Background
Mother-infant separation post birth is common. In standard hospital care, newborn infants are held wrapped or dressed in their mother’s arms, placed in open cribs or under radiant warmers. Skin-to-skin contact (SSC) begins ideally at birth and should last continually until the end of the first breastfeeding. SSC involves placing the dried, naked baby prone on the mother's bare chest, often covered with a warm blanket. According to mammalian neuroscience, the intimate contact inherent in this place (habitat) evokes neuro-behaviors ensuring fulfillment of basic biological needs. This time frame immediately post birth may represent a 'sensitive period' for programming future physiology and behavior.

Objectives
To assess the effects of immediate or early SSC for healthy newborn infants compared to standard contact on establishment and maintenance of breastfeeding and infant physiology.

Search methods
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (17 December 2015), made personal contact with trialists, consulted the bibliography on kangaroo mother care (KMC) maintained by Dr Susan Ludington, and reviewed reference lists of retrieved studies.

Selection criteria
Randomized controlled trials that compared immediate or early SSC with usual hospital care.

Data collection and analysis
Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. Quality of the evidence was assessed using the GRADE approach.

Main results
We included 46 trials with 3850 women and their infants; 38 trials with 3472 women and infants contributed data to our analyses. Trials took place in 21 countries, and most recruited small samples (just 12 trials randomized more than 100 women). Eight trials included women who had SSC after cesarean birth. All infants recruited to trials were healthy, and the majority were full term. Six trials studied late preterm infants (greater than 35 weeks' gestation). No included trial met all criteria for good quality with respect to methodology and reporting; no trial was successfully blinded, and all analyses were imprecise due to small sample size. Many analyses had statistical heterogeneity due to considerable differences between SSC and standard care control groups.

Results for women

SSC women were more likely than women with standard contact to be breastfeeding at one to four months post birth, though there was some uncertainty in this estimate due to risks of bias in included trials (average risk ratio (RR) 1.24, 95% confidence interval (CI) 1.07 to 1.43; participants = 887; studies = 14; I² = 41%; GRADE: moderate quality). SSC women also breast fed their infants longer, though data were limited (mean difference (MD) 64 days, 95% CI 37.96 to 89.50; participants = 264; studies = six; GRADE:low quality); this result was from a sensitivity analysis excluding one trial contributing all of the heterogeneity in the primary analysis. SSC women were probably more likely to exclusively breast feed from hospital discharge to one month post birth and from six weeks to six months post birth, though both analyses had substantial heterogeneity (from discharge average RR 1.30, 95% CI 1.12 to 1.49; participants = 711; studies = six; I² = 44%; GRADE: moderate quality; from six weeks average RR 1.50, 95% CI 1.18 to 1.90; participants = 640; studies = seven; I² = 62%; GRADE: moderate quality).

Women in the SCC group had higher mean scores for breastfeeding effectiveness, with moderate heterogeneity (IBFAT (Infant Breastfeeding Assessment Tool) score MD 2.28, 95% CI 1.41 to 3.15; participants = 384; studies = four; I² = 41%). SSC infants were more likely to breast feed successfully during their first feed, with high heterogeneity (average RR 1.32, 95% CI 1.04 to 1.67; participants = 575; studies = five; I² = 85%).

Results for infants

SSC infants had higher SCRIP (stability of the cardio-respiratory system) scores overall, suggesting better stabilization on three physiological parameters. However, there were few infants, and the clinical significance of the test was unclear because trialists reported averages of multiple time points (standardized mean difference (SMD) 1.24, 95% CI 0.76 to 1.72; participants = 81; studies = two; GRADE low quality). SSC infants had higher blood glucose levels (MD 10.49, 95% CI 8.39 to 12.59; participants = 144; studies = three; GRADE: low quality), but similar temperature to infants in standard care (MD 0.30 degree Celcius (°C) 95% CI 0.13 °C to 0.47 °C; participants = 558; studies = six; I² = 88%; GRADE: low quality).

