Journal of Perinatology (2014) 34, 364–368

& 2014 Nature America, Inc. All rights reserved 0743-8346/14

www.nature.com/jp

ORIGINAL ARTICLE
Effect of early skin-to-skin contact following normal
delivery on incidence of hypothermia in neonates more than
1800 g: randomized control trial
SM Nimbalkar, VK Patel, DV Patel, AS Nimbalkar, A Sethi and A Phatak

OBJECTIVE: To investigate the impact of early skin-to-skin contact (SSC) provided for first 24 h on incidence of hypothermia in
stable newborns weighing 1800 g or more during first 48 h of life.
STUDY DESIGN: Stable newborns (term and late preterm: Mean gestational age 37.7 (1.35) weeks, range 34–40 weeks) having birth
weight 1800 g or more (Mean weight 2605.6 (419.8) grams) were enrolled after approval from Institutional Human Research Ethics
Committee (CTRI/2013/06/003790) and randomized into early SSC (intervention group) and conventional care (control group).
Initial care in the delivery room for few minutes immediately after birth in both the groups was given under radiant warmer. In the
intervention group, newborns were provided SSC by their mother started between 30 min and 1 h after birth for first 24 h with
minimal interruption and were provided conventional care other than SSC for next 24 h of life. In the control group, newborns
were kept with their mother and received conventional care other than SSC for first 48 h. Temperature and heart rate of newborns
were recorded at 30 min, 1, 2, 3, 4, 5, 6, 12, 24 and at 48 h of life in both the groups. Independent Samples t-Test and relative risk
were used to analyze the data.
RESULT: Both groups had 50 neonates each with similar baseline characteristics. Heart rates were in normal range in both the
groups. The intervention group provided an average (s.d.) of 16.98 (0.28) h of SSC over the first 24 h period. The mean temperature
was significantly high in the SSC group at all time intervals starting from 1 to 48 h (Po0.05 for all). In the SSC group only two
newborns (4%) had mild hypothermia (cold stress), and, of these two newborns, one had two episodes of hypothermia. All these
three episodes of hypothermia occurred within first 3 h of life. In the control group 16 newborns (32%) developed hypothermia
(temperatureo36.5 1C) during first 48 h of life. Of them, 11 newborns had single episode, 4 newborns had two episodes and one
newborn had three episodes of hypothermia. Of these 22 hypothermic episodes, 20 occurred in the first 6 h of life and 2 episodes
occurred at 48 h of life. Moderate hypothermia was seen in two newborns, whereas rest had mild hypothermia. The relative risk of
developing hypothermia in the control group as compared with the SSC group was 8.00 (95% CI 1.94–32.99). There was no seasonal
variation in incidence of hypothermia in both the groups.
CONCLUSION: Newborns in the SSC group achieved rapid thermal control as compared with the control group. Early SSC for 24 h
after birth decreases incidence of hypothermia for initial 48 h of life. Early SSC needs to be aggressively promoted in term and late-
preterm newborns to reduce incidence of hypothermia.

Journal of Perinatology (2014) 34, 364–368; doi:10.1038/jp.2014.15; published online 20 February 2014
Keywords: skin-to-skin care; hypothermia; thermal control; neonates

INTRODUCTION thermogenesis.1 However, in a cool environment thermogenic

Maintenance of infant’s neutral temperature requires under-
standing of various mechanisms influencing heat loss in newborn,
and maintaining neutral temperature has an important role in
improving the neonatal outcome.1 Practices such as keeping baby
unattended, bathing immediately after birth, delayed drying and
wrapping put the baby at an additional risk for heat loss.2 Fetus
maintains about 0.5 1C temperature higher than that of the
mother due to heat production by its tissues.3 At birth, the
newborn is exposed to relatively cold environment and various
mechanisms cause the temperature to drop rapidly.4 On an
average, the temperature drops by 2–4 1C in the first few minutes
after birth and even greater fall can occur in the absence of
adequate thermal protection.5 The main mechanism contri-
buting to the heat production in newborn is nonshivering
response is limited during first 12 h of life. This necessitates
adoption of measures and practices to limit heat loss during this
period.6
World Health Organization (WHO) defines hypothermia as
present when the newborn’s axillary temperature falls below
36.5 1C.7 Hypothermia leads to adverse neonatal outcomes like
impaired growth, hypoglycemia, generalized internal bleeding,
and increased risk of infection, metabolic acidosis, respiratory
distress and even death.7
Kangaroo mother care (KMC) in the management of low birth
weight (LBW) newborns was pioneered in 1978 in Colombia and it
incorporates skin-to-skin contact (SSC), frequent and exclusive, or
nearly exclusive breastfeeding and early discharge from hospital.8
In the beginning, KMC represented an appropriate use of scarce

Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, India. Correspondence: Professor SM Nimbalkar, Professor of Pediatrics, Department of Pediatrics,
Pramukhswami Medical College, Karamsad, Anand 388325, India.
E-mail: somu_somu@yahoo.com
Received 8 July 2013; revised 17 December 2013; accepted 6 January 2014; published online 20 February 2014

resources in low-income countries.9 Effective thermal control is
achieved with reduced risk of hypothermia by SSC.10 Rewarming
of hypothermic neonates in SSC position is at least as effective as
an incubator.11 Mori et al.12 in their meta-analysis concluded that
in low middle income settings SSC is effective in increasing the
body temperature of newborns by 0.22 1C. SSC has been as
effective as radiant warmers in preventing heat loss in healthy
full-term infants.13 Early SSC involves placing naked baby prone on
mother’s bare chest at birth or soon afterward. Early SSC for
term or late-preterm infants can be divided in to birth SSC
(during the first minute post birth), very early SSC (beginning
B30–40 min post birth) and early SSC (anytime between 1 and
24 h post birth).13
Studies on incidence of hypothermia in newborns in limited
resource countries like India are based on single axillary
temperature reading within first 24 h of birth at home using
varying case definitions.14,15 Kumar et al.14 in their study from
Haryana, North India considered hypothermia present when
axillary temperature o35.6 1C and reported its incidence to be
11.1%. Darmstadt et al.15 in their study from Uttar Pradesh, North
India defined it when axillary temperature o36.5 1C and reported
its incidence to be 45%. In both of these studies, authors did not
stratify the severity of hypothermia. In Gadchiroli, Western India,
Bang et al.16 recorded the temperature at home and demon-
strated incidence of hypothermia (axillary temperatureo35 1C) to
be 17%. Christensson et al.17 from Sweden and Marı́n Gabriel
et al.18 from Spain studied influence of early SSC for initial first few
hours of life and found SSC to be beneficial in thermal stability.
According to the past records in our hospital, incidence of
hypothermia is around 40% including term and late-preterm
newborns, indicating need of low-cost intervention that can
reduce the incidence of hypothermia. To address this issue and to
overcome deficiencies mentioned in previous studies in India, this
study was undertaken to evaluate the effect of early SSC for first
24 h on incidence of hypothermia based on standard WHO
definition in term and late-preterm newborns.
METHODS
Study design
Superiority Randomized Control Trial (CTRI/2013/06/003790). Randomiza-
tion was done based on web based software (WINPEPI) and selection cards
were sealed in the opaque envelopes.
Study site
This study was conducted at Maternity ward of Shree Krishna Hospital
(SKH) attached to Pramukhswami Medical College, Karamsad from Anand
district of Gujarat, North India over a period of 10 months from June 2012
to March 2013.
As a routine policy, before 20 min of expected time of delivery, open
care servo-controlled radiant warmer is switched on to full heater output
on manual mode and blankets are kept under it to make them warm and
temperature of delivery room newborn care corner is maintained above
25 1C. All the newborns delivered at delivery room are immediately taken
under the radiant warmer, dried immediately and then wet blankets are
removed and covered with fresh warm blankets. This policy is different
from the WHO recommendations of keeping the newborn on mother’s
bare chest immediately after birth. Before transporting newborns to
maternity ward with their mothers, they are clothed and cap is applied.
Maternity wards are not climate controlled like the delivery room.
Temperature of maternity ward was recorded with room temperature
monitor at 12 h interval in the noon and midnight when the temperature
differences are highest.
As per the protocol, stable newborns weighing X1800 g are provided
level I care in maternity ward with their mothers. Rest of the newborns are
cared at the attached level II neonatal intensive care unit (NICU) accredited
by National Neonatology Forum of India. Being a tertiary care referral
center, rates of premature (20–25%) and LBW (40–45%) deliveries in SKH
are high. All the staff nurses are formally trained in the implementation of
KMC for LBW newborns during induction training and regular biyearly
& 2014 Nature America, Inc.
Early skin-to-skin care in neonates and hypothermia
SM Nimbalkar et al
365
updates. KMC has been a standard of care for more than 10 years to
physiologically stable LBW newborns in maternity ward and NICU. Early
SSC for term newborns was not implemented before this study.
Study population
Stable newborns with birth weight 1800 g or more and delivered vaginally
were eligible to participate in this study. Newborns were excluded if
delivered by cesarean section, needed any resuscitation measures or were
detected to have any congenital malformation at birth. Practice of KMC
