Newborn behaviour to locate the breast when skin-to-skin: a possible method for enabling early self-regulation.

AIM: The aim of this study was to provide a more detailed analysis of the infant's behavioural sequence that begins immediately after birth and terminates with grasping the nipple, suckling and then falling asleep. METHOD: Twenty-eight full-term infants were videotaped immediately after birth. A video protocol was developed to examine infant behaviours identified from five random videotapes. RESULTS: When birth crying had stopped, the babies showed a short period of relaxation and then successively became alert. They went through an 'awakening phase', an 'active phase' with movements of limbs, rooting activity and looking at the mother's face, a 'crawling phase' with soliciting sounds, a 'familiarization phase' with licking of the areola, and a 'suckling phase' and last a 'sleeping phase'. Five factors related to the time spent to locate the breast: more number of looks at the breast 10-20 min after birth (p < 0.0001); and exposure to meperidine (p = 0.0006) related to increased time. Early start of crawling (p = 0,0040); increased number of 'soliciting sounds' (p = 0.0022); and performing hand-breast-mouth movements (p = 0.0105) related to shorter time. CONCLUSION: Inborn breastfeeding reflexes were depressed at birth, possibly because of a depressed sensory system. It is hypothesized that when the infant is given the option to peacefully go through the nine behavioural phases birth cry, relaxation, awakening, activity, crawling, resting, familiarization, suckling and sleeping when skin-to-skin with its mother this results in early optimal self-regulation.

State of the art and recommendations. Kangaroo mother care: application in a high-tech environment.

UNLABELLED: Since Kangaroo Mother Care (KMC) was developed in Colombia in the 1970s, two trends in clinical application emerged. In low income settings, the original KMC model is implemented. This consists of continuous (24 h/day, 7 days/week) and prolonged mother/parent-infant skin-to-skin contact; early discharge with the infant in the kangaroo position; (ideally) exclusive breastfeeding; and, adequate follow-up. In affluent settings, intermittent KMC with sessions of one or a few hours skin-to-skin contact for a limited period is common. As a result of the increasing evidence of the benefits of KMC for both infants and families in all intensive care settings, KMC in a high-tech environment was chosen as the topic for the first European Conference on KMC, and the clinical implementation of the KMC model in all types of settings was discussed at the 7th International Workshop on KMC. Kangaroo Mother Care protocols in high-tech Neonatal Intensive Care Units (NICU) should specify criteria for initiation, kangaroo position, transfer to/from KMC, transport in kangaroo position, kangaroo nutrition, parents' role, modification of the NICU environment, performance of care in KMC, and KMC in case of infant instability. CONCLUSION: Implementation of the original KMC method, with continuous skin-to-skin contact whenever possible, is recommended for application in high-tech environments, although scientific evaluation should continue.

Towards universal Kangaroo Mother Care: recommendations and report from the First European conference and Seventh International Workshop on Kangaroo Mother Care.

UNLABELLED: The hallmark of Kangaroo Mother Care (KMC) is the kangaroo position: the infant is cared for skin-to-skin vertically between the mother's breasts and below her clothes, 24 h/day, with father/substitute(s) participating as KMC providers. Intermittent KMC (for short periods once or a few times per day, for a variable number of days) is commonly employed in high-tech neonatal intensive care units. These two modalities should be regarded as a progressive adaptation of the mother-infant dyad, ideally towards continuous KMC, starting gradually and progressively with intermittent KMC. The other components in KMC are exclusive breastfeeding (ideally) and early discharge in kangaroo position with strict follow-up. Current evidence allows the following general statements about KMC in affluent and low-income settings: KMC enhances bonding and attachment; reduces maternal postpartum depression symptoms; enhances infant physiologic stability and reduces pain, increases parental sensitivity to infant cues; contributes to the establishment and longer duration of breastfeeding and has positive effects on infant development and infant/parent interaction. Therefore, intrapartum and postnatal care in all types of settings should adhere to a paradigm of nonseparation of infants and their mothers/families. Preterm/low-birth-weight infants should be regarded as extero-gestational foetuses needing skin-to-skin contact to promote maturation. CONCLUSION: Kangaroo Mother Care should begin as soon as possible after birth, be applied as continuous skin-to-skin contact to the extent that this is possible and appropriate and continue for as long as appropriate.

