Journal of Pediatric Nursing (2016) 31, 430438

The Effects of Kangaroo Care in the Neonatal

Intensive Care Unit on the Physiological
Functions of Preterm Infants, MaternalInfant
Attachment, and Maternal Stress
Eun-Sook Cho MPH, RN a , Shin-Jeong Kim PhD, RN b , Myung Soon Kwon PhD, RN b,,
Haeryun Cho PhD, RN c , Eun Hye Kim MSN, RN, CPNP-PC d ,
Eun Mi Jun PhD, RN e , Sunhee Lee PhD, RN f
a
Kangnam Sacred Heart Hospital, 1, Singil-ro, Yeongdeungpo-gu, Seoul, South Korea
b
Hallym University, College of Medicine, Div. of Nursing, Chuncheon, Gangwon-do, South Korea
c
Wonkwang University, Department of Nursing, Jeonbuk, South Korea
d
Goyang Foreign Language High School, Tongil-ro, Deogyang-gu, Goyang-si, Gyeonggi-do, South Korea
e
Pai Chai University, Department of Nursing, Baejae-ro(Doma-Dong) Seo-Gu, Daejeon, South Korea
f
Gimcheon University, Department of Nursing, Gyungbuk, South Korea

Received 28 October 2015; revised 12 February 2016; accepted 16 February 2016

Key words: Purpose: This study was conducted to identify the effects of kangaroo care on the physiological functions of
Infant;
preterm infants, maternalinfant attachment, and maternal stress.
Kangaroo care;
Design and Methods: For this study, a quasi-experiment design was used with a nonequivalent control
Object attachment;
group, and a pre- and post-test. Data were collected from preterm infants with corrected gestational ages of
Premature;
33 weeks who were hospitalized between May and October 2011. Twenty infants were assigned to the
Stress
experimental group and 20 to the control group. As an intervention, kangaroo care was provided in 30-min
sessions conducted thrice a week for a total of 10 times. The collected data were analyzed by using the t test,
repeated-measures ANOVA, and the ANCOVA test.
Results: After kangaroo care, the respiration rate significantly differed between the two groups (F = 5.701,
p = .020). The experimental group had higher maternalinfant attachment scores (F = 25.881, p b .001)
and lower maternal stress scores (F = 47.320, p b .001) than the control group after the test. In other words,
kangaroo care showed significantly positive effects on stabilizing infant physiological functions such as
respiration rate, increasing maternalinfant attachment, and reducing maternal stress.
Conclusion: This study suggests that kangaroo care can be used to promote emotional bonding and support
between mothers and their babies, and to stabilize the physiological functions of premature babies.
Practice Implications: Kangaroo care may be one of the most effective nursing interventions in the neonatal
intensive care unit for the care of preterm infants and their mothers.
2016 Elsevier Inc. All rights reserved.

Background
Corresponding author: Myung Soon Kwon, PhD, RN. A preterm infant is an infant born prior to 37 weeks of
E-mail addresses: kwon1314@hallym.ac.kr, kwon1314@hanmail.net. gestation or 259 days before the mothers last menstruation

