Original Article

Kangaroo Mother Care in Very Low Birth Weight Infants

K. Ramanathan, V.K. Paul, A.K. Deorari, U. Taneja and G. George

Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India

Abstract. Objective : This study was conducted (i) to study through a randomized control trial the effect of Kangaroo Mother
Care (KMC) on breast feeding rates, weigh t gain and length of hospitalization of very low birth neonates and (ii) to assess the
acceptability of Kangaroo Mother Care by nurses and mothers. Methods : Babies whose birth weight was less than 1500
Grams were included in the study once they were stable. The effect of Kangaroo Mother Care on breast feeding rates, weight
gain and length of hospitalization of very low birth weight neonates was studied through a randomized control trial in 28
neonates. The Kangaroo group (n=14) was subjected to Kangaroo Mother Care of at least 4 hours per day in not more than
3 sittings. The babies received Kangaroo Care after shifting out from NICU and at home. The control group (n=14) received
only standard care (incubator or open care system). Attitude of mothers and nurses towards KMC was assessed on Day 3
_+1 and on day 7 + 1 after starting Kangaroo Care in a questionnaire using Likert's scale. Results : The results of the clinical
trial reveal that the neonates in the KMC group demonstrated better weight gain after the first week of life (15.9 + 4.5 gm/day
vs. 10.6 + 4.5 gm/day in the KMC group and control group respectively p<0.05) and earlier hospital discharge (27.2 + 7 vs.
34.6 + 7 days in KMC and control group respectively, p<0.05). The number of mothers exclusively breastfeeding their babies
at 6 week follow-up was double in the KMC group than in the control group (12/14 vs. 6/14) (p< 0.05). Conclusion : KMC
managed babies had better weight gain, earlier hospital discharge and, more impressively, higher exclusive breast-feeding
rates. KMC is an excellent adjunct to the routine preterm care in a nursery. [Indian J Pediatr 2001; 68 (11) 9 1019-1023]

Key words : Kangaroo Mother Care; Low birth weight infants; Breast feeding

Edgar Rey and Hector Martinez developed Kangaroo
Mother Care (KMC) in Columbia as a substitute for
incubators in the care of the low birth weight infants. 1
Kangaroo Mother Care is defined as early, prolonged and
continuous skin-to-skin contact between the mother and
the low birth weight infant both in hospital and after
discharge, with exclusive breastfeeding and proper follow
up. 1 In this method the diaper clad infant is placed
upright between the mothers' breasts. Kangaroo Mother
Care does not need expensive and sophisticated
equipment, and for its simplicity it can be applied almost
everywhere, including peripheral maternity units of very
low income countries. Published findings from different
countries demonstrate that Kangaroo Mother Care
promotes stable heart rates, respiratory rates, oxygen
saturation, and thermoregulation in infants.2-7Moreover
the physical closeness has the potential to help parents
grow in their attachment and move through their grief
following the birth of the sick premature infant.8
Experience with Kangaroo Mother Care is limited in
South Asia. There is insufficient data in our own country
regarding the acceptability of Kangaroo Care to the
mothers and health staff, early discharge policies and
long-term outcomes. A feasibility s t u d y from
Ahmedabad, India, has shown encouraging results. 9 The
Reprintrequests : Dr. V.K.Paul,AdditionalProfessor,Department
of Pediatrics, All India Institute of MedicalSciences,New Delhi-
110029. Fax : 91-11-6862663, E-mail : vinodkpaul@hotmail.com
positive findings in this study make it a case for gathering
more experience in other centers in the country as a
prelude to a wider dissemination. The present study was
envisaged as a step in that direction. This simple method,
if found suitable and culturally acceptable, may prove as
a new primary modality which can be incorporated into
the essential newborn care package of the 'Reproductive
and Child Health Programme.
MATERIALS AND METHODS
Babies whose birth weight was less than 1500 gm were
included in the study once their cardiopulmonary status
was stable, they were tolerating enteral feeds and
maintaining temperature in the thermoneutral
environment. Babies whose mothers were unable to come
to the nursery because of illness or disability were
excluded from the study. Informed consent was obtained
from all the mothers participating in the study. In a
previous study at AIIMS it was found that 30% of mothers
of nursery graduate very low birth weight (VLBW)babies
were exclusively breastfeed at 6 weeks of age
(unpublished data). At 80% power of detecting tripling of
this proportion to 90% (at p<0.05) required 12 subjects in
each group. In our study 14 neonates were enrolled each
in both experimental and control group. The babies were
randomized using a table of random numbers to receive
either Kangaroo Mother Care along with standard care or

