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Page 2

Benefits of KC in non-pain context

Reference	Sample and setting	Design	Provider	Outcome measures	Results
Temperature regulation
Christensson et al12	Sample: n=80, >1,500 gMode of delivery: not reported Setting: teaching hospital, Zambia	RCT: KC versus incubator for treatment of hypothermia	Mother	Rectal temperature	KC > control normal temperature at 240 minutes (90% versus 60%, P<0.001)
Conde-Agudelo et al10	Sample: n=698 LBW infants (six studies)	Meta-analysis of RCTs	Mother	Hypothermia at discharge or 40–41 weeks of PMA	KC < SC (RR 0.34, 95% CI 0.17–0.67)
Ludington-Hoe et al13	Sample: n=29, preterm (26–35 weeks)Mode of delivery: not reported Setting: level II NICU in USA	RCT: KC ×3 2.5–3.0 hours versus SC	Mother	Abdominal and toe temperature	Abdominal temperature: no difference Toe temperature: KC > SC (F=7.04, P=0.02)
Legault and Goulet14	Sample: n=61, premature (32–35 weeks)Mode of delivery: not reported Setting: level III NICU, Canada	Randomized crossover trial	Mother	Skin temperature	No difference
Chwo et al15	Sample: n=34, 34–36 weeks GAMode of delivery: V (n=11) C/S (n=23) Setting: Taiwan	RCT: KC versus control versus SC	Mother	Tympanic temperature	KC > SC (MD 37.3°C versus 37.0°C, P=0.01)
Marin Gabriel et al16	Sample: n=137, 35–42 weeks GAMode of delivery: V Setting: hospital, Spain	RCT: early KC ×2 hours versus SC	Mother, early KC ×2 hours	Axillary temperature	Rise in temperature first 5 minutes: KC > SC 0.07°C±0.58°C versus −0.22°C±0.52°C in the CG (P<0.001). Mean temperature first 5 minutes of life: 36.6°C±0.79°C in the KC group versus 36.9°C±0.58°C in the CG (P<0.01)
Gathwala et al43	Sample: n=110 LBW infants (35 weeks mean GA) Mode of delivery: not reported	RCT: KC at least 6 hours/day versus incubator care; 16-month longitudinal study	Mother	Mean axillary temperature, episodes of hypothermia	Mean temperature: KC > SC (36.67°C±0.24°C versus 36.44°C±0.22°C; P<0.05) Episodes of hypothermia: no statistically significant difference
Physiological stability
Bergman et al17	Sample: 31 KC, mean 34.2 weeks; 13 controls, mean 35.3 weeksMode of delivery: V Setting: two secondary hospitals in South Africa	31 KC, mean 34.2 weeks; 13 controls, mean 35.3 weeks	Mother	SCRIPa score during first 6 hours after birth Infants who did not exceed defined physiological parameters requiring attention	Higher scores in KC (MD 2.88; 95% CI 0.53–5.23). Attention more likely to be required in SC group (RR 10.83; 95% CI 1.63–72.02)
Ludington-Hoe et al18	Sample: 24 preterm (33–35 weeks GA at birth)Mode of delivery: N/A Setting: NICU, USA	RCT: KC versus SC in infants nearing discharge	Mother	HR, RR, O2 saturation, abdominal skin temperature	Mean cardiorespiratory and temperature outcomes within acceptable ranges during KC; no apnea, bradycardia, or periodic breathing in KC; KC > regular breathing
Mitchell et al19	Sample: n=38, 27–30 weeks GAMode of delivery: not reported Setting: NICU, USA	RCT: 2 hours KC versus SC	Mother	HR, O2 saturation	Bradycardia/hour: KC < SC (P=0.048) O2 desaturation events: KC < SC (P=0.017)
