the scientific and evidence basis for skin--toto--skin contactskin...

Dr Nils BergmanDr Nils Bergman

THE SCIENTIFIC AND THE SCIENTIFIC AND EVIDENCE BASIS FOR EVIDENCE BASIS FOR

SKINSKIN--TOTO--SKIN CONTACTSKIN CONTACT


MB MB ChBChB, DCH, MPH, MD, DCH, MPH, MD

(USA equiv: MD, MPH ,PhD)(USA equiv: MD, MPH ,PhD)

Cape Town, RSACape Town, RSA

www.kangaroomothercare.comwww.kangaroomothercare.com

Speaker DisclosureUnder ACCME guidelines:Under ACCME guidelines:

a)a) I am the South African distributor ofI am the South African distributor ofMIRIS : Human Milk AnalyzerMIRIS : Human Milk Analyzer

b)b) My My wife markets educational materials and shirts wife markets educational materials and shirts b)b) My My wife markets educational materials and shirts wife markets educational materials and shirts related to the talk content related to the talk content

Kangaroo Mother Care Kangaroo Mother Care PromotionsPromotions


THE SCIENTIFIC THE SCIENTIFIC AND AND EVIDENCEEVIDENCE BASIS FOR BASIS FOR







SEPARATION:SEPARATION:

Science from Science from

NEUROSCIENCE & EVIDENCENEUROSCIENCE & EVIDENCE& SKIN& SKIN--TOTO--SKIN CONTACTSKIN CONTACT

Science from Science from ALL diverse fields ALL diverse fields ��

separation = poor outcome separation = poor outcome


Separated newborns from Separated newborns from


Separated newborns from Separated newborns from experience anxious arousal experience anxious arousal

��

TOXIC STRESSTOXIC STRESS

SKINSKIN--TOTO--SKIN CONTACT: SKIN CONTACT: Scientific Scientific EvidenceEvidence


��

What is What is ““scientific evidencescientific evidence” ??” ??

PerinatalPerinatal Neuroscience &Neuroscience &SkinSkin--toto--Skin ContactSkin Contact

NeuroscienceNeuroscience

Evolutionary biologyEvolutionary biologyEvolutionary biologyEvolutionary biologyprimatologyprimatology

EpigeneticsEpigeneticsTOXIC STRESSTOXIC STRESS

DOHADDOHAD

“TRUTH” “TRUTH” CREATION CREATION ��

BIOLOGY BIOLOGY -- ANTHROPOLOGY ANTHROPOLOGY -- SOCIOLOGYSOCIOLOGY

“SCIENCE”“SCIENCE”KNOWLEDGEKNOWLEDGE

EXPERIENCEEXPERIENCE

EVIDENCEEVIDENCE




8%8%EXPERIENCEEXPERIENCE

EVIDENCEEVIDENCE

8%8%





EVIDENCEEVIDENCEEBMEBM

8%8%

“Vetenskap och beprovad erfarenhet” “Vetenskap och beprovad erfarenhet” (swedish)(swedish)Knowledge (science) & tested (proven) experienceKnowledge (science) & tested (proven) experience


BIOLOGY BIOLOGY -- ANTHROPLOGY ANTHROPLOGY -- SOCIOLOGYSOCIOLOGY



EVIDENCE PRACTICE EVIDENCE PRACTICE

8%8%






GUIDELINESGUIDELINESPOLICIESPOLICIES

PROTOCOLS PROTOCOLS

8%8%

Kangaroo Mother Care:Kangaroo Mother Care:Restoring Restoring the Original the Original

Paradigm for Infant Paradigm for Infant CareCare

WHAT IS A

PARADIGM ??

PARADIGM SHIFT !!PARADIGM SHIFT !!

What is a paradigmWhat is a paradigm??

The American Heritage® Dictionary of the English The American Heritage® Dictionary of the English Language: Fourth Edition.Language: Fourth Edition. 2000.2000.

paradigmparadigm 3.3.A set of A set of assumptions, concepts, values, and assumptions, concepts, values, and assumptions, concepts, values, and assumptions, concepts, values, and practices that constitutes a way of practices that constitutes a way of viewing reality for the community viewing reality for the community that shares them, especially in an that shares them, especially in an intellectual discipline.intellectual discipline.

What is a paradigmWhat is a paradigm??

[Kuhn, T S; The Structure of Scientific [Kuhn, T S; The Structure of Scientific Revolutions, 2nd Ed., Univ. of Chicago Press, Revolutions, 2nd Ed., Univ. of Chicago Press, Chicago & London, 1970, p.175].Chicago & London, 1970, p.175].

Kuhn defines a paradigm as: Kuhn defines a paradigm as: Kuhn defines a paradigm as: Kuhn defines a paradigm as: “an entire constellation of beliefs, “an entire constellation of beliefs, values and techniques, and so on, values and techniques, and so on, shared by the members of a given shared by the members of a given community”community”

BASIC ASSUMPTIONS:

FOUNDATION / PLATFORM / BASE

PARADIGM CONSTRUCT


BASIC ASSUMPTIONS:

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 forming a conceptual framework

within which scientific research is carried out”

MSN Encarta


BASIC ASSUMPTIONS:

PARADIGM CONSTRUCTParadigm has internal

IntelligenceHonestyIntegrity

Consistency Consistency


BASIC ASSUMPTION:



WHAT IS THECURRENT PARADIGMFOR INFANT CARE?

child helpless

OLD OLD PARADIGMPARADIGM

Restoring the Original Restoring the Original Paradigm for Infant CareParadigm for Infant Care

child helpless

mother clueless



mother clueless

father useless



father useless

What determines a paradigm ??What determines a paradigm ??


TraditionTradition


Tradition Tradition CultureCulture





ExperienceExperience

Clinics in Clinics in PerinatologyPerinatology,,June 2004, June 2004, VolVol 31(2) p29331(2) p293

Robert WhiteRobert White“Mothers’ arms “Mothers’ arms –– the past andthe past andfuture locus of neonatal care ?”future locus of neonatal care ?”

“(Our care) still views the “(Our care) still views the “(Our care) still views the “(Our care) still views the infant as a solitary infant as a solitary individual who sleeps individual who sleeps most of the time in a bed."most of the time in a bed."





BASIC ASSUMPTION:= INFANT SLEEPS ALONE

Culture Producing Science Producing Culture:How A Folk Myth Achieved Scientific Validation

From James McKenna

#2: Derive

#1: Initial test condition#1: Initial test condition——infant sleeps alone, is bottle fed, infant sleeps alone, is bottle fed, and has little or no parental contactand has little or no parental contact

#2: Derive measurements of infant sleep

under these conditions

From James McKenna,Notre Dame Sleep Laboratory


#2: Derive




From James McKenna


#2: Derive




#3: Repeat measurements across ages, creating an “infant sleep model”

#4: Publish clinical model on what constitutes desirable, healthy infant sleep.

From James McKenna


“Scientific”


#2: Derive

#5: To produce “healthy” infant sleep, replicate the test condition

“Scientific” validation of solitary

infant sleep as “normal” and

“healthy”



#3: Repeat measurements across ages, creating an “infant sleep model”

#4: Publish clinical model on what constitutes desirable, healthy infant sleep.

