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Skin‐to‐skin contact the first hour after birth and underlying implications and Clinical practice

  • Healthy Children Project, Inc

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Aim This paper integrates clinical expertise to earlier research about the behaviors of the healthy, alert, full‐term infant placed skin‐to‐skin with the mother during the first hour after birth following a non‐instrumental vaginal birth. Method This state‐of‐the‐art article forms a link within the knowledge‐to‐action cycle, integrating clinical observations and practice with evidence‐based findings to guide clinicians in their work to implement safe uninterrupted skin‐to‐skin contact the first hours after birth. Results Strong scientific research exists about the importance of skin‐to‐skin in the first hour after birth. This unique time for both mother and infant, individually and in relation to each other, provides vital advantages to short‐ and long‐term health, regulation and bonding. However, worldwide, clinical practice lags. A deeper understanding of the implications for clinical practice, through review of the scientific research, has been integrated with enhanced understanding of the infant's instinctive behavior and maternal responses while in skin‐to‐skin contact. Conclusion The first hour after birth is a sensitive period for both the infant and the mother. Through an enhanced understanding of the newborn infant's instinctive behavior, practical, evidence‐informed suggestions strive to overcome barriers and facilitate enablers of knowledge translation. This time must be protected by evidence‐based routines of staff.
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Skin-to-skin contact the first hour after birth, underlying implications and
clinical practice
Ann-Marie Widstr
, Kajsa Brimdyr
, Kristin Svensson
, Karin Cadwell
, Eva Nissen (
1.Karolinska Institutet, Stockholm, Sweden
2.Healthy Children Project Inc., Sandwich, MA, USA
3.Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden
Breastfeeding, Clinical practice, Maternal behaviour,
Newborn infant behaviour, Skin-to-skin contact
Eva Nissen, Karolinska Institutet, Widerstr
Huset, Tomtebodav
agen 18 a, 171 77 Stockholm,
Tel: +46737121553 |
Fax: +46737121553 |
20 April 2018; revised 28 January 2019;
accepted 11 February 2019.
Aim: This paper integrates clinical expertise to earlier research about the behaviours of the
healthy, alert, full-term infant placed skin-to-skin with the mother during the first hour after
birth following a noninstrumental vaginal birth.
Method: This state-of-the-art article forms a link within the knowledge-to-action cycle,
integrating clinical observations and practice with evidence-based findings to guide
clinicians in their work to implement safe uninterrupted skin-to-skin contact the first hours
after birth.
Results: Strong scientific research exists about the importance of skin-to-skin in the first
hour after birth. This unique time for both mother and infant, individually and in relation to
each other, provides vital advantages to short- and long-term health, regulation and
bonding. However, worldwide, clinical practice lags. A deeper understanding of the
implications for clinical practice, through review of the scientific research, has been
integrated with enhanced understanding of the infant’s instinctive behaviour and maternal
responses while in skin-to-skin contact.
Conclusion: The first hour after birth is a sensitive period for both the infant and the
mother. Through an enhanced understanding of the newborn infant’s instinctive behaviour,
practical, evidence-informed suggestions strive to overcome barriers and facilitate enablers
of knowledge translation. This time must be protected by evidence-based routines of staff.
The evidence supporting the practice of skin-to-skin con-
tact after birth is robust, indicating multiple benefits for
both mother and baby. The 2016 Cochrane Review sup-
ports using immediate or early skin-to-skin contact to
promote breastfeeding (1). Advantages for the mother
include earlier expulsion of the placenta (2,3), reduced
bleeding (3), increased breastfeeding self-efficacy (4) and
lowered maternal stress levels (5). It has been suggested that
the rise in the mother’s oxytocin during the first hour after
birth is related to the establishment of motherinfant
bonding (6, 7). Advantages for the baby include a decrease
of the negative consequences of the ‘stress of being born’
(8), more optimal thermoregulation (9), continuing even in
the first days (8) and less crying (10). Skin-to-skin contact
has been shown to increase breastfeeding initiation and
exclusive breastfeeding while reducing formula supplemen-
tation in hospital, leading to an earlier successful first
breastfeed (2,11,12), as well as more optimal suckling
(3,13). The evidence supporting skin-to-skin the first hour is
so compelling that the 2018 revision of the World Health
Organization (WHO)/United Nations International Chil-
dren’s Emergency Fund (UNICEF) Ten Steps to Successful
Breastfeeding that form the basis of the Baby-Friendly
Hospital Initiative. Step 4 states ‘Facilitate immediate and
uninterrupted skin-to-skin contact and support mothers to
initiate breastfeeding as soon as possible after birth’ (14)
with the understanding that the newborn infant will self-
During this first hour after childbirth, both mother and
newborn infant experience a special and unique time, a
sensitive period (15,16), which has been biologically pre-
determined, especially after vaginal birth. This is aided by
Key notes
A lag exists between research knowledge and clinical
practice surrounding skin-to-skin in the first hour after
A mutual early sensitive period includes prepro-
grammed behaviours for bonding and other survival
mechanisms, for example through the eye contact,
suggesting long-term implications.
The framework of the newborn infant’s 9 stages creates
an opportunity to understand the biological and phys-
iological situation for the dyad, and clinical implications
of practice during this sensitive time.
©2019 The Authors. Acta P
diatrica published by John Wiley & Sons Ltd on behalf of Foundation Acta Pædiatrica 1
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the
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Acta Pædiatrica ISSN 0803-5253
the physiological state of each: the mother’s high oxytocin
levels and newborn infant’s extremely high catecholamine
Being in skin-to-skin contact with the mother after birth
elicits the newborn infant’s internal process to go through
what could be called 9 instinctive stages: birth cry, relax-
ation, awakening, activity, rest, crawling, familiarization,
suckling and sleeping (17) (Table 1).
This process is suggested to contribute to an early
coordination of infant’s five senses: sight, hearing, touch,
taste and smell, as well as movement (17,18).
Whereas prolactin is the most important milk-producing
hormone, oxytocin plays a key role in maternal behaviour
and bonding immediately after birth. In animal studies, for
example, if an ewe is separated from her lamb soon after
birth, she will reject the lamb when they later are reunited.
Interestingly, it has been shown that simulating a birth
through the birth channel at reunion of mother and lamb
enhances oxytocin release in the mother ewe, resulting in
her acceptance of her lamb. This illustrates that natural
oxytocin facilitates the bonding between the ewe and the
lamb during the first hour after birth (19).
In the human mother, a surge of oxytocin is released in the
mother’s blood vessels during the first hour after birth to
contract the uterus, facilitate placental discharge and to
decrease blood loss (6). Oxytocin released to the blood
stream in this situation is likely to be paralleled by an intense
firing of parvocellular oxytocin neurons in the brains, as
Theodosis has shown in animal experiments (20), causing an
increased maternal sensitivity for the young. In humans, this
has been illustrated through the mother’s desire to keep her
infant close to her throughout the hospital stay if the newborn
infant suckled or even just touched her nipple during the first
hour while skin-to-skin (21).
The mother is attracted to the infant’s smell, facilitating a
chemical communication between the two (22,23). This
highlights the importance of a new mother’s access to her
newborn infant’s bare head to smell her baby. This is an
example of the early symbiotic biological relationship
between the dyad (24,25).
The newborn infant has high levels of catecholamine
immediately after a normal, vaginal birth (10). These are
highest closest to the time of birth, especially for the first
thirty minutes. Catecholamines strengthen memory and
In newborn infants less than 24 hours old, the odour of
the mother’s colostrum increases the amount of oxy-
genated haemoglobin over the olfactory cortex, as mea-
sured by near-infrared spectroscopy. In addition, the
closer to birth, the more oxygenated haemoglobin was
observed over the olfactory cortex (26). This increased
sensitivity for the odour of breastmilk, especially soon after
the birth, indicates a physiologically based early sensitive
period in the newborn infant. This reaction matches the
mother’s biologically based enhancements of the breast
odour through the increase of the surface of the areola and
Montgomery gland secretions during the corresponding
time (27). Thus, the increased early sensitivity for the
odour of breastmilk, in the presence of high levels of
catecholamine which strengthens this memory, is indica-
tion of a physiologically based early sensitive period in the
newborn infant.
The aim of this paper is to integrate clinical expertise to
earlier research about the behaviours of the healthy, alert,
full-term infant placed skin-to-skin with the mother during
the first hour after birth following a noninstrumental
vaginal birth.