http://dx.doi.org/10.1016/j.pedn.2016.02.007
0882-5963/ 2016 Elsevier Inc. All rights reserved.
Kangaroo Care in the Neonatal Intensive Care Unit
period (Ahn, 2012). According to Statistics Korea (2012),
the number of premature babies born between January 1,
2012, and December 31, 2012, was 30,376 (6.3%) of the
484,550 total births for that year. In addition, regardless of
gestational age, the number of low-birth-weight infants who
weighed b 2500 g at birth was 25,870 (5.3%). Furthermore,
3037 (0.6%) of the low-birth-weight infants weighed b 1500 g
at birth (Statistics Korea, 2012). The percentage of premature
births increased steadily from 3.8% in 2000 to 4.9% in 2012.
Premature babies are well known to have many health
problems. They commonly have poor body temperature
control and can have cardiovascular and respiration
complications. In addition, intracranial hemorrhage is a
possible problem in premature babies (Bera et al., 2014).
Further disadvantages of hospitalization occur in the
neonatal intensive care unit (NICU). In the NICU, premature
infants are exposed to stressors such as noise from medical
machines, bright light, and invasive medical procedures
(Cho & Lee, 2010). It is important to note that infants
separation from their mothers and the NICU environment
itself limit the visual, acoustic, and tactile interactions
between mothers and babies. This limitation causes anxiety
in mothers, affects maternal bonding, and leads mothers to a
negative understanding of their maternal role (Bang, Kang,
& Kwon, 2015).
In addition, having a preterm infant is a stressful
experience for mothers. They tend to feel guilty because
they believe that the premature birth was caused by their
carelessness or ignorance, and is an unexpected event in their
lives, so the hospitalization of their babies is extremely
stressful (Bang et al., 2015; Hwang, Kim, Yoo, & Shin,
2013). Thus, such events could result in a crisis that disturbs
the normal living patterns of the family (Jang, 2009). The
birth and hospitalization of a premature baby increase the
mothers emotional vulnerability, thereby contributing to the
increases in stress and anxiety related to the infant, the risk of
possible complications, and the need for long-term separa-
tion. Although both parents of premature babies have this
level of stress, a study by Jeon (2011) demonstrated that
mothers have greater stress than fathers and other family
members. Long-term hospitalization of premature babies
leads to limited contact with parents and difficulty bonding
with mothers. These issues can produce developmental
delay, developmental disorders, and personality disorders, as
well as interrupt the natural attachment between mothers and
infants (Jang, 2009; Lee, 2008). In the care of preterm
infants, perceiving and interpreting their needs, and
providing appropriate stimulation, experienced nursing
interventions are needed to eliminate these barriers. Moreover,
providing an optimal environment for these infants is crucial
for their later development (Head, 2014).
Many research studies have identified the positive effects
of skin-to-skin contact such as sense stimulation on the
growth and behavioral development of preterm infants (Bera
et al., 2014; Head, 2014; Jang, 2009; Samra, Taweel, &
Cadwell, 2013). In fact, a study by Lee (2009) showed that
431
kangaroo care leads to greater preterm infant growth
development, and physiological and behavioral stability through
positive and consistent skin-to-skin contact with mothers.
Therefore, skin-to-skin care, called kangaroo care, can be effective
for reducing the possible complications in preterm infants.
Kangaroo care was developed in Columbia in the 1970s
to maintain infant body temperature. The position used in
kangaroo care is similar to the position of baby kangaroos
with their mothers, where the human infant has skin-to-skin
contact by being positioned between the mothers clothes
and her skin (Samra et al., 2013). The World Health
Organization (WHO) in 2003 indicated that kangaroo care is
the most effective method for body temperature mainte-
nance, infection prevention, sense stimulation, and offering
maternal love for the babys well-being. In addition,
kangaroo care is beneficial to preterm infants for maintaining
their regular breathing and reducing energy consumption,
thereby providing the needed weight gain in infants. Further-
more, a regular sleeping pattern with kangaroo care helps brain
development, allows for smoother delivery of oxygen supply to
the brain and better secretion of gastric hormones, reduces the
risk of infection, and reduces pain (Bera et al., 2014). Kangaroo
care is a safe, effective, and feasible method for premature
infant care, and thus designated as an effective and compre-
hensive intervention in the NICU setting (Samra et al., 2013).
This study was conducted to identify the effects of kangaroo
care on preterm infants physiological functions, maternal
infant attachment, and maternal stress in South Korea.
Purpose
This study aimed to analyze the physiological effects (weight,
heart and respiration rates, oxygen saturation, and body temper-
ature) of kangaroo care in two groups, one provided with kangaroo
care and the other not provided with kangaroo care. In particular,
the study was conducted with the following objectives:
1. To determine the effects of kangaroo care on the
physiological functions of premature infants
2. To analyze the difference in maternalinfant attach-
ment between the two aforementioned groups
3. To analyze the difference in maternal stress between
the two groups
Methods
Design
In this study, a nonequivalent comparison group design
was used with both a pre- and a post-test (Figure 1).
Setting and Sample
The participants included in this study were preterm infants
with corrected gestational ages 33 weeks who completed
ventilator care in a general hospital in Seoul, South Korea. The
reason for using 33 weeks as the gestational age cutoff was that
premature babies aged b 33 weeks are more prone to health
problems such as respiration distress syndrome, apnea, and
infection. Preterm babies without sepsis, eating disorders, and
432
P a r t ic i p a n t s Corrected GA 33weeks
Pre
T ime test
EG
( n= 20)
Group
CG
( n= 20)
Phys iological functions
Body we ight
Heart rate
Res piration rate
Variables Oxygen s aturation
Body t emperature
Maternal- infant attachment
Maternal s tres s
*Note
EG : Experimental group, CG : Control age, min : minutes, GA : Gestational age
Figure 1
congenital deformity were included. The exclusion criteria
were as follows: 1) receiving respiration therapy with a
ventilator and E-tube insertion; 2) receiving medicines that
could influence sleeping patterns; 3) having a possible risk of
infection and skin disease; and 4) having a catheter inserted in
the artery and veins or the umbilical cord.
The maternal inclusion criteria were mothers without
infectious disease, epileptic illness, skin disease, or scars,
and the provision of informed consent for this study. Mothers
who did not want to participate in kangaroo care were
classified as the control group, while mothers who agreed to
participate in kangaroo care as an intervention were
