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Volume Vii | March 2017

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From the heart of the Editors

Dear Readers,

It is our immense pleasure to present this newsletter, the second in 2017 and seventh in the series. This year the Kangaroo Mother Care Foundation has taken a giant step in spreading theme of KMC in the country with KMCCON – The 1st National Conference on Kangaroo Mother Care in India. With the noble objective of the promotion of KMC in India, the first national conference was held at Hyderabad, Telangana from 24th to 26th February 2017.

It was the culmination of all the hard work put in by the KMCF (Kangaroo Mother Care Foundation), in association with UNICEF. The Government of India has included KMC as a core intervention for the care of low birth weight infants and has initiated KMC promotion in the country. This conference was the good step where majority of the delegates and experts got together from different states of India for the first time to discuss about KMC practice. Experts were invited from abroad and the effort was very well received. All the delegates learned from the experts in the field and exchanged the ideas on kangaroo mother care. This newsletter presents the detail report of the activity of the conference.

“The special invitees to the first KMCCON included Dr. Nathalie Charpak from Kangaroo Foundation, Bogota Columbia and her colleague Dr. Julieta Villegas, Dr. P.K. Prabhakar from Child Health Division of Ministry of Health of GOI, Dr. Gagan Gupta, Health Specialist, UNICEF, India. Dr. Rohit Vasa from Chicago, Health Commissioner of Telangana, Senior professors of Pediatrics and nursing from all over India, Heads of Professional bodies like NNF, ISOPARB, TNAI, SOMI, Dr. Sanjeev Upadhyay, UNICEF Hyderabad and others. Dr. Srikrishna from UNICEF Hyderabad and Dr. Yadaiah from Nalgonda, Telengana deserve special thanks for all their support for the conference and also many others from Telangana including members of Fernandez hospital, Hyderabad. Release of a joint statement by the professional organizations of India was another milestone achievement for KMCF, India. Thanks to all the presidents who made it possible.”

KMC has been practiced for the low birth weight babies in the hospital after they are born. But the full advantage of KMC can be extended after being discharged from hospital. We present the Columbian perspective of KMC method which includes outpatient Kangaroo mother care with Kangaroo follow up to the term. It is very interesting to know this kind of practice of KMC happening in other parts of the world.

Dr. Ravi Parikh Dr. Shashi N [email protected] [email protected]

Kangaroo Mother Care (KMC)A Commitment to Action

26 February 2017, Hyderabad

A Joint Statement has been signed by professional organization of India endorsing KMC as an accepted method of care of the stable Low Birth Weight babies including preterm Neonates as requested by Kangaroo Mother Care Foundation, India and was release during the 1st National Conference of KMC at Hyderabad on 26th February 2017.

Following were the signatories :

Personally Present :■ Dr. B D Bhatia – President , National Neonatology Forum (NNF)■ Dr. Milind Shah- President, Indian Society of Perinatology & Reproductive

Biology (ISOPARB)■ Mrs. Anita A Deodhar- President, Trained Nurses Association of India (TNAI)■ Mrs. Bandana Das -President. Society of Midwives India (SOMI)

Signed Statement Sent :■ Dr. Navin Thakker – President, Asia Pacific Pediatric Association, (APPA)■ Dr. C P Bansal – President, South Asia Pediatric Association (SAPA)

Endorsed but signed commitment awaited from :■ Dr. K K Aggarwal – President, Indian Medical Association, (IMA)■ Dr. Anupam Sachdeo – President , Indian Academy of Pediatrics (IAP)■ Dr. Pai - President, Federation of Obstetrics & Gynecological Associations of India (FOGSI)

Background

Complications of prematurity and low birth weight (LBW) are among the leading causes of neonatal deaths in India.

In September 2014, Government of India issued Operational Guidelines on Kangaroo Mother Care (KMC) and Optimal Feeding of Low Birth Weight Infants under the National Health Mission.

In November 2015, The World Health Organization (WHO) issued recommendations for the care of preterm infants, including kangaroo mother care (KMC), defined as

care of preterm infants carried skin-to-skin with the mother and exclusive breastfeeding or feeding with breast milk. KMC provides advantages to preterm and low birth weight infants in high, middle, and low income settings. WHO recommends KMC for the routine care of newborns weighing 2000 grams or less at birth, and should be initiated in health-care facilities as soon as the newborns are clinically stable.

KMC is associated with lower mortality of preterm babies compared to conventional care. Other benefits include convincing reductions in hypothermia, nosocomial

2 NEWSLETTER | Kangaroo Mother Care Foundation

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infection, sepsis, and length of hospital stay, as well as increases in breastfeeding, attachment, and measures of infant growth, including gain in weight, length, and head circumference.

KMC is a standard of care in India

The national guidelines recommend KMC for all LBW infants with priority being given to infants with birth weight less than 2000 grams.

The timing of initiation of KMC depends on the birth weight and stability of the infant:

1. Birth weight more than 1,800 grams and less than 2500 g: These infants are generally stable at birth. Therefore, in most such cases KMC can be initiated soon after birth in the postnatal ward.

2. Birth weight more than 1,200g and less than 1800 g: Many infants of this group have significant problems in the neonatal period. It might take a few days before KMC can be initiated. Such infants may need care in a Special Newborn Care Unit (SNCU) or a Newborn Intensive Care Unit (NICU). Intermittent KMC can be given to a hemodynamically stable infant receiving IV fluids, antibiotics and oxygen. KMC should be practiced under medical supervision. The duration may be gradually increased.

3. Birth weight less than 1,200 g: These infants frequently experience serious prematurity related morbidity often starting soon after birth. It may take days to weeks before the infant’s condition allows initiation of KMC. Duration of KMC should be gradually increased based on the tolerance of infant.

Commitment to Action

We, the professional bodies and other stakeholders of health and development of the people of India, endorse the national guidelines on KMC and Optimal Feeding of LBW Infants, and commit ourselves to:

• Wholeheartedly support efforts of the Centre and State governments toward the nationwide scale up of KMC under the National Health Mission

• Advocate for universal practice of KMC by all maternal and newborn healthcare providers in public as well as private sector in accordance with the national guidelines

• Advocate for the incorporation of KMC into pre-service and in-service curricula for all health workers who care for

The neonate weighing less than 2000g should be accorded priority for initiation of KMC considering the huge burden of LBW infants in the country.

NEWSLETTER | Kangaroo Mother Care Foundation 3K

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newborns

• Advocate for increased investments by government and non-government stakeholders to improve increase utilization and coverage with KMC.

• Advocate for promotion of KMC as a part of corporate social responsibility (CSR) initiatives

• To educate families, general public, PRIs, community leaders, private hospital managers, corporate leaders and about the benefits of KMC in order to build a people’s movement for KMC

• Take all steps to disseminate this statement to all members of its organization.

References

Government of India, Ministry of Health and Family Welfare. Operational guidelines on Kagaroo Mother Care and optimal feeding of LBW infants. September 2014. http://nrhm.gov.in/images/pdf/programmes/child-health/guidelines/Operational_Guidelines-KMC_&_Optimal_feeding_of_Low_Birth_Weight_Infants.pdf

WHO. Recommendations on interventions to improve preterm birth outcomes. 2015. http://apps.who.int/iris/handle/10665/183037.

A request from KMC Foundation, India

www.kmcfoundationindia.org

BREAST sutras include Breast crawl, Refraining from prelacteal feeds like sugar water and formula, Exclusive breastfeeding, proper Attachment, Support to the mother and Training of paramedics.

