BreathingBreathing• Right after birth

the most important thing for the infant is to

- start breathing, and then - establish an optimal respiration.

• This happens more easily when a baby is placed STS, instead of experiencing the physiological stress of separation. (Christensson K et al. Acta Paediatrica 1992;81:488-93.)

Prematures kept STS:Prematures kept STS:More stable heart-lung functionMore stable heart-lung function

Also premature infants have higher oxygen levels and greater heart-lung stability

when they are STS than when they are kept in incubators

Bergman NJ et al.

Acta Paediatr. 2004

Mammalian ”protest-despair”Mammalian ”protest-despair”No will to live?No will to live?

• 34 infants 1.2-2.2 kg RCT by computer before birth to STS or control.

• After 6 hrs: all STS-infants (8/18)

as opposed to 6/13 incubator infants were hearth-lung stable.

• Cardio-respiratory instability in separated infants is consistent with ”protest-despair”/”dissociation”.

• Bergman NJ et al, Acta Paediatr. 2004

Born wet, into cool, baby gets coldBorn wet, into cool, baby gets cold

• Also term newborns are often put in incubators or wrapped in warm blankets to help them maintain an optimal temperature.

• A number of studies have demonstrated that skin-to-skin contact with mother is better for regulating the baby’s temperature.

(Christensson K et al.1992, Bergman et al. 2004)

Rewarming hypothermic Rewarming hypothermic newbornsnewborns

Christensson K et al. Lancet 1998;352:1115Christensson K et al. Lancet 1998;352:1115

Cumulative proportion of rewarmed infants

0

20

40

60

80

100

0 60 120 180 240 300 360 420 480 540 600

Time (minutes)

% r

each

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36.5

°C

skin-to-skinincubator

CChhrriisstteennssssoonn KK eett aall.. LLaanncceett 11999988;;335522::11111155

(By compliments of A.Cattaneo)

It’s warmest up frontIt’s warmest up front

• A mother’s chest gets warmer during STS

• Lactating breasts are warmer than non-lactating ones.

• An infant in a “maternal nest”, made up of her chest and arms, will have a higher temperature than one placed in a warmed cot.

Uvnäs-Moberg K. 2000

Blood sugar and metabolismBlood sugar and metabolism

Low bloodsugar, hypoglucemia, is common in newborns after an hour or more. 50 healthy, term babies randomized to be:

- placed STS with mother, or - “separated”, put in cot next to mother

90 minutes after birth those placed STS had significantly higher blood-glucoseand maintained their bloodglucose better even without feeding.

Christensson K. et al. Acta Paediatr 1992)

Cold hands and feet need energyCold hands and feet need energy

Separation:

Colder babies have lower bloodsugar

This may have to do e.g. with less optimal bloodcirculation, as the small vessels contract in babies kept in their cots, resulting particularly in colder hands and feet for hours, requiring more energy.

Uvnäs-Moberg K. Acta Paediatr 1989.

Crying: a separation distress call?Crying: a separation distress call?

Newborns obs. for 90 min.randomized to

• A) STS with mother• B) Cot• C) Cot, then STSInfants recognize separation,cry in pulses, stop at reunion.Genetically encoded reaction.

Christensson K et al. Acta Paediatr 1995

Baby’s calling affects motherBaby’s calling affects mother

• Most newborns will after a while emitt calling sound like ”eh!, eh!”

• AM Widstrøm was a pioneer in making us all concious of this every-day event.

• Most mothers will react to baby’s call by talking to the infant, some for the first time.

• Most mothers recognize the voice of their own babies in the maternity ward.

Mother's voice organize brain Mother's voice organize brain function in the newbornfunction in the newborn

• Mother’s well known voice has a strong influence on the newborn with bothacute and enduring effects on the developing brain.

• This has ramifications for the development of the auditory system, as well as for later social and emotional development.

• New York State Psychiatric Institute, Fifer WP, Moon CM..Acta Paediatr Suppl. 1994 Jun;397:86-93

Love at first sight?Love at first sight?

Right after birth most babies • are wide awake, • can see well• have visual preferences:they want to see a face!

Faroni T et al. Proc Natl Acad Sci 2005

Organized pre-feeding behaviourOrganized pre-feeding behaviour

• Most unsedated newborns placed STS will undergo the now well known behaviour with ”crawling”, touching, tongue- and lipmovements, calling, rooting, sucking.

• Breastfeeding initiated after such an uninterupted sequence of events is very often successfull also long term.

• Widstrøm AM at al Acta Paedr Scand 1987

Baby’s touch does things to mom?Baby’s touch does things to mom?

