1. Introduction
2. Recommendations and Breast Crawl
3. Our Vision
1. Introduction
The Breast Crawl was described 20 years ago. The discovery, in spite of its
tremendous potential, has failed to reach the beneficiaries (i.e. mothers and
infants) at large. The scientific community, the medical fraternity, health
managers, breastfeeding advocates and international health organizations have
missed out on a powerful ‘change’ agent for early initiation and hence short and
long term breastfeeding success. We tried to analyze the reasons for this
failure and observed that:
Article Titles do not mention the Breast Crawl: Most articles related to
the Breast Crawl, including the first one which described the phenomenon
(Widström et al, 1987), have titles which convey the aims of the study with
great clarity without mentioning the word ‘Breast Crawl’, even though the babies
were kept in the ‘Breast Crawl’ position.
Transition from Verb to Noun: Klaus (1998) used the term ‘Breast Crawl’
as a ‘noun’ for the first time. All previous studies have used it as a ‘verb’.
We feel that this is a landmark transition which resulted in widespread use of
the term ‘Breast Crawl’. Had this significance been realized earlier, perhaps
the titles of many Breast Crawl studies could have used the term.
Breast Crawl and Search Engines: Interestingly, simply because most
article titles do not mention the term ‘Breast Crawl’, the internet search
yields very few articles when the search engines use this term.
Recommendation failures: The body of scientific evidence presented in the
previous section is strong enough to recommend ‘Breast Crawl’ as ‘the method’
for initiating breastfeeding. However, there has been no such widespread
recommendation. In fact, no particular method for initiation of breastfeeding
has been recommended by the BFHI documents.
The purpose of this dossier, and our mission, is to strongly recommend an
evidence based workable method in form of the Breast Crawl for initiation of
breastfeeding. This is especially relevant when the focus of World Breastfeeding
Week for 2007 is on ‘Initiation of Breastfeeding’.
2. Recommendations and Breast Crawl
WHO and UNICEF BFHI documents’ subtle descriptions of the initiation of
breastfeeding are similar to the process of the ‘Breast Crawl’. If interpreted
properly and practised in its true spirit, initiation of breastfeeding would
naturally follow the ‘Breast Crawl’ pattern.
By the time the foundation stone of the Baby Friendly Hospital Initiative was
laid, the Breast Crawl had already been discovered. This was reflected in the
‘Joint WHO / Unicef Statement’ (1989) as ‘The newborn infant should therefore
be cleaned and dried and placed over the mother's abdomen for her to take and
put to her breast.’
WHO and UNICEF BFHI documents have evolved since ‘Ten Steps to Successful
Breastfeeding’ were described in 1989. Though the 4th step remains
unchanged, the interpretation has changed with time.
The initiation of breastfeeding comprises of two components i.e. skin-to-skin
contact and suckling. These were discussed and differentiated subsequently (WHO,
1998).
‘Early skin-to-skin contact and the opportunity to suckle within the first
hour or so after birth are both important. However, contact and suckling are so
closely interrelated that most studies reviewed have used the terms
interchangeably, and few researchers distinguish clearly between them.
Optimally, the infant should be left with the mother continuously from birth,
and allowed to attach spontaneously to the breast whenever she shows signs of
readiness to do so. An arbitrary but practical minimum recommendation is for
skin-to-skin contact to start within at most half-an-hour of birth and to
continue for at least 30 minutes.’
Revised BFHI guidelines (UNICEF/WHO, 2006) interpret ‘Step 4’ as ‘Place
babies in skin-to-skin contact with their mothers immediately following birth
for at least an hour and encourage mothers to recognize when their babies are
ready to breastfeed, offering help if needed.’
The same document further defines the ‘Revised Global Criteria’ for Step Four’
as ‘At least 80% mothers confirm that their babies were placed in
skin-to-skin contact with them immediately or within five minutes after
birth and that this contact continued for at least an hour, unless there were
medically justifiable reasons for delayed contact.’
The revised criteria have precisely defined the maximum upper limit of the
interval between delivery and initiation of breastfeeding as five minutes which
is consistent with the recommendation by Klaus and Kennel (2001):‘Once it is
clear that the baby has good colour and is active and appears normal (usually
within 5 minutes), she can go to her mother.’
The interpretation, description and global criteria for Step four in Revised
BFHI Guidelines almost matches the process of ‘Breast Crawl’ with some subtle
differences which are tabulated below:
| |
Breast Crawl |
Revised BFHI Guidelines |
| Process labelled |
Yes |
No |
| Abilities of the newborn addressed |
Yes |
No |
| Start position |
Nose in the midline of the mother’s chest, eyes at the level of the nipples |
Only one of the positions is similar to the Breast Crawl |
| Recommended duration of skin-to-skin contact |
Till completion of the first breastfeed |
For at least one hour |
We have following suggestions to strengthen the Revised BFHI guidelines (UNICEF/WHO, 2006)
Define and describe in detail a specific method to initiate breastfeeding.
The ‘Breast Crawl’ would help to bridge this gap.
Labelling or naming the process will tremendously help the implementation.
The slogan for the World Breastfeeding Week for 2007 has focussed on initiation
in one hour because it is linked to a study in Ghana (Edmond, 2006) where
neonatal mortality was studied for initiation within one hour. It should not
therefore be misunderstood that WABA recommends delaying initiation of
breastfeeding to ‘within an hour’. WABA supports ‘Ten Steps to Successful
Breastfeeding’ and Revised BFHI Guidelines.
