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Meta-Analysis
. 2016 Aug 23;2016(8):CD002771.
doi: 10.1002/14651858.CD002771.pub4.

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

Agustin Conde-Agudelo  1 , José L Díaz-Rossello
Affiliations
Meta-Analysis

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

Agustin Conde-Agudelo et al. Cochrane Database Syst Rev. .

Abstract

Background: Kangaroo mother care (KMC), originally defined as skin-to-skin contact between a mother and her newborn, frequent and exclusive or nearly exclusive breastfeeding, and early discharge from hospital, has been proposed as an alternative to conventional neonatal care for low birthweight (LBW) infants.

Objectives: To determine whether evidence is available to support the use of KMC in LBW infants as an alternative to conventional neonatal care before or after the initial period of stabilization with conventional care, and to assess beneficial and adverse effects.

Search methods: We used the standard search strategy of the Cochrane Neonatal Review Group. This included searches in CENTRAL (Cochrane Central Register of Controlled Trials; 2016, Issue 6), MEDLINE, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), LILACS (Latin American and Caribbean Health Science Information database), and POPLINE (Population Information Online) databases (all from inception to June 30, 2016), as well as the WHO (World Health Organization) Trial Registration Data Set (up to June 30, 2016). In addition, we searched the web page of the Kangaroo Foundation, conference and symposia proceedings on KMC, and Google Scholar.

Selection criteria: Randomized controlled trials comparing KMC versus conventional neonatal care, or early-onset KMC versus late-onset KMC, in LBW infants.

Data collection and analysis: Data collection and analysis were performed according to the methods of the Cochrane Neonatal Review Group.

Main results: Twenty-one studies, including 3042 infants, fulfilled inclusion criteria. Nineteen studies evaluated KMC in LBW infants after stabilization, one evaluated KMC in LBW infants before stabilization, and one compared early-onset KMC with late-onset KMC in relatively stable LBW infants. Sixteen studies evaluated intermittent KMC, and five evaluated continuous KMC. KMC versus conventional neonatal care: At discharge or 40 to 41 weeks' postmenstrual age, KMC was associated with a statistically significant reduction in the risk of mortality (risk ratio [RR] 0.60, 95% confidence interval [CI] 0.39 to 0.92; eight trials, 1736 infants), nosocomial infection/sepsis (RR 0.35, 95% CI 0.22 to 0.54; five trials, 1239 infants), and hypothermia (RR 0.28, 95% CI 0.16 to 0.49; nine trials, 989 infants; moderate-quality evidence). At latest follow-up, KMC was associated with a significantly decreased risk of mortality (RR 0.67, 95% CI 0.48 to 0.95; 12 trials, 2293 infants; moderate-quality evidence) and severe infection/sepsis (RR 0.50, 95% CI 0.36 to 0.69; eight trials, 1463 infants; moderate-quality evidence). Moreover, KMC was found to increase weight gain (mean difference [MD] 4.1 g/d, 95% CI 2.3 to 5.9; 11 trials, 1198 infants; moderate-quality evidence), length gain (MD 0.21 cm/week, 95% CI 0.03 to 0.38; three trials, 377 infants) and head circumference gain (MD 0.14 cm/week, 95% CI 0.06 to 0.22; four trials, 495 infants) at latest follow-up, exclusive breastfeeding at discharge or 40 to 41 weeks' postmenstrual age (RR 1.16, 95% CI 1.07 to 1.25; six studies, 1453 mothers) and at one to three months' follow-up (RR 1.20, 95% CI 1.01 to 1.43; five studies, 600 mothers), any (exclusive or partial) breastfeeding at discharge or at 40 to 41 weeks' postmenstrual age (RR 1.20, 95% CI 1.07 to 1.34; 10 studies, 1696 mothers; moderate-quality evidence) and at one to three months' follow-up (RR 1.17, 95% CI 1.05 to 1.31; nine studies, 1394 mothers; low-quality evidence), and some measures of mother-infant attachment and home environment. No statistically significant differences were found between KMC infants and controls in Griffith quotients for psychomotor development at 12 months' corrected age (low-quality evidence). Sensitivity analysis suggested that inclusion of studies with high risk of bias did not affect the general direction of findings nor the size of the treatment effect for main outcomes. Early-onset KMC versus late-onset KMC in relatively stable infants: One trial compared early-onset continuous KMC (within 24 hours post birth) versus late-onset continuous KMC (after 24 hours post birth) in 73 relatively stable LBW infants. Investigators reported no significant differences between the two study groups in mortality, morbidity, severe infection, hypothermia, breastfeeding, and nutritional indicators. Early-onset KMC was associated with a statistically significant reduction in length of hospital stay (MD 0.9 days, 95% CI 0.6 to 1.2).

