Skin-to-Skin EBP

Running head: SKIN-TO-SKIN CONTACT 1
Benefits of Newborn Skin-to-Skin Contact Compared to No Contact in Low-Birth-
Weight Infants
Rachel White
NURS 411: Evidence-Based Practice for Nurses
October 18, 2016
Dr. Nancy Downing

SKIN-TO-SKIN CONTACT 2
Abstract
The purpose of this research is to examine the guideline published by Cincinnati
Children’s Hospital Medical Center in April of 2013 regarding the use of skin-to-skin
contact in the treatment of low-birth-weight infants. The guideline asserts that there is not
enough evidence to support the claim that skin-to-skin contact is beneficial in the
treatment of these neonates. However, my findings suggest that skin-to-skin contact is a
safe and beneficial treatment option for the population in question and, as a result, the
aforementioned guideline should be changed. This change could result in improved care
for millions of low-birth-weight infants.

Benefits of Newborn Skin-to-Skin Contact Compared to No Contact
According to the World Health Organization ([WHO], 2016), more than 20
million infants are considered low-birth-weight, meaning that they weigh less than 2.5 kg
at birth. Because of their low weight, these infants are at an increased risk of further
health complications such as delayed growth, infectious disease, delayed development,
and death.” Countless studies have linked improvement in the conditions of these low-
birth-weight infants to the use of skin-to-skin contact (also known as kangaroo care,
kangaroo mother care, and KMC). However, one guideline (see Appendix A) by the
Cincinnati Children’s Hospital Medical Center (2013), asserts that there is insufficient
evidence to make a recommendation on the use of kangaroo care.
It is important that this guideline be reviewed because the sources used to support
the guideline are outdated and new evidence and studies present opposite conclusions.
More recent evidence supports that kangaroo care is beneficial for infant health, mother
and child bonding, and is of little or no cost to hospitals; and a large percentage of low-
weight births occur in developing countries that do not have access to advanced medicine
and, thus, need to improve the health of their infants with easy, low cost treatments such
as kangaroo care.
Recommendations for practice as well as conclusions drawn from the research
will follow an overview of the practice guideline and synthesis of the evidence examined.
Also attached is a full copy of the guideline previously mentioned, an evidence grid, and
references.

Overview of the Practice Guideline
In the guideline “Best evidence statement (BESt). Skin to skin care in a level III-
IV NICU.” (see Appendix A for full guideline) published by Cincinnati Children’s
Hospital Medical Center, it is presented that there is not enough evidence to make a
decision as to whether skin to skin contact (also referred to as kangaroo care) between
babies in the NICU and their parents is beneficial. This guideline focuses mainly on
premature or sick infants that are residing in a neonatal intensive care unit rather than a
newborn nursery and its objective is to evaluate is receiving skin-to-skin care improves
infant outcomes. A nurse in the neonatal intensive care unit can take this guideline into
consideration when determining if kangaroo care should be initiated between the
premature infant and their mother (and often father).
While this guideline comes from a reputable hospital source, it does have a few
problems. The methodology section of the guideline states that information from 1999 to
2012 was used in the collection of evidence but only two articles were cited as sources
upon which this decision was made. First, thirteen years is an extremely large window of
time from which to obtain sources, many of which are considered out of date by the
publication of this guideline. Second, the guideline only names two sources to support
their assertion that there is not enough evidence to claim that skin-to-skin contact
between mother and baby is beneficial to infants hospitalized in the NICU after birth.
This guideline could possibly be changed with the review of new research, but there have
been no developments or updates since its publication by Cincinnati Children’s Hospital
Medical Center in April of 2013.

Synthesis of Evidence
Each of the five articles analyzed and presented in the evidence grid (see
Appendix B) sought to determine if kangaroo care (also referred to as kangaroo mother
care, KMC, and skin to skin contact) was beneficial for newborns. These studies
observed and measured the affect of kangaroo care on variables such as weight, head
circumference, feedings, length of hospital stay, incidence of disease or other
complications, and feelings of mothers and other caretakers. They then compared these
observations to those seen in infants that were not exposed to kangaroo care.
Two of the articles presented in the evidence grid specifically analyzed the
feelings of mothers and caregivers participating in skin to skin contact and the barriers
and enablers that they experienced to providing this care. A large percentage of the
people studied voiced positive experiences with kangaroo care. One common theme
voiced by mother and caregivers throughout the articles is the feeling of attachment and
bonding with their infant (Seidman et al., 2015). Individuals also frequently reported
feeling good and the sense of doing something beneficial for their child (Anderzén-
Carlsson, Lamy, Eriksson, 2014). While the majority of those studied had positive
experiences and feelings to share regarding kangaroo care, others had a more negative
opinion. Some considered kangaroo care to be an energy draining form of caring for their
child accompanied with fear of hurting their baby (Anderzen-Carlsson et al., 2014) .
Others described their experiences as being negative due to lack of knowledge, resources,
and assistance with the process (Seidman et al., 2015).
Three of the articles that were analyzed in the evidence grid studied the effects of
kangaroo care on infants using quantitative measures. Each of these studies reported

