| | The effect of Russian Maternity Home routines on breastfeeding and neonatal weight loss with special reference to swaddlingAccepted 30 March 2006. Abstract BackgroundFew 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. AimsTo 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 subjectsIn 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. ResultsBabies 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). ConclusionSupplements 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. 1. Introduction  Practices in labor and maternity wards have been shown to influence the outcome of breastfeeding. In particular, skin-to-skin contact between mother and baby after birth in combination with early and/or frequent suckling has been shown to be conducive to breastfeeding [1], [2], [3]. Although no evidence has yet been found that indicates that skin-to-skin contact alone is beneficial to breastfeeding [4], [5], skin-to-skin contact has been shown to stimulate the baby's inborn pre-feeding behaviour [6] and thus, may optimise initiation of breastfeeding. Recent research has also indicated that skin-to-skin contact increases the babies' body temperature [7] and counteracts “the stress of being born” [8]. The practice of rooming-in, whereby mother and baby share the same room at the maternity ward, allows for breastfeeding on demand. Breastfeeding on demand results in larger milk volume produced by mothers, whereby infants' needs for supplements is decreased [9], [10]. Breastfed infants have also been shown to lose more weight the first two days than supplemented infants but instead regain weight faster than do supplemented infants. Neonatal weight loss as well as recovery from weight loss can serve as an indirect marker not only of the amount of the infant's nutritional intake, but also of the infant's ability to use calories for anabolic purposes. Thus, neonatal weight could potentially serve as a tool for the evaluation of ward routines and hospital policies. The present study was performed in St. Petersburg, Russia in the middle of the 1990s in collaboration with a team of Swedish health care professionals. At that time in Russia early skin-to-skin contact and suckling were not practiced since infants were normally swaddled, separated from their mothers after birth and put in a cot in a labor ward nursery. Nor did infants experience rooming-in; they usually remained in the nursery during the maternity stay. At that time in Sweden, infant care practices included skin-to-skin contact and breastfeeding immediately after birth, as well as rooming-in with the mother. Thus, the different routines in Russia and Sweden gave an ideal and natural experimental research design to compare ward routines and their outcome. From an ethical point of view, the comparison of ward practices did not presuppose that one type of care was better than the other, but rather allowed a serious investigation of several significant variables and factors representative within each culture. As mentioned above, another important difference between the Russian and Swedish routines at this time was that Russian infants were swaddled after birth. The custom of swaddling, which is common not only in Russia, is old and may have originated in nomadic tribes [11]. Swaddled babies are tightly wrapped by swaddling sheets and only the infant's front face is left unbound. According to our knowledge, no studies have been published that show that swaddling affects the outcome of breastfeeding or weight loss in newborn infants. Since tight swaddling restricts infant's movements (even head's movements) we hypothesized that it might hinder inborn feeding behaviour and thus interfere in breastfeeding performance. In addition as swaddling was believed to keep the babies warm [11] and might thus serve energy-saving purposes, we predicted that neonatal weight loss could be less in swaddled babies. Thus, the aim of the present study was to investigate how labor and maternity ward routines (including swaddling) influence breastfeeding parameters (amount of ingested milk, volume of supplements, number of breastfeeds, and total duration of breastfeeding time) day 4 after birth, and recovery from neonatal weight loss and infant's weight on day 5. In a randomized trial with factorial design we studied the effect of: 1)skin-to-skin contact versus contact in clothes versus separation at the delivery ward; 2)rooming-in versus nursery care at the maternity ward; 3)swaddling versus baby clothes. 2. Material and methods The study, which was conducted at Maternity Home 13, in St. Petersburg, began in 1995 with data collection completed in 1998. The Ethics Committee at the Karolinska Institutet in Stockholm and the Health Care Division of the mayor-council of St. Petersburg approved the study. 