Abstract
Aim
This national survey aimed to evaluate the adoption and implementation of delivery room cuddles (DRC) for preterm infants (<32 weeks’ gestation) in neonatal units across the UK. We sought to determine the extent of the practice, and understand the consistency and challenges associated with DRC, with the goal of enhancing care for preterm infants.
Methods
Between January and March 2024, all UK level 2 and 3 neonatal units were invited to complete a structured survey on DRC practices. We collected data on the existence, frequency and facilitation of DRC, as well as any institutional guidelines and barriers for its practice.
Results
We received complete responses from all 131 centres invited (100% response rate). Among these, 60 centres (45.8%) reported routinely practising DRC, 66 (50.4%) did so occasionally and 5 (3.8%) reported not practising DRC at all. Notably, 81 centres (61.8%) practised DRC without formal institutional guidelines. Main barriers to practice included equipment limitations, varying staff attitudes, and concerns about the clinical condition of preterm infants.
Conclusion
This survey demonstrates an encouraging high uptake of DRC in recent years, typically offered after initial stabilisation (within 30–60 min post-birth). Despite the recognised benefits of DRC to parents and in enhancing neonatal outcomes, considerable variability remains in its implementation underscoring the need for comprehensive guidelines and professional training. These could standardise DRC practices across the UK, promoting more consistent and effective care for preterm infants.
Keywords: Neonatology, Infant
WHAT IS ALREADY KNOWN ON THIS TOPIC
Delivery room cuddles (DRC) for preterm infants are a key element of family-centred neonatal care, associated with positive parental experiences and potential neonatal benefits. Although increasingly adopted in the UK, practice remains inconsistent, influenced by local resources and attitudes, and lacks national guidance.
WHAT THIS STUDY ADDS
This study provides the first national overview of DRC practice for preterm infants in UK neonatal units, demonstrating widespread but variable implementation and identifying gaps in guidance, monitoring and organisational support.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
The findings highlight the need for national guidance and focused staff training to reduce variation and ensure equitable access to DRC. Standardised practice could improve safety, consistency and integration of DRC into routine early neonatal care across the UK.
Introduction
Delivery room cuddles (DRC), also known as birthday cuddles, represent an extension of skin-to-skin ‘kangaroo care’ and are increasingly recognised as a core component of optimal neonatal care.1 These practices facilitate early bonding and have been linked to health benefits for infants and their families,2 reflecting a shift in care towards patient-centred and family-integrated care models.
For the context of this survey, we focused on DRC in preterm infants. These early interactions may not fully meet the WHO criteria for skin-to-skin contact but nevertheless represent important initial physical contact between mother and baby shortly after birth. Kangaroo care originated in Bogotá, Colombia, in the 1970s3 4 and demonstrated reductions in morbidity and mortality.
In the UK, DRC practice was first described for extremely preterm infants in 2017,5 and has since been shaped by ongoing research, practical guidance, enthusiastic parental feedback,6 and quality improvement initiatives (British Association of Perinatal Medicine - BAPM) and policy recommendations7 aimed at optimising early postnatal care for preterm infants.8 The effects of DRC have also been well described in the palliative care setting and emphasise the importance of early physical and emotional connection between parents and their newborns, particularly in situations where an infant’s life may be short-lived.6 This practice provides comfort, fosters bonding and allows parents meaningful time with their baby, enhancing family well-being and dignity in profoundly difficult circumstances during comfort care (figure 1).
Figure 1. Mother holding her preterm newborn 24+0 week gestation infant during a delivery room cuddle, illustrating early parent–infant contact in the delivery room.
Despite the rationale and proven benefits of DRC, the implementation of DRC remains inconsistent. Implementation is influenced by different factors, such as an awareness of the importance of this practice, equipment available in the unit, staffing levels and lack of national guidelines on its facilitation, and considerations regarding safety and the suitable clinical condition of the infant and mother. Our aim was to undertake a comprehensive survey to evaluate current DRC adoption and practices, and to identify potential barriers to its wider implementation in the UK.
