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Skin To Skin Contact at Birth: Feasibility and Impact on Neonatal Thermoregulation and Breastfeeding Outcome in Low
Birth Weight Babies
1. Introduction
In humans, routine mother-infant separation not long after birth is one of a kind to the
twentieth century. This practice veers from developmental history, where neonatal survival
relied on upon close and for all intents and purposes nonstop maternal contact. In spite of the
fact that from a developmental point of view skin-to-skin contact (SSC) is the standard,
isolating the infant from its mother not long after birth has now gotten to be normal practice
in many industrialized social orders. Hence, with the end goal of this survey, SSC must be the
experimental intervention. Incidentally, and vitally, the experimental intervention in studies
with every single other vertebrate is to separate babies from their mothers.
Mother and infant skin-to-skin contact is outstanding in full-term infants with regular
deliveries [1]. Notwithstanding, it is trusted that infants conveyed by means of cesarean area
are inclined to hypothermia because of low temperature in the operation room, mother's
unconsciousness, spread of mother's heat from the inside to the earth, and decrease in
mother's focal temperature. In this manner, mother and infant skin-to-skin contact is
conceivably restricted in infants after birth by means of cesarean deliveries [2].
One of the most important needs of infants at birth is the maintenance of temperature because
an infant is not able to generate heat due to lack of shivering mechanism, and this leads to a
rapid decline in its temperature. Maintenance of a normal body temperature is of vital
importance to the low birth weight neonates. The first studies revealing increased morbidity
and mortality in infants exposed to hypothermia and cold stress were published more than
half a century ago, and temperature control remains a cornerstone of neonatology. Many
advances in neonatal care, including measures to improve thermal balance and care
environment, have contributed to the increased survival of low birth weight infants. One of
the modalities to prevent hypothermia is to put the infant under a warmer, causing the
separation of the mother and new-born. Another measure is the kangaroo mother care
technique, which features early initiated and continuous skin-to skin care (SSC).
The SSC reduces infant heat loss by minimizing the skin surface area exposed to the cooler
environment, and allows conductive heat gain through skin-to-skin contact between infant
and mother. Kangaroo mother care is recommended for use in stable low birth weight (LBW)
infants. Infants born with low birth weight are at particular risk for hypothermia and require a
strictly controlled care environment to maintain thermal homeostasis. . Because the loss of
fluid from the skin is inversely related to ambient relative humidity, creating a high–releative
humidity microenvironment close to the skin will reduce fluid loss and improve thermal
balance.
Furthermore, the high body surface-to-mass ratio and poor capacity for thermogenesis of low
birth weight infants implies that they need to gain heat from the environment to avoid
hypothermia and cold stress The movement of the infant's hands over the mother breasts in
kangaroo care leads to increased secretion of oxytocin, which results in increased secretion of
breast milk and breast heat.
Breast milk is the best gift that a mother can give to her newborn baby. In ancient India, early
and exclusive breastfeeding was the custom and so was proximity between the mother and
her baby. The ancient scriptures are substantial testimony of the same. The concept of
rooming in described in the Sushruta Samhita, states that the sight, sound, or touch of the
baby is enough to promote lactation in the mother. Modernization has brought with it the
trend of separating the baby from its mother. These blunders over years gradually resulted in
an increase in neonatal mortality and morbidity. The purpose of this study is to demonstrate
the impact on neonatal thermoregulation and breastfeeding outcome in low birth weight
babies
1.1 Research Background
Early SSC is the setting of the naked baby inclined on the mother's bare chest at birth or soon
a short time later. In the developmental setting, this would have been "prompt and
consistent". In the present care setting, start and duration are not characterized. The idea of
"care" does not change; just where such care is given changes. Assist, in spite of the fact that
a dosage reaction impact has not been archived in randomized controlled trials (RCTs), the
general conviction is that SSC ought to proceed until the end of the main fruitful
breastfeeding to demonstrate an impact and to improve early infant self-direction [3].
The rationale for SSC originates from creature concentrates on in which a portion of the
inborn practices of neonates that are important for survival are appeared to be environment
subordinate [4]. In mammalian biology, upkeep of the maternal milieu taking after birth is
required to inspire natural practices from the neonate and the mother that prompt to fruitful
breastfeeding, and in this manner survival. Separation from this milieu brings about prompt
trouble cries and "challenge give up" conduct. Human infants set in a bunk cry 10 times more
than SSC infants. Their cry is like the vocalizations of separated rat pups [5]. In rat ponders,
the pups who had the slightest mindful contact from their mothers were the ones whose
wellbeing and knowledge were traded off over the lifespan [6]. Likewise in the report by Liu
2000 a cross-cultivating study gave confirmation to an immediate relationship between
maternal conduct and hippocampal advancement in the posterity.
Healthy, full term infants utilize an animal groups particular arrangement of natural practices
quickly taking after delivery when put in SSC with the mother [7]. They restrict the nipple by
smell and have an increased reaction to scent signs in the initial couple of hours after birth
[8]. All the more as of late Widstrom (2011) portrayed the arrangement of nine inborn
practices as the birth cry, unwinding, arousing and opening the eyes, action (taking a gander
at the mother and bosom, establishing, hand to mouth developments, requesting sounds), a
moment resting stage, creeping towards the nipple, touching and licking the nipple, suckling
at the bosom lastly nodding off [9]. This 'sensitive period' inclines or primes mothers and
infants to build up a synchronous proportional communication design, if they are as one and
in intimate contact. Infants who are permitted continuous SSC promptly after birth and who
self-join to the mother's nipple may keep on nursing all the more viably. Viable nursing
builds drain creation and infant weight pick up [10]. Anderson (2004) utilized SSC as an
intercession for 48 healthy mother/full term infant dyads with breastfeeding issues
distinguished between 12 to 24 hours postbirth. SSC was given amid the following three
continuous breastfeedings [11]. Breastfeeding was fruitful, even in this racially dissimilar
specimen and was selective in 81% of these dyads at hospital release, 73% at one week, and
52% at one month postbirth. Temperatures were taken before (gauge), amid, and after each
SSC breastfeeding. Standard temperatures came to, and stayed in thermoneutral territory
recommending that mothers can balance infant temperature if given the chance to breastfeed
in SSC [12]. Since these mothers and their infants were having breastfeeding troubles,
hospital staff and guardians can legitimately be consoled that healthy babies, with or without
breastfeeding challenges, may securely breastfeed in SSC so far as temperature is concerned.
In an investigation of infrared thermography of the entire body amid the primary hour
postbirth, Christidis (2003) found that SSC was as powerful as brilliant warmers in
anticipating heat misfortune in healthy full term infants [13].
SSC through sensory stimuli such as touch, warmth, and odour is a powerful vagal stimulant,
which among other effects releases maternal oxytocin [14]. Oxytocin causes the skin
temperature of the mother’s breast to rise, providing warmth to the infant [15]. When
operating in a safe environment, oxytocin, and direct SSC stimulation of vagal efferents, are
probably part of a broader neuro-endocrine milieu [16]. A global physiological regulation of
the autonomic nervous system is achieved, supporting growth and development,
(homeorhesis). Under conditions perceived by the newborn to be dangerous, stress
mechanisms come into operation, with the focus on survival rather than development
(allostasis). The theory of allostasis is the relationship between psycho-neurohormonal
responses to stress and physical and psychological manifestations of health and illness [17].
Allostasis is necessary, and it can be viewed as beneficial, because its goal is to bring
aberrant physiology closer to normal; however, an allostatic response comes with a
physiological cost referred to as allostatic load. The higher the allostatic load the greater the
damage from stress, because allostatic load is cumulative. SSC also lowers maternal stress
levels. Handlin (2009) founded a dose-response relationship between the amount of SSC and
maternal plasma cortisol two days postbirth. A longer duration of SSC was correlated with a
lower median level of cortisol (r = − 0.264, P = 0.044) [18].
Oxytocin antagonizes the flight-fight effect, decreasing maternal anxiety and increasing
calmness and social responsiveness [19]. During the early hours after birth, oxytocin may
also enhance parenting behaviours. SSC outcomes for mothers suggest improved
bonding/attachment; other outcomes are increased sense of mastery and self-enhancement,
resulting in increased confidence. Sense of mastery and confidence are relevant outcomes
because they predict breastfeeding duration [20]. Women with low breastfeeding confidence
have three times the risk of early weaning and low confidence is also associated with
perceived insufficient milk supply [21].
