No Slide Title · Slide by: Jack P. Shonkoff, M.D. Reflections for practice Sleep organization...

1

Dr Nils Bergman

MB ChB, DCH, MPH, MD

(USA equiv: MD, MPH ,PhD)

Cape Town, RSA

www.skintoskincontact.com

PERINATAL NEUROSCIENCE

NEURODEVELOPMENT

The DNA Behaviour

EVOLUTIONARY BIOLOGY

The Neuroscience of Birth & BreastfeedingThe Brain

EPIGENETICS

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

Scientific

American,December 2011

INK

PENCIL

CORTISOL

HISTONE MODIFICATION

DNA METHYLATION

MICRO-RNA

2

“Phenotype” – specimen resulting from

gene – environment interactionPencil

EPIGENES …controls on the DNA/gene

“switches in the mind”

G x E

NEURODEVELOPMENT

The DNA Behaviour



EPIGENETICS


Making of theneural tube

200000 new nerve cells/minHammarberg 1896 Caviness 2008

Neuronal migration

12

The brain is not a computer, it is a jungle

G Edelman

3

13

(Ner

vous

tiss

ue

cell

s –

gli

al

cell

s)

Impulse

Presynaptic neuron

Vesicle

Transmitters

Synaptic cleft

ReceptorsPostsynaptic

neuronPostsynaptic activity

fetal REM sleep(or active sleep) seems to

be particularly importantto the developing organism

... spontaneous synchronous firing

Marks et al 1995

”Neurons that fire together wire together while those which don’t,won’t”

Hebb/Carla Shatz

”Neurons that fire together wire together while those which don’t,won’t”

Hebb/Carla Shatz

Optimal neural pathways are selected - J-P Changeux

Early wiring phase

Pruning of excess

Adult stage (efficient)

Panksepp 1998

Siegel 2005

Non-REM 4

4

REMNR1NR2NR3NR4

ACQUISITION CONSOLIDATION MEMORYFORMATION

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

hippocampus organizedAwake and REM NREM stage 4 REM

BRAIN WIRING

Stanley Graven 2006

BRAIN WIRING

Peirano 2003

In adult:sleep pertains

to memory

In child:neurodevelopment

(brain wiring)1st 1000 days

BRAIN WIRING

PATHWAYS CIRCUITSNETWORKSCONNECTOME

LUDINGTON-HOE … SCHER

5

SCHER … LUDINGTON-HOEBrain Architecture and Skills are

Built in a Hierarchical “Bottom-Up” Sequence

• Neural circuits that process basic information

are wired earlier than those that process more

complex information.

• Higher circuits build on lower circuits, and

skill development at higher levels is more

difficult if lower level circuits are not wired

properly.

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

Reflections for practice

Sleep organization should guide care”DEFENCE NUTRITION REPRODUCTION

HORMONES NERVES MUSCLES

endocrine autonomic NS somatic

HIGHLY CONSERVED NEURO-ENDOCRINE

BEHAVIOR

6

AT BIRTH,

the brain has TWO CRITICAL SENSORY NEEDS:

SMELL & CONTACT

... these data indicate that pups have a unique learning circuit relying onthe olfactory bulb for

neural plasticity and on the hyperfunctioning noradrenergic locus coeruleus flooding the olfactory bulb with norepinephrine to support the neural changes.

APPROACH RESPONSE … learned prenatally, reinforced both during the birth process and

repeatedly throughout the postnatal period,

… supported by a unique neural framework … a system that ensures rapid and robust maternal odor learning

SMELL vanilla / colostrum / water (control)

read NIRS activity FRONTAL LOBE

• This was confirmed by

demonstration of a statistically

significant negative correlation

between changes in [Hb O2] and

postnatal age (r 520.64, p 5 0.001

with 95% confidence interval) (Fig.

