kangaroo mother care: 1818 - 65 restoring the original ... kangaroo care slide .pdf · robert koch...

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Kangaroo Mother Care:Restoring the Original

Paradigm for Infant Care

THE SCIENTIFIC AND EVIDENCE BASE FOR

SKIN-TO-SKIN CONTACT

Ignaz SEMMELWEISS 1818 - 65


Hungarian obstetrician1840’s – Vienna 30% diedof puerperal fever –

Pushed handwashing, cleanliness & standards:Maternal death ratefrom 12% to 1% in 2 years

Ostracised by peers,Died insane

LOUIS PASTEUR 1822 - 95

Germ theory did NOT EXIST !

Was being researchedBetween 1860- 64, same decade Semmelweis died

ROBERT KOCH 1843 - 1910

TuberculosisAnthraxCholera

BACTERIOLOGY:Koch’s fourpostulates …

Semmelweis's observations

conflicted with the established

scientific and medical opinions

of the time and his ideas were

rejected by the medical

community.

Semmelweis could offer no

acceptable scientific

explanation for his findings ….


1 2

3 4

5 6

2

The Semmelweis reflex

… reflex-like tendency to reject new evidence

and knowledge because it

contradicts established beliefs, paradigms.

WHAT IS A

PARADIGM ??



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 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.

PARADIGM SHIFT !!

WHAT IS THECURRENT PARADIGMFOR INFANT CARE?



7 8

9 10

11 12

3

child helpless

OLD PARADIGM

Restoring the Original Paradigm for Infant Care

mother clueless

OLD PARADIGM


father useless

OLD PARADIGM


Stephane TARNIER 1828 -97

French obstetrician

Saw a warmed box forhatching chickens, hadone designed for “weaklings” …

… invented incubator

PARADIGM SOURCE

Pierre BUDIN 1846 - 1907 Pierre BUDIN 1846 - 1907

Friend of Tarniers …took Incubators, made centresfor the care of weaklings,wrote book on subject.

Political support …France versus Germany

BUDIN was very particular to includemother, reason for the glass window ….

13 14

15 16

17 18

4

Martin COUNEY 1860 - 1950

Born in Germany

claims he learnedthe techniques forBudin ....

Berlin Exhibition 1896, success !

Photograph: Pan-American Exhibition in Buffalo, New York, 1901.

Baby Incubator, 1904 St.Louis Fair


Berlin 1896, success

to USA: Buffalo →Omaha 1902-4,

Chicago Fair 1932 2nd highest receipts,Last show New York 1940.

New York Worlds Fair, 1939


... famous for “preemie road show”.

MONEY MAKING SHOW

PERMANENT pavilion in Dreamland


Born in Germany

claims he learnedthe techniques forBudin ....

Berlin Exhibition 1896, success !London World fair 1898, fiasco!

ALL THE BABIES DIED ....“MOTHERS TO BLAME”


Couney succesfullyraised 5000 prems!

BUT –used wet-nurses, excluded mothers

(mother got free pass to the shows !)

Mothers were excluded – “germs” …

19 20

21 22

23 24

5

Sarah Morris Hospital, Chicago 1923, others followed –

accepting the “policy of strict separation”.

Sarah Morris Hospital, Chicago 1923, others followed –

accepting the “policy of strict separation”.

SEPARATION

is a 20th century

PARADIGM

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 CONSTRUCTParadigm has internal

IntelligenceHonestyIntegrity

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”


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

25 26

27 28

29 30

6

• CIRCULAR

SCIENCE -

A SELF-

FULFILLING

PROPHECY

Culture Producing Science Producing Culture:

How A Folk Myth Achieved Scientific Validation


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”

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


BASIC ASSUMPTION:

= INCUBATORS STABILIZE

PARADIGM CONSTRUCT

Specifically, all the recommendations involving clinical medicine in a CME activity must be based on evidence

that is accepted within the professionof medicine as adequate justification

for their indications and contra-indications in the care of patients.


