Running head: CLINICAL PROJECT PAPER
Clinical Project on Skin-to-Skin Articles
Nicole Durrance
Azusa Pacific University
December 4, 2013
1
CLINICAL PROJECT PAPER
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Clinical Project on Skin-to-Skin Articles
Introduction
For the past few decades one of the most popular topics of research for the obstetric
community is the effects skin-to-skin care (STS) has on the newborn and maternal relationship.
Currently, research specifically focuses on benefits STS care has for newborn development. This
review will utilize six articles to further understand how best to implement STS care and the
common benefits seen for mothers, fathers, and infants.
Literature Review
Skin-to-Skin Benefits for Infants
Breastfeeding.
One of the most documented benefits seen in newborns is that STS care promotes
breastfeeding. Bramson et al.’s (2009) study, Erlandsson, Dsilna, Fagerberg, and Christensson’s
(2007) study, Gouchon et al. (2010) study, and Hung and Berg ‘s (2011) study all identify
increased success of breastfeeding when STS care was utilized.
The Bramson et al. (2009) study utilized 19 different hospitals in which researchers
observed 21,842 mothers who had delivered singleton infants of 37-40 weeks. The hypothesis of
the study found that STS mother-infant contact, within the first three hours of life, increased the
success for breastfeeding. The researchers looked at the following variables: initial method of
feeding, the mother’s sociodemographic characteristics, maternal intrapartum variables, type of
hospital birth, and length of time spent in STS care in the first three hours of life. The results
concluded that “exclusive breastfeeding was higher in mothers who experienced STS contact for
one to fifteen minutes” (p. 130). This supports the hypothesis that STS care and exclusive
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breastfeeding has a “dose-response relationship” (p. 130) and that “early STS contact is clinically
effective with respect to increasing exclusive breastfeeding” (p. 136).
The Erlandsson et al. (2007) study was a randomized controlled trial that tape recorded
and observed father-infant interactions. The infants in the study were from full term, healthy,
cesarean births whose fathers provided STS care. The study looked at the effects STS contact
had on the crying and prefeeding behavior of these newborns. The infants who experienced STS
contact with their fathers demonstrated characteristics supporting the facilitation of the
“development of the infant’s prefeeding behavior” (p.105). This result further supports the
correlation of STS contact and prefeeding behavior for breastfeeding.
Gouchon et al.’s (2010) study primarily focused on the correlation of STS contact and the
temperature of newborns after a cesarean. The second focus was on the correlation STS contact
had with the first attachment newborns made to the breast. STS contact reinforced the likelihood
that the mothers would exclusively breastfeed at discharge. The sample included 34 motherinfant dyads that were randomized into STS care or routine care. It was observed that the infants
who underwent STS care attached to the breast earlier and were breastfed more exclusively at
discharge then the infants who had received routine care after cesarean births. The study further
expands the importance of STS care for infants not only of vaginal births but also of cesarean
births.
The Hung and Berg (2011) study was a quality improvement project that focused solely
on increasing the time STS care was conducted between a mother-infant dyad after a cesarean
birth. The main focus of the project was that increased STS care would escalate the initiation of
breastfeeding after a cesarean birth. The project took three months of intervention and nine
months of data collection on approximately 260 births. The participants included culturally
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diverse dyads that lived in poverty and half of the women were single (not married or partnered).
Infants were observed at different STS contact intervals including: infants who experienced STS
care in the operating room (OR), infants who had STS care ranging from a few minutes to over
30 minutes, infants who had STS care within 90 minutes of birth, and infants who did not have
STS care before 90 minutes. As STS contact increased the likelihood that the mothers solely
breastfed enhanced due to the infants preference and the bonding that had occurred. This result
parallels with the above studies that breastfeeding is a known beneficial outcome of STS care.
Comfort.
In the Erlandsson et al. (2007) study a parallel was seen between STS contact and the
comfort of the infant. The infants who had received STS care by their fathers were noted to stop
crying, became calmer, and reached a drowsy state earlier than the infants who did not have STS
contact. Although this is the only study that drew this conclusion it can be hypothesized that
infants who receive STS care will react in this way because of the comfort they feel when cared
for.
Development.
The effects STS care has on the development of infants, especially preterm infants, has
been studied robustly. The research of Neu and Robinson (2010) study as well as the Neu,
Robinson, and Schmiege (2013) study support the finding that STS contact plays a positive, vital
role in the development and progression of preterm infants.
