Kangaroo Mother Care and skin-to-skin contact as determinants of breastfeeding success. Bergman N. J. MB ChB, MPH, MD Mowbray Maternity Hospital, Cape Town, South Africa 8 Francis Road, Pinelands 7405, South Africa +27 21 5315819 email@example.com “What is effective in increasing breastfeeding rates?” Current breastfeeding rates in many parts of the world affirm that we do not really know the answer to this seemingly simple question. If the answer were simple we would have it, the answer is clearly complex. I shall in this presentation nevertheless make a proposal which is simple: the most important barrier to breastfeeding success is the practice of separating mothers and newborns. This assertion is based on an understanding of the neurodevelopment of the fetus and newborn, built on recent advances in neuroscience. The first part of this paper will summarise this science, and present a body of research evidence in which the science has been applied. The second part will identify some barriers, and suggest how to address them. Given the neuroscience, such policy and practice centres around preventing separation, and promoting uninterrupted and continuous skin-to-skin contact. The origin of our current belief systems about newborns and prematures will be traced. Fetal neurodevelopment Many people feel that the human being with its massive forebrain and cortex cannot be compared to other animals. It should be noted however, that the cortex does not replace the more “primitive parts” of the brain, but is in fact utterly dependent on them. The understanding we can gain from biology can teach us much about our humanity. A huge body of research on mammalian neurodevelopment and neurobehaviour exists, going back some 60 years. However, in the last 15 years, new techniques have allowed research on living human neurodevelopment, which confirms the conclusions from animal studies. For the first 14 weeks of “post-conceptional life” the emphasis is on structural development, and the primary drivers are DNA instructions. Key processes include neurulation, neurogenesis and synaptogenesis. By 20 weeks all the structures in the brain are identifiable and in place. From this point, structural development and functional development go hand in hand, and are parallel. Thus, at 23 weeks the fetus is aware and conscious. Stimuli and environment combine to stimulate brain growth and brain connections. Stimuli “fire” brain cells, and migration of cells, dendrification and axonal arborisation take place. Synaptogenesis continues, and “cells that fire together, wire together”, this creates neuronal pathways which eventually myelinate, (hardwire). At the same time, cells that are not used are pruned, “elimination of redundancy”, there is competitive elimination, unused brain parts are removed. The total effect is described as neuronal plasticity. By 25 weeks the various layers in the brain are identifiable, and by 28 weeks the fetus has its full complement of neural cells, which have yet to grow for some years. The autonomic nervous system, essential to this talk in its own right, illustrates in its development the above structure and function parallel(1). The first part to form is the “primitive unmyelinated vagus” (parasympathetic), which is controls basic metabolism, and which responds to stress by “immobilisation behaviours”. However, after birth the sympathetic nervous system is developing, which controls the wellknown “fight or flight”, effectively the opposite behaviour of the vagal, it comes in to operation at about two months. At about six months the vagus starts to myelinate, and this allows rapid regulation and the ability to chose. between engagement and disengagement. Thus the structure, as in the vagal nerve, had a primitive function early in development, immobilisation; later fight or flight. Later still in development, myelinization allows for the same structure to make choices, but only if correctly connected to the sympathetic system. Effect of correct environment on newborn behaviour The animal studies have shown conclusively the paramount importance of an optimal environment for proper brain development(2). Though there are variations on the theme, mother’s presence is an absolute pre-requisite for survival. Mother’s presence is in this context not about breastfeeding: newborn mammals deprived of mother but given mother’s breastmilk do badly. What is essential is the entire “maternal milieu”, with the full spectrum of sensory stimulations this provides, this set of stimulations makes the brain cells fire together to create a secure platform for its future. At birth, the human being has sensory perceptions with no “filters” – it experiences all its sensations maximally. As it develops, it learns to “dampen down” sensory inputs.The fetus has well developed sensations for touch and position (tactile and kinesthestic sensations). After birth, “the infant actively seeks to adhere to as much skin surface on the mother’s body as possible”,(3). Tactile stimulations “facilitate the flow of affective information from the infant … to the mother”, and this determines the development of brain