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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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Skin-to-Skin Contact,Breastfeeding, and

Perinatal Neuroscience

Hollister

Breastfeeding

Program 2006

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


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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


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Skin-to-Skin Contact,Breastfeeding, and

Perinatal Neuroscience:

Implementing Best Practice in U.S. Hospitals

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


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KANGAROO MOTHER CARE

IMPLEMENTATION

PRACTICAL

POTENTIAL

POLITICAL


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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…


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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 ………)


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Declaration of Alma-Ata on

Primary Health Care

… based on

practical,

scientifically sound

socially acceptable

methods and technology made

universally accessible ….


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Primary Health Care:

… is based on the application of

relevant results of

social,

biomedical

health services research

and public health experience


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BIOMEDICAL

SOCIAL

HEALTH

SERVICES


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SOCIAL

Socially

acceptable

BIOMEDICAL

Scientifically

sound

HEALTH

SERVICES

practical


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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


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PROBLEM 1:

When is 36w GA ?

Many only started 38w GA

Many delivered

at 38w GA

or before!!

NOT PRACTICAL !!

HEALTH

SERVICES


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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


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PROBLEM 3:

Enormous social

STIGMA !

Tablets could

be hidden

But “tins = HIV +ve”

Tins sold on station …

NOT ACCEPTABLE !!

SOCIAL


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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


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BIOMEDICAL

Thai protocol:

PMTCT (for

HIV)

SOCIAL

HEALTH

SERVICES


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Thai protocol:

PMTCT (for HIV):

scientifically sound

YES – BUT NOT

practical,

socially acceptable


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Primary Health Care:

… is based on the application of

relevant results of

biomedicalresearch

YES – BUT ALSO

socialresearch, and

health services research


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BIOMEDICAL

Changed to

NVP

single dose

in hospital

SOCIAL

Encourage Strict

Exclusive BF

& M2M2B

HIV

transmission

about 8%

HEALTH

SERVICES


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“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.”


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“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 ???


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The biomedical paradigm practice on sound research evidence.”

IS TOO NARROW !!


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“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 !!


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Declaration of Alma-Ata on practice on sound research evidence.”

Primary Health Care

… based on

practical,

scientifically sound

socially acceptable

methods and technology made

universally accessible ….


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Primary Health Care: practice on sound research evidence.”

… is based on the application of

relevant results of

social,

biomedical

health services research

and public health experience


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What determines a paradigm ?? practice on sound research evidence.”

Tradition

Culture

Experience

Research

Science


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What determines a paradigm ?? practice on sound research evidence.”

Tradition

Culture

Experience

Research

Science

Fashion !!!!


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Basic assumptions come from: practice on sound research evidence.”

Tradition

Culture

Experience


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Neuronal Plasticity practice on sound research evidence.”

“the first three years are decisive”

 platform for

subsequent

development of

higher cognitive

functions.

Attachment

Regulation

Emotion

Control

Arousal

Appetite

Sleep


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BASIC ASSUMPTIONS: practice on sound research evidence.”

PLATFORM / FOUNDATION / BASE


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PARADIGM CONSTRUCT practice on sound research evidence.”

Paradigm has internal

Intelligence

Honesty

Integrity

Consistency

BASIC ASSUMPTIONS:

FOUNDATION / PLATFORM / BASE


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What determines a paradigm ?? practice on sound research evidence.”

Tradition

Culture

Experience

Research

Science


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PARADIGM CONSTRUCT practice on sound research evidence.”

Paradigm has internal

Intelligence

Honesty

Integrity

Consistency

BASIC ASSUMPTIONS:

FOUNDATION / PLATFORM / BASE


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PARADIGM CONSTRUCT practice on sound research evidence.”

Biomedical model: reductionist

Odent’s “circular research”

If challenges paradigm:

Odent’s “cul-de-sac research”


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Impact of Birthing practice on sound research evidence.”

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


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PARADIGM CONSTRUCT practice on sound research evidence.”

Paradigm has internal

Intelligence

Honesty

Integrity

Consistency

BASIC ASSUMPTIONS:

FOUNDATION / PLATFORM / BASE

‘too many gaps’ in solid scientific

literature to warrant publication”


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WHAT NEW INFORMATION ? practice on sound research evidence.”

challenged paradigms: cul-de-sac

Without awakening to assumptions and

“basic belief system”

New information cannot be grasped !!


