The literature search has been divided in different categories to present the effects of kangaroo mother care (KMC). After stating the organization of the paper the first section will provide the definition, history, and components of KMC. The second section will describe the Universe of Developmental Care Model and its components. The next section will reflect on the effects of KMC in maintaining the temperature of premature and LBW infants. The fourth section will present the relationship of KMC with the frequency of feeds and how this intervention assists in resolving the issues related to breast feeding; while the fifth section will present the results of KMC with respect to achieving the weight gain. The sixth section will describe the effects of KMC in reducing suspected infections and length of stay in hospital. The last section will summarize the literature review stating the purpose of the literature review.

The Search Strategy

The literature search was done on two search engines: Pubmed and Science Direct will be use of key terms ‘Kangaroo mother care’ (KMC) and ‘skin-to -skin’ (STS) the Pubmed searched resulted in 100 hits. It was further filtered by adding the terms low birth weight (LBW). Finally twenty articles were reviewed. Similarly, the database of Science Direct showed 30 relevant articles .The second step was to search database in Google Scholar. The result showed very pertinent articles, including a website of the KMC foundation. This website facilitated the researcher in searching the systemic review and origin of KMC, original articles were then searched from the reference lists of these articles.

Definition, History, and Components of Kangaroo Mother Care (KMC)

Kangaroo Mother Care (KMC) is an alternative intervention for hypothermia among preterm infants by, keeping the baby close to the mother’s skin (Lawn, Mwansa-Kambafwile, Horta, Barros, & Cousens,2010). Dr Edgar Rey Sanabria, a pediatrician initiated the model of KMC at the Department of Health in Mobato, Colombia in 1978 Since then, KMC has been well known for provide a quality care to newborn infants especially to LBW babies in Colombia (Lawn et al.2010).

A wide range of literature is available that evaluates the physiological, psychological, emotional, and developmental outcomes of KMC. However, this literature review will primarily focus on the physiological and breastfeeding outcomes of KMC in hospital. However, the secondary outcome variables like weight gain, infection and length of stay will also be presented in the this literature review.Gradually this model was adopted by many developed countries like US, UK, and Brazil, and in 2003, WHO provided international guidelines to implement KMC. Based on the effectiveness of KMC in hospital settings, it was recommended to incorporate KMC into a package of neonatal care and not as an individual intervention (Pattinson, Woods, Greenfield, & Velaphi, 2005). According to Charpak “It is not ‘alternative’ medicine but a scientifically sound, multilevel intervention” (Charpak & Ruiz-Pelaez, 2001). Though it is initiated in the hospital, it can be continued at home until rejected by the infant usually towards the completion of gestation at 37 weeks (Charpak & Ruiz-Pelaez, 2001).

Universe of Developmental Care (UDC)

The model is the renewal of Al’s Synactive theory of neonatal development. The theoretical concept of the model is shared surface; the manifestation of the shared surface is the skin. Through the skin the linkages are created among the body organism , and the environment. The key concept of the model is that an infant’s skin is considered as boundary of infant where as the shared surface includes environmental influences. The impact of these influences is inter- linked with care practices and the family (Gibbins, Hoath, Coughlin, Gibbins& Franck, 2008).

Components of Model

This model is based on infant, environment, and staff.

Infant:

Infant is the core component of the model, who occupies central position, as shown in model (refer fig 1.). The first circle immediate to the central position of the infant in the model represents specific physiological systems, such as: respiratory, cardiac, and nervous, hematologic, metabolic, immunological, musculoskeletal, integumentry, and gastrology system. These physiological systems are interrelated with each other and they are highly influenced by the surrounding environment.

Care Practices

Specific care practices behaviors are symbolized as care planets of the UDC model. There are nine care planets surrounding the physiological system which depict care giving behaviors like monitoring/assessment, feeding, positioning, infection control, safety, comfort, thermoregulation, skin care, and respiratory care (Gibbins, et al., 2008, p. 145).

Family:

In the UDC model family is the central focus;however, staff and institution support is required to provide effective care to the infant, for instance, for any care practice approach like provision of comfort to an extremely low birth infant. If the parental touch is been replaced in an intensive care unit with staff support and institution’s policy, the care planet of comfort will not only be affected, but it may alter the other planets like sleep, positioning, safety, and like. Therefore, within the hospital environment the family is shown as very close to the infant in the UDC model, which demonstrates the natural family-infant dyads bonding.