Marin (2010) found that time to expulsion of the placenta was shorter (M = 409 ± 245 sec.) in
mothers of SSC infants than in control mothers (M = 475 ± 277 sec., P = 0.05). When SSC on
the mother’s abdomen, the infant’s knees and legs press into her abdomen in a massaging
manner which would logically induce uterine contractions and thereby reduce risk of
postpartum hemorrhage. Mothers who experience SSC have reduced bleeding and more rapid
delivery of the placenta [22].
In previous meta-analyses with full term infants, early contact was associated with continued
breastfeeding [23]. Just altering hospital routines can increase breastfeeding levels in the
developed world [24]. Conde-Agudelo (2011) conducted a Cochrane review of 16
randomized clinical trials of kangaroo mother care (KMC), a strategy of continuous or
intermittent SSC with exclusive or nearly exclusive breastfeeding and early hospital
discharge of infants less than 2500 g at birth in settings with limited resources [25]. KMC
was associated with reductions in several clinically important adverse infant outcomes,
including mortality at hospital discharge and at latest follow-up, nosocomial infection/sepsis
at hospital discharge and severe infection/sepsis at latest follow-up, hypothermia and hospital
length of stay.
1.2 Research Aims
This research is aimed to study the effect of SSC on following outcomes:
Body temperature of low birth weight babies.
Lactation status of mother on day 3 following SSC
1.3 Research Objectives
The objective of this research is:
To study the impact of skin to skin contact on the following outcomes:
a) Body temperature of low birth weight infants
b) Lactation status of mother on day 3 following SSC
2. Literature Review
2.1 Introduction
One of the most important early steps in a research project is the conducting of the
literature review. A literature review is an account of what has been published on a topic
by accredited scholars and researchers. In writing the literature review, your purpose is to
convey to your reader what knowledge and ideas have been established on a topic, and
what their strengths and weakness are. A literature review discusses published
information in a particular subject area and sometimes information in a particular subject
area within a certain time period [26].
2.2 Concept of Skin-To-Skin Contact
Kangaroo mother care, or skin-to-skin contact, was first suggested in 1978 by Dr. Rey in
Bogota, Columbia. This care is based on the idea that early contact has a bonding effect for
mother and infant. Skin to skin contact (SSC) is seen as a non-conventional, low cost way to
provide newborn care [26]. To perform skin-to-skin contact, a newborn must be placed skin
to skin on the mother’s chest and abdomen [27]. This is a natural process that ideally starts
immediately after birth, or shortly after, with the newborn remaining skin-to-skin with mother
until the end of the first breastfeeding session [28]. SSC can be classified as immediate, very
early (30-40 minutes postbirth), or early (any that takes place during the first 24 hours) [29].
Infants eligible for skin-to-skin contact are ones that are medically stable. However, SSC has
proven to be effective in stabilizing newborns when done immediately. Studies have shown
even premature babies are more stable metabolically and breathe better if placed skin-to-skin
directly after birth [30]. A study done in 2013 showed evidence that SSC helps the newborn
transition from intrauterine life with greater respiratory, temperature, and glucose stability
and significantly less crying, indicating decreased stress [31]. All of these benefits seem to
improve newborn outcomes, so why has it not been implemented everywhere?
As with all changes in healthcare, there are barriers to implementing this care. One potential
barrier is that there is concern about mother’s alertness after a C-section. However, the use of
spinal or epidural anesthesia allows the mother to remain alert, which would allow SSC to be
achieved immediately without fear of mother’s altered level of consciousness [32]. When in
the operating room, SSC is achievable with some modification. After the cord is cut, a
receiving nurse will dry the baby, assign an Apgar, place a diaper on the baby, and then place
the newborn on the mother’s chest in transverse position on the breasts, and then cover mom
and baby with a towel. A diaper is used as precaution for the mother’s surgical incision.
According to the Healthy Newborn Network, some of the benefits of SSC include normal
infant breathing and heart rates, less stress on the infant, faster stabilization of blood sugars
and temperatures, and encouragement of breastfeeding. The primary goal of skin-to-skin
contact is to promote bonding and initiate breastfeeding as soon as possible after birth. In a
meta-analysis on immediate SSC after Caesarean section, a compilation of the benefits listed
are: maintains newborn thermoregulation and blood glucose levels, decreases risk of
jaundice, reduces stress of birth, encourages bonding between the mother and newborn, and
encourages longer duration of breastfeeding [33]. Some psychosocial benefits of SSC are that
newborns do not suffer the negative effects of separation. This contact supports optimal brain
development and actually facilitates attachment, which can help promote the infant’s self-
regulation in the long term [34]. It is the responsibility of the nurse to educate parents about
the importance of this practice. SSC after a C-section has some barriers. These include:
operating room staff not willing to accept the change, some hospitals will require a
designated baby nurse to be in the OR and there may be staff shortages, concern for the
mother’s alertness, and concern for the incision site [35]. Skin-to-skin contact cannot be
achieved without collaboration between surgical team, anesthesia, pediatrics, and obstetrics
departments. To implement this in any setting, the newborn is placed on the mother’s bare
chest, quickly dried off by the nurse, a hat applied, and is left skin-to-skin with mother for a
minimum of one hour [36]. In an ideal situation, SSC will be maintained until after the first
feeding. At some study hospitals, health care personnel that were involved in C-sections
participated in an educational program provided by the lactation consultant. This educational
program helped the staff to understand the benefits of SSC and feel confident in
implementing it [37]. There is even a DVD titled “Skin-to-Skin in the First Hour After Birth:
Practical Advice for Staff after Vaginal and Cesarean Birth” that could be shown to staff
members for education on how to properly handle SSC at any hospital or setting. Another
barrier could be that parents do not know the benefits of SSC or what it is. This has been
addressed in some hospitals by giving out a detailed information leaflet and verbally
informing the parents about this option before birth. One study suggested that hospitals
modify protocols to support uninterrupted skin-to-skin contact immediately after birth,
including both vaginal and cesarean deliveries [38]. If there is an actual protocol for SSC, it is
more likely to be implemented on a consistent basis. This care is recommended by major
organizations such as the World Health Organization, American Academy of Pediatrics, the
Academy of Breastfeeding Medicine, and the Neonatal Resuscitation Program [39]. The
World Health Organization and the United Nations International Children’s Emergency Fund
both recommend that skin-to-skin contact be initiated immediately after a vaginal birth, and
as soon as the mother is stable after a Caesarean section [40]. The Baby Friendly initiative,
which was started by these two organizations, recommends that all babies have the
opportunity for immediate SSC. For hospitals that are trying to become an accredited Baby-
Friendly hospital, facilitating breastfeeding is one of the main goals [41]. The
recommendation from American Academy of Pediatrics is that babies have nothing but breast
milk the first six months of their life. The reason that it is so important to breastfeed, as
recommended for the first six months of a newborn’s life, is the nutritional, immunological,
and cognitive outcomes mentioned earlier [42]. Babies that are placed skin-to-skin with
mother after birth have the natural instinct to attach to the breast and begin breastfeeding.