2.1. Participants 2.1.1. Inclusion criteria Healthy women with normal full term pregnancies admitted to the delivery ward during the daytime hours were informed about the study; those who agreed to participate signed a letter of consent. After parturition those women who gave birth vaginally to healthy singleton babies were included in the study. Women who received oxytocin infusion during labor or analgesia like epidural, paracervical or pudendal block were not included in the study. Infants diagnosed as “small for gestational age”, sick infants, and those with congenital malformations as well as infants with Apgar score less than 8 at 5 min after birth were not included. 2.1.3. Excluded mothers Of the 176 mothers who were randomly assigned to the four main treatment groups, 23 were excluded for diverse reasons during the stay at the maternity ward: –Four mothers refused to participate without giving a reason. –Twelve mothers did not follow the randomization schedule (4 switched from nursery to rooming-in, 5 switched from rooming-in to nursery and 3 wanted another type of apparel for the baby than that to which they were assigned). –Seven mother–infant dyads were excluded due to medical complications (4 cases due to maternal bleeding, one case due to maternal heart problem and 2 cases due to blood incompatibility and hyperbilirubinemia in the infant). There was no significant difference between the 23 mothers who were excluded and the 153 mothers who participated in the study in respect to educational background or the other background variables. 2.2. Procedure 2.2.1. Routines at the delivery and maternity wards According to the Russian tradition at the time of the study, all mothers were lying on their backs during the first 2 h after birth and all mothers received intravenous administration of methylergometrin in connection with birth of the babies' head. The umbilical cord was clamped 10 to 15 s after birth and all babies were immediately put on an examination table with a radiant heater above. The infants were carefully dried, wrapped in a dry sheet and left on the examination table while the attending midwife took care of the mother. The infants were then washed under tap water and cared for by a midwife according to hospital routines which included weighing, taking anthropometric measurements and dripping of 30% Sulfacyl Natrium into the babies' conjunctivae for prophylaxis of gonococcal ophthalmia. To prevent cord infection Xeroform powder or 1% Iodine solution was applied to the umbilical cord stump and on the baby's skin pleats. Babies in treatment groups II–IV were then dressed according to the randomization and left on the examination table. The babies randomized to the Skin-to-skin group were left on the examination table covered with a blanket. After a mean time of 22 min (range 20–25 min) after birth the babies were brought to their mothers or to the labor ward nursery. Babies dressed in baby clothes or those who were naked were put between the mothers' breasts in a prone position. Swaddled babies were put between the mothers' breasts on their side to secure free airways. The mean air temperature did not differ significantly between the delivery room and the labor ward nursery or between the mother's room and the maternity nursery during the subsequent days of the study (see previous article [8] for more details). Before the infants were brought to the maternity ward a pediatrician examined them. Provided there was no bleeding the suturing of vaginal ruptures and/or episiotomies was postponed in study women until 2 h after delivery. 2.2.2. Swaddling Traditional Russian hospital practice of swaddling included the use of six cotton cloths per infant. Two cloths were positioned as diapers and one was used to bandage the infant's legs. The next cloth was used to wrap the babies' arms close to the body and was also used to serve as an extra layer over the babies' body and legs. After this, one more cloth was drawn from behind of the head to cover the forehead and then ending cross wise on the thorax. The last cloth was used as an inner layer of the blanket and together with the blanket was tightly swept around the body of the baby. 2.2.3. Baby's clothes Babies who were randomized to wear clothes were dressed in identical sets of clothes that were specially brought from Sweden for the purpose of the study. Each set consisted of the ordinary cotton shirt with long sleeves and infant leggings, wool socks and cap. Infants were dressed in this apparel after birth. Prefabricated diapers were used. 2.2.4. Traditional post partum hospital practices Typical Scandinavian maternity care at the time of the study was to put the baby skin-to-skin with the mother at the delivery ward and later at the maternity ward dress the baby in ordinary baby clothes. Swedish infant care included the practice of rooming-in and breastfeeding on demand. Typical Russian maternity care was to keep the baby separated from the mother and to swaddle the infant after birth in the delivery ward. Swaddled babies were then kept in the nursery during their stay in the hospital. Swaddled infants were transported on small guerneys from the nursery to the maternity ward and back seven times a day for breastfeeding. 