Acta Pædiatrica ISSN 0803–5253

REGULAR ARTICLE

Sex differences in newborn interaction with mother or father during skin-

to-skin contact after Caesarean section
Marianne Velandia (Marianne.Velandia@ki.se)1, Kerstin Uvnäs-Moberg2, Eva Nissen1
1.Department of Women’s and Children’s Health, Division Reproductive Health, Karolinska Institutet, Stockholm, Sweden
2.Department of Animal Environment and Health, Swedish University of Agriculture, Skara, Sweden

Keywords
Breastfeeding, Caesarean section, Newborn
behaviour, Sex, Skin-to-skin contact
Correspondence
Marianne Velandia, Department of Women’s and
Children’s Health, Division Reproductive Health,
Karolinska Institutet, Retzius väg 13A, S-171 77
Stockholm, Sweden.
Tel: +46 8-524 824 15 |
Fax: +46 8-524 824 00 |
Email: Marianne.Velandia@ki.se
Received
15 July 2011; accepted 8 November 2011
DOI:10.1111/j.1651-2227.2011.02523.x
ABSTRACT
Aim: To investigate differences between the breast-seeking and crying behaviour of
girls and boys in skin-to-skin contact (SSC) with their mother or their father after Caesarean
section as well as the point-in-time for the first breastfeeding and to compare mothers’ and
fathers’ interactive behaviour with their newborn girl or boy.
Methods: Twenty girls and 17 boys were randomized to 25 min of SSC with one or
the other parent immediately after birth. The interaction was videotaped.
Results: Girls started rooting movements earlier than boys in SSC with either parent
(p = 0.027). Infants started to breastfeed significantly earlier if having been in SSC with
mothers compared with SSC with fathers during the first 5–30 min (p = 0.018). Girls cried
more than boys in SSC with either parent (p = 0.02). Mothers used more touching behav-
iour towards their newborn infant than fathers (p = 0.001). Mothers touched girls less than
boys (p = 0.038). Fathers directed less speech towards girls compared with boys
(p = 0.042).
Conclusion: Early mother–infant SSC immediately after Caesarean section should
be promoted until the occurrence of the first breastfeed. If the mother is unable to provide
SSC immediately after birth, the father–infant SSC is a valuable alternative because it
enhances paternal interaction.

INTRODUCTION In a previous study, we explored parent–infant vocal

Early mother–infant SSC induces a biological programme
that facilitates breastfeeding and interaction. Oxytocin
released during mother–infant interaction may facilitate
several aspects of the interaction between mother and child
(1–3). A healthy newborn put in SSC on their mother’s
chest perform an inborn breast-seeking behaviour to find
the breast and start to breastfeed (3). The newborns’ inborn
behaviour is triggered and modulated by sensory cues dur-
ing SSC, such as maternal breast odour (4), warm tempera-
ture (5) and voices (6).
Fathers who have SSC with their newborn after birth
reduce the infants’ cry, and they feel satisfied when they feel
they can offer similar care as mothers (7).
Parental tactile contact with their newborn may assist in
eliciting feelings of love for the newborn infant and
enhance parental sensitivity and responsiveness to their
infant’s cues. Tactile touch has been utilized as a marker of
attachment (8).
Abbreviation
SSC, skin-to-skin contact.
communication when the baby is in SSC with either the
mother or the father after a planned Caesarean section. It
was found that infants, placed in SSC, performed soliciting
calls to initiate communication with the parents after hear-
ing the parents’ communication, as quickly as 15 min after
birth (6). Furthermore, SSC increased parental vocal com-
munication with the infant, especially in the fathers. The
hypothesis that there might be sex difference in behaviour
already at birth is based on the idea that the brain is influ-
enced by sex hormones during foetal development leading
to sex differences in the structure of the brain and thus
Key notes
• The result highlights the importance of immediate
infant–parent skin-to-skin contact (SSC), even after
Caesarean section. The parents interacted differently
with their infant. Uninterrupted SSC with the mother
facilitated the initiation of breastfeeding in the mother–
infant dyad exposed to a planned Caesarean section. If
the mother is unable to provide SSC immediately after
birth, the father is a valuable alternative, because SSC
promotes his interaction with the newborn infant.