From James McKenna




ExperienceExperienceResearchResearch

ScienceScience





BASIC ASSUMPTION:= INFANT SLEEPS ALONE

BASIC ASSUMPTIONS:

= = INFANT SLEEPS ALONEINFANT SLEEPS ALONE



“Scientific”

#1: Initial test condition—infant sleeps in INCUBATORINCUBATOR, is FORMULA fed, SEPARATEDFORMULA fed, SEPARATED

“Scientific” validation of SEPARATED NEONATE

as “normal” and “healthy”

From James McKenna


#1: Initial test condition—infant sleeps in INCUBATORINCUBATOR, is FORMULA fed, SEPARATEDFORMULA fed, SEPARATED

#2: Derive measurements

#5: “replicatethe test condition”SEPARATED SEPARATED NEONATES NEONATES ARE NORMAL ARE NORMAL

“Scientific” measurements NEONATESNEONATESunder these conditions

#3: Repeat measurements across ages, defining “NEONATAL PHYSIOLOGY”NEONATAL PHYSIOLOGY”

#4: Publish TEXTBOOKSTEXTBOOKSDESCRIBINGDESCRIBING

“NORMAL”“NORMAL”

NEONATESNEONATES

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 forming a conceptual framework

within which scientific research is carried out”

MSN Encarta


BASIC ASSUMPTION:= = INCUBATORS STABILIZEINCUBATORS STABILIZE

PARADIGM CONSTRUCTPARADIGM CONSTRUCT

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

that is accepted within the professionthat is accepted within the professionthat is accepted within the professionthat is accepted within the professionof medicine as adequate justification of medicine as adequate justification

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



SEPARATION= CURRENT= CURRENTROUTINE !!

(Positive (Positive �� Tolerable Tolerable ��))TToxic Stressoxic Stress

•• Strong and prolonged activation of the body’s Strong and prolonged activation of the body’s stress management systems in the stress management systems in the absence of absence of stress management systems in the stress management systems in the absence of absence of the buffering protection of adult supportthe buffering protection of adult support . .

•• Disrupts brain architecture and leads to stress Disrupts brain architecture and leads to stress management systems that respond at relatively management systems that respond at relatively lower thresholds, thereby increasing the risk of lower thresholds, thereby increasing the risk of stressstress--related physical and mental illness.related physical and mental illness.

Jack P. Shonkoff, M.D.

HYPERAROUSAL HYPERAROUSAL --DISSOCIATION DISSOCIATION (Schore 2001)(Schore 2001)

“in this state both sympathetic “in this state both sympathetic and parasympathetic components and parasympathetic components are hyperactivated … Creatingare hyperactivated … Creatingand parasympathetic components and parasympathetic components are hyperactivated … Creatingare hyperactivated … Creating

… chaotic biochemical alterations… chaotic biochemical alterations

… a toxic neurochemistry in the… a toxic neurochemistry in thedeveloping braindeveloping brain

DO YOU BELIEVE IN THE DEVIL ?

YOU KNOW, A SUPREME EVIL BEING DEDICATED TO THE TEMPTATION, CORRUPTION AND

DESTRUCTION OF MAN ?DESTRUCTION OF MAN ?

I’M NOT SURE MAN NEEDS THE HELP.

TOXIC STRESSTOXIC STRESSI’M NOT SURE MAN NEEDS THE HELP.

WHY do we separatemothers frombabies ??mothers frombabies ??

WHYDO WE

UMHC Central Nursery, April 2008

DO WESEPARATEBABIES FROM MOTHERS ???



WHAT IS THESCIENCE BEHINDINCUBATOR ??

Ignaz SEMMELWEISS Ignaz SEMMELWEISS 1818 1818 -- 6565

Hungarian obstetricianHungarian obstetrician1840’s 1840’s –– Vienna 30% diedVienna 30% diedof puerperal fever of puerperal fever ––Pushed handwashing, Pushed handwashing, Pushed handwashing, Pushed handwashing, cleanliness & standards:cleanliness & standards:Maternal death rateMaternal death ratefrom 12% to 1% in 2 yearsfrom 12% to 1% in 2 years

Ostracised by peers,Ostracised by peers,Died insaneDied insane

Stephane TARNIER Stephane TARNIER 1828 1828 --9797

French obstetricianFrench obstetrician

Saw a warmed box forSaw a warmed box forhatching chickens, hadhatching chickens, hadhatching chickens, hadhatching chickens, hadone designed for one designed for “weaklings” …“weaklings” …… invented incubator… invented incubator

Pierre BUDIN Pierre BUDIN 1846 1846 -- 19071907

Pierre BUDIN Pierre BUDIN 1846 1846 -- 19071907

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

Political support …Political support …France versus GermanyFrance versus Germany

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

Martin COUNEY Martin COUNEY 1860 1860 -- 19501950

Born in Germany Born in Germany

claims he learnedclaims he learnedthe techniques forthe techniques forBudin .... Budin .... the techniques forthe techniques forBudin .... Budin ....

Berlin ExhibitionBerlin Exhibition 1896, success !1896, success !

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

Baby Incubator, Baby Incubator, 1904 St.Louis Fair1904 St.Louis Fair


Berlin 1896, successBerlin 1896, success

to USA: Buffalo to USA: Buffalo ��OmahaOmaha 19021902--4, 4, OmahaOmaha 19021902--4, 4,

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

New York Worlds Fair, 1939


... famous for ... famous for “preemie road show”.“preemie road show”.

MONEY MAKING SHOWMONEY MAKING SHOW

PERMANENT pavilion in DreamlandPERMANENT pavilion in Dreamland

Dreamland delivered novel and fantastic diversions of the odd and unusual ... Catering to the public's endless fascination with oddities and freaks . It was the oddities and freaks . It was the home to scientific, ethnological and cultural exhibits, including Dr. Couney's Baby Incubator pavilion ...



claims he learnedclaims he learnedthe techniques forthe techniques forBudin .... Budin .... Budin .... Budin ....

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



claims he learnedclaims he learnedthe techniques forthe techniques forBudin .... Budin .... Budin .... Budin ....

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

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


CouneyCouney succesfullysuccesfullyraised 5000 raised 5000 premsprems!!

BUT BUT ––BUT BUT ––used wetused wet--nurses, nurses, excluded mothersexcluded mothers

(mother got free pass to the shows !)(mother got free pass to the shows !)

Mothers were excluded Mothers were excluded –– “germs” …“germs” …

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

Habitat AND niche now synthetic !!Habitat AND niche now synthetic !!

The modern era ....The modern era ....

Sarah Morris Hospital, Sarah Morris Hospital, Chicago 1923, Chicago 1923, others followed others followed ––

accepting the accepting the “policy of strict separation”.“policy of strict separation”.

HOW MUCH HOW MUCH

SCIENCE ??SCIENCE ??SCIENCE ??SCIENCE ??

RESEARCH ??RESEARCH ??


INCUBATOR & SEPARATION

= ACCIDENT of HISTORY


... famous for ... famous for “preemie road show”.“preemie road show”.

MONEY MAKING SHOWMONEY MAKING SHOW

PERMANENT pavilion in DreamlandPERMANENT pavilion in Dreamland


BASIC ASSUMPTIONS:= = INCUBATOR STABILIZES BABYINCUBATOR STABILIZES BABY

THETHEINCUBATORINCUBATOR


INCUBATORINCUBATOR

HAS HAS NONO SCIENTIFIC SCIENTIFIC

FOUNDATION !!FOUNDATION !!

MATERNALMATERNAL--INFANTINFANTSEPARATIONSEPARATION


SEPARATIONSEPARATION

HAS HAS NONO SCIENTIFIC SCIENTIFIC

FOUNDATION.FOUNDATION.



WHAT IS

“SCIENCE” ??







PROTOCOLS PROTOCOLS

8%8%

http://apps.who.int/rhl/en/index.html

“MYTHS”“MYTHS”ASSUMPTIONSASSUMPTIONS

PRACTICE ?PRACTICE ?


8%8%

POLICIESPOLICIESPROTOCOLS PROTOCOLS




8%8%

POLICIESPOLICIESPROTOCOLS PROTOCOLS DO DO INCUBATORSINCUBATORS

IMPROVE SURVIVAL ??IMPROVE SURVIVAL ??




