Kangaroo Mother Care - International Initiative for Impact

Transcription

Kangaroo Mother Care
Prof. Somashekhar Nimbalkar
Professor of Pediatrics and Chairman (Research)
Pramukhswami Medical College, Karamsad –Anand- Gujarat
Governing Council Member 2013 and 2014 (National NNF)
West Zone IAP PALS Coordinator (2009-2010)
West Zone Coordinator (BNCRP)
4 million newborn deaths - When?
Up to 50%
of neonatal
deaths are in
the first 24 hours
75% of neonatal
deaths are in
the first week –
3 million deaths
Source: Lawn JE et al Lancet 2005, Based on analysis of 47 DHS datasets (1995-2003), 10,048 neonatal deaths)
Lancet 2010; 375: 1969–87
Lancet 2010; 375: 1969–87
8·795 million
child deaths
in 2008
3.6 million
neonatal
deaths
Lancet 2010; 375: 1969–87
1.2906 million
neonatal deaths
Estimated numbers of deaths by cause in children
younger than 5 years in South East Asia
All cause by age
Bangladesh
Bhutan
Burma
India
Indonesia
Maldives
Nepal
North Korea
Sri Lanka
Thailand
Timor-Leste
<5 years
182 936
1199
123 562
1 829 826
173 036
163
36 822
18 246
6239
14035
3924
0–27 days
113 884
523
49 119
1 003 767
80 140
90
22 578
9373
3165
9971
1901
1–59 months
69 053
676
74 443
826 060
92 895
73
14 244
8873
3073
4064
2023
Estimated numbers of deaths by cause in children
younger than 5 years in South East Asia
All cause by age
Bangladesh
Bhutan
Burma
India
Indonesia
Maldives
Nepal
North Korea
Sri Lanka
Thailand
Timor-Leste
<5 years
182 936
1199
123 562
1 829 826
173 036
163
36 822
18 246
6239
14035
3924
0–27 days
113 884
523
49 119
1 003 767
80 140
90
22 578
9373
3165
9971
1901
1–59 months
69 053
676
74 443
826 060
92 895
73
14 244
8873
3073
4064
2023
Neonatal deaths contribute to about 40%
deaths of the total under 5 child mortality.
Deaths in
children <5 y is
7.6 million
3.07 Million
deaths in 0-27
days
Global, regional, and national causes of child mortality: an updated systematic
analysis for 2010 with time trends since 2000
Estimated numbers of deaths by cause
in 2010
Estimated number (UR; millions)
Neonates aged 0–27 days
Preterm birth complications
Intrapartum-related complications
Sepsis or meningitis
Pneumonia*
Congenital abnormalities
Other disorders
Tetanus
Diarrhoea†
Children aged 1–59 months
Other neonatal disorders
Pneumonia*
Diarrhoea†
Malaria
Injury
Meningitis
AIDS
Measles
1·078 (0·916–1·325)
0·717 (0·610–0·876)
0·393 (0·252–0·552)
0·325 (0·209–0·470)
0·270 (0·207–0·366)
0·181 (0·115–0·284)
0·058 (0·020–0·276)
0·050 (0·017–0·151)
1·356 (1·112–1·581)
1·071 (0·977–1·176)
0·751 (0·538–1·031)
0·564 (0·432–0·709)
0·354 (0·274–0·429)
0·180 (0·136–0·237)
0·159 (0·131–0·185)
0·114 (0·092–0·176)
Amount of Reduction (%) in all-cause neonatal mortality or evidence
morbidity/major risk factor if specified (effect range)
Evidence of efficacy for interventions during Postnatal periods
Resuscitation of newborn baby
IV
Breastfeeding
V
Prevention and management of hypothermia IV
Kangaroo mother care (low birth weight
infants in health facilities)
6–42%
55–87%
18–42%
Incidence of infections: 51% (7–
IV
75%)
V – Best evidence -------------------- I –Poor Evidence
Lancet 2005; 365: 977–88
Amount of Reduction (%) in all-cause neonatal mortality or evidence
morbidity/major risk factor if specified (effect range)
Evidence of efficacy for interventions during Postnatal periods
Resuscitation of newborn baby
IV
Breastfeeding
V
Prevention and management of hypothermia IV
Kangaroo mother care (low birth weight
infants in health facilities)
6–42%
55–87%
18–42%
Incidence of infections: 51% (7–
IV
75%)
V – Best evidence -------------------- I –Poor Evidence
Lancet 2005; 365: 977–88
Kangaroo Joey – Is it Magic?
