Author Name:
Unicef India

Biography:

1. Introduction

Every newborn, when placed on the mother’s abdomen, has ability to find his mother’s breast all on her own and to decide for herself when to take the first breastfeed. This is known as the ‘Breast Crawl’.

Breast Crawl was first described in 1987 by a Swedish group in the article: Gastric suction in healthy newborn infants. Effects on circulation and developing feeding behaviour (Widstrom AM, Ransjo-Arvidson AB, Christensson K, Matthiesen AS, Winberg J, Uvnas-Moberg K (1987). Acta Paediatrica Scandinavica, 76(4):566-72.)

The description of the Breast Crawl, compiled from the article, is as follows:

‘Immediately after birth the child was dried and laid on the mother’s chest. The child always started to breathe without having had mucus sucked out from the airways. The umbilical cord was cut 30 to 60 sec after birth in accordance with the hospital routines.

In the control group a regular behavioural sequence, previously not described in the literature, was observed. After 15 min of comparative inactivity, spontaneous suckling and rooting movements occurred, reaching maximal intensity at 45 minutes. The first hand-to-mouth movement was observed at a mean of 34± 2 min after birth and at 55+ mins the infant spontaneously found the nipple and started to suckle.

These findings suggest that an organized feeding behaviour develops in a predictable way during the first hours of life, initially expressed only as spontaneous suckling and rooting movements, soon followed by hand-to-mouth activity together with more intense suckling and rooting activity, and culminating in suckling of the breast.’

Excellent photographs were included in the article & the word ‘crawl’ appeared in the description of the photographs: ‘The baby has by itself crawled towards the nipple’

Many studies with different aims were published subsequently in relation to “Breast Crawl”

1) Study the effect of other hindering factors
(Righard et al 1990)

2) Biological mechanisms for homing on the nipple
(Varendi et al 1994, Varendi et al 1996, Varendi et al 2000)

3) Advantages of breast crawl
(Widstrom 1990, Christensson et al 1992, Christensson et al 1995, Matthiesen 2001)

A beautiful account of the “Breast Crawl” has been given in two good articles (Klaus 1998, Klaus 2001) which reviewed many of the above studies. These articles greatly inspired us to include the Breast Crawl in our ‘Lactation Management’ curriculum & to prepare the documentary. We have quoted frequently from these references.

The credit for using the word ‘Breast Crawl’ as a ‘noun’ for the first time should be given to Klaus (1998) – All previous studies have used it as a ‘verb’.

The start position for the ‘Breast Crawl’ has been specified by Varendi et al (1994, 1996,) i.e. nose in the midline of the mother’s chest, eyes at the level of the nipples.

3. What makes a baby capable of ‘Breast Crawl’?

The Baby is born with many instinctive abilities to perform the Breast Crawl. With all these innate programmes, the infant seems to come into life carrying a small computer chip with the set of instructions. It appears that these young humans, like other baby mammals, know how to find their mother’s breast. (Klaus, 2001). ‘Breast Crawl’ is associated with a variety of sensory, central, motor and neuro-endocrine components, all directly or indirectly helping the baby to move & facilitate her survival in the new world.


3.1 Sensory Inputs:
Smell, vision & taste all help the newborn detect & find the breast. Other senses make her comfortable & help create a suitable environment. (Olfactory / Visual / Taste / Auditory / Touch)


3.1.1 Olfactory:

This is the most studied input for the Breast Crawl & believed to be the most important

Babies preferred their mother’s unwashed breast within 1 to 2 hrs after birth (Varendi, 1994). The preference for the unwashed breast was due to babies responding to differences in smell. Besides secreting milk and colostrum, the nipple/areola is dense in glands that might secrete attractive odours. Washing could have reduced or eliminated such odours. This was thought to be consistent with a previous study (Makin & Porter, 1989) where infants preferentially moved towards a gauze pad contaminated with the breast odour of a lactating woman.