BASIC ASSUMPTION:

= INCUBATORS STABILIZE

… reflex-like tendency to reject new evidence and knowledge because


PARADIGM CONSTRUCT




Slide courtesy of Susie Ludington-Hoe

31 32

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7

Both babies and their parents may experience a stay in

the newborn intensive care unit (NICU) as a traumatic or

a ‘toxic stress,’ which can lead to dysregulation of the

hypothalamic–pituitary–adrenal axis and ultimately to

poorly controlled cortisol secretion.

… strongly linked to poor health outcomes

… trauma-informed care is an approach to caregiving

based on the recognition of this relationship.

STRESSES IN PREGNANT WOMEN

STRESSES IN NICU INFANTS

MODIFICATION OF THE STRESS RESPONSE THROUGH SOCIAL

CONNECTEDNESS

THE POLYVAGAL THEORY IN THE NICU

ADAPTATION OF PRINCIPLES OF TRAUMA-INFORMED CARE TO

THE NICU SETTING

TRAUMA-INFORMED CARE OF THE FAMILY AND BABY:

NEWBORN INTENSIVE PARENTING UNITS

PROACTIVE COMMUNICATION AND EDUCATIONAL STRATEGIES

PROVIDING TRAUMA-INFORMED SUPPORTS TO STAFF

CARING FOR PREGNANT WOMEN, NEW MOTHERS,

FAMILIES AND BABIES

PARADIGM CONSTRUCT










SEPARATION

is a 20th century

PARADIGM



1988 –1994

Origin of Immediate K M C

Drs Rey & Martinez1979 Bogota, Colombia

LATE K M C

1985 Andrew Whitelaw

1987Agneta JurisooBIRTH K M C

37 38

39 40

41 42

8

DEFINITION of KMC (1990)MANAMA, ZIMBABWE

# Skin-to-skin contactfrom birth, continuous

# Breastmilk from birth & exclusive breastfeeding

# Psychological supportto mother

KMC as above used regardless of weight and gestation.

KMC provides the baby with very intensive care.

KC (in the USA) - In-hospital skin-to-skin contact, any duration, primarily adjunct to CMC (Conventional Method of Care).

Hu

PERCENTAGE SURVIVAL BY BIRTH-WEIGHT

0

20

40

60

80

100

<1000g 1000g 1100g 1200g 1300g 1400g 1500g 1600g 1700g 1800g 1900g

Birth weight intervals

Pe

rce

nta

ge

su

rviv

ed

KMC babies Pre-KMC babies

Results - Manama

PERCENTAGE SURVIVAL BY GESTATIONAL AGE

0

20

40

60

80

100

28 29 30 31 32 33 34 35 36 37 38 39

Gestational age in weeks

Pe

rce

nta

ge

su

rviv

ed

KMC babies

Results - Manama Results – Manama

(Born 1000g to 1500g)

Survival before KMC 10%Survival with KMC 50%

(Stabilized in 6 hours)

Weight gain per day 30 g/dBreastfeeding rate 100%

43 44

45 46

47 48

9

Mortality 1000g-1500g pre KMC 90%

with KMC 50%

KMC = 40 % reduction in mortality

Pre-KMC10% survival

With KMC50% survival

INCLUDED UNSTABLE

Historical control

1994Is there an alternative

for premature infants ??

Is THIS an alternative

for premature infants ??





… baby’s condition MUST BE STABLE, … breathing without additional oxygen.

WHO, 2003

NEUROSCIENCE & EVIDENCE& SKIN-TO-SKIN CONTACT

1996 - 2003

The PLACE MODEL

→ scientifically derived → alternative approach → hypothesis falsifiable/testable


SEPARATION

BREAST- VAGALMOTHER FEEDING (PSNS) GROWTH

OTHER PROTEST- STRESS SURVIVAL DESPAIR (SNS)

THE PLACE MODELPLACE MODEL

DEFENCE

NUTRITION

NEUROSCIENCE & EVIDENCE& SKIN-TO-SKIN CONTACT

49 50

51 52

53 54

10

Dr Nils Bergman

MB ChB, DCH, MPH, MD

Cape Town, RSA

www.skintoskincontact.com

IMMEDIATE SKIN-TO-SKIN CONTACTthe primary ecology for mothering,

and also NICU care.

