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Skin-to-Skin Contact, Breastfeeding, and Perinatal Neuroscience

Hollister Breastfeeding Program 2006 Boston, MA Denver, CO Redlands, CA Mission Viejo, CA

Skin-to-Skin Contact, Breastfeeding, and Perinatal Neuroscience

Dr Nils Bergman

M.D., D.C.H., M.P.H., Ph.D.

Cape Town, South Africa www.kangaroomothercare.com

Skin-to-Skin Contact, Breastfeeding, and Perinatal Neuroscience: Implementing Best Practice in U.S. Hospitals

Boston, MA Denver, CO Redlands, CA Mission Viejo, CA

Overview Perinatal neuroscience brain development normal newborn behaviour adverse factors Defining the original paradigm Kangaroo Mother Care Randomised trial Implications

NEUROSCIENCE

90% of what we know

about the brain has been discovered in

the last 15 years

Society of Neuroscience estimate Dr Sandra Witelson, McMaster

FETAL BRAIN DEVELOPMENT The first 10 – 14 weeks, fetal brain growth is determined by genes (the DNA) Thereafter, brain growth is an active process.

FETAL BRAIN DEVELOPMENT The neurons migrate, extend their axons and branches, and make synapses (thousands) connecting to sensory organs More sensations  more synapses Brain growth depends on experiences !!

Neurulation

NEURODEVELOPMENT

NEUROGENESIS Arborisation SYNAPTOGENESIS Myelination

0 10 20 30 40w Birth 6m 2y 10y 60y

EARLY DEVELOPMENT Gestational age 20w all structures completed parallel development of structure & function (Hugo Lagercrantz 2004)

23w fetus is aware / conscious parallel development of structure & function Neurobehaviour and neurodevelopment are inseparable a single integrated whole.

EARLY DEVELOPMENT 25w layering, dendrification, synapse formation “The brain is not a computer, it is a jungle.”

“The perinatal sensorium is never in chaos ….

… the infant’s world is structured, competent and organized, developing in an ever ordered, yet ever more complex and more flexible field of perception”

(Schore)

Porges SW Polyvagal theory.

evolution of autonomic nervous system 1 2 nd 3 st rd primitive unmyelinated vagus immobilisation behaviours sympathetic nervous system, Behaviours for “fight or flight” myelinated vagus – rapid regulation cardiac output engagement / disengagement

Gestational age 23w fetus is aware / conscious 25w layering, dendrification, synapse formation 28w full complement of neural cells (Hugo Lagercrantz 2004)

30 w fetus can recognise mother’s voice from other women, from single words played back to it by a tape-recorder, It can distinguish mother’s language from another language, again from a single word or phoneme.

The fetus has a GREATER SENSORIUM than the adult …

FETAL BRAIN DEVELOPMENT

Cells that fire together, wire together

FETAL BRAIN DEVELOPMENT

Use it, or lose it.

Neuronal Plasticity

• programmed cell death or apoptosis • pruning and elimination of redundancy = neuronal plasticity

Neurulation

NEURODEVELOPMENT

NEUROGENESIS Arborisation SYNAPTOGENESIS Myelination

Programmed cell death

10 20 30

COMPETITIVE ELIMINATION

40w Birth 6m 2y 10y 60y

FETAL BRAIN DEVELOPMENT At birth, the human being has more synapses in its brain than at any other stage of life.

FETAL BRAIN DEVELOPMENT Development is a process of “pruning” some, and developing other synapses – creating “neural pathways”.

These can be good or bad – depending on type of sensations and experience of the newborn

SENSORY STIMULUS synapse store chemical signal chemical signal stronger THRESHOLD  EXEMPT from elimination (synapse stabilised) PATHWAY (Rima Shore 1997)

R Shore

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.”

Schore

Critical period concept : “brain is exquisitely susceptible to adverse factors” at particular times or stages

Schore

Critical period : “Early interpersonal events positively and negatively impact the structural organisation of the brain.”

NEWBORN DEVELOPMENT Tactile stimulations “facilitate the flow of affective information from the infant … to the mother” “the language of mother and infant consists of signals produced by the autonomic nervous system of both parties”.

This is the basis of healthy development!

Schore

In early postnatal life, maintenance of critical levels of tactile input … is important for normal brain maturation. Areas of the amygdala …. are in a critical period of maturation, … in the first two months of life

FETAL BRAIN DEVELOPMENT The fetus has well developed sensations for touch and position (tactile and kinesthestic sensations).