Methods
We developed a detailed questionnaire survey proforma to gather data on the implementation and practice of DRC in neonatal units across the UK (see online supplemental file). The survey targeted all level 2 (n=82) and level 3 (n=49) neonatal units in the UK (total n=131) which provide care to preterm infants born at <32 weeks’ gestational age. We sent the proforma by e-mail where possible; in the absence of an e-mail contact, we conducted a structured telephone interview. Most of the responses were from telephone conversations, with only 10 of the responses being submitted via email. The survey period was from January to March 2024. The survey was completed on behalf of individual neonatal units by personnel working in senior positions, including consultants, sisters in charge, advanced neonatal nurse practitioners, and resident doctors.
Survey development
The survey comprised a structured questionnaire focusing on the practice of DRC for preterm infants. Key areas addressed included the following:
Details of respondents and their hospitals.
Existence and frequency of DRC practices.
Facilitating cuddles or contact with fathers or birthing partners when mothers were not able to provide cuddles.
Components and monitoring during DRC.
Airway support strategies for intubated and non-intubated preterm infants.
Guidelines and policies pertaining to DRC.
Results
We achieved complete responses from all level 2 (n=82) & level 3 (n=49) units (131/131; 100%) . Table 1 summarises the main questions asked, responses received according to designated care level of neonatal intensive care unit (NICU), and overall responses. When comparing level 2 and level 3 units, level 3 units were more likely to practise DRC routinely for all infants (55.2% vs 40.2%). Figure 2 summarises questions 1, 2 and 6, reflecting the frequency of practice of DRC for mother and birthing partners and frequency of encouragement of photos.
Table 1. Summary of survey questions and responses received from the 131 UK units surveyed.
| Survey questions | Options | Level 2 N = 82 |
Level 3 N = 49 |
Total N = 131 |
|---|---|---|---|---|
| Q1, Do you practise DRC? |
Routinely | 33 (40%) | 27 (55%) | 60 (46%) |
| Sometimes | 45 (55%) | 21 (43%) | 66 (50%) | |
| Never | 4 (5%) | 1 (2%) | 5 (4%) | |
| Q2, Do you offer DRC for birthing partners? |
Routinely | 32 (39%) | 17 (35%) | 49 (37%) |
| Sometimes | 28 (34%) | 21 (43%) | 49 (37%) | |
| Never | 22 (27%) | 11 (22%) | 33 (25%) | |
| Among units offering DRC: Q3, How frequently do you offer DRC? |
Always | 22 (27%) | 15 (32%) | 37 (28%) |
| Often | 42 (51%) | 28 (57%) | 70 (53%) | |
| Rarely | 7 (9%) | 4 (8%) | 11 (8%) | |
| N/A or no response | 11 (13%) | 2 (4%) | 13 (10%) | |
| Q4, Barriers to DRC implementation?* |
Unaware of the practice | 2 (2%) | 1 (2%) | 3 (2%) |
| Lack of guidelines | 2 (2%) | 1 (2%) | 3 (2%) | |
| Not the unit practice | 4 (5%) | 4 (8%) | 8 (6%) | |
| Equipment issues | 5 (6%) | 4 (8%) | 9 (7%) | |
| Baby’s condition | 40 (49%) | 18 (37%) | 58 (44%) | |
| Others | 15 (18%) | 3 (6%) | 18 (14%) | |
| Q5, What does delivery room cuddles look like? |
Show | 63 (78%) | 38 (77%) | 100 (77%) |
| Touch | 66 (82%) | 38 (77%) | 97 (74%) | |
| Kiss | 49 (59%) | 28 (58%) | 75 (57%) | |
| Skin to skin | 52 (63%) | 32 (65%) | 86 (66%) | |
| Q6, Do you encourage parents to take photographs/videos during cuddles? |
Routinely | 69 (84%) | 40 (82%) | 109 (83%) |
| Sometimes | 11 (13%) | 9 (18%) | 20 (15%) | |
| No | 2 (2%) | 0 | 2 (2%) |
Data are n (%).
Please note some of the units that practise DRC routinely and without contraindications did not respond to this question; the percentages are calculated based on the total of 131 units and not on the responses obtained.
DRC, delivery room cuddles; N/A, not applicable.
