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THE IINCET
;R
E
.z
.9
16
T4
10
a
6
4
O>10 weeks @>12
weeks a>18
weeks
Mean
+ 1.O SD
..........4
.........T9:l:.119.,s.q..............o...'
__-€-------{
Mean + 1.8 SD and mean 2.O
+ SD
diagnosis are limited. If facilities are available, especially
during the first trimester, fetal DNA analysis of cr genes
still remains the method of choice.
Retsroncsg
I lai-Inio LE . Atpha-chlin thslassaemia bd hyatrops fetalis in Malaya:
repon offive cases.
alood t962120:581 91.
2 Todd D, lli MCS, BEsa CA. Thalassaemi. dd hy&ops fet iF
family studies. a {t 1967; 3: 347-52.
3 Thum.srlhir B, Nsd.sui. A, Silpisorukasol S. Hydrops fetalis
associ.ted with Ban\ haemoglobir in Nonh€m Thziland. J Pediorr
t9a6t73, \32 34.
4 !fi/€athe.sll
DJ,
Cless
JB,
vons HB. The haemoslobin
constitution of
infants $'ith ha€moglobin Ban's hydrops fetalis s}aldrome. BrJ
Ha atol197Otlat 357-67 -
5 Li.ns ST, Vons V, So
"0K Ma HK, ChD V, Todd D. Homozysous
o-thalassaemia: €linical
presentation,
diagnosis and management. A
review of46 cases. B/tObset Gtnae.ol l985j92t 6a0-a4.
6 Chan V, Ghosh A, Chan TK, Vong V, Todd D. Prenalal diaenosis of
homozygous
d-thalassaenia by direct DNA Dalysis of ucultured
amniotic fluid €€lls. B/VJ 1984;244. t327 39.
7 Rubin EM, Kan YW. A simple sensirive
prenaral test for hydrops fetalis
c.used by o-thllassaemia - Lafl.et l9a5t i: 7 5-77 .
8 Hsieh FJ, Chang FM, Ko TM, Kuo Pr. Chans
DY, CbeD
HY. The
antenatal blood
gas
and acid-base status ofnormal fetuses and
hydiopic feruses wirh Bart's hemoglobiDop{hy. Obrkt q)iecol rS89i
74t722 2t.
9 Kanokponssakdi S, Fucharoetr S, Varanasiri C, Thonslairosm P,
Vinichasoon
P, ManassakomJ.
UlEasonosrrphic merhods for
detection
ofhaemoglobin Ban's hydrops feralis in $e second rimesrer
ofpregnancy. ,t'at Drap, 1990; 10:809 13.
lo Ghosh
A, Tang MHY, Liang ST, Ma HK Chan V, Chan TK.
Uhrasound evaluation of pregnancies
at risk for homozygous d-
thalassaemia- 1 . Irtaar D,iTr l9A7:7t 3O7 11.
Proportion
positive
among cases
(%)
Figure: Percentago of posltives
among cases
(pregnancles
affocted by homozygous cr-thalassaeml+1) and controls
(nolmal
and o-thalassaemia-1
pregnancles)
at dlfferent
gostatlons
at varlous cutdts of placental
thlckness
12 weeks', a cut-off lower tlun mean plus 2 SD only
decreased specificiry wiLhour any increase
in sensitiviry.
Measurement of placental thickness du ng first and
second trimeste$ can differentiate normal ftom an
affected pregnancy in women at risk of giving birth to an
infant with homozygous cr-thalassaemia- l. A cut-off of
mean placental thickness plus 2 SD is appropriate. The
sensitivfty of placental drickness measulement in
derecting an affected pregnancy before 12 weeks'
gestation is low. In 2 pregnancies with a false-negative
result after 12 weeks' tie placentas were large on
ulrrasound, bur dickness was normal. With experience,
one should be able to recognise this tlpe ofplacenta. Both
these placentas were thought to be abnormal at the time
of amniocentesis. Measurement of placental volume
insread of thickness might be moie useful in dris situation.
However, in real-time sector scan, the whole length ofthe
placenta cannot be imaged during second trimester, and
volume measurement may be inaccurate.
Fetuses affected by homozygous c-thalassaemia-l
develop severe anaemia in early fetal life. This leads to
hydropic changes including an increase in placental
thickness and cardiomegaly. Increases in placental
thickness precede cardiomegaly.lo The increase in
placental rhickness occurred as early as the 10th
gestational week. !(/ith mean plus 2 SD, we could identifu
most affected pregnancies after 12 weeks and by 18
weeks' gestation, all affected pregnancies were detected.
Hence a normal placental thickness at or after the l8th
gestational week is reassuring and may obviate the need
for further invasive procedures to confrm normality.