classified as the experimental group.
To calculate the sample size, the G*Power 3.1.7 program
(Faul, Erdfelder, Lang, & Buchner, 2007) was used for the t
test. The result showed that 40 participants were required to
achieve a large effect size of 0.7, that is, two groups with 70%
power at a significance level of 0.05. Thus, 40 participants in
this study were acceptable for the sample size.
Accordingly, 40 participants (20 in the experimental
group and 20 in the control group) were included in this
study. None of these participants dropped out of the study.
Measurements
Physiological Functions
Physiological function is a phenomenon of the human body
that occurs in response to stimulation from the interaction
between humans and their environment (Bera et al., 2014).
Physiological functions are measured by determining the
E.-S. Cho et al.
Pos t
On s e t
tes t
Routine care with Kangaroo care
for 10 t imes , 30min/ t ime
( 3 t imes / week)
Routine care
P h y s i o lo g ic a l f u n c t io n s
Bo d y w e i g h t
He a r t r a t e
Re s p ir a t io n r a t e
Ox y ge n s a t u r a t ion
Bo d y t e m p e r a t u r e
M a t e r n a l - in f a n t a t t a c h m e n t
Ma t e r n a l s t r e s s
Research design.
body weight, heart and respiration rates, oxygen saturation, and
body temperature.
Infant body weight was measured every morning at
a designated time (6:00 AM) after their baths, by using
a weighing machine (AD-15 T, CAS scale, Seoul,
South Korea).
Infant heart rate, respiration rate, and oxygen satura-
tion level were measured and recorded via a patient
monitor (IntelliVue MP 60, Philips, Eindhoven, the
Netherlands), 5 min before and after the intervention for
the experimental group and at a fixed time (3:00 PM) for
the control group.
Infant body temperature was measured by using a
digital axillary body temperature monitor (MT200,
Microlife, NeiHu Taipei, Taiwan) and recorded 5 min
before and after the intervention for the experimental
group and at a fixed time (3:00 PM) for the control
group, on the same day of measurement as in the
experimental group.
The reasons for measuring the physiological functions at a
fixed time were possible fluctuations in biorhythms during the
daytime and for minimizing the measurement error by making
the situation as similar as possible with the experimental group.
The instruments used in this study were checked periodically by
the instruments company to ensure the accuracy of the scale. We
also carefully overhauled the instruments that were not working
or that had any error during the study period.
Kangaroo Care in the Neonatal Intensive Care Unit
MaternalInfant Attachment
Maternalinfant attachment is the initial social relationship
between mothers and infants after birth. It is the emotional bond
established between mothers and their infants, and consistently
formed from early infancy to maturity (Bowlby, 1977). In this
study, a modified and corrected maternalinfant attachment
measurement tool was used. The tool was developed based on
Mllers (1994) maternal attachment inventory and then adapted
by Han (2001). The questionnaire for this tool contained 24
questions. Each question included a scale from 1 point for
strongly disagree to 5 points for strongly agree. Higher
points indicated stronger maternalinfant attachment. The
reliability test yielded a Cronbach = .83 in the study by Han
(2001) and a Cronbach = .96 in the present study. We also
tested the validity of the tool and confirmed from experts that
this modified tool was acceptable for this study.
Maternal Stress
The stress level of a mother with a preterm infant is defined as
the maternal perception of stress factors that are related to
experiences within the physical and psychological environments
of preterm infant birth and hospitalization in a NICU (Miles,
Funk, & Carlson, 1993). In this study, the maternal stress level
related to stress factors in the NICU was measured by using the
Parental Stress Scale that Miles et al. (1993) initially developed
and Jeon (2011) modified. This questionnaire contained 20
questions, and points ranging from 1 point for never worried
to 5 points for most worried were given to each answer. A
score of 5 indicated most stressful, and a score of 1 point
indicated least stressful. A higher score indicated a higher
level of maternal stress. The Cronbach for this study and in
that by Jeon (2011) was .91. A validity test was performed by 7
experts, including two child health nursing professors, three
womens health nursing professors, and two head nurses who
had a masters degree in nursing and were working at the
postpartum ward of their respective general hospitals.
Training Procedure
Three nurses (including the first author of this study) who
were working in the NICU and had N over 10 years of clinical
experience were selected as trainees to collect high-quality data.
The first author explained the purpose and method of this study,
the protocols of kangaroo care, and the method of data
collection to the other trainees by using two presentations. After
that, each trainee gave two demonstrations that were recorded
via a video camera, and the trainee was evaluated, given
feedback, and asked to modify the process as per the results of
the feedback in order to provide kangaroo care of equal quality.
In addition, the first author observed them periodically to make
sure that they were measuring and recording the physiological
functions consistently throughout the study.
Experimental Intervention
Kangaroo care (skin-to-skin contact) is a method of
contact between parents and infants such that parents hold
infants upright and position them directly on the chest
433
(WHO, 2003). In this study, a modified skin-to-skin contact
method was used as a practical guide, based on the care
provided by kangaroo mothers to their babies.
At the beginning of the intervention, mothers with infants
receiving kangaroo care were educated individually for 10 min by
using brochures as follows: Mothers were recommended to take a
shower before kangaroo care and to wear clean placket shirts.
Mothers were prohibited to use perfume and makeup on days of
providing kangaroo care. They were recommended to wear
front-opening shirts that are easy to take them off before providing
kangaroo care. Before the study was initiated, the mothers were
asked about their willingness to continue kangaroo care until the
end and maintain a good health status without infection risk. They
were restricted from comforting their infants during the procedure,
for example, by singing and patting their backs.
Kangaroo care was conducted three times per week, on
Monday, Wednesday, and Friday, between 2:30 PM and
4:00 PM, with 30-min duration, for a total of 10 times. The
duration of 30 min was chosen as per the WHO (2003)
guidelines and the intervention used in the study by Moon and
Koo (2000). When the mothers arrived for the intervention at the
arranged time, they removed their shirts and sterilized their
chests, abdomens, and hands with 0.4% chlorohexidine and a
sterilized cotton ball, according to the contact precaution
protocol in the NICU. They were not permitted to wear any
accessories or put on body oil or lotion. The mothers changed
