ho a1 gr 130219 60m ssc pns into ebm rwh

1

Dr Nils Bergman

MB ChB, DCH, MPH, MD

(USA equiv: MD, MPH ,PhD)

Cape Town, RSA

www.skintoskincontact.com

SKIN-TO-SKIN CONTACT – Making perinatal neuroscience into evidence based practice.

Speaker Disclosure Under ACCME guidelines:

a) I am the South African distributor of

MIRIS : Human Milk Analyzer

b) My wife markets educational materials and shirts related

to the talk content

Kangaroo Mother Care Promotions

SKIN-TO-SKIN CONTACT – Making perinatal neuroscience into evidence based practice.

“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

NEUROSCIENCE

The DNA Everything else

EVOLUTIONARY BIOLOGY

The Brain

EPIGENETICS

The Place ENVIRONMENT

EXPERIENCE FITNESS ADAPTATION

“Scientific foundation” … a synthesis

“except in the light of mother’s body.”

“EEA” Environment of Evolutionary Adaptedness



2

MOTHER is the key to

neurodevelopment … Environment of

Evolutionary Adaptedness

MOTHER is the key to

neurodevelopment …

… because she is the

RIGHT PLACE !!

NEUROSCIENCE






The Brain

EPIGENETICS

… because she is the

RIGHT PLACE !!

DEFENCE NUTRITION REPRODUCTION

HORMONES NERVES MUSCLES

endocrine autonomic NS somatic

HIGHLY CONSERVED NEURO-ENDOCRINE BEHAVIOR

“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 Cot Blood glucose (1 hr) 3.17 2.56 Base excess drop 3.4 1.8 (Christenson 1992)

3

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

NEUROSCIENCE






The Brain

EPIGENETICS

Kangaroo POSITION Kangaroo NUTRITION Kangaroo SUPPORT DISCHARGE



KANGAROO MOTHER CARE SKIN-TO-SKIN CONTACT

“Cells which

FIRE TOGETHER, WIRE TOGETHER, and those which don’t, won’t.” Carla Shatz

fetal REM sleep (or active sleep) seems to be particularly important to the developing organism

... spontaneous synchronous firing

Marks et al 1995

Panksepp 1998

Siegel 2005

Non-REM 4

4

REM NR1 NR2 NR3 NR4

ACQUISITION CONSOLIDATION MEMORY FORMATION poly-sensory input transfer information P waves short-term memory “SNR” strong signals returns info stored cortex amygdala / to neocortex: hippocampus organized Awake and REM NREM stage 4 REM

BRAIN WIRING

Stanley Graven 2006

BRAIN WIRING

Peirano 2003

When does

the infant

become

conscious? Noradrener-

gic neurons

from locus

coeruleus may

activate the

whole brain

during

wakefulness

Awake at birth

AT BIRTH, the brain has TWO CRITICAL SENSORY NEEDS:

SMELL & CONTACT connect direct to the amygdala

THE NEWBORN BRAIN SKIN-TO-SKIN CONTACT fires and wires the amygdala-prefronto-orbital cortical pathway (PFOC)

AMYGDALA: Emotional Processing Unit

Prefrontal cortex Executive function approach / avoid

5

AMYGDALA: Emotional Processing Unit CPU

Prefrontal cortex Executive function

SOCIAL and EMOTIONAL

INTELLIGENCE

SOCIAL EMOTIONAL INTELLIGENCE INTELLIGENCE

Behavioural activation system reward-based (dopamine)

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

6

Smell

Skin contact

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 level milk heart rate

“ physiological set points “ internal working models scripts – templates

7

a mother precisely controls every element 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” ...

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.