An abnormal placental thickness is highly suggesrive
but not absolutely diagncistic of an affected pregnancy
and for earlier gestationr some of the abnormal
pregnancies could not be detected, Therefore invasive
diagnostic evaluation is necessary- Since the main
objective of prenatal diagnosis of homozygous o-
thalassaernia-l is reduction of maternal morbidity rather
tian prevention of birth of afected infants, serial
measurement of placental thickness may be an altemative
cost-effective method for exclusion of the disolder,
particularly in areas where resources for prenatal
Dop.rtment ot Otstetrlcs and Gynaecology.
Unlvsl3lty ot Hong Nong,
Tsan Yuk Hospltal, Hospltal Road,
Hong Kong
(A Ghosh
FRcoc, I\, H Y Tang MRcoG, Y H Lam MRcoG,
E Fung MRcoc); and Departnent of Mediclne,
Queen
Mary HGpltal,
Pokfulam, Hong Kong
(V Chan PhD)
Cor€Dond6nce to: Dr A Ghosh
Does the newboln baby find the nipple by
smell?
H Varendi, R H Poftet, J Winbery
We studied the
involvement of naturally occurring odours in
guiding
the baby to the nipple. One breast of each
participating
mother was washed immediately after
delivery. The newborn
infant was
placed prone
between the
breasts. Of 30 infants, 22 spontaneously selected the
unwashed breast. The washing
procedure
had no effect on
breast temperature.
We concluded that the infants
responded to olfactory differences
between the washed and
unwashed breast6.
Lancet
1994; 344: 989-90
Healdry newbom infants placed
between their mother's
breasts
locate the nipple without assistance
and typically
begin to suck within the first hour after bi-rrh.r Newbom
rats, for exampler fail to locate the oipple if their sense
of
smell is experimentally disrupred'? or if the modrels
ventrum is thoroughly washed.! Breastfed human infants
responded
differentially to a gauze pad that had been
wom over dleir mother's nipple compared with an
odorised pad ftorn an unfamiliar woman, indicating that
vol 144
' Ocrcber 8, 1994 989
THE IINCET
they recognise their mother's scent.d' Bteast odours from
lactating women are generally attractive to infantsr
regardless of their mode of feeding..t At 2 weeks of age,
babies drat had been boftle-fed since birdr spent more
time tumed toward the breast pad ftom an unfamiliat
nursing mother than in the direction of a pad treated widt
their familiar formula.s Could chemical cues associared
with the areola and nipple be implicated in initial
(unassisted) nipple localisation and sucking?' To assess
this hypothesis, nipple searching was observed after one of
the mother's breasts
had been thoroughly washed> drereby
pardy eliminating narural odou!.
36 full-term babies
bom of mothers wilhout analgesia and who
had no postpartum complications wete aecruited. 6 were
subsequently excluded
because of disrurbed
nasal breathing
(4)
or failure to respond to the mothe!'s breast during a test session
(2). The final sample was 14 girls and 16 boys (gestarionel
age
37-41 weeksj mean
binhweight 3676 ISD 4231
g; Apgar scores
>7 at I and 5 min).
Irnmediately
after birth, the baby was dried, laid skin-to-skin
on rhe mother's abdomen altd covered with a blanket. An
assistent washed
one of the mother's breasts for about 15 cm
around
the nipple with an odou.less liquid soap: Mild$el for t5
mothels and hctacyd (Sanofi,
pH 3.5) for the remailring
15.
The washed breast was rinsed with lukewarm weter and dried.
The right breest was
washed in 15 cases
and the left breast in the
others. Modrers were randomly assigned to the two sogps and to
the right/left sides.
After the washed breast was dried, the obsetver (unaware of
which breast had been cleaned) entered the room and moved the
baby from the mother's abdomen to the "starr" posirion-ie,
nose in the midline of the mother's chest, eyes at the level of the
nipples.
Observation and recording
of the baby's behaviour
then
began
(5-13 min after birrh; mean 9.9) and continued until the
infant found
the nipple and began ro suck vigorously.
Before delivery, the mother was rold that she and the observer
would watch whether the infant could find the nipple withour
help. Mothers were instrucred not to tell the observer which
breast had
been
washed.
Informed consent was
obtained fiom all
mothers, and fathers when present, and the study was approved
by the locel ethics
committee.
To sludy any effecr of the washing on breast temperaruie, en
additionel 6 rnothers underwent
lbe same washing within 12
hours after delivery. Surface temperatures were recorded et the
nipple, border betwi:en the areola and white breast-skin, and
midway between rhe areola
and centre of the ches! at 5-10,
l5-20, 30-35, and 50-55 min.
25 infants spontaneously grasped a nipple and sucked
(median latency 5l min after birth [range 22-100]). The
odrer 5 requiled assistance in grasping the prolapsed
nipple; the baby had moudr contacr wirh one of rhe
nipples and repeatedly attempted to grasp it before the
observer assisted by placing rhe nipple in the infant's
mouth (median latency 54 min after birth [22-85]). None
of these 5 infants aftempted to gasp the altemative
nipple. 22 (12 boys, l0 girls) ofthe 30 infants selected the '
unwashed breast, The unwashed breast was selected by
l0 infants in the Mild$el and 12 in the Lactacyd soap
groups. The table shows median times for other early
behaviours.