pathways. “The language of mother and infant consists of signals produced by the autonomic nervous system of both parties”. This is the basis of healthy development!Just providing nutrition will make the brain grow (albeit not as well) but its function will be affected permanently. The neural development is directly dependant on the sensation and experiences of the fetus and newborn, and can be for better or for worse. Dysfunction expresses itself primarily in the sphere of relationships, and this sphere is anchored in the function of the right brain. Basic mechanisms for brain growth Schore presents a new slant with the same message in two recent in depth reviews from developmental psychology, infant psychiatry and developmental neuroscience(3;4;4). The development, growth and function of the human brain has been studied extensively in the last decade, and in the following section some 40 pages are summarised in a few quotes (verbatim): “Maturation of … adaptive right brain regulatory capacities is experience dependent, and this experience is embedded in the attachment relationship between infant and primary caregiver, …“ … the environment affects the structure and function of the brain. “ … an early postnatal period represents a “critical period” of limbic –autonomic circuit development, during which time experience or environmental events might participate in shaping ongoing synapse formation.” (Bowlby) The capacity to cope with change and stress is a right brain function, which is built up over time. After birth, the critical neural pathway that develops is the amygdala- orbitofrontal tract, and the salient stimulation or experience required is tactile: “ … skin-to-skin contacts come on line early ….. the infant actively seeks to adhere to as much skin surface on the mother’s body as possible” (Harlow) “ … areas of the amygdala … are in a critical period of maturation …. through the first two months of human life, the earliest period of bonding.” At eight weeks, visual parts of the brain develop dramatically, and the next tract to develop requires eye-to- eye contact, and maternal infant interactions. These interactions are vital to optimal development. “The growth of the baby’s brain literally requires brain-brain interaction, and occurs in the context of a positive affective relationship” (Trevarthen). “The early right brain capacities … are not only central to the origin of the self, they are required for the ongoing development of the self over the lifespan.” Neurobehavioural understanding of breastfeeding Biological research in all mammals has shown that the neural events in pregnancy are "highly conserved"(5) , that is they are almost identical in all species. The subsequent endocrine priming of pregnancy, again, is "remarkably similar across species"(5). Once birth takes place, all mammals studied show a "set sequence of behaviours"(6), which leads to the initiation and the sustaining of breastfeeding behaviour. These behaviours do differ, each species having its own set sequence. These "highly conserved neural events " can be understood as brain based programmes, and there are only three(7) 1. Nutrition programme (default mode, described above) 2. Defence programme 3. Reproduction programme. Each programme is expressed through its own unique battery of hormones, its own unique expression of autonomic controls, and its own somatic behaviours. It is essentially only the last that is visible to us as outside observers, but it is the others that are more critical. In biological terms “initiation of breastfeeding might be a “reproduction” program behaviour, and the “maintenance of breastfeeding” a nutrition programme behaviour. Biologists describe mammals as developing through a progression of habitats, (for example in the rat: from the uterus, to mother's body, to nest of siblings, then the world)(6). In each habitat, the developing organism is physically capable and neurobehaviourally equipped and programmed to behave in such a way as to provide for its own needs. The key concept is that the developing organism is endowed with the behaviours required, those behaviours are specific for the habitat for which they are designed, and it is the habitat that provides the needs of the organism. While it is stated that the human newborn biologically is “exceedingly immature”(8), it is a mistake to regard the human newborn as helpless and incapable. The immaturity is relative to ourselves and our habitat, in that the human newborn arrives extremely early into a habitat requiring abilities that are yet to develop. But “our” habitat is not the newborns habitat; when placed in the habitat for which it is designed, the human newborn exhibits some remarkable capabilities. The “habitat-niche” relationship described by Alberts(6) and other biologists emphasises that the developing organism is fully equipped with the neurological circuitry to display behaviours which ensure the provision of its “basic biological needs”. Those needs are provided by the correct habitat, and the manner in which the organism through its own abilities exploits those resources earns the term “niche”. A