ORIGINAL ARTICLE

Effect of Kangaroo Mother Care on the

Likelihood of Breastfeeding from Birth
up to 6 Months of Age: A Meta-analysis
Angelica Joyce A. Gacutno-Evardone, MD,1 Fay S. De Ocampo, MD1
and Maria Esterlita T. Villanueva-Uy, MD, MSPH1,2
1
Division of Newborn Medicine, Department of Pediatrics, Philippine General Hospital, University of the Philippines Manila
2
Institute of Child Health and Human Development, National Institutes of Health, University of the Philippines Manila

ABSTRACT

Background. One of the World Health Organization (WHO) nutrition target by 2025 is 50% exclusive breastfeeding
rate among infants until age 6 months. Kangaroo mother care (KMC) known to increase breastfeeding rates, especially
in preterm and low birth weight (LBW) infants.

Objectives. This study determined the effect of KMC to the rate of exclusive breastfeeding among preterm and LBW
infants at 6 months of age.

Methods. Conducted searches in MEDLINE and CENTRAL databases, likewise hand searched local publications
December 1996 until June 2018. Included several randomized controlled trials and prospective observational
studies comparing KMC and conventional care among preterm and LBW infants. The primary outcome was exclusive
breastfeeding of infants at six months of age. Two authors independently assessed trial quality and extracted data
the statistical analysis applied using Review Manager version 5.3.

Results. Identified nine eligible trials involving 1,202 neonates. All studies had low-to-moderate risk of bias. KMC
significantly noted to increase the likelihood of exclusive breastfeeding by 1.9 times at birth up to 6 months (OR 1.93
[1.18,3.17], p=0.009).

Conclusion. KMC can increase exclusive breastfeeding among preterm and LBW infants from birth up to 6 months
of age.

Key Words: Kangaroo mother care, kangaroo care, breastfeeding, low birth weight, preterm

BACKGROUND
Around 15 million babies are born too soon, as esti-
mated by the World Health Organization (WHO) in
2018. Furthermore, an estimated of 4 million infants
who die each year due to complications of preterm birth.1
Prematurity noted as the leading cause of global mortality
in children under 5 years old. In Southeast Asia, including
the Philippines, 14% of live births are preterm, and 12%
are low birth weight (LBW) births.2
Corresponding author: Angelica Joyce A. Gacutno-Evardone, MD In low-income settings, infants born prematurely or
Division of Newborn Medicine with LBW are at higher risk of death and morbidity such
Department of Pediatrics as impaired growth and development. These are due to the
Philippine General Hospital
University of the Philippines Manila
lack of accessible and cost-effective care, which includes
Taft Avenue, Ermita, Manila 1000, Philippines warmth, breastfeeding support, and basic needs for
Email: angelicajoycegacutno@gmail.com infection prevention.3

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 The effect of KMC among infants on exclusive breastfeeding from birth up to 6 months

