Can skin-to-skin contact save premature babies?
A few days ago I found myself at the podium of a large lecture hall in Uppsala, Sweden, a three-century-old, grand space with a great chandelier and the look of an opera house, but then the scene of a symposium at the academic medical center of Uppsala University.
We had just heard the sound of a primitive trumpet from the curtained balcony, then some eerily beautiful yodeling from a singer in traditional Swedish dress. She went on to sing a sweet, haunting folk song from the south of Sweden—one, I was later told, all Swedes know well—full of yearning for home, the place to live, and to die. Last, she sang the rock song, “Mother and Child Reunion,” with its lilting dual refrain, “only a motion” or “only a moment away.”
Both songs, but especially the second, were appropriate to the subject matter of the meeting. I soon gave the keynote address on the evolution of mother-infant relations, including infant care among the !Kung and other hunter-gatherers.
My research was not on preemies, but it dealt with the foundations of infant care, which evolved with mammals around 225 million years ago; this meant the first relationships, the first emotional attachments, and the first warmth, in both senses of the word.
Much later, during primate evolution, the mother-infant bond deepened and lengthened, and by 30 million years ago there was what I call the Catarrhine Mother-Infant Complex—catarrhine being a term for Old World monkeys, apes, and us. This includes an advanced placenta, singleton births, continuous physical contact for the first months at least, close proximity until weaning, nursing three times an hour, prompt response to distress, and weaning at around a fourth to a third of the age at sexual maturity.
But, you say, we humans don’t do this. Well, hunter-gatherers do. The generalizations I made after studying infancy among the !Kung, quite consistent with the picture among our primate ancestors, have held up in studies of other hunter-gatherer groups. Father care is greater in some, multiple-caregiving greater in others, but in all the infant’s experience is similar.
So Kangaroo Care builds on eons of experience. It involves skin-to-skin contact with mother or father, breast feeding from birth, and prompt response to distress-and to top it off, all of this is directed at premature infants as much or more than at normal newborns.
I’ll be frank. When I got this invitation the idea made me nervous. My own (limited) experience with neonatal intensive care left me feeling that preemies need not just medical but hypermedical care. These tiny creatures, some weighing less than two pounds, lived in high-tech incubators with nurses and doctors hovering like ghosts in sterile gowns. They had monitors on every organ and tubes in every pore.
Or so it seemed. And who could say that these exquisitely vulnerable mini-humans could survive on less? Far better this medical isolation than for a hand-size babe to be swept away by infection, hypothermia, suffocation, or internal bleeding. And surely the received wisdom could believed, no? By the end of these two days in Uppsala, I was ready to question all that and more.
South African/Swedish neonatologist Nils Bergman recounted the history of incubators. It seems they did not arise from research and were not tested against other methods in randomized controlled trials. They were introduced at a late-nineteenth-century World’s Fair and spread by their doctor-inventor’s marketing skill.
A digression: When I worked on the public TV series “Medicine at the Crossroads,” I met David Eddy, who had dropped out of surgical residency when he realized that many of the procedures he did had no research basis. He studied the problem, and he estimated that 80 percent of medical and surgical procedures are in this category. Let’s say he was half right. Does that make you nervous? It does me.
So Bergman’s incubator story was quite believable to me. But there are some things you don’t have to test; we know that if you take these little babies out of their incubators they get infected, they get cold, and they often die; that is, if you leave them on an ordinary cot and give them ordinary care.
But what if you take them out and place them, with only a diaper on, lying on the mothers’ bare chest? This was the radical idea that two physicians in Colombia hit upon in the late ‘70s, when the poverty of their hospital had them putting three preemies in one incubator, a recipe for infection if there ever was one. So they tried what they came to call Kangaroo Care, and it seemed to work.
Now, “seemed to work” is not a basis for changing medical practice, even if it was the basis for what you are already doing. It took years before randomized controlled trials began, pitting small amounts of skin-to-skin contact per day (with incubators the rest of the time) against 24/7 incubator care.
