1

Integrative Review of the Literature

Natalie I. King

Bon Secours Memorial College of Nursing

NUR4322 Nursing Research

Dr. Karen Mellott

April 24, 2021

I pledge.
2

Abstract

Purpose: The purpose of this review was to determine the effect skin-to-skin contact can have on preterm

infants’ physiological stability during their hospital stay after birth. Background: Preterm babies are

often admitted to the NICU for observation and care. Implementing the practice of SSC in preterm babies

residing in the NICU can improve physiological stability (i.e., temperature, heart rate, respiratory rate,

oxygen saturation, and cardiorespiratory function), can promote maternal-infant bonding, can decrease

stress, and may even reduce the length of the hospital stay. Design and Search Method: The research

design is an integrative review based on five quantitative articles selected from Bon Secours’s eLibrary

Ovid Discovery Service, an online database. Results and Findings: When compared to a control group,

skin-to-skin contact benefits preterm infants and their physiological stability. SSC serves as a feasible

and cost-effective intervention. Limitations: A weakness of this review was that all articles chosen were

quantitative studies, with one of the five failing to incorporate a control group and another selecting

different physiological parameters to study. Implications for Practice: The results of this review

indicate a change of practice to incorporate the use of skin-to-skin contact in hospitals with premature

infants due to the unyielding benefits for both mother and baby. Recommendations for Future

Research: Future research should focus on observing the long-term effects early skin-to-skin contact can

have on those who were born prematurely. Additionally, it is recommended that various hospitals be

included in the studies rather than just the one.

3

Integrative Review of the Literature

The purpose of this integrative review is to investigate the effect of skin-to-skin (SSC) (also

referred to as kangaroo care (KC) or kangaroo mother care (KMC)) on preterm infants’ physiological

stability during hospitalization after birth. SSC is the practice where a naked infant is lain on their

mother’s bare chest after the first feed and covered with a warm blanket. While it is encouraged after the

first feed, it can be practiced any time the infant needs comforting or soothing. This has been proven

especially beneficial in neonatal intensive care units (NICUs) as it can help parents bond with their

newborns and can support physical and developmental outcomes in the infant (Unicef, n.d.).

Preterm babies (babies born earlier than 37 weeks gestation) are often admitted to the NICU for

observation and care. This hospitalization makes physiological adaptation difficult for these neonates due

to surrounding stressors (Shattnawi & Al-Ali, 2019). Implementing the practice of SSC in preterm babies

residing in the NICU can improve physiological stability (i.e., temperature, heart rate (HR), respiratory

rate (RR), oxygen saturation (O2 sat.), and cardiorespiratory function), can encourage pre-feeding

behavior, can aid in growth, and may even reduce the length of the hospital stay (Unicef, n.d.). SSC was

established by Rey and Martinez in 1978 in Bogota, Columbia when a neonatal hospital was short on

incubators (Jones, H. & Santamaria, N., 2018). They found that placing the naked infant on its mother’s

bare chest is safe, cost-effective, feasible, and even beneficial to both mother and baby. The aim of this

integrative review is to discuss and analyze quantitative research studies related to the PICOT question: In

preterm infants (P), what is the effect of skin-to-skin contact (I) on neonatal physiological outcomes (O)

during the hospitalization period (T)?

Design and Search Method

The research design is an integrative review. The search for research articles was done using the

computer-based search engine Ovid Discovery Service. This service displayed articles available from

various databases including, PubMed, UpToDate, and EBSCO. Search terms that were used included,

‘preterm,’ ‘neonate,’ ‘skin-to-skin contact,’ ‘kangaroo care,’ ‘vital signs,’ ‘physiological stability,’

‘physiological parameters,’ and ‘physiological outcomes.’ Thousands of articles came up using these
4

search terms, so filters were applied to focus the results. These filters included research articles, reviews,

English, and [published] since 2011. While this still yielded hundreds of results many of the articles still

were not relevant to the research being sought out. Some articles were obtained from these search terms,

and some were obtained from the reference lists of review articles on the subject.

The articles had to pertain to the researcher’s PICOT question, “In preterm infants, what is the

effect of skin-to-skin contact on neonatal physiological outcomes during the hospitalization period?” The

articles were then selected based on the following inclusion criteria: preterm infant population (anywhere

under 37 weeks of gestation when born), defined SSC or KC practice criteria and defined physiologic

parameters. The research article was screened based on inclusion criteria and PICOT question

significance. Articles that did not meet the criteria were excluded from the review. The screening

produced five quantitative (Cho, et al., 2016; Jones & Santamaria, 2018; Lee & Bang,2011; Parsa et al.,

2018; Shattnawi et al., 2019), NICU based intervention articles.

Findings and Results

The findings and results of the five reviewed studies suggests SSC be practiced in hospitals

around the world caring for preterm infants as indicated by physiological stability among those infants

practicing SSC compared to those who were not (Cho, et al., 2016; Jones & Santamaria, 2018; Lee &

Bang,2011; Parsa et al., 2018; Shattnawi et al., 2019). A synopsis of the compiled research articles is

presented in Appendix I. The researcher framed the review according to the following categories:

identification and evaluation of physiological stability and maternal-infant bonding.

