A neurobehavioural approach to breastfeeding, … Dr Nils Bergman MB ChB, DCH, MPH, MD (USA equiv:...
Transcript of A neurobehavioural approach to breastfeeding, … Dr Nils Bergman MB ChB, DCH, MPH, MD (USA equiv:...
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Dr Nils Bergman
MB ChB, DCH, MPH, MD
(USA equiv: MD, MPH ,PhD)
Cape Town, RSA
www.skintoskincontact.com
A neurobehavioural approach to breastfeeding, including
premature infants
NEURODEVELOPMENT
The DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth & BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
MICRO-RNA
HISTONE MODIFICATION
DNA METHYLATION
NEURODEVELOPMENT
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EVOLUTIONARY BIOLOGY
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EPIGENETICS
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“Phenotype” – specimen resulting from
gene – environment interaction
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”Neurons that fire together wire together while those which don’t,won’t”
Hebb/Carla Shatz REMNR1NR2NR3SWS
ACQUISITION CONSOLIDATION MEMORYFORMATION
poly-sensory input transfer information P wavesshort-term memory “SNR” strong signals returns infostored cortex amygdala / to neocortex:
hippocampus organizedAwake and REM NREM stage 4 REM
BRAIN WIRING
Stanley Graven 2006
Amodio 2008
CPU
AMYGDALA:
EmotionalProcessing Unit
GPS
HIPPOCAMPUSMemory functionand spatial code
modulates state organisationelicits emotional behaviours
activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour
SMELL
Schaal 2004 11
The secretion of Areolar(Montgomery’s) Glands
“In early ontogeny the sleeping brain may thusremain sentient of an organism’s odor environment.”
Doucet 2009 12
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Joseph 2014 Arch Dis Child Fetal Neonatal Ed. 2014 Sep 22. pii: fetalneonatal-2014-306104.
doi: 10.1136/archdischild-2014-306104. [Epub ahead of print]
Getting rhythm: how do babies do it?
Birth ~ /~ 8w 9w 10w 11w
dates averaged “between 6 and 18 weeks”
CORTISOLday-nightrhythm
MELATONINday-night rhythm
TEMPERATUREday-nightrhythm
H3f3b genedetected
In adult:sleep cycles are blocked;
hormonesswing
Infant:sleep cycles
begin to block on diurnalrhythms
Mother-infant synchrony
… at 12 weeks
(circadian)
START at 3 months
Can be “adult-like”
at 6 months.
Thomas 2014
In child:will appear on its own 3 – 12 m
ONE SIZE DOES NOT
FIT ALL:
Equally *normal*at 6 months
to sleep 2hoursas 6 hours
3 12 m
PLAY FEED
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SLEEP SLEEP
SLEEP SLEEPPLAY
FEED
Infant sleep cycling and synchronicity with maternal sleep ensure development.
Infant:sleep cycles
begin to block on diurnalrhythms
4
BOND SUCKLE SLEEP SLEEP PLAY
FEED
137
SLEEP SLEEP SLEEP SLEEPPLAY
FEED
Infant sleep cycling and synchronicity with maternal sleep ensure development.
Infant sleep cycling critical for brain
development,BUT is also determined by brain requirements:
TEMPERAMENTPERSONALITYOREXIN METABOLISM“MORE SLEEP MORE WIRING”
In adult:sleep pertains
to memory
In child:neurodevelopment
(brain wiring)1st 1000 days
BRAIN WIRING
Peirano 2003
Brain Architecture and Skills are Built in a Hierarchical “Bottom-Up”
Sequence• Neural circuits that process basic information
are wired earlier than those that process more
complex information.
• Higher circuits build on lower circuits, and
skill development at higher levels is more
difficult if lower level circuits are not wired
properly.
Slide by: Jack P. Shonkoff, M.D.
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HIGHLY CONSERVED NEURO-ENDOCRINE
BEHAVIOR
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5
AT BIRTH,
the brain has TWO CRITICAL SENSORY NEEDS:
SMELL & CONTACT
APPROACH RESPONSE … learned prenatally, reinforced both during the birth process and
repeatedly throughout the postnatal period,
… supported by a unique neural framework … a system that ensures rapid and robust maternal odor learning
SMELL vanilla / colostrum / water (control)
read NIRS activity FRONTAL LOBE
• This was confirmed by
demonstration of a statistically
significant negative correlation
between changes in [Hb O2] and
postnatal age (r 520.64, p 5 0.001
with 95% confidence interval) (Fig.