Figure 2. Responses to survey questions 1, 2 and 6, showing frequency of practice of delivery room cuddles, inclusion of birthing partners, and encouragement of photographs.
Some of the other barriers to implementation (figure 3) mentioned included the following: operator dependant 8/131 (6.1%), general anaesthetic for mother precluding 2/131 (1.5%), concerns about the risk of endotracheal tube dislodgement 1/131 (0.8%) and considered contraindicated as per local intraventricular haemorrhage prevention guidelines 1/131 (0.8%).
Figure 3. Reported barriers to implementation of delivery room cuddles across UK neonatal units.
Monitoring during DRC is essential to prevent any clinical deterioration of the infant. We asked survey questions regarding monitoring and support provided during DRC by various neonatal units (table 2).
Table 2. Monitoring and support during DRC.
| Survey questions | Options | Level 2 N = 82 |
Level 3 N = 49 |
Total N = 131 |
|---|---|---|---|---|
| Q7, What monitoring do you use during DRC?* |
Heart rate | 57 (70%) | 45 (92%) | 102 (78%) |
| Oxygen saturation | 69 (84%) | 45 (92%) | 114 (87%) | |
| Skin temp | 17 (21%) | 16 (33%) | 33 (25%) | |
| No monitoring | 14 (17%) | 2 (4%) | 16 (12%) | |
| Q8, What airway support is offered during DRC for intubated infants? |
T-piece ventilation | 14 (17%) | 20 (41%) | 34 (26%) |
| Via the ventilator | 14 (17%) | 20 (41%) | 34 (26%) | |
| None | 6 (7%) | 2 (4%) | 8 (6%) | |
| DRC not offered for intubated infants | 48 (59%) | 7 (14%) | 55 (42%) | |
| Q9, What type of support for non-intubated infants?* |
T-piece via mask | 32 (39%) | 15 (31%) | 47 (36%) |
| RPAP/NIPPV/CPAP | 31 (38%) | 34 (69%) | 65 (50%) | |
| Nasal high flow | 21 (26%) | 8 (16%) | 29 (22%) | |
| None | 10 (12%) | 3 (6%) | 13 (10%) | |
| Other | 12 (15%) | 5 (10%) | 17 (13%) |
Some units do more than one.
CPAP, continuous positive airway pressure; DRC, delivery room cuddles; NIPPV, nasal intermittent positive pressure ventilation; RPAP, respiratory positive airway pressure.
The responses to whether units have guidelines for DRC reveal that the majority, 61.8% (81/131), reported their unit does not have guidelines. An additional 20.6% (27/131 centres) noted that unit guidelines were currently being developed and only 17.5% (23/131) reported having a written unit guideline for DRC.
Discussion
This study presents the first national survey demonstrating the uptake and practice of DRC in UK NICUs. Remarkably, despite DRC first being reported in the literature only as recently as 2017,5 our findings show that nearly half of level 2 and level 3 UK units now routinely practise DRC.
The rapid increase in DRC adoption across UK NICUs over the past 6–7 years has likely been driven by the compelling voices of parents who have directly experienced its benefits. Notably, the testimony of the mother featured in this first literature report and her 2021 YouTube video ‘Emma’s story – my delivery room cuddle’9 has been particularly influential. Her advocacy, along with the powerful testimony of other parents who have either experienced or been denied a DRC with their newborns,6 8 has likely played a pivotal role in persuading professionals of the vitality of the DRC and so achieving the overall 46% adoption rate observed in this survey.
Despite DRC being a current significant topic advancing early neonatal and family-centred care, our extensive literature search done on 9 January 2025 revealed a surprising gap: there has not yet been any comprehensive survey published on this subject. Our national survey has found that DRC are inconsistently offered across UK neonatal units. It is disappointing to consider that a minority of UK NICUs are still not currently offering their inborn preterm infants and families this crucial early contact, so depriving them of the potential mutual benefits for infants and mothers.
