Publications by authors named "Nils Bergman"

17 Publications

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Immediate "Kangaroo Mother Care" and Survival of Infants with Low Birth Weight.

N Engl J Med 2021 05;384(21):2028-2038

The affiliations of the members of the writing committee are as follows: the Department of Maternal, Newborn, Child, and Adolescent Health, and Ageing, World Health Organization, Geneva (S.P.N.R., S.Y., N.M., H.V.J., H.T., R.B.); Vardhman Mahavir Medical College and Safdarjung Hospital (S.A., P.M., N.C., J.S., P.A., K.N., I.S., K.C.A., H.C.) and the All India Institute of Medical Sciences (M.J.S.), New Delhi, and Translational Health Science and Technology Institute, Faridabad (N.W.) - all in India; Muhimbili University of Health and Allied Sciences (H.N., E.A., A.M.) and Muhimbili National Hospital (M.N., R.M.) - both in Dar es Salaam, Tanzania; the University of Malawi, College of Medicine, Blantyre, Malawi (K.K., L.G., A.T.M., V.S., Q.D.); Obafemi Awolowo University, Ile-Ife, Nigeria (C.H.A., O.K., B.P.K., E.A.A.); Kwame Nkrumah University of Science and Technology (S.N., R.L.-R., D.A., G.P.-R.) and Komfo Anokye Teaching Hospital (A.B.-Y., N.W.-B., I.N.), Kumasi, and the School of Public Health, University of Ghana, Accra (A.A.M.) - all in Ghana; Karolinska University Hospital (A.L.) and Karolinska Institute (N.B., A.L., B.W.), Stockholm; the Institute for Safety Governance and Criminology, University of Cape Town, Cape Town, South Africa (B.M.); and Stavanger University Hospital, Stavanger, Norway (S.R.).

Background: "Kangaroo mother care," a type of newborn care involving skin-to-skin contact with the mother or other caregiver, reduces mortality in infants with low birth weight (<2.0 kg) when initiated after stabilization, but the majority of deaths occur before stabilization. The safety and efficacy of kangaroo mother care initiated soon after birth among infants with low birth weight are uncertain.

Methods: We conducted a randomized, controlled trial in five hospitals in Ghana, India, Malawi, Nigeria, and Tanzania involving infants with a birth weight between 1.0 and 1.799 kg who were assigned to receive immediate kangaroo mother care (intervention) or conventional care in an incubator or a radiant warmer until their condition stabilized and kangaroo mother care thereafter (control). The primary outcomes were death in the neonatal period (the first 28 days of life) and in the first 72 hours of life.

Results: A total of 3211 infants and their mothers were randomly assigned to the intervention group (1609 infants with their mothers) or the control group (1602 infants with their mothers). The median daily duration of skin-to-skin contact in the neonatal intensive care unit was 16.9 hours (interquartile range, 13.0 to 19.7) in the intervention group and 1.5 hours (interquartile range, 0.3 to 3.3) in the control group. Neonatal death occurred in the first 28 days in 191 infants in the intervention group (12.0%) and in 249 infants in the control group (15.7%) (relative risk of death, 0.75; 95% confidence interval [CI], 0.64 to 0.89; P = 0.001); neonatal death in the first 72 hours of life occurred in 74 infants in the intervention group (4.6%) and in 92 infants in the control group (5.8%) (relative risk of death, 0.77; 95% CI, 0.58 to 1.04; P = 0.09). The trial was stopped early on the recommendation of the data and safety monitoring board owing to the finding of reduced mortality among infants receiving immediate kangaroo mother care.

