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  1. 1. Feeding of Healthy Newborn 1
  3. 3. SSC position for baby• SSC positions build on the Tummy to Mummyposition.• Full SSC position entails the baby lying on topof the mother:FacingCloseTouching• Mother does not have to hold the baby.Gravity maintains baby position 3
  4. 4. Full SSC Position• Baby’s chest is in close contact withmum’s body Contour.• Unrestricted access to breast 4
  5. 5. Advantages offered by the Breast Crawl• Warmth• Comfort• Metabolic adaptation• Quality of attachment 5
  6. 6. Warmth• Prevents hypothermia 6
  7. 7. Comfort• The infants in the cot cried for a significantly longer time than the babies in Breast Crawl position during all observation periods. 7
  8. 8. Metabolic adaptation• Babies kept in the Breast Crawl position had higher 90 minute blood sugar levels and more rapid recovery from transient acidosis at birth, as compared to babies separated and kept in a cot next to the mother (Christensson et al, 1992). 8
  9. 9. For the Mother Expulsion of placenta and reduction of postpartum haemorrhage 9
  10. 10. The effects ofOxytocin• Calm• Lower heart rate• Higher pain threshold• Higher social interaction• Less anxious• Soporific 10
  11. 11. Advantages for Both: Bonding• A mothers feeling of love for the baby may not necessarily begin with birth or instantaneously with the first contact. During the Breast Crawl, while resting skin to skin and gazing eye to eye, they begin to learn about each other on many different planes.• For the mother, the first few minutes and hours after birth are a time when she is uniquely open, emotionally, to respond to her baby and to begin the new relationship. Suckling enhances the closeness and new bond between mother and baby. Mother and baby appear to be carefully adapted for these first moments together 11
  12. 12. Finally.SSC works for every other mammal onthe planet.. Why should we be any different? 12
  13. 13. • http://breastcrawl.org/video.htm 13
  14. 14. Benefits of breast milk to the baby• Breast milk and human colostrum are made for babies and is the best first food• Easily digested and well absorbed• Contains essential amino acids• Rich in polyunsaturated essential fatty acids• Better bioavailability of iron and calcium 14
  15. 15. Benefits of breast milk (contd.)• Protects against infection• Prevents allergies• Better intelligence• Promotes emotional bonding• Less heart disease, diabetes and lymphoma 15
  16. 16. Protection against infection 1. WBC in 1. Mother mother’s infected body make antibodies to protect mother 1. Some WBCs go1. Antibody to to breast mother’s and make infection antibodies secreted in milk there to protect baby 16
  17. 17. Benefits to mother• Helps in involution of uterus• Delays pregnancy• Decreases mother’s workload, saves time and energy• Lowers risk of breast and ovarian cancer• Helps regain figure faster 17
  18. 18. Benefits to family• Contributes to child survival• Saves money• Promotes family planning• Environment friendly 18
  19. 19. Anatomy of breast Myoepithelial cells Epithelial cells ducts Lactiferous sinus Nipple Areola Montgomery gland Alveoli Supporting tissue and fat 19
  20. 20. Physiology of lactation• Hormonal secretions in the mother – Prolactin helps in production of milk – Oxytocin causes ejection of milk• Reflexes in the baby – rooting, sucking & swallowing 20
  21. 21. Prolactin productionEnhanced by• How early the baby is put to the breast• How often and how long baby feeds at breast• How well the baby is attached to the breast 21
  22. 22. Prolactin reflexHindered by• Delayed initiation of breastfeeds• Prelacteal feeds• Making the baby wait for feeds• Dummies, pacifiers, bottles• Certain medication given to mothers• Painful breast conditions 22
  23. 23. Prolactin “milk secretion” reflex Enhancing factors Hindering factors Emptying of breast Bottle feeding, Sucking Incorrect positioning, Painful breast Expression of milk Night feeds Prolactin in Sensory impulse blood from nipple 23
  24. 24. Oxytocin “milk ejection” reflexOxytocin contractsmyoepithelial cells Sensory impulse from nipple to brain Baby sucking 24
