Author Name:
Sharon Breward ABM, BFC, IBCLC

Biography:
Sharon Breward is the Asocciation of Breastfeeding Mothers (ABM) Vice Chair, she is also an International Board Certified Lactation Consultant and an ABM breastfeeding counsellor

KMC was developed by Dr Bergman and colleagues for the care of premature babies it has resulted in a five-fold improvement in survival rates of very low birth weight infants. KMC is official policy of care of premature babies in all hospitals of the Western Cape province of South Africa and has been adopted by many other hospitals around the world.

My overwhelming impression from this fantastic presentation was that Dr Bergman totally justified KMC as an essential ethos of care for all babies (not just those born prematurely). Dr Bergman used both evolutionary and developmental criteria to explain why KMC and in particular skin to skin contact is so essential for mothers & babies.

Evolution
Dr Bergman expertly navigated about 210 million years of evolution! He identified the common heritage of mammalian species, starting with the development of milk producing modified sweat glands by the monotremes: the earliest mammals or “breastfeeders”, and the provision of the necessary “delivery system”, the nipple by marsupials.

Around 60 million years ago mammalian diversification occurred and different systems of care evolved for mammalian young that were dependant on the maturity of the newborn. Primates developed “carry care” whereby the baby is to be kept in direct close contact with it’s mother. When homo sapiens got up & walked on 2 legs about 6-7 million years ago (posh word = bipedalism) it led to the narrowing of the birth canal and this together with the increasing brain size of the human infant led to the human baby needing to be born when still neurologically very immature. 80% of brain growth for other mammals takes place in utero but if humans did this it would mean a 21month gestation! The human infant thus completes gestation (and most crucially, brain development) outside of the womb. The premature baby faces a greater challenge due to it’s even shorter gestation. Dr Bergman suggests we should consider how our DNA “remembers” our mammal history and revert to a marsupial mode of care for premature babies as the marsupial pouch provides ongoing direct skin contact, food and protection for this particularly vulnerable infant. KMC therefore restores a baby to an evolutionary origin of care with skin to skin contact being not only an integral part of care for any human new born but absolutely essential for the premature baby. Thus the correct “habitat” for a premature baby is in skin to skin contact with it’s mother.

Development
In the first 14 weeks fetal brain growth is influenced by genes, after this brain growth depends on intra uterine and extra-uterine experiences. After 23 weeks there is parallel development of structure & function: “cells that fire together, wire together”. After 30 weeks the fetus can recognise it’s mothers’ voice from single spoken words and it has more synapses at this time than any other stage of life, brain development is then a process of “pruning and hard wiring”. For these processes to occur the baby is 100% sensitive to it’s environment.

The mammalian brain is designed to be sculpted into it’s final configuration by the effects of it’s early experiences, the infant brain is thus exquisitely susceptible to adverse factors and stressors are far more detrimental to the new born.

For continued brain development to take place the infant is primed to actively seek out both mothers’ smell and contact with as much of it’s mothers’ skin as possible. In skin to skin contact therefore there is both brain to brain communication and face to face communication. The fetus is already primed for life with it’s well developed sense of touch & position. We know that the fetus practices movements necessary for establishing breastfeeding e.g hand to mouth movements, sucking & swallowing.

After birth the fetus is responsible for establishing breastfeeding NOT the mother (if we allow them!). If the new born baby is put in the right place i.e in skin to skin contact he will demonstrate a set sequence of behaviours (remember the work of Widstrom et al 1994 in the video “Delivery : Self-attachment”?).

The new born baby will be attracted to the familiar smell & taste of amniotic liquor that he identifies in mother’s milk. The lactating breast is hotter than the rest of mother’s skin & baby will actively seek out it’s warmth & security. The behaviours seen in the newborn when in it’s correct habitat : skin to skin contact - reflect the baby’s instinct to reach mother’s breast and breastfeed:
Rooting behaviours performed by newborn :
- kicking of the feet ) to move into right position on mother’s body
- arching of the back, )
- tilting of the head back – to move head into right position
- hand to mouth movements
- massaging (gentle pummelling or stretching) of nipple - stimulates erectile tissue and help baby identify the location of the nipple.
- protrusion of curled tongue (furrow down middle ready for the nipple)
- practice latches

Skin to skin contact is thus where babies make the transition to extra-uterine life and learn to breastfeed, it is the baby’s breastfeeding classroom!

