EDITORIAL
The Journal of Tropical Pediatrics and
Volume 22 number 6 December 1976
The Importance of Neonatal Care Routines editorial... Many routines in our neonatal and maternity wards, such as separation, were introduced to prevent infections and to improve treatment of the newborn, and while the adverse influences on the mother-infant relationship were recognized 12 many mothers today are still not allowed to touch, hold and care for their newborn premature ot sick infants. If the period immediately following delivery is a particularly sensitive one, many changes in our day-to-day care and hospital practices have to be made to ensure that mother and infant remain together during this period. In animals, like goat, monkey and rat, studies of variations in neonatal care and their possible impact upon development of the offspring and behaviour as adults have first given us evidence of the special importance of the early post partum period. In man separation of mother and infant was gradually introduced as delivery was brought from the home into the hospital. To counteract this separation healthy fullterm infants and their mothers were given extended contact for one hour within the first three hours after birth and also five extra hours of contact each afternoon of the three days after delivery.3 In followup studies one month, one year and two years later, differences were found in maternal attachment behaviour and linguistic behaviour between this extended contact and a control group. A very short
extra contact of approximately 20 minutes during the first hour of life could bring about changes in maternal behaviour 36 hours after delivery and in both maternal and infant behaviour 3 months later.4 3 6 An extra skin to skin contact and suckling contact was given to 22 primiparous mothers and their infants. One control group of 20 primiparous mothers and a second one of 20 multiparous mothers and infants was given routine care immediately after birth. All mothers and infants were healthy with normal pregnancies and deliveries. At 36 hours a first observation was made of maternal and infant behaviour during breast feeding in all three groups. At this stage primiparae with extra contact showed behaviour much more like the behaviour of multiparae with routine care. Infants of primiparae with" routine care cried most frequently. At three months, when observation of primiparae and their infants was made during free-play in a home situation, mothers in the extra contact group spent more time kissing and looking en face at their infants, these infants smiled more often cried less frequently. In our view many of these differences observed in maternal and infant behaviour have an emotional background and a value in the relationship of mother and infant. The facilities for mothers and infants may differ greatly during their hospital stay. Rooming-in has long ago proved to be very useful in the prevention of 257
Downloaded from http://tropej.oxfordjournals.org/ at RMIT University Library on August 15, 2015
environmental child health
EDITORIAL
The global decrease is breast feeding during the last decades is probably connected with some of our routines in the maternity ward. In a series of studies we therefore examined how changes in these routines could influence the duration of breast feeding.4 The habit of weighing before and after breast feeding to estimate how much milk the infant has received and eventually supplementary feeding is widespread in western countries. Such routines may be necessary for the care of sick and small babies. There is no study demonstrating the need for such routines in healthy full-term babies with healthy mothers. After cancelling of weighing and supplementary feeding in our maternity ward we found a decrease in early failures to breast feed and an increase in the mean duration of breastfeeding from 58 to 99 days. These new instructions were contrary to most of what the nursing staff had been taught about infant care before. They seemed to lose some of their professional identity and felt uncertain about their task in the new situation. However, they observed the infants more closely, being afraid the babies would starve. The weight development of the babies was however equal to that of the babies before the change was made. Also the atmosphere in the ward changed gradually after rejection of weighing. The mothers became relaxed 258
and feeding time more of a pleasure. Their fear of having little or no milk diminished. Mothers with earlier experiences said spontaneously that they felt themselves to be under less pressure this time. In another study the role of the father, who in modern neonatal and infant care too often is the forgotten factor, was explored.4 It was interesting to find that there was an association between the giving of information about breast feeding to the father and the duration of it. This suggests that we should give more attention to his importance and explore his role in the adjustment of the family to the newly born more than has been done until now. The mother's comments on his participation, like: He will not feel outside; he will remember what I forgot etc., in the information on breast feeding reinforces this conclusion. The most drastic effect on the duration of breast feeding observed in our experiments was that associated with an early naked skin to skin and suckling contact.4 6 In this group the mean lactation period was 175 days, among controls 108 days. The fact that an extra contact during the first hours and days following delivery influences mother-infant relationship 3 * and may improve synchrony between mother and infant may be decisive in the causation of this effect. Nursing is an act of co-operation between mother and infant and if early postnatal extra contact promotes motherinfant synchrony it should be associated with more successful breastfeeding. The observations discussed here should have implications for neonatal care as well as for child rearing. Infants differ greatly from each other right from the start. Their mothers and fathers have different backgrounds and capacities. Flexibility to the individual requirements of each and every family is therefore needed. For example, mothers with an unwanted pregnancy might not be capable of accepting and benefiting from the early extra contact with their infants. And in fact we have experienced that during the period following our studies some mothers have refused the extra contact offered to them. One has therefore to be very cautious in offering all mothers this contact immediately after delivery. The offer should be made in an open-minded way, permitting the mother to make her own choice. It is regrettable that the trend in our society is in exactly the opposite direction.13 Certain child care practices and certain forms of early stimulation and soothing are considered universally beneficial regardless of a given child's particular needs.