surprising and key finding in animal studies has been the finding that it is the newborn's behaviour that is determining or paramount, the newborn's actions elicit care giving responses from the mother(9). Once initiated by the newborn, "breastfeeding is established through a set of mutual complex sensory stimulations"(10). This behaviour is evident in the newborn domestic dog (illustrated in a series of photographs.) However, in all species, suckling "is a remarkably fragile and transient behaviour"(11), and is easily disturbed by any intervention. The human self-attachment behaviours described by Widstrom and Righard are now well known(12;13). In biological terms this is called “initiation”, and this is an innate neurobehaviour, and is distinct from the “maintenance of breastfeeding” behaviour. This has also been identified as a “critical period”, a unique period in time in which an event can take place and a behaviour can be fully expressed, and that period is vital for the optimal development of the organism. What is critical to appreciate is that while the suckling we observe we have labelled as “breastfeeding”, this is only the physical expression of an innate and global neurobehaviour seen in a brief period. From a neurobehavioural perspective, breastfeeding is the entire “nutrition programme”, and it is dependent on being in the right habitat. Further, the nutrition programme requires the continuous and constant and uninterrupted habitat for which it is designed. The nutrition programme is expressed through specific hormones and the autonomic nervous system, and are on night and day. The behaviours observed between “breastfeeds” are also part of the nutrition programme. This can also be described under the label “state organisation”, and NIDCAP has taught us much about it, albeit in a technological context. State organisation refers to the organism’s level of alertness, and ranges from deep sleep through several stages to awake and at the extreme “hard crying”. Critical for the well- being of a newborn is the requirement of “cycling” appropriately between levels of sleep that is not too deep, and being awake for feeding, and avoiding crying and stress. Optimal synaptogenesis and wiring is related to normal sleep cycling. Electroencephalographic recordings have shown that the normal sleep cycling of a newborn is 60 to 90 minutes, and disruption of this cycling leads to stress and pathology. This kind of optimal state cycling is only observed in infants that are together with their mothers, and optimally so where there is maximal skin-to-skin contact.(14;15;15-17) The pattern of breastfeeding that results when an infant is never separated from the mother is very different from that we believe to be “normal” in our western culture. Firstly – the pattern is entirely determined by the infant and not the mother, and each infant is unique. An infant allowed to decide its own feeding pattern from initiation will settle in to “maintenance” feeding, and will feed every hour or two at most, will ingest the full ejection load of a single let down reflex, which just happens to be the comfortable maximum capacity of its stomach, and which happens to contain enough food and calories for one or two hours at most, and it will cycle its state organisation effectively. This is the pattern observed from almost all non-western cultures.(18) Consequences of adverse environment on brain growth Removed from the correct habitat, all mammals exhibit an identical pre-programmed response, referred to in biology as the "protest - despair response"(6). This is the defence programme, and has its own set of hormones, autonomic controls and somatic expressions. The “protest” response is one of intense activity seeking reuniting with the habitat/mother, the “despair” response is a withdrawal and survival response of decreased temperature and heart rate, mediated by a massive rise in stress hormones. Reunited with the correct habitat (mother), there is a rapid rise in heart rate and temperature. The "protest-despair response" was first described in humans, in orphans after WWII(3;4) , it was subsequently studied in monkeys and then in many other mammals. Separation has been shown to cause maladaptive changes in brain structure and subsequent behaviour, and changes in the fundamental efficiency of all the body systems(8). Early separation produces major shifts in susceptibility to stress-induced pathology(2). The origins of many human behavioural deviations are unknown, it has been suggested that most of these can be traced back to “violations of an innate agenda?"