Skin-to-Skin Contact, Breastfeeding, and Perinatal Neuroscience

Skin-to-Skin Contact, Breastfeeding, and Perinatal Neuroscience
Hollister Breastfeeding Program 2006 Boston, MA Denver, CO Redlands, CA Mission Viejo, CA Intro

Skin-to-Skin Contact, Breastfeeding, and Perinatal Neuroscience
Dr Nils Bergman M.D., D.C.H., M.P.H., Ph.D Cape Town, South Africa Intro

Skin-to-Skin Contact, Breastfeeding, and Perinatal Neuroscience:
Implementing Best Practice in U.S. Hospitals Boston, MA Denver, CO Redlands, CA Mission Viejo, CA Intro

Perinatal neuroscience brain development normal newborn behaviour
Overview Perinatal neuroscience brain development normal newborn behaviour adverse factors Defining the original paradigm Kangaroo Mother Care Randomised trial Implications Intro

90% of what we know the last 15 years NEUROSCIENCE about the brain has
been discovered in the last 15 years Society of Neuroscience estimate Dr Sandra Witelson, McMaster

FETAL BRAIN DEVELOPMENT
The first 10 – 14 weeks, fetal brain growth is determined by genes (the DNA) Thereafter, brain growth is an active process.

depends on experiences !!
FETAL BRAIN DEVELOPMENT The neurons migrate, extend their axons and branches, and make synapses (thousands) connecting to sensory organs More sensations  more synapses Brain growth depends on experiences !!

NEURODEVELOPMENT Neurulation NEUROGENESIS Arborisation SYNAPTOGENESIS
Myelination w 6m 2y 10y 60y Birth

of structure & function
EARLY DEVELOPMENT Gestational age 20w all structures completed parallel development of structure & function (Hugo Lagercrantz 2004)

a single integrated whole.
23w fetus is aware / conscious parallel development of structure & function Neurobehaviour and neurodevelopment are inseparable a single integrated whole.

“The brain is not a computer, it is a jungle.”
EARLY DEVELOPMENT 25w layering, dendrification, synapse formation “The brain is not a computer, it is a jungle.”

“The perinatal sensorium
is never in chaos …. … the infant’s world is structured, competent and organized, developing in an ever ordered, yet ever more complex and more flexible field of perception” (Schore)

Porges SW Polyvagal theory. evolution of autonomic nervous system
1st primitive unmyelinated vagus immobilisation behaviours 2nd sympathetic nervous system, Behaviours for “fight or flight” 3rd myelinated vagus – rapid regulation cardiac output engagement / disengagement

28w full complement of neural cells
Gestational age 23w fetus is aware / conscious 25w layering, dendrification, synapse formation 28w full complement of neural cells (Hugo Lagercrantz 2004)

30 w fetus can recognise mother’s voice from other women, from single words played back to it by a tape-recorder, It can distinguish mother’s language from another language, again from a single word or phoneme. The fetus has a GREATER SENSORIUM than the adult …

Cells that fire together, wire together

Use it, or lose it.

Neuronal Plasticity programmed cell death or apoptosis
pruning and elimination of redundancy = neuronal plasticity

NEURODEVELOPMENT Neurulation NEUROGENESIS Arborisation SYNAPTOGENESIS
Myelination Programmed cell death COMPETITIVE ELIMINATION w 6m 2y 10y 60y Birth

At birth, the human being has more synapses in its brain than at any other stage of life.

Development is a process of “pruning” some,
FETAL BRAIN DEVELOPMENT Development is a process of “pruning” some, and developing other synapses – creating “neural pathways”. These can be good or bad – depending on type of sensations and experience of the newborn

SENSORY STIMULUS synapse store chemical signal chemical signal stronger THRESHOLD  EXEMPT from elimination (synapse stabilised) PATHWAY (Rima Shore 1997)

R Shore Critical period concept : “Windows of opportunity in early life when a child’s brain is exquisitely primed to receive sensory input in order to develop more advanced neural systems.”

“brain is exquisitely susceptible to adverse factors”
Schore Critical period concept : “brain is exquisitely susceptible to adverse factors” at particular times or stages

structural organisation of the brain.”
Schore Critical period : “Early interpersonal events positively and negatively impact the structural organisation of the brain.”

NEWBORN DEVELOPMENT Tactile stimulations “facilitate the flow of affective information from the infant … to the mother” “the language of mother and infant consists of signals produced by the autonomic nervous system of both parties”. This is the basis of healthy development!

Schore In early postnatal life, maintenance
of critical levels of tactile input … is important for normal brain maturation. Areas of the amygdala …. are in a critical period of maturation, … in the first two months of life

The fetus has well developed sensations for touch and position (tactile and kinesthestic sensations). “The infant actively seeks to adhere to as much skin surface on the mother’s body as possible” (Harlow 1958, from Schore 2001)

skin-to-skin contact eye-to-eye contact NEWBORN DEVELOPMENT
Tactile stimulations build the amygdala - preorbital cortical tract during the first 8 weeks The next pathway requires eye-to-eye contact This is the basis of healthy right brain development!

