Scientific background and justification
The first 2 h of a baby’s life has been defined as the optimum time to begin human lactation. Skin-to-skin contact (SSC) between newborn and mother in this period improves the chance of successful lactancy in the first hour of life and in the long term [
1,
2]. The exclusive use of breast milk is the optimal food for infants in the first 6 months. The SSC birth involves placing the naked newborn in the prone position on the bare chest of the mother, drying and covering the baby’s head with a cap and the baby and mother with a sheet. This strategy offers benefits to the mother and baby in both the short and long term. Secondary complications for the mother (e.g., mastitis) often lead to inadequate breastfeeding whereas adequate breastfeeding decreases rates of maternal postpartum bleeding and depression, leads to greater cardiorespiratory and thermal stability of the newborn and a decrease in the need for newborn hospitalization within the first week of life; it also initiates the colonization of the mother’s own gut flora in the newborn which leads to a decreased risk of infection [
3‐
5], a lower incidence of infectious diseases in the first year of life, and a positive impact on reducing the risk of obesity and of contracting chronic noncommunicable diseases; these human lactation benefits are directly related to the duration of lactation [
6,
7].
The SSC strategy has been applied at different times at birth and for different time durations, the latter being understood as being a dose of SSC. Depending on the time of initiation of the SSC intervention, it has been divided into subcategories (Table
1) [
3]. Although the optimum duration for SSC has not been defined, it has been accepted that we must continue and maintain it at least until the baby has completed its first proper sucking of the breast and is physiologically stable [
1,
3,
6]. In Colombia, in the 2013 Clinical Practice Guidelines of the Ministry of Health and Social Protection for healthy newborn care, it is recommended that SSC should be made immediately during the postpartum procedure while performing immediate interventions and postponing newborn adaptation measures in order to prevent the separation of the newborn from their mother in the immediate newborn period [
8]. In the obstetric literature, it is not clear if the benefits of the strategy remain independent of the initiation time of SSC at birth [
3]. In Colombia however, the average duration of exclusive lactancy is 1.8 months which is well below the worldwide recommendation; additionally, only 56.6 % of Colombian mothers feed their babies breast milk in the first hour of life [
9]. Currently, widespread care practices for mothers and newborns in hospitals and care centers make it common for the mother and baby to be separated in the immediate moment following birth, breaking the bonding link between them at this time and altering the ratio and benefits deriving from this contact [
10,
11].
Table 1
Subcategories on the time of initiation of skin-to-skin contact (SSC) intervention
When contact is made within the first minute of birth | Within the first 30 to 40 min after birth and after the mediate and immediate neonatal adaptation interventions have been carried out | At any time between the first hour and 24 h of life |
Through conducting a randomized, blind clinical trial, this study aims to determine the effects of two different SSC initiation times (immediate versus early) on the duration of exclusive human lactation in healthy full-term newborns treated at the Universidad de La Sabana Clinic.
State of the art
Variability is evident in both clinical practice and the obstetric literature for both the optimum start time for implementing SCC and its optimum duration, which has created heterogeneous strategy results in research studies as well as interpretation. No studies have been conducted comparing the different SSC initiation times regarding breastfeeding, while recommendations have been made to study whether the initiation time makes a difference in the benefits of the technique [
3].
Interventions at birth and the practice of separating the baby from the mother at birth have negative effects on the initiation of breastfeeding. A cross-sectional study of the factors involved in the initiation of lactancy within the first hour of life was conducted in different hospitals in Rio de Janeiro between 1999 and 2001 [
11], and found that human lactation occurring during the first hour of life was less frequent if infants were subjected to immediate interventions after birth (odds ratio (OR) 0.47, 95 % confidence interval (CI) 0.15 to 0.80), if mothers had no contact with their newborns in the delivery room (OR 0.62, 95 % CI 0.29 to 0.95), if mothers were undergoing caesarean section (OR 0.48, 95 % CI 0.24 to 0.72) and if mothers were treated at private institutions. Regarding practices that promote exclusive breastfeeding during the hospital stay postpartum, Bramson et al. [
12] in California, USA, conducted a cohort study; the analysis of multivariate logistic regression showed that the following factors – intention of breastfeeding before birth, the sociodemographic characteristics of the mother and early SSC applied within the first 3 h of the birth – all correlated positively with exclusive human lactancy during the hospital stay. In addition, a link between the duration of the SSC (dose) and exclusive human lactancy was revealed and there is a directly proportional relationship between the dose or time and exclusive lactancy: contact time between 1 and 15 min (OR 1.37, 95 % CI 1189 to 1593), 16 and 30 min (OR 1.66, 95 % CI 1468 to 1888), 31 and 59 min (OR 2.35, 95 % CI 2061 to 2695), and more than an hour (OR 3.14, 95 % CI 2905 to 3405).
Carfoot et al. [
13] conducted a randomized clinical trial in the UK in order to assess the effects of early SSC in healthy newborns over 36 weeks on the initiation and duration of human lactation. It included 204 mothers and their newborns who were divided randomly into two groups: early SSC (
n = 102): initiated at birth, delaying the adaptation intervention until after contact, the duration was at least 45 min until the first feed was completed or the mother chose to withdraw the SSC and the control group, were receiving routine care (
n = 102) understanding this to mean that once born, the routine adaptation interventions are applied, separating the newborn from the mother and/or parent. The investigators measured the success of the first breastfeed as a primary result and as secondary results they measured exclusive lactancy until 4 months, thermoregulation in the first hour of life and the mother’s degree of satisfaction. The IBFAT (Infant Breast feeding Assessment Tool) scale was used to evaluate the success of the baby’s first breastfeed. They found that the success of the first feed within the first hour of life was higher in the SSC group (mean 8 %, 95 % CI 1.6 % to 17.6 %) and also higher for the duration of exclusive breastfeeding until the first 4 months of life. Likewise, the thermal stability of the baby was better in the SSC group and mothers also reported greater satisfaction in this group.