Legault and Goulet14	Sample: n=61, premature (32–35 weeks)Mode of delivery: not reported Setting: level III NICU, Montreal, Canada	RCT crossover	Mother	HR, RR, O2 saturation	O2 saturation: KC > SC (92.8% versus 90.5%, P<0.0001)
Rojas et al20	Sample: 60 LBW (32 weeks, <1,500 g)Mode of delivery: not reported Setting: pediatric hospital, USA	RCT: KC for 1 hour versus holding clothed in supine position	Mothers and fathers (70±40 minutes/day)	Percentage of infants with O2 desaturation during observation	KC < control (30% versus 56%, P=0.05)
Sleep organization
Ludington-Hoe et al30	Sample: n=28, PMA 32 weeksMode of delivery: not reported Setting: USA	RCT: 2–3 hours KC versus SC	Mother	Sleep arousal, REM, quiet sleep, indeterminate sleep	Sleep arousal: KC < SC (BKC = −7.35, P=0.015); REM counts during AS: KC < SC REM counts during AS (BKC = −8.9, P=0.029) REM counts during study period: KC < SC (BKC = −5.11, P=0.013) Quiet sleep: KC > SC % QS (β = +10.3, P=0.05), Indeterminate sleep: KC < SC % IS (β = −9.0, P=0.01)
Chwo et al15	Sample: n=34, 34–36 weeks GAMode of delivery: V (n=11) C/S (n=23) Setting: Taiwan	RCT: KC versus control versus SC	Mother, 3 hours	Quiet sleep (recorded at 5-minute intervals)	KC > control (62% versus 22%, P=0.001)
Scher et al31	Sample: eight pretermMode of delivery: not reported Setting: USA	Cohort comparison	Mother	Sleep analysis (EEG)	REM counts during study period: KC < SC (P<0.0001) Sleep cycle length: KC > control (P=0.01) Quiet sleep: KC > control (P=0.0001) Spectral beta power: KC < control (P=0.025) Spectral respiratory irregularity: KC > control (P=0.02)
Mortality
Conde-Agudelo et al10	Sample: 1,736 LBW infants (eight studies) 2,167 LBW infants (eleven studies)	Meta-analysis of RCTs		Mortality at discharge or 40–41 weeks PMA Mortality at latest follow-up	KC < SC (RR 0.60; 95% CI 0.39–0.92) KC < SC (RR 0.67; 95% CI 0.48–0.95)
Infection
Conde-Agudelo et al10	Sample: 1,343 stabilized LBW infants (seven studies)	Meta-analysis of RCTs	Mother	Severe infection/sepsis at latest follow-up	KC < SC (RR 0.56; 95% CI 0.40–0.78)
283 LBW (one study)			Severe illness at 6 months	KC < SC (RR 0.30; 95% CI 0.14–0.67)
913 LBW (three trials)			Nosocomial infection/sepsis at discharge or 41 weeks PMA	KC < SC (RR 0.45; 95% CI 0.27–0.76)
283 LBW (one study)			Lower respiratory tract disease at 6 months follow-up	KC < SC (RR 0.89; 95% CI 0.15–0.89)
1,266 LBW infants (four studies)			Mild/moderate infection or illness at latest follow-up	No difference (RR 1.28; 95% CI 0.87–1.88)
448 LBW (four studies)	RCT	Mother	Hyperthermia at discharge or 40–41 weeks’ PMA	No difference (RR 0.79; 95% CI 0.59–1.05)
Sloan et al21	Sample: 283 LBW (mean GA 33 weeks)Mode of delivery: not reported Setting: Ecuador	RCT: KC w/frequent BF versus SC with scheduled BF	Mother	Diarrhea at 6 months follow-up	No difference (RR 0.65; 95% CI 0.35–1.20)
Growth
Conde-Agudelo et al10	1,072 LBW (ten studies)	Meta-analysis of RCTs	Mother	Weight/day	KC > control (MD 3.7 g, 95% CI 1.9–5.6)
251 LBW (two studies)			Length (cm)	KC > control (MD 0.29 cm, 95% CI 0.27–0.31)
369 LBW (three studies)			Head circumference	KC > control (MD 0.18 cm, 95% CI 0.09–0.27)
Charpak et al48	592 LBW	RCT: 24 hours/day KC versus SC	Mother	Head circumference at 6 months’ corrected age	KC > control (MD 0.34 cm, 95% CI 0.11–0.57)
