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Effect of whole-body massage on growth and neurodevelopment in term healthy newborns: A systematic review

Mayank Priyadarshi1, Vivek Kumar2, Bharathi Balachander3, Shuchita Gupta4, Mari Jeeva Sankar2

1 Department of Neonatology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
2 Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
3 Department of Neonatology, St. Johns Medical College Hospital, Bangalore, Karnataka, India
4 World Health Organization, Geneva, Switzerland

DOI: 10.7189/jogh.12.12005

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Abstract

Background

Infant massage is commonly practiced in many parts of the world. However, the effectiveness of this intervention has not been reviewed for term, healthy newborns.

Methods

This systematic review of randomized and quasi-randomized controlled trials assessed the effect of whole-body massage with or without oil, compared to no massage in term healthy newborns. Key outcomes were neonatal mortality, systemic infections, growth, behaviour (crying or fussing time, sleep duration), and neurodevelopment. We searched MEDLINE via PubMed, Cochrane CENTRAL, EMBASE, and CINAHL (updated till November 2021), and clinical trials databases and reference lists of retrieved articles. Two authors separately evaluated the risk of bias, extracted data, and synthesized effect estimates using mean difference (MD) and standardized mean difference (SMD). The GRADE approach was used to assess the certainty of evidence.

Results

We included 31 randomized and quasi-randomized trials involving 3860 participants. Infant massage was performed by different care providers starting in the neonatal period and continuing for 1-2 months in most studies. Thirteen studies reported the use of oil with body massage. No study reported neonatal mortality or systemic infections. Meta-analyses suggested that whole-body massage may increase infant length at the end of the intervention period (median assessment age 6 weeks; mean difference (MD) = 1.6 cm, 95% confidence interval (CI) = 1.4 to 1.7 cm; low certainty evidence), but the effect on weight (MD = 340 g, 95% CI = 240 to 441 g), head circumference (MD = 0.8 cm, 95% CI = 0.6 to 1.1 cm), sleep duration (MD = 0.62 hours/d, 95% CI = 0.12 to 1.12 hours/d) and bilirubin levels (MD = -31.8 mmol/L or -1.8 mg/dL, 95% CI = -23.5 to -40.0 mmol/L) was uncertain. The effect on crying/fussing time at median 3 months of age, sleep duration at 6 months of age, weight, length, and head circumference at 6-12 months follow-up, and neurodevelopment outcomes, both at the end of the intervention period and follow-up was uncertain.

Conclusions

Whole-body massage may improve the infant length at the end of the intervention period (median age 6 weeks, range 1-6 months) but the effect on other short- or long-term outcomes is uncertain. There is a need for further well-designed trials in future.

Registration

Priyadarshi M, Balachander B, Rao S, Gupta S, Sankar MJ. Effect of body massage on growth and neurodevelopment in term healthy newborns: a systematic review. PROSPERO 2020 CRD42020177442.

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Infant massage is commonly practiced in many parts of the world, especially in African and Asian countries. Systematic tactile stimulation of the body by hands is known as massage. Massage involves the process of rubbing and gentle slow stroking of body parts in turns, which can be done using different techniques. It can be done with or without the application of oil, such as mineral oil, olive oil, and other vegetable oils [1].

Several mechanisms may explain the positive effects of body massage on neonatal and infant outcomes. Body massage serves to improve circulation and soothe the peripheral and central nervous systems [2]. Massage has been shown to stimulate parasympathetic activity by acting on cutaneous pressure receptors and thereby increasing vagal activity [3]. Increased vagal activity leads to decreased cortisol and catecholamine levels as was demonstrated by Schanberg and colleagues [4]. Increased vagal activity also leads to an increase in bowel movements and hence, stool frequency, which reduces the enterohepatic circulation of bilirubin. This provides the rationale for the effect of massage on stress and jaundice, respectively. Secretion of insulin and gastrin is also enhanced with vagal activity, which may explain better absorption of food and growth. Massage has also been found to promote soothing behaviour in infants and better parent-infant interactions [5]. The tactile stimulation provided by the massage might contribute to a better neonatal experience that could help with overall development [2].

A 2013 Cochrane systematic review assessed the effect of massage on infants under 6 months of age [6]. The meta-analysis of 34 randomized controlled trials (RCTs) suggested that massage improves weight, length, and head circumference growth as well as developmental outcomes (gross motor skills, fine motor skills, personal and social behaviour), but most studies were found to be at high risk of bias. We did not find any systematic review evaluating the effectiveness of massage where the intervention had to be started in the neonatal period. The objective of the current review was to determine the effect of body massage with/without oil on critical neonatal and infant growth and development outcomes in term, healthy newborns.

