Early skin-to-skin contact for mothers and their healthy newborn infants

Data were scarce to assess the effect of early skin-to-skin contact on breastfeeding up to 4-6 and 12 months of life. However, the review found that skin-to-skin contact between the mother and her baby immediately after birth reduces crying, improves mother-infant interaction, keeps the baby warm, and helps the mother to breastfeed successfully. No important negative effects were identified. RHL Commentary by Puig G, Sguassero Y

1. EVIDENCE SUMMARY
Ideally, early skin-to-skin contact (SSC) begins immediately after birth by placing the naked newborn baby prone on the mothers bare chest. This practice based on intimate contact within the first hours of life may facilitate maternal-infant behaviour and interactions through sensory stimuli such as touch, warmth, and odour. Moreover, SSC is considered a critical component for successful breastfeeding initiation. Based on these premises, the updated version of this review aimed at assessing randomized controlled trials (RCTs) or quasi-RCTs about the effect of early SSC starting within the first 24 hours of life versus routine neonatal care in both healthy full-term and late preterm babies (i.e., 34-37 weeks gestational age). The principal outcome of interest was breastfeeding. New outcomes were added in this update of the review, e.g., maternal bonding behaviours and maternal psychological changes after SSC that were explored by observation or by applying questionnaires/subscales of maternal-infant bonding, and infant physiological adaptation. Regarding the intervention, three categories of early SSC were considered by the authors: a) in birth SSC (during the first minute of life), b) very early SSC (beginning at 30-40 minutes after birth), and c) early SSC (anytime between 1 and 24 hours after birth) The search methods for identifying relevant studies included two independent searches conducted in MEDLINE by the Cochrane Pregnancy and Childbirth Group and the Cochrane Neonatal Group. In this regard, no databases relevant for developing countries such as Latin American and Caribbean Literature and African Index Medicus were explored. Additional efforts were done by hand searching more than twenty pertinent journals. No language restrictions were applied. Three main quality criteria were applied: 1) allocation concealment (adequate, unclear or inadequate), 2) completeness of follow-up, and 3) blinding of participants, caregivers and outcome assessors. Overall, thirty trials were included (twenty-nine were RCTs). The majority of the included studies were conducted in developed countries such as USA, UK, Canada and Sweden. Eight studies were conducted in developing countries. Only four studies conducted in the USA, South Africa and Taiwan involved preterm babies. Early skin-to-skin contact varied largely across studies in terms of timing and duration. For example, in some study settings the intervention could not begin immediately after birth because of hospital policy and duration ranged from 15 minutes to a mean of 48 hours of continuous SSC. These factors precluded the authors from pooling the results. Sixty-four clinical outcomes were reported. It is important to highlight that only twenty were measured in more than one study and that not all the reported outcomes were relevant to poor countries. For breastfeeding

outcomes (the most commonly reported) comparison of early SSC (n= 70/74) versus standard contact (n= 54/75) showed a positive effect on breastfeeding at discharge hospital (odds ratio [OR] 6.35, 95% confidence interval [CI] 2.15 to 18.71). However, this result should be interpreted with caution due to small sample sizes that are reflected by the wide confidence intervals. When considering long-term impact on breastfeeding (e.g., 1-4 months), results from 10 studies involving 552 mothers-healthy term infants pairs showed also a positive impact (OR: 1.82, 95% CI: 1.08 to 3.07, I2 = 41.2%). Again this result should be interpreted with caution because the confidence intervals are showing imprecision. Data were scarce to assess the effect on breastfeeding up to 4-6 and 12 months of life, maternal outcomes in terms of satisfaction, self-confidence status and maternal parenting confidence. Nevertheless, according to the review findings, skin-to-skin contact between mother and babies after birth reduces crying, improves motherinfant interaction, keeps the baby warmer, and helps mothers to breastfeed successfully. Furthermore, on a positive note, no important negative effects were identified.

