1. Anthropological andAnthropological and
sociological aspects ofsociological aspects of
skin-to-skin contact.skin-to-skin contact.
Dr Nils BergmanDr Nils Bergman
M.B.Ch.B., M.P.H., M.D.M.B.Ch.B., M.P.H., M.D.
Cape Town, South AfricaCape Town, South Africa
3. CENTRAL DOGMACENTRAL DOGMA – all biological processes– all biological processes
NEUROSCIENCENEUROSCIENCE
The DNAThe DNAEverything elseEverything else
EVOLUTIONARYEVOLUTIONARY
BIOLOGYBIOLOGY
The BrainThe Brain
EPIGENETICSEPIGENETICS
The PlaceThe Place
ENVIRONMENTENVIRONMENT
EXPERIENCEEXPERIENCEFITNESSFITNESS ADAPTATIONADAPTATION
Skin-to-skin = key thatSkin-to-skin = key that
unlocks the neuroscience !unlocks the neuroscience !
4. Sequence human newborn breast-feedingSequence human newborn breast-feeding
Pre-requisite = habitatPre-requisite = habitat
hand to mouthhand to mouth
tongue movestongue moves
mouth movesmouth moves
eye focuses nippleeye focuses nipple
crawls to nipplecrawls to nipple
latches to nipplelatches to nipple
sucklessuckles
(Widstrom et al 1994)(Widstrom et al 1994)
5. Cells which
FIRE TOGETHER,FIRE TOGETHER,
WIRE TOGETHERWIRE TOGETHER,,
and those which
don’t, won’t.”
Carla Shatz
There are “needed neural processes” !There are “needed neural processes” !
6. fetal REM sleepfetal REM sleep
(or active sleep) seems to be(or active sleep) seems to be
particularly importantparticularly important
to the developing organismto the developing organism
... spontaneous... spontaneous
synchronous firingsynchronous firing
Marks et al 1995
8. AT BIRTH,AT BIRTH,
the brain hasthe brain has
TWOTWO
CRITICALCRITICAL
SENSORYSENSORY
NEEDS:NEEDS:
SMELL & CONTACTSMELL & CONTACT
connect direct to the amygdalaconnect direct to the amygdala
20. PROTEST – DESPAIR
causes DYSREGULATION
This pathology ... cannot be cured ...This pathology ... cannot be cured ...
Social deprivationSocial deprivation
alters neurobiological systems.alters neurobiological systems.
21. 3-day separation:
induces physiological
changes (immune,system,
heart rate, sleep, cortisol,
loss of body temperature..
anaclitic depression:
•hyperactivity
•conservation- withdrawal;
•death or recovery
Slide & photo from
James McKenna
22. Primate separation studiesPrimate separation studies
Maternal Separation ParadigmMaternal Separation Paradigm
0w0w 1w1w 2w2w 3w3w 4w4w 5w5w 6w6w 12w12w
n 4n 4 MatMat MNSMNS group reared no mothergroup reared no mother
n 4n 4 MatMat MNSMNS group as abovegroup as above
n 4n 4 MatMat ((controlcontrol))
23. Gene specific for the AMYGDALAGene specific for the AMYGDALA
( GUYC1A3)( GUYC1A3)
Separated at 1 week:Separated at 1 week:
LOW gene expressionLOW gene expression
Increased self soothingIncreased self soothing
AnxietyAnxiety
Decreased socialityDecreased sociality
DepressionDepression
24. Primate separation studiesPrimate separation studies
Maternal Separation ParadigmMaternal Separation Paradigm
Early Deprivation (ED) vs control (CON)Early Deprivation (ED) vs control (CON)
0d0d 2d2d 28d28d 48w48w
ED n 11ED n 11 MatMat 30 -120 min daily30 -120 min daily
CON n 4CON n 4 MatMat 48w48w
27. Positive StressPositive Stress
• Moderate, short-lived stress responses, suchModerate, short-lived stress responses, such
as brief increases in heart rate or mild changesas brief increases in heart rate or mild changes
in stress hormone levels.in stress hormone levels.
• An important and necessary aspect of healthyAn important and necessary aspect of healthy
development that occurs in the context ofdevelopment that occurs in the context of
stable and supportive relationships.stable and supportive relationships.
Slide by: Jack P. Shonkoff, M.D.
29. Tolerable StressTolerable Stress
• Stress responses that could disrupt brainStress responses that could disrupt brain
architecture, but are buffered by supportivearchitecture, but are buffered by supportive
relationships that facilitate adaptive coping.relationships that facilitate adaptive coping.
• Generally occurs within a time-limited period,Generally occurs within a time-limited period,
which gives the brain an opportunity to recoverwhich gives the brain an opportunity to recover
from potentially damaging effects.from potentially damaging effects.