METHODS

Randomized controlled trials including cluster randomized trials or quasi-randomized trials in human neonates were eligible for this review. The study population was term healthy neonates up to 28 completed days after birth. Neonates who were low birth weight (BW) or preterm or had any illness or complications during birth hospitalization were excluded. The intervention was whole-body massage with or without oil started in the neonatal period and the comparator was no massage. The critical outcomes for this review were neonatal mortality (all-cause death in the first 28 days of life); systemic infections (sepsis, pneumonia, or possible serious bacterial infection); growth (weight, length, and head circumference, both short-term and long-term); neurodevelopment and neurobehavior (as assessed by standardized or validated tools); sleep characteristics (assessed by melatonin secretion, phase adjustment of rest-activity rhythms, duration of sleep, awakening episodes during sleep, the onset of sleep or based on paternal responses to a questionnaire) and parent-infant interactions (assessed by any standardized or validated tools or methods).

Search methodology

Two review authors (MP and BB) independently searched MEDLINE (1966 onwards) via PubMed, Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), EMBASE (1988 onwards), and CINAHL (1981 onwards). We conducted the first search till March 31, 2020. The search was then updated till November 30, 2021. Searches were limited to human studies. There were no language restrictions. Related conference proceedings (like Pediatric Academic Societies (PAS) abstracts) were also be searched for relevant abstracts. Organizations and researchers in the field were contacted, if necessary, for information on unpublished and ongoing trials. Reference lists of all relevant studies were searched. The clinical trial registry, www.clinicaltrials.gov was searched to identify any ongoing trial. The search strategy is provided in Appendix S1 in the Online Supplementary Document.

Data extraction and management

Two review authors (MP and BB) extracted data independently using a pilot-tested data collection form to collect information on design, methods, participants, interventions, outcomes, and treatment effects from each included study. We discussed disagreements until we reached a consensus. If data from trial reports were insufficient, we contacted study authors to request further information or any clarifications, if required. Data was extracted from Cochrane review [6] for 17 studies as these were in Chinese language, and from abstract for one study as the full text was not available [7].

Assessment of risk of bias in included studies

Two review authors (MP and VK) independently assessed the methodological quality of the selected studies. For randomized trials, quality assessment was undertaken using the Cochrane Risk of bias (RoB 2.0) tool [8]. Any disagreements between the review authors were resolved by discussion.

Statistical analysis

Meta-analysis was performed using RevMan 5.4. For continuous variables, mean difference (MD) and weighted mean differences (WMD) or standardized MD (SMD) were calculated if outcomes were measured using different scales. We examined heterogeneity between trial results by inspecting the forest plots and quantifying the impact of heterogeneity using the I2 statistic. If there was no significant heterogeneity (I2<60% or P ≥ 0.1, we pooled the results using the fixed-effect model. If there was significant heterogeneity (I2>60% or P < 0.1), we explored the possible causes of heterogeneity. If there was no obvious clinical heterogeneity, we used the random-effects model for meta-analysis. We used GRADEpro software for assigning the certainty of evidence [9].

RESULTS

We included 31 studies, of which 28 studies were used for quantitative analysis (Figure 1). The characteristics of included studies are provided in Table 1.

Figure 1.  PRISMA flowchart depicting the selection of studies included in the review.

Table 1.  Characteristics of the studies included in the review

WordPress Data Table

HIC – high-income country, LIC – low-income country, RCT – randomized controlled trial, UMIC – upper middle-income country, BW – birth weight, Gest – gestation

Design

Twenty-four of the 31 included studies were randomized and seven were quasi-randomized trials. In the seven quasi-randomized studies, randomization was done based on birth date or time, or admission number in six studies and was not described in one study [19]. All included studies were two arm-trials except one which was a 3-arm [18] and two which were 4-arm trials [15,24]. For the multi-arm trials, we used data from “massage only” and control or no massage groups.

Setting

Six studies were done in high-income countries (USA, Canada, Japan, and Israel), 24 studies in upper-middle-income countries (China, Turkey, and Iran), and one in a low-income country (Indonesia). Three studies were primarily hospital-based, six were conducted in both hospitals and community settings after discharge, and nine trials were community-based. One study enrolled and followed up neonates in daycare nurseries [17]. Twelve studies, conducted in China, did not specify the setting.