When the mother has a chance to hold the baby after birth, the mother will produce more
breast milk and breastfeed longer without use of formula. The Academy of Breastfeeding
Medicine protocol calls for breastfeeding one hour after the delivery, early skin-to-skin
contact, side-lying football breastfeeding position to minimize incision discomfort, and a
pillow to protect the incision site. Protection of the incision site is one of the main concerns
for skin-to-skin contact immediately after Cesarean section [43]. The ABM protocol also
states that procedures such as weighing, measuring, and administering vitamin K and eye
prophylaxis can be delayed to promote early parent-infant interaction. Looking at a 2012
study, newborns that received SSC were two times more likely to be exclusively
breastfeeding at 3-6 months compared to the babies who did not receive it [44]. In another
study, newborns with immediate SSC had 24% more mothers initiate breastfeeding and they
did so an hour earlier than ones who did not receive SSC. Women who give birth by cesarean
instead of vaginally are shown to be more prone to postpartum depression, bonding
difficulties, and unsuccessful breastfeeding [45]. There is an increased number of C-sections,
yet only a few hospitals are implementing skin-to-skin contact in the operating room. The
CDC said that in 2009, only 32% of hospitals were implementing skin-to-skin contact after
an uncomplicated Caesarean birth. This is significant because the rate of C-sections has
increased greatly in the U.S. and represents about 32% of babies that are born. Studies have
shown that Caesarean birth can reduce the initiation of breastfeeding, delay the first feeding
and reduce the incidence of exclusive breastfeeding, which in turn increases the likelihood
that a mother will use supplementation. A study by Hung and Berg (2011) discovered that
supplementation was decreased by 41% in the study hospital when immediate or early SSC
was implemented in the operating room [46]. With such a big number of babies being born
via Caesarean section, it is time to optimize their outcomes. When a baby is separated from
its mother for hours after a C-section, breastfeeding can become more difficult than it should
be. Mothers get frustrated and do not continue to attempt breastfeeding, as reflected in lower
breastfeeding rates after most cesarean deliveries. This separation should not be the reason
for decreased breastfeeding rates and increased use of supplemental formula. One study even
showed an increase of exclusive breastfeeding three months after discharge [47].
Skin-to-skin contact not only has positive benefits for baby, but also improves mother’s
mood. Mothers who have a Caesarean delivery report having a less satisfactory birth
experience and have a higher frequency of postnatal depression, along with breastfeeding
difficulties. SSC may also help reduce maternal pain and keep both the mother and newborn
physiologically stable. Mothers who get to participate in SSC have increased maternal
behaviours, show more confidence in caring for their babies, and also breastfeed for longer
duration. This can be an effect of the early parent-infant bonding interactions. One study even
9 showed a double in breastfeeding duration associated with as little as 15 minutes of
immediate SSC [48]. Mothers have given feedback on the topic as well, stating that
breastfeeding was easy when their baby had an opportunity for SSC immediately after
Cesarean birth. Another study that analyzed maternal satisfaction scores said that maternal
satisfaction with how well their baby was breastfeeding was higher in an intervention group
that received skin-to-skin contact [49].
Hospitals have been reluctant to try skin-to-skin contact because it was originally thought that
this might put infants at risk for hypothermia. However, studies have proven that this should
not be a concern. Research shows that “thermal synchrony” occurs when a newborn is placed
on its mother’s chest, which is where the mother’s chest temperature increases to warm a cool
baby and decreases to cool an overly warm baby. A study done with newborns after cesarean
delivery with SSC actually showed higher temperatures compared to babies under warmers.
Skin-to-skin contact has many advantages for both newborn and mother. If this contact can
be initiated right after Cesarean section instead of two hours later, the newborn will have a
more stable temperature and heart rate [50]. Talking about temperature is important because a
problem with premature or low birth weight newborns is their inability to control their
temperature, which can be a preventable cause of morbidity and mortality [51]. All of the
results these studies have found show that the mother can be the best regulator for the baby,
not a warmer or medical intervention. At Adventist Hinsdale Hospital where skin-to-skin
contact has been implemented, over 90% of mothers choose to continue breastfeeding at
discharge, although statistics are not yet available on how long they maintain breastfeeding at
home. In a study conducted at San Francisco General Hospital, after implementation of early
skin-to-skin contact in the operating room, babies were more effective in breastfeeding and
less likely to require supplemental formula during their hospital stay [52]. Within three
months of implementing this program, skin-to-skin contact increased from 20% up to 68%. It
is assumed that implementation of skin-to-skin contact in the study hospital will have the
same results as hospitals who have implemented this already. The results being a correlation
between immediate skin-to-skin contact after Caesarean sections specifically and an increase
in exclusive breastfeeding rates.
2.3 Studies Related to Low Birth Weight
Mbazor and Umeora (2007) conducted a study to determine the incidence of and risk
factors associated with delivery of low birth weight singletons at term at Benin City. A
review of retrospective data extracted from the case records of all booked parturient who
had low birth weight singletons at term at the Teaching Hospital over a four-year period.
The term low birth weight singletons constituted 3.4% of the 4735 term deliveries at the
Benin City. They discussed that Low birth weight in term infants is a major determinant
of neonatal and infant morbidity and mortality [53].
Kazuhiko et al (2006) conducted a study to describe the characteristics and morbidity of
very low birth weight infants, to identify the medical intervention for these infants, and to
evaluate the factors affecting the mortality of these infants among the participating
hospitals. A large multicenter neonatal research network that included level III NICUs
from throughout Japan was established. Results revealed that overall, 11% of the infants
died before being discharged from hospitals (range: 0%-21%). Among all of the very low
birth weight infants, 14% were outborn infants, 72% were delivered by cesarean sections,
27% had patent ductus arteriosus, 3% had gastrointestinal perforation, 8% had bacterial
sepsis, and 13% had intraventricular hemorrhage. Medical interventions involved were:
41% antenatal corticosteroids, 54% surfactant therapy, 18% postnatal steroids for chronic
lung disease, and 29% high-frequency oscillatory ventilation. The overall survival rate for
very low birth weight infants among neonatal centers in Japan was approximately 90%.
Low birth weight babies are one of the major causes of morbidity and morbidity of
infants which is calls for effective management [54].
2.4 Studies Related to Low Birth Weight and Kangaroo Mother Care
Suman, Udani and Nanavathi (2008) conducted a randomized controlled trial to compare
the effect of Kangaroo Mother Care (KMC) and Conventional Methods of Care (CMC)
on Growth in Low Birth Weight babies (>2000g) on 206 neonates with weight <2000g.
The subjects were randomized into two groups; the intervention group (KMC-103)
received Kangaroo Mother Care. The control group (CMC-103) received conventional
care. Study finding revealed that KMC group babies had better average weight gain/day
(KMC: 23.99g v/s CMC: 15.58g, p<0.0001). The weekly increments in head
circumferences (KMC: 0.75 cm v/s CMC: 0.49cm, p<0.02). A significantly higher
number of babies in the CMC group suffered from hypothermia, hypoglycemia and
sepsis. By this study it can be concluded that Kangaroo Mother Care improves growth
and reduces morbidities in low birth weight infants. And also it is simple, acceptable to
mothers and can be practiced in home [55].
Ndiaye et al (2006) conducted a retrospective study to evaluate the efficiency of
Kangaroo Mother Care on thermoregulation and weight gain of a cohort of preterm.
Based on the files of preterm baby weighing below 2000grams included after discharge to
neonatal unit of Aristide Le Dantec Maternity for Kangaroo Mother Care. Efficiency was
appreciated on thermic curve evolution and daily weight gain. Findings of the study
revealed that mean temperature was satisfying during follow-up and was stable around
37+/- 7.6° C at discharge of program with mean daily weight gain of 33 +/- 7.6 g with
one case of death. The results of this study point out efficacy of Kangaroo method on
thermoregulation, weight gain and survival of preterm babies. So it can be promoted in
developing countries as it is low cost and more effective [56].
2.5 Studies Related to Knowledge, Attitude and Perceptions of Mothers
Sivapriya, Subash and Kamala (2008) conducted a quasi experimental study to assess the
knowledge of mothers of preterm babies regarding kangaroo mother care and to evaluate
the effectiveness of structured teaching programme on kangaroo care among the mothers
of preterm babies. A total of 35 mothers were selected for the study. Findings of the study
revealed that, the pre-test knowledge of the Kangaroo Care was Nil. After the structured
teaching programme post test knowledge of the mother regarding Kangaroo Care was
increased. 6 (17.10%) mothers had inadequate knowledge on Kangaroo Care, 25 (71.4%)
mothers had moderately adequate knowledge and 4 (11.5%) mothers had adequate
knowledge on Kangaroo Care. Kangaroo Mother Care is a simple low cost and highly
effective intervention for low birth weight babies. And also teaching programmes can
improve the knowledge of mothers on Kangaroo Care. So, educational programme on
Kangaroo Care can be provided to Mothers, which in turn will improve the preterm and
low birth care [57].