Women and infants after cesarean birth

Women practicing SSC after cesarean birth were probably more likely to breast feed one to four months post birth and to breast feed successfully (IBFAT score), but analyses were based on just two trials and few women. Evidence was insufficient to determine whether SSC could improve breastfeeding at other times after cesarean. Single trials contributed to infant respiratory rate, maternal pain and maternal state anxiety with no power to detect group differences.

Subgroups

We found no differences for any outcome when we compared times of initiation (immediate less than 10 minutes post birth versus early 10 minutes or more post birth) or lengths of contact time (60 minutes or less contact versus more than 60 minutes contact).

Authors' conclusions
Evidence supports the use of SSC to promote breastfeeding. Studies with larger sample sizes are necessary to confirm physiological benefit for infants during transition to extra-uterine life and to establish possible dose-response effects and optimal initiation time. Methodological quality of trials remains problematic, and small trials reporting different outcomes with different scales and limited data limit our confidence in the benefits of SSC for infants. Our review included only healthy infants, which limits the range of physiological parameters observed and makes their interpretation difficult.

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Early skin‐to‐skin contact for mothers and their healthy newborn infants

Background
Keeping vulnerable preterm infants warm is problematic even when recommended routine thermal care guidelines are followed in the delivery suite.

Objectives
To assess efficacy and safety of interventions designed for prevention of hypothermia in preterm and/or low birthweight infants applied within 10 minutes after birth in the delivery suite compared with routine thermal care.

Search methods
We used the standard search strategy of the Cochrane Neonatal Review Group (CNRG). The review was updated in October 2009.

Selection criteria
Trials using randomised or quasi-randomised allocations to test a specific intervention designed to prevent hypothermia, (apart from 'routine' thermal care) applied within 10 minutes after birth in the delivery suite to infants of < 37 weeks' gestational age or birthweight ≤ 2500 g.

Data collection and analysis
We used the methods of the CNRG for data collection and analysis.

Main results
1) Barriers to heat loss [5 studies; plastic wrap or bag (3), plastic cap (1), stockinet cap (1)]:

Plastic wraps or bags were effective in reducing heat losses in infants < 28 weeks' gestation (4 studies, n = 223; WMD 0.68 °C; 95% CI 0.45, 0.91), but not in infants between 28 to 31 week's gestation. Plastic caps were effective in reducing heat losses in infants < 29 weeks' gestation (1 study, n = 64; MD 0.80 °C; 95% CI 0.41, 1.19). There was insufficient evidence to suggest that either plastic wraps or plastic caps reduce the risk of death within hospital stay. There was no evidence of significant differences in other clinical outcomes for either the plastic wrap/bag or the plastic cap comparisons. Stockinet caps were not effective in reducing heat losses.

2) External heat sources [2 studies; skin-to-skin (1), transwarmer mattress (1)]:

Skin-to-skin care (SSC) was shown to be effective in reducing the risk of hypothermia when compared to conventional incubator care for infants (1 study, n = 31; RR 0.09; 95% CI 0.01, 0.64). The transwarmer mattress reduced the incidence of hypothermia on admission to NICU in VLBW infants (1 study, n = 24; RR 0.30; 95% CI 0.11, 0.83).

Authors' conclusions
Plastic wraps or bags, plastic caps, SSC and transwarmer mattresses all keep preterm infants warmer leading to higher temperatures on admission to neonatal units and less hypothermia. However, the small numbers of infants and studies and the absence of long-term follow-up mean that firm recommendations for clinical practice cannot be given.

/pdf/interventions-to-prevent-hypothermia-at-birth-in-preterm-and-d2hes9wvs0.pdf

Interventions to prevent hypothermia at birth in preterm and/or low birthweight infants

Background
Despite the widely documented health advantages of breastfeeding over formula feeding, initiation rates remain relatively low in many high-income countries, particularly among women in lower income groups.

Objectives
To evaluate the effectiveness of interventions which aim to encourage women to breastfeed in terms of changes in the number of women who start to breastfeed.

