Método Madre Canguro Ciencia y ternura

Presentación del tema: "Método Madre Canguro Ciencia y ternura"— Transcripción de la presentación:

1 Método Madre Canguro Ciencia y ternura
Módulo 1 Introducción Definiciones y Epidemiología del niño prematuro o de bajo peso al nacer. Historia del Método Madre Canguro Principales intervenciones del Método Madre Canguro

2 1.1 Introducción

3 “La llegada del nuevo milenio es un pretexto excelente para dar un paso atrás y evaluar qué estamos haciendo y la forma en la que las cosas se vuelven nuestros propios proyectos de vida. En nuestro caso esto hace referencia al cuidado del niño prematuro o de bajo peso al nacer.” Dr. N. Charpak y J.G. Ruiz 2012 During the past century medical technologies have experienced an exponential and explosive development. During this period, the role of the health care providers including physicians has gone from being almost helpless witnesses of the struggle for survival of a sick infant and his mother to a gradual and progressive capacity to understand and help the immature and altered physiology of the newborn, with increasing success. Too often along the way, parents were physically and emotionally separated from their sick babies. Children were alternately and progressively placed in an increasingly complex technical environment. All this, was of course, done with the most altruistic intention, to improve the babies’ condition with the pseudo support of “science and technology.”

4 Definiciones Un niño prematuro es aquel que nace antes de completar las 37 semanas de gestación, o el que nace 1 o 2 meses antes de la fecha calculada. El prematuro Tardío/Leve/Casi a término (70% de todos los niños pretérmino): Nacidos en forma prematura entre las semanas de gestación Nacidos un mes antes de la fecha calculada Prematuro extremo (<5% de todos los niños pretérmino): Nacidos en forma prematura antes de las 28 semanas de gestación Nacidos más de dos meses antes de la fecha calculada Bajo peso se define como peso menor a 2,500 g al nacer Muy bajo peso se define como peso menor a 1,500g al nacer Preterm infants could have a normal weight for their gestational age, or to have a low weight for their gestational age. Keep in mind that in many cases the exact gestational age in not known and that in 60% of the cases newborn are not weighted at birth. WHO proposes the term of “small infant” which cover all infants weighting less than 2,500 g at birth including both preterm and Low birth weight infants.

5 Nacido Vivo: Definición de la OMS
Nacido vivo: Expulsión o extracción del producto de la concepción del cuerpo de la madre Independientemente de la duración del embarazo Que después de dicha separación respire o dé cualquier otra señal de vida: latidos del corazón pulsaciones del cordón umbilical o movimientos efectivos de los músculos de contracción voluntaria, independientemente de que se haya cortado o no el cordón umbilical y de que esté o no desprendida la placenta. Cada niño es considerado como vivo. The WHO definition says an infant is alive if it exhibits any signs of life. This definition is important as sometime extremely small infants(less than 1, 000 g )are declared still births if they survived only few minutes. The Soviet era-definition—still dominant in several CIS countries-uses breathing as the sole indicator of life. Under the Soviet definition, moreover, infants who are born before 28 weeks of gestation, who weigh less than 1,000 grams, or who are less than 35 centimeters long are not considered live births unless they survive for seven days.

6 Tabla de crecimiento intrauterino
The intra uterine growth chart is the tool used by neonatologist to assess the quality of the intra uterine growth . The appropriate growth for gestational age is the space between the 10% and 90% lines of this growth chart. Under the 10% line infant are consider as Small of gestational age or as Low birth weight. Intra uterine growth retardation is affected by different factor such as tobacco or drugs consumption or by mother condition such as high blood pressure, preeclampsia, anemia, etc. It is extemely important when a small infant( < 2, 500g ) is born to evaluate the quality of intra uterine growth, as the infant could be classified as a preterm infant with appropriate weight for gestational age, or preterm small for gestational age(SGA ). Low birth weight infant could be born full term or preterm . It is recommended to conduced a group “quiz” asking participants to identify through few examples if infants are preterm with AGA, or LBW full term or preterm ( a 26 weeks infant born with a weight of 1000g ; a 30 week infant born with a weight of 1000g, a 34 weeks born with a weight of g, an infant born at 36 weeks weighting at birth 1,600g , etc…. Worldwide, prematurity accounts for 10% of neonatal mortality, or around 500,000 deaths per year.[3] In the U.S. where many infections and other causes of neonatal death have been markedly reduced, prematurity is the leading cause of neonatal mortality at 25%.[4] Prematurely born infants are also at greater risk for having subsequent serious chronic health problems.

7 1.2 Desarrollo y Tecnología

8 Primeros progresos tecnológicos para niños prematuros
Hasta el final del siglo 19 los niños prematuros nacían y eran cuidados en casa y vivían o morían sin intervención médica. 1880: El Dr. Tarnier inventó la primera incubadora basada en la “incubadora de huevos de gallina”. 1893: El Dr. Budin creó el primer departamento específico para el cuidado del niño prematuro en París Usando el método de la incubadora, Budin redujjo la tasa de mortalidad para los niños < 2000 gr del 98 % al 23% Budin reconoció la importancia de la lactancia materna y el apego de la madre hacia su hijo The incubators were advertised as “The Amazing Mechanized Mom”  Incubators with the preterm infants inside (!) were on display at International exhibitions until 1931, in Coney Island they were exhibit for 40 years. Dr. Budin, “the Nursling “ 1895

