Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr. Mamta Gupta,
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Aug 2018

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Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
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Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
On May 11,2011

Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
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Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
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Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
On April 2011

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.

Dr. Anuradha
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : November | Volume : 16 | Issue : 11 | Page : SC05 - SC08 Full Version

Kangaroo Mother Care versus Prone Position in Preterm Neonates: A Non Randomised Clinical Study

Published: November 1, 2022 | DOI:
Arghya Roy Naskar, Prativa Biswas, Neha Karar, Dipanjan Halder

1. Senior Resident, Department of Paediatric Medicine, R.G. Kar Medical College and Hospital, Kolkata, West Bengal, India. 2. Assistant Professor, Department of Paediatric Medicine, R.G. Kar Medical College and Hospital, Kolkata, West Bengal, India. 3. Assistant Professor, Department of Biochemistry, Prafulla Chandra Sen Government Medical College and Hospital, Arambagh, Hooghly, West Bengal, India. 4. Assistant Professor, Department of Paediatric Medicine, R.G. Kar Medical College and Hospital, Kolkata, West Bengal, India.

Correspondence Address :
Dr. Dipanjan Halder,
C/o Asit Roy Naskar, AB-7/1, Kestopur Main Road, No. 3 Camp, Near Indian Overseas Bank, PO Krishnapur, PS Baguiati, Kolkata-700102, West Bengal, India.


Introduction: One of the major problems of preterm neonates is immature alimentation. This may lead to inadequate weight gain, higher chances of sepsis and increased mortality. Positioning during and after feeding affects nutritional tolerance. Kangaroo Mother Care (KMC) is a method of skin-to-skin contact between mother and neonate, claimed to improve infant outcomes.

Aim: To compare prone and Kangaroo Mother Care positioning of preterm neonates of 28-32 weeks gestational age during orogastric tube feeding.

Materials and Methods: The study was a single-centre Institution-based, non randomised cross-over clinical study, carried out at Sick Newborn Care Unit and Neonatal Intensive Care Unit (NICU), Department of Paediatrics, R.G. Kar Medical College and Hospital, Kolkata, India, from April 2020 to March 2021. The studied parameters included gastric residual volume (three hours postprandial), vital signs like respiratory rate, heart rate, SpO2 level, body temperature, Capillary Blood Glucose (CBG), also comfort scores using a comfort scale. Total 110 preterm neonates of 28-32 weeks gestational age were sampled as per inclusion criteria and divided into two groups. Each group was fed by orogastric tube feeding in its respective position, in which they were kept for three hours. Vital signs, comfort scores and gastric residual volume were re-assessed. Groups were crossed over on the next day. Statistical analysis was done by t-test.

Results: Of the total 110 neonates, KMC sample and prone position sample were compared after three hours. Heart rate was 147.5±4.3 and 151.08±9.1 beats per minute and respiratory rate 52.8±2.9 and 55.6±4.9 cycles per minute, which were lower in KMC than in prone position. There was better glycaemic control {n=107 (97.27) and 80 (72.73) mg/dL}, higher comfort scores (11.2±1.1 and 10.1±2.0) and minimal to negligible gastric residuals (0.03±0.05 mL and 0.13±0.12 mL) in KMC position, when compared to prone position, respectively.

Conclusion: Kangaroo mother care produced more stable physiological indices, and was more comfortable for preterm neonates and resulted in better feeding, absorption and metabolism.


Comfort, Feeding, Orogastric tube, Vital signs

Infants born before 37 weeks from the 1st day of the last menstrual period are termed premature by World Health Organisation (WHO) (1). Prematurity hampers normal alimentation. Proper nutrition in preterm neonates decreases mortality, improves weight gain and shortens hospitalisation. Neonatal positioning during and after feeding can have significant effect on nutritional tolerance. Different positions have different effects; prone position improves respiration and attenuates regurgitation (2). Kangaroo Mother Care (KMC) is a technique associated with improved infant and maternal outcomes. The kangaroo position consists of skin-to-skin contact between mother and infant in a vertical position between the mother’s breasts with the provider being in a semi-reclining position. Baby’s head is turned to one side, in a slightly extended position; hips flexed and abducted; arms flexed; abdomen at the level of mother’s epigastrium [3,4]. A Cochrane review on benefits of KMC demonstrated improved exclusive breastfeeding rates at discharge, reduction in the risk of mortality, reduction in nosocomial infection/sepsis, reduction in hypothermia, reduction in length of hospital stay, increase in length head circumference and weight gain (5).

A single homogenous study comparing effects of KMC and prone positioning on preterm neonates is scarce. The present study aimed to fulfil this void in knowledge by directly comparing the two positions in neonates. This will help in re-evaluating the existing knowledge base. KMC and prone positioning are inexpensive interventions, targeted for improved neonatal survival, hence relevant in resource-poor settings.

