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Skin-to-Skin Contact, Breastfeeding, and Perinatal Neuroscience Hollister HollisterBreastfeeding Program 2006 Boston, MADenver, CORedlands, CAMission Viejo,

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Presentation on theme: "Skin-to-Skin Contact, Breastfeeding, and Perinatal Neuroscience Hollister HollisterBreastfeeding Program 2006 Boston, MADenver, CORedlands, CAMission Viejo,"— Presentation transcript:

1 Skin-to-Skin Contact, Breastfeeding, and Perinatal Neuroscience Hollister HollisterBreastfeeding Program 2006 Boston, MADenver, CORedlands, CAMission Viejo, CA

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

3 Skin-to-Skin Contact, Breastfeeding, and Perinatal Neuroscience: Implementing Best Practice in U.S. Hospitals Boston, MADenver, CORedlands, CAMission Viejo, CA

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

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

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

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

8 w6m2y10y60y Birth Neurulation NEUROGENESIS Myelination Arborisation SYNAPTOGENESIS NEURODEVELOPMENT

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

10 23wfetus is aware / conscious parallel development of structure & function Neurobehaviour and neurodevelopment are inseparable a single integrated whole.

11 EARLY DEVELOPMENT 25wlayering, dendrification, synapse formation The brain is not a computer, it is a jungle.

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

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

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

15 30 w fetus can recognise mothers voice from other women, from single words played back to it by a tape-recorder, It can distinguish mothers language from another language, again from a single word or phoneme. The fetus has a GREATER SENSORIUM than the adult …

16 FETAL BRAIN DEVELOPMENT Cells that fire together, wire together

17 FETAL BRAIN DEVELOPMENT Use it, or lose it.

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

19 w6m2y10y60y Birth Neurulation NEUROGENESIS Myelination Arborisation SYNAPTOGENESIS Programmed cell death COMPETITIVE ELIMINATION NEURODEVELOPMENT

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

21 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

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

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

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

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

26 NEWBORN DEVELOPMENT Tactile stimulations facilitate the flow of affective information from the infant … to the mother 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!

27 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 … in the first two months of life

28 FETAL BRAIN DEVELOPMENT The fetus has well developed sensations for touch and position sensations for touch and position (tactile and kinesthestic sensations). (tactile and kinesthestic sensations). The infant actively seeks to adhere to as much skin surface on the to as much skin surface on the mothers body as possible mothers body as possible (Harlow 1958, from Schore 2001)

29 NEWBORN DEVELOPMENT skin-to-skin contact 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!

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

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

32 Through such hidden maternal regulators he discovered that regulators he discovered that a mother precisely controls every element of her infants physiology, 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)

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

34 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. a specific effect on the infant. (Gallagher 1992)

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

36 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

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

38 Infant brain development Early brain development is INTERACTIVE RAPID DRAMATIC

39 Infant brain development CRITICAL PERIODS require specific stimulations at specific times

40 Infant brain development Quality SENSORY STIMULATION makes brain able to think and regulate

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

42 = FALSE ASSUMPTION !! Current paradigm: Infant brain development 1.Genetically determined 2.Develops in linear time 3.Activity increases w age 4.Mother = good context 5.Deficits correctable later

43 Current paradigm versus NEW: Infant brain development 1.Genetically determinedEXPERIENCE 2.Develops in linear timeCRITICAL PERIOD 3.Activity increases w ageGREATEST 3 yrs 4.Mother = good context = WIRES BRAIN 5.Deficits correctable laterLimbic FIXED at 3y (Rima Shore 1997)

44 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.

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

46 THE OLD BRAIN HAS 3 PROGRAMMES DEFENCE NUTRITIONREPRODUCTION

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

48 DEFENCENUTRITIONREPRODUCTION HORMONES NERVESMUSCLES endocrineautonomic NS somatic endocrineautonomic NS somatic

49 DEFENCE NUTRITIONREPRODUCTION HORMONES NERVESMUSCLES

50 REPRODUCTIONNUTRITION DEFENCE HORMONES NERVESMUSCLES

51 DEFENCE NUTRITIONREPRODUCTION HORMONES NERVESMUSCLES

52 BODY HORMONES NERVESMUSCLES

53 BEHAVIOUR WHOLE BODY HORMONES NERVESMUSCLES

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

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

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

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

58 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)

59 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)

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

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

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

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

64 The habitat - niche concept HABITAT DETERMINES BEHAVIOUR

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

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

67 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. a specific effect on the infant. (Gallagher 1992)

68 1000 million years 100 million years 10 million years 4 million years LIFE ? DINOSAURS MAMMALS PRIMATES 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 LOGARITHMIC TIME SCALE UNIQUELY HUMAN ….