9 Progresos del siglo 20 en países desarrollados
Después de 1945: creación en la mayoría de países desarrollados de salas especiales para el cuidado del prematuro separadas de los padres. Finales de 1970’: creación de las Unidades de Cuidados Intensivos Neonatales 20% de los niños nunca recibieron visitas parentales durante su estancia en la UCIN 1980’: desarrollo del surfactante mejoró las técnicas de ventilación Aumento de las necesidades y uso de sistemas de monitoreo y soporte vital Estrés por ruido, luz, procedimientos dolorosos, contacto físico reducido, separación de la madre, interferencia con las oportunidades de lactancia materna. Tasa de supervivencia de <1,500g : 1960: 40% : ≈ 80% Preocupaciones a largo plazo: alta proporción de discapacidades Parents were allowed to watch them through the windows of the unit. During this period, the role of the health care providers including physicians has gone from being almost helpless witnesses of the struggle for survival of a sick infant and his mother to a gradual and progressive capacity to understand and help the immature and altered physiology of the newborn, with increasing success. Too often along the way, parents were physically and emotionally separated from their sick babies. Children were alternately and progressively placed in an increasingly complex technical environment. All this, was of course, done with the most altruistic intention, to improve the babies’ condition with the pseudo support of “science and technology.”

10 Evolución de la Tecnología
These fragile neonates, born in economically powerful societies seemed doomed to a strange destiny: in order to survive they had to be placed in the efficient but inhuman environment of medical technology and separated from their parents. Preoccupation with biomedical aspects obscured common sense to extremes which were hard to believe. Painful procedures were routinely performed without regard for the “nightmare” experienced by a completely defenseless child. Temperature regulation, prevention of infection, monitoring of vital signs and support of physiological functions imposed noisy, harshly lit, aggressive and invasive environments in which the infant was submerged in order to receive care. 1909 :Incubadora 2010 :NICU

11 Manejo del niño pretérmino o de bajo peso en países en vía de desarrollo
Poco personal capacitado y escasos equipos médicos: Salas congestionadas Incubadoras ocupadas Número deficiente de monitores Infección nosocomial frecuente Suministro de electricidad inconstante La prematurez es responsable por el 61% de la mortalidad infantil temprana y es la principal causa de muerte inclusive en embarazos cerca del término. The fate of preterm and/or low birth weight infants in developing countries has been even stranger. Access to sophisticated and costly technology was and continues to be difficult. In many cases, neonatal care units having few health staffs and limited medical equipment could not circumvent deadly traps: overcrowded incubators, deficient monitors, nosocomial infection, etc. Fragile children in developing countries are not experiencing the true and complete advantages of technology, because good quality technology is rarely available. The ghost of dehumanized medical care, associated to technological advances is also spreading widely to developing countries, regardless of how scarce technology may be

12 1.3 Geografía y epidemiología del niño Prematuro y/o de Bajo Peso al Nacer

13 Geografía y Recursos El 90 % de los niños pretérmino o de BPN nacen en países en vías de desarrollo, pero El 90% de los recursos en investigación para niños de alto riesgo (prematuros y de BPN) se utilizan en los países desarrollados Los recién nacidos independientemente del lugar de nacimiento deben tener el derecho de recibir el cuidado médico de mejor calidad posible desde las perspectivas biomédica, tecnológica, psicológica, emocional y humana. Es esencial unir lo mejor de los dos mundos. . It is essential to join  the best of both worlds. Newborns, regardless of their place of birth, must have the right to receive the best possible quality of care, from the biomedical technology, psychological, emotional and “human” perspectives. In many places and times, health care professionals have called attention to the need to provide humanized care to infants and families. Pierre Budin in 1907 defended the active involvement of mothers caring for their hospitalized, sick newborns. Miller, in 1948, provided home care to preterm infants in Newcastle-on-Tyne. Klaus & Kennel in 1976, among others, emphasized the importance of physical and emotional contact between the mother and the baby immediately after delivery to support the development of a strong and healthy bond. Knowledge about newborns experiencing pain is relatively recent and has led to questions regarding the need for sedation and analgesia during exhausting and/or painful procedures.

14 Epidemiología del prematuro/BPN
Los niños prematuros o de BPN representan una carga para la salud pública especialmente en países en vías de desarrollo En 2007 UNICEF reportó que cada año: Nacen > de 20 millones de niños prematuros o de BPN 17% de todos los nacimientos con en países en vías de desarrollo 7% de todos los nacimientos en países industrializados 60% de todos los recién nacidos alrededor del mundo no se pesan La falta de datos comparables hace difícil evaluar el progreso Los datos de algunos países desarrollados (UK, USA) muestran un crecimiento dramático en los últimos 20 años “We estimate that in ,9 million premature births were registered, which represents 9,6 % of all births in the world. Approximately 11 million (85%) of them are concentrated in Africa and Asia, while 0,5 million are registered in Europe and North America (excluding Mexico), and 0,9 million in Latin American and the Caribbean. The highest prematurity rates occur in Africa and North America (11,0% and 10,6% of all births respectively) and the lowest in Europe (6,2%). (WHO, 2010).

15 Porcentaje de niños de bajo peso al nacer < 2,500 g en algunas regiones (1999-2006)
The map of premature and LBW births is superimposed to the world map of poverty. 90 % of these children are born in developing countries, with higher risk for presenting physical, neuropsychomotor and neurosensory sequels as well as chronic illness such as cardiovascular diseases and diabetes in the adult years and risk to die early. They also have 50% risk for developmental and learning problems and mental retardation. Their Intelectual Quotient (IQ)  is usually 5 to 10 points below the standard; and they may develop long term hearing and visual impairements.