  25. 25. Oxytocin reflex Stimulated by Inhibited by•Thinks lovingly of baby •Worry•Sound of the baby •Stress•Sight of the baby •Pain•CONFIDENCE •Doubt 25
  26. 26. Feeding reflexes in the baby Rooting reflex Mother learns to Sucking reflex position babyBaby learns to takebreast Swallowing reflex 26
  27. 27. Composition of preterm and full termmilk (g/dl) Full Term Preterm Fat 3.5 3.5 1.0 Protein 2.0 7.0 Lactose 6.0 27
  28. 28. How breast milk composition varies Colostrum Foremilk Hindmilk FatProteinLactose 28
  29. 29. For successful breastfeeding• A willing and motivated mother• An active and sucking newborn• A motivator who can bring both mother and newborn together ( health professional or relative ) 29
  30. 30. Successful breastfeeding• Have a written breastfeeding policy• Motivate mother from antenatal period• Put to breast within 30 minutes of birth• Promote rooming -in of mother and baby• Promote frequent breastfeeding 30
  31. 31. Successful breastfeeding(contd.)• Don’t give prelacteal feeds• Don’t use bottle to feed• Support mother in breastfeeding the baby• Arrange mother craft classes in health facilities• Treat breastfeeding problems early• Exclusive breastfeeding till 6 months• Addition of home-based semisolids after 6 months 31
  32. 32. Position of baby in relation to themother1. The baby’s whole body should face the mother and be close to her3. The baby’s head and neck should be supported, in a straight line with his body, to face the breast5. Baby’s abdomen should touch mother’s abdomen, to be as close as possible to his mother 32
  33. 33. Signs that a baby is attached wellat the breast 1. The baby’s mouth is wide open 2. The baby’s chin touches the breast 3. The baby’s lower lip is curled outward 4. Usually the lower portion of the areola is not visible 33
  34. 34. Signs that a baby is attached well at the breast lower lip is curled outward baby’s mouth is wide openchin touches lower portionthe breast of the areola is not visible 34
  35. 35. Treatment of inverted nippleTreatment should begin after birth• Syringe suction method• Manually stretch and roll the nipple between the thumb and finger several times a day• Teach the mother to grasp the breast tissue so that areola forms a teat, and allows the baby to feed 35
  36. 36. Treatment of inverted nipple by syringemethod Cut along this STEP 1 line with blade Use 10 or 20cc syringe STEP 2 Insert the plunger from cut end STEP 3 Mother gently pulls the plunger Before the feeds 5-8 times a day 36
  37. 37. Sore nipple Causes • Incorrect attachment : Nipple suckling • Frequent use of soap and water • Candida (fungal) infection Treatment • Continue breastfeeding and correct the position & attachment • Apply hind milk to the nipple after a breastfeed • Expose the nipple to air between feeds 37
  38. 38. Breast engorgementCauses• Delayed and infrequent breastfeeds• Incorrect latching of the babyTreatment• Give analgesics to relieve pain• Apply warm packs locally• Gently express milk prior to feed• Put the baby frequently to the 38 breast
  39. 39. Causes of “Not enough milk”• Not breastfeeding often enough• Too short or hurried breastfeeding• Night feeds stopped early• Poor suckling position• Poor oxytocin reflex (anxiety, lack of confidence)• Engorgement or mastitis 39
  40. 40. Management of “Not enough milk”• Put baby to breast frequently• Baby to be correctly attached to breast• Build mother’s confidence• Use galactogogues judiciously Adequate weight gain and urine frequency 5-6 times a day are reliable signs of enough milk intake 40
  41. 41. Expressed breast milkIndications• Sick mother, local breast problems• Preterm / sick baby• Working motherStorage• Clean wide-mouthed container with tight lid• At room temperature 8-10 hrs• Refrigerator – 24 hours, Freezer - 20° C – for 3 months 41
  42. 42. Ten steps to successful breastfeeding Every facility providing maternity services and care for newborn infants should 3. Have a written breastfeeding policy that is routinely communicated to all health care staff 4. Train all health care staff in skills necessary to implement this policy 5. Inform all pregnant women about the benefits and management of breastfeeding 42