The effect of Russian Maternity Home routines on breastfeeding and neonatal weight loss with special reference to swaddling.

BACKGROUND: Few investigations have considered evaluating the effects of certain combinations of ward routines like swaddling of the baby and separation of mother and baby on infant variables such as neonatal weight loss. AIMS: To study the effect of different ward routines in respect to proximity to mother and type of infant apparel, on breastfeeding parameters (amount of ingested milk, volume of supplements, number of breastfeeds, total duration of breastfeeding time) day 4 after birth as well as recovery from neonatal weight loss and infant's weight on day 5. STUDY DESIGN AND SUBJECTS: In a randomized trial with factorial design four treatment groups including 176 mother-infant dyads were studied 25-120 min after birth. Randomized treatments focused on care routines administered to the infants after delivery and later in the maternity ward as well as to the type of clothing the infants received. Group 1 infants were placed skin-to-skin with their mothers after delivery, and had rooming-in while in the maternity ward. Group 2 infants were dressed and placed in their mothers' arms after delivery, and roomed-in with mothers in the maternity ward. Group 3 infants were kept in the nursery both after birth and while their mothers were in the maternity ward. Group 4 infants were kept in the nursery after birth, but roomed-in with their mothers in the maternity ward. Equal numbers of infants were either swaddled or clothed in baby attire. Breastfeeding parameters were documented during day 4 after birth. Infant's weight was measured daily. RESULTS: Babies who were kept in the nursery received significantly more formula and significantly less breast-milk, than did babies who roomed-in with their mothers. Swaddling did not influence the breastfeeding parameters measured. However, swaddled babies who had experienced a 2-h separation period after birth and then were reunited with their mothers tended to have a delayed recovery of weight loss compared to those infants who were exposed to the same treatment but dressed in clothes. Furthermore, swaddled babies who were kept in the nursery and received breast-milk supplements had a significantly delayed recovery of weight loss after birth when compared to those infants ingesting only breast-milk. On day 5, regression analyses of predicted weight gain in the exclusively breastfed infants indicated a significant increase per 100 ml breast-milk (59 g), compared to the predicted weight gain on day 5 per 100 ml supplements in the swaddled babies (14 g) (P=0.001). CONCLUSION: Supplements given to the infants in the nursery had a negative influence on the amount of milk ingested. In addition, supplement feeding or a short separation after birth when combined with swaddling was shown to have a negative consequence to infant weight gain.

Some early indicators for depressive symptoms and bonding 2 months postpartum--a study of new mothers and fathers.

The aim was to investigate associations between blues, bonding, perception of the child's temperament and depressive symptoms two months postpartum in both parents. Questionnaires to be filled out during the first week were; Blues Questionnaires day 1-5, Postpartum Bonding Questionnaire (PBQ) and Edinburgh Postpartum Depressive Scale (EPDS) and at two months; questions about breastfeeding, EPDS, PBQ and the Infant Characteristic Questionnaire (ICQ). In all, 106 couples returned all questionnaires on both occasions. Although there were differences in parents' rated levels of blues, depressive symptoms and postpartum bonding, we found many similarities in the ratings. Blues, bonding and depressive symptoms in the other partner were significantly related to EPDS in both parents. Thus, we found a risk for couple morbidity. The similarities between the parents' responses could be interpreted in terms of a broader human way of reacting to childbirth, while the differences e.g. their understanding of the child could refer to different gender roles.

Induction of anti-secretory factor in human milk may prevent mastitis.

