Annals of Tropical Paediatrics (2004) 24, 245–251

A comparison of kangaroo mother care and conventional

incubator care for thermal regulation of infants <2000 g
in Nigeria using continuous ambulatory temperature
monitoring

O. E. IBE, T. AUSTIN*, K. SULLIVAN†, O. FABANWO‡, E. DISU‡ &

A. M. DE L. COSTELLO†

POLICY Project, Abuja and ‡Lagos State University Teaching Hospital, Ikeja, Lagos, Nigeria, and
*University College Hospital and †International Perinatal Care Unit, Institute of Child Health,
University College London, UK

(Accepted March 2004)

Summary Although skin-to-skin contact (or kangaroo mother care, KMC) for preterm infants is a practical
alternative to incubator care, no studies have compared these methods using continuous ambulatory temperature
monitoring. To compare thermal regulation in low birthweight infants (<2000 g) managed by KMC alternating
with conventional care (CC) and to determine the acceptability to mothers of KMC, an experimental study with a
crossover design with observational and qualitative data collected on temperature patterns and mothers attitudes to
skin-to-skin care was conducted in the neonatal wards of three hospitals in Lagos, Nigeria. Thirteen eligible infants
were nursed by their mothers or surrogates in 38 4-hour sessions of KMC and the results compared with 38 sessions
of incubator care. The risk of hypothermia was reduced by >90% when nursed by KMC rather than conventional
care, relative risk (RR) 0.09 (0.03–0.25). More cases of hyperthermia (>37.5dC) occurred with KMC, and core-
periphery temperature differences were widened, but the risk of hyperthermia >37.9dC (RR 1.3, 0.9–1.7) was not
significant. Micro-ambient temperatures were higher during KMC, although the average room temperatures during
both procedures did not differ significantly. Mothers felt that KMC was safe, and preferred the method to CC
because it did not separate them from their infants, although some had problems adjusting to this method of care.
Where equipment for thermal regulation is lacking or unreliable, KMC is a preferable method for managing stable
low birthweight infants.