The initial Golden One Hour is not to be lost. The importance of skin to skin contact must be understood and encouraged at every visit to the maternity homes. Kangaroo Mother Care (KMC) is a simple method where the infant is placed in an upright position on the upper part of mother’s bare chest, in between the breasts. Mother’s own body temperature keeps her infant warm.KMC includes Kangaroo Father Care (KFC) too! KMC is particularly useful for nursing low birth weight infants. In addition to providing ATM (Any Time Milk) for the baby it satisfies all the five senses of the baby and helps in overall better development. Immediate benefits of KMC include prevention of hypothermia, early physiological stability in terms of stable heart rate and respirations, better breastfeeding and growth, secure feeling, better mother infant bonding and prevention of infections. Long term benefits include successful exclusive breastfeeding rate, good weight gain, better IQ and brain growth. I fully endorse KMC

Dr. Pramod JogPresident, IAP 2016


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Kangaroo Mother Care MethodOUTPATIENT KANGAROO MOTHER CARE WITH KANGAROO FOLLOW UP

(up to term) AND HIGH RISK FOLLOW UP (up to one year of corrected age)

COLOMBIAN PRACTICE CONCEPT Dr Ravi Parikh, Dr Anuj Grover, Dr Jatin Mistri,

Dr Neha TewariNeonatologist, Setu Newborn Care Centre, Ahmedabad.

Kangaroo care method – colombian training

• The Kangaroo Mother Care method, as described in this training kit, includes a follow up program in 2 steps:

• From discharge from the neonatal unit up to 40 weeks of gestational age.

• From term up to one year of corrected age

Outpatient follow upFollow up programs includes the following aspects:

• Outpatient Kangaroo adaptation: re-enforcement of the training in kangaroo position and the kangaroo nutrition for families trained in KMC in the hospital and then discharge to home in kangaroo position and training for new parents joining the KMC program after discharge from different units not implementing KMC.

• Regular monitoring of somatic growth, neurological and psychomotor development, as compared to referral standards during the first year of life.

• Early identification, treatment, and rehabilitation of any disorders in preterm and/or LBW infants, which may include the intervention of specialists.

• Support and counseling strategies for the family.

• Quality monitoring of the kangaroo clinical practice

• Active immunization.

Early Discharge from the Neonatal Unit

Child’s eligibility criteria for discharge

• The child’s in-hospital kangaroo adaptation has been successful; he is regulating his temperature in kangaroo position and has an adequate sucking–swallowing-breathing coordination.

• The child demonstrated adequate weight gain in the Neonatal Unit in kangaroo position and incubator, for at least 3 days, if older than 10 days. (The child may lose weight during the first few days and eligibility criteria for a stable child during the first week are different).

• The child completed his treatment, if any.

• If the child is receiving oxygen through a cannula, it must be below ½ l/min.

• The child is breastfed and/or fed with extracted milk.

• There is a Kangaroo Mother Program available able to offer adequate follow-up.

Mother’s eligibility criteria for discharge

• She has accepted to participate in the KMC Program and has received the necessary training in the Kangaroo Mother Method.


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• She feels able to care for her child using KMC (position and nutrition) at home.

• She succeeds in in-hospital kangaroo adaptation. In particular, she has adequate breastfeeding and milk extraction techniques.

• She is physically and mentally able to care for her child. The mother received a positive recommendation from the multidisciplinary team in the case of a difficult situation, such as a teenage mother, single mother with a child under oxygen, in difficult socio economic situation, or alcoholism or drug addiction.

• The mother should not be under anti-depressive drugs or using sleeping pills.

• She is supported by her family in the KMC ward or/and in the outpatient KMC program.

Family’s discharge eligibility criteria

• The family is committed to and able to attend follow-up visits in the kangaroo outpatient clinic and to comply with its requirements.

• The family has the will to be trained in KMC.

• The family understands well the method and it is feasible for them to care for the baby at home.

• The family is available and will cooperate to care for the baby and insure his safety.

• The family will comply with follow-up appointments, specialized medical exams, breastfeeding schedules, and drugs prescriptions.

• The family will adapt to the temporary changes implied by the adoption of KMC.: maintain the kangaroo position

24 hours a day (sleep in semi-sitting position) and redefine the cooperation roles of all family members, to support the primary caregiver. Family members involved in Kangaroo child care should be free of infectious or contagious, skin disease, fever, or significant obesity, and must be physically and mentally able to manage the child under the KMC.

Physical Structure of a KMC Outpatient Consultation

• Outpatient kangaroo follow up activities are usually organized daily in premises staffed with a multi-disciplinary team, including pediatricians, nurses, and psychologists trained in KMC. Sick children are not admitted in the KMC outpatient clinic to avoid possible contamination.

• Ideally, this place is located in a hospital where there is a Neonatal Unit equipped with human and technological resources in case of an emergency.

• The follow up consultation team includes a pediatrician, a nurse, a psychologist, and a social worker. When necessary, other health professionals join the team, such as nutritionists, physiotherapists, ophthalmologists, optometrists, and orthophonists.

• Each child is assessed individually and each family receives personalized recommendations; yet, at the same time, the entire group is taught about KMC procedures and benefits.

• The open (group) consultation is facilitated by a team of health care personnel working together and using multimodal communication techniques, resulting in better adherence to the


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program by the parents.

• This methodology also facilitates the collective learning processes and reinforces the mother’s knowledge when she repeatedly hears the same advice. Parents, while waiting, can also listen to the problems of other parents and exchange experiences and difficulties.

• This “group consultation” also decreases the parents’ anxiety. The presence and availability of a psychologist supports parents in cases of depression, insecurity, or vulnerability.

• The commitment to attend the daily consultations at the beginning of the outpatient KMC Program is demanding on parents, and in a way is similar to the daily visits they did when the child was hospitalized, creating a link between neonatal unit and home care.

Assessment of the Newborn when admitted to an Outpatient KMC• The gestational age at birth is

determined according to the Lubchenco’s classification tables.

• The anthropometric parameters are assessed (weight, height, head perimeter)

• A full clinical assessment is conducted (from head to toes)

• Outpatient KMC adaptation is reinforced or initiated as necessary.

• Brain sonography and ophthalmologic screenings are requested if possible and if necessary.

• Routine and specific drugs are prescribed.

• The need for oxygen is assessed.

• The need for family support is assessed and provided.

Gestational age at birth

• The child is classified according to the correlations between his age and his weight at the time of birth (using the Lubchenco’s classification) and this classification is noted in his medical record.

• It is important to make parents aware that the initial period of care until the child reaches 40 weeks will be difficult and extremely demanding; but that the benefits of these efforts extend for the rest of the child’s life.

Anthropometric parameters (weight, height, head perimeter)

• The weight, the height in supine position, and the head circumferences, are generally considered to be the most important indicators of growth and nutritional status.

• Anthropometry must be a routine procedure in NCIU as it helps to identify those neonates at a higher risk for morbidity and mortality as well as those who may present nutritional problems.

• During the first visit and every subsequent visit, anthropometric measurements are recorded in the charts specific to the child’s gender and age.

The majority of anthropometric measurements must be compared to tables of a reference population similar to the target population.

• Establish the gestational age

• Measure weight, height, and head circumference

• Record these measurements with a dot in the appropriate place on the growth charts


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• Interpret the growth indicators according to percentiles or standard deviations

• Connecting the dots from consecutive visits shows the child’ growth trend, and any abnormality can then help health personnel to recognize deviations in a timely manner

Height for age(H/A)

Cut-off point(Standard deviation or Percentile)

Denomination

< 2 Below length for age or stunting.

