BONDING & UNDISTURBED ATTACHMENT
Recent Observations on the Importance of
Immediate Skin-to-Skin Bonding,
Newborn-led Suckling, and
Postpartum Support for Early Parenting
from
The Child Institute Foundation for Children
authored by
Sem Pringpuangkaew M.D., Prawase Wasi M.D, Dr.Aree Wanyasewi M.D., Kaisit TantiSirin M.D., San
Singhaphakdee M.D., Rajit Buri M.D.
*** This article is helpful to refer to when requesting these protocols of any medical attendants. Understand and
discuss this research BEFORE you give birth.
RECENT RESEARCH
In recent years, several physiologic and behavioral studies of mothers and infants have added new and
critical information. Both mother and infant bring a wealth of internal resources to their early moments
together.
INITIAL SUCKLING
Perhaps the most revealing example is the ability of newborns, if left quietly on the mother's abdomen after
birth, to crawl gradually up to her breast, find the nipple, and start to suckle. If the mother has received
no pain medication during labor and birth and the infant is placed on her abdomen, kept warm with the
heat of her body and a towel, and not taken from her for the next 60 minutes, the baby usually begins a
five-part sequence that ends with proper latching onto the mother's nipple. For the first 20 minutes, the
newborn rests and looks up periodically at the mother. At 30 to 45 minutes, mouthing and lip-smacking
movements begin, and the infant begins to drool. The baby then begins to move forward slowly, starts to
turn the head from side to side, and opens the mouth widely upon nearing the nipple. After several
attempts, the lips latch onto the areola, not the nipple. The odor of the nipple appears to guide the newborn
to the breast. When the right breast is washed, the baby goes to the left breast.
In one group of mothers who did not receive pain medication and whose babies were not taken away
during the first hours of life for a bath, vitamin K administration, or application of eye ointment, 15 of 16
babies were observed to make this trip on their own and to begin to suckle effectively. These and other
observations have made us question our present policy of putting infants to the breast immediately after
birth. This newly discovered process suggests that the newborn, after recovering from the stress of birth,
begins suckling, and is ready to eat at a more appropriate time, when he or she is ready.
PHYSIOLOGIC ASPECTS OF EARLY INFANT-MOTHER CONTACT
Swedish researchers have shown that the normal infant, when placed nude on the mother's chest and then
covered with a blanket, will maintain his or her body temperature as well as when elaborate, high-tech
heating devices that usually separate the mother and baby are used. The same researchers found that
when the infants are skin-to-skin with their mothers for the first 90 minutes after birth, they cry
hardly at all compared with infants who were dried aand wrapped in a towel. It seems 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 and evolved genetically more than 400,000
years ago to help preserve the infant's life.
When the infant suckles from the breast, there is a large outpouring of 19 different gastrointestinal
hormones in both the mother and the infant, including cholecystokinin and gastrin, which stimulate growth
of the baby's and mother's intestinal 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. These responses were essential for survival thousands of years ago when periods of famine were
more common before the development of modem agriculture and the storage of grain. These new research
findings explain some of the underlying physiologic processes and provide additional support for the
importance of two of the ten caregiving procedures that the United Nations International Children's
Emergency Fund (UNICEF) is promoting as part of its Baby Friendly Initiative to increase breastfeeding.
EARLY CONTACT AND ABANDONMENT
Following the introduction of the Baby Friendly Initiative in maternity units in several countries throughout
the world, an unexpected observation was made. In Thailand, in a hospital where a disturbing number of
babies are abandoned by their mothers, the use of rooming-in and early skin-to-skin contact with suckling
significantly reduced the frequency of abandonment from 33/10,000 births to 1/10,000 births a year.
Similar observations have been made in Russia, the Philippines, and Costa Rica when early contact and
rooming-in were introduced.
