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Kangaroo mother care to reduce morbidity and mortality in low birthweight infants

  1. Agustin Conde-Agudelo1,*,
  2. José M Belizán2,
  3. Jose Diaz-Rossello3

Editorial Group: Cochrane Neonatal Group

Published Online: 16 MAR 2011

Assessed as up-to-date: 30 JAN 2011

DOI: 10.1002/14651858.CD002771.pub2

How to Cite

Conde-Agudelo A, Belizán JM, Diaz-Rossello J. Kangaroo mother care to reduce morbidity and mortality in low birthweight infants. Cochrane Database of Systematic Reviews 2011, Issue 3. Art. No.: CD002771. DOI: 10.1002/14651858.CD002771.pub2.

Author Information

  1. 1

    Eunice Kennedy Shriver National Institute of Child Health and Human Development/National Institutes of Health/Department of Health and Human Services, Perinatology Research Branch, Detroit, Michigan, USA

  2. 2

    Institute for Clinical Effectiveness and Health Policy (IECS), Department of Mother and Child Health Research, Buenos Aires, Argentina

  3. 3

    University Hospital, Department of Neonatology, Montevideo, Uruguay

*Agustin Conde-Agudelo, Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development/National Institutes of Health/Department of Health and Human Services, Detroit, Michigan, USA. condeagu@hotmail.com.

Publication History

  1. Publication Status: New search for studies and content updated (conclusions changed)
  2. Published Online: 16 MAR 2011

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This is not the most recent version of the article. View current version (22 APR 2014)

 

Background

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. What's new
  11. History
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms
 

Description of the condition

Low birthweight (LBW), defined as weight at birth of less than 2500 g irrespective of gestational age, has an adverse effect on child survival and development, and may even be an important risk factor for adult diseases (Barker 1995). About 20.6 million infants worldwide, representing 15.5% of all births, were born with LBW in 2000, 95.6% of them in developing countries (UNICEF/WHO 2004). LBW is a major contributor to infant mortality accounting for 60 to 80% of neonatal deaths (Lawn 2005) and about two thirds of infant deaths (Guyer 1998). A complex process of care named either conventional or modern neonatal care includes interventions already proven to lower the burden of both neonatal morbidity and mortality. Conventional neonatal care of LBW infants is expensive and needs both trained personnel and permanent logistic support. This complexity is critical mainly during the stabilization period, until the infant has adapted to autonomous extrauterine life. In low- and middle- income countries, financial and human resources for neonatal care are limited and hospital wards for LBW infants are often overcrowded. Thus, interventions for LBW infants that reduce neonatal morbidity and mortality and costs would be an important advance in care.

 

Description of the intervention

In 1978, Edgar Rey (Rey 1983) proposed and developed kangaroo mother care (KMC) at Instituto Materno Infantil in Santa Fe de Bogotá, Colombia, as an alternative to the conventional contemporary method of care for LBW infants. KMC was initially conceived to address the lack of incubators, high rate of nosocomial infections, and infant abandonment in the local hospital. The term KMC is derived from similarities to marsupial caregiving. The mothers are used as "incubators" to maintain the infants' body temperature and as the main source of food and stimulation for LBW infants while they mature enough to face extrauterine life in similar conditions as those born at term. Initially, the method was applied only after the LBW infant had stabilized since LBW infants need a variable period of conventional care before being eligible for KMC. Respiratory, thermal and feeding stabilization have been considered crucial for the success of this intervention. The definition of stabilization is not precise, and has been defined as independent of gestational age and weight, which are the main variables associated with those vital functions. Some recent studies, however, have evaluated the effectiveness of early onset KMC (as soon as possible after birth) in LBW infants born in hospitals with little neonatal intensive care capacity (Worku 2005; Nagai 2010). The major component of KMC is skin-to-skin contact (SSC) in which infants are placed vertically between the mother's breasts firmly attached to the chest and below her clothes. SSC is offered to infants as far as the mother-infant dyad can tolerate it. Mothers can share the role of provider of SSC with others, especially the babies' fathers. The aim is to empower the mother (parents or caregivers) by gradually transferring the skills and responsibility for becoming the child's primary caregiver and meeting every physical and emotional need (Nyqvist 2010). The other two components of KMC are frequent and exclusive or nearly exclusive breastfeeding and attempt of early discharge from hospital regardless of weight or gestational age with strict follow up. However, these two last components are less frequently identified as part of KMC.

Different modalities of KMC have been adopted around the world (Charpak 1996) according to the needs of the settings. This diversity includes exclusive and non-exclusive breastfeeding, breast or gavage feedings, completely or partially naked, continuous (≥ 20 hours per day) or intermittent (for short periods once or a few times per day and for a variable number of days) SSC with variable duration of exposure, and early-or-not hospital discharge.

KMC has been reported to be associated with similar neonatal mortality after stabilization, some reduction of neonatal morbidity, greater quality of mother to child bonding and lower hospital stay and costs compared with standard, conventional care of LBW infants. Some researchers have claimed that KMC is the best option if neonatal care units are unavailable, or if they are available but overwhelmed by demand, KMC would allow rationalization of resources by freeing up incubators for sicker infants (Ruiz-Peláez 2004)

This updated review covered all the randomized controlled trials of KMC with all its components irrespective of duration of intervention, breastfeeding patterns, and time at discharge from hospital. Moreover, we have included subgroup analyses for the primary outcome mortality at discharge or 40 - 41 weeks' postmenstrual age and at latest follow up according to type of KMC (intermittent versus continuous), infant age at initiation of KMC (≤10 days versus > 10 days), setting in which the trial was conducted (low/middle income countries versus high income countries), and infant stabilization (before versus after). For all outcomes in stabilized LBW infants we performed subgroup analyses according to type of KMC (intermittent versus continuous). In addition, we included randomized controlled trials that compared early onset (starting within 24 hours after birth) versus late onset (starting after 24 hours after birth) KMC.

 

How the intervention might work

The intervention assumes that the mother maintains the infant's body temperature and is the main source of nutrition and stimulation, which are the main components of the conventional neonatal care (Rey 1983). SSC would allow that infant's demands for care may trigger neuropsychobiological paths that increase maternal behavior and immediate response to its needs as well as increased lactogenesis (Diaz-Rossello 2008). In addition, KMC would empower the mother (parents or caregivers) by gradually transferring the skills and responsibility for becoming the child’s primary caregiver and meeting every physical and emotional need (Nyqvist 2010).

 

Why it is important to do this review

This systematic review was undertaken because of the need to determine if KMC reduces morbidity and mortality in LBW infants. We believe that this review provides a valuable resource for clinicians and policy makers in summarizing current best evidence and highlighting gaps in the research.

 

Objectives

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. What's new
  11. History
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms

To determine whether there is evidence to support the use of KMC in LBW infants as an alternative to conventional neonatal care before or after the initial period of stabilization with conventional care. Beneficial and adverse effects were assessed.

 

Methods

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. What's new
  11. History
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms
 

Criteria for considering studies for this review

 

Types of studies

Randomized controlled trials, including cluster randomized trials, in which KMC was compared with conventional neonatal care in LBW infants. Moreover, we included randomized trials that compared early onset (starting within 24 hours after birth) versus late onset (starting after 24 hours after birth) KMC. Trials were excluded if they were quasi-randomized, or if they evaluated the effect of KMC in healthy full-term infants or with birthweight ≥ 2500 g which is the subject of a separate review (Moore 2007), or if they had crossover design, or if they only reported results for physiological parameters, or if they only evaluated the effect of KMC on procedural pain in infants which is the subject of a separate review (Johnston 2010). In addition, we did not include studies in which KMC was part of a package of interventions for newborn care. In the previous version of this review, we included only trials that evaluated continuous kangaroo mother care (KMC) after infant stabilization. For the 2011 update, we have also included studies that evaluated KMC before infant stabilization and intermittent KMC.

Where trials were reported in abstracts we planned to include them, provided that there was sufficient information on study methods to allow us to assess eligibility and risk of bias. If there was insufficient information reported, then we attempted to contact trial authors requesting further information before deciding to exclude any study.

 

Types of participants

LBW infants (defined as birthweight less than 2500 g) regardless of gestational age.

 

Types of interventions

1. Comparisons of KMC with conventional neonatal care in LBW infants. This was regardless of duration of intervention, breastfeeding patterns, and irrespective of whether discharge from hospital was early or not.

2. Comparisons of early onset KMC (starting within 24 hours post-birth) with late onset KMC (starting after 24 hours post-birth) in LBW infants, irrespective of infant stabilization status.

 

Types of outcome measures

We chose primary outcomes to be most representative of the clinically important measures of effectiveness and safety for the infants. Secondary outcomes included other clinical measures of effectiveness, mother-infant attachment or interaction, satisfaction with care, home environment and father involvement, and costs of care.

 

Primary outcomes

1. Mortality

  • At discharge or 40 - 41 weeks' postmenstrual age (from randomization until discharge or 40 - 41 weeks' postmenstrual age).
  • At six months of age or six months follow up (from randomization until six months of age or six months follow up).
  • At 12 months' corrected age (from randomization until 12 months' corrected age).
  • At latest follow up (from randomization until last follow up).

2. Severe infection/sepsis (as defined in the individual studies).

3. Severe illness (as defined in the individual studies).

4. Infant growth

  • Weight gain at latest follow up.
  • Weight at discharge or 40 - 41 weeks' postmenstrual age.
  • Weight at six months' corrected age.
  • Weight at 12 months' corrected age.
  • Length gain at latest follow up.
  • Length at discharge or 40 - 41 weeks' corrected gestational age.
  • Length at six months' corrected age.
  • Length at 12 months' corrected age
  • Head circumference gain at latest follow up.
  • Head circumference at discharge or 40 - 41 weeks' postmenstrual age.
  • Head circumference at six months' corrected age.
  • Head circumference at 12 months' corrected age.

5. Neurodevelopmental disability (measured by Griffith's Psychomotor Developmental Scales at 12 months' corrected age and review of clinical charts).

 

Secondary outcomes

1. Nosocomial infection/sepsis (as defined in the individual studies).

2. Mild/moderate infection or illness (as defined in the individual studies).

3. Lower respiratory tract disease (as defined in the individual studies).

4. Diarrhea (as defined in the individual studies).

5. Hypothermia (as defined in the individual studies).

6. Readmission to hospital.

7. Breastfeeding.

8. Length of hospital stay.

9. Mother-infant attachment (measured by interviews and observations).

10. Mother-infant interaction (measured by Still-Face Paradigm).

11. Parental and familiar satisfaction (measured by interviews).

12. Home environment and father involvement (measured by interviews).

13. Costs of care.

 

Search methods for identification of studies

 

Electronic searches

The standard search strategy for the Cochrane Neonatal review Group was used. This included searches of MEDLINE, EMBASE, LILACS, POPLINE, and CINAHL databases (all from inception to January 31, 2011), and the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2011) using a combination of keywords and text words related to KMC or SSC and LBW or preterm infants. To ensure maximum sensitivity we placed no limits or filters on the searches.

 
INDEX TERMS

Text words

Kangaroo mother care; kangaroo mother method; kangaroo care; skin-to-skin contact, skin-to-skin care

 
Medical Subject Headings (MeSH)

*Infant, Low Birth Weight; *Infant Mortality; *Breast Feeding; *Mother-Child Relations; Infant, Newborn; Infant care [*Methods]; Length of Stay; Physical Stimulation; [*Methods]; Randomized Controlled Trials as Topic; Weight Gain

 
MeSH check words

Humans; Infant

We searched for ongoing trials most recently in January 2011 in the following databases using the terms "kangaroo care" and "skin-to-skin contact" :

 

Searching other resources

Web page of the Kangaroo Foundation, International Network of Kangaroo Care, conference and symposia proceedings on KMC, reference lists of identified studies, textbooks, review articles, and Google scholar were also searched. In addition, we performed journal hand searching and contacted investigators involved in the field to locate unpublished studies. No language restrictions were applied. For studies with multiple publications, the data from the most complete report were used and supplemented if additional information appeared in other publications.

 

Data collection and analysis

 

Selection of studies

The standard methods of the Cochrane Collaboration and its Neonatal Review Group were used. All studies deemed suitable were retrieved and reviewed independently by the two review authors to determine inclusion. Disagreements were resolved through consensus.

 

Data extraction and management

Data were extracted in duplicate from all reports and recorded on a piloted form independently by the two review authors. There was no blinding of authorship. The following data were extracted for each trial: authors; year of publication; country; inclusion and exclusion criteria; study characteristics; mean or median weight and gestational age at birth, and infant age at enrollment by group; description of interventions; co-interventions; mean or median duration of KMC; number randomized and analyzed; number and reasons of withdrawals; and outcomes. Differences among reviewers in data extracted were resolved by discussion and consensus was reached. Additional information was sought from the individual investigators where the published information did not contain the required detail. One review author (A.C-A.) entered data into Review Manager software (RevMan 2008) and the other review author (J.L.D-R.) checked for accuracy. We processed included trial data as described in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2009).     

 

Assessment of risk of bias in included studies

The risk of bias in each included trial was assessed individually by the two review authors who were not associated with any of the trials. Methodological assessments were not conducted blind to author, institution, journal of publication or results, as the reviewers were familiar with most of the studies. When differences in assessment of risk of bias existed, a consensus was reached. We assessed risk of bias using the dimensions outlined in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2009). Five domains related to risk of bias were assessed in each included trial since there is evidence that these are associated with biased estimates of treatment effect: (1) sequence generation, (2) allocation concealment, (3) blinding of participants, clinical staff and outcome assessors, (4) incomplete outcome data, (5) selective outcome reporting, and (6) other potential threats to validity. We assigned a judgment relating to the risk of bias by answering a pre-specified question about the adequacy of the study in relation to the entry, such that a judgment of "Yes" indicates low risk of bias, "No" indicates high risk of bias, and "Unclear" indicates unclear or unknown risk of bias.

(1) Sequence generation

"YES": the investigators described a random component in the sequence generation process such as random number table, computer random number generator, shuffling cards or envelopes, drawing of lots, or computerized minimization.