Brain-to brain interaction
Face-to-face communication Eye-to-eye orientations voice, hands, movements Interpersonal awareness Emotions

sensory stimulation constructed by the mother and infant from
Myron Hofer … the private realm of sensory stimulation constructed by the mother and infant from numberless exchanges of subtle clues. (Gallagher 1992)

a mother precisely controls every element of her infants physiology,
Through such “hidden maternal regulators” he discovered that a mother precisely controls every element of her infants physiology, from its heart rate to its release of hormones from its appetite to the intensity of its activity (Gallagher 1992)

environment is the mother”
The mere presence of the mother not only ensures the infants well-being, but also creates a kind of invisible hothouse in which the infant’s development can unfold. “For a baby the environment is the mother” (Hofer in Gallagher 1992)

a specific effect on the infant.
Hofer discovered that what seems to be a single physical function, such as grooming or nursing, is actually a kind of umbrella that covers stimuli of touch, balance, smell, hearing and vision, each with a specific effect on the infant. (Gallagher 1992)

a kind of invisible hothouse
“the wiring of the brain’s pathways is best supported when it can integrate quality sensory input through several pathways at once, particularly during critical periods of development.” (McCain 1999)

Neuronal Plasticity “the first three years are decisive”
The cortex retains some plasticity throughout life … But the limbic system and the midbrain is fixed after the age of three years … Attachment Regulation Emotion Control Arousal Appetite Sleep

Neuronal Plasticity subsequent development of higher cognitive
“the first three years are decisive”  platform for subsequent development of higher cognitive functions. Attachment Regulation Emotion Control Arousal Appetite Sleep

Infant brain development
Early brain development is INTERACTIVE RAPID DRAMATIC

CRITICAL PERIODS require specific stimulations at specific times

Quality SENSORY STIMULATION makes brain able to think and regulate

Negative experiences (both absence of good … and presence of bad) have long lasting effects

Current paradigm: Infant brain development Genetically determined Develops in linear time Activity increases w age Mother = good context Deficits correctable later = FALSE ASSUMPTION !!

Current paradigm versus NEW: Infant brain development
Genetically determined EXPERIENCE Develops in linear time CRITICAL PERIOD Activity increases w age GREATEST 3 yrs Mother = good context = WIRES BRAIN Deficits correctable later Limbic FIXED at 3y (Rima Shore 1997)

These experiences are embedded in the attachment relationship.
“The mammalian brain is designed to be sculpted into its final configuration by the effects of early experience” These experiences are embedded in the attachment relationship.

Our cortex distinguishes us from other animals … BUT The “primitive” hindbrain is vital We can learn about ourselves from animals, and mammals!

THE “OLD” BRAIN HAS 3 PROGRAMMES DEFENCE NUTRITION REPRODUCTION

The neurobehavioural programmes originate in the LIMBIC SYSTEM
Expressed through hypothalamus (autonomic nervous system) hypophysis (endocrine system, hormones) cerebellar connections (somatic system) Hindbrain programmes

HORMONES NERVES MUSCLES endocrine autonomic NS somatic
DEFENCE NUTRITION REPRODUCTION HORMONES NERVES MUSCLES endocrine autonomic NS somatic

HORMONES NERVES MUSCLES
DEFENCE NUTRITION REPRODUCTION HORMONES NERVES MUSCLES

BODY

BEHAVIOUR HORMONES NERVES MUSCLES WHOLE BODY

BREASTFEED All mammals have set sequence of behaviours at birth ………….
REPRODUCTION ……. All with a single purpose : to BREASTFEED … MUSCLES

After birth, events are determined … … by the neonate stimulating the mother! (Rosenblatt 1994)

Breast-feeding is “established
through a set of mutual, complex sensory stimulations in mother and child.” (Kjellmer & Winberg 1994)

In all mammals ……. ….. the newborn is responsible for initiating breastfeeding, not the mother !! EXCEPT IN HUMAN ???

Sequence human newborn breast-feeding
Pre-requisite = habitat hand to mouth tongue moves mouth moves eye focuses nipple crawls to nipple latches to nipple suckles (Widstrom et al 1994)

“The newborn may appear helpless, but displays an impressive and purposeful motor activity which, without maternal assistance, brings the baby to the nipple. (Michelson et al 1996)

R Shore Critical period concept : “Windows of opportunity in early life when a child’s brain is exquisitely primed to receive sensory input in order to develop more advanced neural systems.”

psycho-physiological caregivers
The first hours after birth are a CRITICAL PERIOD Mother and infant are mutual psycho-physiological caregivers

protection behaviours are intricately, inseparably
Warming, feeding and protection behaviours are intricately, inseparably linked to the right place. (Alberts 1994) = NUTRITION PROGRAMME