Participants

The participants were term neonates, with normal BW and no major comorbidities (asphyxia, anomalies, etc.). One study included neonates born to depressed mothers but the neonates were clinically healthy [17]. Though population characteristics were not mentioned in 17 studies (2577 neonates) from China, there was no indication that the included neonates had any illness or complications. In one study, the participants were infants aged 0-2 months, and mean age at enrolment or proportion of neonates in the enrolled population were not specified, but we included this study assuming at least half of the enrolled participants to be neonates [25].

Intervention

The intervention was initiated from birth in two trials [19,22], within 24 hours of birth in six trials, within 48 hours of birth in one trial [21], after five days of birth in one trial [20] and after the second week of life in one trial [15]. The exact timing of initiation was not reported in 20 trials but specified that the participants were newborns (19 trials) or 0-2-month infants [25].

There was variation in massage techniques across studies, but all included studies applied whole-body massage, with or without the use of oil. Four trials employed the massage technique promoted by Johnson and Johnson [40]. Four trials applied the method prescribed by Field in 1986 [11,13,17,18,41]. One trial had an additional component of kneading the back along with whole-body massage [23]. Most studies from China did not describe the massage technique.

Thirteen trials used oils or emollients for massage but only nine specified the type of oil used. Six studies used “baby oil” or “massage oil” with no other description, one study each used olive oil [10], mineral oil [17], and lavender-scented lotion [18]. In the rest four trials, methods suggest that some kind of oil was used but the description is not provided. The remaining 18 trials do not specify the use of oils or other emollients during the massage.

Duration and dosage of intervention were variable across included trials: 4 days, 15-20-minute sessions, 2-3 times daily (3 trials); 14 days, 30-minute sessions, once daily (1 trial); 28 days, 15-minute sessions, 2-3 times daily (7 trials); 6 weeks, 15-minute sessions, 1-3 times daily (10 trials); 2 months, 15-20-minute sessions, 1-2 times daily (2 trials); 14 weeks, 10-20-minute sessions, once daily (1 trial); 3 months, 15-20-minute sessions, twice daily (4 trials); 6 months, 15-minute sessions, once daily (1 trial); and 12 months, 15-minute sessions once daily (1 trial). One trial did not specify the duration of the intervention [28].

In two studies [11,17], researchers provided massage while in other studies, massage was provided by their care providers (mothers) after training. Eleven studies from China did not mention the specifics of massage providers in their methods [14,23,26,29,3134,3638].

All studies had a “no massage” comparator group. One study used “rocking” as a comparator [17]. Since rocking is considered a normal soothing technique for neonates, this study was included in the review. Routine newborn care was provided by all studies.

Risk of bias in included studies

A summary of risk of bias assessment in the included studies is provided in Appendix S2 in the Online Supplementary Document. Thirty of the 31 trials were judged to be at high risk of bias, with most studies being at high risk of bias in the randomization process, either due to non-reporting of random sequence generation or allocation concealment or owing to their quasi-randomized design.

Effects of interventions

Neonatal and infant mortality, systemic infections (sepsis, pneumonia, or possible serious bacterial infection), and adverse events were not reported by any of the included studies. (Table S1 in the Online Supplementary Document).

Infant growth

The mean weight, length, and head circumference of infants were reported at two time points. First, at the end of the intervention period for which the median age at assessment was 6 weeks, ranging from 1 to 6 months for length and weight, and 1 to 3 months for head circumference. The second assessment was conducted at follow-up which varied for different outcomes and is reported below.

The mean length of infants in the massage group was higher at the end of the intervention period (MD = 1.6 cm higher, 95% confidence interval (CI) = 1.4 cm higher to 1.7 cm higher; 9 studies, 1294 participants; low certainty evidence) (Figure 2 Panel B). Funnel plot did not reveal any visual asymmetry (Figure S3 Panel B in the Online Supplementary Document). There was little data on infant length at 12 months follow-up (MD = 0.7 cm, 95% CI = 0.2 cm lower to 1.6 cm higher; 1 study, 116 participants; very low certainty evidence).

Figure 2.  Forest plots for anthropometric outcomes. Panel A. Forest plot for comparison – massage vs no massage Outcome – infant weight at i) the end of intervention period and at ii) 8-12 months follow-up. Panel B. Forest plot for comparison – massage vs no massage, Outcome – infant length at i) the end of intervention period and at ii) 12 months follow-up. Panel C. Forest plot for comparison – massage vs no massage, Outcome – infant head circumference at i) the end of intervention period and at ii) 6 months follow-up.

