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

  1. Agustin Conde-Agudelo1,*,
  2. José L Díaz-Rossello2

Editorial Group: Cochrane Neonatal Group

Published Online: 22 APR 2014

Assessed as up-to-date: 31 MAR 2014

DOI: 10.1002/14651858.CD002771.pub3


How to Cite

Conde-Agudelo A, Díaz-Rossello JL. Kangaroo mother care to reduce morbidity and mortality in low birthweight infants. Cochrane Database of Systematic Reviews 2014, Issue 4. Art. No.: CD002771. DOI: 10.1002/14651858.CD002771.pub3.

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

    United Nations Population Fund UNFPA, 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 (no change to conclusions)
  2. Published Online: 22 APR 2014

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Characteristics of included studies [ordered by study ID]
Ali 2009

MethodsRandomized controlled trial carried out in Aligarh, India.


ParticipantsNumber of infants: 114

Inclusion criteria: hemodynamically stable infants delivered by vaginal route with birthweight between 1200 and 1800 g.

Exclusion criteria: neonates delivered by cesarean section, major life threatening congenital malformations, severe perinatal complications, and parental refusal for KMC intervention.

Infant's stabilization status at trial entry: stabilized.

Infant's age and weight at trial entry: mean age and weight at recruitment was 4.7 ± 2.9 and 4.8 ± 2.4 days, and 1607 ± 211 and 1615 ± 179 g for KMC and control infants, respectively.


InterventionsKMC group: SSC between the mother's breasts in an upright position. Infants were dressed with a cap, socks, and diaper and supported in bottom with a sling/binder. The duration of KMC during hospital stay was 6.3 ± 1.5 hours (range, 4-12) per day, and was given for a period of 25.7 ± 6.9 (range, 15-43) days after enrollment in the study (n = 58).

Control group: infants were kept in radiant warmers or open cots in warm rooms (n = 56).

In both groups, mothers were allowed to handle their babies at any hour of the day and breastfeed them by nasogastric tube, paladai or directly. Babies in both groups were provided with vitamins and mineral supplementation.

Level of care: NICU of a tertiary care hospital.

Human resources: doctors and nurses.

Criteria for infant discharge from the hospital: weight gain for at least 3 consecutive days, no overt illness, no intravenous medications, and on exclusive breastfeeding.

Scheme of follow up of infants after discharge: weekly until 40 weeks' postmenstrual age, fortnightly until 3 months' corrected age, and monthly thereafter until 6 months' corrected age.


OutcomesDuration of hospital stay, weight gain, head circumference, length, exclusive breastfeeding, nosocomial sepsis, hypothermia, mild/moderate infection, severe infection, and mortality.


Notes81% of LBW infants met eligibility criteria.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskBlock randomization technique

Allocation concealment (selection bias)Unclear riskNo information provided

Blinding of participants and personnel (performance bias)
All outcomes
High riskBlinding of participants: no/unfeasible; blinding of clinical staff: no/unfeasible

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskNo information provided

Incomplete outcome data (attrition bias)
All outcomes
Low risk10 infants (8.8%) were lost at 40 weeks' corrected gestational age follow up (KMC 4, control 6), 21 (18.4%) were lost at 3 months' corrected age (KMC 10, control 11), and 39 (34.2%) were lost at 6 months' corrected age (KMC 19, control 20)

Selective reporting (reporting bias)High riskNon-significant results such as infant mortality (prand weight, length, and head circumference at discharge and follow up (secondary outcomes listed in Methods) were mentioned but not reported adequately

Other biasHigh riskUse of blocked randomization which could make possible to predict future assignments in an unblinded trial when the assignments are revealed subsequent to the person recruiting into the trial

Blaymore Bier 1996

MethodsRandomized controlled trial conducted in Providence, United States


ParticipantsNumber of infants: 50

Inclusion criteria: medically stable infants from singleton or multiple pregnancy with birth weight <1500 g and whose mothers planned to breast-feed. The infants were no longer ventilator dependent and without chest tubes, and they no longer required continuous positive airway pressure when the study was begun.

Exclusion criteria: mother's positive history of illicit drug use, mental illness, human immunodeficiency virus (HIV) infection, or receiving any medications contraindicative to breast-feeding. In addition, any infants who had a positive toxicologic screen for cocaine or other illicit drugs or were showing drug withdrawal symptoms at birth were excluded.

Infant's stabilization status at trial entry: stabilized.

Infant's age and weight at trial entry: mean age and weight at recruitment was 29 and 30 days, and 993 ± 275 and 942 ± 322 g for KMC and control infants, respectively.


InterventionsKMC group: SSC involved the infant clothed in only a diaper and hat, held upright between the mother's breasts, with the mother and infant covered with a blanket (n = 25).

Control group: standard contact involved a fully clothed infant wrapped in a blanket and held cradled in his or her mother's arms (n = 25).

During the study, the mother-infant dyad was observed participating in SSC or standard contact once each weekday until bottle and breast-feedings were initiated or for a maximum of 10 days.The duration of the SSC and standard contact sessions was 10 minutes per day.

Level of care: special care nursery of a hospital.

Human resources: doctors and nurses.

Criteria for infant discharge from the hospital: unreported.

Scheme of follow up of infants after discharge: at 1, 3, and 6 months after hospital discharge.


OutcomesBreastfeeding and physiological data.


NotesNo data on percentage of LBW infants that met eligibility criteria.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskShuffling envelopes

Allocation concealment (selection bias)Unclear riskNo information provided

Blinding of participants and personnel (performance bias)
All outcomes
High riskBlinding of participants: no/unfeasible; blinding of clinical staff: no/unfeasible

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskNo information provided

Incomplete outcome data (attrition bias)
All outcomes
Low risk21 mothers of 25 infants were allocated to KMC group, and 20 mothers of 25 infants were allocated to standard contact group. One mother in the KMC group was lost to follow up after discharge. Two mothers in the control group were excluded because they wanted to participate in KMC group

Selective reporting (reporting bias)Low riskAll outcomes stated in the methods section were adequately reported or explained in results

Other biasLow riskOther biases have not been identified

Boo 2007

MethodsRandomized controlled trial carried out in Kebangsaan, Malaysia.


ParticipantsNumber of infants: 128

Inclusion criteria: very low birthweight infants (<1501 g) in stable condition, nursed in a closed incubator, not requiring ventilatory support other than nasal continuous positive airway pressure, able to tolerate enteral feeds of at least 50% of the required fluid volume, and having at least one parent or guardian who was willing to participate in the study.

Exclusion criteria: lethal or major malformations, severe perinatal asphyxia, with evidence of hypoxic ischemic encephalopathy, transfer to another hospital, abandoned by parents or parental refusal to participate.

Infant's stabilization status at trial entry: stabilized.

Infant's age and weight at trial entry: median age and weight at recruitment was 24.5 and 20.5 days, and 1514 and 1492 g for KMC and control infants, respectively.


InterventionsKMC group: parent held the infant prone on their naked chest, in a semi-upright position and between his/her breasts. Infants wore only a nappy and a bonnet. Both parent and infant were covered with a thermal blanket. Median duration of SSC was 1 hour per day with a mean total duration of 12.7 ± 5.0 days (n = 65).

Control group: infants were not exposed to SSC while in the NICU.

All mothers were encouraged to breastfeed their infants (n = 63).

Level of care: NICU of a tertiary care hospital.

Human resources: doctors and nurses.

Criteria for infant discharge from the hospital: clinically well, able to tolerate oral feeds totally, weight gain of at least 10 g/d, and no apnea, bradycardia and/or desaturation for at least 5 consecutive days.

Scheme of follow up of infants after discharge: unreported.


OutcomesDuration of hospital stay, weight gain, weekly increase in head circumference, breastfeeding rate at discharge, sepsis, and mortality at discharge.


