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84. Hendricks-Muñoz KD, Li Y, Kim YS, Prendergast CC, Mayers R, Louie M. Maternal and neonatal nurse perceived
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93. Cameroon Ministry of Public Health, Global Financing Facility for Women, Children and Adolescents (GFF), Grand
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20 December 2022).
94. Launching Saving Little Lives. In: Laerdal Global Health [website]. Stavanger, Norway; undated (https://
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95. McFadden A, Siebelt L, Marshall JL, Gavine A, Girard L-C, Symon A et al. Counselling interventions to enable women
to initiate and continue breastfeeding: a systematic review and meta-analysis. Int Breastfeed J. 2019;14(1):42.
doi:10.1186/s13006-019-0235-8.
96. Salim N, Shabani J, Peven K, Rahman QS-U, Kc A, Shamba D et al. Kangaroo mother care: EN-BIRTH multi-country
validation study. BMC Pregnancy Childbirth. 2021;21(Suppl 1):231. doi:10.1186/s12884-020-03423-8.
97. Allisyn Moran, Unit Head UHL/MCA/MAH, WHO, personal communication.
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manual. Geneva: World Health Organization; 2015 (WHO/HIS/HIS/2014.5 Rev.1; https://cdn.who.int/media/docs/
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17 January 2023).
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pubs/pdf/SPAQ8/SPA_Combined_QRE_EN_20April2022.pdf, accessed 17 January 2023).
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102. Harmonized health facility assessment (HHFA) combine questionnaire (availability and readiness): core questions
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103. Guenther T, Moxon S, Valsangkar B, Wetzel G, Ruiz J, Kerber K et al. Consensus-based approach to develop a
measurement framework and identify a core set of indicators to track implementation and progress towards effective
coverage of facility-based kangaroo mother care. J Glob Health. 2017;7(2):020801. doi:10.7189/jogh.07.020801.
104. Alaofe H, Lott B, Kimaru L, Okusanya B, Okechukwu A, Chebet J et al. Emergency transportation interventions for
reducing adverse pregnancy outcomes in low- and middle-income countries: a systematic review. Ann Glob Health.
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system on access to and use of maternal and newborn health services: findings of a prospective cohort study in Homa
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107. Shibanuma A, Ansah EK, Kikuchi K, Yeji F, Okawa S, Tawiah C et al. Evaluation of a package of continuum of care
interventions for improved maternal, newborn, and child health outcomes and service coverage in Ghana: a cluster-
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randomized trial. PLoS Med. 2021;18(6):e1003663. doi:10.1371/journal.pmed.1003663.
108. Okawa S, Gyapong M, Leslie H, Shibanuma A, Kikuchi K, Yeji F et al. Effect of continuum-of-care intervention package
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109. Cattaneo A, Amani A, Charpak N, De Leon-Mendoza S, Moxon S, Nimbalkar S et al. Report on an international
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2018;18(1). doi:10.1186/s12884-018-1819-9
54
Kangaroo
mother
care:
Implementation
strategy


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For more information, please contact:
World Health Organization
20 Avenue Appia
1211 Geneva 27
Switzerland
Department of Maternal, Newborn, Child
and Adolescent Health and Ageing 978-92-4-007163-6
Email: mncah@who.int
Website: www.who.int/teams/maternal-newborn-
child-adolescent-health-and-ageing/


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k a n g a r o o
mother care
A p r a c t i c a l g u i d e
Department of Reproductive Health and Research
World Health Organization
Geneva


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KANGAROO MOTHER CARE
© World Health Organization 2003
All rights reserved. Publications of the World Health Organization can be obtained from Marketing and Dissemination,
World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel: +41 22 791 2476; fax: +41 22 791 4857;
email: bookorders@who.int). Requests for permission to reproduce or translate WHO publications - whether for sale or
for noncommercial distribution - should be addressed to Publications, at the above address (fax: +41 22 791 4806; email:
permissions@who.int).
The designations employed and the presentation of the material in this publication do not imply the expression of any
opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory,
city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps
represent approximate border lines for which there may not yet be full agreement.


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represent approximate border lines for which there may not yet be full agreement.
The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or
recommended by the World Health Organization in preference to others of a similar nature that are not mentioned.
Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters.
The World Health Organization does not warrant that the information contained in this publication is complete and
correct and shall not be liable for any damages incurred as a result of its use.
Printed in France


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TABLE OF CONTENTS
GLOSSARY
ABBREVIATIONS
1. Introduction 7
1.1 The problem – improving care and outcome for low-birth-weight babies 7
1.2 Kangaroo mother care – what it is and why it matters 8
1.3 What is this document about? 9
1.4 Who is this document for? 9
1.5 How should this document be used? 9
2. Evidence 11
2.1 Mortality and morbidity 12
2.2 Breastfeeding and growth 13
2.3 Thermal control and metabolism 14
2.4 Other effects 14
2.5 Research needs 15
3. Requirements 17
3.1 Setting 17
3.2 Policy 18
3.3 Staffing 18
3.4 Mother 19
3.5 Facilities, equipment and supplies 19
3.6 Feeding babies 22
3.7 Discharge and home care 23
4. Practice guide 25
4.1 When to start KMC 25
4.2 Initiating KMC 27
4.3 Kangaroo position 27
4.4 Caring for the baby in kangaroo position 29
4.5 Length and duration of KMC 30
4.6 Monitoring baby’s condition 31
4.7 Feeding 34
4.8 Monitoring growth 41
4.9 Inadequate weight gain 43
4.10 Preventive treatment 44
4.11 Stimulation 44
4.12 Discharge 44


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4.9 Inadequate weight gain 43
4.10 Preventive treatment 44
4.11 Stimulation 44
4.12 Discharge 44
4.13 KMC at home and routine follow-up 46
REFERENCES 47


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KANGAROO MOTHER CARE
ANNEXES 51
I Records and indicators 51
II Birth weight and gestational age 53
III Constraints 54
kK
TABLES
1. The effect of KMC on breastfeeding 14
2. Amount of milk (or fluid) needed per day by birth weight and age 40
3. Approximate amount of breast milk needed per feed by birth weight and age 40
4. Mean birth weights with 10th and 90th percentiles by gestational age 53
5. Implementing KMC 54
ILLUSTRATIONS
1 Holding the baby close to the chest 20
2 Carrying pouches for KMC babies 21
3 Dressing the baby for KMC 21
4a Positioning the baby for KMC 27
4b Baby in KMC position 28
4c Moving the baby in and out of the binder 28
5 Sleeping and resting during KMC 30
6 Father’s turn for KMC 31
7 Breastfeeding in KMC 36
8 Tube-feeding in KMC 41
ABBREVIATIONS
LBW Low birth weight
KMC Kangaroo mother care
RCT Randomized controlled trial
RDS Respiratory distress syndrome
kK
GLOSSARY
Terms in this glossary are listed under key words in alphabetical order.
Age


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kK
GLOSSARY
Terms in this glossary are listed under key words in alphabetical order.
Age
Chronological age: age calculated from the date of birth.
Gestational age: age or duration of the gestation, from the last menstrual period to birth.
Post-menstrual age: gestational age plus chronological age.
Birth
Term birth: delivery occurring between 37 and 42 weeks of gestational age.
Preterm birth: delivery occurring before 37 weeks of gestational age.
Post-term birth: delivery occurring after 42 weeks of gestational age.


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Birth weight
Low-birth-weight infant: infant with birth weight lower than 2500g (up to and including
2499g), regardless of gestational age.
Very low-birth-weight infant: infant with birth weight lower than 1500g (up to and
including 1499g), regardless of gestational age.
Extremely low-birth-weight infant: infant with birth weight lower than 1000g (up to
and including 999g), regardless of gestational age.
Different cut-off values are used in this guide since they are more useful for clinical purposes.
Body temperature
Hypothermia: body temperature below 36.5°C.
Growth
Intrauterine growth retardation: impaired growth of the foetus due to foetal disorders,
maternal conditions (e.g. maternal malnutrition) or placental insufficiency.
Milk/feeding
Foremilk: breast milk initially secreted during a breast feed.
Hind milk: breast milk remaining in the breast when the foremilk has been removed (hind
milk has a fat content and a mean caloric density higher than foremilk).


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milk has a fat content and a mean caloric density higher than foremilk).
Alternative feeding method: not breastfeeding but feeding the baby with expressed breast
milk by cup or tube; expressing breast milk directly into baby’s mouth.
Preterm/full-term infant
Premature or preterm infant: infant born before 37 weeks of gestational age.
Preterm infant appropriate for gestational age (AGA): infant born preterm with
birth weight between the 10th and the 90th percentile for his/her gestational age.
Preterm infant small for gestational age (SGA): infant born preterm with a birth weight
below the 10th percentile for his/her gestational age.
Full-term infant small for gestational age (SGA): infant born at term with birth weight
below the 10th percentile for his/her gestational age.
Small baby: in this guide, a baby who is born preterm with low birth weight.
Stable preterm or low-birth-weight infant: a newborn infant whose vital functions


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Stable preterm or low-birth-weight infant: a newborn infant whose vital functions
(breathing and circulation) do not require continuous medical support and monitoring,
and are not subject to rapid and unexpected deterioration, regardless of intercurrent disease.
Note: Throughout this document babies are referred to by the personal pronoun “she” or “he” in
preference to the impersonal (and inaccurate!) “it”. The choice of gender is random.
kK


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1.
Introduction
1.1 The problem – improving care and outcome for low-birth-weight babies
Some 20 million low-birth-weight (LBW) babies are born each year, because of either
preterm birth or impaired prenatal growth, mostly in less developed countries. They contribute
substantially to a high rate of neonatal mortality whose frequency and distribution correspond
to those of poverty.1, 2 LBW and preterm birth are thus associated with high neonatal and infant
mortality and morbidity.3, 4 Of the estimated 4 million neonatal deaths, preterm and LBW
babies represent more than a fifth.5 Therefore, the care of such infants becomes a burden for
health and social systems everywhere.
In affluent societies the main contributor to LBW is preterm birth. The rate has been
decreasing thanks to better socioeconomic conditions, lifestyles and nutrition, resulting in
healthier pregnancies, and to modern neonatal care technology and highly specialised and
skilled health workers. 6-8


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skilled health workers. 6-8
In less developed countries high rates of LBW are due to preterm birth and impaired
intrauterine growth, and their prevalence is decreasing slowly. Since causes and determinants
remain largely unknown, effective interventions are limited. Moreover, modern technology
is either not available or cannot be used properly, often due to the shortage of skilled staff.
Incubators, for instance, where available, are often insufficient to meet local needs or are not
adequately cleaned. Purchase of the equipment and spare parts, maintenance and repairs are
difficult and costly; the power supply is intermittent, so the equipment does not work properly.
Under such circumstances good care of preterm and LBW babies is difficult: hypothermia
and nosocomial infections are frequent, aggravating the poor outcomes due to prematurity.
Frequently and often unnecessarily, incubators separate babies from their mothers, depriving
them of the necessary contact.


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them of the necessary contact.
Unfortunately, there is no simple solution to this problem since the health of an infant is
closely linked to the mother’s health and the care she receives in pregnancy and childbirth.
For many small preterm infants, receiving prolonged medical care is important. However,
kangaroo mother care (KMC) is an effective way to meet baby’s needs for warmth,
breastfeeding, protection from infection, stimulation, safety and love.
1


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KANGAROO MOTHER CARE
1.2 Kangaroo mother care – what it is and why it matters
Kangaroo mother care is care of preterm infants carried skin-to-skin with the mother. It is a
powerful, easy-to-use method to promote the health and well-being of infants born preterm as
well as full-term. Its key features are:
(cid:1) early, continuous and prolonged skin-to-skin contact between the mother and the baby;
(cid:1) exclusive breastfeeding (ideally);
(cid:1) it is initiated in hospital and can be continued at home;
(cid:1) small babies can be discharged early;
(cid:1) mothers at home require adequate support and follow-up;
(cid:1) it is a gentle, effective method that avoids the agitation routinely experienced in a busy ward
with preterm infants.
It was first presented by Rey and Martinez,9 in Bogotá, Colombia, where it was developed as
an alternative to inadequate and insufficient incubator care for those preterm newborn infants


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an alternative to inadequate and insufficient incubator care for those preterm newborn infants
who had overcome initial problems and required only to feed and grow. Almost two decades
of implementation and research have made it clear that KMC is more than an alternative to
incubator care. It has been shown to be effective for thermal control, breastfeeding and
bonding in all newborn infants, irrespective of setting, weight, gestational age, and clinical
conditions.10, 11
Most published experience and research concerning KMC comes from health facilities,
where care was initiated with the help of skilled health workers. Once a mother was confident in
the care she gave her baby, she continued it at home under guidance and with frequent visits for
specialised follow-up.
Evidence of the effectiveness and safety of KMC is available only for preterm infants without
medical problems, the so-called stabilised newborn. Research and experience show that:


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medical problems, the so-called stabilised newborn. Research and experience show that:
(cid:1) KMC is at least equivalent to conventional care (incubators), in terms of safety and thermal
protection, if measured by mortality.
(cid:1) KMC, by facilitating breastfeeding, offers noticeable advantages in cases of severe morbidity.
(cid:1) KMC contributes to the humanization of neonatal care and to better bonding between mother
and baby in both low and high-income countries.12, 13
(cid:1) KMC is, in this respect, a modern method of care in any setting, even where expensive
technology and adequate care are available.
(cid:1) KMC has never been assessed in the home setting.
Ongoing research and observational studies are assessing the effective use of this method in
situations where neonatal intensive care or referral are not available, and where health workers
are properly trained. In those settings KMC before stabilisation may represent the best chance
of healthy survival. 14, 15


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of healthy survival. 14, 15
This guide will therefore refer to KMC initiated at a health facility and continued at home
under the supervision of the health facility (domiciliary KMC). KMC as described in this
document recommends continuous skin-to-skin contact acknowledging that it might not be
possible in all settings and under all circumstances. The principles and practice of KMC
outlined in this document are also valid for intermittent skin-to-skin contact, provided
adequate care is offered to LBW and preterm newborn infants when they are separated from
their mothers. Such intermittent skin-to-skin contact has been shown to be beneficial,16 if
2


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complemented by proper incubator care. Guidance on skin-to-skin care may be used for
rewarming newborn infants with hypothermia or keeping them warm during transportation
to the referral facility.17
1.3 What is this document about?
This document describes the KMC method for care of stable preterm/LBW infants (i.e.
those who can breath air and have no major health problems) who need thermal protection,
adequate feeding, frequent observation, and protection from infection.
It provides guidance on how to organize services at the referral hospital and on what is
needed to introduce and carry out KMC, focusing on settings where resources are limited.
Evidence for the recommendations is provided18 whenever possible. However, for many
statements, especially those related to secondary procedures, sound evidence is not available as
in many other fields of health care. In these cases, the text reports the experience of health


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in many other fields of health care. In these cases, the text reports the experience of health
professionals who have implemented KMC for many years, many of whom carefully revised
previous versions of this document.
For breastfeeding counselling and support, readers should refer to Breastfeeding Counselling:
A Training Course -Trainer’s Guide.19 For HIV and infant feeding, refer to HIV and Infant Feeding
Counselling: A Training Course -Trainer’s Guide.20
Management of medical problems of small babies is not part of this guide. Further guidelines
can be found in textbooks or the WHO document Managing newborn problems. A guide for
doctors, nurses and midwives.56
1.4 Who is this document for?
This text has been prepared for health professionals in charge of LBW and preterm newborn
infants in first referral hospitals in settings with scarce resources.
It is not written for all potential care providers. Practical instructions (or protocols) adapted


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It is not written for all potential care providers. Practical instructions (or protocols) adapted
to the categories of health workers available in different settings should be prepared locally.
It is also aimed at decision-makers and planners at national and local levels. They need
to know whether KMC suits the needs of their health systems, whether it is practical and
feasible, and what is required to implement it successfully.
1.5 How should this document be used?
KMC guidelines have to be adapted to specific circumstances and available resources at
national or local level. This document can be used to develop national and local policies,
guidelines and protocols from which training material can be developed. This document cannot,
as it stands, be used for training purposes. Other training material and activities, especially on
breastfeeding support and counselling on HIV and infant feeding, are needed to acquire all the


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breastfeeding support and counselling on HIV and infant feeding, are needed to acquire all the
necessary skills. We hope that pre-service institutions will include those skills in their curricula.
kK
3


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2.
Evidence
This chapter reviews the evidence on KMC, from both developing and developed countries,
with regard to the following outcomes: mortality and morbidity; breastfeeding and growth;
thermal protection and metabolism, and other effects. The experience with KMC has been
reviewed by several authors,12, 13, 16, 21, 22 and in a systematic review.23 We also present evidence
on the acceptability of the intervention for mothers and health-care staff.
While reviewing the evidence, regardless of the outcome, it became clear that it was
important to highlight two essential variables: time of initiation of KMC, and daily and overall
duration of skin-to-skin contact.
Time of initiation of KMC in the studies under consideration varied from just after birth
to several days after birth. Late initiation means that the preterm/LBW infants have already
overcome the period of maximum risk for their health.


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overcome the period of maximum risk for their health.
Length of daily and overall duration of skin-to-skin contact also varied from minutes (e.g. 30
minutes per day on average) to virtually 24 hours per day; from a few days to several weeks.
The longer the care, the stronger the possible direct and causal association between KMC and
the outcome. Furthermore, when KMC was carried out over a long period of time, care was
predominantly provided by the mother rather than the nursing staff or the conventional
incubator.
Some other variables that might have affected the outcome of KMC are:
(cid:1) the position in which the baby was kept;
(cid:1) the changes in the type and mode of feeding;
(cid:1) the timing of discharge from the institution and the transition to home care;
(cid:1) condition at discharge;
(cid:1) the intensity of support and follow-up offered to mothers and families after discharge from the
institution.


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institution.
Many other factors (e.g. social conditions, environment and health care, especially services
offered for KMC) may be associated with the positive effects observed in KMC studies. It is
very important to separate the effects of these factors from those deriving from KMC. Below,
in reviewing the evidence, we try to address those additional factors.
No published study on KMC was found in the context of high HIV prevalence among mothers.
5


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KANGAROO MOTHER CARE
2.1 Mortality and morbidity
Clinical trials
Three published randomized controlled trials (RCT) comparing KMC with conventional
care were conducted in low-income countries.24-26 The results showed no difference in survival
between the two groups. Almost all deaths in the three studies occurred before eligibility,
i.e. before LBW infants were stabilised and enrolled for research. Infants weighing less than
2000g were enrolled after an average period of 3-14 days on conventional care, in urban third-
level hospitals. The KMC infants stayed in hospital until they fulfilled the usual criteria for
discharge, as the control infants did, in two of the studies,24, 26 while in the third study they were
discharged earlier and subjected to a strict ambulatory follow-up.25 The follow-up periods lasted
one,26 six24 and twelve months,25 respectively.
The RCT carried out in Ecuador by Sloan and collaborators showed a lower rate of severe


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The RCT carried out in Ecuador by Sloan and collaborators showed a lower rate of severe
illness among KMC infants (5%) than in the control group (18%).24 The sample size required
for that study was 350 subjects per group for a total of 700 infants, but only 603 babies were
recruited. Recruitment, in fact, was interrupted when the difference in the rate of severe illness
became apparent. The other controlled studies conducted in low-income countries revealed no
significant difference in severe morbidity, but found fewer hospital infections and readmissions
in the KMC group. Kambarami and collaborators from Zimbabwe also reported reduced
hospital infections.27 High-income countries report no difference in morbidity. However, it is
notable that no additional risk of infection seems to be associated with skin-to-skin contact.24-27
Observational studies showed that KMC could help reduce mortality and morbidity in


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Observational studies showed that KMC could help reduce mortality and morbidity in
preterm/LBW infants. Rey and Martinez,9 in their early account, reported an increase in
hospital survival from 30% to 70% in infants between 1000g and 1500g. However, the
interpretation of their results is difficult because numerators, denominators and follow-up in
the KMC group were different from those in the historical control group.28 Bergman and
Jürisoo, in another study with an historical control group conducted in a remote mission
hospital without incubator care in Zimbabwe,14 reported an increase in hospital survival from
10% to 50% in infants weighing less than 1500g, and from 70% to 90% in those weighing
between 1500 to 1999g. Similar results are reported from a secondary hospital in nearby
Mozambique.15 The difference in survival, however, may be due to some uncontrolled variables.
The studies in Zimbabwe and Mozambique, conducted in hospitals with very limited resources,


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The studies in Zimbabwe and Mozambique, conducted in hospitals with very limited resources,
applied KMC very early on, well before LBW and preterm infants were stabilized. In the early
study by Rey and Martinez, KMC was applied later, after stabilization. In both cases the skin-
to-skin contact was maintained virtually 24 hours a day.
Charpak and collaborators, in a two-cohort study carried out in Bogotá, Colombia,29 found
a crude death rate higher in the KMC group (relative risk = 1.9; 95%CI: 0,6 to 5.8), but their
results reverted in favour of KMC (relative risk = 0.5, 95%CI: 0.2 to 1.2) after adjustment for
birth weight and gestational age. The differences, however, were not statistically significant.
The two cohorts recruited in two third-level hospitals, showed many social and economic
differences. KMC was also applied after stabilization and 24 hours a day. In a controlled but
not randomized trial carried out in a tertiary-care hospital in Zimbabwe, there was a slight


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not randomized trial carried out in a tertiary-care hospital in Zimbabwe, there was a slight
difference in survival in favour of the KMC infants, but this might have been due to differences
in feeding.27
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Conclusion
On balance the evidence shows that although KMC does not necessarily improve survival, it
does not reduce it. After stabilization, there is no difference in survival between KMC and good
conventional care. The hypothesis that KMC might improve survival when applied before
stabilization needs to be further explored with well-designed studies. If such an effect on
survival exists, it will be more evident and easier to demonstrate in the poorest settings, where
mortality is very high.
As for morbidity, while there is no strong evidence of a beneficial effect of KMC, there is
no evidence of it being harmful. In addition to the little evidence already published,14, 15 some
preliminary results on a small number of newborn infants with mild respiratory distress seem to
confirm that very early skin-to-skin contact might have a beneficial effect.30 A word of warning
about discharge: KMC infants discharged during the cold season may be more susceptible to