8%8%

POLICIESPOLICIESPROTOCOLS PROTOCOLS DO DO INCUBATORSINCUBATORS

IMPROVE SURVIVAL ??IMPROVE SURVIVAL ??Or is it …Or is it …Surfactant ??Surfactant ??Ventilation / CPAP ??Ventilation / CPAP ??Antibiotics ?? Antibiotics ??

NeuroscienceNeuroscience

Evolutionary biologyEvolutionary biology

THE SCIENCE BEHINDTHE SCIENCE BEHINDSKINSKIN--TOTO--SKIN CONTACTSKIN CONTACT

Evolutionary biologyEvolutionary biologyprimatologyprimatology

EpigeneticsEpigeneticsTOXIC STRESSTOXIC STRESS

DOHADDOHAD


THE THE SCIENTIFIC AND SCIENTIFIC AND EVIDENCE BASIS FOR EVIDENCE BASIS FOR







SEPARATION SEPARATION ��HARM ?HARM ?

PRIMUM PRIMUM NON NON

NOCERENOCERE

Is there an alternative Is there an alternative for premature infants ??for premature infants ??

--SkinSkin--toto--skinskin CALORCALOR warmthwarmth

--BreastfeedingBreastfeeding LECHELECHE milkmilk

--ProtectionProtection AMORAMOR lovelove

KANGAROO MOTHER CAREKANGAROO MOTHER CARE

KMC started by KMC started by Drs Rey and Drs Rey and MartinezMartinez,,(1979) Bogota, Colombia.(1979) Bogota, Colombia.UNICEF report 1983UNICEF report 1983

“remarkable claims”“remarkable claims”

Pr Edgar Rey, Dr H. Martinez, Dr L.Navarette (photo from Dr Charpak)

Rey and Rey and MartinezMartinezStarted in 1979Started in 1979UNICEF report 1993UNICEF report 1993“remarkable claims”“remarkable claims”

Survival 1001Survival 1001--1500g before : 27%1500g before : 27%afterafter 89%89%

Rey and Rey and MartinezMartinezStarted in 1979Started in 1979UNICEF report 1993UNICEF report 1993“remarkable claims”“remarkable claims”

Survival 1001Survival 1001--1500g before : 27%1500g before : 27%afterafter 89%89%

Hammersmith in LondonHammersmith in London 91%91%

“intriguing and incredible”“intriguing and incredible”

11000 births annually, overcrowded11000 births annually, overcrowdedcrosscross--infections infections �� poor survivalpoor survival

“kangaroo babies”“kangaroo babies” ::At birth: incubator, conventional care,At birth: incubator, conventional care,At birth: incubator, conventional care,At birth: incubator, conventional care,“ ... do not see this as an alternative to“ ... do not see this as an alternative toconventional care ... babies need to conventional care ... babies need to survive hazards of first few days insurvive hazards of first few days inorder to enter programme” order to enter programme” �� 1/3 do!1/3 do!

11000 births annually, overcrowded11000 births annually, overcrowdedcrosscross--infections infections �� poor survivalpoor survival

“kangaroo babies”“kangaroo babies” ::At birth: incubator, conventional care,At birth: incubator, conventional care,At birth: incubator, conventional care,At birth: incubator, conventional care,“ ... do not see this as an alternative “ ... do not see this as an alternative totoconventional care ...conventional care ...babies need to babies need to survive hazards of first few days survive hazards of first few days ininorder to enter programme” order to enter programme” �� 1/3 do!1/3 do!

Andrew Whitelaw Andrew Whitelaw (Lancet 1985)(Lancet 1985)

“The myth“The mythof the marsupial mother”of the marsupial mother”

Survival 89% .... Survival 89% .... “but figures misleading because omitted“but figures misleading because omitted“but figures misleading because omitted“but figures misleading because omittedbabies who died in first few days”babies who died in first few days”

Valuable in developing countriesValuable in developing countriesColombia has nothing to teach developedColombia has nothing to teach developed

countries about survival ....countries about survival ....

Andrew Whitelaw (Lancet 1985)Andrew Whitelaw (Lancet 1985)

“The “The mythmyth of the marsupial mother”of the marsupial mother”Survival 89% .... Survival 89% ....

“but figures “but figures misleadingmisleadingbecause omittedbecause omitted“but figures “but figures misleadingmisleadingbecause omittedbecause omittedbabies who died in first few days”babies who died in first few days”

Valuable inValuable indevelopingdevelopingcountriescountriesColombia hasColombia hasnothingnothingto teach to teach developeddeveloped

countries countries about survival ....about survival ....

Miramare Castle, Trieste

In Trieste, this intervention had 30 different names,terminology wasdiscussed, and weagreed to use –

Kangaroo Mother Care

Kangaroo Mother CareKangaroo Mother Care

was there defined was there defined

Kangaroo Position SkinKangaroo Position Skin--toto--skin contactskin contactKangaroo Position SkinKangaroo Position Skin--toto--skin contactskin contactKangaroo NutritionKangaroo Nutrition Breastfeeding (excl)Breastfeeding (excl)Kangaroo DischargeKangaroo DischargeHome followupHome followup

Kangaroo SupportKangaroo Support Adjunct to technologyAdjunct to technology

NEXT (9NEXT (9th) th) meeting inmeeting inAhmadebadAhmadebad, INDIA !!!, INDIA !!!

2222ndnd --2525thth November 2012November 2012

SKINSKIN--TOTO--SKIN starts LATE !SKIN starts LATE !

Pr Edgar Rey, Dr H. Martinez, Dr L.Navarette

Origin of BIRTH K M C Origin of BIRTH K M C

Drs Rey & MartinezDrs Rey & Martinez1979 Bogota, Colombia1979 Bogota, Colombia

LATE K M CLATE K M C

19851985 Andrew Whitelaw Andrew Whitelaw

19871987Agneta JurisooAgneta JurisooBIRTH K M CBIRTH K M C

DEFINITION of KMC (1990)DEFINITION of KMC (1990)MANAMA, ZIMBABWEMANAMA, ZIMBABWE

## SkinSkin--toto--skin contactskin contactfrom birth, continuousfrom birth, continuous

## Breastmilk from birth Breastmilk from birth & exclusive breastfeeding& exclusive breastfeeding

## Psychological supportPsychological supportto motherto mother

KMC as above used regardless KMC as above used regardless of weight and gestation.of weight and gestation.

KMC provides the baby KMC provides the baby with very intensive care.with very intensive care.with very intensive care.with very intensive care.

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

Results Results -- ManamaManama

Results Results –– ManamaManama

(Born 1000g to 1500g)(Born 1000g to 1500g)

Survival before KMC Survival before KMC 10%10%Survival with KMCSurvival with KMC 50%50%Survival with KMCSurvival with KMC 50%50%(Stabilized in 6 hours)(Stabilized in 6 hours)

Weight gain per day Weight gain per day 30 g/d30 g/dBreastfeeding rateBreastfeeding rate 100%100%

BREAST- VAGALMOTHER FEEDING (PSNS) GROWTH

SKIN-TO-SKIN CONTACTTHE PLACE MODELPLACE MODEL

OTHER PROTEST- STRESS SURVIVAL orDESPAIR (SNS)

SEPARATION



50% SURVIVAL


SEPARATION

10% SURVIVAL

Mother is a superior incubator

SKINSKIN--TOTO--SKIN CONTACT :SKIN CONTACT :



�� MUST START @ BIRTHMUST START @ BIRTH

�� MUST BE CONTINUOUSMUST BE CONTINUOUS

(MANAMA)(MANAMA)


(MANAMA)(MANAMA)

BIRTH SKINBIRTH SKIN--TOTO--SKINSKIN

�� SUPERIOR SURVIVALSUPERIOR SURVIVAL

SKIN-TO-SKIN& BREASTFEEDING :

THEN ADDTHEN ADD

TECHNOLOGY


INCUBATOR & SEPARATION

= ACCIDENT of HISTORY

Is there an alternative Is there an alternative for premature infants ??for premature infants ??

