Acta Pædiatrica ISSN 0803–5253

REGULAR ARTICLE

Extremely preterm infants tolerate skin-to-skin contact during the first

weeks of life
Ragnhild Maastrup (ram@rh.regionh.dk)1,2, Gorm Greisen1,3
1.Department of Neonatology, Rigshospitalet, Copenhagen, Denmark
2.Knowledge Centre for Breastfeeding Infants with Special Needs, Rigshospitalet, Copenhagen, Denmark
3.University of Copenhagen, Copenhagen, Denmark

Keywords ABSTRACT
Extremely preterm infants, Skin temperature, Aim: To determine if clinically stable extremely preterm infants can maintain their
Skin-to-skin contact
temperature during skin-to-skin contact and to screen for other negative effects.
Correspondence Methods: Continuous measurement of 22 stable infants’ physical parameters 2 h
R Maastrup, Department of Neonatology 5023,
Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen
before, during, and 2 h after skin-to-skin-contact. Mean gestational age at birth was
Ø, Denmark. 25 weeks and 4 days, mean post-natal age was 8 days, postmenstrual age was 26 weeks
Tel: +45 3545 0833 | and 6 days, and mean actual weight 702 g. Mean duration of skin-to-skin-contact was
Fax: +45 3545 5025 |
Email: ram@rh.regionh.dk
98 min. 16 infants were skin-to-skin with the mother, five with the father and one with an
older sister.
Received
25 January 2010; revised 11 March 2010;
Results: There were no significant differences in mean skin temperature, heart rate,
accepted 19 March 2010. respiration rate, or oxygen saturation before, during, and after skin-to-skin contact. While
DOI:10.1111/j.1651-2227.2010.01806.x
staying within normal range, the mean skin temperature increased 0.1C during skin-to-skin
contact with the mother and decreased 0.3C during skin-to-skin contact with the father
(p = 0.011) (without post-hoc correction).
Conclusion: Clinically stable, extremely preterm infants can keep adequate skin temperature and
adequate physical stability during skin-to-skin contact with their parents.

INTRODUCTION
The benefits of skin-to-skin contact for extremely preterm
infants (1,2) are not as well documented as for other pre-
term infants (3–9). Skin-to-skin contact promotes stable
temperature, weight gain, calm behaviour, breastfeeding
and parent-infant bonding. Little is known about the limits
of gestational age (GA), weight or stability (if any) for skin-
to-skin contact, resulting in restrictions in many neonatal
intensive care units (NICUs).
Extremely preterm infants differ from other preterm
infants by a more immature temperature regulation, less
subcutaneous fat, and a more permeable skin during the
first weeks of life, resulting in higher evaporative heat loss.
The concerns are whether extremely preterm infants can
maintain adequate temperature during skin-to-skin contact,
can do without the high humidity of the incubator, can tol-
erate the transfer from incubator to the parent’s chest, and
whether the infant can be observed properly during skin-to-
skin contact when the infant is covered by the blanket or
eiderdown.
Abbreviations
BW, birth weight; CPAP, continuous positive airway pressure;
FiO2, fraction of inspired oxygen; GA, gestational age; NICU,
neonatal intensive care unit.
The hypotheses for the study were: 1) When transfers and
position are optimized, the extremely preterm infants will
keep adequate temperature (36.5–37.5C) while they are
skin-to-skin with their parents, and 2) the infants do not
become more unstable.
PATIENTS AND METHODS
A prospective clinically intervention study was chosen,
where the infants serve as their own control group, in a pre-
test–test–posttest design. The Biomedical Research Ethics
Committee Capital Region approved the project (no. H-
A-2007-0110).
Extremely preterm infants were defined as infants born
before 28 weeks of gestation; Skin-to-skin contact was
defined as the infant – only dressed in a diaper and a cap –
lying on the parent’s bare chest.
Infants were tested in the NICU at Rigshospitalet, Copen-
hagen University Hospital in Denmark, a 36-bed level III
unit with 2-bedded and 5-bedded rooms. All thirteen 2-bed-
ded rooms are equipped with a bed for the parent beside
each incubator ⁄ crib. Two infants in each of the two 5-bed-
ded rooms have a parent bed beside the incubator ⁄ crib.
From March 2008 to December 2008 fifty-seven extre-
mely preterm infants were admitted to the NICU. The
researcher was not available for 22 of the infants and two of