NEUROSCIENCE



The Brain

EPIGENETICS




“needed neural processes”

SEPARATION DYSREGULATES

CORTISOL

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 ” CORTISOL

8

HG BABY HG BABY LOW Grooming care

HG - High Grooming Low Grooming LG

HG BABY LG BABY

MOTHER MOTHER

Healthy UNHEALTHY adult adult

HG – High Grooming Low Grooming - LG

Makes MOTHER Makes MOTHER

UNHEALTHY adult

LOW Grooming LG

Makes MOTHER

CORTISOL

LG BABY LG BABY HIGH grooming care

HG - High Grooming Low Grooming LG

HG BABY LG BABY

MOTHER MOTHER

Healthy UNHEALTHY adult adult



HEALTHY adult

HIGH Grooming HG

Makes MOTHER



HEALTHY adult

HIGH Grooming HG

Makes MOTHER

Earliest care at birth matters

Same gene switched

LG BABY LG BABY HIGH grooming care

Primate separation studies

Maternal Separation Paradigm Early Deprivation (ED) vs control (CON) 0d 2d 28d 48w ED n 11 Mat 30 -120 min daily CON n 4 Mat 48w

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

CORTISOL

9

Allostasis the mechanism by which homeostatic systems are maintained in balance … Allostatic state elevated activity of mediators, with return to baseline and no impact on health.

Allostatic load elevated activity – sustained over time, or severe … changes target cells of mediators, and so changes the “set points” for homeostasis (e.g. increasing blood pressure, change in cholesterol level)

BRUCE McEWEN allostasis

RESILIENCE / SENSITIVITY

PERCEPTIONS “NEUROCEPTION”

RESPONSE STRESS

ALLOSTATIC STATE

ALLOSTASIS

Psychological Neurological

Endocrine Immune

HEALTH DISEASE

ALLOSTATIC LOAD

ALLOSTATIC OVERLOAD

WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY

NEUROSCIENCE





SPECTRUM of expression in POPULATION

HEALTH DISEASE


The Brain

EPIGENETICS

EXPECTED UNEXPECTED

NEUROSCIENCE






HEALTH DISEASE


Platform for better understanding of PUBLIC HEALTH. … policy and practice that impacts the care of mothers and babies.

The Brain

EPIGENETICS

EXPECTED UNEXPECTED

10

Positive Stress

• 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.

Slide by: Jack P. Shonkoff, M.D.

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.

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.

JACK SHONKOFF

“Buffering protection of adult support”

11

The basic

science of

pediatrics.

Shonkoff J P et al.

Pediatrics 2012;

129:e232-e246

©2012 by American Academy of Pediatrics

2 … advances in the biological sciences underscore the foundational

importance of the early years and support an EBD framework for understanding

the evolution of human health and disease across the life span.

EARLY YEARS LIFE SPAN

Learning Behavior Physical well being Mental well being

3. The biology of early childhood adversity reveals the important role of toxic

stress in disrupting developing brain architecture and adversely affecting the

concurrent development of other organ systems and regulatory functions.



TOXIC STRESS

EARLY LIFE ADVERSITY

4 Toxic stress can lead to potentially permanent changes in learning ( … ),

behavior ( … ), and physiology ( … ) and can cause … higher levels of stress

related chronic diseases, …increase the prevalence of unhealthy lifestyles that lead

to widening health disparities.



TOXIC STRESS


MAKES POORER Linguistic Cognitive Emotional Adaption

responsivity unhealthy lifestyle

Chronic disease health disparity

5. The lifelong costs of childhood toxic stress are enormous, … and

effective early childhood interventions provide critical opportunities

to prevent these undesirable outcomes and generate large economic

returns for all of society.



TOXIC STRESS





MASSIVE COST $$$$

6. The consequences of significant adversity early in life prompt an urgent call for

innovative strategies to reduce toxic stress within the

context of a coordinated system of policies and services guided by an

integrated science of early childhood and early brain development.



TOXIC STRESS





MASSIVE COST $$$$

REDUCE TOXIC STRESS

12



BERGMAN COMMENTARY – NEWBORN Early years = early hours & days



TOXIC STRESS


BERGMAN COMMENTARY – NEWBORN Maternal absence is TOXIC STRESS



TOXIC STRESS





BERGMAN COMMENTARY – NEWBORN For separated preterm newborns, we have decades of evidence for this.



