Breathing

• Right after birth

the most important thing
for the infant is to
- start breathing, and then
- establish an optimal respiration.

• This happens more easily when

a baby is placed STS, instead of
experiencing the physiological stress of
separation.
(Christensson K et al. Acta Paediatrica 1992;81:488-93.)
 Prematures kept STS:
More stable heart-lung function
Also premature infants
have higher oxygen
levels and greater
heart-lung stability
when they are STS
than when they are
kept in incubators
Bergman NJ et al.
Acta Paediatr. 2004
 Mammalian ”protest-despair”
No will to live?
• 34 infants 1.2-2.2 kg RCT
by computer before birth
to STS or control.
• After 6 hrs:
all STS-infants (8/18)
as opposed to
6/13 incubator infants
were hearth-lung stable.
• Cardio-respiratory instability in separated
infants is consistent with ”protest-
despair”/”dissociation”.
• Bergman NJ et al, Acta Paediatr. 2004
Born wet, into cool, baby gets cold
• Also term newborns are often put in
incubators or wrapped in warm blankets to
help them maintain an optimal temperature.
• A number of studies have demonstrated
that skin-to-skin contact with mother
is better for regulating
the baby’s temperature.

(Christensson K et al.1992, Bergman et al. 2004)

 Rewarming hypothermic
newborns
Christensson K et al. Lancet 1998;352:1115

Cumulative proportion of rewarmed infants

100
% reaching 36.5°C

80
60 skin-to-skin
40 incubator

20
0
0 60 120 180 240 300 360 420 480 540 600
Time (minutes)
(By compliments of A.Cattaneo)

C
 It’s warmest up front
• A mother’s chest gets warmer during STS
• Lactating breasts are warmer than non-
lactating ones.

• An infant in a “maternal nest”, made up of

her chest and arms, will have a higher
temperature than one placed in a warmed
cot.
Uvnäs-Moberg K. 2000
 Blood sugar and metabolism
Low bloodsugar, hypoglucemia, is common
in newborns after an hour or more.
50 healthy, term babies randomized to be:
- placed STS with mother, or
- “separated”, put in cot next to mother
90 minutes after birth those placed STS
had significantly higher blood-glucose
and maintained their bloodglucose better
even without feeding.
Christensson K. et al. Acta Paediatr 1992)
 Cold hands and feet need energy

Separation:
Colder babies have lower bloodsugar
This may have to do e.g. with less optimal
bloodcirculation, as the small vessels
contract in babies kept in their cots,
resulting particularly in colder hands and
feet for hours, requiring more energy.
Uvnäs-Moberg K. Acta Paediatr 1989.
 Crying: a separation distress call?
Newborns obs. for 90 min.
randomized to
• A) STS with mother
• B) Cot
• C) Cot, then STS
Infants recognize separation,
cry in pulses, stop at reunion.
Genetically encoded reaction.
Christensson K et al. Acta Paediatr 1995
 Baby’s calling affects mother
• Most newborns will after a while emitt
calling sound like ”eh!, eh!”
• AM Widstrøm was a pioneer in making us all
concious of this every-day event.
• Most mothers will react to baby’s call by
talking to the infant, some for the first time.
• Most mothers recognize the voice of their
own babies in the maternity ward.
 Mother's voice organize brain
function in the newborn
• Mother’s well known voice has a strong
influence on the newborn with both
acute and enduring effects on the
developing brain.
• This has ramifications for the development
of the auditory system, as well as for later
social and emotional development.
• New York State Psychiatric Institute, Fifer WP, Moon
CM..Acta Paediatr Suppl. 1994 Jun;397:86-93
 Love at first sight?
Right after birth
most babies
• are wide awake,
• can see well
• have visual
preferences:
they want
to see a face!

Faroni T et al. Proc Natl Acad Sci

2005
 Organized pre-feeding behaviour
• Most unsedated newborns placed STS will
undergo the now well known behaviour
with ”crawling”, touching, tongue- and
lipmovements, calling, rooting, sucking.

• Breastfeeding initiated after such an

uninterupted sequence of events is very
often successfull also long term.
• Widstrøm AM at al Acta Paedr Scand 1987
Baby’s touch does things to mom?

