New Initiative - Colour Coded Hats on Newborns - No Thanks!

I felt a bit like I'd stepped back in time this morning, when I read the following Tweet from King's in London:

I really thought we were well and truly over the idea of "hatting up" term newborn babies? It seems not:

To be honest I'm even more confused, and the plan sounds more than a little flawed in a number of fronts:

1) Studies show no temperature benefits to infants wearing a hat if held skin to skin
2) Hats may actually HINDER important newborn behaviours
3) Questionable infection control
4) Better alternatives 

Historically hats were used as way back in the 70s as they were thought to prevent a dip in newborn body temperature. Then we learnt about skin to skin:

"Skin Contact is a powerful vagal stimulant, through sensory stimuli such as touch, warmth, and odor, which among other effects releases maternal oxytocin (Uvnas-Moberg 1998; Winberg 2005). Oxytocin causes the skin temperature of the mother’s breast to rise, providing warmth to the infant (Uvnas-Moberg 1996). In a study of infrared thermography of the whole body during the first hour post birth, Christidis 2003 found that SSC was as effective as radiant warmers in preventing heat loss in healthy full-term infants."

Cochrane Database of Systematic Reviews,Early skin-to-skin contact for mothers and their healthy newborn infants (Review)

Another 2018 paper "The effect of mother and newborn early skin-to-skin contact on initiation of breastfeeding, newborn temperature and duration of third stage of labor" - found separation hindered all areas and those kept close breastfed sooner, were warmer and their mothers had a more rapid third stage.

Focus shifted to "the undisturbed hour" after which babies don't need a hat. Even back in 2003 and the birth of my first, the midwives took the dinky hat I'd taken and placed it neatly back in my bag. Instead they tucked baby down my nightie and said after that, the ward was quite warm enough.

This seems logical right?  If newborns needed a hat to survive those first few hours, surely they would pop out with their own built in hoodie?  


But alas no - I made a few calls and it seems hats are indeed back in fashion; in fact mums are expected to have early skin to skin WITH a hat, and the colour coded initiative may be rolled out on a wider scale.

As a mum and an IBCLC, I have to say this is horrifying to me.

The claim is the coloured hat enables them to identifying babies at risk of hypoglycemia (low blood sugars). All term babies apparently wear a hat for the first few hours to help maintain their temperature, including during skin to skin. This intervention it is proposed, reduces risks of separation of the dyad.

The reality is somewhat different.

First, the scent of her baby's head is extremely important to mum during skin to skin and continuing into the early days for early bonding. I'm going to bet anyone who has sniffed their newly born baby's head knows exactly what I'm talking about - mothers often describe the scent as "addictive", which in turn encourages her to plant lots of kisses, colonising her with any microbes on her baby, enabling the tailor made production of antibodies, which are passed back via colostrum.

The scent also prompts mum to release oxytocin (often called the bonding hormone), which in turn causes uterine contractions, forcing an instant constriction of the blood vessels that were running to the placenta. (Odent, 2013). Oxytocin is also important when it comes to breastfeeding, and as outlined above it generates heat for the baby - and so it all neatly comes full circle. 


What's more, Dr Kajsa Brimdyr, researcher and expert in the field, covered at the UNICEF Baby Friendly Conference 2018, how hats can impede baby's "breast-crawling" reflexes after birth.

So, you'd think that if we're going to implement an intervention that has the potential to impact on all the above, plus hello, can you imagine skin to skin, half chewing on a pom pom instead of inhaling that delicious newborn scent? There must be some stonking evidence it helps.  A lot.  Right?

Nup, not at all.

There's a paucity of studies on hat wearing at all, there's differences in terms of which hats are used (plastic, stockinette etc) and almost none in conjunction with skin to skin.

However a super amazing midwife, IBCLC friend of mine (thanks Marilyn!) sent me a 2018 study, exploring the preterm baby and knits - in a rural setting where low cost interventions can be hugely beneficial:

"Thermal Effect of a Woolen Cap in Low Birth Weight Infants During Kangaroo Care."

"The use of a woolen cap was safe but provided no advantages in maintaining LBWI in the normal thermal range while being in a KMC ward."

Again these babies are low birthweight and so far more challenged in terms of maintaining their own body temperature - even for them, there was no advantage to a hat.

Going back to the cochrane review above, we can see what did make a difference to hypoglycemia?  Yep, skin to skin.