4). Those babies showing the

greatest increase in [Hb O2] were

between 6 and 24 h old at testing

• In the 14 babies older than 24 h

there was no significant difference

between the changes in [Hb O2]

during control and colostrum

exposure

APPROACH RESPONSE

In the 14 babies

older than 24 h

there was

no significant

difference

between the

changes in [Hb

O2] during control

and colostrum

exposure

Those babies

showing the

greatest

increase in

[Hb O2] were

between 6 and

24 h old at

testing

The first hours after birth are a

CRITICAL PERIOD

7

9 steps“Skin-to-skin contact” is the salient stimulus for infant-parent behavior.

“The newborn may appear

helpless, but

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

(Widstrom 1987)

METABOLIC ADAPTATION

SSC started in the first 20 minutes after birth

SSC CotBlood glucose (1 hr) 3.17 2.56Base excess drop 3.4 1.8

(Christenson 1992)Images courtesy of Prof Peter Hartmann, UWA

Warming, feeding and

protection behaviours areintricately, inseparablylinked to the right place.

(Alberts 1994)

The BOND is made up of the

sensory inputs from the parent to the infant

REGULATION

Bowlby 1969, 1973, 1980

8

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)



“ physiological set points “

“ internal working models’“ scripts – templates”

NEURODEVELOPMENT

The DNA Behaviour




EPIGENETICS

BIRTH

BABY

BONDING

When does the infant

become conscious?

Scientific American 1986

Scientific American Mind 2009

Noradrenergic neurons from

LOCUS COERULEUS

may activate the whole brain during wakefulness

Awake at birth

AWAKE ON OFF ASLEEP

9

You can never reach the same highlevels of catecholamine levels

during your whole life as at birth Reduced catecholamine surge after C-section

Vaginal delivery Elective C-section

Reduced catecholamine surge after C-section

catecholamine surge required to activate (epithelial sodium channel) pump to get

lung liquid clearance BIRTH


Riccardo Pfister

Riccardo Pfister Riccardo Pfister

10


Why?

Vaginal delivery Elective C-section

The newborn brain consumes 50 %

of all the blood glucose-

In the adult 20 %

Scientific American 2010

The infant brain is not

blank!Resting activity

-“stream of

consciousness”

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)

AMYGDALA:EmotionalProcessingUnit CPU

Prefrontal cortexExecutive

function

SOCIAL and EMOTIONAL

INTELLIGENCE

SOCIAL EMOTIONALINTELLIGENCE INTELLIGENCE

Behavioural activation systemreward-based(dopamine)

11

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

OXYTOCIN

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

Morphing emotion AMYGDALA FUSIFORMGYRUS

12

Smell

Skin contact

A primary visual areas,

B somatosensory motor cortex

C primary auditorycortex

D parietal cortex & cerebellum

E m l anterior pre-frontal cortex

Fransson 2007

Smell

Skin contact

EMOTIONCONTROL CENTRE

FACE RECOGNITIONCENTRE

OXYTOCIN

E prefrontal

A primary visual

B somatosensory

C primary auditory

D parietal& cerebellum

Here we demonstrate that in 2-d-old infants, the language-related neural substrate is

fully active in both hemispheres with a preponderance in the right auditory cortex.

… although the brain responds to spoken language

already at birth, thereby providing a strong biological

basis to acquire language, progressive maturation

of intrahemispheric functional connectivity is yet to be established with language exposure as the brain develops.

28 days old, 30 w PMA

13



REGULATION

Bowlby 1969, 1973, 1980


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)




REGULATION

Bowlby 1969, 1973, 1980

SEPARATION

SEPARATION DYSREGULATES

CORTISOL

14

CORTISOL

Maternal absence causesneonatal instability.

PROTEST – DESPAIR is accompanied by

DYSREGULATION

“Phenotype” – specimen resulting from

gene – environment interactionPencil

EPIGENES …controls on the DNA/gene

“switches in the mind”

G x E

MICHAEL MEANEY

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

“In response to stress, CRF

… and vasopressin are

released … anterior pituitary

… synthesis release ACTH

…glucocorticoids ”CORTISOL

MICHAEL MEANEY epigenetics

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

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

15

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

OXYTOCINCORTISOL

This maternal carewas NOT abusive,just sub-standard.

