RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BANGALORE, KARNATAKA.

ANNEXURE-2PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION.

1 NAME OF THE CANDIDATE AND ADDRESS

Mrs. MANJULA.R

I YEAR MSc NURSING STUDENT,

N.D.R.K. COLLEGE OF NURSING,

B.M. ROAD,

HASSAN - 573201, KARNATAKA.

2 NAME OF THE INSTITUTION

N.D.R.K. COLLEGE OF NURSING,

HASSAN

3 COURSE OF STUDY AND SUBJECT

MASTER OF SCIENCE IN NURSING

(PAEDIATRIC NURSING)

4 DATE OF ADMISSION TO THE COURSE

15-07-2013

5 TITLE OF THE TOPIC EVALUATE THE EFFECTIVENESS OF BREAST CRAWL

TECHNIQUE AMONG TERM NEWBORNS TO INTIATE

BREAST FEEDING WITH IN AN HOUR OF BIRTH

5.1 STATEMENT OF THE PROBLEM

“ A STUDY TO EVALUATE THE EFFECTIVENESS OF

BREAST CRAWL TECHNIQUE AMONG TERM

NEWBORNS TO INTIATE BREAST FEEDING WITH IN AN

HOUR OF BIRTH IN SELECTED HOSPITALS AT HASSAN,

KARNATAKA..”

6. BRIEF RESUME OF THE INTENDED WORK

6.1 INTRODUCTION

“Nursing does not diminish the beauty of a woman's breasts; it enhances their charm by making them look lived

in and happy.”

― Robert A. Heinlein

Lawrence R states that breast milk is the nature’s most previous gift to the newborns. Breast feeding is

as old as human being. Breast milk is accepted as the unique, natural and nutritive food provide by nature for

the newborns. Breast feeding is a mother’s gift to herself, her baby and the earth. Just as there is no substitute

for mothers love, there is no substitute for mother’s milk.1

Mother’s milk is a divine gift for a baby. Breast milk is only the food for the baby which is natural,

physiological way of feeding. Breast feeding could save the lives of 1.3million children a year. Breast milk

provides the exact combination of nutrients that a developing infant needs. Improved breast feeding alone could

save the lives of more than 3500children every day, more than any other preventive intervention. (Declaration,

2005by IYFC). Increasing optimal breast feeding could save an estimated 1.5 million infant lives annually. Up

to 55%of infant deaths from diarrheal disease and acute respiratory tract infection may result from inappropriate

feeding practices. Optimal feeding for sustained child health and growth includes initiation of breast feeding

within first hour of life, exclusive breast feeding for 6 month, timely complementary feeding with appropriate

foods, and continued breast feeding for 2 years and beyond. 2

The first hour after birth has a major influence on the survival, future health, and wellbeing of a newly

born infant. The basic needs of a baby at birth are warmth, normal breathing, mother’s milk and protection from

infection. Early initiation of breast feeding serves as the starting point for a continuum of care for mother and

newborns that can have long lasting effects on health and development.3

UNICEF, WHO and WABA, along with the scientific community strongly recommend initiating breast

feeding within half hour of birth. Evidence showed that early initiation can prevent 22% of deaths among babies

between one million countries. Globally over 1 million new born infants could be saved each year by initiating

the breast feed in the first hour of life. In developing countries alone, early initiation of breastfeeding could save

as many as 1.45million lives each year by reducing deaths mainly due to diarrheal disorders and lower

respiratory tract infection in children.4

Every newborn, when placed on the mother’s abdomen soon after birth, has the ability to find mother’s

breast all on her/his own and to decide when to take the first breast feed. This is called the “Breast Crawl”. It

was first described in 1987 at Karolinska institute in Sweden.4

The description of breast crawl, complied from the article as follows, ‘Immediately after birth the child

was dried and laid on mother’s chest. In the control group a regular behavioral sequence, previously not

described in the literature was observed. After 15 minutes of comparative inactivity, spontaneous sucking and

rooting movements occurred reaching maximum intensity at 45 minutes. The first hand to mouth movement

was observed at 34 minutes after birth and at 55 minutes the infant spontaneously found the nipple and started

to suckle. These findings suggest that an organized feeding behavior develops in a predictable way during the

first hours of life, initially expressed only as spontaneous sucking and rooting movements, soon followed by

hand to mouth activity together with more intense sucking and rooting activity, and culminating in sucking to

the breast.4

Many studies with different aims were published subsequently in relation to the ‘breast crawl’ study the

effect of other hindering factors biological mechanisms for homing in on the nipple Advantages of the breast

crawl. Klaus reviewed many of these studies and gave a beautiful description of the breast crawl. This inspired

them to include the breast crawl in our ‘Lactation Management’ curriculum and to prepare this documentary.

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 starting position for the’ Breast crawl’ has been specified by

veranda t al. (1994.1996) i.e. nose in the midline of the mother’s chest, eyes at the level of the nipples.4

Babies completing the ‘Breast crawl’ with spontaneous attachment is instinctive and almost a rule with

very few requiring assistance. The Breast crawl is associated with a variety of sensory, central, motoral and

neuro-endocrine components, all directly or indirectly helping the baby to move and facilitate her survival in the

new world. The promotion of early imitation of breast feeding has great potential: 16% of neonatal deaths could

be saved if all infants were breastfeed from day 1 and 22% if breastfeeding were started within the first hour

after birth .All these advantages will obviously be maximally tapped with Breast crawl. In 2006, authorities of

the WHO/ UNICEF and baby-friendly hospital initiative added an optional component to the baby-friendly

assessment tools, which examines mother-friendly care. Each country will determine whether it will integrate

this module as it updates assessment criteria and tool to the new standards. Implementing ‘Ten steeps of mother

friendly care’ will facilitate successful initiation (Breast crawl). Hence, every maternity service should consider

implementing these steps.4

6.2 NEED FOR THE STUDY.

“bottles fill his stomach, but breastfeeding fills his soul”

― diane wiessinger

UNICEF,WHO,WABA, BPNI strongly recommended initiate breast feeding with in half hour of birth.