Guest Editor: Peter de Chateau, M.D. Departments of Pediatrics and Child Psychiatry, University of Umea, S-90185 Umea SWEDEN
Environmental Child Health, December 1976
Downloaded from http://tropej.oxfordjournals.org/ at RMIT University Library on August 15, 2015
childhood behaviour disorders.7 Rooming-in provides a natural mother-child experience under supervision of maternity personnel and facilitates instruction of mothers and fathers in infant care. First-mothers rooming-in with their newborn babies judged themselves, one day prior to discharge, to be more confident and competent in baby care and thought that they would need less help in caring for their infants at home.8 Rooming-in mothers also claimed to understand the attributes of their baby's cry in a better way than control mothers did. Significantly less crying was found in infants to whom five hours of extra handling by their own mothers (mild, firm support and rhythmical body stimulation at feeding time) was given daily during the first 4\ days of life.9 Distress during feeding in infants with multiple caretakers has been reported,10 enrichment of the infant's hospital environment by means of single caretaker practices could reduce this distress. Full-term infants given extra handling during the first five weeks of life11 showed significantly more visual interest in their environment than non-handled controls. In another study supplementary handling by hospital personnel during early life had no long-lasting influence on child development. It was suggested that permanence of effects may not have been achieved because the optimal amount of critical stimulation may not have been reached.10 Another explanation might be that the extra stimulation was not done by the infants' own mothers or not given at the appropriate time.4 If a special sensitive period for the developing motherinfant relationship exists,3 stimulation by the infant's own mother might be found to produce more lasting advantages.
EDITORIAL
Environmental Child Health, December 1976
7. Jackson, E. (1950). Am. J. Orthopsychiatry. 25, 81 and 8. Greenburg, M., Rosenburg, J. and Lind, J. (1973. Am. J. Orthopsychiatry, 43, 783. 9. Ourth, L. and Brown, B.(1961). ChildDev., 32, 287. 10. Burns, P., Sander, L. W., Stechler, G. and Julia, H. (1972). J. Am. Acad. Child Psychiat., 11,427. 11. White, B. L. and Castle, P. W. (1964). Percept. Mot. Skills, 18,497. 12. Wachs, T. D. and Cucinotta, P. (1972). In: Williams, T. (ed). Infant Care: Abstracts of the literature. Consortium on early childbearing and childrearing. Washington, p. 10. 13. Korner, A. F. (1972) Am. J. Orthopsychiatry, 41,608.
259
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References 1. Barnett, C. R. Leiderman, P. H. Grobstein, R. and Klaus, M. H. (1970). Pediatrics, 45,197. 2. Klaus, M. H. and Kennell, J. H. (1970). Pediatr. Clin. North Am., 17,1015 3. Kennell, J. H., Trause, M. A. and Klaus, M. H. (1975). Ciba Foundation Symposium 33, Elsevier, Amsterdam, p87. 4. de Chateau, P. (1976). Umea University Medical Dissertations, New Series, no: 20. 5. de Chateau, P. and Wiberg, B.,ActaPaediatr. Scand.I: in press. 6. de Chateau, P. and Wiberg, B. Ada Paediatr. Scand. II: in press.