The median temperature of washed breasts was slighdy
above that of unwashed breasts (maximum median
difference was 0'5"C).
Vithin l-2 h after birth, babies preferred their modrer's
unwashed bteast, which is consistent with studies of non-
human mammals showing dlat washing the mother's
nipplevventrum resulted in disturbed nipple finding and
feeding. \fe excluded the possibility thar our infants had
responded to differences in the warmth of dre two breasts.
M€daan
{
range)
time
{
min) alter birth.
Table: Early
postnatal
behavlour In
30 nowborn
Intante
rJge
explain the preference
for the unwashed breast in that
the infants were responding to differences in snell.
Besides
secreting milk and colostrum,
rhe nipple/areola is
dense in glands that might secrere attractive odours. The
washing
would have reduced o! eliminated such cues,
which is consistent
with infants orienring prefelentially
towards a gauze
pad contaminared with the breast odour
of a lactating woman compared with an odourless control
pad.+"
Naturally occurring matemal odoun may have a
role in guiding dre neonate ro rhe nipple, and thereby
contribute to early nipple attachment and sucking. The
causes of early failures of breasdeeding are often
unknown.' Since breasdeeding is sensitive
ro even minor
disturbances of the spontaneous interactions between
mother and baby,'o biological facton should be given
attention, Ijnnecessary routine cleaning may interfere
with the establishmenr
ofsuccessful early
breasdeedhg by
elimination of iie infant's access
ro biologically relevant
chemical signals.
This study was aided by grsnts ftom rhe Foundarion "Frimurare
BamhuseC' and fiom the Karclirst€ lnslirure.
Unwasned Washed
breasl
(n=22) breasl
{n-8)
Firsl handlomouth
movement
No oi head tornings belore
choice ot side
First moutt}areola
contact
Fnsi successiulnippl€
contacl
(in
mouth)
N0 ol sucking attempts betore success
20 (1I41t 19 (10-30)
23 (10-60) 20 t7-291
1(0-6) 2 (G6)
50
(1+99) 44122-72)
51(22-100) 45
t22-73)
5
(1-2r) 411-71
54122-LOO\ 4a122-73\
Reiarencog
I Widsirttm AM, Ransjo-Arvisson AB, Chrisr€nsson K, er al. casric
suction in healthy n€wbom intun$. Acto Paediat l9a7 ; 75t 566-72.
2 Teicher MH, Flaum LE, ViUiams M, Eckhen SJ, Lumia AR. Swivll,
sowth and suckling behavior of neoniolly butbecromiz€d rats. P,lry'bi
Behao 1978i 2lt 553-61 .
3 Hofe. MA, Shair H, Sinsh P. Evidence thsr mitemal venrlal skir
substances
promote suckling in infa rirs. Pr),'rio/aehao 1976:17.
l3t-36.
4 Macfarlane A. Olfaction in lhe developm€nr ofsocial preferences
in the
humd neonate.
ln: Poner R, O'Connor M, €ds. Parenr-infanr
interaction
(Ciba
Foundation Slrnposium 33). N€w York Elsevier,
1975:103-13.
5 Schaal B, Monmgner H, Henlingq er al. Les stimulations oflactives
dans
les.elations
€ntre I'enfant et la mere. R?rrcd Nlf D@ 1980:
20:
443 54.
6 Makn I f, Poner RH. Att"activeness of lacraring females' breast odors
to neonltes.
CirrTdDe!, 1989;60: 803-10.
7 Po(er RH, Makin J$f, Davis LB, Christensen KM. BressFfed inflnls
respond to olfactory cues fiom deir o$n moth€r a.d unfamilia.
lactatins femafes. lrldz, A.hao D@ r992t lst a5-93.
8 Poner RH, Makin IV, Dlvis LB. Chrisrensen KM. An assessm€nt of
th€ salient olfadory enimnment of formula-fed infrn6. Pb)tiol Behal)
1991, 50: 907-l l.
9 Goldman AS, Garza C. Futur€ research in hrman milk. Ped;ot Res
1987
t 22t 493-96.
l0 Rishard I- Alad€ MO. Efrect of delivery mom routines on success
of
first breasFfeed. lar..r 1990;336:
I105-07.
Tartu Unlverslty Chlldton'6 Hospltal, Tartu, Eatonla
(H
Varendi MD);
Isbo6tollo de
Compo.toment Anlmal, URA ll91CI{RS,/INRA,
l{ouzllly, Franco
(R H Porter
pnD);
and
lnstltutlon
tor Womsn and
Chlld floalth, t(arollnska llo3pltal, Karolltuk ln3tltuto, Stockholh,
Sw€don
(Prof
J Winberg MD)
Corospondonco to: Dr Heili Varendi, Tanu University Children's
Hospital, 6 Lunini
Str,
EE 2400 Tartu.
Estonia
990 Vol 344
. Octobe! 8, 1994