Later Varendi et al (1996) showed that within the first hour after birth, significantly more babies spontaneously selected a breast treated with amniotic fluid than the alternative untreated breast. This attraction appears to be based on olfactory cues. Thus amniotic fluid potentiates or overrides the attractiveness of the natural scent of the mother’ breast. They postulated that observed attraction to amniotic fluid odour may reflect foetal exposure to that substance (i.e. prenatal olfactory learning). They also suggested that it was probably common for women to handle their baby themselves during and following delivery throughout the evolution of our species. Immediately after parturition, the mother’s hands soiled with birth fluids would transfer the amniotic fluid to her breasts when she first attempted to nurse her neonate. This may be observed currently amongst non-human primates. The data presented illustrates the importance of maternal odours for newborn infants. Aside from guiding neonate’s overt behavioural responses, such olfactory stimuli also appear to have a calming effect on the infant & provide a basis for early individual recognition of the mother.

In 1998 Wineberg et al stated that about 1-2% of the human genome is allocated to production of receptors for the olfactory epithelium--a hint as to the possible importance of this chemical sense.

Breast odours from the mother exert a pheromone-like effect at the newborn's first attempt to locate the nipple.

Olfactory recognition may be implicated in the early stages of the mother-infant attachment process, when the newborns learn to recognize the own mother's unique odour signature--a process possibly facilitated by the high norepinephrine release and the arousal of the locus coeruleus at birth.

Mother is the source of an array of olfactory, visual, auditory and tactile stimulation that the infant may perceive and respond to when placed on her bare chest. In an attempt to elucidate further the role of olfaction per se in early orientation to the breast, babies were observed when additional maternal cues (e.g. voice, skin temperature and texture, body form, heart & respiratory sounds and movement) were not available (Varendi et al, 2000). Total 22 babies were observed during the two trials on a warming bed. In one trial a pad carrying the mother’s breast odour was placed 17 cms in front of the baby’s nose. In the other trial a clean pad was used. More babies moved towards and reached the breast pad than the clean pad. It was concluded that natural breast odours unsupported by other maternal stimuli therefore appear to be sufficient to attract & guide neonate to the source of odour.

It appears that amniotic fluid contains some substance that is similar to certain secretion of the breast, albeit not the milk. The baby uses the taste & smell of amniotic fluid on his hands to make a connection with a certain lipid substance on the nipple related to the amniotic fluid. (Klaus, 2001)

3.1.2 Visual:

Illingworth (1987) quoting many references has discussed the visual abilities of the newborn. They are listed as follows:

• Within minutes after birth, the infant follows a face like pattern more than other patterns of similar brightness
  
• She will look at a black on white drawing of a face longer than three black dots on white
  
• 40 newborn babies, at a median age of 9 minutes, moving stimuli caused turning of head & eyes. There was a greater response to a proper picture of a face than to a scrambled one, indicating that organized visual perception is an unlearned capacity.

Newborns can recognize mother’s face (Bushnell, 1989) and can follow it for short distance (Brazelton, 1990)

In the past most caretakers believed that the newborn needs help to begin to nurse. So, immediately after birth, the baby was given to the mother with his lips placed near or on the mother’s nipple. In this situation, some babies do start to suckle, but the majority just lick the nipple or peer up at the mother. They appear to be much more interested in the mother’s face, especially her eyes, even though the nipple is right next to their lips. If kept in between mother’s breasts, the infant usually begins with a time of rest & quiet alertness during which he rarely cries and often appears to take pleasure in looking at his mother’s face. (Klaus, 2001) There is a beautiful interlocking of gaze, at this early time, with the mother’s interest in the infant’s eyes and the baby’s ability to interact and to look eye to eye (Klaus, 2001).Visual interaction during the first few hours may explain the significantly reduced incidence of abandonment later in babies who were given early contact with suckling & were roomed in. This may be partly due to the special interest that mother’s have, shortly after birth, in hoping that their infant will look at them and to the infant’s ability to interact during the prolonged period of the quite alert state in the first hour of life.

We are tempted to speculate that if a baby can appreciate mother’s face, it can definitely see the areola & nipple (perceived as dark on light pattern).

This is consistent with Illingworth (1987) stating that a newborn baby shows more interest in a black & white pattern than in a blank grey card. Perhaps that is the only reason why the areola is hyperpigmented. This is in sharp contrast to animals' breasts / nipples.

