Newborn behaviour to locate the breast when skin-to-skin: a possible method for enabling early self-regulation.

AIM: The aim of this study was to provide a more detailed analysis of the infant's behavioural sequence that begins immediately after birth and terminates with grasping the nipple, suckling and then falling asleep. METHOD: Twenty-eight full-term infants were videotaped immediately after birth. A video protocol was developed to examine infant behaviours identified from five random videotapes. RESULTS: When birth crying had stopped, the babies showed a short period of relaxation and then successively became alert. They went through an 'awakening phase', an 'active phase' with movements of limbs, rooting activity and looking at the mother's face, a 'crawling phase' with soliciting sounds, a 'familiarization phase' with licking of the areola, and a 'suckling phase' and last a 'sleeping phase'. Five factors related to the time spent to locate the breast: more number of looks at the breast 10-20 min after birth (p < 0.0001); and exposure to meperidine (p = 0.0006) related to increased time. Early start of crawling (p = 0,0040); increased number of 'soliciting sounds' (p = 0.0022); and performing hand-breast-mouth movements (p = 0.0105) related to shorter time. CONCLUSION: Inborn breastfeeding reflexes were depressed at birth, possibly because of a depressed sensory system. It is hypothesized that when the infant is given the option to peacefully go through the nine behavioural phases birth cry, relaxation, awakening, activity, crawling, resting, familiarization, suckling and sleeping when skin-to-skin with its mother this results in early optimal self-regulation.

State of the art and recommendations. Kangaroo mother care: application in a high-tech environment.

UNLABELLED: Since Kangaroo Mother Care (KMC) was developed in Colombia in the 1970s, two trends in clinical application emerged. In low income settings, the original KMC model is implemented. This consists of continuous (24 h/day, 7 days/week) and prolonged mother/parent-infant skin-to-skin contact; early discharge with the infant in the kangaroo position; (ideally) exclusive breastfeeding; and, adequate follow-up. In affluent settings, intermittent KMC with sessions of one or a few hours skin-to-skin contact for a limited period is common. As a result of the increasing evidence of the benefits of KMC for both infants and families in all intensive care settings, KMC in a high-tech environment was chosen as the topic for the first European Conference on KMC, and the clinical implementation of the KMC model in all types of settings was discussed at the 7th International Workshop on KMC. Kangaroo Mother Care protocols in high-tech Neonatal Intensive Care Units (NICU) should specify criteria for initiation, kangaroo position, transfer to/from KMC, transport in kangaroo position, kangaroo nutrition, parents' role, modification of the NICU environment, performance of care in KMC, and KMC in case of infant instability. CONCLUSION: Implementation of the original KMC method, with continuous skin-to-skin contact whenever possible, is recommended for application in high-tech environments, although scientific evaluation should continue.

Towards universal Kangaroo Mother Care: recommendations and report from the First European conference and Seventh International Workshop on Kangaroo Mother Care.

UNLABELLED: The hallmark of Kangaroo Mother Care (KMC) is the kangaroo position: the infant is cared for skin-to-skin vertically between the mother's breasts and below her clothes, 24 h/day, with father/substitute(s) participating as KMC providers. Intermittent KMC (for short periods once or a few times per day, for a variable number of days) is commonly employed in high-tech neonatal intensive care units. These two modalities should be regarded as a progressive adaptation of the mother-infant dyad, ideally towards continuous KMC, starting gradually and progressively with intermittent KMC. The other components in KMC are exclusive breastfeeding (ideally) and early discharge in kangaroo position with strict follow-up. Current evidence allows the following general statements about KMC in affluent and low-income settings: KMC enhances bonding and attachment; reduces maternal postpartum depression symptoms; enhances infant physiologic stability and reduces pain, increases parental sensitivity to infant cues; contributes to the establishment and longer duration of breastfeeding and has positive effects on infant development and infant/parent interaction. Therefore, intrapartum and postnatal care in all types of settings should adhere to a paradigm of nonseparation of infants and their mothers/families. Preterm/low-birth-weight infants should be regarded as extero-gestational foetuses needing skin-to-skin contact to promote maturation. CONCLUSION: Kangaroo Mother Care should begin as soon as possible after birth, be applied as continuous skin-to-skin contact to the extent that this is possible and appropriate and continue for as long as appropriate.