The Journal of Tropical Pediatrics and
Volume 22 number 6 December 1976
The Importance of Neonatal Care Routines editorial... Many routines in our neonatal and maternity wards, such as separation, were introduced to prevent infections and to improve treatment of the newborn, and while the adverse influences on the mother-infant relationship were recognized 12 many mothers today are still not allowed to touch, hold and care for their newborn premature ot sick infants. If the period immediately following delivery is a particularly sensitive one, many changes in our day-to-day care and hospital practices have to be made to ensure that mother and infant remain together during this period. In animals, like goat, monkey and rat, studies of variations in neonatal care and their possible impact upon development of the offspring and behaviour as adults have first given us evidence of the special importance of the early post partum period. In man separation of mother and infant was gradually introduced as delivery was brought from the home into the hospital. To counteract this separation healthy fullterm infants and their mothers were given extended contact for one hour within the first three hours after birth and also five extra hours of contact each afternoon of the three days after delivery.3 In followup studies one month, one year and two years later, differences were found in maternal attachment behaviour and linguistic behaviour between this extended contact and a control group. A very short
extra contact of approximately 20 minutes during the first hour of life could bring about changes in maternal behaviour 36 hours after delivery and in both maternal and infant behaviour 3 months later.4 3 6 An extra skin to skin contact and suckling contact was given to 22 primiparous mothers and their infants. One control group of 20 primiparous mothers and a second one of 20 multiparous mothers and infants was given routine care immediately after birth. All mothers and infants were healthy with normal pregnancies and deliveries. At 36 hours a first observation was made of maternal and infant behaviour during breast feeding in all three groups. At this stage primiparae with extra contact showed behaviour much more like the behaviour of multiparae with routine care. Infants of primiparae with" routine care cried most frequently. At three months, when observation of primiparae and their infants was made during free-play in a home situation, mothers in the extra contact group spent more time kissing and looking en face at their infants, these infants smiled more often cried less frequently. In our view many of these differences observed in maternal and infant behaviour have an emotional background and a value in the relationship of mother and infant. The facilities for mothers and infants may differ greatly during their hospital stay. Rooming-in has long ago proved to be very useful in the prevention of 257
Downloaded from http://tropej.oxfordjournals.org/ at RMIT University Library on August 15, 2015
environmental child health
EDITORIAL
The global decrease is breast feeding during the last decades is probably connected with some of our routines in the maternity ward. In a series of studies we therefore examined how changes in these routines could influence the duration of breast feeding.4 The habit of weighing before and after breast feeding to estimate how much milk the infant has received and eventually supplementary feeding is widespread in western countries. Such routines may be necessary for the care of sick and small babies. There is no study demonstrating the need for such routines in healthy full-term babies with healthy mothers. After cancelling of weighing and supplementary feeding in our maternity ward we found a decrease in early failures to breast feed and an increase in the mean duration of breastfeeding from 58 to 99 days. These new instructions were contrary to most of what the nursing staff had been taught about infant care before. They seemed to lose some of their professional identity and felt uncertain about their task in the new situation. However, they observed the infants more closely, being afraid the babies would starve. The weight development of the babies was however equal to that of the babies before the change was made. Also the atmosphere in the ward changed gradually after rejection of weighing. The mothers became relaxed 258
and feeding time more of a pleasure. Their fear of having little or no milk diminished. Mothers with earlier experiences said spontaneously that they felt themselves to be under less pressure this time. In another study the role of the father, who in modern neonatal and infant care too often is the forgotten factor, was explored.4 It was interesting to find that there was an association between the giving of information about breast feeding to the father and the duration of it. This suggests that we should give more attention to his importance and explore his role in the adjustment of the family to the newly born more than has been done until now. The mother's comments on his participation, like: He will not feel outside; he will remember what I forgot etc., in the information on breast feeding reinforces this conclusion. The most drastic effect on the duration of breast feeding observed in our experiments was that associated with an early naked skin to skin and suckling contact.4 6 In this group the mean lactation period was 175 days, among controls 108 days. The fact that an extra contact during the first hours and days following delivery influences mother-infant relationship 3 * and may improve synchrony between mother and infant may be decisive in the causation of this effect. Nursing is an act of co-operation between mother and infant and if early postnatal extra contact promotes motherinfant synchrony it should be associated with more successful breastfeeding. The observations discussed here should have implications for neonatal care as well as for child rearing. Infants differ greatly from each other right from the start. Their mothers and fathers have different backgrounds and capacities. Flexibility to the individual requirements of each and every family is therefore needed. For example, mothers with an unwanted pregnancy might not be capable of accepting and benefiting from the early extra contact with their infants. And in fact we have experienced that during the period following our studies some mothers have refused the extra contact offered to them. One has therefore to be very cautious in offering all mothers this contact immediately after delivery. The offer should be made in an open-minded way, permitting the mother to make her own choice. It is regrettable that the trend in our society is in exactly the opposite direction.13 Certain child care practices and certain forms of early stimulation and soothing are considered universally beneficial regardless of a given child's particular needs.