Physiological Stability Parameters

All five studies identified and evaluated consistent parameters for physiological stability when

considering how SSC effects these parameters in preterm newborns (Cho, et al., 2016; Jones &

Santamaria, 2018; Lee & Bang,2011; Parsa et al., 2018; Shattnawi et al., 2019).

The purpose of this experimental design study by Cho et al. (2016) to was to identify the effects

of kangaroo care in premature infants (hospitalized in neonatal intensive care units) on maternal self-

esteem, premature infants weight gain, and physiological stability. This study took place in a university
5

hospital NICU in Korea over two years. The study followed 34 preterm infants; 17 were assigned to an

experimental group and 17 were assigned to a control group. Maternal-infant dyads in the experimental

group were evaluated once a day for two weeks while practicing skin-to-skin contact for 30 minutes;

infants in the control group received the same treatment with the exception of skin-to-skin contact.

Physiological parameters (body temperature, heart rate, respiratory rate, oxygen saturation, and SCRIP

score) were measured at the onset of kangaroo care, and then at 10 minutes, 20 minutes, and 30 minutes.

The data was statistically processed through SPSS for Windows (PASW) 28.0. Parametric

statistics were used for analysis despite the small sample size because the data was shown to be within

normal distribution. Parametric statistics compared the homogeneity between the two groups using a t-test

and explored the significant effects of interventions on the dependent variables using a repeated measure

ANOVA test. The study reported a significant difference between the experimental group and the control

group when comparing their respiratory rate, oxygen saturation, and physiological responses according to

reported SCRIP scores. The insignificant findings of heart rates could be attributed to the warm and

calming atmosphere that SSC promoted. The results of this suggest SSC, when practiced in a nursing

environment, may promote maternal-infant attachment as well as promoting growth in the premature

infant.

The purpose of this descriptive design study by Jones & Santamaria (2018) to was to determine if

there was a relationship between the duration of skin-to-skin contact and the neonate’s oxygen saturation,

heart rate, respiratory rate, and temperature. This took place in the NISC at The Royal Women’s Hospital

in Melbourne, Australia. The study followed 26 preterm infants; 17 were male and 9 were female. No

comparison group was used in this study. Parental-infant dyads were evaluated one time while practicing

skin-to-skin for no specified amount of time. Physiological parameters were measured (oxygen

saturation, heart rate, and respiratory rate) at the beginning of skin-to-skin contact, every five minutes

during skin-to-skin, and then at the conclusion of skin-to-skin, temperature was measured before, every

30 minutes throughout, and upon completion of skin-to-skin contact.

6

The data was analyzed using Microsoft Office Excel 2013 and SPSS V 22 (IBM). To compare the

relationship between the duration of skin-to-skin contact with the physiological parameters, a bivariate

correlation was used. There was an overall lack of significant findings on the impact between the

duration of skin-to-skin contact and the physiological parameters of the neonate. Despite these

insignificant findings, it is suggested that some skin-to-skin contact is better than no skin-to-skin contact

with the duration of practice having no effect. Therefore, the incorporation of skin-to-skin contact should

be encouraged in NISC settings.

The purpose of this quasi-experimental design study by Lee & Bang (2011) to was to name and

analyze the physiological effects of kangaroo care between an experimental group and a control group.

This study took place in a hospital NICU in Seoul, South Korea over five months. The study followed 40

preterm infants; 20 were assigned to an experimental group and 20 were assigned to a control group.

Maternal-infant dyads in the experimental group were evaluated three times a week for a total of ten times

while practicing skin-to-skin contact for 30 minutes. Physiological functions were measured in the

experimental group and control group; weight was measured every morning at a designated time for both

groups, all other physiological parameters (heart rate, respiratory rate, oxygen saturation, and body

temperature) were measured five minutes before and five minutes after kangaroo care in the experimental

group and measured at a fixed time in the control group.

Data was analyzed with the SPSS 21.0 program. For the variables, a homogeneity test was

performed with a t-test. Repeated measures analysis of variance (ANOVA) what is used to analyze the

difference in body weight between the groups. Heart and respiration rates were analyzed by using

analysis of covariance (ANCOVA), while a t-test was used for oxygen saturation and body temperature

analyses. Body weight, heart rate, respiration rate, maternal-infant attachment, and maternal stress or

considered covariates in the ANCOVA indicating homogeneity between the experimental and control

groups. Among the physiological effects being studied (weight, heart rate, body temperature, and oxygen

saturation), no significance was found between the infants who received kangaroo care and those who did

not. This study concluded that kangaroo care yielded positive effects on stabilizing breathing patterns in
7

preterm infants, improving maternal-infant attachment, and decreasing the amount of maternal stress.

