Quantitative parameters of skin-to-skin contact and infant interactive behavior in very preterm infants: a systematic review

Nunes, Cynthia Ribeiro Nascimento; Freitas, Nathália Faria; Prates, Ana Beatriz Cordeiro; Silva, Cecilia Andrade; Lemos, Stela Maris Aguiar; Bouzada, Maria Cândida Ferrarez

doi:10.1590/1806-9304202520240225-en

person Cynthia Ribeiro Nascimento Nunes

approved the final version of the article · declared no conflict of interests · Conceptualization · data curation · formal analysis · investigation · methodology · project administration · software · validation · visualization · writing - original draft · writing - review · editing

schoolCenter for Postgraduate Studies/Medicine. Federal University of Minas Gerais. Av. Professor Alfredo Balena, 190. Belo Horizonte, MG, Brazil. CEP: 30.130-100

0000-0002-9846-7754

person Nathália Faria Freitas

approved the final version of the article · declared no conflict of interests · Formal analysis · data curation · validation · visualization · writing - review · editing

schoolDepartment of Medicine. Federal University of Minas Gerais. Belo Horizonte, MG, Brazil

0000-0002-6747-2331

person Ana Beatriz Cordeiro Prates

approved the final version of the article · declared no conflict of interests · Data curation · investigation · validation · visualization · writing - review · editing

schoolDepartment of Medicine. Federal University of Minas Gerais. Belo Horizonte, MG, Brazil

0009-0001-8565-4171

person Cecilia Andrade Silva

approved the final version of the article · declared no conflict of interests · Data curation · investigation · validation · visualization · writing - review · editing

schoolInternal Medicine Residency Program. Hospital Alberto Cavalcanti. Belo Horizonte, MG, Brazil

0000-0001-9940-0482

person Stela Maris Aguiar Lemos

approved the final version of the article · declared no conflict of interests · Conceptualization · investigation · methodology · visualization · writing - review · editing

schoolDepartment of Speech-Language Therapy. Federal University of Minas Gerais. Belo Horizonte, MG, Brazil

0000-0003-4104-5179

person Maria Cândida Ferrarez Bouzada

approved the final version of the article · declared no conflict of interests · Conceptualization · data curation · formal analysis · investigation · methodology · project administration · supervision · validation · visualization · writing - review · editing

schoolDepartment of Pediatrics. Federal University of Minas Gerais. Belo Horizonte, MG, Brazil

0000-0002-7397-6931

Associated Editor:

Kelly Abud

Author (year) country	Study objective	Study design	Sample size (sampling power %)	Comparison group	Results	Study limitations
^*Lillieskold et al*.³¹ (2023) Sweden	To determine the effect of immediate SSC at birth on mother-infant interaction at 4 months of corrected infant age in very preterm infants.	Randomized clinical trial	71 infants and 56 mothers (if 100, 90% power)	Control (conventional care) vs. SSC group	Infant positive affect, communicative and social skills score were higher at 4 months during mother-child interaction in the SSC group whose SSC was onset at 6 hours of life. Results were adjusted for the child sex, primiparity and observation setting (p=0.02).	The authors consider the sample size was small. The randomization of the groups was not blinded by the researchers.
^*Nunes et al*.³² (2021) Brazil	To compare the difference in socio-emotional development between hospital discharge and at six months corrected age in infants ≤32 weeks and assess the impact of maternal and infantile factors on socioemotional development rate within six months.	Observational, prospective	72 preterm mother-child dyads (98%)	NA	The onset of SSC (≤3 days) had a statistically significant association with the onset of contact (p=0.013) and vocalization (p=0.016). The number of days of SSC performance during hospitalization showed a statistically significant association with the response to communication (p=0.039).	It was not possible to propose an experimental study design (ethical issues). Difficulty comparing pioneering methodology with pre-existing literature.
Buil et al.³⁵ (2020) France	Further investigation of the immediate benefits of the Supported Diagonal Flexion position during SSC on the quality of mother-infant communication in very preterm newborns.	Case control, prospective	34 preterm mother-child dyads	Vertical vs. Diagonal SSC	Infant vocalization frequency was higher in the diagonal kangaroo position group (3.68 times/min) vs. control group (1.06 times/min), with a statistically significant difference (p<0.001). In addition, infant vocalizations occupy more space in the dialogue (1.9% x 0.7%; p=0.01).	The authors consider the sample size, the dyads from only one level three unit and non-blinding of the kangaroo group, the type of allocation of the case and control groups.
^*Mehler et al*.²⁵ (2020) Germany	To investigate the effects of 60 minutes of skin-to-skin contact in the delivery room compared to 5 minutes of eye contact on mother-child interaction, salivary cortisol, maternal depression, stress and bonding at six months corrected age.	Randomized Clinical Trial	77 preterm mother-child dyads (if 88, 80% power)	Visual contact versus skin-to-skin contact in the delivery room	In the SSC group, infant’s vocal and motor responses were higher and statistically significant. Vocal= 7 (±6) vs 5 (±5) 0.044 and motor = 20 (±9) vs 15 (±7) 0.032.	Psychological and neurodevelopmental aspects were not evaluated. These results are limited to primiparous mothers.
Nunes et al.³³ (2017) Brazil	To analyze the influence of the skin-to-sin contact duration in the initial interactions between mothers and preterm infants.	Observational, prospective	32 preterm mother-child dyads	NA	The longer the time in SSC, the more newborns made attempts at physical contact with their mothers during breastfeeding (r=0.37; p=0.03).	The reduced sample size was considered, in addition to environmental issues during filming, such as noise and the presence of the camera.
Buil et al.³⁴ (2016) France	Assess the safety of SDF kangaroo positioning compared to usual upright positioning. To assess the position of the SDF in early mother-infant communication and in improving their well-being.	Observational prospective	15 preterm mother-child dyads	SSC vertical vs. Diagonal	The tenth session revealed that the children’s vocalizations and smiles were more frequent in the diagonal kangaroo position groups but statistically non-significant.	The authors consider a small sample and the use of elastic wrap in the diagonal SSC.
Bigelow et al.³⁰ (2010) South Africa	To investigate the relationship between early mother-infant skin-to-skin contact and maternal sensitivity with low birth weight infants	Randomized Clinical Trial	12 preterm mother-child dyads	SSC vs. incubator	Scores on the NCATS Child Behavior Subscale correlated significantly only with the age of the infants at the time of the follow-up visit.	It was considered a small sample size and a wide age range for child care. The mothers performed the recording of home SSC time in an abstract way. A high-risk mother-child dyad sample limited the generalizability of the results.
^*Feldman et al*.²¹ (2003) Israel	To examine the effects of dyadic and triadic interactions.	Cohort study	146 preterm mother-child dyads	Control (conventional care) vs. SSC group	In the SSC group, the level of dyadic reciprocity was higher (3.71 ±1.02 vs 3.24 ±1.10), and children showed fewer negative emotions (1.38 ±0.65 vs 1.51± 0.70) during social play p<0.01. Univariate tests showed that the SSC group had less time in blurred gaze compared to controls (0.55 ±0.21 vs 0.71±0.33).	Local ethical constraints limited randomization criteria. SSC initiation occurred at varying times during the study

Studies/country	Skin-to-skin contact quantitative parameters
Studies/country	Onset	Duration	Frequency
Lillieskold et al.³¹ (2023) Sweden	Median 15 (0-62) minutes vs. 5.25 (4.5-5.5) hours	Median 68 (10-70) hours vs. 46 (5-44) hours	8 days of life
Nunes et al.³² (2021) Brazil	Median 7.00 (5-10) days	23.55 (10.72-44.75) hours during hospitalization	12.00 (7-20) days
Buil et al.³⁵ (2020) France	3º day of life	Unreported	Unreported
Mehler et al.²⁵ (2020) Germany	45 min of life in the exposure group	Duration/day=1.6 hours vs. 1.7 hours.	Unreported
Nunes et al.³³ (2017) Brazil	Median 9.04 ± 5.42 days	Median 14.7 ± (0.2) hours during hospitalization	Median 6 days during hospitalization (1 - 9)
Buil et al.³⁴ (2016) France	Average weight 1330 ±419 grams	Unreported	10 sessions
Bigelow et al.³⁰ (2010) South Africa	6 hours of life in the exposure group	Average SSC in the first 24h = 7.8 (±4.8) hours.	15.00 (±9) days*
Feldman et al.²¹ (2003) Israel	PTNB with a mean GA of 32 weeks	1 hour/day - average 26.62 (±12.14) hours	14 consecutive days