This care isbasicallyskin-to-skin contact.

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

HG BABY HG BABYLOW Grooming care


HG BABY LG BABY

MOTHER MOTHER

Healthy UNHEALTHYadult adult



UNHEALTHYadult

LOW Grooming LG

Makes MOTHER

CORTISOL


HG BABY LG BABY

MOTHER MOTHER




LG BABY LG BABYHIGH grooming care


HG BABY LG BABY

MOTHER MOTHER




HEALTHYadult

HIGH Grooming HG

Makes MOTHER OXYTOCIN



HEALTHYadult

HIGH Grooming HG

Makes MOTHER

Earliest care at birth matters

Same gene switched

LG BABY LG BABYHIGH grooming care

OXYTOCIN

16

The PlaceENVIRONMENT

EXPERIENCEFITNESS ADAPTATION

Earliest care at birth matters

Same gene switched

OXYTOCIN

Primate separation studies

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

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

Gene specific for the AMYGDALA( GUYC1A3)

Separated at 1 week:

LOW gene expression

Increased self soothing Anxiety

Decreased sociality Depression

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

17

2ND

KNOCK

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

Sabatini

Arabadzisz

18

Nelson &

Panksepp 1998

SAFE UNSAFENEURODEVELOPMENT

The DNA Behaviour




EPIGENETICS

BIRTH

BABY

BONDING

SEPARATION

MATERNAL DEPENDENCEHABITAT

MATERNALMOTHER

OTHERALTERNATE

AM I SAFE HERE ??

THE THE ““OLDOLD”” BRAIN HAS BRAIN HAS

3 PROGRAMMES3 PROGRAMMES

DEFENCE NUTRITION REPRODUCTION

SKIN-TO-SKIN CONTACT

SEPARATION

BREAST- VAGALMOTHER FEEDING (PSNS) GROWTH

OTHER PROTEST- STRESS SURVIVAL orDESPAIR (SNS)

THE PLACE MODEL

R

Research funded byTHRASHER RESEARCH FUND, U.S.A.

Admin and stats byMEDICAL RESEARCH COUNCIL, R.S.A.

SKIN-TO-SKIN CONTACTFROM BIRTH

COMPARED TO CONVENTIONAL INCUBATOR CARE

Reference

RCT of skin-to-skin contact from birth versus conventional incubator care for physiological stabilisation in 1200- and 2199-gram newborns.

Bergman NJ, Linley LL, Fawcus SR.

Acta Paediatrica 2004 Vol 93(6); 779-785

19

Primary hypothesis

SSC (skin-to-skin contact) from birth is superior to incubator care for low birthweight infants

ONLY HABITAT DIFFERS

ResultsMinimisation techniqueensured groups balanced

for confounders.

( n = 34) KMC CMCMean weight 1813g 1866gMean GA 34.2w 35.3wApprop’ GA 65% 64%Male 60% 50%

(p 783)

RControl

Intervention

Research hypotheses

Stabilising

DURING 6h

Stabilised

AT 6 hours

BAILOUT H1a H1b

SCRIP H2a H2b

BAILOUT points ….

“physiological parameters exceeding normal limits, requiring medical assessment and or intervention”

1 Skin temp consistently <35.5oC

2 Heart rate <100; or > 180 bpm

3 Apnoea longer than 20 seconds

4 O2 sats below 89% (x2), (CPAP/60% O2)

5 Blood glucose < 2,6mmol/l, (laboratory) Bergman et al 2004

INSTABILITY

H1b (SPECIFIC)

Doctor Stablesummoned: .

