Plain language summary
Early skin-to-skin contact for mothers and their healthy newborn infants
Skin-to-skin contact between a mother and her baby at birth reduces crying, and helps the mother to breastfeed successfully.
In many cultures, babies are generally cradled naked on their mother's bare chest at birth. Historically, this was necessary for the baby's survival. In recent times, in some societies such as in industrialized countries more babies are born in hospital, and as part of usual hospital care babies are often separated and swaddled or dressed before being given to their mothers. It has been suggested that hospital routines may significantly disrupt early mother and baby interactions and have harmful effects. This review was done to see if there was any impact of early skin-to-skin contact between the mother and her newborn baby on infant health, behavior, and breastfeeding.
The review included 34 randomized studies involving 2177 mothers and their babies. It showed that babies exposed to skin-to-skin contact interacted more with their mothers and cried less than babies receiving usual hospital care. Mothers were more likely to breastfeed in the first one to four months, and tended to breastfeed longer, if they had early skin-to-skin contact with their babies. Babies were possibly more likely to have a good early relationship with their mothers but this was difficult to measure. The overall methodological quality of trials was mixed. There was variation in how the intervention was implemented, including the time of skin-to-skin contact started after the birth and how long it lasted, the outcomes looked at and how they were measured. No clear negative outcomes were reported in association with skin-to-skin contact.
Contact corporel précoce pour les mères et leurs nouveau-nés sains
Le contact corporel entre une mère et son bébé à la naissance réduit les pleurs et aide la mère à réussir à allaiter.
Dans de nombreuses cultures, les bébés sont généralement tenus nus sur la poitrine nue de leur mère à la naissance. Historiquement, cela était nécessaire à la survie du bébé. Dans la période récente, il est plus courant dans certaines sociétés, notamment dans les pays industrialisés, que les bébés naissent à l'hôpital et dans le cadre des soins hospitaliers usuels, les bébés sont souvent éloignés et enveloppés ou habillés avant d'être donnés à leur mère. Il a été suggéré que les routines hospitalières pouvaient perturber significativement les interactions précoces entre la mère et le bébé, et avoir des effets néfastes. Cette revue a été réalisée pour déterminer s'il existait un impact du contact corporel précoce entre la mère et son nouveau-né sur la santé, le comportement et l'allaitement du nourrisson.
La revue incluait 34 études randomisées impliquant 2 177 mères et leurs bébés. Elle a démontré que les bébés exposés à un contact corporel interagissaient davantage avec leur mère et pleuraient moins que les bébés recevant les soins hospitaliers habituels. Les mères étaient plus susceptibles d'allaiter au cours du premier au quatrième mois et avaient tendance à allaiter plus longtemps si elles avaient eu un contact corporel précoce avec leurs bébés. Les bébés étaient peut-être plus susceptibles d'entretenir précocement une bonne relation avec leur mère, mais cela a été difficile à mesurer. Globalement, les essais étaient de qualité méthodologique diverse. On a observé des variations dans la manière dont l'intervention était mise en œuvre, notamment le moment du contact corporel après la naissance et sa durée, dans les critères d'évaluation examinés et dans la manière dont ils étaient mesurés. Aucun critère d'évaluation négatif clair associé au contact corporel n'a été signalé.
Notes de traduction
Traduit par: French Cochrane Centre 8th June, 2012
Traduction financée par: Ministère du Travail, de l'Emploi et de la Santé Français
本摘要由重庆医科大学中国循证卫生保健协作网（China Effective Health Care Network）翻译。
Translated by: China Effective Health Care Network
翻譯: East Asian Cochrane Alliance
Резюме на простом языке
Ранний контакт кожа-к-коже для матерей и их здоровых новорожденных
Контакт кожа-к-коже между матерью и ее ребенком при рождении снижает плач, и помогает матери успешно вскармливать грудью.
Во многих культурах, детей, как правило, прижимали голыми к обнаженной груди матери сразу же после их рождения. Исторически сложилось так, что это было необходимо для выживания ребенка. В последнее время, в некоторых обществах, таких как промышленно развитые страны, больше детей рождаются в больнице, и в условиях обычной стационарной (госпитальной) помощи младенцы часто разделены с матерью, их пеленают или одевают перед тем, Â как отдать их матерям. Было предположено, что эта госпитальная рутинная практика может существенно нарушить раннее взаимодействие междуÂ матерью и ребенком и оказать вредное воздействие. Этот обзор был проведен, чтобы определить, имеет ли какое-либо влияние ранний контакт кожа-к-коже между матерью и ее новорожденным ребенком на здоровье ребенка, поведение и грудное вскармливание.
В этот обзор были включены 34 рандомизированных исследования с участием 2177 матерей и их детей. Было показано, что младенцы, которым позволили контакт кожа-к-коже, больше взаимодействовали со своими матерями и плакали меньше, чем младенцы, которые получали обычную стационарную (госпитальную) помощь. Матери, более вероятно,кормили бы грудью в первые 1-4 месяца, и были бы склонны кормить грудью дольше, если бы у них был ранний контакт кожа-к-коже с их младенцами. Младенцы, возможно, более вероятно, имели бы хорошие ранние взаимоотношения со своими матерями, но это было трудно оценить. В целом, методологическое Â качество испытаний было неоднозначным. Были различия в том, как это вмешательство было реализовано, в том числе по времени начала контакта кожа-к-коже после рождения и его продолжительности, какие исходы были рассмотрены и как их оценивали. Никаких четких негативных последствий (отрицательных исходов), связанных с контактом кожа-к-коже, не было зарегистрировано.