> - 2 a < - 1 At risk for below length> - 1 Adequatelength< - 3 Very low weight for age or

severe chronic malnutri-tion.

< - 2 Low weight for age or chronic malnutrition.

> - 2 a < - 1 At risk for low weight for age.

> - 1 a < - 1 Adequate weight for age.

Head Circumference (HC/A)

Cut-off point(Standard deviation or Percentile)

Denomination

< - 2 Risk factor for neurodevel-opment

> - 2 a < 2 Normal> 2 Eventually Risk factor for

neurodevelopment

Full clinical assessment (from head to toes)• Skin: It is important to check for pallor,

cyanosis, jaundice, bruises or birth marks.

• Head: The head is assessed for shape and symmetry by observation and palpation and to recognize mainly the following points/conditions:

– Caput succedaneum. Contusion and edema of the scalp.

– Molding. Overlapping of fetal skullbones can produce a pointed or flattened shape in the baby’s head.

– Fontanels size:. Anterior and posterior fontanels are found at each end of the sagittal suture. They must be open and normotensive.

– Plagiocephaly. Asymmetry of the skull.

– Craneotabes: Small areas of the parietal bones close to the suture lines; they may feel soft and produce a clicking sound under pressure.

– Cephalohematome: Blood collection under the periostium of one of the bones of the skull.

– Presence of the scaly suture, when performing a bilateral palpation of the skull. This sign is part of Amiel Tison’s neurological triad, which is described further down in this chapter.

• Full clinical assessment (from head to toes)

• Ears: Abnormalities of the pinna aligned with the ear or the corners of the mouth, may be related to renal or gastrointestinal malformations.

• Face: Assess the appearance of the face; its symmetry, detect the presence of malformations, lesions of the facial nerve, hemangiomas, etc.

• Eyes:– Epicanthic folds (skin fold in the

inner corner of the palpebral fissure

– Hypertelorism (the distance between the 2 eyes is too large)


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– Sub-conjunctival hemorrhage

– An ocular secretion may be observed due to a conjunctive irritation or a blockage of the nasal-lacrymal ductus.

• Mouth: Check the size and position of the tongue and the integrity of the palate. It is also important to check for mycosis, petechiae, and for any malformations.

• Thorax: Assess shape, symmetry, and movement.

• Clavicles: In case of fracture the bone will be felt bigger, painful with a discontinued surface and sometimes a click can be heard when the clavicle is moved.

• Breast buds: they are not noticeable by palpation in immature boys and girls. Their size is determined by gestational age and adequate nutrition.

• Lungs:

– Abdominal breathing in the newborn. Lungs expand symmetrically.

– Respiratory rate is counted during one minute; it should be between 40 to 60 breaths per minute.

• Heart:

– Rate is from 120 to 160 beats per minute.

– A systolic murmur is frequently heard due to a permeable oval foramen, which will close on its own. All murmurs accompanied by other symptoms or persisting must be assessed carefully.

• Abdomen:

• The palpation of the abdomen on a newborn requires patience and a gentle hand from the physician. Femoral

pulse must be included in the physical assessment along with the palpation of both arteries as compared to the radial pulse in the wrist.

• Umbilical stump: Detachment of the cord usually takes place between 5 and 10days after birth, but can take longer when the cord has been kept moist or in case of infection.

• Umbilical hernias:

– May be present at birth, but appear more frequently during the first year. In some cases could be associated with other malformations, such as the Beckwith syndrome, trisomy, and hypothyroidism.

– They spontaneously resolve as the abdominal muscles develop. If the hernia is still present at one year of corrected age, an appropriate treatment should be proposed by a pediatric surgeon.

• Genitalia: Assess for boys and girls the opening and position of the ureteral orifice. For boys, both testicles must be palpable and descended into the scrotum. In girls with in later stages of development; the clitoris and labia majora are more prominent.

• Anus and rectum: Examine the location and permeability of the anus and the absence of an anal fissure.

• Extremities: assessment of lengths of superior and inferior limbs and a comparison of both sides. Major alterations include: absence of bones, equinovarus, polydactyly, and syndactyly. Occasionally, fractures may be palpable.

• Hips: Symmetric abduction is required;


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congenital hip dysplasia must be suspected when limitations in abduction occur or if a distinctive ‘clunk’ can be heard and felt as the femoral head relocates anteriorly into the acetabulum (Ortolani sign). Presence of cortical thumb must be assessed.

• Back: After the child has been placed in prone position, a thorough inspection and palpation of the back, spine, gluts, and the inter-gluteal cleft is necessary, verifying the absence of fistulae.

• Outpatient kangaroo adaptation

• It begins upon first contact in the outpatient follow up or in the KMC ward.

• It is a sensitive period requiring careful attention since the child will be under the mother’s supervision, whether in rooming-in or at home.

• It is important to increase the mother’s confidence and to trust her.

• The health team must be available to solve any problems, even by phone.

• It is important to keep in mind the risk of hypoglycemia if the mother is not ready and expert in feeding her child.

• It is necessary to discuss the use of nutritional supplements, especially for children hospitalized and separated for a long time from their mothers. Milk production increases progressively, but not from one day to the next.

• All weak aspects of in-hospital adaptation, or those in the process of being attained, must be reinforced.

• An explanation on ‘sun baths’ for management of jaundice must be included.

• It is necessary to reinforce the technique for massage.

The Nurse:

• Assess if the child and the family meet the eligibility criteria for admission to rooming-in accommodation or outpatient follow up.

• Evaluate the knowledge of the mother/ family on the KMC Method.

• Assess the management of the child in kangaroo position.

• Assess the breastfeeding technique.

• Assess the quality of care provided by the mother/family at home and check to see if they are able to identify alarm/danger signs in the child.

• Make sure the family knows how to use the equipment for oxygen if the child needs it.

• Explain what the follow up program is and how it will be conducted, in rooming-in accommodation or in the outpatient program.

• Enquire about the social situation and emotional situation of the family and inform the social worker and psychologist in order to react timely.

Brain sonography

• It is advisable, but not mandatory for all preterm and/or LBW infants. Where this exam is not easily available, it should be prescribed only to higher risk children according to the local protocols.

• If during the first year of life a child has an abnormal neuro psychomotor development with a normal or abnormal brain sonography, a cerebral magnetic resonance imaging scan is recommended (if available).


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• It is not necessary to repeat brain sonography in children with normal muscle tone and normal neuro psychomotor development.

Ophthalmologic screening

• It is necessary to screen all at-risk preterm infants admitted in Neonatal Care Units in order to timely diagnose ROP.

• In the KMCP all preterm infants <37 weeks attending the Program are screened at 31-32 weeks or 28 days of life and will continue until the vascularization of the retina is completed.

• An optometric assessment is conducted at 3 months of corrected age, to diagnose refractive problems common in preterm and/or LBW children.

Drugs prescribed to Children in the KMC in Colombia

• Vitamin K

• Multivitamins

• Antireflux medication

• Xanthine

• Iron supplementation

Assessing the need for Oxygen

• Besides improving survival rates and quality of life, using oxygen at home reduces the duration of hospitalization and cost of medical care.

• Oximetry helps to determine the minimum quantity of oxygen that is needed to maintain an adequate saturation.

• The child must be monitored for at least 10 continuous minutes awake, sleeping and suckling. The reference oxygen saturation used is more than 90% and less than 94%.

Evaluating the family need for Support

• In the outpatient KMC, it is important to develop a organized training/teaching plan that includes individual and group sessions.

• It is important to have a pediatrician available on call day and night to answer the parents’ questions and concerns regarding care for their fragile infant.