  43. 43. Ten steps to successful breastfeeding (contd….)1. Help mothers initiate breastfeeding within half hour of birth2. Show mothers how to breastfeed, and how to maintain lactation even if they are separated from their infants3. Give no food or drink, unless medically indicated4. Practice rooming-in : allow mothers and infants to remain together 24 hrs a day 43
  44. 44. Ten steps to successful breastfeeding (contd….)1. Encourage breastfeeding on demand2. Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants3. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital. 44
  45. 45. 45
  46. 46. Feeding •The World Health Organization (WHO) recommends that all babies be exclusively breastfed for six months •Semi-solids can be introduced after six months, and baby can continue to have breast milk for two years and beyond to enjoy the maximum protection breast-feeding can provide. 46
  47. 47. Strategy for Successful BreastfeedingAt the delivery suite: first breastfeed within 1 hour after birth unlessmedically contraindicatedPost-natal Ward:Mothers who have had a Caesarean delivery can breastfeed lying downwith help from the nursing staffOnce you are able to sit up, you can breastfeed using the football hold,which is nursing the baby in a side lying position supported by your arm.Rooming-in: Having your baby together with you after delivery helps tobuild the mother-child bonding process. 47
  48. 48. Strategy for Successful BreastfeedingFrequency of feed:√Newborns should be breastfed whenever they show signs of hunger,for example rooting reflex or increased alertness.√ at least 8 to 12 breastfeeds per day.√The frequent breastfeeds help to stimulate the milk production 48
  49. 49. Strategy for Successful BreastfeedingHelpful tips to Mums:√ Prepare your nipple, if retracted start pulling it outwards antenatally√Your baby should be well positioned, correctly latched on and sucklingwell when on the breast√A baby who is sleepy on the breast needs to be coaxed to suckle√Ensure you are drinking adequately, >3 lit /day√Have adequate rest, are not stressed or distracted or in pain√Observe your babys suckling cues. Your baby may take 15 to 20minutes to finish a feed from the first breast before offering the secondbreast•Breastfeeding is not always easy and sometimes, a lot of patience and perseverance isrequired as mothers may find that breastfeeding is a totally new learning experience 49
  50. 50. How do you know if your baby is getting enough?Observe the following:√Baby passes light yellow urine at least 6 to 8 times in 24 hours.√The frequency of your baby’s bowel movement may vary a lot. On theaverage, 3 or more bowel movements per day indicates that yourbaby’s milk intake is sufficient.√Your baby is generally alert, contented and gaining weight.(There is some weight loss in the first few days of life. Your baby shouldgain back the birth weight by 7 to 14 days of life and should then gainweight weekly.) 50
  51. 51. Working And Breastfeeding√Introduce a bottle of expressed milk to your baby about 2 weeks prior to yourcommencement of work as some babies may take some time to get√used to feeding from the bottle.√Breastfeed your baby before going to work and when you return home.√Express your milk regularly or at least once while at work.√Store the expressed milk in the fridge or freezer.√Use an ice-filled cooler box to keep the breast milk cool during transportation 51
  52. 52. Storage of expressed breast milk Label the name, date and time of expression of breast milk 52
  53. 53. Storage of expressed breast milk √Freshly expressed breast milk kept in the general compartment of the fridge at a temperature of 4 degrees Celsius should be used within 48 hours. √Breast milk kept in the freezer which has a separate door, should be used within 3 months. 53
  54. 54. Thawing of frozen expressed breast milk A bottle of frozen expressed breast milk can be thawed in the fridge by placing it in a cup filled with water at room temperature (Indicate the date and time that the milk is taken out from the freezer and placed in the general compartment of the fridge. Use this milk in 24 hours.) 54
  55. 55. Warming up of expressed breast milk √For immediate use, you can thaw a bottle of frozen or chilled expressed milk by placing it in a mug of warm water √Test the temperature of the milk before feeding √Discard any unused remainder √Do not boil or microwave the milk. 55