Заметки по переводу
Перевод: Хазиахметова Вероника Николаевна.
Редактирование: Юдина Екатерина Викторовна, Зиганшина Лилия Евгеньевна.
Координация проекта по переводу на русский язык: Казанский федеральный университет.
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Перевод: Russian translation team
母親とその新生児の出生時のskin-to-skin contactにより、泣くことが少なくなり、母乳哺育の確立に役立つ。 多くの文化では、新生児は出生時に裸で母親の裸の胸に抱かれるのが一般的である。歴史的にこれは新生児の生存に必要なことであった。最近、先進国などの一部の国では病院で出生する新生児が増加し、通常の院内ケアの一部として、新生児は母親から離され母親に渡される前に、布にくるまれたり服を着せられたりすることが多い。病院のルーチンのケアにより母親と新生児の早期の相互作用が非常に妨げられ、有害な影響を及ぼしていると示唆されている。本レビューは、母親とその新生児との早期skin-to-skin contactが子どもの健康、行動および母乳哺育に及ぼす影響があるか検討するために実施した。 2,177名の母親と新生児を対象とした34件のランダム化試験を本レビューに選択した。通常の院内ケアを受けた新生児に比べて、早期接触を受けた新生児の方が母親とより相互作用があり、泣くことが少なかったことが示された。早期skin-to-skin contactを行った母親の方が生後1～4ヵ月に母乳哺育を行う可能性が高く、長期にわたり母乳哺育を行う傾向があった。子どもは母親と早期に良好な関係を持つ可能性が高かったが、これを測定するのは困難であった。全体として試験の方法論的質は混合していた。生後のskin-to-skin contact開始時期と持続期間などの介入の実施方法、検討したアウトカムとその測定方法にばらつきがみられた。skin-to-skin contactに関連した明らかな負のアウトカムは報告されなかった。
監 訳: 江藤 宏美,2012.9.27
ご注意 : この日本語訳は、臨床医、疫学研究者などによる翻訳のチェックを受けて公開していますが、訳語の間違いなどお気づきの点がございましたら、Minds事務局までご連絡ください。Mindsでは最新版の日本語訳を掲載するよう努めておりますが、編集作業に伴うタイム・ラグが生じている場合もあります。ご利用に際しては、最新版（英語版）の内容をご確認ください。
Ringkasan bahasa mudah
Hubungan awal kulit-ke-kulit di antara ibu dan bayi sihat yang baru lahir.
Hubungan awal kulit-ke-kulit di antara ibu dan bayi ketika lahir akan mengurangkan tangisan bayi, dan membantu ibu menyusu dengan senang.
Dalam banyak budaya, bayi biasanya dihamparkan bogel di dada ibu mereka yang terdedah sebaik selepas dilahirkan. Dari segi sejarah, ini adalah amat diperlukan untuk kehidupan bayi. Baru-baru ini, dalam beberapa golongan masyarakat,terutamanya di negara-negara berasaskan perindustrian, bayi dilahirkan di hospital, dan sebahagian daripadanya dibiarkan dalam penjagaan hospital serta sering dipisahkan dan dibebat dengan lampin atau diberi pakaian sebelum diberikan kepada ibu-ibu mereka. Kebiasaan hospital ini dengan ketaranya boleh mengganggu perhubungan serta interaksi awal ibu dan bayi serta mempunyai kesan buruk bagi kedua-dua pihak. Kajian sistematik ini dilakukan untuk melihat jika terdapat apa-apa kesan hubungan awal kulit-ke-kulit antara ibu dan bayi yang baru lahir pada kesihatan bayi, tingkah laku, dan penyusuan.
Kajian ini merangkumi 34 percubaan rawak yang melibatkan 2177 ibu dan bayi-bayi mereka. Kajian ini menunjukkan bahawa bayi yang terdedah kepada hubungan kulit-ke-kulit dengan ibunya menunjukkan interaksi dengan ibu mereka dan kurang menangis berbanding dengan bayi yang menerima rawatan biasa di hospital. Ibu-ibu lebih cenderung untuk menyusu dalam satu sehingga empat bulan yang pertama dan cenderung untuk menyambung penyusuan jika mereka mempunyai hubungan awal kulit-ke-kulit dengan bayi mereka. Bayi-bayi ini mungkin lebih cenderung untuk mempunyai hubungan awal yang baik dengan ibu-ibu mereka tetapi tahap hubungan ini sukar untuk diukur. Keseluruhan kualiti metodologi bagi ujian ini adalah bercampuran. Terdapat beberapa variasi dalam bagaimana intervensi ini telah dilaksanakan, termasuk masa hubungan kulit-ke-kulit bermula selepas kelahiran dan berapa lama ia berlangsung, cara mengukur dan mengenalpasti hasilnya. Tiada kesan negatif yang jelas dilaporkan dalam kes-kes berkaitan dengan hubungan kulit-ke-kulit ini.
Diterjemahkan oleh: Teguh Haryo Sasongko dan Rajasunthari Thambiraja
Terjemahan dibiayai oleh: Kumpulan Cochrane Universiti Sains Malaysia
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Rani kontakt kožom na kožu majki i zdrave novorođenčadi
Dodir kožom na kožu između majke i njenog djeteta pri rođenju smanjuje djetetovo plakanje i pomaže majci u uspješnom dojenju.
