The Neuroscience of Birth, and the case for ZERO SEPARATION · Slide by: Jack P. Shonkoff, M.D....

1

Dr Nils Bergman

MB ChB, DCH, MPH, MD

Cape Town, RSA

www.skintoskincontact.com

The Neuroscience of Birth, and the case for

ZERO SEPARATION

Disclosure of Financial Interest

• I, Nils Bergman, DO have a financial interest with

one or more organizations that could be perceived as

a real or apparent conflict of interest in the context of

the subject of this presentation, they are:• Affiliation/Financial Interest Name of Organization(s)

• Owner / Director NINO Academy

• NINO Academy produces educational and

promotional materials related to Kangaroo Mother

Care, and a garment for skin-to-skin contact.

600gr, 26 w GA, 48 hrs Even at 600gr,26 w GA

2

What is going on in that brain?

EYE CONTACTThe Neuroscience of Birth,

and the case for ZERO SEPARATION

What is going on in that brain?


ZERO SEPARATION

Garner 2011

Positive Stress

• Moderate, short-lived stress responses, such

as brief increases in heart rate or mild changes

in stress hormone levels.

• An important and necessary aspect of healthy

development that occurs in the context of

stable and supportive relationships.

Slide by: Jack P. Shonkoff, M.D.

Toxic Stress

• Strong and prolonged activation of the body’s

stress management systems in the absence of

the buffering protection of adult support.

• Disrupts brain architecture and leads to stress

management systems that respond at relatively

lower thresholds, thereby increasing the risk of

stress-related physical and mental illness.

Slide by: Jack P. Shonkoff, M.D. CORTISOL

3

Shonkoff 2012

The basic

science of

pediatrics.

Shonkoff J P et al.

Pediatrics 2012;

129:e232-e246

©2012 by American Academy of Pediatrics

6. The consequences of significant adversity early in life prompt an urgent call for

innovative strategies to reduce toxic stress within the

context of a coordinated system of policies and services guided by an

integrated science of early childhood and early brain development.

EARLY YEARS → LIFE SPAN

LearningBehavior

Physical well beingMental well being

TOXIC STRESS

EARLY LIFE ADVERSITY

MAKES POORER LinguisticCognitiveEmotionalAdaption

responsivity→ unhealthy lifestyle

→Chronic disease→health disparity

MASSIVE COST $$$$

REDUCETOXIC STRESS

NEURODEVELOPMENT

The DNA Behaviour

EVOLUTIONARY BIOLOGY

The Brain

EPIGENETICS

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

MICRO-RNA

HISTONE MODIFICATION

DNA METHYLATION

The Neuroscience of Birth & Breastfeeding

4

NEURODEVELOPMENT

The DNA Behaviour


The Brain

EPIGENETICS



REMNR1NR2NR3SWS

ACQUISITION CONSOLIDATION MEMORYFORMATION

poly-sensory input transfer information P wavesshort-term memory “SNR” strong signals returns infostored cortex amygdala / to neocortex:

hippocampus organizedAwake and REM NREM stage 4 REM

SLEEP CYCLING - BRAIN WIRING

Stanley Graven 2006

1. Messages are

collected in cortex

4. End of sleep

cycle - circuit

completed

3. In REM sleep –

fire to front of brain

(approach/ avoid)

2. In SWS sleep –

moved to emotional

brain (amygdala)

Peirano 2003

Brain Architecture and Skills are Built in a Hierarchical “Bottom-Up”

Sequence• Neural circuits that process basic information

are wired earlier than those that process more

complex information.


Brain Architecture and Skills are Built in a Hierarchical “Bottom-Up”

Sequence• Neural circuits that process basic information

are wired earlier than those that process more

complex information.

• Higher circuits build on lower circuits, and

skill development at higher levels is more

difficult if lower level circuits are not wired

properly.


NEURODEVELOPMENT

The DNA Behaviour


The Brain

EPIGENETICS

• Higher circuits build on lower circuits, and

skill development at higher levels is more

difficult if lower level circuits are not wired

properly.



Developmental timetable

CRITICAL PERIODS of development

5

NEURODEVELOPMENT

The DNA Behaviour


The Brain

EPIGENETICS


HIGHLY CONSERVED NEURO-ENDOCRINE

BEHAVIOR

“LIFE SCIENCES THEORY”


NEURODEVELOPMENT

The DNA Behaviour


The Brain

EPIGENETICS


HIGHLY CONSERVED NEURO-ENDOCRINE

BEHAVIOR


NEURODEVELOPMENT

The DNA Behaviour


The Brain

EPIGENETICS



NEURODEVELOPMENT

The DNA Behaviour


The Brain

EPIGENETICS


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

Sarah Blaffer Hrdy, Mother Nature (1999)


NEURODEVELOPMENT

The DNA Behaviour


The Brain

EPIGENETICS


Nothing an infant can or

cannot do makes sense,

except in light of mother’s body


NEURODEVELOPMENT

The DNA Behaviour


The Brain

EPIGENETICS


Skin-to-skin contact

except in light of mother’s body


ENVIRONMENT SKIN-TO-SKIN CONTACT

6

NEURODEVELOPMENT

The DNA Behaviour



The Neuroscience of Birth & BreastfeedingThe Brain

EPIGENETICS

Shonkoff 2012

NEURODEVELOPMENT

The DNA Behaviour




EPIGENETICS

BIRTH

BEYOND BREASTFEEDINGFeed → Sleep Cycling

SEPARATIONMOTHERBABY

BONDING Sensitization

Secure attachment

Attuned parenting

Resilience Vulnerability

DISEASEHEALTH

Disordered attachment

Toxic stress

Insensitiveparenting

raises its own temperature,has a higher blood glucose,metabolic adaptation faster.