(10) The primary violation, the worst case scenario, to any newborn is separation from its habitat/mother. In current neurobehaviour studies in human beings, protest-despair is referred to as “hyperarousal and dissociation”. This work is summarised in the long but illuminating psychoneurobiological review by Allan Schore(4). “ … the human infant’s psychobiological response to trauma is composed of two separate response patterns – hyperarousal and dissociation. (Perry et al) “ … (In hyperarousal) the sympathetic autonomic nervous system is suddenly and significantly activated, increasing heart rate, blood pressure, tone and vigilance, distress is expressed in crying then screaming … this state of “frantic distress”, or what Perry terms fear-terror, is known as ergotropic arousal … with excessive levels of major stress hormone releasing factor … resulting in a hypermetabolic state in the brain. “(Dissociation) is a second later-forming reaction in response to terror, and involves numbing and avoidance, … a state of conservation-withdrawal, a parasympathetic regulatory strategy that occurs in helpless and hopeless situations … a hypometabolic process used throughout the lifespan, in which the individual passively disengages “to conserve energies” … to foster survival by the risky posture of feigning death. “In this passive state of profound detachment, pain numbing and blunting endogenous opiates are elevated, instantly triggering analgesia and immobility and inhibition of cries for help … vagal tone increases dramatically, decreasing blood pressure and heart rate … in this state both the sympathetic energy-expending and parasympathetic energy-conserving components of the infant’s developing brain are hyperactivated … (creating) chaotic biochemical alterations, a toxic neurochemistry in the developing brain “ … the psychotoxic contexts of early relational trauma … intense relational stress alters calcium metabolism, a critical mechanism of cell death … result in permanent alterations in receptors … (causing ) high risk for developing severe psychopathologies at later stages of life.” Neurobehavioural evidence of environmental deprivation Prematures and newborns have a nervous system which lacks the ability to dampen down sensory signals. Over-stimulation of any of the senses will be experienced as PAIN by the newborn. Stress hormones increases the perception of pain. When the entire environment provides noxious stimuli to the developing brain, the effects or early abuse and neglect have catastrophic impact(4).“Severe levels of stress associated with infant abuse and neglect are pathogenic to all immature human brains, and neglect may be even more detrimental than abuse. “Caregiver induced trauma is qualitatively and quantitatively more potentially psychopathogenic than any other stressor … “In human infancy, relational trauma, like exposure to inadequate nutrition during brain growth spurt, biological pathogens or chemical agents, and to physical trauma to the baby’s brain interferes with the experience dependent maturation of the brain’s coping systems, and have a long-enduring negative impact on the trajectory of developmental processes. Birth complications … affect personality, relationships, self esteem … and behaviour patterns later on in life”(13). "The origins of many behavioural deviations are unknown ... can some be traced back to violations of an innate agenda?" Maternal rejection and lack of bonding combined gives a strong correlation to violent criminal behaviour. Advent of hospital nurseries and early separations correlates with attachment disorders, maternal abandonment of baby, increased addictive behaviours (unmet oral needs). In short, separation of mother from infant is psychotoxic for the infant’s brain. Kangaroo Mother Care Kangaroo Mother Care has been variously defined, but two essential components are skin-to-skin contact and breastfeeding(19). From the biological perspective, in the immediate newborn period of Homo sapiens, skin-to-skin contact represents the correct "habitat", and breastfeeding represents the "niche" or pre-programmed behaviour designed for that habitat(20). The KMC paradigm holds that prematurity is not a disease, but that separation from the habitat (mother) will make a premature diseased. Likewise withholding of the niche (breastfeeding and breast milk as two separate concepts) will make the premature diseased. In the KMC paradigm the original habitat and niche is the starting point of care, to which we add whatever available technology and “support” is available. This triad of habitat, niche and support reflects the key relationships essential to being a species, to being human: mother, child and father. Newborns have fully developed competencies for needs / growth Our current basic assumptions and belief systems in respect of infant care are based on a view that sees the human newborn as helpless, due to its developmental immaturity. On this basis our technologically advanced civilisation has improved child survival through use of incubators and associated technology(21). The “immaturity and helplessness of a newborn” requires to be interpreted in developmental terms: given the right habitat, the human newborn is perfectly equipped to ensure its own needs. That habitat is maternal-infant skin-to-skin contact. Deprivation of that habitat does render the human newborn helpless and vulnerable. Our current paradigm falsely assumes that the observed helplessness is inherent, and does not recognise that the false paradigm caused the helplessness. Mother’s behaviours must be attuned to the infant’s basic needs. Our current paradigm regards mothers as generally ill-equipped