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deined as the combination of continuous skin-to-skin contact, support for exclusive breastfeeding or other appropriate feeding and early recognition, and response to
complications. Studies where KMC was only commenced ater the irst week of life were excluded. Measured outcomes were neonatal mortality due to complications of
preterm birth, or morbidity related to prematurity.
he review included 15 studies: nine randomized controlled trials RCT, and six observational studies. All studies were from low or middle-income countries. Of the
RCTs, six reported mortality data, but only three were included in the analysis. Two studies were excluded because median time of initiation of KMC was greater than
1 week ater birth, and the third study – a community trial from Bangladesh – was thought to have important methodological limitations and was not conducted in
health facilities. Analysis of the three remaining trials – from India, Colombia and Ethiopia – showed a major mortality reduction with KMC for babies 2000 g RR
0.49, 95 CI 0.29 to 0.82; 988 infants High quality evidence,
see GRADE table A7.6
. hese mortality results are supported by results from three observational studies
8257 infants which also showed a mortality reduction RR 0.68, 95 CI 0.58–0.79, though this was heavily inluenced by a large South African study that contributed
96 to the weight of the pooled estimate. Five RCTs reported data on serious morbidity, deined as severe pneumonia,
sepsis, jaundice, and other severe illness. here were variations in study deinitions and heterogeneity in the results I
2
= 70, P 0.01. However, KMC was associated with a reduction in serious neonatal morbidity RR 0.34; 95 CI 0.17 to 0.65; 1520
babies. Moderate quality evidence,
see GRADE table A7.6
. 5.8.2
Benefits and risks
Benefits here is high quality evidence that KMC leads to a signiicant reduction in neonatal
mortality, and moderate quality evidence that it reduces serious morbidity, when compared to conventional care for babies 2000 grams in low- to middle-income
countries. Other beneits were seen with breastfeeding and bonding.
Risks Possible risks include apnoea and bradycardia in some babies. It should be noted that
KMC should be started once the LBW infants are clinically stable.
5.8.3 Acceptability and feasibility
he beneits would be highly valued by families, health providers and programme managerspolicy makers. Additional costs for training health workers and counseling
mothers and families in KMC would be ofset by the cost for conventional care i.e. use of incubators.
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5.9 Prevention of hypothermia immediately after birth in low birth
weight infants
Low birth weight LBW neonates weighing 1200 g who do not have complications and are clinically stable should be put in skin-to-skin contact with the mother soon
ater birth and ater drying them thoroughly to prevent neonatal hypothermia.
Strong recommendation, low quality evidence
In making the recommendation, the panel noted that although the plastic wraps for LBW infants are beneicial in reducing hypothermia, the possible risks of using
plastic wraps in settings in developing country were not known. here is very little experience with this intervention in developing countries and further research into
the type of plastic to be used, as well as the practicality and appropriateness of using the plastic-wrap technique in low-resource settings, is required.
5.9.1 Evidence and summary of findings
We identiied one recent systematic review through Cochrane [McCall 2010] that sought to assess the efect on interventions to prevent hypothermia in preterm andor
LBW infants. he review included three interventions of interest: 1 plastic wraps; 2 plastic caps; and 3 skin-to-skin contact. Studies were included that evaluated these
interventions started within 10 minutes of birth. Hypothermia was deined as core body temperature 36.5 °C on admission to neonatal intensive care unit NICU or
up to 2 hours ater birth. here was low to moderate quality evidence that caps or plasticwraps reduced hypothermia, and moderate quality evidence that skin to skin
contact signiicantly reduced hypothermia in LBW newborns
GRADE table A7.7
Plastic wraps or bags were efective in reducing heat loss in infants 28 weeks’ gestation four studies; n = 223; WMD 0.68 °C; 95 CI 0.45, 0.91, but not in infants
between 28 to 31 weeks gestation 1 study, n = 41. Two of the studies in infants of gestational age 29 weeks showed that plastic wrap signiicantly reduces the risk of
hypothermia on admission to the NICU two studies, n = 152; RR 0.66, 95 CI 0.51, 0.84; RD -0.27; 95 CI -0.41, -0.13 . Four infants would need to be wrapped in plastic
in order to prevent one infant from becoming hypothermic NNT 4, 95 CI 2 to 8.
Plastic caps were efective in reducing heat losses in infants 29 weeks’ gestation one study; n = 64; MD 0.80°C; 95 CI 0.41, 1.19. his study also reported that
plastic caps signiicantly reduce the risk of hypothermia on admission to the NICU RR 0.48, 95 CI 0.32, 0.73; RD -0.47; 95 CI -0.67, -0.27. Two infants would need to
wear a plastic cap in order to prevent one infant from becoming hypothermic NNT 2, 95 CI 2 to 4.
For infants with a birth weight between 1200 and 2199g, evidence suggests that skin-to-skin contact signiicantly reduces the risk of hypothermia as deined by
the study within 6 hours of birth when compared to conventional incubator care one study; n = 31; RR 0.09, 95 CI 0.01, 0.64; RD -0.56, 95 CI -0.84, -0.27. Two
infants would need to receive skin-to-skin contact in order to prevent one infant from becoming hypothermic NNT 2, 95 CI 1 to 4.
