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BreathingBreathing

Right after birththe most important thing

for the infant is to

- start breathing, and then- establish an optimal respiration.

This happens more easily when

a baby is placed STS, instead ofexperiencing the physiological stress ofseparation.(Christensson K et al. Acta Paediatrica 1992;81:488-93.)

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Prematures kept STS:Prematures kept STS:

More stable heartMore stable heart--lung functionlung function

Also premature infants

have higher oxygen

levels and greaterheart-lung stability

when they are STS

than when they are

kept in incubatorsBergman NJ et al.

Acta Paediatr. 2004

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Mammalian protestMammalian protest--despairdespair

No will to live?No will to live? 34 infants 1.2-2.2 kg RCT

by computer before birthto STS or control.

A

fter 6 hrs:all STS-infants (8/18)

as opposed to

6/13 incubator infants

were hearth-lung stable. Cardio-respiratory instability in separated

infants is consistent with protest-despair/dissociation.

Bergman NJ et al, Acta Paediatr. 2004

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Born wet, into cool, baby gets coldBorn wet, into cool, baby gets cold

Also term newborns are often put inincubators or wrapped in warm blankets tohelp them maintain an optimal temperature.

A number of studies have demonstratedthat skin-to-skin contact with motheris betterfor regulatingthe babys temperature.

(Christensson K et al.1992, Bergman et al. 2004)

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Rewarming hypothermicRewarming hypothermic

newbornsnewbornsChristensson K et al. Lancet 1998;352:1115Christensson K et al. Lancet 1998;352:1115

Cumulative proportion of rewarmed infants

0

20

40

60

80

100

0 60 120 180 240 300 360 420 480 540 600

Time (minutes)

%r

eaching36.5

C

skin-to-skin

incubator

CC

(By compliments ofA.Cattaneo)

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Its warmest up frontIts warmest up front

A mothers chest gets warmer during STS

Lactating breasts are warmerthan non-

lactating ones.

An infant in a maternal nest, made up of

her chest and arms, will have a higher

temperature than one placed in a warmedcot.

Uvns-Moberg K. 2000

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Blood sugar and metabolismBlood sugar and metabolism

Low bloodsugar, hypoglucemia, is common

in newborns after an hour or more.

50 healthy, term babies randomized to be:

- placed STS with mother, or- separated, put in cot next to mother

90 minutes after birth those placed STS

had significantly higher blood-glucoseand maintained their bloodglucose better

even without feeding.Christensson K. et al. Acta Paediatr 1992)

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Crying: a separation distress call?Crying: a separation distress call?

Newborns obs. for 90 min.

randomized to

A

) STS with mother B) Cot

C) Cot, then STS

Infants recognize separation,

cry in pulses, stop at reunion.

Genetically encoded reaction.Christensson K et al. Acta Paediatr 1995

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Babys calling affects motherBabys calling affects mother

Most newborns will after a while emitt

calling sound like eh!, eh! AM Widstrm was a pioneer in making us all

concious of this every-day event.

Most mothers will react to babys call by

talking to the infant, some for the first time.

Most mothers recognize the voice of theirown babies in the maternity ward.

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Mother's voice organize brainMother's voice organize brain

function in the newbornfunction in the newborn

Mothers well known voice has a stronginfluence on the newborn with both

acute and enduring effects on thedeveloping brain.

This has ramifications for the developmentof the auditory system, as well as for later

social and emotional development. New York State Psychiatric Institute, Fifer WP, Moon

CM..Acta Paediatr Suppl. 1994 Jun;397:86-93

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Love at first sight?Love at first sight?

Right after birth

most babies

are wide awake,

can see well have visual

preferences:

they wantto see a face!

Faroni T et al. Proc NatlAcad Sci 2005

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Organized preOrganized pre--feeding behaviourfeeding behaviour

Most unsedated newborns placed STS willundergo the now well known behaviourwith crawling, touching, tongue- and

lipmovements, calling, rooting, sucking.

Breastfeeding initiated after such an

uninterupted sequence of events is veryoften successfull also long term. Widstrm AM at al Acta Paedr Scand 1987

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Babys touch does things to mom?Babys touch does things to mom?

Babys post partum contact with the breast

influences later maternal behaviour:

Mothers whose infants had touched orlicked the areola and nipple within 30 min.

left babies less in the nursery (p

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Hands on: Touch releases oxytocinHands on: Touch releases oxytocin

10 newborns were placed STS andvideofilmed with assessment every 30 sek.

