Hands-On or Hands-Off When First Milk Matters Most?

Abstract

S ince the early 2000s, there has been encouragement in the lactation/midwifery/nursing literature to use a handsoff approach to lactation support, believing this empowers mothers and demonstrates respect for their bodies. 1,2 These recommendations coincide and complement the observational reports from Sweden on first hour ''breast crawl.'' 3 The authors described nine behavioral phases for ''optimal selfregulation'': birth cry, relaxation, awakening, activity, crawling, resting, familiarization, and suckling. This behavior sheds light on the healthy term infant's innate ability to maintain the olfactory connection between prenatal pheromone priming of nutritive behavior and the last step of the birth process, breastfeeding. The recognition of the unique scent of each mother's amniotic fluid, the secretions from her Montgomery glands, and early milk, along with the infant's well-developed sense of smell, led us to recognize that searching for the breast was an olfactory response rather than a visual response. This gave us all pause and a healthy appreciation for ''cue-based'' lactation support. With profound respect for nature, our obstetrical practices frequently counter the natural birth process, with drugs, surgery, and other interventions, which compromise the newborn's ability to complete the breast crawl. For example, in term healthy infants, roughly 75% complete a breast crawl in 60 minutes, given immediate uninterrupted skin-to-skin time on their mothers' chest (88.01% unmedicated vaginal; 11.21% cesarean). 4 The authors conclude that encouraging breast crawl in all dyads, especially in cesarean births, may unduly delay the infant's first breastfeed. Even induction of a term vaginal birth impedes this behavior, with 31% induced versus 57% spontaneous births successful. 5 What would studies report if the infants were late preterm infants (34 to £37 weeks gestation)? Related to the relative immaturity of these infants, over one-third of primiparous mothers discontinue breastfeeding by 1 month. 6 There are no randomized controlled trials (RCT) to demonstrate any beneficial outcome comparing independent breast crawl with gentle cue-based assistance in term infants without prior interventions (suctioning, separation, etc.). Likewise, there are no RCT to evaluate outcome measures of respectful and gentle hands-on assistance compared with a hands-off approach. Interestingly, concurrent with the popularity of a hands-off approach, there have been documented resurgences of the diagnosis of flat nipples, yeast infections, and tongue-tie, leading to recommendations for nipple shields, frenectomy, antifungals, and topicals, based on marginal evidence.

Mother-infant bonding and breastfeeding in neonates with hypoxic ischemic encephalopathy or seizures

“…Skin-to-skin and holding experiences experienced through baby-to-breast feeding supports optimal long-term neurodevelopmental outcomes (22). However, early-onset breast milk provision is key to mothers' ability to provide breast milk over a longer period as well as successful coaching in hand-expression and pump use (23).…”