Villalón et al. [
14] in Chile, conducted a prospective randomized study with newborns of between 38 and 42 weeks’ gestation and weighing between 2500 and 4250 g at birth; the intervention group was defined as
early SSC in which the baby and mother have contact at birth and SCC was continued for 4 h. The control group was defined as the
post-birth routine care group in which the mother is separated from the newborn in order for adaptation care routines to be applied. They evaluated lactancy independent of whether suction took place at birth or not and they considered 2 to 4 h as adequate time for exclusive lactancy and inadequate for those requiring whole or mixed formula feeding. Significant differences were found in favor of the group using early SSC in exclusive breastfeeding at 24 h of life (89.9 % versus 63.3 %,
p < 0.001), at discharge from hospital (93.3 % versus 66.7 %,
p < 0.001), and at 14 days of age (78.8 % versus 56.2 %,
p < 0.02).
The systematic review by the Cochrane Collaboration [
3] found that the SSC has positive effects on human lactation during the first to fourth months of life (OR 1.82, 95 % CI 1.08 to 3.07) and a positive effect on the duration of lactancy (mean difference 42.55, 95 % CI −1.69 to −86.79). Trends in improvement in the overall scores of maternal affection during lactancy, as well as in maternal attachment behaviors, were also found. Other reported benefits are that the newborns cry less (mean difference −0.01, 95 % CI −8.98 to −7.04). No adverse effects were observed or reported. It is important to note that the reviewers reported limitations given the variability in the intervention (initiation time of contact and duration) and the definition of variables; proposing SSC initiation time subcategories (
immediate,
birth,
very early, and
early), thus highlighting the need for studies investigating the benefits of the technique in this field.
As to the time of SSC and its duration, Takahashi et al. [
15] evaluated the effectiveness of the initiation time and the duration of the SSC using by three indices: the measurement of stress-related cortisol in saliva, circulatory evaluation of heart rate and respiratory adaptation, and oxygen saturation. They found that the body temperature at 60 min and 120 min was lower in the SSC
birth group (
p < 0.001) compared to the
very early group (
p < 0.05), but all remained within normal ranges. A faster heart rate stability was found in the SSC
birth group compared to
early (
p = 0.001), there were no significant differences in respiratory adaptation. Stress levels as indicated by the cortisol level were lower in babies who were in SSC for more than 60 min compared to those who were in SSC for less than 60 min (
p = 0.046). This study concludes that
early SSC within the first 5 min of life, with a continuous duration of more than 60 min, reduces the stress on the baby and improves cardiopulmonary stability at birth.
In Iran, Aghdas et al. [
16] evaluated the effect of immediate SSC efficacy for human lactation through a randomized clinical trial with first-time mothers, measured by the BSES (Breastfeeding Self-efficacy Scale) until day 28. The mothers were randomized into two groups:
early SSC, in which the newborn was left in SSC with the mother from birth for 2 h, postponing interventions up until that point; and
routine care, in which the baby was taken to the radiant heat lamp once the umbilical cord had been cut in order to proceed with the interventions. The success of the first breastfeed was evaluated as a secondary result using the IBFAT and the average first lactation. In the SSC group, the self-efficacy in human lactation (BSES) score was 53.42 (standard deviation (SD) 8.57) versus 49.85 (SD 5.5) in the control group (
p = 0.0003). The successful initiation of human lactation was 56.6 % in the intervention group versus 35.6 % in the control group (
p = 0.02) and finally, the initiation time of the first feed was 21.98 ± 9.1 min in the SSC group versus 66.55 ± 20.76 min in the routine care group (
p = 0.001).
Infant Breast-Feeding Assessment Tool (IBFAT)
Various tools or tests to assess lactancy have been developed. The IBFAT tool was developed and published by Matthews et al. in 1993 to evaluate the behavior of the baby during sucking and swallowing, with a reliability of 91 % [
17]. Using six items, the behavior of the baby was quantified and evaluated during lactancy in the first week of life and the focus was concentrated on both the baby and the mother.
Schlomer et al. [
18] evaluated two scores as tools to assess lactancy, to correlate problems during lactancy and the degree of maternal satisfaction. The LATCH tool, which is a system for the documentation of lactation, identifies areas where intervention is required to support lactancy and focuses on the role of the mother in the process of breastfeeding whereas the IBFAT scale focuses on the baby during feeding. They found that as the scores of both instruments increased there was a tendency to an increase in maternal satisfaction with a decrease in breastfeeding problems, but this was not statistically significant (LATCH
r = 0.5,
p = 0.06 and IBFAT
r = 0.49,
p = 0.06).
Riordan et al. [
19] initially included the IBFAT, MBA (Mother-Baby ASSESS tool) and LATCH tools to assess the reliability and validity of three clinical assessment instruments for lactancy evaluation. They found that the coefficient reliability was not acceptable for clinical decision-making. Subsequently, Altuntas et al. [
20] in 2104, again assessed the validity and reliability of these three scales, finding a positive and significant correlation; the MBA tool had a correlation ranging from 0.81 to 0.88, the IBFAT from 0.9 to 0.95, and the LATCH tool between 0.85 and 0.91. They concluded that the three scales or tools are compatible, reliable, and appropriate to evaluate the efficiency of lactancy.