(from Greek: οἶκος, "house", or "environment"; -λογία, "study of")

IMMEDIATE SKIN-TO-SKIN CONTACTthe primary ecology for mothering,

and also NICU care.

MATERNAL DEPENDENCE

MATERNAL SEPARATION

HABITAT

MOTHER

OTHER

HABITAT

MATERNALMOTHER

OTHERALTERNATE

There are only these two habitat choices available

THE THE ““OLDOLD”” BRAIN HAS BRAIN HAS

3 PROGRAMMES3 PROGRAMMES

DEFENCE NUTRITION REPRODUCTION

MATERNAL DEPENDENCE

HABITAT

MATERNALMOTHER

OTHERALTERNATE

AM I SAFE HERE ??

THE THE ““OLDOLD”” BRAIN HAS BRAIN HAS

3 PROGRAMMES3 PROGRAMMES

DEFENCE NUTRITION REPRODUCTION

MATERNAL DEPENDENCEHABITAT NICHE

BREAST-MOTHER FEEDING

OTHER PROTEST-DESPAIR

SAFE ? → YES

SAFE ? → NO

55 56

57 58

59 60

11


SEPARATION


OTHER PROTEST- STRESS SURVIVAL orDESPAIR (SNS)

THE PLACE MODEL

CORTISOL

OXYTOCIN BREAST- VAGALMOTHER FEEDING (PSNS) GROWTH


THE PLACE MODEL

→ alternative approach → hypothesis falsifiable/testable


SEPARATION



THE PLACE MODEL

R

→ hypothesis falsifiable/testable

Research funded byTHRASHER RESEARCH FUND, U.S.A.

Admin and stats byMEDICAL RESEARCH COUNCIL, R.S.A.

KANGAROO MOTHER CAREFROM BIRTH

COMPARED TO CONVENTIONAL INCUBATOR CARE

Primary hypothesis

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

ONLY PLACE DIFFERS THE ONLY DIFFERENCE = THE PLACE or the HABITAT


FROM BIRTH

61 62

63 64

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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

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 summoned:

INCUBATOR 92% SKIN-TO-SKIN 17%

Met baleout criteria (YES=1, NO=0)

10

Cou

nt

16

14

12

10

8

6

4

2

0

Allocation KMC = 1

CMC

KMC


SEPARATION



THE PLACE MODEL

92% UNSTABLE

17% UNSTABLE

monitors continuously

SCRIP

Heart rate

Oxygen saturation

Respiratory rate

STABILITY

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

67 68

69 70

71 72

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“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



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

Skin-to-skin

STABILIZES

&

PREVENTS

INSTABILITY

Physiological stabilisation


OTHERPROTEST- STRESS SURVIVAL orDESPAIR (SNS)


SEPARATION

THE PLACE MODEL

DYS-REGULATION

STABILISATION

CORTISOL

73 74

75 76

77 78

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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

Hu 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





Effectiveness of Skin-to-Skin Contact to stabilize low birth

weight infants at birth.

Luong Kim Chi, Nguyen Tien Long, Huynh Thi Duy

Huong, Nils Bergman

2015

Ho Chi Minh CITY, Vietnam

60,000 deliveries per year

Obstetric beds: 1200

Neonatal beds: 180

16,200 neonatal cases /year 2012 in

neonatal department

Low birth weight rate Vietnam 9%,

this hospital 12,5 %

2015 Low birth weight births n 2230

Born during working hours n 1020

Consented prior to birth n 675

Eligible mother and infant n 212

RANDOMISED n 100

MIS (Maternal Infant Separation) n 50SSC (Skin-to-Skin Contact) n 50

Analysed n 50Analysed n 50

Refused consent, Caesarean births n 345

Did not meet eligibility criteria n 463

Research space not available n 112

Received intervention n 50

Completed intervention n 49

Received intervention n 50

Completed intervention n 50

NICU care after 4 hours n 1

79 80

81 82

83 84

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NEURODEVELOPMENT

The DNA Behaviour

EVOLUTIONARY BIOLOGY

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

The Neuroscience of Birth & BreastfeedingThe Brain

EPIGENETICS

BIRTH TRANSITION

… to extra-uterine liferaises its own temperature,has a higher blood glucose,metabolic adaptation faster.