Kadam et al (2005) conducted randomized controlled trial to determine the feasibility and
acceptability of Kangaroo Care in a tertiary care hospital in India. Over one year period in
which 89 neonates were randomized into two groups Kangaroo Mother Care (KMC) and
Conventional Method of Care (CMC) group. 45 babies were randomized into KMC group
and 45 to CMC group. Findings of study revealed that 70% of mothers felt comfortable
during the Kangaroo Mother Care. 73% felt they would able to give Kangaroo Mother
Care. Kangaroo Mother Care is a easy and powerful way to improve the attachment
between Mother and her low birth weight baby. It also plays a very important role in
reducing the incidences of hypothermia in low birth weight babies [58].
2.6 Studies Related to Knowledge and Attitude of Nurses
Mallet et al (2007) conducted a study to evaluate the barriers, knowledge and
expectations of health professionals regarding this care in 2 level III neonatal care units in
the Nord-Pas-de-Calais. Study was conducted by means of 2 questionnaires, one intended
to physicians, the other to the nursing staff sharing some common questions. Study results
revealed that 80% of the physicians and 71.4% of the paramedical staff answered to the
questionnaires. The difficulties were linked to technical or architectural constraints.
Responses were not very different between the 2 teams. The majority (90%) considered
this practice as a fully-fledged care. The positive effects on attachment (96% of the
answers) were well-known but those on sleep (2, 9%), breast-feeding (5%) and pain
(0%) were only rarely mentioned. Barriers to implementation were centred on infant's
safety. The majority of the team wished to benefit from an educational intervention [59].
Kaur et al (2004) conducted a study to assess the feasibility and attitude of nurses towards
Kangaroo Mother Care (KMC) in low birth weight neonates in an Intensive Care Unit.
All neonates once stable are provided KMC for a minimum period of 4 hours/24 hours,
which was continued till discharge. Sixty two low birth weight babies were given KMC.
Of these19 (31%) were <1000 gm, 32(52%) 1001-1500gms and rest between 1501 and
2500 gms (Smallest 548 grams). KMC was initiated within first week in 50 % and by 2nd
week in 27.4%. Findings of the study revealed that Temperature remained within 36.5°C
to 37.4°C even in VLBW babies under incubator care. Nurses felt that the requirement
of manpower, close supervision by them and use of heat convectors in NICU decreased
considerably. Babies who received KMC had fewer complications and their survival
outcome was better. An increase in expressed breast milk in mothers was reported.
Mothers accepted KMC well, were more confident in handling their LBW babies. Their
milk yield increased and they felt that they are contributing positively in the care of
their tiny babies [60].
2.7 Studies Related to effects of Skin to Skin Contact on Breast Feeding
A study was conducted to examine the effect of skin-to-skin contact between mothers and
their healthy full-term babies on initiation and duration of breast feeding. It was a randomized
controlled trial comparing skin-to-skin with routine care conducted among 204 mother and
baby pairs; 102 randomized to each group. The result was, in the skin-to-skin group, 89 out
of 98 (91%) babies had a successful first feed compared with 82 out of 89 (83%) in the
routine care group. A larger proportion of mothers were very satisfied with skin-to-skin care,
compared with 60 out of 102 (59%) in the control group; 83 out of 97 (86%) of the mothers
in the intervention group said that they would prefer to receive the same care in the future
compared with 31 out of 102 (30%) mothers in the control group. The study conclude that
the difference between the groups in the success rate for the first breast feed and rates at 4
months was not statistically significant. However, mothers who had skin-to-skin contact
enjoyed the experience, and most reported that they would choose to have skin-to skin care in
the future. In this, the largest trial to date, previous concerns about baby-body temperature
after skin-to-skin care were dispelled [61].
A study was conducted to determine the effects of skin-to-skin contact on breastfeeding
status in mother-preterm infant dyads from postpartum through18months. The study design
was Randomized, controlled trial. The control group received standard nursery care; in the
intervention group, unlimited STSC was encouraged. It measured by the Index of
Breastfeeding Status. The result was, skin to skin contact dyads, compared to control dyads,
breastfed significantly longer. And more skin to skin contact dyads than control dyads
breastfed at full exclusively [62].
A study of Birth skin-to-skin care and breastfeeding was conducted in 1999. In this study skin
to skin contact was used for a mother in a high-risk situation: eclampsia. This mother gave
birth to a 34-week preterm infant, and desired breastfeeding. Skin to skin contact was
initiated, and due to the high risk for subsequent seizures, included close observation by these
nurses. The mother successfully breastfed, and continued the skin to skin contact at home
[63].
A study was conducted to determine whether breastfeeding behaviors, skin temperature, and
blood glucose values could be influenced through the use of skin to skin contact at the time of
birth in healthy full term infants. The result was, Skin temperature rose during birth skin to
skin contact in eight of the nine infants, and temperature remained within neutral thermal
zone for all infants. Blood glucose levels varied between 43 and 85 mg/dL for infants who
had not already fed and between 43 and 118 mg/dL for those who had fed. Skin to skin care
has been implemented successfully with all women who wish to participate [64].
A study conducted to evaluate effects of maternal–infant skin-to-skin contact during the first
2 hours post birth compared to standard care (holding the infant swaddled in blankets) on
breastfeeding outcomes through 1 month follow-up. The Infant Breastfeeding Assessment
Tool was used to measure success of first breastfeeding and time to effective breastfeeding
(time of the first of three consecutive scores of 10–12). Intervention dyads experienced a
mean of 1.66 hours of skin-to-skin contact. These infants, compared to swaddled infants, had
higher mean sucking competency during the first breastfeeding and achieved effective
breastfeeding sooner. Very early skin-to-skin contact enhanced breastfeeding success during
the early postpartum period [65].
All mammals have a set sequence of behaviours at birth – all with a single purpose – to
breastfeed. Baby mammals are born to breastfeed! Surprisingly, it is the newborn that
initiates breastfeeding, not the mother. However, being warm, being fed and being protected
are intricately and inseparably linked to being in the right place, and the "right place" is
bodily contact with mother. When skin to skin, the newborn displays an impressive and
purposeful motor activity, which, without maternal assistance, brings the baby to the mother's
breast. All newborn mammals are born knowing how to breastfeed, but this is a place-
dependent competence that requires skin-to-skin contact.
As early as the 1970s, Ann-Marie Widstrom, PhD, RN, MTD, a Swedish nurse-midwife,
began to notice a pattern in the behaviours of babies that were placed skin to skin with their
mothers’ immediately after birth and allowed to peacefully adjust to extra-uterine life with no
interruptions. Being a researcher, she began to document what she saw and published her
observations in 1990 [66]. In 2011, a beautiful teaching film was created by Healthy Children
Project documenting nine instinctive stages Dr. Widstrom had observed in the behaviours of
healthy newborn infants when they are placed skin to skin with the mother immediately after
birth and left uninterrupted until after the first breastfeeding. The DVD, entitled "Skin to Skin
in the First Hour After Birth: Practical Advice for Staff after Vaginal and Cesarean Birth" is a
very useful tool for anyone involved in caring for newborns to learn about normal infant
behaviours when babies are placed skin to skin after birth [67].
The nine instinctive stages include:
1. Birth cry
2. Relaxation
3. Awakening
4. Activity
5. Resting
6. Crawling
7. Familiarization
8. Suckling
9. Sleeping
The birth cry (1st stage) occurs immediately after birth as the baby's lungs expand but usually
ends abruptly when the baby is placed onto the mother's chest. Relaxation (2nd stage) begins
when the birth cry stops and usually lasts 2–3 minutes during which the baby is very quiet
and still. Awakening (3rd stage) begins with small head movements, as the infant opens his
eyes and shows some mouth activity. During activity (4th stage) the baby has more stable eye
opening, increased mouthing, and suckling movements and often some rooting. Resting (5th
stage) can occur at any time between the other stages. Many assume, when babies were
resting, that they have given up trying to find the breast and seem to clearly need assistance to
breastfeed successfully. With knowledge of the nine instinctive stages, we know this is
simply a normal stage and babies will move on when they are ready [68]. Indeed, rushing a
newborn to the breast during a resting stage is usually counterproductive. During crawling
(6th stage) the baby makes short pushing exertions with his feet or slides his body towards
one of the mother's breasts. The baby may lift the upper torso and bob his head in a clear
effort to get near the breast. After reaching the breast, familiarization (7th stage) begins and
may last up to 20 minutes while the baby becomes acquainted with the nipple by licking,
touching and massaging. During all of these stages, the baby moves in a purposeful manner
but without frustration or hurry. The challenge for those observing is to relax, leave the baby
and the mother alone and marvel at the amazing drama unfolding as the baby finds the breast,
latches and suckles without assistance or interference. After adequate familiarization with the
new environment and mother's nipple, the newborn opens his mouth wide, cupping the
tongue which is now low in the bottom of the mouth, grasps the nipple in a correct latch and
begins to suckle (8th stage). This usually occurs about an hour after birth. Sleeping (9th
stage) follows usually between 1.5 and 2 hours after birth [69].