• "Blood glucose mg/ dL at 75 to 180 minutes post birth Thresholds for low glucose vary from 40 mgto 50 mg/ dL 

• The control group mean blood glucose at 75 to 180 minutes post birth was 49.8 mg/ dL

• The mean blood glucose mg/ dL at 75 to 180 minutes post birth in the intervention group was 10.49 mg/ dL more (8.39 more to 12.59 more) 

• The mean difference (MD) of 10.49 mg/ dL is clinically significant" 

When not in use the hat is kept "near the cot".

Now I love the NHS, I think midwives do a sterling job in the face of ridiculous demands - with most having developed the bladder capacity of a Shire horse. But seriously, now they have to ensure colour coded hats, that are likely to be rarely atop a head, stay with the right baby too?  

Even under normal circumstances the hats wouldn't be needed, but anyone who has spent any time in summer in a typical NHS ward, knows colour coded fans may have been more appropriate. The air-con sucks, the windows barely open and the thought of a chunky knit hat becomes preposterous.

It's important to understand, I'm not questioning the the need to identify at risk infants - I'm questioning the implementation.

Surely a large acrylic colour coded magnetic disk that sticks to the side of the cot would be a far more reliable and environmentally friendly indicator, one that doesn't interfere with mums and babies?

9000 babies are born in King's hospitals each year - imagine if all hospitals roll this out, acrylic yarn isn't sustainable nor is the production of hats via volunteers.

The hat may in fact never even be worn - each baby gets a new hat for infection control reasons or it is burnt.

Now hold up here.

The knitter may be sat knitting in the grottiest conditions, smoking whilst knitting, coughing or sneezing on the item - that’s fine to put on a newborn head. Yet the moment the hat is officially allocated to a newborn, even if green and infection free - it must be burnt?  

It also surely raises the question from vegans (or anyone else who chooses to avoid animals based products) of - is that hat real wool or acrylic?  (I asked and they think mainly synthetic, but they're donated so don't really know). 

An alternative option which I think is at least worthy of consideration, is colour coded kangaroo care carriers.  

These are carriers designed to protect baby's airways during skin to skin (if mum falls asleep) and hold baby close when mum wants to be mobile.  

This facilitates best practice and could provide a mobile visual indicator. 

The other benefit of carriers is they could further protect against newborn falls.

Paediatrics 2019 published "In-hospital Neonatal Falls: An Unintended Consequence of Efforts to Improve Breastfeeding".  The study claimed that in an effort to improve breastfeeding rates, rooming in rather than newborns in a nursery was putting babies at risk of falls.  

Therefore surely the appropriate response is to identify and minimise risks?

When newborn nurseries were introduced, the problem of increased infection risk, mixing up babies or them being stolen, would all be higher than when babies weren't separated from their caregivers. As a result, tags and improved security systems followed. Hospitals have evaluated and adapted to visible risks based on separating babies from their primary caregivers.   

Of course they didn't know then that separation was a bad idea for mothers and babies.

A 2011 paper however highlighed:

"The profound impact of maternal separation on the infant. We knew that this was stressful, but the current study suggests that this is major physiologic stressor for the infant."

They didn't know then that separating mother and infants who need intensive care support and were sent to different units, forcing increased separation - resulted in increased mortality.

They didn't know then that Mother-Child Separation Causes Neurobiological Vulnerability Into Adulthood or that scores and incidence of SAD were increased among children who were cared in the NICU and both were correlated with the duration of stay in the NICU.

These risks, whilst not as visible as dropping an infant, are far more common and wider reaching.

Now hospitals know more - they need to re-evaluate and react according. Dr Nils Bergman (a prominent expert and kangaroo care proponont) has long-said mothers shouldn't be left alone. 

The Paediatrics study noted:

All events were associated with mothers falling asleep while feeding their infant, and all occurred between midnight and 6 am

A UK hospital explored their fall rate even further. There they noticed:

"similarities in many of the circumstances in which the falls occurred. These were that the mother had:

• Had a Caesarean section;
• A low haemoglobin level [anaemic];
• Restricted mobility, such as epidural or spinal anaesthesia.

The most common scenario was that the mother had restricted mobility, due to having had a Caesarean section, felt sleepy, and fell asleep with the baby in her arms. The baby then fell from her arms and onto the floor.

• Simple interventions like open curtains and using bedside cots can reduce baby falls"

These strategies brought about a marked reduction of baby falls and are now being established across all the maternity units across the trust.