Conclusions: Among infants with a birth weight between 1.0 and 1.799 kg, those who received immediate kangaroo mother care had lower mortality at 28 days than those who received conventional care with kangaroo mother care initiated after stabilization; the between-group difference favoring immediate kangaroo mother care at 72 hours was not significant. (Funded by the Bill and Melinda Gates Foundation; Australian New Zealand Clinical Trials Registry number, ACTRN12618001880235; Clinical Trials Registry-India number, CTRI/2018/08/015369.).
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http://dx.doi.org/10.1056/NEJMoa2026486DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8108485PMC
May 2021

Immediate parent-infant skin-to-skin study (IPISTOSS): study protocol of a randomised controlled trial on very preterm infants cared for in skin-to-skin contact immediately after birth and potential physiological, epigenetic, psychological and neurodevelopmental consequences.

BMJ Open 2020 07 6;10(7):e038938. Epub 2020 Jul 6.

Women's and Children's Health, Karolinska Institute, Stockholm, Sweden.

Introduction: In Scandinavia, 6% of infants are born preterm, before 37 gestational weeks. Instead of continuing in the in-utero environment, maturation needs to occur in a neonatal unit with support of vital functions, separated from the mother's warmth, nutrition and other benefits. Preterm infants face health and neurodevelopment challenges that may also affect the family and society at large. There is evidence of benefit from immediate and continued skin-to-skin contact (SSC) for term and moderately preterm infants and their parents but there is a knowledge gap on its effect on unstable very preterm infants when initiated immediately after birth.

Methods And Analysis: In this ongoing randomised controlled trial from Stavanger, Norway and Stockholm, Sweden, we are studying 150 infants born at 28+0 to 32+6 gestational weeks, randomised to receive care immediately after birth in SSC with a parent or conventionally in an incubator. The primary outcome is cardiorespiratory stability according to the stability of the cardiorespiratory system in the preterm score. Secondary outcomes are autonomic stability, thermal control, infection control, SSC time, breastfeeding and growth, epigenetic profile, microbiome profile, infant behaviour, stress resilience, sleep integrity, cortical maturation, neurodevelopment, mother-infant attachment and attunement, and parent experience and mental health.

Ethics And Dissemination: The study has ethical approval from the Swedish Ethical Review Authority (2017/1135-31/3, 2019-03361) and the Norwegian Regional Ethical Committee (2015/889). The study is conducted according to good clinical practice and the Helsinki declaration. The results of the study will increase the knowledge about the mechanisms behind the effects of SSC for very preterm infants by dissemination to the scientific community through articles and at conferences, and to the society through parenting classes and magazines.

Study Status: Recruiting since April 2018. Expected trial termination June 2021.

Trial Registration Number: NCT03521310 (ClinicalTrials.gov).
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http://dx.doi.org/10.1136/bmjopen-2020-038938DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7342825PMC
July 2020

Birth practices: Maternal-neonate separation as a source of toxic stress.

Authors:
Nils J Bergman

Birth Defects Res 2019 09 3;111(15):1087-1109. Epub 2019 Jun 3.

Department of Neonatology, Karolinska Institute, Stockholm, Sweden.

Maternal-neonate separation for human newborns has been the standard of care since the last century; low birth weight and preterm infants are still routinely separated from their mothers. With advanced technology, survival is good, but long-term developmental outcomes are very poor for these especially vulnerable newborns. The poor outcomes are similar to those described for adversity in childhood, ascribed to toxic stress. Toxic stress is defined as the absence of the buffering protection of adult support. Parental absence has been strictly enforced in neonatal care units for many reasons and could lead to toxic stress. The understanding of toxic stress comes from discoveries about our genome and epigenetics, the microbiome, developmental neuroscience and the brain connectome, and life history theory. The common factor is the early environment that gives (a) signals to epigenes, (b) sensory inputs to neural circuits, and (c) experiences for reproductive fitness. For human newborns that environment is direct skin-to-skin contact from birth. Highly conserved neuroendocrine behaviors determined by environment are described in this review. The scientific rationale underlying skin-to-skin contact is presented: autonomic development and regulation of the physiology leads to emotional connection and achieving resilience. Maternal-neonate separation prevents these critical neural processes from taking place, but also channel development into an alternative developmental strategy. This enables better coping in a stressful environment in the short term, but with permanently elevated stress systems that negatively impact mental and physical health in the long term. This may explain the increasing incidence of developmental problems in childhood, and also Developmental Origins of Health and Disease. Arguments are presented that maternal-neonate separation is indeed a source of toxic stress, and some suggestions are offered toward a "zero separation" paradigm.
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http://dx.doi.org/10.1002/bdr2.1530DOI Listing
September 2019

Historical background to maternal-neonate separation and neonatal care.