The “habitat - niche” concept
DETERMINES BEHAVIOUR

Self-attachment: Is this feeding ?? Success ?
everything depends on a good start !!! CRITICAL PERIOD BEHAVIOUR

protection behaviours are intricately, inseparably
Warming, feeding and protection behaviours are intricately, inseparably linked to the right place. (Alberts 1994) = NUTRITION PROGRAMME

a specific effect on the infant.
Hofer discovered that what seems to be a single physical function, such as grooming or nursing, is actually a kind of umbrella that covers stimuli of touch, balance, smell, hearing and vision, each with a specific effect on the infant. (Gallagher 1992)

LUCY UNIQUELY HUMAN …. Brief history of our origins !!
4,6 billion years – earth forms 230 million years DINOSAURS 200 million years – MAMMALS 50 million years – PRIMATES 6 million years - HOMINIDS 1000 million years LIFE ? DINOSAURS 100 million years MAMMALS LOGARITHMIC TIME SCALE PRIMATES 10 million years 4 million years LUCY

“LUCY” walked upright = bipedalism The pelvis flattened
and narrowed as a result BIPEDALISM & NARROWER PELVIS

“LUCY’s” descendants, having free hands, started using tools
BIPEDALISM & NARROWER PELVIS TOOL USE & LANGUAGE “LUCY’s” descendants, having free hands, started using tools

PROBLEM ! ! ! About one million years ago, the brain size
BIPEDALISM & NARROWER PELVIS About one million years ago, the brain size started increasing = encephalisation PROBLEM ! ! ! TOOL USE & LANGUAGE INCREASED BRAIN SIZE

How is the bigger head going to be born out of the smaller pelvis ??
BIPEDALISM & NARROWER PELVIS … PROBLEM ? How is the bigger head going to be born out of the smaller pelvis ?? TOOL USE & LANGUAGE INCREASED BRAIN SIZE

SOLUTION … BIPEDALISM & NARROWER PELVIS TOOL USE & LANGUAGE INCREASED
BRAIN SIZE EXCEEDINGLY IMMATURE BIRTH

“THE EVOLUTIONARY COMPROMISE”
BIPEDALISM & NARROWER PELVIS TOOL USE & LANGUAGE INCREASED BRAIN SIZE EXCEEDINGLY IMMATURE BIRTH “THE EVOLUTIONARY COMPROMISE” Bipedalism and encephalisation (McKenna et al 1993)

The growing brain must come out before it is too big to pass through
BIPEDALISM & NARROWER PELVIS The growing brain must come out before it is too big to pass through the birth canal ... INCREASED BRAIN SIZE EXCEEDINGLY IMMATURE BIRTH

SOLUTION: “the birth of exceedingly neurologically immature infants for whom the majority of brain growth will occur postnatally and not in the womb.” (McKenna 1993)

80% In all mammals, brain grows in utero until it reaches 80% of
100% 80% In all mammals, brain grows in utero until it reaches 80% of full adult size …. … then BIRTH … then the brain grows the last 20% to final full adult size. 25% FETUS NEWBORN 0% BIRTH ADULT CONCEPTION

… the brain reaches 80% of final size at the age of 21 months
100% Homo sapiens = HUMAN also has a brain that grows along this pattern … … the brain reaches 80% of final size at the age of 21 months EXPECTED BIRTH 25% 0% 21/12

EXCEEDINGLY IMMATURE Actual birth takes place at 9 months …
100% Actual birth takes place at 9 months … … which makes the human birth one year too soon: EXCEEDINGLY IMMATURE EXPECTED BIRTH ACTUAL BIRTH 25% 0% 9/12 21/12

Humans essentially complete gestation OUTSIDE THE WOMB. 100% EXPECTED
BIRTH ACTUAL BIRTH 25% 0% 9/12 21/12

A fullterm newborn has 12 months of gestation to complete ! 100%
EXPECTED BIRTH A fullterm newborn has 12 months of gestation to complete ! ACTUAL BIRTH 25% 0% 9/12 21/12

The placenta via the umbilical cord is the means whereby the fetus
CONTINUES ITS GESTATION. Oxygenation Warmth Nutrition Protection +++ - ++ UTERUS UMBILICAL CORD In the UTERINE HABITAT, the umbilical cord delivers all the basic biological needs to the fetus.

whereby the immature infant CONTINUES ITS GESTATION.
Human milk is the means whereby the immature infant CONTINUES ITS GESTATION. Oxygenation Warmth Nutrition Protection (+) + +++ ++ CHEST MOTHER’S MILK (BREAST) In the NEWBORNS HABITAT, the mother’s breast delivers all the basic biological needs to the fetus.

whereby the immature infant CONTINUES ITS GESTATION.
Human milk is the means whereby the immature infant CONTINUES ITS GESTATION. Oxygenation Warmth Nutrition Protection +++ - ++ UTERUS UMBILICAL CORD Oxygenation Warmth Nutrition Protection (+) + +++ ++ CHEST MOTHER’S MILK (BREAST)

Full term completes 12 months gestation by skin-to-skin contact. 100%
EXPECTED BIRTH ACTUAL BIRTH 25% 0% 9/12 21/12

What if the gestation required is 14 months rather than 12 months?
100% What if the gestation required is 14 months rather than 12 months? 9/12 EXPECTED BIRTH ACTUAL BIRTH 25% 0% 7/12 21/12

If skin-to-skin contact
is essential for the the immature newborn, IS IT MORE ?? OR LESS ?? essential for the premature newborn ??