• Training workshops conducted during group consultation help to reinforce the parents’/caretakers’ knowledge

• Address parental concerns

Routine Kangaroo follow up, up to 40 Weeks of Gestational Age and a Weight of 2500g

Daily kangaroo follow up is done until the child is 40 weeks of gestational age and reaches 2 500 g.

• These visits can be conducted in outpatient care or while the child is in a KMC ward.

• Mothers who have already returned home or who are staying at a temporary home must travel to the Kangaroo Mother Program outpatient consultation.

Activities during follow up visit up to 40 weeks

a) Careful and complete clinical assessment, similar to the one described during the first follow up visit.

b) Regular monitoring of the somatic growth

– After discharge, the monitoring is done on a daily basis to assess the child’s nutrition, and the parents’ adherence to the KMC.

– The goal is to achieve a weight


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gain around 15-20 g/kg/day, a weekly average increase in height of 0.8 cm, and an increase of head circumference of 0.5 to 0.8 cm.

– There may be a “normal” weight loss around 10% of his birth weight in the first 10 days of birth.

c) Strategies in case of insufficient weight gain

• Reinforce adequate child’s position at the breast and check the frequency of feedings (every1 ½ hours during the day and every 2 hours at night).

• Assess the type of nutrition received by the child during hospitalization, as well as his weight gain during the days before discharge.

• Assess the compliance with the KMC guidelines.

• Teach the Hindmilk technique.

• Decide to use fortifiers or preterm formula.

d) Advice on child care for “kangaroo infant” at home

• Mothers, families, and often the health staff must be reminded that the kangaroo position does not last long, only few weeks.

• Bathing: A daily bath is not necessary and not recommended before 40 weeks, especially for those infants in kangaroo position.

• Mother’s activities: Mothers with the baby in Kangaroo position can have several recreational and educational activities at home.

• Sleep and rest of kangaroo mother/caretaker: The mother, the father, or another family member will sleep better

with her baby in kangaroo position in a semi-sitting position, with a 15°- 30° degree-tilt. This position reduces the risk of apnea and reflux.

e) Duration of the kangaroo position

• Daily duration: will need to increase gradually until it is as continuous as possible, day and night, interrupted only for diaper change and feeding sessions.

• Total duration: As long as the mother and her baby are comfortable, skin-to-skin contact may continue, at first in the institution and later, at home.

f) Neurological assessment at 40 weeks of gestational age using axial tone (Dr. Amiel Tison)

• Clinical assessment of axial tone: Passive tone and Active tone

• Global hypotonia: Active and passive tone of flexor and extensor muscles of the axis is almost absent.

• Hypotonia confined to the axial flexor muscles

• Hypertonia of the axial extensor muscles

• Raised intracranial tension: association with yawning, drowsiness, lethargy, irregular breathing, apneic episodes, bradycardia and vomiting .

Summary

• This gives the optimum effect of KMC during the whole period of exposure

• Facilitates early discharge from neonatal unit.

• Parents need full training and co-operation for the maximum benefit.

• Hospital staff also needs training and dedication in promoting the method.

• Both physical and neurological benefit is maximised in the care of preterm baby.

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Breast milk is best milk.

Off late, there have been reinventions of several natural principles, breast crawl & KMC

(Kangaroo Mother care) seem to be 2 of them.

Often people believe, if you deliver a baby, you can breastfeed your baby automatically

(Naturally!!). Paradoxically, in the current era, many mothers face (practical) problems with

breastfeeding & often need to opt for risky options like cow’s milk or formulas.

Typically a baby rested in a pram has to cry out

aloud to reveal hunger. Imagine a fresh mom

going to the pram every time the baby cries,

picking up the baby, sitting & carrying the 3 kg

bundle to adjust at breast, pushing nipple into the mouth. More often, baby fails to get a good grip,

fuzzes & goes to sleep after several unsuccessful

attempts. The whole process becomes an exercise

that the mom carries on day & night in the hope

that she will be successful some time & till then, to satisfy the baby’s hunger, she will feed her/him any other animal milk.

Very soon the animal milk seems to reduce the baby’s cry & avoids mother’s exhaustion. In few

mothers, pain at breast due to improper sucking would make her believe that she can’t satisfy

the baby probably because her breasts make less milk. Categorically, animal milk feeding

(deceptively famous as top milk or formula milk) seems more & more easier & breastfeeding seems too difficult. The baby is switched from human to animal milk in just few days of birth.

We as doctors & healthcare professionals are taught about methods of breastfeeding specifying

the way mother should sit, hold the baby & attach it to her breasts with “4 signs of each”. The

complexity of “successful breastfeeding method” contradicts the theory of “Natural skills”.

If we look at any primitive mammal, almost immediately after birth, the baby gets breastmilk.

A lioness, cow or mama bear gives birth to the

baby. The mom stays close enough, starts licking

the baby & prompts the baby to go near the

breasts. The baby with its inherent capacities, finds out the nipple. It tries to have a bite of it, fails,

tries, fails, …. & succeeds accidentally to have a

mouthful of grasp within minutes of birth (with

only patience on mother’s part). Baby starts suckling & breast starts delivering milk. The whole

process repeats, driven by baby’s desire to suckle. What is the effort of a mama cow to feed her baby? Or a cat or a lioness? They shower unlimited love, milk is a part of total package. The

mother without learning any signs of “Good latch”, instinctively nurses the baby “on demand”.

The very existence of mammalian species is the evidence of efficiency of nature designed feeding

WITH BREAST CRAWL & KMC BREASTFEEDING IS NOT VERY EASY

DR PARAG DAGLI BREAST FEEDING COUNSELLOR

PEDIATRIC & NEONATAL INTENSIVIST APPLE CHILDREN HOSPITAL, AHMEDABAD


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Breast milk is best milk.

strategy. Then what is different in human species that leads to breastfeeding problems so

commonly? What we can learn from other mammals? or perhaps from our own ancestors?

A 2 inch sized baby

k a n g a r o o a f t e r

coming out of the

vagina, climbs with

its tiny hands, to reach the pouch by

3rd minute of birth

& starts suckling one

of the 4 nipples

inside the pouch, s t ay s t he re t i l l

months to grow from 2 inch to 2 feet. Inside the pouch, it gets

continuous supply of milk, warmth & lots of stimuli without any

visible efforts of the mother.

Nature must have designed a way to take care of a normal human baby right after birth. She/he is empowered with several inborn abilities & reflexes. Given an opportunity, she/he has got a

capacity to crawl, right at birth towards a darker spot surrounded by lighter skin, having a

peculiar attractive smell & feel. She/he can lift & move head in prone position. If a cloth or

finger touches the nose or cheek, the baby will automatically turn the face to the object, open

the mouth & bite it.

A healthy human naked baby after birth when placed on bare abdomen of mom, it crawls towards

breast & nipple on its own probably guided by senses of smell & vision. On reaching, it lifts the

head, tries to get hold of breast & with few trials, succeeds to suckle at breast. This intentional

movement at birth is called Breast Crawl. It takes 30 - 40 minutes & 99 out of 100 kids succeed to

have their first feed. Thus, breast crawl facilitates first feed after birth.

After birth, a baby kept skin to skin for prolonged hours is

called Kangaroo Care. The baby enjoys the warmth,

transfer of friendly germs from mother’s skin, plenty of

stimuli (movements, sound, vision, smell & taste) to

stimulate optimum brain growth, peace of mind and along with all this breastfeeding, on demand. With KMC,

t h e c u e s l i k e

smacking, sucking,

rooting or mouthing will be identified early & mom will

facilitate baby to suckle before cry or irritability. Baby will try frequently & will become expert faster. The mother

plays a passive role in relaxed reclining or sleeping position

& so demand feeding is free from exhaustion. Thus KMC

facilitates demand feeding.

