Proposed guidelines for skin-to-skin care and rooming-in should be more inclusive

Dear Editor,

We read with interest the recent commentary “The Baby Friendly Hospital Initiative and the ten steps for successful breastfeeding. A critical review of the literature” published in the Journal of Perinatology [1]. Table 2, created by Gomez-Pomar and Blubaugh, provides a potential order set for “safe skin-to-skin care,” reportedly based on recommendations provided by the AAP [2] and Davanzo [3]. However, the guidance provided is unnecessarily restrictive and is inconsistent with recommendations endorsed by the American Heart Association/American Academy of Pediatrics/International Liaison Committee on Resuscitation (AHA/AAP/ILCOR) neonatal resuscitative guidelines [4]. There is no evidence that near-term newborns (37–38 weeks gestation), or those with no prenatal care, maternal fever, history of drug exposure, prolonged rupture of membranes, non-life-threatening congenital anomalies, infants <2500 g, or suspicion of chorioamnionitis require stabilization on a warmer bed. These newborns may be stabilized and assessed on the mother while in skin-to-skin care (SSC). Infants with meconium staining with normal respiratory effort, good tone, and heart rate >100 may also be placed immediately in SSC. Furthermore, late preterm newborns (≥35 weeks gestation) may have SSC if stable, with good tone, normal heart rate, respiratory effort, and Apgar score of ≥7 at 5 min. In the event of positive pressure ventilation, SSC should be postponed until the infant is stabilized, but is not precluded [5].

Suggestions for monitoring during SSC included in Table 2 are also overly conservative and may be impractical. The AAP Clinical Report [2] and others [6] recommend the following guidance for monitoring:

  • Continuous observational monitoring: staff member at the bedside of the dyad, preferably for the first 2 h, until transitioned to the mother–infant unit; the first 2 h after birth poses the highest risk for sudden unexpected post-natal collapse (SUPC).

  • Vital signs obtained at 10, 30, 60, 90, and 120 min until transitioned to the mother–infant unit/postpartum unit.

  • Color is pink after circulatory transition has occurred.

  • Respiratory rate is 30–60 breaths/min.

  • Temperature obtained (axillary) at 60 and 120 min is 36.5–37.5 °C, not hypothermic (<36.5 °C).

  • Routine continuous pulse oximetry is unnecessary; however, if pulse oximetry is used, the oxygen saturation should be >90%.

Given the recognized benefits of SSC, unnecessary limitations pose a risk for adverse outcomes, such as hypothermia, hypoglycemia, and decreased breastfeeding [7]. Finally, while the authors indicated proposed guidelines for rooming-in, these do not appear in Table 2, despite the table’s title. We agree there are safety considerations for rooming-in, outlined in the AAP Clinical Report; however, we disagree with the authors that there is little evidence to support this practice. The results of the randomized controlled trial involving 176 dyads were inconclusive, not negative, regarding breastfeeding outcomes [8]. Additional benefits of rooming-in include bonding, maternal self-efficacy, and newborn comfort, especially in newborns suffering from neonatal abstinence syndrome. Evidence that mothers are “made to feel guilty is lacking;” on the contrary, patient satisfaction scores have increased after rooming-in has been instituted [9]. Patient safety is paramount and can be implemented along with the AAP’s endorsement of the ten steps to successful breastfeeding.


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Correspondence to Lori Feldman-Winter.

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Feldman-Winter, L., Goodstein, M.H., Hauck, F.R. et al. Proposed guidelines for skin-to-skin care and rooming-in should be more inclusive. J Perinatol 38, 1277–1278 (2018).

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