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. 2020 Jun 23;29(3):123–133. doi: 10.1891/J-PE-D-18-00043

Role of Kangaroo Mother Care in the Management of Neonatal Hyperbilirubinemia in Both Term and Preterm Neonates: A Systematic Review

Bhawan Deep Garg, Anju Bansal, Nandkishor S Kabra
PMCID: PMC7360130  PMID: 32760181

Abstract

Background

Neonatal hyperbilirubinemia (NNH) is the most common clinical sign seen in neonatal practice. Kangaroo mother care (KMC), a new strategy has been tried for the management of hyperbilirubinemia.

Aims

To evaluate the role of KMC for reduction of bilirubin and duration of phototherapy in term and preterm neonates.

Method

The literature search was done for various randomized control trials by searching the Cochrane Central Register of Controlled Trials, PubMed, EMBASE, ongoing clinical trials and abstracts of conferences.

Results

This review included five RCTs that fulfilled inclusion criteria. Out of five trials, two trials reported a significant reduction in bilirubin and three trials reported a significant reduction in duration of phototherapy.

Conclusion

KMC may be a novel strategy in the management of NNH. However, due to small sample size and heterogeneity between the trials, the current evidence is not sufficient. Hence, large trials with adequate sample sizes are needed.

Keywords: neonatal hyperbilirubinemia, kangaroo mother care, term neonates, preterm neonates

BACKGROUND

Description of the Condition

Neonatal hyperbilirubinemia (NNH) is one of the most common clinical signs in neonatal practice (Rennie, 2012). Approximately 60% of healthy term neonates and 80% of premature neonates develop clinically visible jaundice within the first week of life (Rennie, 2012). NNH is usually harmless, but high levels of unconjugated bilirubin is neurotoxic and can lead to acute bilirubin encephalopathy (ABE) or kernicterus (Barrington & Sankaran, 2007; Brites, 2012; Kaplan et al., 2011). The most conventional treatment of NNH is phototherapy (Maisels & McDonagh, 2008). Various other strategies such as probiotics (Brites, 2012), prebiotics (Chandil & Jajoo, n.d.; Conde-Agudelo & Diaz-Rossello, 2016), massage therapy (Dennery, 2002), and kangaroo mother care (KMC) are in the experimental stage (Armanian et al., 2016; Bisceglia et al., 2009; Deshmukh et al., 2019; Garg et al., 2019). In this review, we discuss the evidence-based role of KMC in the reduction of NNH in both term and preterm neonates.

Description of the Intervention

KMC includes thermal care through continuous skin-to-skin contact, support for exclusive breastfeeding or other appropriate feeding, and early recognition/response to illness (Lawn et al., 2011). Recent meta-analysis revealed KMC was associated with 36% to 40% lower mortality (Boundy et al., 2016; Conde-Agudelo & Diaz-Rossello, 2016). KMC decreased the risk of neonatal sepsis (relative risk [RR] 0.53, 95% confidential interval [CI] 0.34–0.83), hypothermia (RR 0.22; 95% CI 0.12–0.41), hypoglycemia (RR 0.12; 95% CI 0.05–0.32), hospital readmission (RR 0.42; 95% CI 0.23–0.76), and increased exclusive breastfeeding (RR 1.50; 95% CI 1.26–1.78; Boundy et al., 2016). Similarly, a review by Sarparast et al. (2015) on Iranian neonatal population revealed several benefits of KMC. Nyqvist et al. (2010) revealed the importance of KMC in high tech environments with specific criteria for initiation, kangaroo position, transfer to⁄from KMC, transport in kangaroo position, kangaroo nutrition, parents' role, modification of the NICU environment, performance of care in KMC, and KMC in case of infant instability.

