REFERENCES and ABSTRACTS from the film: Skin-to-Skin in the First Hour After Birth.
1. Crying in separated and non-separated newborns: sound spectrographic analysis.
Michelsson K, Christensson K, Rothgänger H, Winberg J.
Acta Paediatr. 1996 Apr;85(4):471-5. Article first published online: 21 JAN 2008 | DOI: 10.1111/j.1651-2227.1996.tb14064.x
Keywords: Crying; newborn infant; separation; sound spectrography
Abstract: During the first 1-2 h after birth crying occurs during separation from the mother and stops on reunion. In rats, such “separation distress calls” have distinct phonetic properties. We examined this early crying by sound spectrography in 29 healthy, full-term, vaginally delivered babies, randomly assigned either to be kept in a cot or to be placed in body contact with the mother during the 90 min following birth. The former babies cried almost 10 times more than the latter ones. The duration of the cry signal (the smallest element of a cry analysed by spectrography) in both groups was 0.8-0.9s; the melody contour was flat or slightly rising-falling with a fundamental frequency of around 500 hertz. The cry is provisionally characterized as a discomfort cry, elicited mainly by separation from the mother.
2. Separation distress call in the human neonate in the absence of maternal body contact.
Christensson K, Cabrera T, Christensson E, Uvnäs-Moberg K, Winberg J.
Acta Paediatr. 1995 May;84(5):468-73K Christensson1,2, Article first published online: 21 JAN 2008/DOI: 10.1111/j.1651-2227.1995.tb13676.x/Issue
Keywords: Cholecystokinin; crying behaviour; distress call; newborn care; oxytocin
Abstract: Few studies have used the baby's cry as a means of evaluating the quality of neonatal care. In this randomized trial the newborn's cry was registered during the first 90 min after birth when infants were cared for either: (a) skin–to–skin with the mother; (b) in a cot; or (c) in a cot for the first 45 min of the 90–min observation period and then skin–to–skin with the mother. The results suggested that human infants recognize physical separation from their mothers and start to cry in pulses. Crying stops at reunion. The observed postnatal cry may be a human counterpart to the “separation distress call” which is a general phenomenon among several mammalian species, and serves to restore proximity to the mother. Our results suggest that in human newborns this cry is not dependent on earlier social experience and may be a genetically encoded reaction to separation. The findings are compatible with the opinion that the most appropriate position of the healthy full–term newborn baby after birth is in close body contact with the mother.
B. INFANT BODY TEMPERATURES:
1. Lower body temperatures in infants delivered by caesarean section than in vaginally delivered infants.
Christensson K, Siles C, Cabrera T, Belaustequi A, de la Fuente P, Lagercrantz H, Puyol P, Winberg J.
Karolinska Institutet, Department of Paediatrics, Stockholm, Sweden.
Abstract. Clinical experience suggests that infants delivered by caesarean section have difficulties maintaining normal body temperature during the first hours after birth. To test this hypothesis, body and skin temperatures were measured and compared in healthy full-term caesarean section and vaginally delivered newborn infants. The babies were studied during the first 90 min after birth. Axillary and skin temperatures were significantly higher in the vaginally delivered group than in infants delivered by caesarean section. Infants born by non-elective caesarean section. Infants born by non-elective caesarean section were slightly warmer during the first 90 min after birth compared to infants born by elective caesarean section. There were no significant differences in temperatures between infants cared for in a cot as compared to those cared for in an incubator. An incubator creates a physical barrier between babies and parents and incubator care might cause parental anxiety. Thus the routine of putting healthy, full-term caesarean section infants in incubators can be abandoned from a thermoregulatory point of view.
