeeding (RR 1.50; 95% CI 1.26, 1.78). Newborns receiving KMC had lower mean respiratory rate and pain measures, and higher oxygen saturation, temperature, and head circumference growth.

LIMITATIONS

Lack of data on KMC limited the ability to assess dose-response.

CONCLUSIONS

Interventions to scale up KMC implementation are warranted.

Skin-to-Skin Care for Term and Preterm Infants in the Neonatal ICU

“Kangaroo mother care” was first described as an alternative method of caring for low birth weight infants in resource-limited countries, where neonatal mortality and infection rates are high because of overcrowded nurseries, inadequate staffing, and lack of equipment. Intermittent skin-to-skin care (SSC), a modified version of kangaroo mother care, is now being offered in resource-rich countries to infants needing neonatal intensive care, including those who require ventilator support or are extremely premature. SSC significantly improves milk production by the mother and is associated with a longer duration of breastfeeding. Increased parent satisfaction, better sleep organization, a longer duration of quiet sleep, and decreased pain perception during procedures have also been reported in association with SSC. Despite apparent physiologic stability during SSC, it is prudent that infants in the NICU have continuous cardiovascular monitoring and that care be taken to verify correct head positioning for airway patency as well as the stability of the endotracheal tube, arterial and venous access devices, and other life support equipment.

Understanding kangaroo care and its benefits to preterm infants

The holding of an infant with ventral skin-to-skin contact typically in an upright position with the swaddled infant on the chest of the parent, is commonly referred to as kangaroo care (KC), due to its simulation of marsupial care. It is recommended that KC, as a feasible, natural, and cost-effective intervention, should be standard of care in the delivery of quality health care for all infants, regardless of geographic location or economic status. Numerous benefits of its use have been reported related to mortality, physiological (thermoregulation, cardiorespiratory stability), behavioral (sleep, breastfeeding duration, and degree of exclusivity) domains, as an effective therapy to relieve procedural pain, and improved neurodevelopment. Yet despite these recommendations and a lack of negative research findings, adoption of KC as a routine clinical practice remains variable and underutilized. Furthermore, uncertainty remains as to whether continuous KC should be recommended in all settings or if there is a critical period of initiation, dose, or duration that is optimal. This review synthesizes current knowledge about the benefits of KC for infants born preterm, highlighting differences and similarities across low and higher resource countries and in a non-pain and pain context. Additionally, implementation considerations and unanswered questions for future research are addressed.

Kangaroo mother care to reduce morbidity and mortality in low birthweight infants

BACKGROUND

Kangaroo mother care (KMC), originally defined as skin-to-skin contact between a mother and her newborn, frequent and exclusive or nearly exclusive breastfeeding, and early discharge from hospital, has been proposed as an alternative to conventional neonatal care for low birthweight (LBW) infants.

OBJECTIVES

To determine whether there is evidence to support the use of KMC in LBW infants as an alternative to conventional neonatal care.

SEARCH METHODS

The standard search strategy of the Cochrane Neonatal Group was used. This included searches in MEDLINE, EMBASE, LILACS, POPLINE, CINAHL databases (all from inception to March 31, 2014) and the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 3, 2014) In addition, we searched the web page of the Kangaroo Foundation, conference and symposia proceedings on KMC, and Google scholar.

SELECTION CRITERIA

Randomized controlled trials comparing KMC versus conventional neonatal care, or early onset KMC (starting within 24 hours after birth) versus late onset KMC (starting after 24 hours after birth) in LBW infants.

DATA COLLECTION AND ANALYSIS

Data collection and analysis were performed according to the methods of the Cochrane Neonatal Review Group.

MAIN RESULTS

Eighteen studies, including 2751 infants, fulfilled inclusion criteria. Sixteen studies evaluated KMC in LBW infants after stabilization, one evaluated KMC in LBW infants before stabilization, and one compared early onset KMC with late onset KMC in relatively stable LBW infants. Thirteen studies evaluated intermittent KMC and five evaluated continuous KMC. At discharge or 40-41 weeks' postmenstrual age, KMC was associated with a reduction in the risk of mortality (typical risk ratio (RR) 0.60, 95% confidence interval (CI) 0.39 to 0.92; eight trials, 1736 infants), nosocomial infection/sepsis (typical RR 0.45, 95% CI 0.27 to 0.76), hypothermia (typical RR 0.34, 95% CI 0.17 to 0.67), and length of hospital stay (typical mean difference 2.2 days, 95% CI 0.6 to 3.7). At latest follow up, KMC was associated with a decreased risk of mortality (typical RR 0.67, 95% CI 0.48 to 0.95; 11 trials, 2167 infants) and severe infection/sepsis (typical RR 0.56, 95% CI 0.40 to 0.78). Moreover, KMC was found to increase some measures of infant growth, breastfeeding, and mother-infant attachment. There were no significant differences between KMC infants and controls in neurodevelopmental and neurosensory impairment at one year of corrected age. Sensitivity analysis suggested that the inclusion of studies with high risk of bias did not affect the general direction of findings or the size of the treatment effect for the main outcomes.

