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Kangaroo Mother Care:Restoring the Original
Paradigm for Infant Care
Dr Nils Bergman”M.D., D.C.H., M.P.H., Ph.D.”
Cape Town, South Africa
www.skintoskincontact.com
What is a paradigm?
The American Heritage® Dictionary of the English Language:
Fourth Edition. 2000.
paradigm 3. A set of
assumptions, concepts, values, and
practices that constitutes a way of
viewing reality for the community
that shares them, especially in an
intellectual discipline.
What is a paradigm?
[Kuhn, T S; The Structure of Scientific
Revolutions, 2nd Ed., Univ. of Chicago Press,
Chicago & London, 1970, p.175].
Kuhn defines a paradigm as:
“an entire constellation of beliefs,
values and techniques, and so on,
shared by the members of a given
community”
WHAT IS THECURRENT PARADIGMFOR INFANT CARE?
Kangaroo Mother Care:Restoring the Original
Paradigm for Infant Care
child helpless
OLD PARADIGM
Restoring the Original Paradigm for Infant Care
mother clueless
father useless
2
Clinics in Perinatology,
June 2004, Vol 31(2) p293
Robert White
“Mothers’ arms – the past and
future locus of neonatal care ?”
“(Our care) still views the
infant as a solitary
individual who sleeps
most of the time in a bed."
PARADIGM CONSTRUCT
Paradigm has internalIntelligenceHonestyIntegrity
Consistency
FOUNDATION / PLATFORM / BASE
BASIC ASSUMPTION:
= INFANT SLEEPS ALONE
#2: Derive
measurements
of infant sleep
under these
conditions
From James McKenna,
Notre Dame Sleep Laboratory
#1: Initial test condition—
infant sleeps alone, is bottle fed,
and has little or no parental contact
Culture Producing Science Producing Culture:
How A Folk Myth Achieved Scientific Validation
“Scientific”
validation of solitary
infant sleep as
“normal” and
“healthy”
#1: Initial test condition—
infant sleeps alone, is bottle fed,
and has little or no parental contact
#2: Derive
measurements
of infant sleep
under these
conditions
#3: Repeat measurements across ages,
creating an “infant sleep model”
#4: Publish
clinical model
on what
constitutes
desirable,
healthy infant
sleep.
#5: To produce
“healthy” infant
sleep, replicate the
test condition
From James McKenna
• CIRCULAR
SCIENCE -
A SELF-
FULFILLING
PROPHECY
Culture Producing Science Producing Culture:
How A Folk Myth Achieved Scientific Validation
#1: Initial test condition—
infant sleeps in INCUBATOR,
is FORMULA fed, SEPARATED
#2: Derive
measurements
NEONATES
under these
conditions
#3: Repeat measurements across ages,
defining “NEONATAL PHYSIOLOGY”
#4: Publish
TEXTBOOKS
DESCRIBING
“NORMAL”
NEONATES
#5: “replicate
the test
condition”
SEPARATED
NEONATES
ARE NORMAL
From James McKenna
“Scientific”
validation of
SEPARATED
NEONATE
as “normal” and
“healthy”
3
PARADIGM CONSTRUCT
Paradigm: “in the philosophy of science, a generally accepted model of how ideas relate to one another,
forming a conceptual framework
within which scientific research is carried out”
MSN Encarta
FOUNDATION / PLATFORM / BASE
BASIC ASSUMPTION:
= INCUBATORS STABILIZE
NEURODEVELOPMENT
The DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth & BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
Scientific
American,December 2011
INK
PENCIL
CORTISOL
HISTONE MODIFICATION
DNA METHYLATION
MICRO-RNA
“Phenotype” – specimen resulting from
gene – environment interactionPencil
EPIGENES …controls on the DNA/gene
“switches in the mind”
G x E
4
NEURODEVELOPMENT
The DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth & BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
“Phenotype” – specimen resulting from
gene – environment interactionMaking of theneural tube
200000 new nerve cells/minHammarberg 1896 Caviness 2008 Neuronal migration
23
The brain is not a computer, it is a jungle
G Edelman
From
National
Geographic
Magazine
April 2014
Each neuronhas on average10 000 synapses.
5
Convolutions of the cortex
•
Robinson RJ & Tizard JPM Br Med Bull 1966 22:49-55
26
(Ner
vous
tiss
ue
cell
s –
gli
al
cell
s)
Impulse
Presynaptic neuron
Vesicle
Transmitters
Synaptic cleft
ReceptorsPostsynaptic
neuronPostsynaptic activity
fetal REM sleep(or active sleep) seems to
be particularly importantto the developing organism
... spontaneous synchronous firing
Marks et al 1995
”Neurons that fire together wire together while those which don’t,won’t”
Hebb/Carla Shatz
Panksepp 1998
Siegel 2005
Non-REM 4
6
REMNR1NR2NR3NR4
ACQUISITION CONSOLIDATION MEMORYFORMATION
poly-sensory input transfer information P wavesshort-term memory “SNR” strong signals returns infostored cortex amygdala / to neocortex:
hippocampus organizedAwake and REM NREM stage 4 REM
BRAIN WIRING
Stanley Graven 2006
BRAIN WIRING
Peirano 2003
In adult:sleep pertains
to memory
In child:neurodevelopment
(brain wiring)1st 1000 days
BRAIN WIRING
PATHWAYS CIRCUITSNETWORKSCONNECTOME
LUDINGTON-HOE … SCHER
7
SCHER … LUDINGTON-HOEBrain Architecture and Skills are
Built in a Hierarchical “Bottom-Up” Sequence
• Neural circuits that process basic information
are wired earlier than those that process more
complex information.