  56. 56. Goals of BreastfeedingMothers should be given every supportto exclusively breastfeed their infantsfrom birth to 6 months of age,start complementary foods at 6 monthswhile continuing to breastfeedtill 2 years and beyond … 56
  57. 57. Breastfeeding GoalsAbout 2000 mothers surveyed• 95% initiated breastfeeding• 21% at 6 monthsExclusive breastfeeding• 14% at 2 months• Health Promotion Board Survey Singapore 2001 1% at 6 months 57
  58. 58. Benefits of Breastfeeding• Infectious diseases• Long term health outcomes• Neurodevelopment• Maternal health benefits• Community benefits Breastfeeding and the use of human milk. Pediatrics. 2005;115:496–506 58
  59. 59. Health Outcomes INFANTS WOMENReduced risk of Reduced risk of• Acute otitis media • type 2 diabetes by 12% for• Nonspecific gastroenteritis each year of breastfeeding• Severe lower respiratory tract • ovarian cancer by 21 % infections • breast cancer 28 % in those• Atopic dermatitis whose lifetime duration of• Asthma breastfeeding was 12 months• Obesity or longer• Type 1 and 2 diabetes• Childhood leukemia• SIDS• Necrotising enterocolitis 59
  60. 60. Practical Aspects of Breastfeeding 60
  61. 61. Mother’s position Any comfortable position 61
  62. 62. Baby’s PositionBaby held close to mother’s body• Infant faces breast with head and body in straight line• Upper lip opposite nipple• Baby can reach breast easily• Move baby to breast, not breast to baby 62
  63. 63. Preparing for Latch Insert video ClipEnsure correct position of baby• Stimulate rooting reflex with nipple• Wait for baby to open mouth wide• Baby’s bottom lip touches base of areola• Help baby take sufficient areola into mouth 63
  64. 64. Correct Latch - CLAMS• Chin touching lip• Bottom Lip curling back• More Areola visible above top lip than below lower lips• Mouth wide open with big mouthful of breast• Sucking pattern change from short sucks to long 64
  65. 65. Assessing Adequacy of Breastfeeding: 3rd day oflifebaby• Weight loss less than 7%, Regain birth weight by day 10 -14• Urine 3 - 4 times/day• Stools 3 – 4 times/day• Stools yellow-green by 3rd-4th day 65
  66. 66. Assessing Adequacy of Breastfeeding: 3rdday of lifeMother• Respond appropriately to early infant feeding cues and feeding 8 – 12 times in 24 hours• Comfortable positioning and effective latch• Recognise signs of effective breastfeeding• Identify available breastfeeding resources and help 66
  67. 67. Fully Breastfed Babies in First Week Day of life Wet diapers in 24 Stools in 24 hours hour First 24 1 1 meconium hours Day 2 2 2 meconium Day 3 3 Stool colour change Day 4 4, light yellow Transitional stools Day 5 5, colourless 3 - 4 yellow stools Day 6+ 6+,colourless 4+ stools, freq and colour varies 67
  68. 68. 68
  69. 69. 69
  70. 70. Formula Feeding• Goal standard for nutrition is the exclusively breast fed infant• Wide range of commercial formulas, mainly cows milk based 70
  71. 71. Formula Feeding in Infancy• Caloric requirements 80 –120 kcal/kg/day• Standard formula: 20 kcal/30 ml or 0.67 kcal/ ml• Therefore, infant requires 120 – 180 ml/kg/day of formula• Feeding on demand, generally 2 – 5 hourly, 71
  72. 72. Human versus Bovine milk: Protein• Higher protein content in bovine milk• Whey – Casein ratio • Human milk 70% whey and 30% casein • Bovine milk 18% whey and 92% casein Whey protein is digested more easily and promotes more rapid gastric emptying• Whey protein – Human: α-lactalbumin, lactoferrin, lysozyme and secretory Ig A – Bovine β-lactoglobulin (? Cow milk protein allergy) 72
  73. 73. Human versus Bovine milk: Lipid• Human milk has variable fat components with changes during day, among women and within one feed• Formulas mimic human milk fat content by adding – Carnitine – Higher Medium chain FA to increase absorption – Essential fatty acids linoleic and linolenic acid – Arachidonic acid (AA) and Docosahexaenoic acid(DHA) • LC-PUFA are phospholipids in brain, retina 73
  74. 74. Human versus Bovine milk:Carbohydrate• Human milk has high lactose (90-95%) and oligosaccharides (10-5%)• Softer stool consistency and non- pathogenic bacterial fecal flora• Oligosaccharides are natural prebiotics, Lactobacillus and Bifidobacterium spp are natural probiotics 74
