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

<p>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.</p><p>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.</p><p>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.</p><p>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.</p><p>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.</p><p>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.</p><p>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.</p><h3>List of scientific papers</h3><p>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. <br><a href="https://doi.org/10.1111/apa.15062">https://doi.org/10.1111/apa.15062</a><br><br> </p><p>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. <br><a href="https://doi.org/10.1111/apa.16371">https://doi.org/10.1111/apa.16371</a><br><br> </p><p>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]</p><p>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. <br><a href="https://doi.org/10.1056/NEJMoa2026486">https://doi.org/10.1056/NEJMoa2026486</a><br><br> </p><p>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]</p>