"NO": the investigators described a non-random component in the sequence generation process such as odd or even date of birth, based on date or day of admission, based on hospital or clinical record number, or allocation by judgment of the clinician, preference of the participant, availability of the intervention, and based on the results of laboratory tests.

"UNCLEAR": Insufficient information to permit judgment of "Yes" or "No".

(2) Allocation concealment

"YES": the investigators used an adequate method to conceal allocation such as central allocation (including telephone or web-based randomization) or sequentially numbered, opaque, sealed envelopes.

"NO": the investigators used a non-adequate method to conceal allocation such as open random allocation schedule (e.g. a list of random numbers), assignment envelopes without appropriate safeguards, alternation or rotation, date of birth, or case record number.

"UNCLEAR": Insufficient information to permit judgment of "Yes" or "No".

(3) Blinding of participants, clinical staff and outcome assessors

"YES": since KMC cannot be implemented masked, we considered adequate blinding any one of the following: (1) no blinding, but the review authors judged that the outcome and the outcome measurement were not likely to be influenced by lack of blinding; or (2) either participants or some study personnel were not blinded, but outcome assessment was blinded and the non-blinding of others unlikely to introduce bias.

"NO": any one of the following: (1) no blinding or incomplete blinding, and the outcome or outcome measurement was likely to be influenced by lack of blinding; or (2) either participants or some study personnel were not blinded, and the non-blinding of others likely to introduce bias.

"UNCLEAR": Insufficient information to permit judgment of "Yes" or "No".

We assessed blinding separately for each outcome or class of outcomes (objective and subjective).

(4) Incomplete outcome data

"YES": any one of the following: (1) no missing outcome data; (2) reasons for missing outcome data unlikely to be related to true outcome; (3) missing outcome data balanced in numbers across intervention groups, with similar reasons for missing data across groups; (4) for dichotomous outcome data, the proportion of missing outcomes compared with observed event risk not enough to have a clinically relevant impact on the intervention effect estimate; (5) for continuous outcome data, plausible effect size among missing outcomes not enough to have a clinically relevant impact on observed effect size; or (6) missing data were imputed using appropriate methods.

"NO": any one of the following: (1) reasons for missing outcome data likely to be related to true outcome with either imbalance in numbers or reasons for missing data across intervention groups, with similar reasons for missing data across groups; (2) for dichotomous outcome data, the proportion of missing outcomes compared with observed event risk enough to induce clinically relevant bias in intervention effect estimate; (3) for continuous outcome data, plausible effect size among missing outcomes enough to induce clinically relevant bias impact in observed effect size; (4) "as-treated" analysis done with substantial departure of the intervention received from that assigned at randomization; or (5) potentially inappropriate application of simple imputation.

"UNCLEAR": Insufficient information to permit judgment of "Yes" or "No".

(5) Selective outcome reporting

"YES": any one of the following: (1) the study protocol was available and all of the study's pre-specified outcomes that were of interest in the review were reported in the pre-specified way; or (2) the study protocol was not available but it was clear that the published reports included all expected outcomes, including those that were pre-specified.

"NO": any one of the following: (1) Not all of the study's pre-specified primary outcomes were reported; (2) one or more primary outcomes were reported using measurements, analysis methods or subsets of the data that were not pre-specified; (3) one or more reported primary outcomes were not pre-specified; (4) one or more outcomes of interest in the review were reported incompletely so that they could not be entered in a meta-analysis; or (5) the study reported fails to include results for a key outcome that would be expected to have been reported for such a study.

"UNCLEAR": Insufficient information to permit judgment of "Yes" or "No".

The investigators independently assessed risk of bias in included studies, and discrepancies were resolved through discussion. We made explicit judgments about whether studies are at high risk of bias, according to the criteria given in the Handbook (Higgins 2009) and explored the impact of the level of bias through undertaking sensitivity analyses - see Sensitivity analysis.

(6) Other potential threats to validity

"YES": the study appears to be free of other sources of bias.

"NO": there is a least one important risk of bias. For example, the study: (1) had a potential source of bias related to the specific study design used; or (2) stopped early (whether or not as a result of a formal stopping rule); or (3) had extreme baseline imbalance; or (4) used blocked randomization in unblinded trials; or (5 ) had differential diagnostic activity; or (6) had some other problem.

"UNCLEAR": There may be a risk of bias but there is either insufficient information to assess whether an important risk of bias exists or insufficient rationale or evidence that an identified problem will introduce bias.

The investigators independently assessed risk of bias in included studies, and discrepancies were resolved through discussion. We made explicit judgments about whether studies are at high risk of bias, according to the criteria given in the Handbook (Higgins 2009) and explored the impact of the level of bias through undertaking sensitivity analyses - see Sensitivity analysis.

 

Measures of treatment effect

For dichotomous data, we present results as risk ratio (RR) with 95% confidence interval (CI). For continuous data, we have used mean difference (MD) with 95% CIs. The number needed to treat (NNT) for benefit or harm was calculated for outcomes for which there was a statistically significant reduction in risk difference.

 

Unit of analysis issues

The unit on analysis is the participating infant in individually randomized trials. We had planned to include cluster randomized trials in the analyses along with individually randomized trials, but none of such trials met inclusion criteria.

We considered that crossover trials would not be feasible for this intervention and consequently such trials were not included.

 

Dealing with missing data

For included studies, we noted levels of attrition in the Characteristics of included studies table. We analyzed outcomes on an intention-to-treat basis. If this was not clear from the original article then we carried out re-analysis where possible. Authors were contacted for missing data.

 

Assessment of heterogeneity

Heterogeneity of the results among studies was tested with the quantity I2, which describes the percentage of total variation across studies that is due to heterogeneity rather than chance (Higgins 2003). A value of 0% indicates no observed heterogeneity whereas I2 values of 50% or more indicate a substantial level of heterogeneity. We planned to pool data across studies using the fixed-effects model if substantial statistical heterogeneity was not present. If there was substantial heterogeneity (I2 values ≥50%), we used a random-effects model to pool data and made an attempt to identify potential sources of heterogeneity based on subgroup analysis by type of KMC, infant age at initiation of KMC, setting in which the trial was conducted, and risk of bias of trial.

 

Assessment of reporting biases

We assessed publication and related biases visually by examining the symmetry of funnel plots and statistically by using the Egger test (Egger 1997). The larger the deviation of the intercept of the regression line from zero, the greater was the asymmetry and the more likely it was that the meta-analysis would yield biased estimates of effect. We considered P < 0.1 to indicate significant asymmetry, as suggested by Egger.

 

Data synthesis

We performed statistical analyses using the Review Manager software (RevMan 2008). We analyzed outcomes on an intention-to-treat basis. If data for similar outcomes from two or more separate studies were available, we combined data in a meta-analysis and calculated a typical RR or MD with associated 95% CIs.

 

Subgroup analysis and investigation of heterogeneity

Pre-specified subgroup analyses for the primary outcome mortality at discharge or 40 - 41 weeks' corrected gestational age and at latest follow up were performed according to type of KMC (intermittent versus continuous), infant age at initiation of KMC (≤ 10 days versus > 10 days), setting in which the trial was conducted (low/middle-income countries versus high-income countries), and infant stabilization status at trial entry (before versus after). For all outcomes in stabilized LBW infants we performed subgroup analyses according to type of KMC (intermittent versus continuous). We also compared early onset KMC (starting within 24 hours post-birth) with late onset KMC (starting after 24 hours post-birth).

It was not possible to perform the planned subgroup analyses according to birthweight, gestational age, and type of LBW due to limited availability of information.

 

Sensitivity analysis

A planned sensitivity analysis was carried out to explore the impact of risk of bias on the general direction of findings or the size of the treatment effect for the main outcomes where more than one study contributed data. This was performed by excluding trials with high risk of bias in their results as judged by the reviewers. For the primary outcomes "mortality at discharge or 40 - 41 weeks' corrected gestational age", "mortality at latest follow up", ''severe infection/sepsis at latest follow up", and "infant growth", we performed sensitivity analyses by excluding trials with unclear allocation concealment and high levels of attrition (> 20%).

 

Results

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. What's new
  11. History
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms
 

Description of studies

See: Characteristics of included studies; Characteristics of excluded studies; Characteristics of studies awaiting classification.

See Characteristics of included studies; Characteristics of excluded studies; Characteristics of studies awaiting classification.

 

Results of the search

In previous versions of this review (Conde-Agudelo 2000; Conde-Agudelo 2003), we included three trials (Cattaneo 1998; Charpak 1997; Sloan 1994) and excluded 11 (Arandia 1993; Bergman 1994; Charpak 1994; Chwo 2002; Dala Sierra 1994; Feldman 2002; Kambarami 1998; Legault 1995; Ohgi 2002; Ramanathan 2001; Roberts 2000 ). For this update, the search strategy identified a further 38 reports, representing 35 studies for possible inclusion. Eleven new studies were included (Ali 2009; Blaymore Bier 1996; Boo 2007; Gathwala 2008; Kadam 2005; Nagai 2010; Neu 2010; Rojas 2003; Suman 2008; Whitelaw 1988; Worku 2005), and another 24 studies were excluded (Ahn 2010; Anderson 2003; Bergman 2004; Chiu 2009; Christensson 1998; Darmstadt 2006; de Almeida 2010; de Macedo 2007; Hake Brooks 2008; Huang 2006; Ibe 2004; Kumar 2008; Lai 2006; Lamy Filho 2008; Legault 1993; Lincetto 2000; Ludington-Hoe 1991; Ludington-Hoe 2000; Ludington-Hoe 2004; Ludington-Hoe 2006; Miles 2006; Miltersteiner 2005; Sloan 2008; Tallandini 2006). In addition, two trials that were excluded in the original review (Ramanathan 2001; Roberts 2000) because they did not evaluate continuous KMC, were now included because we have considered trials evaluating intermittent KMC for inclusion in this update. Finally, two papers by Tessier et al (published in 2003 and 2009) and one by Gathwala et al (published in 2010), reported additional results of previously included studies (Charpak 1997 and Gathwala 2008, respectively).

 

Included studies

Sixteen studies, including 2518 infants, fulfilled inclusion criteria of which 14 evaluated KMC in LBW infants after stabilization (Ali 2009; Blaymore Bier 1996; Boo 2007; Cattaneo 1998; Charpak 1997; Gathwala 2008; Kadam 2005; Neu 2010; Ramanathan 2001; Roberts 2000; Rojas 2003; Sloan 1994; Suman 2008; Whitelaw 1988), one evaluated KMC in LBW infants before stabilization (Worku 2005), and one compared early onset KMC with late onset KMC (Nagai 2010) in relatively stable LBW infants. Eleven studies were conducted in low or middle-income countries (India [Ali 2009; Gathwala 2008; Kadam 2005; Ramanathan 2001; Suman 2008]; Ethiopia [Cattaneo 1998, Worku 2005]; Malaysia [Boo 2007]; Madagascar [Nagai 2010]; Indonesia [Cattaneo 1998]; Ecuador [Sloan 1994]; Colombia [Charpak 1997]; and Mexico [Cattaneo 1998]) and five in high-income countries (United States [Blaymore Bier 1996; Neu 2010; Rojas 2003]; United Kingdom [Whitelaw 1988]; and Australia [Roberts 2000]). The sample size ranged from 28 (Ramanathan 2001) to 777 (Charpak 1997) (median, 100). Five studies included infants from multiple pregnancies (Ali 2009; Blaymore Bier 1996; Boo 2007; Charpak 1997; Whitelaw 1988). Infants with major congenital malformations or severe perinatal complications, and parental refusal to participate in the study were reported as exclusion criteria in the great majority of included studies.

Five studies did not provide data on percentage of LBW infants that met eligibility criteria. Among studies conducted in low or middle-income countries, 43% (Boo 2007) to 81% (Ali 2009) of LBW infants met eligibility criteria whereas in studies conducted in high-income countries the percentages ranged from 19% (Rojas 2003) to 50% (Whitelaw 1988). The mean or median age of LBW infants at enrollment varied from 10 hours (Worku 2005) to 32 days (Roberts 2000) (median, nine days). Median or mean infant age at enrollment was ≤10 days in eight studies (Ali 2009; Cattaneo 1998; Charpak 1997; Gathwala 2008; Kadam 2005; Nagai 2010; Suman 2008; Worku 2005;), 11 to 20 days in five studies (Ramanathan 2001; Neu 2010; Rojas 2003; Sloan 1994; Whitelaw 1988), and 20 to 32 days in three studies (Blaymore Bier 1996; Boo 2007; Roberts 2000). In the study that compared early onset KMC with late onset KMC (Nagai 2010), the mean age at initiation of KMC was 19.8 hours in the early onset KMC group and 33.0 hours in the late onset KMC. The mean or median weight of infants at recruitment ranged from 968 g (Blaymore Bier 1996) to 2076 g (Nagai 2010) (median, 1595 g).

The trials were conducted under a variety of hospital conditions, regulations, and routines. However, there was remarkable consistency in the descriptions of the KMC intervention across the trials. In all instances, the intervention included SSC and encouraged breastfeeding. Early neonatal discharge from hospital was only considered in the Colombian study (Charpak 1997). Among studies evaluating KMC in stabilized LBW infants, 11 used intermittent KMC (Ali 2009; Blaymore Bier 1996; Boo 2007; Gathwala 2008; Kadam 2005; Neu 2010; Ramanathan 2001; Roberts 2000; Rojas 2003; Suman 2008; Whitelaw 1988) and three used continuous KMC (Cattaneo 1998; Charpak 1997; Sloan 1994). A detailed definition of stabilization was provided in only one study (Nagai 2010). The mean or median duration of KMC per day was < 2 hours in six studies (Boo 2007; Blaymore Bier 1996; Neu 2010; Roberts 2000; Rojas 2003; Whitelaw 1988), four to eight hours in two studies (Ali 2009; Ramanathan 2001), 10 to 14 hours in three studies (Gathwala 2008; Kadam 2005; Suman 2008), and ≥ 20 hours in three studies (Cattaneo 1998; Charpak 1997; Sloan 1994). The studies that evaluated KMC in LBW infants before stabilization (Worku 2005) and compared early onset KMC with late onset KMC (Nagai 2010) used continuous KMC. In studies evaluating intermittent KMC, the intervention was a combination of SSC and radiant warmer/incubator. The standard neonatal care included infant stay in incubator only (Blaymore Bier 1996; Boo 2007; Charpak 1997; Neu 2010; Roberts 2000; Rojas 2003; Whitelaw 1988) or in radiant warmer only (Ali 2009; Kadam 2005; Suman 2008; Worku 2005) or in incubator or radiant warmer (Cattaneo 1998; Gathwala 2008; Ramanathan 2001; Sloan 1994). Information provided to mothers in the conventional neonatal care group on promotion of breastfeeding and facilitation and promotion of maternal involvement in the care of the neonate, which are critical for the outcomes measured, was not reported in five trials (Blaymore Bier 1996; Charpak 1997; Nagai 2010; Suman 2008; Worku 2005).

