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Kangaroo Care: A Different Way of Nurturing Preterm Babies

Colombian-Canadian collaboration changing the world's thinking about preterm care

It began more than three decades ago in Bogotá, Colombia. In the late 1970s, an incubator shortage at a hospital in the city had led to outbreaks of infection from double-bunking preterm and low-birth-weight babies. In response, Colombian pediatrician Dr. Edgar Rey Sanabria introduced a new practice called Kangaroo Mother Care (KMC), in which the tiny newborn is carried under the clothing and between the breasts of the mother in continuous skin-to-skin contact.

Today, KMC is an emerging global trend in caring for preterm and low-birth-weight babies. The World Health Organization (WHO) first endorsed KMC in 2003, calling it “an effective way to meet baby’s needs for warmth, breastfeeding, protection from infection, stimulation, safety and love.”¹ In May 2012, WHO published Born Too Soon: The Global Action Report on Preterm Birth² that strongly recommended KMC. The report cited a systematic review³ of several randomized controlled trials that linked KMC to a 51% reduction in neonatal mortality for stable babies weighing less than 2,000 grams compared to incubator care.

WHO also pointed to a recently updated review by the Cochrane Collaboration, the world’s leading independent assessor of medical interventions, that reported a 40% reduction in risk of post-discharge mortality, about a 60% reduction in neonatal infections and an almost 80% reduction in hypothermia.⁴

Canadian researcher Dr. Réjean Tessier of Laval University, working in close partnership with the Colombian research team, has played a key role in building the body of research evidence to support KMC as a viable practice for the delivery of neonatal health care services around the world.

Dr. Tessier’s involvement in KMC dates back to the early 1990s when he travelled to Colombia to work with Dr. Nathalie Charpak, a Bogotá pediatrician/researcher and the world’s leading proponent of KMC. Her work builds on Dr. Sanabria’s innovative response to his hospital’s incubator shortage and double-bunking infection outbreak.

Dr. Charpak understood that widespread adoption of KMC would require research evidence to demonstrate the benefits to preterms’ physical health. As part of the efforts to build evidence, she also wanted to assess the effects of KMC on babies’ mental health and mother-child bonding.

Preterm babies typically have cognitive deficits. These are initially caused by the disturbance in brain maturation from leaving the womb early and exacerbated by a stressful neonatal environment in which they are separated from their mothers and placed in sterile, light-filled, sometimes noisy surroundings.

“We decided to evaluate, scientifically with rigour, the KMC intervention,” says Dr. Charpak. “So I contacted three professors around the world and they all answered me, but Dr. Tessier came to Bogotá. We designed the psychology component of the study together and began a collaboration, doing different studies and working on different aspects of KMC.”

According to Dr. Tessier, the question was a simple one: “Can we do something for these preterm babies? With incubators, we help the children to survive, but there’s nothing done for the brain.”

Evidence in Action: KMC in use in 30 countries

More than 30 countries have taken up KMC, buoyed by clinical trials conducted by Dr. Tessier and the Colombian team that have proven the efficacy of the intervention in providing “brain care” for preterm babies who are at risk for cognitive deficits.

In 2003, Dr. Tessier and the Colombian team published a paper showing firm evidence that KMC provides “brain care” during this highly sensitive period of the preterm infant’s neurological development.⁵ They were able to demonstrate that at 12 months, KMC infants had higher IQ scores than those given conventional care.

Dr. Tessier’s CIHR-funded longitudinal studies suggest the “brain benefits” of KMC stand preterms in good stead well into their teenage years. His most recent paper, co-authored with his Laval colleague Dr. Cyril Schneider and the Colombian team, and accepted for publication by Acta Paediatrica, confirms “the positive impact of KMC on brain circuits and synaptic efficacy up to adolescence” based on evaluation of preterms at age 15.

