Immediate skin-to-skin contact, breastfeeding beats conventional care for neonatal survival

Infants with low birth weight who received immediate skin-to-skin contact with their mother or caregiver—known as “kangaroo mother care”—had lower 28-day mortality than infants who received conventional care prior to kangaroo mother care, the WHO Immediate KMC Study Group found.

Infants with low birth weight who are born preterm, small for gestational age, or both account for 15% of neonates around the globe; however, they also account for 70% of neonatal deaths, Rajiv Bahl, MD, PhD, and colleagues from the WHO Immediate KMC Study Group explained inThe New England Journal of Medicine.

Initiating kangaroo mother care (consisting of continuous skin-to-skin contact with the chest of the mother or a surrogate and feeding exclusively with breast milk) following stabilization was previously found to lead to lower mortality, fewer infections, higher rates of exclusive breast-feeding, and better weight gain compared to infants who received conventional care in an incubator or a radiant warmer—and according to findings from trials conducted in South Africa and Vietnam—kangaroo mother care soon after birth may lead to earlier stabilization than conventional care in low birth weight infants.

The Study Group conducted their large, multicenter, randomized, controlled trial to assess the safety and efficacy of continuous kangaroo mother care initiated immediately after birth versus conventional care in infants with a birth weight between 1.0 and 1.799 kg in five hospitals in Ghana, India, Malawi, Nigeria, and Tanzania.

The study authors found that immediate kangaroo mother care “improved neonatal survival by 25% as compared with kangaroo mother care initiated after stabilization, the approach that is currently recommended,” they wrote. “In order to prevent one neonatal death, the intervention would have to be provided to 27 infants (95% CI, 17 to 77). Implementation of the intervention required the mother or a surrogate to be with the infant 24 hours a day for the duration of stay in the [neonatal intensive care unit] NICU, which required the establishment of Mother–NICUs.”

In fact, immediate kangaroo mother care was so effective that the study was stopped early on the recommendation of the data and safety monitoring board “owing to the finding of reduced mortality” among infants in the intervention group.

They added that the results from this study are generalizable to most hospitals in low-resource settings where immediate kangaroo mother care can be implemented as described in their study; however, they also acknowledged challenges in scaling up the intervention, including “the involvement of multiple stakeholders, the establishment of Mother–NICUs, the need for strong collaboration between the obstetrics and neonatal departments, and changes in policy that would allow surrogates to provide kangaroo mother care.”

Any live-born infants born in participating hospitals with birth weight between 1.0 and 1.799 kg were eligible for study inclusion, regardless of gestational age, type of delivery, or singleton or twin status, the study authors wrote. Mother-infant pairs were excluded if the mother was younger than 15 years of age, did not provide consent, had given birth to three or more infants in the pregnancy, was sick and unlikely to be able to provide kangaroo mother care within three days of birth, or lived outside of the study area; infants were also excluded if they could not breathe spontaneously by one hour after birth or had a major congenital malformation.

In order to accommodate the study intervention group, hospitals were required to make structural changes in the NICUs and alter the nature of obstetrical and neonatal care to create what the study authors referred to as “Mother-NICUs.” Infants receiving kangaroo mother care were secured to the mother’s chest with a binder; all care for the mother and infant was provided while maintaining skin-to-skin contact, and any interruptions in contact were documented. Infants in the control group were transferred to a control NICU without their mother and “mothers provided expressed breast milk and participated in brief sessions of kangaroo mother care when their infant began to recover from preterm birth complication and was at least 24 hours old,” they wrote.

The study’s primary outcomes were death in the neonatal period (the first 28 days of life) and in the first 72 hours of life; secondary outcomes included hypothermia, hypoglycemia, suspected sepsis, time to clinical stabilization, exclusive breast feeding, maternal satisfaction, and maternal depression. A total of 3,211 infants and their mothers participated in the study, with 1,609 in the intervention group and 1,602 in the control group.

“The median daily duration of skin-to-skin contact in the neonatal intensive care unit was 16.9 hours (interquartile range, 13.0 to 19.7) in the intervention group and 1.5 hours (interquartile range, 0.3 to 3.3) in the control group,” the Study Group wrote. “Neonatal death occurred in the first 28 days in 191 infants in the intervention group (12.0%) and in 249 infants in the control group (15.7%) (relative risk of death, 0.75; 95% confidence interval [CI], 0.64 to 0.89; P=0.001)…”

The between-group difference for kangaroo mother care in the first 72 hours of life “was not significant,” they added—74 infants in the intervention group (4.6%) died within 72 hours compared to 92 infants in the control group (5.8%) (relative risk of death, 0.77; 95% CI, 0.58 to 1.04; P=0.09).

As for secondary outcomes:

  • Suspected sepsis: 22.9% in the intervention group versus 27.8% in the control group (adjusted risk ratio [ARR] 0.82; 95% CI, 0.73-0.93).
  • Hypothermia: 5.6% versus 8.3%, respectively (ARR 0.65, 95% CI, 0.51-0.83).
  • Similar time to stabilization, incidence of hypoglycemia, exclusive breast feeding, maternal satisfaction, and maternal depression in both groups.

The study authors noted that the lower rates of sepsis and hypothermia may partially explain the lower mortality among infants in the intervention group. Other possible mechanisms by which kangaroo mother care may increase mortality include a higher chance of colonization by the mother’s protective microbiome and early breast feeding; less handling of the baby by others, which may reduce infection risk; constant monitoring of the infant by the mother; and the absence of stress related to mother-infant separation.

Study limitations included the impossibility of blinding, possible measurement bias in the secondary outcomes due to the open-label design, and that roughly 20% of infants weighing from 1.0-1.799 kg born in study hospitals were not enrolled “because the mother or the newborn were determined to be too sick to participate.”

  1. Immediate initiation of “kangaroo mother care” led to lower 28-day mortality among preterm infants with low birth weight compared to conventional care.

  2. Note that the study by the WHO Immediate KMC Study Group was stopped early on the recommendation of the data and safety monitoring board owing to the finding of reduced mortality among infants receiving immediate kangaroo mother care.

John McKenna, Associate Editor, BreakingMED™

Funded by the Bill and Melinda Gates Foundation.

No potential conflicts of interest were reported.

Cat ID: 191

Topic ID: 83,191,728,791,730,191,41,138,192,925