4). Those babies showing the
greatest increase in [Hb O2] were
between 6 and 24 h old at testing
• In the 14 babies older than 24 h
there was no significant difference
between the changes in [Hb O2]
during control and colostrum
exposure
APPROACH RESPONSE
In the 14 babies
older than 24 h
there was
no significant
difference
between the
changes in [Hb
O2] during control
and colostrum
exposure
Those babies
showing the
greatest
increase in
[Hb O2] were
between 6 and
24 h old at
testing
The first hours after birth are a
CRITICAL PERIOD NEURODEVELOPMENT
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“For species such as primates, the mother IS the environment.”
Sarah Blaffer Hrdy, Mother Nature (1999)
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Nothing an infant can or
cannot do makes sense,
except in light of mother’s body raises its own temperature,has a higher blood glucose,metabolic adaptation faster.
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“The newbornmay appear
helpless, but
TRANSITION
Images courtesy of Prof Peter Hartmann, UWA
Warming, feeding and
protection behaviours areintricately, inseparablylinked to the right place.
(Alberts 1994)
The BOND is made up of the
sensory inputs from the parent to the infant
REGULATION
Bowlby 1969, 1973, 1980
Through “hidden maternal regulators” ...
warmth activity levelmilk heart rate
“ physiological set points “internal working modelsscripts – templates
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a mother precisely controls everyelement of her infant’s physiology,
from its heart rate to its release of hormones
from its appetite to the intensity of its activity
(Gallagher 1992)
Through “hidden maternal regulators” ...
The BOND is made up of the
sensory inputs from the parent to the infant
REGULATION
Bowlby 1969, 1973, 1980
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BABY
BONDING
AT BIRTH,
the brain has TWO CRITICAL SENSORY NEEDS:
SMELL & CONTACTconnect direct to the amygdala
AMYGDALA:EmotionalProcessingUnit CPU
Prefrontal cortexExecutive function
SOCIAL and EMOTIONAL
INTELLIGENCE
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BONDING
Smell
Skin contact
Simulation theory:EMPATHY is generated by inner imitationof actions of others
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BONDING
Morphing emotion AMYGDALA FUSIFORMGYRUS
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BABY
BONDING
Smell
Skin contact
Simulation theory:EMPATHY is generated
by inner imitationof actions of others
In humans, oxytocin increases gaze to the
eye region of human faces and enhances
interpersonal trust and the ability to infer
the emotions of others from facial cues.
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Smell
Skin contact
A primary visual areas,
B somatosensory motor cortex
C primary auditorycortex
D parietal cortex & cerebellum
E m l anterior pre-frontal cortex
Fransson 2007
Smell
Skin contact
EMOTIONCONTROL CENTRE
FACE RECOGNITIONCENTRE
OXYTOCIN
E prefrontal
A primary visual
B somatosensory
C primary auditory
D parietal& cerebellum
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SEPARATIONBABY
BONDING Toxic stress
Garner 2011
Positive Stress
• Moderate, short-lived stress responses, such
as brief increases in heart rate or mild changes
in stress hormone levels.
Slide by: Jack P. Shonkoff, M.D.
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Bad
Good
• An important and necessary
aspect of healthy development
that occurs in the context of
stable and supportive relationships.
High
StressLow
Stress
Tolerable Stress
• Stress responses that could disrupt brain
architecture, but are buffered by supportive
relationships that facilitate adaptive coping.
• Generally occurs within a time-limited period,
which gives the brain an opportunity to recover
from potentially damaging effects.
Slide by: Jack P. Shonkoff, M.D.
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SEPARATIONBABY
BONDING Toxic stress
• Strong and prolonged activation of the body’s
stress management systems in the
absence of the buffering
protection of adult support.
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SEPARATIONBABY
BONDING Toxic stress
•Disrupts brain architecture and leads to stress management systems that
respond at relatively lower thresholds, thereby
increasing the risk of stress-
related physical and mental illness.
SEPARATION DYSREGULATES
CORTISOL CORTISOL
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MICHAEL MEANEY epigenetics
CORTISOL
Unsafe environment activates HPAaxis (autonomic nervous system, ANS).
Psychobiology
and molecular
genetics of
resilience
Adriana Feder*, Eric
J. Nestler‡, and
Dennis S. Charney‡ Nat Rev Neurosci. 2009 June ; 10(6): 446–457. doi:10.1038/nrn2649
HG BABY HG BABYLOW Grooming care
HG - High Grooming Low Grooming LG
HG BABY LG BABY
MOTHER MOTHER
Healthy UNHEALTHYadult adult
HG – High Grooming Low Grooming - LG
Makes MOTHER Makes MOTHER
UNHEALTHYadult
LOW Grooming LG
Makes MOTHER
CORTISOL
HG - High Grooming Low Grooming LG
HG BABY LG BABY
MOTHER MOTHER
Healthy UNHEALTHYadult adult
HG – High Grooming Low Grooming - LG
Makes MOTHER Makes MOTHER
Early stress alters gene expression,with health impact across lifespan.
