Care For Small Babies: A DOH Policy-in-waiting

Caring for preterm and low birthweight babies, collectively termed ‘small babies,’ has long been the predicament of perinatal and neonatal medicine experts throughout the world. Its occurrence is, by and large, associated with maternal morbidities, which consequently contribute to neonatal mortality and morbidity, both in the short and long term. For this reason, its prevention and optimal management remain a challenge and the subject of much deliberation, research, policy and even, legislation. Traditionally kept in incubators for long periods, small premature babies grow in this environment; not much different from ‘poultry hatcheries’ where the environment is artificially controlled, and nurturing is programmed. The shortage of incubators in an overcrowded Colombian neonatal intensive care unit (NICU) turned out to be a blessing-in-disguise for Dr. Edgar Rey Sanabria,1 who recognized that such an environment only led to more unwanted complications and even death. Taking the cue from the kangaroo and other marsupials, he transferred the caring of stable small babies from incubators to their mothers’ chests and valiantly sent them home earlier than the standard recommendation, with the mothers’ breastmilk and warmth to nurture and care for them. This innovation which took place in the 1970s, took 15 years for the scientific community to take notice after the first scientific evidence was published in the literature.2 This landmark study and all those that followed, consistently showed the impact of kangaroo mother care (KMC) on neonatal mortality, growth, neurodevelopment, and overall wellness of the mother-baby dyad in the company of a supportive family, decreased postpartum anxiety and depression, improved breastfeeding exclusivity and duration, decreased NICU sepsis rates3,4 with no increase in community-acquired infections.2 Amidst the shortage of NICU nursing personnel, the other significant ‘side-effect’ of the KMC intervention is the improved allocation of NICU nursing and auxiliary personnel to high-risk neonates with the integration of the mother in the overall care of the small baby, a prelude to the concept of family-centered/ integrated NICU care currently being recommended.5 KMC in the Philippines started in 1999 at the Dr. Jose Fabella Memorial Hospital, after two of its personnel received training in Colombia (Fundacion Canguro). Its standard implementation as a hospital policy of care for small babies soon followed the first local in-house publication of data6 showing its favorable impact on mortality and overall outcomes on its population of preterm small babies. Involvement of the community of Manila through the city health government improved follow-up and ambulatory KMC implementation.7 By 2005, the nidus of a comprehensive KMC program implementation was realized and technically ready for replication in other health facilities caring for preterm and small babies. Such endeavor, however, was not possible at the time. The KMC Foundation Philippines, registered in 2008, helped pave the way for KMC acceleration in the country. This followed the issuance of the DOH Administrative Order 2009-0025 in Dec 2009 on the essential newborn care (ENC) protocol, which included initiation of KMC for small babies at birth, for better thermoregulation and maternal-infant bonding. The KMC Foundation offered the complete program concept to regional DOH facilities and helped establish regional KMC Centers of Excellence nationwide. Between 2012 and 2014, the foundation gained the support and collaboration of development partners in the Philippines, i.e., the World Health Organization, UNICEF, Save The Children/USAID, and most importantly, the Family Health Office of the Department of Health. ENC, basic newborn resuscitation, and KMC integration into the Care for Small Babies (CSB) package of interventions, henceforth, was cascaded to all DOH facilities.8 Capacity-building efforts have led to the establishment of 27 CSB centers for training and excellence and 195 program-implementing facilities nationwide by the end of 2018. The first draft of the DOH Policy on CSB, entitled “National Policy on the Quality of Care for Small Babies: Accelerating the Reduction of Newborn Deaths” was composed in 2015. Included in this policy, are 1) capacity development of health care providers 2) provision of a KMC unit within the NICU complex or Pediatrics ward and 3) networking with the community through the service delivery network and collaboration with local government units. The initial draft fueled the constitution of a PhilHealth Z-benefit package for the care of preterm and small babies which was launched in 2016 and initiated by 2017 in the established CSB Centers of Excellence. The draft policy has been revised in a workshop in 2019. While so much has happened on the ground level towards the acceleration and efficient implementation of the CSB package of interventions, the DOH policy that should reinforce its standard practice in all of 1,871 PhilHealth-accredited facilities nationwide, remains in the shadows, awaiting an official stamp of approval. This focused Acta Medica Philippina special issue on KMC highlights the research evidence generated by various institutions currently implementing the standard program in the Philippines. It is hoped that this publication will help substantiate and facilitate the approval of the pending DOH policy on care for small babies. Socorro De Leon-Mendoza, MD, FPPS, FPSNbM President, Kangaroo Mother Care Foundation Philippines, Inc. Immediate Past President, Federation of Asia and Oceania Perinatal Societies REFERENCES Rey SE, Martínez HG. Rational management of the premature child. Fetal Medicine Course. Bogotá: National University; 1983. p. 137-15. Charpak N, Ruiz-Peláez 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. Pediatrics. 1994 Dec; 94(6 Pt 1):804-10. PMID: 7970993. Conde-Agudelo A, Díaz-Rossello JL. Kangaroo mother care to reduce morbidity and mortality in low birthweight infants. Cochrane Database Syst Rev. 2016 Aug 23; 2016(8):CD002771. doi: 10.1002/14651858.CD002771.pub4. PMID: 27552521. Charpak N, Tessier R, Ruiz JG, Hernandez JT, Uriza F, Villegas J, et al. Twenty-year follow-up of kangaroo mother care versus traditional care. Pediatrics. 2017 Jan; 139(1):e20162063. doi: 10.1542/peds.2016-2063. Epub 2016 Dec 12. PMID: 27965377. USAID. Every Preemie: Nurturing Care for Small and Sick Newborns. Evidence Review and Country Case Studies. Eds. New K, Durairaj A, Robb-McCord J, Khadka N. Aug 2019. pp54-62 [Internet]. 2021 [cited October 2021]. Available from: https://www.everypreemie.org/wp-content/uploads/2019/09/Nurturing-Care-Evidence-Review-and-Case-Studies-13Aug2019.pdf De Leon-Mendoza S. Impact of kangaroo mother care (KMC) on the survivability of the moderately-low birth weight neonate. Dr. Jose Fabella Memorial Hospital Medical J. 2001; 2:1 Bergh AM, de Graft-Johnson J, Khadka N, Om’Iniabohs A, Udani R, Pratomo H, et al. The three waves in implementation of facility-based kangaroo mother care: a multi-country case study from Asia. BMC Int Health Hum Rights. 2016 Jan 27; 16:4. doi: 10.1186/s12914-016-0080-4. PMID: 26818943. Calibo AP, De Leon Mendoza S, Silvestre MA, Murray JCS, Li Z, Mannava P, et al. Scaling up kangaroo mother care in the Philippines using policy, regulatory and systems reform to drive changes in birth practices. BMJ Glob Health. 2021 Aug; 6(8):e006492. doi: 10.1136/bmjgh-2021-006492. PMID: 34417273.

