Dr. Nathalie Charpak: “Kangaroo Mother Care” and Neurological Development of Premature Babies

Kangaroo mother care is a method of care of preterm infants. The method involves infants being carried, usually by the mother, with skin-to-skin contact.

Kangaroo mothercareKangaroo Mother Care (KMC) according to Dr. Nathalie Charpak, an internationally respected pediatrician and daughter of the Nobel Prize-winning physicist George Charpak, represents a way of humanizing neonatal healthcare. Like other forms of “kangaroo care,” KMC is an incubation method to keep newborns weighing 2000 grams or less at birth and those unable to regulate their own body temperatures warm. Rather than isolating babies in loud, mechanical neonatal intensive care units (NICUs)—which have been shown to cause both psychological stress and adverse physiological changes—KMC positions preterm and low-birth weight babies in direct skin-to-skin contact with a parent or caregiver once stabilized. While KMC was originally conceived in 1978 in response to overcrowding and inadequate resources for NICUs in Colombia, more recent research studies have shown that skin-to-skin contact works as an effective technique not only for thermal control but for breastfeeding, and bonding irrespective of clinical settings, gestational age, or weight. This case study recounts how research evidence has drawn attention to important aspects of neonatal development.

Research to Practice

During an interview with PAHO, Dr. Charpak outlined three types of surrogate benefits emerging from an intervention like KMC. Firstly, from a sociological standpoint, placing babies in direct contact with their parents presents an immediate opportunity to establish a parent-child relationship without delay and avoids separating the neonate from caregivers simply because of illness. She argued that by involving them directly, parents and caregivers are naturally compelled to assume the roles of providers for their preterm babies. For the infant, investigators have observed a stronger tendency for babies to quickly settle down into a deep sleep (lower state of consciousness) or become less fussy before feeding when in KMC position 4. By enhancing the parent-infant bonding, KMC facilitates the psychological bonding process necessary to overcome the initial stress and shock already associated with a premature birth.

kangaroo-father

Secondly, kangaroo care promotes growth and development. Notably, KMC encourages exclusive breastfeeding and lactation which contribute to proper nutrition needed to sustain appropriate growth and weight-gain rates. Dr. Charpak also alludes to neural stimuli: “It’s favorable for the baby to smell his/her mother, hear the heartbeat, and experience tactile stimulation which resembles the comfort experienced in-utero.”

Research done at the Université Laval supports these claims. Comparing the motor cortex of premature adolescents (39 who underwent KMC and 18 who underwent NICU), the investigators discovered that premature infants under KMC had better brain functions in adolescence than their counterparts who underwent incubator care. When comparing brain maturation, the KMC-patients had brain connectivity more similar to patients born at term. This research suggests an association between KMC and optimized neuroplasticity during critical stages of infancy by reproducing intrauterine environments that NICUs cannot simulate.

Thirdly, Kangaroo Mother Care has led to some changes to standard of care that has improved how neonates are treated. The implementation of KMC units is a 24/7 service requiring clinics to operate non-stop. In contrast, in some low and middle income settings babies in NICUs are left alone while attached to monitors, ventilators, and other mechanical contraptions. Further, NICUs are subject to the dangers of outdated equipment or inconsistent electricity grids found in resource-poor hospital settings. However, KMC, by removing the automation, obliges hospital staff to treat newborns like regular patients (e.g. respecting sleep patterns, reducing exposure to stressors such as noise). This has been associated with dramatic reductions in negative physiological responses such as sleep apnea and fluctuations in heart rate, blood pressure, and oxygen saturation. At the same time, they also they lessen the hospital workload by introducing parents as additional caregivers.

In practice, maternity wards, for example in Nicaragua, have shown KMC to be a cost-saving implementation because it decreases the average lengths of stay in hospitals and thus lowers resource consumption. Additionally, for hospital units surrounded by varying road conditions and surface disruptions, KMC position provides a safer form of transportation. While little data about this adaptation exists in the Americas, studies from Belgium show that the mother and her body provides adequate safety and comfort. This data suggest that KMC as an intervention decreases parental stress and increases quality of care for the infant while gaining high satisfaction among hospital staff.