Blood tests from mother every 15 min.

Infants used theirhands to explore andstimulate the breast before feeding,

resulting in surges of oxytocin in mother.

During suckling babys hands were still,but restarted during pauses in suckling.

Mattiesen AS et al. Birth 2001

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Areolar scent attracts babyAreolar scent attracts baby

The more

areolar skin glands

the better neonatal

weight gain,

onset of lactation,

maternal perception

oflatch onand sucking,

on day 1-3Schaal B Dev Psychobiol 2006

,

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Infants recognize odour of ownInfants recognize odour of own

mothers milk after early STSmothers milk after early STS60 healthy, full-term neonates randomlyassigned to STS postpartum or control

1 and 4 d after birth STS infantsresponded differently to own mothers milkcompared to another mothers milk,formula, orange juice, distilled water.

STS infants: larger difference at 4 days STS infants were breastfed an average of

1.9 months longer.Mizuno k et al. Acta Paediatrica 2004;93:1640-45

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STS and neurobehavioralSTS and neurobehavioral

responses of the term newbornresponses of the term newborn 15 min after birth 47 healthy infants RCT:A) STS lasting another hour, or

B) Standard care in nursery After 4 hrs: one hour-long observation:infants who had been STS slept longer,were mostly in a quiet sleep state,

had more flexormovements and posturesshowed less extensormovements STSseems to influence neurobehaviour

and system modulation of the newborn Goldstein Ferber S, Makhoul IR.. Pediatrics 2004;113 858-65

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Early STSEarly STS -- Lasting psycologicLasting psycologic

effect on newborn humans?effect on newborn humans?

Newborn rats: Separation from motherresults in disturbance not only of e.g.

future hormone regulation, but of

future behaviouras well.

In humans there is some evidence that earlyseparation may disturb subtle processes

influencing both body and mind andfuture social relationships.

HoferMAActa Paediatr Suppl 1994

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Neonatal brain: sensitive periodsNeonatal brain: sensitive periods

Mammalian imprinting models are

of critical importance in mammals,

including humansNewborn neural circuitry including

amygdala: different from adult.

The brain of a newborn is uniquelydesigned to optimize attachment.

Moriceau S & Sullivan RM. Dev Psykobiol 2005

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Can we make up for lost time?Can we make up for lost time?

Luckily there seems to be compensatory

mechanisms particularly in young who

depends for a long time on parental care.

Humans have their large brains,and canuse reason, inventivenes, emotional

reassurance, patience etc to make up:

Environmental enrichment during theperipubertal period Francis DDJ Neurosci. 2002

But what about vulnerable families?

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STS and maternal stress, mood,STS and maternal stress, mood,

heart rateheart rate and cortisoland cortisolPremature infants 25-33 wSTS mothers compared to ctrl:

salivary cortisol down (32%)

lower heart rates (7%)less stress (89%)improved mood (6%)

STS Infants:lower heart rateslower pain scorescortisol up or down

(some need stress?)Morelius E et al. Pediatrics 2005;116:110513

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Maternal psycological wellMaternal psycological well--beingbeing

Increased quantity of

neo-maternal exposure

in NICU has abeneficial effect on

maternal self-esteem

and attatchment

Ahn YM & Kim MR.

Taechan Kanho Hakhoe Chi 2005

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Endorphins promote happinessEndorphins promote happiness

Why do mothers go to all the trouble?

Whats in it for her right now?

In non-human primates beta-endorpin arecentral as regulators of

mother-infant interaction,as well as for groupsocializing.

In humans, levels of endorpins doubleduring breastfeeding peaking after 20 m.

Franceschini R et al. Br J Obstet Gynaecol 1989.

When I feed you I feel great myself!

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OxytocinOxytocin -- mediator of STS effectsmediator of STS effects

Oxytocin - not only usefull for uterine

contractions and milk let-down reflex.

It has a number of effects in humans:

Overflows brain to make mom drowsy and

relaxed, improves sleep-quality

Increases during massage, intercourse

HORMONE OF LOVE

Affects men, but w. much more sensitive

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Functional magnetic resonance imaging data (red) superimposed on structural MRI scans. Frightful faces triggered a dramatic reduction in amygdala activity in subjects who had sniffed oxytocin, suggesting that oxytocin mediates social fear and trust viathe amygdala and related circuitry.