Early initiation can prevent 22% of all deaths below 1month in developing countries. This is due to the several

advantages it affects to the mother and baby. Such as, Prevent hypothermia, due to skin-to-skin contact with

mother, baby achieves effective feeding skill faster so chances of long term breast feeding success increases,

baby gets early protection from infections from colostrum as the first feed, early feeding prevents hypoglycemia

and helps in better maintenance of other biochemical parameters, it may have a role in boosting development of

the baby’s nervous system, it leads to better mother-infant bonding. Maternal advantage of early initiation are

better uterine contractions due to oxytocin surge, leading to faster expulsion of the placenta, reduction in

maternal blood loss and thus prevention of anemia.

All the above advantages of early initiation are best achieved by Breast Crawl then by initiating feeding

by other methods. Breast crawl offers proper acclimatization from the intrauterine to extra uterine environment

it is an innate and instinctive process with other mammalians; so why not in human beings.5

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, breast feeding advocates and international health organizations have missed out on

a powerful ‘change’ agent for early initiation and hence short and long term breastfeeding success .even in those

places where health professionals are well informed and keen to initiate breast feeding within an hour of birth,

awareness of breast crawl is lacking.2

The body of scientific evidence 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 breast feeding has been recommended by the BFHI documents. The purpose of this

study is to strongly recommend evidence based workable method in form of the breast crawl for initiation of

breast feeding. The lessons from the breast crawl, like skin to skin contact and the newborns’s spectrum of

abilities would com handly in this period. Some of the mothers whom we have seen initiation breastfeeding by

the breast crawl, continued to use the ‘crawling in position advantageously, so as to establish successful

breastfeeding. Through ‘Kangaroo Mother Care’ was invented to care for low birth weight babies, Klaus

visualized a unification of this concept with the breast crawl, in this extended initiation period , for normal full

term newbornss.2

In the current scenario, the prevalent rate of under-nutrition in young children is high 46% in India,

according to third national family health survey. This coupled with high morbidity and mortality lead to full

need in India for the identification of an evidence based workable method which is easily replicable and cost

effective.2 For a bright talented generation we have to start the provision of health services from womb to tomb.

Here lies the importance of breast crawl.

In India government of Maharashtra, Nutrition mission, I C D S, B P N I jointly with UNICEF have

initiated an ambitious programme to train GOVT/NGO functionaries in the basis of I Y C F. Dr. Karthikeya

Bhagat of Grace Maternity home Mumbai-have first experimented breast crawl and continued as a method on

recommendation from care of high risk neonate. 3

During our clinical experience most of them believe that newborns need help to begin breast feeding.

But the study by Klaus and others revealed this was not true.

According to Jones G 3 majority of the neonatal deaths occur are developing countries including India,

where more than 26 million children are born every year and these, 1.2 million die during the neonatal period.

Infant mortality rate can be reduced substantially if the children are exclusively breastfed up to six moths. Even

is low in care countries, 13-15% of child deaths can be prevented if children are breast food exclusively for six

months6

Wadhwni N reminds that “How a baby takes its first breast feed”. This was the subject of world breast

feeding week. This material is much needed tool for trainers in Infant and Young Child feeding programme. In

order to strengthen the step 4 of Baby Friendly Hospital Initiative, that is Help the mothers to initiate

breastfeeding with in half hour of birth5, by focusing on natures miraculous way of initiating breastfeeding by a

phenomenon called breast crawl. This is a marvelous tool to assist in establishing when and how a new born is

first nourished. Breast crawl is the natural instinctive behavior of the human newborns. The mother and the

newborns dyad are mutually responsive in the most sensitive period of help to one hour following delivery. This

period is crucial for laying the foundation for successful breast feeding7.

Breast feeding is natural and unique system of supply and demand which best serves both the mother

and baby. Breast crawl is the simplest method that provides prolonged skin to skin contact and culminates in the

first breast feed. Breast feeding is an art of that can be learned and its skills can and should be made available to

very mother who plans to breast feed. Each mother requires individuals teaching in the practicalities of

breastfeeding to suit her particular needs and to achieve successful breast feeding.

6.3 STATEMENT OF THE PROBLEM

“A STUDY TO EVALUATE THE EFFECTIVENESS OF BREAST CRAWL TECHNIQUE AMONG

TERM NEWBORNS TO INTIATE BREAST FEEDING WITH IN AN HOUR OF BIRTH IN SELECTED

HOSPITALS AT HASSAN, KARNATAKA.”

6.4 OBJECTIVES OF THE STUDY

1. To administer breast crawl technique among term newborns soon after delivery.

2. To evaluate the effectiveness of breast crawl technique in the initiation of breast feeding within one hour of

birth among term newborns.

3. To associate the breast crawl of the term newborns with their socio-demographic variables.

6.5 RESEARCH HYPOTHESES:

H1: Breast crawl may be the most suitable technique in the initiation of breast feeding among term

newborns.

H2: There will be significant association between breast crawl of term newborns with their socio

demographic variables.

6.6 ASSUMPTIONS:

1. Breast crawl technique is an accepted strategy to initiate breast feeding among term newborns.

2. Term newborns with good APGAR score may have good rooting and sucking reflex.

3. Both term newborns and their mothers may get the positive outcomes of breast crawl in terms of good

initiation and establishment of breast feeding as well as bonding.

6.7 OPERATIONAL DEFINITIONS:

An operational definition defines something (e.g.: variable, term or term object) in terms of the specific

process or set of validation tests used to determine its presence and quality. That is, one defines something in

terms of the operations that count as measuring it.

