Skin-to-skin contact in neonatal intensive care units: a narrative review of implementation challenges and strategies within infant- and family-centered care.

Skin-to-skin contact (SSC) is a key component of infant- and family-centered developmental care in neonatal intensive care units (NICU) and is associated with improved clinical and neurodevelopmental outcomes. However, SSC implementation in NICUs remains highly variable, often limited by perceived barriers and uncertainties regarding safety. This review aims to identify these barriers and summarize strategies to support the safe and consistent integration of SSC into routine neonatal care. Current evidence identifies barriers at multiple levels, including clinical factors (extreme prematurity, respiratory support, hemodynamic instability, maternal conditions), organizational constraints (lack of standardized protocols, limited staffing, variability in professional training), and emotional challenges (parental stress, insufficient guidance, and inconsistent support from healthcare professionals). Although concerns about safety-such as accidental device dislodgement or clinical instability-are frequently cited, current evidence does not support withholding SSC when appropriate monitoring, preparation, and positioning are ensured. Recent studies highlight that interventions like multidisciplinary professional training, simulation-based learning, institutional protocols, standardized safety checklists, algorithms for eligibility and structured parental education, are effective to reduce variability and support safe implementation of SSC. These interventions have been associated with increased SSC rates, improved parental engagement, and enhanced alignment with developmental care practices. Addressing these multilevel barriers is essential to promote the safe, equitable, and sustainable implementation of SSC across diverse neonatal care settings.