EFFECTIVENESS KMC IN PROMOTING BREAST FEEDING AND CONFIDENCE BUILDING IN MOTHERS OF LBW BABIES - A HOSPITAL BASED RANDOMISED CONTROL TRIAL. YEARS
Dr. Deepti Kulkarni*, Dr. N S Mahantshetti**
Department of Paediatrics, Jawaharlal Nehru Medical College, Belgaum 590 010. Email: deepti.ak@gmail.com *, Department of Paediatrics, Jawaharlal Nehru Medical College, Belgaum 590 010. Email: deepti.ak@gmail.com **
Abstract
KMC is defined as early, prolonged and continuous skin to skin contact between the mother and her low birth weight baby by promoting effective thermal control, breast feeding, bonding and early hospital discharge.

Objective:
To determine benefits of KMC in LBW <2.2 kg with respect to promotion of breast feeding and confidence building in the mother.

Study Design:
A randomised control trial of 40 babies admitted to NICU of KLES Hospital and Medical Research Centre, Belgaum between March 2006 - Aug 2006.

Materials and Methods:
Babies with birth weight of less than 2.2 Kg were included in the study. Once babies were stable the effect of KMC on breast feeding and confidence building was studied using a questionnaire and assessed on Likert's scale. The Kangaroo group was subjected to KMC for at least 13 to 14 hrs/day.

The control group (n=20) received conventional care.

Results:
There was a significant difference in the duration of exclusive breastfeeding between the two groups. (KMC - 12.3 ± 1.34, Control - 9.2 ± 1.32, p = 0.000). Kangaroo mothers expressed high levels of satisfaction and showed a significant increase in confidence in handling their low birth weight babies (KMC p = 0.000, Control p = 0.617).

Conclusion:
KMC promotes breast feeding in low birth weight babies and it builds confidence in mothers with respect to taking care of low birth weight babies.
Introduction
Kangaroo mother care was an idea born in Colombia, suggested by Dr. Edgar Rey. It was developed initially as a way of compensating for the overcrowding and scarcity of resources in hospitals caring for low birth weight infants Kangaroo mother care (KMC) is defined as a early prolonged and continuous skin-to-skin contract between the mother and LBW infants both in hospital & after discharge with exclusive breast feeding. The two components of KMC are:
  • Skin to skin contact: Early continuous and prolonged skin to skin contact between the mother and her baby is the basic component.
  • Exclusive breastfeeding: Skin to skin contact promotes lactation and facilitates the feeding interaction.
  • Studies have revealed that KMC results in increased breast feeding rates as well as increased duration of breast feeding.
  • Studies have reported a stronger bonding with the baby, increased confidence, and a deep satisfaction that they were able to do something special for their babies.
Aims and Objectives
To determine the effectiveness of KMC in promotion of exclusive breast feeding, and confidence building in mothers taking care of LBW babies whose birth weight is <2200 gms.
Materials and Methods
All neonates born / admitted in KLES Hospital of birth weight <2200 gms during March 2006 to August 2006 were included whose mothers were willing for KMC / conventional method of care after their consent were considered as participants.

About 20 each in KMC & conventional group were enrolled. Babies were randomized using a table of random members to receive either KMC or conventional care alone. Inclusion Criteria:

All neonates who were born / admitted with birth weight <2200 gms in KLES Hospital Belgaum who are stable and able to take oral feeds.Exclusion Criteria:
  • Critically ill babies
  • Critically ill mothers who are unable to remain with their babies because of their medical problem.
  • Congenital anomalies like cleft palate which interferes with breast feeding.
  • Mothers unwilling to participate in the study.

In KMC group, babies were kept in skin to skin contact as per KMC module as long as possible contact for a minimizing 13 - 14 hrs per day and exclusively breast fed to the utmost extent.

In conventional group babies received standard care under the warmer. Mothers were allowed to visit the babies touch and handle and breast feed them.