Is THIS an alternative Is THIS an alternative for premature infants ??for premature infants ??

ALTERNATIVE:ALTERNATIVE:

BIRTH S S CBIRTH S S C

IMPLICATIONS Third WorldIMPLICATIONS Third World

The solution:The solution:

BIRTH S S CBIRTH S S C

Is SSC safe forIs SSC safe forUnstable newborns?Unstable newborns?

EVIDENCE BASED MEDICINE.EVIDENCE BASED MEDICINE.


INCUBATOR invented INCUBATOR invented 19001900


INCUBATOR invented INCUBATOR invented 19001900INCUBATOR in wide use INCUBATOR in wide use 19401940Randomised trialsRandomised trials 19601960Randomised trialsRandomised trials 19601960

Archie COCHRANE Archie COCHRANE 1909 1988 1909 1988

Any intervention Any intervention should be subject toshould be subject toRANDOMISEDRANDOMISEDCONTROLLED TRIALCONTROLLED TRIALCONTROLLED TRIALCONTROLLED TRIALand metaand meta--analysis … analysis …

EVIDENCE BASEDEVIDENCE BASEDMEDICINE.MEDICINE.


INCUBATOR invented INCUBATOR invented 19001900INCUBATOR in wide use INCUBATOR in wide use 19401940Randomised trialsRandomised trials 19601960Randomised trialsRandomised trials 19601960KMC first describedKMC first described 19801980


INCUBATOR invented INCUBATOR invented 19001900INCUBATOR in wide use INCUBATOR in wide use 19401940Randomised trialsRandomised trials 19601960Randomised trialsRandomised trials 19601960KMC first describedKMC first described 19801980Birth KMC describedBirth KMC described 19901990


INCUBATOR invented INCUBATOR invented 19001900INCUBATOR in wide use INCUBATOR in wide use 19401940Randomised trialsRandomised trials 19601960Randomised trialsRandomised trials 19601960KMC first describedKMC first described 19801980Birth KMC describedBirth KMC described 1990 1990 INCUBATOR vs Birth KMC INCUBATOR vs Birth KMC 20002000


The PLACE MODELThe PLACE MODEL

�� scientifically derived scientifically derived �� alternative approach alternative approach �� falsifiable/testable hypothesisfalsifiable/testable hypothesis




SEPARATION

SKIN-TO-SKIN CONTACTBREAST- VAGAL

MOTHER FEEDING (PSNS) GROWTH

THE PLACE MODELPLACE MODEL

R

SEPARATION


R

Research funded by

KANGAROO MOTHER CAREFROM BIRTH

COMPARED TO CONVENTIONAL INCUBATOR CARE

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

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

ReferenceReference

RCT of skin-to-skin contact from birth versus conventional incubator care for physiological stabilisation in 1200- and 2199-gram newborns. in 1200- and 2199-gram newborns.

Bergman NJ, Linley LL, Fawcus SR.

Acta Paediatrica 2004 Vol 93(6); 779-785

Primary hypothesisPrimary hypothesis

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

ONLY HABITAT DIFFERS

SKIN-TO-SKIN CONTACT

FROM BIRTH

THE ONLY DIFFERENCE = THE PLACE or the HABITAT

ResultsMinimisation techniqueensured groups balanced for confounders.

( n = 34) KMC CMCMean weight 1813g 1866gMean weight 1813g 1866gMean GA 34.2w 35.3wApprop’ GA 65% 64%Male 60% 50%

(p 783)

Research hypotheses

Stabilising

DURING 6h

Stabilised

AT 6 hours

BAILOUT H1a H1bBAILOUT H1a H1b

SCRIP H2a H2b

BAILOUT points ….

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

1 Skin temp consistently <35.5oC

INSTABILITY

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

H1b (SPECIFIC)

Doctor summoned:

INCUBATORINCUBATOR 92%92%

H1b (SPECIFIC)

Doctor summoned:

INCUBATORINCUBATOR 92% 92% SKINSKIN--TOTO--SKINSKIN 17%17%

H1b (SPECIFIC)

DoctorDoctor StableStablesummoned:summoned: .

INCUBATORINCUBATOR 92% 92% 8% 8% INCUBATORINCUBATOR 92% 92% 8% 8% SKINSKIN--TOTO--SKINSKIN 17%17% 83%83%

Bergman et al 2004



17% UNSTABLE


SEPARATION

92% UNSTABLE



83% “STABLE”


SEPARATION

8% “STABLE”

SCRIPHeart rate

Oxygen saturation

Respiratory rate

monitors continuously

STABILITY

SCRIPSCORE

2 1 0

Heart rate Regular Deceleration to 80-100

Rate <80 or >200 bpm

Respiratory rate

Regular Apnoea <10s, or periodic

Apnoea >10sTachypnoea

“Stability of Cardio-Respiratory system In Preterm Infants”

rate or periodic breathing

Tachypnoea >80 pm

Oxygen saturation

Regular >87% Any fall to 80 – 87%

Any fall below 80%

Score allocated for a five minute period ofcontinuous observation, maximum six for period

Fischer et al, 1988 STABILITY

SCRIPHeart rate

Oxygen saturation

Respiratory rate

DASH 3000 monitorscontinuously

STABILIZATION TREND.

SKIN-TO-SKIN: STABLE AT 6 hours

INCUBATOR INFANTS REMAIN UNSTABLE,WITH NO TREND TO STABILIZATION.

“100% SCRIP STABILIY”“100% SCRIP STABILIY”

S S CS S C C M CC M C

1200g to1200g to

2200 g2200 g1 1 -- 6h6h 56%56% 11%11%



1200g to1200g to

2200 g2200 g1 1 -- 6h6h 56%56% 11%11%

@ 6h@ 6h 100%100% 46%46%@ 6h@ 6h 100%100% 46%46%



100% STABLE


SEPARATION

46% STABLE



1200g to1200g to

2200 g2200 g1 1 -- 6h6h 56%56% 11%11%

@ 6h@ 6h 100%100% 46%46%@ 6h@ 6h 100%100% 46%46%

1200g to1200g to

1800g1800g1 1 -- 6h6h 44%44% 0%0%

@ 6h@ 6h 100%100% 25%25%

Stabilization 1200g Stabilization 1200g –– 1800g1800g

Skin-to-skin

Hourly average of SCRIP score, 2nd to 6th hour

Incubator

INCUBATORS INCUBATORS DEDE--STABILISESTABILISENEWBORNSNEWBORNSNEWBORNSNEWBORNS

SKIN-TO-SKIN BREAST- VAGAL


Stabilization Stabilization

SEPARATION


Bergman et al 2004



STABILISATION


SEPARATION

DYS-REGULATION

Nelson & Panksepp 1998

SAFE UNSAFE

SEPARATION DYSREGULATES

PROTEST – DESPAIRcauses

DYSREGULATION

((ModiModi & Glover 1998, & Glover 1998, MoonceyMooncey et al 1997)et al 1997)

“Non-pharmacological reduction of hypercortisolaemia in preterm infants”

Preterm Preterm infants experience prolonged severe stressinfants experience prolonged severe stresswith tenfold increases in with tenfold increases in stress hormonesstress hormones..

Stress hormones at such levels are Stress hormones at such levels are neurotoxicneurotoxic..Stress hormones at such levels are Stress hormones at such levels are neurotoxicneurotoxic..