Skin-to-skin contact is ESSENTIAL if premature 100% 9/12 EXPECTED
BIRTH Skin-to-skin contact is ESSENTIAL if premature ACTUAL BIRTH 25% 0% 7/12 21/12

THE CORRECT HABITAT IS EVEN MORE ESSENTIAL IN PREMATURITY

THE CORRECT HABITAT IS MATERNAL-INFANT SKIN-TO-SKIN CONTACT

Breastfeeding Support to the dyad KANGAROO MOTHER CARE
Skin-to-skin contact *********** Breastfeeding Support to the dyad

WHY KANGAROO ? Marsupials have a pouch …which has four nipples … and can close tight for protection HUMAN KANGAROO MOTHER CARE! does the same for the premature ! - Skin-to-skin - Breastfeeding - Protection

KMC started by Drs Rey and Martinez, (1979) Bogota, Colombia.
KANGAROO MOTHER CARE Skin-to-skin CALOR warmth Breastfeeding LECHE milk Protection AMOR love KMC started by Drs Rey and Martinez, (1979) Bogota, Colombia. UNICEF report 1983 “remarkable claims”

Further information Research and Physiology of temperature
Video: Rediscover the Natural Way Research and Physiology of temperature oxygenation, nutrition, protection

HUMANITY FIRST TECHNOLOGY SECOND
KANGAROO MOTHER CARE HUMANITY FIRST TECHNOLOGY SECOND Skin-to-skin PLACE or HABITAT Breastfeeding BEHAVIOUR or NICHE Protection SUPPORT to DYAD

A mother and baby DYAD are a single psychobiological organism
KANGAROO MOTHER CARE A mother and baby DYAD are a single psychobiological organism Intro

DEFENSE NUTRITION REPRODUCTION HORMONES NERVES MUSCLES

HORMONES NERVES MUSCLES = BREASTFEEDING
DEFENSE NUTRITION REPRODUCTION HORMONES NERVES MUSCLES = BREASTFEEDING

= PROTEST - DESPAIR The DEFENCE program shuts
off the others immediately DEFENSE NUTRITION REPRODUCTION HORMONES NERVES MUSCLES = PROTEST - DESPAIR

Universal response to separation (wrong habitat): protest - ….. … intense activity, trying to find the habitat …

Universal response to separation (wrong habitat): - despair response …. …when separation is prolonged … …system shuts down for prolonged survival

Massive amounts of stress hormones (increase HR, RR)
DEFENCE program prepares the separated newborn for SURVIVAL - protest DEFENSE Massive amounts of stress hormones (increase HR, RR) HORMONES

Switches on the adrenergic system (stress response of protest)
DEFENCE program prepares the separated newborn for SURVIVAL - protest DEFENSE Switches on the adrenergic system (stress response of protest) NERVES

Extensor and frantic movements (Wastes energy)
DEFENCE program prepares the separated newborn for SURVIVAL- protest DEFENSE Extensor and frantic movements (Wastes energy) MUSCLES “Fight or flight”

Massive amounts of vagal hormones
DEFENCE program prepares the separated newborn for SURVIVAL - despair DEFENSE Massive amounts of vagal hormones Low temperature, Slow heart rate, (conserve energy) HORMONES (Vagal associates)

(on top of the adrenergic !! )
DEFENCE program prepares the separated newborn for SURVIVAL - despair DEFENSE Switches on the vagal system (on top of the adrenergic !! ) NERVES

Dissociation (playing dead)
DEFENCE program prepares the separated newborn for SURVIVAL- despair DEFENSE Dissociation (playing dead) “ … immobility and inhibition of cries for help … “ MUSCLES Superimposed PSNS (vagal) stimulation.

HYPERAROUSAL - DISSOCIATION
Protest – despair is also called HYPERAROUSAL - DISSOCIATION DEFENSE

HYPERAROUSAL - (Schore 2001)
“… sympathetic system activated, increasing HR, BP, tone, vigilance, distress is expressed as in crying then screaming, a state of “frantic distress” or “fear-terror” hypermetabolic state in the brain”

DISSOCIATION (Schore 2001)
“… later forming, parasympathetic, state of “conservation-withdrawal” a hypometabolic process, in which the individual passively disengages ”to conserve energies” … “to foster survival by the risky posture of feigning death”.

HYPERAROUSAL - DISSOCIATION (Schore 2001)
“in this state both sympathetic and parasympathetic components are hyperactivated … Creating … chaotic biochemical alterations … a toxic neurochemistry in the developing brain

“in the developing brain, states organize neural systems, resulting in enduring traits.”

