Running Head: AN INTEGRATIVE REVIEW 1

An Integrative Review

Gabrielle Jean

Bon Secours Memorial College of Nursing

Arlene Holowaychuk MSN, RN

Nursing Research - NUR 4122

April 1, 2018

“I Pledge”
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Abstract

The purpose of this integrative review is to appraise the literature related to skin-to-skin contact

with neonates in relation to their temperature regulation. Hypothermia is a very serious issue

concerning newborns in their first days of life. Skin-to-skin care has been identified as a cost-

effective, successful means of care. Design methods consisted of searches conducted using

databases such as EBSCO Discovery Services and PubMed. The search yielded 714 articles, five

of these articles met the criteria necessary to be utilized for this topic. The research articles used

were published within the last five years. Descriptive statistics were used to analyze the findings

in all research articles. Findings from the various studies suggest that the implementation of skin-

to-skin care with newborns is successful in preventing the development of hypothermia and in

controlling temperature. The studies indicate that newborns who receive skin-to-skin care after

birth have better thermoregulation than newborns who receive standard care. There were no

negative outcomes or deaths. Limitations of the studies include locations where the studies were

conducted and different levels of cooperation from the participants. Some participants did not

correctly implement skin-to-skin care which limits reliability. Implications indicate that skin-to-

skin care should be further implemented in the hospital setting. The results of each study discuss

success with skin-to-skin care indicating that the information can be applied in multiple levels of

healthcare. Recommendations involve promoting skin-to-skin care, applying the positive

correlation between skin-to-skin care and thermoregulation to multiple areas of healthcare, and

further studying this form of care.

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Integrative Review

The purpose of this integrative review is to identify the impact that skin-to-skin contact

has on temperature regulation of the newborn following birth. Skin-to-skin care is a cost

effective, easy medical intervention to aid in the temperature regulation of the newborn.

Newborns are at risk for hypothermia after a vaginal or cesarean birth. “The World Health

Organization defines hypothermia as present when the newborn’s axillary temperature falls

below 36.5 degrees Celsius. Hypothermia leads to adverse neonatal outcomes like impaired

growth, hypoglycemia, generalized internal bleeding, and increased risk for infection, metabolic

acidosis, respiratory distress and even death” (Nimbalkar et al. 2014). It is important to identify

effective ways to regulate the newborns temperature immediately following birth. Skin-to-skin

time between mother and baby or father and baby is a sufficient way to regulate the newborns

temperature and avoid hypothermia. Being that not all areas have the equipment available to

regulate the newborns temperature such as an incubator or warmer, implementation of skin-to-

skin time after birth is an excellent alternative that is just as effective if not more effective. In a

study by Beiranvand, Valizadeh, Hosseinabadi, & Pournia (2014), it is stated that the most

important needs of infants at birth is the maintenance of temperature because an infant is not able

to generate heat due to lack of a shivering mechanism which this leads to a rapid decline in

temperature. The aim of this integrative review is to compile pertinent literature to the

researcher’s PICO question, what effect does skin-to-skin time have on newborns in regards to

thermoregulation in comparison to newborns who do not receive skin-to-skin time after birth?
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Design and Research Methods

The research design is an integrative review. EBSCO Discovery and PubMed were the

computer-based search engines utilized to acquire these research articles. The search terms

included, ‘skin-to-skin’, ‘newborns’, ‘temperature’, thermoregulation’, kangaroo care’, and

‘neonates’. This search yielded 714 articles from the EBSCO Delivery and PubMed databases,

indicating a reasonable amount of information on this topic. In order to obtain information on

this issue, the search was limited to peer-reviewed quantitative and qualitative journal articles.

Each article was written in English and published between the years of 2014 and 2018. The

articles were relevant to the researcher’s PICO question, “What effect does skin-to-skin time

have on newborns in regards to thermoregulation in comparison to newborns who do not receive

skin-to-skin time after birth?”

The articles were then selected based on the following inclusion criteria:

neonates/newborns, temperature regulation, skin-to-skin time, kangaroo care, and

thermoregulation. The research articles were screened and based on inclusion criteria and PICO

question significance. The search process was limited to healthy newborn’s being born without

congenital defects or need for critical medical intervention. The researcher excluded articles that

did not meet the criteria necessary to support the PICO question. The screening produced five

quantitative articles.