1. EVALUATE: statistical measurement of initiation of breast feeding by breast crawl technique.

2. EFFECTIVENESS: In this study, effectiveness refers to how efficiently the newborn initiate breast

feeding by breast crawl technique.

3. BREAST CRAWL: In this study breast crawl refers to an ability of a new born baby to find the

mother’s breast all on its own when placed on the mother’s abdomen soon after birth and to decide when to take

the first breastfeed.

4. TERM NEWBORNS: The Newborns born with the successful completion of 37 weeks in the womb

of the mother and being in a healthy condition after the birth.

5. BREAST FEEDING: In this study breast feeding refers to feeding a newborns with breast milk

directly on mother’s breast.

6. SELECTED HOSPITALS: In this study, selected hospitals refers to the hospitals having a facility to

conduct deliveries include vatsalya hospital, malnad hospital,SSM hospital ,Mangala hospital, Hoysala hospital

and sanjeevini hospital.

6.8 CRITERIA FOR SAMPLING:

1. Inclusion criteria:

The mothers who are:

Given child birth at term

Willing to participate in the study.

Available during the time of data collection.

Both illiterate and literate mothers.

Delivered by both normal vaginal delivery and by caesarean section.

2. Exclusion criteria:

The Newborns:

Not having a Healthy APGAR score

Newborns with congenital anomalies.

High risk newborns.

6.9 DELIMITATIONS:

1) The study is limited to those healthy term Newborns with a good APGAR score.

6.10 SIGNIFICANCE OF THE STUDY: This study will help the researcher to understand the importance breast crawl technique in initiation of

breast feeding and emotional bonding between the mother and the newborn.

6.11 CONCEPTUAL FRAME WORK: Roy’s Adaption theory.

6.11 REVIEW OF LITERATURE:

Review of literature is a key step in research process. Review of literature refers to an extensive,

exhaustive and systematic examination of publications relevant to the research project. Before any research can

be started whether it is a single study or an extended project, literature reviews of previous studies and

experiences related to proposed investigations should be done. One of the most satisfying aspects of the

literature review is the contribution it makes to the new knowledge, insight and general scholarship of the

researcher.

The review of literature is presented under the following areas:-

1. Studies related to breast crawl

2. Studies related to importance of breast crawl technique in initiation of breast feeding.

STUDIES RELATED TO BREAST CRAWL

A study on effects of early contact versus separation on mother-infant interactions one year later. The

study was conducted on 176 mother-infant pairs who were randomized into four groups. The first group infants

were placed skin-to-skin with their mother after birth and had rooming in while in Maternity Ward (MW).

Second group infants were dressed and placed in mothers arm after birth and roomed in with their mothers in

MW. 3rd group infants were kept in nursery without rooming in both after birth and in MW and fourth group

infants were kept in nursery after birth but roomed in with their mother in MW. The mother infant interaction

was videotaped according to Parent Child Early Relational Assessment (PCERA) one year after birth which

showed that early practice of skin-to-skin contact (SSC) and early suckling had positive effects on PCERA

variables. The study concluded that the early SSC for 25 to 120 minutes after birth and early suckling positively

influenced in mother infant interaction one year later when compared with routines involving separation.8

A study was conducted on to assess the effect of early Skin-to-Skin Contact(SSC) on breast feeding

behavior and physiological adaptation in healthy mother-infant dyads. The study included randomized and quasi

randomized clinical trials comprising of 30 studies involving 1925 participants. Studies statistically found

significant and positive effects of early SSC on breast feeding at 1-4 months after birth.The study suggested that

early SSC may benefit in above aspects and has no apparent short or long term negative effects.9

A descriptive was study on Kangaroo Care at birth for full term infants. It was conducted on 9 full term

infants who were given kangaroo care beginning within one minute of birth and continuing until completion of

first breast feeding. Among 9 infants, the skin temperature of 8 infants got increased, blood glucose level of all

infants got raised and one infant spontaneously crawled towards mother’s breast and initiated breast feeding by

itself. The study concluded that Kangaroo Mother Care and early breastfeeding will greatly influence the skin

temperature, blood glucose level and will distract mothers from discomfort or pain during episiotomy or

laceration repair.10

A study was conducted to prove that mother- infant Skin-to-Skin Contact (SSC) immediately after

delivery results in early recognition of own mother’s milk odour. In this study 60 healthy full term neonates

were randomized into group A with SSC and group B without. Infants’ responses to own mother’s milk, another

mother’s milk, formula, orange juice and distilled water were recorded on first and fourth day after birth was

statistically analyzed by ANOVA with Fisher’s PLSD. Kaplan-Meier analysis with a log rank test was used to

compare breast feeding rates between the groups which showed that infants in group A demonstrated larger

difference in mouthing movements between their own and another mother’s milk odour compared to other

group infants.Thus study proved that mother–infant SSC for more than 50 minutes immediately after birth

results in enhanced infant recognition of their own mother’s milk odour and longer breast feeding duration.11

A study was conducted on to evaluate the effect of Kangaroo Care (K C) used shortly after delivery on

the neurobehavioural responses of the healthy newborns. Study involved a randomized controlled trial where

subjects of 47 healthy mother–infant pairs were given KC immediately after delivery which lasted for one hour.

