The components of the Kangaroo Mother Care (KMC) intervention, their rational bases, and their current uses in low-, middle-, and high-income countries are described. KMC was started in 1978 in Bogotá (Colombia) in response to overcrowding and insufficient resources in neonatal intensive care units associated with high morbidity and mortality among low-birthweight infants. The intervention consists of continuous skin-to-skin contact between the mother and the infant, exclusive breastfeeding, and early home discharge in the kangaroo position. In studies of the physiological effects of KMC, the results for most variables were within clinically acceptable ranges or the same as those for premature infants under other forms of care. Body temperature and weight gain are significantly increased, and a meta-analysis showed that the kangaroo position increases the uptake and duration of breastfeeding. Investigations of the behavioral effects of KMC show rapid quiescence. The psychosocial effects of KMC include reduced stress, enhancement of mother-infant bonding, and positive effects on the family environment and the infant's cognitive development.Conclusion: Past and current research has clarified some of the rational bases of KMC and has provided evidence for its effectiveness and safety, although more research is needed to clearly define the effectiveness of the various components of the intervention in different settings and for different therapeutic goals.

PROBLEM Clinical care of infants with a very low birth weight (less than 1500 g) in developing countries can be labour intensive and is often associated with a prolonged stay in hospital. The Aga Khan University Medical Center in Karachi, Pakistan, established a neonatal intensive care unit in 1987. By 1993-4, very low birthweight infants remained in hospital for 18-21 days. STRATEGIES FOR CHANGE A stepdown unit was established in September 1994, with mothers providing all basic nursing care for their infants before being discharged under supervision. KEY MEASURES FOR IMPROVEMENT We analysed neonatal outcomes for the time periods before and after the stepdown unit was created (1987-94 and 1995-2001). We compared these two time periods for survival after birth until discharge, morbidity patterns during hospitalisation, length of stay in hospital, and readmission rates to hospital in the four weeks after discharge. EFFECTS OF CHANGE Of 509 consecutive, very low birthweight infants, 494 (97%) preterm and 140 (28%) weighing < 1000 g at birth), 391 (76%) survived to discharge from the hospital. The length of hospitalisation fell significantly from 1987-90, when it was 34 (SD 18) days, to 16 (SD 14) days in 1999-2001 (P < 0.001). Readmission rates to hospital did not rise, nor did adverse outcomes at 12 months of age. LESSONS LEARNT Our results indicate that it is possible to involve mothers in the active care of their very low birthweight infants before discharge. This may translate into earlier discharge from hospital to home settings without any increase in short term complications and readmissions.

This pilot study was conducted to compare the effectiveness of the kangaroo care method with current, mainly incubator-based care in managing well preterm infants in a tertiary level hospital in a developing country. Altogether, 74 infants (37 per group) were consecutively allocated to receive either kangaroo care or incubator care. After adjusting for age and weight on admission to the study, we found that infants in the kangaroo care group gained twice as much weight per day (20.8 vs 10.2 g, p = 0.0001), had a shorter stay in hospital (16.6 vs 20.7 days, p = 0.0457) and had a better survival rate (0% vs 9% deaths). Also, they were ill less frequently, but after adjusting for age and weight this difference was not significant. This pilot study suggests that the kangaroo care method has major advantages over incubator care of preterm infants in our hospital. Hospitals which cannot use incubators optimally may find kangaroo care to be a better method of improving perinatal and neonatal morbidity and mortality.

Several hospital-based studies have shown the beneficial effect of kangaroo care on preterm infants. Long-term outcome was studied in 297 preterm infants born at Harare Hospital weighing 500-1800 g, discharged home on kangaroo care and followed up for 12 months. Of these, 79 (26.6%) died, 141 (47.5%) survived to complete follow-up and 77 (25.9%) were lost to follow-up. Of those who died, median birthweight was 1460 g, median age at hospital discharge 7 days, median weight at discharge 1400 g and median age at death 66 days. Of those who completed follow-up, median birthweight was 1575 g, median age at hospital discharge was 6 days and median weight at hospital discharge was 1500 g. Of those who were lost to follow-up, median age at loss to follow-up was 70 days, median birthweight was 1540 g, median age at hospital discharge was 5 days and median weight at hospital discharge was 1500 g. The hospital re-admission rate was 22.9% with 8.8% mortality. Maternal mortality and chronic morbidity rates were 4.7% and 7.4%, respectively. On comparing those who died with those who completed follow-up, mother's age <20 years, birthweight <1500 g and maternal mortality and chronic morbidity were significant risk factors for infant mortality. Age at discharge and weight at birth and on discharge were not significantly associated with infant mortality.