Effects of Intermittent Kangaroo Mother Care on Low-Birth-Weight Neonates: A Retrospective Before-and-After Study

Objective. To compare outcomes of low-birth-weight neonates delivered before and after implementation of intermittent kangaroo mother care (KMC) in terms of duration of hospital stay, mortality rate, and clinical outcome. Methods. This is a retrospective analytical study that included all neonates delivered in a tertiary government hospital with birth weight of less than 2000 grams before and after intermittent KMC implementation from January 2015 to December 2016. Chart review was done for demographics, mortality profile, and length of hospital stay. Chi-square test and Student’s t-test were used to compare mortality rate and length of hospital stay, and odds ratio was used for mortality outcome. Results. A total of 677 low birth weight newborns were reviewed and of these, 276 (79.8%) neonates in group 1 (Pre-intermittent KMC implementation), and 263 (79.4%) neonates in group 2 (Post-intermittent KMC implementation) fulfilled the inclusion criteria. The duration of hospital stay of neonates enrolled in KMC was significantly shorter (p ≤ 0.05). In Groups 1 and 2, 93–94% of neonates were discharged improved with a 5–6% mortality of almost equal distribution. There was no significant difference in mortality between groups 1 and 2 (OR 1.19, 95% CI 0.59, 2.42). Conclusion. There was no significant difference in mortality rate and cause of death pre- and post-intermittent KMC implementation. However, the length of hospital stay among the LBW neonates discharged improved was significantly shortened.

