- Email: [email protected]
Latin American Clinical Epidemiology Network Series – Paper 9: The Kangaroo Mother Care Method: from scientific evidence generated in Colombia to worldwide practice
Accepted Manuscript The Kangaroo Mother Care Method: From scientific evidence generated in Colombia to worldwide practice Nathalie Charpak, MD, Juan Gabriel Ruiz, MD MMedSci PII:
S0895-4356(16)30549-2
DOI:
10.1016/j.jclinepi.2016.05.019
Reference:
JCE 9256
To appear in:
Journal of Clinical Epidemiology
Received Date: 29 January 2015 Revised Date:
9 May 2016
Accepted Date: 9 May 2016
Please cite this article as: Charpak N, Ruiz JG, The Kangaroo Mother Care Method: From scientific evidence generated in Colombia to worldwide practice, Journal of Clinical Epidemiology (2016), doi: 10.1016/j.jclinepi.2016.05.019. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
The Kangaroo Mother Care Method: From scientific evidence
RI PT
generated in Colombia to worldwide practice
Authors : Nathalie Charpak MD1, Juan Gabriel Ruiz MD MMedSci1 2 3 1
Fundación Canguro, 2 Pontificia Universidad Javeriana, 3 Hospital Universitario San
M AN U
SC
Ignacio
Corresponding Author: Nathalie Charpak
Nathalie Charpak. MD Pediatrician
TE D
Contact Information:
Director of the Kangaroo Foundation
Hospital
EP
Coordinator of the Kangaroo Mother Care Program at the San Ignacio Universitary
AC C
Calle 44b # 53-50, barrio la Esmeralda, Bogotá, Colombia (571) 745 8182
Email: [email protected]
ACCEPTED MANUSCRIPT
Short Title: Kangaroo Mother Care in Colombia Abbreviations:
RI PT
KMC: Kangaroo Mother Care method LBWI: Low Birth Weight Infant KP: Kangaroo Position
M AN U
SC
KF: Kangaroo Foundation
There are no financial statements to disclose. There are no conflicts of interest, from any
TE D
of the authors.
What is known of this subject: Kangaroo Mother Care is an intervention with demonstrated effectiveness and safety, which might be less expensive than usual
EP
incubator care for stable preemies. It empowers families and is preferred by parents, but there is still resistance from health care providers, slowing down the universal diffusion of
AC C
the method.
Key Words: Kangaroo Mother Care Method, evidence based medicine, non-systematic review, low birth weight infant, premature infant.
ACCEPTED MANUSCRIPT
Abstract (109 words) Kangaroo Mother Care (KMC) is a human-based care intervention devised to complement neonatal care for low birth weight and premature infants. Kangaroo position (skin-to-skin
RI PT
contact on the mother’s chest) offers thermal regulation, physiological stability, appropriate stimulation and enhances bonding and breastfeeding. Kangaroo nutrition is based on breastfeeding and kangaroo discharge policy relies on family empowerment and early
SC
discharge in kangaroo position with close ambulatory follow-up.
We describe how the evidence has been developed, and how it has been put into practice
M AN U
by means of direct preterm infants care and dissemination of the method, including training of KMC excellence centers in many countries not only in Latin America but worldwide.
Manuscript: (1493 words)
TE D
Low Birth Weight (LBW) is either the direct or the associated cause in 44% of the 2 800 000 children’s deaths occurring annually worldwide (1). Caring for these infants is technologically challenging and poses an economic burden, which is heavier for middle-
EP
and low-income countries.
Health professionals and scientists have called for humanization of the care provided for
AC C
infants and their families and have stressed the importance of the physical and emotional contact between the mother and the infant immediately after birth. This establishes a strong, healthy relationship and protects brain development in the “kangaroo microenvironment”(2,3).
In developing countries, alternative methods have been sought for incubator care of newborns because of limited technical resources. In 1978, at the “Instituto Materno Infantil”
ACCEPTED MANUSCRIPT
in Bogotá, Colombia, Edgar Rey developed what is now universally known as Kangaroo Mother Care (KMC) for the care of premature or LBW infants (4). The method involves the efficient use of available human and technological resources for
RI PT
premature and LBW infants, which is critical in resource-restricted settings. Kangaroo position (skin-to-skin contact on the mother’s chest) offers thermal regulation, physiological stability, appropriate stimulation and enhances bonding and breastfeeding, Kangaroo
SC
nutrition is based on breastfeeding and Kangaroo discharge policy relies on family empowerment and early discharge in kangaroo position with close ambulatory follow-up.