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about discharge: KMC infants discharged during the cold season may be more susceptible to
severe illness, especially lower respiratory tract infections, than those discharged during the
warm season.31 A closer follow-up is needed in such cases.
It should be noted that all the studies so far have taken place in well-equipped hospitals,
yet arguably the most significant impact of KMC will be felt in settings with limited resources.
There is an urgent need for further research in these settings. In the meantime, it seems that
where poor conventional care is available, KMC offers a safe substitute, with little risk of raised
morbidity or mortality.
2.2 Breastfeeding and growth
Breastfeeding
Two randomized controlled trials and a cohort study carried out in low-income countries
looked at the effect of KMC on breastfeeding. All three studies found that the method increased
the prevalence and duration of breastfeeding.25, 26, 29 Six other studies conducted in high-income


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the prevalence and duration of breastfeeding.25, 26, 29 Six other studies conducted in high-income
countries, where skin-to-skin contact was applied late and only for a limited amount of time per
day, also showed a beneficial effect on breastfeeding.32-37 The results of all these studies are
summarized in Table 1.
It appears that KMC and skin-to-skin contact are beneficial for breastfeeding in settings
where it is less commonly used for preterm/LBW infants, especially if these are cared for in
incubators and the prevailing feeding method is the bottle. Other studies have shown a positive
effect of skin-to-skin contact on breastfeeding. It could therefore be expected that the earlier
KMC is begun and the earlier skin-to-skin contact is initiated, the greater the effect on
breastfeeding will be.
Growth
The two-cohort study conducted in Colombia29 revealed slower weight gain in KMC
infants when compared with the control group, but the two cohorts also showed many social


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infants when compared with the control group, but the two cohorts also showed many social
and economic differences. In the subsequent RCT25 no difference in growth was observed at
one year of age. In another RCT,26 KMC infants showed a slightly larger daily weight gain while
they were cared for in hospital, but in the overall period of study their growth did not differ
from that of the control group. Similar results in terms of daily weight gain were observed in
Zimbabwe.27
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KANGAROO MOTHER CARE
Table 1. The effect of KMC on breastfeeding
Study Author Year Ref. Outcome KMC Control
RCT Charpak et al. 1994 29 Partial or exclusive breastfeeding at:
1 month 93% 78%
6 months 70% 37%
1 year 41% 23%
RCT Charpak et al. 1997 25 Partial or exclusive breastfeeding at 3 months 82% 75%
RCT Cattaneo et al. 1998 26 Exclusive breastfeeding at discharge 88% 70%
Schmidt et al. 1986 32 Daily volume 640 ml 400 ml
Daily feeds 12 9
Whitelaw et al. 1988 33 Breastfeeding at 6 weeks 55% 28%
Wahlberg et al. 1992 34 Breastfeeding at discharge 77% 42%
Syfrett et al. 1993 35 Daily feeds (34 weeks of gestational age) 12 12
Blaymore-Bier 1996 36 Breastfeeding at: discharge 90% 61%
et al. 1 month 50% 11%
Hurst et al. 1997 37 Daily volume at 4 weeks 647 ml 530 ml
Exclusive breastfeeding at discharge 37% 6%
2.3 Thermal control and metabolism
Studies carried out in low-income countries26 show that prolonged skin-to-skin contact


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Studies carried out in low-income countries26 show that prolonged skin-to-skin contact
between the mother and her preterm/LBW infant, as in KMC, provides effective thermal
control and may be associated with a reduced risk of hypothermia. Fathers too can effectively
conserve heat in newborn infants38 despite an initial report of worse performance of males in
thermal control.39
Heart and respiratory rates, respiration, oxygenation, oxygen consumption, blood glucose,
sleep patterns and behaviour observed in preterm/LBW infants held skin-to-skin tend to be
similar to or better than those observed in infants separated from their mothers.40-42 Contact
between mother and child has other effects also. For instance, salivary cortisol, an indicator of
possible stress, appears to be lower in newborn infants held skin-to-skin.43 This observation is
consistent with the reporting of significantly more crying in full-term healthy infants 90 minutes


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consistent with the reporting of significantly more crying in full-term healthy infants 90 minutes
after birth44, 45 and in LBW and preterm infants at 6 months33 of age when they are separated
from their mothers.
2.4 Other effects
Kangaroo care helps both infants and parents. Mothers report being significantly less stressed
during kangaroo care than when the baby is receiving conventional care. Mothers prefer
skin-to-skin contact to conventional care26 and report an increased confidence, self-esteem,
and feeling of fulfilment, also in high-income countries. They describe a sense of empowerment,
confidence and a feeling that they can do something positive for their preterm infants in
different settings and cultures.46-49 Fathers too said that they felt relaxed, comfortable and
contented while providing kangaroo care. KMC thus empowers mothers and increases their
confidence in handling and feeding their LBW and preterm infants. Tessier and collaborators,


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confidence in handling and feeding their LBW and preterm infants. Tessier and collaborators,
using data from the RCT conducted in Colombia, concluded that KMC should be encouraged
as soon as possible after birth because it improves bonding and makes mothers feel more
competent.50
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KMC is acceptable to health-care staff, and the presence of mothers in the ward does not
seem to be a problem. Most health workers consider KMC beneficial. They may think that
conventional incubator care allows better monitoring of sick LBW and preterm infants, but
they recognize that it increases the risk of hospital infections and it separates infants from their
mothers. Health workers would prefer KMC for their own preterm/LBW infant.26
Lower capital investment and recurrent costs is yet another advantage of KMC and could
bring about some savings to hospitals and health care systems in low-income countries.
Savings may result from reduced spending on fuel, electricity, maintenance and repair of
equipment26 as well as possible reduction in staffing costs, since mothers provide the greater
proportion of care. Compared with conventional incubator care, Ecuador24 has reported lower
costs per infant, in part associated with a reduced rate of readmission to hospital. This may


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costs per infant, in part associated with a reduced rate of readmission to hospital. This may
partly be due to a shorter length of hospital stay in KMC infants, reported from both low 25-27
and high-income countries.33, 35, 46 Capital and recurrent savings may be more substantial in
tertiary than in first-referral and small facilities in low-income countries.
2.5 Research needs
More evidence of the advantages of KMC over other methods of care is needed, particularly
on:
(cid:1) the effectiveness and safety of KMC before stabilization, in settings with very limited resources
(i.e. without incubators and other expensive technologies);
(cid:1) breastfeeding and feeding supplements in LBW infants less than 32 weeks of gestational age;
(cid:1) simpler and reliable methods for monitoring the well-being of KMC infants, especially breathing
and feeding;
(cid:1) KMC in LBW infants weighing less than 1000g, and in newborn infants who are critically ill;


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(cid:1) KMC in LBW infants weighing less than 1000g, and in newborn infants who are critically ill;
(cid:1) KMC in very special circumstances, e.g. in very cold climates or in refugee camps;
(cid:1) cultural and managerial barriers that may hinder the implementation of KMC, and
interventions that may foster it, particularly in settings with very limited resources;
(cid:1) the implementation of KMC for LBW and preterm infants delivered at home without the help
of trained personnel and without the possibility of referral to the appropriate level of care.
This last situation may well be the most important current source of perinatal and neonatal
mortality and morbidity. The evidence about the benefits of KMC for LBW and preterm
infants relates to those born and assisted in health facilities or who can benefit from careful
follow-up at home, not to those delivered at home. Clear scientific evidence is needed to


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follow-up at home, not to those delivered at home. Clear scientific evidence is needed to
establish the safety and suitability of domiciliary KMC for babies born at home. However,
there is no evidence that such care would be harmful or less safe than current practice. It might
be reasonable, unless future research showed that other methods of home care were more
effective, to recommend KMC for the home care of LBW and preterm infants born at home
and who cannot be taken to hospital. Local culture and local activities to improve birth care at
home should be taken into account if such a recommendation were issued.
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3.
Requirements
The most important resources for KMC are the mother, personnel with special skills and a
supportive environment. The requirements described in this chapter are formulation of policy,
organization of services and follow-up, equipment and supplies for mothers and babies, and
skilled providers for the facilities. Some common constraints faced when implementing KMC,
and possible solutions, are discussed in Annex III.
Very small newborn infants and those with complications are best cared for in incubators
where they can receive the necessary attention and care. As soon as the general condition
improves and the baby no longer needs intensive medical care, but simply warmth, protection
from infections and adequate feeding to ensure growth, KMC can be the method of choice.
3.1 Setting
KMC can be implemented in various facilities and at different levels of care. The most
common settings where such care can be implemented, are described below:
Maternity facilities


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common settings where such care can be implemented, are described below:
Maternity facilities
Small maternity units with several deliveries per day, these facilities are usually staffed by
skilled midwives but often have no doctors and lack special equipment (incubators and radiant
warmers) and supplies (oxygen, drugs and preterm formula) for the care of LBW and preterm
newborn infants. If possible, such infants are transferred to a higher level of care; otherwise they
are kept with their mothers and discharged early for home care. Hypothermia, infections,
respiratory and feeding problems contribute to high mortality rates among those infants.
Referral hospitals
This category includes a wide range of special care units in district and provincial hospitals.
A common feature is the availability of skilled personnel (specialized nurses and midwives,
paediatricians, obstetricians, or at least experienced physicians) and basic equipment and


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paediatricians, obstetricians, or at least experienced physicians) and basic equipment and
supplies for special neonatal care. However, in reality, staff and equipment are often in short
supply: competent physicians may be available a few hours per day only, small newborn infants
are kept in large nurseries or wards, sometimes in contact with older patients. Mothers cannot
stay with their infants and they have difficulty establishing and maintaining breastfeeding.
Mortality may also be high for the same reasons. Abandonment may be a common problem.
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KANGAROO MOTHER CARE
There is a range of institutions between the two types of facility mentioned above, where
skilled health workers can provide KMC.
3.2 Policy
Implementation of KMC and its protocol will need to be facilitated by supportive health
authorities at all levels. These include the hospital director and the people in charge of the health
care system at district, provincial and regional levels.
A national policy ensures a coherent and effective integration of the practice within
pre-existing structures of the health system and education and training.
Preterm babies are best born in institutions that can provide the special medical care required
for managing their frequent complications. Thus, when a premature baby is expected, the
mother should be transferred to such an institution before birth. If this is not possible, very
small babies or small babies with problems should be transferred there as soon as possible.


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small babies or small babies with problems should be transferred there as soon as possible.
The referral system should be organized in such a way as to guarantee the safety of the baby.
National standards and protocols need to be developed for the care of small babies, including
those mentioned above, once they have overcome the initial problems. Standards must include
clear criteria for monitoring and evaluation. These can best be developed by the appropriate
professional groups with the participation of parents. Furthermore, local protocols will be easier
to implement if national policies and guidelines are clearly set out.
Continuous monitoring and regular evaluation according to established criteria will help
improve practice and design, and carry out research that may help refine the method.
Each health facility that implements KMC should, in its turn, have a written policy and
guidelines adapted to the local situation and culture. Such policies and guidelines will be more


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guidelines adapted to the local situation and culture. Such policies and guidelines will be more
effective if they are agreed on by consensus, involving all the staff, where possible, in developing
local protocols based on national or international guidelines. The protocol should cover KMC
as presented here, and should, of course, include follow-up. It could also be complemented by
detailed instructions on general problems (e.g. hygiene of staff and mothers) or on problems
commonly occurring in preterm infants (e.g. prevention and treatment of infection). After the
introduction of the KMC protocol, monthly meetings with the staff will be useful to discuss and
analyse data and problems, and to improve the protocol if necessary.
3.3 Staffing
KMC does not require any more staff than conventional care. Existing staff (doctors and
nurses) should have basic training in breastfeeding and adequate training in all aspects of
KMC as described below:


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KMC as described below:
(cid:1) when and how to initiate the KMC method;
(cid:1) how to position the baby between and during feeds;
(cid:1) feeding LBW and preterm infants;
(cid:1) breastfeeding;
(cid:1) alternative feeding methods until breastfeeding becomes possible;
(cid:1) involving the mother in all aspects of her baby’s care, including monitoring vital signs and
recognizing danger signs;
(cid:1) taking timely and appropriate action when a problem is detected or the mother is concerned;
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(cid:1) deciding on the discharge;
(cid:1) ability to encourage and support the mother and the family.
Each institution should have a programme of continuing education in the area of KMC and
breastfeeding. Nursing and medical schools should include KMC in their curricula as soon
as possible.
3.4 Mother
Research and experience show that mothers like KMC once they have become familiar with
it. KMC must therefore be discussed with the mother as soon as a preterm baby is born and
offered to her as an alternative to the conventional methods when the baby is ready. Since
KMC requires the continuous presence of the mother, it would be helpful to explain to her the
advantages of each method and discuss with her the possible options regarding baby care. She
must have time and opportunity to discuss the implications of KMC with her family, since this
would require her to stay longer in hospital, continue the method at home and attend follow-up


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would require her to stay longer in hospital, continue the method at home and attend follow-up
visits. If obstacles arise, talk about them and try to find solutions with the family before
abandoning KMC. The mother must also be fully supported by the health workers to gradually
take over the responsibility for the care of her small baby.
In theory it is possible to fully implement KMC with a surrogate mother (e.g. the grand-
mother) but this is difficult to accomplish in practice.
3.5 Facilities, equipment and supplies
KMC does not require special facilities, but simple arrangements can make the mother’s stay
more comfortable.
Mother’s needs
Two or four-bed rooms of reasonable size, where mothers can stay day and night, live with
the baby, and share experience, support and companionship; at the same time they can have
private visits without disturbing the others. The rooms should be equipped with comfortable


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private visits without disturbing the others. The rooms should be equipped with comfortable
beds and chairs for the mothers, if possible adjustable or with enough pillows to maintain an
upright or semi-recumbent position for resting and sleeping. Curtains can help to ensure pri-
vacy in a room with several beds. The rooms should be kept warm for small babies (22-24°C).
Mothers also need bathroom facilities with tap water, soap and towels. They should have nutri-
tious meals and a place to eat with the baby in KMC position. Another warm, smaller room
would be useful for individual work with mothers, discussion of private and confidential issues,
and for reassessing babies. The ward should have an open-door policy for fathers and siblings.
Daily shower or washing is sufficient for maternal hygiene; strict hand-washing should be
encouraged after using the toilet and changing the baby. Mothers should have the opportunity
to change or wash clothes during their stay at the KMC facility.


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to change or wash clothes during their stay at the KMC facility.
Recreational, educational and even income-generating activities can be organized for
mothers during KMC in order to prevent or reduce the inevitable frustrations of being away
from home and in an institution. Noise levels should, however, be kept low during such
activities to avoid disturbing the small babies. Mothers should also be allowed to move around
freely during the day at the institution and, if possible, in the garden, provided they respect the
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KANGAROO MOTHER CARE
hospital schedules for patient care and regularly feed their babies. The staff should use the long
period in hospital (and the frequent contacts after discharge) to carry out other educational
activities on infant and maternal health.
Mothers should be discouraged from smoking while providing KMC and supported in their
anti-smoking efforts. Visitors should not be allowed to smoke where there are small babies, and
the measure should be reinforced if necessary.
During the long stay at the facility visits by fathers and other members of the family should
be allowed and encouraged. They can sometimes help the mother, replacing her for skin-to-skin
contact with the baby so that she can get some rest.
Mothers, however, appreciate privacy while breastfeeding, taking care of their personal
hygiene and during visits.
Fig.1 Holding the baby close to the chest
Clothing for the mother
The mother can wear whatever she finds comfortable and warm in the ambient temperature,


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The mother can wear whatever she finds comfortable and warm in the ambient temperature,
provided the dress accommodates the baby, i.e. keeps him firmly and comfortably in contact
with her skin. Special garments are not needed unless traditional ones are too tight.
The support binder
This is the only special item needed for KMC. It helps mothers hold their babies safely close
to their chest (Fig.1). To begin with, use a soft piece of fabric, about a meter square, folded
diagonally in two and secured with a safe knot or tucked up under the mother’s armpit. Later
a carrying pouch of mother’s choice (Fig. 2) can replace this cloth. All these options leave the
mother with both hands free and allow her to move around easily while carrying the baby skin-
to-skin. Some institutions prefer to provide their own type of pouch, shirt or band.
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Fig.2 Carrying pouches for KMC babies
Baby’s needs
When baby receives continuous KMC, he does not need any more clothing than an infant
in conventional care. If KMC is not continuous, the baby can be placed in a warm bed and
covered with a blanket between spells of KMC.
Clothing for the baby
When the ambient temperature is 22-24°C, the baby is carried in kangaroo position naked,
except for the diaper, a warm hat and socks (Fig.3). When the temperature drops below 22°C,
baby should wear a cotton, sleeveless shirt, open at the front to allow the face, chest, abdomen,
arms and legs to remain in skin-to-skin contact with the mother’s chest and abdomen. The
mother then covers herself and the baby with her usual dress.
Fig.3 Dressing the baby for KMC
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KANGAROO MOTHER CARE
Other equipment and supplies
They are the same as for conventional care and are described below for convenience:
(cid:1) a thermometer suitable for measuring body temperature down to 35°C;
(cid:1) scales: ideally neonatal scales with 10g intervals should be used;
(cid:1) basic resuscitation equipment, and oxygen where possible, should be available where preterm
babies are cared for;
(cid:1) drugs for preventing and treating frequent problems of preterm newborn babies may
be added according to local protocols. Special drugs are sometimes needed, but are not
recommended in this guide. Treatment of medical problems is not part of this guide.
Record keeping
Each mother-baby pair needs a record sheet to note daily observations, information about
feeding and weight, and instructions for monitoring the baby as well as specific instructions
for the mother. Accurate standard records are the key to good individual care; accurate


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for the mother. Accurate standard records are the key to good individual care; accurate
standard indicators are the key to sound programme evaluation.
A register (logbook) contains basic information on all infants and type of care received, and
provides information for monitoring and periodic programme evaluation. Annex I includes an
example of the type of record sheet that can be used for this purpose and adapted to different
settings. The data thus collected would also allow for regular calculation (e.g. quarterly and
annually) of important indicators, listed also in Annex I.
3.6 Feeding babies
Mother’s milk is suited to baby’s needs, even if birth occurred before term or the baby is
small. Breast milk is thus the best food for preterm/LBW infants and breastfeeding is the best
method of feeding.51, 52 Mother’s milk should always be considered a nutritional priority due to
the biological uniqueness of the preterm milk, which adjusts itself to the baby’s gestational age


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the biological uniqueness of the preterm milk, which adjusts itself to the baby’s gestational age
and requirements.
In this guide only mother’s milk is recommended for feeding her baby. Although pasteurized
breast milk from another woman or the milk bank can be used, recommendations on
pasteurization and milk banking are not included in this guide.
Breastfeeding preterm and LBW infants is a difficult task, and is almost impossible if the
hospital and home environment are not supportive of breastfeeding in general. The staff need
to be knowledgeable about breastfeeding and alternative feeding methods, and skilled in helping
mothers to feed their term and normal weight infants, before they can effectively help mothers
with LBW babies.
The ultimate goal is exclusive breastfeeding. KMC facilitates the initiation and establishment
of breastfeeding in small infants. However, many babies may not breastfeed well at the


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of breastfeeding in small infants. However, many babies may not breastfeed well at the
beginning or not at all, and need alternative feeding methods. Therefore the staff should
teach and help the mother to express breast milk in order to provide milk for her baby and
to maintain lactation, to feed the baby by cup and to assess the baby’s feeding. They should
know how to assess the readiness of small babies for breastfeeding.
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Hand expression is the simplest way to express breast milk. It needs no appliances, so a
woman can do it anywhere at any time. Expressing breast milk by hand is recommended and
described in this document.
Mothers need containers for expressed breast milk: a cup, glass, jug or a wide-mouthed jar.
Different kinds of breast pumps can also be used for expressing breast milk:
(cid:1) rubber bulb or syringe pumps;
(cid:1) mechanical or electrical pumps, either hand or foot operated.
These are particularly convenient for women who express breast milk several times a day
over a long period. This is often the case when the baby is born long before term or requires
prolonged intensive care (for more on breast pumps, see WHO breastfeeding counselling
course19 ).
Cups, No. 5 to No. 8 French gauge feeding tubes and syringes are needed for feeding
expressed breast milk or formula milk. Other tools such as droppers, syringes and teaspoons


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expressed breast milk or formula milk. Other tools such as droppers, syringes and teaspoons
have been used instead of a cup. Traditional feeding devices, such as the “paladai” in India, have
been shown to be effective.53 A refrigerator also is needed for storing milk. Excess breast milk
can be frozen.
Preterm formula must be available when breastfeeding is not adequate or for replacement
feeding.
Health workers must be familiar with local harmful cultural practices, such as refusal to give
colostrum or negative attitudes towards LBW and preterm infants (“they are ugly” or “they
will not survive”). They should be trained to discuss such practices and attitudes with the
mother and her family and find ways to overcome them.
3.7 Discharge and home care
Once the baby is feeding well, maintaining stable body temperature in KMC position and
gaining weight, mother and baby can go home. Since most babies will still be premature at


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gaining weight, mother and baby can go home. Since most babies will still be premature at
the time of discharge, regular follow-up by a skilled professional close to mother’s home must
be ensured. Frequency of visits may vary from daily at the beginning, to weekly and monthly
later. The better the follow-up, the earlier mother and baby can be discharged from the facility.
As a guide, services must plan at least 1 visit for every preterm week. Those visits can also be
carried out at home.
Mothers also need free access to health professionals for any type of counselling and
support related to the care of their small babies. There should be at least one home visit by
a public health nurse to assess home conditions, home support and ability to travel for
follow-up visits.
If possible, support groups in the community should be involved in the home (to provide
social, psychological, and domestic work support). Mothers with previous KMC experience can


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social, psychological, and domestic work support). Mothers with previous KMC experience can
be effective providers of this kind of community assistance.
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4.
Practice guide
This chapter describes how to practice kangaroo mother care in the institution where a
small baby has been taken care of and when to begin. It describes each component: thermal
protection through the correct position, feeding, observing the baby, deciding when mother
and baby can go home to continue KMC, and the follow-up needed to ensure adequate growth
and to support the mother.
4.1 When to start KMC
When a small baby is born, complications can be expected – the more preterm and small
for gestational age the infant is, the more frequent the problems are. Initial care for infants with
complications is provided according to national or institutional guidelines. KMC will have to be
delayed until the medical conditions improve. When exactly KMC can begin for those small
babies must be judged individually, and full account should be taken of the condition and status
of each baby and his mother. However, the mother of a small baby can be encouraged to adopt