The KC infants slept longer than controlled infants. The study suggested that KC seems to influence state

organization and motor system, modulation of the new born infant shortly after delivery.12

A study was conducted to prove that breast odour is the only maternal stimulus that elicits crawling

towards the odour source. The study was done on 22 babies who were observed during 2 trials. In one trial, a

pad carrying mother’s breast odour was placed 17 cm in front of babies’ nose and in another a clean pad was

used. More babies moved towards and reached breast pad than the clean pad. The study concluded that natural

breast odour unsupported by other maternal stimulus appeared to be sufficient enough to attract and guide

neonates towards the odour source.13

A study was conducted on emotional ties between and infant. In this study he found a virtually striking

observation of baby crawling towards mother’s breast when placed on mother’s abdomen immediately after

birth and initiating breast feeding by itself just within one hour and also observed that the odour of the nipple

appeared to guide the journey of baby towards breast. Out of 16 samples,15 infants crawled towards breast and

in infants who didn’t make crawling on their own when placed between the breast, there was a delay of 30 to 40

minutes. The study suggested that these findings should be taken in to consideration in institutions to attempt to

place infants on the breast immediately after birth.14

A study was conducted on the effects of delivery room routines on success of first breast feeding. In this

study 72 infants were grouped in to separation group(n=34)where infants were placed on mothers abdomen

immediately after birth but removed after 20 minutes and in contact group (n=38)where contact between the

dyad was uninterrupted for at least one hour. The study found that infants started crawling towards breast after

20 minutes and rooting reflex occurred at 50 minutes and started sucking at breast. It was also observed that

contact group showed correct sucking technique than separation group .The study concluded that the contact

between mother and infant should be uninterrupted during the first hour after birth or until the accomplishment

of first breast feeding.15

Two recently published studies conducted in Ghana and southern Nepal on the impact of early initiation

of breast feeding on neonatal mortality evaluated the relationship between the timing of initiation of breast

feeding and neonatal death between day 2and 28 by community based observation study. The study sample was

10,947 breast feeding infants and 22,838breast feeding infants in southern Nepal. The authors of the Ghana

study estimated that 16% of neonatal deaths could have been prevented if all newborns had been breast feed

starting from day 1 and 22% if breast feed within the first hour of life. Initiation of breast feed after the first 24

hour was associated with a 2.4 fold increased risk of mortality in Ghana and 1.4 fold increase risk in Nepal

when compared to initiation before 24 hours.16

A study was conducted on initiation of breast feeding within 1 st hour of birth could have prevented 19%

of neonatal deaths. These studies conclude that, initiation of breast feeding within the first hour can help to

prevent neonatal deaths caused by infections such as sepsis, pneumonia and diarrhoea and also prevent

additional hypothermia related deaths, especially in preterm and low birth weight infants in developing

countries. These studies further recommended that, research is needed on how to encourage women to

participate early and exclusive breast feeding, how to reach women in different settings. Identifying the optimal

type, content, and duration of communication programme to increase the early initiation and care for mother

and baby.16

A prospective coherent study was conducted to investigate influence of skin to skin contact after birth on

breast feeding by breast crawl method in Poland. It was analyzed in a group of 1250 three year old polish

children. The practice significantly increased the mean exclusive breast feeding duration by 0.4 month and

overall breast feeding by 1.4 month. The effect of skin to skin contact after birth was also observed. The infant

kept with the mother at least 30 minutes were 1-2 month longer exclusively breast feed and 1.7 month later

weaned than those who had shorter contact. Multivariate linear regression analysis showed that mother infant

contact after birth was significant.17

A study was conducted To examine the rate and duration of breastfeeding among recent Ethiopian 93

Ethiopian born mothers of children aged 2 months to 5 years living in northern Israel was studied by using a

structured questionnaire interview. Results revealed that 92% of the children born in Ethiopia were exclusively

breastfed as compared to 76.3% of the Israeli born children, in whom the rate of mixed feeding was 18.3%.

Although the duration of breastfeeding of the youngest child was significantly shorter than that of the firstborn

(20.1 vs. 24.8 months), it remains much longer than the average duration for native Israeli mothers. No

association was seen between breastfeeding rates or duration and the years since immigration, work outside the

home or exposure to formula. The women's attitude towards breastfeeding was positive despite the lack of

specific knowledge concerning breast milk and importance of breast crawl method. Study concluded that

Breastfeeding patterns among Ethiopian women have changed since their immigration to Israel.18

A clinic-based and community-related intervention trial was carried out to assess the knowledge

regarding the ‘Ten steps to successful breast feeding’, among the maternity professionals of ten hospitals in

Lower Bavaria as a model region with below average breast-feeding rates. A singular assessment of the

advanced training programme was undertaken concerning an increase of knowledge and the practicability in

clinical everyday life by participants; improvements of the maternity wards were assessed via structural

interviews with maternity ward staff before and after intervention. Results revealed that approximately 85%

(n=378) of the staff of the 10 maternity clinics attended the training course. The survey after the training

programme (response rate 83%) indicated that more than 80% of the participants stated to have learned

something new and to be able to use the knowledge acquired for their own practice. Results of the clinic

interviews showed a transfer of training contents into clinical work routines. Improvements at interview date

were shown best for bonding (all 10 maternity clinics), for additional feeding (8 maternity clinics) as well as for

24-h rooming-in and mother counselling (7 maternal clinics each). Study concluded that training of maternity

ward professionals accounts for baby-friendly conditions in maternity clinics. Most willingness for

improvements was shown by maternity ward staff particularly for bonding between the hospitals were observed

for the promotion of infant formulas before and after the intervention.19

A study was conducted to assess the Breastfeeding in infancy: identifying the program-relevant issues.

