Kangaroo Mother Care 20 Years Later: Connecting Infants and Families

Kangaroo mother care (KMC), developed in Bogota, Columbia in the 1970s, was considered an innovative and daring practice at the time. Dr Nathalie Charpak and several colleagues introduced the world to a new way of caring for low birth weight infants: In comparison with the usual cautious practice of incubator nursing with severely restricted parental access and discharge only when a weight of 1700 g was attained, KMC involved “strapping the baby upright to the mother's chest in skin-to-skin contact, frequent [exclusive or nearly exclusive] breast feeding, formula supplements if weight gain did not exceed 20 g/day, and early discharge.”¹ What now seems a usual intervention was at the time a revolution in newborn care. These scientist–clinicians courageously tested their new method in an observational cohort study² and a randomized controlled trial,³ documenting equivalent survival among infants in the KMC and traditional care groups, thus demonstrating the safety of KMC to skeptics around the world.

Since then, KMC in its original and newer flavors has been integrated into the mainstream of newborn care. A 2016 Cochrane review examined 21 studies including 3042 infants and concluded that KMC for (stabilized) low birth weight infants in low-resource settings was preferable to conventional neonatal care, with lower risk of death and severe infection and higher rates of breastfeeding at term postmenstrual age or discharge from the hospital.⁴ Variations of KMC involving briefer periods of infant holding by the mother or father, appropriately called skin-to-skin care (SSC), are practiced in birthing hospitals in high-, low-, and middle-income countries in support of the Baby Friendly Hospital Initiative Step 4 (“help mothers initiate breastfeeding within one hour of birth”). By placing babies in SSC with their mother immediately after birth, “baby crawl” is facilitated (http://www.breastcrawl.org/video.shtml), mothers can learn early feeding cues, and breastfeeding outcomes are improved.⁵ Paternal KMC and SSC offer a wealth of benefits too.^6,7 Despite technical obstacles, provider concern, and infant fragility, SSC is being practiced cautiously in NICUs in high-income countries, even with ventilator-dependent infants, because it can promote parental attachment, decrease stress, and increase breast milk volumes.^8–11 KMC clearly makes the world a better place for babies and families.

Some 20 years after the original KMC randomized controlled trial, Dr Charpak et al⁷ systematically recontacted, reenrolled, and examined the (now) young adults who were infants in the original study, and present to readers of Pediatrics the results of extensive psychological testing comparing their outcomes. Certainly there is good precedent for examining the long-term impact of neonatal care on young adult outcomes of preterm infants.¹² But the challenges of this specific KMC-based research are several. First, KMC is a “bundled intervention” in which parental nurturing, nearly exclusive breastfeeding, and SSC may have individual, synergistic, and overlapping contributions to the studied outcomes. Second, it is difficult to quantify and qualify parent-associated and parent-delivered interventions because all parents are different. Third, we are a full 20 years out, and “life has happened,” so numerous potentially unmeasured contributions to each individual child’s life (and outcomes) have occurred. Demonstrating these very challenges, in a seminal 10-year cohort follow-up study that compared preterm infants who received 1 hour of SSC daily for 14 days versus traditional care, the results were not straightforward. Although there was a positive impact on executive function and mother–child reciprocity predicted by SSC, other factors may also have contributed, including maternal–child attachment and neonatal respiratory sinus arrhythmia.¹³ Similarly, in their current study Charpak et al identify significantly reduced school absenteeism, a more optimal home environment (as best can be measured), and clinically meaningful reduced hyperactivity, aggressiveness, and externalization in the KMC group at 20 years. Yet the authors are pressed to explain the significantly higher math and language academic scores in the traditional care group. In other words, it is complicated.

Important efforts are ongoing to examine the impact of neonatal events and interventions not traditionally considered medical, which may help explain major outcome differences between infants. For example, untreated pain or stressful events such as procedures may actually lead to localized changes in brain structure and function in premature infants.^14,15 Human milk, just 1 piece of the KMC puzzle, may be an even more powerful and beneficial intervention for both full-term and preterm infants than we have ever realized, with both short- and long-term brain effects.^15–17 KMC straddles the great divide between the medical and nonmedical, and between the parent and the professional. Bridging that divide and continuing to assess the impact of intervention, as Dr Nathalie Charpak and colleagues have worked so long to do, brings us closer to optimal care for every infant and family.

• Copyright © 2017 by the American Academy of Pediatrics