Fetal and Pediatric Pathology, 31:191194, 2012

C Informa Healthcare USA, Inc.

Copyright

ISSN: 1551-3815 print / 1551-3823 online
DOI: 10.3109/15513815.2011.650291

Kangaroo Mother Care May Help Oral Growth and

Development in Premature Infants
Feng Zhang and Shoutao Liu
Shenzhen Maternity and Child Healthcare Hospital, Department of Stomatology,
Shenzhen, China

Premature infants have a shorter prenatal development period and are prone to many serious
medical problems during neonatal period. This may impact the development of oral tissues, as
manifested by enamel hypoplasia, palatal distortion, malocclusion, or delay in tooth eruption and
maturation. Kangaroo mother care (KMC) is a standardized and protocol-based care system for
premature infants, based on skin-to-skin contact between the infant and their mother. Kangaroo
mother care has been demonstrated to greatly improve the nurturing of premature infants and
comparatively reduce the risk factors of oral defects. We hypothesize that KMC also facilitates oral
growth and development in premature infants.
Keywords kangaroo mother care (KMC), premature development, growth

INTRODUCTION
The World Health Organization (WHO) defines a premature infant as being born prior
to 37 weeks of gestation or having a birth weight of less than 2500 g [1]. These infants
suffer from developmental delays, perinatal and neonatal complications, motherinfant separation, etc. Kangaroo mother care (KMC) is an alternative to conventional
neonatal care, endorsed by WHO, and is widely practiced in many neonatal intensive care units. Several studies have demonstrated many benefits of KMC in terms of
the physiology, behavior, and development of premature infants. For example, KMC
greatly improves thermal regulation, respiratory patterns, and oxygen saturation [2,
3]. It also reduces respiratory distress, accelerates weight gain, promotes and prolongs
breastfeeding, shortens hospital stay, functions as an analgesic during painful procedures and positively influences infant development [4, 5]. Data are not yet available to
demonstrate the effects of KMC on oral tissues in preterm infants.
ORAL CONDITIONS OF PREMATURE INFANTS
Premature infants comprise approximately 6% of all live births in developed western
countries [6]. They are poorly equipped for extrauterine life and usually require intensive neonatal care. This is especially true for extremely preterm neonates and/or very
low birth weight infants. Many serious complications may occur in nearly all of the
major organs and systems, including the respiratory, gastrointestinal, cardiovascular,
renal, metabolic, hematologic, immunologic, and cerebral systems [7]. In addition to
Address correspondence to Dr. Shoutao Liu, Shenzhen Maternity and Child Healthcare Hospital,
Department of Stomatology, Fu-Qiang Road 3012, Shenzhen, 518048 China. E-mail:
liust.szfy@gmail.com

F. Zhang and Shoutao Liu

these deficits, oral tissues are also affected. Premature infants have a higher incidence
of oral defects when compared to full term infants; these defects include palatal grooving, high arched palate, malocclusion, palatal asymmetry, enamel hypoplasia, delayed
tooth eruption, and reduced dental dimensions [6, 8]. The pathogenesis of these defects remains unclear but is likely caused by systematic and local causes [6, 8, 9].
Mineral supply deficiency is a possible etiologic factor. Teeth are formed by mineralization of a protein matrix. The essential nutrients required for dental development
are calcium, phosphorus, fluoride, and vitamins A, C, and D [8]. Systematic factors,
such as metabolic and nutritional disturbances and infections associated with mineral
loss during the neonatal period, may cause these alternations [9]. Nutritional factors
may also have an influence on odontogenesis and tooth eruption. A deficit of critical
vitamins during the period of formation and dental eruption can determine predisposition to defect or delay in tooth formation and eruption [10].
Local trauma, or pressure associated with prolonged endotracheal intubation, can
also account for some of these defects. Because premature infants often have respiratory distress syndrome as a result of immature lung tissues, they are generally treated
with oxygen ventilation through an oro- or nasotracheal tube. The pressure caused
by the tube (or direct trauma from the laryngoscope) might inhibit the normal dental growth, which in turn promotes abnormalities in tooth eruption, notching of the
alveolar ridge, and malocclusion [1, 6, 8].
KANGAROO MOTHER CARE
Kangaroo mother care was introduced by Drs. Rey and Martinez in 1970s to engage
mothers to be the incubators for stable but tiny infants. The intention was to prevent
cross-infection and to discourage mother abandonment [11]. According to a recent report of the first European Conference and Seventh International Workshop on KMC,
three components are involved in KMC: 1) The kangaroo position (KP): the infant is
carried vertically between the mothers breasts and underneath her clothes with direct
skin-to-skin contact. 2) Kangaroo nutrition: nutrition is based exclusively on breastfeeding whenever possible. 3) Early discharge and strict follow-up: the infant is monitored daily on a regular basis, until they are gaining at least 20 g per day. Afterwards,
weekly clinic visits are scheduled until term, which constitute the ambulatory minimal
neonatal care [12, 13].
Kangaroo mother care has been reported to substantially reduce neonatal mortality
among premature infants (birth weight <2000 g) in hospitals, and it was also highly effective in reducing severe morbidity, particularly from infections [14, 15]. A large body
of evidence also supports the concept that KMC correlates with reduced risks, including decreased nosocomial infections, less severe illnesses, and lower respiratory tract
diseases [3, 1416]. A significant decrease has also been found in severe infections,
such as pneumonia and septicemia [15]. Furthermore, KMC also equips premature
infants to recover from respiratory distress and helps to stabilize and improve the oxygenation of infants [16, 17]. As a result, KMC premature infants have a shorter than
average hospital stay [4, 18].
Premature infants treated with KMC have a significantly longer breastfeeding
period [4, 13, 18, 19]. With KMC, the mother and baby skin-to-skin contact contributes greatly to sensory stimulations (the taste and smell of maternal milk) for
the premature infant to make contact with the nipple. It therefore facilitates the
establishment of direct breastfeeding and assists in maintaining the mothers milk
supply.
Kangaroo mother care was shown to create a better parenting situation facilitating
the growth and development of the premature infants [12, 20]. After KMC, mothers
Fetal and Pediatric Pathology