Cells that fire together, wire together

“brain is exquisitely susceptible to adverse factors”
Schore Critical period concept : “brain is exquisitely susceptible to adverse factors” at particular times or stages

“early adverse experiences result in an increased sensitivity to the effects of stress later in life, and render an individual vulnerable to stress related psychiatric disorders.”

SEPARATION IS HARMFUL “Origins of many behavioural deviations are unknown - child neglect, abuse, abnormal shyness, attention deficiencies, hyperactivity, colic, sleep disorders etc,

SEPARATION IS HARMFUL “Origins of many behavioural deviations are unknown … … can some be traced back to violations of an innate agenda?" (Kjellmer and Winberg 1994).

NEWBORN DEVELOPMENT Advent of hospital nurseries and early separations correlates with attachment disorders, maternal abandonment of baby increased addictive behaviours (unmet oral needs) (Zimberoff & Hartman 2002)

NEWBORN DEVELOPMENT Birth complications … affect personality, relationships, self-esteem … and behaviour patterns later on in life” (Emerson 1998) Maternal rejection and lack of bonding added: strong correlation to violent criminal behaviour”.

"Early separation can produce major shifts in susceptibility to
SEPARATION IS HARMFUL "Early separation can produce major shifts in susceptibility to stress-induced pathology" (Hofer 1994) (Maladaptive pathways have formed… )

"Early separation can produce major shifts in susceptibility to
SEPARATION IS HARMFUL "Early separation can produce major shifts in susceptibility to stress-induced pathology" (Hofer 1994) Syndrome X Obesity Diabetes Hypertension

currently exploring early beginnings of adult brain pathology …
Contemporary neuroscience currently exploring early beginnings of adult brain pathology … … alterations in the functional organisation of the human brain … … correlated with the absence of early learning experiences.

than nonsocial aversive stimuli” “infant’s immature brain
Contemporary neuroscience “social stressors are far more detrimental than nonsocial aversive stimuli” “infant’s immature brain exquisitely vulnerable to early adverse experiences, including adverse social experiences.”

Schore “developmental psychoneurobiological model” good attachment 
 efficient right brain regulation   infant mental health   adult mental health .

Schore / Bergman “developmental psychoneurobiological model”
good attachment   efficient right brain regulation   infant mental health   adult mental health . Poor adult mental health  caused by Poor infant mental health  caused by Poor right brain regulation  caused by POOR ATTACHMENT  caused by lack of skin-to-skin contact  caused by SEPARATION

BUT = OUR CURRENT PRACTICE !!

THE CURRENT PARADIGM SEPARATES MOTHERS & BABIES

Dr Bergman translation: “hospital labour ward routines …”
Contemporary neuroscience currently exploring early beginnings of adult brain pathology … … alterations in the functional organisation of the human brain … … correlated with the absence of early learning experiences. Dr Bergman translation: “hospital labour ward routines …”

INCUBATOR CARE separates - causes “protest - despair response”

it learns to “dampen down”
STRESS & FETAL BRAIN DEVELOPMENT At birth, the human being has sensory perceptions with no “filters” – it experiences all its sensations maximally. As it develops, it learns to “dampen down” sensory inputs.

increase the perception of pain.
SEPARATION EFFECT ON NEWBORN Prematures and newborns have a nervous system which lacks the ability to dampen down sensory signals. Over-stimulation of any of the senses will be experienced as PAIN. Stress hormones increase the perception of pain.

Newborn separation switches on both cholinergic and adrenergic systems

Only one other medical condition has a similar
pathophysiology 

In medical literature – two conditions uniquely show hyperstimulation
of both arms of the ANS --- NEWBORN SEPARATION and BUTHID SCORPIONISM

it learns to “dampen down”
NEONATE At birth, the human being has sensory perceptions with no “filters” – it experiences all its sensations maximally. As it develops, it learns to “dampen down” sensory inputs.

“no filters” Buthid scorpionism
Buthid toxins act on Na and K channels of all excitable tissues, resulting in hyperstimulation of the nerve or tissue, every sensory nerve hyperstimulated. “no filters”

… causes the most severe pain possible and imaginable …
BUTHID SCORPIONISM Buthid scorpionism … … is a potentially deadly condition, … causes the most severe pain possible and imaginable … Biblical writers use “scorpion sting” as a metaphor to convey the worst kind of pain !!

BUTHID SCORPIONISM The clinical effect is a hyperstimulation of all
the nerves of the body including the autonomic nervous system. “Autonomic storm” used to be the explanation for the fatal illness seen.

BUTHID SCORPIONISM P. granulatus P. transvaalicus
Unique – P. transvaalicus cholinergic without adrenergic - thought impossible!! P. granulatus P. transvaalicus sympathetic parasympathetic (= adrenergic) (= cholinergic) Pulmonary oedema Fatal syncope

sympathetic parasympathetic (= adrenergic) (= cholinergic)
PROTEST DESPAIR HYPERAROUSAL DISSOCIATION

Mother and offspring live in a biological state that has much in common with addiction. When they are parted the infant does not just miss its mother; it experiences a physical and psychological with-drawal from a host of her sensory stimuli, not unlike the plight of a heroin addict who goes cold turkey. (Gallagher 1992)

HARDWIRING PRIMITIVE DEFENCE PATHWAYS !!!
THE SEPARATED BABY THAT HAS “SETTLED” IS RESTING, IT IS IN DESPAIR , DISSOCIATION IT IS HARDWIRING PRIMITIVE DEFENCE PATHWAYS !!!

