Maternal behavior one year after early and extended post-partum contact

Observational measures of caregiver's touch behavior in infancy: A systematic review

The caregiver's touch behavior during early infancy is linked to multiple developmental outcomes. However, social touch remains a challenging construct to operationalize, and although observational tools have been a gold standard for measuring touch in caregiver-infant interactions, no systematic review has been conducted before. We followed the PRISMA guidelines and reviewed the literature to describe and classify the main characteristics of the available observational instruments. Of the 3042 publications found, we selected 45 that included an observational measure, and from those we identified 12 instruments. Most of the studies were of infants younger than six months of age and assessed touch in two laboratory tasks: face-to-face interaction and still-face procedure. We identified three approaches for evaluating the caregiver's touch behavior: strictly observational (the observable touch behavior), functional (the functional role of the touch behavior), or mixed (a combination of the previous two). Half of the instruments were classified as functional, 25% as strictly observational, and 25% as mixed. The lack of conceptual and operational uniformity and consistency between instruments is discussed.

Editorial: Maternal Bonding: How and Why Does It Matter?

In 1970, Klaus and Kennell¹ endorsed the idea of a sensitive period immediately after birth, associated with skin-to-skin contact, that was key to a human mother developing an affectional bond with her infant. Since that time, studies have investigated how the mother's affectional bond to her infant supports infant development as well as a variety of factors that impact the development of such a bond, including maternal engagement in fetal movements, experiences during the birth process, social support including that from the partner, and maternal mental health. This editorial aims to set the large, longitudinal study by Le Bas et al.² in the context of past and current other work on the significance of parents' bonds to their infants.

Mother-Newborn Couplet Care from theory to practice to ensure zero separation for all newborns

With an increasing awareness of the importance of nurturing care and within a framework of Infant- and Family-Centred Developmental Care (IFCDC), zero separation, keeping parent and infant in continuous close physical and psychological proximity to each other, is key. In modern neonatology, high technological and pharmaceutical treatments are consistently integrated with caregiving considerations. Mother-Newborn Couplet Care is a concept of care where the dyad of the ill or prematurely born infant and the mother, needing medical care of her own, are cared for together, from the birth of the baby to its discharge. Mother-Newborn Couplet Care requires systems changes in both obstetrics and paediatrics considering planning and organisation of care, equipment and design of units. Accordingly, strong leadership setting clear goals and changing the professional mindset by providing targeted education and training is crucial to ensure the warranted high quality of care of all mother-baby dyads.

Postpartum bonding in father with baby in the East Jakarta sub-district's community health center

The father's ability to form bonds both physically and emotionally with his baby is a condition that is very important for the development of a father's mental health. This study aims to identify postpartum bonding images in fathers and infants. This study used a cross-sectional design with consequtive sampling, which conducted to390 fathers who had babies aged three to six months. This research was conducted in the East Jakarta Sub-District Community Health Center from March to June 2019. The instruments used in this study were modified from the English-language Postpartum Bonding Questionaires (PBQ). The results of this study found that the images of the father's relationship with the baby, in which about 142 fathers (36.4%), had a bad bond. The study is expected to provide motivation for fathers to bond with babies from the wife's pregnancy to prevent the occurrence of paternal depression in the postpartum period.

Oxytocin: Potential to mitigate cardiovascular risk

Cardiovascular disease (CVD) remains the leading cause of death worldwide, despite multiple treatment options. In addition to elevated lipid levels, oxidative stress and inflammation are key factors driving atherogenesis and CVD. New strategies are required to mitigate risk and most urgently for statin-intolerant patients. The neuropeptide hormone oxytocin, synthesized in the brain hypothalamus, is worthy of consideration as a CVD ancillary treatment because it moderates factors directly linked to atherosclerotic CVD such as inflammation, weight gain, food intake and insulin resistance. Though initially studied for its contribution to parturition and lactation, oxytocin participates in social attachment and bonding, associative learning, memory and stress responses. Oxytocin has shown promise in animal models of atherosclerosis and in some human studies as well. A number of properties of oxytocin make it a candidate CVD treatment. Oxytocin not only lowers fat mass and cytokine levels, but also improves glucose tolerance, lowers blood pressure and relieves anxiety. Further, it has an important role in communication in the gut-brain axis that makes it a promising treatment for obesity and type 2 diabetes. Oxytocin acts through its receptor which is a class I G-protein-coupled receptor present in cells of the vascular system including the heart and arteries. While oxytocin is not used for heart disease at present, residual CVD risk remains in a substantial portion of patients despite multidrug regimens, leaving open the possibility of using the endogenous nonapeptide as an adjunct therapy. This review discusses the possible role for oxytocin in human CVD prevention and treatment.

Hospital routines promote parent-infant closeness and cause separation in the birthing unit in the first 2 hours after birth: A pilot study

BACKGROUND

Despite the evidence of multiple benefits of early skin-to-skin contact, it does not always happen and infants are separated from their parents because of different hospital practices. The aim of this study was to explore parent-infant closeness and separation, and which factors promote closeness or result in separation in the birthing unit in the first 2 hours after birth from the point of view of staff members.

METHODS

This qualitative descriptive pilot study was conducted in one university hospital in Finland in December 2014. Midwives and auxiliary nurses working in the birthing unit were eligible for the study. The data were collected with a new application downloaded on a smartphone. The participants were asked to record all the closeness and separation events they observed between the infants and parents using the application.

