Introduction: Kangaroo care (KC) is defined by the World Health Organization as a method of care consisting in putting premature infants or newborns in skin-to-skin contact with their parents. KC is an effective method of promoting health and well-being of infants and their families. Physiological stability during KC has been widely analyzed, however with controversial results. Methods: A systematic review was conducted. Electronic databases searched included MEDLINE, Embase, CINAHL, and Scopus. Two authors independently reviewed and extracted information using a data extraction form. The methodological quality of the observational studies was assessed using “STROBE” and the “Cochrane Collaboration tool” for randomized controlled trials. The physiological monitoring parameters included were heart rate (HR), arterial oxygen saturation (SpO2), regional cerebral oxygen saturation (rScO2), and fractional oxygen extraction (FtOE). Results: A total of 345 articles were identified. First, 302 articles were excluded by title and then 34 articles after full-text analysis. Finally, a total of 25 studies were included. Physiological parameters monitored (HR, SpO2, rScO2, and FtOE) showed no significant changes at different study periods: pre-KC, during KC, and post-KC. Conclusions: We conclude that stable preterm infants receiving or not respiratory support show no significant differences in HR, SpO2, FtOE during KC compared to routine incubator care. rScO2 remains stable during KC with slight upward trend. Further studies with a higher level of methodological quality are needed to confirm these findings.

Kangaroo care (KC) is defined by the World Health Organization as a method of care consisting in putting premature infants or newborns in skin-to-skin contact with their parents. KC is an effective method of promoting health and well-being of infants and their families [1]. KC helps to improve thermal control, encourages breastfeeding, reduces stress, improves sleep wake cycle maturation, favors the establishment of bonding, and reduces the risk of infection and hospital stay [2-6].

However, studies on the physiological stability during KC have reported controversial results [7-19]. The physiological parameters most frequently monitored have been heart rate (HR), respiratory rate, temperature (T), fraction of inspired oxygen (FiO2), pulse oximetry (SpO2), regional cerebral oxygen saturation (rScO2), and fractional tissue oxygen extraction (FtOE) [7, 8, 11, 20, 21]. In addition, hypoxic (SpO2 <80% for >5 s) and bradycardic (HR <80 bpm for >5 s) events during KC have been compared to incubator care with contradictory results. Hence, while Boju et al. [12] reported an increase of hypoxic and bradycardic events during KC, Mitchell et al. [16] reported a reduction of both.

Uncertainty regarding the consequences of KC upon oxygen saturation and regional cerebral oxygen saturation could be a hindrance for the implementation of KC in premature infants [22, 23]. To shed length on this conundrum, we performed a systematic review of scientific articles that assessed oxygenation during KC in the neonatal intensive care unit using pulse oximetry and near-infrared spectroscopy (NIRS).

Design

This systematic review was conducted according to the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [22, 23].

Criteria for Considering Studies for This Review

Randomized controlled trials (RCTs), controlled clinical trials, and observational studies which reported on physiological stability or physiological monitoring parameters during KC were eligible. Poster presentations, conference papers, single-case studies, study protocols, as well as review articles were excluded since the availability of full text was essential.

Type of Study Population

The target population consisted of premature infants (<37 weeks of gestational age).

Type of Outcome Measures

Outcome measures included hypoxic and bradycardic events or physiological monitoring of HR, SpO2, rScO2, FtOE during KC.

Electronic Search

We conducted a systematic search of the following databases: MEDLINE, Embase, CINAHL, and Scopus. The research was performed between June 25th and September 4th, 2021.

The main subjects’ headings and free text terms used were “Kangaroo-Mother Care Method”, “vital signs”, “heart rate”, “oxygen saturation”, “cerebral perfusion”, “cardiorespiratory stability”, infant, “premature”. Complete searching strategy is reported in online supplementary Table 1 (for all online suppl. material, see www.karger.com/doi/10.1159/000525014). The search was not limited by date of publication, to avoid missing studies. However, to unify the search the following search filters were used: human studies and newborns (birth – 1 month). We included articles written in English, Spanish, French, and German.

Another Search

Additional studies were hand searched.

Selection of Studies

Titles and abstracts of every article searched were independently assessed by two authors who also decided upon their inclusion in the analysis (A.S.G and I.L.C.). Disagreements were solved in consensus with a third author (A.P.G.).

Data Extraction

Two authors independently reviewed and extracted information using a data extraction form. In case of disagreement, a third reviewer was consulted, and the final decision was taken by consensus. The following data were extracted and analyzed: study design, setting and patient characteristics, data collection, results (SpO2, HR, rScO2, and FtOE), conclusions, and quality assessment.