Focus on preterm births needed to accelerate their breastfeeding rates in VLBW neonates (Deepak 2017); (3)
progress thus reducing neonatal mortality. WHO defined KMC to reduce morbidity and mortality in LBW infants
“kangaroo mother care” (KMC) as a period of skin-to-skin (Conde-Agudelo 2009); and (4) skin-to-skin contact for
contact (SSC) wherein the infant clothed only with a diaper mothers and their healthy newborn infants (Moore 2016).
and a bonnet, placed on the chest of a mother or caregiver All four meta-analyses has no outcome of breastfeeding up
who is lying in a (nearly) horizontal position, with the former to 6 months of age. The previous reviews on KMC involved
held to the mother with a cloth. KMC maintained the entire assessment of outcomes such as mortality, morbidity, length
day. The more holistic definition of KMC includes four of hospital stay and breastfeeding rates on discharge and on
components: early, continuous and prolonged skin-to-skin 1- to 4-month follow up of both term and preterm infants.1,5-7
contact between mother-infant dyad, exclusive breastfeeding, This meta-analysis aims to review the effect of KMC
early discharge with close monitoring and follow up.2,3 on exclusive breastfeeding up to 6 months old among LBW
In 1978, Dr. Edgar Sanabria introduced KMC in infants, which is recommended by the WHO. The results
Bogota, Colombia as an alternative to warmers and from this meta-analysis would potentially help policy makers
incubators for LBW infants. The KMC method decreases to strengthen the policies on KMC and exclusive breast-
newborn mortality and morbidity by preventing infections feeding to achieve our global nutrition target for 2025.
and hypothermia, and promoting better weight gain thru
exclusive breastfeeding.3 It also strengthens the emotional OBJECTIVES
bonding between parents or caregivers, and the infant, hence
giving a more stable family unit. To determine the effectiveness of KMC on exclusive
The WHO nutrition targets for 2025 is to increase breastfeeding among preterm and LBW at 6 months of age.
the exclusive breastfeeding rate by 50% among infants in
the first six months of life. The purpose of this policy is to METHODS
increase awareness, promote cost-effective interventions and
strengthen policies that can help member states and their Criteria for considering studies for this review
partners improve the rates of exclusive breastfeeding among
infants less than six months.4 Types of studies
According to a 2014 WHO update, exclusive breast- We included published and unpublished randomized
feeding practice rates vary between different Asia-Pacific controlled trials and prospective observational studies.
regions: Cambodia (74%), Republic of Korea (50%), Fiji We excluded prospective and retrospective cohort studies
(40%), Philippines (34%), Marshall Islands (31%), China on KMC and duration of breastfeeding without a control
(28%) Japan (21%) and Viet Nam (17%). Breastfeeding rates group.
continuously decline as the child reaches two years of age.4
A systematic review (Deepak 2017) on the role of Types of participants
KMC in very low birth weight (VLBW) neonates showed We included studies on preterm infants < 36 weeks
not only a positive effect on growth but also an increase in age of gestation or <2500 grams (LBW) with breastfeeding
the breastfeeding rates. In a meta-analysis (Boundy 2016) duration of at least 6 months.
on KMC was found to decrease the risks of mortality,
neonatal sepsis, hypothermia, hypoglycemia and hospital Types of interventions
readmission. It also showed an increased likelihood of We included studies that compared KMC to
breastfeeding upon discharge and at 1- to 4- month follow conventional care. KMC is continuous skin-to-skin contact
up which increased by 39%.1,5 between mother’s chest and her diaper-clad infant in a semi-
In 2009, a review of the three studies conducted by Conde upright position. The back of the infant covered with either a
et al. showed that KMC found to decrease severe illness and blanket or a cloth sling/binder, inside the mother’s clothing.
lower respiratory tract infection at 6 months. Likewise it also Mothers were encouraged to render KMC for a minimum
increase the chance of exclusive breastfeeding at discharge of eight hours per day. Conventional care refers to infants
(RR =0.4; 95% CI: 0.25 to 0.68) compared to conventional who received standard nursery care while placed inside
care.6 In another review by Moore et al. demonstrated the an incubator or warmer/cradle with heat lamps until they
superior performance of immediate SSC contact over could maintain their temperature.
standard care on breastfeeding status, infant physiologic
stability after delivery, infant behavior and maternal-infant Types of outcome measures
bonding among healthy newborns.7
Previously conducted about four Cochrane reviews. Primary outcome:
(1) A meta-analysis on neonatal outcomes (Boundy 2016); • Exclusive breastfeeding up to 6 months old, measured by
(2) a systematic review on role of KMC in growth and breastfeeding rates.

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Effect of KMC on the Likelihood of Breastfeeding from Birth up to 6 Months of Age

