Effect of Intermittent Kangaroo Mother

Care on Weight Gain of Low Birth Weight

Neonates With Delayed Weight Gain
Nashwa M. Samra, MD
Amal El Taweel, MD
Karin Cadwell, PhD

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: 40LBW
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.
24.56days) 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 intervention for LBWs with delayed weight gain and should be considered to be an effective strategy.

The Journal of Perinatal Education, 22(4), 194200, http://dx.doi.org/10.1891/1058-1243.22.4.194

Keywords: Kangaroo mother care, neonatal weight gain, delayed neonatal weight gain

Each year, about 20 million low birth weight (LBW)

infants are born worldwide. The care of such infants is a burden for health and social systems
everywhere (World Health Organization [WHO],
2003). Although it is expected that newborns
will lose some weight, a loss of 7% is maximum
and weight should plateau by 72 hr (Lawrence &
Lawrence, 2011).
Although term neonates initially lose about 3%
5% of their birth weight over the first 35 days and
regain birth weight by about 10 days, preterm infants
may be allowed to lose 5%15% of their birth weight
over the first 56 days because of immature skin and

194

kidneys. Preterm infants take longer to regain their

birth weight (Doherty & Simmons, 2008; Ellard &
Anderson, 2008).
Kangaroo Mother Care (KMC) was developed in
Colombia in the 1970s (Nyqvist et al., 2010a). However, it remains unavailable in most low-income
countries (Lawn, Mwansa-Kambafwile, Horta,
Barros, & Cousens, 2010). The hallmark of KMC is
the kangaroo position: the infant is cared for skinto-skin (ventral surface of the mother to ventral
surface of the baby) vertically between the mothers
breasts and under her clothes, 24 hr per day, with
the father/substitute(s) participating as relief KMC

The Journal of Perinatal Education | Fall 2013, Volume 22, Number 4

 roviders. The other components in KMC are

p
exclusive breastfeeding (ideally) and early discharge
continuing KMC at home with close follow-up
(Nyqvist et al.2010a).
Lawnet al. (2010) concluded that KMC in the
first week of life showed a significant reduction in
neonatal mortality (relative risk 0.49, 95% confidence interval 5 0.290.82) compared with standard care among preterm babies in hospital, and
was highly effective in reducing severe morbidity, particularly from infection. Thukral, Chawla,
Agarwal, Deotari, & Paul (2008) concluded that all
stable LBW babies are candidates for KMC. This is a
desirable practice for the reasons described earlier
and should be continued until the babys postmenstrual age reaches term. Even unstable infants
can be provided KMC irrespective of their clinical
condition (WHO, 2003).

The infants were enrolled in the study at 8 days of

postnatal age when intermittent KMC with inherent
ad lib breastfeeding opportunity was begun for the
intervention group. All babies were generally stable
all throughout the study.
Inclusion criteria:

METHODS
The aim of this study was to examine the effectiveness of intermittent KMC with increased opportunities to breastfeed on weight gain in LBW neonates
who did not start to gain weight after Day 7. Weight
gain problems represent about 25% of cases in our
neonatal intensive care unit (NICU).
The study followed the principles of research
ethics adopted by the 18th World Medical Assembly,
Helsinki, Finland, June 1964 and amendments
including approval by the University Hospitals
Institutional Review Board (IRB).
The study followed a nonrandomized controlled,
quasi-experimental design. It was conducted at the
NICU of Fayoum University Hospital, which serves
a limited resource district (Fayoum) in Egypt.
As part of the efforts to promote breastfeeding, humanize care, and introduce baby-friendly
attitudes and practices in our NICU, a private room
has been allocated for mothers for breastfeeding
and KMC. After complete stabilization, parents
of 40 LBW infants (birth weight ,2,500 g) who
met the inclusion criteria were informed about
the study and were asked if they would like to
participateall consented. A convenience sample
of 22 neonates whose mothers had permitting
family and household commitments and were able
to come to the NICU and provide KMC, including breastfeeding twice daily for at least an hour as
described by Nyqvist et al. (2010a), were assigned to
the KMC group. The remaining 18 infants received
routine care.