ª2010 The Author(s)/Journal Compilation ª2010 Foundation Acta Pædiatrica/Acta Pædiatrica 2010 99, pp. 1145–1149 1145
Skin-to-skin contact in extremely preterm infants Maastrup and Greisen

these infants died. Eleven infants were too unstable to par- participated, sixteen infants were skin-to-skin with their
ticipate and of them nine died. The 22 infants who attended mother, five with the father and one with and older sister
the study were on average born with lower gestational age (who had almost adult body size). Eleven parents were posi-
(GA) and lower birth weight (BW) than the group as a tioned in beds during the test, and the rest in arm-
whole, but not different from the infants who were too chairs ⁄ recliners.
unstable to participate (Fig. 1). Two of the participating Eleven infants needed additional oxygen, the room air
infants died afterwards. The deaths were not related to the temperature during the test ranged between 25 and 27C.
skin-to-skin contact. None of the parents refused to let their
infant participate. Data collection
The pre-test lasted for 2 h while the infant was in the incu-
Background information bator, followed by the test, which was the entire period the
The participating infants’ mean GA was 25 weeks and four infant had skin-to-skin contact with its parents. The skin-to-
days. The infants’ mean postmenstrual age when they par- skin period lasted from 51 min to six and a half hours. Post-
ticipated in the study was 26 weeks and five days with a test began once the infant was back into the incubator and
mean weight of 702 g. Mean age at study time was eight lasted for 2 h.
days; ten infants participated in the first week of life Temperature was measured continuously from the start
(Table 1). The duration of skin-to-skin contact was mean of the pre-test to the end of the post-test with a Philips skin
98 min, but with considerable variation. temperature probe fixed on the infants lower back with
Incubator temperature before skin-to-skin contact was Mepilex border lite (Mölnlycke Healthcare, Göteborg,
high (mean 34.1C) and there was also a high humidity in Sweden) and covered with a thermal reflector Neo Guard
the incubator (mean 63%). Five infants were not provided (Casmed, Branford, CT, USA). Skin temperature values for
with additional humidity in their incubators, so that their every minute were monitored electronically (Philips
humidity level was 30% (as measured in a Giraffe Incubator IntelliVue MP 30 (Philips Healthcare, Boeblingen,
(GE Healthcare, Madison, WI, USA)). Ten infants had Germany)) and entered to Excel 2000, and mean values
umbilical catheters and eight infants had peripheral or per- for each infant’s pre-test, test and post-test period were cal-
cutanious lines. One infant was mechanically ventilated, the culated.
rest were treated with nasal Continuous Positive Airway Heart rate, respiration rate, and oxygen saturation were
Pressure (CPAP) (Table 1). Fourteen girls and eight boys monitored electronically (Philips IntelliVue MP 30). The
pre-test, test and post-test trend curves were printed on
paper from the monitoring system, trimmed to the correct
Extremely preterm infants time segment, and assessed blindly by visual inspection to
born in the research period: 57 determine the mean values. Twenty-one values were re-read
GA 26 + 1, BW 825 grams Researcher not available:
13 deaths 22 infants blindly. Mean difference was 0.01% (range )5% to +3%).
GA 27 + 1, BW 955 grams Stimulation-requiring events were recorded (bradycardias,
Possible participants: 2 deaths
oxygen desaturations or apnoeas).
35 infants
Infant to unstable: Transfer between the incubator and parents were stan-
11 infants dardized and optimized to prevent heat loss. A blanket with
GA 25 + 3, BW 710 grams
Consent: 9 deaths plastic inside was placed in the incubator for heating and
24 infants moistening before transfer. The infant wore a cap, was
Not skin-to-skin because
wrapped in the warm blanket, transferred, and placed on
of instability:
2 infants the parent’s naked chest sternum to sternum. The blanket
Participants: GA 26 + 1, BW 963 grams was partly removed in order to allow full skin-to-skin con-
22 infants
GA 25 + 4, BW 735 grams
tact, but still covering the infant’s back. Another blanket
2 deaths was formed as a ‘U’, and placed around the infant in order
to create a warm and moist microclimate. Upon this a warm
Figure 1 Flow diagram. eiderdown from the incubator was placed.