Introduction method of providing a stable, individualised

Hypothermia is a major cause of morbidity
and mortality in preterm,, low birthweight
(LBW) infants.1–4 LBW infants use nearly
half their energy intake maintaining body
temperature, so provision of warmth and
prevention of heat loss can significantly
improve survival rates.1,5,6 The use of air-
heated incubators has been the standard
Reprint requests to: Professor Anthony Costello, Inter-
national Perinatal Care Unit, Institute of Child Health,
University College London, 30 Guilford Street, London
WC1N 1EH. E-mail: ipu@ich.ucl.ac.uk
© 2004 The Liverpool School of Tropical Medicine
DOI: 10.1179/027249304225019082
thermal environment for the newborn infant
at risk. The availability of incubators and
radiant warmers in industrialised countries
has made neonatal hypothermia uncom-
mon, except in infants transported over long
distances.3,7 In developing countries, how-
ever, hypothermia still poses a significant
threat to the survival of LBW infants. Even
where incubators are available, their use is
often fraught with operational difficulties.7,8
These include maintaining incubator air
temperature, air flow and relative humidity
within a narrow range in order to provide a
thermoneutral environment for the infant
246 O. E. Ibe et al.
being nursed naked.9 This level of regulation
requires sophisticated modern equipment,
neonatal intensive care units, highly skilled
professionals and a constant electricity sup-
ply. The cost of such infrastructure is often
prohibitive in developing countries such as
Nigeria.8
Rey & Martinez10 in Colombia introduced
a method of ambulatory neonatal care called
kangaroo mother care (KMC). LBW infants
wearing nappies were nursed naked between
their mothers’ breasts, providing the preterm/
LBW infant’s basic needs of warmth,
nutrition and love.8,10 Data from other
countries have shown that KMC can signifi-
cantly improve the survival of preterm
infants in low-resource settings.11–14 Studies
of the physiological effects of skin-to-skin
contact using continuous monitoring in
neonatal intensive care units in the USA
and Europe15–18 show that infants nursed
by KMC maintain body temperatures well,
have fewer apnoeic episodes, similar or
better blood oxygenation, lower infection
rates, and are alert for longer and cry less
than infants nursed in incubators.19 Also,
they are breastfed for longer, are better
bonded to their mothers and have a shorter
duration of hospital stay.14,20 To date there
are no published reports of KMC as a
method of care for stable LBW infants in
Africa evaluated by continuous temperature
monitoring. We report here the use of KMC
compared with incubator care among stable,
preterm, LBW infants in Lagos, Nigeria.
Subjects and Methods
The study was conducted at Ayinke House,
a government maternity hospital, and at
R-Jolad and Motayo private hospitals in
Lagos, Nigeria from May to July 2001.
Ayinke House is the largest state-owned
maternity unit with an average of 3050 deli-
veries annually. About 17% of deliveries
are LBW and about 40% of these weigh
<2000 g at birth. During the study, the
ambient temperature in the special care baby
unit (C ward) varied between 28 and 30dC
in the day and 22 and 24dC at night.
This was an experimental study, with
a crossover design, with observational and
qualitative data collected on temperature
patterns and mothers’ attitudes to skin-
to-skin care. The Lagos State Hospitals
Management Board and the Ethics Com-
mittee of the Institute of Child Health,
London approved the protocol.
Stable LBW infants (n=13) aged from 24
hours to 30 days were recruited by incident
density sampling: any baby born during the
stipulated time period who met the eligibility
criteria was enrolled in the study and those
who did not were omitted. Each infant acted
as its own control. The inclusion criteria
were: birthweight of 1200–1999 g, an Apgar
score of at least six at 1 minute, able to
tolerate handling without distress; exclusion
criteria were: Apgar score of five or less at
birth, requiring prolonged resuscitation and
oxygen therapy after 4 hours of life, illness
or gross congenital anomalies. Informed
consent was obtained from the parent(s) of
eligible infants. Mothers who were stable
enough to hold their infants in skin-to-skin
contact were enrolled; if a mother was
unwell, a willing female relative was enrolled
in her place.
After enrolment, the infants were assigned
to have temperature monitored continuously
and were started either on KMC or conven-