Secondary Outcome/s: Sequence generation

• Other reported neonatal outcomes include weight gain, The methods done for sequence generation in the
infection, mortality, infants’ physiologic outcome, length included studies noted, to assess possible selection bias. The
of hospital stay and prolactin level among postpartum methods assessed as to:
mothers. These outcomes cannot be combined. • Low risk (note of application of randomization in the
article, e.g., random number via table or computer-
Search methods used to identify the studies generated);
• High risk (any non-random process, e.g., hospital
Electronic Searches   number); or
The search strategies for CENTRAL and MEDLINE • Unclear risk
used MeSH terms for kangaroo care, low birth weight
infant, skin-to skin care AND breastfeeding. No language Allocation concealment
restrictions applied. Other databases and websites searched The allocation concealment methods noted to determine
included: Clinicaltrials.gov, Google Scholar, Oxford Journals, whether intervention allocation have been foreseen in
ProQuest, WHO International Clinical Trials Registry advance of, or during recruitment or changed after assignment.
and Platform (http://www.who.int/ictrp/search/en/), and The methods assessed as follows:
HERDIN, with the search terms “kangaroo care” AND • Low risk (e.g., phone or central randomization;
“breastfeeding,” “kangaroo mother care,” “skin to skin care,” numbered-sealed envelopes; coding by third party.
“low birth weight,” “breastfeeding outcomes.” Computer generated sequence);
• High risk (e.g., not sealed or non-opaque envelopes;
Searching other Resources alternation)
Citation lists in review articles, relevant publications,
included and excluded studies searched. Conference Blinding
proceedings and local journals were hand searched for related The methods for blinding noted, to determine possible
research. Unpublished research papers submitted to the performance and detection bias. Studies considered at
Philippine Society of Newborn Medicine and Philippine low risk of bias if the process of blinding described in the
Pediatric Society related to breastfeeding personally requested included studies. The methods assessed as:
from the societies. • Low, high or unclear risk for personnel; or
• Low, high or unclear risk for outcome assessors
Selection of studies
Full articles of the studies that satisfied the inclusion Incomplete outcome data
criteria retrieved. Abstracts considered if enough information The completeness of data observed by looking at the
was presented. Any inconsistency regarding inclusion/ number of withdrawals/dropouts and their corresponding
exclusion of the studies resolved by discussion and unanimity reasons for non-inclusion, the numbers included in the
by the principal investigator and the co-authors. analysis compared with the total randomized participants
to check for possible attrition bias.
Data extraction and management • Low risk (e.g., absence of missing data or where reasons
For each review, the author independently extracted data for missing data were described and balanced across
and compared entries separately from the included studies groups)
and counter-checked. The data included during the review • High risk (e.g., whether missing data are likely to be
as follows: authors, participants inclusion and exclusion related to outcomes or are not balanced across groups)
criteria, methodology, interventions and outcomes, as well • Unclear (e.g., inadequate reporting of attritions and
as the year of publication. Differences encountered during exclusions)
data extraction were discussed and resolved with consensus.
Review Manager Version 5.3 (RevMan) software used to Selective reporting bias
enter the data by one review author and data counterchecked The methods assessed as:
by the other author. • Low risk (e.g., report of the study’s pre-specified
outcomes and all expected outcomes of interest to the
Assessment of risk of bias in included studies review);
The methodological quality of the studies were • High risk (e.g., whether not all the study’s pre-specified
assessed independently by the review authors, as outlined outcomes have been reported; outcomes of interest are
in the Cochrane Handbook for Systematic Reviews of reported incompletely and so cannot be used; non-
Intervention.8 Any disparity was resolved by discussion or inclusion of results of an important outcome expected
by involving a third assessor. to have been reported)
• Unclear risk

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 The effect of KMC among infants on exclusive breastfeeding from birth up to 6 months

Other sources of bias questionable allocation concealment and significant loss

Any important concern for other possible sources of bias to follow-up.
investigated. The included studies evaluated whether they
were free of other problems as: RESULTS
• Low risk
• High risk Description of studies
• Unclear risk
Results of the search  
Overall risk of bias Out of 308 records from the database search, we
According to the criteria given in the Cochrane Handbook removed 68 duplicates, and excluded 201 that were not able
for Systematic Reviews of Intervention, the authors made to meet the inclusion criteria (Figure 1). Of the remaining 39
a summary to review the overall risk of bias through clear studies that were retrieved for full text review, we excluded 17
judgment whether the studies were at low, unclear or high studies for the qualitative synthesis: 15 studies on term infants,
risk of bias. The magnitude and direction of bias whether 2 studies that compared intermittent versus continuous
it was likely to make an impact on the findings assessed. KMC. 22 studies were included in the qualitative review:
4 Cochrane reviews, and 9 studies that had breastfeeding
Measures of treatment effect outcomes only upon discharge and only up to 4 months old.
The authors analyzed dichotomous data and results The remaining 9 studies were eligible for inclusion (Bier
reflected as summary odds ratios with an odds ratio (OR) 1996; Charpak 2001, Hake-Brook 2008, Roberts 2009, Chiu
1.93 (1.18-3.17) at 95% confidence intervals (CI). 2009, Ali 2009, De Almeida 2010, Dumalag 2014, Ghavane
2016) and eventually analyzed for the meta-analysis.9-17
Unit of analysis issues
Included studies were randomized controlled trials,
and prospective cohort studies, both foreign and local, with
control and intervention, and with no issues in the unit of
analysis were infants as participants receiving more than
one intervention, and multiple observations for the same
outcome.