U mnogim je kulturama uobičajeno da majke drže djecu na golim prsima neposredno nakon porođaja. Povijesno gledajući, ovo je bilo nužno za djetetovo preživljenje. U današnje vrijeme veći se broj djece rađa u bolnicama, te se kao dio uobičajenog postupka odvajaju od majke kako bi ih previli u pelene i obukli, te ih zatim vratili majkama. Pretpostavlja se kako je moguće da te bolničke rutine mogu značajno poremetiti rane odnose majke i djeteta i imati štetne učinke. Cilj ovog sustavnog pregleda bio je ustanoviti ima li rani kontakt kožom na kožu između majke i njenog novorođenčeta utjecaj na zdravlje i ponašanje djeteta, kao i na dojenje.
Pregledom su obuhvaćene 34 randomizirane studije koje su uključivale 2177 majki i njihovu novorođenčad. Pokazano je kako novorođenčad izložena kontaktu kožom na kožu više komunicira sa majkom i u prosjeku plače manje od novorođenčadi koja prima uobičajenu bolničku skrb. Veća je bila i vjerojatnost da će majke dojiti u prva četiri mjeseca i da će razdoblje dojenja biti sveukupno duže, ako su imale rani kontakt kožom na kožu sa svojom djecom. Rani odnos između majke i djeteta je također bio bolji, no ovaj ishod je teško točno izmjeriti. Sveukupna kvaliteta korištenih metoda je raznolika. Načini primjene intervencija nisu bili jednaki u svim istraživanjima (uključujući vrijeme kada je kontakt kožom na kožu započeo nakon rođenja i sama duljina trajanja kontakta), kao i promatrani ishodi i načini njihova mjerenja. Nije bilo negativnih ishoda povezanih s kontaktom kožom na kožu.
Prevela: Ružica Tokalić
Ovaj sažetak preveden je u okviru volonterskog projekta prevođenja Cochrane sažetaka. Uključite se u projekt i pomozite nam u prevođenju brojnih preostalih Cochrane sažetaka koji su još uvijek dostupni samo na engleskom jeziku. Kontakt: email@example.com
Resumo para leigos
Contato pele a pele precoce entre a mãe e seus recém-nascidos saudáveis
O contato pele a pele entre a mãe e seu bebê ao nascer reduz o choro e ajuda a mãe a amamentar com sucesso.
Em muitas culturas, os bebês são aconchegados nus sobre o peito nu das suas mães assim que nascem. Historicamente, isso era necessário para a sobrevivência do bebê. Em tempos recentes, em algumas sociedades, como as dos países industrializados, mais bebês nascem nos hospitais e, como parte dos cuidados hospitalares aos bebês, eles são geralmente separados e enfaixados ou vestidos antes de serem entregues às mães. Tem sido sugerido que as rotinas hospitalares podem atrapalhar de forma significativa as primeiras interações entre as mães e seus filhos e ter efeitos danosos. Esta revisão foi realizada para verificar se havia algum impacto do contato pele a pele entre a mãe e seu recém-nascido na saúde, no comportamento do bebê e na amamentação.
A revisão incluiu 34 estudos randomizados envolvendo 2.177 mães e seus bebês. A conclusão foi que os bebês expostos precocemente ao contato pele a pele interagiram mais com suas mães e choraram menos do que os bebês que receberam cuidados hospitalares usuais. As mães que tiveram contato precoce pele a pele com seus bebês eram mais propensas a amamentar nos primeiros quatro meses e mais propensas a amamentar por mais tempo. É possível que os bebês tenham tido maior probabilidade de ter um bom relacionamento inicial com suas mães, mas isso foi difícil de mensurar. A qualidade metodológica dos estudos em geral foi mista. Houve variação entre os estudos na forma de implementar a intervenção, incluindo o momento exato depois do nascimento quando o contato pele a pele foi iniciado e sua duração, e também na forma de medir os desfechos. Não foi relatado nenhum desfecho claramente negativo associado ao contato pele a pele.
Notas de tradução
Tradução do Centro Cochrane do Brasil (Maíra T. Parra).
Früher Haut-zu-Haut - Kontakt zwischen Müttern und ihren gesunden Neugeborenen
Hautkontakt zwischen Mutter und ihrem Säugling verringert Weinen und hilft der Mutter erfolgreich zu stillen.
In vielen Kulturen umsorgen Mütter ihre Babies direkt nach der Geburt generell nackt auf ihrer entblößten Brust. Dies war früher für das Überleben des Säuglings notwendig. Heutzutage werden besonders in industrialisierten Ländern Babies meist in Krankenhäusern geboren, und im Rahmen der üblichen Pflege häufig von der Mutter entfernt umgewickelt und angezogen, ehe sie der Mutter gegeben werden. Es weist einiges darauf hin, dass dieses routinemäßige Vorgehen die frühen Mutter-Kind Interaktionen signifikant stört und nachteilige Folgen haben kann. Dieser Review wurde durchgeführt um festzustellen, ob ein Einfluss von frühem Haut-zu-Haut-Kontakt zwischen der Mutter und ihrem Neugeborenen, auf Säuglingsgesundheit, Verhalten und Stillen besteht.