This is a state-of-the-art article integrating clinical observa-
tions and practice with evidence-based findings to guide
clinicians in their work to implement safe uninterrupted
skin-to-skin contact the first hours after birth. This paper,
presented from the nurse clinician perspective, is informed
by the scientific literature around newborn infant behaviour
and mother-to-infant interaction, in order to translate
existing knowledge and facilitate clinician behaviour
change. In this way, it forms a link within the knowledge-
to-action cycle and offers the underlying implications of this
important behaviour change to enhance the translation
between the evidence and implementation through a deeper
understanding of the newborn infant’s instinctive behaviour
while skin-to-skin immediately after birth.
This paper is organised around nine developmental stages
of the newborn infant during skin-to-skin contact in the first
hours after birth (17). It expands the understanding of each of
these through the lens of the authors’ clinical expertise and
research experience from direct observation of newborn
infant behaviour. Expertise comes from experience as well as
analysis of hundreds of hours of videotapes of newborn
infants’ developing feeding behaviour in skin-to-skin contact
Table 1 Shows the nine stages
Stages Behaviours
1. Birth cry Intense cry just after birth, transition to breathing air.
2. Relaxation stage Infant rests. No activity of mouth, head, arms, legs
or body.
3. Awakening stage Infant begins to show signs of activity. Small thrusts
of head: up, down, from side-to-side. Small
movements of limbs and shoulders.
4. Active stage Infant moves limbs and head, more determined
movements. Rooting activity, ‘pushing’ with limbs
without shifting body.
5. Resting stage* Infant rests, with some activity, such as mouth
activity, sucks on hand.
7. Familiarization Infant has reached areola/nipple with mouth
positioned to brush and lick areola/nipple.
8. Suckling stage Infant has taken nipple in mouth and
commences suckling.
9. Sleeping stage Infant closes eyes and falls asleep.
*The Resting Stage could be interspersed with all the stages.
2©2019 The Authors. Acta P
diatrica published by John Wiley & Sons Ltd on behalf of Foundation Acta Pædiatrica
Clinical practice of skin-to-skin Widstr
om et al.
(12,17,18,21,2842). Additionally, the authors had the
opportunity to improve skin-to-skin care after birth, both in
vaginal and caesarean delivery at 10 hospitals in Egypt and
the United States according to a 5-day video-ethnographic
intervention. This methodology has five features: (i) a lecture
educating staff (obstetricians, paediatricians, midwives,
nurses and other staff at the delivery and neonatal wards)
about the theory behind the procedure of skin-to-skin care;
(ii) practical application of the skin-to-skin procedure, with
the American and Swedish team and staff working at the
delivery ward together, to continue the educational process;
(iii) videotaping the evolving process as the hospital staff
work to implement the new procedures; (iv) conducting an
interaction analysis workshop to review videotapes and
discuss barriers and solutions; and (v) administering the
continuing application of the procedure (12,28).
Before labour
Ideally, education related to the placement of the baby skin-
to-skin with the mother should also have occurred as part
of her antenatal care. When the mother and her companion
(s) arrive at the birthing facility, a review of their under-
standing of the newborn infant’s instinctive behaviours and
the process of safe skin-to-skin immediately after birth
should take place (Table 1). It has been our experience that
parents are captivated by the newborn infant’s instinctive
behaviours and respond positively when they learn about
the 9 stages and can identify the newborn infant’s actions
(32). Parents should also have an understanding about the
importance of monitoring the newborn infant’s position,
breathing and safety. Providing the parents with a pamphlet
or tear sheet or having a poster of the 9 instinctive stages
somewhere in the birthing suite has been found to be
helpful for the parents to follow the baby throughout the
stages and recognise their newborn infant’s ability. This also
gives a clear role to the companion and provides both
motivation to remain with the mother and newborn infant,
and an additional opportunity for the baby’s safety. Parents
thereby have this additional knowledge and can prioritise
focus on the newborn infant rather than distractive actions
such as phone calls (43,44), posting on the Internet, talking
to friends or family in the room, which are behaviours that
are best postponed until after this unique time.
Staff have the opportunity to protect this important, small
window of time for the parents to follow their newborn
infant’s behavioural development. This creates a shelter for
the mother and baby’s right to not be separated (45), to stay
skin-to-skin after birth until the newborn infant has suckled
and/or fallen asleep. Interruption of skin-to-skin contact
during the first two hours reduces the infant’s chances of
early breastfeed (13,46).
Staff should also assure practical arrangements have been
made for the experience of skin-to-skin. This includes
ensuring that the mother’s clothing has been arranged so it
will be easy to remove and will allow access to the mother’s
chest immediately after the birth, being aware of any
intravenous lines in relation to the sleeves of the mother’s
gown, etc. Regardless of the birthing position, the mother
needs a comfortable and supportive position during the first
hours while skin-to-skin with the newborn infant. Hospital
protocol should be reviewed to ensure it reflects best
Stage 1 The birth cry
This first stage is characterised by the initial birth cry, when
the lungs expand for the first time as the newborn infant
transitions to breathing, and other survival instincts
(Fig. 1A). These behaviours could include the moro reflex,
grimacing, coughing, lifting the full body from the mother’s
torso, abruptly opening the eyes and tension in the body.
The baby’s motions during the birth cry stage emanates
from the drive to survive. During this extremely alert period,
the newborn infant is able to make defensive movements
with the hands to protect their airway, for example against a
suction catheter or bulb.
The initial birth cry, and the subsequent crying during the
first minutes after the birth, has the effect of expectorating
the airways of the amniotic fluid (47). In addition, extremely
high catecholamine levels at birth help in absorbing liquid
from the airways (48). The American Association of
Pediatrics (49) and Academy of Gynecologists and Obste-
tricians (ACOG) (50) have strong statements about the
ability of healthy full-term babies to clear their own airways
and successfully transition without the need of any form of
suctioning. Research has shown that suctioning may disrupt
the inborn sequential behaviours of the newborn infant
(34). Interruption of the natural newborn behaviours
immediately after birth could affect cell proliferation in
the locus coeruleus in rats (51), with consequences of
impaired locus coeruleus connected autism (52) and to
stress-induced fear-circulatory disorders (53).
While transitioning the baby to the mother’s chest, it is
important to avoid compressing the baby’s thorax, which
could hamper breathing. Clinical practice should include
gentle hands to hold the newborn infant in the drainage
position (tilted with the head lower than the torso and the
head slightly to the side) immediately after the birth,
allowing the fluid to flow freely from the mouth and nose.
The comfortably positioned, semi-reclined mother
receives the baby, to hold prone, skin-to-skin. The
mother’s semi-reclined position is conducive to the baby’s
breathing adaptation, in contrast to a horizontal position
(54). If possible, the baby should be in a lengthwise position
on the mother’s body, with the head on the mother’s chest,
and above her breasts. The lengthwise mid-chest position
also emphasises the importance of the upcoming stages.
Positioning the baby’s mouth close to the mother’s nipple
would put the focus on immediate breastfeeding, which the
newborn infant is not ready to do now.
Standard practice includes drying the baby’s head and
body with a clean, dry cloth to help maintain body
©2019 The Authors. Acta P
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om et al. Clinical practice of skin-to-skin
temperature. The baby’s face should initially be turned to
the side, which facilitates free airways and monitoring of the
baby’s breathing. After settling in the skin-to-skin position
with the mother, the baby’s body should be covered with a
dry cloth, leaving the face uncovered.
During a caesarean surgery, the newborn infant might be
positioned horizontally above the drape instead of verti-
cally. In this case, the newborn infant is placed across the
mother’s breasts. This position requires additional attention
from the staff to watch the baby’s breathing and to ensure
that the newborn infant does not push or jump-off of the
Placement of the newborn infant skin-to-skin increases
uterine contraction immediately after birth, increases the
completeness of the delivered placenta and decreases
uterine atony and excessive blood loss (3). Skin-to-skin
also significantly decreases the duration of the third stage of
labour (3).
Delayed cord clamping (>180 seconds after delivery) is
recommended when compared to early cord clamping
(>10 seconds after delivery). Delayed cord clamping
reduced the risk of anaemia at 8 and 12 months in a group
of high-risk children. In addition, there was a possible
positive effect in infant’s health and development (55,56).
‘From a physiological point of view the appropriate time for
umbilical cord clamping in healthy full-term infants is after
the infant has aerated its lungs, commenced breathing and
the pulmonary blood flow has increased to sustain ventric-
ular preload and cardiac output’ (57). Deferred cord
clamping is in line with recommendations from the World
Health Organization (58).
Clinical practice shows that the umbilical cord should be
left long, not clamped close to the newborn infant’s belly, so
that the newborn infant is not disturbed by the clamp, since
clamps, and hard clamps especially, can be uncomfortable
in a prone position. This can result in the babies lifting their
body from the mother’s chest, which reduces skin-to-skin
contact and thus compromises the newborn infant’s
temperature. It can also cause a cry of discomfort.