Studies	Interaction assessment tool	Nature of the variable	Age of assessment	Infant´s constructs	Recording duration
Lillieskold et al.³¹ (2023)	Parent-Child Early Relational Assessment (PCERA)³⁷	Likert scale	4 months (±2 weeks) of corrected infant age	Infant Positive Affect; Communicative and Social Skills; Infant Dysregulation and Irritability and Dyadic Emotional Tone; Reciprocity and Regulation.	5 minutes
Nunes et al.³² (2021)	Observation Protocol of Mother-Infant Interaction 0-6³⁸	Likert scale/difference between two phases (median)	Close to hospital discharge and at 6 months CA	Gaze; Response to communications Intensity of positive response; Verbal and/or physical contact; smile; Good mood; vocalization; cry; Interaction Tuning	3 minutes
Buil et al.³⁵ (2020)	Author Developed Instrument	Microanalysis (frequency of occurrence)	18 days of life	Visual attention, smile, and vocalization	5 minutes
Mehler et al.²⁵ (2020)	Mannheim Rating System	Microanalysis (frequency of occurrence)	6 months	Motor, vocal and facial responsiveness. Positive mood and negative mood	4 minutes
Nunes et al.³³ (2017)	Observation Protocol of Mother-Infant Interaction 0-6³⁸	Likert Scale (median)	Close to hospital discharge (mean 31.88 ±12.61 days of life)	Gaze; Response to communications Intensity of positive response; Verbal and/or physical contact; smile; Positive mood; vocalization; cry; Interaction Tuning	3 minutes
Buil et al.³⁴ (2016)	Author Developed Instrument	Microanalysis (frequency of occurrence)	Weight in the intervention: 1605±349	Visual attention, smile, and vocalization	10 minutes
Bigelow et al.³⁰ (2010)	Nursing Child Assessment Scale(NCATS)³⁹	23-item checklist	<12 (3.1 to 11.9) months	Clarity of signals and responsiveness to the mother	Direct observation of the trained evaluator
Feldman et al.²¹ (2003)	Global Codes of Dyadic and Triadic Interactions⁴⁰	Likert scale (averages)	6 months	Positive affect, negative emotional affect, child initiation and involvement, and infant reciprocity.	5 minutes

Author (year)	Methodological design^a	1	2	3	4	5	6	7	8	9	10	11	12	13	14	Total	%	Classification
^*Nunes et al*.³² (2021)	Prospective Cohort	+	+	+	+	+	/	+	+	+	+	+	+	+	+	13/14	92.85	Good
Buil et al.³⁵ (2020)	Prospective case-control	+	+	+	+	-	/	+	/	+	?	+	-	-	+	8/14	57.14	Regular
Nunes et al.³³ (2017)	Prospective observational	+	+	+	+	-	/	+	+	+	+	+	+	+	-	11/14	78.57	Good
Buil et al.³⁴ (2016)	Prospective observational	+	+	+	+	-	/	+	/	+	?	+	+	/	-	8/14	57.14	Regular
Feldman et al.²¹ (2003)	Prospective Cohort	+	+	?	+	-	/	+	-	+	+	+	+	?	+	9/14	64.28	Regular
Randomized Clinical Trial^b		Study participation				Study attrition			PF measurement			Outcome measurement			Study confounding			Statistical analysis and Reporting
Lillieskold et al.³¹ (2023)		Medium*				Low*			Low*			Low*			Medium*			Low*
Mehler et al.²⁵ (2020)		Low*				Low*			Low*			Low*			Medium*			Low*
Bigelow et al.³⁰ (2010)	High*				High*			Medium*			Low*			Medium*			Low*