How the Intervention Might Work

KMC facilitates exclusive breastfeeding, which promotes early excretion of meconium and decreases enterohepatic circulation (Gartner, 1994). This leads to an early decrease in serum bilirubin. Evidence revealed repeated breast sucking by neonates shortens the intestinal transit time, and increases excretion of bilirubin in feces, which in turn reduces serum bilirubin concentration (Kelly & Stanton, 1995). Another possible mechanism is that vibratory stimulation from mother's abdomen and breast transfer to neonates, which stimulates the bowel movements and contributes to the increase excretion of bilirubin in feces (Rasouli Larimmani, Ahmadpour-kacho, Zahed Pasha, Hajiahmadi, & Mazloomi, 2016).

Why It Is Important to Do This Review

Phototherapy is the most common intervention used for the management of NNH. It has its own side effects. Phototherapy is associated with hyperthermia, dehydration, hypocalcemia, and watery diarrhea (Drew et al., 1976; Maayan-Metzger et al., 2001; Sethi et al., 1993). Phototherapy is also associated with purpuric eruption, childhood asthma, and infantile cancer (Aspberg et al., 2010; LaRusso et al., 2015; Wickremasinghe et al., 2016). NNH is one of the most common reasons for readmission to the hospital in the first week of life, which is associated with increased parental anxiety and increased economic burden on parents (Dennery, 2002; Ramy et al., 2016; Rennie, 2012).

KMC may translate into improved outcomes in terms of decreasing the duration of phototherapy, which ultimately decreases its side-effects. KMC also decreases the duration of hospital stays, reduces parental anxiety and economic burdens. Therefore, this review was planned to critically analyze the various randomized controlled trials (RCTs) that have evaluated KMC for reduction in NNH and need for phototherapy in both term and preterm neonates.

OBJECTIVE

Primary Objective

  1. To evaluate the efficacy of KMC in reduction of serum/cutaneous bilirubin in both term and preterm neonates.

Secondary Objective

  1. Effect on duration of phototherapy.

METHODS

Criteria for Considering Studies for This Review

Types of Studies

We included all RCTs and quasi-randomized trials in which KMC has been given either prophylactically alone or therapeutically along with phototherapy for the management of NNH.

Type of Participants

We included all healthy preterm and term neonates admitted to neonatal intensive or special care units.

Type of Interventions

KMC for any duration in neonates either as prophylactically or therapeutically. Phototherapy was used as a standard of treatment in both groups.

 Outcomes of Review.

  1. Duration of phototherapy

  2. Serum/Cutaneous bilirubin levels

Literature Search

A literature search was done of various RCTs for this review by searching the following:

  1. Cochrane Central Register of Controlled Trials (CENTRAL).

  2. Electronic database searches of PubMed, EMBASE, Web of Science, Scopus, Index Copernicus, African Index Medicus (AIM), Thomson Reuters (ESCI), Chemical Abstracts Service (CAS), SCIWIN (Scientific World Index), Google Scholar, Latin American and Caribbean Health Sciences Information System (LILACS), Index Medicus for the Eastern Mediterranean Region (IMEMR), Index Medicus for the South-East Asian Region (IMSEAR), and Western Pacific Region Index Medicus (WPRIM).

  3. The following sites for ongoing trials: clinical trial registry (www.clinicaltrials.gov; www.controlled-trials.com), Australian and New Zealand Clinical Trials Registry (http://www.anzctr.org.au), Indian Clinical Trials Registry (http://ctri.nic.in/Clinicaltrials), and the World Health Organization (WHO) International Clinical Trials Registry and Platform (http://www.who.int/ictrp/search/en/)

  4. Abstracts of conferences: proceedings of Pediatric Academic Societies (American Pediatric Society, Society for Pediatric Research, and European Society for Pediatric Research)

Search Methods for Identification of Studies

We searched MEDLINE and EMBASE by using following terms through March 15, 2018. No language restrictions were applied. Additional details were sought from authors as and when required. We searched all trials identified by reviewing the abstract. We also identified studies by citation tracking.

