NIHR Signal Skin-to-skin contact improves breastfeeding of healthy babies

Published on 28 March 2017

Early skin-to-skin contact improves breastfeeding of healthy full-term babies. Skin-to-skin contact is the direct contact between a naked baby and the mother’s bare chest. It can occur before or after the baby is cleaned following birth.

This review found that about a quarter more women who have this contact with their babies are still breastfeeding at one to four months after birth compared with those who don’t. The evidence that skin-to-skin contact may also help to stabilise the baby’s heart and breathing rates and blood sugar levels after birth was based on fewer trials and less strong.

These findings support UK good practice to promote immediate skin-to-skin contact after birth to improve breastfeeding rates. It remains one of the important steps recommended by NICE and UNICEF aimed at improving the low rates of breastfeeding in the UK. Other measures include providing a favourable environment, support and education.

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Why was this study needed?

There are many well documented benefits to breastfeeding. For the child, it reduces infections, helps brain development and reduces the risk of obesity and diabetes later in life. For the mother, it reduces the risk of breast and ovarian cancer and diabetes.

Despite the benefits, breastfeeding rates are low in the UK. Only 34% of women do any breastfeeding by six months, with just 1% exclusively breastfeeding as per international recommendations.

Previous studies had shown a link between immediate or early skin-to-skin contact and likelihood of continuing to breastfeed. It is believed to decrease the baby’s distress, reduce maternal anxiety and improve the bond between mother and baby.

This review combined results of other trials to quantify the effect of skin-to-skin contact on breastfeeding and ease of transition of the baby to life outside the womb.

What did this study do?

This systematic review compared skin-to-skin contact in the 24 hours following birth to contact through a layer of clothing or having the baby in a crib. It included 38 trials from 21 countries with different resource levels and a total of 3,472 mother-baby pairs. This is the third update of a review first published in 2003.

The main outcomes were breastfeeding one to four months after birth and physiological stability of the baby in the first hours of life.

This study focussed on healthy full-term babies, and the majority of women had a normal birth. Only eight trials included women who had a caesarean section, so the results may not be as reliable for this type of birth.

The main limitations are small sample sizes and participants and health professionals being aware of the type of mother-baby contact.

What did it find?

  • Women who had skin-to-skin contact with their babies were more likely to be breastfeeding one to four months after giving birth. Breastfeeding rates were 67% versus 54% for women without skin-to-skin contact, (risk ratio [RR] 1.24, 95% confidence interval [CI] 1.07 to 1.43. These results came from 14 trials of 887 participants).
  • The breastfeeding period was 64 days longer on average in women who had skin-to-skin contact with their babies, though this was based on low quality evidence (95% CI 38 to 89 days).
  • Women were more likely to exclusively breastfeed following birth when they had skin-to-skin contact with their babies. From hospital discharge up to one month after birth, 84% of women were exclusively breastfeeding following skin-to-skin contact compared to 64% following standard contact (RR 1.30, 95% CI 1.12 to 1.49). Exclusive breastfeeding rates in trials running for six weeks to six months after birth were 78% following skin-to-skin contact compared to 52% (RR 1.50, 95% CI 1.18 to 1.90).
  • Women who underwent a caesarean procedure and had skin-to-skin contact with their babies were also more likely to be breastfeeding one to four months after giving birth (95% CI 1.04 to 1.44). However, the small sample (220 mother-baby pairs) limits confidence in these results.
  • The heart and breathing rates were more stable in babies who had skin-to-skin contact. They were also less likely to have low blood sugar levels. These results should be viewed with some caution as they are based on a small number of babies and stability was averaged from multiple time points.

What does current guidance say on this issue?

The NICE clinical guideline on postnatal care up to eight weeks after birth was last updated in 2015. It recommends that hospitals create an environment that helps to promote breastfeeding, and that “women should be encouraged to have skin-to-skin contact with their babies as soon as possible after the birth”. This echoes the UNICEF UK Baby Friendly Initiative which recommends women have skin-to-skin contact after birth and at least until after the first feed. For women who are unable to have immediate contact, the guidelines recommend it occurs as soon as possible.

