REVIEW

1 57
2 58
3
4
Systematic Review of Skin-to-Skin Care 59
60
5
6 for Full-Term, Healthy Newborns 61
62
7 63
Lisa Cleveland, Catherine M. Hill, Wendi Strauss Pulse, Heather Condo DiCioccio, Tiffany Field, Q13
8 64
and Rosemary White-Traut
9 65
10 66
11 67
12 Correspondence ABSTRACT 68
Catherine M. Hill, FNP-BC,
13 MSN, Association of Objective: To determine the effect of skin-to-skin mother–infant holding, touch, and/or massage on full-term, healthy 69
14 Women’s Health, Obstetric newborns and their primary caregivers. 70
15 and Neonatal Nurses, Data Sources: A seven-member scientific advisory panel searched the databases PubMed, CINAHL, and Scopus 71
16 1800 M St. NW, Ste. 740
South, Washington, using the search terms massage, skin-to-skin contact, kangaroo care, touch, therapeutic touch, and full-term newborns 72
17 DC 20036. for research with human participants published in English with no date parameters. 73
18 chill@awhonn.org Study Selection: The initial search yielded 416 articles. After reviewing titles and retaining only articles that met the 74
19 review criteria, 280 articles remained. The panel co-chairs reviewed and discussed the abstracts of these articles and 75
Keywords
20 Q1 retained 90 for review. 76
---
21 77
Data Extraction: Each article was assigned to one panel member and one co-chair for review. Members of the panel
22 78
met via teleconference to present articles and to determine whether they had scientific merit and addressed the
23 79
research question. Articles that did not meet these standards were eliminated. Forty articles included relevant evi-
24 dence: 33 articles on skin-to-skin holding and 7 on infant massage. 80
25 81
Data Synthesis: We created a table that included the purpose, design, and findings of each study. This information
26 82
was synthesized into a feasibility report by the co-chairs.
27 83
28 Conclusion: Evidence supports recommendations for skin-to-skin care for all full-term, healthy newborns. Although
84
29 there is inadequate evidence to recommend massage as standard care for all newborns, massage has been shown to
85
help consolidate sleep patterns and reduce jaundice.
30 86
31 JOGNN, -, -–-; 2017. https://doi.org/10.1016/j.jogn.2017.08.005 87
32 Accepted August 2017 88
33 89
34 90
35 91
36 92
N urturing touch is a powerful way to provide full-term, healthy newborns and to develop
Lisa Cleveland, PhD, RN,
37 CPNP, IBCLC, is an human connections that help foster infant evidence-based recommendations for nursing 93
assistant professor,
38 attachment behaviors (Duhn, 2010). This type of practice. 94
University of Texas Health
39 Science Center, San touch typically involves skin-to-skin (STS) contact 95
40 Antonio, TX. between a newborn and a primary caregiver, 96
41 Catherine M. Hill, FNP-BC, usually the biological mother, and infant mas- Background and Significance 97
42 MSN, is a family nurse sage. Many researchers have addressed touch The sensory experience of a newborn depends 98
43 practitioner and a nurse and massage for preterm newborns (Abdallah, on the developmental status of the sensory sys- 99
program development
44 Badr, & Hawwari, 2013; Diego, Field, & tem (Clark-Gambelunghe & Clark, 2015). At birth, 100
specialist, Association of
45 Women’s Health, Obstetric Hernandez-Reif, 2014; Juneau, Aita, & Héon, tactile sense is the most developed of the sensory 101
46 and Neonatal Nurses, 2015; Wang, He, & Zhang, 2013), which has led pathways (Clark-Gambelunghe & Clark, 2015). 102
47 Washington, DC.
to routine integration of these interventions into After birth, the sensory experiences of newborns 103
48 Wendi Strauss Pulse, DNP, their care in high-risk settings. However, to our are typically provided by their biological mothers 104
49 MSN, is Regional Manager knowledge, a systematic literature review during primary care giving. Mothers typically 105
of Nursing Practice, Kaiser
50 focused on the effect of nurturing touch on provide tactile stimulation through STS contact 106
Permanente, Aurora, CO.
51 healthy full-term newborns has not previously and through touch that includes gentle stroking 107
(Continued)
52 been conducted, and a consensus on the role of and massage. These caregiving behaviors play 108
53 nurturing touch does not currently exist for this an essential role in supporting early mother– 109
54 population. Therefore, the purpose of this sys- newborn social interactions that may affect later 110
The authors report no con-
55 flict of interest or relevant tematic literature review was to analyze published childhood neurobehavioral outcomes (Field et al., 111
56 financial relationships. evidence on STS care, touch, and massage for 2004; Head, 2014). 112

