Why is skin-to-skin so important?

1. Why is skin-to-skin so important? Picture from AMWidström, with permission Louise Dumas, RN MSN, PhD For the Russian-Swedish-Quebecer team

2. Plan for today • Some definitions • What is an evidence? • Russian-Swedish-Quebecer team • Objectives and design of the research • Results and their importance • Links with BFI Picture by Dumas, with permission

3. What do we mean by Russian swaddling? “...immediately after birth, babies are tightly bound in layers of cloth. Complete swaddling immobilizes the baby from the neck to the feet.....The layers of cloth are not only pulled tightly but they are also securely tied to minimize body movements.” Yurdakok, Yavuz & Taylor, 1990, p. 873

4. Russian swaddled infants Picture by L Dumas, with permission Picture by K.Jurkova, with permission

5. Russian Swaddling Process From K Bystrova (2008), p.28

6. What is bundling? “fitting blanket tightly around the baby with arms on chest. Wrapped this way, the baby cannot move arms or body but can move his/her head.” Dumas, Lepage & Grondin, 2007

7. Picture of a bundled infant From: Karp, 2002, page117 Author calls this swaddling

8. How to bundle an infant From: Karp, 2002, p 115-117 Author calls this swaddling

9. “Blanketing” a baby “loosely cover the baby with a blanket. Wrapped this way, the baby can move any part of his/her body, sometimes leading to hands or feet coming out of the blanket.” Dumas, Lepage & Grondin, 2007

10. Picture of a “blanketed” infants Ann Geddes calendar, 2009

11. What is skin-to-skin? • Uninterrupted skin-to-skin contact between the mother and the healthy term infant • Similar to Kangaroo care, which concerns premature babies

12. How do we achieve skin-to-skin? for research purposes • Nude newborn directly on mother’s nude chest, without drying • Newborn is either completely nude or with a diaper • Newborn is placed vertically between mother’s breasts (vaginal birth) • Newborn is place horizontally just below or on mother’s breasts (cesarean section) • Newborn is then covered with a blanket

13. Picture of an infant skin-to-skin (same as kangaroo) Picture from Sweden, with permission to Dumas and Lemire Picture from Dumas, Gatineau, with permission

14. What is rooming-in? Photo by Dumas, Gatineau, with permission Photo Sweden, with permission to Dumas and Lemire

15. What is separation mother and baby? St.Petersburg, picture from M Velandia, with permission Picture from Materneo.com

16. Which is the best way to welcome our newborns? Swaddling? Rooming-in? Bundling? Nursery? Blanketing? Skin-to-skin? We need evidences, proofs, in order to advance that one option is better than the others

17. To convince scientifically-driven professionals * We need the strongest evidences, as skin-to-skin is still considered as “soft, nice thing to do”. * So we need clinical randomized trials; meta-analyses; systematic reviews. Picture from Thomas Bergman, Sweden

18. Priority to statistically significant data • Randomized controlled trials (RCT): THE standard; controlled study; experimental group vs control group; random choices; controlled variables; blind choices • Systematic reviews: hierarchise many studies according to strength of evidences -- 6 levels: from clear benefits to no benefit and even clearly dangerous; research experts panel • Meta-analyses statisticallycombine results from many small studies in order to get global results for one treatment/intervention

19. My experience at Karolinska Institutet • Medical and paramedical university • Founded in 1810 • 3,600 employees • 1,500 doctoral students • One of the most renown medical research centers and university level research groups in Europe • Yearly award the Nobel prizes for medicine and physiology

20. Russian-Swedish-Quebecer team RCT; quantitative data; very rigourous research design • Studying perinatal practices related to mother and infant variables especially, • Breastfeeding and breastmilk • Skin-to-skin versus apparel • Mother/infant separation • Mother/infant interaction