16 Mortalidad neonatal y BPN
Cada año cerca de 4 millones de niños mueren antes de alcanzar los 28 días de vida ( período neonatal) Los niños de bajo peso tienen 40 veces más riesgo de morir antes de alcanzar un mes de vida comparado con los niños más grandes. In 2007 UNICEF studies on low birth weight infants report that every year more than 20 million of infants are born with a low birth weight and prematurely or at term with low birth weight. This represents 17% of all births in the developing world, double as compared to the rate of industrialized countries- 7%.

17 Mortalidad Infantil y BPN
≈ 1/3 of infant death are related to prematurity. In fact to be born prematurely increases the risk to be infected and to suffer from other associated conditions such as respiratory problem or nutrition problems. La Prematurez/BPN representaron el 27% de toda la mortalidad infantil Mejorar la supervivencia neonatal es esencial para reducir la mortalidad infantil

18 Causas globales de mortalidad infantil
Almost 40% of all deaths in children younger than 5 years of age occur during the neonatal period, during the first year of life. Around 26 %t of these neonatal deaths (which comprise 10% of all deaths of children younger than 5 years of age), are due to infection. A significant proportion of these infections originate due to pneumonia and sepsis. (a severe blood-transmitted bacterial infection, which can be treated with antibiotics ). Nearly 2 million children below the age of 5, die every year of pneumonia (approximately 1/5 deaths in the world), In spite of progress achieved since 1980, diarrheal diseases are still responsible for 17% of deaths in children before 5 years of age. Together, malaria, measles and AIDS are responsible for 15 percent of children infant deaths. Gráfico derivado de datos de Black RE, Cousens S, Johnson HL et al. en “Global, regional, and national causes of child mortality in 2008: a systemic analysis,” The Lancet, May 12, 2010.

19 Causes of premature births or LBW infants
Parto prematuro (antes de la semana 37 de gestación) 50% de los casos es de causa idiopática Retardo del crecimiento intrauterino Pobre nutrición materna, incluyendo deficiencias de vitamina A, hierro, ácido fólico y zinc Hipertensión arterial materna Embarazo múltiple (gemelos, trillizos) Embarazo en adolescentes Madre expuesta a una carga de trabajo intensa Estrés, ansiedad y otros factores psicológicos Consumo de cigarrillo activo y pasivo Infecciones agudas y crónicas durante el embarazo : malaria, vaginitis bacteriana A LBW infant is defined by the World Health Organization (WHO) as an infant born with a weight of 2,500 g or less. This definition is based on the epidemiologic observation of this category of children (weighing ≤ 2,500 g at birth), who have 20 times more probability of dying than heavier children.   

20 Intervenciones eficientes de bajo costo para disminuir la mortalidad de niños de BPN
Estadíos Intervenciones Antes de la concepción Suplemento de ácido fólico para prevenir defectos del tubo neural Antenatal Tamizaje y tratamiento de sífilis Prevención de preeclampsia y eclampsia Inmunización contra tétano Tratamiento preventivo para Malaria intermitente Tratamiento de la anemia Diagnóstico y tratamiento de bacteriuria asintomática Intraparto (Nacimiento) Antibiótico en caso de ruptura prematura de membranas Corticoesteroides durante el trabajo de parto pretérmino Reconocimiento y manejo de la presentación podálica Diagnóstico temprano de las complicaciones del parto Asepsia en los procedimientos de parto Post-parto Resucitación y adaptación adecuada del recién nacido Prevención y manejo de la hipotermia Lactancia materna Método Madre Canguro (para niños de bajo peso al nacer) Manejo de casos de neumonía adquirida en la comunidad The KMCM has been proposed as one of the low cost interventions bases on scientific evidence to decrease infant mortality. The United Nations Program for Development (UNDP), in 2010 recognized the KMCM as an available tool to decrease infant mortality in the world and to achieve the Millennium’s Goal 4. NIDCAP (Newborn Individualized Developmental Care and Assessment Program) has set out a new philosophy for the care of the premature infant for more than three decades, with great concern for the environmental impact on the development of preterm infants in their long term evolution. In NIDCAP, the child and his family is become the center of attention and the intervention itself taking a subordinate place. Procedures are adapted to the child’s and the family’s characteristics and not the other way around. In NIDCAP the relationship between the child and his parents and caretakers is reinforced. El PNUD en 2010 reconoció al MMC como una herramienta disponible para disminuir la tasa de mortalidad infantil y para alcanzar el objetivo 4 del Milenio  

21 1.3 Historia del Método Madre Canguro

22 Creación del Método Madre Canguro
En 1978 el Dr. E Rey Sanabria en Bogotá, Colombia concibió el MMC para: Resolver la escasez de incubadoras Reducir la separación de madres e hijos Reducir la tasa de abandono Los componentes claves del MMC son: Contacto piel a piel continuo y prolongado Lactancia materna Alta temprana El MMC reinstaló a la madre en su rol de cuidador principal His work, pioneer in this field, has been carried out and developed by others and today, different modalities of the KMCM are being provided both in developed and developing countries.