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SEPARATION practice on sound research evidence.”VIOLATES

THE INNATE AGENDA

OF MOTHER

AND NEWBORN


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“Why do doctors practice on sound research evidence.”

use treatments

that do not work?”

Jenny Doust , Chris Del Mar.

British Medical Journal, 28th February 2004


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  • “Why do doctors practice on sound research evidence.”

  • 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)


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  • “Why do doctors practice on sound research evidence.”

  • use treatments

  • that do not work?”

  • No one asks the question

  • Paradigm = basic assumption,

  • things we take for granted ….


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Culture practice on sound research evidence.”

Science

BIOMEDICAL

SOCIAL

RCT

Stigma

EBM

Disease

HEALTH

SYSTEMS

Efficiency /

effectiveness


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Culture practice on sound research evidence.”

Science

BIOMEDICAL

SOCIAL

RCT

Stigma

EBM

Disease

?

HEALTH

SYSTEMS

Efficiency /

effectiveness


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Culture practice on sound research evidence.”

Science

BIOMEDICAL

SOCIAL

RCT

Stigma

EBM

Disease

8%

HEALTH

SYSTEMS

Efficiency /

effectiveness


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Culture practice on sound research evidence.”

Science

BIOMEDICAL

SOCIAL

RCT

Stigma

EBM

Disease

HEALTH

SYSTEMS

Efficiency /

effectiveness


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Culture practice on sound research evidence.”

Science

BIOMEDICAL

SOCIAL

?

RCT

Stigma

EBM

Disease

HEALTH

SYSTEMS

Efficiency /

effectiveness


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Anthropology practice on sound research evidence.”

Culture

Values

Science

BIOMEDICAL

SOCIAL

Ethics

PHC

RCT

Stigma

Disease

EBM

Costs

HEALTH

SYSTEMS

Efficiency /

effectiveness


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Anthropology practice on sound research evidence.”

Culture

Values

Science

BIOMEDICAL

SOCIAL

Ethics

Centre of

excellence

RCT

Stigma

Disease

EBM

Costs

HEALTH

SYSTEMS

Efficiency /

effectiveness


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Anthropology practice on sound research evidence.”

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


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Anthropology practice on sound research evidence.”

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


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Infant brain development practice on sound research evidence.”

POTENTIAL

TIME


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Infant brain development practice on sound research evidence.”

OLD PARADIGM

POTENTIAL

TIME


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Infant brain development practice on sound research evidence.”

100%

ACTUAL or IDEAL

POTENTIAL

x

0 1 2 3 4 5y TIME


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Infant brain development practice on sound research evidence.”

100%

ACTUAL or IDEAL

POTENTIAL

0 1 2 3 4 5y TIME


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Infant brain development practice on sound research evidence.”

Sensory deprivation 100%

70%

POTENTIAL

0 1 2 3 4 5y TIME


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Infant brain development practice on sound research evidence.”

100%

Temporary insult

Early

POTENTIAL

0 1 2 3 4 5y TIME


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Infant brain development practice on sound research evidence.”

70%

Temporary insult

Early

POTENTIAL

0 1 2 3 4 5y TIME


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Infant brain development practice on sound research evidence.”

Late 100%

70%

Temporary insult

Early

POTENTIAL

0 1 2 3 4 5y TIME


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Infant brain development practice on sound research evidence.”EXCELLENCE

100%

70%

MEDIOCRITY

POTENTIAL

0 1 2 3 4 5y TIME


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SOCIAL practice on sound research evidence.”

Socially

acceptable

BIOMEDICAL

Scientifically

sound

HEALTH

SERVICES

practical


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Ethics practice on sound research evidence.”

BIOMEDICAL

SOCIAL

Values 

better brain

& quality

PHC

RCT 

outcomes

EBM

Costs

HEALTH

SYSTEMS

Effectiveness 

survival


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SOCIAL practice on sound research evidence.”

Better brain

& quality

BIOMEDICAL

Better

outcomes

HEALTH

SERVICES

Better survival


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“Improved survival” practice on sound research evidence.”

IS TOO LITTLE !!

NOT ENOUGH !!!


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  • “Why do doctors practice on sound research evidence.”

  • use treatments

  • that do not work?”

  • Over-reliance on

    • surrogate outcome


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INCUBATORS DE-STABILISE practice on sound research evidence.”