NEURODEVELOPMENT

The DNA Behaviour




EPIGENETICS

BIRTH

“The newbornmay appear

helpless, but

TRANSITIONENVIRONMENT SKIN-TO-SKIN CONTACT

Images courtesy of Prof Peter Hartmann, UWA

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATIONENVIRONMENT SKIN-TO-SKIN CONTACT

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATIONENVIRONMENT SKIN-TO-SKIN CONTACT

Transition score

Heart rate score

Breathing score

Heart stability

Resp’ stability

CVS stability

Oxygen sat’

Apnoea

Temperature

7

The BOND is made up of the

sensory inputs from the parent to the infant

Bowlby 1969, 1973, 1980

Attachment Theory

The BOND is made up of the

sensory inputs from the parent to the infant

REGULATION

Bowlby 1969, 1973, 1980

Through “hidden maternal regulators” ...

warmth → activity levelmilk → heart rate

“ physiological set points “internal working modelsscripts – templates

a mother precisely controls everyelement of her infant’s physiology,

from its heart rate to its release of hormones

from its appetite to the intensity of its activity

(Gallagher 1992)

Through “hidden maternal regulators” ...

Warming, feeding and

protection behaviours areintricately, inseparablylinked to the right place.

(Alberts 1994) Skin-to-skin “causes” breastfeeding

8

Warming, feeding and

protection behaviours areintricately, inseparablylinked to the right place.

(Alberts 1994)

MICROBIOTA

3. NEUROLOGICAL DEVELOPMENT

2. METABOLIC FUNCTION

1. IMMUNITY

2. METABOLIC FUNCTION

1. IMMUNITY

3. NEUROLOGICAL DEVELOPMENT

9

… microbiota disturbances with antibiotic use,

cesarean section, and formula feeding that may

contribute to obesity, asthma, and other disorders.

NEURODEVELOPMENT

The DNA Behaviour



EPIGENETICS

intricately, inseparablylinked to the right place→ ZERO SEPARATION

(Alberts 1994)


BIRTH


intricately, inseparablylinked to the right place→ ZERO SEPARATION

AT BIRTH

SMELL vanilla / colostrum / water (control)

read NIRS activity FRONTAL LOBE

• This was confirmed by

demonstration of a statistically

significant negative correlation

between changes in [Hb O2] and

postnatal age (r 520.64, p 5 0.001

with 95% confidence interval) (Fig.

4). Those babies showing the

greatest increase in [Hb O2] were

between 6 and 24 h old at testing

• In the 14 babies older than 24 h

there was no significant difference

between the changes in [Hb O2]

during control and colostrum

exposure

APPROACH RESPONSE

10

In the 14 babies

older than 24 h

there was

no significant

difference

between the

changes in [Hb

O2] during control

and colostrum

exposure

Those babies

showing the

greatest

increase in

[Hb O2] were

between 6 and

24 h old at

testing

The first hours after birth are a

CRITICAL PERIOD

APPROACH RESPONSE

Smell

Skin contact

TWO CRITICAL SENSORY NEEDS:

SMELL & CONTACTconnect direct to the amygdala

AT BIRTH,

the brain has TWO CRITICAL SENSORY NEEDS:

SMELL & CONTACTconnect direct to the amygdala

THE NEWBORN

BRAIN

SKIN-TO-SKINCONTACT

fires and wires

the amygdala-prefronto-orbital cortical pathway (PFOC)Schore 2001

AMYGDALA:EmotionalProcessingUnit CPU

Prefrontal cortexExecutive

function

SOCIAL and EMOTIONAL

INTELLIGENCE

SOCIAL EMOTIONALINTELLIGENCE INTELLIGENCE

Behavioural activation systemreward-based(dopamine)

11

Welch 2013

Als 2004

Smell

Skin contact

Lenzi 2009

The newborn can imitate –

Mirror neurons

Meltzoff 1999

12

In humans, oxytocin increases gaze to the

eye region of human faces and enhances

interpersonal trust and the ability to infer

the emotions of others from facial cues.

Interpersonal awareness

Emotions

Kerstin

Uvnas-Moberg

Ross 2009

Smell

Skin contact

Smell

Skin contact

FACE RECOGNITIONCENTRE

OXYTOCIN

EMOTIONCONTROL CENTRE

The infant brain is not

blank!Resting activity

-“stream of

consciousness”

Fransson 2007

A primary visual areas,

B somatosensory motor cortex

C primary auditorycortex

D parietal cortex & cerebellum

E m l anterior pre-frontal cortex

Fransson 2007

13

Smell

Skin contact


FACE RECOGNITIONCENTRE

OXYTOCIN

E prefrontal

A primary visual

B somatosensory

C primary auditory

D parietal& cerebellum

NEURODEVELOPMENT

The DNA Behaviour




EPIGENETICS

BIRTH

BABY

BONDING

Smell

Skin contact


BIRTH


BABY

BONDING

ZERO SEPARATIONthe science behind the concept

Suckling and expression should start very early!