23 Factores adicionales a la creación del MMC
Altas tasas de morbilidad/mortalidad en niños prematuros y de BPN hospitalizados Infecciones nosocomiales frecuentes ++ Una profunda convicción de los beneficios de la leche materna para los niños prematuros y/o BPN hospitalizados Convicción de que el calor de la incubadora puede ser reemplazado por el calor del cuerpo de la madre del niño La observación de niños de BPN que sobrevivieron gracias al cuidado de madres y abuelas que pusieron a estos niños en contacto piel a piel en su regazo La observación de la experiencia de los marsupiales en la naturaleza Guided by these thoughts, Dr. Edgar Rey Sanabria decided to establish an ambulatory program for LBW infants that he called Kangaroo Mother Program (KMP). In this program regardless of weight or gestational age, once a preterm or LBW infant was stable and didn’t need any treatment except to be kept warm and fed, he was sent home. The infant should stay day and night in skin-to-skin contact on his mother´s chest; he should be fed at will and be monitored through frequent ambulatory consultations.

24 Fortalecimiento del Programa MMC ambulatorio
Independientemente del peso o edad gestacional, una vez el niño prematuro o de BPN esté estable y no necesite un tratamiento adicional aparte de ser calentado y alimentado, se envía a casa: El niño debe permanecer día y noche en contacto piel a piel con el tórax de la madre El niño debe ser alimentado según su voluntad El niño debe monitorearse a través de consultas ambulatorias frecuentes En 1979 el Dr. Martínez y en 1982 el Dr. Navarrete fortalecieron y sistematizaron las consultas de seguimiento Se deben realizar conferencias diarias para las familias (nutrición, estimulación) Se debe crear solidaridad y sentimientos de calidez humana entre las familias y el equipo de salud From this experience, the three principles of the method emerge: i) love: emotional contact, sensory stimulation; ii) warmth: through the Kangaroo Position and iii) mother´s milk: providing nutrition and protection.

25 Diseminación del MMC 1981: La OMS transmitió el mensaje a varios países. Muchos expertos tanto de países ricos como países pobres visitaron el programa e iniciaron la diseminación del MMC : se realizaron los 1eros estudios basados en la evidencia sobre el MMC en Colombia y Europa (Impacto sobre mortalidad; papel del contacto piel a piel sobre la termoregulación) 1993: Se escribieron las primeras guías y metodología del MMC intrahospitalario y del seguimiento  These professionals exported the kangaroo position or skin-to-skin contact component that then appeared in Anglo-Saxon literature as Kangaroo Care. Among the first visitors were Dr. Susan Wahlberg from Sweden, Dr. Andrew Whitelaw, neonatologist and Kathy Sleath, a neonatologist nurse both from United Kingdom This group began the first research on skin-to-skin contact in Europe along with Dr. Leew in the Netherlands and other professionals in Germany.  In 2007, the Kangaroo Foundation and The University Javeriana in Bogotá, Colombia, published a ““Practical Clinical Guide based on evidence for the optimal use of the Kangaroo Mother Care Method in the preterm and/or low birth weight infant”. This publication, with the objective of standardizing the growing use of this methodology, was translated to English and provide freely to professionals interested. At the end of 2010, the Colombian Ministry of Social Protection, together with the United Nations World Food Program( WFP) publishes the document ”Technical Guidelines for the Implementation of a Kangaroo Mother Program in Colombia” as a support tool for Health Providing Institutions and Hospitals caring for preterm and LBW infants.

26 Diseminación del MMC 1994: Creación de la Fundación Canguro en Bogotá
dirigida por las pediatras Charpak y Figueroa, y el epidemiólogo Juan Gabriel Ruiz 1997: “Guías Clínicas prácticas basadas en la evidencia para el uso óptimo del Método Madre Canguro en el niño prematuro o de Bajo Peso al Nacer”

27 El Rol de la Fundación Canguro
Humanizar el Cuidado Neonatal Continuar de forma sistemática la evaluación científica del MMC Facilitar la transmisión del conocimiento sobre el MMC Compartir resultados a través de publicaciones Entrenar profesionales de la salud Promover alrededor del mundo un manejo de alta calidad del recién nacido de alto riesgo de una forma humana, científica y eficiente, haciendo uso racional de costos y recursos The kangaroo foundation has the mission to humanize neonatal care. The ‘Foundation “, continues the systematic scientific evaluation of the KMCM. Moreover, the “Foundation” facilitates the transfer of knowledge on KMCM, shares the results through publications, train health professionals promoting around the world, a high-quality management of the high risk newborn in a humane, scientific, efficient manner, making rational use of cost and resources.

28 Especificidades del MMC
El MMC fue concebido e implementado inicialmente en países con bajos recursos tecnológicos Por lo tanto ha sido erróneamente considerado como la alternativa para los pobres El MMC actualmente está incluido en iniciativas como el cuidado centrado en la familia o NIDCAP en muchos países desarrollados   El MMC es fisiológicamente, emocionalmente y humanamente apropiado para los requerimientos de los recién nacidos El MMC para niños prematuros no está en contra del cuidado médico basado en la tecnología ni ha sido propuesto como una alternativa a este; se considera como un aliado. KMCM authors and promoters are scientifically well structured physicians, who recognize and value the role of highly sophisticated neonatal units and technology in the neonate’s survival and quality of life. The KMCM continues to be disseminated, not only in Colombia but in the world with a wide range of researchers in developed and developing countries, producing an ever-growing body of scientific evidences to support a better use of its components in preterm and/or LBW infants as well as full-term babies. Advances in neonatal medicine have notoriously contributed to increase the survival of children born prematurely and or with low birth weight. Critical stages of respiratory, metabolic and infectious disorders tend to resolve with greater success each time; however, recovery periods following these crises tend to be prolonged and it is then where the environmental impact of neonatal units is inadequate for the integral development of the infant and his family.