2. RELEVANCE TO UNDER-RESOURCED SETTINGS 2.1. Magnitude of the problem

Each year, new scientific and epidemiological evidence contributes to our knowledge of breastfeeding's role in the survival, growth, and development of a child as well as the health and well-being of a mother.1 Current breastfeeding patterns are still far from the recommended level and considerable variation exists across regions.2 Extra tactile, odour, and thermal cues provided by skin-to-skin contact may stimulate babies to initiate breastfed more successfully. So, this practice should be seen as a beneficial, low cost, and feasible intervention to promote lactation after delivery especially in settings that lack sanitation and safe water where breastfeeding can be life saving. In addition, a recent study conducted in Ghana3, demonstrated that the promotion of early initiation of breastfeeding has the potential to make a major contribution to the achievement of the child survival millennium development goal; 16% of neonatal deaths could be saved if all infants were breastfed from day 1 and 22% if breastfeeding started within the first hour.

2.2. Applicability of the results

It is not easy to extrapolate the results of the review to poor countries, since the review is largely based on studies carried out in well-resourced settings where contextual factors such as cultural beliefs and lack of accessibility to basic health care may not be seen as major barriers to support exclusive breastfeeding. In this regard, to develop and implement long-term breastfeeding early support systems is considered a major challenge in developing countries.

2.3. Implementation of the intervention

Early SSC should be considered as a routine health care intervention after delivery both in developed and developing country settings. However, the implementation of this intervention requires further considerations in under-resourced communities. On one hand, factors such as room temperature, lack of privacy/space, overcrowding, etc., may interfere with its potential benefits and, on the other hand, the situation is often worsened by inaccurate medical advice from health workers who lack proper skills and training in early breastfeeding support starting with early skin-to-skin contact. Practices such as how infants are handled after birth are part of institutional functioning, and may not be easy to change. For example, the current practice at Maternidad Martin in Rosario (Argentina), with 4000

deliveries per year, is to place the newborn prone on the mothers bare abdomen for one minute while it is smoothly dried with a blanket. It is worth pointing out that this new practice has been recently introduced following the implementation of delayed cord clamping intervention.4, 5 In this scenario, SSC starts immediately after birth but it lasts only 1-3 minutes. Thus, prolonging the duration of the SSC as part of routine practice for early breastfeeding support could be easy to implement, especially in Baby Friendly Hospitals.6

3. RESEARCH
Appropriate definition of SSC is a priority for future research taking into account specific timing, frequency and duration of intervention. As neonates tend to be more alert within the first two hours of life, this should be considered a convenient period for initiating successful mother and child interaction. Well-conducted RCTs are warranted to demonstrate the real impact of early SSC on maternal and infant health, including preterm babies and mothers who deliver by caesarean section and in different settings (developed and developing countries). Sources of support: Centro Rosarino de Estudios Perinatales, Rosario, Argentina.

References

The Pan American Health Organization. Quantifying the benefits of breastfeeding: a summary of the evidence. Washington, D.C.: PAHO 2002. Web site: http://www.childinfo.org (acceded 17 August 2007) Edmond KM, Zandoh C, Quigley MA, Amenga-Etego S, Owusu-Agyei S, Kirkwood BR. Delayed breastfeeding initiation increases risk of neonatal mortality. Pediatrics, 2006;117(3):e380-6. Ceriani Cernadas JM, Carroli G, Pellegrini L, Otano L, Ferreira M, Ricci C, Casas O, Giordano D, Lardizabal J. The effect of timing of cord clamping on neonatal venous hematocrit values and clinical outcome at term: a randomized, controlled trial. Pediatrics. 2006 Apr;117(4):e779-86. Ceriani Cernadas, JM, Carroli G, Lardizabal J. The effect of timing of cord clamping on neonatal venous hematocrit values and clinical outcome at term: a randomized, controlled trial. In reply, Pediatrics, 2006,118:3,1317-1319 World Health Organization. Evidence for the ten steps to successful breastfeeding. Geneva: The Organization; 1998. Web site:www.who.int/child-adolescenthealth/New_Publications/NUTRITION/WHO_CHD_98.9.pdf (accessed 6 Sept 2007).