Slide by: Jack P. Shonkoff, M.D.
30. Toxic StressToxic Stress
• Strong and prolonged activation of the body’sStrong and prolonged activation of the body’s
stress management systems in the absence ofstress management systems in the absence of
the buffering protection of adult support.the buffering protection of adult support.
• Disrupts brain architecture and leads to stressDisrupts brain architecture and leads to stress
management systems that respond at relativelymanagement systems that respond at relatively
lower thresholds, therebylower thresholds, thereby increasing the risk ofincreasing the risk of
stress-related physical and mental illnessstress-related physical and mental illness..
Slide by: Jack P. Shonkoff, M.D.
31. MICHAEL MEANEYMICHAEL MEANEY
Unsafe environment activates HPAUnsafe environment activates HPA
axisaxis (autonomic nervous system, ANS)(autonomic nervous system, ANS)..
““In response to stress, CRF … and vasopressin are released …In response to stress, CRF … and vasopressin are released …
anterior pituitary … synthesis release ACTH …glucocorticoidsanterior pituitary … synthesis release ACTH …glucocorticoids ””
Early stress alters gene expression,Early stress alters gene expression,
with health impact across lifespan.with health impact across lifespan.
33. VocabularyVocabulary
Homeostasis the coordinated operation ofHomeostasis the coordinated operation of
physiological processes that maintainphysiological processes that maintain
the steady state required to sustain lifethe steady state required to sustain life
AllostasisAllostasis the mechanism by whichthe mechanism by which
homeostatic systems are maintained in balancehomeostatic systems are maintained in balance
as life cycle and environment changesas life cycle and environment changes
Allostatic stateAllostatic state elevated activity ofelevated activity of
mediators, with returnmediators, with return
to baseline and no impact on health.to baseline and no impact on health.
34. (similar to earlier … )(similar to earlier … )
REGULATIONREGULATION
the objective is to achieve thethe objective is to achieve the
ability to establish:ability to establish:
‘‘STABILITY THROUGH CHANGE’STABILITY THROUGH CHANGE’
The foundation forThe foundation for
INFANT MENTAL HEALTHINFANT MENTAL HEALTH
35. VocabularyVocabulary
Allostatic loadAllostatic load elevated activity –elevated activity –
sustained over time, or severe, or mediatorssustained over time, or severe, or mediators
dysregulateddysregulated changes target cells of mediators,changes target cells of mediators,
and so changes the “set points” for homeostasisand so changes the “set points” for homeostasis
(e.g. increasing blood pressure,(e.g. increasing blood pressure,
change in cholesterol level)change in cholesterol level)
Allostatic overloadAllostatic overload the point at whichthe point at which
chronic load results in actual diseasechronic load results in actual disease
or abnormal conditions.or abnormal conditions.
36. ALLOSTATIC LOAD:ALLOSTATIC LOAD:
““wear and tear that results fromwear and tear that results from
chronic overactivitychronic overactivity
(or underactivity)(or underactivity)
of allostatic systems.”of allostatic systems.”
(McEwen 1998, 1999)(McEwen 1998, 1999)
TOXIC
STRESS
Sensitivity
HIGH
2ND
KNOCK
37. DevelopingDeveloping
BrainBrain (1)(1)
NeurogenesisNeurogenesis
Neural morphologyNeural morphology
SynaptogenesisSynaptogenesis
MyelinationMyelination
EarlyEarly
StressStress (2)(2)
Neuronal death, smaller brainNeuronal death, smaller brain
Fewer dendritic spinesFewer dendritic spines
Poorer connectionsPoorer connections
Fewer glial cells, less myelinFewer glial cells, less myelin
Sensitivity (3)Sensitivity (3)
GeneticGenetic
GenderGender
TimingTiming
Developmental rateDevelopmental rate
GCR densityGCR density
Enduring (4)Enduring (4)
consequencesconsequences
Attenuated L brain devlopmentAttenuated L brain devlopment
Poor R / L integrationPoor R / L integration
Irritability limbic systemIrritability limbic system
Poorer function vermisPoorer function vermis
NeuropsychiatricNeuropsychiatric
vulnerabilitiesvulnerabilities (5)(5)
Dissociative identity disorderDissociative identity disorder
DepressionDepression Personality disorderPersonality disorder
Substance abuseSubstance abuse
Post Traumatic Stress DisorderPost Traumatic Stress Disorder
StimulationStimulation
ResilienceResilience
MENTAL HEALTHMENTAL HEALTH
TEICHER’STEICHER’S
EARLY STRESSEARLY STRESS
CASCADE MODELCASCADE MODEL
38. Schore:Schore:
““Infant trauma will interfere withInfant trauma will interfere with
critical period limbic organisation ...critical period limbic organisation ...
future capacity to adapt ...future capacity to adapt ...
correlated with maladaptivecorrelated with maladaptive
adult mental health”adult mental health”
39. Schore:Schore:
““long term alterations brain functionlong term alterations brain function
““risk for developing severe psycho-risk for developing severe psycho-
pathologies at later stages of life.”pathologies at later stages of life.”