29 MMC alrededor del Mundo
En América del Sur y Centro América Replicaciones tempranas del PMC en varios países En Europa y Norte América El MMC ha sido implementado en diferentes momentos: Inmediatamente después del nacimiento En las unidades neonatales El MMC se ha implementado con tiempos de duración distintos: Esto permite la medición de diferentes efectos y beneficios en niños prematuros y/o de BPN, e incluso en niños a término En 1996 : 1era reunión internacional del MMC en Italia Se consolidó un núcleo de 36 expertos en MMC de 15 diferentes países Participantes de África, Asia, Europa, Norte América y Sur Ámerica   In 1988, in the United States, Dr. Gene Anderson and Susan Ludington begin the first study of the effects of kangaroo care in the neonatal care unit in the Presbyterian Medical Center of Hollywood, Los Angeles, California. Since then they have been investigating the KMCM, especially the kangaroo position. They are great advocates of the position, not only for preterm but also for full term babies. Ludington developed guides based on evidence for implementing Kangaroo Care in premature infants of less than 30 weeks gestational age and its effects. (Ludington-Hoe, 2008) In Europe, implementation of the Kangaroo Mother Care Method began with studies conducted by Dr. Andrew Whitelaw and K. Sleath with a descriptive and systematic study of the kangaroo position. (Whitelaw, Heisterkamp, Sleath, Acolet & Richards, 1988). Other researchers followed this experience and started using the kangaroo position from different time after birth. These first studies confirmed that implementing KMCM was safe for preterm infants and beneficial for parents allowing positive emotional bonding and parental empowerment in infant care (Anderson, 1999). This is how an International Network in Kangaroo Mother Care began. Since the 1st meeting, a bi-annual encounter has been taking place in different countries around the world, with different topics of world interest with the aim of further developing the Kangaroo Mother Care Method.

30 Implementación MMC 2011

31 Definiciones del Cuidado Canguro
El Programa Madre Canguro – PMC es un conjunto de actividades e intervenciones organizadas, realizadas por un equipo de personal de salud bien entrenado, dentro de una estructura física y administrativa definida. Intervención Madre Canguro – IMC consiste en una serie de componentes aplicados de una manera sistemática y organizada siguiendo el siguiente método: El Método Madre Canguro EL Método Madre Canguro – MMC está basado en un protocolo estandarizado para el cuidado del niño prematuro y/o de BPN, que consiste en el contacto piel a piel entre la madre y el niño. Se busca empoderar a la madre, transfiriéndole la capacidad y responsabilidad de ser el cuidador principal de su hijo, satisfaciendo sus propios requerimientos físicos y emocionales. These interventions have some degree of heterogeneity manifested from the diversity of names by which they are identified, such as: i) kangaroo care, ii) kangaroo mother care, iii) Kangaroo Method, iv) Kangaroo Mother Care Method, v) kangaroo mother intervention, vi) kangaroo technique, vii) Kangaroo Program, viii) Kangaroo Mother Program, and ix) skin-to-skin contact. The term “skin-to-skin contact” in particular has been frequently employed in Anglo-Saxon literature to describe intervention using only one of the components of the Kangaroo Mother Care Method such as the kangaroo position. The name Kangaroo Mother Program is derived from specific meanings: Program, refers to a succession of different actions with the objective to decrease mortality in preterm infants and compensate the lack of incubators . Mother, refers to the fact that the infant´s mother is asked to actively participate in the care of her infant. It is true that the father (when present) participates, but responsibility lies on the mother; therefore mother is acknowledged in the name of the method. Kangaroo evokes the extra uterine maturation of a fetus as its take place in non-placental mammals. It refers to the mother as provider of the so-called kangaroo position , continuously holding her infant until he reaches the expected maturity. Use in scientific literature (and health professionals´ jargon) of the terms program, intervention and method is imprecise, which generates some degree of confusion.

32 Características del MMC
Desde 1978 el método se modificó incluyendo cambios derivados de la práctica e investigaciones científicas. Se definió un escenario de referencia, el cual caracteriza los elementos y las circunstancias de la implementación del MMC. Contiene los componentes considerados como fundamentales en el MMC Población blanco: prematuros (<37 semanas de edad gestacional) y/o niños de BPN (< 2500 g) iniciar lo antes posible, cuando sea prudente y cuando el niño sea capaz de tolerarlo : signos vitales estables, no bradicardia, no hipoxemia durante la manipulación del niño, no apnea primaria o en caso de estar presente que ésta esté controlada. La intervención canguro no remplaza las unidades de cuidado neonatal. Se considera como una intervención en salud complementaria en el cuidado del recién nacido. In order to characterize and understand what the KMCM is, it becomes necessary to define some basic items such as: i) what is the target population of the intervention, ii) what is the kangaroo position (KP), iii) how breast feeding-based feeding and nutrition is conceived and iv) what are the kangaroo discharge policies and ambulatory follow up . Based on the specification of these characteristic elements of the KMCM, a typical, basic or reference scenario is defined, which characterizes the elements and circumstances of implementation of the KMCM. This scenario contains the components considered fundamental in KMCM. Evidence-based researches are centered on identifying, recovering, critically analyzing and summarizing the evidence referring to questions emerging about each of these fundamental components. The specification of this typical scenario, also serves as checklist to avoid leaving aside any aspect or element considered important in the provision of the kangaroo care. Different variations of this typical scenario are also described. Observational data in nearly 7,000 “kangaroo” children, show that when they reach 2,500 grs. Nearly 95% of children have already rejected the kangaroo position (Kangaroo Foundation, unpublished data). Full term babies with weight adequate for gestational age may benefit from the kangaroo position for a limited duration during day time and for a limited number of days, as long as he tolerates being placed and maintained in skin-to-skin contact. There is evidence about the positive effect of the kangaroo position on breast feeding and on the mother-infant relationship. These effects are similar in direction, although not necessarily in magnitude, to that obtained in premature or low birth weight infants. This manual does not include the revision of the evidence and does not offer recommendations for the use of the KMCM in healthy full term babies, but rather focuses on premature or full term infants, with low birth weight.