Staff should create a teaching situation at their routine
frequent observations of the baby during skin-to-skin
contact, involving the parents in unobtrusive, gentle, close
observation, ‘helping them understand and avoid poten-
tially hazardous positions’ (59) during the first few hours
after the birth. In addition, the nine stages offer an
opportunity for staff to discuss the progress of the newborn
infant and to ensure continued observation by the parents
or attendants. The focus on following the newborn infant’s
progress through the nine instinctive stages results in a close
examination of the baby by the mother’s companion(s) and
staff throughout the vulnerable first two hours. This may
help to illuminate the capabilities and limitations of a
AStage 1: Birth cry BStage 2: Relaxaon CStage 3: Awakening
DStage 4: Acvity EStage 5: Rest FStage 6: Crawling
GStage 7: Familiarizaon HStage 8: Suckling IStage 9: Sleeping
Figure 1 (AI): Pictures of the 9 stages ©Healthy Children Project, Inc. Used with permission.
4©2019 The Authors. Acta P
diatrica published by John Wiley & Sons Ltd on behalf of Foundation Acta Pædiatrica
Clinical practice of skin-to-skin Widstr
om et al.
specific baby, and thereby increase the safety during this
important time. The safety of the newborn infant and
mother is always the highest priority (Table 2).
We have seen that when an unmedicated mother receives
her newborn infant into her arms immediately after birth,
she grasps the baby with confidence. She will often hold the
baby gently around the torso, look at the baby and then
bring the baby to her heart, allowing the newborn infant to
lie quietly skin-to-skin with her, as both relax. When the
mother has the newborn infant immediately after birth on
her naked chest, it has a profound impact on her. A
systematic review of mother’s experiences of skin-to-skin
contact includes overwhelming feelings of love, a natural
experience that taught them how to be a mother, improved
self-esteem, and a way of knowing and understanding the
infant (60). We have noticed that this simple act of the staff
handing over the newborn infant to the mother supports
early parental confidence.
If the mother has received analgesics during labour,
special care must be taken to watch for free airways. For
example, pethidine can cross the placenta and affect the
newborn infant’s breastfeeding behaviour negatively (33)
and may specifically hamper the newborn infant’s ability to
lift the head (38) as well as infant’s temperature and crying
(39). Fentanyl given in the epidural space passes rapidly
into maternal blood. A placental transfer of 90% has been
measured by Moises (61). Fentanyl has been measured in
the newborn infant’s urine for at least 24 hours postpartum
(62). Fentanyl exposure can depress the newborn infant’s
behaviour during the first hours after birth, especially the
suckling behaviour in a dose-dependent manner (29).
Stage 2 Relaxation
During the relaxation stage (Fig. 1B), the newborn infant is
still and quiet, making no movements (Fig. 1B). Clinical
experience shows it is not possible to elicit a rooting reflex
during the relaxation stage. The baby’s sensory system
seems to be depressed. From an evolutionary perspective,
this silent and motionless period may be a way to hide from
predators during a vulnerable time (17). When lying quietly
on the mother’s chest, the baby can hear the mother’s
heartbeat. This familiar sound from in utero seems to
comfort the newborn infant after the rapid transition to
extra-uterine life.
It is suggested that the pressure on the head through the
birth canal is the cause of extremely high catecholamine
level after birth, a level 20 times higher than that of a resting
adult (63). This high catecholamine concentration might
partly be the cause of the higher pain threshold in the baby
close to birth (64) and be a mirror of nature’s way to relieve
pain in the baby when passing through the birth canal.
Consequently, the baby’s temporarily impaired sensation at
birth causes the relaxation stage the baby has decreased
sensitivity to the surroundings.
We have noticed that staff members exhibit concerns
about the newborn infant’s silent and relaxed state during
this time. This stems from a lack of understanding of the
baby’s stage, often resulting in rubbing or massaging the
newborn infant in a disruptive and vigorous manner,
repositioning or lifting the baby from the mother. If, during
the relaxation stage, the newborn infant is disturbed by the
actions of the staff, the baby will react with crying,
grimacing and protective reflexes.
If separated from their mother, babies exhibit a distinct
separation distress call. This separation distress vocalisation
in mammalian species that stops at reunion may be nature’s
way of keeping newborn infants warm with maternal body
temperature. The baby’s call at separation is thus a survival
mechanism (65,66).
Mammalian species, including human mothers, react to
these separation distress calls and intuitively attempt to
retrieve the newborn infant. In hospital settings, where the
mother has limited control over her environment, we have
noticed her straining to look at the infant who has been
taken away and asking others about the state of the infant.
(Fig. 2)
Table 2 Safe skin-to-skin care
Safe Interactive Skin-to-Skin Contact in the First Hour After Birth
1. Make sure that the mother is in a comfortable semi-reclined
position with support under her arms.
2. After drying the newborn infant, lift the newborn infant gently
to avoid compression of the thorax when placing the baby skin-to-skin.
Put the baby prone, in a lengthwise position with the head on
the mother’s chest above the breast.
3. Cover the baby with a dry blanket/towel. Leave the face visible.
4. Make sure that the nose and mouth are not enveloped by
the mother’s breast or body or obscured by the blanket. Initially,
the baby’s head should be turned to the side.
5. The newborn infant must have the opportunity to use its reflexes
to lift the head so the nose and mouth can be free. This is of special
concern if the mother has large and/or very soft breasts.
6. The nipple must be accessible to the newborn infant. For some
mothers, this may require positioning a towel or pillow under or on
the side of the mother’s breast.
7. Show the parents how to support the breast to secure free airways
especially during the time the baby starts searching for the breast.
Verify understanding.
8. Remind the parents to focus on the newborn infant and follow the
newborn infant’s early behavior, making sure that the parents follow the
9 stages. The other parent should be observant, not distracted by
mobile phones, etc., during skin-to-skin.
9. Extra attention may be required if the mother is affected by sedation
after childbirth as well as during possibly postpartum suturing.
The other parent should be aware of the situation and watch for
the safety of the infant.
10. Labor medications can affect the newborn infant, and hamper
reflexes. The medications may impair the newborn infant’s reflexes
enough to prevent the ability to lift the head to protect itself from
suffocation. Babies affected by labor medications must be
constantly monitored.
Adapted from The Swedish-American Team for Baby Adapted Care of Health
Infants in the First Hours after Birth, Widstr
om, Svensson and Brimdyr, for
Kom Ombo Hospital, Egypt, 2007 and from
©2019 The Authors. Acta P
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om et al. Clinical practice of skin-to-skin
It is possible to conduct the assessment of the APGAR
score, as well as any other necessary assessments, on a
healthy full-term newborn infant without disturbing the
infant, allowing skin-to-skin to continue uninterrupted. It is
more effective and advantageous to assess the newborn
infant when skin-to-skin with mother since babies are less
likely to cry; they are more likely to remain warm and not
waste energy.
If administration of vitamin K shot is a routine, this
should occur soon after birth while the catecholamine
levels are highest (10), preferably with the newborn infant
skin-to-skin with the mother, as skin-to-skin contact has
been shown to lower the baby’s reaction to pain in the
postpartum (67).
Stage 3 Awakening
The awakening stage (Fig. 1C) is a transition from the
relaxation stage to the activity stage. The baby makes small
motions. Small movements of the head, face and shoulders
gently ripple down through the arms to the fingers. The
baby makes small mouth movements. They will gradually
open their eyes during this stage, blinking repeatedly until
the eyes are stable and focused (Fig. 1C).
Stage 4 Activity
During the activity stage (Fig. 1D), the baby exhibits a greater
range of motion throughout the head, body, arms and hands.
The limbs move with greater determination; the baby may
root and lift the head from the mother’s chest. The fingers
often begin the stage as fisted but may expand to massage,
transfer tastes with a hand-to-nipple-to-mouth movement,
catch the nipple and explore the mother’s chest (17). Rooting
also becomes more obvious during this stage (34).
The successive protrusion of the tongue continues
throughout this stage. At the beginning of this stage, the
newborn infant may have only moved the tongue within
the mouth. During the activity stage, the baby will bring the
tongue to the edge of the lips, then protrude beyond the lips,
then protrude repeatedly beyond the lips (40). These tongue
exercises, which may pave the way for later tongue
behaviours, specifically suckling, can be affected by medi-
cations, such as pethidine (33).