NEURODEVELOPMENT

The DNA Behaviour




EPIGENETICS

BIRTH

“The newbornmay appear

helpless, but

TRANSITIONENVIRONMENT SKIN-TO-SKIN CONTACT

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87 88

89 90

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Images courtesy of Prof Peter Hartmann, UWA

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATIONENVIRONMENT SKIN-TO-SKIN CONTACT ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATIONENVIRONMENT SKIN-TO-SKIN CONTACT

Transition score

Heart rate score

Breathing score

Heart stability

Resp’ stability

CVS stability

Oxygen sat’

Apnoea

Temperature

PRETERM BIRTH

TRANSITION

REGULATION

improved physiology

Resp’ stabilityTemperature






Semmelweis could offer no acceptable scientific explanation for his findings ….

Ostracized by peers,Died insane

91 92

93 94

95 96

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Does the incubator make the small baby unstable?

Stabilization 1200g – 1800g

Skin-to-skin

Incubator

SKIN-TO-SKIN 17% INCUBATOR 92%

NEURODEVELOPMENT

The DNA Behaviour



The Brain

EPIGENETICS

BIRTH

BEYOND BREASTFEEDINGFeed → Sleep Cycling

SEPARATIONMOTHERBABY

BONDING Sensitization

Secure attachment

Attuned parenting

Resilience Vulnerability

DISEASEHEALTH

Disordered attachment

Toxic stress

Insensitiveparenting

The Science behind Family Centred Care

SEPARATION

Vulnerability

DISEASE


Toxic stress


Feb 19, 2018Conclusions and Relevance:

Extremely or very preterm children born in the antenatal

corticosteroids and surfactant era show large deficits in

intelligence. No improvement in cognitive outcome was

observed between 1990 and 2008.

…

Bronchopulmonary dysplasia was found to be a crucial

factor for cognitive outcome. Lowering the high

incidence of BPD may be key to improving long-term

outcomes after EP/VP birth.

n = 366CONCLUSIONS This study demonstrated a reduction in total length of hospital stay for infants born prematurely by providing facilities for parents to stay in the NICU 24 hours/day from admission to discharge. Analyses of secondary outcomes also suggested a reduction in pulmonary morbidity, such as moderate-to-severe BPD.

97 98

99 100

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NEURODEVELOPMENT

The DNA Behaviour



The Brain

EPIGENETICS

BIRTH




Secure attachment

Attuned parenting


DISEASEHEALTH


Toxic stress



NEURODEVELOPMENT

The DNA Behaviour




EPIGENETICS

BIRTH




Secure attachment

Attuned parenting


HEALTH


Toxic stress






Early Experience and the Development of Stress

Reactivity and Regulation in Children (Gunnar 2010)

Neurosci Biobehav Rev. 2010 May ; 34(6): 867–876. doi:10.1016/j.neubiorev.2009.05.007.

Nelson &

Panksepp 1998

SAFE UNSAFE

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

Early stress alters gene expression,with health impact across lifespan.

NURTURESCIENCE

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.

103 104

105 106

107 108

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NURTURESCIENCE

?a new model with ancient roots.

Introducing NURTURESCIENCE a new model with ancient roots.

• The basic science of pediatrics.