M AN U
Nevertheless its value is not limited to developing countries: KMC is increasingly used in neonatal units in wealthy countries to humanize neonatal care. The main aims are to promote breastfeeding, reduce pain from procedures, help the achievement of physiological stability, accelerate maturation and end mother–infant separation. Direct skin-to-skin contact with the mother re-establishes the mother-infant bond and rescues the
TE D
infant from the isolation of extra-uterine life in even the warmest neonatal units (5) . KMC has progressively been accepted as an innovative method not only for decreasing mortality but also for improving the quality of life of premature and LBW infants around the
EP
world. Since the technique was developed in Colombia, the scientific community has studied the rational basis of KMC and the impact of skin-to-skin contact on physiological
AC C
outcomes in hospitalized LBW infants (6,7). By 1989 there was controversy about the effectiveness and safety of KMC (8). A group of researchers in Colombia including one professional of the Clinical Epidemiology Unit created by INCLEN in the Javeriana University, began the evaluation of the safety and effectiveness of KMC. First, a two-cohort study was conducted in Bogotá and followed-up periodically during one year. After adjusting for major baseline differences between the two cohorts, mortality was not higher in the kangaroo cohort (9).
ACCEPTED MANUSCRIPT
In 1991, Anderson (10) provided a review of published and unpublished studies on the responses to limited skin-to-skin contact in hospitalized patients in developed countries. The major findings with regard to the infants were: 1) Temperature regulation was at least
RI PT
as good as that obtained inside an incubator 2) Regular breathing patterns were more frequent, with a decrease in episodes of apnoea and periodic breathing 3) Transcutaneous oxygen levels did not decrease 4) Regulation of the infants’ behavioural state was better,
SC
including longer periods of alertness and less crying 5) Infants had no additional risk for infection and the rates and duration of breastfeeding were higher.
M AN U
With regard to the mothers, findings showed that they reported greater self-confidence, had a sense of fulfilment, less stress and were more confident in breastfeeding. Some of the studies mentioned a shorter time spent in hospital and a positive change of attitude among health personnel.
In 1993, the Kangaroo Foundation (KF) was founded to develop further research, training
TE D
and advocacy for the KMC method. Responding to continued scepticism, the KF team conducted a randomized clinical trial to compare short- and medium-term outcomes among 746 LBW infants randomly assigned to KMC or to usual care, of whom 80% were
EP
preterm infants. Follow-up at 12 months of corrected age showed that KMC improved the rate of successful breastfeeding, and decreased the rate of severe infections in these
AC C
children. The length of the hospital stay was reduced in kangaroo newborns ≤ 1800 g at birth. A non-significant reduction in mortality (RR 0.57 95%CI 0.17, 1.18) and slight improvements in developmental indices were found with KMC. No significant differences were evidenced in physical growth patterns, or rates of cerebral palsy, failure to thrive, visual problems or deafness (11,12). Analysis of blind assessments of mother–infant bonding from videos in a sub-sample of 488 mother–infant dyads showed a marked improvement in bonding, neurodevelopment in infants at higher risk, familial attitude
ACCEPTED MANUSCRIPT
towards the premature infant and provision of a nurturing and stimulating home environment (13-15). Between 1996 and 2005 the KF team reviewed literature that evaluated KMC worldwide.
RI PT
Two papers (16,17) reported reduction in mortality of infants weighing <1500g and support the hypothesis that KMC is an acceptable alternative when technical resources are absent. A third paper (18) showed that use of KMC breastfeeding and intra-hospital skin-to-skin
SC
contact, was as good as or better than the traditional method. The last paper (19) evaluated the results of in-hospital KMC (skin-to-skin contact and breastfeeding) in a
M AN U
multicentre trial conducted in five countries. KMC was well accepted by health personnel in all five centres, showing that KMC may reduce costs for hospitals in developing countries with diverse cultural practices. In 2005, the KF conducted an extensive nonsystematic review of new publications on KMC (20) and concluded that research had established the rational bases of the intervention and provided evidence for its
TE D
effectiveness and safety, although more research was needed to clearly define the effectiveness of the intervention in different settings and for different therapeutic goals. Between 2010 and 2012, a pilot study was conducted in Colombia by the KF in
EP
collaboration with Laval University (Canada), in which transcranial magnetic stimulation was used to explore the effect of KMC on brain maturation in adolescents who were
AC C
former preterm infants.