During pregnancy, the nipple has become more pig-
mented (68) and is easy for the newborn infant to discover
(Fig. 1C). We have observed that soon after birth, the areola
expands and takes a bulb-like shape (Fig. 1G). The Mont-
gomery glands also become more pronounced (Fig. 1G).
The scent of areolar secretions has been linked to
behavioural responses, such as head turning (69) and
directional crawling in newborn infants (70). This release
of the breast odour by the Montgomery glands is known to
help the newborn infant find the nipple (17,27,69). The
newborn infant recognises the scent of the mother’s breast
from the amniotic fluid (71), touches the breast and
transmits the taste of the breast to the mouth (hand-to-
breast-mouth movements) (17). This stimulates rooting and
crawling movements in the newborn infant to reach the
nipple. The connection between the taste of amniotic fluid
and the scent of the breast from the Montgomery glands
highlights a biological survival mechanism a pathway of
flavour with lifelong consequences. (Fig. 3) ([17,7180])
When knowing of this sensitive odour-dependent mecha-
nism, it might be wise not to interfere with unfamiliar
The infant has learned to recognise the mother’s voice
during intrauterine life (81).The infant’s learning and
memory skills are quite sophisticated; the foetus can learn
to recognise a vowel from the surrounding language and is
some days after birth able to discriminate this vowel from a
vowel from a foreign language (82).
After the newborn infant has located the nipple by sight,
the mother’s voice will attract the baby’s attention to her
face. Arousal transfer between mother and 4- to 6-month-
old babies is likely to happen through pupillary contagion
(respond to pupil size with changes in one’s own) is
fundamental for social and emotional development (83).
Interestingly, it is described in a paediatric essay that
‘immediately after birth the newborn’s eyes become wide
open, usually with large pupils’ (63). When skin-to-skin
with the mother after birth and free to safely move, the
newborn infant searches for eye contact with the mother
around half an hour after birth (17) (Fig. 1E). We suggest
that infantmaternal bonding through pupillary contagion
may start early after birth as our clinical experience is that
mothers often recall the first moment of eye-to-eye contact
as unforgettable. The complex experiences of the newborn
infant during the first hour encompass more than simply a
journey to the breast; the opportunity for eye contact
emphasises the importance of parents and staff valuing
instinctive behaviour during this time, and the avoidance of
Stage 5 Resting
The resting stage (Fig. 1E) is intertwined with all of the
other stages. A baby may stop or start during any of the
stages to rest, and then continue with that same stage, or
move on to the next (12,84). The baby could be lying still
sucking on fingers or just gazing at the nipple. The eyes may
be open or closed.
It is important to value the resting stage and not worry
that the baby is done and has not been successful with the
process of the first hour. We have seen this stage being
misinterpreted by parents or staff, resulting in the newborn
infant being removed from skin-to-skin with the mother in
favour of other routine care. It is vital to allow the newborn
infant to take these pauses throughout the first hour or so
without being interrupted or separated, remembering that
this stage is naturally interspersed throughout other stages.
Research about adult ‘awake rest’ points to the importance
of this time to the consolidation of memories, and it’s
contribution to learning (85). This could be applicable to
the newborn infant’s rest during the first hour as well (41).
Separation causes a critical break of the stages (31). If the
newborn infant is separated from the mother, even if the
infant is returned, the newborn infant might need to begin
again at the first stage crying and relaxing before
6©2019 The Authors. Acta P
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Clinical practice of skin-to-skin Widstr
om et al.
beginning to progress through the stages again, which might
take some time. The likelihood increases that the newborn
infant may not be able to go through all the stages before
needing to sleep, compromising the possibility to suckle,
Stage 8.
Stage 6 Crawling
The crawling stage (Fig. 1F) could include crawling, leap-
ing, sliding, bulldozing or many other interesting names of
ways to move from the position between the breasts to a
position very close to the nipple. Sometimes this process is
so subtle that parents and staff are surprised to notice that
the baby has made its way over to the breast. Other times,
the baby may make strong and overt motions, collecting the
attention of everyone in the room. The evolutionary
purpose behind the newborn infant’s innate so-called
stepping reflex becomes clear as the newborn infant crawls
to the mother’s breast. The movements of these steps of the
feet over the mother’s uterus may contribute to the
contractions of the uterus, and the decreased time to expel
the placenta (2,3) and decreased blood loss (3) during skin-
During this process, it is important to protect the
newborn infant’s effort to reach the breast, with the
intention not to lift or turn the baby’s body. Placing a towel
or pillow under the mother’s arms is important during this
stage, since the newborn infant will be travelling over to one
side of the chest and therefore (in many settings) close to
the edge of the bed (18). This support can help the newborn
infant to reach the nipple without becoming exhausted by
unnecessary sliding in the wrong direction. It is also
important for parents to be aware of the travelling process,
since they may try to reorient the baby back to the middle of
the chest, to keep the newborn infant from the edges of the
bed. Support under the mother’s arms may also allow the
nipple to remain in an area easy for the baby to find and
grasp. A mother might use her own palm to arrange the
breast as well. A baby needs to use the feet to achieve
crawling, and sometimes the feet are in a less than ideal
position. They may be off the side of the mother’s body or
pushing in the air. In those cases, it may be helpful if the
mother puts her hand under the newborn infant’s foot to
give the baby something to push against in order to move
towards the breast.
Stage 7 Familiarization
Since the baby is prone on a semi-reclined mother, the alert
newborn infant has the control over their experience, rather
than being placed in a dependent position by the mother
Fig. 1G). To reach the breast, it must be possible for the
baby to manoeuvre into an appropriate position. When
approaching the breast the newborn infant performs speci-
fic soliciting calls to mother a short clinging call that
usually results in a gentle response from the mother. The
frequency of these sounds increases as the newborn infant
gets closer to the mother’s nipple (17). The odours from the
mother’s breast are likely to be inducing this response.
Parents respond to the newborn infant’s soliciting (42).
During the familiarization stage (Fig. 1G), the baby
becomes familiar with the breast by licking the nipple and
areola. This period could last 20 minutes or more. The
newborn infant massages the breast, which increases the
mother’s oxytocin levels (35) and shapes the nipple by
licking. During this stage, it is evident that the baby is
smelling and tasting, and previous actions become more
vigorous and more coordinated. Therefore, it is important
not to interfere or introduce odours from unfamiliar hands.
The baby continues with tongue activity during this stage,
now more overtly related to eventual breastfeeding, by
licking above and below the nipple. The baby may make
noises with the mouth and lips, like smacking sounds,
during this stage. The breast and nipple are shaped by the
massaging and licking actions of the newborn infant. The
newborn infant is preparing the tongue, breast and nipple
for the moment of attachment and suckling.
The actions of the tongue inform the staff of the newborn
infant’s coordination of the tongue with the rooting reflex,
and the ability to move the tongue to the bottom of the
mouth, curved and thin. The newborn infant needs to
practice this coordination of the rooting-tongue reflex (36).
Figure 2 Caesarean mother looking towards her baby ©Healthy Children Project, Inc. Used with permission.
©2019 The Authors. Acta P
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om et al. Clinical practice of skin-to-skin
Staff and parents should allow the baby the time needed to
practice this coordination during this stage; the newborn
infant is perfecting many important oral-motor functions.
This learning is vital as the newborn infant initiates the
suckling process.
There is often a resting stage between the familiarization
stage and the suckling stage, which unfortunately can make
parents and staff prone to (so-called) help the newborn
infant to the breast.
It is also common for the baby to attach, suck once or
twice, and then disengage. The newborn infant will be
conducting a normal step of the familiarization Stage, but it
may look to staff like the newborn infant is unable to attach.
The baby must thus be allowed to do these moves to adjust
into an instinctive position. This is conducive to the
newborn infant’s chin making an initial contact with the
mother’s breast as the baby endeavours to catch the nipple.
‘Chin-first contact’ is associated with sustained deep,
rhythmical suckling (86).
In a study of babies who had later been diagnosed with
significant latch problems, the majority of mothers reported
that the newborn infant had been forced to latch to his
mother’s breast. According to the mothers, the babies
screamed, acted in a panicky way, exhibited avoidance
behaviours and had other strong reactions against the
forceful treatment (87). It has also been shown that mothers
who had this type of so-called help have a more negative
experience of the first breastfeeding (88) and breastfeed for
a shorter time (88,89).
If infants with an aversive behaviour are allowed to
peacefully go through the stages in skin-to-skin contact at a
later time, they may successfully reach the nipple, attach to
the nipple by themselves and start suckling. This could
happen even weeks after birth if not possible earlier (87).
