In a groundbreaking exploration of neonatal care, scientists are championing the role of surrogate skin-to-skin care (SSC) as an essential complement—not a replacement—to parental SSC in the neonatal intensive care unit (NICU). This nuanced approach recognizes the unparalleled benefits of parents’ physical closeness with their preterm infants, highlighting the profound biological and psychological impacts parental SSC has on an infant’s development. Yet, acknowledging the constraints parents face in terms of availability, surrogate SSC emerges as a critical adjunct, fortifying the infant’s chances of healthy growth and survival during vulnerable early stages.
Parental SSC establishes an intimate environment where newborns, inherently familiar with their parents’ touch, smell, and heartbeat, receive crucial developmental support. This connection extends beyond the immediate physiological regulation of temperature, heart rate, and breathing—it significantly contributes to long-term cognitive and emotional trajectories. Moreover, SSC fosters parental bonding and mitigates stress, which reciprocally benefits both infant and caretaker. However, real-world circumstances such as parental health issues, socioeconomic challenges, or complex hospital logistics may limit the duration or frequency of parental SSC, thereby underscoring the strategic value of surrogate SSC.
To optimize infant care outcomes, healthcare providers are encouraged to introduce surrogate SSC sensitively, ensuring that parents remain central collaborators in deciding when, how, and by whom surrogate care is administered. Ideally, surrogate SSC providers, whether they be relatives such as grandparents or trusted family friends, are individuals who will continue to play a supportive role in the infant’s ongoing life, maintaining emotional continuity and fostering stable attachment networks. Research has shown promising parallels in physiological benefits when SSC is performed by mothers, fathers, or grandmothers, yet the comparative efficacy and outcomes between familial and non-familial surrogates—along with potential differences due to surrogate gender—remain areas ripe for investigation.
The implementation of surrogate SSC requires meticulous attention to safety and appropriateness. Consensus guidelines emphasize the exclusion of potential surrogates who may pose infection risks, such as those recently hospitalized, having received broad-spectrum antibiotics, or currently experiencing illness symptoms. This precaution safeguards the fragile immune systems of preterm infants, minimizing nosocomial infections. Furthermore, parents should be actively engaged in selecting surrogates to honor family dynamics and comfort levels, particularly in more complex scenarios such as single-parent families or those caring for multiples, where surrogate support may be an indispensable resource.
Training is paramount not only for surrogate caregivers but also for clinical staff. Comprehensive education programs equip surrogate SSC providers with the knowledge necessary for safe handling, proper hygiene, and effective interpretation of the subtle behavioral cues exhibited by preterm infants during SSC. This preparation includes techniques for careful transfer of infants from incubators or beds to the surrogate’s bare chest, hand hygiene protocols to reduce pathogen transmission, and the incorporation of soothing vocal interactions, such as soft singing or tender conversations, which have been shown to further stabilize neonatal physiology and emotional states.
Within the NICU environment, the integration of surrogate SSC demands a cultural shift. Medical teams must be thoroughly educated on the critical role of both parental and surrogate SSC in supporting neonatal development. Providers trained in advanced neonatal care should be confident and competent in safely facilitating SSC with high-acuity infants, ensuring their comfort and adherence to best practices. Institutional policies ideally should eliminate restrictive barriers to SSC access, moving toward a 24/7 availability that maximizes skin-to-skin contact opportunities. Empowering families and caregivers with such freedoms has been correlated with improved breastfeeding rates, decreased hospital stays, and enhanced neurodevelopmental outcomes.
Beyond the NICU’s physical and procedural adaptations, systemic advocacy plays a pivotal role in enabling parental involvement. Policies promoting paid parental leave, particularly extended leave for families with hospitalized preterm infants, can transform the feasibility of consistent parental SSC. Likewise, establishing supportive infrastructure—such as proximal housing options near hospitals, coverage for travel expenses and parking, and childcare services—addresses the multifaceted challenges parents face during prolonged NICU admissions. Such societal investments translate directly to enhanced parental presence and engagement, which remain the bedrock of neonatal care and psychosocial support.