360 ª2011 The Author(s)/Acta Pædiatrica ª2011 Foundation Acta Pædiatrica 2012 101, pp. 360–367
Velandia et al.
behaviour (9–12). Different sex-related reaction patterns
may also be seen in adults (13,14).
Our model involving SSC between parents and infants
might represent an ideal model to study inborn reaction pat-
tern because no learning has occurred. Considering the
increased use of Caesarean section, studies providing a dee-
per understanding of infant–parent interaction in regard to
the sex of the parent and infant are extremely important as
they may contribute to develop guidelines for care in con-
nection with Caesarean section.
Therefore, this study aims to (i) investigate differences
between the breast-seeking and crying behaviours of
newborn girls and newborn boys, in SSC with their mother
or their father after a planned Caesarean section; (ii)
compare differences in mothers’ and fathers’ interactive
behaviours with their newborn girl or boy; and (iii)
evaluate the time point for the first breastfeeding event, for
girls and boys, after having been in SSC with their mother
or their father.
PATIENTS AND METHODS
This study is a part of a larger, randomized controlled study
to investigate parent–infant interaction immediately after
birth with a planned Caesarean section (6). The study took
place between 1997 and 2001, in a large obstetric clinic in
Stockholm, Sweden.
Inclusion criteria
To be included in the study, the primiparas needed to have
had a healthy, uncomplicated pregnancy and a planned
Caesarean section at term (38–42 gestational weeks). The
woman should not have smoked during the third trimester.
The baby should be healthy at birth, have had an Apgar
score of at least 7, at the 1-min testing mark, and should be
immediately placed in SSC. All women fulfilling the inclu-
sion criteria were consecutively recruited at the maternity
ward the day before surgery. The only inclusion criterion for
fathers was that they were willing to participate in the study.
Primiparas and their partners were informed of the study
design, and both women and men were asked separately to
sign if they agreed to participate. All consented to partici-
pate.
Randomization
The newborns were randomized to SSC with either their
mother or their father, for the 5- to 30-min period after
birth, by a person who was not directly involved in collect-
ing research data for this study. Information about the treat-
ment was placed into an opaque envelope, which was
marked with an identity number. On the day of the surgery,
the envelope was opened, and the parents were informed as
to whether the father or the mother would have the new-
born in SSC.
Description of the intervention
For women having a Caesarean section at this clinic, rou-
tine procedures prescribed a shower and a thorough body
ª2011 The Author(s)/Acta Pædiatrica ª2011 Foundation Acta Pædiatrica 2012 101, pp. 360–367
Sex differences in infant–parent interaction
scrub (including the breasts), using chlorhexidine, the day
before and the day of surgery. For anaesthesia, all women
received a spinal block with 12.5 mg of high-density bupiva-
caine and 10 lg fentanyl. Additional drugs were used to reg-
ulate blood pressure, when needed. Before the surgical
procedure, the project leader placed a video recorder 1.5 m
from the mother. The lens focused on the upper parts of the
infant’s body and on the chest and face of the parent, allow-
ing for the observation of the facial expressions and hand
movements of the infant and his ⁄ her parent.
Immediately after birth, at approximately 1 min after
birth, the naked newborn was placed in SSC in a trans-
verse position on the mother’s naked chest. The infant’s
head was placed to the right, and his ⁄ her feet were placed
to the left, allowing the infant to touch the mother’s nipple.
Placing the infant in this position also enabled the surgery
to continue.
In each case, the infant’s body was covered with warm
towels to maintain the newborn in a stable temperature. All
babies stayed with their mothers in this position for 5 min.
Thereafter, the baby either stayed in SSC with his ⁄ her
mother or was placed in SSC on his ⁄ her father’s chest for
the next 25 min, according to the outcome of randomiza-
tion. The baby was put on the father’s chest, with its eyes
