Skin to Skin

Question
I do have another question which I know has been raised many times by our staff, and in perinatal mortality meetings it comes up often too. It is the question of "skin to skin". This is practiced immediately after birth for at least 1 hr and is recommended for the first day/days to promote breastfeeding. The baby sleeps prone skin to skin on Mum's chest. What are your thoughts/ evidence re safety of this?? Obviously the mother is educated that this is done for the reason above and info re safe sleep is also given. This is seen by some staff to be giving conflicting advice.  I appreciate your input as this is a real "curly" one.

Response

I will pass this one by paediatricians for a definitive response, as the review below suggests more research is needed to clarify safety guidelines, but my educational response, based on understandings of SUDI risks are these:

  • Encourage colleagues to work from principle, with evidence and always considering the context. Encourage them to do the cost benefit analysis as this is what we are expecting parents to do. Encourage them to be clear about benefits and potential harm and think about safety for the baby if things change. They need to get good at the who, what, when, where, how and why questions of assessment. They need to get comfortable with tensions between what is good in one context and may not be in another.
    • Skin to skin has benefits if practiced within guidelines and it is likely to carry risk if practiced outside those guidelines. Just what those guidelines are may be a developing process in many settings.
    • Sleeping non-supine has real risks, as does more vulnerable babies sleeping with sleeping others.
  • My thoughts and they are just that:
    • Encourage skin to skin for the purposes of promoting breastfeeding and calming unsettled babies within safety guidelines. Such guidelines might be:
      • Always with an awake parent
      • Always in a safe place (hospital adult beds were not designed to be safe for babies and would need to be made safe or a safer alternative found) and with consideration for safety should things change during the skin to skin session (e.g. mother falls asleep, baby rolls off mother …)
      • Supervised by an aware adult if there is any risk the mother might fall asleep
      • Only when both baby and mother are awake, for more vulnerable babies (babies exposed to smoking in pregnancy, of low birthweight or born before 36 weeks).

As I have said, there is unlikely to be a black and white answer here, and discussion and looking for a sensible middle road may have to support us until there is. I hope this helps and no doubt the CC'd pediatricians will have a more authoritative response.

Response from Dr Pat Tuohy
A well reasoned response Stephanie.  I would support your suggested guidelines.  They are similar to guidelines which have been developed for care of infants in the immediate postnatal situation, where the mum has had a caesarian section, and may not be fully responsive to the baby.
Dr Pat Tuohy
Chief Advisor - Child & Youth
Health & Disability Services Policy Group
Population Health Directorate
Ministry of Health

Article
Breastfeeding promotion for infants in neonatal units: a systematic review and economic analysis.
Renfrew MJ, Craig D, Dyson L, McCormick F, Rice S, King SE, Misso K, Stenhouse E, Williams AF.
Mother and Infant Research Unit, Department of Health Sciences, University of York, UK.
OBJECTIVES: To evaluate the effectiveness and cost-effectiveness of interventions that promote or inhibit breastfeeding or feeding with breastmilk for infants admitted to neonatal units, and to identify an agenda for future research. DATA SOURCES: Electronic databases were searched (including MEDLINE and MEDLINE In-Process Citations, EMBASE, CINAHL, Maternity and Infant Care, PsycINFO, British Nursing Index and Archive, Health Management Information Consortium, Cochrane Central Register of Controlled Trials, Science Citation Index, Pascal, Latin American and Caribbean Health Sciences, MetaRegister of Controlled Trials, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effectiveness, Health Technology Assessment Database, National Research Register) from inception to February 2008. Advisors identified further published or unpublished material. REVIEW METHODS: All papers fulfilled eligibility criteria covering participants, interventions, study design and outcomes. Results from primary studies were assessed and summarised in a qualitative synthesis for each type of intervention and across types of intervention. To estimate long-term cost utility, a decision tree was developed to synthesise data on enhanced staff contact, breastmilk effectiveness, incidence of necrotising enterocolitis (NEC) and sepsis, resource use, survival and utilities. RESULTS: Forty-eight studies met the selection criteria for the effectiveness review, of which 65% (31/48) were RCTs, and 17% (8/48) were conducted in the UK. Seven were rated as good quality and 28 as moderate quality. No studies met the selection criteria for the health economics review. There is strong evidence that short periods of kangaroo skin-to-skin contact increased the duration of any breastfeeding for 1 month after discharge [risk ratio (RR) 4.76, 95% confidence interval (CI) 1.19 to 19.10] and for more than 6 weeks (RR 1.95, 95% CI 1.03 to 3.70) among clinically stable infants in industrialised settings. There is strong evidence for the effectiveness of peer support at home (in Manila) for mothers of term, low birthweight infants on any breastfeeding up to 24 weeks (RR 2.18, 95% CI 1.45 to 3.29) and exclusive breastfeeding from birth to 6 months (RR 65.94, 95% CI 4.12 to 1055.70), and for the effectiveness of peer support in hospital and at home for mothers of infants in Special Care Baby Units on providing any breastmilk at 12 weeks [odds ratio (OR) 2.81, 95% CI 1.11 to 7.14; p = 0.01]. There is more limited evidence for the effectiveness of skilled professional support in a US Neonatal Intensive Care Unit on infants receiving any breastmilk at discharge (OR 2.0, 95% CI 1.2 to 3.2, p = 0.004). Multidisciplinary staff training may increase knowledge and can increase initiation rates and duration of breastfeeding, although evidence is limited. Lack of staff training is an important barrier to implementation of effective interventions. Baby Friendly accreditation of the associated maternity hospital results in improvements in several breastfeeding-related outcomes for infants in neonatal units. Limited evidence suggests that cup feeding (versus bottle feeding) may increase breastfeeding at discharge and reduce the frequency of oxygen desaturation. Breastmilk expression using simultaneous pumping with an electric pump has advantages in the first 2 weeks. Pharmaceutical galactagogues have little benefit among mothers who have recently given birth. Our economic analysis found that additional skilled professional support in hospital was more effective and less costly (due to reduced neonatal illness) than normal staff contact. Additional support ranged from 0.009 quality-adjusted life-years (QALYs) to 0.251 QALYs more beneficial per infant and ranged from 66 pounds to 586 pounds cheaper per infant across the birthweight subpopulations. Donor milk would become cost-effective given improved mechanisms for its provision. CONCLUSIONS: Despite the limitations of the evidence base, kangaroo skin-to-skin contact, peer support, simultaneous breastmilk pumping, multidisciplinary staff training and the Baby Friendly accreditation of the associated maternity hospital have been shown to be effective, and skilled support from trained staff in hospital has been shown to be potentially cost-effective. All these point to future research priorities. Many of these interventions inter-relate: it is unlikely that specific clinical interventions will be effective if used alone. There is a need for national surveillance of feeding, health and cost outcomes for infants and mothers in neonatal units; to assist this goal, we propose consensus definitions of the initiation and duration of breastfeeding/breastmilk feeding with specific reference to infants admitted to neonatal units and their mothers.