|Year : 2015 | Volume
| Issue : 1 | Page : 26-31
A randomized controlled trial of kangaroo mother care versus conventional method on vital signs and arterial oxygen saturation rate in newborns who were hospitalized in neonatal intensive care unit
Khadijeh Dehghani, Zahra Pour Movahed, Hamideh Dehghani, Khadijeh Nasiriani
Department of Nursing, Nursing and Midwifery School, Shaheed Sadoughi University of Medical Sciences and Health Services, Yazd, Iran
|Date of Web Publication||10-Feb-2015|
Department of Nursing, Nursing and Midwifery School, Shaheed Sadoughi University of Medical Sciences and Health Services, Yazd
Source of Support: None, Conflict of Interest: None
Background and Objectives: The Kangaroo mother care (KMC) method is the best care method that can provide the newborn's skin normal contact with the mother's skin for all newborns, especially the premature or underweight. However, this method has not still become common in some countries and many hospitals in Iran. Thus, the present study aimed to determine the impact of KMC method on vital signs and arterial oxygen saturation of newborns compared to the incubator care method in order to facilitate this method. Materials and Methods: This clinical trial study was performed on 53 neonates who have been hospitalized in Neonatal Intensive Care Unit; they were randomly divided into two case and control groups. The KMC was conducted on newborns in the study group for an hour each day for 3 consecutive days. The vital signs including temperature, respiratory and heart rate per minute, and the arterial oxygen saturation rate were measured and recorded before, during and after caring process in both groups and then were compared and analyzed. Results and Conclusion: The results showed that the average temperature variations and the arterial oxygen saturation rate between the two groups had significant differences in 3 days of examining (P < 0/056, P = 0/00), but there were no significant differences in the mean heart and respiration rate between the two groups (P = NS). Thus, the Kangaroo care method is effective in the improvement and stabilizing of vital signs of newborns, and nurses can train this method to mothers.
Keywords: Body temperature and oxygen level, Kangaroo mother care method, vital signs
|How to cite this article:|
Dehghani K, Movahed ZP, Dehghani H, Nasiriani K. A randomized controlled trial of kangaroo mother care versus conventional method on vital signs and arterial oxygen saturation rate in newborns who were hospitalized in neonatal intensive care unit. J Clin Neonatol 2015;4:26-31
|How to cite this URL:|
Dehghani K, Movahed ZP, Dehghani H, Nasiriani K. A randomized controlled trial of kangaroo mother care versus conventional method on vital signs and arterial oxygen saturation rate in newborns who were hospitalized in neonatal intensive care unit. J Clin Neonatol [serial online] 2015 [cited 2019 Jun 18];4:26-31. Available from: http://www.jcnonweb.com/text.asp?2015/4/1/26/151163
| Background and objectives|| |
The Kangaroo care method (Kangaroo mother care [KMC]) is skin-to-skin contact between mother and infant  and a method of care for all newborns, especially the premature or underweight, and creates better conditions for mother and newborn compared to incubator caring method. ,, KMC was first introduced in Bogotα, Columbia by Dr. Edgar Rey and Hector Martinez in 1978 as a way of compensation for the overcrowding of incubators in hospitals caring for preterm infants.  This method is based on three basic principles, including skin-to-skin contact, exclusive breastfeeding, and support to the mother-infant dyad. To establish the skin-to-skin contact, the newborn is placed in front of the mother's chest and is guided by a cloth bag, wrapped around a newborn and the mother. This could be done from the beginning of birth or anytime during the night and day, but its short and intermittent periods are also useful.  Many studies show that skin-to-skin contact through KMC leads to breathing regulation and stabilizing, improvement in respiratory distress, increased and/or heart rate (HR) regulation, and increased arterial oxygen saturation rate. ,, In addition, the mother's supportive and caring behaviors become further during this procedure; her lactation enhances, and her conditions and discomforts will relieve, and her postpartum hemorrhage will be prevented.  Furthermore, the newborn feeding is performed better in this method; the newborn grows faster.  Usually, separating the newborn from the mother and incubator care will cause the secretion of stress hormones, intense crying and despair in newborn, which are harmful to the newborn's health and can decrease the body temperature and irregularity in heartbeat and breathing. , The KMC can, therefore, be effective in supplying the newborn's needs and stabilizing the newborn's physiological states and survival of the preterm neonate. ,,,, However, some studies indicate no significant differences in physiological measures of newborns under KMC.  This indicates the need to further research in this area. What done today in most of the newborn units in Iranian hospitals is different from that must be done. Mother-newborn separation due to hospitalization of newborn in the ward and his/her incubator care may have adverse effects on both mother and the newborn. Furthermore, no study has been already conducted in this regard in the city of Yazd. Thus, the researchers decided to conduct a study aimed at determining the impact of KMC on vital signs and arterial oxygen saturation rate in newborns hospitalized in Neonatal Intensive Care Unit (NICU). It is hoped that the results can enhance the improvement of newborns and facilitate the implementation of this care method in our hospitals.