RESULTS

The application was used during 20 work shifts by 14 midwives or auxiliary nurses. The participants described more closeness than separation events. Our findings indicated that the staff of the birthing unit aimed for mother-infant closeness, and father-infant closeness was a secondary goal. Closeness was mostly skin-to-skin contact and justified as a normal routine care practice. Infants were separated from their parents for routine measurements and because of infants' compromised health.

CONCLUSION

Routines and normal care practices both promoted parent-infant closeness and caused separation. Parent-infant closeness and separation were controlled by staff members of the birthing unit.

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

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 womenSSC 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 infantsSSC 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 birthWomen 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. SubgroupsWe 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.

Plasma Oxytocin Levels in Untreated Adult Obsessive-Compulsive Disorder Patients

BACKGROUND AND AIM

Given the paucity of information on the possible role of oxytocin (OT) in the pathophysiology of obsessive-compulsive disorder (OCD), our study aimed at evaluating plasma OT levels in a group of 44 OCD outpatients, as compared with a similar group of healthy control subjects. At the same time, the relationships between OT and clinical features and romantic attachment characteristics were examined as well.

METHODS

Diagnosis was assessed according to DSM-IV-TR criteria, while the OCD severity was measured by means of the Y-BOCS rating scale. All patients were drug free and not depressed. The romantic attachment was assessed by means of the Italian version of the 'Experiences in Close Relationships' questionnaire. Plasma OT levels were evaluated by means of a standard RIA kit.

RESULTS

The main findings of our study showed that OT levels were increased in OCD patients, as compared with healthy subjects, and negatively related to symptom severity. Positive relationships were detected between OT levels and the fearful-avoidant and dismissing styles of romantic attachments, but only in male OCD patients.

CONCLUSION

Taken together, these findings suggest that OT may play a role in OCD pathophysiology and also in the romantic attachment of patients with gender specificity.

Early Post-Partum Contact and Later Attitudes

In a randomized, prospective study the long-term effects of early post-partum skin-toskin and suckling contact was studied. In follow-up studies 36 hours, 3 and 12 months after delivery maternal behaviour, infant behaviour, the duration of breast feeding and certain attitudes towards child rearing procedures were shown to develop differently in a group of mothers and infants with early post-natal contacts as compared to a control group. Three years after delivery parents with early contact appreciated their children's language development to be faster; the number of siblings born in these families was greater than in controls. In the discussion, the relative importance of the immediate postnatal period is emphasized, a more family oriented development seems to occur in the presence of early post-delivery interaction.

Emotional Rejection of the Infant: Status of the Concept

Emotional rejection of the infant is a morbid, clinical phenomenon, central to mother-infant psychiatry. It occurs in about 1% of births in the general population, but much more often in mothers referred to specialist services. It has severe consequences for children, but responds well to treatment. It is now better recognized, but research is required, especially cohort studies and neuroscientific investigations.

Mother-infant bonding : A scientific fiction

A study of the research on postpartum mother-infant bonding shows that results from poorly constructed research programs were published in major journals and became a part of hospital policy because the bonding concept was politically useful in the struggle between advocates of natural childbirth and managers of the medical model of birth. The concept was also uncritically accepted because it was consistent with a longstanding ideology of motherhood that sees women as the prime architects of their children's personalities.

Experience-facilitated improvements in pup retrieval; evidence for an epigenetic effect

The quality and quantity of maternal care received during infancy are highly predictive of successful infant development. It has been well established, primarily in rats, that the combination of hormonal and infant stimuli at birth modifies neural circuits that regulate maternal responsiveness. During subsequent interactions, infant stimuli are more likely to elicit rapid maternal responsiveness. Some species, such as humans, can display maternal care in the absence of the endocrine events of pregnancy and birth. Similarly, virgin C57BL/6J female mice, display maternal care toward infants, and experience with infants elicits long-lasting increases in maternal care. We hypothesized that these experience-induced changes in behavior may be mediated by chromatin modifications, which in turn change expression of genes that promote maternal care. One site of action is the medial preoptic area (MPOA). To test our hypothesis we treated virgin female mice with sodium butyrate, a histone deacetylase inhibitor. This treatment potentiated maternal responsiveness as well as the expression of several genes: estrogen receptor β (Esr2), oxytocin (Oxt), and cyclicAMP response element binding protein (CREB) binding protein (Crebbp; a histone acetyltransferase) in the MPOA. These data suggest that experience induces high levels of maternal care via epigenetic modifications.

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

BACKGROUND

Mother-infant separation postbirth is common in Western culture. Early skin-to-skin contact (SSC) begins ideally at birth and involves placing the naked baby, head covered with a dry cap and a warm blanket across the back, prone on the mother's bare chest. According to mammalian neuroscience, the intimate contact inherent in this place (habitat) evokes neurobehaviors ensuring fulfillment of basic biological needs. This time may represent a psychophysiologically 'sensitive period' for programming future physiology and behavior.

OBJECTIVES

To assess the effects of early SSC on breastfeeding, physiological adaptation, and behavior in healthy mother-newborn dyads.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 November 2011), made personal contact with trialists, and consulted the bibliography on kangaroo mother care (KMC) maintained by Dr. Susan Ludington.

SELECTION CRITERIA

Randomized controlled trials comparing early SSC with usual hospital care.

DATA COLLECTION AND ANALYSIS

We independently assessed trial quality and extracted data. Study authors were contacted for additional information.