During the study exclusive feeding and confidence building in mother were assessed. Breast feeding was assessed as per BPNI guidelines.1 Confidence building in mother assessed by a questionnaire incorporating Likert's scale on day 2 and day 7 of KMC.
Results
During our study 40 babies full filled the criteria for enrollment. These babies were randomly assigned to KMC group (n=20). Baseline characteristics of the newborn infants at birth were comparable in both the groups that is birth weight, gestational age, sex, Apgar score.

Table No. 1: Baseline characteristics

Characteristics

KMC group (n=20)

Control Group (n=20)

Male / female

9/11

11/9

Birth weight Mean ± S.D.

1810 ± 170

1820 ± 240

Gestational age (weeks)

35.25 ±3.29

35.05 ± 2.43



In both the groups we did not find any gross difference regarding characteristics of mothers that is age, problems during pregnancy, parity, mode of delivery, and mothers education level and employment. The median age at which KMC was started was 7.05 days. In 10 infants KMC was started in the first week of life.

Table No. 2: Comparison of weight gain, discharge and duration of stay

Characteristics

KMC group (n=20)

Control Group (n=20)

't'

'p'

Birth weight

1.810 ± 0.17

1.820 ± 2.40

0.232

0.818

Discharge weight

1.840 ± 0.170

1.790 ± 2.60

0.569

0.573

Change in weight

0.28 ± 0.330

-0.035 ± 0.086

0.891

0.382

Hospital stay

13.9 ± 5.35

14.2 ± 7.31

0.148

0.863



Babies in the KMC group demonstrated better weight gain at the time of discharge compared to control group who showed on an average slight decrease in weight at discharge. Duration of hospital stay in KMC group was similar to control group but with a better weight gain at discharge.

There was a significant difference in the duration of exclusive breast feeding between the two groups. The effectiveness of KMC in confidence building in mothers of low birth weight babies was assessed by questionnaire on day 2 and day 7 of KMC which contained 4 questions. Statistical analysis was done using Wilcoxon Signed Rank test (WSR test) & Mann Whitney (MW Test) used to test the significance between the two groups. Students 't' test was used to compare the adjusted means in KMC v/s control group. The responses were as follows:

Table No. 3: Responses

 

KMC group (n=20)

Control Group (n=20)

't'

'p'

No of breast feeds per day

12.3 ± 1.34

9.2 ± 1.32

7.364

0.000



The number of breast feeds per day was significantly higher in the KMC group as compared to controls. A 'p' value of 0.000 was obtained and a 't' test value of 7.361.

To the question whether the mother are happy and comfortable with baby in NICU.

Table No. 4: Questionnaire Answers at 48 hrs and 7 days of Admission

Day

1

2

2/7

3

2/7

4

2/7

5

2/7

CONTROL Are you happy and comfortable with baby in NICU? 4/0 10/14 5/3 1/3 0/0
Are you confident in handling the baby ? 2/0 7/9 8/9 3/7 0/0
Would you prefer incubator rather than KMC 6/0 4/15 4/2 6/3 0/0
Are you confident in looking after the baby at home? 3/0 8/11 5/2 2/6 0/0

KMC

Are you happy and comfortable with baby in NICU? 0/0 7/0 13/0 0/8 0/12
Are you confident in handling the baby? 0/0 0/0 20/0 0/5 0/12
Would you prefer incubator rather than KMC? 0/18 20/2 0/0 0/0 0/0
Are you confident in looking after the baby at home? 0/0 0/0 20/0 0/5 0/15
1 - Not at all
2 - NO
3 - Not sure
4 - Yes
5 - Very much
 


Most control were not happy at 48 hrs as well as 7 th day of KMC. In comparison there was increase in comfort level of mothers giving KMC.

A significant increase in ability to handle the baby was again seen with KMC mothers 'p' 0.000 in control there was no significant change over a period of 7 days. (P = 0.083)

A comparative study between the two groups showed a significant difference at the beginning p = 0.022 and end p = 0.000 to the question whether they prefer incubator. 6 control mothers preferred incubator care at day 2. The number was reduced to 3 on day 7.

In KMC, most mothers at 48 hrs and 7 days gave responses favouring KMC. A comparative study between the two groups showed that mothers in the KMC group were happier with their LBW babies being with them.