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113 History of STS Care 1951). Although researchers have shown many 169
114 STS care, kangaroo care (KC), and kangaroo benefits of STS for healthy, term newborns, this 170
115 mother care (KMC), which are different practices, method of care is not routinely practiced in all 171
116 are terms that are often used interchangeably to U.S. obstetric settings, particularly for those 172
117 describe direct skin contact between a mother newborns born by cesarean. 173
118 and her infant. The benefits of early mother–infant 174
119 contact were first recognized in the 1970s in History of Infant Massage Therapy 175
120 Bogota, Colombia, where few incubators were The effects of massage on preterm newborns 176
121 available to care for low-birth-weight infants. KMC have been widely published. It is thought that 177
122 is uninterrupted, STS holding between a mother providing touch to preterm newborns through 178
123 and her low-birth-weight infant for several days or massage offers a positive sensory experience 179
124 weeks, during which the mother is always that influences brain development (Wang et al., 180
125 available as a heat and nutritional source 2013). At-risk newborns, including premature 181
126 (Conde-Agudelo & Dı́az-Rossello, 2016). STS newborns and those in high-risk neonatal care 182
127 care involves placement of the diapered infant in settings, showed positive responses to infant 183
128 an upright position on the mother’s bare chest massage that included (a) decreased length of 184
129 between her breasts (Moore, Bergman, hospital stay (Mendes & Procianoy, 2008), 185
130 Anderson, & Medley, 2016) for shorter periods (b) lower rates of infection (Mendes & Procianoy), 186
131 of time and is more commonly used for full-term (c) less pain response to interventions (Abdallah 187
132 infants. KC is similar to STS in that the infant is et al., 2013), (d) faster weight gain (Diego et al., 188
133 placed upright on the mother’s chest; however, 2014; Diego, Field, & Hernandez-Reif, 2005; 189
134 the term KC is most often used in reference to the Field et al., 2010), (e) better neurodevelopmental Q2 190
135 care of preterm infants in high-risk settings outcomes (Procianoy, Mendez, & Silviera, 2010), 191
136 (Mitchell, Yates, Williams, & Hall, 2013). (f) improved mother–infant interaction (White- 192
137 Traut et al., 2013), and (g) more caregiver and 193
138 nurse satisfaction (Livingston et al., 2009). Less 194
139 A large body of evidence supports the benefits of 195
attention has been given to massage for full-term,
140 STS care, KC, and KMC for preterm newborns; 196
healthy newborns, perhaps because their hospi-
141 these benefits include (a) decreased infection 197
tal stays tend to be brief. Thus, infant massage
142 rates (Lawn, Mwansa-Kambafwile, Horta, Barros, 198
has not been recommended as a routine care
143 & Cousens, 2010), (b) improved cardiorespiratory 199
practice for full-term, healthy newborns after birth
144 and thermal stability (Boundy et al., 2016; 200
and through discharge.
145 Ludington-Hoe, Anderson, Swinth, Thompson, & 201
146 Hadeed, 2004; Mitchell et al., 2013), (c) more 202
147 organized sleep–wake patterns (Ludington-Hoe Methods 203
148 et al., 2006), (d) longer duration of breastfeed- Scientific Advisory Panel 204
ing and increased milk volume (Giannı̀ et al., The Power of Touch Scientific Advisory Panel was
149 205
2016; Renfrew et al., 2010), (e) more positive convened by the Association of Women’s Health,
150 206
parent–infant interactions (Athanasopoulou & Obstetric and Neonatal Nurses to investigate the
151 Heather Condo DiCioccio,
207
Fox, 2014), and (f) improved infant neuro- benefits of STS care, touch, and massage for full-
152 DNP, RNC-MNN, is a 208
nursing professional developmental outcomes (Feldman, Eidelman, term, healthy newborns. All members had
153 209
development specialist in Sirota, & Weller, 2002; Feldman, Rosenthal, & expertise in STS care, touch, and/or infant mas-
154 210
the Mother/Baby Unit, Eidelman, 2014). Therefore, all three types of sage and had master’s degrees or greater. All
155 Cleveland Clinic Hillcrest 211
STS contact are now considered routine in most members were nurses except one, who had a
156 Hospital, Mayfield, OH. 212
high-risk neonatal settings in the United States PhD in developmental psychology. The team
157 Tiffany Field, PhD, is
213
and in many high- and low-risk nurseries in conducted this systematic review and prepared a
158 Director of the Touch 214
Research Institute, Miller developing countries. clinical practice brief (Association of Women’s
159 215
School of Medicine, Health, Obstetric and Neonatal Nurses, 2016).
160 216
University of Miami,
161 Miami, FL. During the 1970s, research was conducted in the 217
162 United States to explore the effect of STS care on Research Question 218
Rosemary White-Traut,
163 PhD, RN, FAAN, is mothers and their healthy, term newborns. In Before beginning the literature review, the co- 219
164 Director of Nursing these studies, researchers found that when STS chairs discussed the purpose of the review and 220
165 Research, Children’s care was encouraged, there was less separation formulated the following research question to 221
166 Hospital of Wisconsin and a 222
of the mother and newborn, more time spent guide the literature search: What is the effect of
professor emerita,
167 University of Illinois, rooming in, and more time spent in STS contact STS care, touch, and/or massage on full-term, 223
168 Chicago, IL. (Ali & Lowry, 1981; Klaus et al., 1973; McBryde, healthy newborns and their primary caregivers? 224

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225 Data Sources and Extraction 281

