Skip to main content

Thank you for visiting You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Population Study Article
  • Published:

Early skin-to-skin contact and risk of late-onset-sepsis in very and extremely preterm infants



To evaluate the association between exposure to early skin-to-skin contact (SSC) and incidence of late-onset sepsis (LOS) in extremely and very preterm infants.


Observational study using the national population-based EPIPAGE-2 cohort in 2011. A propensity score for SSC exposure was used to match infants with and without exposure to SSC before day 4 of life and binomial log regression used to estimate risk ratios and CIs in the matched cohort. The primary outcome was at least one episode of LOS during hospitalization. Secondary outcomes were the occurrence of any late-onset neonatal infection (LONI), LOS with Staphylococcus or Staphylococcus aureus, incidence of LOS and LONI per 1000 central venous catheter days.


Among the 3422 included infants, 919 were exposed to early SSC. The risk ratio (RR) for LOS was 0.86 (95% CI, 0.67–1.10), for LONI was 1.00 (95% CI, 0.83–1.21), and for LOS with Coagulase-negative Staphylococcus or Staphylococcus aureus infection was 0.91 (95% CI, 0.68–1.21) and 0.77 (95% CI, 0.31–1.87). The incidence RR for LOS per-catheter day was 0.87 (95% CI, 0.64–1.18).


Early SSC exposure was not associated with LOS or LONI risk. Thus, their prevention should not be a barrier to a wider use of SSC.


  • Kangaroo Mother Care decreased neonatal infection rates in middle-income countries.

  • Skin-to-skin contact is beneficial for vulnerable preterm infants but barriers exist to its implementation.

  • In a large population-based study using a propensity score methods, we found that skin-to-skin contact before day 4 of life was not associated with a decreased risk of late-onset-sepsis in very and extremely preterm infants.

  • Early skin-to-skin contact was not associated with an increased risk of any late-onset-neonatal-infection, in particular with staphylococcus.

  • The fear of neonatal infection should not be a barrier to a wider use of early skin-to-skin contact in this population.

This is a preview of subscription content, access via your institution

Access options

Buy this article

Prices may be subject to local taxes which are calculated during checkout

Fig. 1: Study Flowchart.
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

Data availability

The EPIPAGE studies are subject to a data-sharing policy that can be downloaded from, especially with the following link:


  1. Mori, R., Khanna, R., Pledge, D. & Nakayama, T. Meta-analysis of physiological effects of skin-to-skin contact for newborns and mothers. Pediatr. Int. 52, 161–170 (2010).

    Article  PubMed  Google Scholar 

  2. Conde-Agudelo, A. & Diaz-Rossello, J. L. Kangaroo mother care to reduce morbidity and mortality in low birthweight infants. Cochrane Database Syst. Rev. 8, CD002771 (2016).

    Google Scholar 

  3. Feldman, R., Rosenthal, Z. & Eidelman, A. I. Maternal-preterm skin-to-skin contact enhances child physiologic organization and cognitive control across the first 10 years of life. Biol. Psychiatry 75, 56–64 (2014).

    Article  PubMed  Google Scholar 

  4. Charpak, N. et al. Twenty-year follow-up of Kangaroo Mother Care versus traditional care. Pediatrics 139, e20162063 (2017).

    Article  PubMed  Google Scholar 

  5. Gonya, J., Ray, W. C., Rumpf, R. W. & Brock, G. Investigating skin-to-skin care patterns with extremely preterm infants in the NICU and their effect on early cognitive and communication performance: a retrospective cohort study. BMJ Open 7, e012985 (2017).

    Article  PubMed  PubMed Central  Google Scholar 

  6. Pierrat, V. et al. Translating neurodevelopmental care policies into practice: the experience of neonatal ICUs in France-The EPIPAGE-2 Cohort Study. Pediatr. Crit. Care Med. 17, 957–967 (2016).

    Article  PubMed  PubMed Central  Google Scholar 

  7. Pallas-Alonso, C. R. et al. Parental involvement and kangaroo care in European neonatal intensive care units: a policy survey in eight countries. Pediatr. Crit. Care Med. 13, 568–577 (2012).

    Article  PubMed  Google Scholar 

  8. Morelius, E., Angelhoff, C., Eriksson, J. & Olhager, E. Time of initiation of skin-to-skin contact in extremely preterm infants in Sweden. Acta Paediatr. 101, 14–18 (2012).