Kangaroo Mother Care
Kangaroo mother care is care of infants carried skin-to-skin
with the mother.
Components of KMC
Key Components are:
 early, continuous and
prolonged skin-to-skin
contact between the
mother and the baby
(Kangaroo Position);
 exclusive
breastfeeding ; Skin to
skin contact promotes
lactation and facilitates
the feeding interaction.
Prerequisites of KMC
Support to the mother in hospital and at home
 A mother cannot successfully provide KMC all alone.
 Mother requires
• counselling along with supervision from care-providers,
• assistance and cooperation from her family members.
Post-discharge follow up
 KMC is continued at home after early discharge.
 Regular follow up and access to health providers is crucial to ensure safe
and successful KMC at home.
Brief History of KMC
Began this method in 1978 in
response to the high burden of Low
Birth Weight babies and paucity of
resources at the Instituto Materno
Infantil (IMI) in Bogota, Colombia
Rey ES, Martinez HG. Manejo racional del niño
prematuro. In: Curso de Medicina Fetal,
Universidad Nacional, Bogotà, Colombia, 1983.
137-151
Dr. Edgar REY SANABRIA
COMPARATIVE STATISTICS BEFORE & AFTER
INTRODUCTION OF KMC AT COLOMBIA
Weight Categories Before KMC
(g.)
1975 – 1976
501 – 1000
0
After KMC
1979-1981
72
1001-1500
27
89
Abandoned Babies 34
10
Benefits of KMC
Breast feeding
Thermal Control
Early Discharge
Decreased Mortality
Reduced neonatal pain
Improved Maternal Attachment
Decreased Maternal depression
Neonatal Transport
Decreased Apnea
Decreased Infections
Better Neurodevelopment
KMC results in increased breastfeeding rates as well
as increased duration of breastfeeding
Study
Author
Year
Outcome
KMC
Control
RCT
Charpak
1994
Partial or excl breastfeeding at
1 month
6 months
1 year
Partial or excl breastfeed at 3 mo
Excl breastfeeding at discharge
Daily volume
Daily feeds
Breastfeeding at 6 weeks
Breastfeeding at discharge
Daily feeds (34 weeks of Gest Age)
Breastfeeding at: discharge
1 month
Daily volume at 4 weeks
Excl breastfeeding at discharge
93%
70%
41%
82%
88%
640 ml
12
55%
77%
12
90%
50%
647 ml
37%
78%
37%
23%
75%
70%
400 ml
9
28%
42%
12
61%
11%
530 ml
6%
RCT
RCT
Charpak
Cattaneo
Schmidt
1997
1998
1986
Whitelaw
Wahlberg
Syfrett
BlaymoreBier
Hurst et al.
1988
1992
1993
1996
1997
Benefits of KMC
Breast feeding
Thermal Control
Early Discharge
Decreased Mortality
Neonatal Transport
Decreased Apnea
KMC provides effective thermal control
with a reduced risk of hypothermia.
X-skin to skin at birth and continuing
O- Skin to skin and transfer to warmer
– Warmer from beginning
Journal of Nurse-Midwifery
Vol. 25, No. 1, Jan/Feb 1980
Body temp and oxygen consumption during skin-to-skin
care in stable preterm infants weighing less than 1500 gms
During skin-to-skin care the mean rectal temperature was
0.2 ° C (p <0.0 I) and the peripheral skin temperature
was 0.6 ° C (p <0.01) higher than during the preceding
hour in the incubator. Back in the incubator, body
temperatures returned to values recorded before skin-toskin care.