Quantitative data were collected through visits to households (n = 356) in rural Chittagong and urban slums in

Dhaka, and qualitative data from sub-samples by applying semi-structured in-depth interviews (n = 42), focus

group discussions (n = 28), and opportunistic observations (n = 21). Trials of Improved Practices (TIPs) (n =

26). Results revealed that the biggest gaps were found to be in putting baby to the breast within the first hour of

birth (76% gap), feeding colostrums and not giving other fluids, foods or substances within the first three days

(54% gap), and exclusive breastfeeding from birth through 180 days (90% gap). Lack of knowledge about

dangers of delaying initiation beyond the first hour and giving other fluids, foods or substances, and the

common perception of "insufficient milk" were main reasons given by mothers for these practices. Health

workers had talked to only 8% of mothers about infant feeding during antenatal and immunization visits, and to

34% of mothers during sick child visits. The major providers of infant feeding information were grandmothers

(28%). Study concluded that the findings showed that huge gaps continue to exist in breastfeeding behaviours,

mostly due to lack of awareness as to why the recommended breastfeeding practices are beneficial, the risks of

not practicing them, as well as how to practice them. Health workers' interactions for promoting and supporting

optimal breastfeeding are extremely low. Counselling techniques should be used to reinforce specific, priority

messages by health facility staff and community-based workers at all contact points with mothers of young

infants.20

A study was conducted to assess the breastfeeding (BF) duration predicts later psychosocial

development (PD) in a large low socioeconomic status (SES) sample in the Philippines. The sample consists of

2,752 children aged 1-3 years who were measured in 2004 as part of the Philippine government's Early

Childhood Development Project. Duration of any BF was the primary independent variable in regression

models predicting a cumulative index of PD that has been shown previously to predict school readiness. Results

revealed that in this sample, mothers who breastfed their children for longer tended to have lower educational

attainment and to come from lower income households. Despite this, BF duration was a positive predictor of

future PD measured in late childhood, but only after adjustment for SES and related confounders. Study

concluded that breast feeding could provide lasting economic and social benefits and underscore the importance

of continuing current public health efforts to promote BF in the Philippines and across the globe.21

A study was conducted to assess the effectiveness of hospital-based interventions to improve the rates of

exclusive breast feeding at four to six months in infants in low- and low-middle-income countries UK.

Databases to identify randomized controlled trials of hospital-based interventions to improve the rate of

exclusive breast feeding in low- and low-middle-income countries. Findings revealed that four studies, from

four different countries, were included in the final review. Although they evaluated slightly different

interventions, all showed a significant improvement in the rate of exclusive breast feeding with a pooled odds

ratio of 5.90 (95% confidence interval 1.81-18.6) on random effects meta-analysis. Study concluded that

hospital-based interventions in low- and low-middle-income countries can substantially increase the rates of

exclusive breast feeding and are therefore a viable option.22

A study was conducted on Maternity Experience Survey targeting women aged 15 years who had

singleton live births between February 2006 - May 2006 in the Canadian provinces and November 2005 -

February 2006 in the territories. A study was conducted to examine the prevalence and predictors of 6-month

exclusive breastfeeding among Canadian women. Sample size in this study was 5,615 weighted to represent

66,810 Canadian women. While ever breastfeeding was 90.3%, the 6-month exclusive breastfeeding rate was

13.8%. Based on the regression model, having higher years of education, residing in the Northern territories and

Western provinces, living with a partner, having had previous pregnancies, having lower pre-pregnancy body

mass index and giving birth at older age were associated with increased likelihood of 6-month exclusive

breastfeeding. Moreover, smoking during pregnancy, Caesarean birth, infant’s admission to the intensive care

unit and maternal employment status before 6 months of infant’s age was negatively associated with exclusive

breastfeeding. Mothers choosing to deliver at home were more likely to remain exclusively breastfeeding for 6

months (Odds Ratio: 5.29, 95% Confidence Interval: 2.95-9.46). Study concluded that the 6-month exclusive

breastfeeding rate is low in Canada.23

The 4th step for successful breast feeding given by BFHI is,

“Help mothers initiate breastfeeding within a half-hour of birth.”

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, and offered

help by a staff member to initiate breastfeeding...At least 50% of mothers who have had caesarean deliveries

should confirm that within a half hour of being able to respond, they were given their babies to hold with skin

contact. (The Global Criteria for the WHO/UNICEF Baby Friendly Hospital Initiative).

The literature search conducted to identify published studies relating to each of the steps and the ten

steps and the effect on breast feeding on their implementation inside health facilities. Observations of 10

newborns(1987) and by of 38 newborns(1990) have shown that non-sedated infants follow a predictable

pattern of pre feeding behavior when held on the mother’s chest immediately after birth, but timing varies

widely. Movements started after 12 to 44 minutes, and were followed by spontaneous suckling with good

attachment at 27 to 71 minutes. observed that sucking movements reached a peak at 45 minutes which thereafter

declined and were absent by two to two and a half hours after birth. After caesarean section, initiation of

breastfeeding may be delayed. The condition of the mother or infant sometimes makes delay unavoidable, but it

should not be necessary as a routine. After caesarean section with local anesthesia, breastfeeding can often be

initiated immediately. With general anaesthesia, breastfeeding can be initiated within a few hours, as soon as

the mother regains consciousness.

Several randomized and quasi-experimental studies have examined the influence of early postnatal

contact on the initiation or continuation of breastfeeding and in some cases on other aspects of mother-infant

interaction. studied the effect of early contact on early suckling. They compared two groups of infants assigned

(the decision being made by the midwife and mother) to a ‘contact’ or ‘separation’ group immediately after

birth. The contact group (38 infants) had immediate contact from birth for at least one hour. Twenty-four of

them were suckling correctly after a mean of 49 minutes. The separation group (34 infants) started contact

immediately after birth, were separated at 20 minutes and returned 20 minutes later. Only 7 of them suckled

effectively, the difference being significant.

A study was conducted on 40 primiparae in Sweden were studied by observation method to study the

effect of “extra contact’. Mothers were randomly assigned to a control group and an intervention group which

had “extra contact” (15-20 min suckling and skin-to-skin contact during the first hour after delivery). At 3

months, 58% of mothers in the extra contact group were still breastfeeding compared with 26% in the control

group (P<0.05). Extra contact mothers spent more time kissing and looking en face at their infants, while their

infants smiled more and cried less.

A meta-analysis of these studies concluded that early contact had a positive effect on the duration of

breast-feeding at 2 to 3 months. However, it is cautions that “the effect of size across studies was

heterogeneous” and some studies included other interventions (breastfeeding guidance, presence of the father

during early contact), which might contribute independently to improve breastfeeding.