2. Temperature, metabolic adaptation and crying in healthy full-term newborns cared for skin-to-skin or in a cot.
Christensson K, Siles C, Moreno L, Belaustequi A, De La Fuente P, Lagercrantz H, Puyol P, Winberg J Karolinska Institutet, Department of Pediatrics, Karolinska Hospital, Stockholm, Sweden. Acta Paediatrica (Oslo, Norway : 1992)[1992, 81(6-7):488-93]
The aim of the present study was to compare temperatures, metabolic adaptation and crying behavior in 50 healthy, full-term, newborn infants who were randomized to be kept either skin-to-skin with the mother or next to the mother in a cot "separated". The babies were studied during the first 90 min after birth. Axillary and skin temperatures were significantly higher in the skin-to-skin group; at 90 min after birth blood glucosewas also significantly higher and the return towards zero of the negative base-excess was more rapid as compared to the "separated" group. Babies kept in cots cried significantly more than those kept skin-to-skin with the mother. Keeping the baby skin-to-skin with the mother preserves energy and accelerates metabolic adaptation and may increase the well-being of the newborn.
3. Maternal axillar and breast temperature after giving birth: effects of delivery ward practices and relation to infant temperature.
Bystrova K, Matthiesen AS, Vorontsov I, Widström AM, Ransjö-Arvidson AB, Uvnäs-
Moberg K. Birth. 2007 Dec;34(4):291-300.
Keywords: early postpartal period; maternal axillar and breast temperature; infant’s axillar and foot temperature; skin-to-skin contact; suckling; separation
ABSTRACT: Background: Little is known about the development and control of skin temperature in human mothers after birth. The purpose of this study was to explore the effects of delivery ward practices and early suckling on maternal axillar and breast temperatures during the first 2 hours postpartum and to relate them to the infant’s foot and axillar temperatures.
Methods: Three groups of 176 mother-infant pairs were randomized as follows—group I: infants lying prone in skin-to-skin contact on their mother’s chest, named the “skin-to-skin group” (n = 44), group II: infants who were dressed and lying prone on their mother’s chest, named the “mother’s arms group” (n = 44), and group III: infants who were dressed and kept in the nursery, named the “nursery group” (n = 88). Maternal axillar and breast temperatures and infants’ axillar and foot temperatures were measured at 15-minute intervals from 30 to 120 minutes after birth. Episodes of early suckling were noted.
Results: The axillar and breast temperatures rose significantly in all mothers. The rise of temperature over time was significantly higher in multiparas than in primiparas but was influenced only slightly by group assignment. The variation in breast temperature was highest in mothers in the skin-to-skin group and lowest in mothers in the nursery group. In the mother’s arms group, variation in breast temperature was larger in those mothers exposed to early suckling than in those not exposed. A positive relationship was found between the maternal axillar temperature and the infant foot and axillar temperature 90 minutes after the start of the experiment (120 min after birth) in the skin-to-skin and mother’s arms groups. The rise in temperature in the infant’s foot was nearly twice that in the axilla. No such relationship was established in the nursery group. In addition, foot temperature in infants from the skin-to-skin group was nearly 2°C higher than that in infants from the mother’s arms group.
Conclusions: Maternal temperature rose after birth, and the rise was higher in multiparas than in primiparas. Skin-to-skin contact and early suckling increased temperature variation. Maternal temperature was related to infant foot and axillar temperatures.
A. PHYSIOLOGICAL STABILIZATION
1. Randomized controlled trial of skin-to-skin contact from birth versus conventional incubator for physiological stabilization in 1200- to 2199-gram newborns. (Note: conversion to pounds: 2.5 lbs – 4.8 lbs—nmadru) Bergman NJ, Linley LL, Fawcus SR. Acta Paediatr. 2004 Jun;93(6):779-85.
Keywords: Hypothermia; prematurity; separation; skin-to-skin contact; stability
Aim: Conventional care of prematurely born infants involves extended maternal-infant separation and incubator care. Recent research has shown that separation causes adverse effects. Maternal-infant skin-to-skin contact (SSC) provides an alternative habitat to the incubator, with proven benefits for stable prematures; this has not been established for unstable or newborn low-birthweight infants. SSC from birth was therefore compared to incubator care for infants between 1200 and 2199 g at birth. Methods: This was a prospective, unblinded, randomized controlled clinical trial; potential subjects were identified before delivery and randomized by computerized minimization technique at 5 min if eligible. Standardized care and observations were maintained for 6 h. Stability was measured in terms of a set of pre-determined physiological parameters, and a composite cardio-respiratory stabilization score (SCRIP). Results: 34 infants were analysed in comparable groups: 3/18 SSC compared to 12/13 incubator babies exceeded the pre-determined parameters (p < 0.001). Stabilization scores were 77.11 for SSC versus 74.23 for incubator (maximum 78), mean difference 2.88 (95% CI: 0.3–5.46, p = 0.031). All 18 SSC subjects were stable in the sixth hour, compared to 6/13 incubator infants. Eight out of 13 incubator subjects experienced hypothermia.
