NIHR DC Discover

NIHR Signal Kangaroo mother care may boost the survival of newborn, premature babies

Published on 23 February 2016

doi: 10.3310/signal-000202

Kangaroo mother care reduced the death rate of newborns by around a quarter compared with conventional care, according to a review of studies from around the world. Other positive outcomes included lower risk of neonatal sepsis, hypothermia, hypoglycaemia, hospital readmission and higher exclusive breast feeding rates.

Kangaroo care definitions vary by study, but typically promote mother and baby skin-to-skin contact, sometimes in combination with other elements like promoting breast feeding, and early supported discharge from hospital. Most of the studies in this review looked at premature babies born before 37 weeks and some studies were in low or middle income countries.

Prolonged skin-to-skin contact with parents is already common practice in the UK and is promoted by organisations supporting the parents of premature babies. Kangaroo mother care is also broadly in line with options for mothers given in 2006 NICE guidance. So, overall practice in the UK has already moved on. The uptake of the kangaroo care could be informed by further research, for example, comparing various aspects of care such as duration of skin-to-skin contact or the specific practices used in a UK setting.

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Why was this study needed?

Effective health resources such as incubators can help improve outcomes for high-risk infants born prematurely or with low birth weight. But in low- and middle-income countries, where 99% of all newborn deaths occur, such equipment can be scarce. As the scale of infant deaths in the first four weeks is huge, estimated as four million babies per year in 2005 worldwide, alternatives are needed.

Kangaroo mother care was first developed in Colombia (a middle-income country) in the late 1970s. The basic definitions describe skin-to-skin contact by placing the baby on the mother’s skin soon after birth and keeping it there. Other explanations add exclusive breast feeding and going home early from the health facility.

Research-to-date has focused on kangaroo care in low birth weight babies, individual aspects such as skin-to-skin contact only, or a limited number of health outcomes.

This was the first comprehensive review to draw on trials and observational studies on kangaroo mother care’s impact on a wide range of health outcomes for premature and full term babies around the world.

What did this study do?

This systematic review included 124 studies including 55 trials on at least one health outcome of kangaroo mother care. The search included research databases from all World Health Organization (WHO) regions of the world and was not restricted by language. To be included, studies needed a comparison group and at least ten participants. There was no restriction by baby’s gestational age or weight.

This was a large and rigorously designed review; however, 60% of the included studies were based in middle- or low-income countries. This limits applicability to the UK because of potentially different definitions of conventional care, which were not described.

The WHO listed four key features of kangaroo mother care as:

  • placing the baby on the mother’s skin soon after birth, and leaving the baby there,
  • breastfeeding only as the baby’s sole source of food,
  • going home early from the clinic or hospital,
  • follow up at home by health professionals.

Most studies (68%) defined kangaroo mother care as skin-to-skin contact only. A further 13% defined kangaroo mother care as skin-to-skin contact plus promotion of exclusive breastfeeding. However, it was not possible to separate out the effects of skin-to-skin contact or breastfeeding alone, versus kangaroo mother care as a whole.

What did it find?

Compared with conventional care, kangaroo mother care was associated with lower mortality, lower risk of neonatal sepsis, hypothermia, hypoglycaemia, hospital readmission and exclusive breast feeding. Newborns receiving kangaroo mother care also showed improved vital signs for respiratory rate, pain measures, oxygen saturation, temperature and head circumference.

For example, compared with conventional care:

  • Pooled results of 16 studies showed that babies receiving kangaroo mother care had a 23% lower risk of death by the latest time assessed in each study (relative risk [RR] 0.77, 95% confidence interval [CI] 0.60 to 0.99).
  • Likelihood of exclusive breastfeeding at hospital discharge increased for kangaroo mother care babies by 50% in pooled results from 13 studies (RR 1.50, 95% CI 1.26 to 1.78). This was the case for most subgroups of different study types, babies or kangaroo mother care characteristics.
  • Pooled results from nine studies showed that receiving kangaroo mother care was associated with lower risk of hypothermia kangaroo mother care did not significantly reduce mortality in two studies including all birth weights – this had not been examined in previous reviews.

