Breastfeeding interventions for low-birth weight and very low birth weight infants in South Asia: A systematic review and meta-analysis

doi:10.21203/rs.3.rs-5140001/v1

Background

This systematic review and meta-analysis evaluate interventions promoting breastfeeding practices among Low Birth Weight (LBW) and Very Low Birth Weight (VLBW) infants in South Asia.

Methods

A systematic literature search was conducted in five databases (PubMed, Web of Science, Embase, CINHAL, and the Cochrane library). Evidence was synthesized to estimate the duration to establish breastfeeding practices among LBW and VLBW infants. Meta-analysis was performed to estimate the effect size on breastfeeding practices using random effect model. Heterogeneity was explored by sub-group and meta-regression analyses. Risk of bias and strength of evidence was assessed by the RoB2, ROBINS-I and NIH Quality Assessment tools considering the study design of the selected articles.

Results

From a pool of 2,524 records screened, 16 studies met the inclusion criteria. The systematic review revealed that various interventions aimed at improving breastfeeding practices among LBW infants largely resulted in positive breastfeeding outcomes such as initiation of breasting and exclusive breastfeeding. The Kangaroo Mother Care (KMC) care was intervened in most cases together with other interventions, including Non-nutritive suckling, Premature Infant Oromotor Intervention, Nutrition Education and Mother Baby Friendly Initiatives Plus. Meta-analysis showed mothers who received KMC demonstrated an earlier initiation of breastfeeding (pooled mean difference: -1.08 days, 95% CI: -2.15, -0.01, p<0.001) as compared to mothers who received conventional care.

Conclusions:

Breastfeeding interventions, particularly KMC, were found to be effective for LBW infants and can be integrated into hospital or community policies, depending on context and available resources.

Breastfeeding

Kangaroo Mother Care

Low Birth Weight Infants

South Asia

Systematic review

Meta analysis

Newborns weighing less than 2500 grams (low birth weight, LBW) and those under 1500 grams (very low birth weight, VLBW), have low nutrient reserves at birth; therefore, they are subjected to physiological and metabolic stress that further escalates their nutrient needs and vulnerability (1). LBW infants are susceptible to early growth faltering, increased infectious morbidity, developmental delay, and mortality during infancy and childhood (2). For instance, LBW is associated with a 25 to 30-fold increased risk of all-cause infant mortality compared to standard birth-weight infants (3).

In 2020, 14.7% of infants, or 19.8 million, were classified as LBW globally, with the majority of them (44%) originating from South Asia (4). The lack of birth weight data for 30.8% of South Asian children born in 2020 poses a significant challenge in assessing the actual prevalence of LBW infants in the region. This indicates a potentially greater prevalence of LBW infants than what is currently estimated (4). Despite South Asia experiencing the most significant decline in LBW infants, with a decrease of 4.5 percentage points from 29.4% in 2000 to 24.9% in 2020, the progress is not on track with the established targets set by the World Health Assembly to reduce LBW by 30% between 2012 and 2030 (4).

Research has proven that breastfeeding is the most effective intervention to improve child survival and health trajectories into both infancy and adulthood (5). As breastfeeding provides nutritional, immunological, and neurological advantages, it also reduces morbidities and mortalities among infants and young children (6, 7). Breastfeeding is also associated with shorter hospital stays, lower incidences of severe complications, including necrotizing enterocolitis, and better developmental outcomes among LBW infants (8, 9).

Therefore, the initiation of breastfeeding and the continuation of exclusive breastfeeding for LBW infants are crucial. However, low birth weight itself stands as a barrier to breastfeeding (10). Both LBW infants and mothers are likely to encounter difficulties in feeding, such as challenges in latching, breastfeeding discontinuation for diseases, perceived insufficient milk supply, and difficulties in breast milk expression (11). These factors underscore the critical need for interventions tailored to resolve the complexities and difficulties of breastfeeding LBW infants.

For optimal feeding of LBW infants, the World Health Organization (WHO) recommends placing newborns in between the breasts immediately after birth when they are clinically stable, alternate oral feeding, intermittent intragastric tube feeding, and 10 mg/kg per day of enteral feeds (2). Additionally, WHO promotes modalities such as Kangaroo Mother Care (KMC) for vulnerable infants, such as LBW infants (12).

There are several interventions implemented to facilitate breastfeeding practices among LBW infants. Some examples are baby friendly initiatives, KMC, non-nutritive sucking such as finger, emptied breast sucking, and lactation education (13–15). Nevertheless, there is a significant lack of knowledge of the overall effects of these interventions on breastfeeding practices among LBW and VLBW infants in the South Asian region. The population in South Asia shares commonalities in genetics, diet, body composition, and lifestyle (16–19). The lack of evidence concerning intervention effectiveness specific to this region obstructs the development of informed decision-making for promoting breastfeeding practices among LBW infants.

A systematic review can evaluate the effectiveness of interventions for informed decision-making regarding breastfeeding and healthcare for LBW infants (20). One such systematic review and meta-analysis (21) found breastfeeding interventions significantly increased exclusive breastfeeding rates in developing countries by 89%. Another study (22) found KMC and other clinical interventions significantly increased breastfeeding odds among LBW infants in neonatal intensive care unit. But both systematic reviews are dated, lack focus on clinically stable LBW infants and are not specific to the South Asian population. Therefore, the objective of this systematic literature review is to assess the effectiveness of breastfeeding interventions specific to LBW and VLBW infants in South Asia.

This review is conducted in accordance with Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines (23). The study protocol is registered in PROSPERO with ID: CRD42024462197.

Data source and search strategy

A comprehensive search strategy was developed to identify relevant studies in five databases-PubMed, Web of Science, Embase, CINHAL, and the Cochrane Library using search strategies tailored to each database (supplementary file, item 1). The objective of the search strategy was to explore breastfeeding practices in South Asia, irrespective of the LBW and VLBW infants. However, in this split review, we only focus on interventions targeting LBW and VLBW infants.

Inclusion and exclusion criteria

This study employed the PICOS framework for inclusion and exclusion criteria (Table 1). Interventions targeting the promotion of breastfeeding practices within South Asian countries; Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan and Sri Lanka were included. Considering the critical vulnerabilities of LBW and VLBW infants, the study aimed at evaluating the impact of interventions on breastfeeding practices. Therefore, randomized control trials (RCTs), quasi-experimental studies, and before-after (pre-post) studies were considered for inclusion.

Study selection process

The identified records from the databases were imported into EndNote for removing duplicates (24). The de-duplicated records were then exported to the Covidence software (https://www.covidence.org/) for title and abstract screening and full text review. Selection of full texts was guided by inclusion and exclusion criteria. In every step, each record was screened by at least two reviewers, with conflicts resolved independently by a third reviewer.

Data extraction and management

The study utilized a customized data extraction template to gather information on breastfeeding practices for LBW and VLBW infants, including intervention outcomes, country, settings, intervention type, comparison groups, sample size, statistical analysis, and ethical approval. At least two reviewers extracted data, and a third reviewer checked, compared and verified the data and reached consensus if there were any discrepancies.

