All-cause mortality and infection-related outcomes of hospital-initiated kangaroo care versus conventional neonatal care for low-birthweight infants: a systematic review and meta-analysis

Abstract

Background: Kangaroo care has a well-established role in preterm infant stabilisation and in protecting low-birthweight newborns from mortality. Yet kangaroo care is far from fully embedded in conventional inpatient neonatal care practice. The evidence on infection outcomes of hospital-initiated kangaroo care is unclear. We aimed to evaluate the existing evidence to understand the role of hospital-initiated kangaroo care in preventing mortality, sepsis, and invasive infection in low-birthweight infants.

Methods: In this systematic review and meta-analysis, we searched Embase, MEDLINE, Cochrane Library, and Web of Science databases for literature published between Jan 1, 2013, and Feb 26, 2025. At least two authors independently undertook study selection, data extraction, and quality assessment. Reports of randomised controlled trials presenting data on at least one of our set primary outcomes (all-cause mortality and/or sepsis and/or invasive infection) comparing kangaroo care with conventional neonatal care in low-birthweight infants (<2500 g) were eligible for inclusion. The primary outcomes were all-cause mortality, sepsis, and invasive infection (composite of necrotising enterocolitis, pneumonia, meningitis, and other severe infections). Hypothermia and apnoea were assessed as adverse events. A random effects model was used to estimate the pooled overall effect sizes for each outcome, presented as odds ratios (OR [95% CI]), with between-study heterogeneity assessed by Cochran's Q test and sources of heterogeneity investigated using univariable random effects meta-regression analyses. This study is registered with PROSPERO, CRD42024501546.

Findings: We synthesised data from 29 studies, mainly from lower-middle income countries, including 17 513 low-birthweight infants. Most studies were moderate-to-high quality. 25 (86%) of 29 studies reporting all-cause mortality were included in the meta-analysis of hospital-initiated kangaroo care, which showed that hospital-initiated kangaroo care reduced all-cause mortality (pooled OR 0·77 [95% CI 0·67-0·89]; high-quality evidence, with I²=0%). 17 (59%) of 29 trials reported sepsis as an outcome, and the pooled results showed that kangaroo care reduced the odds of sepsis (OR 0·55 [95% CI 0·37-0·82]; moderate-quality evidence, with I² =53%). Similarly, among the 11 (38%) of 29 studies reporting invasive infection, the pooled results showed that kangaroo care reduced the odds of invasive infection (OR 0·49 [95% CI 0·33-0·74]; moderate-quality evidence, with I² =0%). Kangaroo care was associated with a significant reduction in the odds of sepsis-related or invasive infection-related mortality (OR 0·63 [95% CI 0·47-0·84], I² =0%, high-quality evidence), hypothermia (0·28 [0·16-0·46], I² =72%, moderate-quality evidence), and apnoea (0·46 [0·25-0·85], I² =45%, moderate-quality evidence). Meta-regression showed that between-study heterogeneity was due to variation in level of kangaroo care offered as part of conventional neonatal care.

Interpretation: The joint protective effect of hospital-initiated kangaroo care against all-cause mortality and infection in low-birthweight infants reinforces its importance in routine neonatal care across settings, in line with WHO recommendations. The extent of the protective effects in low-birthweight infants through averted infections suggests that kangaroo care should be integrated into standard infection prevention and control practice globally.

Funding: European Society for Paediatric Infectious Diseases, the EU, and the Machaon Foundation.