62 BIRTH 25:1 March 1998

LETTERS

Kangaroo Care: Commentary on a Commentary

New ideas do not take place by persuading those not believing in them,

but by waiting for them to die.

Max PlanckTo the Editor,We are writing in reference to a commentary entitled‘‘Caring for the Mother and the Preterm Infant: Kanga-roo Care’’ by Dr. J. Dı

´az-Rossello (Birth 1996;23(2):

108-11). In his paper, Dı´az-Rosello makes serious criti-

cisms against the early discharge policy that is a com-ponent of the kangaroo mother care program developedby Professor Edgar Rey in 1978. He also accuses ourresearch team of being unethical. We maintain that ourresearch process is ethical, scientifically solid, andrelevant.

Definition of Kangaroo Care

Dıaz-Rossello’s definition of kangaroo care as a ‘‘non-conventional medical practice that was proposed as analternative to high-technology care’’ is only partiallytrue. Early discharge in the kangaroo position takesthe place of minimal care units; it never has attemptedto replace high-tech hospital neonatal care. In addition,at the time the intervention was developed, kangarooearly discharge was an alternative to inpatient minimalcare in an overcrowded referral maternity hospital,Instituto Materno Infantil in Bogota. Minimal care atthat time and in that hospital meant very few incuba-tors, many of them not in proper working condition,and lots of otherwise healthy low birthweight infantsexposed to hyperthermia and hypothermia, and to dev-astating nosocomial infection outbreaks.

The method has three components: (1) kangarooposition: prolonged and continuous skin-to-skin con-tact between mother and her infant with the babyplaced vertically between the mother’s breasts andunder her clothes; (2) kangaroo feeding: exclusive ornearly exclusive breastfeeding; and (3) kangaroo dis-charge policy: early discharge while in kangaroo posi-tion and under kangaroo feeding, as soon as the infanthas overcome all major adaptation problems to extra-uterine life. Currently, there are three distinct applica-tions of the method (1): First, in places withoutappropriate facilities, the technique is proposed as theonly alternative to the lack of incubators. Kangaroocare usually takes place inside health facilities (2).Second, in places with easy access to all levels ofneonatal care, early skin-to-skin contact is employed

looking for benefits such as an enhancement of thequality of the mother-to-infant bonding and successfulbreastfeeding (3–5). Third, in places where technicaland human resources are of good standard but insuffi-cient to cope with all the demand, kangaroo mothercare is an alternative for a minimal care unit. Kangaroocare can be delivered within the hospital, as describedby Sloan et al (6) or as outpatient care, as it was doneat the Instituto Materno Infantil in Bogota (7).

Infants in kangaroo mother care in Bogota receivehospital care. In fact, in our observational study (7),kangaroo care infants spent an average of 9.1 daysin hospital before being eligible for discharge in thekangaroo position, and were discharged on average atthe age of 10.4 days (after adaptation to the kangarooposition). In contrast, control infants (from a tertiarylevel care hospital offering ‘‘usual’’ care) were dis-charged on average at the age of 12 days. This meansthat control infants were also discharged ‘‘early,’’ andwe would like to remind the reader that the study wasobservational, which means that we, as researchers,could not influence current practices at the participantinstitutions at the time of the study. The fact that earlydischarge also occurred at the control hospital reflectsthe reality in many tertiary level care centers in devel-oping countries: resources are not enough to care forall low-birthweight infants until they reach a givenweight or a given postconceptional age, and thereforeinfants are discharged early, in many instances evenbefore they regulate body temperature, and are givento a frightened and inexperienced mother.