was continued for the LBW newborns not enrolled in the study. To prevent
contamination of KMC in the enrolled newborns, two strategies were
employed: (i) the enrolled newborns’ treatment record files were labelled
‘Follow the study protocol: intervention/control’ and (ii) in the daily
treatment advise form of the newborns, ‘Instructions to be followed as per
study protocol: intervention/control’ was mentioned.
Sample size
According to the past records, incidence of hypothermia is roughly 40% in
our hospital. An absolute drop of 25% in the incidence was considered
clinically important. Considering alpha (type I error) at 5%, 47 neonates
were required in each group to achieve a power of 80%. Drop outs were
not expected because of the study design, and hence 100 participants
were recruited in the study (50 per group).
Study procedure
Newborns fulfilling inclusion criteria were included in the study after taking
informed consent from their mother (that is, after their immediate post
delivery care is over by around 15 to 20 min of birth) and randomized in
two groups either to receive (a) early SSC (intervention group) or
(b) conventional care (control group).
In the intervention group, mothers were explained immaculately about
the procedure of SSC by the nurses/resident doctor working in the
maternity ward. Mothers were provided clothing in the form of front open
gowns with short sleeves and were advised to start SSC at 30 min to 1 h
after delivery and continue for as long as possible in the first 24 h with
each session lasting for minimum 60 min. SSC was discontinued after 24 h.
In the control group, after providing routine care under radiant warmer,
newborns were kept clothed (including head cap) and covered with
blanket with their mother (bedding in) for first 48 h. In both the groups
newborns were exclusively breast fed.
Temperature and heart rate in the SSC group (irrespective of whether
SSC was ongoing or not) and in the control group were recorded first at
30 min and subsequently at 1, 2, 3, 4, 5, 6, 12, 24 and 48 h of life. Axillary
temperature was recorded with a Smart Care–Digital Thermometer
(SCT01), and pulse rate was monitored by pulse Oximeter of L&T medical
(Model- L&T/STELLAR). Order of recording parameters was pulse rate from
monitor followed by axillary temperature to avoid physical effect on pulse
rate during temperature recording. WHO definition of hypothermia was
followed in this study.
Statistical analysis
Descriptive statistics were used to depict the characteristics of the study
population. The difference in the mean temperature between the two
groups at different time points was assessed using Independent Samples
t-Test. The overall trend in the mean temperatures of the two groups was
portrayed using a line diagram. Relative risk (RR) was used to estimate the
effect of SSC on the incidence of hypothermia. w2 test was used to assess
association between incidence of hypothermia and season. Data were
entered using Microsoft Office Excel 2010 and imported to SPSS 14 (SPSS
Inc, Chicago, IL, USA) for analysis after validation and cleaning.
Ethical considerations
The study was approved by human research ethics committee of HM Patel
Centre for Medical Care and Education, Karamsad.
RESULTS
Out of the 232 consecutive newborns assessed for eligibility, 132
newborns were excluded. Thus, 50 participants were recruited in
each group (Figure 1). The mean (s.d.) baseline heart rate was
140.95 (7.28) (range: 128 to 159 min) and mean (s.d.) baseline
Journal of Perinatology (2014), 364 – 368
 Early skin-to-skin care in neonates and hypothermia
SM Nimbalkar et al
366
Assessed for eligibility (n=232)
Excluded (n=132)
- Cesarean (n=98)
- Refused to participate (n=4)
- Congenital malformation (n=3)
- Other (n=27)
Randomized (n=100)
Allocated for intervention (n=50)
Received SSC (n=50) Allocated for control (n=50)
Lost to follow up (n=0) Lost to follow up (n=0)
Discontinued intervention (n=0)
Analyzed (n=50) Analyzed (n=50)
Excluded from analysis (n=0) Excluded from analysis (n=0)
Figure 1. Flow of recruitment of study participants.
temperature was 36.88 (0.25) (Range: 36.6 to 37.6 1C). Other
clinical characteristics of the two groups were similar at the
baseline (Table 1).
The mean (s.d.) time to start SSC in the intervention group was
43 (12.5) minutes after birth. The mean (s.d.) time of SSC was 16.98
(0.28) (range: 16.5 to 17.5 h) during the first 24 h.
Among controls, 16 (32%) newborns developed hypothermia
(temperatureo36.5 1C) during the initial 48 h of life. Of these 16
newborns, 10 (62.5%) were LBW, whereas 5 (31.2%) were late
preterm. All these 16 newborns became hypothermic within first
6 h of life, and, of these, two newborns (both were LBW as well as
preterm) also had repeat episode of hypothermia at 48 h of life.
Eleven newborns had a single episode of hypothermia, four
newborns had two episodes of hypothermia and one newborn
had three episodes of hypothermia adding to 22 episodes of
hypothermia in first 48 h of life. Out of these five newborns with