NEWBORNS


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BREAST- VAGAL practice on sound research evidence.”

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


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  • “Why do doctors practice on sound research evidence.”

  • use treatments

  • that do not work?” (BMJ 03/04)

  • Love of the pathophysiological model (that is wrong)

    • “Our pathophysiological

      • model IS wrong !!”


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NEUROSCIENCE practice on sound research evidence.”

90% of what we know

about the brain has

been discovered in

the last 15 years

Society of Neuroscience estimate

Dr Sandra Witelson, McMaster


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NEW PARADIGM CONSTRUCT practice on sound research evidence.”

Brain based paradigm

BASIC ASSUMPTION:

NEVER SEPARATE !!

FOUNDATION / PLATFORM / BASE


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Skin-to-Skin Contact, practice on sound research evidence.”Breastfeeding, and

Perinatal Neuroscience:

Implementing Best Practice in U.S. Hospitals

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


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Ottawa Charter practice on sound research evidence.”

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 -


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HEALTH PROMOTION practice on sound research evidence.”

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 ...


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Pillar number 5 practice on sound research evidence.”

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”)


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responsibility … is shared practice on sound research evidence.”

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


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Reorienting health services …. practice on sound research evidence.”

… 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”)


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REORIENT HEALTH SERVICES practice on sound research evidence.”

a change in attitude

Reorientation requires change

Change requires energy

Change always meets resistance

Resistance is very seldom rational


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REORIENTATION PACKAGE practice on sound research evidence.”

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 ….


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THE PACKAGE practice on sound research evidence.”

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.


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THE PACKAGE practice on sound research evidence.”

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.


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THE PACKAGE practice on sound research evidence.”

PARTNERSHIPS – networking with other

organisations and like minded …

POLICY - policies must be such to make

KMC easy and attractive

PURSE STRINGS - Resources needed !!


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Social marketing practice on sound research evidence.”

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 !!


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Social marketing (2) practice on sound research evidence.”

PRODUCT ORIENTATION

SELLING ORIENTATION

MARKETING ORIENTATION

Start with the client’s perspective

Meeting people’s needs and wants,

Understand their values and perceptions.


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DIFFUSION OF INNOVATIONS practice on sound research evidence.”

Early

majority

34%

Late

majority

34%

Innovators

2%

14%

Early

adopters

Laggards

16%

Time of adoption of innovations.


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DIFFUSION OF INNOVATIONS practice on sound research evidence.”

Early

majority

34%

Late

majority

34%

Innovators

2%

14%

Early

adopters

Laggards

16%

Pioneers Leaders Followers ‘diehards’

good to... ought to… have to…


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Motivation to change: practice on sound research evidence.”

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!


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Each stake holder, practice on sound research evidence.”

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


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Implementation practice on sound research evidence.”

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 :


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The “wheel of change” practice on sound research evidence.”

PERMANENT

EXIT

RELAPSE

MAIN-

TENANCE

PRE-

CONTEM-

PLATION

CONTEM-

PLATION

ACTION

DETER-

MINATION

(Prochaska and DiClemente 1982)


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PRE- practice on sound research evidence.”

CONTEM-

PLATION


Slide90 l.jpg

PRE- practice on sound research evidence.”

CONTEM-

PLATION

CONTEM-

PLATION


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PRE- practice on sound research evidence.”

CONTEM-

PLATION

CONTEM-

PLATION

DETER-

MINATION


Slide92 l.jpg

PRE- practice on sound research evidence.”

CONTEM-

PLATION

CONTEM-

PLATION

ACTION

DETER-

MINATION


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MAIN- practice on sound research evidence.”

TENANCE

PRE-

CONTEM-

PLATION

CONTEM-

PLATION

ACTION

DETER-

MINATION


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The “wheel of change” practice on sound research evidence.”

RELAPSE

MAIN-

TENANCE

PRE-

CONTEM-

PLATION

CONTEM-

PLATION

ACTION

DETER-

MINATION


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START practice on sound research evidence.”

AGAIN

RELAPSE

MAIN-

TENANCE

PRE-

CONTEM-

PLATION

CONTEM-

PLATION

ACTION

DETER-

MINATION


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PERMANENT practice on sound research evidence.”

EXIT

RELAPSE

MAIN-

TENANCE

PRE-

CONTEM-

PLATION

CONTEM-

PLATION

ACTION

DETER-

MINATION


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Motivation to change: practice on sound research evidence.”

