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Anthropological and sociological aspects of skin-to-skin contact. Dr Nils Bergman M.B.Ch.B., M.P.H., M.D. M.B.Ch.B., M.P.H., M.D. Cape Town, South Africa.

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Presentation on theme: "Anthropological and sociological aspects of skin-to-skin contact. Dr Nils Bergman M.B.Ch.B., M.P.H., M.D. M.B.Ch.B., M.P.H., M.D. Cape Town, South Africa."— Presentation transcript:

1 Anthropological and sociological aspects of skin-to-skin contact. Dr Nils Bergman M.B.Ch.B., M.P.H., M.D. M.B.Ch.B., M.P.H., M.D. Cape Town, South Africa

2 “For species such as primates, the mother IS the environment.” Sarah Blaffer Hrdy, Mother Nature (1999) Babies Celebrated, Beatrice Fontanel and Claire D’Harcourt, © 1998 Harry N. Abrams, Inc. Nothing an infant can or cannot do makes sense, except in light of mother’s body

3 CENTRAL DOGMA – all biological processes NEUROSCIENCE The DNA Everything else EVOLUTIONARYBIOLOGY The Brain EPIGENETICS The Place ENVIRONMENTEXPERIENCEFITNESSADAPTATION Skin-to-skin = key that unlocks the neuroscience !

4 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)

5 Cells which FIRE TOGETHER, WIRE TOGETHER, and those which don’t, won ’ t.” Carla Shatz There are “needed neural processes” !

6 fetal REM sleep fetal REM sleep (or active sleep) seems to be (or active sleep) seems to be particularly important to the developing organism... spontaneous... spontaneous synchronous firing Marks et al 1995

7 BRAIN WIRING Peirano 2003

8 AT BIRTH, the brain has TWO CRITICAL SENSORY NEEDS: SMELL & CONTACT connect direct to the amygdala

9 THE NEWBORN BRAINSKIN-TO-SKINCONTACT fires and wires the amygdala-prefronto-orbital cortical pathway (PFOC) the amygdala-prefronto-orbital cortical pathway (PFOC)

10 AMYGDALA:EmotionalProcessing Unit CPU Prefrontal cortex Executive Executive function function SOCIAL and EMOTIONAL INTELLIGENCE

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12 SEES Mum’s eyes Hand TOUCH Mum’s skin Skin-to-skinCONTACT SENSATIONS THAT WIRE BRAIN Back FEELS Mum’s arm holding TASTES Mum’s milk Ear HEARS Mum’s voice SMELLS Mum’s milk WARMED on Mum’s front MOVES with Mum Slide from JILL BERGMAN

13 a kind of invisible hothouse Through “hidden maternal regulators”... “hidden maternal regulators”... “ physiological set points “ “ physiological set points “ “ internal working models’ “ scripts – templates”

14 The brain is a SENSORY ORGAN BREAST - FEEDING = BRAIN – WIRING SOCIAL ORGAN

15 NEUROSCIENCE The DNA Everything else EVOLUTIONARYBIOLOGY The Place ENVIRONMENTEXPERIENCEFITNESSADAPTATION “Scientific foundation” … a synthesis The Brain EPIGENETICS GENETICFACTORS ENVIRONMENT

16 NURTURE GENETICFACTORS STIMULATION ENVIRONMENT EXPERIENCE BEHAVIOUR NATURENICHE MOTHERBREASTMILK BREASTFEEDING

17 MOTHER MOTHER is the KEY for NEURODEVELOPMENT

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19 SEPARATION DYSREGULATES

20 PROTEST – DESPAIR causes DYSREGULATION This pathology... cannot be cured... Social deprivation alters neurobiological systems.

21 3-day separation: induces physiological changes (immune,system, heart rate, sleep, cortisol, loss of body temperature.. anaclitic depression: hyperactivity conservation- withdrawal; death or recovery Slide & photo from James McKenna

22 Primate separation studies Maternal Separation Paradigm 0w1w2w3w4w5w6w   12w n 4Mat MNS  group reared no mother n 4Mat MNS  group reared no mother n 4 Mat  MNS  group as above n 4 Mat  MNS  group as above n 4Mat  (control) n 4Mat  (control)

23 Gene specific for the AMYGDALA ( GUYC1A3) Separated at 1 week: LOW gene expression Increased self soothing  Anxiety Decreased sociality  Depression

24 Primate separation studies Maternal Separation Paradigm Early Deprivation (ED) vs control (CON) 0d2d   28d  48w ED n 11Mat min daily  ED n 11Mat min daily  CON n 4 Mat  48w CON n 4 Mat  48w

25 Repeated short separations: LOW gene expression Correlate to human adult depression Correlate to human adult depression

26 Sabatini Arabadzisz

27 Positive Stress Moderate, short-lived stress responses, such as brief increases in heart rate or mild changes in stress hormone levels.Moderate, short-lived stress responses, such as brief increases in heart rate or mild changes in stress hormone levels. An important and necessary aspect of healthy development that occurs in the context of stable and supportive relationships.An important and necessary aspect of healthy development that occurs in the context of stable and supportive relationships. Slide by: Jack P. Shonkoff, M.D.

