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Skin-to-Skin Contact, Breastfeeding, and Perinatal Neuroscience Hollister Breastfeeding Program 2006 Boston, MA Denver, CO Redlands, CA Mission Viejo, CA. Skin-to-Skin Contact, Breastfeeding, and Perinatal Neuroscience Dr Nils Bergman

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slide1

Skin-to-Skin Contact,Breastfeeding, and

Perinatal Neuroscience

Hollister

Breastfeeding

Program 2006

Boston, MA Denver, CO Redlands, CA Mission Viejo, CA

slide2

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.kangaroomothercare.com

slide3

Skin-to-Skin Contact,Breastfeeding, and

Perinatal Neuroscience:

Implementing Best Practice in U.S. Hospitals

Boston, MA Denver, CO Redlands, CA Mission Viejo, CA

slide4

KANGAROO MOTHER CARE

IMPLEMENTATION

PRACTICAL

POTENTIAL

POLITICAL

slide5

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…

slide6

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 ………)

slide7

Declaration of Alma-Ata on

Primary Health Care

… based on

practical,

scientifically sound

socially acceptable

methods and technology made

universally accessible ….

slide8

Primary Health Care:

… is based on the application of

relevant results of

social,

biomedical

health services research

and public health experience

slide9

BIOMEDICAL

SOCIAL

HEALTH

SERVICES

slide10

SOCIAL

Socially

acceptable

BIOMEDICAL

Scientifically

sound

HEALTH

SERVICES

practical

slide11

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

slide12

PROBLEM 1:

When is 36w GA ?

Many only started 38w GA

Many delivered

at 38w GA

or before!!

NOT PRACTICAL !!

HEALTH

SERVICES

slide13

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

slide14

PROBLEM 3:

Enormous social

STIGMA !

Tablets could

be hidden

But “tins = HIV +ve”

Tins sold on station …

NOT ACCEPTABLE !!

SOCIAL

slide15

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

slide16

BIOMEDICAL

Thai protocol:

PMTCT (for

HIV)

SOCIAL

HEALTH

SERVICES

slide17

Thai protocol:

PMTCT (for HIV):

scientifically sound

YES – BUT NOT

practical,

socially acceptable

slide18

Primary Health Care:

… is based on the application of

relevant results of

biomedicalresearch

YES – BUT ALSO

socialresearch, and

health services research

slide19

BIOMEDICAL

Changed to

NVP

single dose

in hospital

SOCIAL

Encourage Strict

Exclusive BF

& M2M2B

HIV

transmission

about 8%

HEALTH

SERVICES

slide20

“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.”

slide21

“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 ???

slide22

The biomedical paradigm

IS TOO NARROW !!

slide23

“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 !!

slide24

Declaration of Alma-Ata on

Primary Health Care

… based on

practical,

scientifically sound

socially acceptable

methods and technology made

universally accessible ….

slide25

Primary Health Care:

… is based on the application of

relevant results of

social,

biomedical

health services research

and public health experience

slide26

What determines a paradigm ??

Tradition

Culture

Experience

Research

Science

slide27

What determines a paradigm ??

Tradition

Culture

Experience

Research

Science

Fashion !!!!

slide28

Basic assumptions come from:

Tradition

Culture

Experience

neuronal plasticity
Neuronal Plasticity

“the first three years are decisive”

 platform for

subsequent

development of

higher cognitive

functions.

Attachment

Regulation

Emotion

Control

Arousal

Appetite

Sleep

slide30

BASIC ASSUMPTIONS:

PLATFORM / FOUNDATION / BASE

slide31

PARADIGM CONSTRUCT

Paradigm has internal

Intelligence

Honesty

Integrity

Consistency

BASIC ASSUMPTIONS:

FOUNDATION / PLATFORM / BASE

slide32

What determines a paradigm ??

Tradition

Culture

Experience

Research

Science

slide33

PARADIGM CONSTRUCT

Paradigm has internal

Intelligence

Honesty

Integrity

Consistency

BASIC ASSUMPTIONS:

FOUNDATION / PLATFORM / BASE

slide34

PARADIGM CONSTRUCT

Biomedical model: reductionist

Odent’s “circular research”

If challenges paradigm:

Odent’s “cul-de-sac research”

slide35

Impact of Birthing

Practices on Breastfeeding

EXAMPLE :

Mary Kroeger’s book:

challenges paradigms: cul-de-sac

“LINKAGES decided there were

‘too many gaps’ in solid scientific

literature to warrant publication”

= paradigm reinforces itself: circular

slide36

PARADIGM CONSTRUCT

Paradigm has internal

Intelligence

Honesty

Integrity

Consistency

BASIC ASSUMPTIONS:

FOUNDATION / PLATFORM / BASE

‘too many gaps’ in solid scientific

literature to warrant publication”

slide37

WHAT NEW INFORMATION ?

challenged paradigms: cul-de-sac

Without awakening to assumptions and

“basic belief system”

New information cannot be grasped !!

slide38

SEPARATION VIOLATES

THE INNATE AGENDA

OF MOTHER

AND NEWBORN

slide39

“Why do doctors

use treatments

that do not work?”