Authors' conclusions: Evidence from this updated review supports the use of KMC in LBW infants as an alternative to conventional neonatal care, mainly in resource-limited settings. Further information is required concerning the effectiveness and safety of early-onset continuous KMC in unstabilized or relatively stabilized LBW infants, as well as long-term neurodevelopmental outcomes and costs of care.

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Conflict of interest statement

None.

Figures

1
1
Study flow diagram: review update
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
3
3
Forest plot of comparison: 1 Kangaroo mother care versus conventional neonatal care, outcome: 1.1 Mortality at latest follow‐up.
4
4
Forest plot of comparison: 1 Kangaroo mother care versus conventional neonatal care, outcome: 1.2 Severe infection/sepsis at latest follow‐up ‐ stabilized infants.
5
5
Forest plot of comparison: 1 Kangaroo mother care versus conventional neonatal care, outcome: 1.10 Weight gain at latest follow‐up (g/d) ‐ stabilized infants.
6
6
Forest plot of comparison: 1 Kangaroo mother care versus conventional neonatal care, outcome: 1.34 Any breastfeeding at discharge or at 40 to 41 weeks' postmenstrual age ‐ stabilized infants.
1.1
1.1. Analysis
Comparison 1 Kangaroo mother care versus conventional neonatal care, Outcome 1 Mortality at discharge or at 40 to 41 weeks' postmenstrual age.
1.2
1.2. Analysis
Comparison 1 Kangaroo mother care versus conventional neonatal care, Outcome 2 Mortality at 6 months of age or 6 months' follow‐up.
1.3
1.3. Analysis
Comparison 1 Kangaroo mother care versus conventional neonatal care, Outcome 3 Mortality at 12 months' corrected age.
1.4
1.4. Analysis
Comparison 1 Kangaroo mother care versus conventional neonatal care, Outcome 4 Mortality at latest follow‐up.
1.5
1.5. Analysis
Comparison 1 Kangaroo mother care versus conventional neonatal care, Outcome 5 Severe infection/sepsis at latest follow‐up ‐ stabilized infants.
1.6
1.6. Analysis
Comparison 1 Kangaroo mother care versus conventional neonatal care, Outcome 6 Severe illness at 6 months' follow‐up ‐ stabilized infants.
1.7
1.7. Analysis
Comparison 1 Kangaroo mother care versus conventional neonatal care, Outcome 7 Nosocomial infection/sepsis at discharge or at 40 to 41 weeks' postmenstrual age ‐ stabilized infants.
1.8
1.8. Analysis
Comparison 1 Kangaroo mother care versus conventional neonatal care, Outcome 8 Mild/moderate infection or illness at latest follow‐up ‐ stabilized infants.
1.9
1.9. Analysis
Comparison 1 Kangaroo mother care versus conventional neonatal care, Outcome 9 Lower respiratory tract disease at 6 months' follow‐up ‐ stabilized infants.
1.10
1.10. Analysis
Comparison 1 Kangaroo mother care versus conventional neonatal care, Outcome 10 Diarrhea at 6 months' follow‐up ‐ stabilized infants.
1.11
1.11. Analysis
Comparison 1 Kangaroo mother care versus conventional neonatal care, Outcome 11 Hypothermia at discharge or at 40 to 41 weeks’ postmenstrual age ‐ stabilized infants.
1.12
1.12. Analysis
Comparison 1 Kangaroo mother care versus conventional neonatal care, Outcome 12 Hyperthermia at discharge or at 40 to 41 weeks' postmenstrual age ‐ stabilized infants.
1.13
1.13. Analysis
Comparison 1 Kangaroo mother care versus conventional neonatal care, Outcome 13 Length of hospital stay (days) ‐ stabilized infants.
1.14
1.14. Analysis
Comparison 1 Kangaroo mother care versus conventional neonatal care, Outcome 14 Re‐admission to hospital at latest follow‐up ‐ stabilized infants.
1.15
1.15. Analysis
Comparison 1 Kangaroo mother care versus conventional neonatal care, Outcome 15 Weight at discharge or at 40 to 41 weeks' postmenstrual age (g) ‐ stabilized infants.
1.16
1.16. Analysis
Comparison 1 Kangaroo mother care versus conventional neonatal care, Outcome 16 Weight at 6 months' corrected age (g) ‐ stabilized infants.
1.17
1.17. Analysis
Comparison 1 Kangaroo mother care versus conventional neonatal care, Outcome 17 Weight at 12 months' corrected age (g) ‐ stabilized infants.
1.18
1.18. Analysis
Comparison 1 Kangaroo mother care versus conventional neonatal care, Outcome 18 Weight gain at latest follow‐up (g/d) ‐ stabilized infants.
1.19
1.19. Analysis