What are the implications?

Midwives have expressed some concerns that time pressures and lack of resources can prevent skin-to-skin contact from being a priority. However, according to a survey of women's experiences of maternity care by NICE in 2015, 90% of the women interviewed had experienced skin-to-skin contact with their baby after birth. Given the finding that this should have improved breastfeeding rates, the challenge to understand and improve UK rates, which are much lower than those seen in this international review, continues.

It remains unclear if the benefits of skin-to-skin contact are equally seen after caesarean birth, if duration of contact influences the outcome and if physiological stability of babies is improved. Despite these limitations, skin-to-skin contact should remain high up the list of priorities for actions following birth.

Citation and Funding

Moore ER, Bergman N, Anderson GC, Medley N. Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database Syst Rev. 2016;11:CD003519.

No funding information was provided for this study.

Bibliography

NICE. Postnatal care up to 8 weeks after birth. CG37. London: National Institute for Health and Clinical Excellence; 2006.

NICE. Intrapartum care. QS105. London: National Institute for Health and Clinical Excellence; 2015.

UNICEF UK. Guide to the baby friendly initiative standards. London: UNICEF UK; 2012.

UNICEF UK. Breastfeeding rates in the UK. London: UNICEF UK; 2016.

Why was this study needed?

There are many well documented benefits to breastfeeding. For the child, it reduces infections, helps brain development and reduces the risk of obesity and diabetes later in life. For the mother, it reduces the risk of breast and ovarian cancer and diabetes.

Despite the benefits, breastfeeding rates are low in the UK. Only 34% of women do any breastfeeding by six months, with just 1% exclusively breastfeeding as per international recommendations.

Previous studies had shown a link between immediate or early skin-to-skin contact and likelihood of continuing to breastfeed. It is believed to decrease the baby’s distress, reduce maternal anxiety and improve the bond between mother and baby.

This review combined results of other trials to quantify the effect of skin-to-skin contact on breastfeeding and ease of transition of the baby to life outside the womb.

What did this study do?

This systematic review compared skin-to-skin contact in the 24 hours following birth to contact through a layer of clothing or having the baby in a crib. It included 38 trials from 21 countries with different resource levels and a total of 3,472 mother-baby pairs. This is the third update of a review first published in 2003.

The main outcomes were breastfeeding one to four months after birth and physiological stability of the baby in the first hours of life.

This study focussed on healthy full-term babies, and the majority of women had a normal birth. Only eight trials included women who had a caesarean section, so the results may not be as reliable for this type of birth.

The main limitations are small sample sizes and participants and health professionals being aware of the type of mother-baby contact.

What did it find?

  • Women who had skin-to-skin contact with their babies were more likely to be breastfeeding one to four months after giving birth. Breastfeeding rates were 67% versus 54% for women without skin-to-skin contact, (risk ratio [RR] 1.24, 95% confidence interval [CI] 1.07 to 1.43. These results came from 14 trials of 887 participants).
  • The breastfeeding period was 64 days longer on average in women who had skin-to-skin contact with their babies, though this was based on low quality evidence (95% CI 38 to 89 days).
  • Women were more likely to exclusively breastfeed following birth when they had skin-to-skin contact with their babies. From hospital discharge up to one month after birth, 84% of women were exclusively breastfeeding following skin-to-skin contact compared to 64% following standard contact (RR 1.30, 95% CI 1.12 to 1.49). Exclusive breastfeeding rates in trials running for six weeks to six months after birth were 78% following skin-to-skin contact compared to 52% (RR 1.50, 95% CI 1.18 to 1.90).
  • Women who underwent a caesarean procedure and had skin-to-skin contact with their babies were also more likely to be breastfeeding one to four months after giving birth (95% CI 1.04 to 1.44). However, the small sample (220 mother-baby pairs) limits confidence in these results.
  • The heart and breathing rates were more stable in babies who had skin-to-skin contact. They were also less likely to have low blood sugar levels. These results should be viewed with some caution as they are based on a small number of babies and stability was averaged from multiple time points.