Nagai et al27	Sample: 73 LBW 32–34 weeks GAMode of delivery: not reported Setting: five hospitals, Iran	RCT, early (<24 hours) versus late (>24 hours) onset KC in relatively stable infants	Mother	Reduction in body weight loss from birth to 48 hours	KC > control (MD 43.4 g, 95% CI 5.5–81.1)
Rojas et al20	Sample: 60 LBW (≤32 weeks, <1,500 g)Mode of delivery: not reported Setting: pediatric Hospital, USA	RCT: KC for 1 hour versus holding clothed in supine	Mothers and fathers (70±40 minutes/day)	Rate of head growth	Total head growth: KC > control (P=0.03) Head growth rate: KC > control (P=0.05)
Suman et al23	Sample: 206 <2,000 gMode of delivery: not reported Setting: level III NICU in Western India	RCT	Mothers, 13.5 hours/day average	Growth	KC > control (weight 2,388 g, length 47.8 cm, and head circumference 33.4 cm versus weight 2,065 g, length 46.4 cm, and head circumference 32.1 cm; P<0.05)
Gathwala et al43	Sample: 110 LBW infants (35 weeks mean GA) Mode of delivery: not reported Setting: hospital, India	RCT KC at least 6 hours/day versus incubator care. 16-month longitudinal study	Mother	Weight gain, length, head circumference	Weight: KC > SC (16.23±0.49 g/day versus 14.10±0.52 g/day; P<0.05) Length: KC > SC (1.03±0.05 cm/week versus 0.74±0.05 cm/week; P<0.05) Head circumference: KC > SC (0.59±0.04 cm/week versus 0.47±0.03 cm/week, P<0.05)
NICU admissions/hospital length of stay/readmission
Bergman et al17	Sample: 31 KC, mean 34.2 weeks; 13 controls, mean 35.3 weeksMode of delivery: V Setting: two secondary hospitals in South Africa	RCT: KC in first 6 hours post birth versus SC	Mother	NICU admission	No difference (RR 1.44; 95% CI 0.15–14.29)
Conde-Agudelo et al10	946 LBW (two studies) 931 LBW (ten studies)	Meta-analysis of RCTs	Mother	Readmission to hospital at latest follow-up Length of hospital stay (days)	No difference (RR 0.60; 95% CI 0.34–1.06) KC < SC (MD −2.17, 95% CI −3.72, −0.63)
Nagai et al27	Sample: 73 LBW 32–34 weeks GAMode of delivery: not reported Setting: five hospitals, Iran	RCT: early (<24 hours) versus late (>24 hours) onset KC in relatively stable infants	Mother	Length of hospital stay (days)	Non-significant difference, early KC < late KC (MD –0.9, 95% CI −3.01 to 1.2)
Breastfeeding rates/milk volume
Conde-Agudelo et al10	1,333 LBW (five studies)600, LBW (five studies)1,576 LBW (nine studies)538 LBW (six studies) 924 LBW (five studies)	Meta-analysis of RCTs	Mother	EBF at discharge or40–41 weeks PMAEBF at 1 month follow-upAny BF at discharge or 40–41 weeks PMAAny BF at 1–2 months follow-up Any BF at 3 months follow-up	KC > control (RR 1.20; 95% CI 1.07–1.34)KC > control (RR 1.20; 95% CI 1.01–1.43)KC > control (RR 1.20; 95% CI 1.06–1.36)KC > control (RR 1.33; 95% CI 1.00–1.78) KC > control (RR 1.14; 95% CI 1.06–1.23)
Svensson et al24	Sample: 103, 1–16 weeks post-partum with difficulty with latchingMode of delivery: V (n=67), C/S (n=36) Setting: university hospital, Sweden	RCT: KC versus fully clothed	Mother	Maternal experience, time to latch	Time to regular latching: KC < control (2.0 weeks, Q1 =1.0, Q3 =3.7 versus 4.7 weeks Q1 =2.0, Q3 =8.0, P=0.020); 94% of infants in KC with hx of “strong reaction” during “hands-on latch intervention” latched within 3 weeks versus 33% of control (P=0.0001) Mothers’ positive feelings: KC > control, P=0.022