levelling the nipples of the father. The baby could turn his
upper body. The fathers sat comfortably in an armchair,
beside the head-end of the operating table, so the parents
could engage in eye contact and freely communicate and
touch each other and the baby. The parents were encour-
aged to interact with each other and the baby and to act as
natural as possible. The approach of the staff in the operat-
ing theatre was gentle, kind and supportive towards the par-
ents.
Data collection and management
Obstetric background data were collected from the birth
records. The time lapse between birth and first breastfeed-
ing was noted. The video recording began immediately at
birth and continued for up to 90 min. After 30 min, all
the babies were kept in SSC with the mother for the fol-
lowing 90-min postpartum. Thereafter, the infant was
removed from the mother’s chest and underwent routine
examination, performed by a midwife. Then, the infant
was dressed and returned to his ⁄ her parents. Four hours
postpartum, the family was transferred to the postpartum
ward where they stayed overnight, together, in a family
room.
Assessment of infant–parent interactive behaviours
The following behaviours that occurred for the first time
were identified for the newborn and were recorded: strong
rooting (breast-seeking behaviours, distinct head turning
and movements, sometimes followed by smacking sounds);
breast-massaging movements (the infant performs repeated
breast-massaging movements); and breastfeeding (appear-
ance of the first latch on and initiation of sucking the
breast). Crying (dissatisfied groaning sounds) and the fol-
lowing parental behaviours were recorded as (1) if it
361
Sex differences in infant–parent interaction
occurred during the 30-sec interval observed or as (0) if it
did not occur during the studied 30-sec interval. The inter-
active parental behaviours coded were finger-tipping touch
(light touching with the fingertips on any part of the
infant’s body); touching (tactile touching and tapping hand
movements on any part of the infant’s body); smiling
(mouth movements with retraction of lips comeasure-
ments); kissing (touching the baby with the lips) and
parental-directed speech (any verbal speech directed
towards the infant).
If an observed behaviour was difficult to identify, a so-
called conference score of observed behaviours was devel-
oped between the four observers (3). A ‘conference score’
was achieved among the observers by simultaneously study-
ing the videos in real time and then summarizing the behav-
iours for each 30-sec periods. The tape was stopped, while
the notes were made but if the observers disagreed on the
coding of a behaviour within the period, the tape was
rewound, and the sequence was restudied until the observ-
ers reached an agreement.
To test the reliability of the observations of the video-
tapes, over time, a second observer scrutinized five ran-
domly selected videotapes. The interobserver agreement
ranged from 65% to 100% (mean 80%) and was considered
satisfactory. The outcome for the different variables is dis-
played in Table 1.
Data transcription and analysis
All behaviours observed during each 30-sec periods were
monitored by an experienced observer who was not
informed about the aims of this study. Data sheets for tran-
scription was developed in Excel and coded manually. The
behaviours were listed in the vertical plane and the time in
the horizontal plane for each observation. This type of cod-
ing has previously been described (15).
During a few observation periods, technical reasons pre-
vented certain behaviours from being visible. As a result,
these were monitored as missing. These missing periods
were equally distributed between participating infant boys
and girls. This type of video transcription has been
described previously.
Table 1 Inter-rater reliability test
Infant behaviours
Skin-to-skin contact
Crying
Strong rooting
Breast-massaging movements
Parental behaviours
Finger-tipping touch
Touching
Smiling
Kissing
Mother’s speech directed to the infant
Father’s speech directed to the infant
Interobserver agreement ranged from 65 to 100% (mean 80%).
362
Velandia et al.
Statistical analysis
For statistical analysis, the SPSS ⁄ PASW Statistics 18 (SPSS,
Chicago, IL, USA) software package was used. As a central