Among studies reporting gestational age, the majority (n = 61, 68%) were among preterm infants <37 weeks’ gestation; 17 (19%) were among full term infants, defined as ≥37 weeks, and 12 (13%) were among infants of all gestational ages.

What does current guidance say on this issue?

Guidance from UNICEF UK, published in 2012, recommends kangaroo care as part of its Baby Friendly Initiative standards. It does not focus on care of premature or low birth weight babies.

The London-based charities BLISS and Best Beginnings have produced resources on skin-to-skin contact for parents of premature or sick babies. These include Best Beginnings’ videos on skin-to-skin contact kangaroo care for both parents, using a sling.

A 2006 NICE guideline on postnatal care supports breastfeeding, and encourages skin contact between the mother and baby soon after birth. It does not specifically cover kangaroo mother care, or address kangaroo mother care as a care approach for premature or low birth weight babies.

What are the implications?

Conventional care was not described in this review and may mean different things in different countries. The fact that premature infants and full term infants were analysed together make it hard to apply the results directly to the UK where the care of premature infants might be quite different from that provided in low and middle income countries. So we don’t know whether kangaroo mother care has specific benefits over conventional care in the UK, for example over an incubator or other usual care practices for premature babies.

Kangaroo mother care for premature and small babies is an option already offered in the UK and has been studied on a small scale in Tunbridge Wells, England.

More research into the effectiveness of each component of kangaroo mother care would be useful. For example, it could look into whether the effects differ for babies of different birth weights and gestational ages. Alternatively it could see if the duration of skin contact makes a difference. However given that its use in practice is widespread, it is good to know based on this international research, that it is safe.

Citation and Funding

Boundy EO, Dastjerdi R, Spiegelman D, et al. Kangaroo mother care and neonatal outcomes: a meta-analysis. Pediatrics. 2016;137(1):1-16.

This study was supported by the Saving Newborn Lives initiative (SNL) of Save the Children. Grants were received from the National Institute of Child Health and Human Development, and the US National Institutes of Health (NIH).

Bibliography

Best Beginnings. Small wonders. London: Best Beginnings; undated.

BLISS. Skin-to-skin and kangaroo care. London: BLISS; undated.

Gregson S, Blacker J. Kangaroo care in pre-term or low birth weight babies in a postnatal ward. British Journal of Midwifery. 2011;19(9):568-77.

also reported in:

Premature and small babies in Kent are being discharged earlier and feeding better, thanks to the RCM 2012 award-winning Kangaroo care project at Tunbridge Wells Hospital. 
Midwives Magazine. 2012;(2).

Lawn JE, Cousens S, Zupan J; Lancet Neonatal Survival Steering Team. 4 million neonatal deaths: When? Where? Why? Lancet. 2005;365(9462):891–900.

Moore E, Anderson G, Bergman N. Early skin-to-skin contact for mothers and 
their healthy newborn infants. 
Cochrane Database Syst Rev. 2012;(5):CD003519.

NICE. Postnatal care up to 8 weeks after birth. CG37. London: National Institute for Health and Care Excellence; July 2006.

UNICEF UK. Guide to the baby friendly initiative standards. London: UNICEF UK; 2012.

World Health Organization Department of Reproductive Health and Research. Kangaroo mother care: a practical guide. Geneva, Switzerland: World Health Organization; 2003.

Why was this study needed?

Effective health resources such as incubators can help improve outcomes for high-risk infants born prematurely or with low birth weight. But in low- and middle-income countries, where 99% of all newborn deaths occur, such equipment can be scarce. As the scale of infant deaths in the first four weeks is huge, estimated as four million babies per year in 2005 worldwide, alternatives are needed.

Kangaroo mother care was first developed in Colombia (a middle-income country) in the late 1970s. The basic definitions describe skin-to-skin contact by placing the baby on the mother’s skin soon after birth and keeping it there. Other explanations add exclusive breast feeding and going home early from the health facility.

Research-to-date has focused on kangaroo care in low birth weight babies, individual aspects such as skin-to-skin contact only, or a limited number of health outcomes.

This was the first comprehensive review to draw on trials and observational studies on kangaroo mother care’s impact on a wide range of health outcomes for premature and full term babies around the world.

What did this study do?

