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Abstract of dissertation entitled

“Evidence-Based Guideline on Kangaroo Mother Care for Mothers with Low

Birth Weight Infants”

Submitted by

Tang Hiu Tung

For the degree of Master of Nursing

at the University of Hong Kong

In June 2016

Kangaroo mother care (KMC) was a simple and safe technique including skin-to-skin

contact between the infants and mothers’ breasts, exclusive and nearly exclusive

breastfeeding and early discharge from the health care facility. There were numerous benefits

associated with KMC for the low birth weight (LBW) infants, including short and long term

health benefits to the infants and mothers and promote breastfeeding. In Hong Kong the

breastfeeding initiation and exclusive breastfeeding rates in 2013 at discharge from neonatal

units were 51.9% and 3.6%, respectively. It was far below the recommendations of World

Health Organization.

Therefore a systemic review and critical appraisal of the literature was conducted to

explore the effectiveness of KMC in comparison to conventional neonatal care in increasing

breastfeeding initiation rate and exclusivity for the mothers with LBW infants. There were

seven randomized controlled trials (RCTs) included in the review. After the critical appraisal

by using methodology checklist for RCTs developed by the Scottish Intercollegiate

Guidelines Network, KMC was an effective strategy to increase breastfeeding initiation rate

and exclusivity for mothers with LBW infants. Then the implementation potential, including

transferability, feasibility, and cost-benefit ratio, of the proposed KMC guideline was

considered and an evidence-based ‘Keep in Touch’ guideline on KMC for mothers with LBW

infants with nine recommendations was developed. Moreover the implementation and

evaluation plan for the proposed KMC innovation was discussed in details.

In conclusion, the ‘Keep in Touch’ KMC guideline could promote breastfeeding for

the mothers with LBW infants and providing higher quality of care for them. In the future,

other health benefits of KMC for the LBW infants and their mothers could be further

explored.

Evidence-Based Guideline on Kangaroo Mother Care for Mothers with Low

Birth Weight Infants

by

Tang Hiu Tung

R.N., B. Nurs, H.K.U.

A dissertation submitted in partial fulfilment of the requirements for the Degree of

Master of Nursing at the University of Hong Kong

June 2016

KEEP IN TOUCH FOR MOTHERS WITH LOW BIRTH WEIGHT INFANTS i

Declaration

I declare that the dissertation represents my own work, except where due

acknowledgement is made, and that it has not been previously included in a thesis, dissertation or

report submitted to this University or to any other institution for a degree, diploma or other

qualifications.

Signed……………………………………………

Tang Hiu Tung

KEEP IN TOUCH FOR MOTHERS WITH LOW BIRTH WEIGHT INFANTS ii

Acknowledgements

I would like to thank my supervisor, Ms. Elizabeth Hui Choi Wai Hing, who provided

expert advice, guidnace and support for my dissertation. Also I would like to show my

gratefulness to all teaching and admistrative staff of the School of Nursing at the Univeristy

of Hong Kong, for their support and encouragement.

Moreover I would like to express my thankfulness to my Nurse Consultant (Neonatal

Care), Ms Maria Chan Kam Ming, for her recognition, driving force, support and careon.

Lastly, I would express my gratitude to my parents, Mr. Tang Kwong and Ms Wong

Pui Fun, and my hunsband, Mr. Stanley Ng Wing Shue, for their endless love and care. They

are my life’s greateast blessing.

KEEP IN TOUCH FOR MOTHERS WITH LOW BIRTH WEIGHT INFANTS iii

Table of Contents

Contents Page

Declaration �� i

Acknowledgements �� Ii

Table of Contents �� iii

List of Appendices �� v

List of Abbreviations and Symbols �� vii

Chapter 1: Introduction

1.1 Background �� 1

1.2 Affirming the Need �� 3

1.3 Objectives and Significance �� 7

1.4 Significance�� 7

1.5 Conclusion �� 8

Chapter 2: Critical Appraisal

2.1 Search Strategies �� 9

2.2 Appraisal Strategies �� 10

2.3 Search Results �� 10

2.4 Table of Evidence �� 11

2.5 Summary of the Appraisal Results �� 15

2.6 Summary and Synthesis �� 20


Chapter 3: Implementation Potential and Clinical Guideline

3.1 Implementation Potential �� 25

3.2 Evidence-Based Practice Guideline �� 37

KEEP IN TOUCH FOR MOTHERS WITH LOW BIRTH WEIGHT INFANTS iv

Contents Page


Chapter 4: Implementation Plan

4.1 Communication Plan �� 38

4.2 Pilot plan �� 42

4.3 Implementation Plan �� 44

4.4 Evaluation Plan �� 45

4.5 Basis for Implementation �� 51


Appendices �� 52

References �� 115

KEEP IN TOUCH FOR MOTHER WITH LOW BIRTH WEIGHT INFANTS v

List of Appendices

Appendices Page

Appendix A – Scottish Intercollegiate Guidelines Network Methodology Checklist for

Controlled Trials �� 52

Appendix B – Scottish Intercollegiate Guidelines Network Grading System 1999-2012

�� 54

Appendix C – Preferred Reporting Items for Systematic reviews and Meta-Analysis

Search Strategies Flowchart �� 55

Appendix D – Table of Evidence of the Included Studies �� 56

Appendix E – Quality Assessment of the Included Studies �� 60

Appendix F – Effect Sizes on Breastfeeding Rate and Exclusivity of the Included

Studies �� 62

Appendix G – Diversity of Intervention of the Included Studies �� 63

Appendix H – Estimated Set-up Cost for the First Year for the Implementation of

Kangaroo Mother Care Guideline �� 65

Appendix I – Estimated Running Cost for the Subsequent Year for the Implementation

of Kangaroo Mother Care Guideline �� 69

Appendix J – Cost-benefit Ratio for the Implementation of Kangaroo Mother Care

Guideline �� 73

Appendix K – Grades of Recommendations of Scottish Intercollegiate Guidelines

Network �� 74

Appendix L – ‘Keep in Touch’ Guideline for Kangaroo Mother Care �� 75

Appendix M – Project Calendar�� 88

Appendix N – Communication Plan �� 89

KEEP IN TOUCH FOR MOTHER WITH LOW BIRTH WEIGHT INFANTS vi

Appendices Page

Appendix O – Checklist for Eligibility for Kangaroo Mother Care �� 92

Appendix P – Evaluation Plan �� 93

Appendix Q –Evaluation Form for Didactic Education Program �� 94

Appendix R – Feeding Mode Data Collection Form �� 97

Appendix S – Implementation Record of ‘Keep in Touch’ Guideline �� 98

Appendix T – Kangaroo Mother Care Diary �� 99

Appendix U – Feeding Diary �� 102

Appendix V – Survey on Acceptability of Kangaroo Mother Care�� 105

Appendix W – Survey on Attitudes of Nurses Towards Kangaroo Mother Care�� 108

Appendix X – Survey on Knowledge of Kangaroo Mother Care�� 111

Appendix Y – Clinical Assessment Form for Implementing Kangaroo Mother Care�� 113

KEEP IN TOUCH FOR MOTHER WITH LOW BIRTH WEIGHT INFANTS vii

List of Abbreviations and Symbols

Abbreviations

AAP American Academy of Pediatrics

APN Advanced Practice Nurse

CMT Clinical Management Team

CNC Conventional neonatal care

COS Chief of Service

DOM Department Operation Manager

EBM Expressed breast milk

Email Electronic mail

HA Hospital Authority

HK Hong Kong

ICT Infection Control Team

LBW Low birth weight

KMC Kangaroo mother care

MeSH Medical subject heading

NC Nurse Consultant

NICU Neonatal intensive care unit

P&AM Department of Paediatrics and Adolescent Medicine

PCA Patient care assistant

PRISMA Preferred Reported Items for Systematic Reviews and Meta-Analysis

RCT Randomized controlled trial

RN Registered Nurse

SIGN Scottish Intercollegiate Guidelines Network

WHO World Health Organization

WM Ward Manager

Symbols

p p-value

SD Standard deviation

KEEP IN TOUCH FOR MOTHERS WITH LOW BIRTH WEIGHT INFANTS 1

Chapter One: Introduction

1.1 Background

1.1.1 Kangaroo mother care and breastfeeding.

Kangaroo mother care (KMC) included early and continuous, as long as 24 hours a

day as possible, skin-to-skin contact between the infants and the mother’s breasts; exclusive

and nearly exclusive breastfeeding; and early discharge from the healthcare facility (Charpak,

Figueroa de Calume, & Ruiz-Pela´ez, 2000; Martinez, Rey Sanabria, & Marquette, 1992;

Nyqvist et al., 2010). The major component of KMC was skin-to-skin contact; while the

other two components were less frequently identified as part of KMC. Skin-to-skin care was

recommended for the vulnerable infants, for example low birth weight (LBW) infants (Spatz,

2004) and it was a humane, safe, effective and low cost alternative to conventional neonatal

care (CNC) for LBW infants (Ludington-Hoe, 2015; Welch et al., 2013). There were

numerous benefits, including better thermal regulation, promotion breastfeeding, fewer

occurrences of bradycardia and apnoea, better weight gain, shorter hospital stay, and

facilitation of mother infant attachment, associated with KMC for LBW infants (Boo & Jamli,

2007; Gathwala, Singh, & Balhara, 2008; Suman Rao, Udani, & Nanavati, 2008). Moreover,

there was an economic benefit of increasing KMC and breastfeeding. Every dollar of

investment to increase KMC and breastfeeding rate, a maximum of 13.8-fold of benefit was


generated (Lowson, Offer, Watson, McGuire, & Renfrew, 2015). The mainstay of KMC was

encouragement of breastfeeding.

Low birth weight was defined as the birth weight was less than 2,500 grams (World

Health Organization [WHO], 2011) and preterm birth was defined as the infant was born

alive before the completion of 37 weeks of gestation (WHO, 2015). Low birth weight could

be resulted as preterm birth or small size of gestation, less than 10th percentile of weight at

gestation.

Breastfeeding was a global and fundamental public health issue (Section of

Breastfeeding. American Academy of Pediatrics [AAP], 2012). World Health Organization

and the United Nations Children’s Fund recommended that all infants should receive

exclusive breastfeeding for the first six months of life and kept breastfeeding up to 24 months

old or beyond with the introduction of solid food (WHO, 2003). Breast milk provided optimal

and integral nutrition supply to infants in the first six months of life. Nothing could imitate

the components of breast milk as it varied during each breastfeeding session and during the

lactation period (Ballard & Morrow, 2013). The health benefits of breastfeeding were well

recognized and documented. The health benefits of breastfeeding were dose-response; the

longer the infants were breastfed or exclusively breastfed, the greater the health benefits

(Section of Breastfeeding. AAP, 2012). Infants who received breast milk had fewer diarrhea,


nonspecific gastrointestinal tract infections, ear infection, and lower respiratory tract

infections, and lower risks of sudden infant death syndrome; meanwhile had long term health

benefits for lower risks of diabetes, and obesity (Section of Breastfeeding. AAP, 2012; Ip et

al., 2007; Leung, Lam, Ho, & Lau, 2005; Owen, Martin, Whincup, Smith, & Cook, 2005). In

addition, breast milk had more pronounced gastrointestinal, immunological, nutritional and

cognitive advantages for preterm infants (Section of Breastfeeding. AAP, 2012, Okamoto et

al., 2007; Schanler, 2011; Vohr et al., 2007). Moreover, the breastfeeding mothers, they had

fewer postpartum bleeding, and reduced the risks of breast and ovarian cancers (Family

Health Service, 2015).

1.2 Affirming the Need

1.2.1 Impact of LBW infants and preterm birth.

Low birth weight infants and preterm birth contributed significantly to infant and

child mortality (WHO, 2012). They caused many complications, including late onset sepsis,

hemodynamically significant patent ductus arteriosus, apnoea of prematurity, necrotizing

enterocolitis, retinopathy of prematurity, intraventricular hemorrhage, bronchopulmonary

dysplasia, maternal depression and anxiety, family stress, and financial burden (DiBiasie,

2006; Garland et al., 2011; Kanmaz et al., 2013; Manzoni et al., 2014; Onland et al., 2013;

Schoen, Yu, Stockmann, Spigarelli, & Sherwin, 2014; Staneva, Bogossian, Pritchard, &


Wittkowski, 2015; Whitelaw et al., 2007). Moreover, born of fragile LBW and preterm

infants caused sudden and traumatic interruption of pregnancy, therefore mothers experienced

physiological and psychological challenges. The separation of mother-infant dyad, difficulty

in production of breast milk, delays in initiating expressing milk, and stress made

breastfeeding difficult for LBW and preterm infants staying in neonatal intensive care units

(NICUs) (Hartmann & Ramsay, 2005; Henderson, Hartmann, Newnham, & Simmer, 2008;

Myers & Rubarth, 2013). These factors molded unfavorable environment to promote

breastfeeding in neonatal units.

Therefore, the Hospital Authority (HA) implemented the ‘Ten Steps to Successful

Breastfeeding’ (WHO, 1989) and complied with the ‘International Code of Marketing of

Breastmilk Substitutes’ (WHO, 1981). In Hong Kong many breastfeeding promotion

programs had been launched; however few targeted at LBW and preterm infants. Neonatal

nurses played a leading role in promoting, protecting and supporting breastfeeding in

neonatal units (Callen & Pinelli, 2005). Nurses spent the most time with the infants and the

mothers when they visited the infants; nurses should encourage the mother to breastfeed and

how to express breast milk for the LBW infants in order to promote breastfeeding. Increasing

the breastfeeding rate, duration and exclusivity, more LBW infants would manifest the health

benefits of the breast milk and the long run cost of taking care of LBW infants would be


reduced.

1.2.2 Numbers of LBW infants and preterm birth in Hong Kong.

In Hong Kong there were 62,305 live births in 2014 (Census and Statistics

Department, 2015), and 3,092 (5.0%) infants were born at short gestation or with LBW, in

which 96.6% were born in the public hospitals (HA, 2015a).

1.2.3 Breastfeeding rate in Hong Kong.

The breastfeeding initiation rate in Hong Kong increased from 33.5% to 84.2% in

1997 and 2013, respectively (Baby Friendly Hospital Initiative Hong Kong Association, 2014;

Leung, Ho, & Lam, 2002). In 2007, the rate of receiving any breast milk at 1-month, 3-month,

6-month and 12-month of infants were 63%, 37.3%, 26.9%, and 12.5% respectively. The

exclusive breastfeeding rates were approximately one-half (Tarrant et al., 2010). However the

breastfeeding rate (direct breastfeeding or fed with expressed breast milk [EBM]) at

discharge from all public neonatal units in 2013 was 51.9% (Chan, 2013) and the rate of

infants who were exclusively breastfed or fed with EBM only was 3.6% (Chan & Liu, 2014).

The breastfeeding rate for the infants staying in neonatal units was suboptimal that more

strategies should be implemented to increase breastfeeding initiation rate and exclusivity.

Intention of breastfeeding correlated to initiation and duration of breastfeeding (Di Manno,

Macdonald, & Knight, 2015). Therefore, it was important to arouse the intention to


breastfeed.

In conclusion, based on the well documented benefits of KMC and breastfeeding for

the LBW infants, and breastfeeding was an essential component of KMC, neonatal nurses

should introduce KMC for the mothers with LBW infants to promote breastfeeding.

1.2.4 Target setting.

The target setting was a neonatal unit of a public hospital that provided general care

for infants requiring special care and comprehensive care for infants born at less than 32

weeks of gestation, with birth weight less than 1,500 grams, or both; provided paediatric

medical subspecialists, surgical specialists, anesthesiologists, ophthalmologists; and provided

full range of respiratory support. In 2014 more than 5,000 infants admitted to the target

setting, in which 349 infants were newborns with LBW (HA, 2015b). By clinical observation,

the average length of stay for every LBW infant was 30 days before discharge to home.

1.2.5 Inform the need of systematic review.

In the target setting, some nurses based on their values, clinical experience,

knowledge and skills, would invite the mother to implement KMC for the LBW infants with

residents’ consensus. The assessment and evaluation for the eligibility for KMC required

knowledge, skills and experience, which were various among the nurses. By clinical

observation less than 10% of LBW infants could receive KMC in the target setting. Moreover,


there was no formal direction for KMC at this moment. Therefore, there was a need to devise

and adopt an evidence-based guideline on KMC for the LBW infants. After searching the

current evidence, systemic review in addressing the effectiveness of KMC on breastfeeding

for the LBW infants was not reported. Therefore a structured review was conducted to

explore the effectiveness of KMC in comparison to CNC (incubator care), among the LBW

infants in promoting breastfeeding initiation rate and exclusivity.

1.3 Objectives

The objectives of the dissertation were (i) to conduct a systematic review and critical

appraisal of the literature on the effectiveness of KMC on breastfeeding initiation rate and

exclusivity for the LBW infants; (ii) to assess the implementation potential of the proposed

KMC innovation; (iii) to devise an evidence-based guideline for KMC for the LBW infants;

and (iv) to devise implementation and evaluation plan for the proposed KMC innovation. The

project question was ‘How effective of kangaroo mother care in comparison to conventional

neonatal care in increasing breastfeeding initiation rate and exclusivity for the mothers with

low birth weight infants?’. The components of the PICO were (i) P, population, was the

mothers with LBW infants; (ii) I, intervention, was the kangaroo mother care; (iii) C,

comparison, was the conventional neonatal care, including incubator or crib care; and (iv) O,

outcomes, were the breastfeeding initiation rate and exclusivity.