• Higher circuits build on lower circuits, and
skill development at higher levels is more
difficult if lower level circuits are not wired
properly.
Slide by: Jack P. Shonkoff, M.D.
DEFENCE NUTRITION REPRODUCTION
HORMONES NERVES MUSCLES
endocrine autonomic NS somatic
HIGHLY CONSERVED NEURO-ENDOCRINE
BEHAVIOR
AT BIRTH,
the brain has TWO CRITICAL SENSORY NEEDS:
SMELL & CONTACT
8
... these data indicate that pups have a unique learning circuit relying onthe olfactory bulb for
neural plasticity and on the hyperfunctioning noradrenergic locus coeruleus flooding the olfactory bulb with norepinephrine to support the neural changes.
APPROACH RESPONSE … learned prenatally, reinforced both during the birth process and
repeatedly throughout the postnatal period,
… supported by a unique neural framework … a system that ensures rapid and robust maternal odor learning
SMELL vanilla / colostrum / water (control)
read NIRS activity FRONTAL LOBE
• This was confirmed by
demonstration of a statistically
significant negative correlation
between changes in [Hb O2] and
postnatal age (r 520.64, p 5 0.001
with 95% confidence interval) (Fig.
4). Those babies showing the
greatest increase in [Hb O2] were
between 6 and 24 h old at testing
• In the 14 babies older than 24 h
there was no significant difference
between the changes in [Hb O2]
during control and colostrum
exposure
APPROACH RESPONSE
In the 14 babies
older than 24 h
there was
no significant
difference
between the
changes in [Hb
O2] during control
and colostrum
exposure
Those babies
showing the
greatest
increase in
[Hb O2] were
between 6 and
24 h old at
testing
The first hours after birth are a
CRITICAL PERIOD
9 steps“Skin-to-skin contact” is the salient stimulus for infant-parent behavior.
9
“The newborn may appear
helpless, but
raises its own temperature,has a higher blood glucose,metabolic adaptation faster.
(Widstrom 1987)
METABOLIC ADAPTATION
SSC started in the first 20 minutes after birth
SSC CotBlood glucose (1 hr) 3.17 2.56Base excess drop 3.4 1.8
(Christenson 1992)
Images courtesy of Prof Peter Hartmann, UWA
Warming, feeding and
protection behaviours areintricately, inseparablylinked to the right place.
(Alberts 1994)
The BOND is made up of the
sensory inputs from the parent to the infant
REGULATION
Bowlby 1969, 1973, 1980
Through “hidden maternal regulators” ...
warmth activity levelmilk heart rate
“ physiological set points “internal working modelsscripts – templates
10
a mother precisely controls everyelement of her infant’s physiology,
from its heart rate to its release of hormones
from its appetite to the intensity of its activity
(Gallagher 1992)
Through “hidden maternal regulators” ... Through “hidden maternal regulators” ...
“ physiological set points “
“ internal working models’“ scripts – templates”
NEURODEVELOPMENT
The DNA Behaviour
EVOLUTIONARY BIOLOGY
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
The Neuroscience of Birth & BreastfeedingThe Brain
EPIGENETICS
BIRTH
BABY
BONDING
When does the infant
become conscious?
Scientific American 1986
Scientific American Mind 2009
Noradrenergic neurons from
LOCUS COERULEUS
may activate the whole brain during wakefulness
Awake at birth
AWAKE ON OFF ASLEEP
You can never reach the same highlevels of catecholamine levels
during your whole life as at birth
11
Reduced catecholamine surge after C-section
Why?
Vaginal delivery Elective C-section
AT BIRTH,
the brain has TWO CRITICAL SENSORY NEEDS:
SMELL & CONTACTconnect direct to the amygdala
THE NEWBORN
BRAIN
SKIN-TO-SKINCONTACT
fires and wires
the amygdala-prefronto-orbital cortical pathway (PFOC)
AMYGDALA:EmotionalProcessingUnit CPU
Prefrontal cortexExecutive
function
SOCIAL and EMOTIONAL
INTELLIGENCE
SOCIAL EMOTIONALINTELLIGENCE INTELLIGENCE
Behavioural activation systemreward-based(dopamine)
12
In humans, oxytocin increases gaze to the
eye region of human faces and enhances
interpersonal trust and the ability to infer
the emotions of others from facial cues.
