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      Early skin‐to‐skin contact for mothers and their healthy newborn infants

      systematic-review
      , , ,
      Cochrane Pregnancy and Childbirth Group
      The Cochrane Database of Systematic Reviews
      John Wiley & Sons, Ltd

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          Abstract

          Background

          Mother‐infant separation post birth is common. In standard hospital care, newborn infants are held wrapped or dressed in their mother’s arms, placed in open cribs or under radiant warmers. Skin‐to‐skin contact (SSC) begins ideally at birth and should last continually until the end of the first breastfeeding. SSC involves placing the dried, naked baby prone on the mother's bare chest, often covered with a warm blanket. According to mammalian neuroscience, the intimate contact inherent in this place (habitat) evokes neuro‐behaviors ensuring fulfillment of basic biological needs. This time frame immediately post birth may represent a 'sensitive period' for programming future physiology and behavior.

          Objectives

          To assess the effects of immediate or early SSC for healthy newborn infants compared to standard contact on establishment and maintenance of breastfeeding and infant physiology.

          Search methods

          We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (17 December 2015), made personal contact with trialists, consulted the bibliography on kangaroo mother care (KMC) maintained by Dr Susan Ludington, and reviewed reference lists of retrieved studies.

          Selection criteria

          Randomized controlled trials that compared immediate or early SSC with usual hospital care.

          Data collection and analysis

          Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. Quality of the evidence was assessed using the GRADE approach.

          Main results

          We included 46 trials with 3850 women and their infants; 38 trials with 3472 women and infants contributed data to our analyses. Trials took place in 21 countries, and most recruited small samples (just 12 trials randomized more than 100 women). Eight trials included women who had SSC after cesarean birth. All infants recruited to trials were healthy, and the majority were full term. Six trials studied late preterm infants (greater than 35 weeks' gestation). No included trial met all criteria for good quality with respect to methodology and reporting; no trial was successfully blinded, and all analyses were imprecise due to small sample size. Many analyses had statistical heterogeneity due to considerable differences between SSC and standard care control groups.

          Results for women

          SSC women were more likely than women with standard contact to be breastfeeding at one to four months post birth, though there was some uncertainty in this estimate due to risks of bias in included trials (average risk ratio (RR) 1.24, 95% confidence interval (CI) 1.07 to 1.43; participants = 887; studies = 14; I² = 41%; GRADE: moderate quality). SSC women also breast fed their infants longer, though data were limited (mean difference (MD) 64 days, 95% CI 37.96 to 89.50; participants = 264; studies = six; GRADE: low quality); this result was from a sensitivity analysis excluding one trial contributing all of the heterogeneity in the primary analysis. SSC women were probably more likely to exclusively breast feed from hospital discharge to one month post birth and from six weeks to six months post birth, though both analyses had substantial heterogeneity (from discharge average RR 1.30, 95% CI 1.12 to 1.49; participants = 711; studies = six; I² = 44%; GRADE: moderate quality; from six weeks average RR 1.50, 95% CI 1.18 to 1.90; participants = 640; studies = seven; I² = 62%; GRADE: moderate quality).

          Women in the SCC group had higher mean scores for breastfeeding effectiveness, with moderate heterogeneity (IBFAT (Infant Breastfeeding Assessment Tool) score MD 2.28, 95% CI 1.41 to 3.15; participants = 384; studies = four; I² = 41%). SSC infants were more likely to breast feed successfully during their first feed, with high heterogeneity (average RR 1.32, 95% CI 1.04 to 1.67; participants = 575; studies = five; I² = 85%).