MAIN RESULTS

Thirty-four randomized controlled trials were included involving 2177 participants (mother-infant dyads). Data from more than two trials were available for only eight outcome measures. For primary outcomes, we found a statistically significant positive effect of early SSC on breastfeeding at one to four months postbirth (13 trials; 702 participants) (risk ratio (RR) 1.27, 95% confidence interval (CI) 1.06 to 1.53, and SSC increased breastfeeding duration (seven trials; 324 participants) (mean difference (MD) 42.55 days, 95% CI -1.69 to 86.79) but the results did not quite reach statistical significance (P = 0.06). Late preterm infants had better cardio-respiratory stability with early SSC (one trial; 31 participants) (MD 2.88, 95% CI 0.53 to 5.23). Blood glucose 75 to 90 minutes following the birth was significantly higher in SSC infants (two trials, 94 infants) (MD 10.56 mg/dL, 95% CI 8.40 to 12.72).The overall methodological quality of trials was mixed, and there was high heterogeneity for some outcomes.

AUTHORS' CONCLUSIONS

Limitations included methodological quality, variations in intervention implementation, and outcomes. The intervention appears to benefit breastfeeding outcomes, and cardio-respiratory stability and decrease infant crying, and has no apparent short- or long-term negative effects. Further investigation is recommended. To facilitate meta-analysis, future research should be done using outcome measures consistent with those in the studies included here. Published reports should clearly indicate if the intervention was SSC with time of initiation and duration and include means, standard deviations and exact probability values.

Effect of early skin-to-skin contact on mother-preterm infant interaction through 18 months: randomized controlled trial

BACKGROUND

Preterm birth often negatively influences mother-infant interaction. Skin-to-skin contact postbirth has positive effects on maternal feelings toward their preterm infants and on infant development and family interaction. However, little is known about the long-term effects of skin-to-skin contact on mother-late preterm infant interaction when skin-to-skin contact was experienced early postbirth and intermittently throughout the next five days.

OBJECTIVE

The purpose of this report was to examine the effect of skin-to-skin contact on mother-late preterm infant interaction through 18 months.

DESIGN

Randomized controlled trial with follow-up.

SETTING

Two hospitals in the United States of America.

PARTICIPANTS

100 mothers and their late preterm infants, 32 to <37 weeks' gestation, were recruited. Mother-preterm infant interactions were assessed in 69, 70, and 76 dyads at 6, 12, and 18 months.

METHODS

Mothers and their preterm infants were videotaped during a feeding session at 6 and 12 months, and a teaching session at 6, 12, and 18 months. Their interactions were then scored using the Nursing Child Assessment Satellite Feeding Scale and Teaching Scale.

RESULTS

Skin-to-skin contact and control dyads had comparable feeding scores at 6 and 12 months. Skin-to-skin contact infants had lower infant teaching scores at six months, a difference that disappeared thereafter.

CONCLUSIONS

These inconclusive results call for additional studies with larger doses of skin-to-skin contact, larger sample sizes, and other outcome measures of mother-late preterm infant interactions. Such measures include the Parent-Child Early Relational Assessment and behavioral coding during play.

Epigenetic mechanisms and the transgenerational effects of maternal care

The transmission of traits across generations has typically been attributed to the inheritance by offspring of genomic information from parental generations. However, recent evidence suggests that epigenetic mechanisms are capable of mediating this type of transmission. In the case of maternal care, there is evidence for the behavioral transmission of postpartum behavior from mothers to female offspring. The neuroendocrine and molecular mediators of this transmission have been explored in rats and implicate estrogen-oxytocin interactions and the differential methylation of hypothalamic estrogen receptors. These maternal effects can influence multiple aspects of neurobiology and behavior of offspring and this particular mode of inheritance is dynamic in response to environmental variation. In this review, evidence for the generational transmission of maternal care and the mechanisms underlying this transmission will be discussed as will the implications of this inheritance system for offspring development and for the transmission of environmental information from parents to offspring.

Mother-infant neonatal separation: some delayed consequences

An earlier study of mothers of premature and full-term infants showed that the type and amount of social interaction between a human mother and her infant in the immediate postpartum period can influence the mother's subsequent behaviour and attitude towards the infant. Separation of a mother from her infant for as short a time as three weeks in the immediate postpartum period can lead to lowered feelings of maternal competency and decreased amounts of attachment behaviour, sometimes continuing for as long as one month after the pair have been reunited. Follow-up of these mothers and infants at 11, 12 and 15 months after discharge from the hospital showed that the effects of separation on maternal attitude and behaviour had disappeared, except that non-separated mothers continued to touch their infants more than separated mothers. Differences in maternal behaviour varied with birth order and sex of the infant and social class membership of the family. These findings are discussed in terms of ethological and social learning theories as they apply to matenal 'social attachment' in the neonatal period. The importance of considering the consequences of neonatal separation for the entire family rather than mother alone is emphasized.

Evidence for a sensitive period in the human mother

In certain animal species immediate separation of a mother from here young for a brief period after deliver (the sensitive period) may result in aberrant maternal behaviour. In the human, disorders of mothering, including child abuse, increase disproportionately in situations associated with early neonatal separation of mother and infant, such as prematurity. Mothers in the United States who were offered early contact with their premature infants showed differences in attachment behaviour when compared with mothers whose first contact with their infants was three weeks after delivery. Mothers who had one hour of close physical contact with their nude full-term infants within the first two hours after delivery and who had 15 extra hours of contact in the frist three days behaved significantly differently during a physical examination of the infant at one month and one year, and in their speech to their infants at two years, from a control group of mothers who had only routine contact. In a similar study in Guatemala, mothers who had 45 minutes of early extra contact showed significantly more attachment behaviour at the time of the first breast-feeding (12 hours). These and other studies in the human suggest that shortly after birth there is a sensitive period which appears to have long-lasting effects on maternal attachment and which may ultimately affect the development of the child.