… we must identify the

stage our target is at …

In promoting KMC,

The message we provide must

be appropriate to the stage!


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The KMC wheel / process of change practice on sound research evidence.”

Ignorance

Skepticism

Acceptance

Excitement

Setbacks &

relapse and

restart

Action

Maintenance

SUCCESS


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Implementation framework. practice on sound research evidence.”


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Implementation framework. practice on sound research evidence.”


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Implementation framework. practice on sound research evidence.”


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Implementation framework. practice on sound research evidence.”


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THE SOCO practice on sound research evidence.”

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 ….


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SOCO’s for the KMC stages of change practice on sound research evidence.”

Information

Encouragement

Education/

Research

Benefits

Protocols

Support and

reassurance

RECOGNITION

Monitoring


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KMC - a healthier alternative practice on sound research evidence.” !

Apply to each stakeholder:

BUILD HEALTHY PUBLIC POLICY

CREATE SUPPORTIVE ENVIRONMENTS

STRENGTHEN COMMUNITY ACTION

DEVELOP PERSONAL SKILLS

REORIENT HEALTH SERVICES


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  • Set a vision practice on sound research evidence.” Act today

  • Concluding statement of Alma Ata :

    • … calls on all … to collaborate in

    • introducing, developing and

    • maintaining Primary Health Care …

    • … or Kangaroo Mother Care


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K M C FRAMEWORK practice on sound research evidence.”

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


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K M C FRAMEWORK practice on sound research evidence.”

CARE VARIABLE

INITIATION The EARLIER the BETTER

CONTINUUM The MORE the BETTER


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K M C FRAMEWORK practice on sound research evidence.”

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


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KangaCarrier practice on sound research evidence.”

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.


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Dangers and contraindications practice on sound research evidence.”

 Obstructive apnoea

 Monitoring caveats

? Smothering

? Skin care

?? Infections


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Technique practice on sound research evidence.”:

Continuous SSC makes

great demands on mother

The KangaCarrier

& wrapper ensure

that MOTHER

and

BABY

are safe and comfortable

.


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Technique practice on sound research evidence.”:

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)


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In this position: practice on sound research evidence.”

The airway is protected,

Gravity helps breathing,

Abdominal breathing helped

There is maximal SSC,

Position is flexed,

Baby can sleep safely.


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Technique practice on sound research evidence.”:

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.


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In this position: practice on sound research evidence.”

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.


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In this position: Mother free practice on sound research evidence.”

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


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In this position: Mother free practice on sound research evidence.”

To sleep,

safely and comfortably


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In this position: Mother free practice on sound research evidence.”

To sleep,

safely and comfortably

In this position

Mother CAN NOT breastfeed !!!

But can easily loosen and feed frequently …


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The principles practice on sound research evidence.”

can be extended to different contexts

- premature birth

- oxygen dependence

- CPAP / IPPV


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KangaCarrier available at practice on sound research evidence.”

www.kangaroomothercare.com


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SELF ATTACHMENT. practice on sound research evidence.”

The newborn should NOT be separated

at birth, specially if premature !!


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Sequence human newborn breast-feeding practice on sound research evidence.”

Pre-requisite = habitat

hand to mouth

tongue moves

mouth moves

eye focuses nipple

crawls to nipple

latches to nipple

suckles

(Widstrom et al 1994)


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“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)


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STATE ORGANISATION. impressive and purposeful motor activity which,

The ability to appropriately

control the level of

sleep and arousal.


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Simplified scale - impressive and purposeful motor activity which,

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 !!


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Simplified scale - impressive and purposeful motor activity which,

HARD CRYING

CRYING

FUSSING

ACTIVE AWAKE

QUIET AWAKE

ALERT INACTIVE

DROWSY

ACTIVE SLEEP

IRREGULAR SLEEP

QUIET SLEEP

DEEP SLEEP

Incubator

KMC


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KMC babies oscillate slowly in safe zones impressive and purposeful motor activity which,

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


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BREASTFEEDING IS NOT JUST EATING! impressive and purposeful motor activity which,

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


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BREASTFEEDING IS NOT JUST EATING! impressive and purposeful motor activity which,

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


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KMC AND SLEEP STUDY impressive and purposeful motor activity which, The basicrest-activity cyclefor prematures and neonates (44-52 weeks post conceptional age) is 60-90 minutes long(Ludington)


