Paediatrica Indonesiana

VOLUME 55 May• 2015 Number 3

Original Article

Prognostic factors for success in the Kangaroo Mother

Care method for low birth weight babies
Rina Pratiwi1, Muhammad Sholeh Kosim1, Noor Wijayahadi2

T
Abstract he World Health Organization (WHO)
Background Low birth weight (LBW) is closely related to reported that 20 million LBW babies are
neonatal morbidity and mortality. Management of LBW infants in born yearly, mainly caused by prematurity
developing countries remains limited, due to the low availability of or intrauterine growth retardation.1 Low
incubators. The Kangaroo Mother Care (KMC) method has been
shown to be effective for newborns, especially LBW infants, in
birth weight is closely related to neonatal morbidity
which skin-to-skin contact may be conducive for infants’ weight and mortality, and it influences growth, cognitive
gain, thermoregulation, and heart rate stability. development, and even chronic disease in later
Objective To determine the prognostic factors for KMC success life. Many factors influence this problem, such as
in LBW babies. gestational age, intrauterine growth, and birth weight.
Methods This cohort study included LBW infants at Dr. Kariadi As these factors are interconnected with the fetal,
General Government Hospital, Semarang, by a consecutive
sampling method. Success of KMC was assessed by infant weight maternal, and physical environment, they have an
gain, as well as stabilization of temperature, heart rate, and important role in determining an infant’s birth weight
respiration. Prognostic factors for KMC success that we assessed and future health.2 The LBW infants may experience
were birth weight, gestational age, KMC duration, age at KMC feeding problems, poor thermoregulation, and
onset and maternal education level. Statistical analyses used were
Chi-square and relative risk (RR) tests.
comorbid diseases. Hypothermia may cause death in
Results Of 40 LBW infants, 24 were successful in KMC. Birth LBW infants, as it can lead to infection, renal failure,
weight ≥ 1500 grams (RR 0.4; 95%CI 0.23 to 0.73; P=0.001)], apnea, or massive hemorrhage.3 Low birth weight
gestational age ≥ 34 weeks (RR 0.94; 95%CI 0.46 to 1.89; morbidity and mortality is influenced by gestational
P=1.00), KMC duration ≥ 65 minutes (RR 1.44; 95%CI 0.76 to age. Infants of younger gestational age have higher
2.75; P= 0.215), high maternal education level (RR 1.25; 95%CI
0.76 to 2.04; P=0.408), and age at KMC onset >10 days (RR
mortality rates and higher incidence of complications
2.69; 95%CI 1.14 to 6.32; P=0.003), were factors that related to due to prematurity or neurological impairment.4
the successful of KMC.
Conclusion Age at KMC onset > 10 days was a prognostic factor
for KMC success in low birth weight babies. [Paediatr Indones.
2015;55:142-6.].
From the Departments of Pediatrics1 and Pharmacology2, Diponegoro
University Medical School/Dr. Kariadi Hospital, Semarang, Central
Keywords: kangaroo mother care, prognostic factor Java, Indonesia.
for success, low birth weight
Reprint requests to: Dr. Rina Pratiwi, Department of Pediatrics,
Diponegoro University Medical School/Dr. Kariadi Hospital, Jl. Dr.
Sutomo No.16, Semarang 50231. Tel/Fax: +6224-8414296, E-mail:
[email protected].

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 Rina Pratiwi et al: Kangaroo Mother Care method for low birth weight babies