3. Our Vision
The Breast Crawl, to our mind, is the most natural, spontaneous and
logical method of initiating breastfeeding. It is also the simplest method that
provides prolonged skin to skin contact and culminates in the first breastfeed.
It is easy, does not require elaborate preparations, can be done in any setting
and is readily reproducible. We recommend that every baby (and mother) should be
given an opportunity to experience this miracle.
3.1 Ideal Recommendations
3.2 Implementing Breast Crawl as the method of initiation of breastfeeding.
3.3 Breast Crawl E-Dialogue
3.4 Breast Crawl Summit
3.5 Avenues for Research
3.1 Ideal Recommendations
Every minute after birth is crucial. The mother-baby interactions are extremely
complex and precise like a computerized programme. All healthcare providers need
to understand this process, which also is genetic, instinctive, unlearnt
behaviour.
Current recommendations need subtle updating in the light of the evidence presented
A description of the precise method of supporting initiation of breastfeeding i.e. the Breast Crawl.
A discussion of the sensory and motor abilities of the newborn.
Educating all the health workers and mothers (as well as fathers and other close
relatives) about these abilities, so as to empower them to explore these abilities, for the benefit of the mother and the baby.
The need to continue skin-to-skin contact, until completion of the first breastfeed.
At a later stage WHO / UNICEF can consider adding just two words to the fourth step as follows:
4. Help mothers initiate breastfeeding within a half-hour of birth by the ‘Breast Crawl’.
At a still later stage the step can be further updated to the following:
4. Help mothers initiate breastfeeding within five minutes of birth by the ‘Breast Crawl’.
We also visualize the need to talk about the ‘Extended Period of Initiation’.
Classically, ‘Initiation of Breastfeeding’ means the first contact and the first
breastfeed. However, there is a need to talk about an ‘Extended Period of
Initiation’. This period can be considered as the entire period from birth till
the time lactation is established. Realizing the importance of this period ILCA
has published a document ‘Clinical Guidelines for the Establishment of Exclusive
Breastfeeding’ in June 2005. The document focuses on issues such as frequency of
feeding, realizing early feeding cues, waking up a sleepy infant, the need for
mothers to learn positioning and attachment, monitoring for adequacy etc., in
addition to other important points. Discussing this period would link Step 4 to
other steps especially Step 5, 7 and 8. The lessons from the Breast Crawl, like
skin to skin contact and the newborn’s spectrum of abilities would come handy in
this period. Some of the mothers whom we have seen initiating breastfeeding by
the Breast Crawl, continued to use the ‘crawling in position’ advantageously, so
as to establish successful breastfeeding. Though ‘Kangaroo Mother Care’ was
invented to care for low birth weight babies, we visualize a unification of this
concept with the Breast Crawl, in this extended initiation period, for normal full term newborns.
3.2 Implementing the Breast Crawl as the method of initiation
BPNI Maharashtra is collaborating with the Government of Maharashtra, with
support from UNICEF, to train health care providers in ‘Basics of IYCF’. The
delegates undergoing this training are given a demonstration to initiate
breastfeeding by Breast Crawl. Those delegates working in the maternity service
have started implementing Breast Crawl whenever possible. However, for wider
implementation, more intense efforts will be necessary. These will be vigorously
followed-up over the next one year.
3.3 Breast Crawl E-Dialogue:
The documentary on Breast Crawl that accompanies this dossier will be sent to
health professionals, researchers and breastfeeding advocates round the world. A
discussion on this will be initiated by E-dialogue as well as other means. This
should culminate in a Breast Crawl Summit. Both the documentary and the dossier
can be put up on multiple websites for open review. WABA can play a crucial role
in the dissemination of this material, along with distribution of resource
material for this year’s World Breastfeeding Week.
3.4 Breast Crawl Summit
UNICEF, WHO and WABA can jointly hold this summit before or during the World
Breastfeeding Week. The goals for the summit will be:
To consider Breast Crawl as ‘the method’ for initiating Breastfeeding.
Recommendations on Step 4 to Revised 2006 BFHI Guidelines.
Further recommendation for worldwide implementation of the Breast Crawl
-
Discussion on further research avenues on the Breast Crawl.
3.5 Avenues for Research
- Studies on implementing the Breast Crawl as the recommended method for initiation and solutions to overcome problems (practicability / feasibility).
- Impact on initiation rates after using the Breast Crawl as ‘the method’ for initiating breastfeeding.
- Studies of the Breast Crawl with larger sample sizes and without hindering factors.
- Detailed studies on the role of various hindering factors with large sample size and with special reference to newer regimes for labour analgesia.
- Breast Crawl in low birth weight babies. This will be important for developing countries which have a high incidence of low birth weight babies.
- Role of infant vision in the Breast Crawl with special reference to evolutionary differences in areola pigmentation.
- Effect of initiating breastfeeding with the Breast Crawl on the establishment of lactation, exclusive breastfeeding for six months and long term breastfeeding success.
- Role of ‘Crawling in’ as an advance over ‘bedding in’ and ‘rooming in’.
Routine use of amniotic fluid application on nipples to augment the Breast Crawl.
- Isolation of chemical from the nipple and amniotic fluid. This may be useful to encourage babies that suddenly refuse to breastfeed.
05 March, 2008
