Kangaroo Mother Care Method

Kangaroo Mother Care Method
< SOCIAL AND EMOTIONAL ASPECTS MODULE 6

SOCIAL AND EMOTIONAL ASPECTS OF THE KANGAROO MOTHER METHOD
GLOSSARY ‘Secure’ attachment: secure attachment refers to the specific and special bond that forms between the mother or the permanent substitute mother and the baby. The child experiences a sensation of safety, security and protection with this person. Contingent social responsiveness: refers to the mother´s interpretation of her child´s behavior as intention to communicate, her sensitivity towards his attempts to initiate interactions and her responsiveness to these behaviors. Emotions can be ‘contained´ in different ways; sometimes, the sole presence of the baby and his mother creates a scenario that ´contains´ emotion. Contained words, contained emotions: the emotional state of mothers and babies is implicit in words. This is why it becomes important to talk to babies and maintain a dialogue with mothers.

SOCIAL AND EMOTIONAL ASPECTS OF THE KANGAROO MOTHER METHOD (2)
GLOSSARY Unbearable impact: the baby´s capacity to deal with external reality is probably limited given his physical and emotional immaturity. Every physical or psychological impact will be unbearable in principle; the baby will need external help from the mother or caregiver to avoid feelings of helplessness and loneliness. Stimulus from other humans: it refers to any message or communicative act from the baby´s parents or caretakers. All of them can be perceived by the baby as positive or negative impact, making an imprint, a mnemonic link that will make up the emotional history of the baby. Mnemonic links: a mnemonic link is when an image and sounds are associated with words or phrases, which in turn are linked to their own meaning. They finally connect with a particular emotion circuit.

GLOSSARY ´Haunting´procedures: are all those stimuli received, which cause discomfort, pain, fear and instability in the baby. Due to his immaturity, he is unable to deal with these stimuli and perceives them as something that haunts and harasses him, generating stress. Premature mother: is the name given to the mother of a premature child. The experience of motherhood during pregnancy completes a natural cycle which is arrested by a physical or emotional event. It is essential that the mother also receives special care or support, in order for her to carry out this experience successfully. Mothering (maternage): a word generally used to describe the exercise of motherhood in a wider context. It entails the focused dedication and concern of the mother for the well-being of her baby. She needs support from her surroundings: the child´s father, a relative or the health care team.

GLOSSARY Fathering (paternage): a word generally used to describe the exercise of fatherhood in a wider context. Fathering refers to the role of the mother´s partner in child care. Fathering describes the permanent, physical and emotional presence of the father, needed by mother and child in order to strengthen the primary bond and to prepare the child´s confident entry into the world Feelings of fragmentation: from the psychoanalytical point of view, this is understood to be the primary state of the baby, where there are only sensations, the body has no precise boundaries in his mind or his experience. These boundaries will later be provided by the touch, voice, gaze and cradling of the mother or her permanent substitute. While these boundaries are established in the baby´s mind, any uncomfortable or unbearable experience will trigger in him a sensation of being torn in pieces that need to be put together. The containing function of the mother will serve this purpose.

GLOSSARY Cognitive reorganization: it refers to the task carried out by the mother during her child´s first days of life, where all her affection, ideas and fantasies adjust in order to modify her priorities and focus on her baby´s needs. J Just as the mother´s hormonal system must reorganize, her new emotions must also be refined and understood and her intellectual or reasoning functions complete a new process of accommodation and organization. ´The symbolic´: it refers to the process that must take place in adolescent fathers or mothers as they are no longer sons or a daughters, and become ´fathers´ or ´mothers´. A process of intellectual, emotional and mental maturation must take place in order for this parental function to have symbolic´ value and for parenthood to become relevant.

MATERNAL INFANT BONDING: AFFECTIVE BOND
Affective bond: The relationship of the mother’s early interest and commitment to her child. The infant and young child should experience a warm, intimate, and continuous relationship with his mother (or permanent mother substitute) in which both find satisfaction and enjoyment”. The affective bonding process promotes a permanent affective tie and has long term effects. This process begins at the time the pregnancy is planned, materializing and becoming real with the birth of the baby.

MATERNAL INFANT BONDING: AFFECTIVE BOND (2)
The affective bond or bonding is expressed in four dimensions in permanent interaction: biological, behavioral, affective and imaginary. Biological dimension: mother and baby are prepared to interact with each other from the moment of birth; there is a predictable pattern of sensory and neuroendocrine events that binds them. Behavioral dimension: real and observable interactions between mother and child. These interactions may be expressed through the following interrelated areas. Bodily: is the way mother and baby hold, manipulate and touch each other. Visual: it refers to the visual encounter of mother and child. Vocal: it refers to all communicative actions that translate the needs and wishes of both members of the dyad; it includes the newborn’s crying and other vocalizations and the words and verbal expressions of the mother. Social: it refers to the strategies used by the mother in order to encourage her baby to socially express his feelings and to stimulate him to interact with her.

Affective dimension: the mother and her child interact and communicate through their feelings. They must identify and figure out the emotion and feeling behind each other´s behavior. Imaginary dimension: the mother interacts with the baby in front of her but also with the unconscious image she has of her child. In some cases, she may relive unresolved conflicts from her past. For instance, since the baby looks so much like her father, in her mind the baby is also going to leave her, just like her father did when she was a child.

Klaus and Kennel (1986) point out how both mother and newborn are prepared to interact from the moment of birth. Mother child Mother child Feels the urge to touch and does so, in an orderly sequence. Seeks visual contact by placing herself facing the baby, within his visual field. Uses a high pitched voice. Feels the desire to nurse. Synchronizes her interactions to those of the baby Release of T and B lymphocytes and macrophages Presence of bacterial flora and microorganisms Mother´s characteristic scent Feels the desire to cradle and keep her baby warm. Imitates/mirrors her baby Feels the urge to touch and move towards the mother´s breast Seeks visual contact Cries to communicate Looks for breast and wants to suckle Synchronizes his interactions to those of his mother Promotes oxytocin, prolactin, and cholecystokinin. Baby´s characteristic scent. Baby sniffs the mother. Sensory awareness and state of alert for interaction. Imitates the mother.

If the mother infant dyad is not reunited after delivery, these interactions will take place at a later time, once mother and child are together, in intimacy, for a considerable period of time. There is a unique sensitive period where there is greater probability to develop attachment behaviors in the mother for her child. This period extends through the first month and requires parents to have early and prolonged contact with their newborn as well as emotional support from the health care staff. The quality of the affective bond, in a process of consolidation, must be assessed during kangaroo adaptation. This can be done through observation of daily interactions such as nursing and diaper change, or through direct questions to the mother and the family.

This quality is observed in the degree of mutual acceptance, the affective ‘tone’ of interactions and by the compliance with the laws of attachment (the observable expression of the bond): symmetry, synchrony, contingency and consistency. Synchrony: it refers to the mother’s behavioral adjustments to fit her baby’s rhythm; she learns his language and controls her own motor behavior. Symmetry: it is the way in which both members of the pair contribute, give, receive, maintain and initiate interactions. Contingency: defined as the mother’s accurate interpretation of her child’s signals (for example, crying) and adequately (starts breast feeding). Consistency: refers to the mother’s similar response to the same stimulus from her baby.

The following conditions pose a risk for a failure in mother-infant bonding: The mother looks tense, anxious, as if unhappy Her behavior show feelings of incompetence to hold, care for and breastfeed her child She can't communicate with her child She can't interpret the child’s signals or doesn’t seem to respond to them Is overly protective or negligent. In some cases, may even seem aggressive She doesn’t understand her baby’s temperament and assigns negative connotations to his behavior Doesn’t ask or seeks information about the baby’s clinical evolution or care needs The baby may in turn exhibit the following behaviors Is irritable and sleepy Averts his gaze Does not quiet down in his mother’s arms His feeding and sleeping cycles are disrupted; exhibits vomit and frequent colic Shows excessive, uncontrollable crying Exhibits gestures and behaviors of discomfort and stress (e.g. frowning, tongue thrust, clenched fists drawn to the chest, etc.)

THE EMOTIONAL RESPONSE OF PARENTS
The neuroscience perspective The relationship between a mother and her child is an expression of a communion, a delicate and vulnerable arrangement. Just as the baby requires of his mother’s presence, her attention and focus around him, the mother also needs her baby. For her physical and emotional reorganization, she needs the baby’s sound, his scent, his gaze.