Conclusion: Newborn care provided by skin-to-skin contact on the mother's chest results in better physiological outcomes and stability than the same care provided in closed servo-controlled incubators. The cardio-respiratory instability seen in separated infants in the first 6 h is consistent with mammalian “protest-despair” biology, and with “hyper-arousal and dissociation” response patterns described in human infants: newborns should not be separated from their mothers.
B. THE STRESS OF BEING BORN
1. The "stress" of being born.
Lagercrantz H, Slotkin TA.
Sci Am. 1986 Apr;254(4):100-7.
Describes the effect of birth on human and animal neonates, focusing on the role of catecholamines in fetal survival. Stress responses of infants, levels of catecholamines in gestation as compared to those during delivery, and adaptational effects of catecholamine surges are considered. Overall, the evidence suggests that elevation of these "stress hormones" in normally delivered newborns reflects not only a response to acute stress but also an attempt by the body to enhance chances for survival at birth, and infants delivered by caesarean section before labor begins may be at a disadvantage. (PsycINFO
Database Record (c) 2010 APA, all rights reserved)
1. Skin-to-Skin contact (Kangaroo care) promotes self-regulation in premature infants: sleep-wake cyclicity, arousal modulation, and sustained exploration.
Feldman R, Weller A, Sirota L, Eidelman AI.
Dev Psychol. 2002 Mar;38(2):194-207.
The effect of mother-infant skin-to-skin contact (kangaroo care, or KC) on self-regulatory processes of premature infants was studied. Seventy-three infants who received KC were compared with 73 infants matched for birth weight, gestational age, medical risk, and family demographics. State organization was measured in 10-s epochs over 4 hr before KC and again at term. No differences between KC infants and controls were found before KC. At term, KC infants showed more mature state distribution and more organized sleep-wake cyclicity. At 3 months, KC infants had higher thresholds to negative emotionality and more efficient arousal modulation while attending to increasingly complex stimuli. At 6 months, longer duration of and shorter latencies to mother-infant shared attention and infant sustained exploration in a toy session were found for KC infants. The results underscore the importance of maternal body contact for infants' physiological, emotional, and cognitive regulatory capacities. (PsycINFO Database Record (c) 2010 APA, all rights reserved)
D. SELF-REGULATION, BONDING, MATERNAL SENSITIVITY
1. Early contact versus separation: effects on mother-infant interaction one year later.
Bystrova K, Ivanova V, Edhborg M, Matthiesen AS, Ransjö-Arvidson AB,
Mukhamedrakhimov R, Uvnäs-Moberg K, Widström AM.
Birth. 2009 Jun;36(2):97-109.
Keywords: delivery ward practices; skin-to-skin contact; early suckling; early separation; swaddling; mother-child interaction; sensitive period
Background:A tradition of separation of the mother and baby after birth still persists in many parts of the world, including some parts of Russia, and often is combined with swaddling of the baby. The aim of this study was to evaluate and compare possible long-term effects on mother-infant interaction of practices used in the delivery and maternity wards, including practices relating to mother-infant closeness versus separation. Methods:A total of 176 mother-infant pairs were randomized into four experimental groups: Group I infants were placed skin-to-skin with their mothers after birth, and had rooming-in while in the maternity ward. Group II infants were dressed and placed in their mothers’ arms after birth, and roomed-in with their mothers in the maternity ward. Group III infants were kept in the nursery both after birth and while their mothers were in the maternity ward. Group IV 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 dressed in baby clothes. Episodes of early suckling in the delivery ward were noted. The mother-infant interaction was videotaped according to the Parent-Child Early Relational Assessment (PCERA) 1 year after birth. Results: The practice of skin-to-skin contact, early suckling, or both during the first 2 hours after birth when compared with separation between the mothers and their infants positively affected the PCERA variables, maternal sensitivity, infant's self-regulation, and dyadic mutuality and reciprocity at 1 year after birth. The negative effect of a 2-hour separation after birth was not compensated for by the practice of rooming-in. These findings support the presence of a period after birth (the early “sensitive period”) during which close contact between mother and infant may induce long-term positive effect on mother-infant interaction. In addition, swaddling of the infant was found to decrease the mother’s responsiveness to the infant, her ability for positive affective involvement with the infant, and the mutuality and reciprocity in the dyad. Conclusions:Skin-to-skin contact, for 25 to 120 minutes after birth, early suckling, or both positively influenced mother-infant interaction1 year later when compared with routines involving separation of mother and infant.