AUTHORS' CONCLUSIONS

The evidence from this updated review supports the use of KMC in LBW infants as an alternative to conventional neonatal care mainly in resource-limited settings. Further information is required concerning effectiveness and safety of early onset continuous KMC in unstabilized or relatively stabilized LBW infants, long term neurodevelopmental outcomes, and costs of care.

Intermittent kangaroo mother care: a NICU protocol

The practice of kangaroo mother care (KMC) is steadily increasing in high-tech settings due to its proven benefits for both infants and parents. In spite of that, clear guidelines about how to implement this method of care are lacking, and as a consequence, some restrictions are applied in many neonatal intensive care units (NICUs), preventing its practice. Based on recommendations from the Expert Group of the International Network on Kangaroo Mother Care, we developed a hospital protocol in the neonatal unit of the Institute for Maternal and Child Health in Trieste, Italy, a level 3 unit, aimed to facilitate and promote KMC implementation in high-tech settings. Our guideline is therefore proposed, based both on current scientific literature and on practical considerations and experience. Future adjustments and improvements would be considered based on increasing clinical KMC use and further knowledge.

Factors affecting parents' presence with their extremely preterm infants in a neonatal intensive care room

AIM

To describe parents' experiences of factors that influenced their stay with their extremely preterm infants in a neonatal intensive care unit (NICU).

METHODS

This study has a qualitative descriptive design based on semistructured interviews conducted with seven mothers and six fathers.

RESULTS

Opportunities to stay overnight together with their infant facilitated parental presence, and opportunities for taking over their infant's care empowered the parents in their parental role and increased their motivation to stay. Kangaroo mother care helped them to feel in control and feel needed, which increased their presence. High levels of illumination and noise rendered it difficult for parents to sleep and stay overnight with the infant. Low staffing levels limited their use of kangaroo mother care when they had to wait for assistance to transfer the infant from the incubator. Several participants perceived the performance of painful procedures on their child as stressful and as an obstacle to their presence.

CONCLUSION

Kangaroo mother care and active involvement in the infant's care gave parents a sense of control and strengthened their motivation to be with their infant. High levels of noise and illumination and a dismissive staff attitude were obstacles to parents' presence.

The Effect of Kangaroo Mother Care (KMC) on Breast Feeding at the Time of NICU Discharge

BACKGROUND

Exclusive breastfeeding is one of the most important essential components of Kangaroo Mother Care.

OBJECTIVE

This study was performed to evaluate the effects of KMC on exclusive breastfeeding just at the time of discharge.

PATIENTS AND METHODS

In this cross sectional study, 251 consecutive premature newborns admitted to neonatal intensive care unit (NICU) between May 2008 and May 2009 in Alzahra University Hospital in Tabriz were evaluated. All of candidate mothers were educated for KMC method by scheduled program. Standard questionnaire was prepared by focus group discussion, and mothers filled it prior to infant hospital discharge.

RESULTS

In this study 157(62.5%) mothers performed kangaroo mother care (KMC group) versus 94 (37.5%) in conventional method care (CMC group). In KMC group exclusive breast feeding was 98 (62.5%) vs. 34 (37.5%), and P =.00 in CMC group, at the time of hospital discharge. Receiving KMC, and gestational age were the only effective factors predicting exclusive breastfeeding. Our result indicated that there was a 4.1 time increase in exclusive breastfeeding by KMC, and also weekly increase in gestational age increased it 1.2 times, but maternal age, birth weight, mode of delivery, and 5 minute Apgar score had no influence on it.

CONCLUSIONS

KMC is more effective, and increases exclusive breast feeding successfully. It can be a good substitution for CMC (conventional methods of care). It is a safe, effective, and feasible method of care for LBWI even in the NICU settings.