Assessment of heterogeneity 
To assess the appropriateness of pooling the data,
heterogeneity between trials examined by visually checking
the forest plots and quantifying the I-squared test. The degree
of heterogeneity was roughly categorized based on the value
of the I2 statistic according to Higgins et al. as: low (25%),
moderate (50%), and high (75 %). If statistical heterogeneity
noted, the authors planned to explore its possible causes
through subgroup analysis (e.g., differences in study quality,
participants, intervention regimens or outcome assessments).
In case the presence of heterogeneity not explained, a
random-effects model used to synthesize the data.8

Data synthesis
Statistical analysis performed using the Review Manager
software (RevMan 5.3). The Mantel-Haenszel method
used for approximations of RR for dichotomous outcomes.

Assessment of publication bias

Visual examination of the funnel plot used to check
for publication bias.

Sensitivity analysis
Sensitivity analysis was planned, should there be enough
studies available (≥ 10 trials), to determine the effect of trial
quality by excluding studies with inadequate randomization, Figure 1. Prisma Flow Chart.

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Effect of KMC on the Likelihood of Breastfeeding from Birth up to 6 Months of Age

Included studies DISCUSSION

We included nine studies (8 RCTs and one prospective
cohort study) that contributed data to the meta-analysis. Summary of Main Results
About of 1,202 newborns < 36 weeks age of gestation and In this meta-analysis, we were able to include nine
< 2500 grams recruited into these trials. The characteristics of studies with 1,202 infants to assess the effect of KMC on
included studies are shown in Appendices 1 and 2. exclusive breastfeeding among preterm and LBW infants up
to 6 months of age. KMC resulted in a 1.9 times increase
Risk of bias in included studies in the likelihood of exclusive breastfeeding among preterm
Majority of studies had overall low risk of bias. Figures infants up to 6 months old (p=0.009).
2 and 3 provided a summary of the risk of bias of included The presence of moderate heterogeneity (I2=46%) in
studies in this review. this study can be attributed to different variables such as the
Funnel plot was symmetrical indicating that publication wide range of low birthweight distribution of the included
bias was unlikely (Figure 4). studies, different primary outcome measures and the
limitations of blinding. Hence a random-effects model was
Effects of intervention used to synthesize the data.
We included nine studies in this review to determine This study analyzed 8 RCTs and 1 prospective study.
the effects of KMC on exclusive breastfeeding duration Sensitivity analysis removing the prospective study did not
among preterm and LBW infants up to 6 months of age change the direction of the treatment effect and even resulted
(Bier 1996, Charpak 2001, Hake-Brook 2008, Roberts 2009, in higher heterogeneity (I2=49%). As such, the 9 studies
Chiu 2009, Ali 2009, De Almeida 2010, Dumalag 2014, were retained in this analysis.
Ghavane 2016).9-17 In the meta-analysis of Boundy et al, their results
showed that KMC increased the likelihood of infants to
Primary Outcome exclusive breastfeeding 1.78 times upon hospital discharge
Pooled data showed that KMC significantly increased or 40 - 41 weeks postmenstrual age and, at 1- 4 month
the odds of exclusive breastfeeding from birth up to 6 months follow up by 1.4 times.1 However, we searched for studies
by 1.93x (95% CI, 1.18, 3.17; 9 studies, N=1202; I2= 46%; with exclusive breastfeeding from birth up to 6 months
p=0.009) (Figure 5). of age since this is the duration of exclusive breastfeeding
Sensitivity analysis removing the prospective study did recommended by WHO Nutritional Targets for 2025.4
not change the direction of the treatment effect and even
resulted in higher heterogeneity (I2=49%).

Other Outcomes
Summary measures of other reported neonatal out-
comes (weight gain, infants’ physiologic outcome, length
of hospital stay and prolactin level among postpartum
mothers), neurodevelopmental indices as well as reduction
in infections and mortality were not pooled since they
varied between studies.

Figure 3. Risk of bias summary: review

authors' judgements about
Figure 2. Risk of bias graph: Review authors’ judgments about each risk of bias item each risk of bias item for each
presented as percentage across all included studies. included study.

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 The effect of KMC among infants on exclusive breastfeeding from birth up to 6 months

Overall completeness and applicability of evidence

The participants in all studies have no significant
difference in baseline characteristics. All outcome measures
analysed and presented. The included studies conducted both
in developed and low-to-middle income countries, namely
the United States, Mexico, Brazil, Colombia, India, Iran,
and the Philippines. In low-to-middle income countries,
the incidence of preterm and low birthweight births is
high and the breastfeeding rates are often suboptimal.
KMC as an intervention to improve breastfeeding rates
recommended helping achieve the 2025 Nutritional Target
of 50% exclusive breastfeeding for at least 6 months of age.