33 Posición Canguro: “Sello” del MMC
Definición de referencia de la Posición Canguro (PC): Se posiciona al niño casi desnudo (excepto por gorro, pañal y medias) en estricta posición vertical sobre el tórax de la madre entre sus senos, en contacto directo con su piel, bajo su ropa, las 24 horas del día El soporte de tela ayuda a prevenir la obstrucción de la vía aérea del niño que condiciona el desarrollo de apneas obstructivas. El niño puede ser alimentado en cualquier momento aún estando en PC. Cualquier otra persona (p.e el padre), puede asumir el rol de la madre cargando al niño en PC. El proveedor del método debe dormir en posición semisentada (30°) La PC se mantiene hasta que el niño no tolere más la PC In Kangaroo position the child finds in his mother a permanent source of heat, kinetic  and tactile stimulation, while maintaining his air way open. The position stimulates and improves breast feeding. Moreover, the intimate and prolonged contact between mother and infant seeks to establish or reinforce a healthy biologic and affective bond that should exist between every newborn and his mother. The establishment of this bond is hampered by the child´s prematurity and illness, and in traditional medical department mother and preterm child are separate.

34 Variaciones de la Posición Canguro
Inicio de la PC: puede iniciarse desde minutos después del nacimiento hasta el egreso hospitalario, tan pronto como el niño prematuro haya sido estabilizado Continuidad de la posición: puede mantenerse durante las 24 horas del día o realizarse de forma intermitente (alternada con la incubadora) por minutos o algunas horas.   Duración de la Posición Canguro: puede ser monitoreada solamente durante la hospitalización; otros mantienen la PC después del alta hospitalaria. Es imposible hablar del Método Madre Canguro si nunca se pone al niño en Posición Canguro This intermittent mode is mostly employed in fragile but stable children, looking to strengthen the mother-infant bond and breast feeding. Other approaches involving parents in caring for their fragile newborns or efforts done to humanize neonatology, for example, by changing the micro-environment (e.g. carrying the baby, breast feeding, NIDCAP5, massage, etc.), but in which the baby is not held in kangaroo position, are not part of the range of variables identified as Kangaroo Mother Care Method.

35 Alimentación y Estrategia Nutricional Canguro
Se han identificado 3 diferentes períodos en la vida temprana del recién nacido prematuro: El período de transición: desde el nacimiento hasta el día 7 a 10. Corresponde a la adaptación a la vida extrauterina. Durante este período se utilizan nutrición parenteral y/o estrategias adaptativas para la nutrición enteral.   El período de “crecimiento estable”: desde el final del período de transición hasta completar el término. Este período es similar al crecimiento intrauterino que habría presentado el niño si no hubiera sido prematuro. Durante este período es apropiado usar nutrición enteral, predominantemente por vía oral. El período post-egreso: desde el término o alta hospitalaria hasta 1 año de edad corregida. The nutritional needs of the preterm infant compare to the needs of low birth weight are different. Newborns with the same birth weight may be full term babies with intra-uterine retardation, preterm infants with adequate weight or preterm infants with intra-uterine growth retardation. Additionally, within the ”preterm category” are included almost mature, near full term (e.g weeks) infants, moderately preterm infants and very preterm infants (23-28 gestational weeks , birth weight less than 1,000 g). The nutritional needs and capacity  to be fed can change also in cases of illnesses, concomitant conditions or complications during the transition period. The feeding strategies in the transition period (e.g., parenteral nutrition) are not considered in this manual. Similarly, the feeding strategies for the child in the post-discharge period, even though they are in continuity with the feeding process initiated during the period of stable growth, exceed the scope of this document. The mother´s milk is always supplemented with vitamins soluble in lipids. Mother milk may also be fortified or supplemented whenever it may be necessary. The use of human milk from a donor with similar gestational age, may be considered as long as it is collected, pasteurized and its benefits and nutritional value are preserved. Feeding is based on the infant’s own mother’s milk to take advantage of all benefits of non-modified human milk, especially its immunological properties, its balanced composition of essential nutrients and its safety profile with respect to the risk for enterocolitis. To start feeding, breast milk is administered at fixed intervals, to ensure minimum nutritional intake.

36 Alimentación y Estrategia Nutricional Canguro
Definición de referencia de la Alimentación y Estrategia Nutricional Canguro La estrategia de alimentación Canguro está pensada para niños durante el “período de crecimiento estable”. La fuente fundamental de nutrición es la leche materna que será usada cada vez que sea posible. La alimentación con leche materna se puede realizar por succión directa del seno o a través de la extracción de la leche misma.