THE EMOTIONAL RESPONSE OF PARENTS (2)
The neuroscience perspective The loving and inclusive presence of the mother’s partner is essential to reassure motherhood as an emotional experience that strengthens the nest that the baby requires in order to find protection and security. There is evidence to support the fact that even though babies cannot talk about it, they are fully aware of such emotionally stimulating contexts, or at least can react to them. The organs of perception and action for conscious communication with others are formed in the fetus body and brain and there is evidence to show that fetal expression and senses are activated before birth. During childhood we learn to manage our emotions, organizing our experiences and affecting our ability to do and to think. A precariously nestled, held and contained child develops a reactive stress response and biochemical patterns which are different from those of a well-contained child. Our emotional responses are not brought out by our biological urges, but rather by the patterns of emotional experiences with other people, deeply rooted in infancy. These patterns are not immutable; but much like habit, once established they are difficult to break.

PREMATURE MOTHERS – PREMATURE BABIES
Premature babies during their first minutes of life are separated from their mothers. The baby experiences mistreatment, loneliness, deprivation and insecurity that the "subconscious is populated". Affective bonds and safe attachment are sacrificed, particularly in countries where health care services restrict the mother’s presence in the Neonatal Wards. The approach of the Kangaroo Mother Program of promoting a close and intense relationship between mother and child through skin-to-skin contact is a ‘care’ intervention that also fosters an essential aspect for survival, such as this socio-emotional relationship, paired with the social development of the brain.

PREMATURE MOTHERS – PREMATURE BABIES (2)
Prematurity presents to us a mother who is psychologically fragile, in need of containment and support, with elements of her motherhood still ‘entangled’ in her fears related to pregnancy and delivery and unbearable feeling of guilt. We must be aware of the fact that parents, and particularly mothers, are grieving for the healthy full-term child they do not have. Parents must reconcile with this reality, with this baby, who is not ideal, but real. Each and every one of the aspects mentioned above can now be addressed with the baby in skin-to-skin contact with his mother. The social relationship is established, brain connections are established within this enabling environment, since emotions are contained, and they obtain a response that matches the baby’s need. The ‘Kangaroo’ Mother-Baby Method proposes a physical and a mental uterus to in which to nestle the baby, recuing in this loving nest, the child’s physical and emotional lives as well as the strength of affective bonds.

Every time the baby is to be placed in kangaroo position whether it is from the incubator to the caregiver’s chest or from one caregiver to another, the action (touching him, caressing him, massaging him, dressing him, prepare him for breastfeeding or for being picked up) must be accompanied by verbal language. Once in skin-to-skin contact, verbalizations must continue until a relaxed and secure position of the baby is achieved. The mother’s gaze, her heart beat and rhythmic breathing will guide the baby while he settles to the mother’s chest. The mother’s arms will provide the initial support for the adjustment of the baby’s body. Later, they will be replaced by a Lycra girdle to keep him in position, against to the mother’s body. Once the baby has been placed in position, following this small ritual that will become a habit for mother and baby, it is utterly important for the mother to get some rest. Just as her premature infant, the premature mother needs special care, since she also requires containment from her environment, in adult form in order for her to cope with the physical and emotional demands of this new experience.

The sooner the child adapts to his mother’s chest, the stronger the possibilities of attaining a strong bond between them. Nature and nurture join forces to offer the best opportunities to this emerging mother-child relationship. The strength of this bond will generate a basic feeling of security, which is required by the infant in his journey to adulthood. This bond it is important in order to face successive separation experiences in the future.

FEAR AND ANXIETY BEFORE EARLY DISCHARGE
The birth of a premature or low birth weight infant is an unexpected event for which no one is prepared. It causes an emotional crisis in the mother, understood as a temporary, non-pathological situation that makes the mother feel sad, distraught, guilty, with low self-esteem, impotent, isolated and misunderstood. It is necessary to identify any signs of crisis in the parents, hopefully from the time of birth, since these could have a negative effect on the development of the affective bond, the adaptation of the family and the development of the child. In case a member of the health care staff detects one such sign, the necessary emotional support must be given to the parents and their family so that it can be overcome it as soon as possible.

FEAR AND ANXIETY BEFORE EARLY DISCHARGE (2)
The Kangaroo Mother Program has implemented some measures to help parents overcome their crises. Hold individual or group support sessions where the mother, the father and other family members who give support to the parents may express their fears, anxieties, doubts and complaints about their child or the experience of having a premature or low birth weight baby. The aims of this intervention are : Removing guilt: premature birth is not caused by anything anyone has done or failed to do. It is the conjunction of several circumstances related to the mother’s health, environmental factors, and prenatal care, which made premature delivery difficult to control. Normalization: ambivalent feelings and lack of knowledge about the baby and his care are common in parents of premature babies. Expressing and sharing these, the sensation of failure is alleviated. Empowering: parents gain control and mastery over the lives of their children through access to information; they participate and take responsibility for their child and his care. Redefine: the role of the father and other family members as active participants in caring emotionally and physically for the mother and the child.

FEAR AND ANXIETY BEFORE EARLY DISCHARGE (3)
Clarify: the role of the KMP and its health care team as the parents’ guide and companion (coach) and not as their replacement in getting information, making decisions and caring for the needs of their child. Promote the creation of informal mother groups: Mothers are a source of mutual support and teaching and are better able to normalize their feelings and behavior. Inform parents about the abilities and limitations of their premature child: show them how to identify his signals and how to respond to them appropriately; help them see what they can do as parents to help their child. Promote, from the NICU, the early and constant participation of the parents, grandparents and siblings in the care of the premature infant and in keeping the health care staff informed about his health and development. Facilitate opportunities for them to see, touch, hold and interact with the baby to develop their sensitivity and ability to respond appropriately to the child. Be attentive and ready to identify and intervene in case other relatives are taking the place of parents as primary caregivers (it is the parents role to care for, protect, stimulate and bring the child to consultation). If this happens, parents will not develop their parental abilities and independence. If the crisis experienced by the parents or the family does not resolve easily, it could be the origin of destabilizing situations of the family dynamics and of the optimal development of the premature or low birth weight child.

EMOTIONAL RISK INDICATORS
High risk Indicators: these indicators determine the significant difficulty or impossibility of establishing the affective bond. Death of the mother Significant postpartum illness of the mother, where she must remain in the ICU more than three days. Postpartum depression (clinically diagnosed major depression). Severe neonatal illness (respiratory dysfunction, surgery, low gestational age, congenital malformations, intrauterine growth retardation, and ROP, among others). Mother with a record of mental illness or disorder (mental retardation, psychosis, among others). Suicide attempt during pregnancy. Grieving situation in the mother (separation from partner, death of a relative or a close or significant person, transfer to another city, physical or psychological neglect from the spouse). Alcoholism and/or drug abuse in the mother

EMOTIONAL RISK INDICATORS (2)
High risk Indicators: these indicators determine the significant difficulty or impossibility of establishing the affective bond. Pregnancy as product of incest or rape Inabilty to establish verbal and affective contact with the baby (even from pregnancy). Great fear of touching the baby. Excessive preoccupation about the baby’s health (fantasies of damage or illness) Evident rejection or discomfort towards the pregnancy or the child (the mother is incapable of perceiving her pregnancy and fetal movements and to construct a mental image of her baby; does not follow a prenatal care program or adopts behaviors to care for herself or her pregnancy). Inadequate responses to her child’s signals. Excessive preoccupation with her appearance following birth. Self-image disorders. Reiterative and recent miscarriage or abortions, Substance or alcohol abuse in one of the members of the couple.

Average risk: factors affecting establishing the bond Miscarriage or perinatal death immediately before the current birth. A weak support network, riddled with conflict (extended family or partner). Dissatisfaction with the baby’s gender or appearance, in one of the members of the couple. Abortion attempt during pregnancy. Significant financial distress. Disinterest in attending medical check-ups or in following care instructions received. Underage mother or over 35. Fertility disorders in one of the members of the couple. Hospitalization of mother or child longer than two weeks. Signs of extreme mental or physical exhaustion during ambulatory kangaroo care. Children with psychological or significant cognitive disorders. Birth of twins, triplets or others. Management issues with other school aged or adolescent children. Serious difficulties to nurse the baby. Prejudice or beliefs against skin-to-skin contact, exposure of body to others or any other resistance associated with the KMM. Antecedents of sexual or physical abuse in the mother. Twins separated by illness in one of them Antecedents in the mother of failure to bond

Low risk Unemployment or financial difficulties of father or mother Low or no schooling in the mother First time mother Threatened miscarriage Initial difficulties to accept the pregnancy Conflict or dissatisfaction in the couple’s relationship

THE ADOLESCENT MOTHER Adolescence is a critical period since it is a time for resolving psychological or physical-psychological situations. It is a period of conflict in which the adolescent seeks to defend himself through the use of defense mechanisms. Every psychological and biological change is experienced as a conflict, if it entails development, change or consolidation. The changes occurring in the body of the adolescent are directly related to the sex drive and the species mandate: reproduction. It is an organic process, expressed through hormonal pressures; the adolescent seems to have no choice but to experience the sexual act as an intense mandate. The young teenage girl standing before the misunderstanding of her search for adulthood as she goes directly into motherhood faces great bewilderment as she holds this very real infant in her arms. An adolescent pregnancy is in itself a high-risk pregnancy and is when the baby is born prematurely the resulting mental scenario is one of utter chaos. The presence of more organized and watchful minds is imperative; someone who can use special containment qualities to show motherhood and fatherhood models to these new parents, so they in turn can identify themselves with them and become parents for their babies