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of each baby and his mother. However, the mother of a small baby can be encouraged to adopt
KMC very early on. The birth weight ranges below are given as a guide.
Babies weighing 1800g or more at birth (gestational age 30-34 weeks or more) may have
some prematurity-related problems, such as respiratory distress syndrome (RDS). This may
raise serious concerns for a minority of those infants, who will require care in special units. In
most cases, however, KMC can start soon after birth.
In babies with birth weight between 1200 and 1799g (gestational age 28-32 weeks), prematurity-
related problems such as respiratory distress syndrome (RDS) and other complications are
frequent, and therefore require some kind of special treatment initially. In such cases the delivery
should take place in a well equipped facility, which could provide the care required. Should
delivery take place elsewhere, the baby should be transferred soon after birth, preferably with the


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delivery take place elsewhere, the baby should be transferred soon after birth, preferably with the
mother. One of the best ways of transporting small babies is keeping them in continuous skin-to-
skin contact with the mother.10,54 It might take a week or more before KMC can be initiated.
Although early neonatal mortality in this group is very high, mostly due to complications, most
babies survive and mothers could be encouraged to express breast milk.
Babies weighing less than 1200g (gestational age below 30 weeks) incur frequent and severe
problems due to preterm birth: mortality is very high and only a small proportion survive
prematurity-related problems. These babies benefit most from transfer before birth to an
institution with neonatal intensive care facilities. It may take weeks before their condition
allows initiation of KMC.
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Neither birth weight nor gestational age alone can reliably predict the risk of complications.
Table 4 in Annex II shows how much the mean, and the 10th and the 90th weight percentiles,
vary by gestational age for a population with mean birth weight of 3350g.55 When exactly to
initiate KMC really depends on the condition of the mother and the baby. Every mother should
be told about the benefits of breastfeeding, encouraged and helped to express breast milk from
the first day, to provide food for the baby and ensure lactation.
The following criteria will help determine when to suggest that the mother adopts KMC.
Mother
All mothers can provide KMC, irrespective of age, parity, education, culture and religion.
KMC may be particularly beneficial for adolescent mothers and for those with social risk factors.
Carefully describe the various aspects of this method to the mother: the position, feeding


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Carefully describe the various aspects of this method to the mother: the position, feeding
options, care in the institution and at home, what she can do for the baby attached to her body
and what she should avoid. Explain the advantages and the implications of such care for her
and her baby, and always give the reasons behind a recommendation. Adopting KMC should
be the result of an informed decision and should not be perceived as an obligation.
The following points must be taken into consideration when counselling on KMC:
(cid:1) willingness: the mother must be willing to provide KMC;
(cid:1) full-time availability to provide care: other family members can offer intermittent
skin-to-skin contact but they cannot breastfeed;
(cid:1) general health: if the mother suffered complications during pregnancy or delivery
or is otherwise ill, she should recover before initiating KMC;
(cid:1) being close to the baby: she should either be able to stay in hospital until discharge or return


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when her baby is ready for KMC;
(cid:1) supportive family: she will need support to deal with other responsibilities at home;
(cid:1) supportive community: this is particularly important when there are social, economic
or family constraints.
If the mother is a smoker, advise her on the importance of stopping smoking or refraining
from it in the room where the baby is. Explain the danger of passive smoking for herself, other
family members and small infants.
Baby
Almost every small baby can be cared for with KMC. Babies with severe illness or requiring
special treatment may wait until recovery before full-time KMC begins. During that period
babies are treated according to national clinical guidelines.56 Short KMC sessions can begin
during recovery when baby still requires medical treatment (IV fluids, low concentration of
additional oxygen). For continuous KMC, however, baby’s condition must be stable; the baby


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additional oxygen). For continuous KMC, however, baby’s condition must be stable; the baby
must be breathing spontaneously without additional oxygen. The ability to feed (to suck and
swallow) is not an essential requirement. KMC can begin during tube-feeding. Once the baby
begins recovering, discuss KMC with the mother.
These general recommendations on starting KMC should be adapted to the situation of the
region, health system, health facility, and individual. In settings with limited resources and when
referral is impossible, the decision on when to start KMC during recovery should be weighed
against the alternatives available for thermal control, feeding and respiratory support.
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4.2 Initiating KMC
When baby is ready for KMC, arrange with the mother a time that is convenient for her and
for her baby. The first session is important and requires time and undivided attention. Ask her
to wear light, loose clothing. Use a private room, warm enough for the small baby. Encourage
her to bring her partner or a companion of her choice if she so wishes. It helps to lend support
and reassurance.
While the mother is holding her baby, describe to her each step of KMC, then demonstrate
them and let her go through all the steps herself. Always explain why each gesture is important
and what it is good for. Emphasize that skin-to-skin contact is essential for keeping the baby
warm and protecting him from illness.
4.3 Kangaroo position
Place the baby between the mother’s breasts in an upright position, chest to chest (as shown in
Fig. 4a).
Fig.4a Positioning the baby for KMC
Secure him with the binder. The head, turned to one side, is in a slightly extended position. The


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Secure him with the binder. The head, turned to one side, is in a slightly extended position. The
top of the binder is just under baby’s ear. This slightly extended head position keeps the airway
open and allows eye-to-eye contact between the mother and the baby. Avoid both forward
flexion and hyperextension of the head. The hips should be flexed and extended in a “frog”
position; the arms should also be flexed. (Fig. 4a)
Tie the cloth firmly enough so that when the mother stands up the baby does not slide out.
Make sure that the tight part of the cloth is over the baby’s chest. Baby’s abdomen should not
be constricted and should be somewhere at the level of the mother’s epigastrium. This way baby
has enough room for abdominal breathing. Mother’s breathing stimulates the baby (Fig. 4b).
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KANGAROO MOTHER CARE
Fig. 4b Baby in KMC position
Show the mother how to move the baby in and out of the binder (Fig. 4c). As the mother gets
familiar with this technique, her fear of hurting the baby will disappear.
Moving the baby in and out of the binder:
 hold the baby with one hand placed behind the neck and on the back;
 lightly support the lower part of the jaw with her thumb and fingers to prevent the baby’s
head from slipping down and blocking the airway when the baby is in an upright position;
 place the other hand under the baby’s buttocks.
Fig. 4c Moving the baby in and out of the binder
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Explain to the mother that she can breastfeed in kangaroo position and that KMC actually
makes breastfeeding easier. Furthermore, holding the baby near the breast stimulates milk
production.
Mother can easily care for twins too: each baby is placed on one side of her chest. She may
want to alternate the position. Initially she may want to breastfeed one baby at a time, later both
babies can be fed at once while in kangaroo position.
After positioning the baby let mother rest with him. Stay with them and check baby’s
position. Explain to the mother how to observe the baby, what to look for. Encourage her to
move.
When introducing the mother to KMC also talk to her about possible difficulties. For some
time her life will revolve around the baby and this may upset her daily routine. Moreover, a
small baby at first might not feed well from the breast. During that period she can express
breast milk and give it to the baby with a cup or other implements, but this will take longer


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breast milk and give it to the baby with a cup or other implements, but this will take longer
than breastfeeding.
Encourage her to ask for help if she is worried and be prepared to respond to her questions
and anxieties. Answer her questions directly and honestly – she needs to be aware of the
limitations that KMC may put upon her daily activities as well as the benefits it can
undoubtedly bring to her baby.
Experience shows that most mothers are very willing to provide KMC, especially if they can
see other babies thriving. By sharing the same room for a long time, KMC mothers exchange
information, opinions and emotions, and develop a sense of mutual support and solidarity.
After a period of impotence and frustration during stabilization, they are empowered as the
main caretakers of their infants and reclaim their maternal role from the staff.
4.4 Caring for the baby in kangaroo position
Babies can receive most of the necessary care, including feeding, while in kangaroo position.


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Babies can receive most of the necessary care, including feeding, while in kangaroo position.
They need to be moved away from skin-to-skin contact only for:
(cid:1) changing diapers, hygiene and cord care; and
(cid:1) clinical assessment, according to hospital schedules or when needed.
Daily bathing is not needed and is not recommended. If local customs require a daily bath
and it cannot be avoided, it should be short and warm (about 37°C). The baby should be
thoroughly dried immediately afterwards, wrapped in warm clothes, and put back into the
KMC position as soon as possible.
During the day the mother carrying a baby in the KMC position can do whatever she likes:
she can walk, stand, sit, or engage in different recreational, educational or income-generating
activities. Such activities can make her long stay in hospital less boring and more bearable.
She has to meet, however, a few basic requirements such as cleanliness and personal hygiene


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She has to meet, however, a few basic requirements such as cleanliness and personal hygiene
(stress frequent hand-washing). She should also ensure a quiet environment for her baby and
feed him regularly.
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Sleeping and resting
Mother will best sleep with the baby in kangaroo position in a reclined or semi-recumbent
position, about 15 degrees from horizontal. This can be achieved with an adjustable bed, if
available, or with several pillows on an ordinary bed (Fig.5). It has been observed that this
position may decrease the risk of apnoea for the baby.57 If the mother finds the semi-recumbent
position uncomfortable, allow her to sleep as she prefers, because the advantages of KMC are
much greater than the risk of apnoea. Some mothers prefer sleeping on their sides in a semi-
reclined bed (the angle makes sleeping on the abdomen impossible), and if the baby is secured
as described above there will be no risk of smothering.
A comfortable chair with adjustable back may be useful for resting during the day.
Fig.5 Sleeping and resting during KMC
4.5 Length and duration of KMC
Length
Skin-to-skin contact should start gradually, with a smooth transition from conventional


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Length
Skin-to-skin contact should start gradually, with a smooth transition from conventional
care to continuous KMC. Sessions that last less than 60 minutes should, however, be avoided
because frequent changes are too stressful for the baby. The length of skin-to-skin contacts
gradually increases to become as continuous as possible, day and night, interrupted only for
changing diapers, especially where no other means of thermal control are available.
When the mother needs to be away from her baby, he can be well wrapped up and placed
in a warm cot, away from draughts, covered by a warm blanket, or placed under an appropriate
warming device, if available. During those breaks family members (father or partner, grand-
mother, etc.), or a close friend, can also help caring for the baby in skin-to-skin kangaroo
position (Fig.6).
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Fig.6 Father’s turn for KMC
Duration
When the mother and baby are comfortable, skin-to-skin contact continues for as long as
possible, first at the institution, then at home. It tends to be used until the baby reaches term
(gestational age around 40 weeks) or 2500g. Around that time the baby also outgrows the
need for KMC. She starts wriggling to show that she is uncomfortable, pulls her limbs out,
cries and fusses every time the mother tries to put her back skin-to-skin. This is when it is
safe to advise the mother to wean the baby gradually from KMC. Breastfeeding, of course,
continues. Mother can return to skin-to-skin contact occasionally, after giving the baby a bath,
during cold nights, or when the baby needs comfort.
KMC at home is particularly important in cold climates or during the cold season and
could go on for longer.
4.6 Monitoring baby’s condition
Temperature
A well-fed baby, in continuous skin-to-skin contact, can easily retain normal body temperature


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A well-fed baby, in continuous skin-to-skin contact, can easily retain normal body temperature
(between 36.5°C and 37°C) when in kangaroo position, if the ambient temperature is not lower
than the recommended range. Hypothermia is rare in KMC infants, but it can occur. Measuring
baby’s body temperature is still needed, but less frequently than when the baby is not in the
kangaroo position.
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KANGAROO MOTHER CARE
When starting KMC, measure axillary temperature every 6 hours until stable for three
consecutive days. Later measure only twice daily. If the body temperature is below 36.5°C,
rewarm the baby immediately: cover the baby with a blanket and make sure that the mother is
staying in a warm place. Measure the temperature an hour later and continue rewarming until
within the normal range. Also look for possible causes of hypothermia in the baby (cold room,
the baby was not in KMC position before measuring the temperature, the baby had a bath or
has not been feeding well). If no obvious cause can be found and the baby continues to have
difficulty in maintaining normal body temperature, or the temperature does not return to
normal within 3 hours, assess the baby for possible bacterial infection.
If an ordinary adult-type thermometer does not record the temperature, assume there
is moderate or severe hypothermia and act accordingly. Ways of identifying and treating


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is moderate or severe hypothermia and act accordingly. Ways of identifying and treating
hypothermia are described in detail in another WHO document.10 Rewarming can be
carried out through skin-to-skin contact.17
How to measure axillary temperature
 Keep the baby warm throughout the procedure, either in skin-to-skin contact with the
mother and properly covered, or well covered on a warm surface;
 use a clean thermometer and shake it down to less than 35°C;
 place the thermometer bulb high up in the middle of the axilla; the skin of the axilla
must be in full contact with the bulb of the thermometer, with no air pockets between
skin and bulb;
 hold the infant’s arm against the side of the chest gently; keep the thermometer in
place for at least three minutes;
 remove the thermometer and read the temperature;
 avoid taking the rectal temperature since it is associated with a small but significant
risk of rectal perforation.
Observing breathing and well-being


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risk of rectal perforation.
Observing breathing and well-being
The normal respiratory rate of an LBW and preterm infant ranges between 30 and 60
breaths per minute, and breathing alternates with intervals of no breathing (apnoea). However,
if the intervals become too long (20 seconds or more) and the baby’s lips and face turn blue
(cyanosis), his pulse is abnormally low (bradycardia) and he does not resume breathing
spontaneously, act quickly: there is a risk of brain damage. The smaller or more premature
the baby is, the longer and more frequent the spells of apnoea. As baby approaches term,
breathing becomes more regular and apnoea less frequent. Research shows that skin-to-skin
contact may make breathing more regular in preterm infants41,58 and may reduce the incidence
of apnoea. Apnoea appearing late may also indicate the beginning of an illness.
The mother must be aware of the risk of apnoea, be able to recognize it, intervene
immediately and seek help if she becomes concerned.


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What to do in case of apnoea
 Teach the mother to observe the baby’s breathing pattern and explain the normal
variations;
 explain what apnoea is and what effects it has on a baby;
 demonstrate the effect of apnoea by asking the mother to hold her breath for a short
time (less than 20 seconds) and a long time (20 seconds or more);
 explain that if breathing stops for 20 seconds or more, or baby becomes blue (blue
lips and face), this may be a sign of a serious disease;
 teach her to stimulate the baby by lightly rubbing the back or head, and by rocking
movements until the baby starts breathing again. If baby is still not breathing, she
should call staff;
 always react immediately to a mother’s call for help;
 in case of prolonged apnoea, when breathing cannot be restarted through stimulation,
resuscitate according to the hospital resuscitation guidelines;
 if apnoeic spells become more frequent, examine the baby: this may be an early sign


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 if apnoeic spells become more frequent, examine the baby: this may be an early sign
of infection. Treat according to the institutional protocol.
Once the baby has recovered from the initial complications due to preterm birth, is stable
and is receiving KMC, the risk of serious illness is small but significant. The onset of a serious
illness in small babies is usually subtle and is overlooked until the disease is advanced and
difficult to treat. Therefore it is important to recognize those subtle signs and give prompt
treatment. Teach the mother to recognize danger signs and ask her to seek care when
concerned. Treat the condition according to the institutional guidelines.
Danger signs
µ Difficulty breathing, chest in-drawing, grunting
µ Breathing very fast or very slowly
µ Frequent and long spells of apnoea
µ The baby feels cold: body temperature is below normal despite rewarming
µ Difficulty feeding: the baby does not wake up for feeds anymore, stops feeding or
vomits
µ Convulsions


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KANGAROO MOTHER CARE
Reassure the mother that there is no danger if the baby:
(cid:1) sneezes or has hiccups;
(cid:1) passes soft stools after each feed;
(cid:1) does not pass stools for 2-3 days.
4.7 Feeding
Breastfeeding preterm babies is a special challenge.
For the first few days a small baby may not be able to take any oral feeds and may need to be
fed intravenously. During this period the baby receives conventional care.
Oral feeds should begin as soon as baby’s condition permits and the baby tolerates them.
This is usually around the time when baby can be placed in kangaroo position. This helps the
mother to produce breast milk, so it increases breastfeeding.
Babies who are less than 30 to 32 weeks gestational age usually need to be fed through a
naso-gastric tube, which can be used to give expressed breast milk. The mother can let her baby
suck her finger while he is having tube feeds. Tube-feeding can be done when the baby is in
kangaroo position.


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kangaroo position.
Babies between 30 and 32 weeks gestational age can take feeds from a small cup. Cup feeds
can be given once or twice daily while a baby is still fed mostly through a naso-gastric tube. If
he takes cup feeds well, tube-feeding can be reduced. For cup-feeding the baby is taken out of
the kangaroo position, wrapped in a warm blanket and returned to the kangaroo position after
the feed. Another way to feed a baby at this stage is by expressing milk directly into the baby’s
mouth. This way the baby does not need to be taken out from the kangaroo position.
Babies of about 32 weeks gestational age or more are able to start suckling on the breast.
Baby may only root for the nipple and lick it at first, or he may suckle a little. Continue giving
expressed breast milk by cup or tube, to make sure that the baby gets all that he needs.
When a small baby starts to suckle effectively, he may pause during feeds quite often and


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When a small baby starts to suckle effectively, he may pause during feeds quite often and
for quite long periods. It is important not to take him off the breast too quickly. Leave him on
the breast so that he can suckle again when he is ready. He can continue for up to an hour if
necessary. Offer a cup feed after the breastfeed, or alternate breast and cup feeds.
Make sure that the baby suckles in a good position. Good attachment may make effective
suckling possible at an earlier stage.
Babies from about 34 to 36 weeks gestational age or more can often take all that they need
directly from the breast. However, supplements from a cup continue to be necessary
occasionally.
During this initial period the mother needs a lot of support and encouragement to establish
and maintain lactation until the baby is ready to breastfeed. Primiparae, adolescent mothers,
and mothers of very small infants may need even more encouragement, help and support
during the institutional stay and later at home.


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Discuss breastfeeding with the mother
 Reassure her that she can breastfeed her small baby and she has enough milk;
 explain that her milk is the best food for such a small baby. Feeding for him is even
more important than for a big baby;
 at the beginning a small baby does not feed as well as a big baby; he may
–tire easily and suck weakly at first
–suckle for shorter periods before resting
–fall asleep during feeding
–have long pauses after suckling, and feed longer
–not always wake up for feeds;
 explain that breastfeeding will become easier as baby becomes older and bigger;
 help her place and attach the baby in the kangaroo position.
Breastfeeding
The kangaroo position is ideal for breastfeeding. As soon as the baby shows signs of readiness
for breastfeeding, by moving tongue and mouth, and interest in sucking (e.g. fingers or
mother’s skin), help the mother to get into a breastfeeding position that ensures good
attachment.


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mother’s skin), help the mother to get into a breastfeeding position that ensures good
attachment.
To start breastfeeding choose appropriate time - when the baby is waking from a sleep,
or is alert and awake. Help the mother to sit comfortably in an armless chair with the baby in
skin-to-skin position. For the first breastfeeds take the baby out of the pouch and wrap or dress
him to better demonstrate the technique. Then put the baby into the kangaroo position and ask
the mother to ensure good position and attachment.19
Help the mother to position her baby
 Show the mother the correct position and attachment for breastfeeding;
 show the mother how to hold her baby:
– hold the baby’s head and body straight;
– make the baby face her breast, the baby’s nose opposite her nipple;
–hold the baby’s body close to her body;
–support the baby’s whole body, not just the neck and shoulders;
 show the mother how to help her baby to attach:
– touch her baby’s lips with her nipple;


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 show the mother how to help her baby to attach:
– touch her baby’s lips with her nipple;
– wait until her baby’s mouth is wide open;
– move her baby quickly onto her breast, aiming the infant’s lower lip well below
the nipple;
 show the mother signs of good attachment:
– baby’s chin is touching her breast;
– his mouth is wide open;
– his lower lip is turned out;
– a larger area of the areola is visible above rather than below the baby’s mouth;
– sucks are slow and deep, sometimes pausing.
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Let the baby suckle on the breast as long as he wants. The baby may feed with long pauses
between sucks. Do not interrupt the baby if he is still trying.
Small babies need breastfeeding frequently, every 2-3 hours. Initially they may not wake up
for feeds and must be wakened. Changing the baby before the feed may make him more alert.
Sometimes it helps to express a little milk with each suck. If the breast is engorged, encourage
the mother to express a small amount of breast milk before starting breastfeeding; this will
soften the nipple area and it will be easier for the baby to attach.
Even if the baby is not yet suckling well and long enough (very preterm), offer the breast
first, and then use an appropriate alternative feeding method. Do whatever works best in your
setting: let the mother express breast milk into baby’s mouth or let her express breast milk and
feed it to the baby by cup or tube.
Fig.7 Breastfeeding in KMC


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feed it to the baby by cup or tube.
Fig.7 Breastfeeding in KMC
Give special support to mothers who breastfeed twins
 Reassure the mother that she has enough breast milk for two babies;
 explain to her that twins may take longer to establish breastfeeding since they are
frequently born preterm and with low birth weight.
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Help the mother feed her twins
 Feeding one baby at a time until breastfeeding is well established;
 finding the best method for her twins: if one is weaker, encourage her to make sure
that the weaker twin gets enough milk. If necessary, she can express milk for him
and feed him by cup after initial breastfeeding;
 alternating the side each baby is offered daily.
Alternative feeding methods
The baby can be fed by expressing breast milk directly into his mouth or giving expressed
mother’s breast milk or appropriate formula by cup or tube.
Expressing breast milk
Hand expression is the best way to express breast milk. It is less likely to carry infection than
a pump, and can be used by every woman at any time. A technique to express milk effectively
is described in the WHO breastfeeding counselling course.19
Show the mother how to express breast milk and let her do it. Do not express her milk for


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Show the mother how to express breast milk and let her do it. Do not express her milk for
her. To establish lactation and feed a small baby she should start expressing milk on the first
day, within six hours of delivery, if possible. She should express as much as she can and as often
as the baby would breastfeed. This means at least every 3 hours, including during the night. To
build up her milk supply, if it seems to be decreasing after a few weeks, she should express her
milk very often for a few days (every hour) and at least every 3 hours during the night.
Mothers often develop their own style of hand expression once they have learned the basic
principles. Some will express both breasts at the same time, leaning forward with a container
between their knees and pausing every few minutes to let the sinuses refill with breast milk.
Every mother will find her own rhythm, which is usually slow and regular. Encourage mothers


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Every mother will find her own rhythm, which is usually slow and regular. Encourage mothers
to express breast milk their own way, providing it works for them.
If a mother is expressing more milk than her small baby needs, let her express the second
half of the milk from each breast into a different container. Let her offer the second half of
the expressed breast milk first. This way the baby gets more hind milk, which gives him the
extra energy he needs and helps him grow better. If the mother can only express very small
volumes at first, give whatever she can produce to her baby and supplement with formula
milk if necessary.
Expressing breast milk takes time, patience and forward planning. Ask the mother to start
at least half an hour before the baby’s feed, irrespective of the method used. If possible, use
freshly expressed breast milk for the next feed. If there is more milk than the baby needs, it
can be stored in a refrigerator for up to 48 hours at 4°C.
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Expressing breast milk directly into baby’s mouth
Breast milk can be expressed directly into the baby’s mouth, but the mother should first
become familiar with expressing breast milk by hand.
The baby can be fed while in kangaroo position
 Hold the baby in skin-to-skin contact, the mouth close to the nipple;
 wait until the baby is alert and opens mouth and eyes (very small babies may need
light stimulation to be kept awake and alert);
 express a few drops of breast milk;
 let the baby smell and lick the nipple, and open the mouth;
 express breast milk into the baby’s open mouth;
 wait until baby swallows the milk;
 repeat the procedure until the baby closes his mouth and will take no more breast milk
even after stimulation;
 ask the mother to repeat this operation every hour if the baby weighs less than 1200g
and every two hours if the baby weighs more than 1200g;
 be flexible at each feed, but check that the intake is adequate by measuring the daily


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 be flexible at each feed, but check that the intake is adequate by measuring the daily
weight gain.
Experience shows that mothers learn this method quickly. Moreover, it has an advantage over
other methods since no utensils are required, thus ensuring good hygiene. It is not possible,
however, to assess the amount of milk given, especially at the beginning, when it could be too
small for the baby’s needs. Later, it can be assumed to be adequate as long as the baby is
gaining weight (see below). The method has, however, not been assessed systematically and
compared to other methods.
Cup-feeding
Cups and other traditional utensils such as the “paladai” in India53 can be used to feed even
very small babies, as long as they swallow the milk.59,60 For details of cup-feeding techniques, see
the WHO breastfeeding counselling course (pp. 340-344).19
Mothers can easily learn this technique and feed their babies with adequate amounts of milk.


