Immediate skin-to-skin contact for very preterm and low birth weight infants : from newborn physiology to mortality reduction

There is a contrast between the incidence of low birth weight and the contents and outcomes of neonatal care in high- versus middle- and low-income countries. Most of the neonatal deaths worldwide are attributed to low birth weight, occur within the first three postnatal days and can be prevented without intensive care.

There are many benefits of skin-to-skin contact when initiated as per today’s recommendations, after an infant has become stable. Intermittent skin-to-skin contact is a component of neonatal care in Sweden. There is a knowledge gap concerning the effects of skin-to-skin contact initiated immediately after birth in unstable newborn very preterm and low birth weight infants.

The overall aim of this thesis was to fill the knowledge gap on the effects of skin-to-skin contact initiated immediately after birth in unstable very preterm and low birth weight infants in high- as well as in low- and middle-income countries. More specifically, the aims were to investigate the cardiorespiratory effects and the effect on mortality.

The five studies in this thesis derive from three randomised clinical trials comparing care in skin-to-skin contact immediately after birth with conventional care for very preterm or low birth weight infants, and from one register study. Studies I and II involved very preterm infants in Scandinavia, where study I (n=55) investigated the effect on infant temperature at one postnatal hour and study II (n=91) infant cardiorespiratory parameters during the first six postnatal hours. Study III (n=1475) reported on skin-to-skin contact initiation time and daily duration as per the Swedish Neonatal Quality Register. Study IV (n=3211) was a trial on the effect on neonatal mortality in low birth weight infants in Ghana, India, Malawi, Nigeria and Tanzania. Study V described the cardiorespiratory parameters during the first four days in the infants enrolled in study IV.

Study I found that infants in skin-to-skin contact had 0.3°C lower temperature at one postnatal hour and study II that they had 0.52 points higher stability on a six-graded scale during the first six postnatal hours. Study III found that currently in Sweden, we initiate skin- to-skin contact for very preterm infants after half a day and daily durations of skin-to-skin contact amount to five hours during the stay in the neonatal unit. Study IV found 25% reduced neonatal mortality in low birth weight infants exposed to immediate and continuous skin-to-skin contact. Study V found similar cardiorespiratory parameters during the first four days of life in the two allocations of the cohort of study IV.

There were benefits of skin-to-skin contact initiated immediately after birth, in terms of cardiorespiratory stabilisation in very preterm infants in high-income countries and mortality reduction in low birth weight infants in low- and middle-income countries. Skin-to-skin contact immediately after birth was not part of the conventional care. Data were collected during different postnatal time periods in the studies and were thus not comparable in detail.

Mother-neonatal intensive care units should be available where low birth weight infants are born and skin-to-skin contact integrated into the neonatal medical care. Future research should focus on risks and scale-up.

List of scientific papers

I. Linner A, Klemming S, Sundberg B, Lilliesköld S, Westrup B, Jonas W, Skiöld B. Immediate skin-to-skin contact is feasible for very preterm infants but thermal control remains a challenge. Acta Paediatrica. 2020;109(4):697-704.
https://doi.org/10.1111/apa.15062

II. Linnér A, Lode Kolz K, Klemming S, Bergman NJ, Lilliesköld S, Markhus Pike H, Rettedal S, Westrup B, Jonas W. Immediate skin-to-skin contact may have beneficial effects on cardiorespiratory stabilisation in very preterm infants. Acta Paediatrica. 2022;00:1-8.
https://doi.org/10.1111/apa.16371

III. Linnér A, Lilliesköld S, Jonas W, Skiöld B. Initiation and duration of skin-to-skin contact for extremely and very preterm infants: A register study. [Submitted]

IV. WHO immediate KMC study group. Immediate “Kangaroo mother care” and survival of infants with low birth weight. New England Journal of Medicine. 2021;384(21):2028–2038.
https://doi.org/10.1056/NEJMoa2026486

V. Linnér A, Westrup B, Rettedal S, Kawaza K, Naburi N, Newton S, Morgan B, Chellani H, Arya S, Samuel V, Adejuyigbe E, Wireko Brobby NA, Boakye-Yiadom AP, Gadama L, Assenga E, Ngarina M, Rao S, Bahl R, Bergman NJ. Cardiorespiratory stabilisation in the “Immediate Kangaroo mother care study”: Post hoc analyses of a randomised clinical trial. [Manuscript]