69 BIPEDALISM & NARROWERPELVIS LUCY walked upright = bipedalism The pelvis flattened and narrowed as a and narrowed as a result result

70 TOOL USE &LANGUAGE BIPEDALISM & NARROWERPELVIS LUCYs descendants, having free hands, having free hands, started using tools started using tools

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

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

73 INCREASED BRAIN SIZE TOOL USE &LANGUAGE BIPEDALISM & NARROWERPELVIS EXCEEDINGLY IMMATURE BIRTH SOLUTION … SOLUTION …

74 INCREASED BRAIN SIZE TOOL USE &LANGUAGE BIPEDALISM & NARROWERPELVIS EXCEEDINGLYIMMATUREBIRTH THE EVOLUTIONARY COMPROMISE Bipedalism and encephalisation (McKenna et al 1993)

75 INCREASED BRAIN SIZE BIPEDALISM & NARROWERPELVIS EXCEEDINGLYIMMATUREBIRTH The growing brain must come out must come out before it is too before it is too big to pass big to pass through through the birth canal... the birth canal...

76 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)

77 100% 25% 0% ADULTBIRTH CONCEPTION FETUSNEWBORN In all mammals, In all mammals, brain grows in brain grows in utero until it utero until it reaches 80% of reaches 80% of full adult size …. full adult size …. … then BIRTH … then BIRTH … then the brain grows the last grows the last 20% to final 20% to final full adult size. full adult size. 80%

78 100% 25% 0% Homo sapiens Homo sapiens = HUMAN also has a brain also has a brain that grows along that grows along this pattern … this pattern … … the brain … the brain reaches 80% reaches 80% of final size of final size at the age of at the age of 21 months 21 months EXPECTEDBIRTH 21/12

79 100% 25% 0% Actual birth takes place at takes place at 9 months … … which makes … which makes the human birth the human birth one year too soon: one year too soon:EXCEEDINGLYIMMATURE EXPECTEDBIRTH 21/12 ACTUALBIRTH 9/12

80 100% 25% 0% Humansessentially complete complete gestation gestation OUTSIDE OUTSIDE THE WOMB. THE WOMB. EXPECTEDBIRTH 21/12 ACTUALBIRTH 9/12

81 100% 25% 0% A fullterm newborn has 12 months of gestation to complete ! EXPECTEDBIRTH 21/12 ACTUALBIRTH 9/12

82 OxygenationWarmthNutritionProtection UTERUS UMBILICAL CORD In the UTERINE HABITAT, the umbilical cord delivers all the basic biological needs to the fetus. delivers all the basic biological needs to the fetus. The placenta via the umbilical cord is the means whereby the fetus CONTINUES ITS GESTATION.

83 Human milk is the means whereby the immature infant CONTINUES ITS GESTATION. OxygenationWarmthNutritionProtection CHESTMOTHERS MILK (BREAST) (+) In the NEWBORNS HABITAT, the mothers breast delivers all the basic biological needs to the fetus. delivers all the basic biological needs to the fetus.

84 OxygenationWarmthNutritionProtection UTERUS UMBILICAL CORD OxygenationWarmthNutritionProtection CHESTMOTHERS MILK (BREAST) (+) Human milk is the means whereby the immature infant CONTINUES ITS GESTATION.

85 100% 25% 0% Full term completes 12 months gestation by skin-to-skincontact. EXPECTEDBIRTH 21/12 ACTUALBIRTH 9/12

86 100% 25% 0% What if the gestation required is 14 months rather than 12 months? EXPECTEDBIRTH 21/12 ACTUALBIRTH 7/12 9/12

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

88 100% 25% 0% EXPECTEDBIRTH 21/12 ACTUALBIRTH 7/12 9/12 Skin-to-skin contact is contact isESSENTIAL if premature

89 THE CORRECTHABITAT IS EVEN MORE ESSENTIAL INPREMATURITY

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

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

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

93 -Skin-to-skin CALORwarmth -Breastfeeding LECHEmilk -Protection AMORlove KMC started by Drs Rey and Martinez, (1979) Bogota, Colombia. (1979) Bogota, Colombia. UNICEF report 1983 remarkable claims KANGAROO MOTHER CARE

94 Further information Video: Rediscover the Natural Way Research and Physiology of temperatureoxygenation,nutrition,protection

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

96 A mother and baby DYAD are a single psychobiologicalorganism

97 DEFENSENUTRITIONREPRODUCTION HORMONES NERVESMUSCLES

98 DEFENSENUTRITIONREPRODUCTION HORMONES NERVESMUSCLES = BREASTFEEDING

99 REPRODUCTIONNUTRITION The DEFENCE program shuts off the others immediately off the others immediately HORMONES NERVESMUSCLES = PROTEST - DESPAIR = PROTEST - DESPAIR DEFENSE

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

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

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

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

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

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

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

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

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

109 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 distress is expressed as in crying then screaming, a state of frantic distress or fear-terror hypermetabolic state in the brain hypermetabolic state in the brain

110 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. a hypometabolic process, in which the individual passively disengages to conserve energies … to foster survival by the risky posture of feigning death.