What works where? A systematic review of child and adolescent mental health interventions for low and middle income countries

PURPOSE

Child and adolescent mental health (CAMH) problems are common and serious all over the world and are linked to pre-mature deaths and serious dysfunction in adult life. Effective interventions have been developed in high income countries (HIC), but evidence from low income settings is scarce and scattered. The aim of this paper is to identify the most promising interventions in the area of global CAMH.

METHOD

A systematic review of all randomised controlled trials in CAMH in low and middle income countries (LAMIC) was carried out and supplemented by 1a level evidence from HIC as well as suitable information from child programme evaluations and adult studies in LAMIC.

RESULTS

In behavioural disorders parent training is a highly promising intervention, which can successfully improve children's compliance and bring down rates of conduct problems significantly. In young children cognitive, emotional and behavioural development can be enhanced through nutritional supplements and by stimulation through play, praise and reading. Trauma treatments can bring positive results even in severely traumatised children, who remain in unstable living conditions. In developmental disorders, there are successful prevention strategies as well as programmes that bring children out of isolation and improve their independence. Some classroom-based interventions for adolescents have reduced symptoms of common mental disorders as well as risk taking behaviours.

CONCLUSIONS

While many results are still tentative the evidence suggests that it is possible to develop affordable and feasible interventions that significantly improve the lives of affected children, their families and their communities around the world.

A pilot cohort analytic study of Family Integrated Care in a Canadian neonatal intensive care unit

Background

We have developed a Family Integrated Care (FIC) model for use in a neonatal intensive care unit (NICU) where parents provide most of the care for their infant, while nurses teach and counsel parents. The objective of this pilot prospective cohort analytic study was to explore the feasibility, safety, and potential outcomes of implementing this model in a Canadian NICU.

Methods

Infants born ≤35 weeks gestation, receiving continuous positive airway pressure or less respiratory support, with a primary caregiver willing and able to spend ≥8 hours a day with their infant were eligible. Families attended daily education sessions and were mentored at the bedside by nurses. The primary outcome was weight gain, as measured by change in z-score for weight 21 days after enrolment. For each enrolled infant, we identified two matched controls from the previous year’s clinical database. Differences in weight gain between the two groups were analyzed using a linear mixed effects multivariable regression model. We also measured parental stress levels using the Parental Stress Survey: NICU, and interviewed parents and nurses regarding their experiences with FIC.

Results

This study included 42 mothers and their infants. Of the enrolled infants, matched control data were available for 31 who completed the study. The rate of change in weight gain was significantly higher in FIC infants compared with control infants (p < 0.05). There was also a significant increase in the incidence of breastfeeding at discharge (82.1 vs. 45.5%, p < 0.05). The mean Parental Stress Survey: NICU score for FIC mothers was 3.06 ± 0.12 at enrolment, which decreased significantly to 2.30 ± 0.13 at discharge (p < 0.05). Feedback from the parents and nurses indicated that FIC was feasible and appropriately implemented.

Conclusions

This study suggests that the FIC model is feasible and safe in a Canadian healthcare setting and results in improved weight gain among preterm infants. In addition, this innovation has the potential to improve other short and long-term infant and family outcomes. A multi-centre randomized controlled trial is needed to further evaluate the efficacy of FIC in the Canadian context.

Initiation and extent of skin-to-skin care at two Swedish neonatal intensive care units

AIM

To describe initiation and extent of parents' application of skin-to-skin care (SSC) with their preterm infants at two Swedish neonatal intensive care units.

METHODS

The duration of SSC was recorded in 104 infants' medical charts during their hospital stay, and the parents answered a questionnaire.

RESULTS

Both parents were involved in the practice of SSC. Three infants experienced SSC directly after birth, 34 within 1 h, 85 within 24 h and the remaining 19 at 24-78 h postbirth. SSC commenced earlier (median age of 50 min) in infants whose first SSC was with their father instead of with their mother (median age of 649 min: p < 0.001). The earlier the SSC was initiated, the longer the infant was cared for skin-to-skin per day during his/her hospital stay (p < 0.001). The median daily duration of SSC was 403 min.

CONCLUSION

Early initiation of SSC had positive impact on the extent of parents' application of SSC. Even though the infants in this study were cared for skin-to-skin to a high extent, there is a potential for extended use of SSC in this type of hospital setting for reducing separation between infants and parents.

Early skin-to-skin contact for mothers and their healthy newborn infants

BACKGROUND

Mother-infant separation postbirth is common in Western culture. Early skin-to-skin contact (SSC) begins ideally at birth and involves placing the naked baby, head covered with a dry cap and a warm blanket across the back, prone on the mother's bare chest. According to mammalian neuroscience, the intimate contact inherent in this place (habitat) evokes neurobehaviors ensuring fulfillment of basic biological needs. This time may represent a psychophysiologically 'sensitive period' for programming future physiology and behavior.