multiple episodes of hypothermia, four were LBW and three were
preterm. Moderate hypothermia was seen in two newborns,
whereas rest had mild hypothermia.
In the SSC group only 2 (4%) newborns developed hypothermia,
and, of these, one newborn had two episodes of hypothermia.
Both newborns had mild hypothermia (cold stress). In two
newborns in the SSC group who had hypothermia, one newborn
was LBW and preterm. The newborn with repeat episode of
hypothermia was a term neonate and had these at the first and
third hour of life. No newborn in the SSC group had hypothermia
after 3 h of life.
The mean temperature was significantly higher in the SSC group
as compared with the control group at all the time intervals starting
from 1 to 48 h (Po0.05) (Figure 2). The relative risk of developing
hypothermia in the control group was eight times higher (95% CI
1.94–32.99) as compared with the SSC group (Table 2).
This study covered 2 months of summer (March and June),
4 months of monsoon (July to October) and 4 months of winter
(November to February). It did not include the warmest period of
the year (May) but included the coolest period of the year
(January). The low average during March and June to October
varied from 21 to 27 1C, whereas in the cooler months varied from
12 to 19 1C. The high averages during the same periods were
32 to 38 1C and 28 to 36 1C, respectively. In the SSC group 1 (7.7%)
of 13 newborns, 1 (3.8%) of 26 newborns and none of 11
newborns developed hypothermia in summer, monsoon and
winter, respectively (P ¼ 0.631). In the control group 2 (25%) of 8
Journal of Perinatology (2014), 364 – 368
Table 1. Baseline characteristics of the study population
Characteristics SSC group Control group
(n ¼ 50) (n ¼ 50)
Mean GA (weeks) 37.8 (1.43) 37.7 (1.28)
Mean weight (grams) 2622.2 (398.69) 2588.9 (443.25)
Baseline heart rate (at 30 min 138.9 (6.58) 142.9 (7.47)
after birth)
Baseline temperate (at 30 min 36.89 (0.24) 36.87 (0.26)
after birth)
Low birth weight 44% 46%
newborns, 5 (26.3%) of 19 newborns and 9 (39.1%) of 23
newborns developed hypothermia in summer, monsoon and
winter, respectively (P ¼ 0.607). Thus, season was not associated
with hypothermia in both the groups in the present study.
DISCUSSION
The study revealed that the incidence of hypothermia in
conventional care was significantly higher as compared with the
SSC (32% vs 4%, Po0.001). Marı́n Gabriel et al.18 estimated
influence of SSC on thermal regulation in term and nearly term
newborns after giving 2 h of continuous SSC immediately after
birth and found an average temperature rise of 0.07 1C more as
compared with the control group newborns who were wrapped
with a warm blanket and then given back to their parents, but
they did not report any changes in axillary temperature at 5 min
and at 2 h of birth in both the groups. In the present study, we
found significantly higher temperature in the SSC group at each
time interval starting from 1 to 48 h. In a study of full-term
newborns during first 90 min of life by Christensson et al.,17 axillary
and the skin temperatures were significantly higher in the SSC
group as compared with newborns kept next to their mother in a
cot. In another study, Christensson et al.17 concluded that STS care
was at least as effective as incubator care for rewarming low-risk
hypothermic infants (clinically stable with admission weight of
X1500 g).11
In the present study, 16 (32%) neonates developed hypother-
mia within first 48 h of life in the control group that is comparable
to the 40% incidence of hypothermia during hospital stay
from the past records as in this study we have not incorpo-
rated the findings after 48 h of life. All these 16 newborns
developed hypothermia within first 24 h of life. Kumar et al.2 also
reported that the majority of the hypothermia episodes occur in
first day of life.
A discussion of the general environmental temperature is
imperative as the maternity wards are not climate controlled and
the temperatures do vary with the incumbent weather in the
region during winter, summer and rainy seasons and this is
applicable to most of the states of India. These vagaries of nature
have also been explained by Bang et al.16 and concluded that
incidence of hypothermia was higher in winter months without
home-based neonatal care in preintervention period, whereas
there was no significant difference in incidence of hypothermia
based on season in post intervention period. However, study from
Nepal with lower environmental temperature showed significantly
higher incidence of hypothermia in winter season, but they have
not mentioned about the practices followed to keep the
newborns warm.19 Thus, SSC is an intervention for term and
late-preterm newborns that can work in all seasons across India
without using additional resources in terms of electricity, which is
often unavailable.
Several studies have shown that SSC is helpful in maintaining
neutral thermal environment. Bystrova et al.20 observed the
temperature every 15 min in the axilla, on the thigh, back and foot
& 2014 Nature America, Inc.

