Skin-to-Skin Contact, Breastfeeding, and

1
Skin-to-Skin Contact,Breastfeeding, and
Perinatal Neuroscience Hollister
Breastfeeding Program 2006 Boston,
MA Denver, CO Redlands, CA Mission Viejo, CA
2
Skin-to-Skin Contact,Breastfeeding, and
Perinatal Neuroscience Dr Nils
Bergman M.D., D.C.H., M.P.H., Ph.D.
Cape Town, South Africa www.kangaroomotherc
are.com
3
Skin-to-Skin Contact,Breastfeeding, and
Perinatal Neuroscience Implementing Best
Practice in U.S. Hospitals Boston,
MA Denver, CO Redlands, CA Mission Viejo, CA
4
KANGAROO MOTHER CARE
IMPLEMENTATION PRACTICAL POTENTIAL POLITI
CAL
5
Declaration of Alma-Ata on Primary Health
Care based on practical, scientifically sound
and socially acceptable methods and technology
made universally accessible . individual
self-reliance and participation., making
fullest use of resources
6
Primary Health Care is based on the
application of relevant results of social,
biomedical and health services research and
public health experience addresses the main
health problems (Prematurity factor in two
thirds of all perinatal mortality )
7
Declaration of Alma-Ata on Primary Health
Care based on practical, scientifically
sound socially acceptable methods and
technology made universally accessible .
8
Primary Health Care is based on the
application of relevant results of social,
biomedical health services research and
public health experience
9
BIOMEDICAL
SOCIAL
HEALTH SERVICES
10
SOCIAL Socially acceptable
BIOMEDICAL Scientifically sound
HEALTH SERVICES practical
11
BIOMEDICAL Thai protocol PMTCT (for
HIV) Give AZT from 36th week 4 weeks, twice a
day Provide AIF, no breast REDUCES HIV by 51
! Implemented 1999 WCape
12
PROBLEM 1 When is 36w GA ? Many only started
38w GA Many delivered at 38w GA or
before!! NOT PRACTICAL !!
HEALTH SERVICES
13
PROBLEM 1 PROBLEM 2 When is 36w GA
? COMPLIANCE !! Many only started 38w
GA Many delivered Side effects at 38w
GA Resistance or before!! NOT
PRACTICAL !! NOT EFFECTIVE !!
HEALTH SERVICES
14
PROBLEM 3 Enormous social STIGMA
! Tablets could be hidden But tins HIV
ve Tins sold on station NOT
ACCEPTABLE !!
SOCIAL
15
PROBLEM 3 Enormous social STIGMA
! Tablets could be hidden But tins HIV
ve Tins sold on station PROBLEM
4 Mixed feeding HIV transmission NOT
ACCEPTABLE !! INCREASES !!!
SOCIAL
16
BIOMEDICAL Thai protocol PMTCT (for HIV)
SOCIAL
HEALTH SERVICES
17
Thai protocol PMTCT (for HIV) scientifically
sound YES BUT NOT practical, socially
acceptable
18
Primary Health Care is based on the
application of relevant results of biomedical
research YES BUT ALSO social research ,
and health services research
19
BIOMEDICAL Changed to NVP single dose in
hospital
SOCIAL Encourage Strict Exclusive BF M2M2B
HIV transmission about 8
HEALTH SERVICES
20
There is currently great emphasis on grounding
medical practice on sound research evidence. .
the most credible research on health care
outcomes is from randomised, controlled, double
blind clinical trials.
21
There is currently great emphasis on grounding
medical practice on sound research evidence. .
the most credible research on health care
outcomes is from randomised, controlled, double
blind clinical trials. AGREED ???
22
The biomedical paradigm IS TOO NARROW !!
23
There is currently great emphasis on grounding
medical practice on sound research evidence. .
the most credible research on health care
outcomes is from randomised, controlled, double
blind clinical trials.
FALSE ASSUMPTION !!
24
Declaration of Alma-Ata on Primary Health
Care based on practical, scientifically
sound socially acceptable methods and
technology made universally accessible .
25
Primary Health Care is based on the
application of relevant results of social,
biomedical health services research and
public health experience
26
What determines a paradigm ?? Tradition
Culture Experience Research
Science
27
What determines a paradigm ?? Tradition
Culture Experience Research
Science
Fashion !!!!
28
Basic assumptions come from Tradition
Culture Experience
29
Neuronal Plasticity

• the first three years are decisive
• ? platform for
• subsequent
• development of
• higher cognitive
• functions.

