Clinical Guidelines (Nursing)

Skin to skin care for the newborn

  • Introduction

    Intermittent skin-to-skin care is widely recognised as a beneficial component of holistic care provision for both term and pre-term neonates. These benefits are just as important for all neonates in providing appropriate developmental care. The improvements for the infant include increased physiological stability, longer periods of quiet sleep, improved self-regulation development, increased breast feeding incidence and duration, decreased pain perception and reduced stress and crying. In very low birth weight infants, SSC has been associated with decreases in mortality and enhanced weight gain. There are also associations between length of SSC and decreased incidence of nosocomial infections.

    Parental benefits include enhanced parent-infant attachment with a reduction in the negative effects of having a sick or preterm infant, greater parental ability to recognise their infant’s cues, increased self-confidence, decreased parental depression and increased maternal breast milk supply. If the mother is not available for SSC, staff should offer to facilitate SSC with father of the baby. 

    Skin to skin care for at least 10 minutes prior to a painful procedure; such as heel lance or intramuscular injection; has been shown to be effective in reducing pain/distress for the neonate, particularly for patients less responsive to sucrose. More information about the use of sucrose can be found here

    Aim

    The aim of this guideline is to provide all clinical staff with the benefits, criteria and procedure to effectively and safely promote and provide skin-to-skin care to infants and parents during admission.

    Definition of terms 

    • Skin-to-Skin Care (SSC): Also known as Kangaroo Care refers to the method of holding an infant in an upright and prone position, skin-to-skin, on the parent’s chest for a period of time.  Clothing or blankets are wrapped around the infant to provide a secure kangaroo-like pouch.
    • CPAP: Continuous Positive Airway Pressure, may be delivered via Single Nasal Prong, Bi-Nasal Prong, or Nasal Mask
    • ETT: Endotracheal Tube
    • Normothermia: An axillary temperature 36.5°C – 37.5°C
    • Cot: this could refer to a radiant warmer, an incubator, or a simple cot

    Assessment

    Criteria

    Skin-to-skin care should be promoted and provided to all haemodynamically stable infants whether pre-term or term, and also offered to families of infants receiving palliative care within the NICU. 

    Contraindications

    • High Frequency Ventilation via the Sensormedics Ventiilator
    • Nitric Oxide delivery
    • Intercostal catheter insitu
    • Umblical arterial catheter insitu
    • Unrepaired surgical conditions including gastroschisis, omphalocele and myelomeningocele
    • Infants in immediate post-operative states requiring ventilation and muscle relaxation

    Considerations

    • The provision of SSC should be discussed by the medical and nursing team, at each baby’s bedside during the ward round.  As always, families should be involved in individualised care planning
    • If there are concerns over the appropriateness of providing SSC for an infant, please raise these concerns with your medical and nursing colleagues.
    • Environmental humidity does not exclude a haemodynamically stable infant from participating in SSC.  The potential increase in transepidermal water loss (TEWL) during SSC is small and transpires to marginal clinical importance.
    • Allow a minimum of 4 hours post extubation or the cessation of CPAP to assess the infant’s stability, some infants who have been on longer term ventilation may benefit from more time to settle post extubation before receiving SSC
    • Caution must be taken to ensure safe management of peripheral arterial lines and central venous access devices while the infant is receiving SSC
    • An infant under droplet or airborne precautions should be nursed in a single room with the door closed prior to coming out of an incubator for SSC
    • Parents may initiate SSC without nursing assistance when their infant is stable, does not require respiratory support and is without IV lines.  Ensure that nursing staff are readily available to assist with gathering equipment or guiding cardiorespiratory monitoring during the transfer

    Management

    Equipment

    Provide a quiet and calm environment, close doors and curtains to ensure privacy:

    • Comfortable and stable chair with arm rests and a high back
    • Pillow
    • If parents do not have a stretchy or button front top, provide a hospital gown to allow front opening
    • Blankets and infant hat
    • Tapes to secure respiratory support tubing
    • Footstool

