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Database of Abstracts of Reviews of Effects
Issue: Volume (1), 2013, [no page #]
Copyright: Copyright 2013 University of York
Publication Type: [Abstracts of quality assessed systematic reviews]
Accession: 00125498-100000000-24133
Keywords: Female, Humans, Male, Breast Feeding, Child Rearing, development, Infant, Newborn, Infant, Premature, growth & development, Infant Care, methods, Infant
Mortality, Parent-Child Relations, Physical Stimulation, Premature Birth, Randomized Controlled Trials as Topic
[Abstracts of quality assessed systematic reviews]
'Kangaroo mother care' to prevent neonatal deaths due to preterm birth complications (Structured abstract)
Centre for Reviews and Dissemination
Author Information
NHS Centre for Reviews and Dissemination. University of York, York, U.K.
Source Reference
Abstract and Commentary for:Lawn JE, Mwansa-Kambafwile J, Horta BL, Barros FC, Cousens S. 'Kangaroo mother care' to prevent neonatal deaths due to preterm birth
complications. International Journal of Epidemiology. 2010;39(Supplement 1):.
CRD summary
This review investigated the effects of Kangaroo Mother Care in preventing neonatal
deaths due to preterm birth complications and concluded that it substantially reduced
neonatal mortality among preterm babies in hospital and was highly effective in reducing
severe morbidity. Overall, the review was well conducted and the conclusion appears
reliable and an accurate reflection of the evidence presented.
Authors' objectives
To update a 2003 Cochrane review to investigate the effects of Kangaroo Mother
Care (KMC) in preventing neonatal deaths due to preterm birth complications.
Searching
PubMed, LILACS, African Medicus, EMRO, World Health Organisation Regional
Databases and The Cochrane Library were searched for studies published in any language
between 1968 and 8 September 2009. Proceedings from major conferences were
searched online for unpublished literature. Search terms used were reported.
Study selection
Eligible studies needed to have a patient population of neonates (defined as babies
less than 28 days old who weighed less than 2,000g) and the intervention had to be KMC
(defined as continuous skin-to-skin contact and support for exclusive breastfeeding or
other appropriate feeding and early recognition and response to complication). KMC had
to be commenced within one week of birth. The comparator (where relevant) had to be
conventional care such as incubator care or more limited care. Eligible studies needed to
report neonatal mortality due to complications of preterm birth or serious neonatal
morbidity related to prematurity (such as respiratory distress syndrome, pneumonia and
septicaemia). Any study design was eligible for inclusion. Where outcomes were reported
for a broader age group that included neonates, study authors were contacted for
outcomes that related only to the neonate subgroup. Studies used to assess mortality
outcomes : These studies all took place in hospitals. Study locations included Bangladesh,
Colombia, Ecuador, Ethiopia, India, Indonesia, Mexico, Mozambique, South Africa and
Zimbabwe. Definitions of low birth weight ranged from less than 1,600g to less than
2,000g. Median time of commencing KMC ranged from four hours to 12.4 days from birth.
There was some variability in mortality outcome definitions (mortality was assessed from
pre-discharge to 12 months). Studies used to determine morbidity outcomes: Comparable
details were not provided. It appeared that more than one reviewer performed the initial
and final screening for study selection.
Validity assessment
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Validity was assessed using a Child Health Epidemiology Reference Group (CHERG)
checklist based on an adaptation of the Grading of Recommendations Assessment,
Development and Evaluation (GRADE). The number of reviewers involved in this stage of
the review process was not reported.
Data extraction
Two reviewers independently extracted data required to calculate risk ratios (RRs)
with 95% confidence intervals (CIs) for the outcomes of morbidity and mortality on a
standardised form. Where required, authors were contacted for additional data.
Methods of synthesis
The review stated that a priori the authors planned to conduct three meta-analyses
producing pooled risk ratio estimates: one that compared mortality outcomes from RCTs
only; a second that compared mortality outcomes from observational studies only; and a
third that compared morbidity outcomes from RCTs only. I2 values were used to assess
heterogeneity. Where heterogeneity was considered significant (threshold of p<0.10 in
the associated Q tests), it appeared that a random-effects model was used to pool data
instead of a Mantel-Haenszel fixed-effect model.
Results of the review
Fifteen studies were included in the review: nine RCTs and six observational studies.