OBJECTIVE To investigate the vitamin A status of pregnant mothers, lactating mothers, preterm and term infants who were being fed exclusively on breast milk. DESIGN Systematic/cross sectional. SETTING Vitamin A research laboratory, animal science research laboratory, University of Zimbabwe, and Harare Central Hospital. SUBJECTS 105 pregnant mothers attending the antenatal clinic at Harare Central Hospital for a routine check up were recruited for the study. Two groups of infants: those born at term and those with gestational age < or = 36 weeks. MAIN OUTCOME MEASURES Serum retinol levels of infants/mothers pairs. Breast milk retinol levels. RESULT The serum retinol levels for the infants were similar irrespective of age with a mean of 26.15 +/- 9.78 microg/dl. There was no statistically significant difference. The mean serum retinol levels of infants and mothers were significantly different,(p = 0.001). With mother/infant ratio of serum retinol concentration of 1.7:1. Maternal serum retinol levels correlated positively with infant serum retinol levels, r = 0.728. Forty four percent of the preterm and 17% of the term infants had serum retinol levels < 20 microg/dl, indicating deficiency, 2 and only 20% of the infants had retinol levels > 40 microg/dl. CONCLUSION The majority of infants might be at risk of vitamin A deficiency. Increased intake of vitamin A in pregnant women is necessary, and direct vitamin A supplementation of infants should be considered.

OBJECTIVE To determine the prevalence of hypothermia, factors associated with hypothermia and risk factors for mortality in hypothermic newborn infants. STUDY DESIGN Cross sectional descriptive study. STUDY SITE Harare Central Hospital Neonatal Unit (NNU). SUBJECT Three hundred and thirteen consecutive newborn infants admitted to the NNU for care. STUDY FACTORS Temperature on admission to the NNU, mode of delivery, time of delivery, age on admission to the NNU, birth weight, sex, birth before arrival, need for resuscitation. RESULTS Prevalence of hypothermia on admission was 85% with a mean axillary temperature of 34.3 degrees C (SD= 1.6). Median age on admission was 120 minutes and there was a case fatality rate of 18.3%. The need for resuscitation, age at admission to NNU, time of delivery, birth weight, sex and being born before arrival were not significantly associated with being hypothermic. The only factors that were associated with mortality were babies being born before arrival and birth weight below 1 500 gms. Age at admission to NNU, sex, time of delivery and need for resuscitation were not significantly associated with mortality. CONCLUSION Neonatal hypothermia on admission remains a major problem in our population. There is need to increase awareness among nursing staff and mothers about the serious consequences of hypothermia particularly in very low birth weight newborns. Training in this area is called for.

OBJECTIVE To determine levels of mortality and risk factors for mortality in infants born with birth weights below 1,800 gms. DESIGN Prospective descriptive study. SETTING Harare Central Hospital in Zimbabwe. SUBJECTS All infants born and admitted to Harare Hospital Neonatal Unit between January and May 2000, with birth weight between 500 gms and 1,800 gms. STUDY FACTORS Mothers' age, parity, booking status, mode of delivery, infants' sex, birth weight, use of intensive care, outcome in hospital, age at death and age at discharge from hospital. RESULTS Four hundred and ninety infants were studied. In hospital, the fatality rate was 39.4%. Only 49.4% of mothers had received antenatal care. The median birth weight of those who died was 1,077 gms (Q1 = 500, Q3 = 1,357) while that of the discharged infants was 1,530 gms (Q1 = 850, Q3 = 1690). Risk factors for mortality were birth weight less than 1,500 gms compared to 1,500 gms or more. Odds Ratio (OR) 7.53 (95% CI = 4.66 to 12.23), breech delivery compared to vaginal delivery, OR 2.40 (95% CI = 1.28 to 4.52) and lack of antenatal care OR 1.59 (95% CI = 1.08 to 2.33). Parity, sex of infant and receiving intensive neonatal care were not significantly associated with mortality. CONCLUSION Strategies to reduce mortality in these infants should include better access to early, high quality obstetric care and avoidance of breech delivery in preterm infants. Identification of avoidable factors leading to preterm delivery is critical.