Quality of the evidence

Figure 4. Funnel Plot: Effect of KMC on exclusive breast-
Three independent reviewers assessed the quality of
feeding until 6 months old.
evidence based in 6 domains: selection bias, performance,
detection, attrition, reporting and other bias. The most
common limitation in the included studies with high-
Other outcome variables measured by the included risk bias was in the area of blinding. The assessors who
studies, such as improvement in weight gain per day, nutri- collected the outcomes measures, monitoring of dropouts,
tional status, physiologic parameters, length of hospital stay, and completeness of follow-up were not blinded. KMC and
maternal-infant interaction, postpartum prolactin levels and conventional care were difficult to blind due to the nature of
neurodevelopmental indices as well as reduction in infections intervention. The other domains were all low risk, hence the
and mortality were not pooled since they varied between overall risk of bias was considered low.
studies. Nevertheless, Ali 2009 an RCT reported that there
was a significant effect of KMC in relation to weight gain Potential biases in the review process
(KMC: 19.3 + 3.8 g vs. Control: 10.4 + 4.8 g, p <0.001) The eligibility and exclusion criteria clearly specified.
thermoregulation (KMC: 1.7% vs. Control 17.9% p <0.003) A systematic and comprehensive search strategy used in
and reduction in the incidence of nosocomial infection (KMC the identification and retrieval of relevant studies included
6.9 % vs. Control 23.2%, p < 0.015).10 On the other hand, an in this meta-analysis. Two review authors independently
RCT by Charpak et al. (N=746 infants) showed a significant examined and extracted data from each study included.
improvement in growth, specifically head circumference but Any disagreements were resolved through discussion or by
no significant difference in the mortality between KMC and a third assessor.
traditional care (RR 0.57 95% CI 0.17-1.18). Regarding
the length of hospital stay, results were varied. The study by Agreements and disagreements with other studies or
Roberts et al. demonstrated a longer hospital duration in the reviews
KMC group compared with the control group (48 ± 28 vs. Presently there are no currently published reviews
46 ± 19 days, p > 0.05), while Bier showed the opposite trend focusing on the effects of KMC on exclusive breastfeeding
(69 + 25 vs. 73 + 22 days, p > 0.05).11 for preterm and low birth weight infants at 6 months of age.

Figure 5. Forest Plot: Effect of KMC on exclusive breastfeeding from birth until 6 months old.

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CONCLUSIONS   studies also needed to improve the outcome of exclusivity

of breastfeeding at 6 months.
Implications for practice
Exclusive breastfeeding for six months up to two years or Statement of Authorship
beyond with sufficient and safe complementary foods, is one Literature and hand search conducted by primary
of the most effective ways to protect child health and promote investigator. Assessment done by primary investigator and
healthy growth and optimal development in early childhood. second co-author. The third co-author guided the protocol
The WHO promotes a complete implementation plan development and consulted for disagreement in trial
on maternal, infant and young child nutrition. This plan assessment. All authors approved the final version submitted.
included six global nutrition targets for 2025 and the 5th
target is to increase the rate of exclusive breastfeeding by Author Disclosure
50% in the first six months. All authors declared no conflicts of interest and no
The global depiction of breastfeeding rates varies affiliation with any pharmaceutical companies.
widely between low-and middle-income and high-income
countries. In countries such as Sri Lanka, Oman, Sweden Funding Source
and Uruguay, almost all their babies are breastfed. On the This study has no funding support.
other hand, countries such as China, Thailand, South Africa,
Thailand and Philippines only have 50% and below who REFERENCES
are breastfed.18
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Lieberman E, et al. Kangaroo mother care and neonatal outcomes: A
breastfeeding rates among different countries. Provision of meta-analysis. Pediatrics. 2016; 137(1):1-16.
a positive environment and strong support from national 2. World Health Organization, Kangaroo Mother Care: A Practical
level such as policies guaranteeing parental leave and right to Guide Geneva: Preterm birth fact sheet [Internet]. 2003 [cited 2018].
breastfeed in the workplace, restrictions on the marketing of Available from: https://www.who.int/publications/i/item/9241590351
3. Resolution WHA65.6. Comprehensive implementation plan on
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requires actions at the level of policy makers, community and Kangaroo mother care in growth and breastfeeding rates in very low
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at 6 months old would enable the policy maker to strengthen morbidity and mortality in low birthweight infants. Cochrane Database
the implementation of KMC in their respective institutions Syst Rev. 2014 April; 22(4):CD002771.doi: 10.1002/14651858.
7. Moore ER, Bergman N, Anderson GC, Medley N. Early skin-to-
in order to achieve our global nutrition target by 2025. skin contact for mothers and their healthy newborn infants. Cochrane
Policies and practices on KMC and breastfeeding in Database Syst Rev 2016 November; 11(11):CD003519. doi:10.1002/
the community, different hospitals and lying-in clinics, 14651858.
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Reviews of Interventions.The Cochrane Collaboration 2011.[Internet].
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surveillance by the top management per institution and the 9. Bier JA, Ferguson AE, Morales Y, Liebling JA, Archer D, Oh W, et
Department of Health. al. Comparison of skin-to- skin contact with standard contact in low-
Regular cascading and information dissemination to all birth-weight infants who are breastfed. Arch Pediatr Adolesc Med.
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about the benefits of KMC and breastfeeding will improve compared to conventional care for low birth weight babies. Dicle Med
their awareness, knowledge and practices, hence improving J. 2009 February; 36(3): 155-160.
the outcome of our LBW infants. Empowering ambulatory 11. Charpak N, Ruiz-Pelaez JG, Figueroa de C Z, Charpak Y. A rando-
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KMC units in an institution and community will lessen the at 1 year of corrected age. Pediatrics. 2001Nov; 108(5):1072–9.
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and account for possible confounders. Long-term follow-up (3):151-159.

