Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
ABSTRACT
Objective: To evaluate intermittent Kangaroo Mother Care (KMC) with additional opportunities to
breastfeed on weight gain of low birth weight (LBW) neonates with delayed weight gain. Methods: 40 LBW
neonates were followed to see whether KMC with additional opportunities to breastfeed improved weight
gain. Results: In the KMC group, the mean age of regaining birth weight was significantly less (15.68 vs.
24.56 days) and the average daily weight gain was significantly higher (22.09 vs. 10.39 g, p , .001) than
controls. Conclusion: KMC with additional opportunities to breastfeed was found to be an effective inter-
vention for LBWs with delayed weight gain and should be considered to be an effective strategy.
Each year, about 20 million low birth weight (LBW) kidneys. Preterm infants take longer to regain their
infants are born worldwide. The care of such in- birth weight (Doherty & Simmons, 2008; Ellard &
fants is a burden for health and social systems Anderson, 2008).
everywhere (World Health Organization [WHO], Kangaroo Mother Care (KMC) was developed in
2003). Although it is expected that newborns Colombia in the 1970s (Nyqvist et al., 2010a). How-
will lose some weight, a loss of 7% is maximum ever, it remains unavailable in most low-income
and weight should plateau by 72 hr (Lawrence & countries (Lawn, Mwansa-Kambafwile, Horta,
Lawrence, 2011). Barros, & Cousens, 2010). The hallmark of KMC is
Although term neonates initially lose about 3%– the kangaroo position: the infant is cared for skin-
5% of their birth weight over the first 3–5 days and to-skin (ventral surface of the mother to ventral
regain birth weight by about 10 days, preterm infants surface of the baby) vertically between the mother’s
may be allowed to lose 5%–15% of their birth weight breasts and under her clothes, 24 hr per day, with
over the first 5–6 days because of immature skin and the father/substitute(s) participating as relief KMC
194 The Journal of Perinatal Education | Fall 2013, Volume 22, Number 4
roviders. The other components in KMC are
p The infants were enrolled in the study at 8 days of
exclusive breastfeeding (ideally) and early discharge postnatal age when intermittent KMC with inherent
continuing KMC at home with close follow-up ad lib breastfeeding opportunity was begun for the
(Nyqvist et al. 2010a). intervention group. All babies were generally stable
Lawnet al. (2010) concluded that KMC in the all throughout the study.
first week of life showed a significant reduction in Inclusion criteria:
neonatal mortality (relative risk 0.49, 95% confi-
1. Babies admitted in the NICU in the first day
dence interval 5 0.29–0.82) compared with stan-
of life.
dard care among preterm babies in hospital, and
was highly effective in reducing severe morbid- 2. Preterm LBW babies: babies born less than
ity, particularly from infection. Thukral, Chawla, 37 weeks’ gestational age (GA; WHO, 2003).
Agarwal, Deotari, & Paul (2008) concluded that all GA was assessed using the Ballard score (Ballard
stable LBW babies are candidates for KMC. This is a et al., 1991).
desirable practice for the reasons described earlier 3. Babies’ birth weights were appropriate for gesta-
and should be continued until the baby’s post- tional age (AGA). AGA 5 birth weight between
menstrual age reaches term. Even unstable infants the 10th and 90th percentile (according to Lee,
can be provided KMC irrespective of their clinical 2008). So all our subjects were LBW and also
condition (WHO, 2003). premature.
Effect of Intermittent Kangaroo Mother Care on Weight Gain | Samra et al. 195
4. Large for GA (whose birth weight was higher The baby was cared for in skin-to-skin contact verti-
than the 90th percentile). (The previous defini- cally between the mother’s breasts under her clothes
tions are according to Lee, 2008.) for at least 1 hr at a time wearing only a diaper and
a cap, and breastfeeding during this time was also
5. Babies who start gaining weight before Day 8.
encouraged as described by Nyqvist et al. (2010a).
6. Babies who lost less than 10% or more than 13% Weight was measured for the babies without
of birth weight in the first week. clothes by using a calibrated electronic scale (Laica
7. Babies who are not stable (did not meet the pre- Model BF 2051) 3 times per day by the same investi-
vious criteria) before enrollment or during the gator. The mean was taken and recorded as the daily
observation period. weight, and the mean rate of daily weight gain was
calculated as the secondary outcome measure.