Over last 2 & half centuries with “modernisation”, mankind has forgotten arts & skills that nature had gifted it over ages of evolution. It is high time we “delearn” mother baby separation,

uncomfortable & unnatural sitting posture of mom while feeding & scheduled feeds. If allowed,

all babies know how to perform survival skills like breast crawl & demand feed while KMC.

Baby kangaroo suckling inside the pouch


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Kangaroo Mother Care including Breast milk Feeding and Regular follow up is now being recognized globally, as evidence based, simple, low cost, and natural

method of care for newborns with special benefits to the Low Birth Weight Newborns including Preterm Babies, with high potential of reducing morbidity and mortality rates. Thus, KMC is of special significance to our country in view of the enormous challenge of providing universal newborn care.

The Government of India has included KMC as a core intervention for the care of Low Birth Weight Infants and has initiated KMC promotion in the country. But still there are very few takers so far. The impact will be appreciated only when KMC is practiced very widely and with proper quality.

With the noble objective of the promotion of KMC in India, the first National conference on KMC in India was held at Hyderabad, Telangana from 24th to 26th February 2017. It was the culmination of all the hard work put in by the Kangaroo Mother Care Foundation (KMCF), a non- profit voluntary service organization, in association with UNICEF. The KMCF was supported in this noble venture by UNICEF, India without which this conference would not have materialized. The newly formed state of Telangana & the city of Hyderabad had the proud privilege to host such an event which was being held for the first time in our country against many odds.

The theme of the conference was ‘Accelerate coverage and quality of KMC in India’. With this basic objective in mind, three pre-conference workshops were organized on 24th and 25th February 2017 and the main conference was held on 26th February 2017. A few reputed International researchers and KMC Champions along with the National experts were the faculty members in the conference and preconference workshops.

The preconference workshops were as shown below –

1. A Certificate Training Course for Master Trainers of KMC (24th and 25th February 2017)

2. A Basic Course for Providers of KMC for one day (25th February 2017)

3. A Special Course for the trainers of Community Health Workers for improving the quality of Home Based Kangaroo Mother Care (HBKMC) (25th February 2017)

Free papers focussing on studies or experiences related to KMC in recent years were invited for presentation during the conference. Because of the time constraint, only six papers were selected for oral presentations. Remaining papers were selected for the poster presentations.

Preconference workshops

1. A Certificate Training Course for Master Trainers of KMC (24th and 25th February 2017) –

The 1st National Conference on Kangaroo Mother Care in India


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• The objective of this workshop was to prepare trainers who could then train other potential trainers of providers.

• The workshop was attended by 60 participants.

• This workshop was supported by UNICEF, India.

• The programme is summarized in the table below –

A Certificate Training Course for Master Trainers of KMC

Program for day I (24th February, 2017)

Time Session Details Speakers/Facilitators

09.00 AM Assemble at Hotel Marigold, Hyderabad

9.05 AM Welcome address Dr. Srikrishna, UNICEF Hyderabad

9.15 AM Objectives of the workshop and program outline Professor Shashi N Vani, KMCF

9.25 AM Self Introduction of the participants

9.35 AM Lighting the lamp by KMC Children

9 40 AM Inaugural Address Dr. Sanjeev Upadhyay, UNICEF, Hyderabad

9.50 AM Address by Chief Guest Dr Nathalie Charpak, International Network of KMC

10.05 AM Pretest

10.15 AM Basics of KMC Professor S N Vani

11.00 AM Tea Break

11.15 AM Leave for District Hospital, Nalagonda

1.30 PM Arrive at Nalagonda and lunch

2.30 PM Assemble at DH - Welcome and Presentation of KMC activities at the district hospital

Dr Yadaiah, Nodal officer

3 00 PM KMC ward visit in batches (to observe actual practice of KMC and interviews with mothers and their family members) /

Concurrent Video presentations

4.30 PM Discussions on the checklists on “Steps for improving the quality of KMC position and feeding”

5.15 PM Tea break

5.30PM Short presentations - Chairperson Professor Deepa Banker

Breast Feeding and KMC in Caesarean Deliveries Dr Parag Dagli

Infection prevention and KMC Dr Niranjan Singh

Brain development and KMC Dr Somashekhar

6.00 PM Leave for Hyderabad

8.00 PM Arrive at Hotel Marigold and Dinner

Program for day I (25th February, 2017)

9.00 AM Assemble at Marigold Hotel, Hyderabad

9.10 AM Recap of the day I Professor Deepa Banker

Dates – 24th and 25th February 2017Venue – Hotel Marigold, Hyderabad & District Hospital, Nalagonda, Telangana

Chief Coordinator: Professor Shashi N VaniCoordinators: Professor Deepa Banker And Dr Parag Dagli

Faculty members: Dr. Nathalie Charpak, Professor Arasar, Dr Rohit VasaDr. Simin Irani , Dr. Julieta & Dr Srinivas Murki *


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9.20 AM Introduction for Group Assignments Professor S N Vani

Group I - Planned early discharge and Follow upTeam Guides –Dr Nathalie Charpak, Dr Deepa Banker & Dr

Rohit Vasa

Group II - Training Programs, Awareness and Demand Generation Program

Team Guides : Professor Simin Irani, Dr Srinivas Murki

Group III - KMC Records, Registers, Reporting and inclusion in HMIS

Team Guides : Prof. Arasar, Dr Julieta

Group IV - Costs and Resources for KMC ActivitiesTeam Guides : Prof Shashi Vani, Dr Parag Dagli, Dr Nathalie

Charpak

11.00 AM Tea Break

11.15 AM Group Presentations & DiscussionChair persons – Dr Srinivas Murki & Dr Deepa Banker

1.00 PM Lunch

1.30 PM Expanding the Horizons of KMC in IndiaChair person – Dr Shashi N Vani

2.30 PM Challenges for Organization of KMC services in SNCUs & Possible solutions

Chairpersons – Professor Simin Irani & Professor Arasar

3.00 PM Tea Break

3.15 PM What steps will we take next for accelerating the Coverage and improving the Quality of KMC in our states?

- Representative from each participating state

4.15 PM Post test & Course evaluation

4.25 PM Participants’ reflections

4.40 PM Distribution of Certificates

4.50 PM Vote of Thanks

5.00 PM Disperse

* Dr Sushma Nangia & Dr Suman Rao could not participate as faculty as they had to cancel their programmes at the last moment due to personal reasons.

2. A Basic Course for Providers of KMC for one day (25th February 2017) –

• The objective of this workshop was to

prepare the potential KMC providers with necessary knowledge and skills.

• The workshop was attended by 35 participants who included nurses and doctors.