1.4 Significance

Breastfeeding gave infants the healthiest start in life and was one of the simplest,

smartest and most cost-effective ways to ensure all infants could survive and thrive.

Meanwhile, KMC for the LBW infants was a safe and effective method to promote

breastfeeding. However, the low breastfeeding initiation rate and exclusivity in the target

setting compromised the well documented health benefits of breastfeeding for the LBW

infants. Therefore, the proposed KMC innovation was significant to increase breastfeeding

initiation rate and exclusivity for the LBW infants staying in the target neonatal unit. In

addition, KMC practice would provide inspiration for more breastfeeding promotion

strategies for the LBW infants and nursing research in the local setting and public in the

future.

1.5 Conclusion

The need for conducting structured review to explore the effectiveness of KMC on

breastfeeding initiation and exclusivity for the mother with the LBW infants was affirmed;

and the objectives and significance of the project were discussed. The search and appraisal

strategies and critical appraisal of the included studies would be presented in Chapter Two.


Chapter Two: Critical Appraisal

In Chapter One, it concluded that there was a need to perform integrated review and

critical appraisal for effectiveness of KMC on breastfeeding initiation rate and exclusivity for

the LBW infants. In this chapter, the search and appraisal strategies and critical appraisal of

the included studies would be discussed.

2.1 Search Strategies

Structured searching to identify relevant studies for critical appraisal on KMC for the

LBW infants on breastfeeding was conducted with three electronic databases, Cochrane

Library, Cumulative Index to Nursing and Allied Health Literature (CINAHL) Plus, and

PubMed; and manual searching. These databases provided comprehensive information for

nursing profession. The proposed key words and Medical subject heading (MeSH) terms

were kangaroo mother care, skin-to-skin contact, low birth weight, and breastfeeding. The

search was completed in November 2015 and was restricted to studies published since year

2000.

The inclusion criteria for the study selection were (i) the study was a primary study;

(ii) KMC was compared with CNC; (iii) the subjects of the study were mothers with LBW

infants or LBW infants; (iv) the study design was randomized controlled trial (RCT); (v) the

breastfeeding initiation rate and/or exclusivity was or were the outcome measures of the


study; and (vi) the study was published in year 2000 or after. There was no language

restrictions applied in order to avoid language bias. After critical appraisal, the studies with

unacceptable quality would be excluded from study selection.

2.2 Appraisal Strategies

The Scottish Intercollegiate Guidelines Network (SIGN) developed evidence-based

clinical guidelines for the National Health Service. The SIGN methodology checklist for

RCTs, including the internal validity and overall assessment (SIGN, 2015b) (see Appendix A)

and the SIGN grading system 1999-2012 (SIGN, 2015a) (See Appendix B) were adopted to

appraise the quality and level of evidence of the selected studies.

2.3 Search Results

After searching the key words and MeSH with different combinations, the electronic

search produced 567 references, four, 188, and 375 citations were retrieved from Cochrane

Library, CINAHL Plus, and PubMed, respectively; and were reported in English. Review of

the titles and abstracts revealed 121 duplicated references and 415 references were excluded.

The full texts of the remaining 31 relevant studies were identified and the full-text of the

studies were retrieved and assessed for eligibility; 24 records were excluded because they

were not RCTs, irrelevant LBW infants and breastfeeding, and not comparing with CNC.

Seven studies met the inclusion and exclusion criteria. Finally the reference lists of the


selected seven studies were scanned for additional studies, which identified one eligible study.

However, one study was excluded because of its unacceptable quality after critical appraisal

because majority of the internal validity, including no randomization method was reported, no

blinding was kept, the KMC and control groups were not comparable at the start of the trial,

the overall drop-out rate was 26.7%, no valid and reliable outcome measures were used and

no intention to treat analysis was carried out, of the SIGN checklist for RCTs were not

fulfilled (Suman Rao, Udani, Nanavati., 2008). Finally, seven studies were included in the

review.

Seven RCTs with acceptable quality met the inclusion criteria and were included in

the review (Ali, Sharma, Sharma, & Alam, 2009; Boo & Jamli, 2007; Charpak, Ruiz-Pela´ez,

Figueroa de Calume, & Charpak, 2001; Gathwala et al., 2008; Ghavane et al., 2012;

Ramanathan, Paul, Deorari, Taneja, & George, 2001; Rojas et al., 2003). The Preferred

Reported Items for Systematic Reviews and Meta-Analysis (PRISMA) flowchart reported the

searching process and the numbers of studies identified (see Appendix C). All the included

studies were published from year 2001 to 2012 and were in English.

2.4 Table of Evidence

Table of evidence was formulated to summarize the important data and to capture the

similarities or differences for the summary and synthesis of the included studies to devise


the evidence-base guideline (see Appendix D). The important information included the

publication year, level of evidence, subjects’ characteristics, sample sizes, intervention

group, control group, outcome measures, measurement time points and effect sizes.

2.4.1 Subjects and clinical settings characteristics.

All mothers of the LBW infants in the included studies were healthy without

complicated obstetric and medical problems; and all infants in the seven studies were LBW

infants with birth weight less than 2,000 grams (Ali et al., 2009; Boo et al., 2007; Charpak et

al., 2001; Gathwala et al., 2010; Ghavane et al., 2012; Ramanathan et al., 2001; Rojas et al.,

2003). All infants were cardiopulmonary stable without life threatening congenital

malformation and severe perinatal complications. Two studies (Boo et al., 2007; Ramanathan

et al., 2001) enrolled infants with well tolerance of enteral feeds and two studies enrolled

subjects required minimal ventilator support (Boo et al., 2007; Rojas et al., 2003). For the

mothers, one study excluded those who were less than 18 years old and had illicit drug use

during pregnancy (Rojas et al., 2003). For the other six studies, no characteristics of the

mothers of the LBW infants were reported (Ali et al., 2009; Boo et al., 2007; Charpak et al.,

2001; Gathwala et al., 2010; Ghavane et al., 2012; Ramanathan et al., 2001).

All the studies were conducted in one site (Ali et al., 2009; Boo et al., 2007; Charpak

et al., 2001; Ghavane et al., 2012; Gathwala et al., 2010; Ramanathan et al., 2001; Rojas et al.,


2003). Five studies were conducted in NICUs of tertiary care hospitals (Ali et al., 2009; Boo

et al., 2007; Charpak et al., 2001; Ghavane et al., 2012; Rojas et al., 2003), while other two

studies were conducted in neonatal units (Gathwala et al., 2010; Ramanathan et al., 2001).

2.4.2 Sample sizes.

The sample sizes of the mother-infant dyads were ranged from 28 to 746. One study

had more than 350 mother-infant dyads (Charpak et al., 2001), while one study had 14

mother-infant dyads in each of the KMC and control group (Ramanathan et al., 2001). Five

studies had 33 to 71 and 27 to 69 mother-infant dyads in the KMC and control groups,

respectively (Ali et al., 2009; Boo et al., 2007; Gathwala et al., 2010; Ghavane et al., 2008;

Rojas et al., 2003).

2.4.3 Intervention and control groups.

Kangaroo mother care was the intervention in all studies with various mean numbers

of hours per day and duration of KMC. Three studies reported the mean (± SD) number of

hours per day for KMC varying from 1.3 (± 0.67) hours to 10.2 (± 1.6) hours per day (Ali et

al., 2009; Gathwala et al., 2010; Rojas et al., 2003). Meanwhile, three studies reported the

mean (± SD) number of days for KMC varying from 10.0 (± 5.6) to 25.7 (± 6.9) days (Ali et

al., 2009; Boo et al., 2007; Rojas et al., 2003). Other than the mentioned studies, no number

of hours and days for KMC were reported.


All studies used CNC for the control groups. The CNC included putting the infants

under radiant warmers, incubators or open cribs. Six studies allowed the parents to join infant

care activities (Ali et al., 2009; Boo et al., 2007; Gathwala et al., 2008; Ghavane et al., 2012;

Ramanathan et al., 2001; Rojas et al., 2003); while the parents in one study were strictly

restricted to access the infants during the study time (Charpak et al., 2001).

2.4.4 Outcome measures.

Four studies measured the breastfeeding initiation rate (Boo et al., 2007; Charpak et

al., 2001; Ghavane et al., 2012; Rojas et al., 2003); and four studies measured exclusive

breastfeeding rate (Ali et al., 2009; Gathwala et al., 2008; Ghavane et al., 2012; Ramanathan

et al., 2001). One study measured both breastfeeding initiation and exclusive breastfeeding

rate (Ghavane et al., 2012).

2.4.5 Measure time points.

Outcome measures were collected at various time points at discharge (Boo et al., 2007;

Rojas et al., 2003), at term (Ali et al., 2009; Charpak et al., 2001; Ghavane et al., 2012),

6-week after discharge (Ramanathan et al., 2001), 3-month old (Ali et al., 2009; Charpak et

al., 2001; Gathwala et al., 2008), 6-month old (Ali et al., 2009; Charpak et al., 2001),

9-month old (Charpak et al., 2001), and 12-month old (Charpak et al., 2001) of the LBW

infants.


2.4.6 Effect sizes.

The effect sizes for breastfeeding and exclusive breastfeeding rates were from -2.5%

(p=not significant) (the exact p value was not reported) (Charpak et al., 2001) to 25% (p=0.06)

(Rojas et al., 2003), and from -0.9% (p=0.91) (Gathwala et al., 2010) to 42.8% (p=0.04)

(Ramanathan et al., 2001), respectively.

2.5 Summary of the Appraisal Results

The summary of the quality assessment using SIGN methodology checklist for

controlled trials was conducted (see Appendix E).

2.5.1 Clearly focused question.

All studies addressed appropriate and clearly focused questions (Ali et al., 2009; Boo

et al., 2007; Charpak et al., 2001; Gathwala et al., 2008; Ghavane et al., 2012; Ramanathan et

al., 2001; Rojas et al., 2003).

2.5.2 Randomization.

The subjects of all the studies were randomly assigned to KMC and control groups.

Three studies used block randomization (Ali et al., 2009; Boo et al., 2007; Charpak et al.,

2001); three studies used random number tables (Gathwala et al., 2008; Ramanathan et al.,

2001; Rojas et al., 2003); and one study used computer generator to assign the subjects

randomly (Ghavane et al., 2012).


2.5.3 Allocation concealment.

Three studies used serially numbered, sealed and opaque envelopes as the

concealment method (Boo et al., 2007; Ghavane et al., 2012; Rojas et al., 2003); while four

studies did not report the concealment method (Ali et al., 2009; Charpak et al., 2001;

Gathwala et al., 2008; Ramanathan et al., 2001).

2.5.4 Blinding.

All studies did not keep the subjects and investigators ‘blind’ about the group

allocation because the mothers of the LBW infants were informed for the aims and

intervention of the study; therefore, blinding to mothers for the group allocation was not

feasible.

2.5.5 Comparable groups.

The subjects of the KMC and control groups of each study had similar characteristics,

including gestational age at birth and birth weight, at the beginning of the trials.

2.5.6 Treatment was the only difference.

The difference in treatment received between the KMC and the control groups was

limited to KMC only for six studies (Ali et al., 2009; Boo et al., 2007; Gathwala et al., 2008;

Ghavane et al., 2012; Ramanathan et al., 2001; Rojas et al., 2003). There was significant

difference for the treatment received, other than KMC, between the KMC and control groups


of one study because the parents in the control group were restricted to access to the infant

during the study time (Charpak et al., 2001).

2.5.7 Valid and reliable outcome measures.

Four studies had unclear measures of the breastfeeding rate (Ali et al., 2009; Boo et al.,

2007; Charpak et al., 2001; Ghavane et al., 2012); and three studies used entirely subjective

and based on human judgement, including report and observation of the nurses and mothers

without validation for recording breastfeeding and exclusivity (Gathwala et al., 2008;

Ramanathan et al., 2001; Rojas et al., 2003).

2.5.8 Drop-out rates.

Six studies had drop-out rate less than 10% (Boo et al., 2007; Charpak et al., 2001;

Gathwala et al., 2008; Ghavane et al., 2012; Ramanathan et al., 2001; Rojas et al., 2003),

while one study had higher than 30% of drop-out rate (Ali et al., 2009).

2.5.9 Intention to treat analysis.

Two studies analyzed the subjects in the groups that they were randomly allocated

(Boo et al., 2007; Ramanathan et al., 2001); while four studies analyzed the subjects who

completed the studies and based only for whom outcome data were obtained (Charpak et al.,

2001; Gathwala et al., 2008; Ghavane et al., 2012; Rojas et al., 2003). One study did not

report adequate information to make a judgement on intention to treat analysis (Ali et al.,


2009).

2.5.10 Comparable results from all sites.

There were no comparable results from different sites because all studies were

conducted in one site (Ali et al., 2009; Boo et al., 2007; Charpak et al., 2001; Gathwala et al.,

2008; Ghavane et al., 2012; Ramanathan et al., 2001; Rojas et al., 2003).

2.5.11 Risks of bias minimize.

Two studies minimized the risks of bias but no blinding was kept; therefore they had

acceptable quality (Boo et al., 2007; Ghavane et al., 2012). Five studies had high risks of bias

because no adequate concealment method was used, no blinding was kept, the difference

between the KMC and control groups was not limited to KMC only, no standard, valid and

reliable way to measure the outcomes, high drop-out rate and/or no intention to treat analysis

was carried out; therefore they had low quality (Ali et al., 2009; Charpak et al., 2001;

Gathwala et al., 2008; Ramanathan et al., 2001; Rojas et al., 2003).

2.5.12 Overall effect due to intervention alone.

Four studies had overall effect due to KMC alone (Boo et al., 2007; Gathwala et al.,

2008; Ramanathan et al., 2001; Rojas et al., 2003) while the other three studies were not (Ali

et al., 2009; Charpak et al., 2001; Ghavane et al., 2012). It was because one study had higher

than 30% drop-out rate and no intention to treat analysis was reported (Ali et al., 2009); one


study strictly restricted the parents of the control group to access the infants during the study

time (Charpak et al., 2001); and stringent adherence to breastfeeding policy in the hospital of

one study (Ghavane et al., 2012). Ghavane et al. (2012) reported that the breastfeeding and

exclusive breastfeeding rates at term for the mothers with LBW infants for KMC and controls

groups were 85.9% versus 87% (p=0.68) and 31% versus 31.9% (p=0.91), respectively. The

nurse researchers would assist the mothers of the KMC group for initial breastfeeding and

provide breastfeeding knowledge; while the mothers of the control group got assistance from

lactation consultant upon their request.

2.5.13 Results applicable to target group.

Results from five studies were applicable to the target group (Ali et al., 2009; Boo et

al., 2007; Gathwala et al., 2008; Ramanathan et al., 2001; Rojas et al., 2003). After

consideration, the results of two studies were not applicable to the target population because

the breastfeeding policy of the local setting was not strict and the parents who did not

perform KMC would not be strictly restricted to access the infants (Charpak et al., 2001;

Ghavane et al., 2012).

2.5.14 Sample size calculation.

One study had sample size calculation to detect a 25% difference in breastfeeding rate

with an alpha 0.05 and power of 80% (Boo et al., 2007). Three studies had sample size


calculation based on to detect difference of weight gain or mother-infant interaction with an

alpha 0.05 and power of 80% to 86% (Ghavane et al., 2012; Ramanthan et al., 2001; Rojas et

al., 2003). Two studies did not report the sample size calculation (Ali et al., 2009; Gathwala

et al., 2010) and sample size of one study fell short (Charpak et al., 2001).

2.5.15 Levels of evidence.

According to SIGN grading system, two studies were rated as low risk of bias, with

‘1+’ level of evidence because they fulfilled majority of the internal validity of SIGN

checklist (Boo et al., Ghavane et al., 2012). They were only limited by no blinding

procedures for the subjects, which might be impractical for most behavioral trials. Although

no intention to treat analysis was carried out for one study, the overall drop-out rate is 2.9%

(Ghavane et al., 2012). Five studies were rated as high risk of bias with ‘1-’ level of evidence

because no allocation concealment was used, no blinding was kept, the difference between

the KMC and control groups was not limited to KMC only, no standard, valid and reliable

way to measure the outcomes, high drop-out rate, and or or no intention to treat analysis was

carried out (Ali et al., 2009; Charpak et al., 2001; Gatheala et al., 2010; Ramanathan et al.,

2001; Rojas et al., 2003).

2.6 Summary and Synthesis

2.6.1 Summary of the outcome measures of the included studies.


The outcome measures, breastfeeding initiation and exclusive breastfeeding rates, of

the included studies were tabulated (See Appendix F). There were diversity of the effects of

KMC on breastfeeding initiation rate and exclusivity. The studies reported that the

breastfeeding and exclusive breastfeeding rate were increased by -2.5% (p=not significant)

(the exact p value was not reported) to 25% (p=0.06), and from -0.9% (p=0.91) to 42.8%

(p=0.04), respectively. In addition, the duration of breastfeeding also increased significantly,

29.1% (p=0.006), up to 6 months old of the LBW infants (Ali et al., 2009). The proportions

of KMC mothers who breastfed up to 3 months were statistically higher (p=0.001) than that

of the control group (Charpak, 2001).