  75. 75. Special formulas• Preterm formulas – Higher caloric content (24kcal/30ml) – Higher protein, lipids – Higher minerals ( Ca, Phosphate)• Formulas for cows milk allergy – Extensively hydrolysed milk• Lactose intolerance – Soy formula – Lactose free cows milk formula 75
  76. 76. Complementary Feeding of the Breastfed Baby• Start weaning about 6 months (WHO guidelines)• Nutritional basis – Need for additional minerals e.g. sodium, iron, zinc – Caloric dense semi-solids – Not as supplement to breast milk, as complement• Developmental basis – Refusal of solids if introduced too late – Baby is developmentally ready • Adequate head/neck/trunk control 76
  77. 77. Kangaroo Care 77
  78. 78. Kangaroo CareKangaroo Care (KC) is skin-to-skinplacement of a diaper clad infantagainst the chest of another humanbeing (usually mother, father) 78
  79. 79. What is Kangaroo MotherCare??Definition:• early, continuous and prolonged skin-to-skin contact between the mother and the baby• A universally available and biologically sound method of care for all newborns, but in particular for premature babies, with three components ...• 1. Skin-to-skin Contact 2. Exclusive breastfeeding 3 .Support to the mother infant dyad. 79
  80. 80. Kangaroo Care- Mother and Father 80
  81. 81. Why the title "KangarooMother Care"?Mother kangaroo is a mammal (just like us), andfeeds its baby milk like we do (or like we should!)from a nipple inside its pouch.The pouch covers the baby with skin, and this notonly protects the very immature baby, but alsoprovides it with a total environment which is essentialfor development.This includes warmth, food, comfort, stimulation,protection.The baby is CARRIED for all this time, withoutinterruption ! 81
  82. 82. At Manama (where birth skin-to-skin contactstarted), phototherapy was also done.The box has lights shining on the baby,and mother!The height of the box can be adjustedusing the pegs on the side, to get optimaltemperature and exposure., the round sideholes allowed for inspection. Sheets in summer, and blankets inwinter, covered all the sides. Mothershead can extend beyond the top sidecover, or be inside, in which case her eyesare covered !!! This picture is posed ... only 3 out of126 skin-to-skin babies ever developedjaundice. This box was used mainly totreat the fullterm babies that developedjaundice, and could be used withoutmother present. 82
  83. 83. HistorySr Agneta Jurisoo studied what little literature was available on KMC during1987. The following year she and Dr Bergman arrived at a small missionhospital in Zimbabwe, where premature births were common. There were noincubators, poor transport over great distances, and overloaded referralcentres: only one of ten premature babies survived.In the absence of incubators, they started a care plan in which the motherbecame the incubator. Instead of waiting for the baby to “stabilise”, themother was used to stabilise premature infants immediately after birth. Itwas immediately clear this was highly effective, no matter how small or howpremature, stabilisation took a mere six hours. With this care, now five of tenvery low birth weight babies survived.This work has been published:The "kangaroo-method" for treating low birth weight babies in a developingcountry. 83
  84. 84. History• 1979 - Dr Rey and Martinez started program in Bogota, Colombia, in response to shortage of incubators and severe hospital infections.• 1983 - UNICEF brought attention to program Spanish!• 1985 - Number of visits from USA, UK and Scandinavia, first English report published in The Lancet by Whitelaw and Sleath, May 1985.• 1986 onwards - Research in Europe and USA. Implementation widespread in Scandinavia and Germany. Early implementation in Mozambique and other African countries. 84
