The power of touch: skin-to-skin contact and kangaroo mother care for newborns

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Source: Lindsay Mgbor/Department for International Development [CC-BY-2.0 (http://creativecommons.org/licenses/by/2.0)%5D, via Wikimedia Commons

Early skin-to-skin contact: What is it?

Early skin-to-skin contact (SSC) involves a parent (although it’s usually a mother) holding their baby to their bare chest, ideally beginning right at birth. Kangaroo mother care (KMC) goes a couple of steps further, with three parts: skin-to-skin contact, exclusive or nearly exclusive breastfeeding, and early discharge from hospital.

What is it used for?

Kangaroo mother care is often used in developing countries, where resources are in short supply, to prevent morbidity and mortality in preterm and low birth weight (LBW) babies. In developed countries, skin-to-skin contact has been proposed to have beneficial effects on breastfeeding, physiological adaptation (thermoregulation; respiratory, cardiac, and metabolic function; neurobehaviour), and behaviour (maternal-infant bonding/attachment) in healthy mother-newborn pairs.

Does it work?

Two Cochrane systematic reviews have looked at this question: one on kangaroo mother care and one on early skin-to-skin contact.

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Source: Fir0002/Flagstaffotos.com.au – http://www.flagstaffotos.com.au/, via Wikimedia Commons

Kangaroo care:

  • 18 randomized controlled trials (2,751 infants) comparing KMC and conventional neonatal care, or early and late onset KMC in LBW infants, were included.
  • There was variation in hospital conditions and implementation, but KMC was defined extremely consistently across studies.
  • At discharge or 40-41 weeks postmenstrual age, KMC was associated with reduced:
    • mortality
    • nosocomial infection/sepsis
    • hypothermia
    • length of hospital stay
  • At latest follow up, the risk of mortality and severe infection/sepsis was significantly reduced.

The authors conclude:

“The evidence from this updated review supports the use of KMC in LBW infants as an alternative to conventional neonatal care mainly in resource-limited settings.”

Early skin-to-skin contact:

  • 34 randomized controlled trials (2,177 mother-infant dyads) comparing SSC with usual hospital care were included.
  • There was a lot of variation in how SSC was implemented, in terms of duration, time initiated, and opportunity for and assistance with breastfeeding, as well as in the amount of separation experienced in the control groups, but the results consistently supported SSC.
  • Benefits included:
    • increased likelihood and length of breastfeeding at one to four months postbirth
    • improved blood glucose levels
    • improved cardio-respiratory stability in late preterm infants
  • There were no significant differences between groups in duration of breastfeeding and infant axillary temperature.

In this review, the authors concluded:

“The intervention appears to benefit breastfeeding outcomes, and cardio-respiratory stability and decrease infant crying, and has no apparent short- or long-term negative effects.”

Comment

Both reviews were well conducted, and despite heterogeneity in some of the factors related to the implementation of the intervention, consistently found moderate treatment effects supporting the use of skin-to-skin contact to improve outcomes for the infant and the mother. Neither identified any negative effects. While some of the issues like timing and technique that differed across studies may still need to be sorted out, this evidence supports early skin-to-skin contact for newborns.

As highlighted in The Lancet’s Every Newborn series, published in May 2014 in concert with UNICEF’s six month countdown to the 25th anniversary of the Convention on the Rights of the Child, one of the most effective interventions in saving newborns is kangaroo care. According to Dr. Mickey Chopra, head of UNICEF’s global health programs, “We have seen tremendous progress in saving children under five, but where the world has stumbled is with the very youngest, most vulnerable children. This group of children needs attention and resources. Focusing on the crucial period between labour and the first hours of life can exponentially increase the chances of survival for both mother and child.”

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How can we do this better?

Health care professionals – nurses, doctors, physical therapists and so on – go into their professions because they want to help people. Sometimes, however, these people find themselves in situations where, even when they are using the best available treatments, they find themselves wondering if the treatment could be done better. 

One way of answering this question is to review the available research evidence related to a particular treatment or condition. The Cochrane Collaboration has been set up to produce systematic reviews of research evidence in order to answer questions about what treatments work best. Sometimes doing this type of review will show that we don’t know enough about a treatment – in other words, more research needs to be done. Other times, it may show that there is reason to use a different treatment. 