Consistency and change in styles of mothering

The idea that the immediate postpartum period is particularly important for the developing relationship between mother and child is being increasingly discussed; however, little is known of the long-term significance of the individual differences in adjustment found in this period. A longitudinal study of 70 mother-baby pairs showed that difficulities during feeds were related to longer labour and to measures of the baby's state at birth. Differences between babies in the latency with which they responded by crying to interruption of sucking (in tests of non-nutritive sucking) were also related to the smoothness of the feed. Measures of affectionate maternal behaviour were associated with differences between babies in sucking rate, and were not influenced by labour and delivery. During later observations (8-30 weeks), strong consistency in individual differences across age was found in the levels of maternal touching, vocalizing, and responsiveness to baby's vocalizing. Maternal affectionate contact during early feeds (babies up to 10 days old) was related to these later maternal measures for breast-fed babies. Other aspects of coordination and warmth in the early feeds did not correlate with later measures, which suggested that predictions based on observations early in the neonatal period should be made with caution. Measures of maternal response to crying showed little consistency across the first seven months and were influenced by how much the baby cried at earlier ages.

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

BACKGROUND

Mother-infant separation postbirth is common in Western culture. Early skin-to-skin contact (SSC) begins ideally at birth and involves placing the naked baby, covered across the back with a warm blanket, prone on the mother's bare chest. According to mammalian neuroscience, the intimate contact inherent in this place (habitat) evokes neurobehaviors ensuring fulfillment of basic biological needs. This time may represent a psychophysiologically 'sensitive period' for programming future behavior.

OBJECTIVES

To assess the effects of early SSC on breastfeeding, behavior, and physiological adaptation in healthy mother-newborn dyads.

SEARCH STRATEGY

Cochrane Pregnancy and Childbirth Group's and Neonatal Group's Trials Registers (August 2006), Cochrane Central Register of Controlled Trials (The Cochrane Library 2006, Issue 2), MEDLINE (1976 to 2006).

SELECTION CRITERIA

Randomized and quasi-randomized clinical trials comparing early SSC with usual hospital care.

DATA COLLECTION AND ANALYSIS

We independently assessed trial quality and extracted data. Study authors were contacted for additional information.

MAIN RESULTS

Thirty studies involving 1925 participants (mother-infant dyads), were included. Data from more than two trials were available for only 8-of-64 outcome measures. We found statistically significant and positive effects of early SSC on breastfeeding at one to four months postbirth (10 trials; 552 participants) (odds ratio (OR) 1.82, 95% confidence interval (CI) 1.08 to 3.07), and breastfeeding duration (seven trials; 324 participants) (weighted mean difference (WMD) 42.55, 95% CI -1.69 to 86.79). Trends were found for improved summary scores for maternal affectionate love/touch during observed breastfeeding (four trials; 314 participants) (standardized mean difference (SMD) 0.52, 95% CI 0.07 to 0.98) and maternal attachment behavior (six trials; 396 participants) (SMD 0.52, 95% CI 0.31 to 0.72) with early SSC. SSC infants cried for a shorter length of time (one trial; 44 participants) (WMD -8.01, 95% CI -8.98 to -7.04). Late preterm infants had better cardio-respiratory stability with early SSC (one trial; 35 participants) (WMD 2.88, 95% CI 0.53 to 5.23). No adverse effects were found.

AUTHORS' CONCLUSIONS

Limitations included methodological quality, variations in intervention implementation, and outcome variability. The intervention may benefit breastfeeding outcomes, early mother-infant attachment, infant crying and cardio-respiratory stability, and has no apparent short or long-term negative effects. Further investigation is recommended. To facilitate meta-analysis, future research should be done using outcome measures consistent with those in the studies included here. Published reports should clearly indicate if the intervention was SSC and include means, standard deviations, exact probability values, and data to measure intervention dose.

The communicative functions of touch in humans, nonhuman primates, and rats: a review and synthesis of the empirical research

Although touch is one of the most neglected modalities of communication, several lines of research bear on the important communicative functions served by the modality. The authors highlighted the importance of touch by reviewing and synthesizing the literatures pertaining to the communicative functions served by touch among humans, nonhuman primates, and rats. In humans, the authors focused on the role that touch plays in emotional communication, attachment, bonding, compliance, power, intimacy, hedonics, and liking. In nonhuman primates, the authors examined the relations among touch and status, stress, reconciliation, sexual relations, and attachment. In rats, the authors focused on the role that touch plays in emotion, learning and memory, novelty seeking, stress, and attachment. The authors also highlighted the potential phylogenetic and ontogenetic continuities and discussed suggestions for future research.

Massage for promoting growth and development of preterm and/or low birth-weight infants

BACKGROUND

It has been argued that infants in Neonatal Intensive Care Units are subject both to a highly stressful environment - continuous, high-intensity noise and bright light - and to a lack of the tactile stimulation that they would otherwise experience in the womb or in general mothering care. As massage seems to both decrease stress and provide tactile stimulation, it has been recommended as an intervention to promote growth and development of preterm and low-birth weight infants.

OBJECTIVES

To determine whether preterm and/or low birth-weight infants exposed to massage experience improved weight gain and earlier discharge compared to infants receiving standard care; to determine whether massage has any other beneficial or harmful effects on this population.

SEARCH STRATEGY

The following databases were searched: the specialized register of the Cochrane Neonatal Review Group and that of the Cochrane Complementary Medicine Field. Searches were also undertaken of the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 3, 2003), MEDLINE, EMBASE, Psychlit, CINAHL and Dissertation Abstracts International (up to July 1, 2003). Further references were obtained by citation tracking, checking personal files and by correspondence with appropriate experts. Data provided in published reports was supplemented by information obtained by correspondence with authors. There were no language restrictions.