tional care (CC), based on the availability of
the mother or a consenting female relative.
The infants were dressed in cotton vests
and caps and placed between their mothers’
breasts for KMC. The infants were held
securely in place by a bra top made of
stretchable nylon material. Mothers wore
dresses or shirts to cover up the baby. With
the infants in this position the mothers were
transferred to individual rooms in the post-
natal wards, walking through a draughty
corridor. The infants were then alternated
between KMC and CC (incubator care for
all except one infant for whom a radiant
warmer was used), over consecutive 4-hour
periods. When placed in the incubator,
 Thermal regulation: kangaroo care v incubator
infants were nursed wearing only nappies,
except when there was an electricity power
cut.
The KMC provider’s axillary temperature
was recorded at the outset with a UNICEF
thermometer. Continuous ambulatory moni-
toring of the infant’s temperature over a
24-hour period was conducted using a
compact, battery-powered Eltek 1000 series
Squirrel Memory Data Logger (Grant
Instruments, Cambridge, UK).21 Two
microthermistor skin probes were attached
with Micropore to the infant’s forehead and
axilla and 5 minutes were allowed for equili-
bration. A third black ball was placed next
to the infant, underneath the bra top when in
the kangaroo position, or in the incubator/
open crib during conventional care. This
probe recorded the ambient temperature
close to the infant.
Temperatures were recorded every 5
minutes for 4-hour periods for each method
and interrupted only when alternating
between KMC and CC. In total, each infant
had three periods of KMC and three of CC
alternately over a 24-hour period. A total of
144 measurements were obtained for each
method.
Information on mother’s socio-
demographic status, obstetric history and
acceptability to her of method of thermal
care of infants was collected. Infants’ gesta-
tional age was determined from the mother’s
last menstrual period (LMP), when known,
and from whether the periods had been
regular. The Ballard score was used for
clinical assessment of an infant’s gestational
age.22 Acceptability to mothers of KMC was
determined through semi-qualitative meth-
ods (interviews) to describe the acceptability
and mothers’ feelings about skin-to-skin
contact as a method of caring for their LBW
infants. Information was sought using
partly structured and partly open-ended
questions. Also, comments made by mothers
while participating in the study were docu-
mented, particularly during the periods of
skin-to-skin contact.
247
A power analysis of expected effect sizes
and standard deviation (SD) of the tem-
peratures with a 95% and b 80% indicates
that at least 20 paired measurements will be
required to show a difference of at least
0.5dC between KMC and CC.23 Forty-eight
(one in six) paired measurements were
analysed for each infant. SPSS for Windows
versions 6 and 10 were used for analysis. Epi
Info version 6 was used for calculating the
95% confidence intervals (CI) of relative
risks. Temperature outcomes of interest
were episodes of hypothermia (<36.5dC),
significant hyperthermia (>37.9dC). Levels
of cold stress (Td — the difference
between axillary and forehead temperature)
were also assessed. A paired t-test was used
to analyse differences in mean temperatures
in both methods of care whilst the x2 test
was used for categorical variables. Mothers’
responses to questions about the acceptabil-
ity of the method of care were analysed
quantitatively and semi-qualitatively.
Results
Thirteen infants, eight mothers and three
female relatives participated in the study.
There were two pairs of twins and nine
singletons. Six mothers were <30 years of
age and five were older. Five mothers
were primiparous and six multiparous. Five
mothers had either no education or only
up to primary school qualification, three
had secondary school education and three
had up to university level qualifications. Ten
of the infants were girls, three boys. The
birthweights of ten infants were between
1500 and 1900 g and <1500 g in three. The
weight at enrolment was, as expected, lower,
five infants then weighing <1500 g. Twelve
of the 13 infants were <37 weeks gestational
age. The mean (SD) gestational age at birth
calculated from the last menstrual period
was 33 (2.4) weeks (range 32–38 weeks).
There was no significant difference between
this method and gestational age determined
by Ballard’s score.22 Four infants were
248 O. E. Ibe et al.

