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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
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 ….
Ignaz SEMMELWEISS 1818 - 65
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2
The Semmelweis reflex
… reflex-like tendency to reject new evidence
and knowledge because it
contradicts established beliefs, paradigms.
WHAT IS A
PARADIGM ??
Kangaroo Mother Care:Restoring the Original
Paradigm for Infant Care
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?
Kangaroo Mother Care:Restoring the Original
Paradigm for Infant Care
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3
child helpless
OLD PARADIGM
Restoring the Original Paradigm for Infant Care
mother clueless
OLD PARADIGM
Restoring the Original Paradigm for Infant Care
father useless
OLD PARADIGM
Restoring the Original Paradigm for Infant Care
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 ….
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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
Martin COUNEY 1860 - 1950
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
Martin COUNEY 1860 - 1950
... famous for “preemie road show”.
MONEY MAKING SHOW
PERMANENT pavilion in Dreamland
Martin COUNEY 1860 - 1950
Born in Germany
claims he learnedthe techniques forBudin ....
Berlin Exhibition 1896, success !London World fair 1898, fiasco!
ALL THE BABIES DIED ....“MOTHERS TO BLAME”
Martin COUNEY 1860 - 1950
Couney succesfullyraised 5000 prems!
BUT –used wet-nurses, excluded mothers
(mother got free pass to the shows !)
Mothers were excluded – “germs” …
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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”
#1: Initial test condition—
infant sleeps alone, is bottle fed,
and has little or no parental contact
#2: Derive
measurements
of infant sleep
under these
conditions
#3: Repeat measurements across ages,
creating an “infant sleep model”
#4: Publish
clinical model
on what
constitutes
desirable,
healthy infant
sleep.
#5: To produce
“healthy” infant
sleep, replicate the
test condition
From James McKenna
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6
• CIRCULAR
SCIENCE -
A SELF-
FULFILLING
PROPHECY
Culture Producing Science Producing Culture:
How A Folk Myth Achieved Scientific Validation
#1: Initial test condition—
infant sleeps in INCUBATOR,
is FORMULA fed, SEPARATED
#2: Derive
measurements
NEONATES
under these
conditions
#3: Repeat measurements across ages,
defining “NEONATAL PHYSIOLOGY”
#4: Publish
TEXTBOOKS
DESCRIBING
“NORMAL”
NEONATES
#5: “replicate
the test
condition”
SEPARATED
NEONATES
ARE NORMAL
From James McKenna
“Scientific”
validation of
SEPARATED
NEONATE
as “normal” and
“healthy”
PARADIGM CONSTRUCT
Paradigm: “in the philosophy of science, a generally accepted model of how ideas relate to one another,
forming a conceptual framework
within which scientific research is carried out”
MSN Encarta
FOUNDATION / PLATFORM / BASE
BASIC ASSUMPTION:
= INCUBATORS STABILIZE
PARADIGM CONSTRUCT
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.
FOUNDATION / PLATFORM / BASE
BASIC ASSUMPTION:
= INCUBATORS STABILIZE
… reflex-like tendency to reject new evidence and knowledge because
contradicts established beliefs, paradigms.
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.
Slide courtesy of Susie Ludington-Hoe
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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
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.
… reflex-like tendency to reject new evidence
and knowledge because it
contradicts established beliefs, paradigms.
… reflex-like tendency to reject new evidence
and knowledge because it
contradicts established beliefs, paradigms.
SEPARATION
is a 20th century
PARADIGM
THE SCIENTIFIC AND EVIDENCE BASE FOR
SKIN-TO-SKIN CONTACT
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
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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%
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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 ??
The Semmelweis reflex
… reflex-like tendency to reject new evidence
and knowledge because it
contradicts established beliefs, paradigms.