RCT RCT on methods to reduce of stress (at one hour):on methods to reduce of stress (at one hour):CortisolCortisol EndorphinEndorphin

MassageMassage slightly lowerslightly lower no changeno changeSoft musicSoft music no changeno change no changeno changeSkinSkin--toto--skinskin 66% lower 74% 66% lower 74% lowerlower

Preterm infants experience prolonged severe stressPreterm infants experience prolonged severe stresswith tenfold increases in with tenfold increases in stress hormonesstress hormones..

Stress hormones at such levels are Stress hormones at such levels are neurotoxicneurotoxic..

SSC – PROTECTION SSC – PROTECTION

SEPARATION RAISESSTRESS HORMONES((ModiModi & Glover 1998, & Glover 1998, MoonceyMooncey et al 1997)et al 1997)

RCT on methods to reduce of stress (at one hour):RCT on methods to reduce of stress (at one hour):CortisolCortisol EndorphinEndorphin

MassageMassage slightly lowerslightly lower no changeno changeSoft musicSoft music no changeno change no changeno changeSkinSkin--toto--skinskin 66% lower 74% lower66% lower 74% lower

STRESS HORMONES

Separation from mother is stressful for humans.Separation from mother is stressful for humans.Salivary cortisol is a good measure of stress.Salivary cortisol is a good measure of stress.

RCT (Anderson et al 1998)RCT (Anderson et al 1998)Two groups of newborns,Two groups of newborns,both given best care, onlyboth given best care, onlyone separated from motherone separated from mother

SSC – RESEARCH protection SSC – RESEARCH protection

one separated from motherone separated from motherat one hour ageat one hour age

Cortisol levels measured Cortisol levels measured every hour.every hour.

Cortisol separate = 9Cortisol separate = 9Cortisol with momCortisol with mom = 4= 4

SEPARATION = STRESSSEPARATION = STRESS



NOCERENOCERE

Should Neonates Sleep Alone ?

Biological Psychiatry 2011 Nov 1;70(9):817-25.

PLACE MODEL PLACE MODEL studystudy

evolutionary survival machineevolutionary survival machine

ANSEEGEEG BASBAS

autonomic autonomic upstreamupstream

HRVHRV

upstreamupstream

autonomic autonomic MEDIATORMEDIATORdownstreamdownstream

PLACE conventionPLACE convention

44 BreastfeedingBreastfeeding33 HoldingHolding22 MNS (Cot)MNS (Cot)11 SSC (SkinSSC (Skin--toto--skin)skin)

ANDERSON BEHAVIOURAL STATE SCALE

1211 Crying10 Fussing9 Active8 Breastfeeding7 Alert Awake7 Alert Awake6 Quiet Awake5 Drowsy43 Active Sleep2 Irregular Sleep1 Regular / Quiet Sleep

Babies 2 days oldMNS, 1hr

SSC 1hr

Left power“APPROACH”

Right power“AVOID”

Left asymmetry“APPROACH”

Right asymmetry“AVOID”

Left power“APPROACH”

Right power“AVOID”

Left asymmetry“APPROACH”

Right asymmetry“AVOID”

SSCSSC ............|............|BrfBrf| | MIS MIS ............................

HRV produces IBIHRV produces IBI(Inter Beat Interval)(Inter Beat Interval)frequency domain (PDS)frequency domain (PDS)

FFT / AR / FFT / AR / waveletwavelet•• social social vagusvagus (validated)(validated)•• sympathetic sympathetic (accepted)(accepted)•• social social vagusvagus (validated)(validated)•• sympathetic sympathetic (accepted)(accepted)

GREEN = VLF

AUTONOMIC STATECOMPONENTS:

RED = SNSSYMPATHETIC

BLUE = NEWBLUE = NEWSOCIAL VAGUSSOCIAL VAGUS

SLEEPING AUTONOMIC TONE:SLEEPING AUTONOMIC TONE:

SkinSkin--toto--skinskin.......| .......| Separation Separation ..................

(Spectral analysis HRV)(Spectral analysis HRV)

Skin-to-skin contact= *NORMAL* PLACE = *NORMAL* PLACE

Skin-to-skin contact= *NORMAL* PLACE

SEPARATE176% IncreaseAutonomic

activity

= *NORMAL* PLACE

SEPARATE 86%

DecreaseQuiet Sleep

7 x more QS is SSC7 x more QS is SSC(one seventh of QS in MNS)(one seventh of QS in MNS)

3 x more ANS in MNS3 x more ANS in MNS

Discussion: Discussion: Quiet Sleep Quiet Sleep latency long in MNSlatency long in MNS

Anxious ArousalAnxious ArousalAnxious ArousalAnxious Arousal

SLEEP CYCLE SLEEP CYCLE -- NeurodevelopmentNeurodevelopment

Peirano 2003

Aaron Jones et al. (2004)Aaron Jones et al. (2004)conducted a study of four groups conducted a study of four groups

of mother of mother –– infant dyads:infant dyads:EEG done on baby at 1 month of ageEEG done on baby at 1 month of age

The first group wasThe first group wasThe first group wasThe first group wasDepressedDepressed--BottlefedBottlefed

EEG asymmetryEEG asymmetrycorrelates ascorrelates as

expected ...expected ...Aaron Jones 2004


SSCSSC ......................| ......................| MIS MIS ............................

(Spectral analysis HRV)(Spectral analysis HRV)


SSCSSC ......................| ......................| MIS MIS ............................

VIGILANCE | FREEZE | DISSOCIATION

Perry:Perry: Responses to threatResponses to threat

Perry:Perry: Responses to threatResponses to threat

Babies in Babies in separationseparation do not sleep …do not sleep …… they FREEZE and DISSOCIATE… they FREEZE and DISSOCIATE



SKIN-TO-SKIN CONTACT

Higher state arousal

Normal sleep cycling


SEPARATION

Higher state arousal

Separated neonates experience Separated neonates experience disturbances of sleep cycling.disturbances of sleep cycling.

Biological Psychiatry 2011 Nov 1;70(9):817-25.

NEURO PHYSIOLOGYNEURO PHYSIOLOGY

of SEPARATIONof SEPARATION

Maternal separation may be Maternal separation may be a stressor the human neonate a stressor the human neonate is not wellis not well--evolved to cope with, evolved to cope with, and may not be benign.and may not be benign.

NILS’ TRANSLATION:NILS’ TRANSLATION:

MATERNAL SEPARATION MATERNAL SEPARATION IS TOXIC STRESS !! IS TOXIC STRESS !!


NEUROSCIENCENEUROSCIENCE

The DNAThe DNAEverything elseEverything else

EVOLUTIONARYEVOLUTIONARY

BIOLOGYBIOLOGY

The BrainThe Brain

EPIGENETICSEPIGENETICS

The PlaceThe Place EXPERIENCEEXPERIENCEFITNESSFITNESS ADAPTATIONADAPTATION

“Scientific foundation” … a synthesis “Scientific foundation” … a synthesis

The PlaceThe Place

ENVIRONMENTENVIRONMENT

EXPERIENCEEXPERIENCEFITNESSFITNESS ADAPTATIONADAPTATION

“except in the light of “except in the light of

mother’s body.”mother’s body.”




