39
1 Dr Nils Bergman ”M.D., D.C.H., M.P.H., Ph.D.” Cape Town, South Africa www.skintoskincontact.com Neurodevelopmental Approach to “needed neural processes” NEURODEVELOPMENT The DNA Behaviour EVOLUTIONARY BIOLOGY The Neuroscience of Birth & Breastfeeding The Brain EPIGENETICS “except in the light of mother’s body.” NEURODEVELOPMENT The DNA Behaviour EVOLUTIONARY BIOLOGY ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESS ADAPTATION The Neuroscience of Birth & Breastfeeding The Brain EPIGENETICS EXPECTED UNEXPECTED “buffering protection of adult support” NEURODEVELOPMENT The DNA Behaviour EVOLUTIONARY BIOLOGY ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESS ADAPTATION The Neuroscience of Birth & Breastfeeding The Brain EPIGENETICS BIRTH SEPARATION MOTHER BABY BONDING Sensitization Vulnerability DISEASE Disordered attachment Toxic stress Insensitive parenting ZERO SEPARATION NEURODEVELOPMENT The DNA Behaviour EVOLUTIONARY BIOLOGY ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESS ADAPTATION The Neuroscience of Birth & Breastfeeding The Brain EPIGENETICS BIRTH SEPARATION MOTHER BABY BONDING Sensitization Disordered attachment Toxic stress Insensitive parenting NEURODEVELOPMENT The DNA Behaviour EVOLUTIONARY BIOLOGY ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESS ADAPTATION The Neuroscience of Birth & Breastfeeding The Brain EPIGENETICS BIRTH BEYOND BREASTFEEDING Feed Sleep Cycling SEPARATION MOTHER BABY BONDING Sensitization Secure attachment Attuned parenting Resilience Vulnerability DISEASE HEALTH Disordered attachment Toxic stress Insensitive parenting

Neurodevelopmental The Neuroscience of Birth ... · breastfeeding pattern, neonatal weight gain, and the dynamics of lactation. Doucet 2012 In the ‘‘scentless breast’’ condition,

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Page 1: Neurodevelopmental The Neuroscience of Birth ... · breastfeeding pattern, neonatal weight gain, and the dynamics of lactation. Doucet 2012 In the ‘‘scentless breast’’ condition,

1

Dr Nils BergmanrdquoMD DCH MPH PhDrdquo

Cape Town South Africa

wwwskintoskincontactcom

Neurodevelopmental Approach to

ldquoneeded neural

processesrdquo

NEURODEVELOPMENT

The DNA Behaviour

EVOLUTIONARY BIOLOGY

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

ldquoexcept in the light

of motherrsquos bodyrdquo

NEURODEVELOPMENT

The DNA Behaviour

EVOLUTIONARY BIOLOGY

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

EXPECTED UNEXPECTED

ldquobuffering

protection of

adult supportrdquo

NEURODEVELOPMENT

The DNA Behaviour

EVOLUTIONARY BIOLOGY

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

BIRTH

SEPARATIONMOTHERBABY

BONDING Sensitization

Vulnerability

DISEASE

Disordered attachment

Toxic stress

Insensitiveparenting

ZERO

SEPARATION

NEURODEVELOPMENT

The DNA Behaviour

EVOLUTIONARY BIOLOGY

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

BIRTH

SEPARATIONMOTHERBABY

BONDING Sensitization

Disordered attachment

Toxic stress

Insensitiveparenting

NEURODEVELOPMENT

The DNA Behaviour

EVOLUTIONARY BIOLOGY

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

BIRTH

BEYOND BREASTFEEDING Feed Sleep Cycling

SEPARATIONMOTHERBABY

BONDING Sensitization

Secure attachment

Attuned parenting

Resilience Vulnerability

DISEASEHEALTH

Disordered attachment

Toxic stress

Insensitiveparenting

2

BREASTFEEDING Feed Sleep Cycling

BONDING Sensitization

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

BRAIN

WIRING

Neurodevelopmental Approach to

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

BRAIN

WIRING

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

WIRE BABY There are ldquoneeded neural processesrdquo

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

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

3

Simulated birth (rat) Simulated birth (rat)

Simulated birth (rat)

No compression

Wrong smell

Nil 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

DOUCETThe secretion of Areolar (Montgomeryrsquos) Glands from Lactating Women Elicits Selective Unconditional Responses in Neonates

ldquohellip breast chemosignalsactivate oral activity on the nipple that releases a cascade of behavioral neural neuroendocrineand endocrine processes in the newborn and the motherrdquo

Doucet 2009 17

The secretion of Areolar(Montgomeryrsquos) Glands

ldquoIn early ontogeny the sleeping brain may thusremain sentient of an organismrsquos odor environmentrdquo

Doucet 2009 18

4

Fewer AG delayed grasp

Fewer AG Slower latch

Fewer AG Weaker suck

Fewer AG More weight loss day 3 of life

Fewer AG Delayed onset of lactation

Primip high AG 23 days Primip low AG 31 days

Difference p lt0001

An overlooked aspect of the human breast Areolar glands in relation with

breastfeeding pattern neonatal weight gain and the dynamics of lactation

Doucet 2012

In the lsquolsquoscentless breastrsquorsquo

condition all infants were

exposed to the motherrsquos breast

fully covered with a perfectly

transparent and airtight plastic

film (polypropylene)

( the habitual visual scene of

the breast devoid of

corresponding odors )

(1) lsquolsquoBreastrsquorsquogroup (fully

uncovered motherrsquos breast)

(2) lsquolsquoNipplersquorsquogroup (all remaining

parts covered with plastic film)

(3) lsquolsquoAreolarsquorsquogroup (remainder of

the breast and nipple covered)

(4) lsquolsquoMilkrsquorsquogroup (milk smeared

on plastic covered breast)

5

lsquolsquoBreastrsquorsquogroup 0102

more than

lsquolsquoAreolarsquorsquogroup 0038

more than

lsquolsquoMilkrsquorsquogroup 0035

Grey bar ndash odourless

plastic film

Black ndash pooled odors

They displayed significantly longer global oral activity

when facing any of the odorous breast with opened

eyes the three other conditions being equivalent

odorous breast opened eyes 1327

odorous breast closed eyes 992

scentless breast opened eyes 663

scentless breast closed eyes 839

hellip only male newborns opened their eyes longer in

response to odorous breast conditions than to the

scentless condition

(0654 vs 0425 plt01)

Related experiments indicate however that the

chemical cues that attract rat pups to the nipples

are not produced in that region Rather initial

nipple orientation is elicited by the odor of

amniotic fluid and saliva that the mother spreads

on her ventrum while grooming herself during

parturition [7]

Babies more often spontaneously selected a breast

treated with a small amount of their own AF applied to

the nippleareola region than the alternative untreated

breast during tests beginning several minutes after

parturition [112]

These results are corroborated by a study in which 2-

day-old infants were offered a simultaneous choice

between two gauze pads the length of time oriented

to the odor of their AF was reliably greater than that

towards an odorless stimulus pad [92]

PSN envisions a community that embraces its mothers and babies and

values the unique

opportunity at birthto impact the physical and emotional

well-being of the newborn

Target 1 for 2005

Report that 65 of infants are placed and remain in

direct skin to skin contactwith their mothers

for at least one hourduring the first 3 hours after birth

6

Skin-to-skin and breastfeeding (4)

0

10

20

30

40

50

60

70

80

90

100

3Q05 4Q05 1Q06 2Q06 3Q06 4Q06 1Q07 2Q07

Breastfeeding intention Skin-to-skin one hour Breastfeeding at discharge

Used with permission Ruth Stanhiser MD

Babies breastfeeding

Mothers intending to breastfeed

Breastfeeding by the NeonateRegistration by skin-to-skin contact

More skin-to-skin more breastfeeding

Thomson 1979

E Early SSC first hourL Late contact next day2 2 hourly feeds from birth4 4 hourly feeds from birth

Group Brf at 12 w Brf duration (days)

2E 643 182 (14 - 392)4E 556 140 (14 ndash 322)2L 556 112 (10 ndash 294)4L 462 77 (11 ndash 280)

Salariya 1978

7

DEFENSE NUTRITION REPRODUCTION

HORMONES NERVES MUSCLES

DEFENSE NUTRITION REPRODUCTION

HORMONES NERVES MUSCLES

= BREASTFEEDING

SAFE

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

WIRE MOTHER

NEURODEVELOPMENTThe DNA Behaviour

EVOLUTIONARY BIOLOGY

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

BIRTH

BEYOND BREASTFEEDING Feed Sleep Cycling

MOTHERBABY

BONDING Sensitization

Secure attachment

Attuned parenting

SEPARATION

OXYTOCIN

8

OXYTOCIN

OXYTOCIN comes from

Cervical dilatation

Skin-to-skin contact

Breastfeeding

Eye-to-eye contact

Effects of doula care

No doula DoulaUSA (Kennell et al 1991)

Epidural 55 8Caesarean section 18 8Forceps delivery 26 8Fetal distress 24 10

ldquoIf a Doula was a drug it would be unethical

not to use itrdquoDr John Kennell

1922 -2013Marshall Klaus amp John Kenell

EARLY CHILDHOOD DEVELOPMENT ECD

ldquoFirst 1000 daysrdquo =gestation 270year one 365year two 365total 1000 days

Resilience Vulnerability

DISEASEHEALTH

EARLY CHILDHOOD DEVELOPMENT ECD

ldquoFirst 1000 daysrdquo =

Resilience Vulnerability

DISEASEHEALTH

First 1000 sec = 16 minutes = 1st hourFirst 1000 min = 166 hours = 1st day First 1000 hrs = 1st six weeks

DOULA-ldquoA WOMAN SERVING WOMENrdquo BIRTH SUPPORT COMPANION

KANGAROO CARE amp DOULA = ldquoKANGAROULArdquo

Resilience Vulnerability

DISEASEHEALTH

9

DOULA and KANGAROULA

DOULA protects

OXYTOCINduringlabour

KANGAROULA protects

OXYTOCINafter birth

lsquothe first 1000 minutesrsquolsquoprevious 1000 minutesrsquo

BIRTH

DOULA and KANGAROULA

-1000 min

BIRTH

+1000 min

DOULA and KANGAROULA

-1000 min

BIRTH

+1000 min 1000 days

OXYTOCIN Zero separation

Caesarean

Separation

Breastfeeding

Zero separation

DOULA and KANGAROULA

-1000 min

BIRTH

+1000 min 1000 days

OXYTOCIN Zero separation

CORTISOL Enemy of oxytocin Stress

White coat

Sarcasm

Hunger

thirst

SEPARATION

Bathing

Noise

Lights

LithotomyWeighing

Crowds

SEPARATION

Perfume

rdquogood nightrsquos sleeprdquo

Birth Transition ParentingLabourPregnancy

DOULA

KANGAROULA

Prematurity Attachment Parenting

MOTHERSUPPORT

NEWBORNSUPPORT

Counselling Counselling

Breastfeeding

During the first 24 hours of life newborns ingested 15 g of milk

10

Milk making NUTRITION

HypothalamusPituitaryPROLACTIN

Maternal ferocityPROTECTION

OXYTOCIN Gaze increase BONDING

OXYTOCINCingulate Suppressed

REGULATION

AmygdalaCHOLECYSTOKININ Emotion satiety

HypothalamusPituitary

Cingulate

Amygdala

ldquoThe newborn may

appear helpless but

skin-to-skin contactstimulates prolactin

ensures nutritionstimulates oxytocin

ensures protectionstimulates cholecystokinin

ensures wellbeing bonding

The first hours after birth are a

CRITICAL PERIOD

mutual psycho-neuro-physiological

caregivers

Critical period concept

ldquoWindows of opportunity in early life when a childrsquos brain is exquisitely primed to receive sensory input in order to develop more advanced neural systemsrdquo

a motherrsquos brain hellip

SENSITIZATION

DOULA and KANGAROULA

DOULA protects

OXYTOCINduringlabour

KANGAROULA protects

OXYTOCINafter birth

lsquothe first 1000 minutesrsquolsquoprevious 1000 minutesrsquo

BIRTH

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

WIRE MOTHER

OXYTOCIN

11

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDINGON-GOING

S S C

WIRE TOGETHER

OXYTOCIN

hellip infant cues - suckling vocalisation and tactile stimulation - stimulate

OXYTOCINrelease in the hypothalamus which may result in the activation of the dopaminergic reward pathway leading to behavioural reinforcement

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

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

DISEASEHEALTH

CORTISOLOXYTOCIN

The psychology of human parent-infant relationships

Parenting is regulated by key hormones and neurotransmitters

Neuroanatomical circuits of parenting

Integrative physiology of normal parenting behaviours

Brain imaging of human parent-infant relationships

The neurobiology of empathy and parenting

Conclusions and critical summary

(Swain et al 2007)

12

FEARCONTROL

CENTRE

REWARDCONTROL

CENTRE

SOCIALCONTROL CENTRE

OXYTOCINDOPAMINE

CORTISOL

EMOTIONCONTROL CENTRE

WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY

DISEASEHEALTH

RESILIENCE VULNERABILITY

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

DOULA and KANGAROULA

-1000 min

BIRTH

+1000 min 1000 days

OXYTOCIN Zero separation

Protect OXYTOCINBefore and after

BIRTH

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDINGON-GOING

S S C

WIRE TOGETHER

Protect OXYTOCINBefore and after

BIRTH

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDINGON-GOING

S S C

WIRE SUCKLING

BREASTFEEDING Feed Sleep Cycling

BONDING Sensitization

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

BRAIN

WIRING

Neurodevelopmental Approach to

Alberts SUCKLING versus FEEDING

DUAL INGESTION SYSTEMS

13

300 mya 200 mya 100 mya 50 mya 300 mya 200 mya 100 mya 50 mya

Amniotes

Synapsids

Cynodonts

Mammaliaformes

PlacentalsMammals

ANCESTRAL STATE

hellip intoMATURE FEEDING

300 mya 200 mya 100 mya 50 mya

WATER

EGGS

Hatch withTEETH

ANCESTRAL STATE

hellip intoMATURE FEEDING

eg TURTLES

CROCODILES DINOSAURS

REPTILES

300 mya 200 mya 100 mya 50 mya

Epibubic bone = pouch care

hellip intoMATURE FEEDING

Amniotes

Synapsids

Cynodonts

Mammaliaformes

Smaller eggs longer in body

The AMNIOTE EGGextra membranes

Copes with AIR

PlacentalsMammals

Viviparity = immature

ENDOTHERMY

MOISTUREfor eggs

Diphyodontism

300 mya 200 mya 100 mya 50 mya

hellip intoMATURE FEEDING

Amniotes

Synapsids

Cynodonts

Mammaliaformes

PlacentalsMammals

ENDOTHERMY

MOISTUREfor eggs

LACTOSE added(apocrine glands)

NUTRIENTSAntimicrobials

LACTATION

SUCKLINGFEEDING

200 million years

Diphyodontism

300 mya 200 mya 100 mya 50 mya

hellip intoMATURE FEEDING

Amniotes

Synapsids

Cynodonts

Mammaliaformes

PlacentalsMammals

ENDOTHERMY

MOISTUREfor eggs

LACTOSE added(apocrine glands)

NUTRIENTSAntimicrobials

LACTATION

SUCKLINGFEEDING

200 million years

DUAL INGESTION SYSTEMS

100 million years

14

DUAL INGESTION SYSTEMS DUAL INGESTION SYSTEMS

SUCKLING WEANING FEEDING

Lactase Digestive enzymes

FEEDING SUCKLING

Influence of SMELL None Totally dependent

Motor mechanism Chewing ndash different

muscles

Suckling ndash different circuits

INSULIN Increases weight No effect

GHRELIN Increases weight No effect

LEPTIN Decreases intake No effect

CHOLECYSTOKININ Decreases intake No effect

AMPHETAMINE Decreases appetite Increases suckling

SEROTONIN Agonist improves feeding Antagonist improves suck

SATIETY Infant determined Maternal supply determine

FEEDING SUCKLING

DISRUPTION ROBUST VERY SENSITIVE

Must have right conditions

Pup-in-a- cup - And STIMULI

separated and fed by tube

From day 2 off life

Starts to feed normally d21 2 days gavage or other

no longer suckles

If starved for 24 hours pup

at d3 will feed food from

floor

(Can be maintained by

smell and other stimuli)

Pup-in-a- cup -

separated and fed by tube

From day 2 off life

Starts to feed normally d21

15

PMA 28 40 64 1y 2y

Nilsrsquo IDEALIZED VIEW

PMA 28 40 64 1y 2y

Nilsrsquo IDEALIZED VIEW

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

Reflections for practice

Suckling and Feeding areNOT THE SAME

16

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDINGON-GOING

S S C

WIRE SUCKLING

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

ON-GOING

S S C

WIRE NEURONS

Up to 6 months milk is 74 fat

96 of this is TRIGLYCERIDE

TRIGLYCERIDE Left glycerol Right palmitic acid oleic acid alpha-linolenic acid

In phosphoglycerides glycerol molecule same

two fatty acids esterified

Phospholipids area major component of all biological membranes

Sphingomyelin particularly concentrated in BRAIN major part of MYELIN

TRIGLYCERIDE

MYELIN

Dendirification and myelinisation peaks occurat 2 and 6 monthsis maximal at one year

At one year human milk has less proteinbut MORE TRIGLYCERIDE

FATTY ACIDS ARESPECIES SPECIFIC

Up to 6 months milk is 74 fat

but after 12 months it is 107

17

ldquocherry pickrdquo

Breastfeed time years school Incomelt 1 month 109 R$ 1238gt 6 month 121 R$ 1915

Group IQ 376 points higher from breatsfeeding

BREASTFEEDINGAND BREAST MILK

INCREASE IQ

BOTTLE FEEDINGamp FORMULA

DECREASE IQ

18

Be sure the wet nurse has plenty of milk because if she lacks it she may give the babymilk of a goat or sheep or some other animalbecause the child nourished on animal milkdoes not have perfect wits like one fed on womanrsquos milk and always looks stupid and vacant and not right in the head

14th century Tuscan text

Conceptual changeDyad careBreast first hour

even CaesareanContinuous SSC

DISCONTINUEGiving waterGlucose waterInfant formulaSeparationPacifier (dummy)

CHANGE POLICY Canrsquot change

biology

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

ON-GOING

S S C

WIRE NEURONS

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C WIRE

TIMING

(behavior)

19

Not so much duration

or density of any sleep stage

or number of sleep stage episodes but

cycling between quiet sleep

and active sleepis what is important

REMREM REM

NREM NREM

This is a healthy sleep pattern

This is a very good cycling pattern

(thanks to Susan Ludington-Hoe)

REMREM REM

NREM NREM

1st hour 2nd hour

So in every hour you would like

to see an EEG pattern that shows this

REM

NREM

REM

NREM

REM

NREM

State

HR

RR

REM Sleep is supposed to be

somewhat active so

HR increases and RR is irregular

SLEEP CYCLING ndashSeparation vs contact

In separation bull Dissociated statebull No cycling chaotic pattern

48 hour baseline chaotic pattern of

activity and quiet HR amp RR

SLEEP CYCLING ndashSeparation vs contact

In SSC bull Normal cyclingbull Non-chaotic pattern

48 hour baseline chaotic pattern of

activity and quiet HR amp RRPre-KC SSC

20

modulates state organisationelicits emotional behavioursactivates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL

Schaal 2004 115

DOUCETThe secretion of Areolar (Montgomeryrsquos) Glands from Lactating Women Elicits Selective Unconditional Responses in Neonates

ldquohellip breast chemosignalsactivate oral activity on the nipple that releases a cascade of behavioral neural neuroendocrineand endocrine processes in the newborn and the motherrdquo

Doucet 2009 116

The secretion of Areolar(Montgomeryrsquos) Glands

ldquoIn early ontogeny the sleeping brain may thusremain sentient of an organismrsquos odor environmentrdquo

Doucet 2009 117

REM

NREM

A skin-to-skin contactsession SHOULD NOT be less than one hour

or 90 minutes

SLEEPING

amp

CONTAINING

FEEDING ampHANDLINGfeed

sleep

HO

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C WIRE

TIMING

(behavior)

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C WIRE

STOMACH

21

STATE organization

Feeding frequency

SLEEP cycling

BRAIN

WIRING

How often should a neonate feed

CNS

ENS

ANS

InternalSomaticenvironment

CNS cortical subcortical(also to PNS)

ANS emotional limbic brain(incl SNS)

ANS myelinated vagus (NA)

ANS unmyelinated vagus (DMC)sub-diaphragmatic

ENS submucous plexusmyenteric plexus

122

The digestive system is endowed with its own local nervous system referred to as the enteric or intrinsic nervous system

The magnitude and complexity of the enteric nervous system is immense - it contains as many neurons as the spinal cord

ENTERIC NERVOUS SYSTEM

123

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

FEEDBACK LOOPS

CNS

ENS

ANS

InternalSomaticenvironment

124

125 126

22

Fetal stomach appears 4 weeks GABy 11 weeks wall capable of muscular

contraction

ldquoPatterns of antropyloric motilityin fed healthy preterm infantsrdquo

the neuroregulatory mechanisms responsible for the coordination of antro-pyloric motility and gastric emptying are

well developed by 30 weeks of PMAHassan 2002 127

Hydrochloric acidimportant for activation of pepsinogen

inactivation of microorganisms such as bacteria

Pepsinogenactivated by acid into active pepsin

responsible for the stomachs ability to initiate digestion of proteins

Chymosinis an enzyme whose role is to curdle or

coagulate milk in the stomach a process of considerable importance in the very young animal

128

Chymosinmakes the milk into ldquocheeserdquohalfway between liquid and solidstomach empties in 60 minutes

milk

129

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

FEEDBACK LOOPS

130

EVIDENCE FORFEEDING FREQUENCY

Edmond 2006 131

Breastfeeding and motherrsquos milkStrong and consistent evidence 132

23

Cup feeding versus bottle feedingCup feeding higher breastfeeding

greater stability133

Only case series Insufficient evidence

No mention of

stomach capacity134

EVIDENCE FORSTOMACH CAPACITY

Edmond 2006 135

0

05

1

15

2

25

3

35

4

0 10 20 30 40 50 60 70 80

volume ingested

fee

din

g f

req

ue

nc

y

Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml

StandardCARE3 hourlyschedule

136

KEY QUESTION

WHAT IS THE

STOMACHVOLUMEOF THE

NEONATE 137 Sase 2005

ldquoOntogeny of gastric emptying patternsin the human fetusrdquo

138

24

Goldstein 1987

ldquoGrowth of the Fetal Stomach in Normal Pregnanciesrdquo

139 Goldstein 1987

Length

Transverse

AP diameter

Using +2SD

140

Formula for calculation of stomach capacity (Charles Bradshaw UCT)Assumptions the stomach can be approximated by dividing into three sections namely a ellipsoidal hemisphere an ellipsoidal cylinder and a skewed ellipsoidal cone Variables a = anteroposterior radius t = transverse radius l = length stomachRelations the height of the cone and the hemisphere are both the same as lsquoarsquo

Ellipsoid = 43 Pi r1r2r3 = 43 Pi a a t therefore volume of hemisphere = 23 Pi a a t

Cylinder = Area of base height = (Pi a t ) ( l - 2a )Skewed cone = 13 base height = 13 Pi a t aTotal volume = 23 Pi aat + Pi a t (l- 2a) + 13 Pi a t a

=Pi atl -Pi a at= Pi a t(l-a)

Goldstein and Sase dataStomach capacity at term 10 - 15 ml

BRADSHAW formula

141

Assumption 25 kg baby 33w GA

requiring 150 mlkgday = 375 ml

45 MIN CYCLES ( 32 cyclesday)

12 ML PER CYCLE = 384 ml142

Newborn stomach volume

Gastric volumes at birthCorrelated with gastric pH

gastrin and somatostatin

ldquofetus drinks 10 ml portions of amniotic fluid helliprdquo

Widstrom 1988 143

Only recent study locatedldquoAutopsyrdquo capacity was determined

in Indian post-mortem studies

100 autopsies (63 SB 37 ENND)Tied at cardia and pylorus filled withwater emptied amp measured repeatedldquohellip obliteration of the gastric curvaturesrdquoldquodue care to minimize stretch artifactsrdquo

Naveed 1992

ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo

144

25

Infants above 2500g onlyAve Range

Stillborn (n 11) 196 ml (10-35)Early death (n 9) 178 ml (10-25)All cases (n 20) 188 ml

Naveed 1992

ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo

145 146

KERNESSUK 1997 (Russian)

Postmortem in situ measures(applied Bradshaw formula)

AveNewborn (n 11) 15 ml2 months (n 11) 35 ml2-4 m (n 10) 50 ml4-6 m (n 8) 100 ml

Known references with data

Scammon and Doyle 1920

Zuccarellirsquos method stomach filled at autopsy to ldquoa pressure of between

15 and 20 centimeters of waterrdquo

Scammon 1920

ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo

147

Anatomic capacity was determined in post-mortem studies

Main data set Alliot 1905 (n 25)Scammon own cases (n 13)

30 ndash 35 ml at birth ndashalmost regardless of birth weight

Scammon 1920

ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo

148

Zangen S et al Rapid maturation of gastric relaxation in newborns

Pressures (mmHg)

Balloon inflates to

15 ml no increase

functional capacity

149

Zangen S et al Rapid maturation of gastric relaxation in newborns

Pressures (mmHg)

Balloon inflates to

15 ml no increase20 ml pressure OK

physiologicalcapacity hellip 150

26

EVIDENCE (NBn 111009)

Author Capacity NoteSase 10-15 ml Live term fetusGoldstein 10-15 ml Live term fetusWidstrom 10 mls Live newbornZangen 20 mls Live (pressure)

Naveed 20 mls Autopsy (SB)20 mls Autopsy (ENND)

Kernessuk 15 mls Autopsy (in situ)Scammon 30-35 ml Autopsy (water

(Alliot) pressure)151

PROPOSAL

The CAPACITY of aweek old babyrsquos stomach is

approx 20 ml152

0

05

1

15

2

25

3

35

4

0 10 20 30 40 50 60 70 80

volume ingested

fee

din

g f

req

ue

nc

y

Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml

StandardCARE3 hourlyschedule

MOTHERNATURE

1 hourlyschedule

153

PHYSIOLOGICAL CAPACITY

RECEPTIVE CAPACITY of stomach

INGESTIVE CAPACITY of BABY

FUNCTIONAL CAPACITY

154

PROPOSAL

The FEEDINGFREQUENCY of theNEONATE is

approx 60 min155

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

BRAIN CYCLING

STOMACH FILLING amp EMPTYING

REMNR1NR2NR3NR4

156

27

Normal physiology of theEnteric Nervous System

ldquoSmall and frequent feeds according to the sleep cyclerdquo

The ldquonicherdquo (occupation) of a neonate (Alberts)

BOND FEED

SLEEP SLEEP

PLAY FEED

157

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

FEEDING SUCKLING

Influence of SMELL None Totally dependent

Motor mechanism Chewing ndash different

muscles

Suckling ndash different circuits

INSULIN Increases weight No effect

GHRELIN Increases weight No effect

LEPTIN Decreases intake No effect

CHOLECYSTOKININ Decreases intake No effect

AMPHETAMINE Decreases appetite Increases suckling

SEROTONIN Agonist improves feeding Antagonist improves suck

SATIETY Infant determined Maternal supply determine

FEEDING SUCKLING

Influence of SMELL None Totally dependent

Motor mechanism Chewing ndash different

muscles

Suckling ndash different circuits

INSULIN Increases weight No effect

GHRELIN Increases weight No effect

LEPTIN Decreases intake No effect

CHOLECYSTOKININ Decreases intake No effect

AMPHETAMINE Decreases appetite Increases suckling

SEROTONIN Agonist improves feeding Antagonist improves suck

SATIETY Infant determined Maternal supply determine

Current dogmaTHE BABY KNOWS

WHEN IT HAS HAD ENOUGH

PROBABLY NOT

WHAT IS THE

STOMACH VOLUME OF THE

PREMATURE

161

Assume low resilience

Assume proportionality

162

28

The CAPACITY of alow birthweight premfrom 20ml 3000g

= 0007 x BWt (g)

1kg x 0007 = 7mls2kg x 0007 = 14mls

163

Gastric overfilling syndrome

164

75 ml per feeding ASSUMPTION

IMMATURE OR OVERWHELMED

many aspects of gastrointestinalmotility are immature in the neonate

Zangen S et al Rapid maturation of gastric relaxation in newborns

A balloon in stomachcan fill to 76 mls

What does the stomach ndashwithout a balloon ndashdo to 76 mls

REFLUX PRESUME each feedapproximately 75 mls

GER

bull Sudden outbursts of crying

bull Awakens in pain

bull Related to feedings

bull Not easily comforted

bull ldquoI know baby hurtsrdquo

bull Sour burps throaty noises

bull Best when upright

Clues to GER

Dr W Sears

29

Mitchell 2001

Kerstin Uvnaumls-Moberg

Food in duodenum

AMYLINreleased

Closes pylorus

Duodenumempty

Pylorusopens

ldquoFeed intolerancerdquo hellip hellip or VOLUME intolerance

HYPOGLYCAEMIA

A babies stomach empties in60 minutes

Blood sugarmay fall hellip

after 90 minutes Options

30

METABOLIC ADAPTATION

SSC started in the first 20 minutes after birth

SSC CotBlood glucose (1 hr) 317 256Base excess drop 34 18

(Christenson 1992)0h 1h 2h 3h 4h 2 days

App

roxim

ate

GLUCOSE

SSC Glucose production = Glucose consumption

Separation

SNS stress Glucose consumption INCREASE

PSNS dissociation Glucose production DECREASE

HYPOGLYCEMIA

SSC Cot

Blood glucose (1 hr) 317 256

0h 1h 2h 3h 4h 2 days

App

roxim

ate

GLUCOSE

SSC Glucose production = Glucose consumption

Separation PSNS dissociation

Glucose production DECREASE

HYPOGLYCEMIA

SSC Cot

Blood glucose (1 hr) 317 256

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

NEURODEVELOPMENTThe DNA Behaviour

EVOLUTIONARY BIOLOGY

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

BONDING ATTACHMENT

MRI HRVEEG

STRESS RESPONES

RESILIENCE

DOHAD

(MAL) ADAPTATION

EPIGENETICS

GENE X ENVIRONMENT

GENETIC VARIANTS

HOSPITAL ACQUIRED INFECTIONIMMUNITY

SLEEP PHYSIOLOGY

GUT FUNCTIONMICROBIOTA

ldquoSTABILITYrdquo

TRANSITION

LONG TERM FOLLOW-UP

NEUROENDOCRINE BEHAVIOURS

MATERNAL NEUROPLASTICITY

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

MORTALITYMETABOLISM

0h 1h 2h 3h 4h

PSNS (vagal)

App

roxim

ate

GLUCOSE

1 HOURLY Milk feed

1 HOURLY Milk feed

1 HOURLY Milk feed

1 HOURLY Milk feed

LACTOSE

METABOLISM

31

0h 1h 2h 3h 4h

PSNS (vagal) SYMPATHETIC STRESS

App

roxim

ate

GLUCOSE

LACTOSE FATGLYCOGEN

METABOLISM

4 HOURLY Milk feed

0h 1h 2h 3h 4h

PSNS (vagal) SYMPATHETIC STRESS

App

roxim

ate

GLUCOSE

4 HOURLY ALLOSTATIC STATELACTOSE FATGLYCOGEN

METABOLISM

4 HOURLY Milk feed

HEALTH DISEASE

EXPECTED UNEXPECTED

NEURODEVELOPMENTThe DNA Behaviour

EVOLUTIONARY BIOLOGY

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

BONDING ATTACHMENT

MRI HRVEEG

STRESS RESPONES

RESILIENCE

DOHAD

(MAL) ADAPTATION

EPIGENETICS

GENE X ENVIRONMENT

GENETIC VARIANTS

HOSPITAL ACQUIRED INFECTIONIMMUNITY

SLEEP PHYSIOLOGY

GUT FUNCTIONMICROBIOTA

ldquoSTABILITYrdquo

TRANSITION

LONG TERM FOLLOW-UP

NEUROENDOCRINE BEHAVIOURS

MATERNAL NEUROPLASTICITY

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

MORTALITYMETABOLISM

Weight gain 1st week

predicts OBESITYat 30 years

Large volume feedsstretched stomach=

doubled absorptivecapacity as adult

Importance

Programming ndash early life chronic disease

32

RESISTANCE SENSITIVITY

PERCEPTIONSldquoNEUROCEPTIONrdquo

RESPONSESTRESS

ALLOSTATIC STATE

ALLOSTASIS

ANY STRESSPsychologicalNeurological

EndocrineImmune

ALLOSTATIC LOAD

ALLOSTATIC OVERLOAD

WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY

DISEASEHEALTH

RESILIENCE VULNERABILITY

RESISTANCE SENSITIVITY

PERCEPTIONSldquoNEUROCEPTIONrdquo

RESPONSESTRESS

ALLOSTATIC STATE

ALLOSTASIS

ANY STRESSPsychologicalNeurological

EndocrineImmune

ALLOSTATIC LOAD

HEALTH

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

Gastric overfilling syndrome

189

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

33

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

Only case series Insufficient evidence

No mention of

stomach capacity196

Baby weight freq reqrsquod size actual

2kg baby 4hrly ~ 320 ml6 = 53ml 14ml

15 baby 3hrly ~ 240 ml8 = 30ml 10ml

10 baby 2hrly ~ 160 ml12 = 13ml 7ml

Standardised from20ml capacityfor 3kg baby( x 0007)

197

0

10

20

30

40

50

60

70

80

90

13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w

LINEAR

TERM

PREM

198

34

0

10

20

30

40

50

60

70

80

90

13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w

LINEAR

TERM

PREM

199

Clues to GER

ldquoI know baby hurtsrdquo

Gastric overfilling syndrome

Excessive volumesreflux aspiration colic

Excessive time intervalhypoglycaemia

Adaptationsdiabetic diathesis obesity

200

Developmental Care of the Enteric Nervous System

ldquoSmall and frequent feeds according to the sleep cyclerdquo

The ldquonicherdquo (occupation) of a neonate (Alberts)

BOND FEED

SLEEP SLEEP

PLAY FEED

201

Gastric overfilling syndrome

Proposed Management 202

Proposed Management

Babies should be fedEVERY TIME THEY WAKE

Stanley Graven 2006

REMNR1NR2NR3SWS

AS (20 mins) QS (40 mins)

A normal sleep cycle is ONE hourHow often should neonates feed

203

Proposed Management

All babies should be fedat least once an hour 204

35

Proposed Management

All babies should be fedat least once an hour

205

The first Milk Ejection Reflex (MER)

elicited in lt 2 minutesworks quicklyswallowed 1 minute

Feeding time (max)3 minutes

Repeat every 1 hour

Prime 2007

The ldquonormalrdquo or usual and common breastfeed

takes 15 minutesdiscomfort afterburping time 5 minutes

Feeding time 20 min

Repeat every 3 hours

Prime 2007

3 minute 20ml feeds x 24d = 72 minutes

20 minute 60ml feeds x 8d = 160 minutes

SMALL AND FREQUENT FEEDS ARE EFFICIENT

FEWER NURSES NEEDED

The calculated dailyrequirement for a 3kgbaby can be given without increase inpressure MINIMAL RISK

PARENTS CAN DOSAFELY

20 mls x 24 feeds= 480mls day

Zangen 2001 209

All babies should be fedat least once an hour

210

36

Infant feeding frequencyProposal based on available evidence and neuroscience

ldquoSmall and frequent feeds

adjusted to the sleep cyclerdquo

211

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

STATE organization

Feeding frequency

SLEEP cycling

BRAIN

WIRING

How often should a neonate feeda neonate sleep

Infantsleep cycles

begin to block on diurnalrhythms

Mother-infant synchrony

hellip at 12 weeks

(circadian)

START at 3 months

Can be ldquoadult-likerdquo

at 6 months

Thomas 2014

STATE organization

Feeding frequency

SLEEP cycling

PLAY FEED

216

SLEEP SLEEP

SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

Infantsleep cycles

begin to block on diurnalrhythms

37

BOND SUCKLE SLEEP SLEEP PLAY

FEED

217

SLEEP SLEEP SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)

Schaal 2004 218

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)rdquoSLEEP-FEED CYCLINGrdquo

Schaal 2004 219

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

WIRE

BRAIN

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

BRAIN

WIRING

NEUROSCIENCE

The DNAEverything else

EVOLUTIONARYBIOLOGY

The Brain

EPIGENETICS

The PlaceENVIRONMENT

EXPERIENCEFITNESS ADAPTATION

ldquoScientific foundationrdquo hellip a synthesis

ZERO

SEPARATION

38

wwwninobirthorgwwwskintoskincontactcom

THE NEUROSCIENCE OFSKIN-TO-SKIN CONTACT

AND BREASTFEEDING

ARE THE SAME

SUMMARY SKIN-TO-SKIN

(Regulation)

SLEEP(Brain)

FEEDING(Stomach)

LOVE ( ldquomindrdquo )

REMNR1NR2NR3NR4

ACQUISITION CONSOLIDATION MEMORYFORMATION

poly-sensory input transfer information P wavesshort-term memory ldquoSNRrdquo strong signals returns infostored cortex amygdala to neocortex

hippocampus organizedAwake and REM NREM stage 4 REM

BRAIN WIRING

Stanley Graven 2006

PLAY

SLEEP

FEEDHOLDYOURPREM

httpswwwfacebookcomninobirth

39

Nelson Mandela

hellip in describing themeasure of a nation

he has argued that

ldquoThere can be no keener revelation of a societyrsquos soul than the way in which it treats its childrenrdquo

Page 2: Neurodevelopmental The Neuroscience of Birth ... · breastfeeding pattern, neonatal weight gain, and the dynamics of lactation. Doucet 2012 In the ‘‘scentless breast’’ condition,

2

BREASTFEEDING Feed Sleep Cycling

BONDING Sensitization

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

BRAIN

WIRING

Neurodevelopmental Approach to

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

BRAIN

WIRING

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

WIRE BABY There are ldquoneeded neural processesrdquo

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

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

3

Simulated birth (rat) Simulated birth (rat)

Simulated birth (rat)

No compression

Wrong smell

Nil 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

DOUCETThe secretion of Areolar (Montgomeryrsquos) Glands from Lactating Women Elicits Selective Unconditional Responses in Neonates

ldquohellip breast chemosignalsactivate oral activity on the nipple that releases a cascade of behavioral neural neuroendocrineand endocrine processes in the newborn and the motherrdquo

Doucet 2009 17

The secretion of Areolar(Montgomeryrsquos) Glands

ldquoIn early ontogeny the sleeping brain may thusremain sentient of an organismrsquos odor environmentrdquo

Doucet 2009 18

4

Fewer AG delayed grasp

Fewer AG Slower latch

Fewer AG Weaker suck

Fewer AG More weight loss day 3 of life

Fewer AG Delayed onset of lactation

Primip high AG 23 days Primip low AG 31 days

Difference p lt0001

An overlooked aspect of the human breast Areolar glands in relation with

breastfeeding pattern neonatal weight gain and the dynamics of lactation

Doucet 2012

In the lsquolsquoscentless breastrsquorsquo

condition all infants were

exposed to the motherrsquos breast

fully covered with a perfectly

transparent and airtight plastic

film (polypropylene)

( the habitual visual scene of

the breast devoid of

corresponding odors )

(1) lsquolsquoBreastrsquorsquogroup (fully

uncovered motherrsquos breast)

(2) lsquolsquoNipplersquorsquogroup (all remaining

parts covered with plastic film)

(3) lsquolsquoAreolarsquorsquogroup (remainder of

the breast and nipple covered)

(4) lsquolsquoMilkrsquorsquogroup (milk smeared

on plastic covered breast)

5

lsquolsquoBreastrsquorsquogroup 0102

more than

lsquolsquoAreolarsquorsquogroup 0038

more than

lsquolsquoMilkrsquorsquogroup 0035

Grey bar ndash odourless

plastic film

Black ndash pooled odors

They displayed significantly longer global oral activity

when facing any of the odorous breast with opened

eyes the three other conditions being equivalent

odorous breast opened eyes 1327

odorous breast closed eyes 992

scentless breast opened eyes 663

scentless breast closed eyes 839

hellip only male newborns opened their eyes longer in

response to odorous breast conditions than to the

scentless condition

(0654 vs 0425 plt01)

Related experiments indicate however that the

chemical cues that attract rat pups to the nipples

are not produced in that region Rather initial

nipple orientation is elicited by the odor of

amniotic fluid and saliva that the mother spreads

on her ventrum while grooming herself during

parturition [7]

Babies more often spontaneously selected a breast

treated with a small amount of their own AF applied to

the nippleareola region than the alternative untreated

breast during tests beginning several minutes after

parturition [112]

These results are corroborated by a study in which 2-

day-old infants were offered a simultaneous choice

between two gauze pads the length of time oriented

to the odor of their AF was reliably greater than that

towards an odorless stimulus pad [92]

PSN envisions a community that embraces its mothers and babies and

values the unique

opportunity at birthto impact the physical and emotional

well-being of the newborn

Target 1 for 2005

Report that 65 of infants are placed and remain in

direct skin to skin contactwith their mothers

for at least one hourduring the first 3 hours after birth

6

Skin-to-skin and breastfeeding (4)

0

10

20

30

40

50

60

70

80

90

100

3Q05 4Q05 1Q06 2Q06 3Q06 4Q06 1Q07 2Q07

Breastfeeding intention Skin-to-skin one hour Breastfeeding at discharge

Used with permission Ruth Stanhiser MD

Babies breastfeeding

Mothers intending to breastfeed

Breastfeeding by the NeonateRegistration by skin-to-skin contact

More skin-to-skin more breastfeeding

Thomson 1979

E Early SSC first hourL Late contact next day2 2 hourly feeds from birth4 4 hourly feeds from birth

Group Brf at 12 w Brf duration (days)

2E 643 182 (14 - 392)4E 556 140 (14 ndash 322)2L 556 112 (10 ndash 294)4L 462 77 (11 ndash 280)

Salariya 1978

7

DEFENSE NUTRITION REPRODUCTION

HORMONES NERVES MUSCLES

DEFENSE NUTRITION REPRODUCTION

HORMONES NERVES MUSCLES

= BREASTFEEDING

SAFE

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

WIRE MOTHER

NEURODEVELOPMENTThe DNA Behaviour

EVOLUTIONARY BIOLOGY

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

BIRTH

BEYOND BREASTFEEDING Feed Sleep Cycling

MOTHERBABY

BONDING Sensitization

Secure attachment

Attuned parenting

SEPARATION

OXYTOCIN

8

OXYTOCIN

OXYTOCIN comes from

Cervical dilatation

Skin-to-skin contact

Breastfeeding

Eye-to-eye contact

Effects of doula care

No doula DoulaUSA (Kennell et al 1991)

Epidural 55 8Caesarean section 18 8Forceps delivery 26 8Fetal distress 24 10

ldquoIf a Doula was a drug it would be unethical

not to use itrdquoDr John Kennell

1922 -2013Marshall Klaus amp John Kenell

EARLY CHILDHOOD DEVELOPMENT ECD

ldquoFirst 1000 daysrdquo =gestation 270year one 365year two 365total 1000 days

Resilience Vulnerability

DISEASEHEALTH

EARLY CHILDHOOD DEVELOPMENT ECD

ldquoFirst 1000 daysrdquo =

Resilience Vulnerability

DISEASEHEALTH

First 1000 sec = 16 minutes = 1st hourFirst 1000 min = 166 hours = 1st day First 1000 hrs = 1st six weeks

DOULA-ldquoA WOMAN SERVING WOMENrdquo BIRTH SUPPORT COMPANION

KANGAROO CARE amp DOULA = ldquoKANGAROULArdquo

Resilience Vulnerability

DISEASEHEALTH

9

DOULA and KANGAROULA

DOULA protects

OXYTOCINduringlabour

KANGAROULA protects

OXYTOCINafter birth

lsquothe first 1000 minutesrsquolsquoprevious 1000 minutesrsquo

BIRTH

DOULA and KANGAROULA

-1000 min

BIRTH

+1000 min

DOULA and KANGAROULA

-1000 min

BIRTH

+1000 min 1000 days

OXYTOCIN Zero separation

Caesarean

Separation

Breastfeeding

Zero separation

DOULA and KANGAROULA

-1000 min

BIRTH

+1000 min 1000 days

OXYTOCIN Zero separation

CORTISOL Enemy of oxytocin Stress

White coat

Sarcasm

Hunger

thirst

SEPARATION

Bathing

Noise

Lights

LithotomyWeighing

Crowds

SEPARATION

Perfume

rdquogood nightrsquos sleeprdquo

Birth Transition ParentingLabourPregnancy

DOULA

KANGAROULA

Prematurity Attachment Parenting

MOTHERSUPPORT

NEWBORNSUPPORT

Counselling Counselling

Breastfeeding

During the first 24 hours of life newborns ingested 15 g of milk

10

Milk making NUTRITION

HypothalamusPituitaryPROLACTIN

Maternal ferocityPROTECTION

OXYTOCIN Gaze increase BONDING

OXYTOCINCingulate Suppressed

REGULATION

AmygdalaCHOLECYSTOKININ Emotion satiety

HypothalamusPituitary

Cingulate

Amygdala

ldquoThe newborn may

appear helpless but

skin-to-skin contactstimulates prolactin

ensures nutritionstimulates oxytocin

ensures protectionstimulates cholecystokinin

ensures wellbeing bonding

The first hours after birth are a

CRITICAL PERIOD

mutual psycho-neuro-physiological

caregivers

Critical period concept

ldquoWindows of opportunity in early life when a childrsquos brain is exquisitely primed to receive sensory input in order to develop more advanced neural systemsrdquo

a motherrsquos brain hellip

SENSITIZATION

DOULA and KANGAROULA

DOULA protects

OXYTOCINduringlabour

KANGAROULA protects

OXYTOCINafter birth

lsquothe first 1000 minutesrsquolsquoprevious 1000 minutesrsquo

BIRTH

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

WIRE MOTHER

OXYTOCIN

11

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDINGON-GOING

S S C

WIRE TOGETHER

OXYTOCIN

hellip infant cues - suckling vocalisation and tactile stimulation - stimulate

OXYTOCINrelease in the hypothalamus which may result in the activation of the dopaminergic reward pathway leading to behavioural reinforcement

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

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

DISEASEHEALTH

CORTISOLOXYTOCIN

The psychology of human parent-infant relationships

Parenting is regulated by key hormones and neurotransmitters

Neuroanatomical circuits of parenting

Integrative physiology of normal parenting behaviours

Brain imaging of human parent-infant relationships

The neurobiology of empathy and parenting

Conclusions and critical summary

(Swain et al 2007)

12

FEARCONTROL

CENTRE

REWARDCONTROL

CENTRE

SOCIALCONTROL CENTRE

OXYTOCINDOPAMINE

CORTISOL

EMOTIONCONTROL CENTRE

WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY

DISEASEHEALTH

RESILIENCE VULNERABILITY

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

DOULA and KANGAROULA

-1000 min

BIRTH

+1000 min 1000 days

OXYTOCIN Zero separation

Protect OXYTOCINBefore and after

BIRTH

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDINGON-GOING

S S C

WIRE TOGETHER

Protect OXYTOCINBefore and after

BIRTH

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDINGON-GOING

S S C

WIRE SUCKLING

BREASTFEEDING Feed Sleep Cycling

BONDING Sensitization

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

BRAIN

WIRING

Neurodevelopmental Approach to

Alberts SUCKLING versus FEEDING

DUAL INGESTION SYSTEMS

13

300 mya 200 mya 100 mya 50 mya 300 mya 200 mya 100 mya 50 mya

Amniotes

Synapsids

Cynodonts

Mammaliaformes

PlacentalsMammals

ANCESTRAL STATE

hellip intoMATURE FEEDING

300 mya 200 mya 100 mya 50 mya

WATER

EGGS

Hatch withTEETH

ANCESTRAL STATE

hellip intoMATURE FEEDING

eg TURTLES

CROCODILES DINOSAURS

REPTILES

300 mya 200 mya 100 mya 50 mya

Epibubic bone = pouch care

hellip intoMATURE FEEDING

Amniotes

Synapsids

Cynodonts

Mammaliaformes

Smaller eggs longer in body

The AMNIOTE EGGextra membranes

Copes with AIR

PlacentalsMammals

Viviparity = immature

ENDOTHERMY

MOISTUREfor eggs

Diphyodontism

300 mya 200 mya 100 mya 50 mya

hellip intoMATURE FEEDING

Amniotes

Synapsids

Cynodonts

Mammaliaformes

PlacentalsMammals

ENDOTHERMY

MOISTUREfor eggs

LACTOSE added(apocrine glands)

NUTRIENTSAntimicrobials

LACTATION

SUCKLINGFEEDING

200 million years

Diphyodontism

300 mya 200 mya 100 mya 50 mya

hellip intoMATURE FEEDING

Amniotes

Synapsids

Cynodonts

Mammaliaformes

PlacentalsMammals

ENDOTHERMY

MOISTUREfor eggs

LACTOSE added(apocrine glands)

NUTRIENTSAntimicrobials

LACTATION

SUCKLINGFEEDING

200 million years

DUAL INGESTION SYSTEMS

100 million years

14

DUAL INGESTION SYSTEMS DUAL INGESTION SYSTEMS

SUCKLING WEANING FEEDING

Lactase Digestive enzymes

FEEDING SUCKLING

Influence of SMELL None Totally dependent

Motor mechanism Chewing ndash different

muscles

Suckling ndash different circuits

INSULIN Increases weight No effect

GHRELIN Increases weight No effect

LEPTIN Decreases intake No effect

CHOLECYSTOKININ Decreases intake No effect

AMPHETAMINE Decreases appetite Increases suckling

SEROTONIN Agonist improves feeding Antagonist improves suck

SATIETY Infant determined Maternal supply determine

FEEDING SUCKLING

DISRUPTION ROBUST VERY SENSITIVE

Must have right conditions

Pup-in-a- cup - And STIMULI

separated and fed by tube

From day 2 off life

Starts to feed normally d21 2 days gavage or other

no longer suckles

If starved for 24 hours pup

at d3 will feed food from

floor

(Can be maintained by

smell and other stimuli)

Pup-in-a- cup -

separated and fed by tube

From day 2 off life

Starts to feed normally d21

15

PMA 28 40 64 1y 2y

Nilsrsquo IDEALIZED VIEW

PMA 28 40 64 1y 2y

Nilsrsquo IDEALIZED VIEW

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

Reflections for practice

Suckling and Feeding areNOT THE SAME

16

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDINGON-GOING

S S C

WIRE SUCKLING

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

ON-GOING

S S C

WIRE NEURONS

Up to 6 months milk is 74 fat

96 of this is TRIGLYCERIDE

TRIGLYCERIDE Left glycerol Right palmitic acid oleic acid alpha-linolenic acid

In phosphoglycerides glycerol molecule same

two fatty acids esterified

Phospholipids area major component of all biological membranes

Sphingomyelin particularly concentrated in BRAIN major part of MYELIN

TRIGLYCERIDE

MYELIN

Dendirification and myelinisation peaks occurat 2 and 6 monthsis maximal at one year

At one year human milk has less proteinbut MORE TRIGLYCERIDE

FATTY ACIDS ARESPECIES SPECIFIC

Up to 6 months milk is 74 fat

but after 12 months it is 107

17

ldquocherry pickrdquo

Breastfeed time years school Incomelt 1 month 109 R$ 1238gt 6 month 121 R$ 1915

Group IQ 376 points higher from breatsfeeding

BREASTFEEDINGAND BREAST MILK

INCREASE IQ

BOTTLE FEEDINGamp FORMULA

DECREASE IQ

18

Be sure the wet nurse has plenty of milk because if she lacks it she may give the babymilk of a goat or sheep or some other animalbecause the child nourished on animal milkdoes not have perfect wits like one fed on womanrsquos milk and always looks stupid and vacant and not right in the head

14th century Tuscan text

Conceptual changeDyad careBreast first hour

even CaesareanContinuous SSC

DISCONTINUEGiving waterGlucose waterInfant formulaSeparationPacifier (dummy)

CHANGE POLICY Canrsquot change

biology

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

ON-GOING

S S C

WIRE NEURONS

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C WIRE

TIMING

(behavior)

19

Not so much duration

or density of any sleep stage

or number of sleep stage episodes but

cycling between quiet sleep

and active sleepis what is important

REMREM REM

NREM NREM

This is a healthy sleep pattern

This is a very good cycling pattern

(thanks to Susan Ludington-Hoe)

REMREM REM

NREM NREM

1st hour 2nd hour

So in every hour you would like

to see an EEG pattern that shows this

REM

NREM

REM

NREM

REM

NREM

State

HR

RR

REM Sleep is supposed to be

somewhat active so

HR increases and RR is irregular

SLEEP CYCLING ndashSeparation vs contact

In separation bull Dissociated statebull No cycling chaotic pattern

48 hour baseline chaotic pattern of

activity and quiet HR amp RR

SLEEP CYCLING ndashSeparation vs contact

In SSC bull Normal cyclingbull Non-chaotic pattern

48 hour baseline chaotic pattern of

activity and quiet HR amp RRPre-KC SSC

20

modulates state organisationelicits emotional behavioursactivates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL

Schaal 2004 115

DOUCETThe secretion of Areolar (Montgomeryrsquos) Glands from Lactating Women Elicits Selective Unconditional Responses in Neonates

ldquohellip breast chemosignalsactivate oral activity on the nipple that releases a cascade of behavioral neural neuroendocrineand endocrine processes in the newborn and the motherrdquo

Doucet 2009 116

The secretion of Areolar(Montgomeryrsquos) Glands

ldquoIn early ontogeny the sleeping brain may thusremain sentient of an organismrsquos odor environmentrdquo

Doucet 2009 117

REM

NREM

A skin-to-skin contactsession SHOULD NOT be less than one hour

or 90 minutes

SLEEPING

amp

CONTAINING

FEEDING ampHANDLINGfeed

sleep

HO

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C WIRE

TIMING

(behavior)

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C WIRE

STOMACH

21

STATE organization

Feeding frequency

SLEEP cycling

BRAIN

WIRING

How often should a neonate feed

CNS

ENS

ANS

InternalSomaticenvironment

CNS cortical subcortical(also to PNS)

ANS emotional limbic brain(incl SNS)

ANS myelinated vagus (NA)

ANS unmyelinated vagus (DMC)sub-diaphragmatic

ENS submucous plexusmyenteric plexus

122

The digestive system is endowed with its own local nervous system referred to as the enteric or intrinsic nervous system

The magnitude and complexity of the enteric nervous system is immense - it contains as many neurons as the spinal cord

ENTERIC NERVOUS SYSTEM

123

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

FEEDBACK LOOPS

CNS

ENS

ANS

InternalSomaticenvironment

124

125 126

22

Fetal stomach appears 4 weeks GABy 11 weeks wall capable of muscular

contraction

ldquoPatterns of antropyloric motilityin fed healthy preterm infantsrdquo

the neuroregulatory mechanisms responsible for the coordination of antro-pyloric motility and gastric emptying are

well developed by 30 weeks of PMAHassan 2002 127

Hydrochloric acidimportant for activation of pepsinogen

inactivation of microorganisms such as bacteria

Pepsinogenactivated by acid into active pepsin

responsible for the stomachs ability to initiate digestion of proteins

Chymosinis an enzyme whose role is to curdle or

coagulate milk in the stomach a process of considerable importance in the very young animal

128

Chymosinmakes the milk into ldquocheeserdquohalfway between liquid and solidstomach empties in 60 minutes

milk

129

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

FEEDBACK LOOPS

130

EVIDENCE FORFEEDING FREQUENCY

Edmond 2006 131

Breastfeeding and motherrsquos milkStrong and consistent evidence 132

23

Cup feeding versus bottle feedingCup feeding higher breastfeeding

greater stability133

Only case series Insufficient evidence

No mention of

stomach capacity134

EVIDENCE FORSTOMACH CAPACITY

Edmond 2006 135

0

05

1

15

2

25

3

35

4

0 10 20 30 40 50 60 70 80

volume ingested

fee

din

g f

req

ue

nc

y

Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml

StandardCARE3 hourlyschedule

136

KEY QUESTION

WHAT IS THE

STOMACHVOLUMEOF THE

NEONATE 137 Sase 2005

ldquoOntogeny of gastric emptying patternsin the human fetusrdquo

138

24

Goldstein 1987

ldquoGrowth of the Fetal Stomach in Normal Pregnanciesrdquo

139 Goldstein 1987

Length

Transverse

AP diameter

Using +2SD

140

Formula for calculation of stomach capacity (Charles Bradshaw UCT)Assumptions the stomach can be approximated by dividing into three sections namely a ellipsoidal hemisphere an ellipsoidal cylinder and a skewed ellipsoidal cone Variables a = anteroposterior radius t = transverse radius l = length stomachRelations the height of the cone and the hemisphere are both the same as lsquoarsquo

Ellipsoid = 43 Pi r1r2r3 = 43 Pi a a t therefore volume of hemisphere = 23 Pi a a t

Cylinder = Area of base height = (Pi a t ) ( l - 2a )Skewed cone = 13 base height = 13 Pi a t aTotal volume = 23 Pi aat + Pi a t (l- 2a) + 13 Pi a t a

=Pi atl -Pi a at= Pi a t(l-a)

Goldstein and Sase dataStomach capacity at term 10 - 15 ml

BRADSHAW formula

141

Assumption 25 kg baby 33w GA

requiring 150 mlkgday = 375 ml

45 MIN CYCLES ( 32 cyclesday)

12 ML PER CYCLE = 384 ml142

Newborn stomach volume

Gastric volumes at birthCorrelated with gastric pH

gastrin and somatostatin

ldquofetus drinks 10 ml portions of amniotic fluid helliprdquo

Widstrom 1988 143

Only recent study locatedldquoAutopsyrdquo capacity was determined

in Indian post-mortem studies

100 autopsies (63 SB 37 ENND)Tied at cardia and pylorus filled withwater emptied amp measured repeatedldquohellip obliteration of the gastric curvaturesrdquoldquodue care to minimize stretch artifactsrdquo

Naveed 1992

ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo

144

25

Infants above 2500g onlyAve Range

Stillborn (n 11) 196 ml (10-35)Early death (n 9) 178 ml (10-25)All cases (n 20) 188 ml

Naveed 1992

ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo

145 146

KERNESSUK 1997 (Russian)

Postmortem in situ measures(applied Bradshaw formula)

AveNewborn (n 11) 15 ml2 months (n 11) 35 ml2-4 m (n 10) 50 ml4-6 m (n 8) 100 ml

Known references with data

Scammon and Doyle 1920

Zuccarellirsquos method stomach filled at autopsy to ldquoa pressure of between

15 and 20 centimeters of waterrdquo

Scammon 1920

ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo

147

Anatomic capacity was determined in post-mortem studies

Main data set Alliot 1905 (n 25)Scammon own cases (n 13)

30 ndash 35 ml at birth ndashalmost regardless of birth weight

Scammon 1920

ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo

148

Zangen S et al Rapid maturation of gastric relaxation in newborns

Pressures (mmHg)

Balloon inflates to

15 ml no increase

functional capacity

149

Zangen S et al Rapid maturation of gastric relaxation in newborns

Pressures (mmHg)

Balloon inflates to

15 ml no increase20 ml pressure OK

physiologicalcapacity hellip 150

26

EVIDENCE (NBn 111009)

Author Capacity NoteSase 10-15 ml Live term fetusGoldstein 10-15 ml Live term fetusWidstrom 10 mls Live newbornZangen 20 mls Live (pressure)

Naveed 20 mls Autopsy (SB)20 mls Autopsy (ENND)

Kernessuk 15 mls Autopsy (in situ)Scammon 30-35 ml Autopsy (water

(Alliot) pressure)151

PROPOSAL

The CAPACITY of aweek old babyrsquos stomach is

approx 20 ml152

0

05

1

15

2

25

3

35

4

0 10 20 30 40 50 60 70 80

volume ingested

fee

din

g f

req

ue

nc

y

Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml

StandardCARE3 hourlyschedule

MOTHERNATURE

1 hourlyschedule

153

PHYSIOLOGICAL CAPACITY

RECEPTIVE CAPACITY of stomach

INGESTIVE CAPACITY of BABY

FUNCTIONAL CAPACITY

154

PROPOSAL

The FEEDINGFREQUENCY of theNEONATE is

approx 60 min155

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

BRAIN CYCLING

STOMACH FILLING amp EMPTYING

REMNR1NR2NR3NR4

156

27

Normal physiology of theEnteric Nervous System

ldquoSmall and frequent feeds according to the sleep cyclerdquo

The ldquonicherdquo (occupation) of a neonate (Alberts)

BOND FEED

SLEEP SLEEP

PLAY FEED

157

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

FEEDING SUCKLING

Influence of SMELL None Totally dependent

Motor mechanism Chewing ndash different

muscles

Suckling ndash different circuits

INSULIN Increases weight No effect

GHRELIN Increases weight No effect

LEPTIN Decreases intake No effect

CHOLECYSTOKININ Decreases intake No effect

AMPHETAMINE Decreases appetite Increases suckling

SEROTONIN Agonist improves feeding Antagonist improves suck

SATIETY Infant determined Maternal supply determine

FEEDING SUCKLING

Influence of SMELL None Totally dependent

Motor mechanism Chewing ndash different

muscles

Suckling ndash different circuits

INSULIN Increases weight No effect

GHRELIN Increases weight No effect

LEPTIN Decreases intake No effect

CHOLECYSTOKININ Decreases intake No effect

AMPHETAMINE Decreases appetite Increases suckling

SEROTONIN Agonist improves feeding Antagonist improves suck

SATIETY Infant determined Maternal supply determine

Current dogmaTHE BABY KNOWS

WHEN IT HAS HAD ENOUGH

PROBABLY NOT

WHAT IS THE

STOMACH VOLUME OF THE

PREMATURE

161

Assume low resilience

Assume proportionality

162

28

The CAPACITY of alow birthweight premfrom 20ml 3000g

= 0007 x BWt (g)

1kg x 0007 = 7mls2kg x 0007 = 14mls

163

Gastric overfilling syndrome

164

75 ml per feeding ASSUMPTION

IMMATURE OR OVERWHELMED

many aspects of gastrointestinalmotility are immature in the neonate

Zangen S et al Rapid maturation of gastric relaxation in newborns

A balloon in stomachcan fill to 76 mls

What does the stomach ndashwithout a balloon ndashdo to 76 mls

REFLUX PRESUME each feedapproximately 75 mls

GER

bull Sudden outbursts of crying

bull Awakens in pain

bull Related to feedings

bull Not easily comforted

bull ldquoI know baby hurtsrdquo

bull Sour burps throaty noises

bull Best when upright

Clues to GER

Dr W Sears

29

Mitchell 2001

Kerstin Uvnaumls-Moberg

Food in duodenum

AMYLINreleased

Closes pylorus

Duodenumempty

Pylorusopens

ldquoFeed intolerancerdquo hellip hellip or VOLUME intolerance

HYPOGLYCAEMIA

A babies stomach empties in60 minutes

Blood sugarmay fall hellip

after 90 minutes Options

30

METABOLIC ADAPTATION

SSC started in the first 20 minutes after birth

SSC CotBlood glucose (1 hr) 317 256Base excess drop 34 18

(Christenson 1992)0h 1h 2h 3h 4h 2 days

App

roxim

ate

GLUCOSE

SSC Glucose production = Glucose consumption

Separation

SNS stress Glucose consumption INCREASE

PSNS dissociation Glucose production DECREASE

HYPOGLYCEMIA

SSC Cot

Blood glucose (1 hr) 317 256

0h 1h 2h 3h 4h 2 days

App

roxim

ate

GLUCOSE

SSC Glucose production = Glucose consumption

Separation PSNS dissociation

Glucose production DECREASE

HYPOGLYCEMIA

SSC Cot

Blood glucose (1 hr) 317 256

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

NEURODEVELOPMENTThe DNA Behaviour

EVOLUTIONARY BIOLOGY

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

BONDING ATTACHMENT

MRI HRVEEG

STRESS RESPONES

RESILIENCE

DOHAD

(MAL) ADAPTATION

EPIGENETICS

GENE X ENVIRONMENT

GENETIC VARIANTS

HOSPITAL ACQUIRED INFECTIONIMMUNITY

SLEEP PHYSIOLOGY

GUT FUNCTIONMICROBIOTA

ldquoSTABILITYrdquo

TRANSITION

LONG TERM FOLLOW-UP

NEUROENDOCRINE BEHAVIOURS

MATERNAL NEUROPLASTICITY

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

MORTALITYMETABOLISM

0h 1h 2h 3h 4h

PSNS (vagal)

App

roxim

ate

GLUCOSE

1 HOURLY Milk feed

1 HOURLY Milk feed

1 HOURLY Milk feed

1 HOURLY Milk feed

LACTOSE

METABOLISM

31

0h 1h 2h 3h 4h

PSNS (vagal) SYMPATHETIC STRESS

App

roxim

ate

GLUCOSE

LACTOSE FATGLYCOGEN

METABOLISM

4 HOURLY Milk feed

0h 1h 2h 3h 4h

PSNS (vagal) SYMPATHETIC STRESS

App

roxim

ate

GLUCOSE

4 HOURLY ALLOSTATIC STATELACTOSE FATGLYCOGEN

METABOLISM

4 HOURLY Milk feed

HEALTH DISEASE

EXPECTED UNEXPECTED

NEURODEVELOPMENTThe DNA Behaviour

EVOLUTIONARY BIOLOGY

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

BONDING ATTACHMENT

MRI HRVEEG

STRESS RESPONES

RESILIENCE

DOHAD

(MAL) ADAPTATION

EPIGENETICS

GENE X ENVIRONMENT

GENETIC VARIANTS

HOSPITAL ACQUIRED INFECTIONIMMUNITY

SLEEP PHYSIOLOGY

GUT FUNCTIONMICROBIOTA

ldquoSTABILITYrdquo

TRANSITION

LONG TERM FOLLOW-UP

NEUROENDOCRINE BEHAVIOURS

MATERNAL NEUROPLASTICITY

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

MORTALITYMETABOLISM

Weight gain 1st week

predicts OBESITYat 30 years

Large volume feedsstretched stomach=

doubled absorptivecapacity as adult

Importance

Programming ndash early life chronic disease

32

RESISTANCE SENSITIVITY

PERCEPTIONSldquoNEUROCEPTIONrdquo

RESPONSESTRESS

ALLOSTATIC STATE

ALLOSTASIS

ANY STRESSPsychologicalNeurological

EndocrineImmune

ALLOSTATIC LOAD

ALLOSTATIC OVERLOAD

WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY

DISEASEHEALTH

RESILIENCE VULNERABILITY

RESISTANCE SENSITIVITY

PERCEPTIONSldquoNEUROCEPTIONrdquo

RESPONSESTRESS

ALLOSTATIC STATE

ALLOSTASIS

ANY STRESSPsychologicalNeurological

EndocrineImmune

ALLOSTATIC LOAD

HEALTH

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

Gastric overfilling syndrome

189

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

33

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

Only case series Insufficient evidence

No mention of

stomach capacity196

Baby weight freq reqrsquod size actual

2kg baby 4hrly ~ 320 ml6 = 53ml 14ml

15 baby 3hrly ~ 240 ml8 = 30ml 10ml

10 baby 2hrly ~ 160 ml12 = 13ml 7ml

Standardised from20ml capacityfor 3kg baby( x 0007)

197

0

10

20

30

40

50

60

70

80

90

13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w

LINEAR

TERM

PREM

198

34

0

10

20

30

40

50

60

70

80

90

13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w

LINEAR

TERM

PREM

199

Clues to GER

ldquoI know baby hurtsrdquo

Gastric overfilling syndrome

Excessive volumesreflux aspiration colic

Excessive time intervalhypoglycaemia

Adaptationsdiabetic diathesis obesity

200

Developmental Care of the Enteric Nervous System

ldquoSmall and frequent feeds according to the sleep cyclerdquo

The ldquonicherdquo (occupation) of a neonate (Alberts)

BOND FEED

SLEEP SLEEP

PLAY FEED

201

Gastric overfilling syndrome

Proposed Management 202

Proposed Management

Babies should be fedEVERY TIME THEY WAKE

Stanley Graven 2006

REMNR1NR2NR3SWS

AS (20 mins) QS (40 mins)

A normal sleep cycle is ONE hourHow often should neonates feed

203

Proposed Management

All babies should be fedat least once an hour 204

35

Proposed Management

All babies should be fedat least once an hour

205

The first Milk Ejection Reflex (MER)

elicited in lt 2 minutesworks quicklyswallowed 1 minute

Feeding time (max)3 minutes

Repeat every 1 hour

Prime 2007

The ldquonormalrdquo or usual and common breastfeed

takes 15 minutesdiscomfort afterburping time 5 minutes

Feeding time 20 min

Repeat every 3 hours

Prime 2007

3 minute 20ml feeds x 24d = 72 minutes

20 minute 60ml feeds x 8d = 160 minutes

SMALL AND FREQUENT FEEDS ARE EFFICIENT

FEWER NURSES NEEDED

The calculated dailyrequirement for a 3kgbaby can be given without increase inpressure MINIMAL RISK

PARENTS CAN DOSAFELY

20 mls x 24 feeds= 480mls day

Zangen 2001 209

All babies should be fedat least once an hour

210

36

Infant feeding frequencyProposal based on available evidence and neuroscience

ldquoSmall and frequent feeds

adjusted to the sleep cyclerdquo

211

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

STATE organization

Feeding frequency

SLEEP cycling

BRAIN

WIRING

How often should a neonate feeda neonate sleep

Infantsleep cycles

begin to block on diurnalrhythms

Mother-infant synchrony

hellip at 12 weeks

(circadian)

START at 3 months

Can be ldquoadult-likerdquo

at 6 months

Thomas 2014

STATE organization

Feeding frequency

SLEEP cycling

PLAY FEED

216

SLEEP SLEEP

SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

Infantsleep cycles

begin to block on diurnalrhythms

37

BOND SUCKLE SLEEP SLEEP PLAY

FEED

217

SLEEP SLEEP SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)

Schaal 2004 218

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)rdquoSLEEP-FEED CYCLINGrdquo

Schaal 2004 219

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

WIRE

BRAIN

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

BRAIN

WIRING

NEUROSCIENCE

The DNAEverything else

EVOLUTIONARYBIOLOGY

The Brain

EPIGENETICS

The PlaceENVIRONMENT

EXPERIENCEFITNESS ADAPTATION

ldquoScientific foundationrdquo hellip a synthesis

ZERO

SEPARATION

38

wwwninobirthorgwwwskintoskincontactcom

THE NEUROSCIENCE OFSKIN-TO-SKIN CONTACT

AND BREASTFEEDING

ARE THE SAME

SUMMARY SKIN-TO-SKIN

(Regulation)

SLEEP(Brain)

FEEDING(Stomach)

LOVE ( ldquomindrdquo )

REMNR1NR2NR3NR4

ACQUISITION CONSOLIDATION MEMORYFORMATION

poly-sensory input transfer information P wavesshort-term memory ldquoSNRrdquo strong signals returns infostored cortex amygdala to neocortex

hippocampus organizedAwake and REM NREM stage 4 REM

BRAIN WIRING

Stanley Graven 2006

PLAY

SLEEP

FEEDHOLDYOURPREM

httpswwwfacebookcomninobirth

39

Nelson Mandela

hellip in describing themeasure of a nation

he has argued that

ldquoThere can be no keener revelation of a societyrsquos soul than the way in which it treats its childrenrdquo

Page 3: Neurodevelopmental The Neuroscience of Birth ... · breastfeeding pattern, neonatal weight gain, and the dynamics of lactation. Doucet 2012 In the ‘‘scentless breast’’ condition,

3

Simulated birth (rat) Simulated birth (rat)

Simulated birth (rat)

No compression

Wrong smell

Nil 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

DOUCETThe secretion of Areolar (Montgomeryrsquos) Glands from Lactating Women Elicits Selective Unconditional Responses in Neonates

ldquohellip breast chemosignalsactivate oral activity on the nipple that releases a cascade of behavioral neural neuroendocrineand endocrine processes in the newborn and the motherrdquo

Doucet 2009 17

The secretion of Areolar(Montgomeryrsquos) Glands

ldquoIn early ontogeny the sleeping brain may thusremain sentient of an organismrsquos odor environmentrdquo

Doucet 2009 18

4

Fewer AG delayed grasp

Fewer AG Slower latch

Fewer AG Weaker suck

Fewer AG More weight loss day 3 of life

Fewer AG Delayed onset of lactation

Primip high AG 23 days Primip low AG 31 days

Difference p lt0001

An overlooked aspect of the human breast Areolar glands in relation with

breastfeeding pattern neonatal weight gain and the dynamics of lactation

Doucet 2012

In the lsquolsquoscentless breastrsquorsquo

condition all infants were

exposed to the motherrsquos breast

fully covered with a perfectly

transparent and airtight plastic

film (polypropylene)

( the habitual visual scene of

the breast devoid of

corresponding odors )

(1) lsquolsquoBreastrsquorsquogroup (fully

uncovered motherrsquos breast)

(2) lsquolsquoNipplersquorsquogroup (all remaining

parts covered with plastic film)

(3) lsquolsquoAreolarsquorsquogroup (remainder of

the breast and nipple covered)

(4) lsquolsquoMilkrsquorsquogroup (milk smeared

on plastic covered breast)

5

lsquolsquoBreastrsquorsquogroup 0102

more than

lsquolsquoAreolarsquorsquogroup 0038

more than

lsquolsquoMilkrsquorsquogroup 0035

Grey bar ndash odourless

plastic film

Black ndash pooled odors

They displayed significantly longer global oral activity

when facing any of the odorous breast with opened

eyes the three other conditions being equivalent

odorous breast opened eyes 1327

odorous breast closed eyes 992

scentless breast opened eyes 663

scentless breast closed eyes 839

hellip only male newborns opened their eyes longer in

response to odorous breast conditions than to the

scentless condition

(0654 vs 0425 plt01)

Related experiments indicate however that the

chemical cues that attract rat pups to the nipples

are not produced in that region Rather initial

nipple orientation is elicited by the odor of

amniotic fluid and saliva that the mother spreads

on her ventrum while grooming herself during

parturition [7]

Babies more often spontaneously selected a breast

treated with a small amount of their own AF applied to

the nippleareola region than the alternative untreated

breast during tests beginning several minutes after

parturition [112]

These results are corroborated by a study in which 2-

day-old infants were offered a simultaneous choice

between two gauze pads the length of time oriented

to the odor of their AF was reliably greater than that

towards an odorless stimulus pad [92]

PSN envisions a community that embraces its mothers and babies and

values the unique

opportunity at birthto impact the physical and emotional

well-being of the newborn

Target 1 for 2005

Report that 65 of infants are placed and remain in

direct skin to skin contactwith their mothers

for at least one hourduring the first 3 hours after birth

6

Skin-to-skin and breastfeeding (4)

0

10

20

30

40

50

60

70

80

90

100

3Q05 4Q05 1Q06 2Q06 3Q06 4Q06 1Q07 2Q07

Breastfeeding intention Skin-to-skin one hour Breastfeeding at discharge

Used with permission Ruth Stanhiser MD

Babies breastfeeding

Mothers intending to breastfeed

Breastfeeding by the NeonateRegistration by skin-to-skin contact

More skin-to-skin more breastfeeding

Thomson 1979

E Early SSC first hourL Late contact next day2 2 hourly feeds from birth4 4 hourly feeds from birth

Group Brf at 12 w Brf duration (days)

2E 643 182 (14 - 392)4E 556 140 (14 ndash 322)2L 556 112 (10 ndash 294)4L 462 77 (11 ndash 280)

Salariya 1978

7

DEFENSE NUTRITION REPRODUCTION

HORMONES NERVES MUSCLES

DEFENSE NUTRITION REPRODUCTION

HORMONES NERVES MUSCLES

= BREASTFEEDING

SAFE

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

WIRE MOTHER

NEURODEVELOPMENTThe DNA Behaviour

EVOLUTIONARY BIOLOGY

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

BIRTH

BEYOND BREASTFEEDING Feed Sleep Cycling

MOTHERBABY

BONDING Sensitization

Secure attachment

Attuned parenting

SEPARATION

OXYTOCIN

8

OXYTOCIN

OXYTOCIN comes from

Cervical dilatation

Skin-to-skin contact

Breastfeeding

Eye-to-eye contact

Effects of doula care

No doula DoulaUSA (Kennell et al 1991)

Epidural 55 8Caesarean section 18 8Forceps delivery 26 8Fetal distress 24 10

ldquoIf a Doula was a drug it would be unethical

not to use itrdquoDr John Kennell

1922 -2013Marshall Klaus amp John Kenell

EARLY CHILDHOOD DEVELOPMENT ECD

ldquoFirst 1000 daysrdquo =gestation 270year one 365year two 365total 1000 days

Resilience Vulnerability

DISEASEHEALTH

EARLY CHILDHOOD DEVELOPMENT ECD

ldquoFirst 1000 daysrdquo =

Resilience Vulnerability

DISEASEHEALTH

First 1000 sec = 16 minutes = 1st hourFirst 1000 min = 166 hours = 1st day First 1000 hrs = 1st six weeks

DOULA-ldquoA WOMAN SERVING WOMENrdquo BIRTH SUPPORT COMPANION

KANGAROO CARE amp DOULA = ldquoKANGAROULArdquo

Resilience Vulnerability

DISEASEHEALTH

9

DOULA and KANGAROULA

DOULA protects

OXYTOCINduringlabour

KANGAROULA protects

OXYTOCINafter birth

lsquothe first 1000 minutesrsquolsquoprevious 1000 minutesrsquo

BIRTH

DOULA and KANGAROULA

-1000 min

BIRTH

+1000 min

DOULA and KANGAROULA

-1000 min

BIRTH

+1000 min 1000 days

OXYTOCIN Zero separation

Caesarean

Separation

Breastfeeding

Zero separation

DOULA and KANGAROULA

-1000 min

BIRTH

+1000 min 1000 days

OXYTOCIN Zero separation

CORTISOL Enemy of oxytocin Stress

White coat

Sarcasm

Hunger

thirst

SEPARATION

Bathing

Noise

Lights

LithotomyWeighing

Crowds

SEPARATION

Perfume

rdquogood nightrsquos sleeprdquo

Birth Transition ParentingLabourPregnancy

DOULA

KANGAROULA

Prematurity Attachment Parenting

MOTHERSUPPORT

NEWBORNSUPPORT

Counselling Counselling

Breastfeeding

During the first 24 hours of life newborns ingested 15 g of milk

10

Milk making NUTRITION

HypothalamusPituitaryPROLACTIN

Maternal ferocityPROTECTION

OXYTOCIN Gaze increase BONDING

OXYTOCINCingulate Suppressed

REGULATION

AmygdalaCHOLECYSTOKININ Emotion satiety

HypothalamusPituitary

Cingulate

Amygdala

ldquoThe newborn may

appear helpless but

skin-to-skin contactstimulates prolactin

ensures nutritionstimulates oxytocin

ensures protectionstimulates cholecystokinin

ensures wellbeing bonding

The first hours after birth are a

CRITICAL PERIOD

mutual psycho-neuro-physiological

caregivers

Critical period concept

ldquoWindows of opportunity in early life when a childrsquos brain is exquisitely primed to receive sensory input in order to develop more advanced neural systemsrdquo

a motherrsquos brain hellip

SENSITIZATION

DOULA and KANGAROULA

DOULA protects

OXYTOCINduringlabour

KANGAROULA protects

OXYTOCINafter birth

lsquothe first 1000 minutesrsquolsquoprevious 1000 minutesrsquo

BIRTH

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

WIRE MOTHER

OXYTOCIN

11

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDINGON-GOING

S S C

WIRE TOGETHER

OXYTOCIN

hellip infant cues - suckling vocalisation and tactile stimulation - stimulate

OXYTOCINrelease in the hypothalamus which may result in the activation of the dopaminergic reward pathway leading to behavioural reinforcement

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

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

DISEASEHEALTH

CORTISOLOXYTOCIN

The psychology of human parent-infant relationships

Parenting is regulated by key hormones and neurotransmitters

Neuroanatomical circuits of parenting

Integrative physiology of normal parenting behaviours

Brain imaging of human parent-infant relationships

The neurobiology of empathy and parenting

Conclusions and critical summary

(Swain et al 2007)

12

FEARCONTROL

CENTRE

REWARDCONTROL

CENTRE

SOCIALCONTROL CENTRE

OXYTOCINDOPAMINE

CORTISOL

EMOTIONCONTROL CENTRE

WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY

DISEASEHEALTH

RESILIENCE VULNERABILITY

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

DOULA and KANGAROULA

-1000 min

BIRTH

+1000 min 1000 days

OXYTOCIN Zero separation

Protect OXYTOCINBefore and after

BIRTH

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDINGON-GOING

S S C

WIRE TOGETHER

Protect OXYTOCINBefore and after

BIRTH

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDINGON-GOING

S S C

WIRE SUCKLING

BREASTFEEDING Feed Sleep Cycling

BONDING Sensitization

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

BRAIN

WIRING

Neurodevelopmental Approach to

Alberts SUCKLING versus FEEDING

DUAL INGESTION SYSTEMS

13

300 mya 200 mya 100 mya 50 mya 300 mya 200 mya 100 mya 50 mya

Amniotes

Synapsids

Cynodonts

Mammaliaformes

PlacentalsMammals

ANCESTRAL STATE

hellip intoMATURE FEEDING

300 mya 200 mya 100 mya 50 mya

WATER

EGGS

Hatch withTEETH

ANCESTRAL STATE

hellip intoMATURE FEEDING

eg TURTLES

CROCODILES DINOSAURS

REPTILES

300 mya 200 mya 100 mya 50 mya

Epibubic bone = pouch care

hellip intoMATURE FEEDING

Amniotes

Synapsids

Cynodonts

Mammaliaformes

Smaller eggs longer in body

The AMNIOTE EGGextra membranes

Copes with AIR

PlacentalsMammals

Viviparity = immature

ENDOTHERMY

MOISTUREfor eggs

Diphyodontism

300 mya 200 mya 100 mya 50 mya

hellip intoMATURE FEEDING

Amniotes

Synapsids

Cynodonts

Mammaliaformes

PlacentalsMammals

ENDOTHERMY

MOISTUREfor eggs

LACTOSE added(apocrine glands)

NUTRIENTSAntimicrobials

LACTATION

SUCKLINGFEEDING

200 million years

Diphyodontism

300 mya 200 mya 100 mya 50 mya

hellip intoMATURE FEEDING

Amniotes

Synapsids

Cynodonts

Mammaliaformes

PlacentalsMammals

ENDOTHERMY

MOISTUREfor eggs

LACTOSE added(apocrine glands)

NUTRIENTSAntimicrobials

LACTATION

SUCKLINGFEEDING

200 million years

DUAL INGESTION SYSTEMS

100 million years

14

DUAL INGESTION SYSTEMS DUAL INGESTION SYSTEMS

SUCKLING WEANING FEEDING

Lactase Digestive enzymes

FEEDING SUCKLING

Influence of SMELL None Totally dependent

Motor mechanism Chewing ndash different

muscles

Suckling ndash different circuits

INSULIN Increases weight No effect

GHRELIN Increases weight No effect

LEPTIN Decreases intake No effect

CHOLECYSTOKININ Decreases intake No effect

AMPHETAMINE Decreases appetite Increases suckling

SEROTONIN Agonist improves feeding Antagonist improves suck

SATIETY Infant determined Maternal supply determine

FEEDING SUCKLING

DISRUPTION ROBUST VERY SENSITIVE

Must have right conditions

Pup-in-a- cup - And STIMULI

separated and fed by tube

From day 2 off life

Starts to feed normally d21 2 days gavage or other

no longer suckles

If starved for 24 hours pup

at d3 will feed food from

floor

(Can be maintained by

smell and other stimuli)

Pup-in-a- cup -

separated and fed by tube

From day 2 off life

Starts to feed normally d21

15

PMA 28 40 64 1y 2y

Nilsrsquo IDEALIZED VIEW

PMA 28 40 64 1y 2y

Nilsrsquo IDEALIZED VIEW

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

Reflections for practice

Suckling and Feeding areNOT THE SAME

16

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDINGON-GOING

S S C

WIRE SUCKLING

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

ON-GOING

S S C

WIRE NEURONS

Up to 6 months milk is 74 fat

96 of this is TRIGLYCERIDE

TRIGLYCERIDE Left glycerol Right palmitic acid oleic acid alpha-linolenic acid

In phosphoglycerides glycerol molecule same

two fatty acids esterified

Phospholipids area major component of all biological membranes

Sphingomyelin particularly concentrated in BRAIN major part of MYELIN

TRIGLYCERIDE

MYELIN

Dendirification and myelinisation peaks occurat 2 and 6 monthsis maximal at one year

At one year human milk has less proteinbut MORE TRIGLYCERIDE

FATTY ACIDS ARESPECIES SPECIFIC

Up to 6 months milk is 74 fat

but after 12 months it is 107

17

ldquocherry pickrdquo

Breastfeed time years school Incomelt 1 month 109 R$ 1238gt 6 month 121 R$ 1915

Group IQ 376 points higher from breatsfeeding

BREASTFEEDINGAND BREAST MILK

INCREASE IQ

BOTTLE FEEDINGamp FORMULA

DECREASE IQ

18

Be sure the wet nurse has plenty of milk because if she lacks it she may give the babymilk of a goat or sheep or some other animalbecause the child nourished on animal milkdoes not have perfect wits like one fed on womanrsquos milk and always looks stupid and vacant and not right in the head

14th century Tuscan text

Conceptual changeDyad careBreast first hour

even CaesareanContinuous SSC

DISCONTINUEGiving waterGlucose waterInfant formulaSeparationPacifier (dummy)

CHANGE POLICY Canrsquot change

biology

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

ON-GOING

S S C

WIRE NEURONS

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C WIRE

TIMING

(behavior)

19

Not so much duration

or density of any sleep stage

or number of sleep stage episodes but

cycling between quiet sleep

and active sleepis what is important

REMREM REM

NREM NREM

This is a healthy sleep pattern

This is a very good cycling pattern

(thanks to Susan Ludington-Hoe)

REMREM REM

NREM NREM

1st hour 2nd hour

So in every hour you would like

to see an EEG pattern that shows this

REM

NREM

REM

NREM

REM

NREM

State

HR

RR

REM Sleep is supposed to be

somewhat active so

HR increases and RR is irregular

SLEEP CYCLING ndashSeparation vs contact

In separation bull Dissociated statebull No cycling chaotic pattern

48 hour baseline chaotic pattern of

activity and quiet HR amp RR

SLEEP CYCLING ndashSeparation vs contact

In SSC bull Normal cyclingbull Non-chaotic pattern

48 hour baseline chaotic pattern of

activity and quiet HR amp RRPre-KC SSC

20

modulates state organisationelicits emotional behavioursactivates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL

Schaal 2004 115

DOUCETThe secretion of Areolar (Montgomeryrsquos) Glands from Lactating Women Elicits Selective Unconditional Responses in Neonates

ldquohellip breast chemosignalsactivate oral activity on the nipple that releases a cascade of behavioral neural neuroendocrineand endocrine processes in the newborn and the motherrdquo

Doucet 2009 116

The secretion of Areolar(Montgomeryrsquos) Glands

ldquoIn early ontogeny the sleeping brain may thusremain sentient of an organismrsquos odor environmentrdquo

Doucet 2009 117

REM

NREM

A skin-to-skin contactsession SHOULD NOT be less than one hour

or 90 minutes

SLEEPING

amp

CONTAINING

FEEDING ampHANDLINGfeed

sleep

HO

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C WIRE

TIMING

(behavior)

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C WIRE

STOMACH

21

STATE organization

Feeding frequency

SLEEP cycling

BRAIN

WIRING

How often should a neonate feed

CNS

ENS

ANS

InternalSomaticenvironment

CNS cortical subcortical(also to PNS)

ANS emotional limbic brain(incl SNS)

ANS myelinated vagus (NA)

ANS unmyelinated vagus (DMC)sub-diaphragmatic

ENS submucous plexusmyenteric plexus

122

The digestive system is endowed with its own local nervous system referred to as the enteric or intrinsic nervous system

The magnitude and complexity of the enteric nervous system is immense - it contains as many neurons as the spinal cord

ENTERIC NERVOUS SYSTEM

123

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

FEEDBACK LOOPS

CNS

ENS

ANS

InternalSomaticenvironment

124

125 126

22

Fetal stomach appears 4 weeks GABy 11 weeks wall capable of muscular

contraction

ldquoPatterns of antropyloric motilityin fed healthy preterm infantsrdquo

the neuroregulatory mechanisms responsible for the coordination of antro-pyloric motility and gastric emptying are

well developed by 30 weeks of PMAHassan 2002 127

Hydrochloric acidimportant for activation of pepsinogen

inactivation of microorganisms such as bacteria

Pepsinogenactivated by acid into active pepsin

responsible for the stomachs ability to initiate digestion of proteins

Chymosinis an enzyme whose role is to curdle or

coagulate milk in the stomach a process of considerable importance in the very young animal

128

Chymosinmakes the milk into ldquocheeserdquohalfway between liquid and solidstomach empties in 60 minutes

milk

129

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

FEEDBACK LOOPS

130

EVIDENCE FORFEEDING FREQUENCY

Edmond 2006 131

Breastfeeding and motherrsquos milkStrong and consistent evidence 132

23

Cup feeding versus bottle feedingCup feeding higher breastfeeding

greater stability133

Only case series Insufficient evidence

No mention of

stomach capacity134

EVIDENCE FORSTOMACH CAPACITY

Edmond 2006 135

0

05

1

15

2

25

3

35

4

0 10 20 30 40 50 60 70 80

volume ingested

fee

din

g f

req

ue

nc

y

Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml

StandardCARE3 hourlyschedule

136

KEY QUESTION

WHAT IS THE

STOMACHVOLUMEOF THE

NEONATE 137 Sase 2005

ldquoOntogeny of gastric emptying patternsin the human fetusrdquo

138

24

Goldstein 1987

ldquoGrowth of the Fetal Stomach in Normal Pregnanciesrdquo

139 Goldstein 1987

Length

Transverse

AP diameter

Using +2SD

140

Formula for calculation of stomach capacity (Charles Bradshaw UCT)Assumptions the stomach can be approximated by dividing into three sections namely a ellipsoidal hemisphere an ellipsoidal cylinder and a skewed ellipsoidal cone Variables a = anteroposterior radius t = transverse radius l = length stomachRelations the height of the cone and the hemisphere are both the same as lsquoarsquo

Ellipsoid = 43 Pi r1r2r3 = 43 Pi a a t therefore volume of hemisphere = 23 Pi a a t

Cylinder = Area of base height = (Pi a t ) ( l - 2a )Skewed cone = 13 base height = 13 Pi a t aTotal volume = 23 Pi aat + Pi a t (l- 2a) + 13 Pi a t a

=Pi atl -Pi a at= Pi a t(l-a)

Goldstein and Sase dataStomach capacity at term 10 - 15 ml

BRADSHAW formula

141

Assumption 25 kg baby 33w GA

requiring 150 mlkgday = 375 ml

45 MIN CYCLES ( 32 cyclesday)

12 ML PER CYCLE = 384 ml142

Newborn stomach volume

Gastric volumes at birthCorrelated with gastric pH

gastrin and somatostatin

ldquofetus drinks 10 ml portions of amniotic fluid helliprdquo

Widstrom 1988 143

Only recent study locatedldquoAutopsyrdquo capacity was determined

in Indian post-mortem studies

100 autopsies (63 SB 37 ENND)Tied at cardia and pylorus filled withwater emptied amp measured repeatedldquohellip obliteration of the gastric curvaturesrdquoldquodue care to minimize stretch artifactsrdquo

Naveed 1992

ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo

144

25

Infants above 2500g onlyAve Range

Stillborn (n 11) 196 ml (10-35)Early death (n 9) 178 ml (10-25)All cases (n 20) 188 ml

Naveed 1992

ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo

145 146

KERNESSUK 1997 (Russian)

Postmortem in situ measures(applied Bradshaw formula)

AveNewborn (n 11) 15 ml2 months (n 11) 35 ml2-4 m (n 10) 50 ml4-6 m (n 8) 100 ml

Known references with data

Scammon and Doyle 1920

Zuccarellirsquos method stomach filled at autopsy to ldquoa pressure of between

15 and 20 centimeters of waterrdquo

Scammon 1920

ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo

147

Anatomic capacity was determined in post-mortem studies

Main data set Alliot 1905 (n 25)Scammon own cases (n 13)

30 ndash 35 ml at birth ndashalmost regardless of birth weight

Scammon 1920

ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo

148

Zangen S et al Rapid maturation of gastric relaxation in newborns

Pressures (mmHg)

Balloon inflates to

15 ml no increase

functional capacity

149

Zangen S et al Rapid maturation of gastric relaxation in newborns

Pressures (mmHg)

Balloon inflates to

15 ml no increase20 ml pressure OK

physiologicalcapacity hellip 150

26

EVIDENCE (NBn 111009)

Author Capacity NoteSase 10-15 ml Live term fetusGoldstein 10-15 ml Live term fetusWidstrom 10 mls Live newbornZangen 20 mls Live (pressure)

Naveed 20 mls Autopsy (SB)20 mls Autopsy (ENND)

Kernessuk 15 mls Autopsy (in situ)Scammon 30-35 ml Autopsy (water

(Alliot) pressure)151

PROPOSAL

The CAPACITY of aweek old babyrsquos stomach is

approx 20 ml152

0

05

1

15

2

25

3

35

4

0 10 20 30 40 50 60 70 80

volume ingested

fee

din

g f

req

ue

nc

y

Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml

StandardCARE3 hourlyschedule

MOTHERNATURE

1 hourlyschedule

153

PHYSIOLOGICAL CAPACITY

RECEPTIVE CAPACITY of stomach

INGESTIVE CAPACITY of BABY

FUNCTIONAL CAPACITY

154

PROPOSAL

The FEEDINGFREQUENCY of theNEONATE is

approx 60 min155

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

BRAIN CYCLING

STOMACH FILLING amp EMPTYING

REMNR1NR2NR3NR4

156

27

Normal physiology of theEnteric Nervous System

ldquoSmall and frequent feeds according to the sleep cyclerdquo

The ldquonicherdquo (occupation) of a neonate (Alberts)

BOND FEED

SLEEP SLEEP

PLAY FEED

157

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

FEEDING SUCKLING

Influence of SMELL None Totally dependent

Motor mechanism Chewing ndash different

muscles

Suckling ndash different circuits

INSULIN Increases weight No effect

GHRELIN Increases weight No effect

LEPTIN Decreases intake No effect

CHOLECYSTOKININ Decreases intake No effect

AMPHETAMINE Decreases appetite Increases suckling

SEROTONIN Agonist improves feeding Antagonist improves suck

SATIETY Infant determined Maternal supply determine

FEEDING SUCKLING

Influence of SMELL None Totally dependent

Motor mechanism Chewing ndash different

muscles

Suckling ndash different circuits

INSULIN Increases weight No effect

GHRELIN Increases weight No effect

LEPTIN Decreases intake No effect

CHOLECYSTOKININ Decreases intake No effect

AMPHETAMINE Decreases appetite Increases suckling

SEROTONIN Agonist improves feeding Antagonist improves suck

SATIETY Infant determined Maternal supply determine

Current dogmaTHE BABY KNOWS

WHEN IT HAS HAD ENOUGH

PROBABLY NOT

WHAT IS THE

STOMACH VOLUME OF THE

PREMATURE

161

Assume low resilience

Assume proportionality

162

28

The CAPACITY of alow birthweight premfrom 20ml 3000g

= 0007 x BWt (g)

1kg x 0007 = 7mls2kg x 0007 = 14mls

163

Gastric overfilling syndrome

164

75 ml per feeding ASSUMPTION

IMMATURE OR OVERWHELMED

many aspects of gastrointestinalmotility are immature in the neonate

Zangen S et al Rapid maturation of gastric relaxation in newborns

A balloon in stomachcan fill to 76 mls

What does the stomach ndashwithout a balloon ndashdo to 76 mls

REFLUX PRESUME each feedapproximately 75 mls

GER

bull Sudden outbursts of crying

bull Awakens in pain

bull Related to feedings

bull Not easily comforted

bull ldquoI know baby hurtsrdquo

bull Sour burps throaty noises

bull Best when upright

Clues to GER

Dr W Sears

29

Mitchell 2001

Kerstin Uvnaumls-Moberg

Food in duodenum

AMYLINreleased

Closes pylorus

Duodenumempty

Pylorusopens

ldquoFeed intolerancerdquo hellip hellip or VOLUME intolerance

HYPOGLYCAEMIA

A babies stomach empties in60 minutes

Blood sugarmay fall hellip

after 90 minutes Options

30

METABOLIC ADAPTATION

SSC started in the first 20 minutes after birth

SSC CotBlood glucose (1 hr) 317 256Base excess drop 34 18

(Christenson 1992)0h 1h 2h 3h 4h 2 days

App

roxim

ate

GLUCOSE

SSC Glucose production = Glucose consumption

Separation

SNS stress Glucose consumption INCREASE

PSNS dissociation Glucose production DECREASE

HYPOGLYCEMIA

SSC Cot

Blood glucose (1 hr) 317 256

0h 1h 2h 3h 4h 2 days

App

roxim

ate

GLUCOSE

SSC Glucose production = Glucose consumption

Separation PSNS dissociation

Glucose production DECREASE

HYPOGLYCEMIA

SSC Cot

Blood glucose (1 hr) 317 256

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

NEURODEVELOPMENTThe DNA Behaviour

EVOLUTIONARY BIOLOGY

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

BONDING ATTACHMENT

MRI HRVEEG

STRESS RESPONES

RESILIENCE

DOHAD

(MAL) ADAPTATION

EPIGENETICS

GENE X ENVIRONMENT

GENETIC VARIANTS

HOSPITAL ACQUIRED INFECTIONIMMUNITY

SLEEP PHYSIOLOGY

GUT FUNCTIONMICROBIOTA

ldquoSTABILITYrdquo

TRANSITION

LONG TERM FOLLOW-UP

NEUROENDOCRINE BEHAVIOURS

MATERNAL NEUROPLASTICITY

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

MORTALITYMETABOLISM

0h 1h 2h 3h 4h

PSNS (vagal)

App

roxim

ate

GLUCOSE

1 HOURLY Milk feed

1 HOURLY Milk feed

1 HOURLY Milk feed

1 HOURLY Milk feed

LACTOSE

METABOLISM

31

0h 1h 2h 3h 4h

PSNS (vagal) SYMPATHETIC STRESS

App

roxim

ate

GLUCOSE

LACTOSE FATGLYCOGEN

METABOLISM

4 HOURLY Milk feed

0h 1h 2h 3h 4h

PSNS (vagal) SYMPATHETIC STRESS

App

roxim

ate

GLUCOSE

4 HOURLY ALLOSTATIC STATELACTOSE FATGLYCOGEN

METABOLISM

4 HOURLY Milk feed

HEALTH DISEASE

EXPECTED UNEXPECTED

NEURODEVELOPMENTThe DNA Behaviour

EVOLUTIONARY BIOLOGY

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

BONDING ATTACHMENT

MRI HRVEEG

STRESS RESPONES

RESILIENCE

DOHAD

(MAL) ADAPTATION

EPIGENETICS

GENE X ENVIRONMENT

GENETIC VARIANTS

HOSPITAL ACQUIRED INFECTIONIMMUNITY

SLEEP PHYSIOLOGY

GUT FUNCTIONMICROBIOTA

ldquoSTABILITYrdquo

TRANSITION

LONG TERM FOLLOW-UP

NEUROENDOCRINE BEHAVIOURS

MATERNAL NEUROPLASTICITY

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

MORTALITYMETABOLISM

Weight gain 1st week

predicts OBESITYat 30 years

Large volume feedsstretched stomach=

doubled absorptivecapacity as adult

Importance

Programming ndash early life chronic disease

32

RESISTANCE SENSITIVITY

PERCEPTIONSldquoNEUROCEPTIONrdquo

RESPONSESTRESS

ALLOSTATIC STATE

ALLOSTASIS

ANY STRESSPsychologicalNeurological

EndocrineImmune

ALLOSTATIC LOAD

ALLOSTATIC OVERLOAD

WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY

DISEASEHEALTH

RESILIENCE VULNERABILITY

RESISTANCE SENSITIVITY

PERCEPTIONSldquoNEUROCEPTIONrdquo

RESPONSESTRESS

ALLOSTATIC STATE

ALLOSTASIS

ANY STRESSPsychologicalNeurological

EndocrineImmune

ALLOSTATIC LOAD

HEALTH

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

Gastric overfilling syndrome

189

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

33

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

Only case series Insufficient evidence

No mention of

stomach capacity196

Baby weight freq reqrsquod size actual

2kg baby 4hrly ~ 320 ml6 = 53ml 14ml

15 baby 3hrly ~ 240 ml8 = 30ml 10ml

10 baby 2hrly ~ 160 ml12 = 13ml 7ml

Standardised from20ml capacityfor 3kg baby( x 0007)

197

0

10

20

30

40

50

60

70

80

90

13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w

LINEAR

TERM

PREM

198

34

0

10

20

30

40

50

60

70

80

90

13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w

LINEAR

TERM

PREM

199

Clues to GER

ldquoI know baby hurtsrdquo

Gastric overfilling syndrome

Excessive volumesreflux aspiration colic

Excessive time intervalhypoglycaemia

Adaptationsdiabetic diathesis obesity

200

Developmental Care of the Enteric Nervous System

ldquoSmall and frequent feeds according to the sleep cyclerdquo

The ldquonicherdquo (occupation) of a neonate (Alberts)

BOND FEED

SLEEP SLEEP

PLAY FEED

201

Gastric overfilling syndrome

Proposed Management 202

Proposed Management

Babies should be fedEVERY TIME THEY WAKE

Stanley Graven 2006

REMNR1NR2NR3SWS

AS (20 mins) QS (40 mins)

A normal sleep cycle is ONE hourHow often should neonates feed

203

Proposed Management

All babies should be fedat least once an hour 204

35

Proposed Management

All babies should be fedat least once an hour

205

The first Milk Ejection Reflex (MER)

elicited in lt 2 minutesworks quicklyswallowed 1 minute

Feeding time (max)3 minutes

Repeat every 1 hour

Prime 2007

The ldquonormalrdquo or usual and common breastfeed

takes 15 minutesdiscomfort afterburping time 5 minutes

Feeding time 20 min

Repeat every 3 hours

Prime 2007

3 minute 20ml feeds x 24d = 72 minutes

20 minute 60ml feeds x 8d = 160 minutes

SMALL AND FREQUENT FEEDS ARE EFFICIENT

FEWER NURSES NEEDED

The calculated dailyrequirement for a 3kgbaby can be given without increase inpressure MINIMAL RISK

PARENTS CAN DOSAFELY

20 mls x 24 feeds= 480mls day

Zangen 2001 209

All babies should be fedat least once an hour

210

36

Infant feeding frequencyProposal based on available evidence and neuroscience

ldquoSmall and frequent feeds

adjusted to the sleep cyclerdquo

211

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

STATE organization

Feeding frequency

SLEEP cycling

BRAIN

WIRING

How often should a neonate feeda neonate sleep

Infantsleep cycles

begin to block on diurnalrhythms

Mother-infant synchrony

hellip at 12 weeks

(circadian)

START at 3 months

Can be ldquoadult-likerdquo

at 6 months

Thomas 2014

STATE organization

Feeding frequency

SLEEP cycling

PLAY FEED

216

SLEEP SLEEP

SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

Infantsleep cycles

begin to block on diurnalrhythms

37

BOND SUCKLE SLEEP SLEEP PLAY

FEED

217

SLEEP SLEEP SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)

Schaal 2004 218

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)rdquoSLEEP-FEED CYCLINGrdquo

Schaal 2004 219

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

WIRE

BRAIN

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

BRAIN

WIRING

NEUROSCIENCE

The DNAEverything else

EVOLUTIONARYBIOLOGY

The Brain

EPIGENETICS

The PlaceENVIRONMENT

EXPERIENCEFITNESS ADAPTATION

ldquoScientific foundationrdquo hellip a synthesis

ZERO

SEPARATION

38

wwwninobirthorgwwwskintoskincontactcom

THE NEUROSCIENCE OFSKIN-TO-SKIN CONTACT

AND BREASTFEEDING

ARE THE SAME

SUMMARY SKIN-TO-SKIN

(Regulation)

SLEEP(Brain)

FEEDING(Stomach)

LOVE ( ldquomindrdquo )

REMNR1NR2NR3NR4

ACQUISITION CONSOLIDATION MEMORYFORMATION

poly-sensory input transfer information P wavesshort-term memory ldquoSNRrdquo strong signals returns infostored cortex amygdala to neocortex

hippocampus organizedAwake and REM NREM stage 4 REM

BRAIN WIRING

Stanley Graven 2006

PLAY

SLEEP

FEEDHOLDYOURPREM

httpswwwfacebookcomninobirth

39

Nelson Mandela

hellip in describing themeasure of a nation

he has argued that

ldquoThere can be no keener revelation of a societyrsquos soul than the way in which it treats its childrenrdquo

Page 4: Neurodevelopmental The Neuroscience of Birth ... · breastfeeding pattern, neonatal weight gain, and the dynamics of lactation. Doucet 2012 In the ‘‘scentless breast’’ condition,

4

Fewer AG delayed grasp

Fewer AG Slower latch

Fewer AG Weaker suck

Fewer AG More weight loss day 3 of life

Fewer AG Delayed onset of lactation

Primip high AG 23 days Primip low AG 31 days

Difference p lt0001

An overlooked aspect of the human breast Areolar glands in relation with

breastfeeding pattern neonatal weight gain and the dynamics of lactation

Doucet 2012

In the lsquolsquoscentless breastrsquorsquo

condition all infants were

exposed to the motherrsquos breast

fully covered with a perfectly

transparent and airtight plastic

film (polypropylene)

( the habitual visual scene of

the breast devoid of

corresponding odors )

(1) lsquolsquoBreastrsquorsquogroup (fully

uncovered motherrsquos breast)

(2) lsquolsquoNipplersquorsquogroup (all remaining

parts covered with plastic film)

(3) lsquolsquoAreolarsquorsquogroup (remainder of

the breast and nipple covered)

(4) lsquolsquoMilkrsquorsquogroup (milk smeared

on plastic covered breast)

5

lsquolsquoBreastrsquorsquogroup 0102

more than

lsquolsquoAreolarsquorsquogroup 0038

more than

lsquolsquoMilkrsquorsquogroup 0035

Grey bar ndash odourless

plastic film

Black ndash pooled odors

They displayed significantly longer global oral activity

when facing any of the odorous breast with opened

eyes the three other conditions being equivalent

odorous breast opened eyes 1327

odorous breast closed eyes 992

scentless breast opened eyes 663

scentless breast closed eyes 839

hellip only male newborns opened their eyes longer in

response to odorous breast conditions than to the

scentless condition

(0654 vs 0425 plt01)

Related experiments indicate however that the

chemical cues that attract rat pups to the nipples

are not produced in that region Rather initial

nipple orientation is elicited by the odor of

amniotic fluid and saliva that the mother spreads

on her ventrum while grooming herself during

parturition [7]

Babies more often spontaneously selected a breast

treated with a small amount of their own AF applied to

the nippleareola region than the alternative untreated

breast during tests beginning several minutes after

parturition [112]

These results are corroborated by a study in which 2-

day-old infants were offered a simultaneous choice

between two gauze pads the length of time oriented

to the odor of their AF was reliably greater than that

towards an odorless stimulus pad [92]

PSN envisions a community that embraces its mothers and babies and

values the unique

opportunity at birthto impact the physical and emotional

well-being of the newborn

Target 1 for 2005

Report that 65 of infants are placed and remain in

direct skin to skin contactwith their mothers

for at least one hourduring the first 3 hours after birth

6

Skin-to-skin and breastfeeding (4)

0

10

20

30

40

50

60

70

80

90

100

3Q05 4Q05 1Q06 2Q06 3Q06 4Q06 1Q07 2Q07

Breastfeeding intention Skin-to-skin one hour Breastfeeding at discharge

Used with permission Ruth Stanhiser MD

Babies breastfeeding

Mothers intending to breastfeed

Breastfeeding by the NeonateRegistration by skin-to-skin contact

More skin-to-skin more breastfeeding

Thomson 1979

E Early SSC first hourL Late contact next day2 2 hourly feeds from birth4 4 hourly feeds from birth

Group Brf at 12 w Brf duration (days)

2E 643 182 (14 - 392)4E 556 140 (14 ndash 322)2L 556 112 (10 ndash 294)4L 462 77 (11 ndash 280)

Salariya 1978

7

DEFENSE NUTRITION REPRODUCTION

HORMONES NERVES MUSCLES

DEFENSE NUTRITION REPRODUCTION

HORMONES NERVES MUSCLES

= BREASTFEEDING

SAFE

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

WIRE MOTHER

NEURODEVELOPMENTThe DNA Behaviour

EVOLUTIONARY BIOLOGY

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

BIRTH

BEYOND BREASTFEEDING Feed Sleep Cycling

MOTHERBABY

BONDING Sensitization

Secure attachment

Attuned parenting

SEPARATION

OXYTOCIN

8

OXYTOCIN

OXYTOCIN comes from

Cervical dilatation

Skin-to-skin contact

Breastfeeding

Eye-to-eye contact

Effects of doula care

No doula DoulaUSA (Kennell et al 1991)

Epidural 55 8Caesarean section 18 8Forceps delivery 26 8Fetal distress 24 10

ldquoIf a Doula was a drug it would be unethical

not to use itrdquoDr John Kennell

1922 -2013Marshall Klaus amp John Kenell

EARLY CHILDHOOD DEVELOPMENT ECD

ldquoFirst 1000 daysrdquo =gestation 270year one 365year two 365total 1000 days

Resilience Vulnerability

DISEASEHEALTH

EARLY CHILDHOOD DEVELOPMENT ECD

ldquoFirst 1000 daysrdquo =

Resilience Vulnerability

DISEASEHEALTH

First 1000 sec = 16 minutes = 1st hourFirst 1000 min = 166 hours = 1st day First 1000 hrs = 1st six weeks

DOULA-ldquoA WOMAN SERVING WOMENrdquo BIRTH SUPPORT COMPANION

KANGAROO CARE amp DOULA = ldquoKANGAROULArdquo

Resilience Vulnerability

DISEASEHEALTH

9

DOULA and KANGAROULA

DOULA protects

OXYTOCINduringlabour

KANGAROULA protects

OXYTOCINafter birth

lsquothe first 1000 minutesrsquolsquoprevious 1000 minutesrsquo

BIRTH

DOULA and KANGAROULA

-1000 min

BIRTH

+1000 min

DOULA and KANGAROULA

-1000 min

BIRTH

+1000 min 1000 days

OXYTOCIN Zero separation

Caesarean

Separation

Breastfeeding

Zero separation

DOULA and KANGAROULA

-1000 min

BIRTH

+1000 min 1000 days

OXYTOCIN Zero separation

CORTISOL Enemy of oxytocin Stress

White coat

Sarcasm

Hunger

thirst

SEPARATION

Bathing

Noise

Lights

LithotomyWeighing

Crowds

SEPARATION

Perfume

rdquogood nightrsquos sleeprdquo

Birth Transition ParentingLabourPregnancy

DOULA

KANGAROULA

Prematurity Attachment Parenting

MOTHERSUPPORT

NEWBORNSUPPORT

Counselling Counselling

Breastfeeding

During the first 24 hours of life newborns ingested 15 g of milk

10

Milk making NUTRITION

HypothalamusPituitaryPROLACTIN

Maternal ferocityPROTECTION

OXYTOCIN Gaze increase BONDING

OXYTOCINCingulate Suppressed

REGULATION

AmygdalaCHOLECYSTOKININ Emotion satiety

HypothalamusPituitary

Cingulate

Amygdala

ldquoThe newborn may

appear helpless but

skin-to-skin contactstimulates prolactin

ensures nutritionstimulates oxytocin

ensures protectionstimulates cholecystokinin

ensures wellbeing bonding

The first hours after birth are a

CRITICAL PERIOD

mutual psycho-neuro-physiological

caregivers

Critical period concept

ldquoWindows of opportunity in early life when a childrsquos brain is exquisitely primed to receive sensory input in order to develop more advanced neural systemsrdquo

a motherrsquos brain hellip

SENSITIZATION

DOULA and KANGAROULA

DOULA protects

OXYTOCINduringlabour

KANGAROULA protects

OXYTOCINafter birth

lsquothe first 1000 minutesrsquolsquoprevious 1000 minutesrsquo

BIRTH

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

WIRE MOTHER

OXYTOCIN

11

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDINGON-GOING

S S C

WIRE TOGETHER

OXYTOCIN

hellip infant cues - suckling vocalisation and tactile stimulation - stimulate

OXYTOCINrelease in the hypothalamus which may result in the activation of the dopaminergic reward pathway leading to behavioural reinforcement

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

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

DISEASEHEALTH

CORTISOLOXYTOCIN

The psychology of human parent-infant relationships

Parenting is regulated by key hormones and neurotransmitters

Neuroanatomical circuits of parenting

Integrative physiology of normal parenting behaviours

Brain imaging of human parent-infant relationships

The neurobiology of empathy and parenting

Conclusions and critical summary

(Swain et al 2007)

12

FEARCONTROL

CENTRE

REWARDCONTROL

CENTRE

SOCIALCONTROL CENTRE

OXYTOCINDOPAMINE

CORTISOL

EMOTIONCONTROL CENTRE

WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY

DISEASEHEALTH

RESILIENCE VULNERABILITY

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

DOULA and KANGAROULA

-1000 min

BIRTH

+1000 min 1000 days

OXYTOCIN Zero separation

Protect OXYTOCINBefore and after

BIRTH

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDINGON-GOING

S S C

WIRE TOGETHER

Protect OXYTOCINBefore and after

BIRTH

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDINGON-GOING

S S C

WIRE SUCKLING

BREASTFEEDING Feed Sleep Cycling

BONDING Sensitization

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

BRAIN

WIRING

Neurodevelopmental Approach to

Alberts SUCKLING versus FEEDING

DUAL INGESTION SYSTEMS

13

300 mya 200 mya 100 mya 50 mya 300 mya 200 mya 100 mya 50 mya

Amniotes

Synapsids

Cynodonts

Mammaliaformes

PlacentalsMammals

ANCESTRAL STATE

hellip intoMATURE FEEDING

300 mya 200 mya 100 mya 50 mya

WATER

EGGS

Hatch withTEETH

ANCESTRAL STATE

hellip intoMATURE FEEDING

eg TURTLES

CROCODILES DINOSAURS

REPTILES

300 mya 200 mya 100 mya 50 mya

Epibubic bone = pouch care

hellip intoMATURE FEEDING

Amniotes

Synapsids

Cynodonts

Mammaliaformes

Smaller eggs longer in body

The AMNIOTE EGGextra membranes

Copes with AIR

PlacentalsMammals

Viviparity = immature

ENDOTHERMY

MOISTUREfor eggs

Diphyodontism

300 mya 200 mya 100 mya 50 mya

hellip intoMATURE FEEDING

Amniotes

Synapsids

Cynodonts

Mammaliaformes

PlacentalsMammals

ENDOTHERMY

MOISTUREfor eggs

LACTOSE added(apocrine glands)

NUTRIENTSAntimicrobials

LACTATION

SUCKLINGFEEDING

200 million years

Diphyodontism

300 mya 200 mya 100 mya 50 mya

hellip intoMATURE FEEDING

Amniotes

Synapsids

Cynodonts

Mammaliaformes

PlacentalsMammals

ENDOTHERMY

MOISTUREfor eggs

LACTOSE added(apocrine glands)

NUTRIENTSAntimicrobials

LACTATION

SUCKLINGFEEDING

200 million years

DUAL INGESTION SYSTEMS

100 million years

14

DUAL INGESTION SYSTEMS DUAL INGESTION SYSTEMS

SUCKLING WEANING FEEDING

Lactase Digestive enzymes

FEEDING SUCKLING

Influence of SMELL None Totally dependent

Motor mechanism Chewing ndash different

muscles

Suckling ndash different circuits

INSULIN Increases weight No effect

GHRELIN Increases weight No effect

LEPTIN Decreases intake No effect

CHOLECYSTOKININ Decreases intake No effect

AMPHETAMINE Decreases appetite Increases suckling

SEROTONIN Agonist improves feeding Antagonist improves suck

SATIETY Infant determined Maternal supply determine

FEEDING SUCKLING

DISRUPTION ROBUST VERY SENSITIVE

Must have right conditions

Pup-in-a- cup - And STIMULI

separated and fed by tube

From day 2 off life

Starts to feed normally d21 2 days gavage or other

no longer suckles

If starved for 24 hours pup

at d3 will feed food from

floor

(Can be maintained by

smell and other stimuli)

Pup-in-a- cup -

separated and fed by tube

From day 2 off life

Starts to feed normally d21

15

PMA 28 40 64 1y 2y

Nilsrsquo IDEALIZED VIEW

PMA 28 40 64 1y 2y

Nilsrsquo IDEALIZED VIEW

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

Reflections for practice

Suckling and Feeding areNOT THE SAME

16

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDINGON-GOING

S S C

WIRE SUCKLING

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

ON-GOING

S S C

WIRE NEURONS

Up to 6 months milk is 74 fat

96 of this is TRIGLYCERIDE

TRIGLYCERIDE Left glycerol Right palmitic acid oleic acid alpha-linolenic acid

In phosphoglycerides glycerol molecule same

two fatty acids esterified

Phospholipids area major component of all biological membranes

Sphingomyelin particularly concentrated in BRAIN major part of MYELIN

TRIGLYCERIDE

MYELIN

Dendirification and myelinisation peaks occurat 2 and 6 monthsis maximal at one year

At one year human milk has less proteinbut MORE TRIGLYCERIDE

FATTY ACIDS ARESPECIES SPECIFIC

Up to 6 months milk is 74 fat

but after 12 months it is 107

17

ldquocherry pickrdquo

Breastfeed time years school Incomelt 1 month 109 R$ 1238gt 6 month 121 R$ 1915

Group IQ 376 points higher from breatsfeeding

BREASTFEEDINGAND BREAST MILK

INCREASE IQ

BOTTLE FEEDINGamp FORMULA

DECREASE IQ

18

Be sure the wet nurse has plenty of milk because if she lacks it she may give the babymilk of a goat or sheep or some other animalbecause the child nourished on animal milkdoes not have perfect wits like one fed on womanrsquos milk and always looks stupid and vacant and not right in the head

14th century Tuscan text

Conceptual changeDyad careBreast first hour

even CaesareanContinuous SSC

DISCONTINUEGiving waterGlucose waterInfant formulaSeparationPacifier (dummy)

CHANGE POLICY Canrsquot change

biology

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

ON-GOING

S S C

WIRE NEURONS

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C WIRE

TIMING

(behavior)

19

Not so much duration

or density of any sleep stage

or number of sleep stage episodes but

cycling between quiet sleep

and active sleepis what is important

REMREM REM

NREM NREM

This is a healthy sleep pattern

This is a very good cycling pattern

(thanks to Susan Ludington-Hoe)

REMREM REM

NREM NREM

1st hour 2nd hour

So in every hour you would like

to see an EEG pattern that shows this

REM

NREM

REM

NREM

REM

NREM

State

HR

RR

REM Sleep is supposed to be

somewhat active so

HR increases and RR is irregular

SLEEP CYCLING ndashSeparation vs contact

In separation bull Dissociated statebull No cycling chaotic pattern

48 hour baseline chaotic pattern of

activity and quiet HR amp RR

SLEEP CYCLING ndashSeparation vs contact

In SSC bull Normal cyclingbull Non-chaotic pattern

48 hour baseline chaotic pattern of

activity and quiet HR amp RRPre-KC SSC

20

modulates state organisationelicits emotional behavioursactivates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL

Schaal 2004 115

DOUCETThe secretion of Areolar (Montgomeryrsquos) Glands from Lactating Women Elicits Selective Unconditional Responses in Neonates

ldquohellip breast chemosignalsactivate oral activity on the nipple that releases a cascade of behavioral neural neuroendocrineand endocrine processes in the newborn and the motherrdquo

Doucet 2009 116

The secretion of Areolar(Montgomeryrsquos) Glands

ldquoIn early ontogeny the sleeping brain may thusremain sentient of an organismrsquos odor environmentrdquo

Doucet 2009 117

REM

NREM

A skin-to-skin contactsession SHOULD NOT be less than one hour

or 90 minutes

SLEEPING

amp

CONTAINING

FEEDING ampHANDLINGfeed

sleep

HO

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C WIRE

TIMING

(behavior)

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C WIRE

STOMACH

21

STATE organization

Feeding frequency

SLEEP cycling

BRAIN

WIRING

How often should a neonate feed

CNS

ENS

ANS

InternalSomaticenvironment

CNS cortical subcortical(also to PNS)

ANS emotional limbic brain(incl SNS)

ANS myelinated vagus (NA)

ANS unmyelinated vagus (DMC)sub-diaphragmatic

ENS submucous plexusmyenteric plexus

122

The digestive system is endowed with its own local nervous system referred to as the enteric or intrinsic nervous system

The magnitude and complexity of the enteric nervous system is immense - it contains as many neurons as the spinal cord

ENTERIC NERVOUS SYSTEM

123

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

FEEDBACK LOOPS

CNS

ENS

ANS

InternalSomaticenvironment

124

125 126

22

Fetal stomach appears 4 weeks GABy 11 weeks wall capable of muscular

contraction

ldquoPatterns of antropyloric motilityin fed healthy preterm infantsrdquo

the neuroregulatory mechanisms responsible for the coordination of antro-pyloric motility and gastric emptying are

well developed by 30 weeks of PMAHassan 2002 127

Hydrochloric acidimportant for activation of pepsinogen

inactivation of microorganisms such as bacteria

Pepsinogenactivated by acid into active pepsin

responsible for the stomachs ability to initiate digestion of proteins

Chymosinis an enzyme whose role is to curdle or

coagulate milk in the stomach a process of considerable importance in the very young animal

128

Chymosinmakes the milk into ldquocheeserdquohalfway between liquid and solidstomach empties in 60 minutes

milk

129

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

FEEDBACK LOOPS

130

EVIDENCE FORFEEDING FREQUENCY

Edmond 2006 131

Breastfeeding and motherrsquos milkStrong and consistent evidence 132

23

Cup feeding versus bottle feedingCup feeding higher breastfeeding

greater stability133

Only case series Insufficient evidence

No mention of

stomach capacity134

EVIDENCE FORSTOMACH CAPACITY

Edmond 2006 135

0

05

1

15

2

25

3

35

4

0 10 20 30 40 50 60 70 80

volume ingested

fee

din

g f

req

ue

nc

y

Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml

StandardCARE3 hourlyschedule

136

KEY QUESTION

WHAT IS THE

STOMACHVOLUMEOF THE

NEONATE 137 Sase 2005

ldquoOntogeny of gastric emptying patternsin the human fetusrdquo

138

24

Goldstein 1987

ldquoGrowth of the Fetal Stomach in Normal Pregnanciesrdquo

139 Goldstein 1987

Length

Transverse

AP diameter

Using +2SD

140

Formula for calculation of stomach capacity (Charles Bradshaw UCT)Assumptions the stomach can be approximated by dividing into three sections namely a ellipsoidal hemisphere an ellipsoidal cylinder and a skewed ellipsoidal cone Variables a = anteroposterior radius t = transverse radius l = length stomachRelations the height of the cone and the hemisphere are both the same as lsquoarsquo

Ellipsoid = 43 Pi r1r2r3 = 43 Pi a a t therefore volume of hemisphere = 23 Pi a a t

Cylinder = Area of base height = (Pi a t ) ( l - 2a )Skewed cone = 13 base height = 13 Pi a t aTotal volume = 23 Pi aat + Pi a t (l- 2a) + 13 Pi a t a

=Pi atl -Pi a at= Pi a t(l-a)

Goldstein and Sase dataStomach capacity at term 10 - 15 ml

BRADSHAW formula

141

Assumption 25 kg baby 33w GA

requiring 150 mlkgday = 375 ml

45 MIN CYCLES ( 32 cyclesday)

12 ML PER CYCLE = 384 ml142

Newborn stomach volume

Gastric volumes at birthCorrelated with gastric pH

gastrin and somatostatin

ldquofetus drinks 10 ml portions of amniotic fluid helliprdquo

Widstrom 1988 143

Only recent study locatedldquoAutopsyrdquo capacity was determined

in Indian post-mortem studies

100 autopsies (63 SB 37 ENND)Tied at cardia and pylorus filled withwater emptied amp measured repeatedldquohellip obliteration of the gastric curvaturesrdquoldquodue care to minimize stretch artifactsrdquo

Naveed 1992

ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo

144

25

Infants above 2500g onlyAve Range

Stillborn (n 11) 196 ml (10-35)Early death (n 9) 178 ml (10-25)All cases (n 20) 188 ml

Naveed 1992

ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo

145 146

KERNESSUK 1997 (Russian)

Postmortem in situ measures(applied Bradshaw formula)

AveNewborn (n 11) 15 ml2 months (n 11) 35 ml2-4 m (n 10) 50 ml4-6 m (n 8) 100 ml

Known references with data

Scammon and Doyle 1920

Zuccarellirsquos method stomach filled at autopsy to ldquoa pressure of between

15 and 20 centimeters of waterrdquo

Scammon 1920

ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo

147

Anatomic capacity was determined in post-mortem studies

Main data set Alliot 1905 (n 25)Scammon own cases (n 13)

30 ndash 35 ml at birth ndashalmost regardless of birth weight

Scammon 1920

ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo

148

Zangen S et al Rapid maturation of gastric relaxation in newborns

Pressures (mmHg)

Balloon inflates to

15 ml no increase

functional capacity

149

Zangen S et al Rapid maturation of gastric relaxation in newborns

Pressures (mmHg)

Balloon inflates to

15 ml no increase20 ml pressure OK

physiologicalcapacity hellip 150

26

EVIDENCE (NBn 111009)

Author Capacity NoteSase 10-15 ml Live term fetusGoldstein 10-15 ml Live term fetusWidstrom 10 mls Live newbornZangen 20 mls Live (pressure)

Naveed 20 mls Autopsy (SB)20 mls Autopsy (ENND)

Kernessuk 15 mls Autopsy (in situ)Scammon 30-35 ml Autopsy (water

(Alliot) pressure)151

PROPOSAL

The CAPACITY of aweek old babyrsquos stomach is

approx 20 ml152

0

05

1

15

2

25

3

35

4

0 10 20 30 40 50 60 70 80

volume ingested

fee

din

g f

req

ue

nc

y

Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml

StandardCARE3 hourlyschedule

MOTHERNATURE

1 hourlyschedule

153

PHYSIOLOGICAL CAPACITY

RECEPTIVE CAPACITY of stomach

INGESTIVE CAPACITY of BABY

FUNCTIONAL CAPACITY

154

PROPOSAL

The FEEDINGFREQUENCY of theNEONATE is

approx 60 min155

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

BRAIN CYCLING

STOMACH FILLING amp EMPTYING

REMNR1NR2NR3NR4

156

27

Normal physiology of theEnteric Nervous System

ldquoSmall and frequent feeds according to the sleep cyclerdquo

The ldquonicherdquo (occupation) of a neonate (Alberts)

BOND FEED

SLEEP SLEEP

PLAY FEED

157

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

FEEDING SUCKLING

Influence of SMELL None Totally dependent

Motor mechanism Chewing ndash different

muscles

Suckling ndash different circuits

INSULIN Increases weight No effect

GHRELIN Increases weight No effect

LEPTIN Decreases intake No effect

CHOLECYSTOKININ Decreases intake No effect

AMPHETAMINE Decreases appetite Increases suckling

SEROTONIN Agonist improves feeding Antagonist improves suck

SATIETY Infant determined Maternal supply determine

FEEDING SUCKLING

Influence of SMELL None Totally dependent

Motor mechanism Chewing ndash different

muscles

Suckling ndash different circuits

INSULIN Increases weight No effect

GHRELIN Increases weight No effect

LEPTIN Decreases intake No effect

CHOLECYSTOKININ Decreases intake No effect

AMPHETAMINE Decreases appetite Increases suckling

SEROTONIN Agonist improves feeding Antagonist improves suck

SATIETY Infant determined Maternal supply determine

Current dogmaTHE BABY KNOWS

WHEN IT HAS HAD ENOUGH

PROBABLY NOT

WHAT IS THE

STOMACH VOLUME OF THE

PREMATURE

161

Assume low resilience

Assume proportionality

162

28

The CAPACITY of alow birthweight premfrom 20ml 3000g

= 0007 x BWt (g)

1kg x 0007 = 7mls2kg x 0007 = 14mls

163

Gastric overfilling syndrome

164

75 ml per feeding ASSUMPTION

IMMATURE OR OVERWHELMED

many aspects of gastrointestinalmotility are immature in the neonate

Zangen S et al Rapid maturation of gastric relaxation in newborns

A balloon in stomachcan fill to 76 mls

What does the stomach ndashwithout a balloon ndashdo to 76 mls

REFLUX PRESUME each feedapproximately 75 mls

GER

bull Sudden outbursts of crying

bull Awakens in pain

bull Related to feedings

bull Not easily comforted

bull ldquoI know baby hurtsrdquo

bull Sour burps throaty noises

bull Best when upright

Clues to GER

Dr W Sears

29

Mitchell 2001

Kerstin Uvnaumls-Moberg

Food in duodenum

AMYLINreleased

Closes pylorus

Duodenumempty

Pylorusopens

ldquoFeed intolerancerdquo hellip hellip or VOLUME intolerance

HYPOGLYCAEMIA

A babies stomach empties in60 minutes

Blood sugarmay fall hellip

after 90 minutes Options

30

METABOLIC ADAPTATION

SSC started in the first 20 minutes after birth

SSC CotBlood glucose (1 hr) 317 256Base excess drop 34 18

(Christenson 1992)0h 1h 2h 3h 4h 2 days

App

roxim

ate

GLUCOSE

SSC Glucose production = Glucose consumption

Separation

SNS stress Glucose consumption INCREASE

PSNS dissociation Glucose production DECREASE

HYPOGLYCEMIA

SSC Cot

Blood glucose (1 hr) 317 256

0h 1h 2h 3h 4h 2 days

App

roxim

ate

GLUCOSE

SSC Glucose production = Glucose consumption

Separation PSNS dissociation

Glucose production DECREASE

HYPOGLYCEMIA

SSC Cot

Blood glucose (1 hr) 317 256

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

NEURODEVELOPMENTThe DNA Behaviour

EVOLUTIONARY BIOLOGY

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

BONDING ATTACHMENT

MRI HRVEEG

STRESS RESPONES

RESILIENCE

DOHAD

(MAL) ADAPTATION

EPIGENETICS

GENE X ENVIRONMENT

GENETIC VARIANTS

HOSPITAL ACQUIRED INFECTIONIMMUNITY

SLEEP PHYSIOLOGY

GUT FUNCTIONMICROBIOTA

ldquoSTABILITYrdquo

TRANSITION

LONG TERM FOLLOW-UP

NEUROENDOCRINE BEHAVIOURS

MATERNAL NEUROPLASTICITY

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

MORTALITYMETABOLISM

0h 1h 2h 3h 4h

PSNS (vagal)

App

roxim

ate

GLUCOSE

1 HOURLY Milk feed

1 HOURLY Milk feed

1 HOURLY Milk feed

1 HOURLY Milk feed

LACTOSE

METABOLISM

31

0h 1h 2h 3h 4h

PSNS (vagal) SYMPATHETIC STRESS

App

roxim

ate

GLUCOSE

LACTOSE FATGLYCOGEN

METABOLISM

4 HOURLY Milk feed

0h 1h 2h 3h 4h

PSNS (vagal) SYMPATHETIC STRESS

App

roxim

ate

GLUCOSE

4 HOURLY ALLOSTATIC STATELACTOSE FATGLYCOGEN

METABOLISM

4 HOURLY Milk feed

HEALTH DISEASE

EXPECTED UNEXPECTED

NEURODEVELOPMENTThe DNA Behaviour

EVOLUTIONARY BIOLOGY

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

BONDING ATTACHMENT

MRI HRVEEG

STRESS RESPONES

RESILIENCE

DOHAD

(MAL) ADAPTATION

EPIGENETICS

GENE X ENVIRONMENT

GENETIC VARIANTS

HOSPITAL ACQUIRED INFECTIONIMMUNITY

SLEEP PHYSIOLOGY

GUT FUNCTIONMICROBIOTA

ldquoSTABILITYrdquo

TRANSITION

LONG TERM FOLLOW-UP

NEUROENDOCRINE BEHAVIOURS

MATERNAL NEUROPLASTICITY

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

MORTALITYMETABOLISM

Weight gain 1st week

predicts OBESITYat 30 years

Large volume feedsstretched stomach=

doubled absorptivecapacity as adult

Importance

Programming ndash early life chronic disease

32

RESISTANCE SENSITIVITY

PERCEPTIONSldquoNEUROCEPTIONrdquo

RESPONSESTRESS

ALLOSTATIC STATE

ALLOSTASIS

ANY STRESSPsychologicalNeurological

EndocrineImmune

ALLOSTATIC LOAD

ALLOSTATIC OVERLOAD

WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY

DISEASEHEALTH

RESILIENCE VULNERABILITY

RESISTANCE SENSITIVITY

PERCEPTIONSldquoNEUROCEPTIONrdquo

RESPONSESTRESS

ALLOSTATIC STATE

ALLOSTASIS

ANY STRESSPsychologicalNeurological

EndocrineImmune

ALLOSTATIC LOAD

HEALTH

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

Gastric overfilling syndrome

189

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

33

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

Only case series Insufficient evidence

No mention of

stomach capacity196

Baby weight freq reqrsquod size actual

2kg baby 4hrly ~ 320 ml6 = 53ml 14ml

15 baby 3hrly ~ 240 ml8 = 30ml 10ml

10 baby 2hrly ~ 160 ml12 = 13ml 7ml

Standardised from20ml capacityfor 3kg baby( x 0007)

197

0

10

20

30

40

50

60

70

80

90

13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w

LINEAR

TERM

PREM

198

34

0

10

20

30

40

50

60

70

80

90

13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w

LINEAR

TERM

PREM

199

Clues to GER

ldquoI know baby hurtsrdquo

Gastric overfilling syndrome

Excessive volumesreflux aspiration colic

Excessive time intervalhypoglycaemia

Adaptationsdiabetic diathesis obesity

200

Developmental Care of the Enteric Nervous System

ldquoSmall and frequent feeds according to the sleep cyclerdquo

The ldquonicherdquo (occupation) of a neonate (Alberts)

BOND FEED

SLEEP SLEEP

PLAY FEED

201

Gastric overfilling syndrome

Proposed Management 202

Proposed Management

Babies should be fedEVERY TIME THEY WAKE

Stanley Graven 2006

REMNR1NR2NR3SWS

AS (20 mins) QS (40 mins)

A normal sleep cycle is ONE hourHow often should neonates feed

203

Proposed Management

All babies should be fedat least once an hour 204

35

Proposed Management

All babies should be fedat least once an hour

205

The first Milk Ejection Reflex (MER)

elicited in lt 2 minutesworks quicklyswallowed 1 minute

Feeding time (max)3 minutes

Repeat every 1 hour

Prime 2007

The ldquonormalrdquo or usual and common breastfeed

takes 15 minutesdiscomfort afterburping time 5 minutes

Feeding time 20 min

Repeat every 3 hours

Prime 2007

3 minute 20ml feeds x 24d = 72 minutes

20 minute 60ml feeds x 8d = 160 minutes

SMALL AND FREQUENT FEEDS ARE EFFICIENT

FEWER NURSES NEEDED

The calculated dailyrequirement for a 3kgbaby can be given without increase inpressure MINIMAL RISK

PARENTS CAN DOSAFELY

20 mls x 24 feeds= 480mls day

Zangen 2001 209

All babies should be fedat least once an hour

210

36

Infant feeding frequencyProposal based on available evidence and neuroscience

ldquoSmall and frequent feeds

adjusted to the sleep cyclerdquo

211

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

STATE organization

Feeding frequency

SLEEP cycling

BRAIN

WIRING

How often should a neonate feeda neonate sleep

Infantsleep cycles

begin to block on diurnalrhythms

Mother-infant synchrony

hellip at 12 weeks

(circadian)

START at 3 months

Can be ldquoadult-likerdquo

at 6 months

Thomas 2014

STATE organization

Feeding frequency

SLEEP cycling

PLAY FEED

216

SLEEP SLEEP

SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

Infantsleep cycles

begin to block on diurnalrhythms

37

BOND SUCKLE SLEEP SLEEP PLAY

FEED

217

SLEEP SLEEP SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)

Schaal 2004 218

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)rdquoSLEEP-FEED CYCLINGrdquo

Schaal 2004 219

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

WIRE

BRAIN

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

BRAIN

WIRING

NEUROSCIENCE

The DNAEverything else

EVOLUTIONARYBIOLOGY

The Brain

EPIGENETICS

The PlaceENVIRONMENT

EXPERIENCEFITNESS ADAPTATION

ldquoScientific foundationrdquo hellip a synthesis

ZERO

SEPARATION

38

wwwninobirthorgwwwskintoskincontactcom

THE NEUROSCIENCE OFSKIN-TO-SKIN CONTACT

AND BREASTFEEDING

ARE THE SAME

SUMMARY SKIN-TO-SKIN

(Regulation)

SLEEP(Brain)

FEEDING(Stomach)

LOVE ( ldquomindrdquo )

REMNR1NR2NR3NR4

ACQUISITION CONSOLIDATION MEMORYFORMATION

poly-sensory input transfer information P wavesshort-term memory ldquoSNRrdquo strong signals returns infostored cortex amygdala to neocortex

hippocampus organizedAwake and REM NREM stage 4 REM

BRAIN WIRING

Stanley Graven 2006

PLAY

SLEEP

FEEDHOLDYOURPREM

httpswwwfacebookcomninobirth

39

Nelson Mandela

hellip in describing themeasure of a nation

he has argued that

ldquoThere can be no keener revelation of a societyrsquos soul than the way in which it treats its childrenrdquo

Page 5: Neurodevelopmental The Neuroscience of Birth ... · breastfeeding pattern, neonatal weight gain, and the dynamics of lactation. Doucet 2012 In the ‘‘scentless breast’’ condition,

5

lsquolsquoBreastrsquorsquogroup 0102

more than

lsquolsquoAreolarsquorsquogroup 0038

more than

lsquolsquoMilkrsquorsquogroup 0035

Grey bar ndash odourless

plastic film

Black ndash pooled odors

They displayed significantly longer global oral activity

when facing any of the odorous breast with opened

eyes the three other conditions being equivalent

odorous breast opened eyes 1327

odorous breast closed eyes 992

scentless breast opened eyes 663

scentless breast closed eyes 839

hellip only male newborns opened their eyes longer in

response to odorous breast conditions than to the

scentless condition

(0654 vs 0425 plt01)

Related experiments indicate however that the

chemical cues that attract rat pups to the nipples

are not produced in that region Rather initial

nipple orientation is elicited by the odor of

amniotic fluid and saliva that the mother spreads

on her ventrum while grooming herself during

parturition [7]

Babies more often spontaneously selected a breast

treated with a small amount of their own AF applied to

the nippleareola region than the alternative untreated

breast during tests beginning several minutes after

parturition [112]

These results are corroborated by a study in which 2-

day-old infants were offered a simultaneous choice

between two gauze pads the length of time oriented

to the odor of their AF was reliably greater than that

towards an odorless stimulus pad [92]

PSN envisions a community that embraces its mothers and babies and

values the unique

opportunity at birthto impact the physical and emotional

well-being of the newborn

Target 1 for 2005

Report that 65 of infants are placed and remain in

direct skin to skin contactwith their mothers

for at least one hourduring the first 3 hours after birth

6

Skin-to-skin and breastfeeding (4)

0

10

20

30

40

50

60

70

80

90

100

3Q05 4Q05 1Q06 2Q06 3Q06 4Q06 1Q07 2Q07

Breastfeeding intention Skin-to-skin one hour Breastfeeding at discharge

Used with permission Ruth Stanhiser MD

Babies breastfeeding

Mothers intending to breastfeed

Breastfeeding by the NeonateRegistration by skin-to-skin contact

More skin-to-skin more breastfeeding

Thomson 1979

E Early SSC first hourL Late contact next day2 2 hourly feeds from birth4 4 hourly feeds from birth

Group Brf at 12 w Brf duration (days)

2E 643 182 (14 - 392)4E 556 140 (14 ndash 322)2L 556 112 (10 ndash 294)4L 462 77 (11 ndash 280)

Salariya 1978

7

DEFENSE NUTRITION REPRODUCTION

HORMONES NERVES MUSCLES

DEFENSE NUTRITION REPRODUCTION

HORMONES NERVES MUSCLES

= BREASTFEEDING

SAFE

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

WIRE MOTHER

NEURODEVELOPMENTThe DNA Behaviour

EVOLUTIONARY BIOLOGY

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

BIRTH

BEYOND BREASTFEEDING Feed Sleep Cycling

MOTHERBABY

BONDING Sensitization

Secure attachment

Attuned parenting

SEPARATION

OXYTOCIN

8

OXYTOCIN

OXYTOCIN comes from

Cervical dilatation

Skin-to-skin contact

Breastfeeding

Eye-to-eye contact

Effects of doula care

No doula DoulaUSA (Kennell et al 1991)

Epidural 55 8Caesarean section 18 8Forceps delivery 26 8Fetal distress 24 10

ldquoIf a Doula was a drug it would be unethical

not to use itrdquoDr John Kennell

1922 -2013Marshall Klaus amp John Kenell

EARLY CHILDHOOD DEVELOPMENT ECD

ldquoFirst 1000 daysrdquo =gestation 270year one 365year two 365total 1000 days

Resilience Vulnerability

DISEASEHEALTH

EARLY CHILDHOOD DEVELOPMENT ECD

ldquoFirst 1000 daysrdquo =

Resilience Vulnerability

DISEASEHEALTH

First 1000 sec = 16 minutes = 1st hourFirst 1000 min = 166 hours = 1st day First 1000 hrs = 1st six weeks

DOULA-ldquoA WOMAN SERVING WOMENrdquo BIRTH SUPPORT COMPANION

KANGAROO CARE amp DOULA = ldquoKANGAROULArdquo

Resilience Vulnerability

DISEASEHEALTH

9

DOULA and KANGAROULA

DOULA protects

OXYTOCINduringlabour

KANGAROULA protects

OXYTOCINafter birth

lsquothe first 1000 minutesrsquolsquoprevious 1000 minutesrsquo

BIRTH

DOULA and KANGAROULA

-1000 min

BIRTH

+1000 min

DOULA and KANGAROULA

-1000 min

BIRTH

+1000 min 1000 days

OXYTOCIN Zero separation

Caesarean

Separation

Breastfeeding

Zero separation

DOULA and KANGAROULA

-1000 min

BIRTH

+1000 min 1000 days

OXYTOCIN Zero separation

CORTISOL Enemy of oxytocin Stress

White coat

Sarcasm

Hunger

thirst

SEPARATION

Bathing

Noise

Lights

LithotomyWeighing

Crowds

SEPARATION

Perfume

rdquogood nightrsquos sleeprdquo

Birth Transition ParentingLabourPregnancy

DOULA

KANGAROULA

Prematurity Attachment Parenting

MOTHERSUPPORT

NEWBORNSUPPORT

Counselling Counselling

Breastfeeding

During the first 24 hours of life newborns ingested 15 g of milk

10

Milk making NUTRITION

HypothalamusPituitaryPROLACTIN

Maternal ferocityPROTECTION

OXYTOCIN Gaze increase BONDING

OXYTOCINCingulate Suppressed

REGULATION

AmygdalaCHOLECYSTOKININ Emotion satiety

HypothalamusPituitary

Cingulate

Amygdala

ldquoThe newborn may

appear helpless but

skin-to-skin contactstimulates prolactin

ensures nutritionstimulates oxytocin

ensures protectionstimulates cholecystokinin

ensures wellbeing bonding

The first hours after birth are a

CRITICAL PERIOD

mutual psycho-neuro-physiological

caregivers

Critical period concept

ldquoWindows of opportunity in early life when a childrsquos brain is exquisitely primed to receive sensory input in order to develop more advanced neural systemsrdquo

a motherrsquos brain hellip

SENSITIZATION

DOULA and KANGAROULA

DOULA protects

OXYTOCINduringlabour

KANGAROULA protects

OXYTOCINafter birth

lsquothe first 1000 minutesrsquolsquoprevious 1000 minutesrsquo

BIRTH

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

WIRE MOTHER

OXYTOCIN

11

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDINGON-GOING

S S C

WIRE TOGETHER

OXYTOCIN

hellip infant cues - suckling vocalisation and tactile stimulation - stimulate

OXYTOCINrelease in the hypothalamus which may result in the activation of the dopaminergic reward pathway leading to behavioural reinforcement

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

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

DISEASEHEALTH

CORTISOLOXYTOCIN

The psychology of human parent-infant relationships

Parenting is regulated by key hormones and neurotransmitters

Neuroanatomical circuits of parenting

Integrative physiology of normal parenting behaviours

Brain imaging of human parent-infant relationships

The neurobiology of empathy and parenting

Conclusions and critical summary

(Swain et al 2007)

12

FEARCONTROL

CENTRE

REWARDCONTROL

CENTRE

SOCIALCONTROL CENTRE

OXYTOCINDOPAMINE

CORTISOL

EMOTIONCONTROL CENTRE

WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY

DISEASEHEALTH

RESILIENCE VULNERABILITY

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

DOULA and KANGAROULA

-1000 min

BIRTH

+1000 min 1000 days

OXYTOCIN Zero separation

Protect OXYTOCINBefore and after

BIRTH

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDINGON-GOING

S S C

WIRE TOGETHER

Protect OXYTOCINBefore and after

BIRTH

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDINGON-GOING

S S C

WIRE SUCKLING

BREASTFEEDING Feed Sleep Cycling

BONDING Sensitization

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

BRAIN

WIRING

Neurodevelopmental Approach to

Alberts SUCKLING versus FEEDING

DUAL INGESTION SYSTEMS

13

300 mya 200 mya 100 mya 50 mya 300 mya 200 mya 100 mya 50 mya

Amniotes

Synapsids

Cynodonts

Mammaliaformes

PlacentalsMammals

ANCESTRAL STATE

hellip intoMATURE FEEDING

300 mya 200 mya 100 mya 50 mya

WATER

EGGS

Hatch withTEETH

ANCESTRAL STATE

hellip intoMATURE FEEDING

eg TURTLES

CROCODILES DINOSAURS

REPTILES

300 mya 200 mya 100 mya 50 mya

Epibubic bone = pouch care

hellip intoMATURE FEEDING

Amniotes

Synapsids

Cynodonts

Mammaliaformes

Smaller eggs longer in body

The AMNIOTE EGGextra membranes

Copes with AIR

PlacentalsMammals

Viviparity = immature

ENDOTHERMY

MOISTUREfor eggs

Diphyodontism

300 mya 200 mya 100 mya 50 mya

hellip intoMATURE FEEDING

Amniotes

Synapsids

Cynodonts

Mammaliaformes

PlacentalsMammals

ENDOTHERMY

MOISTUREfor eggs

LACTOSE added(apocrine glands)

NUTRIENTSAntimicrobials

LACTATION

SUCKLINGFEEDING

200 million years

Diphyodontism

300 mya 200 mya 100 mya 50 mya

hellip intoMATURE FEEDING

Amniotes

Synapsids

Cynodonts

Mammaliaformes

PlacentalsMammals

ENDOTHERMY

MOISTUREfor eggs

LACTOSE added(apocrine glands)

NUTRIENTSAntimicrobials

LACTATION

SUCKLINGFEEDING

200 million years

DUAL INGESTION SYSTEMS

100 million years

14

DUAL INGESTION SYSTEMS DUAL INGESTION SYSTEMS

SUCKLING WEANING FEEDING

Lactase Digestive enzymes

FEEDING SUCKLING

Influence of SMELL None Totally dependent

Motor mechanism Chewing ndash different

muscles

Suckling ndash different circuits

INSULIN Increases weight No effect

GHRELIN Increases weight No effect

LEPTIN Decreases intake No effect

CHOLECYSTOKININ Decreases intake No effect

AMPHETAMINE Decreases appetite Increases suckling

SEROTONIN Agonist improves feeding Antagonist improves suck

SATIETY Infant determined Maternal supply determine

FEEDING SUCKLING

DISRUPTION ROBUST VERY SENSITIVE

Must have right conditions

Pup-in-a- cup - And STIMULI

separated and fed by tube

From day 2 off life

Starts to feed normally d21 2 days gavage or other

no longer suckles

If starved for 24 hours pup

at d3 will feed food from

floor

(Can be maintained by

smell and other stimuli)

Pup-in-a- cup -

separated and fed by tube

From day 2 off life

Starts to feed normally d21

15

PMA 28 40 64 1y 2y

Nilsrsquo IDEALIZED VIEW

PMA 28 40 64 1y 2y

Nilsrsquo IDEALIZED VIEW

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

Reflections for practice

Suckling and Feeding areNOT THE SAME

16

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDINGON-GOING

S S C

WIRE SUCKLING

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

ON-GOING

S S C

WIRE NEURONS

Up to 6 months milk is 74 fat

96 of this is TRIGLYCERIDE

TRIGLYCERIDE Left glycerol Right palmitic acid oleic acid alpha-linolenic acid

In phosphoglycerides glycerol molecule same

two fatty acids esterified

Phospholipids area major component of all biological membranes

Sphingomyelin particularly concentrated in BRAIN major part of MYELIN

TRIGLYCERIDE

MYELIN

Dendirification and myelinisation peaks occurat 2 and 6 monthsis maximal at one year

At one year human milk has less proteinbut MORE TRIGLYCERIDE

FATTY ACIDS ARESPECIES SPECIFIC

Up to 6 months milk is 74 fat

but after 12 months it is 107

17

ldquocherry pickrdquo

Breastfeed time years school Incomelt 1 month 109 R$ 1238gt 6 month 121 R$ 1915

Group IQ 376 points higher from breatsfeeding

BREASTFEEDINGAND BREAST MILK

INCREASE IQ

BOTTLE FEEDINGamp FORMULA

DECREASE IQ

18

Be sure the wet nurse has plenty of milk because if she lacks it she may give the babymilk of a goat or sheep or some other animalbecause the child nourished on animal milkdoes not have perfect wits like one fed on womanrsquos milk and always looks stupid and vacant and not right in the head

14th century Tuscan text

Conceptual changeDyad careBreast first hour

even CaesareanContinuous SSC

DISCONTINUEGiving waterGlucose waterInfant formulaSeparationPacifier (dummy)

CHANGE POLICY Canrsquot change

biology

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

ON-GOING

S S C

WIRE NEURONS

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C WIRE

TIMING

(behavior)

19

Not so much duration

or density of any sleep stage

or number of sleep stage episodes but

cycling between quiet sleep

and active sleepis what is important

REMREM REM

NREM NREM

This is a healthy sleep pattern

This is a very good cycling pattern

(thanks to Susan Ludington-Hoe)

REMREM REM

NREM NREM

1st hour 2nd hour

So in every hour you would like

to see an EEG pattern that shows this

REM

NREM

REM

NREM

REM

NREM

State

HR

RR

REM Sleep is supposed to be

somewhat active so

HR increases and RR is irregular

SLEEP CYCLING ndashSeparation vs contact

In separation bull Dissociated statebull No cycling chaotic pattern

48 hour baseline chaotic pattern of

activity and quiet HR amp RR

SLEEP CYCLING ndashSeparation vs contact

In SSC bull Normal cyclingbull Non-chaotic pattern

48 hour baseline chaotic pattern of

activity and quiet HR amp RRPre-KC SSC

20

modulates state organisationelicits emotional behavioursactivates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL

Schaal 2004 115

DOUCETThe secretion of Areolar (Montgomeryrsquos) Glands from Lactating Women Elicits Selective Unconditional Responses in Neonates

ldquohellip breast chemosignalsactivate oral activity on the nipple that releases a cascade of behavioral neural neuroendocrineand endocrine processes in the newborn and the motherrdquo

Doucet 2009 116

The secretion of Areolar(Montgomeryrsquos) Glands

ldquoIn early ontogeny the sleeping brain may thusremain sentient of an organismrsquos odor environmentrdquo

Doucet 2009 117

REM

NREM

A skin-to-skin contactsession SHOULD NOT be less than one hour

or 90 minutes

SLEEPING

amp

CONTAINING

FEEDING ampHANDLINGfeed

sleep

HO

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C WIRE

TIMING

(behavior)

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C WIRE

STOMACH

21

STATE organization

Feeding frequency

SLEEP cycling

BRAIN

WIRING

How often should a neonate feed

CNS

ENS

ANS

InternalSomaticenvironment

CNS cortical subcortical(also to PNS)

ANS emotional limbic brain(incl SNS)

ANS myelinated vagus (NA)

ANS unmyelinated vagus (DMC)sub-diaphragmatic

ENS submucous plexusmyenteric plexus

122

The digestive system is endowed with its own local nervous system referred to as the enteric or intrinsic nervous system

The magnitude and complexity of the enteric nervous system is immense - it contains as many neurons as the spinal cord

ENTERIC NERVOUS SYSTEM

123

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

FEEDBACK LOOPS

CNS

ENS

ANS

InternalSomaticenvironment

124

125 126

22

Fetal stomach appears 4 weeks GABy 11 weeks wall capable of muscular

contraction

ldquoPatterns of antropyloric motilityin fed healthy preterm infantsrdquo

the neuroregulatory mechanisms responsible for the coordination of antro-pyloric motility and gastric emptying are

well developed by 30 weeks of PMAHassan 2002 127

Hydrochloric acidimportant for activation of pepsinogen

inactivation of microorganisms such as bacteria

Pepsinogenactivated by acid into active pepsin

responsible for the stomachs ability to initiate digestion of proteins

Chymosinis an enzyme whose role is to curdle or

coagulate milk in the stomach a process of considerable importance in the very young animal

128

Chymosinmakes the milk into ldquocheeserdquohalfway between liquid and solidstomach empties in 60 minutes

milk

129

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

FEEDBACK LOOPS

130

EVIDENCE FORFEEDING FREQUENCY

Edmond 2006 131

Breastfeeding and motherrsquos milkStrong and consistent evidence 132

23

Cup feeding versus bottle feedingCup feeding higher breastfeeding

greater stability133

Only case series Insufficient evidence

No mention of

stomach capacity134

EVIDENCE FORSTOMACH CAPACITY

Edmond 2006 135

0

05

1

15

2

25

3

35

4

0 10 20 30 40 50 60 70 80

volume ingested

fee

din

g f

req

ue

nc

y

Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml

StandardCARE3 hourlyschedule

136

KEY QUESTION

WHAT IS THE

STOMACHVOLUMEOF THE

NEONATE 137 Sase 2005

ldquoOntogeny of gastric emptying patternsin the human fetusrdquo

138

24

Goldstein 1987

ldquoGrowth of the Fetal Stomach in Normal Pregnanciesrdquo

139 Goldstein 1987

Length

Transverse

AP diameter

Using +2SD

140

Formula for calculation of stomach capacity (Charles Bradshaw UCT)Assumptions the stomach can be approximated by dividing into three sections namely a ellipsoidal hemisphere an ellipsoidal cylinder and a skewed ellipsoidal cone Variables a = anteroposterior radius t = transverse radius l = length stomachRelations the height of the cone and the hemisphere are both the same as lsquoarsquo

Ellipsoid = 43 Pi r1r2r3 = 43 Pi a a t therefore volume of hemisphere = 23 Pi a a t

Cylinder = Area of base height = (Pi a t ) ( l - 2a )Skewed cone = 13 base height = 13 Pi a t aTotal volume = 23 Pi aat + Pi a t (l- 2a) + 13 Pi a t a

=Pi atl -Pi a at= Pi a t(l-a)

Goldstein and Sase dataStomach capacity at term 10 - 15 ml

BRADSHAW formula

141

Assumption 25 kg baby 33w GA

requiring 150 mlkgday = 375 ml

45 MIN CYCLES ( 32 cyclesday)

12 ML PER CYCLE = 384 ml142

Newborn stomach volume

Gastric volumes at birthCorrelated with gastric pH

gastrin and somatostatin

ldquofetus drinks 10 ml portions of amniotic fluid helliprdquo

Widstrom 1988 143

Only recent study locatedldquoAutopsyrdquo capacity was determined

in Indian post-mortem studies

100 autopsies (63 SB 37 ENND)Tied at cardia and pylorus filled withwater emptied amp measured repeatedldquohellip obliteration of the gastric curvaturesrdquoldquodue care to minimize stretch artifactsrdquo

Naveed 1992

ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo

144

25

Infants above 2500g onlyAve Range

Stillborn (n 11) 196 ml (10-35)Early death (n 9) 178 ml (10-25)All cases (n 20) 188 ml

Naveed 1992

ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo

145 146

KERNESSUK 1997 (Russian)

Postmortem in situ measures(applied Bradshaw formula)

AveNewborn (n 11) 15 ml2 months (n 11) 35 ml2-4 m (n 10) 50 ml4-6 m (n 8) 100 ml

Known references with data

Scammon and Doyle 1920

Zuccarellirsquos method stomach filled at autopsy to ldquoa pressure of between

15 and 20 centimeters of waterrdquo

Scammon 1920

ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo

147

Anatomic capacity was determined in post-mortem studies

Main data set Alliot 1905 (n 25)Scammon own cases (n 13)

30 ndash 35 ml at birth ndashalmost regardless of birth weight

Scammon 1920

ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo

148

Zangen S et al Rapid maturation of gastric relaxation in newborns

Pressures (mmHg)

Balloon inflates to

15 ml no increase

functional capacity

149

Zangen S et al Rapid maturation of gastric relaxation in newborns

Pressures (mmHg)

Balloon inflates to

15 ml no increase20 ml pressure OK

physiologicalcapacity hellip 150

26

EVIDENCE (NBn 111009)

Author Capacity NoteSase 10-15 ml Live term fetusGoldstein 10-15 ml Live term fetusWidstrom 10 mls Live newbornZangen 20 mls Live (pressure)

Naveed 20 mls Autopsy (SB)20 mls Autopsy (ENND)

Kernessuk 15 mls Autopsy (in situ)Scammon 30-35 ml Autopsy (water

(Alliot) pressure)151

PROPOSAL

The CAPACITY of aweek old babyrsquos stomach is

approx 20 ml152

0

05

1

15

2

25

3

35

4

0 10 20 30 40 50 60 70 80

volume ingested

fee

din

g f

req

ue

nc

y

Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml

StandardCARE3 hourlyschedule

MOTHERNATURE

1 hourlyschedule

153

PHYSIOLOGICAL CAPACITY

RECEPTIVE CAPACITY of stomach

INGESTIVE CAPACITY of BABY

FUNCTIONAL CAPACITY

154

PROPOSAL

The FEEDINGFREQUENCY of theNEONATE is

approx 60 min155

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

BRAIN CYCLING

STOMACH FILLING amp EMPTYING

REMNR1NR2NR3NR4

156

27

Normal physiology of theEnteric Nervous System

ldquoSmall and frequent feeds according to the sleep cyclerdquo

The ldquonicherdquo (occupation) of a neonate (Alberts)

BOND FEED

SLEEP SLEEP

PLAY FEED

157

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

FEEDING SUCKLING

Influence of SMELL None Totally dependent

Motor mechanism Chewing ndash different

muscles

Suckling ndash different circuits

INSULIN Increases weight No effect

GHRELIN Increases weight No effect

LEPTIN Decreases intake No effect

CHOLECYSTOKININ Decreases intake No effect

AMPHETAMINE Decreases appetite Increases suckling

SEROTONIN Agonist improves feeding Antagonist improves suck

SATIETY Infant determined Maternal supply determine

FEEDING SUCKLING

Influence of SMELL None Totally dependent

Motor mechanism Chewing ndash different

muscles

Suckling ndash different circuits

INSULIN Increases weight No effect

GHRELIN Increases weight No effect

LEPTIN Decreases intake No effect

CHOLECYSTOKININ Decreases intake No effect

AMPHETAMINE Decreases appetite Increases suckling

SEROTONIN Agonist improves feeding Antagonist improves suck

SATIETY Infant determined Maternal supply determine

Current dogmaTHE BABY KNOWS

WHEN IT HAS HAD ENOUGH

PROBABLY NOT

WHAT IS THE

STOMACH VOLUME OF THE

PREMATURE

161

Assume low resilience

Assume proportionality

162

28

The CAPACITY of alow birthweight premfrom 20ml 3000g

= 0007 x BWt (g)

1kg x 0007 = 7mls2kg x 0007 = 14mls

163

Gastric overfilling syndrome

164

75 ml per feeding ASSUMPTION

IMMATURE OR OVERWHELMED

many aspects of gastrointestinalmotility are immature in the neonate

Zangen S et al Rapid maturation of gastric relaxation in newborns

A balloon in stomachcan fill to 76 mls

What does the stomach ndashwithout a balloon ndashdo to 76 mls

REFLUX PRESUME each feedapproximately 75 mls

GER

bull Sudden outbursts of crying

bull Awakens in pain

bull Related to feedings

bull Not easily comforted

bull ldquoI know baby hurtsrdquo

bull Sour burps throaty noises

bull Best when upright

Clues to GER

Dr W Sears

29

Mitchell 2001

Kerstin Uvnaumls-Moberg

Food in duodenum

AMYLINreleased

Closes pylorus

Duodenumempty

Pylorusopens

ldquoFeed intolerancerdquo hellip hellip or VOLUME intolerance

HYPOGLYCAEMIA

A babies stomach empties in60 minutes

Blood sugarmay fall hellip

after 90 minutes Options

30

METABOLIC ADAPTATION

SSC started in the first 20 minutes after birth

SSC CotBlood glucose (1 hr) 317 256Base excess drop 34 18

(Christenson 1992)0h 1h 2h 3h 4h 2 days

App

roxim

ate

GLUCOSE

SSC Glucose production = Glucose consumption

Separation

SNS stress Glucose consumption INCREASE

PSNS dissociation Glucose production DECREASE

HYPOGLYCEMIA

SSC Cot

Blood glucose (1 hr) 317 256

0h 1h 2h 3h 4h 2 days

App

roxim

ate

GLUCOSE

SSC Glucose production = Glucose consumption

Separation PSNS dissociation

Glucose production DECREASE

HYPOGLYCEMIA

SSC Cot

Blood glucose (1 hr) 317 256

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

NEURODEVELOPMENTThe DNA Behaviour

EVOLUTIONARY BIOLOGY

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

BONDING ATTACHMENT

MRI HRVEEG

STRESS RESPONES

RESILIENCE

DOHAD

(MAL) ADAPTATION

EPIGENETICS

GENE X ENVIRONMENT

GENETIC VARIANTS

HOSPITAL ACQUIRED INFECTIONIMMUNITY

SLEEP PHYSIOLOGY

GUT FUNCTIONMICROBIOTA

ldquoSTABILITYrdquo

TRANSITION

LONG TERM FOLLOW-UP

NEUROENDOCRINE BEHAVIOURS

MATERNAL NEUROPLASTICITY

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

MORTALITYMETABOLISM

0h 1h 2h 3h 4h

PSNS (vagal)

App

roxim

ate

GLUCOSE

1 HOURLY Milk feed

1 HOURLY Milk feed

1 HOURLY Milk feed

1 HOURLY Milk feed

LACTOSE

METABOLISM

31

0h 1h 2h 3h 4h

PSNS (vagal) SYMPATHETIC STRESS

App

roxim

ate

GLUCOSE

LACTOSE FATGLYCOGEN

METABOLISM

4 HOURLY Milk feed

0h 1h 2h 3h 4h

PSNS (vagal) SYMPATHETIC STRESS

App

roxim

ate

GLUCOSE

4 HOURLY ALLOSTATIC STATELACTOSE FATGLYCOGEN

METABOLISM

4 HOURLY Milk feed

HEALTH DISEASE

EXPECTED UNEXPECTED

NEURODEVELOPMENTThe DNA Behaviour

EVOLUTIONARY BIOLOGY

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

BONDING ATTACHMENT

MRI HRVEEG

STRESS RESPONES

RESILIENCE

DOHAD

(MAL) ADAPTATION

EPIGENETICS

GENE X ENVIRONMENT

GENETIC VARIANTS

HOSPITAL ACQUIRED INFECTIONIMMUNITY

SLEEP PHYSIOLOGY

GUT FUNCTIONMICROBIOTA

ldquoSTABILITYrdquo

TRANSITION

LONG TERM FOLLOW-UP

NEUROENDOCRINE BEHAVIOURS

MATERNAL NEUROPLASTICITY

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

MORTALITYMETABOLISM

Weight gain 1st week

predicts OBESITYat 30 years

Large volume feedsstretched stomach=

doubled absorptivecapacity as adult

Importance

Programming ndash early life chronic disease

32

RESISTANCE SENSITIVITY

PERCEPTIONSldquoNEUROCEPTIONrdquo

RESPONSESTRESS

ALLOSTATIC STATE

ALLOSTASIS

ANY STRESSPsychologicalNeurological

EndocrineImmune

ALLOSTATIC LOAD

ALLOSTATIC OVERLOAD

WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY

DISEASEHEALTH

RESILIENCE VULNERABILITY

RESISTANCE SENSITIVITY

PERCEPTIONSldquoNEUROCEPTIONrdquo

RESPONSESTRESS

ALLOSTATIC STATE

ALLOSTASIS

ANY STRESSPsychologicalNeurological

EndocrineImmune

ALLOSTATIC LOAD

HEALTH

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

Gastric overfilling syndrome

189

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

33

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

Only case series Insufficient evidence

No mention of

stomach capacity196

Baby weight freq reqrsquod size actual

2kg baby 4hrly ~ 320 ml6 = 53ml 14ml

15 baby 3hrly ~ 240 ml8 = 30ml 10ml

10 baby 2hrly ~ 160 ml12 = 13ml 7ml

Standardised from20ml capacityfor 3kg baby( x 0007)

197

0

10

20

30

40

50

60

70

80

90

13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w

LINEAR

TERM

PREM

198

34

0

10

20

30

40

50

60

70

80

90

13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w

LINEAR

TERM

PREM

199

Clues to GER

ldquoI know baby hurtsrdquo

Gastric overfilling syndrome

Excessive volumesreflux aspiration colic

Excessive time intervalhypoglycaemia

Adaptationsdiabetic diathesis obesity

200

Developmental Care of the Enteric Nervous System

ldquoSmall and frequent feeds according to the sleep cyclerdquo

The ldquonicherdquo (occupation) of a neonate (Alberts)

BOND FEED

SLEEP SLEEP

PLAY FEED

201

Gastric overfilling syndrome

Proposed Management 202

Proposed Management

Babies should be fedEVERY TIME THEY WAKE

Stanley Graven 2006

REMNR1NR2NR3SWS

AS (20 mins) QS (40 mins)

A normal sleep cycle is ONE hourHow often should neonates feed

203

Proposed Management

All babies should be fedat least once an hour 204

35

Proposed Management

All babies should be fedat least once an hour

205

The first Milk Ejection Reflex (MER)

elicited in lt 2 minutesworks quicklyswallowed 1 minute

Feeding time (max)3 minutes

Repeat every 1 hour

Prime 2007

The ldquonormalrdquo or usual and common breastfeed

takes 15 minutesdiscomfort afterburping time 5 minutes

Feeding time 20 min

Repeat every 3 hours

Prime 2007

3 minute 20ml feeds x 24d = 72 minutes

20 minute 60ml feeds x 8d = 160 minutes

SMALL AND FREQUENT FEEDS ARE EFFICIENT

FEWER NURSES NEEDED

The calculated dailyrequirement for a 3kgbaby can be given without increase inpressure MINIMAL RISK

PARENTS CAN DOSAFELY

20 mls x 24 feeds= 480mls day

Zangen 2001 209

All babies should be fedat least once an hour

210

36

Infant feeding frequencyProposal based on available evidence and neuroscience

ldquoSmall and frequent feeds

adjusted to the sleep cyclerdquo

211

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

STATE organization

Feeding frequency

SLEEP cycling

BRAIN

WIRING

How often should a neonate feeda neonate sleep

Infantsleep cycles

begin to block on diurnalrhythms

Mother-infant synchrony

hellip at 12 weeks

(circadian)

START at 3 months

Can be ldquoadult-likerdquo

at 6 months

Thomas 2014

STATE organization

Feeding frequency

SLEEP cycling

PLAY FEED

216

SLEEP SLEEP

SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

Infantsleep cycles

begin to block on diurnalrhythms

37

BOND SUCKLE SLEEP SLEEP PLAY

FEED

217

SLEEP SLEEP SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)

Schaal 2004 218

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)rdquoSLEEP-FEED CYCLINGrdquo

Schaal 2004 219

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

WIRE

BRAIN

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

BRAIN

WIRING

NEUROSCIENCE

The DNAEverything else

EVOLUTIONARYBIOLOGY

The Brain

EPIGENETICS

The PlaceENVIRONMENT

EXPERIENCEFITNESS ADAPTATION

ldquoScientific foundationrdquo hellip a synthesis

ZERO

SEPARATION

38

wwwninobirthorgwwwskintoskincontactcom

THE NEUROSCIENCE OFSKIN-TO-SKIN CONTACT

AND BREASTFEEDING

ARE THE SAME

SUMMARY SKIN-TO-SKIN

(Regulation)

SLEEP(Brain)

FEEDING(Stomach)

LOVE ( ldquomindrdquo )

REMNR1NR2NR3NR4

ACQUISITION CONSOLIDATION MEMORYFORMATION

poly-sensory input transfer information P wavesshort-term memory ldquoSNRrdquo strong signals returns infostored cortex amygdala to neocortex

hippocampus organizedAwake and REM NREM stage 4 REM

BRAIN WIRING

Stanley Graven 2006

PLAY

SLEEP

FEEDHOLDYOURPREM

httpswwwfacebookcomninobirth

39

Nelson Mandela

hellip in describing themeasure of a nation

he has argued that

ldquoThere can be no keener revelation of a societyrsquos soul than the way in which it treats its childrenrdquo

Page 6: Neurodevelopmental The Neuroscience of Birth ... · breastfeeding pattern, neonatal weight gain, and the dynamics of lactation. Doucet 2012 In the ‘‘scentless breast’’ condition,

6

Skin-to-skin and breastfeeding (4)

0

10

20

30

40

50

60

70

80

90

100

3Q05 4Q05 1Q06 2Q06 3Q06 4Q06 1Q07 2Q07

Breastfeeding intention Skin-to-skin one hour Breastfeeding at discharge

Used with permission Ruth Stanhiser MD

Babies breastfeeding

Mothers intending to breastfeed

Breastfeeding by the NeonateRegistration by skin-to-skin contact

More skin-to-skin more breastfeeding

Thomson 1979

E Early SSC first hourL Late contact next day2 2 hourly feeds from birth4 4 hourly feeds from birth

Group Brf at 12 w Brf duration (days)

2E 643 182 (14 - 392)4E 556 140 (14 ndash 322)2L 556 112 (10 ndash 294)4L 462 77 (11 ndash 280)

Salariya 1978

7

DEFENSE NUTRITION REPRODUCTION

HORMONES NERVES MUSCLES

DEFENSE NUTRITION REPRODUCTION

HORMONES NERVES MUSCLES

= BREASTFEEDING

SAFE

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

WIRE MOTHER

NEURODEVELOPMENTThe DNA Behaviour

EVOLUTIONARY BIOLOGY

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

BIRTH

BEYOND BREASTFEEDING Feed Sleep Cycling

MOTHERBABY

BONDING Sensitization

Secure attachment

Attuned parenting

SEPARATION

OXYTOCIN

8

OXYTOCIN

OXYTOCIN comes from

Cervical dilatation

Skin-to-skin contact

Breastfeeding

Eye-to-eye contact

Effects of doula care

No doula DoulaUSA (Kennell et al 1991)

Epidural 55 8Caesarean section 18 8Forceps delivery 26 8Fetal distress 24 10

ldquoIf a Doula was a drug it would be unethical

not to use itrdquoDr John Kennell

1922 -2013Marshall Klaus amp John Kenell

EARLY CHILDHOOD DEVELOPMENT ECD

ldquoFirst 1000 daysrdquo =gestation 270year one 365year two 365total 1000 days

Resilience Vulnerability

DISEASEHEALTH

EARLY CHILDHOOD DEVELOPMENT ECD

ldquoFirst 1000 daysrdquo =

Resilience Vulnerability

DISEASEHEALTH

First 1000 sec = 16 minutes = 1st hourFirst 1000 min = 166 hours = 1st day First 1000 hrs = 1st six weeks