The authors stated that most of the RCTs had minor limitations. None of the five RCTs
that assessed mortality were blinded. Mortality outcomes (RCTs): Three studies were
included (n=988). There was a statistically significant reduction in mortality risk with KMC
compared to standard care (RR 0.49, 95% CI 0.29 to 0.82 using a fixed-effect model,
I2=0%). Mortality outcomes (observational studies): Three studies were included
(n=8,257). Mortality risk was statistically significantly reduced compared with standard
incubator care (RR 0.68, 95% CI 0.58 to 0.79 model used not reported, I2=54.4%).
Morbidity outcomes (RCTs): Five studies were included (n=1,520). The risk was
statistically significantly lower in the KMC group compared with the standard care group
(RR 0.34, 95% CI 0.17 to 0.65 using a random-effects model, I2=69.7%). Sensitivity
analyses for mortality outcomes: Including studies with later initiation of KMC brought
the RR closer to one, but the difference was still statistically significant (RR 0.64, 95% CI
0.42 to 0.96, model details not specified). Including a study with incomplete population
details did not affect the results. Using a random-effects model changed the results from
statistically significant to statistically insignificant (RR 0.68, 95% CI 0.38 to 1.22).
Cost information
This review addressed a clear review question using appropriate and clearly stated
study selection criteria. The search strategy was clearly reported and appeared
comprehensive and clearly reported; a large number of databases were searched without
date or language restrictions and search terms were reported. It appeared that study
selection and other stages of the review process such as data extraction were conducted
in duplicate to reduce risks of reviewer error and bias. Reporting of primary study
characteristics appeared appropriate. Validity was assessed, but results were not fully
reported in the paper (the review stated that supplementary tables were available online
but these could not be obtained on 29/9/2010). The method of synthesis appeared
appropriate and comprehensive, although the authors appeared to suggest that random-
effects Mantel-Haenszel meta-analyses were possible when they were not. The results
were comprehensively and clearly reported. One of the sensitivity analyses explored the
effect of using a random-effects rather than fixed-effect model and indicated that the
statistical significance of some results may have been sensitive to modelling assumptions.
Overall the authors' conclusion appears reliable and to accurately reflect the evidence
presented.
Authors' conclusions
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Kangaroo Mother Care substantially reduced neonatal mortality among preterm
babies in hospital and was highly effective in reducing severe morbidity.
CRD commentary
This review addressed a clear review question using appropriate and clearly stated
study selection criteria. The search strategy was clearly reported and appeared
comprehensive and clearly reported; a large number of databases were searched without
date or language restrictions and search terms were reported. It appeared that study
selection and other stages of the review process such as data extraction were conducted
in duplicate to reduce risks of reviewer error and bias. Reporting of primary study
characteristics appeared appropriate. Validity was assessed, but results were not fully
reported in the paper (the review stated that supplementary tables were available online
but these could not be obtained on 29/9/2010). The method of synthesis appeared
appropriate and comprehensive, although the authors appeared to suggest that random-
effects Mantel-Haenszel meta-analyses were possible when they were not. The results
were comprehensively and clearly reported. One of the sensitivity analyses explored the
effect of using a random-effects rather than fixed-effect model and indicated that the
statistical significance of some results may have been sensitive to modelling assumptions.
Overall the authors' conclusion appears reliable and to accurately reflect the evidence
presented.
Implications of the review for practice and research
Practice: The authors stated that KMC should be used routinely in facilities for all
stable babies less than 2,000g at birth. Research: The authors stated that there was need
for further assessment of KMC in settings with no medical care for all except the smallest
babies and a need for analysis of potential cost savings on nursing time and length of
in-patient stay.
Funding
Bill and Melinda Gates Foundation (Grant 43386, Grant 50124); UNICEF; Save the
Children USA; Global Alliance for Prevention of Prematurity and Stillbirths.
URL for original research
http://ije.oxfordjournals.org/content/39/suppl_1/i144.abstract
Other publications of related interest
Cande-Agudelo A, az-Rossello JL, Belizan JM. Kangaroo mother care to reduce
morbidity and mortality in low birthweight infants. Cochrane Database Syst Rev 2003; 2:
CD002771
Record status
This is a critical abstract of a systematic review that meets the criteria for inclusion
on DARE. Each critical abstract contains a brief summary of the review methods, results
and conclusions followed by a detailed critical assessment on the reliability of the review
and the conclusions drawn.
CRD database number
DARE-12010003310
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Index terms
Medical Subject Headings (MeSH)
[Subject indexing assigned by CRD]
Female; Humans; Male; Breast Feeding; Child Rearing; development; Infant,
Newborn; Infant, Premature/growth & development; Infant Care/methods; Infant
Mortality; Parent-Child Relations; Physical Stimulation; Premature Birth; Randomized
Controlled Trials as Topic
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