to provide care to newborns, needing health service assistance and other support. Maternal rights to work and optimal use of their own time prioritised, and is assisted by adequate replacement feeding. However, given uninterrupted and continuous contact to their newborns, highly competent maternal behaviours are elicited which do not require intellectual understanding of the process and mechanisms involved. The maternal limbic system is programmed to provide optimal newborn care, the “neocortex” is of secondary importance, but can easily be manipulated to cause the limbic system programme to fail. Father’s role is to protect integrity of dyad, and provide support. Our current paradigm regards fathers as having no meaningful role in this period of life. The father’s role however, is to ensure that the maternal-infant dyad is protected and provided for. For prehistoric fullterms, father’s presence to ensure there was no need for separation was critical for survival. For mild degrees of prematurity, such protection would have been adequate. In our context and in view of more extreme prematurity, the father’s role is replaced by the health care system, which must now take over the responsibility of ensuring there is no separation. Whatever technological needs are now available and appropriate should therefore be added to the maternal infant dyad. Definition of KMC This provides the rationale for a definition of Kangaroo Mother Care. KMC can be defined as 1) maternal-infant skin-to-skin contact, (continuous and uninterrupted) 2) exclusive breastfeeding, (mother’s milk, & access to nipple and breast) 3) providing support to dyad, (whether psychological or technological) There have been approximately 300 published papers on skin-to-skin contact. The message from all these is summarised under the headings of the “four basic biological needs” as follows. Oxygenation has been shown to be improved on skin-to-skin contact (SSC), to the extent that SSC has been used successfully to treat respiratory distress (16). Infants removed from incubators and placed SSC show a rise in temperature(22), and maintain that temperature in a very narrow and stable range. Nutrition is improved, both with respect to the mother’s ability to breastfeed, and with respect to the newborn’s absorption and use of the feed. Fullterm undrugged infants, left on their mother's chest and undisturbed, will all breastfeed spontaneously within one hour, with no help at all (23). The stimulations the newborn gives the mother during SSC elicit caregiving and protective behaviours from the mother. SSC care to sick premature infants causes a dramatic lowering in stress hormones(24), as predicted by the "protest-despair response" (see below). Infant immunity is improved, demonstrable even 6 months later (25). In no published paper (anno 2001) is a single adverse outcome reported for KMC. Positive effects on the mother are better bonding, healing of emotional problems associated with premature birth, among others. Twenty years ago the importance of breastfeeding was held in such low esteem that it was not considered as an outcome to study. In recent years this has changed, specifically for the premature infant, and there is now clear evidence of the hypothesis described above. A Cochrane review shows increased breastfeeding rates and duration from early skin-to-skin contact. Early experience of “Birth Kangaroo Mother Care”. The author and Sr Agneta Jurisoo arrived in 1988 at a remote mission hospital in Zimbabwe, where referral of premature infants to higher levels of care was not possible. Best possible care had been provided according to resources, with a 10% survival of Very Low Birthweight infants (VLBW, below 1500g). Kangaroo Care had been described in a few published articles, (reviewed by Sr Agneta during a diploma course) all suggesting that skin-to-skin contact was safe for stabilised newborns(26-30). In the absence of technology to achieve such stabilisation, skin-to-skin contact (SSC) was started immediately after birth on all infants. The effects were dramatic(31). Infants with a gestational age of 32 weeks or more uniformly did well, and stabilised much more rapidly than had been observed in incubators. One of the first infants treated was born at 1010g and survived, fully convincing the staff that this was the only way to treat premature infants. Persuading mothers of this truth was more challenging, as it was evident the SSC had to be continuous. A wrapper or tie to ensure fixation of the baby was developed, with a wrap-around shirt to provide comfort for the mother. This allowed the mother to have free hands, and be able to do other things. The mother was encouraged to be ambulant after the first day, and slept at angle of 30 degrees from the horizontal. Both mother and infant could sleep safely in this position, this was essential as nights could be very cold. It generally took between two and four days for the nursing staff to get a mother to get the idea of how to ensure continuous care. However, a mother already in the unit could help a new mother in the unit to get the idea in less than two days. Once