into a sterile gown and prepared for kangaroo care by rubbing
their hands to avoid being cold and sitting in a chair designated
only for kangaroo care. For performing kangaroo care, a monitor
and comforting chair were placed next to the incubator with a
curtain for privacy. Room temperature was maintained at 24 C,
and noise was minimized to reduce any stress incurred from
hearing noise from phones ringing and workers conversation.
The mother held her infant to her bare chest in a vertical
position, holding the infants bottoms in one hand and letting the
other hand touch the infants head and back, with the infant wearing
only a diaper and hat. Both mother and infant touched each others
skin as closely as possible. At this time, the mother sat down in the
armchair and leaned her infant forward by 60. The infants head
was turned to one side to touch the ear to the mothers chest. The
infants mouth and nose were faced sideways to ensure open
breathing. At this time, the trainees helped both mother and infant
relax. The mother sat down and bent her legs. Periodic checks by
the first author were conducted to ensure that mothers administered
kangaroo care adequately and to answer questions and solve
problems regarding kangaroo care. We arranged the visiting time
for the experimental groups after the regular NICU visiting hours
(12:00 to 2:00 PM) so that the mothers of the infants in the control
group did not have to face any contamination.
Data Collection
Data were collected between May 1, 2011, and October
31, 2011. Physiological functions, including body weight,
heart rates, respiration rates, and oxygen saturation were
measured and recorded by the researchers. All the measure-
ments were repeated twice. If the numerical values were not
434
the same, they were measured one more time, and the two
matching numerical values were used. A research assistant
collected the questionnaires to decrease the testing effect.
Ethical Considerations
This study was approved by the institutional review board of H
hospital, Seoul, South Korea (IRB No. 2011-05-41). After
providing information about the purpose of the study, guarantee-
ing anonymity and credibility, clarifying voluntary participation,
and indicating the benefits of the study, written consent was
obtained from all the participants who agreed to participate in the
study; parents or guardians provided consent for infants. Members
of the control group who wanted to participate in the intervention
were provided the same intervention program as the test group
after completion of the study.
Data Analysis
Data were analyzed with the SPSS 21.0 program (SPSS
Inc., Chicago, IL). The general characteristics of the
participants were evaluated and presented as frequencies
and percentages. A homogeneity test of the general
characteristics of the experimental and control groups was
analyzed by using the 2 test, t test, and Fisher exact test.
The homogeneity test for the variables was performed with a
t test. Repeated-measures analysis of variance (ANOVA)
was used to analyze the difference in body weight between
the groups. Heart and respiration rates were analyzed by
using analysis of covariance (ANCOVA), while a t test was
used for oxygen saturation and body temperature analyses. In
addition, the maternalinfant attachment and maternal stress
levels in the experimental and control group were tested with
ANCOVA. Body weight, heart rate, respiration rate, mater-
nalinfant attachment, and maternal stress were considered
covariates in the ANCOVA, indicating homogeneity between
the experimental and control groups.
Results
Homogeneity Test
General Characteristics
The characteristics of both groups were similar except for
gestational age. The mothers general characteristics did not
significantly differ (Table 1). Therefore, their general
characteristics were considered homogeneous.
Dependent Variables
Physiological functions were homogeneous for body
temperature and oxygen saturation, except for body weight,
heart rate, and respiration rate (Table 2). Maternalinfant
attachment significantly differed, showing that the groups
were not homogeneous in terms of maternalinfant
attachment (Table 2).
Effects on Physiological Functions
After controlling for body weight, heart rate, and
respiration rate (which were not homogeneous in the pre-test
E.-S. Cho et al.
for physiological function), body weight was tested by using
repeated-measures ANOVA with a covariate, and heart and
respiration rates were tested by using ANCOVA. The result
showed that the respiration rate after kangaroo care signifi-
cantly differed between the groups (F = 5.70, p = .020;
Table 3). The respiration rate of the preterm babies in the
experimental group was significantly stabilized compared with
the control group.
Difference in MaternalInfant Attachment
The ANCOVA results showed that when controlling for
maternalinfant attachment (which was not homogenous in
the pre-test between the groups), maternalinfant attachment
significantly changed at post-test (Table 4). The experimen-
tal group had higher maternalinfant attachment scores
than the control group at post-test (F = 25.881, p b .001).
Thus, kangaroo care positively influenced maternalinfant
attachment.
Difference in Maternal Stress
Even though the homogeneity test of the maternal stress at
pre-kangaroo care was not statistically significant between
the groups, the maternal stress variable was used as a
covariate. Maternal stress significantly differed (F = 47.320,
p b .001), with kangaroo care being effective in reducing
maternal stress (Table 5).
Discussion
In the past, nurses focused on the medical and
technological aspects in caring for premature babies.
Currently, however, they perform tactile stimulation as a
nursing intervention to promote the growth and development
of preterm infants (Fenwick, Barclay, & Schmied, 2001).
Many studies have demonstrated that tactile stimulants
resulted in improvements in growth factors such as weight
gain, stabilized vital physiology, and increased height and
head circumference (Bera et al., 2014; Jang, 2009).
This study was conducted to investigate the effects of
kangaroo care on the physiological functions of preterm
infants, maternalinfant attachment, and maternal stress. The
results of this study showed that among the physiological
effects, only the effect on the respiration rate of the preterm
infants who received kangaroo care was significant when
compared with the effects in the preterm infants who did not
receive kangaroo care. This finding is consistent with those
of previous studies (Bera et al., 2014; Lee, 2009; Lee &
Bang, 2011; Lee et al., 2014). The respiration rates for both
groups in this study were within the normal range at pre-test.
However, the respiration rate of the experimental group
decreased significantly after receiving kangaroo care, while
that of the control group increased. Ludington-Hoe (2011)
reported that kangaroo care affected preterm infants
respiration rate. During kangaroo care, preterm infants
were placed in contact with their mothers skin, with their
mothers bodies leaning forward by 60. This posture
Kangaroo Care in the Neonatal Intensive Care Unit 435