| Materials and methods|| |
This study is a randomized clinical trial study type. This study is a double-blind; Infants due to age and statistical analyst were not informed from groups. That has been posed in the Ethics Committee of the Shaheed Sadoughi University of Yazd city and registered in IRCT138901223679N1. In this study, to determine the sample size by considering test power of 80% and significance level of 5% and (s = 4, d = 3) based on previous studies, the sample size was calculated 50 neonate. Initially, the eligible newborns hospitalized in the NICU, who required incubator-caring, after getting written consent from their mothers and with physician's coordination were divided into two groups of the case group (27 subjects) of KMC and the control group (26 subjects) of conventional incubator care using the random number table. The study inclusion criteria included: Consent and mental and physical ability of mothers for performing KMC, the physicians allowance, weighing more than 1800 g for the newborn, gestational age of 32 weeks and above, no abnormalities and problems of nervous, cardiovascular and respiratory systems in newborns, no clinical instability and infections, no surgery performed on them, exacerbated crying newborn, and not being NPO. All newborns not meeting the above conditions were excluded from the study. In order to gather information, the registration forms, including two sections of demographic data (age, sex, birth weight) and vital signs (HRs, respiratory rate, and the auxiliary temperature) and the arterial oxygen saturation rate on percentage scale were used. The vital signs and arterial oxygen saturation rate of newborns in both groups were recorded 5 min before the start of the care process. Mothers were instructed before the procedure.
Also during the mother and baby were supported by a nurse and researcher. Mothers showed desire and good cooperation during the procedure. Hence, the case group mothers were trained properly, and the required information and explanations along with displaying the video description about the KMC method were provided for them, and the KMC was applied to their newborns. Thus, the naked newborn, only wearing diaper and cap, was placed in a straight state between the mother's breasts and was supported by a cloth bag. The caring was performed for 3 consecutive days and each time for 1-h. The procedure was conducted for all samples by the head nurse and with the researcher's presence and monitoring in the morning shift, and the mothers were supported and encouraged during the caring process. The changes in pulse, respiration, temperature, and arterial oxygen saturation rate of the case group were controlled and recorded during the care process, at 30 min after starting the procedure and at the end of caring process before returning the newborn to the incubator. The mentioned items in the control group (conventional incubator care) were also measured and recorded simultaneously with the case group.