“The infant actively seeks to adhere to as much skin surface on the mother’s body as possible” (Harlow 1958, from Schore 2001)

NEWBORN DEVELOPMENT

skin-to-skin contact Tactile stimulations build the amygdala - preorbital cortical tract during the first 8 weeks The next pathway requires eye-to-eye contact This is the basis of healthy right brain development!

Brain-to brain interaction Face-to-face communication Eye-to-eye orientations voice, hands, movements Interpersonal awareness Emotions

Myron Hofer … the private realm of sensory stimulation constructed by the mother and infant from numberless exchanges of subtle clues.

(Gallagher 1992)

Through such “hidden maternal regulators” he discovered that a mother precisely controls every element of her infants physiology , from its heart rate to its release of hormones from its appetite to the intensity of its activity

(Gallagher 1992)

The mere presence of the mother not only ensures the infants well being, but also creates a kind of invisible hothouse in which the infant’s development can unfold.

“For a baby the environment is the mother”

(Hofer in Gallagher 1992)

Hofer discovered that what seems to be a single physical function, such as grooming or nursing, is actually a kind of umbrella that covers stimuli of touch, balance, smell, hearing and vision, each with a specific effect on the infant.

(Gallagher 1992)

a kind of invisible hothouse “the wiring of the brain’s pathways is best supported when it can integrate quality sensory input through several pathways at once, particularly during critical periods of development.”

(McCain 1999)

Neuronal Plasticity

“the first three years are decisive” The cortex retains some plasticity throughout life … But the limbic system and the midbrain is fixed after the age of three years … Attachment Regulation Emotion Control Arousal Appetite Sleep

Neuronal Plasticity

“the first three years are decisive” Attachment Regulation Emotion Control Arousal Appetite Sleep  platform for subsequent development of higher cognitive functions.

Infant brain development

Early brain development is INTERACTIVE RAPID DRAMATIC

Infant brain development

CRITICAL PERIODS require specific stimulations at specific times

Infant brain development

Quality SENSORY STIMULATION makes brain able to think and regulate

Infant brain development

Negative experiences (both absence of good … and presence of bad) have long lasting effects

Current paradigm: Infant brain development 1. Genetically determined 2. Develops in linear time 3. Activity increases w age 4. Mother = good context 5. Deficits correctable later = FALSE ASSUMPTION !!

Current paradigm versus NEW: Infant brain development 1. Genetically determined 2. Develops in linear time 3. Activity increases w age 4. Mother = good context 5. Deficits correctable later EXPERIENCE CRITICAL PERIOD GREATEST 3 yrs = WIRES BRAIN Limbic FIXED at 3y (Rima Shore 1997)

“The mammalian brain is designed to be sculpted into its final configuration by the effects of early experience” These experiences are embedded in the attachment relationship.

Our cortex distinguishes us from other animals … BUT The “primitive” hindbrain is vital We can learn about ourselves from animals, and mammals!

THE “OLD” BRAIN HAS 3 PROGRAMMES

DEFENCE

NUTRITION REPRODUCTION

The neurobehavioural programmes originate in the

LIMBIC SYSTEM

Expressed through

hypothalamus

(autonomic nervous system)

hypophysis

(endocrine system, hormones)

cerebellar connections

(somatic system)

DEFENCE NUTRITION REPRODUCTION

HORMONES endocrine NERVES autonomic NS MUSCLES somatic

DEFENCE NUTRITION REPRODUCTION

HORMONES NERVES MUSCLES

DEFENCE NUTRITION REPRODUCTION

HORMONES NERVES MUSCLES

DEFENCE NUTRITION REPRODUCTION

HORMONES NERVES MUSCLES

BODY

BEHAVIOUR

HORMONES NERVES MUSCLES

WHOLE BODY

All mammals have set sequence of behaviours at birth ………….

REPRODUCTION ……. All with a single purpose : to

… MUSCLES BREASTFEED

After birth, events are determined … … by the neonate stimulating the mother!

(Rosenblatt 1994)

Breast-feeding is “established through a set of mutual, complex sensory stimulations in mother and child.”

(Kjellmer & Winberg 1994)

In all mammals ……. ….. the newborn is responsible for initiating breastfeeding, not the mother !!

EXCEPT IN HUMAN ???

Sequence human newborn breast-feeding

Pre-requisite = habitat hand to mouth tongue moves mouth moves eye focuses nipple crawls to nipple latches to nipple suckles (Widstrom et al 1994)

“The newborn may appear helpless, but displays an impressive and purposeful motor activity which, without maternal assistance , brings the baby to the nipple. (Michelson et al 1996)

R Shore

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.”