Population

“Infant, newborn” [MeSH Terms] OR (“infant” [All Fields] AND “newborn” [All Fields]) OR “newborn infant” [All Fields] OR “neonates” [All Fields]

Intervention

“Kangaroo mother care” [MeSH Terms] OR “Kangaroo care” [All Fields] OR “Skin to skin care”

Comparison

Clinical trials (MeSH) OR Controlled Clinical Trials (MeSH) OR RCTs (MeSH) OR Random Allocation (MeSH) OR Multicenter studies (MeSH) OR Control groups (MeSH) OR Evaluation studies (MeSH)

Outcome

“Hyperbilirubinaemia” [All Fields] OR “hyperbilirubinemia” [MeSH Terms] OR “hyperbilirubinemia” [All Fields] OR “Jaundice” [MeSH Terms]

All these four subheadings were combined by “AND.”

Selection of Studies

All randomized and quasi-randomized trials, which fulfill our inclusion criteria were included in this review. Two review authors screened the titles and abstracts of all relevant studies identified by the search. When eligibility for inclusion was unclear from the abstract, the full text was screened.

Data Extraction and Management

We collected data of the trial methodology using the “PICO” format (population, intervention, control, and outcome) of the unpublished and published results. One author extracted the data and a second author checked the extracted data. We used the predesigned proforma for data abstraction and it included reduction in the mean serum bilirubin levels and duration of phototherapy.

Risk of Bias Assessment

Risk of bias assessment was evaluated independently by the two authors according to criteria suggested in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins & Green, 2011). To assess methodological quality of included studies criteria were adequate randomization, allocation concealment, blinding of parents, blinding of caregivers, blinding of assessors of outcomes and completeness of follow-up (over and under 90%). For each included study, we categorized the risk of selection bias, performance bias, detection bias, attrition bias, reporting bias, and other source of bias. They were further categorized into low risk, high risk, and unclear risk. Trials that met all criteria were categorized as low risk whereas those that met none were categorized as high risk of bias. The others were classified as unclear risk of bias if the information was insufficient to make a judgment.

RESULTS

We identified a total of five trials that fulfilled the inclusion criteria (Figure 1).

Figure 1.

Figure 1.

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Flow chart of the systematic literature search. (PRISMA flow chart; Moher, Liberati, Tetzlaff, & Altman, 2009)

Description of the Included Studies

Details of the included studies are described in Table 1.

TABLE 1. Description of Included Studies on Kangaroo Mother Care Showing Its Effect on Hyperbilirubinemia in Neonates.