TABLE 1. Comparison of temperature recordings during both methods of care.

Method of providing warmth

Mean (SD) Relative risk (95% CI)
KMC, n (%) CC, n (%) difference(95% CI) t-test and p-value

No. of care sessions 38 38

No. of temperature readings analysed 303 (100) 303 (100)
Normothermia 127 (42) 143 (47)
36.5–37.5dC
Hypothermia 5 (2) 60 (20) 0.09 (0.03–0.25)
<36.5dC
Hyperthermia 171 (56) 100 (33)
37.6–37.9dC 91 49 1.39 (1.17–1.67)
>37.9dC 80 51 1.28 (0.94–1.74)
Mean (SD) ambient temperatures 34.3 (1.2) 33.6 (3.5) -0.7 (3.8) t=-3.2
(–1.1, –0.3) p=0.001
Mean (SD) axilla temperatures 37.6 (0.5) 37.1 (0.8) -0.5 (0.7) t=-11.0
Mean core-periphery temperature (–0.5, –0.4) p<0.0001
difference 1.5 (0.6) 1.0 (0.7) 0.5 (0.8) t=10.7
(0.4, 0.6) p<0.0001

enrolled aged h2 days, six between 3 and 7
days and three after 7 days of age.
The forehead and axilla temperatures of
the infants were recorded whilst in KMC
and compared with that recorded when in
CC (incubator/radiant warmer). All infants
studied had significantly higher tempera-
tures during KMC than CC (Table 1). Of
the 606 temperature readings analysed, 65
(11%) were <36.5dC and 92% of these
were recorded with infants in CC, mostly
when the incubator was not functioning
adequately. A major problem with the incu-
bators was electricity supply cuts, but even
when there was power the incubators
maintained temperature erratically as their
regulators were often non-functional. Thus,
to prevent overheating, they were intermit-
tently switched off, sometimes resulting in
episodes of hyper- or hypothermia.
The risk of an infant having an episode of
hypothermia was reduced by >90% when
nursed skin-to-skin rather than convention-
ally (RR 0.09, 95% CI 0.03–0.25). The
sample trace of baby 6 shown in Fig. 1 shows
how, adjusting for the changes in ambient
temperature, the periods of nursing by KMC
showed greater thermal stability and less
core-periphery differences than the periods
of incubator care.
Most cases of hyperthermia (>37.5dC)
occurred with KMC (Table 1). Regarding
core (axilla) and surface (forehead) tempera-
ture differences, using a cut-off Td of 2.5dC,
there were significantly more episodes
during KMC than CC. This reflects the
higher core temperatures during KMC
rather than any significant cold stress. With a
cut-off of 3dC difference, the usual definition
of cold stress, levels in either method were
not significantly different (Table 2).
Despite the fact that skin-to-skin contact
(KMC) as a method of care for small infants
was new to the mothers who participated in
the study, all of them preferred it to having
their infants nursed in an incubator in a ward
separate from them (Table 3).
Discussion
This study shows that skin-to-skin contact
between a mother and her stable, LBW
infant (kangaroo mother care, KMC) has
advantages over conventional care in a ter-
tiary government hospital in a developing
country. Continuous ambulatory tempera-
ture monitoring techniques have not been
used previously to compare incubator care
 Thermal regulation: kangaroo care v incubator 249

FIG. 1. Sample trace from an infant comparing ambient (왎), axillary (core) (쏆) and forehead (periphery) (왖)
temperatures in conventional incubator care (Inc) with kangaroo mother care (KMC).

TABLE 2. Core–skin temperature differences (Td) in both methods of care.

Core–skin temperatures Skin-to-skin care (KMC) Conventional care

(Td) n=303 n=303 Relative risk (95% CI)

Td h2dC 254 (83.8) 284 (93.7)

Td >2dC 49 (16.2) 19 (6.3) 2.58 (1.6–4.3)
Td >2.5dC 19 4 3.87 (1.3–11.2)
Td >3dC 7 1 5.71 (0.7–46)

TABLE 3. Responses of mothers on acceptability of method of care.

Conventional care Kangaroo care

No. of mothers=8 (%) No. of mothers=8 (%)

Safety of method 6 (75) 7 (88)