DOULA-ldquoA WOMAN SERVING WOMENrdquo BIRTH SUPPORT COMPANION

KANGAROO CARE amp DOULA = ldquoKANGAROULArdquo

Resilience Vulnerability

DISEASEHEALTH

9

DOULA and KANGAROULA

DOULA protects

OXYTOCINduringlabour

KANGAROULA protects

OXYTOCINafter birth

lsquothe first 1000 minutesrsquolsquoprevious 1000 minutesrsquo

BIRTH

DOULA and KANGAROULA

-1000 min

BIRTH

+1000 min

DOULA and KANGAROULA

-1000 min

BIRTH

+1000 min 1000 days

OXYTOCIN Zero separation

Caesarean

Separation

Breastfeeding

Zero separation

DOULA and KANGAROULA

-1000 min

BIRTH

+1000 min 1000 days

OXYTOCIN Zero separation

CORTISOL Enemy of oxytocin Stress

White coat

Sarcasm

Hunger

thirst

SEPARATION

Bathing

Noise

Lights

LithotomyWeighing

Crowds

SEPARATION

Perfume

rdquogood nightrsquos sleeprdquo

Birth Transition ParentingLabourPregnancy

DOULA

KANGAROULA

Prematurity Attachment Parenting

MOTHERSUPPORT

NEWBORNSUPPORT

Counselling Counselling

Breastfeeding

During the first 24 hours of life newborns ingested 15 g of milk

10

Milk making NUTRITION

HypothalamusPituitaryPROLACTIN

Maternal ferocityPROTECTION

OXYTOCIN Gaze increase BONDING

OXYTOCINCingulate Suppressed

REGULATION

AmygdalaCHOLECYSTOKININ Emotion satiety

HypothalamusPituitary

Cingulate

Amygdala

ldquoThe newborn may

appear helpless but

skin-to-skin contactstimulates prolactin

ensures nutritionstimulates oxytocin

ensures protectionstimulates cholecystokinin

ensures wellbeing bonding

The first hours after birth are a

CRITICAL PERIOD

mutual psycho-neuro-physiological

caregivers

Critical period concept

ldquoWindows of opportunity in early life when a childrsquos brain is exquisitely primed to receive sensory input in order to develop more advanced neural systemsrdquo

a motherrsquos brain hellip

SENSITIZATION

DOULA and KANGAROULA

DOULA protects

OXYTOCINduringlabour

KANGAROULA protects

OXYTOCINafter birth

lsquothe first 1000 minutesrsquolsquoprevious 1000 minutesrsquo

BIRTH

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

WIRE MOTHER

OXYTOCIN

11

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDINGON-GOING

S S C

WIRE TOGETHER

OXYTOCIN

hellip infant cues - suckling vocalisation and tactile stimulation - stimulate

OXYTOCINrelease in the hypothalamus which may result in the activation of the dopaminergic reward pathway leading to behavioural reinforcement

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

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

DISEASEHEALTH

CORTISOLOXYTOCIN

The psychology of human parent-infant relationships

Parenting is regulated by key hormones and neurotransmitters

Neuroanatomical circuits of parenting

Integrative physiology of normal parenting behaviours

Brain imaging of human parent-infant relationships

The neurobiology of empathy and parenting

Conclusions and critical summary

(Swain et al 2007)

12

FEARCONTROL

CENTRE

REWARDCONTROL

CENTRE

SOCIALCONTROL CENTRE

OXYTOCINDOPAMINE

CORTISOL

EMOTIONCONTROL CENTRE

WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY

DISEASEHEALTH

RESILIENCE VULNERABILITY

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

DOULA and KANGAROULA

-1000 min

BIRTH

+1000 min 1000 days

OXYTOCIN Zero separation

Protect OXYTOCINBefore and after

BIRTH

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDINGON-GOING

S S C

WIRE TOGETHER

Protect OXYTOCINBefore and after

BIRTH

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDINGON-GOING

S S C

WIRE SUCKLING

BREASTFEEDING Feed Sleep Cycling

BONDING Sensitization

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

BRAIN

WIRING

Neurodevelopmental Approach to

Alberts SUCKLING versus FEEDING

DUAL INGESTION SYSTEMS

13

300 mya 200 mya 100 mya 50 mya 300 mya 200 mya 100 mya 50 mya

Amniotes

Synapsids

Cynodonts

Mammaliaformes

PlacentalsMammals

ANCESTRAL STATE

hellip intoMATURE FEEDING

300 mya 200 mya 100 mya 50 mya

WATER

EGGS

Hatch withTEETH

ANCESTRAL STATE

hellip intoMATURE FEEDING

eg TURTLES

CROCODILES DINOSAURS

REPTILES

300 mya 200 mya 100 mya 50 mya

Epibubic bone = pouch care

hellip intoMATURE FEEDING

Amniotes

Synapsids

Cynodonts

Mammaliaformes

Smaller eggs longer in body

The AMNIOTE EGGextra membranes

Copes with AIR

PlacentalsMammals

Viviparity = immature

ENDOTHERMY

MOISTUREfor eggs

Diphyodontism

300 mya 200 mya 100 mya 50 mya

hellip intoMATURE FEEDING

Amniotes

Synapsids

Cynodonts

Mammaliaformes

PlacentalsMammals

ENDOTHERMY

MOISTUREfor eggs

LACTOSE added(apocrine glands)

NUTRIENTSAntimicrobials

LACTATION

SUCKLINGFEEDING

200 million years

Diphyodontism

300 mya 200 mya 100 mya 50 mya

hellip intoMATURE FEEDING

Amniotes

Synapsids

Cynodonts

Mammaliaformes

PlacentalsMammals

ENDOTHERMY

MOISTUREfor eggs

LACTOSE added(apocrine glands)

NUTRIENTSAntimicrobials

LACTATION

SUCKLINGFEEDING

200 million years

DUAL INGESTION SYSTEMS

100 million years

14

DUAL INGESTION SYSTEMS DUAL INGESTION SYSTEMS

SUCKLING WEANING FEEDING

Lactase Digestive enzymes

FEEDING SUCKLING

Influence of SMELL None Totally dependent

Motor mechanism Chewing ndash different

muscles

Suckling ndash different circuits

INSULIN Increases weight No effect

GHRELIN Increases weight No effect

LEPTIN Decreases intake No effect

CHOLECYSTOKININ Decreases intake No effect

AMPHETAMINE Decreases appetite Increases suckling

SEROTONIN Agonist improves feeding Antagonist improves suck

SATIETY Infant determined Maternal supply determine

FEEDING SUCKLING

DISRUPTION ROBUST VERY SENSITIVE

Must have right conditions

Pup-in-a- cup - And STIMULI

separated and fed by tube

From day 2 off life

Starts to feed normally d21 2 days gavage or other

no longer suckles

If starved for 24 hours pup

at d3 will feed food from

floor

(Can be maintained by

smell and other stimuli)

Pup-in-a- cup -

separated and fed by tube

From day 2 off life

Starts to feed normally d21

15

PMA 28 40 64 1y 2y

Nilsrsquo IDEALIZED VIEW

PMA 28 40 64 1y 2y

Nilsrsquo IDEALIZED VIEW

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

Reflections for practice

Suckling and Feeding areNOT THE SAME

16

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDINGON-GOING

S S C

WIRE SUCKLING

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

ON-GOING

S S C

WIRE NEURONS

Up to 6 months milk is 74 fat

96 of this is TRIGLYCERIDE

TRIGLYCERIDE Left glycerol Right palmitic acid oleic acid alpha-linolenic acid

In phosphoglycerides glycerol molecule same

two fatty acids esterified

Phospholipids area major component of all biological membranes

Sphingomyelin particularly concentrated in BRAIN major part of MYELIN

TRIGLYCERIDE

MYELIN

Dendirification and myelinisation peaks occurat 2 and 6 monthsis maximal at one year

At one year human milk has less proteinbut MORE TRIGLYCERIDE

FATTY ACIDS ARESPECIES SPECIFIC

Up to 6 months milk is 74 fat

but after 12 months it is 107

17

ldquocherry pickrdquo

Breastfeed time years school Incomelt 1 month 109 R$ 1238gt 6 month 121 R$ 1915

Group IQ 376 points higher from breatsfeeding

BREASTFEEDINGAND BREAST MILK

INCREASE IQ

BOTTLE FEEDINGamp FORMULA

DECREASE IQ

18

Be sure the wet nurse has plenty of milk because if she lacks it she may give the babymilk of a goat or sheep or some other animalbecause the child nourished on animal milkdoes not have perfect wits like one fed on womanrsquos milk and always looks stupid and vacant and not right in the head

14th century Tuscan text

Conceptual changeDyad careBreast first hour

even CaesareanContinuous SSC

DISCONTINUEGiving waterGlucose waterInfant formulaSeparationPacifier (dummy)

CHANGE POLICY Canrsquot change

biology

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

ON-GOING

S S C

WIRE NEURONS

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C WIRE

TIMING

(behavior)

19

Not so much duration

or density of any sleep stage

or number of sleep stage episodes but

cycling between quiet sleep

and active sleepis what is important

REMREM REM

NREM NREM

This is a healthy sleep pattern

This is a very good cycling pattern

(thanks to Susan Ludington-Hoe)

REMREM REM

NREM NREM

1st hour 2nd hour

So in every hour you would like

to see an EEG pattern that shows this

REM

NREM

REM

NREM

REM

NREM

State

HR

RR

REM Sleep is supposed to be

somewhat active so

HR increases and RR is irregular

SLEEP CYCLING ndashSeparation vs contact

In separation bull Dissociated statebull No cycling chaotic pattern

48 hour baseline chaotic pattern of

activity and quiet HR amp RR

SLEEP CYCLING ndashSeparation vs contact

In SSC bull Normal cyclingbull Non-chaotic pattern

48 hour baseline chaotic pattern of

activity and quiet HR amp RRPre-KC SSC

20

modulates state organisationelicits emotional behavioursactivates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL

Schaal 2004 115

DOUCETThe secretion of Areolar (Montgomeryrsquos) Glands from Lactating Women Elicits Selective Unconditional Responses in Neonates

ldquohellip breast chemosignalsactivate oral activity on the nipple that releases a cascade of behavioral neural neuroendocrineand endocrine processes in the newborn and the motherrdquo

Doucet 2009 116

The secretion of Areolar(Montgomeryrsquos) Glands

ldquoIn early ontogeny the sleeping brain may thusremain sentient of an organismrsquos odor environmentrdquo

Doucet 2009 117

REM

NREM

A skin-to-skin contactsession SHOULD NOT be less than one hour

or 90 minutes

SLEEPING

amp

CONTAINING

FEEDING ampHANDLINGfeed

sleep

HO

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C WIRE

TIMING

(behavior)

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C WIRE

STOMACH

21

STATE organization

Feeding frequency

SLEEP cycling

BRAIN

WIRING

How often should a neonate feed

CNS

ENS

ANS

InternalSomaticenvironment

CNS cortical subcortical(also to PNS)

ANS emotional limbic brain(incl SNS)

ANS myelinated vagus (NA)

ANS unmyelinated vagus (DMC)sub-diaphragmatic

ENS submucous plexusmyenteric plexus

122

The digestive system is endowed with its own local nervous system referred to as the enteric or intrinsic nervous system

The magnitude and complexity of the enteric nervous system is immense - it contains as many neurons as the spinal cord

ENTERIC NERVOUS SYSTEM

123

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

FEEDBACK LOOPS

CNS

ENS

ANS

InternalSomaticenvironment

124

125 126

22

Fetal stomach appears 4 weeks GABy 11 weeks wall capable of muscular

contraction

ldquoPatterns of antropyloric motilityin fed healthy preterm infantsrdquo

the neuroregulatory mechanisms responsible for the coordination of antro-pyloric motility and gastric emptying are

well developed by 30 weeks of PMAHassan 2002 127

Hydrochloric acidimportant for activation of pepsinogen

inactivation of microorganisms such as bacteria

Pepsinogenactivated by acid into active pepsin

responsible for the stomachs ability to initiate digestion of proteins

Chymosinis an enzyme whose role is to curdle or

coagulate milk in the stomach a process of considerable importance in the very young animal

128

Chymosinmakes the milk into ldquocheeserdquohalfway between liquid and solidstomach empties in 60 minutes

milk

129

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

FEEDBACK LOOPS

130

EVIDENCE FORFEEDING FREQUENCY

Edmond 2006 131

Breastfeeding and motherrsquos milkStrong and consistent evidence 132

23

Cup feeding versus bottle feedingCup feeding higher breastfeeding

greater stability133

Only case series Insufficient evidence

No mention of

stomach capacity134

EVIDENCE FORSTOMACH CAPACITY

Edmond 2006 135

0

05

1

15

2

25

3

35

4

0 10 20 30 40 50 60 70 80

volume ingested

fee

din

g f

req

ue

nc

y

Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml

StandardCARE3 hourlyschedule

136

KEY QUESTION

WHAT IS THE

STOMACHVOLUMEOF THE

NEONATE 137 Sase 2005

ldquoOntogeny of gastric emptying patternsin the human fetusrdquo

138

24

Goldstein 1987

ldquoGrowth of the Fetal Stomach in Normal Pregnanciesrdquo

139 Goldstein 1987

Length

Transverse

AP diameter

Using +2SD

140

Formula for calculation of stomach capacity (Charles Bradshaw UCT)Assumptions the stomach can be approximated by dividing into three sections namely a ellipsoidal hemisphere an ellipsoidal cylinder and a skewed ellipsoidal cone Variables a = anteroposterior radius t = transverse radius l = length stomachRelations the height of the cone and the hemisphere are both the same as lsquoarsquo

Ellipsoid = 43 Pi r1r2r3 = 43 Pi a a t therefore volume of hemisphere = 23 Pi a a t

Cylinder = Area of base height = (Pi a t ) ( l - 2a )Skewed cone = 13 base height = 13 Pi a t aTotal volume = 23 Pi aat + Pi a t (l- 2a) + 13 Pi a t a

=Pi atl -Pi a at= Pi a t(l-a)

Goldstein and Sase dataStomach capacity at term 10 - 15 ml

BRADSHAW formula

141

Assumption 25 kg baby 33w GA

requiring 150 mlkgday = 375 ml

45 MIN CYCLES ( 32 cyclesday)

12 ML PER CYCLE = 384 ml142

Newborn stomach volume

Gastric volumes at birthCorrelated with gastric pH

gastrin and somatostatin

ldquofetus drinks 10 ml portions of amniotic fluid helliprdquo

Widstrom 1988 143

Only recent study locatedldquoAutopsyrdquo capacity was determined

in Indian post-mortem studies

100 autopsies (63 SB 37 ENND)Tied at cardia and pylorus filled withwater emptied amp measured repeatedldquohellip obliteration of the gastric curvaturesrdquoldquodue care to minimize stretch artifactsrdquo

Naveed 1992

ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo

144

25

Infants above 2500g onlyAve Range

Stillborn (n 11) 196 ml (10-35)Early death (n 9) 178 ml (10-25)All cases (n 20) 188 ml

Naveed 1992

ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo

145 146

KERNESSUK 1997 (Russian)

Postmortem in situ measures(applied Bradshaw formula)

AveNewborn (n 11) 15 ml2 months (n 11) 35 ml2-4 m (n 10) 50 ml4-6 m (n 8) 100 ml

Known references with data

Scammon and Doyle 1920

Zuccarellirsquos method stomach filled at autopsy to ldquoa pressure of between

15 and 20 centimeters of waterrdquo

Scammon 1920

ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo

147

Anatomic capacity was determined in post-mortem studies

Main data set Alliot 1905 (n 25)Scammon own cases (n 13)

30 ndash 35 ml at birth ndashalmost regardless of birth weight

Scammon 1920

ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo

148

Zangen S et al Rapid maturation of gastric relaxation in newborns

Pressures (mmHg)

Balloon inflates to

15 ml no increase

functional capacity

149

Zangen S et al Rapid maturation of gastric relaxation in newborns

Pressures (mmHg)

Balloon inflates to

15 ml no increase20 ml pressure OK

physiologicalcapacity hellip 150

26

EVIDENCE (NBn 111009)

Author Capacity NoteSase 10-15 ml Live term fetusGoldstein 10-15 ml Live term fetusWidstrom 10 mls Live newbornZangen 20 mls Live (pressure)

Naveed 20 mls Autopsy (SB)20 mls Autopsy (ENND)

Kernessuk 15 mls Autopsy (in situ)Scammon 30-35 ml Autopsy (water

(Alliot) pressure)151

PROPOSAL

The CAPACITY of aweek old babyrsquos stomach is

approx 20 ml152

0

05

1

15

2

25

3

35

4

0 10 20 30 40 50 60 70 80

volume ingested

fee

din

g f

req

ue

nc

y

Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml

StandardCARE3 hourlyschedule

MOTHERNATURE

1 hourlyschedule

153

PHYSIOLOGICAL CAPACITY

RECEPTIVE CAPACITY of stomach

INGESTIVE CAPACITY of BABY

FUNCTIONAL CAPACITY

154

PROPOSAL

The FEEDINGFREQUENCY of theNEONATE is

approx 60 min155

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

BRAIN CYCLING

STOMACH FILLING amp EMPTYING

REMNR1NR2NR3NR4

156

27

Normal physiology of theEnteric Nervous System

ldquoSmall and frequent feeds according to the sleep cyclerdquo

The ldquonicherdquo (occupation) of a neonate (Alberts)

BOND FEED

SLEEP SLEEP

PLAY FEED

157

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

FEEDING SUCKLING

Influence of SMELL None Totally dependent

Motor mechanism Chewing ndash different

muscles

Suckling ndash different circuits

INSULIN Increases weight No effect

GHRELIN Increases weight No effect

LEPTIN Decreases intake No effect

CHOLECYSTOKININ Decreases intake No effect

AMPHETAMINE Decreases appetite Increases suckling

SEROTONIN Agonist improves feeding Antagonist improves suck

SATIETY Infant determined Maternal supply determine

FEEDING SUCKLING

Influence of SMELL None Totally dependent

Motor mechanism Chewing ndash different

muscles

Suckling ndash different circuits

INSULIN Increases weight No effect

GHRELIN Increases weight No effect

LEPTIN Decreases intake No effect

CHOLECYSTOKININ Decreases intake No effect

AMPHETAMINE Decreases appetite Increases suckling

SEROTONIN Agonist improves feeding Antagonist improves suck

SATIETY Infant determined Maternal supply determine

Current dogmaTHE BABY KNOWS

WHEN IT HAS HAD ENOUGH

PROBABLY NOT

WHAT IS THE

STOMACH VOLUME OF THE

PREMATURE

161

Assume low resilience

Assume proportionality

162

28

The CAPACITY of alow birthweight premfrom 20ml 3000g

= 0007 x BWt (g)

1kg x 0007 = 7mls2kg x 0007 = 14mls

163

Gastric overfilling syndrome

164

75 ml per feeding ASSUMPTION

IMMATURE OR OVERWHELMED

many aspects of gastrointestinalmotility are immature in the neonate

Zangen S et al Rapid maturation of gastric relaxation in newborns

A balloon in stomachcan fill to 76 mls

What does the stomach ndashwithout a balloon ndashdo to 76 mls

REFLUX PRESUME each feedapproximately 75 mls

GER

bull Sudden outbursts of crying

bull Awakens in pain

bull Related to feedings

bull Not easily comforted

bull ldquoI know baby hurtsrdquo

bull Sour burps throaty noises

bull Best when upright

Clues to GER

Dr W Sears

29

Mitchell 2001

Kerstin Uvnaumls-Moberg

Food in duodenum

AMYLINreleased

Closes pylorus

Duodenumempty

Pylorusopens

ldquoFeed intolerancerdquo hellip hellip or VOLUME intolerance

HYPOGLYCAEMIA

A babies stomach empties in60 minutes

Blood sugarmay fall hellip

after 90 minutes Options

30

METABOLIC ADAPTATION

SSC started in the first 20 minutes after birth

SSC CotBlood glucose (1 hr) 317 256Base excess drop 34 18

(Christenson 1992)0h 1h 2h 3h 4h 2 days

App

roxim

ate

GLUCOSE

SSC Glucose production = Glucose consumption

Separation

SNS stress Glucose consumption INCREASE

PSNS dissociation Glucose production DECREASE

HYPOGLYCEMIA

SSC Cot

Blood glucose (1 hr) 317 256

0h 1h 2h 3h 4h 2 days

App

roxim

ate

GLUCOSE

SSC Glucose production = Glucose consumption

Separation PSNS dissociation

Glucose production DECREASE

HYPOGLYCEMIA

SSC Cot

Blood glucose (1 hr) 317 256

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

NEURODEVELOPMENTThe DNA Behaviour

EVOLUTIONARY BIOLOGY

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

BONDING ATTACHMENT

MRI HRVEEG

STRESS RESPONES

RESILIENCE

DOHAD

(MAL) ADAPTATION

EPIGENETICS

GENE X ENVIRONMENT

GENETIC VARIANTS

HOSPITAL ACQUIRED INFECTIONIMMUNITY

SLEEP PHYSIOLOGY

GUT FUNCTIONMICROBIOTA

ldquoSTABILITYrdquo

TRANSITION

LONG TERM FOLLOW-UP

NEUROENDOCRINE BEHAVIOURS

MATERNAL NEUROPLASTICITY

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

MORTALITYMETABOLISM

0h 1h 2h 3h 4h

PSNS (vagal)

App

roxim

ate

GLUCOSE

1 HOURLY Milk feed

1 HOURLY Milk feed

1 HOURLY Milk feed

1 HOURLY Milk feed

LACTOSE

METABOLISM

31

0h 1h 2h 3h 4h

PSNS (vagal) SYMPATHETIC STRESS

App

roxim

ate

GLUCOSE

LACTOSE FATGLYCOGEN

METABOLISM

4 HOURLY Milk feed

0h 1h 2h 3h 4h

PSNS (vagal) SYMPATHETIC STRESS

App

roxim

ate

GLUCOSE

4 HOURLY ALLOSTATIC STATELACTOSE FATGLYCOGEN

METABOLISM

4 HOURLY Milk feed

HEALTH DISEASE

EXPECTED UNEXPECTED

NEURODEVELOPMENTThe DNA Behaviour

EVOLUTIONARY BIOLOGY

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

BONDING ATTACHMENT

MRI HRVEEG

STRESS RESPONES

RESILIENCE

DOHAD

(MAL) ADAPTATION

EPIGENETICS

GENE X ENVIRONMENT

GENETIC VARIANTS

HOSPITAL ACQUIRED INFECTIONIMMUNITY

SLEEP PHYSIOLOGY

GUT FUNCTIONMICROBIOTA

ldquoSTABILITYrdquo

TRANSITION

LONG TERM FOLLOW-UP

NEUROENDOCRINE BEHAVIOURS

MATERNAL NEUROPLASTICITY

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

MORTALITYMETABOLISM

Weight gain 1st week

predicts OBESITYat 30 years

Large volume feedsstretched stomach=

doubled absorptivecapacity as adult

Importance

Programming ndash early life chronic disease

32

RESISTANCE SENSITIVITY

PERCEPTIONSldquoNEUROCEPTIONrdquo

RESPONSESTRESS

ALLOSTATIC STATE

ALLOSTASIS

ANY STRESSPsychologicalNeurological

EndocrineImmune

ALLOSTATIC LOAD

ALLOSTATIC OVERLOAD

WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY

DISEASEHEALTH

RESILIENCE VULNERABILITY

RESISTANCE SENSITIVITY

PERCEPTIONSldquoNEUROCEPTIONrdquo

RESPONSESTRESS

ALLOSTATIC STATE

ALLOSTASIS

ANY STRESSPsychologicalNeurological

EndocrineImmune

ALLOSTATIC LOAD

HEALTH

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

Gastric overfilling syndrome

189

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

33

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

Only case series Insufficient evidence

No mention of

stomach capacity196

Baby weight freq reqrsquod size actual

2kg baby 4hrly ~ 320 ml6 = 53ml 14ml

15 baby 3hrly ~ 240 ml8 = 30ml 10ml

10 baby 2hrly ~ 160 ml12 = 13ml 7ml

Standardised from20ml capacityfor 3kg baby( x 0007)

197

0

10

20

30

40

50

60

70

80

90

13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w

LINEAR

TERM

PREM

198

34

0

10

20

30

40

50

60

70

80

90

13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w

LINEAR

TERM

PREM

199

Clues to GER

ldquoI know baby hurtsrdquo

Gastric overfilling syndrome

Excessive volumesreflux aspiration colic

Excessive time intervalhypoglycaemia

Adaptationsdiabetic diathesis obesity

200

Developmental Care of the Enteric Nervous System

ldquoSmall and frequent feeds according to the sleep cyclerdquo

The ldquonicherdquo (occupation) of a neonate (Alberts)

BOND FEED

SLEEP SLEEP

PLAY FEED

201

Gastric overfilling syndrome

Proposed Management 202

Proposed Management

Babies should be fedEVERY TIME THEY WAKE

Stanley Graven 2006

REMNR1NR2NR3SWS

AS (20 mins) QS (40 mins)

A normal sleep cycle is ONE hourHow often should neonates feed

203

Proposed Management

All babies should be fedat least once an hour 204

35

Proposed Management

All babies should be fedat least once an hour

205

The first Milk Ejection Reflex (MER)

elicited in lt 2 minutesworks quicklyswallowed 1 minute

Feeding time (max)3 minutes

Repeat every 1 hour

Prime 2007

The ldquonormalrdquo or usual and common breastfeed

takes 15 minutesdiscomfort afterburping time 5 minutes

Feeding time 20 min

Repeat every 3 hours

Prime 2007

3 minute 20ml feeds x 24d = 72 minutes

20 minute 60ml feeds x 8d = 160 minutes

SMALL AND FREQUENT FEEDS ARE EFFICIENT

FEWER NURSES NEEDED

The calculated dailyrequirement for a 3kgbaby can be given without increase inpressure MINIMAL RISK

PARENTS CAN DOSAFELY

20 mls x 24 feeds= 480mls day

Zangen 2001 209

All babies should be fedat least once an hour

210

36

Infant feeding frequencyProposal based on available evidence and neuroscience

ldquoSmall and frequent feeds

adjusted to the sleep cyclerdquo

211

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

STATE organization

Feeding frequency

SLEEP cycling

BRAIN

WIRING

How often should a neonate feeda neonate sleep

Infantsleep cycles

begin to block on diurnalrhythms

Mother-infant synchrony

hellip at 12 weeks

(circadian)

START at 3 months

Can be ldquoadult-likerdquo

at 6 months

Thomas 2014

STATE organization

Feeding frequency

SLEEP cycling

PLAY FEED

216

SLEEP SLEEP

SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

Infantsleep cycles

begin to block on diurnalrhythms

37

BOND SUCKLE SLEEP SLEEP PLAY

FEED

217

SLEEP SLEEP SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)

Schaal 2004 218

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)rdquoSLEEP-FEED CYCLINGrdquo

Schaal 2004 219

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

WIRE

BRAIN

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

BRAIN

WIRING

NEUROSCIENCE

The DNAEverything else

EVOLUTIONARYBIOLOGY

The Brain

EPIGENETICS

The PlaceENVIRONMENT

EXPERIENCEFITNESS ADAPTATION

ldquoScientific foundationrdquo hellip a synthesis

ZERO

SEPARATION

38

wwwninobirthorgwwwskintoskincontactcom

THE NEUROSCIENCE OFSKIN-TO-SKIN CONTACT

AND BREASTFEEDING

ARE THE SAME

SUMMARY SKIN-TO-SKIN

(Regulation)

SLEEP(Brain)

FEEDING(Stomach)

LOVE ( ldquomindrdquo )

REMNR1NR2NR3NR4

ACQUISITION CONSOLIDATION MEMORYFORMATION

poly-sensory input transfer information P wavesshort-term memory ldquoSNRrdquo strong signals returns infostored cortex amygdala to neocortex

hippocampus organizedAwake and REM NREM stage 4 REM

BRAIN WIRING

Stanley Graven 2006

PLAY

SLEEP

FEEDHOLDYOURPREM

httpswwwfacebookcomninobirth

39

Nelson Mandela

hellip in describing themeasure of a nation

he has argued that

ldquoThere can be no keener revelation of a societyrsquos soul than the way in which it treats its childrenrdquo

Page 7: Neurodevelopmental The Neuroscience of Birth ... · breastfeeding pattern, neonatal weight gain, and the dynamics of lactation. Doucet 2012 In the ‘‘scentless breast’’ condition,

7

DEFENSE NUTRITION REPRODUCTION

HORMONES NERVES MUSCLES

DEFENSE NUTRITION REPRODUCTION

HORMONES NERVES MUSCLES

= BREASTFEEDING

SAFE

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

WIRE MOTHER

NEURODEVELOPMENTThe DNA Behaviour

EVOLUTIONARY BIOLOGY

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

BIRTH

BEYOND BREASTFEEDING Feed Sleep Cycling

MOTHERBABY

BONDING Sensitization

Secure attachment

Attuned parenting

SEPARATION

OXYTOCIN

8

OXYTOCIN

OXYTOCIN comes from

Cervical dilatation

Skin-to-skin contact

Breastfeeding

Eye-to-eye contact

Effects of doula care

No doula DoulaUSA (Kennell et al 1991)

Epidural 55 8Caesarean section 18 8Forceps delivery 26 8Fetal distress 24 10

ldquoIf a Doula was a drug it would be unethical

not to use itrdquoDr John Kennell

1922 -2013Marshall Klaus amp John Kenell

EARLY CHILDHOOD DEVELOPMENT ECD

ldquoFirst 1000 daysrdquo =gestation 270year one 365year two 365total 1000 days

Resilience Vulnerability

DISEASEHEALTH

EARLY CHILDHOOD DEVELOPMENT ECD

ldquoFirst 1000 daysrdquo =

Resilience Vulnerability

DISEASEHEALTH

First 1000 sec = 16 minutes = 1st hourFirst 1000 min = 166 hours = 1st day First 1000 hrs = 1st six weeks

DOULA-ldquoA WOMAN SERVING WOMENrdquo BIRTH SUPPORT COMPANION

KANGAROO CARE amp DOULA = ldquoKANGAROULArdquo

Resilience Vulnerability

DISEASEHEALTH

9

DOULA and KANGAROULA

DOULA protects

OXYTOCINduringlabour

KANGAROULA protects

OXYTOCINafter birth

lsquothe first 1000 minutesrsquolsquoprevious 1000 minutesrsquo

BIRTH

DOULA and KANGAROULA

-1000 min

BIRTH

+1000 min

DOULA and KANGAROULA

-1000 min

BIRTH

+1000 min 1000 days

OXYTOCIN Zero separation

Caesarean

Separation

Breastfeeding

Zero separation

DOULA and KANGAROULA

-1000 min

BIRTH

+1000 min 1000 days

OXYTOCIN Zero separation

CORTISOL Enemy of oxytocin Stress

White coat

Sarcasm

Hunger

thirst

SEPARATION

Bathing

Noise

Lights

LithotomyWeighing

Crowds

SEPARATION

Perfume

rdquogood nightrsquos sleeprdquo

Birth Transition ParentingLabourPregnancy

DOULA

KANGAROULA

Prematurity Attachment Parenting

MOTHERSUPPORT

NEWBORNSUPPORT

Counselling Counselling

Breastfeeding

During the first 24 hours of life newborns ingested 15 g of milk

10

Milk making NUTRITION

HypothalamusPituitaryPROLACTIN

Maternal ferocityPROTECTION

OXYTOCIN Gaze increase BONDING

OXYTOCINCingulate Suppressed

REGULATION

AmygdalaCHOLECYSTOKININ Emotion satiety

HypothalamusPituitary

Cingulate

Amygdala

ldquoThe newborn may

appear helpless but

skin-to-skin contactstimulates prolactin

ensures nutritionstimulates oxytocin

ensures protectionstimulates cholecystokinin

ensures wellbeing bonding

The first hours after birth are a

CRITICAL PERIOD

mutual psycho-neuro-physiological

caregivers

Critical period concept

ldquoWindows of opportunity in early life when a childrsquos brain is exquisitely primed to receive sensory input in order to develop more advanced neural systemsrdquo

a motherrsquos brain hellip

SENSITIZATION

DOULA and KANGAROULA

DOULA protects

OXYTOCINduringlabour

KANGAROULA protects

OXYTOCINafter birth

lsquothe first 1000 minutesrsquolsquoprevious 1000 minutesrsquo

BIRTH

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

WIRE MOTHER

OXYTOCIN

11

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDINGON-GOING

S S C

WIRE TOGETHER

OXYTOCIN

hellip infant cues - suckling vocalisation and tactile stimulation - stimulate

OXYTOCINrelease in the hypothalamus which may result in the activation of the dopaminergic reward pathway leading to behavioural reinforcement

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

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

DISEASEHEALTH

CORTISOLOXYTOCIN

The psychology of human parent-infant relationships

Parenting is regulated by key hormones and neurotransmitters

Neuroanatomical circuits of parenting

Integrative physiology of normal parenting behaviours

Brain imaging of human parent-infant relationships

The neurobiology of empathy and parenting

Conclusions and critical summary

(Swain et al 2007)

12

FEARCONTROL

CENTRE

REWARDCONTROL

CENTRE

SOCIALCONTROL CENTRE

OXYTOCINDOPAMINE

CORTISOL

EMOTIONCONTROL CENTRE

WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY

DISEASEHEALTH

RESILIENCE VULNERABILITY

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

DOULA and KANGAROULA

-1000 min

BIRTH

+1000 min 1000 days

OXYTOCIN Zero separation

Protect OXYTOCINBefore and after

BIRTH

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDINGON-GOING

S S C

WIRE TOGETHER

Protect OXYTOCINBefore and after

BIRTH

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDINGON-GOING

S S C

WIRE SUCKLING

BREASTFEEDING Feed Sleep Cycling

BONDING Sensitization

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

BRAIN

WIRING

Neurodevelopmental Approach to

Alberts SUCKLING versus FEEDING

DUAL INGESTION SYSTEMS

13

300 mya 200 mya 100 mya 50 mya 300 mya 200 mya 100 mya 50 mya

Amniotes

Synapsids

Cynodonts

Mammaliaformes

PlacentalsMammals

ANCESTRAL STATE

hellip intoMATURE FEEDING

300 mya 200 mya 100 mya 50 mya

WATER

EGGS

Hatch withTEETH

ANCESTRAL STATE

hellip intoMATURE FEEDING

eg TURTLES

CROCODILES DINOSAURS

REPTILES

300 mya 200 mya 100 mya 50 mya

Epibubic bone = pouch care

hellip intoMATURE FEEDING

Amniotes

Synapsids

Cynodonts

Mammaliaformes

Smaller eggs longer in body

The AMNIOTE EGGextra membranes

Copes with AIR

PlacentalsMammals

Viviparity = immature

ENDOTHERMY

MOISTUREfor eggs

Diphyodontism

300 mya 200 mya 100 mya 50 mya

hellip intoMATURE FEEDING

Amniotes

Synapsids

Cynodonts

Mammaliaformes

PlacentalsMammals

ENDOTHERMY

MOISTUREfor eggs

LACTOSE added(apocrine glands)

NUTRIENTSAntimicrobials

LACTATION

SUCKLINGFEEDING

200 million years

Diphyodontism

300 mya 200 mya 100 mya 50 mya

hellip intoMATURE FEEDING

Amniotes

Synapsids

Cynodonts

Mammaliaformes

PlacentalsMammals

ENDOTHERMY

MOISTUREfor eggs

LACTOSE added(apocrine glands)

NUTRIENTSAntimicrobials

LACTATION

SUCKLINGFEEDING

200 million years

DUAL INGESTION SYSTEMS

100 million years

14

DUAL INGESTION SYSTEMS DUAL INGESTION SYSTEMS

SUCKLING WEANING FEEDING

Lactase Digestive enzymes

FEEDING SUCKLING

Influence of SMELL None Totally dependent

Motor mechanism Chewing ndash different

muscles

Suckling ndash different circuits

INSULIN Increases weight No effect

GHRELIN Increases weight No effect

LEPTIN Decreases intake No effect

CHOLECYSTOKININ Decreases intake No effect

AMPHETAMINE Decreases appetite Increases suckling

SEROTONIN Agonist improves feeding Antagonist improves suck

SATIETY Infant determined Maternal supply determine

FEEDING SUCKLING

DISRUPTION ROBUST VERY SENSITIVE

Must have right conditions

Pup-in-a- cup - And STIMULI

separated and fed by tube

From day 2 off life

Starts to feed normally d21 2 days gavage or other

no longer suckles

If starved for 24 hours pup

at d3 will feed food from

floor

(Can be maintained by

smell and other stimuli)

Pup-in-a- cup -

separated and fed by tube

From day 2 off life

Starts to feed normally d21

15

PMA 28 40 64 1y 2y

Nilsrsquo IDEALIZED VIEW

PMA 28 40 64 1y 2y

Nilsrsquo IDEALIZED VIEW

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

Reflections for practice

Suckling and Feeding areNOT THE SAME

16

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDINGON-GOING

S S C

WIRE SUCKLING

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

ON-GOING

S S C

WIRE NEURONS

Up to 6 months milk is 74 fat

96 of this is TRIGLYCERIDE

TRIGLYCERIDE Left glycerol Right palmitic acid oleic acid alpha-linolenic acid

In phosphoglycerides glycerol molecule same

two fatty acids esterified

Phospholipids area major component of all biological membranes

Sphingomyelin particularly concentrated in BRAIN major part of MYELIN

TRIGLYCERIDE

MYELIN

Dendirification and myelinisation peaks occurat 2 and 6 monthsis maximal at one year

At one year human milk has less proteinbut MORE TRIGLYCERIDE

FATTY ACIDS ARESPECIES SPECIFIC

Up to 6 months milk is 74 fat

but after 12 months it is 107

17

ldquocherry pickrdquo

Breastfeed time years school Incomelt 1 month 109 R$ 1238gt 6 month 121 R$ 1915

Group IQ 376 points higher from breatsfeeding

BREASTFEEDINGAND BREAST MILK

INCREASE IQ

BOTTLE FEEDINGamp FORMULA

DECREASE IQ

18

Be sure the wet nurse has plenty of milk because if she lacks it she may give the babymilk of a goat or sheep or some other animalbecause the child nourished on animal milkdoes not have perfect wits like one fed on womanrsquos milk and always looks stupid and vacant and not right in the head

14th century Tuscan text

Conceptual changeDyad careBreast first hour

even CaesareanContinuous SSC

DISCONTINUEGiving waterGlucose waterInfant formulaSeparationPacifier (dummy)

CHANGE POLICY Canrsquot change

biology

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

ON-GOING

S S C

WIRE NEURONS

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C WIRE

TIMING

(behavior)

19

Not so much duration

or density of any sleep stage

or number of sleep stage episodes but

cycling between quiet sleep

and active sleepis what is important

REMREM REM

NREM NREM

This is a healthy sleep pattern

This is a very good cycling pattern

(thanks to Susan Ludington-Hoe)

REMREM REM

NREM NREM

1st hour 2nd hour

So in every hour you would like

to see an EEG pattern that shows this

REM

NREM

REM

NREM

REM

NREM

State

HR

RR

REM Sleep is supposed to be

somewhat active so

HR increases and RR is irregular

SLEEP CYCLING ndashSeparation vs contact

In separation bull Dissociated statebull No cycling chaotic pattern

48 hour baseline chaotic pattern of

activity and quiet HR amp RR

SLEEP CYCLING ndashSeparation vs contact

In SSC bull Normal cyclingbull Non-chaotic pattern

48 hour baseline chaotic pattern of

activity and quiet HR amp RRPre-KC SSC

20

modulates state organisationelicits emotional behavioursactivates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL

Schaal 2004 115

DOUCETThe secretion of Areolar (Montgomeryrsquos) Glands from Lactating Women Elicits Selective Unconditional Responses in Neonates

ldquohellip breast chemosignalsactivate oral activity on the nipple that releases a cascade of behavioral neural neuroendocrineand endocrine processes in the newborn and the motherrdquo

Doucet 2009 116

The secretion of Areolar(Montgomeryrsquos) Glands

ldquoIn early ontogeny the sleeping brain may thusremain sentient of an organismrsquos odor environmentrdquo

Doucet 2009 117

REM

NREM

A skin-to-skin contactsession SHOULD NOT be less than one hour

or 90 minutes

SLEEPING

amp

CONTAINING

FEEDING ampHANDLINGfeed

sleep

HO

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C WIRE

TIMING

(behavior)

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C WIRE

STOMACH

21

STATE organization

Feeding frequency

SLEEP cycling

BRAIN

WIRING

How often should a neonate feed

CNS

ENS

ANS

InternalSomaticenvironment

CNS cortical subcortical(also to PNS)

ANS emotional limbic brain(incl SNS)

ANS myelinated vagus (NA)

ANS unmyelinated vagus (DMC)sub-diaphragmatic

ENS submucous plexusmyenteric plexus

122

The digestive system is endowed with its own local nervous system referred to as the enteric or intrinsic nervous system

The magnitude and complexity of the enteric nervous system is immense - it contains as many neurons as the spinal cord

ENTERIC NERVOUS SYSTEM

123

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

FEEDBACK LOOPS

CNS

ENS

ANS

InternalSomaticenvironment

124

125 126

22

Fetal stomach appears 4 weeks GABy 11 weeks wall capable of muscular

contraction

ldquoPatterns of antropyloric motilityin fed healthy preterm infantsrdquo

the neuroregulatory mechanisms responsible for the coordination of antro-pyloric motility and gastric emptying are

well developed by 30 weeks of PMAHassan 2002 127

Hydrochloric acidimportant for activation of pepsinogen

inactivation of microorganisms such as bacteria

Pepsinogenactivated by acid into active pepsin

responsible for the stomachs ability to initiate digestion of proteins

Chymosinis an enzyme whose role is to curdle or

coagulate milk in the stomach a process of considerable importance in the very young animal

128

Chymosinmakes the milk into ldquocheeserdquohalfway between liquid and solidstomach empties in 60 minutes

milk

129

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

FEEDBACK LOOPS

130

EVIDENCE FORFEEDING FREQUENCY

Edmond 2006 131

Breastfeeding and motherrsquos milkStrong and consistent evidence 132

23

Cup feeding versus bottle feedingCup feeding higher breastfeeding

greater stability133

Only case series Insufficient evidence

No mention of

stomach capacity134

EVIDENCE FORSTOMACH CAPACITY

Edmond 2006 135

0

05

1

15

2

25

3

35

4

0 10 20 30 40 50 60 70 80

volume ingested

fee

din

g f

req

ue

nc

y

Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml

StandardCARE3 hourlyschedule

136

KEY QUESTION

WHAT IS THE

STOMACHVOLUMEOF THE

NEONATE 137 Sase 2005

ldquoOntogeny of gastric emptying patternsin the human fetusrdquo

138

24

Goldstein 1987

ldquoGrowth of the Fetal Stomach in Normal Pregnanciesrdquo

139 Goldstein 1987

Length

Transverse

AP diameter

Using +2SD

140

Formula for calculation of stomach capacity (Charles Bradshaw UCT)Assumptions the stomach can be approximated by dividing into three sections namely a ellipsoidal hemisphere an ellipsoidal cylinder and a skewed ellipsoidal cone Variables a = anteroposterior radius t = transverse radius l = length stomachRelations the height of the cone and the hemisphere are both the same as lsquoarsquo

Ellipsoid = 43 Pi r1r2r3 = 43 Pi a a t therefore volume of hemisphere = 23 Pi a a t

Cylinder = Area of base height = (Pi a t ) ( l - 2a )Skewed cone = 13 base height = 13 Pi a t aTotal volume = 23 Pi aat + Pi a t (l- 2a) + 13 Pi a t a

=Pi atl -Pi a at= Pi a t(l-a)

Goldstein and Sase dataStomach capacity at term 10 - 15 ml

BRADSHAW formula

141

Assumption 25 kg baby 33w GA

requiring 150 mlkgday = 375 ml

45 MIN CYCLES ( 32 cyclesday)

12 ML PER CYCLE = 384 ml142

Newborn stomach volume

Gastric volumes at birthCorrelated with gastric pH

gastrin and somatostatin

ldquofetus drinks 10 ml portions of amniotic fluid helliprdquo

Widstrom 1988 143

Only recent study locatedldquoAutopsyrdquo capacity was determined

in Indian post-mortem studies

100 autopsies (63 SB 37 ENND)Tied at cardia and pylorus filled withwater emptied amp measured repeatedldquohellip obliteration of the gastric curvaturesrdquoldquodue care to minimize stretch artifactsrdquo

Naveed 1992

ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo

144

25

Infants above 2500g onlyAve Range

Stillborn (n 11) 196 ml (10-35)Early death (n 9) 178 ml (10-25)All cases (n 20) 188 ml

Naveed 1992

ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo

145 146

KERNESSUK 1997 (Russian)

Postmortem in situ measures(applied Bradshaw formula)

AveNewborn (n 11) 15 ml2 months (n 11) 35 ml2-4 m (n 10) 50 ml4-6 m (n 8) 100 ml

Known references with data

Scammon and Doyle 1920

Zuccarellirsquos method stomach filled at autopsy to ldquoa pressure of between

15 and 20 centimeters of waterrdquo

Scammon 1920

ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo

147

Anatomic capacity was determined in post-mortem studies

Main data set Alliot 1905 (n 25)Scammon own cases (n 13)

30 ndash 35 ml at birth ndashalmost regardless of birth weight

Scammon 1920

ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo

148

Zangen S et al Rapid maturation of gastric relaxation in newborns

Pressures (mmHg)

Balloon inflates to

15 ml no increase

functional capacity

149

Zangen S et al Rapid maturation of gastric relaxation in newborns

Pressures (mmHg)

Balloon inflates to

15 ml no increase20 ml pressure OK

physiologicalcapacity hellip 150

26

EVIDENCE (NBn 111009)

Author Capacity NoteSase 10-15 ml Live term fetusGoldstein 10-15 ml Live term fetusWidstrom 10 mls Live newbornZangen 20 mls Live (pressure)

Naveed 20 mls Autopsy (SB)20 mls Autopsy (ENND)

Kernessuk 15 mls Autopsy (in situ)Scammon 30-35 ml Autopsy (water

(Alliot) pressure)151

PROPOSAL

The CAPACITY of aweek old babyrsquos stomach is

approx 20 ml152

0

05

1

15

2

25

3

35

4

0 10 20 30 40 50 60 70 80

volume ingested

fee

din

g f

req

ue

nc

y

Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml

StandardCARE3 hourlyschedule

MOTHERNATURE

1 hourlyschedule

153

PHYSIOLOGICAL CAPACITY

RECEPTIVE CAPACITY of stomach

INGESTIVE CAPACITY of BABY

FUNCTIONAL CAPACITY

154

PROPOSAL

The FEEDINGFREQUENCY of theNEONATE is

approx 60 min155

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

BRAIN CYCLING

STOMACH FILLING amp EMPTYING

REMNR1NR2NR3NR4

156

27

Normal physiology of theEnteric Nervous System

ldquoSmall and frequent feeds according to the sleep cyclerdquo

The ldquonicherdquo (occupation) of a neonate (Alberts)

BOND FEED

SLEEP SLEEP

PLAY FEED

157

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

FEEDING SUCKLING

Influence of SMELL None Totally dependent

Motor mechanism Chewing ndash different

muscles

Suckling ndash different circuits

INSULIN Increases weight No effect

GHRELIN Increases weight No effect

LEPTIN Decreases intake No effect

CHOLECYSTOKININ Decreases intake No effect

AMPHETAMINE Decreases appetite Increases suckling

SEROTONIN Agonist improves feeding Antagonist improves suck

SATIETY Infant determined Maternal supply determine

FEEDING SUCKLING

Influence of SMELL None Totally dependent

Motor mechanism Chewing ndash different

muscles

Suckling ndash different circuits

INSULIN Increases weight No effect

GHRELIN Increases weight No effect

LEPTIN Decreases intake No effect

CHOLECYSTOKININ Decreases intake No effect

AMPHETAMINE Decreases appetite Increases suckling

SEROTONIN Agonist improves feeding Antagonist improves suck

SATIETY Infant determined Maternal supply determine

Current dogmaTHE BABY KNOWS

WHEN IT HAS HAD ENOUGH

PROBABLY NOT

WHAT IS THE

STOMACH VOLUME OF THE

PREMATURE

161

Assume low resilience

Assume proportionality

162

28

The CAPACITY of alow birthweight premfrom 20ml 3000g

= 0007 x BWt (g)

1kg x 0007 = 7mls2kg x 0007 = 14mls

163

Gastric overfilling syndrome

164

75 ml per feeding ASSUMPTION

IMMATURE OR OVERWHELMED

many aspects of gastrointestinalmotility are immature in the neonate

Zangen S et al Rapid maturation of gastric relaxation in newborns

A balloon in stomachcan fill to 76 mls

What does the stomach ndashwithout a balloon ndashdo to 76 mls

REFLUX PRESUME each feedapproximately 75 mls

GER

bull Sudden outbursts of crying

bull Awakens in pain

bull Related to feedings

bull Not easily comforted

bull ldquoI know baby hurtsrdquo

bull Sour burps throaty noises

bull Best when upright

Clues to GER

Dr W Sears

29

Mitchell 2001

Kerstin Uvnaumls-Moberg

Food in duodenum

AMYLINreleased

Closes pylorus

Duodenumempty

Pylorusopens

ldquoFeed intolerancerdquo hellip hellip or VOLUME intolerance

HYPOGLYCAEMIA

A babies stomach empties in60 minutes

Blood sugarmay fall hellip

after 90 minutes Options

30

METABOLIC ADAPTATION

SSC started in the first 20 minutes after birth

SSC CotBlood glucose (1 hr) 317 256Base excess drop 34 18

(Christenson 1992)0h 1h 2h 3h 4h 2 days

App

roxim

ate

GLUCOSE

SSC Glucose production = Glucose consumption

Separation

SNS stress Glucose consumption INCREASE

PSNS dissociation Glucose production DECREASE

HYPOGLYCEMIA

SSC Cot

Blood glucose (1 hr) 317 256

0h 1h 2h 3h 4h 2 days

App

roxim

ate

GLUCOSE

SSC Glucose production = Glucose consumption

Separation PSNS dissociation

Glucose production DECREASE

HYPOGLYCEMIA

SSC Cot

Blood glucose (1 hr) 317 256

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

NEURODEVELOPMENTThe DNA Behaviour

EVOLUTIONARY BIOLOGY

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

BONDING ATTACHMENT

MRI HRVEEG

STRESS RESPONES

RESILIENCE

DOHAD

(MAL) ADAPTATION

EPIGENETICS

GENE X ENVIRONMENT

GENETIC VARIANTS

HOSPITAL ACQUIRED INFECTIONIMMUNITY

SLEEP PHYSIOLOGY

GUT FUNCTIONMICROBIOTA

ldquoSTABILITYrdquo

TRANSITION

LONG TERM FOLLOW-UP

NEUROENDOCRINE BEHAVIOURS

MATERNAL NEUROPLASTICITY

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

MORTALITYMETABOLISM

0h 1h 2h 3h 4h

PSNS (vagal)

App

roxim

ate

GLUCOSE

1 HOURLY Milk feed

1 HOURLY Milk feed

1 HOURLY Milk feed

1 HOURLY Milk feed

LACTOSE

METABOLISM

31

0h 1h 2h 3h 4h

PSNS (vagal) SYMPATHETIC STRESS

App

roxim

ate

GLUCOSE

LACTOSE FATGLYCOGEN

METABOLISM

4 HOURLY Milk feed

0h 1h 2h 3h 4h

PSNS (vagal) SYMPATHETIC STRESS

App

roxim

ate

GLUCOSE

4 HOURLY ALLOSTATIC STATELACTOSE FATGLYCOGEN

METABOLISM

4 HOURLY Milk feed

HEALTH DISEASE

EXPECTED UNEXPECTED

NEURODEVELOPMENTThe DNA Behaviour

EVOLUTIONARY BIOLOGY

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

BONDING ATTACHMENT

MRI HRVEEG

STRESS RESPONES

RESILIENCE

DOHAD

(MAL) ADAPTATION

EPIGENETICS

GENE X ENVIRONMENT

GENETIC VARIANTS

HOSPITAL ACQUIRED INFECTIONIMMUNITY

SLEEP PHYSIOLOGY

GUT FUNCTIONMICROBIOTA

ldquoSTABILITYrdquo

TRANSITION

LONG TERM FOLLOW-UP

NEUROENDOCRINE BEHAVIOURS

MATERNAL NEUROPLASTICITY

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

MORTALITYMETABOLISM

Weight gain 1st week

predicts OBESITYat 30 years

Large volume feedsstretched stomach=

doubled absorptivecapacity as adult

Importance

Programming ndash early life chronic disease

32

RESISTANCE SENSITIVITY

PERCEPTIONSldquoNEUROCEPTIONrdquo

RESPONSESTRESS

ALLOSTATIC STATE

ALLOSTASIS

ANY STRESSPsychologicalNeurological

EndocrineImmune

ALLOSTATIC LOAD

ALLOSTATIC OVERLOAD

WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY

DISEASEHEALTH

RESILIENCE VULNERABILITY

RESISTANCE SENSITIVITY

PERCEPTIONSldquoNEUROCEPTIONrdquo

RESPONSESTRESS

ALLOSTATIC STATE

ALLOSTASIS

ANY STRESSPsychologicalNeurological

EndocrineImmune

ALLOSTATIC LOAD

HEALTH

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

Gastric overfilling syndrome

189

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

33

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

Only case series Insufficient evidence

No mention of

stomach capacity196

Baby weight freq reqrsquod size actual

2kg baby 4hrly ~ 320 ml6 = 53ml 14ml

15 baby 3hrly ~ 240 ml8 = 30ml 10ml

10 baby 2hrly ~ 160 ml12 = 13ml 7ml

Standardised from20ml capacityfor 3kg baby( x 0007)

197

0

10

20

30

40

50

60

70

80

90

13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w

LINEAR

TERM

PREM

198

34

0

10

20

30

40

50

60

70

80

90

13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w

LINEAR

TERM

PREM

199

Clues to GER

ldquoI know baby hurtsrdquo

Gastric overfilling syndrome

Excessive volumesreflux aspiration colic

Excessive time intervalhypoglycaemia

Adaptationsdiabetic diathesis obesity

200

Developmental Care of the Enteric Nervous System

ldquoSmall and frequent feeds according to the sleep cyclerdquo

The ldquonicherdquo (occupation) of a neonate (Alberts)

BOND FEED

SLEEP SLEEP

PLAY FEED

201

Gastric overfilling syndrome

Proposed Management 202

Proposed Management

Babies should be fedEVERY TIME THEY WAKE

Stanley Graven 2006

REMNR1NR2NR3SWS

AS (20 mins) QS (40 mins)

A normal sleep cycle is ONE hourHow often should neonates feed

203

Proposed Management

All babies should be fedat least once an hour 204

35

Proposed Management

All babies should be fedat least once an hour

205

The first Milk Ejection Reflex (MER)

elicited in lt 2 minutesworks quicklyswallowed 1 minute

Feeding time (max)3 minutes

Repeat every 1 hour

Prime 2007

The ldquonormalrdquo or usual and common breastfeed

takes 15 minutesdiscomfort afterburping time 5 minutes

Feeding time 20 min

Repeat every 3 hours

Prime 2007

3 minute 20ml feeds x 24d = 72 minutes

20 minute 60ml feeds x 8d = 160 minutes

SMALL AND FREQUENT FEEDS ARE EFFICIENT

FEWER NURSES NEEDED

The calculated dailyrequirement for a 3kgbaby can be given without increase inpressure MINIMAL RISK

PARENTS CAN DOSAFELY

20 mls x 24 feeds= 480mls day

Zangen 2001 209

All babies should be fedat least once an hour

210

36

Infant feeding frequencyProposal based on available evidence and neuroscience

ldquoSmall and frequent feeds

adjusted to the sleep cyclerdquo

211

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

STATE organization

Feeding frequency

SLEEP cycling

BRAIN

WIRING

How often should a neonate feeda neonate sleep

Infantsleep cycles

begin to block on diurnalrhythms

Mother-infant synchrony

hellip at 12 weeks

(circadian)

START at 3 months

Can be ldquoadult-likerdquo

at 6 months

Thomas 2014

STATE organization

Feeding frequency

SLEEP cycling

PLAY FEED

216

SLEEP SLEEP

SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

Infantsleep cycles

begin to block on diurnalrhythms

37

BOND SUCKLE SLEEP SLEEP PLAY

FEED

217

SLEEP SLEEP SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)

Schaal 2004 218

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)rdquoSLEEP-FEED CYCLINGrdquo

Schaal 2004 219

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

WIRE

BRAIN

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

BRAIN

WIRING

NEUROSCIENCE

The DNAEverything else

EVOLUTIONARYBIOLOGY

The Brain

EPIGENETICS

The PlaceENVIRONMENT

EXPERIENCEFITNESS ADAPTATION

ldquoScientific foundationrdquo hellip a synthesis

ZERO

SEPARATION

38

wwwninobirthorgwwwskintoskincontactcom

THE NEUROSCIENCE OFSKIN-TO-SKIN CONTACT

AND BREASTFEEDING

ARE THE SAME

SUMMARY SKIN-TO-SKIN

(Regulation)

SLEEP(Brain)

FEEDING(Stomach)

LOVE ( ldquomindrdquo )

REMNR1NR2NR3NR4

ACQUISITION CONSOLIDATION MEMORYFORMATION

poly-sensory input transfer information P wavesshort-term memory ldquoSNRrdquo strong signals returns infostored cortex amygdala to neocortex

hippocampus organizedAwake and REM NREM stage 4 REM

BRAIN WIRING

Stanley Graven 2006

PLAY

SLEEP

FEEDHOLDYOURPREM

httpswwwfacebookcomninobirth

39

Nelson Mandela

hellip in describing themeasure of a nation

he has argued that

ldquoThere can be no keener revelation of a societyrsquos soul than the way in which it treats its childrenrdquo

Page 8: Neurodevelopmental The Neuroscience of Birth ... · breastfeeding pattern, neonatal weight gain, and the dynamics of lactation. Doucet 2012 In the ‘‘scentless breast’’ condition,

8

OXYTOCIN

OXYTOCIN comes from

Cervical dilatation

Skin-to-skin contact

Breastfeeding

Eye-to-eye contact

Effects of doula care

No doula DoulaUSA (Kennell et al 1991)

Epidural 55 8Caesarean section 18 8Forceps delivery 26 8Fetal distress 24 10

ldquoIf a Doula was a drug it would be unethical

not to use itrdquoDr John Kennell

1922 -2013Marshall Klaus amp John Kenell

EARLY CHILDHOOD DEVELOPMENT ECD

ldquoFirst 1000 daysrdquo =gestation 270year one 365year two 365total 1000 days

Resilience Vulnerability

DISEASEHEALTH

EARLY CHILDHOOD DEVELOPMENT ECD

ldquoFirst 1000 daysrdquo =

Resilience Vulnerability

DISEASEHEALTH

First 1000 sec = 16 minutes = 1st hourFirst 1000 min = 166 hours = 1st day First 1000 hrs = 1st six weeks

DOULA-ldquoA WOMAN SERVING WOMENrdquo BIRTH SUPPORT COMPANION

KANGAROO CARE amp DOULA = ldquoKANGAROULArdquo

Resilience Vulnerability

DISEASEHEALTH

9

DOULA and KANGAROULA

DOULA protects

OXYTOCINduringlabour

KANGAROULA protects

OXYTOCINafter birth

lsquothe first 1000 minutesrsquolsquoprevious 1000 minutesrsquo

BIRTH

DOULA and KANGAROULA

-1000 min

BIRTH

+1000 min

DOULA and KANGAROULA

-1000 min

BIRTH

+1000 min 1000 days

OXYTOCIN Zero separation

Caesarean

Separation

Breastfeeding

Zero separation

DOULA and KANGAROULA

-1000 min

BIRTH

+1000 min 1000 days

OXYTOCIN Zero separation

CORTISOL Enemy of oxytocin Stress

White coat

Sarcasm

Hunger

thirst

SEPARATION

Bathing

Noise

Lights

LithotomyWeighing

Crowds

SEPARATION

Perfume

rdquogood nightrsquos sleeprdquo

Birth Transition ParentingLabourPregnancy

DOULA

KANGAROULA

Prematurity Attachment Parenting

MOTHERSUPPORT

NEWBORNSUPPORT

Counselling Counselling

Breastfeeding

During the first 24 hours of life newborns ingested 15 g of milk

10

Milk making NUTRITION

HypothalamusPituitaryPROLACTIN

Maternal ferocityPROTECTION

OXYTOCIN Gaze increase BONDING

OXYTOCINCingulate Suppressed

REGULATION

AmygdalaCHOLECYSTOKININ Emotion satiety

HypothalamusPituitary

Cingulate

Amygdala

ldquoThe newborn may

appear helpless but

skin-to-skin contactstimulates prolactin

ensures nutritionstimulates oxytocin

ensures protectionstimulates cholecystokinin

ensures wellbeing bonding

The first hours after birth are a

CRITICAL PERIOD

mutual psycho-neuro-physiological

caregivers

Critical period concept

ldquoWindows of opportunity in early life when a childrsquos brain is exquisitely primed to receive sensory input in order to develop more advanced neural systemsrdquo

a motherrsquos brain hellip

SENSITIZATION

DOULA and KANGAROULA

DOULA protects

OXYTOCINduringlabour

KANGAROULA protects

OXYTOCINafter birth

lsquothe first 1000 minutesrsquolsquoprevious 1000 minutesrsquo

BIRTH

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

WIRE MOTHER

OXYTOCIN

11

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDINGON-GOING

S S C

WIRE TOGETHER

OXYTOCIN

hellip infant cues - suckling vocalisation and tactile stimulation - stimulate

OXYTOCINrelease in the hypothalamus which may result in the activation of the dopaminergic reward pathway leading to behavioural reinforcement

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

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

DISEASEHEALTH

CORTISOLOXYTOCIN

The psychology of human parent-infant relationships

Parenting is regulated by key hormones and neurotransmitters

Neuroanatomical circuits of parenting

Integrative physiology of normal parenting behaviours

Brain imaging of human parent-infant relationships

The neurobiology of empathy and parenting

Conclusions and critical summary

(Swain et al 2007)

12

FEARCONTROL

CENTRE

REWARDCONTROL

CENTRE

SOCIALCONTROL CENTRE

OXYTOCINDOPAMINE

CORTISOL

EMOTIONCONTROL CENTRE

WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY

DISEASEHEALTH

RESILIENCE VULNERABILITY

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

DOULA and KANGAROULA

-1000 min

BIRTH

+1000 min 1000 days

OXYTOCIN Zero separation

Protect OXYTOCINBefore and after

BIRTH

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDINGON-GOING

S S C

WIRE TOGETHER

Protect OXYTOCINBefore and after

BIRTH

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDINGON-GOING

S S C

WIRE SUCKLING

BREASTFEEDING Feed Sleep Cycling

BONDING Sensitization

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

BRAIN

WIRING

Neurodevelopmental Approach to

Alberts SUCKLING versus FEEDING

DUAL INGESTION SYSTEMS

13

300 mya 200 mya 100 mya 50 mya 300 mya 200 mya 100 mya 50 mya

Amniotes

Synapsids

Cynodonts

Mammaliaformes

PlacentalsMammals

ANCESTRAL STATE

hellip intoMATURE FEEDING

300 mya 200 mya 100 mya 50 mya

WATER

EGGS

Hatch withTEETH

ANCESTRAL STATE

hellip intoMATURE FEEDING

eg TURTLES

CROCODILES DINOSAURS

REPTILES

300 mya 200 mya 100 mya 50 mya

Epibubic bone = pouch care

hellip intoMATURE FEEDING

Amniotes

Synapsids

Cynodonts

Mammaliaformes

Smaller eggs longer in body

The AMNIOTE EGGextra membranes

Copes with AIR

PlacentalsMammals

Viviparity = immature

ENDOTHERMY

MOISTUREfor eggs

Diphyodontism

300 mya 200 mya 100 mya 50 mya

hellip intoMATURE FEEDING

Amniotes

Synapsids

Cynodonts

Mammaliaformes

PlacentalsMammals

ENDOTHERMY

MOISTUREfor eggs

LACTOSE added(apocrine glands)

NUTRIENTSAntimicrobials

LACTATION

SUCKLINGFEEDING

200 million years

Diphyodontism

300 mya 200 mya 100 mya 50 mya

hellip intoMATURE FEEDING

Amniotes

Synapsids

Cynodonts

Mammaliaformes

PlacentalsMammals

ENDOTHERMY

MOISTUREfor eggs

LACTOSE added(apocrine glands)

NUTRIENTSAntimicrobials

LACTATION

SUCKLINGFEEDING

200 million years

DUAL INGESTION SYSTEMS

100 million years

14

DUAL INGESTION SYSTEMS DUAL INGESTION SYSTEMS

SUCKLING WEANING FEEDING

Lactase Digestive enzymes

FEEDING SUCKLING

Influence of SMELL None Totally dependent

Motor mechanism Chewing ndash different

muscles

Suckling ndash different circuits

INSULIN Increases weight No effect

GHRELIN Increases weight No effect

LEPTIN Decreases intake No effect

CHOLECYSTOKININ Decreases intake No effect

AMPHETAMINE Decreases appetite Increases suckling

SEROTONIN Agonist improves feeding Antagonist improves suck

SATIETY Infant determined Maternal supply determine

FEEDING SUCKLING

DISRUPTION ROBUST VERY SENSITIVE

Must have right conditions

Pup-in-a- cup - And STIMULI

separated and fed by tube

From day 2 off life

Starts to feed normally d21 2 days gavage or other

no longer suckles

If starved for 24 hours pup

at d3 will feed food from

floor

(Can be maintained by

smell and other stimuli)

Pup-in-a- cup -

separated and fed by tube

From day 2 off life

Starts to feed normally d21

15

PMA 28 40 64 1y 2y

Nilsrsquo IDEALIZED VIEW

PMA 28 40 64 1y 2y

Nilsrsquo IDEALIZED VIEW

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

Reflections for practice

Suckling and Feeding areNOT THE SAME

16

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDINGON-GOING

S S C

WIRE SUCKLING

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

ON-GOING

S S C

WIRE NEURONS

Up to 6 months milk is 74 fat

96 of this is TRIGLYCERIDE

TRIGLYCERIDE Left glycerol Right palmitic acid oleic acid alpha-linolenic acid

In phosphoglycerides glycerol molecule same

two fatty acids esterified

Phospholipids area major component of all biological membranes

Sphingomyelin particularly concentrated in BRAIN major part of MYELIN

TRIGLYCERIDE

MYELIN

Dendirification and myelinisation peaks occurat 2 and 6 monthsis maximal at one year

At one year human milk has less proteinbut MORE TRIGLYCERIDE

FATTY ACIDS ARESPECIES SPECIFIC

Up to 6 months milk is 74 fat

but after 12 months it is 107

17

ldquocherry pickrdquo

Breastfeed time years school Incomelt 1 month 109 R$ 1238gt 6 month 121 R$ 1915

Group IQ 376 points higher from breatsfeeding

BREASTFEEDINGAND BREAST MILK

INCREASE IQ

BOTTLE FEEDINGamp FORMULA

DECREASE IQ

18

Be sure the wet nurse has plenty of milk because if she lacks it she may give the babymilk of a goat or sheep or some other animalbecause the child nourished on animal milkdoes not have perfect wits like one fed on womanrsquos milk and always looks stupid and vacant and not right in the head

14th century Tuscan text

Conceptual changeDyad careBreast first hour

even CaesareanContinuous SSC

DISCONTINUEGiving waterGlucose waterInfant formulaSeparationPacifier (dummy)

CHANGE POLICY Canrsquot change

biology

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

ON-GOING

S S C

WIRE NEURONS

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C WIRE

TIMING

(behavior)

19

Not so much duration

or density of any sleep stage

or number of sleep stage episodes but

cycling between quiet sleep

and active sleepis what is important

REMREM REM

NREM NREM

This is a healthy sleep pattern

This is a very good cycling pattern

(thanks to Susan Ludington-Hoe)

REMREM REM

NREM NREM

1st hour 2nd hour

So in every hour you would like

to see an EEG pattern that shows this

REM

NREM

REM

NREM

REM

NREM

State

HR

RR

REM Sleep is supposed to be

somewhat active so

HR increases and RR is irregular

SLEEP CYCLING ndashSeparation vs contact

In separation bull Dissociated statebull No cycling chaotic pattern

48 hour baseline chaotic pattern of

activity and quiet HR amp RR

SLEEP CYCLING ndashSeparation vs contact

In SSC bull Normal cyclingbull Non-chaotic pattern

48 hour baseline chaotic pattern of

activity and quiet HR amp RRPre-KC SSC

20

modulates state organisationelicits emotional behavioursactivates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL

Schaal 2004 115

DOUCETThe secretion of Areolar (Montgomeryrsquos) Glands from Lactating Women Elicits Selective Unconditional Responses in Neonates

ldquohellip breast chemosignalsactivate oral activity on the nipple that releases a cascade of behavioral neural neuroendocrineand endocrine processes in the newborn and the motherrdquo

Doucet 2009 116

The secretion of Areolar(Montgomeryrsquos) Glands

ldquoIn early ontogeny the sleeping brain may thusremain sentient of an organismrsquos odor environmentrdquo

Doucet 2009 117

REM

NREM

A skin-to-skin contactsession SHOULD NOT be less than one hour

or 90 minutes

SLEEPING

amp

CONTAINING

FEEDING ampHANDLINGfeed

sleep

HO

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C WIRE

TIMING

(behavior)

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C WIRE

STOMACH

21

STATE organization

Feeding frequency

SLEEP cycling

BRAIN

WIRING

How often should a neonate feed

CNS

ENS

ANS

InternalSomaticenvironment

CNS cortical subcortical(also to PNS)

ANS emotional limbic brain(incl SNS)

ANS myelinated vagus (NA)

ANS unmyelinated vagus (DMC)sub-diaphragmatic

ENS submucous plexusmyenteric plexus

122

The digestive system is endowed with its own local nervous system referred to as the enteric or intrinsic nervous system

The magnitude and complexity of the enteric nervous system is immense - it contains as many neurons as the spinal cord

ENTERIC NERVOUS SYSTEM

123

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

FEEDBACK LOOPS

CNS

ENS

ANS

InternalSomaticenvironment

124

125 126

22

Fetal stomach appears 4 weeks GABy 11 weeks wall capable of muscular

contraction

ldquoPatterns of antropyloric motilityin fed healthy preterm infantsrdquo

the neuroregulatory mechanisms responsible for the coordination of antro-pyloric motility and gastric emptying are

well developed by 30 weeks of PMAHassan 2002 127

Hydrochloric acidimportant for activation of pepsinogen

inactivation of microorganisms such as bacteria

Pepsinogenactivated by acid into active pepsin

responsible for the stomachs ability to initiate digestion of proteins

Chymosinis an enzyme whose role is to curdle or

coagulate milk in the stomach a process of considerable importance in the very young animal

128

Chymosinmakes the milk into ldquocheeserdquohalfway between liquid and solidstomach empties in 60 minutes

milk

129

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

FEEDBACK LOOPS

130

EVIDENCE FORFEEDING FREQUENCY

Edmond 2006 131

Breastfeeding and motherrsquos milkStrong and consistent evidence 132

23

Cup feeding versus bottle feedingCup feeding higher breastfeeding

greater stability133

Only case series Insufficient evidence

No mention of

stomach capacity134

EVIDENCE FORSTOMACH CAPACITY

Edmond 2006 135

0

05

1

15

2

25

3

35

4

0 10 20 30 40 50 60 70 80

volume ingested

fee

din

g f

req

ue

nc

y

Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml

StandardCARE3 hourlyschedule

136

KEY QUESTION

WHAT IS THE

STOMACHVOLUMEOF THE

NEONATE 137 Sase 2005

ldquoOntogeny of gastric emptying patternsin the human fetusrdquo

138

24

Goldstein 1987

ldquoGrowth of the Fetal Stomach in Normal Pregnanciesrdquo

139 Goldstein 1987

Length

Transverse

AP diameter

Using +2SD

140

Formula for calculation of stomach capacity (Charles Bradshaw UCT)Assumptions the stomach can be approximated by dividing into three sections namely a ellipsoidal hemisphere an ellipsoidal cylinder and a skewed ellipsoidal cone Variables a = anteroposterior radius t = transverse radius l = length stomachRelations the height of the cone and the hemisphere are both the same as lsquoarsquo

Ellipsoid = 43 Pi r1r2r3 = 43 Pi a a t therefore volume of hemisphere = 23 Pi a a t

Cylinder = Area of base height = (Pi a t ) ( l - 2a )Skewed cone = 13 base height = 13 Pi a t aTotal volume = 23 Pi aat + Pi a t (l- 2a) + 13 Pi a t a

=Pi atl -Pi a at= Pi a t(l-a)

Goldstein and Sase dataStomach capacity at term 10 - 15 ml

BRADSHAW formula

141

Assumption 25 kg baby 33w GA

requiring 150 mlkgday = 375 ml

45 MIN CYCLES ( 32 cyclesday)

12 ML PER CYCLE = 384 ml142

Newborn stomach volume

Gastric volumes at birthCorrelated with gastric pH

gastrin and somatostatin

ldquofetus drinks 10 ml portions of amniotic fluid helliprdquo

Widstrom 1988 143

Only recent study locatedldquoAutopsyrdquo capacity was determined

in Indian post-mortem studies

100 autopsies (63 SB 37 ENND)Tied at cardia and pylorus filled withwater emptied amp measured repeatedldquohellip obliteration of the gastric curvaturesrdquoldquodue care to minimize stretch artifactsrdquo

Naveed 1992

ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo

144

25

Infants above 2500g onlyAve Range

Stillborn (n 11) 196 ml (10-35)Early death (n 9) 178 ml (10-25)All cases (n 20) 188 ml

Naveed 1992

ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo

145 146

KERNESSUK 1997 (Russian)

Postmortem in situ measures(applied Bradshaw formula)

AveNewborn (n 11) 15 ml2 months (n 11) 35 ml2-4 m (n 10) 50 ml4-6 m (n 8) 100 ml

Known references with data

Scammon and Doyle 1920

Zuccarellirsquos method stomach filled at autopsy to ldquoa pressure of between

15 and 20 centimeters of waterrdquo

Scammon 1920

ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo

147

Anatomic capacity was determined in post-mortem studies

Main data set Alliot 1905 (n 25)Scammon own cases (n 13)

30 ndash 35 ml at birth ndashalmost regardless of birth weight

Scammon 1920

ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo

148

Zangen S et al Rapid maturation of gastric relaxation in newborns

Pressures (mmHg)

Balloon inflates to

15 ml no increase

functional capacity

149

Zangen S et al Rapid maturation of gastric relaxation in newborns

Pressures (mmHg)

Balloon inflates to

15 ml no increase20 ml pressure OK

physiologicalcapacity hellip 150

26

EVIDENCE (NBn 111009)

Author Capacity NoteSase 10-15 ml Live term fetusGoldstein 10-15 ml Live term fetusWidstrom 10 mls Live newbornZangen 20 mls Live (pressure)

Naveed 20 mls Autopsy (SB)20 mls Autopsy (ENND)

Kernessuk 15 mls Autopsy (in situ)Scammon 30-35 ml Autopsy (water

(Alliot) pressure)151

PROPOSAL

The CAPACITY of aweek old babyrsquos stomach is

approx 20 ml152

0

05

1

15

2

25

3

35

4

0 10 20 30 40 50 60 70 80

volume ingested

fee

din

g f

req

ue

nc

y

Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml

StandardCARE3 hourlyschedule

MOTHERNATURE

1 hourlyschedule

153

PHYSIOLOGICAL CAPACITY

RECEPTIVE CAPACITY of stomach

INGESTIVE CAPACITY of BABY

FUNCTIONAL CAPACITY

154

PROPOSAL

The FEEDINGFREQUENCY of theNEONATE is

approx 60 min155

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

BRAIN CYCLING

STOMACH FILLING amp EMPTYING

REMNR1NR2NR3NR4

156

27

Normal physiology of theEnteric Nervous System

ldquoSmall and frequent feeds according to the sleep cyclerdquo

The ldquonicherdquo (occupation) of a neonate (Alberts)

BOND FEED

SLEEP SLEEP

PLAY FEED

157

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

FEEDING SUCKLING

Influence of SMELL None Totally dependent

Motor mechanism Chewing ndash different

muscles

Suckling ndash different circuits

INSULIN Increases weight No effect

GHRELIN Increases weight No effect

LEPTIN Decreases intake No effect

CHOLECYSTOKININ Decreases intake No effect

AMPHETAMINE Decreases appetite Increases suckling

SEROTONIN Agonist improves feeding Antagonist improves suck

SATIETY Infant determined Maternal supply determine

FEEDING SUCKLING

Influence of SMELL None Totally dependent

Motor mechanism Chewing ndash different

muscles

Suckling ndash different circuits

INSULIN Increases weight No effect

GHRELIN Increases weight No effect

LEPTIN Decreases intake No effect

CHOLECYSTOKININ Decreases intake No effect

AMPHETAMINE Decreases appetite Increases suckling

SEROTONIN Agonist improves feeding Antagonist improves suck

SATIETY Infant determined Maternal supply determine

Current dogmaTHE BABY KNOWS

WHEN IT HAS HAD ENOUGH

PROBABLY NOT

WHAT IS THE

STOMACH VOLUME OF THE

PREMATURE

161

Assume low resilience

Assume proportionality

162

28

The CAPACITY of alow birthweight premfrom 20ml 3000g

= 0007 x BWt (g)

1kg x 0007 = 7mls2kg x 0007 = 14mls

163

Gastric overfilling syndrome

164

75 ml per feeding ASSUMPTION

IMMATURE OR OVERWHELMED

many aspects of gastrointestinalmotility are immature in the neonate

Zangen S et al Rapid maturation of gastric relaxation in newborns

A balloon in stomachcan fill to 76 mls

What does the stomach ndashwithout a balloon ndashdo to 76 mls

REFLUX PRESUME each feedapproximately 75 mls

GER

bull Sudden outbursts of crying

bull Awakens in pain

bull Related to feedings

bull Not easily comforted

bull ldquoI know baby hurtsrdquo

bull Sour burps throaty noises

bull Best when upright

Clues to GER

Dr W Sears

29

Mitchell 2001

Kerstin Uvnaumls-Moberg

Food in duodenum

AMYLINreleased

Closes pylorus

Duodenumempty

Pylorusopens

ldquoFeed intolerancerdquo hellip hellip or VOLUME intolerance

HYPOGLYCAEMIA

A babies stomach empties in60 minutes

Blood sugarmay fall hellip

after 90 minutes Options

30

METABOLIC ADAPTATION

SSC started in the first 20 minutes after birth

SSC CotBlood glucose (1 hr) 317 256Base excess drop 34 18

(Christenson 1992)0h 1h 2h 3h 4h 2 days

App

roxim

ate

GLUCOSE

SSC Glucose production = Glucose consumption

Separation

SNS stress Glucose consumption INCREASE

PSNS dissociation Glucose production DECREASE

HYPOGLYCEMIA

SSC Cot

Blood glucose (1 hr) 317 256

0h 1h 2h 3h 4h 2 days

App

roxim

ate

GLUCOSE

SSC Glucose production = Glucose consumption

Separation PSNS dissociation

Glucose production DECREASE

HYPOGLYCEMIA

SSC Cot

Blood glucose (1 hr) 317 256

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

NEURODEVELOPMENTThe DNA Behaviour

EVOLUTIONARY BIOLOGY

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

BONDING ATTACHMENT

MRI HRVEEG

STRESS RESPONES

RESILIENCE

DOHAD

(MAL) ADAPTATION

EPIGENETICS

GENE X ENVIRONMENT

GENETIC VARIANTS

HOSPITAL ACQUIRED INFECTIONIMMUNITY

SLEEP PHYSIOLOGY

GUT FUNCTIONMICROBIOTA

ldquoSTABILITYrdquo

TRANSITION

LONG TERM FOLLOW-UP

NEUROENDOCRINE BEHAVIOURS

MATERNAL NEUROPLASTICITY

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

MORTALITYMETABOLISM

0h 1h 2h 3h 4h

PSNS (vagal)

App

roxim

ate

GLUCOSE

1 HOURLY Milk feed

1 HOURLY Milk feed

1 HOURLY Milk feed

1 HOURLY Milk feed

LACTOSE

METABOLISM

31

0h 1h 2h 3h 4h

PSNS (vagal) SYMPATHETIC STRESS

App

roxim

ate

GLUCOSE

LACTOSE FATGLYCOGEN

METABOLISM

4 HOURLY Milk feed

0h 1h 2h 3h 4h

PSNS (vagal) SYMPATHETIC STRESS

App

roxim

ate

GLUCOSE

4 HOURLY ALLOSTATIC STATELACTOSE FATGLYCOGEN

METABOLISM

4 HOURLY Milk feed

HEALTH DISEASE

EXPECTED UNEXPECTED

NEURODEVELOPMENTThe DNA Behaviour

EVOLUTIONARY BIOLOGY

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

BONDING ATTACHMENT

MRI HRVEEG

STRESS RESPONES

RESILIENCE

DOHAD

(MAL) ADAPTATION

EPIGENETICS

GENE X ENVIRONMENT

GENETIC VARIANTS

HOSPITAL ACQUIRED INFECTIONIMMUNITY

SLEEP PHYSIOLOGY

GUT FUNCTIONMICROBIOTA

ldquoSTABILITYrdquo

TRANSITION

LONG TERM FOLLOW-UP

NEUROENDOCRINE BEHAVIOURS

MATERNAL NEUROPLASTICITY

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

MORTALITYMETABOLISM

Weight gain 1st week

predicts OBESITYat 30 years

Large volume feedsstretched stomach=

doubled absorptivecapacity as adult

Importance

Programming ndash early life chronic disease

32

RESISTANCE SENSITIVITY

PERCEPTIONSldquoNEUROCEPTIONrdquo

RESPONSESTRESS

ALLOSTATIC STATE

ALLOSTASIS

ANY STRESSPsychologicalNeurological

EndocrineImmune

ALLOSTATIC LOAD

ALLOSTATIC OVERLOAD

WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY

DISEASEHEALTH

RESILIENCE VULNERABILITY

RESISTANCE SENSITIVITY

PERCEPTIONSldquoNEUROCEPTIONrdquo

RESPONSESTRESS

ALLOSTATIC STATE

ALLOSTASIS

ANY STRESSPsychologicalNeurological

EndocrineImmune

ALLOSTATIC LOAD

HEALTH

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

Gastric overfilling syndrome

189

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

33

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

Only case series Insufficient evidence

No mention of

stomach capacity196

Baby weight freq reqrsquod size actual

2kg baby 4hrly ~ 320 ml6 = 53ml 14ml

15 baby 3hrly ~ 240 ml8 = 30ml 10ml

10 baby 2hrly ~ 160 ml12 = 13ml 7ml

Standardised from20ml capacityfor 3kg baby( x 0007)

197

0

10

20

30

40

50

60

70

80

90

13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w

LINEAR

TERM

PREM

198

34

0

10

20

30

40

50

60

70

80

90

13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w

LINEAR

TERM

PREM

199

Clues to GER

ldquoI know baby hurtsrdquo

Gastric overfilling syndrome

Excessive volumesreflux aspiration colic

Excessive time intervalhypoglycaemia

Adaptationsdiabetic diathesis obesity

200

Developmental Care of the Enteric Nervous System

ldquoSmall and frequent feeds according to the sleep cyclerdquo

The ldquonicherdquo (occupation) of a neonate (Alberts)

BOND FEED

SLEEP SLEEP

PLAY FEED

201

Gastric overfilling syndrome

Proposed Management 202

Proposed Management

Babies should be fedEVERY TIME THEY WAKE

Stanley Graven 2006

REMNR1NR2NR3SWS

AS (20 mins) QS (40 mins)

A normal sleep cycle is ONE hourHow often should neonates feed

203

Proposed Management

All babies should be fedat least once an hour 204

35

Proposed Management

All babies should be fedat least once an hour

205

The first Milk Ejection Reflex (MER)

elicited in lt 2 minutesworks quicklyswallowed 1 minute

Feeding time (max)3 minutes

Repeat every 1 hour

Prime 2007

The ldquonormalrdquo or usual and common breastfeed

takes 15 minutesdiscomfort afterburping time 5 minutes

Feeding time 20 min

Repeat every 3 hours

Prime 2007

3 minute 20ml feeds x 24d = 72 minutes

20 minute 60ml feeds x 8d = 160 minutes

SMALL AND FREQUENT FEEDS ARE EFFICIENT

FEWER NURSES NEEDED

The calculated dailyrequirement for a 3kgbaby can be given without increase inpressure MINIMAL RISK

PARENTS CAN DOSAFELY

20 mls x 24 feeds= 480mls day

Zangen 2001 209

All babies should be fedat least once an hour

210

36

Infant feeding frequencyProposal based on available evidence and neuroscience

ldquoSmall and frequent feeds

adjusted to the sleep cyclerdquo

211

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

STATE organization

Feeding frequency

SLEEP cycling

BRAIN

WIRING

How often should a neonate feeda neonate sleep

Infantsleep cycles

begin to block on diurnalrhythms

Mother-infant synchrony

hellip at 12 weeks

(circadian)

START at 3 months

Can be ldquoadult-likerdquo

at 6 months

Thomas 2014

STATE organization

Feeding frequency

SLEEP cycling

PLAY FEED

216

SLEEP SLEEP

SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

Infantsleep cycles

begin to block on diurnalrhythms

37

BOND SUCKLE SLEEP SLEEP PLAY

FEED

217

SLEEP SLEEP SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)

Schaal 2004 218

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)rdquoSLEEP-FEED CYCLINGrdquo

Schaal 2004 219

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

WIRE

BRAIN

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

BRAIN

WIRING

NEUROSCIENCE

The DNAEverything else

EVOLUTIONARYBIOLOGY

The Brain

EPIGENETICS

The PlaceENVIRONMENT

EXPERIENCEFITNESS ADAPTATION

ldquoScientific foundationrdquo hellip a synthesis

ZERO

SEPARATION

38

wwwninobirthorgwwwskintoskincontactcom

THE NEUROSCIENCE OFSKIN-TO-SKIN CONTACT

AND BREASTFEEDING

ARE THE SAME

SUMMARY SKIN-TO-SKIN

(Regulation)

SLEEP(Brain)

FEEDING(Stomach)

LOVE ( ldquomindrdquo )

REMNR1NR2NR3NR4

ACQUISITION CONSOLIDATION MEMORYFORMATION

poly-sensory input transfer information P wavesshort-term memory ldquoSNRrdquo strong signals returns infostored cortex amygdala to neocortex

hippocampus organizedAwake and REM NREM stage 4 REM

BRAIN WIRING

Stanley Graven 2006

PLAY

SLEEP

FEEDHOLDYOURPREM

httpswwwfacebookcomninobirth

39

Nelson Mandela

hellip in describing themeasure of a nation

he has argued that

ldquoThere can be no keener revelation of a societyrsquos soul than the way in which it treats its childrenrdquo

Page 9: Neurodevelopmental The Neuroscience of Birth ... · breastfeeding pattern, neonatal weight gain, and the dynamics of lactation. Doucet 2012 In the ‘‘scentless breast’’ condition,