AIM: The aim of the study was to try to induce anti-secretory factor (AF) in human milk and possibly prevent mastitis. METHODS: Forty mothers who had normal deliveries and healthy full-term infants were randomly divided into two groups, 3-7 days postpartum. The experimental group received a food inducing AF. The control group received the same type of food, without AF-inducing properties. Milk was tested for AF after the mothers had eaten the cereals for 4-5 wk. AF was determined by intravenous injection of milk samples into rats measuring their capacity to prevent secretion into a gut loop of the rat injected with cholera toxin. RESULTS: The median levels of AF differed between the experimental (n = 12) and control groups (n = 16): 1.1 (0.7-1.25) units vs 0.1 (0.0-0.25) units, Z = -4.492, p < 0.0001 (11 mothers dropped out and one milk sample is missing from one of the control mothers). The frequency of mastitis in the experimental compared with the control group was reduced (p = 0.0086, permutation test). The median AF levels in mothers with or without mastitis differed; 0.0 (0.0-0.1) vs 0.5 (0.2-1.1), Z = -2.399, p = 0.017. CONCLUSION: We suggest a specially treated cereal induces AF in human milk and protects against clinically manifested mastitis.

The parent-child relationship in the context of maternal depressive mood.

The aim of this study was to examine parent-child interactions 15-18 months postpartum, in families where the mother either showed depressive symptoms two months postpartum or did not. Maternal mood was assessed with the Edinburgh Postnatal Depression Scale (EPDS). Eleven women scoring >12 (signs of depressive mood) and 14 women scoring <10 (no signs of depressive mood) on the EPDS and their partners were videotaped in parent-child interactions, assessed by the Parent Child Early Relational Assessment (PCERA). Our results indicate that children of high EPDS-scoring mothers showed less persistence in play with, and less joy in reunion after separation from, their mothers than children of low EPDS-scoring mothers. In contrast, most fathers in families where the mothers scored high on the EPDS seemed to establish joyful relationships with their children and secure child-father attachment 15-18 months postpartum, as if the father "compensated" for the mothers' depressive symptoms.

Skin-to-skin contact may reduce negative consequences of "the stress of being born": a study on temperature in newborn infants, subjected to different ward routines in St. Petersburg.

AIM: To evaluate how different delivery-ward routines influence temperature in newborn infants. METHODS: A total of 176 newborn mother-infant pairs were included in a randomized study. The babies were kept skin-to-skin on the mother's chest (Skin-to-skin group), held in their mother's arms, being either swaddled or clothed (Mother's arms group), or kept in a cot in the nursery, being either swaddled or clothed (Nursery group). Temperature was measured in the axilla, on the thigh, back and foot at 15-min intervals at from 30 to 120 min after birth. RESULTS: During this time period the axilla, back and thigh temperatures rose significantly in all the treatment groups. The foot temperature displayed a significant fall in the babies in the Nursery group and this decrease was greatest in the swaddled babies. In contrast, foot temperature rose in the babies in the Mother's arms group and in particular in babies in the Skin-to-skin group. Foot temperature remained high in the Skin-to-skin group, whereas the low temperature observed in the Nursery group gradually increased and two days after birth the difference was no longer significant. CONCLUSION: The results show that delivery-ward routines influence skin temperature in infants in the postnatal period. Allowing mother and baby the ward routine of skin-to-skin contact after birth may be a "natural way" of reversing stress-related effects on circulation induced during labour.

Maternal analgesia during labor disturbs newborn behavior: effects on breastfeeding, temperature, and crying.