The care of LBW infants in developing countries from their time of admission. Informed consent was
remains limited, due to the low availability of obtained from all parents.
incubators compared to the number of LBW babies, We collected the following data: infant gender,
costs, geography, transportation and communication birth weight, KMC duration, gestational age,
limitations. Incubators also require maintenance age at KMC onset, as well as parental data on
to properly adjust temperature and humidity, and occupation, education, and age. We evaluated
prevent infection. 5 An alternative and effective subjects’ temperature, heart rate, and respiratory rate
substitute for incubators is the Kangaroo Mother Care every 8 hours and birth weight daily, until the time of
(KMC) method, or skin-to-skin contact. The KMC hospital discharge. The KMC success was defined as
provides the baby with care, warmth, breastfeeding, fulfilled all criteria of weight gain, and stabilization of
stimulation, and safety.6 Kangaroo mother care is heart rate, temperature, and respiratory rate.
known to be effective for newborns, especially those Data were analyzed to assess for prognostic
with LBW, as skin-to-skin contact can improve weight factors of KMC success, and relative risks (RR) were
gain, thermoregulation and heart rate stabilization. calculated. This study was approved by the Ethics
The KMC decreases the risk of nosocomial infection, Committee for Health Research at Diponegoro
improves growth and development, and leads to good University Medical School.
survival and physiological outcomes.7,8
The aim of this study was to determine factors
related to the succeed of KMC method in LBW Results
babies.
This cohort study included 40 LBW babies admitted to
Kariadi Hospital from July to October 2013. Subjects’
Methods characteristics are shown in Table 1. There were 20
males and 20 females, with 24 babies in the successful
An observational, prognostic study with a cohort group and 16 babies in the unsuccessful group. The
design was done in the Neonatology Ward at Kariadi mean maternal ages were 28.71 (SD 5.93) years in
Hospital from July to October 2013. Subjects were the successful group and 27.25 (SD 5.78) years in the
LBW infants who fulfilled the inclusion criteria. unsuccessful group. Mean gestational ages were 31.75
Inclusion criteria were birth weight <2,500 grams (SD 2.58) weeks in the successful group and 32.63
and no congenital anomalies. Unstable infants with (SD 3.16) weeks in the unsuccessful group.
shock, respiratory distress, or severe hypothermia The KMC success was evaluated by the following
were excluded. We included subjects consecutively variables: weight gain, temperature, heart rate, and

Table 1. Demographic characteristics of subjects

KMC
Characteristics Successful Unsuccessful P value
(n = 24) (n=16)
Gender, n
Male 13 7 0.519*
Female 11 9
Mean parity (SD), n 1.63(0.97) 1.94(1.06) 0.604***
Mean maternal age (SD), years 28.71(5.93) 27.25(5.78) 0.446**
Mean birth weight (SD), gr 1,384.17(271.72) 1,773.13(264.06) 0.000**
Mean gestational age (SD), weeks 31.75(2.58) 32.63(3.16) 0.154***
Maternal employment, n
Employed 15 10 1.000*
Unemployed 9 6

* Pearson’s Chi-square test; ** Independent T-test; *** Mann-Whitney test

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 Rina Pratiwi et al: Kangaroo Mother Care method for low birth weight babies

Table 2. KMC success indicators infants > 10 days of age at the time of KMC onset
KMC who were successful, with RR 2.69 (95%CI 1.14 to
Variables Successful Unsuccessful 6.32), which means those infants had 2.69 times better
(N=24) (N=16)
chance of KMC success.
Weight gain
Yes 23 1
From the study, length of stay for the successful
No 1 15 group was 21.67 (SD 10.19) days, and for the
Temperature stabilization unsuccessful group was 11.19 (SD 7.10) days.
Normothermy 23 15
Hypothermia/hyperthermia 1 1
Respiratory stabilization
Discussion
No apnea 23 11
Apnea 1 5
Heart rate stabilization Kangaroo mother care was first founded by Rey and
Normal 23 15 Martinez in Bogota, Colombia as an alternative
Bradycardia/tachycardia 1 1 method to care for stable low birth weight babies.9
The KMC is simple, as mothers use their own
body temperature to maintain their baby’s warmth,
respiratory rate stabilization, as shown in Table 2. especially in areas of limited neonatal care.10,11
Twenty-three infants had weight gain in the successful In our study, 40 LBW infants fulfilled the inclu-
group. Two infants had hypothermia, 6 infants had sion criteria, with 50% males and mean gestational age
apnea and 2 infants had bradycardia during KMC. of 31.75 (SD 2.58) weeks and mean birth weight of
Table 3 shows that infants with birth weight 1,384.17 (SD 271.72) grams in the successful group.
≥ 1,500 grams had 0.4 times KMC success than More than half of the subjects’ mothers received junior
infants with lower birth weight. Four infants with high school formal education Mean maternal age of
gestational age ≥ 34 weeks had KMC success with the successful group was 28.71 (SD 5.93) years. All
RR 0.94 (95%CI 0.46 to 1.89). Eighteen infants with subjects in this study had intermittent KMC while
KMC duration ≥ 65 minutes had KMC success with hospitalized with level II neonatal care, where the
RR 1.44 (95%CI 0.76 to 2.75). Nine infants whose baby was in an incubator. Similarly, a Brazilian study on
mothers had a high education level had KMC success KMC found mean maternal age to be 24.6 years, with
with RR 1.25 (95%CI 0.76 to 2.04). There were 20 mothers receiving a mean of 7 years of formal educa-