9

DOULA and KANGAROULA

DOULA protects

OXYTOCINduringlabour

KANGAROULA protects

OXYTOCINafter birth

lsquothe first 1000 minutesrsquolsquoprevious 1000 minutesrsquo

BIRTH

DOULA and KANGAROULA

-1000 min

BIRTH

+1000 min

DOULA and KANGAROULA

-1000 min

BIRTH

+1000 min 1000 days

OXYTOCIN Zero separation

Caesarean

Separation

Breastfeeding

Zero separation

DOULA and KANGAROULA

-1000 min

BIRTH

+1000 min 1000 days

OXYTOCIN Zero separation

CORTISOL Enemy of oxytocin Stress

White coat

Sarcasm

Hunger

thirst

SEPARATION

Bathing

Noise

Lights

LithotomyWeighing

Crowds

SEPARATION

Perfume

rdquogood nightrsquos sleeprdquo

Birth Transition ParentingLabourPregnancy

DOULA

KANGAROULA

Prematurity Attachment Parenting

MOTHERSUPPORT

NEWBORNSUPPORT

Counselling Counselling

Breastfeeding

During the first 24 hours of life newborns ingested 15 g of milk

10

Milk making NUTRITION

HypothalamusPituitaryPROLACTIN

Maternal ferocityPROTECTION

OXYTOCIN Gaze increase BONDING

OXYTOCINCingulate Suppressed

REGULATION

AmygdalaCHOLECYSTOKININ Emotion satiety

HypothalamusPituitary

Cingulate

Amygdala

ldquoThe newborn may

appear helpless but

skin-to-skin contactstimulates prolactin

ensures nutritionstimulates oxytocin

ensures protectionstimulates cholecystokinin

ensures wellbeing bonding

The first hours after birth are a

CRITICAL PERIOD

mutual psycho-neuro-physiological

caregivers

Critical period concept

ldquoWindows of opportunity in early life when a childrsquos brain is exquisitely primed to receive sensory input in order to develop more advanced neural systemsrdquo

a motherrsquos brain hellip

SENSITIZATION

DOULA and KANGAROULA

DOULA protects

OXYTOCINduringlabour

KANGAROULA protects

OXYTOCINafter birth

lsquothe first 1000 minutesrsquolsquoprevious 1000 minutesrsquo

BIRTH

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

WIRE MOTHER

OXYTOCIN

11

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDINGON-GOING

S S C

WIRE TOGETHER

OXYTOCIN

hellip infant cues - suckling vocalisation and tactile stimulation - stimulate

OXYTOCINrelease in the hypothalamus which may result in the activation of the dopaminergic reward pathway leading to behavioural reinforcement

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

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

DISEASEHEALTH

CORTISOLOXYTOCIN

The psychology of human parent-infant relationships

Parenting is regulated by key hormones and neurotransmitters

Neuroanatomical circuits of parenting

Integrative physiology of normal parenting behaviours

Brain imaging of human parent-infant relationships

The neurobiology of empathy and parenting

Conclusions and critical summary

(Swain et al 2007)

12

FEARCONTROL

CENTRE

REWARDCONTROL

CENTRE

SOCIALCONTROL CENTRE

OXYTOCINDOPAMINE

CORTISOL

EMOTIONCONTROL CENTRE

WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY

DISEASEHEALTH

RESILIENCE VULNERABILITY

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

DOULA and KANGAROULA

-1000 min

BIRTH

+1000 min 1000 days

OXYTOCIN Zero separation

Protect OXYTOCINBefore and after

BIRTH

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDINGON-GOING

S S C

WIRE TOGETHER

Protect OXYTOCINBefore and after

BIRTH

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDINGON-GOING

S S C

WIRE SUCKLING

BREASTFEEDING Feed Sleep Cycling

BONDING Sensitization

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

BRAIN

WIRING

Neurodevelopmental Approach to

Alberts SUCKLING versus FEEDING

DUAL INGESTION SYSTEMS

13

300 mya 200 mya 100 mya 50 mya 300 mya 200 mya 100 mya 50 mya

Amniotes

Synapsids

Cynodonts

Mammaliaformes

PlacentalsMammals

ANCESTRAL STATE

hellip intoMATURE FEEDING

300 mya 200 mya 100 mya 50 mya

WATER

EGGS

Hatch withTEETH

ANCESTRAL STATE

hellip intoMATURE FEEDING

eg TURTLES

CROCODILES DINOSAURS

REPTILES

300 mya 200 mya 100 mya 50 mya

Epibubic bone = pouch care

hellip intoMATURE FEEDING

Amniotes

Synapsids

Cynodonts

Mammaliaformes

Smaller eggs longer in body

The AMNIOTE EGGextra membranes

Copes with AIR

PlacentalsMammals

Viviparity = immature

ENDOTHERMY

MOISTUREfor eggs

Diphyodontism

300 mya 200 mya 100 mya 50 mya

hellip intoMATURE FEEDING

Amniotes

Synapsids

Cynodonts

Mammaliaformes

PlacentalsMammals

ENDOTHERMY

MOISTUREfor eggs

LACTOSE added(apocrine glands)

NUTRIENTSAntimicrobials

LACTATION

SUCKLINGFEEDING

200 million years

Diphyodontism

300 mya 200 mya 100 mya 50 mya

hellip intoMATURE FEEDING

Amniotes

Synapsids

Cynodonts

Mammaliaformes

PlacentalsMammals

ENDOTHERMY

MOISTUREfor eggs

LACTOSE added(apocrine glands)

NUTRIENTSAntimicrobials

LACTATION

SUCKLINGFEEDING

200 million years

DUAL INGESTION SYSTEMS

100 million years

14

DUAL INGESTION SYSTEMS DUAL INGESTION SYSTEMS

SUCKLING WEANING FEEDING

Lactase Digestive enzymes

FEEDING SUCKLING

Influence of SMELL None Totally dependent

Motor mechanism Chewing ndash different

muscles

Suckling ndash different circuits

INSULIN Increases weight No effect

GHRELIN Increases weight No effect

LEPTIN Decreases intake No effect

CHOLECYSTOKININ Decreases intake No effect

AMPHETAMINE Decreases appetite Increases suckling

SEROTONIN Agonist improves feeding Antagonist improves suck

SATIETY Infant determined Maternal supply determine

FEEDING SUCKLING

DISRUPTION ROBUST VERY SENSITIVE

Must have right conditions

Pup-in-a- cup - And STIMULI

separated and fed by tube

From day 2 off life

Starts to feed normally d21 2 days gavage or other

no longer suckles

If starved for 24 hours pup

at d3 will feed food from

floor

(Can be maintained by

smell and other stimuli)

Pup-in-a- cup -

separated and fed by tube

From day 2 off life

Starts to feed normally d21

15

PMA 28 40 64 1y 2y

Nilsrsquo IDEALIZED VIEW

PMA 28 40 64 1y 2y

Nilsrsquo IDEALIZED VIEW

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

Reflections for practice

Suckling and Feeding areNOT THE SAME

16

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDINGON-GOING

S S C

WIRE SUCKLING

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

ON-GOING

S S C

WIRE NEURONS

Up to 6 months milk is 74 fat

96 of this is TRIGLYCERIDE

TRIGLYCERIDE Left glycerol Right palmitic acid oleic acid alpha-linolenic acid

In phosphoglycerides glycerol molecule same

two fatty acids esterified

Phospholipids area major component of all biological membranes

Sphingomyelin particularly concentrated in BRAIN major part of MYELIN

TRIGLYCERIDE

MYELIN

Dendirification and myelinisation peaks occurat 2 and 6 monthsis maximal at one year

At one year human milk has less proteinbut MORE TRIGLYCERIDE

FATTY ACIDS ARESPECIES SPECIFIC

Up to 6 months milk is 74 fat

but after 12 months it is 107

17

ldquocherry pickrdquo

Breastfeed time years school Incomelt 1 month 109 R$ 1238gt 6 month 121 R$ 1915

Group IQ 376 points higher from breatsfeeding

BREASTFEEDINGAND BREAST MILK

INCREASE IQ

BOTTLE FEEDINGamp FORMULA

DECREASE IQ

18

Be sure the wet nurse has plenty of milk because if she lacks it she may give the babymilk of a goat or sheep or some other animalbecause the child nourished on animal milkdoes not have perfect wits like one fed on womanrsquos milk and always looks stupid and vacant and not right in the head

14th century Tuscan text

Conceptual changeDyad careBreast first hour

even CaesareanContinuous SSC

DISCONTINUEGiving waterGlucose waterInfant formulaSeparationPacifier (dummy)

CHANGE POLICY Canrsquot change

biology

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

ON-GOING

S S C

WIRE NEURONS

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C WIRE

TIMING

(behavior)

19

Not so much duration

or density of any sleep stage

or number of sleep stage episodes but

cycling between quiet sleep

and active sleepis what is important

REMREM REM

NREM NREM

This is a healthy sleep pattern

This is a very good cycling pattern

(thanks to Susan Ludington-Hoe)

REMREM REM

NREM NREM

1st hour 2nd hour

So in every hour you would like

to see an EEG pattern that shows this

REM

NREM

REM

NREM

REM

NREM

State

HR

RR

REM Sleep is supposed to be

somewhat active so

HR increases and RR is irregular

SLEEP CYCLING ndashSeparation vs contact

In separation bull Dissociated statebull No cycling chaotic pattern

48 hour baseline chaotic pattern of

activity and quiet HR amp RR

SLEEP CYCLING ndashSeparation vs contact

In SSC bull Normal cyclingbull Non-chaotic pattern

48 hour baseline chaotic pattern of

activity and quiet HR amp RRPre-KC SSC

20

modulates state organisationelicits emotional behavioursactivates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL

Schaal 2004 115

DOUCETThe secretion of Areolar (Montgomeryrsquos) Glands from Lactating Women Elicits Selective Unconditional Responses in Neonates

ldquohellip breast chemosignalsactivate oral activity on the nipple that releases a cascade of behavioral neural neuroendocrineand endocrine processes in the newborn and the motherrdquo

Doucet 2009 116

The secretion of Areolar(Montgomeryrsquos) Glands

ldquoIn early ontogeny the sleeping brain may thusremain sentient of an organismrsquos odor environmentrdquo

Doucet 2009 117

REM

NREM

A skin-to-skin contactsession SHOULD NOT be less than one hour

or 90 minutes

SLEEPING

amp

CONTAINING

FEEDING ampHANDLINGfeed

sleep

HO

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C WIRE

TIMING

(behavior)

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C WIRE

STOMACH

21

STATE organization

Feeding frequency

SLEEP cycling

BRAIN

WIRING

How often should a neonate feed

CNS

ENS

ANS

InternalSomaticenvironment

CNS cortical subcortical(also to PNS)

ANS emotional limbic brain(incl SNS)

ANS myelinated vagus (NA)

ANS unmyelinated vagus (DMC)sub-diaphragmatic

ENS submucous plexusmyenteric plexus

122

The digestive system is endowed with its own local nervous system referred to as the enteric or intrinsic nervous system

The magnitude and complexity of the enteric nervous system is immense - it contains as many neurons as the spinal cord

ENTERIC NERVOUS SYSTEM

123

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

FEEDBACK LOOPS

CNS

ENS

ANS

InternalSomaticenvironment

124

125 126

22

Fetal stomach appears 4 weeks GABy 11 weeks wall capable of muscular

contraction

ldquoPatterns of antropyloric motilityin fed healthy preterm infantsrdquo

the neuroregulatory mechanisms responsible for the coordination of antro-pyloric motility and gastric emptying are

well developed by 30 weeks of PMAHassan 2002 127

Hydrochloric acidimportant for activation of pepsinogen

inactivation of microorganisms such as bacteria

Pepsinogenactivated by acid into active pepsin

responsible for the stomachs ability to initiate digestion of proteins

Chymosinis an enzyme whose role is to curdle or

coagulate milk in the stomach a process of considerable importance in the very young animal

128

Chymosinmakes the milk into ldquocheeserdquohalfway between liquid and solidstomach empties in 60 minutes

milk

129

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

FEEDBACK LOOPS

130

EVIDENCE FORFEEDING FREQUENCY

Edmond 2006 131

Breastfeeding and motherrsquos milkStrong and consistent evidence 132

23

Cup feeding versus bottle feedingCup feeding higher breastfeeding

greater stability133

Only case series Insufficient evidence

No mention of

stomach capacity134

EVIDENCE FORSTOMACH CAPACITY

Edmond 2006 135

0

05

1

15

2

25

3

35

4

0 10 20 30 40 50 60 70 80

volume ingested

fee

din

g f

req

ue

nc

y

Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml

StandardCARE3 hourlyschedule

136

KEY QUESTION

WHAT IS THE

STOMACHVOLUMEOF THE

NEONATE 137 Sase 2005

ldquoOntogeny of gastric emptying patternsin the human fetusrdquo

138

24

Goldstein 1987

ldquoGrowth of the Fetal Stomach in Normal Pregnanciesrdquo

139 Goldstein 1987

Length

Transverse

AP diameter

Using +2SD

140

Formula for calculation of stomach capacity (Charles Bradshaw UCT)Assumptions the stomach can be approximated by dividing into three sections namely a ellipsoidal hemisphere an ellipsoidal cylinder and a skewed ellipsoidal cone Variables a = anteroposterior radius t = transverse radius l = length stomachRelations the height of the cone and the hemisphere are both the same as lsquoarsquo

Ellipsoid = 43 Pi r1r2r3 = 43 Pi a a t therefore volume of hemisphere = 23 Pi a a t

Cylinder = Area of base height = (Pi a t ) ( l - 2a )Skewed cone = 13 base height = 13 Pi a t aTotal volume = 23 Pi aat + Pi a t (l- 2a) + 13 Pi a t a

=Pi atl -Pi a at= Pi a t(l-a)

Goldstein and Sase dataStomach capacity at term 10 - 15 ml

BRADSHAW formula

141

Assumption 25 kg baby 33w GA

requiring 150 mlkgday = 375 ml

45 MIN CYCLES ( 32 cyclesday)

12 ML PER CYCLE = 384 ml142

Newborn stomach volume

Gastric volumes at birthCorrelated with gastric pH

gastrin and somatostatin

ldquofetus drinks 10 ml portions of amniotic fluid helliprdquo

Widstrom 1988 143

Only recent study locatedldquoAutopsyrdquo capacity was determined

in Indian post-mortem studies

100 autopsies (63 SB 37 ENND)Tied at cardia and pylorus filled withwater emptied amp measured repeatedldquohellip obliteration of the gastric curvaturesrdquoldquodue care to minimize stretch artifactsrdquo

Naveed 1992

ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo

144

25

Infants above 2500g onlyAve Range

Stillborn (n 11) 196 ml (10-35)Early death (n 9) 178 ml (10-25)All cases (n 20) 188 ml

Naveed 1992

ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo

145 146

KERNESSUK 1997 (Russian)

Postmortem in situ measures(applied Bradshaw formula)

AveNewborn (n 11) 15 ml2 months (n 11) 35 ml2-4 m (n 10) 50 ml4-6 m (n 8) 100 ml

Known references with data

Scammon and Doyle 1920

Zuccarellirsquos method stomach filled at autopsy to ldquoa pressure of between

15 and 20 centimeters of waterrdquo

Scammon 1920

ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo

147

Anatomic capacity was determined in post-mortem studies

Main data set Alliot 1905 (n 25)Scammon own cases (n 13)

30 ndash 35 ml at birth ndashalmost regardless of birth weight

Scammon 1920

ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo

148

Zangen S et al Rapid maturation of gastric relaxation in newborns

Pressures (mmHg)

Balloon inflates to

15 ml no increase

functional capacity

149

Zangen S et al Rapid maturation of gastric relaxation in newborns

Pressures (mmHg)

Balloon inflates to

15 ml no increase20 ml pressure OK

physiologicalcapacity hellip 150

26

EVIDENCE (NBn 111009)

Author Capacity NoteSase 10-15 ml Live term fetusGoldstein 10-15 ml Live term fetusWidstrom 10 mls Live newbornZangen 20 mls Live (pressure)

Naveed 20 mls Autopsy (SB)20 mls Autopsy (ENND)

Kernessuk 15 mls Autopsy (in situ)Scammon 30-35 ml Autopsy (water

(Alliot) pressure)151

PROPOSAL

The CAPACITY of aweek old babyrsquos stomach is

approx 20 ml152

0

05

1

15

2

25

3

35

4

0 10 20 30 40 50 60 70 80

volume ingested

fee

din

g f

req

ue

nc

y

Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml

StandardCARE3 hourlyschedule

MOTHERNATURE

1 hourlyschedule

153

PHYSIOLOGICAL CAPACITY

RECEPTIVE CAPACITY of stomach

INGESTIVE CAPACITY of BABY

FUNCTIONAL CAPACITY

154

PROPOSAL

The FEEDINGFREQUENCY of theNEONATE is

approx 60 min155

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

BRAIN CYCLING

STOMACH FILLING amp EMPTYING

REMNR1NR2NR3NR4

156

27

Normal physiology of theEnteric Nervous System

ldquoSmall and frequent feeds according to the sleep cyclerdquo

The ldquonicherdquo (occupation) of a neonate (Alberts)

BOND FEED

SLEEP SLEEP

PLAY FEED

157

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

FEEDING SUCKLING

Influence of SMELL None Totally dependent

Motor mechanism Chewing ndash different

muscles

Suckling ndash different circuits

INSULIN Increases weight No effect

GHRELIN Increases weight No effect

LEPTIN Decreases intake No effect

CHOLECYSTOKININ Decreases intake No effect

AMPHETAMINE Decreases appetite Increases suckling

SEROTONIN Agonist improves feeding Antagonist improves suck

SATIETY Infant determined Maternal supply determine

FEEDING SUCKLING

Influence of SMELL None Totally dependent

Motor mechanism Chewing ndash different

muscles

Suckling ndash different circuits

INSULIN Increases weight No effect

GHRELIN Increases weight No effect

LEPTIN Decreases intake No effect

CHOLECYSTOKININ Decreases intake No effect

AMPHETAMINE Decreases appetite Increases suckling

SEROTONIN Agonist improves feeding Antagonist improves suck

SATIETY Infant determined Maternal supply determine

Current dogmaTHE BABY KNOWS

WHEN IT HAS HAD ENOUGH

PROBABLY NOT

WHAT IS THE

STOMACH VOLUME OF THE

PREMATURE

161

Assume low resilience

Assume proportionality

162

28

The CAPACITY of alow birthweight premfrom 20ml 3000g

= 0007 x BWt (g)

1kg x 0007 = 7mls2kg x 0007 = 14mls

163

Gastric overfilling syndrome

164

75 ml per feeding ASSUMPTION

IMMATURE OR OVERWHELMED

many aspects of gastrointestinalmotility are immature in the neonate

Zangen S et al Rapid maturation of gastric relaxation in newborns

A balloon in stomachcan fill to 76 mls

What does the stomach ndashwithout a balloon ndashdo to 76 mls

REFLUX PRESUME each feedapproximately 75 mls

GER

bull Sudden outbursts of crying

bull Awakens in pain

bull Related to feedings

bull Not easily comforted

bull ldquoI know baby hurtsrdquo

bull Sour burps throaty noises

bull Best when upright

Clues to GER

Dr W Sears

29

Mitchell 2001

Kerstin Uvnaumls-Moberg

Food in duodenum

AMYLINreleased

Closes pylorus

Duodenumempty

Pylorusopens

ldquoFeed intolerancerdquo hellip hellip or VOLUME intolerance

HYPOGLYCAEMIA

A babies stomach empties in60 minutes

Blood sugarmay fall hellip

after 90 minutes Options

30

METABOLIC ADAPTATION

SSC started in the first 20 minutes after birth

SSC CotBlood glucose (1 hr) 317 256Base excess drop 34 18

(Christenson 1992)0h 1h 2h 3h 4h 2 days

App

roxim

ate

GLUCOSE

SSC Glucose production = Glucose consumption

Separation

SNS stress Glucose consumption INCREASE

PSNS dissociation Glucose production DECREASE

HYPOGLYCEMIA

SSC Cot

Blood glucose (1 hr) 317 256

0h 1h 2h 3h 4h 2 days

App

roxim

ate

GLUCOSE

SSC Glucose production = Glucose consumption

Separation PSNS dissociation

Glucose production DECREASE

HYPOGLYCEMIA

SSC Cot

Blood glucose (1 hr) 317 256

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

NEURODEVELOPMENTThe DNA Behaviour

EVOLUTIONARY BIOLOGY

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

BONDING ATTACHMENT

MRI HRVEEG

STRESS RESPONES

RESILIENCE

DOHAD

(MAL) ADAPTATION

EPIGENETICS

GENE X ENVIRONMENT

GENETIC VARIANTS

HOSPITAL ACQUIRED INFECTIONIMMUNITY

SLEEP PHYSIOLOGY

GUT FUNCTIONMICROBIOTA

ldquoSTABILITYrdquo

TRANSITION

LONG TERM FOLLOW-UP

NEUROENDOCRINE BEHAVIOURS

MATERNAL NEUROPLASTICITY

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

MORTALITYMETABOLISM

0h 1h 2h 3h 4h

PSNS (vagal)

App

roxim

ate

GLUCOSE

1 HOURLY Milk feed

1 HOURLY Milk feed

1 HOURLY Milk feed

1 HOURLY Milk feed

LACTOSE

METABOLISM

31

0h 1h 2h 3h 4h

PSNS (vagal) SYMPATHETIC STRESS

App

roxim

ate

GLUCOSE

LACTOSE FATGLYCOGEN

METABOLISM

4 HOURLY Milk feed

0h 1h 2h 3h 4h

PSNS (vagal) SYMPATHETIC STRESS

App

roxim

ate

GLUCOSE

4 HOURLY ALLOSTATIC STATELACTOSE FATGLYCOGEN

METABOLISM

4 HOURLY Milk feed

HEALTH DISEASE

EXPECTED UNEXPECTED

NEURODEVELOPMENTThe DNA Behaviour

EVOLUTIONARY BIOLOGY

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

BONDING ATTACHMENT

MRI HRVEEG

STRESS RESPONES

RESILIENCE

DOHAD

(MAL) ADAPTATION

EPIGENETICS

GENE X ENVIRONMENT

GENETIC VARIANTS

HOSPITAL ACQUIRED INFECTIONIMMUNITY

SLEEP PHYSIOLOGY

GUT FUNCTIONMICROBIOTA

ldquoSTABILITYrdquo

TRANSITION

LONG TERM FOLLOW-UP

NEUROENDOCRINE BEHAVIOURS

MATERNAL NEUROPLASTICITY

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

MORTALITYMETABOLISM

Weight gain 1st week

predicts OBESITYat 30 years

Large volume feedsstretched stomach=

doubled absorptivecapacity as adult

Importance

Programming ndash early life chronic disease

32

RESISTANCE SENSITIVITY

PERCEPTIONSldquoNEUROCEPTIONrdquo

RESPONSESTRESS

ALLOSTATIC STATE

ALLOSTASIS

ANY STRESSPsychologicalNeurological

EndocrineImmune

ALLOSTATIC LOAD

ALLOSTATIC OVERLOAD

WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY

DISEASEHEALTH

RESILIENCE VULNERABILITY

RESISTANCE SENSITIVITY

PERCEPTIONSldquoNEUROCEPTIONrdquo

RESPONSESTRESS

ALLOSTATIC STATE

ALLOSTASIS

ANY STRESSPsychologicalNeurological

EndocrineImmune

ALLOSTATIC LOAD

HEALTH

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

Gastric overfilling syndrome

189

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

33

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

Only case series Insufficient evidence

No mention of

stomach capacity196

Baby weight freq reqrsquod size actual

2kg baby 4hrly ~ 320 ml6 = 53ml 14ml

15 baby 3hrly ~ 240 ml8 = 30ml 10ml

10 baby 2hrly ~ 160 ml12 = 13ml 7ml

Standardised from20ml capacityfor 3kg baby( x 0007)

197

0

10

20

30

40

50

60

70

80

90

13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w

LINEAR

TERM

PREM

198

34

0

10

20

30

40

50

60

70

80

90

13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w

LINEAR

TERM

PREM

199

Clues to GER

ldquoI know baby hurtsrdquo

Gastric overfilling syndrome

Excessive volumesreflux aspiration colic

Excessive time intervalhypoglycaemia

Adaptationsdiabetic diathesis obesity

200

Developmental Care of the Enteric Nervous System

ldquoSmall and frequent feeds according to the sleep cyclerdquo

The ldquonicherdquo (occupation) of a neonate (Alberts)

BOND FEED

SLEEP SLEEP

PLAY FEED

201

Gastric overfilling syndrome

Proposed Management 202

Proposed Management

Babies should be fedEVERY TIME THEY WAKE

Stanley Graven 2006

REMNR1NR2NR3SWS

AS (20 mins) QS (40 mins)

A normal sleep cycle is ONE hourHow often should neonates feed

203

Proposed Management

All babies should be fedat least once an hour 204

35

Proposed Management

All babies should be fedat least once an hour

205

The first Milk Ejection Reflex (MER)

elicited in lt 2 minutesworks quicklyswallowed 1 minute

Feeding time (max)3 minutes

Repeat every 1 hour

Prime 2007

The ldquonormalrdquo or usual and common breastfeed

takes 15 minutesdiscomfort afterburping time 5 minutes

Feeding time 20 min

Repeat every 3 hours

Prime 2007

3 minute 20ml feeds x 24d = 72 minutes

20 minute 60ml feeds x 8d = 160 minutes

SMALL AND FREQUENT FEEDS ARE EFFICIENT

FEWER NURSES NEEDED

The calculated dailyrequirement for a 3kgbaby can be given without increase inpressure MINIMAL RISK

PARENTS CAN DOSAFELY

20 mls x 24 feeds= 480mls day

Zangen 2001 209

All babies should be fedat least once an hour

210

36

Infant feeding frequencyProposal based on available evidence and neuroscience

ldquoSmall and frequent feeds

adjusted to the sleep cyclerdquo

211

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

STATE organization

Feeding frequency

SLEEP cycling

BRAIN

WIRING

How often should a neonate feeda neonate sleep

Infantsleep cycles

begin to block on diurnalrhythms

Mother-infant synchrony

hellip at 12 weeks

(circadian)

START at 3 months

Can be ldquoadult-likerdquo

at 6 months

Thomas 2014

STATE organization

Feeding frequency

SLEEP cycling

PLAY FEED

216

SLEEP SLEEP

SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

Infantsleep cycles

begin to block on diurnalrhythms

37

BOND SUCKLE SLEEP SLEEP PLAY

FEED

217

SLEEP SLEEP SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)

Schaal 2004 218

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)rdquoSLEEP-FEED CYCLINGrdquo

Schaal 2004 219

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

WIRE

BRAIN

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

BRAIN

WIRING

NEUROSCIENCE

The DNAEverything else

EVOLUTIONARYBIOLOGY

The Brain

EPIGENETICS

The PlaceENVIRONMENT

EXPERIENCEFITNESS ADAPTATION

ldquoScientific foundationrdquo hellip a synthesis

ZERO

SEPARATION

38

wwwninobirthorgwwwskintoskincontactcom

THE NEUROSCIENCE OFSKIN-TO-SKIN CONTACT

AND BREASTFEEDING

ARE THE SAME

SUMMARY SKIN-TO-SKIN

(Regulation)

SLEEP(Brain)

FEEDING(Stomach)

LOVE ( ldquomindrdquo )

REMNR1NR2NR3NR4

ACQUISITION CONSOLIDATION MEMORYFORMATION

poly-sensory input transfer information P wavesshort-term memory ldquoSNRrdquo strong signals returns infostored cortex amygdala to neocortex

hippocampus organizedAwake and REM NREM stage 4 REM

BRAIN WIRING

Stanley Graven 2006

PLAY

SLEEP

FEEDHOLDYOURPREM

httpswwwfacebookcomninobirth

39

Nelson Mandela

hellip in describing themeasure of a nation

he has argued that

ldquoThere can be no keener revelation of a societyrsquos soul than the way in which it treats its childrenrdquo

Page 10: Neurodevelopmental The Neuroscience of Birth ... · breastfeeding pattern, neonatal weight gain, and the dynamics of lactation. Doucet 2012 In the ‘‘scentless breast’’ condition,

10

Milk making NUTRITION

HypothalamusPituitaryPROLACTIN

Maternal ferocityPROTECTION

OXYTOCIN Gaze increase BONDING

OXYTOCINCingulate Suppressed

REGULATION

AmygdalaCHOLECYSTOKININ Emotion satiety

HypothalamusPituitary

Cingulate

Amygdala

ldquoThe newborn may

appear helpless but

skin-to-skin contactstimulates prolactin

ensures nutritionstimulates oxytocin

ensures protectionstimulates cholecystokinin

ensures wellbeing bonding

The first hours after birth are a

CRITICAL PERIOD

mutual psycho-neuro-physiological

caregivers

Critical period concept

ldquoWindows of opportunity in early life when a childrsquos brain is exquisitely primed to receive sensory input in order to develop more advanced neural systemsrdquo

a motherrsquos brain hellip

SENSITIZATION

DOULA and KANGAROULA

DOULA protects

OXYTOCINduringlabour

KANGAROULA protects

OXYTOCINafter birth

lsquothe first 1000 minutesrsquolsquoprevious 1000 minutesrsquo

BIRTH

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

WIRE MOTHER

OXYTOCIN

11

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDINGON-GOING

S S C

WIRE TOGETHER

OXYTOCIN

hellip infant cues - suckling vocalisation and tactile stimulation - stimulate

OXYTOCINrelease in the hypothalamus which may result in the activation of the dopaminergic reward pathway leading to behavioural reinforcement

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

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

DISEASEHEALTH

CORTISOLOXYTOCIN

The psychology of human parent-infant relationships

Parenting is regulated by key hormones and neurotransmitters

Neuroanatomical circuits of parenting

Integrative physiology of normal parenting behaviours

Brain imaging of human parent-infant relationships

The neurobiology of empathy and parenting

Conclusions and critical summary

(Swain et al 2007)

12

FEARCONTROL

CENTRE

REWARDCONTROL

CENTRE

SOCIALCONTROL CENTRE

OXYTOCINDOPAMINE

CORTISOL

EMOTIONCONTROL CENTRE

WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY

DISEASEHEALTH

RESILIENCE VULNERABILITY

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

DOULA and KANGAROULA

-1000 min

BIRTH

+1000 min 1000 days

OXYTOCIN Zero separation

Protect OXYTOCINBefore and after

BIRTH

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDINGON-GOING

S S C

WIRE TOGETHER

Protect OXYTOCINBefore and after

BIRTH

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDINGON-GOING

S S C

WIRE SUCKLING

BREASTFEEDING Feed Sleep Cycling

BONDING Sensitization

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

BRAIN

WIRING

Neurodevelopmental Approach to

Alberts SUCKLING versus FEEDING

DUAL INGESTION SYSTEMS

13

300 mya 200 mya 100 mya 50 mya 300 mya 200 mya 100 mya 50 mya

Amniotes

Synapsids

Cynodonts

Mammaliaformes

PlacentalsMammals

ANCESTRAL STATE

hellip intoMATURE FEEDING

300 mya 200 mya 100 mya 50 mya

WATER

EGGS

Hatch withTEETH

ANCESTRAL STATE

hellip intoMATURE FEEDING

eg TURTLES

CROCODILES DINOSAURS

REPTILES

300 mya 200 mya 100 mya 50 mya

Epibubic bone = pouch care

hellip intoMATURE FEEDING

Amniotes

Synapsids

Cynodonts

Mammaliaformes

Smaller eggs longer in body

The AMNIOTE EGGextra membranes

Copes with AIR

PlacentalsMammals

Viviparity = immature

ENDOTHERMY

MOISTUREfor eggs

Diphyodontism

300 mya 200 mya 100 mya 50 mya

hellip intoMATURE FEEDING

Amniotes

Synapsids

Cynodonts

Mammaliaformes

PlacentalsMammals

ENDOTHERMY

MOISTUREfor eggs

LACTOSE added(apocrine glands)

NUTRIENTSAntimicrobials

LACTATION

SUCKLINGFEEDING

200 million years

Diphyodontism

300 mya 200 mya 100 mya 50 mya

hellip intoMATURE FEEDING

Amniotes

Synapsids

Cynodonts

Mammaliaformes

PlacentalsMammals

ENDOTHERMY

MOISTUREfor eggs

LACTOSE added(apocrine glands)

NUTRIENTSAntimicrobials

LACTATION

SUCKLINGFEEDING

200 million years

DUAL INGESTION SYSTEMS

100 million years

14

DUAL INGESTION SYSTEMS DUAL INGESTION SYSTEMS

SUCKLING WEANING FEEDING

Lactase Digestive enzymes

FEEDING SUCKLING

Influence of SMELL None Totally dependent

Motor mechanism Chewing ndash different

muscles

Suckling ndash different circuits

INSULIN Increases weight No effect

GHRELIN Increases weight No effect

LEPTIN Decreases intake No effect

CHOLECYSTOKININ Decreases intake No effect

AMPHETAMINE Decreases appetite Increases suckling

SEROTONIN Agonist improves feeding Antagonist improves suck

SATIETY Infant determined Maternal supply determine

FEEDING SUCKLING

DISRUPTION ROBUST VERY SENSITIVE

Must have right conditions

Pup-in-a- cup - And STIMULI

separated and fed by tube

From day 2 off life

Starts to feed normally d21 2 days gavage or other

no longer suckles

If starved for 24 hours pup

at d3 will feed food from

floor

(Can be maintained by

smell and other stimuli)

Pup-in-a- cup -

separated and fed by tube

From day 2 off life

Starts to feed normally d21

15

PMA 28 40 64 1y 2y

Nilsrsquo IDEALIZED VIEW

PMA 28 40 64 1y 2y

Nilsrsquo IDEALIZED VIEW

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

Reflections for practice

Suckling and Feeding areNOT THE SAME

16

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDINGON-GOING

S S C

WIRE SUCKLING

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

ON-GOING

S S C

WIRE NEURONS

Up to 6 months milk is 74 fat

96 of this is TRIGLYCERIDE

TRIGLYCERIDE Left glycerol Right palmitic acid oleic acid alpha-linolenic acid

In phosphoglycerides glycerol molecule same

two fatty acids esterified

Phospholipids area major component of all biological membranes

Sphingomyelin particularly concentrated in BRAIN major part of MYELIN

TRIGLYCERIDE

MYELIN

Dendirification and myelinisation peaks occurat 2 and 6 monthsis maximal at one year

At one year human milk has less proteinbut MORE TRIGLYCERIDE

FATTY ACIDS ARESPECIES SPECIFIC

Up to 6 months milk is 74 fat

but after 12 months it is 107

17

ldquocherry pickrdquo

Breastfeed time years school Incomelt 1 month 109 R$ 1238gt 6 month 121 R$ 1915

Group IQ 376 points higher from breatsfeeding

BREASTFEEDINGAND BREAST MILK

INCREASE IQ

BOTTLE FEEDINGamp FORMULA

DECREASE IQ

18

Be sure the wet nurse has plenty of milk because if she lacks it she may give the babymilk of a goat or sheep or some other animalbecause the child nourished on animal milkdoes not have perfect wits like one fed on womanrsquos milk and always looks stupid and vacant and not right in the head

14th century Tuscan text

Conceptual changeDyad careBreast first hour

even CaesareanContinuous SSC

DISCONTINUEGiving waterGlucose waterInfant formulaSeparationPacifier (dummy)

CHANGE POLICY Canrsquot change

biology

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

ON-GOING

S S C

WIRE NEURONS

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C WIRE

TIMING

(behavior)

19

Not so much duration

or density of any sleep stage

or number of sleep stage episodes but

cycling between quiet sleep

and active sleepis what is important

REMREM REM

NREM NREM

This is a healthy sleep pattern

This is a very good cycling pattern

(thanks to Susan Ludington-Hoe)

REMREM REM

NREM NREM

1st hour 2nd hour

So in every hour you would like

to see an EEG pattern that shows this

REM

NREM

REM

NREM

REM

NREM

State

HR

RR

REM Sleep is supposed to be

somewhat active so

HR increases and RR is irregular

SLEEP CYCLING ndashSeparation vs contact

In separation bull Dissociated statebull No cycling chaotic pattern

48 hour baseline chaotic pattern of

activity and quiet HR amp RR

SLEEP CYCLING ndashSeparation vs contact

In SSC bull Normal cyclingbull Non-chaotic pattern

48 hour baseline chaotic pattern of

activity and quiet HR amp RRPre-KC SSC

20

modulates state organisationelicits emotional behavioursactivates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL

Schaal 2004 115

DOUCETThe secretion of Areolar (Montgomeryrsquos) Glands from Lactating Women Elicits Selective Unconditional Responses in Neonates

ldquohellip breast chemosignalsactivate oral activity on the nipple that releases a cascade of behavioral neural neuroendocrineand endocrine processes in the newborn and the motherrdquo

Doucet 2009 116

The secretion of Areolar(Montgomeryrsquos) Glands

ldquoIn early ontogeny the sleeping brain may thusremain sentient of an organismrsquos odor environmentrdquo

Doucet 2009 117

REM

NREM

A skin-to-skin contactsession SHOULD NOT be less than one hour

or 90 minutes

SLEEPING

amp

CONTAINING

FEEDING ampHANDLINGfeed

sleep

HO

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C WIRE

TIMING

(behavior)

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C WIRE

STOMACH

21

STATE organization

Feeding frequency

SLEEP cycling

BRAIN

WIRING

How often should a neonate feed

CNS

ENS

ANS

InternalSomaticenvironment

CNS cortical subcortical(also to PNS)

ANS emotional limbic brain(incl SNS)

ANS myelinated vagus (NA)

ANS unmyelinated vagus (DMC)sub-diaphragmatic

ENS submucous plexusmyenteric plexus

122

The digestive system is endowed with its own local nervous system referred to as the enteric or intrinsic nervous system

The magnitude and complexity of the enteric nervous system is immense - it contains as many neurons as the spinal cord

ENTERIC NERVOUS SYSTEM

123

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

FEEDBACK LOOPS

CNS

ENS

ANS

InternalSomaticenvironment

124

125 126

22

Fetal stomach appears 4 weeks GABy 11 weeks wall capable of muscular

contraction

ldquoPatterns of antropyloric motilityin fed healthy preterm infantsrdquo

the neuroregulatory mechanisms responsible for the coordination of antro-pyloric motility and gastric emptying are

well developed by 30 weeks of PMAHassan 2002 127

Hydrochloric acidimportant for activation of pepsinogen

inactivation of microorganisms such as bacteria

Pepsinogenactivated by acid into active pepsin

responsible for the stomachs ability to initiate digestion of proteins

Chymosinis an enzyme whose role is to curdle or

coagulate milk in the stomach a process of considerable importance in the very young animal

128

Chymosinmakes the milk into ldquocheeserdquohalfway between liquid and solidstomach empties in 60 minutes

milk

129

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

FEEDBACK LOOPS

130

EVIDENCE FORFEEDING FREQUENCY

Edmond 2006 131

Breastfeeding and motherrsquos milkStrong and consistent evidence 132

23

Cup feeding versus bottle feedingCup feeding higher breastfeeding

greater stability133

Only case series Insufficient evidence

No mention of

stomach capacity134

EVIDENCE FORSTOMACH CAPACITY

Edmond 2006 135

0

05

1

15

2

25

3

35

4

0 10 20 30 40 50 60 70 80

volume ingested

fee

din

g f

req

ue

nc

y

Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml

StandardCARE3 hourlyschedule

136

KEY QUESTION

WHAT IS THE

STOMACHVOLUMEOF THE

NEONATE 137 Sase 2005

ldquoOntogeny of gastric emptying patternsin the human fetusrdquo

138

24

Goldstein 1987

ldquoGrowth of the Fetal Stomach in Normal Pregnanciesrdquo

139 Goldstein 1987

Length

Transverse

AP diameter

Using +2SD

140

Formula for calculation of stomach capacity (Charles Bradshaw UCT)Assumptions the stomach can be approximated by dividing into three sections namely a ellipsoidal hemisphere an ellipsoidal cylinder and a skewed ellipsoidal cone Variables a = anteroposterior radius t = transverse radius l = length stomachRelations the height of the cone and the hemisphere are both the same as lsquoarsquo

Ellipsoid = 43 Pi r1r2r3 = 43 Pi a a t therefore volume of hemisphere = 23 Pi a a t

Cylinder = Area of base height = (Pi a t ) ( l - 2a )Skewed cone = 13 base height = 13 Pi a t aTotal volume = 23 Pi aat + Pi a t (l- 2a) + 13 Pi a t a

=Pi atl -Pi a at= Pi a t(l-a)

Goldstein and Sase dataStomach capacity at term 10 - 15 ml

BRADSHAW formula

141

Assumption 25 kg baby 33w GA

requiring 150 mlkgday = 375 ml

45 MIN CYCLES ( 32 cyclesday)

12 ML PER CYCLE = 384 ml142

Newborn stomach volume

Gastric volumes at birthCorrelated with gastric pH

gastrin and somatostatin

ldquofetus drinks 10 ml portions of amniotic fluid helliprdquo

Widstrom 1988 143

Only recent study locatedldquoAutopsyrdquo capacity was determined

in Indian post-mortem studies

100 autopsies (63 SB 37 ENND)Tied at cardia and pylorus filled withwater emptied amp measured repeatedldquohellip obliteration of the gastric curvaturesrdquoldquodue care to minimize stretch artifactsrdquo

Naveed 1992

ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo

144

25

Infants above 2500g onlyAve Range

Stillborn (n 11) 196 ml (10-35)Early death (n 9) 178 ml (10-25)All cases (n 20) 188 ml

Naveed 1992

ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo

145 146

KERNESSUK 1997 (Russian)

Postmortem in situ measures(applied Bradshaw formula)

AveNewborn (n 11) 15 ml2 months (n 11) 35 ml2-4 m (n 10) 50 ml4-6 m (n 8) 100 ml

Known references with data

Scammon and Doyle 1920

Zuccarellirsquos method stomach filled at autopsy to ldquoa pressure of between

15 and 20 centimeters of waterrdquo

Scammon 1920

ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo

147

Anatomic capacity was determined in post-mortem studies

Main data set Alliot 1905 (n 25)Scammon own cases (n 13)

30 ndash 35 ml at birth ndashalmost regardless of birth weight

Scammon 1920

ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo

148

Zangen S et al Rapid maturation of gastric relaxation in newborns

Pressures (mmHg)

Balloon inflates to

15 ml no increase

functional capacity

149

Zangen S et al Rapid maturation of gastric relaxation in newborns

Pressures (mmHg)

Balloon inflates to

15 ml no increase20 ml pressure OK

physiologicalcapacity hellip 150

26

EVIDENCE (NBn 111009)

Author Capacity NoteSase 10-15 ml Live term fetusGoldstein 10-15 ml Live term fetusWidstrom 10 mls Live newbornZangen 20 mls Live (pressure)

Naveed 20 mls Autopsy (SB)20 mls Autopsy (ENND)

Kernessuk 15 mls Autopsy (in situ)Scammon 30-35 ml Autopsy (water

(Alliot) pressure)151

PROPOSAL

The CAPACITY of aweek old babyrsquos stomach is

approx 20 ml152

0

05

1

15

2

25

3

35

4

0 10 20 30 40 50 60 70 80

volume ingested

fee

din

g f

req

ue

nc

y

Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml

StandardCARE3 hourlyschedule

MOTHERNATURE

1 hourlyschedule

153

PHYSIOLOGICAL CAPACITY

RECEPTIVE CAPACITY of stomach

INGESTIVE CAPACITY of BABY

FUNCTIONAL CAPACITY

154

PROPOSAL

The FEEDINGFREQUENCY of theNEONATE is

approx 60 min155

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

BRAIN CYCLING

STOMACH FILLING amp EMPTYING

REMNR1NR2NR3NR4

156

27

Normal physiology of theEnteric Nervous System

ldquoSmall and frequent feeds according to the sleep cyclerdquo

The ldquonicherdquo (occupation) of a neonate (Alberts)

BOND FEED

SLEEP SLEEP

PLAY FEED

157

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

FEEDING SUCKLING

Influence of SMELL None Totally dependent

Motor mechanism Chewing ndash different

muscles

Suckling ndash different circuits

INSULIN Increases weight No effect

GHRELIN Increases weight No effect

LEPTIN Decreases intake No effect

CHOLECYSTOKININ Decreases intake No effect

AMPHETAMINE Decreases appetite Increases suckling

SEROTONIN Agonist improves feeding Antagonist improves suck

SATIETY Infant determined Maternal supply determine

FEEDING SUCKLING

Influence of SMELL None Totally dependent

Motor mechanism Chewing ndash different

muscles

Suckling ndash different circuits

INSULIN Increases weight No effect

GHRELIN Increases weight No effect

LEPTIN Decreases intake No effect

CHOLECYSTOKININ Decreases intake No effect

AMPHETAMINE Decreases appetite Increases suckling

SEROTONIN Agonist improves feeding Antagonist improves suck

SATIETY Infant determined Maternal supply determine

Current dogmaTHE BABY KNOWS

WHEN IT HAS HAD ENOUGH

PROBABLY NOT

WHAT IS THE

STOMACH VOLUME OF THE

PREMATURE

161

Assume low resilience

Assume proportionality

162

28

The CAPACITY of alow birthweight premfrom 20ml 3000g

= 0007 x BWt (g)

1kg x 0007 = 7mls2kg x 0007 = 14mls

163

Gastric overfilling syndrome

164

75 ml per feeding ASSUMPTION

IMMATURE OR OVERWHELMED

many aspects of gastrointestinalmotility are immature in the neonate

Zangen S et al Rapid maturation of gastric relaxation in newborns

A balloon in stomachcan fill to 76 mls

What does the stomach ndashwithout a balloon ndashdo to 76 mls

REFLUX PRESUME each feedapproximately 75 mls

GER

bull Sudden outbursts of crying

bull Awakens in pain

bull Related to feedings

bull Not easily comforted

bull ldquoI know baby hurtsrdquo

bull Sour burps throaty noises

bull Best when upright

Clues to GER

Dr W Sears

29

Mitchell 2001

Kerstin Uvnaumls-Moberg

Food in duodenum

AMYLINreleased

Closes pylorus

Duodenumempty

Pylorusopens

ldquoFeed intolerancerdquo hellip hellip or VOLUME intolerance

HYPOGLYCAEMIA

A babies stomach empties in60 minutes

Blood sugarmay fall hellip

after 90 minutes Options

30

METABOLIC ADAPTATION

SSC started in the first 20 minutes after birth

SSC CotBlood glucose (1 hr) 317 256Base excess drop 34 18

(Christenson 1992)0h 1h 2h 3h 4h 2 days

App

roxim

ate

GLUCOSE

SSC Glucose production = Glucose consumption

Separation

SNS stress Glucose consumption INCREASE

PSNS dissociation Glucose production DECREASE

HYPOGLYCEMIA

SSC Cot

Blood glucose (1 hr) 317 256

0h 1h 2h 3h 4h 2 days

App

roxim

ate

GLUCOSE

SSC Glucose production = Glucose consumption

Separation PSNS dissociation

Glucose production DECREASE

HYPOGLYCEMIA

SSC Cot

Blood glucose (1 hr) 317 256

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

NEURODEVELOPMENTThe DNA Behaviour

EVOLUTIONARY BIOLOGY

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

BONDING ATTACHMENT

MRI HRVEEG

STRESS RESPONES

RESILIENCE

DOHAD

(MAL) ADAPTATION

EPIGENETICS

GENE X ENVIRONMENT

GENETIC VARIANTS

HOSPITAL ACQUIRED INFECTIONIMMUNITY

SLEEP PHYSIOLOGY

GUT FUNCTIONMICROBIOTA

ldquoSTABILITYrdquo

TRANSITION

LONG TERM FOLLOW-UP

NEUROENDOCRINE BEHAVIOURS

MATERNAL NEUROPLASTICITY

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

MORTALITYMETABOLISM

0h 1h 2h 3h 4h

PSNS (vagal)

App

roxim

ate

GLUCOSE

1 HOURLY Milk feed

1 HOURLY Milk feed

1 HOURLY Milk feed

1 HOURLY Milk feed

LACTOSE

METABOLISM

31

0h 1h 2h 3h 4h

PSNS (vagal) SYMPATHETIC STRESS

App

roxim

ate

GLUCOSE

LACTOSE FATGLYCOGEN

METABOLISM

4 HOURLY Milk feed

0h 1h 2h 3h 4h

PSNS (vagal) SYMPATHETIC STRESS

App

roxim

ate

GLUCOSE

4 HOURLY ALLOSTATIC STATELACTOSE FATGLYCOGEN

METABOLISM

4 HOURLY Milk feed

HEALTH DISEASE

EXPECTED UNEXPECTED

NEURODEVELOPMENTThe DNA Behaviour

EVOLUTIONARY BIOLOGY

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

BONDING ATTACHMENT

MRI HRVEEG

STRESS RESPONES

RESILIENCE

DOHAD

(MAL) ADAPTATION

EPIGENETICS

GENE X ENVIRONMENT

GENETIC VARIANTS

HOSPITAL ACQUIRED INFECTIONIMMUNITY

SLEEP PHYSIOLOGY

GUT FUNCTIONMICROBIOTA

ldquoSTABILITYrdquo

TRANSITION

LONG TERM FOLLOW-UP

NEUROENDOCRINE BEHAVIOURS

MATERNAL NEUROPLASTICITY

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

MORTALITYMETABOLISM

Weight gain 1st week

predicts OBESITYat 30 years

Large volume feedsstretched stomach=

doubled absorptivecapacity as adult

Importance

Programming ndash early life chronic disease

32

RESISTANCE SENSITIVITY

PERCEPTIONSldquoNEUROCEPTIONrdquo

RESPONSESTRESS

ALLOSTATIC STATE

ALLOSTASIS

ANY STRESSPsychologicalNeurological

EndocrineImmune

ALLOSTATIC LOAD

ALLOSTATIC OVERLOAD

WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY

DISEASEHEALTH

RESILIENCE VULNERABILITY

RESISTANCE SENSITIVITY

PERCEPTIONSldquoNEUROCEPTIONrdquo

RESPONSESTRESS

ALLOSTATIC STATE

ALLOSTASIS

ANY STRESSPsychologicalNeurological

EndocrineImmune

ALLOSTATIC LOAD

HEALTH

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

Gastric overfilling syndrome

189

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

33

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

Only case series Insufficient evidence

No mention of

stomach capacity196

Baby weight freq reqrsquod size actual

2kg baby 4hrly ~ 320 ml6 = 53ml 14ml

15 baby 3hrly ~ 240 ml8 = 30ml 10ml

10 baby 2hrly ~ 160 ml12 = 13ml 7ml

Standardised from20ml capacityfor 3kg baby( x 0007)

197

0

10

20

30

40

50

60

70

80

90

13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w

LINEAR

TERM

PREM

198

34

0

10

20

30

40

50

60

70

80

90

13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w

LINEAR

TERM

PREM

199

Clues to GER

ldquoI know baby hurtsrdquo

Gastric overfilling syndrome

Excessive volumesreflux aspiration colic

Excessive time intervalhypoglycaemia

Adaptationsdiabetic diathesis obesity

200

Developmental Care of the Enteric Nervous System

ldquoSmall and frequent feeds according to the sleep cyclerdquo

The ldquonicherdquo (occupation) of a neonate (Alberts)

BOND FEED

SLEEP SLEEP

PLAY FEED

201

Gastric overfilling syndrome

Proposed Management 202

Proposed Management

Babies should be fedEVERY TIME THEY WAKE

Stanley Graven 2006

REMNR1NR2NR3SWS

AS (20 mins) QS (40 mins)

A normal sleep cycle is ONE hourHow often should neonates feed

203

Proposed Management

All babies should be fedat least once an hour 204

35

Proposed Management

All babies should be fedat least once an hour

205

The first Milk Ejection Reflex (MER)

elicited in lt 2 minutesworks quicklyswallowed 1 minute

Feeding time (max)3 minutes

Repeat every 1 hour

Prime 2007

The ldquonormalrdquo or usual and common breastfeed

takes 15 minutesdiscomfort afterburping time 5 minutes

Feeding time 20 min

Repeat every 3 hours

Prime 2007

3 minute 20ml feeds x 24d = 72 minutes

20 minute 60ml feeds x 8d = 160 minutes

SMALL AND FREQUENT FEEDS ARE EFFICIENT

FEWER NURSES NEEDED

The calculated dailyrequirement for a 3kgbaby can be given without increase inpressure MINIMAL RISK

PARENTS CAN DOSAFELY

20 mls x 24 feeds= 480mls day

Zangen 2001 209

All babies should be fedat least once an hour

210

36

Infant feeding frequencyProposal based on available evidence and neuroscience

ldquoSmall and frequent feeds

adjusted to the sleep cyclerdquo

211

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

STATE organization

Feeding frequency

SLEEP cycling

BRAIN

WIRING

How often should a neonate feeda neonate sleep

Infantsleep cycles

begin to block on diurnalrhythms

Mother-infant synchrony

hellip at 12 weeks

(circadian)

START at 3 months

Can be ldquoadult-likerdquo

at 6 months

Thomas 2014

STATE organization

Feeding frequency

SLEEP cycling

PLAY FEED

216

SLEEP SLEEP

SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

Infantsleep cycles

begin to block on diurnalrhythms

37

BOND SUCKLE SLEEP SLEEP PLAY

FEED

217

SLEEP SLEEP SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)

Schaal 2004 218

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)rdquoSLEEP-FEED CYCLINGrdquo

Schaal 2004 219

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

WIRE

BRAIN

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

BRAIN

WIRING

NEUROSCIENCE

The DNAEverything else

EVOLUTIONARYBIOLOGY

The Brain

EPIGENETICS

The PlaceENVIRONMENT

EXPERIENCEFITNESS ADAPTATION

ldquoScientific foundationrdquo hellip a synthesis

ZERO

SEPARATION

38

wwwninobirthorgwwwskintoskincontactcom

THE NEUROSCIENCE OFSKIN-TO-SKIN CONTACT

AND BREASTFEEDING

ARE THE SAME

SUMMARY SKIN-TO-SKIN

(Regulation)

SLEEP(Brain)

FEEDING(Stomach)

LOVE ( ldquomindrdquo )

REMNR1NR2NR3NR4

ACQUISITION CONSOLIDATION MEMORYFORMATION

poly-sensory input transfer information P wavesshort-term memory ldquoSNRrdquo strong signals returns infostored cortex amygdala to neocortex

hippocampus organizedAwake and REM NREM stage 4 REM

BRAIN WIRING

Stanley Graven 2006

PLAY

SLEEP

FEEDHOLDYOURPREM

httpswwwfacebookcomninobirth

39

Nelson Mandela

hellip in describing themeasure of a nation

he has argued that

ldquoThere can be no keener revelation of a societyrsquos soul than the way in which it treats its childrenrdquo

Page 11: Neurodevelopmental The Neuroscience of Birth ... · breastfeeding pattern, neonatal weight gain, and the dynamics of lactation. Doucet 2012 In the ‘‘scentless breast’’ condition,

11

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDINGON-GOING

S S C

WIRE TOGETHER

OXYTOCIN

hellip infant cues - suckling vocalisation and tactile stimulation - stimulate

OXYTOCINrelease in the hypothalamus which may result in the activation of the dopaminergic reward pathway leading to behavioural reinforcement

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

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

DISEASEHEALTH

CORTISOLOXYTOCIN

The psychology of human parent-infant relationships

Parenting is regulated by key hormones and neurotransmitters

Neuroanatomical circuits of parenting

Integrative physiology of normal parenting behaviours

Brain imaging of human parent-infant relationships

The neurobiology of empathy and parenting

Conclusions and critical summary

(Swain et al 2007)

12

FEARCONTROL

CENTRE

REWARDCONTROL

CENTRE

SOCIALCONTROL CENTRE

OXYTOCINDOPAMINE

CORTISOL

EMOTIONCONTROL CENTRE

WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY

DISEASEHEALTH

RESILIENCE VULNERABILITY

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

DOULA and KANGAROULA

-1000 min

BIRTH

+1000 min 1000 days

OXYTOCIN Zero separation

Protect OXYTOCINBefore and after

BIRTH

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDINGON-GOING

S S C

WIRE TOGETHER

Protect OXYTOCINBefore and after

BIRTH

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDINGON-GOING

S S C

WIRE SUCKLING

BREASTFEEDING Feed Sleep Cycling

BONDING Sensitization

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

BRAIN

WIRING

Neurodevelopmental Approach to

Alberts SUCKLING versus FEEDING

DUAL INGESTION SYSTEMS

13

300 mya 200 mya 100 mya 50 mya 300 mya 200 mya 100 mya 50 mya

Amniotes

Synapsids

Cynodonts

Mammaliaformes

PlacentalsMammals

ANCESTRAL STATE

hellip intoMATURE FEEDING

300 mya 200 mya 100 mya 50 mya

WATER

EGGS

Hatch withTEETH

ANCESTRAL STATE

hellip intoMATURE FEEDING

eg TURTLES

CROCODILES DINOSAURS

REPTILES

300 mya 200 mya 100 mya 50 mya

Epibubic bone = pouch care

hellip intoMATURE FEEDING

Amniotes

Synapsids

Cynodonts

Mammaliaformes

Smaller eggs longer in body

The AMNIOTE EGGextra membranes

Copes with AIR

PlacentalsMammals

Viviparity = immature

ENDOTHERMY

MOISTUREfor eggs

Diphyodontism

300 mya 200 mya 100 mya 50 mya

hellip intoMATURE FEEDING

Amniotes

Synapsids

Cynodonts

Mammaliaformes

PlacentalsMammals

ENDOTHERMY

MOISTUREfor eggs

LACTOSE added(apocrine glands)

NUTRIENTSAntimicrobials

LACTATION

SUCKLINGFEEDING

200 million years

Diphyodontism

300 mya 200 mya 100 mya 50 mya

hellip intoMATURE FEEDING

Amniotes

Synapsids

Cynodonts

Mammaliaformes

PlacentalsMammals

ENDOTHERMY

MOISTUREfor eggs

LACTOSE added(apocrine glands)

NUTRIENTSAntimicrobials

LACTATION

SUCKLINGFEEDING

200 million years

DUAL INGESTION SYSTEMS

100 million years

14

DUAL INGESTION SYSTEMS DUAL INGESTION SYSTEMS

SUCKLING WEANING FEEDING

Lactase Digestive enzymes

FEEDING SUCKLING

Influence of SMELL None Totally dependent

Motor mechanism Chewing ndash different

muscles

Suckling ndash different circuits

INSULIN Increases weight No effect

GHRELIN Increases weight No effect

LEPTIN Decreases intake No effect

CHOLECYSTOKININ Decreases intake No effect

AMPHETAMINE Decreases appetite Increases suckling

SEROTONIN Agonist improves feeding Antagonist improves suck

SATIETY Infant determined Maternal supply determine

FEEDING SUCKLING

DISRUPTION ROBUST VERY SENSITIVE

Must have right conditions

Pup-in-a- cup - And STIMULI

separated and fed by tube

From day 2 off life

Starts to feed normally d21 2 days gavage or other

no longer suckles

If starved for 24 hours pup

at d3 will feed food from

floor

(Can be maintained by

smell and other stimuli)

Pup-in-a- cup -

separated and fed by tube

From day 2 off life

Starts to feed normally d21

15

PMA 28 40 64 1y 2y

Nilsrsquo IDEALIZED VIEW

PMA 28 40 64 1y 2y

Nilsrsquo IDEALIZED VIEW

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

Reflections for practice

Suckling and Feeding areNOT THE SAME

16

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDINGON-GOING

S S C

WIRE SUCKLING

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

ON-GOING

S S C

WIRE NEURONS

Up to 6 months milk is 74 fat

96 of this is TRIGLYCERIDE

TRIGLYCERIDE Left glycerol Right palmitic acid oleic acid alpha-linolenic acid

In phosphoglycerides glycerol molecule same

two fatty acids esterified

Phospholipids area major component of all biological membranes

Sphingomyelin particularly concentrated in BRAIN major part of MYELIN

TRIGLYCERIDE

MYELIN

Dendirification and myelinisation peaks occurat 2 and 6 monthsis maximal at one year

At one year human milk has less proteinbut MORE TRIGLYCERIDE

FATTY ACIDS ARESPECIES SPECIFIC

Up to 6 months milk is 74 fat

but after 12 months it is 107

17

ldquocherry pickrdquo

Breastfeed time years school Incomelt 1 month 109 R$ 1238gt 6 month 121 R$ 1915

Group IQ 376 points higher from breatsfeeding

BREASTFEEDINGAND BREAST MILK

INCREASE IQ

BOTTLE FEEDINGamp FORMULA

DECREASE IQ

18

Be sure the wet nurse has plenty of milk because if she lacks it she may give the babymilk of a goat or sheep or some other animalbecause the child nourished on animal milkdoes not have perfect wits like one fed on womanrsquos milk and always looks stupid and vacant and not right in the head

14th century Tuscan text

Conceptual changeDyad careBreast first hour

even CaesareanContinuous SSC

DISCONTINUEGiving waterGlucose waterInfant formulaSeparationPacifier (dummy)

CHANGE POLICY Canrsquot change

biology

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

ON-GOING

S S C

WIRE NEURONS

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C WIRE

TIMING

(behavior)

19

Not so much duration

or density of any sleep stage

or number of sleep stage episodes but

cycling between quiet sleep

and active sleepis what is important

REMREM REM

NREM NREM

This is a healthy sleep pattern

This is a very good cycling pattern

(thanks to Susan Ludington-Hoe)

REMREM REM

NREM NREM

1st hour 2nd hour

So in every hour you would like

to see an EEG pattern that shows this

REM

NREM

REM

NREM

REM

NREM

State

HR

RR

REM Sleep is supposed to be

somewhat active so

HR increases and RR is irregular

SLEEP CYCLING ndashSeparation vs contact

In separation bull Dissociated statebull No cycling chaotic pattern

48 hour baseline chaotic pattern of

activity and quiet HR amp RR

SLEEP CYCLING ndashSeparation vs contact

In SSC bull Normal cyclingbull Non-chaotic pattern

48 hour baseline chaotic pattern of

activity and quiet HR amp RRPre-KC SSC

20

modulates state organisationelicits emotional behavioursactivates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL

Schaal 2004 115

DOUCETThe secretion of Areolar (Montgomeryrsquos) Glands from Lactating Women Elicits Selective Unconditional Responses in Neonates

ldquohellip breast chemosignalsactivate oral activity on the nipple that releases a cascade of behavioral neural neuroendocrineand endocrine processes in the newborn and the motherrdquo

Doucet 2009 116

The secretion of Areolar(Montgomeryrsquos) Glands

ldquoIn early ontogeny the sleeping brain may thusremain sentient of an organismrsquos odor environmentrdquo

Doucet 2009 117

REM

NREM

A skin-to-skin contactsession SHOULD NOT be less than one hour

or 90 minutes

SLEEPING

amp

CONTAINING

FEEDING ampHANDLINGfeed

sleep

HO

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C WIRE

TIMING

(behavior)

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C WIRE

STOMACH

21

STATE organization

Feeding frequency

SLEEP cycling

BRAIN

WIRING

How often should a neonate feed

CNS

ENS

ANS

InternalSomaticenvironment

CNS cortical subcortical(also to PNS)

ANS emotional limbic brain(incl SNS)

ANS myelinated vagus (NA)

ANS unmyelinated vagus (DMC)sub-diaphragmatic

ENS submucous plexusmyenteric plexus

122

The digestive system is endowed with its own local nervous system referred to as the enteric or intrinsic nervous system

The magnitude and complexity of the enteric nervous system is immense - it contains as many neurons as the spinal cord

ENTERIC NERVOUS SYSTEM

123

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

FEEDBACK LOOPS

CNS

ENS

ANS

InternalSomaticenvironment

124

125 126

22

Fetal stomach appears 4 weeks GABy 11 weeks wall capable of muscular

contraction

ldquoPatterns of antropyloric motilityin fed healthy preterm infantsrdquo

the neuroregulatory mechanisms responsible for the coordination of antro-pyloric motility and gastric emptying are

well developed by 30 weeks of PMAHassan 2002 127

Hydrochloric acidimportant for activation of pepsinogen

inactivation of microorganisms such as bacteria

Pepsinogenactivated by acid into active pepsin

responsible for the stomachs ability to initiate digestion of proteins

Chymosinis an enzyme whose role is to curdle or

coagulate milk in the stomach a process of considerable importance in the very young animal

128

Chymosinmakes the milk into ldquocheeserdquohalfway between liquid and solidstomach empties in 60 minutes

milk

129

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

FEEDBACK LOOPS

130

EVIDENCE FORFEEDING FREQUENCY

Edmond 2006 131

Breastfeeding and motherrsquos milkStrong and consistent evidence 132

23

Cup feeding versus bottle feedingCup feeding higher breastfeeding

greater stability133

Only case series Insufficient evidence

No mention of

stomach capacity134

EVIDENCE FORSTOMACH CAPACITY

Edmond 2006 135

0

05

1

15

2

25

3

35

4

0 10 20 30 40 50 60 70 80

volume ingested

fee

din

g f

req

ue

nc

y

Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml

StandardCARE3 hourlyschedule

136

KEY QUESTION

WHAT IS THE

STOMACHVOLUMEOF THE

NEONATE 137 Sase 2005

ldquoOntogeny of gastric emptying patternsin the human fetusrdquo

138

24

Goldstein 1987

ldquoGrowth of the Fetal Stomach in Normal Pregnanciesrdquo

139 Goldstein 1987

Length

Transverse

AP diameter

Using +2SD

140

Formula for calculation of stomach capacity (Charles Bradshaw UCT)Assumptions the stomach can be approximated by dividing into three sections namely a ellipsoidal hemisphere an ellipsoidal cylinder and a skewed ellipsoidal cone Variables a = anteroposterior radius t = transverse radius l = length stomachRelations the height of the cone and the hemisphere are both the same as lsquoarsquo

Ellipsoid = 43 Pi r1r2r3 = 43 Pi a a t therefore volume of hemisphere = 23 Pi a a t

Cylinder = Area of base height = (Pi a t ) ( l - 2a )Skewed cone = 13 base height = 13 Pi a t aTotal volume = 23 Pi aat + Pi a t (l- 2a) + 13 Pi a t a

=Pi atl -Pi a at= Pi a t(l-a)

Goldstein and Sase dataStomach capacity at term 10 - 15 ml

BRADSHAW formula

141

Assumption 25 kg baby 33w GA

requiring 150 mlkgday = 375 ml

45 MIN CYCLES ( 32 cyclesday)

12 ML PER CYCLE = 384 ml142

Newborn stomach volume

Gastric volumes at birthCorrelated with gastric pH

gastrin and somatostatin

ldquofetus drinks 10 ml portions of amniotic fluid helliprdquo

Widstrom 1988 143

Only recent study locatedldquoAutopsyrdquo capacity was determined

in Indian post-mortem studies

100 autopsies (63 SB 37 ENND)Tied at cardia and pylorus filled withwater emptied amp measured repeatedldquohellip obliteration of the gastric curvaturesrdquoldquodue care to minimize stretch artifactsrdquo

Naveed 1992

ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo

144

25

Infants above 2500g onlyAve Range

Stillborn (n 11) 196 ml (10-35)Early death (n 9) 178 ml (10-25)All cases (n 20) 188 ml

Naveed 1992

ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo

145 146

KERNESSUK 1997 (Russian)

Postmortem in situ measures(applied Bradshaw formula)

AveNewborn (n 11) 15 ml2 months (n 11) 35 ml2-4 m (n 10) 50 ml4-6 m (n 8) 100 ml

Known references with data

Scammon and Doyle 1920

Zuccarellirsquos method stomach filled at autopsy to ldquoa pressure of between

15 and 20 centimeters of waterrdquo

Scammon 1920

ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo

147

Anatomic capacity was determined in post-mortem studies

Main data set Alliot 1905 (n 25)Scammon own cases (n 13)

30 ndash 35 ml at birth ndashalmost regardless of birth weight

Scammon 1920

ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo

148

Zangen S et al Rapid maturation of gastric relaxation in newborns

Pressures (mmHg)

Balloon inflates to

15 ml no increase

functional capacity

149

Zangen S et al Rapid maturation of gastric relaxation in newborns

Pressures (mmHg)

Balloon inflates to

15 ml no increase20 ml pressure OK

physiologicalcapacity hellip 150

26

EVIDENCE (NBn 111009)

Author Capacity NoteSase 10-15 ml Live term fetusGoldstein 10-15 ml Live term fetusWidstrom 10 mls Live newbornZangen 20 mls Live (pressure)

Naveed 20 mls Autopsy (SB)20 mls Autopsy (ENND)

Kernessuk 15 mls Autopsy (in situ)Scammon 30-35 ml Autopsy (water

(Alliot) pressure)151

PROPOSAL

The CAPACITY of aweek old babyrsquos stomach is

approx 20 ml152

0

05

1

15

2

25

3

35

4

0 10 20 30 40 50 60 70 80

volume ingested

fee

din

g f

req

ue

nc

y

Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml

StandardCARE3 hourlyschedule

MOTHERNATURE

1 hourlyschedule

153

PHYSIOLOGICAL CAPACITY

RECEPTIVE CAPACITY of stomach

INGESTIVE CAPACITY of BABY

FUNCTIONAL CAPACITY

154

PROPOSAL

The FEEDINGFREQUENCY of theNEONATE is

approx 60 min155

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

BRAIN CYCLING

STOMACH FILLING amp EMPTYING

REMNR1NR2NR3NR4

156

27

Normal physiology of theEnteric Nervous System

ldquoSmall and frequent feeds according to the sleep cyclerdquo

The ldquonicherdquo (occupation) of a neonate (Alberts)

BOND FEED

SLEEP SLEEP

PLAY FEED

157

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

FEEDING SUCKLING

Influence of SMELL None Totally dependent

Motor mechanism Chewing ndash different

muscles

Suckling ndash different circuits

INSULIN Increases weight No effect

GHRELIN Increases weight No effect

LEPTIN Decreases intake No effect

CHOLECYSTOKININ Decreases intake No effect

AMPHETAMINE Decreases appetite Increases suckling

SEROTONIN Agonist improves feeding Antagonist improves suck

SATIETY Infant determined Maternal supply determine

FEEDING SUCKLING

Influence of SMELL None Totally dependent

Motor mechanism Chewing ndash different

muscles

Suckling ndash different circuits

INSULIN Increases weight No effect

GHRELIN Increases weight No effect

LEPTIN Decreases intake No effect

CHOLECYSTOKININ Decreases intake No effect

AMPHETAMINE Decreases appetite Increases suckling

SEROTONIN Agonist improves feeding Antagonist improves suck

SATIETY Infant determined Maternal supply determine

Current dogmaTHE BABY KNOWS

WHEN IT HAS HAD ENOUGH

PROBABLY NOT

WHAT IS THE

STOMACH VOLUME OF THE

PREMATURE

161

Assume low resilience

Assume proportionality

162

28

The CAPACITY of alow birthweight premfrom 20ml 3000g

= 0007 x BWt (g)

1kg x 0007 = 7mls2kg x 0007 = 14mls

163

Gastric overfilling syndrome

164

75 ml per feeding ASSUMPTION

IMMATURE OR OVERWHELMED

many aspects of gastrointestinalmotility are immature in the neonate

Zangen S et al Rapid maturation of gastric relaxation in newborns

A balloon in stomachcan fill to 76 mls

What does the stomach ndashwithout a balloon ndashdo to 76 mls

REFLUX PRESUME each feedapproximately 75 mls

GER

bull Sudden outbursts of crying

bull Awakens in pain

bull Related to feedings

bull Not easily comforted

bull ldquoI know baby hurtsrdquo

bull Sour burps throaty noises

bull Best when upright

Clues to GER

Dr W Sears

29

Mitchell 2001

Kerstin Uvnaumls-Moberg

Food in duodenum

AMYLINreleased

Closes pylorus

Duodenumempty

Pylorusopens

ldquoFeed intolerancerdquo hellip hellip or VOLUME intolerance

HYPOGLYCAEMIA

A babies stomach empties in60 minutes

Blood sugarmay fall hellip

after 90 minutes Options

30

METABOLIC ADAPTATION

SSC started in the first 20 minutes after birth

SSC CotBlood glucose (1 hr) 317 256Base excess drop 34 18

(Christenson 1992)0h 1h 2h 3h 4h 2 days

App

roxim

ate

GLUCOSE

SSC Glucose production = Glucose consumption

Separation

SNS stress Glucose consumption INCREASE

PSNS dissociation Glucose production DECREASE

HYPOGLYCEMIA

SSC Cot

Blood glucose (1 hr) 317 256

0h 1h 2h 3h 4h 2 days

App

roxim

ate

GLUCOSE

SSC Glucose production = Glucose consumption

Separation PSNS dissociation

Glucose production DECREASE

HYPOGLYCEMIA

SSC Cot

Blood glucose (1 hr) 317 256

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

NEURODEVELOPMENTThe DNA Behaviour

EVOLUTIONARY BIOLOGY

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

BONDING ATTACHMENT

MRI HRVEEG

STRESS RESPONES

RESILIENCE

DOHAD

(MAL) ADAPTATION

EPIGENETICS

GENE X ENVIRONMENT

GENETIC VARIANTS

HOSPITAL ACQUIRED INFECTIONIMMUNITY

SLEEP PHYSIOLOGY

GUT FUNCTIONMICROBIOTA

ldquoSTABILITYrdquo

TRANSITION

LONG TERM FOLLOW-UP

NEUROENDOCRINE BEHAVIOURS

MATERNAL NEUROPLASTICITY

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

MORTALITYMETABOLISM

0h 1h 2h 3h 4h

PSNS (vagal)

App

roxim

ate

GLUCOSE

1 HOURLY Milk feed

1 HOURLY Milk feed

1 HOURLY Milk feed

1 HOURLY Milk feed

LACTOSE

METABOLISM

31

0h 1h 2h 3h 4h

PSNS (vagal) SYMPATHETIC STRESS

App

roxim

ate

GLUCOSE

LACTOSE FATGLYCOGEN

METABOLISM

4 HOURLY Milk feed

0h 1h 2h 3h 4h

PSNS (vagal) SYMPATHETIC STRESS

App

roxim

ate

GLUCOSE

4 HOURLY ALLOSTATIC STATELACTOSE FATGLYCOGEN

METABOLISM

4 HOURLY Milk feed

HEALTH DISEASE

EXPECTED UNEXPECTED

NEURODEVELOPMENTThe DNA Behaviour

EVOLUTIONARY BIOLOGY

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

BONDING ATTACHMENT

MRI HRVEEG

STRESS RESPONES

RESILIENCE

DOHAD

(MAL) ADAPTATION

EPIGENETICS

GENE X ENVIRONMENT

GENETIC VARIANTS

HOSPITAL ACQUIRED INFECTIONIMMUNITY

SLEEP PHYSIOLOGY

GUT FUNCTIONMICROBIOTA

ldquoSTABILITYrdquo

TRANSITION

LONG TERM FOLLOW-UP

NEUROENDOCRINE BEHAVIOURS

MATERNAL NEUROPLASTICITY

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

MORTALITYMETABOLISM

Weight gain 1st week

predicts OBESITYat 30 years

Large volume feedsstretched stomach=

doubled absorptivecapacity as adult

Importance

Programming ndash early life chronic disease

32

RESISTANCE SENSITIVITY

PERCEPTIONSldquoNEUROCEPTIONrdquo

RESPONSESTRESS

ALLOSTATIC STATE

ALLOSTASIS

ANY STRESSPsychologicalNeurological

EndocrineImmune

ALLOSTATIC LOAD

ALLOSTATIC OVERLOAD

WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY

DISEASEHEALTH

RESILIENCE VULNERABILITY

RESISTANCE SENSITIVITY

PERCEPTIONSldquoNEUROCEPTIONrdquo

RESPONSESTRESS

ALLOSTATIC STATE

ALLOSTASIS

ANY STRESSPsychologicalNeurological

EndocrineImmune

ALLOSTATIC LOAD

HEALTH

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

Gastric overfilling syndrome

189

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

33

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

Only case series Insufficient evidence

No mention of

stomach capacity196

Baby weight freq reqrsquod size actual

2kg baby 4hrly ~ 320 ml6 = 53ml 14ml

15 baby 3hrly ~ 240 ml8 = 30ml 10ml

10 baby 2hrly ~ 160 ml12 = 13ml 7ml

Standardised from20ml capacityfor 3kg baby( x 0007)

197

0

10

20

30

40

50

60

70

80

90

13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w

LINEAR

TERM

PREM

198

34

0

10

20

30

40

50

60

70

80

90

13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w

LINEAR

TERM

PREM

199

Clues to GER

ldquoI know baby hurtsrdquo

Gastric overfilling syndrome

Excessive volumesreflux aspiration colic

Excessive time intervalhypoglycaemia

Adaptationsdiabetic diathesis obesity

200

Developmental Care of the Enteric Nervous System

ldquoSmall and frequent feeds according to the sleep cyclerdquo

The ldquonicherdquo (occupation) of a neonate (Alberts)

BOND FEED

SLEEP SLEEP

PLAY FEED

201

Gastric overfilling syndrome

Proposed Management 202

Proposed Management

Babies should be fedEVERY TIME THEY WAKE

Stanley Graven 2006

REMNR1NR2NR3SWS

AS (20 mins) QS (40 mins)

A normal sleep cycle is ONE hourHow often should neonates feed

203

Proposed Management

All babies should be fedat least once an hour 204

35

Proposed Management

All babies should be fedat least once an hour

205

The first Milk Ejection Reflex (MER)

elicited in lt 2 minutesworks quicklyswallowed 1 minute

Feeding time (max)3 minutes

Repeat every 1 hour

Prime 2007

The ldquonormalrdquo or usual and common breastfeed

takes 15 minutesdiscomfort afterburping time 5 minutes

Feeding time 20 min

Repeat every 3 hours

Prime 2007

3 minute 20ml feeds x 24d = 72 minutes

20 minute 60ml feeds x 8d = 160 minutes

SMALL AND FREQUENT FEEDS ARE EFFICIENT

FEWER NURSES NEEDED

The calculated dailyrequirement for a 3kgbaby can be given without increase inpressure MINIMAL RISK

PARENTS CAN DOSAFELY

20 mls x 24 feeds= 480mls day

Zangen 2001 209

All babies should be fedat least once an hour

210

36

Infant feeding frequencyProposal based on available evidence and neuroscience

ldquoSmall and frequent feeds

adjusted to the sleep cyclerdquo

211

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

STATE organization

Feeding frequency

SLEEP cycling

BRAIN

WIRING

How often should a neonate feeda neonate sleep

Infantsleep cycles

begin to block on diurnalrhythms

Mother-infant synchrony

hellip at 12 weeks

(circadian)

START at 3 months

Can be ldquoadult-likerdquo

at 6 months

Thomas 2014

STATE organization

Feeding frequency

SLEEP cycling

PLAY FEED

216

SLEEP SLEEP

SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

Infantsleep cycles

begin to block on diurnalrhythms

37

BOND SUCKLE SLEEP SLEEP PLAY

FEED

217

SLEEP SLEEP SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)

Schaal 2004 218

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)rdquoSLEEP-FEED CYCLINGrdquo

Schaal 2004 219

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

WIRE

BRAIN

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

BRAIN

WIRING

NEUROSCIENCE

The DNAEverything else

EVOLUTIONARYBIOLOGY

The Brain

EPIGENETICS

The PlaceENVIRONMENT

EXPERIENCEFITNESS ADAPTATION

ldquoScientific foundationrdquo hellip a synthesis

ZERO

SEPARATION

38

wwwninobirthorgwwwskintoskincontactcom

THE NEUROSCIENCE OFSKIN-TO-SKIN CONTACT

AND BREASTFEEDING

ARE THE SAME

SUMMARY SKIN-TO-SKIN

(Regulation)

SLEEP(Brain)

FEEDING(Stomach)

LOVE ( ldquomindrdquo )

REMNR1NR2NR3NR4

ACQUISITION CONSOLIDATION MEMORYFORMATION

poly-sensory input transfer information P wavesshort-term memory ldquoSNRrdquo strong signals returns infostored cortex amygdala to neocortex

hippocampus organizedAwake and REM NREM stage 4 REM

BRAIN WIRING

Stanley Graven 2006

PLAY

SLEEP

FEEDHOLDYOURPREM

httpswwwfacebookcomninobirth

39

Nelson Mandela

hellip in describing themeasure of a nation

he has argued that

ldquoThere can be no keener revelation of a societyrsquos soul than the way in which it treats its childrenrdquo

Page 12: Neurodevelopmental The Neuroscience of Birth ... · breastfeeding pattern, neonatal weight gain, and the dynamics of lactation. Doucet 2012 In the ‘‘scentless breast’’ condition,

12

FEARCONTROL

CENTRE

REWARDCONTROL

CENTRE

SOCIALCONTROL CENTRE

OXYTOCINDOPAMINE

CORTISOL

EMOTIONCONTROL CENTRE

WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY

DISEASEHEALTH

RESILIENCE VULNERABILITY

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

DOULA and KANGAROULA

-1000 min

BIRTH

+1000 min 1000 days

OXYTOCIN Zero separation

Protect OXYTOCINBefore and after

BIRTH

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDINGON-GOING

S S C

WIRE TOGETHER

Protect OXYTOCINBefore and after

BIRTH

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDINGON-GOING

S S C

WIRE SUCKLING

BREASTFEEDING Feed Sleep Cycling

BONDING Sensitization

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

BRAIN

WIRING

Neurodevelopmental Approach to

Alberts SUCKLING versus FEEDING

DUAL INGESTION SYSTEMS

13

300 mya 200 mya 100 mya 50 mya 300 mya 200 mya 100 mya 50 mya

Amniotes

Synapsids

Cynodonts

Mammaliaformes

PlacentalsMammals

ANCESTRAL STATE

hellip intoMATURE FEEDING

300 mya 200 mya 100 mya 50 mya

WATER

EGGS

Hatch withTEETH

ANCESTRAL STATE

hellip intoMATURE FEEDING

eg TURTLES

CROCODILES DINOSAURS

REPTILES

300 mya 200 mya 100 mya 50 mya

Epibubic bone = pouch care

hellip intoMATURE FEEDING

Amniotes

Synapsids

Cynodonts

Mammaliaformes

Smaller eggs longer in body

The AMNIOTE EGGextra membranes

Copes with AIR

PlacentalsMammals

Viviparity = immature

ENDOTHERMY

MOISTUREfor eggs

Diphyodontism

300 mya 200 mya 100 mya 50 mya

hellip intoMATURE FEEDING

Amniotes

Synapsids

Cynodonts

Mammaliaformes

PlacentalsMammals

ENDOTHERMY

MOISTUREfor eggs

LACTOSE added(apocrine glands)

NUTRIENTSAntimicrobials

LACTATION

SUCKLINGFEEDING

200 million years

Diphyodontism

300 mya 200 mya 100 mya 50 mya

hellip intoMATURE FEEDING

Amniotes

Synapsids

Cynodonts

Mammaliaformes

PlacentalsMammals

ENDOTHERMY

MOISTUREfor eggs

LACTOSE added(apocrine glands)

NUTRIENTSAntimicrobials

LACTATION

SUCKLINGFEEDING

200 million years

DUAL INGESTION SYSTEMS

100 million years

14

DUAL INGESTION SYSTEMS DUAL INGESTION SYSTEMS

SUCKLING WEANING FEEDING

Lactase Digestive enzymes

FEEDING SUCKLING

Influence of SMELL None Totally dependent

Motor mechanism Chewing ndash different

muscles

Suckling ndash different circuits

INSULIN Increases weight No effect

GHRELIN Increases weight No effect

LEPTIN Decreases intake No effect

CHOLECYSTOKININ Decreases intake No effect

AMPHETAMINE Decreases appetite Increases suckling

SEROTONIN Agonist improves feeding Antagonist improves suck

SATIETY Infant determined Maternal supply determine

FEEDING SUCKLING

DISRUPTION ROBUST VERY SENSITIVE

Must have right conditions

Pup-in-a- cup - And STIMULI

separated and fed by tube

From day 2 off life

Starts to feed normally d21 2 days gavage or other

no longer suckles

If starved for 24 hours pup

at d3 will feed food from

floor

(Can be maintained by

smell and other stimuli)

Pup-in-a- cup -

separated and fed by tube

From day 2 off life

Starts to feed normally d21

15

PMA 28 40 64 1y 2y

Nilsrsquo IDEALIZED VIEW

PMA 28 40 64 1y 2y

Nilsrsquo IDEALIZED VIEW

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

Reflections for practice

Suckling and Feeding areNOT THE SAME

16

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDINGON-GOING

S S C

WIRE SUCKLING

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

ON-GOING

S S C

WIRE NEURONS

Up to 6 months milk is 74 fat

96 of this is TRIGLYCERIDE

TRIGLYCERIDE Left glycerol Right palmitic acid oleic acid alpha-linolenic acid

In phosphoglycerides glycerol molecule same

two fatty acids esterified

Phospholipids area major component of all biological membranes

Sphingomyelin particularly concentrated in BRAIN major part of MYELIN

TRIGLYCERIDE

MYELIN

Dendirification and myelinisation peaks occurat 2 and 6 monthsis maximal at one year

At one year human milk has less proteinbut MORE TRIGLYCERIDE

FATTY ACIDS ARESPECIES SPECIFIC

Up to 6 months milk is 74 fat

but after 12 months it is 107

17

ldquocherry pickrdquo

Breastfeed time years school Incomelt 1 month 109 R$ 1238gt 6 month 121 R$ 1915

Group IQ 376 points higher from breatsfeeding

BREASTFEEDINGAND BREAST MILK

INCREASE IQ

BOTTLE FEEDINGamp FORMULA

DECREASE IQ

18

Be sure the wet nurse has plenty of milk because if she lacks it she may give the babymilk of a goat or sheep or some other animalbecause the child nourished on animal milkdoes not have perfect wits like one fed on womanrsquos milk and always looks stupid and vacant and not right in the head

14th century Tuscan text

Conceptual changeDyad careBreast first hour

even CaesareanContinuous SSC

DISCONTINUEGiving waterGlucose waterInfant formulaSeparationPacifier (dummy)

CHANGE POLICY Canrsquot change

biology

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

ON-GOING

S S C

WIRE NEURONS

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C WIRE

TIMING

(behavior)

19

Not so much duration

or density of any sleep stage

or number of sleep stage episodes but

cycling between quiet sleep

and active sleepis what is important

REMREM REM

NREM NREM

This is a healthy sleep pattern

This is a very good cycling pattern

(thanks to Susan Ludington-Hoe)

REMREM REM

NREM NREM

1st hour 2nd hour

So in every hour you would like

to see an EEG pattern that shows this

REM

NREM

REM

NREM

REM

NREM

State

HR

RR

REM Sleep is supposed to be

somewhat active so

HR increases and RR is irregular

SLEEP CYCLING ndashSeparation vs contact

In separation bull Dissociated statebull No cycling chaotic pattern

48 hour baseline chaotic pattern of

activity and quiet HR amp RR

SLEEP CYCLING ndashSeparation vs contact

In SSC bull Normal cyclingbull Non-chaotic pattern

48 hour baseline chaotic pattern of

activity and quiet HR amp RRPre-KC SSC

20

modulates state organisationelicits emotional behavioursactivates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL

Schaal 2004 115

DOUCETThe secretion of Areolar (Montgomeryrsquos) Glands from Lactating Women Elicits Selective Unconditional Responses in Neonates

ldquohellip breast chemosignalsactivate oral activity on the nipple that releases a cascade of behavioral neural neuroendocrineand endocrine processes in the newborn and the motherrdquo

Doucet 2009 116

The secretion of Areolar(Montgomeryrsquos) Glands

ldquoIn early ontogeny the sleeping brain may thusremain sentient of an organismrsquos odor environmentrdquo