This systematic review included 124 studies including 55 trials on at least one health outcome of kangaroo mother care. The search included research databases from all World Health Organization (WHO) regions of the world and was not restricted by language. To be included, studies needed a comparison group and at least ten participants. There was no restriction by baby’s gestational age or weight.

This was a large and rigorously designed review; however, 60% of the included studies were based in middle- or low-income countries. This limits applicability to the UK because of potentially different definitions of conventional care, which were not described.

The WHO listed four key features of kangaroo mother care as:

  • placing the baby on the mother’s skin soon after birth, and leaving the baby there,
  • breastfeeding only as the baby’s sole source of food,
  • going home early from the clinic or hospital,
  • follow up at home by health professionals.

Most studies (68%) defined kangaroo mother care as skin-to-skin contact only. A further 13% defined kangaroo mother care as skin-to-skin contact plus promotion of exclusive breastfeeding. However, it was not possible to separate out the effects of skin-to-skin contact or breastfeeding alone, versus kangaroo mother care as a whole.

What did it find?

Compared with conventional care, kangaroo mother care was associated with lower mortality, lower risk of neonatal sepsis, hypothermia, hypoglycaemia, hospital readmission and exclusive breast feeding. Newborns receiving kangaroo mother care also showed improved vital signs for respiratory rate, pain measures, oxygen saturation, temperature and head circumference.

For example, compared with conventional care:

  • Pooled results of 16 studies showed that babies receiving kangaroo mother care had a 23% lower risk of death by the latest time assessed in each study (relative risk [RR] 0.77, 95% confidence interval [CI] 0.60 to 0.99).
  • Likelihood of exclusive breastfeeding at hospital discharge increased for kangaroo mother care babies by 50% in pooled results from 13 studies (RR 1.50, 95% CI 1.26 to 1.78). This was the case for most subgroups of different study types, babies or kangaroo mother care characteristics.
  • Pooled results from nine studies showed that receiving kangaroo mother care was associated with lower risk of hypothermia kangaroo mother care did not significantly reduce mortality in two studies including all birth weights – this had not been examined in previous reviews.

Among studies reporting gestational age, the majority (n = 61, 68%) were among preterm infants <37 weeks’ gestation; 17 (19%) were among full term infants, defined as ≥37 weeks, and 12 (13%) were among infants of all gestational ages.

What does current guidance say on this issue?

Guidance from UNICEF UK, published in 2012, recommends kangaroo care as part of its Baby Friendly Initiative standards. It does not focus on care of premature or low birth weight babies.

The London-based charities BLISS and Best Beginnings have produced resources on skin-to-skin contact for parents of premature or sick babies. These include Best Beginnings’ videos on skin-to-skin contact kangaroo care for both parents, using a sling.

A 2006 NICE guideline on postnatal care supports breastfeeding, and encourages skin contact between the mother and baby soon after birth. It does not specifically cover kangaroo mother care, or address kangaroo mother care as a care approach for premature or low birth weight babies.

What are the implications?

Conventional care was not described in this review and may mean different things in different countries. The fact that premature infants and full term infants were analysed together make it hard to apply the results directly to the UK where the care of premature infants might be quite different from that provided in low and middle income countries. So we don’t know whether kangaroo mother care has specific benefits over conventional care in the UK, for example over an incubator or other usual care practices for premature babies.

Kangaroo mother care for premature and small babies is an option already offered in the UK and has been studied on a small scale in Tunbridge Wells, England.

More research into the effectiveness of each component of kangaroo mother care would be useful. For example, it could look into whether the effects differ for babies of different birth weights and gestational ages. Alternatively it could see if the duration of skin contact makes a difference. However given that its use in practice is widespread, it is good to know based on this international research, that it is safe.

Citation and Funding

Boundy EO, Dastjerdi R, Spiegelman D, et al. Kangaroo mother care and neonatal outcomes: a meta-analysis. Pediatrics. 2016;137(1):1-16.

This study was supported by the Saving Newborn Lives initiative (SNL) of Save the Children. Grants were received from the National Institute of Child Health and Human Development, and the US National Institutes of Health (NIH).

Bibliography

Best Beginnings. Small wonders. London: Best Beginnings; undated.