Bedside cots were so in demand they had to source more!

Kangaroo Carriers could reduce falls, protect airways and provided the additional colour coding re hypoglycemia.  Either way - ditch the wooly pom poms and let mothers smell their babies.

Edited to add: A midwife friend raised an interesting theory this morning, that newborns (she felt) were at risk of becoming colder with a hat, particularly the babies with hair. Although wiped, their heads are still damp and a hat on a damp head can reduce temperature.  Another interesting theory to throw into the mix!

Update Nov 2019 as the scheme has been rolled out nationally.
Comments from Facebook readers:

This one really made me chuckle:
“ I just gave birth last week, and my baby was an amber hat--there was a picture of an amber hat stuck to the end of her cot. We never saw an actual hat 🙂”


Maybe hats themselves have secret magical properties only the NHS knows about? Why not an amber circle or square, why is hat imagery essential? 🤷‍♀️😂

“ YES! Thank you The Analytical Armadillo, I've seen this shared so many times and every time I was thinking If there's a hat you can't sniff them!
The idea that a green hatted baby is of lower concern, would set alarm bells off with me, because the nurses could completely unintentionally be a little complacent.
Baffles me how this gains support within hospital walls, even ten years ago, after the birth (home) of our first, the midwives said, oooh no hat unless it's chilly out!”

“ I’m not sure how I’d feel if my newborns had been made to wear red hats; marking them out as a concern? I think I’d probably feel like they were less than perfect or not as good as those in green hats in some way. This might sound a bit ridiculous but your hormones are all over the place and I was so worried about everything right at the start. It feels a bit dehumanising.”

“ My little guy would have been in a red hat (resuscitated, suspected neonatal sepsis, 5 days of antibiotics). It's hard enough for a mother on an extended stay in hospital with a sick newborn without the constant visual reminder.”

“ They're after them round us too, acrylic for 60 deg washing, sob. All that plasticky yarn on your beautiful new baby!”

“ I always thought the hat ridiculous, particularly because I didn’t want to take it home and then heard it would be destroyed for infection control. What waste, on so many fronts. Now that I’ve read this article (so well evidenced, well argued, as always), I’m even more incensed. It’s a silly implementation of an otherwise sensible need - to easily identify babies in need of extra care.”

“ I gave birth 5 months ago in July. My daughter was 9lb4. They put a hat on her and when i took it off to breastfeed (i couldnt see to get her to latch) i was told she had to wear it for 24 hours! Like something out of the 1970s.”

Further reading:

• Care Practice #6: No Separation of Mother and Baby, With Unlimited Opportunities for Breastfeeding
• RCM Keeping mothers and babies together — breastfeeding and bonding

WBAW post - Are newborns helpless and struggling to communicate?

or are we just failing to understand?

I've written this piece for www.studentmidwives.net for World Breastfeeding Awareness Week - the topic of which is communication.

I often hear it said that newborns are helpless. I also hear it said they need to “learn to feed”, or that feeding is a learning process for both parties – and at times the latter at least is true.

But it makes little sense that whilst every other mammal can feed without instruction – humans supposedly amongst the most advanced, are not born equipped with the skills for survival. That we need hours of “training” about how to hold our infants and attach them to the breast, in order to facilitate good milk transfer without pain.

We often hear that this is because breastfeeding is no longer held as the norm in modern western society, and that previously sisters, mothers, aunts and cousins would all have had handy tips and tricks to help along the way. Without doubt this of course impacts, but what if we’re missing something big along the way – what if it isn’t that an infant is utterly helpless, but that we have lost the skill of understanding?

When pregnancy and birth are “typical”, infants are born with every reflex and instinct they need to find the breast and feed – all without a whisper of positioning and attachment. We know that if we pop a healthy term infant on his mother’s chest and wait – and he will crawl to the breast, self attach and feed.

“Immediately after birth the child was dried and laid on the mother's chest. In the control group a regular behavioural sequence, previously not described in the literature, was observed. After 15 minutes of comparative inactivity, spontaneous sucking and rooting movements occurred, reaching maximal intensity at 45 minutes. The first hand-to-mouth movement was observed at a mean of 34± 2 minutes after birth and at 55+ minutes the infant spontaneously found the nipple and started to suckle.”

Widström et al, 1987 – first written observation of the breast crawl.