Notes43% of LBW infants met eligibility criteria.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskShuffling envelopes

Allocation concealment (selection bias)Low riskNumbered sealed envelopes

Blinding of participants and personnel (performance bias)
All outcomes
High riskBlinding of participants: no/unfeasible; blinding of clinical staff: no/unfeasible

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskUnreported

Incomplete outcome data (attrition bias)
All outcomes
High risk8 infants in the KMC group (12.3%) were excluded because SSC sessions were carried out on less than 50% of hospital stay days after recruitment

Selective reporting (reporting bias)Low riskAll outcomes stated in the methods section were adequately reported or explained in results

Other biasLow riskOther biases have not been identified

Cattaneo 1998

MethodsMulticentre randomized controlled trial conducted in Addis Ababa (Ethiopia), Yogyakarta (Indonesia), and Merida (Mexico).


ParticipantsNumber of infants: 285

Inclusion criteria: infants with birthweight between 1000 and 1999 g without gestational age limits, no dependency on oxygen, and/or i.v. fluids, ability (at least partial) to feed, no visible major malformation, and mother present and willing to collaborate.

Exclusion criteria: unreported.

Infant's stabilization status at trial entry: stabilized.

Infant's age and weight at trial entry: median age (range) and mean weight (SD) at recruitment was 10 (1-74) and 8 (1-40) days, and 1584 (223) and 1574 (251) g for KMC and control infants, respectively.


InterventionsKMC group: infants were kept in close and continuous SSC, between the mother's breasts, naked except for a diaper and a hat covered across their backs with their mother's clothes, day and night, for an average of about 20 hours/day, including when the mother was asleep. The mother was occasionally replaced, for few hours, by another person usually the father or a member of the family. For short absences of the mother (<1 hour) the baby was left on the mother's bed, covered by a blanket (n = 149).

Control group: infants were kept in a warm room in Addis Ababa, with open cribs and the possibility of rewarming in a bulb-heated cot, and in incubators in the other two hospitals. SSC with their mothers was not allowed (n = 136).

Level of care: neonatal units of teaching hospitals.

Human resources: doctors and nurses.

Criteria for infant discharge from the hospital: weight at least 1500 g, clear upward growth trend (at least 15 g/kg/day) and stable temperature for at least 3 days, satisfactory ability to suck, good general conditions, and mother considered capable of good home care.

Scheme of follow up of infants after discharge: at least 4 times, at 3, 10, 20 and 30 days, and as usually scheduled in each hospital afterwards.


OutcomesSevere illness, hypothermia, hyperthermia, breastfeeding, weight gain, neonatal death, acceptability to health workers, acceptability to mothers, and costs.


Notes44% of LBW infants met eligibility criteria.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskRandom number table

Allocation concealment (selection bias)Unclear riskNo information provided

Blinding of participants and personnel (performance bias)
All outcomes
High riskBlinding of participants: no/unfeasible; blinding of clinical staff: no/unfeasible

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskUnreported

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskIt was not reported the number of infants lost to follow up or excluded after randomization

Selective reporting (reporting bias)Low riskAll outcomes stated in the methods section were adequately reported or explained in results

Other biasUnclear riskIn Indonesia, randomization was carried out in blocks of six and stratifying by weight which could make possible to predict future assignments in an unblinded trial when the assignments are revealed subsequent to the person recruiting into the trial

Charpak 1997

MethodsRandomized controlled trial carried out in Bogotá, Colombia.


ParticipantsNumber of infants: 777

Inclusion criteria: infants from singleton or multiple pregnancy with birthweights ≤2000 g, with a mother or a relative able to understand and willing to follow the general program instructions. Infants were eligible when they had overcome major problems of adaptations to extrauterine life, received proper treatment for infection or concomitant condition, sucked and swallowed properly, and achieved a positive weight gain.

Exclusion criteria: being referred to another institution, plans to leave Bogota in the near future, life-threatening or major malformations, early-detected major conditions arising from perinatal problems, and parental or family refusal to comply with the follow up program or, for those assigned to the KMC group, refusal to comply with the specifics of the intervention.

Infant's stabilization status at trial entry: stabilized.

Infant's age and weight at trial entry: median age (range) and mean weight (SD) at recruitment was 4 (1-60) and 3 (1-55) days, and 1678 (226) and 1715 (228) g for KMC and control infants, respectively.


InterventionsKMC group: infants were kept 24 hours a day in a strict upright position, in SSC firmly attached to the mother's chest. Infants were breastfed regularly, although premature formula supplements were administered if necessary (n = 396).

Control group: infants were kept in an incubator until they were able to regulate temperature and were thriving. The parent's access to their babies was severely restricted (n = 381).

Level of care: pediatric hospital (KMC infants) and NICU of a tertiary care hospital (controls).

Human resources: doctors and nurses.

Criteria for infant discharge from the hospital: (1) for infants in the KMC group: to regulate temperature in the kangaroo position, to have an adequate weight gain, to have completed their treatment, if any, be able to be fed by direct suction from the breast or expressed milk, to have adequate sucking-swallowing-breathing coordination, and mother able to care for her baby with the kangaroo methodology at home. Infants were discharged from the hospital regardless of their weight or gestational age. (2) for infants in the control group: weight ≥1700 g.

Scheme of follow up of infants after discharge: at least once a week until 40 weeks' postmenstrual age; then, monthly up to 3 months' corrected age, every 6 weeks until at least 6 months' corrected age, and every third month until 12 months' corrected age.


Outcomes1. At 40-41 weeks' postmenstrual: mortality, infant growth, length of hospital stay, infection, breastfeeding, and mother-infant attachment.

2. At 12 months' corrected age: neurodevelopmental disability, and social and home environment.


Notes72% of LBW infants met eligibility criteria. Informed consent was not asked to parents of infants allocated to the control group. Additional data provided by Dr Nathalie Charpak.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskRandom number table

Allocation concealment (selection bias)Unclear riskThe person managing allocation was aware of weight at birth and whether the infant was a twin or triplet

Blinding of participants and personnel (performance bias)
All outcomes
High riskBlinding of participants: no/unfeasible; blinding of clinical staff: no/unfeasible

Blinding of outcome assessment (detection bias)
All outcomes
High riskInfants allocated to the KMC group were managed in a pediatric hospital whereas infants allocated to the control group remained in a NICU of a tertiary care hospital

Incomplete outcome data (attrition bias)
All outcomes
Low risk31 infants (4%) (KMC 14, control 17) were excluded after randomization due to pre-existing neurologic impairment, or fetal intrauterine infection not detected at time of randomization. follow up at 40 to 41 weeks' corrected gestational age was incomplete for 67 (8.6%) survivor infants (KMC 33, control 34), but mortality data were available in 30 of these, giving mortality data for 364 vs 345

Selective reporting (reporting bias)Low riskAll outcomes stated in the methods section were adequately reported or explained in results

Other biasHigh riskUse of blocked randomization (block size of 4) which could make possible to predict future assignments in an unblinded trial when the assignments are revealed subsequent to the person recruiting into the trial

Eka Pratiwi 2009

MethodsRandomized controlled trial conducted in Bali, Indonesia.


ParticipantsNumber of infants: 93

Inclusion criteria: infants with birthweights between 1500 and 2250 g, with Apgar score >6 at 5 minutes, and mother willing to follow the study instructions.

Exclusion criteria: infants with major congenital malformations, cardiopulmonary problems, critically ill (sepsis, necrotizing enterocolitis, intracranial bleeding), or from a twin gestation or complicated pregnancy and/or labor, or mothers with history of drug abuse, psychiatric disorders, cesarean section or unable to take care of themselves or their babies.

Infant's stabilization status at trial entry: stabilized.

Infant's age and weight at trial entry: mean birthweight at recruitment was 2034 ± 159 and 1988 ± 176 g for KMC and control infants, respectively. No data on infant age at recruitment. However, it was mentioned that KMC was started "in the first day or in several hours after birth".