Interestingly, by framing surrogate SSC similarly to the concept of donor milk, the medical community is fostering an empowering understanding of its auxiliary, yet indispensable, role. Just as donor milk supplements maternal milk feeding without supplanting it, surrogate SSC provides crucial added skin-to-skin contact during periods when parents cannot be physically present. This analogy not only elevates the importance of surrogate SSC but also conveys a progressive model of shared caregiving responsibility, encouraging healthcare providers and families to adopt more flexible, inclusive approaches to neonatal support.
Nevertheless, the scientific exploration of surrogate SSC’s full potential and limitations is ongoing. There remains a significant gap in research comparing physiological responses in preterm infants receiving SSC from non-parental family members versus unrelated surrogates. Similarly, quantifiable distinctions in outcomes when SSC is performed by female or male surrogates have yet to be elucidated. Addressing these knowledge gaps is essential to refining surrogate SSC protocols and ensuring they are evidence-based, culturally sensitive, and responsive to diverse family structures.
A critical aspect underscored in current consensus is the empowerment of parents in every decision related to SSC—parental consent is non-negotiable, affirming respect for family autonomy and bonding priorities. Beyond consent, involving parents in identifying appropriate surrogates and defining the breadth of surrogate involvement builds trust and aligns the care plan with their values and circumstances. This inclusion can mitigate anxiety, preserve familial agency, and enhance cooperative care dynamics between families and medical teams.
Emerging evidence suggests that extensive surrogate SSC may indirectly elevate parental SSC rates by reinforcing the perceived significance of skin-to-skin contact. This mirrors the dynamic observed in breastfeeding campaigns where donor milk availability increases parental motivation to provide maternal milk. Therefore, surrogate SSC has the dual potential not only to safeguard infant development during parental absences but also to catalyze increased parental SSC engagement, ultimately leading to more robust caregiving partnerships.
As NICUs globally strive to integrate surrogate SSC, resource allocation becomes a pragmatic concern. Staffing models must accommodate the increased demand for assistance in transferring and monitoring infants during SSC sessions. Adequate nurse-to-patient ratios and ongoing professional development ensure that SSC, whether parental or surrogate, is executed safely and effectively without compromising other critical care responsibilities. Investment in these operational domains reflects a hospital’s commitment to holistic infant and family-centered care.
The psychological dimension of SSC also warrants attention. The soothing presence of a surrogate during parental absence can assuage stress responses in infants, potentially modulating the hypothalamic-pituitary-adrenal axis and reducing episodic instability. Such physiological stability may influence long-term neuroendocrine regulation, though substantive longitudinal studies remain limited. Nonetheless, the theoretical underpinnings and early empirical data advocate for SSC’s inclusion in standard NICU therapeutic modalities beyond parental involvement alone.
In summary, surrogate SSC stands at the frontier of neonatal care innovation, recognized for its potential to bridge gaps in parental presence while preserving the irreplaceable benefits of parental skin-to-skin contact. Continuous refinement of clinical guidelines, coupled with robust research efforts, promises to clarify and enhance surrogate SSC’s implementation. This evolving paradigm marries the imperatives of infant health, family autonomy, and interdisciplinary collaboration, heralding a new era where every vulnerable neonate’s right to nurturing touch is safeguarded against parental unavailability.
Subject of Research: Surrogate skin-to-skin care in preterm infants and its role as an adjunct to parental SSC in the NICU
Article Title: Surrogate skin-to-skin care: the “donor milk” of kangaroo mother care
Article References:
Nitzan, I., Phillips, R., White, R.D. et al. Surrogate skin-to-skin care: the “donor milk” of kangaroo mother care. J Perinatol (2025). https://doi.org/10.1038/s41372-025-02538-0
Image Credits: AI Generated
DOI: 22 December 2025
