Kangaroo mother care to reduce morbidity and mortality in low-birth-weight infants
Current evidence suggests that kangaroo mother care is an effective and safe alternative to conventional neonatal care in low-birth-weight infants in under-resourced settings. The potential beneficial effects of kangaroo mother care on morbidity and mortality is expected to be greatest in settings in which conventional neonatal care is unavailable.
RHL Commentary by Bergh A-M
Kangaroo mother care (KMC) was first practised in 1978 in Bogotá, Colombia. It involves skin-to-skin positioning of the infant in an upright position against the mother’s chest. The two other components of KMC are frequent and exclusive breastfeeding (where possible) and early discharge from hospital (regardless of weight or gestational age), but with frequent follow-up visits to the health centre. Infants can be cared for in the kangaroo position intermittently (for a number of hours per day) or continuously (> 20 hours per day) (1).
Almost all (99%) of the 4 million neonatal (in the first 4 weeks of life) deaths worldwide occur in low- and middle-income countries. Three quarters of these deaths occur in the first week of life. Preterm birth is estimated to be the direct cause of 28% of neonatal deaths worldwide (2). Although KMC has been promoted since its inception as one of the strategies for reducing neonatal mortality in low-birth-weight (LBW) infants (3, 4), Cochrane reviews published in 2000 and 2003 had concluded that "there was insufficient evidence to recommend the routine use of KMC in LBW infants“ (5, 6). This commentary pertains to the 2011 updated of the same review. The authors of the updated review had the same objective of determining whether KMC could be used effectively in LBW infants as an alternative to conventional neonatal care (7).
2. METHODS OF THE REVIEW
The review authors used the Cochrane Neonatal Review Group’s standard search strategy to identify relevant studies. Additional sources were also searched. The unit of analysis was the LBW infant with a birth weight of <2500 g, regardless of gestational age. Randomized controlled trials were considered for inclusion. Trials with quasi-randomized and cross-over design were excluded, as were studies on physiological parameters only, or those in which KMC was a part of a package of interventions. Two review authors extracted the data independently. They also assessed the risk of bias in the included studies.
Different stages of life were identified for evaluating the outcomes: at discharge or at 40–41 weeks’ postmenstrual age; at latest follow-up; at 6 months of age or 6 months' follow-up; and at 12 months’ corrected age. The primary outcomes selected as clinical measures of effectiveness and safety for infants were mortality, severe infection/sepsis, severe illness, infant growth (weight, length, head circumference) and neurodevelopmental disability. The clinical measures selected as secondary outcomes included other clinical conditions (nosocomial infection/sepsis, mild/moderate infection or illness, lower respiratory tract disease, diarrhoea, admission to hospital), breast-feeding, length of hospital stay, costs of care, and psychosocial outcomes (mother–infant attachment or interaction, satisfaction with care, home environment and father's involvement).
3. RESULTS OF THE REVIEW
Out of the 49 studies identified, 16 (comprising 2518 infants) were included. KMC in LBW infants was evaluated in 14 studies after stabilization (11 using intermittent KMC and three continuous KMC), in one study before stabilization, and in one study comparing early onset with late onset of KMC. The study settings included 11 low- or middle-income countries and five high-income countries. A further subgroup of analysis was performed to compare KMC initiated at <10 days versus >10 days after birth.
At discharge or at 40–41 weeks’ postmenstrual age, KMC was associated with a significant reduction in the risk of: mortality [typical risk ratio (RR) 0.60; 95% confidence interval (CI) 0.39–0.93]; nosocomial infection/sepsis (typical RR 0.42; 95% CI 0.24–0.73); and hypothermia (typical RR 0.23; 95% CI 0.10–0.55). There was also a reduction in the length of hospital stay for KMC infants [typical mean difference (MD) 2.4 days; 95% CI 0.7–4.1]. At latest follow-up, KMC was associated with a reduction in the risk of mortality (typical RR 0.68; 95% CI 0.48–0.96) and severe infection/sepsis (typical RR 0.57; 95% CI 0.40–0.80).
KMC was also found to increase some of the measures of infant growth, breast-feeding and mother–infant attachment. There was, however, high heterogeneity among the trials reporting on infant growth and breast-feeding. Measures of mother–infant attachment were mostly reported in only one trial.
At latest follow-up visit, compared with controls, KMC infants showed statistically significant gains in weight (typical MD 3.9 g; 95% CI 1.9–5.8), length (typical MD 0.29 cm; 95% CI 0.27–0.31), and head circumference (typical MD 0.18 cm; 95% CI 0.09–0.27).