Doucet 2009 117

REM

NREM

A skin-to-skin contactsession SHOULD NOT be less than one hour

or 90 minutes

SLEEPING

amp

CONTAINING

FEEDING ampHANDLINGfeed

sleep

HO

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C WIRE

TIMING

(behavior)

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C WIRE

STOMACH

21

STATE organization

Feeding frequency

SLEEP cycling

BRAIN

WIRING

How often should a neonate feed

CNS

ENS

ANS

InternalSomaticenvironment

CNS cortical subcortical(also to PNS)

ANS emotional limbic brain(incl SNS)

ANS myelinated vagus (NA)

ANS unmyelinated vagus (DMC)sub-diaphragmatic

ENS submucous plexusmyenteric plexus

122

The digestive system is endowed with its own local nervous system referred to as the enteric or intrinsic nervous system

The magnitude and complexity of the enteric nervous system is immense - it contains as many neurons as the spinal cord

ENTERIC NERVOUS SYSTEM

123

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

FEEDBACK LOOPS

CNS

ENS

ANS

InternalSomaticenvironment

124

125 126

22

Fetal stomach appears 4 weeks GABy 11 weeks wall capable of muscular

contraction

ldquoPatterns of antropyloric motilityin fed healthy preterm infantsrdquo

the neuroregulatory mechanisms responsible for the coordination of antro-pyloric motility and gastric emptying are

well developed by 30 weeks of PMAHassan 2002 127

Hydrochloric acidimportant for activation of pepsinogen

inactivation of microorganisms such as bacteria

Pepsinogenactivated by acid into active pepsin

responsible for the stomachs ability to initiate digestion of proteins

Chymosinis an enzyme whose role is to curdle or

coagulate milk in the stomach a process of considerable importance in the very young animal

128

Chymosinmakes the milk into ldquocheeserdquohalfway between liquid and solidstomach empties in 60 minutes

milk

129

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

FEEDBACK LOOPS

130

EVIDENCE FORFEEDING FREQUENCY

Edmond 2006 131

Breastfeeding and motherrsquos milkStrong and consistent evidence 132

23

Cup feeding versus bottle feedingCup feeding higher breastfeeding

greater stability133

Only case series Insufficient evidence

No mention of

stomach capacity134

EVIDENCE FORSTOMACH CAPACITY

Edmond 2006 135

0

05

1

15

2

25

3

35

4

0 10 20 30 40 50 60 70 80

volume ingested

fee

din

g f

req

ue

nc

y

Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml

StandardCARE3 hourlyschedule

136

KEY QUESTION

WHAT IS THE

STOMACHVOLUMEOF THE

NEONATE 137 Sase 2005

ldquoOntogeny of gastric emptying patternsin the human fetusrdquo

138

24

Goldstein 1987

ldquoGrowth of the Fetal Stomach in Normal Pregnanciesrdquo

139 Goldstein 1987

Length

Transverse

AP diameter

Using +2SD

140

Formula for calculation of stomach capacity (Charles Bradshaw UCT)Assumptions the stomach can be approximated by dividing into three sections namely a ellipsoidal hemisphere an ellipsoidal cylinder and a skewed ellipsoidal cone Variables a = anteroposterior radius t = transverse radius l = length stomachRelations the height of the cone and the hemisphere are both the same as lsquoarsquo

Ellipsoid = 43 Pi r1r2r3 = 43 Pi a a t therefore volume of hemisphere = 23 Pi a a t

Cylinder = Area of base height = (Pi a t ) ( l - 2a )Skewed cone = 13 base height = 13 Pi a t aTotal volume = 23 Pi aat + Pi a t (l- 2a) + 13 Pi a t a

=Pi atl -Pi a at= Pi a t(l-a)

Goldstein and Sase dataStomach capacity at term 10 - 15 ml

BRADSHAW formula

141

Assumption 25 kg baby 33w GA

requiring 150 mlkgday = 375 ml

45 MIN CYCLES ( 32 cyclesday)

12 ML PER CYCLE = 384 ml142

Newborn stomach volume

Gastric volumes at birthCorrelated with gastric pH

gastrin and somatostatin

ldquofetus drinks 10 ml portions of amniotic fluid helliprdquo

Widstrom 1988 143

Only recent study locatedldquoAutopsyrdquo capacity was determined

in Indian post-mortem studies

100 autopsies (63 SB 37 ENND)Tied at cardia and pylorus filled withwater emptied amp measured repeatedldquohellip obliteration of the gastric curvaturesrdquoldquodue care to minimize stretch artifactsrdquo

Naveed 1992

ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo

144

25

Infants above 2500g onlyAve Range

Stillborn (n 11) 196 ml (10-35)Early death (n 9) 178 ml (10-25)All cases (n 20) 188 ml

Naveed 1992

ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo

145 146

KERNESSUK 1997 (Russian)

Postmortem in situ measures(applied Bradshaw formula)

AveNewborn (n 11) 15 ml2 months (n 11) 35 ml2-4 m (n 10) 50 ml4-6 m (n 8) 100 ml

Known references with data

Scammon and Doyle 1920

Zuccarellirsquos method stomach filled at autopsy to ldquoa pressure of between

15 and 20 centimeters of waterrdquo

Scammon 1920

ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo

147

Anatomic capacity was determined in post-mortem studies

Main data set Alliot 1905 (n 25)Scammon own cases (n 13)

30 ndash 35 ml at birth ndashalmost regardless of birth weight

Scammon 1920

ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo

148

Zangen S et al Rapid maturation of gastric relaxation in newborns

Pressures (mmHg)

Balloon inflates to

15 ml no increase

functional capacity

149

Zangen S et al Rapid maturation of gastric relaxation in newborns

Pressures (mmHg)

Balloon inflates to

15 ml no increase20 ml pressure OK

physiologicalcapacity hellip 150

26

EVIDENCE (NBn 111009)

Author Capacity NoteSase 10-15 ml Live term fetusGoldstein 10-15 ml Live term fetusWidstrom 10 mls Live newbornZangen 20 mls Live (pressure)

Naveed 20 mls Autopsy (SB)20 mls Autopsy (ENND)

Kernessuk 15 mls Autopsy (in situ)Scammon 30-35 ml Autopsy (water

(Alliot) pressure)151

PROPOSAL

The CAPACITY of aweek old babyrsquos stomach is

approx 20 ml152

0

05

1

15

2

25

3

35

4

0 10 20 30 40 50 60 70 80

volume ingested

fee

din

g f

req

ue

nc

y

Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml

StandardCARE3 hourlyschedule

MOTHERNATURE

1 hourlyschedule

153

PHYSIOLOGICAL CAPACITY

RECEPTIVE CAPACITY of stomach

INGESTIVE CAPACITY of BABY

FUNCTIONAL CAPACITY

154

PROPOSAL

The FEEDINGFREQUENCY of theNEONATE is

approx 60 min155

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

BRAIN CYCLING

STOMACH FILLING amp EMPTYING

REMNR1NR2NR3NR4

156

27

Normal physiology of theEnteric Nervous System

ldquoSmall and frequent feeds according to the sleep cyclerdquo

The ldquonicherdquo (occupation) of a neonate (Alberts)

BOND FEED

SLEEP SLEEP

PLAY FEED

157

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

FEEDING SUCKLING

Influence of SMELL None Totally dependent

Motor mechanism Chewing ndash different

muscles

Suckling ndash different circuits

INSULIN Increases weight No effect

GHRELIN Increases weight No effect

LEPTIN Decreases intake No effect

CHOLECYSTOKININ Decreases intake No effect

AMPHETAMINE Decreases appetite Increases suckling

SEROTONIN Agonist improves feeding Antagonist improves suck

SATIETY Infant determined Maternal supply determine

FEEDING SUCKLING

Influence of SMELL None Totally dependent

Motor mechanism Chewing ndash different

muscles

Suckling ndash different circuits

INSULIN Increases weight No effect

GHRELIN Increases weight No effect

LEPTIN Decreases intake No effect

CHOLECYSTOKININ Decreases intake No effect

AMPHETAMINE Decreases appetite Increases suckling

SEROTONIN Agonist improves feeding Antagonist improves suck

SATIETY Infant determined Maternal supply determine

Current dogmaTHE BABY KNOWS

WHEN IT HAS HAD ENOUGH

PROBABLY NOT

WHAT IS THE

STOMACH VOLUME OF THE

PREMATURE

161

Assume low resilience

Assume proportionality

162

28

The CAPACITY of alow birthweight premfrom 20ml 3000g

= 0007 x BWt (g)

1kg x 0007 = 7mls2kg x 0007 = 14mls

163

Gastric overfilling syndrome

164

75 ml per feeding ASSUMPTION

IMMATURE OR OVERWHELMED

many aspects of gastrointestinalmotility are immature in the neonate

Zangen S et al Rapid maturation of gastric relaxation in newborns

A balloon in stomachcan fill to 76 mls

What does the stomach ndashwithout a balloon ndashdo to 76 mls

REFLUX PRESUME each feedapproximately 75 mls

GER

bull Sudden outbursts of crying

bull Awakens in pain

bull Related to feedings

bull Not easily comforted

bull ldquoI know baby hurtsrdquo

bull Sour burps throaty noises

bull Best when upright

Clues to GER

Dr W Sears

29

Mitchell 2001

Kerstin Uvnaumls-Moberg

Food in duodenum

AMYLINreleased

Closes pylorus

Duodenumempty

Pylorusopens

ldquoFeed intolerancerdquo hellip hellip or VOLUME intolerance

HYPOGLYCAEMIA

A babies stomach empties in60 minutes

Blood sugarmay fall hellip

after 90 minutes Options

30

METABOLIC ADAPTATION

SSC started in the first 20 minutes after birth

SSC CotBlood glucose (1 hr) 317 256Base excess drop 34 18

(Christenson 1992)0h 1h 2h 3h 4h 2 days

App

roxim

ate

GLUCOSE

SSC Glucose production = Glucose consumption

Separation

SNS stress Glucose consumption INCREASE

PSNS dissociation Glucose production DECREASE

HYPOGLYCEMIA

SSC Cot

Blood glucose (1 hr) 317 256

0h 1h 2h 3h 4h 2 days

App

roxim

ate

GLUCOSE

SSC Glucose production = Glucose consumption

Separation PSNS dissociation

Glucose production DECREASE

HYPOGLYCEMIA

SSC Cot

Blood glucose (1 hr) 317 256

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

NEURODEVELOPMENTThe DNA Behaviour

EVOLUTIONARY BIOLOGY

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

BONDING ATTACHMENT

MRI HRVEEG

STRESS RESPONES

RESILIENCE

DOHAD

(MAL) ADAPTATION

EPIGENETICS

GENE X ENVIRONMENT

GENETIC VARIANTS

HOSPITAL ACQUIRED INFECTIONIMMUNITY

SLEEP PHYSIOLOGY

GUT FUNCTIONMICROBIOTA

ldquoSTABILITYrdquo

TRANSITION

LONG TERM FOLLOW-UP

NEUROENDOCRINE BEHAVIOURS

MATERNAL NEUROPLASTICITY

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

MORTALITYMETABOLISM

0h 1h 2h 3h 4h

PSNS (vagal)

App

roxim

ate

GLUCOSE

1 HOURLY Milk feed

1 HOURLY Milk feed

1 HOURLY Milk feed

1 HOURLY Milk feed

LACTOSE

METABOLISM

31

0h 1h 2h 3h 4h

PSNS (vagal) SYMPATHETIC STRESS

App

roxim

ate

GLUCOSE

LACTOSE FATGLYCOGEN

METABOLISM

4 HOURLY Milk feed

0h 1h 2h 3h 4h

PSNS (vagal) SYMPATHETIC STRESS

App

roxim

ate

GLUCOSE

4 HOURLY ALLOSTATIC STATELACTOSE FATGLYCOGEN

METABOLISM

4 HOURLY Milk feed

HEALTH DISEASE

EXPECTED UNEXPECTED

NEURODEVELOPMENTThe DNA Behaviour

EVOLUTIONARY BIOLOGY

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

BONDING ATTACHMENT

MRI HRVEEG

STRESS RESPONES

RESILIENCE

DOHAD

(MAL) ADAPTATION

EPIGENETICS

GENE X ENVIRONMENT

GENETIC VARIANTS

HOSPITAL ACQUIRED INFECTIONIMMUNITY

SLEEP PHYSIOLOGY

GUT FUNCTIONMICROBIOTA

ldquoSTABILITYrdquo

TRANSITION

LONG TERM FOLLOW-UP

NEUROENDOCRINE BEHAVIOURS

MATERNAL NEUROPLASTICITY

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

MORTALITYMETABOLISM

Weight gain 1st week

predicts OBESITYat 30 years

Large volume feedsstretched stomach=

doubled absorptivecapacity as adult

Importance

Programming ndash early life chronic disease

32

RESISTANCE SENSITIVITY

PERCEPTIONSldquoNEUROCEPTIONrdquo

RESPONSESTRESS

ALLOSTATIC STATE

ALLOSTASIS

ANY STRESSPsychologicalNeurological

EndocrineImmune

ALLOSTATIC LOAD

ALLOSTATIC OVERLOAD

WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY

DISEASEHEALTH

RESILIENCE VULNERABILITY

RESISTANCE SENSITIVITY

PERCEPTIONSldquoNEUROCEPTIONrdquo

RESPONSESTRESS

ALLOSTATIC STATE

ALLOSTASIS

ANY STRESSPsychologicalNeurological

EndocrineImmune

ALLOSTATIC LOAD

HEALTH

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

Gastric overfilling syndrome

189

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

33

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

Only case series Insufficient evidence

No mention of

stomach capacity196

Baby weight freq reqrsquod size actual

2kg baby 4hrly ~ 320 ml6 = 53ml 14ml

15 baby 3hrly ~ 240 ml8 = 30ml 10ml

10 baby 2hrly ~ 160 ml12 = 13ml 7ml

Standardised from20ml capacityfor 3kg baby( x 0007)

197

0

10

20

30

40

50

60

70

80

90

13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w

LINEAR

TERM

PREM

198

34

0

10

20

30

40

50

60

70

80

90

13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w

LINEAR

TERM

PREM

199

Clues to GER

ldquoI know baby hurtsrdquo

Gastric overfilling syndrome

Excessive volumesreflux aspiration colic

Excessive time intervalhypoglycaemia

Adaptationsdiabetic diathesis obesity

200

Developmental Care of the Enteric Nervous System

ldquoSmall and frequent feeds according to the sleep cyclerdquo

The ldquonicherdquo (occupation) of a neonate (Alberts)

BOND FEED

SLEEP SLEEP

PLAY FEED

201

Gastric overfilling syndrome

Proposed Management 202

Proposed Management

Babies should be fedEVERY TIME THEY WAKE

Stanley Graven 2006

REMNR1NR2NR3SWS

AS (20 mins) QS (40 mins)

A normal sleep cycle is ONE hourHow often should neonates feed

203

Proposed Management

All babies should be fedat least once an hour 204

35

Proposed Management

All babies should be fedat least once an hour

205

The first Milk Ejection Reflex (MER)

elicited in lt 2 minutesworks quicklyswallowed 1 minute

Feeding time (max)3 minutes

Repeat every 1 hour

Prime 2007

The ldquonormalrdquo or usual and common breastfeed

takes 15 minutesdiscomfort afterburping time 5 minutes

Feeding time 20 min

Repeat every 3 hours

Prime 2007

3 minute 20ml feeds x 24d = 72 minutes

20 minute 60ml feeds x 8d = 160 minutes

SMALL AND FREQUENT FEEDS ARE EFFICIENT

FEWER NURSES NEEDED

The calculated dailyrequirement for a 3kgbaby can be given without increase inpressure MINIMAL RISK

PARENTS CAN DOSAFELY

20 mls x 24 feeds= 480mls day

Zangen 2001 209

All babies should be fedat least once an hour

210

36

Infant feeding frequencyProposal based on available evidence and neuroscience

ldquoSmall and frequent feeds

adjusted to the sleep cyclerdquo

211

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

STATE organization

Feeding frequency

SLEEP cycling

BRAIN

WIRING

How often should a neonate feeda neonate sleep

Infantsleep cycles

begin to block on diurnalrhythms

Mother-infant synchrony

hellip at 12 weeks

(circadian)

START at 3 months

Can be ldquoadult-likerdquo

at 6 months

Thomas 2014

STATE organization

Feeding frequency

SLEEP cycling

PLAY FEED

216

SLEEP SLEEP

SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

Infantsleep cycles

begin to block on diurnalrhythms

37

BOND SUCKLE SLEEP SLEEP PLAY

FEED

217

SLEEP SLEEP SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)

Schaal 2004 218

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)rdquoSLEEP-FEED CYCLINGrdquo

Schaal 2004 219

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

WIRE

BRAIN

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

BRAIN

WIRING

NEUROSCIENCE

The DNAEverything else

EVOLUTIONARYBIOLOGY

The Brain

EPIGENETICS

The PlaceENVIRONMENT

EXPERIENCEFITNESS ADAPTATION

ldquoScientific foundationrdquo hellip a synthesis

ZERO

SEPARATION

38

wwwninobirthorgwwwskintoskincontactcom

THE NEUROSCIENCE OFSKIN-TO-SKIN CONTACT

AND BREASTFEEDING

ARE THE SAME

SUMMARY SKIN-TO-SKIN

(Regulation)

SLEEP(Brain)

FEEDING(Stomach)

LOVE ( ldquomindrdquo )

REMNR1NR2NR3NR4

ACQUISITION CONSOLIDATION MEMORYFORMATION

poly-sensory input transfer information P wavesshort-term memory ldquoSNRrdquo strong signals returns infostored cortex amygdala to neocortex

hippocampus organizedAwake and REM NREM stage 4 REM

BRAIN WIRING

Stanley Graven 2006

PLAY

SLEEP

FEEDHOLDYOURPREM

httpswwwfacebookcomninobirth

39

Nelson Mandela

hellip in describing themeasure of a nation

he has argued that

ldquoThere can be no keener revelation of a societyrsquos soul than the way in which it treats its childrenrdquo

Page 13: Neurodevelopmental The Neuroscience of Birth ... · breastfeeding pattern, neonatal weight gain, and the dynamics of lactation. Doucet 2012 In the ‘‘scentless breast’’ condition,

13

300 mya 200 mya 100 mya 50 mya 300 mya 200 mya 100 mya 50 mya

Amniotes

Synapsids

Cynodonts

Mammaliaformes

PlacentalsMammals

ANCESTRAL STATE

hellip intoMATURE FEEDING

300 mya 200 mya 100 mya 50 mya

WATER

EGGS

Hatch withTEETH

ANCESTRAL STATE

hellip intoMATURE FEEDING

eg TURTLES

CROCODILES DINOSAURS

REPTILES

300 mya 200 mya 100 mya 50 mya

Epibubic bone = pouch care

hellip intoMATURE FEEDING

Amniotes

Synapsids

Cynodonts

Mammaliaformes

Smaller eggs longer in body

The AMNIOTE EGGextra membranes

Copes with AIR

PlacentalsMammals

Viviparity = immature

ENDOTHERMY

MOISTUREfor eggs

Diphyodontism

300 mya 200 mya 100 mya 50 mya

hellip intoMATURE FEEDING

Amniotes

Synapsids

Cynodonts

Mammaliaformes

PlacentalsMammals

ENDOTHERMY

MOISTUREfor eggs

LACTOSE added(apocrine glands)

NUTRIENTSAntimicrobials

LACTATION

SUCKLINGFEEDING

200 million years

Diphyodontism

300 mya 200 mya 100 mya 50 mya

hellip intoMATURE FEEDING

Amniotes

Synapsids

Cynodonts

Mammaliaformes

PlacentalsMammals

ENDOTHERMY

MOISTUREfor eggs

LACTOSE added(apocrine glands)

NUTRIENTSAntimicrobials

LACTATION

SUCKLINGFEEDING

200 million years

DUAL INGESTION SYSTEMS

100 million years

14

DUAL INGESTION SYSTEMS DUAL INGESTION SYSTEMS

SUCKLING WEANING FEEDING

Lactase Digestive enzymes

FEEDING SUCKLING

Influence of SMELL None Totally dependent

Motor mechanism Chewing ndash different

muscles

Suckling ndash different circuits

INSULIN Increases weight No effect

GHRELIN Increases weight No effect

LEPTIN Decreases intake No effect

CHOLECYSTOKININ Decreases intake No effect

AMPHETAMINE Decreases appetite Increases suckling

SEROTONIN Agonist improves feeding Antagonist improves suck

SATIETY Infant determined Maternal supply determine

FEEDING SUCKLING

DISRUPTION ROBUST VERY SENSITIVE

Must have right conditions

Pup-in-a- cup - And STIMULI

separated and fed by tube

From day 2 off life

Starts to feed normally d21 2 days gavage or other

no longer suckles

If starved for 24 hours pup

at d3 will feed food from

floor

(Can be maintained by

smell and other stimuli)

Pup-in-a- cup -

separated and fed by tube

From day 2 off life

Starts to feed normally d21

15

PMA 28 40 64 1y 2y

Nilsrsquo IDEALIZED VIEW

PMA 28 40 64 1y 2y

Nilsrsquo IDEALIZED VIEW

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

Reflections for practice

Suckling and Feeding areNOT THE SAME

16

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDINGON-GOING

S S C

WIRE SUCKLING

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

ON-GOING

S S C

WIRE NEURONS

Up to 6 months milk is 74 fat

96 of this is TRIGLYCERIDE

TRIGLYCERIDE Left glycerol Right palmitic acid oleic acid alpha-linolenic acid

In phosphoglycerides glycerol molecule same

two fatty acids esterified

Phospholipids area major component of all biological membranes

Sphingomyelin particularly concentrated in BRAIN major part of MYELIN

TRIGLYCERIDE

MYELIN

Dendirification and myelinisation peaks occurat 2 and 6 monthsis maximal at one year

At one year human milk has less proteinbut MORE TRIGLYCERIDE

FATTY ACIDS ARESPECIES SPECIFIC

Up to 6 months milk is 74 fat

but after 12 months it is 107

17

ldquocherry pickrdquo

Breastfeed time years school Incomelt 1 month 109 R$ 1238gt 6 month 121 R$ 1915

Group IQ 376 points higher from breatsfeeding

BREASTFEEDINGAND BREAST MILK

INCREASE IQ

BOTTLE FEEDINGamp FORMULA

DECREASE IQ

18

Be sure the wet nurse has plenty of milk because if she lacks it she may give the babymilk of a goat or sheep or some other animalbecause the child nourished on animal milkdoes not have perfect wits like one fed on womanrsquos milk and always looks stupid and vacant and not right in the head

14th century Tuscan text

Conceptual changeDyad careBreast first hour

even CaesareanContinuous SSC

DISCONTINUEGiving waterGlucose waterInfant formulaSeparationPacifier (dummy)

CHANGE POLICY Canrsquot change

biology

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

ON-GOING

S S C

WIRE NEURONS

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C WIRE

TIMING

(behavior)

19

Not so much duration

or density of any sleep stage

or number of sleep stage episodes but

cycling between quiet sleep

and active sleepis what is important

REMREM REM

NREM NREM

This is a healthy sleep pattern

This is a very good cycling pattern

(thanks to Susan Ludington-Hoe)

REMREM REM

NREM NREM

1st hour 2nd hour

So in every hour you would like

to see an EEG pattern that shows this

REM

NREM

REM

NREM

REM

NREM

State

HR

RR

REM Sleep is supposed to be

somewhat active so

HR increases and RR is irregular

SLEEP CYCLING ndashSeparation vs contact

In separation bull Dissociated statebull No cycling chaotic pattern

48 hour baseline chaotic pattern of

activity and quiet HR amp RR

SLEEP CYCLING ndashSeparation vs contact

In SSC bull Normal cyclingbull Non-chaotic pattern

48 hour baseline chaotic pattern of

activity and quiet HR amp RRPre-KC SSC

20

modulates state organisationelicits emotional behavioursactivates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL

Schaal 2004 115

DOUCETThe secretion of Areolar (Montgomeryrsquos) Glands from Lactating Women Elicits Selective Unconditional Responses in Neonates

ldquohellip breast chemosignalsactivate oral activity on the nipple that releases a cascade of behavioral neural neuroendocrineand endocrine processes in the newborn and the motherrdquo

Doucet 2009 116

The secretion of Areolar(Montgomeryrsquos) Glands

ldquoIn early ontogeny the sleeping brain may thusremain sentient of an organismrsquos odor environmentrdquo

Doucet 2009 117

REM

NREM

A skin-to-skin contactsession SHOULD NOT be less than one hour

or 90 minutes

SLEEPING

amp

CONTAINING

FEEDING ampHANDLINGfeed

sleep

HO

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C WIRE

TIMING

(behavior)

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C WIRE

STOMACH

21

STATE organization

Feeding frequency

SLEEP cycling

BRAIN

WIRING

How often should a neonate feed

CNS

ENS

ANS

InternalSomaticenvironment

CNS cortical subcortical(also to PNS)

ANS emotional limbic brain(incl SNS)

ANS myelinated vagus (NA)

ANS unmyelinated vagus (DMC)sub-diaphragmatic

ENS submucous plexusmyenteric plexus

122

The digestive system is endowed with its own local nervous system referred to as the enteric or intrinsic nervous system

The magnitude and complexity of the enteric nervous system is immense - it contains as many neurons as the spinal cord

ENTERIC NERVOUS SYSTEM

123

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

FEEDBACK LOOPS

CNS

ENS

ANS

InternalSomaticenvironment

124

125 126

22

Fetal stomach appears 4 weeks GABy 11 weeks wall capable of muscular

contraction

ldquoPatterns of antropyloric motilityin fed healthy preterm infantsrdquo

the neuroregulatory mechanisms responsible for the coordination of antro-pyloric motility and gastric emptying are

well developed by 30 weeks of PMAHassan 2002 127

Hydrochloric acidimportant for activation of pepsinogen

inactivation of microorganisms such as bacteria

Pepsinogenactivated by acid into active pepsin

responsible for the stomachs ability to initiate digestion of proteins

Chymosinis an enzyme whose role is to curdle or

coagulate milk in the stomach a process of considerable importance in the very young animal

128

Chymosinmakes the milk into ldquocheeserdquohalfway between liquid and solidstomach empties in 60 minutes

milk

129

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

FEEDBACK LOOPS

130

EVIDENCE FORFEEDING FREQUENCY

Edmond 2006 131

Breastfeeding and motherrsquos milkStrong and consistent evidence 132

23

Cup feeding versus bottle feedingCup feeding higher breastfeeding

greater stability133

Only case series Insufficient evidence

No mention of

stomach capacity134

EVIDENCE FORSTOMACH CAPACITY

Edmond 2006 135

0

05

1

15

2

25

3

35

4

0 10 20 30 40 50 60 70 80

volume ingested

fee

din

g f

req

ue

nc

y

Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml

StandardCARE3 hourlyschedule

136

KEY QUESTION

WHAT IS THE

STOMACHVOLUMEOF THE

NEONATE 137 Sase 2005

ldquoOntogeny of gastric emptying patternsin the human fetusrdquo

138

24

Goldstein 1987

ldquoGrowth of the Fetal Stomach in Normal Pregnanciesrdquo

139 Goldstein 1987

Length

Transverse

AP diameter

Using +2SD

140

Formula for calculation of stomach capacity (Charles Bradshaw UCT)Assumptions the stomach can be approximated by dividing into three sections namely a ellipsoidal hemisphere an ellipsoidal cylinder and a skewed ellipsoidal cone Variables a = anteroposterior radius t = transverse radius l = length stomachRelations the height of the cone and the hemisphere are both the same as lsquoarsquo

Ellipsoid = 43 Pi r1r2r3 = 43 Pi a a t therefore volume of hemisphere = 23 Pi a a t

Cylinder = Area of base height = (Pi a t ) ( l - 2a )Skewed cone = 13 base height = 13 Pi a t aTotal volume = 23 Pi aat + Pi a t (l- 2a) + 13 Pi a t a

=Pi atl -Pi a at= Pi a t(l-a)

Goldstein and Sase dataStomach capacity at term 10 - 15 ml

BRADSHAW formula

141

Assumption 25 kg baby 33w GA

requiring 150 mlkgday = 375 ml

45 MIN CYCLES ( 32 cyclesday)

12 ML PER CYCLE = 384 ml142

Newborn stomach volume

Gastric volumes at birthCorrelated with gastric pH

gastrin and somatostatin

ldquofetus drinks 10 ml portions of amniotic fluid helliprdquo

Widstrom 1988 143

Only recent study locatedldquoAutopsyrdquo capacity was determined

in Indian post-mortem studies

100 autopsies (63 SB 37 ENND)Tied at cardia and pylorus filled withwater emptied amp measured repeatedldquohellip obliteration of the gastric curvaturesrdquoldquodue care to minimize stretch artifactsrdquo

Naveed 1992

ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo

144

25

Infants above 2500g onlyAve Range

Stillborn (n 11) 196 ml (10-35)Early death (n 9) 178 ml (10-25)All cases (n 20) 188 ml

Naveed 1992

ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo

145 146

KERNESSUK 1997 (Russian)

Postmortem in situ measures(applied Bradshaw formula)

AveNewborn (n 11) 15 ml2 months (n 11) 35 ml2-4 m (n 10) 50 ml4-6 m (n 8) 100 ml

Known references with data

Scammon and Doyle 1920

Zuccarellirsquos method stomach filled at autopsy to ldquoa pressure of between

15 and 20 centimeters of waterrdquo

Scammon 1920

ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo

147

Anatomic capacity was determined in post-mortem studies

Main data set Alliot 1905 (n 25)Scammon own cases (n 13)

30 ndash 35 ml at birth ndashalmost regardless of birth weight

Scammon 1920

ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo

148

Zangen S et al Rapid maturation of gastric relaxation in newborns

Pressures (mmHg)

Balloon inflates to

15 ml no increase

functional capacity

149

Zangen S et al Rapid maturation of gastric relaxation in newborns

Pressures (mmHg)

Balloon inflates to

15 ml no increase20 ml pressure OK

physiologicalcapacity hellip 150

26

EVIDENCE (NBn 111009)

Author Capacity NoteSase 10-15 ml Live term fetusGoldstein 10-15 ml Live term fetusWidstrom 10 mls Live newbornZangen 20 mls Live (pressure)

Naveed 20 mls Autopsy (SB)20 mls Autopsy (ENND)

Kernessuk 15 mls Autopsy (in situ)Scammon 30-35 ml Autopsy (water

(Alliot) pressure)151

PROPOSAL

The CAPACITY of aweek old babyrsquos stomach is

approx 20 ml152

0

05

1

15

2

25

3

35

4

0 10 20 30 40 50 60 70 80

volume ingested

fee

din

g f

req

ue

nc

y

Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml

StandardCARE3 hourlyschedule

MOTHERNATURE

1 hourlyschedule

153

PHYSIOLOGICAL CAPACITY

RECEPTIVE CAPACITY of stomach

INGESTIVE CAPACITY of BABY

FUNCTIONAL CAPACITY

154

PROPOSAL

The FEEDINGFREQUENCY of theNEONATE is

approx 60 min155

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

BRAIN CYCLING

STOMACH FILLING amp EMPTYING

REMNR1NR2NR3NR4

156

27

Normal physiology of theEnteric Nervous System

ldquoSmall and frequent feeds according to the sleep cyclerdquo

The ldquonicherdquo (occupation) of a neonate (Alberts)

BOND FEED

SLEEP SLEEP

PLAY FEED

157

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

FEEDING SUCKLING

Influence of SMELL None Totally dependent

Motor mechanism Chewing ndash different

muscles

Suckling ndash different circuits

INSULIN Increases weight No effect

GHRELIN Increases weight No effect

LEPTIN Decreases intake No effect

CHOLECYSTOKININ Decreases intake No effect

AMPHETAMINE Decreases appetite Increases suckling

SEROTONIN Agonist improves feeding Antagonist improves suck

SATIETY Infant determined Maternal supply determine

FEEDING SUCKLING

Influence of SMELL None Totally dependent

Motor mechanism Chewing ndash different

muscles

Suckling ndash different circuits

INSULIN Increases weight No effect

GHRELIN Increases weight No effect

LEPTIN Decreases intake No effect

CHOLECYSTOKININ Decreases intake No effect

AMPHETAMINE Decreases appetite Increases suckling

SEROTONIN Agonist improves feeding Antagonist improves suck

SATIETY Infant determined Maternal supply determine

Current dogmaTHE BABY KNOWS

WHEN IT HAS HAD ENOUGH

PROBABLY NOT

WHAT IS THE

STOMACH VOLUME OF THE

PREMATURE

161

Assume low resilience

Assume proportionality

162

28

The CAPACITY of alow birthweight premfrom 20ml 3000g

= 0007 x BWt (g)

1kg x 0007 = 7mls2kg x 0007 = 14mls

163

Gastric overfilling syndrome

164

75 ml per feeding ASSUMPTION

IMMATURE OR OVERWHELMED

many aspects of gastrointestinalmotility are immature in the neonate

Zangen S et al Rapid maturation of gastric relaxation in newborns

A balloon in stomachcan fill to 76 mls

What does the stomach ndashwithout a balloon ndashdo to 76 mls

REFLUX PRESUME each feedapproximately 75 mls

GER

bull Sudden outbursts of crying

bull Awakens in pain

bull Related to feedings

bull Not easily comforted

bull ldquoI know baby hurtsrdquo

bull Sour burps throaty noises

bull Best when upright

Clues to GER

Dr W Sears

29

Mitchell 2001

Kerstin Uvnaumls-Moberg

Food in duodenum

AMYLINreleased

Closes pylorus

Duodenumempty

Pylorusopens

ldquoFeed intolerancerdquo hellip hellip or VOLUME intolerance

HYPOGLYCAEMIA

A babies stomach empties in60 minutes

Blood sugarmay fall hellip

after 90 minutes Options

30

METABOLIC ADAPTATION

SSC started in the first 20 minutes after birth

SSC CotBlood glucose (1 hr) 317 256Base excess drop 34 18

(Christenson 1992)0h 1h 2h 3h 4h 2 days

App

roxim

ate

GLUCOSE

SSC Glucose production = Glucose consumption

Separation

SNS stress Glucose consumption INCREASE

PSNS dissociation Glucose production DECREASE

HYPOGLYCEMIA

SSC Cot

Blood glucose (1 hr) 317 256

0h 1h 2h 3h 4h 2 days

App

roxim

ate

GLUCOSE

SSC Glucose production = Glucose consumption

Separation PSNS dissociation

Glucose production DECREASE

HYPOGLYCEMIA

SSC Cot

Blood glucose (1 hr) 317 256

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

NEURODEVELOPMENTThe DNA Behaviour

EVOLUTIONARY BIOLOGY

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

BONDING ATTACHMENT

MRI HRVEEG

STRESS RESPONES

RESILIENCE

DOHAD

(MAL) ADAPTATION

EPIGENETICS

GENE X ENVIRONMENT

GENETIC VARIANTS

HOSPITAL ACQUIRED INFECTIONIMMUNITY

SLEEP PHYSIOLOGY

GUT FUNCTIONMICROBIOTA

ldquoSTABILITYrdquo

TRANSITION

LONG TERM FOLLOW-UP

NEUROENDOCRINE BEHAVIOURS

MATERNAL NEUROPLASTICITY

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

MORTALITYMETABOLISM

0h 1h 2h 3h 4h

PSNS (vagal)

App

roxim

ate

GLUCOSE

1 HOURLY Milk feed

1 HOURLY Milk feed

1 HOURLY Milk feed

1 HOURLY Milk feed

LACTOSE

METABOLISM

31

0h 1h 2h 3h 4h

PSNS (vagal) SYMPATHETIC STRESS

App

roxim

ate

GLUCOSE

LACTOSE FATGLYCOGEN

METABOLISM

4 HOURLY Milk feed

0h 1h 2h 3h 4h

PSNS (vagal) SYMPATHETIC STRESS

App

roxim

ate

GLUCOSE

4 HOURLY ALLOSTATIC STATELACTOSE FATGLYCOGEN

METABOLISM

4 HOURLY Milk feed

HEALTH DISEASE

EXPECTED UNEXPECTED

NEURODEVELOPMENTThe DNA Behaviour

EVOLUTIONARY BIOLOGY

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

BONDING ATTACHMENT

MRI HRVEEG

STRESS RESPONES

RESILIENCE

DOHAD

(MAL) ADAPTATION

EPIGENETICS

GENE X ENVIRONMENT

GENETIC VARIANTS

HOSPITAL ACQUIRED INFECTIONIMMUNITY

SLEEP PHYSIOLOGY

GUT FUNCTIONMICROBIOTA

ldquoSTABILITYrdquo

TRANSITION

LONG TERM FOLLOW-UP

NEUROENDOCRINE BEHAVIOURS

MATERNAL NEUROPLASTICITY

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

MORTALITYMETABOLISM

Weight gain 1st week

predicts OBESITYat 30 years

Large volume feedsstretched stomach=

doubled absorptivecapacity as adult

Importance

Programming ndash early life chronic disease

32

RESISTANCE SENSITIVITY

PERCEPTIONSldquoNEUROCEPTIONrdquo

RESPONSESTRESS

ALLOSTATIC STATE

ALLOSTASIS

ANY STRESSPsychologicalNeurological

EndocrineImmune

ALLOSTATIC LOAD

ALLOSTATIC OVERLOAD

WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY

DISEASEHEALTH

RESILIENCE VULNERABILITY

RESISTANCE SENSITIVITY

PERCEPTIONSldquoNEUROCEPTIONrdquo

RESPONSESTRESS

ALLOSTATIC STATE

ALLOSTASIS

ANY STRESSPsychologicalNeurological

EndocrineImmune

ALLOSTATIC LOAD

HEALTH

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

Gastric overfilling syndrome

189

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

33

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

Only case series Insufficient evidence

No mention of

stomach capacity196

Baby weight freq reqrsquod size actual

2kg baby 4hrly ~ 320 ml6 = 53ml 14ml

15 baby 3hrly ~ 240 ml8 = 30ml 10ml

10 baby 2hrly ~ 160 ml12 = 13ml 7ml

Standardised from20ml capacityfor 3kg baby( x 0007)

197

0

10

20

30

40

50

60

70

80

90

13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w

LINEAR

TERM

PREM

198

34

0

10

20

30

40

50

60

70

80

90

13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w

LINEAR

TERM

PREM

199

Clues to GER

ldquoI know baby hurtsrdquo

Gastric overfilling syndrome

Excessive volumesreflux aspiration colic

Excessive time intervalhypoglycaemia

Adaptationsdiabetic diathesis obesity

200

Developmental Care of the Enteric Nervous System

ldquoSmall and frequent feeds according to the sleep cyclerdquo

The ldquonicherdquo (occupation) of a neonate (Alberts)

BOND FEED

SLEEP SLEEP

PLAY FEED

201

Gastric overfilling syndrome

Proposed Management 202

Proposed Management

Babies should be fedEVERY TIME THEY WAKE

Stanley Graven 2006

REMNR1NR2NR3SWS

AS (20 mins) QS (40 mins)

A normal sleep cycle is ONE hourHow often should neonates feed

203

Proposed Management

All babies should be fedat least once an hour 204

35

Proposed Management

All babies should be fedat least once an hour

205

The first Milk Ejection Reflex (MER)

elicited in lt 2 minutesworks quicklyswallowed 1 minute

Feeding time (max)3 minutes

Repeat every 1 hour

Prime 2007

The ldquonormalrdquo or usual and common breastfeed

takes 15 minutesdiscomfort afterburping time 5 minutes

Feeding time 20 min

Repeat every 3 hours

Prime 2007

3 minute 20ml feeds x 24d = 72 minutes

20 minute 60ml feeds x 8d = 160 minutes

SMALL AND FREQUENT FEEDS ARE EFFICIENT

FEWER NURSES NEEDED

The calculated dailyrequirement for a 3kgbaby can be given without increase inpressure MINIMAL RISK

PARENTS CAN DOSAFELY

20 mls x 24 feeds= 480mls day

Zangen 2001 209

All babies should be fedat least once an hour

210

36

Infant feeding frequencyProposal based on available evidence and neuroscience

ldquoSmall and frequent feeds

adjusted to the sleep cyclerdquo

211

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

STATE organization

Feeding frequency

SLEEP cycling

BRAIN

WIRING

How often should a neonate feeda neonate sleep

Infantsleep cycles

begin to block on diurnalrhythms

Mother-infant synchrony

hellip at 12 weeks

(circadian)

START at 3 months

Can be ldquoadult-likerdquo

at 6 months

Thomas 2014

STATE organization

Feeding frequency

SLEEP cycling

PLAY FEED

216

SLEEP SLEEP

SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

Infantsleep cycles

begin to block on diurnalrhythms

37

BOND SUCKLE SLEEP SLEEP PLAY

FEED

217

SLEEP SLEEP SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)

Schaal 2004 218

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)rdquoSLEEP-FEED CYCLINGrdquo

Schaal 2004 219

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

WIRE

BRAIN

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

BRAIN

WIRING

NEUROSCIENCE

The DNAEverything else

EVOLUTIONARYBIOLOGY

The Brain

EPIGENETICS

The PlaceENVIRONMENT

EXPERIENCEFITNESS ADAPTATION

ldquoScientific foundationrdquo hellip a synthesis

ZERO

SEPARATION

38

wwwninobirthorgwwwskintoskincontactcom

THE NEUROSCIENCE OFSKIN-TO-SKIN CONTACT

AND BREASTFEEDING

ARE THE SAME

SUMMARY SKIN-TO-SKIN

(Regulation)

SLEEP(Brain)

FEEDING(Stomach)

LOVE ( ldquomindrdquo )

REMNR1NR2NR3NR4

ACQUISITION CONSOLIDATION MEMORYFORMATION

poly-sensory input transfer information P wavesshort-term memory ldquoSNRrdquo strong signals returns infostored cortex amygdala to neocortex

hippocampus organizedAwake and REM NREM stage 4 REM

BRAIN WIRING

Stanley Graven 2006

PLAY

SLEEP

FEEDHOLDYOURPREM

httpswwwfacebookcomninobirth

39

Nelson Mandela

hellip in describing themeasure of a nation

he has argued that

ldquoThere can be no keener revelation of a societyrsquos soul than the way in which it treats its childrenrdquo

Page 14: Neurodevelopmental The Neuroscience of Birth ... · breastfeeding pattern, neonatal weight gain, and the dynamics of lactation. Doucet 2012 In the ‘‘scentless breast’’ condition,

14

DUAL INGESTION SYSTEMS DUAL INGESTION SYSTEMS

SUCKLING WEANING FEEDING

Lactase Digestive enzymes

FEEDING SUCKLING

Influence of SMELL None Totally dependent

Motor mechanism Chewing ndash different

muscles

Suckling ndash different circuits

INSULIN Increases weight No effect

GHRELIN Increases weight No effect

LEPTIN Decreases intake No effect

CHOLECYSTOKININ Decreases intake No effect

AMPHETAMINE Decreases appetite Increases suckling

SEROTONIN Agonist improves feeding Antagonist improves suck

SATIETY Infant determined Maternal supply determine

FEEDING SUCKLING

DISRUPTION ROBUST VERY SENSITIVE

Must have right conditions

Pup-in-a- cup - And STIMULI

separated and fed by tube

From day 2 off life

Starts to feed normally d21 2 days gavage or other

no longer suckles

If starved for 24 hours pup

at d3 will feed food from

floor

(Can be maintained by

smell and other stimuli)

Pup-in-a- cup -

separated and fed by tube

From day 2 off life

Starts to feed normally d21

15

PMA 28 40 64 1y 2y

Nilsrsquo IDEALIZED VIEW

PMA 28 40 64 1y 2y

Nilsrsquo IDEALIZED VIEW

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

Reflections for practice

Suckling and Feeding areNOT THE SAME

16

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDINGON-GOING

S S C

WIRE SUCKLING

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

ON-GOING

S S C

WIRE NEURONS

Up to 6 months milk is 74 fat

96 of this is TRIGLYCERIDE

TRIGLYCERIDE Left glycerol Right palmitic acid oleic acid alpha-linolenic acid

In phosphoglycerides glycerol molecule same

two fatty acids esterified

Phospholipids area major component of all biological membranes

Sphingomyelin particularly concentrated in BRAIN major part of MYELIN

TRIGLYCERIDE

MYELIN

Dendirification and myelinisation peaks occurat 2 and 6 monthsis maximal at one year

At one year human milk has less proteinbut MORE TRIGLYCERIDE

FATTY ACIDS ARESPECIES SPECIFIC

Up to 6 months milk is 74 fat

but after 12 months it is 107

17

ldquocherry pickrdquo

Breastfeed time years school Incomelt 1 month 109 R$ 1238gt 6 month 121 R$ 1915

Group IQ 376 points higher from breatsfeeding

BREASTFEEDINGAND BREAST MILK

INCREASE IQ

BOTTLE FEEDINGamp FORMULA

DECREASE IQ

18

Be sure the wet nurse has plenty of milk because if she lacks it she may give the babymilk of a goat or sheep or some other animalbecause the child nourished on animal milkdoes not have perfect wits like one fed on womanrsquos milk and always looks stupid and vacant and not right in the head

14th century Tuscan text

Conceptual changeDyad careBreast first hour

even CaesareanContinuous SSC

DISCONTINUEGiving waterGlucose waterInfant formulaSeparationPacifier (dummy)

CHANGE POLICY Canrsquot change

biology

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

ON-GOING

S S C

WIRE NEURONS

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C WIRE

TIMING

(behavior)

19

Not so much duration

or density of any sleep stage

or number of sleep stage episodes but

cycling between quiet sleep

and active sleepis what is important

REMREM REM

NREM NREM

This is a healthy sleep pattern

This is a very good cycling pattern

(thanks to Susan Ludington-Hoe)

REMREM REM

NREM NREM

1st hour 2nd hour

So in every hour you would like

to see an EEG pattern that shows this

REM

NREM

REM

NREM

REM

NREM

State

HR

RR

REM Sleep is supposed to be

somewhat active so

HR increases and RR is irregular

SLEEP CYCLING ndashSeparation vs contact

In separation bull Dissociated statebull No cycling chaotic pattern

48 hour baseline chaotic pattern of

activity and quiet HR amp RR

SLEEP CYCLING ndashSeparation vs contact

In SSC bull Normal cyclingbull Non-chaotic pattern

48 hour baseline chaotic pattern of

activity and quiet HR amp RRPre-KC SSC

20

modulates state organisationelicits emotional behavioursactivates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL

Schaal 2004 115

DOUCETThe secretion of Areolar (Montgomeryrsquos) Glands from Lactating Women Elicits Selective Unconditional Responses in Neonates

ldquohellip breast chemosignalsactivate oral activity on the nipple that releases a cascade of behavioral neural neuroendocrineand endocrine processes in the newborn and the motherrdquo

Doucet 2009 116

The secretion of Areolar(Montgomeryrsquos) Glands

ldquoIn early ontogeny the sleeping brain may thusremain sentient of an organismrsquos odor environmentrdquo

Doucet 2009 117

REM

NREM

A skin-to-skin contactsession SHOULD NOT be less than one hour

or 90 minutes

SLEEPING

amp

CONTAINING

FEEDING ampHANDLINGfeed

sleep

HO

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C WIRE

TIMING

(behavior)

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C WIRE

STOMACH

21

STATE organization

Feeding frequency

SLEEP cycling

BRAIN

WIRING

How often should a neonate feed

CNS

ENS

ANS

InternalSomaticenvironment

CNS cortical subcortical(also to PNS)

ANS emotional limbic brain(incl SNS)

ANS myelinated vagus (NA)

ANS unmyelinated vagus (DMC)sub-diaphragmatic

ENS submucous plexusmyenteric plexus

122

The digestive system is endowed with its own local nervous system referred to as the enteric or intrinsic nervous system

The magnitude and complexity of the enteric nervous system is immense - it contains as many neurons as the spinal cord

ENTERIC NERVOUS SYSTEM

123

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

FEEDBACK LOOPS

CNS

ENS

ANS

InternalSomaticenvironment

124

125 126

22

Fetal stomach appears 4 weeks GABy 11 weeks wall capable of muscular

contraction

ldquoPatterns of antropyloric motilityin fed healthy preterm infantsrdquo

the neuroregulatory mechanisms responsible for the coordination of antro-pyloric motility and gastric emptying are

well developed by 30 weeks of PMAHassan 2002 127

Hydrochloric acidimportant for activation of pepsinogen

inactivation of microorganisms such as bacteria

Pepsinogenactivated by acid into active pepsin

responsible for the stomachs ability to initiate digestion of proteins

Chymosinis an enzyme whose role is to curdle or

coagulate milk in the stomach a process of considerable importance in the very young animal

128

Chymosinmakes the milk into ldquocheeserdquohalfway between liquid and solidstomach empties in 60 minutes

milk

129

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

FEEDBACK LOOPS

130

EVIDENCE FORFEEDING FREQUENCY

Edmond 2006 131

Breastfeeding and motherrsquos milkStrong and consistent evidence 132

23

Cup feeding versus bottle feedingCup feeding higher breastfeeding

greater stability133

Only case series Insufficient evidence

No mention of

stomach capacity134

EVIDENCE FORSTOMACH CAPACITY

Edmond 2006 135

0

05

1

15

2

25

3

35

4

0 10 20 30 40 50 60 70 80

volume ingested

fee

din

g f

req

ue

nc

y

Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml

StandardCARE3 hourlyschedule

136

KEY QUESTION

WHAT IS THE

STOMACHVOLUMEOF THE

NEONATE 137 Sase 2005

ldquoOntogeny of gastric emptying patternsin the human fetusrdquo

138

24

Goldstein 1987

ldquoGrowth of the Fetal Stomach in Normal Pregnanciesrdquo

139 Goldstein 1987

Length

Transverse

AP diameter

Using +2SD

140

Formula for calculation of stomach capacity (Charles Bradshaw UCT)Assumptions the stomach can be approximated by dividing into three sections namely a ellipsoidal hemisphere an ellipsoidal cylinder and a skewed ellipsoidal cone Variables a = anteroposterior radius t = transverse radius l = length stomachRelations the height of the cone and the hemisphere are both the same as lsquoarsquo

Ellipsoid = 43 Pi r1r2r3 = 43 Pi a a t therefore volume of hemisphere = 23 Pi a a t

Cylinder = Area of base height = (Pi a t ) ( l - 2a )Skewed cone = 13 base height = 13 Pi a t aTotal volume = 23 Pi aat + Pi a t (l- 2a) + 13 Pi a t a

=Pi atl -Pi a at= Pi a t(l-a)

Goldstein and Sase dataStomach capacity at term 10 - 15 ml

BRADSHAW formula

141

Assumption 25 kg baby 33w GA

requiring 150 mlkgday = 375 ml

45 MIN CYCLES ( 32 cyclesday)

12 ML PER CYCLE = 384 ml142

Newborn stomach volume

Gastric volumes at birthCorrelated with gastric pH

gastrin and somatostatin

ldquofetus drinks 10 ml portions of amniotic fluid helliprdquo

Widstrom 1988 143

Only recent study locatedldquoAutopsyrdquo capacity was determined

in Indian post-mortem studies

100 autopsies (63 SB 37 ENND)Tied at cardia and pylorus filled withwater emptied amp measured repeatedldquohellip obliteration of the gastric curvaturesrdquoldquodue care to minimize stretch artifactsrdquo

Naveed 1992

ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo

144

25

Infants above 2500g onlyAve Range

Stillborn (n 11) 196 ml (10-35)Early death (n 9) 178 ml (10-25)All cases (n 20) 188 ml

Naveed 1992

ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo

145 146

KERNESSUK 1997 (Russian)

Postmortem in situ measures(applied Bradshaw formula)

AveNewborn (n 11) 15 ml2 months (n 11) 35 ml2-4 m (n 10) 50 ml4-6 m (n 8) 100 ml

Known references with data

Scammon and Doyle 1920

Zuccarellirsquos method stomach filled at autopsy to ldquoa pressure of between

15 and 20 centimeters of waterrdquo

Scammon 1920

ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo

147

Anatomic capacity was determined in post-mortem studies

Main data set Alliot 1905 (n 25)Scammon own cases (n 13)

30 ndash 35 ml at birth ndashalmost regardless of birth weight

Scammon 1920

ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo

148

Zangen S et al Rapid maturation of gastric relaxation in newborns

Pressures (mmHg)

Balloon inflates to

15 ml no increase

functional capacity

149

Zangen S et al Rapid maturation of gastric relaxation in newborns

Pressures (mmHg)

Balloon inflates to

15 ml no increase20 ml pressure OK

physiologicalcapacity hellip 150

26

EVIDENCE (NBn 111009)

Author Capacity NoteSase 10-15 ml Live term fetusGoldstein 10-15 ml Live term fetusWidstrom 10 mls Live newbornZangen 20 mls Live (pressure)

Naveed 20 mls Autopsy (SB)20 mls Autopsy (ENND)

Kernessuk 15 mls Autopsy (in situ)Scammon 30-35 ml Autopsy (water

(Alliot) pressure)151

PROPOSAL

The CAPACITY of aweek old babyrsquos stomach is

approx 20 ml152

0

05

1

15

2

25

3

35

4

0 10 20 30 40 50 60 70 80

volume ingested

fee

din

g f

req

ue

nc

y

Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml

StandardCARE3 hourlyschedule

MOTHERNATURE

1 hourlyschedule

153

PHYSIOLOGICAL CAPACITY

RECEPTIVE CAPACITY of stomach

INGESTIVE CAPACITY of BABY

FUNCTIONAL CAPACITY

154

PROPOSAL

The FEEDINGFREQUENCY of theNEONATE is

approx 60 min155

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

BRAIN CYCLING

STOMACH FILLING amp EMPTYING

REMNR1NR2NR3NR4

156

27

Normal physiology of theEnteric Nervous System

ldquoSmall and frequent feeds according to the sleep cyclerdquo

The ldquonicherdquo (occupation) of a neonate (Alberts)

BOND FEED

SLEEP SLEEP

PLAY FEED

157

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

FEEDING SUCKLING

Influence of SMELL None Totally dependent

Motor mechanism Chewing ndash different

muscles

Suckling ndash different circuits

INSULIN Increases weight No effect

GHRELIN Increases weight No effect

LEPTIN Decreases intake No effect

CHOLECYSTOKININ Decreases intake No effect

AMPHETAMINE Decreases appetite Increases suckling

SEROTONIN Agonist improves feeding Antagonist improves suck

SATIETY Infant determined Maternal supply determine

FEEDING SUCKLING

Influence of SMELL None Totally dependent

Motor mechanism Chewing ndash different

muscles

Suckling ndash different circuits

INSULIN Increases weight No effect

GHRELIN Increases weight No effect

LEPTIN Decreases intake No effect

CHOLECYSTOKININ Decreases intake No effect

AMPHETAMINE Decreases appetite Increases suckling

SEROTONIN Agonist improves feeding Antagonist improves suck

SATIETY Infant determined Maternal supply determine

Current dogmaTHE BABY KNOWS

WHEN IT HAS HAD ENOUGH

PROBABLY NOT

WHAT IS THE

STOMACH VOLUME OF THE

PREMATURE

161

Assume low resilience

Assume proportionality

162

28

The CAPACITY of alow birthweight premfrom 20ml 3000g

= 0007 x BWt (g)

1kg x 0007 = 7mls2kg x 0007 = 14mls

163

Gastric overfilling syndrome

164

75 ml per feeding ASSUMPTION

IMMATURE OR OVERWHELMED

many aspects of gastrointestinalmotility are immature in the neonate

Zangen S et al Rapid maturation of gastric relaxation in newborns

A balloon in stomachcan fill to 76 mls

What does the stomach ndashwithout a balloon ndashdo to 76 mls

REFLUX PRESUME each feedapproximately 75 mls

GER

bull Sudden outbursts of crying

bull Awakens in pain

bull Related to feedings

bull Not easily comforted

bull ldquoI know baby hurtsrdquo

bull Sour burps throaty noises

bull Best when upright

Clues to GER

Dr W Sears

29

Mitchell 2001

Kerstin Uvnaumls-Moberg

Food in duodenum

AMYLINreleased

Closes pylorus

Duodenumempty

Pylorusopens

ldquoFeed intolerancerdquo hellip hellip or VOLUME intolerance

HYPOGLYCAEMIA

A babies stomach empties in60 minutes

Blood sugarmay fall hellip

after 90 minutes Options

30

METABOLIC ADAPTATION

SSC started in the first 20 minutes after birth

SSC CotBlood glucose (1 hr) 317 256Base excess drop 34 18

(Christenson 1992)0h 1h 2h 3h 4h 2 days

App

roxim

ate

GLUCOSE

SSC Glucose production = Glucose consumption

Separation

SNS stress Glucose consumption INCREASE

PSNS dissociation Glucose production DECREASE

HYPOGLYCEMIA

SSC Cot

Blood glucose (1 hr) 317 256

0h 1h 2h 3h 4h 2 days

App

roxim

ate

GLUCOSE

SSC Glucose production = Glucose consumption

Separation PSNS dissociation

Glucose production DECREASE

HYPOGLYCEMIA

SSC Cot

Blood glucose (1 hr) 317 256

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

NEURODEVELOPMENTThe DNA Behaviour

EVOLUTIONARY BIOLOGY

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

BONDING ATTACHMENT

MRI HRVEEG

STRESS RESPONES

RESILIENCE

DOHAD

(MAL) ADAPTATION

EPIGENETICS

GENE X ENVIRONMENT

GENETIC VARIANTS

HOSPITAL ACQUIRED INFECTIONIMMUNITY

SLEEP PHYSIOLOGY

GUT FUNCTIONMICROBIOTA

ldquoSTABILITYrdquo

TRANSITION

LONG TERM FOLLOW-UP

NEUROENDOCRINE BEHAVIOURS

MATERNAL NEUROPLASTICITY

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

MORTALITYMETABOLISM

0h 1h 2h 3h 4h

PSNS (vagal)

App

roxim

ate

GLUCOSE

1 HOURLY Milk feed

1 HOURLY Milk feed

1 HOURLY Milk feed

1 HOURLY Milk feed

LACTOSE

METABOLISM

31

0h 1h 2h 3h 4h

PSNS (vagal) SYMPATHETIC STRESS

App

roxim

ate

GLUCOSE

LACTOSE FATGLYCOGEN

METABOLISM

4 HOURLY Milk feed

0h 1h 2h 3h 4h

PSNS (vagal) SYMPATHETIC STRESS

App

roxim

ate

GLUCOSE

4 HOURLY ALLOSTATIC STATELACTOSE FATGLYCOGEN

METABOLISM

4 HOURLY Milk feed

HEALTH DISEASE

EXPECTED UNEXPECTED

NEURODEVELOPMENTThe DNA Behaviour

EVOLUTIONARY BIOLOGY

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

BONDING ATTACHMENT

MRI HRVEEG

STRESS RESPONES

RESILIENCE

DOHAD

(MAL) ADAPTATION

EPIGENETICS

GENE X ENVIRONMENT

GENETIC VARIANTS

HOSPITAL ACQUIRED INFECTIONIMMUNITY

SLEEP PHYSIOLOGY

GUT FUNCTIONMICROBIOTA

ldquoSTABILITYrdquo

TRANSITION

LONG TERM FOLLOW-UP

NEUROENDOCRINE BEHAVIOURS

MATERNAL NEUROPLASTICITY

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

MORTALITYMETABOLISM

Weight gain 1st week

predicts OBESITYat 30 years

Large volume feedsstretched stomach=

doubled absorptivecapacity as adult

Importance

Programming ndash early life chronic disease

32

RESISTANCE SENSITIVITY

PERCEPTIONSldquoNEUROCEPTIONrdquo

RESPONSESTRESS

ALLOSTATIC STATE

ALLOSTASIS

ANY STRESSPsychologicalNeurological

EndocrineImmune

ALLOSTATIC LOAD

ALLOSTATIC OVERLOAD

WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY

DISEASEHEALTH

RESILIENCE VULNERABILITY

RESISTANCE SENSITIVITY

PERCEPTIONSldquoNEUROCEPTIONrdquo

RESPONSESTRESS

ALLOSTATIC STATE

ALLOSTASIS

ANY STRESSPsychologicalNeurological

EndocrineImmune

ALLOSTATIC LOAD

HEALTH

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

Gastric overfilling syndrome

189

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

33

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

Only case series Insufficient evidence

No mention of

stomach capacity196

Baby weight freq reqrsquod size actual

2kg baby 4hrly ~ 320 ml6 = 53ml 14ml

15 baby 3hrly ~ 240 ml8 = 30ml 10ml

10 baby 2hrly ~ 160 ml12 = 13ml 7ml

Standardised from20ml capacityfor 3kg baby( x 0007)

197

0

10

20

30

40

50

60

70

80

90

13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w

LINEAR

TERM

PREM

198

34

0

10

20

30

40

50

60

70

80

90

13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w

LINEAR

TERM

PREM

199

Clues to GER

ldquoI know baby hurtsrdquo

Gastric overfilling syndrome

Excessive volumesreflux aspiration colic

Excessive time intervalhypoglycaemia

Adaptationsdiabetic diathesis obesity

200

Developmental Care of the Enteric Nervous System

ldquoSmall and frequent feeds according to the sleep cyclerdquo

The ldquonicherdquo (occupation) of a neonate (Alberts)

BOND FEED

SLEEP SLEEP

PLAY FEED

201

Gastric overfilling syndrome

Proposed Management 202

Proposed Management

Babies should be fedEVERY TIME THEY WAKE

Stanley Graven 2006

REMNR1NR2NR3SWS

AS (20 mins) QS (40 mins)

A normal sleep cycle is ONE hourHow often should neonates feed

203

Proposed Management

All babies should be fedat least once an hour 204

35

Proposed Management

All babies should be fedat least once an hour

205

The first Milk Ejection Reflex (MER)

elicited in lt 2 minutesworks quicklyswallowed 1 minute

Feeding time (max)3 minutes

Repeat every 1 hour

Prime 2007

The ldquonormalrdquo or usual and common breastfeed

takes 15 minutesdiscomfort afterburping time 5 minutes

Feeding time 20 min

Repeat every 3 hours

Prime 2007

3 minute 20ml feeds x 24d = 72 minutes

20 minute 60ml feeds x 8d = 160 minutes

SMALL AND FREQUENT FEEDS ARE EFFICIENT

FEWER NURSES NEEDED

The calculated dailyrequirement for a 3kgbaby can be given without increase inpressure MINIMAL RISK

PARENTS CAN DOSAFELY

20 mls x 24 feeds= 480mls day

Zangen 2001 209

All babies should be fedat least once an hour

210

36

Infant feeding frequencyProposal based on available evidence and neuroscience

ldquoSmall and frequent feeds

adjusted to the sleep cyclerdquo

211

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

STATE organization

Feeding frequency

SLEEP cycling

BRAIN

WIRING

How often should a neonate feeda neonate sleep

Infantsleep cycles

begin to block on diurnalrhythms

Mother-infant synchrony

hellip at 12 weeks

(circadian)

START at 3 months

Can be ldquoadult-likerdquo

at 6 months

Thomas 2014

STATE organization

Feeding frequency

SLEEP cycling

PLAY FEED

216

SLEEP SLEEP

SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

Infantsleep cycles

begin to block on diurnalrhythms

37

BOND SUCKLE SLEEP SLEEP PLAY

FEED

217

SLEEP SLEEP SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)

Schaal 2004 218

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)rdquoSLEEP-FEED CYCLINGrdquo

Schaal 2004 219

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

WIRE

BRAIN

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

BRAIN

WIRING

NEUROSCIENCE

The DNAEverything else

EVOLUTIONARYBIOLOGY

The Brain

EPIGENETICS

The PlaceENVIRONMENT

EXPERIENCEFITNESS ADAPTATION

ldquoScientific foundationrdquo hellip a synthesis

ZERO

SEPARATION

38

wwwninobirthorgwwwskintoskincontactcom

THE NEUROSCIENCE OFSKIN-TO-SKIN CONTACT

AND BREASTFEEDING

ARE THE SAME

SUMMARY SKIN-TO-SKIN

(Regulation)

SLEEP(Brain)

FEEDING(Stomach)

LOVE ( ldquomindrdquo )

REMNR1NR2NR3NR4

ACQUISITION CONSOLIDATION MEMORYFORMATION

poly-sensory input transfer information P wavesshort-term memory ldquoSNRrdquo strong signals returns infostored cortex amygdala to neocortex

hippocampus organizedAwake and REM NREM stage 4 REM

BRAIN WIRING

Stanley Graven 2006

PLAY

SLEEP

FEEDHOLDYOURPREM

httpswwwfacebookcomninobirth

39

Nelson Mandela

hellip in describing themeasure of a nation

he has argued that

ldquoThere can be no keener revelation of a societyrsquos soul than the way in which it treats its childrenrdquo

Page 15: Neurodevelopmental The Neuroscience of Birth ... · breastfeeding pattern, neonatal weight gain, and the dynamics of lactation. Doucet 2012 In the ‘‘scentless breast’’ condition,

15

PMA 28 40 64 1y 2y

Nilsrsquo IDEALIZED VIEW

PMA 28 40 64 1y 2y

Nilsrsquo IDEALIZED VIEW

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

Reflections for practice

Suckling and Feeding areNOT THE SAME

16

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDINGON-GOING

S S C

WIRE SUCKLING

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

ON-GOING

S S C

WIRE NEURONS

Up to 6 months milk is 74 fat

96 of this is TRIGLYCERIDE

TRIGLYCERIDE Left glycerol Right palmitic acid oleic acid alpha-linolenic acid

In phosphoglycerides glycerol molecule same

two fatty acids esterified

Phospholipids area major component of all biological membranes

Sphingomyelin particularly concentrated in BRAIN major part of MYELIN

TRIGLYCERIDE

MYELIN

Dendirification and myelinisation peaks occurat 2 and 6 monthsis maximal at one year

At one year human milk has less proteinbut MORE TRIGLYCERIDE

FATTY ACIDS ARESPECIES SPECIFIC

Up to 6 months milk is 74 fat

but after 12 months it is 107

17

ldquocherry pickrdquo

Breastfeed time years school Incomelt 1 month 109 R$ 1238gt 6 month 121 R$ 1915

Group IQ 376 points higher from breatsfeeding

BREASTFEEDINGAND BREAST MILK

INCREASE IQ

BOTTLE FEEDINGamp FORMULA

DECREASE IQ

18

Be sure the wet nurse has plenty of milk because if she lacks it she may give the babymilk of a goat or sheep or some other animalbecause the child nourished on animal milkdoes not have perfect wits like one fed on womanrsquos milk and always looks stupid and vacant and not right in the head

14th century Tuscan text

Conceptual changeDyad careBreast first hour

even CaesareanContinuous SSC

DISCONTINUEGiving waterGlucose waterInfant formulaSeparationPacifier (dummy)

CHANGE POLICY Canrsquot change

biology

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

ON-GOING

S S C

WIRE NEURONS

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C WIRE

TIMING

(behavior)

19

Not so much duration

or density of any sleep stage

or number of sleep stage episodes but

cycling between quiet sleep

and active sleepis what is important

REMREM REM

NREM NREM

This is a healthy sleep pattern

This is a very good cycling pattern

(thanks to Susan Ludington-Hoe)

REMREM REM

NREM NREM

1st hour 2nd hour

So in every hour you would like

to see an EEG pattern that shows this

REM

NREM

REM

NREM

REM

NREM

State

HR

RR

REM Sleep is supposed to be

somewhat active so

HR increases and RR is irregular

SLEEP CYCLING ndashSeparation vs contact

In separation bull Dissociated statebull No cycling chaotic pattern

48 hour baseline chaotic pattern of

activity and quiet HR amp RR

SLEEP CYCLING ndashSeparation vs contact

In SSC bull Normal cyclingbull Non-chaotic pattern

48 hour baseline chaotic pattern of

activity and quiet HR amp RRPre-KC SSC

20

modulates state organisationelicits emotional behavioursactivates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL

Schaal 2004 115

DOUCETThe secretion of Areolar (Montgomeryrsquos) Glands from Lactating Women Elicits Selective Unconditional Responses in Neonates

ldquohellip breast chemosignalsactivate oral activity on the nipple that releases a cascade of behavioral neural neuroendocrineand endocrine processes in the newborn and the motherrdquo

Doucet 2009 116

The secretion of Areolar(Montgomeryrsquos) Glands

ldquoIn early ontogeny the sleeping brain may thusremain sentient of an organismrsquos odor environmentrdquo

Doucet 2009 117

REM

NREM

A skin-to-skin contactsession SHOULD NOT be less than one hour

or 90 minutes

SLEEPING

amp

CONTAINING

FEEDING ampHANDLINGfeed

sleep

HO

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C WIRE

TIMING

(behavior)

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C WIRE

STOMACH

21

STATE organization

Feeding frequency

SLEEP cycling

BRAIN

WIRING

How often should a neonate feed

CNS

ENS

ANS

InternalSomaticenvironment

CNS cortical subcortical(also to PNS)

ANS emotional limbic brain(incl SNS)

ANS myelinated vagus (NA)

ANS unmyelinated vagus (DMC)sub-diaphragmatic

ENS submucous plexusmyenteric plexus

122

The digestive system is endowed with its own local nervous system referred to as the enteric or intrinsic nervous system

The magnitude and complexity of the enteric nervous system is immense - it contains as many neurons as the spinal cord

ENTERIC NERVOUS SYSTEM

123

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

FEEDBACK LOOPS

CNS

ENS

ANS

InternalSomaticenvironment

124

125 126

22

Fetal stomach appears 4 weeks GABy 11 weeks wall capable of muscular

contraction

ldquoPatterns of antropyloric motilityin fed healthy preterm infantsrdquo

the neuroregulatory mechanisms responsible for the coordination of antro-pyloric motility and gastric emptying are

well developed by 30 weeks of PMAHassan 2002 127

Hydrochloric acidimportant for activation of pepsinogen

inactivation of microorganisms such as bacteria

Pepsinogenactivated by acid into active pepsin

responsible for the stomachs ability to initiate digestion of proteins

Chymosinis an enzyme whose role is to curdle or

coagulate milk in the stomach a process of considerable importance in the very young animal

128

Chymosinmakes the milk into ldquocheeserdquohalfway between liquid and solidstomach empties in 60 minutes

milk

129

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

FEEDBACK LOOPS

130

EVIDENCE FORFEEDING FREQUENCY

Edmond 2006 131

Breastfeeding and motherrsquos milkStrong and consistent evidence 132

23

Cup feeding versus bottle feedingCup feeding higher breastfeeding

greater stability133

Only case series Insufficient evidence

No mention of

stomach capacity134

EVIDENCE FORSTOMACH CAPACITY

Edmond 2006 135

0

05

1

15

2

25

3

35

4

0 10 20 30 40 50 60 70 80

volume ingested

fee

din

g f

req

ue

nc

y

Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml

StandardCARE3 hourlyschedule

136

KEY QUESTION

WHAT IS THE

STOMACHVOLUMEOF THE

NEONATE 137 Sase 2005

ldquoOntogeny of gastric emptying patternsin the human fetusrdquo

138

24

Goldstein 1987

ldquoGrowth of the Fetal Stomach in Normal Pregnanciesrdquo

139 Goldstein 1987

Length

Transverse

AP diameter

Using +2SD

140

Formula for calculation of stomach capacity (Charles Bradshaw UCT)Assumptions the stomach can be approximated by dividing into three sections namely a ellipsoidal hemisphere an ellipsoidal cylinder and a skewed ellipsoidal cone Variables a = anteroposterior radius t = transverse radius l = length stomachRelations the height of the cone and the hemisphere are both the same as lsquoarsquo

Ellipsoid = 43 Pi r1r2r3 = 43 Pi a a t therefore volume of hemisphere = 23 Pi a a t

Cylinder = Area of base height = (Pi a t ) ( l - 2a )Skewed cone = 13 base height = 13 Pi a t aTotal volume = 23 Pi aat + Pi a t (l- 2a) + 13 Pi a t a

=Pi atl -Pi a at= Pi a t(l-a)

Goldstein and Sase dataStomach capacity at term 10 - 15 ml

BRADSHAW formula

141

Assumption 25 kg baby 33w GA

requiring 150 mlkgday = 375 ml

45 MIN CYCLES ( 32 cyclesday)

12 ML PER CYCLE = 384 ml142

Newborn stomach volume

Gastric volumes at birthCorrelated with gastric pH

gastrin and somatostatin

ldquofetus drinks 10 ml portions of amniotic fluid helliprdquo

Widstrom 1988 143

Only recent study locatedldquoAutopsyrdquo capacity was determined

in Indian post-mortem studies

100 autopsies (63 SB 37 ENND)Tied at cardia and pylorus filled withwater emptied amp measured repeatedldquohellip obliteration of the gastric curvaturesrdquoldquodue care to minimize stretch artifactsrdquo

Naveed 1992

ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo

144

25

Infants above 2500g onlyAve Range

Stillborn (n 11) 196 ml (10-35)Early death (n 9) 178 ml (10-25)All cases (n 20) 188 ml

Naveed 1992

ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo

145 146

KERNESSUK 1997 (Russian)

Postmortem in situ measures(applied Bradshaw formula)

AveNewborn (n 11) 15 ml2 months (n 11) 35 ml2-4 m (n 10) 50 ml4-6 m (n 8) 100 ml

Known references with data

Scammon and Doyle 1920

Zuccarellirsquos method stomach filled at autopsy to ldquoa pressure of between

15 and 20 centimeters of waterrdquo

Scammon 1920

ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo

147

Anatomic capacity was determined in post-mortem studies

Main data set Alliot 1905 (n 25)Scammon own cases (n 13)

30 ndash 35 ml at birth ndashalmost regardless of birth weight

Scammon 1920

ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo

148

Zangen S et al Rapid maturation of gastric relaxation in newborns

Pressures (mmHg)

Balloon inflates to

15 ml no increase

functional capacity

149

Zangen S et al Rapid maturation of gastric relaxation in newborns

Pressures (mmHg)

Balloon inflates to

15 ml no increase20 ml pressure OK

physiologicalcapacity hellip 150

26

EVIDENCE (NBn 111009)

Author Capacity NoteSase 10-15 ml Live term fetusGoldstein 10-15 ml Live term fetusWidstrom 10 mls Live newbornZangen 20 mls Live (pressure)

Naveed 20 mls Autopsy (SB)20 mls Autopsy (ENND)

Kernessuk 15 mls Autopsy (in situ)Scammon 30-35 ml Autopsy (water

(Alliot) pressure)151

PROPOSAL

The CAPACITY of aweek old babyrsquos stomach is

approx 20 ml152

0

05

1

15

2

25

3

35

4

0 10 20 30 40 50 60 70 80

volume ingested

fee

din

g f

req

ue

nc

y

Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml

StandardCARE3 hourlyschedule

MOTHERNATURE

1 hourlyschedule

153

PHYSIOLOGICAL CAPACITY

RECEPTIVE CAPACITY of stomach

INGESTIVE CAPACITY of BABY

FUNCTIONAL CAPACITY

154

PROPOSAL

The FEEDINGFREQUENCY of theNEONATE is

approx 60 min155

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

BRAIN CYCLING

STOMACH FILLING amp EMPTYING

REMNR1NR2NR3NR4

156

27

Normal physiology of theEnteric Nervous System

ldquoSmall and frequent feeds according to the sleep cyclerdquo

The ldquonicherdquo (occupation) of a neonate (Alberts)

BOND FEED

SLEEP SLEEP

PLAY FEED

157

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

FEEDING SUCKLING

Influence of SMELL None Totally dependent

Motor mechanism Chewing ndash different

muscles

Suckling ndash different circuits

INSULIN Increases weight No effect

GHRELIN Increases weight No effect

LEPTIN Decreases intake No effect

CHOLECYSTOKININ Decreases intake No effect

AMPHETAMINE Decreases appetite Increases suckling

SEROTONIN Agonist improves feeding Antagonist improves suck

SATIETY Infant determined Maternal supply determine

FEEDING SUCKLING

Influence of SMELL None Totally dependent

Motor mechanism Chewing ndash different

muscles

Suckling ndash different circuits

INSULIN Increases weight No effect

GHRELIN Increases weight No effect

LEPTIN Decreases intake No effect

CHOLECYSTOKININ Decreases intake No effect

AMPHETAMINE Decreases appetite Increases suckling

SEROTONIN Agonist improves feeding Antagonist improves suck

SATIETY Infant determined Maternal supply determine

Current dogmaTHE BABY KNOWS

WHEN IT HAS HAD ENOUGH

PROBABLY NOT

WHAT IS THE

STOMACH VOLUME OF THE

PREMATURE

161

Assume low resilience

Assume proportionality

162

28

The CAPACITY of alow birthweight premfrom 20ml 3000g

= 0007 x BWt (g)

1kg x 0007 = 7mls2kg x 0007 = 14mls

163

Gastric overfilling syndrome

164

75 ml per feeding ASSUMPTION

IMMATURE OR OVERWHELMED

many aspects of gastrointestinalmotility are immature in the neonate

Zangen S et al Rapid maturation of gastric relaxation in newborns

A balloon in stomachcan fill to 76 mls

What does the stomach ndashwithout a balloon ndashdo to 76 mls

REFLUX PRESUME each feedapproximately 75 mls

GER

bull Sudden outbursts of crying

bull Awakens in pain

bull Related to feedings

bull Not easily comforted

bull ldquoI know baby hurtsrdquo

bull Sour burps throaty noises

bull Best when upright

Clues to GER

Dr W Sears

29

Mitchell 2001

Kerstin Uvnaumls-Moberg

Food in duodenum

AMYLINreleased

Closes pylorus

Duodenumempty

Pylorusopens

ldquoFeed intolerancerdquo hellip hellip or VOLUME intolerance

HYPOGLYCAEMIA

A babies stomach empties in60 minutes

Blood sugarmay fall hellip

after 90 minutes Options

30

METABOLIC ADAPTATION

SSC started in the first 20 minutes after birth

SSC CotBlood glucose (1 hr) 317 256Base excess drop 34 18

(Christenson 1992)0h 1h 2h 3h 4h 2 days

App

roxim

ate

GLUCOSE

SSC Glucose production = Glucose consumption

Separation

SNS stress Glucose consumption INCREASE

PSNS dissociation Glucose production DECREASE

HYPOGLYCEMIA

SSC Cot

Blood glucose (1 hr) 317 256

0h 1h 2h 3h 4h 2 days

App

roxim

ate

GLUCOSE

SSC Glucose production = Glucose consumption

Separation PSNS dissociation

Glucose production DECREASE

HYPOGLYCEMIA

SSC Cot

Blood glucose (1 hr) 317 256

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

NEURODEVELOPMENTThe DNA Behaviour

EVOLUTIONARY BIOLOGY

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

BONDING ATTACHMENT

MRI HRVEEG

STRESS RESPONES

RESILIENCE

DOHAD

(MAL) ADAPTATION

EPIGENETICS

GENE X ENVIRONMENT

GENETIC VARIANTS

HOSPITAL ACQUIRED INFECTIONIMMUNITY

SLEEP PHYSIOLOGY

GUT FUNCTIONMICROBIOTA

ldquoSTABILITYrdquo

TRANSITION

LONG TERM FOLLOW-UP

NEUROENDOCRINE BEHAVIOURS

MATERNAL NEUROPLASTICITY

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

MORTALITYMETABOLISM

0h 1h 2h 3h 4h

PSNS (vagal)

App

roxim

ate

GLUCOSE

1 HOURLY Milk feed

1 HOURLY Milk feed

1 HOURLY Milk feed

1 HOURLY Milk feed

LACTOSE

METABOLISM

31

0h 1h 2h 3h 4h

PSNS (vagal) SYMPATHETIC STRESS

App

roxim

ate

GLUCOSE

LACTOSE FATGLYCOGEN

METABOLISM

4 HOURLY Milk feed

0h 1h 2h 3h 4h

PSNS (vagal) SYMPATHETIC STRESS

App

roxim

ate

GLUCOSE

4 HOURLY ALLOSTATIC STATELACTOSE FATGLYCOGEN

METABOLISM

4 HOURLY Milk feed

HEALTH DISEASE

EXPECTED UNEXPECTED

NEURODEVELOPMENTThe DNA Behaviour

EVOLUTIONARY BIOLOGY

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

BONDING ATTACHMENT

MRI HRVEEG

STRESS RESPONES

RESILIENCE

DOHAD

(MAL) ADAPTATION

EPIGENETICS

GENE X ENVIRONMENT

GENETIC VARIANTS

HOSPITAL ACQUIRED INFECTIONIMMUNITY

SLEEP PHYSIOLOGY

GUT FUNCTIONMICROBIOTA

ldquoSTABILITYrdquo

TRANSITION

LONG TERM FOLLOW-UP

NEUROENDOCRINE BEHAVIOURS

MATERNAL NEUROPLASTICITY

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

MORTALITYMETABOLISM

Weight gain 1st week

predicts OBESITYat 30 years

Large volume feedsstretched stomach=

doubled absorptivecapacity as adult

Importance

Programming ndash early life chronic disease

32

RESISTANCE SENSITIVITY

PERCEPTIONSldquoNEUROCEPTIONrdquo

RESPONSESTRESS

ALLOSTATIC STATE

ALLOSTASIS

ANY STRESSPsychologicalNeurological

EndocrineImmune

ALLOSTATIC LOAD

ALLOSTATIC OVERLOAD

WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY

DISEASEHEALTH

RESILIENCE VULNERABILITY

RESISTANCE SENSITIVITY

PERCEPTIONSldquoNEUROCEPTIONrdquo

RESPONSESTRESS

ALLOSTATIC STATE

ALLOSTASIS

ANY STRESSPsychologicalNeurological

EndocrineImmune

ALLOSTATIC LOAD

HEALTH

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

Gastric overfilling syndrome

189

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

33

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

Only case series Insufficient evidence

No mention of

stomach capacity196

Baby weight freq reqrsquod size actual

2kg baby 4hrly ~ 320 ml6 = 53ml 14ml

15 baby 3hrly ~ 240 ml8 = 30ml 10ml

10 baby 2hrly ~ 160 ml12 = 13ml 7ml

Standardised from20ml capacityfor 3kg baby( x 0007)

197

0

10

20

30

40

50

60

70

80

90

13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w

LINEAR

TERM

PREM

198

34

0

10

20

30

40

50

60

70

80

90

13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w

LINEAR

TERM

PREM

199

Clues to GER

ldquoI know baby hurtsrdquo

Gastric overfilling syndrome

Excessive volumesreflux aspiration colic

Excessive time intervalhypoglycaemia

Adaptationsdiabetic diathesis obesity

200

Developmental Care of the Enteric Nervous System

ldquoSmall and frequent feeds according to the sleep cyclerdquo

The ldquonicherdquo (occupation) of a neonate (Alberts)

BOND FEED

SLEEP SLEEP

PLAY FEED

201

Gastric overfilling syndrome

Proposed Management 202

Proposed Management

Babies should be fedEVERY TIME THEY WAKE

Stanley Graven 2006

REMNR1NR2NR3SWS

AS (20 mins) QS (40 mins)

A normal sleep cycle is ONE hourHow often should neonates feed

203

Proposed Management

All babies should be fedat least once an hour 204

35

Proposed Management

All babies should be fedat least once an hour

205

The first Milk Ejection Reflex (MER)

elicited in lt 2 minutesworks quicklyswallowed 1 minute

Feeding time (max)3 minutes

Repeat every 1 hour

Prime 2007

The ldquonormalrdquo or usual and common breastfeed

takes 15 minutesdiscomfort afterburping time 5 minutes

Feeding time 20 min

Repeat every 3 hours

Prime 2007

3 minute 20ml feeds x 24d = 72 minutes

20 minute 60ml feeds x 8d = 160 minutes

SMALL AND FREQUENT FEEDS ARE EFFICIENT

FEWER NURSES NEEDED

The calculated dailyrequirement for a 3kgbaby can be given without increase inpressure MINIMAL RISK

PARENTS CAN DOSAFELY

20 mls x 24 feeds= 480mls day

Zangen 2001 209

All babies should be fedat least once an hour

210

36

Infant feeding frequencyProposal based on available evidence and neuroscience

ldquoSmall and frequent feeds

adjusted to the sleep cyclerdquo

211

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

STATE organization

Feeding frequency

SLEEP cycling

BRAIN

WIRING

How often should a neonate feeda neonate sleep

Infantsleep cycles

begin to block on diurnalrhythms

Mother-infant synchrony

hellip at 12 weeks

(circadian)

START at 3 months

Can be ldquoadult-likerdquo

at 6 months

Thomas 2014

STATE organization

Feeding frequency

SLEEP cycling

PLAY FEED

216

SLEEP SLEEP

SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

Infantsleep cycles

begin to block on diurnalrhythms

37

BOND SUCKLE SLEEP SLEEP PLAY

FEED

217

SLEEP SLEEP SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)

Schaal 2004 218

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)rdquoSLEEP-FEED CYCLINGrdquo

Schaal 2004 219

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

WIRE

BRAIN

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

BRAIN

WIRING

NEUROSCIENCE

The DNAEverything else

EVOLUTIONARYBIOLOGY

The Brain

EPIGENETICS

The PlaceENVIRONMENT

EXPERIENCEFITNESS ADAPTATION

ldquoScientific foundationrdquo hellip a synthesis

ZERO

SEPARATION

38

wwwninobirthorgwwwskintoskincontactcom

THE NEUROSCIENCE OFSKIN-TO-SKIN CONTACT

AND BREASTFEEDING

ARE THE SAME

SUMMARY SKIN-TO-SKIN

(Regulation)

SLEEP(Brain)

FEEDING(Stomach)

LOVE ( ldquomindrdquo )

REMNR1NR2NR3NR4

ACQUISITION CONSOLIDATION MEMORYFORMATION

poly-sensory input transfer information P wavesshort-term memory ldquoSNRrdquo strong signals returns infostored cortex amygdala to neocortex

hippocampus organizedAwake and REM NREM stage 4 REM

BRAIN WIRING

Stanley Graven 2006

PLAY

SLEEP

FEEDHOLDYOURPREM

httpswwwfacebookcomninobirth

39

Nelson Mandela

hellip in describing themeasure of a nation

he has argued that

ldquoThere can be no keener revelation of a societyrsquos soul than the way in which it treats its childrenrdquo

Page 16: Neurodevelopmental The Neuroscience of Birth ... · breastfeeding pattern, neonatal weight gain, and the dynamics of lactation. Doucet 2012 In the ‘‘scentless breast’’ condition,

16

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDINGON-GOING

S S C

WIRE SUCKLING

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

ON-GOING

S S C

WIRE NEURONS

Up to 6 months milk is 74 fat

96 of this is TRIGLYCERIDE

TRIGLYCERIDE Left glycerol Right palmitic acid oleic acid alpha-linolenic acid

In phosphoglycerides glycerol molecule same

two fatty acids esterified

Phospholipids area major component of all biological membranes

Sphingomyelin particularly concentrated in BRAIN major part of MYELIN

TRIGLYCERIDE

MYELIN

Dendirification and myelinisation peaks occurat 2 and 6 monthsis maximal at one year