2.6.2 Reasons for the diversity of the studies’ conclusions.

The variations in the level of evidence of studies, subject characteristics, intervention,

control, sample size, and sample size calculation contributed to the diversity of the study

results.

2.6.2.1 Level of evidence.

Randomized controlled trials were the gold standard for yielding reliable evidence for

causes and effects (Polit & Beck, 2012). All included studies were RCTs that provided the

best available and reliable evidence about the effects of KMC on breastfeeding initiation rate

and exclusivity. However the quality and level of evidence of the included studies were


varied.

2.6.2.2 Subjects characteristics.

Infants of each study had mean birth weight from 906 to 1,705 grams, and with mean

gestation at birth from 26.6 to 35.5 weeks (Ali et al., 2009; Boo et al., 2007; Charpak et al.,

2001; Gathwala et al., 2010; Ghavane et al., 2012; Ramanathan et al., 2001; Rojas et al.,

2003). The mean age at enrollment among the subjects varied from 1.7 to 14.1days (Ali et al.,

2009; Gathwala et al., 2010; Ghavane et al., 2012). The significant differences in birth

weights, gestation at birth, and the age at enrollment would contribute to the diversity of the

study results.

2.6.2.3 Intervention.

All included studies performed KMC for the intervention group; however the quality

and characteristics of KMC in each study were different. The summary of KMC of each

study was formulated (see Appendix G).

The subjects from three studies were put in upright position during KMC (Ali et al.,

Charpak et al., 2001; Ghavane et al., 2012); while the subjects from other two studies were

put in prone and semi-upright position (Boo et al., 2007; Rojas et al., 2003). One study

encouraged breastfeeding during KMC (Charpark et al., 2001); but the other studies did not

report breastfeeding during KMC (Ali et al., 2009; Boo et al., 2007; Gatheala et al., 2010;


Ghavane et al., 2012; Ramanthan et al., 2001; Rojas, 2003). Six studies provided comfortable

chairs, bed, or both (Ali et al., 2009; Boo etal., 2007; Gatheala et al., 2010; Ghavane et al.,

2012; Ramanthan et al., 2001; Rojas, 2003); and one study did not report this element

(Charpark et al., 2001). Two studies invited both parents to perform KMC (Boo etal., 2007;

Rojas et al., 2003), while the other five studies only the mothers provided KMC (Ali et al.,

2009; Charpak et al., 2001; Gatheala et al., 2010; Ghavane et al., 2012; Ramanthan et al.,

2001). Moreover, five studies continued KMC after discharged from hospital (Ali et al., 2009;

Charpak et al., 2001; Gathwala et al., 2010; Ghanvane et al., 2012; Ramanathan et al., 2001).

Only one study (Boo et al., 2007) provided training to KMC providers. In addition three

studies reported the mean length of KMC were from 1.3 to 10.2 hours per day (Ali et al.,

2009; Gathwala et al., 2010; Rojas et al., 2003); and one study had median 1 hour and total

11.3 hours for KMC (Boo et al., 2007). Three studies reported the mean duration of KMC

were from10.0 to 25.7 days (Ali et al., 2009; Boo et al., 2007; Rojas et al., 2003). Differences

in quality, length and duration of KMC would contribute to the diversity of the study results.

2.6.2.4 Control.

The control of all studies were CNC but one study did not allow the parents to access

the infant during the study time (Charpak et al., 2001); while the parents of other six studies

were encouraged to hold and feed the infants (Ali et al., 2009; Boo et al. 2007; Gathwala et


al., 2010; Ghanvane et al., 2012; Ramanathan et al., 2001; Rojas et al., 2003)

2.6.2.5 Sample size and sample size calculation.

The sample sizes of the studies varied from 28 to 746 mother-infant dyads. Moreover

only one study had sample size calculation aimed at detecting a 25% difference in

breastfeeding rate with an alpha 0.05 and power of 80% (Boo et al., 2007); while the other

studies had no sample size calculation or the calculation aimed at detecting other outcome

measures, for an example weight gain.

2.7 Conclusion

Through the extensive and structured review and critical appraisal of the best

available and reliable evidence, there was adequate evidence to support that KMC was

effective in increasing breastfeeding initiation rate and exclusivity among the mothers with

LBW infants. Therefore an evidence-based protocol should be proposed to the nurses and the

mothers with LBW infants in order to increase breastfeeding initiation rate and exclusivity.


Chapter Three: Implementation Potential and Clinical Guideline

3.1 Implementation Potential

In Chapter Two, the integrated review and critical appraisal showed clear evidence

that KMC was an effective intervention for increasing breastfeeding initiation rate and

exclusivity. In this Chapter, the implementation potential, including transferability, feasibility,

and cost-benefit ratio of the proposed evidence-based KMC guideline, would be evaluated

and discussed. Meanwhile, the KMC guideline would be developed.

3.1.1 Transferability of the findings.

Transferability was the fitness of the proposed evidence-based KMC guideline in the

local setting (Polit & Beck, 2012). Comparison in target setting and the demographic

characteristics of the target population and philosophy of care between the local setting and

the settings of the identified studies would be carried out. In addition the number of benefited

clients would be discussed.

3.1.1.1 Target setting and population.

The local setting was a tertiary care neonatal unit of a public hospital, including ten

beds for neonatal intensive care and 35 beds for special baby care, which provided general

care for infants requiring special care and comprehensive care for infants born at less than 32

weeks of gestation, with birth weight less than 1,500 grams, or both; provided paediatric


medical subspecialists, surgical specialists, anesthesiologists, ophthalmologists; and provided

full range of respiratory support, including conventional ventilation, high frequency

oscillatory ventilation and ventilation with inhaled nitric oxide. Other than doctors, the unit

was staffed by one Department Operation Manager (DOM), one Nurse Consultant (NC)

(Neonatal Care), one Ward Manager (WM), 11 Advanced Practice Nurses (APNs), 44

Registered Nurses (RNs), 22 patient care assistants (PCAs), and allied health care

professionals. For the identified studies, five identified studies were carried out in NICUs of

tertiary care hospitals and two studies were carried out in neonatal units (Ali et al., 2009; Boo

& Jamli, 2007; Charpak et al., 2001; Gathwala et al., 2008; Ghavane et al., 2012;

Ramanathan et al., 2001; Rojas et al., 2003).

In 2014, more than 5,000 infants admitted to the local neonatal unit, in which 349

infants were newborns with LWB (HA, 2015b). For the identified studies, all the subjects

were LBW infants. By clinical observation, the mean gestation at birth of the admitted LBW

infants in the local neonatal unit was 30 weeks (range: 24 - 40 weeks) and that of the

identified studies varied from 26.6 to 35.5 weeks; the mean birth weight of the admitted

LBW infants at the local neonatal unit was 1,300 grams (range: 500 - 2,500 grams) and that

of the identified studies varied from 906 to 1,705 grams. Moreover, the mothers with LBW

infants in the identified studies were healthy without complicated obstetric and medical


problems; that was similar to the mothers of the LBW infants in the local neonatal unit.

Therefore the target neonatal unit, demographic characteristics of the target population,

mothers and the LBW infants, were comparable to the identified studies.

3.1.1.2 Philosophy of care.

Another major determinant of transferability was philosophy of care. All public

hospitals strived for continuous quality improvement through evidence-based practice (HA,

2016). Annually, the HA Convention provided a platform for nurses to share researches and

innovations. Moreover the HA launched the ‘Ten Steps to successful Breastfeeding’ and

‘International Code of Marketing of Breast Milk Substitutes’ to promote breastfeeding for

more than ten years . Meanwhile, the Nursing Service Division provided total support,

education, development and empowerment and leads to happy nurses and professionalism

(United Christian Hospital, 2016). All the identified studies aimed at promoting breastfeeding

through evidence-based KMC practice. Therefore, the philosophy of care underlying the

proposed KMC guideline was fundamentally similar to that of the identified studies in order

to provide high quality care through evidence-based KMC practice for the mothers with

LBW infants to increase breastfeeding initiation rate and exclusivity.

3.1.1.3 Numbers of benefited mothers with LBW infants.

The third component of transferability was the numbers of benefited infants. In 2014,


4,861 infants were born in the local hospital, in which 349 were LBW infants and admitted to

the local neonatal unit (HA, 2015a). Assuming the number of LBW infants was similar to the

previous years, and 70% of the mother-infant dyads were eligible for KMC and could be

recruited; about 240 mother-infant dyads would be benefited from the proposed KMC

guideline.

In conclusion, the demographic characteristics of the target population and the

philosophy of care of local neonatal unit were congruent with the identified studies; and the

proposed KMC guideline would benefit significant number of mothers with LBW infants; it

would possible to fit KMC practice into local nursing practice.

3.1.1.4 Duration of the implementation and evaluation.

The implementation duration of the proposed KMC practice would be varied from one

to 16 weeks depending on acceptability, comfort and tolerance of the mother-infant dyads to

KMC and the evaluation would be up to 3-month-old of the LBW infants in order to evaluate

the breastfeeding initiation rate and exclusivity at 3-month-old of the LBW infants.

3.1.2 Feasibility.

Besides transferability, the feasibility of the proposed KMC guideline should be

considered as an important part of the implementation potential. The feasibility concerned the

availability of staff and resources, the organization climate, the need for the availability of


external assistance, and the potential for clinical evaluation (Polit & Beck, 2012).

3.1.2.1 Availability of staff and resources.

The target users of the proposed KMC guideline were the nurses working in the

neonatal unit. The KMC guideline would change the current nursing practice but would not

interfere inordinately with nurse’s function because it would take 15 minutes for the

preparation for KMC, transferring LBW infants to the mothers’ breasts and transferring back

to the incubators or cribs. The nurses would have control and freedom to carry out or

determinate the proposed KMC guideline when they follow the guideline after appropriate

training. The major pockets of resistance to implement the proposed KMC guideline might be

fail to have strong belief in importance of KMC, lack of skills, knowledge, confidence and

help, fear and anxiety of hurting the LBW infants, increased workload, concerns about other

medical condition, shortage of manpower, and lack of resources, space and privacy (Chan,

Labar, Wall, & Atun, 2016; Seidman et al., 2015). However, these barriers could be overcome

by a consultation period to collect opinions, suggestions, solutions from the stakeholders,

nurses and other disciplines and appropriate in-service training, and marketing

(Hendricks-Munoz, & Mayers, 2014; Penn, 2015). Moreover, good communication among

the administrators of the hospital and the frontline staff would facilitate the implementation

and evaluation of the proposed KMC guideline.


A NC and an APN would be appointed to be the project leaders by the DOM and the

WM to provide the in-service training, implementation and evaluation of the proposed KMC

guideline, and communicate with the stakeholders. The project leaders had more than 20

years’ experience in neonatal care and received training for KMC in Children’s Hospital of

Philadelphia and Johns Hopkins Hospital two years ago. Therefore, they were knowledgeable

and confident to provide training, implementation, evaluation and coordination for the

proposed KMC guideline.

A comprehensive simulation-based KMC didactic education program would include

60-minute mini-lecture and 60-minute simulation session with six to ten nurses per session

and would be provided by the project leaders to 54 nurses. Eight identical mini-lectures and

eight simulation sessions would be scheduled in four weeks. The scientific basis of KMC,

impact of KMC on breastfeeding, supporting mothers during KMC, assessing and identifying

LBW infants, and mothers and nurses readiness for KMC would be delivered and discussed

during the mini-lectures. A manikin simulation practice included scenarios to assess nurses’

provision of parental KMC education and to identify skill level in the evaluation of infants,

mothers, and nurses’ readiness for KMC would be provided. Each nurse would complete four

KMC practice stations with infant mannequins receiving room air, nasal cannula, nasal

continuous positive airway pressure ventilation and intubation on conventional ventilators.


Debriefings would be held immediately following each scenario (Hendricks-Munoz, &

Mayers, 2014).

All the training sessions would be arranged during the three overlapping hours of the

nurses’ morning and evening shifts. Therefore, the nurses to be trained could be released from

other practice activities to learn how to implement the proposed KMC guideline without

interference to the routine practice. Moreover, the education materials and the video

recording of the KMC practice would be posted on the website of the local neonatal unit so

that the nurses could retrieve the information whenever and wherever they want.

The hospital would provide all the equipment and facilities necessary for the proposed

KMC practice including the comfortable recline chairs with footstools, privacy screens,

handheld mirrors, front-opening gowns for the mothers, bonnets, socks and warm covering

cloths for the LBW infants, and the printing of input and output charts, feeding mode data

collection forms, implementation records of KMC, KMC diaries, feeding diaries, posters and

parent education flyers.

Therefore, the project team, training personnel, target users, and the resources were

available.

3.1.2.2 The organization climate.

The hospital was conductive to research utilization, encouraged and supported the


nurses to provide high quality care and helped them to overcome the challenges throughout

the process to success. The neonatal unit had experiences in implementing quality

improvement programs including ‘SuperWarm project’ and ‘Resuscitation support by

neonatal nurses in delivery suite program’. Neonatal nurses were working in times of

changing and profession was being influenced by that strong spirit. Therefore, the hospital

and the neonatal unit would support the proposed KMC guideline.

3.1.2.3 The need for the availability of external assistance.

In addition to the nurses, assistance and collaboration from other disciplines were

necessary in order not to cause friction within the hospital. A multidisciplinary team was

pivotal for the successful implementation of the proposed KMC guideline. Before the

implementation of the proposed KMC guideline, the possibility of rescheduling time for

doctors’ round, physical assessment, blood taking; chest physiotherapy, stimulation and

developmental training provided by the physiotherapists and occupational therapists; taking

x-ray; and infant bathing should be considered in order not to disrupt KMC practice.

Therefore, meetings and discussion would be arranged to collect advices and suggestions

from all the potential affected disciplines, for examples the residents, physiotherapists,

occupational therapists, radiologists and the PCAs. Meanwhile, opinions from Infection

Control Team (ICT) would be consulted and considered in order to prevent cross infection


among the LBW infants and their mothers during the skin-to-skin contact.

3.1.2.4 The potential of clinical evaluation.

Furthermore, clinical evaluation was imperative to evaluate the effectiveness of the

proposed evidence-based KMC guideline for increasing breastfeeding initiation rate and

exclusivity. A pilot test, a small scale preliminary implementation of guideline, would be

carried out to determine its feasibility and fine-tune the procedures and guideline. The

duration for the evaluation would be up to 3-month-old of the LBW infants. There were

available measuring tools, for examples the input and output charts, feeding mode data

collection form, record of KMC, KMC diaries, feeding diaries, and the acceptability of KMC

by the mothers and nurses, to evaluate its effectiveness and the details of the evaluation plan

would be discussed in Chapter Four.

3.1.3 Cost-benefit ratio.

It was vital to perform the cost-benefit analysis for the proposed KMC guideline in

details so that the high quality care can be provided with reasonable or even lower set-up and

running costs.

3.1.3.1 Risks.

There were risks of spreading infections, including respiratory syncytial virus,

methicillin-resistant staphylococcus aureus, and mycobacterium tuberculosis among the


KMC mother-infant dyads; and the LBW infants might experience physiologic changes,

including hyperthermia, and increased episodes of desaturation (Heyns et al., 2006; Sakaki,

Nishioka, Kanda, & Takahashi, 2009; Visser, Delport, & Venter, 2008). However, four of the

identified studies reported that there were no statistically significant differences in

morbidities, including sepsis, hypothermia, apnoea, bradycardia and hypoglycemia during

and after KMC between the KMC and control groups (Ali et al., 2009; Boo & Jamli, 2007;

Ghavane et al., 2012; Rojas et al., 2003). On the other hand, Ali et al. (2009) reported that

there was a mean increase in 1.5% (+/- 1.5 SD, p<0.001) of oxygen saturation when

compared with the LBW infants in the KMC group with that of the control group. Another

study found that there were 56% and 30% (p<0.05) of LBW infants had desaturation during

traditional holding and KMC respectively (Rojas et al., 2003). To minimize the risk, the

project leaders would confirm the eligibility of the mother-infant dyads before implementing

KMC by using a checklist.

Minimization for spreading infection could be achieved by seeking advice from ICT

when the infectious status of the mothers with LBW infants may be contraindicated for KMC,

for an example mother with methicillin-resistant staphylococcus aureus infection. Moreover,

the physiologic condition including heart rates, respiration rates, oxygen saturation and the

body temperature of the LBW infants should be monitored continuously and prudently before,


during and after KMC; and the correct head position for airway patency, stability of the

endotracheal tube, nasal prongs, and intravenous access devices would be verified during

KMC in order to maintain physiologic stability and minimize the risks.

The risks of not implementing KMC guideline would be maintaining low

breastfeeding initiation and exclusive breastfeeding rates at 51.9% and 3.6%, respectively, at

discharge from the neonatal units (Chan, 2013; Chan & Liu, 2014).

To conclude that it would be safe to implement the KMC guideline after consideration

the risks of implementing and not implementing it.

3.1.3.2 Potential material and nonmaterial benefits.

There would be numerous potential benefits, material and nonmaterial, to implement

the KMC guideline. The identified studies showed that KMC increased breastfeeding

initiation rate and exclusivity. Moreover, the length of stay was ten days shorter for LBW

infants in the KMC group when compared with that of the control group (Boo & Jamli, 2007;

Charpak et al., 2001). There would be reduction in maternal anxiety and depression; more

positive mother-infant interaction; enhancement of LBW infants’ physiologic stability;

reduction in pain; and reduction in morbidity, health care utilization and environmental costs

associated with breastfeeding (Athanasopoulou & Fox, 2014; Nyqvist et al., 2010; Rollins et

al., 2016).