This is a promising way to calmly solve breastfeeding
problems, especially since a new study shows that breast-
feeding is associated with decreased childhood maltreat-
ment (90).
Stage 8 Suckling
The newborn infant attaches to the nipple during this stage
and successfully breastfeeds (Fig. 1H). When babies self-
attach, they are positioning the wide-open mouth appro-
priately on the areola and nipple, protecting against sore
nipples. It is interesting to note that the hands, which have
been so busy, often stop moving once suckling begins (35);
the eyes, which have been looking at the breast, the mother
and the room, often become focused after attaching.
During this first hour, when the unmedicated baby self-
attaches, it is a perfect first breastfeeding, although the
infant will continue to readjust until satisfied with the latch.
The newborn infant does not need help to adjust the latch.
Babies who self-attach during the first hour after birth have
few problems with breastfeeding, latch and milk transfer
(13). Skin-to-skin in the first hour strengthens the mother’s
self-confidence, including decreasing the concerns about
having enough milk (4). When babies are placed skin-to-
skin with the mother, they have more optimal blood glucose
levels. Both skin-to-skin and the suckling contribute to this
effect (91). Thus, this reduces the risk of supplementation.
Medicated babies can successfully go through the nine
stages and self-attach. However, there is increasing evi-
dence concerning the negative consequences of certain
medications such as fentanyl and oxytocin, on success with
the food the
mother eats
flavours the
amniotic fluid
(72,73, 74, 75)
the foetus drinks
the amniotic
fluid (77, 78, 79)
the foetus
preferences for
the taste of the
amnitoic fluid
During prenatal development:
During skin-to-skin
contact the baby:
is stimulated by
maternal breast odour
(71, 78)
transmits taste by
movements (17)
licks the areola, starts
suckling and recognises
the taste in the
breastmilk and is
rewarded by the
‘family taste‘ (17)
amniotic fluid
development of
the olfactory
bulb (76)
During the lifespan:
Elderly are attracted
to flavours of their
childhood (80)
will be facilitated by the
experience of maternal
and family flavours (76)
Figure 3 Pathway of flavours.
8©2019 The Authors. Acta P
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Clinical practice of skin-to-skin Widstr
om et al.
breastfeeding (29). Parents and staff must take into account
the consequences when considering amount, timing and
choice of specific labour medications.
Stage 9 Sleeping
Towards the end of suckling, about an hour and a half after
birth, the newborn infant becomes drowsy and falls asleep
(Fig. 1I). The oxytocin, released in both mother and infant
by suckling, triggers the release of gastrointestinal (GI)
hormones, including cholecystokinin (CCK) and gastrin.
The high level of CCK in both mother and newborn infant
will cause a relaxing and satisfying postprandial sleep (37).
The GI activity will also improve maternal and infant
nutritional absorption. The advantages, and the feel-good
effect, will continue at each breastfeeding session.
If the mother and newborn infant were unable to
experience these first hours together, or if the newborn
infant did not self-attach before falling asleep, the dyad
should have the opportunity to stay skin-to-skin as much as
possible. If separation occurs, hand expression of milk
within the first hour after birth enhances milk production
(92). The partner can also spend time skin-to-skin with a
new baby if separation from the mother is necessary (42).
When the baby is alert and shows signs of readiness to
feed, the processes of finding the mother’s breast when skin-
to-skin usually happen more quickly in the postpartum
period than soon after birth. One reason for this is that the
initial stages of a birth cry, relaxation and awakening are
associated with the situation and hormonal status unique to
the time immediately after birth. Later after birth, the baby
has more control over his body and movements.
Understanding the stages, and the breastfeeding beha-
viours of the newborn infant, is indeed, reassuring to the
parents, even in the postpartum ward.
There have been discussions about a possible relationship
between skin-to-skin contact and Sudden Unexpected
Postnatal Collapse (SUPC) (43). The background to SUPC
is multifactorial. However, one of the common causes of the
collapse seems to be respiratory distress (44,9395). The
possibility of labour medications affecting the newborn
infant adversely is not highlighted in the Sudden Unex-
pected Postnatal Collapse (SUPC) literature. (43,96,97).
The majority of the cases occur in early skin-to-skin care,
without observance of the child, or when sleeping with
accidentally covered respiratory tract (98,99). A review of
Sudden Unexpected Early Neonatal Deaths (SUENDs) in
Sweden shows that a higher incidence of SUENDs was
reported before the practice of early skin-to-skin contact
was introduced (100,101). Staff need to be aware of the
importance of safe skin-to-skin, including the close obser-
vation of the newborn infant’s airways (Table 2).
Possible long-term benefits of skin-to-skin contact
Immediate skin-to-skin contact provides the initial coloni-
sation of the baby’s microbiome outside of the mother, a
swarming of the mother’s skin bacteria. The microbial
colonisation of the infant begins before birth and continues
through the birth canal. This is one of the reasons the
newborn infant should not be washed during this time.
Colonisation after caesarean surgery does not match vagi-
nal colonisation (102); skin-to-skin may be of extra impor-
tance in these cases. As the hour progresses, the first tastes
of colostrum will provide vital sustenance to the infant’s
developing gut microbiota, which has been implicated in
the expression of genes (103). Evolving research on epige-
netics and the microbiome highlights the importance of the
optimal microbiome (104), enhanced by breastfeeding,
which has been implicated in long-term health, including
decreased obesity and metabolic diseases (103).
In a longitudinal study, it was found that the mother’s
breast temperature increases when mother and newborn
infant are in skin-to-skin contact, resulting in an increase of
newborn infant’s foot temperature (8). The warmer foot
temperature is an indication of the decrease of the negative
effect of the ‘stress of being born’ that is associated with
skin-to-skin. Those mothers who hold their babies skin-to-
skin after birth were rated as ‘less rough’ when latching and
stimulating their babies during breastfeeding at day 4
postpartum (105). Skin-to-skin was also linked to improved
mother/infant mutuality one year later. Skin-to-skin after
birth also positively influenced the infant’s self-regulation at
one year (106). Self-regulation is a part of the concept of
Interestingly, Moffitt et al. showed that if a child has good
self-control at the age of 4, this has consequences into
adulthood, in terms of increased education and income and
decreased drug addiction and criminal behaviours as
measured at 30 years of age, compared to those with low
self-control at four years of age, among a cohort of 1,000
children (107). Thus, skin-to-skin contact after birth may
contribute to positive long-term consequences.
From the beginning, biological processes during the first
hour after birth ensure survival of the mother and infant. This
sensitive period has an emotional consequence on the
mother’s understanding of the newborn infant, enhancing
bonding. Humans are resilient, and there are opportunities to
bond and breastfeed even when the experience immediately
after the birth is less than optimal. For example, even days and
months after the birth, the infant will exhibit these same
instinctive breastfeeding behaviours, with the potential to
overcome early breastfeeding problems. But this sensitive
period immediately after birthmust be recognised and valued,
both by parents and staff, to provide the opportunity for this
unique experience. It is vital not to interrupt these natural
behaviours, as they form nature’s basis for attachment, and
support the mother’s confidence in her infant’s inborn
capability. This may have significant consequences for the
parent’s understanding of the baby throughout childhood,
protecting the child from parental roughness and laying a
foundation for the child’s self-regulation and self-control.
A sensitive period of the newborn infant coincides with
mother’s sensitive period during the first hour after birth.
This is a unique situation for both, individually and in
©2019 The Authors. Acta P
diatrica published by John Wiley & Sons Ltd on behalf of Foundation Acta Pædiatrica 9
om et al. Clinical practice of skin-to-skin
relation to each other, and must be protected by evidence-
based routines of hospital staff. Clinical expertise, together
with systematic evidence, combines to enhance the under-
standing of the best practice of skin-to-skin care in the first
hours after birth. Hospital guidelines must support and
enhance this important time.
The study did not receive any specific funding.
The authors have no conflicts of interest to declare.
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... Favorece la conducta prealimentaria67 . m. Estimula los sentidos del recién nacido 150 . n. Disminuye el riesgo de depresión postparto. ...
... f. Menor llanto 148 . g. Facilita el apego, vital para el desarrollo social y emocional que influyen en el desarrollo cognitivo 149,150 . h. ...
... Favorece la conducta prealimentaria 67 . m. Estimula los sentidos del recién nacido 150 . n. Disminuye el riesgo de depresión postparto. ...
The current book is an update revision and adaptation of the New BFHI 2018 for the Hospital Materno Infantil, Caja Nacional de Bolivia. More content on baby problems to suck was added. Also we kept the warning signs of pregnancy as well as for the new born.