E. NATURAL AWAKENING OF BREASTFEEDING REFLEXES
1. Gastric suction in healthy newborn infants. Effects on circulation and developing feeding behaviour. Widström AM, Ransjö-Arvidson AB, Christensson K, Matthiesen AS, Winberg J, Uvnäs-Moberg K. Acta Paediatr Scand. 1987 Jul;76(4):566-72.
Keywords: gastric suction; newborn infants; circulation; postnatal feeding behaviour; breastfeeding
ABSTRACT.Gastric emptying of newborn infants is a procedure performed to prevent aspiration of gastric contents. The present investigation was conducted to study the effects of gastric suction on circulatory and behavioural parameters in 21 healthy newborn children (11 cases, 10 controls). A small elevation in mean arterial blood pressure was observed during gastric suction. The incidence of retching was also increased. In all children spontaneous sucking and rooting movements, as well as state of sleep and wakefulness were recorded. In the control group spontaneous sucking and rooting movements started to occur 15 min after birth and reached a maximum at 45 and 60 min, respectively. The first hand to mouth movement was observed after a mean of 34 min and the infants found the nipple and started to suckle at about 55 min. This sequence of prefeeding behaviour was disrupted in children who had undergone gastric suction. The physiological side-effects induced by gastric suction are minor, but it seemed to be unpleasant for the child and no clear advantages are gained by the procedure.
2. Gastric aspirates of newborn infants: pH, volume and levels of gastrin- and somatostatin-like immunoreactivity.
Widström AM, Christensson K, Ransjö-Arvidson AB, Matthiesen AS, Winberg J, Uvnäs-
Moberg K. Acta Paediatr Scand. 1988 Jul;77(4):502-8.
Keywords: gastric aspirates; newborn infants; pH; volume; gastrin; somatostatin; amniotic fluid
ABSTRACT. The aim of the present investigation was to study volume, pH and the levels of gastrin- and somatostatin-like immunoreactivity in gastric aspirates obtained immediately after birth from 25 healthy infants. In addition, the same parameters were measured in amniotic fluid collected from 11 of the mothers. The median volume of the gastric contents was 4 ml (range 0–11) and median pH was 6.96 (range 2.77–9.58). Gastrin and somatostatin median concentrations were 8 pM (range 0–52) and 67 pM (range 15–>1000), respectively. The corresponding levels in amniotic fluid were 8.2±3.6 pM and 28.4±5.3 pM, median pH was 9.22 (range 8.05–9.58). There was a significant correlation between volume and pH of gastric contents. The pH of the gastric aspirate was inversely correlated with the somatostatin levels. No correlation could be demonstrated as regards levels in amniotic fluid and gastric content. Gastric content and amniotic fluid were not correlated regarding pH, gastrin and somatostatin. It is suggested that the foetus drinks about 10 ml portions of amniotic fluid which are gradually emptied from the stomach and that these drinking episodes are associated with gastric exocrine and endocrine secretion normally seen following feeding after birth.
3. Maternal analgesia during labor disturbs newborn behavior: effects on breastfeeding, temperature, and crying.
Ransjö-Arvidson AB, Matthiesen AS, Lilja G, Nissen E, Widström AM, Uvnäs-Moberg K.
Birth. 2001 Mar;28(1):5-12.
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 massage-like 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.
4. Postpartum maternal oxytocin release by newborns: effects of infant hand massage and sucking.
Matthiesen AS, Ransjö-Arvidson AB, Nissen E, Uvnäs-Moberg K.