The results showed that the hemispheric and callosal motor
circuits worked better in KMC adolescents (21). These findings provided new insights into the critical period of ex-utero preterm brain development and the effect of KMC on brain plasticity. Twenty years after the original RCT in Bogotá, 70% of the 693 participants (491 now young adults) who were known to be alive at 1 year of corrected age, were rerecruited by the same research team . First results will be available at the end of 2016.
ACCEPTED MANUSCRIPT
In 2014 a Cochrane review showed the impact of KMC on mortality and morbidity, our 1993-1996 RCT being one of the main sources of data (22). Putting evidence into practice
RI PT
Since 1994, the KF team has been translating research results on KMC into health care interventions. In 2003, the World Health Organization published a practical guide on KMC (23), which has been translated into more than 15 languages. In 2010, the United Nations
SC
Development Programme stated that the KMC method reduced infant morbidity and mortality worldwide (24) and KMC has been adopted by large nongovernmental
(25). Dissemination in Latin America
M AN U
organizations, such as Save the Children, the Bill & Melinda Gates Foundation and USAID
Since 1994, more than 70 multidisciplinary health care teams in 30 developing countries,
TE D
have been trained in Bogotá with the financial support of various institutions. We have trained teams from various Caribbean and Latin American countries, including Haiti, Salvador, the Dominican Republic, Honduras, Nicaragua, Brazil, Venezuela, Guatemala,
EP
Ecuador, Chile and Argentina.
The model of dissemination is “see one, do one, teach one”. We invite health care leaders
AC C
to our centre ("see one"), to run a KMC programme in their home institutions ("do one") and, afterwards, train others in centres in their regions and help them to implement KMC ("teach one"). Knowledge transfer has been successful in Latin America, as nearly all the teams trained in Bogotá successfully set up programmes, despite lack of certain equipment and difficulties. There is sound scientific evidence for the effectiveness and safety of KMC in terms of mortality, early infectious morbidity, growth (including better cranial growth) and
ACCEPTED MANUSCRIPT
development, promotion and maintenance of breastfeeding. There is also strong evidence for the beneficial effects of KMC on the establishment of healthy bonding between mothers and infants, which may also be related to good performance in neurodevelopmental tests,
RI PT
familial attitude towards the premature infant and the provision of a nurturing and stimulating home environment. Two aspects deserve deeper exploration: long-term effects on the neuropsychological and emotional development of the infant and the economic
SC
consequences of the use of the method (cost–effectiveness and cost–utility analyses) (26). The image of KMC as a pseudo-scientific intervention should be erased and forgotten. The
M AN U
biological bases of KMC, although not completely understood, have been subjected to scrutiny in physiological and psychological studies and rigorous evaluations of its biomedical effectiveness and safety. Rational, scientifically oriented health professionals use KMC in order to enhance and complement standard neonatal care, not to replace it. There is no more excuse to not apply KMC. It should be regarded as a complementary
AC C
EP
TE D
routine care in neonatal care.
ACCEPTED MANUSCRIPT
RI PT
References 1. UNICEF: Levels & trends in child mortality: report 2014. Estimates developed by the UN Inter-agency Group for Child Mortality Estimation. New York: United Nations Children's Fund 2014.
SC
2. Klaus MH, Jerauld R, Kreger NC, McAlpine W, Steffa M, Kennel JH. Maternal attachment. Importance of the first post-partum days. N Engl J Med 1972 March
M AN U
2;286(9):460-3.
3. Lozoff B, Brittenham GM, Transe MA, Kennel JH, Klaus MH. The mother-newborn relationship: limit of adaptability. Josanpu Zasshi 1978 September;32(9):564-7. 4. Rey E, Martínez H. Manejo racional del niño prematuro. Curso de Medicina Fetal; 1983 Jan 1; Bogotá, Colombia: Universidad Nacional; 1983.
TE D
5. Nyqvist K, Anderson G, Bergman N, Cattaneo A, Charpak N, Davanzo R et al. State of the art and recommendations Kangaroo mother care: application in a hightech environment. Acta Paediatrica 2010;99(6).