HG – High Grooming Low Grooming - LG
Makes MOTHER Makes MOTHER
HEALTHYadult
HIGH Grooming HG
Makes MOTHER
Earliest care at birth matters
Same gene switched
LG BABY LG BABYHIGH grooming care
OXYTOCIN
Primate separation studies
Maternal Separation Paradigm0w 1w 2w 3w 4w 5w 6w 12w
n 4 Mat MNSgroup reared no mothern 4 Mat MNS group as aboven 4 Mat (control)
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Gene specific for the AMYGDALA( GUYC1A3)
Separated at 1 week:
LOW gene expression
Increased self soothing Anxiety
Decreased sociality Depression
Repeated shortseparations:
LOW gene expression
Correlate to human adult depression
2ND
KNOCK
Adults with depression, suicides:LOW gene expression
smalller hippocampal volumereduced expression frontal lobe
DOHAD
Developmental Origins of
Health and Adult Disease
… very early, once off, and forever.
Early stress alters gene expression,with health impact across lifespan.
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SEPARATIONBABY
BONDING Toxic stress
SKIN-TO-SKIN CONTACT
SEPARATION
BREAST- VAGALMOTHER FEEDING (PSNS) GROWTH
OTHER PROTEST- STRESS SURVIVAL orDESPAIR (SNS)
THE PLACE MODEL
Reference
RCT of skin-to-skin contact from birth versus conventional incubator care for physiological stabilisation in 1200- and 2199-gram newborns.
Bergman NJ, Linley LL, Fawcus SR.
Acta Paediatrica 2004 Vol 93(6); 779-785
“100% SCRIP STABILIY”
S S C C M C
1200g to
2200 g1 - 6h 56% 11%
@ 6h 100% 46%
1200g to
1800g1 - 6h 44% 0%
@ 6h 100% 25%
Stabilisation first 6 hours, average hourly SCRIP score
5.1
5.2
5.3
5.4
5.5
5.6
5.7
5.8
5.9
6
6.1
2nd 3rd 4th 5th 6th
KMC all
KMC <1800
CMC all
CMC <1800
Hourly average of SCRIP score, 2nd to 6th hour
Stabilization 1200g – 1800g
Skin-to-skin
Incubator
INCUBATORS DE-STABILISE
NEWBORNSStabilisation first 6 hours, average hourly SCRIP score
5.1
5.2
5.3
5.4
5.5
5.6
5.7
5.8
5.9
6
6.1
2nd 3rd 4th 5th 6th
KMC all
KMC <1800
CMC all
CMC <1800
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Premature babies are not in incubators because they are unstable.
Premature babies are unstable because they are in incubators.
H1b (SPECIFIC)
DoctorDoctor StableStablesummoned:summoned: .
INCUBATORINCUBATOR 92% 92% 8% 8% SKINSKIN--TOTO--SKINSKIN 17%17% 83%83%
Bergman et al 2004
REGULATION vs STIMULATION
Expected vs UnexpectedEcologic salience vs Potential threatResource growth vs threat readiness
OXYTOCIN vs CORTISOL HOMEORHESIS vs HOMEOSTASIS
MOTHER vs OTHER
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MOTHERBABY
BONDING Sensitization
SEPARATION
Toxic stress
Milk making NUTRITION
HypothalamusPituitary:PROLACTIN
Maternal ferocityPROTECTION
OXYTOCIN Gaze increase: BONDING
OXYTOCINCingulate Suppressed
REGULATION
Amygdala:CHOLECYSTOKININ Emotion / satiety
HypothalamusPituitary:
Cingulate
Amygdala
Critical period concept :
“Windows of opportunity in early life when a child’s brain is exquisitely primed to receive sensory input in order to develop more advanced neural systems.”
a mother’s brain …
SENSITIZATION SENSITIZATION
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0
5
10
15
20
25
-0.2 0 0.2 0.4 0.6 0.8 1
Maternal Behavior Q-Sort
Ho
urs
of
SS
C i
n In
fan
ts' F
irst
24 H
ou
rs
Dose of SCC first 24 hours correlatesMaternal behaviour Q SortPredicts attachment security
SENSITIZATION
0
5
10
15
20
25
25 27 29 31 33 35 37 39 41 43 45
Maternal Behavior Subscale of the NCATS
Ho
urs
of
SS
C i
n In
fan
ts' F
irst
24 H
ou
rs
Dose of SCC first 24 hours correlatesNCATS ( Nursing Child Assessment Teaching Scale )
Predicts cognitive outcome
Conclusion: Mother/infant SSC benefits mothers by reducing their depressive symptoms and physiological stress in the postpartum period.