stable, the only nursing intervention required was to ensure that feeding took place every two hours, and particularly through the night. In 1988, the HIV/AIDS epidemic was just starting in Zimbabwe, and there was almost no knowledge about vertical transmission, it was assumed it was negligible. Sr Agneta and her midwives nevertheless decided they would use only mother’s own milk. 100% of babies were raised using mother’s own milk, only occasionally were clear fluids used to supplement liquid needs in the first day or two. Smaller babies were fed by nasogastric tube, later with teaspoons or small cups, or by direct expression from mothers nipple to baby’s mouth. Transition to full breastfeeding was allowed to happen at its own pace. After the expected weight drop in the first week, these infants grew rapidly, many with an average weight gain of 30g/day. They required no monitoring, and were weighed only three times a week. Mother’s self-reported problems and concerns early. Failure to gain weight was most often due to failure to feed at night, but was otherwise an indicator to investigate. For example, three of 126 infants had patent ductus arteriosus, all responded to oral indomethacin. There were of course many infants that did not survive. What was rapidly clear however was that the physiological parameters at 6 hours of age were predictive. If the infant was stable at 6 hours, no matter what its weight or gestational age, it did well. If it remained unstable at that point, its prognosis was poor. The only available technology was nasal cannula oxygen and umbilical vein catheterisation for resuscitation; for improved survival such infants were in need of CPAP and ventilation, and other technology. All babies were kept in hospital until they weighed 2500g, after which they were discharged for routine followup in Well Baby Clinics. After five years, the data was collected and analysed. The survival of VLBW overall had increased from 10% to 50%, and for babies 1500g to 2000g the survival had increased from 70% to 90%(31). Other experience. Prior to this, KMC was generally practiced only on stabilised babies. Comparisons from Third world contexts are difficult to make given the lack of controls and the paucity of articles. Data were available to compare results from Colombia, Mozambique and Ecuador(25;32-34). Each of these describe KMC started late, but with access to ventilators and some technology. Despite the latter, results from Manama with “Birth KMC” (but lacking technology) were either better or equivalent with respect to daily weight gain, total survival below 1500g, total survival below 2000g, and survival after first week. In particular, the daily weight gain noted was higher than that even seen in First World contexts. Dr Ornella Lincetto, working in Mozambique, established a 6 bedded KMC unit in a large secondary level hospital with poor resources and few staff. Because the beds were so few, they were restricted to infants between 1200g and 1800g. Overall, 75% of these babies survived. However, only 39% of infants between 1880g and 2500g survived the care provided in conventional incubators(35). Worku and Kassie (2005) conducted a randomised controlled trial comparing skin-to- skin contact with incubator care on newborn infants arriving at their unit in the capital of Ethiopia, within the 24 hours of birth. Overall, the mortality for KMC was 23% compared to 38% for incubator. However, the mortality of infants randomised in the first six hours was 17% in KMC compared to 46% in incubator. Rationale for randomised controlled trial: importance of habitat. The widespread implementation of incubator care preceded the advent of the randomised controlled trial by some thirty years, and the incubator has not been compared to any other way of treating prematures until recently. Maternal-infant skin- to-skin contact from birth is the biological alternative to incubator care. The neurobehavioural foundation for this is based on the concept that the “maternal habitat” is determinant for brain development. A randomised controlled trial was conducted 2001-2002, in which only the “habitat” differed. In terms of the scientific paradigm in which our western culture operates: to test the hypothesis that incubator care is inferior to maternal-infant skin-to-skin contact for care of lowbirth weight newborns(36). Design and results of trial Mothers had to be identified and have given consent before the delivery, and for the first five minutes, there was no separation between mother and child, (apart from the time on the weighing scale). Babies had to weigh between 1200g and 2200g to be included. Randomisation was then done 5 minutes after delivery, when allocation to maternal-infant skin-to-skin contact (SSC) or to incubator care (CMC, Conventional Method of Care) took place. (This was done by a computer, which resulted in groups of uneven size). Both SSC and CMC was provided in the same delivery suite for the first hour, and in the same observation unit of the neonatal department for the next five hours, after which the controlled conditions of the trial ended. All aspects of