2.2.5. Breastfeeding variables measured During day 4 (i.e. from 72 to 96 h after delivery) mothers filled in a specific breastfeeding protocol. They marked the number of breastfeeds; duration of each feed; milk volume ingested, measured as the difference in the babies' weight before and after breastfeeding (Electronic scale, Tanita 1581, Tanita Corporation, Japan, accuracy±1 g); and volume of additional food given to the baby. Nursery group babies were weighed by the nurses on day 4 before and after breastfeeds. Nurses also noted the amount of extra supplements, (formula and/or glucose), given to the babies. 2.2.6. Statistics Means and standard deviations (SD) were used as descriptive measures if otherwise not indicated. To compare the treatment groups t-test and one-way ANOVAs were used. Two-way ANOVAs were used to explore the effect of swaddling on breastfeeding parameters within the four treatment groups. Repeated measures ANOVA together with Fisher's Protected Least Significant Differences (Fisher's PLSD) were used to analyze recovery of neonatal weight loss for days 3 to 5 after birth [12]. Infant weight in the Nursery group on day 5 was studied in a series of exploratory regression analyses using different combinations of the explanatory variables. These variables included birth weight, gestational age, mothers' age, years of education, breast-milk ingested during day 4, formula supplemented during day 4, glucose supplemented during day 4, swaddling (yes/no) and interaction between swaddling and amount of supplements. The interaction term in the regression was constructed using an extra explanatory variable in the regression model taking the value of the amount of supplements for the swaddled babies and zero for the non-swaddled babies. The regression coefficient for the interaction term was used to predict the mean weight gain per additional 100 ml of supplements given to swaddled babies. 3. Results 3.1. Effects of ward routines on breastfeeding variables No group difference was found between the infants who were swaddled and those who were dressed in respect to breastfeeding variables (“number of breastfeeds”, “duration of breastfeeds”, “amount of supplements”, and “amount of ingested breast-milk”) in any of the four treatment groups studied on day 4 after birth. (Two-way ANOVA see Fig. 1a–e). Nor were there significant differences in the three rooming-in groups of infants (Skin-to-skin, Mother's arms and Reunion group) regarding number and duration of breastfeeds, amount of ingested breast-milk or amount of supplements (Table 3). However, there was a significant difference regarding the number of breastfeeds in each of the rooming-in groups where breastfeeding on demand was more frequent that the 7 scheduled breastfeeds in the Nursery group (t-test, P<0.05). All other breastfeeding variables studied were significantly higher in the three rooming-in groups than in the Nursery group except for the amount of supplements which was significantly lower for the three groups of rooming-in infants (see below and Table 3). Thus, statistical analyses showed that Nursery group babies who remained in the nursery between feeds were: –breastfed for a significantly shorter mean time than babies in the rooming-in groups (ANOVA F3, 133=5.167, P=0.0021 and Fisher's PLSD P-values 0.0003–0.0126); –given significantly more formula than babies in the groups where rooming-in was practiced (ANOVA F3, 139=13.247, P-value <0.0001 and Fisher's PLSD P<0.0001); –received significantly less breast-milk than babies in the groups where rooming-in was practiced (ANOVA F3, 139=6.177, P-value=0.0006 and Fisher's PLSD P-values 0.0002–0.0020). 3.2. Effect of supplements on breast-milk volume and duration of breastfeeds on day four The majority of study infants received no formula during their hospital stay. However, of the 26 babies who were given formula, 19 belonged to the Nursery group. The 7 remaining infants who were supplemented with formula, were distributed evenly among the rooming-in groups. The mean amount of formula given to the 19 infants within the Nursery group averaged 121 ml (SD=79 ml). Twelve of the infants in the Nursery group also had some glucose (mean=38 ml, SD=24 ml). No infants in the rooming-in groups received glucose. Thus, to explore the effect of formula and glucose intake on total duration of breastfeeds and on milk volume ingested by the infants, analyses were performed on the infants in the Nursery group (Table 4). Some important differences between supplemented and non-supplemented infants were found. | | |  | | Exclusively breastfed babies (n=17) | Supplemented babies (n=20) | P-values | |