Chiu and Anderson25	Sample: 100 dyads, 32–37 weeks GAMode of delivery: V (n=73), C/S (27) Setting: university Hospital, USA	RCT: early KC (mean 1.3 hours ×11.6 times) versus SC	Mother	Nursing Child Assessment Satellite Feeding Scale and Teaching Scale	Infant teaching scores: KC < SC at 6 months (P=0.001), SC > child’s response to caregiver subscale (P=0.001)
Rojas et al20	Sample: 60 LBW (≤32 weeks, <1,500 g)Mode of delivery: not reported Setting: pediatric hospital, USA	RCT: KC for 1 hour versus holding clothed in supine	Mothers and fathers (70±40 minutes/day)	Successful BF	KC > control (OR 10, 95% CI 8–57, P=0.01)
Hake-Brooks and Anderson44	Sample: 66 preterm infants 32–36 weeksMode of delivery: N/A in Setting: hospital, USA	RCT	Mothers (4.47 hours)	Breastfeeding status at hospital discharge and at 1.5, 3, 6, 12, and 18 months as measured by Breastfeeding Index	Breastfeeding duration: KC > control (5.08 months versus 2.05 months, P=0.003) Breastfeeding exclusivity: KC > control P=0.047 Full exclusivity: KC > control at discharge, 1, 5, 3, and 6 months
Gathwala et al43	Sample: 110 LBW infants (35 weeks mean GA)Mode of delivery: not reported Setting: hospital, India	RCT, KC (at least 6 hours/day) versus incubator care. 16-month follow-up.	Mother	Breastfeeding status	Exclusive BF initiated with all infants; at study conclusion (16 months): KC > SC (44/50 versus 36/50; P<0.05)
Heidarzadeh et al42	Sample: 251 premature (>27 weeks)Mode of delivery: V (n=86), C/S (n=165) Setting: hospital, Iran	Cross-sectional	Mothers and fathers	Exclusive breastfeeding at time of discharge	KC > SC (OR: 4.1; 95% CI: 2.2–7.5
Hurst et al40	Sample: 24 LBW infantsMode of delivery: NA Setting: N/A	Retrospective comparison following policy initiation of KC	Mother	24-hour milk volume	KC > control (strong linear increase, versus no change)
Time crying
Chwo et al15	Sample: n=34, 34, 36 weeks GAMode of delivery: V (n=11) C/S (n=23) Setting: Taiwan	RCT: KC versus control versus SC	Mother, KC 3 hours ×2 days	Number of times observed crying during 3-hour period	KC < control (2% versus 6%, P=0.001)
Neurodevelopment
Charpak et al48	Sample: 588 LBWMode of delivery: V, C/S Setting: tertiary center, Colombia	RCT (all outcomes at 12 months corrected age)	Mother	Psychomotor development, cerebral palsy, deafness, visual impairment	Psychomotor development: no differenceCerebral palsy: no difference (RR 0.65; 95% CI 0.21–2.02) Deafness: no difference (RR 0.30; 95% CI 0.03–2.90) Visual impairment: no difference (RR 0.91; 95% CI 0.53–1.56)
	Sample: 579 LBW			General developmental quotient	KC > control (P<0.01)
Schneider et al35	Sample: 39 adolescent former premature (<33 weeks GA) and nine born at termMode of delivery: not reported Setting: Bogotá, Colombia	Longitudinal follow-up of RCT	Mothers/fathers/family (24 hours/day)	Motor systems maturation via transcranial magnetic stimulation	MEP latency: KC < control (P=0.03); in KC, decrease in MEP latency correlated with time in KC (P=0.02)Short-interval intracortical inhibition and facilitation in M1: no difference, but obtained more easily in KC and term groups Interhemispheric inhibition: more frequent, with shorter latency and longer duration in KC (P<0.0001) Group × sex × side interaction: shorter latency in all KC and term subjects in dominant (P≤0.0001) and non-dominant (P≤0.001) hemispheres No differences between KC and term
