What I would like neonatologists to know about the Norwegian RCT on Immediate SSC for Very Preterm Neonates

A recent randomized clinical trial published in JAMA Network Open challenges assumptions about the neurodevelopmental impact of immediate skin-to-skin contact (SSC) for very preterm infants (28–31 weeks’ gestation). Conducted across three Norwegian neonatal units (2014–2020), the study compared 2 hours of SSC in the delivery room versus standard incubator care, following 108 stable preterm neonates until age 2–3 years. While the primary outcome—neurodevelopmental scores on the Bayley-III—showed no difference between groups, the trial confirmed SSC’s significant benefits for breastfeeding, with 84% of SSC infants breastfed at discharge versus 67% in standard care (p=0.04).

Published in April 16th, 2025, these findings refine our understanding of SSC: though brief early contact may not independently alter long-term cognition, it remains a vital, low-risk intervention that supports bonding and lactation—key components of developmental care. The study underscores that clinical value isn’t solely defined by neurodevelopmental metrics, but by tangible, family-centered outcomes.This well-designed randomized clinical trial (RCT) from Norway provides important but nuanced evidence about the neurodevelopmental impact of immediate skin-to-skin contact (SSC) in very preterm infants (28-31 weeks GA). While the negative primary outcome has garnered attention, several key aspects warrant careful interpretation:

Strengths:

1. Methodological Rigor: As one of the first RCTs specifically evaluating immediate SSC's neurodevelopmental outcomes in this gestational age range, the study addresses an important evidence gap. The intention-to-treat analysis and 80% follow-up rate bolster validity.

2. Clinical Realism: The intervention (2 hours of SSC in delivery room) reflects achievable practice in most tertiary centers, enhancing generalizability. The inclusion criteria (stable infants >1000g not requiring >40% O2) appropriately target the population most likely to benefit.

3. Breastfeeding Benefit: The significant improvement in breastfeeding rates at discharge (84% vs 67%, p=0.04) aligns with robust existing evidence, reinforcing SSC's role in lactation support.

Limitations & Open Questions:

1. Power Considerations: With only 81 infants completing the primary outcome assessment, the study may be underpowered to detect smaller but clinically meaningful differences in BSID-III scores. The 95% CI for cognitive scores (-5.26 to 5.68) doesn't exclude potentially important effects.

2. Dose-Response Uncertainty: The single 2-hour SSC session represents a minimal intervention. Emerging evidence suggests neurodevelopmental benefits may require prolonged SSC (e.g., Kangaroo Mother Care protocols with daily SSC hours), particularly for more immature infants.

3. Outcome Timing: Assessment at 2-3 years may be premature. Some preterm neurodevelopmental differences (especially executive function, attention) often emerge at school age. The BSID-III has known limitations in predicting later cognitive function.

Clinical Implications:

1. No Harm Shown: The null finding shouldn't discourage SSC implementation, given its other proven benefits (breastfeeding, bonding, physiological stability) and absence of adverse effects.

2. Targeted Counseling: Clinicians can reassure families that brief separation for stabilization doesn't appear to compromise neurodevelopment in stable late preterm/VLBW infants, while still advocating SSC when feasible.

3. Research Directions: Future studies should evaluate:

• Longer/more frequent SSC exposures

• Extremely preterm populations (<28 weeks)

• Advanced neuroimaging correlates

• School-age outcomes using more sensitive measures

Conclusion: This study makes an important contribution by challenging assumptions about immediate SSC's neuroprotective effects in stable very preterms, while reinforcing its role in breastfeeding promotion. It highlights the complexity of neurodevelopment - while SSC remains a cornerstone of developmental care, its benefits may be domain-specific (affective vs cognitive) and dose-dependent. The findings should be interpreted as refining rather than refuting the value of SSC in neonatal practice.

As a Brazilian researcher particularly interested in preterm breastfeeding, I would like to share some personal perspective on the SSC Study Findings:

This study’s most critical takeaway isn’t that SSC "failed" to improve neurodevelopment—it’s that expecting just two hours of skin-to-skin contact to reshape long-term cognitive outcomes was an overly optimistic hypothesis to begin with. Neurodevelopment is shaped by a complex interplay of biological, environmental, and caregiving factors over years, not a single intervention in the delivery room. The fact that such a brief SSC exposure didn’t move the needle on Bayley scores at 2–3 years isn’t surprising; if anything, it underscores how simplistic it would be to assume that a one-time intervention could override the multitude of influences on a preterm infant’s brain development.

What is remarkable—and far more clinically meaningful—is that this minimal, low-cost intervention still demonstrated clear benefits in breastfeeding and maternal-infant bonding. The significant increase in breastfeeding rates at discharge (84% vs. 67%) is a big deal—especially since breastfeeding itself is linked to better neurodevelopmental outcomes in preterms, reduced NEC risk, and long-term metabolic health. SSC and breastfeeding are deeply intertwined; SSC promotes early latch, maternal milk production, and parental confidence in handling their fragile infant. Trying to isolate SSC’s effects from breastfeeding seems nearly impossible—and perhaps missing the point.

What this paper made me think is we shouldn’t dismiss SSC because it didn’t change Bayley scores. Instead, we should celebrate that something as simple as placing a stable preterm infant on their mother’s chest for two hours can:

• Improve breastfeeding success (a known protective factor for preterms)

• Enhance bonding (critical for parental mental health and infant stress regulation)

• Cost nothing (unlike high-tech NICU interventions)

The study’s conclusion that SSC "should be encouraged in clinical practice" is exactly right—not because it’s a magic bullet for neurodevelopment, but because it’s a foundational practice that supports multiple positive outcomes. Future research should explore whether prolonged, repeated SSC (e.g., daily Kangaroo Care) has neurodevelopmental effects, but in the meantime, we have more than enough evidence to prioritize immediate SSC as a standard of care—not for what it might do someday, but for what it already does today.

The bottom line is that if we expect every NICU intervention to show dramatic neurodevelopmental effects, we’ll overlook the power of small, humane practices that make a real difference to families. SSC isn’t about test scores—it’s about giving preterms and their parents the best possible start. That’s more than enough justification to keep doing it...

Many thanks @Mariana Oliveira, and I fully agree to your take home message. Only because something is not the Big Time Magic Bullet, some small magic is often enough as that also has value.

Perfect is said to be the enemy of Good, I think this applies also to much of our NICU ambitions.