A neurobehavioural approach to breastfeeding, … Dr Nils Bergman MB ChB, DCH, MPH, MD (USA equiv: MD, MPH ,PhD) Cape Town, RSA A neurobehavioural approach to breastfeeding, including

1

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

The DNA Behaviour



EPIGENETICS


“Phenotype” – specimen resulting from

gene – environment interaction

NEURODEVELOPMENT

The DNA Behaviour



EPIGENETICS


2

”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

3

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

18

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.

NEURODEVELOPMENT

The DNA Behaviour



EPIGENETICS


HIGHLY CONSERVED NEURO-ENDOCRINE

BEHAVIOR

NEURODEVELOPMENT

The DNA Behaviour



EPIGENETICS


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

The DNA Behaviour



EPIGENETICS


“For species such as primates, the mother IS the environment.”

Sarah Blaffer Hrdy, Mother Nature (1999)

6

NEURODEVELOPMENT

The DNA Behaviour



EPIGENETICS


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.

NEURODEVELOPMENT

The DNA Behaviour




EPIGENETICS

BIRTH

“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

NEURODEVELOPMENT

The DNA Behaviour




EPIGENETICS

BIRTH

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

NEURODEVELOPMENT

The DNA Behaviour




EPIGENETICS

BIRTH

BABY

BONDING

Smell

Skin contact

Simulation theory:EMPATHY is generated by inner imitationof actions of others

NEURODEVELOPMENT

The DNA Behaviour




EPIGENETICS

BIRTH

BABY

BONDING

Morphing emotion AMYGDALA FUSIFORMGYRUS

NEURODEVELOPMENT

The DNA Behaviour




EPIGENETICS

BIRTH

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.

8

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

NEURODEVELOPMENT

The DNA Behaviour




EPIGENETICS

BIRTH

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.


9

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.


NEURODEVELOPMENT

The DNA Behaviour




EPIGENETICS

BIRTH

SEPARATIONBABY


• Strong and prolonged activation of the body’s

stress management systems in the

absence of the buffering

protection of adult support.

NEURODEVELOPMENT

The DNA Behaviour




EPIGENETICS

BIRTH

SEPARATIONBABY


•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

10

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



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



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.

12

NEURODEVELOPMENT

The DNA Behaviour




EPIGENETICS

BIRTH

SEPARATIONBABY


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

13

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

NEURODEVELOPMENT

The DNA Behaviour




EPIGENETICS

BIRTH

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

14

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

NEURODEVELOPMENT

The DNA Behaviour




EPIGENETICS

BIRTH

SEPARATIONMOTHERBABY

BONDING Sensitization Toxic stress

Insensitiveparenting

… anxious parenting … mediated by stress-related mechanisms

and greater neural disorganization.

SEPARATION

Toxic stress


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 …

15

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



Orbitofrontal cortex –activates approach

Nucleus accumbens –Reward and pleasure motivation- (dopamine)

Fusiform gyrus –(face coding unit of brain)

seeks her baby’s face


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


CHANGES MOTHER’S BRAIN !!

Same brain circuits …as RESILIENCE,

“highly conservedneuro-endocrine behavior”

DISEASEHEALTH

RESILIENCE VULNERABILITY

NEURODEVELOPMENT

The DNA Behaviour




EPIGENETICS

BIRTH


BONDING Sensitization Toxic stress


There is a critical period for maternal neuroplasticity at birth.

16

BIDIRECTIONAL !!