41. ALLOSTATIC LOAD:ALLOSTATIC LOAD:
““wear and tear that results ….wear and tear that results ….
SPECTRUM of expression inSPECTRUM of expression in POPULATIONPOPULATION
HEALTHHEALTH DISEASEDISEASE
42. NEUROSCIENCENEUROSCIENCE
The DNAThe DNAEverything elseEverything else
EVOLUTIONARYEVOLUTIONARY
BIOLOGYBIOLOGY
The PlaceThe Place
ENVIRONMENTENVIRONMENT
EXPERIENCEEXPERIENCEFITNESSFITNESS ADAPTATIONADAPTATION
SPECTRUM of expression inSPECTRUM of expression in POPULATIONPOPULATION
HEALTHHEALTH DISEASEDISEASE
““Scientific foundation” … a synthesisScientific foundation” … a synthesis
Platform for better understanding ofPlatform 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.
The BrainThe Brain
EPIGENETICSEPIGENETICS
EXPECTED UNEXPECTEDEXPECTED UNEXPECTED
48. Stephane TARNIERStephane TARNIER 1828 -971828 -97
French obstetricianFrench obstetrician
Saw a warmed box forSaw a warmed box for
hatching chickens, hadhatching chickens, had
one designed forone designed for
““weaklings” …weaklings” …
…… invented incubatorinvented incubator
49. Pierre BUDINPierre BUDIN 1846 - 19071846 - 1907
Friend of Tarniers …tookFriend of Tarniers …took
Incubators, made centresIncubators, made centres
for the care of weaklings,for the care of weaklings,
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 include
mother, reason for the glass window ….mother, reason for the glass window ….
50. Martin COUNEYMartin COUNEY 1860 - 19501860 - 1950
Born in GermanyBorn in Germany
claims he learnedclaims he learned
the techniques forthe techniques for
Budin ....Budin ....
Berlin ExhibitionBerlin Exhibition 1896, success !1896, success !
Photograph: Pan-American Exhibition in Buffalo, New York, 1901.
51. Martin COUNEYMartin COUNEY 1860 - 19501860 - 1950
Berlin 1896, successBerlin 1896, success
to USA: Buffaloto USA: Buffalo
Omaha 1902-4,Omaha 1902-4,
Chicago Fair 1932 2Chicago Fair 1932 2ndnd
highest receipts,highest receipts,
Last show New York 1940.Last show New York 1940.
Baby Incubator,Baby Incubator,
1904 St.Louis Fair1904 St.Louis Fair
52. Martin COUNEYMartin COUNEY 1860 - 19501860 - 1950
... famous for... famous for
““preemie road show”.preemie road show”.
MONEY MAKING SHOWMONEY MAKING SHOW
PERMANENTPERMANENT
pavilion inpavilion in
DreamlandDreamland
New York Worlds Fair, 1939
53. Martin COUNEYMartin COUNEY 1860 - 19501860 - 1950
Born in GermanyBorn in Germany
claims he learnedclaims he learned
the techniques forthe techniques for
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”
54. Martin COUNEYMartin COUNEY 1860 - 19501860 - 1950
Couney succesfullyCouney succesfully
raised 5000 prems!raised 5000 prems!
BUT –BUT –
used wet-nurses,used wet-nurses,
excluded mothersexcluded mothers
(mother got free pass to the shows !)(mother got free pass to the shows !)
Mothers were excluded – “germs” …Mothers were excluded – “germs” …
55. Sarah Morris Hospital,Sarah Morris Hospital,
Chicago 1923,Chicago 1923,
others followed –others followed –
accepting theaccepting the
““policy of strict separation”.policy of strict separation”.
58. MOTHERMOTHER
is the key tois the key to
neurodevelopment …neurodevelopment …
…… because she is thebecause she is the
RIGHT PLACE !!RIGHT PLACE !!
59. MOTHERMOTHER
is the key tois the key to
neurodevelopment …neurodevelopment …
EEnvironment ofnvironment of
EEvolutionaryvolutionary
AAdaptednessdaptedness
60. KEY TO MONITORINGKEY TO MONITORING
WELL BEINGWELL BEING
AUTONOMIC NERVOUSAUTONOMIC NERVOUS
SYSTEM MONITOR !SYSTEM MONITOR !
if HARM can be monitored,if HARM can be monitored,
HARMING CARE MUST CHANGEHARMING CARE MUST CHANGE
61. Separation from motherSeparation from mother
is stressful for humans.is stressful for humans.