BACKGROUND: Newborns not exposed to analgesia, when placed on the mother's chest, exhibit an inborn prefeeding behavior. This study was performed to assess the effects of different types of analgesia during labor on the development of spontaneous breastfeeding movements, crying behavior, and skin temperature during the first hours of life in healthy term newborns. METHODS: Video recordings were made of 28 newborns who had been dried and placed in skin-to-skin contact between their mother's breasts immediately after delivery. The video recordings were analyzed blindly with respect to infant exposure to analgesia. Defined infant behaviors were assessed every 30 seconds. Group 1 mothers (n = 10) had received no analgesia during labor, group 2 mothers (n = 6) had received mepivacaine via pudendal block, and group 3 mothers (n = 12) had received pethidine or bupivacaine or more than one type of analgesia during labor. RESULTS: All infants made finger and hand movements, but the infant's massagelike hand movements were less frequent in infants whose mothers had received labor analgesia. A significantly lower proportion of group 3 infants made hand-to-mouth movements (p < 0.001), and a significantly lower proportion of the infants in groups 2 and 3 touched the nipple with their hands before suckling (p < 0.01), made licking movements (p < 0.01), and sucked the breast (p < 0.01). Nearly one-half of the infants, all in groups 2 or 3, did not breastfeed within the first 2.5 hour of life. The infants whose mothers had received analgesia during labor had higher temperatures (p = 0.03) and they cried more (p = 0.05) than infants whose mothers had not received any analgesia. CONCLUSIONS: The present data indicate that several types of analgesia given to the mother during labor may interfere with the newborn's spontaneous breast-seeking and breastfeeding behaviors and increase the newborn's temperature and crying.

Changes in personality pattern during the first pregnancy and lactation.

In order to study personality changes in first pregnancy and lactation, two groups of women (n = 161, mean age 26.8 years) completed the self-report inventory Karolinska Scales of Personality and a scale for emotional dependency during pregnancy and 3 or 6 months after delivery. The results were within normal limits when compared with the normative values. Analysis of variance showed that the subscales Muscular Tension, Somatic Anxiety, and Monotony Avoidance diminished significantly from pregnancy and to the test periods after delivery (all p values < 0.01). Impulsiveness showed the same trend (p = 0.1). The women who had breastfed for at least 8 weeks (91%) differed significantly from those who had not. They had lower scores on the Somatic Anxiety (p = 0.006), Muscular Tension (p = 0.003), Monotony Avoidance (p = 0.039), Suspicion (p = 0.03), Social Desirability (p = 0.045) and the Impulsiveness scale (p = 0.078) and higher scores on the Socialization scale (p = 0.001). Thus, we conclude that most personality traits are stable during first pregnancy and lactation, but some significant changes occur toward a lifestyle interpreted as more relaxed and tolerant to monotony.

Oxytocin, prolactin, milk production and their relationship with personality traits in women after vaginal delivery or Cesarean section.

The aim of the present study was to investigate if personality profiles reflecting anxiety and social interaction of mothers who delivered by Cesarean section (CS) or by the vaginal route (VD) differed in early postpartum and to investigate whether these personality traits were correlated with hormonal data. Seventeen women delivered by emergency CS and 20 by the vaginal route were selected for this study. The amount of milk transferred to the baby was measured. Blood samples were collected during the second breast-feeding on the second day after delivery. The samples were analysed for oxytocin and prolactin. After breastfeeding, the mothers were asked to fill in the personality inventory, Karolinska Scales of Personality (KSP). The scores were compared between the two groups and with a normative group of women. Each scale on the personality inventory was correlated with hormonal parameters. The KSP showed significant differences between the delivered mothers and the normative group in variables related to anxiety and socialization. The VD mothers deviated more than the CS mothers from the normative group. Correlations with hormonal data indicated that anxiety was inversely related with basal levels of oxytocin and prolactin in the CS mothers, whereas the pulsatility of oxytocin was related to social desirability in both groups. Social desirability and oxytocin pulsativity were also correlated with the amount of milk transferred from the mother to the baby. The correlations indicate that central oxytocin, as reflected by basal plasma levels and patterns, may be involved in behavioral adaptations to the maternal role.

Effects of routinely given pethidine during labour on infants' developing breastfeeding behaviour. Effects of dose-delivery time interval and various concentrations of pethidine/norpethidine in cord plasma.