The effect of Russian Maternity Home routines on breastfeeding and neonatal weight loss with special reference to swaddling.

BACKGROUND: Few investigations have considered evaluating the effects of certain combinations of ward routines like swaddling of the baby and separation of mother and baby on infant variables such as neonatal weight loss. AIMS: To study the effect of different ward routines in respect to proximity to mother and type of infant apparel, on breastfeeding parameters (amount of ingested milk, volume of supplements, number of breastfeeds, total duration of breastfeeding time) day 4 after birth as well as recovery from neonatal weight loss and infant's weight on day 5. STUDY DESIGN AND SUBJECTS: In a randomized trial with factorial design four treatment groups including 176 mother-infant dyads were studied 25-120 min after birth. Randomized treatments focused on care routines administered to the infants after delivery and later in the maternity ward as well as to the type of clothing the infants received. Group 1 infants were placed skin-to-skin with their mothers after delivery, and had rooming-in while in the maternity ward. Group 2 infants were dressed and placed in their mothers' arms after delivery, and roomed-in with mothers in the maternity ward. Group 3 infants were kept in the nursery both after birth and while their mothers were in the maternity ward. Group 4 infants were kept in the nursery after birth, but roomed-in with their mothers in the maternity ward. Equal numbers of infants were either swaddled or clothed in baby attire. Breastfeeding parameters were documented during day 4 after birth. Infant's weight was measured daily. RESULTS: Babies who were kept in the nursery received significantly more formula and significantly less breast-milk, than did babies who roomed-in with their mothers. Swaddling did not influence the breastfeeding parameters measured. However, swaddled babies who had experienced a 2-h separation period after birth and then were reunited with their mothers tended to have a delayed recovery of weight loss compared to those infants who were exposed to the same treatment but dressed in clothes. Furthermore, swaddled babies who were kept in the nursery and received breast-milk supplements had a significantly delayed recovery of weight loss after birth when compared to those infants ingesting only breast-milk. On day 5, regression analyses of predicted weight gain in the exclusively breastfed infants indicated a significant increase per 100 ml breast-milk (59 g), compared to the predicted weight gain on day 5 per 100 ml supplements in the swaddled babies (14 g) (P=0.001). CONCLUSION: Supplements given to the infants in the nursery had a negative influence on the amount of milk ingested. In addition, supplement feeding or a short separation after birth when combined with swaddling was shown to have a negative consequence to infant weight gain.

Effect of variations in basal plasma glucose concentration on glucose utilization (M) and metabolic clearance (MCR) rates during insulin clamp studies in patients with non-insulin-dependent diabetes mellitus.

Two insulin clamp studies were performed at different steady-state plasma glucose concentrations in 13 patients with non-insulin-dependent diabetes mellitus (NIDDM). Steady-state plasma insulin concentrations were comparable, with mean +/- SEM levels of 94 +/- 3 and 95 +/- 4 muU/ml being achieved during the two studies. Glucose utilization rate (M) varied directly with plasma glucose concentration in each subject. Thus, the mean +/- SEM value of M was 4.92 +/- 0.73 mg/kg/min when patients were studied at a mean +/- SEM plasma glucose concentration of 226 +/- 15 mg/dl, and M was 2.71 mg/kg/min when the same subjects were studied at a glucose concentration of 118 +/- 6 mg/dl. In contrast, the values for glucose metabolic clearance rate (MCR), which were 2.35 +/- 0.50 and 2.49 +/- 0.47 ml/kg/min, respectively, during the two studies, did not vary significantly with plasma glucose concentration. These data indicate that the glucose metabolic clearance rate (MCR), but not glucose utilization rate (M), can be used to compare in vivo insulin action when insulin clamp studies are performed in subjects with different basal plasma glucose concentrations.

