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1

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?



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”


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


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


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



EPIGENETICS


“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




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



BEHAVIOR


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



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”



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.


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.


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




EPIGENETICS

BIRTH

SEPARATIONBABY

Toxic stress





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



HEALTHYadult

HIGH Grooming HG

Makes MOTHER OXYTOCIN



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




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


19

PERCEPTIONS“NEUROCEPTION”

RESPONSESTRESS

ALLOSTATIC STATE


EndocrineImmune

HEALTH

elevated activity of mediators,

with return to baseline and no impact on

health.

RESISTANCE / SENSITIVITY


RESPONSESTRESS

ALLOSTATIC STATE


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



RESPONSESTRESS

ALLOSTATIC STATE


EndocrineImmune

ALLOSTATIC LOAD

ALLOSTATIC OVERLOAD

HEALTH

the point at which chronic load results in actual

disease or abnormal conditions.

2ND

KNOCK



RESPONSESTRESS

ALLOSTATIC STATE


EndocrineImmune

ALLOSTATIC LOAD

ALLOSTATIC OVERLOAD

WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY

DISEASEHEALTH

RESILIENCE VULNERABILITY

20

DISEASEHEALTH





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


OXYTOCINDOPAMINE

CORTISOL


FEARCONTROL

CENTRE

REWARDCONTROL

CENTRE


OXYTOCINDOPAMINE

CORTISOL



DISEASEHEALTH


… there is considerable overlap in the brain structures associated with these neural mechanisms … functional interactions among the circuits.

FEARCONTROL

CENTRE

REWARDCONTROL

CENTRE


OXYTOCINDOPAMINE

CORTISOL



DISEASEHEALTH


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.





BEHAVIOR


PARADIGM CONSTRUCT


Consistency


BASIC ASSUMPTION:


PARADIGM CONSTRUCT


Consistency


BASIC ASSUMPTION:


MATERNAL-INFANTSEPARATION

HAS NO SCIENTIFIC

FOUNDATION.

KANGAROO MOTHER CARE:RESTORING THE ORIGINAL PARADIGM

22

WHAT IS

K M C ??


Paradigm for Infant CareToxic Stress








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








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%


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%


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%


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%


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




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



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


OTHERPROTEST- STRESS SURVIVAL orDESPAIR (SNS)


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




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



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




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




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




EPIGENETICS

BIRTH

BABY

BONDING

“needed

neural

processes”

PARADIGM CONSTRUCT




MSN Encarta


BASIC ASSUMPTION:


PARADIGM CONSTRUCT




MSN Encarta


BASIC ASSUMPTION:


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




MSN Encarta


BASIC ASSUMPTION:


THEINCUBATOR

HAS NO EVIDENCE BASE !!

KANGAROO MOTHER CARE:RESTORING THE ORIGINAL PARADIGM

SO WHERE

TO NOW ??



NEURODEVELOPMENT

The DNA Behaviour




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




EPIGENETICS

BIRTH


BABY

BONDING

Secure attachment

NEURODEVELOPMENT

The DNA Behaviour




EPIGENETICS

BIRTH


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




EPIGENETICS

BIRTH


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




EPIGENETICS

BIRTH


MOTHERBABY


Secure attachment

Attuned parenting

SEPARATION

Resilience



Resilience

Secure attachment

Attuned parenting

PR - Peer Reared



RESILIENCE:“capacity to maintain

healthy emotional functioning in the after-

math of stressful experiences”

DISEASEHEALTH MR PR

CORTISOLOXYTOCIN

NEURODEVELOPMENT

The DNA Behaviour




EPIGENETICS

BIRTH


SEPARATIONMOTHERBABY


Secure attachment

Attuned parenting

Disordered attachment

Toxic stress

Insensitiveparenting

Resilience Vulnerability

CORTISOLOXYTOCIN

NEURODEVELOPMENT

The DNA Behaviour




EPIGENETICS

BIRTH




Secure attachment

Attuned parenting


DISEASEHEALTH


Toxic stress


33

BIRTH




Secure attachment

Attuned parenting


DISEASEHEALTH


Toxic stress




“buffering

protection of

adult support”

NEURODEVELOPMENT

The DNA Behaviour




EPIGENETICS

BIRTH



Vulnerability

DISEASE


Toxic stress


NEURODEVELOPMENT

The DNA Behaviour



EPIGENETICS


buffering protection

of adult support”

“Absence of the


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



EPIGENETICS



of adult support”

“Absence of the

NEURODEVELOPMENT

The DNA Behaviour



EPIGENETICS


“needed neural

processes”

34

NEURODEVELOPMENT

The DNA Behaviour



EPIGENETICS


“except in the light

of mother’s body.”

ZERO

SEPARATION

NEURODEVELOPMENT

The DNA Behaviour




EPIGENETICS

BIRTH




Toxic stress


ZERO

SEPARATION

NEURODEVELOPMENT

The DNA Behaviour




EPIGENETICS

BIRTH




Toxic stress


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

http://www.ninobirth.org/

http://www.skintoskincontact.com/

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




Toxic stress


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



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.


SEPARATION

Vulnerability

DISEASE


Toxic stress


SEPARATION

VIOLATESthe innate agendaof mother and baby


BIRTH


MOTHERBABY


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.”

http://www.google.co.za/url?sa=i&rct=j&q=Mandela+children+no+keener+measure&source=images&cd=&cad=rja&docid=28ZeDnl7FonrOM&tbnid=Lis73rdl0IBzEM:&ved=0CAUQjRw&url=http://www.eddysvision.com/2011_10_01_archive.html&ei=KjhjUbS7Fq2l0wXn54HYDQ&bvm=bv.44770516,d.ZG4&psig=AFQjCNFMsFQRVjw5-SZT6XPglGuoh9jo0Q&ust=1365543072105327

http://www.google.co.za/url?sa=i&rct=j&q=Mandela+children+no+keener+measure&source=images&cd=&cad=rja&docid=28ZeDnl7FonrOM&tbnid=Lis73rdl0IBzEM:&ved=0CAUQjRw&url=http://www.eddysvision.com/2011_10_01_archive.html&ei=KjhjUbS7Fq2l0wXn54HYDQ&bvm=bv.44770516,d.ZG4&psig=AFQjCNFMsFQRVjw5-SZT6XPglGuoh9jo0Q&ust=1365543072105327

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