POCKET BABIES
Kangaroo care not only improves the survival and health of premature and low-birth-weight infants but establishes a more solid bond between parent and child
By Jin Paul de Guzman
This is hardly the age of touching: a growing number of relationships can be defined more by physical distance than closeness; the possibility of transmitting disease has strained communal prayer rituals (illustrated recently by SARS forcing most churches to discourage the faithful from joining hands in prayer); "touching" as a description of matters that encourage compassion has been reduced to triteness. Few situations are left that allow this word to inhabit both its literal and figurative senses without being total schlock.
Therefore it may come as a slight surprise that the world of medicine-often perceived as distant, objective, and coolly impersonal-has been rediscovering the value of touch in healing.
Neonatologist John Chan is one of the more avid advocates of the value of both literal and figurative touching, especially in these "high-tech but low touch" times. In a lecture he delivered before the Society of Pediatric Critical Care Medicine-Philippines, he put it succinctly: "Do not just touch the patients; touch their lives!"
What's surprising about compassionate touch is that there is growing scientific evidence to back up its claims to healing. Touch and massage therapies have been shown to improve the health and development of all infants, especially preemies. Chan said: "Infant massage improves communication skills, enhances body awareness, and leads to better development. It relaxes the baby and releases stress, and improves muscle coordination, as well as the hormonal and digestive functions. The circulation, respiration, the sense of well-being, and sleep patterns are affected. The baby experiences soothing quality time, gains more weight, sleeps better, responds better to social stimulation, and develops a healthy body. It also fosters a sense of love, acceptance, respect, trust, and self-esteem."
But there is a variation on touch therapy and infant massage that is starting to change neonatal care all over the world, not only in improving the survival and health of premature and low-birth-weight (LBW) infants but in establishing a more solid bond between parent and infant-kangaroo care.
Embrace
As the old chestnut goes, necessity is the mother of invention. And as in other situations where people and institutions struggle with limited resources, kangaroo mother care (KMC) came about as solution to crowding in neonatal intensive care units and nurseries.
Started in 1979 in Santa Fé de Bogotá, Colombia, KMC considered using mothers as their own babies' incubator. The method Drs. Édgar Rey Sanabria and Héctor Martínez Gómez initially employed involved the following: Small neonates (about 1,000 grams), once clinically stable and in no need of mechanical breathing support, were brought to the mothers. For six to eight hours, the mothers had to ensure that they had skin-to-skin contact with their babies-they had to keep their babies in a semivertical position, wearing only their diapers, inside the paja (a large piece of cloth that functions as the upper garment) they wore. The babies must also be breastfed.
The mothers and babies were discharged-with advice on the necessity of consistent follow-up-once the babies could suck, swallow, and breathe effectively, even if the babies hadn't achieved their ideal weight or gestational age.
The results were very positive: survival rates increased, hospital infections decreased, lactation improved. Weight gain, though slow, did happen. Expenses-both for the families and the hospital-dropped significantly. In addition, none of the mothers in the program abandoned their babies.
However, the rest of the world only started to pay attention to this method in the 1990s, when the first few major studies appeared in international scientific publications.
The Pinoy Experience
It is no joke for a mother to keep a fragile infant close to her breast for hours, days, weeks on end. Then again, there's nothing jokey about parenthood in the first place. In the Philippines there seems to be a big need for KMC -infant mortality at 19.7 per 1,000 is still very high; premature births rate high at six to 15 percent; more than 223,000 Filipino babies are born with birth weights severely wanting every year.
And so in 1999, with an educational grant coming from the Kangaroo Mother Care Foundation-an international network supported by different nongovernment organizations and such agencies as the World Health Organization and the United Nations Children's Fund-two Filipinos went to Colombia to undergo training on KMC. One of these was neonatologist Socorro de Leon-Mendoza of the Dr. Jose Fabella Memorial Hospital. The idea was that the foundation would train two representatives from every country, and these representatives would then take charge of training others in their area. So far more than 40 countries have sent representatives to train in Colombia.
"Our task to disseminate [information on KMC] was not funded anymore," says Mendoza. However, she explains that funding is not so big an issue as in other projects. How could it, when it actually aims to significantly cut down cost? And so after some preparation-which included convincing obstetricians to participate, setting up the needed space, and training personnel-the Dr. Fabella Memorial Hospital Kangaroo Care Unit opened in August 1999.