InterventionsKMC group: infants were kept in close SSC with the mother whilst in vertical position. Specially tailored kangaroo suits were used by mother-infant pairs to enable SSC. Mean duration of KMC was 10.0 ± 1.8 hours per day (range, 5.3-13.5 hours) (n = 48).

Control group: infants were kept in incubators or open cribs in warm rooms (n = 45).

Level of care: NICU of a public hospital.

Human resources: doctors and nurses.

Criteria for infant discharge from the hospital: Unreported.

Scheme of follow up of infants after discharge: Unreported.


OutcomesHypothermia, birthweight regain, sepsis and mortality.


Notes37% of LBW infants met eligibility criteria.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskRandom number table

Allocation concealment (selection bias)Unclear riskNo information provided

Blinding of participants and personnel (performance bias)
All outcomes
High riskBlinding of participants: no/unfeasible; blinding of clinical staff: no/unfeasible

Blinding of outcome assessment (detection bias)
All outcomes
High riskUnblinded assesors

Incomplete outcome data (attrition bias)
All outcomes
Low riskOne infant (1%) was lost to follow up and four (4.1%) were excluded after randomization due to sepsis

Selective reporting (reporting bias)Low riskAll outcomes stated in the methods section were adequately reported or explained in results

Other biasHigh riskUse of blocked randomization (block size of 6) which could make possible to predict future assignments in an unblinded trial when the assignments are revealed subsequent to the person recruiting into the trial

Gathwala 2008

MethodsRandomized controlled trial carried out in Rohtak, India.


ParticipantsNumber of infants: 110

Inclusion criteria: infants with birthweight ≤1800 g, stable cardiopulmonary status, Apgar score ≥7 at 1 and 5 minute, tolerating enteral feeds, and maintaining temperature.

Exclusion criteria: infants sick, unstable, or with major congenital malformations, or whose mothers were unwell and unable to come or refused consent.

Infant's stabilization status at trial entry: stabilized.

Infant's age and weight at trial entry: mean age at recruitment was 1.7 ± 0.5 days. Mean birthweight was 1690 ± 110 and 1690 ± 120 g for KMC and control infants, respectively.


InterventionsKMC group: infants were kept in SSC, between the mother's breasts, naked except for a cap and nappy, for at least 6 hours per day. The duration of KMC in the first month was 10.2 ± 1.5 hours per day, in the second month was 10.0 ± 1.6, and in the third month was 9.0 ± 1.4. The gown covered the baby's trunk and extremities but not the head. The KMC was given for a minimum of one hour at a stretch and continued for as long as it was comfortable to baby and mother. When not receiving KMC the infants received standard care under a warmer or incubator. Infants continued to receive KMC after they were shifted to the mother in the ward (n = 50).

Control group: infants were kept in a warmer or incubator. Mothers were allowed to visit their babies and touch and handle them. Infants were shifted to the mother in her bed but did not receive KMC (n = 50).

Level of care: Neonatal unit of a public hospital.

Human resources: doctors and nurses.

Criteria for infant discharge from the hospital: Unreported.

Scheme of follow up of infants after discharge: weekly until 3 months' age.


OutcomesAttachment between mother and infant at 3 months follow up, duration of hospital stay, breastfeeding, and weight, length and circumference head gain.


NotesNo data on percentage of LBW infants that met eligibility criteria.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskRandom number table

Allocation concealment (selection bias)Unclear riskNo information provided

Blinding of participants and personnel (performance bias)
All outcomes
High riskBlinding of participants: no/unfeasible; blinding of clinical staff: no/unfeasible

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskUnreported

Incomplete outcome data (attrition bias)
All outcomes
Unclear risk10 infants (9.1%) were lost to follow up. It was not reported the number of infants lost to follow up in each intervention group. Out of the remaining 100, 50 received KMC and 50 received standard care

Selective reporting (reporting bias)Low riskAll outcomes stated in the methods section were adequately reported or explained in results

Other biasLow riskOther biases have not been identified

Ghavane 2012

MethodsRandomized controlled trial conducted in Hyderabad, India.


ParticipantsNumber of infants: 140

Inclusion criteria: infants with birthweight <1500 g, tolerating spoon feeds of 150/mL/kg/day, and hemodynamically stable (not on oxygen or respiratory support, no apnea for 72 hours, not on any intravenous fluids).

Exclusion criteria: major malformations or refused consent.

Infant's stabilization status at trial entry: stabilized.

Infant's age and weight at trial entry: mean age and weight at recruitment was 14.1 ± 10.3 and 13.7 ± 10.2 days, and 1191 ± 131 and 1223 ± 125 g, for KMC and control infants, respectively.


InterventionsKMC group: infants were kept in SSC, between the mother's breasts in an upright position dressed with a cap, socks and diaper, and supported at the bottom with a cloth sling/binder, for at least 8 hours per day. When not receiving KMC the infants were placed in open cribs (n = 71).

Control group: infants were kept in a warmer or incubator. Mothers were allowed to visit their babies and were encouraged for infant care activities such as diaper change, oil massage, and paladai feeding (n = 69).

Level of care: "kangaroo ward” (KMC infants) and neonatal intermediate care unit (controls) in a level III tertiary care hospital.

Human resources: infants in KMC group were cared for solely by their mothers, assisted by a trained nurse. Infants in control group were cared by doctors and nurses.

Criteria for infant discharge from the hospital: (1) for infants in the KMC group: weight ≥1300 g or weight gain ≥10 g/day on 3 consecutive days if weight at randomization was >1300 g. (2) for infants in the control group: weight ≥1300 g, weight gain ≥10 g/day on 3 consecutive days, and skin temperature of 36-37 ˚C in the servo mode of the incubator with heater output <25%.

Scheme of follow up of infants after discharge: weekly until 40 weeks' postmenstrual age.


Outcomes1. At 40 weeks' postmenstrual age: infant growth.

2. At discharge: breastfeeding, sepsis, hypothermia, apnea, hypoglycemia, length of hospital stay, and mortality.


NotesNo data on percentage of LBW infants that met eligibility criteria. Additional data provided by Dr Srinivas Murki.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskWeb-based random number generator

Allocation concealment (selection bias)Low riskNumbered sealed opaque envelopes

Blinding of participants and personnel (performance bias)
All outcomes
High riskBlinding of participants: no/unfeasible; blinding of clinical staff: no/unfeasible

Blinding of outcome assessment (detection bias)
All outcomes
Low riskThe physician that assessed the growth outcomes was blinded to the intervention group of the infant

Incomplete outcome data (attrition bias)
All outcomes
Low risk4 infants (2.9%) were lost to follow up (KMC 3, control 1); no exclusions

Selective reporting (reporting bias)Low riskAll outcomes stated in the methods section were adequately reported or explained in results

Other biasLow riskOther biases have not been identified

Kadam 2005

MethodsRandomized controlled trial carried out in Mumbai, India.


ParticipantsNumber of infants: 89

Inclusion criteria: infants with birthweight ≤1800 g, stable cardiopulmonary status, Apgar score ≥7 at 5 minute, and on feeds (breastfeeds or spoon wati feeds with expressed breast milk).

Exclusion criteria: infants sick and unstable, or with major congenital malformations, or whose parents refused consent.

Infant's stabilization status at trial entry: stabilized.

Infant's age and weight at trial entry: mean age (range) at enrolment was 3.2 (1-8) days for both groups. Mean birthweight was 1467 ± 228 and 1461 ± 217 g for KMC and control infants, respectively.


InterventionsKMC group: infants were placed on mother's chest in between the breasts in vertical position supported by a cloth dupatta, with mothers seating in a semi-reclining position, for a mean of 9.8 ± 3.7 hours per day. In case of any problem the baby was transferred to conventional care and after stabilization was transferred back to KMC, which was continued till discharge (n = 44).

