Jorge César Martínez the Modern Neonatal Paradigm International Perspectives: Skin-to-skin Contact: A Paramount Contribution to http:neoreviews.aappublications.orgcgicontentfullneoreviews;82e55 located on the World Wide Web at: The online version of this

  

International Perspectives: Skin-to-skin Contact: A Paramount Contribution to

the Modern Neonatal Paradigm

Jorge César Martínez

  NeoReviews 2007;8;e55-e57

DOI: 10.1542/neo.8-2-e55

  

The online version of this article, along with updated information and services, is

located on the World Wide Web at:

  

NeoReviews is the official journal of the American Academy of Pediatrics. A monthly publication,

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  Author Disclosure Prof Dr Martı´nez did not disclose any financial relationships relevant to this article.

  Skin-to-skin Contact: A Paramount Contribution

to the Modern

Neonatal Paradigm

  Jorge Ce´sar Martı´nez*

  It is of paramount significance to un- derstand clearly the substantial dif- ference between an excellent inno- vation and real progress in modern neonatal assistance. Real progress is built on those interventions (actions) that can be implemented worldwide and whose tested beneficial effects are long-lasting or better, last for- ever.

  One such advance has been the rediscovery of the oldest beneficial stimulation for humans: the somato- sensory stimulation produced by the special and deep contact between in- fants and mothers, represented by skin-to-skin contact. The kangaroo care technique involves placing ba- bies naked in the prone position on their mothers’ bare chests for early, prolonged, or even continuous skin- to-skin contact.

  Numerous studies have documented the clear benefits of this simple tech- nique on the physiologic and emo- tional well-being of infants and mothers, especially for preterm ba- bies. (1)(2)(3)(4) Elegant studies and reviews have assessed its short- and long-term effects on infant vital functions and successful develop- ment, prompting the World Health

  Organization to recommend that skin-to-skin contact be available in neonatal environments. (5) Among the beneficial findings of investiga- tions of skin-to-skin contact are car- diorespiratory stability, decreased ap- neic and periodic breathing episodes, (6)(7) protection of thermoregula- tion and mother-infant thermal syn- chrony, (8)(9)(10) sleep-wake cy- clicity, better sleep patterns, (11) arousal modulation, organized activ- ity levels, sustained exploration, (12)(13) increased duration and quality of breastfeeding, (14)(15)(16) better weight gain, (17)(18)(19) de- creased hospital stay, and savings in health-care costs.

Introduction

  This technique also has been shown to help mothers develop and strengthen self-confidence and ma- ternal attachment behaviors (20)(21) as well as a family atmosphere in which parents become more exposed to sensitive caregiving. The mothers realize that the emotional dimension of the interaction can ensure the suc- cessful discharge from the hospital even of very tiny babies, which enlists them as integral members of the team that is helping the infant to survive.

Benefits of Skin-to-skin Contact

  Better physiologic and behavioral organization (22) of the infants may contribute to lower levels of stress hormones and balance in autonomic central system reactivity due to less immunologic deficit, fewer infec- tions and diseases, and potential an- algesic effects. (23)(24)(25)(26)(27) (28) Decreased stress hormone secretion (salivary cortisol) (29) also has been described in mothers dur-

  international perspectives

• Chairman, Department of Pediatrics, Del Salvador

  University School of Medicine B.A.; Chief, Neonatal

  Unit, Mother-Infant Hospital R. Sarda, Buenos Aires, Argentina; Consultant, Rockefeller University, New York, NY.

ing and after skin-to-skin contact, and even better results were shown with repeated skin-to-skin contact.

  Less infant crying has been de- scribed in several studies. A baby who is spending more time in the quiet alert state, or deep sleep, instead of crying, is saving energy to grow and develop neurophysiologic organiza- tion. (10)(11)(12)(13)(14)(15)(16) (17) Anderson proposed an evidence-based rationale that mater- nal separation is associated with ex- cessive crying. (30) During crying, some patterns of prenatal circulation are re-established, with desaturated venous blood shunted through the foramen ovale into the systemic cir- culation instead of the lungs, creat- ing hypoxemia and increasing fluctu- ations in cerebral flow and velocity that increase the risk of ventricular hemorrhage.

  Exposure to maternal odors (31) facilitates infants’ adaptation to the postnatal environment and can be attained with skin-to-skin care even in the presence of mechanical venti- lation. (32) Finally, twins can be held simultaneously in kangaroo care without thermal compromise be- cause each breast responds individu- ally to the infants’ thermal needs. (33)

  international perspectives

  Ohgi S, Fukuda M, Moriuchi H, et al. Comparison of kangaroo care and standard

  Ferber SG, Makhoul IR. The effect of skin-to-skin contact (kangaroo care) shortly after birth on the neurobehavioral responses of the term newborn: a randomized, con- trolled trial. Pediatrics. 2004;113:858 – 865 13.