37 Objetivos de la Alimentación Canguro/ Estrategia Nutricional
El objetivo es alcanzar idealmente a través de la lactancia materna exclusiva un peso similar al crecimiento normal que se habría tenido en la vida intrauterina - 15 g/Kg/día hasta completar el término Si no se logra el objetivo 1ero identifique y corrija condiciones que expliquen la ganancia de peso inadecuada Inicialmente complemente la lactancia materna con el 30% de las necesidades diarias Luego disminuya el complemento para alcanzar 40 semanas de lactancia materna exclusiva Variaciones de la Estrategia Nutricional Madre Canguro Aunque en algunos casos hay niños que se ponen en PC a pesar de que no se beneficien de la estrategia nutricional basada en leche materna. Esta intervención aún se considera una Intervención Canguro, dada la implementación de la posición canguro. it is necessary to identify and to correct conditions which may explain inadequate weight gain (e.g. anemia, infection, hypothermia, non-adherence to kangaroo position, etc.). Once the abnormal condition is corrected, growth must improve. If not, or if there was no any secondary cause for inadequate growth, breast feeding should be complemented with fortification of the mother’s milk and/or special formula for preterm, administered with dropper, cup or spoon not interfere with breast feeding. It is the case for infants unable to suck and swallow, or those receiving parenteral or gastroclisis -based nutrition, or in those cases where lactation is not a possible (adopted child kept in kangaroo position by the adopting parents, death of the mother, absolute or relative counter indications for breast milk).

38 Alta Temprana Un niño “Canguro” es elegible para cuidado canguro ambulatorio, independientemente de su peso o edad gestacional, cuando : Se logra la adaptación Canguro por parte de la madre y el niño incluyendo la Posición y la Nutrición Canguro El niño sea capaz de coordinar succión, deglución y respiración Algunos Programas Madre Canguro dan egreso a niños alimentados por la madre mediante sonda u otro método alternativo, después del entrenamiento de la misma La familia está dispuesta y es capaz de seguir protocolos, asesoramientos y políticas de seguimiento El niño y su familia tienen acceso a un seguimiento canguro sistemático, riguroso, y bien establecido. El niño se mantiene en posición canguro las 24 horas del hasta que rechace el método Kangaroo care Method is a continuous process. Both kangaroo position and feeding are initiated at some point during hospitalization; it is the beginning of the kangaroo adaptation and it continues for as long as the child requires it, independent of whether or not child is still in the hospital. In fact, when mother and child successfully adapt to the kangaroo position and feeding, there is little the hospital can offer that cannot be ensured in appropriate ambulatory environment. Therefore, in-hospital kangaroo adaptation can be seen as a preparation process for mother and child to have a timely, safe and successful discharge, and to be able to maintain the kangaroo care at home for as long as the child requires it. Likewise, family should be willing and able to strictly follow at home the recommendation, protocols and follow up policies, the Kangaroo Mother Program must guarantee close and timely follow up and be able to provide emergency care to the child in ambulatory care.

39 Seguimiento Ambulatorio de Alto Riesgo
Después del egreso, se realiza un control diario hasta que los niños alcanzan una ganancia de peso de 15 g/Kg/día Luego se realizan controles semanales hasta que se alcanza el término (40 semanas de edad gestacional y 2,500 g) El seguimiento incluye tratamiento preventivo como profilaxis antireflujo, apnea primaria y vitaminas Durante este seguimiento se realiza tamizaje oftalmológico, audiométrico y neurológico que incluye ecografía cerebral. El programa de seguimiento para los niños de alto riesgo, se realiza hasta que el niño complete un año de edad corregida Care provided in ambulatory is similar to care received in a “minimal -care neonatal unit” and could be called “minimal ambulatory neonatal care”. This care includes systematic prophylactic treatment such as anti-reflux and prophylaxis of primary apnea, and vitamins, etc. During this follow up, ophthalmologic and neurologic screening is conducted, including a brain echography. High-risk Follow up It is necessary to complete this final stage of the Kangaroo Mother Care Method with a description of the follow up program of the high-risk newborn, which is done at least until the child is one year old, corrected age. Often kangaroo children belong to the category of biologic high risk related to inadequate somatic growth and or for their problems in neuro psychomotor and sensory development. It is not t exactly kangaroo follow up as the child is no longer in kangaroo position but it is considered essential that appropriate follow up be carried out for high risk children, after completing the “normal” kangaroo follow up (40 weeks post conception age or 2,500 g, whichever happens later). It is for these reasons that the minimum activities that a follow up program for high risk children should perform on its premature or high birth weight babies are described in this manual.

40 Objetivos del MMC (1) Cuidado hospitalario y ambulatorio de forma más humana para los niños prematuros y/o de BPN Ofrecer cuidado especializado orientado en la calidad de supervivencia y la preservación de un adecuado desarrollo cerebral Apoyar el desarrollo del apego entre el niño y sus padres lo antes posible después del nacimiento A través del entrenamiento, empoderar a la madre o a los cuidadores, transfiriéndoles gradualmente las habilidades y responsabilidad del cuidado del niño, satisfaciendo sus necesidades físicas y emocionales. La detección temprana y el tratamiento de cualquier secuela inherente a la prematurez y el bajo peso se realizan durante este seguimiento de alto riesgo (mínimo hasta un año de edad corregida )

41 Objetivos del MMC (2) Mejorar el pronóstico de vida de los niños pre término y de BPN, fomentando un desarrollo físico, neurológico y psicosocial adecuado. Promover y proteger la lactancia materna. Contribuir a la disminución del abandono infantil y maltrato. El MMC se reconoce como una alternativa a la atención clínica, cuando hay una capacidad limitada de la tecnología disponible, que permite un uso racional de los recursos humanos y tecnológicos. The objectives of the Kangaroo Mother Care Method are to improve the conditions of the health of preterm and/or LBW infants in a global and comprehensive way and to humanize the care in neonatal units both for children and their families.