The aim of the present study was to compare prone and kangaroo mother care positioning of preterm neonates of 28-32 weeks gestational age during intragastric tube feeding. Further research will help in revising treatment guidelines, which could be implemented in health policies. The null hypothesis of the present study was, no difference existed between kangaroo mother care and prone positions after feeding in preterm neonates.

Material and Methods

The study was a single-centre Institution-based non randomised cross-over clinical trial. The study was conducted at Sick Newborn Care Unit (SNCU) and Neonatal Intensive Care Unit (NICU), Department of Paediatrics, R.G. Kar Medical College and Hospital, Kolkata, India for a duration of 12 months, from April 2020 to March 2021. Study population were neonates of 28-32 weeks gestational age.

Ethical clearance was obtained from the Institutional Ethics Committee, R.G. Kar Medical College (Registered with The Drugs Controller General India Registration No. ECR/322/Inst/WB/2013): RKC/171 dated 12.02.2020. Written informed consent was obtained from parents of all neonates enrolled in the study.

Inclusion criteria: Neonates having full consent from parents, gestational age of 28-32 weeks, birth weight of 800 grams or more, mean Appearance, Pulse, Grimace, Activity and Respiration (APGAR) score at birth ≥6, stable physiological indices (heart rate, respiratory rate, SpO2, body temperature, capillary blood glucose), not on intravenous fluids, feeding expressed breast milk, feeding via gavage feeding, having atleast two days of hospitalisation were included.

Exclusion criteria: Neonates with lack of consent, development of intraventricular haemorrhage, development of necrotising enterocolitis, congenital malformations, having convulsions, sepsis, feed intolerance, unstable vital signs, on mechanical ventilation or Continuous Positive Airway Pressure (CPAP) were excluded.

Sample size calculation: The formula for calculation of sample size for comparison between two groups when end point is quantitative data, was:


Where, SD=Standard Deviation (from previous study by Ozdel D and Sari HY (6);
Z is standard normal variate:
Zα=1.96 at Type 1 error of 5% (p-value <0.05),
Zβ=0.84 at 80% power;
d is effect size (difference between mean values).
SD2=35.93; (Zα+Zβ)2=7.84; d2=10.24.

On calculating, the sample size was found to be 55.02. Hence, the sample size for this study was set as 55 for each group. Total sample size of 110 neonates were divided into two groups A and B.

Study Procedure

On the first day, group A neonates were placed in kangaroo mother care position intermittently and group B neonates were placed in prone position intermittently. They were fed by orogastric tube feeding in their respective positions by the prescribed amount of expressed breast milk. Vital signs (respiratory rate, heart rate, SpO2, body temperature, capillary blood glucose) and comfort scores of the neonates were assessed 10 minutes before feeding while the neonates were supine. The neonates were then placed in their respective positions and feeds were given 10 minutes afterwards. The neonates were kept in their respective positions for three hours, at the end of which vital signs were reassessed. The neonates were then kept supine and comfort scores reassessed by their positions. Postprandial gastric residual volume was measured by aspirating gastric contents from the orogastric tube gently into a 2 mL syringe three hours after feeding. Heart rate and SpO2 were measured by pulse oximetry while CBG was measured by point of care glucometry. Body temperature was measured with digital thermometer via axillary route. All the readings were recorded in preformed and pretested score cards. Such readings were taken four times in a day at 6 am, 12 pm, 6 pm and 12 am. The same procedure was repeated on the second day but now, groups were crossed over to eliminate confounding factors, i.e., group A neonates were placed in prone positions intermittently while group B neonates were placed in KMC positions intermittently. The same readings were taken.

Data gathering tool was a form with two sections. Section 1 dealt with demographics of the participants. In section 2, a table was made which was used for recording the parameters at the four specified time intervals of the day. The parameters were: amount of expressed breast milk fed (at 6 am, 12 pm, 6 pm and 12 am), volume of gastric aspirate/ three hours postprandial gastric residual volume (at 9 am, 3 pm, 9 pm and 3 am), vital signs such as respiratory rate, heart rate, SpO2 level, body temperature, capillary blood glucose recorded 10 minutes before feed (at 5:50 am, 11:50 am, 5:50 pm and 11:50 pm) and three hours after feed (at 9 am, 3 pm, 9 pm and 3 am), comfort scores were-recorded 10 minutes before feed (at 5:50 am, 11:50 am, 5:50 pm and 11:50 pm) and three hours after feed (at 9 am, 3 pm, 9 pm and 3 am), using appropriate comfort scale, which was Infant Position Assessment Tool (IPAT) (Table/Fig 1) (4). The average of the four readings of each parameter was taken for each participant in each position.