• An emerging, multidisciplinary science of development supports an

EBD framework for understanding the evolution of human health and

disease across the life span. In recent decades, epidemiology,

developmental psychology, and longitudinal studies of early childhood

interventions have demonstrated significant associations (hashed red

arrow) between the ecology of childhood and a wide range of

developmental outcomes and life course trajectories. Concurrently,

advances in the biological sciences, particularly in developmental

neuroscience and epigenetics, have made parallel progress in

beginning to elucidate the biological mechanisms (solid arrows)

underlying these important associations. The convergence of these

diverse disciplines defines a promising new basic science of

pediatrics.


• The basic science of pediatrics.

• An emerging, multidisciplinary science of development supports an

EBD framework for understanding the evolution of human health and

disease across the life span. In recent decades, epidemiology,

developmental psychology, and longitudinal studies of early childhood

interventions have demonstrated significant associations (hashed red

arrow) between the ecology of childhood and a wide range of

developmental outcomes and life course trajectories. Concurrently,

advances in the biological sciences, particularly in developmental

neuroscience and epigenetics, have made parallel progress in

beginning to elucidate the biological mechanisms (solid arrows)

underlying these important associations. The convergence of these

diverse disciplines defines a promising new basic science of

pediatrics.



109 110

111 112

113 114

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Hominines were prey at Sterkfontein, “Cradle of Mankind”

Immediate feedingresponse to crying

Father frequently and closely involved ...

EXTREME EGALITARIANISMEQUALITY (gender, age, capacity)INTENSE SOCIAL COHESION

→ NO AGGRESSION !!!!!

BERGMAN‘sharing phenotype’

UNIQUEhominin feature:carry food hometo share …

THE HUNTER GATHERER (cont)

Infant care patterns in such societies (which are closest to our origins):

1 Infant carried most of time2 Mother sleeps with infant same bed3 Immediate feeding response to crying4 Breastfeeding 24 months or more5 Father frequently and closely involved ...

115 116

117 118

119 120

21

From James McKenna a new model with ancient roots.

SEPARATION for 100 years

a new model with ancient roots.

SEPARATION for 100 years

NURTURE and NATURE was all there was.

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


121 122

123 124

125 126

22

NURTURESCIENCE

Neuroscience developed

in the old paradigm of

maternal-infant separation.


NEURODEVELOPMENT

The DNA Behaviour




EPIGENETICS

BIRTH




Secure attachment

Attuned parenting


HEALTH


Toxic stress


DISEASE

NEURODEVELOPMENT

The DNA Behaviour



The Brain

EPIGENETICS

BIRTH




Secure attachment

Attuned parenting


HEALTH


Toxic stress


DISEASE

NURTURESCIENCENEURODEVELOPMENT

Behaviour



The Brain

EPIGENETICS

BIRTH




Secure attachment

Attuned parenting


HEALTH


Toxic stress


DISEASE

Genome

NURTURESCIENCE

NEURODEVELOPMENT

Behaviour



EPIGENETICS

BIRTH




Secure attachment

Attuned parenting


HEALTH


Toxic stress


DISEASE

Genome Connectome

NURTURESCIENCEBrain 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.

127 128

129 130

131 132

23

• 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.

The human connectome is the result of an elaborate developmental trajectory.

orbitofrontal

vmPFC

TPJ

Post’ Insula

Planum temporale

(Wernickes)Pars opercularis

Middle cingulate

dmPFC

amPFC

Hypothalamus

ANS

Nuc accumbens

Inferior frontal gyrus

Broca’s

Thalamus

Precuneus

V1 primary visual cortex

Occipital face area

Fusiform face area

Fusiform gyrus

Cerebellum

Sup’ temporal sulcus

Hippocampus

Post cingulateAnt Cingulate

Caudate

Amygdala

Anterior insula

Stigler 2011 Structural and functional magnetic resonance imaging of autism spectrum disorders

Brain Res. 2011 March 22; 1380: 146–161. doi:10.1016/j.brainres.2010.11.076.