“Essentially, we stimulated the brain on one side and observed the length of time to get a response on the hand of the other side,” he explains. “The preterms who were carried in the kangaroo position had a much quicker response. It was comparable to full-term children. This is a very big thing because we have long known that being born premature has negative consequences in terms of poorer cognitive function, academic performance and ability to sustain attention.”

KMC also strengthens what Dr. Tessier calls “the attachment relationship” between the parents (fathers can take turns doing the carrying) and their baby. Without KMC, says Dr. Tessier, “developing attachments can be more difficult. It’s often hard to understand what the child needs. The baby’s cues are not that clear. They cry and their parents don’t know why. It becomes difficult to create positive interactions.”

The skin-to-skin contact in the kangaroo-carrying position tends to calm the child, strengthening the “bonding effect” and, because they have a direct role in caring for their baby, giving the parents a sense of connection and empowerment.⁶

Dr. Charpak, who heads the Kangaroo Foundation, credits Dr. Tessier with providing a critical piece of research evidence required to begin convincing neonatal units around the world to take up KMC.

“More than 30 countries have trained with the Kangaroo Foundation in Bogotá and are now using KMC. We are doing it in Chile, in Africa and India and Vietnam. It’s mostly developing countries, but you can go to the Nordic countries – Sweden, Denmark and Finland – and they are doing KMC. It’s not easy to change; medical/nursing practice professionals are very conservative. You have to demonstrate that this is the right thing. Dr. Tessier has been working on that for 20 years and is one of the main actors in the evaluation and diffusion of KMC.”

Dr. Tessier knows first-hand how difficult it can be to effect change in clinical practice – especially when it means introducing a low-tech intervention in a high-tech environment. While he has successfully spearheaded the implementation of KMC at the neonatal intensive care unit of the Centre hospitalier de l’Université Laval, it took more than a decade. “When I first suggested that we start this program they said, ‘No, why do that? We already save the children. We don’t need anything else.’ We are very careful in our country not to do something that is not supported by the official academics.”

“It has been described as the choice of poor countries, designed to help the babies of developing countries survive. So it’s taken a long time for people to consider that this is something that may be effective in northern, developed countries.” – Dr. Réjean Tessier

Since implementation in January, more than 100 preterm babies have been cared for with KMC, says Dr. Tessier. The plan, he says, is that all preterms will receive KMC once the hospital has all the equipment – essentially new chairs and beds to accommodate parents – in place.

As well, Dr. Tessier is working with Dr. Charpak and other colleagues on a new project, funded by the Bill and Melinda Gates Foundation with CIHR collaboration, to do a full physiological and psychological work-up on the 400 children they began studying in the early 1990s in Bogotá. The aim is to see if the benefits of KMC carry on into adulthood.

Nurses become educators with Kangaroo model

Because KMC boosts the role of parents in providing “hands on” care for their preterm babies, it also changes the role of neonatal nurses.

“There has been some resistance from nurses, who see responsibility taken away from them,” says Dr. Tessier. “In the long run, though, nurses change their minds. They become more teachers to the parents than being responsible for all the care.”

1. WHO Department of Reproductive Health and Research. Kangaroo Mother Care: A practical guide, 2003.
2. March of Dimes, Partnership for Maternal, Newborn & Child Health, Save the Children, WHO. Born Too Soon: The Global Action Report on Preterm Birth, 2012.
3. Lawn et al. ‘Kangaroo mother care’ to prevent neonatal deaths due to preterm birth complications, International Journal of Epidemiology 39 (Suppl 1) (April 2010): i144–i154.
4. Conde-Agudelo et al. Kangaroo mother care to reduce morbidity and mortality in low birthweight infants. Cochrane Database of Systematic Reviews (2011): doi: 10.1002/14651858.CD002771.pub2.
5. Tessier et al. Kangaroo Mother Care: A method for protecting high-risk low-birth-weight and premature infants against developmental delay. Infant Behavior & Development 26, 3 (August 2003): 384–397.
6. Tessier et al. Kangaroo Mother Care and the Bonding Hypothesis. Pediatrics 102, 2 (August 1998): e17.