Authors:
Nils J Bergman

Birth Defects Res 2019 09 30;111(15):1081-1086. Epub 2019 May 30.

Department of Neonatology, Karolinska Institute, Stockholm, Sweden.

Maternal-neonate separation after birth is standard practice in the modern obstetric care. This is however a relatively new phenomenon, and its origins are described. Around 1890, two obstetricians in France expanded on a newly invented egg hatchery as a method of caring for preterm newborns. Mothers provided basic care, until incubators became part of commercial exhibitions that excluded them. After some 40 years hospitals accepted incubators, and adopted the strict separation of mothers from babies observed at the exhibitions. The introduction of artificial infant formula made the separation practical, and this also became normal practice rather than breastfeeding. Incubators and formula were unquestioned standard practices before randomized controlled trials were introduced, and therefore never subjected to such trials. The introduction of Kangaroo Care began 40 years ago in Colombia, now as a novel intervention. Recent trials do in fact show that maternal-neonate separation is detrimental to mothers and babies. Recent scientific discoveries such as the microbiome, epigenetics, and neuroimaging provide the scientific explanations that have not been available before, suggesting that skin-to-skin contact and breastfeeding are defining for the basic reproductive biology of human beings.
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http://dx.doi.org/10.1002/bdr2.1528DOI Listing
September 2019

Nurturescience versus neuroscience: A case for rethinking perinatal mother-infant behaviors and relationship.

Birth Defects Res 2019 09 30;111(15):1110-1127. Epub 2019 May 30.

Department of Pediatrics, Columbia University Irving Medical Center, New York, New York.

Behavioral and emotional outcomes for babies who experienced maternal separation due to prematurity or birth defects have not improved significantly for the last 20 years. Current theories and treatment paradigms based on neuroscience have not generated explanatory mechanisms that work, or provided testable hypotheses. This article proposes a new field of scientific investigation, "nurturescience" within which new hypotheses can be tested with novel instruments. Key distinctions between neuroscience and nurturescience are described. Our definition of nurturescience is based on the basic needs of all newborns and of the needs of mothers and their families. This understanding is drawn from biology, anthropology, sociology, physiological, and clinical research. Mechanisms are described from studies on microbiota, epigenetics, allostasis, brain imaging, and developmental origins of health and adult disease. The converging message from these and other fields is that the mother-infant dyad should not be separated. Ongoing emotional connection is the cornerstone of development, leading to life-long resilience. This has implications for making the correct diagnosis (emotional disconnection vs. attachment disorder), providing the appropriate care (infant and family centered developmental care) in the biologically expected place (skin-to-skin contact), and potential for rehabilitation (calming cycle theory). Nurturescience has particular relevance to the care of "small and sick" infants, with profound potential for decreasing the "likelihood of developing developmental problems."
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http://dx.doi.org/10.1002/bdr2.1529DOI Listing
September 2019

Early skin-to-skin contact for mothers and their healthy newborn infants.

Cochrane Database Syst Rev 2016 11 25;11:CD003519. Epub 2016 Nov 25.

School of Nursing, Vanderbilt University, 314 Godchaux Hall, 21st Avenue South, Nashville, Tennessee, USA, 37240-0008.

Background: Mother-infant separation post birth is common. In standard hospital care, newborn infants are held wrapped or dressed in their mother's arms, placed in open cribs or under radiant warmers. Skin-to-skin contact (SSC) begins ideally at birth and should last continually until the end of the first breastfeeding. SSC involves placing the dried, naked baby prone on the mother's bare chest, often covered with a warm blanket. According to mammalian neuroscience, the intimate contact inherent in this place (habitat) evokes neuro-behaviors ensuring fulfillment of basic biological needs. This time frame immediately post birth may represent a 'sensitive period' for programming future physiology and behavior.