Interpersonal awareness
Emotions
Kerstin
Uvnas-Moberg
Ross 2009
OXYTOCIN
Simulation theory:EMPATHY is generated by inner imitationof actions of others
The newborn can imitate –Mirror neurons
Courtesy from
Andrew Meltzoff'sexperiments on
Neonates' imitation
13
Morphing emotion AMYGDALA FUSIFORMGYRUS
Smell
Skin contact
A primary visual areas,
B somatosensory motor cortex
C primary auditorycortex
D parietal cortex & cerebellum
E m l anterior pre-frontal cortex
Fransson 2007
Smell
Skin contact
EMOTIONCONTROL CENTRE
FACE RECOGNITIONCENTRE
OXYTOCIN
E prefrontal
A primary visual
B somatosensory
C primary auditory
D parietal& cerebellum
key biological systems … that contribute to maternal caregiving behaviour … the oxytocinergic and dopaminergic systems.
… dopamine pathways contribute to the processing of infant-related sensory cues leading to a behavioural response. c
… infant cues - suckling, vocalisation and tactile stimulation - stimulate
OXYTOCINrelease in the hypothalamus, which may result in the activation of the dopaminergic reward pathway leading to behavioural reinforcement
14
FEARCONTROL
CENTRE
REWARDCONTROL
CENTRE
SOCIALCONTROL CENTRE
OXYTOCINDOPAMINE
CORTISOL
EMOTIONCONTROL CENTRE
HIGHLY CONSERVED NEURO-ENDOCRINE
BEHAVIOR
EMOTIONCONTROL CENTRE
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
CONCLUSIONSScientific findings do not support the perceived benefits of permanent, preweaningmother–infant separation.
PR - Peer Reared
MR – Mother Reared
Plasma CORTISOL response to STRESS (2y)
PR - Peer Reared
MR – Mother Reared
Plasma CORTISOL response to STRESS (2y)
RESILIENCE:“capacity to maintain
healthy emotional functioning in the after-
math of stressful experiences”
DISEASEHEALTH MR PR
15
RESILIENCE(= STRESS RESISTANCE)
“capacity to maintain healthy emotional functioning in the after-math of stressful experiences”
EMOTIONCONTROL CENTRE
HIGHLY CONSERVED NEURO-ENDOCRINE
BEHAVIOR
EMOTIONCONTROL CENTRE Garner 2011
Positive Stress
• Moderate, short-lived stress responses, such
as brief increases in heart rate or mild changes
in stress hormone levels.
Slide by: Jack P. Shonkoff, M.D.
Bad
Good
• An important and necessary
aspect of healthy development
that occurs in the context of
stable and supportive relationships.
High
StressLow
Stress
Tolerable Stress
• 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.
Slide by: Jack P. Shonkoff, M.D.
Toxic Stress
• 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.
Slide by: Jack P. Shonkoff, M.D. CORTISOL
16
NEURODEVELOPMENT
The DNA Behaviour
EVOLUTIONARY BIOLOGY
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
The Neuroscience of Birth & BreastfeedingThe Brain
EPIGENETICS
BIRTH
SEPARATIONBABY
Toxic stress
• 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.
CORTISOL
SEPARATION DYSREGULATES
CORTISOL
CORTISOL
MICHAEL MEANEY epigenetics
CORTISOL
Unsafe environment activates HPAaxis (autonomic nervous system, ANS).
Psychobiology
and molecular
genetics of
resilience
Adriana Feder*, Eric
J. Nestler‡, and
Dennis S. Charney‡ Nat Rev Neurosci. 2009 June ; 10(6): 446–457. doi:10.1038/nrn2649
HG BABY HG BABYLOW Grooming care
HG - High Grooming Low Grooming LG
HG BABY LG BABY
MOTHER MOTHER
Healthy UNHEALTHYadult adult
HG – High Grooming Low Grooming - LG
Makes MOTHER Makes MOTHER
UNHEALTHYadult
LOW Grooming LG
Makes MOTHER
CORTISOL
17
LG BABY LG BABYHIGH grooming care
HG - High Grooming Low Grooming LG
HG BABY LG BABY
MOTHER MOTHER
Healthy UNHEALTHYadult adult
HG – High Grooming Low Grooming - LG
Makes MOTHER Makes MOTHER
HEALTHYadult
HIGH Grooming HG
Makes MOTHER OXYTOCIN
HG – High Grooming Low Grooming - LG
Makes MOTHER Makes MOTHER
HEALTHYadult
HIGH Grooming HG
Makes MOTHER
Earliest care at birth matters
Same gene switched
LG BABY LG BABYHIGH grooming care
OXYTOCIN
NEURODEVELOPMENT
The DNA Behaviour
EVOLUTIONARY BIOLOGY
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
The Neuroscience of Birth & BreastfeedingThe Brain
EPIGENETICS
BIRTH
BABY
BONDING
SEPARATION
Toxic stress
OXYTOCIN CORTISOL
Primate separation studies
Maternal Separation ParadigmEarly Deprivation (ED) vs control (CON)
0d 2d 28d 48wED n 11 Mat 30 -120 min daily
CON n 4 Mat 48w
Repeated shortseparations:
LOW gene expression
Correlate to human adult depression
18
Adults with depression, suicides:LOW gene expression
smalller hippocampal volumereduced expression frontal lobe
2ND
KNOCK
Adults with depression, suicides:LOW gene expression
smalller hippocampal volumereduced expression frontal lobe
These findings translate previous results from rats / monkeys to humans
Sabatini
Arabadzisz
Nelson &
Panksepp 1998
SAFE UNSAFE
RESPONSESTRESS
ALLOSTASIS ANY STRESS:PsychologicalNeurological
EndocrineImmune
EMOTIONCONTROL CENTRE
19
PERCEPTIONS“NEUROCEPTION”
RESPONSESTRESS
ALLOSTATIC STATE
ALLOSTASIS ANY STRESS:PsychologicalNeurological
EndocrineImmune
HEALTH
elevated activity of mediators,
with return to baseline and no impact on
health.
