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Cot-nursing versus incubator care for preterm infants

  • Conclusions changed
  • Review
  • Intervention


  • Peter H Gray,

    Corresponding author
    1. University of Queensland, Newborn Services, South Brisbane, Queensland, Australia
    • Peter H Gray, Newborn Services, University of Queensland, Mater Mothers' Hospital, Raymond Tce, South Brisbane, Queensland, 4101, Australia.

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  • Vicki Flenady

    1. Mater Health Services, Translating Research Into Practice (TRIP) Centre - Mater Medical Research Institute, Woolloongabba, Queensland, Australia
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Preterm infants are usually nursed in incubators, but cot-nursing may provide an alternative. While there may be benefits of nursing preterm infants in open cots, there may be potential risks such as nosocomial infection caused by more handling due to easier access.


To assess effects of cot-nursing versus incubator care on temperature control and weight gain in preterm infants.

Search methods

The standard search strategy of the Cochrane Neonatal Review Group was used. This included searches of electronic databases including the Cochrane Central Register of Controlled Trials (The Cochrane Library), Oxford Database of Perinatal Trials, MEDLINE, CINAHL, and EMBASE, as well as previous reviews including cross references through November 2009.

Selection criteria

All trials using random or quasi-random patient allocation in which infants receiving care in standard newborn cots were compared to infants managed in a conventional air heated incubator.

Data collection and analysis

The authors independently assessed trial quality and extracted data for the primary outcomes of temperature control and weight gain. Meta-analysis was conducted using a fixed-effect model.

Main results

Eleven potential studies were identified of which five, involving 247 infants, were included in this review. When compared to incubator care, cot-nursing resulted in no significant difference in mean body temperature (MD 0.02 degrees C; 95% CI -0.02 to 0.07, four trials), though the one trial that reported on episodes of hyperthermia found this to be statistically more common in the cot-nursing group (RR 1.48; 95% CI 1.04 to 2.09). There were no statistically significant differences in weight gain. In the cot-nursing group, fewer infants were breast fed on discharge (typical RR 0.74; 95% CI 0.48 to 1.14, three trials, 150 infants) and fewer infants died prior to hospital discharge (typical RR 0.59, 95% CI 0.28 to 1.25, four trials, 235 infants) but these results failed to reach statistical significance. The comparison of cot-nursing using a heated water-filled mattress versus incubator care, which included five trials and a total of 231 infants, produced similar results. Cot-nursing with warming of the nursery resulted in statistically significantly smaller weight gain during week one compared to the incubator group in one trial that involved 38 infants (MD -5.90 g/kg/day; 95% CI -11.13 to -0.67) but no significant difference was found for weeks two and three.

Authors' conclusions

Cot-nursing using a heated water-filled mattress has similar effects to incubator care with regard to temperature control and weight gain. Important clinical outcomes need to be investigated further using randomised controlled trials. This is especially the case in the situation of developing countries, where differences in these outcomes are likely to be encountered. As limited data is available on cot-nursing using a space-heated room, this method is not recommended as practice.



Atención en la cuna versus atención en incubadora para niños prematuros

Habitualmente, a los neonatos prematuros se les atiende en incubadoras, aunque la atención en la cuna puede ser una alternativa. Si bien la atención de niños prematuros en cunas abiertas brinda beneficios, también implica riesgos potenciales tales como la infección nosocomial causada por una mayor manipulación debida a un acceso más fácil.


Evaluar los efectos de la atención en la cuna versus la atención en incubadora sobre el control de la temperatura y el aumento de peso en los neonatos prematuros.

Estrategia de búsqueda

Se utilizó la estrategia de búsqueda estándar del Grupo Cochrane de Neonatología (Cochrane Neonatal Review Group). Se hicieron búsquedas en las bases de datos electrónicas, incluyendo el Registro Cochrane Central de Ensayos Controlados (Cochrane Central Register of Controlled Trials) (The Cochrane Library), Oxford Database of Perinatal Trials, MEDLINE, CINAHL y EMBASE, así como en revisiones anteriores, incluidas las referencias cruzadas hasta noviembre 2009.

Criterios de selección

Todos los ensayos que utilizaron asignación de los pacientes al azar o casi al azar en los cuales los neonatos recibieron atención en las cunas estándar para recién nacidos se compararon con neonatos tratados en una incubadora convencional de aire caliente.

