OUTPATIENT KANGAROO MOTHER CARE
WITH KANGAROO FOLLOW UP (up to term)
AND HIGH RISK FOLLOW UP (up to one year of corrected age)
MODULE 5

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• Follow 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.

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–swallowingbreathing 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.

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

• 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 semisitting 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.

• 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 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.

1. The gestational age at birth is determined according to the
Lubchenco’s classification tables.
2. The anthropometric parameters are assessed (weight, height, head perimeter)
3. A full clinical assessment is conducted (from head to toes)
4. Outpatient KMC adaptation is reinforced or initiated as necessary.
5. Brain sonography and ophthalmologic screenings are requested if possible and if necessary.
6. Routine and specific drugs are prescribed.
7. The need for oxygen is assessed.
8.
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
• 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

Cut-off point
(Standard deviation or Percentile)
< 2
> - 2 a < - 1
Denomination
Below length for age or stunting.
At risk for below length
Cut-off point
(Standard deviation or percentile)
< - 3
< - 2
> - 1 Adequatelength
> - 2 a < - 1
> - 1 a < - 1
Cut-off point
(Standard deviation or percentile)
< - 2
> - 2 a < 2
> 2
Denomination
Risk factor for neurodevelopment
Normal
Eventually Risk neurodevelopment factor for
Denomination
Very low weight for age or severe chronic malnutrition.
Low weight for age or chronic malnutrition.
At risk for low weight for age.
Adequate weight for age.

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)
– 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; 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 roomingin 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).
• 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%.

• 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

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 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, skinto-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 .

• Every high risk child must be followed until the first year of corrected age (counting from the moment he reaches 40 weeks) for adequate monitoring of somatic growth and early detection of audition, ophthalmological, and neurological sequel.
• Physical examination
• Monitoring somatic growth
• Complementary feeding:
– The best way to feed a child from birth to at least 4 months of age is to breastfeed exclusively, and ideally until 6 months.
– Mothers should breastfeed children at this age as often as the child wants, day and night. This will be at least 8 times in 24 hours in the case of preterm or
LBW infant and sometimes 12 times in 24 hours. Preterm or LBW infants do not request feedings, they need to be woken up.

• Complementary feeding:
– At some time between the ages of 4 and 6 months, some children begin to need foods in addition to breast milk. These foods are often called complementary or weaning foods because they complement breast milk.
– By 6 months of age, all children should receive thick, nutritious, complementary foods.
– From age 6 months up to 12 months, gradually increase the amount of complementary foods given.
– If the child is not breastfed, give complementary foods 5 times daily.

• Abnormal neuromotor signs in the first year of life
• Various abnormal neuromotor signs observed at the end of the second year and considered a manifestation of mild brain damage
• Signs:
– Imbalance of axial tone,
– Phasic reflex stretching (up to 6 months of life)
– Ridging of the squamous suture
– Cortical thumb
The functional consequences of perinatal brain damage may fluctuate throughout childhood. Some may not be identified until later in life or even early adult life.

• Tracing the effects of perinatal damage through childhood:
• Deficits that persist throughout the first year of life indicate neurological damage, even if they are subtle and without apparent functional neuromotor consequences.
• These early neuromotor deficits are sometimes described as transient. It is probable that they do not just disappear; rather, they are too subtle to be elicited in the more robust 2 to 4 year old child.
• However, with correct examination techniques, several persisting signs, such as imbalance of axial tone, phasic response to dorsiflexion and squamous ridge can be found in affected children.

The INFANIB screening or Infant neurological battery test
• The Infant neurological international battery, INFANIB, is a diagnostic/screening method used to identify children with neuromotor anomalies during the first year of life.
• INFANIB is used in children older than 40 weeks and is useful for conducting a
“diagnostic screening” of the systematic monitoring of the preterm and LBW population of the Kangaroo Mother Program.
• Evaluates global motor development, tone and archaic reflexes, allowing clinicians to detect multiple neurological alterations such as hypotonia, hypertonia, dystonia, diplegie, and hemiparesis, among others.

Factors Items
Factor I
Spasticity
Hands held open or closed
Tonic labyrinthine in supine
Factor II
Head and trunk
Body derotative
All fours
Tonic labyrinthine in prone
Asymmetric tonic neck reflex
Pulled sitting to
Sitting
Factor III
Vestibular
Factor IV
Legs
Body rotative
Positive support réflex
Sideways parachute
Dorsiflexion of the foot
Factor V
French angles
Abductor’s angle
Popliteal angle
Forward parachute
BAckwards parachute
Foot grasp Standing
Heel-to-ear Scarf sign

The INFANIB screening or Infant neurological battery test
• This test makes possible to integrate results in relation to the children’s neurological evolution, from onset to later findings
• It is highly specific and sensitive
• Facilitates early detection of neurological disorders
• Offers the possibility of taking timely and adequate therapeutic action to decrease the emergence of inadequate patterns
The necessary elements to conduct the exam are:
– A stretcher with a padded mat, the child must be naked
– The child’s corrected age at three, six, nine, and twelve months is used
– The exam must not be performed if the child exhibits irritability, fever, is ill, hungry, sleepy or tired; this could interfere with the results.