There was an economic analysis carried out in the United Kingdom that every £1

invested in increase KMC and breastfeeding initiation rate, from 4-fold to 13.8-fold of

benefits would be generated (Lowson, Offer, Watson, McGuire, & Renfrew, 2015). The

benefits generated were relating to reduction in length of hospital stay in neonatal units and

readmission after the primary discharge.

3.1.3.3 Material and nonmaterial costs.

The total estimated set-up cost for the first year for the equipment, facilities, printings,

didactic education program and implementation of KMC guideline would be Hong Kong

(HK) $1,232,250.7. The total estimated running cost for subsequent year would be

HK$1,219,495.8. There would be nonmaterial costs including meeting time with the

stakeholders and other disciplines; and the time and passion for preparing the training

materials and developing the KMC guideline. There would be no material cost for not

implementing the KMC guideline. The nonmaterial cost for not implementing the KMC

guideline would be the health and environmental benefits generated from breastfeeding .The

cost-benefit ratio would be 1:4 (Lowson, Offer, Watson, McGuire, & Renfrew, 2015).

Therefore, the total estimated HK$4,929,002.8 benefits would be generated one year after the

implementation of the KMC guideline. The details of the cost and benefits calculation were

presented in Appendices H, I, and J.


In conclusion, barriers and facilitators were identified and transferability, feasibility

and cost-benefit ratio were discussed; it would be high potential and cost-effective to

implement KMC guideline successfully in the local neonatal unit.

3.2 Evidence-Based Practice Guideline

After affirming the implementation potential of the KMC guideline, an

evidence-based KMC guideline, named ‘Keep in Touch’, with nine recommendations were

developed for the nurses and the mothers with LBW infants in neonatal unit to provide KMC

smoothly without hurting the vulnerable LBW infants and to achieve the intended objectives,

increasing breastfeeding initiation rate and exclusivity. They were based on the

recommendations of the identified studies and they were graded according to the grades of

recommendations of the SIGN (2016) (see Appendix K). The details of the evidence-based

KMC practice guidelines were presented in Appendix L.

3.3 Conclusion

The evidence-based ‘Keep in Touch’ guideline was developed after assessing the

implementation potential. The implementation and evaluation plan of the guideline would be

illustrated in Chapter Four.


Chapter Four: Implementation Plan

In Chapter Three, the implementation potential of the evidence-based ‘Keep in Touch’

guideline on KMC for mothers with LBW infants was discussed and the ‘Keep in Touch’

guideline was developed. Implementing new guideline caused changes that impact the routine,

value, standard, and relationship. For the success of the change, strategic implementation and

evaluation plan should be set up with effective communication with the stakeholders and

target population. In this chapter, the communication and evaluation plans were explored.

4.1 Communication Plan

It would be a two-way communication among the stakeholders and project leaders

that building up supportive relationship, improving effectiveness, and achieving objectives of

the proposed guideline. Therefore, it would be vital to perform stakeholders analysis in

advance setting up the communication plan.

4.1.1 Stakeholders analysis.

Stakeholders were the people who affect or to be affected by the implementation of

the KMC guideline. Firstly, the key stakeholders should be identified and prioritized

depending on the degree of influence; people had higher degree of influence should be

approached earlier (Polit & Beck, 2012). There were four groups of stakeholders,

administrators, project leaders, frontline and administrative staff.


The administrators were the Chief of Service (COS) of the Department of Paediatrics

and Adolescent Medicine (P&AM), DOM of P&AM, and WM of the neonatal unit. The COS

and DOM were the arbitrators of resources and authority, and responsible for facilitation and

enabling changes. The WM organized day-to-day operation of the unit and arrange duty

roster for nurses and PCAs. Therefore, it would essential to obtain their support and advice at

the very beginning of the development of the guideline.

The project leaders would be a NC and an APN. They would responsible for the

liaison, development of the guideline, sourcing equipment, training, marketing, pilot testing,

implementation, evaluation, and melioration of the guideline regularly.

Nurses would be the most important personnel for the success of the implementation

of the KMC guideline; besides other frontline staffs would include doctors, house officers,

PCAs, allied health care professional, including physiotherapists, occupational therapists, and

radiologists. There were 54 nurses, 25 doctors, four house officers, 20 PCAs, and 60 allied

health care professionals. Their opinions, feedbacks, passion and following KMC guidelines

strictly for the target population would be necessary. The administrative staffs would include

ten persons of each of the audiovisual and procurement and supplies teams.

4.1.2 Communication process and implementation strategies.

A well planned with strategic communication would be incorporated into the project


development and would be carried out in four phases, preparation, pilot, implementation and

evaluation. The project calendar illustrated the tasks to be completed and timeline of the

proposed guideline (see Appendix M).

4.1.2.1 Preparation.

In the preparation phase, three months period, the project leaders would introduce the

scientific basis of KMC to WM to obtain advice and would formally propose the significance,

evidence, and cost-benefit ratio of KMC, problems of current practice, and the vision on the

necessity to translate evidence-based KMC into practice to COS and DOM in order to obtain

approval and resources. After getting approval from the administrators, the project leaders

would invite six RNs with different seniority and clinical experience who were interested at

KMC, and with passion and same direction to promote breastfeeding to form KMC the ‘focus

group’.

The KMC ‘focus group’ would form boarder and stronger network to collect

comments, facilitate brainstorming, and develop a detailed project plan. They would be

responsible for communication with the stakeholders; developing the guideline; preparing

and providing didactic education program; marketing; implementing and evaluating the

project. The audiovisual and procurement and supplies teams would be invited to source and

purchase equipment, and design the posters and flyers, respectively. Multiple Clinical


Management Team (CMT) and project development meetings would be held in every other

week and electronic mails (Emails) would be used to discuss the project development and

report the progress.

There would be a 1-month consultation period through Emails, informal discussion,

and meetings, to gather opinions and motivate frontline staff for the preparation of the

forthcoming implementation of the KMC guideline. After consultation, marketing including

putting posters on the notice board and in the hallway; sending Emails to all stakeholders;

and announcement in the CMT and department meetings and nursing handover during

morning and evening shifts, would be undertaken.

Moreover, 1-month training period, including eight mini-lectures and eight simulation

sessions, would be scheduled for all nurses. During the training sessions, the project leaders

would observe the attitudes of the nurses towards KMC; they would address their concerns,

difficulties and emotional impact and would provide support and reassurance accordingly

through Emails and informal discussion.

4.1.2.2 Pilot.

The second phase, pilot, would last for one month. The nurses would conduct pilot for

the target population. During the pilot, the group would observe the progress and hold

meeting weekly and communicate with the stakeholders through Emails, observation, and


informal discussion. After the pilot, report would be conducted and presented to the

administrators during CMT and department meetings.

4.1.2.3 Implementation.

The next phase would be the 6-month implementation period. The guideline would be

implemented for the target population by all nurses. The ‘focus group’ would observe the

performance, collect feedback, identify unforeseeable problems, review the guideline, and

communicate with the stakeholders with Emails, discussion in the CMT, department and

project development meetings.

4.1.2.4 Evaluation.

The last phase, evaluation, would last for four months. The ‘focus group’ would

collect data, perform data analysis, generate report, and disseminate evaluation report to the

stakeholders through Emails, meetings and informal discussion. The details of the

communication plan were illustrated in Appendix N.

4.2 Pilot Plan

The pilot was crucial to determine the feasibility of implementation of KMC guideline

in a small scale in the target setting. It provided occasion uncovering potential problems,

identifying logistical problems, and improving strategies to implement guideline into practice

(van Teijlingen, & Hundley, 2002). During pilot, minimum one committee of the ‘focus


group’ would be scheduled to work in each of the morning and evening shift to perform assist

and observe the nurses to implement KMC. They would review the problems encountered,

collect feedbacks from the frontline staff, solve the problems accordingly, and refine the

guideline comprehensively.

4.2.1 Subject enrollment strategies.

The identical inclusion and exclusion criteria for the mothers and the LBW infants

listed in the KMC guideline would be adopted to recruit eligible mother-infant dyads.

Convenience samples of eligible mother-infant dyads in the neonatal unit during the pilot

would be recruited. By observation, 20 eligible mother-infant dyads would be recruited

monthly. Every day, the duty-in-charge of the morning shift would identify eligible

mother-infant dyads for initiate KMC and the project leaders would confirm the eligibility

before implementing KMC by using a checklist (see Appendix O).

4.2.2 ‘Keep in Touch’ guideline.

After identifying the eligible mother-infant dyads and confirm the eligibility, the

nurses would approach them; would provide evidence-based KMC flyers; and implement the

‘Keep in Touch’ KMC guideline after obtaining consent. They would adhere to the guideline

strictly in order to protect the mother-infant dyads from human errors, for examples,

recruiting ineligible mother-infant dyads, accidental extubation, and dislodgement of other


medical devices during transferring and performing KMC. The nurses would monitor the

condition of all recruited mother-infant dyads.

4.2.3 Data collection.

Logistics, unforeseeable problems, and performance of implementing KMC would be

observed; and the appropriateness and completeness of documentation by nurses would be

assessed by the ‘focus group’ during the pilot phase. Moreover, feedbacks from the recruited

mothers would be collected. The observations and notes would be recorded in a reflective

diary.

4.2.4 Intervention after pilot.

The feedbacks collected during the pilot would be analyzed by the ‘focus group’.

They would investigate the concerns and barriers, for examples selecting eligible

mother-infant dyads, mothers reluctant to initiate KMC, lack of manpower and time, and

environmental and administrative factors; provide possible solutions; generate report; and

present to the stakeholders. After the discussion with the stakeholders for the problems and

solutions, the finalized KMC guideline would be developed.

4.3 Implementation Plan

After the pilot and development of the finalized KMC guideline, full implementation

of KMC guideline would be undergone.


4.4 Evaluation Plan

A comprehensive evaluation plan was essential to evaluate the process and the

outcomes; therefore, reviewing the current clinical services, improving quality of care and

providing data for scientific research would be achieved. The overall evaluation plan was

illustrated in Appendix P.

4.4.1 Process evaluation.

The didactic education program would be evaluated to improve the quality of the

teachers and the didactic education program. A self-reporting evaluation form using a 5-point

Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree) would be developed with

reference and expert opinions obtaining from NC and used to evaluate the didactic education

program (Likert, 1932; Social Sciences Research Centre, the University of Hong Kong, 2015)

(see Appendix Q).

4.4.2 Outcomes evaluation.

There were three types of outcomes, patient, healthcare provider and system, would

be evaluated.

4.4.2.1 Patient outcomes.

The patient outcomes were crucial to form the basis for the evaluation of the

effectiveness of the proposed guideline. The breastfeeding rate and exclusivity of the


mother-infant dyads were the primary outcomes; and the acceptability of KMC by the

mothers was the secondary outcome. Clear instructions would be provided by the project

leaders to the nurses for how to record the input and output charts, feeding mode data

collection forms, implementation records of KMC, KMC diaries and feeding diaries (See

Appendices R, S, T and U). Meanwhile the KMC and feeding diaries would be given to the

mothers with LBW infants when the LBW infants to be discharge home to record their KMC

practice and feeding mode at home. Clear instructions for how to record the KMC practice

and feeding mode would be provided to the mothers by the nurses. The acceptability of KMC

by the mothers with LBW infants would be evaluated with a self-reporting survey using a

5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree) with references

of the studies and expert opinions obtaining from NC to assess their perception and worries

about KMC (Chia, Sellick, & Gan, 2006; Gathwala, Singh, & Balhara, 2008) (see Appendix

V). The ‘focus group’ would retrieve the breastfeeding data from the medical records and

feeding diaries; and distribute and collect the surveys from all the recruited mothers.

4.4.2.2 Healthcare provider outcomes.

The positive and supportive attitudes of the nurses would lead to successful KMC

practice. Therefore, a self-reporting survey would be developed with references of the studies

and expert opinions obtaining from NC and used to evaluate the nurses’ attitudes towards


KMC and the knowledge of KMC of the nurses (Gathwala, Singh, & Balhara, 2008; Strand,

Blomqvist, Gradin, & Nyqvist, 2014) (See Appendix W and X). In addition, a performance

assessment form would be formulated to evaluate the extent of the guideline actually

followed by the nurses (see Appendices Y). The ‘focus group’ would distribute and collect

the surveys from nurses and the project leaders would execute the performance assessment.

4.4.2.3 System outcomes.

Improvement in quality of care and cost saving from the implementation of KMC

guideline could be considered to be the system outcomes; however, these would be difficult

to be measured and evaluated solitarily. Therefore, a financial report would be submitted to

evaluate the actual cost of the proposed guideline. The actual cost of the equipment, facilities,

printings, and time for implementing KMC would be calculated and presented in the financial

report. Moreover, the adverse events, including hypothermia, hyperthermia, number of

desaturation, apnoea, bradycardia, infection of the LBW infants, if any; and complaints from

the mothers, if any, would be evaluated by observation, data from medical records, reflective

diary, and record of complaints.

4.4.3 Nature and number of clients to be involved.

4.4.3.1 Mothers with LBW infants.

Identical inclusion and exclusion criteria for the mothers and LBW infants listed in


the KMC guideline would be adopted to recruit target mother-infant dyads. Convenience

samples of eligible mother-infant dyads admitting to the neonatal unit would be recruited.

The sample size of the target mother-infant dyads should be precisely considered to

control the risk of reporting false-negative finding; detect a meaningful difference; estimate

precision; maintain ethical; and prevent wastage of resources (Biau, Kernéis, & Porcher,

2008). The sample size would be calculated by using a Java Applet, Piface (Lenth, 2011).

Two-tailed z-test for testing one proportion would be used to calculate the sample size. The

breastfeeding initiation and exclusive breastfeeding rates at discharge of the local setting

were 51.9% and 3.6%, respectively (Chan, 2013; Chan & Liu, 2014); and the effect sizes of

the included studies for breastfeeding initiation rate at discharge was 15% and exclusive

breastfeeding rate at 3-month old of the LBW infants were 16% and 27.4% (Ali, Sharma,

Sharma, & Alam, 2009; Boo & Jamli, 2007; Gathwala, Singh, & Balhara, 2008). Therefore,

102 mother-infant dyads should be recruited to detect differences of 15% and 10% for

breastfeeding initiation and exclusive breastfeeding rates, respectively, with 95% level of

confidence and a power of 80%. Allowing for 10% attrition up to 3-month old of the LBW

infants, additional 12 mother-infant dyads would be required. The total required

mother-infant dyads would be 114. Assuming a recruitment rate of 70% and 30 LBW infants

would admit the neonatal unit monthly, six months would be required to recruit 114


mother-infant dyads.

4.4.3.2 Frontline staff.

All 54 nurses, except the committees of the ‘focus group’, attending the didactic

education program would be recruited to evaluate the didactic education program, attitudes

towards KMC, and knowledge on KMC. There would be 48 nurses eligible to be involved.

All nurses, except the project leaders would be recruited to be evaluated for the clinical

performance assessment for implementing KMC.

4.4.4 Timing and Frequency of Taking Measures.

4.4.4.1 Process outcome.

The evaluation of the didactic education program would be undertaken immediately

after the program.

4.4.4.2 Patient outcomes.

The breastfeeding mode, exclusively, partial, or none, of the mothers would be

collected at discharge, 1-month, and 3-month old of the LBW infants. If the LBW infants had

been discharged, interview at out-patient clinic, if arranged prior based on the medical

condition of the infants, or telephone interview, would be provided at 1-month and 3-month

old of the LBW infants. The acceptability of KMC by mothers would be collected after

completion of KMC or before discharge of the LBW infant, whichever comes first.


4.4.4.3 Healthcare provider outcomes.

The surveys on attitudes towards KMC would be collected at 3-months after

implementation and the knowledge on KMC would be collected before the pilot and

3-months after the implementation of the KMC guideline. The clinical performance

assessment would be carried out at 3-month and 6 month after the implementation of KMC

guideline.

4.4.4.4 System outcomes.

The adverse events and complaints, if any, would be evaluated at 3-month and

6-month after the implementation of the KMC guideline to review the drawbacks. A financial

report to compare the actual and estimated costs would be generated at 6-month after the

implementation of the KMC guideline.

4.4.5 Analysis of data.

IBM Statistical Package for the Social Science Statistics (IBM Corp., 2012) would be

used for statistical analysis. Descriptive statistics, including mean, median, range, standard

deviation and percentage would be used to describe the samples characteristics, breastfeeding

rate and exclusivity. Two-sample z-test would be performed to analyze the breastfeeding rate

and exclusivity with level of significance at p-value <0.05. The quality of the didactic

education program, acceptability of KMC by the mothers, attitudes, knowledge, and


compliance rate of the KMC guideline of the nurses would be reported with response

frequency, percentage and mean ratings. All data, results, recommendations and implication

would be reported to the administrators in the CMT and staff meetings.

4.5 Basis for Implementation

The target of the proposed KMC guideline were set on the basis of the primary patient

outcomes of evidence synthesis accomplished in Chapter Two, achievability in practical, and

recommendation from the experts in neonatal care. The proposed KMC guideline would be

determined to be effective when 15% and 20% increases in the breastfeeding initiation and

exclusive breastfeeding rates at discharge, respectively.