Oxygen consumption during skin-to-skin care (6. I + 0.9
ml/kg per minute)was not significantly higher than in the
incubator (5.8 + 0.8 ml/kg per minute)
J Pediatr 1997;130:240-4
Randomised study of skin-to-skin versus incubator
care for rewarming low risk hypothermic neonates
STS care was at least as
effective as incubator care
for rewarming low-risk
hypothermic neonates.
Healthy fullterm infants
cared for with STS by their
mothers gain heat when
their body temperature is
less than 36·3 C, but lose
heat to the mother when the
body temperature has
increased to 37 C.
THE LANCET • Vol 352 • October 3, 1998
Benefits of KMC
Breast feeding
Thermal Control
Early Discharge
Decreased Mortality
Neonatal Transport
Decreased Apnea
KMC managed babies had better weight gain, earlier
hospital discharge and higher excl. breast-feeding rates.
Randomized control trial in 28 neonates(<1500 gms) . The
Kangaroo group (n=14) was subjected to KMC of at least
4 hours per day in not more than 3 sittings. The babies
received Kangaroo Care after shifting out from NICU and
at home. The control group (n=14) received only
standard care (incubator or open care system).
Neonates in the KMC group demonstrated better weight
gain after the first week of life (15.9 + 4.5 gm/day vs.
10.6 + 4.5 gm/day in the KMC group and control group
respectively p<0.05) and earlier hospital discharge (27.2
+ 7 vs. 34.6 + 7 days in KMC and control group
respectively, p<0.05).
Ramnathan et al Indian J Pediatr 2001; 68 (11) 9 1019-1023
KMC improves growth low birth
weight infants.
206 neonates with birth weight <2000 g were randomized into
(KMC-103) and control group (CMC: 103)
The KMC babies had better average weight gain per day
(KMC: 23.99 g vs CMC: 15.58 g, P<0.0001). The weekly
increments in head circumference (KMC: 0.75 cm vs CMC:
0.49 cm, P = 0.02) and length (KMC: 0.99 cm vs CMC: 0.7
cm, P = 0.008) were higher in the KMC group.
A significantly higher number of babies in the CMC group
suffered from hypothermia, hypoglycemia, and sepsis.
SUMAN RAO et al Indian Pediatrics 2008 Vol 45
Benefits of KMC
Breast feeding
Thermal Control
Early Discharge
Decreased Mortality
Neonatal Transport
Decreased Apnea
‘Kangaroo mother care’ to prevent neonatal
deaths due to preterm birth complications
Meta-analysis of three RCTs commencing KMC in the first
week of life showed a significant reduction in neonatal
mortality
Joy Lawn et al in IJE 2010;39:i144–i154
A meta-analysis of three observational trials comparing KMC with
standard incubator care showing cause specific mortality effect for
babies of birthweight <2000 g
Meta-analysis of five RCTs comparing KMC with CMC showing effect on
severe morbidity (severe pneumonia, sepsis, jaundice and other severe
illness) for babies of BW <2000 g . KMC was started in first week of life.
Major mortality reduction [51% (18–71%)] for neonatal
mortality in babies with birthweight <2000 g, with even
greater reductions in serious morbidity
Recommend the routine use of KMC for all babies <2000 g as
soon a they are stable.
Up to half a million neonatal deaths due to preterm birth
complications could be prevented each year if this
intervention were implemented at scale.
Benefits of KMC
Breast feeding
Thermal Control
Early Discharge
Decreased Mortality
Neonatal Transport
Decreased Apnea
Kangaroo Care is effective in decreasing
pain response in preterm neonates
PIPP scores across the first 90 sec from the heel lancing
procedure were significantly lower(0.002<P<0.04) than
by 2 points in the KC condition (Preterm>32 weeks)
Arch Pediatr Adol Med 2003; 157 : 1084 -1088
KMC is effective in decreasing pain response in
very preterm(28-32 weeks) neonates
PIPP scores at 90 seconds post lance were significantly
lower in the KMC condition (8.871 (95%CI 7.852–9.889)
versus 10.677 (95%CI 9.563–11.792) p < .001).