Control group: infants were kept in radiant warmers (n = 45).

More than 95% of infants in both groups received exclusive breastfeeding and the remaining were supplemented by banked human milk. Mothers in both groups were allowed to enter and handle the babies at any hour of the day, change diapers, and breastfeed the babies.

Level of care: NICU of a tertiary care hospital.

Human resources: doctors and nurses.

Criteria for infant discharge from the hospital: weight gain for at least 3 consecutive days, maintenance of temperature without need for warmer, feeding well on breastfeeds or wati spoon-feeds, and mother confident of taking care of the infant at home.

Scheme of follow up of infants after discharge: Unreported.


OutcomesMortality, morbidity (hypothermia, hyperthermia, sepsis, apnea), onset of breastfeeding, duration of hospital stay, and weight at discharge.


NotesNo data on percentage of LBW infants that met eligibility criteria.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskSealed envelope method

Allocation concealment (selection bias)Low riskSealed envelopes

Blinding of participants and personnel (performance bias)
All outcomes
High riskBlinding of participants: no/unfeasible; blinding of clinical staff: no/unfeasible

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskUnreported

Incomplete outcome data (attrition bias)
All outcomes
Low riskThere were no infants lost to follow up

Selective reporting (reporting bias)Low riskAll outcomes stated in the methods section were adequately reported or explained in results

Other biasLow riskOther biases have not been identified

Nagai 2010

MethodsRandomized controlled trial conducted in Mahajanga, Madagascar.


ParticipantsNumber of infants: 73

Inclusion criteria: infants with birthweight <2500 g, less than 24 hours post birth, no serious malformation, relatively stable clinical condition (oxygen saturation ≥95%; heart rate >100 beats/min; respiratory rate <60 times/min; capillary refilling time <3 sec), and healthy mother and/or other family members willing to practice KMC.

Exclusion criteria: prolonged apnea (>20 sec) and intravenous infusion.

Infant's stabilization status at trial entry: relatively stabilized.

Infant's age and weight at trial entry: mean age and weight at recruitment was 19.8 ± 14.3 and 33.0 ± 13.2 hours, and 2075 ± 272 and 2078 ± 292 g for early onset KMC and late onset KMC infants, respectively.


InterventionsEarly KMC group: infants were kept in direct and continuous SSC (without any underwear, except for a diaper, a warm hat, and socks for the baby) for as long as possible. SSC was begun as soon as possible, within 24 hours post birth (n = 37).

Late KMC group: initially, infants were kept in incubator or radiant warmer. Later, infants were covered with cotton cloth and laid beside the mothers. KMC was begun after complete stabilization (generally after 24 hours post birth) of infant (n = 36).

After initiating KMC, all participants were encouraged to continue KMC for as long as possible during hospitalization and after discharge. Other family members assisted the mother occasionally in performing continuous KMC.

Level of care: neonatal unit of a referral university hospital.

Human resources: doctors and nurses.

Criteria for infant discharge from the hospital: Unreported.

Scheme of follow up of infants after discharge: at 14 and 28 days' age.


OutcomesPrimary outcome: mortality at 4 weeks' age.

Secondary outcomes: morbidity, severe infection, readmission to hospital, and adverse events (hypothermia, hyperthermia, bradycardia and/or tachycardia, and prolonged apnea) at 4 weeks' age, body weight changes from birth to 24 hours, 48 hours, 14 days, and 28 days post birth, length of hospital stay, discharge within 7 days post birth, exclusive breastfeeding at 24 and 48 hours, 2 and 4 weeks, and 6 months postbirth, and mortality, readmission to hospital, and nutritional indicators at 6-12 months' age.


Notes52% of LBW infants met eligibility criteria.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskMinimization method by software "minim".

Allocation concealment (selection bias)Low riskSoftware automatically provided the random allocation for each participant.

Blinding of participants and personnel (performance bias)
All outcomes
High riskBlinding of participants: no/unfeasible; blinding of clinical staff: no/unfeasible.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskA neonatologist who was masked to the allocation of participants and who did not have any contact with participants, determined the classification of morbidities based on the interview records and medical charts.

Incomplete outcome data (attrition bias)
All outcomes
Low riskThere were no infants lost to follow up.

Selective reporting (reporting bias)Low riskAll outcomes stated in the methods section were adequately reported or explained in results

Other biasLow riskOther biases have not been identified.

Neu 2010

MethodsRandomized controlled trial carried out in Aurora (Colorado), United States.


ParticipantsNumber of infants: 60

Inclusion criteria: healthy infants with gestational age between 32 and 34 weeks, oxygen requirement <½ liter O2 per nasal cannula, infant without umbilical lines, intraventricular hemorrhage, physical anomalies, or anticipated major surgery, mother fluent in English or Spanish without recorded or stated illicit drug use, or diagnosis of serious chronic illness.

Exclusion criteria: unreported.

Infant's stabilization status at trial entry: stabilized.

Infant's age and weight at trial entry: mean age at recruitment and birthweight was 15.0 ± 6.7 and 15.0 ± 4.9 days, and 1990 ± 450 and 1880 ± 340 g for KMC and control infants, respectively.


InterventionsKMC group: infant in SSC on mother's chest for 60 consecutive minutes at least once daily during 8 weeks (n=31).

Control group: infant wrapped in blanket and held in mother's arms for 60 consecutive minutes at least once daily during 8 weeks (n=29).

In both conditions, weekly home visits by and experienced Registered Nurse included encouragement to hold the infant, emotional support, and information about infant behavior and development. Other control group received brief social visits, had no holding constraints and participated in all assessments. In the meta-analysis, we excluded results from this last control group.

Level of care: Initially at the hospital, then at home.

Human resources: nurses.

Criteria for infant discharge from the hospital: not applicable.

Scheme of follow up of infants after discharge: twice a week for 2 weeks followed by weekly visits for 6 months.


OutcomesMother-infant interaction at six months follow up and infant vitality during the neutral-face period of the Still-Face Procedure.


NotesNo data on percentage of LBW infants that met eligibility criteria. Approximately 60% of mothers who were approached declined to be in the study.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskComputer random number generator

Allocation concealment (selection bias)Low riskOpaque sealed envelopes

Blinding of participants and personnel (performance bias)
All outcomes
High riskBlinding of participants: no/unfeasible; blinding of clinical staff: no/unfeasible

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskFour researchers assessed outcome measures. Two outcome assessors 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

Incomplete outcome data (attrition bias)
All outcomes
High risk87 infants were randomized, 31 to KMC group, 29 to traditional holding and 36 to control group. At 6 months of age, 8 infants (9.2%) were lost to follow up and 14 (16.1%) were excluded (8 withdrawn by maternal reasons and 6 due to technical problems videotaping)

Selective reporting (reporting bias)Low riskAll outcomes stated in the methods section were adequately reported or explained in results

Other biasLow riskOther biases have not been identified

Ramanathan 2001

MethodsRandomized controlled trial conducted in New Delhi, India.


ParticipantsNumber of infants: 28

Inclusion criteria: infants with birthweight <1500 g, stable cardiopulmonary status, tolerating enteral feeds and maintaining temperature in the thermoneutral environment.

Exclusion criteria: infants whose mothers were unable to come to the nursery because of illness or disability.

Infant's stabilization status at trial entry: stabilized.

Infant's age and weight at trial entry: median age at initiation of KMC was 11.8 days. Mean birthweight was 1219 ± 186 and 1271 ± 170 g for KMC and control infants, respectively.


InterventionsKMC group: infants were kept between the mother's breasts, for at least 4 hours per day in not more than 3 sittings. The gown covered the baby's trunk and extremities but not the head. When not receiving KMC the infants received standard care under a warmer or incubator (n = 14).

