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Effect of Kangaroo Mother Care on the

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Article in Indian Journal of Child Health · June 2017

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 Original Article
Effect of Kangaroo Mother Care on the breastfeeding, morbidity, and mortality
of very low birth weight neonates: A prospective observational study
Pravakar Mishra1, Narayan Rai1, Nihar Ranjan Mishra2, Rashmi Ranjan Das3
From Department of Pediatrics, 1MKCG Medical College and Hospital, Berhampur, 2Veer Surendra Sai Institute of Medical Sciences and Research,
Burla, Sambalpur, 3All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
Correspondence to: Nihar Ranjan Mishra, Assistant Professor, P.G. Department of Pediatrics, Veer Surendra Sai Institute of Medical
Sciences and Research, Burla, Sambalpur, Odisha, India. Phone: +91-9337797072. E-mail: drnihar.mishra@gmail.com
Received – 28 February 2017 Initial Review – 02 March 2017 Published Online – 19 June 2017

ABSTRACT
Objective: To compare the effect of Kangaroo Mother Care (KMC) versus conventional mother care (CMC) on growth, morbidity,
mortality, and length of hospitalization in very low birth weight (VLBW) neonates. Study Design: A hospital based prospective
observational study conducted in the pediatric department of a tertiary care teaching hospital in Southern Odisha. Materials and
Methods: A total of 100 VLBW neonates were included. The effect of KMC on growth, morbidity, breastfeeding, and length of
hospitalization was studied. The KMC group (n=50) was subjected to KMC for at least 6 h/day. The neonates received kangaroo care
during hospitalization and at home. The control group (n=50) received CMC. Results: The KMC babies had better average weight
gain per day (15.9±4.5 vs. 10.6±4.5 g, p<0.0001). The weekly increments in head circumference (0.75 vs. 0.49 cm, p=0.001), length
(0.99 vs. 0.7 cm, p=0.021), and chest circumference (0.73 vs. 0.45 cm, p=0.004) were higher in the KMC group. Significantly more
neonates receiving CMC suffered from hypothermia (36% vs. 6%), apnea (16% vs. 2%), and other minor illnesses (44% vs. 16%)
than those receiving KMC. There was earlier hospital discharge in KMC group (6 vs. 18 days). More neonates of KMC group were
exclusively breastfed at the end of the study (86% vs. 42%). No mortality was noted in either group. Conclusions: KMC improves
growth, reduces morbidities, improves breastfeeding rates, and reduces hospitalization in VLBW neonates.

Key words: Conventional mother care, Breastfeeding, Morbidity, Kangaroo Mother Care, Very low birth weight

K
angaroo mother care (KMC) is continued skin to skin The state of Odisha has one of the highest numbers of
contact between the mother or caregiver and the neonate premature deliveries including LBW and VLBW neonates
which has been recognized as an effective method to as well as a high neonatal mortality rate in India. Being a low
provide thermal care and promote breastfeeding. The prevalence cost intervention, KMC has the potential for wider applicability
of low birth weight (LBW) neonates is around 16% globally and and acceptability in resource poor setting in improving various
28% in South Asia (including India) as per the UNICEF [1]. outcomes in VLBW neonates. As there is no previous published
Most (48%) of the neonatal deaths are related to prematurity and data from this part of the country, this study was designed to
very low birth weight (VLBW) [1,2]. There are limited financial study the usefulness of KMC on various outcomes of VLBW
resources for infrastructure and manpower needed for the care of neonates. We planned to study the effect of KMC on morbidity,
all such babies in developing countries like India. As regards to breastfeeding, weight gain, and hospital stay of VLBW neonates
keeping a VLBW neonate warm, Kangaroo Mother Care (KMC) (1000-1500 g).
is a cost effective alternative to costly incubator/warmer care in
these settings [3,4]. MATERIALS AND METHODS
Studies have found that besides promotion of euthermia and
breastfeeding in VLBW neonates, KMC has many additional This prospective hospital based observational study was
advantages that include but not limited to facilitation of mother to conducted in the Special Newborn Care Unit (SNCU), and
child bonding, improved growth and neurodevelopment behavior, Pediatric Outpatient Department of MKCG Medical College
decreased neonatal morbidity and mortality as well as earlier and Hospital, Berhampur, Odisha, India over 24 months period
hospital discharge or discharge from the Neonatal Intensive (from December 2013 to November 2015). The care provided
Care Unit [5-8]. Besides the mother, any other family member in SNCU includes Level II neonatal care with facility for
including the father can do KMC as Indian mothers are busy administration of oxygen via various non-invasive devices,
doing household work most of the time. temperature maintenance via open care system, continuous