EP
6. Ludington SM, Hadeed AJ, Anderson GC. Physiologic responses to skin-to-skin contact in hospitalized premature infants. J Perinatol 1991;Mar; 11(1):19-24.
AC C
7. Whitelaw A, Sleath K. Myths of the marsupial mother: home care for very low birth weight infants in Bogota Colombia. Lancet 1985;1:1206-8.
8. Whitelaw A. Kangaroo baby care: just a nice experience or an important advance for preterm infants? Pediatrics 1990;85:604-5.
9. Charpak N, Ruiz Pelaez JG, Charpak Y. Rey-Martinez Kangaroo Mother Program: an alternative way of caring for low birth weight infants? One year mortality in a two cohort study [see comments]. Pediatrics 1994;94:804-10.
ACCEPTED MANUSCRIPT
10. Anderson GC. Current knowledge about skin-to-skin (kangaroo) care for preterm infants. J Perinatol 1991;11:216-26. 11. Charpak N, Ruiz-Pelaez JG, Figueroa de CZ, Charpak Y. Kangaroo mother versus traditional care for newborn infants
RI PT
Pediatrics 1997 October;100(4):682-8.
12. Charpak N, Ruiz-Pelaez JG, Figueroa de CZ, Charpak Y. A randomized, controlled trial of kangaroo mother care: results of follow-up at 1 year of corrected age.
SC
Pediatrics 2001 November;108(5):1072-9.
13. Tessier R, Cristo M, Velez S, Giron M, de Calume ZF, Ruiz-Palaez JG et al. mother
care
August;102(2):e17.
and
the
bonding
hypothesis.
M AN U
Kangaroo
Pediatrics
1998
14. Tessier R, Cristo M, Nadeau L, Figueroa Z, Ruiz-Palaez JG, Charpak N. Kangaroo Mother Care: a method for protecting high-risk low birth weight and premature infants against
developmental
delay.
Infant Behaviour
and Development
TE D
2003;26(3):384-97.
15. Tessier R, Charpak N, Giron M, Cristo M, de Calume ZF, Ruiz-Peláez JG. Kangaroo Mother Care, home environment and father involvement in the first year
EP
of life: a randomized controlled study. Acta Paediatr 2009;98(9). 16. Colonna F, Uxa F, da Graca AM, de Vonderweld U. The "kangaroo-mother"
AC C
method: evaluation of an alternative model for the care of low birth weight newborns in developing countries. Int J Gynaecol Obstet 1990;31:335-9.
17. Bergman NJ, Jurisoo LA. The 'kangaroo-method' for treating low birth weight babies in a developing country. Trop Doct 1994;24:57-60.
18. Sloan NL, Camacho LW, Rojas EP, Stern C. Kangaroo mother method: randomised controlled trial of an alternative method of care for stabilised lowbirthweight infants. Maternidad Isidro Ayora Study Team. Lancet 1994;344:782-5.
ACCEPTED MANUSCRIPT
19. Cattaneo A, Davanzo R, Worku B, Surjono A, Echeverria M, Bedri A et al. Kangaroo mother care for low birthweight infants: a randomized controlled trial in different settings. Acta Paediatr 1998 September;87(9):976-85.
RI PT
20. Charpak N, Ruiz JG, Zupan J, Cattaneo A, Figueroa Z, Tessier R et al. Kangaroo Mother Care: 25 years after. Acta Paediatr 2005 May;94(5):514-22.
21. Schneider C, Charpak N, Ruiz-Peláez J, Tessier R. Cerebral motor function in very
SC
premature-at-birth adolescents: a brain stimulation exploration of kangaroo mother care effects. Acta Paediatr. 2012;101(10):1045–53
M AN U
22. Conde-Agudelo A, Diaz-Rossello JL, Belizan JM. Kangaroo mother care to reduce morbidity and mortality in low birthweight infants. Cochrane Database Syst Rev 2014;4:CD002771.
23. Department of Reproductive Health & Research; World Health Organization Kangaroo Mother
Care: a
practical
guide http://www.who.int/reproductive-
TE D
health/publications/kmc/kmctext.pdf 2003
24. http://ssc.undp.org/content/ssc/library/solutions/partners/expo/Implementation_of_t he_Kangaroo_Mother_Care__KMC__method_in_developing_countries_Fundacion _Canguro.html
EP
25. Engmann C, Wall S, Darmstadt G, Valsangkar B. Claeson M, on behalf of the participants of the Istanbul KMC Acceleration Meeting: Consensus on kangaroo mother care acceleration. Lancet. 2013;382:e26–7
AC C
26. Broughton, Gomez, et al. The cost-savings of implementing KMC in Nicaragua. Rev Panam Salud Publica. 2013;34(3):176–82.