Environment:

The macro-environment of the model, based on the infrastructure and physical environment such as lay -out, lighting, noise levels, unit’s physical design, affects the shared surfaces. Moreover, interpersonal behavior and hospital culture are also considered as part of enviroment in the UDC model (Gibbins, et al., 2008, p. 145). These environmental influences can affect any of the care planets of the universal model. Due to interdependence of care planets of the UDC model, the care practice that alters any one of the care planet will automatically affect the other care planets. (Ludington, 2009). Just like the laws of solar system movement, an infant is expected to respond to the environmental influences by showing some developmental behaviors (Gibbins, et al., 2008, p. 143).

Staff:

The position of staff in the model is just as a protective orbit that supports family of very high risk and critical infants. The authors have emphasized the role of education and staff training in the context of UDC model in order to apply the theoretical concepts of developmental care model in clinical practices (Gibbins, et al., 2008, p. 144).

Application of the Model

The UDC model is applicable for infant’s care providing clinical approach for nurses to follow. The model captured an extensive list of nursing care, which involves holistic developmental care. Therefore, it can be easily applied as bedside practice; in addition this model provides opportunities to the nursing researchers to explore any one of the care planets and then identify its interdependence with other care planets. Since the model is based on Nightingale, environmental theory can be widely applied in nursing care practices.However, a lot of research work is needed to validate the concept of ‘shared surfaces’ of the model. The literature review,so far,has not depicted any scholarly work for the application of the model to kangaroo mother care, though it is one of the essential components of the model’s “comfort care planet”

( Ludington, 2009).The intention of the current study is to apply this model to explore the physiological and developmental effects of kangaroo mother care among low birth weight and preterm infants. The application and modification of the model would be discussed in detail in chapter 3. However, the model also guided us to present the effectiveness of KMC through literature review.

Thermoregulation

Kangaroo Mother Care (KMC) has been recognized as an effective model for thermal stability (Charpak et al., 2005; Ludington-Hoe, Nguygen, Swinth & Satyshur, 2000; Cong, 2006). Due to large body surface, little fat size LBW infants are at high risk of heat loss. When this loss exceeds the ability of infant to produce heat, hypothermia develops (WHO, 1997). Infants are more susceptible to hypothermia immediately after birth, during bath or during weighing. It has been found that countries with high neonatal morbidities deaths showed higher rates of hypothermia (Kumar, Shearer, Kumar & Darmstadt, 2009). Therefore, to minimize the risk of hypothermia a set of procedure has been recommended for thermal regulation of newborn infants. These procedures include warm delivery room, drying of infant’s body and skin-to-skin contact, breast feeding and postponing bathing and weighing of infants and keeping mother-infant together etc. In case of breaking in this warm- chain infant can be at risk of cold stress (WHO, 1997). In such cases thermal protections can be fulfilled by either keeping infant in warmer incubator or under radiant heat. The positive outcome of randomized trials among preterm has suggested the KMC as an alternative of incubators (Bergman et al., 2004; Cattaneo et al., 1998; Chwo et al., 2002; Kadam et al., 2005; Ludington-Hoe et al., 2000; Ludington-Hoe et al., 2004). The abdomen of mother due to the appropriate temperature for newborn is considered as the best means for immediate postnatal interventions (AAP & AAH, 2000). It is also suggested in the guidelines of World Health Organization that skin-to-skin contacts should be continue during transfer as well as after shifting of infant in ward (WHO, 2003).

The consistence findings of KMC among various trials and metaanalysis (conde, et, al, 2010), systemic review of kangaroo care (Brett, Staniszewska, Newburn, Jones, & Taylor, 2011) and literature review by (Bulfone, Nazzi, & Tenore, 2011) made it possible to include kangaroo care as one of the integral component of newborn care (Carlo, et al., 2010; Darmstadt et al., 2006; Kumar et al., 2008; Moore & McDermott, 2004; Senarath, Fernando, & Rodrigo, 2007; Tinker, Paul, & Ruben, 2006), including preterm infants.

Bergman et al. (2004) investigated effects of one hour dose of KMC after birth to assess the rate of hypothermia. Out of 20 LBW infants 18 maintained their temperature with KMC, whereas in control group six out of 14 infants maintained their temperature. Similarly, Cattaneoet al. (1998) assessed the KMC interventions by continuous skin-to-skin contact, day & night with an average of 20 hrs /day by mothers. Researcher found 13.5 episodes of hypothermia in a sample of 100 infants in intervention group as compared to 31.5 episodes in control group.