Daily Miracles
In the traditional setting, the LBW baby is usually not allowed to get out of the incubator until it is about four pounds. With KMC, the LBW, even if it were only 2.5 or three pounds, is left to the care of the mother (under the supervision of the KMC staff) as long as the baby has no problems with breathing or swallowing, or the mother has no health problems. "For this program the baby grows with the mother in the ward," Mendoza says. "For many mothers it's a new experience: many mothers are not easily adjusted to the method.
Marami diyan reluctant pa nga e, they will not hold their tiny babies."
Once the mothers get the hang of KMC, the babies are monitored for overall improvements in health. The results are often positive. For example, there is strong evidence showing the high rate of survivability of infants, regardless of weight, in KMC. In other studies, babies once in the KMC setting have significantly higher temperatures and better behavior scores, even if heart and respiratory rates are not significantly different. Breastfeeding rates are also significantly improved. "Kung tutuusin, the LBW [babies] are the least breastfed," Mendoza says. "Commonly they are separated from their mothers, isolated [in the NICU], so the mother loses touch with the baby; the bonding process is not established."
As mentioned earlier, weight is hardly an issue for babies to be sent home. But some more things need to be done before discharge: some days before discharge, the father, or any other relative, is called in to do some training on how it feels like to be a kangaroo. "So far, even if we have 40 percent single mothers, the fathers of the babies come and we train them to hold the baby…Our nurses 'grade' them before assuring them they're OK to go home. That is part of the SOP."
Which is, to say the least, a clever way to force traditionally uninvolved males in parenting. "There is resistance, reluctance, but realizing that we cannot send them home unless they assure us that they are capable of holding their baby [properly], then eventually they give in," Mendoza says.
Regular follow-ups are a must, if only to "assure ourselves that discharging them early did not compromise their health and their life." Also, the first few months after discharge are crucial, since the change in environment may lead to further weight loss. At first the KMC Unit recommended daily follow-ups; however, that was "not feasible in our setup." So follow-up schedules were trimmed down to three days, then two days, during the first month. Follow-up becomes weekly, until the baby reaches full-term size, or full-term gestation. Then follow-up becomes monthly, until the baby's first birthday.
But follow-up rates fall dramatically by the third month after discharge. Even if breastfeeding rates in those who underwent KMC are significantly higher than normal (75 percent of babies in KMC are breastfed even after three months of discharge, as opposed to the 45-percent national breastfeeding rate in the first week of life alone), even if fewer babies were abandoned, even if the risk of death is significantly diminished-follow-up rates drop. In a paper Mendoza delivered at the Fourth International Workshop on Kangaroo Mother Care November last year in Cape Town, South Africa, follow-up plummeted to nearly 50 percent by the third month. Among the reasons were larger mean birth weight, older age of gestation, lower level of maternal education, larger mean weight upon discharge, and the distance that must be traveled just to follow up. It is after all a practical concern: why follow up at a tertiary hospital when the health center is there? Or why leave home when you can't afford it?
Midwife Power
And so four years after the establishment of the center, Mendoza and the rest of the Fabella KMC team trained an initial 32 midwives from local health centers all over the city of Manila last June. This August, the municipal health officers will undergo training. The KMC Program then, Mendoza says, has become "an instrument in the networking process in an effort to improve perinatal and neonatal care."
"While we have already improved our own inpatient population," she continues, "and have seen how this program improves outcomes considerably-and less cost for the hospital, since we don't keep them as long anymore-we have to make sure that our follow-ups are consistent through the local health centers. We'd like to see them back, pero we will give them the option [of going to the local health center] once the people in the health center are capable of handling them."
Only 31 percent of births are assisted by doctors; midwives assist 25 percent of births. All the others are seen by the traditional birth attendant or
hilot. This means 66 percent of babies are delivered outside the hospital, and sometimes, they are born in "less than ideal situations," and there may be a large chunk of the LBW population being left out. So by training health center-based Manila midwives-who Mendoza says really man the health centers, and they are "the ones who know 'yung mga hilot na nagpapaanak; they know their district much better than the Manila health officers, no offense meant"-the LBW babies and all other possibly problematic pregnancies will be better monitored.
The program hopes that the network will be operational by 2004, where Fabella's LBW graduates may choose to follow up at their local health centers. In addition, risky pregnancies and low-weight neonates may easily be referred to the Fabella KMC Unit. Once done, the training of other health facilities will follow, and then institutions outside Manila.
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