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14. Chiu SH, Anderson GC. Effect of early skin-to-skin contact on General Hospital Who Underwent Kangaroo Mother Care 2015. Acta
mother-preterm infant interaction through 18 months: randomized Medica Philippina. Forthcoming 2021
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15. Almeida H, Venancio SI, Sanches MT, Onuki D. The impact of Infants. Journal of Clinical and Diagnostic Research. 2016 Dec, 10(12):
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APPENDICES

Appendix 1. Table of Included Studies

Bier 1996 Bier JA, Ferguson AE, Morales Y, Liebling JA, Archer D, Oh W, et al. Comparison of skin-to- skin contact with standard
contact in low-birth-weight infants who are breastfed. Arch Pediatr Adolesc Med. 1996 Dec;150(12):1265–9.
Roberts 2000 Roberts KL, Paynter C, McEwan B. A comparison of kangaroo mother care and conventional cuddling care. Neonatal
Network - Journal of Neonatal Nursing 2000;19(4): 31–5.
Charpak 2001 Charpak N, Ruiz-Pelaez JG, Figueroa de C Z, Charpak Y. A randomized, controlled trial of kangaroo mother care: Results of
follow-up at 1 year of corrected age. Pediatrics. 2001Nov;108(5):1072–9.
Hake-Brook 2008 Hake-Brooks, S. J., & Anderson, G. C. (2008). Kangaroo care and breast- feeding of mother-preterm infant dyads 0-18
months: A randomized, controlled trial. Neonatal Network. 2008 June; 27 (3):151-159.
Chiu 2009 Chiu SH, Anderson GC. Effect of early skin-to-skin contact on mother-preterm infant interaction through 18 months:
randomized controlled trial. International Journal of Nursing Studies 2009 September;46(9):1168–80.
Ali Syed 2009 Ali SM, Sharma J, Sharma R, Alam S. Kangaroo Mother Care as compared to conventional care for low birth weight babies.
Dicle Med J. 2009 February; 36(3): 155-160.
De Almeida 2010 Almeida H, Venancio SI, Sanches MT, Onuki D. The impact of kangaroo care on exclusive breastfeeding in low birth weight
newborns. J Pediatr (Rio J). 2010;86(3):250– 253.
Dumalag 2014 Dumalag JA, Raguindin P, Uy ME. Low Birth Weight Infants Admitted to a Level II Neonatal Intensive Care Unit of the
Philippine General Hospital Who Underwent Kangaroo Mother Care 2015. Acta Medica Philippina. Forthcoming 2021
Ghavane 2016 Ghavani Sunil, Eklare Deepak, Mohammad Haseeb. Long Term Outcomes of Kangaroo Mother Care in Very Low Birth
Weight Infants. Journal of Clinical and Diagnostic Research. 2016 Dec, 10(12): SC13-SC15