Kangaroo care should be implemented in NICU’s as it promotes emotional bonding between mother and

baby and stabilizes physiological functions.

The purpose of this quasi-experimental design study by Parsa et al. (2018) to was to evaluate the

effect of kangaroo mother care on physiological parameters of premature infants. This study took place in

Fatemiyeh Hospital NICU in Hamadan City, Iran over seven months. The study followed 100 preterm

infants; 50 were assigned to an experimental group and 50 were assigned to a control group. Maternal-

infant dyads in the experimental group were evaluated for one hour per day while practicing skin-to-skin

contact for seven days while the control group received conventional care (incubators). The physiological

parameters were measured and recorded on the first, third, fifth, and seventh days of kangaroo mother

care; parameters were measured three times in each kangaroo mother care session (one recording was 15

minutes before kangaroo mother care practice, one 15 minutes into practice, and one after the completion

of practice).

Data was analyzed using SPSS version 19, independent t-test, paired t-test, and chi-square test.

Prior to intervention, there were no significant variations between the experimental group and the control

group. Once kangaroo mother care was implemented in the experimental group, the tested physiological

parameters (heart rate, respiratory rate, arterial blood oxygen saturation, and axillary temperature) showed

a significant difference when compared to the control group.

The study concluded that kangaroo mother care has a positive effect on the sustainability of physiological

parameters during supplied care. Therefore, kangaroo mother care is recommended for practice between

maternal-infant dyads.

The purpose of this quasi-experimental (control group) design study by Shattnawi & Al-Ali

(2019) to was to determine the effect of short duration skin-to-skin practice on premature infant’s short

term physiological and behavioral outcomes. This study took place in a large teaching hospital NICU in

Northern Jordan over six months. Maternal/infant dyads were assigned to one of two groups: an

experimental group and a control group. The study followed 89 preterm infants; 48 were assigned to an
8

experimental group and 41 were assigned to a control group. Maternal-infant dyads in the experimental

group were evaluated for five consecutive days while practicing skin-to-skin contact for a minimum of 60

minutes; infants in the control group received only standard care. Physiological outcomes (weight,

length, head circumference, periods of apnea) were measured in both the experimental group and the

control group.

The data was processed using Statistical Package for Social Science (SPSS) version 22 for

Windows. Chi-square tests and Mann-Whitney tests were used to compare the intervention group to the

control group. There were no significant variations between the experimental group and control group

prior to the initiation of research. Significant findings were found in weight gain, feeding method, apneic

periods, and crying and sleep patterns between the experimental group and the control group. The overall

significance was not evaluated post-intervention, but it was suggested that the application of skin-to-skin

intervention may have positively influenced these variables.

The results conclude that five days of practicing skin-to-skin contact for at least one hour was effective in

improving weight, feeding, crying, and sleeping patterns in preterm infants. Mothers should be supported

and encouraged by nursing staff to implement and practice early skin-to-skin contact in the NICU.

Maternal-Infant Bonding and Physiological Stability

Two out of five of the studies further investigates the effects SSC had on maternal-infant bonding

and the impact this has on preterm infant’s physiological stability (Cho et al., 2016; Lee & Bang, 2011).

The purpose of this experimental design study by Cho et al. (2016) to was to identify the effects

of kangaroo care in premature infants (hospitalized in neonatal intensive care units) on maternal self-

esteem, premature infants weight gain, and physiological stability. The study followed 34 preterm infants;

17 were assigned to an experimental group and 17 were assigned to a control group. Maternal-infant

dyads in both the experimental group and control group completed a pre-test, then were evaluated once a

day for two weeks while practicing skin-to-skin contact for 30 minutes, then completed a post-test at the

conclusion of the two weeks evaluation.

9

Parametric statistics compared the homogeneity between the two groups using a t-test and

explored the significant effects of interventions on the dependent variables using a repeated measure

ANOVA test. In the pre-test there was no evident effect in maternal-infant bonding between the

experimental group and the control group; however, in the post test, the intervention group showed higher

scores than the control group after the kangaroo care had ended. Due to the premature separation of the

preterm infant and its mother, physical contact is often delayed which may impede on the development of

the maternal-infant relationship. Kangaroo care allows mothers to have this physical contact with their

newborn which allows them to bond and can improve the maternal-infant relationship and make parents

feel more confident. The results of this suggest SSC, when practiced in a nursing environment, may

promote maternal-infant attachment as well as promoting growth in the premature infant.

The purpose of this quasi-experimental design study by Lee & Bang (2011) to was to name and

analyze the physiological effects of kangaroo care between an experimental group and a control group.

The study followed 40 preterm infants; 20 were assigned to an experimental group and 20 were assigned

to a control group. Maternal-infant dyads in both the experimental group and control group completed a

pre-test, then were evaluated three times a week for a total of ten times while practicing skin-to-skin

contact for 30 minutes, then completed a post-test at the conclusion of the conclusion of the study.