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
S0895-4356(16)30549-2
DOI:
10.1016/j.jclinepi.2016.05.019
Reference:
JCE 9256
To appear in:
Journal of Clinical Epidemiology
Received Date: 29 January 2015 Revised Date:
9 May 2016
Accepted Date: 9 May 2016
Please cite this article as: Charpak N, Ruiz JG, The Kangaroo Mother Care Method: From scientific evidence generated in Colombia to worldwide practice, Journal of Clinical Epidemiology (2016), doi: 10.1016/j.jclinepi.2016.05.019. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
The Kangaroo Mother Care Method: From scientific evidence
RI PT
generated in Colombia to worldwide practice
Authors : Nathalie Charpak MD1, Juan Gabriel Ruiz MD MMedSci1 2 3 1
Fundación Canguro, 2 Pontificia Universidad Javeriana, 3 Hospital Universitario San
M AN U
SC
Ignacio
Corresponding Author: Nathalie Charpak
Nathalie Charpak. MD Pediatrician
TE D
Contact Information:
Director of the Kangaroo Foundation
Hospital
EP
Coordinator of the Kangaroo Mother Care Program at the San Ignacio Universitary
AC C
Calle 44b # 53-50, barrio la Esmeralda, Bogotá, Colombia (571) 745 8182
Email: [email protected]
ACCEPTED MANUSCRIPT
Short Title: Kangaroo Mother Care in Colombia Abbreviations:
RI PT
KMC: Kangaroo Mother Care method LBWI: Low Birth Weight Infant KP: Kangaroo Position
M AN U
SC
KF: Kangaroo Foundation
There are no financial statements to disclose. There are no conflicts of interest, from any
TE D
of the authors.
What is known of this subject: Kangaroo Mother Care is an intervention with demonstrated effectiveness and safety, which might be less expensive than usual
EP
incubator care for stable preemies. It empowers families and is preferred by parents, but there is still resistance from health care providers, slowing down the universal diffusion of
AC C
the method.
Key Words: Kangaroo Mother Care Method, evidence based medicine, non-systematic review, low birth weight infant, premature infant.
ACCEPTED MANUSCRIPT
Abstract (109 words) Kangaroo Mother Care (KMC) is a human-based care intervention devised to complement neonatal care for low birth weight and premature infants. Kangaroo position (skin-to-skin
RI PT
contact on the mother’s chest) offers thermal regulation, physiological stability, appropriate stimulation and enhances bonding and breastfeeding. Kangaroo nutrition is based on breastfeeding and kangaroo discharge policy relies on family empowerment and early
SC
discharge in kangaroo position with close ambulatory follow-up.
We describe how the evidence has been developed, and how it has been put into practice
M AN U
by means of direct preterm infants care and dissemination of the method, including training of KMC excellence centers in many countries not only in Latin America but worldwide.
Manuscript: (1493 words)
TE D
Low Birth Weight (LBW) is either the direct or the associated cause in 44% of the 2 800 000 children’s deaths occurring annually worldwide (1). Caring for these infants is technologically challenging and poses an economic burden, which is heavier for middle-
EP
and low-income countries.
Health professionals and scientists have called for humanization of the care provided for
AC C
infants and their families and have stressed the importance of the physical and emotional contact between the mother and the infant immediately after birth. This establishes a strong, healthy relationship and protects brain development in the “kangaroo microenvironment”(2,3).
In developing countries, alternative methods have been sought for incubator care of newborns because of limited technical resources. In 1978, at the “Instituto Materno Infantil”
ACCEPTED MANUSCRIPT
in Bogotá, Colombia, Edgar Rey developed what is now universally known as Kangaroo Mother Care (KMC) for the care of premature or LBW infants (4). The method involves the efficient use of available human and technological resources for
RI PT
premature and LBW infants, which is critical in resource-restricted settings. Kangaroo position (skin-to-skin contact on the mother’s chest) offers thermal regulation, physiological stability, appropriate stimulation and enhances bonding and breastfeeding, Kangaroo
SC
nutrition is based on breastfeeding and Kangaroo discharge policy relies on family empowerment and early discharge in kangaroo position with close ambulatory follow-up.
