Author Name:
Dr Nils Bergman

Biography:
Dr Bergman graduated at the University of Cape Town, and has worked in South Africa, Ciskei and, Sweden, before working seven years as Medical Superintendent and District Medical Officer at Manama Mission, Zimbabwe. Here he, together with Midwife Agneta Jurisoo, developed and implemented Kangaroo Mother Care (KMC) for premature infants right from birth. This resulted in a five-fold improvement in survival of Very Low Birth Weight babies.

Article:
This paper presents biological, physiological, neurobehavioural, evolutionary and anthropological arguments for the contention that maternal-infant skin-to-skin contact is the natural "habitat" or place for all newborns, and that in this habitat they have a programmed "niche" or behaviour, which in the immediate newborn period is to breastfeed. There is an urgent need to restore this original paradigm, in preference to the current normal standard of incubator care and formula feeding with bottle.

Homo sapiens is a mammal, and defining for all mammals is that they have breasts (Latin mammae) for suckling their young. Biological research in numerous mammals has shown that the neural events in pregnancy are "highly conserved", that is they are almost identical in all species. The subsequent endocrine priming of pregnancy, again, is "remarkably similar across species". Once birth takes place, all mammals studied show a "set sequence of behaviours" , which leads to the initiation and the sustaining of breastfeeding behaviour. These behaviours do differ, each species having its own set sequence. A surprising and key finding in this research has been the finding that it is the newborn's behaviour which is determining, the newborn's actions elicit care taking responses from the mother. Once initiated by the newborn, "breastfeeding is established through a set of mutual complex sensory stimulations in mother and child". However, in all species, suckling "is a remarkably fragile and transient behaviour", and is easily disturbed by any intervention.

Biologists describe mammals as developing through a series of habitats, (uterus, mother's body, nest of siblings, the world), and in each habitat, the developing organism is physically capable and neurobehaviourally programmed to behave in such a way as to provide for its own needs. The key concept is that the developing organism is endowed with the behaviours required, those behaviours express themselves in the habitat for which they are designed, and it is the habitat that provides the needs of the organism. Removed from the correct habitat, all mammals exhibit an identical pre-programmed response, referred to as the "protest - despair response", which was first described in human babies. The protest response is one of intense activity seeking reuniting with the habitat, the despair response a withdrawal and survival response of decreased temperature and heart rate, mediated by massive rise in stress hormones. Reunited with the correct habitat (mother), there is a rapid rise in heart rate and temperature. The "protest-despair response" was first described in humans, in orphans after WWII , it was subsequently studied in monkeys and then in many other mammals. "Separation distress calls" have been documented very carefully in rats. Very similar distress calls have been shown in human infants placed in cots, and such cot babies make 10 times as many cry signals as babies on SSC. The calls of SSC babies have a completely different character, and it has been suggested they are intended to elicit assistance from the mother to reach the nipple for suckling.

Kangaroo Mother Care has been variously defined, but two essential components are skin-to-skin contact and breastfeeding. From the biological perspective, in the immediate newborn period of Homo sapiens, skin-to-skin contact represents the correct "habitat", and breastfeeding represents the "niche" or pre-programmed behaviour designed for that habitat.

The habitat provides more than just nutritional needs. In the uterine habitat, it is clear that oxygenation is provided through the placenta and the cord, warmth is provided, nutrition also from the placenta, and protection. These are the four basic biological needs. Parturition (birth) represents a "habitat transition". In the new habitat, the basic needs remain the same. Research over the last ten years provides strong support for the contention that newborn itself in the skin-to-skin habitat, not the mother or the health services, provides these basic needs. Oxygenation has been shown to be improved on SSC, to the extent that KMC is used successfully to treat respiratory distress. Infants removed from incubators and placed SSC show a rise in temperature and a dramatic drop in glucocorticoids, as predicted by the "protest-depair response". Nutrition is improved, both with respect to the mother’s ability to breastfeed, and with respect to the newborn’s utilisation of the feed. Fullterm undrugged infants, left on their mother's chest and undisturbed, will all breastfeed spontaneously within one hour, with no help at all. The stimulations the newborn gives the mother during SSC elicit caregiving and protective behaviours from the mother. Immunity is improved, demonstrable even 6 months later. In no published paper is a single adverse outcome reported for KMC. Positive effects on the mother are better bonding, healing of emotional problems associated with premature birth, among others.