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Mothers can easily learn this technique and feed their babies with adequate amounts of milk.
Cup-feeding presents a few advantages over bottle-feeding since it does not interfere with
suckling at the breast; a cup is easily cleaned with soap and water, if boiling is not possible, and
enables the baby to control his own intake. At first, the mother may prefer to take the baby out
of the kangaroo position.
Syringe or dropper-feeding
The technique is similar to that for expressing breast milk in baby’s mouth: measure the
required amount of breast milk in a cup and pour it directly into the baby’s mouth with a
regular or special spoon, syringe or dropper. Some more milk is given once the baby has
swallowed the given amount. Spoon-feeding takes longer than cup-feeding and spillage can
be substantial. Feeding with syringes and droppers is not faster than cup-feeding. Moreover,
syringes and droppers are more difficult to clean and more expensive.
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Bottle-feeding
This is the least preferred feeding method and is not recommended. It may hinder breathing
and oxygenation61, 62 and it interferes with suckling. Bottles and teats must be sterilized in
institutions, and boiled at home.
Tube-feeding
Tube-feeding is used when the baby cannot yet swallow, or coordinate swallowing and
breathing, or tires too easily and does not get enough milk. While the health worker inserts
the tube and prepares the syringe or dropper, mother can let the baby suck her breast.
The baby can be tube-fed in the kangaroo position.
How to insert a tube
 Take the baby out of the kangaroo position, wrap her in a warm cloth and place her on
a warm surface;
 insert the tube through the baby’s mouth rather than the nose: small babies breathe
through the nose and the tube placed in the nostrils may obstruct breathing;
 use No. 5 to No. 8 French gauge short feeding tubes, depending on the size of the
infant;


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 use No. 5 to No. 8 French gauge short feeding tubes, depending on the size of the
infant;
 measure and mark the distance from the mouth to the ear and to the lower tip of the
sternum on the tube with a felt pen;
 pass the tube through the mouth into the stomach until the felt pen mark reaches the
lips; baby’s breathing should be normal with the tube in place;
 secure the tube to the infant’s face with a tape;
 replace the tube every 24-72 hours. Keep it closed or pinched while removing it to
avoid dripping fluid into the baby’s throat.
How to prepare and use the syringe
 Determine the amount of milk for the feed (Table 3);
 choose the corresponding size syringe;
 remove the piston from the syringe and discard it;
 attach the syringe to the tube;
 pour the required amount of breast milk into the syringe;
 hold the syringe barrel above baby’s stomach and let the milk flow by gravity;
do not inject the milk;


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do not inject the milk;
 observe the baby during feeding for any change in breathing and spilling;
 when feeding is completed close off the tube with a spigot;
 during tube-feeding baby can suck the breast or the mother’s finger (Fig.8).
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KANGAROO MOTHER CARE
As soon as the baby shows signs of readiness for oral feeding (breastfeeding or cup, spoon,
syringe, or dropper-feeding), feed at first once or twice a day, while the baby is still mostly fed
through a tube. Gradually reduce tube feeds and remove the tube when the baby takes at least
three consecutive feeds of breast milk by cup.
Quantity and frequency
Frequency of feeding will depend on the quantity of milk the baby tolerates per feed and the
required daily amount. As a guide, the amount per feed for small newborn preterm babies
should be steadily increased as follows:
(cid:1) up to day 5 slowly increase the total amount and the amount per feed, to help the
newborn infant get used to enteral feeding;
(cid:1) after day 5 steadily increase the quantity to achieve the amount required for the baby’s age as
indicated in Tables 2 and 3;
(cid:1) by day 14 the baby should take 200ml/kg/day, which is the amount required for steady growth.


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Table 3 shows the approximate amount and number of feeds required as the baby grows
older. Avoid overfeeding or feeding too rapidly to lessen the risk of milk aspiration or
abdominal distension.
Very small babies should be fed every two hours, larger babies every three hours. If necessary,
wake mother and baby during the day and night to ensure regular feeding.
Table 2. Amount of milk (or fluid) needed per day by birth weight and age
Birth weight Feed every Day 1 Day 2 Day 3 Day 4 Day 5 Days 6-13 Day 14
1000-1499g 2 hours 60 ml/kg 80 ml/kg 90 ml/kg 100 ml/kg 110 ml/kg 120-180 180-200
≥1500 g 3 hours ml/kg ml/kg
Table 3. Approximate amount of breast milk needed per feed by birth weight and age
Birth weight Number Day 1 Day 2 Day 3 Day 4 Day 5 Days 6-13 Day 14
of feeds
1000g 12 5 ml/kg 7 ml/kg 8 ml/kg 9 ml/kg 10 ml/kg 11-16 ml/kg 17 ml/kg
1250g 12 6 ml/kg 8 ml/kg 9 ml/kg 11 ml/kg 12 ml/kg 14-19 ml/kg 21 ml/kg
1500g 8 12 ml/kg 15 ml/kg 17 ml/kg 19 ml/kg 21 ml/kg 23-33 ml/kg 35 ml/kg


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1500g 8 12 ml/kg 15 ml/kg 17 ml/kg 19 ml/kg 21 ml/kg 23-33 ml/kg 35 ml/kg
1750g 8 14 ml/kg 18 ml/kg 20 ml/kg 22 ml/kg 24 ml/kg 26-42 ml/kg 45 ml/kg
2000g 8 15 ml/kg 20 ml/kg 23 ml/kg 25 ml/kg 28 ml/kg 30-45 ml/kg 50 ml/kg
Transition from an alternative feeding method to exclusive breastfeeding may occur earlier
in larger babies and much later in very small babies and may take a week. Encourage mother
to start breastfeeding as soon as the baby shows signs of readiness. At the beginning the baby
may not suckle long enough but even short sucking stimulates milk production and helps the
baby to “practice”. Keep reassuring the mother and helping her with breastfeeding the baby.
As the baby grows, gradually replace scheduled feeding with feeding on demand.
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When the baby moves on to exclusive breastfeeding and measuring the amount of milk intake
is not possible, weight gain remains the only way to assess whether feeding is adequate.
Fig.8 Tube-feeding in KMC
If the mother is HIV-positive and chooses replacement feeding, suggest using cup-feeding.
For further information on this issue, please refer to HIV and infant feeding counselling
course.20
4.8 Monitoring growth
Weight
Weigh small babies daily and check weight gain to assess first the adequacy of fluid intake
and then growth. Small babies lose weight at first, immediately after birth: weight loss of up to
10% in the first few days of life has been considered acceptable. After the initial weight loss,
newborn babies will slowly regain birth weight, usually between 7 and 14 days after birth. After
that babies should be gaining weight, a little at the beginning, more later on. No weight loss is


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that babies should be gaining weight, a little at the beginning, more later on. No weight loss is
acceptable though after this initial period. Good weight gain is considered a sign of good health,
poor weight gain is a serious concern. There is no upper limit for weight gain for breastfed
infants, but the lower limit should be no less than 15g/kg/day.
Adequate daily weight gain from the second week of life is15g/kg/day.
Approximate weight gains for different post-menstrual ages are given
below:
(cid:1) 20g/day up to 32 weeks of post-menstrual age, corresponding approximately
to 150-200g/week;
(cid:1) 25g/day from 33 to 36 weeks of post-menstrual age, corresponding approximately
to 200-250g/week;
(cid:1) 30g/day from 37 to 40 weeks of post-menstrual age, corresponding approximately
to 250-300g/week.
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KANGAROO MOTHER CARE
There are no universally accepted recommendations regarding frequency of growth
monitoring for LBW and preterm infants. There is no universal reference chart for plotting the
postnatal weight gain of those babies but intrauterine growth charts by week of gestation, with
percentiles or standard deviations, are used instead.
It is not known whether an extrauterine growth similar to the one the preterm infant would
have had in utero is an appropriate criterion for monitoring postnatal weight gain. It seems
reasonable, however, to aim for a weight of at least 2500g or more by the 40th week of
post-menstrual age.
The following recommendations are based on experience
 Weigh babies once a day; more frequent weighing might upset the baby and be a
cause of anxiety and concern for the mother. Once the baby has started gaining
weight, weigh every second day for a week and then once weekly until the baby has
reached full term (40 weeks or 2500g);


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reached full term (40 weeks or 2500g);
 weigh the baby in the same way every time, i.e. naked, with the same calibrated scales
(with 10g intervals if possible), placing a clean warm towel on the scales to avoid
cooling the infant;
 weigh the baby in a warm environment;
 if you have a local weight chart showing the expected intrauterine growth, plot the
weight on the graph to monitor growth.
Growth monitoring, especially for daily weight gain, requires accurate and precise scales
and a standardized weighing technique. Spring scales are not precise enough for frequent
monitoring of weight gain when weight is low, and may lead to wrong decisions. Analogue
maternity hospital scales (with 10g intervals) are the best alternative. If such accurate and
precise scales are not available, do not weigh KMC infants daily but rely on weekly weighing
for growth monitoring. Weight is recorded on a weight chart and weight gain is assessed daily
or weekly.
Head circumference


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or weekly.
Head circumference
Measure head circumference weekly. Once baby is gaining weight, head circumference will
increase by between 0.5 and 1cm per week. For adequacy of head growth refer to national
anthropometric standards.
Alternative methods for monitoring growth
Alternative methods, such as measuring baby’s length, and chest and arm circumference, are
less useful for growth monitoring and are not recommended for the following reasons:
– length is less reliable than weight. It increases more slowly and does not help to make
decisions about feeding or illness;
– surrogates, such as chest and arm circumference, have been proposed to assess size
at birth and as a tool to evaluate the need for special care.63, 64 Their effectiveness for
growth monitoring in LBW and preterm infants has not yet been assessed.
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4.9 Inadequate weight gain
If weight gain is inadequate for several days, first assess the feeding technique, frequency,
duration and schedule, and check that night feeds are given. Advise the mother to increase
the frequency of feeds or to feed on demand. Encourage her to drink fluids when thirsty.
Then look for other conditions as possible reasons for poor weight gain:
(cid:1) oral thrush (white patches in the mouth) can interfere with feeding. Treat the baby by giving her
an oral suspension of nystatin (100,000 IU/ml); use a dropper to apply 1ml in the oral mucosa
and paint the mother’s nipples after each feed until the lesions heal. Treat for 7 days;
(cid:1) rhinitis is quite disturbing for the baby because it interferes with feeding. Nasal drops of normal
saline solution in each nostril before each feed may help to relieve nasal obstruction;
(cid:1) urinary tract infection is a possible insidious cause. Investigate if the baby fails to grow without


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obvious reasons. Treat according to national/local treatment guidelines;
(cid:1) severe bacterial infection can initially manifest itself with poor weight gain and poor feeding.
If a previously healthy baby becomes unwell and stops feeding, consider this as a serious danger
sign. Investigate for infection and treat according to national/local treatment
guidelines.
Other causes of failure to gain weight include patent ductus arteriosus and other diseases
that may be difficult to diagnose in settings with scarce resources. Refer the baby who fails to
gain weight after the exclusion or treatment of the above common causes to a higher level of
care, for further investigation and treatment.
If a mother’s breast milk supply is reduced and does not satisfy baby’s needs, she must in-
crease it. This often happens where there is a breastfeeding difficulty: baby is not suckling well,
the mother has been away or sick and stopped feeding her baby (on increasing breast milk and


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the mother has been away or sick and stopped feeding her baby (on increasing breast milk and
relactation see the WHO breastfeeding counselling course, pp 348-358,19 and the WHO
document Relactation: A review of experience and recommendations for practice 65 ). This should be
the first step before turning to other methods.
Lactogogues
Herbal teas obtained from sesame, fenugreek, fennel, cumin, basil and aniseed have not been
proven effective in increasing breast milk production. Beer and other alcoholic drinks used
in some cultures to increase lactation should be discouraged since alcohol in breast milk is
dangerous for babies.66, 67 Domperidone can help increase milk supply. It could be used as a
supportive procedure and only after all other effective methods for improving milk production
have been tried out. Always follow national guidelines.
If despite all these efforts the baby is not gaining weight, consider supplementing


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If despite all these efforts the baby is not gaining weight, consider supplementing
breastfeeding with preterm formula, given by cup after each feed. To prepare formula milk
follow the instructions on the box.
Do not make important decisions about formula supplementation on the basis of daily
weight, since this is subject to large variations. Only weight change over a few days, or weekly
weight gain, is a good basis for such decisions.
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KANGAROO MOTHER CARE
Discuss with the mother whether this is a feasible, affordable and safe option that will
be available for several months. Show her how to prepare it and give it safely. Follow the
instructions on the package. Return to exclusive breastfeeding as soon as possible after the
infant has gained weight for some time. Monitor more closely the health and growth of small
infants fed or supplemented with formula since they are more exposed than breastfed babies to
infection and malnutrition. Try, if at all possible, not to discharge a small baby with formula
supplements.
Ensure that the facility follows the rules prescribed by the International Code of Marketing of
Breast-milk Substitutes, issued by WHO.68
4.10 Preventive treatment
Small babies are born without sufficient stores of micronutrients. Preterm babies, irrespective
of weight, should receive iron and folic acid supplementation from the second month of life


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of weight, should receive iron and folic acid supplementation from the second month of life
until one year of chronological age. The recommended daily dose of iron is 2mg/kg body
weight/day.
 Explain to the mother that:
– iron is essential for baby’s health and growth;
– the baby needs to take iron regularly: at the same time every day, after breastfeeding;
– baby’s stools may become darker, which is normal.
Explore her concerns.
4.11 Stimulation
All infants need love and care to flourish, but very preterm babies need even more attention
to be able to develop normally since they have been deprived of an ideal intrauterine environment
for weeks or even months. They are instead exposed to too much light, noise and painful stimuli
during their initial care. KMC is an ideal method since the baby is rocked and cuddled, and
listens to the mother’s voice while she goes about her everyday activities. Fathers too can


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listens to the mother’s voice while she goes about her everyday activities. Fathers too can
provide such an environment. Health workers have an important role to play in encouraging
mothers and fathers to express their emotions and love to their babies.
However, if the baby has other problems due to preterm birth or its complications, additional
treatment may be necessary. Guidance on such treatment can be found in standard textbooks or
in the WHO manual Managing newborn problems. A guide for doctors, nurses and midwives.56
4.12 Discharge
Discharge means letting the mother and baby go home. Their own environment, however,
could be very different from the KMC unit at the facility, where they were surrounded by
supportive staff. They will continue to need support even though this will not have to be as
intensive and frequent. The time of discharge may therefore vary depending on the size of the
baby, bed availability, home conditions and accessibility of follow-up care. Usually, a KMC


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baby, bed availability, home conditions and accessibility of follow-up care. Usually, a KMC
baby can be discharged from the hospital when the following criteria are met:
(cid:1) the baby’s general health is good and there is no concurrent disease such as apnoea or infection;
(cid:1) he is feeding well, and is exclusively or predominantly breastfed;
(cid:1) he is gaining weight (at least 15g/kg/day for at least three consecutive days);
38


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(cid:1) his temperature is stable in the KMC position (within the normal range for at least three
consecutive days);
(cid:1) the mother is confident in caring for the baby and is able to come regularly for follow-up visits.
These criteria are usually met by the time the baby weighs more than 1500g.
The home environment is also very important for the successful outcome of KMC. The mother
should go back to a warm, smoke-free home and should have support for everyday household tasks.
Where there are no follow-up services and the hospital is far away, mother and baby should
be discharged later.
Immunize the baby according to national policy and give enough iron/folate tablets to last
until the follow-up visit. Fill in the home-based baby’s record. Ensure that the mother knows:
(cid:1) how to apply skin-to-skin contact until baby shows signs of discomfort;
(cid:1) how to dress the baby, when he is not in kangaroo position, to keep him warm at home;


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(cid:1) how to dress the baby, when he is not in kangaroo position, to keep him warm at home;
(cid:1) how to bath the baby and keep him warm after the bath;
(cid:1) how to respond to baby’s needs such as increasing the duration of skin-to-skin contact if he has
cold hands and feet or low temperature at night;
(cid:1) how to breastfeed the baby during the day and night according to instructions;
(cid:1) when and where to return for follow-up visits (schedule the first visit and give the mother
written/pictorial instructions for the above issues);
(cid:1) how to recognize danger signs;
(cid:1) where to seek care urgently if danger signs appear;
(cid:1) when to wean the baby from KMC.
She should return immediately to hospital, or go to another appropriate
provider, if the baby:
(cid:1) stops feeding, is not feeding well, or vomits;
(cid:1) becomes restless and irritable, lethargic or unconscious;
(cid:1) has fever (body temperature above 37.5°C);


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(cid:1) has fever (body temperature above 37.5°C);
(cid:1) is cold (hypothermia - body temperature below 36.5°C) despite rewarming;
(cid:1) has convulsions;
(cid:1) has difficulty breathing;
(cid:1) has diarrhoea;
(cid:1) shows any other worrying sign.
Tell the mother that it is always better to seek help, if in doubt: when caring for small
infants it is better to seek care too often than to disregard important symptoms.
Early discharge becomes a goal for the mother as she gains confidence in her ability to care
for her baby. A baby can be discharged earlier if the following criteria are met:
(cid:1) adequate information on home care is given at discharge to mothers and their families, preferably
as written and pictorial instructions;
(cid:1) mothers have received instructions on danger signs, and know when and where to seek care.
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KANGAROO MOTHER CARE
4.13 KMC at home and routine follow-up
Ensure follow-up for the mother and the baby, either at your facility or with a skilled provider
near the baby’s home. The smaller the baby is at discharge, the earlier and more frequent
follow-up visits he will need. If the baby is discharged in accordance with the above criteria,
the following suggestions will be valid in most circumstances:
– two follow-up visits per week until 37 weeks of post-menstrual age;
– one follow-up visit per week after 37 weeks.
The content of the visit may vary according to mother’s and baby’s needs; check the follow-
ing, however, at each follow-up visit:
KMC
Duration of skin-to-skin contact, position, clothing, body temperature, support for the
mother and the baby. Is the baby showing signs of intolerance? Is it time to wean the baby
from KMC (usually at around 40 weeks of post-menstrual age, or just before)? If not,
encourage the mother and family to continue KMC as much as possible.


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encourage the mother and family to continue KMC as much as possible.
Breastfeeding
Is it exclusive? If yes, praise the mother and encourage her to continue. If not, advise her on
how to increase breastfeeding and decrease supplements or other fluids. Ask and look for any
problem and provide support. If the baby is taking formula supplements or other foods,
check their safety and adequacy; make sure that the family has the necessary supply.
Growth
Weigh the baby and check weight gain in the last period. If weight gain is adequate, i.e. at
least 15g/kg/day on average, praise the mother. If it is inadequate, ask and look for possible
problems, causes and solutions; these are generally related to feeding or illness. To check
adequate daily weight gain please refer to box on page 37.
Illness
Ask and look for any signs of illness, reported by the mother or not. Manage any illness
according to your local protocols and guidelines. In case of non-exclusive breastfeeding, ask


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according to your local protocols and guidelines. In case of non-exclusive breastfeeding, ask
and look particularly for signs of nutritional or digestive problems.
Drugs
Give a sufficient supply of drugs, if needed, to last until the next follow-up visit.
Immunization
Check that the local immunization schedule is being followed.
Mother’s concerns
Ask the mother about any other problem, including personal, household, and social
problems. Try to help her find the best solution for all of them.
Next follow-up visit
Always schedule or confirm the next visit. Do not miss the opportunity, if time allows, to
check and advise on hygiene, and to reinforce the mother’s awareness of danger signs that
need prompt care.
Special follow-up visits
If these are required for other medical or somatic problems, encourage the mother to attend
them and help her if needed.
Routine child care
Encourage the mother to attend routine child care once the baby reaches 2500g or 40 weeks
of post-menstrual age.
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47 Affonso D, et al. Reconciliation and healing for mothers through skin-to-skin contact provided in an
American tertiary level intensive care nursery. Neonatal Network, 1993,12:25-32.
48 Legault M, Goulet C. Comparison of kangaroo and traditional methods of removing preterm infants
from incubators. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 1995, 24:501-506.
49 Bell EH, Geyer J, Jones L. A structured intervention improves breast-feeding success for ill or preterm
infants. American Journal of Maternal and Child Nursing, 1995, 20:309-314.
50 Tessier R, et al. Kangaroo mother care and the bonding hypothesis. Pediatrics, 1998, 102:390-391.
51 Hylander MA, Strobino DM, Dhanireddy R. Human milk feedings and infection among very low
birth weight infants. Pediatrics, 1998, 102:E38.
52 Schanler RJ, Shulman RJ, Lau C. Feeding strategies for premature infants: beneficial outcomes of
feeding fortified human milk versus preterm formula. Pediatrics, 1999, 103:1150-1157.