The main characteristics of the included studies are shown in the table Characteristics of included studies.

 

Excluded studies

We excluded 33 studies: 14 (Ahn 2010; Arandia 1993; Bergman 1994; Charpak 1994; Dala Sierra 1994; de Almeida 2010; de Macedo 2007; Feldman 2002; Ibe 2004; Lamy Filho 2008; Legault 1995; Lincetto 2000; Ohgi 2002; Tallandini 2006) because they were non-randomized trials, seven (Anderson 2003; Chiu 2009; Chwo 2002; Hake Brooks 2008; Huang 2006; Lai 2006; Sloan 2008) because they included infants with birthweight ≥ 2500 g and did not report results separately for subgroup of infants with birthweight < 2500 g, five (Bergman 2004; Ludington-Hoe 1991; Ludington-Hoe 2000; Ludington-Hoe 2004; Ludington-Hoe 2006) because they reported only physiological outcomes, two (Kambarami 1998; Miltersteiner 2005) because the method of generation of allocation to treatment was quasi-randomized, two (Darmstadt 2006; Kumar 2008) because KMC was part of a preventive package of interventions for essential newborn care, two (Legault 1993; Miles 2006) because allocation was by a crossover design, and one (Christensson 1998) because it evaluated only KMC for rewarming hypothermic infants.

The main characteristics of the excluded studies are presented in the table Characteristics of excluded studies.

 

Risk of bias in included studies

The risk of bias in included studies is depicted in Figure 1 and Figure 2. Only one study (Nagai 2010) was considered to be free of main sources of bias. The methodological quality of the included trials was mixed and we have carried out a sensitivity analysis to examine the impact of excluding trials at high risk of bias. See Sensitivity analysis. The main threats to validity were performance bias (by the lack of blinding of participants, clinicians, and assessors) and selection bias (by the lack of information on methods used for concealment of treatment allocation).

 FigureFigure 1. Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
 FigureFigure 2. Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

 

Allocation

Most of the included studies used adequate methods to generate allocation sequence. Random number tables were used in seven studies (Cattaneo 1998; Charpak 1997; Gathwala 2008; Ramanathan 2001; Rojas 2003; Sloan 1994; Worku 2005) and shuffling envelopes in four studies (Blaymore Bier 1996; Boo 2007; Roberts 2000; Whitelaw 1988). Other methods of sequence generation used were computer random number generator (Neu 2010), minimization computerized technique (Nagai 2010), block randomization technique (Ali 2009), sealed envelope method (Kadam 2005), and simple randomization (Suman 2008).

Sealed envelopes were used in seven studies (Boo 2007; Kadam 2005; Neu 2010; Roberts 2000; Rojas 2003; Suman 2008; Whitelaw 1988) for concealment of treatment allocation although only in three studies (Neu 2010; Rojas 2003; Whitelaw 1988) it was explicitly stated the envelopes were opaque, sealed and numbered. Allocation was concealed by using a software that provided automatically random allocation (minimization method) in only one study (Nagai 2010). The method of allocation concealment was not reported in eight studies (Ali 2009; Blaymore Bier 1996; Cattaneo 1998; Charpak 1997; Gathwala 2008; Ramanathan 2001; Sloan 1994; Worku 2005).

 

Blinding

Since KMC cannot be implemented masked, there was lack of blinding of participants and clinical staff in all included studies. Only one study (Nagai 2010) reported that a neonatologist who was masked to allocation of participants and did not have any contact with participants, independently determined the classification of morbidities based on the interview records and medical charts. Neu 2010 reported that four researchers assessed outcome measures of which two were blinded to the hypotheses of the study but not to group assignment of the mother-infant dyads. The other two researchers were blinded to group assignment and hypotheses. The remaining trials did not state if any attempt was made to "blind" outcome assessment.

We consider that performance and observer bias cannot be excluded due to the lack of blinding of participants and clinicians. However, while this could affect the assessment of subjective outcomes such as parental and familiar satisfaction, mother-infant attachment, and social and home environment, or objective outcomes such as breastfeeding, length of hospital length, and readmission to hospital after discharge, it is much less likely to have affected the primary outcomes of this review (infant mortality, severe infection/sepsis, severe illness, infant growth, and neurodevelopmental disability) and some secondary outcomes (nosocomial infection, mild/moderate infection or illness, and hypothermia).

 

Incomplete outcome data

Six trials had no losses to follow up or exclusions post-randomization (Kadam 2005; Nagai 2010; Ramanathan 2001; Roberts 2000; Rojas 2003; Whitelaw 1988). In five studies, 2 to 10% of recruited infants were lost to follow up (Ali 2009Blaymore Bier 1996; Charpak 1997; Gathwala 2008; Sloan 1994). In the study by Boo 2007, 12.3% of infants in the KMC group were excluded because SSC sessions were carried out on less than 50% of hospital stay days after recruitment. Two trials (Cattaneo 1998; Worku 2005) did not report the number of infants lost to follow up or excluded after randomization. The study by Suman 2008 had a high risk of attrition bias because 22.3% of infants were lost to follow up. Moreover, there was imbalance in numbers for losses to follow up across intervention groups (KMC 10.2%; control 33.9%). In addition, 6.4% of infants were omitted from reports of analyses because they did not receive assigned care. The Neu 2010 study also had high risk of attrition bias because 9.2% of infants were lost to follow up and 16.1% were excluded post-randomization.

 

Selective reporting

No study protocols were available. We compared outcomes listed in the Methods section of the articles with those reported in the Results section. Eleven studies (Blaymore Bier 1996; Boo 2007; Cattaneo 1998; Charpak 1997; Gathwala 2008; Kadam 2005; Nagai 2010; Neu 2010; Roberts 2000; Rojas 2003; Suman 2008) reported all outcomes listed in the Methods section and we assume that the reports probably included all of the pre-specified variables. In two studies (Ali 2009; Worku 2005) there was a high risk of bias due to selection outcome reporting. Worku 2005 did not report the great majority of outcomes listed in the Methods section such as mild/moderate and severe illness, sepsis, diarrhea, pneumonia, aspiration, weight gain, and mother's feelings. In Ali 2009, non-significant results such as infant mortality (primary outcome), and weight, length, and head circumference at discharge and follow up (secondary outcomes) were mentioned but not reported adequately. In the remaining three studies some secondary outcomes listed in the Methods section were not reported (Ramanathan 2001) or mentioned but not reported adequately (Sloan 1994; Whitelaw 1988).

 

Other potential sources of bias

We did not identify other potential sources of biases in 11 studies (Blaymore Bier 1996; Boo 2007; Gathwala 2008; Kadam 2005; Nagai 2010; Neu 2010; Ramanathan 2001; Roberts 2000; Rojas 2003; Whitelaw 1988; Worku 2005). Two studies (Ali 2009; Charpak 1997) used blocked randomization for sequence generation. When blocked randomization is used in an unblinded trial, and when the assignments are revealed subsequent to the person recruiting into the trial, then it is sometimes possible to predict future assignments. This is particularly the case when blocks are of a fixed size. In Cattaneo 1998, randomization was carried out in blocks of six and stratifying by weight in one of the three participating centers. The trial performed by Sloan 1994 was stopped early because a highly significant difference in severe morbidity was found at two and six months. Randomized controlled trials that are stopped early are more likely to be associated with greater effect sizes than randomized controlled trials not stopped early (Bassler 2010). This difference is independent of the presence of statistical stopping rules and is greatest in smaller studies. In the study by Suman 2008, the groups were significantly different at baseline in weight and age at enrollment.

 

Effects of interventions

The comparison between KMC and conventional neonatal care included 15 studies (2445 infants) and 47 outcomes, of which 23 were reported in more than one study. One study (73 infants), with eight outcomes, was included for the comparison early onset KMC versus late onset KMC.

 

Comparison 1: KMC versus conventional neonatal care

 

1. Mortality (outcomes 1.1 - 1.4)

Seven trials (1614 infants) reported on mortality at discharge or 40 - 41 weeks’ postmenstrual age, two (354 infants) on mortality at six months of age or six months follow up, 1 (693 infants) on mortality at 12 months’ corrected age, and nine (1952 infants) on mortality at latest follow up. Overall, KMC was associated with a statistically significant reduction in the risk of mortality at discharge or 40 - 41 weeks’ postmenstrual age (3.4% vs 5.7%; typical RR 0.60, 95% CI 0.39 to 0.93; I2 = 0%; NNT for benefit 43, 95% CI 28 to 251) (Figure 3), and at latest follow up (4.7% vs 7.1%; typical RR 0.68, 95% CI 0.48 to 0.96; I2 = 0%; NNT for benefit 44, 95% CI 27 to 353) (Figure 4). The significantly decreased risk of death at discharge or 40 - 41 weeks’ postmenstrual age, and at latest follow up was also demonstrated in the subgroup of studies that used continuous KMC (mortality at discharge or 40 - 41 weeks’ postmenstrual age: three trials, 1117 infants; typical RR 0.60, 95% CI 0.38 to 0.96; I2 = 0%; mortality a latest follow up: four trials, 1384 infants; typical RR 0.67, 95% CI 0.46 to 0.98; I2 = 0%), the subgroup of studies in which KMC was initiated within 10 days post-birth (mortality at discharge or 40 - 41 weeks’ corrected gestational age: five trials, 1426 infants; typical RR 0.57, 95% CI 0.36 to 0.89; I2 = 0%; mortality a latest follow up: five trials, 1410 infants; typical RR 0.57, 95% CI 0.37 to 0.86; I2 = 0%), the subgroup of studies conducted in low/middle income countries (mortality at discharge or 40 - 41 weeks’ corrected gestational age: six studies, 1554 infants; typical RR 0.58, 95% CI 0.37 to 0.90; I2 = 0%; mortality a latest follow up: seven trials, 1821 infants; typical RR 0.65, 95% CI 0.45 to 0.93; I2 = 0%), and the trial in which KMC was used in unstabilized infants (RR 0.57, 95% CI 0.33 to 1.00). The beneficial effect of KMC on both mortality at discharge or 40 - 41 weeks’ corrected gestational age and mortality at latest follow up was not demonstrated in the subgroup of trials that used intermittent KMC, or that initiated KMC after 10 days post-birth, or that were conducted in high-income countries, or that used KMC in stabilized infants.

 FigureFigure 3. Forest plot of comparison: 1 Kangaroo mother care versus conventional neonatal care, outcome: 1.1 Mortality at discharge or 40-41 weeks' corrected gestational age.
 FigureFigure 4. Forest plot of comparison: 1 Kangaroo mother care versus conventional neonatal care, outcome: 1.4 Mortality at latest follow up.

In the sensitivity analysis limited to the studies with low risk of attrition bias, there was a similar reduction in mortality at discharge or 40 - 41 weeks’ postmenstrual age, and at latest follow up although this was not statistically significant (mortality at discharge or 40 - 41 weeks’ postmenstrual age: six trials; typical RR 0.65, 95% CI 0.42 to 1.01; I2 = 0%; mortality at latest follow up: eight trials; typical RR 0.71, 95% CI 0.50 to 1.01; I2 = 0%). Similar results were obtained when we excluded studies with unclear method of allocation concealment (mortality at discharge or 40 - 41 weeks’ postmenstrual age: five studies; typical RR 0.60, 95% CI 0.20 to 1.85; I2 = 0%; mortality at latest follow up: five studies; typical RR 0.69, 95% CI 0.26 to 1.79; I2 = 0%).

There was no overall difference in the risk of mortality at six months of age or 6 months follow up ( Analysis 1.2), and at 12 months’ corrected age ( Analysis 1.3) between KMC infants and controls.

 

2. Infection/illness (outcomes 1.5 - 1.12)

In stabilized LBW infants, KMC was associated with a statistically significant reduction in severe infection/sepsis at latest follow up (7.2% vs 12.6%; typical RR 0.57, 95% CI 0.40 to 0.80; I2 = 7%; NNT for benefit 19, 95% CI 13 to 40; six trials, 1250 infants) (Figure 5), severe illness at six months follow up (5.3% vs 17.8%; RR 0.30, 95% CI 0.14 to 0.67; NNT for benefit 8, 95% CI 7 to 17; one trial, 283 infants) ( Analysis 1.6), nosocomial infection/sepsis at discharge or 40 - 41 weeks’ corrected gestational age (4.2% vs 10.1%; typical RR 0.42, 95% CI 0.24 to 0.73; I2 = 0%; NNT for benefit 17, 95% CI 13 to 37; two trials, 777 infants) ( Analysis 1.7), lower respiratory tract disease at six months follow up (4.6% vs 12.5%; RR 0.37, 95% CI 0.15 to 0.89; NNT for benefit 13, 95% CI 9 to 73; one trial, 283 infants) ( Analysis 1.9), and hypothermia at discharge or 40 - 41 weeks' corrected gestational age (7.6% vs 32.0%; typical RR 0.23, 95% CI 0.10 to 0.55; I2 = 56%; NNT for benefit 4, 95% CI 3 to 7; four trials, 469 infants; ) ( Analysis 1.11).

 FigureFigure 5. Forest plot of comparison: 1 Kangaroo mother care versus conventional neonatal care, outcome: 1.5 Severe infection/sepsis at latest follow up - stabilized infants.

The significantly reduced risk of severe infection/sepsis at latest follow up and hypothermia was demonstrated in the subgroup of trials that used intermittent KMC but not in the subgroup of trials that used continuous KMC. The reduced risk of nosocomial infection/sepsis at discharge or 40 - 41 weeks’ postmenstrual age was statistically significant in the subgroups of trials that used either intermittent or continuous KMC. 

