Global health
BMJ Case Rep: first published as 10.1136/bcr-2018-228402 on 9 December 2019. Downloaded from http://casereports.bmj.com/ on December 19, 2019 at Royal Free Hospital Pharmacy
1
Obstetrics and Gynaecology,
Services Institute of Medical
Sciences, Lahore, Pakistan
2
Obstetrics and Gynaecology,
Hameed Latif Hospital, Lahore,
Pakistan
3
Paediatrics, Services Institute
of Medical Sciences, Lahore,
Pakistan
Correspondence to
Professor Rubina Sohail;
​rubina95@​gmail.​com
Accepted 31 October 2019
© BMJ Publishing Group
Limited 2019. No commercial
re-­use. See rights and
permissions. Published by BMJ.
To cite: Sohail R, Rasul N,
Naeem A, et al. BMJ Case
Rep 2019;12:e228402.
doi:10.1136/bcr-2018-
228402
Case report
Kangaroo mother care: need of the day
Rubina Sohail,1,2 Noreen Rasul,1 Ammara Naeem,3 Humayun Iqbal Khan3
SUMMARY
Each year approximately 20 million low birthweight
babies are born globally. Prematurity is a leading cause
of neonatal mortality in developing countries and results
in 60%–80% of neonatal deaths. Neonatal mortality is
the major contributor to under-5 mortality. According to
Pakistan Demographic and Health Survey 2017–2018,
neonatal mortality in Pakistan is 42 per 1000 live births
and under-5 mortality is 74 per 1000 live births. One
out of every 22 newborns dies in Pakistan, which is an
alarming figure. Majority of these deaths are preventable.
They can be prevented by well-­trained midwives, safe
delivery, early initiation of breast feeding within an
hour after birth and skin-­to-­skin contact. Pakistan is
among the top 10 countries with the highest number
of preterm births and with limited resources to manage
the burden. Kangaroo mother care (KMC) is a safe
and economical alternative to provide preterm care in
developing countries. In babies at gestational age less
than 37 weeks or with neonatal weight less than 2.5 kg,
skin-­to-­skin contact prevents hypothermia and infection.
Neonatal mortality and morbidity can be reduced by
providing preterm care through KMC. This case report
is of a preterm baby who was delivered at 33 weeks
of gestation with a weight of 1.3 kg and was saved by
KMC in the paediatric department of Services Hospital in
Lahore.
Background
The first 28 days of life of a neonate is the most
crucial period for child survival, and in low birth-
weight babies (including both preterm and intra-
uterine growth retardation) this is exacerbated due
to insufficient reserves and immature systems.1 In
low birthweight babies temperature regulation
is difficult due to immature hypothalamus and
limited brown fat, underdeveloped organs (espe-
cially lungs and intestine, leading to respiratory
distress syndrome and necrotising enterocolitis),
immature immune function and increased suscepti-
bility to severe infections, making them vulnerable
to problems associated with the transition to extra-
uterine life.2 Globally, the risk of dying in the first
28 days after birth is 19 deaths per 1000 live births
(UNICEF 20183). The rate of neonatal mortality
globally decreased from 37 per 1000 live births in
1990 to 19 per 1000 live births in 2016, but this is
a slow decline as compared with under-5 mortality.
There are disparities in data all over the world, but
prematurity remains a leading cause of neonatal
mortality.4
Of all early neonatal deaths that are not related to
congenital malformations, 28% are due to preterm
Sohail R, et al. BMJ Case Rep 2019;12:e228402. doi:10.1136/bcr-2018-228402
birth.5 These morbidities directly affect their fami-
lies. Around 7% of global neonatal deaths occur in
Pakistan, most of which are due to prematurity and
its complications.6 Most of preterm births occur in
developing countries.7 Newborn health has become
a global and national public health priority, with
attention given to child survival in the Millennium
Development Goals.8 Newborn survival is a sensi-
tive index in any health system.
