Kangaroo mother care: a simple, smart, no-cost investment in our children’s future

courtesy:HNN   

Kangaroo mother care (KMC) refers to the practice of providing continuous skin-to-skin contact between mother and baby, exclusive breastmilk feeding, and early discharge from the hospital. It helps save millions of preterm babies in poor resource setting by regulating the baby’s temperature, speeding up the weight gain, and reducing the risk of infections.

KMC was first introduced in Bogotá, Colombia by two pediatricians Dr. Rey and Dr. Martinez in 1970s following increasing preterm morbidity and mortality.

Both the pediatricians were deeply troubled by the lack of incubators in poor resource settings and while looking for solutions were inspired by the way mother kangaroo care for their young ones.

Born immature, about 1-inch long and weighing less than a gram, the baby kangaroo immediately crawls up the mother’s body to enter the pouch. Once inside, they attach to one of the four teats to get nourishment, warmth and develop to become active and independent.

Years later, many studies and meta-analysis have proven the benefits of kangaroo care. A 2015 study has shown a 36% reduction in mortality for preterm babies who receive kangaroo care vs. conventional neonatal care. Adopted on a national scale in Rwanda, it has brought down neonatal mortality by 30% between 2008 and 2015.

The World Health Organization recommends KMC for the routine care of newborns weighing 2000 grams or less at birth. However, surprisingly a tiny percentage of newborns who could benefit from kangaroo care receive it.

KMC day is celebrated on May 15th

Country-level adoption and implementation are very poor. It is often considered as “ second best” to incubator care. Every year, about 2.7 million newborns die during their first month of life, the majority occurring in parts of the world where there are no hospitals or clinics nearby, and no access to skilled birth attendants. These areas could greatly benefit from the adoption of kangaroo care.

KMC also has long-term cultural, social and behavioral benefits for our society. A recent study noted that this practice is a gift whose value keeps on multiplying over time.  Parents that practiced kangaroo care were more protective and nurturing and very well bonded with their children. The children were less likely to be absent from school and less likely to have antisocial behavior.

These positive effects were still present in the children 20 years later! Now that is a simple, smart, no-cost investment in our children’s future.

Here is a video about kangaroo care from gatesnotes

WHO Kangaroo mother care: a practical guide

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Preterm births more common after IVF/ICSI: a meta-analysis of cohort studies

Pregnancies conceived after IVF/ICSI face a greater risk of preterm delivery as compared to natural conceived cohorts reports the results of meta-analysis published recently in Journal Ultrasound in Obstetrics and Gynecology.

Earlier studies have also documented an increased risk of having a premature baby in couples who have conceived after IVF/ICSI, but whether this is a spontaneous (SPTB) phenomenon or iatrogenic has not been studied.

A research of literature identified 71 studies out of which 15 met the inclusion criteria, and resulted in total sample size of 61,677births.

Statistical analysis showed that SPTB occurred before 37 weeks in nearly 50% more pregnancies conceived by IVF/ICSI (10.1%) than natural conception (5.5%) (odds ratio 1.75; 95% CI 1.50-2.03). The corresponding rates before 34 weeks were 3.6% and 2.1% respectively.

Dr Paolo Cavoretto of IRCCS San Raffaele Hospital in Milan, Italy, is one of the study authors, and he opined that all pregnancies conceived with IVF/ICSI should undergo a mid-trimester transvaginal cervical length evaluation.

If a short cervix is diagnosed, intravaginal progesterone or cerclage should be considered as per individual patient obstetric history.

The researchers called for bigger studies in future, to explore in-depth the mechanism behind SPTB and also differentiate between iatrogenic or indicated PTB.

Abstract

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Vaginal fluid Interleukin-6 seems to be a promising non-invasive marker for the prediction of inflammation in amniotic cavity in PPROM.

Preterm PROM complicates 3% of all pregnancies and is responsible for one third of preterm labors which leads to significant fetal morbidity and mortality. [1]Once the membrane ruptures the protective and sterile environment of the amniotic cavity is breeched linking it to bacterial cervicovaginal flora. This increases the risk of amniochorial infection which in turn is responsible for fetal inflammatory response syndrome.

Obstetricians have to weigh the benefits of prolonging the pregnancy at the risk of intrauterine infection. vs active induction of  labor. Numerous biomarkers have been studied in predicting the occurrence of infection and decide the clinical course of the pregnancy.

Maternal serum markers are not much useful in prediction of the fetal inflammatory response; hence researchers have studied various biomarkers from vaginal fluid like tumor necrosis factor-α, metalloproteinase-8 (MMP-8), soluble HLA-G (sHLA-G) and interleukin-6.

A recent paper published ahead of print in July issue of American Journal of Perinatology concluded that MMP-8, IL-6, glucose, and lactate concentrations in vaginal fluid did predict poor neonatal outcome but it was not reach statistical significance. Only increased levels of metalloproteinase-8 (MMP-8) were associated with poor neurological outcome. [2]

A recent study published in the forthcoming issue of American Journal of Obstetrics and Gynecology aimed to determine the diagnostic indices and predictive value of vaginal fluid interleukin-6 concentration as a point of care tool(POCT) in predicting microbial invasion of the amniotic cavity(MIAC), intra-amniotic inflammation, and microbial-associated intra-amniotic inflammation in patients with preterm PROM.[3]

The researchers also intended to know the relationship between vaginal and amniotic fluid interleukin-6 concentrations in fresh unprocessed samples obtained simultaneously.

This prospective cohort study recruited 153 women with singleton pregnancy who had PROM at between 24+0 and 36+6 weeks. Preterm PROM was confirmed by examination with a sterile speculum to verify the pooling of amniotic fluid in the vagina.

Samples of vaginal and amniotic fluids were collected from posterior fornix and transabdominal. IL6 assessment was done in both fluids by lateral immunoassay.

The cut-off level to define Intra-amniotic inflammation for IL6 was ≥745 pg/mL.

Out of 153 women in the study, samples of vaginal fluid were obtained in 141 women. It was possible to predict the microbial invasion of the amniotic cavity, intra-amniotic inflammation or microbial-associated intra-amniotic inflammation by higher vaginal fluid interleukin-6 concentrations.

The levels of vaginal fluid IL-6 were higher than amniotic fluid IL-6 concentrations.

A IL6 level of ≥2500 pg/mL identified patients with MIAC, intra-amniotic inflammation, and microbial associated intra-amniotic inflammation. Levels of IL6 < 2500 pg/mL could 100 % exclude patients with microbial-associated intra-amniotic inflammation. These findings need future corroboration by larger studies and meta-analysis before a clinical recommendation is made.

This finding has very important clinical implications, because in future it can be used as triage, to decide the expectant vs active management of women with preterm PROM.

By using this easy, cheap, noninvasive and rapid method, women will be spared of the invasive procedure of amniocentesis to evaluate the intrauterine environment.

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[1] http://www.aafp.org/afp/2006/0215/p659.html

[2] http://www.ncbi.nlm.nih.gov/pubmed/27120475

[3] http://www.ajog.org/article/S0002-9378(16)30439-2/abstract