What does current guidance say on this issue?

The NICE clinical guideline on postnatal care up to eight weeks after birth was last updated in 2015. It recommends that hospitals create an environment that helps to promote breastfeeding, and that “women should be encouraged to have skin-to-skin contact with their babies as soon as possible after the birth”. This echoes the UNICEF UK Baby Friendly Initiative which recommends women have skin-to-skin contact after birth and at least until after the first feed. For women who are unable to have immediate contact, the guidelines recommend it occurs as soon as possible.

What are the implications?

Midwives have expressed some concerns that time pressures and lack of resources can prevent skin-to-skin contact from being a priority. However, according to a survey of women's experiences of maternity care by NICE in 2015, 90% of the women interviewed had experienced skin-to-skin contact with their baby after birth. Given the finding that this should have improved breastfeeding rates, the challenge to understand and improve UK rates, which are much lower than those seen in this international review, continues.

It remains unclear if the benefits of skin-to-skin contact are equally seen after caesarean birth, if duration of contact influences the outcome and if physiological stability of babies is improved. Despite these limitations, skin-to-skin contact should remain high up the list of priorities for actions following birth.

Citation and Funding

Moore ER, Bergman N, Anderson GC, Medley N. Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database Syst Rev. 2016;11:CD003519.

No funding information was provided for this study.

Bibliography

NICE. Postnatal care up to 8 weeks after birth. CG37. London: National Institute for Health and Clinical Excellence; 2006.

NICE. Intrapartum care. QS105. London: National Institute for Health and Clinical Excellence; 2015.

UNICEF UK. Guide to the baby friendly initiative standards. London: UNICEF UK; 2012.

UNICEF UK. Breastfeeding rates in the UK. London: UNICEF UK; 2016.

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

Published on 26 November 2016

Moore, E. R.,Bergman, N.,Anderson, G. C.,Medley, N.

Cochrane Database Syst Rev Volume 11 , 2016

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 womenSSC 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; I(2) = 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; I(2) = 44%; GRADE: moderate quality; from six weeks average RR 1.50, 95% CI 1.18 to 1.90; participants = 640; studies = seven; I(2) = 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; I(2) = 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; I(2) = 85%). Results for infantsSSC 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 ( degrees C) 95% CI 0.13 degrees C to 0.47 degrees C; participants = 558; studies = six; I(2) = 88%; GRADE: low quality). Women and infants after cesarean birthWomen 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. SubgroupsWe 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.

Skin-to-skin contact is the first direct contact between the mother’s bare chest and her naked baby, usually covered with a warm blanket. In some countries, standard care does not include skin-to-skin contact; instead, the baby is held wrapped or dressed or placed in a crib. The definition is further divided into “immediate” skin-to-skin contact, which occurs within ten minutes of birth, and “early” contact, which happens between ten minutes and 24 hours after birth.

Expert commentary

Ensuring new born babies are placed in immediate skin-to-skin contact with their mother, and maintaining this in order to promote breast-feeding seems sensible. Trials are difficult because skin-to-skin contact cannot be blinded, and many health practitioners now feel it is inappropriate not to support skin-to-skin contact. Therefore, whilst this review identifies the limitations and challenges in conducting and interpreting trials, the findings confirm the importance for prolonged breast-feeding. Whilst skin-to-skin contact must now be a key priority for new born care, whether the same findings apply to babies who are less healthy remains unclear.

Dr Nicholas D Embleton, Consultant Neonatal Paediatrician, Honorary Reader in Neonatal Medicine, Royal Victoria Infirmary, Newcastle Hospitals NHS Foundation Trust