INCUBATOR 92% 8% SKIN-TO-SKIN 17% 83%

Bergman et al 2004


OTHERPROTEST- STRESS SURVIVAL orDESPAIR (SNS)


SEPARATION

THE PLACE MODEL

8% “STABLE”

83% “STABLE”

20

monitors continuously

SCRIP

Heart rate

Oxygen saturation

Respiratory rate

STABILITY

SCRIPSCORE

2 1 0

Heart rate Regular Deceleration to 80-100

Rate <80 or >200 bpm

Respiratory rate

Regular Apnoea <10s, or periodic breathing

Apnoea >10sTachypnoea

>80 pm

Oxygen saturation

Regular >87% Any fall to 80 – 87%

Any fall below 80%

“Stability of Cardio-Respiratory system In Preterm Infants”

Score allocated for a five minute period ofcontinuous observation, maximum six for period

Fischer et al, 1988 STABILITY

“100% SCRIP STABILIY”

S S C C M C

1200g to

2200 g1 - 6h 56% 11%

@ 6h 100% 46%

1200g to

1800g1 - 6h 44% 0%

@ 6h 100% 25%

Stabilisation first 6 hours, average hourly SCRIP score

5.1

5.2

5.3

5.4

5.5

5.6

5.7

5.8

5.9

6

6.1

2nd 3rd 4th 5th 6th

KMC all

KMC <1800

CMC all

CMC <1800

Hourly average of SCRIP score, 2nd to 6th hour

Stabilization 1200g – 1800g

Skin-to-skin

Incubator

INCUBATORS DE-STABILISE

NEWBORNSStabilisation first 6 hours, average hourly SCRIP score

5.1

5.2

5.3

5.4

5.5

5.6

5.7

5.8

5.9

6

6.1

2nd 3rd 4th 5th 6th

KMC all

KMC <1800

CMC all

CMC <1800

SKIN-TO-SKIN

SEPARATION


OTHER PROTEST- STRESS SURVIVAL orDESPAIR (SNS)

Stabilization

Stabilisation first 6 hours, average hourly SCRIP score

5.1

5.2

5.3

5.4

5.5

5.6

5.7

5.8

5.9

6

6.1

2nd 3rd 4th 5th 6th

KMC all

KMC <1800

CMC all

CMC <1800

Bergman et al 2004 CORTISOL

21


SEPARATION


OTHER PROTEST- STRESS SURVIVAL DESPAIR (SNS)

THE PLACE MODEL

DEFENCE

NUTRITION


OTHERPROTEST- STRESS SURVIVAL orDESPAIR (SNS)


SEPARATION

THE PLACE MODEL

DYS-REGULATION

STABILISATION

CORTISOL

PROTEST – DESPAIRcauses

DYSREGULATION

SEPARATION DYSREGULATES

CORTISOL

Premature babies are not in incubators because they are unstable.

Premature babies are unstable because they are in incubators.

REGULATION vs STIMULATION

Expected vs UnexpectedEcologic salience vs Potential threatResource growth vs threat readiness

OXYTOCIN vs CORTISOL HOMEORHESIS vs HOMEOSTASIS

MOTHER vs OTHER

22

NEURODEVELOPMENT

The DNA Behaviour




EPIGENETICS

intricately, inseparablylinked to the right place.

(Alberts 1994)

CORTISOL


CORTISOL


Maternal presence (SSC)regulates preterm physiology.

Clinics in Perinatology,

June 2004, Vol 31(2) page 210

Stanley Graven

Early neurosensory visual

development of fetus and newborn.

“It is a serious mistake to assume that the

principles derived from careful animal studies

do not apply to human infants.

The risk of suppression or disruption of

needed neural processes ...

is very significant and potentially lasts a life time.

