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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