If all staff personnel are educated about this normal and instinctive process, they will be
equipped to be supportive of baby's progress towards the first breastfeeding. Knowledge of
the nine instinctive stages of newborn behaviours provides a roadmap to reassure staff that
assistance is not necessary and often interferes rather than helps. Newborns should not be
rushed to suckle when they have not had time to go through the previous seven stages, as they
will not be ready. It has been noted, for example, that early in the familiarization stage, the
newborn's tongue is flat and high in the roof of the mouth, whereas just prior to self-
attaching, the baby cups the tongue and drops it while opening the mouth wide for a deep and
effective latch. When babies are rushed to the breast before all their senses are awakened and
before their tongues are familiar enough with the nipple, latching is often unsuccessful and
everyone is frustrated.
A DVD entitled "The Magical Hour: Holding Your Baby Skin to Skin During the First Hour
after Birth" is a wonderful resource for families that includes interviews with parents whose
babies had been placed skin to skin immediately after birth. The DVD includes an
explanation of the nine instinctive stages of newborn behaviours and beautifully filmed video
recordings of babies experiencing each stage. A double-sided, one-page handout describing
the nine instinctive stages of newborn behaviours is also available to be given to parents
prenatally and/or just prior to delivery [70]. If parents and family members are educated
about what to expect after their baby is born, they will be less inclined to interrupt the process
by wanting to hold the baby and be willing to leave the baby skin to skin with the mother
until after the first breastfeeding. Fathers and other family members love knowing what to
expect and watch in amazement as babies progress through the stages as described by staff, in
the DVD and on the handout.
Exclusive breast-feeding for the initial 6 months of life has been prescribed in view of
essential solid, medical, social and formative advantages to both mothers and children [71].
Drawn out early skin-to-skin contact (SSC) between the mother and sound newborn not long
after birth has been suggested, on the grounds that it has appeared to enhance mother–infant
holding and fruitful breast-feeding [72]. Be that as it may, it has not been totally embraced in
maternity wards in Japan in light of worries about wellbeing (Nakamura and Sano 2008). In
2008, Nakamura and Sato reported two instances of term Japanese infants who experienced
life-debilitating scenes amid SSC taking after birth. In Japan, in view of such tragic cases
before, there have been many negative remarks on early mother-to-child contact, in daily
papers and transmissions; in any case, each infant inside 24 h of birth ought to be thought to
be in a shaky physiological state with or without SSC [73].
In instances of vaginal singleton delivery, in view of the present outcomes, early SSC is by
all accounts a vital factor connected with the expanded pervasiveness of restrictive breast-
feeding in Japanese nulliparous ladies, if early SSC is completed securely by maternity staff,
as indicated by the rule by the Kangaroo Care Guidelines Working Group in Japan.
A review led in Japan by Suzuki (2013) demonstrated that there have been many negative
remarks on early mother-to-child contact, in light of tragic cases in the past. In spite of the
fact that mother–infant partition post-delivery had been regular in Western culture, as of late,
the benefits of early SSC have been perceived. Early SSC starts preferably at birth and
includes setting the naked baby inclined on the mother's bare chest, with a warm blanket over
the baby's back [74]. To date, early SSC has been proposed to profit breast-feeding results,
early mother–infant connection, infant crying and cardiorespiratory security and has no
obvious short-or long haul negative impacts. Besides, this personal contact has been proposed
to summon neurobehaviours, guaranteeing the satisfaction of fundamental organic needs.
Sadly, this start might be misunderstood in Japan because of some late reports by the
gathering of casualties of kangaroo-care or potentially selective breast-feeding in Japan, that
this start may build the danger of sudden infant demise and serious evident life-undermining
occasions in sound infants. The outcomes may bolster the advantage of early SSC in Japanese
ladies after vaginal delivery; accordingly, early SSC might be suggested through the
execution of security rules in Japan.
2.8 Studies Related to effects of Skin to Skin Contact on Thermoregulation
A study was conducted to compare standard newborn care under radiant heat with two
methods of warming babies that provided immediate parent-infant contact. Fifty-one mother-
infant dyads were randomly assigned to three treatment groups. Control group babies had no
skin-to-skin contact with their mothers during the study period. One group of experimental
infants began skin-to-skin contact after completion of initial nursing care in a radiant heater.
The second groups of experimental babies had the earliest, most continuous skin-to-skin
contact with their mothers and were never under radiant heat. The result was more control
than experimental newborns had skin and rectal temperatures below the neutral thermal range
at 21 and 45 minutes of life. High delivery room temperature and drying babies well
immediately after birth did not differ significantly among the three groups, but were found to
be positively correlated with neonatal body temperature for the sample as a whole [75].
A study of skin to skin care and conventional incubator care for thermal regulation of infants
was conducted in 2004.The risk of hypothermia was reduced by > 90% when nursed by skin
to skin contact rather than conventional care, relative risk. Mothers felt that skin to skin
contact was safe, and preferred the method to CC because it did not separate them from their
infants, although some had problems adjusting to this method of care. Where equipment for
thermal regulation is lacking or unreliable, skin to skin contact is a preferable method for
managing stable low birth weight infants [76].
A study was done to determine the feasibility and acceptability of skin to skin contact in a
tertiary care hospital in India. In which 89 neonates were randomized into two groups skin to
skin contact (STSC) and conventional method of care (CMC) .The result of the study was
STSC is a simple and feasible intervention; acceptable to most mothers admitted in hospitals.
There may be benefits in terms of reducing the incidence of hypothermia with no adverse
effects of STSC demonstrated in the study. The present study has important implications in
the care of LBW infants in the developing countries, where expensive facilities for
conventional care may not be available at all place [77].
A study was conducted to evaluate the effectiveness of skin to skin contact compared to
incubators in maintaining body warmth in preterm infants. A randomized clinical trial of 16
skin to skin contact and 13 control infants using a pretest-posttest design of three consecutive
interfeeding intervals of 2.5 to 3.0 h duration each was conducted over 1 day. Infant
abdominal and toe temperatures were measured in and out of the incubator; maternal breast
temperature was measured during skin to skin contact. Toe temperatures were significantly
higher during skin to skin contact than incubator periods, and maternal breast temperature
met each infant's neutral thermal zone requirements within 5 min of onset of skin to skin
contact. Preterm infants similar to those studied here will maintain body warmth with up to 3
h of skin to skin contact [78].
A study was conducted to evaluate the efficacy of skin to skin method on thermoregulation
and weight gain of a cohort of preterm babies. It was a retrospective study based on files of
preterm baby weighting below 2000 g, included after discharge to neonatal unit . Efficiency
was appreciated on thermic curve evolution and daily weight gain. 56 preterm babies were
including. Mean gestational age was 33 +/- 7,6 weeks and mean birth weight, 1488 +/- 277,6
g (median = 1500g). Mean temperature was satisfying during follow up and was stable
around 37 +/-0,5 degrees C at discharge of program with mean daily weight gain of 33 +/-
7,6g. We had only one case of death. The results of this study point out efficacy of skin to
skin contact method on thermoregulation, weight gain and survival of preterm babies. We
advocate for promotion in developing countries because of its low cost [79].