  85. 85. History1991 - First review of research published by Gene Cranston Anderson.1996 - First International Workshop, Trieste, Italy, hosted by Adreano Cattaneo and team. Noted over thirty different terms used, agreed to use KMC (Kangaroo Mother Care), defining the program of skin-to-skin contact, breastfeeding and early discharge. The term “K C” refers only to intervention “intrahospital maternal-infant skin-to-skin contact”.1998 - First International Conference on Kangaroo Care, Baltimore, Maryland, USA, arranged by Susan Ludington-Hoe1998 - Second International Workshop, Bogota, Colombia, arranged by Nathalie Charpak and team; focus on research and implementation2000 - Third International Workshop, Yogyakarta, Indonesia. 85
  86. 86. 86
  87. 87. OUTLINEI. Definition & History of Kangaroo CareII. Physical & Psychological responsesIII. Intubated infantsIV. Applying K.C.V. Kangaroo Care and Lactation 87
  88. 88. APPLYING KANGAROONormal Newborn NICU• Temp stabilizer • Thermal regulation• Slow respiratory rate • Less A’s & B’s• Early breastfeeding • Weight gain• Early attachment • Bonding• process • Parent involvement• Less crying • with care of baby • Earlier discharge 88
  89. 89. Physical & Psychological Responses from Skin To Skin Contact Infant & Maternal 89
  90. 90. Benefits of KC for InfantsEarly Postpartum Period• Cry 10 times less and for shorter periods thaninfants in cots• Less distress crying• More flexor & few extensor muscle movements• Greater physiologic stability, less crying, & fewergrimaces during painful procedures (ex. Injections)• Better attachment to mothers 90
  91. 91. RESPIRATORY RATE• Stabilizes a preemie’s breathing rate 35-50 per minute• Depth of each breath becomes more even• Apnea decreases fourfold or is absent during KC• Length of apnea episode diminishes• Periodic breathing is significantly decreased with normal breathing taking over. 91
  92. 92. THERMAL REGULATION• Neutral thermal zone - the temperaturerange at which a baby has minimal oxygenneeds.• Baby’s temp rises quickly in the first 10minutes and then stabilizes to their neutralthermal zone for the remainder of K.C.session 92
  93. 93. OXYGENATION• Increased oxygenation with increased blood flow through the vessels the oxygenation is increased.• Tools to assess is clinical assessment of baby• Transcutaneous pressure of oxygen(TCPO2), pulse oximeter , carbon dioxide monitor or blood gases. 93
  94. 94. INFANT RESPONSECARDIAC• CARDIAC STABILITY - blood flow is steady and sustained to the brain with oxygen when there is less variability of heart rate• Babies with episodes of bradycardia may not have bradycardia with Kangaroo Care• K.C. improves post-extubation cardiorespiratory parameters after open heart surgery continued 94
  95. 95. INFANT RESPONSES• Increased regular sleep• Increase states of alertness• Self-regulatory feeding: relax & feed,frequently repeat pattern, this aids insustained blood glucose levels• Early opportunity to learn suckling andbreathing coordinationThis can save calories thus better weight gain• Reduces pain score with painful procedure 95
  96. 96. 96
  97. 97. Long Term Benefits of KC forInfants- 1 year• Fewer infections at 6 & 12months• Less fussy/crying and more alert states• Infant in cribs cried 10 timesmore frequently than KC infants• Smiles more often at 3 months• Ahead in social, linguistic, fine/gross motor indices at 1 year 97
  98. 98. Long Term Benefits of KC forInfants- 3 year• Earlier urinary continence• Earlier stubbornness• In free play mothers & children were smiling & laughing more• Mothers more encouraging & instructingtowards childrenRef; (de Chateau & Weiberg, 1977a, 1977b, 1984) 98
  99. 99. Full Term Studies• Breastfeeding Difficulties - 2003 Anderson & Chiu Found 30 -90 minutes of KC before anticipated feeding increased latch-on Increased mothers perception of getting enough display of cues associated with breastfeedingThermal Regulation - Chiu et.al, 2005 and Durand et al, 1997• Infants breastfed in the KC position stay warm and are warmer that those breastfed while swaddled or in a cot (bed).• Exclusive Breastfeeding - Mikiel-Kostryra et al. 2002• KC promotes exclusive BF >20 minutes of KC is significant predictor of exclusive BF duration, the more KC they have, the longer the mother will exclusive BF. 99
  100. 100. FAMILIES WHO BENEFITFROM KANGAROO CARE• All families benefit from Kangaroo Care• Fathers & Support Persons• Teen Parents• Adoptive Families• Substance Abuse Mothers• Grandparents• Siblings 100