The practice of DRC should be considered integral to the early care of all preterm infants wherever possible, and irrespective of birth gestation,5 6 fostering early bonding and potentially offering some of the same numerous benefits of kangaroo mother care.10 Despite the now-recognised importance of the DRC, this survey reveals considerable variation in its adoption and implementation in the UK. It is also important to consider that this first cuddle might be the parents’ sole intimate contact with their baby if not destined to survive.5 6 9
Approximately 50% of units practise cuddles occasionally but not routinely, suggesting a potential lack of uniform protocols or lack of wider appreciation of their benefits among staff members. Other reasons for some units only ‘sometimes’ practising DRC might be the infant’s condition, availability of appropriate equipment, or operator confidence. This is juxtaposed with the~46% of units that have integrated these practices into their routine care, highlighting a divide that may stem from differing unit strategies, resources, or leadership support.
The lack of formal guidelines is notable, with ~62% of units overall operating without any structured policy. This gap likely contributes to the inconsistency observed in the implementation of DRC. Barriers such as staffing levels, available equipment and the clinical condition of infants and mothers further complicate standard practice, indicating a clear need for overarching guidelines that can adapt to varying unit capacities and situations.
Our findings indicate a nearly equal split between units that routinely versus sometimes offer cuddles to fathers/birthing partners when the mother is incapacitated/unavailable (eg, during Caesarean section under general anaesthesia), with ~25% never offering this option. Yet this practice is crucial in situations where mothers cannot immediately interact with their newborns and underlines the need for policies that support the place of fathers and wider family involvement in neonatal care.
The key difference identified between level 2 and level 3 neonatal units was the higher consistency of DRC practice in level 3 units, these units also reported a higher frequency of ‘always’ offering DRC and more comprehensive monitoring during DRC, with 91.8% tracking both heart rate and oxygen saturation compared with 69.5% and 84.1% in level 2 units. This suggests that level 3 units are better equipped and supported to integrate DRC into routine care. We identified that the 3.8% of units not practising DRC cited barriers such as equipment shortages, perceived safety risks, or local policy restrictions. These represent opportunities for targeted support.
An unexpected finding from the survey was that 16 (12.2%) neonatal units reported offering DRC without using any physiological monitoring such as heart rate, oxygen saturation or temperature tracking. Additionally, eight (6.1%) units indicated they did not provide ventilator or T-piece breaths for intubated infants during cuddles. While this may reflect local practices tailored to specific clinical situations, it also highlights an important area for further exploration. These responses suggest variability in the perceived monitoring requirements for safe DRC and may indicate differing thresholds of clinical stability among units. Survey results also suggest opportunities to define guideline components: monitoring of heart rate and oxygen saturation as a standard, eligibility based on clinical stability rather than gestational age, and flexibility in protocols to accommodate different staffing and resource contexts.
Many identified barriers such as the absence of clear unit guidelines, inadequate staffing levels, lack of training and confidence of healthcare professionals, supportive leadership within the unit, parental advocacy and enthusiasm, and availability of appropriate equipment and monitoring devices. These factors may have led to 3.8% of units ‘never’ practising DRC. Even though level 1 units were not included in the survey, similar challenges may exist even there for DRC.
Detailed guidance on the practical implementation of DRC has recently been published.6 Our survey results indicate an urgent need for the further development and implementation of comprehensive national guidelines to standardise DRC practices, and to promote the wider access of babies and their parents to optimised early postnatal contact. Such guidelines should be backed by training sessions that not only educate about the benefits but also instruct on the logistical and practical aspects of safely conducting cuddles even in more challenging circumstances, such as in awake Caesarean section deliveries, and with the most extreme preterm infants.
Despite these advancements, Brimdyr et al. highlight a notable gap in systematic implementation across various birth settings, particularly in contexts involving non-hospital or preterm environments.11 Our study, while focusing on the local practices, resonates with this observation, as we identified variability in how skin-to-skin contact is applied, suggesting that certain units are still not providing this crucial early contact to infants and families. This inconsistency mirrors findings from Brimdyr et al., where guidelines, though strongly recommended, have not been universally adopted, leading to discrepancies in care.11
An advantage of DRC is that they can be routinely practised for most preterm infants irrespective of birth gestation, birthweight, and delivery room ventilatory needs.6 In contrast, routine direct early skin-to-skin contact has not yet been studied or practised in extremely preterm infants. A recent Norwegian study has examined the impact of immediate skin-to-skin contact on the neurodevelopmental outcomes of very preterm infants from birth gestation 28+0 to 31+6 and birthweight >1000 g, and with no major congenital malformation or need for intubation or supplementary oxygen requirement >40%12 Despite the low-cost and feasible nature of this intervention, the study found no significant improvement in long-term neurodevelopment at ages 2–3 years. However, it did highlight the benefit of enhanced breastfeeding practices, with more infants in the immediate skin-to-skin contact group being breastfed at hospital discharge. This finding emphasises the importance of early maternal-neonatal bonding and supports the need for scalable interventions in neonatal care that are not only cost-effective but also culturally adaptable.