Demonstration of a relationship between level of physical training and insulin-stimulated glucose utilization in normal humans.

The relationship between level of physical training and in vivo insulin-stimulated glucose utilization was investigated in 33 healthy nonobese subjects. Status of physical training was estimated by maximal oxygen consumption (VO2 max) during graded bicycle ergometry, and insulin action by the insulin clamp technique. Within the study population we defined a significant (r = 0.63, P less than 0.001) correlation between these two variables. This relationship was independent of age and obesity and accounted for over 40% of the variance in insulin-stimulated glucose utilization among these subjects. In addition, significant correlations existed between VO2 max and the plasma glucose (r = -0.35, P less than 0.05) and insulin (r = -0.37, P less than 0.05) responses to an oral glucose load. These results suggest that differences in level of physical training play a regulatory role in control of in vivo insulin action.

Effect of sulfonylurea treatment on in vivo insulin secretion and action in patients with non-insulin-dependent diabetes mellitus.

The effect of glipizide treatment on diabetic control and on in vivo insulin secretion and action was studied in 20 patients with non-insulin-dependent diabetes mellitus (NIDDM). Patients were examined before and after a minimum of 3 mo treatment. Mean (+/- SEM) fasting plasma glucose level fell from 264 +/- 12 mg/dl to 172 +/- 10 mg/dl (P < 0.001) after glipizide treatment, and this was associated with a fall in total plasma glucose response to a test meal of approximately 35%. Mean (+/- SEM) fasting plasma insulin levels increased slightly from 15 +/- 2 micronU/ml following sulfonylurea treatment, and the total plasma insulin response to the test meal increased by 63%. However, there was no correlation (r = - 0.20) between the increase in plasma insulin response and the fall in plasma glucose levels that occurred as the result of sulfonylurea therapy. Glipizide treatment also led to enhanced in vivo insulin action, whether measured by the insulin clamp technique (P < 0.001) or the insulin suppression test (P< 0.02). Furthermore, in this instance there was a significant correlation (r - 0.69, P < 0.001) between the enhanced insulin action and the improvement on diabetes control. Thus, chronic therapy with glipizide, a new sulfonylurea agent, led to increased in vivo insulin secretion and insulin action. These results lend direct support to the assumption that sulfonylurea compounds have a substantial extrapancreatic effect on glucose homeostasis, and suggest that this effect contributes to the therapeutic efficacy of these drugs.

Palsy of the recurrent nerve following mediastinoscopy.

As demonstrated in earlier material, the frequency of palsy of the recurrent nerve following mediastinoscopy varies from 0.18 to 0.53 percent (17,000 patients). In 67 patients operated via mediastinoscopy, where pre- and postoperation indirect laryngoscopy was carried out, four postoperative palsies (6 percent) were discovered. Of these, 3 were found among the 24 patients with malignant infiltration of the mediastinum. The value of pre- and postoperation examination of the larynx is stressed.

Effect of age on glucose tolerance, insulin secretion, and in vivo insulin action.

The effect of age on glucose tolerance, insulin secretion, and in vivo insulin action (insulin clamp) was studied in 48 nonobese subjects, all of whom were fully ambulatory and in good general health. The observed age-related increase in fasting plasma glucose (r = 0.35, P less than 0.01) was not due to an increase in relative body weight (RBW). Plasma insulin levels, both fasting and postprandial, tended to rise with age, but these changes were not significant. There was a marginally significant correlation (r = -0.21) between age and insulin-stimulated glucose utilization, which fell to -0.13 when controlled for RBW. However, steady-state insulin levels during the insulin-clamp period were higher in the older subjects, suggesting that age leads to an impairment in insulin catabolism; thus it is likely that the impairment of in vivo insulin action with age was underestimated. The variation in in vivo action between individuals was much greater among the older subjects. It was concluded that the glucose intolerance associated with aging is of relatively minor magnitude when ambulatory, generally healthy, nonobese, and nondiabetic subjects are studied. The cause of the glucose intolerance associated with aging seems to be loss of normal in vivo insulin action. On the other hand, this defect is not shared by all older persons, and in many over the age of 70, glucose transport is as efficient as in persons in their 20s.

