Low-Cost Intervention Keeps Tiny Newborns Alive - MedPage Today

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Immediate "kangaroo mother care" for infants born with low birth weight led to substantially lower risk of early death, researchers reported.

The intervention, in which mothers maintain skin-to-skin contact with their newborns immediately after birth, reduced 28-day infant mortality by nearly 4 percentage points relative to a control group receiving conventional care until they stabilized (12.0% vs 15.7%; RR 0.75, 95% CI 0.64-0.89), according to results from a randomized trial organized by the WHO Immediate KMC Study Group and conducted in five resource-limited countries.

Deaths within the first 72 hours were also numerically lower with immediate kangaroo mother care, with a rate of 4.6% compared with 5.8% in the control group, the group reported in the New England Journal of Medicine. However, this difference fell just short of statistical significance.

Study authors estimated that providing the intervention to 27 infants would prevent one neonatal death.

"The results of the study are generalizable to most hospitals in low-resource settings in which immediate kangaroo mother care can be implemented" in the way that was studied in the trial, wrote Suman Rao, MD, of the WHO in Geneva, Switzerland, and colleagues. But the intervention wasn't without cost: hospitals had to adapt their neonatal intensive care units (NICUs) to allow mothers (and surrogates) to be with newborns around the clock, or build special ones from scratch.

The WHO study was not the first trial of kangaroo mother care; others have shown that it reduces mortality in infants with low birth weight. But those studies called for it to begin after infants were stabilized with standard NICU care. Most neonatal deaths occur prior to stabilization, Rao and colleagues noted. Hence they sought to examine whether implementing the kangaroo mother care immediately after birth could be beneficial.

About 3,200 infant-mother pairs were enrolled in the open-label trial, conducted in Ghana, Malawi, Nigeria, Tanzania, and India. Low birth weight was defined as 1.0-1.799 kg; the mean for participants was 1.5 kg (SD 0.02), with mean gestational age of 32.6 weeks. Infants and mothers could not be extremely sickly, and mothers had to be at least 15 years old. Mean maternal age was 27. About 20 infants were excluded from the final 28-day mortality analysis because mothers quit the study or newborns could not be located.

Participants were randomized in blocks, such that 1,609 were assigned to immediate kangaroo mother care and 1,602 to the control group. The latter received standard NICU care until infants were clinically stable -- with respiratory rates of 40-60 breaths per minute, no apnea or need for CPAP, oxygen saturation greater than 90% on room air, heart rate of 80-160 beats per minute, and axillary temperature of 36.0-37.4°C -- and then received kangaroo mother care.

Each mother was asked to name one or two other adults to act as surrogates for kangaroo mother care for those periods when the mother needed to leave the NICU. This care involved strapping the infant to the mother's or surrogate's chest, just loosely enough to ensure airway patency. Median time from birth to start of kangaroo mother care was 1.3 hours in the intervention group and 54 hours for controls.

Secondary outcomes did not differ significantly between groups, but there were trends favoring immediate kangaroo mother care over control for several:

• Hypothermia: 5.6% vs 8.3%
• Suspected sepsis: 22.9% vs 27.8%
• Maternal depression: 0.2% vs 0.6%

Subgroup analyses for 28-day mortality, with stratifications by birth weight, gestational age, type of delivery, and hospital location, did not show many differences. One exception: there was no hint of benefit for immediate kangaroo mother care in the Ghanaian site.

Overall, Rao and colleagues concluded, the trial results mirrored those in earlier studies involving clinically stable neonates. As was the case with those previous studies, mechanisms underlying the reported benefit remain speculative. Rao's group suggested that colonization by the mothers' microbiome may play a role, as could the reduced handling of infants by others, perhaps minimizing infection risk. To the extent that newborns feel stress from maternal separation, the intervention would presumably reduce that as well.

Limitations to the analysis included the lack of blinding (although outcomes were determined from records reviewed by researchers who did not know infants' assignments) and potential differences among study sites and providers in the details of how the intervention was implemented.

Last Updated May 26, 2021

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  John Gever was Managing Editor from 2014 to 2021; he is now a regular contributor.

Disclosures

This study was supported by the Bill and Melinda Gates Foundation through a grant to the WHO.

No potential conflicts of interest relevant to this article were reported.

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