JOGNN, 41, 369-382; 2012. DOI: 10.1111/j.1552-6909.2012.01350.x
EPDS (depression) score DECREASED significantly for first two visits.
JOGNN, 41, 369-382; 2012. DOI: 10.1111/j.1552-6909.2012.01350.x
Control
SSC
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SEPARATIONMOTHERBABY
BONDING Sensitization Toxic stress
Insensitiveparenting
… anxious parenting … mediated by stress-related mechanisms
and greater neural disorganization.
SEPARATION
Toxic stress
Insensitiveparenting
Well-adapted parenting … reward-related motivational mechanisms, temporal organization, and affiliation hormones
OXYTOCIN
may contribute to mental health risks & RESILIENCY in the mother–infant dyad.
Brain differences between VD & CSD mothers …
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C/S
NVD
NVD
OXYTOCIN DURING LABOUR
CHANGES MOTHER’S BRAIN !!
This brain responds tobaby’s cry differently :
Amygdala –The emotional brain - to love her baby –relationship - to focus on care for baby
FEARCONTROL
CENTRE
REWARDCONTROL
CENTRE
SOCIALCONTROL CENTRE
OXYTOCINDOPAMINE
CORTISOL
EMOTIONCONTROL CENTRE
OXYTOCIN DURING LABOUR
Orbitofrontal cortex –activates approach
Nucleus accumbens –Reward and pleasure motivation- (dopamine)
Fusiform gyrus –(face coding unit of brain)
seeks her baby’s face
OXYTOCIN DURING LABOUR
Cingulate - (inhibition)switched off - makes ferocity for defence
Thalamus -activity coordinating centre of brain - to focus on care for baby
Hypothalamus –activates arousal response to respond
OXYTOCIN DURING LABOUR
CHANGES MOTHER’S BRAIN !!
Same brain circuits …as RESILIENCE,
“highly conservedneuro-endocrine behavior”
DISEASEHEALTH
RESILIENCE VULNERABILITY
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SEPARATIONMOTHERBABY
BONDING Sensitization Toxic stress
Insensitiveparenting
There is a critical period for maternal neuroplasticity at birth.
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BIDIRECTIONAL !!
Affect regulation
“Human brains are RELATIONAL”
… co-creating touch… signature unique to caregiver
PRATHIBA REEBYE
BONDING Sensitization
Secure attachment
Attuned parenting
The first hours after birth are a
CRITICAL PERIOD
mutual psycho-neuro-physiological
caregivers
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BEYOND BREASTFEEDING Feed Sleep Cycling
MOTHERBABY
BONDING Sensitization
Secure attachment
Attuned parenting
EMOTIONAL INTELLIGENCE
SOCIAL INTELLIGENCE
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BEYOND BREASTFEEDINGFeed Sleep Cycling
BABY
BONDING
Secure attachment
SEES
Mum’s eyes
Hand TOUCH
Mum’s skin
Skin-to-skin
CONTACT
SENSATIONS THAT WIRE BRAIN
Back FEELS
Mum’s arm
holding
TASTES
Mum’s milk
Ear HEARS
Mum’s voice
SMELLS
Mum’s milk
WARMED on
Mum’s front
MOVES
with Mum
Slide from JILL BERGMAN
a kind of invisible hothouse
… through several
pathwaysat once …
BREAST - FEEDING=
BRAIN - WIRING
17
BREASTFEEDING Feed Sleep Cycling
BONDING Sensitization
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C
BRAIN
WIRING
A neurobehavioural approach to breastfeeding, including
premature infants
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C
BRAIN
WIRING
Target #1 for 2005:
Report that 65% of infants are placed and remain in
direct skin to skin contactwith their mothers
for at least one hourduring the first 3 hours after birth.
Skin-to-skin and breastfeeding (4)
0
10
20
30
40
50
60
70
80
90
100
3Q05 4Q05 1Q06 2Q06 3Q06 4Q06 1Q07 2Q07
Breastfeeding intention Skin-to-skin one hour Breastfeeding at discharge
Used with permission: Ruth Stanhiser, MD
Babies breastfeeding
Mothers intending to breastfeed
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
ON-GOING
S S C
WIRE NEURONS
TRIGLYCERIDE Left : glycerol, Right: palmitic acid, oleic acid, alpha-linolenic acid
In phosphoglycerides, glycerol molecule same:
two fatty acids esterified
Phospholipids area major component of all biological membranes,
Sphingomyelin particularly concentrated in BRAIN major part of MYELIN.