Data synthesis and meta-analysis

The selected studies were categorized according to intervention types and their effects on breastfeeding outcomes such as initiation of breastfeeding and exclusive breastfeeding. We adopted the meta-analysis approach to observe the mean difference in breastfeeding initiation between the intervention group and control group. The pooled Standard Mean Difference (SMD) was calculated using the Der Simonian-Laird inverse variance random-effects model (25). The variance was stabilized using the Freeman-Tukey double arcsine transformation before calculating the pooled SMD (26). Heterogeneity was assessed using I² indices (27) and publication bias was assessed by funnel plot and applied Egger's regression test to examine the publication bias (28). The statistical significance level was considered at p < 0.05. All analyses were performed using STATA 18.0 (StataCorp, College Station, Texas) and meta-analysis was conducted using the “metan”command in STATA.

Quality assessment and risk of bias

The quality assessment tools used in selected articles vary based on the study design. For RCT studies, Risk of Bias 2 (ROB2) (29), is used, while for non-RCT studies, ROBINS-I (30) and for before-after study with no control group, NIH Quality Assessment Tool (31) was used.

Selection and study characteristics

A search of five databases yielded 4,817 studies out of which 164 were selected for full text review, with 119 reporting breastfeeding practices as intervention outcomes. Only 16 studies targeted LBW and VLBW infants. Figure 1 illustrates the study selection process.

[Figure 1 Caption: Identification and selection of studies

Please insert Figure 1 here]

The studies, published between 1991 (32) and 2023 (33), were conducted only in two countries of South Asia; Bangladesh (34,35) and India (32,33,36–47). There are 12 RCTs, three quasi-experimental (32,34,46), and one pre-post study (47). All interventions were conducted in urban areas, except one in a semi-urban area (44). Most studies were conducted in hospital/facility setting, one in community setting (44) and in one study, control group was in a facility setting whereas the intervention group was in a community setting (42). Although all participants were LBW infants, only four studies (33,37,38,42) enrolled VLBW infants. Characteristics of the included studies are outlined in Table 2.

Intervention characteristics

Five different types of interventions were found across the included studies: KMC, Non-nutritive sucking, Mother Baby Friendly Initiatives Plus (MBFI+), Nutrition education and Premature Infant Oromotor Intervention (PIOMI). KMC was found as the core intervention component across 12 studies (34,36–39,41–47). However, the overall dose and delivery mode of the KMC differed in terms of practice period, setting (facility vs. community), practice frequency, intervention arms and material supported with, for example, cap, sock, diaper, reclining bed, chair, kangaroo bag etc. (Supplementary file, item 4). A Non-nutritive sucking (emptied breast vs. finger) method was used in three studies (32,33,40), MBFI+ was conducted in a before-after (pre-post) study with no control group (47). Nutrition education focused on exclusive breastfeeding was implemented by one study (35) and Premature Infant Oromotor Intervention (PIOMI) was also implemented by one study (33).

KMC was integrated within the MBFI+ method (47) and non-nutritive sucking was a component of the Premature Infant Oromotor Intervention (PIOMI) program (33). Notably, all intervention was initiated once the infants were clinically stable, which included the inability to suckle at the breasts. The criteria for intervention participants also varied across the interventions, with details provided in Supplementary file (item 4).

Intervention duration and follow-up duration varied across the interventions. For example, two studies used KMC with varying lengths of intervention and follow-up to promote exclusive breastfeeding (36,37). One study (36) implemented a seven-day KMC intervention with a seven-day follow-up (36), while another study continued KMC until infants achieved a specific weight gain rate and followed-up until 40 weeks of gestational age (37). Similarly, the methodologies used to quantify outcomes also vary across different studies. One study (34) used face-to-face interviews and observations to evaluate the initiation of breastfeeding, another study (41) solely relied on observations despite both studies using KMC as an intervention.

Intervention effects

Initiation of breastfeeding

Table 3 outlines the studies, interventions and effects of those interventions on the initiation of breastfeeding. Of the studies that used KMC, three reported reductions in time for initiation of breastfeeding in the intervention groups (34,41,46) and one (45) reported a longer duration to initiate breastfeeding (3.76±4.49 days in the experiment group vs. 2.95±3.85 days in the control). The other interventions, PIOMI, Non-nutritive sucking and Nutrition education reported positive outcomes for the initiation of breastfeeding. When PIOMI was used, the preterm oral feeding readiness assessment scale (PORFAS) score was higher (33), non-nutritive sucking (emptied breast) cut down on the time it took to start breastfeeding (40), and nutrition education helped more mothers (59.8% in intervention vs. 37% in control) initiate breastfeeding (35).

Exclusive breastfeeding

Table 4 provides a summary of the success of various interventions, including KMC, Non-nutritive sucking, Nutrition education, and MBFI+, in encouraging exclusive breastfeeding. Out of the seven studies that used KMC (including early KMC and community initiated KMC), two studies (39,45) found that exclusive breastfeeding was achieved in a shorter amount of time. The remaining five studies (34,36,38,42,44) reported a higher percentage of infants exclusively breastfed at specific time intervals.

Non-nutritive sucking on the infant’s finger was found to promote exclusive breastfeeding at six weeks, three months, and six months for a higher proportion of infants compared to non-nutritive sucking on the emptied breast (40). In contrast, another study (32) on sucking emptied breasts reported a higher proportion of infants exclusively breastfed compared to sucking full breasts. Though the mean duration of exclusive breastfeeding (in a four-month follow-up period) in both emptied and full breast cases was the same (3.7±1.3 months).

Nutrition education effectively promoted exclusive breastfeeding among infants, with 59.8% of recipients achieving this after two months of intervention, compared to 37% who did not (35). The MBFI+ intervention resulted in a 20% increase in exclusive breastfeeding infants, from 60.5% before to 80.7% after the intervention (47).

Other breastfeeding practices

Apart from initiation of breastfeeding and exclusive breastfeeding, other breastfeeding outcomes such as colostrum feeding, breastfeeding rate, breastfeeding frequency, full/partial breastfeeding and total lactation were identified. Their details are summarized in Table 5.

Nutrition education (35) and MBFI+ intervention (47) foster colostrum giving to infants. However, KMCs improve breastfeeding rate and breastfeeding frequency (37,46) and full/partial breastfeeding compared to conventional medical care (CMC) (37) and increases the Bristol Breastfeeding Assessment Tool (BBAT) score, which quantifies overall lactation, particularly attachments and positioning (43). The mean duration of total lactation was higher among recipients of non-nutritive sucking of empty breast compared to nutritive sucking of full breast when both groups received an additional intermittent bolus via the orogastric route (32).

Meta-analysis

The pooled Standard Mean Difference (SMD) for duration of initiation of breastfeeding was lower (-1.08 days, 95% CI: -2.15 days to -0.01 days, p<0.001) for infants receiving KMC interventions compared to those who did not (Figure 2). The high heterogeneity (I²=95.8%, p<0.000), uncertainty (R²=97.39%) and publication bias (Egger p=0.0001) was detected in the meta-analysis (supplementary file, item 3). While exploring the heterogeneity by meta-regression using both univariate and multivariate model, the country of the study setting, and study types (RCT, Quasi-experimental and non-RCT) were found to have significant associations (Supplementary file, item 3).