TOXIC STRESS





MASSIVE COST $$$$

BERGMAN COMMENTARY – NEWBORN even more massive ??



TOXIC STRESS





MASSIVE COST $$$$

REDUCE TOXIC STRESS

BERGMAN COMMENTARY – NEWBORN Reducing toxic stress IS VERY EASY !!

Skin-to-Skin

Contact

Attachment

Bonding

Breast-feeding Regulation

13

An ecobiodevelopmental framework for early childhood policies and programs.

BERGMAN COMMENTARY – NEWBORN Reducing toxic stress IS VERY EASY !!

Attachment

Bonding

Breast-feeding

Skin-to-Skin

Contact

NEUROSCIENCE






EXPECTED UNEXPECTED

HEALTH DISEASE


Platform for better understanding of PUBLIC HEALTH. … policy and practice that impacts the care of mothers and babies.

The Brain

EPIGENETICS

NEUROSCIENCE



The Brain

EPIGENETICS




“buffering protection of adult support”

NEUROSCIENCE



The Brain

EPIGENETICS




“needed neural processes”

NEUROSCIENCE



The Brain

EPIGENETICS




“except in the light of mother’s body.”

NEUROSCIENCE



The Brain

EPIGENETICS




ZERO SEPARATION

14

EVOLUTIONARY BIOLOGY,

EPIGENETICS, NEUROSCIENCE

THE SCIENTIFIC AND EVIDENCE BASIS FOR

SKIN-TO-SKIN CONTACT

HABITAT MATERNAL MOTHER OTHER ALTERNATE

AM I SAFE HERE ??

MATERNAL DEPENDENCE

HABITAT NICHE BREAST- MOTHER FEEDING OTHER PROTEST- DESPAIR

SAFE ? YES

SAFE ? NO

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

SKIN-TO-SKIN CONTACT SEPARATION

THE PLACE MODEL

The PLACE MODEL

scientifically derived alternative approach falsifiable/testable hypothesis

PERINATAL NEUROSCIENCE & SKIN-TO-SKIN CONTACT

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

Bergman et al 2004

15

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

ONLY PLACE DIFFERS Bergman et al 2004

Results

Minimisation technique ensured groups balanced for confounders. ( n = 34) SSC CMC Mean weight 1813g 1866g Mean GA 34.2w 35.3w Approp’ GA 65% 64% Male 60% 50% (p 783)

Bergman et al 2004

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 Stable summoned: .

INCUBATOR 92% 8% SKIN-TO-SKIN 17% 83%

Bergman et al 2004



THE PLACE MODEL

8% “STABLE”

83% “STABLE”

SCRIP SCORE

2 1 0

Heart rate

Regular

Deceleration

to 80-100

Rate <80 or >200 bpm

Respiratory rate

Regular

Apnoea <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”

Score allocated for a five minute period of continuous observation, maximum six for period

Fischer et al, 1988 STABILITY

16

“100% SCRIP STABILIY”

S S C C M C

1200g to

2200 g 1 - 6h 56% 11%

@ 6h 100% 46%



THE PLACE MODEL

46% STABLE

100% STABLE

“100% SCRIP STABILIY”

S S C C M C

1200g to

2200 g 1 - 6h 56% 11%

@ 6h 100% 46%

1200g to

1800g 1 - 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



THE PLACE MODEL

DYS-REGULATION

STABILISATION

SEPARATION DYSREGULATES

CORTISOL

17

INCUBATORS DE-STABILISE

NEWBORNS 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

Premature babies are not in incubators because they are unstable. Premature babies are unstable because they are in incubators.

The Relation of Early Mother-Infant Skin-to-Skin Contact to Later Maternal Sensitivity in South African Mothers of Low Birth Weight Infants

Ann E. Bigelow, et al (in press IMHJ) From Bergman et al 2004 RCT SSC time first 24 hr correlated with SSC time first month.