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


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REM impressive and purposeful motor activity which,

REM

REM

NREM

NREM

This is a healthy sleep pattern

This is a very good cycling pattern

(thanks to Susan Ludington-Hoe)


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REM impressive and purposeful motor activity which,

REM

REM

NREM

NREM

1st hour 2nd hour

So in every hour, you would like

to see an EEG pattern that shows this


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State impressive and purposeful motor activity which,

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 l.jpg
Brain cycling in incubator impressive and purposeful motor activity which,

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 l.jpg
What do we see during KMC? impressive and purposeful motor activity which,

In KMC:

  • Normal cycling

  • Non-chaotic pattern

KMC

48 hour baseline chaotic pattern of

activity and quiet HR & RR

Pre-KC


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REM impressive and purposeful motor activity which,

feed

FEEDING &HANDLING

SLEEPING

&

CONTAINING

sleep

NREM

During sleep time - the newborn

should NOT BE HANDLED !!


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Compared to incubator babies, impressive and purposeful motor activity which,

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)


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K MC and neurobehavioural state organisation impressive and purposeful motor activity which,

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)


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BREASTFEEDING THE PREMATURE impressive and purposeful motor activity which,

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.


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BREASTFEEDING THE PREMATURE impressive and purposeful motor activity which,

Premature babies will need help.

BERLITH PERSSON

has provided that help …

PERSSON’S WHEEL !


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Breastfeeding & Suckling impressive and purposeful motor activity which,

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


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1 impressive and purposeful motor activity which,

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


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Step 2 and 3 Olfactory impressive and purposeful motor activity which,

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


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Step 4 Taste impressive and purposeful motor activity which,

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


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Step 6 First suckling. impressive and purposeful motor activity which,

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


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Step 6 First suckling. impressive and purposeful motor activity which,

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


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Step 7 Latching & swallowing impressive and purposeful motor activity which,

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 l.jpg

Step 8 First breast milk meal. impressive and purposeful motor activity which,

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 l.jpg

10 impressive and purposeful motor activity which,

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 l.jpg

The wheel impressive and purposeful motor activity which,

is not

round

Turns

slow at

first

but

then

picks

up speed!


Slide153 l.jpg

BREASTFEEDING A impressive and purposeful motor activity which,

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 l.jpg

Breast-feeding of Premature babies. impressive and purposeful motor activity which,

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 l.jpg

Gut hormones. impressive and purposeful motor activity which,

(Uvnas-Moberg 1989)

20 different hormones

work in the gut –

regulated by the vagal nerve.

Each has a specific function.


Slide156 l.jpg

Gut hormones. impressive and purposeful motor activity which,

"Bad guy" - SOMATOSTATIN:

inhibits gastrointestinal secretion,

inhibits motility ,

reduces blood flow to gut

and absorption,

causes gastric retention,

vomiting, constipation.


Slide157 l.jpg

SOMATOSTATIN: impressive and purposeful motor activity which,

inhibits the good hormones,

contributes to

slow weight gain.

At high levels also

inhibits release of

growth hormone.


Slide158 l.jpg

It takes 30 to 60 minutes impressive and purposeful motor activity which,

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  …


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Photograph series impressive and purposeful motor activity which,

available on website

www.kangaroomothercare.com


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Ziggy impressive and purposeful motor activity which,

… 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 l.jpg

Apes (and all mammals) impressive and purposeful motor activity which,

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 l.jpg

THE NEWBORN impressive and purposeful motor activity which,

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.


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Meier 1988 impressive and purposeful motor activity which,

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 l.jpg

Sensitive Midwife - PREMATURE impressive and purposeful motor activity which,

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 l.jpg

Sensitive Midwife - PREMATURE impressive and purposeful motor activity which,

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 l.jpg

Sensitive Midwife - PREMATURE impressive and purposeful motor activity which,

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 l.jpg

Bottle feeding requires impressive and purposeful motor activity which, 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.


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FEEDING impressive and purposeful motor activity which,

FREQUENCY

Fetus is fed continuously …


Slide169 l.jpg

A normal impressive and purposeful motor activity which,

sleep cycle for

a premature is

60 – 90 minutes

A babies stomach

empties in

60 - 90 minutes.