• Baby’s post partum contact with the breast

influences later maternal behaviour:
• Mothers whose infants had touched or
licked the areola and nipple within 30 min.
• left babies less in the nursery (p<.002) and
• talked more to them during breastfeeding
on day four (31/31 vs 18/25)
• Widstom AM et al. Early Hum Dev. 1990
Hands on: Touch releases oxytocin
• 10 newborns were placed STS and
videofilmed with assessment every 30 sek.
• Blood tests from mother every 15 min.
• Infants used their hands to explore and
stimulate the breast before feeding,
resulting in surges of oxytocin in mother.
During suckling baby’s hands were still,
but restarted during pauses in suckling.
• Mattiesen AS et al. Birth 2001
 Areolar scent attracts baby
The more
areolar skin glands
the better neonatal
weight gain,
onset of lactation,
maternal perception
of latch on
and sucking,
on day 1-3
Schaal B Dev Psychobiol 2006
,
 Infants recognize odour of own
mother’s milk after early STS
60 healthy, full-term neonates randomly
assigned to STS postpartum or control
• 1 and 4 d after birth STS infants
responded differently to own mother’s milk
compared to another mother’s milk,
formula, orange juice, distilled water.
• STS infants: larger difference at 4 days
• STS infants were breastfed an average of
1.9 months longer.
Mizuno k et al. Acta Paediatrica 2004;93:1640-45
 STS and neurobehavioral
responses of the term newborn
• 15 min after birth 47 healthy infants RCT:
A) STS lasting another hour, or
B) Standard care in nursery
• After 4 hrs: one hour-long observation:
infants who had been STS slept longer,
were mostly in a quiet sleep state,
had more flexor movements and postures
showed less extensor movements
• STS seems to influence neurobehaviour
and system modulation of the newborn
• Goldstein Ferber S, Makhoul IR.. Pediatrics 2004;113 858-65
 Early STS - Lasting psycologic
effect on newborn humans?
Newborn rats: Separation from mother
results in disturbance not only of e.g.
• future hormone regulation, but of
• future behaviour as well.
In humans there is some evidence that early
separation may disturb subtle processes
influencing both body and mind and
future social relationships.
Hofer MA Acta Paediatr Suppl 1994
 Neonatal brain: sensitive periods

Mammalian imprinting models are

of critical importance in mammals,
including humans
Newborn neural circuitry including
amygdala: different from adult.
”The brain of a newborn is uniquely
designed to optimize attachment.”
Moriceau S & Sullivan RM. Dev Psykobiol 2005
 Can we make up for lost time?
• Luckily there seems to be compensatory
mechanisms particularly in young who
depends for a long time on parental care.
• Humans have their large brains,and can
use reason, inventivenes, emotional
reassurance, patience etc to make up:
”Environmental enrichment during the
peripubertal period” Francis DDJ Neurosci. 2002
But what about vulnerable families?
STS and maternal stress, mood,
heart rate and cortisol
Premature infants 25-33 w
STS mothers compared to ctrl:
salivary cortisol down (32%)
lower heart rates (7%)
less stress (89%)
improved mood (6%)
STS Infants:
lower heart rates
lower pain scores
cortisol up or down
(some need stress?)
Morelius E et al. Pediatrics 2005;116:1105–13
 Maternal psycological well-being
Increased quantity of
neo-maternal exposure
in NICU has a
beneficial effect on
maternal self-esteem
and attatchment

Ahn YM & Kim MR.

Taechan Kanho Hakhoe Chi 2005
 Endorphins promote happiness
• Why do mothers go to all the trouble?
• What’s in it for her – right now?
• In non-human primates beta-endorpin are
central as regulators of
mother-infant interaction,
as well as for groupsocializing.
• In humans, levels of endorpins double
during breastfeeding –peaking after 20 m.
Franceschini R et al. Br J Obstet Gynaecol 1989.
”When I feed you I feel great myself!”
Oxytocin - mediator of STS effects

• Oxytocin - not only usefull for uterine

contractions and milk let-down reflex.
• It has a number of effects in humans:
• Overflows brain to make mom drowsy and
relaxed, improves sleep-quality
• Increases during massage, intercourse
”HORMONE OF LOVE”
• Affects men, but w. much more sensitive
                                                                

.Frightful faces trigges activity in amygdala. In subj. who had sniffed

oxytocin there was a dramtic reduction, suggesting that oxytocin
Functional magnetic resonance imaging data (red) superimposed on structural MRI scans. Frightful faces triggered a dramatic reduction in amygdala activity in subjects who had sniffed oxytocin, suggesting that oxytocin mediates social fear and trust via
the amygdala and related circuitry.

mediates trust. Kirsch P et al. J Neurosci, 25(49):11489-93, 2005.