Quality Appraisal of Individual Studies

Two authors (A.S.G and I.L.C.) evaluated the methodological quality. Disagreements were solved by a third reviewer (A.P.G.) by consensus. The methodological quality of observational studies was assessed using “Strengthening the Reporting of Observational Studies in Epidemiology (STROBE)” [24]. A total of 22 items were evaluated with a total score of 22. Items were classified as “weak” when achieving a score <33%; as “moderate” if the score was between 34 and 66%, and “strong” when the score was >66%. For RCT, we employed the “Cochrane Collaboration tool” [25]. The Cochrane Collaboration risk of bias assesses the risk of various forms of bias: selection bias, performance bias, attrition bias, and reporting bias. Each item can be classified as low, unclear, or high risk of bias.

Grading Quality of a Body of Evidence

The quality of the evidence was evaluated using the GRADE approach. This scale classifies articles in four evidence grades: “high,” “moderate,” “low,” and “very low” [26].

Study Selection

A total of 345 articles were identified. The initial selection, based on title and abstract, included 34 papers that fulfilled the predefined criteria. After reading and analyzing full-text articles, nine articles were disregarded and 25 were finally included (see Fig. 1).

Fig. 1.

Flowchart of included and excluded studies.

Fig. 1.

Flowchart of included and excluded studies.

Close modal

Description of Studies

A total of 1,039 premature infants undergoing KC were included. The number of subjects per study ranged from 8 to 265. KC duration ranged from 60 min to 160 min. From a total of 25 studies, twenty-two studies were prospective observational, two quasi-experimental, and one RCT. Online supplementary Table 2 provides a complete overview of results, conclusion, methodology, quality, and evidence grade of the included studies.

In the selected studies, physiological monitoring parameters (HR, SpO2, rScO2, and FtOE) were analyzed at different study periods: pre-KC, during KC, and post-KC. Four studies included patients with invasive respiratory support, 14 included patients with noninvasive respiratory support, and 10 included patients without respiratory support. Principal methodological allows were summarized in Table 1.

Table 1.

Table of methodological results

Table of methodological results
Table of methodological results

Monitoring of Physiological Parameters

A total of 25 articles included HR and involved 1,019 subjects. 22 studies did not show significant differences at different study periods: pre-KC, during KC, and post-KC [7, 17, 18, 21, 27-30]. However, three studies reported a small significant decrease during KC [8, 12, 30]. 19 studies involving 922 subjects analyzed SpO2 did not show significant differences at different study periods too [7-12, 17-19, 21, 27-29, 31-34]. Only two studies showed a significant increase during KC period [8, 19]. Six articles involving 157 subjects included rScO2 (Table 2). Four studies did not show significant differences [7, 17, 27, 33], while two studies showed a significant rScO2 increase during KC [8, 29]. Finally, five studies involving 141 premature infants which included FtOE did not show differences in the three study periods [7, 8, 17, 33, 34].

Table 2.

Overview of included studies

Overview of included studies
Overview of included studies

Multiple studies have described the benefits of KC to promote health and well-being of newborn infants and their families [1-6, 35]. However, recent studies analyzed the physiological stability during KC with controversial results which could result in a hindrance for the implementation of KC in the first days of life, in ventilated patients, or in extremely preterm infants [7, 8, 10, 11, 16, 20, 21]. To provide an answer to this conundrum, we performed a systematic review of the scientific literature dealing with the physiological stability of premature infants during KC in the neonatal intensive care unit. The studies included in this systematic review showed no evidence of clinically relevant effects on physiological monitoring parameters during KC. Studies that included HR and SpO2 showed no clinically significant differences between KC and incubator care. However, studies which included rScO2 and FtOE showed a significant increase of rScO2 while FtOE only showed nonsignificant differences clinically irrelevant. These findings warrant further investigation [7, 8].

Physiological Monitoring Parameters

Most of the studies that analyzed HR did not show significant differences between KC and incubator care [7, 17, 18, 21, 27-30]. However, Boju et al. [12], Kommers et al. [30], and Lorenz et al. [8] reported a small but significant decrease in HR during KC compared with incubator care. Conversely, Bisanalli et al. [31] showed a significant increase.

The quality (STROBE) and evidence (GRADE) was found to be different among those studies which analyzed HR. The differences between KC and incubator care for HR were small and not clinically significant. Thus, all studies concluded that KC is safe in stabilized and nonstabilized premature infants.

Most of the studies that included monitoring of SpO2 did not show significant differences between KC and incubator care [7-12, 17-19, 21, 27-29, 31-34]. Hence, while Mitchell et al. [16] found a significant reduction in oxygen desaturations during KC, other studies [7, 11, 18, 27, 28, 33] did not find significant differences concluding that KC did not influence oxygenation and respiratory stability. Contrarily, Lorenz et al. [8] and Parsa et al. [19] reported a significant increase in SpO2 during KC although the differences were clinically irrelevant. They concluded that KC provides a SpO2 stability comparable to incubator care.