Effect of early breastmilk expression Parker LA. J

Perinatol. 2012Parker LA. Breastfeeding Medicine 2015

. • First hour expression ( vs. hrs. 2-6) ↓ time to lactogenesis and ↑production by 130% at 6 weeks (613.0 vs. 267.2)

Milk Volumes From Day 1 To 6 Weeks

Parker, J Perinatol, 2012

3 weeks 6 weeks

Suckling and expression should start very early!

Slides thanks to

Jane Morton

Skin-to-skin “causes” breastfeeding

SUCKLING precedes breastfeeding

Skin-to-skin “causes” breastfeeding

14

NEURODEVELOPMENT

The DNA Behaviour




EPIGENETICS

BIRTH


BABY

BONDING

NEURODEVELOPMENT

The DNA Behaviour




EPIGENETICS

BIRTH


MOTHERBABY


Secure attachment

Attuned parenting

Smell

Skin contact

Milk making NUTRITION

Hypothalamus→Pituitary:PROLACTIN →

Maternal ferocityPROTECTION

OXYTOCIN→ Gaze increase:→ BONDING

OXYTOCINCingulate Suppressed →

REGULATION

Amygdala:CHOLECYSTOKININ→ Emotion / satiety

Hypothalamus→Pituitary:

Cingulate

Amygdala

… infant cues - suckling, vocalisation and tactile stimulation - stimulate

OXYTOCINrelease in the hypothalamus, which may result in the activation

of the DOPAMINEreward pathway leading to behavioural reinforcement

SENSITIZATION

0

5

10

15

20

25

-0.2 0 0.2 0.4 0.6 0.8 1

Maternal Behavior Q-Sort

Ho

urs

of

SS

C i

n In

fan

ts' F

irst

24 H

ou

rs

SENSITIZATION

Dose of SCC first 24 hours correlatesMaternal behaviour Q SortPredicts attachment security

15

0

5

10

15

20

25

-0.2 0 0.2 0.4 0.6 0.8 1

Maternal Behavior Q-Sort

Ho

urs

of

SS

C i

n In

fan

ts' F

irst

24 H

ou

rs

Dose of SCC first 24 hours correlatesMaternal behaviour Q SortPredicts attachment security

SENSITIZATION

0

5

10

15

20

25

25 27 29 31 33 35 37 39 41 43 45

Maternal Behavior Subscale of the NCATS

Ho

urs

of

SS

C i

n In

fan

ts' F

irst

24 H

ou

rs

Dose of SCC first 24 hours correlatesNCATS ( Nursing Child Assessment Teaching Scale )

Predicts cognitive outcomeEPDS (depression) score DECREASED

significantly for first two visits.

JOGNN, 41, 369-382; 2012. DOI: 10.1111/j.1552-6909.2012.01350.x

Control

SSC




EARLY !!BIDIRECTIONAL !!

Affect regulation

“Human brains are RELATIONAL”

… co-creating touch… signature unique to caregiver

PRATHIBA REEBYE


Secure attachment

Attuned parenting

NEURODEVELOPMENT

The DNA Behaviour




EPIGENETICS

BIRTH


MOTHERBABY


Secure attachment

Attuned parenting

EMOTIONAL INTELLIGENCE

SOCIAL INTELLIGENCE

The first hours after birth are a

CRITICAL PERIOD

mutual psycho-neuro-physiological

caregivers

16

Critical period concept :

“Windows of opportunity in early life when a child’s brain is exquisitely primed to receive sensory input in order to develop more advanced neural systems.”

a mother’s brain …

SENSITIZATION

ENVIRONMENT

BIRTH

Maternal sensitization

BREASTFEEDINGFeed → Sleep Cycling

BABY


Secure attachment

Attuned parenting

SKIN-TO-SKIN CONTACT


Toxic Stress








Slide by: Jack P. Shonkoff, M.D. CORTISOL

NEURODEVELOPMENT

The DNA Behaviour




EPIGENETICS

BIRTH




Secure attachment

Attuned parenting

Resilience

HEALTH

Toxic stress




key biological systems … that contribute to maternal caregiving behaviour … the oxytocinergic and dopaminergic systems.

… dopamine pathways contribute to the processing of infant-related sensory cues leading to a behavioural response.

17

key biological systems … that contribute to maternal caregiving behaviour … the oxytocinergic and dopaminergic systems.

… dopamine pathways contribute to the processing of infant-related sensory cues leading to a behavioural response.

SEPARATION

Toxic stress


REPRODUCTIVE FITNESS

OXYTOCIN

OXYTOCIN is PULSATILE

Cervical dilatation

Skin-to-skin contact

Breastfeeding

Eye-to-eye contact

What about PITOCIN ?(Synthetic OXYTOCIN)

What about PITOCIN ?(Synthetic OXYTOCIN)

Olza 2012 Acta Paed 101 (7): 749-754

… intrapartum exogenous oxytocin

seems to disturb sucking and

breastfeeding duration

Association of peripartum synthetic oxytocin

administration and depressive and anxiety

disorders within the first postpartum year.

n 9684

n 37048

OXT inperipartum

No OXT

given

Depression 1yr

36% more (if before)32% more (if not)

doi: 10.1002/da.22599.