Kangaroo mother care may help oral growth and development

showed more positive affect, touch, and adaptation to infant cues at 37 week gestation,
became more sensitive, and provided a better home environment. At 6 months, KMC
infants scored higher on the Bayley Mental Development Index and the Psychomotor
Development Index [20]. Weight gain is an important indication of health and thriving
used in discharge criteria and infancy. It was shown that KMC resulted in a greater
weight gain than traditional care patterns [15]. Premature infants who were treated
with KMC also had a larger head circumstance [4].
HYPOTHESIS AND DISCUSSION
It is clear from the literature that KMC has many clinical and social benefits. The effects on the infants oral health are currently unknown. We hypothesize that KMC promotes oral growth and development in premature infants. At least three mechanisms
may be involved: First, KMC may decrease the risk factors of oral defects. As previously mentioned, several medical complications are significantly reduced with KMC,
which may lead to less mineral loss that could promote teeth formation. Second, due
to the reduced severity of infection, assistance in respiratory distress recovery and the
shortened hospital stay, preterm infants may need less intubation time, which may
decrease the levels of oral defects due to intubation. Third, KMC promotes improved
nurturing of premature infants, which may facilitate the growth and development of
oral structures.
Breastfeeding is considered an ideal stimulus for the physiological development
of both muscular and skeletal components of the oro-facial complex (jaws, dental
arches, tongue, facial muscles) in infants. During breastfeeding, infants use as much
as six times more energy ingesting their food when compared to babies drinking from
a bottle. The infants oral muscles are strenuously exercised during sucking and breastfeeding, thereby significantly contributes to the growth of the mandible [21]. A higher
percentage of children with normal occlusion were found in infants who had been
breastfed [22, 23].
Furthermore, maternal milk has many systemic nutritional and immunological advantages over proprietary baby formulas [24]. Breast milk contains adequate levels of
vitamins and minerals, which are necessary for the growth of oral tissue and teeth mineralization. The anti-infectious and immunological properties of maternal milk are
also helpful in reducing illness and in decreasing the risk factors causing oral defects
[25].
As a safe and humane technique, KMC is becoming an integral part of the care of
premature infants worldwide. This approach has been explored with regard to safety,
growth, and maternal bonding. As research continues, studying expected outcomes
should be more specific. The effects of KMC on oral growth and development of premature infants is an important field to be investigated.
Declaration of interest
The authors report no conflicts of interest. The authors alone are responsible for the
content and writing of this article.
ACKNOWLEDGMENTS
This work is supported by grant 200903106 from the Bureau of Science and Technology
of Shenzhen. We would like to thank Dr. W.A. Coetzee, Department of Pediatric Cardiology and Physiology and Neurosciences, New York University School of Medicine,
for reviewing the manuscript.
C Informa Healthcare USA, Inc.
Copyright

F. Zhang and Shoutao Liu

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