Search methods
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (July 2007), handsearched the Journal of Human Lactation, Health Promotion International and Health Education Quarterly from inception to 15 August 2007, and scanned reference lists of all articles obtained.

Selection criteria
Randomised controlled trials, with or without blinding, of any breastfeeding promotion intervention in any population group except women and infants with a specific health problem.

Data collection and analysis
One review author independently extracted data and assessed trial quality, checked by a second author. We contacted investigators to obtain missing information.

Main results
Eleven trials were included. Statistical analyses were conducted on data from eight trials (1553 women). Five studies (582 women) on low incomes in the USA with typically low breastfeeding rates showed breastfeeding education had a significant effect on increasing initiation rates compared to standard care (risk ratio (RR) 1.57, 95% confidence interval (CI) 1.15 to 2.15, P = 0.005). Subgroup analyses showed that one-to-one, needs-based, informal repeat education sessions and generic, formal antenatal education sessions are effective in terms of an increase in breastfeeding rates among women on low incomes regardless of ethnicity and feeding intention. Needs-based, informal peer support in the antenatal and postnatal periods was also shown to be effective in one study conducted among Latina women who were considering breastfeeding in the USA (RR 4.02, 95% CI 2.63 to 6.14, P < 0.00001).

Authors' conclusions
This review showed that health education and peer support interventions can result in some improvements in the number of women beginning to breastfeed. Findings from these studies suggest that larger increases are likely to result from needs-based, informal repeat education sessions than more generic, formal antenatal sessions. These findings are based only on studies conducted in the USA, among women on low incomes with varied ethnicity and feeding intention, and this raises some questions regarding generalisability to other settings.

/pdf/interventions-for-promoting-the-initiation-of-breastfeeding-3vqnjb1re7.pdf

Interventions for promoting the initiation of breastfeeding

Scientific progress, social and cultural changes, and, in particular, legal change have led to a fundamental change in attitudes to cesarean section among patients and doctors. In fact, the consensus around the indications for cesarean section has changed in many countries, now including psychosocial factors such as anxiety about the delivery, or even the mother’s wish to have a cesarean section in the absence of any medical indication (1). Nevertheless, the reasons for increasingly liberal attitudes toward cesarean section are diverse and not always easily discernable.

In recent years, a number of factors have been under consideration as possible influences on the rising cesarean rate. Changing risk profiles among increasingly older primiparae are often cited as a reason for the rise in cesarean deliveries (2– 4). An increase in maternal request cesarean sections also plays a part (5, 6). However, the rise in cesarean section rates should not be viewed in isolation from changes in society. On the contrary, financial (7, 8), social (9– 13), and cultural (8, 14– 17) elements appear to play an important part. These factors—taken together with the public perception that a cesarean delivery is now an almost risk-free procedure—might well be contributing to the rise in the number of cesarean sections performed (18).

This perspective, however, overlooks the fact that a cesarean section is a surgical procedure with numerous potential complications for both mother and child. Apart from the intraoperative risks (i.e., infection, organ injuries, or the need for blood transfusion [19–27]), many side effects can occur post partum: thromboembolic complications, for example (19, 28– 33). In particular, the complications relating to later pregnancies should be mentioned: uterine rupture (34– 36), infertility (37– 40), or even placental anomalies such as placenta previa, increta, or accreta (29– 32, 40, e1– e3). In recent years a number of risks have also been described for babies delivered by elective cesarean section: the development of bronchial asthma (e4, e5), for example, or type 1 diabetes mellitus (e6) or allergic rhinitis (e4, e7). Existing data are unsatisfactory, however, and a focus of current controversy. Two review articles point to neonatal risk associated with elective cesarean section compared with vaginal delivery, including increased mortality, increased risk of respiratory disease, or type 1 diabetes (e8, e9). Other authors, however, found no difference in neonatal outcome between elective cesearean and vaginal delivery, although they emphasize that only limited data are available (e10). The WHO stated, on the basis of a study of maternal and fetal complications between 2004 and 2008 in 24 countries, that cesarean sections are associated with an increase in risks for both mother and child compared to vaginal delivery and should therefore be performed only when significant advantages are expected (e11).