Appendix 2. Characteristics of Included Studies

Type of Country Intervention
Author Inclusion Exclusion Outcomes
Study Of Study vs. Control
Bier 1996 RCT Rhode Infants with BW Mother's positive history of KMC or skin-to- Primary Outcome:
Island, New < 1500 g and illicit drug use, mental illness, skin versus control Infant physiological data, i.e.,
England whose mothers human immunodeficiency oxygen saturation, heart rate,
Region planned to virus (HIV) infection, or respiratory rate, and axillary
of United breastfeed receiving any medications temperature; maternal milk
States contraindicated to breast- production; and duration of
feeding. In addition, any breastfeeding
infants who had a positive
toxicology screen for Secondary outcome:
cocaine or other illicit drugs Percentage of mothers who
or were showing drug continued breast-feeding for
withdrawal symptoms at the duration of their infants'
birth were excluded. hospitalization and 1, 3, and
6 months after discharge
from the hospital
Roberts RCT Australia Infants born Infants who are not stable or KMC vs. Main outcomes:
2000 > 30 weeks AOG, with congenital anomalies conventional Infant weight gain,
clinically stable cuddling care temperature maintenance
and cleared by the during KMC and CCC, and
unit specialist. length of hospital stay.

Secondary outcomes:
breastfeeding at discharge,
6 weeks, 3 months and
6 months.

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Effect of KMC on the Likelihood of Breastfeeding from Birth up to 6 Months of Age

Appendix 2. Characteristics Of Included Studies (continued)

Type of Country Intervention
Author Inclusion Exclusion Outcomes
Study Of Study vs. Control
Charpak RCT Colombia All liveborn infants Referral to another KMC vs. Control, Main outcomes:
2001 who weighed institution, plans to infants kept in the Morbidity, mortality, growth,
2000 g and were leave Bogota ́ in the near incubators development, breastfeeding,
eligible for KMC future, lethal or major hospital stay, and sequelae
and whose mother malformations, early major
or a relative was conditions arising from Secondary outcomes:
able to understand perinatal problems (e.g., Length of hospital stay, the
and was willing to severe hypoxic ischemic overall incidence of infection;
follow the general encephalopathy, pulmonary the incidence of severe
instructions for hypertension), and parental nosocomial infections or
taking care of a or family refusal to comply severe infections detected
premature infant with the follow-up program after discharge
and complying or, in those assigned to Proportion of infants entirely
with a 1-year KMC, with the intervention or partially breastfed up to
follow-up schedule 12 months old
Hakebrooks RCT Cleveland Mothers: English Mothers with known drug KMC versus Main outcome variables:
2008 Ohio, speaking, 18 abusers during pregnancy control infants Breastfeeding status at
Northern years or older, or if they had eclampsia, were either on the hospital discharge and at
America anticipating a uncontrolled seizure postpartum unit 1.5, 3, 6, 12, and 18 months
singleton birth, and disorder, severe depression or in the NICU, as measured by the Index of
healthy enough to or mental illness refractory were wrapped in breastfeeding status
experience KMC. to treatment, or maternal blankets whenever
Infants were disease requiring transport they were held
included if they to an intensive care unit
had 5 min Apgar post birth
≥6 and were Infants were excluded if they
1,300–3,000 g had a condition that could
at birth, 32–36 prevent KMC post birth or if
completed weeks they were diagnosed with a
gestation, and severe congenital anomaly.
healthy enough to
experience KMC
Chui 2009 RCT Cleveland Healthy preterm Infants with congenital KMC versus Mother-preterm infant
Ohio, infants 32-36 anomalies control group interaction (MPI) is measured
Northern weeks’ gestation (infants kept warm by mean scores on the
America and their mothers. in incubators, Nursing Child Assessment
warmer beds, Satellite Training Program
bassinets or (NCAST) Feeding and
held wrapped Teaching scales at 6,12
in blankets) and 18 months post birth
(reported in Chiu 2009
using the same data set).
Breastfeeding status
(exclusivity) at hospital
discharge, 6 weeks and
3, 6 and 12 months
Ali 2009 RCT India Infants delivered Neonates delivered by KMC versus Effect on growth, physiologic
by spontaneous caesarean section, with conventional care parameters, length of
vaginal delivery major life threatening hospital stay, mortality,
with weight congenital mal- formation, morbidity and exclusive
1200 grams to severe perinatal complication breastfeeding rates at
1800 grams and pa- rental refusal for 40 weeks post-conceptual
KMC intervention were age, 3 and 6 months
excluded from the study.
De Almeida Prospective Brazil Infants weighing Refusal to do KMC Control group Primary Outcome:
2010 cohort < 2,000 g and is conventional Exclusive breastfeeding
staying in the care prior to after discharge, 40 weeks,
neonatal unit for implementation 3 months and 6 months
at least 7 days of KMC.