THE ADOLESCENT MOTHER (2)
The adolescent mother in KMCP requires the following sources of external support. Become acquainted with the psychological realities of adolescent pregnancy, delivery and postpartum. In experiencing her motherhood this adolescent must have someone who displays this quality of care. She needs to be helped to use language and creative actions as opportunities to engage in direct contact with the baby in her womb. The premature baby, once in the KMCP, becomes a real being for the teenage mother. The permanent presence of the baby’s grandmother, close to the new mother is necessary not as a mother substitute, but as an identification figure. The teenage mother must not be alone with her baby; she needs a special containment force. The health care service has an enormous responsibility in this task. The specialized care required by the adolescent mother is of a psychological nature, as she must go from thought to action in her motherly role. Promotion of breastfeeding must be intense. It is an opportunity to form and strengthen the mother-infant bond. This ‘communion’ will impose the ‘commitment’ needed for the deployment of motherhood. Every bit of information given to a premature mother, and particularly to an adolescent premature mother, must be relayed more intensely to her companion, and with special care to the mother. She is a process of emotional but also cognitive reorganization.

THE ADOLESCENT MOTHER (3)
The adolescent mother is in a situation of greater emotional vulnerability due to her own psychological, mental and emotional state, characteristic of adolescence. The professional specializing in emotional care, and aware of this psycho-emotional and social reality of teenage pregnancy, must first approach this mother using appropriate register. When questions arise as to whether the adolescents are capable of forming a family, the real and overwhelming answer is that it the familial and social spheres that must rise to help the adolescent create an adequate scenario for this reality. This shaping of a family or of the affective bonds that strengthen family relations may be placed at risk if the adolescent is stripped of his or her parental functions. Therefore, they require a social and familial motherhood or fatherhood that shelters the mother in her relationship with her infant and the father in his fatherly role.

NURSING, A BONDING EXPERIENCE
The experience of nursing a child follows such forceful plans that fundamental nature and nurture law becomes evident.

NURSING, A BONDING EXPERIENCE (2)
If all goes well, in the intimate communion of mother and child, the infant sends signals to his mother (e.g. he is hungry) she perceives this signal and responds accordingly (by offering the breast to her child). This way, the mother-infant dyad synchronizes their responses, stimulating each other as active participants of the interaction. Nursing is the only act which is exclusive of the mother towards her child which helps her reinforce her self-esteem and her maternal role. The mother’s state of mind and her intent are read by the baby, who in turn emits signals to provide feedback to the mother and make her feel as a good mother: nursing is not only offering milk, it is essentially nurturing the bonds of life. This maternal predisposition, present from pregnancy, is indicative of her ability or inability to nurse that child. The mother needs to be free from the stress resulting from the grief and possibly the guilt she feels from what she considers being a failure in her maternity. The baby’s permanence on her mother’s chest in skin-to-skin contact, and an environment that is stimulating and positive towards her motherly role, favors the connection necessary for nursing.

Arms to cradle: very small babies in the Kangaroo Mother Program must be placed in safe contact with the mother’s body. She will use her arms, to put her child in the desired position. Voice that rock: placing the baby, connecting with him. The entire breastfeeding experience must be paired with words that guide the baby. Breathing that sets the pace: the slow pace of the mother’s breathing, the exact distance at which the baby is held, cradled in his mother’s arms promotes stress management in the child. Encompassing gaze: the baby perceives and registers the way in which his mother’s gaze conveys her ‘intent’. Mother and child are the minimal loving, communicative unit that the human brain can metabolize.

Listening to decipher: each baby has a specific suction pattern and also a peculiar sounds, which arise from those heard while in the mother’s womb: the mother’s voice and register, for example. A non-anxious mother can recognize this tone and cadence in her baby and decipher those codes, filled with emotional significance; these signals are obviously sent by the baby in order to get a response, to construct a dialog of mutual understanding. Mind that contains: all this physical and emotional exercise of the mother as she cradles her baby in nursing, with each one of her senses connected in this idyllic act, generates a state of mind of emotional ‘commitment’ with her baby. Love that integrates: this emotion, of such a biological, social and cultural importance seems to be called upon to be the primordial nucleus of survival, procreation and the formation of the affective bond. It is a physiological need. This feeling is an organizer of the cognitive-emotional development of the infant and ensures what has been called the infallible glue to seal the affective bonds towards joy and mental growth. A story of loss and recovery of that loved object begins with that first nursing experience. If this takes place in a satisfactory manner, it develops adequate ability to relate and to separate. In ‘kangaroo’ mother-infant couples, the above task must be guided, closely followed by a health care team and a close and containing family, who has been sensitized to the emotional meanings of this first postnatal stage.

SUPPORT NETWORK: GRANDPARENTS AND SIBLINGS
Grandparents are vital since their life experience can contribute physical and emotional tools to the new parents so that in being ‘contained’ they can extend the essence of maternal and paternal care to their newborn. Grandparents not only relive their own past parenting experience, but have elements to exercise a role of care and support. This support is fundamental in the Neonatal Unit, their support is unrivaled. These grandparent ‘visits’, may be individual or in group. The methodology of group sessions consists of a first reception of the group of grandparents, where they can verbalize their impressions on this experience. The parents of the premature infants will receive the grandparents and introduce the babies. It may be the child’s first family reunion in the hospital. The health care staff will be available during the visit, to give instructions, answer questions or monitor the groups in case there is an inadequate, careless or clumsy behavior, or perhaps due to lack of awareness.

SUPPORT NETWORK: GRANDPARENTS AND SIBLINGS (2)
Once the visit is over, grandparents reunite with the group to comment on the experience and share it, reinforcing their own containing role. Intensive and frequent work is done with grandmothers who are mothers of adolescents in order to help them give their daughters or sons the special care needed by this new parent without the required maturity for their new role. Siblings, grandparents and other relatives who have been protagonists of stories told to the babies by the health care staff and product of the contained word and the construction of reality will have a real contact with their babies. There are two modalities of visits from grandparents and other relatives: a guided group visit and an individual visit; they will be conducted according to the circumstances and will show the flexibility of the health care team and the directives.

A special program will be followed every time there is a visit from the baby’s siblings. It may also be a guided group visit and at the discretion of the medical, nursing and psychology staff, may be individual. In both cases, without exception, the psychologist must identify anxieties and expectations in the babies’ siblings. An explanation of all medical care procedures to which the baby is subjected is immediate: a member of the nursing staff begins a conversation with them and teaches them how they will find their hospitalized baby brother or sister. A baby doll will be used to simulate the baby’s situation, the cables connected to his tiny body and the monitors. This initial contact and explanation diminishes their anxiety and familiarizes them with the Unit’s environment. Once hygiene regulations, required by the local authorities for the control of infection are fulfilled (hand washing, use of a robe and mask) siblings can go in the Unit, accompanied by a member of the health care staff, who will take them to their parents, who will be waiting for them to introduce them to their baby brother or sister. The psychologist and/or health care staff must encourage the baby’s siblings to talk to the baby, touch him, sing to him, ask him questions, in other words, to promote a family dialogue. This is part of sharing the experience as a family. It is expected for the siblings’ anxiety to diminish, forming a brotherly bond. The parents may also be better able to reach these children when they have been helped to build bridges to reach their newborn baby brother and sister, who up until now only existed as an imaginary one.

Once the visit to the different Neonatal Wards is over, the siblings are welcomed by the psychology staff. Through close dialogue, they relay their stories on what they saw, felt and understood; their perception of the baby. The psychologist will acknowledge their anxieties. All siblings will then be invited to make a picture, write a letter or something they want to leave for the baby, as a present. Mothers and fathers who are present as long as they can, sometimes 24 hours a day; grandparents and siblings as directly involved in the experience of receiving a new baby, fulfill a welcoming function, one of rooting and belonging. Once the infant is discharged from hospital, his arrival generates big changes in the life of the family, demanding important adaptation from every member of the family. A small child who up until now, reigned on the household, was expecting a brother or sister-playmate, of his same size while still being the center of attention and family interest. However, his baby brother or sister is born before time and the mother must be away for a few days and focus all her energy on the new member of the family. The child feels displaced, threatened, disconcerted, insecure, lonely and furious. This is known as sibling rivalry and could generate on the one hand, changes in his behavior and family and school performance, and on the other, alter the interaction that must exist between the small child, his parents and the premature baby.