Preterm birth is also responsible for loss of
human potential by increasing neonatal morbidity.9
Many preterm babies who are saved by interven-
tions develop significant morbidity, including
neurodevelopment delay, learning deficiencies,
visual disorders and long-­term health problems.10
These morbidities directly affect their families. Care
of low birthweight babies is expensive and requires
specialised units. Effective interventions and
Dept. Protected by copyright.
modern technology are limited in developing coun-
tries, and there is shortage of skilled staff and incu-
bators. Kangaroo mother care (KMC) is an effective
and safe substitute to incubators in preterm infants
and was first introduced by Rey and Martinez in
1978 in Bogota, Colombia.11 The components of
KMC are skin-­ to-­skin contact, exclusive breast
feeding and early discharge. KMC also improves
maternal bonding and decreases the risk of noso-
comial and respiratory tract infections and hypo-
thermia.12 It also helps in the improvement of sleep
pattern and in the relief of colic.13
KMC is a cost-­ effective strategy to improve
newborn survival. The KMC project was started in
Services Hospital in Lahore in August 2016, both in
the paediatric and gynaecology departments. Since
then many babies have been saved. KMC improved
neonatal outcome and decreased the burden on
medical staff.
Case presentation
This is a case report of a baby girl delivered at 33
weeks of gestation with a birth weight of 1.3 kg.
She is one of the triplets, with her two siblings
weighing 600 g and 1100 g. All of them were trans-
ferred to the neonatal intensive care unit (NICU).
Her two siblings expired in NICU due to respira-
tory distress syndrome, while the baby girl weighing
1.3 kg survived. The baby was managed in NICU
for 4 days, where she was kept in the incubator and
on intravenous fluids. She was active with good
neonatal reflexes, but sucking was not well devel-
oped. The baby remained oxygen-­ dependent for
2 days, following which the oxygen was tapered off.
On initial investigations, haemoglobin was 155 g/L,
total leucocyte count was 9.5×103 µL and platelet
count was 320×109/L.14 Nasogastric feeding was
1
 Global health
Figure 1  The baby is transferred to the kangaroo mother care ward.
started on the second day. Repeat investigations after 48 hours
revealed C reactive protein was 79.6 U/mL, haemoglobin was
135 g/L, total leucocyte count was 16.7 µL and platelet count was
216×109/L. There was no growth on blood culture. However,
taking into consideration the high C reaction protein, antibiotics
were started. On day 4, the baby was stable; however, her weight
had reduced from 1.3 kg to 1.13 kg. As the baby was stable, she
was transferred to the KMC unit (figure 1), where breast feeding
was started and she was kept in continuous skin-­to-­skin contact
with her mother (at least 20 hours a day). Room temperature was
kept at 25°C–28°C to prevent hypothermia and her temperature
was maintained at 37°C. The couple and the family were coun-
selled about the benefits of KMC and its components including
breast feeding, hospital stay, criteria for discharge and follow-­up.
On day 5, the baby developed jaundice and her serum total
bilirubin was 14.3  mg/dL, during which phototherapy was
started in KMC position. During phototherapy, the baby was
kept in skin-­to-­skin contact with her mother. One day later,
her bilirubin level dropped to 12.8 mg/dL, and 2 days later the
level further reduced to 9.5 mg/dL. Phototherapy was discon-
tinued. Gradually the mother feed was increased with tapering
of nasogastric feed. During stay in the KMC unit, feeding and
temperature were monitored 2 hourly and her weight gain was
monitored daily. The mother was taught proper hand-­washing
technique and was advised to clean hands before touching the
baby and before and after every feed. Chlorhexidine gel was
applied to the site of the umbilical cord.
The baby was monitored by weekly measurement of head
circumference and length to assess growth. On day 15, the baby
was breast feeding every 2 hours for 20 min and she had gained
weight to 1.5 kg. The criteria for discharge from the KMC
2 Sohail R, et al. BMJ Case Rep 2019;12:e228402. doi:10.1136/bcr-2018-228402
BMJ Case Rep: first published as 10.1136/bcr-2018-228402 on 9 December 2019. Downloaded from http://casereports.bmj.com/ on December 19, 2019 at Royal Free Hospital Pharmacy
Dept. Protected by copyright.