These reviews study also conclude that, there is good evidence in principle for step 4 which relates to

early contact, through the optimal timing of a newborns first breast feeding is probably not as restricted as the

original wording at the step suggests. The most important part of the procedure is for the baby to have skin-to

skin contact with the mother from immediately after delivery until he or she spontaneously shows readiness to

feed. This usually occurs within an hour of birth though it may be any time in the first 2 hours, or later if the

mother received pethidine.24

A study was conducted says that the task of reviewing literature involves the identification,selection,

critical analysis and reporting of existing information on the topic of interest . It is important for broadening the

understanding and insight necessary for the development of broad conceptual frame work keeping this in mind

the investigators probed into the variable sources to gain a more in depth understanding from the related

studies.25

A qualitative study was conducted on supporting breast feeding mothers. Aim of the study was to report

a synthesis of mothers and health care professionals experience and perception of breast feeding support. Result

from the 1990 to 2005 search, five themes emerged in health service support of breast feeding the mother health

professional relationship skilled help, pressure to time, medicalization of breast feeding and the ward as a public

place. The author concluded that the mother tended to rate social support as more important than health service

support. Health service support was described unfavorably with emphasis on time pressure, lack of availability

of health professionals or guidance, promotion of unhelpful practices and conflictive advice. Changes are

required within the health services to address the needs \of both the mother and staff.26

A study was conducted on a systemic review of professional support interventions for breast feeding.

The objective of the study was to describe how breast feeding is professionally supported during pregnancy at

maternity hospitals and during the postnatal period. Secondly to find out how effective interventions are in

supporting breast feeding. Study emphasize that, interventions expanding from pregnancy to the intrapartum

period and throughout the postnatal period were more effective than interventions concentrating on a shorter

period. In addition intervention package using various methods of education and support from well trained

professionals are more effective than intervention concentrating on a single method. He concluded that during

pregnancy the effective interventions were interactive, involving mothers in conversations. The Baby Friendly

Hospital Initiative as well as practical hands-off teaching, when combined with support and encouragement,

was effective approaches. Postnatal effective were home visit, telephone support and breast feeding centers

combined with peer support. Relevance to clinical practices professional need breast feeding education and

support of their organizations to act as breast feeding support.27

A study was conducted on initiation of breast feeding – the cultural factors. The objective of the study

was to assess the breast feeding practices among neonates in admitted in Neonatal Intensive Care Unit and to

understand the role of health professionals for the promotion of breast feeding among neonates. Data were

gathered with the help of semi-structured interview schedule. A group of 50 mothers were interview and the

findings revealed that 94% of them were either Hindus or Sikhs and78% of them were below 25 years. Only1/5

the respondents had initiated breast feeding with in a few hours after delivery (22%). Colostrum was not given

to neonates by 66% of the respondents as it was believed to be impure and causes obstruction in the intestine of

the neonates. Thus negative attitude towards colostrum and delay in initiation of breast feeding should be

changed by educating mothers. Nurses can play important role as they are in direct contact with mothers of the

neonates while taking care of them in the ward.28

A descriptive study was conducted on Student Nurse’s Attitudes and Beliefs about Breast-Feeding. This

study explored the breast-feeding attitudes and beliefs of students newly enrolled in an urban university

baccalaureate nursing program. A qualitative approach was used to conduct in-depth, semi structured interviews

with 12 students prior to their formal course work in maternal–child nursing. Four themes emerged from the

data analysis: Personal experiences are important in the development of breast-feeding attitudes and beliefs, The

students generally believed that breast-feeding offered benefits for babies and mothers, but the beliefs were

stronger for those who grew up with breast-feeding as the norm. The students identified an educational rather

than promotional role for nurses in breast-feeding because of conflicts about personal choice. This study

suggests that students need help identifying their attitudes and beliefs about breast-feeding and reflecting how

their personal experiences influence breast-feeding promotion.29

A descriptive study was conducted on the effect of early mother baby close contact over the duration of

exclusive breastfeeding. Lactating mother infant pairs were followed for six months to deference effect of

perenatal factors on duration of exclusive breastfeeding. Early post partum had powerful influence (p<001) over

duration of exclusive up to 4-6 month and was more significant than early initiation of breastfeeding (p<0.05).

Mode of delivery had no effect on duration of exclusive breastfeeding. Recommends that a few minuts of early

post partum k c and early initiation of breast feeding to promote breast feeding. 30

A descriptive study was conducted on about first time mother’s views of breast feeding support from

nurses. Purpose of the study was to gain insights into the perceptions of first-time mothers regarding nurses'

support of breastfeeding. Audiotaped interviews were conducted with 20 primiparous breastfeeding mothers

within the first month after giving birth vaginally to healthy term infants..Study emphasis that, nurses provided

emotional, informational, and tangible support. Non-supportive behaviors were also identified, including a

sense that the nurse was in a hurry, failed to offer breastfeeding assistance, and was inflexible while working

with the mother and infant. Clinical implications of the study were nurses can contribute significantly to the

successful initiation of and continuation of breastfeeding, and provide new mothers with the confidence and

reassurance critical for breastfeeding success.31

A study was conducted on early initiation of breast feeding through breast crawl. A total of 22 babies

were observed during the two trials on a warming bed. Around 30-40 minutes after birth, the newborns begins

making mouthing movements, sometimes with lip smacking. Suckling of hands and fingers is commonly seen.