Table 1 Study group (n = 22)
Gestational age, weeks + days
Postmenstrual age at test, weeks + days
Birth weight (g)
Weight at test (g)
Postnatal age at test (days)
Duration of skin-to-skin contact (min)
Incubator temperature at pre-test, (C)
Incubator humidity at pre-test (%)
Statistical analysis
Data were analyzed using Microsoft Excel 2000 and SPSS
Mean (range)
12.0 (SPSS inc, Chicago, IL, USA). 22 infants were designed
25 + 4 (23 + 6–27 + 0) to participate in the study as this number allows excluding a
26 + 5 (25 + 1–27 + 6) difference of one standard deviation with a p-value of 0.05
735 (460–1050) and a power of 80%. All variables, except for number of
702 (435–900) apnoeas, were reasonably normally distributed. Repeated
8 (1–27) measures analysis of variance was used. When analysing the
98 (51–387)
effect on temperature, mother ⁄ not mother was used as a
34.1 (29.3–37.5)
‘between subject factor’. There was no evidence of inhomo-
63 (30–84)
geneity of variance. The number of apnoeas in each infant

1146 ª2010 The Author(s)/Journal Compilation ª2010 Foundation Acta Pædiatrica/Acta Pædiatrica 2010 99, pp. 1145–1149
Maastrup and Greisen
Table 2 Physical parameters (n = 22)
Pretest mean Test mean
(±SD) (±SD)
Mean skin temperature (C) 37.1 (±0.33) 37 (±0.40)
Heart rate (bpm) 160 (±11) 160 (±12)
Respiration rate (per min) 47 (±7) 47 (±6)
Oxygen saturation (%) 95 (±3) 96 (±2)
FiO2 0.25 (±0.06) 0.24 (±0.05)
Stimulation required 12 5 6
apnoeas in total
(varying between 0 and 2) before, during and after SSC were
compared with the Kruskall–Wallis’ test. p value <0.05 was
considered as statistically significant.
Criterion for inclusion and exclusion
The infants should be <28 weeks post menstrual age at
study time and considered stable for transfer to the parents
for skin-to-skin contact. The parents should be willing to
provide skin-to-skin contact with their infant, and signed
consent from both parents obtained. The infant could be on
conventional mechanical ventilation.
Exclusion criteria were use of nitrogen oxide, high fre-
quency oscillation, FiO2 >0.70, chest drain, fever of infant
or parent, unstable infant (many apnoeas requiring stimula-
tion or any apnoea requiring ventilation) during 3 h preced-
ing the pre-test period.
Infants younger than 26 weeks GA were at least 3 days
old before skin-to-skin contact. Umbilical catheters and
endotracheal tubes were fixed to ensure no displacements
during transfer. Guidelines for transfer and position were
followed to ensure standardized and comparable situations.
Skin-to-skin contact continued as long as the parent
wished if the infant was stable.
Once the signed consent from both parents was obtained,
the next skin-to-skin session was used for the study. All
infants wore caps, and all infants were placed prone at the
parent’s chest including the ten infants with umbilical cath-
eter. In one case the skin-to-skin contact was interrupted
because of the infant’s instability, and in one case the
mother wore a bra during the skin-to-skin contact. In both
cases a new test was performed the following day, and only
the last test was used in the statistics.
RESULTS
The infants’ mean skin temperature during skin-to-skin
contact was 37.0C (±0.33). There were no significant dif-
ferences between mean values in the pre-test, test or post-
test (Table 2). The mean skin temperature decreased in two
infants to 36.3C and 36.4C, and increased in one infant to
38.0C during skin-to-skin contact, all other mean skin tem-
peratures were in normal range.
Some infants had apnoeas requiring stimulation in the
pre-test, test and post-test periods. The tendency was to less
apnoeas during and after skin-to-skin contact, but this was
not statistically significant.
ª2010 The Author(s)/Journal Compilation ª2010 Foundation Acta Pædiatrica/Acta Pædiatrica 2010 99, pp. 1145–1149
Skin-to-skin contact in extremely preterm infants
Temperature variations
Posttest mean When comparing mean skin temperature in the pre-test and
(±SD) the test period, the mean change of temperature was +0.1C
for infants with skin-to-skin contact with the mother and
37.1 (±0.28)