M AN U
Nevertheless its value is not limited to developing countries: KMC is increasingly used in neonatal units in wealthy countries to humanize neonatal care. The main aims are to promote breastfeeding, reduce pain from procedures, help the achievement of physiological stability, accelerate maturation and end mother–infant separation. Direct skin-to-skin contact with the mother re-establishes the mother-infant bond and rescues the
TE D
infant from the isolation of extra-uterine life in even the warmest neonatal units (5) . KMC has progressively been accepted as an innovative method not only for decreasing mortality but also for improving the quality of life of premature and LBW infants around the
EP
world. Since the technique was developed in Colombia, the scientific community has studied the rational basis of KMC and the impact of skin-to-skin contact on physiological
AC C
outcomes in hospitalized LBW infants (6,7). By 1989 there was controversy about the effectiveness and safety of KMC (8). A group of researchers in Colombia including one professional of the Clinical Epidemiology Unit created by INCLEN in the Javeriana University, began the evaluation of the safety and effectiveness of KMC. First, a two-cohort study was conducted in Bogotá and followed-up periodically during one year. After adjusting for major baseline differences between the two cohorts, mortality was not higher in the kangaroo cohort (9).
ACCEPTED MANUSCRIPT
In 1991, Anderson (10) provided a review of published and unpublished studies on the responses to limited skin-to-skin contact in hospitalized patients in developed countries. The major findings with regard to the infants were: 1) Temperature regulation was at least
RI PT
as good as that obtained inside an incubator 2) Regular breathing patterns were more frequent, with a decrease in episodes of apnoea and periodic breathing 3) Transcutaneous oxygen levels did not decrease 4) Regulation of the infants’ behavioural state was better,
SC
including longer periods of alertness and less crying 5) Infants had no additional risk for infection and the rates and duration of breastfeeding were higher.
M AN U
With regard to the mothers, findings showed that they reported greater self-confidence, had a sense of fulfilment, less stress and were more confident in breastfeeding. Some of the studies mentioned a shorter time spent in hospital and a positive change of attitude among health personnel.
In 1993, the Kangaroo Foundation (KF) was founded to develop further research, training
TE D
and advocacy for the KMC method. Responding to continued scepticism, the KF team conducted a randomized clinical trial to compare short- and medium-term outcomes among 746 LBW infants randomly assigned to KMC or to usual care, of whom 80% were
EP
preterm infants. Follow-up at 12 months of corrected age showed that KMC improved the rate of successful breastfeeding, and decreased the rate of severe infections in these
AC C
children. The length of the hospital stay was reduced in kangaroo newborns ≤ 1800 g at birth. A non-significant reduction in mortality (RR 0.57 95%CI 0.17, 1.18) and slight improvements in developmental indices were found with KMC. No significant differences were evidenced in physical growth patterns, or rates of cerebral palsy, failure to thrive, visual problems or deafness (11,12). Analysis of blind assessments of mother–infant bonding from videos in a sub-sample of 488 mother–infant dyads showed a marked improvement in bonding, neurodevelopment in infants at higher risk, familial attitude
ACCEPTED MANUSCRIPT
towards the premature infant and provision of a nurturing and stimulating home environment (13-15). Between 1996 and 2005 the KF team reviewed literature that evaluated KMC worldwide.
RI PT
Two papers (16,17) reported reduction in mortality of infants weighing <1500g and support the hypothesis that KMC is an acceptable alternative when technical resources are absent. A third paper (18) showed that use of KMC breastfeeding and intra-hospital skin-to-skin
SC
contact, was as good as or better than the traditional method. The last paper (19) evaluated the results of in-hospital KMC (skin-to-skin contact and breastfeeding) in a
M AN U
multicentre trial conducted in five countries. KMC was well accepted by health personnel in all five centres, showing that KMC may reduce costs for hospitals in developing countries with diverse cultural practices. In 2005, the KF conducted an extensive nonsystematic review of new publications on KMC (20) and concluded that research had established the rational bases of the intervention and provided evidence for its
TE D
effectiveness and safety, although more research was needed to clearly define the effectiveness of the intervention in different settings and for different therapeutic goals. Between 2010 and 2012, a pilot study was conducted in Colombia by the KF in
EP
collaboration with Laval University (Canada), in which transcranial magnetic stimulation was used to explore the effect of KMC on brain maturation in adolescents who were
AC C
former preterm infants.