Kangaroo mother care to reduce morbidity and mortality in low-birth-weight infants

Current evidence suggests that kangaroo mother care is an effective and safe alternative to conventional neonatal care in low-birth-weight infants in under-resourced settings. The potential beneficial effects of kangaroo mother care on morbidity and mortality is expected to be greatest in settings in which conventional neonatal care is unavailable. RHL Commentary by Bergh A-M

1. INTRODUCTION
Kangaroo mother care (KMC) was first practised in 1978 in Bogot, Colombia. It involves skin-to-skin positioning of the infant in an upright position against the mothers chest. The two other components of KMC are frequent and exclusive breastfeeding (where possible) and early discharge from hospital (regardless of

weight or gestational age), but with frequent follow-up visits to the health centre. Infants can be cared for in the kangaroo position intermittently (for a number of hours per day) or continuously (> 20 hours per day) (1). Almost all (99%) of the 4 million neonatal (in the first 4 weeks of life) deaths worldwide occur in low- and middle-income countries. Three quarters of these deaths occur in the first week of life. Preterm birth is estimated to be the direct cause of 28% of neonatal deaths worldwide (2). Although KMC has been promoted since its inception as one of the strategies for reducing neonatal mortality in low-birth-weight (LBW) infants (3, 4), Cochrane reviews published in 2000 and 2003 had concluded that "there was insufficient evidence to recommend the routine use of KMC in LBW infants (5, 6). This commentary pertains to the 2011 updated of the same review. The authors of the updated review had the same objective of determining whether KMC could be used effectively in LBW infants as an alternative to conventional neonatal care (7).

2. METHODS OF THE REVIEW

The review authors used the Cochrane Neonatal Review Groups standard search strategy to identify relevant studies. Additional sources were also searched. The unit of analysis was the LBW infant with a birth weight of <2500 g, regardless of gestational age. Randomized controlled trials were considered for inclusion. Trials with quasi-randomized and cross-over design were excluded, as were studies on physiological parameters only, or those in which KMC was a part of a package of interventions. Two review authors extracted the data independently. They also assessed the risk of bias in the included studies. Different stages of life were identified for evaluating the outcomes: at discharge or at 4041 weeks postmenstrual age; at latest follow-up; at 6 months of age or 6 months' follow-up; and at 12 months corrected age. The primary outcomes selected as clinical measures of effectiveness and safety for infants were mortality, severe infection/sepsis, severe illness, infant growth (weight, length, head circumference) and neurodevelopmental disability. The clinical measures selected as secondary outcomes included other clinical conditions (nosocomial infection/sepsis, mild/moderate infection or illness, lower respiratory tract disease, diarrhoea, admission to hospital), breast-feeding, length of hospital stay, costs of care, and psychosocial outcomes (motherinfant attachment or interaction, satisfaction with care, home environment and father's involvement).

3. RESULTS OF THE REVIEW

Out of the 49 studies identified, 16 (comprising 2518 infants) were included. KMC in LBW infants was evaluated in 14 studies after stabilization (11 using intermittent KMC and three continuous KMC), in one study before stabilization, and in one study comparing early onset with late onset of KMC. The study settings included 11 low- or middle-income countries and five high-income countries. A further subgroup of analysis was performed to compare KMC initiated at <10 days versus >10 days after birth. At discharge or at 4041 weeks postmenstrual age, KMC was associated with a significant reduction in the risk of: mortality [typical risk ratio (RR) 0.60; 95% confidence interval (CI) 0.390.93]; nosocomial infection/sepsis (typical RR 0.42; 95% CI 0.240.73); and hypothermia (typical RR 0.23; 95% CI 0.100.55). There was also a reduction in the length of hospital stay for KMC infants [typical mean difference (MD) 2.4 days; 95% CI 0.74.1]. At latest follow-up, KMC was associated with a reduction in the risk of mortality (typical RR 0.68; 95% CI 0.480.96) and severe infection/sepsis (typical RR 0.57; 95% CI 0.400.80). KMC was also found to increase some of the measures of infant growth, breast-feeding and motherinfant attachment. There was, however, high heterogeneity among the trials reporting on infant growth and breastfeeding. Measures of motherinfant attachment were mostly reported in only one trial.