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

112 HYPERAROUSAL - DISSOCIATION (Schore 2001) in the developing brain, states organize neural systems, resulting in enduring traits.

113 FETAL BRAIN DEVELOPMENT Cells that fire together, wire together

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

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

116 HYPERAROUSAL - DISSOCIATION (Schore 2001) 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.

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

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

119 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)

120 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.

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

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

123 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.

124 Contemporary neuroscience social stressors are far more detrimental than nonsocial aversive stimuli infants immature brain exquisitely vulnerable to early adverse experiences, including adverse social experiences.

125 Schore developmental psychoneurobiological modeldevelopmental psychoneurobiological model good attachment good attachment efficient right brain regulation efficient right brain regulation infant mental health infant mental health adult mental health. adult mental health.

126 Schore / Bergman developmental psychoneurobiological modeldevelopmental psychoneurobiological model good attachment good attachment efficient right brain regulation efficient right brain regulation infant mental health infant mental health adult 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

127 BUT = OUR CURRENT PRACTICE !!

128 THE CURRENT PARADIGM SEPARATES MOTHERS & BABIES

129 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 …

130 INCUBATOR CARE separates - causes protest - despair response

131 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.

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

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

134 Newborn separation switches on both cholinergic and adrenergic systems

135 Only one other medical condition has a similar pathophysiology

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

137 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.

138 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

139 BUTHID SCORPIONISM 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 !!

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

141 BUTHID SCORPIONISM Unique – P. transvaalicus cholinergic without adrenergic - thought impossible!! P. granulatusP. transvaalicus sympatheticparasympathetic (= adrenergic) (= cholinergic) Pulmonary oedemaFatal syncope

142 sympatheticparasympathetic (= adrenergic) (= cholinergic) PROTESTDESPAIR HYPERAROUSALDISSOCIATION

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

144 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)

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

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

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

148 SEPARATION VIOLATES THE INNATE AGENDA OF MOTHER AND NEWBORN

149 MATERNAL-INFANTSEPARATION = ABUSE

150 WHY DO WE SEPARATE BABIES FROM MOTHERS ???

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

152 Stephane TARNIER French obstetrician Saw a warmed box for hatching chickens, had one designed for weaklings … … invented incubator … invented incubator

153 Pierre BUDIN 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 ….

154 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.

155 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,"

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

157 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 !!

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

159 HOW MUCH SCIENCE ??

160 HOW MUCH SCIENCE ?? RESEARCH ??

161 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.

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

163 Is there an alternative for premature infants ??

164 -Skin-to-skin CALORwarmth -Breastfeeding LECHEmilk -Protection AMORlove KMC started by Drs Rey and Martinez, (1979) Bogota, Colombia. (1979) Bogota, Colombia. UNICEF report 1983 remarkable claims KANGAROO MOTHER CARE

165 Origin of BIRTH K M C Drs Rey & Martinez 1979 Bogota, Colombia LATE K M C 1985Andrew Whitelaw 1987Agneta Jurisoo BIRTH K M C

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

167 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).

168 Results – Manama (Infants 1000g to 1500g) (Infants 1000g to 1500g) Survival pre KMC 10% Survival with KMC50% Weight gain / day24g/d Breastfeeding rate100%

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

170 SKIN-TO-SKIN & BREASTFEEDING : THEN ADD TECHNOLOGY

171 Is there an alternative for premature infants ??

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

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

174 EVIDENCE BASED MEDICINE. The INCUBATOR was invented 1900 was invented 1900 The INCUBATOR was standard Care for prems by 1940 standard Care for prems by 1940 The Randomised Controlled TRIAL was invented by 1960 TRIAL was invented by 1960 Kangaroo Mother Care was discovered in 1980 was discovered in 1980

175 EVIDENCE BASED MEDICINE. The INCUBATOR was standard Care for prems by 1940 standard Care for prems by 1940 The Randomised Controlled TRIAL was invented by 1960 TRIAL was invented by 1960 Birth Kangaroo Mother Care was discovered in 1990 was discovered in 1990 First RCT comparing birth KMC to incubator started in 2000

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

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

178 BREAST-VAGAL MOTHER FEEDING(PSNS) GROWTH OTHERPROTEST-STRESSSURVIVAL or DESPAIR(SNS) SKIN-TO-SKIN CONTACT SEPARATION

179 HABITATNICHEMEANSRESULT BREAST-VAGAL MOTHER FEEDING(PSNS) GROWTH OTHERPROTEST-STRESSSURVIVAL or DESPAIR(SNS) Habitat – niche hypothesis

180 HABITATNICHEMEANSRESULT BREAST-VAGAL MOTHER FEEDING(PSNS) GROWTH OTHERPROTEST-STRESSSURVIVAL or DESPAIR(SNS) Habitat – niche hypothesis How would YOU design an RCT ?