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Mishra et al. Effect of KMC on outcome of VLBW neonates

positive airway pressure, and surfactant administration. Ethics The Control or Conventional Mother Care (CMC) Group
Committee clearance was taken before starting the study. After
taking consent from the parents, hemodynamically stable It included 60 age and sex matched VLBW neonates whose
VLBW (1000-1499 g) neonates, both inborn and outborn, were mothers were not practicing KMC, and were mostly delivered
included in the study. Extremely LBW (<1000 g), newborn at home. Mothers were advised to provide usual standard care
with birth weight (>1500 g), with congenital malformations or (diaper/nappy change, massage with oil, paladai/katori-spoon
chromosomal abnormality, and those who died within 72 h of feeding of expressed breast milk or preterm formula 2 hourly).
enrollment were excluded from the study. Recruited neonates The temperature was maintained in the euthermic range by the
were then divided into following two groups (Figure 1). servo mode. The neonates were monitored clinically as well as
through vital sign monitors. The unit protocol for discharge from
The Case (KMC) Group hospital or discontinuation of KMC was followed. After dropout
of 10 cases in each group, 50 cases per each of KMC and CMC
It comprises 60 neonates whose mothers/parents were ready group were followed up till end of the study (Figure 1).
to provide kangaroo care. The eligible neonates were shifted Primary objectives were to compare the growth rate (weight
to KMC ward where KMC was done under the supervision of gain, and gain in length, head and chest circumference) and
trained nurses and residents on duty. Neonates were positioned breastfeeding rate (exclusive breastfeeding rate at 40 weeks post-
between the mother breasts in an upright position dressed conceptional age) in both the groups. Secondary objectives were
properly with a cap, socks/mitten and diaper, and were given to assess the occurrence of various morbidities (hypothermia,
skin-to-skin contact. Mothers were advised to wear front open apnea, and other minor illness), hospitalization (time from birth
gowns, and were provided with comfortable chairs and beds. to discharge), and mortality.
Mothers were advised to continue KMC as long as possible but An electronic weighing scale was used to record daily weight
not <8 h/day. Paladai/katori-spoon feeding of expressed breast with a variability of 5 g. A non-stretchable tape was used to
milk or preterm formula was provided 2 hourly. The neonates measure the occipitofrontal (head) circumference and recorded in
were monitored clinically as well as through vital sign monitors. centimeters. An infantometer was used to record the length to the
The unit protocol for discharge from hospital or discontinuation nearest 0.1 cm. Apnea was defined as the cessation of respiration
of KMC was followed. After discharge, advice was given to for >20, or <20 s in the presence of cyanosis or bradycardia.
continue KMC at home with involvement of family members if Hypothermia was defined as an axillary temperature of <36.5°C.
required. Gestational age assessment was done as per the New Ballard score.
Following data were collected: Detailed maternal history,
socioeconomic status (modified Kuppuswamy scale), birth
events, sex of the baby, weight of the baby, head circumference,
chest circumference, length, hospital stay, any major illness, and
any minor illness were recorded on the prerecorded performance.
Thorough general examination and systemic examination were
done for all the neonates included in the study. Continuation
of KMC at home was ensured through telephonic follow-up.
Follow-up was done till 40 weeks post-conceptional age or
attainment of birth weight of 2,500 g whichever is earlier.
Statistical analysis was performed with GraphPad prism
version 5 software. Continuous date was computed as mean plus or
minus standard deviation. Student’s unpaired t-test was applied for
comparison of means. Chi-square tests were performed to compare
categorical variables. Statistical significance was set at p<0.05.

RESULTS

The baseline characteristics of included neonates have been

presented in Table 1. Baseline neonatal characteristic was
statistically nearly similar except for the birth weight which
was higher in KMC group. In KMC group, 37 (61.7%) neonates
were delivered normally, 16 (26.7%) were delivered by cesarean
section, and 7 (11.6%) had instrumental delivery. In the CMC
group, 36 (60%) had normal delivery, 24 (40%) neonates
were delivered by cesarean section, and none had instrumental
Figure 1: Flow chart of group allocation delivery. Incidence of cesarean section and instrumental delivery

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Mishra et al. Effect of KMC on outcome of VLBW neonates