RESISTANCE / SENSITIVITY
PERCEPTIONS“NEUROCEPTION”
RESPONSESTRESS
ALLOSTATIC STATE
ALLOSTASIS ANY STRESS:PsychologicalNeurological
EndocrineImmune
ALLOSTATIC LOAD
HEALTH
elevated activity –sustained over time,
or severe … changes the “set
points” for homeostasis(e.g. increasing blood pressure,
change in cholesterol level)
CORTISOL
http://www.imr.no/copewell/work_packages/wp3/en
CORTISOL
RESISTANCE / SENSITIVITY
PERCEPTIONS“NEUROCEPTION”
RESPONSESTRESS
ALLOSTATIC STATE
ALLOSTASIS ANY STRESS:PsychologicalNeurological
EndocrineImmune
ALLOSTATIC LOAD
ALLOSTATIC OVERLOAD
HEALTH
the point at which chronic load results in actual
disease or abnormal conditions.
2ND
KNOCK
RESISTANCE / SENSITIVITY
PERCEPTIONS“NEUROCEPTION”
RESPONSESTRESS
ALLOSTATIC STATE
ALLOSTASIS ANY STRESS:PsychologicalNeurological
EndocrineImmune
ALLOSTATIC LOAD
ALLOSTATIC OVERLOAD
WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY
DISEASEHEALTH
RESILIENCE VULNERABILITY
20
DISEASEHEALTH
WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY
RESILIENCE VULNERABILITY
RESILIENCE(= STRESS RESISTANCE)
“capacity to maintain healthy emotional functioning in the after-math of stressful experiences”
DISEASEHEALTH
CORTISOLOXYTOCIN
DISEASEHEALTH
CORTISOLOXYTOCIN
Nat Rev Neurosci. 2009 June ; 10(6): 446–457. doi:10.1038/nrn2649
OXYTOCINCORTISOL
This maternal carewas NOT abusive,just sub-standard.
This care isbasicallyskin-to-skin contact.
Nat Rev Neurosci. 2009 June ; 10(6): 446–457. doi:10.1038/nrn2649
OXYTOCINCORTISOL
This maternal carewas NOT abusive,just sub-standard.
This care isbasicallyskin-to-skin contact.
key biological systems … that contribute to maternal caregiving behaviour … the oxytocinergic and dopaminergic systems.
DISEASEHEALTH
CORTISOLOXYTOCIN
DISEASEHEALTH
CORTISOLOXYTOCIN
21
FEARCONTROL
CENTRE
REWARDCONTROL
CENTRE
SOCIALCONTROL CENTRE
OXYTOCINDOPAMINE
CORTISOL
EMOTIONCONTROL CENTRE
FEARCONTROL
CENTRE
REWARDCONTROL
CENTRE
SOCIALCONTROL CENTRE
OXYTOCINDOPAMINE
CORTISOL
EMOTIONCONTROL CENTRE
WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY
DISEASEHEALTH
RESILIENCE VULNERABILITY
… there is considerable overlap in the brain structures associated with these neural mechanisms … functional interactions among the circuits.
FEARCONTROL
CENTRE
REWARDCONTROL
CENTRE
SOCIALCONTROL CENTRE
OXYTOCINDOPAMINE
CORTISOL
EMOTIONCONTROL CENTRE
WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY
DISEASEHEALTH
RESILIENCE VULNERABILITY
An overly responsive fear circuit … may negatively influence functioning of the reward system.
… a properly functioning reward circuit may be necessary for …positive social behaviors.
RESILIENCE(= STRESS RESISTANCE)
“capacity to maintain healthy emotional functioning in the after-math of stressful experiences”
EMOTIONCONTROL CENTRE
HIGHLY CONSERVED NEURO-ENDOCRINE
BEHAVIOR
EMOTIONCONTROL CENTRE
PARADIGM CONSTRUCT
Paradigm has internalIntelligenceHonestyIntegrity
Consistency
FOUNDATION / PLATFORM / BASE
BASIC ASSUMPTION:
= INFANT SLEEPS ALONE
PARADIGM CONSTRUCT
Paradigm has internalIntelligenceHonestyIntegrity
Consistency
FOUNDATION / PLATFORM / BASE
BASIC ASSUMPTION:
= INFANT SLEEPS ALONE
MATERNAL-INFANTSEPARATION
HAS NO SCIENTIFIC
FOUNDATION.
KANGAROO MOTHER CARE:RESTORING THE ORIGINAL PARADIGM
22
WHAT IS
K M C ??
Kangaroo Mother Care:Restoring the Original
Paradigm for Infant CareToxic Stress
• 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.