A Prospective Study on the Efficacy and Safety of Kangaroo Mother Care as an Alternative Means of Transport of Preterm and Term Small-for-Gestational Age Infants

Background. The unavailability of transport incubators in resource-limited areas increases the risk for hypothermia in low birthweight neonates requiring transfer to another hospital. The kangaroo mother care (KMC) position may be a better alternative than swaddling the neonates during transport. Objective. To determine the safety and efficacy of KMC as an alternative means of transport of preterm and term small-for-gestational age (SGA) infants who need to be transferred to a higher level of care. Specifically, it aims to establish if KMC is safe and efficacious in terms of thermoregulation during inter-facility transfers. It also aims to determine the impact of transport distance from the referring hospital, age of gestation, sex, birthweight, and Apgar score on the efficacy of KMC in preventing hypothermia. Methods. We did a prospective, single-blinded, parallel-randomized controlled trial from September 2016 to October 2017 from a community-based primary care facility to a tertiary government hospital. We included newborn preterm infants and term SGA infants weighing 1200–1800 grams, delivered at health centers, district and provincial hospitals who needed to be transferred for a higher level of care. Outcomes included physiologic variables such as temperature, heart rate, respiratory rate. We conducted statistical analysis using t-test, risk ratio, and multiple regression analysis. Results. Thirty-one neonates were randomized to KMC transport (n=15) and conventional transport (swaddled) (n=16). Fifty percent of the swaddled infants developed hypothermia against none in the KMC infants. The risk of hypothermia was reduced by 93.75% in the neonates transported in KMC. The gestational age, birthweight, sex, Apgar scores and distance travelled had no confounding effect on the neonates’ temperature during transport. Conclusions. Kangaroo mother care transport is a safe, effective, and low-cost alternative in inter-facility neonatal transport especially in limited-resource areas.

A Randomized Controlled Trial of Intermittent Kangaroo Mother Care versus Conventional Care in Increasing the Rate of Weight Gain among Low-Birth-Weight Neonates

Objective. To determine the effectiveness of Kangaroo Mother Care (KMC) in increasing the rate of weight gain and decreasing hypothermia, apnea, and sepsis rate, and shorten hospital stay among low-birth-weight infants. Methods. Very low birth weight (VLBW) infants (≤1500 grams) were randomized to either the KMC or conventional care group. KMC provided skin-to-skin contact at least 6 hours per day while the conventional group received the usual care in the newborn intensive care unit (NICU). Daily weight measurements and weekly measurements of length, head, and chest circumference were recorded until discharge. Occurrence of hypothermia, apnea, sepsis, and length of stay was noted. Results. KMC group had a higher mean weight gain per day (p=0.0102). There was no difference in the length, head, and chest circumference between the two groups. Sepsis and apnea rates were not significant between the two groups. Significantly more neonates experience hypothermia in the control group (p<0.0069). Conclusion. KMC is effective in increasing the weight per day compared with the control group. KMC protects the neonates against hypothermia. There is not enough evidence to show a difference in the incidence of sepsis, apnea, and the length of hospital stay between the two groups.

A Meta-analysis on the Effect of Kangaroo Mother Care on Preterm Mortality

Background. Kangaroo mother care (KMC) is a low-cost but high-impact intervention for preterm and low birth weight (LBW) infants. Objectives. To determine the effect of KMC on in-hospital mortality among preterm and LBW infants, taking into consideration their gestational age, birth weight, income category of the country of birth, and medical stability. Materials and Methods. A comprehensive search of several databases, as well as local listings of research papers, was performed to look for randomized controlled studies with KMC as intervention, and mortality and length of hospitalization as outcome measures. The risk of bias and publication bias was assessed. We did subgroup analyses based on income category of the country of birth, gestational age, birth weight, and medical stability of the infants. Results. Sixteen randomized controlled trials (RCTs) with 1738 infants in the KMC group and 1674 infants in the control group were included. Based on the GRADE approach, although all the studies were RCTs, the evidence is assessed as moderate certainty due to the nature of the intervention (KMC) that prevented blinding. There was a 41% reduction in risk of dying among preterm and low birth weight infants who received KMC compared to conventional medical care (3.86%% vs 6.87%; RR = 0.59, 95% CI 0.44, 0.79; I2 = 0%; number needed to treat for additional benefit (NNTB) = 34; 16 RCTs; 3,412 infants). Furthermore, there were also reductions in the risk of dying among infants who were <34 weeks AOG (KMC: 4.32% vs CMC: 8.17%, RR = 0.55, 95% CI 0.38, 0.79; I2 = 0%; NNTB = 26; 10 RCTs; 1795 infants), with birthweight of >1500 g (KMC: 3.97% vs CMC: 6.83%, RR = 0.60; 95% CI 0.45, 0.82; I2 = 0%; NNTB = 35; 10 RCTs; 2960 infants), and born in low- and middle income countries (LMIC) (3.77% vs 6.95%; RR = 0.57, 95% CI 0.43, 0.77; I2 = 0%; NNTB = 32; 14 RCTs; 3281 infants). There was a significant reduction in mortality (KMC: 11.05% vs CMC: 20.94%; RR = 0.54; 95% CI 0.34, 0.87; I2 = 0%; NNTB = 11; 5 RCTs; 387 infants) even among medically unstable infants who received KMC compared to those who did not. The length of hospitalization did not significantly differ between the KMC and the control groups. Due to high heterogeneity, subgroup analyses were performed, which showed a trend towards a shorter length of hospital stay among preterm infants <34 weeks AOG, with birthweight ≥1500 g, medically unstable during admission, and belonging to LMIC but did not reach statistical significance. Conclusion. There was moderate certainty evidence that KMC can decrease mortality among preterm and LBW infants. Furthermore, KMC was beneficial among relatively more premature, bigger, medically unstable preterm infants and born in low to middle-income countries.