Schore

Critical period : “Early interpersonal events positively and negatively impact the structural organisation of the brain.”

The first hours after birth are a CRITICAL PERIOD Mother and infant are mutual psycho-physiological caregivers

Warming, feeding and protection

behaviours

are intricately, inseparably linked to the right place.

(Alberts 1994)

= NUTRITION PROGRAMME

The “habitat - niche” concept

HABITAT DETERMINES BEHAVIOUR

Self-attachment: Is this feeding ??

Success ? everything depends on a good start !!!

CRITICAL PERIOD BEHAVIOUR

Warming, feeding and protection

behaviours

are intricately, inseparably linked to the right place.

(Alberts 1994)

= NUTRITION PROGRAMME

(Gallagher 1992)

UNIQUELY HUMAN ….

1000 million years

LIFE ?

DINOSAURS

100 million years

MAMMALS

10 million years 4 million years

PRIMATES

Brief history of our origins !!

4,6 billion years – earth forms 230 million years DINOSAURS 200 million years – MAMMALS 50 million years – PRIMATES 6 million years - HOMINIDS

BIPEDALISM &

“LUCY” walked upright = bipedalism

NARROWER PELVIS

The pelvis flattened and narrowed as a result

BIPEDALISM & NARROWER PELVIS TOOL USE & LANGUAGE

“LUCY’s” descendants, having free hands, started using tools

TOOL USE & LANGUAGE BIPEDALISM & NARROWER PELVIS INCREASED BRAIN SIZE

About one million years ago, the brain size started increasing = encephalisation PROBLEM ! ! !

BIPEDALISM & NARROWER PELVIS

… PROBLEM ?

TOOL USE & LANGUAGE INCREASED BRAIN SIZE

How is the bigger head going to be born out of the smaller pelvis ??

BIPEDALISM & NARROWER PELVIS

SOLUTION …

TOOL USE & LANGUAGE INCREASED BRAIN SIZE EXCEEDINGLY IMMATURE BIRTH

BIPEDALISM & NARROWER PELVIS TOOL USE & LANGUAGE INCREASED BRAIN SIZE

“THE EVOLUTIONARY COMPROMISE”

EXCEEDINGLY IMMATURE BIRTH

Bipedalism and encephalisation (McKenna et al 1993)

BIPEDALISM & NARROWER PELVIS INCREASED BRAIN SIZE

The growing brain must come out before it is too big to pass through the birth canal ...

EXCEEDINGLY IMMATURE BIRTH

SOLUTION: “the birth of exceedingly neurologically immature infants for whom the majority of brain growth will occur postnatally and not in the womb.” (McKenna 1993)

100% 25% 0% CONCEPTION 80% FETUS BIRTH NEWBORN In all mammals, brain grows in utero until it reaches 80% of full adult size ….

… then BIRTH … then the brain grows the last 20% to final full adult size. ADULT

100% 25% 0% EXPECTED BIRTH Homo sapiens = HUMAN also has a brain that grows along this pattern … … the brain reaches 80% of final size at the age of 21 months 21/12

100% 25% 0% ACTUAL BIRTH 9/12 EXPECTED BIRTH Actual birth takes place at 9 months … … which makes the human birth one year too soon: EXCEEDINGLY IMMATURE 21/12

100% ACTUAL BIRTH 25% 0% 9/12 EXPECTED BIRTH Humans essentially complete gestation OUTSIDE THE WOMB .

21/12

100% ACTUAL BIRTH 25% 0% 9/12 EXPECTED BIRTH A fullterm newborn has 12 months of gestation to complete !

21/12

The placenta via the umbilical cord is the means whereby the fetus CONTINUES ITS GESTATION .

UTERUS UMBILICAL CORD Oxygenation Warmth Nutrition Protection

+++ +++ ++

In the UTERINE HABITAT, the umbilical cord delivers all the basic biological needs to the fetus.

Human milk is the means whereby the immature infant CONTINUES ITS GESTATION .

CHEST MOTHER’S MILK (BREAST) Oxygenation Warmth Nutrition Protection

(+) + +++ ++

In the NEWBORNS HABITAT, the mother’s breast delivers all the basic biological needs to the fetus.

Human milk is the means whereby the immature infant CONTINUES ITS GESTATION .

UTERUS UMBILICAL CORD Oxygenation Warmth Nutrition Protection

+++ +++ ++

CHEST MOTHER’S MILK (BREAST) Oxygenation Warmth Nutrition Protection

(+) + +++ ++

100% ACTUAL BIRTH 25% 0% 9/12 EXPECTED BIRTH Full term completes 12 months gestation by skin-to-skin contact.