The INFANIB screening or Infant neurological battery test
Recommendations:
• Tone anomalies (hypotonia, hypertonia, and dystonia) at 40 weeks, abnormal brain ultrasound during the neonatal period: intensive physical therapy and careful neurological follow up during the first year with a nuclear magnetic resonance imaging (MRI).
• CAT scan or MRI are only requested if hydrocephaly is suspected or to document another lesion.
• INFANIB is repeatedly administered throughout the year to assess the impact of physical and other therapies, encouraging the participation of the parents.
• When INFANIB results are normal, therapies are suspended.

BCG
Vaccines and booster shots
Polio vaccine
Hepatitis B
DPT
Haemophilus influenzae type b (Hib)
Age Comments
Newborn and children over
2000g.
If under 2000g at one month of life, delay until two months of chronological age and administer with the first dose of
DPT-Polio.
Two, four and six months of chronological age, with booster shots at 18 months, five years and then every 10 years.
Due to the theoretical risk of transmission to other infants, the vaccine should not be given to preterm infants until they are discharged from hospital. Inactivated polio vaccine (IPV) may be used for long term hospitalized infants.
It is also recommended if there is group consultation in the KMC.
Newborn, two, four and six months of age.
Two, four and six months of age, with a tetanus booster shot every ten years.
Diphtheria-tetanus-pertussis
Following scientific evidence, it is emphatically recommended to administer it with acellular pertussis component (DPaT), due to the high neurological risk of apnea, hypothermia-induced seizures, and poor tolerance to vaccines.
Two, four and six months of age.
Booster shot at 12 months or at 18 months with pentavalent vaccine.

Triple viral vaccine
(MMR)
One year chronological age, a booster shot at five years.
Yelllow fever
Influenza
Pneumococcal vaccine
Other vaccines optional
One year of age, a booster every ten years
Beginning at six months (two doses on the first immunization), booster shots every year.
Two, four and six months (booster between one year and 18 months)
Mumps, measles and rubella
The seasonal vaccine is administered.
It is advised that every family member to be in contact with the child is immunized.
Any additional immunization will depend on the physician’s judgment
(rotavirus, measles, hepatitis A).
The extended Immunization Program (EPI) depends on each country and needs to be adapted according to local political guidelines.

Periodicity corrected age according
1.5 months
3 months to
Aims of consultation
If oxygen-dependent upon admittance to outpatient KMP
Weekly oxymetry and pediatrics control twice a month until complete oxygen weaning.
Anthropometry (growth assessment: weight, length, head circumference)
Physical exam
Exclusive breast feeding (EBF), if possible
Nutrition recommendations, at-home stimulation
Check immunization card
Deliver infant stimulation and information leaflet
Ferrous sulfate and metoclopramide, if gastro esophageal reflux is present
Special medication (Palivizumab if there is an outbreak of syncytial respiratory virus –SRV- along with administration criteria)
Anthropometry
Physical exam
EBF, if possible
Standardized neurological exam (for instance, INFANIB 3m)
Ferrous sulphate and metoclopramide, if gastro esophageal reflux is present
Clinical exam; hip dysplasia and optometry screening
Information leaflet with exercises
Exercises
Refer to physical, occupational or speech therapy as needed
Check immunization card

4.5 months
6 months
7.5 months
Anthropometry
EBF, if possible; if adequate growth is not achieved and socio-economic condition are depressed, advise on supplementary nutrition.
Physical examination
Review hip dysplasia screening
Optometry consultation
Hearing screening: between three and six months of corrected age, with referral to speech therapy if needed. If screening was performed in the NICU or at 40 weeks, only those children with poor results will be screened again.
Recommendations for stimulation.
Special recommendations
Ferrous sulphate, if reflux symptoms persist, continue administering metoclopramide
Check immunization card
Anthropometry
Physical exam
Standardized neurological exam (for instance, INFANIB 6m)
Test of psychomotor development test, preferably adapted to the country (in Colombia, the Griffiths and part of the Bayley are used)
Recommendations for supplementary nutrition
Recommendations for exercises
Refer to physical, occupational or speech therapy as needed
Following the results of INFANIB, refer for a nuclear magnetic resonance, as needed
Check immunization card
Anthropometry
Physical exam
Revise diet
Check for improvement in abnormal or transient findings in neurological examby the pediatrician or in psychomotor development by the psychologist
Refer to therapy as needed or continue with home exercise plan
Ferrous sulphate
Check immunization card

Nine months
Ten months
Twelve months
Anthropometry
Physical exam
Standardized neurological exam (for instance, INFANIB 9m)
Recommendations for supplementary nutrition
Recommendations for exercises
Therapy or exercises as needed
Ferrous sulphate
Check immunization card
Anthropometry
Physical exam
Recommendations for supplementary nutrition
Ferrous sulphate
Check immunization card
Anthropometry
Diet
Physical exam
Standardized neurological exam (for instance, INFANIB 9m)
Recommendations for diet
Test of psychomotor development test, preferably adapted to the country (in Colombia, the Griffiths and part of the Bayley are used)
Control at twelve months if independent walking is not developed
Check immunization card
Eighteen months
Anthropometry
Diet
Physical exam
Walking and language assessment
Check immunization card