226 After developing the research question, the Researchers have shown many benefits of skin-to-skin 282
227 co-chairs consulted with an experienced medical contact for healthy, term newborns, but this practice is not 283
228 librarian, who provided input on the selection of routinely implemented in all U.S. obstetric settings. 284
229 the most relevant search terms and databases to 285
230 identify evidence that would directly address the 286
massage, and 1 on infant touch (see Figure 1).
231 research question. We conducted an initial 287
The publication dates for these articles ranged
232 search that was intentionally broad to capture as 288
from 1982 through 2015.
233 many relevant research articles as possible using 289
234 varying combinations of the following search 290
Each of the articles was assigned to one of the
235 terms: massage, skin-to-skin contact, kangaroo 291
five panel members for primary review and one of
236 care, touch, therapeutic touch, and full-term 292
the co-chairs for secondary review to ensure
237 newborns. We used the databases PubMed, 293
in-depth review by two different panel members.
238 Q3 CINAHL, and Scopus. Inclusion criteria were that 294
Furthermore, care was taken to evenly distribute
239 articles must be published in English and that 295
the STS and infant massage articles across panel
240 authors must report findings from research with 296
members so that the same member did not
241 human participants. We did not limit the time of 297
review only STS or only massage articles. In the
242 publication because of concern that this might 298
spring of 2016 during four teleconference meet-
243 eliminate older but still valuable studies. This 299
ings, the panel member who was assigned to
244 initial search yielded 416 articles. 300
review an article presented it to the group. This
245 301
presentation included the purpose, participants,
246 Next, because we were specifically interested in 302
methods, major findings, and limitations. After
247 full-term, healthy newborns, the co-chairs 303
this, the co-chair who read the article made
248 excluded articles with the following terms in 304
additional comments if needed, and the mem-
249 their titles: low birth weight, very low birth weight, 305
bers voted on whether the article had scientific
250 and intensive care unit; 267 articles remained. 306
merit. We evaluated scientific merit based on the
251 During an in-person meeting of the seven panel 307
following criteria: was likely to answer our pro-
252 members, an additional 13 articles (7 about STS 308
posed research question, used procedures
253 and 6 about infant massage) that were not 309
consistent with sound research design, did not
254 retrieved during the literature search were added 310
unnecessarily expose participants to risk, and
255 to the list. Panel members had prior knowledge of 311
had the potential to produce scientifically impor-
256 these articles, although they were not identified 312
tant knowledge (Grove, Gray, & Burns, 2015).
257 during the search. 313
Articles that did not meet these criteria were
258 314
eliminated from the review. Common reasons for
259 315
elimination included inadequate sample size;
260 Article Selection 316
lack of description and/or consistency in the
261 The titles and abstracts of all 280 articles were 317
massage techniques that were used; and use of
262 reviewed and discussed by the full panel. Based 318
research protocols that placed participants at
263 on discussion and review, the panel determined 319
unnecessary risk, such as excessive blood
264 that KC was most often used to describe STS 320
draws. At the end of this process, our research
265 holding sessions between a mother and her 321
question was answered by the scientific evidence
266 preterm newborn and that KMC was most often 322
presented in 33 articles on STS and 7 articles on
267 used to describe continuous, uninterrupted STS 323
infant massage (see Tables S1 and S2 provided
268 contact between a mother and her preterm 324
as online supplemental information to this article).
269 newborn. Because this review was focused 325
270 specifically on full-term, healthy newborns, we 326
271 eliminated all articles with the terms kangaroo Results 327
272 care and kangaroo mother care in their titles. STS Care Q4 328
273 Also, because we were interested in the research Findings of the 33 articles selected on STS for full- 329
274 evidence on STS care, touch, and massage, we term, healthy newborns indicated many benefits: 330
275 excluded articles that were focused only on (a) greater breastfeeding initiation and exclusivity 331
276 implementation projects or were reports of quality rates, (b) more rapid mother–infant interaction, 332
277 improvement initiatives. This eliminated 186 arti- (c) earlier infant thermoregulation, (d) decreased 333
278 cles, and after we removed four duplicates, our maternal and newborn stress reactivity/salivary 334
279 final selection consisted of 90 articles that met cortisol levels, and (e) reduction in newborn pain 335
280 inclusion criteria: 68 on STS, 21 on infant response during painful procedures (heel lances 336

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337 393
338 Citations identified from original 394
339 search of PubMed, CINAHL, and 395
340 Scopus 396
N = 416
341 Excluded high-risk infants: Very- 397
342 low-birth-weight, low-birth- 398
weight, intensive care unit
343 N = 149
399
344 Citations pertinent to identified 400
345 population 401
346 N = 267 402
347 Added citations from advisory 403
348 panel (not found in original search) 404
N = 13
349 405
350 Abstracts reviewed for relevancy 406
351 to research question 407
352 N = 280 Excluded: not relevant to research 408
353 question 409
N = 186
354 Excluded repeat abstracts 410
355 N=4 411
356 Full-text articles reviewed for 412
357 inclusion in recommendations 413
N = 90
358 414
359 415
360 416
361 417
362 418
Full text review Full text review
363 skin-to-skin contact Full text review infant touch 419
364 N = 68 infant massage therapy N=1 420
365 N = 21 421
366 422
367 423
368 Excluded: not relevant, 424
369 implementation projects, unethical, 425
major study limitations
370 426
N = 50
371 427