CONCLUSIONS:

Contrary to our hypothesis, results indicate ….

a higher risk of receiving a documented depressive

or anxiety disorder diagnosis

Kroll-Desrosiers 2016

NEURODEVELOPMENT

The DNA Behaviour




EPIGENETICS

BIRTH




Secure attachment

Attuned parenting


HEALTH


Toxic stress


18

NEURODEVELOPMENT

The DNA Behaviour




EPIGENETICS

BIRTH

SEPARATIONBABY

BONDING Toxic stress

•Disrupts brain architecture and leads to stress management systems that

respond at relatively lower thresholds, thereby

increasing the risk of stress-

related physical and mental illness.

CORTISOL

Positive Stress

• Moderate, short-lived stress responses, such

as brief increases in heart rate or mild changes

in stress hormone levels.

• An important and necessary aspect of healthy

development that occurs in the context of



Under-activity

EUSTRESS

Over-activity

Positive Stress

= Eustress

• An important and necessary

aspect of healthy development

that occurs in the context of


Tolerable Stress

• Stress responses that could disrupt brain

architecture, but are buffered by supportive

relationships that facilitate adaptive coping.

• Generally occurs within a time-limited period,

which gives the brain an opportunity to recover

from potentially damaging effects.


Toxic Stress




JACK SHONKOFF

“Buffering

protection

of adult support”

19

PROTEST –DESPAIR

OXYTOCIN CORTISOL

OXYTOCIN

Toxic Stress









SEPARATION DYSREGULATES

OXYTOCIN

CORTISOL

SEPARATION

Toxic stress

absence

SEPARATION DYSREGULATES

CORTISOL

OXYTOCIN

20

CORTISOL

MICHAEL MEANEY epigenetics

CORTISOL

Unsafe environment activates HPAaxis (autonomic nervous system, ANS).

Psychobiology

and molecular

genetics of

resilience

Adriana Feder*, Eric

J. Nestler‡, and

Dennis S. Charney‡ Nat Rev Neurosci. 2009 June ; 10(6): 446–457. doi:10.1038/nrn2649

HG BABY HG BABYLOW Grooming care

HG - High Grooming Low Grooming LG

HG BABY LG BABY

MOTHER MOTHER

Healthy UNHEALTHYadult adult

HG – High Grooming Low Grooming - LG

Makes MOTHER Makes MOTHER

UNHEALTHYadult

LOW Grooming LG

Makes MOTHER

CORTISOL


HG BABY LG BABY

MOTHER MOTHER




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

REGULATIONIn simple system

ONLY environment → reversibleice – water – steam

In complex system -irreversible = development

(PREDICTIVE ADAPTIVE RESPONSE)

Barak Morgan 2013


http://www.amazon.com/gp/reader/0521834570/ref=sib_dp_pt

21

CANALISATION

Developmental programming is therefore

VERY EARLY ONCE OFFFOREVER

Barak Morgan 2013

(PREDICTIVE ADAPTIVE RESPONSE)




HEALTHYadult

HIGH Grooming HG

Makes MOTHER

Earliest care at birth matters

Same gene → switched

LG BABY LG BABYHIGH grooming care

OXYTOCIN

NEURODEVELOPMENT

The DNA Behaviour




EPIGENETICS

BIRTH

SEPARATIONBABY

BONDING Toxic stress

OXYTOCIN CORTISOL

NEURODEVELOPMENT

The DNA Behaviour




EPIGENETICS

BIRTH

BABY

BONDING

SEPARATION

Toxic stress

OXYTOCIN CORTISOL

Perry: Responses to threat

TERRORFEARAROUSALCALMMental State

REFLEXIVEREACTIVE‘EMOTIONAL’CONCRETEABSTRACTCognition

BRAINSTEM

Autonomic

MIDBRAIN

Brainstem

LIMBIC

Midbrain

SUBCORTEX

LimbicNEOCORTEX

Subcortex

PRIMARY

secondary

Brain Areas

FAINTING

‘Mini-

psychosis’

DISSOCIATION

‘Numbing’COMPLIANCE

Freeze

AVOIDANCE

(Crying)

REST

(Female

Child)

Dissociative

Continuum

AGGRESSIONDEFIANCE

‘Posturing’

RESISTANCE

Freeze

VIGILANCE

(Crying)

REST

(Male Child)

Hyperarousal

Continuum

FIGHTFLIGHTFREEZEVIGILANCEREST

(Adult Male)Adaptative

Response



BRAINSTEM

Autonomic

MIDBRAIN

Brainstem

LIMBIC

Midbrain

SUBCORTEX

LimbicNEOCORTEX

Subcortex

PRIMARY

secondary

Brain Areas

FAINTING

‘Mini-

psychosis’

DISSOCIATION


Freeze

AVOIDANCE

(Crying)

REST

(Female

Child)

Dissociative

Continuum

AGGRESSIONDEFIANCE

‘Posturing’

RESISTANCE

Freeze

VIGILANCE

(Crying)

REST

(Male Child)