positive outcomes for infants in their different areas studied. One of the studies found that
kangaroo care could be used as a safe alternative to traditional neonatal care, particularly
in areas of limited resources (Conde-Agudelo, Díaz-Rossello, 2016). Another
observational study sought to evaluate the effects of kangaroo care on newborn feedings
and reported that infants exposed to skin to skin contact at an earlier age were able to
achieve full oral feedings at an earlier date (Gianni et al., 2016). The last article reported
that although kangaroo care is equally as effective as standard care in improving the
growth rates of preterm infants, the infants not exposed to kangaroo care stayed an
average of 5.5 days longer in the hospital (Sharma, Murki, Pratap, 2016).
The evidence provided through these studies refutes the guideline in question and
supports my opinion that it should be changed. The guideline, published by Cincinnati
Children’s Hospital Medical Center, states that there is not enough evidence to conclude
whether skin to skin contact is beneficial for newborns. However, all five of these studies
present evidence that kangaroo care between a mother and her infant not only brings
health benefits for the baby, but can also benefit the mother or caretaker as well. The
positive results for infants and some mothers reported in these newer studies combined
with the possibility of decrease in hospital stays support my opinion that the guideline
should be changed.

Recommendations for Practice
The evidence grid (see Appendix B) outlines information presented by five
different research studies. These studies range in levels of evidence and content. Two are
of level I evidence; one studied randomized controlled trials to compare kangaroo care
and conventional care and the other examined other studies to determine barriers and
enablers to the practice of kangaroo care. One study was level II evidence and also
compared skin-to-skin contact to traditional methods of care using randomized controlled
trials. A fourth study presented level IV evidence by observing neonates to determine
whether kangaroo care affects the development of infant feeding skills. The fifth study
analyzed presented level V evidence (if not higher) by reviewing the experiences of
mothers and other caregivers participating in skin-to-skin contact. Each study was taken
from a peer-reviewed journal to ensure strong and reliable content. All of the articles
present in the grid were also published within the last five years (three were published in
the present year) so they represent the most recent medical knowledge and findings.
The references given in support of the article published by the Cincinnati
Children’s Hospital Medical Center is extremely different than that of the articles
presented in the evidence grid. The first problem with the guideline evidence is the
number of sources given. While the evidence grid in Appendix B cites five sources, the
guideline published for national use only uses two to support their conclusion. Another
issue is the age of the data presented. Not only are the two articles listed as references
two to three years older than all of the studies in the grid, the guideline also uses data
from as early as 1999. The five studies presented here are all recent, credible, and show
positive results in favor of the use of skin-to-skin contact between newborns (especially

those of low-birth-weight) and their mothers or other caregivers. Instead of considering
the multiple sources of current data that have been published, the Cincinnati Children’s
Hospital Medical Center guideline uses very few sources and extremely outdated data to
make their recommendation against using a method of treatment that could possibly helps
millions of neonates.
Based on the mostly positive data presented in the studies included in the
evidence grid, kangaroo care should be used in the care of low-birth-weight infants.
According to this data, infants exposed to skin-to-skin contact earlier achieved full oral
feedings earlier and infants not exposed to skin-to-skin contact stayed an average of 5.5
days longer than those that were. It was also concluded to be a safe alternative to
conventional care for low-birth-weight infants. Kangaroo care costs little to nothing,
which could save hospital systems money and be of use in underdeveloped areas.
Because mothers frequently reported kangaroo care increased their bond with their infant
and it is not an invasive treatment, it is not limited to babies with low birth weights.
Based on these factors, the guideline in question should be altered to reflect the positive
impact kangaroo care can have on infants.