21/12

100% ACTUAL BIRTH 25% 9/12 0% 7/12 EXPECTED BIRTH What if the gestation required is 14 months rather than 12 months?

21/12

If skin-to-skin contact is essential for the the immature newborn, IS IT MORE ??

OR LESS ??

essential for the premature newborn ??

100% ACTUAL BIRTH 25% 9/12 0% 7/12 EXPECTED BIRTH Skin-to-skin contact is ESSENTIAL if premature 21/12

THE CORRECT

HABITAT

IS EVEN MORE ESSENTIAL IN

PREMATURITY

THE CORRECT

HABITAT

IS MATERNAL-INFANT SKIN-TO-SKIN CONTACT

KANGAROO MOTHER CARE

Skin-to-skin contact

***********

Breastfeeding

***********

Support to the dyad

WHY KANGAROO ?

Marsupials have a pouch …which has four nipples … and can close tight for protection HUMAN KANGAROO MOTHER CARE!

does the same for the premature !

- Skin-to-skin - Breastfeeding - Protection

KANGAROO MOTHER CARE -Skin-to-skin -Breastfeeding -Protection CALOR LECHE AMOR KMC started by Drs Rey and Martinez, (1979) Bogota, Colombia.

UNICEF report 1983 “remarkable claims” warmth milk love

Further information Video: Rediscover the Natural Way Research and Physiology of temperature oxygenation, nutrition, protection

KANGAROO MOTHER CARE

HUMANITY FIRST TECHNOLOGY SECOND

-Skin-to-skin -Breastfeeding -Protection PLACE or HABITAT BEHAVIOUR or NICHE SUPPORT to DYAD

KANGAROO MOTHER CARE

A mother and baby

DYAD

are a single psychobiological organism

DEFENSE NUTRITION REPRODUCTION

HORMONES NERVES MUSCLES

DEFENSE NUTRITION REPRODUCTION

HORMONES NERVES MUSCLES = BREASTFEEDING

DEFENSE

The DEFENCE program shuts off the others immediately

NUTRITION REPRODUCTION

HORMONES NERVES MUSCLES = PROTEST - DESPAIR

Universal response to separation (wrong habitat):

protest - …..

… intense activity, trying to find the habitat …

Universal response to separation (wrong habitat):

despair response

…when separation is prolonged … …system shuts down for prolonged survival ….

DEFENCE program prepares the separated newborn for SURVIVAL - protest

DEFENSE

HORMONES Massive amounts of stress hormones (increase HR, RR)

DEFENSE

NERVES DEFENCE program prepares the separated newborn for SURVIVAL - protest Switches on the adrenergic system (stress response of protest)

DEFENSE

MUSCLES DEFENCE program prepares the separated newborn for SURVIVAL - protest

“Fight or flight”

Extensor and frantic movements (Wastes energy)

DEFENCE program prepares the separated newborn for SURVIVAL - despair

DEFENSE

HORMONES

(Vagal associates)

Massive amounts of vagal hormones Low temperature, Slow heart rate, (conserve energy)

DEFENSE

NERVES DEFENCE program prepares the separated newborn for SURVIVAL - despair Switches on the vagal system (on top of the adrenergic !! )

DEFENSE

MUSCLES

Superimposed PSNS (vagal) stimulation.

DEFENCE program prepares the separated newborn for SURVIVAL - despair Dissociation (playing dead) “ … immobility and inhibition of cries for help … “

DEFENSE

Protest – despair is also called HYPERAROUSAL DISSOCIATION

HYPERAROUSAL (Schore 2001) “… sympathetic system activated, increasing HR, BP, tone, vigilance, distress is expressed as in crying then screaming, a state of “frantic distress” or “fear-terror” hypermetabolic state in the brain”

DISSOCIATION (Schore 2001) “… later forming, parasympathetic, state of “conservation-withdrawal” a hypometabolic process, in which the individual passively disengages ”to conserve energies” … “to foster survival by the risky posture of feigning death”.

HYPERAROUSAL DISSOCIATION (Schore 2001) “in this state both sympathetic and parasympathetic components are hyperactivated … Creating … chaotic biochemical alterations … a toxic neurochemistry in the developing brain

HYPERAROUSAL DISSOCIATION (Schore 2001) “in the developing brain, states organize neural systems, resulting in enduring traits.”