[Please insert Figure 2 here]

Risk of bias, quality assessment and strength of assessment

The biasness of the included studies was measured by the RoB2 tool for RCTs, and ROBINS-I tool for quasi-experimental studies. Of three non-randomized control trails evaluated, one showed moderate risk of bias, while two other studies demonstrated serious concerns regarding bias. Among 12 RCTs, four studies were identified having some concerns of bias and eight studies were assessed as having high risk of bias. Some domains, such as deviations from the intended interventions and bias in the measurement of outcomes were found susceptible among the included articles. However, other domains such as bias due to missing outcomes, randomization process (RCTs only), selection of reported results (for non-RCTs only) were relatively well described. One study (47), which was assessed by NIH Quality Assessment tool for before and after studies with no control group, was found to have good quality. Details of the quality assessment/risk of bias are presented in the supplementary file (item 5).

This systematic review and meta-analysis investigated the effectiveness of interventions that promote breastfeeding practices for LBW and VBLW infants in the South Asian context. KMC significantly reduces the time to initiate breastfeeding by 1.08 days. The reduced duration to initiate breastfeeding is critical for the infants as it can improve survival outcomes of LBW infants (49).

In all included studies KMC was found to have positive outcomes for the LBW and VLBW infants in terms of initiation of breastfeeding (Table 3), exclusive breastfeeding (Table 4), complete or partial breastfeeding, breastfeeding rate, daily frequency of breastfeeding and BBAT score (Table 5). The included studies showed different effect sizes of the same interventions. For example, KMC showed both positive (34, 41) and negative effect (45) for initiation of breastfeeding. Perhaps, the negative effect reported by Sumona et al., 2008 (45) was due to the significantly higher (p = 0.03) weight of infants at enrollment in control group (1690.5 ± 273 g) compared to intervention group (1607.6 ± 278 g). Similarly both positive (35) and negative (48) effects were observed for exclusive breastfeeding. The negative effects reported by Ghavane et al. 2012 may be attributed to the intervention being solely provided by the mothers (48). Sources of potential heterogeneities among included studies include sample size, birth weight and duration of intervention implementation. In both arms, the minimum number of participants was 14 (40), while the maximum number of participants was 550 (44). Likewise, the weight at birth varied across the included studies. For example, at least three studies (37, 42, 48) included only VLBW infants, whereas other studies (34, 45, 46) included both VLBW and LBW infants. The effects of a certain intervention might be different for the weights of infants enrolled in the study since KMC works better for VLBW infants compared to LBW infants (50). The duration of interventions also differed among studies. For instance, KMC was implemented for seven days in one study (36) and in another study (48) intervention was continued until achieving a certain weight gain rate and clinical stability of the children. These factors need to be taken into consideration while interpreting the findings of the review.

The included studies were assessed and found to have different levels of bias. For example, the RCT studies showed concerns due to deviations from the intended interventions for relevant information not being reported (37), and no information about published protocol (39, 40), researcher bias (33) and bias in the measurement of the outcomes for unblinded assessors or their knowledge about interventions (35, 39, 41, 43, 45, 48). Non-RCT studies raised concerns about measurement bias due to assessors intervention knowledge about interventions (34, 46), potential confounding (46), selection bias, classification bias, and lack of participant adherence information, as well as deviation from interventions (32). The risk of bias or the quality of the included articles is further exacerbated by the insufficient information provided regarding the source of funding for the studies; two studies disclosed funds with sources (44, 47), five studies (34, 39, 43, 45, 48) declared that they received no funding, and the rest nine studies did not report at all.

The meta-analysis was conducted synthesizing data from four studies. Unlike the other studies included in this review, these four studies (34, 41, 45, 46) had similarities in intervention (KMC), control (CMC), approach to statistical analysis and interest of breastfeeding practices (initiation of breastfeeding) (Table 3). Unfortunately, the meta-analysis could not be conducted for other breastfeeding practices as well as for other interventions such as nutrition education, non-nutritive sucking etc. The meta-analysis revealed a high degree of heterogeneity indicating a significant variation in effect sizes across the included studies and publication bias (Supplementary file, item 3) for KMC. Thus, the findings need to be interpreted with caution.

An advantage of this study is its comprehensive coverage of a population spanning a wide geographical area with similar characteristics. This demographic also represents the highest proportion of infants born with LBW worldwide. This review also included VLBW infants, who are more susceptible than LBW infants. The meta-analysis yields a pooled effect size that supports the use of KMC, which is another advantage of this study. We utilized validated tools for quality assessment and provided a comprehensive summary, despite variations in research design.

The imbalanced representations of interventions from South Asian countries, influence our findings, raising questions about the generalizability of these outcomes. We did not include any grey literature, which might negatively affect inflated effect size estimation and over representation of statistically significant findings (51). Meta analysis was conducted for only KMC and not for other interventions due to a lack of similarities in study design and outcomes. Meta-analysis based on only four studies for KMC might not be true representative of the intervention effect. Nonetheless, the outcome of this study can help construct policies for the countries in South Asia and countries with similar context.

Despite the risk, the potential benefits of this systematic review stretch to gathering and generating evidence that might outweigh the risk as consequences of the application of findings. In addition, considering the low resource settings in South Asia and LBW infants among unweighted newborns, the outcome of the study implies a policy analysis framework focused on the interventions to address the unique needs of LBW and VLBW infants in hospital and community settings in South Asia or similar contexts elsewhere.

Interventions to promote different breastfeeding practices for LBW and VLBW infants, particularly KMC, were found to be effective in contrast to conventional care. Although studies were available for only two countries (Bangladesh and India), KMC seems effective for all relevant breastfeeding practices of LBW infants. Other interventions can be implemented based on context and resources.

Clinical Trial number

Not applicable

Ethics approval and consent to participate

Not applicable

Consent for publications

All authors have approved the manuscript for publication.

Competing interest

Authors declared no competing interest.

Funding

No funding was received to conduct this research.

Author contributions as per CRediT criteria

Plabon Sarkar (PS): Conceptualization, Validation, Investigation, Data curation, Writing-Original Draft , Writing-Review & Editing, Visualization, Project administration; M. A. Rifat (MAR): Conceptualizaton, Methodology, Validation, Data curation, Writing-Review & Editing, Visualization, Project administration; Md. Masum Ali (MMA): Methodology, Software, Validation, Formal analysis, Investigation, Data curation, Writing-Review & Editing, Visualization; Mahashweta Chakrabarty (MC): Validation, Investigation, Data curation, Writing-Review & Editing, Visualization ; Syeda Saima Alam (SSA): Validation, Investigation, Data curation; Syeda Sumaiya Nasrin (SSN): Validation, Investigation, Data curation; Aditya Singh (AS): Writing-Review & Editing, Visualization; Sanjib Saha (SS): Conceptualization, Methodology, Software, Validation, Investigations, Resources, Writing-Review & Editing, Visualization, Supervision

CRediT Criteria: Conceptualizaton, Methodology, Software, Validation, Formal analysis, Investigations, Resources, Data curation, Writing-Original Draft, Writing-Review & Editing, Visualization, Supervision, Project administration, Funding

Acknowledgement

We would like to express our gratitude to Krister Aronson (librarian at the Lund University) for helping us to develop the search strategy. Thanks to Kazi Turjaun for contributing to title and abstract and full text screening.

