Every month, we ask a NeoIPC friend to review an interesting paper on infection prevention and control in neonatal care.
This month, Helen Brotherton from the London School of Hygiene and Tropical Medicine is reviewing:
WHO Immediate KMC Study Group, Arya S, Naburi H, et al. Immediate “Kangaroo Mother Care” and Survival of Infants with Low Birth Weight. N Engl J Med. 2021;384(21):2028-2038. Published 2021 May 27.
Why is this important?
Complications of being born preterm and/or low birth weight (LBW) are the most important contributors to neonatal mortality globally, with hospital acquired infections a major risk to survival for this vulnerable population. Evaluation of feasible interventions to reduce infections and mortality in the highest burden settings is urgently needed if global neonatal mortality reduction targets are to be met. Kangaroo mother care (KMC) is an evidence based, recommended care practice involving prolonged skin-to-skin contact, exclusive breastmilk feeding and early hospital discharge linked to close follow-up. A priority evidence gap existed for early onset of KMC prior to stabilisation, with scanty high quality evidence for infection prevention effects.
What was done?
This multi-centre randomised controlled trial was conducted at 4 African hospitals (in Ghana, Nigeria, Malawi and Tanzania) and one Indian tertiary hospital. 3,211 singleton and twin neonates weighing between 1.0kg and 1.799kg received either KMC as soon as possible after delivery from their mothers (intervention) or care in incubators or under radiant heaters with KMC after stabilisation (control). Skin-to-skin contact was started within 2 hours of birth for two-thirds of neonates (median 1.3 hours of age) and was given for prolonged periods (median 16.9 hours/day), predominantly by the mother. ‘Mother-NICUs’ were used to facilitate constant maternal presence and two of the sites used a newly built ‘Mother-NICU’ separate from the control NICUs. All other treatments were as per World Health Organisation guidelines and included invasive and non-invasive ventilation. Neonates were followed up to 29 days with suspected sepsis clinically defined for hospitalised neonates >24hrs old but excluding neonates who died or were discharged before 48hrs of age.
What did the study find?
Starting KMC immediately after delivery reduced the risk of dying during the first 28 days by 25%, principally by reducing early (<3 day) mortality. The risk of developing non-fatal sepsis was also reduced by 18% and the authors hypothesized a possible benefit via neonatal colonization with mothers’ protective microbiome, early breastmilk feeding and reduced handling. There were differences in the effect of immediate KMC on mortality across different countries, with the strongest effect seen in India, which contributed 40% of recruitment.
Key takeaway points
- KMC should be commenced as soon as possible after delivery, especially in resource-limited settings.
- Early and prolonged KMC reduces non-fatal infections in hospitalised preterm/LBW neonates, although different environmental exposures during the iKMC trial may have influenced this finding and further information is required.
- The mechanisms underpinning infection prevention effects are not yet known and warrant further research, especially to understand the effect of KMC on bacterial carriage by small vulnerable newborns in the highest risk settings.