Mothers of KMC infants were more likely than mothers of control infants to be exclusively and/or partially breastfeeding at discharge or at 40–41 weeks’ corrected gestational age (typical RR 1.25; 95% CI 1.06–1.47), at 1–2 months follow-up (typical RR 1.33; 95% CI 1.00–1.78), and 3 months follow-up (typical RR 1.14; 95% CI 1.06–1.23).
In one trial KMC mothers demonstrated higher levels of satisfaction with the method of caring than mothers in the control group. In another trial KMC mothers scored more positively than the controls on certain scale items related to a sense of competence, levels of worry and stress, and sensitivity towards the infant. In the same trial, kangaroo care families scored significantly higher than conventional care families on home environment.
In the one study reporting on neurodevelopmental outcomes at one year of corrected age, no statistically significant differences were found between KMC and control infants in terms of psychomotor development, cerebral palsy, deafness and visual impairment. No study reported data suitable for an in-depth cost-of-care analysis.
4.1 Applicability of the results
KMC is an effective and safe alternative to conventional neonatal care for the management of LBW infants, especially in under-resourced settings. The beneficial effects of KMC on infant mortality and morbidity could be used as further evidence to promote the wide-scale adoption and implementation of KMC as part of efforts to reach the Millennium Development Goals on child survival.
The breakdown of evidence for subgroups (e.g. low- and middle-income countries versus high-income countries and continuous versus intermittent KMC) opens up the possibility for a more precise definition of outcomes in future interventions involving KMC. In under-resourced settings where incubators or radiant warmers are scarce, interventions that include KMC should strongly focus on reducing neonatal mortality and morbidity. Evidence from high-income countries suggests that KMC can potentially be used to improve breast-feeding rates in those settings.
4.2 Implementing the Intervention
Implementation of KMC can be initiated at the institutional or health-system level. Implementation of the skin-to-skin and breast-feeding components of KMC will require little additional resources with minimal cost implications for health-care facilities. For initiating the practise of continuous KMC, additional space may be required at health-centres to accommodate mother–infant dyads.
Currently, KMC forms part of many newborn care packages rolled out in under-resourced settings. The orientation of health-care workers in KMC implementation is important and could either be integrated into these packages or provided separately, depending on the needs of a particular setting. However, if a specific focus on translating KMC knowledge and skills into practice is absent, there will be a danger of KMC declining in priority when too many new demands are simultaneously placed on already overburdened health-care workers. Guidance on how to deal with resistance to KMC from mothers and communities would also need to be developed.
4.3 Implications for research
More methodologically rigorous trials are needed to explore further the effectiveness of early-onset and continuous use of KMC in low-income settings, for both unstabilized and relatively stabilized LBW infants. Also, randomized trials with an adequate sample size are needed to evaluate the impact of KMC (continuous or intermittent) on infant morbidity in high-income settings. Other research areas include long-term neurodevelopment outcomes related to KMC and outcomes of mother–infant attachment. Also needed are well-designed economic evaluations to assess the cost–effectiveness of KMC in all types of setting. Before assessing the effect of community-based KMC programmes on neonatal mortality, additional trials are recommended to ensure baseline comparability of mortality, adequate KMC implementation, and birth weight assessment.
Only one trial included in this review had the KMC component of early discharge in its design. More trials on the effects of early discharge of KMC infants from a health-care facility are needed. Where appropriate, this could be combined with trials investigating community-based KMC programmes.
Sources of support: South African Medical Research Council Maternal and Infant Health Care Strategies Research Unit and the University of Pretoria, South Africa.
Acknowledgements: Dr Elise van Rooyen, Department of Paediatrics, Kalafong Hospital, University of Pretoria, South Africa.
- Charpak N, Ruiz JG, Zupan J, Cattaneo A, Figueroa Z, Tessier R, et al. Kangaroo mother care: 25 years after. Acta Paediatrica 2005; 94:514-522.
- Lawn J, Cousens S, Zupan J, for the Lancet Neonatal Survival Steering Team. 4 million neonatal deaths: When? Where? Why? The Lancet 2005; 365:891-900.
- Kinney MV, Lawn, JE, Kerber KJ (ed). Science in action: saving the lives of Africa’s mothers, newborns, and children. Cape Town, South Africa: Report for the African Academy Science Development Initiative; 2009.
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This document should be cited as: Bergh A-M. Kangaroo mother care to reduce morbidity and mortality in low-birth-weight infants (last revised: 1 September 2011). The WHO Reproductive Health Library; Geneva: World Health Organization.