If parents refer family problems due to any of the following behaviors of their child, listen to them and offer the necessary support and guidance: i) defiance or misbehavior, ii) constantly asks who will be caring for him and whether they still love him iii) begin to behave in immature ways or exhibits regressions iv) is aggressive towards the baby or wishes the baby to leave or return to the hospital v) is socially isolated or his school performance deteriorates. Parents feel disgusted, overwhelmed and guilty. The members of the KMP health care staff must not ignore or dismiss these complaints and feelings; on the contrary, they must understand them and take measures to help parents overcome them, through actions such as the following. If at all possible, siblings must be encouraged to visit their baby brothers and sisters in the NU in order to meet him and begin interacting with the premature infant. In KMP ambulatory follow up, when parents come for control visits with their babies, it is necessary to allow the visit of siblings. they may ask and get to know the setting and participate in routine care activities such as diaper change, massage and breastfeeding; If they’re older than six years, they can be allowed and accompanied in the experience of holding the baby in skin-to-skin contact with the infant, for short periods of time.

THE PREMATURE BABY STEREOTYPE AND THE VULNERABLE CHILD SYNDROME
In some cases mothers have preconceived and unjustified ideas about what a premature baby is and will be in the future. These ideas are known as the premature baby stereotype: i) being less developed, physically and intellectually ii) be less active and attentive iii) be weaker and sicker iv) be less sociable and personable v) be more difficult to interact with or to care for vi) be more irritable and hyperactive and in many cases the premature infant is perceived by his parents as non-normal. This stereotype may generate a less positive attitude of the family towards the child. All these lead to a vulnerable child syndrome. In this syndrome, parents perceive their child as someone in constant risk of presenting health, mental or developmental problems, in spite of being a perfectly healthy child, with adequate development. This behavior is a product of excessive parental anxiety and their difficulties to set limits.

THE PREMATURE BABY STEREOTYPE AND THE VULNERABLE CHILD SYNDROME (2)
When a premature child is perceived as a vulnerable being by his parents, he may handle frustration poorly (temper tantrums), exhibit a low self-esteem, suffer from depression in the future. Health care personnel must carefully observe the behavior of the parents, especially the mother, towards their premature child. If any of the following signs are detected, a vulnerable child syndrome must be suspected and the mother or the parents must be referred to psychological counseling. Constant medical consultations for unconfirmed illnesses or symptoms. Maintains breastfeeding as primary source of nutrition after a year. Does not provide adequate toys and stimulation for the child’s developmental level. The child is under stimulated and everything is done for him. Any illness is perceived as more severe than it really is. Perceives, describes and talks about her child in a less than positive way. Is constantly overly vigilant of her child to detect problems and shortcomings.

COGNITIVE AND PSYCHOMOTOR DEVELOPMENT
In humans, development is understood as the progression of vital states from fertilization to senescence; a series of changes that go from simple to complex and specialized. Human development is a complex process, generally divided in the following four dimensions: i) physical development ii) cognitive development iii) emotional development iv) social development Development may be assessed transversally, that is in a given point of time, or longitudinally, through successive evaluations carried out during a given period or even throughout the entire life. The premature and/or low birth weight may be associated with short and long term shortcomings in the child’s process of integral development. Some of these, at a cognitive level are difficulties with processing visual information, with expressive language.

COGNITIVE AND PSYCHOMOTOR DEVELOPMENT (2)
Some of these, at a cognitive level are difficulties with processing visual information, with expressive language, irritability and attention deficit disorders, with or without hyperactivity. In terms of the socio emotional sphere, there may be difficulties in establishing the mother-infant affective bond, and parents may exhibit problems in adapting to the premature baby and/or their own parental role. There are several tests to measure the development in children, globally or by areas. The KMCP uses the first version of the Griffiths Mental Development Scales for the cognitive and socio emotional evaluation of the child, complemented by the behavioral scale from the Bayley Scales.

THE GRIFFITHS MENTAL DEVELOPMENT SCALES
This test was created by John Griffiths in England, in 1954 and was revised and completed in 1964 by Ruth Griffiths. High correlation between the child’s neurodevelopment at one year, as measured by the Griffiths Mental Development Scales, and cognitive performance at four years (McCarthy) and eight years (WISC-R). The Griffiths Mental Development Scales was standardized in Colombian population in 1977 and 1985 by Vuori and Ortiz and has been used for over 20 years in KMCP. This test aims to measure the psychomotor and social development of children between the ages of zero to eight months. The scale is divided into five sub-scales, which have a balance number of items, with an equitable value of representation and difficulty . These sub-scales are: locomotor personal-social hearing and language eye-hand co-ordination performance and practical reasoning. After the age of three, an extra sub-scale is added known as practical reasoning.

THE GRIFFITHS MENTAL DEVELOPMENT SCALES (2)
Locomotor: measures general muscle tone and maturation of limbs, neck and head. It identifies weaknesses and specific defects and movement difficulties exhibited by the child. Personal-social: measures emotional disturbance and the process of autonomy development in the child. It also measures the child’s relationship with his family and his social environment. Hearing and language: Assesses the child’s hearing and his ability to understand and produce language. Eye-hand coordination: it measures the child’s ability to use his hands and eyes simultaneously. It also measures the deliberate manipulation and exploration of his environment; persistence, care and diligence with which he performs his actions. It also identifies possible visual and fine motor difficulties. Performance: this sub-scale measures planning and reasoning. It places the child before a (problem) situation which he must solve with some degree of coordination between his hands and eyes. It measures the particular style with which the child solves his problems and applies his skills (Griffiths, 1970).

The following aspects must be considered when administering the Griffiths Mental Development Scales: Children must not be ill, hungry or tired. The test must be conducted in a safe, well-lit, comfortable and pleasant for the child. Only the specified objects and safe and washable toys must be used. Getting information and precise results with small children may be difficult and it demands skill and sensitivity from the evaluator. The evaluator is required to have knowledge and expertise on child development and on the indicators corresponding to each age. If possible, he or she must know what processes are measured by the indicators. Before beginning to administer of the test, the evaluator must take the necessary time to establish rapport with the child and ensure his full cooperation. The evaluator must show genuine interest and friendliness to the child. His or her attitude must be adjusted to match the child’s needs and rhythm, but always observing, guiding and playing with him.

The administration of the test begins with those items corresponding to three months below the child’s current age and continues in progression until the child misses three consecutive items. Fluidity and flexibility are allowed in the administration procedures of the test. The evaluator may administer one sub-scale and then a different one, altering the order of administration of the themes and, in some cases, make three demonstrations. The mother’s her anxiety associated with the child’s performance or her wishes to help or correct the child must be controlled. The evaluator must be cautious in interpreting information given by her on her child’s achievements and explain clearly to her the procedure to be performed with the child. It has been suggested to administer the Griffiths Mental Development Scales at least twice a year: at six and twelve months of corrected age. This way, it will be possible to compare the child’s performance and establish a pattern for the premature child’s cognitive, psychomotor and socio emotional development.

Scoring the Griffiths Mental Development Scales One point is given for each item passed; to mark an item as passes, it must be observed in the child’s behavior. A few aspects may be reported by the parents, for example, whether the child enjoys bathing. All information is recorded in a pre-established format. All items passed in each sub-scale are added up and then, by adding the scores of all sub-scales, the total score is obtained. Scores from the scales allow the examiner to obtain a profile of the child and identify possible areas of difficulty or success.(Griffiths, 1970). Modifications made for premature infants After over 20 years of experience in administering this scale with premature infants, the Kangaroo Mother Program in Bogotá has successfully implemented some modifications. These are outlined below. The evaluation begins by administering items corresponding to an age six months below the child’s current age, since premature development is asymmetrical as compared with the full term infant. By beginning at this level, the aim is to find symmetry in development, the severity of any possible delays and imprecisions in estimation of corrected age (which is affected by imprecision inherent to calculation of gestational age).

Corrected age is used until the child is one year old. From the experience of the KMP experts, a mark labeled “R” has been added, in order to show that the child has not reached the expected level to pass a certain item, but is in the process of achieving it. The experience of the experts has lead them to make slight modifications on the original kit, to include common toys that measure the same processes as the original toys. The test is administered in the presence of the parents and immediate feedback is provided. The global results must be correlated with the results of optometry, audiology and neurology assessments conducted on the child during follow up. It would also be convenient to determine if results from hip x-rays showed hip dysplasia and the use of a Pavlic harness or Spica cast, which in turn could impair the child’s adequate mobility, the quality of stimulation and therefore his adequate gross motor performance.