Conclusion
According to the data collected during the studies outlined in the evidence grid,
kangaroo care could help shorten hospital stays and the time it takes an infant to achieve
full oral feeding. In addition to the benefits it provides for the infant, skin-to-skin contact
also results in mostly positive emotions and experiences from the mothers or other
caregivers participating. The flaws of the original guideline combined with these recent
positive findings and list of possible benefits of kangaroo care make it clear that the
guideline needs to be changed. While the research outlined in the evidence grid makes a
strong case for this change, continued research could be beneficial in discovering further
benefits of the use of skin-to-skin contact. By changing this guideline to reflect recent
research, parents and hospitals would be encouraged to treat millions of low-birth-weight
neonates with a method of care that is non-invasive and not costly while still being
extremely beneficial for the infant.

References
Anderzén-Carlsson, A., Lamy, Z. C., & Eriksson, M. (2014). Parental experiences of
providing skin-to-skin care to their newborn infant—Part 1: A qualitative
systematic review. International Journal of Qualitative Studies on Health and
Well-Being, 9. doi: 10.3402/qhw.v9.24906
Conde-Agudelo, A. & Díaz-Rossello, J. (2016). Kangaroo mother care to reduce
morbidity and mortality in low birthweight infants. The Cochrane Library, (4), 3..
doi: 10.1002/14651858.CD002771.pub4
Gianni, M., Sannino, P., Bezze, E., Comito, C., Plevani, L., Roggero, P., . . . Masca, F.
(2016). Does parental involvement affect the development of feeding skills in
preterm infants? A prospective study. Early Human Development, 103, 123-128.
Seidman, G., Unnikrishnan, S., Kenny, E., Myslinski, S., Cairns-Smith, S., Mulligan, B.,
& Engmann, C. (2015). Barriers and enablers of kangaroo mother care practice: A
systematic review. PLoS One: A peer reviewed, open access journal, 10(5). doi:
10.1371/journal.pone.0125643
Sharma, D., Murki, S. & Pratap, O.T. (2016). The effect of kangaroo ward care in
comparison with “intermediate intensive care” on the growth velocity in preterm
infant with birth weight <1100 g: Randomized control trial. European Journal of
Pediatrics, 175(10), 1317-1324.
World Health Organization (2016). Kangaroo mother care to reduce morbidity and
mortality in low-birth-weight infants. Retrieved from
http://www.who.int/elena/titles/kangaroo_care_infants/en/

Appendix A: Practice Guideline
Best evidence statement (BESt). Skin to
skin care in a level III-IV NICU.
 Developer
 Source
 Status
 Classification
Cincinnati Children's Hospital Medical Center. Best evidence statement (BESt). Skin to skin care in
a level III-IV NICU. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2013 Apr 30.
6 p. [6 references]
View the original guideline documentation
 Sections
 Download
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 Cite
 Save
Recommendations
Major Recommendations
The strength of the recommendation (strongly recommended, recommended, or no
recommendation) and the quality of the evidence (1a‒5b) are defined at the end of the
"Major Recommendations" field.
1. There is insufficient evidence and lack of consensus to make a recommendation
on the use of skin to skin care (SSC) to decrease the number of days on non-
invasive respiratory support or number of days on ventilation in a Level III-IV
neonatal intensive care unit (NICU) in a high income country.
2. There is insufficient evidence and lack of consensus to make a recommendation
on the use of SSC to decrease infection in a Level III-IV NICU in a high income
country.

3. It is not recommended that SSC be used to reduce mortality or length of stay in
a Level III-IV NICU in a high income country (Conde-Agudelo, Belizán, &
Diaz-Rossello, 2011 [1a]; Moore et al., 2012 [1a]).
Note: Randomized control trials in high income countries reported lower mean
duration in hours/day of intermittent SSC (Conde-Agudelo, Belizán, & Diaz-
Rossello, 2011 [1a]).
Definitions:
Table of Evidence Levels
Quality Level Definition
1a† or 1b† Systematic review, meta-analysis, or meta-synthesis of multiple studies
2a or 2b Best study design for domain
3a or 3b Fair study design for domain
4a or 4b Weak study design for domain
5a or 5b General review, expert opinion, case report, consensus report, or guideline
5 Local Consensus
†a = good quality study; b = lesser quality study
Table of Language and Definitions for Recommendation Strength
Language for Strength Definition
It is strongly recommended
that…
that… not…
There is consensus that benefits clearly outweigh risks and burdens
(or visa-versa for negative recommendations).
It is recommended that…
not…
There is consensus that benefits are closely balanced with risks and
burdens.
There is insufficient evidence and a lack of consensus to make a recommendation…