Der Review beinhaltet 34 randomisierte Studien mit 2177 Müttern und ihren Säuglingen. Es wurde gezeigt, dass Säuglinge mit Haut-zu-Haut-Kontakt mehr mit ihren Müttern interagierten und weniger weinten als solche, welche die normale Krankenhauspflege erhielten. Wenn Mütter frühen Haut-zu-Haut-Kontakt mit ihren Säuglingen hatten, war es wahrscheinlicher, dass sie zwischen dem ersten und vierten Monat, und auch darüberhinaus, stillten, Möglicherweise hatten Säuglinge eher eine gute frühe Beziehung zu ihren Müttern, dies war allerdings schwierig zu messen. Die Gesamtqualität der Studien war unterschiedlich. Die Interventionen wurden unterschiedlich durchgeführt, hinsichtlich der Zeitspanne zwischen Haut-zu-Haut-Kontakt und Geburt, wie lange der Kontakte dauerte. Es gab Unterschiede in den untersuchten Endpunkten und darin, wie diese gemessen wurden. Es wurden keine deutlich negativen Endpunkte im Zusammenhang mit Haut-zu-Haut-Kontakt berichtet.
Anmerkungen zur Übersetzung
L. Hamminger, freigegeben durch Cochrane Schweiz und Cochrane Deutschland.
Description of the condition
In humans, routine mother-infant separation shortly after birth is unique to the 20th century. This practice diverges from evolutionary history, where neonatal survival depended on close and virtually continuous maternal contact. Although from an evolutionary perspective skin-to-skin contact (SSC) is the norm, separating the newborn from its mother soon after birth has now become common practice in many industrialized societies. Therefore, for the purpose of this review, SSC has to be the experimental intervention. Ironically, and importantly, the experimental intervention in studies with all other mammals is to separate newborns from their mothers.
Description of the intervention
Early SSC is the placing of the naked baby prone on the mother's bare chest at birth or soon afterwards. In the evolutionary context, this would have been "immediate and continuous". In the current care context, initiation and duration are not defined. The concept of "care" does not change; only the place where such care is provided changes. Further, although a dose-response effect has not been documented in randomized controlled trials (RCTs), the general belief is that SSC should continue until the end of the first successful breastfeeding to show an effect and to enhance early infant self-regulation (Widstrom 2011).
How the intervention might work
The rationale for SSC comes from animal studies in which some of the innate behaviors of neonates that are necessary for survival are shown to be habitat dependent (Alberts 1994). In mammalian biology, maintenance of the maternal milieu following birth is required to elicit innate behaviors from the neonate and the mother that lead to successful breastfeeding, and thus survival. Separation from this milieu results in immediate distress cries (Alberts 1994) and "protest-despair" behavior. Human infants placed in a cot cry 10 times more than SSC infants.Their cry is similar to the vocalizations of separated rat pups (Michelsson 1996). In rodent studies, the pups who had the least attentive contact from their mothers were the ones whose health and intelligence were compromised across the lifespan (Francis 1999; Liu 1997; Liu 2000; Meaney 2005; Plotsky 2005). Also in the report by Liu 2000 a cross-fostering study provided evidence for a direct relationship between maternal behavior and hippocampal development in the offspring.
Healthy, full term infants employ a species-specific set of innate behaviors immediately following delivery when placed in SSC with the mother (Righard 1990; Varendi 1994; Varendi 1998; Widstrom 1987; Widstrom 1990). They localize the nipple by smell and have a heightened response to odor cues in the first few hours after birth (Porter 1999; Varendi 1994; Varendi 1997). More recently Widstrom 2011 described the sequence of nine innate behaviors as the birth cry, relaxation, awakening and opening the eyes, activity (looking at the mother and breast, rooting, hand to mouth movements, soliciting sounds), a second resting phase, crawling towards the nipple, touching and licking the nipple, suckling at the breast and finally falling asleep. This 'sensitive period' predisposes or primes mothers and infants to develop a synchronous reciprocal interaction pattern, provided they are together and in intimate contact. Infants who are allowed uninterrupted SSC immediately after birth and who self-attach to the mother's nipple may continue to nurse more effectively. Effective nursing increases milk production and infant weight gain (De Carvalho 1983; Dewey 2003). Anderson 2004a used SSC as an intervention for 48 healthy mother/full term infant dyads with breastfeeding problems identified between 12 to 24 hours postbirth. SSC was provided during the next three consecutive breastfeedings. Breastfeeding was successful, even in this racially disparate sample (Chiu 2008) and was exclusive in 81% of these dyads at hospital discharge, 73% at one week, and 52% at one month postbirth. Temperatures were taken before (baseline), during, and after each SSC breastfeeding. Baseline temperatures reached, and remained in thermoneutral range (Chiu 2005) suggesting that mothers have the ability to modulate infant temperature if given the opportunity to breastfeed in SSC. Because these mothers and their infants were having breastfeeding difficulties, hospital staff and parents can logically be reassured that healthy newborn infants, with or without breastfeeding difficulties, may safely breastfeed in SSC so far as temperature is concerned. In a study of infrared thermography of the whole body during the first hour postbirth, Christidis 2003 found that SSC was as effective as radiant warmers in preventing heat loss in healthy full term infants.
SSC through sensory stimuli such as touch, warmth, and odor is a powerful vagal stimulant, which among other effects releases maternal oxytocin (Uvnas-Moberg 1998; Winberg 2005). Oxytocin causes the skin temperature of the mother's breast to rise, providing warmth to the infant (Uvnas-Moberg 1996). When operating in a safe environment, oxytocin, and direct SSC stimulation of vagal efferents, are probably part of a broader neuro-endocrine milieu (Porges 2007). 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 (McEwen 1998; Shannon 2007). 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 found 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).