Comments on Study Findings

We conducted an observational study because a ran-domized controlled trial was not feasible. The ‘‘kanga-roo’’ institution had been providing kangaroo mothercare for 12 years, whereas the ‘‘control’’ institutionwas the largest Social Security Hospital providing‘‘usual’’ care to all low-birthweight infants. The twocohorts were very different regarding baseline risks,kangaroo infants being at higher risk. Our findingswere as follows: (1) After controlling for birthweightand gestational age, there was no statistically signifi-cant reduction of the risk of dying in kangaroo infants(relative risk = 0.54, 95% CI = 0.2–1.2); (2) earlygrowth in both groups was suboptimal but was poorerin the kangaroo infants. Given the nature of the study,our data did not allow us to clarify if the difference

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in growth was due to the kangaroo technique or dueto the large baseline differences; (3) developmentalscores, after controlling for differences in socioeco-nomic status, were similar in the two groups; (4) sav-ings in hospital stay due to early discharge were lostdue to more frequent and prolonged readmission tohospital by kangaroo infants; and (5) breastfeedingwas longer and more successful in the kangaroo group.

Our conclusions were cautious (7):

In conclusion, we think that our study, although not experi-mental, shows that it may be feasible to substitute mothers forincubators to care for LBW infants once they have overcomemajor adaptation changes to extrauterine life, and that thisdoes not jeopardize the probability of survival of those in-fants. Nevertheless, important questions remain unsolved,that deserve further well designed and conducted studiesbefore this strategy is ready for a widespread use. In particu-lar, further research should address two items: exclusivebreast feeding during Kangaroo position, and how earlydischarge should be attempted, in order to maximize benefitsand minimize problems. It also will be important to evaluatethe impact of the KI (Kangaroo Intervention) on the qualityof the mother and child attachment.

We interpreted these results as promising, and in1993 started a randomized controlled trial (with a fewenhancements suggested by our previous experience)at the hospital that participated as a control institution.Early results from this study have been accepted forpublication in Pediatrics, and were presented at severalinternational meetings (8,9). These results confirm thatnot only are kangaroo infants not at a higher risk ofdying, but there is a large, although nonstatisticallysignificant, reduction in mortality. The results also pro-vide evidence contradicting previous findings of poorearly growth in kangaroo infants.

Ethics and Scientific Papers

In his paper, Dıaz-Rossello attacks the early dischargecomponent of the Rey-Martınez kangaroo mother careprogram: ‘‘The method proposed by Rey and Martinezis not safe. Discharging infants regardless of weightand gestational age is inappropriate and would neverbe approved by an ethics committee.’’ He accuses Reyof jeopardizing infants by discharging them early andunder suboptimal conditions. His opinions originatedduring a visit he paid to Rey in the early 1980s (Insti-tuto Materno Infantil, personal communication, 1997).Dıaz-Rossello also complains of the methodologicalweaknesses of Rey’s reports. Dr. Rey was aware ofthese flaws in his early reports. He was a devoted andcommitted clinician, not a researcher, and he welcomedour efforts to evaluate his program formally. Dr. Reydied in 1995, and therefore he cannot respond to thesecriticisms.

Dıaz-Rossello also accuses us of two serious

charges: first, abandoning study patients to their fate,letting them die while we could have done somethingfor them: ‘‘All nine mothers had almost no family orcommunity support. . . . Although this was under aresearch protocol . . . the authors give no explanationfor this finding’’; and second, data manipulation todeviate conclusions in favor of the kangaroo mothercare: ‘‘a systematic bias favoring the kangaroo careproposal can be observed, including inconsistency be-tween data analysis and conclusions.’’

With respect to the first assertion, Dıaz-Rosselloclaims that nine deaths occurred under kangaroo careand three under minimal care at the hospital. He omitsstating that the total number of deaths were 17 (12%)and 10 (7%), respectively, and that the difference wasfar from significant (1). He also says that seven infantsdied at home without medical care being sought forthem. Despite our aggressive and successful follow-up activities that allowed us to detect and correct manyhealth problems of infants during their ambulatorycare, the magnitude of the task clearly overwhelmedour possibilities as a research team. We were not thedirect health care providers for those infants. Livingconditions of most families in the kangaroo group andin some of the control group were extremely poor.Neither we nor the Instituto Materno Infantil have thelegal right to prevent these high social risk familiesfrom taking their infants with them, or have the re-sources to provide them with in-hospital care. TheColombian government also does not have such re-sources. Of course, as Dıaz-Rossello pointed out, noethics committee would have ever approved of dis-charging infants of any weight or gestational age tolive in those conditions. The fact remains, however,that kangaroo mother care or not, those infants had tobe discharged as soon as possible to give room to otheryounger and sicker infants who were claiming thosescarce health resources, and to protect them from seri-ous threats posed by deadly outbreaks of nosocomialinfection. If the Instituto Materno Infantil had re-sources available to take proper care of all low-birthweight infants for long periods, the kangaroo in-tervention would not have been developed. Dıaz-Rossello disregards the socioeconomic conditions ofthe participants and the inability of the health caresystem from a less developed country to do somethingabout it. Although he says that they were not offeredany alternative form of care, he knew that such alterna-tives were unavailable.