|---|
| Duration of breastfeeds (min) | 173 (61) | 117 (50) | 0.0131 | | | Breast-milk (ml) | 212 (100) | 120 (85) | 0.0045 | | | Formula (ml) | 0 | 121 (79) | | | | Glucose (ml) | 0 | 38 (24) | | | | Breast-milk+formula (ml) | 212 (100) | 235 (64) | 0.4128 | | | Breast-milk+formula+glucose (ml) | 212 (100) | 258 (68) | 0.1092 | | | | |
The total duration of breastfeeds in the Nursery group during day 4 was 173 min (SD=61) in exclusively breastfed infants versus 117 min (SD=50) in supplemented babies. This difference was significant (F1, 26=7.1, P=0.0131). The mean amount of breast-milk ingested by exclusively breastfed infants was 212 ml (SD=100 ml), whereas infants also given supplementation ingested 120 ml (SD=85 ml). This difference was also significant (F1, 35=9.2, P=0.0045). The total volume of liquid intake was about the same in supplemented and non-supplemented infants (Table 4). 3.3. Effect of ward routines and supplements on recovery of neonatal weight loss There was no significant difference in recovery of weight loss day 3 to day 5 between the four main treatment groups (Skin-to-skin, Mother's arms, Nursery and Reunion groups), (Repeated measures ANOVA, data not shown). The influence of swaddling on recovery of weight loss by means of Repeated measures ANOVA was observed only in the Reunion group. In this group, infants were separated from their mothers for 2 h after birth and then were reunited with their mothers for rooming-in. Swaddled babies tended to have a greater weight loss than did babies dressed in clothes (F1, 26=3.946, P=0.0576) (Fig. 2). Influence of supplements on the recovery of weight loss could only be tested in the Nursery group since few infants in the rooming-in groups were supplemented. Nursery group infants receiving supplements in addition to mother's milk seemed to have a delayed recovery of weight loss day 3–5 after birth compared to those receiving only breast-milk (Fig. 3a). This delay was found to be significant in swaddled babies (Repeated measures ANOVA, F1, 17=5.969, P=0.0258) (Fig. 3b). In order to further explore the influence of supplements (formula+glucose) and swaddling on the infant's weight on day 5, regression analyses were performed (see statistical paragraph). In the final explorative model the mean weight on day 5 of the Nursery group infants was used as a dependent variable. Main explanatory variables were “birth weight”, amount of “breast-milk ingested on day 4”, “amount of supplements ingested on day 4” and “swaddling (yes/no)”. In addition an interaction term between the amount of supplements and swaddling (“supplements×swaddling”) was added to the regression model (Table 5). It should be noted that the variables “amount of breast-milk on day 4” and “amount of supplements on day 4” also reflect the total amount of breast-milk or supplements received from birth to day 5. Likewise, infant weight on day 5 reflects the total previous food intake. Glucose occurred in combination with formula and did not add much to the model by itself. Thus, the total amount of supplements was used in the model. In this final model, 99% of the variation in infant weight on day 5 was explained. All coefficients in the regression analysis, except the one corresponding to the main effect of swaddling, were significantly different from zero. The interaction between swaddling and supplements was significant, but not swaddling alone (main effect). This means that the amount of supplements has a different effect on weight gain in swaddled infants than in non-swaddled infants. This can be illustrated by inserting the calculated regression coefficients given in Table 5 into separate regression equations for swaddled and non-swaddled babies1. Thus, according to the estimated regression coefficients Nursery group babies would, on the average, gain about 59 g more five days after birth per every 100 ml of breast-milk ingested on day 4, given constant levels of the other independent variables. Weight gain per 100 ml is less for supplements than for breast-milk and differs between non-swaddled and swaddled babies (see Table 5). Thus, the model predicts an average weight gain corresponding to about 50 g per 100 ml ingested supplements in the non-swaddled infants and about 14 g in the swaddled infants. Predicted weight gain per 100 ml breast-milk (59 g) differs significantly from the predicted weight gain per 100 ml supplements in the swaddled babies (14 g) (P=0.001). 