Author Patient Characteristics Intervention Control Group Outcomes Limitations and Strength
Goudarzvand, Dabirian, Nourian, Jafarimanesh, and Ranjbaran (2019) (Iran) Total of 70 term neonates were randomized. Inclusion criteria were: (a) birth weight within normal range of 2500–4000 g, (b) birth age of infants within 37–42 weeks, (c) First and fifth minute Apgar score higher than 7, (d) all infants should be hospitalized with a diagnosis of physiological jaundice (second or third day jaundice diagnosed by the doctor, (e) neonates should be breastfed, (f) neonates should not receive medication to reduce bilirubin, (g) neonates with no exchange transfusion, (h) neonates should be Iranian, and (i) neonates should not be dehydrated. Exclusion criteria: Exclusion criteria were: (a) obvious congenital disorders, respiratory failure, and known infection, (b) jaundice caused by mother milk, (c) symptoms of sepsis, (d) cephalohematoma, purpura, petechiae asphyxia, and birth trauma, (e) history of anemia or jaundice in the mother, father, brother, or sister, (f) umbilical artery catheter or tube into the chest, (g) central venous catheter on shoulder of baby, (h) vasoconstrictor medication receiving neonatal, (i) intraventricular hemorrhage, (j), Non-cooperation of mother during the study, (k) negative RH mother and history of Intrauterine infection, (l) need for exchange transfusion, (m) family history of hemolytic disease (such as G6PD enzyme deficiency), and (n) babies with ABO and RH incompatibility (o) discharge with parental consent before treatment. 35 neonates received KMC along with phototherapy. KMC was given for 1 hour per day. 35 neonates received only phototherapy. Intermittent phototherapy (1 hour break for every 3 hours of phototherapy) was given in both groups. Average skin bilirubin every 24 hours after treatment was lower in the intervention group than the control group, this difference was not statistically significant (p = .236). Mean duration of hospital stay was significantly less in intervention group. (2.09 vs. 3.03 days, p < .001) Small sample size. Blinding was not performed due to inherent nature of study.
Rasouli Larimmani et al. (2016) (Iran) Total of 106 neonates were randomized. Inclusion criteria: Term neonates who were admitted due to NNH were included in the study. Exclusion criteria: (a)presentation of jaundice on the first day after birth; (b) breastfeeding jaundice; (c) blood group incompatibility; (d) positive Coombs' test results; and (e) hemolysis. 53 neonates were received standard phototherapy along with KMC. KMC was given for 30–45 minutes at least six times a day in the morning, afternoon, and night. 53 neonates were received standard phototherapy only. Mean serum bilirubin level after 72 hours was significantly less in intervention group (9.01 ± 1:53 vs. 11.21 ± 1.11; p = .000). Duration of phototherapy was significantly less in the intervention group (64.25 ± 17.54 hours 91.12 ± 16.26 hours; p =.000). Small sample size. Method of randomization was not described.
Li, Zhang, and Li (2017) (China) Total of 216 neonates with 35–40 weeks and birth weight 2000–3750 g were randomized. Inclusion criteria: (a) jaundice occurred at 48–72 hours of age; (b) the peak of serum bilirubin appeared at day 3–5 of age; (c) the rate of rise of bilirubin was < 5 mg/dL/day; (d) the level of conjugated bilirubin was < 2 mg/dL at any time. Exclusion criteria: Neonates who were born with small gestational age or extremely low birth weight; congenital malformation; babies carrying with high risk or known cause for hyperbilirubinemia, such as ABO and RH incompatibility; perinatal asphyxia; neonatal infections; cephalohematoma or significant bruises; breastmilk jaundice; late onset of clinical jaundice (5–10 days of age); babies with peak serum bilirubin level appear at day 15; those with rising rate of bilirubin over 1–2 mg/dL/day; symptoms of jaundice in first 24 hours or beyond 3rd weeks of life. 112 neonates received standard phototherapy along with KMC. KMC were carried three time daily for at least 1 hour every time and 7 days a week until the end of the therapy. 104 neonates received standard phototherapy only. Duration of phototherapy was significantly less in KMC group (67.04 ± 20.58 hours vs. 97.74 ± 41.08 hours; p =.000) Methods of randomization was not described.
Ludington-Hoe and Swinth (2001) (USA) Total of 30 neonates were included in this trial. Inclusion criteria: Birth weight < 2 kg; Gestational age 30–35 weeks who required phototherapy. 10 neonates received KMC along with phototherapy. In this group, neonates received traditional phototherapy 23 hours per day and for the 24th hour were given KMC with a fiberoptic phototherapy panel held against their back. 10 neonates received traditional bank or spotlight phototherapy 24 hours per day. 10 neonates received traditional phototherapy 23 hours per day and for the 24th hour lay prone on a fiberoptic photo-therapy panel. Duration of phototherapy in between the groups was not statistically significant. Daily decrement of bilirubin was not statistically significant in between the groups. Small sample size
Keshavarz and Bolbol Haghighi (2016) (Iran) Total of 160 mother–infant dyads were enrolled in this trial. Inclusion criteria: Healthy term neonates. Exclusion criteria: Premature rupture of the membrane (rupture of the membrane for at least 17 hours before cesarean surgery, requiring the baby to be admitted to the neonatal intensive care unit), maternal disease (diabetes, hypertension and heart disease, preeclampsia, and preeclampsia and maternal hypertension, and any type of abnormality in the neonates), esophageal atresia, duodenum and pylorus, Hirschsprung, central nervous system anomalies, and so on (requiring resuscitation) Apgar < 7 at birth), mother's illness to mental illness, mother's divorce, unwanted or illegitimate pregnancy, mother's addiction, hospitalization for any reason NICU baby, mother's reluctance, failed marriages, and rejection of child sex. 80 neonates received kangaroo care only. Neonate was given about 2 hours after surgery for KMC. KMC was given three times in a day and each time around one hour for 48 hours. In contact with the skin and between the two breasts of the mother using the appropriate cover provided, and then, if communicated, the care program continued for 60 minutes. 80 neonates received routine care only. There was no statistically significant different in reduction of bilirubin in both groups. KMC was given prophylactically. Randomization methods was not described.
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Note. KMC = kangaroo mother care; NNH = neonatal hyperbilirubinemia.