What’s Next

Although KMC originated in response to limitations of resource-poor hospitals, the benefits attributable to this health service has undoubtedly extended beyond its original purposes and generated new knowledge to improve the standards of care for newborns. From discussion with Dr. Charpak, there is the conclusion that KMC is neither a return to ancestral practice nor an alternative to more conventional means of neonatal care; instead, it complements the NICU. By adopting a more holistic form of medicine and introducing an intervention that looks natural despite of not actually being “natural in nature,” research presents one cost-effective, functional care system that improves the way preterm and low birth weight babies are cared for in hospitals.

At the same time, Dr. Charpak cautions that in addition to implementation, “numbers must be published and guidelines must be actualized.” More published observations will be needed to more comprehensively understand the returns of health services like KMC in varying settings. The strength behind this intervention, nevertheless, is that it has been and continues to be extensively researched, thus further pushing the boundaries of knowledge for better health.

Source: Paho.org

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Dr. Francis Ohanyido: Ending Preventable Child Deaths in Nigeria by 2030

Dr. Francis Ohanyido

Dr. Francis Ohanyido

In 2015 alone, it was estimated that nearly a million children worldwide, died before their fifth birthday. One out of nine of these children (121,000) died in Nigeria. It is estimated that there are 6.7 million cases of childhood pneumonia annually. Nigeria thus has the second largest burden of the disease after India which has about ten times our population. In addition, pneumonia is estimated to constitute 15% of all causes of death in children below the age of 5.

One of the key highlights of the 2014 World Pneumonia Day was the release of a new report by the Institute for Health Metrics and Evaluation (IHME) titled “Pushing the Pace: Progress and Challenges in Fighting Childhood Pneumonia”. This report found that there had been a reduction in child pneumonia deaths over the last fifteen years of about 58%, but that this had not kept pace with reductions in deaths from other childhood killers such as measles and diarrhoea whose reduction stood at 83% and 68% respectively. In addition, funding remained an issue; illustrated by the fact that in 2011 only 2% ($US670 million) of the estimated $US30.6 billion of international development aid for health, was spent on fighting pneumonia, the leading cause of death among children under-five years! The IHME report has attracted a lot of comments from major actors in the pneumonia landscape worldwide. My good friend Ms. Leith Greenslade, Vice Chair at the MDG Health Alliance, clearly articulated my own take on the report:

“ …There is an opportunity to achieve a better alignment between the major causes of child death and the allocation of development assistance. The fact that many of the countries that have performed so poorly in reducing child pneumonia deaths have achieved remarkable reductions in reducing child deaths from other causes (e.g. diarrhea and measles) suggests that disease prioritization and level of investment are critical factors. If we want to achieve MDG4 by 2015 and end preventable child deaths by 2030 we need to make sure that our spending tracks disease burden more closely than it has to date.”

It comes as no surprise that the report further confirmed the relative neglect of pneumonia disease among the top five causes of child mortality. This neglect has consequences on the institutional response to tackling the problem and even the health literacy of the population. A simple random chat with people in Nigeria clearly highlights that strong myths largely affect people’s understanding of the disease. Whenever I explain to people that Nigeria carries a significant chunk of the global burden of the disease, it has often been greeted by surprise…and even incredulity.

Sadly, a significant number of people still think pneumonia is a disease of “cold environments”, rather than as a result of disease causing organisms. It is also not surprising that in the same report, Nigeria has showed only 4% reduction in pneumonia deaths among children under five years in the time reviewed.

During the course of a discussion on pneumonia with a senior legislator in the Nigerian National Assembly two months ago, she had asked me two questions:

What can we do to change this state of affairs?

What has been done so far in Nigeria?