Statistical Analysis

Data was entered in Microsoft Excel spreadsheet and analysed using software RStudio version 1.3.1056. Test applied was t-test and p-value <0.05 was taken as statistically significant.


In the present study, 31 neonates amongst the 110 sample were of 30 weeks gestational age, contributing to 28.18% followed closely by 27 (24.54%) neonates with a gestational age of 31 weeks. Neonates were taken with birth weights ranging from 0.8 kg to 1.499 kg and were divided into weight bands of 99 grams. 34 neonates belonged to the weight band of 1.0 to 1.099 kg, showing highest percentage of 30.91%. The mean birth weight was 1.1 kgs. Sixty neonates were girl babies (54.55%) while 50 neonates were boy babies (45.45%). In the present study, 60 neonates (54.55%) were born by caesarean section while, the rest were delivered by normal vaginal delivery. A maximum of 40 neonates showed a mean APGAR score of 8 (36.36%) followed closely by 34 newborns (30.9%) with a mean APGAR score of 9. The total mean AGPAR score was 7.9 (Table/Fig 2).

All vital parameters as well as comfort scores were recorded before positioning to obtain baseline values. These baseline values of vital parameters were all within normal range. Hence, before positioning the neonates in either position, it was shown that all neonates were physiologically stable and comfortable.

Total 22 neonates (20%) had tachypnoea (respiratory rate >60 per minute) after being placed in prone position as opposed to only three neonates (2.73%) who had tachypnoea after KMC positioning. The mean respiratory rate in KMC position was 52.8 per minute while that in prone position was 55.6, implying lower and more normalised respiratory rate after being fed in KMC position. About 22 neonates (20%) had tachycardia (heart rate >160 beats per minute) after prone positioning as compared to only 3 neonates (2.73%), who had tachycardia after being placed in KMC position. The mean heart rate in KMC position was 147.5 beats per minute while that in prone position was 151.08 beats per minute, implying lower and more normalised heart rate after being fed in KMC position. A higher number of neonates i.e., 42 (38.18%) attained SpO2 of 99% after being placed in KMC position while 36 neonates (32.73%) attained SpO2 of 99% after being placed in prone position. The mean SpO2 was however similar; being 97.9% and 97.7% respectively in KMC and prone positions. Neonates placed in KMC position attained body temperature of 37.3-37.6°C, with a maximum of 52 babies (47.27%) having ideal physiological body temperature of 37.5°C, whereas neonates placed in prone position attained a body temperature of 36.6-37.3°C. The mean temperatures were 37.5°C in KMC position while 37.0°C in prone position. Thirty neonates (27.27%), following prone positioning had hyperglycaemia (CBG >125 mg/dL), most likely ascribed to stress, as opposed to only 3 neonates (2.73%) placed in KMC position, suggesting increased comfort and more normalised metabolism in KMC position. 107 out of 110 newborns representing 97.27% neonates had comfort score >8 (acceptable IPAT scores) after positioning in KMC compared to 88 neonates (80%) in prone position having an IPAT score >8. The mean scores, in KMC and prone positions, were respectively 11.2 and 10.1. Hence, contrary to prone position comfort levels were higher in KMC. With respect to gastric residual volume, 80 neonates amongst 110 (72.73%) in KMC had no gastric residuals as opposed to only 37 (33.64%) in prone position. The range of volume was less in KMC, being 0.1-0.2 mL as opposed to prone where it was 0.1-0.3 mL. The mean gastric residual volume was 0.03 mL in KMC position contrary to 0.13 mL in prone position. All these figures clearly signify better alimentation and utilisation of nutrients in KMC position (Table/Fig 3).


The Cochrane review on benefits of KMC demonstrated improved exclusive breast feeding at discharge or 40-41 weeks’ postmenstrual age and at 1-3 months’ follow-up; reduction in the risk of mortality; reduction in nosocomial infection or sepsis; reduction in hypothermia; reduction in length of hospital stay with mean difference being 2.4 days; increase in weight gain with mean difference being 4.1 gm/day; increase in length with mean difference being 0.21 cm/week; increase in head circumference gain with mean difference being 0.14 cm/week (5). Prone positioning stabilises the chest wall and may reduce apnoea (7).

In the study conducted by Miltersteiner AR et al., mean gestational age was 34 weeks, mean birth weight was 1.78 kg, male: female ratio was 13:7, caesarean deliveries were 43% while normal vaginal deliveries were 57% (8). In a study, conducted by Bera A et al., mean gestational age was 33.2±3.3 weeks, mean birth weight was 1.45±0.31 kg (9). In the study, conducted by Ozdel D and Sari HY, mean gestational age was 30.2±2.6 weeks ranging between 24 to 34 weeks, mean birth weight was 1.45±0.6 kg, 25 neonates were delivered by caesarean section while five neonates were delivered by normal vaginal delivery and there were nine female with 21 male neonates (6). In the present study, most of the neonates were of 30 weeks gestational age, with birth weight around 1.1 kg. Majority were females; majority were delivered by caesarean section; most neonates had an APGAR score around 8 at birth.