Data availability statement

Supporting data and information are provided with the manuscripts as supplementary files. The corresponding author could be contacted for further information.

Walsh V, Brown JVE, Copperthwaite BR, Oddie SJ, McGuire W. Early full enteral feeding for preterm or low birth weight infants. Cochrane Neonatal Group, editor. Cochrane Database Syst Rev [Internet]. 2020 Dec 27 [cited 2024 Aug 9];2020(12). Available from: http://doi.wiley.com/10.1002/14651858.CD013542.pub2
Guidelines on Optimal Feeding of Low Birth Weight Infants in Low- and Middle-income Countries. World Health Organization; 2012.
Tessema ZT, Tamirat KS, Teshale AB, Tesema GA. Prevalence of low birth weight and its associated factor at birth in Sub-Saharan Africa: A generalized linear mixed model. Petry CJ, editor. PLOS ONE [Internet]. 2021 Mar 11 [cited 2024 Aug 9];16(3):e0248417. Available from: https://dx.plos.org/10.1371/journal.pone.0248417
UNICEF Data: Monitoring the situation of children and women [Internet]. 2023 [cited 2024 Aug 9]. Low birthweight - UNICEF data. Available from: https://data.unicef.org/topic/nutrition/low-birthweight/#1
North K, Gao M, Allen G, Lee AC. Breastfeeding in a Global Context: Epidemiology, Impact, and Future Directions. Clin Ther [Internet]. 2022 Feb [cited 2024 Aug 9];44(2):228–44. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0149291821004914
Prentice AM. Breastfeeding in the Modern World. Ann Nutr Metab [Internet]. 2022 [cited 2024 Aug 9];78(Suppl. 2):29–38. Available from: https://karger.com/ANM/article/doi/10.1159/000524354
Taylor SN. Solely human milk diets for preterm infants. Semin Perinatol [Internet]. 2019 Nov [cited 2024 Aug 9];43(7):151158. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0146000519300849
Cortez J, Makker K, Kraemer DF, Neu J, Sharma R, Hudak ML. Maternal milk feedings reduce sepsis, necrotizing enterocolitis and improve outcomes of premature infants. J Perinatol [Internet]. 2018 Jan [cited 2024 Aug 9];38(1):71–4. Available from: https://www.nature.com/articles/jp2017149
Serrao F, Papacci P, Costa S, Giannantonio C, Cota F, Vento G, et al. Effect of Early Expressed Human Milk on Insulin-Like Growth Factor 1 and Short-Term Outcomes in Preterm Infants. Simeoni U, editor. PLOS ONE [Internet]. 2016 Dec 14 [cited 2024 Aug 9];11(12):e0168139. Available from: https://dx.plos.org/10.1371/journal.pone.0168139
Gianni ML, Bezze EN, Sannino P, Baro M, Roggero P, Muscolo S, et al. Maternal views on facilitators of and barriers to breastfeeding preterm infants. BMC Pediatr [Internet]. 2018 Dec [cited 2024 Aug 9];18(1):283. Available from: https://bmcpediatr.biomedcentral.com/articles/10.1186/s12887-018-1260-2
Dong D, Ru X, Huang X, Sang T, Li S, Wang Y, et al. A prospective cohort study on lactation status and breastfeeding challenges in mothers giving birth to preterm infants. Int Breastfeed J [Internet]. 2022 Dec [cited 2024 Aug 9];17(1):6. Available from: https://internationalbreastfeedingjournal.biomedcentral.com/articles/10.1186/s13006-021-00447-4
WHO Immediate KMC Study Group. Immediate “Kangaroo Mother Care” and Survival of Infants with Low Birth Weight. N Engl J Med [Internet]. 2021 May 27 [cited 2024 Aug 9];384(21):2028–38. Available from: http://www.nejm.org/doi/10.1056/NEJMoa2026486
Omidi A, Rahmani S, Amini R, Karami M. The effect of a planned lactation education program on the mother’s breastfeeding practice and weight gain in low birth weight infants: a randomized clinical trial study. BMC Pregnancy Childbirth [Internet]. 2022 Dec [cited 2024 Aug 9];22(1):482. Available from: https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-022-04810-z
Rafael Pérez-Escamilla, Josefa L. Martinez, Sofia Segura-Pérez. Impact of the Baby‐friendly Hospital Initiative on breastfeeding and child health outcomes: a systematic review. Matern Child Nutr [Internet]. 2016 Jul;12(3). Available from: https://onlinelibrary.wiley.com/doi/full/10.1111/mcn.12294
Sivanandan S, Sankar MJ. Kangaroo mother care for preterm or low birth weight infants: a systematic review and meta-analysis. BMJ Glob Health [Internet]. 2023 Jun [cited 2024 Aug 9];8(6):e010728. Available from: https://gh.bmj.com/lookup/doi/10.1136/bmjgh-2022-010728
Ayub Q, Tyler-Smith C. Genetic variation in South Asia: assessing the influences of geography, language and ethnicity for understanding history and disease risk. Brief Funct Genomic Proteomic [Internet]. 2009 Sep 1 [cited 2024 Aug 9];8(5):395–404. Available from: https://academic.oup.com/bfg/article-lookup/doi/10.1093/bfgp/elp015
Flowers E, Lin F, Kandula NR, Allison M, Carr JJ, Ding J, et al. Body Composition and Diabetes Risk in South Asians: Findings From the MASALA and MESA Studies. Diabetes Care [Internet]. 2019 May 1 [cited 2024 Aug 9];42(5):946–53. Available from: https://diabetesjournals.org/care/article/42/5/946/40475/Body-Composition-and-Diabetes-Risk-in-South-Asians
Kang Y, Park C, Young AMP, Kim J. Socio-economic disparity in food consumption among young children in eight South Asian and Southeast Asian countries. Nutr Res Pract [Internet]. 2022 [cited 2024 Aug 9];16(4):489. Available from: https://e-nrp.org/DOIx.php?id=10.4162/nrp.2022.16.4.489
WHO expert consultation, Tan K. Appropriate body-mass index for Asian populations and its implications for policy and intervention strategies. The Lancet [Internet]. 2004 Jan [cited 2024 Aug 9];363(9403):157–63. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0140673603152683
Aromataris E, Pearson A. SYSTEMATIC REVIEWS: An Overview. He Am J Nurs [Internet]. 2014;114(3):53–8. Available from: https://journals.lww.com/ajnonline/fulltext/2014/03000/the_systematic_review__an_overview.28.aspx
Imdad A, Yakoob MY, Bhutta ZA. Effect of breastfeeding promotion interventions on breastfeeding rates, with special focus on developing countries. BMC Public Health [Internet]. 2011 Dec [cited 2024 Aug 9];11(S3):S24. Available from: https://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-11-S3-S24
Song JT, Kinshella MLW, Kawaza K, Goldfarb DM. Neonatal Intensive Care Unit Interventions to Improve Breastfeeding Rates at Discharge Among Preterm and Low Birth Weight Infants: A Systematic Review and Meta-Analysis. Breastfeed Med [Internet]. 2023 Feb 1 [cited 2024 Aug 9];18(2):97–106. Available from: https://www.liebertpub.com/doi/10.1089/bfm.2022.0151
Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ [Internet]. 2021 Mar 29 [cited 2024 Aug 9];n71. Available from: https://www.bmj.com/lookup/doi/10.1136/bmj.n71
Analytics C. Endnote X7 Referencing Software [Internet]. Clarivate Analytics, New York, NY. 2016.; 2016. Available from: https://endnote.com/
Kontopantelis E, Reeves D. Performance of statistical methods for meta-analysis when true study effects are non-normally distributed: A simulation study. Stat Methods Med Res [Internet]. 2012 Aug [cited 2024 Aug 9];21(4):409–26. Available from: http://journals.sagepub.com/doi/10.1177/0962280210392008
Guyatt G, Oxman AD, Kunz R, Brozek J, Alonso-Coello P, Rind D, et al. Corrigendum to GRADE guidelines 6. Rating the quality of evidence-imprecision. J Clin Epidemiol 2011;64:1283–1293. J Clin Epidemiol [Internet]. 2021 Sep [cited 2024 Aug 9];137:265. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0895435621001372