8. Babies with congenital anomalies, hypoxic ischemic When the baby regained his birth weight, our
encephalopathy, central nervous system (CNS) primary outcome measure was recorded (postnatal
impairment, neonatal sepsis, urinary tract infec- age of regaining birth weight).
tion, or one of twins or higher order multiples.
Statistical Methods
All investigations necessary to confirm the diagnosis Data were analyzed using SPSS win statistical pack-
of the exclusion criteria were performed (e.g., echo- age version 15 (SPSS Inc., Chicago, IL). Numerical
cardiography (echo), ultrasound, computed tomog- data were expressed as mean, standard deviation, and
raphy (CT) of the brain, blood gases, and blood or range. Qualitative data were expressed as frequency
urine cultures). and percentage. Chi-square test (Fisher’s exact test)
Standardized nutrition and care were provided was used to examine the relation between qualitative
for all 40 neonates. All of the studied newborns of variables. For quantitative data, comparison between
both groups received the same nutrition (130 Kcal/ two groups was done using Mann-Whitney test for
kg/day equivalent to 160 mL/kg/day; Doherty & univariate analysis. Factors possibly affecting the
Simmons, 2008; Ellard & Anderson, 2008) through- numerical outcome measures were tested in a general
out the observation period. Feeds were given every linear model univariate analysis for detection of the
2 hr (full-strength LBW formula alternating with independent factors. A p value ,.05 was considered
expressed breastmilk when available). significant. The power of the study was calculated
The infants of the KMC group had opportunities according to the number of patients in each group
to directly breastfeed ad lib in addition to the stan- and the resultant rate of weight gain at an alpha level
dard nutrition. All the 40 studied neonates received of 0.05, and it resulted in a power of 100%.
standard care and monitoring inside the incubators
(Dräger air-shields isolette C450 H-1C). For all RESULTS
40 neonates, we followed serum electrolytes, blood There were 40 LBW infants (KMC group 5 22,
gases, complete blood count, daily urine output, renal control group 5 18) included in this study. There
and liver functions, serum albumin, and other inves- were no statistically significant differences between
tigations for the assessment of the nutritional status. the two groups regarding the demographic char-
For the 22 neonates of the KMC group, inter acteristics, namely, mode of delivery (p 5 .455)
mittent KMC was begun twice daily, 7 days per week. and gender (p 5 .482; Table 1) or baseline values
TABLE 1
Comparison Between KMC Group and Control Group Regarding Mode of Delivery and Gender
196 The Journal of Perinatal Education | Fall 2013, Volume 22, Number 4
TABLE 2 TABLE 4
Comparison Between KMC Group and Control Group Relation of Mode of Delivery, Gender, Gestational Age, and
Regarding Gestational Age, Birth Weight, Weight Loss, and Birth Weight With the Outcome Measures
Weight at Enrollment
Time of Regaining Rate of
Kangaroo Points of Birth Weight Weight Gain
Mother Care, Control, Comparison (Days Postpartum) (Grams/Day)
Points of Mean, 6 SD Mean, 6 SD
Mode of delivery
Comparison (Range) (Range) p value Vaginal delivery 19.7 6 5.3 17.0 6 6.5
Gestational age 31.1 6 2.5 32.0 6 2.1 .270 Cesarean surgery 19.7 6 5.0 16.5 6 6.3
(weeks) (27–35) (28–35) p value .455 .437
Birth weight 1,381.8 6 391.1 1,502.8 6 285.7 .218 Gender
(grams) (850–2,100) (900–1,900) Male 20.0 6 5.0 16.6 6 6.6
Weight loss (%) 11.4 6 1.4 11.4 6 1.0 .834 Female 19.3 6 5.5 17.1 6 6.3
Weight at 1,226.7 6 339.7 1,329.3 6 247.0 .258 p value .199 .079
enrollment (765–2,100) (810–1,672) Gestational age
(grams) ,32 weeks 18.4 6 4.4 17.3 6 7.4
$32 weeks 20.5 6 5.5 16.5 6 5.8
p value .279 .692
Birth weight
at enrollment, namely, GA at birth (p 5 .270), birth ,1,500 g 19.0 6 5.3 17.4 6 7.3
weight (p 5 .218), mean weight loss (p 5 .834), and $1,500 g 20.6 6 5.0 16.1 6 5.2
p value .218 .581
weight at enrollment (p 5 .258; Table 2).