)0.3C for infants with skin-to-skin contact with the father
161 (±14)
or sister (p 0.011) (without post-hoc correction). All six
48 (±8)
95 (±3) infants who were skin-to-skin with their father or sister
0.24 (±0.06) decreased in skin temperature (one of these six infants was
skin-to-skin with both the father and the mother in the test
period, resulting in an extra transfer). The two infants who
decreased below 36.5C were skin-to-skin with their father
or older sister. Five infants who were skin-to-skin with the
mother decreased in mean skin temperature, the remaining
eleven infants had increased or unchanged mean skin tem-
perature.
Regarding change of temperature no other trends or sig-
nificant differences were found in gestational age, post natal
age, weight, weight loss, incubator temperature, incubator
humidity, oxygen requirement or instability.
Temperature decrease during transfer
The group mean skin temperature per minute decreased
with 0.1C, when the infants were transferred from the incu-
bator to the parents, and decreased with mean 0.3C when
they were transferred from the parents and back to the incu-
bator (Fig. 2). After the back transfer the decrease period
was longer (10 min), and the infants took a longer time to
regain their ‘pre-temperature’.
DISCUSSION
The study confirmed the hypothesis that extremely preterm
infants can keep adequate skin temperature during skin-to-
skin contact with the parent. This is similar to van Zanten’s
study (2) of eighteen infants born before 27 weeks GA, who
had skin-to-skin contact at a mean postnatal age of three
days, but different from the study by Bauer (1) with eleven
infants born before 28 weeks GA and studied during skin-
to-skin contact in the first and second week of life. Bauer’s
infants decreased in rectal temperature in the first week of
life with mean 0.3C but had increased temperature in the
second week of life. These infants’ heads were left uncov-
ered and exposed to room air (26C). We only studied the
infants once, and only ten infants were studied in the first
week of life. But the small number of infants limits further
statistical analysis. All infants in our study wore caps, and
blankets covered overtop their entire body.
Two infants’ mean skin temperature decreased to 36.3C
and 36.4C, this was considered clinically unimportant.
Placing warm blankets at the infant’s back could properly
prevent even these temperature decreases. This procedure
was subsequently used with good effect on two other
infants, where we wanted the skin temperature to increase.
All other infants had adequate temperature without provid-
ing extra warmth.
Temperature decreased more when the infant was skin-
to-skin with the father than with the mother (p = 0.011).
This comparison, however, was made together with 12
1147
Skin-to-skin contact in extremely preterm infants
38.5
38.0
Skin temperature
37.5
37.0
36.5
36.0
35.0
0 10
Figure 2 Temperature change following transfer. Group mean per minute. The line with open dots shows the mean skin temperature following transfer to skin-to-
skin contact; the bold line shows the mean skin temperature following transfer back to the incubator. The thin lines indicate ±2 SD.
other possible variables and this finding may be coinciden-
tal. As far as we know, it has not previous been shown, that
infant temperature decreases more when the infant is skin-
to-skin with the father compared to the mother. Other stud-
ies found no difference in infant temperature between
mother and father (2,10). On the other hand, it is known
from Ludington-Hoe’s work (3) that new mothers and
breastfeeding mothers’ temperature on the chest and breast
is higher than in other women and in men. This is due to both
changes during pregnancy (hormones and increased breast
gland tissue) and that the blood circulation in and around
the breast is increased when the mother produces milk. All
mothers in our study provided breast milk for their infant. It
is likely that the difference in chest temperature may only
have importance for the extremely preterm infants. Infants
in the present study had lower GA and BW than in Bauer’s