4. Weight loss of 10%13% of birth weight during

the first week.

1. Babies admitted in the NICU in the first day

oflife.
2. Preterm LBW babies: babies born less than
37 weeks gestational age (GA; WHO, 2003).
GAwas assessed using the Ballard score (Ballard
et al., 1991).
3. Babies birth weights were appropriate for gestational age (AGA). AGA 5 birth weight between
the 10th and 90th percentile (according to Lee,
2008). So all our subjects were LBW and also
premature.

5. Babies who are generally stable and met the

criteria for discharge according to May and
Zaccagnini (2008) except for not starting to gain
weight until Day 7.
Criteria for discharge according to May and
Zaccagnini (2008):
Alert, healthy appearance.
Ability to maintain temperature in an open crib.
(We frequently tested our subjects during feeding,
weighing, and delivery of care and all maintained
their temperature outside the incubator.)
Ability to take feeding by bottle or breast without
respiratory compromise.
No apnea or bradycardia for 5 days.
Steady weight gain.
Exclusion criteria:
1. Term babies (3741 6/7 weeks GA).
2. Postterm babies (42 weeks or more GA).
3. Small for GA (whose birth weight was lower than
the 10th percentile).

The aim of this study was to examine the effectiveness of

intermittent KMC with increased opportunities to breastfeed on
weight gain in LBW neonates who did not start to gain weight after
Day 7.

Effect of Intermittent Kangaroo Mother Care on Weight Gain | Samra et al.

195

4. Large for GA (whose birth weight was higher

than the 90th percentile). (The previous definitions are according to Lee, 2008.)
5. Babies who start gaining weight before Day 8.
6. Babies who lost less than 10% or more than 13%
of birth weight in the first week.
7. Babies who are not stable (did not meet the previous criteria) before enrollment or during the
observation period.
8. Babies with congenital anomalies, hypoxic ischemic
encephalopathy, central nervous system (CNS)
impairment, neonatal sepsis, urinary tract infection, or one of twins or higher order multiples.
All investigations necessary to confirm the diagnosis
of the exclusion criteria were performed (e.g., echocardiography (echo), ultrasound, computed tomography (CT) of the brain, blood gases, and blood or
urine cultures).
Standardized nutrition and care were provided
for all 40 neonates. All of the studied newborns of
both groups received the same nutrition (130 Kcal/
kg/day equivalent to 160 mL/kg/day; Doherty &
Simmons, 2008; Ellard & Anderson, 2008) throughout the observation period. Feeds were given every
2 hr (full-strength LBW formula alternating with
expressed breastmilk when available).
The infants of the KMC group had opportunities
to directly breastfeed ad lib in addition to the standard nutrition. All the 40 studied neonates received
standard care and monitoring inside the incubators
(Drger air-shields isolette C450 H-1C). For all
40 neonates, we followed serum electrolytes, blood
gases, complete blood count, daily urine output, renal
and liver functions, serum albumin, and other investigations for the assessment of the nutritional status.
For the 22 neonates of the KMC group, inter
mittent KMC was begun twice daily, 7 days per week.

The baby was cared for in skin-to-skin contact vertically between the mothers breasts under her clothes
for at least 1 hr at a time wearing only a diaper and
a cap, and breastfeeding during this time was also
encouraged as described by Nyqvist et al. (2010a).
Weight was measured for the babies without
clothes by using a calibrated electronic scale (Laica
Model BF 2051) 3 times per day by the same investigator. The mean was taken and recorded as the daily
weight, and the mean rate of daily weight gain was
calculated as the secondary outcome measure.
When the baby regained his birth weight, our
primary outcome measure was recorded (postnatal
age of regaining birth weight).
Statistical Methods
Data were analyzed using SPSS win statistical package version 15 (SPSS Inc., Chicago, IL). Numerical
data were expressed as mean, standard deviation, and
range. Qualitative data were expressed as frequency
and percentage. Chi-square test (Fishers exact test)
was used to examine the relation between qualitative
variables. For quantitative data, comparison between
two groups was done using Mann-Whitney test for
univariate analysis. Factors possibly affecting the
numerical outcome measures were tested in a general
linear model univariate analysis for detection of the
independent factors. A p value ,.05 was considered
significant. The power of the study was calculated
according to the number of patients in each group
and the resultant rate of weight gain at an alpha level
of 0.05, and it resulted in a power of 100%.
RESULTS
There were 40 LBW infants (KMC group 5 22,
control group 5 18) included in this study. There
were no statistically significant differences between
the two groups regarding the demographic characteristics, namely, mode of delivery (p 5 .455)
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

