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Ho a1 gr 130219 60m ssc pns into ebm rwh

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Ho a1 gr 130219 60m ssc pns into ebm rwh

  1. 1. 1Dr Nils BergmanMB ChB, DCH, MPH, MD(USA equiv: MD, MPH ,PhD)Cape Town, RSAwww.skintoskincontact.comSKIN-TO-SKIN CONTACT –Making perinatal neuroscienceinto evidence based practice.Speaker DisclosureUnder ACCME guidelines:a) I am the South African distributor ofMIRIS : Human Milk Analyzerb) My wife markets educational materials and shirts relatedto the talk contentKangaroo Mother Care PromotionsSKIN-TO-SKIN CONTACT –Making perinatal neuroscienceinto evidence based practice.“For species such asprimates, the motherIS the environment.”Sarah Blaffer Hrdy, Mother Nature (1999)Babies Celebrated, Beatrice Fontanel and Claire D’Harcourt, © 1998 Harry N. Abrams, Inc.Nothing an infant can orcannot do makes sense,except in light of mother’s bodyNEUROSCIENCEThe DNAEverything elseEVOLUTIONARYBIOLOGYThe BrainEPIGENETICSThe PlaceENVIRONMENTEXPERIENCEFITNESS ADAPTATION“Scientific foundation” … a synthesis“except in the light ofmother’s body.”“EEA”Environment ofEvolutionaryAdaptednessThe PlaceENVIRONMENTEXPERIENCEFITNESS ADAPTATION
  2. 2. 2MOTHERis the key toneurodevelopment …Environment ofEvolutionaryAdaptednessMOTHERis the key toneurodevelopment …… because she is theRIGHT PLACE !!NEUROSCIENCEThe DNAEverything elseEVOLUTIONARYBIOLOGYThe PlaceENVIRONMENTEXPERIENCEFITNESS ADAPTATION“Scientific foundation” … a synthesisThe BrainEPIGENETICS… because she is theRIGHT PLACE !!DEFENCE NUTRITION REPRODUCTIONHORMONES NERVES MUSCLESendocrine autonomic NS somaticHIGHLY CONSERVEDNEURO-ENDOCRINEBEHAVIOR“The newborn may appearhelpless, butraises its own temperature,has a higher blood glucose,metabolic adaptation faster.(Widstrom 1987)METABOLIC ADAPTATIONSSC started in the first20 minutes after birthSSC CotBlood glucose (1 hr) 3.17 2.56Base excess drop 3.4 1.8(Christenson 1992)
  3. 3. 3Warming,feeding andprotectionbehaviours areintricately, inseparablylinked to the right place.(Alberts 1994)NEUROSCIENCEThe DNAEverything elseEVOLUTIONARYBIOLOGYThe PlaceENVIRONMENTEXPERIENCEFITNESS ADAPTATION“Scientific foundation” … a synthesisThe BrainEPIGENETICSKangaroo POSITIONKangaroo NUTRITIONKangaroo SUPPORTDISCHARGEThe PlaceENVIRONMENTEXPERIENCEFITNESS ADAPTATIONKANGAROO MOTHER CARE SKIN-TO-SKIN CONTACT“Cells whichFIRE TOGETHER,WIRE TOGETHER,and those whichdon’t, won’t.”Carla Shatzfetal REM sleep(or active sleep) seems to beparticularly importantto the developing organism... spontaneoussynchronous firingMarks et al 1995Panksepp 1998Siegel 2005Non-REM 4
  4. 4. 4REMNR1NR2NR3NR4ACQUISITION CONSOLIDATION MEMORYFORMATIONpoly-sensory input transfer information P wavesshort-term memory “SNR” strong signals returns infostored cortex amygdala / to neocortex:hippocampus organizedAwake and REM NREM stage 4 REMBRAIN WIRINGStanley Graven 2006BRAIN WIRINGPeirano 2003When doesthe infantbecomeconscious? Noradrener-gic neuronsfrom locuscoeruleus mayactivate thewhole brainduringwakefulnessAwake at birthAT BIRTH,the brain hasTWOCRITICALSENSORYNEEDS:SMELL & CONTACTconnect direct to the amygdalaTHENEWBORNBRAINSKIN-TO-SKINCONTACTfires and wiresthe amygdala-prefronto-orbitalcortical pathway (PFOC)AMYGDALA:EmotionalProcessingUnitPrefrontal cortexExecutivefunctionapproach / avoid