measure to describe background data, the mean is pre-
sented, and as a measure of dispersion, 95% confidence
intervals or standard deviation (SD) is presented. Median
(Md) was used as a central measure, and interquartile dis-
tances (Q25–Q75) were used as a measure of dispersion for
the time from birth to first occurrence of a specific behaviour
like rooting, breast massage movements and breastfeeding.
To test differences in crying, touching, smiling, kissing
and speech, over time and between groups, ANOVA for
repeated measurements was used. The following nonpara-
metric tests were used: the Mann–Whitney U-test, the Krus-
kal–Wallis test for independent samples and the
Kolmogorov–Smirnoff test. For calculating correlations in
behaviours with parents and infants, Spearman rank coeffi-
cient (Rs) was used. p-values <0.05 were considered as sta-
tistical significant.
Ethical considerations
The ethical issue is whether it is acceptable to separate
mother and infant immediately after birth with Caesarean
section and hand the baby over to the father. The common
ward routine at the time when the study was performed was
to separate the infant from its parents for at least 2 h. The
design of the study brought about an improvement for the
parents and infant, which was more in accordance with the
guidelines for normal birth and Baby Friendly Hospital Ini-
tiative. The study was approved by the ethical committee at
Karolinska Hospital, Stockholm, Sweden.
RESULTS
Forty-two couples were asked to participate, and the new-
borns were randomly assigned either to SSC with their
mother or to SSC with their father. Thus, all infants were in
SSC with either the mother or the father.
Drop-outs and exclusions
Two newborns dropped out of the study after the randomi-
zation, because their fathers had changed their minds and
no longer wanted to participate. Furthermore, one newborn
infant was excluded, because of a low Apgar score, and two
Mean ratio
newborns were excluded as the randomization protocol
was not followed because their mothers felt sick; in these
100 instances, the fathers kept their babies on their chests, but
77 no SSC was established. On the day of the surgery, two
92
mothers arrived at the hospital without the father of their
65
babies’, but accompanied by another person; however, these
67
mothers were able to participate in the study because the
77 outcome of the randomization protocol indicated infant-to-
80 parent SSC with the mother. Ultimately, study participants
99 included 37 healthy, full-term infants [mean gestational age
90 38.5 weeks (95% CI 38.4–39.0)] and their first-time mothers
74 and fathers. Of the 37 newborns, a total of 20 girls and 17
boys participated in the study and randomized to SSC with
their mother (n = 17) or father (n = 20).
ª2011 The Author(s)/Acta Pædiatrica ª2011 Foundation Acta Pædiatrica 2012 101, pp. 360–367
Velandia et al.
There were no significant differences in background data.
For mothers, the mean use of high-density bupivacaine (mg)
was 12 (95% CI 11–12.4), of fentanyl (lg) was 13 (95% CI
7.6–19), and of ephedrine (mg) was 26 (95% CI 20–32.7).
The total mean bleeding for mothers was 874 mL (95% CI
721–1027). All infants were healthy at birth with an Apgar
score of at last 7, at 1 min of age. There was no significant
difference in mean birthweight between girls and boys
(df = 35, F = 1.139, p = 0.6). The mean birthweight for girls
was 3555.8 g (95% CI 3388.3–3723.2) and for boys
3474.3 g (95% CI 3201.3–3748.3).
Infants’ breast-seeking and breastfeeding behaviour in
skin-to-skin contact with father or mother
There were no significant differences in the appearance of
the first strong rooting or breast-massaging movements
between infants (regardless of their sex), in SSC with their
mothers or their fathers, Table 2. Infants’ first breastfeeding
in SSC with mothers appeared significantly earlier than in
SSC with the father (p = 0.018) (Table 2). For infants in
SSC with the mother (n = 17), the first breastfeeding
occurred at a median of 117.5 min (69.5–208), and for
infants in SSC with the father (n = 20) at a median of
235 min (120–430). Infants’ first breastfeed appeared signif-
icantly earlier if they had been continuously in SSC with the
mother during the first 30 min after birth.