The mean weight of infants receiving whole-body massage was higher at the end of the intervention period (MD = 340 g higher, 95% CI = 240 g higher to 441 g higher; 17 studies, 2182 infants; very low certainty evidence), but there was little data on infant weight at 8-12 months follow-up (MD = 455 g higher, 95% CI = 86 g higher to 824 g higher; 2 trials, 157 infants; very low certainty evidence) (Figure 2 Panel A). There was no visual asymmetry on funnel plot (Figure S3 Panel A in the Online Supplementary Document).

The mean head circumference of infants in the massage group was higher at the end of the intervention period (0.8 cm higher, 95% CI = 0.6 cm higher to 1.1 cm higher; 6 studies, 1000 participants; very low certainty evidence), with little data at 6 months (MD = 1.3 cm higher, 95% CI = 0.6 cm higher to 2.1 cm higher; 1 study, 115 participants; very low certainty evidence) (Figure 2 Panel C).

Infant behaviour

The mean sleep duration was slightly higher at the end of the intervention period (median age of 6 weeks; range 6 weeks to 3 months) for infants receiving whole-body massage (MD = 0.62 hours/d higher, 95% CI = 0.12 hours/d higher to 1.12 hours/d higher; 3 studies, 534 participants; very low certainty evidence), but there was little data at 6 months of age (MD = 0.08 hours/d higher, 95% CI = 0.48 hours/d lower to 0.64 hours/d higher; 1 study, 124 participants; very low certainty evidence) (Figure 3 Panel A).

Figure 3.  Forest plots for behavioural outcomes. Panel A. Forest plot for comparison – massage vs no massage. Outcome – sleep duration at i) the end of intervention period and at ii) 6 months follow-up. Panel B. Forest plot for comparison – massage vs no massage. Outcome – crying or fussing time at i) the end of intervention period and at ii) 6 months follow-up.

There was little data for mean crying or fussing time for infants at a median age of 3 months (range 6 weeks to 4 months) (MD = 0.36 hours/d lower, 95% CI = 0.16 hours/d lower to 0.53 hours/d lower; 3 studies, 271 participants; very low certainty evidence), and at 6 months of age (MD = 0.15 hours/d lower after receiving massage till 3 months of age; 95% CI = 0.01 hours/d lower to 0.29 hours/d; 1 study, 124 participants; very low certainty evidence) (Figure 3 Panel B).

There was little data for maternal-infant interaction measured using Maternal Attachment Inventory (MAI) at the age of 6 weeks (MAI mean score, MD = 5.77 higher, 95% CI = 0.95 higher to 10.59 higher; 1 study; 117 participants; very low certainty evidence).

Neurodevelopment outcomes

Three studies reported Psychomotor Development Indices (PDI) at the end of the intervention period (median age of 4 months)- two studies measured PDI using the Bayley Scale of Infant Development [24,25] and one study used the Levin PDI tool adapted by the China Institute of Psychology and Child Development Center [39]. Only one study reported PDI at 24 months of age after providing intervention for 3 months after birth [24].

There was limited data for mean PDI scores at the end of the intervention period (SMD 0.39 SD higher, 95% CI = 0.18 higher to 0.6 higher; 3 studies, 388 infants; very low certainty evidence) (Figure 4 Panel A), and at 24 months after receiving massage till 3 months of age (MD = 7.52 higher, 95% CI = 1.49 lower to 16.53 higher; 1 study, 41 infants; very low certainty evidence).

Figure 4.  Forest plots for neurodevelopment outcomes. Panel A. Forest plot for comparison – massage vs no massage. Outcome – psychomotor development indices (PDI) at the end of the intervention period (median age 4 months). Panel B. Forest plot for comparison – massage vs no massage. Outcome – mental development indices (MDI) at the end of the intervention period (median age 4 months). Panel C. Forest plot for comparison – massage vs no massage. Outcome – gross motor, fine motor, language and personal-social development.

Similarly, there was little data on Mental Development Indices (MDI) at the end of the intervention period (SMD = 0.29 SD higher, 95% CI = 0.18 lower to 0.77 higher; 3 studies and 388 participants; very low certainty evidence) (Figure 4 Panel B) and at 24 months (MD = 8.59 higher, 95% CI = 1.62 lower to 18.8 higher; 1 study, 41 participants; very low certainty evidence).