  Messmer PR, Rodriguez S, Adams J, et al. Effect of kangaroo care on sleep time for neonates. Pediatr Nurs. 1997;23:408 – 414 12.

  Christensson K, Siles C, Moreno L, et al. Temperature, metabolic adaptation and crying in healthy full-term newborns cared for skin-to-skin or in a cot. Acta Paediatr. 1992;81:488 – 493 11.

  Res. 2002;10:129 –142 10.

  Chwo MJ, Anderson GC, Good M, Dowling DA, Shiau SH, Chu DM. A ran- domized controlled trial of early kangaroo care for preterm infants: effects on temper- ature, weight, behavior, and acuity. J Nurs

  Trop Paediatr. 2004;24:245–251 9.

  Ibe OE, Austin T, Sullivan K, Fabanwo O, Disu E, Costello AM. A comparison of kangaroo mother care and conventional in- cubator care for thermal regulation of in- fants ⬍ 2000 g in Nigeria using continuous ambulatory temperature monitoring. Ann

  McCain GC, Ludington-Hoe SM, Swinth JY, Hadeed AJ. Heart rate variability responses of a preterm infant to kangaroo care. J Obstet Gynecol Neonatal Nurs. 2005; 34:689 – 694 8.

  2004;23:39 – 48 7.

  Ludington-Hoe SM, Anderson GC, Swinth JY, Thompson C, Hadeed AJ. Ran- domized controlled trial of kangaroo care: cardiorespiratory and thermal effects on healthy preterm infants. Neonatal Netw.

  of the Midwifery Congress, Philippines, May 1999. Geneva, Switzerland: World Health Organization 6.

  Proceedings of the Symposium The Mother- Baby Package . International Confederation

  Pediatrics. 2002;110:16 –26 5.

  Feldman R, Eidelman AI, Sirota L, Weller A. Comparison of skin-to-skin (kan- garoo) and traditional care: parenting out- comes and preterm infant development.

  rics. 2001;108:1072–1079 4.

  Charpak N, Ruiz-Pelaez JG, Figueroa de CZ, Charpak Y. A randomized, controlled trial of kangaroo mother care: results of follow-up at 1 year of corrected age. Pediat-

  contact (kangaroo care) accelerates auto- nomic and neurobehavioural maturation in preterm infants. Dev Med Child Neurol. 2003;45:274 –281 3.

  2. Feldman R, Eidelman AI. Skin-to-skin

  CD003519

  Cochrane Database Syst Rev. 2003;2:

  Anderson GC, Moore E, Hepworth J, Bergman N. Early skin-to-skin contact for mothers and their healthy newborn infants. care: behavioral organization, development, and temperament in healthy, low-birth- weight infants through 1 year. J Perinatol. 2002;2:374 –379 14.

  Skin-to-skin contact should be con- sidered an important tool of and valuable contribution to the neonatal assistance paradigm that, from my point of view, promotes high-tech in conjunction with high-touch. We have performed skin-to-skin contact in our hospital since 1991, (35) after we tested its effectiveness and safety in our population. One of the un- measurable benefits is the experience for both clinician and patient. The most touching personal example happened to me when I met, several years after the fact, a mother who had skin-to-skin contact with her preterm baby who was receiving mechanical ventilation and died few days later. She told me, “I will never forget my little son. I will never forget that moment. I feel that at least I could do something good for him. I know that both of us will always remem- ber, wherever he is now.” To view a video of skin-to-skin contact, click here ^VIDEO .

  The participation of health-care services and organized family net- works is fundamental for the de- velopment of successful programs, well-designed and appropriate edu- cational plans, and professional facil- itators. Neonatologists should gar- ner support for research initiatives and clinical strategies to overcome barriers to the practice of the skin-to- skin technique. Separation of moth- ers from the infants at birth has be- come a common practice, despite evidence of potential harmful effects.

Conclusion

Why is Skin-to-skin Contact Not Universal?

  Universal acceptance of the skin-to- skin contact technique between the preterm baby and his or her mother requires serious support from the sci- entific community as a medical indi- cation, not simply a nice initiative. Systematic reviews and meta-analyses have highlighted the difficulties in finding well-designed, randomized, controlled trials of the implemented intervention that have comparable outcome variables. Further, many neonatal intensive care units have not instituted this therapy because of a lack of appropriate protocols, imple- mentation teams, and correct stan- dardization of the technique. (34)

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  international perspectives

  

International Perspectives: Skin-to-skin Contact: A Paramount Contribution to

the Modern Neonatal Paradigm

Jorge César Martínez

  NeoReviews 2007;8;e55-e57

DOI: 10.1542/neo.8-2-e55

  Updated Information including high-resolution figures, can be found at:

& Services http://neoreviews.aappublications.org/cgi/content/full/neoreview

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