Figure 2  The baby is discharged from the kangaroo mother care
ward.
unit were fulfilled, and counselling of the mother and family
members was done to highlight the importance of continuing
KMC at home. The mother had strong family support. The
family members were encouraged to support the mother by
keeping the baby in skin-­to-­skin contact with themselves for
some time to provide opportunity for the mother to rest. The
mother and the baby were discharged in a satisfactory condition
(figure 2). The mother was advised exclusive breast feeding and
skin-­to-­skin contact until her expected date of delivery, which
was at 40 weeks, and to maintain regular follow-­up.
The family lived in another province (Sindh) which was far, so
they decided to stay in Lahore for 3 months to ensure follow-­up.
The follow-­ up plan was at 1 week, 1 month, 3 months and
6 months. At each follow-­up, weight, length, temperature, head
circumference, feeding status and general condition of the baby
were evaluated. At 5 weeks postdischarge, skin-­to-­skin contact
was stopped; the mother, however, continued to exclusively
breast feed the baby. After 6 weeks eye examination was done
by an ophthalmologist to rule out retinopathy of prematurity. At
3 months, hearing assessment and consultation by a neurologist
for neurodevelopment were done. At 3 months the weight of the
baby increased to 3.8 kg and the baby was doing well. There-
after, the family went home to Sindh, and since then have main-
tained telephonic follow-­up. The progress has been satisfactory.
At 6 months of age, the baby’s weight was 5.8 kg and there were
no issues (figure 3).

Figure 3  Follow-­up at 6 months.
Global health problem list
►► Prematurity can lead to problems such as hypothermia,
hypoglycaemia and infections.
►► Problems in incubators and admissions to neonatal units can
lead to decreased bonding between the baby and the mother,
delayed initiation of breast feeding, problems in temperature
regulation and infection.
Global health problem analysis
KMC is the care of newborns through continuous skin-­ to-­
skin contact to provide a thermo-­neutral environment to the
baby, done as a substitute to incubators. According to litera-
ture, thermal care can be provided through continuous skin-­
to-­skin contact between the mother and her baby using a cloth
or a binder to tie the baby with her in order to keep the baby
warm and provide opportunity for exclusive breast feeding. The
earliest report was published and results were shared in 1981 in
Spanish and the term kangaroo mother care was used here for
the first time. This term got the attention of 30 international
researchers at a meeting convened by Dr Adriano Cattaneo and
colleagues15 in November 1996 in Trieste, Italy, together with
the WHO. Since then it has been practised in various countries.
KMC was basically designed for developing and low-­income
countries. Recently, there has been a lot of emphasis on reducing
neonatal mortality in developing as well as developed countries.
Every 2 years, KMC workshops are conducted worldwide, and
currently it is practised in various countries in America, Africa
and Asia.
A meta-­analysis was conducted in 2010 where 15 studies were
included, and it was concluded that KMC is associated with
Sohail R, et al. BMJ Case Rep 2019;12:e228402. doi:10.1136/bcr-2018-228402
Global health
BMJ Case Rep: first published as 10.1136/bcr-2018-228402 on 9 December 2019. Downloaded from http://casereports.bmj.com/ on December 19, 2019 at Royal Free Hospital Pharmacy
up to 51% reduction in cause-­specific mortality.16 According
to the latest recommendation of WHO, KMC is one of the
cost-­effective strategies to reduce preterm mortality, globally.
Evidence of this recommendation is derived from multiple
based studies from different middle-­
facility-­ income to low-­
income countries.17 Ongoing research and observational studies
are assessing the effective use of this method in situations where
neonatal intensive care units and referrals are not available.
Acceptance of KMC is increasing worldwide due to its effective-
ness. Continuous skin-­to-­skin contact for 20 hours or more is
recommended. It can be practised by the mother, the father or
other relatives. Mothers are advised to keep the baby in contin-
uous skin-­to-­skin contact except when changing nappy or when
they want to go to the washroom. She can sleep or take rest from
KMC in a reclined or semirecumbent position, 44° horizontally.
