Kangaroo mother care to reduce morbidity and mortality in low-birth-weight infants
Kangaroo mother care appears to be an attractive alternative to conventional interventions in the care of low-birth-weight infants in under-resourced settings. With one third reduction in mortality among low-birth-weight neonates at a potentially lower cost and fewer health-care resources, evidence from this Cochrane review supports the use of this method on a large scale.
RHL Commentary by Sachdev HPS, Shah D
Low-birth-weight (LBW) is an important contributor to neonatal deaths, 99% of which occur in low- and middle-income countries (1, 2). Conventional care of LBW neonates in hospital settings is prolonged and expensive. In under-resourced and overcrowded settings, these problems are further compounded by the lack of sufficiently trained personnel and associated risk of nosocomial infections. Thus, there has been an obvious need to develop simple and low-cost strategies that would reduce morbidity and mortality in LBW neonates and allow greater participation of mothers and families in the care LBW neonates. Kangaroo mother care (KMC), which involves skin-to-skin contact between the mother and her newborn, frequent and exclusive breastfeeding, and early discharge from hospital, has been proposed as one such strategy. In KMC practice, the neonate is placed vertically between the mother’s breasts and wrapped firmly by a sheet, blanket or mother’s clothing. This Cochrane review (3) examines whether there is evidence to support the use of KMC in LBW infants as an alternative to conventional neonatal care before or after the initial period of stabilization with conventional care.
2. METHODS OF THE REVIEW
This review authors planned to include randomized controlled trials and cluster randomized trials comparing KMC with conventional neonatal care in LBW (birth weight < 2500 g) infants. For this 2011 updated review, trials were included irrespective of the timing (early onset or late onset) of KMC, duration (continuous or intermittent) of KMC or stabilization status (before or after stabilization) of the neonate. KMC was defined as continuous or intermittent skin-to-skin contact between the caregiver and the baby irrespective of the breast-feeding pattern or time of discharge from hospital. Conventional care in the included studies involved infant stay in incubator or radiant warmer. Quasi-randomized and crossover-design trials were excluded, as were studies in which KMC was part of a package of interventions for newborn care. The primary outcomes assessed were mortality at discharge or 40–41 weeks' gestational age, mortality at various follow-up periods, severe infection/sepsis/illness, infant growth at various follow-up periods, and neurodevelopmental disability at 12 months of corrected age. Secondary outcomes included nosocomial infection/sepsis, hypothermia, breast-feeding, length of hospital stay, mild/moderate infection or illness, and parental satisfaction.
The review authors planned subgroup analyses for the primary outcome according to type of KMC (intermittent versus continuous), early onset versus late onset of KMC (< 24 hours versus > 24 hours post birth), setting in which the trial was conducted (low-/middle-income countries versus high-income countries), and infant stabilization status at trial entry (before versus after). The authors did not plan a subgroup analyses according to birth weight, gestational age, and type of LBW due to limited availability of such information from the included studies.
The search of relevant studies was detailed and as per criteria Cochrane Pregnancy and Childbirth Group. All studies up to January 2011 were included. The review authors made an attempt to retrieve also ongoing studies by searching databases of literature, but this search was mainly limited to databases from developed countries. Since one-third of included published studies were from India, the authors should have searched the Clinical Trials Registry of India (CTRI) to identify ongoing studies from this region. Quality assessment for the risk of bias in the included studies was done using the dimensions outlined in the Cochrane Handbook for Systematic Reviews of Interventions, and sensitivity analyses were undertaken to explore the impact of the level of bias. Results were presented as risk ratio (RR) with 95% confidence interval (CI). The number needed to treat (NNT) for benefit or harm was calculated for outcomes for which there was a statistically significant reduction in risk difference.
3. RESULTS OF THE REVIEW
Sixteen randomized controlled trials of KMC involving 2518 LBW infants were included in this review. Fourteen trials evaluated KMC in LBW infants after stabilization, one evaluated it before stabilization, and one compared early onset KMC (starting within 24 hours of birth) with late onset of KMC in relatively stable LBW infants. Eleven studies had been conducted in low- or middle-income countries (five in India; one each in Ecuador, Ethiopia, Colombia, Madagascar and Malaysia; and one multicentre study had been conducted in Ethiopia, Indonesia and Mexico) and five in high-income countries (three in the USA and one each in Australia and the United Kingdom). In all the included studies, KMC involved skin-to-skin contact and breast-feeding was encouraged and early neonatal discharge from hospital was considered in one study only. Among the studies evaluating KMC in stabilized LBW infants, 11 had used intermittent KMC and three had used continuous KMC. A detailed definition of stabilization was provided in one study only.
