General

Guideline Title

Best evidence statement (BESt). Skin to skin care in a level III-IV NICU.

Bibliographic Source(s)

Cincinnati Children’s Hospital Medical Center. Best evidence statement (BESt). Skin to skin care in a level III-IV NICU. Cincinnati (OH): Cincinnati Children’s Hospital Medical Center; 2013 Apr 30. 6 p. [6 references]

Guideline Status

This is the current release of the guideline.

Recommendations

Major Recommendations

The strength of the recommendation (strongly recommended, recommended, or no recommendation) and the quality of the evidence (1a‒5b) are defined at the end of the “Major Recommendations” field.

There is insufficient evidence and lack of consensus to make a recommendation on the use of skin to skin care (SSC) to decrease the number of days on non-invasive respiratory support or number of days on ventilation in a Level III-IV neonatal intensive care unit (NICU) in a high income country.
There is insufficient evidence and lack of consensus to make a recommendation on the use of SSC to decrease infection in a Level III-IV NICU in a high income country.
It is not recommended that SSC be used to reduce mortality or length of stay in a Level III-IV NICU in a high income country (Conde-Agudelo, Belizán, & Diaz-Rossello, 2011 [1a]; Moore et al., 2012 [1a]).

Note : Randomized control trials in high income countries reported lower mean duration in hours/day of intermittent SSC (Conde-Agudelo, Belizán, & Diaz-Rossello, 2011 [1a]).

Definitions:

Table of Evidence Levels

Quality Level	Definition
1a† or 1b†	Systematic review, meta-analysis, or meta-synthesis of multiple studies
2a or 2b	Best study design for domain
3a or 3b	Fair study design for domain
4a or 4b	Weak study design for domain
5a or 5b	General review, expert opinion, case report, consensus report, or guideline
5	Local Consensus

†a = good quality study; b = lesser quality study

Table of Language and Definitions for Recommendation Strength

Language for Strength

Definition

It is strongly recommended that…

It is strongly recommended that… not…

There is consensus that benefits clearly outweigh risks and burdens (or visa-versa for negative recommendations).

It is recommended that…

It is recommended that… not…

There is consensus that benefits are closely balanced with risks and burdens.

There is insufficient evidence and a lack of consensus to make a recommendation…

Note : See the original guideline document for the dimensions used for judging the strength of the recommendation.

Clinical Algorithm(s)

None provided

Scope

Disease/Condition(s)

Diseases and conditions requiring care in a Level III-IV neonatal intensive care unit (NICU)

Guideline Category

Management
Prevention
Treatment

Clinical Specialty

Family Practice
Obstetrics and Gynecology
Pediatrics
Preventive Medicine

Intended Users

Advanced Practice Nurses
Hospitals
Nurses
Physician Assistants
Physicians
Respiratory Care Practitioners

Guideline Objective(s)

To evaluate, among neonates in a Level III-IV neonatal intensive care unit (NICU), if receiving skin to skin care (SSC) compared to those not receiving SSC improves outcomes of decreased mortality, infection, length of hospital stay days on non-invasive respiratory support, or days on a ventilator

Target Population

Neonates in a Level III-IV neonatal intensive care unit (NICU) in a high income country

Note : These guidelines do not apply to the following populations:

Neonates in the low acuity setting (such as a newborn nursery)
Neonates in a resource limited setting (low income country)

Interventions and Practices Considered

Skin to skin care (SSC)

Major Outcomes Considered

Mortality
Infection
Length of hospital stay
Days on non-invasive respiratory support
Days on a ventilator

Methodology

Methods Used to Collect/Select the Evidence

Searches of Electronic Databases

Description of Methods Used to Collect/Select the Evidence

Search Strategy

Databases : Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library, Medline

Search Terms : Skin to Skin Care, Kangaroo Care, Kangaroo Mother Care

Filters : 1999 to 2012, Human, English

Search Dates : October 16, 2012

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence

Weighting According to a Rating Scheme (Scheme Given)

Rating Scheme for the Strength of the Evidence

Table of Evidence Levels

Quality Level	Definition
1a† or 1b†	Systematic review, meta-analysis, or meta-synthesis of multiple studies
2a or 2b	Best study design for domain
3a or 3b	Fair study design for domain
4a or 4b	Weak study design for domain
5a or 5b	General review, expert opinion, case report, consensus report, or guideline
5	Local Consensus

†a = good quality study; b = lesser quality study

Methods Used to Analyze the Evidence

Review of Published Meta-Analyses
Systematic Review

Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations

Expert Consensus

Description of Methods Used to Formulate the Recommendations

Not stated

Rating Scheme for the Strength of the Recommendations

Table of Language and Definitions for Recommendation Strength

Language for Strength	Definition
It is strongly recommended that… It is strongly recommended that… not…	There is consensus that benefits clearly outweigh risks and burdens (or visa-versa for negative recommendations).
It is recommended that… It is recommended that… not…	There is consensus that benefits are closely balanced with risks and burdens.
There is insufficient evidence and a lack of consensus to make a recommendation…

Note : See the original guideline document for the dimensions used for judging the strength of the recommendation.