Jenny Doust , Chris Del Mar.

British Medical Journal, 28th February 2004

slide40

“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)
slide41

“Why do doctors

  • use treatments
  • that do not work?”
  • No one asks the question
  • Paradigm = basic assumption,
  • things we take for granted ….
slide42

Culture

Science

BIOMEDICAL

SOCIAL

RCT

Stigma

EBM

Disease

HEALTH

SYSTEMS

Efficiency /

effectiveness

slide43

Culture

Science

BIOMEDICAL

SOCIAL

RCT

Stigma

EBM

Disease

?

HEALTH

SYSTEMS

Efficiency /

effectiveness

slide44

Culture

Science

BIOMEDICAL

SOCIAL

RCT

Stigma

EBM

Disease

8%

HEALTH

SYSTEMS

Efficiency /

effectiveness

slide45

Culture

Science

BIOMEDICAL

SOCIAL

RCT

Stigma

EBM

Disease

HEALTH

SYSTEMS

Efficiency /

effectiveness

slide46

Culture

Science

BIOMEDICAL

SOCIAL

?

RCT

Stigma

EBM

Disease

HEALTH

SYSTEMS

Efficiency /

effectiveness

slide47

Anthropology

Culture

Values

Science

BIOMEDICAL

SOCIAL

Ethics

PHC

RCT

Stigma

Disease

EBM

Costs

HEALTH

SYSTEMS

Efficiency /

effectiveness

slide48

Anthropology

Culture

Values

Science

BIOMEDICAL

SOCIAL

Ethics

Centre of

excellence

RCT

Stigma

Disease

EBM

Costs

HEALTH

SYSTEMS

Efficiency /

effectiveness

slide49

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

slide50

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

slide52

Infant brain development

OLD PARADIGM

POTENTIAL

TIME

slide53

Infant brain development

100%

ACTUAL or IDEAL

POTENTIAL

x

0 1 2 3 4 5y TIME

slide54

Infant brain development

100%

ACTUAL or IDEAL

POTENTIAL

0 1 2 3 4 5y TIME

slide55

Infant brain development

Sensory deprivation 100%

70%

POTENTIAL

0 1 2 3 4 5y TIME

slide56

Infant brain development

100%

Temporary insult

Early

POTENTIAL

0 1 2 3 4 5y TIME

slide57

Infant brain development

70%

Temporary insult

Early

POTENTIAL

0 1 2 3 4 5y TIME

slide58

Infant brain development

Late 100%

70%

Temporary insult

Early

POTENTIAL

0 1 2 3 4 5y TIME

slide59

Infant brain development EXCELLENCE

100%

70%

MEDIOCRITY

POTENTIAL

0 1 2 3 4 5y TIME

slide60

SOCIAL

Socially

acceptable

BIOMEDICAL

Scientifically

sound

HEALTH

SERVICES

practical

slide61

Ethics

BIOMEDICAL

SOCIAL

Values 

better brain

& quality

PHC

RCT 

outcomes

EBM

Costs

HEALTH

SYSTEMS

Effectiveness 

survival

slide62

SOCIAL

Better brain

& quality

BIOMEDICAL

Better

outcomes

HEALTH

SERVICES

Better survival

slide63

“Improved survival”

IS TOO LITTLE !!

NOT ENOUGH !!!

slide64

“Why do doctors

  • use treatments
  • that do not work?”
  • Over-reliance on
        • surrogate outcome
slide66

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

slide67

“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 !!”
slide68

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

slide69

NEW PARADIGM CONSTRUCT

Brain based paradigm

BASIC ASSUMPTION:

NEVER SEPARATE !!

FOUNDATION / PLATFORM / BASE

slide70

Skin-to-Skin Contact,Breastfeeding, and

Perinatal Neuroscience:

Implementing Best Practice in U.S. Hospitals

Boston, MA Denver, CO Redlands, CA Mission Viejo, CA

slide71

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 -

slide72

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 ...

slide73

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”)

slide74

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

slide75

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”)

slide76

REORIENT HEALTH SERVICES

a change in attitude

Reorientation requires change

Change requires energy

Change always meets resistance

Resistance is very seldom rational

slide77

REORIENTATION PACKAGE

Modern marketing science …

Marketing is about a product …

but the existence of a good product

won’t make anyone buy it.