Maternal somatostatin levels and their correlation with infant birth weight.

Samples of blood were obtained from 52 primiparous breast-feeding women 4 days post partum. Thirty-six of the mothers were still breast-feeding 3-4 months later and had further blood samples taken. Somatostatin levels were analyzed by radioimmunoassay. A highly significant rank correlation (P = 0.0001) between average somatostatin levels on the two occasions was established, although somatostatin levels recorded 3-4 months post partum were significantly higher than those found 4 days post partum (P less than 0.01). Furthermore, somatostatin levels obtained 4 days and 3-4 months post partum were inversely related to the birth weight of their children (P = 0.006 and P = 0.03). The significant negative correlation between somatostatin levels recorded 4 days post partum and birth weight of the infants persisted only when non-smokers were investigated. A strong positive correlation between infant birth weight and weight of placenta was found (P = 0.0001) and a negative correlation (P = 0.04) between somatostatin levels and placental weight. A stepwise regression was performed to explain the importance of somatostatin levels in birth weight. Somatostatin levels and smoking had an almost equal influence on the variation in birth weight (approximately 10%). It is suggested that low maternal somatostatin levels are related to an efficient storage of nutrients in the fetoplacental unit, thereby leading to a high birth weight.

Immunoreactive calcitonin in maternal milk and serum in relation to prolactin and neurotensin.

Maternal milk four days post partum contained immunoreactive calcitonin in concentrations which were 22-89 times higher than those noted in concomitantly sampled maternal sera. Neurotensin-like immunoreactivity was barely detectable in milk. It is suggested that calcitonin may be a prerequisite for the concentration of calcium ions in milk but there is also possibility that it acts locally on the intestinal mucosa.

Suckling in lactating women stimulates the secretion of insulin and prolactin without concomitant effects on gastrin, growth hormone, calcitonin, vasopressin or catecholamines.

The levels of growth hormone, vasopressin, prolactin, calcitonin, gastrin, insulin, epinephrine, norepinephrine and dopamine were measured in six lactating women during breast feeding. Prolactin levels increased in response to suckling as expected. In addition, insulin levels rose two-fold. No consistent changes were observed in the levels of the other hormones. It is suggested that the suckling related insulin release is either secondary to a reflexly induced activation of the vagal nerves or to the increased circulating levels of prolactin. Furthermore, it is suggested that the insulin release in response to suckling participates in the stimulation of milk production.

Different patterns of oxytocin, prolactin but not cortisol release during breastfeeding in women delivered by caesarean section or by the vaginal route.

The aim of this study was to find out whether the hormonal patterns of oxytocin, prolactin and cortisol differed between women delivered by emergency section or by the vaginal route and if these patterns show any relation to the duration of breastfeeding. Seventeen mothers with emergency section (C.S.) and 20 mothers with normal vaginal deliver (V.D.) were blood sampled in connection with breastfeeding on day 2 post partum for oxytocin, prolactin and cortisol. The number of oxytocin pulses as calculated with the PULSAR program occurring during the first 10 min of the breastfeeding session varied between 0 and 5. The V.D. mothers had significantly more pulses than the C.S. ones. Furthermore the C.S. women lacked a significant rise in prolactin levels at 20-30 min after the onset of breastfeeding. Logistic regression analysis revealed mode of delivery and infant's age at first breastfeed to be the most important, independent variables showing a relation to the release pattern of oxytocin on day 2. Correlations between oxytocin pulsatility on day 2 and the duration of the exclusive breastfeeding period in the V.D. group suggest that development of an early pulsatile oxytocin pattern is of importance for breastfeeding.