A standard dose of 100 mg of pethidine was given im to 13 healthy primiparae during labour. The aim of the study was to investigate whether developing breastfeeding behaviour in the newborn infant was associated with the dose-delivery time interval (DDI) or with the plasma concentration of pethidine and norpethidine in mixed cord blood at birth. The DDI was found to be unevenly distributed with no pethidine exposures in the time interval 5.4-8 h. The material was therefore divided into a "short DDI" group (1.1-5.3 h) and a "long DDI" group (8.1-9.9 h). The infants in the "short DDI" group had a depressed sucking behaviour in 15-45 min of observation and a delayed initiation of lip and mouth movements when compared with the infants in the "long DDI" group. Six of the thirteen infants did not suck their mothers' breasts during the observation period. These infants had higher median plasma concentrations of pethidine at birth than the seven infants who did start sucking. No differences wer found between the plasma levels of norpethidine and the behaviour. It was concluded that 100 mg of pethidine im as an analgesic given under routine conditions may have unfavourable effects on infants' developing breastfeeding behaviour if the DDI is short.

Different patterns of oxytocin, prolactin but not cortisol release during breastfeeding in women delivered by caesarean section or by the vaginal route.

The aim of this study was to find out whether the hormonal patterns of oxytocin, prolactin and cortisol differed between women delivered by emergency section or by the vaginal route and if these patterns show any relation to the duration of breastfeeding. Seventeen mothers with emergency section (C.S.) and 20 mothers with normal vaginal deliver (V.D.) were blood sampled in connection with breastfeeding on day 2 post partum for oxytocin, prolactin and cortisol. The number of oxytocin pulses as calculated with the PULSAR program occurring during the first 10 min of the breastfeeding session varied between 0 and 5. The V.D. mothers had significantly more pulses than the C.S. ones. Furthermore the C.S. women lacked a significant rise in prolactin levels at 20-30 min after the onset of breastfeeding. Logistic regression analysis revealed mode of delivery and infant's age at first breastfeed to be the most important, independent variables showing a relation to the release pattern of oxytocin on day 2. Correlations between oxytocin pulsatility on day 2 and the duration of the exclusive breastfeeding period in the V.D. group suggest that development of an early pulsatile oxytocin pattern is of importance for breastfeeding.

The effects of medically-orientated labour ward routines on prefeeding behaviour and body temperature in newborn infants.

The effects of medically-orientated labour ward routines were studied during the the first hour after birth, in 48 vaginal, single deliveries. All infants were immediately separated from their mothers and left on a resuscitation table. There was no significant difference in onset of crying if the infant received cutaneous stimulation or not. It was found that 17 infants, not showing hand-to-mouth activity, were bathed at an average time of 17 min (12-23 min) after birth, while those who did were bathed at 28.5 (24.5-41.5) min (P = 0.002). One infant was breastfed during the first hour. Being separated from its mother, bathed early, and swaddled after birth seemed to interfere with the infant's inborn ability to signal hunger. Forty-one infants were hypothermic at 1 hour. According to a multiple regression analysis infant body temperature at 60 min of age corresponded positively with birth weight (P = 0.0001) and time of oxygen administration (P = 0.0002). A plausible explanation for the effect of oxygen exposure is that there is brown fat inactivation in normal newborn infants and administration of oxygen activates the brown fat. It might be advantageous to let the mother keep the baby warm, rather than manipulate the baby's metabolism with oxygen.

Elevation of oxytocin levels early post partum in women.

BACKGROUND: The aim of this study was to determine plasma levels of oxytocin in women immediately after delivery. METHODS: Oxytocin was measured in 18 healthy women at 15 minute intervals after normal vaginal deliveries with healthy infants. The mothers had their infants put skin-to-skin on their chests immediately after birth. The infants stayed there up to two hours post partum. RESULTS: There were significant elevations of oxytocin 15, 30 and 45 minutes after delivery (p = 0.007, 0.02 and 0.02 respectively) when compared with average pre partum levels sampled approximately 7-15 minutes before partus. This elevation of oxytocin coincided with the expulsion of placenta. In most women this first elevation was followed by repeated elevations of oxytocin. Oxytocin levels returned to pre partum levels at 60 minutes post partum. CONCLUSIONS: Oxytocin is known to play a role in maternal bonding in animals. Earlier studies indicate that there is a sensitive period for bonding the first hour after giving birth even in women. Our study demonstrates a coincidence of this putative 'sensitive period' and high levels of oxytocin.