BLISS. Skin-to-skin and kangaroo care. London: BLISS; undated.

Gregson S, Blacker J. Kangaroo care in pre-term or low birth weight babies in a postnatal ward. British Journal of Midwifery. 2011;19(9):568-77.

also reported in:

Premature and small babies in Kent are being discharged earlier and feeding better, thanks to the RCM 2012 award-winning Kangaroo care project at Tunbridge Wells Hospital. 
Midwives Magazine. 2012;(2).

Lawn JE, Cousens S, Zupan J; Lancet Neonatal Survival Steering Team. 4 million neonatal deaths: When? Where? Why? Lancet. 2005;365(9462):891–900.

Moore E, Anderson G, Bergman N. Early skin-to-skin contact for mothers and 
their healthy newborn infants. 
Cochrane Database Syst Rev. 2012;(5):CD003519.

NICE. Postnatal care up to 8 weeks after birth. CG37. London: National Institute for Health and Care Excellence; July 2006.

UNICEF UK. Guide to the baby friendly initiative standards. London: UNICEF UK; 2012.

World Health Organization Department of Reproductive Health and Research. Kangaroo mother care: a practical guide. Geneva, Switzerland: World Health Organization; 2003.

Kangaroo Mother Care and Neonatal Outcomes: A Meta-analysis

Published on 25 December 2015

Boundy, E. O.,Dastjerdi, R.,Spiegelman, D.,Fawzi, W. W.,Missmer, S. A.,Lieberman, E.,Kajeepeta, S.,Wall, S.,Chan, G. J.

Pediatrics , 2015

CONTEXT: Kangaroo mother care (KMC) is an intervention aimed at improving outcomes among preterm and low birth weight newborns. OBJECTIVE: Conduct a systematic review and meta-analysis estimating the association between KMC and neonatal outcomes. DATA SOURCES: PubMed, Embase, Web of Science, Scopus, African Index Medicus (AIM), Latin American and Caribbean Health Sciences Information System (LILACS), Index Medicus for the Eastern Mediterranean Region (IMEMR), Index Medicus for the South-East Asian Region (IMSEAR), and Western Pacific Region Index Medicus (WPRIM). STUDY SELECTION: We included randomized trials and observational studies through April 2014 examining the relationship between KMC and neonatal outcomes among infants of any birth weight or gestational age. Studies with <10 participants, lack of a comparison group without KMC, and those not reporting a quantitative association were excluded. DATA EXTRACTION: Two reviewers extracted data on study design, risk of bias, KMC intervention, neonatal outcomes, relative risk (RR) or mean difference measures. RESULTS: 1035 studies were screened; 124 met inclusion criteria. Among LBW newborns, KMC compared to conventional care was associated with 36% lower mortality(RR 0.64; 95% [CI] 0.46, 0.89). KMC decreased risk of neonatal sepsis (RR 0.53, 95% CI 0.34, 0.83), hypothermia (RR 0.22; 95% CI 0.12, 0.41), hypoglycemia (RR 0.12; 95% CI 0.05, 0.32), and hospital readmission (RR 0.42; 95% CI 0.23, 0.76) and increased exclusive breastfeeding (RR 1.50; 95% CI 1.26, 1.78). Newborns receiving KMC had lower mean respiratory rate and pain measures, and higher oxygen saturation, temperature, and head circumference growth. LIMITATIONS: Lack of data on KMC limited the ability to assess dose-response. CONCLUSIONS: Interventions to scale up KMC implementation are warranted.

Expert commentary

I am pleased to see this meta-analysis published, however, I would like to see further analysis extend to babies of all birth weights and gestation. Professionally I came to the concept of kangaroo mother care at a very early stage of its adoption in UK. As a mother of a preterm baby, I benefitted at first hand, especially in establishing breast feeding. So I am delighted to see evidence of the benefits. However, this is countered by disappointment when I visit some units where kangaroo mother care it is not being proactively adopted. We should expect to see mothers or fathers being supported to establish kangaroo mother care for their babies, even those requiring intensive care and high dependency care.

Dr Jane M Hawdon, Consultant Neonatologist, Executive Director, Women’s and Children’s Health Clinical Academic Group, Barts Health NHS Trust