Interpretation of the scale scores and development of the child’s profile The scale has ten items per month of age (two in each sub-scale) for a total of 60 items for the age of six months and 120 for the age of 12 months. The following results are therefore possible. General developmental age: it is obtained by dividing the total number of items passed by 10. Specific developmental age: it is obtained by dividing the total number of items passed in a specific sub-scale by 2. General developmental quotient: obtained by dividing the developmental age by the corrected age and multiplying that by 100. The importance of using the child’s exact corrected age (in months and decimal fractions of months) is emphasized. A developmental delay of up to a month is considered acceptable. That is, a raw score of 50 to 60 for six months and for 12 months. To develop the child’s profile the following actions are indicated. Elaboration of a bar graph with the raw scores of each sub-scale and the total score of the test to easily identify those areas in need of stimulation and those in which the child excels. The results found in the evaluation, the actions suggested and the date of the next control are recorded in the child’s medical history.

Feedback This part of the evaluation is based on the evaluator’s expertise, his skill and tact in communicating with the parents. When the administration and scoring of the evaluation are completed, the parents must be informed on his child’s situation as compared to his peers (age group). Immediately after, parents will be given the recommendations for actions to take in order to overcome the child’s difficulties: “he will be referred to physical therapy”. Parents will be taught exercises to be done at home to stimulate their child’s development. These exercises must be in accord to the child’s developmental level and with the parent’s cultural and financial resources.

Advantages of the Scale Flexible and easy to administer Easy to score, interpret; provides a developmental profile, both general and by sub-scale Equitable value of the different sub-scales Only test standardized in Colombia High correlation with neurologic screening test (INFANIB) No additional cost for the materials needed for its administration The testing situation experienced by the child, the mother and the evaluator may permit the assessment of more aspects of the child, his environment and his development than those measured by the Griffiths Scales. This way it is possible to determine, for example, if the mother is indeed the child’s primary caregiver and what the child’s temperament and frustration tolerance are like.

BEHAVIORAL DEVELOPMENT ASSESSMENT: BAYLEY SCALES OF INFANT DEVELOPMENT
The Bayley Scales of Infant Development is one of three scales to assess the development of children, created in 1935 by Nancy Bayley in the United States. Its aim is to describe the patterns and quality of behavior and temperament of children between one and 42 months, as they become evident through the mental and psychomotor evaluation of the child. A mark between one and five points is given by choosing the best descriptor of the child’s behavior during the session, based on direct observation of the child during the session, the qualitative judgments emitted by the evaluator and information given by the parents. Only those aspects corresponding to the child’s age are scored and especial care is exercised when the child’s mood or performance do not seem to represent his normal self. On a pre-established format, the score for each item is marked and then all scores of each sub-scale are added. Finally, all sub totals are added in order to obtain the total behavioral score. It allows obtaining a general profile and one for specific aspects. This helps to understand the child and his cognitive and psychomotor performance.

KANGAROO MOTHER METHOD AND COGNITIVE DEVELOPMENT
The KMCP is a modality of care that supports child development, where parents appropriate their child. This way, they can provide protection to the child’s brain, during a highly sensitive period of neurological development in the premature and/or low birth weight infant. This type of care promotes intellectual recovery, family environment and paternal involvement as well as the child’s and the entire family’s resilience. This is done by decreasing the mother-infant separation and the early onset of the KMP, the multi-sensory stimulation characteristic of the kangaroo position, breastfeeding, the emotional guidance and support of the health care staff to the parents and the active participation of the parents in child care. The KMC Method is most effective if it begins during the first three months of life or if administered groups of the most vulnerable newborns Child admitted in the ICU during the neonatal period, whose results from one of the evaluations administered using INFANIB are compatible to a transient neurological alteration, with less of 33 weeks of gestation and from the most disadvantaged socio-economic background.

CHILDREADING GUIDELINES
Parenting or childrearing guidelines are those attitudes and behaviors which parents take on in relation to health, nutrition, the importance of the physical and social environment and the learning opportunities for their children at home. These vary according to the culture and subculture, since each one differs on what is expected, allowed or forbidden. The first childrearing guidelines are the daily routines which are established by parents with their children from the days following the birth of the baby. The first such routines are associated with nursing and sleeping.

CHILDREADING GUIDELINES (2)
Benefits Obtained: The child is guided in his behavior (he knows what is expected of him and what he can in turn expect from his parents). The child grows in a sense of self-confidence; he develops as an imaginative, adaptable and independent being. Since social and personal behaviors are influenced, better relationships and family life. Establishing routines is a gradual process; they are not acquired with the first attempt, but rather through time, repetition and patience. Such guidelines must be appropriate to the child’s developmental level and maturity. Demands must not exceed what his age, capacities and circumstances allow. These guidelines are not synonymous of punishment or aggression; in fact they are quite the opposite. They propose, in a consistent manner, a relationship style and draw reasonable boundaries. These guidelines must be established by the parents, well informed and with the best of intentions. It is therefore important for parents and other caretakers to agree on them and be consistent.

Childrearing guidelines must follow these basic rules: i) be consistent: consequences must be firm and be the same every time the situation arises ii) be congruent: parents must abide by the same rules they are placing their children under iii) be contingent: positive or negative reinforcement must be given immediately after the behavior, so that the child may associate the reason and the consequence. As for how these guidelines are learned and maintained by: Modeling: directing the child towards the desired behavioral pattern by reinforcing the presence of a desired behavior and discouraging the undesirable behavior. Reinforcing: it refers to the consolidation of the behavioral pattern. It consists of rewarding or correcting the appearance/non-appearance of a selected behavior. Reinforcers must not only be material things: money, candy, toys, but rather of a social kind: hugs, kisses and congratulatory words. These are given during various daily situations such as feeding time, bathing time, play time or bed time.

Meal time A few days after his birth, it is advisable for the premature child to ingest specified volumes of food, given his reduced gastric capacity and his immature regulation of his sleep-hunger cycles. As the child matures and weight gain is satisfactory, the feeding pattern may be adjusted to the child’s demand (whenever he shows the wish-need to eat), and after the 40th week of gestational age, the child will usually eat every three to four hours. After this stage, the parents must remember: To establish and maintain a schedule to feed the child, allowing enough time to eat well. At one year of corrected age, meal times can be at the same time as the one for his parents and siblings. Meal times must be pleasant, quiet, stimulating and within an environment conducive to communication. Accompany the child through the meal and not show concern for crumbs or spills. Teach the child to chew, allowing him to eat or drink by himself, when appropriate (after six months). Prepare simple dishes with colorful foods which are easy to eat and served in small portions. Avoid using punishment when the child does not finish all his food or following him around the house trying to make him eat. Realize that the child must eat what he needs and not what his parents think he must eat. Recognize that a toddler, even one who was premature, may significantly vary the amount of food consumed from day to day. This is in no way a risk factor for malnutrition nor is it a sign of illness. Realize how normal it is for a child to prefer play to food, especially at the time his teeth are erupting or after his first year. This will soon pass.

Bed time Bed time, as a moment of temporary separation of parents and child, may be difficult for working parents who are away during the day. Bed time and those occasions when the child awakens during the night may be perceived by parents as a moment of togetherness. By doing so, parents alter the sleep routines of the child to fit their work schedules, which is inappropriate for the child’s well-being and feelings of security; he needs to establish a sleeping routine. The child needs to sleep enough time each day. The total amount of time, appropriate for a child is divided between night sleep and daytime naps. Lack or interruption of sleep alters the mood and behavior of the child and causes daytime drowsiness, decrease in attention, restlessness, irritability, excessive physical activity, impulsivity, diminished memory, excessive crying and temper-tantrums. This also affects the parents, which could be reflected in their interaction with their child.

Bed time Parents must implement the following practices: Carefully observe their child in order to identify any signs of tiredness or sleepiness. It is necessary to create an environment conducive to sleeping: quiet, with dim light, and to prepare the child for bed time: child in his own room, crib or bed, parents leave the room before the child falls asleep. Establish routines (rituals), such as bath time, putting the pajamas on, singing a song or reading a story. These help the child associate them to bed time, anticipating this moment as soon as these actions begin to happen. From the eight month on, it is necessary to establish a fixed time for bed. At the age of three months, the child must sleep in his own bed and only eventually awaken once, during the night to be fed. At six months of age, the baby must sleep through the night, without eating (7-8 hours). If possible, the baby must have his own room to sleep. Avoid excessively active games for the child around bed time, putting him down to sleep in the parents’ bed or rocking him to sleep. also, keep the baby from falling asleep with the breast in his mouth or eating. A night light may be left on the night table if this quiets the child. Every time the child cries during the night, the parents must check on him, if possible, without waking him. If he awakens and also cries, the parents must transmit a message of their presence and love; that they will be available if he needs them, but must not remain in the room (American Sleep Association, 2002).

CONSULTATION IN THE KANGAROO MOTHER PROGRAM
Consultation is open (in group), carried out by health care professionals who work as a team and manages multimodal communication which lead to good adherence of the parents to the program.