Neu and Robinson’s (2010) study was a randomized controlled trial consisting of 65
mother-infant dyads at the mean gestation age of 33 weeks. The infants were 50% male and 50%
non-Caucasian. Over a course of eight weeks a nurse would make home visits where she would
encourage daily one hour, uninterrupted mother-infant holding. The mothers held their children
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either in a blanket or STS contact. A control group was also utilized where the mothers were
given no limitations or instructions for holding. When the infants were six months old a StillFace Paradigm was conducted. The results showed significant difference between the blanket
and STS groups. As hypothesized, the STS contact group displayed an increase in coregulation
behavior during playtime. This result supports the conclusion that STS care is vital for preterm
infants to thrive in development.
The Neu et al. (2013) study was similar to the Neu and Robinson’s (2010) study in that it
also was a randomized controlled trial. The study included 87 infants born at the gestational ages
of 32-35 weeks. Like the study before, the infant-mother dyads were put into the same separate
holding groups of STS, blanket or control. Again, the groups received visits for eight weeks
where daily holding was encouraged for an increased period of 4-5 hours. When the infants were
at the post-conceptional age of 40-44 weeks they were assessed via the Assessment of Preterm
Infant Behavior (APIB) scale. This scale included measuring the following areas: physiologic
organization, motor organization, state organization, attention, self-regulation, and the amount of
effort the examiner had in maintaining the child’s behavioral organization during the exam. The
infants robust crying was also measured using a separate scale. The results found that infants in
the STS group had more optimal scoring in robust crying and in all other categories except for
attention and state regulation. The infant’s optimal scores were parallel with the scores of full
term infants. This supported the hypothesis that STS care is vital for the behavioral and
developmental aspects of preterm infants.
Skin-to-Skin Benefits for Moms
The STS dyad that is typically studied is between a newborn and its mother. Although
much focus has been on how STS benefits newborns, there are observations in the majority of
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the studies that discuss the benefits to mothers. The Gouchon et al. (2010) study looked at the
satisfaction mothers felt directly when they utilized STS care. Women in this study reported that
STS care made them feel closer to their child, improved the relationship they had with their
child, and that it significantly improved breastfeeding. None of the women in the study reported
uneasiness with STS care and only two women did not perceive it as being beneficial.
Skin-to-Skin and the Father’s Role
The father’s role and involvement with their infant often depends on one’s culture and
religion. In regards to STS care, the father’s role has been studied in the incidence of a cesarean
birth. Popular studies include father-infant dyads after a cesarean with a focus on how the
father’s involvement benefits the child. In the benefits for infants section, STS contact with
fathers after a cesarean comforts infants and helps them develop prefeeding behavior. The infants
are observed to be calmer and their crying is less vigorously and of a shorter duration. However,
the infants are not the only ones to benefit from this father-infant STS contact time.
In the Erlandsson et al.’s (2007) study, it was briefly noted and observed that fathers who
were part of the STS care group appeared to be more involved with their child during the
hospital stay. Other studies that solely focused on the benefits fathers had when involved in STS
care also concluded the same result; that fathers become more interested and involved with their
children.
In the Gouchon et al. (2010) study fathers were asked along with their wives if they
experienced any satisfaction with STS care. Although this was directed more to the mothers, one
father felt that STS care between the mother and infant made him feel excluded. The other
fathers did not share his view and instead found that it was very satisfying to see their wives
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conduct STS care. These fathers also participated themselves in STS care and found it to be
satisfying.
Ways to Promote Skin-to-Skin
Nurses and doctors advising and advocating for their patients to take part in STS care is
the primary way STS care will be increased. Due to the vital roles medical professionals have, it
is important that all staff members have appropriate training in why STS care is significant and
how to properly advise their patients. In the Bramson et al. (2010) and the Hung and Berg (2011)
studies the medical professionals received training prior to participating in the trial. Each study
saw a great increase in STS care as a result. Other research has shown favorable results,
however, these studies could have been enhanced with proper STS staff training.
Research Utilization
Clinical Implications
These six studies illustrate that STS care results in a variety of beneficial outcomes. It has
been proven that infants of all gestational ages and types of births benefit greatly from STS care.