Table 1 Characteristics of the participants and homogeneity between the groups (N = 40)
Demographics EG (n = 20) CG (n = 20) t or p
n (%) or Mean SD n (%) or Mean SD X2

Mother
Mother Age (year)
2630 4 (20.0) 5 (25.0) 0.24 .814
3135 13 (65.0) 10 (50.0)
36 3 (15.0) 5 (25.0)
Mother Education
High school 11 (55.0) 9 (45.0) 0.28 .780
University 8 (40.0) 11 (55.0)
Graduate school 1 (5.0)
Mother Occupation
None 15 (75.0) 11 (55.0) 1.76 .160 a
Have 5 (25.0) 9 (45.0)
Mother Income
b 200 1 (5.0) 0.00 1.000
201300 8 (40.0) 6 (30.0)
301 12 (60.0) 13 (65.0)
Delivery Type
SD 11 (55.0) 6 (30.0) 2.56 .100 a
C/S 9 (45.0) 14 (70.0)
Delivery Frequency
Once 12 (60.0) 13 (65.0) 0.46 .647
Twice 8 (40.0) 5 (25.0)
Three times 1 (5.0)
Four times 1 (5.0)
Pregnancy Type
Spontaneous Pregnancy 14 (70.0) 15 (75.0) 0.13 .500 a
Artificial Pregnancy 6 (30.0) 5 (25.0)