Fourteen of the 16 included studies had enrolled LBW infants irrespective of their gestational age, whereas two had enrolled only preterm neonates. All except one study had enrolled neonates with birth weight of < 2000 g. The mean or median weight of infants at recruitment ranged from 968–2076 g (median 1595 g).
Meta-analysis of the results from seven trials (1641 infants) revealed that KMC was associated with a lower risk of mortality (RR 0.60, 95% CI 0.39–0.93) at discharge from hospital or at 40–41 weeks' gestational age, as well as at latest follow up (RR 0.68, 95% CI 0.48–0.96; nine trials, 1952 infants). The lower risk of mortality was also demonstrated in the subgroup of studies conducted in low- and middle-income countries (mortality at discharge or at 40–41 weeks’ corrected gestational age: RR 0.58, 95% CI 0.37–0.90; six trials, 1554 infants; mortality a latest follow up: RR 0.65, 95% CI 0.45–0.93; seven trials, 1821 infants). The beneficial effect of KMC in terms of both mortality at discharge or at 40–41 weeks’ corrected gestational age and mortality at latest follow-up was not demonstrated in the subgroup of trials that used intermittent KMC or those that had initiated KMC after 10 days post birth, or that were conducted in high-income countries, or that had used KMC in stabilized infants. In the sensitivity analysis limited to the studies with low risk of attrition bias, reduction in mortality at discharge or at 40–41 weeks’ postmenstrual age (RR 0.65, 95% CI 0.42–1.01) and at latest follow-up (RR 0.71, 95% CI 0.50 to 1.01) was not statistically significant.
In stabilized LBW infants, KMC was also associated with a statistically significant reduction in severe infection/sepsis at latest follow-up (7.2% versus 12.6%; RR 0.57, 95% CI 0.40–0.80; six trials, 1250 infants), nosocomial infection/sepsis at discharge or at 40–41 weeks’ corrected gestational age (4.2% versus 10.1%; typical RR 0.42, 95% CI 0.24–0.73; two trials, 777 infants), hypothermia at discharge or at 40–41 weeks’ corrected gestational age (7.6% versus 32.0%; RR 0.23, 95% CI 0.10–0.55; four trials, 469 infants), and length of hospital stay (mean difference 2.4 days, 95% CI 0.7–4.1). The beneficial effect on severe infection/sepsis at latest follow up and hypothermia was maintained when only high-quality trials were included. There was, however, no overall difference in the risk of mild/moderate infection or illness at latest follow up. KMC infants gained more weight per day (mean difference 3.9 g, 95% CI 1.9–5.8; nine trials, 936 infants) and length (mean difference 0.29 cm, 95% CI 0.27–0.31; two trials, 251 infants) and head circumference (mean difference 0.18 cm, 95% CI 0.09–0.27; three trials, 369 infants). However, there was considerable heterogeneity among trials reporting weight gain. No significant differences between the groups in anthropometric indices were noted during the various follow-up points.
Compared with conventional care, KMC was associated with an increase in the likelihood of exclusive breast-feeding at discharge or at 40 – 41 weeks’ postmenstrual age (67.4% versus 56.8%; RR 1.21, 95% CI 1.08–1.36; four trials, 1197 mothers) and at 1–3 months follow-up (86.9% versus 76.5%; RR 1.20, 95% CI 1.01–1.43; five studies, 600 mothers). No study reported analysable data on the costs of the two interventions, but two studies reported lower cost of treatment with the KMC strategy. Results from a single study showed similar neurodevelopment between the two groups at one year of age.
4.1 Applicability of the results
KMC appears to be an attractive alternative to conventional interventions in the care of LBW infants in under-resourced settings. With one third reduction in mortality among LBW neonates at a potentially lower cost and fewer health-care resources, evidence from this Cochrane review supports the use of this method on a large scale.