Attachment Regulation Emotion Control Arousal
Appetite Sleep
30
BASIC ASSUMPTIONS
PLATFORM / FOUNDATION / BASE
31
PARADIGM CONSTRUCT Paradigm has
internal Intelligence Honesty Integrity Consistenc
y
BASIC ASSUMPTIONS
FOUNDATION / PLATFORM / BASE
32
What determines a paradigm ?? Tradition
Culture Experience Research
Science
33
PARADIGM CONSTRUCT Paradigm has
internal Intelligence Honesty Integrity Consistenc
y
BASIC ASSUMPTIONS
FOUNDATION / PLATFORM / BASE
34
PARADIGM CONSTRUCT Biomedical model
reductionist Odents circular research If
challenges paradigm Odents cul-de-sac research
35
Impact of Birthing Practices on Breastfeeding
EXAMPLE Mary Kroegers book challenges
paradigms cul-de-sac LINKAGES decided there
were too many gaps in solid scientific
literature to warrant publication paradigm
reinforces itself circular
36
PARADIGM CONSTRUCT Paradigm has
internal Intelligence Honesty Integrity Consistenc
y
BASIC ASSUMPTIONS
FOUNDATION / PLATFORM / BASE
too many gaps in solid scientific literature
to warrant publication
37
WHAT NEW INFORMATION ?
challenged paradigms cul-de-sac Without
awakening to assumptions and basic belief
system New information cannot be grasped !!
38
SEPARATION VIOLATES THE INNATE AGENDA OF MOTHER
AND NEWBORN
39
Why do doctors use treatments that do not
work? Jenny Doust , Chris Del Mar. British
Medical Journal, 28th February 2004
40

• Why do doctors
• use treatments
• that do not work?
• Clinical experience
• Over-reliance on surrogate outcome
• Natural history of the illness
• Love of the pathophysiological model (that is
  wrong)
• Ritual and mystique
• A need to do something
• No one asks the question
• Patients expectations (real or assumed)

41

• Why do doctors
• use treatments
• that do not work?
• No one asks the question
• Paradigm basic assumption,
• things we take for granted .

42
Culture
Science
BIOMEDICAL
SOCIAL
RCT
Stigma
EBM
Disease
HEALTH SYSTEMS
Efficiency / effectiveness
43
Culture
Science
BIOMEDICAL
SOCIAL
RCT
Stigma
EBM
Disease
?
HEALTH SYSTEMS
Efficiency / effectiveness
44
Culture
Science
BIOMEDICAL
SOCIAL
RCT
Stigma
EBM
Disease
8
HEALTH SYSTEMS
Efficiency / effectiveness
45
Culture
Science
BIOMEDICAL
SOCIAL
RCT
Stigma
EBM
Disease
HEALTH SYSTEMS
Efficiency / effectiveness
46
Culture
Science
BIOMEDICAL
SOCIAL
?
RCT
Stigma
EBM
Disease
HEALTH SYSTEMS
Efficiency / effectiveness
47
Anthropology
Culture
Values
Science
BIOMEDICAL
SOCIAL
Ethics
PHC
RCT
Stigma
Disease
EBM
Costs
HEALTH SYSTEMS
Efficiency / effectiveness
48
Anthropology
Culture
Values
Science
BIOMEDICAL
SOCIAL
Ethics
Centre of excellence
RCT
Stigma
Disease
EBM
Costs
HEALTH SYSTEMS
Efficiency / effectiveness
49
Anthropology
Culture
Values
Science
BIOMEDICAL
SOCIAL
Ethics
PHC
RCT
Stigma
Disease
EBM
Costs
Reductionist Territorial Outcome
issues Affordability Ethics (1 vs many) Values
issues
HEALTH SYSTEMS
Efficiency / effectiveness
50
Anthropology
Culture
Values
Science
BIOMEDICAL
SOCIAL
Ethics
PHC
RCT
Stigma
Disease
EBM
Costs
Reductionist Territorial Outcome
issues Affordability Ethics (1 vs many) Values
issues
HEALTH SYSTEMS
SOCIAL is also SCIENCE
Efficiency / effectiveness
51
Infant brain development
POTENTIAL
TIME
52
Infant brain development OLD
PARADIGM
POTENTIAL
TIME
53
Infant brain development
100 ACTUAL or IDEAL
POTENTIAL
x
0 1 2 3 4 5y TIME
54
Infant brain development
100 ACTUAL or IDEAL
POTENTIAL
0 1 2 3 4 5y TIME
55
Infant brain development Sensory
deprivation 100 70
POTENTIAL
0 1 2 3 4 5y TIME
56
Infant brain development
100 Temporary insult Early
POTENTIAL
0 1 2 3 4 5y TIME
57
Infant brain development
70 Temporary
insult Early
POTENTIAL
0 1 2 3 4 5y TIME
58
Infant brain development Late
100 70 Temporary
insult Early
POTENTIAL
0 1 2 3 4 5y TIME
59
Infant brain development EXCELLENCE
100 70 MEDIOCRITY
POTENTIAL
0 1 2 3 4 5y TIME
60
SOCIAL Socially acceptable
BIOMEDICAL Scientifically sound
HEALTH SERVICES practical
61
Ethics
BIOMEDICAL
SOCIAL
Values ? better brain quality
PHC
RCT ? outcomes
EBM
Costs
HEALTH SYSTEMS
Effectiveness ? survival
62
SOCIAL Better brain quality
BIOMEDICAL Better outcomes
HEALTH SERVICES Better survival
63
Improved survival IS TOO LITTLE !! NOT ENOUGH
!!!
64