… 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
SKIN-TO-SKIN CONTACT
SEPARATION
BREAST- VAGALMOTHER FEEDING (PSNS) GROWTH
OTHER PROTEST- STRESS SURVIVAL DESPAIR (SNS)
THE PLACE MODELPLACE MODEL
DEFENCE
NUTRITION
NEUROSCIENCE & EVIDENCE& SKIN-TO-SKIN CONTACT
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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
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SKIN-TO-SKIN CONTACT
SEPARATION
BREAST- VAGALMOTHER FEEDING (PSNS) GROWTH
OTHER PROTEST- STRESS SURVIVAL orDESPAIR (SNS)
THE PLACE MODEL
CORTISOL
OXYTOCIN BREAST- VAGALMOTHER FEEDING (PSNS) GROWTH
OTHER PROTEST- STRESS SURVIVAL orDESPAIR (SNS)
THE PLACE MODEL
→ alternative approach → hypothesis falsifiable/testable
SKIN-TO-SKIN CONTACT
SEPARATION
BREAST- VAGALMOTHER FEEDING (PSNS) GROWTH
OTHER PROTEST- STRESS SURVIVAL orDESPAIR (SNS)
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
SKIN-TO-SKIN CONTACT
FROM BIRTH
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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
SKIN-TO-SKIN CONTACT
SEPARATION
BREAST- VAGALMOTHER FEEDING (PSNS) GROWTH
OTHER PROTEST- STRESS SURVIVAL orDESPAIR (SNS)
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
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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
BREAST- VAGALMOTHER FEEDING (PSNS) GROWTH
OTHER PROTEST- STRESS SURVIVAL orDESPAIR (SNS)
Stabilization
Stabilisation first 6 hours, average hourly SCRIP score
5.1
5.2
5.3
5.4
5.5
5.6
5.7
5.8
5.9
6
6.1
2nd 3rd 4th 5th 6th
KMC all
KMC <1800
CMC all
CMC <1800
Bergman et al 2004 CORTISOL
Skin-to-skin
STABILIZES
&
PREVENTS
INSTABILITY
Physiological stabilisation
BREAST- VAGALMOTHER FEEDING (PSNS) GROWTH
OTHERPROTEST- STRESS SURVIVAL orDESPAIR (SNS)
SKIN-TO-SKIN CONTACT
SEPARATION
THE PLACE MODEL
DYS-REGULATION
STABILISATION
CORTISOL
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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
The Semmelweis reflex
… reflex-like tendency to reject new evidence
and knowledge because it
contradicts established beliefs, paradigms.
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
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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
EVOLUTIONARY BIOLOGY
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
The Neuroscience of Birth & BreastfeedingThe Brain
EPIGENETICS
BIRTH
“The newbornmay appear
helpless, but
TRANSITIONENVIRONMENT SKIN-TO-SKIN CONTACT
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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
The Semmelweis reflex
… reflex-like tendency to reject new evidence
and knowledge because it
contradicts established beliefs, paradigms.
Ignaz SEMMELWEISS 1818 - 65
Semmelweis could offer no acceptable scientific explanation for his findings ….
Ostracized by peers,Died insane
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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
EVOLUTIONARY BIOLOGY
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
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
Disordered attachment
Toxic stress
Insensitiveparenting
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.
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NEURODEVELOPMENT
The DNA Behaviour
EVOLUTIONARY BIOLOGY
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
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
NEURODEVELOPMENT
The DNA Behaviour
EVOLUTIONARY BIOLOGY
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
The Neuroscience of Birth & BreastfeedingThe Brain
EPIGENETICS
BIRTH
BEYOND BREASTFEEDINGFeed → Sleep Cycling
SEPARATIONMOTHERBABY
BONDING Sensitization
Secure attachment
Attuned parenting
Resilience Vulnerability
HEALTH
Disordered attachment
Toxic stress
Insensitiveparenting
Kangaroo Mother Care:Restoring the Original
Paradigm for Infant Care
THE SCIENTIFIC AND EVIDENCE BASE FOR
SKIN-TO-SKIN CONTACT
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.
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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.
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.
Introducing NURTURESCIENCE a new model with ancient roots.
Introducing NURTURESCIENCE a new model with ancient roots.
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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 ...
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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
Introducing NURTURESCIENCE a new model with ancient roots.
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NURTURESCIENCE
Neuroscience developed
in the old paradigm of
maternal-infant separation.
a new model with ancient roots.