print & web 4C=FPO

372 428
373 Selected articles to create recommendations 429
374 N = 40 430
375 Skin-to-skin (33), infant massage therapy (7), infant touch (0) 431
376 432
377 Figure 1. Article selection process. 433
378 434
379 and vaccinations were most common in the im- & Dutta, 2014), had more organized rooting 435
380 mediate postpartum period). and pre-feeding behaviors (Erlandsson, Dsilna, 436
381 Fagerberg, & Christensson, 2007; Widström 437
382 Breastfeeding. We found a large body of evi- et al., 2011), and more readily recognized 438
383 dence dating back to the 1980s (de Château & their own mother’s milk scent (Mizuno, Mizuno, 439
384 Wiberg, 1984) to support the claim that use of Shinohara, & Noda, 2004) than newborns who 440
385 STS contact after birth improves breastfeeding received no STS contact after birth. These 441
386 outcomes. More specifically, newborns who benefits were also observed when the infant’s 442
387 received STS care at birth showed a better father was the provider of STS. Newborns 443
388 overall ability to suckle at the breast (Aghdas, reached a drowsy state more quickly and 444
389 Talat, & Sepideh, 2014; Beiranvand, Valizadeh, showed better rooting and pre-feeding behav- 445
390 Hosseinabafi, & Pournia, 2014; Carfoot, iors when in STS contact with their fathers than 446
391 Williamson, & Dickson, 2005; Moore & newborns who received no STS (Erlandsson 447
392 Anderson, 2007; Srivastava, Gupta, Bhatnagar, et al., 2007). 448

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449 Furthermore, greater breastfeeding readiness 505

450 was observed even in newborns who did not Immediate skin-to-skin contact should be initiated in a safe 506
451 receive STS contact immediately after birth but and therapeutic manner after vaginal and cesarean birth. 507
452 were provided this contact sometime during the 508
453 early postpartum period (Beiranvand et al., 509
infants should remain in STS care after birth
454 2014). Specifically, newborns who received STS 510
(anywhere from 20 minutes to 2 hours), some
455 contact sometime during the postpartum period 511
researchers identified a sensitive period, or
456 breastfed more readily than those who received 512
golden hour, during which STS contact was most
457 standard care (swaddled in blankets in a bassi- 513
effective (Bramson et al., 2010; Dumas et al.,
458 nette). Breastfeeding exclusivity and duration 514
2013). Unfortunately, standard birthing room
459 may also be aided by the initiation of STS contact 515
and postpartum routines may create barriers to
460 after birth (Carfoot, Williamson, & Dickson, 2003; 516
immediate STS contact after birth and through the
461 de Château & Wiberg, 1984; Mahmood, Jamal, & 517
postpartum period (Moore et al., 2012). Visitors
462 Khan, 2011; Marı́n Gabriel et al., 2010; Mikiel- 518
who want to hold the newborn and concerns
463 Kostryra, Mazur, & Bołtruszko, 2002; Mizuno 519
about safety were reported as other barriers
464 et al., 2004; Moore, Anderson, Bergman, & 520
(Ferrarello & Hatfield, 2014).
465 Dowswell, 2012; Srivastava et al., 2014; Stevens, 521
466 Schmied, Burns, & Dahlen, 2014; Suzuki, 2013; 522
467 Thukral et al., 2012) with a possible dose- Patterns of interaction (bonding). In addition to 523
468 dependent relationship. This means that new- the breastfeeding benefits, researchers found 524
469 borns who receive STS contact for more time after that STS care strengthens the newly developing 525
470 birth breastfeed more effectively than those who patterns of mother–newborn interaction. For 526
471 receive STS contact for less time (Bramson et al., example, mothers expressed positive feelings 527
472 2010; Moore & Anderson, 2007; Moore et al., associated with providing STS care for their 528
473 2012). Moreover, effective breastfeeding may newborns, including feelings of bonding, a sense 529
474 also help explain the more rapid expulsion of the of “naturalness” with the experience, and overall Q6 530
475 placenta observed in mothers who practice STS satisfaction with the birth process (Carfoot et al., 531
476 contact immediately after birth (Marı́n Gabriel 2005; Finigan & Davies, 2004). Moreover, 1 year 532
477 et al., 2010). Finally, the swaddling of newborns after birth, mothers and newborns who practiced 533
478 in blankets immediately after birth may interfere STS care had more quality interactions with one 534
479 with breastfeeding and with the way mothers another, and mothers spoke more positively 535
480 interact with their newborns (Dumas et al., 2013). about their infants than mothers who did not 536
481 provide this care (de Château & Wiberg, 1984). 537
482 The benefits of STS contact may be unrelated to STS contact after birth can also support fathers’ 538
483 the method of birth, and newborns who are born interactions with their newborns. STS performed 539
484 by cesarean receive the same benefits as those by either parent immediately after birth was found 540
485 born vaginally. In a review article, Stevens et al. to increase vocal interactions between newborns 541
486 (2014) presented evidence from seven studies and their parents and to increase interactions 542
487 on the numerous benefits of STS contact in the between parents (Velandia, Matthisen, Unväs- 543
488 operating room that included enhanced mother– Moberg, & Nissen, 2010). 544
489 infant bonding, improved breastfeeding initiation 545
490 and decreased formula supplementation, and Thermoregulation. Thermoregulation of the 546
491 improved newborn thermoregulation. Further- newborn is vital for survival. Newborns lack the 547
492 more, the practice of STS contact in the operating ability to shiver to generate heat; therefore, 548
493 room is feasible provided that adequate re- external heat sources must be used (Beiranvand 549
494 sources and support staff are readily available to et al., 2014; Christensson et al., 1992). Tradition- 550
495 care for the newborn (Stevens et al., 2014). ally, thermoregulation has been supported by 551
496 swaddling newborns in blankets, by placing them 552
497 Currently, guidelines for how soon after birth STS under heat sources, or through STS contact with 553
498 care should be initiated or how long newborns their mothers. STS contact immediately after 554
499 Q5 should receive STS care do not exist. However, birth, or as close to birth as possible in the case 555
500 we found that most evidence supported imme- of cesarean, effectively supported thermoregula- 556
501 diate STS contact after birth for at least 1 sus- tion in the newborn (Carfoot et al., 2005; Chiu, 557
502 tained hour or until after the first feeding was Anderson, & Buckhammer, 2005; Marı́n Gabriel 558
503 successfully completed. Although there is some et al., 2010; Srivastava et al., 2014; Stevens 559
504 variation in the recommended amount of time et al., 2014). The mother’s body temperature 560

