ho a1 gr anthro & socio aspects ssc sd 1203

Anthropological and Anthropological 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

““For species such as For species such as primates, the mother primates, the mother ISIS the environment.” the environment.”Sarah Blaffer Hrdy, Sarah Blaffer Hrdy, Mother NatureMother Nature (1999) (1999)

Babies Celebrated, Beatrice Fontanel and Claire D’Harcourt, © 1998 Harry N. Abrams, Inc.

Nothing an infant can or Nothing an infant can or

cannot do makes sense, cannot do makes sense,

except in light of mother’s except in light of mother’s bodybody

CENTRAL DOGMA CENTRAL DOGMA – all biological processes– all biological processesNEUROSCIENCENEUROSCIENCE

The DNAThe DNAEverything elseEverything else

EVOLUTIONARYEVOLUTIONARYBIOLOGYBIOLOGY

The BrainThe Brain

EPIGENETICSEPIGENETICS

The PlaceThe PlaceENVIRONMENTENVIRONMENT

EXPERIENCEEXPERIENCEFITNESSFITNESS ADAPTATIONADAPTATION

Skin-to-skin = key that Skin-to-skin = key that unlocks the unlocks the

neuroscience !neuroscience !

Sequence human newborn breast-feedingSequence human newborn breast-feedingPre-requisite = habitatPre-requisite = habitat

hand to mouthhand to mouthtongue movestongue movesmouth movesmouth moveseye focuses nippleeye focuses nipplecrawls to nipplecrawls to nipplelatches to nipplelatches to nipplesuckles suckles

(Widstrom et al 1994)(Widstrom et al 1994)

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” !

fetal REM sleepfetal REM sleep (or active sleep) seems to be(or active sleep) seems to be

particularly importantparticularly important to the developing organism to the developing organism

... spontaneous ... spontaneous synchronous firingsynchronous firing

Marks et al 1995

BRAIN WIRINGBRAIN WIRING

Peirano 2003

AT BIRTH,AT BIRTH,

the brain has the brain has TWO TWO CRITICAL CRITICAL SENSORY SENSORY NEEDS:NEEDS:

SMELL & CONTACTSMELL & CONTACTconnect direct to the connect direct to the amygdala amygdala

THE THE NEWBORNNEWBORN

BRAINBRAIN

SKIN-TO-SKINSKIN-TO-SKINCONTACTCONTACT

fires and wiresfires and wires

the amygdala-prefronto-orbital the amygdala-prefronto-orbital cortical pathway cortical pathway (PFOC)(PFOC)

AMYGDALA:AMYGDALA:EmotionalEmotionalProcessingProcessingUnit CPU Unit CPU

Prefrontal cortexPrefrontal cortex Executive Executive functionfunction

SOCIAL and EMOTIONALSOCIAL and EMOTIONAL

INTELLIGENCEINTELLIGENCE

SEESSEESMum’s eyesMum’s eyes

Hand TOUCHHand TOUCHMum’s skinMum’s skin

Skin-to-skinSkin-to-skinCONTACTCONTACT

SENSATIONS THAT WIRE BRAINSENSATIONS THAT WIRE BRAIN

Back FEELSBack FEELSMum’s armMum’s armholdingholding

TASTES TASTES Mum’s milkMum’s milk

Ear HEARS Ear HEARS Mum’s voiceMum’s voice

SMELLS SMELLS Mum’s milkMum’s milk

WARMED on WARMED on Mum’s front Mum’s front

MOVES MOVES with Mumwith Mum

Slide from JILL BERGMAN Slide from JILL BERGMAN

a kind of invisible hothouse

Through Through “ “hidden maternal regulators” ... hidden maternal regulators” ... “ “ physiological set points “physiological set points ““ “ internal working models’internal working models’“ “ scripts – templates”scripts – templates”

The brain is a

SENSORY ORGAN BREAST - FEEDING

= BRAIN – WIRING

SOCIAL ORGAN

NEUROSCIENCENEUROSCIENCE





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

The BrainThe Brain


GENETICGENETICFACTORSFACTORS

ENVIRONMENTENVIRONMENT

NURTURENURTURE

GENETICGENETICFACTORSFACTORS

STIMULATIONSTIMULATION

ENVIRONMENTENVIRONMENT

EXPERIENCEEXPERIENCEBEHAVIOURBEHAVIOUR

NATURENATURE NICHENICHE

MOTHERMOTHERBREASTMILKBREASTMILK

BREASTFEEDINGBREASTFEEDING

MOTHERMOTHER

is the KEY foris the KEY forNEURODEVELOPMENNEURODEVELOPMEN

TT

SEPARATION DYSREGULATES

PROTEST – DESPAIR causes DYSREGULATION

This pathology ... cannot be cured ...This pathology ... cannot be cured ...