These reports further suggest that events occurring in the first hours and days after birth have special
significance, and they are additional evidence that the first hours and days of life are a sensitive period for
the human mother. This may be due in part to the special interest that mothers have shortly after birth in
hoping their infant will look at them and the interacting behavior of the infant in the first hour of life during
the prolonged period of the quiet alert state. Thus, there is a beautiful interlocking at this early time of the
mother's interest in the infant's eyes and the baby's ability to interact and to look 'eye-to-eye.' A possible
key to understanding what is happening physiologically in the first minutes and hours comes from
investigators who noted that if the lips of the infant touch the 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.
OXYTOCIN RELEASE
Measurements of plasma oxytocin levels in 18 healthy women who had their babies skin-to-skin on their
chests immediate after birth showed significant elevations compared with the prepartum levels and a return
to prepartum levels at 60 minutes. For the majority of women, a significant and spontaneous peak
concentration was recorded about 15 minutes after delivery, with expulsion of the placenta. Most mothers
had several peaks of oxytocin up to 1 hour after birth. The vigorous oxytocin release after birth and with
breastfeeding not only help contract the uterine muscle to prevent bleeding, but enhance bonding of the
mother to her infant.
These findings may explain an observation made in France in the 19th century when many mothers were
giving up their babies. Poor mothers who breastfed for at least 8 days rarely abandoned their infants. We
hypothesize that a cascade of interactions between the mother and baby occurs during this early period,
locking them together and ensuring further development of attachment. The remarkable change in maternal
behavior with just the touch of the infant's lips on the mother's nipple, the reduction in abandonment with
early contact, suckling, and rooming-in; and the raised maternal oxytocin levels shortly after birth in
conjunction with known sensory physiologic, immunologic and behavioral mechanisms all contribute to the
attachment of the parent to the infant.
PROMOTION OF EARLY AND EXTENDED CONTACT
Although debate continues on the interpretation and significance of the many research studies regarding the
effects of early and extended contact for mothers and fathers on bonding with infants, all sides agree that all
parents should be offered such contact time with their infants.
Anisfeld observed a low incidence of secure attachment behavior at 1 year in a poor, stressed urban
population where most of the mothers put young infants in firm plastic infant seats throughout the first year.
In nonindustrialized societies, where most babies are carried on the mother's body through the
day and sleep with the mother at night, there is much less infant crying. Drawing on the idea that
increased physical contact would promote greater maternal sensitivity to the signals of the infant and, thus,
increased responsiveness, Anisfeld and associates conducted a randomized study in which one group of
babies was carried on the mother's body in a soft baby carrier and another group was placed in firm infant
seats that provided less contact. When the infants were assessed in the home at 3 months by naive
observers, the mothers using the soft baby carriers were more appropriately interactive and responsive to
their babies' cues. When all the infants reached 13 months of age, the Ainsworth Strange Situation test was
applied: 83% of the babies carried in the soft carrier were securely attached compared with 39% of the
infants from the group that used the firm infant seats.
The significant effects of the first hours and days are explained in part by observations noted by Winnicott,
who reported a special mental state of the mother in the perinatal period that involves a greatly increased
sensitivity to, and focus upon the needs of her baby. He indicated that this state of "primary maternal
preoccupation" starts near the end of pregnancy and continues for a few weeks after the birth of the baby.
A mother needs nurturing support and a protected environment to develop and maintain this state.
This special preoccupation and the openness of the mother to her baby are key factors in the bonding
process. Winnicott wrote that "Only if a mother is sensitized in the way I am describing, can she feel herself
into her infant's place, and so meet the infant's needs." In the state of "primary maternal preoccupation" the
mother is better able to sense and provide what her new infant has signaled, which is her primary task. If
she senses the needs and responds to them in a sensitive and timely manner, mother and infant will establish
a pattern of synchronized and mutually rewarding interactions. It is our hypothesis that as the mother-infant
pair continues this dance pattern day after day, the infant more frequently will develop a secure attachment,
with the ability to be reassured by well-known caregivers and the willingness to explore and master the
environment when care givers are present. In a sense, the child becomes an optimist rather than a
pessimist. The characteristics of a secure attachment, if present at 1 year of age, usually persist
through childhood and into adult life.