SELECTION CRITERIA

Randomised trials in which infants with gestational age at birth <37 weeks or weight at birth <2500g received systematic tactile stimulation by human hands. At least one outcome assessing weight gain, length of stay, behaviour or development must be reported.

DATA COLLECTION AND ANALYSIS

Data extracted from each trial were baseline characteristics of sample, weight gain, length of stay and behavioural and developmental outcomes. Physiological and biochemical outcomes were not recorded. Data were extracted by three reviewers independently. Statistical analysis was conducted using the standard Cochrane Collaboration methods.

MAIN RESULTS

Massage interventions improved daily weight gain by 5.1g (95% CI 3.5, 6.7g). There is no evidence that gentle, still touch is of benefit (increase in daily weight gain 0.2g; 95% CI -1.2, 1.6g). Massage interventions also appeared to reduce length of stay by 4.5 days (95% CI 2.4, 6.5) though there are methodological concerns about the blinding of this outcome. There was also some evidence that massage interventions have a slight, positive effect on postnatal complications and weight at 4 - 6 months. However, serious concerns about the methodological quality of the included studies, particularly with respect to selective reporting of outcomes, weaken credibility in these findings.

REVIEWERS' CONCLUSIONS

Evidence that massage for preterm infants is of benefit for developmental outcomes is weak and does not warrant wider use of preterm infant massage. Where massage is currently provided by nurses, consideration should be given as to whether this is a cost-effective use of time. Future research should assess the effects of massage interventions on clinical outcome measures, such as medical complications or length of stay, and on process-of-care outcomes, such as care-giver or parental satisfaction.

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

BACKGROUND

Early skin-to-skin contact involves placing the naked baby prone on the mother's bare chest at birth or soon afterwards (< 24 hour). This could represent a 'sensitive period' for priming mothers and infants to develop a synchronous, reciprocal, interaction pattern, provided they are together and in intimate contact. Routine separation shortly after hospital birth is a uniquely Western cultural phenomenon that may be associated with harmful effects including discouragement of successful breastfeeding.

OBJECTIVES

To assess the effects of early skin-to-skin contact on breastfeeding, behavior, and physiology in mothers and their healthy newborn infants.

SEARCH STRATEGY

The Cochrane Pregnancy and Childbirth Group and Neonatal Group trials registers (December 2002), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 4, 2002), MEDLINE (1976 to 2002).

SELECTION CRITERIA

Randomized and quasi-randomized clinical trials comparing early skin-to-skin contact with usual hospital care.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data. We contacted study authors for additional information. We collected adverse effects information from the trials.

MAIN RESULTS

Seventeen studies, involving 806 participants, were included. We found statistically significant and positive effects of early skin-to-skin contact on breastfeeding at one to three months postbirth (odds ratio (OR) 2.15, 95% confidence interval (CI) 1.10 to 4.22), breastfeeding duration (weighted mean difference (WMD) 41.99, 95% CI 13.97 to 70.00), maintenance of infant temperature in the neutral thermal range (OR 12.18, 95% CI 2.04 to 72.91), infant blood glucose (WMD 11.07, 95% CI 3.97 to 18.17), infant crying (OR 21.89, 95% CI 5.19 to 92.30) and summary scores of maternal affectionate love/touch (SMD 0.73, 95% CI 0.36 to 1.11) during an observed breastfeeding within the first few days postbirth. We found no statistically significant benefit of early skin-to-skin contact for other major clinical variables: breastmilk maturation, maternal chest circumference, infant heart rate.

REVIEWER'S CONCLUSIONS

Limitations included the methodological quality of the studies, variations in the implementation of the intervention and outcome variability. Early skin-to-skin contact appears to have some clinical benefit especially regarding breastfeeding outcomes and infant crying and has no apparent short or long-term negative effects. Further investigation is recommended. To facilitate meta-analysis of the data, future research in this area should involve outcome measures consistent with those used in the studies included here. Published reports should also clearly indicate if the intervention was skin-to-skin contact and include means, standard deviations and exact probability values.

The oxytocin receptor system: structure, function, and regulation

The neurohypophysial peptide oxytocin (OT) and OT-like hormones facilitate reproduction in all vertebrates at several levels. The major site of OT gene expression is the magnocellular neurons of the hypothalamic paraventricular and supraoptic nuclei. In response to a variety of stimuli such as suckling, parturition, or certain kinds of stress, the processed OT peptide is released from the posterior pituitary into the systemic circulation. Such stimuli also lead to an intranuclear release of OT. Moreover, oxytocinergic neurons display widespread projections throughout the central nervous system. However, OT is also synthesized in peripheral tissues, e.g., uterus, placenta, amnion, corpus luteum, testis, and heart. The OT receptor is a typical class I G protein-coupled receptor that is primarily coupled via G(q) proteins to phospholipase C-beta. The high-affinity receptor state requires both Mg(2+) and cholesterol, which probably function as allosteric modulators. The agonist-binding region of the receptor has been characterized by mutagenesis and molecular modeling and is different from the antagonist binding site. The function and physiological regulation of the OT system is strongly steroid dependent. However, this is, unexpectedly, only partially reflected by the promoter sequences in the OT receptor gene. The classical actions of OT are stimulation of uterine smooth muscle contraction during labor and milk ejection during lactation. While the essential role of OT for the milk let-down reflex has been confirmed in OT-deficient mice, OT's role in parturition is obviously more complex. Before the onset of labor, uterine sensitivity to OT markedly increases concomitant with a strong upregulation of OT receptors in the myometrium and, to a lesser extent, in the decidua where OT stimulates the release of PGF(2 alpha). Experiments with transgenic mice suggest that OT acts as a luteotrophic hormone opposing the luteolytic action of PGF(2 alpha). Thus, to initiate labor, it might be essential to generate sufficient PGF(2 alpha) to overcome the luteotrophic action of OT in late gestation. OT also plays an important role in many other reproduction-related functions, such as control of the estrous cycle length, follicle luteinization in the ovary, and ovarian steroidogenesis. In the male, OT is a potent stimulator of spontaneous erections in rats and is involved in ejaculation. OT receptors have also been identified in other tissues, including the kidney, heart, thymus, pancreas, and adipocytes. For example, in the rat, OT is a cardiovascular hormone acting in concert with atrial natriuretic peptide to induce natriuresis and kaliuresis. The central actions of OT range from the modulation of the neuroendocrine reflexes to the establishment of complex social and bonding behaviors related to the reproduction and care of the offspring. OT exerts potent antistress effects that may facilitate pair bonds. Overall, the regulation by gonadal and adrenal steroids is one of the most remarkable features of the OT system and is, unfortunately, the least understood. One has to conclude that the physiological regulation of the OT system will remain puzzling as long as the molecular mechanisms of genomic and nongenomic actions of steroids have not been clarified.