Hyperarousal

Continuum



Response

OXYTOCIN

Perry: Responses to threat - FAR

VIGILANCE



BRAINSTEM

Autonomic

MIDBRAIN

Brainstem

LIMBIC

Midbrain

SUBCORTEX

LimbicNEOCORTEX

Subcortex

PRIMARY

secondary

Brain Areas

FAINTING

‘Mini-

psychosis’

DISSOCIATION


Freeze

AVOIDANCE

(Crying)

REST

(Female

Child)

Dissociative

Continuum

AGGRESSIONDEFIANCE

‘Posturing’

RESISTANCE

Freeze

VIGILANCE

(Crying)

REST

(Male Child)

Hyperarousal

Continuum



Response



BRAINSTEM

Autonomic

MIDBRAIN

Brainstem

LIMBIC

Midbrain

SUBCORTEX

LimbicNEOCORTEX

Subcortex

PRIMARY

secondary

Brain Areas

FAINTING

‘Mini-

psychosis’

DISSOCIATION


Freeze

AVOIDANCE

(Crying)

REST

(Female

Child)

Dissociative

Continuum

AGGRESSIONDEFIANCE

‘Posturing’

RESISTANCE

Freeze

VIGILANCE

(Crying)

REST

(Male Child)

Hyperarousal

Continuum



Response Vasopressin

http://www.amazon.com/gp/reader/0521834570/ref=sib_dp_pt

22

Perry: Responses to threat - NEAR

FREEZE



BRAINSTEM

Autonomic

MIDBRAIN

Brainstem

LIMBIC

Midbrain

SUBCORTEX

LimbicNEOCORTEX

Subcortex

PRIMARY

secondary

Brain Areas

FAINTING

‘Mini-

psychosis’

DISSOCIATION


Freeze

AVOIDANCE

(Crying)

REST

(Female

Child)

Dissociative

Continuum

AGGRESSIONDEFIANCE

‘Posturing’

RESISTANCE

Freeze

VIGILANCE

(Crying)

REST

(Male Child)

Hyperarousal

Continuum



Response



BRAINSTEM

Autonomic

MIDBRAIN

Brainstem

LIMBIC

Midbrain

SUBCORTEX

LimbicNEOCORTEX

Subcortex

PRIMARY

secondary

Brain Areas

FAINTING

‘Mini-

psychosis’

DISSOCIATION


Freeze

AVOIDANCE

(Crying)

REST

(Female

Child)

Dissociative

Continuum

AGGRESSIONDEFIANCE

‘Posturing’

RESISTANCE

Freeze

VIGILANCE

(Crying)

REST

(Male Child)

Hyperarousal

Continuum



Response

CORTISOL


DISSOCIATION



BRAINSTEM

Autonomic

MIDBRAIN

Brainstem

LIMBIC

Midbrain

SUBCORTEX

LimbicNEOCORTEX

Subcortex

PRIMARY

secondary

Brain Areas

FAINTING

‘Mini-

psychosis’

DISSOCIATION


Freeze

AVOIDANCE

(Crying)

REST

(Female

Child)

Dissociative

Continuum

AGGRESSIONDEFIANCE

‘Posturing’

RESISTANCE

Freeze

VIGILANCE

(Crying)

REST

(Male Child)

Hyperarousal

Continuum



Response



BRAINSTEM

Autonomic

MIDBRAIN

Brainstem

LIMBIC

Midbrain

SUBCORTEX

LimbicNEOCORTEX

Subcortex

PRIMARY

secondary

Brain Areas

FAINTING

‘Mini-

psychosis’

DISSOCIATION


Freeze

AVOIDANCE

(Crying)

REST

(Female

Child)

Dissociative

Continuum

AGGRESSIONDEFIANCE

‘Posturing’

RESISTANCE

Freeze

VIGILANCE

(Crying)

REST

(Male Child)

Hyperarousal

Continuum



Response


REFLEXIVE

Adaptative

Response

REST

(Adult Male)

VIGILANCE FREEZE FLIGHT FIGHT

Hyperarousa

l

Continuum

REST

(Male Child)

VIGILANCE

(Crying)

RESISTANCE

Freeze

DEFIANCE

‘Posturing’

AGGRESSION

Dissociative

Continuum

REST

(Female

Child)

AVOIDANCE

(Crying)

COMPLIANCE

Freeze

DISSOCIATION

‘Numbing’FAINTING

‘Mini-

psychosis’

PRIMARY

secondary

Brain Areas

NEOCORTEX

Subcortex

SUBCORTEX

LimbicLIMBIC

Midbrain

MIDBRAIN

Brainstem

BRAINSTEM

Autonomic

Cognition ABSTRACT CONCRETE ‘EMOTIONAL’ REACTIVE REFLEXIVE

Mental State CALM AROUSAL FEAR TERROR

SSHHH!!