Kangaroo Mother Care

Variable
Mode of delivery
Vaginal delivery
Cesarean surgery
Gender
Boys
Girls

196

Control

Frequency

(%)

Frequency

(%)

p value

17
5

(77.3)
(22.7)

12
6

(66.7)
(33.3)

.455

11
11

(50.0)
(50.0)

11
7

(61.1)
(38.9)

.482

The Journal of Perinatal Education | Fall 2013, Volume 22, Number 4

TABLE 2
Comparison Between KMC Group and Control Group
Regarding Gestational Age, Birth Weight, Weight Loss, and
Weight at Enrollment

Points of
Comparison
Gestational age
(weeks)
Birth weight
(grams)
Weight loss (%)
Weight at
enrollment
(grams)

Kangaroo
Mother Care,
Mean, 6 SD
(Range)

Control,
Mean, 6 SD
(Range)

31.1 6 2.5
(2735)
1,381.8 6 391.1
(8502,100)
11.4 6 1.4
1,226.7 6 339.7
(7652,100)

32.0 6 2.1
(2835)
1,502.8 6 285.7
(9001,900)
11.4 6 1.0
1,329.3 6 247.0
(8101,672)

Points of
Comparison
p value
.270
.218
.834
.258

atenrollment, namely, GA at birth (p 5 .270), birth

weight (p 5 .218), mean weight loss (p 5 .834), and
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,
15.7 6 0.7 days, compared to the control group,
24.6 6 3.8 days (p , .001). The mean daily weight
gain (secondary outcome measure) was significantly higher in the KMC group, 22.1 6 2.5 g, compared to the control group, 10.4 6 2.5 g (p , .001;
Table3). No significant associations were noticed of
the primary outcome measure (age of regained birth
weight) or the secondary outcome measure (average
daily weight gain) with mode of delivery, gender, GA,
or birth weight (Table 4). In a general linear model,
univariate analysis for these factors in addition to the
kangaroo care with ad lib breastfeeding, the intervention was the only independent factor affecting the
outcome measures (Table 5). Neonates of the KMC

Time of regaining
birth weight
(days postpartum)
Rate of weight
gain (g/day)

Mode of delivery
Vaginal delivery
Cesarean surgery
p value
Gender
Male
Female
p value
Gestational age
,32 weeks
$32 weeks
p value
Birth weight
,1,500 g
$1,500 g
p value

Time of Regaining
Birth Weight
(Days Postpartum)

Rate of
Weight Gain
(Grams/Day)

19.7 6 5.3
19.7 6 5.0
.455

17.0 6 6.5
16.5 6 6.3
.437

20.0 6 5.0
19.3 6 5.5
.199

16.6 6 6.6
17.1 6 6.3
.079

18.4 6 4.4
20.5 6 5.5
.279

17.3 6 7.4
16.5 6 5.8
.692

19.0 6 5.3
20.6 6 5.0
.218

17.4 6 7.3
16.1 6 5.2
.581

group were found to have had a mean of additional

breastfeeding opportunities of 17.4 6 1.3 times.