Oxytocin antagonizes the flight-fight effect, decreasing maternal anxiety and increasing calmness and social responsiveness (Uvnas-Moberg 2005). During the early hours after birth, oxytocin may also enhance parenting behaviors (Uvnas-Moberg 1998; Winberg 2005). SSC outcomes for mothers suggest improved bonding/attachment (Affonso 1989); 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 (Dennis 1999). Women with low breastfeeding confidence have three times the risk of early weaning (O'Campo 1992) and low confidence is also associated with perceived insufficient milk supply (Hill 1996).
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 (Dordevic 2008) and more rapid delivery of the placenta (Marin 2010).
In previous meta-analyses with full term infants, early contact was associated with continued breastfeeding (Bernard-Bonnin 1989; Inch 1989; Perez-Escamilla 1994). Just altering hospital routines can increase breastfeeding levels in the developed world (Rogers 1997). 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. 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. SSC mothers were more satisfied with the method of care, and more likely to be exclusively breastfeeding at hospital discharge. In another meta-analysis of 24 studies (13 case-series, five RCT's, one cross-over and four cohort), Mori 2010 evaluated outcomes in both low and normal birthweight infants up to 28 days old. Infant body temperature increased 0.22 ºC during and 0.14 ºC after SSC (P < 0.001, 21 studies); heart rate increased 2.04 beats per minute (bpm) during (P = 0.05) and decreased 0.07 bpm after SSC (P = 0.95, 12 studies); oxygen saturation decreased 0.60% (three/fifths of 1%) during (P = 0.01) and 0.48% (essentially one-half of 1%) after SSC (P = 0.06, 10 studies). These decreases in oxygen saturation are too small to be of clinical significance.
Why it is important to do this review
Separation of mothers from their newborn infants at birth has become standard practice, despite mounting evidence that this may have harmful effects. However, delivery room and postpartum hospital routines may significantly disrupt early maternal-infant interactions including breastfeeding (Anderson 2004a; Odent 2001; Winberg 1995). The possibility exists that postnatal separation of human infants from their mothers is stressful (Anderson 1995) and might result in harmful effects that persist across the lifespan, if the studies with laboratory animals cited earlier hold true for humans. This possibility needs careful evaluation using the allostatic theoretical framework (McEwen 1998) as well as new epigenetic findings (Meaney 2005).
A concurrent widespread decline in breastfeeding is of major public health concern. Although more women are initiating breastfeeding, fewer are breastfeeding exclusively. Using data from the Infant Feeding Practices Study II conducted in the United States by the Food and Drug Administration in 2005 to 2007, Grummer-Strawn 2008 found that 83% of mothers initiated breastfeeding, but only 48% exclusively breastfed during their hospital stay. These innate behaviors can be disrupted by early postpartum hospital routines as shown experimentally by Widstrom 1990 and in descriptive studies by Gomez 1998; Jansson 1995 and Righard 1990. Gomez 1998 found that infants were eight times more likely to breastfeed spontaneously if they spent more than 50 minutes in SSC with their mothers immediately after birth, and concluded that the dose of SSC might be an essential component regarding breastfeeding success. Bramson 2010 showed a clear dose-response relationship between SSC in the first three hours postbirth and exclusive breastfeeding at discharge in a large (N = 21,842 mothers) hospital-based cohort study, (odds ratio (OR) for exclusive breastfeeding = 1.665 if in SSC for 16 to 30 minutes, and OR = 3.145 for more than 60 minutes of SSC).
The purpose of this review is to examine the available evidence of the effects of early SSC on breastfeeding exclusivity and duration and other outcomes in mothers and their healthy full term and late preterm newborn infants. Although our intent is to examine all clinically important outcomes, breastfeeding is the predominant outcome investigated so far in healthy newborns. Hence, our emphasis is on breastfeeding, although we also will examine maternal-infant physiology and behavior. Because the focus of this review is on mothers and their healthy infants, potential effects of early SSC on father-infant attachment and also the resistance of staff to this intervention are beyond the scope of this review. Maternal feelings about early SSC and satisfaction with the birth experience are important and relevant but require more qualitative methods. The focus of this review is on randomized controlled trials used to test the effects of early SSC. This is an update of a Cochrane review first published in 2003 and previously updated in 2007.
To assess the effects of early skin-to-skin contact for healthy newborn infants compared to standard contact (infants held swaddled or dressed in their mothers arms, placed in open cribs or under radiant warmers).
The three main outcome categories include:
a) establishment and maintenance of breastfeeding/lactation;
b) infant physiology - thermoregulation, respiratory, cardiac, metabolic function, neurobehavior;
c) maternal-infant bonding/attachment.
Summary of main results
The results of this review demonstrated a statistically significant positive effect of skin-to-skin contact (SSC) on the following primary outcomes: breastfeeding one month to four months postbirth, SCRIP score first six hours postbirth, and blood glucose mg/dL at 75 to 90 minutes postbirth, We did not identify significant between group differences in duration of breastfeeding, and results relating to infant axillary temperature at 90 minutes to two hours 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 (IBFAT score), mean variation in maternal breast temperature 30 to 120 minutes postbirth, infant did not exceed physiological parameters for stability, number of babies not crying for more than one minute during a 90-minute observation, amount of crying in minutes during a 75-minute observation period and PCERA dyadic mutuality and reciprocity 12 months postbirth. We did not identify significant between group differences in successful first breastfeeding (IBFAT score 10 to 12 or BAT score 8 to 12), infant heart rate 75 minutes to two hours postbirth, infant respiratory rate 75 minutes to two hours postbirth, infant body weight change (grams) day 14 postbirth, transfers to the neonatal intensive care unit, infant hospital length of stay in hours, or PCERA maternal positive affective involvement and responsiveness 12 months postbirth.