BIOLOGYBIOLOGY

The BrainThe Brain




The PlaceThe Place






BIOLOGYBIOLOGY

The BrainThe Brain




The PlaceThe Place



“needed neural “needed neural

processes” processes”




BIOLOGYBIOLOGY

The BrainThe Brain




The PlaceThe Place






BIOLOGYBIOLOGY

The BrainThe Brain




The PlaceThe Place



“buffering protection “buffering protection

of adult support” of adult support”




BIOLOGYBIOLOGY

The BrainThe Brain




The PlaceThe Place






BIOLOGYBIOLOGY

The BrainThe Brain




The PlaceThe Place



ZERO ZERO



Separated newborns from Separated newborns from

KANGAROO MOTHER CARE:KANGAROO MOTHER CARE:RESTORING THE ORIGINAL PARADIGMRESTORING THE ORIGINAL PARADIGM

Separated newborns from Separated newborns from experience anxious arousal experience anxious arousal

��

TOXIC STRESSTOXIC STRESS

a “hierarchy paradigm”a “hierarchy paradigm”

BASIC BINARY CHOICE: BASIC BINARY CHOICE: “AM I SAFE ?”“AM I SAFE ?”YESYES NONO

APPROACH : APPROACH : AVOID: AVOID: APPROACH : APPROACH : DEVELOPMENTDEVELOPMENT

AVOID: AVOID: DEFENCEDEFENCE

Biological needsBiological needsfeed / sleep / play feed / sleep / play

Biological prioritiesBiological prioritiesvigilance / freezevigilance / freeze

STATE STATE organisationorganisation STATE STATE organisationorganisation


Quantity and qualityQuantity and qualityof sleep compromised:of sleep compromised:


Quantity and qualityQuantity and qualityof sleep compromised:of sleep compromised:

May be inMay be in“freeze / dissociation”“freeze / dissociation”


Can we distinguishCan we distinguish“healthful” sleep from“healthful” sleep from


Can we distinguishCan we distinguish“healthful” sleep from“healthful” sleep from

freeze & dissociationfreeze & dissociationresponses in neonates?responses in neonates?

ALLOSTATIC LOAD:ALLOSTATIC LOAD:

TOXICSTRESS

SensitivityHIGH

2ND

KNOCK

ALLOSTATIC LOAD:ALLOSTATIC LOAD:“wear and tear that results ….“wear and tear that results ….

SPECTRUM of expression in SPECTRUM of expression in POPULATIONPOPULATION

HEALTHHEALTH DISEASEDISEASE

idealideal benignbenign malevolentmalevolent unsuitableunsuitable




OUR “NORMAL”OUR “NORMAL”CARE CULTURECARE CULTURE



MOTHER ISMOTHER IS OUR “NORMAL”OUR “NORMAL”“BETTER”“BETTER” CARE CULTURECARE CULTURE

(>300 publications)(>300 publications)




OUR “NORMAL”OUR “NORMAL”BIOLOGYBIOLOGY




OUR “NORMAL”OUR “NORMAL” THIS ISTHIS ISBIOLOGYBIOLOGY “WORSE”“WORSE”



NOCERENOCERE

SEPARATION SEPARATION ��HARM !!HARM !!


NOCERENOCERE


All scientific research referred All scientific research referred to, reported or used in CME in to, reported or used in CME in support or justification of a support or justification of a support or justification of a support or justification of a patient care recommendation patient care recommendation must conform to the generally must conform to the generally

accepted standardsaccepted standards of of experimental design, data experimental design, data collection and analysis.collection and analysis.

SKIN-TO-SKIN CONTACTBREAST- VAGAL


THE PLACE MODELPLACE MODEL

NUTRITION

SEPARATION

OTHER PROTEST- STRESS SURVIVAL DESPAIR (SNS)

DEFENCE

(MOWBRAY)(MOWBRAY)


(MOWBRAY)(MOWBRAY)

BIRTH SKINBIRTH SKIN--TOTO--SKIN SKIN

= STABILIZATION= STABILIZATION

(MOWBRAY)(MOWBRAY)


(MOWBRAY)(MOWBRAY)

INCUBATOR CARE INCUBATOR CARE

�� DESTABILIZATION .....DESTABILIZATION .....




�� MUST START @ BIRTHMUST START @ BIRTH

�� MUST BE MUST BE CONTINUOUSCONTINUOUS

�� Aim ZERO SEPARATIONAim ZERO SEPARATION

Premature babies are Premature babies are not in incubators because not in incubators because they are unstable.they are unstable.

Premature babies are Premature babies are not in incubators because not in incubators because they are unstable.they are unstable.

Premature babies Premature babies are unstable because are unstable because they are in incubators.they are in incubators.

INCUBATORS INCUBATORS DEDE--STABILISESTABILISEDEDE--STABILISESTABILISENEWBORNSNEWBORNS

SkinSkin--toto--skin skin contact contact

IS MORE IS MORE essential foressential foressential foressential for

premature premature newborns!newborns!




Our NORMALOur NORMAL biologybiology

Even at 600grEven at 600gr

Scientific Validation Scientific Validation

#5: “replicatethe test condition”SEPARATED SEPARATED NEONATES NEONATES ARE NORMAL ARE NORMAL

Scientific Validation Scientific Validation of a of a

False AssumptionFalse Assumption

“It’s not what we “It’s not what we know that gets us know that gets us into trouble….into trouble….

“It’s not what we “It’s not what we know that gets us know that gets us into trouble….into trouble….

it’s what we know…it’s what we know…it’s what we know…it’s what we know…

that just ain’t so!that just ain’t so!FromFrom: : Everybody’s FriendEverybody’s Friend (1874)(1874)

By Josh BillingsBy Josh Billings

NORMALNORMAL

IncubatorIncubator

NORMALNORMAL

Perceived harm: Perceived harm: NO NO

NORMALNORMAL

SSCSSC

IncubatorIncubator

NORMALNORMAL


SSCSSCNORMALNORMAL

SSCSSC

IncubatorIncubator

IncubatorIncubator

NORMALNORMAL


SSC 83%SSC 83%NORMALNORMAL

SSC 17%SSC 17%

MIS 92%MIS 92%

MIS 8%MIS 8%

NORMALNORMAL

Perceived HARM: Perceived HARM: NO NO YESYES

Late Preterm Infant (LPI)Late Preterm Infant (LPI)

LPI have poor outcomesLPI have poor outcomes

APPLICABILITY TO NEONATOLOGY ???APPLICABILITY TO NEONATOLOGY ???

Question: do PRETERMS experienceQuestion: do PRETERMS experienceQuestion: do PRETERMS experienceQuestion: do PRETERMS experienceTOXIC STRESS ??TOXIC STRESS ??

SSC 83%SSC 83%NORMALNORMAL

MIS 8%MIS 8%

NORMALNORMAL

Perceived HARM: Perceived HARM: NO NO YESYES

((ModiModi & Glover 1998, & Glover 1998, MoonceyMooncey et al 1997)et al 1997)

“Non-pharmacological reduction of hypercortisolaemia in preterm infants”

Preterm Preterm infants experience prolonged severe stressinfants experience prolonged severe stresswith tenfold increases in with tenfold increases in stress hormonesstress hormones..

Stress hormones at such levels are Stress hormones at such levels are neurotoxicneurotoxic..Stress hormones at such levels are Stress hormones at such levels are neurotoxicneurotoxic..

RCT RCT on methods to reduce of stress (at one hour):on methods to reduce of stress (at one hour):CortisolCortisol EndorphinEndorphin

MassageMassage slightly lowerslightly lower no changeno changeSoft musicSoft music no changeno change no changeno changeSkinSkin--toto--skinskin 66% lower 74% 66% lower 74% lowerlower

Preterm infants experience prolonged severe stressPreterm infants experience prolonged severe stresswith tenfold increases in with tenfold increases in stress hormonesstress hormones..

Stress hormones at such levels are Stress hormones at such levels are neurotoxicneurotoxic..

SSC – PROTECTION SSC – PROTECTION

SEPARATION RAISESSTRESS HORMONES((ModiModi & Glover 1998, & Glover 1998, MoonceyMooncey et al 1997)et al 1997)

RCT on methods to reduce of stress (at one hour):RCT on methods to reduce of stress (at one hour):CortisolCortisol EndorphinEndorphin

MassageMassage slightly lowerslightly lower no changeno changeSoft musicSoft music no changeno change no changeno changeSkinSkin--toto--skinskin 66% lower 74% lower66% lower 74% lower

STRESS HORMONES

Separation from mother is stressful for humans.Separation from mother is stressful for humans.Salivary cortisol is a good measure of stress.Salivary cortisol is a good measure of stress.