Breast feeding-induced effects on plasma gastrin and somatostatin levels and their correlation with milk yield in lactating females.

Maternal gastrin and somatostatin levels have been shown to be influenced during suckling in dogs and pigs. The present study was performed to investigate whether the levels of gastrin and somatostatin are influenced by breast feeding in lactating women. Repeated blood samples were drawn in connection with nursing in 15 females and plasma levels of gastrin and somatostatin were measured by radioimmunoassay. Gastrin levels rose significantly (P = 0.01) within two minutes after onset of suckling. Somatostatin levels either decreased or increased as an effect of breast feeding. The direction of the change was correlated to the pre-suckling somatostatin levels (P less than 0.01). The somatostatin level recorded 60 min after start of breast feeding was significantly lower than basal levels (P less than 0.01) indicating a long-term inhibitory effect on somatostatin secretion. The suckling-induced effect on somatostatin levels was correlated with the amount of milk ejected (Rs - 0.52, P less than 0.05). The mechanism by which suckling influences circulating gastrin and somatostatin levels is unknown, but we suggest that suckling leads to a reflex activation of the vagal nerves, which influence the release of these hormones from the stomach. The size of the gastrointestinal tract is increased during pregnancy and lactation, illustrating that the maternal digestive capacity is adapted to the high demand for energy intake occurring during lactation. We speculate that the suckling stimulus enhances gastric functions by influencing the release of gastrin and somatostatin, which stimulate and inhibit gastric functions and growth, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Short-term effects of early suckling and touch of the nipple on maternal behaviour.

The objective was to evaluate the effects of suckling within 30 min after birth when skin-to-skin body contact for mothers and infants was held constant in both cases (n = 32) and control groups (n = 25). Mother-infant interaction during breast-feeding, infants' time spent in nursery and different aspects of breast-feeding were evaluated. Prolactin and gastrin were measured in maternal serum before and after breast-feeding on day 4 post partum. The aim to evaluate effects of early post delivery suckling failed since only six of the 32 case infants did suck at this time. In spite of this, we found three significant differences among cases and controls. In the case group where all infants had touched or licked the areola and nipple, the mothers left the infants in the nursery for a significantly shorter time and significantly more mothers talked to their infants during the short breast-feeding observation. Median gastrin levels were significantly lower in cases than in controls both before (P less than 0.01) and after (P less than 0.03) breast-feeding. In conclusion, the infant's early touch of the mother's areola and nipple seemed to have positively influenced the mother/infant relationship during the first four days after birth. It was also associated with lower maternal gastrin levels which suggests that maternal neuroendocrine functions were also influenced. Ten months after birth, we found no differences between cases and controls.

Oxytocin, prolactin, milk production and their relationship with personality traits in women after vaginal delivery or Cesarean section.

The aim of the present study was to investigate if personality profiles reflecting anxiety and social interaction of mothers who delivered by Cesarean section (CS) or by the vaginal route (VD) differed in early postpartum and to investigate whether these personality traits were correlated with hormonal data. Seventeen women delivered by emergency CS and 20 by the vaginal route were selected for this study. The amount of milk transferred to the baby was measured. Blood samples were collected during the second breast-feeding on the second day after delivery. The samples were analysed for oxytocin and prolactin. After breastfeeding, the mothers were asked to fill in the personality inventory, Karolinska Scales of Personality (KSP). The scores were compared between the two groups and with a normative group of women. Each scale on the personality inventory was correlated with hormonal parameters. The KSP showed significant differences between the delivered mothers and the normative group in variables related to anxiety and socialization. The VD mothers deviated more than the CS mothers from the normative group. Correlations with hormonal data indicated that anxiety was inversely related with basal levels of oxytocin and prolactin in the CS mothers, whereas the pulsatility of oxytocin was related to social desirability in both groups. Social desirability and oxytocin pulsativity were also correlated with the amount of milk transferred from the mother to the baby. The correlations indicate that central oxytocin, as reflected by basal plasma levels and patterns, may be involved in behavioral adaptations to the maternal role.