37.3
Axillary Temperature 0C
37.2
37.1
37
36.9
36.8
36.7
36.6
Figure 2. Mean temperature at various time intervals after birth in both the groups. P-value suggests difference between means of two groups
at respective time.
Table 2. Hypothermia and group status (n ¼ 100)
Group
Hypothermia SSC Control
Yes 2 16
No 48 34
Total 50 50
during 30 to 120 min of life in SSC and nursery group (newborns
were clothed and kept in the nursery) and found significant lower
temperature in the nursery group along with significant increase
in temperature over time in the SSC group. Bergman et al.21
compared SSC with conventional incubator care in newborn of
1200 to 2199 g to see the physiological stabilization for first 6 h of
life. Temperature as well as cardio-respiratory stabilization score
was higher in the SSC group compared with conventional
incubator care.
Our study results are consistent with these studies, and the
mean temperature in the SSC group was higher compared with
the control group at all stages of reading during first 48 h of life.
Temperature of newborns in SSC groups progressively increased
after birth, whereas in the control group there was reduction in
temperature at1 h of birth and never matched with the SSC group
for first 48 h. This study also showed that early SSC for first 24 h
can reduce risk of hypothermia at 48 h of life. In a large hospital-
based study from NICU at Mumbai, Western India, Rao et al.22
reported 36.9% incidence of hypothermia in control arm as
compared with 5.9% in the SSC group. In this study, the average
age of enrollment in the intervention group was 3.7±2.8 days,
suggesting that few newborns received SSC on the first day of life
and did not address the prevention of hypothermia on the first
day of life. The present study adds to this knowledge base and
provides information of effect of early SSC on incidence of
hypothermia within first 48 h of life.
Hypothermia is an independent predictor of neonatal mortality
and is additionally closely associated with many other factor like
sepsis, prematurity and birth asphyxia that are major causes of
neonatal mortality.23 Lunze et al.23 in systematic review reported
the case fatality for neonatal hypothermia ranged from 8.5 to 52%.
In a study from Nepal, the relative risk of death ranged from 2 to
30 times within the WHO classification for moderate hypothermia
and increased with greater severity of hypothermia.24 These
observed risks of neonatal hypothermia for neonatal mortality
emphasize the importance of temperature control and prevention
& 2014 Nature America, Inc.
Early skin-to-skin care in neonates and hypothermia
SM Nimbalkar et al
367
37.18 37.186
37.136 37.134
37.18
37.1 37.162 37.138
37.026 36.974 Control
36.952
36.914 group
36.894 36.954 36.958
36.812
36.908 SSC
36.866 36.872
36.8 group
Time after birth
of hypothermia in newborn. In the current study, the proportion of
neonates developing hypothermia was eight times higher in
Relative risk conventional care compared with the SSC group. Hence, the
reduced risk of hypothermia will translate to an improvement in
neonatal outcomes. Our study is hospital based, yet it is gene-
ralizable to the context of low resource countries as the enviro-
8 (95% CI 1.94–32.99) nments are similar. Community-based study is also warranted as
many local beliefs and behaviors like early bathing, delayed drying
and wrapping may increase the risk of hypothermia and interfere
with implementing simple steps of hypothermia prevention.23
In today’s world, majority of newborns including preterm are born
in lower and lower middle income counties without the availability
of incubator or radiant warmer care. Many neonates succumb before
stabilization and acclimatization to environments before the first 3
days of life. SSC is an alternative to an incubator and radiant warmer
in reducing heat loss in stable newborns. Even where such resources
are available it may be the better alternative due to possible neuro-
developmental benefits. As early SSC reduces incidence of hypo-
thermia in newborns within first 48 h of life, it can contribute in
reduction of neonatal mortality due to hypothermia.
CONCLUSION
Newborns in the SSC group achieved rapid thermal control and
maintained it as compared with the control group, thus
emphasizing the importance of early SSC on prevention of
hypothermia during first 48 h of life. The risk of hypothermia was
significantly high in the term and late-preterm newborns cared on
cot with mother compared with SSC care. Early SSC for 24 h
reduced hypothermia in newborns even for the next 24 h when
not given. Early SSC needs to be aggressively promoted to prevent
hypothermia in term and late-preterm newborns.
CONFLICT OF INTEREST
The authors declare no conflict of interest.
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