NEURODEVELOPMENT

The DNA Behaviour




EPIGENETICS

BIRTH

BABY

BONDING

“needed

neural

processes”

BONDING components

ANS

Upstream

Downstream

EmotionalANS

Social

Physical

23

BONDING components

EmotionalANS

Social

Physical

SEES

Mum’s eyes

Hand TOUCH

Mum’s skin

Skin-to-skin

CONTACT

SENSATIONS THAT WIRE BRAIN

Back FEELS

Mum’s arm

holding

TASTES

Mum’s milk

Ear HEARS

Mum’s voice

SMELLS

Mum’s milk

WARMED on

Mum’s front

MOVES

with Mum

Slide from JILL BERGMAN

a kind of invisible hothouse

BREAST - FEEDING=

BRAIN - WIRING

NEURODEVELOPMENT

The DNA Behaviour




EPIGENETICS

BIRTH

BEYOND BREASTFEEDINGFeed Sleep Cycling

BABY

BONDING

Secure attachment

John Bowlbysecure attachment

“a safe base from which to explore the world”.

Safe HavenSecure baseProximity

maintenanceSeparation

distress

BONDING consequence

EmotionalANS

Social

Physical

Child: Insecureattachment

Adult: AttachmentANXIETY to partner

Adult: Higher CORTISOL andlower immunity

(CD4 cells) Jaremka 2013

CORTISOL

24

NEURODEVELOPMENT

The DNA Behaviour




EPIGENETICS

BIRTH


MOTHERBABY

BONDING Sensitization

Secure attachment

Attuned parenting

SEPARATION

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

PREDATOR

Smell cingulate

FEARFREEZE

+ OXYTOCIN

cingulatesuppressed

Less fearFORAGE

OXYTOCINCORTISOL

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

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

0

5

10

15

20

25

-0.2 0 0.2 0.4 0.6 0.8 1

Maternal Behavior Q-Sort

Ho

urs

of

SS

C i

n In

fan

ts' F

irst

24 H

ou

rs

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

SENSITIZATION

0

5

10

15

20

25

25 27 29 31 33 35 37 39 41 43 45

Maternal Behavior Subscale of the NCATS

Ho

urs

of

SS

C i

n In

fan

ts' F

irst

24 H

ou

rs

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

Predicts cognitive outcome

25

NEURODEVELOPMENT

The DNA Behaviour




EPIGENETICS

BIRTH


MOTHERBABY


Secure attachment

Attuned parenting

SEPARATION

Resilience

RESILIENCE(= STRESS RESISTANCE)

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

Resilience

Secure attachment

Attuned parenting

RESPONSESTRESS

ALLOSTASIS ANY STRESS:PsychologicalNeurological

EndocrineImmune

Resilience

PERCEPTIONS“NEUROCEPTION”

RESPONSESTRESS


EndocrineImmune

Severity of stress uniquely determined by

individual.


RESPONSESTRESS

ALLOSTATIC STATE


EndocrineImmune

HEALTH

elevated activity of mediators,

with return to baseline and no impact on

health.

RESISTANCE / SENSITIVITY


RESPONSESTRESS

ALLOSTATIC STATE


EndocrineImmune

ALLOSTATIC LOAD

HEALTH

elevated activity –sustained over time,

or severe … changes the “set

points” for homeostasis(e.g. increasing blood pressure,

change in cholesterol level)

26

CORTISOL

http://www.imr.no/copewell/work_packages/wp3/en

CORTISOL



RESPONSESTRESS

ALLOSTATIC STATE


EndocrineImmune

ALLOSTATIC LOAD

ALLOSTATIC OVERLOAD

HEALTH

the point at which chronic load results in actual

disease or abnormal conditions.