Girls’ and boys’ breast-seeking and breastfeeding
behaviour in skin-to-skin contact with parents
The first strong rooting behaviour in girls (n = 20)
appeared significantly earlier than in boys (p = 0.035) in
SSC with either parent. For girls, it appeared at a median
of 7 min (3.63–15.5), and for boys (n = 17) at a median of
17 min (11.0–21.0). There were no significant differences
in the median duration of rooting behaviours, between
girls and boys (p = 0.56), either in SSC with the mother
(p = 0.301) or in SSC with the father (p = 0.661). For girls,
the median duration for this behaviour was 5 min (1–15)
and for boys was 6 min (0.7–13.5). There was also a statis-
tical difference in the appearance of the first breast-mas-
saging movements between girls and boys in SSC with
mother or father (p = 0.027), shown in Table 2. The first
breastfeeding for girls appeared at a median of 157 min
(101–304) and for boys at a median of 170 min (74–345);
Table 2 First appearance of a specific breast-seeking behaviour during the first hours of life after Caesarean section. Comparison of the development of feeding behaviour between
infants in skin-to-skin contact (SSC) with (a) mother or father and (b) between girls and boys irrespective of placement with mother or father. Data presented as median minutes and
interquartile distances (Q25–Q75) values
(a) Newborn breast-seeking behaviour in SSC with mother
or father
Mothers (n = 17)
Variable Md (Q25–Q75)
First time of strong rooting 12.5 (5.5–19.0)
First time of breast massage movements 11.0 (7.13–16.6)
First breastfeeding 117.5 (70–208)
ª2011 The Author(s)/Acta Pædiatrica ª2011 Foundation Acta Pædiatrica 2012 101, pp. 360–367
Sex differences in infant–parent interaction
this difference was not significant (p = 0.886) and is shown
in Table 2.
Girls’ and boys’ breast-seeking and breastfeeding behav-
iour in skin-to-skin contact with mother or father
To further analyse differences in girls’ and boys’ first breast-
feeding in SSC with the mother or in SSC with the father, a
subgroup analysis was performed.
Girls (n = 11) who were in SSC with the mother during
the first 30 min after birth started their first breastfeeding
significantly earlier than girls (n = 9) who had been in SSC
with the father (p = 0.037) during the first 30 min. No sig-
nificant difference was found among boys (p = 0.525).
Girls’ and boys’ crying behaviour in skin-to-skin contact
with mother or father
During the observation period, girls cried significantly more
than boys (df = 1, F = 5.972, p = 0.02) (Fig. 1). Addition-
ally, girls cried significantly more when in SSC with the
mother than in SSC with the father (df = 1, F = 10.977,
p = 0.004). Girls cried for a mean of 13 min (95% CI 9.46–
15.99) in SSC with the mother and for a mean of 6 min
(95% CI 2.635–9.145) in SSC with the father. In contrast,
no significant differences were found in crying behaviours
among boys when they were in SSC with the mother or in
SSC with the father (df = 1, F = 1.433, p = 0.251). Boys
cried for a mean of 7 min (95% CI 1.175–15.505) in SSC
with the mother and for a mean of 3 min (95% CI )3.35 to
6.935) when in SSC with the father.
Parental behaviour in skin-to-skin contact with their baby
Touching
Mothers in SSC touched their infants significantly more
than fathers in SSC [df = 1, F = 14.138, p = 0.001 (Fig. 2)].
Furthermore, mothers touched girls significantly less than
boys (df = 1, F = 5.152, p = 0.038). Mothers touched girls
for a mean of 7.59 min (95% CI 2.955–12.225) and boys for
a mean of 14.5 min (95% CI 6.81–22.19).
There was no significant difference in the time fathers
spent touching girls or the time they spent touching boys
(df = 1, F = 1.538, p = 0.232). Touching occurred for a
mean of 1.5 min (95% CI 0.01–2.99) in girls and for a mean
of 4.5 min (95% CI )0.18 to 9.18) in boys. Mothers per-
formed significantly more finger-tipping touch than fathers
(b) Girls and boys breast-seeking behaviour in SSC
with parent
Fathers (n = 20) Girls (n = 20) Boys (n = 17)
Md (Q25–Q75) p Md (Q25–Q75) Md (Q25–Q75) p
14.75 (4.6–20.6.3) 0.603 7.0 (3.63–15.5) 17.0 (11.0–21.0) 0.035
16.0 (4.4–27.0) 0.576 7.75 (3.5–15.5) 18.5 (9.9–26) 0.027
235.1 (120–430) 0.018 157 (101–304) 170 (74–345) 0.886
363
Sex differences in infant–parent interaction Velandia et al.