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TRIGLYCERIDE
MYELIN.
Dendirification and myelinisation peaks occurat 2 and 6 monthsis maximal at one year ....
At one year: human milk has less protein,but MORE TRIGLYCERIDE !!!
FATTY ACIDS ARESPECIES SPECIFIC
Up to 6 months, milk is 7.4% fat,
but after 12 months it is 10.7%
“cherry pick”
Breastfeed time years school Income< 1 month 10.9 R$ 1238> 6 month 12.1 R$ 1915
Group IQ 3.76 points higher from breatsfeeding
BREASTFEEDINGAND BREAST MILK
INCREASE IQ
19
BOTTLE FEEDING& FORMULA
DECREASE IQ
Be sure the wet nurse has plenty of milk ... because if she lacks it she may give the babymilk of a goat or sheep or some other animal,because the child ... nourished on animal milkdoes not have perfect wits like one fed on woman’s milk and always looks stupid and vacant and not right in the head.
14th century Tuscan text
Conceptual change:Dyad careBreast first hour
even CaesareanContinuous SSC
DISCONTINUE:Giving waterGlucose waterInfant formulaSeparationPacifier (dummy)
CHANGE POLICY: Can’t change
biology:
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C WIRE
STOMACH
20
KEY QUESTION:
WHAT IS THE
STOMACHVOLUMEOF THE
NEONATE ???115
EVIDENCE: (NBn 111009)
Author Capacity Note:Sase 10-15 ml Live, term fetusGoldstein 10-15 ml Live, term fetusWidstrom 10 mls Live, newbornZangen 20 mls Live, (pressure)
Naveed 20 mls Autopsy (SB)20 mls Autopsy (ENND)
Kernessuk 15 mls Autopsy (in situ)Scammon 30-35 ml Autopsy (water
(Alliot) pressure)116
PROPOSAL:
The CAPACITY of aweek old baby’s stomach is
approx 20 ml.117
0
0.5
1
1.5
2
2.5
3
3.5
4
0 10 20 30 40 50 60 70 80
volume ingested
fee
din
g f
req
ue
nc
y
Assumption: 3kg baby, requiring 160 ml/kg/daydaily requirement = 480ml
StandardCARE:3 hourlyschedule
MOTHERNATURE:
1 hourlyschedule
118
The CAPACITY of alow birthweight premfrom 20ml / 3000g
= 0.007 x BWt (g)
1kg x 0.007 = 7mls2kg x 0.007 = 14mls
119
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
BRAIN CYCLING
STOMACH FILLING & EMPTYING
REMNR1NR2NR3NR4
120
21
75 ml per feeding ... ?? ASSUMPTION
IMMATURE ????OR OVERWHELMED !!!
.... many aspects of gastrointestinalmotility are immature in the neonate
Food in duodenum
AMYLINreleased
Closes pylorus
Duodenumempty
Pylorusopens
“Feed intolerance” … … or VOLUME intolerance?
DIFFICULT VERY EASYto treat to treat
AMYLINreleased
Closes pylorus
Infant feeding frequency:Proposal based on available evidence and neuroscience
“Small and frequent feeds,
adjusted to the sleep cycle”
126
22
0h 1h 2h 3h 4h 2 days
App
roxim
ate
GLUCOSE
SSC Glucose production = Glucose consumption
Separation
SNS stress Glucose consumption INCREASE
PSNS dissociation Glucose production DECREASE
OTHER FUELS …
LACTATE KETONES
0h 1h 2h 3h 4h
PSNS (vagal)
App
roxim
ate
GLUCOSE
1 HOURLY Milk feed
1 HOURLY Milk feed
1 HOURLY Milk feed
1 HOURLY Milk feed
LACTOSE
METABOLISM
0h 1h 2h 3h 4h
PSNS (vagal) SYMPATHETIC STRESS
App
roxim
ate
GLUCOSE
4 HOURLY ALLOSTATIC STATELACTOSE FATGLYCOGEN
METABOLISM
4 HOURLY Milk feed
HEALTH DISEASE
EXPECTED UNEXPECTED
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C
BRAIN
WIRING
BREASTFEEDING Feed Sleep Cycling
BONDING Sensitization
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C
BRAIN
WIRING
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
BIRTH
MOTHERBABY
23
NEURODEVELOPMENT
The DNA Behaviour
EVOLUTIONARY BIOLOGY
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
The Neuroscience of Birth & BreastfeedingThe Brain
EPIGENETICS
BIRTH
BEYOND BREASTFEEDINGFeed Sleep Cycling
BABY
BONDING
Secure attachment
John Bowlbysecure attachment
“a safe base from which to explore the world”.