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feeding fortified human milk versus preterm formula. Pediatrics, 1999, 103:1150-1157.
53 Malhotra N, et al. A controlled trial of alternative methods of oral feeding in neonates. Early Human
Development, 1999, 54:29-38.
54 Sontheimer D, et al. Pitfalls in respiratory monitoring of premature infants during kangaroo care.
Archives of Disease in Childhood, 1995, 72:F115-117.
55 Lubchenco LO, et al. Intrauterine growth as estimated from live born birth weight data at 24 to 42
weeks of gestation. Pediatrics, 1963, 32:793-800.
56 Managing newborn problems. A guide for doctors, nurses and midwives. Geneva, World Health
Organization (in press).
57 Jenni OG, et al. Effect of nursing in the head elevated tilt position (15 degrees) on the incidence of
bradycardic and hypoxemic episodes in preterm infants. Pediatrics, 1997, 100:622-625.
58 Ludington-Hoe SM, Hadeed AJ, Anderson GC. Physiologic responses to skin-to-skin contact in


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58 Ludington-Hoe SM, Hadeed AJ, Anderson GC. Physiologic responses to skin-to-skin contact in
hospitalized premature infants. Journal of Perinatology, 1991, 11:19-24.
59 Gupta A, Khanna K, Chattree S. Cup feeding: an alternative to bottle feeding in a neonatal intensive
care unit. Journal of Tropical Pediatrics, 1999, 45:108-110.
60 Lang S, Lawrence CJ, Orme RL. Cup feeding: an alternative method of infant feeding. Archives of
Disease in Childhood, 1994, 71:365-369.
61 Bier JB, et al. Breast-feeding of very low birth weight infants. Journal of Pediatrics, 1993, 123:
773-778.
62 Poets CF, Langner MU, Bohnhorst B. Effects of bottle feeding and two different methods of gavage
feeding on oxygenation and breathing patterns in preterm infants. Acta Paediatrica, 1997, 86:
419-423.
63 Birth weight surrogates: The relationship between birth weight, arm and chest circumference. Geneva, World
Health Organization, 1987.


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Health Organization, 1987.
64 Diamond JD, et al. The relationship between birth weight and arm and chest circumference in Egypt.
Journal of Tropical Pediatrics, 1991, 37:323-6.
65 Relactation: A review of experience and recommendations for practice. Geneva, World Health Organization,
1998 (WHO/CHS/CAH/98.14).
66 Mennella JA, Gerrish CJ. Effects of exposure to alcohol in mother’s milk on infant sleep. Pediatrics,
1998, 101:E2.
67 Rosti L, et al. Toxic effects of a herbal tea mixture in two newborns. Acta Paediatrica, 1994, 83:683.
68 International code of marketing of breast-milk substitutes. Geneva, World Health Organization, 1981
(HA34/1981/REC/1, Annex 3).
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Annexes
I Records and indicators
Clinical records for hospital and follow-up care of small babies vary from place to place and
according to the level of care offered to LBW and preterm infants. Essential information on
KMC, when this is part of the care programme, must also be recorded. The following additional
information should be recorded daily:
(cid:1) For the baby hospital record:
– when KMC began (date, weight and age);
– condition of the baby;
– details on duration and frequency of skin-to-skin contact;
– whether the mother is hospitalized or is coming from home;
– predominant feeding method;
– observations about lactation and feeding;
– daily weight gain;
– episodes of illness, other conditions or complications;
– the drugs baby is receiving;
– details on discharge: condition of the baby, maternal readiness, conditions at home that
make discharge possible; date, age, weight and post-menstrual age at discharge; feeding


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make discharge possible; date, age, weight and post-menstrual age at discharge; feeding
method and instructions for follow-up (where, when and how frequently).
Mother should be given a discharge letter summarizing the course of hospitalization and
instructions for home care, medication and follow-up. It is also necessary to record whether the
baby was transferred to another institution or died.
(cid:1) The follow-up record should contain, besides the usual data on the baby, the following
information:
– when the baby was first seen (date, age, weight and post-menstrual age);
– feeding method;
– daily duration of skin-to-skin contact;
– any concerns mother may have;
– whether baby has to be or has been readmitted to hospital;
– when mother stopped skin-to-skin contact (date, age of the baby, weight, post-menstrual
age, reasons for stopping and feeding method at weaning);
– other important remarks.


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age, reasons for stopping and feeding method at weaning);
– other important remarks.
If the follow-up care is provided at the facility where the baby was hospitalized, the hospital
record and the follow-up record should be a single document. If this cannot be done, the two
records must be linked by an identification number. The records can obviously be used to
develop an electronic database. The follow-up record presented in this annex is derived from
those used by KMC programmes in some countries.
45


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KANGAROO MOTHER CARE
An example of how information on KMC can be added to the follow-up record:
Date of visit .. /.. /.... .. /.. /.... .. /.. /.... .. /.. /.... .. /.. /.... .. /.. /.... .. /.. /.... .. /.. /....
Age
Weight
weight gain
Feeding
method
Average daily
duration of
skin-to-skin
contact
Complaints
Readmission
to hospital
Weaned Reasons for weaning and other comments
Date
Age (in days)
Post-menstrual age
Weight
These data will provide basic information for daily baby care and process and outcome
indicators for programme monitoring.
(cid:1) When KMC forms part of a care programme for small babies it is important to know the
following:
– the number of small babies (<2000g and/or <34 weeks) treated and the proportion
receiving KMC;
– mean age at start of KMC (stratified by weight and gestational age at birth, and weight
and post-menstrual age when starting);
– type of KMC (predominant or partial);
– mean duration of KMC (in days);


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– type of KMC (predominant or partial);
– mean duration of KMC (in days);
– mean weight gain during KMC in institution and at home;
– mean age of weaning from KMC (stratified by weight and gestational age at birth, and weight
and post-menstrual age when starting);
– feeding method for babies at weaning from KMC (exclusively/partly breastfed, or not
breastfed);
– proportion of babies needing hospitalization during home KMC;
– death rate during KMC, at institution and at home.
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II Birth weight and gestational age
At different gestational ages birth weight can vary by about one kilogram; at a given weight
babies can be of different gestational ages.
Table 4. Mean birth weights (g) with 10th and 90th percentiles by gestational age
Gestational age Mean birth weight 10th percentile 90th percentile
28 1200 900 1500
29 1350 1000 1650
30 1500 1100 1750
31 1650 1200 2000
32 1800 1300 2350
33 2000 1500 2500
34 2250 1750 2750
35 2500 2000 3000
36 2750 2250 3250
37 3000 2450 3500
38 3200 2650 3700
39 3350 2800 3900
40 3500 3000 4100
47


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KANGAROO MOTHER CARE
III Constraints
KMC has been included in national guidelines for the care of LBW and preterm infants,
and successfully implemented in many countries. Experience shows that the main problems,
obstacles and constraints fall under four categories: policy, implementation, communication and
feeding. Some possible solutions are suggested in Table 5.
Table 5. Implementing KMC
Problems, obstacles and constraints Possible solutions
Policy
(cid:2)Lack of plans, policies, guidelines, protocols, manuals (cid:2)Development of plans, policies, guidelines, protocols, manuals
(cid:2)Lack of institutional, academic and professional support (cid:2)Establishing links with ministries, medical schools, agencies and
organizations; advocacy work
(cid:2)Lack of adequate training and continuous education (cid:2)Establishing basic, post-graduate and in-service courses
(cid:2)Risk of an isolated and vertical programme (cid:2)Integration with existing programmes


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(cid:2)Risk of an isolated and vertical programme (cid:2)Integration with existing programmes
(cid:2)Poor access to evidence, literature and documentation (cid:2)Creation of local and regional libraries; links with
main documentation centres
(cid:2)Legal problems (e.g. KMC not included in the interventions (cid:2)Proposing changes to existing laws, rules and regulations;
financed by the health care system) involving mothers and families
Implementation
(cid:2)Resistance of managers, administrators and health workers (cid:2)Adequate information on effectiveness, safety, feasibility and cost
(cid:2)Poor facilities, equipment, supplies, organization, (cid:2)Improving structure and organization, procurement of
lack of time basic equipment; ensuring supplies
(cid:2)Cultural problems: misguided beliefs, attitudes, practices (cid:2)Appropriate training and information strategies, community
participation
(cid:2)Apparent initial increase of workload (cid:2)Introducing changes step-by-step


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participation
(cid:2)Apparent initial increase of workload (cid:2)Introducing changes step-by-step
(cid:2)Redistribution of tasks, multidisciplinary approach (cid:2)Writing new job descriptions, encouraging team work and
frequent joint review of problems
(cid:2)Resistance of mothers and families (cid:2)Hospital and community support groups
(cid:2)Lack of monitoring and evaluation (cid:2)Gathering, analysing and discussing standard data
Communication
(cid:2)Mothers and families unaware of KMC (cid:2)Adequate information in the antenatal period and at the referral
facility
(cid:2)Poor communication and support in hospital and during (cid:2)Improving communication and support skills of health workers
follow-up
(cid:2)Inadequate community and family support (cid:2)Community meetings, mass media, hot lines
(cid:2)Hostility of politicians and other health professionals (cid:2)Articles, newsletters, interest groups, testimonies
Feeding


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Feeding
(cid:2)Low rate of exclusive breastfeeding after long separation (cid:2)Reducing separation as much as possible; implementation
of infants from mothers of feeding guidelines
(cid:2)Difficult growth monitoring, lack of adequate standards (cid:2)Accurate scales, appropriate growth charts, clear instructions
(cid:2)Inadequate growth despite good implementation (cid:2)Good skills for assessing breastfeeding and alternative
of breastfeeding guidelines feeding methods
(cid:2)High prevalence of HIV-positive mothers (cid:2)Voluntary counselling and testing of parents; infant feeding
counselling, appropriate replacement feeding for preterm infants;
safe alternatives to breast milk; pasteurisers
48


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What is KMC
A special way of caring for Low birth

weight (LBW) babies
It promotes

Effective thermal control

Breast feeding

Prevention of infection

Parental bonding

Teaching Aids: NNF KMC-2


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Components of KMC
Skin-to-skin contact

Early, continuous and
prolonged skin-to-
skin contact
Exclusive breast

feeding
Promotes lactation
and facilitates
feeding
Teaching Aids: NNF KMC-3


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Pre-requisites of KMC
Support to the mother

In hospital &

At home

Post-discharge follow up

Teaching Aids: NNF KMC-4


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Benefits of KMC
Breast feeding

Increased breast feeding rates

Increased duration of breast feeding

Thermal control

Effective thermal control

Equivalent to conventional incubator

care
Teaching Aids: NNF KMC-5


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Benefits of KMC (cont..)
Early discharge

Better weight gain ______.

Early discharge
Lesser morbidity

Regular breathing

Decreased episodes of apnea

Protection from nosocomial infections

Teaching Aids: NNF KMC-6


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Benefits of KMC (cont..)
Other benefits

Less stress to the infant

Stronger bonding

Deep satisfaction for mother

More confident parents

Teaching Aids: NNF KMC-7


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Requirements for KMC
implementation
Training

Nurses, physicians and other staff
Educational material

Information sheets, posters and video films on KMC
Furniture

Semi-reclining easy chairs
Beds with adjustable back rest
Teaching Aids: NNF KMC-8


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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
Teaching Aids: NNF KMC-9


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Eligibility criteria: Mother
Willingness

General health & nutrition

Hygiene

Supportive family

Supportive community

Teaching Aids: NNF KMC-10


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Preparing for KMC
Counseling

Demonstrate procedure

Ensure family support

KMC support group

Mother’s clothing

Front-open, light dress as per the local culture

Baby’s clothing

Cap, socks, nappy and front-open sleeveless shirt

or ‘jhabala’
Teaching Aids: NNF KMC-11


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KMC procedure:
Kangaroo positioning
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

Teaching Aids: NNF KMC-12


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KMC procedure:
Kangaroo positioning (cont..)
Head turned
to one side
Baby between
mother’s breasts
Frog-leg
Support baby’s
position
bottom
Teaching Aids: NNF KMC-13


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Monitoring during KMC
Check if
Neck position is neutral

Airway is clear

Breathing is regular

Color is pink

Temperature is being maintained

Teaching Aids: NNF KMC-15


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Initiation of KMC
Baby should be stable

Short KMC sessions can be initiated even if

the baby is receiving
IV fluids

Oxygen therapy

Orogastric tube feeding

Teaching Aids: NNF KMC-16


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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

Teaching Aids: NNF KMC-17


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KMC during sleep and resting
Resting
Reclining or semi-recumbent position

Adjustable bed

Several pillows on an ordinary bed

Easy reclining chair

Sleep
Supporting garment restraint for baby

Teaching Aids: NNF KMC-18


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Any family member can do it !
Grandmother
Father
Father & other family members can
also provide skin-to-skin care
Teaching Aids: NNF KMC-21


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Criteria for transfer
From nursery to ward
Stable baby

Gaining weight

Mother confident of looking after the

baby
Teaching Aids: NNF KMC-22


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Discharge criteria
Baby is well with no evidence of infection

Feeding well (predominant breast milk)

Gaining weight (15-20 gm/kg/day)

Maintaining body temperature (in room

temperature)
Mother confident of taking care of the baby

Follow-up visits ensured

Teaching Aids: NNF KMC-23


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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
Teaching Aids: NNF KMC-24


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Post-discharge f ollow up
Once or twice a week till 37-40 wks / 2.5-3 kg

Thereafter, once in 2-4 wks till 3 months PCA

Subsequently, every 1-2 months during first

year
More frequent visits if baby is not growing

well (< 15-20 gm/kg/day up to 40 weeks PCA
and then < 10 gm/kg/day)
Teaching Aids: NNF KMC-25


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Kangaroo Mother Care
&
optiMal feeding of low birth weight infants
Operational Guidelines | September 2014
For Programme Managers & Service Provider
Child Health Division
Ministry of Health and Family Welfare
Government of India


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FOrewOrD
Birth Weight is a reliable and sensitive indicator for predicting the immediate and long term
outcome of a newborn. Low Birth Weight (LBW) is a challenging multifaceted public health
problem because it is associated with increased risk of morbidity and mortality in infants.
Low Birth Weight newborns are four times more likely to die from common childhood
diseases in the first year of life, than their normal counterpart. The public health significance
of Low Birth Weight is accentuated by its association with mental retardation, specialized
institutional care and intensive care units. There is also emerging evidence that Low Birth
Weight neonates are more prone to Non-Communicable Diseases (NCDs) like Diabetes
Mellitus, Hypertension and Coronary Artery Disease in later life.
Kangaroo Mother Care(KMC) and optimal feeding in Low Birth Weight infants are evidence
based cost-effective interventions which, when upscaled and implemented across all facilities


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based cost-effective interventions which, when upscaled and implemented across all facilities
can save up to half a million newborns. Despite the KMC network having been established in
India in 1990s, this simple technique is still not being practiced universally across the country.
“Kangaroo Mother Care and Optimal Feeding of Low Birth Weight Infants” guidelines have
been designed to emphasize the implementation of KMC in SNCUs and Medical Colleges on
priority.
This guideline I am sure will help the service providers and programme managers alike to
implement KMC and optimal feeding and will go a long way in improving the survival and
development of low birth infants.
C.K. Mishra


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PreFaCe
Preterm births and intra-uterine growth retardation lead to low birth weight (LBW),
which is an important indirect cause of neonatal deaths. The global prevalence of
LBW is 15.5% and in India, 27% of all live births are LBW.
Kangaroo Mother Care (KMC) is a simple, cost-effective way of caring for low birth
weight infants and has been included in many guidelines and training modules
released by Government of India. It has been observed that despite undergoing
training, service providers are not adept at providing Kangaroo Mother Care for
LBW newborns. It was therefore the need of the hour to have an implementation
guideline for rolling out KMC at the facility level.
These guidelines will give a clear idea to service providers on what exactly KMC is
and how KMC techniques can be implemented when caring for low birth weight
infants. I am confident that the guidelines will also be used by programme managers


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infants. I am confident that the guidelines will also be used by programme managers
and health facility managers to establish KMC units across the country and help in
reducing neonatal mortality.
(Dr. rakesh Kumar)


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aCKnOwleDGeMent
In India, Low Birth Weight (LBW) is an important underlying cause of neonatal
mortality. Experience from world over shows that appropriate care of LBW infants,
which encompasses feeding, temperature maintenance, hygienic care, early
detection of infections and treatment of complications can substantially reduce
mortality rates.
“Kangaroo mother care”-a simple and cost effective technique was introduced
in India in 1994 and KMC Network of India was also established. Though this
intervention finds a place in various training modules it is not being implemented
across the facilities in the country.
Child Health Division, Ministry of Health & Family Welfare (MOHFW), Govt. of India
has taken a decision to implement Kangaroo Mother Care at facility level. Operational
Guidelines for “Kangaroo Mother Care and Optimal Feeding of Low birth Weight
infants” is a step towards this direction.
Dr. P.K. Prabhakar, Deputy Commissioner, MOHFW coordinated the development of


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Dr. P.K. Prabhakar, Deputy Commissioner, MOHFW coordinated the development of
these guidelines and led the team of Child Health Division and experts from various
institutions and development partners. Contribution of all experts is gratefully
acknowledged. Special thanks are due to Dr. Vinod K. Paul, Dr. A. Deorari, Dr. Rekha
Udani, Dr. Sushma Nangia and Dr. Sadhana Mehta for reviewing the draft and
helping in finalizing the guidelines. Contribution of USAID-MCHIP in coordinating
the development and printing of this guideline is also acknowledged.
(Dr. ajay Khera)


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list of ContribUtors
MINISTRY OF HEALTH AND FAMILY WELFARE
Dr. Ajay Khera
Dr. P.K. Prabhakar
Dr. Renu Srivastava
Dr. Nimisha Goel
Mr. Sharad Singh
EXPERTS
Dr. Vinod K. Paul Dr. Arun Kumar Singh Dr. Reeta Raisaily
Dr. Shashi Vani Dr. Harish Chellani Dr. R. Srinivasan
Dr. Siddharth Ram Ji Dr. Harish Kumar Prof. A.T. Arasar Seeralar
Dr. Rekha H. Udani Dr. Sachin Gupta Dr. Anju Puri
Dr. Ashok Deorari Dr. Gagan Gupta Dr. Pawan Pathak
Dr. Sushma Nangia Dr. Kanya Mukhopadhyay Dr. Rajesh Khanna
Dr. Sadhana Mehta Dr. Suman Rao Dr. Javvad Suri
Dr. J. Kumutha Dr. Rita Bora Dr. Sebanti Ghosh
Dr. Ruchi Nanavati Dr. Ramesh Agarwal Dr. Lata Bhat
LIST OF CONTRIBUTORS ix


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table of Contents
Acronyms .........................................................................................................................................................................................xiii
Introduction .......................................................................................................................................................................................1
Kangaroo Mother Care Implementation .................................................................................................................................7
Optimal Feeding of Low Birth Weight Infants .....................................................................................................................17
Action Plan for Implementation and Scale-up ...................................................................................................................27


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Annexure ..........................................................................................................................................................................................35
Annexure I: Manual Expression of Breast milk and Storage thereof ...........................................................................37
Annexure II: Alternative Feeding Methods (Cup/Spoon/Paladai Feeding) ..............................................................39
Annexure III: Follow-up Protocol after Discharge of a High-risk infant......................................................................43
Annexure IV: Infant Milk Substitutes Act ..............................................................................................................................46
Annexure V: Orientation on Kangaroo Mother Care ........................................................................................................48


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References ........................................................................................................................................................................................49
LISTTA OBFL EC OONF TCROIBNUTTEONRTSS xi


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aCronYMs
AIIMS All India Institute of Medical Sciences KMC Kangaroo Mother Care
ANM Auxiliary Nurse & Midwife KMCU Kangaroo Mother Care Unit
ASHA Accredited Social Health Activist KSCH Kalawati Saran Children’s hospital
AV aids Audio Visual aids LBW Low Birth weight
BERA Brainstem evoked response LHMC Lady Hardinge Medical College
audiometry MCH Maternal and Child Health
CC Chest Circumference MCHIP Maternal and Child Health
DEIC District Early Intervention Centre Integrated Program
FBNC Facility Based Newborn Care MEN Minimal Enteral Nutrition
F-IMNCI Facility based Integrated NHM National Health Mission
Management of Neonatal and NICU Newborn Intensive Care Unit
Childhood Illnesses
NNF National Neonatology Forum
FOGSI Federation of Obstetric and
OAE Otoacoustic Emissions
Gynaecological Societies of India
PMA Post Menstrual Age
GNM General Nursing and Midwifery
PVL Periventricular leukomalacia
HBNC Home Based Newborn Care
RBSK Rashtriya Bal Swasthya Karyakram
HC Head Circumference


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HBNC Home Based Newborn Care
RBSK Rashtriya Bal Swasthya Karyakram
HC Head Circumference
RCC Regional Collaborative Centre
Hib Haemophilus influenzae type B
RMNCH+A Reproductive, Maternal, Newborn,
IANN Indian Association of Neonatal
Child and Adolescent Health
Nurses
SGA Small for Gestational Age
IAP Indian Academy of Paediatrics
SNCU Sick Newborn Care Unit
IM Intramuscular
STS Skin-to-Skin
IMS Act Infant Milk Substitutes Act
USAID United States Agency for
IQ Intelligence Quotient
Internation Development
JSSK Janani Shishu Suraksha Karyakram
WHO-CC World Health Organization
KEM King Edward Medical College Collaborative Centre
ACRONYMS xiii


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introdUCtion
l KANGAROO MOTHER CARE (KMC)
l DEFINITIONS
l EVIDENCE FOR KMC
l PURPOSE OF THE GUIDELINES