Findings and Results

The findings and results of the five reviewed studies indicate a strong correlation between

immediate skin-to-skin care and the regulation of temperature in newborns (Beiranvand et al.,

2014; Bera, Ghosh, Kumerendu, Hazra, Som, & Munian 2014; Irum, Jabeen, Baloch, & Mawani

2017; Nimbalkar et al., 2014; Srivastava, Gupta, Bhatnagar, & Dutta 2014). All five studies are
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summarized in tables at the conclusion of this integrative review. The researcher framed the

review according to the following themes: skin-to-skin care versus conventional care and

inclusion/exclusion criteria.

Early Skin-to-Skin Care vs. Conventional Care

In all five studies there was a comparison between the implantation of skin-to-skin care

and conventional care in neonates following delivery (Beiranvand et al., 2014; Bera et al., 2014;

Irum et al., 2017; Nimbalkar et al., 2014; Srivastava et al., 2014). The quantitative study by

Beiranvand et al. (2014) was a randomized clinical control trial that was conducted in Asali

Hospital. The aim of this study was to compare the temperatures of mothers’ and infants’ after a

cesarean section delivery. This study included 96 mother-infant dyads. The study excluded

mothers with medical issues such as: severe bleeding, uterine inertia, gestational diabetes,

hypertension and heart disease. The study excluded infants that were high risk or that had

abnormalities of any kind. The 96 mother-infant dyads were split into two groups, a control

group and an experimental group. The four parts included in the data collection were:

demographic data, temperatures, the standard Infant Breastfeeding Assessment Tool, and

maternal satisfaction. Descriptive statistics were used to analyze the data such as frequencies,

means, standard deviations, t-tests, chi-square tests, and Kolmogorv tests. All participants were

provided with necessary information before hand in order to address ethical considerations

within the study. The study was approved by the Ethics Committee of Lorestan University of

Medical Sciences. The findings of this study indicate that skin-to-skin care after a cesarean

delivery is effective in maintaining temperature in the newborn.

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Similarly, the quasi-experimental quantitative study by Bera et al., (2014) consisted of

data from 265 mother-baby pairs. The aim of this study was to assess the effect that skin-to-skin

care has on the physiologic states of low birth weight babies before and after the implementation

of skin-to-skin care. The mother-baby pairs that participated in the study were selected through

purposive sampling. This study was also approved by the institutional ethics committee.

Statistical analysis used to analyze the data in this study included: mean and standard deviation,

confidence interval values and t-test. Statistica version 6 software was used for analysis. The

temperatures were taken immediately before and after skin-to-skin care for 3 days. The findings

of this study show that most babies temperatures steadily rose over the 3- day period and none

developed hypothermia.

The comparative, quantitative study by Irum et al., (2017) focused on comparing the

impact on newborn body temperature after skin contact of mother and newborn versus the

conventional method of care. The sample size for this study included 120 women that were

selected and distributed into two groups. The study excluded babies with any presenting medical

issues or mothers with medical disorders such as diabetes and hypertension. The statistical

analysis of this study included t-test using SPSS version 16. The study design is a cross sectional

analytical study. Written and verbal consent was obtained by all participants in the study

addressing ethical considerations. The participants were divided into two groups, Group A and

Group B. Group A were babies that were to be placed in the baby warmer after birth. Group B

consisted of babies that were to receive skin-to-skin contact after birth. The temperatures of the

newborns were taken with a mercury thermometer after one minute after birth, five minutes after

birth, and after one hour of birth. The findings of this study indicate that skin-to-skin contact

reduces hypothermia in neonates and should be further encouraged in practice.

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The quantitative study by Nimbalkar et al., (2014) investigated the impact of early skin-

to-skin contact provided for the first 24 hours on incidence of hypothermia in stable newborns.