2ND

KNOCK



RESPONSESTRESS

ALLOSTATIC STATE


EndocrineImmune

ALLOSTATIC LOAD

ALLOSTATIC OVERLOAD

WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY

DISEASEHEALTH

RESILIENCE VULNERABILITY

DISEASEHEALTH

CORTISOLOXYTOCIN



DISEASEHEALTH

CORTISOLOXYTOCIN

27

Noradrenergic neurons from

LOCUS COERULEUS

may activate the whole brain during wakefulness

Awake at birth

AWAKE ON OFF ASLEEP

A primary visual areas,

B somatosensory motor cortex

C primary auditorycortex

D parietal cortex & cerebellum

E m l anterior pre-frontal cortex

Fransson 2007

Smell

Skin contact


FACE RECOGNITIONCENTRE

OXYTOCIN

E prefrontal

A primary visual

B somatosensory

C primary auditory

D parietal& cerebellum

FEARCONTROL

CENTRE

REWARDCONTROL

CENTRE

SOCIALCONTROL CENTRE

OXYTOCINDOPAMINE

CORTISOL

FEARCONTROL

CENTRE

REWARDCONTROL

CENTRE


OXYTOCINDOPAMINE

CORTISOL




DISEASEHEALTH

CORTISOLOXYTOCIN

28

FEARCONTROL

CENTRE

REWARDCONTROL

CENTRE


OXYTOCINDOPAMINE

CORTISOL



DISEASEHEALTH


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

FEARCONTROL

CENTRE

REWARDCONTROL

CENTRE


OXYTOCINDOPAMINE

CORTISOL



DISEASEHEALTH


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

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

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

CORTISOLOXYTOCIN

DISEASEHEALTH



CORTISOLOXYTOCIN

NEURODEVELOPMENT

The DNA Behaviour




EPIGENETICS

BIRTH


SEPARATIONMOTHERBABY


Secure attachment

Attuned parenting

Toxic stress

CORTISOLOXYTOCINResilience

Garner 2011

29

Shonkoff 2012

The basic

science of

pediatrics.

Shonkoff J P et al.

Pediatrics 2012;

129:e232-e246

©2012 by American Academy of Pediatrics

NEURODEVELOPMENT

The DNA Behaviour




EPIGENETICS Positive Stress

• Moderate, short-lived stress responses, such

as brief increases in heart rate or mild changes

in stress hormone levels.


Bad

Good

• An important and necessary

aspect of healthy development

that occurs in the context of

stable and supportive relationships.

High

StressLow

Stress

Tolerable Stress

• Stress responses that could disrupt brain

architecture, but are buffered by supportive

relationships that facilitate adaptive coping.

• Generally occurs within a time-limited period,

which gives the brain an opportunity to recover

from potentially damaging effects.


30

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

“Non-pharmacological reduction of

hypercortisolaemia in preterm infants”(Modi & Glover 1998, Mooncey et al 1997)

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

Stress hormones at such levels are neurotoxic.

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

Cortisol EndorphinMassage slightly lower no change

Soft music no change no change

Skin-to-skin 66% lower 74% lower

SEPARATION CORTISOL

OXYTOCIN

SEPARATION CORTISOL

SKIN-TO-SKINCONTACT

OPPOSITES

“Of a good beginning cometh a good end”John Heywood, Proverbs (1546)

When is the beginning?

SEPARATION CORTISOL

Garner 2011

EARLY YEARS LIFE SPAN

LearningBehavior

Physical well beingMental well being

BERGMAN COMMENTARY – NEWBORNEarly years = early hours & days

“FIRST 1000 MINUTES”

31


LearningBehavior


TOXIC STRESS

EARLY LIFE ADVERSITY

BERGMAN COMMENTARY – NEWBORNMaternal absence is TOXIC STRESS

Toxic Stress





LearningBehavior


TOXIC STRESS


MAKES POORER LinguisticCognitiveEmotionalAdaption

responsivity unhealthy lifestyle

Chronic diseasehealth disparity

BERGMAN COMMENTARY – NEWBORNFor separated preterm newborns, wehave decades of evidence for this.


LearningBehavior


TOXIC STRESS





MASSIVE COST $$$$

BERGMAN COMMENTARY –NEWBORN even more massive ??