Skin-to-skin contact (SSC) during this time provides the infant with natural thermoregulation
and promotes oxygenation. Philips (2013) addresses the theories on how skin to skin care
(SSC) is thought to improve a newborn’s ability to transition from womb to life outside the
womb by stabilizing their physical and emotional state. Phillips (2013) references the World
Health Organization (WHO) when reminding of the importance of thermoregulation and that
skin-to-skin contact should be promoted, as well as encouraged within the first 24 hours after
birth. The American Academy of Pediatrics also theorizes that healthy infants should be
placed and should remain in direct skin-to-skin contact with their mothers immediately after
delivery until the first feeding is accomplished [80].
Implementation of uninterrupted skin-to-skin contact with the full-term newborn will begin
immediately after birth. Desired outcomes include short and long-term consequences. There
is good evidence that normal, term newborns that are placed skin to skin with their mothers
immediately after birth make the transition from fetal to newborn life with greater respiratory,
temperature, and glucose stability [81]. It is desired that the newborn innate system of self-
regulation will be controlled to promote optimal regulation of vital signs. Baseline outcome
measures will include data to indicate the benefits of kangaroo care to include blood pressure
being stabilized through parasympathetic control, hypoglycemia prevention, improved
respirations, and improved metabolic functions to include thermoregulation of the full-term
newborn [82].
The Moore et al. (2012) article pertains to the PICOT question by addressing gaps in the use
of skin-to-skin care with full-term infants. The evidence presented supports the use of skin-
to-skin care for infant stabilization and thermoregulation. The article suggested areas for
nursing care improvement utilizing skin-to-skin care more frequently [83]. However, the
article also addresses areas where more research is needed for the future
Thermal synchrony phenomenon that takes place whereby the temperature of the mother’s
chest increases to warm a cool newborn and decreases to cool an overly warm newborn.
When a newborn enters the world for the first time, he or she is wet and easily chilled in the
cool extra-uterine environment. Therefore, the newborn experiences a sense of comfort when
warmed by the mother’s chest, which further enhances the bonding process. Kangaroo care
involves laying the newborn prone on the mother’s chest, and is one of the simplest ways to
support bonding between the newborn and the mother [84]. Premature newborns that have
experienced kangaroo care have been shown to have a reduced need for extra oxygen [85].
Preterm newborns requiring oxygen can be cared for skin-to-skin while receiving oxygen
therapy.
Lagercrantz (1986) found that newborn infants experience a catecholamine surge after
vaginal birth, caused by compression of the fetal head and intermittent hypoxia during
contractions. This response is felt to aid in adaptation to the extrauterine environment
immediately postbirth by causing an increase in infant level of alertness, lung compliance,
blood glucose, body temperature, and shunting of blood to the vital organs [86]. However,
this response may become maladaptive if allowed to continue. Bystrova et al (2003) found a
decrease in foot temperature (indicating peripheral vasoconstriction) in control infants cared
for in the nursery and an increase in foot temperature in SSC infants. She proposed that this
difference was related to vasodilatation caused by decreased sympathetic tone in the SSC
infants and hypothesized that SSC may activate the somatosensory nerves, thus antagonizing
the “stress of being born” [87]. These findings correlate accurately with findings predicted
from mammalian research on separation in the newborn period. The neurobehavioral
stabilization achieved in SSC correlates in mammalian studies with a parasympathetically
mediated homeostasis, the purpose of which is growth and development. The stabilization
achieved in the separated state is mediated by a sympathetically driven defense program,
whose purpose is primarily to survive the period of separation. In so far as the differences
observed corroborate the findings from mammalian research, they can be considered
clinically significant.
2.9 Long-Term Effects of SSC on Mother-Preterm Infant Interaction
In a review, Moore, Anderson, and Bergman (2007) reported more maternal affectionate
touching and attachment behaviours at follow-up in randomized controlled trials (RCTs) with
mothers of full term infants who experienced SSC [88]. However, only one RCT has been
conducted in which long-term effects of SSC on mother-preterm infant interaction (MPI)
have been reported. In this RCT (N = 488) which was conducted in Bogota, Colombia, 488
mothers were encouraged to provide KMC for their infants 24 hours a day. An objective
instrument, Nursing Child Assessment Feeding Scale, was used to measure maternal
perception and the state of each mother’s readiness to respond to her infant’s needs at 41
weeks post-conception. KMC dyads had higher scores on maternal sensitivity (a subscale of
the feeding scale) than controls (p = .05).
Positive effects of SSC on MPI and infant and family health were also reported in three
publications from a matched-control study conducted with 146 preterm infants in two
hospitals in Jerusalem, Israel. Feldman, Eidelman et al. (2002) reported that at 37 weeks’
gestation, SSC mothers were less depressed and had more positive effect, touch, adaptation to
infant cues, and perception of their infants [89]. At three months SSC parents were more
sensitive and provided a better home environment and SSC infants scored higher on the
Bayley Mental and Motor Developmental Indices. Feldman, Weller et al. (2002) found that at
hospital discharge SSC infants had more mature state distribution and organized sleep-wake
cycle and at three months SSC infants were more tolerant to negative maternal emotion,
displayed less negative effect, and their parents were more sensitive and less intrusive [90].
SSC parents also demonstrated more affectionate touching of their infants and of each other,
and more often held their infants in a position conducive to mutual gaze and touch. At six
months, SSC mother-infant dyads shared attention, and infants’ sustained exploration of their
environment began sooner and lasted longer. Feldman, Weller et al. (2003) found that SSC
had a positive impact on mother-infant interaction, father-infant interaction, and the spousal
relationship [91]. Feldman and Eidelman (2003) then conducted a prospective case-control
study in one hospital with 70 very-low- and low-birth-weight preterm infants. The 35 infants
who experienced SSC for at least one hour a day for 14 days had significantly more rapid
maturation of vagal tone between 32 and 37 weeks' gestation and better behavioral
organization (e.g., longer periods of quiet sleep and alert wakefulness, and shorter periods of
active sleep) [92]
In a historical-control study with healthy low-birth-weight infants, Ohgi et al. (2002) found
that SSC infants scored higher than controls on behavioural organization during the neonatal
period and on the Bayley Developmental Indices at 12 months [93]. In a comparison study in
Italy, Tallandini and Scalembra (2006) examined the effects of KMC on very-low-birth-
weight preterm infants and their mothers. Control dyads (n = 21) received routine care and
KMC dyads (n = 19), who experienced SSC for at least one hour per day for a mean of 24.37
days (SD = 11.06). KMC mothers were less emotionally stressed while in the hospital, and
mother-infant interaction was better 38 gestational weeks [94].
The above review supports the beneficial effects of SSC on mother-preterm infant
interaction. However, the focus of most of these was on subjective self-report of maternal
feelings during or shortly after SSC. When an objective measure was used, follow-up data
were collected only once at 41 weeks’ gestation or once right after hospital discharge, or the
study was not an RCT [95].
Inspired by the early work of Ourth and Brown (1961), the Mutual Care giving Model was
developed by the author [96]. Briefly stated, beginning with birth, the ideal habitat
(ecological niche) for each newborn infant is the specific and relatively familiar milieu
provided by its mother. Although human infants are born with the skills needed to survive
and be nourished in a self-regulatory fashion, this can only happen optimally if infants remain
with their mothers in this habitat and in skin-to-skin contact. This experience promotes a
broad parasympathetic (vagal) response (e.g., glandular secretion), which is physiologically
beneficial and comforting for both mother and infant and would logically promote bonding
and attachment. Similar conceptualizations have been set forth by others [97]. Thus, an RCT
was conducted to further examine the effects of early SSC on the health of preterm infants
and their mothers during their hospital stay and through 18 months. Two publications have
resulted from this RCT to date. Anderson et al. (2003) reported mother-infant contact
information during the first two days’ post birth, and Hake-Brooks & Anderson (2008)
focused on breastfeeding duration and exclusivity of mother-infant dyads in the hospital and
through 18 months. The purpose of the report presented here was to examine the effect of
SSC on mother-preterm infant interaction at 6, 12, and 18 months [98].
