Evaluation of the Effects of Skin-to-Skin Contact on Newborn Sucking,

Evaluation of the Effects of Skin-to-Skin Contact on Newborn Sucking, and Breastfeeding Abilities: A Quasi-Experimental Study Design Jia-Zhen Huang 1,2, Chi-Nien Chen 3,* , Chih-Ping Lee 1 , Chien-Huei Kao 2,*, Heng-Cheng Hsu 4 and An-Kuo Chou 3 1 Department of Nursing, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu 30059, Taiwan; k..o@gmail.com (J.-Z.H.); c..e@hch.gov.tw (C.-P.L.) 2 Department of Nurse-Midwifery and Women Health, National Taipei University of Nursing and Health Sciences, Taipei 112303, Taiwan 3 Department of Pediatrics, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu 30059, Taiwan; d..4@gmail.com 4 Department of Obstetrics and Gynecology, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu 30059, Taiwan; b..7@gmail.com * Correspondence: c..n@hch.gov.tw (C.-N.C.); c..i@ntunhs.edu.tw (C.-H.K.) Abstract: Mother and newborn skin-to-skin contact (SSC) after birth has numerous protective effects. Although positive associations between SSC and breastfeeding behavior have been reported, the evidence for such associations between early SSC and breastfeeding success was limited in highincome countries. This quasi-experimental intervention design study aimed to evaluate the impact of different SSC regimens on newborn breastfeeding outcomes in Taiwan. In total, 104 healthy mother- infant dyads (52 in the intervention group and 52 in the control group) with normal vaginal delivery were enrolled from 1 January to 30 July 2019. The intervention group received 60 min of immediate SSC, whereas the control group received routine care (early SSC with 20 min duration). Breastfeeding performance was evaluated by the IBFAT and BSES-Short Form. Generalized estimating equations (GEEs) were used to evaluate the effectiveness of the intervention. In the intervention group, the breastfeeding ability of newborns increased significantly after 5 min of SSC and after SSC. The intervention also improved the total score for breastfeeding self-efficacy (0.18 point; p = 0.003). GEE analysis revealed that the interaction between group and time was significant (0.65 point; p = 0.003). An initial immediate SSC regimen of 60 min can significantly improve neonatal breastfeeding ability and maternal breastfeeding self-efficacy in the short term after birth. Keywords: breastfeeding; skin-to-skin contact; feeding ability; breastfeeding self-efficacy; GEE modeling 1. Introduction Breastfeeding has long-term health benefits for mothers and children, and knowledge of ways to improve breastfeeding can increase the chances of breastfeeding success [1]. Early mother-infant skin-to-skin contact (SSC) is a key factor in the success of breastfeeding [1-3]. SSC also has other benefits, such as reduced mortality among low-birth-weight infants [4]. A national survey in Taiwan found that the prevalence of SSC reached more than 60%, and early SSC had a significant impact on exclusive breastfeeding success up to 6 months [5]. In addition, SSC can help reduce early hospitalization rates after birth [6]. Previous studies have found that breastfeeding success is related to the duration of SSC, and longer duration may positively correlate with greater breastfeeding rates [7]. The World Health Organization recommends that SSC between mother and baby be performed for more than an hour after birth [8]. In contrast, the mother- and infant-friendly medical institution regulation in Taiwan states only that early SSC is encouraged and that an SSC duration of at least 20 min is recommended. The definitions for the duration of SSC Nutrients 2022, 14, 1846. https://doi.org/10.3390/nu14091846 https://www.mdpi.com/journal/nutrients Nutrients 2022, 14, 1846 2 of 12 and the exact timing for the initiation of SSC differed in previous studies and were also heterogeneous [9]. There are limited studies on the SSC duration needed for it to be effective, and most of these studies were conducted in low-income countries [2,3,7,10]. Although skin-toskin contact was positively associated with breastfeeding behavior in many countries, a cross-sectional study found no association between early SSC and breastfeeding success in Australia [11]. The breastfeeding outcomes after SSC in high-income countries are controversial, and the prevalence rates of SSC in high-income countries were mostly over 50~60% in a systematic review [9]. It is worth exploring whether the duration of SSC can enhance breastfeeding success in high-income countries and whether there is a dose- response relationship. Many concerns have not been addressed yet, probably due to the lack of a consistent definition for SSC initiating time or duration in the current clinical practice setting. There are insufficient randomized studies related to SSC and breastfeeding outcomes to support the evidence [3,10,12]. A study in Colombia found that SSC immediately after birth was not associated with better breastfeeding outcomes than early skin-to-skin contact at 60 min after birth [13]. Whether there are no differences in the onset time of SSC in high-income countries remains to be confirmed. Given the many advantages of SSC, there are ethical concerns about using randomized controlled studies to understand the effect of SSC. Thus, the comparison of the immediate and prolonged SSC with routine neonatal care in Taiwan might be an implementable project for exploration. We hypothesized that immediate onset of SSC and longer duration may promote the later breastfeeding ability in neonates. To test this hypothesis, this study aimed to investigate whether the breastfeeding outcomes are affected by SSC for different onset times and durations through a quasi-experimental study design. 