One study assessed gross motor, fine motor, language, and personal-social development at the age of 6 months using Gessel Developmental Quotient [22] and one study at the end of the 2-month intervention period using the Capital Institute Mental checklist [35]. Given the similarity in the domains of these tools, we meta-analyzed the outcomes but still there was little data (gross motor skills, SMD = 0.44 SD higher, 95% CI = 0.18 higher to 0.7 higher; fine motor skills, SMD = 0.61 SD higher, 95% CI = 0.35 higher to 0.87 higher; personal-social behaviour, SMD = 0.9 SD higher, 95% CI = 0.18 higher to 1.61 higher; language, SMD = 0.82 SD higher, 95% CI = 0.03 lower to 1.67 higher (very low certainty evidence) (Figure 4 Panel C).

There was limited data for development outcomes at 12 months (fine motor skills, MD = 8.12 higher, 95% CI = 4.57 to 11.67; language MD = 7.9 higher, 95% CI = 4.1 to 11.7; personal-social behaviour, MD = 6.19 higher, 95% CI = 2.55 to 9.83; and gross motor skills, MD = 2.85 higher, 95% CI = -2.48,8.18 (very low certainty evidence).

Additional outcome

The mean bilirubin levels were slightly lower in the massage group at the median age of 4 days (MD = 31.75 mmol/L lower, 95% CI = 23.46 mmol/L lower to 40.05 mmol/L lower; 4 studies, 345 participants; very low certainty evidence) (Figure 5).

Figure 5.  Forest plot for comparison – massage vs no massage. Outcome – bilirubin levels.

Results from studies with qualitative data

Three studies could not be included in quantitative analysis [18,31,38]. One study employed a three-arm trial, comparing the effects of “lotion” massage, “no lotion” massage, and “no” massage on sleep behaviour in 76 mothers and their infants [18]. At the end of 1 month, the lotion massage group showed a shorter latency to sleep and longer sleep duration for mothers and fewer night awakenings and longer sleep duration for their infants, compared with the other two groups. However, the authors did not mention the number of participants in each group. One trial examined the effect of massage vs no massage on the weight of 210 neonates at the end of 30 days and found a significantly higher weight gain in the massage group (only means and significance levels provided) [31]. Another trial compared the massage group with no massage group, looking at the effects on growth (weight, length, and head circumference) at the end of 1 month in 100 neonates [38]. There was significantly better growth in the massage group, though the study provided means and significance levels only.

DISCUSSION

Our review suggests that whole-body massage may increase infant length at the end of the intervention period (median assessment age 6 weeks, range 1-6 months), but the effect on weight, head circumference, sleep duration, and bilirubin levels at the end of the intervention period was uncertain. The effect on crying/fussing time at median 3 months of age, sleep duration at 6 months of age, weight, length, and head circumference at 6-12 months follow-up, and neurodevelopment outcomes, both at the end of the intervention period and follow-up was also uncertain. None of the studies reported neonatal and infant mortality, systemic infections (sepsis, pneumonia, or possible serious bacterial infection), and adverse events.

Though limited by low quality evidence, whole-body massage may prove to be one of the interventions among others which have been shown to improve infant length during the initial months of life [42]. For all other outcomes, the direction of effect favored whole-body massage for various outcomes specified above, but the evidence was ascertained as very low certainty either because of the paucity of data resulting in wide confidence intervals or high risk of bias in most studies. The effects of intervention can be explained by several plausible biological mechanisms described earlier related to its effect on various body systems. However, the pooled effect sizes for several outcomes in this review are quite large in magnitude and it is difficult to explain these completely based on the alluded mechanisms [3,4]. There is a need to further understand the biological mechanisms that may underlie some of these potential benefits. The other possible reason for such results may be related to the lack of methodological robustness in the included trials. Thirty of the 31 included studies were at high risk of bias, mainly owing to bias in randomization, measurement and missing outcome domains. To explore the effect of measurement bias, we dropped the studies which were at high risk of bias for measurement domain and performed sensitivity analyses with the remaining studies, which yielded similar results as their primary analyses (Figure S4 Panels A-C in the Online Supplementary Document). The evidence was also downgraded for unexplained heterogeneity. Though the population and interventions in the included trials were consistent, clinical heterogeneity might have been the result of differences in the settings, massage providers, duration of intervention, massage techniques, and outcome assessment. Therefore, while it appears that the intervention is probably beneficial, there is a need for larger, well-designed studies addressing the short- and longer-term outcomes.