There was no overall difference in the risk of mild/moderate infection or illness at latest follow up (typical RR 1.28, 95% CI 0.87 to 1.88) ( Analysis 1.8), diarrhea at six months follow up (RR 0.65, 95% CI 0.35 to 1.20) ( Analysis 1.10), and readmission to hospital (typical RR 0.60, 95% CI 0.34 to 1.06) ( Analysis 1.12) between KMC infants and controls.

Sensitivity analysis using only studies with adequate allocation concealment demonstrated a similar result for severe infection/sepsis at latest follow up (typical RR 0.51, 95% CI 0.29 to 0.88; I2 = 16%) and hypothermia (typical RR 0.26, 95% CI 0.10 to 0.67; I2 = 63%). An additional sensitivity analysis did not indicate that removing the study with high risk of attrition bias (Suman 2008) had any important impact on overall effects of KMC on severe infection/sepsis at latest follow up (typical RR 0.64, 95% CI 0.44 to 0.92; I2 = 0%) and hypothermia (typical RR 0.33, 95% CI 0.18 to 0.59; I2 = 40%).

 

3. Infant growth (outcomes 1.13 - 1.24)

KMC infants gained more weight per day (typical MD 3.9 g, 95% CI 1.9 to 5.8; nine trials, 936 infants) (Figure 6), and length (typical MD 0.29 cm, 95% CI 0.27 to 0.31; two trials, 251 infants) ( Analysis 1.17) and head circumference (typical MD 0.18 cm, 95% CI 0.09 to 0.27; three trials, 369 infants) ( Analysis 1.21) per week than controls. Moreover, one trial (Charpak 1997) reported that KMC infants had a larger head circumference at six months' corrected age than controls (MD 0.34 cm, 95% CI 0.11 to 0.57; 592 infants) ( Analysis 1.23). Nevertheless, there was considerable heterogeneity (I2 = 88%) among trials reporting weight gain. No differences were observed in weight, length, or head circumference at discharge or 40 - 41 weeks' postmenstrual age ( Analysis 1.14;  Analysis 1.18;  Analysis 1.22) or at 12 months' corrected age ( Analysis 1.16;  Analysis 1.20;  Analysis 1.24), or in weight or length at six months’ corrected age ( Analysis 1.15;  Analysis 1.19). Sloan 1994 reported "there were no significant differences between the groups in growth indices during the six month follow up".

 FigureFigure 6. Forest plot of comparison: 1 Kangaroo mother care versus conventional neonatal care, outcome: 1.13 Weight gain at latest follow up (g/day) - stabilized infants.

We undertook sensitivity analysis by excluding studies with unclear allocation concealment and high risk of attrition bias to examine the impact on gain of both weight and head circumference. There were no differences in the overall direction of the findings.

 

4. Neurodevelopmental disability (outcomes 1.25 - 1.28)

Only one study (Charpak 1997) reported neurodevelopmental results at one year of corrected age. No statistically significant differences were found between KMC infants and controls in Griffith quotients for psychomotor development ( Analysis 1.25), cerebral palsy ( Analysis 1.26), deafness ( Analysis 1.27), and visual impairment ( Analysis 1.28). A secondary publication of the Charpak 1997 trial reported that subgroup of KMC infants with birthweight ≤1800 g had a higher general developmental quotient than controls at one year of corrected age (P < 0.01).

 

5. Breastfeeding (outcomes 1.29 - 1.37)

Mothers of KMC infants were more likely to be breastfeeding at discharge or 40 - 41 weeks' corrected gestational age and at 1 - 3 months follow up than mothers in the control group. Compared with conventional care, KMC was associated with an increase in the likelihood of exclusive breastfeeding at discharge or 40 - 41 weeks' postmenstrual age (67.4% vs 56.8%; typical RR 1.21, 95% CI 1.08 to 1.36; I2 = 57%; four studies, 1197 mothers) ( Analysis 1.29) and at 1 - 3 months follow up (86.9% vs 76.5%; typical RR 1.20, 95% CI 1.01 to 1.43; I2 = 76%; five studies, 600 mothers) ( Analysis 1.30) or any (exclusive and/or partial) breastfeeding at discharge or 40 - 41 weeks' postmenstrual age (88.4% vs 74.8%; typical RR 1.25, 95% CI 1.06 to 1.47; I2=84%; eight studies, 1440 mothers) ( Analysis 1.32), at 1 - 2 months follow up (77.9% vs 67.9%; typical RR 1.33, 95% CI 1.00 to 1.78; I2 = 78%; six studies, 538 mothers) ( Analysis 1.33), and at three months follow up (79.7% vs 69.8%; typical RR 1.14, 95% CI 1.06 to 1.23; I2 = 41%; five studies, 924 mothers) ( Analysis 1.34). However, it is noted that there was substantial heterogeneity (I2 > 50%) among trials reporting breastfeeding. No statistically significant differences were seen for exclusive or any breastfeeding at 6 - 12 months follow up ( Analysis 1.31; Analysis 1.35;  Analysis 1.36), and onset of breastfeeding ( Analysis 1.37).

The statistically significant positive effects of KMC on breastfeeding were demonstrated in the subgroup of trials that used intermittent KMC but not in the subgroup of trials that used continuous KMC. In addition, the increase in the likelihood of any breastfeeding at 1 - 2 months follow up was also demonstrated in the subgroup of three trials (131 infants) conducted in high income countries (typical RR 2.02, 95% CI 1.28 to 3.21; I2 = 23%).

 

6. Length of hospital stay (outcome 1.38)

KMC decreased length of hospital stay by 2.4 days (95% CI 0.7 to 4.1) in a meta-analysis of nine studies that used intermittent KMC ( Analysis 1.38). The mean hospital stay from randomization to 41 weeks' postmenstrual age was 4.5 days for KMC infants and 5.6 for control infants in the Charpak 1997 study. No standard deviations were provided. Cattaneo 1998 only reported median hospital stay, which was 11 days in the KMC group, compared to 13 days in the control group. Length of hospital stay was two days greater in KMC infants than in control infants in the Sloan 1994 study.

 

7. Parental and familiar satisfaction (outcome 1.39)

Only one study (Cattaneo 1998) evaluated parental and familiar satisfaction with method of infant care. Mothers of the KMC group were more satisfied with method of care than mothers of the control group (91% versus 78%; RR 1.17, 95% CI 1.05 to1.30; 269 mothers) ( Analysis 1.39). There were no significant differences in satisfaction with method of care between fathers and families of KMC and control groups.

 

8. Mother-infant attachment or interaction (outcomes 1.40 - 1.46)

Three studies (Charpak 1997; Gathwala 2008; Roberts 2000) reported results about mother-infant attachment, and one (Neu 2010) on mother-infant interaction.

A secondary publication of the Charpak 1997 trial reported two series of outcomes that were assessed as manifestations of mother-infant attachment. The first was the mother's feelings and perceptions of her premature birth experience, measured through a "mother's perception of premature birth questionnaire" using a Likert scale (1 to 5), 24 hours after birth and when the infant reached 41 weeks' postmenstrual age. The second outcome was derived from observations made of the mother and child's responsiveness to each other during breastfeeding, using a "nursing child assessment feeding scale". A total of nine items were compared between KMC and control group according to interval between birth and start of intervention (1 - 2 days, 3 - 14 days, and > 14 days) and admission of infant to neonatal intensive care unit (NICU) (yes or not) for a total of 45 comparisons. Overall, scores of six comparisons (mother's sense of competence [interval between birth and start of intervention of 1 - 2 days, infant admitted or not admitted to NICU], mother’s feelings of worry and stress [interval between birth and start of intervention of 1 - 2 days], mother’s sensitivity [interval between birth and start of intervention > 14 days], and infant responsiveness [interval between birth and start of intervention > 14 days] were significantly higher in KMC than in control group. Scores of two comparisons (mother’s perceptions of social support [interval between birth and start of intervention > 14 days, and infant not admitted to NICU] were significantly lower in KMC group than in control group. There were no significant differences in scores of the remaining 37 comparisons ( Analysis 1.40;  Analysis 1.41;  Analysis 1.42).

Gathwala 2008 evaluated mother-infant attachment at three months follow up through a structured maternal interview that used attachment questions scored in such a manner that a higher score indicated a greater attachment. The total attachment score in the KMC group (24.46 ± 1.64) was significantly higher than that obtained in the control group (18.22 ± 1.79) ( Analysis 1.43).   

Roberts 2000 measured maternal stress levels in NICU and mothers' perceptions of their maternal competence. Only the score on scale "relationship with the infant" was significantly higher in the KMC group (4.4 ± 0.46) than in control group (3.4 ± 1.16). There was no significant difference between the KMC and control groups' scores on nursery environment, infant appearance, staff behavior and communication, and parental confidence in their parenting abilities ( Analysis 1.44;  Analysis 1.45).

The trial by Neu 2010 evaluated the mother-infant interaction at six months of age by using the Stiil-Face Paradigm tool. Mother-infant dyads in the KMC group showed more symmetrical, and less asymmetrical coregulation than mother-infant dyads in the control group. ( Analysis 1.46). Multivariate analysis showed no differences between groups in infant vitality during the neutral face portion of the Stiil-Face procedure.

 

9. Home environment and father involvement (outcome 1.47)

One trial (Charpak 1997) evaluated home environment and father involvement at 12 months' corrected age through a structured interview administered to parents during a home visit. The total Home Observation for Measurement of the Environment (HOME) score was significantly higher in Kangaroo families (0.28 ± 0.24) than in conventional care families (-0.51 ± 0.26) ( Analysis 1.47). Scores on father involvement were not reported but authors claimed that KMC increased father involvement (father's sense of responsibility and competence).

 

10. Costs of care

No study reported data on mean (SD) total medical and non-medical costs. The overall cost was "about 50% less for KMC" in the Cattaneo 1998 study. Specifically, it was US$ 19,289 for KMC and US$ 39,764 for conventional care. In the Sloan 1994 study, "costs of neonatal care were greater in the control than in the KMC group". Overall, the cost of hospital stay and post-neonatal care at five months was US$ 741 greater for the control than KMC group. However, data were available for only 49 infants (24 KMC, 25 control) at six month follow up.

All funnel plots showed no asymmetry, either visually or in terms of statistical significance (P >.10 for all, by Egger test)

 

Comparison 2: Early onset versus late onset KMC in relatively stable infants

There was only one trial (Nagai 2010), considered as high quality, that compared early onset KMC versus late onset KMC in relatively stable LBW infants. Early continuous KMC was begun as soon as possible, within 24 hours post-birth, and late continuous KMC was begun after complete stabilization (generally after 24 hours post-birth). A total of 73 LBW infants (early 37, late 36) were included. No statistically significant differences were found between early onset KMC and late onset KMC for mortality (RR 1.95, 95% CI 0.18 to 20.53) ( Analysis 2.1), morbidity (RR 0.49, 95% CI 0.18 to 1.28) ( Analysis 2.2), severe infection (RR 0.42, 95% CI 0.12 to 1.49) ( Analysis 2.3), readmission to hospital (RR 1.95, 95% CI 0.18 to 20.53) ( Analysis 2.4), hypothermia (RR 0.58, 95% CI 0.15 to 2.27) ( Analysis 2.5), weight gain (MD 58.9 g, 95% CI -116.9 to 234.6) ( Analysis 2.6), and exclusive breastfeeding (RR 0.94, 95% CI 0.85 to 1.04) ( Analysis 2.7) at four weeks of age. However, compared with late onset KMC, early onset KMC was associated with a statistically significant reduction in body weight loss from birth to 48 hours post-birth (MD 43.3 g, 95% CI 5.5 to 81.1) ( Analysis 2.6) and length of hospital stay (MD -0.9 days, 95% CI -1.2 to -0.6) ( Analysis 2.8).

 

Discussion

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. What's new
  11. History
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms
 

Summary of main results

This updated systematic review of 15 randomized controlled trials comparing KMC and conventional neonatal care found compelling evidence that KMC is associated with a reduction in mortality at discharge or 40 - 41 weeks' postmenstrual age and at latest follow up, severe infection/sepsis, hypothermia, and length of hospital stay, and an increase in weight gain and exclusive or any breastfeeding at discharge or 40 - 41 weeks' postmenstrual age and at one to three months follow up. Moreover, there was some evidence that KMC reduces the risk of nosocomial infection/sepsis at discharge or 40 - 41 weeks’ corrected gestational age, and increases head circumference gain, maternal satisfaction with the method, maternal-infant attachment, and home environment. One trial (Charpak 1997) reported no significant differences between KMC infants and controls in a variety of neurodevelopmental outcomes at one year of corrected age.

Overall, continuous KMC led to a reduction in mortality at discharge or 40 - 41 weeks' postmenstrual age and at latest follow up, nosocomial infection/sepsis, severe illness, and lower respiratory tract disease, and an increase in weight gain, maternal satisfaction with the method, and some measures of mother-infant attachment and home environment. On the other hand, intermittent KMC was associated with a decrease in the risk of severe infection/sepsis, nosocomial infection/sepsis, hypothermia, and length of hospital stay, and an increase in weight, length, and head circumference gain, exclusive or any breastfeeding at discharge or 40 - 41 weeks' postmenstrual age and at one to three months follow up, and mother-infant attachment at three months follow up.

Subgroup analyses showed that decreased risk of death at discharge or 40 - 41 weeks' postmenstrual age and at latest follow up was demonstrated in the subgroup of trials in which KMC was initiated within 10 days post-birth, the subgroup of trials conducted in low/middle-income countries, and the trial in which KMC was used in unstabilized infants. Sensitivity analysis suggested that the inclusion of studies with high risk of bias did not affect the general direction of findings or the size of the treatment effect although the beneficial effect of KMC on mortality turned non significant.

One small high quality trial (Nagai 2010) suggested that early onset KMC, compared with late onset KMC, is associated with a significant reduction in body weight loss from birth to 48 hours post-birth and length of hospital stay, with no significant difference in mortality, morbidity, severe infection, readmission to hospital, hypothermia, and exclusive breastfeeding at four weeks of age.