Social deprivation Social deprivation alters neurobiological systems. alters neurobiological systems.

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 fromJames McKenna

Primate separation studiesPrimate separation studies

Maternal Separation ParadigmMaternal Separation Paradigm0w0w 1w1w 2w2w 3w3w 4w4w 5w5w 6w 6w 12w 12w

n 4n 4 Mat Mat MNSMNSgroup reared no mothergroup reared no mother n 4 n 4 Mat Mat MNSMNS group as above group as above n 4n 4 Mat Mat ((controlcontrol))

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

Primate separation studiesPrimate separation studies

Maternal Separation ParadigmMaternal Separation ParadigmEarly Deprivation (ED) vs control (CON)Early Deprivation (ED) vs control (CON)

0d0d 2d2d 28d28d 48w 48w ED n 11ED n 11 Mat Mat 30 -120 min daily30 -120 min daily CON n 4 CON n 4 Mat Mat 48w 48w

Repeated shortRepeated shortseparations:separations:

LOW gene expressionLOW gene expression

Correlate to human adult depressionCorrelate to human adult depression

Sabatini

Arabadzisz

Positive StressPositive Stress

• Moderate, short-lived stress responses, such Moderate, short-lived stress responses, such as brief increases in heart rate or mild changes as brief increases in heart rate or mild changes in stress hormone levels.in stress hormone levels.

• An important and necessary aspect of healthy An important and necessary aspect of healthy development that occurs in the context of development that occurs in the context of stable and supportive relationships.stable and supportive relationships.

Slide by: Jack P. Shonkoff, M.D.

Under-Under-activityactivity

EUSTRESSEUSTRESS

Over-Over-activityactivity

Positive Stress= Eustress

• An important and necessaryAn important and necessary aspect of healthy development aspect of healthy development that occurs in the context of that occurs in the context of stable and supportive relationships.stable and supportive relationships.

Tolerable StressTolerable Stress

• Stress responses that could disrupt brain Stress responses that could disrupt brain architecture, but are buffered by supportive architecture, 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 recover which gives the brain an opportunity to recover from potentially damaging effects.from potentially damaging effects.


Toxic StressToxic Stress

• Strong and prolonged activation of the body’s Strong and prolonged activation of the body’s stress management systems in the absence of stress management systems in the absence of the buffering protection of adult support.the 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, therebylower thresholds, thereby increasing the risk of increasing the risk of stress-related physical and mental illnessstress-related physical and mental illness..


MICHAEL MEANEYMICHAEL MEANEY

Unsafe environment activates Unsafe environment activates HPAHPAaxis axis (autonomic nervous system, (autonomic nervous system,

ANS)ANS). .

““In response to stress, CRF … and vasopressin are released … In response to stress, CRF … and vasopressin are released … anterior pituitary … synthesis release ACTH …glucocorticoids anterior pituitary … synthesis release ACTH …glucocorticoids ” ”

Early stress alters gene Early stress alters gene expression,expression, with health impact across with health impact across lifespan.lifespan.

BRUCE McEWEN allostasisBRUCE McEWEN allostasis

VocabularyVocabulary

Homeostasis the coordinated operation of Homeostasis the coordinated operation of physiological processes that maintain physiological processes that maintain the steady state required to sustain lifethe steady state required to sustain life

AllostasisAllostasis the mechanism by which the mechanism by whichhomeostatic systems are maintained in balancehomeostatic systems are maintained in balance as life cycle and environment changesas life cycle and environment changes

Allostatic state Allostatic state elevated activity of elevated activity of mediators, with returnmediators, with returnto baseline and no impact on health.to baseline and no impact on health.

(similar to earlier … )(similar to earlier … )

REGULATIONREGULATIONthe objective is to achieve thethe objective is to achieve theability to establish:ability to establish:

‘‘STABILITY THROUGH CHANGE’STABILITY THROUGH CHANGE’

The foundation for The foundation for INFANT MENTAL HEALTHINFANT MENTAL HEALTH

VocabularyVocabulary

Allostatic load Allostatic load elevated activity – elevated activity – sustained over time, or severe, or mediators sustained over time, or severe, or mediators dysregulated dysregulated 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 overload Allostatic overload the point at whichthe point at which chronic load results in actual disease chronic load results in actual disease or abnormal conditions.or abnormal conditions.