Convenient for mother 2 (25) 5 (53)
Comfortable for mother 3 (38) 6 (75)
Comfortable for baby 3 (38) 8 (100)
Feels separated from baby 8 (100) 0
Problems with method of care 1 (13) 5 (63)
250 O. E. Ibe et al.
and KMC in a developing country. It is also
the first study documenting the use of KMC
in Nigeria. KMC is an adequate, low-cost
and preferable alternative for maintaining
warmth in situations where equipment for
thermal regulation is unreliable.12,16,24,25
The LBW infants were observed to have
fewer episodes of hypothermia in KMC
than in CC. Episodes of hypothermia
recorded during CC occurred when there
were electricity cuts or malfunctioning of the
incubators (with incubator temperatures
<31dC).1
Although the infants had fewer and
smaller variations in core temperature whilst
in KMC, an unexpected finding was that of
more episodes of mild hyperthermia. A pos-
sible explanation might be that the stretch-
able nylon tops (worn by the mothers to hold
the infants in place) were too warm for the
ambient temperatures in Lagos during the
study period which ranged between 20 and
23dC at night and 27dC during the day. It is
worth noting that, except in cases of extreme
hyperthermia (i38dC), infants are more at
risk of severe complications when they are
hypothermic rather than hyperthermic.26
KMC was also a useful way of transporting a
subject from lower to higher levels of care.
KMC does seem to provide greater thermal
stability than CC for preterm infants being
nursed in a resource-poor setting, but our
finding of significantly more episodes of mild
hyperthermia in the KMC babies suggests
that concern about sepsis might be more
common in this group. In practice, this is
unlikely to present a clinical dilemma
because temperature monitoring is infre-
quent in this setting, except in infants who
are clearly clinically unwell.
Although, when a Td cut-off value of
2.5dC was used, infants had higher core-
periphery temperature differences with
KMC, it was not significantly different with
a cut-off of 3dC. The number of events, how-
ever, was low. These values are drawn from
studies investigating core–skin temperature
differences in both normal and LBW infants
being managed by CC and KMC.21,27,28
Ellis et al.21chose a Td of 3dC to define cold
stress, using forehead skin temperature as
the peripheral site, which shows minimal
vasomotor nerve reactions on exposure to
cold air in contrast with other parts of the
skin. Our finding (of a wide Td) is a result
of more frequent episodes of hyperthermia
during KMC rather than more episodes of
cold stress. It could also be that the infants’
forehead skin was more exposed to cold air
during breastfeeds than during feeds whilst
in CC, as the latter was done with the infants
still within the confines of the incubator.
All the mothers, regardless of age or edu-
cational background, found KMC accept-
able in terms of suitability and safety, which
is encouraging as nursing a tiny infant in
skin-to-skin contact between the mother’s
breasts is an uncommon practice in Nigeria.
The local belief is that tiny infants are better
swaddled and nursed in warm rooms, with
minimal contact with their mothers. Most
mothers expressed delight about KMC,
especially at the opportunity to commence
breastfeeding earlier than had been practised
in the study hospitals. Some mothers
queried the possibility of practising KMC
whilst at home because of having to attend to
other family members.
In situations of unavailability or poor
functioning of conventional thermo-
regulatory equipment, as in most health
establishments in Nigeria,8 the use of KMC
to maintain adequate temperatures in
preterm/LBW infants is a safer alternative.
As KMC was done for short periods during
this study compared with the recommen-
dations of the International Network on
Kangaroo Care (INK), further research on
its acceptability in Nigeria when fully imple-
mented for mothers and stable, preterm
infants might be necessary to bring about a
change in clinical practice.
References
1 Silverman WA, Fertig JW, Berger AP. The influ-
ence of the thermal environment upon the survival
of newly born premature infants. Pediatrics 1958;
22:876–86.
 Thermal regulation: kangaroo care v incubator