          Results for infants

          SSC infants had higher SCRIP (stability of the cardio‐respiratory system) scores overall, suggesting better stabilization on three physiological parameters. However, there were few infants, and the clinical significance of the test was unclear because trialists reported averages of multiple time points (standardized mean difference (SMD) 1.24, 95% CI 0.76 to 1.72; participants = 81; studies = two; GRADE low quality). SSC infants had higher blood glucose levels (MD 10.49, 95% CI 8.39 to 12.59; participants = 144; studies = three; GRADE: low quality), but similar temperature to infants in standard care (MD 0.30 degree Celcius (°C) 95% CI 0.13 °C to 0.47 °C; participants = 558; studies = six; I² = 88%; GRADE: low quality).

          Women and infants after cesarean birth

          Women practicing SSC after cesarean birth were probably more likely to breast feed one to four months post birth and to breast feed successfully (IBFAT score), but analyses were based on just two trials and few women. Evidence was insufficient to determine whether SSC could improve breastfeeding at other times after cesarean. Single trials contributed to infant respiratory rate, maternal pain and maternal state anxiety with no power to detect group differences.

          Subgroups

          We found no differences for any outcome when we compared times of initiation (immediate less than 10 minutes post birth versus early 10 minutes or more post birth) or lengths of contact time (60 minutes or less contact versus more than 60 minutes contact).

          Authors' conclusions

          Evidence supports the use of SSC to promote breastfeeding. Studies with larger sample sizes are necessary to confirm physiological benefit for infants during transition to extra‐uterine life and to establish possible dose‐response effects and optimal initiation time. Methodological quality of trials remains problematic, and small trials reporting different outcomes with different scales and limited data limit our confidence in the benefits of SSC for infants. Our review included only healthy infants, which limits the range of physiological parameters observed and makes their interpretation difficult.

          Plain language summary

          Early skin‐to‐skin contact for mothers and their healthy newborn infants

          What is the issue?

          Babies are often separated from their mothers at birth. In standard hospital care, newborn infants can be held wrapped or dressed in their mother’s arms, placed in open cribs or under warmers. In skin‐to‐skin contact (SSC), the newborn infant is placed naked on the mother's bare chest at birth or soon afterwards. Immediate SSC means within 10 minutes of birth while early SSC means between 10 minutes and 24 hours after birth. We wanted to know if immediate or early SSC improved breastfeeding for mothers and babies, and improved the transition to the outside world for babies.

          Why is this important?

          There are well‐known benefits to breastfeeding for women and their babies. We wanted to know if immediate or early SSC could improve women's chances of successfully breastfeeding. Having early contact may also help keep babies warm and calm and improve other aspects of a baby's transition to life outside the womb.

          What evidence did we find?

          We searched for randomized controlled studies of immediate and early SSC on 17 December 2015. We found thirty‐eight studies with 3472 women that provided data for analysis. Most studies compared early SSC with standard hospital care for women with healthy full‐term babies. In eight studies women gave birth by cesarean, and in six studies the babies were healthy but born preterm at 35 weeks or more. More women who had SSC with their babies were still breastfeeding at one to four months after giving birth (14 studies, 887 women, moderate‐quality evidence). Mothers who had SSC breast fed their infants longer, too, on average over 60 days longer (six studies, 264 women, low‐quality evidence). Babies held in SSC were more likely to have breast fed successfully during their first breast feed (five studies, 575 women). Babies held in SSC had higher blood glucose levels (three studies, 144 women, low‐quality evidence), but similar temperature to babies with standard care (six studies, 558 women, low‐quality evidence). We had too few babies in our included studies and the quality of the evidence was too low for us to be very confident in the results for infants.

          Women giving birth by cesarean may benefit from early SSC, with more women breastfeeding successfully and still breastfeeding at one to four months (fourteen studies, 887 women, moderate‐quality evidence), but there were not enough women studied for us to be confident in this result.

          We found no clear benefit to immediate SSC rather than SSC after the baby had been washed and examined. Neither did we find any clear advantage of a longer duration of SSC (more than one hour) compared with less than one hour. Future trials with more women and infants may help us answer these questions with confidence.