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Workshop On Kangaroo Mother Care & Breast FeedingVenue : Gandhi Hospital Hyderabad

Date : 25/02/2017Academic Coordinator : Dr Shashi N Vani

Workshop Coordinators : Dr Jatin Mistri and Dr Somashekhar Nimbalkar

Time Topic Faculty

08.00 - 08.45 Registration & Breakfast

08.45 - 09.00 Inauguration

Session I: Introductory session

9.00 Welcome address Dr Jatin Mistri

9.05 Self Introduction by the Participants

9.15 Neonatal Mortality and Morbidity Where do we stand? Will this workshop help?

Dr Somashekhar Nimbalkar

9.25 Pretest

9.30 Basic facts about KMC and Applicability in Indian Settings Dr Jatin Mistri

10.00 Tea Break

Session II : Special aspects of KMC

10.15 KMC and Hypothermia Dr Asha Benakappa

10.30 KMC and Infection prevention Dr Rekha Udani

10:45 KMC and Neurodevelopment Dr Somashekhar Nimbalkar

11:00 Session III : Group work All (in small groups)

Practical aspects of KMC (Preparation, counselling, KMC position,video demonstration and hands on training)

(To be done in 4 groups )

12.10 Monitoring during KMC Dr Rekha Udani

12.30 KMC for sick and unstable newborns Dr Asha Benakappa

12.50 Ambulatory care during KMC, KMC at Home Dr Rekha Udani

13.10 KMC during neonatal transport Dr Jatin Mistri

13.30 Lunch Break

Session IV: Practical issues in feeding of LBWI during KMC

14.15 Direct Breast Feeding, Expressed Breast Milk Feeding and supplements (Collection, storage administration, monitoring, video

demonstration)

Dr Asha Benakappa

15.00 KMC Poor man’s incubator? Dr Jatin Mistri

15.15 Tea Break

Session V: Panel Discussion

15.30 Challenges and Solutions for improving the quality of KMC - Open House

All Faculties

Session VI: Valedictory session

16.15 Is Training enough? Ensuring Sustainability of change in practice Dr Somashekhar Nimbalkar

16.25 Bogota Resolution

Post test

Workshop evaluation by the participants

Concluding remarks and vote of thanks

17.00 Certificate Distribution


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3. A Special Course for the trainers of Community Health Workers for improving the quality of Home Based Kangaroo Mother Care (HBKMC) (25th February 2017)• In view of the enormous need

compared to the limited capacity of the existing SNCU facilities Home Based KMC (HBKMC) acquires special significance in our health services.

• This workshop was, thus, aimed at preparing trainers who could train the community based health workers like ASHAs and other such grassroot workers of NGOs.

• The workshop was attended by 42 participants who included nurses and doctors.


Workshop for the trainers of Community Health Workers for improving the quality of Home Based Kangaroo Mother Care (HBKMC)

Date : 25th February, 2017Venue : Nilofer Hospital, Hyderabad

Academic Coordinator : Dr Shashi N VaniWorkshop Coordinator : Dr Nikhil M Kharod

Time Session Details Facilitator

8.30 – 9.00 Registration & Breakfast

Session – 1, Introductory Session

9.00 – 9.05 Welcome Address Dr Alimelu

9.05 – 9.15 Self Introduction by the participants

9.15 – 9.30 Pretest

9.30 – 10.00 Basic facts about KMC & Applicability in Indian Setting Dr Nikhil Kharod

10.00 – 10.15 Tea Break

Session – 2, Special Aspects of Home Based KMC

10.15 – 10.30 Importance of Home Based KMC (HBKMC) Dr Niranjan Singh

10.30 – 10.45 Benefits of KMC Dr Niranjan Singh

10.45 – 11.00 Counselling and Preparation for HBKMC Dr Nikhil Kharod

Session – 3, Group work on practical aspects of KMC

11.00 – 12.00 Preparation, counselling, KMC position, video demonstration and hands on training

All the participants & faculties in 4 groups

12.00 – 12.30 Monitoring during KMC Professor Suvarna Devi

12.30 – 12.50 How to handle danger signals during KMC? Dr Nikhil Kharod

12.50 – 13.10 Ambulatory care during KMC Dr Niranjan Singh

13.10 – 13.30 KMC during neonatal transport Dr Nikhil Kharod

13.30 – 14.15 Lunch

Session – 4, Practical issues in feeding of LBWI during KMC

14.15 – 15.00 Direct Breast feeding, Expressed Breast Milk feeding & Supplements (Collection, Storage administration, monitoring & video demonstration)

Professor Suvarna Devi

15.00 – 15.15 Experiences of HBKMC Dr Reeta Rasaily Dr Nikhil Kharod

15.15 – 15.30 Tea Break

Session – 5, Panel Discussion

15.30 – 16.25 Challenges & Solutions for improving the quality of HBKMC – Open House

All Facilitators

16.25 – 17.00 Valedictory Function

Bogota Resolution Post TestWorkshop evaluation by the participantsConcluding remarks Vote of thanks & certificate distribution

All Facilitators


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Main Conference The main conference was held on 26th February, 2017. It was attended by about 300 delegates including doctors, nurses and community based functionaries. The conference programme is summarized in the table below –

1st National Conference on Kangaroo Mother CareDate: 26th February

Venue: Hotel Marigold, Hyderabad, Telangana State, India

Time Session Details Speaker/Facilitator

8:30 - 9:00 Registration

Session I – Inaugural Session

9:00 - 9:05 Prayer, Welcome address,Lamp lighting by KMC children

9.05 – 9.10 Inauguration of KMC ExhibitionMs. Anita Deodhar – President, TNAI & representatives from

IAP, SOMI, IMA

9.10 – 9.15 Inauguration of KMC Poster Session Dr B D Bhatia – President, Central NNF & Representatives from

NNF, ISOPARB

Session II – Technical Session on Science of KMC Chairpersons: Dr Swarnarekha Bhatt & Dr Deepa Banker

9.15 – 9.30 Early Skin to Skin contact & KMC Dr Rekha Udani

9.30 – 10.00 Improving KMC Efficacy Dr Rohit Vasa

10.00 – 10.15 KMC for VLBW Neonates Dr Srinivas Murki

10.15 – 10.30 Follow up of KMC – A missing component Dr Ruchi Nanavati

10.30 – 10.45 Open House for Interactions

10.45 – 11.00 Tea Break

Session III – Plenary Session Chairpersons: Dr Simin Irani & Dr Sanjeev Upadhyaya

11.00 – 11.20 Status of KMC in SNCUs of India and Roll out Plan Dr P K Prabhakar, Deputy Commissioner, Child Health, GOI

11.20 – 11.40 Scaling up KMC in India – Need, Challenges & way forward

Dr Gagan Gupta, Health Specialist, UNICEF Country Office,

India

11.40 – 12.00 Improving Home Based KMC – An urgent need of the hour in India

Dr Shashi N Vani, Founder, KMC Foundation of India


Session IV – Prime session Chairpersons: Dr Ajay Khera & Dr Nikhil Kharod

12.15 – 12.30 Key Note Address Dr Nathalie Charpak, Director, International Network

of KMC

12.30 – 12.45 Release of Joint Statement on KMC & Pledge by Professional Associations

12.45 – 13.00 Release of KMCF Newsletter & Report of KMCF Activities

13.00 – 13.15 Presidential Address Ms. Vakati Karuna, IAS, Commissioner, H&FW and MD,

NHM, Telangana

13.15 – 14.00 Lunch


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Time Session Details Speaker/Facilitator

Session V – Symposium on KMC Chairpersons: Dr Balamba

14.00 – 14.20 Zero separation of the mother & the newly born

Dr Nils Bergman

14.20 – 14.35 Role of Obstetricians in promoting KMC Dr Evita Fernandez

14.35 – 14.50 Role of Nurses in KMC Dr Alpanamayi

14.50 – 15.05 Role of society and parents in implementing KMC Dr P Sudarshan Reddy


Session VI : Paper presentations on KMC Chairpersons : Dr JV Rao,

Judges: Dr Swarnarekha Bhatt, Dr Suvarnadevi

15.15 – 16.00 Free Papers presentation 7minutes for each presenter,

6 papers for presentation

16.00 – 16.15 Tea Break

Session VII : KMC Implementation across India Chairpersons: Dr Arasar & Dr Neelima Singh

16.15 – 16.45 KMC Implementation – Experience of different states

Odisha – Dr Suvarnadevi Tamilnadu – Dr Srinivasan Gujarat – Dr Kharod Telangana – Dr Srikrishna Andhra Pradesh – Dr Srikrishna


Session VIII: KMC Implementation - Challenges and Solutions Chairpersons / Moderators: Dr Daivadheenam & Dr Kumutha

17.00 – 17.30 Panel Discussion KMC Implementation –

Challenges and Solutions

Dr Jatin Mistry Dr Pramod Gaddam Dr Damera Yadaiah Dr Dhiren Modi Dr Ajit Sudke


17.45 – 18.00 Valedictory Session

* Dr Sushma Nangia & Dr Suman Rao could not participate as faculty as they had to cancel their programmes at the last moment due to personal reasons.