Thermoregulation is a critical factor in newborn survival, as
30%–90% of sick children admitted to NICUs in hospitals of
developing countries experience hypothermia.18 19 According
to WHO hypothermia is defined as a core body temperature
less than 36.5°C. Another study favoured the previous results
showing that 89% of preterm babies admitted to NICU in
Nigeria experienced hypothermia.19 20 Babies with hypothermia
are at increased risk of dying due to complications such as intra-
ventricular haemorrhage, respiratory distress, hypoglycaemia,
coagulopathy and metabolic acidosis. Hypothermia increases the
risk of neonatal death to more than three times the normal.20 21
Previously incubators were used to maintain body temperature
Dept. Protected by copyright.
of preterm babies. In low-­income and middle-­income countries,
there is limited availability of incubators, which are expensive
and difficult to maintain. The infection rates are also high due
to overcrowding and reduced breastfeeding rates. Therefore, it
is recommended that mothers can also help in thermoregulation.
Evidence supports that infants who are nursed with KMC opti-
mise their body temperature more efficiently (Kangaroo Mother
Care Implementation Guide 2012).22 23 Studies have shown that
infants nursed with KMC showed almost no fluctuation in body
temperature, compared with babies treated in incubators, who
have multiple fluctuations in body temperature.
KMC has significant positive psychological effects on the baby
as well as the mother, and improves newborn bonding. With the
baby being in close proximity to the mother, skin-­to-­skin contact
proves to be an effective method that prevents distress routinely
experienced in a busy preterm infant unit. KMC also improves
physiological parameters, including heart rate, respiratory rate
and oxygen saturation.21 24 It was observed that, following KMC
sessions, the mean increase in body temperature was about 0.4°C,
respiratory rate improved by 3 breaths per minute, heart rate by
5 beats per minute and oxygen saturation by 5%. The results
of this study strengthen the belief that apart from improving
weight gain KMC also helps in stabilising the babies. KMC also
has psychological and other physiological impacts.
KMC aims to provide newborns the basic tools for survival,
including the mother’s warmth, nutrition, protection and love.
KMC can also play an important role in the promotion of breast
feeding and can improve newborn survival. Multiple studies have
proved that KMC is associated with improved rates of breast
feeding. According to one study, KMC was associated with 4.1
times increase in breastfeeding rate.24 25 Further studies exam-
ining breastfeeding outcomes showed that daily volume of milk
for babies managed by KMC was 640 mL vs 400 mL for babies
managed in incubators.26 Expressed breast milk can also be given
by alternate methods including cup, spoon and nasogastric tube.
KMC has general benefits for the mother, baby, family and
health system. Benefits to mothers include early bonding, early
3
 Global health

BMJ Case Rep: first published as 10.1136/bcr-2018-228402 on 9 December 2019. Downloaded from http://casereports.bmj.com/ on December 19, 2019 at Royal Free Hospital Pharmacy
exclusive breast feeding, more confidence and less depression.
Table 1  Outcome of KMC babies admitted in hospital
As mentioned previously, babies also benefit in the form of
maintenance of body temperature at a minimum energy expen- Preterm KMC babies n=82 %
diture, stabilisation of heart rate and respiratory rate, early and Discharged 81 98.7
exclusive breast feeding, and reduced risk of infections.24 For Expired 1 1.3
the family there is increased involvement and increased equity in KMC, kangaroo mother care.
child healthcare. On the part of the paediatric staff and nursery,
there are shorter stays and less burden. There is also reduced
requirement for staff, and hence reduced burden on the health
Table 2  Duration of hospital stay of KMC babies
system. There is no need for additional resources, so a major
health problem can be solved by minimum resources. In a similar Duration of stay in hospital (days) Neonates (n)
fashion, in Kenya, KMC was implemented in 2016, where the 1–3 12
average reduction in mortality was 52%. No extra staff were 3–7 56
recruited, and only training and basic materials were provided 7–14 14
by UNICEF.27 In a study conducted in India, it was demon- KMC, kangaroo mother care.
strated that there was significant reduction in expenditures in
the KMC group compared with the neonatal intensive care
group. Around 33 800 rupees were saved, equivalent to $475, There are many challenges faced in running KMC units.