And that often is the key – to wait, but in modern society that often seems oh so hard to do! Babies are wiped, examined away from mum, weighed and dressed – each act killing a little more of those natural instincts. Even mothers who have their infants delivered onto their chest often only have a brief spell before they are whisked away for the above.

“Of 17 babies kept in the Breast Crawl position and kept in uninterrupted skin-to-skin contact for 1 hour, 16 attached to the breast correctly. Fifteen babies in the other group were separated after about 20 minutes for routine measuring and weighing procedures. After an interval of approximately 20 minutes, they were returned to the mother. Only seven babies in this group attached correctly (Table 4). These findings are crucial because the early suckling pattern is of prognostic value for the duration and success of breastfeeding)”

Righard and Alade, 1990

Continues HERE on www.studentimidwife.net

Waterbirths - a hidden cause of breastfeeding problems?

The popularity of water births has increased dramatically in recent years; not only do many hospitals now offer a pool, but the price to hire or buy one has fallen too, making them more accessible to mums birthing at home.  Water births are also often suggested as a natural way to try and avoid pharmacological pain relief, which may impact upon labour outcome, baby or breastfeeding.

But is the assumption water births do not affect breastfeeding correct?  I've always been a big advocate, but I'm now not convinced things are that cut and dry.  I know this will probably raise eyebrows for a lot of people, but I now think there is a very real possibility that water births can contribute to problems.

As many lactation supporters will know, when a healthy baby is born naturally without exposure to medication, when placed on mums chest they will crawl to the breast, root, self attach and begin breastfeeding.  All their instincts are primed for this immediately after birth, which is why UNICEF and  the World Health Organisation strongly recommend skin to skin and initiating breastfeeding within half an hour.



As long as there are no underlying issues such as tongue tie or palate abnormalities - this group by far has the highest rate of early lactation success, and it's far less common to find mums in this position suffering from problems such as sore nipples, latching issues, breast refusal and so on.

But I'm not sure this is the case for water births; as the "breast crawl" becomes more well known, mothers are starting to mention it - and I'm finding more are stating their baby simply didn't do it.  In fact now when I'm supporting a mum who describes a normal unmedicated delivery followed by problems initiating feeding, my next question is "was it in water?".

How could water cause a problem?
As mentioned above, the primary instinct for a newborn is to locate the breast and feed - but how does it do that?  We know that during pregnancy the nipples and areola darken and enlarge,  because we know newborns with immature vision, see the contrast between dark and light most easily; but infants do not rely solely on sight, in fact it may actually play quite a small role in terms of initially locating the breast.

The infant's senses are stimulated by the sounds and feel of the mother's body and more importantly in this case, scent - as you can see in the clip above, baby is constantly smelling and tasting.

Why?
Mum's sweat and the amniotic fluid on baby, both play a very significant part in the breast crawl and newborn breastfeeding (and many sources also link this with bonding, but one for another blog post I think!).  Mum's sweat smells the same as amniotic fluid, which is still present on baby's hands - so he uses this taste to guide him to the breast, which is also conveniently located close to the armpit.  As the breast is actually an enlarged and modified sweat gland, this means the odour is strongest in the area baby needs to reach.

A 1994 study examining whether the infant found the nipple by smell states:

One breast of each participating mother was washed immediately after delivery. The newborn infant was placed prone between the breasts. Of 30 infants, 22 spontaneously selected the unwashed breast.  We concluded that the infants responded to olfactory differences between the washed and unwashed breasts.

Lancet. 1994 Oct 8;344(8928):989-90 

I don't have access to the full study to find out what the other 8 did, but they may not have crawled anywhere or become disorientated due to analgesics, perhaps separated from mum too - which as seen in the clip above can also influence co-ordination.  I think this also clearly highlights why babies should not be removed, wiped and wrapped in a towel before being given to mum!

Evidence?
A 1997 study entitled "Unique salience of maternal breast odors for newborn infants" found:

Human infants are particularly responsive to olfactory cues emanating from their mother's nipple/areola region. Beginning within minutes after birth, maternal breast odors elicit preferential head orientation by neonates and help guide them to the nipple. Such odors also influence babies' general motor activity and arousal, which may contribute further to successful nipple localization and sucking. To some extent, the chemical profile of breast secretions overlaps with that of amniotic fluid. Therefore, early postnatal attraction to odors associated with the nipple/areola reflect prenatal exposure and familiarization

There's more...
I also found a small study from 2001 that specifically explored crawling behaviour based solely on scent:

Breast odour as the only maternal stimulus elicits crawling towards the odour source -This study investigated the influence of breast odours per se on orientated physical movement of neonates. In total, 22 babies were observed during two trials on a warming bed. In one trial, a pad carrying the mother's breast odour was placed 17 cm 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. Conclusion: Natural breast odours unsupported by other maternal stimuli therefore appear to be sufficient to attract and guide neonates to the odour source.