• Why do doctors
• use treatments
• that do not work?
• Over-reliance on
• surrogate outcome

65
INCUBATORS DE-STABILISE NEWBORNS
66
BREAST- VAGAL MOTHER FEEDING (PSNS)
GROWTH OTHER PROTEST- STRESS SURVIVAL
or DESPAIR (SNS)
SKIN-TO-SKIN CONTACT SEPARATION
THIS IS THE PHYSIOLOGY IN OUR TEXT BOOKS
actually PATHOPHYSIOLOGY
67

• Why do doctors
• use treatments
• that do not work? (BMJ 03/04)
• Love of the pathophysiological model (that is
  wrong)
• Our pathophysiological
• model IS wrong !!

68
NEUROSCIENCE 90 of what we know about the
brain has been discovered in the last 15
years Society of Neuroscience estimate Dr
Sandra Witelson, McMaster
69
NEW PARADIGM CONSTRUCT
Brain based paradigm

BASIC ASSUMPTION
NEVER SEPARATE !!
FOUNDATION / PLATFORM / BASE
70
Skin-to-Skin Contact,Breastfeeding, and
Perinatal Neuroscience Implementing Best
Practice in U.S. Hospitals Boston,
MA Denver, CO Redlands, CA Mission Viejo, CA
71
Ottawa Charter for HEALTH PROMOTION built
on Declaration of Alma Ata expectations of
a new public health movement describes
fundamental pre-requisites for health Five
key pillars -
72
HEALTH PROMOTION Five key pillars BUILD
HEALTHY PUBLIC POLICY CREATE SUPPORTIVE
ENVIRONMENTS STRENGTHEN COMMUNITY ACTION DEVELOP
PERSONAL SKILLS REORIENT HEALTH SERVICES All are
necessary specially for our prematures ...
73
Pillar number 5 REORIENT HEALTH SERVICES The
responsibility is shared among individuals,
community groups, health professionals,
health service institutions and governments.
They must work together .. (extracted from
Ottawa Charter)
74
responsibility is shared We need to
identify all the stakeholders who share
the responsibility for changing to
Kangaroo-Mother Care mother and the
infant nurses, doctors and health
workers hospital managers and service
providers policy makers and governments
75
Reorienting health services . requires
attention to health research, changes in
professional education must lead to a change
in attitude and organisation of health services,
which refocuses on the total needs of the
individual .. (extracted from Ottawa Charter)
76
REORIENT HEALTH SERVICES a change in
attitude Reorientation requires change Change
requires energy Change always meets
resistance Resistance is very seldom rational
77
REORIENTATION PACKAGE Modern marketing science
Marketing is about a product but the
existence of a good product wont make anyone
buy it. Marketing is about selling but clever
salesmanship in itself wont make people want
anything. Marketing is therefore .
78
THE PACKAGE Marketing is therefore .
CHANGING HUMAN BEHAVIOUR Establishing the
wants and needs of the customer or
community Finding out what the community sees as
its best interests Identifying the VALUES that
underlie those wants and needs, Present KMC
with RESPECT to values.
79
THE PACKAGE PRODUCT design presentation to
meet the needs and wants PRICE show the
benefits in such a way to cleary outweigh the
disadvanatges PLACE make it easy to do,