RCT (Anderson et al 1998)RCT (Anderson et al 1998)Two groups of newborns,Two groups of newborns,both given best care, onlyboth given best care, onlyone separated from motherone separated from mother

SSC – RESEARCH protection SSC – RESEARCH protection

one separated from motherone separated from motherat one hour ageat one hour age

Cortisol levels measured Cortisol levels measured every hour.every hour.

Cortisol separate = 9Cortisol separate = 9Cortisol with momCortisol with mom = 4= 4

SEPARATION = STRESSSEPARATION = STRESS

Skin-to-skin contact= *NORMAL* PLACE

SEPARATE176% IncreaseAutonomic

activity

= *NORMAL* PLACE

SEPARATE 86%

DecreaseQuiet Sleep

NILS’ TRANSLATION:NILS’ TRANSLATION:

MATERNAL SEPARATION MATERNAL SEPARATION IS TOXIC STRESS !! IS TOXIC STRESS !!


... the newborn child ... the newborn child ... the newborn child ... the newborn child is a small human being, is a small human being, with all its senses developed, with all its senses developed,

open and receptive.open and receptive.(John Lind, 1979)(John Lind, 1979)

Preterm infants havePreterm infants haveLESS RESILIENCE LESS RESILIENCE ��Need “ideal” EEANeed “ideal” EEALESS RESILIENCE LESS RESILIENCE Need “ideal” EEANeed “ideal” EEA

TOXIC STRESS TOXIC STRESS concerns the NEONATOLOGIST concerns the NEONATOLOGIST more than the PEDIATRICIANmore than the PEDIATRICIAN

The basic science of pediatrics .

©2012 by American Academy of Pediatrics

Shonkoff J P et al. Pediatrics 2012;129:e232-e246




BIOLOGYBIOLOGY



The BrainThe Brain


The PlaceThe Place




EXPECTED EXPECTED �� UNEXPECTED UNEXPECTED


Platform for better understanding of Platform for better understanding of PUBLIC HEALTHPUBLIC HEALTH..

… policy and practice that impacts the care of mothers and babies.… policy and practice that impacts the care of mothers and babies.

LearningLearningBehaviorBehavior

Physical well beingPhysical well beingMental well beingMental well being

2 … advances in the biological sciences underscore the foundational importance of the early years and support an EBD framework for understanding the evolution of human health and disease across the life span.

EARLY YEARS EARLY YEARS �� LIFE SPANLIFE SPAN



TOXIC TOXIC STRESSSTRESS

EARLY EARLY LIFE LIFE ADVERSITYADVERSITY

3. The biology of early childhood adversity reveals the important role of toxic stress in disrupting developing brain architecture and adversely affecting the concurrent development of other organ systems and regulatory functions.

EARLY YEARS EARLY YEARS �� LIFE SPANLIFE SPANSTRESSSTRESS





MAKES POORER MAKES POORER LinguisticLinguisticCognitiveCognitiveEmotionalEmotionalAdaptionAdaption

responsivityresponsivity

4 Toxic stress can lead to potentially permanent changes in learning ( … ), behavior ( … ), and physiology ( … ) and can cause … higher levels of stress related chronic diseases, …increase the prevalence of unhealthy lifestyles that lead to widening health disparities.

EARLY YEARS EARLY YEARS �� LIFE SPANLIFE SPANSTRESSSTRESS responsivityresponsivity

�� unhealthy lifestyleunhealthy lifestyle��Chronic diseaseChronic disease��health disparityhealth disparity







5. The lifelong costs of childhood toxic stress are enormous, … andeffective early childhood interventions provide critical opportunitiesto prevent these undesirable outcomes and generate large economicreturns for all of society.



MASSIVE MASSIVE COST $$$$COST $$$$







6. The consequences of significant adversity early in life prompt an urgent call for innovative strategies to reduce toxic stress within thecontext of a coordinated system of policies and services guided by anintegrated science of early childhood and early brain development.




REDUCEREDUCETOXIC STRESSTOXIC STRESS

An ecobiodevelopmental framework for early childhood policies and programs.



7. An EBD framework, grounded in an integrated basic science, provides a clear theory of change to help leaders in policy and practice craft new solutions to the challenges of societal disparities in health, learning, and behavior (see Fig 2).

8. Pediatrics provides a powerful yet underused platform for 8. Pediatrics provides a powerful yet underused platform for translating scientific advances into innovative early childhood policies, and practicing pediatricians are ideally positionedto participate “on the ground” in the design, testing, and refinement of new models of disease prevention, health promotion, and developmental enhancement beginning in the earliest years of life.



BERGMAN COMMENTARY BERGMAN COMMENTARY -- NEWBORNNEWBORN

For newborn:For newborn:it is MOTHERit is MOTHERthat is that is

ecology, ecology, biology, biology,

developmentdevelopment




BIOLOGYBIOLOGY



The BrainThe Brain


The PlaceThe Place










EARLY YEARS EARLY YEARS �� LIFE SPANLIFE SPAN

BERGMAN COMMENTARY BERGMAN COMMENTARY –– NEWBORNNEWBORNEarly years = early hours & daysEarly years = early hours & days





EARLY YEARS EARLY YEARS �� LIFE SPANLIFE SPANSTRESSSTRESS

BERGMAN COMMENTARY BERGMAN COMMENTARY –– NEWBORNNEWBORNMaternal absence is TOXIC STRESSMaternal absence is TOXIC STRESS









BERGMAN COMMENTARY BERGMAN COMMENTARY –– NEWBORNNEWBORNFor separated preterm newborns, weFor separated preterm newborns, wehave decades of evidence for this.have decades of evidence for this.










BERGMAN COMMENTARY BERGMAN COMMENTARY –– NEWBORNNEWBORNeven more massive ??even more massive ??










REDUCEREDUCETOXIC STRESSTOXIC STRESS

BERGMAN COMMENTARY BERGMAN COMMENTARY –– NEWBORNNEWBORNReducing toxic stress IS VERY EASY !!Reducing toxic stress IS VERY EASY !!

Evolutionary biologyEvolutionary biology

SkinSkin--toto--Skin Skin

ContactContact

AttachmentAttachment

BondingBonding

ContactContact

BreastBreast--feedingfeeding

RegulationRegulation

An ecobiodevelopmental framework for early childhood policies and programs.

AttachmentAttachment

BondingBonding

SkinSkin--toto--Skin Skin

ContactContact

BERGMAN COMMENTARY BERGMAN COMMENTARY –– NEWBORNNEWBORNReducing toxic stress IS VERY EASY !!Reducing toxic stress IS VERY EASY !!

BreastBreast--feedingfeeding

ContactContact




BIOLOGYBIOLOGY



The BrainThe Brain


The PlaceThe Place








Innovative strategies …Innovative strategies …… reduce toxic stress… reduce toxic stress

Creative new Creative new Creative new Creative new strategiesstrategies

“compelling need for bold “compelling need for bold new strategies”new strategies”

“compelling need for bold new “compelling need for bold new strategies”strategies”NOT NOT �� Kangaroo Care !!!Kangaroo Care !!!

“compelling need for bold new “compelling need for bold new strategies”strategies”NOT NOT �� Kangaroo Care !!!Kangaroo Care !!!