Changes in personality pattern during the first pregnancy and lactation.

In order to study personality changes in first pregnancy and lactation, two groups of women (n = 161, mean age 26.8 years) completed the self-report inventory Karolinska Scales of Personality and a scale for emotional dependency during pregnancy and 3 or 6 months after delivery. The results were within normal limits when compared with the normative values. Analysis of variance showed that the subscales Muscular Tension, Somatic Anxiety, and Monotony Avoidance diminished significantly from pregnancy and to the test periods after delivery (all p values < 0.01). Impulsiveness showed the same trend (p = 0.1). The women who had breastfed for at least 8 weeks (91%) differed significantly from those who had not. They had lower scores on the Somatic Anxiety (p = 0.006), Muscular Tension (p = 0.003), Monotony Avoidance (p = 0.039), Suspicion (p = 0.03), Social Desirability (p = 0.045) and the Impulsiveness scale (p = 0.078) and higher scores on the Socialization scale (p = 0.001). Thus, we conclude that most personality traits are stable during first pregnancy and lactation, but some significant changes occur toward a lifestyle interpreted as more relaxed and tolerant to monotony.

Patterns of emotional responses to pregnancy, experience of pregnancy and attitudes to parenthood among IVF couples: a longitudinal study.

The aim of this longitudinal study was to compare couples who had conceived by in-vitro fertilization (IVF) with couples who had conceived naturally, regarding patterns of emotional response to different stages of pregnancy and to compare their expectations of and attitudes to pregnancy, parenthood and children. Fifty-seven IVF women and 55 of their male partners, and a control group of 43 pregnant women and 39 of their male partners participated. They completed scales measuring emotional responses to pregnancy, attitudes to pregnancy, parenthood and children. The IVF couples were interviewed about their experience of pregnancy. The overall anxiety about losing the pregnancy was higher among the IVF couples from early to late pregnancy. The IVF women experienced the pregnancy in a more positive way and they were less concerned about the child's gender and loss of freedom in their future lives as parents compared to controls. The IVF men were more anxious about the baby being injured during birth. The interviews with the IVF couples confirmed the self-ratings. In conclusion, the results suggest that it is important for healthcare providers to pay attention to an elevated anxiety among IVF couples and to give them extra time to discuss emotions during pregnancy and their future life as parents.

Fine-needle biopsy of the thyroid gland: a cytohistological comparison in cases of goiter.

At the ENT Clinic of the Regional Hospital in Orebro, cytological investigation of fine-needle biopsy specimens has been carried out to a steadily increasing extent for more than ten years as a complement to clinical methods in investigation and laboratory tests in cases of goiter. Evaluated here are the method's diagnostic accuracy and its value in investigatory work. The material consists of 303 patients with goiter who were operated from 1964 to 1971 following fine-needle biopsy. Cases where biopsy only was undertaken are not included. Assessable cytological material was obtained in 284 cases (94%). Although not less than 15 doctors carried out the fine-needle biopsies there was approximately a 93% agreement between the cytological and histological diagnoses. In 15 of 28 cases of thyroid carcinoma it was possible to make a definite diagnosis preoperatively, while in 12 of the remaining cases atypia suspected of malignancy was found. The possibility of being able to demonstrate or suspect a carcinoma preoperatively is of greate importance for the surgeon, as a more extensive intervention can be planned in advance and the patient informed before the operation.

Adenocarcinoma originating in the thyroglossal duct.

Eighty-six cases of carcinoma of the thyroglossal duct have been reported in the literature, most of these being well-differentiated adenocarcinomas. Three new cases of the latter type are presented. Cases where carcinoma of the thyroglossal duct is suspected should be investigated with fine-needle biopsy, thyroid scintigraphy, skeletal and pulmonary X-ray, determination of TSH, T 3, PBI and blood serum calcium. The treatment of well-differentiated adenocarcinomas is a combination of surgical and medical procedures.