 

Overall completeness and applicability of evidence

The participants in the included trials reflect the population for which this intervention is currently considered, that is LBW infants. Eleven trials, including all four trials that evaluated continuous KMC, were conducted in hospitals in low/middle income countries. Mortality at discharge was the only outcome reported in the sole trial (Worku 2005) that compared KMC with conventional neonatal care in LBW infants before stabilization. The remaining 46 outcomes were reported in 14 trials that evaluated KMC in stabilized LBW infants. We were unable to draw conclusions about the effectiveness of KMC in unstabilized LBW infants. Given these factors, the great majority of results of our meta-analysis can only be applied in stabilized LBW infants in low/middle-income countries. However, the beneficial effect of KMC on any breastfeeding at one to two months follow up was also found in stabilized LBW infants in high income countries.

As only a small trial compared early onset KMC with late onset KMC, firm conclusions cannot be drawn on any apparent differences between these two managements.

The effect of community-based KMC on overall neonatal mortality, infant mortality, and LBW neonatal mortality was assessed in one randomized controlled cluster trial (Sloan 2008) in which 4165 infants in rural Bangladesh were assigned to community-based KMC or control without KMC. Unfortunately, this study was not included in the review because 40% overall and 65% of newborns who died were not weighed at birth, and missing birthweight was differential for study group. There was no difference in overall neonatal mortality rate or infant mortality rate. However, for infants whose modeled birthweight was ≤ 2000 g, the neonatal mortality rate was 9.5% in the community-based KMC group and 22.5% in the control group (adjusted odds ratio 0.37, 95% CI 0.16 to 0.86).

 

Quality of the evidence

We assessed risk of bias in included studies by addressing six specific domains (sequence generation, allocation concealment, blinding, incomplete outcome data, selective outcome reporting, and other potential sources of bias) discussed in the section Risk of bias in included studies. Eight studies were judged by the reviewers to address adequately ≥ 4 domains (Blaymore Bier 1996; Boo 2007; Kadam 2005; Nagai 2010; Neu 2010; Roberts 2000; Rojas 2003; Whitelaw 1988). Four studies addressed adequately three domains (Charpak 1997; Gathwala 2008; Ramanathan 2001; Suman 2008) and four addressed adequately ≤ 2 domains (Ali 2009; Cattaneo 1998; Sloan 1994; Worku 2005).

Overall, the quality of the studies was mixed, although sensitivity analysis suggests that the inclusion of studies with high risk of bias did not affect the general direction of findings or the size of the treatment effect. Nevertheless, the lack of blinding of outcome assessors in most of the studies and the unclear method of allocation concealment might be a problem in terms of the overall quality of the evidence. Further progress must be made to improve research quality.

For some of the results described in the review (hypothermia, weight gain, breastfeeding, and length of hospital stay), there was evidence of high levels of statistical heterogeneity. Some of this heterogeneity may have occurred as a result of clinical heterogeneity; for example, different definitions of hypothermia used or women may not have been asked about breastfeeding in the same way in different trials. Results from meta-analysis with substantial heterogeneity should be interpreted cautiously.

 

Potential biases in the review process

We attempted to reduce bias in the reviewing process wherever possible. Two review authors independently assessed the risk of bias and the findings of the included studies. We tried to contact authors of studies with missing data with limited response. Despite differences in the timing of the outcome measurements among studies, we proceeded with the meta-analyses for several outcomes as the intervention effects were consistent among studies, although to varying degrees. About 50% of outcomes evaluated in the review were reported in only one study precluding drawing convincing conclusions on the effect of KMC on such outcomes.

The beneficial effects of KMC on mortality at discharge or 40 - 41 weeks' postmenstrual age and at latest follow up, severe infection/sepsis, and nosocomial infection found in our meta-analyses are enhanced by the impressive statistical homogeneity among trials (I2 = 0% to7%).

Up to now, only one study (Charpak 1997) reported neurodevelopmental results at one year of corrected age. Longer term assessments of neurodevelopmental outcomes have not been published yet, and some caution should perhaps be exercised in applying these findings at 12 months corrected age since it has been suggested that assessments done at a relatively young age may be insufficiently predictive of longer term neurodevelopmental outcomes, particularly with regard to cognitive functioning (Roberts 2010).

 

Agreements and disagreements with other studies or reviews

 

Previous versions of this review

Our assessment of the evidence differs from that used in previous versions of this review (Conde-Agudelo 2000; Conde-Agudelo 2003) which concluded that "there was insufficient evidence to recommend the routine use of KMC in LBW infants". In the current version of this review, we included 12 additional trials and more data from individual studies in meta-analyses, and performed subgroup analysis according to type of KMC (intermittent versus continuous) for all outcomes of the comparison KMC versus conventional neonatal care and sensitivity analysis according to risk of bias of included studies. Moreover, we have used the recent methodology introduced for Cochrane reviews in 2008, which assesses risk of bias in the individual studies more carefully than in the past (Higgins 2009).

The findings of the current version of this review allow us to conclude that there is sufficient evidence to recommend the use of KMC in stabilized LBW infants.

 

Other systematic reviews on KMC

Lawn 2010 performed a systematic review and meta-analysis to estimate the effect of KMC on neonatal mortality due to direct complications of preterm birth. This review included observational studies and excluded randomized controlled trials which initiated KMC after the first week of life. In the meta-analysis of randomized controlled trials, which included three studies (Charpak 1997; Suman 2008; Worku 2005) that provided data on neonatal specific mortality, KMC was associated with a reduction in neonatal death in infants < 2000 g (RR 0.49, 95% CI 0.29 to 0.82; I2 = 0%; 988 infants). In the meta-analysis of three observational studies, KMC was also associated with a decreased risk of neonatal death in infants < 2000 g (RR 0.68, 95% CI 0.58 to 0.79; I2 = 54%; 8151 infants). Other meta-analysis, which included five randomized controlled trials, showed that KMC reduced significantly the risk of severe morbidity (RR 0.34, 95% CI 0.17 to 0.65; I2 = 70%; 1520 infants). The results of the present review also suggest that KMC reduces the risk of mortality at discharge or 40 - 41 weeks' corrected gestational age and at latest follow up. However, our estimated effect was smaller than that of Lawn 2010. Differences in our findings compared to this review reflect the addition of more studies which reported mortality (all causes) from randomization until one year of corrected age.

 

Authors' conclusions

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. What's new
  11. History
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms

 

Implications for practice

The results of this updated review indicate that, currently, there is sufficient evidence to support the use of KMC in stabilized LBW infants as an alternative to conventional neonatal care in resource limited settings. Although current evidence is mainly limited to the use of KMC in low/middle income countries, there is emerging evidence that use of KMC could improve breastfeeding rates in high income countries. Subgroup analyses suggest that both continuous and intermittent KMC are beneficial for stabilized LBW infants. Since the control group in studies evaluating continuous KMC was in incubators or radiant warmers, the potential beneficial effects of KMC on morbidity and mortality of LBW infants would be expected to be greatest in settings in which conventional neonatal care is unavailable.

 
Implications for research

There are several areas which require further study in the light of the results of this review.

  • Methodologically rigorous trials are needed to further explore the effectiveness of early onset continuous KMC in unstabilized or relatively stabilized LBW infants in low income settings. Studies should provide detailed information on inclusion and exclusion criteria, methods used to generate and conceal the allocation sequence, measures used to blind outcome assessors to allocation of participants, completeness of outcome data for each main outcome (attrition and exclusions), definition of infant stabilization, infant age at initiation of KMC, frequency, daily duration and total duration of the intervention, and to report adequately all pre-specified outcomes in the study protocol.

  • Only five randomized controlled trials, including a total of 256 infants, which were conducted in developed countries and reported clinical outcome measures, met minimal inclusion criteria. (Blaymore Bier 1996; Neu 2010; Roberts 2000; Rojas 2003; Whitelaw 1988). Thereby, there is a clear need for randomized trials with an adequate sample size that evaluate the use of continuous or intermittent KMC in high income settings and report results mainly on infant morbidity.

  • Although some data are available on long term neurodevelopmental outcomes, continuing follow up and additional data of randomized children are justified as more subtle differences in later childhood may become apparent (Roberts 2010).

  • Further well-designed economic evaluations are needed to assess the cost-effectiveness of KMC in low, middle, and high income settings.

  • Further exploration of mother-infant attachment should be included in future trials as this element was inconsistently evaluated across studies.

  • Additional trials in different settings ensuring baseline comparability of mortality, adequate KMC implementation, and birthweight assessment are required to clarify the effect of community-based KMC on LBW neonatal mortality before implementation of community-based KMC programs or inclusion of community-based KMC in essential newborn care.

 

Acknowledgements

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. What's new
  11. History
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms

We thank the trial authors who provided additional information on request: Drs Charpak, Sloan, Ludington-Hoe, Neu, Suman, and Miltersteiner.

Editorial support of the Cochrane Neonatal Review Group has been funded with Federal funds from the Eunice Kennedy Shriver National Institute of Child Health and Human Development National Institutes of Health, Department of Health and Human Services, USA, under Contract No. HHSN267200603418C.

 

Data and analyses

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. What's new
  11. History
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms
Download statistical data

 
Comparison 1. Kangaroo mother care versus conventional neonatal care

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Mortality at discharge or 40-41 weeks' postmenstrual age7Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    1.1 All studies
71614Risk Ratio (M-H, Fixed, 95% CI)0.60 [0.39, 0.93]

    1.2 Intermittent KMC
4497Risk Ratio (M-H, Fixed, 95% CI)0.60 [0.20, 1.85]

    1.3 Continuous KMC
31117Risk Ratio (M-H, Fixed, 95% CI)0.60 [0.38, 0.96]

    1.4 Infant age ≤10 days at initiation of KMC
51426Risk Ratio (M-H, Fixed, 95% CI)0.57 [0.36, 0.89]

    1.5 Infant age >10 days at initiation of KMC
2188Risk Ratio (M-H, Fixed, 95% CI)1.32 [0.22, 7.73]

    1.6 Low/middle income countries
61554Risk Ratio (M-H, Fixed, 95% CI)0.58 [0.37, 0.90]

    1.7 High income countries
160Risk Ratio (M-H, Fixed, 95% CI)1.64 [0.16, 17.09]

    1.8 infant entered into trial before stabilization
1123Risk Ratio (M-H, Fixed, 95% CI)0.57 [0.33, 1.00]

    1.9 infant entered into trial after stabilization
61491Risk Ratio (M-H, Fixed, 95% CI)0.63 [0.32, 1.24]

 2 Mortality at 6 months of age or 6 months follow up2354Risk Ratio (M-H, Fixed, 95% CI)0.99 [0.48, 2.02]

    2.1 Intermittent
171Risk Ratio (M-H, Fixed, 95% CI)1.03 [0.15, 6.90]

    2.2 Continuous
1283Risk Ratio (M-H, Fixed, 95% CI)0.98 [0.46, 2.12]

 3 Mortality at 12 months' corrected age1693Risk Ratio (M-H, Fixed, 95% CI)0.57 [0.27, 1.17]

   3.1 Intermittent
00Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    3.2 Continuous
1693Risk Ratio (M-H, Fixed, 95% CI)0.57 [0.27, 1.17]

 4 Mortality at latest follow up9Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    4.1 All studies
91952Risk Ratio (M-H, Fixed, 95% CI)0.68 [0.48, 0.96]

    4.2 Intermittent KMC
5568Risk Ratio (M-H, Fixed, 95% CI)0.69 [0.26, 1.79]

    4.3 Continuous KMC
41384Risk Ratio (M-H, Fixed, 95% CI)0.67 [0.46, 0.98]

    4.4 Infant age ≤10 days at initiation of KMC
51410Risk Ratio (M-H, Fixed, 95% CI)0.57 [0.37, 0.86]

    4.5 Infant age >10 days at initiation of KMC
4542Risk Ratio (M-H, Fixed, 95% CI)1.03 [0.53, 2.00]

    4.6 Low/middle income countries
71821Risk Ratio (M-H, Fixed, 95% CI)0.65 [0.45, 0.93]

    4.7 High income countries
2131Risk Ratio (M-H, Fixed, 95% CI)1.25 [0.29, 5.42]

    4.8 infant entered into trial before stabilization
1123Risk Ratio (M-H, Fixed, 95% CI)0.57 [0.33, 1.00]

    4.9 infant entered into trial after stabilization
81829Risk Ratio (M-H, Fixed, 95% CI)0.73 [0.47, 1.14]

 5 Severe infection/sepsis at latest follow up - stabilized infants61250Risk Ratio (M-H, Fixed, 95% CI)0.57 [0.40, 0.80]

    5.1 Intermittent
5587Risk Ratio (M-H, Fixed, 95% CI)0.46 [0.28, 0.76]

    5.2 Continuous
1663Risk Ratio (M-H, Fixed, 95% CI)0.69 [0.43, 1.12]

 6 Severe illness at 6 months follow up - stabilized infants1283Risk Ratio (M-H, Fixed, 95% CI)0.30 [0.14, 0.67]

   6.1 intermittent
00Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    6.2 Continuous
1283Risk Ratio (M-H, Fixed, 95% CI)0.30 [0.14, 0.67]

 7 Nosocomial infection/sepsis at discharge or 40-41 weeks' postmenstrual age - stabilized infants2777Risk Ratio (M-H, Fixed, 95% CI)0.42 [0.24, 0.73]

    7.1 Intermittent
1114Risk Ratio (M-H, Fixed, 95% CI)0.30 [0.10, 0.86]

    7.2 Continuous
1663Risk Ratio (M-H, Fixed, 95% CI)0.49 [0.25, 0.93]

 8 Mild/moderate infection or illness at latest follow up - stabilized infants41266Risk Ratio (M-H, Random, 95% CI)1.28 [0.87, 1.88]

    8.1 Intermittent
2320Risk Ratio (M-H, Random, 95% CI)1.52 [0.43, 5.38]

    8.2 Continuous
2946Risk Ratio (M-H, Random, 95% CI)1.42 [0.53, 3.79]

 9 Lower respiratory tract disease at 6 months follow up - stabilized infants1283Risk Ratio (M-H, Fixed, 95% CI)0.37 [0.15, 0.89]