SEPARATION !!! THE “PRIMARY VIOLATION” … the very worst thing … to any newborn according to biologists is SEPARATION.

SEPARATING MOTHERS NEWS NEVER BE SEPARATED FROM BABIES IS BAD BABIES
SHOULD NEVER BE SEPARATED

SEPARATION VIOLATES THE INNATE AGENDA OF MOTHER AND NEWBORN

MATERNAL-INFANT SEPARATION = ABUSE

WHY DO WE SEPARATE BABIES FROM MOTHERS ???

Ignaz SEMMELWEISS 1818 - 65 Hungarian obstetrician
1840’s – Vienna 30% died of puerperal fever – Pushed handwashing, cleanliness & standards: Maternal death rate from 12% to 1% in 2 years Ostracised by peers, Died insane

Stephane TARNIER 1828 -97 French obstetrician Saw a warmed box for
hatching chickens, had one designed for “weaklings” … … invented incubator

Pierre BUDIN 1846 - 1907 Friend of Tarniers …took
Incubators, made centres for the care of weaklings, wrote book on subject. Political support … France versus Germany BUDIN was very particular to include mother, reason for the glass window ….

Martin COUNEY German born, learnt of incubator from Budin, took “hatchery” to Exhibitions, famous for “preemie road show”. MONEY MAKING SHOW Berlin 1896, Buffalo  Omaha , Chicago Fair nd highest receipts, Last show New York 1940.

Equal parts P.T. Barnum-style circus sideshows and World's Fair wonders, Dreamland delivered novel and fantastic diversions of the odd and unusual. It was the home to scientific, ethnological and cultural exhibits, including Dr. Couney's Baby Incubator pavilion, which had been shown at the 1901 Buffalo Exhibition and the St. Louis Pike (seen here). Catering to the public's endless fascination with oddities and freaks, Dreamland had, as one of its main attractions, "Lilliputia,"

Martin COUNEY 1860 - 1950 Couney succesfully raised 5000 prems! BUT –
used wet-nurses, excluded mothers (mother got free pass to the shows !) Mothers were excluded – “germs” …

Sarah Morris Hospital, Chicago 1923, others followed – all with a
“policy of strict separation”. With the advent of artificial infant formula, mother not needed at all !! Habitat AND niche now synthetic !!

EVIDENCE BASED MEDICINE.
The INCUBATOR was invented 1900 The INCUBATOR was standard Care for prems by 1940

HOW MUCH SCIENCE ??

HOW MUCH SCIENCE ?? RESEARCH ??

Martin COUNEY German born, learnt of incubator from Budin, took “hatchery” to Exhibitions, famous for “preemie road show”. MONEY MAKING SHOW Berlin 1896, Buffalo  Omaha , Chicago Fair nd highest receipts, Last show New York 1940.

WHY DO WE SEPARATE BABIES FROM MOTHERS ? The INCUBATOR is an
ACCIDENT OF HISTORY

Is there an alternative
for premature infants ??

KMC started by Drs Rey and Martinez, (1979) Bogota, Colombia.
KANGAROO MOTHER CARE Skin-to-skin CALOR warmth Breastfeeding LECHE milk Protection AMOR love KMC started by Drs Rey and Martinez, (1979) Bogota, Colombia. UNICEF report 1983 “remarkable claims”

Origin of BIRTH K M C Drs Rey & Martinez 1979 Bogota, Colombia
LATE K M C 1985 Andrew Whitelaw Agneta Jurisoo BIRTH K M C

# Skin-to-skin contact
DEFINITION of KMC (1990) MANAMA, ZIMBABWE # Skin-to-skin contact from birth, continuous # Breastmilk from birth & exclusive breastfeeding # Psychological support to mother

KMC as above used regardless of weight and gestation.
KMC provides the baby with very intensive care. KC (in the USA) - In-hospital skin-to-skin contact, any duration, primarily adjunct to CMC (Conventional Method of Care).

Results – Manama Survival pre KMC 10% Survival with KMC 50%
(Infants 1000g to 1500g) Survival pre KMC 10% Survival with KMC 50% Weight gain / day 24g/d Breastfeeding rate 100%

in neonatology, has been equivalent to that of the advent to the world
The impact of Kangaroo Mother Care, in neonatology, has been equivalent to that of the advent to the world of Penicillin . Prof Bob Pattinson, Kalofong Hospital, South Africa.

SKIN-TO-SKIN & BREASTFEEDING : THEN ADD TECHNOLOGY

Is there an alternative
for premature infants ??

BIRTH K M C Is KMC safe for Unstable newborns?
IMPLICATIONS Third World The solution: BIRTH K M C Is KMC safe for Unstable newborns?

