Running head: SKIN TO SKIN CONTACT AND BREASTFEEDING 1

The Effects of Skin-to-Skin Contact on Exclusively Breastfeeding

Courtney P. Whyte

University of South Florida

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Abstract

Clinical Problem: The standard of practice currently is that mothers and infants are separated

immediately after birth, evaluated then the infant is placed in the mothers arms or underneath a

warmer which prevents from the baby having skin-to-skin contact and easy access to the breast

to initiate feeding.

Objective: The purpose of this synthesis paper is to examine if early skin to skin contact

compared to routine care improves the likelihood of exclusively breastfeeding for the first month

of life. In order to find randomized control trials, PubMed was utilized to find trials related to the

objective question.

Results: Initiating skin-to-skin contact immediately after birth compared to routine care has

increased the continuation of exclusively breastfeeding for the first month of life. This is evident

through the randomized control trials that were performed. Khadivzadeh, Karimi, Tara, &

Bagheri (2017) found that skin-to-skin contact within the first two hours postpartum

considerably improves the number of mothers who will continue breastfeeding exclusively for

the first month of life as evidenced by p<0.05. Mahmood, Jamal, and Khan (2011) examined the

effects of skin-to-skin contact versus routine care on the success of first breastfeeding (p=0.001),

initiation of first feed (p<0.001), and exclusively breastfed for the first month of life (p=0.025).

Moore, Bergman, Anderson, and Medley (2016) used skin-to-skin contact to evaluate the success

of the first feed (CI 1.04 to 1.67) and exclusively breastfeeding for the first month of life (CI

1.12 to 1.49).

Conclusion: Skin-to-skin contact performed immediately after birth compared to routine care has

been proven to help the initiation, success, and continuation of exclusively breastfeeding.

Keywords: Infants, skin-to-skin contact, breastfeeding

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The Effects of Skin-to-Skin Contact on Exclusively Breastfeeding

The benefits of breastfeeding are numerous but the greatest benefit is that it’s the most

nutritious source of foods for infants (World Health Organization [WHO], 2016). Infants are

born with an innate ability to search for food, this ability is referred to as the breast crawl. The

breast crawl occurs when the baby is first born and is placed on the mothers abdomen. The infant

then uses its legs to push its way up the mother, in search of the breast. Once it reaches the

breast, it then can decide if it wants to latch on and feed or wait. (United Nations International

Children’s Emergency Fund [UNICEF], 2007). To initiate this process of the breast crawl,

infants need to be placed on the mothers bare skin. Currently, the standard of practice is to

separate the baby from the mother as she is recovering and to place the infant under a warmer

and to evaluate them there. Placing the infant on the mothers skin promotes bonding as well as

the mothers skin helps to regulate the infants temperature, (Moore et al., 2016). To initiate this

process of the breast crawl, infants need to be placed on the mothers bare skin. Therefore,

initiating skin-to-skin contact (SSC) immediately after birth will help with the breast crawl and

hopefully the initiation and continuation of breastfeeding.

Literature Search

In order to locate randomized controlled trials (RCTs) relating to SSC and exclusively

breastfeeding for the first month of life, the search engine PubMed was utilized. To find relevant

RCTs the keywords infant, skin-to-skin contact, and breastfeeding were searched. Articles

published within the past ten years (2008-2018) appeared in the search results.

Literature Review

To determine the effectiveness of using SSC to improve the number of mothers

exclusively breastfeeding for the first month of life three RCTs were used. The Baby Friendly
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Hospital Initiative is a guideline that has been put into place to help promote SSC immediately

postpartum. The US Preventive Services Task Force (USPSTF) recognizes The Baby Friendly

Hospital Initiative in their recommendation statement regarding primary care interventions to

support breastfeeding (2016). Khadivzadeh et al. (2017) demonstrated that continuous skin-to-

skin contact during first two hours post-partum improved the likelihood of the continuation of

exclusively breastfeeding for the first twenty-eight days of life.114 healthy primiparous

participated in the study, and when admitted to the hospital for labor, they were randomly

assigned to either the control group or the intervention group. For the mothers to be randomly

assigned to either the control or intervention group is a strength for this RCT. 57 mother-infant

dyads (n=57) participated in each group. For the control group, after the mother gave birth, the

baby was taken while the mother had her episiotomy repaired and while the newborn was getting

their routine care, such as APGAR scoring, and as newborn assessment. For the intervention

group, the newborn was placed immediately on the mothers as they repaired the mothers

episiotomy and while the newborn was being assessed. The baby remained on the mothers chest

for at least the first two hours after birth. On the twenty-eighth day after birth, the mothers in

both groups were interviewed on if they had continued to breastfeed and if they were

breastfeeding exclusively. The follow up researchers were blind to which group they were

interviewing but they were aware of what was being studied; this is a strength for the RCT. The

interviewer found that those in the intervention group had a significantly higher rate of

exclusively breastfeeding twenty-eight days after birth than those in the control group (p<0.05).

Other strengths for this RCT trial is that it was conducted long enough to fulfill the purpose of

the study, the demographics and baseline variables were similar between the control and

intervention group and the data was valid and reliable. One weakness that was observed in this
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RCT was that ten mothers and neonates from the intervention group and 12 from the control

group were excluded from the study due to either hospitalization, unable to follow up with, or

discontinuation of participation.

Mahmood et al. (2011) studied the effects of early SSC on the time to initiate the first

feeding, success of first feeding, and exclusive breastfeeding for the first month of life. There

was a total of 183 mother-infant dyads (N=183) and they were randomly placed into either the

control group or intervention group, which is a strength for this trial. 91 of the pairs were placed

in the control group (n=91), and the other 92 pairs in the intervention group (n=92). The

participants were made aware of what group that they were in, which is a weakness for this RCT.