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561 co-regulates to meet the heat needs of the less, calmed more quickly, and returned to their 617
562 newborn and stabilizes the newborn’s body baseline heart rates and oxygen saturation levels 618
563 temperature (Beiranvand et al., 2014; Moore faster than those who experienced standard care 619
564 et al., 2012). This thermoregulatory effect was (Gray, Watt, & Blass, 2000; Kostandy et al., 2013; 620
565 noted centrally in the newborn’s core temperature Liu, Zhao, & Li, 2015; Okan et al., 2010). 621
566 and in the extremities (Bystrova et al., 2003; Researchers also found that STS contact with 622
567 Christensson et al., 1992). breastfeeding provided the greatest pain relief, 623
568 followed by STS alone (Okan et al., 2010). In a 624
569 Beiranvand et al. (2014) focused specifically on different study, STS care coupled with 25% oral 625
570 newborns born by cesarean and randomized dextrose was more effective than either method 626
571 them to two groups: STS contact immediately alone to manage infant pain; however, as few as 2 627
572 after birth and routine care (wrapped in blankets minutes of STS before a vaccination was effective 628
573 and placed in a bassinette). They discovered no to reduce a newborn’s pain response (Chermont, 629
574 statistically significant differences between the Falcão, de Souza Silva, de Cassia Xavier Balda, 630
575 experimental and control groups and concluded & Guinsburg, 2009). 631
576 that STS was a safe and effective method to 632
577 provide thermoregulatory support for newborns Infant Massage 633
578 after cesarean birth. Finally, thermoregulatory The articles we reviewed on infant massage for 634
579 support provided through STS contact may healthy, full-term newborns were limited because 635
580 continue into the postpartum period for at least 12 of the quality of the available research. More 636
581 to 24 hours after birth (Chiu et al., 2005) and may specifically, we found an overall inconsistency in 637
582 be used as a supplement to routine newborn the type of massage that was evaluated and a 638
583 care. general lack of scientific merit in many of the 639
584 studies. The findings of the seven studies that did 640
585 Stress reactivity/cortisol levels. STS contact has meet the criteria for our review included some 641
586 been found to reduce stress reactivity in the evidence to support the benefits of massage for 642
587 mother and newborn. More specifically, re- full-term, healthy newborns: reduction of bilirubin 643
588 searchers assessed salivary cortisol levels as a level, establishment of day–night circadian 644
589 measure of cardiopulmonary stabilization and rhythms, and enhancement of early growth and 645
590 found that newborns’ cortisol levels after birth development. The findings of these studies also 646
591 decreased significantly within minutes of being lend support for the maternal benefits of newborn 647
592 Q7 placed in STS care (Takahashi, Tamakoshi, massage, including increased attachment, 648
593 Matsushima, & Kawabe, 2011). Beginning STS enhanced mother–infant interactions, and reduc- 649
594 contact 30 minutes after birth assisted with car- tion in postpartum depression symptoms. 650
595 diopulmonary stabilization but not as rapidly as 651
596 initiation immediately after birth. Mothers also Reduction of bilirubin. Newborn jaundice, which 652
597 experienced a reduction in cortisol levels when consists of elevated bilirubin levels, is common 653
598 practicing STS contact immediately after birth and affects more than 50% of full-term, healthy 654
599 and throughout the postpartum period. For this newborns (Chen, Sadakata, Ishida, Sekizuka, & 655
600 reason, researchers theorized that STS care may Sayama, 2011). In a study conducted in Japan, 656
601 serve as a nonpharmacologic means to reduce jaundiced, breastfed newborns (who did not 657
602 the risk of postpartum depression (Bigelow, require phototherapy) were semi-randomly 658
603 Power, MacLellan-Peters, Alex, & McDonald, assigned to a massage intervention or a control 659
604 2012). Finally, in general, infants spent less time group (n ¼ 22 in each group; Chen et al., 2011). 660
605 crying while in STS contact (Christensson et al., The intervention group received massage twice 661
606 1992; Ferber & Makhoul, 2004; Kostandy, daily from the first through fifth days after birth. 662
607 Anderson, & Good, 2013; Moore et al., 2012; During the first and second days of the study, the 663
608 Okan, Ozdil, Bulbul, Yapici, & Nuhoglu, 2010; massaged newborns had greater stooling fre- 664
609 Velandia et al., 2010), including with their quency than those in the control group. By the 665
610 fathers (Erlandsson et al., 2007). fourth day of the study, the massaged newborns 666
611 had significantly lower serum bilirubin levels than 667
612 Newborn pain response. STS contact has been those in the control group. The researchers 668
613 found to reduce the newborn pain response. For concluded that the reduction of serum bilirubin 669
614 example, newborns who were provided STS care levels in the intervention group was a result of 670
615 before and during painful procedures, such as greater stooling frequency that was stimulated by 671
616 vaccinations or heel lances, cried and grimaced massage. 672