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iinnttrrooddUUCCttiioonn
Introduction
Of the 20 million low birth weight infants born globally stabilizes body temperature, promotes breast feeding,
every year, about 8 million are in India. Over 80% of prevents infection and other morbidities. This also
neonatal deaths occur among small infants - 65% leads to early discharge, better neurodevelopment
are attributable to preterm infants and 19% to term- and encourages bonding between mother and
small for gestational age, (SGA) (Lawn Every Newborn infant. KMC is initiated in the hospital and continued
Lancet Series 2014). India has the highest number at home until the infant needs it and for optimum
of preterm births and also accounts for maximum care a regular follow-up must be ensured.
number of neonatal deaths due to prematurity.
Kangaroo mother care has following components:
Incidence of LBW in India is about 27% of total live
births. 1. Skin-to-skin contact
2. Exclusive breast feeding
Kangaroo Mother Care (KMC)


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births. 1. Skin-to-skin contact
2. Exclusive breast feeding
Kangaroo Mother Care (KMC)
However, KMC should not be confused with routine
skin-to-skin care at birth. World Health Organization
Kangaroo Mother Care is a low resource, evidence
(WHO) recommends skin-to-skin care immediately
based, high impact intervention and standardised
after delivery for every newborn, irrespective of the
care for low birth weight infants which, like
birth weight to ensure warmth and early initiation of
breastfeeding, should be part of routine care. It can
breast feeding in the delivery room KMC is meant for
prevent up to half of all deaths in infants weighing
stable LBW infants and denotes a sustained, long-
<2000g (Lawn et al, 2010).
duration skin-to-skin contact.
DEFINITIONS
Kangaroo is an animal found in Australia. She
Kangaroo Mother Care (KMC) is a simple method of
invariably delivers a premature baby. The premature,
care for low birth weight infants that includes early


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care for low birth weight infants that includes early
baby kangaroo stays in the pouch of her mother,
and prolonged skin-to-skin contact with the mother
where it gets warmth and exclusive breast feeding
(or a substitute caregiver) and exclusive and frequent
till it is mature enough to survive outside.
breastfeeding. This natural form of human care
Introduction 3


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 Better mother-infant bonding and maternal
DuratiOn OF KMC
satisfaction with the method of care, as
Short: 4 hours daily* extended: 5-8 hours daily* compared with conventional methods
long: 9-12 hours daily*
Above review included seven trials that assessed
Continuous: More than12 hours daily*
mortality at discharge or 40–41weeks and reported
*Documented on two consecutive days or more a statistically significant reduction in the risk of
prior to discharge. mortality among KMC infants (3.4%), compared
with 5.7% for infants receiving traditional care. the
Duration to be counted as cumulative completed
review ultimately concluded that KMC should be
hours during a 24 hour period.
used for all stabilized lBw infants.
there is now sufficient evidence to recommend
low birth weight (lBw) has been defined by the
the routine use of KMC for all low birth weight
World Health organization (WHO) as weight at birth
infants. However in our country newborn infants


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World Health organization (WHO) as weight at birth
infants. However in our country newborn infants
less than 2,500 grams which can be a consequence
weighing less than 2,000 grams should be started
of preterm birth or due to small size for gestational
on KMC, on priority in view of the high burden of
age or both. Preterm is defined as born before 37
lBw infants.
weeks completed and SGA is defined as weight for
gestation less than 10th percentile of the gestation
norm. Newborn infants weighing less than 2000 grams
should be started on KMC on priority.
EvIDENcE FOR KMc
other benefits
evidence of the effectiveness and safety of
KMC for clinically stable preterm newborns, is KMC is associated with reduced incidence of severe
now formally established. In 2011, an updated illness including pneumonia during infancy. In most
Cochrane review (Conde-Agudelo, Diaz-Rossello, of the studies KMC has been found to be more


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Cochrane review (Conde-Agudelo, Diaz-Rossello, of the studies KMC has been found to be more
Belizan 2011) assessed 35 studies. This review effective than incubator care for stable newborns
demonstrated even more convincing results than in: providing adequate thermal care, reducing
the previous one published in 2008. Compared nosocomial infections, improving exclusive
with conventional neonatal care, KMC was found breastfeeding and weight gain, and fostering greater
to reduce: maternal and family involvement in care—all at a
lower cost than incubator care.
 Mortality at discharge and at the latest
follow-up,
 Severe infection/sepsis, nosocomial infections, KMC satisfies all five senses of the infant. The infant
lower respiratory tract disease, feels the mother’s warmth through skin-to-skin
contact (touch), listens to her voice and heartbeat
 Hypothermia and length of hospital stay.
(hearing), sucks breast milk (taste) has eye contact


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 Hypothermia and length of hospital stay.
(hearing), sucks breast milk (taste) has eye contact
The 2011 review also revealed that KMC resulted in: with her (vision) and smells her odor (olfaction).
 Improved weight, length and head
circumference,
Management of LBW is covered in various training
 Increased breastfeeding rates, packages under NHM (including, Facility-Based
4 KANGAROO MOTHER CARE & OPTIMAL FEEDING OF LOW BIRTH WEIGHT INFANTS


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have special nutritional needs. Evidence based
HiStOry OF KMC
principles exist which highlight the importance
l A team of pediatricians started KMC in of ‘breast milk feeding’ and practical aspects of
Instituto Materno Infantil (IMI) in Bogota, ‘enabling LBW infants achieve optimum growth’
Colombia in 1978. through optimum feeding. Therefore there was
l In 2003, WHO formally endorsed KMC and a need to develop integrated guidelines for
published KMC practice guidelines. implementing KMC and feeding of low birth weight
infants.
l KMC was introduced in India, in 1994 in BJ
Medical College Hospital, Ahmedabad. This
PuRPOSE OF THE GuIDELINES
was followed by experiences in KEM Mumbai
and at the All India Institute Medical Sciences
The purpose of the guidelines is to:
(AIIMS).
l A KMC India Network (www.kmcindia.org)
 Present evidence based technical protocols
to be observed at the health facilities for
comprising six institutions was started in
KMC and feeding of LBW infants.
2003.


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comprising six institutions was started in
KMC and feeding of LBW infants.
2003.
 Provide appropriate guidance on:
Newborn Care, Facility-IMNCI) with mention of KMC. l Operationalization of KMC and LBW
Yet the practice of KMC in public health facilities feeding practices at different levels of
(including SNCUs and medical colleges) as also in health facilities.
private hospitals remains inadequate. A recent
l Choice of initial feeding method,
assessment of KMC in selected tertiary care hospitals
progression of oral feeds, and nutritional
in a few states in the western and southern parts of
supplementation.
India revealed many bottlenecks in implementing
The guidelines discuss not only various protocols,
KMC including:
but also the essential skills and monitoring
1. Lack of institutionalization
involved. It has been prepared for health
2. No ownership of KMC even in facilities professionals providing care to LBW and preterm


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2. No ownership of KMC even in facilities professionals providing care to LBW and preterm
providing care infants in health facilities. Practical instructions
3. Inadequate continuum of KMC after (or protocols) may be adapted to local norms for
discharge different categories of health workers available in
various settings. The guidelines are also aimed at
The study recommended the need for strengthening
decision-makers and planners at various levels
training of service providers, appropriate job aids
to help them understand the prerequisites to
and IEC materials, and appropriate system for follow-
implement KMC, optimal feeding and follow-up
up of LBW infants.
of LBW infants. These should also be incorporated
Situation analysis also indicates that KMC and into pre-service and in-service educational
feeding go hand-in-hand for LBW infants as they packages on neonatal care.
Introduction 5


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Kangaroo Mother
Care iMpleMentation
l What is required for implementing KMC
l Who can provide KMC?
l How to Provide KMC
w Counselling
w Clothing
w KMC Position
l Duration of KMC
l Monitoring of the infant
l Feeding during KMC
l Special situations
l Discharge from hospital and follow-up
w Follow-up
Frequency of visits
n
l Don’ts of Kangaroo Mother Care


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Kangaroo Mother Care
iMpleMentation
Even though KMC is simple, it needs to be initiated most crucial for assisting mothers in KMC practice
at the hospital under skilled supervision. The and LBW feeding.
mother needs guidance by a health professional
c. IEc
to provide KMC and optimally breastfeed the LBW
infant, starting at the facility and continuing on her Ensure adequate IEC material, including video films
own at home. once the mother goes home, it is on KMC in local language for mothers, families and
important that the continuum of KMC is maintained; community.
community health workers (ASHAs, ANMs, AWWs)
Counselling of the mothers, fathers and relatives by
should ensure that the mother continues to provide
service providers is catalytic in ensuring KMC practice
kangaroo care at home. It is equally important that
during their stay at the hospital and after discharge
they should facilitate follow-up visits to the facility
so that they can continue to practice KMC till the


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so that they can continue to practice KMC till the
for review and problem solving as this support is
infant requires it. Community awareness activities
crucial for the infant’s health after discharge.
should be conducted to maximize the benefits of
KMC and breastfeeding.
WHAT IS REquIRED FOR
IMPLEMENTING KMc?
Nurses and other service providers learn to
a. Infrastructure
appreciate KMC once they observe the health
Dedicated space near Special Newborn Care Unit benefits to the infant and satisfaction of the
(SNCU), post-natal ward or neonatal ward/ NBSU mother.
which is furnished with comfortable reclining chairs
& cots, provides privacy for expression of breast milk
and is equipped with storage facility for expressed
D. Which infants should be provided KMC
breast milk.
Though all LBW infants should be provided KMC but
B. human resources:
considering the huge burden at facilities, priority


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B. human resources:
considering the huge burden at facilities, priority
The availability of adequate number of trained and must be given to infants with birth weight less than
willing health service providers for 24x7 services is 2000 grams.
KANGAROO MOTHER CARE IMPLEMENTATION 9


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The timing of initiation of KMC depends on the birth need care in a Special Newborn Care Unit
weight and stability of the infant. (SNCU) or a Newborn Intensive Care Unit
(NICU). Intermittent KMC can be given to a
1. Birth weight more than 1,800 grams and
hemodynamically stable infant receiving IV
less than 2500 g: These infants are generally
fluids, antibiotics and oxygen. KMC should
stable at birth. Therefore, in most such cases
be practiced under medical supervision. The
KMC can be initiated soon after birth in the
duration may be gradually increased and
postnatal ward. The neonate weighing less
thereafter the infant may be transferred to a
than 2000g should be accorded priority for
dedicated KMC ward.
initiation of KMC considering the huge bur-
3. Birth weight less than 1,200 g: These
den of LBW infants in the country.
infants frequently experience serious
2. Birth weight more than 1,200g and less
prematurity related morbidity often starting
than 1800 g: Many infants of this group


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prematurity related morbidity often starting
than 1800 g: Many infants of this group
soon after birth. It may take days to weeks
have significant problems in the neonatal before the infant’s condition allows initiation
period. It might take a few days before of KMC. Duration of KMC should be gradually
KMC can be initiated. Such infants may increased based on the tolerance of infant.
Figure 1: Time of Initiation of KMC
Birth Weight*
More than1200 upto less than More than1800 upto less than
Less than 1200 gram
1800 grams 2500 grams
Generally stable at birth
Most infants suffer from ) Many infants suffer from
serious morbidities
serious morbidities,
therefore birth should ) Transfer to a specialized
take place in specialized centre, if possible
centres
) Best transported in STS
with mother/family
member (if transport
incubator not available)
May take days to weeks
May take days before KMC KMC can be initiated
before KMC can be
can be initiated immediately after birth
initiated


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before KMC can be
can be initiated immediately after birth
initiated
* Cut-off birth weight for KMC has been based on Operational Guideline of Facility Based Newborn Care
10 KANGAROO MOTHER CARE & OPTIMAL FEEDING OF LOW BIRTH WEIGHT INFANTS


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WHO cAN PROvIDE KMc? Clothing
KMC can be provided by mothers, fathers and Mother:
other adult family members. The KMC provider
KMC can be provided using any front-open, light
should be willing, in good health, free from serious
dress as per the local culture. KMC works well with
illness and should maintain basic standards of
sari-blouse, gown or shawl. A suitable apparel
hygiene such as hand washing, daily bath, clipped
like Kangaroo bag, baby bag, sari, binder that can
fingernails, tied up hair and clean clothes. It is
retain the infant for an extended period can be
recommended that jewellery, watches and sacred
adapted locally.
threads must be removed as they may be a barrier
to maintain hygiene and might cause injury to the
newborn. It is not mandatory to have any special dress,
garment or binder for KMC. It can be provided using
any clothing that is acceptable to the mother and
HOW TO PROvIDE KMc?
the family.
Counselling
Effective counselling for the initiation of KMC is a infant:


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the family.
Counselling
Effective counselling for the initiation of KMC is a infant:
prerequisite to overcome socio-cultural barriers and
The infant should be dressed in cap, socks, disposable
anxiety regarding handling a LBW infant both by the
diapers and front-open sleeveless shirt or ‘jhabala’
mother and other care providers.
made of a soft natural fabric like cotton.
When the infant is ready for KMC, the first
Figure 1: Examples of KMC supporter
counselling session should be organized at a time
convenient to the mother. The first few sessions
are important and require extended interaction
to develop a rapport with the mother and
to alleviate any fear. KMC procedure should be
demonstrated to her explaining correct position
in a caring, gentle manner and with patience.
Her queries should be answered to allay her
anxieties. Kangaroo Bag Baby Bag
Encourage her to bring her mother/mother-in-
Figure 2: Example of clothing for infants
law, husband or any other member of the family.


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Figure 2: Example of clothing for infants
law, husband or any other member of the family.
It helps in building a positive attitude of the family
and ensuring family support to the mother which
is particularly crucial for post-discharge home-
based KMC. It is helpful that the mother and family
members starting KMC interact with someone
already practicing KMC for her infant.
a supportive family is a very important
pre requisite for successful KMC.
KANGAROO MOTHER CARE IMPLEMENTATION 11


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KMC Position
Figure 3: How to hold the infant in KMC
Head turned to
Baby between one side
mother’s breasts
Frog-leg position
Support baby’s bottom
Baby: Figure 4: How to handle the baby
 The infant should be placed between the
mother’s breasts in an upright position.
 The head should be turned to one side and
in a slightly extended position. This slightly
extended head position keeps the air way
open and allows eye to eye contact between
the mother and her infant.
The hips should be flexed and abducted in a “frog”
position; the arms should also be flexed.
 The infant’s abdomen should be at the
level of the mother’s epigastrium. Mother’s
breathing stimulates the infant, thus
reducing the occurrence of apnoea.
 Support the infant from the bottom with a
sling/binder.
12 KANGAROO MOTHER CARE & OPTIMAL FEEDING OF LOW BIRTH WEIGHT INFANTS


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Health provider should help the mother initiate KMC
by assisting in positioning the infant and explaining the mother carrying an infant in the KMC position
how to handle the infant during KMC. Repeated can walk, stand, sit, or engage in different
training helps the mother overcome the fear of activities. If comfortable, the mother can sleep with
handling her newborn and improves her skill related the infant in kangaroo position in a reclined or semi-
to KMC. recumbent position
Mother:
DuRATION OF KMc
 A semi-reclining position (40º-45º) is to be
adopted while sleeping. This can be achieved
Minimum duration of a KMC session should be one
with the help of 3-4 pillows on the hospital
hour because frequent handling may be stressful for
bed or special semi-reclining chairs.
the infant. The duration of each KMC session should
be gradually increased for as long as the mother can
Figure 5: Examples of various support
comfortably provide KMC. The infants in KMC need
methods for KMC


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comfortably provide KMC. The infants in KMC need
methods for KMC
to be removed from skin-to-skin contact only for
changing diapers and clinical assessment according
to hospital schedules.
MONITORING OF THE INFANT
 Infants receiving KMC should be monitored
carefully especially during the initial stages
to ensure that the infant’s airway is clear,
breathing is regular, colour is pink and s/he
is maintaining temperature. All the above
clinical observations and duration of KMC
should be duly recorded in the newborn
case-sheet being used in the unit.
 Mother should be trained to observe her
infant for danger signs, like- hypothermia,
respiratory problems, feeding difficulty,
change in colour during KMC so that she can
continue monitoring at home.
FEEDING DuRING KMc
Feeding and nutrition strategies during the
postnatal period are very important for ensuring
optimum growth and development of LBW infants.
The nutritional needs of infants with similar birth


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optimum growth and development of LBW infants.
The nutritional needs of infants with similar birth
weight may vary depending upon whether the baby
is appropriate for gestational age (AGA) or small for
KANGAROO MOTHER CARE IMPLEMENTATION 13


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gestational age (SGA). Initially, breastfeed is given transport: Ideally, transport incubators with
at fixed intervals of two hours and not on demand, appropriate monitoring equipment are the best
to ensure an adequate and assured minimal intake. method to transport sick infants. However, in case
The mother should be explained how to breastfeed they are not available, the best method to keep a
while the infant is in KMC position. Holding the infant preterm/LBW infant warm during transport after
near the breast stimulates milk production. She may initial stabilisation is by continuous skin-to-skin
express milk while the infant is still in KMC position. contact with the mother/family member.
(For details on feeding please see the next section
if some other family member is not available for
on optimal feeding.)
KMC or KMC is not initiated: Ensure the baby is
kept in warm room 25oC-28oC, adequately covered
SPEcIAL SITuATIONS or if below 1800 grams not able to maintain normal


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SPEcIAL SITuATIONS or if below 1800 grams not able to maintain normal
temperature under a warmer.
There may be special situations where despite the
newborn being sick KMC can be given with some DIScHARGE FROM HOSPITAL
precautions.
anD FolloW-uP
Sick lBw infants: KMC is recommended for stable
The standard policy of the unit for discharge from
LBW infants. However, it is beneficial even for sick
the hospital should be followed. Generally, the
LBW infants. In such cases kangaroo mother care may
following criteria are accepted at most centres.
be given only under close and constant supervision
in centres that are well versed with the practice of
KMC. Hemodynamically stable preterm infants on The infant is
prolonged ventilation or on CPAP can also be given l Stable and not on parenteral medication
KMC. Treating MO should use her/his judicious
l Maintaining temperature in mother’s bed for 3
discretion on case-to-case basis. consecutive days at room temperature


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discretion on case-to-case basis. consecutive days at room temperature
Figure 6: Health provider explaining the KMC l Gaining 15-20 grams per day for at least 3
consecutive days
position to mother
l Accepting feeds directly from breast (preferable)
or by spoon, paladai or cup
Usually, the infant’s weight is around 1,500 to 1,600
grams at the time of discharge. Infants who are
above 1,800 grams birth weight, do not require
admission into a nursery/SNCU, are given KMC soon
after birth and can be sent home once adequacy of
breastfeeding is established.
At discharge, the mother and family members must
be taught to ensure that the infant is nursed in a warm
room and is breastfed (Given expressed milk using
paladai or cup). They should be adequately told about
hygiene, danger signs, follow-up visits, immunisation
and prompt care seeking at a health facility.
KMC should be continued as long as required and baby
and mother should not be discharged in a hurry.


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and mother should not be discharged in a hurry.
14 KANGAROO MOTHER CARE & OPTIMAL FEEDING OF LOW BIRTH WEIGHT INFANTS


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At the time of discharge, the infant should be taken  Infants discharged on KMC should be
home in KMC position by the mother or relatives so followed up in the regular follow-up OPD
as to encourage continued KMC at home. of SNCUs and linkage with District Early
Intervention Centre (DEIC) under RBSK
At the time of discharge, the family should be
for screening of neurodevelopmental
counselled and linked to the ASHA worker of the
morbidities should be established.
village who shall provide home based care and
follow-up to the baby (as per protocol).  SNCU discharged infants are to be followed
up till one year while LBW infants are to be
Follow-up
followed up at home for one year by ASHA
as per HBNC guidelines
Close follow-up is a fundamental prerequisite
of KMC practice to make a regular assessment
of growth, sensory functions, behaviour and DON’TS OF KANGAROO MOTHER
neurodevelopment. During the follow-up visits cARE
anthropometric measurements (e.g., weight, length,


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anthropometric measurements (e.g., weight, length,
head circumference) of the infant should be recorded  Do not bathe till infant weighs 2,500 g,
sponging may be done
to monitor the growth. More frequent visits should
be made if the infant is not growing well or if her/his  Do not handle infant too frequently
condition demands. ASHA will continue to provide
 Do not give bottle feed
care to the infant under home based newborn care
in the community, following discharge.  Do not allow infant to be in contact with sick
people
First Follow-up should be at one week, followed by
fortnightly follow-ups till next two visits. Additional
follow-up visits may be done until s/he reaches 40
when should KMC be discontinued?
weeks of post-conception age or achieves a weight
Often an infant is taken off kangaroo mother care
of 2,500 grams.
when gestation reaches term or the weight is around
If infant is receiving immunization at a facility where


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If infant is receiving immunization at a facility where
2,500 grams. By this time the infant starts wriggling
KMC services are available, a follow-up may be
to show that he or she is uncomfortable, pulls out
ensured.
the limbs from the kangaroo garment and cries and
 Detailed follow-up protocols are attached fusses every time the mother tries to put the infant
as annexure 3 as per the chapter 17 of the back in skin-to-skin contact. This is the time to wean
Training Module for Doctors and Nurses for the infant from KMC.
FBNC.
KANGAROO MOTHER CARE IMPLEMENTATION 15


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optiMal feeding of
low birth weight
infants
l What to feed the LBW infant?
w Breastfeeding
l Alternative methods of feeding when direct
breastfeeding is not possible
l Deciding the initial method of providing fluids and
feeding
l Feeding progression
l How often and how much to feed?
l Special considerations for infants below 1200 grams
l Adequate weight gain


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optiMal feeding of low
birth weight infants
Low birth weight (LBW) infants need optimal Lower the birth weight, greater is the likelihood of
nutrition during the neonatal period for proper feeding difficulties.
growth and development. Appropriate feeding of
These infants may not be stable enough to
low birth weight and very low birth weight infants
tolerate enteral feeds and are therefore provided
improves their chances of survival and is important
intravenous fluids till such time that enteral feeding
for their optimum growth and development.
can be established optimally. Direct feeding from
Breast milk is the ideal food for all infants including the mother’s breast may not be possible or may not
those who are LBW. WHO recommends that all LBW be enough to fulfill the need in many others and in
infants, irrespective of their gestation be fed breast this situation, feeding may need to be provided by