42 Diferentes enfoques para aplicar el MMC
Teniendo en cuenta las expectativas específicas y el nivel de desarrollo, el MMC puede ser utilizado para lograr a la vez 1 o varios objetivos. El MMC puede ser implementado en 3 formas diferentes: Como complemento a la incubadora – la forma más completa de utilizar el MMC logrando 2 objetivos : Optimizar el uso de los recursos humanos y tecnológicos Permitir al niño estar con su madre lo antes posible Este método es de especial interés para los países de medianos ingresos con accesos limitados a recursos económicos, humanos y tecnológicos, que están preocupados por las consecuencias de separar la madre de su hijo. It has the enormous advantage of having families actively participating in the baby´s care

43 Different approaches to implement the KMCM
2. As a substitute to an incubator : In countries with no incubators, the kangaroo method represents a survival possibility for LBW infants where there is no option different from the Kangaroo Mother Care Method for thermoregulation and nutrition of the low birth weight infant. This way to implement the Kangaroo Mother Care Method is a transitional alternative Developing countries, must insist on having adequate referral centers to receive these fragile children, aiming not just for their survival but for quality of these lives In countries with no incubators, the kangaroo method represents a survival possibility for LBW infants. We refer to poor countries, where there is no option different from the Kangaroo Mother Care Method for thermoregulation and nutrition of the low birth weight infant. We consider this way to implement the Kangaroo Mother Care Method as a transitional alternative. Developing countries, must insist on having adequate referral centers to receive these fragile children, aiming not just for their survival but for quality of these lives. This must be done in order to deliver, to their families and their countries, citizens who can contribute to its development. This modality of the Kangaroo Mother Care Method is a first stage to decrease neonatal and infant mortality. Kangaroo Mother Care Method does not treat illness; it is only implemented for caring for low birth weight and/or preterm infants, without pathologies or with mild immaturity. Other children, with associated pathologies will be at risk for death if they do not receive the specialized clinical care they may need.

44 Diferentes enfoques para aplicar el MMC
2. Como un sustituto de la incubadora: En los países sin incubadoras el método madre canguro representa una posibilidad de supervivencia para los niños con BPN, en donde no existe una opción distinta al MMC para lograr la termorregulación y la nutrición de los lactantes de bajo peso al nacer. Esta forma de implementar el MMC se considera como una alternativa de transición. Los países en vías de desarrollo, deben insistir en tener centros de referencia adecuados para recibir a estos niños frágiles, con el objetivo no sólo de ayudar con la sobrevida, sino también de asegurar la calidad de vida de estos niños. Modern neonatology is usually quite aggressive for the small newborn arriving to a high technology environment, where, in spite their vulnerability they must face their first stage of life overwhelmed by stress. NICUs are rooms where small patients experience frequent aggressive procedures, indiscriminate manipulation, interruption of sleep, unpleasant oral medication, and excessive light and noise. Immediate and long term effects of being placed under such stress vary. A 26 week-old infant must tolerate in average 400 painful procedures before going home and will not have slept more than 19 straight minutes during his hospitalization. The effects of such cumulative stress is probably critical for brain formation, since several studies show that some of the brain disorders of these children (in learning, behavior and motor problems) can be attributed to the stress and pain suffered in neonatal unit. The visiting schedule in most neonatal units does not depend on the mother´s or the family´s wishes, but rather on what the medical staff of the hospital decides. The child is nearly kidnapped in order to be cared for by ever rotating health care teams. The mother, however recognized as the child´s guardian, comes to be treated as a visitor and, in many cases physicians can even overlook the need to obtain her consent to order a procedure that may prove traumatic or even unnecessary.

45 3. Limitar la separación entre madre e hijo: donde no hay ninguna limitación para acceder a cuidado neonatal de alta tecnología. El MMC se introduce para promover la lactancia materna y el desarrollo de la unión madre e hijo. Los cambios que incluyen contacto madre-hijo temprano, posición canguro cuando se necesite, alojamiento conjunto, lactancia materna exclusiva y frecuente y contacto mínimo con los equipos de atención en salud, están siendo introducidos en salas de maternidad y salas neonatales al rededor del mundo. The visiting schedule in most neonatal units does not depend on the mother´s or the family´s wishes, but rather on what the medical staff of the hospital decides. The child is nearly kidnapped in order to be cared for by ever rotating health care teams. The mother, however recognized as the child´s guardian, comes to be treated as a visitor and, in many cases physicians can even overlook the need to obtain her consent to order a procedure that may prove traumatic or even unnecessary. Key steps proposed by the different initiatives that seek to humanize the care of low birth weight infants, promote breast feeding and the establishment of an early mother-infant bond, propose several changes in maternity wards around the world. These changes include early mother-infant contact, kangaroo position when needed, joint accommodation, exclusive and frequent breast feeding and minimal contact with rotating health care teams. Parents are a constant presence throughout any child´s life. Moreover, the family is one of the most influential factors for the children´s future; more so when there is a developmental disorder.

46 La Neonatología requiere un cambio en el paradigma que concierne el cuidado del niño de BPN, en referencia a la participación y el protagonismo de los padres en su cuidado. La introducción del Método Madre Canguro permite este cambio en la práctica, ya que las unidades deben no solo abrir sus puertas a los padres sino también ofrecer un enfoque holístico: la integración de los padres y transferencia de la responsabilidad del cuidado de su hijo durante su tratamiento.