Indications for and Risks of Elective Cesarean Section.

Objective: To evaluate the effect of mother-infant early skin-to-skin contact on breastfeeding behavior of infants. Study Design: A randomized controlled trial. Place and Duration of Study: The study was conducted in the Department of Obstetrics of Pakistan Institute of Medical Sciences, Islamabad, from November to December 2009. Methodology: Eligible mothers were assessed for the successful breastfeeding by using IBFAT tool. The time to initiate the first feed, time to effective breastfeeding, maternal satisfaction with the care provided, preference for the same care in future and level of exclusive breastfeeding at the age of one month were also noted. The data was compared by using X2 and t-test. Significant p-value was taken as < 0.05. Results: A total of 183 mother-infant pairs (92 in skin-to-skin care [SSC] group and 91 in conventional care [CC] group) were analyzed for breastfeeding behavior of the infants. The first breastfeed was 26.25% more successful in SSC group (58.8% in SSC group as compared to 32.5% in CC group with p-value of 0.001). In SSC group, the mean time to initiate first breastfeed was 61.6 minutes shorter than CC group (40.62 vs. 101.88; p < 0.001). Mean time to achieve effective breastfeeding was 207 minutes earlier in SSC group (149.69 vs. 357.50; p < 0.001). The level of satisfaction in the mothers of SSC group was significantly high as compared to controls (56% vs. 6.2%). Similarly, 53.8% mothers of SSC group showed preference for similar care in future as compared to 5% in CC group. In SSC group 85.3% infants were exclusively breastfed at one month as compared to 65.7% in CC group (p=0.025). Conclusion: Maternal-infant early skin-to-skin contact significantly enhanced the success of first breastfeed and continuation of exclusive breastfeeding till one month of age. It also reduced the time to initiate first feed and time to effective breastfeeding.

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Effect of mother-infant early skin-to-skin contact on breastfeeding status: a randomized controlled trial.

This is a prospective study involving ninety-two lactating mother- infant pairs in the first six months of birth. They were followed-up up to six months for various perinatal factors determining the duration of exclusive breastfeeding. Early postpartum mother-baby skin-to-skin contact had a powerful influence (P<0.001) over the duration of exclusive breastfeeding up to 4-6 months and was found to be more significant than early initiation of breastfeeding (P<0.05). Mode of delivery did not have any significant effect (P<0.5) over the duration of exclusive breastfeeding. Thus health care centers can easily adopt a policy to allow few minutes of early postpartum mother-baby skin-to-skin contact and early initiation of breastfeeding to all vaginal as well as caesarian deliveries to promote breastfeeding.

Effect of early mother-baby close contact over the duration of exclusive breastfeeding.

OBJECTIVE To assess the relation between lower respiratory tract infection and feeding pattern in infancy. SETTING Hospital based descriptive. METHODS Two hundred and five infants presenting with lower respiratory infection (LRTI) admitted in the ward were studied over a period of one year. Criteria for the clinical diagnosis of LRTI were based on the lines of TUCSON CHILDREN RESPIRATORY STUDY. RESULTS Forty three percent of LRTI in infancy were seen in age group of 0 to 3 months. Sixty percents of pre-lacteal feeding and 71% of bottle-feeding were observed. Late introduction of solid food was very commonly practiced. In 64.7% solid food was introduced at the age of 9 to 12 months. Fifty three percent of LRTI were associated with diarrhoea, which was the commonest factor associated with mortality due to LRTI. There was male preponderance with male:female = 2.8:1(P value <0.001), which is highly significant. Mixed feeding/artificial feeding had more incidence of LRTI than exclusively breast-fed children (1.7:1) and the mortality rate was 10 times more in mixed/artificial fed infants than exclusively breast fed infants.

Kamala Vaidya

Papers

Effect of early mother-baby close contact over the duration of exclusive breastfeeding.

Lower respiratory tract infection in infancy in relation to feeding pattern.