FETAL BRAIN DEVELOPMENT

Cells that fire together, wire together

Schore

Critical period concept : “brain is exquisitely susceptible to adverse factors” at particular times or stages

Schore

Critical period : “Early interpersonal events positively and negatively impact the structural organisation of the brain.”

HYPERAROUSAL DISSOCIATION (Schore 2001) “early adverse experiences result in an increased sensitivity to the effects of stress later in life, and render an individual vulnerable to stress related psychiatric disorders.”

SEPARATION IS HARMFUL

“Origins of many behavioural deviations are unknown child neglect, abuse, abnormal shyness, attention deficiencies, hyperactivity, colic, sleep disorders etc,

SEPARATION IS HARMFUL

“Origins of many behavioural deviations are unknown … … can some be traced back to

violations of an innate agenda?"

(Kjellmer and Winberg 1994).

NEWBORN DEVELOPMENT Advent of hospital nurseries and early separations correlates with attachment disorders, maternal abandonment of baby increased addictive behaviours (unmet oral needs) (Zimberoff & Hartman 2002)

NEWBORN DEVELOPMENT Birth complications … affect personality, relationships, self-esteem … and behaviour patterns later on in life” (Emerson 1998) Maternal rejection and lack of bonding added: strong correlation to violent criminal behaviour”.

SEPARATION IS HARMFUL

"Early separation can produce major shifts in susceptibility to stress-induced pathology" (Hofer 1994)

(Maladaptive pathways have formed… )

SEPARATION IS HARMFUL

"Early separation can produce major shifts in susceptibility to stress-induced pathology" (Hofer 1994) Syndrome X Obesity Diabetes Hypertension

Contemporary neuroscience currently exploring early beginnings of adult brain pathology … … alterations in the functional organisation of the human brain … … correlated with the absence of early learning experiences.

Contemporary neuroscience “social stressors are far more detrimental than nonsocial aversive stimuli” “infant’s immature brain exquisitely vulnerable to early adverse experiences, including adverse social experiences.”

Schore

“ developmental psychoneurobiological model ” good attachment   efficient right brain regulation   infant mental health   adult mental health .

Schore / Bergman

“ developmental psychoneurobiological model ” good attachment   efficient right brain regulation   infant mental health   adult mental health .

Poor adult mental health Poor infant mental health Poor right brain regulation POOR ATTACHMENT SEPARATION     lack of skin-to-skin contact  caused by caused by caused by caused by caused by

BUT

= OUR CURRENT PRACTICE !!

THE CURRENT PARADIGM

SEPARATES

MOTHERS & BABIES

Dr Bergman translation: “hospital labour ward routines …”

INCUBATOR CARE

separates - causes “

protest - despair response

”

STRESS & FETAL BRAIN DEVELOPMENT At birth, the human being has sensory perceptions with no “filters” – it experiences all its sensations maximally.

As it develops, it learns to “dampen down” sensory inputs.

SEPARATION EFFECT ON NEWBORN Prematures and newborns have a nervous system which lacks the ability to dampen down sensory signals. Over-stimulation of any of the senses will be experienced as PAIN .

Stress hormones increase the perception of pain.

Newborn separation switches on both cholinergic and adrenergic systems

Only one other medical condition has a similar pathophysiology



In medical literature – two conditions uniquely show hyperstimulation of both arms of the ANS -- NEWBORN SEPARATION and BUTHID SCORPIONISM

NEONATE At birth, the human being has sensory perceptions with no “filters” – it experiences all its sensations maximally.

As it develops, it learns to “dampen down” sensory inputs.

Buthid scorpionism Buthid toxins act on Na and K channels of all excitable tissues, resulting in hyperstimulation of the nerve or tissue, every sensory nerve hyperstimulated.

“no filters”

BUTHID SCORPIONISM Buthid scorpionism … … is a potentially deadly condition, … causes the most severe pain possible and imaginable … Biblical writers use “scorpion sting” as a metaphor to convey the worst kind of pain !!

BUTHID SCORPIONISM The clinical effect is a hyperstimulation of all the nerves of the body including the autonomic nervous system.

“Autonomic storm” used to be the explanation for the fatal illness seen.

BUTHID SCORPIONISM Unique – P. transvaalicus cholinergic without adrenergic - thought impossible!!

P. granulatus sympathetic P. transvaalicus parasympathetic (= adrenergic) (= cholinergic) Pulmonary oedema Fatal syncope

sympathetic HYPERAROUSAL parasympathetic (= adrenergic) (= cholinergic) PROTEST DESPAIR DISSOCIATION

Mother and offspring live in a biological state that has much in common with addiction. When they are parted the infant does not just miss its mother; it experiences a physical and psychological with drawal from a host of her sensory stimuli, not unlike the plight of a heroin addict who goes cold turkey.