Parent–infant attachment
Charpak et al48	Sample: 82–406 LBWMode of delivery: V, C/S Setting: tertiary center, Colombia	RCT	Mother	Mother’s perception of premature birth questionnaire (1–5) and nursing child assessment feeding scale	KC > control (MD, 95% CI): Mothers’ perceptions: sense of competence 1–2 days post birth (0.41, 0.14–0.68); sense of competence, infant admitted to NICU (0.54, 0.05–0.43); sense of competence, infant not admitted to NICU (0.24, 0.05–0.43); worry and stress free at 1–2 days (0.31, 0.04–0.58); social support at 14 days (−0.47, −0.84, −0.10); social support, infant not admitted to NICU (−0.20, −0.39, −0.01)Feeding scale: mothers sensitivity at 14 days (0.06, 0.01–0.11);Responsiveness, 14 days (0.05, 0.01–0.09) KC > SC (MD 0.79, 95% CI 0.74–0.84)
	338 LBW			HOMEb environment total score	No data reported on fathers, but author claims increased involvement
Gathwala et al47	Sample: 100 LBW (mean GA 35 weeks)Mode of delivery: V (81), C/S (9) Setting: India	RCT: KC 6 hours/day versus SC	Mother	Mother–infant attachment at 3 months	KC > control (MD 6.24, 95% CI 5.57–6.91)
Roberts et al49	Sample: 30 LBWMode of delivery: N/A Setting: Australia	RCT: KC versus cuddling minimum 2 hours/day	Mother	Mother–infant attachment: stress in the NICU	Relationship with infant: KC > control (MD 1.00, 95% CI 0.35–1.65)
Neu and Robinson50	Sample: 65 LBW 32–34 weeks GAMode of delivery: not reported Setting: five hospitals, USA	RCT: 1 hour a day of either holding in blanket or KC for 8 weeks	Mother	Mother–infant interaction at 6 months	Symmetrical coregulation: KC > control :(MD 16.38, 95% CI 13.61–19.1)Asymmetrical coregulation: KC < control (MD −18.31, 95% CI −21.42, −15.20)
Miles et al51	Sample: n=79, <32 weeks GAMode of delivery: not reported Setting: UK	Randomized crossover by site: 20 minutes KC daily ×4 weeks	Mother	Infant interaction	No statistically significant difference
Tessier et al26	Sample: 338, LBWMode of delivery: not reported Setting: Colombia	RCT: (70±40 minutes/day)	Mothers and fathers 24 hours/day until no longer tolerated by infants	HOME score	HOME score: KC > mean score [0.28 versus −0.51, F(1,330)=4.9, P<0.03], neurologically at-risk subgroup [0.33 versus −1.09, F(1,330)=5.2, P<0.03], boys subgroup [0.26 versus −1.02, F(1,330)=7.3, P<0.001]; KC families > openness [F(1,330)=3.9, P<0.05] boys and girls, girls only [F(1,330)=9.4, P<0.01], neurologically at risk girls subgroup [0.17 versus −0.87, F(1,330)=9.03, P<0.01]; KC > for boys only subscales for responsiveness [F(1,330)=9.1, P<0.01] more positive (less punitive) [F(1,330)=3.5, P<0.10] and structured environment [F(1,330)=5.3, P<0.03]; higher HOME scores correlated with infants’ developmental quotient [F(2,325)=5.6, P<0.01]

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