Indian Journal of Pediatrics, Volume 68---November, 2001 1019

 Ramanathan et al
s t a n d a r d care alone. The K a n g a r o o g r o u p (n=14) was
subjected to Kangaroo Mother Care of at least 4 hours per
d a y in not m o r e than 3 sittings. During Kangaroo Care
each mother wore a cover g o w n and sat in an inclined
chair. The b a b y w a s p o s i t i o n e d inside her dress a n d
b e t w e e n the breasts. The g o w n s c o v e r e d the infant's
t r u n k a n d extremities, b u t not the h e a d , w h i c h w a s
covered with a cap. The mother was encouraged to hold
her baby in this position whenever she came to visit her
baby. The baby was nursed in warmer / incubator for the
rest of the time. The babies received Kangaroo Care after
shifting out from NICU and at home.
The b a b i e s in the c o n t r o l g r o u p (n=14) r e c e i v e d
standard care. This consisted of care under w a r m e r or in
the incubator. Mothers were allowed to visit the babies
and touch and handle them. They also contributed to
their care b y feeding t h e m w i t h s p o o n a n d c h a n g i n g
napkins.
Breast feeding guidelines were followed for both the
g r o u p s and lactational counseling was e m p h a s i z e d to
ensure breast milk feeding. Nurses assisted the mothers
of both groups in positioning and attachment. They also
assisted in expression of breast milk for spoon feeding.
W e i g h i n g of the b a b i e s w a s d o n e o n c e a d a y on a
w e i g h i n g scale w i t h s e n s i t i v i t y of l g . Babies w e r e
provided vitamin and mineral supplements on the same
pattern as per nursery protocols.
Maternal and neonatal characteristics and
c o m p l i c a t i o n s w e r e p r o s p e c t i v e l y r e c o r d e d . Breast
f e e d i n g r a t e s w e r e c a l c u l a t e d b a s e d on the h i s t o r y
obtained from the mothers at 6 weeks follow-up. Weight
gain velocity was calculated as mean weight gain per day
each week. The babies were discharged once they meet
the criteria of weight greater than 1400 grn, gestation over
34 weeks, only on enteral feeds, mother's readiness to go
TABLE1. Baseline Characteristics of the Newborn Infants at Birth
Characteristic
Male/Female
Birth weight (G)
Mean _+S.D.
Gestational age (weeks)
Median
Range
AGA: SGA
Neonatal problems (no. of infants)*
Respiratory Distress
Treatment (hours)
(Mean + S.D.)
Oxygen*
Nasal CPAP*
IPPV*
Phototherapy
KMC = Kangaroo Mother Care; AGA = Appropriate for dates; SGA = Small for dates; CPAP = Continuous positive airway pressure; IPPV
= Intermittent positive pressure ventilation
1020
home/confidence to look after the baby, gaining weight
adequately, no overt illness, no intravenous medications
and essentially on exclusive breast feeds.
Acceptability was defined as the positive attitude of
the mothers and nurses towards KMC. Acceptability was
assessed b y a questionnaire incorporating Likert scale.
Mothers' attitude towards KMC was assessed on day 3 +
1 and on day 7 + 1 after starting Kangaroo Care using a
questionnaire, which contained 10 items. Nurses' attitude
towards Kangaroo Care was assessed similarly using a
questionnaire, which contained 11 items.
Statistical analysis w a s d o n e u s i n g stata6, statistix
4,and epi info 6 computer programs. Two-sample t-test,
Wilcoxon Test and Fisher's Exact Test were used to test
the significance b e t w e e n the t w o groups. Analysis of
Covariance was used to c o m p u t e adjusted m e a n s and
s t a n d a r d d e v i a t i o n s for the o u t c o m e v a r i a b l e s after
adjusting for the confounding variables. Students t-test
w a s used to c o m p a r e the adjusted m e a n s in KMC vs.
control group.
RESULTS
During the course of the study, 33 babies fulfilled the
criteria for enrollment. Five of these babies w e r e not
enrolled because they were either due for early discharge
(n=3) or the m o t h e r s could not carry out KMC due to
their illness (n=2). A total of 28 babies were r a n d o m l y
a s s i g n e d to r e c e i v e either K a n g a r o o C a r e (n=14) or
standard care (n=14). Table I shows the characteristics of
the infants at birth. None of the mothers allocated to the
Kangaroo Care group refused to participate. There was no
significant difference in birth weight, gestationa] age, sex
and A p g a r scores birth. But the neonates in the KMC
group required positive pressure ventilation, CPAP and
KMC Group Control Group
(n=14) (n=14)
9/5 9/5
1219 + 186.4 1270.9 + 170.4
30.4 30.9
28.8 -34.1 29 - 33.3
10:4 12:2
8 4
43.7 + 83.0 22.5 + 42.6
32.0 _+75.0 9.7 + 19.4
19.2 _+37.6 27 + 8.5
73.9 + 39.0 62.2 _+22.8
Indian Joumal of Pediatrics, Volume 68---November, 2001