Thermal care is a critical part of caring for neonates. The need to identify simple, affordable and effective tools for detecting hypothermia in newborn infants that can be used by mothers and other caregivers in resource-poor countries remains crucial in our efforts to reduce perinatal and neonatal mortality and morbidity. The objective of this study was to determine the effectiveness of ThermoSpot in detecting hypothermia in newborn infants in a developing country. The prevalence of hypothermia (< 36 degrees C) in our study population was 51.4%. The ThermoSpot disc indicated green (normothermia) in 82% of infants whose axillary temperature was between 32 and 35.9 degrees C. However, the disc had a 100% specificity and positive predictive value at body temperatures below 36 degrees C and axillary temperatures below 36 degrees C or above 37.5 degrees C. Sensitivity, negative predictive value and accuracy were 19%, 52% and 57%, respectively. Mortality was significant in infants with black or blue ThermoSpot disc colours compared with green. For ThermoSpot discs placed on the abdomen, the risk of dying was 2.67 times higher if the disc colour was black compared with green and 2.43 times higher if the disc colour was blue compared with green. Similarly for ThermoSpot discs placed in the axilla, the risk of dying was 2.54 times higher if the disc colour was black and 2.5 times higher if the disc colour was blue as opposed to green. There is a need to improve the sensitivity and accuracy of ThermoSpot in detecting hypothermia before its widespread use.

The widespread use of 'kangaroo care' is yet to be realized despite strong evidence to suggest that this method of preterm care is safe, effective and affordable. We need to understand users' perception of this method of care. We studied, through focus group discussions, caregivers' experiences and perceptions of this method in a tertiary level hospital of a developing country. We conclude that, in this hospital, caregivers preferred kangaroo care to conventional methods. Communities' awareness of this method of care and its advantages must be improved.

OBJECTIVE To determine outcome and factors associated with mortality in a tertiary level neonatal intensive care unit. DESIGN Retrospective descriptive study. SETTING Harare Central Hospital Neonatal Intensive Care Unit (NICU). SUBJECTS All neonates admitted to the NICU in 1998. MAIN OUTCOME MEASURE Mortality. RESULTS A total of 234 neonates were admitted to the NICU in 1998. Median age at admission was one day (Q1 = 0, Q3 = 3). Median birth weight was 1,730 gms (Q1 = 690, Q3 = 2,209). The commonest reason for admission was respiratory distress. Medical cases were 171 (73.1%), surgical 61 (26.1%) and two were not indicated. The median duration of stay in the NICU was three days (Q1 = 1, Q3 = 6). Median age at death was three days (Q1 = 1, Q3 = 5). Case fatality rate was 46.4% and 85.9% died during the first week. Receiving mechanical ventilation was associated with high mortality. The odds of dying were 12.29 times greater for those who were ventilated compared to those who received continuous positive airways pressure (CPAP) via nasal prongs. Birth weight, age at admission to the NICU, sex and duration of stay in the NICU had no significant influence on mortality. CONCLUSION Mortality rates in this NICU were unacceptably high and call for urgent action. Attempts to identify true risk factors for the NICU mortality on the face of sub-optimal care may be misleading. There is need to improve neonatal audit in order to identify effective treatments and guide policies for the NICU care.