Comparison 1 Kangaroo mother care versus conventional neonatal care, Outcome 19 Length at discharge or at 40 to 41 weeks' postmenstrual age (cm) ‐ stabilized infants.
1.20
1.20. Analysis
Comparison 1 Kangaroo mother care versus conventional neonatal care, Outcome 20 Length at 6 months' corrected age (cm) ‐ stabilized infants.
1.21
1.21. Analysis
Comparison 1 Kangaroo mother care versus conventional neonatal care, Outcome 21 Length at 12 months' corrected age (cm) ‐ stabilized infants.
1.22
1.22. Analysis
Comparison 1 Kangaroo mother care versus conventional neonatal care, Outcome 22 Length gain at latest follow‐up (cm/wk) ‐ stabilized infants.
1.23
1.23. Analysis
Comparison 1 Kangaroo mother care versus conventional neonatal care, Outcome 23 Head circumference at discharge or at 40 to 41 weeks' postmenstrual age (cm) ‐ stabilized infants.
1.24
1.24. Analysis
Comparison 1 Kangaroo mother care versus conventional neonatal care, Outcome 24 Head circumference at 6 months' corrected age (cm) ‐ stabilized infants.
1.25
1.25. Analysis
Comparison 1 Kangaroo mother care versus conventional neonatal care, Outcome 25 Head circumference at 12 months' corrected age (cm) ‐ stabilized infants.
1.26
1.26. Analysis
Comparison 1 Kangaroo mother care versus conventional neonatal care, Outcome 26 Head circumference gain at latest follow‐up (cm/wk) ‐ stabilized infants.
1.27
1.27. Analysis
Comparison 1 Kangaroo mother care versus conventional neonatal care, Outcome 27 Psychomotor development (Griffith quotients) at 12 months' corrected age.
1.28
1.28. Analysis
Comparison 1 Kangaroo mother care versus conventional neonatal care, Outcome 28 Cerebral palsy at 12 months' corrected age.
1.29
1.29. Analysis
Comparison 1 Kangaroo mother care versus conventional neonatal care, Outcome 29 Deafness at 12 months' corrected age.
1.30
1.30. Analysis
Comparison 1 Kangaroo mother care versus conventional neonatal care, Outcome 30 Visual impairment at 12 months' corrected age.
1.31
1.31. Analysis
Comparison 1 Kangaroo mother care versus conventional neonatal care, Outcome 31 Exclusive breastfeeding at discharge or at 40 to 41 weeks' postmenstrual age ‐ stabilized infants.
1.32
1.32. Analysis
Comparison 1 Kangaroo mother care versus conventional neonatal care, Outcome 32 Exclusive breastfeeding at 1 to 3 months' follow‐up ‐ stabilized infants.
1.33
1.33. Analysis
Comparison 1 Kangaroo mother care versus conventional neonatal care, Outcome 33 Exclusive breastfeeding at 6 to 12 months' follow‐up ‐ stabilized infants.
1.34
1.34. Analysis
Comparison 1 Kangaroo mother care versus conventional neonatal care, Outcome 34 Any breastfeeding at discharge or at 40 to 41 weeks' postmenstrual age ‐ stabilized infants.
1.35
1.35. Analysis
Comparison 1 Kangaroo mother care versus conventional neonatal care, Outcome 35 Any breastfeeding at 1 to 2 months' follow‐up ‐ stabilized infants.
1.36
1.36. Analysis
Comparison 1 Kangaroo mother care versus conventional neonatal care, Outcome 36 Any breastfeeding at 3 months' follow‐up ‐ stabilized infants.
1.37
1.37. Analysis
Comparison 1 Kangaroo mother care versus conventional neonatal care, Outcome 37 Any breastfeeding at 1 to 3 months' follow‐up ‐ stabilized infants.
1.38
1.38. Analysis
Comparison 1 Kangaroo mother care versus conventional neonatal care, Outcome 38 Any breastfeeding at 6 months' follow‐up ‐ stabilized infants.
1.39
1.39. Analysis
Comparison 1 Kangaroo mother care versus conventional neonatal care, Outcome 39 Any breastfeeding at 12 months' follow‐up ‐ stabilized infants.
1.40
1.40. Analysis
Comparison 1 Kangaroo mother care versus conventional neonatal care, Outcome 40 Onset of breastfeeding (days) ‐ stabilized infants.
1.41
1.41. Analysis
Comparison 1 Kangaroo mother care versus conventional neonatal care, Outcome 41 Parental and familial satisfaction (continuous KMC).
1.42
1.42. Analysis
Comparison 1 Kangaroo mother care versus conventional neonatal care, Outcome 42 Mother‐infant attachment: mother's feelings and perceptions according to interval between birth and start of intervention, and infant admission to NICU.
1.43
1.43. Analysis
Comparison 1 Kangaroo mother care versus conventional neonatal care, Outcome 43 Mother‐infant attachment: mother's responses to the infant according to interval between birth and start of intervention, and infant admission to NICU.
1.44
1.44. Analysis