OBJECTIVES

To assess the effects of early SSC on breastfeeding, physiological adaptation, and behavior in healthy mother-newborn dyads.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 November 2011), made personal contact with trialists, and consulted the bibliography on kangaroo mother care (KMC) maintained by Dr. Susan Ludington.

SELECTION CRITERIA

Randomized controlled trials comparing early SSC with usual hospital care.

DATA COLLECTION AND ANALYSIS

We independently assessed trial quality and extracted data. Study authors were contacted for additional information.

MAIN RESULTS

Thirty-four randomized controlled trials were included involving 2177 participants (mother-infant dyads). Data from more than two trials were available for only eight outcome measures. For primary outcomes, we found a statistically significant positive effect of early SSC on breastfeeding at one to four months postbirth (13 trials; 702 participants) (risk ratio (RR) 1.27, 95% confidence interval (CI) 1.06 to 1.53, and SSC increased breastfeeding duration (seven trials; 324 participants) (mean difference (MD) 42.55 days, 95% CI -1.69 to 86.79) but the results did not quite reach statistical significance (P = 0.06). Late preterm infants had better cardio-respiratory stability with early SSC (one trial; 31 participants) (MD 2.88, 95% CI 0.53 to 5.23). Blood glucose 75 to 90 minutes following the birth was significantly higher in SSC infants (two trials, 94 infants) (MD 10.56 mg/dL, 95% CI 8.40 to 12.72).The overall methodological quality of trials was mixed, and there was high heterogeneity for some outcomes.

AUTHORS' CONCLUSIONS

Limitations included methodological quality, variations in intervention implementation, and outcomes. The intervention appears to benefit breastfeeding outcomes, and cardio-respiratory stability and decrease infant crying, and has no apparent short- or long-term negative effects. Further investigation is recommended. To facilitate meta-analysis, future research should be done using outcome measures consistent with those in the studies included here. Published reports should clearly indicate if the intervention was SSC with time of initiation and duration and include means, standard deviations and exact probability values.

Kangaroo Mother Care helps fathers of preterm infants gain confidence in the paternal role

AIM

This article is a report on a descriptive study of fathers’ experiences of providing their preterm infants with Kangaroo Mother Care.

BACKGROUND

During neonatal intensive care, fathers describe the incubator as a barrier and the separation from their infant as stressful. Fathers consider it important to be close to the infant, and performing Kangaroo Mother Care makes them feel an important participant in their infants' care.

METHOD

Individual interviews conducted in 2009 with seven fathers who performed Kangaroo Mother Care were analysed using qualitative content analysis.

RESULTS

The fathers' opportunity for being close to their infants facilitated attainment of their paternal role in the neonatal intensive care unit. Kangaroo Mother Care allowed them to feel in control and that they were doing something good for their infant, although the infant's care could be demanding and stressful. As active agents in their infant's care, some fathers stayed with the infant during the whole hospital stay, others were at the neonatal intensive care unit all day long. Despite the un-wished-for situation, they adapted to their predicament and spent as much time as possible with their infants.

CONCLUSION

Fathers' opportunities for Kangaroo Mother Care helped them to attain their paternal role and to cope with the unexpected situation. The physical environment and conflicting staff statements influenced their opportunity for, and experience of, caring for their preterm infants.

Kangaroo mother care to reduce morbidity and mortality in low birthweight infants

BACKGROUND

Kangaroo mother care (KMC), originally defined as skin-to-skin contact between a mother and her newborn, frequent and exclusive or nearly exclusive breastfeeding, and early discharge from hospital, has been proposed as an alternative to conventional neonatal care for low birthweight (LBW) infants.

OBJECTIVES

To determine whether there is evidence to support the use of KMC in LBW infants as an alternative to conventional neonatal care.

SEARCH STRATEGY

The standard search strategy of the Cochrane Neonatal Group was used. This included searches of MEDLINE, EMBASE, LILACS, POPLINE, CINAHL databases (from inception to January 31, 2011), and the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2011). In addition, we searched the web page of the Kangaroo Foundation, conference and symposia proceedings on KMC, and Google scholar.

SELECTION CRITERIA

Randomized controlled trials comparing KMC versus conventional neonatal care, or early onset KMC (starting within 24 hours after birth) versus late onset KMC (starting after 24 hours after birth) in LBW infants.