(access) PROMOTION commuicate the
benefits and the VALUES offered.
80
THE PACKAGE PARTNERSHIPS networking with
other organisations and like minded POLICY -
policies must be such to make KMC easy and
attractive PURSE STRINGS - Resources needed !!
81
Social marketing Applying commercial marketing
technologies to influence people to change their
behaviour to improve their personal welfare and
that of their families and society.
BEHAVIOUR CHANGE !!
82
Social marketing (2) PRODUCT ORIENTATION SELLING
ORIENTATION MARKETING ORIENTATION Start with
the clients perspective Meeting peoples needs
and wants, Understand their values and
perceptions.
83
DIFFUSION OF INNOVATIONS
Early majority 34
Late majority 34
Innovators 2
14 Early adopters
Laggards 16
Time of adoption of innovations.
84
DIFFUSION OF INNOVATIONS
Early majority 34
Late majority 34
Innovators 2
14 Early adopters
Laggards 16
Pioneers Leaders Followers
diehards good to...
ought to have to
85
Motivation to change Implementation involves
stakeholders. responsibility is shared For
KMC these include mothers, nurses, doctors,
hospital managers, policy makers, community,
media. The message we provide must be
appropriate to the stakeholder!
86
Each stake holder, Each target audience will
have its own needs and wants and
Values. Therefore Each will require its own
marketing package AND, for each, That will
depend on the stage of change
87
Implementation What motivates people to
change ? (Rollnick S and Miller WR,
1991) (Prochaska and DiClemente
1982) Motivation is a state of readiness to
change, a state which can be influenced, has a
number of identified stages
88
The wheel of change
PERMANENT EXIT
RELAPSE
MAIN- TENANCE
PRE- CONTEM- PLATION
CONTEM- PLATION
ACTION
DETER- MINATION
(Prochaska and DiClemente 1982)
89
PRE- CONTEM- PLATION
90
PRE- CONTEM- PLATION
CONTEM- PLATION
91
PRE- CONTEM- PLATION
CONTEM- PLATION
DETER- MINATION
92
PRE- CONTEM- PLATION
CONTEM- PLATION
ACTION
DETER- MINATION
93
MAIN- TENANCE
PRE- CONTEM- PLATION
CONTEM- PLATION
ACTION
DETER- MINATION
94
The wheel of change
RELAPSE
MAIN- TENANCE
PRE- CONTEM- PLATION
CONTEM- PLATION
ACTION
DETER- MINATION
95
RELAPSE
START AGAIN
MAIN- TENANCE
PRE- CONTEM- PLATION
CONTEM- PLATION
ACTION
DETER- MINATION
96
PERMANENT EXIT
RELAPSE
MAIN- TENANCE
PRE- CONTEM- PLATION
CONTEM- PLATION
ACTION
DETER- MINATION
97
Motivation to change we must identify the
stage our target is at In promoting KMC,
The message we provide must be appropriate to
the stage!
98
The KMC wheel / process of change
Ignorance
Skepticism
Acceptance
Excitement
Setbacks relapse and restart
Action
Maintenance
SUCCESS
99
Implementation framework.
Moms Nurse Doctor Etc
1 IGNORANCE
2 SKEPTICISM
3 ACCEPTANCE
4 EXCITEMENT
5 ACTION
6MAINTENANCE
7 RELAPSE
8 RESTART
9 SUCCESS

100
Implementation framework.
Moms Nurse Doctor Etc
1 IGNORANCE Media Talks CME
2 SKEPTICISM Soaps Visit Journals
3 ACCEPTANCE ANC
4 EXCITEMENT WS
5 ACTION
6MAINTENANCE
7 RELAPSE
8 RESTART
9 SUCCESS