care were carefully standardised, same resuscitation, same intravenous fluids and feeding, and same observations. Thus, apart from the habitat, or place of care, everything was the same for both groups of babies. A scientific trail required an objective measure of “inferior or superior”, and the key issue is that of stability or stabilisation. Despite “stability” of the premature being a widely used term, there is no validated instrument to measure this. However, a “SCRIP score” (Stability of the Cardio-Respiratory system In Preterm infants) is described from Germany, this was modified to local conditions. Essentially it provides a measure of cardiorespiratory stability through a 5 minute observation of heart rate, respiratory rate and oxygen saturation, with scores allocated for defined ranges of these. A blunter but more specific measure was to define outer ranges of objective physiological parameters and count such events: apart from the above this included temperature and blood sugar. The computer randomisation was successful in ensuring that both groups were comparable in terms of a variety of significant factors. Infants provided SSC from birth were significantly more stable as measured by both criteria for stability. It was hypothesised that more incubator infants would end up in ICU, this was not shown, most probably due to the fact that they were observed far more closely than was usual in the neonatal department (Hawthorne effect). During the study period fully 12 of the 13 incubator babies exceeded one or more of the blunt parameters, compared to only 3 of the 18 skin-to-skin babies. The incubator babies had temperature control problems in the first two hours, were at risk of hypoglycaemia in the next two hours, and had more cardiorespiratory instability in the final two hours. The SCRIP score during this period was maximal for 10 of 18 SSC babies, but only for 2 of 13. At the end of the study period (six hours of age), 100% of SSC cases had optimal cardio-respiratory stability, even the smallest 1200g infant in the group; compared to 50% (6 out of 13) of the incubator babies. It could be questioned that the bigger babies were responsible for this finding. When the bigger babies above 1800g were removed from the analysis, the differences in the two groups was greater, not less. For SSC, 9/9 babies had perfect scores, only 1/4 CMC babies (25%). Thus, the lower the birthweight, the more important the maternal habitat was to ensure stabilisation of the newborn(36). (Note that these small numbers do not provide for statistical power). All the incubator babies showed the responses predicted by “protest-despair”, of lowered temperature and unstable heart rates, with respiratory instability. This study was not designed to show any long term effects, and no such study is known to this author. However, the inferences from mammalian studies are obvious: separated human newborns show the exact physiological changes that mammals do, and such mammals all go on to exhibit adverse sequelae across the life span. Concept of a paradigm The term “paradigm” here is used to describe the set of basic assumptions and beliefs that underpin or underlie our behaviour and our culture. This may include knowledge that is subconscious, perhaps imprinted in our brains before our consciousness developed. The issue is that such knowledge is not questioned, and it may be false. Our conscious intelligence however builds a “superstructure” on that paradigm, and that superstructure makes the best possible sense of our conscious reality. The superstructure has to shift when the consciousness discovers false subconscious assumptions and beliefs. Brief history of origin of current infant care paradigm. The widespread use of incubator care and mother-infant separation is almost an historical accident. Semelweiss identified the cause of high maternal deaths as infections, spread by doctors. By the end of the 19th century infection was recognised as a cause of mortality of premature newborns. Tarnier and Budin in France developed and implemented the “child hatchery” to protect from infection, and gave it glass walls so that mother could see and be part of the care team. A German called Cooney exploited this knowledge and successfully raised small infants donated to him by hospitals in exhibitions, circuses and fairs, and in so doing excluded mothers. He took the concept to America, using his daughter and her friends to raise the babies(37). When American hospitals eventually accepted his practice and techniques, they also accepted the exclusion of the mother, regarding her as being the source of infections for the neonates. . With mothers excluded, provision of formula became a convenient and almost essential way of providing feeds. As a result, technology could now take over altogether, both “habitat and niche” have become synthetic and artificial. This societal shift was accomplished by the end of 1950. Only in the beginning of 1960 did randomised controlled trials test new methods of care. Incubator care and formula feeds (institutionalised before 1950), were never subjected to such trials. The result