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673 In another study conducted in Taiwan, re- Assessment Scale (Brazelton, 1973), and sleep– 729
674 searchers investigated the effect of massage on wake behaviors (45-minute observations). At 730
675 jaundiced newborns (bilirubin level > 15 mg/dl) 1 month, the infants in the intervention group had Q8 731
676 who underwent phototherapy treatment (Lin, greater increases in weight and length than those 732
677 Yang, Chang, & Yen, 2015). By the third day of in the control group. Their Brazelton scores sug- 733
678 the study, stooling frequency was significantly gested that they were less excitable and 734
679 greater and bilirubin levels were significantly depressed, were more alert and attentive, and 735
680 lower in the massage group than the control had less gross body movement than the infants in 736
681 group. The researchers concluded that massage the control group. 737
682 might lead to shorter phototherapy treatment and 738
683 earlier hospital discharge and suggested that Maternal attachment, depression, and mother– 739
684 massage therapy may increase vagal activity that newborn interactions. Evidence of maternal 740
685 results in greater gastric motility and more rapidly benefit from newborn massage has also been 741
686 declining bilirubin levels. found (Glover, Onozawa, & Hodgkinson, 2002; 742
687 Gürol & Polat, 2012). In a study conducted in 743
688 Circadian rhythms. In a study conducted in Turkey, 57 newborns were given 15-minute mas- 744
689 Israel, investigators explored the effects of sages by their mothers every day for 38 days 745
690 newborn massage on the establishment of day– (Gürol & Polat, 2012). The Maternal Attachment 746
691 night circadian rhythms (Ferber, Laudon, Kuint, Inventory was used to compare an intervention 747
692 Weller, & Zisapel, 2002). Twenty-six mother– group of mothers who massaged their newborns 748
693 newborn pairs participated in the study. The with a control group of mothers who did not. 749
694 newborns’ rest–activity cycles were measured by Although Maternal Attachment Inventory scores 750
695 actigraphy, and their urine melatonin levels were did not differ significantly between the two groups 751
696 assayed at several points during a period of on the first day, last day scores were significantly 752
697 12 weeks. At 8 weeks, the massage group greater in the intervention group. These results 753
698 showed a significant activity peak early in the should be interpreted with caution, because only 754
699 morning (3 a.m. to 7 a.m.) and a secondary peak one outcome variable was used to compare the 755
700 in the late afternoon (3 p.m. to 7 p.m.), which two groups. 756
701 suggested more organized rest–activity cycles 757
702 than the control group. Further, the urine mela- In another study, conducted in the United 758
703 tonin levels of the infants who received massage Kingdom, researchers focused on the maternal 759
704 were measured through the night (8:00 p.m. to benefits of newborn massage. Newborns and 760
705 7:00 a.m.) during routine diaper changes. Levels their mothers were randomly assigned to a mas- 761
706 were significantly greater in the massage group sage group class or a control group (Glover et al., 762
707 and were inversely related to rapid eye movement 2002). Five instructional massage classes were 763
708 sleep, which suggests that the infants with held for the experimental group when the infants 764
709 greater melatonin levels spent more time in deep, were between the ages of 4 and 8 weeks. By the 765
710 restorative sleep. The researchers concluded that end of the intervention period, the mothers in the Q9 766
711 massage therapy supported the adjustment of experimental group had improved interaction 767
712 circadian rhythms to a day–night pattern. scores with their infants and lowered depression 768
713 scores. The researchers hypothesized that the 769
714 Newborn growth and development. Mothers who decrease in the mothers’ depression scores may 770
715 massage their newborns may positively affect have been the result of greater oxytocin levels 771
716 growth and development. In one study, 96 new- stimulated by touch. 772
717 borns were randomly assigned to a moderate 773
718 pressure massage group or to a control group In a different study from the United Kingdom, 774
719 that received light pressure for 15 minutes each researchers compared initial scores on the Edin- 775
720 day before nighttime sleep (Field et al., 2004). To burgh Postnatal Depression Scale (Cox, Holden, 776
721 ensure adherence to the study protocol, the & Henshaw, 2014) that were greater than or 777
722 mothers were asked to record their massages on equal to 13 (indicative of major depression 778
723 a calendar, and each mother’s massage tech- symptoms) in mothers randomly assigned to an 779
724 nique was observed at a 1-month follow-up visit. infant massage group or a support group 780
725 Additional data were collected in the newborn (Onozawa, Glover, Adams, Modi, & Kumar, 2001). 781
726 nursery and at 1 month of age, including growth The mothers in the massage group attended a 782
727 measures (weight, length, and head circumfer- weekly infant massage class, whereas those in 783
728 ence), scores on the Brazelton Neonatal Behavior the support group attended a weekly support 784