Effect of Continuous versus Intermittent Kangaroo Mother Care on Weight Gain and Duration of Hospital Stay among Low-Birth-Weight Admitted at a Level II NICU: A Randomized Control Trial

Background. The Neonatal Intensive Care Unit (NICU) admission at the Philippine General Hospital (PGH) exceeds total bed capacity. Decreasing admissions to the NICU would prevent overcrowding of patients, improve patient care, reduce hospital stay, and reduce predisposition to hospital-acquired infections. Objective. To determine the effect of continuous versus intermittent Kangaroo Mother Care (KMC) on weight gain and duration of hospital stay among low birth weight (LBW) neonates weighing 1,800 - 2,220 grams. Methods. Forty-six (46) stable LBW were randomized to either continuous (≥12 hours in the maternity ward) or intermittent (≤6 hours in the NICU step-down unit) KMC groups. Daily weight and weekly length, head and chest circumference until discharge, and duration of hospital stay were measured. Data were analyzed using the Mann-Whitney U-test and Fisher's exact test. Results. Infants in continuous KMC had an average weight gain of 50 grams/day (p=0.509) and had an average duration of hospital stay of 3 days (p=0.218). Results were not statistically different from intermittent KMC. Conclusion. There was no evidence to show that weight gain and duration of hospital stay among infants in continuous KMC were significantly different from those in the intermittent KMC group.

Effect of Kangaroo Mother Care on Maternal Anxiety and Depression States at the Neonatal ICU: A Prospective Cohort Study

Objectives. To determine the effect of kangaroo mother care (KMC) on anxiety and depression of mothers of low-birth-weight neonates during the immediate newborn period. Method. Eligible participants were mothers of low-birth-weight infants (birth weight ≤2500 grams) admitted at a tertiary hospital's neonatal intensive care unit. Mothers were instructed on providing KMC daily to their infants during the study period (first seven days of life). Main Outcome Measure(s). The primary study outcome was the effect of KMC in improving maternal anxiety and depression scores in the immediate postpartum period using the locally validated Hospital Anxiety and Depression Scale-Pilipino (HADS/HADS-P). Results. A total of 171 mothers were enrolled in the study. Only 79 mothers provided KMC, and the rest (92) did not provide KMC. The anxiety and depression scores improved significantly from day 1 to 7 postpartum in both groups (p<0.05). Frequency of mothers categorized as having severe anxiety significantly decreased over time whether they provided KMC or not (KMC: 40.5%, 13.9%, 7.6% at Day 1 and 7 postpartum and day of discharge; No KMC: 35.9% and 27.2% at Day 1 and Day 7 postpartum). There was a significant reduction in the percentage of mothers categorized in the depressed group from Day 1 to Day 7 postpartum, among those who rendered KMC compared with those who did not (KMC: 7.6%, 2.5%, 0% at Day 1 and 7 postpartum and at the day of discharge vs. No KMC: 7.6% and 10.9% at Day 1 and 7 postpartum). There were no significant differences in the anxiety and depression scores at any period between mothers who rendered KMC > 6 hours and KMC ≤ 6 hours/day. Conclusion. Anxiety and depression scores significantly decreased over time in both mothers who rendered and did not render KMC to their infants. However, there was a significant reduction in the percentage of mothers categorized as having severe depression over time among those who rendered KMC compared to those who did not. Other factors aside from KMC may affect the maternal anxiety and depression states, such as instability of the infant.