Safe HavenSecure baseProximity
maintenanceSeparation
distress
… dopamine pathways contribute to the processing of infant-related sensory cues leading to a behavioural response.
BREASTFEEDINGFeed Sleep Cycling
Secure attachment
Attuned parenting
key biological systems … that contribute to maternal caregiving behaviour … the oxytocinergic and dopaminergic systems.
… dopamine pathways contribute to the processing of infant-related sensory cues leading to a behavioural response.
… infant cues - suckling, vocalisation and tactile stimulation - stimulate
OXYTOCINrelease in the hypothalamus, which may result in the activation of the dopaminergic reward pathway leading to behavioural reinforcement
FEARCONTROL
CENTRE
REWARDCONTROL
CENTRE
SOCIALCONTROL CENTRE
OXYTOCINDOPAMINE
CORTISOL
EMOTIONCONTROL CENTRE
24
DISEASEHEALTH
CORTISOLOXYTOCIN
DISEASEHEALTH
CORTISOLOXYTOCIN
Nat Rev Neurosci. 2009 June ; 10(6): 446–457. doi:10.1038/nrn2649
OXYTOCINCORTISOL
This maternal carewas NOT abusive,just sub-standard.
This care isbasicallyskin-to-skin contact.
Nat Rev Neurosci. 2009 June ; 10(6): 446–457. doi:10.1038/nrn2649
OXYTOCINCORTISOL
This maternal carewas NOT abusive,just sub-standard.
This care isbasicallyskin-to-skin contact.
RESILIENCE(= STRESS RESISTANCE)
“capacity to maintain healthy emotional functioning in the after-math of stressful experiences”
DISEASEHEALTH
CORTISOLOXYTOCIN
PR - Peer Reared
MR – Mother Reared
Plasma CORTISOL response to STRESS (2y)
PR - Peer Reared
MR – Mother Reared
Plasma CORTISOL response to STRESS (2y)
RESILIENCE:“capacity to maintain
healthy emotional functioning in the after-
math of stressful experiences”
DISEASEHEALTH MR PR
25
FEARCONTROL
CENTRE
REWARDCONTROL
CENTRE
SOCIALCONTROL CENTRE
OXYTOCINDOPAMINE
CORTISOL
EMOTIONCONTROL CENTRE
FEARCONTROL
CENTRE
REWARDCONTROL
CENTRE
SOCIALCONTROL CENTRE
OXYTOCINDOPAMINE
CORTISOL
EMOTIONCONTROL CENTRE
WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY
DISEASEHEALTH
RESILIENCE VULNERABILITY
… there is considerable overlap in the brain structures associated with these neural mechanisms … functional interactions among the circuits.
FEARCONTROL
CENTRE
REWARDCONTROL
CENTRE
SOCIALCONTROL CENTRE
OXYTOCINDOPAMINE
CORTISOL
EMOTIONCONTROL CENTRE
WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY
DISEASEHEALTH
RESILIENCE VULNERABILITY
An overly responsive fear circuit … may negatively influence functioning of the reward system.
… a properly functioning reward circuit may be necessary for …positive social behaviors.
NEURODEVELOPMENT
The DNA Behaviour
EVOLUTIONARY BIOLOGY
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
The Neuroscience of Birth & BreastfeedingThe Brain
EPIGENETICS
BIRTH
BEYOND BREASTFEEDINGFeed Sleep Cycling
SEPARATIONMOTHERBABY
BONDING Sensitization
Secure attachment
Attuned parenting
Resilience Vulnerability
DISEASEHEALTH
Disordered attachment
Toxic stress
Insensitiveparenting
A neurobehavioural approach to breastfeeding, including
premature infants
BIRTH
BEYOND BREASTFEEDINGFeed Sleep Cycling
SEPARATIONMOTHERBABY
BONDING Sensitization
Secure attachment
Attuned parenting
Resilience Vulnerability
DISEASEHEALTH
Disordered attachment
Toxic stress
Insensitiveparenting
OXYTOCIN
SEPARATION CORTISOL
SKIN-TO-SKINCONTACT
OPPOSITES
26
NEURODEVELOPMENT
The DNA Behaviour
EVOLUTIONARY BIOLOGY
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
The Neuroscience of Birth & BreastfeedingThe Brain
EPIGENETICS
intricately, inseparablylinked to the right place.