OBJECTIVE To conduct a situation analysis of obstetric services in a rural district of Zimbabwe. DESIGN Observational study. SETTING 13 primary health care centres in Murewa district in Zimbabwe. MAIN OUTCOME MEASURES Number of maternity beds, antenatal attendance, deliveries per month, availability of antenatal, intrapartum and neonatal care equipment, intrapartum monitoring and neonatal resuscitation skills. RESULTS 13 of 15 primary health care clinics providing obstetric care in Murewa district were surveyed in 1995. Median number of maternity beds were nine (Q1 = 0, Q3 = 11) per clinic, median number of first ANC attenders per month was 15 (Q1 = 3, Q3 = 18), median number of deliveries per clinic per month were eight (Q1 = 0, Q3 = 16). While all clinics had laboratory facilities, 6/13 could estimate haemoglobin, 5/13 syphilis serology, none of the clinics sent blood to district hospitals for blood grouping and there were no microscopes at clinics for malaria parasite determination. Only 6/13 clinics used partographs for monitoring labour, 10/13 had suction machines for neonatal resuscitation while only 3/13 had ambu bags, 3/13 had oxygen and 2/13 had heaters. Correct methods for neonatal resuscitation were used in 3/13 clinics. Clean water supply, reliable power supply and the referral system were not optimal. CONCLUSION Basic equipment for antenatal, intrapartum and neonatal care was inadequate. Essential laboratory facilities for obstetric care were lacking. Skills for intrapartum monitoring and neonatal resuscitation were inadequate. The referral system was poor. There is need for more strategic planning at primary health care level in this district which is known to have high perinatal and neonatal death rates. More emphasis should be placed on strengthening basic laboratory back up service for obstetric care, strengthening infrastructural and referral systems as well as training in areas of lost or no skills.

Aim:  To study the effect of Kangaroo mother care in the Kangaroo ward in comparison with conventional care at neonatal unit on growth and breastfeeding in very low birth weight infants at 40 weeks' corrected gestational age. Methods:  One hundred and forty neonates with birth weight <1500 g were randomized. The primary outcome was the average weight gain (g/kg/day) from the time of randomization to term gestational age. Results:  Mean birth weight, age in days and weight at randomization were similar in both the groups. At term gestational age, average weight gain (g/kg/day) post randomization (23.3 ± 8.7 g vs. 22.64 ± 9.1 g, p = 0.67) and breastfeeding rate (85.9% vs. 87.0%) were comparable. There was no difference in weight gain (g/kg/day) from randomization to hospital discharge between the Kangaroo care group and conventional care group (18.01 g vs. 15.64 g, p = 0.12). Mortality, morbidities like sepsis, hypothermia, apnoea, hypoglycaemia and duration of hospitalization were equally distributed. On average, 11.5 days of intermediate care were saved in the kangaroo group. Conclusion:  Kangaroo mother care in the Kangaroo ward is as effective as conventional care in the neonatal unit without any increase in morbidity or mortality in stable VLBW infants.

Background: The concept of family-centred care in neonatal practice has become increasingly recognised internationally. The underlying philosophy puts parents and the family at the centre of health care and promotes "individualised, flexible care." Aims: To develop the first international model of family-centred care based on strong parental collaboration in the synthesis of robust research evidence to generate the philosophy, principles, model, and indicators for implementation. Methods and Synthesis: Seven key steps were followed to develop the POPPY model of care collaboratively with parents. Step 1 drew on the POPPY systematic review to identify effective interventions. Step 2 drew on the POPPY qualitative study to identify good parent experiences. Step 3 identified the philosophy and principles of the POPPY model of care. Step 4 identified the key stages of the POPPY model of care. Step 5 populated the POPPY model of care with data from steps 1 and 2. Step 6 developed the indicators of family-centred care; and Step 7 undertook some initial testing with parents and practitioners. Results: Seven key stages of the parents' journey through their neonatal unit experience were identified and formed the architecture of the POPPY model of care. These include: before admission to the unit, admission, early days, growing and developing, transfers between units and between levels of care, preparing for discharge, and transition to home and at home. A philosophy, a set of principles to underpin the model, and a set of indicators to guide implementation in neonatal units were developed. Conclusion: The POPPY model of family-centred care provides the first robust, collaboratively developed, parent-centred model, which can be implemented to deliver high quality care to parents of preterm infants. Implications: Implementing the POPPY model could help neonatal units to develop parent-focused services which better meet parents' needs for information, communication and support, key elements of family-centred care.