Moro reflex –often called a STARTLE REFLEX

because it occurs when a baby is startled by a loud sound or movement

Moro reflexSTARTLE

Thumb flexfinger claw

FREEZE

23


DISSOCIATION



BRAINSTEM

Autonomic

MIDBRAIN

Brainstem

LIMBIC

Midbrain

SUBCORTEX

LimbicNEOCORTEX

Subcortex

PRIMARY

secondary

Brain Areas

FAINTING

‘Mini-

psychosis’

DISSOCIATION


Freeze

AVOIDANCE

(Crying)

REST

(Female

Child)

Dissociative

Continuum

AGGRESSIONDEFIANCE

‘Posturing’

RESISTANCE

Freeze

VIGILANCE

(Crying)

REST

(Male Child)

Hyperarousal

Continuum



Response



BRAINSTEM

Autonomic

MIDBRAIN

Brainstem

LIMBIC

Midbrain

SUBCORTEX

LimbicNEOCORTEX

Subcortex

PRIMARY

secondary

Brain Areas

FAINTING

‘Mini-

psychosis’

DISSOCIATION


Freeze

AVOIDANCE

(Crying)

REST

(Female

Child)

Dissociative

Continuum

AGGRESSIONDEFIANCE

‘Posturing’

RESISTANCE

Freeze

VIGILANCE

(Crying)

REST

(Male Child)

Hyperarousal

Continuum



Response

Jacksonian Dissolution

The more threatened the individual,the more 'primitive' (or regressed) becomes the style of thinking and behaving.

Perry 1995

DVC

VVC

SNS

CORTISOL

Toxic Stress









CORTISOL

Primate separation studies

Maternal Separation Paradigm0w 1w 2w 3w 4w 5w 6w →→ 12w

n 4 Mat MNS→group reared no mothern 4 Mat → → → MNS→ group as aboven 4 Mat → → → → → → (control)

Gene specific for the AMYGDALA( GUYC1A3)

Separated at 1 week:

LOW gene expression

Increased self soothing→ Anxiety

Decreased sociality→ Depression

24

Primate separation studies

Maternal Separation ParadigmEarly Deprivation (ED) vs control (CON)

0d 2d → →28d → → 48wED n 11 Mat 30 -120 min daily →

CON n 4 Mat → → → → → → 48w

Repeated shortseparations:

LOW gene expression

Correlate to human adult depression

Adults with depression, suicides:LOW gene expression

smalller hippocampal volumereduced expression frontal lobe

Adults with depression, suicides:LOW gene expression

smalller hippocampal volumereduced expression frontal lobe

These findings translate previous results from rats / monkeys to humans

2ND

KNOCK

25

DOHAD

Developmental Origins of

Health and Adult Disease

… very early, once off, and forever.


FEARCONTROL

CENTRE

REWARDCONTROL

CENTRE

SOCIALCONTROL CENTRE

OXYTOCINDOPAMINE

CORTISOL


Sabatini

Arabadzisz

Nelson &

Panksepp 1998

SAFE UNSAFE

MICHAEL MEANEY epigenetics

CORTISOL

Unsafe environment activates HPAaxis (autonomic nervous system, ANS).

26


HG BABY LG BABY

MOTHER MOTHER





SAME CORTISOL RECEPTOR SWITCHED OFF BY STRESS


DISEASEHEALTH

CORTISOLOXYTOCIN

RESILIENCE(= STRESS RESISTANCE)

“capacity to maintain healthy emotional functioning in the after-math of stressful experiences”

DISEASEHEALTH

CORTISOLOXYTOCIN

REWARDCONTROL

CENTRE


OXYTOCINDOPAMINE

SOCIALITY

becomes

REWARDING

… IN BOTHMOTHER

AND BABY.

FEARCONTROL

CENTRE

REWARDCONTROL

CENTRE


OXYTOCINDOPAMINE

CORTISOL

27

FEARCONTROL

CENTRE

REWARDCONTROL

CENTRE


OXYTOCINDOPAMINE

CORTISOL


FEARCONTROL

CENTRE

REWARDCONTROL

CENTRE


OXYTOCINDOPAMINE

CORTISOL


WELL-BEING → SUSCEPTIBILITY →MORBIDITY → MORTALITY

DISEASEHEALTH

RESILIENCE VULNERABILITY

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

FEARCONTROL

CENTRE

REWARDCONTROL

CENTRE


OXYTOCINDOPAMINE

CORTISOL


An overly responsive fear circuit … may negatively influence functioning of the reward system.

… a properly functioning reward circuit may be necessary for …positive social behaviors.


DISEASEHEALTH

CONCLUSIONSScientific findings do not support the perceived benefits of permanent, preweaningmother–infant separation.

PR - Peer Reared

MR – Mother Reared

Plasma CORTISOL response to STRESS (2y)

RESILIENCE:“capacity to maintain

healthy emotional functioning in the after-

math of stressful experiences”

DISEASEHEALTH MR PR

RESILIENCE(= STRESS RESISTANCE)

“capacity to maintain healthy emotional functioning in the after-math of stressful experiences”


DISEASEHEALTH

28

NEURODEVELOPMENT

The DNA Behaviour




EPIGENETICS

BIRTH




Secure attachment

Attuned parenting


DISEASEHEALTH


Toxic stress


1 Transition2 Regulation3 Breastfeeding4 Microbiota5 Bonding6 Sensitization7 SEPARATION → HARM !!!



AT BIRTH

NEURODEVELOPMENT

The DNA Behaviour




EPIGENETICS

BIRTH




Secure attachment

Attuned parenting


DISEASEHEALTH


Toxic stress


1 Transition2 Regulation3 Breastfeeding4 Microbiota5 Bonding6 Sensitization7 SEPARATION → HARM !!!



AT BIRTH

1 Maternal insensitivity to cues2 Maternal OXT receptor dysfunction,3 Maternal depression4 Neonatal cortisol receptor decrease5 Neonatal limbic brain: loss resilience6 Neonatal feeding problems, DOHAD

7 etc, SEPARATION → HARM !!!