Departments
involved

• Obstetrics
• Maternity
• Operating theatre
• Anesthesiology
• Postopertive (PO/Recovery)
• Pediatrics (Neonatal)
Lower maternal stresshormones
skin-to-skin
Mothers with baby STS:

• salivary cortisol down

• lower heart rates
• less stress
• improved mood
Morelius E et al.
Pediatrics 2005;116:1105–13

Extra important in C-section mothers?

                                                                

.Frightful faces trigges activity in amygdala. In subj. who had sniffed

oxytocin there was a dramtic reduction, suggesting that oxytocin
Functional magnetic resonance imaging data (red) superimposed on structural MRI scans. Frightful faces triggered a dramatic reduction in amygdala activity in subjects who had sniffed oxytocin, suggesting that oxytocin mediates social fear and trust via
the amygdala and related circuitry.

mediates trust. Kirsch P et al. J Neurosci, 25(49):11489-93, 2005.

Hands on: Touch releases oxytocin
• 10 newborns were placed STS and
videofilmed with assessment every 30 sek.
• Blood tests from mother every 15 min.
• Infants used their hands to explore and
stimulate the breast before feeding,
resulting in surges of oxytocin in mother.
During suckling baby’s hands were still,
but restarted during pauses in suckling.
• Mattiesen AS et al. Birth 2001
 Elevated p.p. oxytocin
peaks with baby STS

Oxytocin is elevated
particularly the first hour after
delivery – peaks with baby STS.
• After 1 hr oxy returns to pre partum levels.
• Oxy needed in maternal bonding in
animals. Nissen E et al. Acta Obstet Gynecol Scand. 1995
• Oxytocin makes the uterus contract and
reduces bleeding.
 Elevated Oxytocin 1. hour p.p.
• Oxytocin is elevated - particularly the first
hour after delivery – peaks with baby STS.
• After 1 hr oxy returns to pre partum levels.
• Oxy needed in maternal bonding in
animals. Nissen E et al. Acta Obstet Gynecol Scand. 1995
• Oxytocin makes the uterus contract and
reduces bleeding.
• Mothers delivered by c.s.,
particularly prone to hemorrage,
usually do not get their babies the 1. hour.
•
 Maternal nest is warmest, BUT
Dad’s skin also provides heat
• 44 infants randomized after c-section to:
a) incubator b) cot c) STS with father
• Results 2 hrs p.p:
• STS- and incubator-babies
warmer than those kept in a cot
• After 24 hrs: STS-babies warmer than
babies who started out
in cot OR incubator
Christenson K. Acta Paediatr 1996
 Early STS with healthy newborns
Cochrane conclusions:
• Seventeen studies involving 806 infants
• Early STS contact associated with:
– better maintenance of temperature
– better maintenance of blood glucose
– less infant crying
– more breastfeeding at 1-3 months
– longer breastfeeding
– higher scores of maternal affectionate
love/touch during breastfeeding
Anderson GC et al. The Cochrane Library, Issue 2, 2003.
C-section moms and neos miss out
Two groups obs for 24 hrs
of rooming-in, after
• A) Natural birth
• B) Cesarean section
Conclusion:
”Mothers who have c-sections need more
attention to begin breastfeeding.”
Rocha SM et al.Rev Bras Enferm. 2003

C.s.moms who get to keep their babies STS

very early, express great satisfaction.
Unpublished data, 2005 Norway
 Early STS with healthy newborns
Cochrane conclusions:
• Seventeen studies involving 806 infants
• Early STS contact associated with:
– better maintenance of temperature
– better maintenance of blood glucose
– less infant crying
– more breastfeeding at 1-3 months
– longer breastfeeding
– higher scores of maternal affectionate
love/touch during breastfeeding
Anderson GC et al. The Cochrane Library, Issue 2, 2003.
Yes, please, support from both
modern medicine and “nature”
• Measurable “hard” facts have typically
dominated modern medicine.
• Today exactly such knowledge may be
used to support evolutionary developed,
well-tested “natural” ways of handling
newborns and their mothers.
• The main conclusion: try not to separate
the newborn baby from it’s mother!