4.6 Conclusion

After exploring and appraising the current evidence, KMC was a safe and effective

intervention to increase breastfeeding initiation rate and exclusivity for mothers with LBW

infants. In addition, the guideline for implementing KMC was developed and the

implementation and evaluation plans were discussed. After implementing the ‘Keep in Touch’

KMC guideline, we could further explore the effectiveness of KMC for LBW infants and

provide higher quality of care for them.


Appendix A – Scottish Intercollegiate Guidelines Network Methodology Checklist for

Controlled Trials

S I G N

Methodology Checklist 2: Controlled Trials

Study identification (Include author, title, year of publication, journal title, pages)

Guideline topic: Key Question No: Reviewer:

Before completing this checklist, consider:

1. Is the paper a randomised controlled trial or a controlled clinical trial ? If in doubt, check the study design algorithm available from SIGN and make sure you have the correct checklist. If it is a controlled clinical trial questions 1.2, 1.3, and 1.4 are not relevant, and the study cannot be rated higher than 1+

2. Is the paper relevant to key question? Analyse using PICO (Patient or Population Intervention Comparison Outcome). IF NO REJECT (give reason below). IF YES complete the checklist.

Reason for rejection:

1. Paper not relevant to key question � 2. Other reason � (please specify):

SECTION 1: INTERNAL VALIDITY

In a well conducted RCT study… Does this study do it?

1.1 The study addresses an appropriate and clearly focused question.

Yes �

Can’t say � No �

1.2 The assignment of subjects to treatment groups is randomised.

Yes �

Can’t say �

No �

1.3 An adequate concealment method is used. Yes �

Can’t say �

No �

1.4 The design keeps subjects and investigators ‘blind’ about treatment allocation.

Yes �

Can’t say �

No �

1.5 The treatment and control groups are similar at the start of the trial.

Yes �

Can’t say □

No �

1.6 The only difference between groups is the treatment under investigation.

Yes �

Can’t say �

No �


1.7 All relevant outcomes are measured in a standard, valid and reliable way.

Yes �

Can’t say �

No �

1.8 What percentage of the individuals or clusters recruited into each treatment arm of the study dropped out before the study was completed?

1.9 All the subjects are analysed in the groups to which they were randomly allocated (often referred to as intention to treat analysis).

Yes �

Can’t say �

No �

Does not apply �

1.10 Where the study is carried out at more than one site, results are comparable for all sites.

Yes �

Can’t say �

No �

Does not apply �

SECTION 2: OVERALL ASSESSMENT OF THE STUDY

2.1 How well was the study done to minimise bias? High quality (++)�

Acceptable (+)�

Low quality (-)�

Unacceptable – reject 0 �

2.2 Taking into account clinical considerations, your evaluation of the methodology used, and the statistical power of the study, are you certain that the overall effect is due to the study intervention?

2.3 Are the results of this study directly applicable to the patient group targeted by this guideline?

2.4 Notes. Summarise the authors’ conclusions. Add any comments on your own assessment of the study, and the extent to which it answers your question and mention any areas of uncertainty raised above.

Source: Scottish Intercollegiate Guidelines Network. (2015b, September 7). Methodology

checklist 2: Randomised controlled trials. Retrieved from

http://www.sign.ac.uk/methodology/checklists.html


Appendix B – Scottish Intercollegiate Guidelines Network Grading System 1999-2012

Levels of evidence

1++ High quality meta-analyses, systematic reviews of RCTs, or RCTs with a

very low risk of bias

1+ Well-conducted meta-analyses, systematic reviews, or RCTs with a low risk

of bias

1- Meta-analyses, systematic reviews, or RCTs with a high risk of bias

2++ High quality systematic reviews of case control or cohort or studies

High quality case control or cohort studies with a very low risk of

confounding or bias and a high probability that the relationship is causal

2+ Well-conducted case control or cohort studies with a low risk of confounding

or bias and a moderate probability that the relationship is causal

2- Case control or cohort studies with a high risk of confounding or bias and a

significant risk that the relationship is not causal

3 Non-analytic studies, e.g. case reports, case series

4 Expert opinion

Source: Scottish Intercollegiate Guidelines Network. (2015a, August 27). Levels of evidence

1999-2012. Retrieved from

http://www.sign.ac.uk/guidelines/fulltext/50/annexoldb.html


Appendix C – Preferred Reporting Items for Systematic reviews and Meta-Analysis

Search Strategies Flowchart

Footnote: CNC, Conventional neonatal care; LBW, Low birth weight; and RCT, Randomized

controlled trial.

Adopted from Liberati, A., Altman, D. G., Tetzlaff, T., Mulrow, C., Gøtzsche, P. C., Ioannidis,

J. P ... Moher, D. (2009). The Preferred Reporting Items for Systematic reviews and

Meta-Analysis statement for reporting systematic reviews and meta-analyses of studies that

evaluate health care interventions: explanation and elaboration. PLoS Medicine, 6(7),

e1000100. doi:10.1371/journal.pmed.1000100

Iden

tific

atio

n

Scr

eeni

ng

Elig

ibili

ty

Incl

uded

Records identified through database searching

Cochrane Library (n=4) CINAHL Plus (n=188)

PubMed (n=375)

Randomized controlled trials included in the review

(n=7)

Additional records identified through manual search of the references of

relevant studies (n=1)

Studies included in qualitative

assessment

(n=8)

Record excluded (n=1) Reason for exclusion: Unacceptable quality (n=1)

Records after duplicates removed

(n=447)

Records screened

(n=447)

Records excluded

(n=415)

Full-text of the studies assessed for

eligibility

(n=32)

Records excluded (n=24) Reasons for exclusion: Not RCTs (n=16) Not breastfeeding (n=2) Not LBW infants (n=4) Not comparing with CNC (n=2)

Appendix D – Table of Evidence of the Included Studies

Citation / Design

(Study quality) Subjects characteristics Intervention group (IG)

Control group

(CG)

Outcomes

measures Effect size

Ali et al. (2009)

RCT (1-)

1. Stable infants in a tertiary

care hospital

2. Mean (± SD) birth weight

(g) = 1,611 ± 211

3. Mean (± SD) gestational

age (week) = 33.3 ± 2.3

4. Mean (± SD) age (years)

of the mothers = 25 ± 3.7

� Infants were put between the mothers’ breasts with

skin-to-skin contact in upright position, dressed with bonnet,

socks and diaper and supported in bottom with a sling/binder

� Front open gowns, comfortable chairs and beds were available

for the mothers and privacy was provided

� KMC was given for a minimum of 1 hour/session and at least

for 4 to 6 hours/day, duration was gradually increased to as

long as comfortable to the mothers and the infants

(n = 58)

� Infants were

put under

radiant

warmers or

open cribs in

a warm room

(n = 56)

1. Exclusive

breastfeeding

rate (%)

1. At term:

22.4

(p=0.002)

3 months:

27.4

(p=0.002)

6 months:

29.1

(p=0.006)

Boo et al. (2007)

RCT (1+)

1. Stable infants in NICU of

a tertiary hospital

2. Mean (± SD) body weight

at enrollment (g) = 1,504

± 128

3. Mean (± SD) gestational

age at enrollment (week)

= 34.7 ± 2.1

4. Mean (± SD) age (years)

of the mothers = 30.6 ±

5.6

� Parents were trained to provide KMC with written instruction

and photographs

� Infants were prone between the naked chest of their parents

with skin-to-skin contact at semi-upright position, dressed

with diaper, bonnet and covered by a clean thermal blanket

� Parents wore clothing with buttons down their chest and sat in

a standard type of sofa

� KMC was performed for minimum1 hour daily

(n=64)

� Infants were

put in

incubators

(n=62)

1. Breastfeeding

rate (%)

1. At discharge:

15.2 (p=0.04)

Footnote: KMC, Kangaroo mother care; NICU, Neonatal intensive care unit; p, p-value; RCT, Randomized controlled trail; and SD, Standard deviation.

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Citation / Design

(Study quality)

Subjects

characteristics Intervention group (IG)

Control group

(CG)

Outcomes


Charpak et al.

(2001)

RCT (1-)

1. Stable infants

admitted to

level III NICU

2. Mean (± SD)

birth weight (g)

= 1,720 ± 261

3. All infants are

less than 37

weeks of

gestational age

� Infants were kept in upright position, skin-to-skin

contact and firmly attached to the mother’s chest

to maintain body temperature for 24 hours per day

� Infants were breastfed regularly and supplemented

with premature formula if indicated

� Infants were remained in the kangaroo position

until they no longer accepted it

(n = 382)

� Infants were kept in

incubators until they could

regulate their temperature

and had appropriate

weight gain

� Parents were severely

restricted to access the

infants

(n = 364)

1. Breastfeeding

rate (%)

1. At term:

4.7 (p=0.001)

3 months:

6.4 (p=0.05)

6 months:

3.4 (p=NS)

9 months:

1.5 ( p=NS)

12 months:

-2.5 (p=NS)

Gathwala et al.

(2010)

RCT (1-)

1. Stable infants in

a neonatal unit

2. Mean (± SD)

birth weight (g)

=1,690 ± 120

3. Mean (± SD)

gestational age

(week) = 35.3 ±

1.2

� Infants were positioned between mothers’ breasts

with skin-to-skin contact. Infants were naked

except for a bonnet and diaper. The gown covered

the infant’s trunk and extremities but not the head

� During KMC, mothers wore open front gowns

and sat in an inclined posture in a chair

� KMC lasted at least 6 hours/day for a maximum

of 4 sessions. Each session lasted for minimum of

1 hour and continued for as long as it was

comfortable for infant and mother.

(n = 50)

� Infants received standard

care under warmers or in

incubators

� Mothers were allowed to

visit, touch and handle the

infants

� Mothers fed the infants

with spoon and katori and

changed diapers

(n = 50)

1. Exclusive

breastfeeding

rate (%)

1. 3 month:

16 (p<0.05)

Footnotes: KMC, Kangaroo mother care; NICU, Neonatal intensive care unit; NS, Not significant; p, p-value; RCT, Randomized control trial; and SD, Standard deviation.

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Citation / Design

(Study quality)

Subjects

characteristics Intervention group (IG)

Control group

(CG)

Outcomes


Ghavane et al.

(2012)

RCT (1+)

1. Stable infants in

a tertiary care

hospital

2. Mean (± SD)

birth weight (g)

= 1,184 ± 194

3. Mean (± SD)

gestational age

(week) = 30.8 ±

2.1

� Infants received skin-to-skin contact between

mother’s breasts in an upright position, dressed

with a bonnet, socks and diaper and supported at

the bottom with a cloth

� Comfortable chair and beds were provided

� Mothers were encouraged to perform KMC for

as long as possible, ensuring a minimum of 8

hours daily

(n = 71)

� Infants were taken care by the

nurses in incubators or under

warmer with constant

monitoring

� Mothers were encouraged to

join infant care activities

(n = 69)

1. Breastfeeding

rate (%)

2. Exclusive

breastfeeding

rate (%)

1. -1.1 (p=0.68)

2. -0.9 (p=0.91)

Ramanathan et al.

(2001)

RCT (1-)

1. Stable infants

2. Mean (± SD)

birth weight (g)

= 1,245 ±186.4

3. Median

gestational age

(week) (Range)

= 30.4 - 30.9

(28.8 - 34.1)

� Infants were positioned inside mothers’ dress

and between the breasts with skin-to-skin

contact and covered with a bonnet

� During KMC, each mother wore a cover gown

and sat in an inclined chair. The gowns covered

the infants’ trunk and extremities, but not the

head

� Infants received KMC for at least 4 hours per

session for maximum 3 sessions daily

(n = 14)

� Infants were put under

warmers or in the incubators

� Mothers were allowed to visit

the infants, touched and

handled the infants

� Mothers fed the infants with

spoon

(n = 14)

1. Exclusive

breastfeeding

rate (%)

1. 42.8

(RR=2; 95%

CI = 1.05 -

3.8),

(p=0.04)

Footnote: CI, Confidence interval; KMC, Kangaroo mother care; p, p-value; RCT, Randomized controlled trial; RR, Relative risk; and SD,

Standard deviation.

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Citation / Design

(Study quality) Subjects characteristics Intervention group (IG)

Control group

(CG) Outcomes measures Effect size

Rojas et al.

(2003)

RCT (1-)

1. Stable infants with

minimal ventilator

support in a tertiary

care hospital

2. Mean (± SD) birth

weight (g) = 921 ±

245

3. Mean (± SD)

gestational age

(week) = 26.9 ± 2.3

4. All mothers were

> 18 years old

� Infants were held in prone

semi-upright position at

approximately a 45 degree angle

with skin-to-skin contact with the

parent’s chest

� The infants wore diaper only and

the backs were covered by a blanket

� Parents were not prohibited to offer

tradition holding in lieu of KMC

(n = 33)

� Infants were put in

incubators for

thermoregulation

� Parents were

allowed to hold the

infants in supine

position with

eye-to-eye contact

(n = 27)

1. Breastfeeding

rate (%)

1. 25

(OR 2.8,

95% CI

1.0-8.3),

(p=0.06)

Footnote: CI, Confidence interval; KMC, Kangaroo mother care; OR, Odds ratio; p, p-value; RCT, Randomized control trial; and SD,

Standard deviation

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Appendix E – Quality Assessment of the Included Studies

Section 1: Internal validity

Ali et al.

(2009)

Boo et al.

(2007)

Charpak et al.

(2001)

Gathwala et

al. (2010)

Ghavane et al.

(2012)

Ramanathan

et al. (2001)

Rojas et al.

(2003)

Clearly focused

question Yes Yes Yes Yes Yes Yes Yes

Randomization Yes Yes Yes Yes Yes Yes Yes

Allocation

concealment No Yes No No Yes No Yes

Blinding No No No No No No No

Comparable

groups Yes Yes Yes Yes Yes Yes Yes

Treatment is the

only difference Yes Yes No Yes Yes Yes Yes

Valid and reliable

outcome measures Can’t say Can’t say Can’t say No Can’t say No No

Drop-out rate (%) CG IG 0

CG IG Overall: 9.1

CG IG 0

CG IG

32.8 35.7 8.4 5.8 4.2 1.4 6.1 2.7

Intention to treat

analysis Can’t say Yes No No No Yes No

Comparable results

from all sites

Not

applicable

Not

applicable

Not

applicable Not applicable

Not

applicable

Not

applicable Not applicable

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Section 2: Overall assessment of the study

Ali et al.

(2009)

Boo et al.

(2007)

Charpak et al.

(2001)

Gathwala et

al. (2010)

Ghavane et al.

(2012)

Ramanathan

et al. (2001)

Rojas et al.

(2003)

Risks of bias

minimize - + - - + - -

Overall effect due

to intervention

alone

No Yes No Yes No Yes Yes

Results applicable

to target group Yes Yes No Yes No Yes Yes

Notes No sample size

calculation

Sample size

calculated was

able to detect a

25% difference

in breastfeeding

rate between

the two groups,

with an alpha

5% and power

of 80%

Sample size

computation

was fell short

No sample size

calculation

Sample size

calculation was

based on to

detect a

difference of

weight gain

5g/day between

the two groups

with an alpha of

0.05 and power

of 80%

Sample size

calculation was

based on

previous study

with an alpha of

0.05 and power

of 80%

Small sample

size

Sample size

calculated was

able to detect

20% difference

in mother-infant

interaction with

alpha of 0.05

and power of

86%

Small sample

size

Level of evidence 1- 1+ 1- 1- 1+ 1- 1-

Footnote: ‘+’, Acceptable quality; ‘-’, Low quality; CG, Control group; and IG, Intervention group.

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Appendix F – Effect Sizes on Breastfeeding Rate and Exclusivity of the Included Studies

Measurement

points

Ali et al.

(2009)

Boo et al.

(2007)

Charpak et

al. (2001)

Gathwala

et al.

(2010)

Ghavane et

al. (2012)

Ramana-

than et al.

(2001)

Rojas et al.

(2003)

Breastfeeding rate

At discharge --- 15.2

(p=0.04) --- --- --- ---

25

(p=0.06)

At term --- --- 4.7

(p=0.001) ---

-1.1

(p=0.68) --- ---

3 months --- --- 6.4

(p=0.05) --- --- --- ---

6 months --- --- 3.4

(p=NS) --- --- --- ---

9 months --- --- 1.5

(p=NS) --- --- --- ---

12 months --- --- -2.5

(p=NS) --- --- --- ---

Exclusive breastfeeding rate

At discharge --- --- --- --- --- --- ---

At term 22.4

(p=0.002) --- --- ---

-0.9

(p=0.91) --- ---

6 weeks after

discharge --- --- --- --- ---

42.8

(p=0.04) ---

3 months 27.4

(p=0.002) --- ---

16

(p<0.05) --- --- ---

6 months 29.1

(p=0.006) --- --- --- --- --- ---

12 months --- --- --- --- --- --- ---

18 months --- --- --- --- --- --- ---

Footnote: ‘---’, No reported results; NS, Not significant; and p, p-value.

Remarks: The exact p-value of all reported as not significant were not reported by the studies.

Appendix G – Diversity of Intervention of the Included Studies

Characteristics of

KMC Ali et al. (2009)

Boo et al.

(2007)

Charpak et al.

(2001)

Gathwala et al.

(2010)

Ghavane et al.

(2012)

Ramanathan et

al. (2001)

Rojas et al.