NEURODEVELOPMENT
The DNA Behaviour
EVOLUTIONARY BIOLOGY
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
The Neuroscience of Birth & BreastfeedingThe Brain
EPIGENETICS
BIRTH
BEYOND BREASTFEEDINGFeed → Sleep Cycling
SEPARATIONMOTHERBABY
BONDING Sensitization
Secure attachment
Attuned parenting
Resilience Vulnerability
HEALTH
Disordered attachment
Toxic stress
Insensitiveparenting
DISEASE
NEURODEVELOPMENT
The DNA Behaviour
EVOLUTIONARY BIOLOGY
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
The Brain
EPIGENETICS
BIRTH
BEYOND BREASTFEEDINGFeed → Sleep Cycling
SEPARATIONMOTHERBABY
BONDING Sensitization
Secure attachment
Attuned parenting
Resilience Vulnerability
HEALTH
Disordered attachment
Toxic stress
Insensitiveparenting
DISEASE
NURTURESCIENCENEURODEVELOPMENT
Behaviour
EVOLUTIONARY BIOLOGY
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
The Brain
EPIGENETICS
BIRTH
BEYOND BREASTFEEDINGFeed → Sleep Cycling
SEPARATIONMOTHERBABY
BONDING Sensitization
Secure attachment
Attuned parenting
Resilience Vulnerability
HEALTH
Disordered attachment
Toxic stress
Insensitiveparenting
DISEASE
Genome
NURTURESCIENCE
NEURODEVELOPMENT
Behaviour
EVOLUTIONARY BIOLOGY
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
EPIGENETICS
BIRTH
BEYOND BREASTFEEDINGFeed → Sleep Cycling
SEPARATIONMOTHERBABY
BONDING Sensitization
Secure attachment
Attuned parenting
Resilience Vulnerability
HEALTH
Disordered attachment
Toxic stress
Insensitiveparenting
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.
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• 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
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From
National
Geographic
Magazine
April 2014
TRACTOGRAPHY BRAIN WIRING
PATHWAYS→ CIRCUITS→ NETWORKSCONNECTOME
NEURODEVELOPMENT
The DNA Behaviour
EVOLUTIONARY BIOLOGY
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
The Neuroscience of Birth & BreastfeedingThe Brain
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
EVOLUTIONARY BIOLOGY
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
EPIGENETICS
BIRTH
BEYOND BREASTFEEDINGFeed → Sleep Cycling
SEPARATIONMOTHERBABY
Sensitization
Secure attachment
Attuned parenting
Resilience Vulnerability
HEALTH
Disordered attachment
Toxic stress
Insensitiveparenting
DISEASE
Genome Connectome
Regulation
NURTURESCIENCE
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25
NEURODEVELOPMENT
Behaviour
EVOLUTIONARY BIOLOGY
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
EPIGENETICS
BIRTH
BEYOND BREASTFEEDINGFeed → Sleep Cycling
SEPARATIONMOTHERBABY
Sensitization
Attuned parenting
Resilience Vulnerability
HEALTH
Disordered attachment
Toxic stress
Insensitiveparenting
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
SOCIALCONTROL CENTRE
OXYTOCINDOPAMINE
FEARCONTROL
CENTRE
REWARDCONTROL
CENTRE
SOCIALCONTROL CENTRE
OXYTOCINDOPAMINE
CORTISOL
RESILIENCE(= STRESS RESISTANCE)
“capacity to maintain healthy emotional functioning in the after-math of stressful experiences”
Resilience Vulnerability
DISEASEHEALTH
NEURODEVELOPMENT
Behaviour
EVOLUTIONARY BIOLOGY
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
EPIGENETICS
BIRTH
BEYOND BREASTFEEDINGFeed → Sleep Cycling
SEPARATIONMOTHERBABY
Sensitization
Resilience Vulnerability
HEALTH
Disordered attachment
Toxic stress
Insensitiveparenting
DISEASE
Genome Connectome
Regulation
EmotionalConnection
Attuned interaction
NURTURESCIENCE
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26
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
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
SOCIALCONTROL CENTRE
OXYTOCINDOPAMINE
SOCIALITY
becomes
REWARDING
REWARDCONTROL
CENTRE
SOCIALCONTROL 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
EVOLUTIONARY BIOLOGY
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
EPIGENETICS
BIRTH
BEYOND BREASTFEEDINGFeed → Sleep Cycling
SEPARATIONMOTHERBABY
Sensitization
Resilience Vulnerability
HEALTH
Disordered attachment
Toxic stress
Insensitiveparenting
DISEASE
Genome Connectome
Regulation
EmotionalConnection
Attuned interaction
Wellness
NURTURESCIENCE
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27
NEURODEVELOPMENT
Genome Behaviour
EVOLUTIONARY BIOLOGY
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
Connectome
EPIGENETICS
BIRTH
BEYOND BREASTFEEDINGFeed → Sleep Cycling
SEPARATIONMOTHERBABY
Regulation Sensitization
EmotionalConnection
Attuned interaction
Resilience Vulnerability
DISEASEHEALTH
Disordered attachment
Toxic stress
Disconnectedparenting
NURTURESCIENCE
Wellness
NURTURESCIENCE
Neuroscience developed
in the old paradigm of
maternal-infant separation.
a new model with ancient roots.