101
Implementation framework.
Moms Nurse Doctor Etc
1 IGNORANCE
2 SKEPTICISM
3 ACCEPTANCE
4 EXCITEMENT AIM TO GET HERE
5 ACTION ALL TOGE THER
6MAINTENANCE
7 RELAPSE
8 RESTART
9 SUCCESS

102
Implementation framework.
CEO Media MedAid Etc
1 IGNORANCE
2 SKEPTICISM swank Save
3 ACCEPTANCE Oh so money
4 EXCITEMENT cute
5 ACTION
6MAINTENANCE
7 RELAPSE
8 RESTART
9 SUCCESS

103
THE SOCO Single Overriding Communication
Objective. Advertising - an art and science
Every cell in the matrix should have its own
action plan what, why, when, who, where, how .
104
SOCOs for the KMC stages of change
Information
Encouragement
Education/ Research
Benefits
Protocols
Support and reassurance
RECOGNITION
Monitoring
105
KMC - a healthier alternative ! Apply to each
stakeholder BUILD HEALTHY PUBLIC POLICY CREATE
SUPPORTIVE ENVIRONMENTS STRENGTHEN COMMUNITY
ACTION DEVELOP PERSONAL SKILLS REORIENT HEALTH
SERVICES
106
Set a vision Act today Concluding statement
of Alma Ata calls on all to collaborate in
introducing, developing and maintaining Primary
Health Care or Kangaroo Mother Care
107
K M C FRAMEWORK
CARE VARIABLE ? ? INITIATION Birth
lt90 lt7h lt7d gt7d CONTINUUM gt20h
gt12h gt4h gt1h lt1h FOOD BM EBM IV
Mix Cow METHOD Breast Cup line NGT
Bottle Resp Support Vent CPAP O2
No
108
K M C FRAMEWORK
CARE VARIABLE ? INITIATION The EARLIER
the BETTER CONTINUUM The MORE the BETTER
109
K M C FRAMEWORK
CARE VARIABLE ? ? INITIATION The
EARLIER the BETTER CONTINUUM The MORE the
BETTER FOOD MUST BE MOTHERS MILK METHOD
BREAST - FEEDING !!! Resp Support ADD
available technology
110
KangaCarrier This shirt was designed to enable
the mother to provide continuous day and night
skin-to-skin contact. The wrapper secures the
baby, the shirt supports the mother, both are
comfortable and safe.
111
Dangers and contraindications ? Obstructive
apnoea ? Monitoring caveats ? Smothering ?
Skin care ?? Infections
112
Technique Continuous SSC makes great demands on
mother The KangaCarrier wrapper ensure that
MOTHER and BABY are safe and comfortable .
113
Technique The WRAPPER is for BABY. Detail
Baby xiphisternum on mothers
xiphisternum, Flex baby, head either side. Folded
edge of wrapper goes UNDER THE EAR tight
! Make reef knot behind axilla (this picture
posed, is too far forward)
114
In this position The airway is protected,
Gravity helps breathing, Abdominal breathing
helped There is maximal SSC, Position is
flexed, Baby can sleep safely.
115
Technique The SHIRT is for MOTHER. Detail
With baby in wrapper, put KangaCarrier on,
flaps facing forwards, over babies head,
right around body, tied below flexed legs,
fixing baby firmly to mothers chest.
116
In this position Baby is fully
contained. (this containment allows the
gestation to continue) Mother is free to
work both hands are free, and she can feel