LearningBehavior


TOXIC STRESS





MASSIVE COST $$$$

REDUCETOXIC STRESS

BERGMAN COMMENTARY – NEWBORNReducing toxic stress IS VERY EASY !!

Toxic Stress




REDUCETOXIC STRESS


NEURODEVELOPMENT

The DNA Behaviour




EPIGENETICS

BIRTH




Secure attachment

Attuned parenting

Disordered attachment

Toxic stress

Insensitiveparenting

Resilience Vulnerability

CORTISOLOXYTOCIN

32

NEURODEVELOPMENT

The DNA Behaviour




EPIGENETICS

BIRTH




Secure attachment

Attuned parenting


DISEASEHEALTH


Toxic stress


“buffering

protection of

adult support”

NEURODEVELOPMENT

The DNA Behaviour




EPIGENETICS

BIRTH



Vulnerability

DISEASE


Toxic stress


NEURODEVELOPMENT

The DNA Behaviour



EPIGENETICS


BONDING ATTACHMENT

MRI HRVEEG

STRESS RESPONES

RESILIENCE

DOHAD

(MAL) ADAPTATION

EPIGENETICS

GENE X ENVIRONMENT

GENETIC VARIANTS

HOSPITAL ACQUIRED INFECTIONIMMUNITY

SLEEP PHYSIOLOGY

GUT FUNCTIONMICROBIOTA

“STABILITY”

TRANSITION

LONG TERM FOLLOW-UP

NEUROENDOCRINE BEHAVIOURS

MATERNAL NEUROPLASTICITY

ENVIRONMENT WHAT IS THE EFFECT OF MATERNAL ABSENCE ON …

MORTALITY

NEURODEVELOPMENT

The DNA Behaviour



EPIGENETICS


HOSPITAL ACQUIRED INFECTIONIMMUNITY

GUT FUNCTIONMICROBIOTA LONG TERM FOLLOW-UP

ENVIRONMENT WHAT IS THE EFFECT OF MATERNAL ABSENCE ON …

MORTALITY

33

NEURODEVELOPMENT

The DNA Behaviour




EPIGENETICS

the key toneurodevelopment …

RIGHT PLACE !!

MOTHER

is the key toneurodevelopment …… because she is the

RIGHT PLACE !!



BIRTH


MOTHERBABY


Secure attachment

Attuned parenting

Resilience

HEALTH

A mother and baby

DYADare asingle

psychoneurobiologicalorganism

BIRTH BONDING Sensitization Toxic stress

IT MATTERS

HOW WE ARE BORN


SEPARATION

Vulnerability

DISEASE


Toxic stress


SEPARATION

VIOLATESthe innate agendaof mother and baby

ZERO

SEPARATION

NEURODEVELOPMENT

The DNA Behaviour




EPIGENETICS

BIRTH




Toxic stress


34

NEURODEVELOPMENT

The DNA Behaviour




EPIGENETICS

BIRTH




Secure attachment

Attuned parenting


DISEASEHEALTH


Toxic stress


NEURODEVELOPMENT

The DNA Behaviour




EPIGENETICS

An ecobiodevelopmental framework for early childhood policies and programs.

Shonkoff J P et al. Pediatrics 2012;129:e232-e246

©2012 by American Academy of Pediatrics

Innovative strategies …… reduce toxic stress

Creative new strategies

“compelling need for bold new strategies”

National Research Council 2000 Shonkoff 2010

“compelling need for bold new strategies”

35

Skin-to-Skin

Contact

Attachment

Bonding

Breast-feeding

Regulation

An ecobiodevelopmental framework for early childhood policies and programs.


Attachment

Bonding

Breast-feeding

Skin-to-Skin

Contact

www.skintoskincontact.com

INTRODUCTION

“It is easier to build strong children

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

PERINATAL NEUROSCIENCE and SKIN-TO-SKIN CONTACT

Reflections for practice

“It is easier to build strong children

than to repair broken men.”

ZERO SEPARATION

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