4. Discussion The different labor ward routines used in the present study (infants with skin-to-skin contact, dressed in clothes, or swaddled immediately after birth and kept in mother's arms or exposed to a short-term separation of 120 min) did not influence the breastfeeding variables measured. However, maternity ward routines did influence the outcome of breastfeeding four days after birth. The data show that Nursery group infants ingested significantly higher amounts of formula and glucose and significantly less amounts of breast-milk on day 4 after birth than did babies in the rooming-in groups (Table 3). The reasons for the lower intake of breast-milk in the Nursery group are probably manifold. Nursery group babies, kept in the nursery during the entire maternity stay, were brought to the mothers only for breastfeeding, which was set at 7 times per 24 h. In the rooming-in groups of infants, feeding on demand was practiced and the number of breastfeeds was significantly higher than 7. It is likely that the restricted number of breastfeeds in the Nursery group contributed to the fact that infants in this group ingested less breast-milk than did infants in the rooming-in groups. Data showing that the numbers of breastfeeds positively correlate to the amount of milk ingested by the infants [9] supports this assumption. However, the main reason for the lower intake of breast-milk in the Nursery group might be that these infants were often given supplements. In Russia it was a common practice for the staff to give formula or glucose to babies who appeared hungry or cried. In fact, several studies have shown that a negative effect on milk-ingestion by infants, and production of milk by mothers, occurs when supplements are given to the infant during the first days of life [9], [10], [13]. Further, it is known from clinical practice that ingestion of formula and glucose between feeds reduces the infant's interest in the breast [10] as well as the duration of breastfeeds, probably due to a reduced hunger drive. During these circumstances the infants ingest less breast-milk. In addition, since the infant's sucking activity is an important stimulator of maternal milk production, less milk will be produced over time, and a vicious circle is created. The present finding that Nursery group infants who received supplements had a significantly shorter duration of breastfeeding and ingested significantly less breast-milk than those infants who only received breast-milk (Table 4) supports the above mentioned hypothesis. Significant findings regarding the rooming-in infants are primarily understood as an effect of infant–mother proximity. One important characteristic of the difference between the Nursery group infants and those who roomed-in with their mothers, is that rooming-in mothers and infants are in constant proximity to each other and consequently exposed to sensory interaction tactile, as well as visual, auditory, and olfactory stimuli. Not only suckling, but also touch and possibly other sensory cues trigger the release of oxytocin and many other hormones in the mothers [14]. Oxytocin stimulates milk ejection, and as a consequence also stimulates milk production and promotes maternal–infant interaction [15]. In rats, separation between mother and young, causes stress, which is evidenced by a rise of both maternal [16] and pups' [17] corticosterone levels following separation. Whether a rise of cortisol occurs in response to separation between human mothers and infants after birth has not been demonstrated. Interestingly, however, is the finding that the outcome of breastfeeding in infants who were exposed to a short (120 min) separation period immediately after birth, but then had rooming-in (Reunion group) did not differ significantly from that of infants who were not separated from their mothers after birth (Skin-to-skin and Mother's arms groups). This finding suggests that a short-term separation after birth does not influence the outcome of breastfeeding 4 days after birth per se, or that possible negative consequences were antagonized by the practice of rooming-in, which might allow higher levels of interaction between mother and infant. A second major finding in the study was that swaddled infants, under certain conditions, had a delayed recovery of weight loss after birth. At first, it appeared as if the Nursery group babies had a delayed recovery of weight loss, when compared to those in the rooming-in groups. Further analysis demonstrated that only those infants who were both supplemented and swaddled had a delayed recovery of weight loss. In addition, swaddled infants who had been separated 120 min after birth, and then brought back to their mothers for rooming-in (Reunion group) had a delayed weight loss recovery when compared to those infants in