the baby is secure.
117
In this position Mother free To socialize To
go home In this position, Mother is giving
intensive care, and is able to do so at home
much sooner EARLY DISCHARGE
118
In this position Mother free To sleep, safely
and comfortably
119
In this position Mother free To sleep, safely
and comfortably
In this position Mother CAN NOT breastfeed !!!
But can easily loosen and feed frequently
120
The principles can be extended to different
contexts - premature birth - oxygen
dependence - CPAP / IPPV
121
KangaCarrier available at www.kangaroomother
care.com
122
SELF ATTACHMENT. The newborn should NOT
be separated at birth, specially if premature !!
123
Sequence human newborn breast-feeding Pre-requisit
e habitat hand to mouth tongue moves mouth
moves eye focuses nipple crawls to
nipple latches to nipple suckles (Widstrom
et al 1994)
124
The newborn may appear helpless, but displays
an impressive and purposeful motor activity
which, without maternal assistance, brings the
baby to the nipple. (Michelson et al 1996)
125
STATE ORGANISATION. The ability to
appropriately control the level of sleep and
arousal.
126
Simplified scale - HARD CRYING CRYING FUSSING AC
TIVE AWAKE QUIET AWAKE ALERT INACTIVE DROWSY ACTIV
E SLEEP IRREGULAR SLEEP QUIET SLEEP DEEP SLEEP
L to R shunting, IVH risk Stressful, wastes
calories, build up to stress This is feeding
zone! Time to connect - stimulation transition
zone transition zone activity consumes
calories Good sleep - digestion zone Apnoea zone
!!
127
Simplified scale - HARD CRYING CRYING FUSSING AC
TIVE AWAKE QUIET AWAKE ALERT INACTIVE DROWSY ACTIV
E SLEEP IRREGULAR SLEEP QUIET SLEEP DEEP SLEEP
Incubator
KMC
128
KMC babies oscillate slowly in safe zones
Separated babies oscillate erratically to danger
zones
Simplified scale - HARD CRYING CRYING FUSSING ACT
IVE AWAKE QUIET AWAKE ALERT INACTIVE DROWSY ACTIVE
SLEEP IRREGULAR SLEEP QUIET SLEEP DEEP SLEEP
risk stress feeding stimulation digestion apn
oea
129
BREASTFEEDING IS NOT JUST EATING!
The whole cycle of feeding and digesting mothers
milk is what is the fully the breastfeeding progra
mme
Simplified scale - HARD CRYING CRYING FUSSING ACT
IVE AWAKE QUIET AWAKE ALERT INACTIVE DROWSY ACTIVE
SLEEP IRREGULAR SLEEP QUIET SLEEP DEEP SLEEP
feeding stimulation digestion
130
BREASTFEEDING IS NOT JUST EATING!
The whole cycle of feeding and digesting mothers
milk is what is the fully the breastfeeding progra
mme
feeding stimulation digestion
SKIN-TO-SKIN CONTACT SHOULD BE CONTINUOUS
131
KMC AND SLEEP STUDYThe basic rest-activity
cycle for prematures and neonates (44-52 weeks
post conceptional age) is 60-90 minutes long
(Ludington)
132
Not so much duration, or density of any sleep
stage, or number of sleep stage episodes, but,
cycling between quiet sleep and active sleep
is what is important
133