It is highly recommended from literature that staff need to be sensitize about this serious issue Kumar, et al, 2009). It has been observed that in the study settings that there are modern equipment to provide warmth to infants are available. However, space and equipment remain the limitation of any organization due to high influx of premature and LBW infant’s delivery. Though an infant gets thermal control in nursery setting but there is need to implement some strategies which protect high risk infants in the ward environment and mother need to educate about monitoring of infant. She should be acknowledging about its management as well.

In order to compare the effects of environmental temperature and kangaroo care interventions, three groups of newborns were selected. One group was given skin-to-skin contact in prone, while another group was prone to mother chest with clothes, while third group of neonates were kept in nursery. After 90 minutes of repeated measures of temperature post birth (30-120 minutes after birth) the infants who were in skin-to-skin contact showed more variation in temperature than their counterparts. This variation was found to be related with sensory stimulation caused by mother infant skin to skin contact. Moreover, researchers have concluded that early suckling promotion also facilitated in oxytocin release which further enhanced metabolism and heat production(Bystrova et al., 2007).

The literature review supports the concept of ‘shared surface’ of UDC model also. The relationship between infant’s brain and environment is apparent through skin-to-skin contact. As parasympathetic nervous system gets stimulated which enhances peripheral circulation (Bystrova et al., 2007) and manifestation of this process is apparent through infant’s skin temperature. According to the recent meta-analysis of KMC, there is a significant reduction of hypothermia (Conde, 2010). Developing counties like India and Bangladesh have shown progress in implementing KMC in low and high technical settings. It can be applied for all healthy newborn >28 weeks of gestation and weight >600 grams safely (Browne, 2007). Initially preterm and LBW infants were given KMC for 24 hrs. Gradually his model was modified to intermittent kangaroo care for minimum 30 to 60 minutes (Nyqvist, 2009). The researchers found KMC effective in thermal protection even if was given for short duration (Boo & Jamli, 2007). In addition to it KMC can be applied to all newborn care setting. There is no need to have a separate setting to implement this model other than privacy to practice in clinical settings.

Some of the challenges identified in implementation of KMC model initially in India (Ramanathan, Paul, Deorari, Taneja, & George, 2001) participated mothers showed reluctance at the initial stage to change the traditional behavior of neonatal care. Similarly, in Uganda values and beliefs of mother were challenging. As mother considered vernix as ‘napaki’ and it should be removed, and infant cannot be placed on mothers abdomen before bathing (Byaruhanga, Bergström, Tibemanya, Nakitto, & Okong, 2008). Another challenge is reluctance in modifying the newborn care policies and protocols. Despite multiple benefits of KMC, there is still a gap in application of this model (Byaruhanga et al., 2008). One Pakistani study also found cultural beliefs as barrier to provide thermal protection; mothers felt blood on newly born infant as ‘napaki’ and they were not in favour of breastfeeding infant soon after birth (Aziz, Akhtar, & Kaleem). This way all live healthy born infants were given bath before feeding. This behavior is considered as one of the major hazard for newborn health; this gap can be fulfilled by research evidences in our cultural context and by following the international guidelines of newborn care.

Effects of KMC in Promoting Lactation

Another major challenge of preterm births is ineffective breastfeeding. These infants need a great deal of struggle while attachment to mother’s breasts. The epidemiological studies have provided sufficient evidences that breast feeding contributes in reducing morbidities and mortalities of infants (Heinig, 2001). It was further evident that preterm and LBW infants who received donor’s breast milk were at lower risk of necrotizing enterocollitis than those who fed formula feed (McGuire & Anthony, 2003). A breadth of literature supports kangroo care as one of the best way to promote early attachment of infants to mother breast.

A number of barriers to breast feeding among preterm infants are, immature systems, poor coordination while sucking, and difficult to keep them awake (Ludington, 2010). As a result mother does not receive sufficient stimulation from infant’s sucking. Therefore, infants are fed supplement milk either with spoon, gavage or bottle feeding. Since exclusive breast feeding is strongly associated with child survival (Bhutta, 2008) it is recommended that breast feeding should be initiated within an hour of birth to produce sufficient calories and to keep the infant warm (WHO, 1996). KMC has shown substantial improvement in promoting exclusive breastfeeding. The literature review has shown suckling outcome of preterm infants with KMC (WHO, 1996). Even one hour session of KMC for two weeks was found to be helpful in attachment of infants with mother’s breasts. (Nyqvist et al., 2006). The researchers found increase in breast feeding rate and duration among 32 -35 weeks of gestation (Nyqvist et al., 2006). This early attachment behavior of infants with the help of Skin-to-skin contact, stimulates sucking behavior and more oxytocin releases to produce more milk (Matthiesen, Ransjö Arvidson, Nissen, & Uvnäs Moberg, 2001). The experimental study on infants exposed to skin-to-skin contact immediately after birth shows that they continue to nurse more efficiently. There was a significant production of milk and weight gain (Andreson, 2004; Charpak 2001; Dewey, 2003). The literature supports KMC to achieve successful breastfeeding among 90% of infants compared to 61% in hospital (Bier et al., 1996). Moreover, infant on KMC found to be relaxed; therefore, gut is prepared by hormones to digest milk adequately. This helps again in reducing the chances of necrotizing of gut and infants gain weight, resulting in a shorter stay at the hospital(Bergman, Linley, & Fawcus, 2004).