Strengths and limitations
Strengths
This study represents the first comprehensive national survey of DRC practices, providing novel insights into a previously underexplored area of neonatal care. The survey achieved complete responses from all UK level 2 and 3 neonatal units approached, ensuring robust and generalisable findings across both these care settings. Furthermore, our study has identified key barriers and challenges to implementing DRC, offering valuable guidance for addressing practical and systemic obstacles to their wider adoption. These strengths help support the research’s contribution to understanding DRC in clinical practice.
Limitations
The exclusion of level 1 neonatal units may limit the applicability of findings to smaller or lower-acuity care settings. Additionally, we did not examine variations in practice within individual units, particularly in relation to gestational age thresholds. For instance, the study did not explore whether some units refrained from practising DRC for infants below certain gestational age thresholds, potentially overlooking nuances in implementation criteria. Future research could address these gaps and investigate other unexamined factors influencing DRC practices across diverse neonatal care environments.
Conclusions
Our comprehensive survey demonstrates that an encouraging high uptake of DRC has been achieved in UK neonatal centres in recent years. But it also highlights significant variability in the implementation of DRC across centres. This inconsistency not only reflects a gap in practice but also points to broader systemic issues within neonatal care frameworks that require standardisation and improvement.
Key barriers to DRC implementation include considerations about the clinical condition of the infant, equipment shortages, institutional policies, and staff attitudes. Most units lack formal guidelines, highlighting a major area for improvement. Developing and disseminating comprehensive national guidelines could standardise practices, ensuring that all preterm infants and their parents benefit from this important care.
Additionally, there is a need for enhanced training and awareness among healthcare professionals to increase the adoption of DRC. Education programmes could dispel misconceptions about risks and emphasise health benefits, thus improving the frequency and quality of family-centred practices.
While many centres now embrace the practice of DRC, there is a substantial need for national policy-driven efforts to address barriers and promote more widespread adoption. Establishing national guidelines and targeted education and training initiatives, including simulation training,6 11 could lead to more uniform implementation across the UK, ultimately improving care and outcomes for preterm infants. This survey serves as a call to action for neonatal units to commit to a standard of care that incorporates the holistic benefits of DRC. Centres that have embraced DRC have likely listened to the compelling testimony of parents.6 9 Might those units that have not yet embraced DRC yet be swayed by the powerful voice of parents?
Supplementary material
Acknowledgements
We would like to extend our sincere gratitude to all our colleagues across the various units who participated in this survey. Their willingness to share practices was invaluable to this research. We are very grateful to the anonymous reviewers who kindly provided constructive suggestions for improvement of the earlier version of our manuscript.
Footnotes
Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Provenance and peer review: Not commissioned; externally peer reviewed.
Patient consent for publication: Consent obtained from parent(s)/guardian(s).
Ethics approval: Ethical considerations for the survey adhered to ethical standards of voluntary participation, anonymity and confidentiality. Given its focus on evaluation of professional practices and the absence of individual patient data collection, this project was classed as a service evaluation and did not require formal ethics approval according to contemporaneous UK Health Research Authority guidance.
Data availability free text: Not applicable.
Patient and public involvement: Patients and/or the public were not involved in the design, conduct, reporting or dissemination plans of this research.
Presented at: These data were presented in abstract form at the 10th British Association of Perinatal Medicine (BAPM) Conference, Sheffield, September 2024, and at the 10th European Academy of Paediatric Sciences congress, Vienna, October 2024.
Data availability statement
Data are available in a public, open access repository.
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