is that in our Western paradigm, the newborn has generally been regarded as helpless, with the newborn requiring help for all its needs. For full term babies, the mother may provide for these needs after graduating from the central nursery, but for prematures, the health service must remove the newborn from the mother and provide for all its needs for an extended period of time. This belief has not been questioned, but it is contrary to science. Nevertheless, our culture and society has established a sophisticated technological and economic environment (=superstructure) unaware of the science. The superstructure is in itself intrinsically or internally logical, intelligent and integrated, but it is built on false information and understanding, and is therefore not sustainable in the long term. Application of finding In our Western paradigm, the newborn has generally been regarded as helpless, (“the mother clueless, and the father useless”) with the newborn requiring help for all its needs. For full term babies, the mother is seen as providing these needs; for prematures, the health service removes the newborn from the mother and provide for it needs. Science demands otherwise. For the fullterm infant, its sole requirement is the correct habitat, which is not the mother as a caregiver, but the mother as a provider of the habitat, through skin-to-skin contact. The fullterm infant is reasonably robust, the premature is frail. However, the premature's need for the correct habitat is even greater than the fullterm's. The premature is endowed with the same neurobehavioural programme and behaviours, but due to its physical immaturity, does require whatever available technology and support is available. That support should be afforded to it, but without removal from the correct habitat and violation of its innate agenda. The neurobehaviour called “breastfeeding” is a critical survival strategy for the newborn human being, and is a behaviour which depends entirely on a limbic system brain programme, which in turn depends entirely on being in the right habitat: the maternal milieu. Any separation results in a opposing and potentially harmful neurobehavioural programme. Thus, the maternal milieu is specifically needed from the moment of birth, and should be continuous. Without this, the neurobehaviour that results is “protest-despair”, which actively shuts off the “breastfeeding behaviour. Thus, on the research I have presented to this Conference, I posit that maternal-infant separation is the single greatest barrier to breastfeeding. Our paradigm provides care to mothers separately from newborns. Almost everything we do as a result mitigates against breastfeeding success. The solution therefore is as simple as I promised: never separate mothers and newborns. To make a difference, and to achieve greater breastfeeding success, all policy and practice must ensure that that mothers and their newborns are never separated. The fetal brain requires mother’s presence to work properly, the result is breastfeeding. Skin-to-skin contact from birth onwards, and a caring paradigm based on a better understanding of neuroscience, are the primary determinants of breastfeeding success. BIRTH KANGAROO MOTHER CARE RANDOMISED CONTROLLED TRIAL Abstract of trial (article copy right Acta Paediatrica) Bergman NJ, Linley LL, Fawcus SR. Randomized controlled trial of maternal-infant skin-to-skin contact from birth versus conventional incubator for physiological stabilization in 1200g to 2199g newborns. Acta Paediatr 2004; 93(6): 779-785. Aim: Conventional care of prematurely born infants involves extended maternal-infant separation and incubator care. Recent research has shown that separation causes adverse effects. Maternal-infant skin-to-skin contact (SSC) provides an alternative habitat to the incubator, with proven benefits for stable prematures; this has not been established for unstable or newborn low birth weight infants. SSC from birth was therefore compared to incubator care for infants between 1200-2199g at birth. Methods: This was a prospective, unblinded, randomized controlled clinical trial; potential subjects were identified before delivery, and randomized by computerized minimization technique at 5 minutes if eligible. Standardized care and observations were maintained for six hours. Stability was measured in terms of a set of pre- determined physiological parameters, and a composite cardio-respiratory stabilization score (SCRIP). Results: 34 infants were analyzed in comparable groups: 3/18 SSC compared to 12/13 incubator babies exceeded the pre-determined parameters (p<0.001). Stabilization scores were 77.11 for SSC versus 74.23 for incubator (maximum 78), mean difference 2.88 (95% CI 0.3 – 5.46, p = 0.031). All 18 SSC subjects were stable in the sixth hour, compared to 6/13 incubator infants. 8/13 incubator subjects experienced hypothermia. Conclusion: Newborn care provided by skin-to-skin contact on the mother’s chest results in better physiological outcomes and stability than the same care provided in closed servo-controlled incubators. 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