The mean postnatal age at which the babies
regained their birth weight (primary outcome
measure) was significantly less in the KMC group, group were found to have had a mean of additional
15.7 6 0.7 days, compared to the control group, breastfeeding opportunities of 17.4 6 1.3 times.
24.6 6 3.8 days (p , .001). The mean daily weight
gain (secondary outcome measure) was signifi- DISCUSSION
cantly higher in the KMC group, 22.1 6 2.5 g, com- Intermittent KMC was found to be a safe, effective,
pared to the control group, 10.4 6 2.5 g (p , .001; and feasible method of care of LBW infants admitted
Table 3). No significant associations were noticed of to the NICU. In the context of our interventions to
the primary outcome measure (age of regained birth promote breastfeeding and introduce baby-friendly
weight) or the secondary outcome measure (average practices in our NICU, we have been exploring the
daily weight gain) with mode of delivery, gender, GA, effect of these interventions on various aspects of
or birth weight (Table 4). In a general linear model, neonatal health problems such as jaundice (Samra,
univariate analysis for these factors in addition to the El Taweel, & Cadwell, 2011), infant cognitive devel-
kangaroo care with ad lib breastfeeding, the inter- opment (El Azim & Samra, 2011), infant vital param-
vention was the only independent factor affecting the eters (Samra & Brimdyr, 2011), and weight gain (this
outcome measures (Table 5). Neonates of the KMC study). Weight gain problems represent about 25% of
cases in our NICU.
LBW newborns that did not start to gain weight
TABLE 3 by Day 7 were intermittently placed ventral surface
Comparison Between KMC Group and Control Group to ventral surface on their mothers’ chests in skin-to-
Regarding the Outcome Measures
skin contact and kept upright. This way, the mother
Kangaroo became the niche and habitat for these immature
Mother Care, Control, beings, just as is done by kangaroos, according to
Points of Mean, 6 SD Mean, 6 SD Parmar et al. (2009). Understanding that parents
Comparison (Range) (Range) p value expect their newborns to receive sophisticated care
Time of regaining 15.7 6 0.7 24.6 6 3.8 ,.001
using advanced technology in our NICU, we could
birth weight (15–17) (20–30)
(days postpartum)
Rate of weight 22.1 6 2.5 10.4 6 2.5 ,.001 Intermittent KMC was found to be a safe, effective, and feasible
gain (g/day) (20–28) (8–15)
method of care of LBW infants admitted to the NICU.
Effect of Intermittent Kangaroo Mother Care on Weight Gain | Samra et al. 197
TABLE 5 postpartum ages and implementing either inter-
General Linear Model Univariate Analysis for Factors Affecting mittent or continuous KMC (Cattaneo et al., 1998;
the Outcome Measures
Charpak et al., 2005; de Leeuw, Colin, Dunnebier,
Points of Time of Regaining Rate of & Mirmiran, 1991; Gathwala, Singh, & Singh,
Comparison Birth Weight Weight Gain 2010; Ludington-Hoe, Morgan, & Abouelfettoh,
2008; Mörelius, Theodorsson, & Nelson, 2005;
Source F p value F p value
Ramanathan, Paul, Deorari, Taneja, & George, 2001;
Kangaroo care 104.400 ,.001 243.251 ,.001
Tallandini & Scalembra, 2006).
Mode of delivery 1.669 .205 1.283 .265
Gender 0.295 .591 1.623 .211 Our explanation for our significant findings is that
Gestational age 0.280 .600 5.340 .070 the mother’s skin-to-skin contact with her preterm
Birth weight 0.003 .955 3.390 .056 infant provides multisensory stimulation including
Weight loss 0.094 .762 3.772 .061 emotional, tactile, proprioceptive, vestibular, olfac-
Weight at 0.753 .392 0.138 .713
tory, auditory, visual, and thermal stimulation in
enrollment
a unique interactive style (Cong, Ludington-Hoe,
McCain, & Fu, 2009) and also promotes beneficial
physiological conditions in preterm infants such as
only try KMC on a convenience sample of neonates increased quiet sleep state and more stable thermo-
and only after they had been stabilized. regulation, heart rate, respiratory rate, and oxygen
We designed the inclusion and exclusion criteria saturation (Chiu & Anderson, 2009). According to
to limit to the utmost extent of the influence of Tourneux et al. (2009), the newborn’s energy expen-
confounding variables on our results. The only diture is used in order of priority for (a) basic metab-
difference between both groups was the intervention. olism, (b) body temperature regulation, and (c) body
This was confirmed by the nonsignificant differences growth. So when KMC decreases the expenditure
between both groups regarding the pre-enrollment needed for metabolism and thermoregulation, most
variables, namely, mode of delivery (p 5 .455), of the energy is directed toward growth.