Control group: infants were kept in a warmer or incubator. Mothers were allowed to visit their babies and touch and handle them (n = 14).

Breastfeeding guidelines were followed for both groups and lactational counseling was emphasized to ensure breast milk feeding.

Level of care: NICU of a tertiary care hospital.

Human resources: doctors and nurses.

Criteria for infant discharge from the hospital: weight >1400 g, “adequate” weight gain, gestation over 34 weeks, only on enteral feeds, no intravenous medications, no overt illness, exclusive breastfeeding, and mother confident of taking care of the infant at home.

Scheme of follow up of infants after discharge: unreported.


OutcomesWeight gain, breastfeeding, and duration of hospital.


NotesNo data on percentage of LBW infants that met eligibility criteria. Infants in the KMC group required positive pressure ventilation, continuous positive airway pressure, and oxygen therapy for more duration of time than the infants in the control group indicating that these infants were sicker before enrollment.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskRandom number table

Allocation concealment (selection bias)Unclear riskNo information provided

Blinding of participants and personnel (performance bias)
All outcomes
High riskBlinding of participants: no/unfeasible; blinding of clinical staff: no/unfeasible

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskUnreported

Incomplete outcome data (attrition bias)
All outcomes
Low riskThere were no infants lost to follow up

Selective reporting (reporting bias)Unclear riskDespite neonatal complications were prospectively recorded, they were not reported

Other biasLow riskOther biases have not been identified

Roberts 2000

MethodsRandomized controlled trial carried out in Darwin, Australia.


ParticipantsNumber of infants: 30

Inclusion criteria: premature or small for gestational age infants born at 30 or more weeks gestation or corrected age, with a five-minute Apgar of at least 5, medically stable, without congenital abnormalities or central nervous system impairment. Infants could have nasal continuous positive airway pressure in place or a nasal cannula. No data on percentage of LBW infants that met eligibility criteria.

Exclusion criteria: phototherapy within the previous 24 hours, resuscitated infants, and mothers with a history of drug use.

Infant's stabilization status at trial entry: stabilized.

Infant's age and weight at trial entry: mean age and weight at recruitment was 31.5 ± 2.7 days and 1690 ± 333 g, respectively.


InterventionsKMC group: infants were dressed only in a diaper, with addition of a bonnet for smaller infants. They were then placed on the mother's skin and covered with a light blanket. Mean duration of KMC was 1.6 ± 0.9 hours per day, five days a week (n = 16).

Control group: infants were swaddled in infant clothing and a light blanket. They had contact with the mother only through normal clothing (n = 14).

Breastfeeding was permitted as desired in both groups.

Level of care: neonatal intensive care nurseries of two hospitals.

Human resources: doctors and nurses.

Criteria for infant discharge from the hospital: unreported.

Scheme of follow up of infants after discharge: at 6 weeks after discharge or 3 months of age, whichever was later, and at 6 months' age.


OutcomesWeight gain, length of stay in hospital, temperature, and breastfeeding.


NotesNo data on percentage of LBW infants that met eligibility criteria.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskShuffling envelopes

Allocation concealment (selection bias)Low riskNumbered envelopes

Blinding of participants and personnel (performance bias)
All outcomes
High riskBlinding of participants: no/unfeasible; blinding of clinical staff: no/unfeasible

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskUnreported

Incomplete outcome data (attrition bias)
All outcomes
Low riskThere were no infants lost to follow up

Selective reporting (reporting bias)Low riskAll outcomes stated in the methods section were adequately reported or explained in results

Other biasLow riskOther biases have not been identified

Rojas 2003

MethodsRandomized controlled trial conducted in Connecticut, United States.


ParticipantsNumber of infants: 60

Inclusion criteria: very low birthweight infants (<1501 g) with gestational age ≤32 weeks, with minimal ventilatory support or extubated on nasal continuous positive airway pressure or nasal canula, and hemodynamic stability. 19% of LBW infants met eligibility criteria.

Exclusion criteria: mother's age <18 years, or if there was a history of illicit drug use during pregnancy, clinical evidence of perinatal asphyxia, potential transfer within the first month after birth, presence of a major congenital anomaly, planned adoption, Grade III or IV intraventricular hemorrhage, fetal growth restriction, or suspected sepsis.

Infant's stabilization status at trial entry: stabilized.

Infant's age and weight at trial entry: mean age and weight at trial entry was 19 days, and 1021 ± 268 and 1002 ± 219 g for KMC and control infants, respectively.


InterventionsKMC group: infants were held in a prone semi-upright position at approximately a 45° angle, in direct SSC with the parent's chest.The infants wore only a diaper, and their backs were covered with a blanket. Mean duration of KMC was 1.3 ± 0.7 hours per day for an average of 15 ± 16 days (n = 33).

Control group: parents removed their infants from the incubator and held them in their arms in supine position with eye-to-eye contact. The infant wore diapers and T-shirts and were wrapped in a blanket (n = 27).

Level of care: NICU of a hospital.

Human resources: doctors and nurses.

Criteria for infant discharge from the hospital: unreported.

Scheme of follow up of infants after discharge: not performed.


OutcomesMortality at discharge, sepsis, necrotizing enterocolitis, intraventricular hemorrhage, weight, head circumference, and length at discharge, rate of weight gain and head circumference growth, total weight gain and head circumference growth, breastfeeding at discharge, and hospital stay


Notes19% of LBW infants met eligibility criteria.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskRandom number table

Allocation concealment (selection bias)Low riskNumbered, sealed, opaque envelopes

Blinding of participants and personnel (performance bias)
All outcomes
High riskBlinding of participants: no/unfeasible; blinding of clinical staff: no/unfeasible

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskUnreported

Incomplete outcome data (attrition bias)
All outcomes
Low riskThere were no infants lost to follow up

Selective reporting (reporting bias)Low riskAll outcomes stated in the methods section were adequately reported or explained in results

Other biasLow riskOther biases have not been identified

Sloan 1994

MethodsRandomized controlled trial carried out in Quito, Ecuador.


ParticipantsNumber of infants: 300

Inclusion criteria: singleton infants weighing less than 2000 g, with no serious congenital abnormalities or respiratory, metabolic, or infectious disease. Infants had to be stabilized for the 24 h before enrolment (temperature between 36.5 and 37.0 ºC); acceptable tolerance of food; and stable weight.

Exclusion criteria: unreported.

Infant's stabilization status at trial entry: stabilized.

Infant's age and weight at trial entry: mean age and weight at recruitment was 13.0 ± 10.5 days, and 1618 ± 317 g, respectively.


InterventionsKMC group: infants were kept in an upright position, in SSC contact (diapers allowed) against the mother's breasts and had frequent breastfeeding. SSC was reported by 68% of mothers at 1 month, 47% at 1.5 months, 20% at 2 months, and 7% at 3 months follow up (n = 140).

Control group: infants stayed in an incubator or thermal crib and were breastfed at scheduled times (n = 160).

Level of care: NICU of a maternity hospital.

Human resources: doctors and nurses.

Criteria for infant discharge from the hospital: unreported.

Scheme of follow up of infants after discharge: at 1, 1.5, 2, 3, 4, 5, and 6 months' age.


OutcomesSevere illnesses (lower respiratory tract disorders, apnea, aspiration, pneumonia, septicemia, general infections), moderate illness (urinary infections), mild illnesses (upper respiratory tract disorders, dermatitis, jaundice, hip displacement), diarrhea, infant growth (weight, length, upper arm and head circumference), duration of hospital stay, re-admission, and costs of care.


