New Evidence-Based Approaches to Obstetrics

APPPAH Congress presentation by Dr. Marshall Klaus, 2009

Dr. Klaus cited important new research at the 2009 APPPAH Congress at Asilomar, in which many APPPAH members were extremely interested. In the spirit of service, we share highlights here, which include some transcribed material directly from Dr. Klaus' presentation, with his generous permission. The research was conducted by Dr. Bystrova, a Russian pediatrician, and published in the journal Birth, June 2009. Dr. Bystrova's study is an important upgrade and verification of a study Klaus and Kennell completed in 1972, whose results were debated for ten years and not settled. One important goal of Bystrova's research was to assess what Klaus seemed to find 37 years earlier, a sensitive period in the first two to three hours of life, when attachment is optimized. Dr. Klaus was the "opponent" for Bystrova's doctoral dissertation, meaning he was a central member on her doctoral committee, to evaluate her research and knowledge in the field of infant bonding. Bystrova's research examines physical closeness versus separation of the mother and infant from 30 to 120 minutes after birth. There was no separation during the first 30 minutes, but they were quite unusual minutes. Babies were placed on a table, were dried thoroughly, and then were put under a faucet of warm water, as a way of making sure all babies, experimental and control, had the same kind of physical treatment during the period. One hundred and seventy-six infants, whose mothers had a normal pregnancy and a normal labor, and not requiring any drugs for pain, were divided into eight groups of babies. [The main research theme in Groups 1-4 was skin to skin contact and breastfeeding, and in Groups 5-8 was swaddling. Those results in a future issue.]
Groups30-120 MinutesFive Day Period After Birth
Group 1skin-to-skin contactroomed-in & breastfeeding
Group 2breastfeedingroomed-in & breastfeeding
Group 3placed in nurserybrought to mother, breastfed, and returned to nursery
Group 4placed in nurseryroomed-in & breastfed
Group 1 babies had skin-to-skin contact with their mothers from 30 to 120 minutes after birth, and five days of rooming-in with their mothers and breastfeeding. Group 2 had breastfeeding from 30 to 120 minutes after birth, and five days of rooming-in and breastfeeding. Group 3 infants were placed in the nursery on the obstetric floor for 30 to 120 minutes, had first breastfeeding contact with their mothers during hours 3-4, and then taken out for breastfeeding seven times a day for five days, but placed back in the nursery each time. This is a bit of old style care. Group 4 babies were placed in the newborn nursery for 30 to 120 minutes, but then breastfed and roomed-in with their mothers beginning in hour 3, and for the next five days. The major findings were that early skin-to-skin contact between mothers and infants, from 30 minutes after to 120 minutes, significantly altered maternal and infant behavior at one year. These infants demonstrated greater self-regulation, dyadic mutuality and reciprocity, and the mothers showed greater interaction and interest in their infants and greater reciprocity than the controls. In the absence of skin-to-skin contact, early breast-feeding from 30 to 120 minutes afterward elicited the same outcomes. Infants separated in the nursery for the first two hours were significantly less regulated, more irritable, had less dyadic mutuality, and their mothers showed less interest in the infants and had less interaction. Of particular interest is that babies who were placed in the nursery for the first two hours and then roomed-in and breastfed on demand the entire five days after birth, were also significantly less regulated and relational than the early skin to skin or breastfed babies. They were irritable with decreased reciprocity and less dyadic mutuality, and mothers were less interested and interactive with their babies. This provided clear evidence of a short, early, sensitive period after delivery, lasting only two to three hours. The calm, regulated, interacting baby only occurred when skin- to-skin contact or breastfeeding was provided from 30 to 120 minutes after the birth, but not during the follow-up breastfeeding of five days. In other words, if the first 30 to 120 minutes of breastfeeding or skin to skin contact are missed, even a follow up of five days of breastfeeding did not provide the benefits of early breast feeding or skin contact. Klaus concluded, "You know I agree whole heartedly with Bystrova and colleagues, that newborn babies should not be separated from their mothers if the mothers and babies are well. The first minutes of life should consist of drying the baby thoroughly and undertaking a brief physical exam. Brief is over in two minutes. Babies should have skin- to-skin contact with their mothers for the next two to three hours, breastfeeding when they are ready, and beginning to know their parents." [Ed. thanks William Emerson for synthesizing Dr. Klaus' presentation data]