Obtención y análisis de los datos

Los autores evaluaron independientemente la calidad de los ensayos y obtuvieron datos para los resultados primarios de control de temperatura y aumento de peso. Se realizó el metanálisis usando el modelo de efectos fijos.

Resultados principales

Se identificaron 11 estudios potenciales y en esta revisión se incluyeron cinco, con 247 neonatos. En comparación con la atención en incubadora, la atención en la cuna no dio lugar a diferencias significativas en la temperatura corporal media (DM 0,02 grados C; IC del 95%: −0,02 a 0,07; cuatro ensayos), aunque el único ensayo que informó episodios de hipertermia encontró que la misma fue estadísticamente más frecuente en el grupo de atención en la cuna (RR 1,48; IC del 95%: 1,04 a 2,09). No hubo diferencias estadísticamente significativas en el aumento de peso. En el grupo de atención en la cuna, menos neonatos lactaban en el momento del alta hospitalaria (RR típico 0,74; IC del 95%: 0,48 a 1,14; tres ensayos, 150 neonatos) y menos neonatos murieron antes del alta hospitalaria (RR típico 0,59; IC del 95%: 0,28 a 1,25; cuatro ensayos, 235 neonatos), pero estos resultados no alcanzaron significación estadística. La comparación de atención en la cuna con un colchón de agua térmico versus la atención en incubadora, que incluyó cinco ensayos y 231 neonatos, produjo resultados similares. En un ensayo con 38 neonatos, la atención en la cuna con climatización de la unidad de recién nacidos dio lugar a un menor aumento de peso estadísticamente significativo durante la primera semana en comparación con el grupo de atención en incubadora (DM −5,90 g/kg/día; IC del 95%: −11,13 a −0,67), pero no se encontraron diferencias significativas durante las semanas dos y tres.

Conclusiones de los autores

La atención en la cuna con un colchón de agua térmico tiene efectos similares a la atención en incubadora con respecto al control de la temperatura y al aumento de peso. Es necesario investigar más a fondo resultados clínicos importantes mediante ensayos controlados aleatorios. Lo anterior es especialmente importante en los países en desarrollo, donde es probable que se encuentren diferencias en estos resultados. Como los datos disponibles sobre la atención en la cuna en una sala con climatización ambiental son limitados, este método no se recomienda como práctica.


Traducción realizada por el Centro Cochrane Iberoamericano

Plain language summary

Cot-nursing versus incubator care for preterm infants

Prematurely born infants are usually nursed in incubators to provide the warmest environment possible. Using cots instead of incubators, allows mothers to have easier access to their babies. However, additional warmth is needed to maintain their body temperature, such as extra clothing, bedding and a heated room. This updated review randomly assigned 247 preterm infants (in five trials), to an intervention of cot-nursing using a heated water-filled mattress. The control babies received routine care in an air heated incubator. One trial had three-arms, including cot-nursing in a room heated with a manually controlled space heater. In the included trials infants in the incubator groups were nursed naked apart from wearing a nappy, except in one trial in which the infants also wore a cotton jacket and booties. Three comparisons were undertaken: the overall comparison of cot-nursing versus incubator care, and two subgroup comparisons: cot-nursing with heated water-filled mattress versus incubator care, and cot-nursing using warming of the nursery versus incubator care. The results of the review showed no evidence of effect of cot-nursing versus incubator care on weight gain in the overall analysis, or in the subgroup analysis comparing cot-nursing using a heated water-filled mattress with incubator care. However, cot-nursing with warming of the nursery during week one when compared to incubator care revealed poorer weight gain. The primary outcomes related to temperature control (mean body temperature and episodes of cold stress) indicated on overall analysis no effect of cot-nursing compared to incubator care. Episodes of hyperthermia in the cot-nursing group were reported more frequently in one trial. The secondary outcomes of oxygen consumption, breast feeding at hospital discharge, episodes of nosocomial sepsis, maternal perceptions of infant's condition, maternal stress and anxiety and death prior to hospital discharge revealed there was no effect of cot-nursing compared to incubator care. There was, however, a strong trend towards less death prior to hospital discharge. This was largely related to the results were obtained from the trials undertaken in Turkey and Ethiopia and thus may not be applicable to neonatal nurseries in developed countries. Nevertheless the implications of these findings deserve consideration, particularly in the context of a developing country.