Data was analyzed with the SPSS 21.0 program. For the variables, a homogeneity test was

performed with a t-test. Body weight, heart rate, respiration rate, maternal-infant attachment, and

maternal stress were considered covariates in the analysis of covariance (ANCOVA) indicating

homogeneity between the experimental and control groups. This study concluded that kangaroo care

yielded positive effects on stabilizing breathing patterns in preterm infants, improving maternal-infant

attachment, and decreasing the amount of maternal stress. Kangaroo care should be implemented in

NICU’s as it promotes emotional bonding between mother and baby and stabilizes physiological

functions.

Discussion and Implications for Practice

10

The research articles for this integrative review offered an understanding of the use of SSC with

premature infants in the NICU and its effect on the infant’s physiologic stability. Clarification was

obtained from the research findings in relation to the PICOT question, “In preterm infants, what is the

effect of skin-to-skin contact on neonatal physiological outcomes during the hospitalization period?” The

authors of all five quantitative research studies highlighted the importance of the findings as related to the

positive physiological effects the practice of SSC has on preterm infants (Cho, et al., 2016; Jones &

Santamaria, 2018; Lee & Bang,2011; Parsa et al., 2018; Shattnawi et al., 2019).

Differences between the studies included the type of research design. Four out of five of the

studies used an experimental design and assigned participants to an experimental group or a control

group. The one article that did not follow the experimental design used a descriptive design that did not

incorporate a control group for comparison. This absence of comparison was later identified as a

limitation of the study (Jones & Santamaria, 2018). Another one of the differences was identified as the

length of time SSC was controlled for. In Lee & Bang (2011) and Cho et al. (2016) KC was controlled to

30 minutes, once a day, for two weeks. In comparison, Jones & Santamaria (2018) set no limits on length

of kangaroo care and only evaluated SSC practice on one occasion; Parsa et al. (2018) didn’t specify any

time frame used for SSC in their study; and Shattnawi & Al-Ali (2019) noted their maternal-infant dyads

practiced SSC for 60 to 120 minutes, so long as the infant was tolerating it. A similarity between four of

the five articles was the identification and use of the same four core physiological parameters

(temperature, HR, RR, and O2 sat.). The one article that did not use these parameters chose to use weight,

length, head circumference, and apneic episodes for their research.

Implications for future practice based on these findings suggest the implementation and use of

SSC in preterm infants residing in the NICU. Despite data for two of the five articles coming back as

insignificant, all five research articles recommended this change in practice. Premature infants are the

largest majority of those who require NICU care after birth. Due to their prematurity are unable to adapt

to extrauterine life and often respond physiologically by increasing their heart rate, decrease in oxygen
11

saturation, and poor weight gain (Shattnawi & Al-Ali, 2019). Future research should explore the long-

term effects SSC has on preterm infants during their NICU stay and after discharge.

Limitations

Two out of five articles included in the review did not identify limitations of their study. The

other three articles identified limitations that warranted further research into this clinical subject. Lee &

Bang (2011) identified the limitations of their study as being a small sample size and the generalization

that came with using only one hospital for the study. Jones & Santamaria (2018) identified the limitations

of their study as being able to the physiological measurements in five-minute intervals, random times

chosen for SSC, a small sample size, and no comparison group. Should they have incorporated a larger

sample size then there would have been more data available to use in the analysis. Additionally, the lack

of control group meant they had no way to compare the effects of SSC in neonates practicing it and those

who were not. Cho et al. (2016) identified the limitations of their study as the use of a small sample size,

collecting their data from one hospital, and participants not being assigned to their groups randomly (this

results in the experimental groups infants being more mature than the control groups). Parsa et al. (2018)

and Shattnawi & Al-Ali (2019) were the two studies that did not identify any limitations of their study.

The author identified limitations as inconsistent definitions between the physiological parameters

defined by each article. This impacted the research findings because comparisons could only be made to

a certain degree. The author also identified limitations of the review due to the article used by Jones and

Santamaria (2018). They excluded a control group from their study while all other four articles included

a control group (Cho, et al., 2016; Lee & Bang,2011; Parsa et al., 2018; Shattnawi et al., 2019). The

absence of this control group produced results without comparison which slightly impacted the validity of

the findings.

Conclusion

In summary, the data that was gathered and analyzed for this integrative review looked at the

effect SSC can have on a preterm newborn’s physiological stability while residing in the NICU. Despite

only three of the five articles supporting significant results, the recommendation for SSC in NICUs was
12

suggested in all five articles. The results indicated that additional benefits could come from SSC in

preterm infants, including decreased morbidity and mortality, positive developmental outcomes,

improved breastfeeding, decreased crying and stress, and an increase in maternal-infant bonding. The

results ultimately suggest SSC serves as a feasible and cost-effective intervention that benefit not only

baby, but mother as well (Cho, et al., 2016; Jones & Santamaria, 2018; Lee & Bang,2011; Parsa et al.,

2018; Shattnawi et al., 2019). In relation to the researcher’s PICOT question, “In preterm infants, what

is the effect of skin-to-skin contact on neonatal physiological outcomes during the hospitalization

period?”, the findings concluded that the practice of SSC can improve a preterm infant’s physiological

stability during their time spent in the NICU.