Slide by: Jack P. Shonkoff, M.D. CORTISOL
“buffering protection
of adult support”
100%
MATERNAL DEPENDENCE
0 10 20 30 40w 1y 3 5 7 9 13 23 53
Birth Puberty
MATERNAL D
EPENDENCE
100%
MATERNAL DEPENDENCE
0 10 20 30 40w 1y 3 5 7 9 13 23 53
Birth Puberty
MATERNAL D
EPENDENCE
100%
MATERNAL DEPENDENCEPREMATURITY
Toxic Stress
• 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.
Slide by: Jack P. Shonkoff, M.D. CORTISOL0 10 20 30 40w 1y 3 5 7 9 13 23 53
Birth Puberty
MATERNAL D
EPENDENCE
100%
MATERNAL DEPENDENCEPREMATURITY
DEPRIVATION
SENSORY
SOCIAL
STIMULATION
BASIC
BIOLOGICAL
NEEDS
23
0 10 20 30 40w 1y 3 5 7 9 13 23 53
Birth Puberty
MATERNAL D
EPENDENCE
100%
MATERNAL DEPENDENCEPREMATURITY
KC (Kangaroo Care)
Mother-infant skin-to-skin contact after extremely preterm birth results in
neither benefit nor adverse consequences.Although there is no reason to dissuade mothers who wish to provide STS contact, we are unable to recommend resource allocation for the implementation of STS programmes for extremely preterm infants in a neonatal intensive care unit setting.
Miles et al 2006
THE NEUROSCIENCEOF KANGAROO CARE
0 10 20 30 40w 1y 3 5 7 9 13 23 53
Birth Puberty
MATERNAL
DEPE
NDENCE
100%
MATERNAL DEPENDENCEPREMATURITY
KC (Kangaroo Care)KC (Kangaroo Care)
TOO LITTLE,TOO LATE ..
Miles et al 20060 10 20 30 40w 1y 3 5 7 9 13 23 53
Birth Puberty
MATERNAL D
EPENDENCE
100%
MATERNAL DEPENDENCEPREMATURITY
KC (Kangaroo Care)
KMC (Kangaroo Mother Care)
KANGAROO MOTHER CARE:
KMC (in the world) –Skin-to-skin contact
WHEN STABLE !!!Exclusive breastfeedingTechnical support added(Early discharge – followup) 0 10 20 30 40w 1y 3 5 7 9 13 23 53
Birth Puberty
MATERNAL D
EPENDENCE
100%
MATERNAL DEPENDENCE
BSSC Birth (or Immediate)Skin-to-Skin Contact
GOOD &QUALITY
SURVIVAL
24
“Non-pharmacological reduction of
hypercortisolaemia in preterm infants”(Modi & Glover 1998, Mooncey et al 1997)
Preterm infants experience prolonged severe stresswith tenfold increases in stress hormones.
Stress hormones at such levels are neurotoxic.
RCT on methods to reduce of stress (at one hour):
Cortisol EndorphinMassage slightly lower no change
Soft music no change no change
Skin-to-skin 66% lower 74% lower
SEPARATION CORTISOL
OXYTOCIN
SEPARATION CORTISOL
SKIN-TO-SKINCONTACT
OPPOSITES
CARE CONTACT
WHO def’nKMC
K position
K nutrition
K discharge
USA use:
KC
NINOuse:
SSC
Moore 2012
G x E
NEURODEVELOPMENT
The DNA Behaviour
EVOLUTIONARY BIOLOGY
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
The Neuroscience of Birth & BreastfeedingThe Brain
EPIGENETICS
BIRTH
BABY
BONDING
SEPARATION
MATERNAL DEPENDENCE
MATERNAL SEPARATION
HABITAT
MOTHER
OTHER
MATERNAL DEPENDENCEHABITAT
MATERNALMOTHER
OTHERALTERNATE
AM I SAFE HERE ??
THE THE ““OLDOLD”” BRAIN HAS BRAIN HAS
3 PROGRAMMES3 PROGRAMMES
DEFENCE NUTRITION REPRODUCTION
25
SKIN-TO-SKIN CONTACT
SEPARATION
BREAST- VAGALMOTHER FEEDING (PSNS) GROWTH
OTHER PROTEST- STRESS SURVIVAL orDESPAIR (SNS)
THE PLACE MODELSKIN-TO-SKIN CONTACT
SEPARATION
BREAST- VAGALMOTHER FEEDING (PSNS) GROWTH
OTHER PROTEST- STRESS SURVIVAL orDESPAIR (SNS)
THE PLACE MODEL
R
Research funded byTHRASHER RESEARCH FUND, U.S.A.
Admin and stats byMEDICAL RESEARCH COUNCIL, R.S.A.
SKIN-TO-SKIN CONTACTFROM BIRTH
COMPARED TO CONVENTIONAL INCUBATOR CARE
Reference
RCT of skin-to-skin contact from birth versus conventional incubator care for physiological stabilisation in 1200- and 2199-gram newborns.
Bergman NJ, Linley LL, Fawcus SR.
Acta Paediatrica 2004 Vol 93(6); 779-785
Primary hypothesis
SSC (skin-to-skin contact) from birth is superior to incubator care for low birthweight infants
ONLY HABITAT DIFFERS
ResultsMinimisation techniqueensured groups balanced
for confounders.