(2003)

Person(s)

providing KMC Mother Parents Mother Mother Mother Mother Parents

Skin-to-skin

contact Yes Yes Yes Yes Yes Yes Yes

Position of the

infants Upright

Prone,

semi-upright Upright --- Upright ---

Prone,

semi-upright

Position of the

KMC provider --- --- --- Inclined posture --- Inclined posture

Clothing of the

infants

� Bonnet, socks

and diaper

� Supported

with cloth

� Bonnet and

diaper

� Covered with

thermal

blanket

---

� Bonnet and

diaper

� Covered with

gown

� Bonnet, socks

and diaper

� Supported

with cloth

� Bonnet

� Covered by

gown

� Diaper

� Covered with

blanket

Clothing for the

KMC provider(s)

Front open

gown

Clothing with

buttons ---

Front open

gown --- Cover gown ---

Breastfeeding

during KMC --- --- Yes --- --- --- ---

Privacy provided Yes --- --- --- --- --- ---

Special facilities Comfortable

chair and bed Sofa ---

Comfortable

chair

Comfortable

chair and bed

Comfortable

chair

Comfortable

chair

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Characteristics of

KMC Ali et al. (2009)

Boo et al.

(2007)

Charpak et al.

(2001)

Gathwala et al.

(2010)

Ghavane et al.

(2012)

Ramanathan et

al. (2001)

Rojas et al.

(2003)

Continue KMC

after discharge Yes NA Yes Yes Yes Yes NA

Training of KMC

to provider --- Yes --- --- --- --- ---

Remarks ---

Mother of the

control group

were

encouraged to

breastfeed at

every 2 to 2 1/2

hour

Parents of the

control group

were restricted

to access the

infants during

the study time

---

Strict adherence

to breastfeeding

policy

64.3% of

mothers

continued KMC

at home

Parents were

not prohibited

to offer tradition

holding in lieu

of KMC

Mean (± SD)

(range) length of

KMC (hours/day)

6.3 ± 1.52

(4 - 12)

Median = 1

Total 11.3 ± 5.9 ---

9.0 (1st month)

to 10.2 (3rd

month) ± 1.6

Minimum

8 hours/day --- 1.3 ± 0.67

Mean (± SD)

(range) duration

of KMC (day)

25.7 ± 6.9

(15 - 43) 10.0 ± 5.6 --- --- --- --- 15 ± 16

Footnote: ‘---’, Not reported; KMC, Kangaroo mother care; NA, Not applicable; and SD, Standard deviation.

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Appendix H – Estimated Set-up Cost for the First Year for the Implementation of

Kangaroo Mother Care Guideline

The estimation is based on the following assumptions:

1. About 240 mother-infant dyads will be eligible and recruited for kangaroo mother care

(KMC) annually, and

2. The average length of stay for each low birth weight (LBW) infant will be 30 days, and

3. Each project leader will conduct four sessions of 60-minute mini-lectures and four sessions

of 60-minutes simulation sessions, and

4. Ten Advanced Practice Nurses (APNs) and 44 Registered Nurses (RNs) will be arranged

to join the mini-lectures and simulation sessions, and

5. The mid-point of Hospital Authority General Pay Scale in April 2015 will be used to

calculate the hourly salary of the Nurse Consultant (NC), APN, and RN (Hospital

Authority, 2016), and

6. The hourly salary for each rank will be calculated with the following formula, and

Hourly salary = Monthly salary

30 (days/month) x 8 (working hours/day)

Rank Start point Midpoint End point Midpoint salary

(HK$)

Hourly salary

(HK$)

NC 34 39 37 70,955.0 295.6

APN 26 33A 30 54,220.0 225.9

RN 15 25 20 34,180.0 142.4

Source: Hospital Authority. (2016, January 28). Hospital Authority pay adjustment

2015/16. Retrieved from

https://gateway1.ha.org.hk/hr/,DanaInfo=kec.home+Hr-2015-21.pdf

7. The preparation time for the equipment and environment for KMC, transferring the LBW

infants to the mothers’ breasts, and transferring back to the incubators/cribs will be 15

minutes, and two-nurse transfer techniques will be used, and

8. Two sessions of KMC will be provided for every LBW infant daily, and

9. Each nurse will have equal chance to implement KMC guideline during the hospital stay of

the LBW infants.

Estimated set-up material cost for equipment and facilities

Items Unit price (HK$) Quantity Amount (HK$)

1. Comfortable reline chair 2,000.0 20 40,000.0

2. Privacy screen 2,000.0 10 20,000.0

3. Handheld mirror 30.0 20 600.0

4. Front-opening gown NA 100 Hospital provided

5. Bonnet NA 100 Hospital provided

6. Sock NA 100 pairs Hospital provided

7. Covering cloth NA 100 Hospital provided

8. Video recorder NA 1 Hospital provided

9. Stationery NA NA Hospital provided

10. Computer and software (Microsoft Word,

Excel, and PowerPoint) NA NA Hospital provided

11. Equipment and facilities for the meetings NA NA Hospital provided

Total estimated set-up cost for equipment and facilities: 60,600.0 (1)

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Estimated set-up material cost for printing

Items Unit price

(HK$) (a)

Number of

personnel involved

(b)

Quantity per

person (c)

Total quantity

(b x c)

Amount (HK$)

(a x b x c)

1. Input and output chart NA 240 30 7,200 Hospital provided

2. Feeding mode data collection form 0.5 240 1 240 120.0

3. Implementation record of KMC 0.5 240 6 1,440 720.0

4. Feeding diary 5.0 240 1 240 1,200.0

5. KMC diary 5.0 240 1 240 1,200.0

6. Poster 10.0 NA NA 10 100.0

7. Parent education flyer 1.0 240 1 240 240.0

8. Survey on acceptability of KMC 1.5 240 1 240 360.0

9. Survey of attitudes towards KMC 1.5 48 1 48 72.0

10. Survey on knowledge of KMC 1.0 48 1 48 48.0

11. Clinical assessment form for

implementing KMC 1.0 54 1 54 54.0

Total estimated set-up material cost for printing: 4,114.0 (2)

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Estimated set-up material cost for KMC didactic education program

Items Hourly salary

(HK$) (a)

Number of

nurses

involved (b)

Training time

required

(Hour/session) (c)

Number of

training sessions

(d)

Total amount (HK$)

(a x b x c x d)

1. Nurse Consultant 295.6 1 1 8 2,364.8

2. Advanced Practice Nurse (trainer) 225.9 1 1 8 1,807.2

3. Advanced Practice Nurse (trainee) 225.9 10 1 2 4,518.0

4. Registered Nurse 142.4 44 1 2 12,531.2

Total estimated set-up material cost for KMC didactic education program: 21,221.2 (3)

Estimated set-up material cost for implementing KMC (two-nurse transfer techniques)

Items Hourly salary

(HK$) (a)

Number of

nurses

involved (b)

Time for KMC

implementation

(Hour/session) (c)

Number of KMC

sessions (per

nurse/year) (d)

Total amount (HK$)

(a x b x c x d)

1. Advanced Practice Nurse 225.9 11 0.25 524 325,521.9

2. Registered Nurse 142.4 44 0.25 524 820,793.6

Total estimated set-up material cost for implementing KMC (two-nurse transfer techniques): 1,146,315.5 (4)

Total estimated set-up cost for the first year for the implementation of KMC guideline ( 1 + 2 + 3 + 4 ):

1,232,250.7

Footnote: HK, Hong Kong; and NA, Not applicable.

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Appendix I – Estimated Running Cost for the Subsequent Year for the Implementation

of Kangaroo Mother Care Guideline

The estimation is based on the following assumptions:

1. About 240 mother-infant dyads will be eligible and recruited for kangaroo mother care

(KMC) annually, and

2. The average length of stay for each low birth weight (LBW) infant will be 30 days, and

3. An Advanced Practice Nurse (APN) will conduct two sessions of 60-minute mini-lectures

and two sessions of 60-minute simulation sessions to 12 newly joined nurses annually, and

4. The mid-point of Hospital Authority General Pay Scale in April 2015 will be used to

calculate the hourly salary of the APNs and RNs (Hospital Authority, 2016)

5. The hourly salary for each rank will be calculated with the following formula, and

Hourly salary = Monthly salary

30 (days/month) x 8 (working hours/day)

Rank Start point Midpoint End point Midpoint salary

(HK$)

Hourly salary

(HK$)

APN 26 33A 30 54,220.0 225.9

RN 15 25 20 34,180.0 142.4

Source: Hospital Authority. (2016, January 28). Hospital Authority pay adjustment

2015/16. Retrieved from

https://gateway1.ha.org.hk/hr/,DanaInfo=kec.home+Hr-2015-21.pdf

6. The preparation time for the equipment and environment for KMC, transferring the LBW

infants to the mothers’ breasts, and transferring back to the incubators/cribs will be 15

minutes, and two-nurse transfer techniques will be used, and

7. Two sessions of KMC will be provided for every LBW infant daily, and

8. Each nurse will have equal chance to implement KMC guideline during the hospital stay of

the LBW infants, and

9. The inflation rates for the equipment, facilities and the salary will be 5%.

Estimated running cost for equipment and facilities

Items Unit price (HK$) Quantity Amount (HK$)

1. Comfortable reline chair 2,100.0 2 4,200.0

2. Privacy screen 2,100.0 1 2,100.0

3. Handheld mirror 31.5 2 63.0

4. Front-opening gown NA 20 Hospital provided

5. Bonnet NA 20 Hospital provided

6. Sock NA 20 pairs Hospital provided

7. Covering cloth NA 20 Hospital provided

8. Stationery NA NA Hospital provided

9. Computer and software (Microsoft Word,

Excel, and PowerPoint) NA NA Hospital provided

10. Equipment and facilities for the meetings NA NA Hospital provided

Total estimated running cost for equipment and facilities: 6,363.0 (1)

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Estimated running cost for printing

Items Unit price

(HK$) (a)

Number of

personnel involved

(b)

Quantity per

person (c)

Total quantity

(b x c)

Amount (HK$)

(a x b x c)

1. Input and output chart NA 240 30 7,200 Hospital provided

2. Feeding mode data collection form 0.6 240 1 240 144.0

3. Implementation record of KMC 0.6 240 6 1,440 864.0

4. Feeding diary 5.3 240 1 240 1,272.0

5. KMC diary 5.3 240 1 240 1,272.0

6. Poster 10.5 NA NA 10 105.0

7. Parent education flyer 1.1 240 1 240 264.0

8. Survey on acceptability of KMC 1.6 240 1 240 384.0

9. Survey of attitudes towards KMC 1.5 48 1 48 76.8

10. Survey on knowledge of KMC 1.1 48 1 48 52.8

11. Clinical assessment form for

implementing KMC 1.1 54 1 54 59.4

Total estimated running cost for printing: 4,494.0 (2)

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Estimated running cost for KMC didactic education program

Items Hourly salary

(HK$) (a)

Number of

nurses

involved (b)

Training time

required

(Hour/session) (c)

Number of

training sessions

(d)

Total amount (HK$)

(a x b x c x d)

1. Advanced Practice Nurse (trainer) 237.2 1 1 4 948.8

2. Registered Nurse 149.6 12 1 2 3,590.4

Total estimated running cost for KMC didactic education program: 4,539.2 (3)

Estimated running cost for implementing KMC (two-nurse transfer techniques)

Items Hourly salary

(HK$) (a)

Number of

nurses

involved (b)

Time for KMC

implementation

(Hour/session) (c)

Number of KMC

sessions (per

nurse/year) (d)

Total amount (HK$)

(a x b x c x d)

1. Advanced Practice Nurse 237.2 11 0.25 524 341,805.2

2. Registered Nurse 149.6 44 0.25 524 862,294.4

Total estimated running cost for implementing KMC (two-nurse transfer techniques): 1,204,099.6 (4)

Total estimated running cost for the subsequent year for the implementation of KMC guideline ( 1 + 2 + 3 + 4 ):

1,219,495.8

Footnote: HK, Hong Kong; and NA, Not applicable.

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Appendix J – Cost-Benefit Ratio for the Implementation of Kangaroo Mother Care

Guideline

The estimation is based on the following assumption:

1. Every $1 invested in the intervention to increase kangaroo mother care (KMC) and

breastfeeding rates, at least $4 of benefit will be generated (Lowson, Offer, Watson,

McGuire, & Renfrew, 2015).

Items Amount (HK$)

Total estimated cost for the first year for the implementation

of KMC guideline 1,232,250.7 (1)

Total estimated benefits generated one year after the

implementation of KMC guideline 4,929,002.8 (2)

Cost-benefit ratio = (1) ÷ (2) = 1 : 4

Footnote: HK, Hong Kong.

Source: Lowson, K., Offer, C., Watson, J., McGuire, B., & Renfrew, M. (2015). The

economic benefits of increasing kangaroo skin-to-skin care and breastfeeding in

neonatal units: Analysis of a pragmatic intervention in clinical practice. International

Breastfeeding Journal, 10, 11. doi:10.1186/s13006-015-0035-8


Appendix K – Grades of Recommendations of Scottish Intercollegiate Guidelines

Network

Grades of Recommendations

A At least one meta-analysis, systematic review, or RCT rated as 1++, and

directly applicable to the target population; or

A body of evidence consisting principally of studies rated as 1+, directly

applicable to the target population, and demonstrating overall consistency of

results

B A body of evidence including studies rated as 2++, directly applicable to the

target population, and demonstrating overall consistency of results; or

Extrapolated evidence from studies rated as 1++ or 1+

C A body of evidence including studies rated as 2+, directly applicable to the

target population and demonstrating overall consistency of results; or

Extrapolated evidence from studies rated as 2++

D Evidence level 3 or 4; or

Extrapolated evidence from studies rated as 2+

Source: Scottish Intercollegiate Guidelines Network (2016, February 28). Grades of

Recommendations. Retrieved from



Appendix L – ‘Keep in Touch’ Guideline for Kangaroo Mother Care

Document no. XXX-P&AM-KMC-V01

Issue date DD-MM-YYYY

Subject: ‘Keep in Touch’ Guideline for

Kangaroo Mother Care

Review date DD-MM-YYYY

Approved by P&AM, XXX Hospital

XXX Hospital

Department of Paediatrics and Adolescent Medicine (P&AM)

‘Keep in Touch’ Guideline for Kangaroo Mother Care

Version Effective date

1 DD-MM-YYYY

Document number: XXX-P&AM-KMC-V01

Author: Tang Hiu Tung, Registered Nurse (Specialty)

Custodian: P&AM, XXX Hospital

Approved by: P&AM, XXX Hospital

Approval date: DD-MM-YYYY

Distribution: All nurses and doctors of P&AM, XXX Hospital


1. Kangaroo mother care project team

Ms. XXX Nurse Consultant (P&AM) Project leader

Ms. XXX Advanced Practice Nurse (P&AM) Project leader

Ms. XXX Registered Nurse (P&AM) Committee






2. Background

In Hong Kong the breastfeeding initiation rate and exclusivity of mothers with low

birth weight (LBW) infants were suboptimal. The breastfeeding initiation rate and the rate

of exclusive breastfeeding at discharge from all public neonatal units were 58.4% and

5.3%, respectively (Chan, 2013; Chan & Liu, 2014). Kangaroo mother care (KMC)

included early and continuous, as long as 24 hours a day as possible, skin-to-skin contact

between the infants and the mother’s breasts; exclusive and nearly exclusive breastfeeding;

and early discharge from the healthcare facility (Charpak, Figueroa de Calume, &

Ruiz-Pela´ez, 2000; Martinez, Rey Sanabria, & Marquette, 1992; Nyqvist et al., 2010).

Skin-to-skin care was recommended for the vulnerable infants, for an example LBW

infants (Spatz, 2004) and it was a humane, safe, effective and low cost alternative to

conventional neonatal care for LBW infants (Ludington-Hoe, 2015; Welch et al., 2013).

There were numerous benefits, including better thermal regulation, promotion

breastfeeding, fewer occurrences of bradycardia and apnoea, better weight gain, shorter

hospital stay, and facilitation of mother infant attachment, associated with KMC for LBW

infants (Boo & Jamli, 2007; Gathwala, Singh, & Balhara, 2008; Suman, Udani, &


Nanavati, 2008). Moreover, there was an economic benefit of increasing KMC and

breastfeeding. Every dollar of investment to increase KMC and breastfeeding rate, a

maximum of 13.8-fold of benefit was generated (Lowson, Offer, Watson, McGuire, &

Renfrew, 2015). The mainstay of KMC was encouragement of breastfeeding.

3. Objectives

The guideline was developed to provide evidence-based knowledge support to

nurses to facilitate the mothers with LBW infants to provide KMC and to increase

breastfeeding initiation rate and exclusivity.

4. Target users

All neonatal nurses of Department of P&AM, XXX Hospital.

5. Target population

Mothers with LBW infants.

6. Inclusion criteria

Mothers who are:

i. Able to follow the general instructions for KMC.

Infants who are:

i. Having birth weight less than 2,500 grams regardless the gestation age at birth, and

ii. Cardiopulmonary stable after recovering from all major adaptation problems to

extrauterine life.

7. Exclusion criteria

Mothers who are:

i. Having severe obstetric and medical problems, or

ii. Unable to come to the hospital because of illness, or

iii. Refusal for KMC.