    Parent preparation

    • Ensure parents are educated on the benefits of SSC and the sequence of events in transferring the infant to and from their chest.
    • Discuss timing around skin-to-skin care, including recognition of infant cues
    • Advise maternal expression and bathroom breaks prior so that SSC can happen uninterrupted
    • Ensure drinking water is close by
    • Offer to change the top clothes for an open-front hospital gown if top or shirt not suitable.  Ideally the mother should remove her bra for optimal skin-to-skin contact.
    • Both parents should be offered the opportunity to provide SSC

    Infant preparation

    • Check the infant’s temperature (ensure normothermia) and place a woollen hat on the infant’s head if low birth weight, or previous temperature instability
    • Ensure infant is nursed only in a nappy
    • Confirm patient monitoring alarms are of appropriate limits and audible
    • Ensure patency and security of intravenous lines and gavage tubes
    • If the infant is intubated, ensure the ETT is secure, check that breath sounds are equal and if required, suction the ETT prior to transfer.
    • If the infant usually requires an increase in oxygen during periods of handling, increase prior to initiating the transfer
    • Notify medical staff of SSC timing if there were concerns over the infant’s stability
    • Drain condensation from respiratory support tubing prior to moving the infant
    • Place the chair close to the ventilator and infusion pumps, and ensure that all respiratory support tubing, lines and monitoring cables will easily reach the chair prior to transfer
    • Disconnect skin temperature probe cables and set the cot to an appropriate air temperature to maintain the correct level of ambient heat while the infant is in SSC

    Transfer

    • If staff feel unfamiliar with the provision of skin-to-skin care, they must enlist the assistance of an experienced nurse. 
    • At least two nurses must be present for the transfer of an infant receiving respiratory support such as CPAP or invasive ventilation
    • Gently rouse the infant prior to initiating transfer or handling and respond to any cues of distress with containment.  Ensure that the handling required to move the infant from a horizontal to vertical position is slow and controlled.
    • Support all respiratory support tubing, intravenous infusions, gavage tubing and monitoring cables during transfer
    • Transfer the infant from the cot to the parent’s chest in a smooth and steady movement. Position the infant comfortably upright and prone with their legs and arms flexed and their head to one side.  Have the parent support the infant with one hand on the infants’ head and the other over the infant’s bottom
    • If the infant is on CPAP ensure prong or mask position is appropriate to not place additional pressure on the nares or septum and that the ventilator is delivering the correct pressure
    • If the infant is ventilated, ensure the ETT remains secure and without additional tension and that the ventilator is delivering the correct pressure
    • Secure respiratory support tubing by taping to the parents clothing at shoulder height, allowing for some movement of tubing as the baby moves their head.  The tubing can then pass over the back corner of the chair
    • Ensure infusion lines, gavage tubes and monitoring leads remain free from tension and well secured
    • Wrap the parent’s shirt or gown around the infant to form the “pouch” and place a blanket over the infant’s back.

    During skin-to-skin care

    • If the infant is receiving respiratory support, the nurse should remain in the room for the duration of skin-to-skin care and regular assessments should be performed 
    • Allow the infant time to settle into SSC.  Adjust oxygen as required, allowing for a 10% increase.  Ensure good head position is maintained and suction the airway as indicated.  If the oxygen requirement remains increased by greater than 10% despite the above interventions, the infant is displaying signs that they are not tolerating the procedure and should be returned to the cot.  Notify medical staff and ensure that the parents understand why SSC was ceased on this occasion.
    • Check the infant’s axillary temperature after 15 minutes of SSC, add or remove hats or blankets as required and continue to monitor
    • A mirror could be provided to allow the parents to see their infant’s face during SSC.  Encourage parents to quietly talk, hum music or sing to their infant.
    • Feeding via gavage tube should continue, ensuring that at least 20 minutes passes after completion of the feed before further transfer.  If the infant is on continuous feeds, pause the infusion during transfers and restart after 10 minutes.
    • Preterm infants less than 32 weeks corrected gestation are not yet able to coordinate effective breastfeeding, however if they are showing signs of interest in sucking, they may ‘nuzzle’ or suck non-nutritively on an empty breast.
    • If infants greater than 32 weeks corrected gestation are not requiring CPAP or ventilation, and are awake and alert during SSC, a breastfeed may be offered.  Assess signs of readiness to feed, and discuss with the infant’s mother regarding rate of milk flow and breast fullness.  Adjustments should be made according to the infant’s ability and stage of feeding.