21. Original Russian-Swedish team • History: • 1991-WHO conference in St-Petersburg: « Giving birth to a healthy child »  Swedish-Russian collaboration • $: • from Sweden especially, also from St.Petersburg State Medical Pediatric Academy • Original Swedish-Russian team: • K.Bystrova, AM.Widström, I.Vorontsof, AB. Ransjö-Arvidson

22. Dr Louise Dumas & Dr Ksenia Bystrova, 2005 Dr Louise Dumas & Dr Ann-Marie Widström, 2008

23. Other contributors over the years From Russia: V. Ivanova K. Jakushera R. Mukhamedrakhimov N. Romanova From Sweden: O. Sajikora M. Edhborg W. Lundh A-S Matthiesen K. Uvnäs-Moberg C. Wassberg B. Welles-Nyström

24. and…2 researchers from Québec How they were involved * Dumas’ mentor = AM Widström * Sabbatical in 2005 * Then, guest researcher * Lepage = responsible for the Quebec part of the quantitative data analyses since 2007 Dr Louise Dumas Dr Mario Lepage

25. Why is this research so important for Canadians? 1. Would not be permitted in Canada by research ethics committees: • quantity of data/no clear knowledge of why each data collected • type of data (videos,…) 2.Very serious research and researchers: • unusually longitudinal; extremely rigorous; strict protocols; quantity of data on mother, baby and environment; various types of data 3. If evidences are clear,then can be directly exported in industrialized countries

26. Why is this research so important for Canadians? Recentinformalsurveyin Canada (Dumas, Lepage & Grondin, 2007) and The Canadian maternityexperiencesurvey(2009) Show that: Not all Canadian babies are placed skin-to-skin immediatelyatbirth There are manyunjustified interruptions to skin-to-skin atbirth Many babies are brought to the nursery for unjustifiedreasons

27. Longitudinal research design • Mothers in good health • Normal pregnancy • Term baby in good health • Vaginal birth • No analgesia, no anesthesia during all labor and birth • No oxytocin for induction nor for stimulation • APGAR ≥ 8 at 5 min • No immediate postnatal hemorrhage

28. Randomization • If all conditions are met at 5 minutes of life, after the 2nd APGAR, one envelope is opened • Blind randomization in 8 different groups • Data collection lasted 4 years… • Many data still to be analyzed

29. We study the effects • of type of contact at birth (swaddling, clothes and blanket, skin-to-skin) • of separation at birth (non separated, separated, separated then reunited after 2 hrs) • of swaddling versus clothes in the postnatal period • of postnatal rooming-in

30. Distribution within the groups Skin to skin : 44 closeness Mom’s arms: 44 Nursery: 88 separation Total: 176 151 dyads left at day 4 124 dyads completed the research at one year

31. Data from babies • 4 temperature sensors : left armpit, between shoulder blades, left thigh exterior, left heel interior; die at 11h am • breathing/heart rate; 7 measures: at 30 min pp + q 15 min ad 120 min • venous blood from umbilical cord: cortisol/oxytocin levels • scalp blood at 2 h of life (routine with swaddling) and day 4 • weight: birth, and die before/after bf at day 4-5 (72 to 96h) • number and duration of breastfeeding episodes • number and type of supplements • medical monitoring with physical exam, weight in 1-2-3-4-6-9-12 months, also videotaped • mental development + Reutor scale for neurobehavioral development + temperament scale

32. Data from mothers • physical assessment at 30 minutes postpartum • 2 temperature sensors : left armpit, on breast that is not breastfeeding at the moment; die at 11h am • breathing/heart rate/BP; 7 measures: at 30 min pp + q 15 min ad 120 min • blood for diverse measures 10 minutes after birth, at 2h after birth, at day 4. • multiple questionnaires (socio-demographic, mood, personality, …) • breastfeeding diary during hospitalization

33. Other data • temperatures of : birthing room, nursery, mother’s room • video during 90 min starting 30 min after birth or as soon as baby is placed skin-to-skin • video during one breastfeeding episode at day 4 postpartum • at 12 months, videotaped assessment with PCERA