Notes53% of LBW infants met eligibility criteria. Additional data provided by Dr Nancy L. Sloan.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskRandom number table

Allocation concealment (selection bias)Unclear riskNo information provided

Blinding of participants and personnel (performance bias)
All outcomes
High riskBlinding of participants: no/unfeasible; blinding of clinical staff: no/unfeasible

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskUnreported

Incomplete outcome data (attrition bias)
All outcomes
Low riskOutcome data were reported for 131 KMC infants and 152 controls. 17 infants (5.7%) lost to follow up (KMC 9, control 8); no exclusions

Selective reporting (reporting bias)Unclear riskSecondary outcomes such as Infant growth indices at follow up and costs of care were mentioned but not reported adequately

Other biasUnclear riskThe trial was stopped early because a highly significant difference (p<0.02 at 2 months, p<0.005 at 6 months) in severe morbidity arose. No information about whether this was a planned interim analysis

Suman 2008

MethodsRandomized controlled trial conducted in Mumbai, India.


ParticipantsNumber of infants: 220

Inclusion criteria: singleton infants with birthweight less than 2000 g.

Exclusion criteria: infants critically ill requiring ventilatory or inotropic support, or with chromosomal and life threatening congenital anomalies, or requiring transfer, or whose mothers were critically ill, or unable to comply with the follow up schedule.

Infant's stabilization status at trial entry: stabilized.

Infant's age and weight at trial entry: mean age and weight at recruitment was 3.7 ± 2.8 and 2.3 ± 1.9 days, and 1608 ± 278 and 1691 ± 273 g for KMC and control infants, respectively.


InterventionsKMC group: infants were kept in SSC using a specially tailored "kangaroo bag" made of soft flannel cloth on the reclining cot in the semi-upright position with the help of pillows. Mothers were encouraged to keep the baby in KMC as long as possible during the day and night with a minimum period of one to two hours at a time. When the baby was not in KMC, the baby was placed either under a servo controlled radiant warmer or in a cradle under hot lamp adequately clothed and covered. Mean duration of KMC was 13.5 hours per day with a mean total duration of 33.8 ± 15.1 days (n = 108).

Control group: infants were managed under a servo controlled radiant warmer or in a cradle under hot lamp in NICU adequately clothed and covered (n = 112).

All babies were exclusively breastfed. Infants who developed a life threatening event or required phototherapy were temporarily withdrawn from the KMC group.

Level of care: NICU of a tertiary care hospital.

Human resources: doctors and nurses.

Criteria for infant discharge from the hospital: weight gain of 10-15 g/kg/day for at least 3 consecutive days, maintenance of temperature without assistance, feeding well, and mother confident of taking care of the infant at home.

Scheme of follow up of infants after discharge: weekly until 40 weeks' postmenstrual age in preterm infants or until a weight of 2500 g was reached in term SGA infants.


OutcomesInfant growth (weight, length, head, chest, and mid-arm circumference, and foot length), mortality, morbidity (hypothermia, hyperthermia, hypoglycemia, sepsis, apnea in <1500 g, other minor illness), and duration of hospital stay.


Notes63% of LBW infants met eligibility criteria.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskSimple randomization

Allocation concealment (selection bias)Low riskSealed envelopes

Blinding of participants and personnel (performance bias)
All outcomes
High riskBlinding of participants: no/unfeasible; blinding of clinical staff: no/unfeasible

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskUnreported

Incomplete outcome data (attrition bias)
All outcomes
High risk49 infants (22.3%) were lost to follow up (KMC 11[10.2%], control 38 [33.9%]); 14 babies (6.4%) were excluded (KMC 5, control 9) because they did not receive assigned care

Selective reporting (reporting bias)Low riskAll outcomes stated in the methods section were adequately reported or explained in results

Other biasUnclear riskThe groups were different at baseline in two important variables: (1) weight at enrolment (1608 ± 278 and 1691 ± 273 g for KMC and control infants, respectively; P=0.03) and (2) age at enrolment (3.7 ± 2.8 and 2.3 ± 1.9 days for KMC and control infants, respectively; P<0.01)

Whitelaw 1988

MethodsRandomized controlled trial carried out in London, United Kinfdom.


ParticipantsNumber of infants: 71

Inclusion criteria: infants from singleton or twin pregnancy with weight less than 1500 g, stable breathing with no oxygen requirement, and a least one parent speaking fluent English. Stable infants were not excluded if they had congenital malformations such as hydronephrosis or scoliosis, nor if they had intracranial lesions such as periventricular leukomalacia or ventricular dilatation.

Exclusion criteria: unreported.

Infant's stabilization status at trial entry: stabilized.

Infant's age and weight at trial entry: mean (range) age at enrolment was 16 (1-66) days. Mean birthweight was 1152 ± 220 and 1135 ± 263 g for KMC and control infants, respectively.


InterventionsKMC group: infants were kept in an upright position, in SSC between the mother's breasts with a cardiac or respiration monitor attached. Mean (range) duration of KMC was 0.6 (0-1.5) hours per day (n = 35).

Control group: mother was encouraged to visit as much as she liked and helped to take her baby out of the incubator for a cuddle. However, baby and mother remained clothed. Care was taken that the normal contact group would have no less attention from the nursing staff (n = 36).

Level of care: NICU of a hospital.

Human resources: doctors and nurses.

Criteria for infant discharge from the hospital: unreported.

Scheme of follow up of infants after discharge: at 6, 9, and 12 months' age.


OutcomesBreastfeeding and infant's behaviour at 6 months of age, and mother's feelings about the infant at discharge and 6 months of age.


Notes50% of LBW infants met eligibility criteria.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskShuffling envelopes

Allocation concealment (selection bias)Low riskSequentially numbered, sealed, opaque envelopes

Blinding of participants and personnel (performance bias)
All outcomes
High riskBlinding of participants: no/unfeasible; blinding of clinical staff: no/unfeasible

Blinding of outcome assessment (detection bias)
All outcomes
High riskNo

Incomplete outcome data (attrition bias)
All outcomes
Low riskThere were no infants lost to follow up

Selective reporting (reporting bias)Unclear riskNon-significant results for some outcome measures (e.g. mother's feelings about the infant at discharge and at 6 months follow up) were mentioned but not reported adequately

Other biasLow riskOther biases have not been identified

Worku 2005

MethodsRandomized controlled trial carried out in Addis Ababa, Ethiopia.


ParticipantsNumber of infants: 123

Inclusion criteria: infants with birthweight less than 2000 g, singletons unless one of the twins died, no major congenital malformation, and mother healthy and willing to participate.

Exclusion criteria: unreported.

Infant's stabilization status at trial entry: non-stabilized.

Infant's age and weight at trial entry: mean age at enrolment and birthweight was 10.0 and 9.8 hours, and 1515 and 1472 g for KMC and control infants, respectively.


InterventionsEarly KMC group: infants were kept in continuous SSC with their mother beginning immediately after birth or within the first 24 hours of life (before stabilization). The mother kept her newborn infant between the breasts, in close contact with her body and covered with her clothes day and night. Breastfeeding was the standard feeding method. However, the mother could also fed her baby with formula milk using tube or cup when needed. KMC could be combined with a heated room during low environmental temperatures (n = 62).

Control group: infants were kept in a heated room overhead lamp warmers with oxygen therapy, and breast, tube, cup, or mixed feeding (n = 61).

The two methods of care were applied and continued until the baby was considered stabilized (stable temperature, stabilized cardiovascular status, satisfactory ability to suck, and good general condition) and then both group of babies were transferred to the ward routine Kangaroo care service. KMC was continued at home after discharge in both groups.

Level of care: neonatal unit of a teaching hospital.

Human resources: doctors and nurses.

Criteria for infant discharge from the hospital: (1) for discharge from the study to the ward routine kangaroo care service: stable temperature, stabilized cardiovascular status, satisfactory ability to suck, and good general condition. (2) for discharge from the hospital: "according to the hospital's protocol".

Scheme of follow up of infants after discharge: unreported.


OutcomesDeath, serious illness (sepsis, diarrhea, pneumonia, aspiration, pneumonia), and mothers' feeling towards the method of care.