No negative outcomes associated with SSC were reported in any of the studies except Sosa 1976a, who reported a longer duration of breastfeeding in the control group.
In summation, the totality of significant outcomes relating to breastfeeding, 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.
Only two breastfeeding meta-analyses contained more that three studies. Thirteen studies (702 infants) reported breastfeeding rates between one and four months postbirth (Analysis 1.1) demonstrating that mothers in the SSC group were more likely to be breastfeeding than those in the control group. The only other outcome with more than three studies (seven studies, 324 infants) was breastfeeding duration (Analysis 1.2). Infants in the SSC group breastfed an average of 42.55 days longer than control infants and when a study with inconsistent results was removed from the analysis the difference between groups was statistically significant. Evidence for breastfeeding exclusivity was conflicting, being no different at hospital discharge (Analysis 1.7, 2 studies) but significantly greater at three to six months postbirth (Analysis 1.9, three studies).The findings of improved breastfeeding for the two largest meta-analyses in this review were obtained in diverse countries and among women of low and high socio-economic class.
Results for IBFAT scores for the first breastfeeding postbirth were conflicting with one meta-analysis which treated this outcome as a dichotomous variable (Analysis 1.12) demonstrating no significant between group differences and another meta-analysis which used interval level data (Analysis 1.11) finding a significant effect of early SSC. Moore 2005 also found that SSC and the mother's nipple protractility contributed equally to the variance in infant IBFAT scores.The mother's nipple protractility was important in relation to the infant's ability to establish competent suckling. Dewey 2003 reported that suboptimal breastfeeding behavior during the first 24 hours postbirth was associated with the mother's flat or inverted nipples (RR 1.56). These infants were also 2.6 times more likely to have excessive weight loss.
Timing of when this outcome is measured may be critical because most healthy full term infants spontaneously grasp the nipple and begin to suckle by approximately 55 minutes postbirth. During the first 30 minutes, they may only lick the nipple. Widstrom 2011 found that some infants may take up to 45 minutes to latch after crawling towards and reaching the nipple and recommended that this process should not be disturbed or forced. Also, the intervention will be more successful if a clinician reassures the mother that healthy full term babies are able to crawl to the breast and begin to nurse on their own without assistance when they are ready. After the first two hours postbirth, infants often become sleepy and difficult to arouse.
Babies breastfed more successfully during SSC immediately postbirth than if they were held swaddled in blankets, 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 2004; Carfoot 2005). 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. 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 (Mizuno 2004).
Moore 2005 suggested that barriers to long-term breastfeeding that exist in the United States, especially the customary absence of, or very brief, paid maternity leave, attenuated the effectiveness of early SSC on breastfeeding status day 28 to one month postbirth (Analysis 1.8). The mothers in Punthmatharith 2001 delivered in a Baby Friendly Hospital in Thailand with 24-hour rooming-in. Control infants were cup fed if they needed supplementation. In addition, most of the SSC took place in extremely warm, un-air conditioned eight-bed postpartum rooms with frequent visitors so that contextual issues, such as body warmth and modesty, may have changed SSC desirability and also effectiveness.
Such factors as room temperature, lack of privacy, modesty, overcrowding, supplemental bottle or pacifier use, and 24-hour rooming-in may play a role in the effectiveness of SSC. Early SSC may not have as strong an effect on long-term breastfeeding in countries with a widespread bottle feeding culture compared to countries with cultures that are supportive of breastfeeding. In the studies by Carfoot 2004, Carfoot 2005 ,and Moore 2005, mothers in the control group received extra assistance with breastfeeding, which is not always available with usual hospital care. In Moore 2005, the investigator was an experienced lactation consultant who assisted mothers in both groups with initiating breastfeeding. In Carfoot 2005, the midwife usually provided breastfeeding assistance, but if she was unavailable, the research assistant often provided help with breastfeeding. More definitive results might have been obtained if the control groups received only usual hospital care.
Infant physiological/behavioral outcomes
The between-group differences in SCRIP scores and maintenance of physiological parameters in late preterm infants is certainly clinically significant, especially given the fact that SSC was compared with a servo-controlled incubator. The clinical significance of some of the other physiological outcomes for healthy full term infants is debatable. Full term infants in the SSC group were less than one degree warmer than control infants.Their heart rate was three BPM slower and their respiratory rate was three breaths less per minute, on average. However, their blood glucose was 10.56 mg/dL higher, a significant finding.The results suggest that early SSC is a safe intervention for healthy infants and that it may increase cardio-respiratory stability, thermal stability, and blood glucose in late preterm infants. Lagercrantz 1986 and Lagercrantz 1996 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. However, this response may become maladaptive if allowed to continue.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 allostasis, 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.