Moore ER et al., found higher body temperature, increased SpO2, decreased respiratory rate following KMC positioning (10). In the study conducted by Bera A et al., mean temperature was increased by 0.4°C; respiratory rate increased by three per minute; heart rate increased by five beats per minute; SpO2 increased by 5% after 1-3 hours of KMC position (9). In the study, by Defilipo EC et al., there was significant reduction in respiratory rate and distress (as assessed by Silverman Anderson scoring system) after 90 minutes of KMC position while other vital signs showed no difference (11). In the study conducted by Ozdel D and Sari HY, there was a decline in mean heart rate by nine beats per minute, decline in mean respiratory rate by 3.2 breaths per minute, rise in mean SpO2 by 0.57%, rise in mean body temperature by 0.03°C in KMC position as compared to prone position, 30 minutes after placing in KMC position and three hours after placing in prone position postfeeding (6). In the present study, the mean respiratory rate and heart rate in KMC position was lower and more normalised than that in prone position. A higher number of neonates had tachypnoea and tachycardia in prone position three hours after feed as compared to KMC position, signifying discomfort. The mean SpO2 in the two positions were almost similar. Several studies have established the positive effects of prone position on ventilation and oxygenation, which could lead to similar saturations in both [6,8,9,12-14]. Neonates placed in KMC position attained body temperature nearer to normal physiological body temperature of 37.5°C as compared to those placed in prone position. This is because KMC keeps neonates warm and protects against cold stress and hypothermia (15). Stress causes hormonal and metabolic changes (16). Higher number of neonates had hyperglycaemia after being placed in prone position as compared to KMC position. The findings were consistent with previous studies [8-11].

In the study, conducted by Ozdel D and Sari HY, there was a significant reduction of mean comfort scores by 2.8, 30 minutes after feeding and by 8.17, three hours after feeding in KMC position as compared to prone position. In the present study, the mean comfort score in KMC position was higher than that in prone position. More neonates had comfort score ≤8 (unacceptable) in prone position than in KMC (6).

In the present study, the mean gastric residual volume was lower in KMC as compared to prone position three hours after feeding. Though there are limited studies available on gastric residual volumes in preterms. Chen SS et al., found lower gastric residual volume in prone position as compared to supine position; whereas, Valizadeh S et al., found lower gastric residual volume in KMC position as compared to supine position two hours after feeding [17,18]. In the study conducted by Ozdel D and Sari HY, there was a reduction in mean gastric residual volume by 0.06 three hours after feeding. Hence, these findings were consistent with former studies [6,18].


The present study was a single-centre study of short period (12 months) only. This period needed to be longer for more accurate results. Neonates were not randomised for feeding position. Further studies with randomisation for a longer duration of time can be conducted in future.


Kangaroo mother care position resulted in more stable vital signs and physiological indices, more comfort and better feeding evidenced by minimal or negligible gastric residual volume, as compared to prone position. Hence, it can be concluded that, kangaroo mother care is a much better position as compared to prone position during feeding in preterm neonates. Kangaroo mother care and prone positioning have the capabilities of better neonatal survival and outcome, especially in resource-limited countries.


Authors are indebted to Prof. (Dr.) Gobinda Chandra Das, Head, Department of Paediatrics, R.G. Kar Medical College and Hospital, Kolkata for his continuous guidance. Authors are also thankful to Dr. Basundhara Saha, Senior Resident, Department of General Medicine, NRS Medical College and Hospital, Kolkata for her support.

Author contributions: ARN: contributed to the conception and design of the present study, ARN: Contributed to the conception and design of the present study, collected the data, performed statistical analysis, interpreted the data and drafted the manuscript. PB: Contributed to the conception and design of the present study, performed statistical analysis, interpreted the data and critically reviewed the manuscript. NK: Contributed to the design of the present study, performed statistical analysis and critically reviewed the manuscript. DH: Contributed to the conception and design of the present study, performed statistical analysis, interpreted the data and critically reviewed the manuscript.


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DOI and Others

DOI: 10.7860/JCDR/2022/59239.17093

Date of Submission: Jul 22, 2022
Date of Peer Review: Aug 20, 2022
Date of Acceptance: Oct 17, 2022
Date of Publishing: Nov 01, 2022

• Financial or other competing interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects? NA

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