Highlights of the conference –

• This conference was the first of its kind focussing on a very crucial intervention which can not only bring down the neonatal mortality in our country but also improve the quality of neonatal survival. And all these can happen at a very low cost as compared to the conventional care in special newborn care units which relies

on expensive equipment and gadgets.

• In view of this, the theme of the conference was very appropriately chosen i.e. ‘Accelerate coverage and quality of KMC in India’.

• Because of this focus on accelerating the coverage with improvement in quality, three preconference workshops were planned to prepare a cadre of trainers and providers.

• The first workshop – A Certificate Training Course for Master Trainers of KMC – has successfully trained master trainers who


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are very important human resource base for accelerating the trainers at various levels.

• To address the need to widen coverage in existing resource limited circumstances the conference also focussed on training trainers on Home Based KMC.

• The main conference was noteworthy because of the following –

o Very comprehensive nature – facility based and community based perspectives; research inputs; participation by experts (International as well as National), students (medical as well as nursing) and also by community based workers

o Support and solidarity expressed by the Government (Union as well State), UNICEF (International agency), Professional Organizations (IAP, NNF, FOGSI, TNAI, IMA, SOMI, ISOPARB) and NGOs

o Concern and commitment on the part of both the GOI & UNICEF as stated at length during the respective presentations during the plenary session

o The Release of Joint Statement on KMC & Pledge by the Professional associations and

o The vibrant spirit reflected in enthusiastic participation by everyone.


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** 24th, 25th and 26th Feb.2017-First National Conference of KMC at Hyderabad- Detailed report enclosed

** 24th and 25th March 2017 Master Trainers’ Course at Pune for the state of Maharashtra with support of UNICEF and Govt. of Maharashtra (Faculty members from KMCF- Dr. S.N.Vani and Dr. Rekha Udani and Dr. Simin Irani from Mumbai)

** 28th and 29th April 2017 Master Trainers course at Kolkata for the state of West Bengal with the support of UNICEF and Govt. of West Bengal (Faculty members from KMCF- Dr. S.N.Vani and Dr. Deepa Banker. Dr. Arasar from Chennai)

** Programs to Commemorate International KMC Awareness day 15th May 2017:

1) 13th May 2017- A training program for workers from Voluntary health care organizations from Gujarat and medical officers and nurses from Palanpur and nearby areas from 9AM to 4PM

Certificates of appreciation given to workers from NGOs working in very deprived sections of rural/tribal communities of Gujarat for doing very good work for the promotion of Home Based KMC in their project areas for past few years.

• Sami ICDS project of the Bhansali Trust, Radhanpur, Banaskantha

• The Tribhuvan Foundation, Rajodpura, Anand

• The Gram Seva Trust, Kharel, Billimora

• Jashoda Narottam Public Charitable Trust, Dharampur, Dang

The Honorable Minister of Health, Government of Gujarat, Sri Shankarbhai Choudhary, presided over the function and distributed the certificates and also released the educational charts and checklists prepared by KMCF for improving the quality of KMC in different settings.

Dr. Viren Doshi and his team from Banas dairy, Palanpur helped in the organization of the whole program.

150 participants from 12 NGOs and others attended.

2) An orientation program on KMC for the community health workers of Deesa and nearby regions (Faculty members from KMCF Dr. Deepa Banker and Dr. Parag Dagli)

The program was supported by Rotary Club of Deesa (President Dr. Hetal Shah) and Indian Medical Association (President Dr. Hiren Patel) (Faculty members from KMCF Dr. Deepa Banker and Dr. Parag Dagli) About 230 workers participated. Venue: Rotary hall, Deesa

3) A meeting with local group of Pediatricians and Obstetricians from private practice

Dr. Varsha Praveen Shah, a senior

A few important activities of KMCF from Jan 2017 onwards:


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pediatrician helped in coordinating the meeting.

4) On 15th May 2017 – a mini workshop on KMC at Indian Institute of Public Health, Gandhinagar (Faculty from KMCF – Dr. S.N.Vani, Dr. Deepa Banker and Dr. Parag Dagli)

Participants included nursing students from different colleges including post graduate nursing 130 Participants

Dr. Dilip Mavlankar, Director of IIPH, Gandhinagar was the Chief Guest and Dr. Narayan Gaonkar, Health Specialist, UNICEF, Gandhinagar was the guest of Honor.

They distributed Certificates of Appreciation to nurses from Medical college hospitals for their very good contributions for the promotion of KMC in their units

• 22nd May 2017-Participation in the SNCU review meeting of the health department of G O Gujarat and presented on suggestions for improving quality of KMC in state, based on the observations of survey of SNCU carried out with the technical assistance of KMCF.

• 10th June 2017-Training of ASHA workers for ENBC including KMC at Tribhuvan Foundation- Dr. N.M.Kharod. Total Participants 27

• 10th June 2017-9 AM to 2 PM -Training program on KMC at Adani Institute of Medical Sciences, Bhuj, Kutch for their students and nursing college

students of the region. (Faculty from KMCF – Dr. S.N.Vani and Dr. Parag Dagli) Dr. Hasmukh Chauhan , HOD of Pediatrics had arranged the program with the support of the management and colleagues in the department. Participants about 200 persons.

• 10th June 2017-3PM to 5PM-A meeting of private practitioners of Pediatrics and Obstetricians was arranged at GAIMS for discussions on challenges and possible solutions for promotion of KMC in private practice.

• 10th June 2017- 6PM to 8PM-An orientation program about KMC arranged at Gandhidham by local branch of Academy of Pediatrics (President Dr. Vikas Goyal) for the nurses and assistants working in pediatrics, neonatal and obstetrics hospitals in private set up at Gandhidham. Participants about 40.

(Faculty from KMCF – Dr. S.N.Vani and Dr. Parag Dagli)

• 10th June 2017-8 PM to 10 PM Discussion with local group of Pediatricians and Obsttricians on Challenges and possible solutions of KMC in private practice.

• 15th June 2017 – Recording of radio talk on KMC by Dr. N. M. Kharod for the local radio station of S. P. University , V.V.Nagar


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Here is a story of ELBW twin babies of a woman

from lower socioeconomic class who survived

with KMC.

Manjulaben is 25 years old woman from village

Salod of Kapadvanj Taluka (District Kheda in

Central Gujarat). She was expected to deliver on

22nd May 2017. The pregnancy was uneventful

and she had undergone four routine antenatal

check-up. She had no significant medical or

surgical illness in past. Her previous 2 pregnancies

and deliveries were also uneventful.

After about 7 months of apparently normal

pregnancy, Manjulaben delivered twin male

babies on 3rd March, 2017 (about two & a half

months before the EDD) in private nursing home

at Baayad (about 35 Km from Kapadvanj town).

