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The effect of kangaroo mother care on physiological parameters of premature infants in Hamadan City, Iran

Introduction Breast-feeding and being with mother have positive effects on the preterm infant's health status. Therefore, this study was conducted to evaluate the effect of Kangaroo Mother Care (KMC) on physiological parameters of premature infants in Fatemiyeh Hospital in Hamadan in 2016. Methods This was a quasi-experimental study. One hundred newborns who were admitted to in neonatal intensive care unit of Fatemiyeh Hospital in Hamadan city, Iran were selected by convenience sampling. They were randomly divided into two groups (experimental group, n = 50 and control group, n = 50). In the experimental group, newborns were taken daily KMC for an hour during 7 days. In the control group, routine care was performed in the incubator. The data gathering tool was questionnaire of infants and mother characteristics, checklists of vital signs and oxygen saturation. Data analysis was performed by SPSS 19 software using descriptive and inferential statistics (Independent t -test, Paired t-test, Chi-square, ANOVA). Results Before intervention, there was no significant difference between the physiological parameters of the infants (heart rate, respiratory rate, arterial blood oxygen saturation and temperature) in experimental and control groups. However, after intervention, there was a significant difference between the two groups in terms of physiological indices (p < 0.001). Conclusion The findings of this study indicate the effect of KMC on enhancement of physiological indices. Therefore, it is recommended that KMC is taken as one of the routine care of premature infants.


Introduction
Neonates born before 37 completed weeks of pregnancy are called premature infants. The birth of premature infants is associated with several problems, such as frequent hospital admissions, infections, apnea and others [1]. Despite the comprehensive efforts to prevent premature delivery and birth of premature infants, the birth rates of such infants are high due to some medical problems, social status and infertility treatment [2,3]. In the United States, there are about 250,000 premature and low birth weight infants each year, accounting for 8.8% of births [4]. In Iran, 5000 neonates are born daily, about 12% of them are underweight [5]. Therefore, care for such infants is a burden on community health systems. Most common method for care of premature infants is incubator method.
In this way, the infant undergoes a special care in a glass device, apart from a mother. Meanwhile, in alternative method as known as Kangaroo Mother Care (KMC), the baby is placed between the mother's breasts in an upright position. Mother secures him with the binder. The baby's head, turned to one side, is in a slightly extended position. This position keeps the airway open and allows eye-to-eye contact between the mother and the baby. The hips should be flexed and extended in a "frog" position; the arms should also be flexed. The tight part of the cloth is over the baby's chest.
Baby's abdomen should not be constricted and should be somewhere at the level of the mother's epigastrium. This way baby has enough room for abdominal breathing. Mother's breathing stimulates the baby [6]. KMC was initiated in 1978 in Colombia as a way to offset the lack of human resources and other infant care facilities [4]. The high prevalence of premature infants, the lack of specialized care equipment and the high mortality rate of premature infants are among the reasons for the use of KMC for premature infants [7]. Various studies have shown that KMC has had favorable results for neonates and mothers, which includes: favorable effects on heart rate, oxygen saturation and respiratory rate [8], maintaining body temperature and sleeping of the infant [9], positive effect on mental and cognitive development, better performance in physical tests during early childhood [10], helping to increase mother's emotional feelings toward the newborn [11,12], positive effect on family attachment [13,14], and confidence in mother-child care [15]. It may also affect the subsequent outcomes and long-term welfare of the mothers and their babies for reducing risky behaviors later in her life [16]. Since there has been no research on the effect of KMC on the physiological indices of premature infants in Hamadan province, this study investigated the effect of KMC on the physiological parameters such as heart rate, respiratory rate, arterial oxygen saturation and body temperature in premature neonates admitted in NICU of Fatemiyeh Hospital, Hamadan city, Iran.

Methods
The present study was a quasi-experimental study in premature neonates admitted to the Neonatal Intensive Care Unit (NICU) of Fatemieh Hospital in Hamadan. The study was conducted from February to September, 2016. Sample size was estimated according to the preliminary study and the following formula with considering 95% confidence level, power of 90% and 10% of sample drop. In the formula: Z is standard normal deviation set at 95% level; µ is assumed population mean and σ is the estimated standard deviation. Therefore, 50 neonate in each group were obtained. In total, two groups of 100 neonates were considered.
Inclusion criteria were: infant weight at birth less than 2500 grams, neonatal birth age of 34-36 weeks of gestation, neonates stable enough to leave the incubator and be with the mother (a pediatrics allows the baby to leave the incubator), and the newborn has not undergone surgery. Exclusion criteria were: neonates too sick to participate in the study, neonates on mechanical ventilation, maternal illness or complications preventing her from caring her baby, decline parental consent before or during the study. The newborns who met the inclusion criteria were selected by convenience sampling to complete the sample size (100 neonates) .
Before the beginning of the study, informed consent was obtained from the infant's parents. Then, the infants were randomly divided into experimental and control groups. The two experimental and control groups were homogeneous in terms of infant's weight and gestational age. Before intervention, demographic data were collected by a questionnaire and neonates of both groups were evaluated for body temperature, oxygen saturation, heart rate, respiratory rate. The questionnaire consisted of characteristics of the mother and her neonate including maternal complications during pregnancy and breastfeeding status. Physiological indicators (heart rate, respiratory rate, oxygen saturation, temperature) were Page number not for citation purposes 3 measured and recorded on the first, third, fifth and seventh days of KMC. In the experimental group, first, mothers got bathing, wearing a special KMC blanket, and perform KMC. With the help of nursing staff, neonate was placed between mothers' breasts . KMC care conducted for an hour per day for seven days. Room temperature was 26-29°C. In the control group, conventional care (incubator) was performed. For both groups, the physiological parameters of the infant were measured 3 times in each KMC practice ((before, 15 minutes after initiation KMC (median) and after completed KMC)) and recorded in the checklist. At the end, changes in physiological indices of premature infants were compared in both groups. Data were analyzed using SPSS version 19, independent t-test, Paired ttest, Chi-square test. P-Value less than 0.05 was considered as significant level.