Kangaroo mother care is a safe, simple method to care for low birth weight infants. This article looks at its origins, what is involved in kangaroo mother care and reviews the evidence for improved outcomes resulting from its implementation.

BACKGROUND Healthy infants typically regain their birth weight by 21 days of age; however, failure to do so may be due to medical, nutritional or environmental factors. Globally, the incidence of low birth weight deliveries is high, but few studies have assessed the postnatal weight changes in this category of infants, especially in Africa. The aim was to determine what proportion of LBW infants had not regained their birth weight by 21 days of age after discharge from the Special Care Unit of Mulago hospital, Kampala. METHODS A cross sectional study was conducted assessing weight recovery of 235 LBW infants attending the Kangaroo Clinic in the Special Care Unit of Mulago Hospital between January and April 2010. Infants aged 21 days with a documented birth weight and whose mothers gave consent to participate were included in the study. Baseline information was collected on demographic characteristics, history on pregnancy, delivery and postnatal outcome through interviews. Pertinent infant information like gestation age, diagnosis and management was obtained from the medical records and summarized in the case report forms. RESULTS Of the 235 LBW infants, 113 (48.1%) had not regained their birth weight by 21 days. Duration of hospitalization for more than 7 days (AOR: 4.2; 95% CI: 2.3 - 7.6; p value < 0.001) and initiation of the first feed after 48 hours (AOR: 1.9; 95% CI 1.1 - 3.4 p value 0.034) were independently associated with failure to regain birth weight. Maternal factors and the infant's physical examination findings were not significantly associated with failure to regain birth weight by 21 days of age. CONCLUSION Failure to regain birth weight among LBW infants by 21 days of age is a common problem in Mulago Hospital occurring in almost half of the neonates attending the Kangaroo clinic. Currently, the burden of morbidity in this group of high-risk infants is undetected and unaddressed in many developing countries. Measures for consideration to improve care of these infants would include; discharge after regaining birth weight and use of total parenteral nutrition. However, due to the pressure of space, keeping the baby and mother is not feasible at the moment hence the need for a strong community system to boost care of the infant. Close networking with support groups within the child's environment could help alleviate this problem.

Background: In developing countries, 80% of the births take place in the community. Methods: Birthweight, mid-arm and chest circumferences were measured in 294 newborns admitted in a tertiary-level hospital in Kolkata between April and August 2010. Colour-coded measuring tapes were devised using receiver operating characteristic curves to calculate the most sensitive and specific cut-off values to identify birthweight <2.5 and 1.8 kg. Result: There is no significant difference in accuracy of Mid-arm circumference (MAC) and Chest circumference (CC) for prediction of low birth weight and birthweight <1.8 kg. The tape has three zones, green [weight (wt) > 2.5 kg, MAC > 8.4 cm, CC > 30 cm], yellow (wt 2.5-1.8 kg, MAC 8.4-6.7 cm, CC 30-25.5 cm) indicating some risk, and red (wt < 1.8 kg, MAC < 6.7 cm, CC < 25.5 cm) indicating babies needing referral and admission in Level II neonatal care unit.