... When newborns breathe for the first time, various physiological changes commence adapting to the world outside the uterus. 1 The first few minutes after birth are significant in the adaptation processes of mothers and newborns and their relationship with each other. 2 Initiation of mutual gaze, skin-to-skin contact, and breastfeeding in the first minutes after birth is crucial for the cardiopulmonary stabilization of the infant and initiation of mother-infant bonding. 3 Early initiation of the mother-infant relationship facilitates the newborn's adaptation to extrauterine life and accelerates the attachment process. 1 The first 60-90 minutes after birth is suitable for initiating mother-infant interaction. ...
... 3 Early initiation of the mother-infant relationship facilitates the newborn's adaptation to extrauterine life and accelerates the attachment process. 1 The first 60-90 minutes after birth is suitable for initiating mother-infant interaction. 4 However, the increase in births given with cesarean section (CS) negatively affects mother-infant attachment. ...
... The baby also responds to the mother by rooting, latch-on, sucking, swallowing, and eye contact. 1 The first acoustic stimuli for the fetus to be exposed before birth are the mother's voice and the sounds of the mother's heartbeat. 8 In the postpartum period, the mother's voice (MV) is an exclusive line of communication between the mother and the infant, and it is the primary auditory stimulus for newborns. ...
Full-text available
Introduction and aim. The present study aims to determine the effects of mother's voice and white noise on newborns' APGAR scores and attachment processes. Material and methods. The current study was a randomized controlled trial and concluded with 87 newborns and their mothers who had given elective cesarean section (mother voice=29; white noise=28; and control group=30). The mother voice and white noise groups were exposed to recordings, and the broadcast continued for five minutes. The APGAR scores and attachment indicators of newborns (eye contact, rooting, and latch-on) of all groups were examined by the Newborn Attachment Indicators Observation Form. Results. The 1 st and 5 th minute APGAR scores in control group were lower than mother voice (1 st p=0.05; 5 th p=0.001) and white noise (1 st p=0.015; 5 th p=0.002) groups. The rooting ratio was higher in mother voice and white noise than in the control group (p=0.004). The newborns in the control group had lower latching on rates than mother voice and white noise (p=0.002) groups. Both mother voice and white noise positively affected APGAR scores, rooting, and latching. However, only mother voice had a positive effect on all attachment indicators. Conclusion. Mother voice and white noise listened to by the newborns born with a cesarean section right after birth in their early-period care positively affect APGAR scores; furthermore, mother voice positively affects attachment indicators as first successful sucking time and eye-to-eye contact. Aközlü Z, Şahin ÖÖ. The effects of mother's voice and white noise on APGAR scores of newborns and attachment processes-a random-ized controlled trial.
... Current research shows the multiple benefits for both mother and newborn infant [4,6]. The first hour of life is a particular time called the sensitive period; the newborn baby presents high levels of catecholamines that keep the child in an alert state; meanwhile, the mother's hormonal response of oxytocin and prolactin supports bonding [6,7]. ...
... Current research shows the multiple benefits for both mother and newborn infant [4,6]. The first hour of life is a particular time called the sensitive period; the newborn baby presents high levels of catecholamines that keep the child in an alert state; meanwhile, the mother's hormonal response of oxytocin and prolactin supports bonding [6,7]. The practice calms and relaxes both mother and baby, meanwhile regulating the baby's heart rate and breathing, helping them to better adapt to life outside the womb, stimulating digestion and interest in feeding, regulating temperature, enabling the colonization of the baby's skin with the mother's friendly bacteria, thus protecting the baby against infection, and stimulates the release of hormones to support breastfeeding and mothering [7]. ...
... In the neonatal unit [NU] improves oxygen saturation, reduces stress levels, particularly following painful procedures, encourages pre-feeding behavior, assists with growth, may reduce hospital stay; improves milk volume if the mother expresses following a period of SSC, with the expressed milk containing the most up-to-date antibodies [6,7]. ...
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Strong scientific evidence supports the importance of practicing skin-to-skin contact immediately after childbirth. It is considered a unique time that provides vital advantages and short- and long-term health benefits for infants and mothers. Skin-to-skin contact has proved to enhance social and emotional development and attachment. Other benefits of skin-to-skin contact are the high impact on promoting breastfeeding and healthy eating behaviors. It promotes neurophysiological adjustment to postnatal life. Newborn infants who received SSC cry less, and mothers experience fewer maternal depression symptoms. The newborn infants experienced less pain responding to vitamin K intramuscular injections. This practice has a great value, and it is a natural and instinctive behavior; therefore, it is essential to convey understandable information to pregnant women and their families, permitting them to follow health-informed decisions to support SSC as the best start for their babies.
... Different factors influence the initiation of EBF, such as skin-to-skin contact, maternal education level, the type of professional who attends the birth as well as their behavior, whether the woman had access to an epidural, whether the birth was induced, admission of the baby to intensive care, or premature birth [18,[20][21][22][23][24][25][26][27][28]. Knowing the impact of all of these on the initiation and subsequent maintenance of EBF is fundamental to be able to support and implement policies that favor EBF. ...
... Early breastfeeding initiation is associated with EBF after hospital discharge, in line with that identified by other researchers who studied early initiation together with the early establishment of skin-to-skin contact [28,40,41]. Starting EBF during the first postpartum hour, regardless of the type of delivery, has been set as a fundamental practice to promote EBF [42]. ...
... These results are consistent with those obtained by French et al., [25] although more research is needed. Within the cascade of events after analgesia, it may be the professional who attends the birth who should address the situation by anticipating and promoting exclusive breastfeeding together with early skin-to-skin contact between the mother and the newborn within the first hour postpartum in mothers who have an in situ epidural, thereby increasing the chances of success, as recommended by several authors [22,28]. ...
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The benefits of exclusive breastfeeding are well known for both mother and baby. Despite this, rates of exclusive breastfeeding remain low. The present study aimed to determine the factors associated with the maintenance of this type of feeding after being discharged from the hospital after childbirth. A cross-sectional study was carried out with 1200 postpartum women in Spain. Sociodemographic, obstetric, and neonatal data were collected. Odds ratios (OR) and adjusted odds ratios (aOR) with 95% confidence intervals were calculated. Early breastfeeding initiation was identified as a factor that favors breastfeeding after hospital discharge (aOR: 2.47; 95%CI: 1.77, 3.45). Other factors that favor breastfeeding after discharge included the woman feeling very supported by her partner during pregnancy, childbirth, and the puerperium (aOR: 2.54; 95%CI:1.30, 5.00) and having previously breastfed other children (aOR: 1.97; 95%CI: 1.40, 2.76). Among the factors that hindered exclusive breastfeeding after discharge were multiple or twin pregnancies (aOR: 0.31; 95%CI 0.12, 0.83), induction of labor (aOR: 0.73; 95%CI: 0.53, 0.99), admission of the newborn to the neonatal intensive care unit (NICU) (aOR: 0.31; 95%CI 0.19, 0.52), using epidural pain relief during labor (aOR: 0.41; 95%CI: 0.27, 0.64), or a preterm newborn (aOR: 0.38; 95%CI: 0.21, 0.69). For all these reasons, it is essential to promote certain practices such as the early start of breastfeeding or the induced onset of labor, among others, in order to promote the maintenance of exclusive breastfeed-ing beyond hospital discharge after childbirth.
... This difference underlined that the OSM at birth underwent variations in the abundance of phyla. The explanation for this variability could be threefold: (i) the environmental variations to which a child is subjected are multiple compared to the newborn [35,36]; (ii) the diet and hand-to-eye contact of infants is different with respect to the child [37]; (iii) during the first years of life, children are frequently subject to surgery or exposure to antibiotics [38,39]. All these factors taken together can contribute to determining changes in the OSM. ...
Full-text available
The ocular microbiome is of fundamental importance for immune eye homeostasis, and its alteration would lead to an impairment of ocular functionality. Little evidence is reported on the composition of the ocular microbiota of term infants and on the impact of antibiotic prophylaxis. Methods: A total of 20 conjunctival swabs were collected from newborns at birth and after antibiotic treatment. Samples were subjected to 16S rRNA sequencing via system MiSeq Illumina. The data were processed with the MicrobAT software and statistical analysis were performed using two-way ANOVA. Results: Antibiotic prophylaxis with gentamicin altered the composition of the microbiota. In detail, a 1.5- and 2.01-fold reduction was recorded for Cutibacterium acnes (C. acnes) and Massilia timonae (M. timonae), respectively, whereas an increase in Staphylococcus spp. of 6.5 times occurred after antibiotic exposure. Conclusions: Antibiotic prophylaxis altered the ocular microbiota whose understanding could avoid adverse effects on eye health.