Although many changes have been made in the perinatal institutional caregiving environment over the past
10 years, it is apparent that further changes are required, including early skin-to-skin contact and extended
maternal caregiving with rooming-in for all healthy mothers. It appears that this type of maternal behavior
during the first year of life will lead more frequently to a securely attached and appropriately independent
child who develops a basic sense of trust in the world.
Fathers
Fathers are expected to be present during labor and delivery in United States hospitals, and a Gallup poll
shows that 80% of mothers have the father present. In surveys, mothers express a belief that it is extremely
important for the father to be present during labor and deliver), and fathers express a desire to be present.
This assures that most fathers are available for early contact with newborns. Research has shown that
paternal caretaking and affectionate interaction with the baby is increased in the first 3 months if the father
has experience with his undressed baby (skin-to-skin), changing diapers and looking "en face"
within the first hours of birth. Sharing the intimate experience of the birth of the baby and interaction
afterward provides fathers a feeling of increased closeness to their partners.
Adolescent fathers are often ill-prepared for establishing the family unit with their poor parenting skills,
immaturity, inconsistent involvement with the mother and infant, and low income. Research shows that if
fathers of children born to adolescent mothers attend prenatal visits and participate during labor and birth,
they are significantly more likely to have monthly or more frequent visits with their child in the first 2 years
of their life.
Postpartum Period
The United States stands out for its lack of societal or governmental public health service support for
mothers and babies during the postpartum period.
In contrast, it is the practice in 183 of 186 representative nonindustrialized cultures for the mother-baby to
stay at home, and be protected, fed, and guided during at least the first 7 days, 6 weeks in many cultures,
and 6 months to 1 year in others. Talking with the parents about the need for extra postpartum support
prior to the birth of the baby can expedite the mother's bonding with her infant by minimizing postpartum
fatigue, irritability, and depression
Preterm and Sick Newborns
Carefully conducted studies in industrialized countries have shown that stable infants weighing
1,361 g (3 Ib) can be held safely skin-to-skin. Parents who give birth to a preterm or sick newborn
generally have two different coping styles and personal adaptations to the stress. Some commit to the baby
and maintain an intense involvement. Others choose a slower acquaintance process in which they rely on
the care provided by the experts and express fear, anxiety, and sometimes denial before accepting the
surviving infant. Parents must reconcile their idealized mental image of the expected baby with the tiny,
weak, and scrawny infant. It is difficult for them to appreciate that this baby will grow into a normal, husky,
vigorous youngster.
Babies' body temperatures are well maintained by the warmth of the mother's or father's body when the
baby wears a cap and is covered by a light blanket. The preterm or sick baby's P02 levels are higher when
the baby is skin-to-skin with the parent for periods of up to 2 to 3 hours a day. After the skin-to-skin
experience, mothers feel more confident in the NICU and increase their milk output at home.
Principles of Human Attachment
Studies and observations made over the past 30 years have led our research group to the formulation of
principles that may govern the parents' attachment to their infant. The strength of the data for each principle
varies and comes from clinical experience and research studies.
1. Monotropy. John Bowlby's term for the process of attachment that allows the father and mother to
become attached to only one infant at a time. With twins, it is not uncommon for a father to become closer
to one infant initially and the mother to the other.
2. Love is a two-way process. During the development of the mother's attachment to her infant, it is
necessary that the infant respond to the mother by some signal such as body or eye movements.
3. For adults, it is difficult to go through simultaneous processes of attachment and detachment; that is, to
become attached to one person while mourning the loss or threatened loss of the same or another person.
When one twin dies, it is difficult for the parents to mourn that twin and at the same time develop their
bonds to the surviving infant.
4. Private time. Just as adults need private time for lovemaking, the parents need time and privacy for
beginning the process of falling in love with their new baby.
5.The more physical and emotional support a mother receives during pregnancy, labor, and the postpartum
period from close relatives and caregivers, the greater attention and love she can give to her infant.