2. Materials and Methods 2.1. Study Participants We conducted a single-centre study using a quasi-experimental intervention design to evaluate whether immediate and longer SSC had an impact on newborn sucking, feeding, and breastfeeding efficiency. We have followed the TREND checklist to report our study [14]. Women who had undergone natural childbirth in the delivery room in the National Taiwan University Hospital Hsin-Chu Branch, a regional teaching hospital with approximately 700 births annually and their newborns were recruited as the study participants. Sample size estimation was performed with a moderate effect size of 0.25 and α error of 0.05 and achieved 80% power for the study. Consequently, the sample size was estimated to be 52 mother-infant dyads and a total of 104 pairs in both the intervention and control groups. From 1 January to 30 July 2019, the following two phases were performed with 2 weeks suspended between these two phases: (1) the first phase with the participation of mother- infant dyads born from 1 January to 28 March 2019, serving as the control group, and (2) the second phase including a training program for neonatal nurses to optimize their clinical practices and with the participation of mother-infant dyads born from 11 April to 30 July 2019, serving as the intervention group. The mother-newborn pairs in the control group had continuous skin contact for 20 min according to original routine neonatal care (for about five to ten minutes) at the institution. Regarding neonatal care before SSC in the control group, we conducted umbilical cord cutting, birth weight, head circumference, birth height, and body temperature measurements. The umbilical cord-cutting was conducted at the same time in both groups. Neonates who received routine nursing care after birth had a significantly longer time to initiate breastfeeding than those who received uninterrupted and immediate SSC [15]. In contrast, those in the intervention group had uninterrupted skin contact for 60 min immediately after birth. The criteria for inclusion in this study were vaginal delivery, singleton pregnancy at 37-42 gestational weeks, infant birth weight between 2500 and 4000 g, and the ability of Nutrients 2022, 14, 1846 3 of 12 the mother to listen, speak, read, and write in Chinese. Women awaiting delivery gave informed consent to participate in the study and agreed to have postpartum mother-infant skin contact. The exclusion criteria were medical and obstetric complications due to a high-risk pregnancy; refusal to breastfeed or choosing to use formula for feeding prior to delivery; interrupted skin contact between the mother and infant for medical reasons, such as postpartum hemorrhage or perineal lacerations; breast structural abnormalities that could affect neonatal sucking, such as flat or inverted nipples; a need for the newborn to be admitted to the infant observation room or neonatal intensive care ward immediately after birth; first Apgar score less than 7 and congenital malformations, such as cleft lip. Nipple problems may affect breastfeeding success [16]; therefore, we excluded women with flat or inverted nipples. 2.2. Research Tools and Outcome Definitions The primary outcomes were newborn sucking, breastfeeding ability, and breastfeeding self-efficacy. The research tools used consisted of (1) a questionnaire for collecting basic information about the mother and neonate, (2) the infant breastfeeding assessment tool (IBFAT) [17], and (3) the Breastfeeding Self-Efficacy Scale-Short Form (BSES-SF) [18]. The research tools utilized in the study were all authorized by the original authors. Both of these two tools have been used by many scholars in Taiwan before. In addition, there are also Chinese versions of these two tools for study with good reliability, which can assist in the conduction of this study [19,20]. To evaluate breastfeeding ability, four consecutive IBFAT scores were collected at the following times: (1) after 5 min of SSC, (2) after skin contact (about 25 to 30 min of age in the control group and 60 min of age in the intervention group), (3) 24 h after birth, and (4) before discharge (3 days of age). Maternal breastfeeding self-efficacy was assessed by the BSES-SF on the day of discharge. We used the above questionnaires to analyse the performance after SSC. The secondary outcome was the success rate of breastfeeding after SSC. Is this a peer reviewed article?

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