Stogiannis D, Siannis F, Androulakis E. Heterogeneity in meta-analysis: a comprehensive overview. Int J Biostat [Internet]. 2024 May 30 [cited 2024 Aug 25];20(1):169–99. Available from: https://www.degruyter.com/document/doi/10.1515/ijb-2022-0070/html
Nakagawa S, Lagisz M, Jennions MD, Koricheva J, Noble DWA, Parker TH, et al. Methods for testing publication bias in ecological and evolutionary meta‐analyses. Methods Ecol Evol [Internet]. 2022 Jan [cited 2024 Aug 25];13(1):4–21. Available from: https://besjournals.onlinelibrary.wiley.com/doi/10.1111/2041-210X.13724
Sterne JAC, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ [Internet]. 2019 Aug 28 [cited 2024 Aug 9];l4898. Available from: https://www.bmj.com/lookup/doi/10.1136/bmj.l4898
Sterne JA, Hernán MA, Reeves BC, Savović J, Berkman ND, Viswanathan M, et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ [Internet]. 2016 Oct 12 [cited 2024 Aug 9];i4919. Available from: https://www.bmj.com/lookup/doi/10.1136/bmj.i4919
Study Quality Assessment Tools [Internet]. 2021. Quality Assessment Tool for Before-After (Pre-Post) Studies With No Control Group. Available from: https://www.nhlbi.nih.gov/health-topics/study-quality-assessment-tools
Narayanan I, Mehta R, Choudhury DK, Jain BK. Sucking on the “emptied” breast: non-nutritive sucking with a difference. Arch Child [Internet]. 1991;66(2):241–4. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1792807/pdf/archdisch00653-0079.pdf
Sasmal S, Shetty AP, Saha B, Knoll B, Mukherjee S. Effect of Prefeeding Oromotor Stimulation on Oral Feeding Performance of Preterm Neonates during Hospitalization and at Corrected One Month of Age at a Tertiary Neonatal Care Unit of India: a Randomized Controlled Trial. J Neonatol [Internet]. 2023; Available from: https://www.cochranelibrary.com/central/doi/10.1002/central/CN-02517072/full
Akter M, Khandker S, Shaheen M, Mehriban N, Ahmad SA. Management of preterm low birth weight infants in Dhaka: a comparison between Standard Care and Kangaroo Mother Care. J Pediatr Neonatal Individ Med [Internet]. 2021;10(1). Available from: ://WOS:000655656800021
Thakur SK, Roy SK, Paul K, Khanam M, Khatun W, Sarker D. Effect of nutrition education on exclusive breastfeeding for nutritional outcome of low birth weight babies. Eur J Clin Nutr [Internet]. 2012;66(3):376‐381. Available from: https://www.cochranelibrary.com/central/doi/10.1002/central/CN-00971502/full
Gathwala G, Singh B, Singh J. Effect of Kangaroo Mother Care on physical growth, breastfeeding and its acceptability. Trop Doct [Internet]. 2010;40(4):199–202. Available from: https://journals.sagepub.com/doi/10.1258/td.2010.090513?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed
Gavhane S. Long Term Outcomes of Kangaroo Mother Care in Very Low Birth Weight Infants. J Clin Diagn Res [Internet]. 2016 [cited 2024 Aug 9]; Available from: http://jcdr.net/article_fulltext.asp?issn=0973-709x&year=2016&volume=10&issue=12&page=SC13&issn=0973-709x&id=9006
Ghavane S, Murki S, Subramanian S, Gaddam P, Kandraju H, Thumalla S. Kangaroo Mother Care in Kangaroo ward for improving the growth and breastfeeding outcomes when reaching term gestational age in very low birth weight infants. Acta Paediatr [Internet]. 2012;101(12):e545-9. Available from: https://onlinelibrary.wiley.com/doi/pdfdirect/10.1111/apa.12023?download=true
Jayaraman D, Mukhopadhyay K, Bhalla AK, Dhaliwal LK. Randomized Controlled Trial on Effect of Intermittent Early Versus Late Kangaroo Mother Care on Human Milk Feeding in Low-Birth-Weight Neonates. J Hum Lact [Internet]. 2017;33(3):533–9. Available from: https://journals.sagepub.com/doi/10.1177/0890334416685072?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed
John HB, Suraj C, Padankatti SM, Sebastian T, Rajapandian E. Nonnutritive Sucking at the Mother’s Breast Facilitates Oral Feeding Skills in Premature Infants: A Pilot Study. Adv Neonatal Care. 2019;19(2):110–7.
Kadam S, Binoy S, Kanbur W, Mondkar JA, Fernandez A. Feasibility of kangaroo mother care in Mumbai. Indian J Pediatr [Internet]. 2005;72(1):35‐38. Available from: https://www.cochranelibrary.com/central/doi/10.1002/central/CN-00560583/full
Ramanathan K, Paul VK, Deorari AK, Taneja U, George G. Kangaroo Mother Care in very low birth weight infants. Indian J Pediatr [Internet]. 2001;68(11):1019‐1023. Available from: https://www.cochranelibrary.com/central/doi/10.1002/central/CN-00376564/full
Shinde SA, Salunkhe JA, Mohite V, Salunkhe A, Kakade SV. Effectiveness of Kangaroo Mother Care (KMC) on Lactation among Mothers of Low Birth Weight (LBW) Newborn. Int J Nurs Educ [Internet]. 2019;11(4):162‐164. Available from: https://www.cochranelibrary.com/central/doi/10.1002/central/CN-02417515/full
Sinha B, Sommerfelt H, Ashorn P, Mazumder S, Taneja S, Bahl R, et al. Effect of community‐initiated kangaroo mother care on breastfeeding performance in low birthweight infants: a randomized clinical trial. Matern Child Nutr [Internet]. 2022;18(4):1‐9. Available from: https://www.cochranelibrary.com/central/doi/10.1002/central/CN-02492952/full
Suman RPN, Rekha Udani, Ruchi Nanavati. Kangaroo mother care for low birth weight infants: a randomized controlled trial. Indian Pediatr [Internet]. 2008 Jan 17;45(1):17–23. Available from: https://www.indianpediatrics.net/jan2008/17.pdf
Gonuguntla Y, Metgud T, Mahantshetti NS. Effectiveness of kangaroo mother care in the management of twin low-birth-weight neonates: A non-randomized, open, controlled trial. Iran J Neonatol [Internet]. 2018;9(3):6–13. Available from: https://www.embase.com/search/results?subaction=viewrecord&id=L624050795&from=export
Mondkar J, Chawla D, Sachdeva RC, Manerkar S, Shanbhag S, Khan A, et al. Impact of mother-baby friendly initiative plus approach on improving human milk feeding for neonates in hospital: a quality improvement before-and-after uncontrolled study. Eur J Pediatr [Internet]. 2022;181(1):107–16. Available from: https://link.springer.com/content/pdf/10.1007/s00431-021-04141-9.pdf
Ghavane S, Murki S, Subramanian S, Gaddam P, Kandraju H, Thumalla S. Kangaroo Mother Care in Kangaroo ward for improving the growth and breastfeeding outcomes when reaching term gestational age in very low birth weight infants. Acta Paediatr [Internet]. 2012 Dec [cited 2024 Aug 9];101(12). Available from: https://onlinelibrary.wiley.com/doi/10.1111/apa.12023
Debes AK, Kohli A, Walker N, Edmond K, Mullany LC. Time to initiation of breastfeeding and neonatal mortality and morbidity: a systematic review. BMC Public Health [Internet]. 2013 Sep [cited 2024 Aug 9];13(S3):S19. Available from: https://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-13-S3-S19
Koreti M, Muntode Gharde P. A Narrative Review of Kangaroo Mother Care (KMC) and Its Effects on and Benefits for Low Birth Weight (LBW) Babies. Cureus [Internet]. 2022 Nov 27 [cited 2024 Aug 9]; Available from: https://www.cureus.com/articles/114683-a-narrative-review-of-kangaroo-mother-care-kmc-and-its-effects-on-and-benefits-for-low-birth-weight-lbw-babies
Conn VS, Valentine JC, Cooper HM, Rantz MJ. Grey Literature in Meta-Analyses. Nurs Res [Internet]. 2003 Jul [cited 2024 Aug 9];52(4):256–61. Available from: http://journals.lww.com/00006199-200307000-00008