BUT …BUT …Developmental scienceDevelopmental scienceDevelopmental scienceDevelopmental science((ecobiodevelopmentalecobiodevelopmental))

APPLYING PRIMATE APPLYING PRIMATE EVOLUTIONARY BIOLOGY EVOLUTIONARY BIOLOGY

MATERNAL D

EPE

NDENCE

100%

MATERNAL DEPENDENCE

0 10 20 30 40w 1y 3 5 7 9 13 23 53Birth Puberty

MATERNAL D

EPE

NDENCE

MATERNAL D

EPE

NDENCE

100%

MATERNAL DEPENDENCEPREMATURITY

0 10 20 30 40w 1y 3 5 7 9 13 23 53Birth Puberty

MATERNAL D

EPE

NDENCE

MATERNAL D

EPE

NDENCE

100%


DEPRIVATIONDEPRIVATION

SENSORY SENSORY SOCIALSOCIALSTIMULATIONSTIMULATION

0 10 20 30 40w 1y 3 5 7 9 13 23 53Birth Puberty

MATERNAL D

EPE

NDENCE

DEPRIVATIONDEPRIVATIONBASIC BASIC BIOLOGICAL BIOLOGICAL NEEDSNEEDS

MATERNAL D

EPE

NDENCE

100%


0 10 20 30 40w 1y 3 5 7 9 13 23 53Birth Puberty

MATERNAL D

EPE

NDENCE

KC (Kangaroo Care)KC (Kangaroo Care)

MotherMother--infant skininfant skin--toto--skin contact after extremely preterm birth results in skin contact after extremely preterm birth results in

neither benefit nor adverse consequences.neither benefit nor adverse consequences.Although there is no reason to dissuade mothers who wish to provide STS contact, 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 we are unable to recommend resource allocation for the implementation of STS we are unable to recommend resource allocation for the implementation of STS we are unable to recommend resource allocation for the implementation of STS programmes for extremely preterm infants in a neonatal intensive care unit setting.programmes for extremely preterm infants in a neonatal intensive care unit setting.

Miles et al 2006

THE NEUROSCIENCETHE NEUROSCIENCEOF KANGAROO CAREOF KANGAROO CARE

TOO LITTLE,TOO LITTLE,TOO LITTLE,TOO LITTLE,TOO LATE ..TOO LATE ..

Miles et al 2006

MATERNAL D

EPE

NDENCE

100%


KMC KMC

0 10 20 30 40w 1y 3 5 7 9 13 23 53Birth Puberty

MATERNAL D

EPE

NDENCE

KC (Kangaroo Care)KC (Kangaroo Care)

KMC KMC (Kangaroo (Kangaroo Mother Care)Mother Care)

KANGAROO MOTHER CARE:KANGAROO MOTHER CARE:

KMC (in the world) KMC (in the world) ––SkinSkin--toto--skin contactskin contactSkinSkin--toto--skin contactskin contact

WHEN STABLE !!!WHEN STABLE !!!Exclusive breastfeedingExclusive breastfeedingTechnical support addedTechnical support added(Early discharge (Early discharge –– followup)followup)

MATERNAL D

EPE

NDENCE

100%

MATERNAL DEPENDENCE

BSSC BSSC Birth (or Immediate)Birth (or Immediate)SkinSkin--toto--Skin ContactSkin Contact

0 10 20 30 40w 1y 3 5 7 9 13 23 53Birth Puberty

MATERNAL D

EPE

NDENCE

GOOD &GOOD &QUALITYQUALITYSURVIVALSURVIVAL




BIOLOGYBIOLOGY

The BrainThe Brain




The PlaceThe Place



“except in the light of “except in the light of

mother’s body.”mother’s body.”




BIOLOGYBIOLOGY

The BrainThe Brain




The PlaceThe Place



“needed neural “needed neural

processes” processes”




BIOLOGYBIOLOGY

The BrainThe Brain




The PlaceThe Place



“buffering protection “buffering protection

of adult support” of adult support”




BIOLOGYBIOLOGY

The BrainThe Brain




The PlaceThe Place



ZERO ZERO





SEPARATION

Relationships are the “Active Ingredients" of Early Experience

•• Nurturing and responsive interactions build Nurturing and responsive interactions build healthy brain architecture that provides a strong healthy brain architecture that provides a strong foundation for later learning, behavior, health.foundation for later learning, behavior, health.foundation for later learning, behavior, health.foundation for later learning, behavior, health.

•• When protective relationships are not provided, When protective relationships are not provided, persistent stresspersistent stress results in elevated cortisol results in elevated cortisol levels that disrupt brain architecture by levels that disrupt brain architecture by impairing cell growth and interfering with the impairing cell growth and interfering with the formation of healthy neural circuits.formation of healthy neural circuits.

Jack P. Shonkoff, M.D.

START @ BIRTHSTART @ BIRTH

The GOLDEN HOURThe GOLDEN HOUR

Premature birthPremature birth

The GOLDEN HOURThe GOLDEN HOUR

Being flexible, willing to Being flexible, willing to question routinesquestion routines

“PETER” “PETER”

Born Born 25w GA 25w GA 520g520g

SSC started d1SSC started d12x daily2x daily2x daily2x daily66--8 h a time8 h a time

Now 27w GANow 27w GA620 grams620 gramsCPAPCPAP

“small”“small”

After a few moments ... After a few moments ... ... awake and alert state... awake and alert state

Bjorn WESTRUP (Bjorn WESTRUP (KarolinskaKarolinska))

Large family room where we also care for mothers Large family room where we also care for mothers who are in need of medical care, except intensive carewho are in need of medical care, except intensive care

Continue skinContinue skin--toto--skin in the NICU …skin in the NICU …

DEVELOPMENTDEVELOPMENT

REGULATION REGULATION

FAMILY FAMILY CENTERED CENTERED CARECARE

VERY LITERALLY !!VERY LITERALLY !!VERY LITERALLY !!VERY LITERALLY !!(not lip service ! )(not lip service ! )

LabourLabour wardwardOperating roomOperating roomNICU and afterNICU and after

FAMILY CENTERED CAREFAMILY CENTERED CARE�� DO IT DO IT LITERALLY !!LITERALLY !!


Large family room where we also care for mothers Large family room where we also care for mothers who are in need of medical care, except intensive carewho are in need of medical care, except intensive care

Bjorn WESTRUP (Bjorn WESTRUP (KarolinskaKarolinskaContinue skinContinue skin--toto--skin in the NICU …skin in the NICU …

“PETER” “PETER” Born Born 25w GA 25w GA

520g520gSSC started d1SSC started d1


SSC started d1SSC started d166--8 h a time8 h a time

After a few After a few moments ... moments ... ... awake and ... awake and alert statealert state


Triplets … requires a teamTriplets … requires a team

Father during C/SFather during C/S

… problem ? … problem ?

PerinatalPerinatal neuroscience and neuroscience and neonatal care: the new neonatal care: the new science of being born.science of being born.

SkinSkin--toto--skin contact skin contact ––our developmental our developmental

environment.environment.

It matters how we are born!It matters how we are born!It influences our emotionalIt influences our emotionaland social development, and social development, our future EQ.our future EQ.



Contrary to old beliefs:Contrary to old beliefs:the human newborn is profoundlythe human newborn is profoundly

sentient and perceptive,sentient and perceptive,at birth and thereafter. at birth and thereafter.



Separation is Separation is a major stressa major stress,,which increases which increases cortisolcortisol,,disrupts development ofdisrupts development ofnew neural pathwaysnew neural pathways




Our NORMALOur NORMAL biologybiology



www.skintoskincontact.comwww.skintoskincontact.com

INTRODUCTION“It is easier to build strong childrenthan to repair broken men.”

Frederick Douglass (1817–1895)

PARADIGM SHIFT !!PARADIGM SHIFT !!

Please care formy brain

Please care formy brain

PUBLIC HEALTH IMPERATIVEPUBLIC HEALTH IMPERATIVE

THANK YOU

References and more information:References and more information:www.skintoskincontact.comwww.skintoskincontact.com

the scientific and evidence basis for skin--toto--skin contactskin...

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