The sample size for this study included 100 newborn participants were included in the study. The

100 participants were divided into two groups of 50. Similar to the other studies mentioned, this

study had an intervention group and a control group. The intervention group received skin-to-

skin time 30 minutes to one hour after birth and the skin-to-skin care was continued as long as

possible for 24 hours. The control group received conventional care and the newborns were

placed in the warmer after birth. In both groups, temperature was recorded first at 30 minutes and

subsequently at 1, 2, 3, 4, 5, 6, 12, 24 and 48 hours of life. The temperatures were taken by

axillary method in both the intervention and control group. Statistical analysis used to analyze

the data in this study included: descriptive statistics and Independent Samples t-tests. The data

was entered using Microsoft Office Excel 2010 and SPSS 14. The findings of this study indicate

that skin-to-skin care is significant when it comes to prevention of hypothermia in neonates

within the first 48 hours of life.

The purpose of the study by Srivastava et al., (2014) was to evaluate the effects of very

early skin-to-skin contact in term babies with their mothers on neonatal well-being. The study

design was a randomized control trial conducted over a two-year period. The sample size was

298 mother and baby dyads. The 298 mother and baby dyads were organized into a study group

and a control group. The block randomization method was used to ensure randomization. Ethical

considerations were taken by attaining informed consent from the mothers participating in the

study. Similar to the other mentioned studies, in this study, babies in the study group received

skin-to-skin time within 30 minutes of birth while babies in the control group received the

standard care. “The data for this study were collected on a preset performa by the observer and
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subjected for analysis using appropriate methods like t-test, Pearson Chi-square test and non

parametric Mann-Whitney test through relevant software SPSS/16.0” (Srivastava et al., 2014).

The findings of this study indicate that very early skin-to-skin time with newborns produces a

significant effect on temperature regulation.

Inclusion / Exclusion Criteria

Four of the five research articles also had inclusion criteria necessary for participants to

be involved in each study regarding skin-to-skin care (Beiranvand et al., 2014; Irum et al., 2017;

Nimbalkar et al., 2014; Srivastava et al., 2014). Beiranvand et al. (2014) required that the

mothers participating in the study were between the age of 18 and 40 having a gestational age of

38-42 weeks. Mothers with health issues such as: hypertension, heart disease, gestational

diabetes, uterine inertia or severe bleeding were excluded from the study. Irum et al. (2017) also

had similar inclusion and exclusion criteria. The inclusion criteria for this study included: babies

born with an Apgar score >6, cephalic presentation, and primagravida or multigravida with no

antenatal complication. The exclusion criteria for this study included: babies in distress, babies

that required instrumental or cesarean section deliveries, babies with congenital abnormalities,

low birth weight babies, babies with an Apgar score <6, and mothers that have diabetes or

hypertension. Nimbalkar et al. (2014) also had inclusion and exclusion requirements similar to

these studies. This study required that participating neonates be stable and weigh 1800g or more.

The newborns had to be born vaginally to participate in the study. Neonates requiring

resuscitation measures or that were born with any congenital malformations were excluded from

the study. Srivastava et al. (2014) mentions similar inclusion and exclusion criteria for the

participants of this study as well. To be a participant of this study the neonate had to be born

without difficulty, no resuscitation requirements, and no congenital malformations. Overall, the

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majority of the research involved in this integrative review had very similar inclusion criteria and

exclusion criteria.

Discussion and Implications

The five articles that were chosen for this integrative review each address the

implementation of skin-to-skin time with newborns and the effect that the use of skin-to-skin

time has on their temperature regulation. Each of the articles reviewed an aspect of newborn

outcomes with the use of skin-to-skin time after birth. The research included in the five research

articles supports the PICO question set by the researcher. From the article by Nimbalkar et al.,

(2014) a randomized control study was done that compared an interventional group and a control

group. The interventional group received early skin-to-skin time after birth and the control group

received conventional care. “This study determined that the use of skin-to-skin time early after

birth has a significant effect on temperature regulation in newborns” (2014). The study

conducted by Bera et al., (2014) concluded that, skin-to-skin care enhances both infant and

maternal well-being and can be practiced in any situation without needing special equipment.