( n = 34) KMC CMCMean weight 1813g 1866gMean GA 34.2w 35.3wApprop’ GA 65% 64%Male 60% 50%
(p 783)
RControl
Intervention
26
Research hypotheses
Stabilising
DURING 6h
Stabilised
AT 6 hours
BAILOUT H1a H1b
SCRIP H2a H2b
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) Bergman et al 2004
INSTABILITY
H1b (SPECIFIC)
Doctor Stablesummoned: .
INCUBATOR 92% 8% SKIN-TO-SKIN 17% 83%
Bergman et al 2004
BREAST- VAGALMOTHER FEEDING (PSNS) GROWTH
OTHERPROTEST- STRESS SURVIVAL orDESPAIR (SNS)
SKIN-TO-SKIN CONTACT
SEPARATION
THE PLACE MODEL
8% “STABLE”
83% “STABLE”
SCRIPSCORE
2 1 0
Heart rate Regular Deceleration to 80-100
Rate <80 or >200 bpm
Respiratory rate
Regular Apnoea <10s, or periodic breathing
Apnoea >10sTachypnoea
>80 pm
Oxygen saturation
Regular >87% Any fall to 80 – 87%
Any fall below 80%
“Stability of Cardio-Respiratory system In Preterm Infants”
Score allocated for a five minute period ofcontinuous observation, maximum six for period
Fischer et al, 1988 STABILITY
DASH 3000 monitorscontinuously
SCRIP
Heart rate
Oxygen saturation
Respiratory rate
27
BREAST- VAGALMOTHER FEEDING (PSNS) GROWTH
OTHERPROTEST- STRESS SURVIVAL orDESPAIR (SNS)
SKIN-TO-SKIN CONTACT
SEPARATION
THE PLACE MODEL
46% STABLE
100% STABLE
“100% SCRIP STABILIY”
S S C C M C
1200g to
2200 g1 - 6h 56% 11%
@ 6h 100% 46%
1200g to
1800g1 - 6h 44% 0%
@ 6h 100% 25%
Stabilisation first 6 hours, average hourly SCRIP score
5.1
5.2
5.3
5.4
5.5
5.6
5.7
5.8
5.9
6
6.1
2nd 3rd 4th 5th 6th
KMC all
KMC <1800
CMC all
CMC <1800
Hourly average of SCRIP score, 2nd to 6th hour
Stabilization 1200g – 1800g
Skin-to-skin
Incubator
INCUBATORS DE-STABILISE
NEWBORNSStabilisation first 6 hours, average hourly SCRIP score
5.1
5.2
5.3
5.4
5.5
5.6
5.7
5.8
5.9
6
6.1
2nd 3rd 4th 5th 6th
KMC all
KMC <1800
CMC all
CMC <1800
SKIN-TO-SKIN
SEPARATION
BREAST- VAGALMOTHER FEEDING (PSNS) GROWTH
OTHER PROTEST- STRESS SURVIVAL orDESPAIR (SNS)
Stabilization
Stabilisation first 6 hours, average hourly SCRIP score
5.1
5.2
5.3
5.4
5.5
5.6
5.7
5.8
5.9
6
6.1
2nd 3rd 4th 5th 6th
KMC all
KMC <1800
CMC all
CMC <1800
Bergman et al 2004 CORTISOL
BREAST- VAGALMOTHER FEEDING (PSNS) GROWTH
OTHERPROTEST- STRESS SURVIVAL orDESPAIR (SNS)
SKIN-TO-SKIN CONTACT
SEPARATION
THE PLACE MODEL
DYS-REGULATION
STABILISATION
CORTISOL
28
PROTEST – DESPAIRcauses
DYSREGULATION
SEPARATION DYSREGULATES
CORTISOL
Nelson &
Panksepp 1998
SAFE UNSAFE
OXYTOCIN
CORTISOL
Premature babies are not in incubators because they are unstable.
Premature babies are unstable because they are in incubators.
H1b (SPECIFIC)
DoctorDoctor StableStablesummoned:summoned: .
INCUBATORINCUBATOR 92% 92% 8% 8% SKINSKIN--TOTO--SKINSKIN 17%17% 83%83%
Bergman et al 2004
REGULATION vs STIMULATION
Expected vs UnexpectedEcologic salience vs Potential threatResource growth vs threat readiness
OXYTOCIN vs CORTISOL HOMEORHESIS vs HOMEOSTASIS
MOTHER vs OTHER
Our NORMAL biology
Skin-to-skin
contact
IS MORE
essential for
premature
newborns!
Our NORMAL biology
29
NEURODEVELOPMENT
The DNA Behaviour
EVOLUTIONARY BIOLOGY
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
The Neuroscience of Birth & BreastfeedingThe Brain
EPIGENETICS
intricately, inseparablylinked to the right place.
(Alberts 1994)
CORTISOL
Maternal absence causesneonatal instability.
Maternal presence (SSC)regulates preterm physiology.
Clinics in Perinatology,
June 2004, Vol 31(2) page 210
Stanley Graven
Early neurosensory visual
development of fetus and newborn.
“It is a serious mistake to assume that the
principles derived from careful animal studies
do not apply to human infants.
The risk of suppression or disruption of
needed neural processes ...
is very significant and potentially lasts a life time.