The large between-group difference in the amount of crying is certainly clinically significant. Anderson 1989 proposed an evidence-based rationale that maternal-infant separation is associated with excessive infant crying and can be harmful because crying re-establishes portions of the fetal circulation. Each cry cycle causes a bolus of desaturated venous blood to shunt through the foramen ovale into the systemic circulation instead of the lungs, creating hypoxemia. This may result in delayed closure of the foramen ovale or explain the approximately 20% incidence in apparently normal adults of a permanently patent foramen ovale (estimates in numerous recent studies range from 15% to 35% (Del Sette 1998). Anderson 1989 further proposed that crying wastes calories meant for growth, and causes increased and fluctuating cerebral blood flow, cerebral blood flow velocity, and intracranial pressure, thereby increasing the risk of intraventricular hemorrhage in preterm infants. Consequences for healthy full term infants are unknown, but may be similar and correlated with gestational age.
The results of this analysis indicate that SSC may affect maternal attachment behaviors, although the results are mixed. A dose-response relationship may exist as well.
Bystrova 2003 found significant between group differences on two of the eight subscales of the PCERA at 12 months postbirth. The effects of rooming-in on these outcomes did not compensate for a short (120 minutes) period of separation.
These findings would make sense from the perspective of programming (Lucas 2005) and early evolution, where human mothers would be expected to form a rapid attachment to their infants to protect them from predators and to provide the high level of parental care necessary for such physiologically immature newborns. However, it is important to document how many infants in the SSC group breastfed and how effectively they nursed. Breastfeeding during SSC stimulates the secretion of hormones such as oxytocin that promote maternal attachment and prolactin which promotes lactation and, at least in rodents, maternal behavior. Breastfeeding has been considered an integral part of the intervention in Kangaroo Mother Care research in low- and middle-income countries. In this review, breastfeeding has been considered an outcome and SSC the habitat that elicits this outcome. However, mothers would logically nurse their infants soon after birth in early human evolution. Early and effective breastfeeding while in SSC may increase the strength of this intervention with respect to maternal attachment behaviors.
Overall completeness and applicability of evidence
The available evidence does address the review question, but seldom abides by any clear definition of acceptable public health breastfeeding outcomes. Only Anderson 2003; Moore 2005; Punthmatharith 2001;and Shiau 1997 used breastfeeding status (Labbok 1990) to measure the degree of breastfeeding exclusivity. In all the other studies, breastfeeding was considered a dichotomous variable. The infant was either breastfeeding (yes/no) or exclusively breastfeeding (yes/no). Further, the actual intervention in terms of timing and duration of SSC was highly variable, and at times very short. Despite this, the evidence is fairly consistent in supporting the effect of SSC in so far as the findings are numerous and pooled findings were consistently in favor of SSC and show moderate effects. However, for many outcomes findings were from individual studies: the variety of outcomes measured and the lack of consistency in the way outcomes were measured meant that meta-analysis was not appropriate.
The high levels of heterogeneity between studies could possibly reflect bias with selective outcome reporting, with data reported on the basis of post-hoc observations rather than predefined public health outcomes. Another possible source of bias concerns the quality of breastfeeding support provided, and whether this was controlled for adequately between groups. In some instances, co-interventions were added to SSC that make it difficult to disentangle the effects of SSC from the other interventions.
The variability in outcomes reported, instruments used, context, and timing made it difficult to combine many of the attachment outcomes for meta-analysis. Because of these methodological limitations, the overall quality of the evidence is again considered moderate.
Quality of the evidence
The presently available evidence has a number of limitations.
(1) Design limitations
All studies were randomized controlled trials. However, the methodological quality of trials was mixed. Overall, the quality of reporting on study methods was poor. For the majority of trials we did not have sufficient information on the methods used to carry out randomization to allow us to assess whether findings were at high risk of bias. A particular problem in all of the included studies was the lack of blinding. SSC cannot be implemented masked, but the assessment of physiologic changes or outcomes can often be carried out by individuals masked to allocation but overall it is very difficult to judge the impact of lack of blinding or only partial blinding on findings. It is possible that differences in the care women received in SSC and control groups were not confined to whether or not they had early SSC. In some studies the staff providing care to the two groups were different, and in these cases it is possible that the overall care experience for women in different arms of trials was not the same, and it may be that aspects of care other than, or in addition to, SSC led to reported differences between groups. This may have been compounded by the fact that in some studies the same staff delivering interventions also measured outcomes. Outcomes such as observed maternal and infant behavior may have been susceptible to detection bias. The impact of lack of blinding may have been less for some of the outcomes measured, for example, some infant physiological outcomes however, even outcomes such as infant temperature may be affected by bias in staff collecting outcome data.
(2) Outcome variability
Meta-analysis was limited in this review, due to the numerous outcomes and the limited number of randomized trials that could be included for each outcome. Although many of the studies measured broadly similar outcomes, the outcomes were too dissimilar to be included in a meta-analysis. In some studies, means were reported without standard deviations, or exact P values, or both. The context, the instruments used, and the timing of the measurement of attachment and temperature outcomes varied greatly among studies. Breastfeeding was measured as a dichotomous variable in some studies or as an interval level measure of breastfeeding exclusivity in four. Modality for measurement of temperature outcomes varied between studies. These contextual and measurement differences should be noted when considering the results of the review.
Potential biases in the review process
We are aware that the review process may be affected by bias; and we attempted to minimize bias in a number of ways. At least two review authors independently assessed study eligibility, carried out data extraction, and assessed risk of bias. However, some aspects of the review process involve subjective judgements: assessing risk of bias in included studies, for example, is not an exact science, and it is possible that a different review team may have reached different conclusions about the quality of the evidence. We have attempted to explain our decisions regarding study quality in the 'Risk of bias' tables. We have also provided details about the participants and interventions in individual studies and we would encourage readers to interpret results in the light of the information set out in the Characteristics of included studies tables.
