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Work Group 2
KMC in Low Resource setting
Members
Adriano Cattaneo
Ochi Ibe
Nancy Sloan
Hadi Pratomo
Joseph de Graft Johnson
Evely Zimba
Suman Rao
Saluddin Ahmed
Nagai Shuko
Zita de Calume
Steve Wall
THU NGA NGUYEN
MUKESH GUPTA
Rationale for the group work
• To respond to WHO’s needs to facilitate revision of KMC guidelines
– Originally composed in 1998-1999, published 2003,
– Due to recent publication of standards for guidelines development in
the Lancet.
– The new WHO guidelines will focus on what should be done for KMC,
universally. Other tools will have to be developed alongside the new
guidelines on how to implement KMC in high and low tech settings,
and at community level, and on how to use KMC for early child
development. Tools will also be needed for advocacy, integration
within health systems and services, training (pre- and in-service),
monitoring and evaluation.
– This working group worked to provide ideas and experience on how to
proceed with the development of the above guidelines and tools from
the point of view of low income settings and communities
The topics the group discussed are:
• What is universally needed, e.g., position,
feeding, follow-up, friendly environment
• How to implement at different levels, e.g.,
referral hospital, primary level, community
• Minimum Resources needed (requirements)
for implementation
What is universally needed
• Skin to Skin (kangaroo Position)
• The earlier after birth, the better (sensitive period in the first two
hours of life; can be done later, but it will be increasingly difficult and
less effective)
• In all full term healthy newborn infants (see the BFHI and other WHO
documents, let alone the abundant literature; not to be discussed
further)
• In all preterm and LBW newborn infants (likely positive effect on
physiological stability; what is meant by “stable” newborn infant?)
• As continuous as possible (ideally day and night over 24 hours),
intermittent STS being a lower quality alternative in case of
prematurity if there is no alternative means of keeping baby warm)
(but some STS is better than no STS, provided each session lasts at
least an hour, and efforts are put in place to achieve continuous STS)
• For as long as possible (until spontaneous weaning off by the baby)
• In the frontal position (oxytocin receptors), vertical or semi-reclined
(also at night), diaper or local surrogate only (keep mother and baby
dry), head covered in cold climate (but allow STS)
• Skin to Skin (kangaroo Position)
• STS needed also in hot wet climate (hypothermia frequent also
in these settings); if mothers complain, help them keep dry
(change clothes, cool, ventilate, use shade, etc); if needed,
allow few hours with light cotton cloth between mother and
baby during hottest day hours; do not bath; dry clean the baby
• With appropriate containment (lycra band or other local
culturally and economically acceptable material)
• Postioning technique must ensure the newborn has a patent
airways
• Primarily by the mother, but father and other designated
family members (limited number) can replace the mother
when needed
• STS provides comfort and promotes attachment and parental
bonding, with positive maternal and paternal reaction and
involvement, as well as acceptance (mediated by oxytocin)
• STS and KMC promote good quality hospital neonatal care and
NICU environment (humanization, mother and family centred
care)
What is universally Needed (ii)
Breastfeeding (BF)/Breastmilk
– All full term newborn infants immediately at the breast for first latch as soon
as the baby is ready, without forcing to the nipple, allowing time as needed
(see BHFI; not to be discussed further)
– All preterm and LBW newborn infants at the breast as early as possible, to
stimulate lactation even if latching and sucking do not occur
– If the baby is unable to breastfeed (suck, swallow), start expressing colostrum
and breastmilk as soon as possible and use to feed the baby (use clean
syringe, teaspoon or other appropriate tool); avoid prelacteal feeds
– If unable to breastfeed and not fed properly, give some glucose solution in first
24-48 hours to avoid hypoglycemia
– Scheduled and/or semi-demand feeding needed in all preterm and LBW
infants until exclusive breastfeeding is well established and adequate growth is
observed
– In case of inadequate growth, try to increase breastmilk production, use
hindmilk, use donor safe breastmilk is available; if no breastmilk available, use
preterm formula (national guidelines and hospital protocols); BF support in
preterm and LBW infants need health workers with special skills
– For HIV, follow national guidelines, no special KMC policy
What is universally Needed (iii)
• Universal (?free) access to effective health
care for preterm and LBW infants, better if in a
preterm/LBWI friendly hospital (certification
like BFHI? With different grades of
achievement to show that progress is
rewarded?) with:
Steps to preterm/LBWI friendly hospital
(certification like BFHI?
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Written KMC policy know to all staff and parents
Health workers (including auxiliaries) trained to implement policy
Information on KMC for all pregnant women
Adequate KMC routines for all preterm/LBWI
Adequate follow up (ambulatory or in continuity with health care
system) with established criteria (ability to suck and feed, gaining
weight, no disease, parents prepared to KMC at home) as close as
possible to home to improve compliance (frequency will depend on age
and weight gain)
Adequate links with family and community for social support
Better if all this is included in national policies and plans for essential
newborn care (pilot phase, assessment, identification of obstacles and
problems, find solution, expansion, monitor process and results); follow
technology assessment procedures, but keep in mind the behavioural
component of KMC
Essential if community-based KMC is implemented
Integrate with other components of maternal and child health
(antenatal care, care at childbirth, postnatal care, early childhood
development)
What is universally Needed (iv)
– Social support and friendly environment:
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Promote mother-to-mother support
Try to overcome physical and economic obstacles
Empower families and promote in neighbourhoods
Positive representation in mass media
National supportive legislation (maternity leave and
protection)
HOW TO IMPLEMENT AT DIFFERENT
LEVELS, INCLUDING RESOURCES
NEEDED AND ESSENTIAL
REQUIREMENTS
Secondary and tertiary referral
hospitals....i
• Necessary if you want to implement KMC at lower and
community levels; a good programme at this level will
facilitate extension
• Have written policy and train all staff to implement it;
involve obstetricians, anesthesiologists, auxiliaries etc; a
BFHI accreditation will facilitate KMC
• Let pregnant women and all hospital users know about the
policy (appropriate written and pictorial materials)
• Essential equipment and supplies are needed: incubator,
radiant warmer, oxygen and flowmeters, pulse oxymeter,
CPAP, phototherapy, lab tests, drugs, micronutrients, i.v.