• Baby’s post partum contact with the breast

influences later maternal behaviour:

• Mothers whose infants had touched or licked the areola and nipple within 30 min.

• left babies less in the nursery (p<.002) and

• talked more to them during breastfeeding on day four (31/31 vs 18/25)

• Widstom AM et al. Early Hum Dev. 1990

Hands on: Touch releases oxytocinHands on: Touch releases oxytocin

• 10 newborns were placed STS and videofilmed with assessment every 30 sek.

• Blood tests from mother every 15 min.• Infants used their hands to explore and

stimulate the breast before feeding, resulting in surges of oxytocin in mother. During suckling baby’s hands were still, but restarted during pauses in suckling.

• Mattiesen AS et al. Birth 2001

Areolar scent attracts babyAreolar scent attracts baby

The more areolar skin glandsthe better neonatal weight gain,onset of lactation,maternal perceptionof latch on and sucking,on day 1-3Schaal B Dev Psychobiol 2006 ,

Infants recognize odour of own Infants recognize odour of own mother’s milk after early STSmother’s milk after early STS

60 healthy, full-term neonates randomly assigned to STS postpartum or control

• 1 and 4 d after birth STS infants responded differently to own mother’s milk compared to another mother’s milk, formula, orange juice, distilled water.

• STS infants: larger difference at 4 days• STS infants were breastfed an average of

1.9 months longer.Mizuno k et al. Acta Paediatrica 2004;93:1640-45

STS and neurobehavioral STS and neurobehavioral responses of the term newbornresponses of the term newborn

• 15 min after birth 47 healthy infants RCT: A) STS lasting another hour, or B) Standard care in nursery

• After 4 hrs: one hour-long observation: infants who had been STS slept longer, were mostly in a quiet sleep state, had more flexor movements and postures showed less extensor movements

• STS seems to influence neurobehaviour and system modulation of the newborn

• Goldstein Ferber S, Makhoul IR.. Pediatrics 2004;113 858-65

Early STS - Lasting psycologic Early STS - Lasting psycologic effect on newborn humans?effect on newborn humans?

Newborn rats: Separation from mother results in disturbance not only of e.g.

• future hormone regulation, but of • future behaviour as well. In humans there is some evidence that early

separation may disturb subtle processes influencing both body and mind and future social relationships.

Hofer MA Acta Paediatr Suppl 1994

Neonatal brain: sensitive periodsNeonatal brain: sensitive periods

Mammalian imprinting models are

of critical importance in mammals, including humans

Newborn neural circuitry including

amygdala: different from adult.

”The brain of a newborn is uniquely designed to optimize attachment.”

Moriceau S & Sullivan RM. Dev Psykobiol 2005

Can we make up for lost time?Can we make up for lost time?• Luckily there seems to be compensatory

mechanisms particularly in young who depends for a long time on parental care.

• Humans have their large brains,and can use reason, inventivenes, emotional reassurance, patience etc to make up: ”Environmental enrichment during the peripubertal period” Francis DDJ Neurosci. 2002

But what about vulnerable families?

STS and maternal stress, mood, STS and maternal stress, mood, heart rate heart rate and cortisoland cortisolPremature infants 25-33 wSTS mothers compared to ctrl:

salivary cortisol down (32%) lower heart rates (7%) less stress (89%)improved mood (6%)

STS Infants: lower heart rates

lower pain scorescortisol up or down

(some need stress?)Morelius E et al. Pediatrics 2005;116:1105–13

Maternal psycological well-beingMaternal psycological well-being

Increased quantity of neo-maternal exposure in NICU has a beneficial effect on maternal self-esteem and attatchment

Ahn YM & Kim MR. Taechan Kanho Hakhoe Chi 2005

Endorphins promote happinessEndorphins promote happiness

• Why do mothers go to all the trouble?• What’s in it for her – right now?• In non-human primates beta-endorpin are

central as regulators of mother-infant interaction,

as well as for groupsocializing.• In humans, levels of endorpins double during breastfeeding –peaking after 20 m.

Franceschini R et al. Br J Obstet Gynaecol 1989.

”When I feed you I feel great myself!”

Oxytocin - mediator of STS effectsOxytocin - mediator of STS effects

• Oxytocin - not only usefull for uterine contractions and milk let-down reflex.

• It has a number of effects in humans:

• Overflows brain to make mom drowsy and relaxed, improves sleep-quality

• Increases during massage, intercourse

”HORMONE OF LOVE”

• Affects men, but w. much more sensitive

Functional magnetic resonance imaging data (red) superimposed on structural MRI scans. Frightful faces triggered a dramatic reduction in amygdala activity in subjects who had sniffed oxytocin, suggesting that oxytocin mediates social fear and trust via the amygdala and related circuitry.