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785 group session for 30 minutes, during which dis- et al., 2011; Marı́n Gabriel et al., 2010; Mikiel- 841
786 cussions were focused on common newborn and Kostryra et al., 2002; Mizuno et al., 2004; Moore 842
787 postpartum problems and coping strategies. et al., 2012; Srivastava et al., 2014; Stevens et al., 843
788 Edinburgh Postnatal Depression Scale scores 2014; Suzuki, 2013; Thukral et al., 2012). This 844
789 improved in both groups; however, mothers who finding is important because the U.S. breast- 845
790 participated in the infant massage group had feeding rate at 6 months of age is 43%, which is 846
791 greater improvement in overall scores. It is short of the Healthy People 2020 goal of 847
792 important to recognize that this study had a high 60% (HealthyPeople.gov, 2017). With all that is 848
793 attrition rate for both groups because of the time known about the many benefits of breastfeeding 849
794 demands associated with the classes. for maternal and child health, any intervention 850
795 that can support breastfeeding success should 851
796 be promoted. Educating nurses on the role and 852
797 Discussion importance of STS in breastfeeding initiation and 853
798 STS Care continuation may better prepare them to advo- 854
799 We found sufficient evidence to recommend STS cate for uninterrupted STS contact after birth. 855
800 care for full-term, healthy newborns and their 856
801 primary care givers. Before the 20th century, STS 857
Unanticipated findings of this review were the
802 was the norm in newborn care and was neces- 858
effect that STS care can have on the newborn
803 sary for the newborn’s survival (Moore et al., 859
pain response during minor painful procedures
804 2016). In mammals, mother–infant separation is 860
(Gray et al., 2000; Kostandy et al., 2013; Liu et al.,
805 globally regarded as a significant stressor that 861
2015; Okan et al., 2010) and that this effect
806 causes documented epigenetic changes in 862
seems to be potentiated when combined with
807 stress regulation systems (Arabadzisz et al., 863
breastfeeding or oral sucrose solution (Okan
808 2010; Sabatini, 2007). Therefore, the evidence 864
et al., 2010). With some adjustment to routine
809 presented in this review provides support for 865
newborn care, it should be feasible to perform
810 making immediate and sustained STS contact for 866
painful procedures, such as heel lances and
811 this population the norm rather than the 867
vaccinations, while the newborn is being held in
812 exception. 868
STS and breastfeeding or receiving oral sucrose
813 869
solution. Before doing so, nurses should inform
814 Furthermore, our results confirm that STS can be 870
parents about the evidence and reassure them
815 delivered in a safe and therapeutic manner even 871
that by offering this contact, their newborns may
816 in the operating room after cesarean birth. Evi- 872
experience less pain.
817 dence shows that newborns can efficiently ther- 873
818 moregulate while they receive STS care 874
819 (Beiranvand et al., 2014; Christensson et al., Our findings showed the importance of STS 875
820 1992) and that STS contact is a powerful vagal contact for early mother–infant attachment; 876
821 stimulant that increases oxytocin release in therefore, nurses should incorporate this practice 877
822 mothers (Saxton, Fahy, Rolfe, Skinner, & Hastie, in routine care of women and their newborns to 878
823 2015). This oxytocin release has been found to enhance early interaction. Researchers found 879
824 increase the skin temperature of the mother’s that shortly after birth, oxytocin release may 880
825 breast tissue, which explains the underlying enhance maternal parenting behaviors 881
826 mechanism of action that promotes newborn (Strathearn, 2011). During the early newborn 882
827 thermoregulation (Moore et al., 2012). This evi- period, stimuli such as STS contact, suckling at 883
828 dence may help alleviate nurses’ concerns and the breast, and newborn vocalizations play a key 884
829 encourage them to promote STS contact after role in connecting maternal oxytocin circuitry to 885
830 cesarean birth. Nurses should develop and dopamine pathways. Neuroimaging showed that 886
831 implement educational protocols and quality a mother’s neglect of her infant may be the result 887
832 improvement initiatives to promote routine STS of a failure to create these connections 888
833 care for healthy, full-term newborns and their (Strathearn, 2011). Consistent with this hypothe- 889
834 families if they have not already done so. sis and the findings of this literature review, 890
835 mothers who practiced STS care with their new- 891
836 Our results further confirm that newborns who borns showed stronger bonding and attachment 892
837 receive STS care show greater breastfeeding behaviors (Affonso, Wahlberg, & Persson, 1989) 893
838 readiness, effectiveness, and duration than in- and appeared to have an increased sense of 894
839 fants who do not receive STS care (Carfoot et al., mastery that led to greater parenting self-efficacy 895
840 2003; de Château & Wiberg, 1984; Mahmood (Dennis, 1999). 896