13

References

Cho, E. S., Kim, S. J., Kwon, M. S., Cho, H., Kim, E. H., Jun, E. M., Lee, S. (2016). The effects of

kangaroo care in neonatal intensive care unit on the physiological functions of preterm infants,

maternal-infant attachment, and maternal stress. Journal of Pediatric Nursing, 31, 430-438.

https://doi.org/10.1016/j.pedn.2016.02.007

Jones, H., & Santamaria, N. (2018). An observational cohort study examining the effect of the duration of

skin-to-skin contact on the physiological parameters of the neonate in a neonatal intensive special

care unit. Advances in Neonatal Care, 18(3), 208-214. https://10.1097/ANC.0000000000000485

Lee, J., & Bang, K. S. (2011). The effects of kangaroo care on maternal self-esteem and premature

infants’ physiological stability. Korean Journal of Women Health Nursing, 17(5), 454-462.

https://doi.org/10.4069/kjwhn.2011.17.5.454 

Parsa, P., Karimi, S., Basiri, B., & Roshanaei, G. (2018). The effect of kangaroo mother care on

physiological parameters of premature infants in Hamadan City, Iran. Pan African Medical

Journal, 30(89). 10.11604/pamj.2018.30.89.14428

Shattnawi, K. K., & Al-Ali, N. (2019). The effect of short duration skin-to-skin contact on premature

infant’ physiological and behavioral outcomes: A quasi-experimental study. Journal of Pediatric

Nursing 46, e24-e28. https://doi.org/10.1016/j.pedn.2019.02.005

Unicef. (n.d.). Skin to skin contact. https://www.unicef.org.uk/babyfriendly/baby-friendly-

resources/implementing-standards-resources/skin-to-skin-contact/
14

Appendix I

APA Citation and Cho, E. S., Kim, S. J., Kwon, M. S., Cho, H., Kim, E. H., Jun, E. M., Lee, S.
Author Qualifications (2016). The effects of kangaroo care in neonatal intensive care unit on the
physiological functions of preterm infants, maternal-infant attachment, and
maternal stress. Journal of Pediatric Nursing, 31, 430-438.
https://doi.org/10.1016/j.pedn.2016.02.007

All authors sport a “RN” title after their name on the article, and all but two
carry a PhD title as well. While it does not mention what their PhD’s are in,
the acknowledgements mention support for the study from the Ministry of
Education of the Republic of Korea and the National Research Foundation
of Korea. While the lack of PhD specification doesn’t ensure complete
qualification, the support from two institutes certainly helps.
Background/Problem Kangaroo care in premature infants has been shown to promote thermal
Statement regulation, decrease the risk of mortality and severe sepsis, build up maternal
confidence, and improve breast-feeding success and mother-infant
attachment. The purpose of this study was to identify the effects of kangaroo
care in premature infants (hospitalized in neonatal intensive care units) on
maternal self-esteem, premature infants weight gain, and physiological
stability.
Conceptual/Theoretic Not identified
al Framework

Design/ Quantitative; experimental design (non-equivalent pre-test and post-test

Method/Philosophical repeated design)
Underpinnings
Sample/Setting/Ethica Setting was a NICU (neonatal intensive care unit) in a university hospital in
l Considerations Korea; sample included 34 preterm infants—17 assigned to an experimental
group, 17 assigned to a control group (determined and sorted by convenience
sampling)
Initially, before any data was collected, the executive nursing department
and NICU ward manager granted permission. Following, the researcher
explained to participating mother’s that they could withdraw from the study
at any time. The attainment of neither written nor verbal consent was
mentioned.
Major Variables Premature infants- current age of more than 32 weeks (does not specify the
Studied (and their gestational age when born)
definition), if Kangaroo care- can also be referred to as skin-to-skin contact; the infant is
appropriate held naked, except for a diaper and hat, on the mother’s bare chest while
*all as defined in this covered with a cotton blanket.
study Physiological stability- measured based on body temperature, heart rate,
respiration rate, oxygen saturation, and SCRIP score (the SCRIP score
measures the level of cardiorespiratory stability)
Measurement Data was collected over a course of two years (July 2007 to March 2009);
Tool/Data Collection maternal-infant dyads in the experimental group were evaluated once a day
Method for two weeks while practicing skin-to-skin contact for 30 minutes; infants in
the control group received the same treatment with the exception of skin-to-
skin contact
A pre-test was recorded at the beginning of kangaroo care and took one-time
15