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milk. The goal is to enable every LBW infant to alternative feeding methods such as feeding tube,
receive feeding directly and exclusively from her/his spoon, paladai or cup.
mother’s breast at the earliest.
LBW infants who are able to breastfeed should be
However, many preterm infants have feeding put to the breast as soon as possible after birth when
difficulties initially because of they are clinically stable, and should be exclusively
breastfed until six months of age.
 Inability to coordinate suck, swallow and
breathing
Low-birth-weight infants, who are unable to take
 Immature and sluggish gut and directly from the breast, should be fed by oro-gastric
tube, feeding cup, paladai or spoon.
 Systemic illness.
Full term small-for-gestational-age infants because
WHAT TO FEED THE LBW INFANT?
of being weak or sick may also experience.
 Poor attachment and sucking effort on the Breastfeeding
breast
Mother’s milk is best for LBW infants of all gestational
 Poor swallowing


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breast
Mother’s milk is best for LBW infants of all gestational
 Poor swallowing
ages. Breast milk and especially colostrum (the
 Easy tiredness (and hence poor intake) thick, yellowish milk which is produced in small
 Vomiting, regurgitation or abdominal distension quantities during the first few days after delivery)
OPTIMAL FEEDING OF LOW BIRTH WEIGHT INFANTS 19


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best assures the survival and well-being of LBW distension or acute serious illness such as
infants. asphyxia or sepsis; on life support)
Breast milk is specially adapted to the nutritional a. Offering expressed breast milk by
needs of LBW infants; for example, the breast milk of alternate methods (described below)
a mother who delivers a preterm LBW infant contains b. As the infant improves, putting her on
extra protein that is necessary for the normal growth the breast to stimulate lactation
of such an infant.
c. Initiating Kangaroo Mother Care (KMC)
once the infant stabilizes
Breast milk is the ideal feed for all infants, including
Another issue of paramount importance is to
LBW infants
ensure optimum lactation in the mother who
has a small infant. Because of the poor or no suck
effort on the breast by the LBW infant (due to
Breast milk provides many anti-infective factors,
sickness, weakness or poor reflexes) and maternal
a vital component of the immune system of a


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sickness, weakness or poor reflexes) and maternal
a vital component of the immune system of a
anxiety, the breast milk output may remain low.
newborn infant, and growth factors which help
Lactation inadequacy must be prevented and
gut development. There is strong and consistent
tackled through counselling. In addition, breast
evidence that feeding mother’s milk to LBW infants
milk should be expressed frequently to provide
of any gestation is associated with lower incidence
expressed breast milk to the infant and to enhance
of infections and better long-term outcomes.
milk output.
Every effort should be made to provide breast milk
to LBW infants. This would require:
The best milk for LBW infants is mother’s milk. All
1. For stable infants else is inferior.
a. Placing infant in skin to skin contact with
the mother immediately after delivery
Breastfeeding is contraindicated when the
b. Initiating breastfeeding within one hour mother is receiving certain drugs like anti-


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b. Initiating breastfeeding within one hour mother is receiving certain drugs like anti-
neoplastic agents, immuno-suppressants, anti-
c. Initiating and providing Kangaroo
thyroid drugs like thiouracil, amphetamines,
Mother Care (KMC)
gold salts, etc. Breastfeeding may be avoided
d. Offering breastfeeding frequently,
when the mother is receiving following drugs-
approximately, every two hours, and on
atropine, reserpine, and psychotropic drugs.
demand
In case mother’s milk is not available, then the
e. Ensuring continued frequent feeding at
choices in the order of preference are:
night
 expressed donor milk from other
f. Ensuring proper positioning and
lactating mothers- At times, breast milk
attachment
output in the mother of the LBW infant may
g. Managing breast/nipple problems such not be sufficient, especially in the first few
as retracted or cracked nipple, and days. Given the importance of breast milk to
breast engorgement the infant, the use of breast milk obtained


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breast engorgement the infant, the use of breast milk obtained
2. For unstable infants (with cardio-respiratory from other lactating women (donor milk)
problems, temperature instability, abdominal is recommended. Ideally, this should be
20 KANGAROO MOTHER CARE & OPTIMAL FEEDING OF LOW BIRTH WEIGHT INFANTS


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organized in places where breast milk bank is Figure 7: Spoon-feeding
established. Proper breast milk bank ensures
that donated milk is safe and healthy.
 Formula milk- When not enough breast
milk is available to meet the needs of a
LBW infant, formula milk may be given with
proper preparation and hygiene. For
infants below 1,500 grams birth weight, a
preterm formula is preferred. The formula
milk should be given under the guidance of
a paediatrician. It should be in compliance
with IMS act (Annexure 4).
 animal Milk- Cow or buffalo milk are the
last choice when all other options have
been exhausted despite best efforts. Such
milks are unsuitable and may be given with
The suck-swallow-breathing coordination develops
great caution without dilution with alternate
by 34 weeks of gestation. Most infants above 34
methods of feeding.
weeks (about 1,800 grams birth weight) should be
able to feed directly from the breast.
There is NO place for bottle feeding in the care of


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able to feed directly from the breast.
There is NO place for bottle feeding in the care of
infants with a gestation of more than 30 weeks
infants
(birth weight more than 1200 grams) can usually
swallow well and coordinate breathing, but are not
able to suck. They can therefore be fed with spoon,
ALTERNATIvE METHODS paladai or cup that is not dependent on sucking
OF FEEDING WHEN DIREcT action.
BREASTFEEDING IS NOT Infants below 30 weeks of gestation (birth weight
POSSIBLE less than 1200 grams) are not in a position to take
feeds even with spoon, paladai or cup. They may be
Feeding tube, spoon, paladai or cup are the fed with intragastric tube.
alternative methods of feeding when direct
Furthermore, sick, unstable infants (of any
breastfeeding is not possible. Paladai is a shallow,
gestation or weight) who do not tolerate enteral
steel bowl with a long beak.
feeds will require administration of intravenous
fluids.
DEcIDING THE INITIAL METHOD
OF PROvIDING FLuIDS AND
FEEDING PROGRESSION


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fluids.
DEcIDING THE INITIAL METHOD
OF PROvIDING FLuIDS AND
FEEDING PROGRESSION
FEEDING
As an infant’s feeding ability develops, he or she
The choice of method of providing fluids and feeds should progress from the initial method through the
is not only dependent on maturity or birth weight intermediate steps to feeding exclusively from the
but also whether the infant is sick or not. breast directly.
OPTIMAL FEEDING OF LOW BIRTH WEIGHT INFANTS 21


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Figure 8: Method of providing fluids and feeds for
low birth weight infants
> 34 Weeks 32-34 Weeks 28-31 weeks <28 weeks
<1200 grams
Initiate Breastfeeding
Observe if:
1. Positioning and attachment are good
2. Able to suck effectively and long enough
(about 10-15 min)
Yes
No
Breastfeeding
Start feeds by spoon/paladai
Observe if:
1. Accepting well without spilling/coughing
2. Able to accept adequate amount
Yes
No
Spoon/Paladai
feeding
Start feeds by OG tube
Note: F or sick infants start with IV fluids and
gradually progress to oral feeds Observe if:
1. Vomiting/abdominal distention occurs
2. I f the abdominal girth increases 2cm. from the baseline
No Yes
Start IV fluids
Gastric tube feeding
The ultimate aim is to ensure direct, exclusive the next feeding method. An infant breastfeeding
breastfeeding. effectively on the first day of life should continue to
breastfeed exclusively up to 6 months.
LBW infants would have different methods of initial


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breastfeed exclusively up to 6 months.
LBW infants would have different methods of initial
feeding based on their weight, gestation and feeding An infant given alternative oral feeds (tube, spoon,
readiness. For progression of feeding, it is essential paladai, cup) should be given frequent opportunity
to periodically assess the infant’s ability to accept to suckle at the breast before the next feed. When
22 KANGAROO MOTHER CARE & OPTIMAL FEEDING OF LOW BIRTH WEIGHT INFANTS


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Figure 5: Principles of advancing feeding modes
Infants on IV fluids
If hemodynamically stable
Start trophic feeds by OG tube
& monitor for feed intolerance
If accepting well
Gradually increase the feed
Infant on OG tube
At 30-32 weeks PMA
Try spoon feeds once or twice a day.
Also, put on mother’s breast
If accepting spoon feeds well
Gradually increase the Infants on spoon/paladai
frequency and amount of feeds
spoon feeds Reduce OG
feeds accordingly
Put them on mother’s breast
before each feed observe for good
attachment & effective sucking
If able to breastfeed effectively
Taper and stop spoon feeds once
the mother is confident
the infant can breastfeed effectively, other modes of HOW OFTEN AND HOW MucH TO
feeding can be reduced gradually, over a few days, FEED?
and discontinued.
LBW infants are usually fed every 2hours at least 12
An infant on IV fluids should be given small
times in a day, the amount of each feed volume (to
intragastric feeds. If the infant tolerates these, the


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intragastric feeds. If the infant tolerates these, the
be given every 2 hour) is calculated on the basis of
volume can be increased and intravenous fluids
daily fluid requirements.
reduced. When two thirds of the daily requirement
is tolerated as enteral feed, IV fluids can be It is usual clinical practice to provide LBW infants of
discontinued and enteral feeds increased over the 1500 grams or more about 60 ml/kg fluids on the first
subsequent days. When the infant shows readiness day of life. Infants less than 1,500g are usually given
for oral feeding, small amounts can be offered by about 80 ml/kg fluids on the first day of life. The feeds/
an alternative oral feeding method. The infant then fluids are increased by 15 ml/kg/day to a maximum of
progresses to breastfeeding as above. 150 ml/kg/day by the end of the first week of life.
OPTIMAL FEEDING OF LOW BIRTH WEIGHT INFANTS 23


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In stable LBW infants who are tolerating feeds with regard to maintenance of temperature,
well, the feed intake may be raised cautiously and prevention of infections, etc. They require constant
gradually from 150 ml/kg to 180 ml/kg after the first monitoring to help in early identification of clinical
week of life. instability.
These infants are initially started on intravenous
table 1*: Fluid requirements for infants (ml/kg
fluids as discussed already. The constant flow of
body weight/day) These needs are met by enteral
intravenous fluids must be ensured to prevent
feeds and/or by intravenous fluid administration or
excess administration or abrupt stoppage of fluids.
a combination of the two
Also, strict aseptic precautions should be observed
while giving intravenous fluids.
Day of Fluid requirement ml/kg/day
life
Birth weight ≥ 1,500 g Birth weight<1,500 g They have to be gradually helped to initiate oral feeding
1 60 80 so that ultimately they can receive direct, exclusive


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1 60 80 so that ultimately they can receive direct, exclusive
2 75 95 breastfeeding. Even while on intravenous fluids, they
3 90 110
can be administered small amounts of intragastric
4 105 125
tube feeds. This small amount of milk feeds is called
5 120 140
minimal enteral nutrition (MEN) or trophic feeds. The
6 135 150 purpose of trophic feeds is to help in the growth and
7 150 150
maturation of the gastrointestinal tract. Infants started
* For detail please read FBNC guideline. on MEN progress to full oral feeds faster.
the usual total amount of breast milk given as
SPEcIAL cONSIDERATIONS FOR
minimal enteral or trophic feeds is only 12 - 24
INFANTS BELOW 1200 GRAMS
ml/kg/day divided into 4 - 6 feeds given via the
intragastric route. as the infant stabilises, breast
Infants with birth weight less than 1,200g
milk feeding is advanced to full requirements to
are usually born premature (before 30 weeks
meet her/his nutritional needs.
gestation) and often have various problems


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meet her/his nutritional needs.
gestation) and often have various problems
such as breathing difficulty, hypothermia, and Criteria for discharge from the hospital and
hypoglycaemia. These infants need special care follow-up will be as mentioned on page 25.
table 2: Micronutrient supplementation (as per WHO recommendations)
Micronutrient Recommended Daily Dosage Duration
Vitamin D 400-1000 IU/day(usually obtained from Six months (starting as soon as
multivitamin drops and calcium and possible)
phosphorus supplement)
Iron 2 mg/kg/day One year (starting at 2 weeks of
age)
Calcium* 120 – 160 mg/kg/day Till 40 weeks postmenstrual age
Phosphorus* 60 – 80 mg/kg/day Till 40 weeks postmenstrual age
*Infants below 32 weeks of gestation
24 KANGAROO MOTHER CARE & OPTIMAL FEEDING OF LOW BIRTH WEIGHT INFANTS


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ADEquATE WEIGHT GAIN weeks PMA or 2500 grams. After that the MCP Card
can be used to monitor growth.
Most LBW infants lose weight in the first few days of
If the infant has inadequate weight gain, the
life. Usually this loss would not exceed 10-15% of the
provider should check the amount of intake, and
birth weight. They regain their birth weight by about
assess attachment (if taking direct breastfeeding),
2 weeks and then start gaining weight at the rate of
and spluttering / spillage (if on paladai / cup /
1.0% to 1.5% of body weight per day. Usually this
spoon feeds). Nipple and breast problems in the
corresponds to a gain of 15-20 grams per kilogram
mother should be looked for. Complications such
of their own body weight per day.
as cold stress, sepsis, oral thrush, anaemia and late
For small infants below 1,500 grams (less than 32 metabolic acidosis also lead to sub-optimal growth.
weeks), it is advisable to use a postnatal growth The underlying reasons for inadequate weight gain


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weeks), it is advisable to use a postnatal growth The underlying reasons for inadequate weight gain
chart to plot weight every day until they are of 40 should be addressed.
Ensuring adequacy of nutrition is perhaps the most important aspect of their care by monitoring
frequency of urine (8-12 times for day) and weight gain (15-20 grams per day)
OPTIMAL FEEDING OF LOW BIRTH WEIGHT INFANTS 25


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aCtion plan for
iMpleMentation and
sCale-Up
l KMC Roll-out Plan
w Structure
w Capacity building strategy
w Developing KMC Unit
Specifications for Building up a KMC Unit
n
l Role of programme managers
l Monitoring and evaluation
w Definitions
w Recording and reporting
w Communication strategy
w Evaluation


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aCtion plan for
iMpleMentation and sCale-Up
This section provides information to the Programme SNCU or the postnatal ward. These units will
Manager and health care providers on how to have provisions for the postnatal mothers
ensure that every LBW infant has access to high- to provide KMC to their infants.
quality KMC and optimal feeding within the existing
Facility Based Newborn Care systems.
The aim is to advocate KMC to be practiced for
To fulfil this vision the roll-out has to be planned
all infants eligible for KMC at public health
in phases by the states. Each state will have the
facilities.
flexibility to fix its own target for the next two years
as per available resources. The state will have two
options:
KMC roll-out Plan
a. Where new SNCUs/MCH wings are planned
adequate provision for KMC will be an
Structure
integral component of SNCU infrastructure
and
The state will submit the budget proposal for
b. Where SNCU is already in place, KMC unit


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and
The state will submit the budget proposal for
b. Where SNCU is already in place, KMC unit
establishing KMC as an additional expenditure
would be added in close proximity to the
under SNCU in the State’s Annual Programme
Implementation Plan of the National Health
ViSiOn KMC Mission. The state lead development partners will
collaborate with the state governments for quality
l Model KMC services to be established in 25
KMC roll out within the RMNCH+A strategy. Child
Regional & State Resource Centres by the end
Health Division, Ministry of Health and Family
of 2017
Welfare GOI will review the progress periodically.
l KMC services to be provided in all SNCUs and
The Collaborative system established under
well-functioning NBSUs (at CHCs and FRUs)
Facility Based Newborn care will provide technical
across the country
support.
ACTION PLAN FOR IMPLEMENTATION AND SCALE-UP 29


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Child Health Division, Ministry of Health and Family
Welfare GOI
national Collaborative Centre Private sector participation
WHO Resource Centre for Training Government of India urges neonatologists,
and Research for Newborn Care at neonatal nurses and obstetrician-gynecologists
AIIMS, along with the designated by engaging with their respective professional
National Collaborative Centre for bodies. These are:
Facility Based Newborn Care at
1. National Neonatology Forum (NNF)
KSCH & LHMC will be responsible
2. Indian Association of Neonatal Nurses (IANN)
for:
3. Indian Academy of Peadiatrics (IAP)
 Providing technical assistance
for roll out of KMC & optimal 4. Federation of Obstetric and Gynaecological
feeding guideline Societies of India (FOGSI)
 Capacity building and 5. Trained Nurses Association of India (TNAI)
Mentoring of Regional/State
These bodies can orient private facilities and nursing
Collaborative Centers
homes at the national, state and district levels so


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Collaborative Centers
homes at the national, state and district levels so
 Developing training module that all private facilities in the country align their
and packages (if required) KMC services and Optimal Feeding for Low Birth
Weight infants along with the national guidelines.
regional Collaborative Centres (rCC, Medical colleges/teaching institute)
Existing FBNC resource centre and centers under KMC India network will serve as RCCs
 Each centre to have a model KMC unit for hands-on training
 RCCs to provide training and mentoring to SCCs and district level health providers
 RCCs will be responsible for monitoring and supervision of SCCs
State Collaborative Centres (SCC, Medical colleges)
 Each centre to have a model KMC unit equipped with mannequins (skill stations) for
hands-on training SCCs
 To provide monitoring, supervision and mentoring to district level facilities
30 KANGAROO MOTHER CARE & OPTIMAL FEEDING OF LOW BIRTH WEIGHT INFANTS


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national level
 Orientation and Dissemination of the guidelines for programme managers and professional
associations
 Regular review by Child Health Division, MoHFW
 Provide cross-learning facility for programme managers and health providers at model units.
State level
 Orientation cum planning workshops at State level
 Identification of medical colleges as state resource centres
 Initially, saturate the SNCUs with KMC services on priority
 Develop resource pool for training
 Ensure adequate and trained human resource at SNCU
 Seek support from respective state lead development partners to ensure high quality
implementation
 Provide mentoring and supportive supervision or hands-on training to the providers
 Review progress of implementation every quarter
 Developing linkages with RBSK and community follow-up by ASHA
 Integrate KMC into FBNC
District level
 Carry out civil work/refabricating necessary for ensuring KMC


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District level
 Carry out civil work/refabricating necessary for ensuring KMC
 Conduct orientation/refresher trainings of counsellors
 Identify high case load facilities for ensuring KMC services
 Ensure record keeping and timely reporting at facilities
Capacity building strategy:
2. KMC unit should be built as an integral part
of the new/upcoming SNCUs (20-bed) and
Job-aids, videos and training agenda for KMC and
in MCH wings
optimal feeding of LBW infants are being provided
along with the guidelines for state support. The 3. KMC services can also be provided in NBSU
existing training modules for F-IMNCI and FBNC may or Postnatal wards. All the stable infants
be used for orientation. The checklist for KMC also weighing more than 2000 grams can be easily
being used in skill lab is placed as Annexure V. nursed in the postnatal ward or at NBSUs
Developing a KMC unit 4. The neonatal units at all Medical Colleges
to be strengthened to provide appropriate


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to be strengthened to provide appropriate
1. KMC Unit of 8-10 beds is recommended for ev-
newborn care including KMC. This will
ery hospital with SNCU or should be located
enable the undergraduate and postgraduate
as close to the SNCU as possible in the exist-
medical students to learn the best practices.
ing / new premises. Infants weighing less than
1800 g, who will form the majority of the KMC
Specifications for Building up a KMC unit
beneficiaries, would be admitted to Special
Newborn Care Units (SNCUs) at district hospi- As a routine, feeding and other care to unstable or
tals if their condition warrants admission sick preterm / LBW infants is provided in Special
ACTION PLAN FOR IMPLEMENTATION AND SCALE-UP 31


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Newborn Care Units (SNCUs). Thereafter, when The room should also be well lit, well ventilated and
the infants become stable, KMC is initiated under have arrangement for dim light at night.
supervision of the nurses/doctors in SNCU. With
Following is the budget for establishing a model
further improvement, infants must be transferred out
KMC unit, however, provision of KMC should not
from the SNCU to the mother in the postnatal ward
wait for the establishment of KMCU.
where KMC is continued till discharge. Accordingly,
it is recommended that each hospital with an SNCU This may also be used as a guide for budgeting
should provide KMC and have a KMC unit (KMC Unit) the proposal for setting up KMC in the state PIP.
State should do need based gap analysis to budget
KMC units must ensure the room temperature is 24
judiciously for setting up KMC units.
to 26 degree Celsius with 50-60% relative humidity.
S. Unit cost Units Total cost
Heads Essential Desirable
No. (INR) needed (INR)


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S. Unit cost Units Total cost
Heads Essential Desirable
No. (INR) needed (INR)
A. infrastructure:total 1500 square feet; i.e. 140 Sq M: 120 square feet for each bed (120x8 = 960
square feet) and rest will use as ancillary area, toilet, bathing & hand washing area
1 Renovation or Minor civil work  100000 1 100,000
B. Furniture
2 Beds semi-reclining  12000 8 96000
3 Easy chairs (reclining with foot support)  5000 8 40000
4 Storage space/locker for mothers  2000 8 16000
5 Office chairs  500 8 4000
C. Furnishing
6 Mattress  3000 8 16000
7 Pillows  300 16 4800
8 Bed sheets  200 16 3200
9 Adult blanket  800 16 12800
10 Baby blanket  500 16 8000
11 Mobile screen  From regular budget
12 Dust bins  From regular supply
13 Refrigerator (165L - 230L)  15,000 1 15000
14 AV aids (Television & CD player)  25,000 1 25,000
D. equipment
15 Bag & Mask (Size 0 & 1)  1500 1 1500
16 Digital Weighing machine  3,000 1 3,000
17 Paediatric stethoscope  2


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16 Digital Weighing machine  3,000 1 3,000
17 Paediatric stethoscope  2
18 Digital & Room thermometers  200X2 2 800
19 Heater (Radiant/air blower)  From regular budget
20 Oxygen cylinder & Oxygen hoods  From regular supply
32 KANGAROO MOTHER CARE & OPTIMAL FEEDING OF LOW BIRTH WEIGHT INFANTS


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S. Unit cost Units Total cost
Heads Essential Desirable
No. (INR) needed (INR)
21 Training manikins etc  10000 1 10000
E. recurring cost per annum
21 Feeding equipment  100 200* 20000
(Tubes, Katoris& Spoons)
22 Clothes for newborns  110 200* 30000
(Disposable
(Disposable Diapers, Cap & Socks) Diapers)
40
(Cap & Socks)
23 Gowns for Mothers  100 200* 20000
24 Soap & other cleaning agents  1000 12 12000
25 Emergency medicines, cotton,  From regular supply
gauge
26 Record registers/case sheets From regular supply
27 Other maintenance cost  1500 12 18000
F. Human resources**
28 ANM/GNM/YASHODA/Counsellor  12000X12 4 576000
Grand total (including cost of desirable heads) 1032110
total (Cost of essential heads) 266100
# For storing breast milk
*Available regularly with most SNCUs. Therefore, utilize from regular supply and may budget, if required.
**States to ensure saturation with adequate and trained HR as per norms including salary . The figures quoted here are normative.