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897 The reduction of stress–reactivity in mothers and 953

898 newborns during STS contact warrants further For stable mothers and infants, nurses should encourage 954
899 discussion. As mentioned, STS contact stimu- uninterrupted skin-to-skin contact for at least 1 hour after 955
900 lates the release of oxytocin, which antagonizes birth or until after completion of the first breastfeeding. 956
901 the fight-or-flight response, decreases anxiety, 957
902 and increases calmness and social responsive- 958
infants’ hospital stays experienced less state
903 ness (Olff, 2012). This may contribute to a phys- 959
anxiety than mothers who did not provide mas-
904 iological state that is more conducive to effective 960
sage (Afand, Keshavarz, Fatemi, & Montazeri,
905 parenting. Further, in a calm and nonthreatening 961
2017). Perhaps examination of this reduction in
906 environment, the release of oxytocin from direct 962
maternal anxiety can help explain the improved
907 mother–newborn STS contact can stimulate vagal 963
mother–infant interactions we found in the litera-
908 efferent nerve pathways that are likely part of a 964
ture on full-term infants. Moreover, because anx-
909 broader neuroendocrine response (Porges, 965
iety and depression can be comorbid conditions,
910 2007). 966
this might also help explain the reduction in
911 967
maternal depression we discovered.
912 When physiologic regulation of the autonomic 968
913 nervous system is achieved in a newborn, normal 969
In one study, focused on the effect of infant
914 growth and development are supported. How- 970
massage on growth and development, re-
915 ever, under conditions that are perceived by the 971
searchers found that full-term infants who
916 newborn as threatening, a stress response may 972
received massage experienced better growth
917 be triggered that shifts the focus from growth 973
and development. Similar findings among pre-
918 and development to survival (Porges, 2007). 974
term infants showed that massaged infants had
919 Repeated and chronic stress imposes a physio- 975
better weight gain. Researchers used path
920 logic state in which a healthy baseline cannot be 976
analyses to explore the underlying physiologic
921 maintained; this results in an up-regulation of the 977
mechanisms for this weight gain and found
922 stress response as a form of adaptation (Cordero, 978
that increased vagal activity was associated with
923 2017; McEwen, 1998; Shannon, King, & Kennedy, 979
increased gastric motility, which was related to
924 2007). Epigenetic changes likely mediate this 980
increased insulin-like growth factor 1, a growth
925 adaptation. During early childhood, chronic 981
hormone, and resulted in greater weight gain
926 exposure to stress in response to environmental 982
(Field et al., 2011). It is not unreasonable, then,
927 cues may alter developmental trajectories, 983
to consider that these underlying mechanisms
928 causing early and permanent gene adaptations 984
might also be at play in full-term infants.
929 in many systems during this early period 985
Furthermore, this finding is congruent with find-
930 (Cordero, 2017). Therefore, a reduction in 986
ings that massaged full-term infants had
931 newborn stress reactivity that results from STS 987
reduced bilirubin levels resulting from increased
932 may help support normal newborn physiological 988
gastric motility. Although these findings may be
933 and neurobehavioral development. 989
promising, there remains a need for further
934 990
rigorous research with full-term newborns before
935 Massage 991
conclusions can be drawn or practice recom-
936 Fewer researchers addressed massage involving 992
mendations made for routine massage. None-
937 full-term, healthy newborns and their primary 993
theless, the evidence suggests that at least for
938 caregivers, most likely because massage is less 994
newborns with jaundice and to stabilize sleep
939 frequently practiced in newborn units. However, 995
patterns, the use of newborn massage had
940 findings suggest that there may be some benefits 996
positive effects.
941 from massage in this population: reduction of 997
942 bilirubin levels, establishment of day–night 998
943 circadian rhythms, enhancement of growth Limitations 999
944 and development, improved mother–infant The goal of this project was to conduct a sys- 1000
945 interactions and bonding, and a reduction in tematic literature review on touch via STS care 1001
946 maternal depression. Furthermore, because the and massage for full-term, healthy newborns. We 1002
947 evidence on massage for full-term newborns is further aimed to develop nursing practice rec- 1003
948 limited, it may be possible to make some ommendations based on our findings. Although 1004
949 inferences from the evidence that exists on we were successful in our completion of both 1005
950 massage and preterm infants. For example, in aims, the possibility remains that some pertinent 1006
951 one study of preterm infants, researchers found evidence was not retrieved. We attempted to 1007
952 that mothers who provided massage during their minimize this possibility by consulting with a 1008

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1009 qualified medical librarian who has experience Supplementary Material 1065
1010 conducting large database searches for system- Note: To access the supplementary material that 1066
1011 atic literature reviews. In 19 of the 33 studies on accompanies this article, visit the online version 1067
1012 STS contact, the sample size was less than 50, of the Journal of Obstetric, Gynecologic, & 1068
1013 and many of the studies had different or absent Neonatal Nursing at http://jognn.org and at 1069
1014 definitions for STS or contact. However, our con- https://doi.org/10.1016/j.jogn.2017.08.005. 1070
1015 clusions were supported by studies with larger 1071
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