... Early skin-to-skin contact (ESSC) in the first hours postpartum provides clear benefits for both the mother and newborn (1)(2)(3)(4) and it is now a generalized practice. An increase in the reporting of sudden unexpected postnatal collapse (SUPC) cases during ESSC has been observed (5)(6)(7)(8). ...
Full-text available
Background: During early skin-to-skin contact (ESSC), alterations in peripheral oxygen saturation (SpO2) and heart rate (HR) have been frequently observed. Objectives: This study aimed to determine the incidence of cardiorespiratory events (CREs) during ESSC in healthy term newborns (HTNs) and estimate the association of maternal and neonatal prognostic factors with the risk of CREs. Methods: A pooled analysis of the cohort from a clinical trial involving healthy mother-child dyads during ESSC was performed. Pulse oximetry was employed to continuously monitor SpO2 and HR within 2 h after birth. The individual and combined prognostic relevance of the demographic and clinical characteristics of dyads for the occurrence of a CRE (SpO2 <91% or HR <111 or >180 bpm) was analyzed through logistic regression models. Results: Of the 254 children assessed, 169 [66.5%; 95% confidence interval (95% CI), 60.5-72.5%] had at least one CRE. The characteristics that increased the risk of CRE were maternal age ≥35 years (odds ratio, 2.21; 95% CI, 1.19-4.09), primiparity (1.96; 1.03-3.72), gestational body mass index (BMI) >25 kg/m2 (1.92; 1.05-3.53), and birth time between 09:00 p.m. and 08:59 a.m. (2.47; 1.02-5.97). Conclusion: CREs were more frequent in HTNs born during nighttime and in HTNs born to first-time mothers, mothers ≥35 years, and mothers with a gestational BMI >25 kg/m2. These predictor variables can be determined during childbirth. Identification of neonates at higher risk of developing CREs would allow for closer surveillance during ESSC.
... Other studies have emphasized the importance of this early contact and have named this time "the sacred hours" or a "sensitive period" (Dahlø et al., 2018;Klaus et al., 1972;Mehler et al., 2011). Lately, Widström et al. (2019) concluded that routines should protect this early contact as much as possible. Contact in this sensitive period has been shown to be especially significant for the attachment process in very preterm births because the mother and the infant are both in an abnormally stressful situation (Mehler et al., 2011). ...
Full-text available
Traditional care immediately after very preterm birth separates the mother and child by the transfer of the infant to the neonatal intensive care unit. A nonseparation approach is currently being considered, allowing early skin-to-skin contact in the delivery room/postoperative care unit. This study aimed to explore mothers’ experiences of early skin-to-skin contact and traditional care. A qualitative study using individual semi-structured interviews with five mothers from each of the two groups was conducted. Content analysis revealed that both groups’ experiences were characterized by (i) mothers’ need to be affirmed of their infants’ vitality, (ii) bonding challenges, and (iii) benefits of skin-to-skin contact. We suggest that early skin-to-skin contact after very preterm births is crucial for the bonding process and mothers’ feelings of safety and well-being. When early skin-to-skin contact is infeasible, our findings reveal the significance of photos, information, and the father’s presence at the time of postpartum separation.
... In our study, the rate of successful lactation was higher in the intervention group than in the control group. A crucial insight is that newborn breastfeeding ability is related to an innate instinct [22]. Although neonates in the control group were also able to breastfeed effectively and successfully after a brief period of skin contact, the present study found that the number of effectively breastfeeding neonates was higher after a prolonged period of 60 min of mother-infant skin contact. ...
Mother and newborn skin-to-skin contact (SSC) after birth has numerous protective effects. Although positive associations between SSC and breastfeeding behavior have been reported, the evidence for such associations between early SSC and breastfeeding success was limited in high-income countries. This quasi-experimental intervention design study aimed to evaluate the impact of different SSC regimens on newborn breastfeeding outcomes in Taiwan. In total, 104 healthy mother-infant dyads (52 in the intervention group and 52 in the control group) with normal vaginal delivery were enrolled from 1 January to 30 July 2019. The intervention group received 60 min of immediate SSC, whereas the control group received routine care (early SSC with 20 min duration). Breastfeeding performance was evaluated by the IBFAT and BSES-Short Form. Generalized estimating equations (GEEs) were used to evaluate the effectiveness of the intervention. In the intervention group, the breastfeeding ability of newborns increased significantly after 5 min of SSC and after SSC. The intervention also improved the total score for breastfeeding self-efficacy (0.18 point; p = 0.003). GEE analysis revealed that the interaction between group and time was significant (0.65 point; p = 0.003). An initial immediate SSC regimen of 60 min can significantly improve neonatal breastfeeding ability and maternal breastfeeding self-efficacy in the short term after birth.
... Furthermore, breastfeeding protects against hypothermia while also assisting in the stabilization of vital signs such as breathing and heart rate through skin-to-skin contact on the mother's bosom. (Widström, A. M., et al., 2019) Breastfeeding a sick infant have as well a positive impact on the mother; it helps to calm her, reduces her stress and depression, and enhances her mood and tolerance to care for her baby through oxytocin and endorphin release . It has also been demonstrated that when a woman is exposed to her infant's infectious microorganism, she develops antibodies that are carried on to the baby through her milk, increasing the protective impact of breastfeeding (Lawrence R. M., 2011). ...
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Preface and Acknowledgements This is the first text book that is prepared as a joint work between four Arab countries including Egypt, Jordan, Lebanon and Syria (in alphabetical order) which seeks to present and integrate relevant information related to the field of infant and young child feeding. It is prepared for individuals who wish to specialize in the field of lactation management for promoting, supporting and protecting breastfeeding and continued support of infant feeding in the first five years of life. It is intended for use by countries in different regions of the world with a focus of developing countries and countries where breastfeeding is mandatory for saving lives and achieving the Sustainable Development Goals. This book was prepared in three phases, the first phase was done between the main authors, in the second phase a team from Egypt and a team from Lebanon reviewed and edited the chapters, in the third phase the book was again reviewed and finalized by the main authors. It is divided into 22 chapters that cover the academic, clinical, nutritional and critical management procedures necessary for nutritionists, physicians, health providers to support mothers at different levels of care and in different chronological periods of child development from conception to five years of age and is centered around the needs of both the mother, the baby and the family and community at large for promoting, supporting and protecting breastfeeding. It is tailored to the needs of specialists globally, but especially for those from the developing countries. This book would not have been made possible without the bulk of authentic and growing literature updates and research work, from all over the world, that was accessed online. We are sincerely grateful to the Nutrition Unit in the Eastern Mediterranean Region (EMRO) for its support in the editing and finalization RI�the book to reach its current state. We sincerely appreciate the team in Lebanon led by Dr. Maha Hoteit and included: Lactation Specialist Rim El Hajj Sleiman; Ms. Carla Ibrahim, Holy Spirit University of Kaslik (USEK); Ms. Hala Mohsen, Lebanese University, and Ms. Nour Yazbeck, Lebanese University, who dedicated much time and effort in this work. We are also grateful to the team who assisted Dr. Azza Abul-Fadl from Egypt who included Professor Salah Ali Ismail Ali, Sohag University; Dr. Ahmed Alsaed Younes, Head of EPA and ESBMF; the team from Benha Univeristy including Professor AlRawhaa Abuamer and Dr. Ranya Abdelatty from Benha Faculty of Medicine, and the team from Alexandria University; Professor Nadia Farghaly, Faculty of Medicine, Dr. Ahlam Mahmoud and Dr. Eman Kaluibi, Faculty of Nursing and the team from MCFC including Dr. Shorouk Haithamy and Dr. Samaah Zohair and Organizational psychologist Ms. Iman Sarhan from Newcastle University. This has been an intense and invigorating experience especially with the feedback received from Syria by Dr. Mahmoud Bozo who participated in the activity despite the difficult circumstances in Syria. We are grateful to Dr. Moataz Saleh, Nutrition Specialist and Dr. Naglaa Arafa, Nutrition officer from UNICEF, Cairo office for their technical support. Indeed this work would not have been made possible without the coordinating efforts of Dr Ms. Nashwa Nasr from WHO-EMRO. We received support from the administrators, designers and information technologists and many other experts who supported this work and to whom we are also very grateful. Last but not least we owe this work to the spiritual support of mothers struggling to breastfeed their babies who have inspired us throughout this work and we hope our efforts will reach out to them and to all those who are encouraging, guiding and supporting them in their exceptionally unique motherhood experience. We commend and applaud the many scientists, research workers and authors of books in this field and are grateful to those who delivered libraries to our homes by the internet. We sincerely hope that this material as a publication or an e-book will be a match of their work and meet the needs of a large spectrum of readers, learners and scientists who wish to expand their knowledge in this field. We look forward to expanding this work and making it available in different languages and welcome those who can assist us to accomplish this
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Background: Although the benefits of immediate, continuous, uninterrupted skin-to-skin contact (SSC) and early breastfeeding have been widely researched and confirmed, the challenge remains to improve the consistency of this practice. Fewer than half of newborns worldwide are breastfed in the first hour. Design: Cross-sectional descriptive study utilizing iterative review and analysis of video ethnography as well as data extracted from patient records. Sample and setting: Eighty-four medically uncomplicated mothers and full-term newborns were observed during the first hour after birth at a Baby-Friendly designated hospital in the United States. Findings: Process mapping using an algorithm which included Robson criteria indicated that although included mothers were expected to give birth vaginally and had no medical concerns that would preclude eligibility for SSC in the first hour after birth, 31 of 84 newborns (37%) did not receive immediate SSC after vaginal birth as planned and only 23 (27.4%) self-attached and suckled. Conclusion: Process mapping of optimal skin-to-skin practice in the first hour after birth using the algorithm, HCP-S2S-IA, produced an accurate and useful measurement, illuminating how work is conducted and providing patterns for analysis and opportunities for improvement with targeted interventions.