Postpartum maternal oxytocin release by newborns: effects of infant hand massage and sucking

BACKGROUND

Newborns placed skin-to-skin with their mothers show an inborn sequence of behavior similar to that seen in other mammals. The purpose of this study was to make a detailed exploration of hand movements and sucking behavior in healthy term newborns who were placed skin-to-skin on their mothers' chests, and to study maternal oxytocin release in relation to these behaviors.

METHODS

Ten vaginally delivered infants whose mothers had not been exposed to maternal analgesia were video-recorded from birth until the first breastfeeding. Video protocols were developed based on observations of the videotapes. Each infant's hand, finger, mouth, and tongue movements, positions of the hand and body, and sucking behavior were assessed every 30 seconds. Maternal blood samples were collected every 15 minutes, and oxytocin levels were analyzed by radioimmunoassay. A statistical test for establishing the relationship between maternal oxytocin levels and infants' hand movements or sucking behavior was developed.

RESULTS

Infants used their hands to explore and stimulate their mother's breast in preparation for the first breastfeeding. A coordinated pattern of infant hand and sucking movements was also identified. When the infants were sucking, the massagelike hand movements stopped and started again when the infants made a sucking pause. Periods of increased massagelike hand movements or sucking of the mother's breast were followed by an increase in maternal oxytocin levels (p < 0.005).

CONCLUSIONS

The findings indicate that the newborns use their hands as well as their mouths to stimulate maternal oxytocin release after birth, which may have significance for uterine contraction, milk ejection, and mother-infant interaction.

Massage for promoting growth and development of preterm and/or low birth-weight infants

BACKGROUND

It has been argued that infants in Neonatal Intensive Care Units are subject both to a highly stressful environment - continuous, high-intensity noise and bright light - and to a lack of the tactile stimulation that they would otherwise experience in the womb or in general mothering care. As massage seems to both decrease stress and provide tactile stimulation, it has been recommended as an intervention to promote growth and development of preterm and low-birth weight infants.

OBJECTIVES

To determine whether preterm and / or low birth-weight infants exposed to massage experience improved weight gain and earlier discharge compared to infants receiving standard care; to determine whether massage has any other beneficial or harmful effects on this population.

SEARCH STRATEGY

Databases were searched using the term 'massage', 'touch' or 'tactile stimulation' with 'infant - newborn', 'infant - premature' and 'infant - low birth weight'. The main databases searched were those of the Cochrane Collaboration Field in Complementary Medicine and the Neonatal Collaborative Review Group.

SELECTION CRITERIA

Randomised trials in which infants with gestational age at birth < 37 weeks or weight at birth < 2500g received systematic tactile stimulation by human hands. At least one outcome assessing weight gain, length of stay, behaviour or development must be reported.

DATA COLLECTION AND ANALYSIS

Data extracted from each trial were baseline characteristics of sample, weight gain, length of stay and behavioural and developmental outcomes. Physiological and biochemical outcomes were not recorded. Data were extracted by three reviewers independently. Statistical analysis was conducted using the standard Cochrane Collaboration methods.

MAIN RESULTS

Massage interventions improved daily weight gain by 5g (95% CI 3.5, 6.7g). There is no evidence that gentle, still touch is of benefit (increase in daily weight gain -0.2g; 95% CI -2.4, 1.9g). Massage interventions also appeared to reduce length of stay by 4.6 days (95% CI 2.6, 6.6) though there are methodological concerns about the blinding of this outcome. There was also some evidence that massage interventions have a slight, positive effect on postnatal complications and weight at 4 - 6 months. However, serious concerns about the methodological quality of the included studies, particularly with respect to selective reporting of outcomes, weaken credibility in these findings.

REVIEWER'S CONCLUSIONS

Evidence that massage for preterm infants is of benefit for developmental outcomes is weak and does not warrant wider use of preterm infant massage. Where massage is currently provided by nurses, consideration should be given as to whether this is a cost-effective use of time. Future research should assess the effects of massage interventions on clinical outcome measures, such as medical complications or length of stay, and on process-of-care outcomes, such as care-giver or parental satisfaction.