Salivary cortisol is aSalivary cortisol is a
good measure of stress.good measure of stress.
62. 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, only
one separated from motherone separated from mother
at one hour ageat one hour age
Cortisol levels measuredCortisol levels measured
every hour.every hour.
Cortisol separate = 9Cortisol separate = 9
Cortisol with momCortisol with mom = 4= 4
SEPARATION = STRESSSEPARATION = STRESS
Separation DOUBLES CORTISOLSeparation DOUBLES CORTISOL
63. Preterm infants experiencePreterm infants experience
prolonged severe stress, withprolonged severe stress, with
tenfold increases intenfold increases in stress hormonesstress hormones..
Stress hormones at such levelsStress hormones at such levels
areare neurotoxic.neurotoxic.
(Modi & Glover 1998, Mooncey et al 1997)(Modi & Glover 1998, Mooncey et al 1997)
RCT on methods to reduce of stress (at one hour):RCT on methods to reduce of stress (at one hour):
Cortisol EndorphinCortisol Endorphin
MassageMassage slightly lowerslightly lower no changeno change
Soft musicSoft music no changeno change no changeno change
Skin-to-skinSkin-to-skin 66% lower 74% lower66% lower 74% lower
66. PLACE conventionPLACE convention
44 BreastfeedingBreastfeeding
33 HoldingHolding
22 MIS (Cot)MIS (Cot)
11 SSC (Skin-to-skin)SSC (Skin-to-skin)
67. ANDERSON BEHAVIOURAL STATE SCALE
12
11 Crying
10 Fussing
9 Active
8 Breastfeeding
7 Alert Awake
6 Quiet Awake
5 Drowsy
4
3 Active Sleep
2 Irregular Sleep
1 Regular / Quiet Sleep
68. HRV produces IBIHRV produces IBI
(Inter Beat Interval)(Inter Beat Interval)
FFT / AR /FFT / AR / waveletwavelet
• social vagussocial vagus (validated)(validated)
• sympatheticsympathetic (accepted)(accepted)
• ““old vagus”old vagus” (our hypothesis)(our hypothesis)
D
V
C
V
V
C
S
N
S
69. GREEN = OLD
VEGETATIVE VAGUS
RED = SNS
SYMPATHETIC
BLUE = NEWBLUE = NEW
SOCIAL VAGUSSOCIAL VAGUS
AUTONOMIC STATE
COMPONENTS:
70. Skin-to-skin contact
= *NORMAL* PLACE
SEPARATE
176%
Increase
Autonomic
activity
SEPARATE
86%
Decrease
Quiet Sleep
7 x more7 x more
QS is SSCQS is SSC
3 x more ANS3 x more ANS
in MISin MIS
71. BREAST- VAGAL
MOTHER FEEDING (PSNS) GROWTH
OTHERPROTEST- STRESS SURVIVAL or
DESPAIR (SNS)
SKIN-TO-SKIN CONTACT
SEPARATION
Higher state arousal
Normal sleep cycling
Separated neonates experienceSeparated neonates experience
disturbances of sleep cycling.disturbances of sleep cycling.
72. NEURO PHYSIOLOGYNEURO PHYSIOLOGY
of SEPARATIONof SEPARATION
Maternal separation may beMaternal separation may be
a stressor the human neonatea stressor the human neonate
is not well-evolved to cope with,is not well-evolved to cope with,
and may not be benign.and may not be benign.
73. idealideal benignbenign malevolentmalevolent unsuitableunsuitable
HEALTHHEALTH DISEASEDISEASE
?
MOTHER ISMOTHER IS OUR “NORMAL”OUR “NORMAL”
““BETTER”BETTER” CARE CULTURECARE CULTURE
OUR “NORMAL”OUR “NORMAL” THIS ISTHIS IS
BIOLOGYBIOLOGY “WORSE”“WORSE”
74. Skin-to-skin contact –Skin-to-skin contact –
our developmentalour developmental
environment.environment.
““Maternal separation may beMaternal separation may be
a stressor the human neonatea stressor the human neonate
is not well-evolved to cope with,is not well-evolved to cope with,
and may not be benign.”and may not be benign.”
75. Skin-to-skin contact –Skin-to-skin contact –
our developmentalour developmental
environment.environment.
It matters how we are born!It matters how we are born!
It influences our emotionalIt influences our emotional
and social development,and social development,
our future EQ.our future EQ.
76. Skin-to-skin contact –Skin-to-skin contact –
our developmentalour developmental
environment.environment.
Separation is perceived as stress,Separation is perceived as stress,
which increases cortisol,which increases cortisol,
disrupts development ofdisrupts development of
new neural pathwaysnew neural pathways
77. Skin-to-skin contact –Skin-to-skin contact –
our developmentalour developmental
environment.environment.
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.