At one year human milk has less proteinbut MORE TRIGLYCERIDE

FATTY ACIDS ARESPECIES SPECIFIC

Up to 6 months milk is 74 fat

but after 12 months it is 107

17

ldquocherry pickrdquo

Breastfeed time years school Incomelt 1 month 109 R$ 1238gt 6 month 121 R$ 1915

Group IQ 376 points higher from breatsfeeding

BREASTFEEDINGAND BREAST MILK

INCREASE IQ

BOTTLE FEEDINGamp FORMULA

DECREASE IQ

18

Be sure the wet nurse has plenty of milk because if she lacks it she may give the babymilk of a goat or sheep or some other animalbecause the child nourished on animal milkdoes not have perfect wits like one fed on womanrsquos milk and always looks stupid and vacant and not right in the head

14th century Tuscan text

Conceptual changeDyad careBreast first hour

even CaesareanContinuous SSC

DISCONTINUEGiving waterGlucose waterInfant formulaSeparationPacifier (dummy)

CHANGE POLICY Canrsquot change

biology

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

ON-GOING

S S C

WIRE NEURONS

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C WIRE

TIMING

(behavior)

19

Not so much duration

or density of any sleep stage

or number of sleep stage episodes but

cycling between quiet sleep

and active sleepis what is important

REMREM REM

NREM NREM

This is a healthy sleep pattern

This is a very good cycling pattern

(thanks to Susan Ludington-Hoe)

REMREM REM

NREM NREM

1st hour 2nd hour

So in every hour you would like

to see an EEG pattern that shows this

REM

NREM

REM

NREM

REM

NREM

State

HR

RR

REM Sleep is supposed to be

somewhat active so

HR increases and RR is irregular

SLEEP CYCLING ndashSeparation vs contact

In separation bull Dissociated statebull No cycling chaotic pattern

48 hour baseline chaotic pattern of

activity and quiet HR amp RR

SLEEP CYCLING ndashSeparation vs contact

In SSC bull Normal cyclingbull Non-chaotic pattern

48 hour baseline chaotic pattern of

activity and quiet HR amp RRPre-KC SSC

20

modulates state organisationelicits emotional behavioursactivates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL

Schaal 2004 115

DOUCETThe secretion of Areolar (Montgomeryrsquos) Glands from Lactating Women Elicits Selective Unconditional Responses in Neonates

ldquohellip breast chemosignalsactivate oral activity on the nipple that releases a cascade of behavioral neural neuroendocrineand endocrine processes in the newborn and the motherrdquo

Doucet 2009 116

The secretion of Areolar(Montgomeryrsquos) Glands

ldquoIn early ontogeny the sleeping brain may thusremain sentient of an organismrsquos odor environmentrdquo

Doucet 2009 117

REM

NREM

A skin-to-skin contactsession SHOULD NOT be less than one hour

or 90 minutes

SLEEPING

amp

CONTAINING

FEEDING ampHANDLINGfeed

sleep

HO

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C WIRE

TIMING

(behavior)

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C WIRE

STOMACH

21

STATE organization

Feeding frequency

SLEEP cycling

BRAIN

WIRING

How often should a neonate feed

CNS

ENS

ANS

InternalSomaticenvironment

CNS cortical subcortical(also to PNS)

ANS emotional limbic brain(incl SNS)

ANS myelinated vagus (NA)

ANS unmyelinated vagus (DMC)sub-diaphragmatic

ENS submucous plexusmyenteric plexus

122

The digestive system is endowed with its own local nervous system referred to as the enteric or intrinsic nervous system

The magnitude and complexity of the enteric nervous system is immense - it contains as many neurons as the spinal cord

ENTERIC NERVOUS SYSTEM

123

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

FEEDBACK LOOPS

CNS

ENS

ANS

InternalSomaticenvironment

124

125 126

22

Fetal stomach appears 4 weeks GABy 11 weeks wall capable of muscular

contraction

ldquoPatterns of antropyloric motilityin fed healthy preterm infantsrdquo

the neuroregulatory mechanisms responsible for the coordination of antro-pyloric motility and gastric emptying are

well developed by 30 weeks of PMAHassan 2002 127

Hydrochloric acidimportant for activation of pepsinogen

inactivation of microorganisms such as bacteria

Pepsinogenactivated by acid into active pepsin

responsible for the stomachs ability to initiate digestion of proteins

Chymosinis an enzyme whose role is to curdle or

coagulate milk in the stomach a process of considerable importance in the very young animal

128

Chymosinmakes the milk into ldquocheeserdquohalfway between liquid and solidstomach empties in 60 minutes

milk

129

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

FEEDBACK LOOPS

130

EVIDENCE FORFEEDING FREQUENCY

Edmond 2006 131

Breastfeeding and motherrsquos milkStrong and consistent evidence 132

23

Cup feeding versus bottle feedingCup feeding higher breastfeeding

greater stability133

Only case series Insufficient evidence

No mention of

stomach capacity134

EVIDENCE FORSTOMACH CAPACITY

Edmond 2006 135

0

05

1

15

2

25

3

35

4

0 10 20 30 40 50 60 70 80

volume ingested

fee

din

g f

req

ue

nc

y

Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml

StandardCARE3 hourlyschedule

136

KEY QUESTION

WHAT IS THE

STOMACHVOLUMEOF THE

NEONATE 137 Sase 2005

ldquoOntogeny of gastric emptying patternsin the human fetusrdquo

138

24

Goldstein 1987

ldquoGrowth of the Fetal Stomach in Normal Pregnanciesrdquo

139 Goldstein 1987

Length

Transverse

AP diameter

Using +2SD

140

Formula for calculation of stomach capacity (Charles Bradshaw UCT)Assumptions the stomach can be approximated by dividing into three sections namely a ellipsoidal hemisphere an ellipsoidal cylinder and a skewed ellipsoidal cone Variables a = anteroposterior radius t = transverse radius l = length stomachRelations the height of the cone and the hemisphere are both the same as lsquoarsquo

Ellipsoid = 43 Pi r1r2r3 = 43 Pi a a t therefore volume of hemisphere = 23 Pi a a t

Cylinder = Area of base height = (Pi a t ) ( l - 2a )Skewed cone = 13 base height = 13 Pi a t aTotal volume = 23 Pi aat + Pi a t (l- 2a) + 13 Pi a t a

=Pi atl -Pi a at= Pi a t(l-a)

Goldstein and Sase dataStomach capacity at term 10 - 15 ml

BRADSHAW formula

141

Assumption 25 kg baby 33w GA

requiring 150 mlkgday = 375 ml

45 MIN CYCLES ( 32 cyclesday)

12 ML PER CYCLE = 384 ml142

Newborn stomach volume

Gastric volumes at birthCorrelated with gastric pH

gastrin and somatostatin

ldquofetus drinks 10 ml portions of amniotic fluid helliprdquo

Widstrom 1988 143

Only recent study locatedldquoAutopsyrdquo capacity was determined

in Indian post-mortem studies

100 autopsies (63 SB 37 ENND)Tied at cardia and pylorus filled withwater emptied amp measured repeatedldquohellip obliteration of the gastric curvaturesrdquoldquodue care to minimize stretch artifactsrdquo

Naveed 1992

ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo

144

25

Infants above 2500g onlyAve Range

Stillborn (n 11) 196 ml (10-35)Early death (n 9) 178 ml (10-25)All cases (n 20) 188 ml

Naveed 1992

ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo

145 146

KERNESSUK 1997 (Russian)

Postmortem in situ measures(applied Bradshaw formula)

AveNewborn (n 11) 15 ml2 months (n 11) 35 ml2-4 m (n 10) 50 ml4-6 m (n 8) 100 ml

Known references with data

Scammon and Doyle 1920

Zuccarellirsquos method stomach filled at autopsy to ldquoa pressure of between

15 and 20 centimeters of waterrdquo

Scammon 1920

ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo

147

Anatomic capacity was determined in post-mortem studies

Main data set Alliot 1905 (n 25)Scammon own cases (n 13)

30 ndash 35 ml at birth ndashalmost regardless of birth weight

Scammon 1920

ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo

148

Zangen S et al Rapid maturation of gastric relaxation in newborns

Pressures (mmHg)

Balloon inflates to

15 ml no increase

functional capacity

149

Zangen S et al Rapid maturation of gastric relaxation in newborns

Pressures (mmHg)

Balloon inflates to

15 ml no increase20 ml pressure OK

physiologicalcapacity hellip 150

26

EVIDENCE (NBn 111009)

Author Capacity NoteSase 10-15 ml Live term fetusGoldstein 10-15 ml Live term fetusWidstrom 10 mls Live newbornZangen 20 mls Live (pressure)

Naveed 20 mls Autopsy (SB)20 mls Autopsy (ENND)

Kernessuk 15 mls Autopsy (in situ)Scammon 30-35 ml Autopsy (water

(Alliot) pressure)151

PROPOSAL

The CAPACITY of aweek old babyrsquos stomach is

approx 20 ml152

0

05

1

15

2

25

3

35

4

0 10 20 30 40 50 60 70 80

volume ingested

fee

din

g f

req

ue

nc

y

Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml

StandardCARE3 hourlyschedule

MOTHERNATURE

1 hourlyschedule

153

PHYSIOLOGICAL CAPACITY

RECEPTIVE CAPACITY of stomach

INGESTIVE CAPACITY of BABY

FUNCTIONAL CAPACITY

154

PROPOSAL

The FEEDINGFREQUENCY of theNEONATE is

approx 60 min155

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

BRAIN CYCLING

STOMACH FILLING amp EMPTYING

REMNR1NR2NR3NR4

156

27

Normal physiology of theEnteric Nervous System

ldquoSmall and frequent feeds according to the sleep cyclerdquo

The ldquonicherdquo (occupation) of a neonate (Alberts)

BOND FEED

SLEEP SLEEP

PLAY FEED

157

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

FEEDING SUCKLING

Influence of SMELL None Totally dependent

Motor mechanism Chewing ndash different

muscles

Suckling ndash different circuits

INSULIN Increases weight No effect

GHRELIN Increases weight No effect

LEPTIN Decreases intake No effect

CHOLECYSTOKININ Decreases intake No effect

AMPHETAMINE Decreases appetite Increases suckling

SEROTONIN Agonist improves feeding Antagonist improves suck

SATIETY Infant determined Maternal supply determine

FEEDING SUCKLING

Influence of SMELL None Totally dependent

Motor mechanism Chewing ndash different

muscles

Suckling ndash different circuits

INSULIN Increases weight No effect

GHRELIN Increases weight No effect

LEPTIN Decreases intake No effect

CHOLECYSTOKININ Decreases intake No effect

AMPHETAMINE Decreases appetite Increases suckling

SEROTONIN Agonist improves feeding Antagonist improves suck

SATIETY Infant determined Maternal supply determine

Current dogmaTHE BABY KNOWS

WHEN IT HAS HAD ENOUGH

PROBABLY NOT

WHAT IS THE

STOMACH VOLUME OF THE

PREMATURE

161

Assume low resilience

Assume proportionality

162

28

The CAPACITY of alow birthweight premfrom 20ml 3000g

= 0007 x BWt (g)

1kg x 0007 = 7mls2kg x 0007 = 14mls

163

Gastric overfilling syndrome

164

75 ml per feeding ASSUMPTION

IMMATURE OR OVERWHELMED

many aspects of gastrointestinalmotility are immature in the neonate

Zangen S et al Rapid maturation of gastric relaxation in newborns

A balloon in stomachcan fill to 76 mls

What does the stomach ndashwithout a balloon ndashdo to 76 mls

REFLUX PRESUME each feedapproximately 75 mls

GER

bull Sudden outbursts of crying

bull Awakens in pain

bull Related to feedings

bull Not easily comforted

bull ldquoI know baby hurtsrdquo

bull Sour burps throaty noises

bull Best when upright

Clues to GER

Dr W Sears

29

Mitchell 2001

Kerstin Uvnaumls-Moberg

Food in duodenum

AMYLINreleased

Closes pylorus

Duodenumempty

Pylorusopens

ldquoFeed intolerancerdquo hellip hellip or VOLUME intolerance

HYPOGLYCAEMIA

A babies stomach empties in60 minutes

Blood sugarmay fall hellip

after 90 minutes Options

30

METABOLIC ADAPTATION

SSC started in the first 20 minutes after birth

SSC CotBlood glucose (1 hr) 317 256Base excess drop 34 18

(Christenson 1992)0h 1h 2h 3h 4h 2 days

App

roxim

ate

GLUCOSE

SSC Glucose production = Glucose consumption

Separation

SNS stress Glucose consumption INCREASE

PSNS dissociation Glucose production DECREASE

HYPOGLYCEMIA

SSC Cot

Blood glucose (1 hr) 317 256

0h 1h 2h 3h 4h 2 days

App

roxim

ate

GLUCOSE

SSC Glucose production = Glucose consumption

Separation PSNS dissociation

Glucose production DECREASE

HYPOGLYCEMIA

SSC Cot

Blood glucose (1 hr) 317 256

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

NEURODEVELOPMENTThe DNA Behaviour

EVOLUTIONARY BIOLOGY

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

BONDING ATTACHMENT

MRI HRVEEG

STRESS RESPONES

RESILIENCE

DOHAD

(MAL) ADAPTATION

EPIGENETICS

GENE X ENVIRONMENT

GENETIC VARIANTS

HOSPITAL ACQUIRED INFECTIONIMMUNITY

SLEEP PHYSIOLOGY

GUT FUNCTIONMICROBIOTA

ldquoSTABILITYrdquo

TRANSITION

LONG TERM FOLLOW-UP

NEUROENDOCRINE BEHAVIOURS

MATERNAL NEUROPLASTICITY

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

MORTALITYMETABOLISM

0h 1h 2h 3h 4h

PSNS (vagal)

App

roxim

ate

GLUCOSE

1 HOURLY Milk feed

1 HOURLY Milk feed

1 HOURLY Milk feed

1 HOURLY Milk feed

LACTOSE

METABOLISM

31

0h 1h 2h 3h 4h

PSNS (vagal) SYMPATHETIC STRESS

App

roxim

ate

GLUCOSE

LACTOSE FATGLYCOGEN

METABOLISM

4 HOURLY Milk feed

0h 1h 2h 3h 4h

PSNS (vagal) SYMPATHETIC STRESS

App

roxim

ate

GLUCOSE

4 HOURLY ALLOSTATIC STATELACTOSE FATGLYCOGEN

METABOLISM

4 HOURLY Milk feed

HEALTH DISEASE

EXPECTED UNEXPECTED

NEURODEVELOPMENTThe DNA Behaviour

EVOLUTIONARY BIOLOGY

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

BONDING ATTACHMENT

MRI HRVEEG

STRESS RESPONES

RESILIENCE

DOHAD

(MAL) ADAPTATION

EPIGENETICS

GENE X ENVIRONMENT

GENETIC VARIANTS

HOSPITAL ACQUIRED INFECTIONIMMUNITY

SLEEP PHYSIOLOGY

GUT FUNCTIONMICROBIOTA

ldquoSTABILITYrdquo

TRANSITION

LONG TERM FOLLOW-UP

NEUROENDOCRINE BEHAVIOURS

MATERNAL NEUROPLASTICITY

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

MORTALITYMETABOLISM

Weight gain 1st week

predicts OBESITYat 30 years

Large volume feedsstretched stomach=

doubled absorptivecapacity as adult

Importance

Programming ndash early life chronic disease

32

RESISTANCE SENSITIVITY

PERCEPTIONSldquoNEUROCEPTIONrdquo

RESPONSESTRESS

ALLOSTATIC STATE

ALLOSTASIS

ANY STRESSPsychologicalNeurological

EndocrineImmune

ALLOSTATIC LOAD

ALLOSTATIC OVERLOAD

WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY

DISEASEHEALTH

RESILIENCE VULNERABILITY

RESISTANCE SENSITIVITY

PERCEPTIONSldquoNEUROCEPTIONrdquo

RESPONSESTRESS

ALLOSTATIC STATE

ALLOSTASIS

ANY STRESSPsychologicalNeurological

EndocrineImmune

ALLOSTATIC LOAD

HEALTH

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

Gastric overfilling syndrome

189

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

33

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

Only case series Insufficient evidence

No mention of

stomach capacity196

Baby weight freq reqrsquod size actual

2kg baby 4hrly ~ 320 ml6 = 53ml 14ml

15 baby 3hrly ~ 240 ml8 = 30ml 10ml

10 baby 2hrly ~ 160 ml12 = 13ml 7ml

Standardised from20ml capacityfor 3kg baby( x 0007)

197

0

10

20

30

40

50

60

70

80

90

13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w

LINEAR

TERM

PREM

198

34

0

10

20

30

40

50

60

70

80

90

13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w

LINEAR

TERM

PREM

199

Clues to GER

ldquoI know baby hurtsrdquo

Gastric overfilling syndrome

Excessive volumesreflux aspiration colic

Excessive time intervalhypoglycaemia

Adaptationsdiabetic diathesis obesity

200

Developmental Care of the Enteric Nervous System

ldquoSmall and frequent feeds according to the sleep cyclerdquo

The ldquonicherdquo (occupation) of a neonate (Alberts)

BOND FEED

SLEEP SLEEP

PLAY FEED

201

Gastric overfilling syndrome

Proposed Management 202

Proposed Management

Babies should be fedEVERY TIME THEY WAKE

Stanley Graven 2006

REMNR1NR2NR3SWS

AS (20 mins) QS (40 mins)

A normal sleep cycle is ONE hourHow often should neonates feed

203

Proposed Management

All babies should be fedat least once an hour 204

35

Proposed Management

All babies should be fedat least once an hour

205

The first Milk Ejection Reflex (MER)

elicited in lt 2 minutesworks quicklyswallowed 1 minute

Feeding time (max)3 minutes

Repeat every 1 hour

Prime 2007

The ldquonormalrdquo or usual and common breastfeed

takes 15 minutesdiscomfort afterburping time 5 minutes

Feeding time 20 min

Repeat every 3 hours

Prime 2007

3 minute 20ml feeds x 24d = 72 minutes

20 minute 60ml feeds x 8d = 160 minutes

SMALL AND FREQUENT FEEDS ARE EFFICIENT

FEWER NURSES NEEDED

The calculated dailyrequirement for a 3kgbaby can be given without increase inpressure MINIMAL RISK

PARENTS CAN DOSAFELY

20 mls x 24 feeds= 480mls day

Zangen 2001 209

All babies should be fedat least once an hour

210

36

Infant feeding frequencyProposal based on available evidence and neuroscience

ldquoSmall and frequent feeds

adjusted to the sleep cyclerdquo

211

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

STATE organization

Feeding frequency

SLEEP cycling

BRAIN

WIRING

How often should a neonate feeda neonate sleep

Infantsleep cycles

begin to block on diurnalrhythms

Mother-infant synchrony

hellip at 12 weeks

(circadian)

START at 3 months

Can be ldquoadult-likerdquo

at 6 months

Thomas 2014

STATE organization

Feeding frequency

SLEEP cycling

PLAY FEED

216

SLEEP SLEEP

SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

Infantsleep cycles

begin to block on diurnalrhythms

37

BOND SUCKLE SLEEP SLEEP PLAY

FEED

217

SLEEP SLEEP SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)

Schaal 2004 218

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)rdquoSLEEP-FEED CYCLINGrdquo

Schaal 2004 219

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

WIRE

BRAIN

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

BRAIN

WIRING

NEUROSCIENCE

The DNAEverything else

EVOLUTIONARYBIOLOGY

The Brain

EPIGENETICS

The PlaceENVIRONMENT

EXPERIENCEFITNESS ADAPTATION

ldquoScientific foundationrdquo hellip a synthesis

ZERO

SEPARATION

38

wwwninobirthorgwwwskintoskincontactcom

THE NEUROSCIENCE OFSKIN-TO-SKIN CONTACT

AND BREASTFEEDING

ARE THE SAME

SUMMARY SKIN-TO-SKIN

(Regulation)

SLEEP(Brain)

FEEDING(Stomach)

LOVE ( ldquomindrdquo )

REMNR1NR2NR3NR4

ACQUISITION CONSOLIDATION MEMORYFORMATION

poly-sensory input transfer information P wavesshort-term memory ldquoSNRrdquo strong signals returns infostored cortex amygdala to neocortex

hippocampus organizedAwake and REM NREM stage 4 REM

BRAIN WIRING

Stanley Graven 2006

PLAY

SLEEP

FEEDHOLDYOURPREM

httpswwwfacebookcomninobirth

39

Nelson Mandela

hellip in describing themeasure of a nation

he has argued that

ldquoThere can be no keener revelation of a societyrsquos soul than the way in which it treats its childrenrdquo

Page 17: Neurodevelopmental The Neuroscience of Birth ... · breastfeeding pattern, neonatal weight gain, and the dynamics of lactation. Doucet 2012 In the ‘‘scentless breast’’ condition,

17

ldquocherry pickrdquo

Breastfeed time years school Incomelt 1 month 109 R$ 1238gt 6 month 121 R$ 1915

Group IQ 376 points higher from breatsfeeding

BREASTFEEDINGAND BREAST MILK

INCREASE IQ

BOTTLE FEEDINGamp FORMULA

DECREASE IQ

18

Be sure the wet nurse has plenty of milk because if she lacks it she may give the babymilk of a goat or sheep or some other animalbecause the child nourished on animal milkdoes not have perfect wits like one fed on womanrsquos milk and always looks stupid and vacant and not right in the head

14th century Tuscan text

Conceptual changeDyad careBreast first hour

even CaesareanContinuous SSC

DISCONTINUEGiving waterGlucose waterInfant formulaSeparationPacifier (dummy)

CHANGE POLICY Canrsquot change

biology

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

ON-GOING

S S C

WIRE NEURONS

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C WIRE

TIMING

(behavior)

19

Not so much duration

or density of any sleep stage

or number of sleep stage episodes but

cycling between quiet sleep

and active sleepis what is important

REMREM REM

NREM NREM

This is a healthy sleep pattern

This is a very good cycling pattern

(thanks to Susan Ludington-Hoe)

REMREM REM

NREM NREM

1st hour 2nd hour

So in every hour you would like

to see an EEG pattern that shows this

REM

NREM

REM

NREM

REM

NREM

State

HR

RR

REM Sleep is supposed to be

somewhat active so

HR increases and RR is irregular

SLEEP CYCLING ndashSeparation vs contact

In separation bull Dissociated statebull No cycling chaotic pattern

48 hour baseline chaotic pattern of

activity and quiet HR amp RR

SLEEP CYCLING ndashSeparation vs contact

In SSC bull Normal cyclingbull Non-chaotic pattern

48 hour baseline chaotic pattern of

activity and quiet HR amp RRPre-KC SSC

20

modulates state organisationelicits emotional behavioursactivates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL

Schaal 2004 115

DOUCETThe secretion of Areolar (Montgomeryrsquos) Glands from Lactating Women Elicits Selective Unconditional Responses in Neonates

ldquohellip breast chemosignalsactivate oral activity on the nipple that releases a cascade of behavioral neural neuroendocrineand endocrine processes in the newborn and the motherrdquo

Doucet 2009 116

The secretion of Areolar(Montgomeryrsquos) Glands

ldquoIn early ontogeny the sleeping brain may thusremain sentient of an organismrsquos odor environmentrdquo

Doucet 2009 117

REM

NREM

A skin-to-skin contactsession SHOULD NOT be less than one hour

or 90 minutes

SLEEPING

amp

CONTAINING

FEEDING ampHANDLINGfeed

sleep

HO

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C WIRE

TIMING

(behavior)

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C WIRE

STOMACH

21

STATE organization

Feeding frequency

SLEEP cycling

BRAIN

WIRING

How often should a neonate feed

CNS

ENS

ANS

InternalSomaticenvironment

CNS cortical subcortical(also to PNS)

ANS emotional limbic brain(incl SNS)

ANS myelinated vagus (NA)

ANS unmyelinated vagus (DMC)sub-diaphragmatic

ENS submucous plexusmyenteric plexus

122

The digestive system is endowed with its own local nervous system referred to as the enteric or intrinsic nervous system

The magnitude and complexity of the enteric nervous system is immense - it contains as many neurons as the spinal cord

ENTERIC NERVOUS SYSTEM

123

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

FEEDBACK LOOPS

CNS

ENS

ANS

InternalSomaticenvironment

124

125 126

22

Fetal stomach appears 4 weeks GABy 11 weeks wall capable of muscular

contraction

ldquoPatterns of antropyloric motilityin fed healthy preterm infantsrdquo

the neuroregulatory mechanisms responsible for the coordination of antro-pyloric motility and gastric emptying are

well developed by 30 weeks of PMAHassan 2002 127

Hydrochloric acidimportant for activation of pepsinogen

inactivation of microorganisms such as bacteria

Pepsinogenactivated by acid into active pepsin

responsible for the stomachs ability to initiate digestion of proteins

Chymosinis an enzyme whose role is to curdle or

coagulate milk in the stomach a process of considerable importance in the very young animal

128

Chymosinmakes the milk into ldquocheeserdquohalfway between liquid and solidstomach empties in 60 minutes

milk

129

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

FEEDBACK LOOPS

130

EVIDENCE FORFEEDING FREQUENCY

Edmond 2006 131

Breastfeeding and motherrsquos milkStrong and consistent evidence 132

23

Cup feeding versus bottle feedingCup feeding higher breastfeeding

greater stability133

Only case series Insufficient evidence

No mention of

stomach capacity134

EVIDENCE FORSTOMACH CAPACITY

Edmond 2006 135

0

05

1

15

2

25

3

35

4

0 10 20 30 40 50 60 70 80

volume ingested

fee

din

g f

req

ue

nc

y

Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml

StandardCARE3 hourlyschedule

136

KEY QUESTION

WHAT IS THE

STOMACHVOLUMEOF THE

NEONATE 137 Sase 2005

ldquoOntogeny of gastric emptying patternsin the human fetusrdquo

138

24

Goldstein 1987

ldquoGrowth of the Fetal Stomach in Normal Pregnanciesrdquo

139 Goldstein 1987

Length

Transverse

AP diameter

Using +2SD

140

Formula for calculation of stomach capacity (Charles Bradshaw UCT)Assumptions the stomach can be approximated by dividing into three sections namely a ellipsoidal hemisphere an ellipsoidal cylinder and a skewed ellipsoidal cone Variables a = anteroposterior radius t = transverse radius l = length stomachRelations the height of the cone and the hemisphere are both the same as lsquoarsquo

Ellipsoid = 43 Pi r1r2r3 = 43 Pi a a t therefore volume of hemisphere = 23 Pi a a t

Cylinder = Area of base height = (Pi a t ) ( l - 2a )Skewed cone = 13 base height = 13 Pi a t aTotal volume = 23 Pi aat + Pi a t (l- 2a) + 13 Pi a t a

=Pi atl -Pi a at= Pi a t(l-a)

Goldstein and Sase dataStomach capacity at term 10 - 15 ml

BRADSHAW formula

141

Assumption 25 kg baby 33w GA

requiring 150 mlkgday = 375 ml

45 MIN CYCLES ( 32 cyclesday)

12 ML PER CYCLE = 384 ml142

Newborn stomach volume

Gastric volumes at birthCorrelated with gastric pH

gastrin and somatostatin

ldquofetus drinks 10 ml portions of amniotic fluid helliprdquo

Widstrom 1988 143

Only recent study locatedldquoAutopsyrdquo capacity was determined

in Indian post-mortem studies

100 autopsies (63 SB 37 ENND)Tied at cardia and pylorus filled withwater emptied amp measured repeatedldquohellip obliteration of the gastric curvaturesrdquoldquodue care to minimize stretch artifactsrdquo

Naveed 1992

ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo

144

25

Infants above 2500g onlyAve Range

Stillborn (n 11) 196 ml (10-35)Early death (n 9) 178 ml (10-25)All cases (n 20) 188 ml

Naveed 1992

ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo

145 146

KERNESSUK 1997 (Russian)

Postmortem in situ measures(applied Bradshaw formula)

AveNewborn (n 11) 15 ml2 months (n 11) 35 ml2-4 m (n 10) 50 ml4-6 m (n 8) 100 ml

Known references with data

Scammon and Doyle 1920

Zuccarellirsquos method stomach filled at autopsy to ldquoa pressure of between

15 and 20 centimeters of waterrdquo

Scammon 1920

ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo

147

Anatomic capacity was determined in post-mortem studies

Main data set Alliot 1905 (n 25)Scammon own cases (n 13)

30 ndash 35 ml at birth ndashalmost regardless of birth weight

Scammon 1920

ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo

148

Zangen S et al Rapid maturation of gastric relaxation in newborns

Pressures (mmHg)

Balloon inflates to

15 ml no increase

functional capacity

149

Zangen S et al Rapid maturation of gastric relaxation in newborns

Pressures (mmHg)

Balloon inflates to

15 ml no increase20 ml pressure OK

physiologicalcapacity hellip 150

26

EVIDENCE (NBn 111009)

Author Capacity NoteSase 10-15 ml Live term fetusGoldstein 10-15 ml Live term fetusWidstrom 10 mls Live newbornZangen 20 mls Live (pressure)

Naveed 20 mls Autopsy (SB)20 mls Autopsy (ENND)

Kernessuk 15 mls Autopsy (in situ)Scammon 30-35 ml Autopsy (water

(Alliot) pressure)151

PROPOSAL

The CAPACITY of aweek old babyrsquos stomach is

approx 20 ml152

0

05

1

15

2

25

3

35

4

0 10 20 30 40 50 60 70 80

volume ingested

fee

din

g f

req

ue

nc

y

Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml

StandardCARE3 hourlyschedule

MOTHERNATURE

1 hourlyschedule

153

PHYSIOLOGICAL CAPACITY

RECEPTIVE CAPACITY of stomach

INGESTIVE CAPACITY of BABY

FUNCTIONAL CAPACITY

154

PROPOSAL

The FEEDINGFREQUENCY of theNEONATE is

approx 60 min155

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

BRAIN CYCLING

STOMACH FILLING amp EMPTYING

REMNR1NR2NR3NR4

156

27

Normal physiology of theEnteric Nervous System

ldquoSmall and frequent feeds according to the sleep cyclerdquo

The ldquonicherdquo (occupation) of a neonate (Alberts)

BOND FEED

SLEEP SLEEP

PLAY FEED

157

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

FEEDING SUCKLING

Influence of SMELL None Totally dependent

Motor mechanism Chewing ndash different

muscles

Suckling ndash different circuits

INSULIN Increases weight No effect

GHRELIN Increases weight No effect

LEPTIN Decreases intake No effect

CHOLECYSTOKININ Decreases intake No effect

AMPHETAMINE Decreases appetite Increases suckling

SEROTONIN Agonist improves feeding Antagonist improves suck

SATIETY Infant determined Maternal supply determine

FEEDING SUCKLING

Influence of SMELL None Totally dependent

Motor mechanism Chewing ndash different

muscles

Suckling ndash different circuits

INSULIN Increases weight No effect

GHRELIN Increases weight No effect

LEPTIN Decreases intake No effect

CHOLECYSTOKININ Decreases intake No effect

AMPHETAMINE Decreases appetite Increases suckling

SEROTONIN Agonist improves feeding Antagonist improves suck

SATIETY Infant determined Maternal supply determine

Current dogmaTHE BABY KNOWS

WHEN IT HAS HAD ENOUGH

PROBABLY NOT

WHAT IS THE

STOMACH VOLUME OF THE

PREMATURE

161

Assume low resilience

Assume proportionality

162

28

The CAPACITY of alow birthweight premfrom 20ml 3000g

= 0007 x BWt (g)

1kg x 0007 = 7mls2kg x 0007 = 14mls

163

Gastric overfilling syndrome

164

75 ml per feeding ASSUMPTION

IMMATURE OR OVERWHELMED

many aspects of gastrointestinalmotility are immature in the neonate

Zangen S et al Rapid maturation of gastric relaxation in newborns

A balloon in stomachcan fill to 76 mls

What does the stomach ndashwithout a balloon ndashdo to 76 mls

REFLUX PRESUME each feedapproximately 75 mls

GER

bull Sudden outbursts of crying

bull Awakens in pain

bull Related to feedings

bull Not easily comforted

bull ldquoI know baby hurtsrdquo

bull Sour burps throaty noises

bull Best when upright

Clues to GER

Dr W Sears

29

Mitchell 2001

Kerstin Uvnaumls-Moberg

Food in duodenum

AMYLINreleased

Closes pylorus

Duodenumempty

Pylorusopens

ldquoFeed intolerancerdquo hellip hellip or VOLUME intolerance

HYPOGLYCAEMIA

A babies stomach empties in60 minutes

Blood sugarmay fall hellip

after 90 minutes Options

30

METABOLIC ADAPTATION

SSC started in the first 20 minutes after birth

SSC CotBlood glucose (1 hr) 317 256Base excess drop 34 18

(Christenson 1992)0h 1h 2h 3h 4h 2 days

App

roxim

ate

GLUCOSE

SSC Glucose production = Glucose consumption

Separation

SNS stress Glucose consumption INCREASE

PSNS dissociation Glucose production DECREASE

HYPOGLYCEMIA

SSC Cot

Blood glucose (1 hr) 317 256

0h 1h 2h 3h 4h 2 days

App

roxim

ate

GLUCOSE

SSC Glucose production = Glucose consumption

Separation PSNS dissociation

Glucose production DECREASE

HYPOGLYCEMIA

SSC Cot

Blood glucose (1 hr) 317 256

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

NEURODEVELOPMENTThe DNA Behaviour

EVOLUTIONARY BIOLOGY

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

BONDING ATTACHMENT

MRI HRVEEG

STRESS RESPONES

RESILIENCE

DOHAD

(MAL) ADAPTATION

EPIGENETICS

GENE X ENVIRONMENT

GENETIC VARIANTS

HOSPITAL ACQUIRED INFECTIONIMMUNITY

SLEEP PHYSIOLOGY

GUT FUNCTIONMICROBIOTA

ldquoSTABILITYrdquo

TRANSITION

LONG TERM FOLLOW-UP

NEUROENDOCRINE BEHAVIOURS

MATERNAL NEUROPLASTICITY

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

MORTALITYMETABOLISM

0h 1h 2h 3h 4h

PSNS (vagal)

App

roxim

ate

GLUCOSE

1 HOURLY Milk feed

1 HOURLY Milk feed

1 HOURLY Milk feed

1 HOURLY Milk feed

LACTOSE

METABOLISM

31

0h 1h 2h 3h 4h

PSNS (vagal) SYMPATHETIC STRESS

App

roxim

ate

GLUCOSE

LACTOSE FATGLYCOGEN

METABOLISM

4 HOURLY Milk feed

0h 1h 2h 3h 4h

PSNS (vagal) SYMPATHETIC STRESS

App

roxim

ate

GLUCOSE

4 HOURLY ALLOSTATIC STATELACTOSE FATGLYCOGEN

METABOLISM

4 HOURLY Milk feed

HEALTH DISEASE

EXPECTED UNEXPECTED

NEURODEVELOPMENTThe DNA Behaviour

EVOLUTIONARY BIOLOGY

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

BONDING ATTACHMENT

MRI HRVEEG

STRESS RESPONES

RESILIENCE

DOHAD

(MAL) ADAPTATION

EPIGENETICS

GENE X ENVIRONMENT

GENETIC VARIANTS

HOSPITAL ACQUIRED INFECTIONIMMUNITY

SLEEP PHYSIOLOGY

GUT FUNCTIONMICROBIOTA

ldquoSTABILITYrdquo

TRANSITION

LONG TERM FOLLOW-UP

NEUROENDOCRINE BEHAVIOURS

MATERNAL NEUROPLASTICITY

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

MORTALITYMETABOLISM

Weight gain 1st week

predicts OBESITYat 30 years

Large volume feedsstretched stomach=

doubled absorptivecapacity as adult

Importance

Programming ndash early life chronic disease

32

RESISTANCE SENSITIVITY

PERCEPTIONSldquoNEUROCEPTIONrdquo

RESPONSESTRESS

ALLOSTATIC STATE

ALLOSTASIS

ANY STRESSPsychologicalNeurological

EndocrineImmune

ALLOSTATIC LOAD

ALLOSTATIC OVERLOAD

WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY

DISEASEHEALTH

RESILIENCE VULNERABILITY

RESISTANCE SENSITIVITY

PERCEPTIONSldquoNEUROCEPTIONrdquo

RESPONSESTRESS

ALLOSTATIC STATE

ALLOSTASIS

ANY STRESSPsychologicalNeurological

EndocrineImmune

ALLOSTATIC LOAD

HEALTH

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

Gastric overfilling syndrome

189

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

33

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

Only case series Insufficient evidence

No mention of

stomach capacity196

Baby weight freq reqrsquod size actual

2kg baby 4hrly ~ 320 ml6 = 53ml 14ml

15 baby 3hrly ~ 240 ml8 = 30ml 10ml

10 baby 2hrly ~ 160 ml12 = 13ml 7ml

Standardised from20ml capacityfor 3kg baby( x 0007)

197

0

10

20

30

40

50

60

70

80

90

13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w

LINEAR

TERM

PREM

198

34

0

10

20

30

40

50

60

70

80

90

13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w

LINEAR

TERM

PREM

199

Clues to GER

ldquoI know baby hurtsrdquo

Gastric overfilling syndrome

Excessive volumesreflux aspiration colic

Excessive time intervalhypoglycaemia

Adaptationsdiabetic diathesis obesity

200

Developmental Care of the Enteric Nervous System

ldquoSmall and frequent feeds according to the sleep cyclerdquo

The ldquonicherdquo (occupation) of a neonate (Alberts)

BOND FEED

SLEEP SLEEP

PLAY FEED

201

Gastric overfilling syndrome

Proposed Management 202

Proposed Management

Babies should be fedEVERY TIME THEY WAKE

Stanley Graven 2006

REMNR1NR2NR3SWS

AS (20 mins) QS (40 mins)

A normal sleep cycle is ONE hourHow often should neonates feed

203

Proposed Management

All babies should be fedat least once an hour 204

35

Proposed Management

All babies should be fedat least once an hour

205

The first Milk Ejection Reflex (MER)

elicited in lt 2 minutesworks quicklyswallowed 1 minute

Feeding time (max)3 minutes

Repeat every 1 hour

Prime 2007

The ldquonormalrdquo or usual and common breastfeed

takes 15 minutesdiscomfort afterburping time 5 minutes

Feeding time 20 min

Repeat every 3 hours

Prime 2007

3 minute 20ml feeds x 24d = 72 minutes

20 minute 60ml feeds x 8d = 160 minutes

SMALL AND FREQUENT FEEDS ARE EFFICIENT

FEWER NURSES NEEDED

The calculated dailyrequirement for a 3kgbaby can be given without increase inpressure MINIMAL RISK

PARENTS CAN DOSAFELY

20 mls x 24 feeds= 480mls day

Zangen 2001 209

All babies should be fedat least once an hour

210

36

Infant feeding frequencyProposal based on available evidence and neuroscience

ldquoSmall and frequent feeds

adjusted to the sleep cyclerdquo

211

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

STATE organization

Feeding frequency

SLEEP cycling

BRAIN

WIRING

How often should a neonate feeda neonate sleep

Infantsleep cycles

begin to block on diurnalrhythms

Mother-infant synchrony

hellip at 12 weeks

(circadian)

START at 3 months

Can be ldquoadult-likerdquo

at 6 months

Thomas 2014

STATE organization

Feeding frequency

SLEEP cycling

PLAY FEED

216

SLEEP SLEEP

SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

Infantsleep cycles

begin to block on diurnalrhythms

37

BOND SUCKLE SLEEP SLEEP PLAY

FEED

217

SLEEP SLEEP SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)

Schaal 2004 218

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)rdquoSLEEP-FEED CYCLINGrdquo

Schaal 2004 219

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

WIRE

BRAIN

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

BRAIN

WIRING

NEUROSCIENCE

The DNAEverything else

EVOLUTIONARYBIOLOGY

The Brain

EPIGENETICS

The PlaceENVIRONMENT

EXPERIENCEFITNESS ADAPTATION

ldquoScientific foundationrdquo hellip a synthesis

ZERO

SEPARATION

38

wwwninobirthorgwwwskintoskincontactcom

THE NEUROSCIENCE OFSKIN-TO-SKIN CONTACT

AND BREASTFEEDING

ARE THE SAME

SUMMARY SKIN-TO-SKIN

(Regulation)

SLEEP(Brain)

FEEDING(Stomach)

LOVE ( ldquomindrdquo )

REMNR1NR2NR3NR4

ACQUISITION CONSOLIDATION MEMORYFORMATION

poly-sensory input transfer information P wavesshort-term memory ldquoSNRrdquo strong signals returns infostored cortex amygdala to neocortex

hippocampus organizedAwake and REM NREM stage 4 REM

BRAIN WIRING

Stanley Graven 2006

PLAY

SLEEP

FEEDHOLDYOURPREM

httpswwwfacebookcomninobirth

39

Nelson Mandela

hellip in describing themeasure of a nation

he has argued that

ldquoThere can be no keener revelation of a societyrsquos soul than the way in which it treats its childrenrdquo

Page 18: Neurodevelopmental The Neuroscience of Birth ... · breastfeeding pattern, neonatal weight gain, and the dynamics of lactation. Doucet 2012 In the ‘‘scentless breast’’ condition,

18

Be sure the wet nurse has plenty of milk because if she lacks it she may give the babymilk of a goat or sheep or some other animalbecause the child nourished on animal milkdoes not have perfect wits like one fed on womanrsquos milk and always looks stupid and vacant and not right in the head

14th century Tuscan text

Conceptual changeDyad careBreast first hour

even CaesareanContinuous SSC

DISCONTINUEGiving waterGlucose waterInfant formulaSeparationPacifier (dummy)

CHANGE POLICY Canrsquot change

biology

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

ON-GOING

S S C

WIRE NEURONS

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C WIRE

TIMING

(behavior)

19

Not so much duration

or density of any sleep stage

or number of sleep stage episodes but

cycling between quiet sleep

and active sleepis what is important

REMREM REM

NREM NREM

This is a healthy sleep pattern

This is a very good cycling pattern

(thanks to Susan Ludington-Hoe)

REMREM REM

NREM NREM

1st hour 2nd hour

So in every hour you would like

to see an EEG pattern that shows this

REM

NREM

REM

NREM

REM

NREM

State

HR

RR

REM Sleep is supposed to be

somewhat active so

HR increases and RR is irregular

SLEEP CYCLING ndashSeparation vs contact

In separation bull Dissociated statebull No cycling chaotic pattern

48 hour baseline chaotic pattern of

activity and quiet HR amp RR

SLEEP CYCLING ndashSeparation vs contact

In SSC bull Normal cyclingbull Non-chaotic pattern

48 hour baseline chaotic pattern of

activity and quiet HR amp RRPre-KC SSC

20

modulates state organisationelicits emotional behavioursactivates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL

Schaal 2004 115

DOUCETThe secretion of Areolar (Montgomeryrsquos) Glands from Lactating Women Elicits Selective Unconditional Responses in Neonates

ldquohellip breast chemosignalsactivate oral activity on the nipple that releases a cascade of behavioral neural neuroendocrineand endocrine processes in the newborn and the motherrdquo

Doucet 2009 116

The secretion of Areolar(Montgomeryrsquos) Glands

ldquoIn early ontogeny the sleeping brain may thusremain sentient of an organismrsquos odor environmentrdquo

Doucet 2009 117

REM

NREM

A skin-to-skin contactsession SHOULD NOT be less than one hour

or 90 minutes

SLEEPING

amp

CONTAINING

FEEDING ampHANDLINGfeed

sleep

HO

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C WIRE

TIMING

(behavior)

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C WIRE

STOMACH

21

STATE organization

Feeding frequency

SLEEP cycling

BRAIN

WIRING

How often should a neonate feed

CNS

ENS

ANS

InternalSomaticenvironment

CNS cortical subcortical(also to PNS)

ANS emotional limbic brain(incl SNS)

ANS myelinated vagus (NA)

ANS unmyelinated vagus (DMC)sub-diaphragmatic

ENS submucous plexusmyenteric plexus

122

The digestive system is endowed with its own local nervous system referred to as the enteric or intrinsic nervous system

The magnitude and complexity of the enteric nervous system is immense - it contains as many neurons as the spinal cord

ENTERIC NERVOUS SYSTEM

123

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

FEEDBACK LOOPS

CNS

ENS

ANS

InternalSomaticenvironment

124

125 126

22

Fetal stomach appears 4 weeks GABy 11 weeks wall capable of muscular

contraction

ldquoPatterns of antropyloric motilityin fed healthy preterm infantsrdquo

the neuroregulatory mechanisms responsible for the coordination of antro-pyloric motility and gastric emptying are

well developed by 30 weeks of PMAHassan 2002 127

Hydrochloric acidimportant for activation of pepsinogen

inactivation of microorganisms such as bacteria

Pepsinogenactivated by acid into active pepsin

responsible for the stomachs ability to initiate digestion of proteins

Chymosinis an enzyme whose role is to curdle or

coagulate milk in the stomach a process of considerable importance in the very young animal

128

Chymosinmakes the milk into ldquocheeserdquohalfway between liquid and solidstomach empties in 60 minutes

milk

129

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

FEEDBACK LOOPS

130

EVIDENCE FORFEEDING FREQUENCY

Edmond 2006 131

Breastfeeding and motherrsquos milkStrong and consistent evidence 132

23

Cup feeding versus bottle feedingCup feeding higher breastfeeding

greater stability133

Only case series Insufficient evidence

No mention of

stomach capacity134

EVIDENCE FORSTOMACH CAPACITY

Edmond 2006 135

0

05

1

15

2

25

3

35

4

0 10 20 30 40 50 60 70 80

volume ingested

fee

din

g f

req

ue

nc

y

Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml

StandardCARE3 hourlyschedule

136

KEY QUESTION

WHAT IS THE

STOMACHVOLUMEOF THE

NEONATE 137 Sase 2005

ldquoOntogeny of gastric emptying patternsin the human fetusrdquo

138

24

Goldstein 1987

ldquoGrowth of the Fetal Stomach in Normal Pregnanciesrdquo

139 Goldstein 1987

Length

Transverse

AP diameter

Using +2SD

140

Formula for calculation of stomach capacity (Charles Bradshaw UCT)Assumptions the stomach can be approximated by dividing into three sections namely a ellipsoidal hemisphere an ellipsoidal cylinder and a skewed ellipsoidal cone Variables a = anteroposterior radius t = transverse radius l = length stomachRelations the height of the cone and the hemisphere are both the same as lsquoarsquo

Ellipsoid = 43 Pi r1r2r3 = 43 Pi a a t therefore volume of hemisphere = 23 Pi a a t

Cylinder = Area of base height = (Pi a t ) ( l - 2a )Skewed cone = 13 base height = 13 Pi a t aTotal volume = 23 Pi aat + Pi a t (l- 2a) + 13 Pi a t a

=Pi atl -Pi a at= Pi a t(l-a)

Goldstein and Sase dataStomach capacity at term 10 - 15 ml

BRADSHAW formula

141

Assumption 25 kg baby 33w GA

requiring 150 mlkgday = 375 ml

45 MIN CYCLES ( 32 cyclesday)

12 ML PER CYCLE = 384 ml142

Newborn stomach volume

Gastric volumes at birthCorrelated with gastric pH

gastrin and somatostatin

ldquofetus drinks 10 ml portions of amniotic fluid helliprdquo

Widstrom 1988 143

Only recent study locatedldquoAutopsyrdquo capacity was determined

in Indian post-mortem studies

100 autopsies (63 SB 37 ENND)Tied at cardia and pylorus filled withwater emptied amp measured repeatedldquohellip obliteration of the gastric curvaturesrdquoldquodue care to minimize stretch artifactsrdquo

Naveed 1992

ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo

144

25

Infants above 2500g onlyAve Range

Stillborn (n 11) 196 ml (10-35)Early death (n 9) 178 ml (10-25)All cases (n 20) 188 ml

Naveed 1992

ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo

145 146

KERNESSUK 1997 (Russian)

Postmortem in situ measures(applied Bradshaw formula)

AveNewborn (n 11) 15 ml2 months (n 11) 35 ml2-4 m (n 10) 50 ml4-6 m (n 8) 100 ml

Known references with data

Scammon and Doyle 1920

Zuccarellirsquos method stomach filled at autopsy to ldquoa pressure of between

15 and 20 centimeters of waterrdquo

Scammon 1920

ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo

147

Anatomic capacity was determined in post-mortem studies

Main data set Alliot 1905 (n 25)Scammon own cases (n 13)

30 ndash 35 ml at birth ndashalmost regardless of birth weight

Scammon 1920

ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo

148

Zangen S et al Rapid maturation of gastric relaxation in newborns

Pressures (mmHg)

Balloon inflates to

15 ml no increase

functional capacity

149

Zangen S et al Rapid maturation of gastric relaxation in newborns

Pressures (mmHg)

Balloon inflates to

15 ml no increase20 ml pressure OK

physiologicalcapacity hellip 150

26

EVIDENCE (NBn 111009)

Author Capacity NoteSase 10-15 ml Live term fetusGoldstein 10-15 ml Live term fetusWidstrom 10 mls Live newbornZangen 20 mls Live (pressure)

Naveed 20 mls Autopsy (SB)20 mls Autopsy (ENND)

Kernessuk 15 mls Autopsy (in situ)Scammon 30-35 ml Autopsy (water

(Alliot) pressure)151

PROPOSAL

The CAPACITY of aweek old babyrsquos stomach is

approx 20 ml152

0

05

1

15

2

25

3

35

4

0 10 20 30 40 50 60 70 80

volume ingested

fee

din

g f

req

ue

nc

y

Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml

StandardCARE3 hourlyschedule

MOTHERNATURE

1 hourlyschedule

153

PHYSIOLOGICAL CAPACITY

RECEPTIVE CAPACITY of stomach

INGESTIVE CAPACITY of BABY

FUNCTIONAL CAPACITY

154

PROPOSAL

The FEEDINGFREQUENCY of theNEONATE is

approx 60 min155

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

BRAIN CYCLING

STOMACH FILLING amp EMPTYING

REMNR1NR2NR3NR4

156

27

Normal physiology of theEnteric Nervous System

ldquoSmall and frequent feeds according to the sleep cyclerdquo

The ldquonicherdquo (occupation) of a neonate (Alberts)

BOND FEED

SLEEP SLEEP

PLAY FEED

157

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

FEEDING SUCKLING

Influence of SMELL None Totally dependent

Motor mechanism Chewing ndash different

muscles

Suckling ndash different circuits

INSULIN Increases weight No effect

GHRELIN Increases weight No effect

LEPTIN Decreases intake No effect

CHOLECYSTOKININ Decreases intake No effect

AMPHETAMINE Decreases appetite Increases suckling

SEROTONIN Agonist improves feeding Antagonist improves suck

SATIETY Infant determined Maternal supply determine

FEEDING SUCKLING

Influence of SMELL None Totally dependent

Motor mechanism Chewing ndash different

muscles

Suckling ndash different circuits

INSULIN Increases weight No effect

GHRELIN Increases weight No effect

LEPTIN Decreases intake No effect

CHOLECYSTOKININ Decreases intake No effect

AMPHETAMINE Decreases appetite Increases suckling

SEROTONIN Agonist improves feeding Antagonist improves suck

SATIETY Infant determined Maternal supply determine

Current dogmaTHE BABY KNOWS

WHEN IT HAS HAD ENOUGH

PROBABLY NOT

WHAT IS THE

STOMACH VOLUME OF THE

PREMATURE

161

Assume low resilience

Assume proportionality

162

28

The CAPACITY of alow birthweight premfrom 20ml 3000g

= 0007 x BWt (g)

1kg x 0007 = 7mls2kg x 0007 = 14mls

163

Gastric overfilling syndrome

164

75 ml per feeding ASSUMPTION

IMMATURE OR OVERWHELMED

many aspects of gastrointestinalmotility are immature in the neonate

Zangen S et al Rapid maturation of gastric relaxation in newborns

A balloon in stomachcan fill to 76 mls

What does the stomach ndashwithout a balloon ndashdo to 76 mls

REFLUX PRESUME each feedapproximately 75 mls

GER

bull Sudden outbursts of crying

bull Awakens in pain

bull Related to feedings

bull Not easily comforted

bull ldquoI know baby hurtsrdquo

bull Sour burps throaty noises

bull Best when upright

Clues to GER

Dr W Sears

29

Mitchell 2001

Kerstin Uvnaumls-Moberg

Food in duodenum

AMYLINreleased

Closes pylorus

Duodenumempty

Pylorusopens

ldquoFeed intolerancerdquo hellip hellip or VOLUME intolerance

HYPOGLYCAEMIA

A babies stomach empties in60 minutes

Blood sugarmay fall hellip

after 90 minutes Options

30

METABOLIC ADAPTATION

SSC started in the first 20 minutes after birth

SSC CotBlood glucose (1 hr) 317 256Base excess drop 34 18

(Christenson 1992)0h 1h 2h 3h 4h 2 days

App

roxim

ate

GLUCOSE

SSC Glucose production = Glucose consumption

Separation

SNS stress Glucose consumption INCREASE

PSNS dissociation Glucose production DECREASE

HYPOGLYCEMIA

SSC Cot

Blood glucose (1 hr) 317 256

0h 1h 2h 3h 4h 2 days

App

roxim

ate

GLUCOSE

SSC Glucose production = Glucose consumption

Separation PSNS dissociation

Glucose production DECREASE

HYPOGLYCEMIA

SSC Cot

Blood glucose (1 hr) 317 256

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

NEURODEVELOPMENTThe DNA Behaviour

EVOLUTIONARY BIOLOGY

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

BONDING ATTACHMENT

MRI HRVEEG

STRESS RESPONES

RESILIENCE

DOHAD

(MAL) ADAPTATION

EPIGENETICS

GENE X ENVIRONMENT

GENETIC VARIANTS

HOSPITAL ACQUIRED INFECTIONIMMUNITY

SLEEP PHYSIOLOGY

GUT FUNCTIONMICROBIOTA

ldquoSTABILITYrdquo

TRANSITION

LONG TERM FOLLOW-UP

NEUROENDOCRINE BEHAVIOURS

MATERNAL NEUROPLASTICITY

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

MORTALITYMETABOLISM

0h 1h 2h 3h 4h

PSNS (vagal)

App

roxim

ate

GLUCOSE

1 HOURLY Milk feed

1 HOURLY Milk feed

1 HOURLY Milk feed

1 HOURLY Milk feed

LACTOSE

METABOLISM

31

0h 1h 2h 3h 4h

PSNS (vagal) SYMPATHETIC STRESS

App

roxim

ate

GLUCOSE

LACTOSE FATGLYCOGEN

METABOLISM

4 HOURLY Milk feed

0h 1h 2h 3h 4h

PSNS (vagal) SYMPATHETIC STRESS

App

roxim

ate

GLUCOSE

4 HOURLY ALLOSTATIC STATELACTOSE FATGLYCOGEN

METABOLISM

4 HOURLY Milk feed

HEALTH DISEASE

EXPECTED UNEXPECTED

NEURODEVELOPMENTThe DNA Behaviour

EVOLUTIONARY BIOLOGY

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

BONDING ATTACHMENT

MRI HRVEEG

STRESS RESPONES

RESILIENCE

DOHAD

(MAL) ADAPTATION

EPIGENETICS

GENE X ENVIRONMENT

GENETIC VARIANTS

HOSPITAL ACQUIRED INFECTIONIMMUNITY

SLEEP PHYSIOLOGY

GUT FUNCTIONMICROBIOTA

ldquoSTABILITYrdquo

TRANSITION

LONG TERM FOLLOW-UP

NEUROENDOCRINE BEHAVIOURS

MATERNAL NEUROPLASTICITY

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

MORTALITYMETABOLISM

Weight gain 1st week

predicts OBESITYat 30 years

Large volume feedsstretched stomach=

doubled absorptivecapacity as adult

Importance

Programming ndash early life chronic disease

32

RESISTANCE SENSITIVITY

PERCEPTIONSldquoNEUROCEPTIONrdquo

RESPONSESTRESS

ALLOSTATIC STATE

ALLOSTASIS

ANY STRESSPsychologicalNeurological

EndocrineImmune

ALLOSTATIC LOAD

ALLOSTATIC OVERLOAD

WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY

DISEASEHEALTH

RESILIENCE VULNERABILITY

RESISTANCE SENSITIVITY

PERCEPTIONSldquoNEUROCEPTIONrdquo

RESPONSESTRESS

ALLOSTATIC STATE

ALLOSTASIS

ANY STRESSPsychologicalNeurological

EndocrineImmune

ALLOSTATIC LOAD

HEALTH

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

Gastric overfilling syndrome

189

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

33

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

Only case series Insufficient evidence

No mention of

stomach capacity196

Baby weight freq reqrsquod size actual

2kg baby 4hrly ~ 320 ml6 = 53ml 14ml

15 baby 3hrly ~ 240 ml8 = 30ml 10ml

10 baby 2hrly ~ 160 ml12 = 13ml 7ml

Standardised from20ml capacityfor 3kg baby( x 0007)

197

0

10

20

30

40

50

60

70

80

90

13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w

LINEAR

TERM

PREM

198

34

0

10

20

30

40

50

60

70

80

90

13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w

LINEAR

TERM

PREM

199

Clues to GER

ldquoI know baby hurtsrdquo

Gastric overfilling syndrome

Excessive volumesreflux aspiration colic

Excessive time intervalhypoglycaemia

Adaptationsdiabetic diathesis obesity

200

Developmental Care of the Enteric Nervous System

ldquoSmall and frequent feeds according to the sleep cyclerdquo

The ldquonicherdquo (occupation) of a neonate (Alberts)

BOND FEED

SLEEP SLEEP

PLAY FEED

201

Gastric overfilling syndrome

Proposed Management 202

Proposed Management

Babies should be fedEVERY TIME THEY WAKE

Stanley Graven 2006

REMNR1NR2NR3SWS

AS (20 mins) QS (40 mins)

A normal sleep cycle is ONE hourHow often should neonates feed

203

Proposed Management

All babies should be fedat least once an hour 204

35

Proposed Management

All babies should be fedat least once an hour

205

The first Milk Ejection Reflex (MER)

elicited in lt 2 minutesworks quicklyswallowed 1 minute

Feeding time (max)3 minutes

Repeat every 1 hour

Prime 2007

The ldquonormalrdquo or usual and common breastfeed

takes 15 minutesdiscomfort afterburping time 5 minutes

Feeding time 20 min

Repeat every 3 hours

Prime 2007

3 minute 20ml feeds x 24d = 72 minutes

20 minute 60ml feeds x 8d = 160 minutes

SMALL AND FREQUENT FEEDS ARE EFFICIENT

FEWER NURSES NEEDED

The calculated dailyrequirement for a 3kgbaby can be given without increase inpressure MINIMAL RISK

PARENTS CAN DOSAFELY

20 mls x 24 feeds= 480mls day

Zangen 2001 209

All babies should be fedat least once an hour

210

36

Infant feeding frequencyProposal based on available evidence and neuroscience

ldquoSmall and frequent feeds

adjusted to the sleep cyclerdquo

211

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

STATE organization

Feeding frequency

SLEEP cycling

BRAIN

WIRING

How often should a neonate feeda neonate sleep

Infantsleep cycles

begin to block on diurnalrhythms

Mother-infant synchrony

hellip at 12 weeks

(circadian)

START at 3 months

Can be ldquoadult-likerdquo

at 6 months

Thomas 2014

STATE organization

Feeding frequency

SLEEP cycling

PLAY FEED

216

SLEEP SLEEP

SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

Infantsleep cycles

begin to block on diurnalrhythms

37

BOND SUCKLE SLEEP SLEEP PLAY

FEED

217

SLEEP SLEEP SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)

Schaal 2004 218

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)rdquoSLEEP-FEED CYCLINGrdquo

Schaal 2004 219

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

WIRE

BRAIN

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

BRAIN

WIRING

NEUROSCIENCE

The DNAEverything else

EVOLUTIONARYBIOLOGY

The Brain

EPIGENETICS

The PlaceENVIRONMENT

EXPERIENCEFITNESS ADAPTATION

ldquoScientific foundationrdquo hellip a synthesis

ZERO

SEPARATION

38

wwwninobirthorgwwwskintoskincontactcom

THE NEUROSCIENCE OFSKIN-TO-SKIN CONTACT

AND BREASTFEEDING

ARE THE SAME

SUMMARY SKIN-TO-SKIN

(Regulation)

SLEEP(Brain)

FEEDING(Stomach)

LOVE ( ldquomindrdquo )

REMNR1NR2NR3NR4

ACQUISITION CONSOLIDATION MEMORYFORMATION

poly-sensory input transfer information P wavesshort-term memory ldquoSNRrdquo strong signals returns infostored cortex amygdala to neocortex

hippocampus organizedAwake and REM NREM stage 4 REM

BRAIN WIRING

Stanley Graven 2006

PLAY

SLEEP

FEEDHOLDYOURPREM

httpswwwfacebookcomninobirth

39

Nelson Mandela

hellip in describing themeasure of a nation

he has argued that

ldquoThere can be no keener revelation of a societyrsquos soul than the way in which it treats its childrenrdquo

Page 19: Neurodevelopmental The Neuroscience of Birth ... · breastfeeding pattern, neonatal weight gain, and the dynamics of lactation. Doucet 2012 In the ‘‘scentless breast’’ condition,

19

Not so much duration

or density of any sleep stage

or number of sleep stage episodes but

cycling between quiet sleep

and active sleepis what is important

REMREM REM

NREM NREM

This is a healthy sleep pattern

This is a very good cycling pattern

(thanks to Susan Ludington-Hoe)

REMREM REM

NREM NREM

1st hour 2nd hour

So in every hour you would like

to see an EEG pattern that shows this

REM

NREM

REM

NREM

REM

NREM

State

HR

RR

REM Sleep is supposed to be

somewhat active so

HR increases and RR is irregular

SLEEP CYCLING ndashSeparation vs contact

In separation bull Dissociated statebull No cycling chaotic pattern

48 hour baseline chaotic pattern of

activity and quiet HR amp RR

SLEEP CYCLING ndashSeparation vs contact

In SSC bull Normal cyclingbull Non-chaotic pattern

48 hour baseline chaotic pattern of

activity and quiet HR amp RRPre-KC SSC

20

modulates state organisationelicits emotional behavioursactivates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL

Schaal 2004 115

DOUCETThe secretion of Areolar (Montgomeryrsquos) Glands from Lactating Women Elicits Selective Unconditional Responses in Neonates

ldquohellip breast chemosignalsactivate oral activity on the nipple that releases a cascade of behavioral neural neuroendocrineand endocrine processes in the newborn and the motherrdquo

Doucet 2009 116

The secretion of Areolar(Montgomeryrsquos) Glands

ldquoIn early ontogeny the sleeping brain may thusremain sentient of an organismrsquos odor environmentrdquo

Doucet 2009 117

REM

NREM

A skin-to-skin contactsession SHOULD NOT be less than one hour

or 90 minutes

SLEEPING

amp

CONTAINING

FEEDING ampHANDLINGfeed

sleep

HO

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C WIRE

TIMING

(behavior)

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C WIRE

STOMACH

21

STATE organization

Feeding frequency

SLEEP cycling

BRAIN

WIRING

How often should a neonate feed

CNS

ENS

ANS

InternalSomaticenvironment

CNS cortical subcortical(also to PNS)

ANS emotional limbic brain(incl SNS)

ANS myelinated vagus (NA)

ANS unmyelinated vagus (DMC)sub-diaphragmatic

ENS submucous plexusmyenteric plexus

122

The digestive system is endowed with its own local nervous system referred to as the enteric or intrinsic nervous system

The magnitude and complexity of the enteric nervous system is immense - it contains as many neurons as the spinal cord

ENTERIC NERVOUS SYSTEM

123

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

FEEDBACK LOOPS

CNS

ENS

ANS

InternalSomaticenvironment

124

125 126

22

Fetal stomach appears 4 weeks GABy 11 weeks wall capable of muscular

contraction

ldquoPatterns of antropyloric motilityin fed healthy preterm infantsrdquo

the neuroregulatory mechanisms responsible for the coordination of antro-pyloric motility and gastric emptying are

well developed by 30 weeks of PMAHassan 2002 127

Hydrochloric acidimportant for activation of pepsinogen

inactivation of microorganisms such as bacteria

Pepsinogenactivated by acid into active pepsin

responsible for the stomachs ability to initiate digestion of proteins

Chymosinis an enzyme whose role is to curdle or

coagulate milk in the stomach a process of considerable importance in the very young animal

128

Chymosinmakes the milk into ldquocheeserdquohalfway between liquid and solidstomach empties in 60 minutes

milk

129

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

FEEDBACK LOOPS

130

EVIDENCE FORFEEDING FREQUENCY

Edmond 2006 131

Breastfeeding and motherrsquos milkStrong and consistent evidence 132

23

Cup feeding versus bottle feedingCup feeding higher breastfeeding

greater stability133

Only case series Insufficient evidence

No mention of

stomach capacity134

EVIDENCE FORSTOMACH CAPACITY

Edmond 2006 135

0

05

1

15

2

25

3

35

4

0 10 20 30 40 50 60 70 80

volume ingested

fee

din

g f

req

ue

nc

y

Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml

StandardCARE3 hourlyschedule

136

KEY QUESTION

WHAT IS THE

STOMACHVOLUMEOF THE

NEONATE 137 Sase 2005

ldquoOntogeny of gastric emptying patternsin the human fetusrdquo

138

24

Goldstein 1987

ldquoGrowth of the Fetal Stomach in Normal Pregnanciesrdquo

139 Goldstein 1987

Length

Transverse

AP diameter

Using +2SD

140

Formula for calculation of stomach capacity (Charles Bradshaw UCT)Assumptions the stomach can be approximated by dividing into three sections namely a ellipsoidal hemisphere an ellipsoidal cylinder and a skewed ellipsoidal cone Variables a = anteroposterior radius t = transverse radius l = length stomachRelations the height of the cone and the hemisphere are both the same as lsquoarsquo

Ellipsoid = 43 Pi r1r2r3 = 43 Pi a a t therefore volume of hemisphere = 23 Pi a a t

Cylinder = Area of base height = (Pi a t ) ( l - 2a )Skewed cone = 13 base height = 13 Pi a t aTotal volume = 23 Pi aat + Pi a t (l- 2a) + 13 Pi a t a

=Pi atl -Pi a at= Pi a t(l-a)

Goldstein and Sase dataStomach capacity at term 10 - 15 ml

BRADSHAW formula

141

Assumption 25 kg baby 33w GA

requiring 150 mlkgday = 375 ml

45 MIN CYCLES ( 32 cyclesday)

12 ML PER CYCLE = 384 ml142

Newborn stomach volume

Gastric volumes at birthCorrelated with gastric pH

gastrin and somatostatin

ldquofetus drinks 10 ml portions of amniotic fluid helliprdquo

Widstrom 1988 143

Only recent study locatedldquoAutopsyrdquo capacity was determined

in Indian post-mortem studies

100 autopsies (63 SB 37 ENND)Tied at cardia and pylorus filled withwater emptied amp measured repeatedldquohellip obliteration of the gastric curvaturesrdquoldquodue care to minimize stretch artifactsrdquo

Naveed 1992

ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo

144

25

Infants above 2500g onlyAve Range

Stillborn (n 11) 196 ml (10-35)Early death (n 9) 178 ml (10-25)All cases (n 20) 188 ml

Naveed 1992

ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo

145 146

KERNESSUK 1997 (Russian)

Postmortem in situ measures(applied Bradshaw formula)

AveNewborn (n 11) 15 ml2 months (n 11) 35 ml2-4 m (n 10) 50 ml4-6 m (n 8) 100 ml

Known references with data

Scammon and Doyle 1920

Zuccarellirsquos method stomach filled at autopsy to ldquoa pressure of between

15 and 20 centimeters of waterrdquo

Scammon 1920

ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo

147

Anatomic capacity was determined in post-mortem studies

Main data set Alliot 1905 (n 25)Scammon own cases (n 13)

30 ndash 35 ml at birth ndashalmost regardless of birth weight

Scammon 1920

ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo

148

Zangen S et al Rapid maturation of gastric relaxation in newborns

Pressures (mmHg)

Balloon inflates to

15 ml no increase

functional capacity

149

Zangen S et al Rapid maturation of gastric relaxation in newborns

Pressures (mmHg)

Balloon inflates to

15 ml no increase20 ml pressure OK

physiologicalcapacity hellip 150

26

EVIDENCE (NBn 111009)

Author Capacity NoteSase 10-15 ml Live term fetusGoldstein 10-15 ml Live term fetusWidstrom 10 mls Live newbornZangen 20 mls Live (pressure)

Naveed 20 mls Autopsy (SB)20 mls Autopsy (ENND)

Kernessuk 15 mls Autopsy (in situ)Scammon 30-35 ml Autopsy (water

(Alliot) pressure)151

PROPOSAL

The CAPACITY of aweek old babyrsquos stomach is

approx 20 ml152

0

05

1

15

2

25

3

35

4

0 10 20 30 40 50 60 70 80

volume ingested

fee

din

g f

req

ue

nc

y

Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml

StandardCARE3 hourlyschedule

MOTHERNATURE

1 hourlyschedule

153

PHYSIOLOGICAL CAPACITY

RECEPTIVE CAPACITY of stomach

INGESTIVE CAPACITY of BABY

FUNCTIONAL CAPACITY

154

PROPOSAL

The FEEDINGFREQUENCY of theNEONATE is

approx 60 min155

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

BRAIN CYCLING

STOMACH FILLING amp EMPTYING

REMNR1NR2NR3NR4

156

27

Normal physiology of theEnteric Nervous System

ldquoSmall and frequent feeds according to the sleep cyclerdquo

The ldquonicherdquo (occupation) of a neonate (Alberts)

BOND FEED

SLEEP SLEEP

PLAY FEED

157

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

FEEDING SUCKLING

Influence of SMELL None Totally dependent

Motor mechanism Chewing ndash different

muscles

Suckling ndash different circuits

INSULIN Increases weight No effect

GHRELIN Increases weight No effect

LEPTIN Decreases intake No effect

CHOLECYSTOKININ Decreases intake No effect

AMPHETAMINE Decreases appetite Increases suckling

SEROTONIN Agonist improves feeding Antagonist improves suck

SATIETY Infant determined Maternal supply determine

FEEDING SUCKLING

Influence of SMELL None Totally dependent

Motor mechanism Chewing ndash different

muscles

Suckling ndash different circuits

INSULIN Increases weight No effect

GHRELIN Increases weight No effect

LEPTIN Decreases intake No effect

CHOLECYSTOKININ Decreases intake No effect

AMPHETAMINE Decreases appetite Increases suckling

SEROTONIN Agonist improves feeding Antagonist improves suck

SATIETY Infant determined Maternal supply determine

Current dogmaTHE BABY KNOWS

WHEN IT HAS HAD ENOUGH

PROBABLY NOT

WHAT IS THE

STOMACH VOLUME OF THE

PREMATURE

161

Assume low resilience

Assume proportionality

162

28

The CAPACITY of alow birthweight premfrom 20ml 3000g

= 0007 x BWt (g)

1kg x 0007 = 7mls2kg x 0007 = 14mls

163

Gastric overfilling syndrome

164

75 ml per feeding ASSUMPTION

IMMATURE OR OVERWHELMED

many aspects of gastrointestinalmotility are immature in the neonate

Zangen S et al Rapid maturation of gastric relaxation in newborns

A balloon in stomachcan fill to 76 mls

What does the stomach ndashwithout a balloon ndashdo to 76 mls

REFLUX PRESUME each feedapproximately 75 mls

GER

bull Sudden outbursts of crying

bull Awakens in pain

bull Related to feedings

bull Not easily comforted

bull ldquoI know baby hurtsrdquo

bull Sour burps throaty noises

bull Best when upright

Clues to GER

Dr W Sears

29

Mitchell 2001

Kerstin Uvnaumls-Moberg

Food in duodenum

AMYLINreleased

Closes pylorus

Duodenumempty

Pylorusopens

ldquoFeed intolerancerdquo hellip hellip or VOLUME intolerance

HYPOGLYCAEMIA

A babies stomach empties in60 minutes

Blood sugarmay fall hellip

after 90 minutes Options

30

METABOLIC ADAPTATION

SSC started in the first 20 minutes after birth

SSC CotBlood glucose (1 hr) 317 256Base excess drop 34 18

(Christenson 1992)0h 1h 2h 3h 4h 2 days

App

roxim

ate

GLUCOSE

SSC Glucose production = Glucose consumption

Separation

SNS stress Glucose consumption INCREASE

PSNS dissociation Glucose production DECREASE

HYPOGLYCEMIA

SSC Cot

Blood glucose (1 hr) 317 256

0h 1h 2h 3h 4h 2 days

App

roxim

ate

GLUCOSE

SSC Glucose production = Glucose consumption

Separation PSNS dissociation

Glucose production DECREASE

HYPOGLYCEMIA

SSC Cot

Blood glucose (1 hr) 317 256

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

NEURODEVELOPMENTThe DNA Behaviour

EVOLUTIONARY BIOLOGY

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

BONDING ATTACHMENT

MRI HRVEEG

STRESS RESPONES

RESILIENCE

DOHAD

(MAL) ADAPTATION

EPIGENETICS

GENE X ENVIRONMENT

GENETIC VARIANTS

HOSPITAL ACQUIRED INFECTIONIMMUNITY

SLEEP PHYSIOLOGY

GUT FUNCTIONMICROBIOTA

ldquoSTABILITYrdquo

TRANSITION

LONG TERM FOLLOW-UP

NEUROENDOCRINE BEHAVIOURS

MATERNAL NEUROPLASTICITY

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

MORTALITYMETABOLISM

0h 1h 2h 3h 4h

PSNS (vagal)

App

roxim

ate

GLUCOSE

1 HOURLY Milk feed

1 HOURLY Milk feed

1 HOURLY Milk feed

1 HOURLY Milk feed

LACTOSE

METABOLISM

31

0h 1h 2h 3h 4h

PSNS (vagal) SYMPATHETIC STRESS

App

roxim

ate

GLUCOSE

LACTOSE FATGLYCOGEN

METABOLISM

4 HOURLY Milk feed

0h 1h 2h 3h 4h

PSNS (vagal) SYMPATHETIC STRESS

App

roxim

ate

GLUCOSE

4 HOURLY ALLOSTATIC STATELACTOSE FATGLYCOGEN

METABOLISM

4 HOURLY Milk feed

HEALTH DISEASE

EXPECTED UNEXPECTED

NEURODEVELOPMENTThe DNA Behaviour

EVOLUTIONARY BIOLOGY

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

BONDING ATTACHMENT

MRI HRVEEG

STRESS RESPONES

RESILIENCE

DOHAD

(MAL) ADAPTATION

EPIGENETICS

GENE X ENVIRONMENT

GENETIC VARIANTS

HOSPITAL ACQUIRED INFECTIONIMMUNITY

SLEEP PHYSIOLOGY

GUT FUNCTIONMICROBIOTA

ldquoSTABILITYrdquo

TRANSITION

LONG TERM FOLLOW-UP

NEUROENDOCRINE BEHAVIOURS

MATERNAL NEUROPLASTICITY

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

MORTALITYMETABOLISM

Weight gain 1st week

predicts OBESITYat 30 years

Large volume feedsstretched stomach=

doubled absorptivecapacity as adult

Importance

Programming ndash early life chronic disease

32

RESISTANCE SENSITIVITY

PERCEPTIONSldquoNEUROCEPTIONrdquo

RESPONSESTRESS

ALLOSTATIC STATE

ALLOSTASIS

ANY STRESSPsychologicalNeurological

EndocrineImmune

ALLOSTATIC LOAD

ALLOSTATIC OVERLOAD

WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY

DISEASEHEALTH

RESILIENCE VULNERABILITY

RESISTANCE SENSITIVITY

PERCEPTIONSldquoNEUROCEPTIONrdquo

RESPONSESTRESS

ALLOSTATIC STATE

ALLOSTASIS

ANY STRESSPsychologicalNeurological

EndocrineImmune

ALLOSTATIC LOAD

HEALTH

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

Gastric overfilling syndrome

189

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

33

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

Only case series Insufficient evidence

No mention of

stomach capacity196

Baby weight freq reqrsquod size actual

2kg baby 4hrly ~ 320 ml6 = 53ml 14ml

15 baby 3hrly ~ 240 ml8 = 30ml 10ml

10 baby 2hrly ~ 160 ml12 = 13ml 7ml

Standardised from20ml capacityfor 3kg baby( x 0007)

197

0

10

20

30

40

50

60

70

80

90

13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w

LINEAR

TERM

PREM

198

34

0

10

20

30

40

50

60

70

80

90

13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w

LINEAR

TERM

PREM

199

Clues to GER

ldquoI know baby hurtsrdquo

Gastric overfilling syndrome

Excessive volumesreflux aspiration colic

Excessive time intervalhypoglycaemia

Adaptationsdiabetic diathesis obesity

200

Developmental Care of the Enteric Nervous System

ldquoSmall and frequent feeds according to the sleep cyclerdquo

The ldquonicherdquo (occupation) of a neonate (Alberts)

BOND FEED

SLEEP SLEEP

PLAY FEED

201

Gastric overfilling syndrome

Proposed Management 202

Proposed Management

Babies should be fedEVERY TIME THEY WAKE

Stanley Graven 2006

REMNR1NR2NR3SWS

AS (20 mins) QS (40 mins)

A normal sleep cycle is ONE hourHow often should neonates feed

203

Proposed Management

All babies should be fedat least once an hour 204

35

Proposed Management

All babies should be fedat least once an hour

205

The first Milk Ejection Reflex (MER)

elicited in lt 2 minutesworks quicklyswallowed 1 minute

Feeding time (max)3 minutes

Repeat every 1 hour

Prime 2007

The ldquonormalrdquo or usual and common breastfeed

takes 15 minutesdiscomfort afterburping time 5 minutes

Feeding time 20 min

Repeat every 3 hours

Prime 2007

3 minute 20ml feeds x 24d = 72 minutes

20 minute 60ml feeds x 8d = 160 minutes

SMALL AND FREQUENT FEEDS ARE EFFICIENT

FEWER NURSES NEEDED

The calculated dailyrequirement for a 3kgbaby can be given without increase inpressure MINIMAL RISK

PARENTS CAN DOSAFELY

20 mls x 24 feeds= 480mls day

Zangen 2001 209

All babies should be fedat least once an hour

210

36

Infant feeding frequencyProposal based on available evidence and neuroscience

ldquoSmall and frequent feeds

adjusted to the sleep cyclerdquo

211

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

STATE organization

Feeding frequency

SLEEP cycling

BRAIN

WIRING

How often should a neonate feeda neonate sleep

Infantsleep cycles

begin to block on diurnalrhythms

Mother-infant synchrony

hellip at 12 weeks

(circadian)

START at 3 months

Can be ldquoadult-likerdquo

at 6 months

Thomas 2014

STATE organization

Feeding frequency

SLEEP cycling

PLAY FEED

216

SLEEP SLEEP

SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

Infantsleep cycles

begin to block on diurnalrhythms

37

BOND SUCKLE SLEEP SLEEP PLAY

FEED

217

SLEEP SLEEP SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)

Schaal 2004 218

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)rdquoSLEEP-FEED CYCLINGrdquo

Schaal 2004 219

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

WIRE

BRAIN

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

BRAIN

WIRING

NEUROSCIENCE

The DNAEverything else

EVOLUTIONARYBIOLOGY

The Brain

EPIGENETICS

The PlaceENVIRONMENT

EXPERIENCEFITNESS ADAPTATION

ldquoScientific foundationrdquo hellip a synthesis

ZERO

SEPARATION

38

wwwninobirthorgwwwskintoskincontactcom

THE NEUROSCIENCE OFSKIN-TO-SKIN CONTACT

AND BREASTFEEDING

ARE THE SAME

SUMMARY SKIN-TO-SKIN

(Regulation)

SLEEP(Brain)

FEEDING(Stomach)

LOVE ( ldquomindrdquo )

REMNR1NR2NR3NR4

ACQUISITION CONSOLIDATION MEMORYFORMATION

poly-sensory input transfer information P wavesshort-term memory ldquoSNRrdquo strong signals returns infostored cortex amygdala to neocortex

hippocampus organizedAwake and REM NREM stage 4 REM

BRAIN WIRING

Stanley Graven 2006

PLAY

SLEEP

FEEDHOLDYOURPREM

httpswwwfacebookcomninobirth

39

Nelson Mandela

hellip in describing themeasure of a nation

he has argued that

ldquoThere can be no keener revelation of a societyrsquos soul than the way in which it treats its childrenrdquo

Page 20: Neurodevelopmental The Neuroscience of Birth ... · breastfeeding pattern, neonatal weight gain, and the dynamics of lactation. Doucet 2012 In the ‘‘scentless breast’’ condition,

20

modulates state organisationelicits emotional behavioursactivates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL

Schaal 2004 115

DOUCETThe secretion of Areolar (Montgomeryrsquos) Glands from Lactating Women Elicits Selective Unconditional Responses in Neonates

ldquohellip breast chemosignalsactivate oral activity on the nipple that releases a cascade of behavioral neural neuroendocrineand endocrine processes in the newborn and the motherrdquo

Doucet 2009 116

The secretion of Areolar(Montgomeryrsquos) Glands

ldquoIn early ontogeny the sleeping brain may thusremain sentient of an organismrsquos odor environmentrdquo

Doucet 2009 117

REM

NREM

A skin-to-skin contactsession SHOULD NOT be less than one hour

or 90 minutes

SLEEPING

amp

CONTAINING

FEEDING ampHANDLINGfeed

sleep

HO

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C WIRE

TIMING

(behavior)

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C WIRE

STOMACH

21

STATE organization

Feeding frequency

SLEEP cycling

BRAIN

WIRING

How often should a neonate feed

CNS

ENS

ANS

InternalSomaticenvironment

CNS cortical subcortical(also to PNS)

ANS emotional limbic brain(incl SNS)

ANS myelinated vagus (NA)

ANS unmyelinated vagus (DMC)sub-diaphragmatic

ENS submucous plexusmyenteric plexus

122

The digestive system is endowed with its own local nervous system referred to as the enteric or intrinsic nervous system

The magnitude and complexity of the enteric nervous system is immense - it contains as many neurons as the spinal cord

ENTERIC NERVOUS SYSTEM

123

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

FEEDBACK LOOPS

CNS

ENS

ANS

InternalSomaticenvironment

124

125 126

22

Fetal stomach appears 4 weeks GABy 11 weeks wall capable of muscular

contraction

ldquoPatterns of antropyloric motilityin fed healthy preterm infantsrdquo

the neuroregulatory mechanisms responsible for the coordination of antro-pyloric motility and gastric emptying are

well developed by 30 weeks of PMAHassan 2002 127

Hydrochloric acidimportant for activation of pepsinogen

inactivation of microorganisms such as bacteria

Pepsinogenactivated by acid into active pepsin

responsible for the stomachs ability to initiate digestion of proteins

Chymosinis an enzyme whose role is to curdle or

coagulate milk in the stomach a process of considerable importance in the very young animal

128

Chymosinmakes the milk into ldquocheeserdquohalfway between liquid and solidstomach empties in 60 minutes

milk

129

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

FEEDBACK LOOPS

130

EVIDENCE FORFEEDING FREQUENCY

Edmond 2006 131

Breastfeeding and motherrsquos milkStrong and consistent evidence 132

23

Cup feeding versus bottle feedingCup feeding higher breastfeeding

greater stability133

Only case series Insufficient evidence

No mention of

stomach capacity134

EVIDENCE FORSTOMACH CAPACITY

Edmond 2006 135

0

05

1

15

2

25

3

35

4

0 10 20 30 40 50 60 70 80

volume ingested

fee

din

g f

req

ue

nc

y

Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml

StandardCARE3 hourlyschedule

136

KEY QUESTION

WHAT IS THE

STOMACHVOLUMEOF THE

NEONATE 137 Sase 2005

ldquoOntogeny of gastric emptying patternsin the human fetusrdquo

138

24

Goldstein 1987

ldquoGrowth of the Fetal Stomach in Normal Pregnanciesrdquo

139 Goldstein 1987

Length

Transverse

AP diameter

Using +2SD

140

Formula for calculation of stomach capacity (Charles Bradshaw UCT)Assumptions the stomach can be approximated by dividing into three sections namely a ellipsoidal hemisphere an ellipsoidal cylinder and a skewed ellipsoidal cone Variables a = anteroposterior radius t = transverse radius l = length stomachRelations the height of the cone and the hemisphere are both the same as lsquoarsquo

Ellipsoid = 43 Pi r1r2r3 = 43 Pi a a t therefore volume of hemisphere = 23 Pi a a t

Cylinder = Area of base height = (Pi a t ) ( l - 2a )Skewed cone = 13 base height = 13 Pi a t aTotal volume = 23 Pi aat + Pi a t (l- 2a) + 13 Pi a t a

=Pi atl -Pi a at= Pi a t(l-a)

Goldstein and Sase dataStomach capacity at term 10 - 15 ml

BRADSHAW formula

141

Assumption 25 kg baby 33w GA

requiring 150 mlkgday = 375 ml

45 MIN CYCLES ( 32 cyclesday)

12 ML PER CYCLE = 384 ml142

Newborn stomach volume

Gastric volumes at birthCorrelated with gastric pH

gastrin and somatostatin

ldquofetus drinks 10 ml portions of amniotic fluid helliprdquo

Widstrom 1988 143

Only recent study locatedldquoAutopsyrdquo capacity was determined

in Indian post-mortem studies

100 autopsies (63 SB 37 ENND)Tied at cardia and pylorus filled withwater emptied amp measured repeatedldquohellip obliteration of the gastric curvaturesrdquoldquodue care to minimize stretch artifactsrdquo

Naveed 1992

ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo

144

25

Infants above 2500g onlyAve Range

Stillborn (n 11) 196 ml (10-35)Early death (n 9) 178 ml (10-25)All cases (n 20) 188 ml

Naveed 1992

ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo

145 146

KERNESSUK 1997 (Russian)

Postmortem in situ measures(applied Bradshaw formula)

AveNewborn (n 11) 15 ml2 months (n 11) 35 ml2-4 m (n 10) 50 ml4-6 m (n 8) 100 ml

Known references with data

Scammon and Doyle 1920

Zuccarellirsquos method stomach filled at autopsy to ldquoa pressure of between

15 and 20 centimeters of waterrdquo

Scammon 1920

ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo

147

Anatomic capacity was determined in post-mortem studies

Main data set Alliot 1905 (n 25)Scammon own cases (n 13)

30 ndash 35 ml at birth ndashalmost regardless of birth weight

Scammon 1920

ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo

148

Zangen S et al Rapid maturation of gastric relaxation in newborns

Pressures (mmHg)

Balloon inflates to

15 ml no increase

functional capacity

149

Zangen S et al Rapid maturation of gastric relaxation in newborns

Pressures (mmHg)

Balloon inflates to

15 ml no increase20 ml pressure OK

physiologicalcapacity hellip 150

26

EVIDENCE (NBn 111009)

Author Capacity NoteSase 10-15 ml Live term fetusGoldstein 10-15 ml Live term fetusWidstrom 10 mls Live newbornZangen 20 mls Live (pressure)

