Running head: INCREASING EXCLUSIVE BREASTFEEDING 1

Increasing Exclusive Breastfeeding Using Immediate Skin-to-Skin Contact in Neonates

Kierstan Thomas, Bianca Labady, and Morgan McMahon

University of South Florida

Kierstan Thomas: 652 words

Abstract, Introduction, and Literature Search, Synthesis

Bianca Labady: 694 words

Literature Review (guidelines, Sharma, and Srivastava)

Morgan McMahon: 659 words

Literature Review (Mahmood), Synthesis, Clinical Recommendations

INCREASING EXCLUSIVE BREASTFEEDING 2

Abstract

Clinical Problem: Breastfeeding is considered to be the optimal choice of nutrition for an infant,

yet according to the World Health Organization (WHO), the rate of infants under six months

exclusively breastfed (EBF) is only 40%. The WHO lists several benefits of EBF, including:

protection from common childhood illnesses and lower rates of diabetes and obesity. The WHO

also recommends that breastfeeding be initiated within the first hour after birth (World Health

Organization, 2017).

Objective: The objective of this synthesis is to discuss if implementing immediate skin-to-skin

contact (SSC) between mother and baby post-birth will increase the rate of EBF. PubMed was

searched for randomized control trials (RCTs) in nursing regarding the use of early SSC

intervention to increase EBF. The key search terms were EBF, SSC, kangaroo care, and

increasing rates of EBF.

Results: With infants who received immediate SSC, there is a statistically significant increase in

the rate of EBF as compared to those who received no intervention. Srivastava et al. (2014)

demonstrated an increase in the rates of EBF at six weeks post-partum who received SSC (p <

0.0001). Mahmood, Jamal, and Khan (2011) likewise demonstrated an increase in the rates of

EBF in infants who received SSC at one month post-partum (p=0.025). Sharma (2016)

demonstrated an increase in the rates of EBF in infants who received SSC at six weeks post-

partum (p=0.04). Immediate SSC is a low risk, cost effective intervention that can be

implemented in the post-partum period to increase the rates of exclusive breastfeeding.

Conclusion: Although early SSC has been observed to show an increase in the rates of EBF,

additional research is needed to determine if the effects of SSC are maintained over time in

relation to the initiation of EBF as well as duration of EBF.

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Increasing Exclusive Breastfeeding Using Immediate Skin-to-Skin Contact in Neonates

Breastfeeding is known to be the most natural and healthiest method of feeding an infant,

and the success of lactation primarily depends on the early initiation of breastfeeding (Mahmood

et al., 2011). Not only does immediate SSC have benefits for both mother and baby in regards to

breastfeeding, but it is also known to have benefits such as a reduced risk of ovarian and breast

cancer for mothers, and protection against diabetes and childhood illnesses for babies. However,

the standard of care in a number of hospitals does not yet involve SSC. According to the World

Health Organization, breastfeeding has the power to save approximately 820,000 lives, if it were

scaled up to near universal levels (World Health Organization, 2017). This synthesis paper will

address the following question: In newborn infants, how does immediate SSC contact compared

to immediate separation increase the rate of exclusive breastfeeding, over a postpartum period of

six weeks?

Literature Search

The database PubMed was used to access randomized controlled trials (RCT) in nursing

examining EBF using SSC as a means of increasing EBF rates. Key search items included skin-

to skin, exclusive breastfeeding, kangaroo care, and neonates. The publication years searched

were 2012 to 2017.

Literature Review

The National Institute for Health and Care Excellence (NICE, 2014) encourages mothers

to participate in SSC with their infant as soon as possible after birth because SSC contributes to

the health of the mother and child in the short and longer term. Three randomized controlled

trials (RCT) were selected to determine the efficacy in promoting EBF among neonates using

SSC. Sharma (2016) revealed that when the initiation of SSC occurs immediately after birth, it
INCREASING EXCLUSIVE BREASTFEEDING 4

helps the full term to move independently to the mother's nipple and latch adequately within

about 60 minutes, which promotes the initiation of breastfeeding. The sample size was 200

neonates. The neonates were randomized into an SSC intervention group (n=100), or a control

group (n=100). Patients in the intervention group were placed on the bare breasts of their

mothers to initiate immediate SSC. The control group neonates were placed under a radiant

warmer for 45 minutes within one minute of birth. A proforma was given to the mothers that

described breastfeeding status, and the mothers were contacted weekly by telephone to record

rates of EBF. The rate of EBF was recorded at six weeks during their first immunization visit in

the follow-up clinic. There was a significantly higher proportion of neonates that were EBF at 6

weeks of age in the SSC group (72%) as compared to the control group (57.6%) (p=0.04).