Infants who are:

i. Having life threatening congenital malformation, or

ii. Having severe perinatal complications, for examples intraventricular hemorrhage,

necrotizing enterocolitis and hypoxic-ischemic encephalopathy, or

iii. Having gastroschisis, omphalocele, or myelomeningocele requiring sterilization prior

to surgery, or

iv. Putting in a humidified incubator, or

v. Having umbilical artery and/or vein catheter(s), or

vi. Receiving phototherapy with jaundice close to exchange transfusion zone.

8. Equipment and facilities

i. Comfortable recline chair with footstool, and

ii. Privacy screen, and

iii. Handheld mirror, and

iv. Front-opening gown, and

v. Bonnet, and

vi. Socks, and

vii. Warm covering cloth.

9. Procedures

Education and discussion with the parents

i. Provide parent education flyer and discuss with the parents for the scientific basis and

risks and benefits of KMC.

ii. Document parental decision and set up KMC plan with the mother such as when and

how often she is available to provide KMC.

iii. Confirm the eligibility by the project leaders with the use of checklist.


Preparation of environment, mother and the LBW infant

i. Collect necessary equipment and create a comfort environment before transfer: collect

comfortable recline chair, privacy screen, and handheld mirror; keep the monitor

alarms at low level of sound; decrease illumination; and limit the staff traffic and

chaos.

ii. Preparation for mothers: recently eaten, empty bladder, recently pumped breast milk,

adequate time allotted (minimal 1 hour), hand washing, and putting on front-opening

gown.

iii. Preparation for LBW infant: the Advanced Practice Nurse (APN) and/or Registered

Nurse (RN) assess and record the heart rates, respiration rates, oxygen saturation, body

temperature, and stability before transfer; secure the endotracheal tube, nasal prongs,

ventilator tubing, nasal catheter, intravenous access device(s) and/or gastric feeding

tube; perform suction when indicated, change diaper, remove clothing, and put on

bonnet and socks.

Transfer of LBW infant to the mother’s chest

i. Use a two-nurse transfer method, one nurse guides the ventilator support and the

second nurse lift and transfer the LBW infant to the mother’s chest with close

skin-to-skin contact.

ii. Place the LBW infant with upright and prone position with the head turning to one

side and cover the LBW infant with a warm cloth.

Stabilize and settle the mother-infant dyad in the KMC position

i. Secure the ventilator tubing over the mother’s shoulder; secure the intravenous access

device(s) and/or gastric feeding tube; and perform suction when indicated.

ii. Ensure the mother can reach the handheld mirror and take pictures for the mother if


she wants.

iii. The APN and/or RN assess and document the physiologic condition of the LBW infant

and starting time for KMC.

Transfer back to the incubator/crib

i. Once the LBW infant showing signs of unsettled activity, for examples frequent

apnoea and/or desaturation, color change, heart rate instability, irritability and/or the

mother is ready to place the LBW infants back to the incubator/crib, perform

two-nurse transfer method, one nurse guides the ventilator support and the second

nurse lift and transfer the LBW infant to the incubator/crib.

ii. Stabilize and settle the LBW infant in the incubator/crib, for examples securing the

ventilator tubing, intravenous access device(s) and/or gastric feeding tube, perform

suction and change diaper when indicated, and put on clothing.

iii. The APN and/or RN assess and document the physiologic condition of the LBW

infants and stopping time for KMC.

iv. Ask the mother to put off the front-opening gown and wash hands.

v. Tidy up the environment.

10. Recommendations with supporting evidence

Nine evidence-based recommendations are set up for the ‘Keep in Touch’ guideline. The

recommendations help the nurses and mothers with LBW infants to provide KMC

smoothly without hurting the fragile LBW infants and to achieve the intended objectives.

Each recommendation is evidence-based with grade of recommendation according to the

Scottish Intercollegiate Guideline Network (2016).


Recommendation 1: Moment to initiate KMC

Description: Initiate KMC when the LBW infants are cardiopulmonary stable after

recovering from all major adaptation problems to extrauterine life.

Grade of recommendation: B

Evidence: Kangaroo mother care associated with many health benefits for the mothers

and the LBW infants. It is safe and beneficial to the mother-infant dyad to

initiate KMC after stabilization and recovering from all major adaptation

problems to extrauterine life (Charpak, Ruiz-Pela´ez, Figueroa de Calume, &

Charpak, 2001; Gathwala et al., 2008; Ghavane et al., 2012; Ramanathan,

Paul, Deorari, Taneja, & George, 2001; Rojas et al., 2003). Risks and benefits

of KMC should be discussed with the parents before the initiation of KMC

(Boo & Jamli, 2007).

Recommendation 2: Length of KMC

Description: Kangaroo mother care preferably to be provided for a minimum 1 hour per

session and at least 6 hours per day. It could increase to as long as possible

and comfortable to the mother-infant dyads.


Evidence: The LBW infants receiving KMC should be constantly maintain in KMC

position except when changing diapers and for breastfeeding or oral feeding.

The mothers are encouraged to keep KMC for minimum 1 hour per session

and at least 6 hours per day to as long as the mother-infant dyads could be

tolerated (Ali, Sharma, Sharma, & Alam, 2009; Gathwala et al., 2008). If the

LBW infants have abnormal vital signs for more than 20 seconds or recur for

more than 1 episode or any life-threatening event takes place, for an example


dislodgement of the endotracheal tube, then terminate KMC immediately (Boo

& Jamli, 2007).

Recommendation 3: Duration of KMC

Description: Kangaroo mother care should be provided on daily basis until the

mother-infant dyads no longer accept and tolerate.


Evidence: The amount of time of KMC is associated with breastfeeding duration. The

mothers are encouraged to provide KMC daily and as long as the

mother-infant dyads could be tolerated. Kangaroo mother care should be

continued at home after the discharge of the LBW infants (Ali et al., 2009;

Charpak et al., 2001; Gathwala et al., 2008; Ghavane et al., 2012).

Recommendation 4: Maternal comfort

Description: Comfortable recline chairs and comfortable environment should be

provided for mothers with LBW infants during KMC.

Grade of recommendation: A

Evidence: Maternal comfort is a core component to provide continuous KMC. To create

a feeling of comfort and relaxation for the mothers and prevention of back

and/or muscle pain after hour(s) of KMC, comfortable recline chairs and

comfortable environment are essential (Ali et al., 2009; Boo & Jamli, 2007;

Gathwala et al., 2008; Ghavane et al., 2012; Ramanathan et al., 2001; Rojas et

al., 2003).

Recommendation 5: Close skin-to-skin contact

Description: Ensure there is close skin-to-skin contact between the mother-infant dyads

during KMC.



Evidence: Close skin-to-skin contact is one of the major determinants of KMC to provide

warm for the LBW infants that they are prone to have rapid heat loss and as a

result of hypothermia. Close skin-to-skin contact between the chests and

abdomens of the mother-infant dyads could be an essential heat source for the

LBW infants (Ali et al., 2009; Boo & Jamli, 2007; Charpak et al., 2001;


al., 2003).

Recommendation 6: Position of the LBW infants

Description: Place the LBW infants between the mother’s breasts with

upright/semi-upright and prone position with the head turns to one side.


Evidence: The upright/semi-upright and prone position of the LBW infants ensures an

patent airway, prevents obstructive apnoea, and allows eye contacts between

the mother-infant dyads with the handheld mirrors (Ali et al., 2009; Boo &

Jamli, 2007; Charpak et al., 2001; Ghavane et al., 2012; Rojas et al., 2003).

Recommendation 7: Clothing of the mothers during KMC

Description: The mothers are required to put on front-opening gowns during KMC.


Evidence: Mothers put on front-opening gown are easier and safer to place the LBW

infants between their breasts because the pullover may obstruct the airway of

the LBW infants and occlude their eye contact (Ali et al., 2009; Boo & Jamli,

2007; Gathwala et al., 2008; Ramanathan et al., 2001).

Recommendation 8: Clothing of the LBW infants during KMC


Description: The LBW infants are naked except the diaper, bonnet and socks and are

covered with a cloth and the gown of the mother.


Evidence: Prevention rapid heat loss from the heads and the feet of the LBW infants that

are difficult to have close skin-to-skin contact with the mother’s breasts, the

LBW infants are required to put on bonnet and socks. Meanwhile, the LBW

infants are covered with a cloth and the gowns of the mothers to prevent heat

loss from the back of the LBW infants. The diapers are used to protect the

mother-infant dyads from excreta (Ali et al., 2009; Boo & Jamli, 2007;


al., 2003).

Recommendation 9: Physiologic monitoring of the LBW infants during KMC

Description: Continuous monitoring for the heart rates, respiration rates, oxygen

saturation and body temperature before, during and after KMC.


Evidence: The physiologic condition of the LBW infants reflects the cardiopulmonary

stability; continuous monitoring for the heart rates, respiration rates, oxygen

saturation and body temperature before, during and after KMC are essential to

evaluate, early detection of changes in physiologic condition and prevent

physiologic instability and possible complication (Ali et al., 2009; Boo &

Jamli, 2007; Ghavane et al., 2012; Rojas et al., 2003).

11. References

i. Ali, S. M., Sharma, J., Sharma, R., & Alam, A. (2009). Kangaroo mother care as

compared to conventional care for low birth weight babies. Dicle Medical Journal, 3,

155-160.


ii. Boo, N. Y., & Jamli, F. M. (2007). Short duration of skin-to-skin contact: Effects on

growth and breastfeeding. Journal of Paediatrics and Child Health, 43, 831-836.

doi:10.1111/j.1440-1754.2007.01198.x

iii. Chan, Y. F. (2013). Breastfeeding survey in neonatal units of HA hospitals: 2013

annual report. Hong Kong Special Administrative Region, China: Hospital

Authority.

iv. Chan, Y. F., & Liu, N. C. (2014). 2014 Report on breastfeeding survey in neonatal

unit. Hong Kong Special Administrative Region, China: Hospital Authority.

v. Charpak, N., Figueroa de Calume, Z., & Ruiz-Pela´ez, J. G. (2000). “The Bogotá

Declaration on Kangaroo Mother Care”: Conclusions at the second international

workshop on the method. Acta Paediatrica, 89, 1137-1140.

doi:10.1111/j.1651-2227.2000.tb03365.x

vi. Charpak, N., Ruiz-Pela´ez, J. G., Figueroa de Calume, Z., & Charpak, Y. (2001). A

randomized, controlled trial of kangaroo mother care: Results of follow-up at 1 year

of corrected age. Pediatrics, 108, 1072-1079. doi:10.1542/peds.108.5.1072

vii. Gathwala, G., Singh, B., & Balhara, B. (2008). KMC facilitates mother baby

attachment in low birth weight infants. Indian Journal of Pediatrics, 75, 43-47.

viii. Ghavane, S., Murki, S., Subramanian, S., Gaddam, P., Kandraju, H., & Thumalla, S.

(2012). Kangaroo mother care in kangaroo ward for improving the growth and

breastfeeding outcomes when reaching term gestational age in very low birth weight

infants. Acta Paediatrica, 101, e545-e549. doi:10.1111/apa.12023

ix. Lowson, K., Offer, C., Watson, J., McGuire, B., & Renfrew, M. J. (2015). The

economic benefits of increasing kangaroo skin-to-skin care and breastfeeding in

neonatal units: Analysis of a pragmatic intervention in clinical practice.

International Breastfeeding Journal, 10, 11. doi:10.1186/s13006-015-0035-8


x. Ludington-Hoe, S. M. (2015). Skin-to-skin contact: a comforting place with comfort

food. American Journal of Maternal Child Nursing, 40, 359-366.

doi:10.1097/NMC.0000000000000178

xi. Martinez Gomez, H., Rey Sanabria, E., & Marquette, C. M. (1992). The mother

kangaroo programme. International Child Health, 3, 55-67.

xii. Nyqvist, K. H., Anderson, G. C., Bergman, N., Cattaneo, A., Charpak, N., Davanzo,

R., … Widström, A. M. (2010). Towards universal kangaroo mother care:

Recommendations and report from the first European conference and seventh

international workshop on kangaroo mother care. Acta Paediatrica, 99, 820-826.

xiii. Ramanathan, K., Paul, V. K., Deorari, V. K., Taneja, U., & George, G. (2001).

Kangaroo mother care in very low birth weight infants. Indian Journal of Pediatrics,

68, 1019-1023.

xiv. Rojas, M. A., Kaplan, M., Quevedo, M., Sherwonit, E., Foster, L., Ehrenkranz, R. A.,

& Mayes, L. (2003). Somatic growth of preterm infants during skin-to-skin care

versus traditional holding: a randomized, controlled trial. Journal of Development

and Behavioral Pediatrics, 24, 163-168.

xv. Scottish Intercollegiate Guidelines Network. (2016, February 28). Grades of



xvi. Spatz, D. L. (2004). Ten steps for promoting and protecting breastfeeding for

vulnerable infants. Journal of Perinatal & Neonatal Nursing, 18, 385-396.

xvii. Suman Rao, P. N., Udani, R., & Nanavati, R. (2008). Kangaroo mother care for low

birth weight infants: a randomized controlled trial. Indian pediatrics, 45, 17-23.

xviii. Welch, M. G., Hofer, M. A., Stark, R. I., Andrews, H. F., Austin, J., Glickstein, S.

B., … the Family Nurture Intervention Trial Group. (2013). Randomized controlled


trial of family nurture intervention in the NICU: Assessments of length of stay,

feasibility and safety. BMC Pediatrics, 13, 148. doi:10.1186/1471-2P431-13-148

Appendix M – Project Calendar

Project Calendar

Preparation Pilot Implementation Evaluation

1 2 3 4 5 6 7 8 9 10 11 12 13 14

Seeking approval

Forming KMC ‘focus group’

Purchase equipment and design posters

Consultation period

Marketing

Didactic education program

Pilot

Feedback collection

Pilot review

Full implementation

Feedback collection

Data collection

Data entry and analysis

Preparing evaluation report

Footnote: KMC, Kangaroo mother care.

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Tasks

Phase/Month

Appendix N – Communication Plan

Phase Tasks Personnel Target

stakeholder(s) Action planned

Communication

modes (frequency)

Seeking

approval

Project

leaders

� Administrators 1. To illustrate significance, benefits, and cost/benefits

ratio of KMC for LBW infants with evidence support

2. To present the workflow, schedule, manpower

allocation and resources required

� Presentation

� Emails

� Informal discussion

� Meetings

Forming KMC

‘focus group’

Project

leaders

� Administrators 1. To invite 6 RNs to form a KMC ‘focus group’ � Emails


Meetings of the

KMC ‘focus

group’

KMC

‘focus

group’

� Administrators

� Audiovisual

team

� Procurement and

supplies team

1. To develop the timeline and workflow for the pilot,

implementation and evaluation of KMC

2. To source and purchase the equipment and facilities

3. To design the posters and flyers

4. To develop the didactic education programs

5. To develop the evaluation plan

� Emails


� Meetings (weekly to

monthly)

Consultation

period

Project

leaders

� Administrators

� Frontline staff

(all disciplines)

1. To gather opinions

2. To motivate frontline staff for the forthcoming

implementation of the proposed guideline

3. To address the emotional impact

� Emails

� Observation


� Meetings

Marketing of

KMC guideline

KMC

‘focus

group’

� Administrators

� Frontline staff

(all disciplines)

1. To announce the pilot of the KMC guideline

2. To put posters on the notice board and in the hallway

� Emails

� Posters

� Meetings

Pre

para

tion

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Communication

modes (frequency)

In-service

training

Project

leaders

� All nurses 1. To deliver didactic education programs

2. To collect comment for the guideline

3. To provide support and reassurance

4. To make appropriate refinement accordingly

5. To evaluate the didactic education programs

� Emails


� Mini-lectures

� Simulation

� Presentation

Pilot Project

leaders

� Frontline staff

(all disciplines)

1. To implement the KMC guideline in small scale

2. To identify possible problems and barriers could be

encountered during the implementation phase

� Observation


� Meetings (bi-weekly)

Feedback

collection

KMC

‘focus

group’

� Frontline staff

(all disciplines)

� Target

population

1. To discuss and observe problems, including

administrative, logistic and environmental problems

2. To collect feedbacks from the mothers

3. To discuss and provide solutions accordingly

� Observation


� Reflective diary

Pilot review Project

leaders

� Administrators 1. To report the result of the pilot

2. To refine the KMC guideline

� Emails


Implementing

KMC guideline

Project

leaders

� Frontline staff

(all disciplines)

1. To implement the KMC guideline

2. To observe performance of the nurses

3. To identify unforeseeable problems

� Observation

� Emails



Reviewing the

implementation

KMC

‘focus

group’

� Administrators

� Frontline staff

(all disciplines)

1. To further meliorate the KMC guideline � Observation

� Emails


� Meetings (monthly)

Impl

emen

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repa

ratio

n P

ilot

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Communication

modes (frequency)

Data collection KMC

‘focus

group’

� Frontline staff

(all disciplines)

� Target

population

1. To collect breastfeeding data

2. To disseminate and collect surveys to the target

population and nurses

3. To evaluate the extent of the guideline actually

followed by the nurses

� Observation

� Emails


Data entry and

analysis

KMC

‘focus

group’

Not applicable 1. To perform data entry and analysis

� Emails

Reporting the

effectiveness

Project

leaders

� Administrators

� Frontline staff

(all disciplines)

1. To generate a report on the effectiveness of the KMC

guideline

� Emails


� Meetings

Footnote: KMC, Kangaroo mother care; and LBW, Low birth weight.