Marketing is about selling …

but clever salesmanship in itself

won’t make people want anything.

Marketing is therefore ….

slide78

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.

slide79

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.

slide80

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 !!

slide81

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 !!

slide82

Social marketing (2)

PRODUCT ORIENTATION

SELLING ORIENTATION

MARKETING ORIENTATION

Start with the client’s perspective

Meeting people’s needs and wants,

Understand their values and perceptions.

slide83

DIFFUSION OF INNOVATIONS

Early

majority

34%

Late

majority

34%

Innovators

2%

14%

Early

adopters

Laggards

16%

Time of adoption of innovations.

slide84

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…

slide85

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!

slide86

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

slide87

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 :

slide88

The “wheel of change”

PERMANENT

EXIT

RELAPSE

MAIN-

TENANCE

PRE-

CONTEM-

PLATION

CONTEM-

PLATION

ACTION

DETER-

MINATION

(Prochaska and DiClemente 1982)

slide89

PRE-

CONTEM-

PLATION

slide90

PRE-

CONTEM-

PLATION

CONTEM-

PLATION

slide91

PRE-

CONTEM-

PLATION

CONTEM-

PLATION

DETER-

MINATION

slide92

PRE-

CONTEM-

PLATION

CONTEM-

PLATION

ACTION

DETER-

MINATION

slide93

MAIN-

TENANCE

PRE-

CONTEM-

PLATION

CONTEM-

PLATION

ACTION

DETER-

MINATION

slide94

The “wheel of change”

RELAPSE

MAIN-

TENANCE

PRE-

CONTEM-

PLATION

CONTEM-

PLATION

ACTION

DETER-

MINATION

slide95

START

AGAIN

RELAPSE

MAIN-

TENANCE

PRE-

CONTEM-

PLATION

CONTEM-

PLATION

ACTION

DETER-

MINATION

slide96

PERMANENT

EXIT

RELAPSE

MAIN-

TENANCE

PRE-

CONTEM-

PLATION

CONTEM-

PLATION

ACTION

DETER-

MINATION

slide97

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!

slide98

The KMC wheel / process of change

Ignorance

Skepticism

Acceptance

Excitement

Setbacks &

relapse and

restart

Action

Maintenance

SUCCESS

slide103

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 ….

slide104

SOCO’s for the KMC stages of change

Information

Encouragement

Education/

Research

Benefits

Protocols

Support and

reassurance

RECOGNITION

Monitoring

slide105

KMC - a healthier alternative !

Apply to each stakeholder:

BUILD HEALTHY PUBLIC POLICY

CREATE SUPPORTIVE ENVIRONMENTS

STRENGTHEN COMMUNITY ACTION

DEVELOP PERSONAL SKILLS

REORIENT HEALTH SERVICES

slide106

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
slide107

K M C FRAMEWORK

CARE VARIABLE



INITIATION Birth <90’ <7h <7d >7d

CONTINUUM >20h >12h >4h >1h <1h

FOOD BM EBM IV Mix Cow

METHOD Breast Cup line NGT Bottle

Resp’ Support Vent’ CPAP O2 No

slide108

K M C FRAMEWORK

CARE VARIABLE

INITIATION The EARLIER the BETTER

CONTINUUM The MORE the BETTER

slide109

K M C FRAMEWORK

CARE VARIABLE



INITIATION The EARLIER the BETTER

CONTINUUM The MORE the BETTER

FOOD MUST BE MOTHER’S MILK

METHOD BREAST - FEEDING !!!

Resp’ SupportADD available technology

slide110

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.

slide111

Dangers and contraindications

 Obstructive apnoea

 Monitoring caveats

? Smothering

? Skin care

?? Infections

slide112

Technique:

Continuous SSC makes

great demands on mother

The KangaCarrier

& wrapper ensure

that MOTHER

and

BABY

are safe and comfortable

.

slide113

Technique:

The WRAPPER is for BABY.

Detail: Baby xiphisternum

on mother’s 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)

slide114

In this position:

The airway is protected,

Gravity helps breathing,

Abdominal breathing helped

There is maximal SSC,

Position is flexed,

Baby can sleep safely.

slide115

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 mother’s chest.

slide116

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.

slide117

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

slide118

In this position: Mother free

To sleep,

safely and comfortably

slide119

In this position: Mother free

To sleep,

safely and comfortably

In this position

Mother CAN NOT breastfeed !!!