The respective birth weights were Twin 1 – 850

gm and Twin 2 – 760 gm. The mode of delivery

was normal vaginal and the gestational age

on assessment was about 28 weeks. Both the

babies cried soon after birth and were shifted

to a private hospital for special care. They were

given Oxygen and antibiotic cover for two days

& then they were tertiary care for advanced

treatment. But due to financial reasons and

lack of an affordable tertiary care centre at a

convenient distance, the attendants brought

them to TF hospital at Kapadvanj* for further

care on 6th March 2017 (3 days after birth).

On arrival at TF hospital at Kapadvanj, the babies

were tachypenic, lethargic & showed absence of

Moro’s reflex, sucking and activity. Their SpO2

KMC helps ELBW twins in a Level 2 set up… Dr Dayaram

Pediatrician, TF Hospital, Kapadvanj

was maintained with minimal oxygen support.

We started Intravenous fluids, antibiotics and

Inj. Aminophylline. Nasogastric tube feeding

was started three days after admission when

babies were vitally stable. On 14th Day of Life

(17/03/017) Nasogastric tube feeding of 10 ml 2

hourly was established. Antibiotics were stopped

in 14 days. We started training mother in KMC,

the basic nursing care and hand washing. KMC

was started after two weeks on 17th March.

Both the babies were given to mother for 1 hour

each for KMC twice daily. She was also involved

in changing diapers, daily morning sponging,

applying oil on the body, Nasogastric tube

feeding & burping regularly. Regular weight gain

started in Twin – 1 after 10 days and in Twin –

2 after 18 days. On 24th March both babies

were given Blood Transfusion due to anaemia.

Multivitamin drops, calcium/D3 & iron were also

given.

The duration of KMC was gradually increased. On

54th Day of Life Twin – 1 had weight of 1.5 kg (BW

850 gm) and Twin – 2 has weight 1.4 kg (BW 760

gm), almost double the respective birth weights.

Breast feeding had also increased. Mother could

take care of her babies with the help of family

members. Babies were hemodynamically stable

& warm. They were tolerating feeds and showed

good activity. Mother was trained in all the basic

aspects of baby care including hand washing

and hygiene and she had started enjoying

motherhood…

* TF – Tribhuvandas Foundation is a community based NGO linked with milk co-operative infrastructure in Anand, Kheda & Mahisagar Districts of Central Gujarat. It covers 835 villages at present and has a Level 2 Newborn care unit and maternity home at Kapadvanj (TF Hospital).


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Komalben Ashwinbhai Tadvi, delivered a baby at CHC – Jabugam*, located in tribal area of Central Gujarat (about 75 km from Vadodara) on 12/4/17. Her Hemoglobin was 7.9 gm/dl and she has had no antenatal check up. The gestational age of the baby was about 34 weeks.

At the time of delivery baby did not cry & she required resuscitation with bag and mask under a baby warmer after which she had oxygen saturation of 70% and pulse rate of 110 / mt. Baby’s birth weight was 1.260 kg. (VLBW)

Baby was kept under warmer and Oxygen inhalation with nasal prongs and was given IV Glucose and Normal saline in appropriate doses. After one hour oxygen saturation improved to 90% and pulse rate was 124-130 / mt.

Having stabilized, the baby was then referred (within about 2 hours after birth) for further management to SSG Hospital (SSGH), Vadodara on 12/4/17 with her mother. Baby was referred in a simple ambulance with Kangaroo Mother Care (KMC) and oxygen inhalation with nasal prongs. A health worker also accompanied them. The distance from

Jabugam CHC to SSGH Vadodara is about 75 Km. (about 2hours by road)

Baby reached SSGH, Vadodara safely without any untoward incident. Baby was admitted in the NICU. On second day baby developed Neonatal Jaundice, so Phototherapy was started along with other treatments.

On 17/4/2017 baby was stable and was shifted out with mother. Baby was planned for discharge after two days of observation.

Similarly another baby with birth weight 900 gm. was

also referred and the outcome was good. But one baby with weight 1.260 Kg was referred without Kangaroo Mother Care (KMC) as mother had LSCS and could not accompany the baby. The baby expired on the way.

So in my two months experience, I found that those babies referred with Kangaroo Mother Care (KMC) reached the destination safely and had better outcome than those without KMC during transport. * This CHC is managed by Deepak Charitable Trust, a Vadodara based NGO, under PPP initiative of Gujarat Government.

KMC Helps in Safe Transport as well…Dr Moiz Jamali

Pediatrician, CHC, Jabugam


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Under the USAID funded Project Vriddhi (2014-18), John Snow India (JSI) has the mandate to establish working models of three high-impact government r e c o m m e n d e d newborn health interventions to document and share learnings that would

support country-wide scale-up of these interventions. The selected interventions are facility-based Kangaroo Mother Care (KMC), use of injection Gentamicin for Possible Serious Bacterial Infections (PSBI) of newborns and strengthening Home Based Newborn Care (HBNC). Two sites – districts Gumla and Haridwar at Jharkhand and Uttarakhand respectively were selected for demonstration. Selection was based on high Neonatal Mortality Rate (NMR), high proportion of NMR to Infant Mortality Rate (IMR) and adequate proportion of institutional deliveries.

KMC intervention was initiated with a master trainers workshop in July 2016 and

John Snow India supports Governments of Jharkhand and Uttarakhand provide loving hugs to small babies

at demonstration sites under USAID supported Project Vriddhi, 2017

Dr. Amrita Misra, Senior Technical Advisor, Child Health, John Snow India

by September of the same year, more than fifty doctors and nurses were trained at their respective districts. SNCU Gumla provided KMC to their first newborn in the month of September 2016 and since then more than a hundred low birth weight and premature infants have received this care. During the subsequent months, more than two

hundred community health workers (ANM and ASHA) were trained to continue KMC at home. Project learnings are being documented and shared with various stakeholders in the form of technical updates, case studies and process documentation. Ongoing in-

depth qualitative assessments will throw further light on implementation challenges and their possible solutions, which will be shared with stakeholders at national and state level dissemination workshops.

A nurse helps a father put his newborn in KMC position at Gumla, John Snow India, 2017

Mother provides KMC to her preterm newborn at Gumla, John Snow India, 2017

Mother reclines on a hospital bed to provide KMC to her newborn, John Snow India, 2016

Mother practices KMC at Haridwar, John Snow India, 2017

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Founder Trustees of KMCF India

Managing Trustee : Dr. Shashi N. Vani | Hon. Secretary: Dr. Nikhil M.KharodHon. Joint Secretaries: Dr. Parag Dagli | Hon. Joint Secretaries : Dr. Abhishek M. Bansal | Treasure: Dr. Viren S. Doshi

Trustees: Dr. K.M.Mehariya | Mr. Bharat Sarabhai Shah | Dr. Narendra T. Vani | Dr. Anuj J. GroverDr. Ravi kumar D. Parikh | Dr. Jatin Gunvantlal Mistri | Dr. Ashish Arunbhai Mehta | Dr. Deepa Alay Banker

Dr. Somsekhar Nimbalkar

Office: 10, Shamiana Apartment, 61, BMM Society, Ellisbridge, Ahmedabad - 380 006Administrative Wing: Department of Paediatrics, Pramukhswami Medical College, Gokal Nagar, Karamsad 388 325, Dist. Anand

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GLIMPSES OFINTERNATIONAL KMC

AwARENESS DAYPhotos with

Health Minister of Gujarat Hon’ble Shri Shankarbhai Chaudhari

Private Circulation Only

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