This is an important aspect of the research in that it provides evidence that skin-to-skin time with

newborns is cost-effective and can be used for thermoregulation in neonates if equipment such as

an incubator or warmer is not available for use. Srivastava et al., (2014), determined that mother

and baby should not be separated after birth and that early skin-to-skin time has a significant

effect on newborn temperature regulation. The quantitative study conducted by Beiranvand,

Valizadeh, Hosseinabadi, and Pournia was more focused on skin-to-skin time following a

cesarean birth. This study concluded that skin-to-skin contact after birth after delivering via

cesarean section increased maternal satisfaction and these neonates were not prone to

hypothermia in comparison to routine method of infant care that were delivered via cesarean
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section. Irum et al., (2017) determined that many newborns can be saved from hypothermia by

providing skin-to-skin contact of mother and newborn.

Each of the articles used for this integrative review mention recommendations and

implications for future research. The authors discuss implications for nursing practice and

establish the importance of continuing research and implementation on this topic. The majority

of the articles included recommendations for applying the effectiveness of skin-to-skin care in

multiple settings. Future research should focus on the long-term effects of skin-to-skin time in

regards to thermoregulation and what health disparities the implementation of regulating

temperature through thermoregulation will prevent.

Limitations

Limitations of this integrative review include information limited to five research articles

written within the last five years. This is the first integrative review experience for the researcher

who is enrolled in a full-time undergraduate program, who has limited knowledge and

application skills in research. The sample sizes in all 5 research articles were adequate based on

the types of studies reducing limitations. General limitations to the research study include

location of where the studies were conducted. Some studies were in areas that were more prone

to successful implementation, making it difficult to determine reliability. Also, some of the

studies were observational rather than a randomized control trial leaving more room for error and

exclusion of some participants. Another limitation to the research study is the level of

cooperation from the participants. Many participants did not implement skin-to-skin care

correctly making it difficult to ensure data accuracy. Further limitations include the general

environments of different maternity wards in that they are not climate controlled and can produce

unwanted variability within the research study.

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Conclusion

The findings of this integrative review indicate that the implementation of skin-to-skin

with newborns significantly reduces their risk for hypothermia. The use of skin-to-skin time after

birth is a very effective way to maintain the temperature and promote bonding between mother

and baby. Skin-to-skin care is also cost-effective and does not require any special equipment.

This form of care is efficient and should be promoted following the birth whether it be a vaginal

birth or a cesarean birth. This integrative review concludes that the use of skin-to-skin care with

neonates following birth directly correlates with temperature regulation in comparison to

neonates who do not receive skin-to-skin care and sufficiently evaluates the PICO question.
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References

Beiranvand, S., Valizadeh, F., Hosseinabadi, R., & Pournia, Y. (2014). The Effects of Skin-to-

Skin Contact on Temperature and Breastfeeding Successfulness in Full-Term Newborns

after Cesarean Delivery. International Journal Of Pediatrics, 1-7.

doi:10.1155/2014/846486

Bera, A., Ghosh, J., Kumarendu Singh, A., Hazra, A., Som, T., & Munian, D. (2014). Effect of

Kangaroo Mother Care on Vital Physiological Parameters of The Low Birth Weight

Newborn. Indian Journal Of Community Medicine, 39(4), 245-249. doi:10.4103/0970-

0218.143030

Irum, S., Jabeen, N., Baloch, R., & Mawani, K. (2017). Newborn Body Temperature;

Comparative Study to See the Impact On Newborn Body Temperature After Skin Contact

of Mother and Newborn V/S Conventional Method. Professional Medical Journal, 24(4),

574-579. doi:10.17957/TPMJ/17.3748

Nimbalkar, S. M., Patel, V. K., Patel, D. V., Nimbalkar, A. S., Sethi, A., & Phatak, A. (2014).

Effect of early skin-to-skin contact following normal delivery on incidence of

hypothermia in neonates more than 1800 g: randomized control trial. Journal Of

Perinatology, 34(5), 364-368. doi:10.1038/jp.2014.15

Srivastava, S., Gupta, A., Bhatnagar, A., & Dutta, S. (2014). Effect of very early skin to skin

contact on success at breastfeeding and preventing early hypothermia in neonates. Indian

Journal Of Public Health, 58(1), 22-26. doi:10.4103/0019-557X.128160

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First Author Beiranvand, S., Valizadeh, F., Hosseinabadi, R., & Pournia, Y.
(Year)/Qualifications (2014). The Effects of Skin-to-Skin Contact on Temperature
and Breastfeeding Successfulness in Full-Term Newborns
after Cesarean Delivery. International Journal Of
Pediatrics, 1-7. doi:10.1155/2014/846486

Background/Problem The skin-to-skin contact of mother and newborn is

Statement uncommon in full-term newborns after delivering via cesarean
section due to the possibility of hypothermia in infants.
Conceptual/theoretical Researchers wanted to see what effect skin-to-skin contact has on
Framework newborns born via cesarean section.