NURTURESCIENCE
Nurturescience now engulfed or embedded in current
neuroscience paradigms,
Needs dissecting out →
NURTURESCIENCE
3 primary occupations:
CONNECTINGBREASTFEEDING
SLEEPING
BREASTFEEDINGFeed → Sleep Cycling
MOTHERBABY
BONDING Sensitization
NEURODEVELOPMENT
The DNA Behaviour
EVOLUTIONARY BIOLOGY
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
The Brain
EPIGENETICS
BIRTH
BEYOND BREASTFEEDINGFeed → Sleep Cycling
SEPARATIONMOTHERBABY
BONDING Sensitization
Secure attachment
Attuned parenting
Resilience Vulnerability
DISEASEHEALTH
Disordered attachment
Toxic stress
Insensitiveparenting
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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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) CONNECTION First 1000 hours (6 weeks) CONSOLIDATION→ First 1000 days Early Childhood
Development
AT BIRTHImmediate
NURTURESCIENCE NEUROSCIENCE
Key time
period
Perinatal, conception to birth to 1
month1 month – 3 years (ECD)
Comparison of nurturescience and neuroscience
NEURODEVELOPMENT
The DNA Behaviour
EVOLUTIONARY BIOLOGY
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
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
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.
NURTURESCIENCE NEUROSCIENCE
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
Comparison of nurturescience and neuroscience
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
NURTURESCIENCE NEUROSCIENCE
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
Dyadic / family (plural) Individual (singular)
Dynamic systems theory Reductionistic logic
Comparison of nurturescience and neuroscience
Essentially ecological:
BREASTFEEDINGFeed → Sleep Cycling
MOTHERBABY
Regulation Sensitization
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
(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
NURTURESCIENCE NEUROSCIENCE
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
Dyadic / family (plural) Individual (singular)
Dynamic systems theory Reductionistic logic
KEY
OUT-
COME
CONNECTION
RESILIENCE
ATTACHMENT
COGNITION
Comparison of nurturescience and neuroscience
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29
NURTURESCIENCE NEUROSCIENCE
Key time
period
Perinatal, conception to birth to 1
month1 month – 3 years (ECD)
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)
Comparison of nurturescience and neuroscience
REGULATION vs STIMULATION
Expected vs UnexpectedEcologic salience vs Potential threatResource growth vs threat readiness
OXYTOCIN vs CORTISOL HOMEORHESIS vs HOMEOSTASIS
MOTHER vs OTHER
NURTURESCIENCE NEUROSCIENCE
Key time
period
Perinatal, conception to birth to 1
month1 month – 3 years (ECD)
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)
Comparison of nurturescience and neuroscience
CORTISOL
SEPARATION DYSREGULATES SEPARATION DYSREGULATES
Co-regulationHomeorhesis
Self-regulationHomeostasis
NURTURESCIENCE NEUROSCIENCE
Key time
period
Perinatal, conception to birth to 1
month1 month – 3 years (ECD)
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)
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
EVOLUTIONARY BIOLOGY
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
Connectome
EPIGENETICS
BIRTH
BEYOND BREASTFEEDINGFeed → Sleep Cycling
SEPARATIONMOTHERBABY
Regulation Sensitization
EmotionalConnection
Attuned interaction
Resilience Vulnerability
DISEASEHEALTH
Disordered attachment
Toxic stress
Disconnectedparenting
NURTURESCIENCE
Wellness
INTRODUCTION
“It is easier to build strong children
than to repair broken men.”Frederick Douglass (1817–1895)
Kangaroo Mother Care:Restoring the Original
Paradigm for Infant Care
PARADIGM SHIFT !!
PUBLIC HEALTH IMPERATIVE
Please care formy brain
References and more information:www.skin2skincontact.com
THANK YOU
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