                                                              

.Frightful faces trigges activity in amygdala. In subj. who had sniffed oxytocin there was a dramtic reduction, suggesting that oxytocin mediates trust. Kirsch P et al. J Neurosci, 25(49):11489-93, 2005.

Departments Departments involvedinvolved

• Obstetrics

• Maternity

• Operating theatre

• Anesthesiology

• Postopertive (PO/Recovery)

• Pediatrics (Neonatal)

Lower maternal stresshormones Lower maternal stresshormones skin-to-skin skin-to-skin

Mothers with baby STS:

• salivary cortisol down• lower heart rates• less stress• improved mood

Morelius E et al. Pediatrics 2005;116:1105–13

Extra important in C-section mothers?

Functional magnetic resonance imaging data (red) superimposed on structural MRI scans. Frightful faces triggered a dramatic reduction in amygdala activity in subjects who had sniffed oxytocin, suggesting that oxytocin mediates social fear and trust via the amygdala and related circuitry.

                                                              

.Frightful faces trigges activity in amygdala. In subj. who had sniffed oxytocin there was a dramtic reduction, suggesting that oxytocin mediates trust. Kirsch P et al. J Neurosci, 25(49):11489-93, 2005.

Hands on: Touch releases oxytocinHands on: Touch releases oxytocin

• 10 newborns were placed STS and videofilmed with assessment every 30 sek.

• Blood tests from mother every 15 min.• Infants used their hands to explore and

stimulate the breast before feeding, resulting in surges of oxytocin in mother. During suckling baby’s hands were still, but restarted during pauses in suckling.

• Mattiesen AS et al. Birth 2001

Elevated p.p. oxytocin Elevated p.p. oxytocin peaks with baby STS peaks with baby STS

Oxytocin is elevated

particularly the first hour after delivery – peaks with baby STS.

• After 1 hr oxy returns to pre partum levels.• Oxy needed in maternal bonding in

animals. Nissen E et al. Acta Obstet Gynecol Scand. 1995

• Oxytocin makes the uterus contract and reduces bleeding.

Elevated Oxytocin 1. hour p.pElevated Oxytocin 1. hour p.p..

• Oxytocin is elevated - particularly the first hour after delivery – peaks with baby STS.

• After 1 hr oxy returns to pre partum levels.• Oxy needed in maternal bonding in

animals. Nissen E et al. Acta Obstet Gynecol Scand. 1995

• Oxytocin makes the uterus contract and reduces bleeding.

• Mothers delivered by c.s., particularly prone to hemorrage,usually do not get their babies the 1. hour.

•

Maternal nest is warmest, BUTMaternal nest is warmest, BUTDad’s skin also provides heatDad’s skin also provides heat

• 44 infants randomized after c-section to:a) incubator b) cot c) STS with father

• Results 2 hrs p.p: • STS- and incubator-babies

warmer than those kept in a cot• After 24 hrs: STS-babies warmer than

babies who started out in cot OR incubator

Christenson K. Acta Paediatr 1996

Early STS with healthy newbornsEarly STS with healthy newbornsCochrane conclusionsCochrane conclusions::

• Seventeen studies involving 806 infants• Early STS contact associated with:

– better maintenance of temperature– better maintenance of blood glucose– less infant crying– more breastfeeding at 1-3 months – longer breastfeeding– higher scores of maternal affectionate

love/touch during breastfeeding Anderson GC et al. The Cochrane Library, Issue 2, 2003.

C-section moms and neos miss out C-section moms and neos miss out Two groups obs for 24 hrs

of rooming-in, after • A) Natural birth• B) Cesarean sectionConclusion:”Mothers who have c-sections need more

attention to begin breastfeeding.” Rocha SM et al.Rev Bras Enferm. 2003

C.s.moms who get to keep their babies STS very early, express great satisfaction.

Unpublished data, 2005 Norway

Early STS with healthy newbornsEarly STS with healthy newbornsCochrane conclusionsCochrane conclusions::

• Seventeen studies involving 806 infants• Early STS contact associated with:

– better maintenance of temperature– better maintenance of blood glucose– less infant crying– more breastfeeding at 1-3 months – longer breastfeeding– higher scores of maternal affectionate

love/touch during breastfeeding Anderson GC et al. The Cochrane Library, Issue 2, 2003.

Yes, please, support from Yes, please, support from bothboth modern medicine and “nature”modern medicine and “nature”

• Measurable “hard” facts have typically dominated modern medicine.

• Today exactly such knowledge may be used to support evolutionary developed, well-tested “natural” ways of handling newborns and their mothers.

• The main conclusion: try not to separate the newborn baby from it’s mother!