    Article  PubMed  Google Scholar 

  9. Stoll, B. J. et al. Neurodevelopmental and growth impairment among extremely low-birth-weight infants with neonatal infection. JAMA 292, 2357–2365 (2004).

    Article  CAS  PubMed  Google Scholar 

  10. Mitha, A. et al. Neonatal infection and 5-year neurodevelopmental outcome of very preterm infants. Pediatrics 132, e372–e380 (2013).

    Article  PubMed  Google Scholar 

  11. Stoll, B. J. et al. Late-onset sepsis in very low birth weight neonates: the experience of the NICHD Neonatal Research Network. Pediatrics 110, 285–291 (2002).

    Article  PubMed  Google Scholar 

  12. Stoll, B. J. et al. Neonatal outcomes of extremely preterm infants from the NICHD Neonatal Research Network. Pediatrics 126, 443–456 (2010).

    Article  PubMed  Google Scholar 

  13. Sakaki, H., Nishioka, M., Kanda, K. & Takahashi, Y. An investigation of the risk factors for infection with methicillin-resistant Staphylococcus aureus among patients in a neonatal intensive care unit. Am. J. Infect. Control 37, 580–586 (2009).

    Article  PubMed  Google Scholar 

  14. Ancel, P. Y. & Goffinet, F. EPIPAGE 2: a preterm birth cohort in France in 2011. BMC Pediatr. 14, 97 (2014).

    Article  PubMed  PubMed Central  Google Scholar 

  15. Didier, C. et al. Late-onset neonatal infections: incidences and pathogens in the era of antenatal antibiotics. Eur. J. Pediatr. 171, 681–687 (2012).

    Article  CAS  PubMed  Google Scholar 

  16. Ego, A. et al. [Customized and non-customized French intrauterine growth curves. II – Comparison with existing curves and benefits of customization]. J. Gynecol. Obstet. Biol. Reprod. (Paris) 45, 165–176 (2016).

    Article  CAS  PubMed  Google Scholar 

  17. Buuren, S. V. & Groothuis-Oudshoorn, K. MICE: Multivariate Imputation by Chained Equations in R. J. Stat. Softw. 45, 1–67 (2011).

    Article  Google Scholar 

  18. Austin, P. C. Balance diagnostics for comparing the distribution of baseline covariates between treatment groups in propensity-score matched samples. Stat. Med. 28, 3083–3107 (2009).

    Article  PubMed  PubMed Central  Google Scholar 

  19. Boundy, E. O. et al. Kangaroo Mother Care and neonatal outcomes: a meta-analysis. Pediatrics 137, 1–16 (2016).

    Article  Google Scholar 

  20. Letouzey, M. et al. Cause of preterm birth and late-onset sepsis in very preterm infants: the EPIPAGE-2 cohort study. Pediatr. Res. 90, 584–592 (2021).

    Article  PubMed  PubMed Central  Google Scholar 

  21. Casper, C., Sarapuk, I. & Pavlyshyn, H. Regular and prolonged skin-to-skin contact Improves short-term outcomes for very preterm infants: a dose-dependent intervention. Arch. Pediatr. 25, 469–475 (2018).

    Article  CAS  PubMed  Google Scholar 

  22. Zaoui-Grattepanche, C., Pindi, B., Lapeyre, F., Huart, C. & Duhamel, A. Skin-to-skin contact with an umbilical venous catheter: prospective evaluation in a level 3 unit. Eur. J. Pediatr. 175, 551–555 (2016).

    Article  Google Scholar 

  23. Lamy-Filho, F. et al. Effect of maternal skin-to-skin contact on decolonization of Methicillin-Oxacillin-Resistant Staphylococcus in neonatal intensive care units: a randomized controlled trial. BMC Pregnancy Childbirth 15, 63 (2015).

    Article  PubMed  PubMed Central  Google Scholar 

  24. Hendricks-Munoz, K. D. et al. Skin-to-skin care and the development of the preterm infant oral microbiome. Am. J. Perinatol. 32, 1205–1216 (2015).

    Article  PubMed  PubMed Central  Google Scholar 

  25. Roze, J. C. et al. Assessment of neonatal intensive care unit practices and preterm newborn gut microbiota and 2-year neurodevelopmental outcomes. JAMA Netw. Open 3, e2018119 (2020).