Table 1: PICOS framework, inclusion, and exclusion criteria

PICOS	Inclusion criteria	Exclusion criteria
P=Population	Infants delivered by healthy mothers, with birth weight less than 2500 grams (LBW/VLBW), were born with no clinical condition, and were born in a South Asian country which includes Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and Sri Lanka.	Children with birth weight equal or more than 2500 gram Non-pregnant and non-lactating mothers Study participants not recruited from South Asia Pregnant and lactating mothers with clinical conditions, including hypogalactia, agalactia, mastitis, metritis etc.
I=Interventions	1) Interventions aimed at improving breastfeeding status, including breastmilk production, colostrum feeding, early breastfeeding initiation, exclusive breastfeeding, and continued breastfeeding. 2) Interventions for better post-natal care practices and breastfeeding is a secondary objective	Intervention not targeted at infant and young child feeding and child health
C= Comparator	LBW or VLBW infants, pregnant and lactating mothers received no intervention, minimal intervention, and/or usual care such as national programs (mass media campaigns, newspaper articles, TV and radio programs)	Not specified
O=Outcome	Breastfeeding status, including breastmilk production, colostrum feeding, early initiation of breastfeeding, exclusive breastfeeding, continuation of breastfeeding, expressed milk. Breastfeeding competing practices, including bottle feeding, provision of breastmilk substitute and infant feeding formula Subset of studies reporting intervention effects according to socioeconomic status of the mothers, including education, income, and any validated measure of social class	Indicators assessing wet nursing, co-breastfeeding, breastfeeding during emergency, and artificial feeding
S=Study design/ characteristics	Experimental studies (RCT, cRCT, and quasi-experimental designs) Policy intervention assessment (pre- and post-analysis or interrupted time series analysis)	Observational (descriptive and analytical) studies, including cross-sectional, case series, ecological. Case report, editorial, commentary and blogs Qualitative designs/studies
Others	Document type: peer-reviewed article; article language: English; publication period: any time before September 2023	Document type: unpublished data and grey literature; language: other than English

Table 2: Characteristics of included studies

Reference	Author, year	Country	Sample size		Mean birth weight (gram)		Gestational age (weeks)		Funding sourced declared	Overall risk of bias assessed
Reference	Author, year	Country	Intervention	Control	Intervention	Control	Intervention	Control	Funding sourced declared	Overall risk of bias assessed
(35)	Thakur, 2012	Bangladesh	92	92	2260±190	2240±140	33.97±2.99	33.48±3.12	Not specified	High
(34)	Akter, 2021^a	Bangladesh	25	25	1566±155.94	1533±146.3	32.96±1.27	33.16±1.40	No fund received	Serious
(36)	Gathwala, 2010	India	50^d	50^d	1690±110	1690±120	35.48±1.20	35.04±1.09	Not specified	Some concerns
(37)	Gavhane, 2016	India	71	69	1145±175	1192±177	30.7±2.0	30.6±1.97	Not specified	Some concerns
(48)	Ghavane, 2012	India	71	69	1170±191	1198±194	30.8±2.1	30.7±2.1	No fund received	Some concerns
(39)	Jayaraman, 2017	India	80	80	1376±203	1369±230	32.3±2.4	32.7±2.2	No fund received	High
(40)	John, 2019	India	07	07	1116±86.73	991.2±73.68	33.42±1.25^b	32.9±1.7^b	Not specified	High
(41)	Kadam, 2005	India	44	45	1467±228	1461.1±217	33.3±2.1	34±1.7	Not specified	High
(42)	Ramanathan, 2001	India	14	14	1219±186.4	1270± 170.4	Median: 30.4 Range: 28.8-34.1 AGA: SGA^c=10:4	Median: 30.9 Range: 29-33.3 AGA: SGA^c=12:2	Not specified	High
(33)	Sasmal, 2023	India	18	18	1233.29±201.31	1171.86±199.47	30.47±2.09	30±1.84	Not specified	High
(43)	Shinde,2019	India	60	60	≤ 2499	≤ 2499	Not reported	Not reported	No fund received	High
(44)	Sinha, 2022	India	258	292	2095±154	2076±166	35.7±2.0	35.6±2.2	Declared	Some concerns
(45)	Suman Rao, 2008	India	103	103	1683.4± 235	1723.6±242	35.3±2.3	35.9±2.1	No fund received	High
(46)	Gonuguntla, 2018^a	India	Intervention 1: 60 Intervention 2: 30	60	Intervention 1: <1500: 04 1500-1800: 08 1800-2200: 18 Intervention 2: <1500: 03 1500-1800: 09 1800-2200:18	<1500: 0 1500-1800: 11 1800-2200: 19	Intervention 1: <32: 0 33-36: 23 ≥37: 7 Intervention 2: <32: 0 33-36: 26 ≥37: 4	<32: 02 33-36: 18 ≥37: 10	Not specified	Serious
(47)	Mondkar, 2022^a	India	Post-intervention:140	Pre-intervention:136	Post-intervention: 1191±224	Pre-intervention/ control: 1181±230	Post-intervention:30.6 ± 3	Pre-intervention: 30.5±3	Declared	Good quality
(32)	Narayanan, 1991^a	India	16	16	1559±228	1605±198	33.2±1.8	34.1±2.4	Not specified	Moderate