(Gallagher 1992)

THE SEPARATED BABY THAT HAS “SETTLED” IS RESTING, IT IS IN DESPAIR , DISSOCIATION IT IS HARDWIRING PRIMITIVE DEFENCE PATHWAYS !!!

SEPARATION !!!

THE “PRIMARY VIOLATION” … the very worst thing … to any newborn according to biologists is

SEPARATION .

SEPARATING

MOTHERS FROM BABIES IS BAD NEWS BABIES SHOULD

NEVER BE SEPARATED

SEPARATION

VIOLATES

THE INNATE AGENDA OF MOTHER AND NEWBORN

MATERNAL-INFANT SEPARATION

= ABUSE

WHY DO WE SEPARATE BABIES FROM MOTHERS ???

Ignaz SEMMELWEISS 1818 - 65

Hungarian obstetrician 1840’s – Vienna 30% died of puerperal fever – Pushed handwashing, cleanliness & standards: Maternal death rate from 12% to 1% in 2 years Ostracised by peers, Died insane

Stephane TARNIER 1828 -97

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

Pierre BUDIN 1846 - 1907

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

Political support … France versus Germany BUDIN was very particular to include mother, reason for the glass window ….

Martin COUNEY 1860 - 1950

German born, learnt of incubator from Budin, took “hatchery” to Exhibitions, famous for “preemie road show”.

MONEY MAKING SHOW Berlin 1896, Buffalo Chicago Fair 1932 2 nd  Omaha 1902-4, highest receipts, Last show New York 1940.

Equal parts P.T. Barnum-style circus sideshows and World's Fair wonders, Dreamland delivered novel and fantastic diversions of the odd and unusual . It was the home to scientific, ethnological and cultural exhibits, including Dr. Couney's Baby Incubator pavilion , which had been shown at the 1901 Buffalo Exhibition and the St. Louis Pike (seen here). Catering to the public's endless fascination with oddities and freaks , Dreamland had, as one of its main attractions, "Lilliputia,"

Martin COUNEY 1860 - 1950

Couney succesfully raised 5000 prems!

BUT – used wet-nurses, excluded mothers (mother got free pass to the shows !) Mothers were excluded – “germs” …

Sarah Morris Hospital, Chicago 1923, others followed – all with a “policy of strict separation”.

With the advent of artificial infant formula, mother not needed at all !!

Habitat AND niche now synthetic !!

EVIDENCE BASED MEDICINE.

The INCUBATOR was invented The INCUBATOR was 1900 standard Care for prems by 1940

HOW MUCH SCIENCE ??

RESEARCH ??

Martin COUNEY 1860 - 1950

German born, learnt of incubator from Budin, took “hatchery” to Exhibitions, famous for “preemie road show”.

MONEY MAKING SHOW Berlin 1896, Buffalo Chicago Fair 1932 2 nd  Omaha 1902-4, highest receipts, Last show New York 1940.

WHY DO WE SEPARATE BABIES FROM MOTHERS ?

The INCUBATOR is an ACCIDENT OF HISTORY

Is there an alternative for premature infants ??

KANGAROO MOTHER CARE -Skin-to-skin -Breastfeeding -Protection CALOR LECHE AMOR KMC started by Drs Rey and Martinez, (1979) Bogota, Colombia.

UNICEF report 1983 “remarkable claims” warmth milk love

Origin of BIRTH K M C Drs Rey & Martinez 1979 Bogota, Colombia LATE K M C 1985 Andrew Whitelaw 1987Agneta Jurisoo BIRTH K M C

DEFINITION of KMC (1990) MANAMA, ZIMBABWE # Skin-to-skin contact from birth, continuous # Breastmilk from birth & exclusive breastfeeding # Psychological support to 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).

Results – Manama (Infants 1000g to 1500g) Survival pre KMC 10% Survival with KMC 50% Weight gain / day 24g/d Breastfeeding rate 100%

The impact of Kangaroo Mother Care , in neonatology, has been equivalent to that of the advent to the world of Penicillin .

Prof Bob Pattinson, Kalofong Hospital, South Africa

SKIN-TO-SKIN & BREASTFEEDING : THEN ADD TECHNOLOGY

Is there an alternative for premature infants ??

IMPLICATIONS Third World The solution:

BIRTH K M C Is KMC safe for Unstable newborns?