Evolutionarily, Homo sapiens is born extremely immature, with only 25% of final brain size, compared to 45% of chimpanzees and much higher in all other mammals. This has been suggested as being a compromise, the consequence of the narrowed pelvis and birth canal following bipedalism, and the enlarging brain wanting to get through the pelvis, the brain therefore grows after birth. Homo sapiens therefore developed mechanisms for coping with immaturity. Being born premature is therefore not such a serious mishap for Homo sapiens as for other animal species, as long as the correct habitat is provided.

Some may feel that the human being with its massive forebrain cannot be compared to other animals. There has however been anthropological research which further supports this view. Homo sapiens evolved as "tropical hunter gatherers" over the last 3 million years. Changes started 10000 years ago with the beginning of agriculture, but there are still tropical hunter gatherer peoples living, which have been studied by anthropologists. Common for all groups is that newborns and infants are carried constantly, they sleep with their mothers, there is immediate nurturant response to crying, feeding takes place every 1 or 2 hours, and breastfeeding continues for two years. In the last 100 years, this million year pattern (of “carry care:”) has been changed to one where the child is left lying still (“cache care”) separated from mother, ignored when crying, fed four hourly by the clock (“nest care”), with formula (from a “follow care” species) and substitutes from an early age. Lozoff et al (1977) state that these changes altar the initiation of the mother-infant relationship, which may be "strained beyond the limits of adaptability". "Separation causes changes in the fundamental efficiency of systems". "Early separation can produce major shifts in susceptibility to stress-induced pathology". "The origins of many behavioural deviations are unknown ... can some be traced back to violations of an innate agenda?"

In our Western paradigm (paradigm = world view, set of basic assumptions), the newborn has generally been regarded as helpless, (“the mother clueless, and the father useless”) with the newborn requiring help for all its needs. For full term babies, the mother is seen as providing these needs; for prematures, the health service must remove the newborn from the mother and provide for it needs. The original paradigm suggests otherwise. For the fullterm infant, its sole requirement is the correct habitat, which is not the mother as a caregiver, but the mother as a provider of SSC. The fullterm infant is reasonably robust, the premature is frail. However, the premature's need for the correct habitat is even greater than the fullterm's. The premature is endowed with the same neurobehavioural programme and behaviours, but due to its physical immaturity, does require support. That support should be afforded to it, but without removal from the correct habitat.

The primary violation, the worst case scenario, to any newborn is separation from its habitat/mother. This applies to Homo sapiens as fully as to other mammals studied. This requires a new paradigm. For prematures, our present paradigm sees the incubator as the habitat and the bottle as the feeding method, and we have defined normal ranges for heart rates and temperatures in the incubator habitat. That habitat is one separated from mother, one with ten-fold increases in stress hormones, which produces despair with lowered heart rates and temperature. Our "normal values" will need redefining. In our health care we need to recognise the central place of the mother as the habitat which the newborn urgently and desperately needs. We need to recognise the capacities of the newborn in providing for its own needs. While it was observed that ability to suck on a bottle only started at 34 weeks post-conceptional age, recent research has shown that suckling, (a myographically distinct behaviour from sucking), from the breast is possible at 28 weeks. We need to design our health care and adjust our routines to ensure that primarily support is afforded to the mother to provide the habitat, and assistance is given to the premature to provide for its own needs, recognising the neurobehavioural capability may not be matched with physical development.

The KMC paradigm holds that prematurity is not a disease, but that separation from the habitat (mother) will make a premature diseased. Likewise withholding of the niche (breastfeeding and breast milk as two separate concepts) will make the premature diseased. In the KMC paradigm the original habitat and niche is the starting point of care, to which we add whatever available technology and support is available.