Kangaroo
Mother Care,
Mean, 6 SD
(Range)

Control,
Mean, 6 SD
(Range)

15.7 6 0.7
(1517)

24.6 6 3.8
(2030)

,.001

DISCUSSION
Intermittent KMC was found to be a safe, effective,
and feasible method of care of LBW infants admitted
to the NICU. In the context of our interventions to
promote breastfeeding and introduce baby-friendly
practices in our NICU, we have been exploring the
effect of these interventions on various aspects of
neonatal health problems such as jaundice (Samra,
El Taweel, & Cadwell, 2011), infant cognitive development (El Azim & Samra, 2011), infant vital parameters (Samra & Brimdyr, 2011), and weight gain (this
study). Weight gain problems represent about 25% of
cases in our NICU.
LBW newborns that did not start to gain weight
by Day 7 were intermittently placed ventral surface
to ventral surface on their mothers chests in skin-toskin contact and kept upright. This way, the mother
became the niche and habitat for these immature
beings, just as is done by kangaroos, according to
Parmar et al. (2009). Understanding that parents
expect their newborns to receive sophisticated care
using advanced technology in our NICU, we could

22.1 6 2.5
(2028)

10.4 6 2.5
(815)

,.001

Intermittent KMC was found to be a safe, effective, and feasible

TABLE 3
Comparison Between KMC Group and Control Group
Regarding the Outcome Measures

Points of
Comparison

TABLE 4
Relation of Mode of Delivery, Gender, Gestational Age, and
Birth Weight With the Outcome Measures

p value

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
General Linear Model Univariate Analysis for Factors Affecting
the Outcome Measures

Points of
Comparison
Source
Kangaroo care
Mode of delivery
Gender
Gestational age
Birth weight
Weight loss
Weight at
enrollment

Time of Regaining
Birth Weight

Rate of
Weight Gain

p value

p value

104.400
1.669
0.295
0.280
0.003
0.094
0.753

,.001
.205
.591
.600
.955
.762
.392

243.251
1.283
1.623
5.340
3.390
3.772
0.138

,.001
.265
.211
.070
.056
.061
.713

only try KMC on a convenience sample of neonates

and only after they had been stabilized.
We designed the inclusion and exclusion criteria
to limit to the utmost extent of the influence of
confounding variables on our results. The only
difference between both groups was the intervention.
This was confirmed by the nonsignificant differences
between both groups regarding the pre-enrollment
variables, namely, mode of delivery (p 5 .455),
gender (p 5 .482), GA at birth (p 5 .270), birth
weight (p 5 .218), mean weight loss (p 5 .834),
and weight at enrollment (p 5 .258). We started the
intervention at Day 8 when the infants should have
started to regain weight, which we determined was
the only factor delaying their discharge. In this study,
we found that the mean postnatal age at which the
babies had regained their birth weight was earlier
in the KMC group (15.7 days) compared with that
of the control group (24.6 days; p , .001). In addition, KMC babies had more than double the average
weight gain per day (22.1 g) of that of the babies in
the control group (10.4 g; p , .001).
These findings agree with those of Suman, Udani,
& Nanavati (2008) whose research at a Level III
NICU of a teaching institution in Western India reported an average weight gain per day in the KMC
babies of 23.99 g versus 15.58 g in the conventional
methods of care. However, they included cases of
small for GA and they reported development of
hypothermia, hypoglycemia, and sepsis in the conventional care group whose ages of enrollment were
significantly younger than the KMC group, and both
were younger than our cases. Several other investigators have reported weight gain in neonates using different inclusion criteria, starting KMC at different