.Frightful faces trigges activity in amygdala. In subj. who had sniffe

oxytocin there was a dramtic reduction, suggesting that oxytocin

mediates trust. Kirsch P et al. J Neurosci, 25(49):11489-93, 2005.

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DepartmentsDepartments

involvedinvolved

Obstetrics

Maternity Operating theatre

Anesthesiology

Postopertive (PO/Recovery) Pediatrics (Neonatal)

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Lower maternal stresshormonesLower maternal stresshormones

skinskin--toto--skinskin

Mothers with baby STS:

salivary cortisol down lower heart rates less stress improved mood

Morelius E et al.Pediatrics 2005;116:110513

Extra important in C-section mothers?

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Functional magnetic resonance imaging data (red) superimposed on structural MRI scans. Frightful faces triggered a dramatic reduction in amygdala activity in subjects who had sniffed oxytocin, suggesting that oxytocin mediates social fear and trust viathe amygdala and related circuitry.

.Frightful faces trigges activity in amygdala. In subj. who had sniffe

oxytocin there was a dramtic reduction, suggesting that oxytocin

mediates trust. Kirsch P et al. J Neurosci, 25(49):11489-93, 2005.

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Elevated p.p. oxytocinElevated p.p. oxytocin

peaks with baby STSpeaks with baby STS

Oxytocin is elevated

particularly the first hour after

delivery peaks with baby STS. After 1 hr oxy returns to pre partum levels. Oxy needed in maternal bonding in

animals. Nissen E et al. Acta Obstet Gynecol Scand. 1995

Oxytocin makes the uterus contract and

reduces bleeding.

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Elevated Oxytocin 1. hour p.pElevated Oxytocin 1. hour p.p..

Oxytocin is elevated - particularly the firsthour after delivery peaks with baby STS.

After 1 hr oxy returns to pre partum levels.

Oxy needed in maternal bonding inanimals. Nissen E et al. Acta Obstet Gynecol Scand. 1995

Oxytocin makes the uterus contract and

reduces bleeding.

Mothers delivered by c.s.,

particularly prone to hemorrage,

usually do not get their babies the 1. hour.

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Maternal nest is warmest, BUTMaternal nest is warmest, BUT

Dads skin also provides heatDads skin also provides heat

44 infants randomized after c-section to:

a) incubator b) cot c) STS with father

Results 2 hrs p.p: STS- and incubator-babies

warmer than those kept in a cot

After 24 hrs: STS-babies warmerthanbabies who started out

in cot OR incubatorChristenson K. Acta Paediatr 1996

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Early STS with healthy newbornsEarly STS with healthy newborns

Cochrane conclusionsCochrane conclusions:: Seventeen studies involving 806 infants Early STS contact associated with:

better maintenance oftemperature

better maintenance ofblood glucose

less infant crying

more breastfeeding at 1-3 months

longerbreastfeeding

higher scores of maternal affectionatelove/touch during breastfeedingAnderson GC et al. The Cochrane Library, Issue 2, 2003.

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CC--section moms and neos miss outsection moms and neos miss out

Two groups obs for 24 hrsof rooming-in, after

A) Natural birth

B) Cesarean sectionConclusion:

Mothers who have c-sections need moreattention to begin breastfeeding.

Rocha SM et al.Rev Bras Enferm. 2003

C.s.moms who get to keep their babies STSvery early, express great satisfaction.

Unpublished data, 2005 Norway

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Early STS with healthy newbornsEarly STS with healthy newborns

Cochrane conclusionsCochrane conclusions:: Seventeen studies involving 806 infants

Early STS contact associated with:

better maintenance oftemperature

better maintenance ofblood glucose

less infant crying

more breastfeeding at 1-3 months

longerbreastfeeding

higher scores of maternal affectionatelove/touch during breastfeedingAnderson GC et al. The Cochrane Library, Issue 2, 2003.

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Yes, please, support fromYes, please, support from bothboth

modern medicine and naturemodern medicine and nature

Measurable hard facts have typically

dominated modern medicine.

Today exactly such knowledge may beused to support evolutionary developed,

well-tested natural ways of handling

newborns and their mothers.

The main conclusion: try not to separate

the newborn baby from its mother!