(Alberts 1994)
MOTHER
is the key toneurodevelopment …… because she is the
RIGHT PLACE !!
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
NEURODEVELOPMENT
The DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth & BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
“except in the light
of mother’s body.”
NEURODEVELOPMENT
The DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth & BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
“needed neural
processes”
NEURODEVELOPMENT
The DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth & BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
buffering protection
of adult support”
“Absence of the
NEURODEVELOPMENT
The DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth & BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
ZERO
SEPARATION
27
ZERO
SEPARATION
A neurobehavioural approach to breastfeeding, including
premature infants
Skin-to-skin
contact
IS MORE
essential for
premature
newborns!
Our NORMAL biology
“Non-pharmacological reduction of
hypercortisolaemia in preterm infants”(Modi & Glover 1998, Mooncey et al 1997)
Preterm infants experience prolonged severe stresswith tenfold increases in stress hormones.
Stress hormones at such levels are neurotoxic.
RCT on methods to reduce of stress (at one hour):
Cortisol EndorphinMassage slightly lower no change
Soft music no change no change
Skin-to-skin 66% lower 74% lower
SEPARATION CORTISOL
buffering protection
of adult support”
“Absence of the
The Neuroscience of Birth & Breastfeeding
Do not measure how much skin-to-skin contact you are doing.Measure minutes of separation Your dose of TOXIC STRESS
ZERO
SEPARATION
A neurobehavioural approach to breastfeeding, including
premature infants
What is going on in that brain?
A neurobehavioural approach to breastfeeding, including
premature infants
28
From Kim Luong Chi
29 week GA – zero separation
& skin-to-skin contact
suckling at 60 minutes.
NEURODEVELOPMENT
The DNA Behaviour
EVOLUTIONARY BIOLOGY
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
The Neuroscience of Birth & BreastfeedingThe Brain
EPIGENETICS
BIRTH
BEYOND BREASTFEEDINGFeed Sleep Cycling
SEPARATIONMOTHERBABY
BONDING Sensitization
Secure attachment
Attuned parenting
Resilience Vulnerability
DISEASEHEALTH
Disordered attachment
Toxic stress
Insensitiveparenting
This science applies to PRETERM BABIES
BREASTFEEDING THE PREMATURE
The ABILITY to breastfeed is INNATE.
The physical CAPACITY to breastfeed
may however be
insufficient in prematures.
Full term babies need no help
Premature babies will need help.
KERSTIN HEDBERG-NYQVIST:(Early Human Dev 55 (1999) 247 -264.)
PIBBS Preterm Infant Breastfeeding Behaviour Scale
rooting 0 - 2areolar grasp 0 - 3latch (and fixation) time 0 - 3sucking 0 - 4longest sucking burst 1 - 6swallowing 0 - 2
KERSTIN HEDBERG-NYQVIST:
PIBBS Preterm Infant Breastfeeding Behaviour Scale
Nutritive sucking = >5ml swallowed
Full breastfeeding = exclusive Brf
KERSTIN HEDBERG-NYQVIST:(Early Human Dev 55 (1999) 247 -264.)
PIBBS Preterm Infant Breastfeeding Behaviour ScaleEARLIEST OBSERVATION:(weeks PMA) 28 29 30 31 32 33 34 35 36rooting 90%
grasp 50%
latch 95%
sucking 90% Nutritive
swallow Effective
burst >30sucks
Full breastfeeding 33w
29
Occasional larger
volumes of milk
intake.
Express milk.
Infant skin-to-skin
on mother's
chest.Commence
breastfeeding.
Several
consecutive
sucks. Eff icient
latch. Stays f ixed for
longer periods of time.
Increasing volumes of
milk intake.
Select strategy: test-w eighing,
gradual or scheduled
reduction of supple-
mentation
Rooting.
Single sucks
or a few sucks
before pauses. Stays
f ixed for short periods.
Occasionally small volumes
of milk intake.
Mature
sucking pattern:
Large number of
consecutive sucks,
vigorous sucking.
On-demand
breast-
feeding Takes all
milk at the breast.
Variable sucking pattern:
Short and long sucking bursts
and pauses. Semi-demand
breastfeeding.
DISSOCIATED INFANTWILL NOT SHOWFEEDING CUES
BREAST- VAGALMOTHER FEEDING (PSNS) GROWTH
OTHER PROTEST- STRESS SURVIVAL orDESPAIR (SNS)
SKIN-TO-SKIN CONTACT
SEPARATION
BREASTFEEDING THE PREMATURE
Premature babies will need help.