Birthing in water strips the process of these vital odours and tastes for baby - given the above it seem to me it at least explains why some babies born in water don't crawl.  I cannot locate any research examining breastfeeding success rates following a water birth, but I would be fascinated to see any if it exists.

My first thoughts were that if using water in later, it would from a breastfeeding point of view make most sense to use just in early labour, to give time for mums body scent to return to normal levels; but many advocates suggest hitting the water too early can slow labour.  I wonder how feasible it is to keep waist up out of the water if the room is nice and warm and perhaps if you have large breasts that would still end up submerged, wearing a comfortable bra (amazingly as per the picture I managed to find!)  it may also be worth leaving the pool for delivery and ensuring you were dried thoroughly to prevent any dilution of amniotic fluid.  If this does not appeal, until I've seen hard evidence examining water birth impact on the breast crawl - I'd say it's worth considering staying where we normally reside, on dry land.

Alternative natural pain relief ideas:

Exercise during pregnancy: may make your labour shorter and less painful. A study published in the American Journal of Obstetrics and Gynecology, reported that women who continued running or aerobic dancing during pregnancy enjoyed labours about 30 percent shorter than women who stopped exercising. Women who maintained a regular exercise program also required less labour stimulation and fewer epidurals, episiotomies, and caesarean deliveries. An Italian study in the same journal examined women having their second or third babies, who rode an exercise bike three times a week for thirty minutes. They began around the fifth month of pregnancy, and during labour maintained higher endorphine levels and reported less pain than a matching group of sedentary women.  The link contains more information about exercising safely whilst pregnant.

Heat: In the same way heat can help period pains, it can also help in labour.  Wheatgerm bags (or alternative filled bags) may be safer than hot water bottles if you are moving about lots and perhaps applying pressure with them.  The link also contains details of how to make your own.

Active birth: although the media most often portrays labour women flat on their back, this is the not a productive position - think about gravity.  Trying positions like kneeling over a bed or birth ball; squatting and rocking hips can often not only offer more relief but help to keep labour progressing.

Massage: Some mums like to be massaged during labour, whilst others prefer not to be touched.  Avoiding oils on the chest which could mask mum's own odour would appear to be a sensible idea.

Hypnobirthing: Many mums swear by hypnobirthing as a fantastic way to reduce pain.  If you do not fancy going the whole hog, visualisation techniques such as imagining the baby moving down the birth canal or balloons inflating with each contraction, then floating away as they dissipate can be great coping strategies.

Nesting: Some mums find making themselves a big nest of beanbags and duvets to snuggle in can provide security to feel comfortable and relaxed during labour.  As muscles are contracting, the more relaxed you can be, the less pain you will feel!

Explore the pain and breathe: A natural reaction to pain is to recoil and if it's your first labour, perhaps be afraid.  Some women find focusing on the pain and exploring it mentally, helps to reduce how much it hurts.  This is based on the concept that pain is how the brain interprets labour contractions because of our inbuilt cultural belief labour hurts - read about the opposite end of the spectrum and orgasmic birth here

Tens Machine: Another popular choice although scientific evidence shows mixed results.  Women seem to find this method of pain relief most effective, when worn over a longer period, ie it's less effective if put on when the pain gets severe in labour - you need to put it on as soon as you get the first twinge for maximum benefit when things get going.

Finally...

Good pain relief in labor is not the same as a perception of personal control or satisfaction in childbirth. In other words, you may have significant pain during your labor, but feel in control during the process and have great satisfaction afterward. On the other hand, you might have total pain relief during your labor, but feel totally out of control and unhappy about your experience when it is over. 

In most languages, the word for the process of giving birth describes a process of work (labor), not of pain. Remember that labor pain is more than a physiological process; coping with labor pain is emotional and complex and results in feelings of fulfillment and achievement for women. Therefore, satisfaction with labor is not necessarily related to the efficacy of pain relief. Your midwife should work with you during the prenatal period to identify personal coping strategies and encourage you to make efficient and effective use of these resources (2).

from an excellent article here