Additionally, mothers and fathers, although not the ones to gain the greatest benefit, also receive
increased bonding and connection with their child. In order for all parties to receive the optimal
care and benefits, it is important for medical professionals to advocate for STS care. STS care
has not had any negative effects reported, which further confirms that this is and should continue
to be perceived as a form of optimal care for all newborns and their parents. It is important to
consider the following recommendations when implementing STS care.
Recommendations
Educate medical professionals.
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If STS care is being perceived as optimal care, it should be recommended that all
hospitals in the United States start an implementation program to help facilitate the use of STS
care. The Hung and Berg (2011) qualitative improvement study has already laid out a rough
outline for how hospitals should implement this practice in the labor and delivery and postpartum
units. This recommendation is further supported by the Bramson et al. (2010) study which also
mandated that their medical professionals underwent a training program prior to the study. In
both studies the outcomes of STS care where enhanced compared to other surrounding studies,
showing that training is essential.
The medical professionals that would need STS care training in a hospital would include
the following: OB and pediatric doctors, surgeons who do cesareans, nurses in the labor and
delivery, NICU, PICU, and post-partum units, nursing assistance (CNAs or LVNs), lactation
consultants, and any other medical professionals who are in direct care of the patients. It is
important that all parts of this caring team, who are in direct care of the mother and infant, have
appropriate knowledge. This education is important because if any of the medical professionals
are asked about STS care they will need to be able to give appropriate answers. Additionally, this
implementation program is not limited to hospitals. Birthing centers, midwives, doulas, and other
places of birth should implement this training to the people in their staff who will be in direct
care for mothers and infants.
In the Hung and Berg (2011) and Bramson et al. (2010) studies, the trainings were
conducted through an in-house (“hospital”) setting. The staff members who were required to
have training attended a workshop at the hospital. Having a workshop like this with the same
presenter or teacher ensures that all medical professionals receive the same material and have
actually been exposed to the information. There are also videos, booklets, and handouts that
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could be given to the medical professionals to watch at home. However, this does not ensure that
they will actually loot at the information which is a barrier to these types of educational tools.
A barrier observed in the workshop approach was the gaps of knowledge that medical
professionals received before the implementing process began. This lack of knowledge was due
to different teachers or presenters at each workshop plus a shortage of attendance in the training
modules. These modules were essential for professional development regarding the
implementation process and knowledge needed for STS care. It is necessary for the success of
STS care that the medical professionals required for this implementation process receive proper
education so that they can accurately advise their patients.
Educate patients.
In all of the six studies the participants were educated on how to facilitate STS care. Now
that research has been conducted and positive conclusions drawn we can utilize this research to
further educate and help implements STS care. Besides medical professionals recommending
STS care to their patients, it would be beneficial to supply expecting parents a variety of
education tools on STS care.
To initially raise awareness outside of the hospital OB/GYN, private practices, Planned
Parenthood, ultrasound departments, and other facilities that cater to expecting mothers could
show educational videos in their waiting rooms and offer handouts, pamphlets, and flyers on STS
care. This would allow for expecting mothers to read and educate themselves on STS before their
baby is born. Another way to raise awareness would be to publish magazine articles, newspaper
articles, and books on STS care. Also using the social media in terms of blogging, creating a STS
care Facebook group, twitter account, or writing online articles are great ways to raise
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awareness. If it is true that first time expecting mothers read anything they can get their hands
on, then printing information of STS care will result in great responsiveness.
The last place to raise awareness is in the labor and delivery unit before a mother goes
into active labor. If the mother gets to the hospital with time to spare, she can be shown a video
and given pamphlets on STS care. These resources should also be offered to mothers in the postpartum unit and PICU. Many of these tools have been successfully utilized to educate the public
on different matters. Reason stands that they will be just as successful when used to educate the
public on STS care.
The lack of knowledge that patients have is a main barrier in STS care. It has been
observed that when the proper education on STS care is conveyed to patients the chances that
they will utilize it increases dramatically. As a result, the patients also report to find great
satisfaction in using STS care (Gouchon et al., 2010). This satisfaction further enhances the
chances of continued STS care use because when a person enjoys an activity is more likely that
they will continue that activity.
Evaluation Plan
In order to assess the success of STS care implementation, hospitals or birthing facilities
could chart for each patient how much STS care was utilized during a hospital or facility stay.