REM
REM
REM
NREM
NREM
This is a healthy sleep pattern This is a very
good cycling pattern (thanks to Susan
Ludington-Hoe)
134

REM
REM
REM
NREM
NREM
1st hour 2nd hour
So in every hour, you would like to see an EEG
pattern that shows this
135
REM
State
REM
REM
NREM
NREM
NREM
HR
RR
REM Sleep is supposed to be somewhat active,
so HR increases and RR is irregular
136
Brain cycling in incubator
48 hour baseline chaotic pattern of activity and
quiet HR RR
Pre-KC

• In incubator
• Chaotic pattern
• No cycling

137
What do we see during KMC?
KMC
48 hour baseline chaotic pattern of activity and
quiet HR RR
Pre-KC

• In KMC
• Normal cycling
• Non-chaotic pattern

138

REM
feed
FEEDING HANDLING
SLEEPING CONTAINING
sleep
NREM
During sleep time - the newborn should NOT BE
HANDLED !!
139
Compared to incubator babies, KMC babies
have less deep sleep (when apnoea occurs) more
quiet sleep (when growth occurs) less active
sleep (wastes calories) more alert
periods(promotes bonding) much less crying (which
is harmful)
140
K MC and neurobehavioural state
organisation State organisation is the ability
to appropriately control the level of sleep or
arousal. Compared to incubator babies, KMC
babies have less deep sleep (which is when
apnoea occurs) more quiet sleep (which is when
growth occurs) less active sleep (which wastes
calories) more alert periods (which promotes
bonding) much less crying (which is harmful)
141
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.
142
BREASTFEEDING THE PREMATURE Premature babies
will need help. BERLITH PERSSON has provided
that help PERSSONS WHEEL !
143
Breastfeeding Suckling
From 16 or 20 weeks gestation, the fetus is
swallowing. From 26 or 28 weeks gestation the
fetus can SUCKLE From 36 weeks gestation
the fetus is able to SUCK SUCKING and
SUCKLING sound same, but VERY different
144
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
145
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
mothers milk!
2
Smell nipple
Smell milk
3
146
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
4
Rooting Sipping
5
147
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.
6
Alert for Suckling
148
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.
6
Alert for Suckling
149
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.
7
Latching
Swallowing
150
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.
8
Breast meal
151
10
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
Together continuously
9
Frequent feeding
152
The wheel is not round Turns slow at first but
then picks up speed!
153
BREASTFEEDING A PREMATURE STEP 1 SSC STEP
2 ALLOW TIME STEP 3 State organisation alert
awake STEP 4 SMELL STEP 5 TASTE STEP 6 LATCH STEP
7 SUCKLE
NUTRITION
154
Breast-feeding of Premature babies. A fullterm
baby NEEDS NO HELP to breastfeed (Does perhaps
need help not to be hindered!) A premature baby
DOES NEED HELP !! The constant sequence is
however constant, but some minor changes will
help Place the baby on mothers chest, not
abdomen Allow longer for each step Recognise
the steps, and assist where needed
155
Gut hormones. (Uvnas-Moberg 1989) 20
different hormones work in the gut regulated
by the vagal nerve. Each has a specific
function.
156
Gut hormones. "Bad guy" - SOMATOSTATIN
inhibits gastrointestinal secretion, inhibits
motility , reduces blood flow to gut and
absorption, causes gastric retention,
vomiting, constipation.
157
SOMATOSTATIN inhibits the good hormones,
contributes to slow weight gain. At high
levels also inhibits release of growth
hormone.
158
It takes 30 to 60 minutes to lower somatostatin
and other stress hormones
Babies need to have had a good sleep first. They
will only have a good sleep if given continuous
skin-to-skin contact. Baby should be allowed to
get to a state of AWAKE and ALERT by
itself. ALLOW TIME ?
159
Photograph series available on website
www.kangaroomothercare.com
160
Ziggy is able to eat and purr (and breathe)
at the same time ! Larynx meets uvula,
separate airway foodway
Emmas cat Zig-Zag Thomas
161
Apes (and all mammals) have a high
larynx separates airway from foodway Human
newborn ALSO !!
Only at 18 months does larynx start migrating,
and ability to make more sounds develop ? speech
From Origins Reconsidered Richard Leakey.
162
THE NEWBORN also has a larynx that meets
the uvula, designed to separate the respiratory
tract from the gastrointestinal tract
, enabling the newborn to feed and breathe
simultaneosuly.
163
Meier 1988 BOTTLE AND BREASTFEEDING IN
PREMATURE Prematures babies weighing 1300g and
34/40 PCA, given alternating bottle and
breastfeeds.
Start feed Ends
feed 10 min later
Breast
Takes longer
Baseline pO2
Suckling continuous
Non-nutritive
SUCKLING and swallowing well coordinated, babys
OXYGENATION remains good.
164
Sensitive Midwife - PREMATURE