  5. 5. 5AMYGDALA:EmotionalProcessingUnit CPUPrefrontal cortexExecutivefunctionSOCIAL and EMOTIONALINTELLIGENCESOCIAL EMOTIONALINTELLIGENCE INTELLIGENCEBehaviouralactivation systemreward-based(dopamine)In humans, oxytocin increases gaze to theeye region of human faces and enhancesinterpersonal trust and the ability to inferthe emotions of others from facial cues.InterpersonalawarenessEmotionsKerstinUvnas-MobergRoss 2009
  6. 6. 6SmellSkin contactThe BONDis made up of thesensory inputsfrom the parentto the infantREGULATIONBowlby 1969, 1973, 1980Through “hidden maternal regulators” ...warmth  activity levelmilk  heart rate“ physiological set points “internal working modelsscripts – templates
  7. 7. 7a mother precisely controls everyelement of her infant’s physiology,from its heart rate to itsrelease of hormonesfrom its appetite to theintensity of its activity(Gallagher 1992)Through “hidden maternal regulators” ... Clinics in Perinatology,June 2004, Vol 31(2) page 210Stanley GravenEarly neurosensory visualdevelopment of fetus and newborn.“It is a serious mistake to assume that theprinciples derived from careful animal studiesdo not apply to human infants.The risk of suppression or disruption ofneeded neural processes ...is very significant and potentially lasts a life time.NEUROSCIENCEThe DNAEverything elseEVOLUTIONARYBIOLOGYThe BrainEPIGENETICSThe PlaceENVIRONMENTEXPERIENCEFITNESS ADAPTATION“Scientific foundation” … a synthesis“needed neuralprocesses”SEPARATION DYSREGULATESCORTISOLMICHAEL MEANEYUnsafe environment activates HPAaxis (autonomic nervous system, ANS).“In response to stress, CRF… and vasopressin arereleased … anterior pituitary… synthesis release ACTH…glucocorticoids  ”CORTISOL
  8. 8. 8HG BABY HG BABYLOW Grooming careHG - High Grooming Low Grooming LGHG BABY LG BABYMOTHER MOTHERHealthy UNHEALTHYadult adultHG – High Grooming Low Grooming - LGMakes MOTHER Makes MOTHERUNHEALTHYadultLOW Grooming LGMakes MOTHERCORTISOLLG BABY LG BABYHIGH grooming careHG - High Grooming Low Grooming LGHG BABY LG BABYMOTHER MOTHERHealthy UNHEALTHYadult adultHG – High Grooming Low Grooming - LGMakes MOTHER Makes MOTHERHEALTHYadultHIGH Grooming HGMakes MOTHERHG – High Grooming Low Grooming - LGMakes MOTHER Makes MOTHERHEALTHYadultHIGH Grooming HGMakes MOTHEREarliest careat birth mattersSame gene  switchedLG BABY LG BABYHIGH grooming carePrimate separation studiesMaternal Separation ParadigmEarly Deprivation (ED) vs control (CON)0d 2d  28d   48wED n 11 Mat 30 -120 min daily CON n 4 Mat       48wRepeated shortseparations:LOW gene expressionCorrelate to human adult depressionCORTISOL