34. Completed or pending analyses up-to-date Picture from Dumas, with permission

35. Results up-to-date and their importance • Baby’s temperature • Reciprocity in mother/infant temperatures • Breastfeeding • Quantity of breast milk • Number of supplements • Baby’s weight • Mother’s feelings of « low/blues » • Mother/infant interaction at day 4 • Mother/infant interaction at one year

36. 1. Baby’s temperature: at all sites except shoulder blades • Skin-to-skin groups : highest temperature •  vasodilatation  «reduction of the stress of being born» (expression from Dr Hugo Lagercrantz) • Nursery groups : lowest temperature • When baby is swaddled: lowest temperature, especially at the foot vasoconstriction due to tight swaddling • No difference at 2 days postpartum except with skin-to-skin postnatally, then higher temperature ad 5 days

37. 2. Reciprocity in mother/infant temperatures • Mother’s temperature at axilla and non suckled breast -- highest when skin-to-skin -- lowest when baby in nursery • When skin-to-skin, at 90 minutes: mother’s axilla temperature directly linked to baby’s foot temperature --so, mother and baby have correlated temperatures --so reciprocity between mother and baby • When separation, no increase in mother’s temperature, doesn’t rise

38. Importance of those results Swaddling is bad during the first hours of life (30 to 120 minutes) Skin-to-skin is great during the first hours of life : - helps baby to adapt to new life at physiological level - helps symbiotic regulation of baby and mother’s temperatures at birth

39. Practice to recommend Immediate and uninterrupted skin-to-skin from birth No separation even for short periods Picture from Dumas, with permission

40. 3. Breastfeeding Neonatal practices (skin-to-skin, clothes or swaddling, and rooming-in after 120 minutes or non separation) do not influence breastfeeding variables at day 4 (number of feeds, quantity of breastmilk ingested, timing of feeds, number of supplements) Except the first suckling at birth (during the first 2 hours)  increased milk production at day 4

41. During this study When mother and baby were rooming-in, baby is more frequently at the breast as demand breastfeeding When baby is in the nursery, breastfeeding is by strict schedule, fixed hours, 7 times a day; this is the Russian practice

42. Postnatal practices (clothes or swaddling, andseparation or non separation) Do influence breastfeeding variables at day 4 (number of feeds, quantity of breastmilk ingested, timing of feeds, number of supplements)

43. Practice to recommend Immediate and uninterrupted skin-to-skin from birth No separation even for short periods as to encourage first suckling Picture by Dumas, with permission

44. 4. Quantity of breast milk Babies in nursery get less breastmilk , which makes sense because of strict schedule Clearer in multipara: separated from their babies, they clearly produce less milk (imprinting?)

45. 5. Number of supplements Babies in the nursery get more supplements and less breastmilk And wealll know the demonstratedbenefits of exclusive breastfeeding for the first 6 months Picture by Dumas, with permission

46. 6. Baby’s weight Swaddled babies return to birth weight slower than the others ***Swaddled babies who received supplements return to birth weight slowerthan swaddled babies who didn’t receive supplements***

47. Importance of these results • Supplements reduce the amount of ingested breastmilk, so risk : - to stop exclusive breastfeeding before 6 months - to stop breastfeeding • Swaddling + supplement = slower weight gain • Swaddling + separation = slower weight gain

48. Practice to recommend • No medicallyunjustifiedsupplement to a breastfed baby • No swaddling • Noseparationatbirtheven if reunionafter 2hrs • YES to earlysuckling Picture by Ann-Marie Widström, with permission

49. 7. Mother’s feelings of « low/blues » Multiparas rooming-in with their babies reportless feelings of low/blue at day 3 and 4 No such thing with primipara ??? Previous imprinting as in animals?????

50. Importance of these results Mothers feel better and are more positive towards their birthing experience when they are rooming-in with their baby ??? Less postpartum depression???