Strengths of the study included: randomization of the infants into the SSC intervention group and

the control group, the concealment of group allocation to the data collector, the vital signs that

were taken served as the instruments which were valid and reliable, the subjects were analyzed in

their randomly assigned group, and reasons were given as to why subjects did not complete the

study. Also, follow-up assessments at 6-weeks were performed in an appropriate amount of time

to understand the effects of the intervention. Weaknesses of the study included: the investigators

inability to enroll infants that were not evaluated immediately after birth, the investigator was not

blind to group allocation, and it is unknown if subjects in each of the groups had similar

demographics.

Srivastava et al. (2014) assessed the efficacy of very early SSC on EBF in neonates. In

this randomized controlled trial (RCT), an assessment of the suckling competence of the baby

was measured within the 24 hours of birth using the modified infant breastfeeding assessment

tool (IBFAT ) to measure the effective breastfeeding, and breastfeeding status reported by the
INCREASING EXCLUSIVE BREASTFEEDING 5

mother at six weeks to determine rate of EBF. The sample size included 240 neonates. The

neonates were randomized into an intervention group (n=122), or a control group (n=118).

Infants in the intervention group were placed naked prone between the mothers bare breasts and

were covered with a bed sheet and blanket. In the control group, the neonates received the

standard care which included the assessment of the infant followed by the neonate being dried,

weighed, clothed, wrapped in a sheet and a blanket, and placed next to the mother. Rates of EBF

were recorded through an in person or phone interview with the mothers at six weeks. SSC

resulted in significantly improved suckling scores, as compared to the control group (p <

0.0001). Strengths of this study included randomization of the intervention and control group, the

subjects were analyzed in their randomly assigned group, concealment of group allocation, and

the vital signs and rate of EBF reported by the mother were valid and reliable instruments used to

measure the outcomes. Weaknesses of the study included the lack of blinding of the mothers to

the study group, it is unknown why subjects did not complete the study (n=26), reasons were not

given as to why subjects did not complete the study, it is unknown if subjects in each of the

groups had similar demographics, and follow-up assessments were only conducted for six weeks

which was not long enough to fully understand the effects of the intervention.

Mahmood et al. (2011) evaluated the effectiveness of early SSC between mother and

baby on EBF rates in infants. To measure breastfeeding status, mothers were contacted one

month postpartum to determine rates of EBF using the infant breastfeeding index. This design of

this study was a randomized controlled trial (RCT). The sample size was 135 term neonates. All

infants were randomized into the SSC intervention group (n=68) or the control group (n=67). All

infants included in the study were delivered vaginally and did not need resuscitation beyond oro-

pharyngeal suction. In the SSC group, naked infants were wiped, dried, and put in between the
INCREASING EXCLUSIVE BREASTFEEDING 6

mother's breasts. SSC continued without interruptions until first breastfeed or for 45 minutes. In

the control group, infants were placed into warmers directly following the cutting of the

umbilical cords. The neonate was then cleaned and wrapped with warm sheets. The neonates and

mothers were transferred to the postnatal unit, with first breastfeeding begun when the mothers

were ready. Mothers were later contacted at one month postpartum, and a measure of the infants

breastfeeding status was collected using the breastfeeding index. Infants in the SSC group had

significantly higher EBF rates at one month (85.3%) as compared to the control group (65.7%)

(p=0.025). Strengths of the study included randomization into intervention and control groups,

concealed random assignment from the individuals enrolling subjects, reasons were given for all

mothers and infants who did not complete the study, and follow-up assessments were completed

in an appropriate time period (one month) to study the rate of EBF with SSC compared to

standard care. Also, all infants in the control group and the SSC were analyzed in their respective

groups, the only difference between the control and intervention group was the SSC, the rate and

infant breastfeeding index used to determine the EBF were valid and reliable, and the infants

were similar in baseline clinical variables. Weaknesses of the study included lack of blinding of

the mothers and providers to the study group assignment, and it is unknown if the infants shared

similar demographics.