I replied to her questions as follows:

There is urgent need to mobilise resources to move against this disease if we want to achieve MDG 4, because it would enable the rollout of vaccines to prevent infection, strengthen programmes around health information, breastfeeding and access to clean cooking stoves. It would enhance the early recognition and treatment of children with pneumonia with the appropriate antibiotics such as the dispersible amoxicillin tablet and access to oxygen therapy where it is needed.

In response to her second question, I explained that despite many challenges, Nigeria was on the road to rolling out the pneumococcal conjugate vaccine at the end of the year, which would serve as the cornerstone of prevention.

The country’s partners at the last United Nations General Assembly week 2014 side meetings, had agreed to strengthen partnerships around breastfeeding including early initiation of breastfeeding due to the poor indices, as poorly breastfed babies are at a fifteen times greater risk of death from pneumonia when compared to babies who are exclusively breastfed for the first six months of life. (Children with malnutrition are also more likely to die of pneumonia). On the side of treatment, following compelling case profiles of several countries across Africa, Nigeria had started the process of rolling out the integrated community case management (ICCM) for malaria, pneumonia and diarrhoeal diseases. The country had also achieved local production of dispersible Amoxicillin tablets which is the first line drug for treatment of community-acquired pneumonia, a landmark achievement on the continent.

Because of the large human resource for health gap at the frontlines of Nigerian health system, the ICCM programme would use community assets by riding on the back of community-based health volunteers (CBHV) also called Community Oriented Resource Persons (CORPs) in underserved communities. Such structures are not new and have done well in Sokoto and Bauchi states in community-based distribution of misoprostol and chlorhexidine to reduce maternal mortality, with the support of USAID’s Targeted States High Impact Project (TSHIP). However, certain enabling policies need to be reviewed for pneumonia to be treated at the frontlines by such volunteers. Among the groups also being considered in this category to expand access to ICCM treatment for children are the ubiquitous patent and proprietary medicine vendors (PPMVs) found in every community in Nigeria.

One of the major challenges in ramping up pneumonia programmes has been around the diagnostic conundrum. Unlike its counterpart malaria, pneumonia diagnosis is mostly based on the clinical acumen of the provider for recognising signs in a child, because confirmation by X-ray is almost impossible at the lowest level of health care. New diagnostic technologies such as pulse-oximeters, mobile applications and other forms of tools to enhance quick, reliable and cost-effective diagnosis are being developed and tried. The inability to deliver compact and cost-effective oxygen therapy at primary care centers has also been a challenge at the frontlines that requires investment.

To end preventable child deaths by 2030 in Nigeria, we must move pneumonia to the centre stage of our child health programme strategies. The level of investment and disease prioritization we give to our strategies are critical factors, and require good integration at community level in managing the major childhood killers, namely, pneumonia, malaria and diarrhea. We must focus on pneumonia if we want to reduce preventable child deaths in Nigeria.

Exclusive Breastfeeding: A Pathway To Reducing Child Mortality

According to experts, breastfeeding can prevent the deaths of many babies. Breastfeeding

Exclusive breastfeeding for the first 6 months can reduce child deaths by at least 800,000 each year – almost 15% of the total 6.3 million annual child deaths. Babies who are not breastfed are particularly vulnerable to the leading killers of small children and are 15 times more likely to die from pneumonia and 11 times more likely to die from diarrhea, compared to babies who are exclusively breastfed.

According to Leith Greenslade, Vice-Chair at the MDG Health Alliance, “It is not that women don’t understand the value of breastfeeding. Surveys repeatedly show that new mothers across many countries know that breast is best for babies.

However new mothers are concerned that they don’t have enough milk or time; that they experience pain, exhaustion and rejection from their babies; that they feel awkward breastfeeding in public; that spouses are often unsupportive and that it’s just too hard to breastfeed and work. And don’t forget that although world health authorities recommend exclusive breast-feeding for 6 months most countries don’t offer maternity leave beyond three, and typically without pay.”