Several randomized trials have now shown that this is safe. The leaders in this field—pediatrician Nathalie Charpak, Gene Cranston Anderson, Susan Ludington, Bergman, and others-have done a lot of research, but much of it is not properly controlled or randomized. Epidemiologist Nancy Sloan’s research is, but more needs to be done.
Charpak believes that there is nothing natural in this method, although she advocates it strongly. It doesn’t feel right to her mothers, and certainly no hunter-gatherer society has succeeded in keeping small preemies alive. But under the right supervision, in a hospital environment, it is safe, even with babies who are still intubated to help them breathe.
Is it better? That is a different question. Clearly it is much better than nothing. Bergman’s research in rural Zimbabwe showed greatly increased survival with Kangaroo Care where you have no incubators, which unfortunately is the case in much of the developing world.
Randomized trials show that on a short-term basis it is effective in controlling the pain that the babies experience with the many heel-sticks and other procedures they are subjected to; that they sleep much more deeply and regularly in this position than in incubators; and that Kangaroo Care is better at keeping them warm. Research also suggests infants may grow more rapidly than in incubators.
What about infection? Surely the parent’s bare chest is a dirty environment compared to an incubator? Maybe, but many people touch the baby every day in incubator care. On the mother’s chest, both share the same microbes and the same antibodies on the skin.
If the mother is breast feeding—and research by Kerstin Hedberg Nyqvist and Eva-Lotta Funkquist, who invited me to the meeting, shows that it can be done by 29 weeks of gestational age—she will raise antibodies to all the microbes they are exposed to and transfer them to the baby; she may even transfer some skin-to-skin.
In any case growing evidence suggests that infection is no more common and may be less. Kangaroo Care appears also to reduce the length of hospital stays and the likelihood of lactation failure, and it increases various measures of parental confidence and psychological wellbeing.
Little wonder that it is spreading. Most countries of Western Europe now have high rates of usage of some skin-to-skin contact in their neonatal intensive care, and many American hospitals are coming along. The World Health Organization is including it in its programs to reduce perinatal mortality.
Bergman calls the doses of Kangaroo Care in these settings homeopathic—twenty minutes to three hours a day—and he is disappointed. I told him that having lived through the natural childbirth revolution, the breast-feeding revolution, and the baby-carrier revolution, I know these things take time, and they should. But they do happen.
Advocates of the method can speed up the process by mounting more randomized controlled trials, Kangaroo Care in various doses head-to-head against incubators, with lots of good measures. This will help the three young nurses I talked to, from a hospital in Salisbury, England, who by now are back in uniform trying to convince the pediatricians there to do more of this.
Personal stories abound. Monica Virchez Figueroa (photo above) presented a poster on her and her husband’s experience giving Kangaroo Care to their triplets, two girls and a boy, born at 29 weeks gestational age. They are now healthy seven-year-olds and their mother counsels others on how to do the same.
But probably the high point of the meeting was the last talk, by a father who mounted the stage with his ten-month-old daughter. She had weighed 1800 grams; her mother was incapacitated after a cesarean. The nurse-midwife came in and told the young man to take his shirt off. Then she put the baby on his chest. “If you need me,” she said, “press that red button.”
He was terrified, as I would have been. He didn’t sleep that night. But, gradually, he came to realize that he could do it. He was relieved when his wife could take turns with him, but by then he felt like a father who could care for his baby, not a stranger staring at a sickly-looking creature shut up in a glass box.
It may not be quite natural for humans, but it is natural for kangaroos, who are born extremely “premature” and complete gestation in the pouch. And even though we are not marsupials, it builds on what we did with newborns for millions of years as primates and then as human hunter-gatherers. That doesn’t make it right, but it’s about time we did the research on it—and I mean large, well-funded trials—so our daughters and grand-daughters will really know what the right thing is.