Note: ^anon-randomized control trial; otherwise, randomized control trial; ^bPost menstrual age at first assessment; ^cAGA = Appropriate for gestational age; SGA = Small for gestational age; ^dFollow up/analyzed sample

Table 3: Effect of interventions on initiation of breastfeeding among low-birth-weight infants

Reference

Author, year

Analyzed sample

Method of outcome measures

Intervention in brief

Intervention duration (days, SD)

Follow up duration

Intervention outcomes

Days (mean, SD) after birth to start breastfeeding

Approach to statistical analysis

Intervention

Control

Intervention

Control

Intervention

Control

Intervention

Control

(34)

Akter, 2021

25

Face to face, interview, observations, and measurement

Kangaroo mother care

Standard care

12.04, 2.74

(length of hospital stay)

25.24, 7.20

(length of hospital stay)

Until 40 weeks of post conceptual age

9.6, 2.16

20.12, 3.82

Intention to treat

(46)

Gonuguntla, 2018

Intervention 1: 60

Intervention 2: 30

60

Not specified

Kangaroo mother care

Conventional maternal care

Until reaching

15-20 g/kg/day weight gain for three consecutive days, successful breastfeeding or expressed breast milk. feeding; stable body temperature,

no sign of illness and mothers’ confidence in care

Until reaching

15-20 g/kg/day weight gain for three consecutive days, successful breastfeeding or expressed breast milk. feeding; maintenance of body temperature,

no evidence of disease and self-confidence of

the mothers.

Until reaching

2.5 kg of weight and adaptation of KMC at home

Intervention 1: 2.68, 1.55

Intervention 2: 2.97, 2.88

5.17, 2.65

Intention to treat

(41)

Kadam, 2005

44

45

Observations

Kangaroo mother care

Conventional maternal care

8.6 (average length of hospital stay)

9.3 (average length of hospital stay)

12 months

4.7, 3.3

5.6, 3.9

Intention to treat

(45)

Suman Rao, 2008

91

60

Observations

Kangaroo mother care

Conventional maternal care

Until children gain weight of 10-15 g/kg/d for three consecutive days, fed well, maintained temperature and the mother was confident of care.

Until post-menstrual age of 40 weeks or reaching weight of 2.5 kg

3.76, 4.49

2.95, 3.85

Intention to treat

(33)

Sasmal, 2023

15

14

Measuring the Preterm Oral Feeding Readiness Assessment Scale (POFRAS) score

Premature Infant Oromotor Intervention (PIOMI)

Developmentally supportive standard care

Seven days

Until the corrected age of one month

24.27, 1.33^a

23.00, 1.3^a

Per protocol analysis

(40)

John, 2019

03

02

Not specified

Non-nutritive sucking at mother’s emptied breast and standard care

Non-nutritive sucking on fingers

61.5, 16.1

(length of hospital stay)

64.4, 12.4 days

(length of hospital stay)

Six months

35, 1.65^b

35.24, 0.64^b

Per protocol analysis

(35)

Thakur, 2012

92

Interview and records

Nutrition education on exclusive breastfeeding twice a month for two months after delivery

Not reported

60 days

59.8%

37.0%

Intention to treat

Note: ^aScore, SD on the day of initiation of oral breastfeeding; ^bPost menstrual age (mean, SD) in week to start direct breastfeeding

Table 4: Effect of interventions on exclusive breastfeeding among low-birth-weight infants