UNICEF’s landmark 2013 report, Breastfeeding on the Worldwide Agenda, outlines a powerful argument for change describing the current environment as “policy rich” but “implementation poor”.

At the same time, the Bill and Melinda Gates Foundation’s flagship breastfeeding investment – Alive & Thrive – is demonstrating that large increase in breastfeeding are possible with multi-sector action to shift attitudes among new mothers, the behavior of employers and the policies of governments. With this approach, the exclusive breastfeeding rate in the Vietnamese project sites has risen from 19 to 63% and across the Bangladesh sites from 49 to 83% in just three years.

Despite this evidence, rates of early and exclusive breastfeeding are very low in Nigeria and are not improving much. The 2013 Nigerian Demographic & Health Survey reports that although almost all babies (98%) are breastfed in Nigeria, only a minority of mothers (33%) achieves the WHO-recommended initiation within one hour of birth and continues to breastfeed exclusively for six months (17%). Further, an alarming 70% of newborns born at home are fed something other than breast milk during the first three days of life compared to 40% in health facilities.

Today in Nigeria, the babies most likely to be breastfed within an hour of birth are delivered by a doctor, nurse or midwife at a health facility in an urban area (40%), and the babies least likely to start breastfeeding early are delivered without any assistance, at home in rural areas (30%). There is a large range in early initiation rates by States, with the highest rates in Kogi (74%), Kwara (71%), Borno (68%), Abia (64%), Edo (55%) and the Federal Capital Territory-Abuja (51%), and the lowest rates in Kebbi (8%), Zamfara (12%), Taraba (14%), Ebonyi (17%), Katsina (18%) and Lagos (20%).

In general, breastfeeding rates are highest in the North Central and South South Zones and lowest in the North West and South West Zones. Across Nigeria, the mothers most likely to start breastfeeding early and continue for six months exclusively have higher levels of education and incomes. For example, 40 per cent of mothers in rich households breastfeed within an hour of birth, compared to 20 per cent of mothers in poor households, and breastfeed exclusively for almost three times as long.

Meanwhile the countries that have achieved the greatest progress in reducing child mortality and achieving Millennium Development Goal 4 have all recorded exclusive rates of breastfeeding well above the global average including Rwanda (85%), Cambodia (74%), Malawi (70%), Bangladesh (64%), Nepal (70%).

Inspired by these successes and also by what we have learned in the areas of global health that have made the greatest gains though intense, sustained and collective public and private sector action, especially AIDS, malaria and vaccines, it is time for public-private partnerships to drive innovation, progress and deliver results in breastfeeding.

With Nigeria’s sharply rising population driven by a very high fertility rate (an average of 6 children per woman), the under 5 population is forecast to grow by 10 million in the next 15 years. We need to look into PATH’s promotion of human milk banks so that vulnerable newborns have access to human milk in the critical days after birth when their mothers cannot provide it.

Hauwa Abbas of Silver Lining for the Needy Initiative, an NGO focused on improving child and maternal health rates suggests integrating awareness, promotion and support at the community level to existing structures in order to accelerate commitment and coverage of sustainable community level activities on breastfeeding, thus contributing effectively to decreasing child morbidity and mortality.

Also speaking on this, Dr Luther-King Fasehun of the Wellbeing Foundation, an NGO that works through policy advisory, issue-based advocacy, awareness creation, and philanthropy, for improved reproductive, maternal, newborn, child and adolescent health (RMNCAH), suggests that a broad-based, multi-sectoral approach, that is context-specific to coordinate the strengths of all stakeholders in different States and regions of Nigeria, including the private sector, religious institutions, government, and CSOs, is necessary, in order to build a massive positive change in attitudes and policies, supported by the appropriate technologies and market dynamics, that will raise the early and exclusive breastfeeding rates for Nigeria’s children.

 

Article originally published on Leadership.ng