Comparison 1 Kangaroo mother care versus conventional neonatal care, Outcome 44 Mother‐infant attachment: infant's responses to the mother according to interval between birth and start of intervention, and infant admission to NICU.
1.45
1.45. Analysis
Comparison 1 Kangaroo mother care versus conventional neonatal care, Outcome 45 Mother‐infant attachment at 3 months' follow‐up.
1.46
1.46. Analysis
Comparison 1 Kangaroo mother care versus conventional neonatal care, Outcome 46 Mother‐infant attachment: stress in NICU.
1.47
1.47. Analysis
Comparison 1 Kangaroo mother care versus conventional neonatal care, Outcome 47 Mother‐infant attachment: parenting skills.
1.48
1.48. Analysis
Comparison 1 Kangaroo mother care versus conventional neonatal care, Outcome 48 Mother‐infant interaction at 6 months' follow‐up.
1.49
1.49. Analysis
Comparison 1 Kangaroo mother care versus conventional neonatal care, Outcome 49 Infant behavior at 40 to 44 weeks’ postmenstrual age.
1.50
1.50. Analysis
Comparison 1 Kangaroo mother care versus conventional neonatal care, Outcome 50 Social and home environment.
2.1
2.1. Analysis
Comparison 2 Early versus late kangaroo mother care in relatively stable LBW infants, Outcome 1 Mortality at 4 weeks of age.
2.2
2.2. Analysis
Comparison 2 Early versus late kangaroo mother care in relatively stable LBW infants, Outcome 2 Morbidity at 4 weeks of age.
2.3
2.3. Analysis
Comparison 2 Early versus late kangaroo mother care in relatively stable LBW infants, Outcome 3 Severe infection at 4 weeks of age.
2.4
2.4. Analysis
Comparison 2 Early versus late kangaroo mother care in relatively stable LBW infants, Outcome 4 Re‐admission to hospital at 4 weeks of age.
2.5
2.5. Analysis
Comparison 2 Early versus late kangaroo mother care in relatively stable LBW infants, Outcome 5 Hypothermia.
2.6
2.6. Analysis
Comparison 2 Early versus late kangaroo mother care in relatively stable LBW infants, Outcome 6 Hyperthermia.
2.7
2.7. Analysis
Comparison 2 Early versus late kangaroo mother care in relatively stable LBW infants, Outcome 7 Weight gain (grams).
2.8
2.8. Analysis
Comparison 2 Early versus late kangaroo mother care in relatively stable LBW infants, Outcome 8 Exclusive breastfeeding.
2.9
2.9. Analysis
Comparison 2 Early versus late kangaroo mother care in relatively stable LBW infants, Outcome 9 Length of hospital stay (days).
2.10
2.10. Analysis
Comparison 2 Early versus late kangaroo mother care in relatively stable LBW infants, Outcome 10 Mortality at 6 months of age.
2.11
2.11. Analysis
Comparison 2 Early versus late kangaroo mother care in relatively stable LBW infants, Outcome 11 Re‐admission to hospital at 6 to 12 months of age.
2.12
2.12. Analysis
Comparison 2 Early versus late kangaroo mother care in relatively stable LBW infants, Outcome 12 Stunting at 6 to 12 months of age.
2.13
2.13. Analysis
Comparison 2 Early versus late kangaroo mother care in relatively stable LBW infants, Outcome 13 Severe stunting at 6 to 12 months of age.
2.14
2.14. Analysis
Comparison 2 Early versus late kangaroo mother care in relatively stable LBW infants, Outcome 14 Wasting at 6 to 12 months of age.
2.15
2.15. Analysis
Comparison 2 Early versus late kangaroo mother care in relatively stable LBW infants, Outcome 15 Severe wasting at 6 to 12 months of age.
2.16
2.16. Analysis
Comparison 2 Early versus late kangaroo mother care in relatively stable LBW infants, Outcome 16 Underweight at 6 to 12 months of age.
2.17
2.17. Analysis
Comparison 2 Early versus late kangaroo mother care in relatively stable LBW infants, Outcome 17 Severe underweight at 6 to 12 months of age.
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References

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Ludington‐Hoe 2000 {published data only}
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Mitchell 2013 {published data only}
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References to studies awaiting assessment

Holditch‐Davis 2014 {published data only}
    1. Holditch‐Davis D, White‐Traut R, Levy J, Williams KL, Ryan D, Vonderheid S. Maternal satisfaction with administering infant interventions in the neonatal intensive care unit. Journal of Obstetric, Gynecologic and Neonatal Nursing 2013;42(6):641‐54. - PMC - PubMed
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