After attaching successfully, newborns continued to suckle for 20 minutes. It was concluded that a baby is born

with many instinctive abilities which enable her to perform the Breast Crawl. With all these innate programs,

the infant seems to come into life carrying a small computer chip with the set of instructions. It appears that

young humans, like other baby mammals, know how to find their mother’s breast. The Breast Crawl is

associated with a variety of sensory, central, motor and neuro-endocrine components, all directly or indirectly

helping the baby to move and facilitate her survival in the new world. Babies preferred their mother’s unwashed

breast to her washed breast, soon after birth. Study emphasis 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. It was concluded that natural breast odors unsupported by

other maternal stimuli are sufficient to attract and guide neonate to the source of odor. The mother’s voice is

reported to be the most intense acoustic signal measured in the amniotic environment. Given these abilities of

the newborns, the Breast Crawl offers the best chance for auditory stimulation with the natural voice of the

mother, which the newborns is accustomed to in utero.32

An experimental study was conducted on an initiation of breast feeding through breast crawl

immediately after birth the child was dried and laid on the mother’s chest. In the control group a regular

behavioral sequence, previously not described in the literature was observed. After 15 mints of comparative is

activity, spontaneous sucking and rooting movements accused coaching maximal intensity at 45 mints. The first

hand to mother movement was observed at a mean of 34+2 after birth and 55+ minutes the infant

spontaneously found the nipple and stayed to suckle. These finding suggest that an organized feeding behavior

develops in a predictable expressed only as spontaneous sucking and rooting movement, soon followed by

hand to mouth activity together with were infants sucking and rooting and activity culminating in sucking of the

breast had fairly good knowledge regarding breast feeding and its advantages.33

A study was conducted on crying pattern of newborns in different position .The objective of the study

was to evaluate differences in crying when infants were cared for by one of three methods during the 90

minutes following birth: Skin to skin contact (Breast Crawl): 90 mints, In a cot next to the mother: 90 mints. In

a cot next to the mother for the first 45 minutes and then skin to skin contact (Breast Crawl) for next 45

mints .Results suggested that human infants recognize physical separation from their mothers and start to cry in

pulses. 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

does not satisfy the needs of the newborns human baby. Authors recommend that the most appropriate position

of the healthy full term newborns baby after birth is in close body contact with the mother. This was ensured in

the study by keeping the babies in the Breast Crawl position34.

7. MATERIAL AND METHOD OF STUDY:

7.1 SOURCE OF DATA:

The data will be collected by observing the newborn movements to initiate breast feeding through breast

crawl process.

7.2 METHODS OF DATA COLLECTION:

Instruments intended to be used:

1. Section I: Demographic proforma.

2. Section II: Observation method.

1. Research design: A Quasi experimental, single group post test only design

R

E=Experimental

N= Number of term neonates

X=Administration of breast crawl technique among term newborns

O2= Post test in terms of outcome of breast crawl.

R=Randomization

2. Research setting: Labour room.

3. Population: Population of the study will consist of term newborns born at selected hospitals at Hassan

during the time of data collection.

4. Sample: Term Newborns.

5. Sample size: A sample size of 60 Term newborns.

6. Sampling technique: Probability sampling includes Simple random sampling method by Lottery method.

7. Collection of data: Data will be collected by using socio demographic variables and Breast crawl checklist.

8. VARIABLES

1. Independent variable: Breast Crawl technique

2. Dependent variable: Initiation of breast feeding within an hour of birth.

3. Extraneous variables: In the present study, an extraneous variable includes Health status of the Newborns,

Health status of the mothers, weight, gestational age, nipple pattern..

9. DATA COLLECTION METHOD:

Group Pretest Intervention Post test

E=Experimental

N=60

- X O2

The investigator will obtain permission from the concerned authority of the Hospital. The purpose of the

study will be explained to them and informed consent will be taken from the subject’s mothers.

Investigator introduces herself to the subject’s mothers and notifies about her aim, objectives, steps of study and

Breast crawl checklist used to assess the Breast crawl process of the Newborns.

10. PLAN FOR DATA ANALYSIS

1. The investigator will use Descriptive and inferential statistics to analyze the data.

2. The analyzed data will be presented in the form of tables, diagrams and graphs.

3. Descriptive statistics is used to analyze socio demographic data.

4. To associate socio demographic variables with the breast crawl of the newborns chi-square test is used.

11. PILOT STUDY:

10% sample size is planned for pilot study.

12. ETHICAL CONSIDERATION:

1. Does the study require any investigations or interventions to be conducted on patients or other humans or

animals? If so, please describe briefly.

Yes, investigation/intervention will be conducted on sample.

2. Has ethical clearance been obtained from your institution?

Yes, ethical clearance will be obtained from the ethical committee of the college of Nursing prior to the

conduction of the study.

Administrative permission will be obtained from the concerned authorities. Written consent will be obtained

from the sample and confidentiality will be assured.

13. LIST OF REFERENCES :( VANCOVER STYLE)

1) Lawrence R .Breast feeding a guide for medical profession .St.Louis: WB Saunders; 1991.

2) Prashant Gangal. Breast Crawl. Initiation of breast feeding by Breast Crawl. 1sted.UNICEF Maharashtra:

Mumbai: 2007.Available from www.breast crawl.org.

3) Impact of early initiation of exclusive breast feeding on newborns death. A&T technical Brief Issue

2010 Jan 1. Available from http://www.Allive and Thrive.org

4) Marshall Klaus. Mother and infant: Early Emotional Ties. Pediatrics 1998; 102; 1244.2007

Mar1.Available from:http://www.pediatrics.org/cgi/content/full/1021515E1/1244

5) P Chaturvedi. Breast Crawl. JMGIMS. Savagram: 2008:13(2):9-14.