for each patient.27 28 KMC was basically designed for developing Despite continuous counselling, refusals among parents
and low-­income countries due to its cost-­effectiveness, but now are seen. Maintaining infection-­ free environment is also
it is also being adopted in developed countries, which shows challenging, and data collection and follow-­ u p are diffi-
changing trends.18 29 cult. Families living in far-­flung areas that do not come for
Another component of the KMC strategy is early discharge follow-­u p of their babies can be approached by community
and prompt referral. Due to early discharge, the risk of nosoco- health workers, and proper training should be given to these
mial infections can be reduced significantly. There is evidence in community health workers. They should have knowledge of
favour of reduced risk of nosocomial infections in KMC units.12 good antenatal care. At home they can check skin-­to-­skin
Infection prevention practices were ensured by medical staff, contact, temperature of the baby and feeding problems.

Dept. Protected by copyright.

patients and the family. Hand hygiene recommendations were Records should be maintained. In case of signs of danger,
strictly followed. Cord care was mandatory as it may provide referrals should be made. The baby should be transferred to
a portal of entry for infectious organisms. Cord care included an appropriate hospital in ambulance with the community
applying 4% chlorhexidine gel on the cord according to the health workers. Guidance on skin-­to-­s kin care may be given
national protocol. The baby was given sponge baths until the to keep newborn infants with hypothermia warm.
cord fell off and the umbilicus was healed.
The KMC team at Services Hospital included professors of Twitter Rubina Sohail @rubinasohail@rubinasohail
obstetrics and gynaecology and paediatrics, doctors, nurses, Acknowledgements  The authors acknowledge the mother of the baby who
members of the infection control committee, and administra- decided to share information for the welfare of other preterm babies and their
tive staff. Since then 82 babies with weight less than 2.5 kg and mothers.
gestational age less than 37 weeks with no danger signs have
been admitted, and the results were encouraging. Out of 82
babies, 81 were saved. One baby became sick due to necrotising
enterocolitis and was transferred to NICU, where he expired
(table 1). Patient’s perspective
Mothers were trained in checking the weight and tempera-
ture of the baby themselves; therefore, no extra staff nurse was I am very satisfied by this mode of treatment and I will
recruited. The average duration of hospital stay in preterm recommend it to other mothers in my family and neighbourhood.
babies was reduced (table 2).
To implement KMC in the hospital, there are six important
phases:
Learning points
1. Planning for KMC implementation.
2. Training for KMC practice.
►► In neonates at gestational age less than 37 weeks and with
3. Resource allocation.
weight less than 2.5 kg, prolonged skin-­to-­skin contact
4. Implementing KMC.
and exclusive breast feeding save them from hypothermia
5. KMC routinely integrated in the basic newborn care.
and improve weight gain, leading to reduced mortality and
6. KMC training centre.
morbidity.
KMC training programmes aimed at training health
►► Kangaroo mother care (KMC) babies discharged from the
professionals who will be involved in taking care of preterm
hospital can benefit from community workers’ follow-­up who
babies. Currently, Services Hospital is at phase 6 of the KMC
have been trained to monitor KMC practices at home and to
implementation plan with KMC training centre in place.
identify danger signs and help in the referral of the baby.
Eight hospitals of Punjab including the district headquarter
►► KMC is a good alternative to expensive incubators in low-­
hospital are implementing KMC services. Thirty-­f ive work-
income and middle-­income countries such as Pakistan.
shops have been conducted and around 700 doctors and
►► KMC is associated with decreased hospital stay and reduced
nurses trained in KMC. More work needs to be done on
treatment expenses, as expensive incubators can be replaced
the role of community workers and on referral systems from
with mothers’ warmth.
districts.
4 Sohail R, et al. BMJ Case Rep 2019;12:e228402. doi:10.1136/bcr-2018-228402

Contributors  RS wrote the manuscript. AN, NR and HIK helped in case
management.
Funding  The authors have not declared a specific grant for this research from any
funding agency in the public, commercial or not-­for-­profit sectors.
Competing interests  None declared.
Patient consent for publication  Parental/guardian consent obtained.
Provenance and peer review  Not commissioned; externally peer reviewed.
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