Reference	Author, year	Analyzed sample		Method of outcome measures	Intervention in brief		Intervention duration (mean days, SD)		Follow up duration	Definition of outcome measures	Intervention outcomes		Approach to statistical analysis
Reference	Author, year	Intervention	Control	Method of outcome measures	Intervention	Control	Intervention	Control	Follow up duration	Definition of outcome measures	Intervention	Control	Approach to statistical analysis
(34)	Akter, 2021	25	25	Face to face, interview, observations, and measurement	Kangaroo mother care	Standard care	12.04, 2.74 (length of hospital stay)	25.24, 7.20 (length of hospital stay)	Until 40 weeks of post conceptual age	Proportion of infants attained exclusive breastfeeding during hospital stay	100 % (25)	92% (23)	Intention to treat
(35)	Thakur, 2012	92	92	Interview and records	Nutrition education on exclusive breastfeeding twice a month for two months after delivery	Not reported	60 days	60 days	60 days	Proportion of infants on exclusive breastfeeding after two months	59.8%	37%	Per protocol analysis
(36)	Gathwala, 2010	50	50	Observation	Kangaroo Mother Care	Standard care	Seven days	Seven days	Three months	Number of children exclusively breastfed for three months	44	36	Per protocol analysis
(48)	Ghavane, 2012	68	68	Not specified	Kangaroo Mother Care	Conventional care	Until weight gain at ≥10 g/day for three consecutive days, or at least 8 hours a day until achieving 1300 gram body weight if weight was <1300 gram during enrollment.	Until weight gain at ≥10 g/day for three consecutive days, or at least 8 hours a day until achieving 1300 gram body weight if weight was <1300 gram during enrollment.	Until 40 weeks (term gestational age)	Proportion of infants on exclusive breastfeeding at 40 weeks	31% (21)	31.9% (22)	Per protocol analysis
(39)	Jayaraman, 2017	78	73	Observation and follow up	Early kangaroo mother care	Late kangaroo mother care	06, (5-12) days (mean, median days)	08, (6-12) days (mean, median days)	One month post discharge	Time (days, median) to reach exclusive human milk feeding. Number of children exclusively breastfeed at one month	6 (5-12) 32 (41%)	8 (6-12) 16 (21.9%)	Per protocol analysis
(40)	John, 2019	04	05	Not specified	Non-nutritive sucking and standard care	Non-nutritive sucking on fingers	61.5, 16.1 days (length of hospital stay)	64.4, 12.4 days (length of hospital stay)	Six months	Number of infants at exclusive breastfeeding at six weeks, three months, and six months	Six weeks: 03 (75%) Three months: 02 (50%) Six months: 01 (25%)	Six weeks: 05 (100%) Three months: 05 (100%) Six months: 03 (60%)	Per protocol analysis
(47)	Mondkar, 2022	Post-intervention: 114	Pre-intervention: 113	Interview and hospital records	Mother Baby Friendly Initiative Plus (MBFI+)	Not reported	Post-intervention: 8.5 days (average length of stay)	Pre-intervention: 11 days (average length of stay)	Preintervention: six months Intervention: eight months Post-intervention: six months	Number of children exclusively human milk feeding Relative risk of exclusive human milk feeding^a,b	Post-intervention: 92 (80.7%) 1.33 (1.12–1.59)	Pre-intervention: 69 (60.5%) 1.00	Per protocol analysis
(32)	Narayanan, 1991	16	16	Observation and recall	Intermittent bolus by the orogastric route + suckling empty breast	Intermittent bolus by the orogastric route + suckling full breast	24.3, 9.5 days (length of hospital stay)	23.1, 9.8 days (length of hospital stay)	About four months	Mean duration of exclusive breastfeeding in months Number of children exclusively breastfeed	3.7, 1.3 13	3.7, 1.3 10	Per protocol analysis
(42)	Ramanathan, 2001	14	14	Self-report	Kangaroo Mother Care	Standard care	Until reach weight >1400 grams, gestation over 34 weeks, only on enteral feeds, mothers’ readiness to return home/ confidence to care		Six weeks	Number of infants exclusively breastfed Relative risk of exclusive breastfeeding^a	12 2.0 (1.05-3.8)	06 1.00	Per protocol analysis
(44)	Sinha, 2022	252	276	24-hour recall	Community-initiated kangaroo mother care	Home based postnatal are visits	28 days or until the baby no longer require kangaroo mother care		28 days	Number of infants exclusively breastfeed Prevalence ratio of exclusive breastfeeding^c	123 (44.6%) 1.61 (1.43−1.80)	225 (89.3%) 1.00	Per protocol analysis
(45)	Suman Rao, 2008	91	60	Observation	Kangaroo Mother Care	Conventional care	Until children gain weight of 10-15 g/kg/d for three consecutive days, fed well, maintained temperature and the mother was confident of care.		Until post-menstrual age of 40 weeks or reaching weight of 2.5 kg	Mean, SD days to reach full feeds/ exclusive breastfeeding	5.71, 5.65	4.85, 4.94	Intention to treat analysis

Note: ^aRelative risk ratio with 95% confidence interval; ^bAdjusted for age of mothers, gravida, 3 or more ANC, gestational or essential hypertension, gestational or essential diabetes, antepartum haemorrhage, premature rupture of membranes, chorioamnionitis, caesarean section, multiple births, gestational age, birth weight, male (gender); ^cUnadjusted prevalence ratio with 95% confidence interval

Table 5: Effect of interventions on any/other breastfeeding practices among low-birth-weight infants

Reference	Author, year	Analyzed sample		Method of outcome measures	Intervention in brief		Intervention duration (mean days, SD)		Follow up duration	Definition of outcome measures	Intervention outcomes		Statistical analysis approach
Reference	Author, year	Intervention	Control	Method of outcome measures	Intervention	Control	Intervention	Control	Follow up duration	Definition of outcome measures	Intervention	Control	Statistical analysis approach
(35)	Thakur, 2012	92	92	Interview and records	Nutrition education on exclusive breastfeeding	Not reported	60 days	60 days	60 days	Proportion of infants given colostrum Early initiation of breastfeeding (within 1 hour of birth)	57 (62%) 55 (59.8%)	47 (51.1%) 34 (37%)	Per protocol analysis
(47)	Mondkar, 2022	114	113	Interview and hospital records	Mother Baby Friendly Initiative Plus (MBFI+)	Not reported	Post-intervention: 8.5 days (average length of stay)	Pre-intervention: 11 days (average length of stay)	Preintervention: six months Intervention: eight months Post-intervention: six months	Proportion of infant given colostrum within 24 hours of birth Relative risk of colostrum feeding within 24 hours of birth^a	37 (32.5%) 9.25 (3.41–25.10)	4 (3.5%) 1.00	Per protocol analysis
(37)	Gavhane, 2016	44	47	Not mentioned but records can be inferred	Kangaroo Mother Care	Conventional care	Until weight gain rate reaches 10 grams/day on 3 consecutive days	Until weight gain rate reaches 10 grams/day on 3 consecutive days	06-12 months	Proportion of breastfeed (complete or partial) at six months post birth	32 (72.7%)	34(72.3%)	Per protocol analysis
(48)	Gavhane, 2012	68	68	Not specified	Kangaroo Mother Care	Conventional care	Until weight gain at ≥10 g/day for three consecutive days, or at least 8 hours a day until achieving 1300 gram body weight if weight was <1300 gram during enrollment	Until weight gain at ≥10 g/day for three consecutive days, or at least 8 hours a day until achieving 1300 gram body weight if weight was <1300 gram during enrollment	Until 40 weeks (term gestational age)	Breastfeeding rate at 40 weeks	61 (85.9%)	60 (87%)	Per protocol analysis
(32)	Narayanan 1991	16	16	Observation and recall	Intermittent bolus by the orogastric route + suckling empty breast	Intermittent bolus by the orogastric route + suckling full breast	24.3, 9.5 days (length of hospital stay)	23.1, 9.8 days	About four months	Mean duration of total lactation in months	5.1, 2.2 (n=16)	3.3, 1.9 (n=14)	Per protocol analysis
(43)	Shinde,2019	60	60	Observation	Kangaroo Mother Care	Breastfeeding, rooming in and swaddling	Seven days	Not reported	Two months	Mean difference of BBAT (Bristol Breastfeeding Assessment Tool) scale between pre and post test Mean BBAT score	–3.300, 1.453 (Pretest: 3.883, 1.416 Posttest: 7.133, 0.8919)	–3.300, 1.453 (Pretest: 4.650, 1.516 Posttest: 5.733, 1.614)	Per protocol analysis
(46)	Gonuguntla, 2018	Intervention 1: 60 Intervention 2: 30	60	Not specified	Kangaroo Mother Care	Conventional care	Intervention 1: 5.66, 1.27 weeks Intervention 2: 6.00, 2.11 weeks (time to reach 2.5 kg of weight)	6.38,2.16 weeks (time to reach 2.5 kg of weight)	Weekly follow-up until reaching 2.5 kilograms of weight, and the adaptation of KMC at home	Daily frequency of breastfeeding (mean times)	Intervention 1: 9.27, 1.49 Intervention 2: 8.57, 2.64	6.67, 2.55	Per protocol analysis

Note:^aRelative risk ratio with 95% confidence interval

No competing interests reported.

Supplementaryfile.docx

Breastfeeding interventions for low-birth weight and very low birth weight infants in South Asia: A systematic review and meta-analysis

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