28 Under- activity EUSTRESS Over- activity Positive Stress = Eustress An important and necessary aspect of healthy development that occurs in the context of stable and supportive relationships.An important and necessary aspect of healthy development that occurs in the context of stable and supportive relationships.

29 Tolerable Stress Stress responses that could disrupt brain architecture, but are buffered by supportive relationships that facilitate adaptive coping.Stress responses that could disrupt brain architecture, but are buffered by supportive relationships that facilitate adaptive coping. Generally occurs within a time-limited period, which gives the brain an opportunity to recover from potentially damaging effects.Generally occurs within a time-limited period, which gives the brain an opportunity to recover from potentially damaging effects. Slide by: Jack P. Shonkoff, M.D.

30 Toxic Stress Strong and prolonged activation of the body’s stress management systems in the absence of the buffering protection of adult support.Strong and prolonged activation of the body’s stress management systems in the absence of the buffering protection of adult support. Disrupts brain architecture and leads to stress management systems that respond at relatively lower thresholds, thereby increasing the risk of stress-related physical and mental illness.Disrupts brain architecture and leads to stress management systems that respond at relatively lower thresholds, thereby increasing the risk of stress-related physical and mental illness. Slide by: Jack P. Shonkoff, M.D.

31 MICHAEL MEANEY Unsafe environment activates HPA axis (autonomic nervous system, ANS). “In response to stress, CRF … and vasopressin are released … anterior pituitary … synthesis release ACTH …glucocorticoids  ” Early stress alters gene expression, with health impact across lifespan. with health impact across lifespan.

32 BRUCE McEWEN allostasis

33 Vocabulary Homeostasis the coordinated operation of physiological processes that maintain the steady state required to sustain life Allostasis the mechanism by which homeostatic systems are maintained in balance as life cycle and environment changes as life cycle and environment changes Allostatic state elevated activity of mediators, with return to baseline and no impact on health.

34 (similar to earlier … ) (similar to earlier … )REGULATION the objective is to achieve the ability to establish: ‘STABILITY THROUGH CHANGE’ The foundation for INFANT MENTAL HEALTH

35 Vocabulary Allostatic load elevated activity – sustained over time, or severe, or mediators dysregulated  changes target cells of mediators, and so changes the “set points” for homeostasis (e.g. increasing blood pressure, change in cholesterol level) change in cholesterol level) Allostatic overload the point at which chronic load results in actual disease chronic load results in actual disease or abnormal conditions.

36 ALLOSTATIC LOAD: “wear and tear that results from chronic overactivity (or underactivity) of allostatic systems.” (McEwen 1998, 1999) (McEwen 1998, 1999) TOXIC STRESS Sensitivity HIGH 2 ND KNOCK

37 Developing Brain (1) Neurogenesis Neural morphology SynaptogenesisMyelinationEarly Stress (2) Neuronal death, smaller brain Fewer dendritic spines Poorer connections Fewer glial cells, less myelin Sensitivity (3) GeneticGenderTiming Developmental rate GCR density Enduring (4) consequences Attenuated L brain devlopment Poor R / L integration Irritability limbic system Poorer function vermis Neuropsychiatric vulnerabilities (5) Dissociative identity disorder Depression Personality disorder Substance abuse Post Traumatic Stress Disorder StimulationResilience MENTAL HEALTH TEICHER’S EARLY STRESS CASCADE MODEL

38 Schore: “Infant trauma will interfere with critical period limbic organisation... future capacity to adapt... correlated with maladaptive adult mental health”

39 Schore: “long term alterations brain function “risk for developing severe psycho- pathologies at later stages of life.”

40  RESILIENCE / SENSITIVITY  PERCEPTIONS“NEUROCEPTION” RESPONSESTRESS ALLOSTATIC STATE ALLOSTASIS PsychologicalNeurologicalEndocrineImmune HEALTHDISEASE ALLOSTATIC LOAD ALLOSTATIC OVERLOAD WELL-BEING  SUSCEPTIBILITY  MORBIDITY  MORTALITY

41 ALLOSTATIC LOAD: “wear and tear that results …. SPECTRUM of expression in POPULATION HEALTHDISEASE

42 NEUROSCIENCE The DNA Everything else EVOLUTIONARYBIOLOGY The Place ENVIRONMENTEXPERIENCEFITNESSADAPTATION SPECTRUM of expression in POPULATION HEALTHDISEASE “Scientific foundation” … a synthesis Platform for better understanding of PUBLIC HEALTH. Platform for better understanding of PUBLIC HEALTH. … policy and practice that impacts the care of mothers and babies. The Brain EPIGENETICS EXPECTED UNEXPECTED

43 “EEA” “EEA” E nvironment of E volutionary A daptedness

44 “Environment” is the usual place and context for which the genes have adjusted

45 MOTHER is the key to MOTHER is the key to neurodevelopment … … because she is the RIGHT PLACE !!

46 Anthropological and sociological aspects of skin-to-skin contact. Anthropology Evolutionary Biology DNA & Epigenetics Neuroscience of stress Mal-Adaptation Sociological consequence

47 Anthropological and sociological aspects of skin-to-skin contact. SCIENTIFIC AND EVIDENCE BASIS FOR INCUBATOR ??

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

49 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 ….