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Appendix O – Checklist for Eligibility for Kangaroo Mother Care

XXX Hospital

Department of Paediatrics and Adolescent Medicine

Checklist for eligibility for kangaroo mother care (KMC)

Date of asssessment: ________/ ________/ ________

(DD) (MM) (YYYY)

Name of assessor: _____________________________

Signiture of assessor: ___________________________

Instructions: 1. Please ‘�’ the most appropraite options for the eligibility for kangaroo mother care

(KMC) of the mother-infant dyad. 2. Please reassess the eligibility for KMC of the mother-infant dyad when change of

conditions is observed. 3. Any ‘No’ for the criteria indicates the mother-infant dyad is ineligible for KMC. Eligibility for KMC

Criteria Yes No

For the mother

1. Able to follow the general instructions for KMC.

2. Do not have severe obstetric and medical problems.

3. Able to come to the hospital.

4. Agree for KMC

For the infant

1. The birth weight is less than 2,500 grams.

2. It is cardiopulmonary stable.

3. Do not have life threatening congenital malformation. 4. Do not has severe perinatal complications, for example IVH,

NEC and HIE.

5. Do not have gastroschisis, omphalocele, or myelomeningocele requiring sterilization prior to surgery.

6. It is not put in a humidified incubator.

7. Do not have umbilical artery and/or vein catheter(s). 8. Do not receive phototherapy with jaundice close to exchange

transfusion zone.

The mother-infnat dyad is eligible for KMC

Footnote: HIE, Hypoxic-ischemic encephalopathy; IVH, Intraventricular hemorrhage; and

NEC, Necrotizing enterocolitis.

Hospital

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Hospital

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Appendix P – Evaluation Plan

Outcomes Personnel to be evaluated Timing and frequency of measurement Instrument

Process evaluation

Quality of the didactic education program

All nurses except the committees of the KMC ‘focus group’

� Immediate after the training sessions � Self-reporting evaluation form

Outcome evaluation

1. Patient outcomes Breastfeeding rate Eligible mother-infant dyads who

perform KMC � At discharge � At 1-month old of the LBW infants � At 3-month old of the LBW infants

� Feeding modes data collection form � Implementation record of KMC � Interview at out-patient clinic � Telephone interview

Exclusivity of breastfeeding

Eligible mother-infant dyads who perform KMC

� At discharge � At 1-month old of the LBW infants � At 3-month old of the LBW infants

� Feeding modes data collection form � Implementation record of KMC � Interview at out-patient clinic � Telephone interview

Acceptability of KMC Eligible mothers who perform KMC � After completion of KMC or before discharge of the LBW infants, whichever comes first

� Self-reporting survey

2. Healthcare provider outcomes Attitudes towards KMC

All nurses except the committees of the KMC ‘focus group’

� 3 months after implementation � Self-reporting survey

Knowledge on KMC All nurses except the committees of the KMC ‘focus group’

� Before the didactic education program � 3 months after implementation

� Self-reporting survey

Extent of the guidelines followed by the nurses

All nurses except the project leaders � 3 months after implementation � 6 months after implementation

� Performance assessment form

3. System outcomes Cost Not applicable � 6 months after implementation � Financial report Adverse events Eligible LBW infants who receive

KMC � 3 and 6 months after implementation � Medical records

� Observation Complaints Eligible mothers who perform KMC � 3 and 6 months after implementation � Record of complaints

Footnote: KMC, Kangaroo mother care; and LBW, Low birth weight

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Appendix Q – Evaluation Form for Didactic Education Program

XXX Hospital


Evaluation of didactic education program for kangaroo mother care

Objectives:

To improve the quality of the didactic education program for kangaroo mother care (KMC).

DO NOT PUT YOUR NAME ON THIS EVALUATION! We wish to get objective

responses from you. By remaining anonymous, you can be honest and we can get a more

accurate impression of how you feel about the mini-lecture, simulation, and/or teacher’s

teaching for KMC didactic education program.

Part A: Personal data

Please choose “�” the appropriate option:

Sex: � Female � Male

Age: � < 26 � 26 – 30 � 31 – 35 � 36 – 40 � 41 – 45 � > 46

Post-registration experience (complete year): __________ year(s)

Working experience in neonatal unit (complete year): __________ year(s)

Hospital

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Hospital

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Part B: Evaluation of the mini-lecture

Please choose one option “�” that best response with your experience for the mini-lecture

for each of the following statement.

Strongly disagree

Disagree Neutral Agree Strongly

agree 1. The information is complete. � � � � �

2. The information is useful. � � � � �

3. The information is clear. � � � � �

4. The information is easy to

understand.

� � � � �

5. The information provided meets

my learning needs for KMC.

� � � � �

6. I would be willing to use the

information to provide KMC

education.

� � � � �

7. The duration of the mini-lecture is

appropriate.

� � � � �

8. Overall, the mini-lecture is

effective in helping me to

implement KMC.

� � � � �

Part C: Evaluation of the simulation

Please choose one option “�” that best response with your experience for simulation for

each of the following statement. Strongly

disagree Disagree Neutral Agree

Strongly agree

1. The simulation enhances my

understanding of the concepts,

techniques, and issues addressed

for KMC.

� � � � �

2. The simulation enriches my skills

in implementing KMC.

� � � � �

3. The duration of the simulation is

appropriate.

� � � � �

4. The simulation is effective in

helping me to implement KMC.

� � � � �


Part D: Overall evaluation of teaching

Please choose one option “�” that best response with your experience for the teaching. Strongly


Strongly agree

1. The teacher is able to help me to

understand the concepts,

techniques, and issues addressed

for KMC.

� � � � �

2. I am intellectually stimulated and

inspired by the teacher.

� � � � �

3. The teacher provides opportunities

for me as well as the others to

interact during simulation.

� � � � �

4. The teacher provides me with

timely and helpful feedback.

� � � � �

5. The teacher is supportive when I

need help during the mini-lecture

and simulation.

� � � � �

6. Overall, the teacher is effective in

helping me to implement KMC.

� � � � �

Part E: Open-ended comments about the didactic education program

Write your comments about the didactic education program in the space below.

What are the best thing(s) about the mini-lecture, simulation and/or teacher’s teaching?

What thing(s) about the mini-lecture, simulation and/or teacher’s teaching could be

improved?

- Thank you -


Appendix R – Feeding Mode Data Collection Form

XXX Hospital


Feeding mode data collection form

Infant information

Gestation at birth: _______ weeks _______ days

Birth weight: ___________ g

Date of birth: _______/_______/_______ (DD) (MM) (YYYY)


At discharge

Date: _______/_______/_______ Age: _______/_______ (DD) (MM) (YYYY) (MM) (DD)

Data source: � Medical records � Face-to-face interview

The breastfeeding mode for the last 24 hours is:

� Exclusive breastfeeding � Partial breastfeeding � None breastfeeding

At 1-month-old of the LBW infant


Data source: � Medical records � Face-to-face interview � Telephone interview



At 3-month-old of the LBW infant


Data source: � Medical records � Face-to face-interview � Telephone interview




Appendix S – Implementation Record of ‘Keep in Touch’ Guideline

XXX Hospital


Record of kangaroo mother care

Infant information

Gestation at birth: _______ weeks _______ days

Birth weight: ___________ g

Date of birth: _______/_______/_______ (DD) (MM) (YYYY)

Record of kangaroo mother care (KMC)

Date Start time End time Duration (hh:mm)

Infant activity *

Mother activity * Remarks **

Footnotes:

* Indicates the activity status of the mother and the low birth weight infant during KMC.

A = Active/awake; I = Irritable/struggle; J = Jittery; Q = Quiet; and S = Sleep.

** Indicates the special event(s) undertaken during KMC, for examples breastfeeding, sucking at

nipples, desaturation, apnoea, bradycardia, and/or dislodgement of medical devices.


Appendix T – Kangaroo Mother Care Diary

Cover Page Layout of the Kangaroo Mother Care (KMC) Diary

Kangaroo Mother CareKangaroo Mother CareKangaroo Mother CareKangaroo Mother Care

DiaryDiaryDiaryDiary

Picture source: WallMonkeys. (2016, June 06). Children's wall decals - Cartoon mom, baby

kangaroo - 12 inch removable graphic. Retrieved from

http://www.amazon.com/Childrens-Wall-Decals-Kangaroo-Removable/dp/B00

4G6L9U4


First Page Layout of the KMC Diary

BabyBabyBabyBaby’s informations informations informations information

Baby’s name :::: ______________

Date of birth :::: ______________

Birth weight :::: ______________

Gestation at birth :::: ______________

Date of going home :::: ______________

Baby’s picture


Inner Page Layout of the KMC Diary

Record of kangaroo mother care

Date Time

Duration

(hour : minute)

Breastfeeding

during KMC (�/�)

---- ::::

---- ::::

---- ::::

---- ::::

---- ::::

---- ::::

---- ::::

---- ::::

---- ::::

---- ::::

---- ::::


Appendix U – Feeding Diary

Cover Page Layout of the Feeding Diary

FeedingFeedingFeedingFeeding

DiaryDiaryDiaryDiary

Picture source: VectorStock. (2016, June 06). Mother breast feeding her baby symbol vector.

Retrieved from

https://www.vectorstock.com/royalty-free-vector/mother-breast-feeding-her-b

aby-symbol-vector-1522173


First Page Layout of the Feeding Diary

BabyBabyBabyBaby’s informations informations informations information

Baby’s name :::: ______________

Date of birth :::: ______________

Birth weight :::: ______________

Gestation at birth :::: ______________

Date of going home :::: ______________

Baby’s picture


Inner Page Layout of the Feeding Diary

Feeding record

Date Time

Duration

(hour : minute)

Feeding mode

(1/2/3)

---- ::::

---- ::::

---- ::::

---- ::::

---- ::::

---- ::::

---- ::::

---- ::::

---- ::::

---- ::::

Remarks: 1: Exclusive breastfeeding/fed with expressed breastmilk only

2. Partial breastfeeding

3. Artificial feeding only


Appendix V – Survey on Acceptability of Kangaroo Mother Care

XXX Hospital


Survey on acceptability of kangaroo mother care

Objective:

To evaluate the acceptability of kangaroo mother care (KMC) by the mothers with low birth

weight (LBW) infants.

DO NOT PUT YOUR NAME ON THIS SURVEY! We wish to get objective responses

from you. By remaining anonymous, you can be honest and we can get a more accurate

impression of how you feel about performing KMC for your LBW infant.

Hospital

logo

Hospital

Authority

logo


Part A: Overall acceptability of KMC

Please choose one option“�” that best response with your experience in performing KMC

for your LBW infant for each of the following statement.

Strongly


Strongly

agree

1. I understand the KMC practice

satisfactory.

� � � � �

2. More KMC sessions should be held. � � � � �

3. I am not scared of performing KMC

for the first time.

� � � � �

4. I feel closer to my infant after

performing KMC.

� � � � �

5. I can maintain infant in KMC

position comfortably.

� � � � �

6. KMC elevates my mood. � � � � �

7. I am more confident to handle my

infant after performing KMC.

� � � � �

8. I am more confident in taking care of

my infant at home after discharge.

� � � � �

9. KMC does not hamper and interfere

with my daily activities.

� � � � �

10. I will advise KMC to mothers with

LBW infants.

� � � � �

11. I will continue KMC at home. � � � � �

12. I do not feel tired for performing

KMC.

� � � � �

13. KMC is useful for me and my LBW

infant.

� � � � �


Part B: Open-ended comments about performing KMC

Write your comments about performing KMC for your LBW infant in the space below.

What are the best thing(s) about performing KMC for your LBW infant?

What thing(s) about performing KMC for your LBW infant could be improved?

- Thank you -


Appendix W – Survey on Attitudes of Nurses Towards Kangaroo Mother Care

XXX Hospital


Survey on attitudes of nurses towards kangaroo mother care

Objective:

To evaluate the attitudes of nurses towards kangaroo mother care (KMC).


from you. By remaining anonymous, you can be honest and we can get a more accurate

impression of how you feel about implementing KMC for the mothers with low birth weight

(LBW) infants.

Part A: Personal data



Age: � < 26 � 26 – 30 � 31 – 35 � 36 – 40 � 41 – 45 � > 46



Hospital

Authority

logo

Hospital

logo


Part B: Attitudes towards KMC

Please choose one option “�” that best response with your experience in implementing

KMC for mothers with LBW infants for each of the following statement.

Strongly


Strongly

agree

1. The guideline is easy to understand. � � � � �

2. The guideline is easy to follow. � � � � �

3. The guideline facilitates me to make

autonomous decision on KMC.

� � � � �

4. There is enough manpower for

KMC.

� � � � �

5. KMC does not increase the work

load.

� � � � �

6. I have better relationship among

colleagues after implementation of

the KMC guideline.

� � � � �

7. The mothers accept KMC easily. � � � � �

8. KMC increases lactation in mother. � � � � �

9. Mothers are more confident to take

care of the LBW infants after KMC.

� � � � �

10. KMC is a useful method to take care

of LBW infants.

� � � � �

11. I will advise mothers to continue

KMC at home.

� � � � �

12. I will recommend KMC practice in

community and hospitals.

� � � � �

13. It is worth putting efforts in

advocating KMC.

� � � � �

14. Family education about KMC is

useful.

� � � � �

15. I receive adequate appreciation from

mothers for implementing KMC.

� � � � �

16. Facilitation of KMC is

professionally satisfying.

� � � � �


Part C: Open-ended comments about KMC

Write your comments about implementing KMC for the mothers with LBW infants in the

space below.

What are the best thing(s) about implementing KMC for the mothers with LBW infants?

What thing(s) about implementing KMC for the mothers with LBW infants could be

improved?

- Thank you -


Appendix X – Survey on Knowledge of Kangaroo Mother Care

XXX Hospital


Survey on knowledge of kangaroo mother care

Objective:

To evaluate the knowledge of kangaroo mother care (KMC) for the low birth weight (LBW)

infants of the nurses.


from you. By remaining anonymous, you can be honest and we can get more accurate

information on your knowledge of KMC.

Part A: Survey data (Confidential) (To be fill out by the project leaders)

Nurse record no.: __________

� Pre-test � Post-test

Part B: Personal data



Age: � < 26 � 26 – 30 � 31 – 35 � 36 – 40 � 41 – 45 � > 46



Hospital

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Hospital

Authority

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Part C: Knowledge of KMC

Please choose one option “�” that represent your knowledge on KMC for each of the

following statement.

True False Don’t know

1. KMC promotes bonding. � � �

2. KMC improves breastfeeding. � � �

3. KMC promotes breastmilk production for the

mothers.

� � �

4. KMC has a positive effect on physical

wellbeing of infant.

� � �

5. KMC has a positive effect on general

condition of infant.

� � �

6. KMC should not be practiced for an intubated

infant.

� � �

7. KMC should not be practiced for an infant

with umbilical catheter.

� � �

8. On-going continuous positive airway pressure

is an obstacle to KMC.

� � �

9. KMC should not been introduced before one

week of life if the infant is born less than 28

weeks of gestational age.

� � �

10. Stable infants should be introduced instantly

after birth to KMC if the infant is born after 28

weeks of gestational age.

� � �

11. KMC leads to increased risk for the LBW

infant.

� � �

- Thank you -


Appendix Y – Clinical Assessment Form for Implementing Kangaroo Mother Care

XXX Hospital


Clinical assessment form for implementing kangaroo mother care

Objectives:

To evaluate the extent of the ‘Keep in Touch’ guideline actually followed by the nurses.

Please ‘�’ the most appropraite option that best represent the performance of the nurses for

implementing kangaroo mother care (KMC) for the low birth weight infants.

Nurse’s performance Yes No NA Remarks

Assessment

1. Assess the general condition of the mothers and the

infants for the eligibility to perform KMC.

2. Assess the vital signs, temperature, stability and

fitness of the infants for implementing KMC.

Planning

3. Explain the reasons and procedures to the mothers.

4. Collect necessary equipment, for example

comfortable recline chair, privacy screen, and mirror.

5. Ask the mother to put on front opening gowns.

6. Remove clothing, if any, of the infant, and put on

bonnet and socks.

7. Secure the medical devices, if indicated, for examples,

endotracheal tube and intravenous access devices.

Implementation

8. Demonstrate two-nurse transfer method to transfer

infant from the incubator/crib to the mother’s breasts.

Hospital

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Hospital

Authority

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Nurse’s performance Yes No NA Remarks

9. Place the infant between the mother’s breasts with

upright/semi-upright and prone position with the head

turns to one side.

10. Ensure close skin-to-skin contact between the

mother-infant dyad during KMC.

11. Stabilize and settle the mother-infant dyad in the

KMC position.

12. Continuous monitor the vital signs of the infant during

KMC.

13. Demonstrate two-nurse transfer method to transfer

infant from KMC position back to the incubator/crib.

After Care

14. Stabilize and settle the infant in the incubator/crib.

15. Put on clothing for the infants, if indicated.

16. Tidy up the environment.

Evaluation and Documentation

17. Evaluate mother and infant’s condition and responses

after performing KMC.

18. Report and document any complications.

19. Appropriate documentation.

Total:

Footnote: NA, Not applicable

Compliance rate = Total number of ‘Yes’

x 100% = _________% Total number of ‘Yes’ + Total number of ‘No’

Name of auditor: _______________________ Signature: _______________________

Date of clinical assessment: ___________________


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