Design/ Quantitative
Method/Philosophical Randomized clinical trial
Underpinnings After delivery, infants were either provided with skin-to-skin care
or with conventional hospital care.
Sample/ 90 mother-infant dyads
Setting/Ethical
Considerations

Major Variables Experimental Group: skin-to-skin contact was performed for

Studied (and their one hour.
definition), if Control Group: Infant was dressed and put in a cot according
appropriate to hospital routine care.

Measurement Researchers observed and collected temperatures.

Tool/Data Collection
Method

Data Analysis Frequencies, means, standard deviations, t-tests, chi-

squares, Kolmogorv-Smirnov
Findings/Discussion
Skin-to-skin care after delivering via cesarean is possible and
produces successful results in regard to temperature
regulation.
Appraisal/Worth to Research has indicated that skin-to-skin care after cesarean
practice delivery is successful when it comes to maintaining newborn
temperature.
More studies should be done on the subject.
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First Author Bera (2014)- Deputy Nursing Superintendent, NRS Medical
(Year)/Qualifications College Hospital pursuing PhD work at Dept. of Neonatology,
IPGME&R and SSKM Hospital, Kolkata.
Background/Problem A major problem with low birth weight babies is their inability to
Statement control body temperature-a preventable cause of their morbidity
and mortality.
The intention of the study is to broaden implantation of Kangaroo
Mother Care (KMC) as a method of care in hospital settings.
Conceptual/theoretical The researchers wanted to assess the physiologic state of low birth
Framework weight babies before and after KMC in a teaching hospital setting.

Design/ Quasi- experimental

Method/Philosophical
Underpinnings

Sample/ The study protocol was approved by the institutional ethics

Setting/Ethical committee, and formal written consent of willing mothers was
Considerations obtained.
265 mother/baby pairs.
Institute of Postgraduate Medical Education &Research
(IPGME&R), Kolkata and its associated SSKM Hospital.
Major Variables Low birth weight babies physiological state before and after
Studied (and their Kangaroo Mother Care in a teaching hospital setting.
definition), if
appropriate

Measurement Four vital physiological parameters of the baby, namely

Tool/Data Collection temperature, resp. rate, heart rate, and oxygen saturation were
Method assessed immediately before and after KMC for 3 consecutive days.

Data Analysis Mean and standard deviation, Boxplots, paired t test, Statistica
version 6 software.

Findings/Discussion During KMC, most babies showed steady rise in temp. and
none developed hypothermia.
KMC sessions protect the newborn against temp. fluctuation
and cold stress.
Limitations: Implementation of KMC requires organized
planning and effort, and lack of these are barriers towards
extending the benefits to all babies in need of such care.
Appraisal/Worth to Nurses can help implement this form of care
practice KMC is a simple and low-cost intervention for care of LBW
infants.
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First Author Irum, S., Jabeen, N., Baloch, R., & Mawani, K. (2017). NEWBORN
(Year)/Qualifications BODY TEMPRATURE; COMPARATIVE STUDY TO SEE
THE IMPACT ON NEWBORN BODY TEMPERATURE
AFTER SKIN CONTACT OF MOTHER AND NEWBORN V/S
CONVENTIONAL METHOD. Professional Medical
Journal, 24(4), 574-579. doi:10.17957/TPMJ/17.3748

Background/Problem In developing countries around 21% infant mortality is caused by

Statement hypothermia. Thermal protection of the newborn is a global
concern and a challenge for healthcare providers despite advances
in technology.
Conceptual/theoretical Not mentioned
Framework

Design/ Comparative
Method/Philosophical Quantitative
Underpinnings

Sample/ 120 women as per selected criteria distributed into two

Setting/Ethical groups
Considerations Verbal and written consent was obtained by participants

Major Variables Group A: babies to be placed in the warmer

Studied (and their Group B: babies that received skin-to-skin care
definition), if
appropriate

Measurement
Tool/Data Collection Cross sectional analytical study
Method Researchers observed participant temperatures

Data Analysis t-test, SPSS version 16.