Reviewing all the available research about a treatment can be a huge task. In some cases, there are many studies, sometimes with conclusions that contradict each other. In those situations, it can be very difficult for a health care professional to know what to conclude. However, a systematic review can help provide clarity about which treatment option is best.

In other cases, a review establishes that very little research has been done. This can encourage researchers to investigate further. This was the case for Denise Harrison, a nurse researcher in Ottawa, Ontario. Her account, which was written for the Canadian Cochrane Centre’s recent competition for stories about the impact of Cochrane reviews, follows.

How can we do this better

Source: Canadian Cochrane Centre

Helping a physician inserting an intravenous line in a tiny baby boy with chronic lung disease is where it all began. The painful procedure was just one of hundreds the baby had endured – all, or at least the large majority, performed with no pain relief. The baby cried weakly, began gasping, turned blue, then white, then grey, and as we watched his heart rate on his ECG monitor plummet down to the 40s, we stopped the procedure so we could perform resuscitation.

A key problem was the baby still had no intravenous line, so we had to start the procedure all over again. Although I had been responsible for performing probably thousands of painful procedures with no pain management on sick, hospitalized infants, this case especially caused me grief, angst, guilt and regret. My question to the physician was, “How can we do this better?”

The year was 1999. I turned to the published literature, and found a Cochrane Systematic Review of sucrose for neonatal procedural pain management (Stevens and Ohlsson, 1998). This review, the first systematic review I had ever read, included 10 RCTs (randomized controlled trials), and demonstrated that sucrose reduced pain during heel lance and venipuncture. From this point on, I could no longer do nothing to reduce sick babies’ pain.

The results of the sucrose systematic review could not simply be extrapolated to the population of sick infants in the NICU (neonatal intensive care unit) I worked in, as all infants had undergone surgery, had a history of opioid exposure, and many had congenital abnormalities. Infants with this history were excluded from all previous RCTs included in the systematic review; therefore I went on to conduct the first RCT of sucrose in infants with surgical and opioid exposure. The results were similar to the ever-growing number of other RCTs – that sucrose reduced behavioural responses during heel lance or venipuncture.

The Cochrane Systematic Review of sucrose for neonatal pain has continued to be updated, and is now one of the largest neonatal systematic reviews, including 57 trials and almost 5000 infants. However, this review only included sucrose, despite many studies evaluating the analgesic effects of other sweet solutions, especially glucose. In collaboration with the same authors of the sucrose review, and a PhD student from Brazil, we conducted a parallel systematic review of glucose for pain management for neonates. In this review, we included 38 trials with nearly 4000 neonates and concluded the same results – that glucose consistently reduced behavioural responses to procedural pain.

Then a key knowledge gap was the effectiveness of sucrose or glucose in older infants up to one year of age, then even older – in children up to 16 years. Cochrane Systematic Reviews have now been published to address sweet taste analgesia in these populations (infants up to 1 year, children 1-16 years). Today, in total, there are over 200 individual RCTs of sweet solutions for pain management in infants and one of my roles now is to try to stop the tide of placebo controlled trials of sucrose or glucose in infants. The world has the evidence. Further placebo controlled trials, especially in the neonatal population, do not tell us more. We now need to look at Cochrane for reviews informing us on best strategies to put evidence into practice; translate knowledge into action.

That first little question asked 15 years ago, “How can we do this better?”, and reviewing one Cochrane Systematic Review of just 10 RCTs, has led me down a research career path I had never intended to take and to the other side of the world to where it all started. I am happy I have helped answer my first question. We can do painful procedures better for sick or healthy, term or preterm infants by using sucrose or glucose or other effective pain management strategies based on Cochrane Systematic Reviews, namely breastfeeding (Shah et al., 2012) or skin-to-skin contact (Johnston et al., 2013). We need to continue asking the “How can we do this better?” questions, and look for Cochrane for answers – you may not only significantly improve your patients/clients outcomes, you may end up in a career you may never have dreamed about.

 

COCHRANE SUMMARIES LINKS