  101. 101. FAMILY CENTERED CARE• Earlier and increased bonding with mother• Earlier parental involvement with care ofthe baby• Parents become more “in tune” withtheir baby’s cues and responses• Increase in parents readiness to carefor infant 101
  102. 102. KANGAROO CARE ANDLACTATION BENEFITS• Skin to skin promotes hormone responsein mother to trigger increased milkproduction• Milk Ejection Reflex (MER) frequentlyoccurs in Kangaroo Care• Babies will find their way to the breast fora little “licking and loving”• Nuzzling at the breast progressing on tobreastfeeding 102
  103. 103. MATERNAL RESPONSES• Bonding to baby - aids in attachmentprocess for neonates that can already bedifficult to bond with.• Increased sense of comfort with parenting and caring for their baby at discharge.• Strongly identify with their infants and feltconfidence in meeting their infants needs• Reduces incidence of post partum depression (PPD) 103
  104. 104. 104
  105. 105. MATERNAL RESPONSES• Milk production - increased prolactinlevels with skin to skin• Milk ejection reflex (MER) - LetdownIncreased oxytocin levels• Mother more relaxed and confident• Lactation longevity 105
  106. 106. Benefits of Kangaroo Carefor Mothers• Enhanced maternal-infant attachment & bonding• Increased maternal self confidence• Increased maternal affectionate behavior• Enhanced relaxation• Experience less anxiety• Less breast engorgement• More rapid involution (uterus returning to pre- pregnant size) 106
  107. 107. Benefits of kangaroo care toinstitutions• Shorter hospital stay Advanced healthcare technology only used in addition to Kangaroo care• More parental involvement with greater opportunities for teaching and assessing• Better use of resources• Less morbidity and mortality especially in developing countries• Opportunities for teaching and during pregnancy and follow up in preparation of postnatal implementation• Less drain on financial resources• Promotion of total family health Benefits of Kangaroo care to community 107
  108. 108. KANGAROO CAREAND THE DYING BABY• For some families it can be comforting tohold their baby until death occurs.• This can provide the family with a sense of comfort and bonding that may not have been established due to the baby’s critical status.• Assists in the grieving process for thefamily. 108
  109. 109. Which babies are not able toKangaroo care• Unstable babies• Baby at risk for IVH• Baby with immature skin• Baby on vasopressor drugs• Babies with arterial lines• Prolonged or severe apnoea• Indwelling chest tubes• UAC,UVC or peripheral arterial lines• Severely jaundiced babies 109
  110. 110. Eligibility criteria: Baby• Birth weight >1800 gm:Start at birth• Birth weight 1200-1799 gm:Hemodynamically stable• Birth weight <1200 gm:Hemodynamically stable• Hemodynamic stability is a MUST 110
  111. 111. Preparing for KMCCounseling• Demonstrate procedure• Ensure family support• KMC support groupMother’s clothing• Front-open, light dress as per the local cultureBaby’s clothingCap, socks, nappy and front-open sleeveless shirt or ‘jhabala’ 111
  112. 112. Kangaroo care :Action• Discuss with parent. Some may feel reluctant or embarrassed• if so, consider kangaroo care with both dressed/ still providing skin to skin at the chest and baby’s cheek areas.• Document parental decision. 112
  113. 113. Requirements for KMCimplementation• TrainingNurses, physicians and other staff• Educational material: Information sheets, posters and video films on KMC• FurnitureSemi-reclining easy chairsBeds with adjustable back rest 113
  114. 114. How to do Kangaroo Care• Equipment• Prepare the environment, quiet, softlighting and relaxed.• Comfortable chair, preferably witharms, foot stool if desired.• Screens (optional)• Parent in opening shirt, Mother braless. 114
  115. 115. How to do Kangaroo Care• Baby needs a nappy on and a hat(optional)• Blanket for baby.• Provide cool drink for parent. 115
  116. 116. KMC procedure: Kangaroopositioning• Place baby between the mother’s breasts in an upright position• Head turned to one side and slightly extended• Hips flexed and abducted in a “frog” position; arms flexed• Baby’s abdomen at mother’s epigastrium• Support baby’s bottom 116