Description of the Excluded Studies

Samra et al. (2012) evaluated the effect of KMC on the duration of phototherapy in 50 neonates with hyperbilirubinemia who were 35 to 40 weeks of gestational age and had a birth weight of 2000 to 3750 g. Neonates with physiological jaundice and breastfeeding associated jaundice (onset of jaundice at 48–72 hours of age, peak serum bilirubin occurring at day 3–5 of age, rate of rise of bilirubin < 5 mg/dL/day, and conjugated bilirubin < 2 mg/dL at any time) were included in the study. Out of a total of 50 neonates, 28 neonates were in the KMC group (phototherapy with intermittent KMC) and 22 neonates were in the control group (only phototherapy). Intermittent KMC was provided three times daily, 7 days/week until the NNH resolved and phototherapy could be stopped. Duration of phototherapy was significantly less in the KMC group (68.14 ± 24.32 hours versus 100.86 ± 42.26 hours, p =.004). This study was not included in this review as it was a prospective observational study (Samra et al., 2012).

Description of the Ongoing Clinical Trials

A randomized clinical trial to study the effect of KMC on duration of phototherapy in neonatal jaundice is ongoing in India. Hemodynamically stable neonates with a gestational age of 30 to 40 weeks, a birth weight of 1000 to 2000 g who require phototherapy were included in this trial. Neonates with major congenital malformations, who were hemodynamically unstable, requiring exchange transfusion and jaundice in first 24 hours of life with a rate of rise of bilirubin > 5 mg/dL/day, were excluded from the study. A total of 50 neonates (25 neonates in each group) were enrolled in this trial. In the control group, neonates will receive conventional phototherapy 24 hours a day. In the intervention group, neonates will receive phototherapy with the same settings along with one hour of KMC ever eight hours. During KMC mother or any other caregiver will be provided goggles. She or he will be sitting in a chair providing KMC to the neonate while the phototherapy panel is held against the back of the baby in a shielded area with a room temperature maintenance of 25 to 30 degree centigrade. The primary outcome is duration of phototherapy. The secondary outcomes are duration of hospital stay, rate of fall in serum bilirubin, temperature maintenance and weight gain per day (Chandil & Jajoo, n.d.).

Assessment of Risk of Bias of Included Trials

Summary of risk of biases are described in Table 2.

TABLE 2. Risk of Bias: Review Authors' Judgments About Each Risk of Bias Item Presented as Table Across all Included Studies.