Whereas in control group mother's were not happy with their babies being separated. A p value of 0.000 in the KMC mothers was obtained.

Mothers were confident in taking care of the baby at home, in both controls and KMC (p = 0.032 control p = 0.000 - KMC).

A comparison between the two groups showed no difference in taking care at home.
Discussion
Through a RCT the affect on KMC on promotion of breastfeeding confidence building of mothers of low birth weight babies of birth weight less than 2.2 Kg (20 in each group).

The no. of breast feeds per day was significantly higher in the KMC group compared to control group (12.3 ± 1.34 / day v/s 9.2 ± 7.32 / day). In KMC group and control group respectively with a p value of 0.000. this is in agreement with other authors who have reported similar results. Ramanathan et al. showed that Kangaroo mothers breast fed their babies for a longer duration as well as gave more no of feeds/day compared to non-Kangaroo. (5)

Tessier R et al. showed that KMC promoted breast feeding in low birth weight. (4)

Wahlberg et al showed that Kangaroo infants continue breast feeding at discharge than control infants. (8)

In our study, the confidence building in mothers in caring for their low birth weight babies was assessed by using a questionnaire incorporating the Likert's scale.

As was learnt out of questionnaire, a Kangaroo mothers expressed high level of satisfaction and showed a significant increase in confidence in handling their low birth weight babies. They were more sensitive to the babies. All mothers said they preferred KMC rather than incubator care.

Analysis of questionnaire on day 7 after starting KMC showed that KMC enhanced the confidence of the mother in handling and taking care of the baby. our study results are in coherence with previous similar trials.

Ramanathan et al showed better acceptability of the mothers in handling their babies in KMC group 5 and also Tessier et al. showed that bonding KMC mothers was significantly higher when compared to controls. (4)
Drawbacks
The drawbacks in the study was that the control groups had to be discharged earlier from NICU due to shortage of beds. They were discharged before meeting discharge criteria. (weight gain for three consecutive days). The other parameters affected by KMC need a further study.
Conclusion
KMC is a safe humane, special way of caring for low birth weight babies even though sample size and our study was small. Our clinical trial shows that there were significant benefits in terms of promotion of exclusive breast feeding and confidence building.
Recommendations
Kangaroo mother care because of its simplicity has a role in home care of low birth weight babies. Large clinical trials of KMC in the community needs to be done. Its role in care of low birth weight in rural areas could prove to be significant.
Acknowledgement
Authors are most grateful Dr. Rekha Udani. K. M. Hospital Mumbai and her team for training faculty post graduates and nurses in KMC. We are also most grateful to Dr. Mallapure for valuable inputs to study design.
References :
  1. World health organization Kangaroo mother care, a practical guide, Department of Reproductive health and research. WHO Geneva: 2003.
  2. Udani RH, Nanavathi RN. Training manual on Kangaroo mother care published by the department of neonatology KEM hospital and Seth G S Medical College, Mumbai, September 2004.
  3. Kangaroo mother care. Clinical practice guidelines published by KMC India Network. Oct. 2004.
  4. Tessier R, Cristo M, Velez S, Charpak Y and Charpak N et al. American Academy of Paediatrics 1998; 102: 17.
  5. Ramanathan UK, Parul VK, Deorari AK, Taneja U, George G. Indian Journal of Pediatrics 2001; 68(11): 1019-23.
  6. Legault M, Gowlet C. Comparison of Kangaroo and traditional methods of removing preturn infants from incubatosis. J. Obst. Gynecol Neonatal Nursing.
  7. Ludinjton - Hoe SM, Hadeed AJ, Anderson GC. Physiologica responses in skin to skin contact in hospitalized premature infants. J Perinatal 1991; 11: 19-24.
  8. Affonso D, Persson B, Wahlberg V. Exploration of mothers reaction to the Kangaroo method of prematurity care. Neonatal Netw 1989; 7(6): 43-51.
  9. Goel A, Vasi SN, Kangaroo mother method for the care of the low birth weight infants - an Indian experience. Paper presented at the 18th Annual conventional of the National neonatalogy Forum, Vellore.
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