3.5 3.5
Girls Mothers

Minutes of finger-tipping touch (mean)

Boys Fathers
3.0 3.0
Minutes of crying (mean)

2.5 2.5

2.0 2.0

1.5 1.5

1.0 1.0

0.5 0.5

0.0
0.0
10 15 20 25 30
10 15 20 25 30
Time (minutes after birth)
Time (minutes after birth)

Figure 1 Newborn girls and boys crying after birth (Mean, SEM), in skin-to-
Figure 3 Mothers and fathers finger-tipping touch (mean, SEM) of the newborn
skin-contact with either parent.
infant after birth.

3.5
Mothers
(95% CI 5.05–15.175) in SSC with girls and for a mean of
Fathers
3.0 7 min (95% CI 2.865–11.635) in SSC with boys. However,
Minutes of touching (mean)

there was a significant negative correlation between the

2.5 amount of smiling in fathers and the crying in newborn girls
(Rs = )0.601, p = 0.005).
2.0

1.5
1.0
0.5
0.0
10 15
Time (minutes after birth)
Figure 2 Minutes of parental touching of the newborn infant after birth (mean,
SEM), when mother or father having the infant in skin-to-skin contact.
(df = 1, F = 26.701, p £ 0.01) (Fig. 3). The sex of the new-
borns did not influence this behaviour in mothers (df = 1,
F = 2.048, p = 0.173) or in fathers (df = 1, F = 0.959,
p = 0.341).
Smiling
Mothers in SSC smiled significantly less during the observa-
tion period than fathers in SSC (df = 1, F = 14.785,
p = 0.001). When this behaviour was analysed separately to
determine differences between mothers smiling at girls and
mothers smiling at boys, no significant difference was found
(df = 1, F = 0.403, p = 0.53). Mothers’ smiling occurred for a
mean of 2 min (95% CI 0.09–3.91) in SSC with girls and for a
mean of 2.25 min (95% CI )2.52 to 7.02) in SSC with boys.
No significant differences were found between the length
of time fathers smiled at girls or at boys (df = 1, F = 0.028,
p = 0.868). Fathers’ smiling occurred for a mean of 10 min
Kissing
No significant differences were found between mothers
kissing their infants and fathers kissing their infants
(p = 0.922). In SSC, five (5 ⁄ 17) of the mothers and six
(6 ⁄ 20) of the fathers kissed the newborn during the first
30 min after birth. For mothers, this behaviour occurred for
a mean of 1.5 min (95% CI 0.26–2.74); and for fathers, it
20 25 30 occurred for a mean of 1.75 min (95% CI 0.77–2.73).
Speech directed towards the newborn
The mothers length of directed speech towards the newborn
girls and boys did not differ (df = 1, F = 0.349, p = 0.558).
When directed at newborn girls, this behaviour occurred for
a mean of 2.68 min (95% CI 0.24–5.125); when directed at
boys, it occurred for a mean of 2.76 min (95% CI )1 to 6.5).
In fact, fathers directed significantly less speech towards
girls than towards boys, (df = 1, F = 4.481, p = 0.042). It
occurred for a mean of 2.5 min (95% CI 1.055–3.835)
towards girls and for a mean of 5.6 min (95% CI 1.67–9.53)
towards boys.
DISCUSSION
Newborns’ first breastfeeding appeared significantly earlier
when in SSC with the mother compared with when in SSC
with the father. Girls performed rooting and breast-massag-
ing movements earlier than boys, and they also cried more
than boys.
Mothers provided more tactile stimulation to their new-
borns, while fathers engaged more in vocal communication
in particular with their newborn boys.