Name of Studies Random Sequence Generation (Selection Bias) Allocation Concealment (Selection Bias) Blinding of Participants and Personnel (Performance Bias) Blinding of Outcome Assessment (Detection Bias) Incomplete Outcome Data (Attrition Bias) Selective Reporting (Reporting Bias) Other Biases
Goudarzvand et al. (2019) (Iran) High risk Unclear risk High risk High risk Low risk Low risk Low risk
Rasouli Larimmani et al. (2016) (Iran) Unclear risk Unclear risk High risk Unclear risk Low risk Low risk Low risk
Li et al. (2017) (China) Unclear risk Unclear risk High risk Unclear risk Low risk Low risk Low risk
Ludington-Hoe and Swinth (2001) (USA) Unclear risk Unclear risk High risk Unclear risk Low risk Low risk Low risk
Keshavarz and Bolbol Haghighi (2016) (Iran) High risk Unclear risk High risk Unclear risk Low risk Unclear risk Low risk
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In trial by Goudarzvand et al. (2019), the method of randomization was non-random which was performed on a weekly basis. Within a week samples of the intervention group were selected and within the next week samples of the control group were selected. This process continued until the desired sample size was achieved. Hence, the risk of selection bias (random sequence generation) is high. However, no information was provided regarding allocation concealment. Risk of selection bias (allocation concealment) is unclear. The researcher and health personnel were not blinded, making the risk of bias high. This trial reported complete outcome data. Risk of attrition bias is low. This trial assessed to be free of risk of selective reporting bias. Baseline characteristics were comparable in both groups. The phototherapy device used was manufactured by Tucson (Iran). The risk of other bias is low (Goudarzvand et al., 2019).

In a trial by Rasouli Larimmani et al. (2016), the method of random sequence generation and allocation concealment was not clear. Hence, the risk of bias is unclear. Caregivers were not blinded, making the risk of performance bias high. Information was not provided regarding the blinding of the outcome assessor, making the risk of detection bias unclear. Out of a total of 106 neonates, all were included in the analysis. Thus, this trial reported complete outcome data. Risk of attrition bias is low. This trial reported all prespecified outcomes, making the risk of reporting bias low. The baseline characteristics were comparable in both groups. In both groups, a phototherapy device equipped with five lamps (David XHZ-90, China) was used. The risk of other biases are low (Rasouli Larimmani et al., 2016).

Li et al. (2017) did not describe a method of random sequence generation and allocation concealment, making the risk of bias unclear. Blinding was not feasible for caregivers, making the risk of performance bias high. Blinding of outcome assessor was not described in the trial, making the risk of detection bias unclear. The risk of attrition bias is low as all participants were included in the analysis. This trial assessed to be free from reporting bias. Baseline characteristics were comparable in both groups. In both groups, the phototherapy equipment YG-I and XHZ (DAVID, Ningbo, China) were used. Risk of other biases are low (Li et al., 2017).

Ludington-Hoe and Swinth (2001) did not describe a method of random sequence generation and allocation concealment. The risk of bias is unclear. As caregivers were not blinded, the risk of performance bias is high. There was no information regarding the blinding of the outcome assessor. Risk of detection bias is unclear. All participants were included in the analysis so the risk of attrition bias is low. The risk of reporting bias is low as all predefined outcomes were reported. Fiberoptic Medical Products, Inc., Allentown, Pennsylvania, was used and the funding source was clearly defined. The risk of other biases are low (Ludington-Hoe & Swinth, 2001).

Keshavarz and Bolbol Haghighi (2016) randomly allocated participants in one of two groups by one of the department personnel. Risk of bias (random sequence generation) is high. There was no information regarding allocation concealment, making the risk of bias (allocation concealment) unclear. Health personnel were not blinded. Hence, the risk of performance bias is high. Blinding of the outcome assessor was not described so the risk of detection bias is unclear. This trial reported complete outcome data, making the risk of attrition bias low. Prespecified outcomes were not clear. The risk of reporting bias is unclear. Baseline characteristics were comparable in both groups. The risk of other biases are low (Keshavarz & Bolbol Haghighi, 2016).