This would give a good baseline for how the implementation process is working and how well
patients are responding to it. In addition, it would further benefit the research if mothers filled
out questionnaires during their infants check-up appointments on STS care utilized at home. It is
important to research and fine tune implementation so that all future newborns receive the best
care possible.
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Future Research
In the six studies reviewed, majority of them used a wide demographic of white and
Hispanic, poor and wealthy, single and couples, and full term or premature infants. The sample
sizes ranged from 29 dyad pairs in the Erlandsson, et al.’s (2007) study to 19 hospitals in the
Bramson, et al.’s (2009) study. In addition, each study was conducted in a hospital setting of an
urban area. The studies collected data during the mothers hospital stay (Bramson, et al., 2009) to
the first few months of the infants life (Neu & Robinson, 2010). In order further enhance the
research these variables of the studies should be expanded upon.
In future analysis it would benefit the research to have additional demographics
incorporated such as greater diversity in religion, culture, and ethnicity. To address any
socioeconomic gaps a study comparing a sample from an impoverished community and a more
affluent community would be required and beneficial. Next, there is a locational gap with most
research having been conducted in urban areas. A study led in different rural areas would
increase the application of the research. Finally, there is a longitudinal gap in the STS care
research. Most of the research has been limited to data being collect on dyads in the hospital.
Some studies, like Bramson, et al.’s (2009), have looked at the first few months after an infant is
born. Conversely, the affects seen when STS care is utilized would be greatly increased if studies
could do longer periods of data collection. To see how a child develops during the first year with
STS care would greatly enhance the strength of the research.
As discussed previously there is minimal research done on STS care and women who
have a cesarean. This is the most important gap that needs to be addressed in future research.
Even though we have looked at the Erlandsson et al. (2007) study, the Gouchon et al.’s (2010)
study, and the Hung and Berg (2011) study, which looks at cesarean births and STS care, there is
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still a significant shortage in this research compared to natural birth. Due to the fact that here has
been a rising of cesarean births throughout the years it would be widely beneficial to further
study cesarean births and STS care. There are many studies that have been done for natural births
which could be replicated for cesarean births, like the Bramson et al.’s (2009) study for example.
The point is that medical care needs to cater to all types of births, meaning that research must
now focus on cesarean births.
Conclusion
The benefits of STS care have been discussed excessively in terms of infant, mothers, and
fathers. It has been demonstrated that breastfeeding, physical development, and motor
development is enhanced in all gestational aged newborns when STS care is utilized and that
there has yet to be any negative outcomes. Barriers of educating medical professionals and
patients have been deliberated and pointed out so that they can be addressed. An evaluation
system has been recommended and discussed for measuring the successfulness of STS care as it
is implemented in hospitals around the United States. And finally, further research on cesarean
births has been recommended in order to further enhance the study of STS care. Overall, STS
care has been proven to be a type of care that is necessary and in the process of being considered
the standard in optimal care nationwide.
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References
Bramson, L., Lee, J. W., Moore, E., Montgomery, S., Neish, C., Bahjri, K., & Melcher, C. L.
(2009). Effect of early skin-to-skin mother-infant contact during the first 3 hours following
birth on exclusive breastfeeding during the maternity hospital stay. Journal of Human
Lactation, 26(2), 130-137. doi: 10.1177/08903344093555779
Erlandsson, K., Dsilna, A., Fagerberg, I., & Christensson, K. (2007). Skin-to-skin care with the
father after cesarean birth and its effect on newborn crying and prefeeding behavior. Birth,
34(2), 105-114. doi: 10.1111/j.1523-536X.2007.00162.x
Gouchon, S., Gregori, D., Picotto, A., Patrucco, G., Nangeroni, M., & Guilio, P. D. (2010). Skinto-skin contact after cesarean delivery: An experimental study. Nursing Research, 59(2), 7884. doi: 10.1097/NNR.0b013e3181d1a8bc
Hung, K. J., & Berg, O. (2011). Early skin-to-skin after cesarean to improve breastfeeding. The
American Journal of Maternal Child Nursing, 36(5), 318-324.
doi:10.109/NMC.0b013e3182266314
Neu, M., & Robinson, J. (2010). Maternal holding of preterm infants during the early weeks after
birth and dyad interaction at six months. Journal of Obstetric, Gynecologic, and Neonatal
Nursing, 39(4), 401-414. doi:10.1111/j.1552-6909.2010.01152.x
Neu, M., Robinson, J., & Schmiege, S. J. (2013). Influence of holding practice on preterm infant
development. The American Journal of Maternal Child Nursing, 38(3), 136-143.
doi:10.109/NMC.0b013e31827ca68c
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Table of Evidence
I.