At latest follow-up visit, compared with controls, KMC infants showed statistically significant gains in weight (typical MD 3.9 g; 95% CI 1.95.8), length (typical MD 0.29 cm; 95% CI 0.270.31), and head circumference (typical MD 0.18 cm; 95% CI 0.090.27). Mothers of KMC infants were more likely than mothers of control infants to be exclusively and/or partially breastfeeding at discharge or at 4041 weeks corrected gestational age (typical RR 1.25; 95% CI 1.061.47), at 12 months follow-up (typical RR 1.33; 95% CI 1.001.78), and 3 months follow-up (typical RR 1.14; 95% CI 1.061.23). In one trial KMC mothers demonstrated higher levels of satisfaction with the method of caring than mothers in the control group. In another trial KMC mothers scored more positively than the controls on certain scale items related to a sense of competence, levels of worry and stress, and sensitivity towards the infant. In the same trial, kangaroo care families scored significantly higher than conventional care families on home environment. In the one study reporting on neurodevelopmental outcomes at one year of corrected age, no statistically significant differences were found between KMC and control infants in terms of psychomotor development, cerebral palsy, deafness and visual impairment. No study reported data suitable for an in-depth cost-of-care analysis.

4. DISCUSSION 4.1 Applicability of the results

KMC is an effective and safe alternative to conventional neonatal care for the management of LBW infants, especially in under-resourced settings. The beneficial effects of KMC on infant mortality and morbidity could be used as further evidence to promote the wide-scale adoption and implementation of KMC as part of efforts to reach the Millennium Development Goals on child survival. The breakdown of evidence for subgroups (e.g. low- and middle-income countries versus high-income countries and continuous versus intermittent KMC) opens up the possibility for a more precise definition of outcomes in future interventions involving KMC. In under-resourced settings where incubators or radiant warmers are scarce, interventions that include KMC should strongly focus on reducing neonatal mortality and morbidity. Evidence from high-income countries suggests that KMC can potentially be used to improve breast-feeding rates in those settings.

4.2 Implementing the Intervention

Implementation of KMC can be initiated at the institutional or health-system level. Implementation of the skin-to-skin and breast-feeding components of KMC will require little additional resources with minimal cost implications for health-care facilities. For initiating the practise of continuous KMC, additional space may be required at health-centres to accommodate motherinfant dyads. Currently, KMC forms part of many newborn care packages rolled out in under-resourced settings. The orientation of health-care workers in KMC implementation is important and could either be integrated into these packages or provided separately, depending on the needs of a particular setting. However, if a specific focus on translating KMC knowledge and skills into practice is absent, there will be a danger of KMC declining in priority when too many new demands are simultaneously placed on already overburdened healthcare workers. Guidance on how to deal with resistance to KMC from mothers and communities would also need to be developed.

4.3 Implications for research

More methodologically rigorous trials are needed to explore further the effectiveness of early-onset and continuous use of KMC in low-income settings, for both unstabilized and relatively stabilized LBW infants. Also, randomized trials with an adequate sample size are needed to evaluate the impact of KMC (continuous or intermittent) on infant morbidity in high-income settings. Other research areas include long-term neurodevelopment outcomes related to KMC and outcomes of motherinfant attachment. Also needed are well-designed economic evaluations to assess the costeffectiveness of KMC in all types of setting. Before assessing the effect of community-based KMC programmes on neonatal mortality, additional trials are recommended to ensure baseline comparability of mortality, adequate KMC implementation, and birth weight assessment. Only one trial included in this review had the KMC component of early discharge in its design. More trials on the effects of early discharge of KMC infants from a health-care facility are needed. Where appropriate, this could be combined with trials investigating community-based KMC programmes. Sources of support: South African Medical Research Council Maternal and Infant Health Care Strategies Research Unit and the University of Pretoria, South Africa. Acknowledgements: Dr Elise van Rooyen, Department of Paediatrics, Kalafong Hospital, University of Pretoria, South Africa.

