Advancing Neonatal Outcomes through Skin-to-Skin Care

Skin-to-skin care (SSC), also referred to as kangaroo care (KC), is a recognized best practice during the neonatal period, with extensive evidence supporting its critical role in promoting optimal physiological, developmental, and psychosocial outcomes(1). SSC facilitates the newborn's adaptation to postnatal life, supports the initiation and establishment of human milk feeding, fosters parent–infant bonding, and enhances both neurodevelopment and physiological stability(1,2).Initiation of SSC should occur immediately following birth, regardless of the mode of delivery, vaginal or caesarean(3). The newborn is placed in a prone position directly on the birthing parent's bare chest or abdomen, ensuring no clothing or barriers interfere with direct skin contact. Unless the infant requires advanced neonatal resuscitation, uninterrupted SSC should continue for a minimum of one hour post-delivery. This duration coincides with the newborn’s progression through innate behavioural stages culminating in the first breastfeeding attempt (1).

To optimize neonatal adaptation and the initiation of human milk feeding, SSC should be prioritized with the birthing parent(1,4,5). However, if the birthing parent is medically unstable, another individual designated by the parent or family may assume SSC responsibilities. The practice confers multiple benefits, including reduced neonatal pain and stress, improved parent-infant attachment, enhanced neurological development, and positive impacts on parental mental well-being. SSC is effective in both clinical and home environments and should be sustained after hospital discharge with continued education and support provided by the healthcare team(1,6).

Recent evidence syntheses have prompted the World Health Organization (WHO) to recommend initiating SSC as soon as possible post-birth, with prolonged daily contact—ideally 8 hours or more, and up to 24 hours per day when feasible(6). The healthcare team plays a pivotal role in promoting and facilitating SSC through culturally sensitive education, provision of appropriate resources and equipment, and support tailored to the unique needs of each family. Importantly, SSC should be encouraged for all infants, irrespective of their feeding modality or clinical care requirements(1,7,8).

Impact of SSC on Breastfeeding and Human Milk Feeding Outcomes

Robust evidence from randomized controlled trials (RCTs) and systematic reviews strongly supports the positive impact of SSC on a wide range of human milk feeding outcomes in both term and preterm infants. For late preterm infants, SSC has been consistently associated with increased rates of exclusive breastfeeding at hospital discharge and up to one month postpartum, as well as improved rates of any breastfeeding at 1 to 4 months of age (9).Systematic reviews and meta-analyses indicate that SSC, particularly in neonatal intensive care settings, significantly enhances the likelihood of exclusive breastfeeding at discharge and during follow-up intervals at 1, 3, and 4 months(1,2,10,11). Notably, evidence suggests a dose–response relationship between SSC duration and breastfeeding outcomes, particularly among preterm infants. Greater cumulative exposure to SSC during hospitalization correlates with improved human milk feeding outcomes (1,2,12).Even brief SSC sessions of up to one hour have been shown to extend the overall duration of any breastfeeding. Furthermore, SSC is associated with increased volumes of expressed human milk and plays a critical role in supporting infants’ transition from enteral (e.g., tube) feeding to direct breastfeeding. As such, SSC should be regarded as an essential component of postnatal care, with far-reaching implications for infant nutrition and parental health(1).

References:

1.         Altit G, Hamilton D, O’Brien K. Skin-to-skin care (SSC) for term and preterm infants. Paediatr Child Health. 2024 Jul 1;29(4):238–45.

2.         Protecting, promoting and supporting breastfeeding: the baby-friendly hospital initiative for small, sick and preterm newborns [Internet]. [cited 2025 May 29]. Available from: https://www.who.int/publications/i/item/9789240005648

3.         WHO recommendations for care of the preterm or low-birth-weight infant [Internet]. [cited 2025 May 29]. Available from: https://www.who.int/publications/i/item/9789240058262

4.         The nine stages of skin‐to‐skin: practical guidelines and insights from four countries - Brimdyr - 2020 - Maternal & Child Nutrition - Wiley Online Library [Internet]. [cited 2025 May 29]. Available from: https://onlinelibrary.wiley.com/doi/10.1111/mcn.13042

5.         Early skin‐to‐skin contact for mothers and their healthy newborn infants - Moore, ER - 2016 | Cochrane Library [Internet]. [cited 2025 May 29]. Available from: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003519.pub4/full

6.         WHO recommendations for care of the preterm or low-birth-weight infant [Internet]. [cited 2025 May 29]. Available from: https://www.who.int/publications/i/item/9789240058262

7.         Canada PHA of. Chapter 6: Breastfeeding [Internet]. 2018 [cited 2025 May 29]. Available from: https://www.canada.ca/en/public-health/services/publications/healthy-living/maternity-newborn-care-guidelines-chapter-6.html

8.         Hubbard JM, Gattman KR. Parent–Infant Skin-to-Skin Contact Following Birth: History, Benefits, and Challenges. Neonatal Netw. 2017 Jan 1;36(2):89–97.

9.         Moore ER, Bergman N, Anderson GC, Medley N. Early skin‐to‐skin contact for mothers and their healthy newborn infants - Moore, ER - 2016 | Cochrane Library. [cited 2025 May 29]; Available from: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD003519.pub4/full

10.       Kangaroo Mother Care and Neonatal Outcomes: A Meta-analysis | Pediatrics | American Academy of Pediatrics [Internet]. [cited 2025 May 29]. Available from: https://publications.aap.org/pediatrics/article-abstract/137/1/e20152238/52828/Kangaroo-Mother-Care-and-Neonatal-Outcomes-A-Meta?redirectedFrom=fulltext

11.       Organization WH, Fund (UNICEF) UNC. Implementation guidance: protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services: the revised baby-friendly hospital initiative [Internet]. World Health Organization; 2018 [cited 2025 May 29]. Available from: https://iris.who.int/handle/10665/272943

12.       Skin‐to‐skin contact is associated with earlier breastfeeding attainment in preterm infants - Oras - 2016 - Acta Paediatrica - Wiley Online Library [Internet]. [cited 2025 May 29]. Available from: https://onlinelibrary.wiley.com/doi/10.1111/apa.13431