Recent studies have focused on the analysis of the possible benefits in brain oxygenation during KC [7, 8, 17, 27, 29, 34, 36, 37]. Two studies employed INVOS (Medtronic, Minnesota, USA) (30,37), three employed Fore-Sight (Edwards LifeScience, California, USA) [7, 8, 17], and one study employed SenSmart X-100 (NONIN Medical, Stockholm, Sweden) [34]. Lorenz et al. [8] showed a significant increase (p < 0.01) in rScO2 during KC (74.8% ± 4.6%) versus incubator care (73.6% ± 6.0%). In a similar study, Meder et al. [29] reported a significant increase of rScO2 during KC (KC, 77.72% ± 3.5%, vs. baseline, 76.87% ± 2.97%; p = 0.01). However, other studies [7, 17, 27, 33] only showed nonsignificant increases in rScO2. Two studies [8, 27] speculated that the small increase in rScO2 during KC might be associated with quiet sleep. However, no concomitant register of aEEG was performed and therefore this explanation warrants further investigation.

Only few studies [7, 8, 17, 29, 33] and with a low degree of evidence have analyzed FtOE during KC. Studies reported that FtOE was within the normal range and remained stable during KC and incubator care independently of the requirement of respiratory support [7, 8, 17, 33, 34]. We found strong quality (STROBE) and moderate evidence (GRADE) showing that the influence of KC compared to incubator care upon cerebral hemodynamics and oxygenation was not clinically significant.

Bias, Measurement Errors, and Monitoring

Probably, the most relevant bias relies in the difference between the methods employed for monitoring physiological parameters. Thus, SpO2 measurements with pulse oximetry showed only a small interindividual variation since oximetry provides absolute values. However, rScO2 measurements with NIRS showed a relevant interindividual variation. NIRS is a tendency monitor. The use of different monitors with different technologies and wavelengths have undoubtedly contributed to an increased variability in the results. Thus, rScO2 and FtOE results should be interpreted with caution [38].

Generalizability

The studies mainly included clinically stable premature infants, most of them with noninvasive respiratory support or no-support. Only four studies included patients with invasive respiratory support. Studies investigating KC in term infants or in extremely preterm infants with severe conditions were not included in the present study. The results of the present systematic review cannot be extrapolated to unstable premature infants requiring critical care.

Limitations and Strengths

This review has limitations. The majority of the studies were observational and therefore qualified as of low quality and low GRADE. Despite including four languages highly relevant to the scientific literature, we may have disregarded relevant scientific evidence. Moreover, homogeneity in the study designs, study periods, KC duration, clinical patients’ characteristics, and physiological monitoring parameter data analysis and statistical analyses is lacking which adds difficulties to reaching conclusions.

The strengths of this review reside in the inclusion of specified, detailed, and structured data collection and the absence of limitation to the publication date. Moreover, the inclusion of two different researchers to complete the data extraction and analysis supported by a third researcher in case of discrepancy adds reliability to this systematic review. Finally, this is the first systematic review that has analyzed the effect of KC on brain oxygenation rScO2 and FtOE.

Implications for Research

Further research including higher quality and graded evidence studies adequately powered which also include extremely premature infants with invasive and noninvasive respiratory support is needed. These studies should pay special attention to the hemodynamic repercussion of transfers back and forth from the incubator to KC.

We conclude that stable preterm infants receiving or not respiratory support showed no significant differences in HR, SpO2, FtOE during KC compared to routine incubator care. rScO2 remained stable during KC with slight upward trend. Further studies with a higher level of methodological quality are needed to confirm these findings.

We would like to thank the nursing and medical staff of our hospital for their contribution to improving kangaroo care in very ill premature infants and parents for their enthusiasm.

An ethics statement is not applicable because this study is based exclusively on published literature.

The authors have no conflicts of interest to declare.

A. Solaz-García and M. Vento are supported by a grant from the ISCIII-Sub-Directorate General for Research Assessment and Promotion and the European Regional Development Fund (FEDER), grant number RD16/0022/0001. A. Pinilla González is a pre-doctoral fellow of the Health Research Institute La Fe (Valencia, Spain) and I. Lara-Cantón enjoys research grant CM20/00187 from the Instituto de Investigación Sanitaria Carlos III (Ministry of Science and Innovation).

A. Solaz-Garcia, I. Lara-Cantón, and A. Pinilla-González conceptualized and designed the study search strategy, selected, and evaluated methodological quality of articles, drafted the initial manuscript, and reviewed and revised the manuscript. M. Vento, P. Saenz-González, A. Gimeno-Navarro, and R. Montejano-Lozoya conceptualized and designed the study, drafted the initial manuscript, and critically reviewed and revised the manuscript for important intellectual contents. A. Sánchez-Illana and A. Marco-Piñol drafted the initial manuscript and reviewed and revised the manuscript, especially methodological aspects, and language.

All data were available in the original articles because this study is based exclusively on published literature.

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