DISCUSSION

In this review, we included a total of five RCTs that have evaluated the role of KMC in the management of NNH. Goudarzvand et al. (2019), Rasouli Larimmani et al. (2016), Li et al. (2017), and Ludington-Hoe and Swinth (2001) evaluated the role of KMC in the treatment of NNH, whereas Keshavarz and Bolbol Haghighi (2016) evaluated the prophylactic role of KMC for the prevention of NNH. The duration of KMC was varied from one hour per day in Goudarzvand et al.'s and Ludington-Hoe and Swinth's studies to a maximum of four and half hours per day in Rasouli Larimmani et al.'s study (Kelly & Stanton, 1995). Phototherapy was used as a standard therapy for treatment of NNH in Rasouli Larimmani et al.'s, Goudarzvand et al.'s, and Ludington-Hoe and Swinth's studies. Goudarzvand et al., Rasouli Larimmani et al., and Keshvaraz and Bolbol Haghighi reported the role of KMC in term neonates whereas Li et al. reported in both term and late preterm neonates (35–40 weeks). Ludington-Hoe and Swinth evaluated the role of KMC in preterm (30–35 weeks) neonates. Bilirubin was measured either as cutaneous bilirubin or serum bilirubin in these trials.

Rasouli Larimmani et al. and Ludington-Hoe and Swinth reported a significant decrement in bilirubin in the intervention group whereas Goudarzvand et al. reported a non-significant reduction in bilirubin. Similarly, Keshvaraz and Bolbol Haghighi reported that prophylactic KMC was associated with a non-significant reduction in the bilirubin. Goudarzvand et al., Rasouli Larimmani et al., and Li et al. reported a significant reduction in the duration of phototherapy in the intervention group, whereas Ludington-Hoe and Swinth reported a non-significant reduction in the duration of phototherapy.

To the best of our knowledge, this is the first systematic review which sought to determine the role of KMC in the management of NNH. The strength of our systematic review is an extensive literature search and the inclusion of the maximum number of studies. However, this systematic review has several limitations. First, the sample size is very small in all trials. Second, there is a significant heterogeneity in between studies regarding population (term, late preterm, and preterm neonates), intervention (varied duration of KMC), bilirubin measurement (cutaneous vs. serum bilirubin) and the management of NNH (prophylactically vs. therapeutically). Hence, this heterogeneity limits generalizability of data. Despite these limitations, KMC is a new insight which may translate into improved outcomes in terms of reducing the duration of phototherapy, as well as the duration of hospital stays.

IMPLICATIONS FOR PRACTICE

This systematic review shows that the use of KMC is associated with a lower bilirubin level possibly via an enhanced gastrointestinal motility, increased stool output, and by decreasing enterohepatic circulation. This beneficial effect of KMC is a novel strategy of prevention and treatment of mild to moderate hyperbilirubinemia in both preterm and term neonates. This is particularly important for developing countries whereby simple measures can reduce the cost of treatment and the socioeconomic burden.

IMPLICATIONS FOR RESEARCH

As per the evidence, KMC has some role in the management of NNH. However, given the small sample size and heterogeneity between the trials, the current evidence is not sufficient. To implicate KMC in the routine clinical practice for the management of hyperbilirubinemia, we need large high-quality trials, with sufficient power to reliably assess clinically relevant differences in important outcomes.

Biographies

BHAWAN DEEP GARG is currently working as consultant neonatologist at Medanta S.N Superspecial-ity Hospital. Areas of interest: Probiotics, prebiotics, preterm, necrotizing enterocolitis.

ANJU BANSAL is currently working as Consultant in Surgery at Jan Sewa Hospital. She has particularly interest in Necrotizing enterocolitis and related surgeries.

NANDKISHOR S. KABRA is a senior neonatologist at Surya Hospital. He has published many original research and reviews.

DISCLOSURE

The authors have no relevant financial interest or affiliations with any commercial interests related to the subjects discussed within this article.

FUNDING

The author(s) received no specific grant or financial support for the research, authorship, and/or publication of this article.

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