BACKGROUND Apnoea of prematurity (AOP) is a common problem in preterm infants which can be treated with various modes of nasal continuous positive airway pressure (NCPAP) or nasal intermittent positive pressure ventilation (NIPPV). It is not known which mode of NCPAP or NIPPV is most effective for AOP. OBJECTIVE To assess the effect of four NCPAP/NIPPV systems on the rate of bradycardias and desaturation events in very low birthweight infants. METHODS Sixteen infants (mean gestational age at time of study 31 weeks, 10 males) with AOP were enrolled in a randomised controlled trial with a crossover design. The infants were allocated to receive nasal pressure support using four different modes for 6 h each: NIPPV via a conventional ventilator, NIPPV and NCPAP via a variable flow device, and NCPAP delivered via a constant flow underwater bubble system. The primary outcome was the cumulative event rate of bradycardias (< or =80 beats per minute) and desaturation events (< or =80% arterial oxygen saturation), which was obtained from cardio-respiratory recordings. RESULTS The median event rate was 6.7 per hour with the conventional ventilator in NIPPV mode, and 2.8 and 4.4 per hour with the variable flow device in NCPAP and NIPPV mode, respectively (p value<0.03 for both compared to NIPPV/conventional ventilator). There was no significant difference between the NIPPV/conventional ventilator and the underwater bubble system. CONCLUSION A variable flow NCPAP device may be more effective in treating AOP in preterm infants than a conventional ventilator in NIPPV mode. It remains unclear whether synchronised NIPPV would be even more effective.

OBJECTIVE Guidelines on oxygenation policies and on the prevention and treatment of retinopathy of prematurity (ROP) were issued by the Chinese Medical Association in 2004. This study was undertaken to determine the incidence of and risk factors for ROP among preterm infants in Beijing, the capital of China, after implementation of the guidelines. METHODS Neonates with birth weights (BW)< or = 2000 g or gestational age (GA)< or = 34 weeks admitted to the six largest neonatal intensive care units in Beijing during 2005 were enrolled. Ophthalmological examinations started 3-4 weeks after birth, and ROP was classified using the revised International Classification. Maternal and perinatal risk factors for type 1 ROP were analysed. RESULTS Retinopathy of prematurity was detected in 10.8% of 639 neonates who had complete eye examinations, 23 of whom (3.6%) developed type 1 ROP and were treated. The rate of ROP needing treatment has not declined since 2002. Logistic regression analysis indicated that low BW, apnoea > 20 s, anaemia, hypoxic-ischaemic encephalopathy and placenta abruption were significantly associated with type 1 ROP. CONCLUSION In Beijing, rates of ROP needing treatment are high, and affected babies are more mature than in NICUs in high-income countries. More needs to be done to prevent ROP through improved neonatal care.

Supine sleeping is recommended to prevent the sudden infant death syndrome (SIDS). Low birth weight infants are at increased risk for SIDS, which is increased further if they are placed prone. Prone sleeping, however, also has advantages for preterm infants, such as a reduced apnoea rate, an increased lung volume and more quiet sleep. In their first weeks of life, these infants are usually on a monitor and under continuous observation. SIDS is extremely unlikely under these circumstances. Because of the aforementioned advantages, these infants may be placed prone during their first few weeks of life in the hospital. One week before discharge, however, they should be changed to back sleeping and the parents be explained that their baby is now nearing discharge and should thus be placed as it should also sleep at home: on its back and in a sleeping sack. We do not prescribe home monitors for SIDS prevention, but occasionally use pulse oximeters at home for a few weeks if an infant continues to exhibit apnoea of prematurity.

There is little or no report of preterm (babies born less than 37 completed weeks of gestation) admission from this part of Sahel Savannah of Nigeria. This study of four-year period is presented to identify areas that require improvement, such as in the Labour ward and neonatal care. The case files of the 428 preterm newborns admitted into Special Care Baby Unit (SCBU) of the University of Maiduguri Teaching Hospital were reviewed. Preterms constituted 54.9% of the overall admissions, 53.4% being Low birth weight newborns (=2500 gm). Premature rupture of membrane, previous preterm deliveries, twin gestation and pregnancy induced hypertension were some of the common maternal factors that were associated with preterm deliveries. Birth asphyxia, Apnoea, Small for gestation age 9weight less than 10th centile), respiratatory distress were the main problem observed among the preterm newborns. Neonatal mortality rate was 349/1000 live birth; 62.1% of the death were preterm infants. Mortalities were common among babies weighing 1000 gm or less and also of babies of lower gestational age. We can improve on this, by implementing simple common measures such as educating our mothers on the need for good antenatal care and hospital deliveries, so that those with pregnancy induced hypertension, premature rupture of membrane, previous preterm delivery can be detected early and institute proper management.