CONSULTATION IN THE KANGAROO MOTHER PROGRAM (2)
Group or open consultation Group consultation is so called because of two reasons: It gathers diverse patients in the same space and period of time, but giving individualized attention. Brings several pediatricians together, by placing them side by side, at the same examining table, in personal attention with each family.

This type of consultation is open and co-participative, where parents and health care staff care for the children together, in cooperation, in permanent communication and interaction with a single aim: the quality health of the premature and/or low birth weight infant. Open consultation is also what happens daily in the waiting room of the ambulatory KMCP. It includes the interaction, the communication and the teaching and learning process that takes places between the various actors (health care staff-parents-family). This type of consultation allows the relocation of parents as parents, to find a parental model to follow, locating sources of information and support to foster their own identification as parents and participants of the Kangaroo Mother Program.

Team work A working team is a group of people with complementary skills and experiences, committed to a common goal and a series of specific objectives regarding results. The team is ruled by the following principles: Complementarity: by having different professionals, roles and personalities in the team, each member contributes to a different aspect of the project. Coordination: under the guidance of a leader, the team works in an organized manner, towards a common goal for which all the members are responsible. Communication: as an open and binding process of all its members (both horizontally and vertically), in such a way as to coordinate actions and promote cohesion. Commitment: every member of the team is committed to give the best of him/her in order to carry forward the project that brought him/her to the team. Comprising a working team demands its members to clarify their roles, to develop a sense of unity and identity under a common purpose and be certain of the contribution expected from each one. In the KMP working as a team requires a change of attitudes, techniques and strategies in the health care personnel; this may generate resistance.

Team work Benefits of team work: More efficient use of resources Better problem resolution Increase in productivity and efficiency in providing health care services Increase in patient satisfaction Improved quality of care Better response to challenges posed by the competition Higher employee satisfaction (more significant work, a sense of unity and belonging)

The attitude of the Kangaroo Mother Program team The multidisciplinary staff who serves in a KMCP must have special professional and personal qualities, training in the Kangaroo Mother Method and above all, be completely convinced, believe in what he or she does and in the benefits for the survival and quality of life of the premature children and their families. Also, the health care staff who Works in this program, must be able to make adjustments and changes in the way he or she works and in his or her perception of the premature patient. Be able to team work in partnership with the parents in consultation. Develop empathy, active listening assertive communication and emotional support skills for the mother, the family and other members of the team. Improve his/her communication systems inside and outside of the KMCP. Allow the participation and collaboration of the whole family nucleus. Develop activities to maintain motivation and a positive attitude in all team members.

Other forms of communication Teaching and continuous support are offered to the families through the use of different complementary resources: informative fliers, videos, workshops, permanent dialog among the participants, a telephone consultation service, the use of the health care staff and other parents as models. Informative fliers available to caregivers are opportunities to remember essential advice for the optimal development of the method. The follow up card (carnet) is another valuable source of information on the child, the mother, the infant health history and evolution. Encourage the parents to read it and take it with them to any medical visit, in or outside the Kangaroo Mother Program. Workshops are essential to keep parents informed and to model care behavior for them. Tare also useful to help them shed any fears they may have to interact with their baby and care for him. The permanent telephone consultation service, whether during working hours or at night, offers the parents an ideal source of support and guidance in the care of their baby and their parenting skills, especially during the first days and months after discharge from the hospital.

This service must be run by professional staff (pediatricians, nurses) and promotes a permanent interaction between the KMP staff and the parents of a premature and/or low birth weight infant. These strategies may prove to be useful in the interaction with families. Always use the mother’s and the child’s name Have colorful mobiles and toys hanging above or placed next to the examining table; this will entertain older children, facilitating consultation. Bear in mind the hygiene and cleanliness protocols and put them into practice, in order to control the risks of crossed contamination and infection derived from the manipulation of these elements. Ask parents about instructions given, to check for comprehension. Use comprehensible language with all parents and relatives; if need be, use didactic elements and aids to foster understanding of your explanations. Listen to parents and other relatives and let them share their opinions and doubts; answer in a warm and honest manner, as privacy in handling information allows.

Adherence to the KMP Obtaining the adherence of the patients to the Program is absolutely necessary (although not enough) to ensure its effectiveness. The concept of adherence or compliance to the treatment refers to a great diversity of behaviors. They range from taking part in the treatment program and continue in it to developing health behaviors, avoiding risks behaviors, attending appointments with the different professionals, taking medications correctly and carrying out the therapeutic regime. It is more than merely keeping or not keeping medical appointments . Adherence to the Kangaroo Mother Program is measured as dichotomy: adherence/non-adherence.

Adherence to the KMP It depends on the following four determining factors. The doctor-patient relationship, which includes motivation, good communication, confidence in the doctor’s abilities and skills and the certainty of the benefits to be obtained. The patient’s characteristics and his environment, which involve his beliefs, his emotional surroundings, his role in society, his isolation or integration to a social network, his knowledge or beliefs about health issues, his socio-demographic characteristics, cultural and schooling level, the support received and his expectations of success. The characteristics of the illness include how chronic it is, the perceived severity and the presence of symptoms. The characteristics of the therapeutics, including duration of treatment, complexity and any adverse effects they may bring.

Adherence to the KMP Non-adherence is a personal choice, of multiple possible causes, that may have very negative consequences for the child and his future. Adherence may vary through time, according to the different factors mentioned before. It is equally necessary to establish methods to periodically evaluate adherence to the KMCP and try to find actions that help improve its indexes. The following are some of the actions suggested by Silva and Galeano : Offer effective information: give clear, sufficient and pertinent to the socio cultural level of the patient. Establish a pattern of assertive communication: both patient and health care professional must find an health-related common area, where together they can begin to reach an agreement as to the nature of the pathology or health condition and the most appropriate therapeutic approach. Promote and maintain an education which is consistent with the actions expressed and promoted during consultation Use any printed materials or pre-printed form that may help the patient and his family remember and follow any instructions given. Promote clarification and satisfaction, as it is possible, of the patient’s expectations upon entering the Program.

DELIVERING BAD NEWS TO PARENTS
Bad news is something with negative connotations and a negative impact for the future of the patient and/or his family. Its impact depends on a variety of factors: the seriousness and prognosis of the situation, the characteristics of the patient and his family, the characteristics of his home environment and above all, the culture and beliefs of the region where the family lives. Parents often forget where, how and when bad news were delivered to them, since it is a shock, a clash between their expectations and the real clinical situation of the moment. The medical team does not want to take hope away from the patient, and is afraid to cause pain to him or his family; is afraid to express his emotions and thus seem unprofessional or relive past experiences or fears. Patients, and particularly the parents of premature babies want the truth be told to them but they also want it to be told in a sensitive way, with a sense of human consideration, developing empathy. Empathy is an innate ability of people that allows them to “build bridges” towards universes which are different from their own, in order to imagine and feel the other person’s world, even before unfamiliar situations.

DELIVERING BAD NEWS TO PARENTS (2)
1. Preparing the setting - Where: the place meticulously chosen, must be equipped with chairs where both the professional and the adult family members can sit, with a certain degree of privacy and the least possible interference. It must be a place where news can be more easily assimilated and where the resulting reactions can be controlled. - How: it is necessary to do it through a personal interview, if at all possible. - To whom: when the patient is an adult, he must be the first to know; in our case, it must first be the mother or primary caregiver. - Who must deliver the news: even though the doctor is taking the responsibility for the diagnosis, it may be another member of the team who takes it upon himself to convey the information, and shoulder the reactions, since he or she may be closer to the family or have better empathy, as long as his personal preparedness and situation with respect to the caregiver or the family are better. 2. Asking how much the family knows What do they know about the state of the patient, his illness, what are their beliefs, and how do they interpret the current state of the patient? They must be confronted with the reality of the illness but taking into account their cultural characteristics in order to adjust the vocabulary and the way to deliver the news. The emotional content of words must also be gauged.

3. Finding out what and how much the caretaker wants to know about the situation and to what detail. There must be clarity on what the prognosis is and on the difference between what the doctor thinks he must say and what the caregiver really wants to know. Identify denial processes in the receptor of the news and define the management actions to be taken. 4. Sharing information: the patient and his doctor The caregiver has the right to accept or reject any possible treatment options, to express with emotion and to ask for or reject the information he receives. Presenting the information in small bits allows for a better understanding and assimilation is the recommended tactic. Ask was I clear? Did I explain myself? Is this clear for you? 5. Respond to the feelings of the caretaker and the family Do it with sensitivity and empathy and watch their reactions closely. 6. Discuss a care plan After observing the family’s ability to face and solve their problem or the situation before them. Offer a positive perspective and guide the caretaker or the family so they can face it. Help diminish the uncertainty, provide comprehensible explanations and establish a concerted treatment plan.