Guest Editor: Peter de Chateau, M.D. Departments of Pediatrics and Child Psychiatry, University of Umea, S-90185 Umea SWEDEN
Environmental Child Health, December 1976
Downloaded from http://tropej.oxfordjournals.org/ at RMIT University Library on August 15, 2015
childhood behaviour disorders.7 Rooming-in provides a natural mother-child experience under supervision of maternity personnel and facilitates instruction of mothers and fathers in infant care. First-mothers rooming-in with their newborn babies judged themselves, one day prior to discharge, to be more confident and competent in baby care and thought that they would need less help in caring for their infants at home.8 Rooming-in mothers also claimed to understand the attributes of their baby's cry in a better way than control mothers did. Significantly less crying was found in infants to whom five hours of extra handling by their own mothers (mild, firm support and rhythmical body stimulation at feeding time) was given daily during the first 4\ days of life.9 Distress during feeding in infants with multiple caretakers has been reported,10 enrichment of the infant's hospital environment by means of single caretaker practices could reduce this distress. Full-term infants given extra handling during the first five weeks of life11 showed significantly more visual interest in their environment than non-handled controls. In another study supplementary handling by hospital personnel during early life had no long-lasting influence on child development. It was suggested that permanence of effects may not have been achieved because the optimal amount of critical stimulation may not have been reached.10 Another explanation might be that the extra stimulation was not done by the infants' own mothers or not given at the appropriate time.4 If a special sensitive period for the developing motherinfant relationship exists,3 stimulation by the infant's own mother might be found to produce more lasting advantages.
EDITORIAL
Environmental Child Health, December 1976
7. Jackson, E. (1950). Am. J. Orthopsychiatry. 25, 81 and 8. Greenburg, M., Rosenburg, J. and Lind, J. (1973. Am. J. Orthopsychiatry, 43, 783. 9. Ourth, L. and Brown, B.(1961). ChildDev., 32, 287. 10. Burns, P., Sander, L. W., Stechler, G. and Julia, H. (1972). J. Am. Acad. Child Psychiat., 11,427. 11. White, B. L. and Castle, P. W. (1964). Percept. Mot. Skills, 18,497. 12. Wachs, T. D. and Cucinotta, P. (1972). In: Williams, T. (ed). Infant Care: Abstracts of the literature. Consortium on early childbearing and childrearing. Washington, p. 10. 13. Korner, A. F. (1972) Am. J. Orthopsychiatry, 41,608.
259
Downloaded from http://tropej.oxfordjournals.org/ at RMIT University Library on August 15, 2015
References 1. Barnett, C. R. Leiderman, P. H. Grobstein, R. and Klaus, M. H. (1970). Pediatrics, 45,197. 2. Klaus, M. H. and Kennell, J. H. (1970). Pediatr. Clin. North Am., 17,1015 3. Kennell, J. H., Trause, M. A. and Klaus, M. H. (1975). Ciba Foundation Symposium 33, Elsevier, Amsterdam, p87. 4. de Chateau, P. (1976). Umea University Medical Dissertations, New Series, no: 20. 5. de Chateau, P. and Wiberg, B.,ActaPaediatr. Scand.I: in press. 6. de Chateau, P. and Wiberg, B. Ada Paediatr. Scand. II: in press.