Start feed Ends
feed 10 min later
Bottle
Sucking burst
Sucking burst
Baseline pO2
Rest
Sucking and swallowing uncoordinated, baby gets
hypoxic, so bad the heart slows.
165
Sensitive Midwife - PREMATURE
Meier 1988 BOTTLE AND BREASTFEEDING IN
PREMATURE Prematures babies weighing 1300g and
34/40 PCA, given alternating bottle and
breastfeeds.
Start feed Ends
feed 10 min later
Sucking burst
Sucking burst
Rest
Baseline pO2
Bottle
Takes longer
Baseline pO2
Breast
Suckling continuous
Non-nutritive
166
Sensitive Midwife - PREMATURE
SUCKLING uses the largest muscle in the
babys head, making the smallest
movement SUCKING requires lots of tiny and
weak muscles, making maximum effort,
also causes hypoxia, and is STRESSFUL !
167
Bottle feeding requires SUCKING, which requires
completely different muscles, and does NOT allow
co- ordination between swallowing and breathing.
Bottle feeding causes STRESS in prematures, and
relative post-prandial hypoxaemia.
SUCKLING - in and of itself, apart from
nutrition intake - has beneficial effects on
both mother and baby.
168
FEEDING FREQUENCY
Fetus is fed continuously
169
A normal sleep cycle for a premature is 60
90 minutes A babies stomach empties in 60
- 90 minutes.
170
Peter Hartmann has measured the volume of milk
in a single let down reflex. Quite regardless
of breast-size amazingly constant a let
down of milk is 30 35 ml.
171
The volume of a single letdown reflex is 30
35 ml The volume of a week old babys
stomach is 30 35 ml.
172
One feed every 90 minutes 16 feeds/ day
16 feeds of 30 mls each 480 mls 480
mls per day for 3 kg baby 160
ml/kg/d requirement of baby. FREQUENT
FEEDS !!!!
173
The volume of a week old babys stomach is 30
35 ml. D7 30ml pinpong ball D3 15ml
shooter marble D1 3-5 ml small marble
174
The volume of a week old babys stomach is 30
35 ml. D7 30ml D3 15ml D1 3-5 ml
Overfilling ????
175
The volume of a week old PREMs stomach is
??? 10 15 ml. D7 10 ml ? D3 5 ml ?
D1 1-2 ml ? Overfilling ????
176
A babies stomach empties in 60 - 90
minutes. Blood sugar may fall Options?
177
One feed every 90 minutes 16 feeds/ day
16 feeds of 30 mls each 480 mls 480
mls per day for 3 kg baby 160
ml/kg/d requirement of baby. FREQUENT
FEEDS !!!!
178
FREQUENT FEEDS !!!! In anthropological
studies, where infants are carried constantly,
and have free access to the breast, they will
breastfeed every hour. Surmise
Cholecystokinin, oxytocin - Behavioural
synchrony.
179
In the Muslim faith context of divorce The
mother shall give suck to their offspring, for
two complete years - Quran Surah II (Baqarah)
verse 233 suckling rights of the infant over
ride fathers rights to child.
180
BRAIN GROWTH BREASTFEEDING
suckling rights of the infant over
ride fathers rights to child. NEWBORNS
CHOICE, or FUNDAMENTAL RIGHT Exclusive
breastfeeding 6 months Ongoing breastfeeding 2
years
181
Babies should be carried for 2 years !!
Observation these mothers are not tired and
stressed out of their minds.
182
How many mothers in this room have breastfed
their babies? How many mothers in this room had
babies that breastfed?
183
BREASTFEEDING IS A BEHAVIOUR OF THE
NEWBORN Not the mother !!
184
Personal testimony of a mother at International
KMC Workshop The instinct of a mother to hold
and care for her baby is primordial
and primitive, and an overwhelmingly powerful
feeling. Jane Davis, Bogota, Dec 1998
185
. mother to hold and care for her baby
186
The neurobehavioural programmes originate in the
LIMBIC SYSTEM Expressed through
hypothalamus (autonomic nervous
system) hypophysis (endocrine system,
hormones) cerebellar connections (somatic system)
187
3 PROGRAMMES
DEFENSE
NUTRITION
REPRODUCTION
188
The reproductive programme is in the mother
and the baby
DEFENSE
NUTRITION
REPRODUCTION
HORMONES NERVES MUSCLES
189
Mothers have an innate, inborn BEHAVIOUR
HORMONES NERVES MUSCLES
HOLD CARE
190
KANGAROO MOTHER CARE
A mother and baby DYAD are a single
psychobiological organism
191
MOTHER is the Only Appropriate ENVIRONMENT
192
MOTHERS MILK is the only Appropriate FOOD
193
Further information Video Restoring the
Original Paradigm Has section on Breastfeeding
and breastmilk
194
SKIN-TO-SKIN BREASTFEEDING THEN
ADD TECHNOLOGY
KANGAROO MOTHER CARE
195
HUMANITY FIRST TECHNOLOGY SECOND
KANGAROO MOTHER CARE
Baby Stohm, 780g
196
CONCLUSIONS. Newborns should never be separated
!! Realistic ?? FUTURE OF KMC ???? process
Mowbray Maternity PHOTOGRAPHS
197
KANGAROO MOTHER CARE
The future of KMC a Public Health
Imperative The future Is NOT a place or
destination NOR some point in time THE FUTURE IS
A JOURNEY
198
Skin-to-Skin Contact,Breastfeeding, and
Perinatal Neuroscience Implementing Best
Practice in U.S. Hospitals Boston,
MA Denver, CO Redlands, CA Mission Viejo, CA
199
Restoring the Original Paradigm Kangaroo Mother
Care Thank you !