    Completing skin-to-skin care

    • SSC should last at least 45 minutes; and if comfort, stability and contentment are evident for both the infant and the parent, it can be continued for 2-3 hours.  Monitor the infant’s cues of restlessness as an indication that they wish to return to their cot 
    • As with the transfer into SSC, ensure sufficient staff are present, and that the infant and tubing, lines and cables are safely supported during the transfer back into the cot.
    • Reattach temperature probes and record an axillary temperature 15 minutes after returning to the cot.  Reengage servo control functions if the infant was previously requiring this thermoregulatory mode
    • Encourage maternal expression after she has partaken in SSC, as a larger volume of milk may be obtained post SSC
    • Document the time of day and duration that the infant participated in SSC, and the relevant observations and assessments during it, this includes any increase in Fi02 on the ventilation observations. Also document in patient notes on EMR

    For more information on pre-term infant management click here

    Evidence table

    The evidence table for this guideline can be viewed here. 

    References

    • Baley, J. (2015). Skin-to-Skin Care for Term and Preterm Infants in the Neonatal ICU. PEDIATRICS, 136(3), pp.596-599.
    • Blomqvist, Y., Ewald, U., Gradin, M., Nyqvist, K. and Rubertsson, C. (2012). Initiation and extent of skin-to-skin care at two Swedish neonatal intensive care units. Acta Paediatrica, 102(1), pp.22-28.
    • Davanzo, R., Brovedani, P., Travan, L., Kennedy, J., Crocetta, A., Sanesi, C., Strajn, T. and De Cunto, A. (2013). Intermittent Kangaroo Mother Care. Journal of Human Lactation, 29(3), pp.332-338.
    • El-Farrash, R., Shinkar, D., Ragab, D., Salem, R., Saad, W., Farag, A., Salama, D. and Sakr, M. (2019). Longer duration of kangaroo care improves neurobehavioral performance and feeding in preterm infants: a randomized controlled trial. Pediatric Research.
    • Hubbard, J. and Gattman, K. (2017). Parent–Infant Skin-to-Skin Contact Following Birth: History, Benefits, and Challenges. Neonatal Network, 36(2), pp.89-97.
    • Hurley, A. and Harrison, C. (2019). Kangaroo care was as effective as sucrose for painful procedures for babies in the neonatal intensive care unit. Archives of disease in childhood - Education & practice edition, pp.edpract-2019-318095.
    • Karlsson, V, Heinemann, A, Sjors, G, Hedberg Nykvist, K & Agren, J (2012), ‘Early Skin-to-Skin Care in Extremely Preterm Infants: Thermal Balance and Care Environment’, Journal of Pediatrics, 161(3): 422-426.
    • Kelley-Quon, L., Kenney, B., Bartman, T., Thomas, R., Robinson, V., Nwomeh, B. and Bapat, R. (2019). Safety and feasibility of skin-to-skin care for surgical infants: A quality improvement project. Journal of Pediatric Surgery, 54(11), pp.2428-2434.
    • Kymre, I. and Bondas, T. (2013). Balancing preterm infants’ developmental needs with parents’ readiness for skin-to-skin care: A phenomenological study. International Journal of Qualitative Studies on Health and Well-being, 8(1), p.21370.
    • Lorenz, L., Dawson, J., Jones, H., Jacobs, S., Cheong, J., Donath, S., Davis, P. and Kamlin, C. (2017). Skin-to-skin care in preterm infants receiving respiratory support does not lead to physiological instability. Archives of Disease in Childhood - Fetal and Neonatal Edition, 102(4), pp.F339-F344.
    • Managan, S & Mosher, S (2012), ‘Challenges to Skin-to-Skin Kangaroo Care: Cesarean Delivery and Critically Ill NICU Patients’, Neonatal Network, 31(4): 259-261.
    • Mangat, A., Oei, J., Chen, K., Quah-Smith, I. and Schmölzer, G. (2018). A Review of Non-Pharmacological Treatments for Pain Management in Newborn Infants. Children, 5(10), p.130.


    Please remember to read the disclaimer

     

    The review of this nursing guideline was coordinated by Emily Dam, Registered Nurse/Registered Midwife, Butterfly Ward, and approved by the Nursing Clinical Effectiveness Committee. Updated January 2020.