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Am Fam Physician. 2018;97(3):170-171

Author disclosure: No relevant financial affiliations.

Clinical Question

Is skin-to-skin care safe and effective in relieving procedural pain in neonates?

Evidence-Based Answer

Skin-to-skin care, also known as kangaroo care, effectively reduces physiologic and behavioral measures of pain in neonates during painful procedures and has no identified adverse effects. Infants who received skin-to-skin care during painful procedures had a heart rate of 10.8 beats per minute less, cried for 34 fewer seconds, and had reduced pain scores immediately following the procedure compared with infants who did not receive skin-to-skin care.1 Family physicians should encourage skin-to-skin care for newborns undergoing painful procedures. (Strength of Recommendation: A, based on consistent, moderate- to good-quality patient-oriented evidence.)

Practice Pointers

Most newborns undergo painful procedures in their first weeks of life, including intramuscular injections (e.g., hepatitis B vaccination2) and heel lance (e.g., state-mandated genetic screening3). Untreated neonatal pain could have adverse behavioral, autonomic, and hormonal responses, and may affect brain and cognitive development. Neonatal pain control is therefore an important part of newborn care. Skin-to-skin care, in which newborns wearing only a diaper are held next to their mother's bare chest, has many benefits, including improved breast milk production, breastfeeding duration, parent satisfaction, sleep organization, and a longer duration of quiet sleep.1 Skin-to-skin care is a possible alternative to pharmacologic analgesics for painful procedures.

The authors of this Cochrane review sought to determine if skin-to-skin care is effective in reducing pain during newborn procedures.1 The 25 studies in the review included 2,001 infants.1 None of the studies reported adverse effects. Studies examined response to pain during or after painful procedures (heel lance, intramuscular injection, venipuncture, or tape removal) with skin-to-skin care compared with no treatment or another treatment (e.g., dextrose, breastfeeding). Outcomes included physiologic measures (e.g., heart rate, oxygen saturation, cortisol levels) or behavioral measures (e.g., cry duration, facial grimacing scores), or a composite score of the two. Because of a high degree of heterogeneity between designs and outcomes, only a few studies could be combined for analysis.

A meta-analysis of five studies (n = 161) showed a mean decrease in heart rate of 10.8 beats per minute (95% confidence interval [CI], −13.6 to −7.9) during painful procedures in infants receiving skin-to-skin care vs. no treatment. Four of the five studies (n = 120) examined heart rate with skin-to-skin care applied before, during, and after the procedure (duration of postprocedure treatment was defined in only one study: 20 minutes), and meta-analysis found no significant difference in postprocedure heart rate recovery vs. no treatment. A meta-analysis of two separate studies (n = 49) examining oxygen saturation during the procedure showed no significant difference between skin-to-skin care and no treatment.

A separate meta-analysis, which included four studies that measured the postprocedure duration of crying (n = 133), favored skin-to-skin care over no treatment after heel lance (mean difference [MD] = −34.16 seconds; 95% CI, −42.86 to −25.45) and intramuscular injection (MD = −8.83; 95% CI, −14.63 to −3.02). A meta-analysis of five studies (n = 267) that used the Premature Infant Pain Profile—a validated composite pain measurement tool scored from 0 to 21 using physiologic and behavioral indicators—showed a significant decrease in postprocedure scores with skin-to-skin care at 30 seconds (MD = −3.21; 95% CI, −3.94 to −2.47) and 60 seconds (MD = −1.64; 95% CI, −2.86 to −0.43), but not at 120 seconds.

Two additional studies compared skin-to-skin care by the mother, father, or another female provider and found no significant difference in Premature Infant Pain Profile scores. Studies comparing skin-to-skin care with other interventions could not be combined for analysis, although they reported that skin-to-skin care had significantly lower composite pain scores (based on physiologic parameters and behaviors observed) compared with the use of sweet-tasting substances (dextrose, sucrose, or glucose) and score reductions similar to those of breastfeeding. The combination of skin-to-skin care with sweet-tasting substances or breastfeeding, or the combination of all three, was also better than any intervention alone.

The American Academy of Pediatrics and the Canadian Paediatric Society have recommended skin-to-skin care as an intervention when feasible.4,5

These are summaries of reviews from the Cochrane Library.

This series is coordinated by Corey D. Fogleman, MD, assistant medical editor.

A collection of Cochrane for Clinicians published in AFP is available at

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