Thus it is useful to remember that mothers do not breastfeed … babies do!

Mothers’ hold and care for their babies, their lactational behaviours are governed by the hind brain and are thus instinctive and hormonally governed. Being in skin to skin contact with her baby is vital for the mother to be able to respond to these powerful natural instincts. Anthropological studies show that babies who have free access to the breast will feed every 1-2 hours but the mother does not become exhausted as there is behaviour synchronicity between mother & child.

KMC
The physical capacity to breastfed may be insufficient in the prem baby but their ability to breastfeed is innate. The help that the prem baby needs is to be in the right place – KMC provides the necessary maternal “nest”.

What happens in separation?
When a baby is separated from it’s mother (e.g in an incubator) it is seen to veer between 2 extremes of behaviour – hard crying and deep sleep. Hard crying is associated with left to right shunting in the brain – “hard wiring” and this deep sleep is described as dissociation or despair.

Separation from the mother is termed the “primary violation” of the newborn i.e the worst thing that can happen. With separation the baby’s survival instinct kicks in. “Protest arousal” behaviour is seen whereby baby switches on his stress responses. There is increased heart rate & blood pressure and frantic movements of muscles means energy is wasted. There is increased release of the gut hormone somatostatin to inhibit gut motility and if this cycle of behaviour is allowed to continue it will result in slow weight gain.

If the baby’s cries for help are not heeded he stops crying to conserve heat the vagal system starts a “shut-down” mechanism, slows the body down by reducing temperature and heart rat, the baby despairs, dissociates and waits to be “saved” (Dissociation = playing dead”). It takes 30-60 minutes of skin to skin contact to re-stabilise somatostatin & the other stress hormones released during a 5 minute period of “hard crying”. Just holding the baby while clothed will NOT provide the same vagal stimulation as skin to skin contact.

The cycle of protest & despair “Hyperarousal – Dissociation” and the “autonomic storm” it releases are associated with toxic neurochemistry in the newborn. It is thought that the origin of many behavioural disorders is this violation of the innate needs of the newborn as early separation can produce major shifts in susceptibility to stress induced pathology.
Current practice of incubator/cot care for babies means that separation is institutionalised in our care systems but research is clear that skin to skin is the best “habitat” for babies.

KMC babies cycle between active awake and quiet sleep, this is the “breastfeeding programme”. Skin to skin contact should be continuous and at least 60-90 minutes long as it is the completion by the baby of the cycling rhythm between quiet sleep and active awake that is important. The new born has to move from the continuous umbilical feeding of fetal life to intermittent bolus feeding. The new born sleep cycle is 60-90 minutes and the new born stomach emptying cycle is 60-90 minutes, there must be a message here for the advocates of 4 hourly feeding as it seems the baby is just not designed for it!
In the research the main determinant of stability was temperature. The effect of the “protest & despair” behaviours in the incubator was to cause a drop in temperature leading to an unstable clinical situation. In the KMC paradigm the temperature is much more stable, prematurity is not seen as a disease but as a habitat transition and the mother & baby are treated as a single psychobiological organism e.g “thermal synchrony”, mothers skin temperature 1 deg higher than blood temperature and can reduce and raise another 2 degrees either way to compensate for babies temperature (who needs an incubator when you have a system that sensitive!?)

Society reaps what it sows in the way infants & children are treated (MH Teicher) Our efforts should be directed towards reducing exposure to stress & associated abuses in early life. Babies should not be separated, should not cry.The KMC paradigm requires a shift in the way we provide care, provide the humanity first and then the technology. Skin to skin, breastfeeding and then technology.

It is impossible to do justice to this topic in the space of this article I recommend that you all go to www.kangaroomothercare.com for all associated clinical details & research information on this important subject.