Delivering bad news requires good listening skills, information, empathy, assertiveness and warmth in the framework of patient-centered communication. Use short, sentences, easy to understand, assimilate and remember. Avoid the use of technical jargon. Avoid words with a heavy emotional load and, without hiding the truth, use words of similar meaning. Keep silent when it is convenient. It evokes the truth much more clearly than too many words. Avoid ascribing blame to the child, his family or another professional. Be attentive to non-verbal communication, as the patient’s expression of feelings, fears or wishes. Avoid offering false information or false hopes. Use messages with “always” as support for a possible bad news. For example, upon an unexpected death, convey messages such as “He was always in someone’s company”. The family’s or caregiver’s reaction may be very unpredictable. It is necessary for the health care professional to adapt with sensitivity, empathy and respect.

EDUCATIONAL SESSIONS WITH THE FAMILIES
The management of the premature baby with adequate technology in the ICUs and the KMCP currently allow babies to be out of critical condition sooner to go back to their families. The design of informative materials and the implementation of the educational sessions with the parents and other family members has demonstrated to be an effective means for offering support and learning on topics of general interest for the emotional management of the event and for adequate childrearing guidelines. The early arrival of the baby Infant stimulation, from 0 to 18 months Childrearing myths and beliefs Childrearing guidelines Managing temper tantrums Developmentally appropriate toys Bath time Meal time Organizing the children’s bed time

EDUCATIONAL SESSIONS WITH THE FAMILIES (2)
These activities (talks, workshops, informative leaflets, and videos) look to promote a process of growth and empowerment of the parents in caring for their fragile children. They are part of an educational process, so it is necessary to understand certain aspects that will facilitate their implementation and the efficiency in achieving their goals.

The following must be addressed during the process of adaptation to the KMP in the NICU and reinforced during adaptation to ambulatory follow up. What is the KMP? Basic needs of the premature and LBW infant Advantages and benefits of the KMP Activities of the KMM Childcare Breastfeeding the premature The mother’s need for support Potential problems Eligibility criteria for early discharge Personal hygiene Things you can do while carrying the baby in kangaroo position The experience in the Unit and the KMM at home Caring for the baby at home Support for the mother for continuing the KMM at home Managing family or community resistance Follow up after discharge Importance of adhering to the program The participation of the father How to sleep with the baby in kangaroo position

The concept of adult learning Adult learning is a process developed by the confrontation of the person with reality of his or her environment and the assimilation of the information it gives. The activities are educational in nature, so the learning outcomes will be the result of individual learning processes. Some participants will need more guidance than others. Principles of adult learning, such as dialog and reflection may be used to promote the knowledge and abilities that parents and families need to adequately use the KMM in caring for their children. External conditions (past experience, concerns, and child care) have an incidence in the learning processes and motivation of the participants, which affects their ability to respond in a productive way. Adults need to feel comfortable within their own learning and this is achieved through a favorable environment. The facilitator’s behavior, his teaching style and expectations towards the learning adults, has direct incidence on their motivation. Teacher-student interaction is a practice that promotes achievement and constitutes a powerful source of information for identifying what needs to be transmitted, what works and what must be improved. The material presented must be well organized and its structure easy to follow and assimilate. It must be susceptible to generate new knowledge. The possibility of receiving certification or recognition stimulates the learners. Define a system of certification, such as a diploma, which may be given out to those parents who have followed the educational process as recognition of their learning process in the care of their baby.

Sample talk 1: The Kangaroo Mother Method Objectives of the talk To present the main concepts of the KMC, its components, benefits and expected participation of caretakers and relatives of the baby during hospitalization and at home, after discharge. Begin the talk by asking the group of participants what they know about the care of premature and LBW infants. What do they do in their communities? If the KMM is not mentioned, ask what they have heard or what experience they may have on this method. If anyone knows it, ask him or her to share what he or she knows. Recommended questions to ask What is the KMM used for? Who can practice the KMM? How is the KMM practice? For how long is it practiced? What are the benefits for the mother and the baby? What are the challenges? What are the difficulties?

Make sure that the following aspects are covered during information exchange: The basic needs of the baby: warmth, food and love The meaning of KMM and KMP Benefits of the KMM Warmth: the mother provides warmth to her baby during day and night Food: breastfeeding is easy to do, so babies are fed more often and for longer periods of time Love: skin-to-skin contact promotes the formation of the affective bond between mother and child; babies cry less and are in permanent contact with their mothers Babies grow at a faster pace because they consume less energy in order to maintain body warmth Babies are discharged from the hospital at an earlier time, as long as KMM can be continued at home The KMM can be applied without increase in cost or use of technology Resistance to the KMM Mothers may get tired There is a strong feeling of faith in technology, which generates resistance to the KMM due to its simplicity Cultural barriers: the community or the family do not believe in the efficiency of the Method There is no monitoring of the KMM by the mothers or the staff

Components of the KMM Kangaroo Position Kangaroo nutrition or breastfeeding of the premature Early discharge with strict follow up in the KMP General care of the baby The baby is not bathed, but rather wiped with a cloth dipped in warm water to avoid loss of body heat. The baby is fed every two to three hours, by tube, cup or at the breast. The baby is weighed every day to monitor weight gain or loss. Make sure all the questions from the parents receive a clear and complete answer.

Sample talk 2: the baby’s early arrival Objectives of the talk To identify emotional issues in families faced with the birth of a premature baby To increase the confidence of the baby in handling the premature baby To combine the experience of parents and extended family members with the expertise of the health care team managing the baby Parents and relatives, gathered in a room that offers privacy, are invited to participate with their comments. Make some questions to the audience, as to identify the ideas they may have with respect to the premature and/or low birth weight baby. How did you imagine the baby would be? How many weeks was your baby at birth? What have you been told about premature and/or low birth weight babies? When fathers and mothers begin to answer those three questions, a process of exteriorizing and liberating their inner emotions in front of other parents, who are undergoing similar experiences, takes place. Feelings are shared and a community is created in experiencing this event. Through the mother’s and father’s comments, a call is made for the awareness of the emotional “rupture” between the imagined-expected baby and the one that arrived.

How many weeks was your baby at birth? The aim of asking this question is for parents to identify the differences between a premature and/or low birth weight infant. This shows them that every baby is particular and unique, with a life experience that is different from that of the next baby, in spite any similarities. What have you been told about premature and/or low birth weight babies? By asking this, a great number of questions arise about the management of each child (modality of nutrition and feeding, time in kangaroo position, management of oxygen, among others), which must be addresses by the health professional. Mothers, fathers, grandparents and other companions, make affirmations about the people’s perceptions with respect to premature babies; it is then that a complete description of premature babies is made. Some of the observable characteristics of premature babies are presented below, along with arguments that may be used to explain and address the parents’ anxiety.

Characteristics of the premature
Clarifying argument Fragile appearance. Is very thin, looks weak and delicate. It is due to the absence of subcutaneous fat, which begins to form after the sixth month. Is small. Babies grow fast in the last three months of pregnancy; they double the weight of the first six months, where they were basically formed. Has fine, shiny skin; is reddish, pink in color, is thin. The seemingly fine skin is quite strong; absence of subcutaneous fat gives it its delicate and transparent appearance, which will evolve to a more pink color as days go by, or take on a brown tonality if child receives parenteral nutrition. The extremities and muscles have a weak appearance, like a rag doll. Has no strength when moved. When lying down, takes the appearance of an open book. This is because the baby’s body is equipped for floating in amniotic fluid. By being in the air, his muscles do not have the strength to resist gravity yet. His muscle strength is just beginning. This will improve as he gets older. He spits up his food Only after six months of corrected age will the valve in his esophagus close firmly to keep his food from being spit up after eating. Gets cold easily There are no mature mechanisms to fight cold.The baby gets temperature from the surfaces in contact with his skin. He doesn’t move much. when he does his movements are rough, like shaking or startling. The baby interacts with his environment through his senses and reflexes. Senses develop from week 25, except for vision, which is developed at week 40. Primary reflexes of reaction to danger, like Moro, which produces these spasms and generalized movements, are present. Doesn’t cry much The baby usually makes several sounds, which are imperceptible through the incubator walls; they produce an audible squeal which becomes a cry as they mature. A strong cry is a sign of maturation

Usually has fine and more abundant body hair, called lanugo, Although he may also be born without it. This lanugo is transient and disappears with the passage of time. It is a protective hair. Has irregular sleep patterns At first, he sleeps is short periods. They become longer as he matures. It is common for the girl’s genitals to look odd, with the labia majora not covering the labia minora. In boys, the testicles have not descended in many cases into the scrotum. These organs generally mature slowly. the labia majora will cover the labia minora will close over. In boys, the testicles will descend into the scrotum. The premature child is easily startled by normal sounds. The premature child is capable of hearing. He is sensitive to the location of and frequency of sounds. A high intensity noise will trigger the Moro reflex, with disorganized movement. He quiets down to his mother’s voice or rhythmic sounds like the heart’s. The child may have semiliquid stools when fed with breast milk.. Breastmilk is metabolized very quickly in the child’s intestines. Stools are usually semi-liquid, yellow-green in color after the first five days. Vision is not well developed. The baby perceives light and identifies contrasts at his arm’s length.