measurements on general characteristics, body weight, and maternal self-

esteem.
Physiological stability was measured in the experimental group and control
group; physiological parameters were measured at the onset of kangaroo
care, and then at 10 minutes, 20 minutes, and 30 minutes; body temperature
was measured via a forehead skin thermometer; heart rate, respiratory rate,
oxygen saturation, and SCRIP score were measured via electrodes placed on
the infants’ back
A post-test was recorded at the end of kangaroo care and took one-time
measurements on body weight and maternal self-esteem.
Data Analysis The data was statistically processed through SPSS for Windows (PASW)
28.0. Parametric statistics were used for analysis despite the small sample
size because the data was shown to be within normal distribution. Parametric
statistics compared the homogeneity between the two groups using a t-test
and explored the significant effects of interventions on the dependent
variables using a repeated measure ANOVA test.
Findings/Discussion The study reported a significant difference between the experimental group
and the control group when comparing their respiratory rate, oxygen
saturation, and physiological responses according to reported SCRIP scores.
The insignificant findings of heart rates could be attributed to the warm and
calming atmosphere that SSC promoted.
The results of this suggest SSC, when practiced in a nursing environment,
may promote maternal-infant attachment as well as promoting growth in the
premature infant.
Limitations were identified as the small sample size and the generalization
from only studying mothers and infants from one hospital.
Appraisal/Worth to Kangaroo care benefits preterm infants as it promotes physiological stability
practice and contributes to their development when practiced consistently and
effectively between mother and baby. All mothers with preterm infants in
the NICU should practice kangaroo care whether it is suggested by the
nursing staff.
APA Citation and Jones, H., & Santamaria, N. (2018). An observational cohort study
Author Qualifications examining the effect of the duration of skin-to-skin contact on the
physiological parameters of the neonate in a neonatal intensive special care
16 unit. Advances in Neonatal Care, 18(3), 208-214.
https://10.1097/ANC.0000000000000485

Both authors are RNs and Santamaria has a PhD. There is no further
information on the authors qualifications.
Background/Problem Previous studies on skin-to-skin contact have been shown to improve
Statement neonatal physiological stability, support brain development, and promote
bonding and attachment. The aim of this study was to determine if there was
a relationship between the duration of skin-to-skin contact and the neonate’s
oxygen saturation, heart rate, respiratory rate, and temperature.
Conceptual/Theoretic Not identified
al Framework

Design/ Quantitative; descriptive design (observational cohort study)

Method/Philosophical
Underpinnings
Sample/Setting/Ethica Setting was a NISC (neonatal intensive special care) at The Royal Women’s
l Considerations Hospital (RHW) in Melbourne, Australia; sample included 26 neonates—17
male and 9 female.
The study was approved by the Human Research Ethics Committee at the
RWH and the University of Melbourne. Consent was obtained from all
participants included in the study, but it was not specified how this consent
was obtained or any further details on it.
Major Variables Neonate- infants ranging between 28 to 34 (+6) weeks’ gestation or
Studied (and their corrected age
definition), if Skin-to-skin contact- can also be referred to as kangaroo care; when a parent
appropriate and their neonate have direct skin-to-skin contact with the neonate laying
*all as defined in this directly on the parent’s bare chest wearing only a diaper and a beanie; their
study legs were placed in a frog-like position with their head turned to face the
side
Physiological parameters- measured based on oxygen saturation, heart rate,
respiratory rate, and temperature
Measurement Data was collected before the initiation of skin-to-skin contact at the same
Tool/Data Collection time that informed consent was obtained. Parental-infant dyads were
Method evaluated one time while practicing skin-to-skin for no specified amount of
time.
Physiological parameters were measured (oxygen saturation, heart rate, and
respiratory rate) at the beginning of skin-to-skin contact, every five minutes
during skin-to-skin, and then at the conclusion of skin-to-skin, temperature
was measured before, every 30 minutes throughout, and upon completion of
skin-to-skin contact; oxygen saturation was measured via a pulse oximeter,
heart rate and respiratory rate were measured via electrodes, temperature was
measured via axillary temperature probe
Data Analysis The data was analyzed using Microsoft Office Excel 2013 and SPSS V 22
(IBM). To compare the relationship between the duration of skin-to-skin
contact with the physiological parameters, a bivariate correlation was used.
Findings/Discussion There was an overall lack of significant findings on the impact between the
duration of skin-to-skin contact and the physiological parameters of the
neonate.
Despite these insignificant findings, it is suggested that some skin-to-skin
contact is better than no skin-to-skin contact with the duration of practice
having no effect. Therefore, the incorporation of skin-to-skin contact should
be encouraged in NISC settings.
Limitations of this study included the parameter measurements in only five-
minute intervals, the length of time for skin-to-skin contact was chosen by
the parent, there were no control groups or access to comparative data, and
the small sample size of 28 neonates.
Appraisal/Worth to There are proven positive effects of skin-to-skin contact between mother and
practice infant in the NICU which stresses the importance of educating nurses on
APA Citation and Lee, J., & Bang, K. S. (2011). The effects of kangaroo care on maternal self-
Author Qualifications esteem and premature infants’ physiological stability. Korean Journal of
Women Health Nursing, 17(5), 454-462.
17 https://doi.org/10.4069/kjwhn.2011.17.5.454 