Naveed 20 mls Autopsy (SB)20 mls Autopsy (ENND)

Kernessuk 15 mls Autopsy (in situ)Scammon 30-35 ml Autopsy (water

(Alliot) pressure)151

PROPOSAL

The CAPACITY of aweek old babyrsquos stomach is

approx 20 ml152

0

05

1

15

2

25

3

35

4

0 10 20 30 40 50 60 70 80

volume ingested

fee

din

g f

req

ue

nc

y

Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml

StandardCARE3 hourlyschedule

MOTHERNATURE

1 hourlyschedule

153

PHYSIOLOGICAL CAPACITY

RECEPTIVE CAPACITY of stomach

INGESTIVE CAPACITY of BABY

FUNCTIONAL CAPACITY

154

PROPOSAL

The FEEDINGFREQUENCY of theNEONATE is

approx 60 min155

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

BRAIN CYCLING

STOMACH FILLING amp EMPTYING

REMNR1NR2NR3NR4

156

27

Normal physiology of theEnteric Nervous System

ldquoSmall and frequent feeds according to the sleep cyclerdquo

The ldquonicherdquo (occupation) of a neonate (Alberts)

BOND FEED

SLEEP SLEEP

PLAY FEED

157

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

FEEDING SUCKLING

Influence of SMELL None Totally dependent

Motor mechanism Chewing ndash different

muscles

Suckling ndash different circuits

INSULIN Increases weight No effect

GHRELIN Increases weight No effect

LEPTIN Decreases intake No effect

CHOLECYSTOKININ Decreases intake No effect

AMPHETAMINE Decreases appetite Increases suckling

SEROTONIN Agonist improves feeding Antagonist improves suck

SATIETY Infant determined Maternal supply determine

FEEDING SUCKLING

Influence of SMELL None Totally dependent

Motor mechanism Chewing ndash different

muscles

Suckling ndash different circuits

INSULIN Increases weight No effect

GHRELIN Increases weight No effect

LEPTIN Decreases intake No effect

CHOLECYSTOKININ Decreases intake No effect

AMPHETAMINE Decreases appetite Increases suckling

SEROTONIN Agonist improves feeding Antagonist improves suck

SATIETY Infant determined Maternal supply determine

Current dogmaTHE BABY KNOWS

WHEN IT HAS HAD ENOUGH

PROBABLY NOT

WHAT IS THE

STOMACH VOLUME OF THE

PREMATURE

161

Assume low resilience

Assume proportionality

162

28

The CAPACITY of alow birthweight premfrom 20ml 3000g

= 0007 x BWt (g)

1kg x 0007 = 7mls2kg x 0007 = 14mls

163

Gastric overfilling syndrome

164

75 ml per feeding ASSUMPTION

IMMATURE OR OVERWHELMED

many aspects of gastrointestinalmotility are immature in the neonate

Zangen S et al Rapid maturation of gastric relaxation in newborns

A balloon in stomachcan fill to 76 mls

What does the stomach ndashwithout a balloon ndashdo to 76 mls

REFLUX PRESUME each feedapproximately 75 mls

GER

bull Sudden outbursts of crying

bull Awakens in pain

bull Related to feedings

bull Not easily comforted

bull ldquoI know baby hurtsrdquo

bull Sour burps throaty noises

bull Best when upright

Clues to GER

Dr W Sears

29

Mitchell 2001

Kerstin Uvnaumls-Moberg

Food in duodenum

AMYLINreleased

Closes pylorus

Duodenumempty

Pylorusopens

ldquoFeed intolerancerdquo hellip hellip or VOLUME intolerance

HYPOGLYCAEMIA

A babies stomach empties in60 minutes

Blood sugarmay fall hellip

after 90 minutes Options

30

METABOLIC ADAPTATION

SSC started in the first 20 minutes after birth

SSC CotBlood glucose (1 hr) 317 256Base excess drop 34 18

(Christenson 1992)0h 1h 2h 3h 4h 2 days

App

roxim

ate

GLUCOSE

SSC Glucose production = Glucose consumption

Separation

SNS stress Glucose consumption INCREASE

PSNS dissociation Glucose production DECREASE

HYPOGLYCEMIA

SSC Cot

Blood glucose (1 hr) 317 256

0h 1h 2h 3h 4h 2 days

App

roxim

ate

GLUCOSE

SSC Glucose production = Glucose consumption

Separation PSNS dissociation

Glucose production DECREASE

HYPOGLYCEMIA

SSC Cot

Blood glucose (1 hr) 317 256

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

NEURODEVELOPMENTThe DNA Behaviour

EVOLUTIONARY BIOLOGY

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

BONDING ATTACHMENT

MRI HRVEEG

STRESS RESPONES

RESILIENCE

DOHAD

(MAL) ADAPTATION

EPIGENETICS

GENE X ENVIRONMENT

GENETIC VARIANTS

HOSPITAL ACQUIRED INFECTIONIMMUNITY

SLEEP PHYSIOLOGY

GUT FUNCTIONMICROBIOTA

ldquoSTABILITYrdquo

TRANSITION

LONG TERM FOLLOW-UP

NEUROENDOCRINE BEHAVIOURS

MATERNAL NEUROPLASTICITY

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

MORTALITYMETABOLISM

0h 1h 2h 3h 4h

PSNS (vagal)

App

roxim

ate

GLUCOSE

1 HOURLY Milk feed

1 HOURLY Milk feed

1 HOURLY Milk feed

1 HOURLY Milk feed

LACTOSE

METABOLISM

31

0h 1h 2h 3h 4h

PSNS (vagal) SYMPATHETIC STRESS

App

roxim

ate

GLUCOSE

LACTOSE FATGLYCOGEN

METABOLISM

4 HOURLY Milk feed

0h 1h 2h 3h 4h

PSNS (vagal) SYMPATHETIC STRESS

App

roxim

ate

GLUCOSE

4 HOURLY ALLOSTATIC STATELACTOSE FATGLYCOGEN

METABOLISM

4 HOURLY Milk feed

HEALTH DISEASE

EXPECTED UNEXPECTED

NEURODEVELOPMENTThe DNA Behaviour

EVOLUTIONARY BIOLOGY

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

BONDING ATTACHMENT

MRI HRVEEG

STRESS RESPONES

RESILIENCE

DOHAD

(MAL) ADAPTATION

EPIGENETICS

GENE X ENVIRONMENT

GENETIC VARIANTS

HOSPITAL ACQUIRED INFECTIONIMMUNITY

SLEEP PHYSIOLOGY

GUT FUNCTIONMICROBIOTA

ldquoSTABILITYrdquo

TRANSITION

LONG TERM FOLLOW-UP

NEUROENDOCRINE BEHAVIOURS

MATERNAL NEUROPLASTICITY

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

MORTALITYMETABOLISM

Weight gain 1st week

predicts OBESITYat 30 years

Large volume feedsstretched stomach=

doubled absorptivecapacity as adult

Importance

Programming ndash early life chronic disease

32

RESISTANCE SENSITIVITY

PERCEPTIONSldquoNEUROCEPTIONrdquo

RESPONSESTRESS

ALLOSTATIC STATE

ALLOSTASIS

ANY STRESSPsychologicalNeurological

EndocrineImmune

ALLOSTATIC LOAD

ALLOSTATIC OVERLOAD

WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY

DISEASEHEALTH

RESILIENCE VULNERABILITY

RESISTANCE SENSITIVITY

PERCEPTIONSldquoNEUROCEPTIONrdquo

RESPONSESTRESS

ALLOSTATIC STATE

ALLOSTASIS

ANY STRESSPsychologicalNeurological

EndocrineImmune

ALLOSTATIC LOAD

HEALTH

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

Gastric overfilling syndrome

189

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

33

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

Only case series Insufficient evidence

No mention of

stomach capacity196

Baby weight freq reqrsquod size actual

2kg baby 4hrly ~ 320 ml6 = 53ml 14ml

15 baby 3hrly ~ 240 ml8 = 30ml 10ml

10 baby 2hrly ~ 160 ml12 = 13ml 7ml

Standardised from20ml capacityfor 3kg baby( x 0007)

197

0

10

20

30

40

50

60

70

80

90

13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w

LINEAR

TERM

PREM

198

34

0

10

20

30

40

50

60

70

80

90

13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w

LINEAR

TERM

PREM

199

Clues to GER

ldquoI know baby hurtsrdquo

Gastric overfilling syndrome

Excessive volumesreflux aspiration colic

Excessive time intervalhypoglycaemia

Adaptationsdiabetic diathesis obesity

200

Developmental Care of the Enteric Nervous System

ldquoSmall and frequent feeds according to the sleep cyclerdquo

The ldquonicherdquo (occupation) of a neonate (Alberts)

BOND FEED

SLEEP SLEEP

PLAY FEED

201

Gastric overfilling syndrome

Proposed Management 202

Proposed Management

Babies should be fedEVERY TIME THEY WAKE

Stanley Graven 2006

REMNR1NR2NR3SWS

AS (20 mins) QS (40 mins)

A normal sleep cycle is ONE hourHow often should neonates feed

203

Proposed Management

All babies should be fedat least once an hour 204

35

Proposed Management

All babies should be fedat least once an hour

205

The first Milk Ejection Reflex (MER)

elicited in lt 2 minutesworks quicklyswallowed 1 minute

Feeding time (max)3 minutes

Repeat every 1 hour

Prime 2007

The ldquonormalrdquo or usual and common breastfeed

takes 15 minutesdiscomfort afterburping time 5 minutes

Feeding time 20 min

Repeat every 3 hours

Prime 2007

3 minute 20ml feeds x 24d = 72 minutes

20 minute 60ml feeds x 8d = 160 minutes

SMALL AND FREQUENT FEEDS ARE EFFICIENT

FEWER NURSES NEEDED

The calculated dailyrequirement for a 3kgbaby can be given without increase inpressure MINIMAL RISK

PARENTS CAN DOSAFELY

20 mls x 24 feeds= 480mls day

Zangen 2001 209

All babies should be fedat least once an hour

210

36

Infant feeding frequencyProposal based on available evidence and neuroscience

ldquoSmall and frequent feeds

adjusted to the sleep cyclerdquo

211

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

STATE organization

Feeding frequency

SLEEP cycling

BRAIN

WIRING

How often should a neonate feeda neonate sleep

Infantsleep cycles

begin to block on diurnalrhythms

Mother-infant synchrony

hellip at 12 weeks

(circadian)

START at 3 months

Can be ldquoadult-likerdquo

at 6 months

Thomas 2014

STATE organization

Feeding frequency

SLEEP cycling

PLAY FEED

216

SLEEP SLEEP

SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

Infantsleep cycles

begin to block on diurnalrhythms

37

BOND SUCKLE SLEEP SLEEP PLAY

FEED

217

SLEEP SLEEP SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)

Schaal 2004 218

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)rdquoSLEEP-FEED CYCLINGrdquo

Schaal 2004 219

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

WIRE

BRAIN

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

BRAIN

WIRING

NEUROSCIENCE

The DNAEverything else

EVOLUTIONARYBIOLOGY

The Brain

EPIGENETICS

The PlaceENVIRONMENT

EXPERIENCEFITNESS ADAPTATION

ldquoScientific foundationrdquo hellip a synthesis

ZERO

SEPARATION

38

wwwninobirthorgwwwskintoskincontactcom

THE NEUROSCIENCE OFSKIN-TO-SKIN CONTACT

AND BREASTFEEDING

ARE THE SAME

SUMMARY SKIN-TO-SKIN

(Regulation)

SLEEP(Brain)

FEEDING(Stomach)

LOVE ( ldquomindrdquo )

REMNR1NR2NR3NR4

ACQUISITION CONSOLIDATION MEMORYFORMATION

poly-sensory input transfer information P wavesshort-term memory ldquoSNRrdquo strong signals returns infostored cortex amygdala to neocortex

hippocampus organizedAwake and REM NREM stage 4 REM

BRAIN WIRING

Stanley Graven 2006

PLAY

SLEEP

FEEDHOLDYOURPREM

httpswwwfacebookcomninobirth

39

Nelson Mandela

hellip in describing themeasure of a nation

he has argued that

ldquoThere can be no keener revelation of a societyrsquos soul than the way in which it treats its childrenrdquo

Page 21: Neurodevelopmental The Neuroscience of Birth ... · breastfeeding pattern, neonatal weight gain, and the dynamics of lactation. Doucet 2012 In the ‘‘scentless breast’’ condition,

21

STATE organization

Feeding frequency

SLEEP cycling

BRAIN

WIRING

How often should a neonate feed

CNS

ENS

ANS

InternalSomaticenvironment

CNS cortical subcortical(also to PNS)

ANS emotional limbic brain(incl SNS)

ANS myelinated vagus (NA)

ANS unmyelinated vagus (DMC)sub-diaphragmatic

ENS submucous plexusmyenteric plexus

122

The digestive system is endowed with its own local nervous system referred to as the enteric or intrinsic nervous system

The magnitude and complexity of the enteric nervous system is immense - it contains as many neurons as the spinal cord

ENTERIC NERVOUS SYSTEM

123

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

FEEDBACK LOOPS

CNS

ENS

ANS

InternalSomaticenvironment

124

125 126

22

Fetal stomach appears 4 weeks GABy 11 weeks wall capable of muscular

contraction

ldquoPatterns of antropyloric motilityin fed healthy preterm infantsrdquo

the neuroregulatory mechanisms responsible for the coordination of antro-pyloric motility and gastric emptying are

well developed by 30 weeks of PMAHassan 2002 127

Hydrochloric acidimportant for activation of pepsinogen

inactivation of microorganisms such as bacteria

Pepsinogenactivated by acid into active pepsin

responsible for the stomachs ability to initiate digestion of proteins

Chymosinis an enzyme whose role is to curdle or

coagulate milk in the stomach a process of considerable importance in the very young animal

128

Chymosinmakes the milk into ldquocheeserdquohalfway between liquid and solidstomach empties in 60 minutes

milk

129

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

FEEDBACK LOOPS

130

EVIDENCE FORFEEDING FREQUENCY

Edmond 2006 131

Breastfeeding and motherrsquos milkStrong and consistent evidence 132

23

Cup feeding versus bottle feedingCup feeding higher breastfeeding

greater stability133

Only case series Insufficient evidence

No mention of

stomach capacity134

EVIDENCE FORSTOMACH CAPACITY

Edmond 2006 135

0

05

1

15

2

25

3

35

4

0 10 20 30 40 50 60 70 80

volume ingested

fee

din

g f

req

ue

nc

y

Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml

StandardCARE3 hourlyschedule

136

KEY QUESTION

WHAT IS THE

STOMACHVOLUMEOF THE

NEONATE 137 Sase 2005

ldquoOntogeny of gastric emptying patternsin the human fetusrdquo

138

24

Goldstein 1987

ldquoGrowth of the Fetal Stomach in Normal Pregnanciesrdquo

139 Goldstein 1987

Length

Transverse

AP diameter

Using +2SD

140

Formula for calculation of stomach capacity (Charles Bradshaw UCT)Assumptions the stomach can be approximated by dividing into three sections namely a ellipsoidal hemisphere an ellipsoidal cylinder and a skewed ellipsoidal cone Variables a = anteroposterior radius t = transverse radius l = length stomachRelations the height of the cone and the hemisphere are both the same as lsquoarsquo

Ellipsoid = 43 Pi r1r2r3 = 43 Pi a a t therefore volume of hemisphere = 23 Pi a a t

Cylinder = Area of base height = (Pi a t ) ( l - 2a )Skewed cone = 13 base height = 13 Pi a t aTotal volume = 23 Pi aat + Pi a t (l- 2a) + 13 Pi a t a

=Pi atl -Pi a at= Pi a t(l-a)

Goldstein and Sase dataStomach capacity at term 10 - 15 ml

BRADSHAW formula

141

Assumption 25 kg baby 33w GA

requiring 150 mlkgday = 375 ml

45 MIN CYCLES ( 32 cyclesday)

12 ML PER CYCLE = 384 ml142

Newborn stomach volume

Gastric volumes at birthCorrelated with gastric pH

gastrin and somatostatin

ldquofetus drinks 10 ml portions of amniotic fluid helliprdquo

Widstrom 1988 143

Only recent study locatedldquoAutopsyrdquo capacity was determined

in Indian post-mortem studies

100 autopsies (63 SB 37 ENND)Tied at cardia and pylorus filled withwater emptied amp measured repeatedldquohellip obliteration of the gastric curvaturesrdquoldquodue care to minimize stretch artifactsrdquo

Naveed 1992

ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo

144

25

Infants above 2500g onlyAve Range

Stillborn (n 11) 196 ml (10-35)Early death (n 9) 178 ml (10-25)All cases (n 20) 188 ml

Naveed 1992

ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo

145 146

KERNESSUK 1997 (Russian)

Postmortem in situ measures(applied Bradshaw formula)

AveNewborn (n 11) 15 ml2 months (n 11) 35 ml2-4 m (n 10) 50 ml4-6 m (n 8) 100 ml

Known references with data

Scammon and Doyle 1920

Zuccarellirsquos method stomach filled at autopsy to ldquoa pressure of between

15 and 20 centimeters of waterrdquo

Scammon 1920

ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo

147

Anatomic capacity was determined in post-mortem studies

Main data set Alliot 1905 (n 25)Scammon own cases (n 13)

30 ndash 35 ml at birth ndashalmost regardless of birth weight

Scammon 1920

ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo

148

Zangen S et al Rapid maturation of gastric relaxation in newborns

Pressures (mmHg)

Balloon inflates to

15 ml no increase

functional capacity

149

Zangen S et al Rapid maturation of gastric relaxation in newborns

Pressures (mmHg)

Balloon inflates to

15 ml no increase20 ml pressure OK

physiologicalcapacity hellip 150

26

EVIDENCE (NBn 111009)

Author Capacity NoteSase 10-15 ml Live term fetusGoldstein 10-15 ml Live term fetusWidstrom 10 mls Live newbornZangen 20 mls Live (pressure)

Naveed 20 mls Autopsy (SB)20 mls Autopsy (ENND)

Kernessuk 15 mls Autopsy (in situ)Scammon 30-35 ml Autopsy (water

(Alliot) pressure)151

PROPOSAL

The CAPACITY of aweek old babyrsquos stomach is

approx 20 ml152

0

05

1

15

2

25

3

35

4

0 10 20 30 40 50 60 70 80

volume ingested

fee

din

g f

req

ue

nc

y

Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml

StandardCARE3 hourlyschedule

MOTHERNATURE

1 hourlyschedule

153

PHYSIOLOGICAL CAPACITY

RECEPTIVE CAPACITY of stomach

INGESTIVE CAPACITY of BABY

FUNCTIONAL CAPACITY

154

PROPOSAL

The FEEDINGFREQUENCY of theNEONATE is

approx 60 min155

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

BRAIN CYCLING

STOMACH FILLING amp EMPTYING

REMNR1NR2NR3NR4

156

27

Normal physiology of theEnteric Nervous System

ldquoSmall and frequent feeds according to the sleep cyclerdquo

The ldquonicherdquo (occupation) of a neonate (Alberts)

BOND FEED

SLEEP SLEEP

PLAY FEED

157

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

FEEDING SUCKLING

Influence of SMELL None Totally dependent

Motor mechanism Chewing ndash different

muscles

Suckling ndash different circuits

INSULIN Increases weight No effect

GHRELIN Increases weight No effect

LEPTIN Decreases intake No effect

CHOLECYSTOKININ Decreases intake No effect

AMPHETAMINE Decreases appetite Increases suckling

SEROTONIN Agonist improves feeding Antagonist improves suck

SATIETY Infant determined Maternal supply determine

FEEDING SUCKLING

Influence of SMELL None Totally dependent

Motor mechanism Chewing ndash different

muscles

Suckling ndash different circuits

INSULIN Increases weight No effect

GHRELIN Increases weight No effect

LEPTIN Decreases intake No effect

CHOLECYSTOKININ Decreases intake No effect

AMPHETAMINE Decreases appetite Increases suckling

SEROTONIN Agonist improves feeding Antagonist improves suck

SATIETY Infant determined Maternal supply determine

Current dogmaTHE BABY KNOWS

WHEN IT HAS HAD ENOUGH

PROBABLY NOT

WHAT IS THE

STOMACH VOLUME OF THE

PREMATURE

161

Assume low resilience

Assume proportionality

162

28

The CAPACITY of alow birthweight premfrom 20ml 3000g

= 0007 x BWt (g)

1kg x 0007 = 7mls2kg x 0007 = 14mls

163

Gastric overfilling syndrome

164

75 ml per feeding ASSUMPTION

IMMATURE OR OVERWHELMED

many aspects of gastrointestinalmotility are immature in the neonate

Zangen S et al Rapid maturation of gastric relaxation in newborns

A balloon in stomachcan fill to 76 mls

What does the stomach ndashwithout a balloon ndashdo to 76 mls

REFLUX PRESUME each feedapproximately 75 mls

GER

bull Sudden outbursts of crying

bull Awakens in pain

bull Related to feedings

bull Not easily comforted

bull ldquoI know baby hurtsrdquo

bull Sour burps throaty noises

bull Best when upright

Clues to GER

Dr W Sears

29

Mitchell 2001

Kerstin Uvnaumls-Moberg

Food in duodenum

AMYLINreleased

Closes pylorus

Duodenumempty

Pylorusopens

ldquoFeed intolerancerdquo hellip hellip or VOLUME intolerance

HYPOGLYCAEMIA

A babies stomach empties in60 minutes

Blood sugarmay fall hellip

after 90 minutes Options

30

METABOLIC ADAPTATION

SSC started in the first 20 minutes after birth

SSC CotBlood glucose (1 hr) 317 256Base excess drop 34 18

(Christenson 1992)0h 1h 2h 3h 4h 2 days

App

roxim

ate

GLUCOSE

SSC Glucose production = Glucose consumption

Separation

SNS stress Glucose consumption INCREASE

PSNS dissociation Glucose production DECREASE

HYPOGLYCEMIA

SSC Cot

Blood glucose (1 hr) 317 256

0h 1h 2h 3h 4h 2 days

App

roxim

ate

GLUCOSE

SSC Glucose production = Glucose consumption

Separation PSNS dissociation

Glucose production DECREASE

HYPOGLYCEMIA

SSC Cot

Blood glucose (1 hr) 317 256

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

NEURODEVELOPMENTThe DNA Behaviour

EVOLUTIONARY BIOLOGY

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

BONDING ATTACHMENT

MRI HRVEEG

STRESS RESPONES

RESILIENCE

DOHAD

(MAL) ADAPTATION

EPIGENETICS

GENE X ENVIRONMENT

GENETIC VARIANTS

HOSPITAL ACQUIRED INFECTIONIMMUNITY

SLEEP PHYSIOLOGY

GUT FUNCTIONMICROBIOTA

ldquoSTABILITYrdquo

TRANSITION

LONG TERM FOLLOW-UP

NEUROENDOCRINE BEHAVIOURS

MATERNAL NEUROPLASTICITY

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

MORTALITYMETABOLISM

0h 1h 2h 3h 4h

PSNS (vagal)

App

roxim

ate

GLUCOSE

1 HOURLY Milk feed

1 HOURLY Milk feed

1 HOURLY Milk feed

1 HOURLY Milk feed

LACTOSE

METABOLISM

31

0h 1h 2h 3h 4h

PSNS (vagal) SYMPATHETIC STRESS

App

roxim

ate

GLUCOSE

LACTOSE FATGLYCOGEN

METABOLISM

4 HOURLY Milk feed

0h 1h 2h 3h 4h

PSNS (vagal) SYMPATHETIC STRESS

App

roxim

ate

GLUCOSE

4 HOURLY ALLOSTATIC STATELACTOSE FATGLYCOGEN

METABOLISM

4 HOURLY Milk feed

HEALTH DISEASE

EXPECTED UNEXPECTED

NEURODEVELOPMENTThe DNA Behaviour

EVOLUTIONARY BIOLOGY

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

BONDING ATTACHMENT

MRI HRVEEG

STRESS RESPONES

RESILIENCE

DOHAD

(MAL) ADAPTATION

EPIGENETICS

GENE X ENVIRONMENT

GENETIC VARIANTS

HOSPITAL ACQUIRED INFECTIONIMMUNITY

SLEEP PHYSIOLOGY

GUT FUNCTIONMICROBIOTA

ldquoSTABILITYrdquo

TRANSITION

LONG TERM FOLLOW-UP

NEUROENDOCRINE BEHAVIOURS

MATERNAL NEUROPLASTICITY

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

MORTALITYMETABOLISM

Weight gain 1st week

predicts OBESITYat 30 years

Large volume feedsstretched stomach=

doubled absorptivecapacity as adult

Importance

Programming ndash early life chronic disease

32

RESISTANCE SENSITIVITY

PERCEPTIONSldquoNEUROCEPTIONrdquo

RESPONSESTRESS

ALLOSTATIC STATE

ALLOSTASIS

ANY STRESSPsychologicalNeurological

EndocrineImmune

ALLOSTATIC LOAD

ALLOSTATIC OVERLOAD

WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY

DISEASEHEALTH

RESILIENCE VULNERABILITY

RESISTANCE SENSITIVITY

PERCEPTIONSldquoNEUROCEPTIONrdquo

RESPONSESTRESS

ALLOSTATIC STATE

ALLOSTASIS

ANY STRESSPsychologicalNeurological

EndocrineImmune

ALLOSTATIC LOAD

HEALTH

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

Gastric overfilling syndrome

189

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

33

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

Only case series Insufficient evidence

No mention of

stomach capacity196

Baby weight freq reqrsquod size actual

2kg baby 4hrly ~ 320 ml6 = 53ml 14ml

15 baby 3hrly ~ 240 ml8 = 30ml 10ml

10 baby 2hrly ~ 160 ml12 = 13ml 7ml

Standardised from20ml capacityfor 3kg baby( x 0007)

197

0

10

20

30

40

50

60

70

80

90

13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w

LINEAR

TERM

PREM

198

34

0

10

20

30

40

50

60

70

80

90

13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w

LINEAR

TERM

PREM

199

Clues to GER

ldquoI know baby hurtsrdquo

Gastric overfilling syndrome

Excessive volumesreflux aspiration colic

Excessive time intervalhypoglycaemia

Adaptationsdiabetic diathesis obesity

200

Developmental Care of the Enteric Nervous System

ldquoSmall and frequent feeds according to the sleep cyclerdquo

The ldquonicherdquo (occupation) of a neonate (Alberts)

BOND FEED

SLEEP SLEEP

PLAY FEED

201

Gastric overfilling syndrome

Proposed Management 202

Proposed Management

Babies should be fedEVERY TIME THEY WAKE

Stanley Graven 2006

REMNR1NR2NR3SWS

AS (20 mins) QS (40 mins)

A normal sleep cycle is ONE hourHow often should neonates feed

203

Proposed Management

All babies should be fedat least once an hour 204

35

Proposed Management

All babies should be fedat least once an hour

205

The first Milk Ejection Reflex (MER)

elicited in lt 2 minutesworks quicklyswallowed 1 minute

Feeding time (max)3 minutes

Repeat every 1 hour

Prime 2007

The ldquonormalrdquo or usual and common breastfeed

takes 15 minutesdiscomfort afterburping time 5 minutes

Feeding time 20 min

Repeat every 3 hours

Prime 2007

3 minute 20ml feeds x 24d = 72 minutes

20 minute 60ml feeds x 8d = 160 minutes

SMALL AND FREQUENT FEEDS ARE EFFICIENT

FEWER NURSES NEEDED

The calculated dailyrequirement for a 3kgbaby can be given without increase inpressure MINIMAL RISK

PARENTS CAN DOSAFELY

20 mls x 24 feeds= 480mls day

Zangen 2001 209

All babies should be fedat least once an hour

210

36

Infant feeding frequencyProposal based on available evidence and neuroscience

ldquoSmall and frequent feeds

adjusted to the sleep cyclerdquo

211

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

STATE organization

Feeding frequency

SLEEP cycling

BRAIN

WIRING

How often should a neonate feeda neonate sleep

Infantsleep cycles

begin to block on diurnalrhythms

Mother-infant synchrony

hellip at 12 weeks

(circadian)

START at 3 months

Can be ldquoadult-likerdquo

at 6 months

Thomas 2014

STATE organization

Feeding frequency

SLEEP cycling

PLAY FEED

216

SLEEP SLEEP

SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

Infantsleep cycles

begin to block on diurnalrhythms

37

BOND SUCKLE SLEEP SLEEP PLAY

FEED

217

SLEEP SLEEP SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)

Schaal 2004 218

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)rdquoSLEEP-FEED CYCLINGrdquo

Schaal 2004 219

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

WIRE

BRAIN

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

BRAIN

WIRING

NEUROSCIENCE

The DNAEverything else

EVOLUTIONARYBIOLOGY

The Brain

EPIGENETICS

The PlaceENVIRONMENT

EXPERIENCEFITNESS ADAPTATION

ldquoScientific foundationrdquo hellip a synthesis

ZERO

SEPARATION

38

wwwninobirthorgwwwskintoskincontactcom

THE NEUROSCIENCE OFSKIN-TO-SKIN CONTACT

AND BREASTFEEDING

ARE THE SAME

SUMMARY SKIN-TO-SKIN

(Regulation)

SLEEP(Brain)

FEEDING(Stomach)

LOVE ( ldquomindrdquo )

REMNR1NR2NR3NR4

ACQUISITION CONSOLIDATION MEMORYFORMATION

poly-sensory input transfer information P wavesshort-term memory ldquoSNRrdquo strong signals returns infostored cortex amygdala to neocortex

hippocampus organizedAwake and REM NREM stage 4 REM

BRAIN WIRING

Stanley Graven 2006

PLAY

SLEEP

FEEDHOLDYOURPREM

httpswwwfacebookcomninobirth

39

Nelson Mandela

hellip in describing themeasure of a nation

he has argued that

ldquoThere can be no keener revelation of a societyrsquos soul than the way in which it treats its childrenrdquo

Page 22: Neurodevelopmental The Neuroscience of Birth ... · breastfeeding pattern, neonatal weight gain, and the dynamics of lactation. Doucet 2012 In the ‘‘scentless breast’’ condition,

22

Fetal stomach appears 4 weeks GABy 11 weeks wall capable of muscular

contraction

ldquoPatterns of antropyloric motilityin fed healthy preterm infantsrdquo

the neuroregulatory mechanisms responsible for the coordination of antro-pyloric motility and gastric emptying are

well developed by 30 weeks of PMAHassan 2002 127

Hydrochloric acidimportant for activation of pepsinogen

inactivation of microorganisms such as bacteria

Pepsinogenactivated by acid into active pepsin

responsible for the stomachs ability to initiate digestion of proteins

Chymosinis an enzyme whose role is to curdle or

coagulate milk in the stomach a process of considerable importance in the very young animal

128

Chymosinmakes the milk into ldquocheeserdquohalfway between liquid and solidstomach empties in 60 minutes

milk

129

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

FEEDBACK LOOPS

130

EVIDENCE FORFEEDING FREQUENCY

Edmond 2006 131

Breastfeeding and motherrsquos milkStrong and consistent evidence 132

23

Cup feeding versus bottle feedingCup feeding higher breastfeeding

greater stability133

Only case series Insufficient evidence

No mention of

stomach capacity134

EVIDENCE FORSTOMACH CAPACITY

Edmond 2006 135

0

05

1

15

2

25

3

35

4

0 10 20 30 40 50 60 70 80

volume ingested

fee

din

g f

req

ue

nc

y

Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml

StandardCARE3 hourlyschedule

136

KEY QUESTION

WHAT IS THE

STOMACHVOLUMEOF THE

NEONATE 137 Sase 2005

ldquoOntogeny of gastric emptying patternsin the human fetusrdquo

138

24

Goldstein 1987

ldquoGrowth of the Fetal Stomach in Normal Pregnanciesrdquo

139 Goldstein 1987

Length

Transverse

AP diameter

Using +2SD

140

Formula for calculation of stomach capacity (Charles Bradshaw UCT)Assumptions the stomach can be approximated by dividing into three sections namely a ellipsoidal hemisphere an ellipsoidal cylinder and a skewed ellipsoidal cone Variables a = anteroposterior radius t = transverse radius l = length stomachRelations the height of the cone and the hemisphere are both the same as lsquoarsquo

Ellipsoid = 43 Pi r1r2r3 = 43 Pi a a t therefore volume of hemisphere = 23 Pi a a t

Cylinder = Area of base height = (Pi a t ) ( l - 2a )Skewed cone = 13 base height = 13 Pi a t aTotal volume = 23 Pi aat + Pi a t (l- 2a) + 13 Pi a t a

=Pi atl -Pi a at= Pi a t(l-a)

Goldstein and Sase dataStomach capacity at term 10 - 15 ml

BRADSHAW formula

141

Assumption 25 kg baby 33w GA

requiring 150 mlkgday = 375 ml

45 MIN CYCLES ( 32 cyclesday)

12 ML PER CYCLE = 384 ml142

Newborn stomach volume

Gastric volumes at birthCorrelated with gastric pH

gastrin and somatostatin

ldquofetus drinks 10 ml portions of amniotic fluid helliprdquo

Widstrom 1988 143

Only recent study locatedldquoAutopsyrdquo capacity was determined

in Indian post-mortem studies

100 autopsies (63 SB 37 ENND)Tied at cardia and pylorus filled withwater emptied amp measured repeatedldquohellip obliteration of the gastric curvaturesrdquoldquodue care to minimize stretch artifactsrdquo

Naveed 1992

ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo

144

25

Infants above 2500g onlyAve Range

Stillborn (n 11) 196 ml (10-35)Early death (n 9) 178 ml (10-25)All cases (n 20) 188 ml

Naveed 1992

ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo

145 146

KERNESSUK 1997 (Russian)

Postmortem in situ measures(applied Bradshaw formula)

AveNewborn (n 11) 15 ml2 months (n 11) 35 ml2-4 m (n 10) 50 ml4-6 m (n 8) 100 ml

Known references with data

Scammon and Doyle 1920

Zuccarellirsquos method stomach filled at autopsy to ldquoa pressure of between

15 and 20 centimeters of waterrdquo

Scammon 1920

ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo

147

Anatomic capacity was determined in post-mortem studies

Main data set Alliot 1905 (n 25)Scammon own cases (n 13)

30 ndash 35 ml at birth ndashalmost regardless of birth weight

Scammon 1920

ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo

148

Zangen S et al Rapid maturation of gastric relaxation in newborns

Pressures (mmHg)

Balloon inflates to

15 ml no increase

functional capacity

149

Zangen S et al Rapid maturation of gastric relaxation in newborns

Pressures (mmHg)

Balloon inflates to

15 ml no increase20 ml pressure OK

physiologicalcapacity hellip 150

26

EVIDENCE (NBn 111009)

Author Capacity NoteSase 10-15 ml Live term fetusGoldstein 10-15 ml Live term fetusWidstrom 10 mls Live newbornZangen 20 mls Live (pressure)

Naveed 20 mls Autopsy (SB)20 mls Autopsy (ENND)

Kernessuk 15 mls Autopsy (in situ)Scammon 30-35 ml Autopsy (water

(Alliot) pressure)151

PROPOSAL

The CAPACITY of aweek old babyrsquos stomach is

approx 20 ml152

0

05

1

15

2

25

3

35

4

0 10 20 30 40 50 60 70 80

volume ingested

fee

din

g f

req

ue

nc

y

Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml

StandardCARE3 hourlyschedule

MOTHERNATURE

1 hourlyschedule

153

PHYSIOLOGICAL CAPACITY

RECEPTIVE CAPACITY of stomach

INGESTIVE CAPACITY of BABY

FUNCTIONAL CAPACITY

154

PROPOSAL

The FEEDINGFREQUENCY of theNEONATE is

approx 60 min155

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

BRAIN CYCLING

STOMACH FILLING amp EMPTYING

REMNR1NR2NR3NR4

156

27

Normal physiology of theEnteric Nervous System

ldquoSmall and frequent feeds according to the sleep cyclerdquo

The ldquonicherdquo (occupation) of a neonate (Alberts)

BOND FEED

SLEEP SLEEP

PLAY FEED

157

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

FEEDING SUCKLING

Influence of SMELL None Totally dependent

Motor mechanism Chewing ndash different

muscles

Suckling ndash different circuits

INSULIN Increases weight No effect

GHRELIN Increases weight No effect

LEPTIN Decreases intake No effect

CHOLECYSTOKININ Decreases intake No effect

AMPHETAMINE Decreases appetite Increases suckling

SEROTONIN Agonist improves feeding Antagonist improves suck

SATIETY Infant determined Maternal supply determine

FEEDING SUCKLING

Influence of SMELL None Totally dependent

Motor mechanism Chewing ndash different

muscles

Suckling ndash different circuits

INSULIN Increases weight No effect

GHRELIN Increases weight No effect

LEPTIN Decreases intake No effect

CHOLECYSTOKININ Decreases intake No effect

AMPHETAMINE Decreases appetite Increases suckling

SEROTONIN Agonist improves feeding Antagonist improves suck

SATIETY Infant determined Maternal supply determine

Current dogmaTHE BABY KNOWS

WHEN IT HAS HAD ENOUGH

PROBABLY NOT

WHAT IS THE

STOMACH VOLUME OF THE

PREMATURE

161

Assume low resilience

Assume proportionality

162

28

The CAPACITY of alow birthweight premfrom 20ml 3000g

= 0007 x BWt (g)

1kg x 0007 = 7mls2kg x 0007 = 14mls

163

Gastric overfilling syndrome

164

75 ml per feeding ASSUMPTION

IMMATURE OR OVERWHELMED

many aspects of gastrointestinalmotility are immature in the neonate

Zangen S et al Rapid maturation of gastric relaxation in newborns

A balloon in stomachcan fill to 76 mls

What does the stomach ndashwithout a balloon ndashdo to 76 mls

REFLUX PRESUME each feedapproximately 75 mls

GER

bull Sudden outbursts of crying

bull Awakens in pain

bull Related to feedings

bull Not easily comforted

bull ldquoI know baby hurtsrdquo

bull Sour burps throaty noises

bull Best when upright

Clues to GER

Dr W Sears

29

Mitchell 2001

Kerstin Uvnaumls-Moberg

Food in duodenum

AMYLINreleased

Closes pylorus

Duodenumempty

Pylorusopens

ldquoFeed intolerancerdquo hellip hellip or VOLUME intolerance

HYPOGLYCAEMIA

A babies stomach empties in60 minutes

Blood sugarmay fall hellip

after 90 minutes Options

30

METABOLIC ADAPTATION

SSC started in the first 20 minutes after birth

SSC CotBlood glucose (1 hr) 317 256Base excess drop 34 18

(Christenson 1992)0h 1h 2h 3h 4h 2 days

App

roxim

ate

GLUCOSE

SSC Glucose production = Glucose consumption

Separation

SNS stress Glucose consumption INCREASE

PSNS dissociation Glucose production DECREASE

HYPOGLYCEMIA

SSC Cot

Blood glucose (1 hr) 317 256

0h 1h 2h 3h 4h 2 days

App

roxim

ate

GLUCOSE

SSC Glucose production = Glucose consumption

Separation PSNS dissociation

Glucose production DECREASE

HYPOGLYCEMIA

SSC Cot

Blood glucose (1 hr) 317 256

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

NEURODEVELOPMENTThe DNA Behaviour

EVOLUTIONARY BIOLOGY

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

BONDING ATTACHMENT

MRI HRVEEG

STRESS RESPONES

RESILIENCE

DOHAD

(MAL) ADAPTATION

EPIGENETICS

GENE X ENVIRONMENT

GENETIC VARIANTS

HOSPITAL ACQUIRED INFECTIONIMMUNITY

SLEEP PHYSIOLOGY

GUT FUNCTIONMICROBIOTA

ldquoSTABILITYrdquo

TRANSITION

LONG TERM FOLLOW-UP

NEUROENDOCRINE BEHAVIOURS

MATERNAL NEUROPLASTICITY

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

MORTALITYMETABOLISM

0h 1h 2h 3h 4h

PSNS (vagal)

App

roxim

ate

GLUCOSE

1 HOURLY Milk feed

1 HOURLY Milk feed

1 HOURLY Milk feed

1 HOURLY Milk feed

LACTOSE

METABOLISM

31

0h 1h 2h 3h 4h

PSNS (vagal) SYMPATHETIC STRESS

App

roxim

ate

GLUCOSE

LACTOSE FATGLYCOGEN

METABOLISM

4 HOURLY Milk feed

0h 1h 2h 3h 4h

PSNS (vagal) SYMPATHETIC STRESS

App

roxim

ate

GLUCOSE

4 HOURLY ALLOSTATIC STATELACTOSE FATGLYCOGEN

METABOLISM

4 HOURLY Milk feed

HEALTH DISEASE

EXPECTED UNEXPECTED

NEURODEVELOPMENTThe DNA Behaviour

EVOLUTIONARY BIOLOGY

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

BONDING ATTACHMENT

MRI HRVEEG

STRESS RESPONES

RESILIENCE

DOHAD

(MAL) ADAPTATION

EPIGENETICS

GENE X ENVIRONMENT

GENETIC VARIANTS

HOSPITAL ACQUIRED INFECTIONIMMUNITY

SLEEP PHYSIOLOGY

GUT FUNCTIONMICROBIOTA

ldquoSTABILITYrdquo

TRANSITION

LONG TERM FOLLOW-UP

NEUROENDOCRINE BEHAVIOURS

MATERNAL NEUROPLASTICITY

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

MORTALITYMETABOLISM

Weight gain 1st week

predicts OBESITYat 30 years

Large volume feedsstretched stomach=

doubled absorptivecapacity as adult

Importance

Programming ndash early life chronic disease

32

RESISTANCE SENSITIVITY

PERCEPTIONSldquoNEUROCEPTIONrdquo

RESPONSESTRESS

ALLOSTATIC STATE

ALLOSTASIS

ANY STRESSPsychologicalNeurological

EndocrineImmune

ALLOSTATIC LOAD

ALLOSTATIC OVERLOAD

WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY

DISEASEHEALTH

RESILIENCE VULNERABILITY

RESISTANCE SENSITIVITY

PERCEPTIONSldquoNEUROCEPTIONrdquo

RESPONSESTRESS

ALLOSTATIC STATE

ALLOSTASIS

ANY STRESSPsychologicalNeurological

EndocrineImmune

ALLOSTATIC LOAD

HEALTH

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

Gastric overfilling syndrome

189

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

33

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

Only case series Insufficient evidence

No mention of

stomach capacity196

Baby weight freq reqrsquod size actual

2kg baby 4hrly ~ 320 ml6 = 53ml 14ml

15 baby 3hrly ~ 240 ml8 = 30ml 10ml

10 baby 2hrly ~ 160 ml12 = 13ml 7ml

Standardised from20ml capacityfor 3kg baby( x 0007)

197

0

10

20

30

40

50

60

70

80

90

13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w

LINEAR

TERM

PREM

198

34

0

10

20

30

40

50

60

70

80

90

13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w

LINEAR

TERM

PREM

199

Clues to GER

ldquoI know baby hurtsrdquo

Gastric overfilling syndrome

Excessive volumesreflux aspiration colic

Excessive time intervalhypoglycaemia

Adaptationsdiabetic diathesis obesity

200

Developmental Care of the Enteric Nervous System

ldquoSmall and frequent feeds according to the sleep cyclerdquo

The ldquonicherdquo (occupation) of a neonate (Alberts)

BOND FEED

SLEEP SLEEP

PLAY FEED

201

Gastric overfilling syndrome

Proposed Management 202

Proposed Management

Babies should be fedEVERY TIME THEY WAKE

Stanley Graven 2006

REMNR1NR2NR3SWS

AS (20 mins) QS (40 mins)

A normal sleep cycle is ONE hourHow often should neonates feed

203

Proposed Management

All babies should be fedat least once an hour 204

35

Proposed Management

All babies should be fedat least once an hour

205

The first Milk Ejection Reflex (MER)

elicited in lt 2 minutesworks quicklyswallowed 1 minute

Feeding time (max)3 minutes

Repeat every 1 hour

Prime 2007

The ldquonormalrdquo or usual and common breastfeed

takes 15 minutesdiscomfort afterburping time 5 minutes

Feeding time 20 min

Repeat every 3 hours

Prime 2007

3 minute 20ml feeds x 24d = 72 minutes

20 minute 60ml feeds x 8d = 160 minutes

SMALL AND FREQUENT FEEDS ARE EFFICIENT

FEWER NURSES NEEDED

The calculated dailyrequirement for a 3kgbaby can be given without increase inpressure MINIMAL RISK

PARENTS CAN DOSAFELY

20 mls x 24 feeds= 480mls day

Zangen 2001 209

All babies should be fedat least once an hour

210

36

Infant feeding frequencyProposal based on available evidence and neuroscience

ldquoSmall and frequent feeds

adjusted to the sleep cyclerdquo

211

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

STATE organization

Feeding frequency

SLEEP cycling

BRAIN

WIRING

How often should a neonate feeda neonate sleep

Infantsleep cycles

begin to block on diurnalrhythms

Mother-infant synchrony

hellip at 12 weeks

(circadian)

START at 3 months

Can be ldquoadult-likerdquo

at 6 months

Thomas 2014

STATE organization

Feeding frequency

SLEEP cycling

PLAY FEED

216

SLEEP SLEEP

SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

Infantsleep cycles

begin to block on diurnalrhythms

37

BOND SUCKLE SLEEP SLEEP PLAY

FEED

217

SLEEP SLEEP SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)

Schaal 2004 218

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)rdquoSLEEP-FEED CYCLINGrdquo

Schaal 2004 219

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

WIRE

BRAIN

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

BRAIN

WIRING

NEUROSCIENCE

The DNAEverything else

EVOLUTIONARYBIOLOGY

The Brain

EPIGENETICS

The PlaceENVIRONMENT

EXPERIENCEFITNESS ADAPTATION

ldquoScientific foundationrdquo hellip a synthesis

ZERO

SEPARATION

38

wwwninobirthorgwwwskintoskincontactcom

THE NEUROSCIENCE OFSKIN-TO-SKIN CONTACT

AND BREASTFEEDING

ARE THE SAME

SUMMARY SKIN-TO-SKIN

(Regulation)

SLEEP(Brain)

FEEDING(Stomach)

LOVE ( ldquomindrdquo )

REMNR1NR2NR3NR4

ACQUISITION CONSOLIDATION MEMORYFORMATION

poly-sensory input transfer information P wavesshort-term memory ldquoSNRrdquo strong signals returns infostored cortex amygdala to neocortex

hippocampus organizedAwake and REM NREM stage 4 REM

BRAIN WIRING

Stanley Graven 2006

PLAY

SLEEP

FEEDHOLDYOURPREM

httpswwwfacebookcomninobirth

39

Nelson Mandela

hellip in describing themeasure of a nation

he has argued that

ldquoThere can be no keener revelation of a societyrsquos soul than the way in which it treats its childrenrdquo

Page 23: Neurodevelopmental The Neuroscience of Birth ... · breastfeeding pattern, neonatal weight gain, and the dynamics of lactation. Doucet 2012 In the ‘‘scentless breast’’ condition,

23

Cup feeding versus bottle feedingCup feeding higher breastfeeding

greater stability133

Only case series Insufficient evidence

No mention of

stomach capacity134

EVIDENCE FORSTOMACH CAPACITY

Edmond 2006 135

0

05

1

15

2

25

3

35

4

0 10 20 30 40 50 60 70 80

volume ingested

fee

din

g f

req

ue

nc

y

Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml

StandardCARE3 hourlyschedule

136

KEY QUESTION

WHAT IS THE

STOMACHVOLUMEOF THE

NEONATE 137 Sase 2005

ldquoOntogeny of gastric emptying patternsin the human fetusrdquo

138

24

Goldstein 1987

ldquoGrowth of the Fetal Stomach in Normal Pregnanciesrdquo

139 Goldstein 1987

Length

Transverse

AP diameter

Using +2SD

140

Formula for calculation of stomach capacity (Charles Bradshaw UCT)Assumptions the stomach can be approximated by dividing into three sections namely a ellipsoidal hemisphere an ellipsoidal cylinder and a skewed ellipsoidal cone Variables a = anteroposterior radius t = transverse radius l = length stomachRelations the height of the cone and the hemisphere are both the same as lsquoarsquo

Ellipsoid = 43 Pi r1r2r3 = 43 Pi a a t therefore volume of hemisphere = 23 Pi a a t

Cylinder = Area of base height = (Pi a t ) ( l - 2a )Skewed cone = 13 base height = 13 Pi a t aTotal volume = 23 Pi aat + Pi a t (l- 2a) + 13 Pi a t a

=Pi atl -Pi a at= Pi a t(l-a)

Goldstein and Sase dataStomach capacity at term 10 - 15 ml

BRADSHAW formula

141

Assumption 25 kg baby 33w GA

requiring 150 mlkgday = 375 ml

45 MIN CYCLES ( 32 cyclesday)

12 ML PER CYCLE = 384 ml142

Newborn stomach volume

Gastric volumes at birthCorrelated with gastric pH

gastrin and somatostatin

ldquofetus drinks 10 ml portions of amniotic fluid helliprdquo

Widstrom 1988 143

Only recent study locatedldquoAutopsyrdquo capacity was determined

in Indian post-mortem studies

100 autopsies (63 SB 37 ENND)Tied at cardia and pylorus filled withwater emptied amp measured repeatedldquohellip obliteration of the gastric curvaturesrdquoldquodue care to minimize stretch artifactsrdquo

Naveed 1992

ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo

144

25

Infants above 2500g onlyAve Range

Stillborn (n 11) 196 ml (10-35)Early death (n 9) 178 ml (10-25)All cases (n 20) 188 ml

Naveed 1992

ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo

145 146

KERNESSUK 1997 (Russian)

Postmortem in situ measures(applied Bradshaw formula)

AveNewborn (n 11) 15 ml2 months (n 11) 35 ml2-4 m (n 10) 50 ml4-6 m (n 8) 100 ml

Known references with data

Scammon and Doyle 1920

Zuccarellirsquos method stomach filled at autopsy to ldquoa pressure of between

15 and 20 centimeters of waterrdquo

Scammon 1920

ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo

147

Anatomic capacity was determined in post-mortem studies

Main data set Alliot 1905 (n 25)Scammon own cases (n 13)

30 ndash 35 ml at birth ndashalmost regardless of birth weight

Scammon 1920

ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo

148

Zangen S et al Rapid maturation of gastric relaxation in newborns

Pressures (mmHg)

Balloon inflates to

15 ml no increase

functional capacity

149

Zangen S et al Rapid maturation of gastric relaxation in newborns

Pressures (mmHg)

Balloon inflates to

15 ml no increase20 ml pressure OK

physiologicalcapacity hellip 150

26

EVIDENCE (NBn 111009)

Author Capacity NoteSase 10-15 ml Live term fetusGoldstein 10-15 ml Live term fetusWidstrom 10 mls Live newbornZangen 20 mls Live (pressure)

Naveed 20 mls Autopsy (SB)20 mls Autopsy (ENND)

Kernessuk 15 mls Autopsy (in situ)Scammon 30-35 ml Autopsy (water

(Alliot) pressure)151

PROPOSAL

The CAPACITY of aweek old babyrsquos stomach is

approx 20 ml152

0

05

1

15

2

25

3

35

4

0 10 20 30 40 50 60 70 80

volume ingested

fee

din

g f

req

ue

nc

y

Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml

StandardCARE3 hourlyschedule

MOTHERNATURE

1 hourlyschedule

153

PHYSIOLOGICAL CAPACITY

RECEPTIVE CAPACITY of stomach

INGESTIVE CAPACITY of BABY

FUNCTIONAL CAPACITY

154

PROPOSAL

The FEEDINGFREQUENCY of theNEONATE is

approx 60 min155

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

BRAIN CYCLING

STOMACH FILLING amp EMPTYING

REMNR1NR2NR3NR4

156

27

Normal physiology of theEnteric Nervous System

ldquoSmall and frequent feeds according to the sleep cyclerdquo

The ldquonicherdquo (occupation) of a neonate (Alberts)

BOND FEED

SLEEP SLEEP

PLAY FEED

157

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

FEEDING SUCKLING

Influence of SMELL None Totally dependent

Motor mechanism Chewing ndash different

muscles

Suckling ndash different circuits

INSULIN Increases weight No effect

GHRELIN Increases weight No effect

LEPTIN Decreases intake No effect

CHOLECYSTOKININ Decreases intake No effect

AMPHETAMINE Decreases appetite Increases suckling

SEROTONIN Agonist improves feeding Antagonist improves suck

SATIETY Infant determined Maternal supply determine

FEEDING SUCKLING

Influence of SMELL None Totally dependent

Motor mechanism Chewing ndash different

muscles

Suckling ndash different circuits

INSULIN Increases weight No effect

GHRELIN Increases weight No effect

LEPTIN Decreases intake No effect

CHOLECYSTOKININ Decreases intake No effect

AMPHETAMINE Decreases appetite Increases suckling

SEROTONIN Agonist improves feeding Antagonist improves suck

SATIETY Infant determined Maternal supply determine

Current dogmaTHE BABY KNOWS

WHEN IT HAS HAD ENOUGH

PROBABLY NOT

WHAT IS THE

STOMACH VOLUME OF THE

PREMATURE

161

Assume low resilience

Assume proportionality

162

28

The CAPACITY of alow birthweight premfrom 20ml 3000g

= 0007 x BWt (g)

1kg x 0007 = 7mls2kg x 0007 = 14mls

163

Gastric overfilling syndrome

164

75 ml per feeding ASSUMPTION

IMMATURE OR OVERWHELMED

many aspects of gastrointestinalmotility are immature in the neonate

Zangen S et al Rapid maturation of gastric relaxation in newborns

A balloon in stomachcan fill to 76 mls

What does the stomach ndashwithout a balloon ndashdo to 76 mls

REFLUX PRESUME each feedapproximately 75 mls

GER

bull Sudden outbursts of crying

bull Awakens in pain

bull Related to feedings

bull Not easily comforted

bull ldquoI know baby hurtsrdquo

bull Sour burps throaty noises

bull Best when upright

Clues to GER

Dr W Sears

29

Mitchell 2001

Kerstin Uvnaumls-Moberg

Food in duodenum

AMYLINreleased

Closes pylorus

Duodenumempty

Pylorusopens

ldquoFeed intolerancerdquo hellip hellip or VOLUME intolerance

HYPOGLYCAEMIA

A babies stomach empties in60 minutes

Blood sugarmay fall hellip

after 90 minutes Options

30

METABOLIC ADAPTATION

SSC started in the first 20 minutes after birth

SSC CotBlood glucose (1 hr) 317 256Base excess drop 34 18

(Christenson 1992)0h 1h 2h 3h 4h 2 days

App

roxim

ate

GLUCOSE

SSC Glucose production = Glucose consumption

Separation

SNS stress Glucose consumption INCREASE

PSNS dissociation Glucose production DECREASE

HYPOGLYCEMIA

SSC Cot

Blood glucose (1 hr) 317 256

0h 1h 2h 3h 4h 2 days

App

roxim

ate

GLUCOSE

SSC Glucose production = Glucose consumption

Separation PSNS dissociation

Glucose production DECREASE

HYPOGLYCEMIA

SSC Cot

Blood glucose (1 hr) 317 256

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

NEURODEVELOPMENTThe DNA Behaviour

EVOLUTIONARY BIOLOGY

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

BONDING ATTACHMENT

MRI HRVEEG

STRESS RESPONES

RESILIENCE

DOHAD

(MAL) ADAPTATION

EPIGENETICS

GENE X ENVIRONMENT

GENETIC VARIANTS

HOSPITAL ACQUIRED INFECTIONIMMUNITY

SLEEP PHYSIOLOGY

GUT FUNCTIONMICROBIOTA

ldquoSTABILITYrdquo

TRANSITION

LONG TERM FOLLOW-UP

NEUROENDOCRINE BEHAVIOURS

MATERNAL NEUROPLASTICITY

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

MORTALITYMETABOLISM

0h 1h 2h 3h 4h

PSNS (vagal)

App

roxim

ate

GLUCOSE

1 HOURLY Milk feed

1 HOURLY Milk feed

1 HOURLY Milk feed

1 HOURLY Milk feed

LACTOSE

METABOLISM

31

0h 1h 2h 3h 4h

PSNS (vagal) SYMPATHETIC STRESS

App

roxim

ate

GLUCOSE

LACTOSE FATGLYCOGEN

METABOLISM

4 HOURLY Milk feed

0h 1h 2h 3h 4h

PSNS (vagal) SYMPATHETIC STRESS

App

roxim

ate

GLUCOSE

4 HOURLY ALLOSTATIC STATELACTOSE FATGLYCOGEN

METABOLISM

4 HOURLY Milk feed

HEALTH DISEASE

EXPECTED UNEXPECTED

NEURODEVELOPMENTThe DNA Behaviour

EVOLUTIONARY BIOLOGY

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

BONDING ATTACHMENT

MRI HRVEEG

STRESS RESPONES

RESILIENCE

DOHAD

(MAL) ADAPTATION

EPIGENETICS

GENE X ENVIRONMENT

GENETIC VARIANTS

HOSPITAL ACQUIRED INFECTIONIMMUNITY

SLEEP PHYSIOLOGY

GUT FUNCTIONMICROBIOTA

ldquoSTABILITYrdquo

TRANSITION

LONG TERM FOLLOW-UP

NEUROENDOCRINE BEHAVIOURS

MATERNAL NEUROPLASTICITY

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

MORTALITYMETABOLISM

Weight gain 1st week

predicts OBESITYat 30 years

Large volume feedsstretched stomach=

doubled absorptivecapacity as adult

Importance

Programming ndash early life chronic disease

32

RESISTANCE SENSITIVITY

PERCEPTIONSldquoNEUROCEPTIONrdquo

RESPONSESTRESS

ALLOSTATIC STATE

ALLOSTASIS

ANY STRESSPsychologicalNeurological

EndocrineImmune

ALLOSTATIC LOAD

ALLOSTATIC OVERLOAD

WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY

DISEASEHEALTH

RESILIENCE VULNERABILITY

RESISTANCE SENSITIVITY

PERCEPTIONSldquoNEUROCEPTIONrdquo

RESPONSESTRESS

ALLOSTATIC STATE

ALLOSTASIS

ANY STRESSPsychologicalNeurological

EndocrineImmune

ALLOSTATIC LOAD

HEALTH

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

Gastric overfilling syndrome

189

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

33

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

Only case series Insufficient evidence

No mention of

stomach capacity196

Baby weight freq reqrsquod size actual

2kg baby 4hrly ~ 320 ml6 = 53ml 14ml

15 baby 3hrly ~ 240 ml8 = 30ml 10ml

10 baby 2hrly ~ 160 ml12 = 13ml 7ml

Standardised from20ml capacityfor 3kg baby( x 0007)

197

0

10

20

30

40

50

60

70

80

90

13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w

LINEAR

TERM

PREM

198

34

0

10

20

30

40

50

60

70

80

90

13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w

LINEAR

TERM

PREM

199

Clues to GER

ldquoI know baby hurtsrdquo

Gastric overfilling syndrome

Excessive volumesreflux aspiration colic

Excessive time intervalhypoglycaemia

Adaptationsdiabetic diathesis obesity

200

Developmental Care of the Enteric Nervous System

ldquoSmall and frequent feeds according to the sleep cyclerdquo

The ldquonicherdquo (occupation) of a neonate (Alberts)

BOND FEED

SLEEP SLEEP

PLAY FEED

201

Gastric overfilling syndrome

Proposed Management 202

Proposed Management

Babies should be fedEVERY TIME THEY WAKE

Stanley Graven 2006

REMNR1NR2NR3SWS

AS (20 mins) QS (40 mins)

A normal sleep cycle is ONE hourHow often should neonates feed

203

Proposed Management

All babies should be fedat least once an hour 204

35

Proposed Management

All babies should be fedat least once an hour

205

The first Milk Ejection Reflex (MER)

elicited in lt 2 minutesworks quicklyswallowed 1 minute

Feeding time (max)3 minutes

Repeat every 1 hour

Prime 2007

The ldquonormalrdquo or usual and common breastfeed

takes 15 minutesdiscomfort afterburping time 5 minutes

Feeding time 20 min

Repeat every 3 hours

Prime 2007

3 minute 20ml feeds x 24d = 72 minutes

20 minute 60ml feeds x 8d = 160 minutes

SMALL AND FREQUENT FEEDS ARE EFFICIENT

FEWER NURSES NEEDED

The calculated dailyrequirement for a 3kgbaby can be given without increase inpressure MINIMAL RISK

PARENTS CAN DOSAFELY

20 mls x 24 feeds= 480mls day

Zangen 2001 209

All babies should be fedat least once an hour

210

36

Infant feeding frequencyProposal based on available evidence and neuroscience

ldquoSmall and frequent feeds

adjusted to the sleep cyclerdquo

211

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

STATE organization

Feeding frequency

SLEEP cycling

BRAIN

WIRING

How often should a neonate feeda neonate sleep

Infantsleep cycles

begin to block on diurnalrhythms

Mother-infant synchrony

hellip at 12 weeks

(circadian)

START at 3 months

Can be ldquoadult-likerdquo

at 6 months

Thomas 2014

STATE organization

Feeding frequency

SLEEP cycling

PLAY FEED

216

SLEEP SLEEP

SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

Infantsleep cycles

begin to block on diurnalrhythms

37

BOND SUCKLE SLEEP SLEEP PLAY

FEED

217

SLEEP SLEEP SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)

Schaal 2004 218

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)rdquoSLEEP-FEED CYCLINGrdquo

Schaal 2004 219

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

WIRE

BRAIN

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

BRAIN

WIRING

NEUROSCIENCE

The DNAEverything else

EVOLUTIONARYBIOLOGY

The Brain

EPIGENETICS

The PlaceENVIRONMENT

EXPERIENCEFITNESS ADAPTATION

ldquoScientific foundationrdquo hellip a synthesis

ZERO

SEPARATION

38

wwwninobirthorgwwwskintoskincontactcom

THE NEUROSCIENCE OFSKIN-TO-SKIN CONTACT

AND BREASTFEEDING

ARE THE SAME

SUMMARY SKIN-TO-SKIN

(Regulation)

SLEEP(Brain)

FEEDING(Stomach)

LOVE ( ldquomindrdquo )

REMNR1NR2NR3NR4

ACQUISITION CONSOLIDATION MEMORYFORMATION

poly-sensory input transfer information P wavesshort-term memory ldquoSNRrdquo strong signals returns infostored cortex amygdala to neocortex

hippocampus organizedAwake and REM NREM stage 4 REM

BRAIN WIRING

Stanley Graven 2006

PLAY

SLEEP

FEEDHOLDYOURPREM

httpswwwfacebookcomninobirth

39

Nelson Mandela

hellip in describing themeasure of a nation

he has argued that

ldquoThere can be no keener revelation of a societyrsquos soul than the way in which it treats its childrenrdquo

Page 24: Neurodevelopmental The Neuroscience of Birth ... · breastfeeding pattern, neonatal weight gain, and the dynamics of lactation. Doucet 2012 In the ‘‘scentless breast’’ condition,

24

Goldstein 1987

ldquoGrowth of the Fetal Stomach in Normal Pregnanciesrdquo

139 Goldstein 1987

Length

Transverse

AP diameter

Using +2SD

140

Formula for calculation of stomach capacity (Charles Bradshaw UCT)Assumptions the stomach can be approximated by dividing into three sections namely a ellipsoidal hemisphere an ellipsoidal cylinder and a skewed ellipsoidal cone Variables a = anteroposterior radius t = transverse radius l = length stomachRelations the height of the cone and the hemisphere are both the same as lsquoarsquo

Ellipsoid = 43 Pi r1r2r3 = 43 Pi a a t therefore volume of hemisphere = 23 Pi a a t

Cylinder = Area of base height = (Pi a t ) ( l - 2a )Skewed cone = 13 base height = 13 Pi a t aTotal volume = 23 Pi aat + Pi a t (l- 2a) + 13 Pi a t a

=Pi atl -Pi a at= Pi a t(l-a)

Goldstein and Sase dataStomach capacity at term 10 - 15 ml

BRADSHAW formula

141

Assumption 25 kg baby 33w GA

requiring 150 mlkgday = 375 ml

45 MIN CYCLES ( 32 cyclesday)

12 ML PER CYCLE = 384 ml142

Newborn stomach volume

Gastric volumes at birthCorrelated with gastric pH

gastrin and somatostatin

ldquofetus drinks 10 ml portions of amniotic fluid helliprdquo

Widstrom 1988 143

Only recent study locatedldquoAutopsyrdquo capacity was determined

in Indian post-mortem studies

100 autopsies (63 SB 37 ENND)Tied at cardia and pylorus filled withwater emptied amp measured repeatedldquohellip obliteration of the gastric curvaturesrdquoldquodue care to minimize stretch artifactsrdquo

Naveed 1992

ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo

144

25

Infants above 2500g onlyAve Range

Stillborn (n 11) 196 ml (10-35)Early death (n 9) 178 ml (10-25)All cases (n 20) 188 ml

Naveed 1992

ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo

145 146

KERNESSUK 1997 (Russian)

Postmortem in situ measures(applied Bradshaw formula)

AveNewborn (n 11) 15 ml2 months (n 11) 35 ml2-4 m (n 10) 50 ml4-6 m (n 8) 100 ml

Known references with data

Scammon and Doyle 1920

Zuccarellirsquos method stomach filled at autopsy to ldquoa pressure of between

15 and 20 centimeters of waterrdquo

Scammon 1920

ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo

147

Anatomic capacity was determined in post-mortem studies

Main data set Alliot 1905 (n 25)Scammon own cases (n 13)

30 ndash 35 ml at birth ndashalmost regardless of birth weight

Scammon 1920

ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo

148

Zangen S et al Rapid maturation of gastric relaxation in newborns

Pressures (mmHg)

Balloon inflates to

15 ml no increase

functional capacity

149

Zangen S et al Rapid maturation of gastric relaxation in newborns

Pressures (mmHg)

Balloon inflates to

15 ml no increase20 ml pressure OK

physiologicalcapacity hellip 150

26

EVIDENCE (NBn 111009)

Author Capacity NoteSase 10-15 ml Live term fetusGoldstein 10-15 ml Live term fetusWidstrom 10 mls Live newbornZangen 20 mls Live (pressure)

Naveed 20 mls Autopsy (SB)20 mls Autopsy (ENND)

Kernessuk 15 mls Autopsy (in situ)Scammon 30-35 ml Autopsy (water

(Alliot) pressure)151

PROPOSAL

The CAPACITY of aweek old babyrsquos stomach is

approx 20 ml152

0

05

1

15

2

25

3

35

4

0 10 20 30 40 50 60 70 80

volume ingested

fee

din

g f

req

ue

nc

y

Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml

StandardCARE3 hourlyschedule

MOTHERNATURE

1 hourlyschedule

153

PHYSIOLOGICAL CAPACITY

RECEPTIVE CAPACITY of stomach

INGESTIVE CAPACITY of BABY

FUNCTIONAL CAPACITY

154

PROPOSAL

The FEEDINGFREQUENCY of theNEONATE is

approx 60 min155

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

BRAIN CYCLING

STOMACH FILLING amp EMPTYING

REMNR1NR2NR3NR4

156

27

Normal physiology of theEnteric Nervous System

ldquoSmall and frequent feeds according to the sleep cyclerdquo

The ldquonicherdquo (occupation) of a neonate (Alberts)

BOND FEED

SLEEP SLEEP

PLAY FEED

157

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

FEEDING SUCKLING

Influence of SMELL None Totally dependent

Motor mechanism Chewing ndash different

muscles

Suckling ndash different circuits

INSULIN Increases weight No effect

GHRELIN Increases weight No effect

LEPTIN Decreases intake No effect

CHOLECYSTOKININ Decreases intake No effect

AMPHETAMINE Decreases appetite Increases suckling

SEROTONIN Agonist improves feeding Antagonist improves suck

SATIETY Infant determined Maternal supply determine

FEEDING SUCKLING

Influence of SMELL None Totally dependent

Motor mechanism Chewing ndash different

muscles

Suckling ndash different circuits

INSULIN Increases weight No effect

GHRELIN Increases weight No effect

LEPTIN Decreases intake No effect

CHOLECYSTOKININ Decreases intake No effect

AMPHETAMINE Decreases appetite Increases suckling

SEROTONIN Agonist improves feeding Antagonist improves suck

SATIETY Infant determined Maternal supply determine

Current dogmaTHE BABY KNOWS

WHEN IT HAS HAD ENOUGH

PROBABLY NOT

WHAT IS THE

STOMACH VOLUME OF THE

PREMATURE

161

Assume low resilience

Assume proportionality

162

28

The CAPACITY of alow birthweight premfrom 20ml 3000g

= 0007 x BWt (g)

1kg x 0007 = 7mls2kg x 0007 = 14mls

163

Gastric overfilling syndrome

164

75 ml per feeding ASSUMPTION

IMMATURE OR OVERWHELMED

many aspects of gastrointestinalmotility are immature in the neonate

Zangen S et al Rapid maturation of gastric relaxation in newborns

A balloon in stomachcan fill to 76 mls

What does the stomach ndashwithout a balloon ndashdo to 76 mls

REFLUX PRESUME each feedapproximately 75 mls

GER

bull Sudden outbursts of crying

bull Awakens in pain

bull Related to feedings

bull Not easily comforted

bull ldquoI know baby hurtsrdquo

bull Sour burps throaty noises

bull Best when upright

Clues to GER

Dr W Sears

29

Mitchell 2001

Kerstin Uvnaumls-Moberg

Food in duodenum

AMYLINreleased

Closes pylorus

Duodenumempty

Pylorusopens

ldquoFeed intolerancerdquo hellip hellip or VOLUME intolerance

HYPOGLYCAEMIA

A babies stomach empties in60 minutes

Blood sugarmay fall hellip

after 90 minutes Options

30

METABOLIC ADAPTATION

SSC started in the first 20 minutes after birth

SSC CotBlood glucose (1 hr) 317 256Base excess drop 34 18

(Christenson 1992)0h 1h 2h 3h 4h 2 days

App

roxim

ate

GLUCOSE

SSC Glucose production = Glucose consumption

Separation

SNS stress Glucose consumption INCREASE

PSNS dissociation Glucose production DECREASE

HYPOGLYCEMIA

SSC Cot

Blood glucose (1 hr) 317 256

0h 1h 2h 3h 4h 2 days

App

roxim

ate

GLUCOSE

SSC Glucose production = Glucose consumption

Separation PSNS dissociation

Glucose production DECREASE

HYPOGLYCEMIA

SSC Cot

Blood glucose (1 hr) 317 256

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

NEURODEVELOPMENTThe DNA Behaviour

EVOLUTIONARY BIOLOGY

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

BONDING ATTACHMENT

MRI HRVEEG

STRESS RESPONES

RESILIENCE

DOHAD

(MAL) ADAPTATION

EPIGENETICS

GENE X ENVIRONMENT

GENETIC VARIANTS

HOSPITAL ACQUIRED INFECTIONIMMUNITY

SLEEP PHYSIOLOGY

GUT FUNCTIONMICROBIOTA

ldquoSTABILITYrdquo

TRANSITION

LONG TERM FOLLOW-UP

NEUROENDOCRINE BEHAVIOURS

MATERNAL NEUROPLASTICITY

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

MORTALITYMETABOLISM

0h 1h 2h 3h 4h

PSNS (vagal)

App

roxim

ate

GLUCOSE

1 HOURLY Milk feed

1 HOURLY Milk feed

1 HOURLY Milk feed

1 HOURLY Milk feed

LACTOSE

METABOLISM

31

0h 1h 2h 3h 4h

PSNS (vagal) SYMPATHETIC STRESS

App

roxim

ate

GLUCOSE

LACTOSE FATGLYCOGEN

METABOLISM

4 HOURLY Milk feed

0h 1h 2h 3h 4h

PSNS (vagal) SYMPATHETIC STRESS

App

roxim

ate

GLUCOSE

4 HOURLY ALLOSTATIC STATELACTOSE FATGLYCOGEN

METABOLISM

4 HOURLY Milk feed

HEALTH DISEASE

EXPECTED UNEXPECTED

NEURODEVELOPMENTThe DNA Behaviour

EVOLUTIONARY BIOLOGY

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

BONDING ATTACHMENT

MRI HRVEEG

STRESS RESPONES

RESILIENCE

DOHAD

(MAL) ADAPTATION

EPIGENETICS

GENE X ENVIRONMENT

GENETIC VARIANTS

HOSPITAL ACQUIRED INFECTIONIMMUNITY

SLEEP PHYSIOLOGY

GUT FUNCTIONMICROBIOTA

ldquoSTABILITYrdquo

TRANSITION

LONG TERM FOLLOW-UP

NEUROENDOCRINE BEHAVIOURS

MATERNAL NEUROPLASTICITY

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

MORTALITYMETABOLISM

Weight gain 1st week

predicts OBESITYat 30 years

Large volume feedsstretched stomach=

doubled absorptivecapacity as adult

Importance

Programming ndash early life chronic disease

32

RESISTANCE SENSITIVITY

PERCEPTIONSldquoNEUROCEPTIONrdquo

RESPONSESTRESS

ALLOSTATIC STATE

ALLOSTASIS

ANY STRESSPsychologicalNeurological

EndocrineImmune

ALLOSTATIC LOAD

ALLOSTATIC OVERLOAD

WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY

DISEASEHEALTH

RESILIENCE VULNERABILITY

RESISTANCE SENSITIVITY

PERCEPTIONSldquoNEUROCEPTIONrdquo

RESPONSESTRESS

ALLOSTATIC STATE

ALLOSTASIS

ANY STRESSPsychologicalNeurological

EndocrineImmune

ALLOSTATIC LOAD

HEALTH

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

Gastric overfilling syndrome

189

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

33

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

Only case series Insufficient evidence

No mention of

stomach capacity196

Baby weight freq reqrsquod size actual

2kg baby 4hrly ~ 320 ml6 = 53ml 14ml

15 baby 3hrly ~ 240 ml8 = 30ml 10ml

10 baby 2hrly ~ 160 ml12 = 13ml 7ml

Standardised from20ml capacityfor 3kg baby( x 0007)

197

0

10

20

30

40

50

60

70

80

90

13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w

LINEAR

TERM

PREM

198

34

0

10

20

30

40

50

60

70

80

90

13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w

LINEAR

TERM

PREM

199

Clues to GER

ldquoI know baby hurtsrdquo

Gastric overfilling syndrome

Excessive volumesreflux aspiration colic

Excessive time intervalhypoglycaemia

Adaptationsdiabetic diathesis obesity

200

Developmental Care of the Enteric Nervous System

ldquoSmall and frequent feeds according to the sleep cyclerdquo

The ldquonicherdquo (occupation) of a neonate (Alberts)

BOND FEED

SLEEP SLEEP

PLAY FEED

201

Gastric overfilling syndrome

Proposed Management 202

Proposed Management

Babies should be fedEVERY TIME THEY WAKE

Stanley Graven 2006

REMNR1NR2NR3SWS

AS (20 mins) QS (40 mins)

A normal sleep cycle is ONE hourHow often should neonates feed

203

Proposed Management

All babies should be fedat least once an hour 204

35

Proposed Management

All babies should be fedat least once an hour

205

The first Milk Ejection Reflex (MER)

elicited in lt 2 minutesworks quicklyswallowed 1 minute

Feeding time (max)3 minutes

Repeat every 1 hour

Prime 2007

The ldquonormalrdquo or usual and common breastfeed

takes 15 minutesdiscomfort afterburping time 5 minutes

Feeding time 20 min

Repeat every 3 hours

Prime 2007

3 minute 20ml feeds x 24d = 72 minutes

20 minute 60ml feeds x 8d = 160 minutes

SMALL AND FREQUENT FEEDS ARE EFFICIENT

FEWER NURSES NEEDED

The calculated dailyrequirement for a 3kgbaby can be given without increase inpressure MINIMAL RISK

PARENTS CAN DOSAFELY

20 mls x 24 feeds= 480mls day

Zangen 2001 209

All babies should be fedat least once an hour

210

36

Infant feeding frequencyProposal based on available evidence and neuroscience

ldquoSmall and frequent feeds

adjusted to the sleep cyclerdquo

211

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

STATE organization

Feeding frequency

SLEEP cycling

BRAIN

WIRING

How often should a neonate feeda neonate sleep

Infantsleep cycles

begin to block on diurnalrhythms

Mother-infant synchrony

hellip at 12 weeks

(circadian)

START at 3 months

Can be ldquoadult-likerdquo

at 6 months

Thomas 2014

STATE organization

Feeding frequency

SLEEP cycling

PLAY FEED

216

SLEEP SLEEP

SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

Infantsleep cycles

begin to block on diurnalrhythms

37

BOND SUCKLE SLEEP SLEEP PLAY

FEED

217

SLEEP SLEEP SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)

Schaal 2004 218

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)rdquoSLEEP-FEED CYCLINGrdquo

Schaal 2004 219

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

WIRE

BRAIN

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

BRAIN

WIRING

NEUROSCIENCE

The DNAEverything else

EVOLUTIONARYBIOLOGY

The Brain

EPIGENETICS

The PlaceENVIRONMENT

EXPERIENCEFITNESS ADAPTATION

ldquoScientific foundationrdquo hellip a synthesis

ZERO

SEPARATION

38

wwwninobirthorgwwwskintoskincontactcom

THE NEUROSCIENCE OFSKIN-TO-SKIN CONTACT

AND BREASTFEEDING

ARE THE SAME

SUMMARY SKIN-TO-SKIN

(Regulation)

SLEEP(Brain)

FEEDING(Stomach)

LOVE ( ldquomindrdquo )

REMNR1NR2NR3NR4

ACQUISITION CONSOLIDATION MEMORYFORMATION

poly-sensory input transfer information P wavesshort-term memory ldquoSNRrdquo strong signals returns infostored cortex amygdala to neocortex

hippocampus organizedAwake and REM NREM stage 4 REM

BRAIN WIRING

Stanley Graven 2006

PLAY

SLEEP

FEEDHOLDYOURPREM

httpswwwfacebookcomninobirth

39

Nelson Mandela

hellip in describing themeasure of a nation

he has argued that

ldquoThere can be no keener revelation of a societyrsquos soul than the way in which it treats its childrenrdquo

Page 25: Neurodevelopmental The Neuroscience of Birth ... · breastfeeding pattern, neonatal weight gain, and the dynamics of lactation. Doucet 2012 In the ‘‘scentless breast’’ condition,

25

Infants above 2500g onlyAve Range

Stillborn (n 11) 196 ml (10-35)Early death (n 9) 178 ml (10-25)All cases (n 20) 188 ml

Naveed 1992

ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo

145 146

KERNESSUK 1997 (Russian)

Postmortem in situ measures(applied Bradshaw formula)

AveNewborn (n 11) 15 ml2 months (n 11) 35 ml2-4 m (n 10) 50 ml4-6 m (n 8) 100 ml

Known references with data

Scammon and Doyle 1920

Zuccarellirsquos method stomach filled at autopsy to ldquoa pressure of between

15 and 20 centimeters of waterrdquo

Scammon 1920

ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo

147

Anatomic capacity was determined in post-mortem studies

Main data set Alliot 1905 (n 25)Scammon own cases (n 13)

30 ndash 35 ml at birth ndashalmost regardless of birth weight

Scammon 1920

ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo

148

Zangen S et al Rapid maturation of gastric relaxation in newborns

Pressures (mmHg)

Balloon inflates to

15 ml no increase

functional capacity

149

Zangen S et al Rapid maturation of gastric relaxation in newborns

Pressures (mmHg)

Balloon inflates to

15 ml no increase20 ml pressure OK

physiologicalcapacity hellip 150

26

EVIDENCE (NBn 111009)

Author Capacity NoteSase 10-15 ml Live term fetusGoldstein 10-15 ml Live term fetusWidstrom 10 mls Live newbornZangen 20 mls Live (pressure)

Naveed 20 mls Autopsy (SB)20 mls Autopsy (ENND)

Kernessuk 15 mls Autopsy (in situ)Scammon 30-35 ml Autopsy (water

(Alliot) pressure)151

PROPOSAL

The CAPACITY of aweek old babyrsquos stomach is

approx 20 ml152

0

05

1

15

2

25

3

35

4

0 10 20 30 40 50 60 70 80

volume ingested

fee

din

g f

req

ue

nc

y

Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml

StandardCARE3 hourlyschedule

MOTHERNATURE

1 hourlyschedule

153

PHYSIOLOGICAL CAPACITY

RECEPTIVE CAPACITY of stomach

INGESTIVE CAPACITY of BABY

FUNCTIONAL CAPACITY

154

PROPOSAL

The FEEDINGFREQUENCY of theNEONATE is

approx 60 min155

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

BRAIN CYCLING

STOMACH FILLING amp EMPTYING

REMNR1NR2NR3NR4

156

27

Normal physiology of theEnteric Nervous System

ldquoSmall and frequent feeds according to the sleep cyclerdquo

The ldquonicherdquo (occupation) of a neonate (Alberts)

BOND FEED

SLEEP SLEEP

PLAY FEED

157

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

FEEDING SUCKLING

Influence of SMELL None Totally dependent

Motor mechanism Chewing ndash different

muscles

Suckling ndash different circuits

INSULIN Increases weight No effect

GHRELIN Increases weight No effect

LEPTIN Decreases intake No effect

CHOLECYSTOKININ Decreases intake No effect

AMPHETAMINE Decreases appetite Increases suckling

SEROTONIN Agonist improves feeding Antagonist improves suck

SATIETY Infant determined Maternal supply determine

FEEDING SUCKLING

Influence of SMELL None Totally dependent

Motor mechanism Chewing ndash different

muscles

Suckling ndash different circuits

INSULIN Increases weight No effect

GHRELIN Increases weight No effect

LEPTIN Decreases intake No effect

CHOLECYSTOKININ Decreases intake No effect

AMPHETAMINE Decreases appetite Increases suckling

SEROTONIN Agonist improves feeding Antagonist improves suck

SATIETY Infant determined Maternal supply determine

Current dogmaTHE BABY KNOWS

WHEN IT HAS HAD ENOUGH

PROBABLY NOT

WHAT IS THE

STOMACH VOLUME OF THE

PREMATURE

161

Assume low resilience

Assume proportionality

162

28

The CAPACITY of alow birthweight premfrom 20ml 3000g

= 0007 x BWt (g)

1kg x 0007 = 7mls2kg x 0007 = 14mls

163

Gastric overfilling syndrome

164

75 ml per feeding ASSUMPTION

IMMATURE OR OVERWHELMED

many aspects of gastrointestinalmotility are immature in the neonate

Zangen S et al Rapid maturation of gastric relaxation in newborns

A balloon in stomachcan fill to 76 mls

What does the stomach ndashwithout a balloon ndashdo to 76 mls

REFLUX PRESUME each feedapproximately 75 mls

GER

bull Sudden outbursts of crying

bull Awakens in pain

bull Related to feedings

bull Not easily comforted

bull ldquoI know baby hurtsrdquo

bull Sour burps throaty noises

bull Best when upright

Clues to GER

Dr W Sears

29

Mitchell 2001

Kerstin Uvnaumls-Moberg

Food in duodenum

AMYLINreleased

Closes pylorus

Duodenumempty

Pylorusopens

ldquoFeed intolerancerdquo hellip hellip or VOLUME intolerance

HYPOGLYCAEMIA

A babies stomach empties in60 minutes

Blood sugarmay fall hellip

after 90 minutes Options

30

METABOLIC ADAPTATION

SSC started in the first 20 minutes after birth

SSC CotBlood glucose (1 hr) 317 256Base excess drop 34 18

(Christenson 1992)0h 1h 2h 3h 4h 2 days

App

roxim

ate

GLUCOSE

SSC Glucose production = Glucose consumption

Separation

SNS stress Glucose consumption INCREASE

PSNS dissociation Glucose production DECREASE

HYPOGLYCEMIA

SSC Cot

Blood glucose (1 hr) 317 256

0h 1h 2h 3h 4h 2 days

App

roxim

ate

GLUCOSE

SSC Glucose production = Glucose consumption

Separation PSNS dissociation

Glucose production DECREASE

HYPOGLYCEMIA

SSC Cot

Blood glucose (1 hr) 317 256

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

NEURODEVELOPMENTThe DNA Behaviour

EVOLUTIONARY BIOLOGY

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

BONDING ATTACHMENT

MRI HRVEEG

STRESS RESPONES

RESILIENCE

DOHAD

(MAL) ADAPTATION

EPIGENETICS

GENE X ENVIRONMENT

GENETIC VARIANTS

HOSPITAL ACQUIRED INFECTIONIMMUNITY

SLEEP PHYSIOLOGY

GUT FUNCTIONMICROBIOTA

ldquoSTABILITYrdquo

TRANSITION

LONG TERM FOLLOW-UP

NEUROENDOCRINE BEHAVIOURS

MATERNAL NEUROPLASTICITY

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

MORTALITYMETABOLISM

0h 1h 2h 3h 4h

PSNS (vagal)

App

roxim

ate

GLUCOSE

1 HOURLY Milk feed

1 HOURLY Milk feed

1 HOURLY Milk feed

1 HOURLY Milk feed

LACTOSE

METABOLISM

31

0h 1h 2h 3h 4h

PSNS (vagal) SYMPATHETIC STRESS

App

roxim

ate

GLUCOSE

LACTOSE FATGLYCOGEN

METABOLISM

4 HOURLY Milk feed

0h 1h 2h 3h 4h

PSNS (vagal) SYMPATHETIC STRESS

App

roxim

ate

GLUCOSE

4 HOURLY ALLOSTATIC STATELACTOSE FATGLYCOGEN

METABOLISM

4 HOURLY Milk feed

HEALTH DISEASE

EXPECTED UNEXPECTED

NEURODEVELOPMENTThe DNA Behaviour

EVOLUTIONARY BIOLOGY

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

BONDING ATTACHMENT

MRI HRVEEG

STRESS RESPONES

RESILIENCE

DOHAD

(MAL) ADAPTATION

EPIGENETICS

GENE X ENVIRONMENT

GENETIC VARIANTS

HOSPITAL ACQUIRED INFECTIONIMMUNITY

SLEEP PHYSIOLOGY

GUT FUNCTIONMICROBIOTA

ldquoSTABILITYrdquo

TRANSITION

LONG TERM FOLLOW-UP

NEUROENDOCRINE BEHAVIOURS

MATERNAL NEUROPLASTICITY

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

MORTALITYMETABOLISM

Weight gain 1st week

predicts OBESITYat 30 years

Large volume feedsstretched stomach=

doubled absorptivecapacity as adult

Importance

Programming ndash early life chronic disease

32

RESISTANCE SENSITIVITY

PERCEPTIONSldquoNEUROCEPTIONrdquo

RESPONSESTRESS

ALLOSTATIC STATE

ALLOSTASIS

ANY STRESSPsychologicalNeurological

EndocrineImmune

ALLOSTATIC LOAD

ALLOSTATIC OVERLOAD

WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY

DISEASEHEALTH

RESILIENCE VULNERABILITY

RESISTANCE SENSITIVITY

PERCEPTIONSldquoNEUROCEPTIONrdquo

RESPONSESTRESS

ALLOSTATIC STATE

ALLOSTASIS

ANY STRESSPsychologicalNeurological

EndocrineImmune

ALLOSTATIC LOAD

HEALTH

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

Gastric overfilling syndrome

189

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

33

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

Only case series Insufficient evidence

No mention of

stomach capacity196

Baby weight freq reqrsquod size actual

2kg baby 4hrly ~ 320 ml6 = 53ml 14ml

15 baby 3hrly ~ 240 ml8 = 30ml 10ml

10 baby 2hrly ~ 160 ml12 = 13ml 7ml

Standardised from20ml capacityfor 3kg baby( x 0007)