The results showed that the hemispheric and callosal motor
circuits worked better in KMC adolescents (21). These findings provided new insights into the critical period of ex-utero preterm brain development and the effect of KMC on brain plasticity. Twenty years after the original RCT in Bogotá, 70% of the 693 participants (491 now young adults) who were known to be alive at 1 year of corrected age, were rerecruited by the same research team . First results will be available at the end of 2016.
ACCEPTED MANUSCRIPT
In 2014 a Cochrane review showed the impact of KMC on mortality and morbidity, our 1993-1996 RCT being one of the main sources of data (22). Putting evidence into practice
RI PT
Since 1994, the KF team has been translating research results on KMC into health care interventions. In 2003, the World Health Organization published a practical guide on KMC (23), which has been translated into more than 15 languages. In 2010, the United Nations
SC
Development Programme stated that the KMC method reduced infant morbidity and mortality worldwide (24) and KMC has been adopted by large nongovernmental
(25). Dissemination in Latin America
M AN U
organizations, such as Save the Children, the Bill & Melinda Gates Foundation and USAID
Since 1994, more than 70 multidisciplinary health care teams in 30 developing countries,
TE D
have been trained in Bogotá with the financial support of various institutions. We have trained teams from various Caribbean and Latin American countries, including Haiti, Salvador, the Dominican Republic, Honduras, Nicaragua, Brazil, Venezuela, Guatemala,
EP
Ecuador, Chile and Argentina.
The model of dissemination is “see one, do one, teach one”. We invite health care leaders
AC C
to our centre ("see one"), to run a KMC programme in their home institutions ("do one") and, afterwards, train others in centres in their regions and help them to implement KMC ("teach one"). Knowledge transfer has been successful in Latin America, as nearly all the teams trained in Bogotá successfully set up programmes, despite lack of certain equipment and difficulties. There is sound scientific evidence for the effectiveness and safety of KMC in terms of mortality, early infectious morbidity, growth (including better cranial growth) and
ACCEPTED MANUSCRIPT
development, promotion and maintenance of breastfeeding. There is also strong evidence for the beneficial effects of KMC on the establishment of healthy bonding between mothers and infants, which may also be related to good performance in neurodevelopmental tests,
RI PT
familial attitude towards the premature infant and the provision of a nurturing and stimulating home environment. Two aspects deserve deeper exploration: long-term effects on the neuropsychological and emotional development of the infant and the economic
SC
consequences of the use of the method (cost–effectiveness and cost–utility analyses) (26). The image of KMC as a pseudo-scientific intervention should be erased and forgotten. The
M AN U
biological bases of KMC, although not completely understood, have been subjected to scrutiny in physiological and psychological studies and rigorous evaluations of its biomedical effectiveness and safety. Rational, scientifically oriented health professionals use KMC in order to enhance and complement standard neonatal care, not to replace it. There is no more excuse to not apply KMC. It should be regarded as a complementary
AC C
EP
TE D
routine care in neonatal care.
ACCEPTED MANUSCRIPT
RI PT
References 1. UNICEF: Levels & trends in child mortality: report 2014. Estimates developed by the UN Inter-agency Group for Child Mortality Estimation. New York: United Nations Children's Fund 2014.
SC
2. Klaus MH, Jerauld R, Kreger NC, McAlpine W, Steffa M, Kennel JH. Maternal attachment. Importance of the first post-partum days. N Engl J Med 1972 March
M AN U
2;286(9):460-3.
3. Lozoff B, Brittenham GM, Transe MA, Kennel JH, Klaus MH. The mother-newborn relationship: limit of adaptability. Josanpu Zasshi 1978 September;32(9):564-7. 4. Rey E, Martínez H. Manejo racional del niño prematuro. Curso de Medicina Fetal; 1983 Jan 1; Bogotá, Colombia: Universidad Nacional; 1983.
TE D
5. Nyqvist K, Anderson G, Bergman N, Cattaneo A, Charpak N, Davanzo R et al. State of the art and recommendations Kangaroo mother care: application in a hightech environment. Acta Paediatrica 2010;99(6).
EP
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