Archie COCHRANE 1909 1988 Any intervention should be subject to
RANDOMISED CONTROLLED TRIAL and meta-analysis … EVIDENCE BASED MEDICINE.

The INCUBATOR was invented 1900 The INCUBATOR was standard Care for prems by 1940 The Randomised Controlled TRIAL was “invented” by 1960 Kangaroo Mother Care was “discovered” in 1980

The INCUBATOR was standard Care for prems by 1940 The Randomised Controlled TRIAL was “invented” by 1960 Birth Kangaroo Mother Care was “discovered” in 1990 First RCT comparing birth KMC to incubator started in

For the human newborn, it is the habitat which determines which brain programme is operating, which then determines the behaviour (niche).

There are only these two habitat choices available
MOTHER OTHER There are only these two habitat choices available

SKIN-TO-SKIN CONTACT SEPARATION BREAST- VAGAL
MOTHER FEEDING (PSNS) GROWTH OTHER PROTEST- STRESS SURVIVAL or DESPAIR (SNS)

Habitat – niche hypothesis
HABITAT NICHE MEANS RESULT BREAST- VAGAL MOTHER FEEDING (PSNS) GROWTH OTHER PROTEST- STRESS SURVIVAL or DESPAIR (SNS)

“Habitat – niche hypothesis” How would YOU design an RCT ?
HABITAT NICHE MEANS RESULT BREAST- VAGAL MOTHER FEEDING (PSNS) GROWTH OTHER PROTEST- STRESS SURVIVAL or DESPAIR (SNS)

COMPARED TO CONVENTIONAL
KANGAROO MOTHER CARE FROM BIRTH COMPARED TO CONVENTIONAL INCUBATOR CARE Research funded by THRASHER RESEARCH FUND, U.S.A. Admin and stats by MEDICAL RESEARCH COUNCIL, R.S.A.

COMPARED TO CONVENTIONAL
KANGAROO MOTHER CARE FROM BIRTH COMPARED TO CONVENTIONAL INCUBATOR CARE Nils Bergman Lucy Linley, Sue Fawcus Mowbray Maternity Cape Town, RSA.

ONLY HABITAT DIFFERS SSC (skin-to-skin contact) from birth is superior
Primary hypothesis SSC (skin-to-skin contact) from birth is superior to incubator care for low birthweight infants ONLY HABITAT DIFFERS

BAILOUT points …. “physiological parameters exceeding normal limits, requiring medical assessment and or intervention” 1 Skin temp consistently <35.5oC 2 Heart rate <100; or > 180 bpm 3 Apnoea longer than 20 seconds 4 O2 sats below 89% (x2), (CPAP/60% O2) 5 Blood glucose < 2,6mmol/l, (laboratory)

Apnoea <10s, or periodic breathing
“Stability of Cardio-Respiratory system In Preterm Infants” (Fischer et al, 1988) SCRIP SCORE 2 1 Heart rate Regular Deceleration to Rate <80 or >200 bpm Respiratory rate Apnoea <10s, or periodic breathing Apnoea >10s Tachypnoea >80 pm Oxygen saturation Regular >87% Any fall to 80 – 87% Any fall below 80% Score allocated for a five minute period of continuous observation, maximum six for period

H1a H1b H2a H2b Research hypotheses Stabilising DURING 6h Stabilised
AT 6 hours BAILOUT H1a H1b SCRIP H2a H2b

Results Minimisation technique ensured groups balanced
for confounders. ( n = 34) KMC CMC Mean weight 1813g g Mean GA 34.2w w Approp’ GA 65% % Male 60% % (p 783)

HAWTHORNE EFFECT RESULTS H1a At six hours, SSC will have
fewer NICU admissions than CMC KMC (n = 20) CMC (n = 14) Chi-square Transferred to NICU 2 1 0.773 (10%) (7%) NS HAWTHORNE EFFECT

H1b In the first six hours, SSC will
have fewer bailout points than CMC KMC CMC Chi-Square (n = 18) (n = 13) Met bailout crit’ 3 12 <0.001 Temp <35.5 C 1 8 0.006 HR <100, >180 NS Apnoea >20 sec Ox sats <89% Blood sugar <2.6 0.02

SSC 17% CMC 92% H1b In the first six hours, SSC will
have fewer bailout points than CMC The results strongly support the hypothesis SSC 17% CMC 92%

SSC 83% CMC 8% H1b In the first six hours, SSC will
have fewer bailout points than CMC STABLE: SSC 83% CMC 8%

H2b During the sixth hour, “SCRIP” better with KMC (24pts)
Research hypotheses H2b During the sixth hour, “SCRIP” better with KMC (24pts) KMC CMC t-test (n = 18) (n = 13) SCRIP 6th hour (mean) 24.0 23.0 0.012 (Std deviation) 1.22 Perfect score24 18 (100%) 6 (46%)

The hypothesis is strongly supported. 100% of KMC infants were stabilised at 6 hours, while less than 50% of CMC …..