Affect regulation

“Human brains are RELATIONAL”

… co-creating touch… signature unique to caregiver

PRATHIBA REEBYE


Secure attachment

Attuned parenting

The first hours after birth are a

CRITICAL PERIOD

mutual psycho-neuro-physiological

caregivers

NEURODEVELOPMENT

The DNA Behaviour




EPIGENETICS

BIRTH

BEYOND BREASTFEEDING Feed Sleep Cycling

MOTHERBABY


Secure attachment

Attuned parenting

EMOTIONAL INTELLIGENCE

SOCIAL INTELLIGENCE

NEURODEVELOPMENT

The DNA Behaviour




EPIGENETICS

BIRTH

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


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


premature infants

BIRTH

S S C



BREASTFEEDING


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


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.

http://en.wikipedia.org/wiki/Image:Fat_triglyceride_shorthand_formula.PNG




http://en.wikipedia.org/wiki/Image:Phosphatidyl-Choline.png

http://en.wikipedia.org/wiki/Image:Phosphatidyl-Choline.png

http://en.wikipedia.org/wiki/Image:Sphingomyelin.png


http://en.wikipedia.org/wiki/Image:Phospholipid.svg

http://en.wikipedia.org/wiki/Image:Phospholipid.svg

18

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





http://en.wikipedia.org/wiki/Image:Myelinated_neuron.jpg

http://en.wikipedia.org/wiki/Image:Myelinated_neuron.jpg

http://en.wikipedia.org/wiki/Image:Neuron-no_labels.png

http://en.wikipedia.org/wiki/Image:Neuron-no_labels.png

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

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


STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

BRAIN

WIRING

BREASTFEEDING Feed Sleep Cycling


BIRTH

S S C



BREASTFEEDING


STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

BRAIN

WIRING


BIRTH

MOTHERBABY

23

NEURODEVELOPMENT

The DNA Behaviour




EPIGENETICS

BIRTH


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


OXYTOCINDOPAMINE

CORTISOL


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


OXYTOCINDOPAMINE

CORTISOL


FEARCONTROL

CENTRE

REWARDCONTROL

CENTRE


OXYTOCINDOPAMINE

CORTISOL


WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY

DISEASEHEALTH


… there is considerable overlap in the brain structures associated with these neural mechanisms … functional interactions among the circuits.

FEARCONTROL

CENTRE

REWARDCONTROL

CENTRE


OXYTOCINDOPAMINE

CORTISOL


WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY

DISEASEHEALTH


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




EPIGENETICS

BIRTH




Secure attachment

Attuned parenting

Resilience Vulnerability

DISEASEHEALTH

Disordered attachment

Toxic stress



premature infants

BIRTH




Secure attachment

Attuned parenting


DISEASEHEALTH


Toxic stress


OXYTOCIN

SEPARATION CORTISOL

SKIN-TO-SKINCONTACT

OPPOSITES

26

NEURODEVELOPMENT

The DNA Behaviour




EPIGENETICS

intricately, inseparablylinked to the right place.

(Alberts 1994)

MOTHER

is the key toneurodevelopment …… because she is the

RIGHT PLACE !!


NEURODEVELOPMENT

The DNA Behaviour



EPIGENETICS


“except in the light

of mother’s body.”

NEURODEVELOPMENT

The DNA Behaviour



EPIGENETICS


“needed neural

processes”

NEURODEVELOPMENT

The DNA Behaviour



EPIGENETICS


buffering protection

of adult support”

“Absence of the

NEURODEVELOPMENT

The DNA Behaviour



EPIGENETICS


ZERO

SEPARATION

27

ZERO

SEPARATION


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


premature infants

What is going on in that brain?


premature infants

28

From Kim Luong Chi

29 week GA – zero separation

& skin-to-skin contact

suckling at 60 minutes.

NEURODEVELOPMENT

The DNA Behaviour




EPIGENETICS

BIRTH




Secure attachment

Attuned parenting


DISEASEHEALTH


Toxic stress


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)


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

https://www.facebook.com/ninobirth

https://www.facebook.com/ninobirth

33

“Put the patient inthe best position for Nature to act upon him.”

Florence NightingaleHUMANITY FIRST

TECHNOLOGY SECOND

Baby Stohm, 780g


Documents

A neurobehavioural approach to breastfeeding, … Dr Nils Bergman MB ChB, DCH, MPH, MD (USA equiv: MD, MPH ,PhD) Cape Town, RSA A neurobehavioural approach to breastfeeding, including