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Budgetary provision: To roll out the KMC and optimal 4. Track the progress of implementation of
feeding practices at scale, the state will have to make KMC according to the guidelines as per the
adequate budgetary provisions for state level training final timeline
workshops and establishment cost of KMC Unit in state
5. Link with the National/Regional/State
PIPs.
collaborative centre and Existing Supportive
Supervision mechanisms in the state
ROLE OF PROGRAMME
and utilize and modify existing checklists
MANAGERS and block monitoring formats to include
practice of KMC
The state programme manager/Child Health nodal
officer will play the most crucial role. S/He must: All contacts with the technical personnel/service
1. Know that KMC is an integral part of facility providers should be utilised for promoting KMC
based newborn care during mentoring visits. The checklist for training in
KMC is being attached for reference and is similar to
2. Ensure orientation of all the district nodal


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2. Ensure orientation of all the district nodal
the one used in skills lab trainings (annexure- ). FBNC
officers on KMC
trainings need to be expedited by the states with
3. Issue a Facility wise timeline where KMC
special focus on KMC and optimal feeding in LBW.
needs to be started to all the districts
ACTION PLAN FOR IMPLEMENTATION AND SCALE-UP 33


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6. Linking the follow-up with SNCU follow-up 4. Percent (%) of pre-term newborns who
and DEIC if required extra care received KMC till 40 weeks (Expected
Delivery Date or full term) = Number of
7. Willing Professionals from private sector/
pre-term newborns who received KMC till
Professional bodies may be involved in
40 weeks X 100 /Total number of newborns
training programmes as trainees as well
as trainers for maximizing effect in private delivered preterm.
sector mentoring and supervision activities
recording and reporting
The data for above monitoring indicators can be
MonItorIng anD evaluatIon:
compiled at the district level every month and can be
Existing monitoring frameworks for FBNC are to sent to the state along with the SNCU reports. For states
be modified to capture the indicators given below; which have migrated to online reporting mechanism,
these indicators will provide information on how the may utilize the same platform for reporting. After


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programme is functioning. compiling and validating the reports at the state level,
these can be shared at the national level on a quarterly
Definitions
basis. During supportive supervision visits the data
Output indicators: may be validated from the case sheets and registers.
1. Percent (%) of health facilities having SN-
Communication strategy
CUs with operational KMC unit= Number
of health facilities having SNCU with op- Any state specific barriers in implementation should
erational KMC unit X 100/ Total number of also be identified. The messages should enhance the
health facilities with functional SNCU woman’s ability to use existing services and to make
appropriate decisions. The communication materials
Outcome indicators
should be consistent with the training materials, so
1. Percent (%) of newborns with birth weight be-
that there is an integrated training-communication
low 2,000 grams delivered in the health facili-
package. Both, the mass media and interpersonal


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low 2,000 grams delivered in the health facili-
package. Both, the mass media and interpersonal
ty= Number of low birth weight infants (below
communication are needed. Equally crucial will be
2,000 grams ) delivered in the facility X 100 /
all those in the community who have a determining
Total number of live births in the facility
influence on the mothers’ behaviour: their husbands
2. Percent (%) of newborns below 2,000 grams and families, elders, religious leaders and others.
who continued KMC till discharge = number Communication messages should also be directed
of newborns with birth weight below 2,000 at key decision-makers. Communication must be
grams who continued KMC till discharge X supplemented by an education programme and
100 / total newborns with birth weight below synchronised with the health services
2,000 grams
Way Forward
3. Percent (%) of pre-term infants (gestation
age less than 37 weeks) delivered in the As the two high impact interventions viz. KMC and


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age less than 37 weeks) delivered in the As the two high impact interventions viz. KMC and
health facility= Number of pre-term infants feeding of Low Birth Weight infants are being up-
(gestation age less than 37 weeks) delivered scaled an implementation research will be useful
in the facility X 100 / Total number of live for sharing the key learning and making midcourse
births in the facility corrections, if required.
34 KANGAROO MOTHER CARE & OPTIMAL FEEDING OF LOW BIRTH WEIGHT INFANTS


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annexUres
Annexure I: Manual Expression of Breast milk and
Storage Thereof
ANNEXURE II: Alternative Feeding Methods (Cup/Spoon/
Paladai Feeding)
Annexure III: Follow-up protocol after discharge of a
high-risk infant
Annexure IV: Infant Milk Substitutes act
Annexure V: Orientation on Kangaroo Mother Care


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annex i
MANuAL EXPRESSION OF BREAST MILK AND STORAGE THEREOF
For whom:
Infants who cannot breastfeed effectively but are  At least 6-8 times in 24 hours, i.e. every 3-4
able to accept oral feeds by alternative feeding hours, including at night to help ensure an
methods and for the purpose of storing breast adequate supply.
milk.
Procedure
how often
The salient steps of manual expression of breast milk
 Within 6 hours of delivery to ensure that are shown in the figure below.
colostrum is available
Figure (i): Expression of breast milk
ANNEX I 37


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If expressed breast milk (EBM) cannot be given to of bacterial growth. It should be kept in a covered
the infant soon after expression, it has to be stored container. Any milk not fed to the infant within 6
and used when necessary. The expressed milk can hours of expression should be discarded.
be stored in one of the following ways:
in a refrigerator: EBM can be stored in the main
at room temperature: EBM can be kept at room compartment of a regular refrigerator (2oC to 8oC)
temperature for up to 6 hours without significant risk for 24 hours.
Storage of expressed breast milk
At room temperature : 6 hours
In refrigerator (2oC to 8oC) : 24 hours
38 KANGAROO MOTHER CARE & OPTIMAL FEEDING OF LOW BIRTH WEIGHT INFANTS


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annex ii
alternatIve FeeDIng MethoDS (CuP/SPoon/PalaDaI FeeDIng)
1. SPoon-FeeDIng Figure (ii): Feeding a LBW infant with a paladai
A spoon is appropriate for an infant who is stable and
is able to co-ordinate breathing and swallowing.
HOw tO SPOOn-FeeD an inFant
1. The infant should be awake and held sitting
semi-upright on the caregiver’s lap.
2. Put a measured amount of milk in a wide
necked container.
3. Take some milk from the container into the
spoon.
4. Hold the spoon so that it rests lightly on the
cultures. It is appropriate for an infant who is stable
infant’s lower lip.
and is able to coordinate sucking, breathing and
5. Tip the spoon so that the milk reaches the swallowing. The advantages of this feeding method
infant’s lips. are that it is usually faster than spoon or even cup
6. If possible allow the infant to take the milk feeding and also that there is less spillage.
by him or herself and do not pour it into the
It has become very popular in neonatal nurseries in


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by him or herself and do not pour it into the
It has become very popular in neonatal nurseries in
infant’s mouth.
all parts of the country.
7. Feed the infant slowly, making sure that
The steps of ‘paladai’ feeding are given in the box
the milk already given has been swallowed
below:
before giving any more.
8. When the infant has had enough, he or she HOw tO FeeD an inFant witH a ‘PalaDai’
will close his or her mouth and will not take
1. The infant should be awake and held sit-
any more. Do not force-feed an infant.
ting semi-upright on the caregiver’s lap, and
9. Estimate the amount of milk taken in the wrapped to provide support and to keep the
same way as for cup feeding. arms out of the way, as for cup feeding.
2. Put a measured amount of milk in the
2. “PALADAI” FEEDING
paladai.
A paladai is a small steel bowl with a long pointed tip 3. Hold the paladai so that the pointed tip rests
traditionally used for feeding LBW infants in some lightly on the infant’s lower lip.
ANNEX II 39


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4. Tilt the paladai to pour a small amount of
milk into the infant’s mouth gently.
5. Feed the infant slowly.
HOw tO CuP FeeD an inFant
6. Make sure that the infant has swallowed
1. The infant should be awake and held sitting
the milk already taken before giving any
semi-upright on the caregiver’s lap. Wrap the
more.
infant in a cloth to provide support and to
7. When the infant has had enough, she will
keep his or her arms out of the way, and put
close his or her mouth and will not take
a small cloth on his or her front to catch drips
any more. Do not force-feed the infant.
of milk.
8. Estimate the amount of milk taken.
2. Put a measured amount of milk in the cup.
9. Wash the paladai with soap in running
3. Hold the cup so that it rests lightly on the
water and air-dry it before and after each
infant’s lower lip.
use.
4. Tilt the cup so that the milk reaches the
infant’s lips.
3. cuP FEEDING
5. Allow the infant to take the milk himself. (A


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infant’s lips.
3. cuP FEEDING
5. Allow the infant to take the milk himself. (A
It is appropriate for an infant who is stable and is able younger infant will initially lap the milk into
to coordinate sucking, breathing and swallowing. his mouth with his tongue. A full term or
The advantages of this feeding method are that it older infant will suck the milk.)
enables an infant to control his own intake in time
6. Do not pour the milk into the infant’s mouth.
and quantity.
Hold the cup to the infant’s lips so that and
The cups used and the method of cup feeding is he or she can take it himself or herself.
depicted in the figures below: 7. Feed the infant slowly. Some milk may spill
from the infant’s mouth. Spilling is commoner
Figure iii: Feeding a LBW infant by cup
with more mature infants.
8. Make sure that the infant has swallowed the
milk before offering more. When the infant
has had enough, he or she will close his or
her mouth and will not take any more. Do not


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has had enough, he or she will close his or
her mouth and will not take any more. Do not
force-feed the infant.
9. To estimate the amount of milk taken,
subtract the milk left in the cup from the
original amount. Also subtract the estimated
spillage, if any.
10. Wash each utensil with soap in running water
and air-dry it before and after each use.
40 KANGAROO MOTHER CARE & OPTIMAL FEEDING OF LOW BIRTH WEIGHT INFANTS


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4. Intra-gaStrIC tuBe FeeDIng PROcEDuRE
Intra-gastric feeding is provided to the stable infants Selecting the correct tube size
who are not able to accept oral feeds (not able to co- The correct tube size for intra-gastric feeding of
ordinate breathing with swallowing). Intra-gastric small infants is shown in below:
tube feeding can be given by two routes, namely,
recommended intra-gastric tube sizes
naso-gastric or oro-gastric. Naso-gastric tube has
Weight Tube size
the advantage that it is more easily fixed in place.
< 2000g French 6
But by blocking one nostril it may lead to apnoea or
≥2000g French 8
breathing difficulty. Oro-gastric tubes is preferred
for smaller infants. Inserting an intra-gastric tube
inSertinG an intra-GaStriC tuBe
1. Estimate the length of gastric tube required
l Hold the tip of the feeding tube at the tip of the infant’s nose, then hold the length of the tube
up to the ear lobe and then on to the infant’s abdomen to a point between the xiphisternum and


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up to the ear lobe and then on to the infant’s abdomen to a point between the xiphisternum and
umbilicus.
l Mark the measured length of the tube with a pen or piece of tape.
2. Inserting the gastric tube
l Flex the infant’s neck slightly and pass the tube gently through the mouth or one nostril to the
required distance.
3. Checking the position of gastric tube
l Take 1-2 ml of air into the syringe. Listen over the infant’s stomach with a stethoscope while
quickly injecting the air down the tube. If the end of the tube is in the stomach, you will hear a
whistling sound as the air passes through.
OR
l Attach a syringe to the open end of the tube and aspirate the contents of the stomach. The
aspirate should look like curdled milk
4. Secure the tube on the infant’s cheek with adhesive tape.
ANNEX II 41


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The steps of insertion and fixation of oro-gastric tube are illustrated in figure A and figure B respectively The
Figure a: Inserting an oro-gastric tube
Figure B: Fixing oro-gastric tube
oro-gastric tube has to be replaced every 3 days or earlier if it is pulled or blocked.
The procedure of giving a gastric tube feed is explained in the box below:
PrOCeDure FOr GiVinG a GaStriC tuBe FeeD
1. Remove the plunger of a 10 or 20 ml sterile syringe.
2. Connect the barrel of the syringe to the end of the gastric tube.
3. Fill the barrel of the syringe with the required volume of milk.
4. Let the milk run from the syringe through the gastric tube under gravity.
5. DO NOT force milk through the gastric tube by using the plunger of the syringe.
6. Hold the syringe 5-10 cm above the infant until the syringe is empty.
7. It should take a few minutes for the milk to flow into the infant’s stomach. Changing the height of the


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syringe will also affect the speed of milk flow. Lowering the syringe slows the milk flow, raising the
syringe makes the milk flow faster.
8. Observe the infant during the entire gastric tube feed. Do not leave the infant unattended. Stop
the tube feed if the infant shows any of the following signs: breathing difficulty, color change (looks
blue), becomes floppy or vomits.
9. Cap the end of the gastric tube after the milk has been instilled. there is no need to rinse the tube
with water. Keep tube capped between feeds.
42 KANGAROO MOTHER CARE & OPTIMAL FEEDING OF LOW BIRTH WEIGHT INFANTS


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annex iii
FolloW-uP ProtoCol aFter DISCharge oF a hIgh-rISK InFant
S. No Area Frequency Details Remarks
A Anthropometry Every visit Weight HC L Always estimate if the
gain is adequate
B Breastfeeding Every visit Attachment Positioning Observe a breastfeeding
Problems session if possible
C Counselling Every visit Feeding Hygiene KMC Ask mother about her
Innocuous issues concerns
D Development 3, 6, 9 , 12 months Use TD screening chart Fill up the chart and refer
screening where needed for detailed
developmental evaluation
E Eye 1 month for infants Emphasize on getting Review in next visit
<1750 grams to a retinopathy (ROP)
<2000 grams with screening from a skilled
stormy NICU course. ophthalmologist
Detailed examina-
tion at 9-12 months
of age
F Follow-up USG At discharge and at To rule out PVL and
40 weeks PMA other abnormalities
G Growth Monitoring Every Visit Plot the growth of the Use of the Fenton chart till
infant on the WHO the infant is 40 wks PMA


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infant on the WHO the infant is 40 wks PMA
growth charts and WHO charts thereafter
H Hearing At 40 wks PMA One can use the OAE/
and in case BERA or combination as
questionable, at 6 per the policy
weeks of age
I Immunization As per schedule
J Others Language/speech Any delay detected
at 1,2 3 years should prompt early
Behavior at/after 1 intervention
year
IQ testing at 3
years of age
ANNEX III 43


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Fetal-infant Growth Chart for Preterm Infants (WHO Growth Standards version)
65 65
60 60
55 55
50 50
45 45
40 40
35 6
30 5.5
25 5
20 4.5
4 4
3.5 3.5
3 3
2.5 2.5
2 2
1.5 1.5
1 1
0.5 0.5
0 0
22 24 26 28 30 32 34 36 38 40 42 44 46 48 50
44 KANGAROO MOTHER CARE & OPTIMAL FEEDING OF LOW BIRTH WEIGHT INFANTS
sretemitneC
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156 Annexures
Annexure 17: Fentons chart
Fenton Chart
97°
90°
L e n
gth 50°
10°
3°
H e a d
Circ u
mfere n c e
1
5
9 9
0
0
0 7
°
°
° °
3°
97°
90°
50°
ht
g
ei
W 10°
3°
Plot growth in terms of completed
weeks of gestation
Source: Intrautenine weight - Kramer MS et al
(ePediatr 2001); Length and Head circumference-
NiklassonA et al (J Paediatr Child Health 1996);
Post term sections-the WHO Growth Chats, 2006.
The Smoothing of the disjunction between the pre
and post term sections generally occurs between 36
and 46 weeks. TR Fenion
Date:
Gestational age (weeks)


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Annexure 18: TDS chart
In 2013 WHO revised it and separate charts for boys and girls are available. To avoid confusion
with the message in FBNC training module only single chart is being referred .
TD Screening Chart
ANNEX III 45
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Annexures 157


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annex iV
INFANT MILK SuBSTITuTES AcT
The Infant Milk Substitutes, Feeding Bottles and can give educational material to health
Infant Foods (regulation of production, Supply and professionals like doctors, nurses etc
Distribution) Act, 1992 and as amended act in 2003 provided it has information prescribed in
clause 7 of the IMS Amendment Act, 2003.
This Act provides for the regulation of production,
The education material should have only
supply and distribution of infant milk substitutes,
factual information and should not promote
feeding bottles and infant foods with a view to the
the products of the company).
protection and promotion of breastfeeding and
ensuring the proper use of infant foods and for 8. Gives tins, cartons, accompanied leaflets of
matters connected to it. It extends to the whole these products having pictures of mothers
of India. It also lays the responsibility of health or infants, cartoons or any other such images


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of India. It also lays the responsibility of health or infants, cartoons or any other such images
workers and of the government to provide accurate to increase saleability.
information to people. Following are the basic 9. Displays placards, posters in a hospital,
provisions of the IMS Act. nursing home, chemist shop etc. for
promoting these products.
THE IMS AcT PROvISIONS
10. Provides direct or indirect inducements to
IMS act is violated if any baby Food Company, its
health workers
distributor or supplier, or any person
11. Demonstrates to mothers or their family
1. Promotes any food by whatever name, for
members how to feed these products.
children up to two years.
However, a doctor can demonstrate this to
2. Promotes use of infant foods before the age the mother.
of six months.
12. Gives benefits to doctors, nurses or
3. Advertises by any means--television, associations like IAP, IMA, NNF etc, for
newspapers, magazines, journals, through example, funds for organizing seminars,


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newspapers, magazines, journals, through example, funds for organizing seminars,
SMS, emails, radio, pamphlets etc. meeting, conferences, contest, fee of
educational course, sponsoring for projects,
4. Distributes the product or samples to any
research work or tours.
person.
13. Fixes commission of employees on the basis
5. Contacts pregnant or lactating mothers
of volume of sales of these products.
using any person.
6. Gives any kind of inducements like free gifts, HIGHLIGHTS OF THE AcT
tied sales, to anyone.
1. Prohibits all persons from any kind of pro-
7. Distributes information and educational motion of infant milk substitutes, infant
material to mothers, families etc. (They foods or feeding bottles
46 KANGAROO MOTHER CARE & OPTIMAL FEEDING OF LOW BIRTH WEIGHT INFANTS


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2. Prohibits the advertisement of infant milk 5. Prohibits display of posters at health care
substitutes and feeding bottles to” ensure facilities / hospitals /health centres.
that no impression is given that feeding of
6. The Act also prescribes that all labels of IMS
these products is equivalent to, or better
/Infant food, must say in English and local,
than, breastfeeding.
languages that breastfeeding is the best.
3. Prohibits providing free samples and gifts Also, the labels must not have pictures of
to pregnant women, mothers of infants and infants or women or phrases designed to
members of the families. increase the sale of the product.
4. Prohibits donation of free or subsided 7. Prohibits any contact of employers
supplies of products for health care manufacturing and distributing company
institutions and prohibits incentives and with pregnant women, even for providing
gifts to health workers. educational material to them.
ANNEX iV 47


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annex V
ORIENTATION ON KANGAROO MOTHER cARE
objective Key Points
By the end of this exercise the participant should be Eligibility criteria for KMC
able to demonstrate Kangaroo Mother Care
 All LBW infants.
Steps for providing Kangaroo Mother Care  Sick hemodynamically stable infants
needing special care (even those on IV Fluid
1 Counsel the mother, provides privacy to the
or on Oxygen)
mother. Request the mother to sit or recline
comfortably The two components of KMC are:
2 Undress the baby gently, except for cap,  Skin-to-skin contact
nappy and socks
 Exclusive breastfeeding
3 Place the baby prone on mother’s chest in
The two prerequisites of KMC are:
an upright position with the head slightly
extended, between her breasts in skin to skin  Support to the mother in hospital and at
contact in a frog like position; turn baby’s home
head to one side to keep airway clear. Support
 Post-discharge follow-up
the baby’s bottom with a sling/binder.
Benefits of KMC


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 Post-discharge follow-up
the baby’s bottom with a sling/binder.
Benefits of KMC
4 Cover the baby with mother’s ‘pallu’ or gown;
wrap the baby-mother duo with an added  Reduces risk of hypothermia
blanket or shawl depending upon the room
 Promotes lactation and weight gain
temperature
 Reducing infections and hospital stay
5 Advise mother to breastfeed the baby
frequently  Better bonding between Mother and
newborn
6 Ensure warm room with room temperature
maintained between 25 – 28° C.
7 Advise the mother to provide KMC for at least
1 hour per session. The length of skin-to-skin
contact should be as long as possible
POintS tO reMeMBer
1. Ensure room is warm (25 -28° C)
2. Health professionals should be skilled for providing immediate emergency care, in case required
48 KANGAROO MOTHER CARE & OPTIMAL FEEDING OF LOW BIRTH WEIGHT INFANTS


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referenCes
Cattaneo A, Davanzo R, Bergman N, Charpak N. income countries: a pooled country analysis.
Kangaroo mother care in low-income countries. Lancet. Aug 3 2013; 382(9890):417-425.World
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Trop Pediatr. 1998 Oct; 44(5):279-82. practical guide. Department of Reproductive
Health and Research, WHO, Geneva. 2003.
Charpak N, Ruiz-Pelaez JG, Charpak Y. Rey-Martinez
Kangaroo Mother Program: an alternative way Kiran Kumar BV, Udani RH. Analgesic effect of skin-
of caring for low birth weight infants. One year to-skin contact in kangaroo position in preterm
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Charpak N ,Ruiz-Pelaez JG, Figueroade CZ,
Charpak Y. A randomized, controlled trial of Ramanathan K, Paul VK, Deorari AK, Taneja U,


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Charpak Y. A randomized, controlled trial of Ramanathan K, Paul VK, Deorari AK, Taneja U,
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Conde-Agudelo, Diaz-Rosello JL, Belizan JM. Tessier R, Cristo M, Velez S, Giron M, de Calume ZF,
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Kangaroo mother care to reduce morbidity and Ruiz-Palaez JG, Charpak Y, Charpak N. Kangaroo
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Evaluation of Kangaroo Mother Care Services in
1998. fMortality risk in preterm and small-for-
India, 2013
gestational-age infants in low-income and middle-
References 49


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KanGarOO MOtHer Care
PreParatiOn FOr KMC COunSellinG & DeMOnStratiOn
FOr KMC
KMC POSitiOn
wHO Can PrOViDe KMC (FatHer anD OtHer relatiVeS)