Table 3. Potential prognostic factors for KMC success

KMC
Variables Successful Unsuccessful RR (95% CI) P value
(N=24) (N=16)
Birth weight
≥1,500 gr 8 14 0.4 (0.23 to 0.73) 0.0001
<1,500 gr 16 2
Gestational age
≥34 weeks 4 3 0.94 (0.46 to 1.89) 1.0
<34 weeks 20 13
KMC duration
≥65 minutes 18 9 1.44 (0.76 to 2.75) 0.215
<65 minutes 6 7
Maternal education
High 9 4 1.25 (0.76 to 2.04) 0.408
Low 15 12
Age at KMC onset
>10 days 20 6 2.69 (1.14 to 6.32) 0.003
≤10 days 4 10

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 Rina Pratiwi et al: Kangaroo Mother Care method for low birth weight babies

tion. Mean birth weight was 1,560 (SD 269) grams Our study differed in design, with KMC duration ≥ 65
and mean gestational age was 32.5 (SD 1.4) weeks.12 minutes, done intermittently not continously, due to
Birth weight in unsuccessful group was significantly facility limitations. In our study, each baby done KMC
higher than in the successful group, this can also af- for unless 65 minutes per session per day, each baby
fect the result that babies who could reach standard had different duration and total length of KMC due to
weight, which in our center is 1800 grams, and were different status of the baby and the hospital length of
stable can continue in outpatient care. stay. Nevertheless, in our study the intermittent KMC
In our study, weight gain occurred in 24/40 method was advantageous for LBW babies, they can get
subjects. For the remaining 16 babies, weight gain the advantage from breastfeeding such as bonding and
may not have occurred because they received KMC nutrition, less incidence of heart rate and respiratory
during the period of physiological weight loss, 10-14 instability during the KMC.
days after birth. The Brazilian study found that LBW In our study, mean gestational age in the
infants who received KMC had a mean birth weight successful group was 31.75 (2.58) weeks, and older
of 1,560 (SD 269) grams over a period of 5-33 days gestational age was not a prognostic factor for KMC
[mean 16.7 (SD 5.9) days].12 success. In contrast, an Indian study with subjects
Age at KMC onset was a prognostic factor for of 35.3 (SD 2.3) weeks gestational age in the KMC
KMC success. We found that babies at > 10 days of group found that their growth increased and morbidity
age at KMC onset had greater success. In addition. decreased.14 Similarly, Sunil et al. found that in the
the Brazilian study found that age at KMC onset was KMC group with mean gestational age of 30.8 (SD
associated with increased breastfeeding frequency, 2.1) weeks there was no incidence of apnea and
which may explain the increased weight gain.12 Also, only 1 subject with hypothermia, but there were no
a study in Madagascar compared early and late KMC significant differences.18
and found no significance differences in mortality, Our study limitations included the period of re-
morbidity, severe infection, readmission, hypothermia, search being only until the time of hospital discharge,
weight gain, or breastfeeding at 4 weeks of age.13 in order to avoid subjects being lost to follow-up.
Furthermore, an Indian study with subjects who Also, subjects only experienced intermittent KMC,
started KMC at a mean age of 3.7 (SD 2.8) days found as continuous KMC was not possible due to facility
decreased morbidity and increased growth in LBW limitations.
infants.14 In our study we found that those at > 10 In conclusion, older age at KMC onset is a
days of age at KMC onset had greater success could be prognostic factor for KMC success. Other factors
caused by some babies were still unstable before their such as KMC duration, gestational age, and maternal
ages reached 10 days in level II neonatal care. educational level are found not to be prognostic
We found that higher maternal education was factors for KMC success. To increase the success
not a prognostic factor for KMC success. An Indian of KMC, it should be started when infants are in a
study on KMC educational intervention given to stable condition, performed continuously. Support of
mothers who visited an antenatal clinic without mothers is needed to improve their self-confidence
looking at their formal educational status, found that for consistency in KMC practice.
mothers had a good understanding about KMC and
how to practice it.15
Kangaroo Mother Care duration ≥ 65 minutes Conflict of interest
was not a prognostic factor for KMC success. Indian
studies found that KMC durations were 11.45 hours, None declared.
Rao et al. for 13.5 hours and Kadam et al. for 9.8
hours.16-18 A Cochrane review shows that severe
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