New evidences on the Kangaroo Mother Care method

N.Charpak*

*MD., Scientific coordinator, Kangaroo Morger Care Program, San Ignacio Hospital, Bogota, Director Fundacion Canguro , Bogota, Colombia.

Thanks to my colleagues Y hernandez, C.Pallas and U Ewald for some of their slides I used in this presentation.

Premature and/or Low Birth Weight infant

NB < 37 weeks of gestation or < 2500 gr at birth. The most common complication of pregnancy (15% worldwide) Responsible for 28% of all infant deaths within the first 7 days of life Increase neonatal mortality Increase neonatal morbidity. Long term neurological desorders:

Cerebral palsy Sensorial , cognitif or motor deficits (mild, severe or moderate).

What is Kangaroo Mother Care (KMC)

1. Kangaroo Position

- Skin-to-skin contact 24 h/day - Upright position

Modalities of the Kangaroo Position

1.

Continuous, at home or in the hospital After stabilization: well documented for temperature, oxygenation and heart rate For stabilization: not well documented

2. Intermittent: for emotional and breastfeeding promotion benefits Optimal duration: minimum 2 h/cycle
4

2. Kangaroo Nutrition:

Based in breast feeding (hind milk, suction,

dropper or spoon)

- Addition of vitamins

- Fortified or supplemented with premature formula in infant not thriving properly (15g/Kg/day) with dropper or cup

Leche League

Breastfeeding twins

3. Kangaroo Discharge Policy and follow up

- Early discharge independently of weight or

gestational age

Strict follow up up to term

Modalities

Early discharge to home Early discharge to a kangaroo ward

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Different modalities of KMC implementation

KMC could be used in three main scenarios:

1. Institutions with a very low level of

technology and severely restricted access to any level of neonatal care. No incubators and no profesionals trained in neonatology

2. Institutions with access to appropriate resources (human and technology) but insufficient for the number of premature births ( overcrowded)

3. Institutions with little or no restriction on access to high-technology neonatal care

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KMC and mortality

Question: Is there any evidence that Kangaroo Mother Care method reduce neonatal mortality?

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Kangaroo mother care to reduce morbidity and mortality in Low Birth Weight infants (Review)

Conde-Agudelo A, Belizn JM, Diaz-Rossello J

This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library 2011, Issue 3 http://www.thecochranelibrary.com
Kangaroo mother care to reduce morbidity and mortality in low birthweight infants (Review)
Copyright 2011 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd.

The 2011 Cochrane review update included seven trials that assessed mortality at discharge and at 40-41 weeks. These trials reported a statistically significant reduction in the risk of mortality among KMC infants, compared with babies receiving traditional care. The review concluded that there is sufficient evidences to recommend the use of KMC in stabilized infants.
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Kangaroo mother care to prevent neonatal deaths due to preterm birth complications

Joy E Lawn, Judith Mwansa-Kambafwile, Bernardo L Horta, Fernando C Barros and Simon Cousens Corresponding author. Saving Newborn Lives/Save the Children-USA, 11 South Way, Pinelands, Cape Town 7405, South Africa. E-mail: joylawn@yahoo.co.ukI 2010

Lawn 2010 performed a systematic review and meta-analysis to establish the effect of KMC on neonatal mortality due to direct complications of preterm birth The results of the present review also suggest that KMC reduces the risk of mortality at discharge or at 40-41 weeks of gestational age and at latest follow-up.
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KMC and morbidity outcomes

4 RCT,1Cross Over Study,6 PrePostest (PPT),1Observational Study

3Cross Over Study,1PPT,1Observational Study

(FC, FR, Apneas)

2 RCT

5RCT,5PPT,3Observational Study,

3Cross Over Study,1PPT,1Observational Study,

RCT,3PPT,1Observational Study, 1 Historical Study,1Case Control Study,

1Observational Study,

1Cross Over Study, 2 PTP,

6RCT

No evidences,

Evidence-based statements have been formulated and consensus has been achieved for KMC and Thermal regulation: (+++) KMC and Physiological stability: (+++) after stability , (-) before stability KMC and Apnea: Analogy (++) KMC and Gastro-esophageal reflux: Analogy (++) KMC and Bonding and attachment and neurodevelopment: (+++) KMC and neonatal transport: (+), Expertsopinion KMC and pain control: (++) KMC and growth: (+) Head Circumference KMC and the dying infant: (+), Expertsopinion KMC and successful breastfeeding (++) KMC and early discharge 2 RCT, (++) KMC and empowerment of the family KMC and staff and parents satisfaction
6 RCT,

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Survival per gestational week (1y)

(Sweden 2007-2009)

100

90

80

70

60

50

40

30

20

10

0 23 24 25 26 27 28 29 30 31

22

Completed gestational weeks

Slide courtesy Pr Uwe Ewald

Weight at birth > 3999 g 0.041 0.037 0.066 0.127 0.51

Wald

RR ratio(95%IC) 1.1 (0.6-2.0) 1.0 (reference) 1.8 (1.2-2.7) 3.5 (2.2-5.4) 13.9 (8.2-23.4)

3000-3999 g

2500-2999 g

1500-2499 g

< 1500 g

Bhutta. JAMA 2002;288:728.