References

Charpak N, Ruiz JG, Zupan J, Cattaneo A, Figueroa Z, Tessier R, et al. Kangaroo mother care: 25 years after. Acta Paediatrica 2005; 94:514-522. Lawn J, Cousens S, Zupan J, for the Lancet Neonatal Survival Steering Team. 4 million neonatal deaths: When? Where? Why? The Lancet 2005; 365:891-900. Kinney MV, Lawn, JE, Kerber KJ (ed). Science in action: saving the lives of Africas mothers, newborns, and children. Cape Town, South Africa: Report for the African Academy Science Development Initiative; 2009. 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 (Suppl 1):i144154. Conde-Agudelo A, Diaz-Rossello JL, Belizn JM. Kangaroo mother care to reduce morbidity and mortality in low birthweight infants. Cochrane Database of Systematic Reviews 2000;Issue (4): Art. No.: CD002771; DOI: 10.1002/14651858.CD002771.pub2. Conde-Agudelo A, Diaz-Rossello JL, Belizn JM. Kangaroo mother care to reduce morbidity and mortality in low birthweight infants. Cochrane Database of Systematic Reviews 2003;Issue (2): Art. No.: CD002771; DOI: 10.1002/ 14651858.CD002771.pub2. Conde-Agudelo A, Belizn 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: 0.1002/14651858.CD002771.pub2.

Topical umbilical cord care at birth

No differences were found in umbilical cord infection rates when use of a topical antiseptic was compared with dry cord care or placebo. However, the author regards the available evidence as incomplete and recommends that in settings where the risk of bacterial infection is high, it may be prudent to use an antiseptic as per local preferences. RHL Commentary by Capurro H

1. EVIDENCE SUMMARY
The revised review covers 22 trials involving 8959 subjects. Eleven of these trials are new, and include 2 conducted in a developing country (Thailand). There were no systemic infections or deathsthe primary outcomes of the reviewin any of the trials. No differences were found in umbilical cord infection rates when a topical antiseptic was compared with dry cord care or placebo (Relative Risk [RR]: 0.53; 95% confidence interval [CI]: 0.351.13). Topical triple dye seemed to be more effective than alcohol (four trials, 1560 infants RR: 0.30; 95% CI: 0.190.49) or povidone-iodine (one trial, 183 infants RR: 0.15, 95% CI: 0.070.32) in preventing cord infection. Topical triple dye and antibiotics seemed to be associated with longer cord separation times. In one study use of a topical antiseptic was associated with less parental anxiety when compared with dry cord care. The statistical methods used were appropriate. A subgroup analysis of term versus preterm and developed versus developing country settings would be appropriate if data permit.

2. RELEVANCE TO UNDER-RESOURCED SETTINGS 2.1. Magnitude of the problem

Each year, one-third of neonatal deaths worldwide (1.5 million) are due to infection (1), and many of them begin as umbilical cord infection. Simple preventive aseptic practices are not universally implemented. In 14 Latin American countries nearly 100 000 infant deaths of babies less than 1 year old were studied. Up to 16% of the deaths were due to infection (2), ranging between 31.3% in El Salvador and 7.5% in Costa Rica. Given the high range of institutional deliveries in the region (with the exception of 24.2% in Haiti) (3), cord infections should be preventable in most cases.

2.2.Applicability of the results

Umbilical cord infections can occur in all settings. However, they are more likely to occur in low-income countries and in settings where the majority of births are not attended by a skilled attendant. All but two the trials included in the review were hospital-based conducted in developed countries. In some settings popular cultural or traditional practices lead to higher susceptibility to cord infection.

2.3. Implementation of the intervention

The patchy evidence reviewed does not lead to a recommendation to implement a specific intervention. At the present time the best way to handle the umbilical cord is not known, regardless of setting. In settings where the risk of bacterial infection is high, it may be prudent to use an antiseptic as per local preferences.

3. RESEARCH
Given that up to a third of neonatal deaths are due to infections, randomized controlled trials with similar outcome indicators as indicated in this review should be undertaken. It would be important to conduct those trials in countries and settings that have high neonatal infection and mortality rates.

References

The World Health Report 1998. Life in the 21st century. A vision for all. Geneva. World Health Organization;1998. World Health Organization. Table 2 Infant death [en lnea]. Accessed: 30 September 2004. World Health Organization. Mortality database http://www3.who.int/whosis/mort/table2.cfm?path .

Pan American Health Organization (PAHO). Regional Office of the World Health Organization. Health Analysis and Information Systems. Health Situation in the Americas 2003. Basic Indicators Accessed: 30 September 2004 .