Birth. 2001 Mar;28(1):13-9.
Background: Newborns placed skin-to-skin with their mothers show an inborn sequence of behavior similar to that seen in other mammals. The purpose of this study was to make a detailed exploration of hand movements and sucking behavior in healthy term newborns who were placed skin-to-skin on their mothers' chests, and to study maternal oxytocin release in relation to these behaviors.
Methods: Ten vaginally delivered infants whose mothers had not been exposed to maternal analgesia were video-recorded from birth until the first breastfeeding. Video protocols were developed based on observations of the videotapes. Each infant's hand, finger, mouth, and tongue movements, positions of the hand and body, and sucking behavior were assessed every 30 seconds. Maternal blood samples were collected every 15 minutes, and oxytocin levels were analyzed by radioimmunoassay. A statistical test for establishing the relationship between maternal oxytocin levels and infants' hand movements or sucking behavior was developed.
Results: Infants used their hands to explore and stimulate their mother's breast in preparation for the first breastfeeding. A coordinated pattern of infant hand and sucking movements was also identified. When the infants were sucking, the massage-like hand movements stopped and started again when the infants made a sucking pause. Periods of increased massage-like hand movements or sucking of the mother's breast were followed by an increase in maternal oxytocin levels (p < 0.005).
Conclusions: The findings indicate that the newborns use their hands as well as their mouths to stimulate maternal oxytocin release after birth, which may have significance for uterine contraction, milk ejection, and mother-infant interaction.
1. Maternal-infant bonding: a joint rebuttal. Anisfeld E, Curry MA, Hales DJ, Kennell JH, Klaus MH, Lipper E, O'Connor S, Siegel E, Sosa R. Pediatrics. 1983 Oct;72(4):569-72.
Inaccuracies in Lamb's recent review1 of studies of maternal-infant bonding have resulted in considerable confusion and misunderstanding among those not well acquainted with the field. This rebuttal, prepared by the investigators whose works were sited, addresses these inaccuracies so that a fuller and more productive discussion of this area of study can occur in the future. Under the name of each investigator, Lamb's criticisms are quoted, after which the original researcher responds with corrected information.
Lamb in his criticism of the work of Hales et al2 notes that, "Many of the researchers have employed multiple measures and observed statistically significant differences on a small proportion of these.
Copyright © 1983 by the American Academy of Pediatrics
2. Parent to infant bonding: setting the record straight. Klaus M, Kennell J. J Pediatr. 1983 Apr;102(4):575-6.
G. BABY’S NINE INSTINCTIVE STAGES
1. Infant behaviour to locate the breast the first hour after birth – a possible way to early self-regulation and psychological bonds.
Widström A-M, Matthiesen A-S Lilja G, AaltomaaMichakias P, Lintula A, Dahllöf A,
Ransjö-Arvidson A-B, Nissen E. Submitted
Keywords: Breastfeeding behaviour skin-to-skin; Newborn; Pain threshold; Psychological bonds; 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.
H. LESS PAIN IN THE BABY CLOSE TO DELIVERY
1. Mode of delivery modulates physiological and behavioral responses to neonatal pain.
Bergqvist LL, Katz-Salamon M, Hertegård S, Anand KJ, Lagercrantz H.
OBJECTIVE:To study whether the mode of delivery alters pain expression.
STUDY DESIGN: Full-term infants born by vaginal delivery or elective caesarean section were observed following high- and low-intensity pain stimuli, with recording of electrocardiogram, facial expression and vocalization.
RESULT: Graded physiological and behavioral responses occurred, with greater responses to higher than lower intensity pain stimuli. Elevation in heart rate following both stimuli increased with time after vaginal delivery. Infants delivered by elective caesarean section showed stronger facial expressions and briefer time in vocalizations response to both interventions.
CONCLUSION: Diminished responses following vaginal delivery suggest that physiological events associated with a normal delivery reduce the physiologic and sympathoadrenal activation by nociceptive mechanisms. Pain and stress reactivity appear to be inhibited during fetal life and sensory inputs during vaginal delivery may reverse this inhibition. To minimize neonatal pain, we recommend that postnatal invasive procedures to be performed shortly after vaginal birth.