The findings of our review are similar to the Cochrane review published by Bennett et al, evaluating the impact of massage on healthy infants less than six months of age [6]. Of its 34 included trials, 22 trials overlapped with our review. The rest 12 trials were excluded from our review, either due to initiation of intervention in the post-neonatal period or due to the different nature of the intervention (multi-modal). Similar to our review, the review suggested significant positive effects on growth and neurodevelopment, but evidence being very low certainty for any meaningful conclusions. Another review evaluated the effect of massage on neonatal jaundice [43]. Two of the six included trials recruited healthy term neonates and were included in our review also, but the rest four were excluded as they enrolled “jaundiced” neonates who received massage as an adjunct to phototherapy. The review concluded that massage was effective in the reduction of serum and transcutaneous bilirubin levels in neonates. The findings are similar to our review, though we ascertained the evidence to be very low certainty due to a very serious risk of bias and serious imprecision. Similar reviews have been done to evaluate the effect of massage on feed intolerance, growth, and neurodevelopment in preterm neonates [44,45].

This review has tried to answer a research question that is important from both a clinical and a public health perspective. A rigorous methodology was followed to conduct this review, with an all-inclusive literature search and no language filters. Eighteen trials were available in the Chinese language (17 trials) and abstract form only (1 trial). Though we tried to translate these articles using a machine translation service (Google translate), however, for accuracy and completeness, we cross-checked our findings with the Cochrane review [6]. We did not include the China Knowledge Resource Integrated Database (CNKI) database as a part of our literature search, which contributed to most of the trials in the Cochrane review, mainly due to the non-availability of freely available database search and its articles.

The 2015 WHO State of inequality report indicates that women who are poor, least educated, and who reside in rural areas have lower coverage of health interventions and worse health outcomes than more advantaged women [46]. Interventions among neonates and infants that promote healthy developmental outcomes could assist to address health equity. Newborn/infant massage is a relatively simple and accessible intervention across a range of settings. Provided the necessary training and support is available, this intervention may increase health equity. However, more evidence is required on the effectiveness of massage including various aspects such as the use of oils/emollients for massage, type of provider, frequency, duration, length, and technique to guide optimal and safe practices. Adequately powered trials should be conducted in future, focusing on short-term and long-term meaningful outcomes and addressing the methodological fallacies of the existing studies. These outcomes may include mortality, growth and neurodevelopment outcomes as well as adverse events like injuries, slippages etc. Some of the important fallacies can be addressed by ensuring adequate randomization, consistency of the intervention (technique, massage provider, dose and duration), optimum follow up with minimal attrition, and blinded outcome assessment by skilled staff using standard measurement tools.

CONCLUSIONS

Whole-body massage may improve the body length in term healthy newborns. The evidence on the effects of infant massage on growth, behavior, and neurodevelopment outcomes is uncertain. There is a need for further well-designed trials to assess the impact of whole-body massage on short- and longer-term outcomes in term healthy newborns.

Additional material:

Online Supplementary Document

Acknowledgments

We are grateful to Dr Rajiv Bahl, WHO, Geneva for technical guidance and support.

Disclaimer: The authors alone are responsible for the views expressed in this publication and they do not necessarily represent the views, decisions or policies of the WHO.

[1] Funding: The authors received grant from WHO, Geneva to support this review work.

[2] Authorship contributorship: Mayank Priyadarshi, Vivek Kumar, and Bharathi Balachander conducted the literature search and extracted data. Mayank Priyadarshi, Shuchita Gupta, and Mari Jeeva Sankar analyzed and interpreted data. Mayank Priyadarshi, Vivek Kumar, Bharathi Balachander prepared the first draft of the manuscript. Shuchita Gupta and Mari Jeeva Sankar reviewed and modified the final draft.

[3] Disclosure of interest: Shuchita Gupta is a staff member of WHO. The remaining authors completed the ICMJE Disclosure of Interest Form (available upon request from the corresponding author) and disclose no relevant interests.

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AUTHOR QUERIES

[4] Citation to Ref 12 is correct.

[5] Citation to Ref 15 is correct.

[6] Citation to Ref 33 is correct.

[7] Citation to Ref 45 is correct.

[8] Citation to Ref 34 is correct.

[9] Citation to Ref 46 is correct.

[10] Citation to Ref 35 is correct.

[11] Citation to Ref 26 is correct.

Correspondence to:
Dr Mari Jeeva Sankar, MD, DM
Department of Pediatrics
All India Institute of Medical Sciences
New Delhi
India
[email protected]