0

5

10

15

20

25

-0.2 0 0.2 0.4 0.6 0.8 1

Maternal Behavior Q-Sort

Ho

urs

of

SS

C i

n I

nfa

nts

' F

irs

t 2

4 H

ou

rs

Maternal behaviour Q Sort Predicts attachment security

NCATS ( Nursing Child Assessment Teaching Scale ) Predicts subsequent cognitive outcome

0

5

10

15

20

25

25 27 29 31 33 35 37 39 41 43 45

Maternal Behavior Subscale of the NCATS

Ho

urs

of

SS

C i

n In

fan

ts' F

irst

24 H

ou

rs

A mother and baby DYAD

are a single psychoneurobiological

organism

18

BONDING (Bergman mini-model) Birth experience: Sensations hormonal changes neural circuits LIMBIC PLATFORM MATERNAL SENSITIVITY Early life experience: Neural circuits emotional & social intelligence CORTICO-LIMBIC CIRCUITRY

ATTACHMENT

BONDING

MATERNAL SENSITIVITY

… this suggests that VD mothers are more sensitive to own baby-cry than CSD mothers in the early postpartum in sensory processing, empathy, arousal, motivation, reward and habit-regulation circuits.

The results of this study show that

attending to own baby-cry evokes

a unique pattern of neural

responses in VD mothers as

compared to CSD mothers in the

early postpartum..

BONDING (Bergman mini-model) Birth experience: Sensations hormonal changes neural circuits LIMBIC PLATFORM MATERNAL SENSITIVITY Early life experience: Neural circuits emotional & social intelligence CORTICO-LIMBIC CIRCUITRY

ATTACHMENT

BONDING

SEPARATION

VIOLATES

THE INNATE AGENDA

OF MOTHER

AND NEWBORN

SSC 83% MIS 8%

NORMAL

Perceived HARM: NO YES

SSC 17% MIS 92%

19

PRIMUM NON NOCERE

TOXIC STRESS ??

HARM ?

evolutionary survival machine

ANS

HRV

EEG BAS autonomic upstream

autonomic MEDIATOR downstream

ANDERSON BEHAVIOURAL STATE SCALE

12

11 Crying

10 Fussing

9 Active

8 Breastfeeding

7 Alert Awake

6 Quiet Awake

5 Drowsy

4

3 Active Sleep

2 Irregular Sleep

1 Regular / Quiet Sleep

PLACE convention

4 Breastfeeding

3 Holding

2 MIS (Cot)

1 SSC (Skin-to-skin)

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

D V C

V V C

S N S

Skin-to-skin contact = *NORMAL* PLACE

Babies 2 days old SSC vs MIS, 1hr

Skin-to-skin contact = *NORMAL* PLACE

SEPARATE 176% Increase Autonomic activity

SEPARATE 86%

Decrease Quiet Sleep

20

SLEEP CYCLE - Neurodevelopment

Peirano 2003



Higher state arousal

Normal sleep cycling

Separated neonates experience disturbed sleep cycling: instead FREEZE & DISSOCIATION.

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.

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

NILS’ TRANSLATION:

MATERNAL SEPARATION IS TOXIC STRESS !!

NO


NEWBORNS

TRUE or FALSE ?

21


NEWBORNS

1. FALSE 2. 3.


NEWBORNS

1. FALSE 2. TRUE 3.


NEWBORNS

1. FALSE 2. TRUE 3. DON’T KNOW

www.skintoskincontact.com

INTRODUCTION

“It is easier to build strong children

than to repair broken men.” Frederick Douglass (1817–1895)

PERINATAL NEUROSCIENCE and SKIN-TO-SKIN CONTACT

ho a1 gr 130219 60m ssc pns into ebm rwh

Health & Medicine

newborn brain skin

right place

skin contact fires

skin contact cells

rem brain wiring stanley

evolutionary biology

brain wiring peirano

metabolic adaptation