50 Martin COUNEY Born in Germany claims he learned the techniques for Budin.... Berlin Exhibition 1896, success ! Photograph: Pan-American Exhibition in Buffalo, New York, 1901.

51 Martin COUNEY Berlin 1896, success to USA: Buffalo  Omaha , Chicago Fair nd highest receipts, Last show New York Baby Incubator, 1904 St.Louis Fair

52 Martin COUNEY famous for “preemie road show”. “preemie road show”. MONEY MAKING SHOW MONEY MAKING SHOWPERMANENT pavilion in Dreamland New York Worlds Fair, 1939

53 Martin COUNEY Born in Germany claims he learned the techniques for Budin.... Berlin Exhibition 1896, success ! London World fair 1898, fiasco! ALL THE BABIES DIED.... “MOTHERS TO BLAME”

54 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” …

55 Sarah Morris Hospital, Chicago 1923, others followed – accepting the “policy of strict separation”.

56 WHY do we separate mothers from babies ?? INCUBATOR & SEPARATION = ACCIDENT of HISTORY

57 THE INCUBATOR HAS NO SCIENTIFIC FOUNDATION !! PERINATAL NEUROSCIENCE & SKIN-TO-SKIN CONTACT

58 MOTHER is the key to MOTHER is the key to neurodevelopment … … because she is the RIGHT PLACE !!

59 MOTHER is the key to MOTHER is the key to neurodevelopment … E nvironment of E volutionary A daptedness

60 KEY TO MONITORING WELL BEING  AUTONOMIC NERVOUS SYSTEM MONITOR !  if HARM can be monitored, HARMING CARE MUST CHANGE

61 Separation from mother is stressful for humans. Salivary cortisol is a good measure of stress.

62 RCT (Anderson et al 1998) Two groups of newborns, both given best care, only one separated from mother at one hour age Cortisol levels measured every hour. Cortisol separate = 9 Cortisol with mom= 4 SEPARATION = STRESS Separation DOUBLES CORTISOL

63 Preterm infants experience prolonged severe stress, with tenfold increases in stress hormones. Stress hormones at such levels are neurotoxic. are neurotoxic. (Modi & Glover 1998, Mooncey et al 1997) RCT on methods to reduce of stress (at one hour): Cortisol Endorphin Massageslightly lowerno change Soft musicno changeno change Skin-to-skin66% lower 74% lower

64 evolutionary survival machine ANS HRV EEG autonomic autonomicdownstream

65

66 PLACE convention 4Breastfeeding 3Holding 2MIS (Cot) 1SSC (Skin-to-skin)

67 ANDERSON BEHAVIOURAL STATE SCALE 12 11Crying 10Fussing 9Active 8Breastfeeding 7Alert Awake 6Quiet Awake 5Drowsy 4 3Active Sleep 2Irregular Sleep 1Regular / Quiet Sleep

68 HRV produces IBI (Inter Beat Interval) FFT / AR / wavelet FFT / AR / wavelet social vagus (validated)social vagus (validated) sympathetic (accepted)sympathetic (accepted) “old vagus” (our hypothesis)“old vagus” (our hypothesis) DVCDVC VVCVVC SNSSNS

69 GREEN = OLD VEGETATIVE VAGUS RED = SNS SYMPATHETIC BLUE = NEW SOCIAL VAGUS AUTONOMIC STATE COMPONENTS:

70 Skin-to-skin contact = *NORMAL* PLACE SEPARATE 176% Increase Autonomic activity SEPARATE 86% Decrease Quiet Sleep 7 x more QS is SSC 3 x more ANS in MIS

71 BREAST-VAGAL MOTHER FEEDING(PSNS) GROWTH OTHERPROTEST-STRESSSURVIVAL or DESPAIR(SNS) SKIN-TO-SKIN CONTACT SEPARATION Higher state arousal Normal sleep cycling Separated neonates experience disturbances of sleep cycling.

72 NEURO PHYSIOLOGY of SEPARATION Maternal separation may be a stressor the human neonate is not well-evolved to cope with, and may not be benign.

73 idealbenignmalevolentunsuitable HEALTHDISEASE ? MOTHER ISOUR “NORMAL” MOTHER ISOUR “NORMAL” “BETTER”CARE CULTURE OUR “NORMAL”THIS IS BIOLOGY “WORSE”

74 Skin-to-skin contact – our developmental environment. “Maternal separation may be a stressor the human neonate is not well-evolved to cope with, and may not be benign.”

75 Skin-to-skin contact – our developmental environment. It matters how we are born! It influences our emotional It influences our emotional and social development, and social development, our future EQ. our future EQ.

76 Skin-to-skin contact – our developmental environment. Separation is perceived as stress, which increases cortisol, which increases cortisol, disrupts development of disrupts development of new neural pathways new neural pathways

77 Skin-to-skin contact – our developmental environment. Contrary to old beliefs: the human newborn is profoundly sentient and perceptive, sentient and perceptive, at birth and thereafter. at birth and thereafter.


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