Archie COCHRANE 1909 1988

Any intervention should be subject to RANDOMISED CONTROLLED TRIAL and meta-analysis … EVIDENCE BASED MEDICINE.

EVIDENCE BASED MEDICINE.

The INCUBATOR was invented The INCUBATOR was 1900 standard Care for prems by The Randomised Controlled 1940 TRIAL was “invented” by Kangaroo Mother Care 1960 was “discovered” in 1980

EVIDENCE BASED MEDICINE.

The INCUBATOR was standard Care for prems by The Randomised Controlled 1940 TRIAL was “invented” by Birth Kangaroo Mother Care 1960 was “discovered” in 1990 First RCT comparing birth KMC to incubator started in 2000

For the human newborn, it is the the habitat behaviour ( which determines which brain programme is operating, which then determines niche ).

HABITAT

MOTHER OTHER There are only these two habitat choices available

SKIN-TO-SKIN CONTACT

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

SEPARATION

Habitat – niche hypothesis

HABITAT NICHE MEANS

BREAST MOTHER FEEDING VAGAL (PSNS)

RESULT

GROWTH OTHER PROTEST- STRESS DESPAIR (SNS) SURVIVAL or

“Habitat – niche hypothesis” How would YOU design an RCT ?

HABITAT NICHE MEANS

BREAST MOTHER FEEDING VAGAL (PSNS)

RESULT

GROWTH OTHER PROTEST- STRESS DESPAIR (SNS) SURVIVAL or

KANGAROO MOTHER CARE FROM BIRTH

COMPARED TO CONVENTIONAL INCUBATOR CARE

Research funded by THRASHER RESEARCH FUND, U.S.A.

Admin and stats by MEDICAL RESEARCH COUNCIL, R.S.A.

KANGAROO MOTHER CARE FROM BIRTH

COMPARED TO CONVENTIONAL INCUBATOR CARE Nils Bergman Lucy Linley, Sue Fawcus Mowbray Maternity Cape Town, RSA.

Primary hypothesis

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

ONLY HABITAT DIFFERS

BAILOUT points ….

“

physiological parameters exceeding normal limits, requiring medical assessment and or intervention

” 1 Skin temp consistently <35.5

o C 2 Heart rate <100; or > 180 bpm 3 Apnoea longer than 20 seconds 4 O 2 sats below 89% (x2), (CPAP/60% O 2) 5 Blood glucose < 2,6mmol/l, (laboratory)

“S

tability of

ardio-

espiratory system

reterm Infants” (Fischer et al, 1988) SCRIP SCORE Heart rate 2 Regular 1 0 Respiratory rate Oxygen saturation Regular Regular >87% Deceleration to 80-100 Apnoea <10s, or periodic breathing Any fall to 80 – 87% Rate <80 or >200 bpm Apnoea >10s Tachypnoea >80 pm Any fall below 80% Score allocated for a five minute period of continuous observation, maximum six for period

Research hypotheses

BAILOUT Stabilising DURING 6h Stabilised AT 6 hours H1a H1b SCRIP H2a H2b

Results

Minimisation technique ensured groups balanced for confounders.

( n = 34) KMC Mean weight 1813g 1866g Mean GA 34.2w 35.3w

Approp’ GA 65% CMC 64% Male 60% 50% (p 783)

RESULTS

H1a At six hours, SSC will have fewer NICU admissions than CMC

KMC ( n = 20 ) CMC ( n = 14 ) Chi square Transferred to NICU 2 1 0.773

(10%) (7%) NS

HAWTHORNE EFFECT

H1b In the first six hours, SSC will have fewer bailout points than CMC KMC CMC Chi Square (n = 18) (n = 13)

Met bailout crit ’

Temp <35.5 C HR <100, >180 Apnoea >20 sec Ox sats <89% Blood sugar <2.6 1 1

1 0 0

8 0 1 0 3

<0.001

0.006

NS NS NS 0.02

H1b In the first six hours, SSC will have fewer bailout points than CMC The results strongly support the hypothesis

SSC 17% CMC 92%

H1b In the first six hours, SSC will have fewer bailout points than CMC

STABLE: SSC 83% CMC 8%

Research hypotheses

H2b During the sixth hour, “SCRIP” better with KMC KMC CMC t-test (24pts)

SCRIP 6 th hour

(mean) (Std deviation) Perfect score24 (n = 18)

24.0

0 18 (100%) (n = 13)

23.0

1.22

6 (46%)

0.012

H2b During the sixth hour, “SCRIP” better with KMC (24pts) The hypothesis is strongly supported.