   9.1 Intermittent
00Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    9.2 Continuous
1283Risk Ratio (M-H, Fixed, 95% CI)0.37 [0.15, 0.89]

 10 Diarrhea at 6 months follow up - stabilized infants1283Risk Ratio (M-H, Fixed, 95% CI)0.65 [0.35, 1.20]

   10.1 Intermittent
00Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    10.2 Continuous
1283Risk Ratio (M-H, Fixed, 95% CI)0.65 [0.35, 1.20]

 11 Hypothermia at discharge or 40-41 weeks' postmenstrual age - stabilized infants4469Risk Ratio (M-H, Random, 95% CI)0.23 [0.10, 0.55]

    11.1 Intermittent
4469Risk Ratio (M-H, Random, 95% CI)0.23 [0.10, 0.55]

   11.2 Continuous
00Risk Ratio (M-H, Random, 95% CI)Not estimable

 12 Readmission to hospital at latest follow up - stabilized infants2946Risk Ratio (M-H, Fixed, 95% CI)0.60 [0.34, 1.06]

   12.1 Intermittent
00Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    12.2 Continuous
2946Risk Ratio (M-H, Fixed, 95% CI)0.60 [0.34, 1.06]

 13 Weight gain at latest follow up (g/day) - stabilized infants9936Mean Difference (IV, Random, 95% CI)3.86 [1.87, 5.84]

    13.1 Intermittent
8651Mean Difference (IV, Random, 95% CI)3.87 [1.67, 6.08]

    13.2 Continuous
1285Mean Difference (IV, Random, 95% CI)3.60 [0.78, 6.42]

 14 Weight at discharge or 40-41 weeks' postmenstrual age (g) - stabilized infants41097Mean Difference (IV, Fixed, 95% CI)21.65 [-15.98, 59.27]

    14.1 Intermittent
2149Mean Difference (IV, Fixed, 95% CI)63.54 [-2.58, 129.67]

    14.2 Continuous
2948Mean Difference (IV, Fixed, 95% CI)1.59 [-44.16, 47.34]

 15 Weight at 6 months' corrected age (g) - stabilized infants1591Mean Difference (IV, Fixed, 95% CI)78.19 [-52.26, 208.64]

   15.1 Intermittent
00Mean Difference (IV, Fixed, 95% CI)Not estimable

    15.2 Continuous
1591Mean Difference (IV, Fixed, 95% CI)78.19 [-52.26, 208.64]

 16 Weight at 12 months' corrected age (g) - stabilized infants1596Mean Difference (IV, Fixed, 95% CI)31.46 [-135.08, 198.00]

   16.1 Intermittent
00Mean Difference (IV, Fixed, 95% CI)Not estimable

    16.2 Continuous
1596Mean Difference (IV, Fixed, 95% CI)31.46 [-135.08, 198.00]

 17 Length gain at latest follow up (cm/week) - stabilized infants2251Mean Difference (IV, Fixed, 95% CI)0.29 [0.27, 0.31]

    17.1 Intermittent
2251Mean Difference (IV, Fixed, 95% CI)0.29 [0.27, 0.31]

   17.2 Continuous
00Mean Difference (IV, Fixed, 95% CI)Not estimable

 18 Length at discharge or 40-41 weeks' postmenstrual age (cm) - stabilized infants2720Mean Difference (IV, Fixed, 95% CI)0.06 [-0.28, 0.39]

    18.1 Intermittent
157Mean Difference (IV, Fixed, 95% CI)0.40 [-0.48, 1.28]

    18.2 Continuous
1663Mean Difference (IV, Fixed, 95% CI)Not estimable

 19 Length at 6 months' corrected age (cm) - stabilized infants1590Mean Difference (IV, Fixed, 95% CI)0.23 [-0.18, 0.64]

   19.1 Intermittent
00Mean Difference (IV, Fixed, 95% CI)Not estimable

    19.2 Continuous
1590Mean Difference (IV, Fixed, 95% CI)0.23 [-0.18, 0.64]

 20 Length at 12 months' corrected age (cm) - stabilized infants1586Mean Difference (IV, Fixed, 95% CI)0.31 [-0.17, 0.79]

   20.1 Intermittent
00Mean Difference (IV, Fixed, 95% CI)Not estimable

    20.2 Continuous
1586Mean Difference (IV, Fixed, 95% CI)0.31 [-0.17, 0.79]

 21 Head circumference gain at latest follow up (cm/week) - stabilized infants3369Mean Difference (IV, Random, 95% CI)0.18 [0.09, 0.27]

    21.1 Intermittent
3369Mean Difference (IV, Random, 95% CI)0.18 [0.09, 0.27]

   21.2 Continuous
00Mean Difference (IV, Random, 95% CI)Not estimable

 22 Head circumference at discharge or 40-41 weeks' postmenstrual age (cm) - stabilized infants2720Mean Difference (IV, Random, 95% CI)0.39 [-0.28, 1.07]

    22.1 Intermittent
157Mean Difference (IV, Random, 95% CI)0.80 [0.20, 1.40]

    22.2 Continuous
1663Mean Difference (IV, Random, 95% CI)0.10 [-0.14, 0.34]

 23 Head circumference at 6 months' corrected age (cm) - stabilized infants1592Mean Difference (IV, Fixed, 95% CI)0.34 [0.11, 0.57]

   23.1 Intermittent
00Mean Difference (IV, Fixed, 95% CI)Not estimable

    23.2 Continuous
1592Mean Difference (IV, Fixed, 95% CI)0.34 [0.11, 0.57]

 24 Head circumference at 12 months' corrected age (cm) - stabilized infants1597Mean Difference (IV, Fixed, 95% CI)0.39 [-0.00, 0.78]

   24.1 Intermittent
00Mean Difference (IV, Fixed, 95% CI)Not estimable

    24.2 Continuous
1597Mean Difference (IV, Fixed, 95% CI)0.39 [-0.00, 0.78]

 25 Psychomotor development (Griffith quotients) at 12 months' corrected age1Mean Difference (IV, Fixed, 95% CI)Subtotals only

    25.1 Locomotion
1579Mean Difference (IV, Fixed, 95% CI)2.25 [-0.45, 4.95]

    25.2 Personal, social
1579Mean Difference (IV, Fixed, 95% CI)0.97 [-1.27, 3.21]

    25.3 Hand-eye coordination
1579Mean Difference (IV, Fixed, 95% CI)0.57 [-1.25, 2.39]

    25.4 Audition, language
1579Mean Difference (IV, Fixed, 95% CI)1.29 [-0.98, 3.56]

    25.5 Execution
1579Mean Difference (IV, Fixed, 95% CI)0.30 [-1.50, 2.10]

    25.6 All criteria
1579Mean Difference (IV, Fixed, 95% CI)1.05 [-0.75, 2.85]

 26 Cerebral palsy at 12 months' corrected age1588Risk Ratio (M-H, Fixed, 95% CI)0.65 [0.21, 2.02]

 27 Deafness at 12 months' corrected age1588Risk Ratio (M-H, Fixed, 95% CI)0.30 [0.03, 2.90]

 28 Visual impairment at 12 months' corrected age1588Risk Ratio (M-H, Fixed, 95% CI)0.91 [0.53, 1.56]

 29 Exclusive breast feeding at discharge or 40-41 weeks' postmenstrual age - stabilized infants41197Risk Ratio (M-H, Random, 95% CI)1.21 [1.08, 1.36]

    29.1 Intermittent
2255Risk Ratio (M-H, Random, 95% CI)1.29 [1.15, 1.44]

    29.2 Continuous
2942Risk Ratio (M-H, Random, 95% CI)1.14 [0.92, 1.42]

 30 Exclusive breast feeding at 1-3 months follow up - stabilized infants5600Risk Ratio (M-H, Random, 95% CI)1.20 [1.01, 1.43]

    30.1 Intermittent
3221Risk Ratio (M-H, Random, 95% CI)1.36 [1.12, 1.65]

    30.2 Continuous
2379Risk Ratio (M-H, Random, 95% CI)1.03 [0.96, 1.10]

 31 Exclusive breast feeding at 6-12 months follow up - stabilized infants3810Risk Ratio (M-H, Fixed, 95% CI)1.29 [0.95, 1.76]

    31.1 Intermittent
175Risk Ratio (M-H, Fixed, 95% CI)1.52 [1.10, 2.10]

    31.2 Continuous
2735Risk Ratio (M-H, Fixed, 95% CI)1.10 [0.66, 1.86]

 32 Any breast feeding at discharge or 40-41 weeks' postmenstrual age - stabilized infants81440Risk Ratio (M-H, Random, 95% CI)1.25 [1.06, 1.47]

    32.1 Intermittent
6498Risk Ratio (M-H, Random, 95% CI)1.31 [1.11, 1.55]

    32.2 Continuous
2942Risk Ratio (M-H, Random, 95% CI)1.14 [0.93, 1.40]

 33 Any breast feeding at 1-2 months follow up - stabilized infants6538Risk Ratio (M-H, Random, 95% CI)1.33 [1.00, 1.78]

    33.1 Intermittent
4159Risk Ratio (M-H, Random, 95% CI)1.89 [1.30, 2.75]

    33.2 Continuous
2379Risk Ratio (M-H, Random, 95% CI)1.03 [0.96, 1.10]

 34 Any breast feeding at 3 months follow up - stabilized infants5924Risk Ratio (M-H, Fixed, 95% CI)1.14 [1.06, 1.23]

    34.1 Intermittent
4261Risk Ratio (M-H, Fixed, 95% CI)1.35 [1.15, 1.59]

    34.2 Continuous
1663Risk Ratio (M-H, Fixed, 95% CI)1.08 [1.00, 1.17]

 35 Any breast feeding at 6 months follow up - stabilized infants5952Risk Ratio (M-H, Fixed, 95% CI)1.12 [0.98, 1.29]

    35.1 Intermittent
3143Risk Ratio (M-H, Fixed, 95% CI)1.50 [1.08, 2.08]

    35.2 Continuous
2809Risk Ratio (M-H, Fixed, 95% CI)1.07 [0.92, 1.24]

 36 Any breast feeding at 12 months follow up - stabilized infants1589Risk Ratio (M-H, Fixed, 95% CI)0.89 [0.65, 1.21]

   36.1 Intermittent
00Risk Ratio (M-H, Fixed, 95% CI)Not estimable

    36.2 Continuous
1589Risk Ratio (M-H, Fixed, 95% CI)0.89 [0.65, 1.21]

 37 Onset of breast feeding (days) - stabilized infants2295Mean Difference (IV, Random, 95% CI)0.03 [-1.64, 1.70]

    37.1 Intermittent
2295Mean Difference (IV, Random, 95% CI)0.03 [-1.64, 1.70]

   37.2 Continuous
00Mean Difference (IV, Random, 95% CI)Not estimable

 38 Length of hospital stay (days) - stabilized infants9795Mean Difference (IV, Random, 95% CI)-2.41 [-4.11, -0.71]

    38.1 Intermittent
9795Mean Difference (IV, Random, 95% CI)-2.41 [-4.11, -0.71]

   38.2 Continuous
00Mean Difference (IV, Random, 95% CI)Not estimable

 39 Parental and familiar satisfaction (continuous KMC)1Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    39.1 Mother satisfied with method
1269Risk Ratio (M-H, Fixed, 95% CI)1.17 [1.05, 1.30]

    39.2 Father satisfied with method
1269Risk Ratio (M-H, Fixed, 95% CI)1.02 [0.91, 1.14]

    39.3 Family satisfied with method
1269Risk Ratio (M-H, Fixed, 95% CI)0.97 [0.83, 1.13]

 40 Mother-infant attachment: mother's feelings and perceptions according to interval between birth and start of intervention, and infant admission to NICU1Mean Difference (IV, Fixed, 95% CI)Subtotals only

    40.1 Sense of competence - interval of 1-2 days
1170Mean Difference (IV, Fixed, 95% CI)0.41 [0.14, 0.68]

    40.2 Sense of competence - interval of 3-14 days
1177Mean Difference (IV, Fixed, 95% CI)0.25 [-0.08, 0.58]

    40.3 Sense of competence - interval >14 days
1141Mean Difference (IV, Fixed, 95% CI)0.21 [-0.17, 0.59]

    40.4 Sense of competence - infant admitted to NICU
182Mean Difference (IV, Fixed, 95% CI)0.54 [0.07, 1.01]

    40.5 Sense of competence - infant not admitted to NICU
1406Mean Difference (IV, Fixed, 95% CI)0.24 [0.05, 0.43]

    40.6 Worry and stress - interval of 1-2 days
1170Mean Difference (IV, Fixed, 95% CI)0.31 [0.04, 0.58]

    40.7 Worry and stress - interval of 3-14 days
1177Mean Difference (IV, Fixed, 95% CI)0.09 [-0.20, 0.38]

    40.8 Worry and stress - interval >14 days
1141Mean Difference (IV, Fixed, 95% CI)-0.29 [-0.70, 0.12]

    40.9 Worry and stress - infant admitted to NICU
182Mean Difference (IV, Fixed, 95% CI)-0.1 [-0.60, 0.40]

    40.10 Worry and stress - infant not admitted to NICU
1406Mean Difference (IV, Fixed, 95% CI)0.12 [-0.06, 0.30]

    40.11 Social support - interval of 1-2 days
1170Mean Difference (IV, Fixed, 95% CI)-0.06 [-0.35, 0.23]

    40.12 Social support - interval of 3-14 days
1177Mean Difference (IV, Fixed, 95% CI)-0.06 [-0.34, 0.22]

    40.13 Social support - interval >14 days
1141Mean Difference (IV, Fixed, 95% CI)-0.47 [-0.84, -0.10]

    40.14 Social support - infant admitted to NICU
182Mean Difference (IV, Fixed, 95% CI)-0.05 [-0.52, 0.42]

    40.15 Social support - infant not admitted to NICU
1406Mean Difference (IV, Fixed, 95% CI)-0.2 [-0.39, -0.01]

 41 Mother-infant attachment: mother's responses to the infant according to interval between birth and start of intervention, and infant admission to NICU1Mean Difference (IV, Fixed, 95% CI)Subtotals only