Effects of maternal pethidine on infants' developing breast feeding behaviour.

The aim of this quasi-experimental study was to examine the effects of maternal pethidine during labour on the developing breast feeding behaviour in infants in the first 2 h after birth compared with infants not exposed to pethidine. Forty-four healthy infants were observed immediately after birth. They were placed skin-to-skin on their mothers' chests. The development of mouth and sucking movements as well as rooting behaviour and state of sleep/wakefulness were noted. The observer was blind as to the pain relief the mother had received during labour. Of the 44 mothers 18 had received pethidine. The main findings were that infants exposed to pethidine had delayed and depressed sucking and rooting behaviour. In addition, a smaller proportion of infants exposed to pethidine started to suckle the breast. Rooting movements which are expected to be vigorous at 30 min after birth were affected both by administration of pethidine and a longer second stage of labour. It is suggested that the differences found in sucking behaviour may be a central effect of pethidine. Depression of rooting movements in the pethidine group may be caused by exhaustion due to a longer second stage of labour and administration of pethidine. It is recommended that pethidine-exposed mother-infant couples stay together after birth long enough to enable the infant to make the choice to attach or not to attach to the nipple without the forceful helping hand of the health staff.

The position of the tongue during rooting reflexes elicited in newborn infants before the first suckle.

A common breast-feeding problem is when the infant "places its tongue in its palate" and has difficulties in attaching to its mother's nipple. The aim of this study was to document the position of the tongue in the mouth cavity during rooting reflexes elicited in newborn infants before the first suckle. Eleven healthy, full-term infants were videotaped 101 +/- 31 min after birth during an evoked distinct rooting reflex before the first suckle. The videotaped rooting reflex was analyzed in detail concerning the degree of turning of the head, mouth opening and position of the tongue, in pictures that were "frozen" at specific intervals. "Licking movements" preceded and followed the rooting reflex in the alert infants. In 10 of the 11 infants the tongue was placed in the bottom of the mouth cavity during a distinct rooting reflex (p = < 0.05). It is suggested that forcing the infant to the breast might abolish the rooting reflex and disturb placement of the tongue. A healthy infant should have the opportunity of showing hunger and optimal reflexes, and attach to its mother's nipple by itself.

Somatostatin levels in plasma in nonsmoking and smoking breast-feeding women.

The objective of the study was to record how somatostatin levels in plasma are altered in response to breast-feeding during the lactation period and to relate somatostatin levels to the success of the lactational performance and to smoking habits. Fifty-two women were investigated 4 days post partum and 3-4 months later. Blood samples were collected and the levels of somatostatin-like immunoreactivity (below referred to as SLI) were measured with radioimmunoassay. The periods of exclusive breast-feeding and of mixed feeding were assessed as well as the milk yield. Smoking habits were noted. SLI levels were found to be significantly lower on day 4 after delivery, compared to 3-4 months later. Also the type of response to breast-feeding was different. Thus, a significant fall of SLI was seen during breast-feeding at the maternity unit, but not 3-4 months later. Smoking women breast-fed fully for a significantly shorter time than nonsmokers and had significantly higher SLI levels at onset of breast-feeding day 4 post partum. Whether the high somatostatin levels recorded in connection with breast-feeding in smokers are related to the shorter period of breast-feeding seen in this group remains to be established. In addition, the highest levels of somatostatin were seen the day after the very last breast-feeding and a possible role for somatostatin in the weaning process should be explored.