  9. 9. 9Allostasis the mechanism by whichhomeostatic systems are maintained in balance …Allostatic state elevated activity of mediators,with return to baseline and no impact on health.Allostatic load elevated activity –sustained over time, or severe … changes target cells of mediators,and so changes the “set points” for homeostasis(e.g. increasing blood pressure,change in cholesterol level)BRUCE McEWEN allostasis RESILIENCE / SENSITIVITY PERCEPTIONS“NEUROCEPTION”RESPONSESTRESSALLOSTATIC STATEALLOSTASISPsychologicalNeurologicalEndocrineImmuneHEALTH DISEASEALLOSTATIC LOADALLOSTATIC OVERLOADWELL-BEING  SUSCEPTIBILITY  MORBIDITY  MORTALITYNEUROSCIENCEThe DNAEverything elseEVOLUTIONARYBIOLOGYThe PlaceENVIRONMENTEXPERIENCEFITNESS ADAPTATIONSPECTRUM of expression in POPULATIONHEALTH DISEASE“Scientific foundation” … a synthesisThe BrainEPIGENETICSEXPECTED UNEXPECTEDNEUROSCIENCEThe DNAEverything elseEVOLUTIONARYBIOLOGYThe PlaceENVIRONMENTEXPERIENCEFITNESS ADAPTATIONSPECTRUM of expression in POPULATIONHEALTH DISEASE“Scientific foundation” … a synthesisPlatform for better understanding of PUBLIC HEALTH.… policy and practice that impacts the care of mothers and babies.The BrainEPIGENETICSEXPECTED UNEXPECTED
  10. 10. 10Positive Stress•Moderate, short-lived stress responses, suchas brief increases in heart rate or mild changesin stress hormone levels.•An important and necessary aspect of healthydevelopment that occurs in the context ofstable and supportive relationships.Slide by: Jack P. Shonkoff, M.D.Under-activityEUSTRESSOver-activityPositive Stress= Eustress• An important and necessaryaspect of healthy developmentthat occurs in the context ofstable and supportive relationships.Tolerable Stress• Stress responses that could disrupt brainarchitecture, but are buffered by supportiverelationships that facilitate adaptive coping.• Generally occurs within a time-limited period,which gives the brain an opportunity to recoverfrom potentially damaging effects.Slide by: Jack P. Shonkoff, M.D.JACK SHONKOFF“Buffering protectionof adult support”
  11. 11. 11The basicscience ofpediatrics.Shonkoff J P et al.Pediatrics 2012;129:e232-e246©2012 by American Academy of Pediatrics2 … advances in the biological sciences underscore the foundationalimportance of the early years and support an EBD framework for understandingthe evolution of human health and disease across the life span.EARLY YEARS  LIFE SPANLearningBehaviorPhysical well beingMental well being3. The biology of early childhood adversity reveals the important role of toxicstress in disrupting developing brain architecture and adversely affecting theconcurrent development of other organ systems and regulatory functions.EARLY YEARS  LIFE SPANLearningBehaviorPhysical well beingMental well beingTOXICSTRESSEARLY LIFEADVERSITY4 Toxic stress can lead to potentially permanent changes in learning ( … ),behavior ( … ), and physiology ( … ) and can cause … higher levels of stressrelated chronic diseases, …increase the prevalence of unhealthy lifestyles that leadto widening health disparities.EARLY YEARS  LIFE SPANLearningBehaviorPhysical well beingMental well beingTOXICSTRESSEARLY LIFEADVERSITYMAKES POORERLinguisticCognitiveEmotionalAdaptionresponsivity unhealthy lifestyleChronic diseasehealth disparity5. 