    41.1 Mother's sensitivity - interval of 1-2 days
1170Mean Difference (IV, Fixed, 95% CI)0.02 [-0.02, 0.06]

    41.2 Mother's sensitivity - interval of 3-14 days
1177Mean Difference (IV, Fixed, 95% CI)-0.01 [-0.05, 0.03]

    41.3 Mother's sensitivity - interval >14 days
1141Mean Difference (IV, Fixed, 95% CI)0.06 [0.01, 0.11]

    41.4 Mother's sensitivity - infant admitted to NICU
182Mean Difference (IV, Fixed, 95% CI)0.02 [-0.04, 0.08]

    41.5 Mother's sensitivity - infant not admitted to NICU
1406Mean Difference (IV, Fixed, 95% CI)0.02 [-0.00, 0.04]

    41.6 Mother's response to child's distress - interval of 1-2 days
1170Mean Difference (IV, Fixed, 95% CI)-0.03 [-0.08, 0.02]

    41.7 Mother's response to child's distress - interval of 3-14 days
1177Mean Difference (IV, Fixed, 95% CI)0.01 [-0.03, 0.05]

    41.8 Mother's response to child's distress - interval >14 days
1141Mean Difference (IV, Fixed, 95% CI)0.01 [-0.04, 0.06]

    41.9 Mother's response to child's distress - infant admitted to NICU
182Mean Difference (IV, Fixed, 95% CI)0.05 [-0.01, 0.11]

    41.10 Mother's response to child's distress - infant not admitted to NICU
1406Mean Difference (IV, Fixed, 95% CI)-0.02 [-0.05, 0.01]

    41.11 Mother's response to child's socioemotional growth fostering - interval of 1-2 days
1170Mean Difference (IV, Fixed, 95% CI)0.01 [-0.04, 0.06]

    41.12 Mother's response to child's socioemotional growth fostering - interval of 3-14 days
1177Mean Difference (IV, Fixed, 95% CI)-0.02 [-0.06, 0.02]

    41.13 Mother's response to child's socioemotional growth fostering - interval >14 days
1141Mean Difference (IV, Fixed, 95% CI)0.05 [-0.00, 0.10]

    41.14 Mother's response to child's socioemotional growth fostering - infant admitted to NICU
182Mean Difference (IV, Fixed, 95% CI)-0.05 [-0.12, 0.02]

    41.15 Mother's response to child's socioemotional growth fostering - infant not admitted to NICUNICU
1406Mean Difference (IV, Fixed, 95% CI)0.02 [-0.01, 0.05]

    41.16 Mother's response to child's cognitive growth fostering - interval of 1-2 days
1170Mean Difference (IV, Fixed, 95% CI)0.02 [-0.04, 0.08]

    41.17 Mother's response to child's cognitive growth fostering - interval of 3-14 days
1177Mean Difference (IV, Fixed, 95% CI)-0.04 [-0.10, 0.02]

    41.18 Mother's response to child's cognitive growth fostering - interval >14 days
1141Mean Difference (IV, Fixed, 95% CI)0.07 [0.00, 0.14]

    41.19 Mother's response to child's cognitive growth fostering - infant admitted to NICU
182Mean Difference (IV, Fixed, 95% CI)-0.07 [-0.17, 0.03]

    41.20 Mother's response to child's cognitive growth fostering - infant not admitted to NICU
1406Mean Difference (IV, Fixed, 95% CI)0.03 [-0.01, 0.07]

 42 Mother-infant attachment: infant's responses to the mother according to interval between birth and start of intervention, and infant admission to NICU1Mean Difference (IV, Fixed, 95% CI)Subtotals only

    42.1 Clarity of cues - interval of 1-2 days
1170Mean Difference (IV, Fixed, 95% CI)0.01 [-0.04, 0.06]

    42.2 Clarity of cues - interval of 3-14 days
1177Mean Difference (IV, Fixed, 95% CI)0.02 [-0.03, 0.07]

    42.3 Clarity of cues - interval >14 days
1141Mean Difference (IV, Fixed, 95% CI)Not estimable

    42.4 Clarity of cues - infant admitted to NICU
182Mean Difference (IV, Fixed, 95% CI)-0.01 [-0.07, 0.05]

    42.5 Clarity of cues - infant not admitted to NICU
1406Mean Difference (IV, Fixed, 95% CI)0.02 [-0.01, 0.05]

    42.6 Responsiveness - interval of 1-2 days
1170Mean Difference (IV, Fixed, 95% CI)-0.02 [-0.06, 0.02]

    42.7 Responsiveness - interval of 3-14 days
1177Mean Difference (IV, Fixed, 95% CI)0.02 [-0.02, 0.06]

    42.8 Responsiveness - interval >14 days
1141Mean Difference (IV, Fixed, 95% CI)0.05 [0.01, 0.09]

    42.9 Responsiveness - infant admitted to NICU
182Mean Difference (IV, Fixed, 95% CI)-0.01 [-0.07, 0.05]

    42.10 Responsiveness - infant not admitted to NICU
1406Mean Difference (IV, Fixed, 95% CI)0.02 [-0.01, 0.05]

 43 Mother-infant attachment at 3 months follow-up1100Mean Difference (IV, Fixed, 95% CI)6.24 [5.57, 6.91]

    43.1 Total attachment score at 3 months follow-up
1100Mean Difference (IV, Fixed, 95% CI)6.24 [5.57, 6.91]

 44 Mother-infant attachment: stress in NICU1Mean Difference (IV, Fixed, 95% CI)Subtotals only

    44.1 Nursery environment score
130Mean Difference (IV, Fixed, 95% CI)0.10 [-0.51, 0.71]

    44.2 Infant appearance score
130Mean Difference (IV, Fixed, 95% CI)Not estimable

    44.3 Relationship with the infant score
130Mean Difference (IV, Fixed, 95% CI)1.00 [0.35, 1.65]

    44.4 Staff behavior and communication score
130Mean Difference (IV, Fixed, 95% CI)0.10 [-0.95, 1.15]

 45 Mother-infant attachment: parenting skills130Mean Difference (IV, Fixed, 95% CI)-0.40 [-0.89, 0.09]

    45.1 Total score at discharge
130Mean Difference (IV, Fixed, 95% CI)-0.40 [-0.89, 0.09]

 46 Mother-infant interaction at 6 months follow-up1Mean Difference (IV, Fixed, 95% CI)Subtotals only

    46.1 Symmetrical coregulation
145Mean Difference (IV, Fixed, 95% CI)16.38 [13.61, 19.15]

    46.2 Asymmetrical coregulation
145Mean Difference (IV, Fixed, 95% CI)-18.31 [-21.42, -15.20]

    46.3 Unilateral regulation
145Mean Difference (IV, Fixed, 95% CI)2.12 [-1.24, 5.48]

 47 Social and home environment1338Mean Difference (IV, Fixed, 95% CI)0.79 [0.74, 0.84]

    47.1 HOME environment total score at 12 months' corrected age
1338Mean Difference (IV, Fixed, 95% CI)0.79 [0.74, 0.84]

 
Comparison 2. Early versus late kangaroo mother care in relatively stable LBW infants

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Mortality at 4 weeks of age173Risk Ratio (M-H, Fixed, 95% CI)1.95 [0.18, 20.53]

 2 Morbidity at 4 weeks of age173Risk Ratio (M-H, Fixed, 95% CI)0.49 [0.18, 1.28]

 3 Severe infection at 4 weeks of age173Risk Ratio (M-H, Fixed, 95% CI)0.42 [0.12, 1.49]

 4 Re-admission to hospital at 4 weeks of age173Risk Ratio (M-H, Fixed, 95% CI)1.95 [0.18, 20.53]

 5 Hypothermia173Risk Ratio (M-H, Fixed, 95% CI)0.58 [0.15, 2.27]

 6 Weight gain (grams)1Mean Difference (IV, Fixed, 95% CI)Subtotals only

    6.1 At 24 hours postbirth
173Mean Difference (IV, Fixed, 95% CI)39.16 [11.11, 67.21]

    6.2 At 48 hours postbirth
173Mean Difference (IV, Fixed, 95% CI)43.3 [5.49, 81.11]

    6.3 At 2 weeks of age
173Mean Difference (IV, Fixed, 95% CI)12.14 [-83.18, 107.46]

    6.4 At 4 weeks of age
173Mean Difference (IV, Fixed, 95% CI)58.85 [-116.93, 234.63]

 7 Exclusive breast feeding1Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    7.1 At 24 hours of age
173Risk Ratio (M-H, Fixed, 95% CI)1.02 [0.67, 1.57]

    7.2 At 2 weeks of age
171Risk Ratio (M-H, Fixed, 95% CI)1.00 [0.89, 1.12]

    7.3 At 4 weeks of age
167Risk Ratio (M-H, Fixed, 95% CI)0.94 [0.85, 1.04]

 8 Length of hospital stay (days)173Mean Difference (IV, Fixed, 95% CI)-0.90 [-1.24, -0.56]

 

What's new

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. What's new
  11. History
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms

Last assessed as up-to-date: 30 January 2011.


DateEventDescription

31 January 2011New search has been performedThis updates the review "Kangaroo mother care to reduce morbidity and mortality in low birthweight infants" published in The Cochrane Database of Systematic Reviews (Conde-Agudelo 2003).

In the previous versions of this review, we included only trials that evaluated continuous kangaroo mother care (KMC) after infant stabilization. For the 2011 update, we have also included studies that evaluated KMC before infant stabilization and intermittent KMC. In addition, we have changed the labels for several primary and secondary outcomes and have performed new subgroup and sensitivity analysis. As the time of measurement for several primary and secondary outcomes varied across trials, we have grouped these outcomes as "outcome at latest follow up". For the primary outcomes mortality at discharge or 40-41 weeks' postmenstrual age and at latest follow up, we have included subgroup analyses according to type of KMC (intermittent versus continuous), infant age at initiation of KMC (≤10 days versus >10 days), setting in which the trial was conducted (low/middle income countries versus high income countries), and infant stabilization (before versus after). For all outcomes in stabilized LBW infants we performed subgroup analyses according to type of KMC (intermittent versus continuous). Finally, we have included randomized controlled trials that compared early onset (starting within 24 hours after birth) versus late onset (starting after 24 hours after birth) KMC.

31 January 2011New citation required and conclusions have changedNew search has been performed. In addition to the three studies (Cattaneo 1998; Charpak 1997; Sloan 1994) included in previous versions of the review, we have included 13 new studies (Ali 2009; Blaymore Bier 1996; Boo 2007; Gathwala 2008; Kadam 2005; Nagai 2010; Neu 2010; Ramanathan 2001; Roberts 2000; Rojas 2003; Suman 2008; Whitelaw 1988; Worku 2005).

We have excluded another 24 studies (Ahn 2010; Anderson 2003; Bergman 2004; Chiu 2009; Christensson 1998; Darmstadt 2006; de Almeida 2010; de Macedo 2007; Hake Brooks 2008; Huang 2006; Ibe 2004; Kumar 2008; Lai 2006; Lamy Filho 2008; Legault 1993; Lincetto 2000; Ludington-Hoe 1991; Ludington-Hoe 2000; Ludington-Hoe 2004; Ludington-Hoe 2006; Miles 2006; Miltersteiner 2005; Sloan 2008; Tallandini 2006).

The updated review used updated methods, includes results for new comparisons, and includes new subgroup and sensitivity analyses.



 

History

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. What's new
  11. History
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms

Protocol first published: Issue 3, 1999
Review first published: Issue 4, 2000


DateEventDescription

26 September 2008AmendedConverted to new review format



 

Contributions of authors

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. What's new
  11. History
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms

The original review was carried out by Agustin Conde-Agudelo, Jose L. Diaz-Rossello, and Jose Belizan (Conde-Agudelo 2000).

The same authors updated the review in 2003 (Conde-Agudelo 2003).

Agustin Conde-Agudelo, Jose L. Diaz-Rossello, and José M. Belizán undertook the 2011 revision and update.
For this update, Dr Agustin Conde-Agudelo wrote the first draft of the review and revised subsequent drafts in response to feedback.
Drs Jose L. Diaz-Rossello and José M. Belizán commented on the first draft of the updated review and contributed to the writing of the final draft.

 

Declarations of interest

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. What's new
  11. History
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms

None.

 

Sources of support

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. What's new
  11. History
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms
 

Internal sources

  • (AC-A) Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development/National Institutes of Health/Department of Health and Human Services, Bethesda, MD and Detroit, MI, USA.
  • (JLD-R) Department of Neonatology, University Hospital, Montevideo, Uruguay.
  • (JMB) Department of Mother and Child Health Research, Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina.

 

External sources

  • No sources of support supplied

 

Differences between protocol and review

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. What's new
  11. History
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms

The background and methods sections have been updated. After the protocol was published, a new version of the Cochrane Handbook recommended a new approach to assess the risk of bias. We changed our method of assessment to be consistent with the recommendations. We decided to group studies into continuous KMC and intermittent KMC after looking at the variation in the interventions. We have changed the labels for most primary and secondary outcomes and have performed several new subgroup and sensitivity analysis. In the protocol and previous versions of this review, we did not include studies that evaluated KMC before stabilization and intermittent KMC. In this updated review, we have also included studies that evaluated KMC before stabilization and intermittent KMC.