To measure the pulse and respiration, the 22,004 data scope passport monitoring system was used. The pulse oximetry in NICU was used to measure the arterial oxygen saturation rate, and a mercury thermometer was used to measure the temperature with an auxiliary approach for 3 min. To maintain the reliability of the instrument during the research, the same pulse oximetry device and monitoring system were applied to newborns in the same situation. The pulse oximetry probe was taped to the toe of the left foot of all newborns. In addition, the calibration of the monitoring device was performed routinely by the ward. The validity of the pulse oximetry device and the monitor system was confirmed and upheld by citing the manufacturer and the brand standards. The simultaneous observation and recording method by two researchers were used for the reliability of temperature measurements (r = 0.087). During the care process, no treatment measures and painful procedures were performed in both groups, and the room temperature was retained between 24°C and 26°C. The newborns could feed during the care process as needed. After recording the vital signs and the arterial oxygen saturation rate, the data were encoded and analyzed using the SPSS version 15 software (IBM corporation). The independent samples t-test was used to compare the means of vital signs and arterial oxygen saturation rates between the two groups. The repeated measure test was used to test the means differences in consecutive days due to repeating of variables review.
| Results|| |
The results of the study showed that there were no significant differences between the means of gestational age, birth weight, and sex in two groups of newborns. The mean gestational age in the case group has been as 34.48 ± 2/42 weeks and in the control group as 35.07 ± 2.4 weeks. The mean chronological age in the case and control groups has been, respectively, as 9.5 ± 6.15 and 9.11 ± 6.89 days. The average birth weight in the two groups has been, respectively, as 2268.84 ± 490.03 and 2192.22 ± 619.85 g. The period time of hospitalization in the case group and the control group has been, respectively, as 12/7 ± 6.42 and 11.07 ± 7.86 days. In the case group, 51.85% of the samples (14 cases) were female and 48.15% (n = 13) were male; in the control group, 50% were female and 50% were male [Table 1].
|Table 1: Comparison of demographic characteristics between the two groups |
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The comparison of temperature means during the first to 3 rd days between the two groups showed a statistically significant difference using the statistical repeated measure test (P = 0.000), so that the average temperature in the case group has increased compared to the control group [Table 2]. Comparing the average HRs and respiratory rate per minute in the 1 st to 3 rd days, respectively, showed that there is no significant difference between the two groups (P = 0.541, P = 0.586) [Table 3] and [Table 4]. However, comparing the means of arterial oxygen saturation rates in the 1 st to 3 rd days showed that there are statistically significant differences between the two groups (P = 0.000) [Table 5].
|Table 2: Determining and comparing temperature average between two case study groups in different days before, during and after the care |
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|Table 3: Determining and comparing arterial oxygen saturation rate between two case study groups in different days before, during and after the care |
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|Table 4: Determining and comparing number of heart beats between two case study groups in different days before, during and after the care |
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|Table 5: Determining and comparing number of respiratory between two case study groups in different days before, during and after the care |
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| Discussion|| |
The study results showed a significant increase in the average temperature in the case group in the 1 st to 3 rd days after KMC; the findings are consistent with the results of many studies in this regard. ,,,,,,, Only a study, before and after, showed that the newborns temperature reduced during KMC compared to the incubator care, although the temperature rates were in the normal range.  Sontheimer et al. showed that even in newborns transferring with KMC compared to incubator care, the HR, respiratory rate, arterial oxygen saturation rate, and the temperature remain constant. Hence, we can say that the KMC leads to the temperature stability or its increase in the normal range. Indeed, putting the newborn in skin contact with the mother will prevent the heat loss.  Increasing temperatures, particularly for low-weight and premature newborns with tendency to hypothermia is very useful and improves the treatment outcomes, while the metabolic rate and oxygen consumption increase with the heat loss and lead to physiological and metabolic instability, homeostatic problems, apnea intensifying, and impaired weight gain. ,,
The research results showed a significant increase in arterial oxygen saturation rate during the 1 st to 3 rd days after KMC compared to the control group, which is consistent with the results of many studies. ,,,,, Increase in arterial oxygen saturation rate can be due to calm and comfortable contact of the newborn with the mother and possibly the reduced oxygen consumption.  In a number of clinical trial studies on similar preterm subjects, no changes have been reported in the rate of arterial oxygen saturation during KMC. , Furthermore, in a study, no change was observed in the rate of arterial oxygen saturation in preterm neonates on heel prick and during puncturing the heel stick during the KMC than to the incubator cure. , Some researchers state that during neonatal transport to the KMC, the rate of arterial oxygen saturation may decrease, statistically, but not clinically, significant and it will become stable in 3 min after the beginning of the care process. However, controlling the head and putting it at the sniff situation in the midline in order to minimize the changes in arterial oxygen during the KMC is important. Thus, based on A-level evidence, oxygen saturation changes during Kangaroo care (KC) are minimal and remain predominantly within acceptable clinical ranges. Controlling infant head in the slightly sniffing position and neck in the midline position is mandatory to minimize desaturations. 