Lee is identified as a graduate student in the College of Nursing at Seoul

National University. Bang is an associate professor at the College of
Nursing and The Research Institute of Nursing Science at Seoul National
University. There is no further information on the authors qualifications.
Background/Problem Premature babies are well known to have health complications including
Statement cardiovascular and respiratory complications, and poor body temperature
regulation. Spending time in the NICU after birth exposes preterm infants to
stressors, bright lights, invasive medical procedures, and separation from
their mother’s—all factors quite different from the environment they have
been in for the duration of their gestation. This study was conducted to name
and analyze the physiological effects of kangaroo care between an
experimental group and a control group.
Conceptual/Theoretic Not identified
al Framework

Design/ Quantitative; quasi-experimental design (non-equivalent control group

Method/Philosophical design used with a pre-test and post-test)
Underpinnings
Sample/Setting/Ethica Setting was a NICU in a hospital in Seoul, South Korea; sample included 40
l Considerations preterm infants—20 assigned to an experimental group, 20 assigned to a
control group
This study was approved by the institutional review board of H hospital,
Seoul, South Korea. The purpose of the study was explained to mothers,
anonymity and credibility was guaranteed, voluntary participation was
clarified, and benefits of the study were explained. Written consent was
obtained from all participants of the study after the prior criteria was
outlined and explained.
Major Variables Preterm infants- infants born prior to 37 weeks of gestation.
Studied (and their Kangaroo care- can also be referred to as skin-to-skin contact; mother holds
definition), if her infant to her bare chest in a vertical position while holding the infant’s
appropriate bottom in one hand and letting the other hand touch and rest on the infant’s
*all as defined in this head and back; the infant wears only a diaper and hat.
study Physiological functions- body response to stimulation that is measured by
weight, heart rate, respiration rate, oxygen saturation, and body temperature
Measurement Data was collected over a course of five months (May 2011 to October
Tool/Data Collection 2011); maternal-infant dyads in the experimental group were evaluated three
Method times a week for a total of ten times while practicing skin-to-skin contact for
30 minutes.
A pre-test was collected prior to kangaroo care initiation and measured body
weight, heart rate, respiratory rate, oxygen saturation, and body temperature.
Physiological functions measured in the experimental group and control
group; weight was measured every morning at a designated time for both
groups, all other physiological parameters (heart rate, respiratory rate,
oxygen saturation, and body temperature) were measured five minutes
before and five minutes after kangaroo care in the experimental group and
measured at a fixed time in the control group; weight was measured via
weighing machine; heart rate, respiratory rate, and oxygen saturation was
measured via monitor; body temperature was measured via digital axillary
monitor
A post-test was collected at the end of kangaroo care and measured body
weight, heart rate, respiratory rate, oxygen saturation, and body temperature.
Data Analysis Data was analyzed with the SPSS 21.0 program. For the variables, a
homogeneity test was performed with a t-test. Repeated measures analysis of
variance (ANOVA) what is used to analyze the difference in body weight
between the groups. Heart and respiration rates were analyzed by using
analysis of covariance (ANCOVA), while a t-test was used for oxygen
saturation and body temperature analyses. Body weight, heart rate,
APA Citation and Parsa, P., Karimi, S., Basiri, B., & Roshanaei, G. (2018). The effect of
Author Qualifications kangaroo mother care on physiological parameters of premature infants in
Hamadan City, Iran. Pan African Medical Journal, 30(89).
18 10.11604/pamj.2018.30.89.14428

Parsa works at the Chronic Disease Research Center at Hamadan University

of Medical Sciences in Hamadan, Iran. Karimi is on the Student Research
Committee at Hamadan University of Medical Sciences in Hamadan, Iran.
Basiri is a Faculty of Medicine at Hamadan University of Medical Sciences
in Hamadan, Iran. Finally, Roshanaei is a Faculty of Public Health at
Hamadan University of Medical Sciences in Hamadan, Iran. None have
qualifications pertaining to neonatal or women’s health, but they do offer a
variety of backgrounds and credible titles to perform this study. This study
was acknowledged and approved by Hamadan University of Medical
Sciences. This study was also approved by the Ethics Committee of
Hamadan University and registered in the Iranian Clinical Trial Registry.
Background/Problem Many studies have proven the positive effects kangaroo mother care can
Statement have on preterm infants. Some of these effects include positive effects on
heart rate, oxygen saturation, respiratory rate, body temperature
maintenance, sleeping patterns, mental and cognitive development all while
boosting the maternal-newborn bonding, attachment, and confidence in care.
Conceptual/Theoretic Not identified
al Framework