          SSC was defined in various ways and different scales and times were used to measure different outcomes. Women and staff knew they were being studied, and women in the standard care groups had varying levels of breastfeeding support. These differences lead to wide variation in the findings and a lower quality evidence. Many studies were small with less than 100 women participating.

          What does this mean?

          The evidence from this updated review supports using immediate or early SSC to promote breastfeeding. This is important because we know breastfeeding helps babies avoid illness and stay healthy. Women giving birth by cesarean may benefit from early SSC but we need more studies to confirm this. We still do not know whether early SSC for healthy infants helps them make the transition to the outside world more smoothly after birth, but future good quality studies may improve our understanding. Despite our concerns about the quality of the studies, and since we found no evidence of harm in any included studies, we conclude the evidence supports that early SSC should be normal practice for healthy newborns including those born by cesarean and babies born early at 35 weeks or more.

          Related collections

          Most cited references167

          • Record: found
          • Abstract: found
          • Article: not found

          Maternal care, hippocampal synaptogenesis and cognitive development in rats.

          We report that variations in maternal care in the rat promote hippocampal synaptogenesis and spatial learning and memory through systems known to mediate experience-dependent neural development. Thus, the offspring of mothers that show high levels of pup licking and grooming and arched-back nursing showed increased expression of NMDA receptor subunit and brain-derived neurotrophic factor (BDNF) mRNA, increased cholinergic innervation of the hippocampus and enhanced spatial learning and memory. A cross-fostering study provided evidence for a direct relationship between maternal behavior and hippocampal development, although not all neonates were equally sensitive to variations in maternal care.
            Bookmark
            • Record: found
            • Abstract: not found
            • Article: not found

            Maternal Care, Hippocampal Glucocorticoid Receptors, and Hypothalamic-Pituitary-Adrenal Responses to Stress

            D. Liu (1997)
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              • Record: found
              • Abstract: found
              • Article: not found

              Postnatal glucose homeostasis in late-preterm and term infants.

              , David Adamkin (2011)
              This report provides a practical guide and algorithm for the screening and subsequent management of neonatal hypoglycemia. Current evidence does not support a specific concentration of glucose that can discriminate normal from abnormal or can potentially result in acute or chronic irreversible neurologic damage. Early identification of the at-risk infant and institution of prophylactic measures to prevent neonatal hypoglycemia are recommended as a pragmatic approach despite the absence of a consistent definition of hypoglycemia in the literature.
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                Author and article information

                Contributors
                elizabeth.moore@vanderbilt.edu
                Journal
                Cochrane Database Syst Rev
                Cochrane Database Syst Rev
                14651858
                10.1002/14651858
                The Cochrane Database of Systematic Reviews
                John Wiley & Sons, Ltd (Chichester, UK )
                1469-493X
                25 November 2016
                November 2016
                14 November 2016
                : 2016
                : 11
                : CD003519
                Affiliations
                Vanderbilt University deptSchool of Nursing 314 Godchaux Hall 21st Avenue South Nashville Tennessee USA 37240‐0008
                University of Cape Town deptSchool of Child and Adolescent Health, and Department of Human Biology Cape Town South Africa
                Professor Emerita, University of Florida deptCase Western Reserve University Oak Hammock at the University of Florida 5000 SW 25th Boulevard #2108 Gainesville FL USA 32608‐8901
                The University of Liverpool deptCochrane Pregnancy and Childbirth Group, Department of Women's and Children's Health First Floor, Liverpool Women's NHS Foundation Trust Crown Street Liverpool UK L8 7SS
                Article
                PMC6464366 PMC6464366 6464366 CD003519.pub4 CD003519
                10.1002/14651858.CD003519.pub4
                6464366
                27885658
                a3028a80-80ce-495e-baa7-a74ea850ee81
                Copyright © 2016 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
                History
                Categories
                Child health
                Complementary & alternative medicine
                Pregnancy & childbirth
                Care after childbirth

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