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.EARLY YEARS  LIFE SPANLearningBehaviorPhysical well beingMental well beingTOXICSTRESSEARLY LIFEADVERSITYMAKES POORERLinguisticCognitiveEmotionalAdaptionresponsivity unhealthy lifestyleChronic diseasehealth disparityMASSIVECOST $$$$6. The consequences of significant adversity early in life prompt an urgent call forinnovative strategies to reduce toxic stress within thecontext of a coordinated system of policies and services guided by anintegrated science of early childhood and early brain development.EARLY YEARS  LIFE SPANLearningBehaviorPhysical well beingMental well beingTOXICSTRESSEARLY LIFEADVERSITYMAKES POORERLinguisticCognitiveEmotionalAdaptionresponsivity unhealthy lifestyleChronic diseasehealth disparityMASSIVECOST $$$$REDUCETOXIC STRESS
  12. 12. 12EARLY YEARS  LIFE SPANLearningBehaviorPhysical well beingMental well beingBERGMAN COMMENTARY – NEWBORNEarly years = early hours & daysEARLY YEARS  LIFE SPANLearningBehaviorPhysical well beingMental well beingTOXICSTRESSEARLY LIFEADVERSITYBERGMAN COMMENTARY – NEWBORNMaternal absence is TOXIC STRESSEARLY YEARS  LIFE SPANLearningBehaviorPhysical well beingMental well beingTOXICSTRESSEARLY LIFEADVERSITYMAKES POORERLinguisticCognitiveEmotionalAdaptionresponsivity unhealthy lifestyleChronic diseasehealth disparityBERGMAN COMMENTARY – NEWBORNFor separated preterm newborns, wehave decades of evidence for this.EARLY YEARS  LIFE SPANLearningBehaviorPhysical well beingMental well beingTOXICSTRESSEARLY LIFEADVERSITYMAKES POORERLinguisticCognitiveEmotionalAdaptionresponsivity unhealthy lifestyleChronic diseasehealth disparityMASSIVECOST $$$$BERGMAN COMMENTARY – NEWBORNeven more massive ??EARLY YEARS  LIFE SPANLearningBehaviorPhysical well beingMental well beingTOXICSTRESSEARLY LIFEADVERSITYMAKES POORERLinguisticCognitiveEmotionalAdaptionresponsivity unhealthy lifestyleChronic diseasehealth disparityMASSIVECOST $$$$REDUCETOXIC STRESSBERGMAN COMMENTARY – NEWBORNReducing toxic stress IS VERY EASY !!Skin-to-SkinContactAttachmentBondingBreast-feedingRegulation
  13. 13. 13An ecobiodevelopmental framework for early childhood policies and programs.BERGMAN COMMENTARY – NEWBORNReducing toxic stress IS VERY EASY !!AttachmentBondingBreast-feedingSkin-to-SkinContactNEUROSCIENCEThe DNAEverything elseEVOLUTIONARYBIOLOGYThe PlaceENVIRONMENTEXPERIENCEFITNESS ADAPTATIONSPECTRUM of expression in POPULATIONEXPECTED   UNEXPECTEDHEALTH DISEASE“Scientific foundation” … a synthesisPlatform for better understanding of PUBLIC HEALTH.… policy and practice that impacts the care of mothers and babies.The BrainEPIGENETICSNEUROSCIENCEThe DNAEverything elseEVOLUTIONARYBIOLOGYThe BrainEPIGENETICSThe PlaceENVIRONMENTEXPERIENCEFITNESS ADAPTATION“Scientific foundation” … a synthesis“buffering protectionof adult support”NEUROSCIENCEThe DNAEverything elseEVOLUTIONARYBIOLOGYThe BrainEPIGENETICSThe PlaceENVIRONMENTEXPERIENCEFITNESS ADAPTATION“Scientific foundation” … a synthesis“needed neuralprocesses”NEUROSCIENCEThe DNAEverything elseEVOLUTIONARYBIOLOGYThe BrainEPIGENETICSThe PlaceENVIRONMENTEXPERIENCEFITNESS ADAPTATION“Scientific foundation” … a synthesis“except in the light ofmother’s body.”NEUROSCIENCEThe DNAEverything elseEVOLUTIONARYBIOLOGYThe BrainEPIGENETICSThe PlaceENVIRONMENTEXPERIENCEFITNESS ADAPTATION“Scientific foundation” … a synthesisZERO SEPARATION