Assaf 2010 Abnormal functional connectivity of default mode sub-networks in autism spectrum disorder

patients

Retrosplenial

Sridharan 2008 switch

133 134

135 136

137 138

24

From

National

Geographic

Magazine

April 2014

TRACTOGRAPHY BRAIN WIRING

PATHWAYS→ CIRCUITS→ NETWORKSCONNECTOME

NEURODEVELOPMENT

The DNA Behaviour




EPIGENETICS

BIRTH

BEYOND

MOTHERBABY

BONDING

What is this ‘bonding’?

The BOND is made up of the

sensory inputs from the parent to the infant

REGULATION

Bowlby 1969, 1973, 1980

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” ...

NEURODEVELOPMENT

Behaviour



EPIGENETICS

BIRTH



Sensitization

Secure attachment

Attuned parenting


HEALTH


Toxic stress


DISEASE

Genome Connectome

Regulation

NURTURESCIENCE

139 140

141 142

143 144

25

NEURODEVELOPMENT

Behaviour



EPIGENETICS

BIRTH



Sensitization

Attuned parenting


HEALTH


Toxic stress


DISEASE

Genome Connectome

Regulation

EmotionalConnection

NURTURESCIENCE… infant cues - suckling,

vocalisation and tactile stimulation - stimulate

OXYTOCINrelease in the hypothalamus, which may result in the activation

of the DOPAMINEreward pathway leading to behavioural reinforcement

REWARDCONTROL

CENTRE


OXYTOCINDOPAMINE

FEARCONTROL

CENTRE

REWARDCONTROL

CENTRE


OXYTOCINDOPAMINE

CORTISOL

RESILIENCE(= STRESS RESISTANCE)

“capacity to maintain healthy emotional functioning in the after-math of stressful experiences”


DISEASEHEALTH

NEURODEVELOPMENT

Behaviour



EPIGENETICS

BIRTH



Sensitization


HEALTH


Toxic stress


DISEASE

Genome Connectome

Regulation

EmotionalConnection

Attuned interaction

NURTURESCIENCE

145 146

147 148

149 150

26


BIRTH

BABY

Smell

Skin contact

Simulation theory:EMPATHY is generated

by inner imitationof actions of others

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.

Regulation

Dopaminergic reward-related brain regions are activated specifically in response to happy, but not sad, baby faces.

Specific to OWN BABY

REWARDCONTROL

CENTRE


OXYTOCINDOPAMINE

SOCIALITY

becomes

REWARDING

REWARDCONTROL

CENTRE


OXYTOCINDOPAMINE

SOCIALITY

becomes

REWARDING

… IN BOTHMOTHER

AND BABY.

BIDIRECTIONAL !!

Affect regulation

“Human brains are RELATIONAL”

… co-creating touch… signature unique to caregiver

PRATHIBA REEBYE

SensitizationRegulation

EmotionalConnection

Attuned interaction

NEURODEVELOPMENT

Behaviour



EPIGENETICS

BIRTH



Sensitization


HEALTH


Toxic stress


DISEASE

Genome Connectome

Regulation

EmotionalConnection

Attuned interaction

Wellness

NURTURESCIENCE

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NEURODEVELOPMENT

Genome Behaviour



Connectome

EPIGENETICS

BIRTH



Regulation Sensitization

EmotionalConnection

Attuned interaction


DISEASEHEALTH


Toxic stress

Disconnectedparenting

NURTURESCIENCE

Wellness

NURTURESCIENCE

Neuroscience developed

in the old paradigm of

maternal-infant separation.


NURTURESCIENCE

Nurturescience now engulfed or embedded in current

neuroscience paradigms,

Needs dissecting out →

NURTURESCIENCE

3 primary occupations:

CONNECTINGBREASTFEEDING

SLEEPING

BREASTFEEDINGFeed → Sleep Cycling

MOTHERBABY


NEURODEVELOPMENT

The DNA Behaviour



The Brain

EPIGENETICS

BIRTH




Secure attachment

Attuned parenting


DISEASEHEALTH


Toxic stress


NURTURESCIENCE

NURTURESCIENCE NEUROSCIENCE

Key time

period

Perinatal, conception to birth to 1

month1 month – 3 years (ECD)