This study showed no statistically significant differences in the average number of HR per minute between the two groups, which are consistent with the results of a number of studies. ,, Nimbalkar and et al. showed the HR was statistically significant and lower in KMC group.  Cong et al. showed longer (30 min), and shorter KC (15 min) in heel stick can stabilize HR response in preterm infants.  The results of a meta-analysis on 23 studies showed that there was no significant difference in HRs at the time of kangaroo and incubator caring methods.  Some studies showed that the KMC causes increased HR in preterm newborns. , The Dodd's study showed the increased HR with no statistically significant difference.  This suggests that the increase in HR may be initially due to placing the newborn in an upright state, and then, reduction in the HR will occur due to more relaxation and less stress of the newborn. Some researchers in randomized clinical trials and quasi-experimental pretest-test-posttest studies state that the newborn's HR may increase more by 5-10 beats/min during the 2 nd h of KMC than the 1 st h due to the newborn's warming and head tilting upward.  The increase in arterial oxygen saturation rate can clarify the reason of this fact that the HR number remains stable despite the increased temperature, since the increase in temperature normally leads to an increase in pulse rate and HR.  KC for infants in our study has been carried out for an hour while other studies differ together in terms of execution time care.
According to the results of this study, there was no significant difference in the average respiratory rate per minute in the KMC group than to the incubator care, which is consistent with the results of some studies. , A meta-analysis study showed that the rate of respiration during the KC reduces compared to the incubator care method. ,, Almeida et al. 2007 quotes Sontheimer et al., the heart and breathing rates are uncertain data, because the mother's respiratory and cardiac patterns may be superimposed on the newborn's.  Reduced breathing number and increased arterial oxygen saturation rate after KMC can be due to the upright situation of the newborn during the caring process; therefore, this status improves the ventilation and perfusion and thus the respiratory functioning. 
In short, the results of research suggesting that the cardiac and respiratory status are clinically in a reasonable range during the KMC and shows more stability compared to the incubator care; in fact, most clinical trial studies show that the KMC has been effective in cardiac-respiratory parametric stability.  Schlez et al. showed infants' physiological responses like respiratory rate did not differ significantly. 
| Conclusion|| |
In general, the results of this study showed that the KMC can contribute in increasing the temperature and arterial oxygen saturation rate and the cardiovascular and respiratory stability in newborns. It is suggested: Training of nursing and midwifery team in regard to the technique will be developed in hospitals and prenatal clinics, and the mothers' knowledge in this area will be improved. Furthermore, particular nurses in each ward would be dedicated to this method, and its performance would be enhanced. It is recommended to conduct further research on the long-term impact of KMC on multiple variables, like weight gain, period time of hospitalization, mother's breastfeeding rate, vital signs, etc., Furthermore, the procedure could be performed for the underweight newborns and lower gestational age under certain circumstances. A limitation of this study was the most crowded ward in the morning shift, so the study was conducted in the evening shift and the quiet hours.
| Acknowledgments|| |
Finally, we have to thank the nursing staff, particularly Mrs. Sotodeh, the NICU head nurse, and Dr. Mohammad Golshan, the neonatologist for their help in this research.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]