2.10 Studies related to Lactation
Laurie et al (2008) conducted a study from 242 exclusively breastfeeding mother-infant pairs,
newborn elimination patterns were analyzed. Sensitivity (Se) and Specificity (Sp) of day 4
(72-96 hours) wet and soiled output, in addition to the timing of onset of lactation, in
identifying cases of breastfeeding inadequacy (defined as neonatal weight loss ≥ 10% of birth
weight) were examined. Their data suggest that there is a significant association between void
and stool frequency and breastfeeding inadequacy. However, their study is the first to
demonstrate that diaper output measures, when applied in the home setting, show too much
overlap between infants with adequate versus inadequate breast milk intake to serve as stand-
alone indicators of breastfeeding inadequacy. This is exemplified by the very low specificity
of any cutoff that is high enough to be clinically useful. To ascertain whether those with low
soiled or wet diaper output, but within the BFA group, represent the “low end” of
breastfeeding adequacy, we examined the proportion with weight loss in the 8% to 9.9%
range. They found that these infants were not overrepresented at the low end of either soiled
or wet diaper output. For example, only 2 of the 10 BFA infants with no soiled diaper output
on day 4 lost more than 8% of birth weight. At least some of the observed overlap may be
due to random error introduced by the variation in diapering products and diaper change
frequency found in the home setting.
It could be observed from the above study that producing fewer than 4 soiled diapers on day
4 or delay of lactogenesis stage II ≥ 72 hours postpartum is suggestive of difficulties with
establishing breastfeeding. However, although it is useful for mothers to have a general idea
of what normal elimination patterns are for the breastfed newborn, it is equally important that
they are aware that normal newborn elimination patterns show wide variation. The findings
of Laurie et al (2008) suggested that diaper counts are not a reliable enough indicator to serve
as a screening tool for breastfeeding inadequacy, supporting the recommendation of the
American Academy of Pediatrics that “all breastfeeding newborn infants should be seen by a
pediatrician or other knowledgeable and experienced health care professional at 3 to 5 days of
age.
3. Materials and Methods
3.1 Types of studies
All randomized controlled trials in which the active encouragement of early skin-to-skin
contact (SSC) between mothers and their low birth weight infants was compared to usual
hospital care.
A study design that randomly assigns participants into an experimental group or a control
group is known as randomized controlled trials. As the study is conducted, the only expected
difference between the control and experimental groups in a randomized controlled trial
(RCT) is the outcome variable being studied [99].
3.2 Types of participants and Sample Size
All neonates delivered in LMH Nagpur with birth weight less than 2.5 kg, during the study
period were included in this study.
Total sample size of the study is 100. Wherein, 50 samples were taken for Group A and 50
for group B respectively
3.3 Types of interventions
In ‘birth SSC’, the infant is placed prone skin-to-skin on the mother’s abdomen or chest
during the first minute post birth. The infant is suctioned while on the mother’s abdomen or
chest, if medically indicated, thoroughly dried and covered across the back with a pre
warmed towel. To prevent heat loss, the infant’s head may be covered with a dry cap that is
replaced when it becomes damp. Ideally, all other interventions are delayed until at least the
end of the first hour post birth or the first successful breastfeeding.
In ‘very early SSC’, beginning approximately 30 to 40 minutes post birth, the naked infant,
with or without a cap, is placed prone on the mother’s bare chest. A towel is placed across the
infant’s back.
’Early SSC’ can begin anytime between one and 24 hours post birth. The baby is naked (with
or without a diaper and cap) and is placed prone on the mother’s bare chest between the
breasts. The mother may wear a blouse or shirt that opens in front, or a hospital gown worn
backwards, and the baby is placed inside the gown so that only the head is exposed. What the
mother wears and how the baby is kept warm and what is placed across the baby’s back may
vary. What is most important is that the mother and baby are in direct ventral-to-ventral SSC
and the infant is kept dry and warm.
In the future these groups may be analyzed separately. However, at present, not enough
studies are available for subgroup analysis. Standard contact includes a number of diverse
conditions, infants held swaddled or dressed in their mother’s arms, or infants placed in open
cribs or under radiant warmers in the mother’s room or elsewhere with no holding allowed.
3.4 Inclusion Criteria
All neonates born in NKP salve institute of medical sciences, Nagpur with:
Birth weight less than 2.5 kgs.
Born through normal vaginal delivery
Without any pre partum complications
3.5 Exclusion Criteria
Babies who require NICU admission.
Babies with congenital anomalies hampering breastfeeding like cleft palate, cleft lip
and severe ankyloglossia.
Babies who have 5 min Apgar score less than 8
The mothers who have medical complications that contraindicates skin to skin
contact
Babies delivered by caeserian section
Babies with more than 2.5 kg
3.6 Data Collection
This study has been conducted in the labour and delivery unit at a tertiary care hospital.
Pregnant mothers have been recruited for the study as soon as they were admitted in the
obstetrics unit during the study period. They were considered eligible if they consent to
participate in the study, have no pre-existing medical or psychiatric illness, and anticipate a
spontaneous vaginal delivery and who do not have peripartum complications.
The infants will be divided into two groups:
Group A (INTERVENTION GROUP): Infants were placed prone on mother’s
abdomen after drying them. The infant was remained skin to skin with mother for 1
hr.
Group B (CONTROL GROUP): Infants were managed according to the hospital
protocol. They were received on a tray covered with a pre-warmed towel and were
moved to a baby corner for immediate care, routine examination and vitamin k.
The axillary temperature of infants in both the groups will be taken at beginning of SSC, half
an hour after and one hour after beginning of SSC with the help of digital thermometer.
3.7 Searches
Systematic searches were undertaken of electronic databases including Cochrane Libraries,
PubMed, LILACS, African Medicus, EMRO and all World Health Organization Databases
and included publications in any language. Online searches of major conference proceedings
were also conducted in order to identify unpublished literature. The key search terms
included were: ‘Kangaroo Mother Care’, ‘Kangaroo Care’ and ‘Skin to skin care’,
‘Thermoregulation’ and ‘Breastfeeding’.
3.8 Randomization
Randomization will be done in following manner:
First 15 days of every month, SSC were given in the labour room.
Last 15 days of every month, SSC were not be given and normal hospital policies
were followed
3.9 Lactation Status
Data collected relevant to this analysis include birth weight, day 3 infant weight, daily wet
and soiled diaper output and timing of onset of lactation. Diaper output was based on
maternal recall. Mothers were encouraged to use study-provided feeding/elimination diary
forms to enhance accuracy of recall data, but no recommendation was given with regard to
frequency of diaper checks or changes. A diaper that was both wet and soiled counted in both
categories.
Lactation adequacies of mothers were checked by following parameters:
Frequency of wet and soiled nappies, soiled with urine within 72 hrs of the delivery, less
than 4 soiled nappies per day in this duration indicates breast feeding inadequacy.
To rate their level of breast fullness on a scale of 1 to 5 where:
1= no change
2= mildly full
3= noticeably full
4= comfortably full
5= uncomfortably full
Where onset of lactation (stage 2 lactogenesis) is defined as level 3 (noticeably fuller)
Babies’ weight were also taken after 72 hrs and weight loss more than 10% indicates
breastfeeding inadequacy
3.10 Data Analysis
Randomised control trial was used to study the impact of skin to skin contact on the body
temperature of low birth weight infants and lactation status of mother on day 3 following
SSC. The analysis was conducted using SPSS version 11.101 where several tests such as T-
test, Pearson Chi-square test and non-parametric Mann-Whitney test were performed.
3.11 Research Ethics
Permission has been obtained from the research committee of LMH Nagpur. Informed
consent was obtained from the subjects who are selected for the study.
Discussion
Positive impact of SSC on feelings of mothers of preterm infants has been reported in several
studies [100] [101]. In most recent publications, SSC mothers were more sensitive and less
intrusive, and their infants showed less negative emotion and more dyadic reciprocity [102]
[103]. The purpose of this study was to demonstrate the impact on neonatal thermoregulation
and breastfeeding outcome in low birth weight babies.