Does this point to a possibility that as compared to young ones of animals, human babies may be more vision dependent in homing on to the nipple?

3.1.3 Taste:

Amniotic fluid on the infant’s hands probably also explains part of the interest in suckling the hands and fingers. The baby uses the taste & smell of amniotic fluid on his hands to make a connection with a certain lipid substance on the nipple related to the amniotic fluid (Klaus, 2001).

3.1.4 Auditory:

The mother’s voice is reported to be the most intense acoustic signal measured in the amniotic environment. Preterm foetus also is capable of responding to speech stimuli. Both the newborn & foetus show heart rate decelerations in response to speech sounds. Newborn infants prefer the sound of the maternal voice and also suck longer when they hear it (DeCasper & Fifer, 1980; Fifer & Moon 1994). They can discriminate the language heard in utero from another language (Mehler et al, 1988). Thus mother’s voice is a naturally occurring and salient stimulus during a critical time period in which there is significant development in several psychobiological systems.

Given these abilities of the newborn, Breast Crawl would offer the best chance for auditory stimulation with the natural voice of the mother which newborn is accustomed to in utero. However it would be equally important to encourage mothers to initiate conversation with the baby in antenatal period & continue conversing in the early tender moments soon after birth. This may not only comfort the baby but also may have bearing on development.

Rhythmic sound of the mother’s heart-beat would also have a calming influence on the baby. Sounds that imitated heart beats at a frequency of about 70 per minute, during the first few days, not only calmed the baby but also reduced postnatal weight loss. (Salk L, 1960; Salk L, 1962)

Early experiences with voices have both acute & enduring effect on the developing brain. These effects have ramifications for the development of auditory system, as well as for later social and emotional development (Fifer & Moon 1994).

Thus Breast Crawl provides continuity in auditory stimulation & development from foetal to newborn or intrauterine to extrauterine life.


3.1.5 Touch:

Skin to skin touch provides heat & variety of other tactile inputs. It offers benefits at many levels:

• Helps maintain temperature (Christensson et al 1992)
• Facilitates metabolic adaptations (Christensson et al 1992)
• Less crying (Christensson et al, 1992; Christensson et al, 1995)
• Bonding (Widstrom et al, 1990)
• Oxytocin release in mother resulting in early placental separation and decreased blood loss post delivery
• Immediate & long term breastfeeding success: (Righard & Alade, 1990; WHO, 1998)

All these benefits are discussed in detail later on.

This is the reason why the ‘Global Criteria for the WHO/UNICEF Baby Friendly Hospital Initiative, 1992’ recommend that Mothers in the maternity ward who have had normal vaginal deliveries should confirm that within a half-hour of birth they were given their babies to hold with skin contact, for at least 30 minutes (WHO, 1992)


3.2 Central Component

After birth, the healthy newborn often undergoes a quiet alert phase, which has been referred to as the first phase of reactivity. When placed skin to skin on mother’s chest shortly after birth, the infant often becomes quiet & starts exploring (D’Harlingue & Durand, 2001) Infants separated from their mothers cry excessively.

Widstrom et al (1987) recorded a state of wakefulness during breast crawl according to Brazelton’s Neonatal Behaviour Assessment Scale (BNBAS). At 15 minutes, the children’s median state was 4. Alertness gradually decreased till 150 minutes after birth, when they were all asleep.

This confirms that the newborn’s brain is optimally ready to integrate various sensory inputs & other components of Breast Crawl soon after birth. If initiation is not attempted soon after birth, a vital period of alertness will be lost – the newborn will go off to sleep & the first breastfeed may be delayed for several hours.

3.3 Motor Outputs:

Orofacial / Lower Limbs / Upper Limbs / Salivation

3.3.1. Orofacial:

Around 30-40 mins after birth, the newborn begins making mouthing movements, sometimes with lip smacking. Suckling of hands & finger is commonly seen.

After latching successfully, newborns continued to suckle for 20 mins (Righard & Alade, 1990

3.3.2 Lower Limbs:

Stepping Reflex helps the newborn push against his mother’s abdomen to propel him towards the breast.