the Reunion group who were dressed in baby's clothes. These findings indicate that the routine of swaddling might make the infants more vulnerable to some types of stress such as formula feeding and early separation. There may be numerous reasons for the negative effects of swaddling. For instance, swaddling may induce a stress reaction in itself, since motor activity is severely impaired and might cause a catabolic state. Another possibility is that the effect of swaddling interferes with tactile interaction between mother/staff and infant. Reduced weight gain in supplemented infants occurred in spite of a similar intake of calories. Infant formula contains the same amount of calories as breast-milk, but it is known that breast-milk also contains substances with growth promoting properties, such as epidermal growth factor (EGF). Such factors may be of particular importance for growth during the first weeks of life, since the intestinal mucosa is relatively more permeable to such molecules at this time [18]. Different sucking patterns between breastfeeding and bottle-feeding infants [19] may partially explain the evidenced differences in weight gain. Gastrointestinal hormones, which are controlled by vagal nerve tone are released in response to breastfeeding [20], [21], [22] as well as in response to sucking on a pacifier [23]. However, ingestion of formula from a bottle does not give rise to the same amount of vagal nerve activation, as does breastfeeding [22]. Since vagal nerve activity and gastrointestinal hormones stimulate digestion and anabolic function — weight gain and growth are secondarily enhanced by such activation [24]. Moreover, sensory stimulation such as touch is important for growth. In other studies, weight gain of full term [25] and of premature infants [26], [27], [28] has been demonstrated to be increased by touch. Interestingly, sensory stimulation of the skin also causes a release of gastrointestinal hormones that indicates that the vagal nerve is activated by such stimulation. An example of this is that infants who receive kangaroo care have higher levels of the gastrointestinal hormones, such as cholecystokinin (CCK) during feeding [29], [30]. Thus, tactile interaction may enhance weight gain and growth by a mechanism that is similar to that induced by suckling. Obviously, swaddling reduces the amount of touch. The routine of swaddling may thereby interfere with tactile interplay between mother/staff and infant, and blocks the positive effect on growth and metabolism induced by tactile stimuli. This blockage might disclose the negative effects of formula feeding and short-term separation. Birth is accompanied by a high level of stress both in mother and infant [31], [32]. This stress results in peripheral vasoconstriction in the infant [33]. We have previously shown that the peripheral vasoconstriction gave rise to cold feet in infants after birth but was reversed almost immediately by skin-to-skin contact between mother and infant. Difference in foot temperature persisted for almost two days for those babies allowed skin-to-skin contact after birth compared to those separated from their mothers by staying in a cot in the nursery [8]. Based on these findings, we postulated in this previous article that skin-to-skin contact between mother and infant – via activation of sensory nerves – counteracts “the stress of being born”. In line with this, Ferber and Makhoul [34] suggest that skin-to-skin contact might be used to reduce the stress associated with birth. Results show that some ward routines such as early separation, staying in the nursery at the maternity ward, as well as swaddling, in combination, interfere with the interaction mothers and infants take for granted in infant care settings, such as those in Sweden. These present findings suggest important examples of stress reducing and growth-promoting effects of mother–infant interaction in general, and of tactile sensory stimulation, in particular. Since sensory stimulation may give rise to relaxation and stimulation of growth in the infant, ward routines that limit close contact between mother and infant may have negative effects on breastfeeding and weight gain in infants. Acknowledgements This work was supported by grants from the East European Committee, SIDA, Royal Swedish Academy of Science, Frimurare barnhuset, Karolinska Institutet, Sällskapet Barnavård, St.Petersburg State Paediatric Medical Academy (Russia), Swedish Institute, Swedish Medical Research Council (grant Nr K2002-04X-05207-25A). References [1]. [1]de Chateau P, Wiberg B. Long-term effects on mother–infant behaviour of extra contact during the first hour post partum: 1. First observation at 36 hours. Acta Paediatr. 1977;66:137–143.
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