In addition improve frequency and duration of breastfeeding; it is also evident from literature that mothers receive extra support for lactation from nurses while giving intervention of KMC. This support also motivates mothers to continue breastfeeding (Carfoot& Moore, 2005). Due to sustained breastfeeding cholecystokinin releases more and it further stimulates parasympathetic nervous system which aids in growth and development of infants. A comparative study of three group of infants discussed in the section of thermal regulation (Bystrova et al., 2007) also support early sucking reflexes with skin-to-skin contact. A systemic review by Ahmed and Sands (2010) found eight studies to support breastfeeding outcome among preterm infants.

Effects of KMC on Weight Gain

As discussed earlier the preterm and LBW infants are prone to hypothermia, poor lactation, and infections during hospitalization which contribute to infant’s weight gain or prolonged stay in hospital just to gain weight. KMC has been found to be effective in growth of infants (Ali, 2009; Anderson, 1991; Boo, 2007; Conde, 2010; Rao, 2007). However, Charpak’s study did not suggest significant difference in weight gain of infants (Charpak, 2005). On the other hand, KMC also did not show adverse effects and none of the studies found that infants with KMC intervention were failing to thrive. Thus the literature shows positive effect of KMC in terms of improving the feeding of LBW infants and weight gain. Studies among LBW infants depicts significant improvement in growth of infants, with mean weight gain of 29gms among infants <1500gms, who received KMC at 4th day of life (Gupta, 2007). Similarly Rao (2007) found average daily weight gain of 23.99 gms in KMC as compared to 15.5g in control group.

Effects of KMC in prevention of Infection and length of stay reduction

Recently it is evident from the literature that KMC reduces the morbidities and mortalities among infants (Lawn, 2010). Total 15 trials were reviewed and researchers found significant decrease in mortalities i.e. (RR =0.49) and morbidities which was (RR= 0.34).The scientist are predicting that by placing infants in skin-to-skin contact may improve barrier function of the skin (Abufatteh, Ludington, Burant -Visscher, 2011). The researchers found only one case of infection at the time of completion of KMC. The progress of KMC in reducing infection is also depicted in developing countries. A substantial reduction in infections among LBW Infants is demonstrated from the literature. For instance Ali in (2009) found 6.9% of sepsis in KMC group as compared to 23.2% in control group during hospitalization. In addition the research findings were consistent at follow-up; incidences of severe infections were high in control group (17.9%) as compared to (5.2%) in KMC (Ali, 2009). This impact is also associated with improvement in breastfeeding through skin-to-skin contacts. The Immunoglobulin and lactoferrin properties of human milk help in prevention of infection. (Furman&Kennell, 2000).

Reducing the length of stay is another goal of KMC which is highlighted by many studies from developing countries (Ali, 2009; Boo, 2007; Charpak, 2001; Ramanthan, 2001). Infants discharged 7.4 days earlier than control group (Ramanthan, 2001). Similarly, Boo found difference of nine days (Boo, 2007). This major impact is further contributing to cost-effective management. Parents of LBW and preterm infants face dual burden of complication of prematurity as well as economic constraints. Thus, KMC could be an appropriate cost-effective intervention for this population. However, it has not been explored in Pakistan to our knowledge. Therefore, keeping in mind the efficacy of KMC there is a need to implement such trial in Pakistan to fill the gap.

Conclusion

The literature review suggests KMC as an effective intervention to achieve thermal stability and breast feeding among LBW and preterm infants. Complications such as infections can be minimized by the help of protective environment of mother’s skin contact and breastfeeding component. Thus countries with scarce resources like Pakistan can benefit from this intervention to promote the health of high risk newborns.

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