Righard & Alade (1990) observed that arm & leg movements started after a mean of 49 mins (SD 7.8)

3.3.3 Upper limbs:

Horizontal motion is achieved by using small push ups and lowering one arm first in the direction they wish to go. The ability to move his hand in a reaching motion enables the baby to claim the nipple. (Klaus, 2001). This would help to stimulate, elongate & protract the nipple. This would help him subsequently to latch on.

Muscular strength in neck, shoulders, and arms helps newborns bob their heads and do small push ups to inch forward & side to side.

The efforts to reach the breast are interspersed with short periods of rest. Sometimes babies change direction in midstream

3.3.4 Salivation:

Occurs in anticipation that food is in close proximity.


3.4 Neuroendocrine Component:

When the infant suckles from the breast, it stimulates the production of oxytocin in both the mother’s & the infant’s brain. Oxytocin in turn stimulates the vagal motor nucleus, releasing 19 different gastrointestinal hormones including insulin, cholecystokinin and gastrin (Tafari & Ross, 1973) Five of these 19 hormones stimulate growth of the baby’s & mother’s villi and increase the surface area and the absorption of calories with each feeding. The stimuli for this release are touch on the mother’s nipple and the inside of the infant’s mouth. (Uvnas-Moberg, 1989)


4. Advantages offered by Breast Crawl:

Promotion of early initiation of breastfeeding has great potential: 16% of neonatal deaths could be saved if all infants were breastfed from day 1 and 22% if breastfeeding were started within the first hour after birth (Edmond et al, 2006).

Several other advantages of early initiation have been mentioned in the section on FAQ. These are listed along with references in International Lactation Consultant Association document (ILCA, 2005).

All these advantages will obviously be maximally tapped with Breast Crawl. We present some of these advantages where evidence is available: For Baby/ For Mother/ For Both


4.1 For the Baby: Warmth / Comfort / Metabolic adaptation / Quality of attachment

4.1.1 Warmth:

Christensson et al (1992) compared temperatures of newborns kept in skin to skin contact in breast crawl position with those kept in bed in first few hours after birth. They found that former had higher body & skin temperatures. They concluded that mother is an important heat source for the newborn. In an evolutionary perspective, the mother’s body must have been the only reliable source of heat for the newborns. The natural body to body contact may have been a part of genetic programme for maternal behaviour, which is worthwhile protecting.
The skin to skin method of care should not be withheld with reference to the risk of cooling, especially when delivery staff prefers to put the baby in bed during the first 1-2 hours following birth as a part of hospital routine. It is important to utilize this method, especially in those developing countries, where the incidence of neonatal hypothermia has been reported to be high and associated with an increased morbidity & mortality rates.


4.1.2 Comfort:

The transition from life in the womb to existence outside the uterus is made easy by the various sensory inputs (discussed above) in Breast Crawl position.

In this position, the infant can experience sensation somewhat similar to what he felt during the last several weeks of intra-uterine life. It is likely that each of these features –the crawling ability of the infant, the decreased crying when close to the mother, and the warming capabilities of the mother’s chest-are adaptive features that have evolved to help preserve the infant’s life. (Klaus, 2001).

Christensson et al (1992) compared crying between babies kept in Breast Crawl position with those kept in cot. The infants in cot cried for a significantly longer time than the babies in skin-to-skin during all observation periods. The sum total of crying time (in seconds) for the 15 babies at each 5 min interval period (25-30 mins, 55-60 mins And 85-90 mins) were 60, 0 and 10 seconds for the skin to skin babies and 1094,985 and 760 seconds for the cot babies.

Similar study was done by Christensson et al in 1995 to objectively evaluate differences in crying when infants were cared for by one of the following methods during 90 minutes of birth

• skin to skin contact (90 mins)
  
• In a cot next to the mother (90 mins)
  
• In a cot for the first 45 minutes & then skin to skin contact for next 45 mins

Results suggested that human infants recognize physical separations from their mothers and start to cry in pulses. Crying stops at reunion. The observed cry may be a human counterpart of the ‘separation distress call’ which is a general phenomenon among several mammalian species and serves to restore proximity to the mother. The results suggest that in human newborns this cry is not dependent on earlier social experience and may be a genetically coded reaction to separation. Whatever the evolutionary foundations, this cry seems to signal that care in a cot, which keeps the baby well within the accepted normal temperature zone, does not satisfy the needs of the newborn human baby. Authors recommend that the most appropriate position of the healthy full term newborn baby after birth is in close body contact with the mother.