Comparison of nurturescience and neuroscience

First 1000 seconds (1st hour) TRANSITIONFirst 1000 minutes (1st day) REGULATION

CONNECTION SUCKLING / BREAST

First 1000 hours (6 weeks) CONSOLIDATION

AT BIRTHImmediate

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28


Key time

period




First 1000 seconds (1st hour) TRANSITIONFirst 1000 minutes (1st day) CONNECTION First 1000 hours (6 weeks) CONSOLIDATION→ First 1000 days Early Childhood

Development

AT BIRTHImmediate


Key time

period




NEURODEVELOPMENT

The DNA Behaviour



The Brain

EPIGENETICS

BIRTH




Secure attachment

Attuned parenting


DISEASEHEALTH


Toxic stress



FEARCONTROL

CENTRE

REWARDCONTROL

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.


Key time

period

Perinatal, conception to

birth to 1 month

1 month – 3 years

(ECD)

First 1000 minutes First 1000 days

ANS purpose HOMEORHESIS HOMEOSTASIS


Homeorhesis, derived from the Greek for "similar flow", is

a concept encompassing dynamical systems which return to

a trajectory, as opposed to systems which return to a

particular state, which is termed homeostasis.

https://en.wikipedia.org/wiki/Homeorhesis


Key time

period


birth to 1 month

1 month – 3 years

(ECD)



Dyadic / family (plural) Individual (singular)

Dynamic systems theory Reductionistic logic


Essentially ecological:

BREASTFEEDINGFeed → Sleep Cycling

MOTHERBABY



(from Greek: οἶκος, "house", or "environment"; -λογία, "study of")

The branch of biology that deals with the relations of

organisms to one another and to their physical surroundings.

NURTURESCIENCE


Key time

period


birth to 1 month

1 month – 3 years

(ECD)



Dyadic / family (plural) Individual (singular)

Dynamic systems theory Reductionistic logic

KEY

OUT-

COME

CONNECTION

RESILIENCE

ATTACHMENT

COGNITION


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https://en.wikipedia.org/wiki/Homeorhesis

29


Key time

period



Emotions

Regulatory

mechanism

Viscera / ANS / limbic brain Limbic brain / neocortex

Maternal regulation then co-

regulationSelf-regulation (within self)

Open feedback loop (with others) Closed feed-back loop (within self)


REGULATION vs STIMULATION

Expected vs UnexpectedEcologic salience vs Potential threatResource growth vs threat readiness

OXYTOCIN vs CORTISOL HOMEORHESIS vs HOMEOSTASIS

MOTHER vs OTHER


Key time

period



Emotions

Regulatory

mechanism






CORTISOL

SEPARATION DYSREGULATES SEPARATION DYSREGULATES

Co-regulationHomeorhesis

Self-regulationHomeostasis


Key time

period



Emotions

Regulatory

mechanism





Emotions

Learning

mechanism

ANS influences on behavior CNS influences on behavior

Autonomic learning

(Pavlovian conditioning)Operant conditioning

Critical periods (brief) Sensitive periods (long)

Brain adaptation Brain maturation

KEY

OUTCOME

CONNECTION

RESILIENCE

ATTACHMENT

COGNITION

Comparison of nurturescience and neuroscience Nurturescience program now planned for

KAROLINSKA, Stockholm

BJORN WESTRUPULRIKA ADEN NILS BERGMAN

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30

MARTHA WELCH Meyers, Hofer, Fifer, Ludwig etc

NEURODEVELOPMENT

Genome Behaviour



Connectome

EPIGENETICS

BIRTH




EmotionalConnection

Attuned interaction


DISEASEHEALTH


Toxic stress

Disconnectedparenting

NURTURESCIENCE

Wellness

INTRODUCTION

“It is easier to build strong children

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



PARADIGM SHIFT !!

PUBLIC HEALTH IMPERATIVE

Please care formy brain

References and more information:www.skin2skincontact.com

THANK YOU

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