Synthesis

Sharma (2016) demonstrated that the SSC intervention group significantly higher EBF

rates at 6 weeks of age (72%) as compared to the control group (57.6%) (p=0.04). At both the

first follow-up visit and at the 6 weeks follow-up assessments, Srivastava et al. (2014) also had

results that indicated a significantly higher proportion of infants who were EBF in the

intervention group as compared to the control group. At the first follow-up assessment (day 4 or
INCREASING EXCLUSIVE BREASTFEEDING 7

5 of life), nearly 86.1% of the newborns in the SSC intervention group were EBF whereas only

66.9% of the newborns in the control group were EBF (p=0.002). The corresponding EBF rates

at 6 weeks follow-up visit were 85.2% and 63.6% for the intervention group and control group

newborns respectively (p < 0.0001). Likewise, Mahmood et al. (2011) found that in the SSC

group 85.3% infants were EBF at one month as compared to 65.7% in the control group

(p=0.025).

One of the major weaknesses within all of three of the studies is the inability to assess the

demographic similarity of the mothers and infants in the study sample, as well as the use of a

single study site, which make the findings less generalizable. In addition, the study is not able to

be replicated due to a lack of record being given of the number of SSC sessions. In research,

demographics are key factors in determining whether the participants in the studies are an

adequate representation of the general population. By conducting the research in one hospital for

each study, the results may not be indicative of the general population. Further studies

researching the effect of SSC on EBF should be conducted in multiple sites with diversity in the

demographics in order to obtain more comprehensive results relating to the general public.

Clinical Recommendations

A review of research suggests that early SSC between mother and infant enhances the

success of EBF in healthy newborn infants. Although much research has been conducted on the

effect of SSC on EBF, the standard of care at some hospitals does not include SSC due to

immediate newborn assessments (Stanford Childrens Health, 2017). In healthy infants, SSC

provides a health promoting, low cost, and simple intervention to promote the success of EBF.

Research indicates that early SSC is an intervention that can aid in the initiation of EBF in

healthy term infants (Sharma, 2016; Srivastava et al., 2014; Mahmood et al., 2011). Due to the
INCREASING EXCLUSIVE BREASTFEEDING 8

health benefits of EBF for infants, interventions promoting the success of EBF should be

considered when adjusting the standard of care in hospitals. Further research is needed on how

SSC can promote EBF for the fully recommended time of six months (World Health

Organization, 2017). Also, research is needed to evaluate the effectiveness of SSC in the preterm

infant population in the promotion of breastfeeding competency and overall health.

INCREASING EXCLUSIVE BREASTFEEDING 9

References

Sharma, A. (2016). Efficacy of early skin-to-skin contact on the rate of exclusive breastfeeding

in term neonates: A randomized controlled trial. African Health Sciences, 16(3), 790.

doi:10.4314/ahs.v16i3.20

Srivastava, S., Amit, G., Anjoo, B., & Sanjeev, D. (2014). Effect of very early skin to skin

contact on success at breastfeeding and preventing early hypothermia in neonates.

Indian Journal Of Public Health, Vol 58, Iss 1, Pp 22-26 (2014), (1), 22.

doi:10.4103/0019-557X.128160

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

on breastfeeding status: A randomized controlled trial. J Coll Physicians Surg Pak,

21(10), 601-605. doi:10.2011/JCPSP.601605

National Institute for Health and Care Excellence. (2014). Intrapartum care: care of healthy

women and their babies during childbirth. (Standard No. 190). Retrieved from

https://www.guideline.gov/summaries/summary/48932/intrapartum-care-care-of-

healthy-women-and-their-babies-during-childbirth?q=skin+to+skin+contact

Stanford Childrens Health. (2017). Care of the baby in the delivery room. Retrieved from

http://www.stanfordchildrens.org/en/topic/default?id=care-of-the-baby-in-the-delivery-

room-90-P02871

World Health Organization. (2017). Exclusive breastfeeding. Retrieved from

http://www.who.int/nutrition/topics/exclusive_breastfeeding/en/

World Health Organization. (2017). 10 facts on breastfeeding. Retrieved from

http://www.who.int/features/factfiles/breastfeeding/en/