  14. 14. 14EVOLUTIONARYBIOLOGY,EPIGENETICS,NEUROSCIENCETHE SCIENTIFIC ANDEVIDENCE BASIS FORSKIN-TO-SKIN CONTACTHABITATMATERNALMOTHEROTHERALTERNATEAM I SAFE HERE ??MATERNAL DEPENDENCEHABITAT NICHEBREAST-MOTHER FEEDINGOTHER PROTEST-DESPAIRSAFE ?  YESSAFE ?  NOBREAST- VAGALMOTHER FEEDING (PSNS) GROWTHOTHER PROTEST- STRESS SURVIVAL orDESPAIR (SNS)SKIN-TO-SKIN CONTACTSEPARATIONTHE PLACE MODELThe PLACE MODEL scientifically derived alternative approach falsifiable/testable hypothesisPERINATAL NEUROSCIENCE& SKIN-TO-SKIN CONTACTReferenceRCT of skin-to-skin contact from birthversus conventional incubator carefor physiological stabilisationin 1200- and 2199-gram newborns.Bergman NJ, Linley LL, Fawcus SR.Acta Paediatrica 2004Vol 93(6); 779-785Bergman et al 2004
  15. 15. 15Primary hypothesisSSC (skin-to-skin contact)from birth is superiorto incubator care forlow birthweight infantsONLY PLACE DIFFERSBergman et al 2004ResultsMinimisation techniqueensured groups balancedfor confounders.( n = 34) SSC CMCMean weight 1813g 1866gMean GA 34.2w 35.3wApprop’ GA 65% 64%Male 60% 50%(p 783)Bergman et al 2004BAILOUT points ….“physiological parameters exceeding normallimits, requiring medical assessment and orintervention”1 Skin temp consistently <35.5oC2 Heart rate <100; or > 180 bpm3 Apnoea longer than 20 seconds4 O2 sats below 89% (x2), (CPAP/60% O2)5 Blood glucose < 2,6mmol/l, (laboratory)Bergman et al 2004INSTABILITY H1b (SPECIFIC)Doctor Stablesummoned: .INCUBATOR 92% 8%SKIN-TO-SKIN 17% 83%Bergman et al 2004BREAST- VAGALMOTHER FEEDING (PSNS) GROWTHOTHER PROTEST- STRESS SURVIVAL orDESPAIR (SNS)SKIN-TO-SKIN CONTACTSEPARATIONTHE PLACE MODEL8% “STABLE”83% “STABLE”SCRIPSCORE2 1 0Heart rate Regular Decelerationto 80-100Rate <80 or>200 bpmRespiratoryrateRegular Apnoea <10s,or periodicbreathingApnoea >10sTachypnoea>80 pmOxygensaturationRegular >87% Any fall to 80– 87%Any fall below80%“Stability of Cardio-Respiratory system In Preterm Infants”Score allocated for a five minute period ofcontinuous observation, maximum six for periodFischer et al, 1988 STABILITY
  16. 16. 16“100% SCRIP STABILIY”S S C C M C1200g to2200 g1 - 6h 56% 11%@ 6h 100% 46%BREAST- VAGALMOTHER FEEDING (PSNS) GROWTHOTHER PROTEST- STRESS SURVIVAL orDESPAIR (SNS)SKIN-TO-SKIN CONTACTSEPARATIONTHE PLACE MODEL46% STABLE100% STABLE“100% SCRIP STABILIY”S S C C M C1200g to2200 g1 - 6h 56% 11%@ 6h 100% 46%1200g to1800g1 - 6h 44% 0%@ 6h 100% 25%Stabilisation first 6 hours, average hourly SCRIP score5.15.25.35.45.55.65.75.85.966.12nd 3rd 4th 5th 6thKMC allKMC <1CMC allCMC <1Hourly average of SCRIP score, 2nd to 6th hourStabilization 1200g – 1800gSkin-to-skinIncubatorBREAST- VAGALMOTHER FEEDING (PSNS) GROWTHOTHER PROTEST- STRESS SURVIVAL orDESPAIR (SNS)SKIN-TO-SKIN CONTACTSEPARATIONTHE PLACE MODELDYS-REGULATIONSTABILISATIONSEPARATION DYSREGULATESCORTISOL