Reference Need special class At 6 years Need special support At 12 years Special support or repeated grade At 14 years Repeated grade before 18 years <1500g Peers <1000g Term <1500g Term

Measures

Groups

Rsults 25% 14% 35% 14% 58% 13%

Hack 94 USA

Botting 98 UK

Saigal 2000 Canada

Lefebvre 2005 Canada

<1001g Term

56% 15%

KMC and brain development outcomes

Premature brain vs term brain (Rueckert 2003-06)

Premature Born at 26 wga Image 40 AG

Control Born at 40 wga Image 40 AG

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KMC time window

7w GA 12w GA 14w GA

41w GA 20-25w GA

Impact of KMC

28w GA

Axonal growth Synaptic connections

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Biological risk = interrupted synaptogenesis and faulty networks (Ex.: CC)

Neurogenesis

> 24 months

Hypothesis
tactile cutaneous olfaction audition balance proprioception and visual

KMC intervention could nurture the infant brain, with multiple sensory informations from the parents:

KMC: optimal condition for cerebral integration of the body sensorimotor scheme

Time window: between 26 and 43 weeks of gestational age= last trimester of pregnancy= synaptogenesis and establishment of the intra and interhemispheric networks
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Brain motor function in adolescents born very preterm and influence of Kangaroo Mother Care : a pilot study with transcranial magnetic stimulation

Cyril Schneider, Ph.D2, Nathalie Charpak, M.D.1, Juan G Ruiz, MSc.4 and Rjean Tessier, Ph.D3.

Canguro ( Kangaroo Foundation), Bogot, Cundinamarca, Colombia; 2Neuroscience Unit (CHUL) CHUQ Research Center, Universit Laval (Rehabilitation), Qubec, QC, Canada; 3Pediatrics Unit (HSFA) CHUQ Research Center, Universit Laval (Psychology), Qubec, QC, Canada and 4Department of Clinical Epidemiology and Biostatistics, Javeriana University, Bogot, Colombia.

1Fundacin Madre

Oct 2012

Programa Madre Canguro Integral Ltda.

NKG (N=21) KG (N=18) CG (N=9)

(Mean) (Mean) (Mean)

Ballard (Weeks)

30.6 1486 2 27 1 17 1429

30.8

39.13 2995 0 1

Birth Weight (g)

IUGR at birth

Neonatal stay (Days)

TMS=NONINVASIVE BRAIN STIMULATION ( testing brain motor excitability and corticospinal function )

White matter & Corpus callosum

Transcranial magnetic stimulation (TMS) to test brain function in prematurity and KMC
500

NONINVASIVE BRAIN STIMULATION ( testing between-hemisphere function = integrity of corpus callosum )

(2) BRAIN STIMULATION
400

(3) Interhemispheric inhibition

TMS
300

Frequency Latency Duration

200

100

0 0 50
TMS

100
Temps (s)

150

200

Time (ms)

Subject 1

(1) Volitional muscle contraction (4) Inhibition of muscle contraction

TMS

Subject 2

FREQUENCY OF OBSERVATION FOR INTERHEMISPHERIC INHIBITION VIA CORPUS CALLOSUM (CC)

Completion of CC fiber myelination

85

TMS

Temps (s)

60

35

***
18 yo

Term Preterm KMC

***

10

15 yo (Bogot)

20 yo (Qubec)

LATENCY FOR INTERHEMISPHERIC INHIBITION (TRANSFER TIME VIA CORPUS CALLOSUM)

27.5

*
25.0

TMS

Temps (s)

**

22.5

20.0 17.5 15.0 12.5 10.0

18 yo

Term Preterm KMC

15 yo (Bogot)

20 yo (Qubec)

DURATION OF INTERHEMISPHERIC INHIBITION (AFTER PASSAGE VIA CORPUS CALLOSUM)

25
TMS
Temps (s)

20

15

?
10

Term Preterm KMC

***
18 yo

***
15 yo (Bogot)

20 yo (Qubec)

TRANSCRANIAL MAGNETIC STIMULATION (TMS) & FUNCTIONAL MRI TO TEST BRAIN FUNCTION IN PREMATURITY AND KMC

CROSSED pathways

IPSILATERAL pathways

30

15 yo (Bogot)

20

10

adults

no KMC

KMC

Term

Synchronization of brain cells (latency

norm

of motor responses)

Main effect of the group (F 2,47=3.41, p=0.04)

14

13

12 mean in adults SD

11

no KMC

KMC

Term

Superposition of TMS and DTI-tractography

CC dun adolescent n a 30 semaines d ge gestationnel et ayant une diplgie spastique.

CC dun adolescent nee a terme

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Conclusion

Hemispheric and callosal motor circuits worked better in KMC preterm adolescents. This finding provides new information about the critical periods of brain plasticity in infants ex-utero and shows that early KMC could promote functional connectivity and synaptic efficacy.

There is a clear need for testing all children of our original RCT cohort (KMC, non KMC) now at early adulthood. We winned a Grand Challenge Canada grant to conduct this research, 460 participants have been already recruted and are actually tested.

Time window : KMC by parents in the intensive care unit

Photo courtesy Pr Uwe Ewald

Skin of the parents = a new space for the care of the premature infant

Photo courtesy Pr Uwe Ewald

Bonding, close monitoring, feeding.

Photo courtesy Pr Uwe Ewald

Phototherapy

Photo courtesy Pr Uwe Ewald

Home ambulatory KMC in Colombia

South African KMC programs

Groote Shuur Hospital

CHB Hospital, Johannesburg

KMC ward

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