ENVIRONMENT SEPARATION

NEURODEVELOPMENT

The DNA Behaviour




EPIGENETICS

BIRTH




Secure attachment

Attuned parenting


DISEASEHEALTH


Toxic stress


1 Maternal insensitivity to cues2 Maternal OXT receptor dysfunction,3 Maternal depression4 Neonatal cortisol receptor decrease5 Neonatal limbic brain: loss resilience6 Neonatal feeding problems, DOHAD

7 etc, SEPARATION → HARM !!!


ENVIRONMENT SEPARATION

NEURODEVELOPMENT

The DNA Behaviour




EPIGENETICS

BIRTH




Secure attachment

Attuned parenting


DISEASEHEALTH


Toxic stress


29

BIRTH BONDING Sensitization Toxic stress

IT MATTERS

HOW WE ARE BORN

SEPARATION

DISEASE

Toxic stress

TOXIC STRESS = absence of the buffering protection of adult support.

SEPARATION IS A STRESSOR FOR FULL TERM NEONATES

SEPARATION

DISEASE

Toxic stress

TOXIC STRESS = absence of the buffering protection of adult support.

SEPARATION IS A STRESSOR FOR FULL TERM NEONATES

preterms have less resilience:

SEPARATION IS A SEVERE STRESSORFOR PRETERMS

REGULATION vs STIMULATION

Expected vs UnexpectedEcologic salience vs Potential threatResource growth vs threat readiness

OXYTOCIN vs CORTISOL HOMEORHESIS vs HOMEOSTASIS

MOTHER vs OTHER

Our NORMAL biology

Skin-to-skin

contact

IS MORE

essential for

premature

newborns!

Our NORMAL biology

Slide courtesy of Susie Ludington-Hoe

30

(Modi & Glover 1998, Mooncey et al 1997)

“Non-pharmacological reduction of

hypercortisolaemia in preterm infants”

Preterm infants experience prolonged severe stresswith tenfold increases in stress hormones.

Stress hormones at such levels are neurotoxic.

RCT on methods to reduce of stress (at one hour):

Cortisol EndorphinMassage slightly lower no change

Soft music no change no change

Skin-to-skin 66% lower 74% lower

CORTISOL

Preterm infants experience prolonged severe stresswith tenfold increases in stress hormones.

Stress hormones at such levels are neurotoxic.

(Modi & Glover 1998, Mooncey et al 1997)

RCT on methods to reduce of stress (at one hour):

Cortisol EndorphinMassage slightly lower no change

Soft music no change no change

Skin-to-skin 66% lower 74% lower

SSC – PROTECTION

SEPARATION RAISESSTRESS HORMONES

CORTISOL

Separation from mother is stressful for humans.Salivary cortisol is a good measure of stress.

RCT (Anderson et al 1998)

Two groups of newborns,

both given best care, only

one separated from mother

at one hour age

Cortisol levels measured

every hour.

Cortisol separate = 9Cortisol with mom = 4

SEPARATION = STRESS

CORTISOL IN NEWBORNS

0

2

4

6

8

10

12

14

16

18

20

0 1 2 3 4 5 6

TIME (hours)

Separated Mother contact

BIR

TH

SE

PA

RA

TIO

N

9

4

SSC – RESEARCH protection

CORTISOL

Both babies and their parents may experience a stay in

the newborn intensive care unit (NICU) as a traumatic or

a ‘toxic stress,’ which can lead to dysregulation of the

hypothalamic–pituitary–adrenal axis and ultimately to

poorly controlled cortisol secretion.

… strongly linked to poor health outcomes

… trauma-informed care is an approach to caregiving

based on the recognition of this relationship.

STRESSES IN PREGNANT WOMEN

STRESSES IN NICU INFANTS

MODIFICATION OF THE STRESS RESPONSE THROUGH SOCIAL

CONNECTEDNESS

THE POLYVAGAL THEORY IN THE NICU

ADAPTATION OF PRINCIPLES OF TRAUMA-INFORMED CARE TO

THE NICU SETTING

TRAUMA-INFORMED CARE OF THE FAMILY AND BABY:

NEWBORN INTENSIVE PARENTING UNITS

PROACTIVE COMMUNICATION AND EDUCATIONAL STRATEGIES

PROVIDING TRAUMA-INFORMED SUPPORTS TO STAFF

CARING FOR PREGNANT WOMEN, NEW MOTHERS,

FAMILIES AND BABIES

NEURODEVELOPMENT

The DNA Behaviour



The Brain

EPIGENETICS

BIRTH




Secure attachment

Attuned parenting


DISEASEHEALTH


Toxic stress


The Science behind Family Centred Care

31

SEPARATION

Vulnerability

DISEASE


Toxic stress


Feb 19, 2018Conclusions and Relevance:

Extremely or very preterm children born in the antenatal

corticosteroids and surfactant era show large deficits in

intelligence. No improvement in cognitive outcome was

observed between 1990 and 2008.