198

postpartum ages and implementing either intermittent or continuous KMC (Cattaneo et al., 1998;
Charpak et al., 2005; de Leeuw, Colin, Dunnebier,
& Mirmiran, 1991; Gathwala, Singh, & Singh,
2010; Ludington-Hoe, Morgan, & Abouelfettoh,
2008; Mrelius, Theodorsson, & Nelson, 2005;
Ramanathan, Paul, Deorari, Taneja, & George, 2001;
Tallandini & Scalembra, 2006).
Our explanation for our significant findings is that
the mothers skin-to-skin contact with her preterm
infant provides multisensory stimulation including
emotional, tactile, proprioceptive, vestibular, olfactory, auditory, visual, and thermal stimulation in
a unique interactive style (Cong, Ludington-Hoe,
McCain, & Fu, 2009) and also promotes beneficial
physiological conditions in preterm infants such as
increased quiet sleep state and more stable thermoregulation, heart rate, respiratory rate, and oxygen
saturation (Chiu & Anderson, 2009). According to
Tourneux et al. (2009), the newborns energy expenditure is used in order of priority for (a) basic metabolism, (b) body temperature regulation, and (c) body
growth. So when KMC decreases the expenditure
needed for metabolism and thermoregulation, most
of the energy is directed toward growth.
Also, the increased opportunities of direct breastfeeding (which amounted up to 17.4 6 1.3 times),
enjoyed by our KMC babies must have definitely
added to the previously noted energy-saving effect,
with the net result of their better weight gain. The
positive impact of KMC on breastfeeding is stated
in reports by WHO (2003), Nyqvist et al. (2010a),
and others. Conversely, very few studies reported
no difference in weight gain in KMC neonates compared to non-KMC neonates (Cerezo, de Leon, &
Gonzales, 1992; Chwo, Anderson, Good, Dowling,
Shiau, & Chu, 2002).
However, Conde-Agudelo, Belizn, & DiazRossello (2011) in their most recent, extensive, and
critical updated systematic review of 15 randomized
controlled trials comparing KMC and conventional
neonatal care, found compelling evidence that KMC
is associated with increases in weight gain among
other important benefits. They have come to that
conclusion after having exhausted all critical appraisal
tools and comparing different study parameters
and inclusion and exclusion criteria with inclusion
of subgroup analyses according to type of KMC
(intermittent vs. continuous), infant age at initiation
of KMC, setting in which the trial was conducted
(low- or middle-income countries vs. high-income

The Journal of Perinatal Education | Fall 2013, Volume 22, Number 4

countries), and infant stabilization (before vs. after).

Using the subgrouping described by Conde-Agudelo
et al. (2011), our cases belong to the late-onset KMC,
low- or middle-income country (but in a Level III
university-based unit) and we used the intermittent
type of KMC after stabilization of the infants.
Although we could not randomly assign our
subjects to either of the two groups because of
inconvenience, we took care that both groups were
matching regarding patient characteristics, baseline values, and physical and environmental conditions before and at enrollment and all throughout
the observation period. Neither of these variables
appeared to have an influence on either of our outcome measures. In a general linear model univariate
analysis for these factors in addition to the kangaroo care, the latter was the only independent factor affecting the outcome measures. Also, to adjust
for the relatively small sample size, the power of
the study was calculated according to the number
of patients in each group and the resultant rate of
weight gain at an alpha level of 0.05, which resulted
in a power of 100%.
In the light of research demonstrating the benefits of KMC, the WHO (2003) stated that:
Almost two decades of implementation and research
have made it clear that KMC is more than an
alternative to incubator care. It has been shown to
be effective for thermal control, breastfeeding and
bonding in all newborn infants irrespective of setting,
weight, gestational age and clinical condition. (p. 2)
In conclusion, intermittent KMC with increased
breastfeeding opportunities was found to be effective for improving weight gain in neonates who have
delayed weight gain irrespective of birth weight,
gender, mode of delivery, or GA. In light of our findings and others, KMC should be considered to be an
effective strategy to increase weight gain in neonates
with delayed weight gain.
More research is needed to explore the effects of
KMC on other neonatal problems and to reconfirm
our findings in other settings.
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Care: A practical guide. Geneva, Switzerland: Author.

NASHWA M. SAMRA is a professor of pediatrics and head

of NICU and Pediatrics Department, Fayoum Faculty
of Medicine near Cairo, Egypt. AMAL EL TAWEEL is a
pediatrician and the treasurer and educational coordinator
of the Egyptian Lactation Consultant Association. KARIN
CADWELL is a member of the faculty of the Healthy
Children Project and professor of Maternal Child Health at
Union Institute and University.

The Journal of Perinatal Education | Fall 2013, Volume 22, Number 4