Agreements and disagreements with other studies or reviews
The findings are in general agreement with results from other studies mentioned in this review notably Bramson 2010. This large hospital-based study (n = 21,842) demonstrated a clear dose-response effect on exclusive breastfeeding at hospital discharge. The data from this review, although suggestive, are inadequate to demonstrate a dose-response effect. Although the modality and timing of measurement of infant temperature varied between studies, this review found minimal increases in temperature with SSC although the results were often not statistically significant. These results support those obtained Mori 2010 who found a mean increase of 0.22 degrees C. in a meta-analysis of 21 studies of infant temperature pre SSC compared with during the intervention. Mori 2010 found an increase in infant heart rate of 2.04 BPM in a meta-analysis of 12 studies of preterm infants pre versus during SSC. The process of transferring a preterm infant from a radiant warmer or isolette to SSC and back again can be somewhat stressful and may account for these findings. The length of SSC in some of the included studies was very short, 15 minutes in one study, 30 minutes in another. This review found a decrease in infant heart rate of 3.05 in between group comparisons of early SSC with usual care. However, the findings were not clinically significant. We assess the methodological quality of the evidence as moderate because these studies have the same limitations as those with breastfeeding outcomes; small samples, varied contexts and heterogenous outcomes.
We thank Dr Busakorn Punthmatharith for her contributions during the earliest phases of the literature review; Dr Mark W Lipsey for his assistance with the categorization of outcome measures for meta-analysis; and Dr Joseph Hepworth for his statistical assistance with the original review. We would also like to thank Anna Fangrath and Lindsay Irish for the English translation of Kastner 2005 and Dr Sheau-Huey Chiu and Danni Li for the translation of Huang 2006. Dr Moore would like to thank Angela Aaron, Ashley Arnold, Candice Bruce, Erin DeBruyn, Monique Deterville, Erin Empting, Kristen McGriff, Jaclyn Miller, Shaunna Parker, Lindsay Piper, Carrie Schrimsher, Lucie Slapnicka, Anna Storvick and Melissa Young, former Women's Health Nurse Practitioner students at Vanderbilt University School of Nursing, for their assistance with reviewing the articles for the updated review, and with completing the Characteristics of included studies tables under the careful supervision and with the guidance of Dr Moore.
Appendix 1. The International Network for Kangaroo Mother Care
The International Network maintains a bibliography of all the research articles published on Kangaroo Mother Care. The bibliography is available from Dr Susan Ludington - Susan.ludington@.case.edu
Appendix 2. Methods used to assess trials included in previous versions of this review
Each study that we identified as a result of the search strategy was evaluated independently for inclusion in the review by two review authors. We rejected trials without a concurrent control group (e.g. those with historical controls). We included relatively high quality quasi-randomized studies in the review. If the assignment to groups appeared to create equivalent groups, then the study was included even if a truly random process was not used for group assignment. For example, if women were alternately assigned to treatment and control groups and there was no reason to think that this should result in nonequivalent groups, that study was included. On the other hand, if assignment to groups was based on woman or provider preference, the study was excluded. Studies conducted by each of the three authors were reviewed for inclusion by the other two authors and a consensus was reached regarding inclusion of these studies in the review. Methods used for generation of the randomization sequence were described for each trial.
Each identified trial was assessed for methodological quality with respect to (1) selection bias, (2) attrition bias, and (3) performance bias. We assigned a quality score for each trial, using the following criteria.
(1) Selection bias (allocation concealment)
(A) Adequate concealment of allocation: centralized randomization, sequentially-numbered, sealed opaque envelopes, computerized minimization technique;
(B) unclear whether adequate concealment of allocation: sealed envelopes but not sequentially numbered or opaque, a trial in which description suggests adequate concealment but other features suspicious, e.g. markedly different treatment and control groups, stated random but unable to obtain further details;
(C) inadequate concealment of allocation: any allocation procedure transparent before assignment, such as open list of random-number tables, use of case record numbers, dates of birth or days of the week.
(2) Attrition bias
We assessed completeness to follow up using the following criteria: complete follow up of all study participants/reasons given for attrition/NSD between participants who terminated their involvement in the study and those who remained enrolled (yes/no/unclear).
(3) Performance bias
We assessed blinding using the following criteria:
(A) blinding of participants (yes/no/unclear);
(B) blinding of caregiver (yes/no/unclear);
(C) blinding of outcome assessment (yes/no/unclear).
We designed a form to extract data. Several review authors extracted data and assessed the methodological quality of each study independently and compared results. Disagreements about study inclusion and methodological quality were resolved through discussion until a consensus was reached. We reviewed the inclusion criteria and therapeutic interventions for each trial to see how they differed between trials. We examined the outcomes in each trial to see how comparable they were between studies. We contacted investigators (if possible) to obtain information about any missing data. For categorical data, we made 2 x 2 tables from each trial for each important outcome, and used odds ratios with 95% CI in the meta-analysis. For continuous variables, we calculated weighted mean differences with 95% CI. We used standardized mean differences to combine trials that used different scales to measure the same outcome. We used fixed-effect meta-analysis for combining data in the absence of significant heterogeneity. We used random-effects meta-analysis for trials with significant heterogeneity identified by using the I² statistic. We were unable to explore heterogeneity using subgroup analysis or sensitivity analysis because there were not enough clinical trials included for the heterogeneous outcomes.