Premature infant
Gestational age (weeks) 30.12 16.29 28.81 20.63 3.76 .001
Corrected age (weeks) 33.70 9.01 33.00 6.63 1.96 .058
Premature Gender
Male 7 (35.0) 10 (50.0) 0.92 .262 a
Female 13 (65.0) 10 (50.0)
Birth Rank
First 11 (55.0) 15 (75.0) 0.88 .387
Second 9 (45.0) 4 (20.0)
Third 1 (5.0)
Note. EG = Experimental group; CG = Control group.
a
Fisher's Exact Test.

allowed the preterm infants to lie beneath the upper abdomen
of the mothers, causing an increase in the negative pressure
beneath the diaphragm, thereby easing their respiration and
thus helping their pulmonary function.
The results of this study show that among the physiolog-
ical effects, weight, heart rate, body temperature, and oxygen
saturation indicated no significant differences between the
preterm infants who received and those who did not receive
kangaroo care. At post-test, the increase in weight gain in the
group who received kangaroo care was greater than that in
the group who did not receive kangaroo care, but the
difference was not significant. In some studies (Lee, 2009;
Lee & Bang, 2011), the weight gain in the group who
received kangaroo care was not significant, as observed in
this study, but most studies reported that the weight of babies
who received kangaroo care increased (Jang, 2009; Samra
et al., 2013). A shorter duration of implementation was likely
to affect the results for body weight because other studies
involved spending more time on kangaroo care, specifically
40 to 60 min after breast feeding for 30 min, and then
measuring the weight gain (Jang, 2008). However, providing
kangaroo care for 30 min in this study was in accordance
with the WHO (2003) guidelines and the intervention
developed by Moon and Koo (2000). Furthermore, we
could not strictly control extraneous variables such as
the feeding state, intravenous fluid administration, and
436 E.-S. Cho et al.