197

0

10

20

30

40

50

60

70

80

90

13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w

LINEAR

TERM

PREM

198

34

0

10

20

30

40

50

60

70

80

90

13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w

LINEAR

TERM

PREM

199

Clues to GER

ldquoI know baby hurtsrdquo

Gastric overfilling syndrome

Excessive volumesreflux aspiration colic

Excessive time intervalhypoglycaemia

Adaptationsdiabetic diathesis obesity

200

Developmental Care of the Enteric Nervous System

ldquoSmall and frequent feeds according to the sleep cyclerdquo

The ldquonicherdquo (occupation) of a neonate (Alberts)

BOND FEED

SLEEP SLEEP

PLAY FEED

201

Gastric overfilling syndrome

Proposed Management 202

Proposed Management

Babies should be fedEVERY TIME THEY WAKE

Stanley Graven 2006

REMNR1NR2NR3SWS

AS (20 mins) QS (40 mins)

A normal sleep cycle is ONE hourHow often should neonates feed

203

Proposed Management

All babies should be fedat least once an hour 204

35

Proposed Management

All babies should be fedat least once an hour

205

The first Milk Ejection Reflex (MER)

elicited in lt 2 minutesworks quicklyswallowed 1 minute

Feeding time (max)3 minutes

Repeat every 1 hour

Prime 2007

The ldquonormalrdquo or usual and common breastfeed

takes 15 minutesdiscomfort afterburping time 5 minutes

Feeding time 20 min

Repeat every 3 hours

Prime 2007

3 minute 20ml feeds x 24d = 72 minutes

20 minute 60ml feeds x 8d = 160 minutes

SMALL AND FREQUENT FEEDS ARE EFFICIENT

FEWER NURSES NEEDED

The calculated dailyrequirement for a 3kgbaby can be given without increase inpressure MINIMAL RISK

PARENTS CAN DOSAFELY

20 mls x 24 feeds= 480mls day

Zangen 2001 209

All babies should be fedat least once an hour

210

36

Infant feeding frequencyProposal based on available evidence and neuroscience

ldquoSmall and frequent feeds

adjusted to the sleep cyclerdquo

211

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

STATE organization

Feeding frequency

SLEEP cycling

BRAIN

WIRING

How often should a neonate feeda neonate sleep

Infantsleep cycles

begin to block on diurnalrhythms

Mother-infant synchrony

hellip at 12 weeks

(circadian)

START at 3 months

Can be ldquoadult-likerdquo

at 6 months

Thomas 2014

STATE organization

Feeding frequency

SLEEP cycling

PLAY FEED

216

SLEEP SLEEP

SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

Infantsleep cycles

begin to block on diurnalrhythms

37

BOND SUCKLE SLEEP SLEEP PLAY

FEED

217

SLEEP SLEEP SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)

Schaal 2004 218

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)rdquoSLEEP-FEED CYCLINGrdquo

Schaal 2004 219

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

WIRE

BRAIN

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

BRAIN

WIRING

NEUROSCIENCE

The DNAEverything else

EVOLUTIONARYBIOLOGY

The Brain

EPIGENETICS

The PlaceENVIRONMENT

EXPERIENCEFITNESS ADAPTATION

ldquoScientific foundationrdquo hellip a synthesis

ZERO

SEPARATION

38

wwwninobirthorgwwwskintoskincontactcom

THE NEUROSCIENCE OFSKIN-TO-SKIN CONTACT

AND BREASTFEEDING

ARE THE SAME

SUMMARY SKIN-TO-SKIN

(Regulation)

SLEEP(Brain)

FEEDING(Stomach)

LOVE ( ldquomindrdquo )

REMNR1NR2NR3NR4

ACQUISITION CONSOLIDATION MEMORYFORMATION

poly-sensory input transfer information P wavesshort-term memory ldquoSNRrdquo strong signals returns infostored cortex amygdala to neocortex

hippocampus organizedAwake and REM NREM stage 4 REM

BRAIN WIRING

Stanley Graven 2006

PLAY

SLEEP

FEEDHOLDYOURPREM

httpswwwfacebookcomninobirth

39

Nelson Mandela

hellip in describing themeasure of a nation

he has argued that

ldquoThere can be no keener revelation of a societyrsquos soul than the way in which it treats its childrenrdquo

Page 26: Neurodevelopmental The Neuroscience of Birth ... · breastfeeding pattern, neonatal weight gain, and the dynamics of lactation. Doucet 2012 In the ‘‘scentless breast’’ condition,

26

EVIDENCE (NBn 111009)

Author Capacity NoteSase 10-15 ml Live term fetusGoldstein 10-15 ml Live term fetusWidstrom 10 mls Live newbornZangen 20 mls Live (pressure)

Naveed 20 mls Autopsy (SB)20 mls Autopsy (ENND)

Kernessuk 15 mls Autopsy (in situ)Scammon 30-35 ml Autopsy (water

(Alliot) pressure)151

PROPOSAL

The CAPACITY of aweek old babyrsquos stomach is

approx 20 ml152

0

05

1

15

2

25

3

35

4

0 10 20 30 40 50 60 70 80

volume ingested

fee

din

g f

req

ue

nc

y

Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml

StandardCARE3 hourlyschedule

MOTHERNATURE

1 hourlyschedule

153

PHYSIOLOGICAL CAPACITY

RECEPTIVE CAPACITY of stomach

INGESTIVE CAPACITY of BABY

FUNCTIONAL CAPACITY

154

PROPOSAL

The FEEDINGFREQUENCY of theNEONATE is

approx 60 min155

CEPHALIC PHASEGASTRIC PHASE

INTESTINAL PHASE

BRAIN CYCLING

STOMACH FILLING amp EMPTYING

REMNR1NR2NR3NR4

156

27

Normal physiology of theEnteric Nervous System

ldquoSmall and frequent feeds according to the sleep cyclerdquo

The ldquonicherdquo (occupation) of a neonate (Alberts)

BOND FEED

SLEEP SLEEP

PLAY FEED

157

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

FEEDING SUCKLING

Influence of SMELL None Totally dependent

Motor mechanism Chewing ndash different

muscles

Suckling ndash different circuits

INSULIN Increases weight No effect

GHRELIN Increases weight No effect

LEPTIN Decreases intake No effect

CHOLECYSTOKININ Decreases intake No effect

AMPHETAMINE Decreases appetite Increases suckling

SEROTONIN Agonist improves feeding Antagonist improves suck

SATIETY Infant determined Maternal supply determine

FEEDING SUCKLING

Influence of SMELL None Totally dependent

Motor mechanism Chewing ndash different

muscles

Suckling ndash different circuits

INSULIN Increases weight No effect

GHRELIN Increases weight No effect

LEPTIN Decreases intake No effect

CHOLECYSTOKININ Decreases intake No effect

AMPHETAMINE Decreases appetite Increases suckling

SEROTONIN Agonist improves feeding Antagonist improves suck

SATIETY Infant determined Maternal supply determine

Current dogmaTHE BABY KNOWS

WHEN IT HAS HAD ENOUGH

PROBABLY NOT

WHAT IS THE

STOMACH VOLUME OF THE

PREMATURE

161

Assume low resilience

Assume proportionality

162

28

The CAPACITY of alow birthweight premfrom 20ml 3000g

= 0007 x BWt (g)

1kg x 0007 = 7mls2kg x 0007 = 14mls

163

Gastric overfilling syndrome

164

75 ml per feeding ASSUMPTION

IMMATURE OR OVERWHELMED

many aspects of gastrointestinalmotility are immature in the neonate

Zangen S et al Rapid maturation of gastric relaxation in newborns

A balloon in stomachcan fill to 76 mls

What does the stomach ndashwithout a balloon ndashdo to 76 mls

REFLUX PRESUME each feedapproximately 75 mls

GER

bull Sudden outbursts of crying

bull Awakens in pain

bull Related to feedings

bull Not easily comforted

bull ldquoI know baby hurtsrdquo

bull Sour burps throaty noises

bull Best when upright

Clues to GER

Dr W Sears

29

Mitchell 2001

Kerstin Uvnaumls-Moberg

Food in duodenum

AMYLINreleased

Closes pylorus

Duodenumempty

Pylorusopens

ldquoFeed intolerancerdquo hellip hellip or VOLUME intolerance

HYPOGLYCAEMIA

A babies stomach empties in60 minutes

Blood sugarmay fall hellip

after 90 minutes Options

30

METABOLIC ADAPTATION

SSC started in the first 20 minutes after birth

SSC CotBlood glucose (1 hr) 317 256Base excess drop 34 18

(Christenson 1992)0h 1h 2h 3h 4h 2 days

App

roxim

ate

GLUCOSE

SSC Glucose production = Glucose consumption

Separation

SNS stress Glucose consumption INCREASE

PSNS dissociation Glucose production DECREASE

HYPOGLYCEMIA

SSC Cot

Blood glucose (1 hr) 317 256

0h 1h 2h 3h 4h 2 days

App

roxim

ate

GLUCOSE

SSC Glucose production = Glucose consumption

Separation PSNS dissociation

Glucose production DECREASE

HYPOGLYCEMIA

SSC Cot

Blood glucose (1 hr) 317 256

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

NEURODEVELOPMENTThe DNA Behaviour

EVOLUTIONARY BIOLOGY

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

BONDING ATTACHMENT

MRI HRVEEG

STRESS RESPONES

RESILIENCE

DOHAD

(MAL) ADAPTATION

EPIGENETICS

GENE X ENVIRONMENT

GENETIC VARIANTS

HOSPITAL ACQUIRED INFECTIONIMMUNITY

SLEEP PHYSIOLOGY

GUT FUNCTIONMICROBIOTA

ldquoSTABILITYrdquo

TRANSITION

LONG TERM FOLLOW-UP

NEUROENDOCRINE BEHAVIOURS

MATERNAL NEUROPLASTICITY

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

MORTALITYMETABOLISM

0h 1h 2h 3h 4h

PSNS (vagal)

App

roxim

ate

GLUCOSE

1 HOURLY Milk feed

1 HOURLY Milk feed

1 HOURLY Milk feed

1 HOURLY Milk feed

LACTOSE

METABOLISM

31

0h 1h 2h 3h 4h

PSNS (vagal) SYMPATHETIC STRESS

App

roxim

ate

GLUCOSE

LACTOSE FATGLYCOGEN

METABOLISM

4 HOURLY Milk feed

0h 1h 2h 3h 4h

PSNS (vagal) SYMPATHETIC STRESS

App

roxim

ate

GLUCOSE

4 HOURLY ALLOSTATIC STATELACTOSE FATGLYCOGEN

METABOLISM

4 HOURLY Milk feed

HEALTH DISEASE

EXPECTED UNEXPECTED

NEURODEVELOPMENTThe DNA Behaviour

EVOLUTIONARY BIOLOGY

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

BONDING ATTACHMENT

MRI HRVEEG

STRESS RESPONES

RESILIENCE

DOHAD

(MAL) ADAPTATION

EPIGENETICS

GENE X ENVIRONMENT

GENETIC VARIANTS

HOSPITAL ACQUIRED INFECTIONIMMUNITY

SLEEP PHYSIOLOGY

GUT FUNCTIONMICROBIOTA

ldquoSTABILITYrdquo

TRANSITION

LONG TERM FOLLOW-UP

NEUROENDOCRINE BEHAVIOURS

MATERNAL NEUROPLASTICITY

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

MORTALITYMETABOLISM

Weight gain 1st week

predicts OBESITYat 30 years

Large volume feedsstretched stomach=

doubled absorptivecapacity as adult

Importance

Programming ndash early life chronic disease

32

RESISTANCE SENSITIVITY

PERCEPTIONSldquoNEUROCEPTIONrdquo

RESPONSESTRESS

ALLOSTATIC STATE

ALLOSTASIS

ANY STRESSPsychologicalNeurological

EndocrineImmune

ALLOSTATIC LOAD

ALLOSTATIC OVERLOAD

WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY

DISEASEHEALTH

RESILIENCE VULNERABILITY

RESISTANCE SENSITIVITY

PERCEPTIONSldquoNEUROCEPTIONrdquo

RESPONSESTRESS

ALLOSTATIC STATE

ALLOSTASIS

ANY STRESSPsychologicalNeurological

EndocrineImmune

ALLOSTATIC LOAD

HEALTH

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

Gastric overfilling syndrome

189

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

33

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

Only case series Insufficient evidence

No mention of

stomach capacity196

Baby weight freq reqrsquod size actual

2kg baby 4hrly ~ 320 ml6 = 53ml 14ml

15 baby 3hrly ~ 240 ml8 = 30ml 10ml

10 baby 2hrly ~ 160 ml12 = 13ml 7ml

Standardised from20ml capacityfor 3kg baby( x 0007)

197

0

10

20

30

40

50

60

70

80

90

13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w

LINEAR

TERM

PREM

198

34

0

10

20

30

40

50

60

70

80

90

13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w

LINEAR

TERM

PREM

199

Clues to GER

ldquoI know baby hurtsrdquo

Gastric overfilling syndrome

Excessive volumesreflux aspiration colic

Excessive time intervalhypoglycaemia

Adaptationsdiabetic diathesis obesity

200

Developmental Care of the Enteric Nervous System

ldquoSmall and frequent feeds according to the sleep cyclerdquo

The ldquonicherdquo (occupation) of a neonate (Alberts)

BOND FEED

SLEEP SLEEP

PLAY FEED

201

Gastric overfilling syndrome

Proposed Management 202

Proposed Management

Babies should be fedEVERY TIME THEY WAKE

Stanley Graven 2006

REMNR1NR2NR3SWS

AS (20 mins) QS (40 mins)

A normal sleep cycle is ONE hourHow often should neonates feed

203

Proposed Management

All babies should be fedat least once an hour 204

35

Proposed Management

All babies should be fedat least once an hour

205

The first Milk Ejection Reflex (MER)

elicited in lt 2 minutesworks quicklyswallowed 1 minute

Feeding time (max)3 minutes

Repeat every 1 hour

Prime 2007

The ldquonormalrdquo or usual and common breastfeed

takes 15 minutesdiscomfort afterburping time 5 minutes

Feeding time 20 min

Repeat every 3 hours

Prime 2007

3 minute 20ml feeds x 24d = 72 minutes

20 minute 60ml feeds x 8d = 160 minutes

SMALL AND FREQUENT FEEDS ARE EFFICIENT

FEWER NURSES NEEDED

The calculated dailyrequirement for a 3kgbaby can be given without increase inpressure MINIMAL RISK

PARENTS CAN DOSAFELY

20 mls x 24 feeds= 480mls day

Zangen 2001 209

All babies should be fedat least once an hour

210

36

Infant feeding frequencyProposal based on available evidence and neuroscience

ldquoSmall and frequent feeds

adjusted to the sleep cyclerdquo

211

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

STATE organization

Feeding frequency

SLEEP cycling

BRAIN

WIRING

How often should a neonate feeda neonate sleep

Infantsleep cycles

begin to block on diurnalrhythms

Mother-infant synchrony

hellip at 12 weeks

(circadian)

START at 3 months

Can be ldquoadult-likerdquo

at 6 months

Thomas 2014

STATE organization

Feeding frequency

SLEEP cycling

PLAY FEED

216

SLEEP SLEEP

SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

Infantsleep cycles

begin to block on diurnalrhythms

37

BOND SUCKLE SLEEP SLEEP PLAY

FEED

217

SLEEP SLEEP SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)

Schaal 2004 218

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)rdquoSLEEP-FEED CYCLINGrdquo

Schaal 2004 219

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

WIRE

BRAIN

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

BRAIN

WIRING

NEUROSCIENCE

The DNAEverything else

EVOLUTIONARYBIOLOGY

The Brain

EPIGENETICS

The PlaceENVIRONMENT

EXPERIENCEFITNESS ADAPTATION

ldquoScientific foundationrdquo hellip a synthesis

ZERO

SEPARATION

38

wwwninobirthorgwwwskintoskincontactcom

THE NEUROSCIENCE OFSKIN-TO-SKIN CONTACT

AND BREASTFEEDING

ARE THE SAME

SUMMARY SKIN-TO-SKIN

(Regulation)

SLEEP(Brain)

FEEDING(Stomach)

LOVE ( ldquomindrdquo )

REMNR1NR2NR3NR4

ACQUISITION CONSOLIDATION MEMORYFORMATION

poly-sensory input transfer information P wavesshort-term memory ldquoSNRrdquo strong signals returns infostored cortex amygdala to neocortex

hippocampus organizedAwake and REM NREM stage 4 REM

BRAIN WIRING

Stanley Graven 2006

PLAY

SLEEP

FEEDHOLDYOURPREM

httpswwwfacebookcomninobirth

39

Nelson Mandela

hellip in describing themeasure of a nation

he has argued that

ldquoThere can be no keener revelation of a societyrsquos soul than the way in which it treats its childrenrdquo

Page 27: Neurodevelopmental The Neuroscience of Birth ... · breastfeeding pattern, neonatal weight gain, and the dynamics of lactation. Doucet 2012 In the ‘‘scentless breast’’ condition,

27

Normal physiology of theEnteric Nervous System

ldquoSmall and frequent feeds according to the sleep cyclerdquo

The ldquonicherdquo (occupation) of a neonate (Alberts)

BOND FEED

SLEEP SLEEP

PLAY FEED

157

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

FEEDING SUCKLING

Influence of SMELL None Totally dependent

Motor mechanism Chewing ndash different

muscles

Suckling ndash different circuits

INSULIN Increases weight No effect

GHRELIN Increases weight No effect

LEPTIN Decreases intake No effect

CHOLECYSTOKININ Decreases intake No effect

AMPHETAMINE Decreases appetite Increases suckling

SEROTONIN Agonist improves feeding Antagonist improves suck

SATIETY Infant determined Maternal supply determine

FEEDING SUCKLING

Influence of SMELL None Totally dependent

Motor mechanism Chewing ndash different

muscles

Suckling ndash different circuits

INSULIN Increases weight No effect

GHRELIN Increases weight No effect

LEPTIN Decreases intake No effect

CHOLECYSTOKININ Decreases intake No effect

AMPHETAMINE Decreases appetite Increases suckling

SEROTONIN Agonist improves feeding Antagonist improves suck

SATIETY Infant determined Maternal supply determine

Current dogmaTHE BABY KNOWS

WHEN IT HAS HAD ENOUGH

PROBABLY NOT

WHAT IS THE

STOMACH VOLUME OF THE

PREMATURE

161

Assume low resilience

Assume proportionality

162

28

The CAPACITY of alow birthweight premfrom 20ml 3000g

= 0007 x BWt (g)

1kg x 0007 = 7mls2kg x 0007 = 14mls

163

Gastric overfilling syndrome

164

75 ml per feeding ASSUMPTION

IMMATURE OR OVERWHELMED

many aspects of gastrointestinalmotility are immature in the neonate

Zangen S et al Rapid maturation of gastric relaxation in newborns

A balloon in stomachcan fill to 76 mls

What does the stomach ndashwithout a balloon ndashdo to 76 mls

REFLUX PRESUME each feedapproximately 75 mls

GER

bull Sudden outbursts of crying

bull Awakens in pain

bull Related to feedings

bull Not easily comforted

bull ldquoI know baby hurtsrdquo

bull Sour burps throaty noises

bull Best when upright

Clues to GER

Dr W Sears

29

Mitchell 2001

Kerstin Uvnaumls-Moberg

Food in duodenum

AMYLINreleased

Closes pylorus

Duodenumempty

Pylorusopens

ldquoFeed intolerancerdquo hellip hellip or VOLUME intolerance

HYPOGLYCAEMIA

A babies stomach empties in60 minutes

Blood sugarmay fall hellip

after 90 minutes Options

30

METABOLIC ADAPTATION

SSC started in the first 20 minutes after birth

SSC CotBlood glucose (1 hr) 317 256Base excess drop 34 18

(Christenson 1992)0h 1h 2h 3h 4h 2 days

App

roxim

ate

GLUCOSE

SSC Glucose production = Glucose consumption

Separation

SNS stress Glucose consumption INCREASE

PSNS dissociation Glucose production DECREASE

HYPOGLYCEMIA

SSC Cot

Blood glucose (1 hr) 317 256

0h 1h 2h 3h 4h 2 days

App

roxim

ate

GLUCOSE

SSC Glucose production = Glucose consumption

Separation PSNS dissociation

Glucose production DECREASE

HYPOGLYCEMIA

SSC Cot

Blood glucose (1 hr) 317 256

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

NEURODEVELOPMENTThe DNA Behaviour

EVOLUTIONARY BIOLOGY

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

BONDING ATTACHMENT

MRI HRVEEG

STRESS RESPONES

RESILIENCE

DOHAD

(MAL) ADAPTATION

EPIGENETICS

GENE X ENVIRONMENT

GENETIC VARIANTS

HOSPITAL ACQUIRED INFECTIONIMMUNITY

SLEEP PHYSIOLOGY

GUT FUNCTIONMICROBIOTA

ldquoSTABILITYrdquo

TRANSITION

LONG TERM FOLLOW-UP

NEUROENDOCRINE BEHAVIOURS

MATERNAL NEUROPLASTICITY

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

MORTALITYMETABOLISM

0h 1h 2h 3h 4h

PSNS (vagal)

App

roxim

ate

GLUCOSE

1 HOURLY Milk feed

1 HOURLY Milk feed

1 HOURLY Milk feed

1 HOURLY Milk feed

LACTOSE

METABOLISM

31

0h 1h 2h 3h 4h

PSNS (vagal) SYMPATHETIC STRESS

App

roxim

ate

GLUCOSE

LACTOSE FATGLYCOGEN

METABOLISM

4 HOURLY Milk feed

0h 1h 2h 3h 4h

PSNS (vagal) SYMPATHETIC STRESS

App

roxim

ate

GLUCOSE

4 HOURLY ALLOSTATIC STATELACTOSE FATGLYCOGEN

METABOLISM

4 HOURLY Milk feed

HEALTH DISEASE

EXPECTED UNEXPECTED

NEURODEVELOPMENTThe DNA Behaviour

EVOLUTIONARY BIOLOGY

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

BONDING ATTACHMENT

MRI HRVEEG

STRESS RESPONES

RESILIENCE

DOHAD

(MAL) ADAPTATION

EPIGENETICS

GENE X ENVIRONMENT

GENETIC VARIANTS

HOSPITAL ACQUIRED INFECTIONIMMUNITY

SLEEP PHYSIOLOGY

GUT FUNCTIONMICROBIOTA

ldquoSTABILITYrdquo

TRANSITION

LONG TERM FOLLOW-UP

NEUROENDOCRINE BEHAVIOURS

MATERNAL NEUROPLASTICITY

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

MORTALITYMETABOLISM

Weight gain 1st week

predicts OBESITYat 30 years

Large volume feedsstretched stomach=

doubled absorptivecapacity as adult

Importance

Programming ndash early life chronic disease

32

RESISTANCE SENSITIVITY

PERCEPTIONSldquoNEUROCEPTIONrdquo

RESPONSESTRESS

ALLOSTATIC STATE

ALLOSTASIS

ANY STRESSPsychologicalNeurological

EndocrineImmune

ALLOSTATIC LOAD

ALLOSTATIC OVERLOAD

WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY

DISEASEHEALTH

RESILIENCE VULNERABILITY

RESISTANCE SENSITIVITY

PERCEPTIONSldquoNEUROCEPTIONrdquo

RESPONSESTRESS

ALLOSTATIC STATE

ALLOSTASIS

ANY STRESSPsychologicalNeurological

EndocrineImmune

ALLOSTATIC LOAD

HEALTH

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

Gastric overfilling syndrome

189

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

33

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

Only case series Insufficient evidence

No mention of

stomach capacity196

Baby weight freq reqrsquod size actual

2kg baby 4hrly ~ 320 ml6 = 53ml 14ml

15 baby 3hrly ~ 240 ml8 = 30ml 10ml

10 baby 2hrly ~ 160 ml12 = 13ml 7ml

Standardised from20ml capacityfor 3kg baby( x 0007)

197

0

10

20

30

40

50

60

70

80

90

13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w

LINEAR

TERM

PREM

198

34

0

10

20

30

40

50

60

70

80

90

13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w

LINEAR

TERM

PREM

199

Clues to GER

ldquoI know baby hurtsrdquo

Gastric overfilling syndrome

Excessive volumesreflux aspiration colic

Excessive time intervalhypoglycaemia

Adaptationsdiabetic diathesis obesity

200

Developmental Care of the Enteric Nervous System

ldquoSmall and frequent feeds according to the sleep cyclerdquo

The ldquonicherdquo (occupation) of a neonate (Alberts)

BOND FEED

SLEEP SLEEP

PLAY FEED

201

Gastric overfilling syndrome

Proposed Management 202

Proposed Management

Babies should be fedEVERY TIME THEY WAKE

Stanley Graven 2006

REMNR1NR2NR3SWS

AS (20 mins) QS (40 mins)

A normal sleep cycle is ONE hourHow often should neonates feed

203

Proposed Management

All babies should be fedat least once an hour 204

35

Proposed Management

All babies should be fedat least once an hour

205

The first Milk Ejection Reflex (MER)

elicited in lt 2 minutesworks quicklyswallowed 1 minute

Feeding time (max)3 minutes

Repeat every 1 hour

Prime 2007

The ldquonormalrdquo or usual and common breastfeed

takes 15 minutesdiscomfort afterburping time 5 minutes

Feeding time 20 min

Repeat every 3 hours

Prime 2007

3 minute 20ml feeds x 24d = 72 minutes

20 minute 60ml feeds x 8d = 160 minutes

SMALL AND FREQUENT FEEDS ARE EFFICIENT

FEWER NURSES NEEDED

The calculated dailyrequirement for a 3kgbaby can be given without increase inpressure MINIMAL RISK

PARENTS CAN DOSAFELY

20 mls x 24 feeds= 480mls day

Zangen 2001 209

All babies should be fedat least once an hour

210

36

Infant feeding frequencyProposal based on available evidence and neuroscience

ldquoSmall and frequent feeds

adjusted to the sleep cyclerdquo

211

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

STATE organization

Feeding frequency

SLEEP cycling

BRAIN

WIRING

How often should a neonate feeda neonate sleep

Infantsleep cycles

begin to block on diurnalrhythms

Mother-infant synchrony

hellip at 12 weeks

(circadian)

START at 3 months

Can be ldquoadult-likerdquo

at 6 months

Thomas 2014

STATE organization

Feeding frequency

SLEEP cycling

PLAY FEED

216

SLEEP SLEEP

SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

Infantsleep cycles

begin to block on diurnalrhythms

37

BOND SUCKLE SLEEP SLEEP PLAY

FEED

217

SLEEP SLEEP SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)

Schaal 2004 218

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)rdquoSLEEP-FEED CYCLINGrdquo

Schaal 2004 219

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

WIRE

BRAIN

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

BRAIN

WIRING

NEUROSCIENCE

The DNAEverything else

EVOLUTIONARYBIOLOGY

The Brain

EPIGENETICS

The PlaceENVIRONMENT

EXPERIENCEFITNESS ADAPTATION

ldquoScientific foundationrdquo hellip a synthesis

ZERO

SEPARATION

38

wwwninobirthorgwwwskintoskincontactcom

THE NEUROSCIENCE OFSKIN-TO-SKIN CONTACT

AND BREASTFEEDING

ARE THE SAME

SUMMARY SKIN-TO-SKIN

(Regulation)

SLEEP(Brain)

FEEDING(Stomach)

LOVE ( ldquomindrdquo )

REMNR1NR2NR3NR4

ACQUISITION CONSOLIDATION MEMORYFORMATION

poly-sensory input transfer information P wavesshort-term memory ldquoSNRrdquo strong signals returns infostored cortex amygdala to neocortex

hippocampus organizedAwake and REM NREM stage 4 REM

BRAIN WIRING

Stanley Graven 2006

PLAY

SLEEP

FEEDHOLDYOURPREM

httpswwwfacebookcomninobirth

39

Nelson Mandela

hellip in describing themeasure of a nation

he has argued that

ldquoThere can be no keener revelation of a societyrsquos soul than the way in which it treats its childrenrdquo

Page 28: Neurodevelopmental The Neuroscience of Birth ... · breastfeeding pattern, neonatal weight gain, and the dynamics of lactation. Doucet 2012 In the ‘‘scentless breast’’ condition,

28

The CAPACITY of alow birthweight premfrom 20ml 3000g

= 0007 x BWt (g)

1kg x 0007 = 7mls2kg x 0007 = 14mls

163

Gastric overfilling syndrome

164

75 ml per feeding ASSUMPTION

IMMATURE OR OVERWHELMED

many aspects of gastrointestinalmotility are immature in the neonate

Zangen S et al Rapid maturation of gastric relaxation in newborns

A balloon in stomachcan fill to 76 mls

What does the stomach ndashwithout a balloon ndashdo to 76 mls

REFLUX PRESUME each feedapproximately 75 mls

GER

bull Sudden outbursts of crying

bull Awakens in pain

bull Related to feedings

bull Not easily comforted

bull ldquoI know baby hurtsrdquo

bull Sour burps throaty noises

bull Best when upright

Clues to GER

Dr W Sears

29

Mitchell 2001

Kerstin Uvnaumls-Moberg

Food in duodenum

AMYLINreleased

Closes pylorus

Duodenumempty

Pylorusopens

ldquoFeed intolerancerdquo hellip hellip or VOLUME intolerance

HYPOGLYCAEMIA

A babies stomach empties in60 minutes

Blood sugarmay fall hellip

after 90 minutes Options

30

METABOLIC ADAPTATION

SSC started in the first 20 minutes after birth

SSC CotBlood glucose (1 hr) 317 256Base excess drop 34 18

(Christenson 1992)0h 1h 2h 3h 4h 2 days

App

roxim

ate

GLUCOSE

SSC Glucose production = Glucose consumption

Separation

SNS stress Glucose consumption INCREASE

PSNS dissociation Glucose production DECREASE

HYPOGLYCEMIA

SSC Cot

Blood glucose (1 hr) 317 256

0h 1h 2h 3h 4h 2 days

App

roxim

ate

GLUCOSE

SSC Glucose production = Glucose consumption

Separation PSNS dissociation

Glucose production DECREASE

HYPOGLYCEMIA

SSC Cot

Blood glucose (1 hr) 317 256

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

NEURODEVELOPMENTThe DNA Behaviour

EVOLUTIONARY BIOLOGY

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

BONDING ATTACHMENT

MRI HRVEEG

STRESS RESPONES

RESILIENCE

DOHAD

(MAL) ADAPTATION

EPIGENETICS

GENE X ENVIRONMENT

GENETIC VARIANTS

HOSPITAL ACQUIRED INFECTIONIMMUNITY

SLEEP PHYSIOLOGY

GUT FUNCTIONMICROBIOTA

ldquoSTABILITYrdquo

TRANSITION

LONG TERM FOLLOW-UP

NEUROENDOCRINE BEHAVIOURS

MATERNAL NEUROPLASTICITY

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

MORTALITYMETABOLISM

0h 1h 2h 3h 4h

PSNS (vagal)

App

roxim

ate

GLUCOSE

1 HOURLY Milk feed

1 HOURLY Milk feed

1 HOURLY Milk feed

1 HOURLY Milk feed

LACTOSE

METABOLISM

31

0h 1h 2h 3h 4h

PSNS (vagal) SYMPATHETIC STRESS

App

roxim

ate

GLUCOSE

LACTOSE FATGLYCOGEN

METABOLISM

4 HOURLY Milk feed

0h 1h 2h 3h 4h

PSNS (vagal) SYMPATHETIC STRESS

App

roxim

ate

GLUCOSE

4 HOURLY ALLOSTATIC STATELACTOSE FATGLYCOGEN

METABOLISM

4 HOURLY Milk feed

HEALTH DISEASE

EXPECTED UNEXPECTED

NEURODEVELOPMENTThe DNA Behaviour

EVOLUTIONARY BIOLOGY

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

BONDING ATTACHMENT

MRI HRVEEG

STRESS RESPONES

RESILIENCE

DOHAD

(MAL) ADAPTATION

EPIGENETICS

GENE X ENVIRONMENT

GENETIC VARIANTS

HOSPITAL ACQUIRED INFECTIONIMMUNITY

SLEEP PHYSIOLOGY

GUT FUNCTIONMICROBIOTA

ldquoSTABILITYrdquo

TRANSITION

LONG TERM FOLLOW-UP

NEUROENDOCRINE BEHAVIOURS

MATERNAL NEUROPLASTICITY

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

MORTALITYMETABOLISM

Weight gain 1st week

predicts OBESITYat 30 years

Large volume feedsstretched stomach=

doubled absorptivecapacity as adult

Importance

Programming ndash early life chronic disease

32

RESISTANCE SENSITIVITY

PERCEPTIONSldquoNEUROCEPTIONrdquo

RESPONSESTRESS

ALLOSTATIC STATE

ALLOSTASIS

ANY STRESSPsychologicalNeurological

EndocrineImmune

ALLOSTATIC LOAD

ALLOSTATIC OVERLOAD

WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY

DISEASEHEALTH

RESILIENCE VULNERABILITY

RESISTANCE SENSITIVITY

PERCEPTIONSldquoNEUROCEPTIONrdquo

RESPONSESTRESS

ALLOSTATIC STATE

ALLOSTASIS

ANY STRESSPsychologicalNeurological

EndocrineImmune

ALLOSTATIC LOAD

HEALTH

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

Gastric overfilling syndrome

189

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

33

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

Only case series Insufficient evidence

No mention of

stomach capacity196

Baby weight freq reqrsquod size actual

2kg baby 4hrly ~ 320 ml6 = 53ml 14ml

15 baby 3hrly ~ 240 ml8 = 30ml 10ml

10 baby 2hrly ~ 160 ml12 = 13ml 7ml

Standardised from20ml capacityfor 3kg baby( x 0007)

197

0

10

20

30

40

50

60

70

80

90

13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w

LINEAR

TERM

PREM

198

34

0

10

20

30

40

50

60

70

80

90

13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w

LINEAR

TERM

PREM

199

Clues to GER

ldquoI know baby hurtsrdquo

Gastric overfilling syndrome

Excessive volumesreflux aspiration colic

Excessive time intervalhypoglycaemia

Adaptationsdiabetic diathesis obesity

200

Developmental Care of the Enteric Nervous System

ldquoSmall and frequent feeds according to the sleep cyclerdquo

The ldquonicherdquo (occupation) of a neonate (Alberts)

BOND FEED

SLEEP SLEEP

PLAY FEED

201

Gastric overfilling syndrome

Proposed Management 202

Proposed Management

Babies should be fedEVERY TIME THEY WAKE

Stanley Graven 2006

REMNR1NR2NR3SWS

AS (20 mins) QS (40 mins)

A normal sleep cycle is ONE hourHow often should neonates feed

203

Proposed Management

All babies should be fedat least once an hour 204

35

Proposed Management

All babies should be fedat least once an hour

205

The first Milk Ejection Reflex (MER)

elicited in lt 2 minutesworks quicklyswallowed 1 minute

Feeding time (max)3 minutes

Repeat every 1 hour

Prime 2007

The ldquonormalrdquo or usual and common breastfeed

takes 15 minutesdiscomfort afterburping time 5 minutes

Feeding time 20 min

Repeat every 3 hours

Prime 2007

3 minute 20ml feeds x 24d = 72 minutes

20 minute 60ml feeds x 8d = 160 minutes

SMALL AND FREQUENT FEEDS ARE EFFICIENT

FEWER NURSES NEEDED

The calculated dailyrequirement for a 3kgbaby can be given without increase inpressure MINIMAL RISK

PARENTS CAN DOSAFELY

20 mls x 24 feeds= 480mls day

Zangen 2001 209

All babies should be fedat least once an hour

210

36

Infant feeding frequencyProposal based on available evidence and neuroscience

ldquoSmall and frequent feeds

adjusted to the sleep cyclerdquo

211

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

STATE organization

Feeding frequency

SLEEP cycling

BRAIN

WIRING

How often should a neonate feeda neonate sleep

Infantsleep cycles

begin to block on diurnalrhythms

Mother-infant synchrony

hellip at 12 weeks

(circadian)

START at 3 months

Can be ldquoadult-likerdquo

at 6 months

Thomas 2014

STATE organization

Feeding frequency

SLEEP cycling

PLAY FEED

216

SLEEP SLEEP

SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

Infantsleep cycles

begin to block on diurnalrhythms

37

BOND SUCKLE SLEEP SLEEP PLAY

FEED

217

SLEEP SLEEP SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)

Schaal 2004 218

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)rdquoSLEEP-FEED CYCLINGrdquo

Schaal 2004 219

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

WIRE

BRAIN

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

BRAIN

WIRING

NEUROSCIENCE

The DNAEverything else

EVOLUTIONARYBIOLOGY

The Brain

EPIGENETICS

The PlaceENVIRONMENT

EXPERIENCEFITNESS ADAPTATION

ldquoScientific foundationrdquo hellip a synthesis

ZERO

SEPARATION

38

wwwninobirthorgwwwskintoskincontactcom

THE NEUROSCIENCE OFSKIN-TO-SKIN CONTACT

AND BREASTFEEDING

ARE THE SAME

SUMMARY SKIN-TO-SKIN

(Regulation)

SLEEP(Brain)

FEEDING(Stomach)

LOVE ( ldquomindrdquo )

REMNR1NR2NR3NR4

ACQUISITION CONSOLIDATION MEMORYFORMATION

poly-sensory input transfer information P wavesshort-term memory ldquoSNRrdquo strong signals returns infostored cortex amygdala to neocortex

hippocampus organizedAwake and REM NREM stage 4 REM

BRAIN WIRING

Stanley Graven 2006

PLAY

SLEEP

FEEDHOLDYOURPREM

httpswwwfacebookcomninobirth

39

Nelson Mandela

hellip in describing themeasure of a nation

he has argued that

ldquoThere can be no keener revelation of a societyrsquos soul than the way in which it treats its childrenrdquo

Page 29: Neurodevelopmental The Neuroscience of Birth ... · breastfeeding pattern, neonatal weight gain, and the dynamics of lactation. Doucet 2012 In the ‘‘scentless breast’’ condition,

29

Mitchell 2001

Kerstin Uvnaumls-Moberg

Food in duodenum

AMYLINreleased

Closes pylorus

Duodenumempty

Pylorusopens

ldquoFeed intolerancerdquo hellip hellip or VOLUME intolerance

HYPOGLYCAEMIA

A babies stomach empties in60 minutes

Blood sugarmay fall hellip

after 90 minutes Options

30

METABOLIC ADAPTATION

SSC started in the first 20 minutes after birth

SSC CotBlood glucose (1 hr) 317 256Base excess drop 34 18

(Christenson 1992)0h 1h 2h 3h 4h 2 days

App

roxim

ate

GLUCOSE

SSC Glucose production = Glucose consumption

Separation

SNS stress Glucose consumption INCREASE

PSNS dissociation Glucose production DECREASE

HYPOGLYCEMIA

SSC Cot

Blood glucose (1 hr) 317 256

0h 1h 2h 3h 4h 2 days

App

roxim

ate

GLUCOSE

SSC Glucose production = Glucose consumption

Separation PSNS dissociation

Glucose production DECREASE

HYPOGLYCEMIA

SSC Cot

Blood glucose (1 hr) 317 256

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

NEURODEVELOPMENTThe DNA Behaviour

EVOLUTIONARY BIOLOGY

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

BONDING ATTACHMENT

MRI HRVEEG

STRESS RESPONES

RESILIENCE

DOHAD

(MAL) ADAPTATION

EPIGENETICS

GENE X ENVIRONMENT

GENETIC VARIANTS

HOSPITAL ACQUIRED INFECTIONIMMUNITY

SLEEP PHYSIOLOGY

GUT FUNCTIONMICROBIOTA

ldquoSTABILITYrdquo

TRANSITION

LONG TERM FOLLOW-UP

NEUROENDOCRINE BEHAVIOURS

MATERNAL NEUROPLASTICITY

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

MORTALITYMETABOLISM

0h 1h 2h 3h 4h

PSNS (vagal)

App

roxim

ate

GLUCOSE

1 HOURLY Milk feed

1 HOURLY Milk feed

1 HOURLY Milk feed

1 HOURLY Milk feed

LACTOSE

METABOLISM

31

0h 1h 2h 3h 4h

PSNS (vagal) SYMPATHETIC STRESS

App

roxim

ate

GLUCOSE

LACTOSE FATGLYCOGEN

METABOLISM

4 HOURLY Milk feed

0h 1h 2h 3h 4h

PSNS (vagal) SYMPATHETIC STRESS

App

roxim

ate

GLUCOSE

4 HOURLY ALLOSTATIC STATELACTOSE FATGLYCOGEN

METABOLISM

4 HOURLY Milk feed

HEALTH DISEASE

EXPECTED UNEXPECTED

NEURODEVELOPMENTThe DNA Behaviour

EVOLUTIONARY BIOLOGY

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

BONDING ATTACHMENT

MRI HRVEEG

STRESS RESPONES

RESILIENCE

DOHAD

(MAL) ADAPTATION

EPIGENETICS

GENE X ENVIRONMENT

GENETIC VARIANTS

HOSPITAL ACQUIRED INFECTIONIMMUNITY

SLEEP PHYSIOLOGY

GUT FUNCTIONMICROBIOTA

ldquoSTABILITYrdquo

TRANSITION

LONG TERM FOLLOW-UP

NEUROENDOCRINE BEHAVIOURS

MATERNAL NEUROPLASTICITY

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

MORTALITYMETABOLISM

Weight gain 1st week

predicts OBESITYat 30 years

Large volume feedsstretched stomach=

doubled absorptivecapacity as adult

Importance

Programming ndash early life chronic disease

32

RESISTANCE SENSITIVITY

PERCEPTIONSldquoNEUROCEPTIONrdquo

RESPONSESTRESS

ALLOSTATIC STATE

ALLOSTASIS

ANY STRESSPsychologicalNeurological

EndocrineImmune

ALLOSTATIC LOAD

ALLOSTATIC OVERLOAD

WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY

DISEASEHEALTH

RESILIENCE VULNERABILITY

RESISTANCE SENSITIVITY

PERCEPTIONSldquoNEUROCEPTIONrdquo

RESPONSESTRESS

ALLOSTATIC STATE

ALLOSTASIS

ANY STRESSPsychologicalNeurological

EndocrineImmune

ALLOSTATIC LOAD

HEALTH

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

Gastric overfilling syndrome

189

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

33

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

Only case series Insufficient evidence

No mention of

stomach capacity196

Baby weight freq reqrsquod size actual

2kg baby 4hrly ~ 320 ml6 = 53ml 14ml

15 baby 3hrly ~ 240 ml8 = 30ml 10ml

10 baby 2hrly ~ 160 ml12 = 13ml 7ml

Standardised from20ml capacityfor 3kg baby( x 0007)

197

0

10

20

30

40

50

60

70

80

90

13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w

LINEAR

TERM

PREM

198

34

0

10

20

30

40

50

60

70

80

90

13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w

LINEAR

TERM

PREM

199

Clues to GER

ldquoI know baby hurtsrdquo

Gastric overfilling syndrome

Excessive volumesreflux aspiration colic

Excessive time intervalhypoglycaemia

Adaptationsdiabetic diathesis obesity

200

Developmental Care of the Enteric Nervous System

ldquoSmall and frequent feeds according to the sleep cyclerdquo

The ldquonicherdquo (occupation) of a neonate (Alberts)

BOND FEED

SLEEP SLEEP

PLAY FEED

201

Gastric overfilling syndrome

Proposed Management 202

Proposed Management

Babies should be fedEVERY TIME THEY WAKE

Stanley Graven 2006

REMNR1NR2NR3SWS

AS (20 mins) QS (40 mins)

A normal sleep cycle is ONE hourHow often should neonates feed

203

Proposed Management

All babies should be fedat least once an hour 204

35

Proposed Management

All babies should be fedat least once an hour

205

The first Milk Ejection Reflex (MER)

elicited in lt 2 minutesworks quicklyswallowed 1 minute

Feeding time (max)3 minutes

Repeat every 1 hour

Prime 2007

The ldquonormalrdquo or usual and common breastfeed

takes 15 minutesdiscomfort afterburping time 5 minutes

Feeding time 20 min

Repeat every 3 hours

Prime 2007

3 minute 20ml feeds x 24d = 72 minutes

20 minute 60ml feeds x 8d = 160 minutes

SMALL AND FREQUENT FEEDS ARE EFFICIENT

FEWER NURSES NEEDED

The calculated dailyrequirement for a 3kgbaby can be given without increase inpressure MINIMAL RISK

PARENTS CAN DOSAFELY

20 mls x 24 feeds= 480mls day

Zangen 2001 209

All babies should be fedat least once an hour

210

36

Infant feeding frequencyProposal based on available evidence and neuroscience

ldquoSmall and frequent feeds

adjusted to the sleep cyclerdquo

211

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

STATE organization

Feeding frequency

SLEEP cycling

BRAIN

WIRING

How often should a neonate feeda neonate sleep

Infantsleep cycles

begin to block on diurnalrhythms

Mother-infant synchrony

hellip at 12 weeks

(circadian)

START at 3 months

Can be ldquoadult-likerdquo

at 6 months

Thomas 2014

STATE organization

Feeding frequency

SLEEP cycling

PLAY FEED

216

SLEEP SLEEP

SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

Infantsleep cycles

begin to block on diurnalrhythms

37

BOND SUCKLE SLEEP SLEEP PLAY

FEED

217

SLEEP SLEEP SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)

Schaal 2004 218

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)rdquoSLEEP-FEED CYCLINGrdquo

Schaal 2004 219

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

WIRE

BRAIN

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

BRAIN

WIRING

NEUROSCIENCE

The DNAEverything else

EVOLUTIONARYBIOLOGY

The Brain

EPIGENETICS

The PlaceENVIRONMENT

EXPERIENCEFITNESS ADAPTATION

ldquoScientific foundationrdquo hellip a synthesis

ZERO

SEPARATION

38

wwwninobirthorgwwwskintoskincontactcom

THE NEUROSCIENCE OFSKIN-TO-SKIN CONTACT

AND BREASTFEEDING

ARE THE SAME

SUMMARY SKIN-TO-SKIN

(Regulation)

SLEEP(Brain)

FEEDING(Stomach)

LOVE ( ldquomindrdquo )

REMNR1NR2NR3NR4

ACQUISITION CONSOLIDATION MEMORYFORMATION

poly-sensory input transfer information P wavesshort-term memory ldquoSNRrdquo strong signals returns infostored cortex amygdala to neocortex

hippocampus organizedAwake and REM NREM stage 4 REM

BRAIN WIRING

Stanley Graven 2006

PLAY

SLEEP

FEEDHOLDYOURPREM

httpswwwfacebookcomninobirth

39

Nelson Mandela

hellip in describing themeasure of a nation

he has argued that

ldquoThere can be no keener revelation of a societyrsquos soul than the way in which it treats its childrenrdquo

Page 30: Neurodevelopmental The Neuroscience of Birth ... · breastfeeding pattern, neonatal weight gain, and the dynamics of lactation. Doucet 2012 In the ‘‘scentless breast’’ condition,

30

METABOLIC ADAPTATION

SSC started in the first 20 minutes after birth

SSC CotBlood glucose (1 hr) 317 256Base excess drop 34 18

(Christenson 1992)0h 1h 2h 3h 4h 2 days

App

roxim

ate

GLUCOSE

SSC Glucose production = Glucose consumption

Separation

SNS stress Glucose consumption INCREASE

PSNS dissociation Glucose production DECREASE

HYPOGLYCEMIA

SSC Cot

Blood glucose (1 hr) 317 256

0h 1h 2h 3h 4h 2 days

App

roxim

ate

GLUCOSE

SSC Glucose production = Glucose consumption

Separation PSNS dissociation

Glucose production DECREASE

HYPOGLYCEMIA

SSC Cot

Blood glucose (1 hr) 317 256

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

NEURODEVELOPMENTThe DNA Behaviour

EVOLUTIONARY BIOLOGY

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

BONDING ATTACHMENT

MRI HRVEEG

STRESS RESPONES

RESILIENCE

DOHAD

(MAL) ADAPTATION

EPIGENETICS

GENE X ENVIRONMENT

GENETIC VARIANTS

HOSPITAL ACQUIRED INFECTIONIMMUNITY

SLEEP PHYSIOLOGY

GUT FUNCTIONMICROBIOTA

ldquoSTABILITYrdquo

TRANSITION

LONG TERM FOLLOW-UP

NEUROENDOCRINE BEHAVIOURS

MATERNAL NEUROPLASTICITY

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

MORTALITYMETABOLISM

0h 1h 2h 3h 4h

PSNS (vagal)

App

roxim

ate

GLUCOSE

1 HOURLY Milk feed

1 HOURLY Milk feed

1 HOURLY Milk feed

1 HOURLY Milk feed

LACTOSE

METABOLISM

31

0h 1h 2h 3h 4h

PSNS (vagal) SYMPATHETIC STRESS

App

roxim

ate

GLUCOSE

LACTOSE FATGLYCOGEN

METABOLISM

4 HOURLY Milk feed

0h 1h 2h 3h 4h

PSNS (vagal) SYMPATHETIC STRESS

App

roxim

ate

GLUCOSE

4 HOURLY ALLOSTATIC STATELACTOSE FATGLYCOGEN

METABOLISM

4 HOURLY Milk feed

HEALTH DISEASE

EXPECTED UNEXPECTED

NEURODEVELOPMENTThe DNA Behaviour

EVOLUTIONARY BIOLOGY

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

BONDING ATTACHMENT

MRI HRVEEG

STRESS RESPONES

RESILIENCE

DOHAD

(MAL) ADAPTATION

EPIGENETICS

GENE X ENVIRONMENT

GENETIC VARIANTS

HOSPITAL ACQUIRED INFECTIONIMMUNITY

SLEEP PHYSIOLOGY

GUT FUNCTIONMICROBIOTA

ldquoSTABILITYrdquo

TRANSITION

LONG TERM FOLLOW-UP

NEUROENDOCRINE BEHAVIOURS

MATERNAL NEUROPLASTICITY

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

MORTALITYMETABOLISM

Weight gain 1st week

predicts OBESITYat 30 years

Large volume feedsstretched stomach=

doubled absorptivecapacity as adult

Importance

Programming ndash early life chronic disease

32

RESISTANCE SENSITIVITY

PERCEPTIONSldquoNEUROCEPTIONrdquo

RESPONSESTRESS

ALLOSTATIC STATE

ALLOSTASIS

ANY STRESSPsychologicalNeurological

EndocrineImmune

ALLOSTATIC LOAD

ALLOSTATIC OVERLOAD

WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY

DISEASEHEALTH

RESILIENCE VULNERABILITY

RESISTANCE SENSITIVITY

PERCEPTIONSldquoNEUROCEPTIONrdquo

RESPONSESTRESS

ALLOSTATIC STATE

ALLOSTASIS

ANY STRESSPsychologicalNeurological

EndocrineImmune

ALLOSTATIC LOAD

HEALTH

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

Gastric overfilling syndrome

189

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

33

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

Only case series Insufficient evidence

No mention of

stomach capacity196

Baby weight freq reqrsquod size actual

2kg baby 4hrly ~ 320 ml6 = 53ml 14ml

15 baby 3hrly ~ 240 ml8 = 30ml 10ml

10 baby 2hrly ~ 160 ml12 = 13ml 7ml

Standardised from20ml capacityfor 3kg baby( x 0007)

197

0

10

20

30

40

50

60

70

80

90

13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w

LINEAR

TERM

PREM

198

34

0

10

20

30

40

50

60

70

80

90

13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w

LINEAR

TERM

PREM

199

Clues to GER

ldquoI know baby hurtsrdquo

Gastric overfilling syndrome

Excessive volumesreflux aspiration colic

Excessive time intervalhypoglycaemia

Adaptationsdiabetic diathesis obesity

200

Developmental Care of the Enteric Nervous System

ldquoSmall and frequent feeds according to the sleep cyclerdquo

The ldquonicherdquo (occupation) of a neonate (Alberts)

BOND FEED

SLEEP SLEEP

PLAY FEED

201

Gastric overfilling syndrome

Proposed Management 202

Proposed Management

Babies should be fedEVERY TIME THEY WAKE

Stanley Graven 2006

REMNR1NR2NR3SWS

AS (20 mins) QS (40 mins)

A normal sleep cycle is ONE hourHow often should neonates feed

203

Proposed Management

All babies should be fedat least once an hour 204

35

Proposed Management

All babies should be fedat least once an hour

205

The first Milk Ejection Reflex (MER)

elicited in lt 2 minutesworks quicklyswallowed 1 minute

Feeding time (max)3 minutes

Repeat every 1 hour

Prime 2007

The ldquonormalrdquo or usual and common breastfeed

takes 15 minutesdiscomfort afterburping time 5 minutes

Feeding time 20 min

Repeat every 3 hours

Prime 2007

3 minute 20ml feeds x 24d = 72 minutes

20 minute 60ml feeds x 8d = 160 minutes

SMALL AND FREQUENT FEEDS ARE EFFICIENT

FEWER NURSES NEEDED

The calculated dailyrequirement for a 3kgbaby can be given without increase inpressure MINIMAL RISK

PARENTS CAN DOSAFELY

20 mls x 24 feeds= 480mls day

Zangen 2001 209

All babies should be fedat least once an hour

210

36

Infant feeding frequencyProposal based on available evidence and neuroscience

ldquoSmall and frequent feeds

adjusted to the sleep cyclerdquo

211

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

STATE organization

Feeding frequency

SLEEP cycling

BRAIN

WIRING

How often should a neonate feeda neonate sleep

Infantsleep cycles

begin to block on diurnalrhythms

Mother-infant synchrony

hellip at 12 weeks

(circadian)

START at 3 months

Can be ldquoadult-likerdquo

at 6 months

Thomas 2014

STATE organization

Feeding frequency

SLEEP cycling

PLAY FEED

216

SLEEP SLEEP

SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

Infantsleep cycles

begin to block on diurnalrhythms

37

BOND SUCKLE SLEEP SLEEP PLAY

FEED

217

SLEEP SLEEP SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)

Schaal 2004 218

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)rdquoSLEEP-FEED CYCLINGrdquo

Schaal 2004 219

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

WIRE

BRAIN

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

BRAIN

WIRING

NEUROSCIENCE

The DNAEverything else

EVOLUTIONARYBIOLOGY

The Brain

EPIGENETICS

The PlaceENVIRONMENT

EXPERIENCEFITNESS ADAPTATION

ldquoScientific foundationrdquo hellip a synthesis

ZERO

SEPARATION

38

wwwninobirthorgwwwskintoskincontactcom

THE NEUROSCIENCE OFSKIN-TO-SKIN CONTACT

AND BREASTFEEDING

ARE THE SAME

SUMMARY SKIN-TO-SKIN

(Regulation)

SLEEP(Brain)

FEEDING(Stomach)

LOVE ( ldquomindrdquo )

REMNR1NR2NR3NR4

ACQUISITION CONSOLIDATION MEMORYFORMATION

poly-sensory input transfer information P wavesshort-term memory ldquoSNRrdquo strong signals returns infostored cortex amygdala to neocortex

hippocampus organizedAwake and REM NREM stage 4 REM

BRAIN WIRING

Stanley Graven 2006

PLAY

SLEEP

FEEDHOLDYOURPREM

httpswwwfacebookcomninobirth

39

Nelson Mandela

hellip in describing themeasure of a nation

he has argued that

ldquoThere can be no keener revelation of a societyrsquos soul than the way in which it treats its childrenrdquo

Page 31: Neurodevelopmental The Neuroscience of Birth ... · breastfeeding pattern, neonatal weight gain, and the dynamics of lactation. Doucet 2012 In the ‘‘scentless breast’’ condition,

31

0h 1h 2h 3h 4h

PSNS (vagal) SYMPATHETIC STRESS

App

roxim

ate

GLUCOSE

LACTOSE FATGLYCOGEN

METABOLISM

4 HOURLY Milk feed

0h 1h 2h 3h 4h

PSNS (vagal) SYMPATHETIC STRESS

App

roxim

ate

GLUCOSE

4 HOURLY ALLOSTATIC STATELACTOSE FATGLYCOGEN

METABOLISM

4 HOURLY Milk feed

HEALTH DISEASE

EXPECTED UNEXPECTED

NEURODEVELOPMENTThe DNA Behaviour

EVOLUTIONARY BIOLOGY

The Neuroscience of Birth amp BreastfeedingThe Brain

EPIGENETICS

ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION

BONDING ATTACHMENT

MRI HRVEEG

STRESS RESPONES

RESILIENCE

DOHAD

(MAL) ADAPTATION

EPIGENETICS

GENE X ENVIRONMENT

GENETIC VARIANTS

HOSPITAL ACQUIRED INFECTIONIMMUNITY

SLEEP PHYSIOLOGY

GUT FUNCTIONMICROBIOTA

ldquoSTABILITYrdquo

TRANSITION

LONG TERM FOLLOW-UP

NEUROENDOCRINE BEHAVIOURS

MATERNAL NEUROPLASTICITY

ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip

MORTALITYMETABOLISM

Weight gain 1st week

predicts OBESITYat 30 years

Large volume feedsstretched stomach=

doubled absorptivecapacity as adult

Importance

Programming ndash early life chronic disease

32

RESISTANCE SENSITIVITY

PERCEPTIONSldquoNEUROCEPTIONrdquo

RESPONSESTRESS

ALLOSTATIC STATE

ALLOSTASIS

ANY STRESSPsychologicalNeurological

EndocrineImmune

ALLOSTATIC LOAD

ALLOSTATIC OVERLOAD

WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY

DISEASEHEALTH

RESILIENCE VULNERABILITY

RESISTANCE SENSITIVITY

PERCEPTIONSldquoNEUROCEPTIONrdquo

RESPONSESTRESS

ALLOSTATIC STATE

ALLOSTASIS

ANY STRESSPsychologicalNeurological

EndocrineImmune

ALLOSTATIC LOAD

HEALTH

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

Gastric overfilling syndrome

189

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

33

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

Only case series Insufficient evidence

No mention of

stomach capacity196

Baby weight freq reqrsquod size actual

2kg baby 4hrly ~ 320 ml6 = 53ml 14ml

15 baby 3hrly ~ 240 ml8 = 30ml 10ml

10 baby 2hrly ~ 160 ml12 = 13ml 7ml

Standardised from20ml capacityfor 3kg baby( x 0007)

197

0

10

20

30

40

50

60

70

80

90

13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w

LINEAR

TERM

PREM

198

34

0

10

20

30

40

50

60

70

80

90

13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w

LINEAR

TERM

PREM

199

Clues to GER

ldquoI know baby hurtsrdquo

Gastric overfilling syndrome

Excessive volumesreflux aspiration colic

Excessive time intervalhypoglycaemia

Adaptationsdiabetic diathesis obesity

200

Developmental Care of the Enteric Nervous System

ldquoSmall and frequent feeds according to the sleep cyclerdquo

The ldquonicherdquo (occupation) of a neonate (Alberts)

BOND FEED

SLEEP SLEEP

PLAY FEED

201

Gastric overfilling syndrome

Proposed Management 202

Proposed Management

Babies should be fedEVERY TIME THEY WAKE

Stanley Graven 2006

REMNR1NR2NR3SWS

AS (20 mins) QS (40 mins)

A normal sleep cycle is ONE hourHow often should neonates feed

203

Proposed Management

All babies should be fedat least once an hour 204

35

Proposed Management

All babies should be fedat least once an hour

205

The first Milk Ejection Reflex (MER)

elicited in lt 2 minutesworks quicklyswallowed 1 minute

Feeding time (max)3 minutes

Repeat every 1 hour

Prime 2007

The ldquonormalrdquo or usual and common breastfeed

takes 15 minutesdiscomfort afterburping time 5 minutes

Feeding time 20 min

Repeat every 3 hours

Prime 2007

3 minute 20ml feeds x 24d = 72 minutes

20 minute 60ml feeds x 8d = 160 minutes

SMALL AND FREQUENT FEEDS ARE EFFICIENT

FEWER NURSES NEEDED

The calculated dailyrequirement for a 3kgbaby can be given without increase inpressure MINIMAL RISK

PARENTS CAN DOSAFELY

20 mls x 24 feeds= 480mls day

Zangen 2001 209

All babies should be fedat least once an hour

210

36

Infant feeding frequencyProposal based on available evidence and neuroscience

ldquoSmall and frequent feeds

adjusted to the sleep cyclerdquo

211

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

STATE organization

Feeding frequency

SLEEP cycling

BRAIN

WIRING

How often should a neonate feeda neonate sleep

Infantsleep cycles

begin to block on diurnalrhythms

Mother-infant synchrony

hellip at 12 weeks

(circadian)

START at 3 months

Can be ldquoadult-likerdquo

at 6 months

Thomas 2014

STATE organization

Feeding frequency

SLEEP cycling

PLAY FEED

216

SLEEP SLEEP

SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

Infantsleep cycles

begin to block on diurnalrhythms

37

BOND SUCKLE SLEEP SLEEP PLAY

FEED

217

SLEEP SLEEP SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)

Schaal 2004 218

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)rdquoSLEEP-FEED CYCLINGrdquo

Schaal 2004 219

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

WIRE

BRAIN

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

BRAIN

WIRING

NEUROSCIENCE

The DNAEverything else

EVOLUTIONARYBIOLOGY

The Brain

EPIGENETICS

The PlaceENVIRONMENT

EXPERIENCEFITNESS ADAPTATION

ldquoScientific foundationrdquo hellip a synthesis

ZERO

SEPARATION

38

wwwninobirthorgwwwskintoskincontactcom

THE NEUROSCIENCE OFSKIN-TO-SKIN CONTACT

AND BREASTFEEDING

ARE THE SAME

SUMMARY SKIN-TO-SKIN

(Regulation)

SLEEP(Brain)

FEEDING(Stomach)

LOVE ( ldquomindrdquo )

REMNR1NR2NR3NR4

ACQUISITION CONSOLIDATION MEMORYFORMATION

poly-sensory input transfer information P wavesshort-term memory ldquoSNRrdquo strong signals returns infostored cortex amygdala to neocortex

hippocampus organizedAwake and REM NREM stage 4 REM

BRAIN WIRING

Stanley Graven 2006

PLAY

SLEEP

FEEDHOLDYOURPREM

httpswwwfacebookcomninobirth

39

Nelson Mandela

hellip in describing themeasure of a nation

he has argued that

ldquoThere can be no keener revelation of a societyrsquos soul than the way in which it treats its childrenrdquo

Page 32: Neurodevelopmental The Neuroscience of Birth ... · breastfeeding pattern, neonatal weight gain, and the dynamics of lactation. Doucet 2012 In the ‘‘scentless breast’’ condition,

32

RESISTANCE SENSITIVITY

PERCEPTIONSldquoNEUROCEPTIONrdquo

RESPONSESTRESS

ALLOSTATIC STATE

ALLOSTASIS

ANY STRESSPsychologicalNeurological

EndocrineImmune

ALLOSTATIC LOAD

ALLOSTATIC OVERLOAD

WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY

DISEASEHEALTH

RESILIENCE VULNERABILITY

RESISTANCE SENSITIVITY

PERCEPTIONSldquoNEUROCEPTIONrdquo

RESPONSESTRESS

ALLOSTATIC STATE

ALLOSTASIS

ANY STRESSPsychologicalNeurological

EndocrineImmune

ALLOSTATIC LOAD

HEALTH

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

Gastric overfilling syndrome

189

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip NICU context

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

33

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

Only case series Insufficient evidence

No mention of

stomach capacity196

Baby weight freq reqrsquod size actual

2kg baby 4hrly ~ 320 ml6 = 53ml 14ml

15 baby 3hrly ~ 240 ml8 = 30ml 10ml

10 baby 2hrly ~ 160 ml12 = 13ml 7ml

Standardised from20ml capacityfor 3kg baby( x 0007)

197

0

10

20

30

40

50

60

70

80

90

13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w

LINEAR

TERM

PREM

198

34

0

10

20

30

40

50

60

70

80

90

13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w

LINEAR

TERM

PREM

199

Clues to GER

ldquoI know baby hurtsrdquo

Gastric overfilling syndrome

Excessive volumesreflux aspiration colic

Excessive time intervalhypoglycaemia

Adaptationsdiabetic diathesis obesity

200

Developmental Care of the Enteric Nervous System

ldquoSmall and frequent feeds according to the sleep cyclerdquo

The ldquonicherdquo (occupation) of a neonate (Alberts)

BOND FEED

SLEEP SLEEP

PLAY FEED

201

Gastric overfilling syndrome

Proposed Management 202

Proposed Management

Babies should be fedEVERY TIME THEY WAKE

Stanley Graven 2006

REMNR1NR2NR3SWS

AS (20 mins) QS (40 mins)

A normal sleep cycle is ONE hourHow often should neonates feed

203

Proposed Management

All babies should be fedat least once an hour 204

35

Proposed Management

All babies should be fedat least once an hour

205

The first Milk Ejection Reflex (MER)

elicited in lt 2 minutesworks quicklyswallowed 1 minute

Feeding time (max)3 minutes

Repeat every 1 hour

Prime 2007

The ldquonormalrdquo or usual and common breastfeed

takes 15 minutesdiscomfort afterburping time 5 minutes

Feeding time 20 min

Repeat every 3 hours

Prime 2007

3 minute 20ml feeds x 24d = 72 minutes

20 minute 60ml feeds x 8d = 160 minutes

SMALL AND FREQUENT FEEDS ARE EFFICIENT

FEWER NURSES NEEDED

The calculated dailyrequirement for a 3kgbaby can be given without increase inpressure MINIMAL RISK

PARENTS CAN DOSAFELY

20 mls x 24 feeds= 480mls day

Zangen 2001 209

All babies should be fedat least once an hour

210

36

Infant feeding frequencyProposal based on available evidence and neuroscience

ldquoSmall and frequent feeds

adjusted to the sleep cyclerdquo

211

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

STATE organization

Feeding frequency

SLEEP cycling

BRAIN

WIRING

How often should a neonate feeda neonate sleep

Infantsleep cycles

begin to block on diurnalrhythms

Mother-infant synchrony

hellip at 12 weeks

(circadian)

START at 3 months

Can be ldquoadult-likerdquo

at 6 months

Thomas 2014

STATE organization

Feeding frequency

SLEEP cycling

PLAY FEED

216

SLEEP SLEEP

SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

Infantsleep cycles

begin to block on diurnalrhythms

37

BOND SUCKLE SLEEP SLEEP PLAY

FEED

217

SLEEP SLEEP SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)

Schaal 2004 218

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)rdquoSLEEP-FEED CYCLINGrdquo

Schaal 2004 219

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

WIRE

BRAIN

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

BRAIN

WIRING

NEUROSCIENCE

The DNAEverything else

EVOLUTIONARYBIOLOGY

The Brain

EPIGENETICS

The PlaceENVIRONMENT

EXPERIENCEFITNESS ADAPTATION

ldquoScientific foundationrdquo hellip a synthesis

ZERO

SEPARATION

38

wwwninobirthorgwwwskintoskincontactcom

THE NEUROSCIENCE OFSKIN-TO-SKIN CONTACT

AND BREASTFEEDING

ARE THE SAME

SUMMARY SKIN-TO-SKIN

(Regulation)

SLEEP(Brain)

FEEDING(Stomach)

LOVE ( ldquomindrdquo )

REMNR1NR2NR3NR4

ACQUISITION CONSOLIDATION MEMORYFORMATION

poly-sensory input transfer information P wavesshort-term memory ldquoSNRrdquo strong signals returns infostored cortex amygdala to neocortex

hippocampus organizedAwake and REM NREM stage 4 REM

BRAIN WIRING

Stanley Graven 2006

PLAY

SLEEP

FEEDHOLDYOURPREM

httpswwwfacebookcomninobirth

39

Nelson Mandela

hellip in describing themeasure of a nation

he has argued that

ldquoThere can be no keener revelation of a societyrsquos soul than the way in which it treats its childrenrdquo

Page 33: Neurodevelopmental The Neuroscience of Birth ... · breastfeeding pattern, neonatal weight gain, and the dynamics of lactation. Doucet 2012 In the ‘‘scentless breast’’ condition,

33

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

PMA 28 40 64 1y 2y

Nilsrsquo QUESTIONS hellip full term

SUCKLING IS

COMPETENT

FEEDING IS

IMMATURE

elevated activity ndashsustained over time

or severe hellip changes the ldquoset

pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)

Only case series Insufficient evidence

No mention of

stomach capacity196

Baby weight freq reqrsquod size actual

2kg baby 4hrly ~ 320 ml6 = 53ml 14ml

15 baby 3hrly ~ 240 ml8 = 30ml 10ml

10 baby 2hrly ~ 160 ml12 = 13ml 7ml

Standardised from20ml capacityfor 3kg baby( x 0007)

197

0

10

20

30

40

50

60

70

80

90

13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w

LINEAR

TERM

PREM

198

34

0

10

20

30

40

50

60

70

80

90

13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w

LINEAR

TERM

PREM

199

Clues to GER

ldquoI know baby hurtsrdquo

Gastric overfilling syndrome

Excessive volumesreflux aspiration colic

Excessive time intervalhypoglycaemia

Adaptationsdiabetic diathesis obesity

200

Developmental Care of the Enteric Nervous System

ldquoSmall and frequent feeds according to the sleep cyclerdquo

The ldquonicherdquo (occupation) of a neonate (Alberts)

BOND FEED

SLEEP SLEEP

PLAY FEED

201

Gastric overfilling syndrome

Proposed Management 202

Proposed Management

Babies should be fedEVERY TIME THEY WAKE

Stanley Graven 2006

REMNR1NR2NR3SWS

AS (20 mins) QS (40 mins)

A normal sleep cycle is ONE hourHow often should neonates feed

203

Proposed Management

All babies should be fedat least once an hour 204

35

Proposed Management

All babies should be fedat least once an hour

205

The first Milk Ejection Reflex (MER)

elicited in lt 2 minutesworks quicklyswallowed 1 minute

Feeding time (max)3 minutes

Repeat every 1 hour

Prime 2007

The ldquonormalrdquo or usual and common breastfeed

takes 15 minutesdiscomfort afterburping time 5 minutes

Feeding time 20 min

Repeat every 3 hours

Prime 2007

3 minute 20ml feeds x 24d = 72 minutes

20 minute 60ml feeds x 8d = 160 minutes

SMALL AND FREQUENT FEEDS ARE EFFICIENT

FEWER NURSES NEEDED

The calculated dailyrequirement for a 3kgbaby can be given without increase inpressure MINIMAL RISK

PARENTS CAN DOSAFELY

20 mls x 24 feeds= 480mls day

Zangen 2001 209

All babies should be fedat least once an hour

210

36

Infant feeding frequencyProposal based on available evidence and neuroscience

ldquoSmall and frequent feeds

adjusted to the sleep cyclerdquo

211

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

STATE organization

Feeding frequency

SLEEP cycling

BRAIN

WIRING

How often should a neonate feeda neonate sleep

Infantsleep cycles

begin to block on diurnalrhythms

Mother-infant synchrony

hellip at 12 weeks

(circadian)

START at 3 months

Can be ldquoadult-likerdquo

at 6 months

Thomas 2014

STATE organization

Feeding frequency

SLEEP cycling

PLAY FEED

216

SLEEP SLEEP

SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

Infantsleep cycles

begin to block on diurnalrhythms

37

BOND SUCKLE SLEEP SLEEP PLAY

FEED

217

SLEEP SLEEP SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)

Schaal 2004 218

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)rdquoSLEEP-FEED CYCLINGrdquo

Schaal 2004 219

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

WIRE

BRAIN

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

BRAIN

WIRING

NEUROSCIENCE

The DNAEverything else

EVOLUTIONARYBIOLOGY

The Brain

EPIGENETICS

The PlaceENVIRONMENT

EXPERIENCEFITNESS ADAPTATION

ldquoScientific foundationrdquo hellip a synthesis

ZERO

SEPARATION

38

wwwninobirthorgwwwskintoskincontactcom

THE NEUROSCIENCE OFSKIN-TO-SKIN CONTACT

AND BREASTFEEDING

ARE THE SAME

SUMMARY SKIN-TO-SKIN

(Regulation)

SLEEP(Brain)

FEEDING(Stomach)

LOVE ( ldquomindrdquo )

REMNR1NR2NR3NR4

ACQUISITION CONSOLIDATION MEMORYFORMATION

poly-sensory input transfer information P wavesshort-term memory ldquoSNRrdquo strong signals returns infostored cortex amygdala to neocortex

hippocampus organizedAwake and REM NREM stage 4 REM

BRAIN WIRING

Stanley Graven 2006

PLAY

SLEEP

FEEDHOLDYOURPREM

httpswwwfacebookcomninobirth

39

Nelson Mandela

hellip in describing themeasure of a nation

he has argued that

ldquoThere can be no keener revelation of a societyrsquos soul than the way in which it treats its childrenrdquo

Page 34: Neurodevelopmental The Neuroscience of Birth ... · breastfeeding pattern, neonatal weight gain, and the dynamics of lactation. Doucet 2012 In the ‘‘scentless breast’’ condition,

34

0

10

20

30

40

50

60

70

80

90

13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w

LINEAR

TERM

PREM

199

Clues to GER

ldquoI know baby hurtsrdquo

Gastric overfilling syndrome

Excessive volumesreflux aspiration colic

Excessive time intervalhypoglycaemia

Adaptationsdiabetic diathesis obesity

200

Developmental Care of the Enteric Nervous System

ldquoSmall and frequent feeds according to the sleep cyclerdquo

The ldquonicherdquo (occupation) of a neonate (Alberts)

BOND FEED

SLEEP SLEEP

PLAY FEED

201

Gastric overfilling syndrome

Proposed Management 202

Proposed Management

Babies should be fedEVERY TIME THEY WAKE

Stanley Graven 2006

REMNR1NR2NR3SWS

AS (20 mins) QS (40 mins)

A normal sleep cycle is ONE hourHow often should neonates feed

203

Proposed Management

All babies should be fedat least once an hour 204

35

Proposed Management

All babies should be fedat least once an hour

205

The first Milk Ejection Reflex (MER)

elicited in lt 2 minutesworks quicklyswallowed 1 minute

Feeding time (max)3 minutes

Repeat every 1 hour

Prime 2007

The ldquonormalrdquo or usual and common breastfeed

takes 15 minutesdiscomfort afterburping time 5 minutes

Feeding time 20 min

Repeat every 3 hours

Prime 2007

3 minute 20ml feeds x 24d = 72 minutes

20 minute 60ml feeds x 8d = 160 minutes

SMALL AND FREQUENT FEEDS ARE EFFICIENT

FEWER NURSES NEEDED

The calculated dailyrequirement for a 3kgbaby can be given without increase inpressure MINIMAL RISK

PARENTS CAN DOSAFELY

20 mls x 24 feeds= 480mls day

Zangen 2001 209

All babies should be fedat least once an hour

210

36

Infant feeding frequencyProposal based on available evidence and neuroscience

ldquoSmall and frequent feeds

adjusted to the sleep cyclerdquo

211

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

STATE organization

Feeding frequency

SLEEP cycling

BRAIN

WIRING

How often should a neonate feeda neonate sleep

Infantsleep cycles

begin to block on diurnalrhythms

Mother-infant synchrony

hellip at 12 weeks

(circadian)

START at 3 months

Can be ldquoadult-likerdquo

at 6 months

Thomas 2014

STATE organization

Feeding frequency

SLEEP cycling

PLAY FEED

216

SLEEP SLEEP

SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

Infantsleep cycles

begin to block on diurnalrhythms

37

BOND SUCKLE SLEEP SLEEP PLAY

FEED

217

SLEEP SLEEP SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)

Schaal 2004 218

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)rdquoSLEEP-FEED CYCLINGrdquo

Schaal 2004 219

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

WIRE

BRAIN

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

BRAIN

WIRING

NEUROSCIENCE

The DNAEverything else

EVOLUTIONARYBIOLOGY

The Brain

EPIGENETICS

The PlaceENVIRONMENT

EXPERIENCEFITNESS ADAPTATION

ldquoScientific foundationrdquo hellip a synthesis

ZERO

SEPARATION

38

wwwninobirthorgwwwskintoskincontactcom

THE NEUROSCIENCE OFSKIN-TO-SKIN CONTACT

AND BREASTFEEDING

ARE THE SAME

SUMMARY SKIN-TO-SKIN

(Regulation)

SLEEP(Brain)

FEEDING(Stomach)

LOVE ( ldquomindrdquo )

REMNR1NR2NR3NR4

ACQUISITION CONSOLIDATION MEMORYFORMATION

poly-sensory input transfer information P wavesshort-term memory ldquoSNRrdquo strong signals returns infostored cortex amygdala to neocortex

hippocampus organizedAwake and REM NREM stage 4 REM

BRAIN WIRING

Stanley Graven 2006

PLAY

SLEEP

FEEDHOLDYOURPREM

httpswwwfacebookcomninobirth

39

Nelson Mandela

hellip in describing themeasure of a nation

he has argued that

ldquoThere can be no keener revelation of a societyrsquos soul than the way in which it treats its childrenrdquo

Page 35: Neurodevelopmental The Neuroscience of Birth ... · breastfeeding pattern, neonatal weight gain, and the dynamics of lactation. Doucet 2012 In the ‘‘scentless breast’’ condition,

35

Proposed Management

All babies should be fedat least once an hour

205

The first Milk Ejection Reflex (MER)

elicited in lt 2 minutesworks quicklyswallowed 1 minute

Feeding time (max)3 minutes

Repeat every 1 hour

Prime 2007

The ldquonormalrdquo or usual and common breastfeed

takes 15 minutesdiscomfort afterburping time 5 minutes

Feeding time 20 min

Repeat every 3 hours

Prime 2007

3 minute 20ml feeds x 24d = 72 minutes

20 minute 60ml feeds x 8d = 160 minutes

SMALL AND FREQUENT FEEDS ARE EFFICIENT

FEWER NURSES NEEDED

The calculated dailyrequirement for a 3kgbaby can be given without increase inpressure MINIMAL RISK

PARENTS CAN DOSAFELY

20 mls x 24 feeds= 480mls day

Zangen 2001 209

All babies should be fedat least once an hour

210

36

Infant feeding frequencyProposal based on available evidence and neuroscience

ldquoSmall and frequent feeds

adjusted to the sleep cyclerdquo

211

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

STATE organization

Feeding frequency

SLEEP cycling

BRAIN

WIRING

How often should a neonate feeda neonate sleep

Infantsleep cycles

begin to block on diurnalrhythms

Mother-infant synchrony

hellip at 12 weeks

(circadian)

START at 3 months

Can be ldquoadult-likerdquo

at 6 months

Thomas 2014

STATE organization

Feeding frequency

SLEEP cycling

PLAY FEED

216

SLEEP SLEEP

SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

Infantsleep cycles

begin to block on diurnalrhythms

37

BOND SUCKLE SLEEP SLEEP PLAY

FEED

217

SLEEP SLEEP SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)

Schaal 2004 218

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)rdquoSLEEP-FEED CYCLINGrdquo

Schaal 2004 219

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

WIRE

BRAIN

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

BRAIN

WIRING

NEUROSCIENCE

The DNAEverything else

EVOLUTIONARYBIOLOGY

The Brain

EPIGENETICS

The PlaceENVIRONMENT

EXPERIENCEFITNESS ADAPTATION

ldquoScientific foundationrdquo hellip a synthesis

ZERO

SEPARATION

38

wwwninobirthorgwwwskintoskincontactcom

THE NEUROSCIENCE OFSKIN-TO-SKIN CONTACT

AND BREASTFEEDING

ARE THE SAME

SUMMARY SKIN-TO-SKIN

(Regulation)

SLEEP(Brain)

FEEDING(Stomach)

LOVE ( ldquomindrdquo )

REMNR1NR2NR3NR4

ACQUISITION CONSOLIDATION MEMORYFORMATION

poly-sensory input transfer information P wavesshort-term memory ldquoSNRrdquo strong signals returns infostored cortex amygdala to neocortex

hippocampus organizedAwake and REM NREM stage 4 REM

BRAIN WIRING

Stanley Graven 2006

PLAY

SLEEP

FEEDHOLDYOURPREM

httpswwwfacebookcomninobirth

39

Nelson Mandela

hellip in describing themeasure of a nation

he has argued that

ldquoThere can be no keener revelation of a societyrsquos soul than the way in which it treats its childrenrdquo

Page 36: Neurodevelopmental The Neuroscience of Birth ... · breastfeeding pattern, neonatal weight gain, and the dynamics of lactation. Doucet 2012 In the ‘‘scentless breast’’ condition,

36

Infant feeding frequencyProposal based on available evidence and neuroscience

ldquoSmall and frequent feeds

adjusted to the sleep cyclerdquo

211

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

STATE organization

Feeding frequency

SLEEP cycling

BRAIN

WIRING

How often should a neonate feeda neonate sleep

Infantsleep cycles

begin to block on diurnalrhythms

Mother-infant synchrony

hellip at 12 weeks

(circadian)

START at 3 months

Can be ldquoadult-likerdquo

at 6 months

Thomas 2014

STATE organization

Feeding frequency

SLEEP cycling

PLAY FEED

216

SLEEP SLEEP

SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

Infantsleep cycles

begin to block on diurnalrhythms

37

BOND SUCKLE SLEEP SLEEP PLAY

FEED

217

SLEEP SLEEP SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)

Schaal 2004 218

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)rdquoSLEEP-FEED CYCLINGrdquo

Schaal 2004 219

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

WIRE

BRAIN

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

BRAIN

WIRING

NEUROSCIENCE

The DNAEverything else

EVOLUTIONARYBIOLOGY

The Brain

EPIGENETICS

The PlaceENVIRONMENT

EXPERIENCEFITNESS ADAPTATION

ldquoScientific foundationrdquo hellip a synthesis

ZERO

SEPARATION

38

wwwninobirthorgwwwskintoskincontactcom

THE NEUROSCIENCE OFSKIN-TO-SKIN CONTACT

AND BREASTFEEDING

ARE THE SAME

SUMMARY SKIN-TO-SKIN

(Regulation)

SLEEP(Brain)

FEEDING(Stomach)

LOVE ( ldquomindrdquo )

REMNR1NR2NR3NR4

ACQUISITION CONSOLIDATION MEMORYFORMATION

poly-sensory input transfer information P wavesshort-term memory ldquoSNRrdquo strong signals returns infostored cortex amygdala to neocortex

hippocampus organizedAwake and REM NREM stage 4 REM

BRAIN WIRING

Stanley Graven 2006

PLAY

SLEEP

FEEDHOLDYOURPREM

httpswwwfacebookcomninobirth

39

Nelson Mandela

hellip in describing themeasure of a nation

he has argued that

ldquoThere can be no keener revelation of a societyrsquos soul than the way in which it treats its childrenrdquo

Page 37: Neurodevelopmental The Neuroscience of Birth ... · breastfeeding pattern, neonatal weight gain, and the dynamics of lactation. Doucet 2012 In the ‘‘scentless breast’’ condition,

37

BOND SUCKLE SLEEP SLEEP PLAY

FEED

217

SLEEP SLEEP SLEEP SLEEPPLAY

FEED

Infant sleep cycling and synchronicity with maternal sleep ensure development

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)

Schaal 2004 218

modulates state organisationelicits emotional behaviours

activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour

SMELL(amp SKIN)rdquoSLEEP-FEED CYCLINGrdquo

Schaal 2004 219

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

WIRE

BRAIN

BIRTH

S S C

Breastfeeding behaviour

Breastfeeding WIRING

BREASTFEEDING

SENSORY BRAINstimulation nutrition

STATE organization

Feeding frequency

SLEEP cycling

ON-GOING

S S C

BRAIN

WIRING

NEUROSCIENCE

The DNAEverything else

EVOLUTIONARYBIOLOGY

The Brain

EPIGENETICS

The PlaceENVIRONMENT

EXPERIENCEFITNESS ADAPTATION

ldquoScientific foundationrdquo hellip a synthesis

ZERO

SEPARATION

38

wwwninobirthorgwwwskintoskincontactcom

THE NEUROSCIENCE OFSKIN-TO-SKIN CONTACT

AND BREASTFEEDING

ARE THE SAME

SUMMARY SKIN-TO-SKIN

(Regulation)

SLEEP(Brain)

FEEDING(Stomach)

LOVE ( ldquomindrdquo )

REMNR1NR2NR3NR4

ACQUISITION CONSOLIDATION MEMORYFORMATION

poly-sensory input transfer information P wavesshort-term memory ldquoSNRrdquo strong signals returns infostored cortex amygdala to neocortex

hippocampus organizedAwake and REM NREM stage 4 REM

BRAIN WIRING

Stanley Graven 2006

PLAY

SLEEP

FEEDHOLDYOURPREM

httpswwwfacebookcomninobirth

39

Nelson Mandela

hellip in describing themeasure of a nation

he has argued that

ldquoThere can be no keener revelation of a societyrsquos soul than the way in which it treats its childrenrdquo

Page 38: Neurodevelopmental The Neuroscience of Birth ... · breastfeeding pattern, neonatal weight gain, and the dynamics of lactation. Doucet 2012 In the ‘‘scentless breast’’ condition,

38

wwwninobirthorgwwwskintoskincontactcom

THE NEUROSCIENCE OFSKIN-TO-SKIN CONTACT

AND BREASTFEEDING

ARE THE SAME

SUMMARY SKIN-TO-SKIN

(Regulation)

SLEEP(Brain)

FEEDING(Stomach)

LOVE ( ldquomindrdquo )

REMNR1NR2NR3NR4

ACQUISITION CONSOLIDATION MEMORYFORMATION

poly-sensory input transfer information P wavesshort-term memory ldquoSNRrdquo strong signals returns infostored cortex amygdala to neocortex

hippocampus organizedAwake and REM NREM stage 4 REM

BRAIN WIRING

Stanley Graven 2006

PLAY

SLEEP

FEEDHOLDYOURPREM

httpswwwfacebookcomninobirth

39

Nelson Mandela

hellip in describing themeasure of a nation

he has argued that

ldquoThere can be no keener revelation of a societyrsquos soul than the way in which it treats its childrenrdquo

Page 39: Neurodevelopmental The Neuroscience of Birth ... · breastfeeding pattern, neonatal weight gain, and the dynamics of lactation. Doucet 2012 In the ‘‘scentless breast’’ condition,

39

Nelson Mandela

hellip in describing themeasure of a nation

he has argued that

ldquoThere can be no keener revelation of a societyrsquos soul than the way in which it treats its childrenrdquo