Design/ Quantitative; quasi-experimental study

Method/Philosophical
Underpinnings
Sample/Setting/Ethica Setting was a NICU of Fatemiyeh Hospital in Hamadan City, Iran; sample
l Considerations included 100 preterm infants—50 assigned to an experimental group, 50
assigned to a control group (determined and sorted by convenience
sampling)
Prior to beginning the study informed consent was obtained but there was no
specification as to how it was obtained or what it encompassed.
Major Variables Premature infants- neonates born before 37 completed weeks of pregnancy
Studied (and their Kangaroo mother care- can also be referred to as simply kangaroo care or
definition), if skin-to-skin contact; baby is placed in an upright position directly against
appropriate their mother’s chest; the head is turned to one side in a slightly extended
*all as defined in this position; the hips should be flexed and extended in a frog like position; the
study arms should also be flexed.
Physiological parameters- heart rate, respiratory rate, oxygen saturation, and
temperature
Measurement Data was collected over 7 months (February 2016 to September 2016);
Tool/Data Collection maternal-infant dyads were evaluated for one hour per day while practicing
Method skin-to-skin contact for seven days; the control group received conventional
care (incubators)
Prior to intervention, demographic data was gathered collected by
questionnaire.
Physiological parameters were measured in both the experimental group and
the control group; the physiological parameters were measured and recorded
on the first, third, fifth, and seventh days of kangaroo mother care;
parameters were measured three times in each kangaroo mother care session
(one recording was 15 minutes before kangaroo mother care practice, one 15
minutes into practice, and one after the completion of practice)
Data Analysis Data was analyzed using SPSS version 19, independent t-test, paired t-test,
and chi-square test.

Findings/Discussion Prior to intervention, there were no significant variations between the

experimental group and the control group. Once kangaroo mother care was
implemented in the experimental group, the tested physiological parameters
(heart rate, respiratory rate, arterial blood oxygen saturation, and axillary
temperature) showed a significant difference when compared to the control
group.
APA Citation and Shattnawi, K. K., & Al-Ali, N. (2019). The effect of short duration skin-to-skin
Author Qualifications contact on premature infant’ physiological and behavioral outcomes: A
quasi-experimental study. Journal of Pediatric Nursing 46, e24-e28.
19 https://doi.org/10.1016/j.pedn.2019.02.005

Both authors are RNs and have their PhDs. There is no further information
on the authors’ qualifications.
Background/Problem It has been proven that skin-to-skin contact promotes exclusive breast
Statement feeding (as opposed to formula or mixed feedings of formula and breast
milk), temperature regulation, physiological stability, and cognitive growth.
The aim of this study was to determine the effect of short duration skin-to-
skin practice on premature infants’ short term physiological and behavioral
outcomes.
Conceptual/Theoretic Not identified
al Framework

Design/ Qualitative; quasi-experimental (control group) design

Method/Philosophical
Underpinnings
Sample/Setting/Ethica Setting was a tertiary level NICU in a large teaching university hospital in
l Considerations Northern Jordan; sample included a total of 89 preterm infants—48 assigned
to an experimental group, 41 assigned to a control group (determined and
sorted by convenience sampling)
IRB approval was obtained from the Ministry of Health and from Jordan
University of Science and Technology prior to the study. Consent was
obtained by the mothers of the infants once they were determined to meet the
study criteria and were informed of the study purpose and skin-to-skin
contact methods.
Major Variables Premature infants- born less than 37 weeks of gestation
Studied (and their Skin-to-skin contact- the infant wears only a diaper and a head cap while
definition), if resting on the mother’s bare chest; the dyad was covered with a warm
appropriate blanket while leaving the infant’s head exposed.
*all as defined in this Physiological outcomes- observation of the infants’ weight (g/day), length
study (cm/day), head circumference (cm/day), and occurrence of apneic episodes
Measurement Data was collected over 6 months; maternal-infant dyads in the experimental
Tool/Data Collection group were evaluated for five consecutive days while practicing skin-to-skin
Method contact for a minimum of 60 minutes; infants in the control group received
only standard care.
Physiological outcomes were measured in both the experimental group and
the control group; weight was measured using a calibrated electronic scale,
length was measured using an infantometer, head circumference was
measured using a mom-stretchable tape, and periods of apnea were measured
using bedside cardiorespiratory monitors
Data Analysis The data was processed using Statistical Package for Social Science (SPSS)
version 22 for Windows. Chi-square tests and Mann-Whitney tests were
used to compare the intervention group to the control group.
Findings/Discussion There were no significant variations between the experimental group and
control group prior to the initiation of research. Significant findings were
found in weight gain, feeding method, apneic periods, and crying and sleep
patterns between the experimental group and the control group. The overall
significance was not evaluated post-intervention, but it was suggested that
the application of skin-to-skin intervention may have positively influenced
these variables.
The results conclude that five days of practicing skin-to-skin contact for at
least one hour was effective in improving weight, feeding, crying, and
sleeping patterns in pre-term infants. Mothers should be supported and
encouraged by nursing staff to implement and practice early skin-to-skin
contact in the NICU.
Limitations of this study were not identified.
Appraisal/Worth to The results of this study prove that even five days of one hour skin-to-skin
practice contact between a pre-term infant and their mother had positive effects on
weight gain, feeding, crying, and sleeping patterns. It is evident that skin-to-
20