    Article  PubMed  PubMed Central  Google Scholar 

  26. Giannoni, E. et al. Neonatal sepsis of early onset, and hospital-acquired and community-acquired late onset: a prospective population-based cohort study. J. Pediatr. 201, 106–114 (2018).

    Article  PubMed  Google Scholar 

  27. Kristoffersen, L. et al. Early skin-to-skin contact or incubator for very preterm infants: study protocol for a randomized controlled trial. Trials 17, 593 (2016).

    Article  PubMed  PubMed Central  Google Scholar 

  28. Linner, A. et al. Immediate parent-infant skin-to-skin study (IPISTOSS): study protocol of a randomised controlled trial on very preterm infants cared for in skin-to-skin contact immediately after birth and potential physiological, epigenetic, psychological and neurodevelopmental consequences. BMJ Open 10, e038938 (2020).

    Article  PubMed  PubMed Central  Google Scholar 

  29. WHO Immediate KMC Study Group. "Kangaroo Mother Care" and survival of infants with low birth weight. N. Engl. J. Med. 384, 2028–2038 (2021).

    Article  PubMed Central  Google Scholar 

  30. Linnér, A. et al. Immediate skin-to-skin contact is feasible for very preterm infants but thermal control remains a challenge. Acta Paediatr. 109, 697–704 (2020).

    Article  PubMed  Google Scholar 

  31. Linnér, A. et al. Immediate skin-to-skin contact may have beneficial effects on the cardiorespiratory stabilisation in very preterm infants. Acta Paediatr. 111, 1507–1514 (2022).

    Article  PubMed  Google Scholar 

  32. Seidman, G. et al. Barriers and enablers of kangaroo mother care practice: a systematic review. PLoS One 10, e0125643 (2015).

    Article  PubMed  PubMed Central  Google Scholar 

  33. Smith, E. R., Bergelson, I., Constantian, S., Valsangkar, B. & Chan, G. J. Barriers and enablers of health system adoption of kangaroo mother care: a systematic review of caregiver perspectives. BMC Pediatr. 17, 35 (2017).

    Article  PubMed  PubMed Central  Google Scholar 

  34. Yue, J. et al. Barriers and facilitators of kangaroo mother care adoption in five Chinese hospitals: a qualitative study. BMC Public Health 20, 1234 (2020).

    Article  PubMed  PubMed Central  Google Scholar 

Download references


All collaborators of the EPIPAGE-2 Neurodevelopmental care writing group and the EPIPAGE-2 Infectious diseases writing group have no conflict of interest or compensation in relation with this article to disclose. All consented to such acknowledgment. We are very grateful to the participating neonates and their parents. We also thank the members of national and regional coordination teams participating in this study for their substantial contribution to acquisition of data. We thank Laura Smales (BioMedEditing, Toronto, Canada) for English editing.


This project received funding support from the following: (1) The French Institute of Public Health Research/Institute of Public Health and its partners: the French Health Ministry, the National Institute of Health and Medical Research (INSERM), the National Institute of Cancer, and the National Solidarity Fund for Autonomy (CNSA). (2) The National Research Agency through the French EQUIPEX program of investments in the future (reference ANR-11-EQPX-0038). (3) The PREMUP Foundation. (4) The University Hospital of Strasbourg France supported ILR for research time. The funder/sponsor did not participate in the work.

Author information

Authors and Affiliations




I.L.R. and P.K. conceptualized and designed this study, drafted the initial manuscript, and reviewed and revised the final version of the manuscript. M.K. and V.P. conceptualized and designed this study, and critically revised and reviewed the manuscript for important intellectual content. P.-Y.A. designed the EPIPAGE-2 study, coordinated and supervised data collection, supervised the analyses, and reviewed the manuscript. M.L. and L.M.-M. managed and cleaned the data, and critically reviewed the manuscript for important intellectual content. J.-M.R., A.M., I.G., L.F.-L. contributed to data collection, discussed the study design and reviewed the manuscript for important intellectual content. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

Corresponding author

Correspondence to Pierre Kuhn.

Ethics declarations

Competing interests

The authors declare no competing interests.

Consent to participate

Recruitment and data collection occurred only after families had received information and agreed to participate in this cohort by written informed consent.

Additional information

Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary information

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Le Ray, I., Kuhn, P., Letouzey, M. et al. Early skin-to-skin contact and risk of late-onset-sepsis in very and extremely preterm infants. Pediatr Res 93, 2091–2100 (2023).

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI:


Quick links