study (1), and lower BW than in van Zanten’s study (2).
It was not possible to avoid temperature decreases when
the infants were transferred from incubator to parents,
despite optimal transfer technique, even though only small
decreases occurred, but the infants had the greatest temper-
ature decrease at mean 0.3C when they were transferred
from the parents and back to the incubator. This highlights
the importance of planning longer skin-to-skin sessions, not
only with moderate preterm infants but also with extremely
preterm infants. Bauer’s study also showed decreasing tem-
perature after transfers (1).
Limitations
The infants were very young and small. Only one infant,
however, was studied the very first time, she was skin-to-
skin, and six infants the second time. Eleven infants were
skin-to-skin for the 3rd, 4th or 5th time, and the remaining
four infants had previously been skin-to-skin for seven or
more times.
Although the infants could participate in the study
while they were on mechanical ventilation, only one
1148 ª2010 The Author(s)/Journal Compilation ª2010 Foundation Acta Pædiatrica/Acta Pædiatrica 2010 99, pp. 1145–1149
Maastrup and Greisen
20 30 40 50 60
Minutes
infant did. (In Denmark nasal CPAP is widely used for
extremely preterm infants from right after birth or
within a few days.)
CONCLUSION
Clinically stable, extremely preterm infants can keep ade-
quate skin temperature during skin-to-skin contact with
their mother or father, and stay stable during and after the
skin-to-skin contact. The finding of lower temperatures dur-
ing skin-to-skin contact with the father compared to the
mother warrants more research.
ACKNOWLEDGEMENT
The authors thank all parents and infants who participated
in this study. They acknowledge the Aase and Ejnar Daniel-
sen Foundation for financial support.
References
1. Bauer K, Pyper A, Sperling P, Uhrig C, Versmold H. Effects of
gestational and postnatal age on body temperature, oxygen
consumption, and activity during early skin-to-skin contact
between preterm infants of 25–30-week gestation and their
mothers. Pediatr Res 1998; 44: 247–51.
2. Van Zanten HA, Havenaar AJ, Stigt HJH, Ligthart PAH,
Walther FJ. The kangaroo method is safe for premature infants
under 30 weeks of gestation during ventilatory support.
J Neonatal Nurs 2007; 13: 186–90.
3. Ludington-Hoe SM, Nguyen N, Swinth JY, Satyshur RD.
Kangaroo care compared to incubators in maintaining
body warmth in preterm infants. Biol Res Nurs 2000;
2: 60–73.
4. Ludington-Hoe SM, Johnson MW, Morgan K, Lewis T,
Gutman J, Wilson PD, et al. Neurophysiologic assessment of
neonatal sleep organization: preliminary results of a random-
ized, controlled trial of skin contact with preterm infants.
Pediatrics 2006; 117: e909–23.
Maastrup and Greisen
5. Bergman NJ, Linley LL, Fawcus SR. Randomized controlled
trial of skin-to-skin contact from birth versus conventional
incubator for physiological stabilization in 1200- to 2199-gram
newborns. Acta Paediatr 2004; 93: 779–85.
6. Cattaneo A, Davanzo R, Worku B, Surjono A, Echeverria M,
Bedri A, et al. Kangaroo mother care for low birthweight
infants: a randomized controlled trial in different settings.
Acta Paediatr 1998; 87: 976–85.
7. Charpak N, Ruiz-Pelaez JG, Figueroa de CZ, Charpak Y. A
randomized, controlled trial of kangaroo mother care: results of
follow-up at 1 year of corrected age. Pediatrics 2001; 108:
1072–9.
ª2010 The Author(s)/Journal Compilation ª2010 Foundation Acta Pædiatrica/Acta Pædiatrica 2010 99, pp. 1145–1149
Skin-to-skin contact in extremely preterm infants
8. Charpak N, Ruiz JG, Zupan J, Cattaneo A, Figueroa Z, Tessier
R, et al. Kangaroo mother care: 25 years after. Acta Paediatr
2005; 94: 514–22.
9. Chwo MJ, Anderson GC, Good M, Dowling DA, Shiau SH,
Chu DM. A randomized controlled trial of early kangaroo care
for preterm infants: effects on temperature, weight, behavior,
and acuity. J Nurs Res 2002; 10: 129–42.
10. Bauer J, Sontheimer D, Fischer C, Linderkamp O. Metabolic
rate and energy balance in very low birth weight infants during
kangaroo holding by their mothers and fathers. J Pediatr
1996; 129: 608–11.
1149