  117. 117. 117
  118. 118. Kangaroo Care : Action• Parent should support baby’s buttocksand back with hands, tucking limbs intoflexion.• Head and neck positioned to protectairway eg. not slumped, chin tucked sothat breathing is not compromised. 118
  119. 119. Kangaroo Care : Action• Provide and prepare equipment.• in addition face mask, oxygenand suction in case of accidentalextubation/collapse.• Take and record vital signs of baby and dress accordingly• Seat parent and place baby ontochest. 119
  120. 120. Kangaroo Care : Action• Cover baby with Parents shirt andplace blanket over.• Consider reclining chair for extracomfort or use of foot stool.• Record vital signs after 15 minutes,reposition ensuring parent and babycomfortable• If stable continue with usualobservations 120
  121. 121. Kangaroo Care : Action• Encourage parent to follow babiescues, if asleep encourage parent toallow baby to sleep.• Allow interactions if baby becomes more alert encouraging eye contact, talking and suckling at breast.• Remain available to offer support tofamily. 121
  122. 122. Kangaroo Care : Action• Feeding can take place duringKangaroo care.• Kangaroo care should be for as long as comfortable providing vital signs of baby are satisfactory from 20minutes to a few hours. 122
  123. 123. Duration of Kangaroo Mother Care• Start KMC sessions in the nursery• Practice one hour sessions initially• Transit from conventional care to longer KMC• Transfer baby to post-natal ward and continue KMC• Increase duration up to 24 hours a day 123
  124. 124. KMC during sleep andrestingResting• Reclining or semi-recumbent position• Adjustable bed• Several pillows on an ordinary bed• Easy reclining chairSleep• Supporting garment restraint for baby 124
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  127. 127. Discontinuation of KMC• Term gestation• Weight ~ 2500 gm• Baby uncomfortable• Wriggling out• Pulls limbs out• Cries and fusses• Mother can continue KMC after giving the baby a bath and during cold nights 127
  128. 128. National & InternationalEndorsementsKangaroo care has been endorsed asthe standard of care by:• American Academy of Pediatrics (AAP)• Academy of Breastfeeding Medicine• World Health Organization• Neonatal Resuscitation Program(American Heart Association & AAP) 128
  129. 129. Universal KC 129
  130. 130. References• Kangaroo care in full termKMC_term_table.pdf• Kangaroo Care in preterm KMC_table.pdf• KMC practical guide kmc_practical_guide.pdf• KMC Manual KMC Partici Manual_Complete.pdf• Guidelines for Infant Development inthe Newborn Nursery. Inga Warren 2001.Holding your baby close: Kangaroocare.• www.MarchofDimes.com/prematurity• Overcoming Emotional Barriers to Kangaroo Care Step by Step guide.• Bliss in association with JNN. 2004 (www.Bliss.org.uk) 130
  131. 131. References• Bergman NJ, Linley LL, Fawcus SR. Randomized controlled trial of maternal-infant skin-to-skin contact from birth versus conventional incubator for physiological stabilization in 1200g to 2199g newborns. Acta Paediatr 2004; 93: 779-785. Stockholm. ISSN 0803-5253• Kangaroo care compared to incubators in maintaining body warmth in preterm infants. Ludington-Hoe,S.M.,Nguyen, N., Swinth,J.Y, Satyrshur,RD. Biol Res Nurs2(1):60-73. 2000.• Infant Holding policies and practices in neonatal units. Neonatal network 21 (2):13-20.Franck, L.S.,Bernal,H., Gale,G 2002. 131
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  133. 133. Bibliography• Anderson G (1986)Kangaroo care forpremature infants.American Journalof Nursing July pg 807-809• Gale G.,Franck L.,Lund (1993)Skin toSkin (Kangaroo) Holding of theintubated Premature Infant neonatalNetwork Vol 12 No 6 pg49-57 133
  134. 134. Kangaroo Position :• maternal infant skin-to-skin contact• between the baby front and the mothers chest. The more skin-to-skin, the better. For comfort a small nappy is fine, and for warmth a cap may be used.• should ideally start at birth, but is helpful at any time.• It should ideally be continuous day and night, but even shorter periods are still helpful. 134
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  136. 136. Baby friendly hospital initiatives 136
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