Early skin-to-skin contact (SSC) refers to the placing of the naked infant prone on the
mother’s bare chest immediately after birth [104]. It helps in initiating breast feeding (BF)
and in reducing infant’s stress in the first few hours after birth. With the rapid technological
advancement in perinatal care, the practice, however, lost its rightful place in most modern-
day obstetric units [105]
The majority of the studies on SSC have evaluated its effect on the duration and exclusivity
of BF during infancy; only a few studies have looked at the success of BF in the immediate
neonatal period [106]. While three trials assessed the success of the first breast feed, only one
study has so far evaluated the effect at a later age. Carfoot et al studied the success of BF by
using a modified infant Breast-Feeding Assessment Tool (BAT) score before discharge and
found no significant difference between the SSC and control groups [107]. However, the
study had a major limitation in that only 25% of the infants’ feeding sessions were observed
by the investigator while the remaining assessments were done by the mothers themselves.
The evidence regarding the effect of SSC on BF behavior before discharge is important from
at least two perspectives – (1) with improper sucking at the breast being one of the major
reasons for stopping BF in the first week of life, a significant improvement noted in rooting
and attachment at around the time of discharge could improve exclusive BF (EBF) rates in
infancy, and (2) evaluation of BF behavior at a later age, as opposed to assessment at the first
breast feed, is less likely to be affected by the mother’s nipple protractility.
The other major effect of SSC in neonates is to reduce the stress levels associated with
separation from their mothers. There is some evidence from previous studies that salivary
cortisol levels considered as a marker of stress decreased in infants given SSC [108]. Taking
these factors into consideration, in our study all randomized controlled trials in which the
active encouragement of early skin-to-skin contact (SSC) between mothers and their low
birth weight infants was compared to usual hospital care.
In our study, 100 patients were enrolled. From these 50% receives SCC and 50% received
general care without SSC. Moreover, most patients in our study were primigravida in group
A (62.0%) as well as in group B (50.0%) followed by second gravida (24% and 26%
respectively in two groups). Mean gestational age was significantly more in patients in group
A than group B. Similarly, proportion of patients above 37 weeks of gestation was greater in
patients of group A (94%) than group B (72%). On the other hand, in babies born, gender was
equal in two groups with 58% male and 42% female each in two groups.
Although other SSC study findings appeared similar at first, more careful examination
revealed dissimilarities between studies to allow valid comparisons, such as study design
[109] and infant populations [110]. Other examples include Tallandini and Scalembra (2006)
who used the same instrument but their study was not a randomized trial and follow-up was
done shortly after discharge [111].
A study conducted by Suzuki (2013) examined the effect of early skin-to-skin contact (SSC)
on breast-feeding at 1 month after delivery, in Japanese women. They reviewed the obstetric
records of healthy nulliparous women with vaginal singleton delivery at 37-41 weeks'
gestation, at the Japanese Red Cross Katsushika Maternity Hospital and between 1 February
and 30 November 2011, there was a total of 403 women who planned to breast-feed their
babies at birth. Of these, 272 women (67.5%) initiated early SSC in the delivery room and
131 women (32.5%) did not initiate early SSC. There were no significant differences in the
obstetric characteristics and birth outcomes between the two groups of women with and
without initiating early SSC [112].
The results of our study demonstrated a statistically significant positive effect of skin-to-skin
contact (SSC) on the following primary outcomes: breastfeeding within 72 hrs postbirth. We
did not identify significant between group differences in duration of breastfeeding, and
results relating to infant axillary temperature at 90 minutes to one hour postbirth were
difficult to interpret due to high heterogeneity.
We found a statistically significant and positive effect of SSC on the following secondary
outcomes: success of the first breastfeeding, mean variation in axillary temperature 30 and 60
minutes postbirth. 30 minutes SSC cases were recorded at a mean of 96.84 with a P value of
0.894. On the other hand, 60 minutes SSC cases were recorded at a mean of 97.46 with a P
value of 0.984. Thus, it could be observed that mean temp in two groups did not differ at each
point of assessment and p values were insignificant for comparison between two groups at
baseline, 30 and 60 minutes of assessment.
We did not identify significant differences in distribution of weight at birth and at day 3 in
two study groups. Mean birth weight did not differ significantly (p=0.418) in two groups.
Also, weight at day 3 did not differ significantly (p=0.116).
The totality of significant outcomes relating to breastfeeding, neonatal thermoregulation,
infant physiology and maternal neurobehavior supports the use of SSC in the early period
after birth. However, this overall finding should be treated with some caution: for many
outcomes only one or two studies contributed data, and for those outcomes where several
studies were combined in meta-analysis there was considerable heterogeneity between
individual studies. At the same time, some of those results that did not reach statistical
significance were derived from small studies which did not have the statistical power to
demonstrate differences between groups.
Parents of breastfeeding infants are commonly advised to monitor wet and soiled diapers
each day during the neonatal period as an indication of infant breast milk intake. Even though
lactation management texts provide guidelines on how many wet and soiled diapers the
adequately fed, exclusively breastfeeding infant should produce, reference to clinical research
to support the guidelines is sparse [113]. Successful breastfeeding promotion and support
campaigns are resulting in increasing numbers of mothers exclusively breastfeeding upon
hospital discharge [114]. It is important that they be sent home with evidence-based, simple-
to understand guidelines for evaluating breastfeeding adequacy.
Yaseen et al reported that exclusively breastfed infants readmitted to a hospital in the United
Arab Emirates for neonatal dehydration (weight loss between 12% and 29% of birth weight)
were significantly more likely to have < 6 voids and < 3 stools in the previous 24 hours
before admission as compared with a control group (P < .0001), supporting a relationship
between these measures and breastfeeding inadequacy [115]. Moreover, Shrago et al present
a model with the variables “first day of yellow stool” and “number of bowel movements
during the first 5 days,” predicting 32.5% of the variation in infant weight gain from birth to
day 14 (P < .005) [116].
In our study, wet nappies suggesting urine frequency of four or less was seen in 68% babies
in group A and 72% babies in group B whereas the frequency above 5 was 32% and 14% in
two groups respectively. The proportion of patients in two groups did not differ significantly
(p=0.663). Similarly frequency of soiled nappies of 4 or less was 88% and 94% in group A
and group B respectively, whereas frequency of more than 5 soiled nappies was 12% and 6%
in two groups respectively with no significant difference in distribution of patients (p=0.295).
Thus, our data suggest that there is no significant difference between the two groups.
Regarding the lactation adequacy score in two groups, it was observed in our study that no
change in breast fullness was reported by 28% women in group B. Proportion of patients
reporting mild fullness was 46% and 44%, noticeable fullness in 42% and 20%, comfortable
fullness in 12% and 2% in patients of group A and B respectively. 4% patients from group B
found to have uncomfortable breast fullness. These proportion of patients were found to be
significantly different in two groups (p<0.0001).
Adequacy of breast feeding (lactation score from 3 and more) was found 54% and 28%
patients group A and B respectively. Inadequacy (suggested by score of 2 or less) was found
in 46% and 72% patients group A and B respectively. The difference in proportion of patients
was statistically significant (p=0.008). The odds ratio was 0.33 (95% confidence interval
0.14, 0.76) suggesting lesser risk of inadequacy of lactation in group A than group B.
In conclusion, babies breastfed more successfully during SSC immediately postbirth than if
they were held swaddled in towel, probably because of the extra tactile, odor, and thermal
cues provided by SSC, but this result did not translate into significantly more mothers
breastfeeding at one to four months postbirth in two studies by the same investigator. Carfoot
(2005) stated that barriers to long-term breastfeeding, such as returning to work, and
breastfeeding problems contributed to the minimal effect that early SSC had on this outcome
[117]. Early SSC appears to have less of an effect on breastfeeding exclusivity or duration in
studies where control infants are held swaddled by their mothers or placed swaddled or
clothed on their mother’s naked chest and given the opportunity to breastfeed soon after birth
than in studies where control infants are separated from their mothers for 12 to 24 hours
immediately postbirth. Given the strong evidence of the negative impact of early mother-
infant separation, it is noteworthy that in some hospitals usual care still includes this practice
for healthy full term newborns [118]. It is useful for mothers to have a general idea of what
normal elimination patterns are for the breastfed newborn, it is equally important that they are
aware that normal newborn elimination patterns show wide variation. Early SSC needs to be
aggressively promoted in term and late-preterm newborns to reduce incidence of
hypothermia. All new mothers, if they are able and whether or not they ask to do SSC, should
be encouraged to experience SSC and assured that they will have additional support from
hospital staff.
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