Note: See the original guideline document for the dimensions used for judging the
strength of the recommendation.
Clinical Algorithm(s)
None provided
Scope
Disease/Condition(s)
Diseases and conditions requiring care in a Level III-IV neonatal intensive care unit
(NICU)
Guideline Category
Management
Prevention
Treatment
Clinical Specialty
Family Practice
Obstetrics and Gynecology
Pediatrics
Preventive Medicine
Intended Users
Advanced Practice Nurses
Hospitals
Nurses
Physician Assistants
Physicians

Respiratory Care Practitioners
Guideline Objective(s)
To evaluate, among neonates in a Level III-IV neonatal intensive care unit (NICU), if
receiving skin to skin care (SSC) compared to those not receiving SSC improves
outcomes of decreased mortality, infection, length of hospital stay days on non-invasive
respiratory support, or days on a ventilator
Target Population
Neonates in a Level III-IV neonatal intensive care unit (NICU) in a high income country
Note: These guidelines do not apply to the following populations:
 Neonates in the low acuity setting (such as a newborn nursery)
 Neonates in a resource limited setting (low income country)
Interventions and Practices Considered
Skin to skin care (SSC)
Major Outcomes Considered
 Mortality
 Infection
 Length of hospital stay
 Days on non-invasive respiratory support
 Days on a ventilator
Methodology
Methods Used to Collect/Select the Evidence
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence
Search Strategy
Databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL),
Cochrane Library, Medline
Search Terms: Skin to Skin Care, Kangaroo Care, Kangaroo Mother Care
Filters: 1999 to 2012, Human, English

Search Dates: October 16, 2012
Number of Source Documents
Not stated
Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence
Table of Evidence Levels
Quality Level Definition
1a† or 1b† Systematic review, meta-analysis, or meta-synthesis of multiple studies
2a or 2b Best study design for domain
3a or 3b Fair study design for domain
4a or 4b Weak study design for domain
5a or 5b General review, expert opinion, case report, consensus report, or guideline
5 Local Consensus
†a = good quality study; b = lesser quality study
Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review
Description of the Methods Used to Analyze the Evidence
Not stated
Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations
Not stated
Rating Scheme for the Strength of the Recommendations
Table of Language and Definitions for Recommendation Strength

that…
that… not…
There is consensus that benefits clearly outweigh risks and burdens
(or visa-versa for negative recommendations).
not…
There is consensus that benefits are closely balanced with risks and
burdens.
There is insufficient evidence and a lack of consensus to make a recommendation…
Note: See the original guideline document for the dimensions used for judging the
strength of the recommendation.
Cost Analysis
A formal cost analysis was not performed and published cost analyses were not reviewed.
Method of Guideline Validation
Peer Review
Description of Method of Guideline Validation
This Best Evidence Statement has been reviewed against quality criteria by two
independent reviewers from the Cincinnati Children's Hospital Medical Center
(CCHMC) Evidence Collaboration.
Evidence Supporting the Recommendations
References Supporting the Recommendations
Conde-Agudelo A, Belizan JM, Diaz-Rossello J. Kangaroo mother care to reduce morbidity and
mortality in low birthweight infants. Cochrane Database Syst Rev.
2011;(3):CD002771. PubMed
Moore ER, Anderson GC, Bergman N, Dowswell T. Early skin-to-skin contact for mothers and
their healthy newborn infants. Cochrane Database Syst Rev. 2012;5:CD003519.PubMed
Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for one recommendation (see
the "Major Recommendations" field). For two outcomes, there was insufficient evidence
to make a recommendation.
Benefits/Harms of Implementing the Guideline
Recommendations
Qualifying Statements
Implementation of the Guideline
Institute of Medicine (IOM) National Healthcare
Quality Report Categories
Identifying Information and Availability
Disclaimer