Quantitative Studies
Study Purpose, Design, Variables, Level of Measurement, Statistical Test(s)
Reference
and year of
publication
Purpose
of Study
Research
Questions
/hypothesis
Variables
Study
Design
Sampling
method and
sample size
Data
Collection
measures
Data
Analysis
Key
Findings/
Results
Limitations
Bramson, L., Lee,
J. W., Moore, E.,
Montgomery, S.,
Neish, C., Bahjri,
K., & Melcher, C.
L. (2009). Effect
of early skin-toskin motherinfant contact
during the first 3
hours following
birth on exclusive
breastfeeding
during the
maternity hospital
stay. Journal of
Human Lactation,
26(2), 130-137.
doi:10.1177/0890
3344093555779
Determine
whether or not
intervals of
skin-to-skin
(STS) contact
has a direct
relationship
with
exclusively
breastfeeding
Longer
periods of
early STS
mother-infant
contact leads
to an increase
of exclusive
breastfeeding
during the
maternity
hospital stay
Independent
variables:
maternal
infant-feeding
method
intention,
maternal
sociodemographic
characteristics
, and duration
spent in early
STS
Dependent
variable:
method of
feeding
Hospitalbased
prospective
cohort study
Sample: 19
hospitals in
San
Bernardino
and Riverside
counties,
21,842
mothers who
had singleton
infants (37-40
wks.
gestation)
Mothers and
infants divided
into STS and
non STS
groups
The Perinatal
Services
Network
(PSN)
developed a
one page data
collection
measurement
form to obtain
results
Multivariate
ordinal
logistic
regression
STS contact
has a doseresponse with
breastfeeding
Not a
randomized
controlled trial
A short time
interval for
determining if
early STS care
was effective
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Erlandsson, K.,
Dsilna, A.,
Fagerberg, I., &
Christensson, K.
(2007). Skin-toskin care with the
father after
cesarean birth
and its effect on
newborn crying
and prefeeding
behavior. Birth,
34(2), 105-114.
doi: 10.1111/j.15
23536X.2007.0016
2.x
Compare the
effects of STS
contact on
crying and
prefeeding
behavior
STS contact
with fathers
after a
cesarean birth
would
comfort and
initiate
display
prefeeding
behavior in
infants
Independent
variable: STS
contact
duration.
Dependent
variables:
crying and
prefeeding
behavior
Randomized
controlled
trial
Sample: 29
fathers-infant
pairs
Full term
infants were
randomly put
into STS with
fathers or a cot
group after
being
delivered by
cesarean
Taperecording and
naturalistic
observation
Tape
recordings
analyzed in
5-min.
periods from
35-135 min.
after birth.
Observations
analyzed
over 30-145
min. Total
mean value,
standard
deviation, &
p values
graphed
Fathers have a
positive
impact on the
infant crying
and behavior
when using
STS contact
Infants on the
cot were not
strictly
confined;
fathers were
allowed to
hold/ comfort
the infant if
absolutely
necessary.
This is a
factor of error
because what
is seen as
necessary is
different for
each father.
Gouchon, S.,
Gregori, D.,
Picotto, A.,
Patrucco, G.,
Nangeroni, M.,
Guilio, P. D.
(2010). Skin-toskin contact after
cesarean
delivery: An
experimental
study. Nursing
Research, 59(2),
78-84.
doi:10.1097/NNR
.0b013e3181d1a8
bc
Compare
mothers’ and
newborns’
body
temperatures,
assess
breastfeeding,
and compare
the mothers’
satisfaction
levels after a
cesarean
Infants with
STS would
have less risk
of
hypothermia,
would attach
to the breast
faster, and
the mothers
would be
more
satisfied
Independent
variables: STS
contact or
routine care
Experimental
noninferiority
adaptive trial
that was
randomized
Sample: 34
mother/
Infant (36-37
wks.) dyads of
cesarean births
Randomly put
into STS care
or routine
care.