Effectiveness of Kangaroo Mother Care in Intubated Preterm Neonates 28 to 36 Weeks Gestational Age, Weighing 600 to 2000 Grams at Birth: A Randomized Controlled Trial

Background. Kangaroo Mother Care (KMC) is the standard of care for stable low birth weight infants. Provision of KMC to intubated preterm infants may also be beneficial, but strong evidence is still lacking. Objective. To determine the effectiveness of KMC in decreasing mortality among intubated preterm neonates. Study Design. This is a non-blinded, parallel, non-inferiority randomized controlled trial. Methodology. All intubated, preterm admissions, 28-36 weeks gestation, weighing 600-2000 grams, with respiratory distress were included. They were randomized to the intervention group who received KMC for 2-4 hours daily while intubated and the control group who received care inside an incubator. Participants’ physiologic status – before, during, and after the intervention – was recorded. The primary outcome was mortality. Secondary outcomes included comorbidities, days intubated, and hospital stay. Results. There was a total of 32 patients. The risk of dying in the KMC group (n=16) was significantly reduced by 78% (RR 0.22; 95% CI 0.06 - 0.87 p=0.009). The KMC patients were also less likely to have hypothermia, nosocomial pneumonia, NEC, and late-onset neonatal sepsis (p<0.05). The KMC group had higher blood sugar levels (110 vs. 58, p=0.001) and required fewer days of intubation (3.5 vs.1.5 days, p<0.000) compared to the control group. There was no difference in the duration of the hospital stay. Conclusion. KMC is effective in decreasing mortality among intubated preterm neonates. Other comorbidities and days of intubation were also reduced.

Effect of Kangaroo Mother Care on the Likelihood of Breastfeeding from Birth up to 6 Months of Age: A Meta-analysis

Background. One of the World Health Organization (WHO) nutrition target by 2025 is 50% exclusive breastfeeding rate among infants until age 6 months. Kangaroo mother care (KMC) known to increase breastfeeding rates, especially in preterm and low birth weight (LBW) infants. Objectives. This study determined the effect of KMC to the rate of exclusive breastfeeding among preterm and LBW infants at 6 months of age. Methods. Conducted searches in MEDLINE and CENTRAL databases, likewise hand searched local publications December 1996 until June 2018. Included several randomized controlled trials and prospective observational studies comparing KMC and conventional care among preterm and LBW infants. The primary outcome was exclusive breastfeeding of infants at six months of age. Two authors independently assessed trial quality and extracted data the statistical analysis applied using Review Manager version 5.3. Results. Identified nine eligible trials involving 1,202 neonates. All studies had low-to-moderate risk of bias. KMC significantly noted to increase the likelihood of exclusive breastfeeding by 1.9 times at birth up to 6 months (OR 1.93 [1.18,3.17], p=0.009). Conclusion. KMC can increase exclusive breastfeeding among preterm and LBW infants from birth up to 6 months of age.

Effectiveness of Kangaroo Mother Care in Reducing Morbidity and Mortality among Preterm Neonates on Nasal Continuous Positive Airway Pressure: A Randomized Controlled Trial

Background. Prematurity is a major cause of neonatal death. Continuous positive airway pressure (CPAP) is the recognized initial intervention among preterm neonates in respiratory distress. Kangaroo mother care (KMC) may help improve neonatal outcomes. Objective. To determine the effectiveness of KMC in reducing morbidity and mortality among preterm neonates on CPAP via RAM nasal cannula (nCPAP). Methods. A prospective, non-blinded, randomized controlled trial was conducted on eligible preterm neonates requiring nCPAP due to respiratory distress. They were randomly allocated to either KMC (n=35) or conventional care groups (n=35). Outcome measures included duration of nCPAP and oxygen support, physiologic parameters, morbidity, mortality, and length of hospital stay. Results. The durations of nCPAP and oxygen support were both significantly shorter in the KMC group. Morbidities (air leak syndrome, necrotizing enterocolitis, and late-onset sepsis) were also significantly lower in the KMC group. Although the mortality rate and the hospital stay were lower in the KMC group, these were not statistically significant. Conclusion. KMC effectively decreased the duration of nCPAP and oxygen support, as well as the incidence of neonatal morbidities. There were trends towards reduced mortality and length of hospital stay in the neonates who received KMC.