Results
Demographic characteristics of subjects are presented in Table 1.
Based on the results of the study, the data were homogeneous in terms of mothers' age, fathers' age, parents' employment status and education levels, and family income (p>0.05). There was no significant difference in the rate of infants' heart rate in two groups before intervention (P > 0.05). After KMC, significant change were observed in heart rate of experimental group while no significant change was seen in the control group ( Table 2). The respiratory rate of infants in the experimental and control groups was not significantly different before intervention (P > 0.05). Significant change was observed in respiratory rate of experimental group after KMC intervention, while no significant change was seen in the control group (Table 3). Before KMC, intervention, the percentage of arterial blood oxygen saturation in the experimental and control groups was not different (p > 0.05). After KMC, significant change was observed in arterial blood oxygen saturation of experimental group after KMC, while no significant change was seen in the control group (Table 4). The axillary temperature of the neonates in two groups did not show a significant difference before KMC (P > 0.05). After KMC, significant change was observed in axillary temperature of experimental group, while no significant change was seen in the control group (p < 0.01) ( Table 5).

Discussion
According to results after KMC, significant differences in physiological indices were observed between the experimental and control groups. In the study of Nourian et al. who compared the effect of KMC and routine care methods on physiological criteria in low birth weight infants, no significant differences were observed between two groups during intervention (P > 0.05). However, significant differences were seen between two groups in terms of heart rate, oxygen saturation and respiratory rate 5 minutes after intervention (p < 0.05). Infants' temperature had no changes during this study. The results showed that KMC care is effective on the sustainability of physiological parameters during care. Therefore, caregivers should take kangaroo mother care for mothers and infants [8].
In the present study, there was a significant difference between the two groups in terms of physiological criteria not only after KMC care (P < 0.001), but also during kangaroo care (P < 0.001). Similarly, Keshavarz and colleagues studied the effect of KMC on infants' physiological parameters, infants' crying, and mothers' pain after cesarean section. One hundred-sixty mothers and infants were randomly assigned into two groups of KMC and routine care. The two groups were not different in terms of mother and infant charactristics. In the Kangaroo care group, the average of the infant's temperature at half an hour (36.8 vs. 36.6°C, P > 0.05) and one hour (36.9 vs. 36.6°C, P < 0.001) after skin to skin contact were more than the control group. Also, in kangaroo care group the score of mothers' pain after cesarean section (6 versus 7.8, P < 0.001), the frequency of infants' crying (5.6 vs. 12.3 times, P < 0.05) were lower than the control group. Overall, mothers were satisfied with Kangaroo care [17]. In contrast of our results, Jafari and colleagues studied KMC in weight gain, duration of hospitalization, and body temperature of premature infants. The findings showed no significant difference in term of infants' temperature between the two groups after KMC (p>0.05) [18].
In a study by Basiri et al., the effect of duration of KMC on the neonatal growth of low birth weight infants was studied. One hundred-fifteen LBW neonates were randomly divided into two groups, the first group received the maximum of 4 hours KMC per a day and the second group got more than 4 hours KMC per day. In the Kangaroo care more than 4 hours, the mean and standard deviation of oxygen saturation was higher than a group with less Page number not for citation purposes 4 than 4 hours Kangaroo care (P > 0.05). But, no significant difference was found between the two groups in terms of body temperature. Infants' growth and physiological criteria were better in the group with more than 4 hours KMC compared to less than 4 hours KMC [19]. Therefore, it is essential that the strategies of increasing the duration of kangaroo care be taken into consideration by policy makers and healthcare providers. In the present study, the duration of kangaroo care was not considered, the results for oxygen saturation were in line with a Basiri study. It is suggested that, the positive effects of kangaroo care and the safety of this method taking into account and KMC is used more widely.

Competing interests
The authors declared they have no competing interests.  Tables   Table 1: Distribution of demographic characteristics of experimental and control groups