NEURODEVELOPMENT
The DNA Behaviour
EVOLUTIONARY BIOLOGY
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
The Neuroscience of Birth & BreastfeedingThe Brain
EPIGENETICS
BIRTH
BABY
BONDING
“needed
neural
processes”
PARADIGM CONSTRUCT
Paradigm: “in the philosophy of science, a generally accepted model of how ideas relate to one another,
forming a conceptual framework
within which scientific research is carried out”
MSN Encarta
FOUNDATION / PLATFORM / BASE
BASIC ASSUMPTION:
= INCUBATORS STABILIZE
PARADIGM CONSTRUCT
Paradigm: “in the philosophy of science, a generally accepted model of how ideas relate to one another,
forming a conceptual framework
within which scientific research is carried out”
MSN Encarta
FOUNDATION / PLATFORM / BASE
BASIC ASSUMPTION:
= INCUBATORS STABILIZE
INCUBATORS DE-STABILISE
NEWBORNSStabilisation first 6 hours, average hourly SCRIP score
5.1
5.2
5.3
5.4
5.5
5.6
5.7
5.8
5.9
6
6.1
2nd 3rd 4th 5th 6th
KMC all
KMC <1800
CMC all
CMC <1800
30
PARADIGM CONSTRUCT
Paradigm: “in the philosophy of science, a generally accepted model of how ideas relate to one another,
forming a conceptual framework
within which scientific research is carried out”
MSN Encarta
FOUNDATION / PLATFORM / BASE
BASIC ASSUMPTION:
= INCUBATORS STABILIZE
THEINCUBATOR
HAS NO EVIDENCE BASE !!
KANGAROO MOTHER CARE:RESTORING THE ORIGINAL PARADIGM
SO WHERE
TO NOW ??
Kangaroo Mother Care:Restoring the Original
Paradigm for Infant Care
NEURODEVELOPMENT
The DNA Behaviour
EVOLUTIONARY BIOLOGY
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
The Neuroscience of Birth & BreastfeedingThe Brain
EPIGENETICS
BIRTH
BEYOND BREASTFEEDINGFeed Sleep Cycling
BABY
BONDING
Secure attachment
SEES
Mum’s eyes
Hand TOUCH
Mum’s skin
Skin-to-skin
CONTACT
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
NEURODEVELOPMENT
The DNA Behaviour
EVOLUTIONARY BIOLOGY
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
The Neuroscience of Birth & BreastfeedingThe Brain
EPIGENETICS
BIRTH
BEYOND BREASTFEEDINGFeed Sleep Cycling
BABY
BONDING
Secure attachment
NEURODEVELOPMENT
The DNA Behaviour
EVOLUTIONARY BIOLOGY
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
The Neuroscience of Birth & BreastfeedingThe Brain
EPIGENETICS
BIRTH
BEYOND BREASTFEEDINGFeed Sleep Cycling
BABY
BONDING
Secure attachment
31
John Bowlbysecure attachment
“a safe base from which to explore the world”.
Safe HavenSecure baseProximity
maintenanceSeparation
distress
BONDING components
EmotionalANS
Social
Physical
BONDING consequence
EmotionalANS
Social
Physical
Child: Insecureattachment
Adult: AttachmentANXIETY to partner
Adult: Higher CORTISOL andlower immunity
(CD4 cells) Jaremka 2013
CORTISOL
NEURODEVELOPMENT
The DNA Behaviour
EVOLUTIONARY BIOLOGY
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
The Neuroscience of Birth & BreastfeedingThe Brain
EPIGENETICS
BIRTH
BEYOND BREASTFEEDINGFeed Sleep Cycling
MOTHERBABY
BONDING Sensitization
Secure attachment
Attuned parenting
SEPARATION
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.”