fluids, facilities for expressed breastmilk, preterm formula,
cups, feeding tubes, scales (10 g precision), refrigerator, etc;
but also leisure room for mothers to socialize, read, chat,
play, watch TV, knit, etc; involve fathers
Secondary and tertiary referral
hospitals....ii
• Use available facilities and resources (rooms, staff,
equipment, money, etc) and reallocate, rather than
request new facilities and resources
• Ensure that KMC staff has the necessary skills to
support BF in preterm/LBWI
• Ensure adequate follow up, ambulatory or at peripheral
facilities depending on distance and circumstances
(hence the need to train also health workers in lower
level facilities), ensure continuity of care
• Keep good records and use database to assess quantity
and quality of KMC, as well as outcomes
First level Hospitals (with admission
policy)
• Clear criteria about which preterm/LBWI will be cared for at which
level, so that only those appropriate for this level will remain here,
or will be sent here after discharge from secondary or tertiary care
unit
• Link with secondary/tertiary unit, but also with lower level health
centres and facilities
• Have a written policy, inform and train all staff, inform all pregnant
women and their families
• Have a minimal package of materials, equipment and supplies that
will allow to care and monitor larger preterm/LBWI (or smaller
preterm/LBWI discharged from secondary/tertiary units) for few
days to monitor health and growth, before discharge home
• Be equipped, including trained staff, to deal with special
breastfeeding support needed for KMC infants
• Keep good records
Other first level facilities
• Differentiate care provided according to capability for
inpatient care, although limited, or not; for example: can
cases of neonatal sepsis be treated or will they be referred
to upper level facility?
• If no inpatient care, train staff to follow up (including
outreach if necessary) preterm/LBWI discharged from upper
levels or referred from CHW/V (see below)
• Weighing, monitoring growth, counseling, etc should be
possible in these and upper level facilities, with appropriate
equipment and supplies, including simple management and
triage (staff must be trained for all this; make sure staff does
not go beyond what they have been trained to do for
preterm/LBWI)
• Keep simple records, ensure regular supervision, have simple
pictorial instructional material (IMCI-like)
Community KMC
• In settings where percentage of births assisted by
skilled attendants is low and unlikely to grow rapidly
• Start simultaneously with KMC in health care facilities
(see above) and teaching institutions; do not use
community KMC to delay access to quality health care
services
• For all newborn infants or only for preterm/LBW (small)
infants, depending on countries and circumstances (GA
impossible to assess everywhere; BW impossible to get
in most places; where scales are available, may only
have colour-coded gross indication of weight
categories; no accurate measures; colour-coded
assessment of mid arm circumference may be an
alternative)
Community KMC..contd 2
• About 500-1500 (based on distances) population per
CHW/V (larger populations difficult to manage) with a
comprehensive but not excessive and unmanageable
number of tasks
• Community sensitised with culturally adapted social
communication for behavioural change that creates a
favourable environment (see recent Lancet paper by V.
Kumar); integrate traditional birth attendants
• Start with information for all pregnant women, with
appropriate instructions and pictorial material (1-2 visits
in pregnancy), counselling materials and skills
• Promote birth in preterm/LBW friendly hospital in case of
preterm labour and birth, or refer to hospital soon after
birth (clear criteria for referral in training and
instructions); use STS for transport, while maintaining BF
Community KMC..contd 3
• Promote as early as possible STS (first 24 hours, maximum 48
hours) and as continuous as possible
• Promote adequate personal hygiene for the mother who is
providing KMC
• Ensure a CHW/V visit as soon as possible after birth (same timing);
then visit every two days in first week and for a total of five times
in the first month; observe BF and give adequate support at every
visit; promote scheduled and/or semi-demand feeding until baby
sucks and feed well and good growth is confirmed
• Use simple checklists for both ante- and postnatal care, so that
essential observation and advice is not missed; identify danger
signs and refer accordingly
• Community (and even ambulatory or facility based) follow up after
hospital discharge may be particularly difficult in peri-urban slum
areas; special efforts needed
Community KMC..contd 4
• If for all newborn infants, monitor adverse events
(unexpected and unexplained deaths reported in
France and UK); the baby may be used to identify which
needs STS beyond sensitive period: term babies will
push away)
• Provided by community health workers or volunteers
(CHW/V), male or female, paid or unpaid, employed by
governments or NGOs, with a given educational level,
depending on circumstances; credible in the
community
• CHW/V appropriately trained: competency based
courses of adequate duration (2-3 weeks?)
• CHW/V with essential equipment (scale?
thermometer? drugs? mobile phone?) and simple
records and adequate supervision to maintain or
improve quality performance
Key take home messages
Integrate KMC in to Essential
newborn care
• For sustainability
• think about cost
• plan accordingly (never as
stand alone KMC, but as part
of comprehensive newborn
care),
• Provide accurate information
that survival may improve, but
deaths will still occur, and that
survivors may have a better
life.
For advocacy
• Involve governments and
donors, set up local
partnerships
• Have “champion” to help
sustain enthusiasm (and deal
with anti champions)
• Award, certify, reward (as in
BFHI or better)
• Present as part of
comprehensive integrated ENC
• Get WHO and UNICEF support