  17. 17. 17INCUBATORSDE-STABILISENEWBORNSStabilisation first 6 hours, average hourly SCRIP score5.15.25.35.45.55.65.75.85.966.12nd 3rd 4th 5th 6thKMC allKMC <1800CMC allCMC <1800Premature babies arenot in incubators becausethey are unstable.Premature babiesare unstable becausethey are in incubators.The Relation of Early Mother-InfantSkin-to-Skin Contactto Later Maternal Sensitivityin South African Mothersof Low Birth Weight InfantsAnn E. Bigelow, et al (in press IMHJ)From Bergman et al 2004 RCTSSC time first 24 hr correlatedwith SSC time first month.0510152025-0.2 0 0.2 0.4 0.6 0.8 1Maternal Behavior Q-SortHoursofSSCinInfantsFirst24HoursMaternal behaviour Q SortPredicts attachment securityNCATS ( Nursing Child AssessmentTeaching Scale )Predicts subsequent cognitive outcome051015202525 27 29 31 33 35 37 39 41 43 45Maternal Behavior Subscale of the NCATSHoursofSSCinInfantsFirst24HoursA mother and babyDYADare a singlepsychoneurobiologicalorganism
  18. 18. 18BONDING (Bergman mini-model)Birth experience:Sensations  hormonal changes neural circuitsLIMBIC PLATFORMMATERNALSENSITIVITYEarly life experience:Neural circuits emotional & social intelligenceCORTICO-LIMBIC CIRCUITRYATTACHMENTBONDINGMATERNAL SENSITIVITY… this suggests that VD mothers are more sensitiveto own baby-cry than CSD mothers in the earlypostpartum in sensory processing, empathy, arousal,motivation, reward and habit-regulation circuits.The results of this study show thatattending to own baby-cry evokesa unique pattern of neuralresponses in VD mothers ascompared to CSD mothers in theearly postpartum..BONDING (Bergman mini-model)Birth experience:Sensations  hormonal changes neural circuitsLIMBIC PLATFORMMATERNALSENSITIVITYEarly life experience:Neural circuits emotional & social intelligenceCORTICO-LIMBIC CIRCUITRYATTACHMENTBONDINGSEPARATIONVIOLATESTHE INNATE AGENDAOF MOTHERAND NEWBORNSSC 83%MIS 8%NORMALPerceived HARM:NO YESSSC 17%MIS 92%
  19. 19. 19PRIMUM NON NOCERETOXIC STRESS ??HARM ?evolutionary survival machineANSHRVEEG BASautonomicupstreamautonomic MEDIATORdownstreamANDERSON BEHAVIOURAL STATE SCALE1211 Crying10 Fussing9 Active8 Breastfeeding7 Alert Awake6 Quiet Awake5 Drowsy43 Active Sleep2 Irregular Sleep1 Regular / Quiet SleepPLACE convention4 Breastfeeding3 Holding2 MIS (Cot)1 SSC (Skin-to-skin)HRV produces IBI(Inter Beat Interval)FFT / AR / wavelet• social vagus (validated)• sympathetic (accepted)• “old vagus” (our hypothesis)DVCVVCSNSSkin-to-skin contact= *NORMAL* PLACEBabies 2 days oldSSC vs MIS, 1hrSkin-to-skin contact= *NORMAL* PLACESEPARATE176%IncreaseAutonomicactivitySEPARATE86%DecreaseQuiet Sleep
  20. 20. 20SLEEP CYCLE - NeurodevelopmentPeirano 2003BREAST- VAGALMOTHER FEEDING (PSNS) GROWTHOTHERPROTEST- STRESS SURVIVAL orDESPAIR (SNS)SKIN-TO-SKIN CONTACTSEPARATIONHigher state arousalNormal sleep cyclingSeparated neonates experiencedisturbed sleep cycling: insteadFREEZE & DISSOCIATION.NEURO PHYSIOLOGYof SEPARATIONMaternal separation may bea stressor the human neonateis not well-evolved to cope with,and may not be benign.Maternal separation may bea stressor the human neonateis not well-evolved to cope with,and may not be benign.NILS’ TRANSLATION:MATERNAL SEPARATIONIS TOXIC STRESS !!NOINCUBATORSDE-STABILISENEWBORNSTRUE or FALSE ?
  21. 21. 21INCUBATORSDE-STABILISENEWBORNS1. FALSE2.3.INCUBATORSDE-STABILISENEWBORNS1. FALSE2. TRUE3.INCUBATORSDE-STABILISENEWBORNS1. FALSE2. TRUE3. DON’T KNOWwww.skintoskincontact.comINTRODUCTION“It is easier to build strong childrenthan to repair broken men.”Frederick Douglass (1817–1895)PERINATAL NEUROSCIENCEand SKIN-TO-SKIN CONTACT

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