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation

Peer Review

Description of Method of Guideline Validation

This Best Evidence Statement has been reviewed against quality criteria by two independent reviewers from the Cincinnati Children’s Hospital Medical Center (CCHMC) Evidence Collaboration.

Evidence Supporting the Recommendations

References Supporting the Recommendations

Conde-Agudelo A, Belizan JM, Diaz-Rossello J. Kangaroo mother care to reduce morbidity and mortality in low birthweight infants. Cochrane Database Syst Rev. 2011;(3):CD002771. PubMed
Moore ER, Anderson GC, Bergman N, Dowswell T. Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database Syst Rev. 2012;5:CD003519. PubMed

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for one recommendation (see the “Major Recommendations” field). For two outcomes, there was insufficient evidence to make a recommendation.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Appropriate use of skin to skin care (SSC) in a level III-IV neonatal intensive care unit (NICU)

Potential Harms

Not stated

Qualifying Statements

This Best Evidence Statement addresses only key points of care for the target population; it is not intended to be a comprehensive practice guideline. These recommendations result from review of literature and practices current at the time of their formulation. This Best Evidence Statement does not preclude using care modalities proven efficacious in studies published subsequent to the current revision of this document. This document is not intended to impose standards of care preventing selective variances from the recommendations to meet the specific and unique requirements of individual patients. Adherence to this Statement is voluntary. The clinician in light of the individual circumstances presented by the patient must make the ultimate judgment regarding the priority of any specific procedure.

Implementation of the Guideline

Description of Implementation Strategy

Applicability Issues

Frequently, in the Level III-IV neonatal intensive care unit (NICU) environment, patients are unstable, admitted after, or stay beyond the optimal period for skin to skin care (SSC).

Further research is needed concerning effectiveness and safety of early onset SSC are in unstabilized low birth weight infants and long term neurodevelopmental outcomes.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need

Getting Better
Living with Illness

IOM Domain

Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)

Cincinnati Children’s Hospital Medical Center. Best evidence statement (BESt). Skin to skin care in a level III-IV NICU. Cincinnati (OH): Cincinnati Children’s Hospital Medical Center; 2013 Apr 30. 6 p. [6 references]

Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released

2013 Apr 30

Guideline Developer(s)

Cincinnati Children’s Hospital Medical Center - Hospital/Medical Center

Source(s) of Funding

No external funding was received for development of this Best Evidence Statement (BESt).

Guideline Committee

Not stated

Composition of Group That Authored the Guideline

Team Leader/Author : Michael Moyer BSN, RNC-NIC

Support/Consultant : Barbara K. Giambra, MS, RN, CPNP, Evidence-Based Practice Mentor, Center for Professional Excellence/Research and Evidence-Based Practice

Ad Hoc/Content Reviewers : Tammy Casper MSN, MEd, RN, Education Specialist II; Linda Lacina, RN, Education Specialist II, NIDCAP Trainer

Financial Disclosures/Conflicts of Interest

Conflicts of interest were declared for each team member. No financial conflicts of interest were found.

Guideline Status

This is the current release of the guideline.

Guideline Availability

Available from the Cincinnati Children’s Hospital Medical Web site.

Availability of Companion Documents

The following are available:

Judging the strength of a recommendation. Cincinnati (OH): Cincinnati Children’s Hospital Medical Center; 2008 Jan. 1 p. Available from the Cincinnati Children’s Hospital Medical Center.
Grading a body of evidence to answer a clinical question. Cincinnati (OH): Cincinnati Children’s Hospital Medical Center; 1 p.
Table of evidence levels. Cincinnati (OH): Cincinnati Children’s Hospital Medical Center; 2008 Feb 29. 1 p. Available from the Cincinnati Children’s Hospital Medical Center.

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on September 6, 2013.

Copyright Statement

This NGC summary is based on the original full-text guideline, which is subject to the following copyright restrictions:

Copies of this Cincinnati Children’s Hospital Medical Center (CCHMC) Best Evidence Statement (BESt) are available online and may be distributed by any organization for the global purpose of improving child health outcomes. Examples of approved uses of the BESt include the following:

Copies may be provided to anyone involved in the organization’s process for developing and implementing evidence based care;
Hyperlinks to the CCHMC website may be placed on the organization’s website;
The BESt may be adopted or adapted for use within the organization, provided that CCHMC receives appropriate attribution on all written or electronic documents; and
Copies may be provided to patients and the clinicians who manage their care.

Notification of CCHMC at EBDMInfo@cchmc.org for any BESt adopted, adapted, implemented or hyperlinked by the organization is appreciated.

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