…

Bronchopulmonary dysplasia was found to be a crucial

factor for cognitive outcome. Lowering the high

incidence of BPD may be key to improving long-term

outcomes after EP/VP birth.

n = 366CONCLUSIONS This study demonstrated a reduction in total length of hospital stay for infants born prematurely by providing facilities for parents to stay in the NICU 24 hours/day from admission to discharge. Analyses of secondary outcomes also suggested a reduction in pulmonary morbidity, such as moderate-to-severe BPD.

NEURODEVELOPMENT

The DNA Behaviour



The Brain

EPIGENETICS

BIRTH




Secure attachment

Attuned parenting


DISEASEHEALTH


Toxic stress



32

NEURODEVELOPMENT

The DNA Behaviour



The Brain

EPIGENETICS

BIRTH




Secure attachment

Attuned parenting


DISEASEHEALTH


Toxic stress



NEURODEVELOPMENT

The DNA Behaviour



The Brain

EPIGENETICS

BIRTH


MOTHERBABY



Early Experience and the Development of Stress

Reactivity and Regulation in Children (Gunnar 2010)

Neurosci Biobehav Rev. 2010 May ; 34(6): 867–876. doi:10.1016/j.neubiorev.2009.05.007.

Nelson &

Panksepp 1998

SAFE UNSAFE


HG BABY LG BABY

MOTHER MOTHER





NURTURESCIENCE

FEARCONTROL

CENTRE

REWARDCONTROL

CENTRE


OXYTOCINDOPAMINE

CORTISOL



DISEASEHEALTH



NEURODEVELOPMENT

The DNA Behaviour



The Brain

EPIGENETICS

BIRTH




Secure attachment

Attuned parenting


DISEASEHEALTH


Toxic stress


NURTURESCIENCE

MARTHA WELCH Meyers, Hofer, Fifer, Ludwig etc

33

Nurturescience program now planned for

KAROLINSKA, Stockholm

BJORN WESTRUPULRIKA ADEN NILS BERGMAN

NURTURESCIENCEEssentially ecological:


MOTHERBABY



(from Greek: οἶκος, "house", or "environment"; -λογία, "study of")

The branch of biology that deals with the relations of

organisms to one another and to their physical surroundings.

NURTURESCIENCE

3 primary occupations:

BREASTFEEDINGSLEEPING

CONNECTING


MOTHERBABY


NURTURESCIENCE

Neuroscience developed

in the old paradigm of

maternal-infant separation.

NURTURESCIENCE

Nurturescience now engulfed or embedded in current

neuroscience paradigms,

Needs dissecting out →

NURTURESCIENCE NEUROSCIENCE

Key time

period

Perinatal, conception to birth to 1

month1 month – 3 years (ECD)

Comparison of nurturescience and neuroscience

First 1000 seconds (1st hour) TRANSITIONFirst 1000 minutes (1st day) SENSITIZATION First 1000 hours (6 weeks) CONNECTION→ First 1000 days ECD

AT BIRTHImmediate

34


Key time

period

Perinatal, conception to

birth to 1 month

1 month – 3 years

(ECD)

First 1000 minutes First 1000 days

ANS purpose HOMEORHESIS HOMEOSTASIS

Dyadic / family (plural) Individual (singular)

Dynamic systems theory Reductionistic logic

KEY

OUT-

COME

CONNECTION

RESILIENCE

ATTACHMENT

COGNITION



Key time

period




NEURODEVELOPMENT

The DNA Behaviour



The Brain

EPIGENETICS

BIRTH




Secure attachment

Attuned parenting


DISEASEHEALTH


Toxic stress



FEARCONTROL

CENTRE

REWARDCONTROL

CENTRE


OXYTOCINDOPAMINE

CORTISOL



DISEASEHEALTH




Key time

period



Emotions

Regulatory

mechanism

Viscera / ANS / limbic brain Limbic brain / neocortex

Maternal regulation then co-

regulationSelf-regulation (within self)

Open feedback loop (with others) Closed feed-back loop (within self)


REGULATION vs STIMULATION

Expected vs UnexpectedEcologic salience vs Potential threatResource growth vs threat readiness

OXYTOCIN vs CORTISOL HOMEORHESIS vs HOMEOSTASIS

MOTHER vs OTHER


Key time

period



Emotions

Regulatory

mechanism






CORTISOL


Key time

period



Emotions

Regulatory

mechanism





Emotions

Learning

mechanism

ANS influences on behavior CNS influences on behavior

Autonomic learning

(Pavlovian conditioning)Operant conditioning

Critical periods (brief) Sensitive periods (long)

Brain adaptation Brain maturation

KEY

OUTCOME

CONNECTION

RESILIENCE

ATTACHMENT

COGNITION


NEURODEVELOPMENT

The DNA Behaviour



The Brain

EPIGENETICS

BIRTH




Secure attachment

Attuned parenting


DISEASEHEALTH


Toxic stress


NURTURESCIENCE

35

INTRODUCTION

“It is easier to build strong children

than to repair broken men.”Frederick Douglass (1817–1895)


ZERO SEPARATION

NURTURESCIENCE

The Neuroscience of Birth, and the case for ZERO SEPARATION · Slide by: Jack P. Shonkoff, M.D....

Documents

Transcript of The Neuroscience of Birth, and the case for ZERO SEPARATION · Slide by: Jack P. Shonkoff, M.D....