gender (p 5 .482), GA at birth (p 5 .270), birth Also, the increased opportunities of direct breast-
weight (p 5 .218), mean weight loss (p 5 .834), feeding (which amounted up to 17.4 6 1.3 times),
and weight at enrollment (p 5 .258). We started the enjoyed by our KMC babies must have definitely
intervention at Day 8 when the infants should have added to the previously noted energy-saving effect,
started to regain weight, which we determined was with the net result of their better weight gain. The
the only factor delaying their discharge. In this study, positive impact of KMC on breastfeeding is stated
we found that the mean postnatal age at which the in reports by WHO (2003), Nyqvist et al. (2010a),
babies had regained their birth weight was earlier and others. Conversely, very few studies reported
in the KMC group (15.7 days) compared with that no difference in weight gain in KMC neonates com-
of the control group (24.6 days; p , .001). In addi- pared to non-KMC neonates (Cerezo, de Leon, &
tion, KMC babies had more than double the average Gonzales, 1992; Chwo, Anderson, Good, Dowling,
weight gain per day (22.1 g) of that of the babies in Shiau, & Chu, 2002).
the control group (10.4 g; p , .001). However, Conde-Agudelo, Belizán, & Diaz-
These findings agree with those of Suman, Udani, Rossello (2011) in their most recent, extensive, and
& Nanavati (2008) whose research at a Level III critical updated systematic review of 15 randomized
NICU of a teaching institution in Western India re- controlled trials comparing KMC and conventional
ported an average weight gain per day in the KMC neonatal care, found compelling evidence that KMC
babies of 23.99 g versus 15.58 g in the conventional is associated with increases in weight gain among
methods of care. However, they included cases of other important benefits. They have come to that
small for GA and they reported development of conclusion after having exhausted all critical appraisal
hypothermia, hypoglycemia, and sepsis in the con- tools and comparing different study parameters
ventional care group whose ages of enrollment were and inclusion and exclusion criteria with inclusion
significantly younger than the KMC group, and both of subgroup analyses according to type of KMC
were younger than our cases. Several other investiga- (intermittent vs. continuous), infant age at initiation
tors have reported weight gain in neonates using dif- of KMC, setting in which the trial was conducted
ferent inclusion criteria, starting KMC at different (low- or middle-income countries vs. high-income
198 The Journal of Perinatal Education | Fall 2013, Volume 22, Number 4
countries), and infant stabilization (before vs. after). mother care for low birthweight infants: A randomized
Using the subgrouping described by Conde-Agudelo controlled trial in different settings. Acta Paediatrica,
87(9), 976–985.
et al. (2011), our cases belong to the late-onset KMC,
Cerezo, M. R., de Leon, R., & Gonzales, B. J. V. (1992).
low- or middle-income country (but in a Level III Mother-child early contact with “the mother kanga-
university-based unit) and we used the intermittent roo” program and natural breastfeeding. Rev Latino
type of KMC after stabilization of the infants. Am Perinatol, 12, 54–60.
Although we could not randomly assign our Charpak, N., Ruiz, J. G., Zupan, J., Cattaneo, A.,
subjects to either of the two groups because of Figueroa, Z., Tessier, R., . . . Worku, B. (2005). Kangaroo
Mother Care: 25 years after. Acta Paediatrica, 94(5),
inconvenience, we took care that both groups were
514–522.
matching regarding patient characteristics, base- Chiu, S. H., & Anderson, G. C. (2009). Effect of early
line values, and physical and environmental condi- skin-to-skin contact on mother-preterm infant inter-
tions before and at enrollment and all throughout action through 18 months: Randomized controlled
the observation period. Neither of these variables trial. International Journal of Nursing Studies, 46(9),
appeared to have an influence on either of our out- 1168–1180.