4.1.3 Metabolic adaptation:

Babies kept in Breast Crawl position had higher 90 minute blood sugar levels and the return towards zero of the negative base excess was more rapid as compared to babies kept in a cot (separated).

4.1.4 Quality of attachment:

Of 17 Babies kept in Breast Crawl position & uninterrupted for 1 hour, 16 latched in correct position (Righard, 1990).

This is crucial because early suckling pattern is of prognostic value for the duration & success of breast-feeding.

4.2 For mother:

4.2.1 Expulsion of placenta & reduction of postpartum haemorrhage

As stated earlier, the newborn’s ability to move his hand in a reaching motion helps to stimulate, elongate & protract the nipple. This would help him subsequently to latch on. Pressure of the infant’s feet on the abdomen may also help in the expulsion of the placenta and in reducing uterine bleeding.

Massage of the breast by the baby and subsequent suckling induce a large oxytocin surge into her bloodstream, which helps to contract the uterus, expelling the placenta and closing off many blood vessels in the uterus, thus reducing bleeding. The stimulation & suckling also helps in the manufacture of prolactin. (Klaus, 2001)

Nissen et al (1995) showed that with baby in breast crawl position had significant elevation of oxytocin levels soon after delivery compared with prepartum levels & levels returned to prepartum levels 1 hr after delivery. Peak occurred at 15 mins with expulsion of placenta. Most mothers had several peaks of oxytocin upto 1 hr after delivery.


4.3 Advantage to both: Bonding:

Mother’s feeling of love for the baby may not necessarily begin with birth or instantaneously with the first contact. During breast crawl, while resting skin to skin and gazing eye to eye, they begin to learn about each other on many different planes. For the mother, the first few minutes and hours after birth are a time when she is uniquely open emotionally to respond to her baby and to begin the new relationship. Suckling enhances the closeness & new bond between mother & baby. Mother & baby appear to be carefully adapted for these first moments together. (Klaus & Kennel, 2001)

Many studies have addressed the question of whether there is a sensitive period for parent infant contact in the first minutes, hours & days of life that may alter the parent’s behaviour with their infant later in life. In many biological disciplines, these moments have been called “sensitive period”. In each study increasing the mother-infant time together or increased suckling improves caretaking by the mother.

Researchers have also observed that mothers exhibit a very orderly and predictable set of behaviour when they first see and come into contact with their newborns. They begin by hesitantly touching the infant's extremities with their fingertips. Within four or five minutes, they begin caressing the child's trunk with the palm, simultaneously showing progressively heightened interest that continues for several minutes. By the end of nine minutes, fingertip touch has dropped substantially, palm contact has more than doubled, and touch now emphasizes the trunk rather than the extremities. (Klaus 1970)

If nurses spend as little as 10 minutes helping each mother discover some of their newborn infant’s abilities, such as turning towards the mother’s voice and following the mother’s face and assisting mothers with suggestions about ways to quieten their infants, the mothers become more appropriately interactive with their infants face to face and during feeding at 3- 4 months of age. (Brazelton, 1990)

If the lips of the infant touch mother’s nipple in the first hour of life, a mother will decide to keep her baby 100 minutes longer in her room every day during her hospital stay than another mother who does not have contact until later. (Widstrom et al 1990).