But can easily loosen and feed frequently …

slide120

The principles

can be extended to different contexts

- premature birth

- oxygen dependence

- CPAP / IPPV

slide121

KangaCarrier available at

www.kangaroomothercare.com

slide122

SELF ATTACHMENT.

The newborn should NOT be separated

at birth, specially if premature !!

slide123

Sequence human newborn breast-feeding

Pre-requisite = habitat

hand to mouth

tongue moves

mouth moves

eye focuses nipple

crawls to nipple

latches to nipple

suckles

(Widstrom et al 1994)

slide124

“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)

slide125

STATE ORGANISATION.

The ability to appropriately

control the level of

sleep and arousal.

slide126

Simplified scale -

HARD CRYING

CRYING

FUSSING

ACTIVE AWAKE

QUIET AWAKE

ALERT INACTIVE

DROWSY

ACTIVE 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 !!

slide127

Simplified scale -

HARD CRYING

CRYING

FUSSING

ACTIVE AWAKE

QUIET AWAKE

ALERT INACTIVE

DROWSY

ACTIVE SLEEP

IRREGULAR SLEEP

QUIET SLEEP

DEEP SLEEP

Incubator

KMC

slide128

KMC babies oscillate slowly in safe zones

Separated babies oscillate

erratically to danger zones

Simplified scale -

HARD CRYING

CRYING

FUSSING

ACTIVE AWAKE

QUIET AWAKE

ALERT INACTIVE

DROWSY

ACTIVE SLEEP

IRREGULAR SLEEP

QUIET SLEEP

DEEP SLEEP

risk

stress

feeding

stimulation

digestion

apnoea

slide129

BREASTFEEDING IS NOT JUST EATING!

The whole

cycle of

feeding and

digesting

mother’s milk

is what is the

fully the

breastfeeding

programme

Simplified scale -

HARD CRYING

CRYING

FUSSING

ACTIVE AWAKE

QUIET AWAKE

ALERT INACTIVE

DROWSY

ACTIVE SLEEP

IRREGULAR SLEEP

QUIET SLEEP

DEEP SLEEP

feeding

stimulation

digestion

slide130

BREASTFEEDING IS NOT JUST EATING!

The whole

cycle of

feeding and

digesting

mother’s milk

is what is the

fully the

breastfeeding

programme

feeding

stimulation

digestion

SKIN-TO-SKIN

CONTACT

SHOULD BE

CONTINUOUS

slide131

KMC AND SLEEP STUDYThe basicrest-activity cyclefor prematures and neonates (44-52 weeks post conceptional age) is 60-90 minutes long(Ludington)

slide132

Not so much duration, or density of any sleep stage, or number of sleep stage episodes, but, cycling between quiet sleep and active sleepis what is important

slide133

REM

REM

REM

NREM

NREM

This is a healthy sleep pattern

This is a very good cycling pattern

(thanks to Susan Ludington-Hoe)

slide134

REM

REM

REM

NREM

NREM

1st hour 2nd hour

So in every hour, you would like

to see an EEG pattern that shows this

slide135

State

REM

REM

REM

NREM

NREM

NREM

HR

RR

REM Sleep is supposed to be

somewhat active, so

HR increases and RR is irregular

brain cycling in incubator
Brain cycling in incubator

In incubator

  • Chaotic pattern
  • No cycling

48 hour baseline chaotic pattern of

activity and quiet HR & RR

Pre-KC

what do we see during kmc
What do we see during KMC?

In KMC:

  • Normal cycling
  • Non-chaotic pattern

KMC

48 hour baseline chaotic pattern of

activity and quiet HR & RR

Pre-KC

slide138

REM

feed

FEEDING &HANDLING

SLEEPING

&

CONTAINING

sleep

NREM

During sleep time - the newborn

should NOT BE HANDLED !!

slide139

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)

slide140

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)

slide141

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.

slide142

BREASTFEEDING THE PREMATURE

Premature babies will need help.

BERLITH PERSSON

has provided that help …

PERSSON’S WHEEL !

slide143

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

slide144

1

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”

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

slide145

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

Smell nipple

Smell milk

3

slide146

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

slide147

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

slide148

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

slide149

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

slide150

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

slide151

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

slide152

The wheel

is not

round

Turns

slow at

first

but

then

picks

up speed!

slide153

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

slide154

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 mother’s chest, not abdomen

Allow longer for each step

Recognise the steps, and assist where needed

slide155

Gut hormones.

(Uvnas-Moberg 1989)

20 different hormones

work in the gut –

regulated by the vagal nerve.

Each has a specific function.

slide156

Gut hormones.