* Indicates the major publication for the study

References

References to studies included in this review

  1. Top of page
  2. AbstractRésumé
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Characteristics of studies
  18. References to studies included in this review
  19. References to studies excluded from this review
  20. References to studies awaiting assessment
  21. Additional references
  22. References to other published versions of this review
Ali 2009 {published data only}
  • Ali SM, Sharma J, Sharma R, Alam S. Kangaroo mother care as compared to conventional care for low birth weight babies. Dicle Medical Journal 2009;36(3):155-60.
Blaymore Bier 1996 {published data only}
  • Bier JA, Ferguson AE, Morales Y, Liebling JA, Archer D, Oh W, Vohr BR. Comparison of skin-to-skin contact with standard contact in low-birth-weight infants who are breast-fed. Archives of Pediatrics & Adolescent Medicine 1996;150(12):1265-9.
Boo 2007 {published data only}
Cattaneo 1998 {published data only}
  • Cattaneo A, Davanzo R, Worku B, Surjono A, Echeverria M, Bedri A, et al. Kangaroo mother care for low birthweight infants: a randomized controlled trial in different settings. Acta Paediatrica 1998;87(9):976-85.
Charpak 1997 {published data only}
Gathwala 2008 {published data only}
Kadam 2005 {published data only}
  • Kadam S, Binoy S, Kanbur W, Mondkar JA, Fernandez A. Feasibility of kangaroo mother care in Mumbai. Indian Journal of Pediatrics 2005;72(1):35-8.
Nagai 2010 {published data only}
Neu 2010 {published data only}
Ramanathan 2001 {published data only}
  • Ramanathan K, Paul VK, Deorari AK, Taneja U, George G. Kangaroo Mother Care in very low birth weight infants. Indian Journal of Pediatrics 2001;68(11):1019-23.
Roberts 2000 {published data only}
  • Roberts KL, Paynter C, McEwan B. A comparison of kangaroo mother care and conventional cuddling care. Neonatal Network 2000;19(4):31-5.
Rojas 2003 {published data only}
  • Rojas MA, Kaplan M, Quevedo M, Sherwonit E, Foster LB, Ehrenkranz RA, Mayes L. Somatic growth of preterm infants during skin-to-skin care versus traditional holding: a randomized, controlled trial. Journal of Developmental and Behavioral Pediatrics 2003;24(3):163-8.
Sloan 1994 {published data only}
  • Sloan NL, Camacho LW, Rojas EP, Stern C. Kangaroo mother method: randomised controlled trial of an alternative method of care for stabilised low-birthweight infants. Lancet 1994;344(8925):782-5.
Suman 2008 {published data only}
  • Suman RP, Udani R, Nanavati R. Kangaroo mother care for low birth weight infants: a randomized controlled trial. Indian Pediatrics 2008;45(1):17-23.
Whitelaw 1988 {published data only}
  • Whitelaw A, Heisterkamp G, Sleath K, Acolet D, Richards M. Skin to skin contact for very low birthweight infants and their mothers. Archives of Disease in Childhood 1988;63(11):1377-81.
Worku 2005 {published data only}
  • Worku B, Kassie A. Kangaroo mother care: a randomized controlled trial on effectiveness of early kangaroo mother care for the low birthweight infants in Addis Ababa, Ethiopia. Journal of Tropical Pediatrics 2005;51(2):93-7.

References to studies excluded from this review

  1. Top of page
  2. AbstractRésumé
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Characteristics of studies
  18. References to studies included in this review
  19. References to studies excluded from this review
  20. References to studies awaiting assessment
  21. Additional references
  22. References to other published versions of this review
Ahn 2010 {published data only}
  • Ahn HY, Lee J, Shin HJ. Kangaroo care on premature infant growth and maternal attachment and post-partum depression in South Korea. Journal of Tropical Pediatrics 2010;56(5):342-4.
Anderson 2003 {published data only}
Arandia 1993 {published data only}
  • Arandia R, Morales L. Program kangaroo mother [Programa Madre-Canguro]. Gaceta Medica Boliviana 1993;17:51-5.
Bergman 1994 {published data only}
Bergman 2004 {published data only}
  • Bergman NJ, Linley LL, Fawcus SR. Randomized controlled trial of skin-to-skin contact from birth versus conventional incubator for physiological stabilization in 1200- to 2199-gram newborns. Acta Paediatrica 2004;93(6):779-85.
Charpak 1994 {published data only}
  • Charpak N, Ruiz-Peláez JG, Charpak Y. Rey-Martinez. Kangaroo Mother Program: an alternative way of caring for low birth weight infants? One year mortality in a two cohort study. Pediatrics 1994;94(6):804-10.
Chiu 2009 {published data only}
  • Chiu SH, Anderson GC. Effect of early skin-to-skin contact on mother-preterm infant interaction through 18 months: randomized controlled trial.. International Journal of Nursing Studies 2009;46(9):1168-80.
Christensson 1998 {published data only}
Chwo 2002 {published data only}
  • Chwo MJ, Anderson GC, Good M, Dowling DA, Shiau SH, Chu DM. A randomized controlled trial of early kangaroo care for preterm infants: effects on temperature, weight, behavior, and acuity. Journal of Nursing Research 2002;10(2):129-42.
Dala Sierra 1994 {published data only}
  • Dala Sierra E, Pineda Barahona E, Banegas RM. Kangaroo mother experience [Experiencia madre canguro]. Revista Medica Hondureña 1994;62:43-6.
Darmstadt 2006 {published data only}
  • Darmstadt GL, Kumar V, Yadav R, Singh V, Singh P, Mohanty S, et al. Introduction of community-based skin-to-skin care in rural Uttar Pradesh, India. Journal of Perinatology 2006;26(10):597-604.
de Almeida 2010 {published data only}
  • de Almeida H, Venancio SI, Sanches MT, Onuki D. The impact of kangaroo care on exclusive breastfeeding in low birth weight newborns. Jornal de Pediatria (Rio J) 2010;86(3):250-3.
de Macedo 2007 {published data only}
  • de Macedo EC, Cruvinel F, Lukasova K, D'Antino ME. The mood variation in mothers of preterm infants in Kangaroo mother care and conventional incubator care. Journal of Tropical Pediatrics 2007;53(5):344-6.
Feldman 2002 {published data only}
  • Feldman R, Eidelman AI, Sirota L, Weller A. Comparison of skin-to-skin (kangaroo) and traditional care: parenting outcomes and preterm infant development. Pediatrics 2002;110(1):16-26..
Hake Brooks 2008 {published data only}
  • Hake-Brooks SJ, Anderson GC. Kangaroo care and breastfeeding of mother-preterm infant dyads 0-18 months: a randomized, controlled trial. Neonatal Network 2008;27(3):151-9.
Huang 2006 {published data only}
  • Huang YY, Huang CY, Lin SM, Wu SC. Effect of very early kangaroo care on extrauterine temperature adaptation in newborn infants with hypothermia problems [In Chinese]. Hu Li Za Zhi Journal of Nursing 2006;53(4):41-8.
Ibe 2004 {published data only}
  • Ibe OE, Austin T, Sullivan K, Fabanwo O, Disu E, Costello AM. A comparison of kangaroo mother care and conventional incubator care for thermal regulation of infants < 2000 g in Nigeria using continuous ambulatory temperature monitoring. Annals of Tropical Paediatrics 2004;24(3):245-51.
Kambarami 1998 {published data only}
  • Kambarami RA, Chidede O, Kowo DT. Kangaroo care versus incubator care in the management of well preterm infants--a pilot study. Annals of Tropical Paediatrics 1998;18(2):81-6..
Kumar 2008 {published data only}
  • Kumar V, Mohanty S, Kumar A, Misra RP, Santosham M, Awasthi S, et al. Effect of community-based behaviour change management on neonatal mortality in Shivgarh, Uttar Pradesh, India: a cluster-randomised controlled trial. Lancet 2008;372(9644):1151-62.
Lai 2006 {published data only}
  • Lai HL, Chen CJ, Peng TC, Chang FM, Hsieh ML, Huang HY, Chang SC. Randomized controlled trial of music during kangaroo care on maternal state anxiety and preterm infants' responses. International Journal of Nursing Studies 2006;43(2):139-46.
Lamy Filho 2008 {published data only}
  • Lamy Filho F, Silva AA, Lamy ZC, Gomes MA, Moreira ME. Evaluation of the neonatal outcomes of the kangaroo mother method in Brazil. Jornal de Pediatria (Rio J) 2008;84(5):428-35.
Legault 1993 {published data only}
  • Legault M, Goulet C. Comparative study of two methods of holding premature infants: the kangaroo method versus the traditional method [Etude comparative de deux méthodes de sortie du prématuré: méthode kangourou versus méthode traditionnelle]. Canadian Journal of Nursing Research 1993;25(4):67-80.
Legault 1995 {published data only}
  • Legault M, Goulet C. Comparison of kangaroo and traditional methods of removing preterm infants from incubators. Journal of Obstetric, Gynecologic and Neonatal Nursing 1995;24(6):501-6.
Lincetto 2000 {published data only}
Ludington-Hoe 1991 {published data only}
  • Ludington SM, Hadeed AJ, Anderson G. Cardiorespiratory, thermal and state effects of kangaroo care for preterm infants: randomized controlled trial. Pediatric Research 1991;29(4):223A.
Ludington-Hoe 2000 {published data only}
  • Ludington-Hoe SM, Nguyen N, Swinth JY, Satyshur RD. Kangaroo care compared to incubators in maintaining body warmth in preterm infants. Biological Research for Nursing 2000;2(1):60-73.
Ludington-Hoe 2004 {published data only}
  • Ludington-Hoe SM, Anderson GC, Swinth JY, Thompson C, Hadeed AJ. Randomized controlled trial of kangaroo care: cardiorespiratory and thermal effects on healthy preterm infants. Neonatal Network 2004;23(3):39-48.
Ludington-Hoe 2006 {published data only}
  • Ludington-Hoe SM, Johnson MW, Morgan K, Lewis T, Gutman J, Wilson PD, Scher MS. Neurophysiologic assessment of neonatal sleep organization: preliminary results of a randomized, controlled trial of skin contact with preterm infants. Pediatrics 2006;117(5):e909-23.
Miles 2006 {published data only}
Miltersteiner 2005 {published data only}
  • Miltersteiner AR, Dalle Molle L, Marchetto Claus S, Rotta NT. Length of hospital stay of preterm infants observed in the Kangaroo position and prone position in incubator [Tempo de internação hospitalar de bebês pré-termos observados na Posição Mãe-Canguru e na Posição Prona na incubadora]. Revista AMRIGS 2005;49(1):20-6.
Ohgi 2002 {published data only}
  • Ohgi S, Fukuda M, Moriuchi H, Kusumoto T, Akiyama T, Nugent JK, Brazelton TB, Arisawa K, Takahashi T, Saitoh H. Comparison of kangaroo care and standard care: behavioral organization, development, and temperament in healthy, low-birth-weight infants through 1 year. Journal of Perinatology 2002;22(5):374-9.
Sloan 2008 {published data only}
  • Sloan NL, Ahmed S, Mitra SN, Choudhury N, Chowdhury M, Rob U, Winikoff B. Community-based kangaroo mother care to prevent neonatal and infant mortality: a randomized, controlled cluster trial. Pediatrics 2008;121(5):e1047-59.
Tallandini 2006 {published data only}

Additional references

  1. Top of page
  2. AbstractRésumé
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Characteristics of studies
  18. References to studies included in this review
  19. References to studies excluded from this review
  20. References to studies awaiting assessment
  21. Additional references
  22. References to other published versions of this review
Barker 1995
Bassler 2010
  • Bassler D, Briel M, Montori VM, Lane M, Glasziou P, Zhou Q, et al. Stopping randomized trials early for benefit and estimation of treatment effects: systematic review and meta-regression analysis. Journal of the American Medical Association 2010;303(12):1180-7.
Charpak 1996
  • Charpak N, Ruiz-Peláez JG, Figueroa de Calume Z. Current knowledge of kangaroo mother Intervention. Current Opinion in Pediatrics 1996;8(2):108-12.
Diaz-Rossello 2008
  • Díaz-Rossello JL, Ferreira-Castro A. Maternology: When a Baby is Born, a Mother is Born. NeoReviews 2008;9(8):e326-e331.
Egger 1997
  • Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta-analyses detected by a simple graphical test. British Medical Journal 1997;315(7109):629-34.
Guyer 1998
Higgins 2003
Higgins 2009
  • Higgins JPT, Green S, editors. Cochrane Handbook for Systematic Reviews of Interventions. Version 5.0.2 [updated September 2009]. The Cochrane Collaboration 2009.
Johnston 2010
  • Johnston C, Campbell-Yeo M, Fernandes A, Inglis D, Streiner D, Zee R. Skin-to-skin care for procedural pain in neonates (Protocol). Cochrane Database of Systematic Reviews 2010, Issue 3. [DOI: 10.1002/14651858.CD008435]
Lawn 2005
Lawn 2010
  • Lawn JE, Mwansa-Kambafwile J, Horta BL, Barros FC, Cousens S. 'Kangaroo mother care' to prevent neonatal deaths due to preterm birth complications. International Journal of Epidemiology 2010;39(Suppl 1):i144-54.
Moore 2007
Nyqvist 2010
RevMan 2008
  • The Nordic Cochrane Centre, Denmark. The Cochrane Collaboration. Review Manager (RevMan). 5.0.24. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration 2008.
Rey 1983
  • Rey E, Martinez H. Rational management of the premature infant [Manejo racional del niño prematuro]. I Curso de Medicina Fetal y Neonatal. Bogota, Colombia:: Universidad Nacional, 1983:137-51.
Roberts 2010
  • Roberts G, Anderson PJ, Doyle LW, Victorian Infant Collaborative Study Group. The stability of the diagnosis of developmental disability between ages 2 and 8 in a geographic cohort of very preterm children born in 1997. Archives of Disease in Childhood 2010;95(10):786-90.
Ruiz-Peláez 2004
UNICEF/WHO 2004
  • United Nations Childrens Fund and World Health Organization. Low birthweight: Country, regional and global estimates. UNICEF. New York, 2004.

References to other published versions of this review

  1. Top of page
  2. AbstractRésumé
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Characteristics of studies
  18. References to studies included in this review
  19. References to studies excluded from this review
  20. References to studies awaiting assessment
  21. Additional references
  22. References to other published versions of this review
Conde-Agudelo 2000
  • Conde-Agudelo A, Diaz-Rossello JL, Belizan JM. Kangaroo mother care to reduce morbidity and mortality in low birthweight infants. Cochrane Database of Systematic Reviews 2000, Issue (4):CD002771. [Art. No.: CD002771. DOI: 10.1002/14651858.CD002771.pub2]
Conde-Agudelo 2003
  • Conde-Agudelo A, Diaz-Rossello JL, Belizan JM. Kangaroo mother care to reduce morbidity and mortality in low birthweight infants. Cochrane Database of Systematic Reviews 2003, Issue (2):CD002771. [Art. No.: CD002771. DOI: 10.1002/14651858.CD002771.pub2]