Findings/Discussion
Skin-to-skin contact reduces hypothermia in neonates.

Appraisal/Worth to Neonates are shown to maintain higher temperatures,

practice avoiding hypothermia, when skin-to-skin care is implemented.
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First Author Nimbalkar, S. M., Patel, V. K., Patel, D. V., Nimbalkar, A. S.,
(Year)/Qualifications Sethi, A., & Phatak, A. (2014). Effect of early skin-to-skin
contact following normal delivery on incidence of
hypothermia in neonates more than 1800 g: randomized
control trial. Journal Of Perinatology, 34(5), 364-368.
doi:10.1038/jp.2014.15

Background/Problem
Statement There is an increased percentage of hypothermia in neonates
including term and late-preterm newborns, this is indicative of a
need for and intervention such as the promotion of skin-to-skin
care.
Conceptual/theoretical Researchers wanted to examine the positive effects that the
Framework implementation of skin-to-skin care has on the incidence of
hypothermia in neonates.
Design/ Quantitative
Method/Philosophical
Underpinnings

Sample/ 100 stable newborns weighing 1800g or more and delivered

Setting/Ethical vaginally.
Considerations

Major Variables Intervention Group: received skin-to-skin care time (50

Studied (and their neonates)
definition), if Control Group: received conventional care (50 neonates)
appropriate

Measurement Newborns fulfilling inclusion criteria were included in the

Tool/Data Collection study after taking informed consent from their mother.
Method Temperature and heart rate in the SSC group and in the
control group were recorded first at 30 min. and subsequently
1,2,3,4,5,6,12,24 and 48h or life.

Data Analysis t-Test, Chi-Square test, Microsoft Excel 2010, SPSS 14

Findings/Discussion
Research findings positively correlate with previous research
that had been conducted on skin-to-skin care. No
weaknesses or limitations are identified in this study. The
results of the study explain the significance of the
implementation of skin-to-skin time and temp. regulation.
Appraisal/Worth to
practice Newborns in the SSC group achieved rapid thermal control
and maintained it as compared with the control group, thus
emphasizing the importance of early skin-to-skin on
prevention of hypothermia during the first 48h of life.
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First Author Srivastava, S., Gupta, A., Bhatnagar, A., & Dutta, S. (2014). Effect
(Year)/Qualifications of very early skin to skin contact on success at breastfeeding and
preventing early hypothermia in neonates. Indian Journal Of Public
Health, 58(1), 22-26. doi:10.4103/0019-557X.128160

Background/Problem The neonatal mortality rates are high in India, hence the need for a
Statement simple and easily applicable intervention such as skin-to-skin time.
Conceptual/theoretical Researchers wanted to identify how early skin-to-skin contact
Framework effects neonatal well-being (thermal regulation in immediate post-
partum period).
Design/ Quantitative
Method/Philosophical Randomized control study
Underpinnings Babies in the study group received very early SSC.
Babies in the control group received the standard care.
Sample/ 298 mother-baby dyads were enrolled.
Setting/Ethical The study was approved by the Hospital’s Ethics committee.
Considerations Babies born by normal delivery who did not require
resuscitation and with no congenital malformations were
included in the study.
Major Variables Study Group: babies received SSC
Studied (and their Control Group: babies received standard care
definition), if
appropriate

Measurement
Tool/Data Collection The data were collected on a preset performa by the
Method observer and subjected for analysis using appropriate
methods.

Data Analysis
t-test, Pearson Chi-square test and nonparametric Mann-
Whitney test. SPSS/16.0
Findings/Discussion
Temperature gain was higher in the intervention group when
compared to the control group.
19 neonates in the control group were found to be in cold
stress after a 2 hour period despite being clothed and with
their mothers.

Appraisal/Worth to
practice Very early skin-to-skin care has a significant effect on baby’s
temperature regulation in the post-partum period.
No adverse effects were found in the babies that received the
skin-to-skin intervention.
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