Chwo, M. J., Anderson, G. C., Good, M., Dowling, D. A.,
come measures. In a general linear model univariate Shiau, S. H., & Chu, D. M. (2002). Randomized con-
analysis for these factors in addition to the kanga- trolled trial of early kangaroo care for preterm infants:
roo care, the latter was the only independent fac- Effects on temperature, weight, behavior, and acuity.
tor affecting the outcome measures. Also, to adjust Journal of Nursing Research, 10(2), 129–142.
for the relatively small sample size, the power of Conde-Agudelo, A., Belizán, J. M., & Diaz-Rossello, J.,
(2011). Kangaroo mother care to reduce morbidity
the study was calculated according to the number
and mortality in low birthweight infants. Cochrane
of patients in each group and the resultant rate of Database of Systematic Reviews, 16(3), CD002771.
weight gain at an alpha level of 0.05, which resulted Cong, X., Ludington-Hoe, S. M., McCain, G., & Fu, P.
in a power of 100%. (2009). Kangaroo Care modifies preterm infant heart
In the light of research demonstrating the ben- rate variability in response to heel stick pain: Pilot
efits of KMC, the WHO (2003) stated that: study. Early Human Development, 85(9), 561–567.
de Leeuw, R., Colin, E. M., Dunnebier, E. A., & Mirmiran,
M. (1991). Physiologic effects of kangaroo care in very
Almost two decades of implementation and research small preterm infants. Biology of the Neonate, 59(3),
have made it clear that KMC is more than an 149–155.
alternative to incubator care. It has been shown to Doherty, E. J., & Simmons, C. F., Jr. (2008). Fluid and elec-
be effective for thermal control, breastfeeding and trolyte management. In J. Cloherty, E. Eichenwald, &
bonding in all newborn infants irrespective of setting, A. Stark (Eds.). Manual of Neonatal Care, (6th ed.,
pp. 100–113). Philadelphia, PA: Lippincott Williams &
weight, gestational age and clinical condition. (p. 2)
Wilkins.
El Azim, S. A., & Samra, N. M. (2011). Cognitive develop-
In conclusion, intermittent KMC with increased ment of breastfed versus formula fed infants in the first
breastfeeding opportunities was found to be effec- six months of life. Journal of Arab Child, 22(2).
tive for improving weight gain in neonates who have Ellard, D., & Anderson, D. M. (2008). Nutrition. In J.
delayed weight gain irrespective of birth weight, Cloherty, E. Eichenwald, & A. Stark (Eds.), Manual of
neonatal care (6th ed., pp. 114–136). Philadelphia, PA:
gender, mode of delivery, or GA. In light of our find-
Lippincott Williams & Wilkins.
ings and others, KMC should be considered to be an Gathwala, G., Singh, B., & Singh, J. (2010). Effect of Kan-
effective strategy to increase weight gain in neonates garoo Mother Care on physical growth, breastfeeding
with delayed weight gain. and its acceptability. Tropical Doctor, 40(4), 199–202.
More research is needed to explore the effects of Lawn, J. E., Mwansa-Kambafwile, J., Horta, B. L., Barros,
KMC on other neonatal problems and to reconfirm F. C., & Cousens, S. (2010). ‘Kangaroo mother care’
to prevent neonatal deaths due to preterm birth
our findings in other settings. complications. International Journal of Epidemiology,
39(Suppl. 1), i144–i154.
REFERENCES Lawrence, R. A., & Lawrence, R. M. (2011). Breastfeeding:
Ballard, J. L., Khoury, J. C., Wedig, K., Wang, L., Eilers- A Guide for the Medical Profession (7th ed.). Maryland
Walsman, B. L., & Lipp, R. (1991). New Ballard Score, Heights, MO: Elsevier Mosby.
expanded to include extremely premature infants. The Lee, K. G. (2008). Identifying the high-risk newborn. In J.