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 The effect of KMC among infants on exclusive breastfeeding from birth up to 6 months

Appendix 2. Characteristics Of Included Studies (continued)

Type of Country Intervention
Author Inclusion Exclusion Outcomes
Study Of Study vs. Control
Dumalag RCT Philippines Infants weighing Unstable infants namely KMC Group versus Primary outcome:
2014 ≤ 2000g, and with extremely low birth weight Control Group Prolactin levels of mothers in
Apgar score ≥ 7 at (ELBWs), infants with (routine newborn KMC versus Control.
5 minutes of life chromosomal and life care) -Milk volume production on
threatening congenital the 3rd and 7th day.
anomalies, and infants with -Mean length of stay
oxygen or cardiovascular
support, b) mothers who Secondary outcome:
are clinically unstable Exclusive breastfeeding until
who cannot render KMC, 6 months old.
c) mothers who have
contraindication for
breastfeeding, and finally
d) mothers diagnosed
with Prolactinoma.
Ghavane RCT Southern Infants with birth Infants with major KMC versus Primary outcome:
Sunil 2016 India weight <1500gm malformation were excluded control infants Growth outcomes
were enrolled. placed inside the
Inborn, singleton, incubator or under Secondary Outcome:
VLBW (birth the warmer Nutritional indicators:
weight <1500gm) Malnutrition, wasting,
infants, who stunting and duration of
are tolerating exclusive breastfeeding at 40
feeding and weeks post conceptual aging,
hemodynamically 3 months and 6 months old
stable

Appendix 3. References to Excluded Studies

Cattaneo A, Davanzo R, Bergman N, Charpak N. Kangaroo mother care in low-income countries. International Network in Kangaroo Mother
Care. J Trop Pediatr. 1998 Oct;44(5):279–82.
Flacking R, Ewald U, Wallin L. Positive effect of kangaroo mother care on long-term breastfeeding in very preterm infants. J Obstet Gynecol
Neonatal Nurs. 2010 November; 40: 190–7.
Heidarzadeh M, Hosseini MB, Ershad Manesh M, Gholamitabar Tabari M, Khazaee S. The Effect of Kangaroo Mother Care (KMC) on
Breastfeeding at the Time of NICU Discharge. Iran Red Crescent Med J. 2013 Apr;15(4):302–310.
Jayaraman D, Mukhopadhyay K, Bhalla AK, Dhaliwal LK. Randomized Controlled Trial on Effect of Intermittent Early Versus Late Kangaroo
Mother Care on Human Milk Feeding in Low-Birth-Weight Neonates. India, Journal of Human Lactation. 2016 Nov; 1–7.
Lamy Filho F, Silva AAM da, Lamy ZC, Gomes MASM, Moreira MEL, Grupo de Avaliação do Método Canguru, et al. Evaluation of the neonatal
outcomes of the kangaroo mother method in Brazil. J Pediatr (Rio J). 2008 Oct;84(5):428–35.
Mahmood I, Jamal M, Khan N. Effect of mother-infant early skin- to-skin contact on breastfeeding status: a randomized controlled trial. J Coll
Physicians Surg Pak. 2011;21(10):601–605
Mörelius E, Örtenstrand A, Theodorsson E, Frostell A. A randomized trial of continuous skin-to-skin contact after preterm birth and the effects
on salivary cortisol, parental stress, depression, and breastfeeding. Early Human Development. 2015 Jan;91(1):63–70.
Oras P, Blomqvist YT, Nyqvist KH, Gradin M, Rubertsson C, Hellstrom-Westas L, et al. skin-to-skin contact is associated with earlier
breastfeeding attainment in preterm infants. Acta Pediatrica.2016 Feb;105: 783–789
Tully Kristin, Duavis D, White-Traut R., Gerardo V. et al. A Test of Kangaroo Care on Preterm Infant Breastfeeding J Obstet Gynecol Neonatal
Nurs. 2016; 45(1): 45-61.

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