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Peter Hartmann impressive and purposeful motor activity which,

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 l.jpg

The volume of impressive and purposeful motor activity which,

a single letdown

reflex is

30 – 35 ml

The volume of a

week old baby’s

stomach is

30 – 35 ml.


Slide172 l.jpg

One feed every 90 minutes impressive and purposeful motor activity which,

= 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 !!!!


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The volume of a impressive and purposeful motor activity which,

week old baby’s

stomach is

30 – 35 ml.

D7 30ml = pinpong ball

D3 15ml = shooter marble

D1 3-5 ml = small marble


Slide174 l.jpg

The volume of a impressive and purposeful motor activity which,

week old baby’s

stomach is

30 – 35 ml.

D7 30ml =

D3 15ml =

D1 3-5 ml =

Overfilling ????


Slide175 l.jpg

The volume of a impressive and purposeful motor activity which,

week old PREM’s

stomach is ???

10 – 15 ml.

D7 10 ml ? =

D3 5 ml ? =

D1 1-2 ml ? =

Overfilling ????


Slide176 l.jpg

A babies stomach impressive and purposeful motor activity which,

empties in

60 - 90 minutes.

Blood sugar

may fall …

Options?


Slide177 l.jpg

One feed every 90 minutes impressive and purposeful motor activity which,

= 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 !!!!


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FREQUENT FEEDS !!!! impressive and purposeful motor activity which,

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.


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In the Muslim faith impressive and purposeful motor activity which,

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.


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BRAIN GROWTH impressive and purposeful motor activity which, & 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


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Babies should be carried impressive and purposeful motor activity which,

for 2

years !!

Observation – these mothers

are not “tired and stressed

out of their minds”.


Slide182 l.jpg

How many mothers impressive and purposeful motor activity which,

in this room have

breastfed their babies?

How many mothers

in this room had

babies that breastfed?


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BREASTFEEDING impressive and purposeful motor activity which,

IS A BEHAVIOUR

OF THE NEWBORN

Not the mother !!


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Personal testimony of a mother impressive and purposeful motor activity which,

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 l.jpg

“ …. mother impressive and purposeful motor activity which,

to hold

and care

for her baby”


Slide186 l.jpg

The neurobehavioural programmes impressive and purposeful motor activity which,

originate in the LIMBIC SYSTEM

Expressed through

hypothalamus

(autonomic nervous system)

hypophysis

(endocrine system, hormones)

cerebellar connections

(somatic system)


Slide187 l.jpg

3 PROGRAMMES impressive and purposeful motor activity which,

DEFENSE

NUTRITION

REPRODUCTION


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The reproductive programme impressive and purposeful motor activity which,

is in the mother and the baby

DEFENSE

NUTRITION

REPRODUCTION

HORMONES NERVES MUSCLES


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Mother’s have an innate, inborn impressive and purposeful motor activity which,

BEHAVIOUR

HORMONES NERVES MUSCLES

HOLD & CARE


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KANGAROO MOTHER CARE impressive and purposeful motor activity which,

A mother and baby

DYAD

are a single

psychobiological

organism


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MOTHER impressive and purposeful motor activity which,

is the

Only

Appropriate

ENVIRONMENT


Slide192 l.jpg

MOTHER’S impressive and purposeful motor activity which,

MILK is

the only

Appropriate

FOOD


Slide193 l.jpg

Further information impressive and purposeful motor activity which,

Video: Restoring the

Original Paradigm

Has section on

Breastfeeding

and breastmilk


Slide194 l.jpg

KANGAROO MOTHER CARE impressive and purposeful motor activity which,

SKIN-TO-SKIN

& BREASTFEEDING :

THEN ADD

TECHNOLOGY


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HUMANITY FIRST impressive and purposeful motor activity which,

TECHNOLOGY SECOND

KANGAROO MOTHER CARE

Baby Stohm, 780g


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CONCLUSIONS. impressive and purposeful motor activity which,

Newborns should never be separated !!

Realistic ??

FUTURE OF KMC ????

process … Mowbray Maternity

PHOTOGRAPHS


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KANGAROO MOTHER CARE impressive and purposeful motor activity which,

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


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Skin-to-Skin Contact, impressive and purposeful motor activity which, Breastfeeding, and

Perinatal Neuroscience:

Implementing Best Practice in U.S. Hospitals

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


Slide199 l.jpg

Restoring the Original Paradigm : impressive and purposeful motor activity which,

Kangaroo Mother Care

Thank you !


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