Appendix B: Evidence Grid
Citation (APA) Purpose Sample Design Measurement Results/Conclusions Level of
Evidence
Anderzén-Carlsson, A.,
Lamy, Z. C., & Eriksson,
M. (2014). Parental
experiences of providing
skin-to-skin care to their
newborn infant—Part 1: A
qualitative systematic
review. International
Journal of Qualitative
Studieson Health and
Well-Being. doi:
10.3402/qhw.v9.24906
Describe parental
experiences of
providing skin-to-
skin contact to
their newborn
N= 66
320 papers were
collected for
review, after which
66 remained for
further evaluation
After a screening
process,data from
the original
articles was
analyzed using
qualitative content
analysis
Data related to the
experiences of
parents using
kangaroo care was
extracted and further
analyzed sing meta-
data analysis
Two major themes and several
subthemes were identified through
the study; these included:
 A restorative experience
o Feeling good
o Doing good
o Becoming us
 An energy draining experience
o Feeling exposed
o Hurting others
Level V
Conde-Agudelo, A.
& Díaz-Rossello, J.
(2016). Kangaroo mother
care to reduce morbidity
and mortality in low
birthweight
infants. Cochrane
Neonatal Group. doi:
10.1002/14651858.CD002
771.pub4
Determine
whether there is
evidence to
support the use of
kangaroo care in
low birth weight
infants and to
assess beneficial
and adverse
effects
N= 3042
Risk ratio= 0.60
3042 infants
spanning 21
different studies
Randomized
controlled trials
used to compare
kangaroo care vs.
conventional
neonatal care and
early vs. late onset
kangaroo care in
low birth weight
infants
Infants were assessed
and observed in the
hospital after birth
and at their next
follow up
appointment
Kangaroo mother care is an effective
and safe alternative to conventional
neonatal care for low birth weight
infants (especially in areas limited in
resources)
Level I
Gianni, M., Sannino, P.,
Bezze, E., Comito, C.,
Plevani, L., Roggero, P., .
. . Masca, F. (2016). Does
parental involvement
affect the development of
feeding skills in preterm
infants? A prospective
Evaluate the effect
of kangaroo care
and parental
involvement on
the timing of
achievement of
full oral feeding in
preterm infants
N= 81
Total of 81 infants
born at or before a
gestationalage of
32 weeks
consecutively
admitted to a
tertiary NICU were
Prospective,
observational,
single-center
study
Neonatal variables,
day of postnatallife
on which kangaroo
care was started,and
information regarding
oral feedings was
recorded
The earlier that parents fed their
infants and the earlier that kangaroo
care was initiated, the earlier the
newborn was able to achieve full
oral feeding.
Level IV

study.Early Human
Development, 103.
observed
Seidman, G.,
Unnikrishnan, S., Kenny,
E., Myslinski, S., Cairns-
Smith, S., Mulligan, B., &
Engmann, C. (2015).
Barriers and enablers of
kangaroo mother care
practice: A systematic
review. PLoS One: A peer
reviewed, open access
journal, 10 (5). doi:
10.1371/journal.pone.012
5643
Identify the most
frequently
reported barriers
and enablers to
kangaroo care
practice
N= 103
Out of the 1264
publications
identified, 103
articles were
deemed relevant for
review
Each publication
was reviewed and
scanned for
barriers and
enablers
Each publication was
weighted based on the
level at which they
had systematically
tried to identify
factors influencing
kangaroo care
Top ranked barriers:
 Issues with
environment/resources
 Negative impressions/
interactions with staff
 Lack of assistance with
kangaroo care
 Low awareness of kangaroo
care
 Pain/fatigue
Top ranked enablers:
 Mother-infant attachment
 Support from family, friends,
mentors
Level I
Sharma, D., Murki, S. &
Pratap, O.T. (2016). The
effect of kangaroo ward
care in comparison with
“intermediate intensive
care” on the growth
velocity in preterm infant
with birth weight <1100 g:
randomized control trial.
European Journal of
Pediatrics, 175 (10).
Compare the
efficacy of
kangaroo care and
standard newborn
care for improving
growth velocity
till term corrected
age
N= 141
Study conducted in
a hospital
department of
neonatology; 71
infants were
randomized to the
kangaroo care ward
while the other70
were randomized to
the intermediate
intensive care area
Randomized
controlled trials
used to compare
efficacy of
kangaroo care vs.
normal newborn
care in an
intermediate
intensive care
setting
Infants were
observed,assessed,
measured and
weighed in their
respective units
throughout their
hospital stay were
followed once a week
in a follow-up clinic
after discharge until
reaching a
postmenstrualage of
40 weeks
Early kangaroo care is equally
effective in improving the growth
outcomes of preterm infants as
standard intermediate intensive care.
However, infants in the intermediate
intensive care unit stayed an average
of 5.5 days longer than those infants
being cared for in the kangaroo care
ward.
Level II

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