Six out of seven trials reporting primary outcome of mortality were from South Asia – the “hot bed” of LBW infants. A substantial difference in mortality between two groups was attributable to a trial from Ethiopia (4) that evaluated effectiveness of early KMC in non-stabilized LBW neonates, and reported a very high (30%) mortality rate in enrolled infants. Thus, the benefit of KMC appear to be greatest in under-resourced settings with a high baseline mortality rate in hospitalized LBW neonates. The lower risk of nosocomial infections and severe sepsis documented with the KMC strategy also makes it very useful for overcrowded health-care settings with limited resources. Almost all studies included in this review enrolled neonates with birth weight of < 2000 g. Hence, the results are applicable to this subgroup of LBW neonates.
In a multicentre study (5), mothers were more satisfied with KMC than with conventional care. However, maternal acceptability of placing the baby for prolonged periods in skin-to-skin contact between her breasts in other hot and humid conditions has not yet been proven conclusively.
The limitations of the review are primarily due to the mixed nature of the LBW neonates included in the trials. Babies with LBW are a heterogeneous population made up of both preterm and growth-impaired neonates whose prognosis is distinctly different (6). Therefore, stratification would have been most useful. Another concern is the lack of details about conventional care in most of the included trials. The inability of the trials to control for conventional care could possibly have confounded the results, as conventional care was non-standardized unlike the KMC method. Also, for the control groups, the review does not provide detailed information on the nature and intensity of maternal involvement in neonatal care. The absence of blinding in the included trials is another potential source of bias as the nature of intervention did not allow for blinding.
4.2 Implementing the Intervention
Implementation of the KMC method in developing countries will require a major shift in national health-care guidelines. There will also be a need to improve the availability of health-care personnel, well trained in educating women for applying the technique correctly (7). This may be feasible in selected hospitals but may be more difficult to achieve at the national level. Transfer of the gains achieved in hospitals to communities will also pose major challenges. Problems with the implementation of KMC were encountered in a community-based cluster randomized trial that showed no benefit of such an approach on neonatal mortality (8). Suboptimal implementation (whereby infants received a few hours of care that was promptly discontinued) and poor transfer of training and messages to mothers resulted in no overall benefit.
4.3 Implications for research
There is a need to look into the effect of KMC on LBW infants stratified by weight and gestation. The effect of prolonged immobilization on bone mineral metabolism of LBW infants also merits exploration. As most of the deliveries in many developing countries occur at home, and even hospitalized infants are discharged early, large-scale community based trials are needed to document the effectiveness of KMC in LBW neonates in under-resourced settings. Feasibility and acceptability of the KMC strategy incorporated in the routine neonatal care also needs to be evaluated outside the research setting. Well-designed economic evaluations are needed to assess the cost-effectiveness of KMC in different socioeconomic settings. The acceptability of KMC in socially and culturally sensitive populations from different settings of South Asia also need a careful examination.
Source of support: None.
- Lawn JE, Wilczynska-Ketende K, Cousens SN. Estimating the causes of 4 million neonatal deaths in the year 2000. International Journal of Epidemiology 2006;35:706-718.
- Million Death Study collaborators. Causes of neonatal and child mortality in India: nationally representative mortality survey. The Lancet 2010;376:1853-1860.
- Conde-Agudelo A, Belizán JM, Diaz-Rossello J. Kangaroo mother care to reduce morbidity and mortality in low birthweight infants. Cochrane Database of Systematic Reviews 2011;Issue 3. Art. No.: CD002771; DOI: 10.1002/14651858.CD002771.pub2.
- Worku B, Kassie A. Kangaroo mother care: a randomized controlled trial on effectiveness of early kangaroo mother care for the low birthweight infants in Addis Ababa, Ethiopia. Journal of Tropical Pediatrics 2005;51:93–97.
- Cattaneo A, Davanzo R, Worku B, Surjono A, Echeverria M, Bedri A, et al. Kangaroo mother care for low birthweight infants: a randomized controlled trial in different settings. Acta Paediatrica 1998;87:976–985.
- Sachdev HPS. Low birth weight in South Asia. In: Gillespie SR, ed. Malnutrition in South Asia: a regional profile. ROSA Publication No. 5. Kathmandu: UNICEF Regional Office for South Asia; 1997.
- Lincetto O, Nazir AI, Cattaneo A. Kangaroo mother care with limited resources. Journal of Tropical Pediatrics 2000;46:293-295.
This document should be cited as: Sachdev H.P.S., Shah D. 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.