Table 2 Homogeneity between the groups (N = 40)

Demographics EG (n = 20) CG (n = 20) t p
Mean SD Mean SD
Weight (g) 1660.00 225.20 1442.00 128.00 3.76 .001
Heart rate 159.30 9.17 149.10 8.00 3.75 .001
Respiratory rate 54.00 11.30 46.90 8.58 2.24 .031
Oxygen saturation 96.45 2.39 95.05 2.54 1.79 .081
Temperature of skin 36.41 0.36 36.53 0.21 1.25 .220
MaternalInfant Attachment 4.48 0.39 4.24 0.27 2.29 .028
Maternal Stress 4.67 0.30 4.49 0.30 1.90 .065
Note. EG = Experimental group; CG = Control group.
a
Fisher's Exact Test.

treatment, which are inevitable in the NICU. The feeding
state affected the infants condition and the Apgar scores.
In future studies, the premature oral feeding state and
Apgar scores of infants receiving kangaroo care should
be considered.
The decrease in the heart rate of the group who received
kangaroo care was greater than that of the control group at
post-test, but the difference was not significant. Mori,
Khanna, Pledge, and Nakayama (2010), who evaluated the
physiological effects of kangaroo care in a meta-analysis,
reported that kangaroo care affected the heart rate of
premature infants. The results obtained in this study were
similar to those obtained previously (Lee, 2008, 2009; Lee &
Bang, 2011). The heart rate was probably affected by holding
the infants upright and positioning them directly on the chest,
which is considered to induce deep sleep in preterm infants
because of the stable embracing position on the mothers soft
chest. Other research studies showed different findings
(Begum et al., 2008). The improved heart rate after kangaroo
care was because of the position and bed change, and was
caused by the increased body temperature due to the infants
skin-to-skin contact with their mothers.
Oxygen saturation slightly increased in the group who did
not receive kangaroo care when compared with that in the
group who received kangaroo care. However, other studies
indicated a significant difference (Bera et al., 2014; Lee &
Bang, 2011). Generally, kangaroo care seems beneficial for
the oxygen requirement of premature infants because the
upright position promotes cardiorespiratory stabilization.
Therefore, oxygen saturation also improves (Fischer,
Sontheimer, Scheffer, Bauer, & Linderkamp, 1998). While
Lee and Bang (2011) measured oxygen saturation at 10, 20,
and 30 min after intervention, we measured oxygen
saturation only once, that is, 5 min after the intervention;
this may have affected the results. Future studies should be
performed such that the effect of kangaroo care on oxygen
saturation is measured several times after the intervention.
The body temperature of the control group did not change
even though the preterm infants who received kangaroo care
had a slightly increased body temperature. Preterm infants

Table 3 Effects of kangaroo care on physiological functions (N = 40)