For the intervention group, after giving birth, the infants were immediately placed on the mothers

abdomen, dried off then placed between the mothers breasts on their bellies, to help facilitate

initiation of breastfeeding. To help prevent heat loss, the infants wore a cap, and had a warmed

blanket placed over them. In the control group, after birth, they were taken to the warmer where

they were dried off, wrapped in a warm sheet and taken to the postpartum ward with their mother

and would begin breastfeeding with the mother felt comfortable to do so. After the first month,

the women were interviewed on if they were exclusively breastfeeding or not. The interviewers

were not blind to the trial which is seen as a weakness for this trial. The interviewers found that

those in the intervention group were more successful in exclusively breastfeeding for the first

month of life as evidenced by p=0.025. The participants in each group had similar demographics

which is a strength, but didn’t have similar baselines which is a weakness for the trial. The chi

squared and t-test were used to evaluate the data, which was found to be reliable and valid. This

RCT supports the early implementation of SSC to promote the continuation of exclusively

breastfeeding for the first month of life.

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Moore et al. (2016) conducted a total of thirty-eight different trials to determine the

efficacy of immediate or early SSC on the establishment and continuation of exclusively

breastfeeding one month postpartum compared to routine care. A total of 3,472 mother and infant

pairs participated in one of the thirty-eight trials (N=3,472). With their being so many trials no

trial met all criteria for good quality with respect to methodology and reporting as well as no trial

was successfully blinded. The trials were consistent in the essence that participants were

randomly assigned into either the control or intervention group and were analyzed in each group

accordingly. The data is valid but is not reliable, the author suggests that more trials be

performed as well include larger sample sizes for each trial. The overall data supports the use of

SSC to promote exclusively breastfeeding for the first month of life. Mother infant pairs that

were in the intervention group in their respective trial, were more likely to be exclusively

breastfeeding one month after birth as evidence by a 95% confidence interval (CI) of 1.12 to

1.49.

Synthesis

Khadivzadeh et al. (2017) found that continuous SSC during the first 2 hours postpartum

considerably improves the number of mothers breastfeeding in the first 30 minutes of life and

exclusive breastfeeding in the neonatal period as supported by p<0.05. Mahmood et al. (2011)

demonstrated that early SSC contact significantly enhances the success of breastfeeding

(p<0.001) and exclusively breastfeeding for the first month of life (p=0.025). Moore et al.

provides evidence that supports the use of SSC to promote breastfeeding (CI 1.12 to 1.49), but

the data is not reliable.

One of the weakness with these RCTs is the consistency of participants and the

population that the trials are looking at. For most of these trials one of the guidelines to be
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included in the trial was to have the intention to breastfeed. The intention to breastfeed is a

variable that needs to be considered when looking at the data. Would the success rate of

exclusively breastfeeding for the first month of life change if those who weren’t planning on

breastfeeding were included in the trial and provided the resources and support to breastfeed?

These are some of the things that need to be taken into account and reevaluated.

Clinical Recommendation

The Baby-Friendly Hospital Initiate is based off of the 10 Steps to Successful

Breastfeeding for Hospital and is considered the gold standard of care. In order to be a

designated Baby-Friendly hospital, this hospital has to follow the ten steps and are continually

evaluated to make sure they are maintaining these guidelines set out by the team of global

experts and evidenced base research that supports the steps. The USPSTF (2016) states that “the

Baby-Friendly Hospital Initiate is the most widely implemented system-level intervention.”

Other system-level intervention that the USPSTF recommended to improve breastfeeding

success is skin-to-skin contact, room-in care, and restriction of pacifier use. The American

College of Obstetricians and Gynecologists (ACOG), supports the use of the ten steps to support

mothers in achieving their goals in regards to breastfeeding. The USPSTF does recommend that

more research be conducted and variables in regards to population choice be changed and

evaluated. Currently the trials conducted focuses on mothers who already have the intention to

breastfeed, whereas the focus needs to be on those who don’t have intention to do so and in

populations who have low breastfeeding rates.

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References

Baby-Friendly USA. (2012). The guidelines and evaluation criteria. Retrieved from:

https://www.babyfriendlyusa.org/get-started/the-guidelines-evaluation-criteria

Khadivzadeh, T., Karimi, F., Tara, F., & Bagheri, S. (2017). The effect of postpartum mother-

infant skin-to-skin contact on exclusive breastfeeding in neonatal period: A randomized

controlled trial. International Journal of Pediatrics, 5(7), 5409-5417.

doi:10.22038/ijp.2016.7522

Mahmood, I., Jamal, M., & Khan, N. (2011). Effect of mother-infant early skin-to-skin contact

on breastfeeding status: a randomized control trial. Journal of the College of Physicians

and Surgeons—Pakistan, 21(10), 601-605. doi: 10.2011/JCPSP.601605.

Moore, E.R., Bergman, N., Anderson, G.C., & Medley, N. (2016). Early skin-to-skin contact for

mothers and their healthy newborn infants. Cochrane Database of Systematic Reviews,

11(1), 1-163. doi: 10.1002/14651858.CD003519.pub4.

United Nations International Children’s Emergency Fund. (2007). ‘Breast crawl’ phenomenon

benefits mothers and newborns. Retrieved from:

https://www.unicef.org/nutrition/india_40548.html.

US Preventive Services Task Force. (2016). Primary care interventions to support breastfeeding:

US preventive services task force recommendation statement. Journal of American

Medical Association, 316(16),1688–1693. doi:10.1001/jama.2016.14697

World Health Organization. (2016). World breastfeeding week. Retrieved from:

http://www.who.int/mediacentre/events/2016/world-breastfeeding-week/en/