Central nervous system actions of oxytocin and modulation of behavior in humans

The posterior pituitary hormone oxytocin has modulatory effects on neural functioning that are significant to the regulation of behavior. Basic research in animals has established the importance of oxytocin in affiliation, including mating, pair bonding and parenting behaviors. It is also an important regulator of feeding, grooming and responses to stress. The actions of oxytocin in the brain are regulated by gonadal steroid hormones, particularly estrogen. Oxytocin might also influence normal behavior in humans, and dysfunctions in the oxytocin system might be involved in the etiology and expression of neuropsychiatric disorders.

Neuroendocrinology of the mother-child interaction

Mother-child interaction is usually described in psychological terms; however, it is becoming increasingly clear that neuroendocrine mechanisms are involved in the mother-child interaction. Mother and fetus influence each other by hormonal mechanisms in utero, and after birth, mother and child interact by way of sensory stimulation. In the breastfeeding situation, the infant's suckling stimulates maternal oxytocin and PRL release and, thereby, milk production and release. In addition, oxytocin, by way of circulating and central neurogenic oxytocinergic mechanisms, adapts maternal physiology and endocrinology to allow milk production. At the same time, suckling influences the physiology and endocrinology of the infant to optimize the growth process. It seems that tactile, olfactory, visual, and perhaps other types of sensory stimuli contribute to the adaptive changes in both mother and infant. In addition, behavioral changes are induced in the mother in connection with birth and breastfeeding. Data are accumulating that suggest that the attachment between mother and infant is facilitated by skin-to-skin contact early postpartum. Furthermore, calm and social interactive behavior is promoted in the mother. Central oxytocinergic mechanisms activated in connection with birth and breastfeeding seem to be involved in the behavioral changes.

Effects of maternal pethidine on infants' developing breast feeding behaviour

The aim of this quasi-experimental study was to examine the effects of maternal pethidine during labour on the developing breast feeding behaviour in infants in the first 2 h after birth compared with infants not exposed to pethidine. Forty-four healthy infants were observed immediately after birth. They were placed skin-to-skin on their mothers' chests. The development of mouth and sucking movements as well as rooting behaviour and state of sleep/wakefulness were noted. The observer was blind as to the pain relief the mother had received during labour. Of the 44 mothers 18 had received pethidine. The main findings were that infants exposed to pethidine had delayed and depressed sucking and rooting behaviour. In addition, a smaller proportion of infants exposed to pethidine started to suckle the breast. Rooting movements which are expected to be vigorous at 30 min after birth were affected both by administration of pethidine and a longer second stage of labour. It is suggested that the differences found in sucking behaviour may be a central effect of pethidine. Depression of rooting movements in the pethidine group may be caused by exhaustion due to a longer second stage of labour and administration of pethidine. It is recommended that pethidine-exposed mother-infant couples stay together after birth long enough to enable the infant to make the choice to attach or not to attach to the nipple without the forceful helping hand of the health staff.

Mothers' parenting self-appraisals: the contribution of perceived infant temperament

To learn how a mother's perception of her infant's temperament contributes to her appraisal of her parenting and of her problem-solving competence during the first 3 months postpartum, we explored a conceptual model, including infant gender and maternal attributes (education and parity) and the personal and social context of the parenting experience (infant centrality and life change), in a sample of 117 mothers. The set of temperament variables contributed to the variance in both parenting evaluation and problem-solving competence at 1 and 3 months. The pattern of infant temperament variables contributing to maternal self-appraisal variables at 1 and at 3 months suggests change in the temperament variables that are salient to mothers as the infants grow older.

Influences on the Extent of Breast-Feeding: A Prospective Study in the PhiLippines

There has been much controversy about the impact of the health sector and the infant food industry on breast-feeding behavior. This study links causal factors to breast-feeding decisions, using a longitudinal survey of more than 3,000 Filipino mother-infant pairs. Most factors decreasing the likelihood that mothers will breast-feed seem to be related to family economics. Delivery in a private hospital, urban residence, high income, absence of spouse, and having worked for wages affect adversely the initiation of breast-feeding. Formula advertising and distribution of samples appear to have relatively little impact on feeding decisions.

Short-term effects of early suckling and touch of the nipple on maternal behaviour

The objective was to evaluate the effects of suckling within 30 min after birth when skin-to-skin body contact for mothers and infants was held constant in both cases (n = 32) and control groups (n = 25). Mother-infant interaction during breast-feeding, infants' time spent in nursery and different aspects of breast-feeding were evaluated. Prolactin and gastrin were measured in maternal serum before and after breast-feeding on day 4 post partum. The aim to evaluate effects of early post delivery suckling failed since only six of the 32 case infants did suck at this time. In spite of this, we found three significant differences among cases and controls. In the case group where all infants had touched or licked the areola and nipple, the mothers left the infants in the nursery for a significantly shorter time and significantly more mothers talked to their infants during the short breast-feeding observation. Median gastrin levels were significantly lower in cases than in controls both before (P less than 0.01) and after (P less than 0.03) breast-feeding. In conclusion, the infant's early touch of the mother's areola and nipple seemed to have positively influenced the mother/infant relationship during the first four days after birth. It was also associated with lower maternal gastrin levels which suggests that maternal neuroendocrine functions were also influenced. Ten months after birth, we found no differences between cases and controls.

What being the parent of a new baby is like: revision of an instrument

Revision of the self-report instrument, What Being the Parent of a New Baby Is Like (WPL), is reported. The WPL, developed to examine parents' perceptions of themselves as parents and of the parenting experience with young infants, was revised by improving its two subscales, Success (renamed Evaluation) and Centrality, and adding a third subscale, Life Change. With a sample of mothers of healthy infants, all three subscales of the revised instrument, WPL-R, had acceptable levels of internal consistency at 7, 30, and 90 days postpartum, and stability across administrations. Parity differences were demonstrated for all three subscales at 7 days and for Centrality at 30 days. Factor analysis identified item clusters consistent with the three subscales. With improved subscales affording a more comprehensive assessment of maternal experience, the WPL-R is a better instrument for evaluation of maternal adaptation than the WPL.