6. Most societies provide strong social support for a woman during pregnancy, labor, delivery, and
especially in the subsequent weeks or months, when mothers are fed, protected, and isolated so that they
can successfully begin breastfeeding and get to know their baby.
Recommendations
1. During labor and delivery, every mother should have the possibility of continuous physical and emotional
support by a knowledgeable, caring woman (eg, Doula) in addition to her partner, as recommended by the
Oxford Perinatal Study Group in England and the Canadian Obstetrical Society.
2. Whenever possible, analgesic medications and epidural analgesia should be avoided so that there will be
no interference with the infant's ability to self-attach to the mother's areola and to breastfeed successfully.
3. Immediately after birth an infant who has a good Apgar score and appears normal should be offered to
the mother for skin-to-skin contact, with warmth provided by her body and a light blanket covering the
baby. The baby should not receive a bath, footprinting, or administration of vitamin K or eye medication
until after the first hour. The baby should be allowed to decide when to start the first suckling.
4. The central nursery at hospitals should be closed. All babies should room in with their mothers
throughout the short hospital course unless this is prevented by illness of mother or infant. A small nursery
area should be available for infants of mothers who are ill.
5. Early and continuous mother infant contact appears to decrease abandonment and increase the length
and success of breastfeeding. All mothers should begin breastfeeding in the first hour, nurse frequently, and
be encouraged to breastfeed for at least the first 2 weeks of life, even if they plan to go back to work.
REFERENCES
Als H, L3whon G. Duffy FH, et al. Individualized developmental care for the very low-birth weight preterm
infant JAMA. 1994;272:853.
Anisfeld E, Curry MA, Hales DJ, et al. Maternal-infant bonding: a joint rebuttal.
Pediatrics. 1983;72:569-571
Bowlby J. A Secure Base: Clinical Applications of Attachment Theory. London, England: Routledge., 1988
Brazelton TB, Cramer B. The Earliest Relationship: Parents. Infants and the Drama of Early Attachment.
Reading, Mass: Addison-Wesley/Uwrence; 1990
Christensson K. Selis C, Moreno L. Temperature, metabolic adaptation and crying in healthy newborns'
cared for skin-to-skin. Acta Paediatr. 1992;81:448-493
Eyer DE. Mother-Infant Booding: A Scientific Fiction. New Haven, Conn: Yale University Press., 1992
Karen R. Becoming Attached. New York, NY: Warner Books: 1994
Klaus M. Kennell J. Parent to infant bonding: setting the record straight. J Pediatrics. 1983.,102:575-606
Klaus MH. Kennell JH, Klaus PH. Bonding: Building the Foundations of Sectire Attachment and
Independence. Reading, Mass: Addision-Wesley; 1995
Klaus MH. Klaus PH.D, The Amazing Newborn. Reading, Mass: Addison-Wesley/Lawrence :1985
Lamb ME. Early contact and maternal-infant bonding: one decade later. Pediatrics. 1982; 70:763-767
Lamb ME. The bonding phenomenon : misinterpretations and their implications.
J Pediatric. 1982.101:555
O'Connor S, Vietze PM. Sherrod KB. Sandler HM, Alterneier WA. Reduced incidence of parenting
inadequacy following rooming in. Pediatrics. 1980;66:176-182
Schneirla TC. Problems in the biopsychology of social organization. J Abnorm Soc Psychol.
1946;41:385-401
Stem DN. The Interpersonal World of the Infant. New York, NY: Basic Books;1985
Thompson M. Westrich R. Restriction of mother-infant contact in the immediate postnatal period. In:
Chalmers I, Enkin NI. Kierse MJMC, eds. Effective Care in Pregnancv. Oxford, England: Oxford
University Press; 1989:1322-1330
Uvnas-Moberg. K. The gastrointestinal tract in growth and reproduction. Scientific American. 1989:78-83
Winnicott DW. Babies and Their Mothers. Reading, Mass: Addison-Wesley:1987