With respect to the second assertion, the commentgives the impression that there were two reports: ‘‘Thecomplete report of this study (only parts of it werepublished in Pediatrics) shows. . . .’’ The alleged dif-ferences between the two documents simply reflectthe fact that for publication in a scientific journal, the

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results of three years of data collection and analyseswere drastically condensed in a six-page document inwhich we did not distort the information. In 1994, oneof us (N. Charpak) gave Dıaz-Rossello a copy of thefull study report. At the Pediatric Research SocietyMeeting, held in San Diego, California, in 1995, hewas provided with data that solved his (and our) doubtsregarding the quality of early growth while infantswere receiving kangaroo care. He was aware of thatinformation at least 17 months before his commentarywas published in Birth.

We invite readers to conduct a careful and dispas-sionate review of current evidence regarding the ad-vantages and disadvantages of kangaroo mother care,including the sensitive early discharge component, andto form their own opinion.

Juan G. Ruiz-Pelaez MD, MMedSciDepartment of Pediatrics and

Clinical Epidemiology Unit,Javeriana University,

Hospital San Ignacio, Piso 2,Cra 7a # 40-62,

Santafe de Bogota, DC, ColombiaNathalie Charpak, MD, WorldLab Coordinator

ISS-WorldLab Kangaroo Mother ProgramPresident, The Kangaroo Foundation

Carrera 7a #46-20, Apto 2001,Santa fe de Bogota, DC, Colombia

References

1. Charpak N, Ruiz JG, Figueroa Z. Current knowledge in kanga-roo mother intervention. Curr Opinion Pediatr 1996;8:108–112.

2. Bergman NJ, Jurisoo LA. The ‘‘kangaroo-method’’ for treatinglow birth weight babies in a developing country. Trop Doct1994;24(2):57–60

3. Ludington-Hoe S, Golant S. Kangaroo Care: The Best YouCan Do To Help Your Preterm Infant. New York: BantamBooks, 1993.

4. Ludington-Hoe SM, Thompson C, Swinth J, et al. Kangaroocare: Research results, and practice implications and guidelines.Neonat-Network 1994;13(4):61–62; 1994;13(1):19–27.

5. Anderson GC. Current knowledge about skin-to-skin (kanga-roo) care for preterm infants. J Perinatol 1991;11(3):216–226.

6. Sloan NL, Camacho LW, Rojas EP, Stern C. Maternidad IsidroAyora Study Team Kangaroo mother method: Randomised con-trolled trial of an alternative method of care for stabilised low-birthweight infants. Lancet 1994;344(8925):782–785.

7. Charpak N, Ruiz JG, Charpak Y. Kangaroo mother program.An alternative way for caring for LBW infants? A two cohortstudy. Pediatrics 1994;94:804–810.

8. Kangaroo Mother Care versus ‘‘Traditional’’ Care in InfantsUnder 2000 g At Birth. A Randomized Clinical Trial. Resultsat 41 Weeks of Gestational Age. Presented at the InternationalClinical Epidemiology Network (INCLEN) Meeting, Bali, In-donesia, 1995.

9. Comparison of Kangaroo Mother Care and ‘‘Traditional’’ Carein Infants Under 2000 g At Birth. A Randomized ClinicalTrial. Results at 41 Weeks of Gestational Age. Presented at thePediatric Research Society Meeting, San Diego, California,1995.