Notes48% of LBW infants met eligibility criteria.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskRandom number table

Allocation concealment (selection bias)Unclear riskNo information provided

Blinding of participants and personnel (performance bias)
All outcomes
High riskBlinding of participants: no/unfeasible; blinding of clinical staff: no/unfeasible

Blinding of outcome assessment (detection bias)
All outcomes
High riskNo

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskThere was no information on infants lost to follow up or exclusions

Selective reporting (reporting bias)High riskThe great majority of outcomes listed in the Methods section of the article, such as weight gain, mild/moderate and severe illness, sepsis, diarrhea, pneumonia, aspiration, and mother's feelings, were collected but not reported

Other biasLow riskOther biases have not been identified

 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Ahn 2010Not a randomized controlled trial

Anderson 2003The study compared SSC (N=48) and standard care (N=43) in preterm infants born at 32-36 weeks' gestation with birth weight between 1300 and 3000 g. No data on daily duration of KMC. Study did not report results for clinical outcomes

Arandia 1993Not a randomized controlled trial

Bera 2014Not a randomized controlled trial

Bergman 1994Not a randomized controlled trial

Bergman 2004The study compared SSC (N=21) from birth and standard care (N=14) in LBW infants. The study period was 6 hours. The study only reported results for physiological parameters. Newborns receiving SSC from birth were significantly advantaged in some measures of cardiorespiratory stability

Charpak 1994Not a randomized controlled trial

Chiu 2009The study compared early KMC (N=52) and standard care (N=48) in late preterm infants (32 to <37 weeks' gestation). The study included infants with birthweight ≥2500 g. No data for subgroup of infants <2500 g at birth. KMC infants had lower infant teaching scores at six months than controls, a difference that disappeared thereafter. Feeding scores at 6 and 12 months follow up were similar for KMC infants and controls

Christensson 1998The study compared SSC and incubator care for rewarming in 80 low-risk hypothermic infants (clinically stable with admission weight of ≥1500 g).

Chwo 2002The study compared SSC (N=17) and standard contact (N=17) in infants born at 34-36 weeks' gestation. 20 of 34 included infants (59%) had a birthweight >2500 g. No data for the remaining 14 LBW infants

Dala Sierra 1994Not a randomized controlled trial

Darmstadt 2006The study evaluated acceptance of KMC within a trial of impact of a package of essential newborn care

de Almeida 2010Not a randomized controlled trial

de Macedo 2007Not a randomized controlled trial

Feldman 2002Not a randomized controlled trial

Gregson 2011Not a randomized controlled trial

Hake Brooks 2008The study compared KMC (N=36) and standard care (N=30) in preterm infants. The study included infants with birthweight of 1300-3000 g. 39% of included infants had a gestational age of 36 weeks. No data for subgroup of infants <2500 g at birth. KMC was associated with a significant longer breastfeeding duration and a higher frequency of exclusive breastfeeding at discharge, and at 1.5, 3, and 6 months

Huang 2006The study compared early KMC (N=39) and use of radiant warmers (N=39) in term infants with hypothermia problems. Mean (SD) birthweight was 3072 (393) and 2808 (428) g for KMC and control infants, respectively. After 4 hours, more infants in the KMC group had reached normal body temperature

Ibe 2004Not a randomized controlled trial

Kambarami 1998Quasi-random allocation to treatment (alternation). 74 (37 per group) infants were subjected to KMC or incubator care. Infants in the KMC group had higher mean daily weight gain, shorter stay in hospital, and better survival rates

Kumar 2008Cluster randomized controlled trial in which SSC was part of a preventive package of interventions for essential newborn care

Lai 2006The study compared music during KMC (N=15) and standard care (N=15) in preterm infants. The study included infants with birthweight of 1505-3285 g. No data for subgroup of infants <2500 g at birth. In addition, the study did not report results for clinical outcomes

Lamy Filho 2008Not a randomized controlled trial

Legault 1993Participant allocation was by a crossover recruitment design. Study did not report results for clinical outcomes

Legault 1995Not a randomized controlled trial

Lincetto 2000Not a randomized controlled trial

Lizarazo-Medina 2012Not a randomized controlled trial

Ludington-Hoe 1991Randomized controlled trial that compared KMC and standard care in cardiorespiratory, thermal and state effects in preterm infants. No data on neonatal morbidity and mortality.

Ludington-Hoe 2000Randomized controlled trial that compared KMC (N=16) and standard care (N=13) in maintenance of body warmth in preterm infants. No data on neonatal morbidity and mortality

Ludington-Hoe 2004Randomized controlled trial that compared KMC (N=11) and standard care (N=13) for assessment of cardiorespiratory and thermal responses in preterm infants. No data on neonatal morbidity and mortality.

Ludington-Hoe 2006Randomized controlled trial that compared KMC (N=14) and standard care (N=14) for assessment of neonatal sleep organization in preterm infants. No data on neonatal morbidity and mortality

Miles 2006The study was a pragmatic, controlled trial in which participant allocation was by a crossover, cluster recruitment design between two tertiary referral NICUs. Each hospital remained in KMC or control group for 4 months and then crossed over following a wash-out phase, during which no recruitment was undertaken. No significant difference was found in any infant or maternal measure at any time point

Miltersteiner 2005Quasi-random allocation to treatment (even or odd number). Length of hospital stay was 8±1 days for the KMC group and 10±1.9 days for the control group (P=0.004)

Mitchell 2013Thirty-eight infants (27-30 weeks of gestational age) were randomly assigned to 2 hours of KMC daily between days of life 5 to 10 or to standard incubator care. The study only reported results for physiological parameters. Infants allocated to KMC had significantly fewer events of bradycardia and oxygen desaturation than infants allocated to the standard care

Ohgi 2002Not a randomized controlled trial

Sloan 2008Randomized controlled cluster trial in which 4165 infants were assigned to community-based KMC or control. 40% overall and 65% of newborns who died were not weighed at birth, and missing birthweight was differential for study group. 68.6% of weighed infants had a birthweight ≥2500 g. There was no difference in overall neonatal mortality rate or infant mortality rate

Tallandini 2006Not a randomized controlled trial

Udani 2008Published as abstract only. Insufficient information to include this study in the systematic review and attempts to locate full publication or to contact the author unsuccessful

 
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 age8Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    1.1 All studies
81736Risk Ratio (M-H, Fixed, 95% CI)0.60 [0.39, 0.92]

    1.2 Intermittent KMC
5619Risk Ratio (M-H, Fixed, 95% CI)0.59 [0.19, 1.81]

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

    1.4 Duration of KMC <2 hours/day
2188Risk Ratio (M-H, Fixed, 95% CI)1.32 [0.22, 7.73]

    1.5 Duration of KMC between 8 and 15 hours/day
3431Risk Ratio (M-H, Fixed, 95% CI)0.34 [0.07, 1.64]

    1.6 Duration of KMC ≥20 hours/day
31117Risk Ratio (M-H, Fixed, 95% CI)0.60 [0.38, 0.96]

    1.7 Infant age ≤10 days at initiation of KMC
51412Risk Ratio (M-H, Fixed, 95% CI)0.56 [0.36, 0.88]

    1.8 Infant age >10 days at initiation of KMC
3324Risk Ratio (M-H, Fixed, 95% CI)1.32 [0.22, 7.73]

    1.9 Low/middle-income countries
71676Risk Ratio (M-H, Fixed, 95% CI)0.57 [0.37, 0.89]

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

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

    1.12 infant entered into trial after stabilization
71613Risk Ratio (M-H, Fixed, 95% CI)0.63 [0.32, 1.23]

 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)0.0 [0.0, 0.0]