Journal of Pediatrics, 119, 417–423. Cloherty, E. Eichenwald, & A. Stark (Eds.) Manual of
Cattaneo, A., Davanzo, R., Worku, B., Surjono, A., Echever- Neonatal Care (6th ed., pp. 34–58). Philadelphia, PA:
ria, M., Bedri, A., . . . Tamburlini, G. (1998). Kangaroo Lippincott Williams & Wilkins.
Effect of Intermittent Kangaroo Mother Care on Weight Gain | Samra et al. 199
Ludington-Hoe, S., Morgan, K., & Abouelfettoh, A. Samra, N. M., & Brimdyr, K. (2011). Effect of early skin
(2008). A clinical guideline for implementation of to skin contact on preterm neonates’ vital parameters.
kangaroo care with premature infants of 30 or more Journal of Arab Child, 22(3).
weeks’ postmenstrual age. Advances in Neonatal Care, Samra, N. M., El Taweel, A., & Cadwell, K. (2011). The
8, S3–S23. effect of kangaroo mother care on the duration of
May, G., & Zaccagnini, L. (2008). Discharge planning. In phototherapy of infants re-admitted for neonatal
J. Cloherty, E. Eichenwald, & A. Stark (Eds.) Manual of jaundice. The Journal of Maternal-Fetal and Neonatal
neonatal care (6th ed., pp. 164–175). Philadelphia, PA: Medicine, 25(8), 1354–1357.
Lippincott Williams & Wilkins. Suman, R. P., Udani, R., & Nanavati, R. (2008). Kangaroo
Mörelius, E., Theodorsson, E., & Nelson, N. (2005). mother care for low birth weight infants: A random-
Salivary cortisol and mood and pain profiles during ized controlled trial. Indian Pediatrics, 45(1), 17–23.
skin-to-skin care for an unselected group of mothers Tallandini, M. A., & Scalembra, C. (2006). Kangaroo mother
and infants in neonatal intensive care. Pediatrics, care and mother—Premature infant dyadic interaction.
116(5), 1105–1113. Infant Mental Health Journal, 27(3), 251–275.
Nyqvist, K. H., Anderson, G. C., Bergmen, N., Cattaneo, A., Thukral, A., Chawla, D., Agarwal, R., Deorari, A. K., &
Charpak, N., Devanzo, R., . . . Widström, A. M. (2010a). Paul, V. K. (2008). Kangaroo mother care—An alterna-
State of the art and recommendations. Kangaroo tive to conventional care. Indian Journal of Pediatrics,
mother care: Application in a high-tech environment. 75(5), 497–503.
Acta Pediatrica, 99(6), 812–819. Tourneux, P., Libert, J. P., Ghyselen, L., Léké, A., Delanaud,
Nyqvist, K. H., Anderson, G. C., Bergman, N., Cattaneo, S., Dégrugilliers, L., . . . Bach, V. (2009). Heat exchanges
A., Charpak, N., Davanzo, R., . . . Widström, A. M. and thermoregulation in the neonate. Archives de
(2010b). Towards universal Kangaroo Mother Care: pédiatrie, 16(7), 1057–1062.
Recommendations and report from the First Euro- World Health Organization. (2003). Kangaroo Mother
pean conference and Seventh International Workshop Care: A practical guide. Geneva, Switzerland: Author.
on Kangaroo Mother Care. Acta Paediatrica, 99(6),
820–826.
Parmar, V. R., Kumar, A., Kaur, R., Parmar, S., Kaur, D., NASHWA M. SAMRA is a professor of pediatrics and head
Basu, . . . & Narula, S. (2009). Experience with kan-
of NICU and Pediatrics’ Department, Fayoum Faculty
garoo mother care in a neonatal intensive care unit
of Medicine near Cairo, Egypt. AMAL EL TAWEEL is a
(NICU) in Chandigarh, India. Indian Journal of Pedi-
atrics, 76(1), 25–28. pediatrician and the treasurer and educational coordinator
Ramanathan, K., Paul, V. K., Deorari, A. K., Taneja, U., & of the Egyptian Lactation Consultant Association. KARIN
George, G. (2001). Kangaroo Mother Care in very CADWELL is a member of the faculty of the Healthy
low birth weight infants. Indian Journal of Pediatrics, Children Project and professor of Maternal Child Health at
68(11), 1019–1023. Union Institute and University.
200 The Journal of Perinatal Education | Fall 2013, Volume 22, Number 4