"Bad guy" - SOMATOSTATIN:

inhibits gastrointestinal secretion,

inhibits motility ,

reduces blood flow to gut

and absorption,

causes gastric retention,

vomiting, constipation.

slide157

SOMATOSTATIN:

inhibits the good hormones,

contributes to

slow weight gain.

At high levels also

inhibits release of

growth hormone.

slide158

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  …

slide159

Photograph series

available on website

www.kangaroomothercare.com

slide160

Ziggy

… is able to

eat and purr (and breathe) at

the same time !

Larynx meets uvula, separate

airway & foodway

Emma’s cat :

“Zig-Zag Thomas”

slide161

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.

slide162

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.

slide163

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, baby’s OXYGENATION remains good.

slide164

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.

slide165

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

slide166

Sensitive Midwife - PREMATURE

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 !

slide167

Bottle feeding requires SUCKING,

which requirescompletely different

muscles, and does NOT allowco-

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.

slide168

FEEDING

FREQUENCY

Fetus is fed continuously …

slide169

A normal

sleep cycle for

a premature is

60 – 90 minutes

A babies stomach

empties in

60 - 90 minutes.

slide170

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.

slide171

The volume of

a single letdown

reflex is

30 – 35 ml

The volume of a

week old baby’s

stomach is

30 – 35 ml.

slide172

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 !!!!

slide173

The volume of a

week old baby’s

stomach is

30 – 35 ml.

D7 30ml = pinpong ball

D3 15ml = shooter marble

D1 3-5 ml = small marble

slide174

The volume of a

week old baby’s

stomach is

30 – 35 ml.

D7 30ml =

D3 15ml =

D1 3-5 ml =

Overfilling ????

slide175

The volume of a

week old PREM’s

stomach is ???

10 – 15 ml.

D7 10 ml ? =

D3 5 ml ? =

D1 1-2 ml ? =

Overfilling ????

slide176

A babies stomach

empties in

60 - 90 minutes.

Blood sugar

may fall …

Options?

slide177

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 !!!!

slide178

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.

slide179

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

father’s rights to child.

slide180

BRAIN GROWTH & BREASTFEEDING

“suckling rights of the infant over ride

father’s rights to child.”

NEWBORN’S CHOICE, or

FUNDAMENTAL RIGHT:

Exclusive breastfeeding 6 months

Ongoing breastfeeding 2 years

slide181

Babies should be carried

for 2

years !!

Observation – these mothers

are not “tired and stressed

out of their minds”.

slide182

How many mothers

in this room have

breastfed their babies?

How many mothers

in this room had

babies that breastfed?

slide183

BREASTFEEDING

IS A BEHAVIOUR

OF THE NEWBORN

Not the mother !!

slide184

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

slide185

“ …. mother

to hold

and care

for her baby”

slide186

The neurobehavioural programmes

originate in the LIMBIC SYSTEM

Expressed through

hypothalamus

(autonomic nervous system)

hypophysis

(endocrine system, hormones)

cerebellar connections

(somatic system)

slide187

3 PROGRAMMES

DEFENSE

NUTRITION

REPRODUCTION

slide188

The reproductive programme

is in the mother and the baby

DEFENSE

NUTRITION

REPRODUCTION

HORMONES NERVES MUSCLES

slide189

Mother’s have an innate, inborn

BEHAVIOUR

HORMONES NERVES MUSCLES

HOLD & CARE

slide190

KANGAROO MOTHER CARE

A mother and baby

DYAD

are a single

psychobiological

organism

slide191

MOTHER

is the

Only

Appropriate

ENVIRONMENT

slide192

MOTHER’S

MILK is

the only

Appropriate

FOOD

slide193

Further information

Video: Restoring the

Original Paradigm

Has section on

Breastfeeding

and breastmilk

slide194

KANGAROO MOTHER CARE

SKIN-TO-SKIN

& BREASTFEEDING :

THEN ADD

TECHNOLOGY

slide195

HUMANITY FIRST

TECHNOLOGY SECOND

KANGAROO MOTHER CARE

Baby Stohm, 780g

slide196

CONCLUSIONS.

Newborns should never be separated !!

Realistic ??

FUTURE OF KMC ????

process … Mowbray Maternity

PHOTOGRAPHS

slide197

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

slide198

Skin-to-Skin Contact,Breastfeeding, and

Perinatal Neuroscience:

Implementing Best Practice in U.S. Hospitals

Boston, MA Denver, CO Redlands, CA Mission Viejo, CA

slide199

Restoring the Original Paradigm :

Kangaroo Mother Care

Thank you !

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