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Skin-to-skin Contact:
A Paramount Contribution
to the Modern
Neonatal Paradigm
Jorge Ce´sar Martı´nez*
Introduction
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.
Benefits of 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.
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.
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-*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.
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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 increascreat-ing 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)
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)
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
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.
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