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Velandia et al.
Differences in the first breast-feeding
Previous studies performed with nonmedicated normally
delivered mothers in SSC with their infants demonstrate
that the infants express an innate breast-seeking behaviour
and start to breastfeed within an hour after birth (3,16).
However, in the present study, which involved infant–par-
ent interactions after Caesarean section, the first breastfeed-
ing was delayed for more than 1 h, compared with infants
delivered vaginally (3,16). In other studies, the occurrence
of the first breastfeeding has been shown to be delayed in
infants subjected to Caesarean section (17,18). In these
studies, the time for the first breastfeeding most often
includes a postponed SSC between mother and infant,
whereas in the present study, SSC was initiated immediately
after birth.
The delay of the first breastfeeding might be associated
with a reduced alertness and wish to suck because of lower
levels of catecholamines and possibly a reduced secretion of
oxytocin in the infants delivered by Caesarean section,
when compared to infants delivered vaginally (19). Factors
related to the mother such as reduced oxytocin secretion or
other types of stress related to the Caesarean section and the
spinal anaesthesia can of course not be excluded (20,21).
Infants’ first breastfeeding appeared significantly earlier
when the newborns had been in SSC with the mother than
with the father. This result demonstrates that SSC with the
mother during the first 30 min after birth facilitates breast-
feeding.
Differences in newborn girls’ and boys’ behaviour
Some differences between newborn girls’ and boys’ behav-
iour when in SSC during the first 30 min after birth were
found. Newborn girls rooted and performed breast-massag-
ing movements earlier than boys irrespective of being in
SSC with mothers or fathers. This finding is in line with pre-
vious observations showing that newborn girls and female
foetuses perform more mouth movements (often associated
with rooting movements) than boys (22,23).
Such inborn behavioural differences have been attributed
to differential actions by the sex steroids oestrogen and ⁄ or
testosterone on the foetal brain. It has e.g. been shown that
the greater fine motor skills (22,23) and the enhanced sen-
sory sensitivity (11,24) and females’ preference of faces and
face recognition (12) are linked to prenatally induced effects
of oestrogen (25).
In this study, girls were shown to cry more than boys,
especially when in SSC with their mothers. The reason for
this is not known. One possible reason could be that the
newborn girls react more than boys to the unnatural and
unpleasant smell of chlorhexidine used to disinfect the
mother’s breast, as girls are more sensitive to some olfactory
cues (24). Another possible reason could be that the par-
ents’ differential behaviour towards boys and girls has influ-
enced the newborns’ behaviour.
Differences in parental interaction with their newborn
Both fathers and mothers showed spontaneous affectionate
feelings; they smiled and kissed the newborn. These types of
ª2011 The Author(s)/Acta Pædiatrica ª2011 Foundation Acta Pædiatrica 2012 101, pp. 360–367
Sex differences in infant–parent interaction
behaviours may play a role in the formation of bonding and
attachment between parents and their infants and vice
versa.
Fathers as well as newly delivered mothers start to touch
the newborn by examining the infant with their hands and
fingertips (14). In this study, a difference between the ways
fathers and mothers touched their newborns was observed.
Mothers approached and explored the newborn with finger
tipping, whereas the father more commonly touched the
infant with the palm of his hand. A specific finding was that
mothers in SSC touched their newborn boys significantly
more than they touched their girls.
In the present study, fathers in SSC with their newborns
directed significantly more speech towards their newborn
boys than they did towards their newborn girls. The
increased parental interaction towards boys, i.e. the moth-
ers increased touch and the fathers increased speech, might
also have made them cry less. It has been suggested that
vocalization may be as important as touch in the activation
of neuroendocrine mechanisms involved in the regulation
of social bonding in humans (26).
The effects observed in parents and their infants during
SSC may in part be caused by activation of sensory nerves
and a consequent release of oxytocin (27). Touch, warmth,
stroking and light pressure have been shown to stimulate
oxytocin release and to induce oxytocin-related effects (28).
Skin-to-skin contact may therefore via the activation of sen-
