Abstract: Eleven potential studies were identified of which five, involving 247 infants, were included in this review. When compared to incubator care, cot-nursing resulted in no significant difference in mean body temperature (MD 0.02 degrees C; 95% CI -0.02 to 0.07, four trials), though the one trial that reported on episodes of hyperthermia found this to be statistically more common in the cot-nursing group (RR 1.48; 95% CI 1.04 to 2.09). There were no statistically significant differences in weight gain. In the cot-nursing group, fewer infants were breast fed on discharge (typical RR 0.74; 95% CI 0.48 to 1.14, three trials, 150 infants) and fewer infants died prior to hospital discharge (typical RR 0.59, 95% CI 0.28 to 1.25, four trials, 235 infants) but these results failed to reach statistical significance. The comparison of cot-nursing using a heated water-filled mattress versus incubator care, which included five trials and a total of 231 infants, produced similar results. Cot-nursing with warming of the nursery resulted in statistically significantly smaller weight gain during week one compared to the incubator group in one trial that involved 38 infants (MD -5.90 g/kg/day; 95% CI -11.13 to -0.67) but no significant difference was found for weeks two and three. Cot-nursing using a heated water-filled mattress has similar effects to incubator care with regard to temperature control and weight gain. Important clinical outcomes need to be investigated further using randomised controlled trials. This is especially the case in the situation of developing countries, where differences in these outcomes are likely to be encountered. As limited data is available on cot-nursing using a space-heated room, this method is not recommended as practice.

Plain-language summary: This updated review randomly assigned 247 preterm infants (in five trials), to an intervention of cot-nursing using a heated water-filled mattress. The control babies received routine care in an air heated incubator. One trial had three-arms, including cot-nursing in a room heated with a manually controlled space heater. In the included trials infants in the incubator groups were nursed naked apart from wearing a nappy, except in one trial in which the infants also wore a cotton jacket and booties. Three comparisons were undertaken: the overall comparison of cot-nursing versus incubator care, and two subgroup comparisons: cot-nursing with heated water-filled mattress versus incubator care, and cot-nursing using warming of the nursery versus incubator care. The results of the review showed no evidence of effect of cot-nursing versus incubator care on weight gain in the overall analysis, or in the subgroup analysis comparing cot-nursing using a heated water-filled mattress with incubator care. However, cot-nursing with warming of the nursery during week one when compared to incubator care revealed poorer weight gain. The primary outcomes related to temperature control (mean body temperature and episodes of cold stress) indicated on overall analysis no effect of cot-nursing compared to incubator care. Episodes of hyperthermia in the cot-nursing group were reported more frequently in one trial. The secondary outcomes of oxygen consumption, breast feeding at hospital discharge, episodes of nosocomial sepsis, maternal perceptions of infant's condition, maternal stress and anxiety and death prior to hospital discharge revealed there was no effect of cot-nursing compared to incubator care. There was, however, a strong trend towards less death prior to hospital discharge. This was largely related to the results were obtained from the trials undertaken in Turkey and Ethiopia and thus may not be applicable to neonatal nurseries in developed countries. Nevertheless the implications of these findings deserve consideration, particularly in the context of a developing country.