Variables Group Pre Post F/t p
Mean SD Mean SD
Body weight (g) EG 1660.00 225.20 2164.00 243.25
CG 1,442.00 128.00 1779.00 146.89
Group 1.1 a .301
Time 145.25 a b .001
Group*Time 2.89 a .098
Heart rates EG 159.30 9.17 149.55 10.52 3.82 b .055
CG 149.10 8.00 146.30 11.42
Respiration rates EG 54.00 11.30 45.40 5.44 5.70 b .020
CG 46.90 8.58 47.65 9.20
O2 Saturation EG 96.45 2.39 98.50 1.40 1.14 c .261
CG 95.05 2.54 97.85 2.13
Body temperature EG 36.41 0.36 36.63 0.17 1.49 c .144
CG 36.53 0.21 36.53 0.23
Note. EG = Experimental group (n = 20); CG = Control group (n = 20).
a
Repeated Measured ANOVA (covariate: pre-test score).
b
ANCOVA (covariate: pre-test score).
c
t-test (post-test score difference of two groups).
Kangaroo Care in the Neonatal Intensive Care Unit
Table 4 Difference in maternalinfant attachment between two groups (N = 40)
Variable Group Pre
Mean SD
Maternal attachment EG 4.48 0.39
CG 4.24 0.27
Note. EG = Experimental group (n = 20); CG = Control group (n = 20).
a
ANCOVA (covariate: pre-test score).
taken out of the incubators for kangaroo care received their
mothers warmth and maintained or even increased their
body temperature. Mori et al. (2010) conducted a meta-
analysis to investigate the effects of kangaroo care on the
body temperature of newborn infants. In addition, Lee and
Bang (2011) and Ludington-Hoe (2011) found that the group
who received kangaroo care had a higher body temperature.
It was due to contact with the mothers warm skin, which
helped the premature infants save energy and maintain their
body temperature (Lee & Bang, 2011).
This study showed significant differences only in
respiration rate because the participants in this study were
physiologically stable after extubation or oxygen therapy
was completed. Thus, body weight, skin temperature, heart
rate, and oxygen saturation did not show significant
differences between the groups. Further study is recom-
mended for severely preterm infants who are receiving
ventilation support or oxygen therapy in order to determine
the complete effects of kangaroo care.
In this study, we found a significant difference in
maternalinfant attachment between the group who received
kangaroo care and the control group. This finding was
consistent with that of previous research studies (Jang, 2008;
Lee, 2008; Roller, 2005; Shin, 2007). In addition, in a
systematic review, kangaroo care improved maternal affec-
tion and attachment. Kangaroo care also improved the
relationship between mothers and infants (Jang, 2009; Lee &
Bang, 2011).
Only a few studies have been conducted on the effects of
kangaroo care on maternal stress. A significant reduction in
maternal stress was observed in the group who received
kangaroo care when compared with the control group. This
supports the results of a previous study by Feldman,
Eidelman, Sirota, and Weller (2002). This maternal stress
reduction could be caused by more direct contact time spent
Table 5 Difference in maternal stress between two Groups (N = 40)
Variable Group Pre
Mean SD
Maternal stress EG 4.67 0.30
CG 4.49 0.30
Note. EG = Experimental group (n = 20); CG = Control group (n = 20).
a
ANCOVA (covariate: pre-test score).
437
Post F p
Mean SD
4.74 0.28 25.88 a b .001
4.48 0.39
by mothers with their babies and adjusting to surroundings at
the NICU, better communication with medical teams during
kangaroo care, and closer monitoring by mothers of their
babies during kangaroo care. The effect on maternal stress in
this study differed from that observed in other studies in that
Hwang et al. (2013) and Lee, Wang, Lin, and Kao (2013)
demonstrated that the most stress was from the infants
appearances, followed by the parents role, with communi-
cation with medical teams as the least stressful. From this
observation, mothers became more confident gradually after
two or three sessions of kangaroo care while they remained
nervous about holding their infants who had an intravenous
catheter and electrocardiographic monitoring. Consequently,
there can be no doubt that kangaroo care helps to reduce
maternal stress, and it should be included as a major nursing
intervention for preterm infants and their mothers.
The design of this study in terms of the limited time and
the frequency of kangaroo care could restrict the potential for
further improving maternalinfant attachment and for further
reducing stress. Therefore, more studies are recommended to
identify maternalinfant attachment and the level of stress,
with consideration of the unlimited time and greater
frequency of kangaroo care for preterm infants.
Limitation of the Study
This study was conducted with a small sample size of
mothers and preterm infants at a single hospital. Therefore,
for higher power and generalization of the findings in this
study, further study is needed with a large sample size.
Another limitation is that the participants were not
randomly assigned to the groups and the natural maturity
of preterm infants was not considered. Although the
corrected age was similar between the two groups, the
infants in the experimental group were more mature at birth.
Thus, those infants had been in the hospital for a shorter
Post F p
Mean SD
3.76 0.23 47.320 a b .001
4.40 0.33
438
length of time prior to the study. This might have influenced
the results of this study. Therefore, internal validity might be
threatened. In the future, the benefit of kangaroo care may be
examined considering these conditions. In addition, in the
present study, we did not consider the mothers decision to
participate in kangaroo care, which might have influenced
our results.
Conclusion
Kangaroo care yielded positive effects on stabilizing the
breathing of the preterm infants, improving maternalinfant
attachment, and reducing maternal stress. Therefore, kanga-
roo care can be used to promote emotional bonding between
mothers and their babies, and to stabilize the physiological
functions of premature babies. In addition, kangaroo care
may be one of the most effective nursing interventions in the
NICU for the care of preterm infants and their mothers.
Acknowledgments
This work was supported by the Ministry of Education of
the Republic of Korea, the National Research Foundation of
Korea (NRF-2015S1A3A2046760) and Hallym University
Research Fund, 2015 (HRF-201505-013).
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