Temporal
temperature
taken at 30
min. intervals,
Breastfeeding
& satisfaction
measured
Temperature
collected by
infrared ray
thermometer
Breastfeeding
collected by
Infant
Breastfeeding
Assessment
Tool and
Likert scale
Satisfaction
collected by a
questionnaire
Calculated
the mean and
standard
deviation
Infants who
have STS care
within one
hour of
delivery are
not at risk for
hypothermia.
These infants
attached to the
breast earlier
and mother
with STS
reported high
satisfaction
Distance of
operating
rooms to
obstetrics
department,
IBAT
questionnaire
not validated
in all
countries,
only women
with
locoregional
considered
Dependent
variables:
body
temperature,
breastfeeding,
and
satisfactory
levels
CLINICAL PROJECT PAPER
Hung, K. J., &
Berg, O. (2011).
Early skin-to-skin
after cesarean to
improve
breastfeeding.
The American
Journal of
Maternal Child
Nursing, 36(5),
318-324.
doi:10.109/NMC.
0b013e31822663
14
Improve
breastfeeding
initiation after
a cesarean
birth.
Neu, M., &
Robinson, J.
(2010). Maternal
holding of
preterm infants
during the early
weeks after birth
and dyad
interaction at six
months. Journal
of Obstetric,
Gynecologic, and
Neonatal
Nursing, 39(4),
401-414.
doi:10.1111/j.155
26909.2010.01152
.x
STS care on
preterm babies
and the effects
it has on
facilitating
coregulation
16
As nurses
advocate and
implement
STS care for
mothers after
cesareans
there would
be an
increase in
breastfeeding
Independent
variable:
interventions
that promote
STS care
STS care
would
increase the
facilitation of
coregulation
between
mothers and
preterm
infants
Independent
variables:
time spent in
STS contact
Quality
improvement
project
Dependent
variable:
breastfeeding
Dependent
variables:
coregulation
behavior of
the infant
Sample: from LATCH tool
teaching
for
hospital with
breastfeeding
estimate of
1,300 cesarean
births yearly
LATCH
scores were
compared
STS contact
was possible
after a
cesarean and
improved the
breastfeeding
Not all of the
staff received
in house
education &
nurses had
mixed
assignments
of healthy and
sick infants
Multivariate
analysis of
covariance
(MANCOVA
)
STS holding
in early weeks
of life may
help in
developing
coregulation
behavior of
preterm
infants
Mothers kept
a holding
diary which
could increase
holding
Women were
culturally
diverse and
infants were
healthy and
term
Randomized
controlled
trial
Sample: 65
mother/infant
dyads at 33
wks.
Divided into
STS holding,
blanket
holding, &
control group
Demographic
questionnaire,
Center for
Epidemiologic
Studies
Depression
Scale, State
Trait Anxiety
Inventory,
Still-Face
Paradigm, and
Fogel Scoring
System for
Still-Face
Observation
CLINICAL PROJECT PAPER
Neu, M.,
Robinson, J., &
Schmiege, S. J.
(2013). Influence
of holding
practice on
preterm infant
development. The
American
Journal of
Maternal Child
Nursing, 38(3),
136-143.
doi:10.109/NMC.
0b013e31827ca6
8c
Determine if
nurse
supported STS
contact of
preterm
infants
facilitates
early
behavioral
organization
and
development
preterm
infants with
STS care
would
display
responses
indicating
enhanced
behavioral
regulation
and
development
compared to
infants who
had nurse
supported
blanket
holding or
infants in no
support
control
17
Independent
variables:
different ways
the infants
were held:
STS, blanket,
or control.
Dependent
variables:
behavioral
organization
and develop
benefits of the
infants
Randomized
controlled
trial
Sample: 87
infants born of
32-35 wks.
gestation and
their mothers
who held them
STS, blanket,
or control
Assessment of
Preterm Infant
Behavior tool
(physiologic
motor,
attention, selfregulation,
and
facilitation
needed to
maintain
behavioral
organization)
NBAS tool
(orientation,
autonomic,
motor, state
regulation,
robust crying,
state stability),
demographic
questionnaire,
holding
diaries, and
state-trait
anxiety
inventory.
ANOVA and
ANCOVA
models
Infants who
were held
STS had more
optimal scores
than the
control group
in robust
crying
STS infant
scores, except
for attention
and state
regulation,
were as high
as full term
infants.
Small sample
size of each
group, unable
to initiate
holding
immediately
after birth, and
not knowing
how mothers
held their
babies before
interventions
started