Time to recovery was significantly shorter, by a minute(123
seconds (95%CI 103–142) versus 193 seconds (95%CI
158–227).
Facial actions were highly significantly lower across all
points in time reaching a two-fold difference by 120
seconds post-lance and heart rate was significantly
lower across the first 90 seconds in the KMC condition.
BMC Pediatrics 2008, 8:13
•
PIPP score was significantly low in KMC
group
•
KMC even for a short duration of 15 minutes
prior to the procedure and continuing during
the heel prick has pain reducing benefits
•
Preterm neonates >32 weeks GA can benefit
from short duration KMC to decrease pain
from heel prick procedure
Benefits of KMC
Breast feeding
Thermal Control
Early Discharge
Decreased Mortality
Neonatal Transport
Decreased Apnea
KMC Facilitates Mother Baby
Attachment in Low Birth Weight Infants
16 month period 110 neonates( 35 weeks, 1-69 kg) were
randomized into KMC group and CMC group
The duration of hospital stay was significantly shorter in the
KMC group (3.56±0.57 days) compared to control group
(6.80±1.30 days).
The total attachment score (24.46±1.64) in the KMC group
was significantly higher than that obtained in control
group (18.22±1.79, p<0.001).
Mothers were significantly more involved in care taking
activities and spent more time beyond usual care taking.
They went out without their babies less often. They
derived greater pleasure from their babies.
Indian J Pediatr 2008; 75 (1) : 43-47
Benefits of KMC
Breast feeding
Thermal Control
Early Discharge
Decreased Mortality
Neonatal Transport
Decreased Apnea
Effect of KMC on Postpartum
Depression
In 177 low-income mothers with their preterm infants 66
mothers (37.3%) had depression and it decreased to 30
(16.9%) after KMC intervention; p<0.0001.
None developed PPD during the Kangaroo stay.
KMC may lessen maternal depression
2008 Journal of Tropical Pediatrics Vol. 55, No. 1
Benefits of KMC
Breast feeding
Thermal Control
Early Discharge
Decreased Mortality
Neonatal Transport
Decreased Apnea
Kangaroo Transport Instead of
Incubator Transport
11 premature infants were transported in Heidelberg,
Germany, in the kangaroo position with their mothers or
female nurses when parents were not available.
In Wernigerode, Germany 20 preterm and term infants
were transported in the kangaroo position by their
mothers, the father, or one of the authors.
Two transports were by helicopter , rest by ambulance.
Pediatrics 2004;113;920-923
Gestational age
Weight at transport
Age at transport
Distance of transport
Time for transport
Range
26–41 wk
1220–3720 g
1 h to 79 d
2–400 km
10–300 min
Median
35 wk
1970 g
17 d
35 km
40 min
Kangaroo Transport Instead of
Incubator Transport
Kangaroo transport might be considered as a safe, effective, and
inexpensive method of transport, promoting parent-infant bonding
Pediatrics 2004;113;920-923
Benefits of KMC
Breast feeding
Thermal Control
Early Discharge
Decreased Mortality
Neonatal Transport
Decreased Apnea
Reduces Apnea
A dramatic drop in the frequency of clinically evident
episodes of obstructive apnea and/or bronchoaspiration.
Pediatrics 1997;100:682– 688
Regular Breathing patterns with a decrease of apneic
episodes and periodic respiration are more frequent in
conventional care
J Perinatology 1991 , 11: 216-226
Benefits of KMC
Breast feeding
Thermal Control
Early Discharge
Decreased Mortality
Neonatal Transport
Decreased Apnea
Kangaroo mother method: randomised controlled trial of an
alternative method of care for stabilised low-birthweight
infants. Maternidad Isidro Ayora Study Team
Lancet. 1994;344:782–785
Kangaroo Mother Vs Traditional Care for
Newborn Infants <2000 Grams: A RCT
The proportions of mild to moderate infectious episodes
that could be treated as on an OPD basis were 6.7% and
2.8% in the KMC and control groups, respectively (P =
.019).