Long-term effect on mother-infant behaviour of extra contact during the first hour post partum. V. Follow-up at three years

Primiparous mothers and their infants who had had an extra 15-20 minutes skin-to-skin and suckling contact (P+) during the first hour after delivery behaved differently, had a longer duration of breast-feeding, and expressed different opinions on child rearing practices at follow-ups 36 hours, 3 and 12 months after delivery as compared with a control group (P) of primiparous mothers and their infants, who were given routine care immediately after birth. The present report is based on parts of the results of the follow-up at 3 years. Asked in retrospect more P mothers found the time together with their infants immediately after delivery to have been insufficient. More P+ children were reported to have been earlier continent during the day and also earlier stubborn than the children in the P group. The Denver Developmental Screening Test showed similar results in both groups. Catecholamine levels in the urine of extra contact mothers and their boys were found to be slightly higher than those of routine care mothers and boys. Two separate analyses of video-tapes of free play showed that mothers and children in the P+ group were smiling/laughing more often than P mothers and children. The P+ mothers were more encouraging and instructing towards their children than the P mothers. Articulated conflicts were more common in the P+ group. Regardless of the type of conflict, more conflicts in the P+ group were solved. As in earlier parts of this longitudinal study differences related to type of neonatal care were more pronounced for boy-mother than for girl-mother pairs.

The interaction between the infant and the environment: the importance of mother-child contact after delivery

Birth is more than just the physical beginning of a new life--it is also the start of the psychosocial development of the newborn infant together with its family. Immediately after delivery parents and infants can start to exchange signals that maybe are of major importance for this development. The early post partum period has been regarded to have great potentials and especially the mother has been regarded to play a very powerful role, whereas the infant's contribution has been accorded little discussion. The individual reactive capacity of the newborn baby and its influence on the environment can be illustrated in a number of ways. In recent years studies of fetal movements have been made by means of ultra sound registration and it has been discussed whether these are precursors of later behavior in the neonate-infant. The transition at birth can be considered either to be continuous or dis-continuous, the outcome of this discussion has great bearing on the importance of early neonate-environment interactions. Short and long term outcome of different routine care procedures around the time of delivery and transition are controversial subjects. Although several studies support the importance of early post delivery interaction, other studies do not seem to find correlations between early experiences and later developmental outcome measurements. In this paper several of these aspects will be discussed, examples from the literature given and possible clinical applications suggested, as well as their impact on the care of healthy and sick newborns and their families.

Breast feeding of low birthweight infants

The incidence and length of breast feeding of LBW (less than or equal to 2500 grams) infants were investigated. A marked increase from 1979 to 1982 was noted: the incidence rose from 78% to 91% and the proportion of infants breast fed for 3 months rose from 54% to 67%. A breast feeding promotion programme did not influence the length of breast feeding of LBW infants within one year of the intervention. Smaller infants, those with RDS and those from lower social classes were breast fed less than others.

Extra early physical contact and aspects of the early mother-infant relationship

We tested the hypothesis that extra early physical contact between mother and infant enhances aspects of their early relationship. Healthy, middle-class mothers and their healthy, firstborn, singleton infants delivered vaginally at full-term were randomly assigned to receive either regular contact (RC; N = 39) or extra early physical contact (EC; N = 39) following delivery. RC infants remained in cribs beside their mothers' beds, while EC infants and mothers had a mean of 46 min of physical contact in the recovery room. There was no difference between EC and RC subjects for the following outcome measures: amount of time mothers chose to have infants with them during the postpartum hospital stay; quality of mother-infant interaction at two days and one month; concern mothers expressed for the infant at one month; mothers' perception of their postpartum adjustment; mothers' perception of the infant at two days and one month, and of the infant's temperament at eight months; and extent of mothers' assisting with and soothing the child during a physical examination at 13 months. EC children cried significantly less during the examination at 13 months. These findings do not support the hypothesis that extra early physical contact between mother and infant enhances their relationship.

Long-term effect on mother-infant behaviour of extra contact during the first hour post partum. III. Follow-up at one year

The present prospective study examined, one year after delivery, the possible effects of early extra contact during the first hour following delivery. An extra skin-to-skin contact and suckling contact was allowed 22 primiparous mothers and their infants (P + group). One control group of 20 primiparous mothers and their infants were given routine care immediately after birth (P group). During observation of a physical examination of the infant, 'extra contact mothers' held and touched their infants more frequently and more often talked positively to their infants than did mothers given routine care. 'Extra contact mothers' had returned to their professional employment outside the home to a lesser extent than had routine care mothers. A greater proportion of 'extra contact' infants slept in a room of their own. In the P+ group, mothers who had returned to gainful employment were also able to have their babies sleep in a room of their own--no such correspondence was found in the P group. The Gesell Developmental Schedules revealed that, in four parts out of five, infants with extra contact immediately after birth, were ahead of those in the control group. On the other hand, the Vineland Social Maturity Scale and the Cesarec Marke Personality Scheme did not reveal any major differences between the two groups. Mothers with early extra skin-to-skin contact and suckling contact breast-fed their infants on an average for 2 1/2 months longer than did routine care mothers. No other differences in feeding habits were found. The influence of extra contact was more pronounced in boy-mother than in girl-mother pairs.