STABILITY better with KMC ….
KMC babies STABLE by 6 hours, INCUBATOR remained unstable, with no trend towards stabilisation.

H2a Through the six hours, “SCRIP” better with KMC (78pts)
Subanalysis <1800g SCRIP KMC (n = 9) CMC (n = 4) t-test SCRIP first six hours (mean) 76.67 71.75 0.049 (standard deviation) 1.5 6.65 Number perfect score (78) 4 (44%) 0 (0%)

Subanalysis <1800g SCRIP KMC (n = 9) CMC (n = 4) t-test SCRIP in 6th hour (mean) 24.0 22.25 0.008 (standard deviation) 1.71 Number perfect score (24) 9 (100%) 1 (25%)

If skin-to-skin contact
is essential for the the immature newborn, IS IT MORE ?? OR LESS ?? essential for the premature newborn ??

Skin-to-skin contact is ESSENTIAL if premature 100% 9/12 EXPECTED
BIRTH Skin-to-skin contact is ESSENTIAL if premature ACTUAL BIRTH 25% 0% 7/12 21/12

Skin-to-skin contact IS MORE essential for premature newborns!

SSC started from birth, is superior to incubator CONCLUSION
for infants g , with respect to stabilisation as defined by basic physiological parameters, (HR, RR, Ox sats, Dx, apnoea).

INCUBATORS DE-STABILISE
NEWBORNS

SKIN-TO-SKIN CONTACT SEPARATION BREAST- VAGAL
MOTHER FEEDING (PSNS) GROWTH OTHER PROTEST- STRESS SURVIVAL or DESPAIR (SNS)

SKIN-TO-SKIN CONTACT SEPARATION THIS IS THE “PHYSIOLOGY”
BREAST- VAGAL MOTHER FEEDING (PSNS) GROWTH OTHER PROTEST- STRESS SURVIVAL or DESPAIR (SNS) THIS IS THE “PHYSIOLOGY” IN OUR TEXT BOOKS …

SKIN-TO-SKIN CONTACT SEPARATION THIS IS THE “PHYSIOLOGY”
BREAST- VAGAL MOTHER FEEDING (PSNS) GROWTH OTHER PROTEST- STRESS SURVIVAL or DESPAIR (SNS) THIS IS THE “PHYSIOLOGY” IN OUR TEXT BOOKS … actually PATHOPHYSIOLOGY

A mother and baby DYAD are a single psychobiological organism
KANGAROO MOTHER CARE A mother and baby DYAD are a single psychobiological organism Intro

Julian Huxley, … to his students, … circa 1900. “During the next century, half of what we know now will be proven wrong. Unfortunately, we don’t know which half.”

EVIDENCE FOR SAFETY OF INCUBATORS … The evidence is assumed, taken for granted! It is part of our paradigm.

EVIDENCE FOR SAFETY OF INCUBATORS … We know their use to achieve
thermal control and appropriate humidity … … but we’ve neglected the brain !

Paradigm shift …. For unstable newborns: Is “Birth KMC” safe ? Is “Birth KMC” safer … ? Is “incubator” safe ? Is “incubator” unsafe ?

INTERVENTION DOES : GOOD LITTLE HARM PRIMUM NON NOCERE SSC SSC SSC SSC
Incubator Incubator Incubator Incubator

INTERVENTION DOES : GOOD LITTLE HARM PRIMUM NON NOCERE SSC Incubator

NEWBORNS

PREEMIES

Further information Video: Restoring the Original Paradigm
(intended for professionals) … on which KMC is grounded: Covers additional topics not covered in this talk: Anthropology Evolutionary theory Habitat niche argument Physiology and research results (Protest-despair behaviour) Breastfeeding and breastmilk

Further information Video: Rediscover the Natural Way
(intended for mothers and all) … including practical application (Immaturity of birth, biology) Physiology of temperature oxygenation, nutrition, (Separation behaviours) (Self-attachment) Milk effects, protection Use of KangaCarrier Interviews mothers and staff …

“Society reaps what it sows in the way that infants and children are treated. Efforts to reduce exposure to stress and abuse in early life may have far-reaching impacts on medical and psychiatric health and may reduce aggression, suspicion and untoward stress in future generations.” Martin H Teicher

INFANT SEPARATION Bergman)
“Society reaps what it sows in the way that infants and children are treated. Efforts to reduce exposure to stress and abuse (specifically MATERNAL INFANT SEPARATION Bergman) in early life may have far-reaching impacts on medical and psychiatric health and may reduce aggression, suspicion and untoward stress in future generations.” Martin H Teicher

Skin-to-Skin Contact, Breastfeeding, and Perinatal Neuroscience:
Implementing Best Practice in U.S. Hospitals Boston, MA Denver, CO Redlands, CA Mission Viejo, CA Intro

Skin-to-Skin Contact, Breastfeeding, and Perinatal Neuroscience

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Skin-to-Skin Contact, Breastfeeding, and Perinatal Neuroscience

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