sory nerves stimulate oxytocin release in brain areas
involved in the control of different aspects of social interac-
tive behaviour. This interpretation is supported by the find-
ings that oxytocin administered as nasal spray in humans
has been demonstrated to stimulate pro-social behaviour,
increase eye gaze and increase the sensitivity to sensory
cues (29). Also, the calming effects of SSC may be related to
oxytocin release, as administration of oxytocin also has
been shown to reduce anxiety and to decrease stress levels
(28). Also, other sensory cues such as visual, auditory and
olfactory cues contribute to the activation of oxytocin
release and oxytocin-mediated effects (26,28).
Studies are in progress to elucidate oxytocin release pat-
terns in mothers and fathers with or without SSC in the
immediate postpartum period.
Our result suggests the existence of some sex-related
effects in the behaviour of newborn boys and girls and also
in the mothers’ and fathers’ interaction with the newborn.
The differences observed between the behaviour of new-
born girls and boys in the immediate postnatal period are
most likely to a great extent inborn and caused by prenatal
effects of sex steroids on the brain in utero. The differences
observed in the type of interaction with the newborn
expressed by mothers and fathers and also the modification
of the behaviour by the sex of the newborn may represent
inborn sex-specific behaviour (30).
Interestingly, the finding of different behaviours towards
boys and girls is consistent with studies on maternal behav-
iour in rats, showing that maternal touching behaviours
(grooming) were sexually dimorphic, with males receiving
more touch than females during the neonatal period (31).
365
Sex differences in infant–parent interaction
Methodological considerations and limitations of the
study
The findings reported in this study are unique but should be
interpreted with caution because of the small sample size.
To be able to draw conclusions, we used strict inclusion cri-
teria limiting variance in background, obstetrical data,
infant status and birthweight. Reducing the variation in
background variables to control the influence of potentially
confounding variables in a randomized trial prior to ran-
domization strengthens the result when the sample is small.
Additionally, all comparisons were planned, and no post
hoc comparisons were made. Some results did not reach
statistical significant differences, probably due to a too small
sample size (Type I error) even though the results pointed
in the same direction as in previous studies (22,23). In the
present study, as a result of the small sample size and a non-
parametric distribution of certain variables, nonparametric
statistical analysis has been performed. We suggest that this
is a hypothesis-generating study, as a part of the research
process and larger studies are needed.
The data collection was extended in time; however, no
changes took place either in the surgical techniques or in
the use of pharmaceuticals or in the operating theatre
setting.
CONCLUSIONS AND CLINICAL IMPLICATIONS
The result highlights the importance of immediate infant–
parent SSC, even after a Caesarean section, and provides an
increased understanding for sex differences in infants’ and
parents’ behaviour. Mothers showed more tactile stimula-
tion, while fathers engaged more in speech, in particular
directed to the newborn boy. The fathers showed more signs
of affection and communicated more when in SSC with
their newborn compared with mothers in SSC with their
newborn. Girls cried less when in SSC with the father than
with the mother.
Skin-to-skin contact with the mother accelerated the time
point for the infants’ first breastfeed as compared to SSC
with the father. Our data support that uninterrupted SSC
with the mother facilitates the initiation of breastfeeding in
the mother–infant dyad exposed to a planned Caesarean
section.
In case the mother is unable to provide SSC immediately
after birth, the father is a valuable alternative, because SSC
promotes his interaction with the newborn infant.
ACKNOWLEDGEMENTS
This study was supported by grants from Vardalsstiftelsen,
the Swedish Research Council, (K 1999-27P-13085-01A
and K2001-27P-13085-036); the Swedish Order of Freema-
son; the Mjölkdroppen Foundation in Stockholm; the
Swedish Foundation for Health Care Sciences the Solstic-
kan Foundation, Strategic Research Program for in Care
Sciences, Karolinska Institutet. We would like to greatly
thank Ann-Sofi Matthiesen for statistical advice and Gud-
run Sandgren for helpful transcription of videotapes.
366 ª2011 The Author(s)/Acta Pædiatrica ª2011 Foundation Acta Pædiatrica 2012 101, pp. 360–367
Velandia et al.
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