6) Jones G, Stekettee R W, Black R F. Child survival study group. How many deaths can we prevent this

year? Lancet 2003;362:675-671

7) Wadhwani N .Initiation of breast feeding through breast crawl. (online). Available

from:URL:http://www.breast crawl. orgl/references.htm

8) Bystrova K.et al. Early Contact Versus Seperation Effects on Mother-Infant Interactions One Year

Later.Birth.2009 June 36(2):97-109.Available from

URL:www.ncbi.nlm.nih.gov/pubmed/19489802

9) Moore E.R. et al.Early Skin-to-Skin Contact for Mothers and their Healthy Newborns Infants. Cochrane

Data Base of Systematic Reviews.2007 July 18(3).URL:www.ncbi.nlm.nih.gov/pubmed/17636727

10) Walter M.W. et al.Kangaroo Care at Birth for Fullterm Infants. American Journal of maternal child

nursing.2007 Nov-Dec 32(6):375-381.Available from

URL:www.ncbi.nlm.nih.gov/pubmed/17968221

11) Mizuno K. et al.Mother-Infant Skin-to-Skin Contact after Delivery Results in Early Recognition of own

Mother’s Milk Odour. Acta Paediatrica.2004 Dec 93(12): 1640-1645.Available from

URL:www.ncbi.nlm.nih.gov/pubmed/15841774

12) Sari Goldstein Ferber. et al.The Effect of Skin-to-Skin Contact Shortly After Birth on the Neuro

Behavioural Responses of the term newborns. Pediatrics.2004 113; 858-865.Available

fromURL:http://www.pediatrics.org/cgi/content/full/113/4/858.

13) Varendi H. et al.Breast Odour as the only Maternal Stimulus elicits Crawling Towards the Odour

Source. Acta Pediatrica.2001 April 90(40):372-375. available

fromURL:www.ncbi.nlm.nih.gov/pubmed/11332925

14) Marshall Klaus. Mother-Infant Early Emotional Ties. Pediatrics.1998 Nov 2(5);1244-1246.Available

from URL:http://aappublications.org/cgi/content/full/102/5/SE1/1244

15) Righard L. et al.Effect of delivery room routines on success of first breastfeed. Lamet.1990 November

3.336(8723):1105-1107.Available fromURL:www.ncbi.nlm.nih.gov/pubmed/1977988

16) Impact of early initiation of exclusive breast feeding on newborns death. A&T technical Brief Issue

2010 Jan 1. Available from http://www.Allive and Thrive.org

17) Kostra Michael, I Boltruszko, J Mazur. Skin to skin contact after birth as a factor determining breast

feeding duration.2006. Available from URL.http:/www.ncbi.nml.

18) Rubin L , Nir-lnbar S, Rishpon S. Breastfeeding patterns among Ethiopian immigrant mothers. Israel:

2005-2006.

19) Meyer N , Spiegel H, Hendrowarsito L, Eschweiler U, Fromm H. Breast-Feeding Training Programme as

Intervention Approach at the Hospital Level. 2010 Dec 15.

20) Hider R , Rushed S, Sanghvi TG, Hassan N. Breastfeeding in infancy: identifying the program-relevant

issues in Bangladesh. 2010 Nov 30; 21(5):

21) Duazo P , Avila J, Kuzawa CW. Breastfeeding and later psychosocial development in the Philippines.

2010 Nov: 22(6):725-30.

22) Hall J. Effective community-based interventions to improve exclusive breast feeding at four to six

months in low- and low-middle-income countries. 2010 May 13.

23) Al-Sahib B , Lanes A, Feldman M, Tamim H. Prevalence and predictors of 6-month exclusive

breastfeeding among Canadian women.2010 Apr 8: 10-20.

24) Dr Constanza Vallenas, Felicity Savallenas. Evidence for the ten steps to successful breast feeding.

WHO/CHD/98.9. Available from: www.breast crawl.org/pdf.

25) Polit D F,Hungler BP. Nursing research: Principles and methods.5th edn. Philadelphia:JB Lippincot

company;2003

26) Innis R J, Chamber J A. Supporting breastfeeding mothers: qualitative synthesis. Journal Of Advanced

Nursing 2008 May; 62(4):407-21.

27) Hannula L, Kaunonen M, Tarkka M T. A systematic review of professional support interventions for

breast feeding. Journal of Clinical Nursing 2008 May;17(9):1132-43

28) Walia I, Raman K, Chopra S. Initiation of Breast feeding-The cultural factors Nursing and midwifery

Research Journal 2009; 5(1):10-18

29) Lissa K C. Student Nurses Attitudes and Beliefs about Breast-Feeding Journal Of Professional Nursing

2006 September; 22(5): 314-321.

30) Vaidya.k,Sharma A.Dhungel S. Effect of early mother-baby close contact over the duration of exclusive

breast feeding. Nepal Medical College Journal. 2005; 7(2), 138-140.

31) Hong H M,Callister L C.Schwartz R. First time mother’s views of breast feeding support from nurses.

The American Journal of Maternal Nursing2003 February;28(1):10-5

32) Varendi H, Porter RH (2001) Breast odour as the only maternal stimulus elicits crawling towards the

odour source. Acta Paediatrica, 90 (4): 372-75.

33) Klaus MH, Kennel JH (2001) Care of the parents in 'Care of the high-risk neonate', 5th edition, W. B.

Saunder's Company: 195-222

34) Christensson K, Seles C, Moreno L et al Temperature, metabolic adaptation and crying in healthy

newbornss cared for skin-to-skin, or in cot Acta Paediatrica Scandinavica 1999; 8: 488–503.

14. SIGNATURE OF THE CANDIDATE

15. REMARKS OF THE GUIDEBreast crawl is a most recent strategy in the

present scenario it is nature’s miraculous

event which may prove it worth in enabling

initiation of breast feeding in a new born.

16. NAME AND DESIGNATION OF[IN BLOCK LETTERS]16.1 GUIDE

Prof.MRS.SALOMI

HOD OF PEADIATRC NURSING

N.D.R.K COLLEGE OF NURSING

HASSAN

16.2 SIGNATURE

16.3 CO-GUIDE [IF ANY]

16.4 SIGNATURE

16.5 HEAD OF THE DEPARTMENT

MRS.SALOMI

PROFESSOR

16.6 SIGNATURE

17.17.1 REMARKS OF THE PRINCIPAL

17.2 SIGNATURE