Sample talk 3: managing the temper tantrum Parents are the main agents of their child socialization. They may foster or weaken certain behaviors by promoting them or punishing them, which is known as positive or negative reinforcement. Objectives of the talk Offer some behavior modification techniques to parents to use to manage the child’s behavior. Identify the different moments when temper tantrums is exhibited Capitalize on the experience and expertise of the health care team that manages the baby to modify inappropriate behavior of the parents Parents and relatives, gathered in the group consultation room are invited to participate with their comments. Ask a few questions to identify the ideas they may have about this topic. What is a tantrum? At some point in our lives, we have all felt nervous or restless when we see a child out of control, throwing himself on the floor, kicking and throwing his arms in the air while his parents do nothing. A tantrum is a learned aggressive behavior that prevents an adequate development in the child as well as his process of relating to adults and to other children. It is produced when the child is accidentally hit by an object, is scolded, or does not receive what he wants (a toy, for example) or does not get immediate attention.

What does a child do during a temper tantrum? Cries non-stop, louder and louder Is furious, kicks and throws his arms up Throws his head back and frequently arches his body Pretends to be a victim to get attention Throws himself on the floor, kicks and induces his own vomit What is the sobbing spasm? When the child is crying, he stops breathing, turns red or purple and in some cases may even lose consciousness; it is called “sobbing spasm” and is considered a type of tantrum. It is generally produced as a consequence of some kind of distress. What is the child looking for? A sharp cry is a natural and reflex response that allows the baby to inform the adult about some type of distress. The baby learns to obtain attention with this behavior. As he grows, more acceptable behaviors are expected to appear to express discomfort. He will use it every time he finds it hard to get something as long as adults reinforce his behavior and do not show him a more efficient way to obtain what he is looking for.

What do caretakers do during a tantrum? They become desperate, anxious and furious They do everything possible to appease the child (they hold him give him toys, offer him what he wants) Do not correct the child so the situation does not happen again Sometimes they may abuse the child (with words, blows or slaps) Often one of the parents tries to correct but the other one spoils him How can a tantrum be controlled? Bear the following aspect in mind A tantrum doesn’t last a long time A tantrum does not provoke death or serious consequences, but must be controlled Do not use aggressive measures during the tantrum (putting the child in the washing tub, hitting him or shaking him); that does not solve the problem As for the control of tantrums, the following are useful recommendations. Be the first to keep calm. React with indifference to the tantrum behavior, but with attention to the call. Maintain a firm position by not responding to the disorganized behavior and talk only when the child stops crying. If you withhold your attention from the tantrum, it will start to lose its power and begin to fade away. Once the child is calm, speak clearly and explain why he must not behave that way and how to behave appropriately. Only respond to the child’s need or explain the reasons for the negative, when the child is no longer throwing a temper tantrum; invite him to go on to another occupation. Each time it happens, you must act in the same manner: if you correct him once and then you don’t, instead of overcoming his tantrums, they will increase. When this behavior appears, everyone must act accordingly (ignore him), as his caretakers do. Following these recommendations does not mean you don’t love your child; on the contrary, you are contributing to his development.

SOCIAL WORK INTERVENTION IN THE KANGAROO MOTHER PROGRAM
The need for intervention from social work in the Kangaroo Mother Program is evident from the start, as the index of desertion of mothers shows the significance of the risk run by the premature children who did not show up for ambulatory follow up. The KMCP includes in its multidisciplinary team a social worker who had the task of developing strategies to achieve adherence of the parents and the family to the KMP, assess the familial and social conditions to detect possible risk factors and promote positive changes in managing these aspects. The role of the social worker in the Kangaroo Mother Program It looks to maximize and promote the individual and collective abilities and resources of the users; strengthening organizations, social structures and ways of life that reinforce social welfare. Its aim is the removal or reduction of inequities in access to health services. In this sense, social work must comply with a series of objectives, directly related to the general objectives of the health care institution of which it is a part, from the point of view of the social needs and problems.

SOCIAL WORK INTERVENTION IN THE KANGAROO MOTHER PROGRAM (2)
The following are the aims of social work: To identify the physical, social and emotional environment where the premature baby will live, detecting risk factors and promoting a favorable change for the well-being and healthy development of the child. To offer specialized care that facilitates the identification of family or social problems that may interfere with the child’s or the mother’s well-being; monitor those cases of ‘kangaroo’ babies who do not have optimal evolution and who have had any medical problems ruled out. Monitor attendance and adherence of children to the Program to avoid interruptions in high risk follow up, to one year of corrected age. Detect the possible cause of desertion of children from the KMP, to generate the necessary changes in the consultation dynamics. Establish an inter-institutional network of support to promote the specific protection of those families with more risk factors. Help families identify and use the support networks available to guarantee the care of mother and child. Intervene and support those families with conflictive situations, generated by changes in routines and the dynamics required by the KMP.

No follow up program can be successful if the social, economic and cultural variables that may affect the parents and families in applying the KMM are not considered. Environmental risks and the complex problems of each family must be approached through comprehensive strategies, where parents feel supported in spite of their difficulties, in search for short and long term solutions. The social worker can contribute to the KMC team the reading and analysis of socio economic variables which may have incidence on the care of the premature baby, at home. Before discharge, it is necessary to know the parents and the family group of the premature and/or low birth weight child very well who will attend ambulatory follow up. It is necessary to approach the mother as soon as possible to identify her characteristics, living conditions, family group, and available family support networks and to know whether the father is present. The purpose of identifying those families whose capacities to exercise maternal-paternal functions is doubtful, is to offer adequate guidance and assistance. They require extra and individualized intervention, looking to avoid or alleviate their functional deficit and to reach the best performance they are capable of in raising this child.

It is important to keep in mind that caring for a premature child demands effort, responsibility and commitment from the mother, the father or the caregivers. From the start, the father or a close relative of the mother must be involved, to give her support in the process of recovering self-confidence, to accompany her and to contribute to the home environment for the arrival of the ‘kangaroo’ baby to his home. Social workers, like other professionals from the Kangaroo Mother Program team, are called upon to support parents in this difficult job. They use instruments such as the social history, interviews with the mother, the father, a relative, and also the home visit During a home visit to the mother with a baby of 6 to 12 months of corrected age, administering an instrument such as THE HOME is very useful. It is an inventory of activities that helps assess the quality of the surroundings and its relationship with the cognitive development of the child. It is comprised of 45 items divided in six sub-scales, with yes/no answers. 18 questions are answered by a simple observation done during the visit, the other 27 need to be asked to parents or caregivers.

Sub-scales: Verbal and emotional response of the mother Avoidance of punishment and restrictions Organization of the temporal physical space Provision of appropriate play material Mother-child involvement Opportunities to vary stimulation By administering this instrument, the quality and quantity of social, emotional and cognitive support offered to the child by his familial environment is measured. Procedure for a home visit in a KMP General objectives Identify the social, familial and economic conditions of the patients of the Kangaroo Mother Program, by establishing alternative solutions that allow a prompt and effective intervention.

Specific objectives To identify and verify the socio economic and familial conditions of the patient in his home, in order to get to know his more immediate environment, his interpersonal relations, which may somehow affect the child’s health and satisfactory evolution. To identify social risk factors suspected to be infringing the child’s rights. To identify the socio economic situation of the child’s parents in order to find alternative solutions to the financial barriers to the opportune access to the appointments at IKMP. To establish actions and commitments with the family. Conducting the home visit The KMP multidisciplinary team will determine which specific cases require attention, according to detected specific situations in need of further information and a more direct approach, such as the ones below. Monitoring of families with risk factors and to the evolution of specific risks. Suspected physical abuse Children under the protection of the ICBF (Colombian Institute of family Welfare, by its acronym in Spanish) Children at risk for disabilities, where there is evidence of inadequate care from the family. The following steps must be taken. Identify the case requiring a home visit Financial situation Poor adherence to the treatment Social risk (negligence, abandonment, abuse)

Coordinate the home visit Record the activity in the patient’s clinical chart Record the observations and/or suggestions made on the visit Attach the home visit format Determine the risks, conduct the visit according to the area, due to security reasons Coordinate the logistics of the visit: date, time, transportation and elements needed for the job Conduct the home visit Record the identification date, such as: family composition living conditions financial situation medical issues psychological issues observations and/or suggestions Referral to inter-disciplinary consultation Monitoring of home visit cases

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