2 Brück K. Temperature regulation in the newborn
infant. Biol Neonate 1961; 3:65–119.
3 World Health Organization. Thermal protection
of the newborn: a practical guide. Geneva: WHO.
Maternal and Newborn Health/Safe Motherhood
Division, 1997 (WHO/RHT/MSM/97.2).
4 Omene JA, Diejamoh FM, Faal M, Diakparomre
MA, Obiaya M. Heat loss in Nigerian newborn
infants in the delivery room. Int J Gynaecol Obstet
1979; 16:300–2.
5 Buetow KMC, Klein SW. Effects of maintenance of
‘normal’ skin temperature on survival of infants of
low birthweight. Pediatrics 1964; 34:163–70.
6 Hey EN, Katz G. The optimum thermal
environment for naked infants Arch Dis Child 1970;
45:328–34.
7 Tafari N, Olsson EE. Neonatal cold injury in the
tropics. Ethiop Med J 1973; 11:57–65.
8 Ajayi OA. Improving neonatal care in Nigeria: using
appropriate technology. Guest lecture, Annual
General and Scientific Conference of the Paediatric
Association of Nigeria, 1998, Ilorin, Kwara State.
9 Bell EF. Infant incubators and radiant warmers.
Early Hum Dev 1983; 8:351–75.
10 Rey ES, Martinez HG. Manejo racional de
nino premature. In Curso de Medicina Fetal,
Universidad Nacional, 1983, Bogotá, Colombia.
11 Sloan LN, Camacho LWL, Rojas EP, Stern C and
Maternidad Isidro Ayora Study Team. Kangaroo
mother method: randomised controlled trial of
an alternative method of care for stabilised low
birthweight infants. Lancet 1994; 344:782–5.
12 Kambarami RA, Chidede O, Kowo DT. Kangaroo
care versus incubator care in the management
of well preterm infants: a pilot study. Ann Trop
Paediatr 1998; 18:81–6.
13 Whitelaw A, Sleath K. Myth of the marsupial
mother: home care of very low birthweight babies in
Bogotá, Colombia. Lancet 1985; 1:1206–8.
14 Cattaneo A, Davanzo R, Worku B, et al. Kangaroo
mother care for low birthweight infants: a
randomised controlled trial in different settings.
Acta Paediatr 1998; 87:976–85.
15 Ludington-Hoe SM. Energy conservation during
skin-skin contact between premature infants and
their mothers. Heart Lung 1990; 19:445–51.
16 Acolet D, Sleath K, Whitelaw A. Oxygenation,
heart rate and temperature in low birthweight
251
infants during skin-to-skin contact with the
mothers. Acta Paediatr Scand 1989; 78:189–93.
17 Bauer K, Uhrig C, Sperling P, Pasel K, Wieland C,
Versmold HT. Body temperatures and oxygen
consumption during skin-to-skin (kangaroo) care
in stable preterm infants weighing less than 1500
grams. J Pediatr 1997; 130:241–4.
18 de Leeuw R, Colin EM, Dunnebier EA, Mirmiran
M. Physiological effects of kangaroo care in
very small preterm infants. Biol Neonate 1991;
59:149–55.
19 Anderson GC. Current knowledge about skin-
to-skin (kangaroo) care for preterm infants. J
Perinatol 1991; 11:216–26.
20 Tessier R, Cristo M, Velez S, et al. Kangaroo
mother care and the bonding hypothesis. Pediatrics
1998; 102:e17.
21 Ellis M, Manandhar N, Shakya U, Manandhar DS,
Fawdry A, de L Costello AM. Postnatal hypother-
mia and cold stress among newborn infants in Nepal
monitored by continuous ambulatory recording.
Arch Dis Child 1996; 75:F42–5.
22 Ballard JL, Novak KK, Driver MA. A simplified
score for assessment of fetal maturation of newly
born infants. J Pediatr 1979; 95:769–74.
23 Bosque EM, Brady JP, Affonso DD, Wahlberg VW.
Physiologic measures of kangaroo versus versus
incubator care in a tertiary-level nursery. J Obstet
Gynecol Neonatal Nurs 1995; 24:219–26.
24 Bergman NJ, Jurisoo LA. The “kangaroo method”
for treating low birthweight infants in a developing
country. Trop Doct 1994; 24:57–60.
25 McMaster P, Haina T, Vince JD. Kangaroo care in
Port Moresby, Papua New Guinea. Trop Doct 2000;
30:136–8.
26 Charpak N, Ruiz-Pelaez, JG, Figueroa de Calume
Z. Rey-Martinez kangaroo-mother programme: an
alternative way of caring for low birthweight infants?
One-year mortality in a two-cohort study. Pediatrics
1994; 94:804–10.
27 Singh M, Rao G, Malhotra AK, Deorari AK.
Assessment of newborn baby’s temperature by
human touch: a potentially useful primary care
strategy. Ind Pediatr 1992; 29:449–52.
28 Lyon AJ, Pikaar ME, Badger P, McIntosh N.
Temperature control in very low birthweight during
first five days of life. Arch Dis Child Fetal Neonatal Ed
1997; 76:F 47–50.