ALLOSTATIC LOAD:ALLOSTATIC LOAD:““wear and tear that results from wear and tear that results from chronic overactivity chronic overactivity

(or underactivity)(or underactivity)of allostatic systems.”of allostatic systems.” (McEwen 1998, 1999)(McEwen 1998, 1999)

TOXICSTRESS

SensitivityHIGH

2ND KNOCK

Developing Developing Brain Brain (1)(1)

NeurogenesisNeurogenesisNeural morphologyNeural morphology

SynaptogenesisSynaptogenesisMyelinationMyelination

Early Early Stress Stress (2)(2)Neuronal death, smaller brainNeuronal death, smaller brainFewer dendritic spinesFewer dendritic spinesPoorer connectionsPoorer connectionsFewer glial cells, less myelinFewer glial cells, less myelin

Sensitivity (3)Sensitivity (3)GeneticGeneticGenderGenderTimingTiming

Developmental rateDevelopmental rateGCR densityGCR density

Enduring (4)Enduring (4)consequencesconsequences

Attenuated L brain devlopmentAttenuated L brain devlopmentPoor R / L integrationPoor R / L integrationIrritability limbic systemIrritability limbic systemPoorer function vermisPoorer function vermis

Neuropsychiatric Neuropsychiatric vulnerabilitiesvulnerabilities (5) (5)

Dissociative identity disorderDissociative identity disorderDepressionDepression Personality disorder Personality disorder

Substance abuseSubstance abusePost Traumatic Stress DisorderPost Traumatic Stress Disorder

StimulationStimulation

ResilienceResilience

MENTAL HEALTHMENTAL HEALTH

TEICHER’STEICHER’SEARLY STRESSEARLY STRESSCASCADE MODELCASCADE MODEL

Schore: Schore:

““Infant trauma will interfere withInfant trauma will interfere withcritical period limbic organisation ...critical period limbic organisation ...

future capacity to adapt ...future capacity to adapt ...correlated with maladaptive correlated with maladaptive adult mental health”adult mental health”

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.”

RESILIENCE / SENSITIVITY RESILIENCE / SENSITIVITY

PERCEPTIONSPERCEPTIONS““NEUROCEPTION”NEUROCEPTION”

RESPONSERESPONSESTRESSSTRESS

ALLOSTATIC STATEALLOSTATIC STATE

ALLOSTASIS ALLOSTASIS

PsychologicalPsychologicalNeurologicalNeurological

EndocrineEndocrineImmune Immune

HEALTHHEALTH DISEASEDISEASE

ALLOSTATIC LOADALLOSTATIC LOADALLOSTATIC OVERLOADALLOSTATIC OVERLOAD

WELL-BEING WELL-BEING SUSCEPTIBILITY SUSCEPTIBILITY MORBIDITY MORBIDITY MORTALITY MORTALITY

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

SPECTRUM of expression in SPECTRUM of expression in POPULATIONPOPULATION


NEUROSCIENCENEUROSCIENCE





SPECTRUM of expression in SPECTRUM of expression in POPULATIONPOPULATION


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

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.

The BrainThe Brain


EXPECTED UNEXPECTED EXPECTED UNEXPECTED

““EEA”EEA”EEnvironment ofnvironment ofEEvolutionary volutionary AAdaptednessdaptedness

““Environment”Environment”is the usual place andis the usual place andcontext for which thecontext for which thegenes have adjustedgenes have adjusted

MOTHERMOTHERis the key tois the key toneurodevelopment neurodevelopment

……

… … because she is because she is

the the RIGHT RIGHT PLACE !!PLACE !!

Anthropological and Anthropological and

sociologicalsociological aspects aspects ofof

skin-to-skin contact.skin-to-skin contact. AnthropologyAnthropologyEvolutionary BiologyEvolutionary BiologyDNA & EpigeneticsDNA & EpigeneticsNeuroscience of stressNeuroscience of stressMal-AdaptationMal-AdaptationSociologicalSociological consequence consequence

Anthropological and Anthropological and sociological aspects ofsociological aspects of

skin-to-skin skin-to-skin contactcontact..

SCIENTIFIC AND EVIDENCE

BASIS FOR INCUBATOR ??

Stephane TARNIER Stephane TARNIER 1828 -971828 -97

French obstetricianFrench obstetrician

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

Pierre BUDIN Pierre BUDIN 1846 - 19071846 - 1907

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.

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 - 19501860 - 1950

Born in Germany Born in Germany

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

Berlin ExhibitionBerlin Exhibition 1896, 1896, success !success !