Proportion of nosocomial infections after eligibility and
before primary discharge was higher in the control group
(kangaroo, 3.8%; control, 7.8%, P = .026).
The number of total infectious episodes that had to be
treated in the hospital was lower in KMC although the
difference was not statistically significant (kangaroo,
7.6%; control, 11%, P = .17).
Pediatrics 1997;100:682– 688
Kangaroo Mother Vs Traditional Care for
Newborn Infants <2000 Grams: A RCT
Kangaroo infants’ infections were less severe, most of them
requiring only ambulatory care.
Traditional care infants had a higher number of nosocomial
infections and greater need for inpatient care of their
infections.
Pediatrics 1997;100:682– 688
Benefits of KMC
Breast feeding
Thermal Control
Early Discharge
Decreased Mortality
Neonatal Transport
Decreased Apnea
KMC: A method for protecting high-risk LBW and
premature infants against developmental delay
431 low-birth-weight and premature infants (≤1801 g) were
assigned randomly to KMC or Traditional Care.
KMC infants had a higher IQ than those given traditional
care (TC).
The difference was most highly significant for infants who
were
• more premature (30–32 weeks of gestational age),
• had required intensive care, and
• had a diagnosis of doubtful or abnormal neurological
development at 6 months
Infant Behavior & Development 26 (2003) 384–397
Comparison of KMC and Traditional Care: Parenting
Outcomes and Preterm Infant Development
Pediatrics 2002;110;16-26
Mother–infant interactive behaviors at 37 weeks’ GA in KC and control subjects.
*P .05; ***P .001.
Comparison of KMC and Traditional Care: Parenting
Outcomes and Preterm Infant Development
Pediatrics 2002;110;16-26
KC: mean: 96.39;
KC: mean: 85.47;
controls: mean: 91.81 controls: mean: 80.53
MDI and PDI scores of KC and control premature infants born at high and low
medical risk. **P .01.
Benefits of KMC
Breast feeding
Thermal Control
Early Discharge
Decreased Mortality
Neonatal Transport
Decreased Apnea
Acta Pediatrica 2010 Nyquist et al
Preterm infants should be considered extero-gestational
foetuses needing KMC to promote maturation.
After the uterus, maternal ⁄ parental–infant SSC is the
expected evolutionary environment for development.
All intrapartum and postnatal care should adhere to a
paradigm of non-separation of infants and their parents.
Kangaroo Mother Care should be used for warming,
comfort, physiological and psychological benefits,
growth, development, and the psychosocial needs of the
family, and to promote lactation, breastfeeding initiation
and longer breastfeeding duration
The KP is the preferred routine place for care, beginning at
birth, taking into consideration the physiological and
behavioral state of the infant and parent; it is possible
that KMC may contribute to the infant’s stabilization.
Removal from this place of care should be for specific
reasons only.
Kangaroo Mother Care should be used for transfer of the
infant to the neonatal unit after birth (when appropriate),
within the hospital, and between hospitals
Most nursing and medical procedures can be performed
with the infant in KP, day and night.
C Section? Ventilation?
Short period on mother’s chest immediately in the
operating room, if possible continued during post-op
observation.
Afterwards the mother is assisted with transportation to the
NICU for as much KMC as possible without unjustified
restrictions:
Father - substitute acts as primary KMC provider.
CPAP/ ventilator treatment does not constitute an obstacle
to KMC
Preterm on CPAP in KC position
Baby on Ventilator
KMC and phototherapy
No need for
separation
Most nursing and medical care
can be performed in KMC
Tube
feeding
Suctioning
Diaper
change
Blood
samples
Extubation
Insert
i.v. cannula
Chest
auscultation
Twins, 26 weeks, ventilator care
In affluence KMC is a valuable addition to infant care
In financial constraints it is a precious gift
In poverty it may be the only means of survival
Prof. Attis Malan,
South Africa
Thank you

Kangaroo Mother Care - International Initiative for Impact

Transcription

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