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The importance of breastfeeding as a public health priority has increased as new research reinforces the health benefits to both mother and nursling, even continuing years after weaning. However, many women do not nurse as long as they intend. Birth practices such as labor medications and the routine separation of mother and baby are two of the several intrapartum influences on breastfeeding outcomes. This paper seeks to elucidate the physiologic mechanisms affecting breastfeeding outcomes of the commonly administered intrapartum drug, synthetic oxytocin. A modified ascending, link tracing methodology was used to identify studies about breastfeeding and human lactation which describe possible physiologic pathways related to the intrapartum use of synthetic oxytocin on breastfeeding outcomes. A cascade model was constructed with the findings of three physiologic pathways: dysregulation of the maternal OT system, crossing of the fetal blood brain barrier, and uterine hyper stimulation. Downstream negative effects related to breastfeeding include decreased maternal endogenous oxytocin, increased risk of negative neonatal outcomes, decreased neonatal rest during the first hour with the potential of decreasing the consolidation of memory, decreased neonatal pre-feeding cues, decreased neonatal reflexes associated with breastfeeding, maternal depression, somatic symptoms and anxiety disorders. No positive relationships between the administration of synthetic oxytocin and breastfeeding were found. Practices that could diminish the nearly ubiquitous practice of inducing and accelerating labor with the use synthetic oxytocin should be considered when evaluating interventions that affect breastfeeding outcomes.
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Evidence supporting the practice of skin-to-skin contact and breastfeeding soon after birth points to physiologic, social, and psychological benefits for both mother and baby. The 2009 revision of Step 4 of the WHO/UNICEF “Ten Steps to Successful Breastfeeding” elaborated on the practice of skin-to-skin contact between the mother and her newly born baby indicating that the practice should be “immediate” and “without separation” unless documented medically justifiable reasons for delayed contact or interruption exist. While in immediate, continuous, uninterrupted skin-to-skin contact with mother in the first hour after birth, babies progress through 9 instinctive, complex, distinct, and observable stages including self-attachment and suckling. However, the most recent Cochrane review of early skin-to-skin contact cites inconsistencies in the practice; the authors found “inadequate evidence with respect to details … such as timing of initiation and dose.” This paper introduces a novel algorithm to analyse the practice of skin to skin in the first hour using two data sets and suggests opportunities for practice improvement. The algorithm considers the mother's Robson criteria, skin-to-skin experience, and Widström's 9 Stages. Using data from vaginal births in Japan and caesarean births in Australia, the algorithm utilizes data in a new way to highlight challenges to best practice. The use of a tool to analyse the implementation of skin-to-skin care in the first hour after birth illuminates the successes, barriers, and opportunities for improvement to achieving the standard of care for babies. Future application should involve more diverse facilities and Robson's classifications.
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Being sensitive and responsive to others’ internal states is critical for social life. One reliable cue to what others might be feeling is pupil dilation because it is linked to increases in arousal. When adults view an individual with dilated pupils, their pupils dilate in response, suggesting not only sensitivity to pupil size, but a corresponding response as well. However, little is known about the origins or mechanism underlying this phenomenon of pupillary contagion. Here we show that 4- to 6-month-old infants show pupillary contagion when viewing photographs of eyes with varying pupil sizes: their pupils dilate in response to others’ large, but not small or medium pupils. The results suggest that pupillary contagion is driven by a transfer of arousal and that it is present very early in life in human infants, supporting the view that it could be an adaptation fundamental for social and emotional development.
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Epigenetic modifications are among the most important mechanisms by which environmental factors can influence early cellular differentiation and create new phenotypic traits during pregnancy and within the neonatal period without altering the deoxyribonucleic acid sequence. A number of antenatal and postnatal factors, such as maternal and neonatal nutrition, pollutant exposure, and the composition of microbiota, contribute to the establishment of epigenetic changes that can not only modulate the individual adaptation to the environment but also have an influence on lifelong health and disease by modifying inflammatory molecular pathways and the immune response. Postnatal intestinal colonization, in turn determined by maternal flora, mode of delivery, early skin-to-skin contact and neonatal diet, leads to specific epigenetic signatures that can affect the barrier properties of gut mucosa and their protective role against later insults, thus potentially predisposing to the development of late-onset inflammatory diseases. The aim of this review is to outline the epigenetic mechanisms of programming and development acting within early-life stages and to examine in detail the role of maternal and neonatal nutrition, microbiota composition, and other environmental factors in determining epigenetic changes and their short- and long-term effects.
Purpose: Child maltreatment has serious implications for youth outcomes, yet its associations with early parenting practices are not fully understood. This study investigated whether breastfeeding practices are correlated with childhood maltreatment. Materials and methods: Data were utilized from the National Longitudinal Study of Adolescent to Adult Health, a nationally representative and longitudinal study of adolescents. The analytic sample comprised 4,159 adolescents. The outcome variables included four subtypes of childhood maltreatment (neglect, inadequate supervision, physical abuse, and sexual abuse). The primary independent variable was breastfeeding duration. Covariates of the child, mother, and household were included in analyses. Logistic regression models were employed to predict odds of maltreatment subtypes from breastfeeding duration and covariates. Results: Compared with adolescents never breastfed, adolescents breastfed 9 months or longer had a reduced odds of having experienced neglect (odds ratio [OR] = 0.54; 95% confidence interval [CI] = 0.35-0.83) and sexual abuse (OR = 0.47; 95% CI = 0.24-0.93) after controlling for covariates. Conclusions: Breastfeeding duration is significantly and inversely associated with childhood neglect and sexual abuse. Breastfeeding practices should be explored as a consideration among clinicians when assessing maltreatment risk. Further research should examine whether a causal relationship exists between breastfeeding and maltreatment.
Early neonatal death (ENND), defined as the death of a newborn between zero and seven days after birth, represents 73% of all postnatal deaths worldwide. Despite a 50% reduction in childhood mortality, reduction of ENND has significantly lagged behind other Millennium Developmental Goal achievements and is a growing contributor to overall mortality in children aged <5 years. The etiology of ENND is closely related to the level of a country's industrialization. Hence, prematurity and congenital anomalies are the leading causes in high-income countries. Furthermore, sudden unexpected early neonatal deaths (SUEND) and collapse have only recently been identified as relevant and often preventable causes of death. Concomitantly, perinatal-related events such as asphyxia and infections are extremely relevant in Africa, South East Asia, and Latin America and, together with prematurity, are the principal contributors to ENND. In high-income countries, according to current research evidence, survival may be improved by applying antenatal and perinatal therapies and immediate newborn resuscitation, as well as by centralizing at-risk deliveries to centers with appropriate expertise available around the clock. In addition, resources should be allocated to the close surveillance of newborn infants, especially during the first hours of life. Many of the conditions leading to ENND in low-income countries are preventable with relatively easy and cost-effective interventions such as contraception, vaccination of pregnant women, hygienic delivery at a hospital, training health care workers in resuscitation practices, simplified algorithms that allow for early detection of perinatal infections, and early initiation of breastfeeding and skin-to-skin care. The future is promising. As initiatives undertaken in previous decades have led to substantial reduction in childhood mortality, it is expected that new initiatives targeting the perinatal/neonatal periods are bound to reduce ENND and provide these babies with a better future.