was significantly more in KMC group (60%) compared to DISCUSSION

CMC group (40%). All the study population was comprised,
preterm neonates. In the KMC group, 41 (68.3%) were born to In this study, babies receiving KMC had a better daily weight gain
primigravida, and 19 (31.7%) were born to multigravida mothers. as compared to those receiving CMC (15.9±4.5 vs. 10.6±4.5 g,
In the CMC group, 38 (63.3%) were born to primigravida, and p<0.0001). This finding is comparable to the results of other
22 (36.7%) were born to multigravida mothers. studies [5,9]. In a study by Ramanathan et al., neonates in KMC
The baseline characteristics of mother of two groups were group demonstrated better weight gain after the 1st week of life
comparable: Education of mother <10th class was 24% in KMC (15.9±4.5 vs. 10.6±4.5 g/day, p<0.05) [5]. In another study,
group and 72% in CMC group, and >10th class 76% in KMC group neonates in KMC group had better average weight gain per day
and 28% in CMC group. Maternal age between 18 and 25 years (23.99 vs. 15.58 g, p<0.001) [9]. Various studies showed that KMC
of age was 52% in KMC group and 48% in CMC group. Maternal is helpful in preventing hypothermia in LBW neonates [9-11]. In
age between 26 and 35 years was 44% in KMC group and 52% our study also, occurrence of hypothermia was significantly lesser
in CMC group. Around 4% of the mothers were >35 years age in in KMC group (6% vs. 36%, p=0.003). One study showed the
KMC group and none in CMC group. lesser incidence of hypothermia in KMC as compared to CMC
A total of 20 neonates did not turn for follow-up (10 in each group (5.9% vs. 36.9%) [9]. Another study showed similar results
group), so final outcome analysis was performed on 100 neonates (22.7% vs. 46.7%, p<0.01) [11]. The hypothermia incidence also
(50 each). The effect of KMC on various neonatal outcome is significantly less when compared post-KMC to pre-KMC [12].
parameters has been presented in Table 2. Average weight gain per Regarding the development of apnea, in this study, 2% of
day (15.9±4.5 vs. 10.6±4.5 g, p<0.0001), weekly increments in head neonates in KMC group developed apnea, but in CMC group 16%
circumference (0.75 vs. 0.49 cm, p=0.001), length (0.99 vs. 0.7 cm, neonates developed apnea (P=0.034). It was comparable with a
p=0.021), and chest circumference (0.73 vs. 0.45 cm, p=0.004) were previous study which showed that babies given KMC had less
significantly higher in KMC group than the CMC group. Morbidities morbidity like apnea [13]. Similarly, another prospective study
were higher in CMC group, and significantly more neonates found no episode of apnea during KMC [4]. In our study, average
receiving CMC suffered from hypothermia (36% vs. 6%), apnea duration of hospital stay was longer in CMC (14-18 days) than the
(16% vs. 2%), and other minor illnesses (44% vs. 16%) than those KMC group (6-8 days) (p=0.038). Ramanathan et al. showed that
receiving KMC. Average duration of hospital stay in KMC group there was earlier hospital discharge in KMC group (27.2±7 vs.
was 6 days as compared to 18 days in CMC group. No mortality 34.6±7 days) [5]. Similarly, Cattaneo et al. showed that neonates
occurred in both the groups. Increase in exclusive breastfeeding rate on KMC were discharged earlier as compared to control group
occurred in 86% in KMC group and 42% in CMC group. (13.4 vs. 16.3 days, after enrolment) [10].
In this study, weekly increment in length (0.99 vs. 0.70 cm,
Table 1: Baseline neonatal characteristics p=0.021), head circumference (0.75 vs. 0.49 cm, p=0.001), and
Characteristics KMC (n=60) CMC (n=60) chest circumference (0.73 vs. 0.45 cm, p=0.004) were significantly
Male sex* 31 32 more in KMC than the CMC group. A significantly higher
Gestational age (weeks) 32.32±2.5 32.74±2.71 number of CMC neonates suffered from hypothermia, apnea, and
Birth weight (g) 1288.6±118.7 1262.28±121.55 other minor illnesses. More neonates on KMC were exclusively
Length at birth 40.76±1.56 40.36±1.43
breastfed than CMC at the end of the study (KMC 86% vs. CMC
42%). The result is supported by other studies [9,14].
Head circumference at birth 27.6±1.18 27.72±1.65
There is a need for further cost analysis of KMC. It is widely
Chest circumference at birth 24.52±1.49 24.88±2.29
accepted that KMC provides a cost-effective method of care
Number of inborn neonates* 37 40
for LBW infants in developing countries where specialized
All parameters are expressed in mean±SD, *Expressed in proportions.
KMC: Kangaroo mother care, and CMC: Conventional mother care equipments and high skilled staffs are in short supply [1]. These

Table 2: Effect of KMC on various outcome parameters

Variables KMC (n=50)** CMC (n=50)** p value
Weight gain (g/day) 15.9±4.5 10.6±4.5 <0.001
Increase in length (cm/week) 0.99±0.75 0.70±0.45 0.021
Increase in head circumference (cm/week) 0.75±0.48 0.49±0.29 0.001
Increase in chest circumference (cm/week) 0.73±0.48 0.45±0.28 0.004
Hypothermia* 3 18 0.003
Apnea* 1 8 0.035
Other minor illnesses* 8 22 0.035
Exclusive breastfeeding rate* 43 21 0.036
Duration of hospital stay (days) 8±6 14±7 0.039
All parameters are expressed in mean±SD. *Expressed in proportions. **20 neonates were excluded from analysis (10 in each group) as they were loss to follow‑up. KMC: Kangaroo
mother care, and CMC: Conventional mother care

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Mishra et al. Effect of KMC on outcome of VLBW neonates

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REFERENCES Funding: None; Conflict of Interest: None Stated.

1. UNICEF Data: Monitoring the Situation of Women and Children. Low Birth How to cite this article: Mishra P, Rai N, Mishra NR, Das RR. Effect of
Weight. Available from: http://www.data.unicef.org/topic/nutrition/low- Kangaroo Mother Care on breastfeeding, morbidity, and mortality of very
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