Extended early contact in first few days helps prevent parenting disorders including child abuse, failure to thrive, abandonment and neglect later on. This may be partly explained by the small secretion of oxytocin (the love hormone) that occurs in both the infant’s & mother’s brain when breastfeeding occurs. In sheep, dilatation of the cervical is during birth releases oxytocin within the brain, which, acting on receptor sites, is important for the initiation of maternal behaviour and for the facilitation of bonding between mother & baby. In humans, there is a blood brain barrier for oxytocin, and only small amounts reach the brain via the blood stream. However, multiple oxytocin receptors in the brain are supplied by de novo oxytocin synthesis in the brain. Increased levels of brain oxytocin result in slight sleepiness, euphoria, increased pain threshold and feeling of increased love for the infant. It appears that, during breastfeeding, elevated blood levels of oxytocin are associated with increased brain levels; women who exhibit the highest plasma oxytocin are the sleepiest. (Klaus & Kennel, 2001)

5. Hindering Factors:

The distribution of lag time between first hand to mouth movement and onset of suckling was significantly different between the two groups. Authors concluded that in infants exposed to gastric suction, the early feeding behaviour was disrupted for which Vagal afferent reflexes induced by gastric suction were thought to be responsible. They stated that value of routine gastric suction must be questioned in healthy infants after normal pregnancy and normal vaginal delivery with normal amount of amniotic fluid.

Righard & Alade (1990) studied the effect of separations on Breast Crawl in 72 infants. In the separations group (n=34), the infant was placed on the mother’s abdomen immediately after birth but removed after 20 mins for measuring & wrapping. These routines took about 20 mins after which infant was returned to the mother. In the contact group (n=38) contact between mother & infant was uninterrupted for at least one hour after birth. Of the 72 mothers, 40 (56%) received pethidine during labour. The suckling technique was studied in both the groups.Of the 11 infants whose mother’s were given pethidine 45 mins to 2 hrs before delivery, 5 sucked correctly. The mothers of the 29 infants who were given pethidine more than 2 hours before delivery (range 2-13 hrs); 3 of these infants sucked correctly.

Authors concluded that brief separation of the infant from the mother during the first hour after birth had a strong effect on the success of the first breastfeed, as did pethidine given during labour. Of infants both separated & exposed to pethidine through their mothers, not one breastfed successfully, whereas almost all those who were neither separated nor exposed to pethidine succeeded in adopting the correct breastfeeding technique. Thus the two crucial determinants for a successful start to breastfeeding seem to be uninterrupted contact with the mother until after the first feed unless separation is unavoidable, and no sedation of the infant by analgesics given to the mother during labour.

Separation for measuring & wrapping procedure after 15 to 20 mins of skin to skin contact seriously disturbed the first breastfeed. This time seems to be a very critical stage for separation; just when the infant was about to start crawling movements, he or she was removed. The infants generally protested loudly when removed. There is no justifiable reason for routine separation- measuring and weighing procedures can simply be put off for 1-2 hours.
Authors recommended that


the naked infant should be left undisturbed on the mother’s abdomen until the first breastfeeding is accomplished, and the infant’s efforts to take the breast actively should be recommended.


Use of drugs given to the mother during labour should be restricted.


As stated earlier olfaction plays a great role in guiding the newborn to the breast. A chemical from nipple is thought to be responsible. Based on this Varendi et al (1994) stated that unnecessary routine cleaning of the breast may interfere with the establishment of successful early breastfeeding by elimination of the infant’s access to biologically relevant chemical signals.

Same researchers in 1996 stated that excessive use of products that eliminate or mask natural odour signals (deodorant, perfume, eau-de-cologne) should perhaps be avoided during the perinatal period.

In order not to remove the taste & smell of the mother’s amniotic fluid, it is necessary to delay washing the baby’s hands. This early hand-sucking behaviour is markedly reduced when infant is bathed before the crawl. To allow this first encounter to be successful, Klaus et al strongly urge that the injection of vitamin K, application of eye ointment, washing and any measuring of infant’s height, weight & head circumference be delayed for at least 1 hour (Klaus & Kennell, 2001).

On basis of above data, the hindering factors for the ‘Breast Crawl’ can be listed as follows:

• Maternal analgesia
• Gastric emptying
• Separation of mother & baby for any reason until after first breastfeed
• Baby bath, Injection Vit K, eye drops
• Mopping/washing newborn’s hands
• Washing breast prior to first breastfeed
• Use of products with strong smell in labour room

29 June, 2007