Database	Search Strategy	Retrieved references
BVS	(“Mother-Child Relations” OR “Relaciones Madre-Hijo” OR “Relações Mãe-Filho” OR “Interação Mãe-Criança” OR “Interação Mãe-Filho” OR “Relacionamento Filho-Mãe” OR “Relacionamento Materno-Filial” OR “Relacionamento Mãe-Filho” OR “Relação Filho-Mãe” OR “Relação Materno-Filial” OR “Relação Mãe-Filho” OR “Relações Criança-Mãe” OR “Relações Filho-Mãe” OR “Relações Materno-Filiais” OR “Relações Mãe-Criança” OR infant OR lactante OR lactente OR lactentes) AND (“Kangaroo-Mother Care Method” OR “Método Madre-Canguro” OR “Método Canguru” OR “Mãe Canguru” OR “Método Mãe Canguru” OR “Método Mãe-Canguru” OR “Posição Canguru” OR “Kangaroo Position” OR “Posição Canguru” OR “Kangaroo Position” OR “Skin to skin contact”) AND (“Infant, Premature” OR “Recien Nacido Prematuro” OR “Recém-Nascido Prematuro” OR “Bebê Prematuro” OR “Bebês Prematuros” OR “Lactente Nascido Prematuramente” OR “Lactente Nascido Pré-Termo” OR “Lactente Prematuro” OR “Lactente Pré-Termo” OR “Lactentes Nascidos Prematuramente” OR “Lactentes Nascidos Prematuros” OR “Lactentes Nascidos Pré-Termo” OR “Lactentes Prematuros” OR “Lactentes Pré-Termo” OR “Neonato Prematuro” OR “Neonato Pré-Termo” OR “Neonatos Prematuros” OR “Neonatos Pré-Termo” OR prematuro OR prematuros OR “Pré-Termo” OR “Recém-Nascido Pré-Termo” OR “Recém-Nascidos Prematuros” OR “Recém-Nascidos Pré-Termo”) AND (instance:”regional”) AND ( db:(“LILACS” OR “BDENF” OR “SES-SP” OR “IBECS” OR “INDEXPSI” OR “LIS” OR “CUMED” OR “colecionaSUS” OR “PAHOIRIS” OR “PERNAL”))	254
MEDLINE via PubMed	(“Mother-Child Relations”[All Fields] OR “Holding”[All Fields] OR “Bonding”[All Fields] OR “Attachment Theory”[All Fields]) AND (“Kangaroo-Mother Care Method”[All Fields] OR “Skin to skin contact”[All Fields] OR “Kangaroo position”[All Fields]) AND (“Infant, Premature”[All Fields] OR (“infant”[MeSH Terms] OR “infant”[All Fields]))	397
CINAHL	(“Mother-Child Relations” OR “Holding” OR “Bonding” OR “Attachment Theory”) AND (“Kangaroo-Mother Care Method” OR “Skin to skin contact” OR “Kangaroo position”) AND (“Infant, Premature” OR Infant)	282
Scopus	(“Mother-Child Relations” OR “Holding” OR “Bonding” OR “Attachment Theory”) AND (“Kangaroo-Mother Care Method” OR “Skin to skin contact” OR “Kangaroo position”) AND (“Infant, Premature” OR Infant)	242
Web of Science	(“Mother-Child Relations” OR “Holding” OR “Bonding” OR “Attachment Theory”) AND (“Kangaroo-Mother Care Method” OR “Skin to skin contact” OR “Kangaroo position”) AND (“Infant, Premature” OR Infant)	103
APA PsycNET	(Any Field: “Mother-Child Relations” OR Any Field: “Holding” OR Any Field: “Bonding” OR Any Field: “Attachment Theory”) AND (Any Field: “Kangaroo-Mother Care Method” OR Any Field: “Skin to skin contact” OR Any Field: “Kangaroo position”) AND (Any Field: “Infant, Premature” OR Any Field: Infant)	3

[TFN1] ^**
Studies with significant results between the SSC quantitative parameters and the infant construct of the mother-child relationship.

[TFN2] ^*
Information provided by the author by email. Unreported information was queried by email from the corresponding author.

Quantitative parameters of skin-to-skin contact and infant interactive behavior in very preterm infants: a systematic review

Abstract