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

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

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

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

185 SCRIP SCORE 210 Heart rateRegularDeceleration to Rate 200 bpm Respiratory rate RegularApnoea <10s, or periodic breathing Apnoea >10s Tachypnoea >80 pm Oxygen saturation Regular >87%Any fall to 80 – 87% Any fall below 80% Stability of Cardio-Respiratory system In Preterm Infants (Fischer et al, 1988) Score allocated for a five minute period of continuous observation, maximum six for period

186 Research hypotheses Stabilising DURING 6h Stabilised AT 6 hours BAILOUT H1aH1b SCRIP H2aH2b

187 Results Minimisation technique ensured groups balanced for confounders. ( n = 34)KMC CMC Mean weight 1813g 1866g Mean GA34.2w 35.3w Approp GA65% 64% Male60% 50% (p 783)

188 RESULTS H1aAt six hours, SSC will have fewer NICU admissions than CMC KMC ( n = 20 ) CMC ( n = 14 ) Chi- square Transferred to NICU (10%)(7%)NS HAWTHORNE EFFECT

189 H1bIn the first six hours, SSC will have fewer bailout points than CMC KMCCMCChi- Square (n = 18)(n = 13) Met bailout crit312<0.001 Temp <35.5 C HR 18000NS Apnoea >20 sec01NS Ox sats <89%10NS Blood sugar <

190 H1bIn the first six hours, SSC will have fewer bailout points than CMC The results strongly support the hypothesis SSC17% CMC92%

191 H1bIn the first six hours, SSC will have fewer bailout points than CMC STABLE: SSC83% CMC8%

192 Research hypotheses H2b During the sixth hour, SCRIP better with KMC (24pts) KMCCMCt-test (n = 18)(n = 13) SCRIP 6 th hour (mean) (Std deviation)01.22 Perfect score2418 (100%) 6 (46%)

193 H2b During the sixth hour, SCRIP better with KMC (24pts) The hypothesis is strongly supported. 100% of KMC infants were stabilised at 6 hours, while less than 50% of CMC …..

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

195 H2aThrough the six hours, SCRIP better with KMC (78pts) Subanalysis <1800g SCRIP KMC (n = 9) CMC (n = 4) t-test SCRIP first six hours (mean) (standard deviation) Number perfect score (78) 4 (44%) 0 (0%)

196 H2b During the sixth hour, SCRIP better with KMC (24pts) Subanalysis <1800g SCRIP KMC (n = 9) CMC (n = 4) t-test SCRIP in 6 th hour (mean) (standard deviation) Number perfect score (24) 9 ( 100%) 1 ( 25%)

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

198 100% 25% 0% EXPECTEDBIRTH 21/12 ACTUALBIRTH 7/12 9/12 Skin-to-skin contact is contact isESSENTIAL if premature

199 Skin-to-skincontact IS MORE essential for prematurenewborns!

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

201 INCUBATORS DE-STABILISE NEWBORNS

202 BREAST-VAGAL MOTHER FEEDING(PSNS) GROWTH OTHERPROTEST-STRESSSURVIVAL or DESPAIR(SNS) SKIN-TO-SKIN CONTACT SEPARATION

203 BREAST-VAGAL MOTHER FEEDING(PSNS) GROWTH OTHERPROTEST-STRESSSURVIVAL or DESPAIR(SNS) SKIN-TO-SKIN CONTACT SEPARATION THIS IS THE PHYSIOLOGY IN OUR TEXT BOOKS …

204 BREAST-VAGAL MOTHER FEEDING(PSNS) GROWTH OTHERPROTEST-STRESSSURVIVAL or DESPAIR(SNS) SKIN-TO-SKIN CONTACT SEPARATION THIS IS THE PHYSIOLOGY IN OUR TEXT BOOKS … actually PATHOPHYSIOLOGY

205 KANGAROO MOTHER CARE A mother and baby DYAD are a single psychobiologicalorganism

206 Julian Huxley, … to his students, … circa During the next century, half of what we know now will be proven wrong. Unfortunately, we dont know which half.

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

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

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

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

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

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

213 INCUBATORS DE-STABILISE NEWBORNS

214 PREEMIES

215 Further information Video: Restoring the Original Paradigm (intended for professionals) … on which KMC is grounded: … 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

216 Further information Video: Rediscover the Natural Way (intended for mothers and all) … including practical application … 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 …

217 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

218 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

219 Skin-to-Skin Contact, Breastfeeding, and Perinatal Neuroscience: Implementing Best Practice in U.S. Hospitals Boston, MADenver, CORedlands, CAMission Viejo, CA


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