100% of KMC infants were stabilised at 6 hours, while less than 50% of CMC …..

STABILITY better with KMC …. KMC babies STABLE by 6 hours, INCUBATOR remained unstable, with no trend towards stabilisation

H2a Through the six hours, “SCRIP” better with KMC Subanalysis <1800g

SCRIP

KMC (n = 9) CMC (n = 4) (78pts) t-test

76.67

71.75

0.049

SCRIP first six hours (mean) (standard deviation) Number perfect score (78) 1.5

4 (44%) 6.65

0 (0%)

H2b During the sixth hour, “SCRIP” better with KMC Subanalysis <1800g

SCRIP

(24pts) KMC (n = 9)

24.0

CMC (n = 4)

22.25

t-test

0.008

SCRIP in 6 th (mean) (standard deviation) hour Number perfect score (24) 0 9 ( 100%) 1.71

1 ( 25%)

If skin-to-skin contact is essential for the the immature newborn, IS IT MORE ??

OR LESS ??

essential for the premature newborn ??

100% ACTUAL BIRTH 25% 9/12 0% 7/12 EXPECTED BIRTH Skin-to-skin contact is ESSENTIAL if premature 21/12

Skin-to-skin contact IS MORE essential for premature newborns!

CONCLUSION

SSC started from birth, is superior to incubator

for infants 1200 - 2199g , with respect to stabilisation as defined by basic physiological parameters, (HR, RR, Ox sats, Dx, apnoea).

INCUBATORS DE-STABILISE NEWBORNS

SKIN-TO-SKIN CONTACT

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

SEPARATION

SURVIVAL or

SKIN-TO-SKIN CONTACT

IN OUR TEXT BOOKS … MOTHER FEEDING (PSNS) GROWTH OTHER PROTEST- STRESS DESPAIR (SNS)

SEPARATION

SURVIVAL or

SKIN-TO-SKIN CONTACT

IN OUR TEXT BOOKS … MOTHER FEEDING (PSNS) OTHER PROTEST- STRESS DESPAIR (SNS)

SEPARATION

SURVIVAL or

KANGAROO MOTHER CARE

A mother and baby

DYAD

are a single psychobiological organism

Julian Huxley, … to his students, … circa 1900.

“During the next century, half of what we know now will be proven wrong.

Unfortunately, we don’t know which half.”

EVIDENCE FOR SAFETY OF INCUBATORS … The evidence is assumed, taken for granted!

It is part of our paradigm.

EVIDENCE FOR SAFETY OF INCUBATORS …

We know their use to achieve thermal control and appropriate humidity … … but we’ve neglected the brain !

Paradigm shift ….

For unstable newborns: Is “Birth KMC” safe ?

Is “Birth KMC” safer … ?

Is “incubator” safe ?

Is “incubator” unsafe ?

INTERVENTION DOES : GOOD SSC SSC SSC SSC LITTLE

Incubator Incubator Incubator

HARM

Incubator

PRIMUM NON NOCERE

INTERVENTION DOES : GOOD SSC LITTLE HARM

Incubator

PRIMUM NON NOCERE

INCUBATORS DE-STABILISE NEWBORNS

INCUBATORS DE-STABILISE PREEMIES

Further information Video: Restoring the Original Paradigm (intended for professionals) … on which KMC is grounded: Covers additional topics not covered in this talk: Anthropology Evolutionary theory Habitat niche argument Physiology and research results (Protest-despair behaviour) Breastfeeding and breastmilk

Further information Video: Rediscover the Natural Way (intended for mothers and all) … including practical application (Immaturity of birth, biology) Physiology of temperature oxygenation, nutrition, (Separation behaviours) (Self-attachment) Milk effects, protection Use of KangaCarrier Interviews mothers and staff …

“Society reaps what it sows in the way that infants and children are treated. Efforts to reduce exposure to stress and abuse in early life may have far-reaching impacts on medical and psychiatric health and may reduce aggression, suspicion and untoward stress in future generations.”

Martin H Teicher

“Society reaps what it sows in the way that infants and children are treated. Efforts to reduce exposure to stress and abuse

(specifically MATERNAL INFANT SEPARATION

generations.”

Martin H Teicher

Bergman

)

in early life may have far-reaching impacts on medical and psychiatric health and may reduce aggression, suspicion and untoward stress in future

Skin-to-Skin Contact, Breastfeeding, and Perinatal Neuroscience: Implementing Best Practice in U.S. Hospitals

Boston, MA Denver, CO Redlands, CA Mission Viejo, CA