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

 4 Mortality at latest follow up11Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

    4.1 All studies
112167Risk Ratio (M-H, Fixed, 95% CI)0.67 [0.48, 0.95]

    4.2 Intermittent KMC
7783Risk Ratio (M-H, Fixed, 95% CI)0.68 [0.26, 1.77]

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

    4.4 Duration of KMC <2 hours/day
3259Risk Ratio (M-H, Fixed, 95% CI)1.18 [0.32, 4.30]

    4.5 Duration of KMC between 8 and 15 hours/day
4524Risk Ratio (M-H, Fixed, 95% CI)0.34 [0.07, 1.64]

    4.6 Duration of KMC ≥20 hours/day
41384Risk Ratio (M-H, Fixed, 95% CI)0.67 [0.46, 0.98]

    4.7 Infant age ≤10 days at initiation of KMC
61489Risk Ratio (M-H, Fixed, 95% CI)0.56 [0.37, 0.85]

    4.8 Infant age >10 days at initiation of KMC
5678Risk Ratio (M-H, Fixed, 95% CI)1.03 [0.53, 2.00]

    4.9 Low/middle-income countries
92036Risk Ratio (M-H, Fixed, 95% CI)0.65 [0.45, 0.93]

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

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

    4.12 infant entered into trial after stabilization
102044Risk Ratio (M-H, Fixed, 95% CI)0.73 [0.47, 1.13]

 5 Severe infection/sepsis at latest follow up - stabilized infants71343Risk Ratio (M-H, Fixed, 95% CI)0.56 [0.40, 0.78]

    5.1 Intermittent
6680Risk Ratio (M-H, Fixed, 95% CI)0.45 [0.28, 0.73]

    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)0.0 [0.0, 0.0]

    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 infants3913Risk Ratio (M-H, Fixed, 95% CI)0.45 [0.27, 0.76]

    7.1 Intermittent
2250Risk Ratio (M-H, Fixed, 95% CI)0.39 [0.16, 0.96]

    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)0.0 [0.0, 0.0]

    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)0.0 [0.0, 0.0]

    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 infants6698Risk Ratio (M-H, Random, 95% CI)0.34 [0.17, 0.67]

    11.1 Intermittent
6698Risk Ratio (M-H, Random, 95% CI)0.34 [0.17, 0.67]

   11.2 Continuous
00Risk Ratio (M-H, Random, 95% CI)0.0 [0.0, 0.0]

 12 Hyperthermia at discharge or 40-41 weeks' postmenstrual age - stabilized infants4448Risk Ratio (M-H, Fixed, 95% CI)0.79 [0.59, 1.05]

    12.1 Intermittent
4448Risk Ratio (M-H, Fixed, 95% CI)0.79 [0.59, 1.05]

   12.2 Continuous
00Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 13 Length of hospital stay (days) - stabilized infants10931Mean Difference (IV, Random, 95% CI)-2.17 [-3.72, -0.63]

    13.1 Intermittent
10931Mean Difference (IV, Random, 95% CI)-2.17 [-3.72, -0.63]

   13.2 Continuous
00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]

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

   14.1 Intermittent
00Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

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

 15 Weight at discharge or 40-41 weeks' postmenstrual age (g) - stabilized infants51233Mean Difference (IV, Fixed, 95% CI)16.07 [-20.54, 52.68]

    15.1 Intermittent
3285Mean Difference (IV, Fixed, 95% CI)41.84 [-19.19, 102.87]

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

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

   16.1 Intermittent
00Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

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

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

   17.1 Intermittent
00Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

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

 18 Weight gain at latest follow up (g/day) - stabilized infants101072Mean Difference (IV, Random, 95% CI)3.74 [1.92, 5.56]

    18.1 Intermittent
9787Mean Difference (IV, Random, 95% CI)3.75 [1.75, 5.74]

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

 19 Length at discharge or 40-41 weeks' postmenstrual age (cm) - stabilized infants3856Mean Difference (IV, Random, 95% CI)-0.11 [-0.69, 0.48]

    19.1 Intermittent
2193Mean Difference (IV, Random, 95% CI)-0.24 [-1.51, 1.04]

    19.2 Continuous
1663Mean Difference (IV, Random, 95% CI)0.0 [-0.36, 0.36]

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

   20.1 Intermittent
00Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

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

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

   21.1 Intermittent
00Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

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

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

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

   22.2 Continuous
00Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

 23 Head circumference at discharge or 40-41 weeks' postmenstrual age (cm) - stabilized infants3856Mean Difference (IV, Random, 95% CI)0.17 [-0.33, 0.66]

    23.1 Intermittent
2193Mean Difference (IV, Random, 95% CI)0.24 [-0.84, 1.31]

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

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

   24.1 Intermittent
00Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

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

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

   25.1 Intermittent
00Mean Difference (IV, Fixed, 95% CI)0.0 [0.0, 0.0]

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

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

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

   26.2 Continuous
00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]

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

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

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

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

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

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

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

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

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

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

 31 Exclusive breastfeeding at discharge or 40-41 weeks' postmenstrual age - stabilized infants51333Risk Ratio (M-H, Random, 95% CI)1.20 [1.07, 1.34]

    31.1 Intermittent
3391Risk Ratio (M-H, Random, 95% CI)1.27 [1.14, 1.42]

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

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

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

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

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

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

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

 34 Any breastfeeding at discharge or 40-41 weeks' postmenstrual age - stabilized infants91576Risk Ratio (M-H, Random, 95% CI)1.20 [1.06, 1.36]

    34.1 Intermittent
7634Risk Ratio (M-H, Random, 95% CI)1.24 [1.04, 1.49]

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

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

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

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

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

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

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

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

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

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

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

   38.1 Intermittent
00Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

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

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

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

   39.2 Continuous
00Mean Difference (IV, Random, 95% CI)0.0 [0.0, 0.0]

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

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

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

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

 41 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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 42 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

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

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

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

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

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

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

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

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

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

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

    42.11 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]

    42.12 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]

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

    42.14 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]

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

    42.16 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]

    42.17 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]

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

    42.19 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]

    42.20 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]

 43 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

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

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

    43.3 Clarity of cues - interval >14 days
1141Mean Difference (IV, Fixed, 95% CI)0.0 [-0.05, 0.05]

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

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

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

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

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

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

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

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

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

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

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

    45.2 Infant appearance score
130Mean Difference (IV, Fixed, 95% CI)0.0 [-0.62, 0.62]

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

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

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

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

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

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

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

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

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

    48.1 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 Readmission 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 Hyperthermia173Risk Ratio (M-H, Fixed, 95% CI)1.05 [0.56, 1.99]

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

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

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

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

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

 8 Exclusive breastfeeding1Risk Ratio (M-H, Fixed, 95% CI)Subtotals only

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

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

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

    8.4 At 6 months of age
155Risk Ratio (M-H, Fixed, 95% CI)2.69 [0.99, 7.31]

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

 10 Mortality at 6 months of age172Risk Ratio (M-H, Fixed, 95% CI)1.0 [0.15, 6.72]

 11 Readmission to hospital at 6-12 months of age172Risk Ratio (M-H, Fixed, 95% CI)1.0 [0.32, 3.16]

 12 Stunting at 6-12 months of age155Risk Ratio (M-H, Fixed, 95% CI)0.83 [0.46, 1.48]

 13 Severe stunting at 6-12 months of age155Risk Ratio (M-H, Fixed, 95% CI)0.67 [0.17, 2.73]

 14 Wasting at 6-12 months of age155Risk Ratio (M-H, Fixed, 95% CI)0.1 [0.01, 1.77]

 15 Severe wasting at 6-12 months of age155Risk Ratio (M-H, Fixed, 95% CI)0.0 [0.0, 0.0]

 16 Underweight at 6-12 months of age155Risk Ratio (M-H, Fixed, 95% CI)0.49 [0.21, 1.14]

 17 Severe underweight at 6-12 months of age155Risk Ratio (M-H, Fixed, 95% CI)0.22 [0.03, 1.88]