a mother’s brain …
SENSITIZATION
32
DISEASEHEALTH
CORTISOLOXYTOCIN
NEURODEVELOPMENT
The DNA Behaviour
EVOLUTIONARY BIOLOGY
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
The Neuroscience of Birth & BreastfeedingThe Brain
EPIGENETICS
BIRTH
BEYOND BREASTFEEDINGFeed Sleep Cycling
MOTHERBABY
BONDING Sensitization
Secure attachment
Attuned parenting
SEPARATION
Resilience
RESILIENCE(= STRESS RESISTANCE)
“capacity to maintain healthy emotional functioning in the after-math of stressful experiences”
Resilience
Secure attachment
Attuned parenting
PR - Peer Reared
MR – Mother Reared
Plasma CORTISOL response to STRESS (2y)
RESILIENCE:“capacity to maintain
healthy emotional functioning in the after-
math of stressful experiences”
DISEASEHEALTH MR PR
CORTISOLOXYTOCIN
NEURODEVELOPMENT
The DNA Behaviour
EVOLUTIONARY BIOLOGY
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
The Neuroscience of Birth & BreastfeedingThe Brain
EPIGENETICS
BIRTH
BEYOND BREASTFEEDINGFeed Sleep Cycling
SEPARATIONMOTHERBABY
BONDING Sensitization
Secure attachment
Attuned parenting
Disordered attachment
Toxic stress
Insensitiveparenting
Resilience Vulnerability
CORTISOLOXYTOCIN
NEURODEVELOPMENT
The DNA Behaviour
EVOLUTIONARY BIOLOGY
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
The Neuroscience of Birth & BreastfeedingThe Brain
EPIGENETICS
BIRTH
BEYOND BREASTFEEDINGFeed Sleep Cycling
SEPARATIONMOTHERBABY
BONDING Sensitization
Secure attachment
Attuned parenting
Resilience Vulnerability
DISEASEHEALTH
Disordered attachment
Toxic stress
Insensitiveparenting
33
BIRTH
BEYOND BREASTFEEDINGFeed Sleep Cycling
SEPARATIONMOTHERBABY
BONDING Sensitization
Secure attachment
Attuned parenting
Resilience Vulnerability
DISEASEHEALTH
Disordered attachment
Toxic stress
Insensitiveparenting
Kangaroo Mother Care:Restoring the Original
Paradigm for Infant Care
“buffering
protection of
adult support”
NEURODEVELOPMENT
The DNA Behaviour
EVOLUTIONARY BIOLOGY
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
The Neuroscience of Birth & BreastfeedingThe Brain
EPIGENETICS
BIRTH
SEPARATIONMOTHERBABY
BONDING Sensitization
Vulnerability
DISEASE
Disordered attachment
Toxic stress
Insensitiveparenting
NEURODEVELOPMENT
The DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth & BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
buffering protection
of adult support”
“Absence of the
buffering protection
of adult support”
“Absence of the
The Neuroscience of Birth & Breastfeeding
Do not measure how much skin-to-skin contact you are doing.Measure minutes of separation Your dose of TOXIC STRESS
NEURODEVELOPMENT
The DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth & BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
buffering protection
of adult support”
“Absence of the
NEURODEVELOPMENT
The DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth & BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
“needed neural
processes”
34
NEURODEVELOPMENT
The DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth & BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
“except in the light
of mother’s body.”
ZERO
SEPARATION
NEURODEVELOPMENT
The DNA Behaviour
EVOLUTIONARY BIOLOGY
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
The Neuroscience of Birth & BreastfeedingThe Brain
EPIGENETICS
BIRTH
SEPARATIONMOTHERBABY
BONDING Sensitization
Disordered attachment
Toxic stress
Insensitiveparenting
ZERO
SEPARATION
NEURODEVELOPMENT
The DNA Behaviour
EVOLUTIONARY BIOLOGY
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
The Neuroscience of Birth & BreastfeedingThe Brain
EPIGENETICS
BIRTH
SEPARATIONMOTHERBABY
BONDING Sensitization
Disordered attachment
Toxic stress
Insensitiveparenting
BREASTFEEDINGFeed Sleep Cycling
www.ninobirth.orgwww.skintoskincontact.com
THE NEUROSCIENCE OFSKIN-TO-SKIN CONTACT
AND BREASTFEEDING
ARE THE SAME !
http://www.independent.ie/irish-news/health/ireland-has-worlds-lowest-rate-for-
breastfeeding-30912066.html
35
http://www.irishtimes.com/life-and-style/health-family/why-don-t-irish-women-breastfeed-1.2090973
babies
BREASTFEEDING IS A BEHAVIOUR OF THE NEWBORN
… because we separate them …
BIRTH
SEPARATIONMOTHERBABY
BONDING Sensitization
Disordered attachment
Toxic stress
Insensitiveparenting
BREASTFEEDINGFeed Sleep Cycling
babies
Skin-to-skin and breastfeeding (4)
0
10
20
30
40
50
60
70
80
90
100
3Q05 4Q05 1Q06 2Q06 3Q06 4Q06 1Q07 2Q07
Breastfeeding intention Skin-to-skin one hour Breastfeeding at discharge
Used with permission: Ruth Stanhiser, MD
Babies breastfeeding
Mothers intending to breastfeed
More skin-to-skin more breastfeeding
BREASTFEEDING IS A BEHAVIOUR OF THE NEWBORN
Kangaroo Mother Care:Restoring the Original
Paradigm for Infant Care
JUST DO ITZERO
SEPARATION
START @ BIRTH
ZERO
SEPARATION
Premature birth
The GOLDEN HOUR
Being flexible, willing to question routines
36
Triplets … requires a team
FAMILY CENTERED CARE DO IT LITERALLY !!
Positive effect on breastfeeding
From the resuscitation room to the delivery room
In the delivery room showing
the boy before going to the NICU
From the delivery room
just entering the NICU
Perinatal neuroscience and neonatal care: the new science of being born.
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
SEPARATION
Vulnerability
DISEASE
Disordered attachment
Toxic stress
Insensitiveparenting
SEPARATION
VIOLATESthe innate agendaof mother and baby
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
BIRTH
BEYOND BREASTFEEDINGFeed Sleep Cycling
MOTHERBABY
BONDING Sensitization
Secure attachment
Attuned parenting
Resilience
HEALTH
A mother and baby
DYADare asingle
psychoneurobiologicalorganism
BIRTH BONDING Sensitization Toxic stress
IT MATTERS
HOW WE ARE BORN
Nelson Mandela
… in describing themeasure of a nation,
he has argued that:
“There can be no keener revelation of a society’s soul than the way in which it treats its children.”