DATA COLLECTION AND ANALYSIS

Data collection and analysis were performed according to the methods of the Cochrane Neonatal Review Group.

MAIN RESULTS

Sixteen studies, including 2518 infants, fulfilled inclusion criteria. Fourteen studies evaluated KMC in LBW infants after stabilization, one evaluated KMC in LBW infants before stabilization, and one compared early onset KMC with late onset KMC in relatively stable LBW infants. Eleven studies evaluated intermittent KMC and five evaluated continuous KMC. At discharge or 40 - 41 weeks' postmenstrual age, KMC was associated with a reduction in the risk of mortality (typical risk ratio (RR) 0.60, 95% confidence interval (CI) 0.39 to 0.93; seven trials, 1614 infants), nosocomial infection/sepsis (typical RR 0.42, 95% CI 0.24 to 0.73), hypothermia (typical RR 0.23, 95% CI 0.10 to 0.55), and length of hospital stay (typical mean difference 2.4 days, 95% CI 0.7 to 4.1). At latest follow up, KMC was associated with a decreased risk of mortality (typical RR 0.68, 95% CI 0.48 to 0.96; nine trials, 1952 infants) and severe infection/sepsis (typical RR 0.57, 95% CI 0.40 to 0.80). Moreover, KMC was found to increase some measures of infant growth, breastfeeding, and mother-infant attachment.

AUTHORS' CONCLUSIONS

The evidence from this updated review supports the use of KMC in LBW infants as an alternative to conventional neonatal care mainly in resource-limited settings. Further information is required concerning effectiveness and safety of early onset continuous KMC in unstabilized LBW infants, long term neurodevelopmental outcomes, and costs of care.

Towards universal Kangaroo Mother Care: recommendations and report from the First European conference and Seventh International Workshop on Kangaroo Mother Care

The hallmark of Kangaroo Mother Care (KMC) is the kangaroo position: the infant is cared for skin-to-skin vertically between the mother's breasts and below her clothes, 24 h/day, with father/substitute(s) participating as KMC providers. Intermittent KMC (for short periods once or a few times per day, for a variable number of days) is commonly employed in high-tech neonatal intensive care units. These two modalities should be regarded as a progressive adaptation of the mother-infant dyad, ideally towards continuous KMC, starting gradually and progressively with intermittent KMC. The other components in KMC are exclusive breastfeeding (ideally) and early discharge in kangaroo position with strict follow-up. Current evidence allows the following general statements about KMC in affluent and low-income settings: KMC enhances bonding and attachment; reduces maternal postpartum depression symptoms; enhances infant physiologic stability and reduces pain, increases parental sensitivity to infant cues; contributes to the establishment and longer duration of breastfeeding and has positive effects on infant development and infant/parent interaction. Therefore, intrapartum and postnatal care in all types of settings should adhere to a paradigm of nonseparation of infants and their mothers/families. Preterm/low-birth-weight infants should be regarded as extero-gestational foetuses needing skin-to-skin contact to promote maturation.

CONCLUSION

Kangaroo Mother Care should begin as soon as possible after birth, be applied as continuous skin-to-skin contact to the extent that this is possible and appropriate and continue for as long as appropriate.

State of the art and recommendations. Kangaroo mother care: application in a high-tech environment

Since Kangaroo Mother Care (KMC) was developed in Colombia in the 1970s, two trends in clinical application emerged. In low income settings, the original KMC model is implemented. This consists of continuous (24 h/day, 7 days/week) and prolonged mother/parent-infant skin-to-skin contact; early discharge with the infant in the kangaroo position; (ideally) exclusive breastfeeding; and, adequate follow-up. In affluent settings, intermittent KMC with sessions of one or a few hours skin-to-skin contact for a limited period is common. As a result of the increasing evidence of the benefits of KMC for both infants and families in all intensive care settings, KMC in a high-tech environment was chosen as the topic for the first European Conference on KMC, and the clinical implementation of the KMC model in all types of settings was discussed at the 7th International Workshop on KMC. Kangaroo Mother Care protocols in high-tech Neonatal Intensive Care Units (NICU) should specify criteria for initiation, kangaroo position, transfer to/from KMC, transport in kangaroo position, kangaroo nutrition, parents' role, modification of the NICU environment, performance of care in KMC, and KMC in case of infant instability.

CONCLUSION

Implementation of the original KMC method, with continuous skin-to-skin contact whenever possible, is recommended for application in high-tech environments, although scientific evaluation should continue.