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


Berlin 1896, Berlin 1896, successsuccess

to USA: Buffalo to USA: Buffalo Omaha 1902-4, Omaha 1902-4,

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

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


... famous for ... famous for “ “preemie road preemie road

show”.show”.

MONEY MAKING SHOWMONEY MAKING SHOW

PERMANENT PERMANENT pavilion in pavilion in DreamlandDreamland New York Worlds Fair, 1939


Born in Germany Born in Germany

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

Berlin ExhibitionBerlin Exhibition 1896, 1896, success !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”


Couney succesfullyCouney succesfullyraised 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” …

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”.

WHY do we separatemothers frombabies ??

INCUBATOR & SEPARATION= ACCIDENT of HISTORY

THETHEINCUBATORINCUBATOR

HAS HAS NONO SCIENTIFIC SCIENTIFIC

FOUNDATION !!FOUNDATION !!

PERINATAL NEUROSCIENCEPERINATAL NEUROSCIENCE& SKIN-TO-SKIN CONTACT& SKIN-TO-SKIN CONTACT


……

… … because she is because she is

the the RIGHT RIGHT PLACE !!PLACE !!


……EEnvironment ofnvironment ofEEvolutionary volutionary AAdaptednessdaptedness

KEY TO MONITORINGKEY TO MONITORING

WELL BEING WELL BEING

AUTONOMIC NERVOUS AUTONOMIC NERVOUS

SYSTEM MONITOR !SYSTEM MONITOR !

if HARM can be monitored,if HARM can be monitored,

HARMING CARE MUST CHANGEHARMING CARE MUST CHANGE

Separation from mother Separation from mother is stressful for humans.is stressful for humans.

Salivary cortisol is a Salivary cortisol is a good measure of stress.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

at one hour ageat one hour ageCortisol levels measured Cortisol levels measured

every hour.every hour.

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

SEPARATION = STRESSSEPARATION = STRESS

Separation DOUBLES CORTISOLSeparation DOUBLES CORTISOL

Preterm infants experience Preterm infants experience prolonged severe stress, with prolonged severe stress, with tenfold increases in tenfold increases in stress hormonesstress hormones..Stress hormones at such levels Stress hormones at such levels are are 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 EndorphinMassageMassage slightly lowerslightly lower no changeno changeSoft musicSoft music no changeno change no changeno change

Skin-to-skinSkin-to-skin 66% lower 74% lower66% lower 74% lower

evolutionary survival machineevolutionary survival machine

ANS

HRVHRV

EEGEEG

autonomic autonomic downstreamdownstream

PLACE conventionPLACE convention

44 BreastfeedingBreastfeeding55 HoldingHolding66 MIS (Cot)MIS (Cot)11 SSC (Skin-to-skin)SSC (Skin-to-skin)

ANDERSON BEHAVIOURAL STATE SCALE

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

HRV produces IBIHRV produces IBI(Inter Beat Interval)(Inter Beat Interval)

FFT / AR / FFT / AR / waveletwavelet• social vagus social vagus (validated)(validated)• sympathetic sympathetic (accepted)(accepted)• ““old vagus” old vagus” (our hypothesis)(our hypothesis)

DVC

VVC

SNS

GREEN = OLD VEGETATIVE VAGUS

RED = SNSSYMPATHETIC

BLUE = NEWBLUE = NEW SOCIAL VAGUSSOCIAL VAGUS

AUTONOMIC STATECOMPONENTS:

Skin-to-skin contact = *NORMAL* PLACE

SEPARATE176%

IncreaseAutonomic activity

SEPARATE 86%

DecreaseQuiet Sleep

7 x more 7 x more QS is SSCQS is SSC

3 x more ANS3 x more ANS in MIS in MIS

BREAST- VAGALMOTHER FEEDING (PSNS) GROWTH

OTHERPROTEST- STRESS SURVIVAL orDESPAIR (SNS)

SKIN-TO-SKIN CONTACT

SEPARATION

Higher state arousal

Normal sleep cycling

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

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 well-evolved to cope with, is not well-evolved to cope with, and may not be benign.and may not be benign.

idealideal benignbenign malevolentmalevolent unsuitableunsuitable


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

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

Skin-to-skin contact –Skin-to-skin contact –our developmental our developmental

environment.environment.

““Maternal separation may be Maternal separation may be a stressor the human neonate a 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.”



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.



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



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.

ho a1 gr anthro & socio aspects ssc sd 1203

Technology

day separation

skin contact

orbitalthe amygdalaprefronto

wiresthe amygdalaprefronto

neural processes

key foris

key thatunlocks

key thatskin