BERLITH PERSSON
has provided that help …
PERSSON’S WHEEL !
Step 1 SKIN-TO-SKIN
Continuous skin contact
The newborn must be in the right
environment for the behaviours that
it is capable of to be expressed. It
requires protection from stress and
provision of warmth.
KMC provides the “maternal nest”
1
SSC
Ideally this should be done on prematures AT BIRTH.
However it can be done later, even with nasogastric tube
providing expressed breast milk in the meantime
Step 2 and 3 Olfactory
The first steps in sequence
require smell of the nipple
which may take longer in
the premature,
and then the smelling of milk.
Babies can identify smells and
tastes from their time in the
uterus in the mother’s milk!
2
3
Smell nipple
Smell milk
4
5
Step 4 Taste
This is re-inforcing the smell.
Fullterm seems to skip this!
Step 5 Rooting
These are mouth movements
the normal sequence
described in the full-terms.
Here the premature
requires help, with position
and “sipping”
= feeling milk in mouth
Taste milk
Rooting
Sipping
30
6
Step 6 First suckling.
Key step, builds on steps 1 to 5.
Must be awake and alert.
Alert period is maximal at birth,
and lasts 45 - 90 minutes.
If missed then, will require feeding,
and several hours delay.Alert
for
Suckling
6
Step 6 First suckling.
Note difference suckling vs sucking!
“ … myographically distinct”
For late premature lactation, allow
suckling to develop in successive
alert periods, while feeding by tube.
Alert
for
Suckling
7
Step 7 Latching & swallowing
Premature is too physically
weak to crawl to nipple,
but if held to nipple will at
this stage latch on.
Once latched, suckling follows.
Suckling squirts a
controlled dose of milk
to the back of throat, which
is safely swallowed without any
interference of breathing
This is INNATE.
Latching
Swallowing
8Breast meal
Step 8 First breast milk meal.
Steps 1 to 7 and on take place
rapidly in the fullterm.
They can occur in the first
alert period after birth in a
premature if allowed to,but
may require a longer period
of defined steps in successive
alert periods. For late prem
lactation, step 8 is the first
time milk is swallowed
Enough to feed the baby.
9
10
Frequent feeding
Together
continuously
Step 9 Frequent feeding
In utero, baby is feeding
Continuously.
Demand feeding
is NOT SUITABLE f
or prematures.
Feeds should be at
most 2 hours apart.
Step 10
Together continuously
The wheelis not
round
Turns
slow at
first
but
then
picks
up speed!
31
From 16 or 20 weeks gestation, the fetus is swallowing.
Breastfeeding & Suckling
Sase 2005
Emma’s cat :“Zig-Zag Thomas”
Ziggy… is able to
eat and purr(and breathe) atthe same time !
Larynx meets uvula, separateairway & foodway
THE NEWBORN
also has a larynx that meets theuvula, designed to separate therespiratory tract from the gastrointestinal tract ,enabling the newborn to feed and breathe simultaneously.
Apes (and all mammals)have a high larynxseparates airway from “foodway”
Human newborn ALSO !!
Only at 18 monthsdoes larynx startmigrating, and abilityto make more sounds develop speech
From “Origins Reconsidered”
Richard Leakey.
Bottle
Breast
Baseline
pO2
Baseline
pO2
Start feed Ends feed 10 min later
Sucking
burstRest
Takes longer
Suckling
continuousNon-nutritive
Sucking
burst
Meier 1988
BOTTLE AND BREASTFEEDING IN PREMATURE
Prematures babies weighing 1300g and 34/40 PCA,
given alternating bottle and breastfeeds.
32
BottleBaseline
pO2
Start feed Ends feed 10 min later
Sucking
burstRest
Sucking
burst
Sucking and swallowing uncoordinated, baby gets hypoxic, so bad the heart slows.
BOTTLEFEEDINGIS STRESSFUL
and DANGEROUS (Chen et al 2000)25 babies in 80 sessions, all <1800g
“There were 2 episodes of apnea and 20 episodes of oxygen desaturation during bottle-feeding and none during breastfeeding. We conclude that breastfeeding is a more physiological feeding method for the preterm infant and bottle-feeding may be more stressful.”
BOTTLEFEEDINGIS STRESSFUL
and DANGEROUS
SUCKLING uses the largest muscle in the baby’s head, making the smallest movement
SUCKING requires lots of tiny and weak muscles, making maximum effort,
… also causes hypoxia,… and is STRESSFUL !
HOLDYOURPREM
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