Objectives: To assess the effects of immediate or early SSC for healthy newborn infants compared to standard contact on establishment and maintenance of breastfeeding and infant physiology.

Search Methods: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (17 December 2015), made personal contact with trialists, consulted the bibliography on kangaroo mother care (KMC) maintained by Dr Susan Ludington, and reviewed reference lists of retrieved studies.

Selection Criteria: Randomized controlled trials that compared immediate or early SSC with usual hospital care.

Data Collection And Analysis: Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. Quality of the evidence was assessed using the GRADE approach.

Main Results: We included 46 trials with 3850 women and their infants; 38 trials with 3472 women and infants contributed data to our analyses. Trials took place in 21 countries, and most recruited small samples (just 12 trials randomized more than 100 women). Eight trials included women who had SSC after cesarean birth. All infants recruited to trials were healthy, and the majority were full term. Six trials studied late preterm infants (greater than 35 weeks' gestation). No included trial met all criteria for good quality with respect to methodology and reporting; no trial was successfully blinded, and all analyses were imprecise due to small sample size. Many analyses had statistical heterogeneity due to considerable differences between SSC and standard care control groups. Results for womenSSC women were more likely than women with standard contact to be breastfeeding at one to four months post birth, though there was some uncertainty in this estimate due to risks of bias in included trials (average risk ratio (RR) 1.24, 95% confidence interval (CI) 1.07 to 1.43; participants = 887; studies = 14; I² = 41%; GRADE: moderate quality). SSC women also breast fed their infants longer, though data were limited (mean difference (MD) 64 days, 95% CI 37.96 to 89.50; participants = 264; studies = six; GRADE:low quality); this result was from a sensitivity analysis excluding one trial contributing all of the heterogeneity in the primary analysis. SSC women were probably more likely to exclusively breast feed from hospital discharge to one month post birth and from six weeks to six months post birth, though both analyses had substantial heterogeneity (from discharge average RR 1.30, 95% CI 1.12 to 1.49; participants = 711; studies = six; I² = 44%; GRADE: moderate quality; from six weeks average RR 1.50, 95% CI 1.18 to 1.90; participants = 640; studies = seven; I² = 62%; GRADE: moderate quality).Women in the SCC group had higher mean scores for breastfeeding effectiveness, with moderate heterogeneity (IBFAT (Infant Breastfeeding Assessment Tool) score MD 2.28, 95% CI 1.41 to 3.15; participants = 384; studies = four; I² = 41%). SSC infants were more likely to breast feed successfully during their first feed, with high heterogeneity (average RR 1.32, 95% CI 1.04 to 1.67; participants = 575; studies = five; I² = 85%). Results for infantsSSC infants had higher SCRIP (stability of the cardio-respiratory system) scores overall, suggesting better stabilization on three physiological parameters. However, there were few infants, and the clinical significance of the test was unclear because trialists reported averages of multiple time points (standardized mean difference (SMD) 1.24, 95% CI 0.76 to 1.72; participants = 81; studies = two; GRADE low quality). SSC infants had higher blood glucose levels (MD 10.49, 95% CI 8.39 to 12.59; participants = 144; studies = three; GRADE: low quality), but similar temperature to infants in standard care (MD 0.30 degree Celcius (°C) 95% CI 0.13 °C to 0.47 °C; participants = 558; studies = six; I² = 88%; GRADE: low quality). Women and infants after cesarean birthWomen practicing SSC after cesarean birth were probably more likely to breast feed one to four months post birth and to breast feed successfully (IBFAT score), but analyses were based on just two trials and few women. Evidence was insufficient to determine whether SSC could improve breastfeeding at other times after cesarean. Single trials contributed to infant respiratory rate, maternal pain and maternal state anxiety with no power to detect group differences. SubgroupsWe found no differences for any outcome when we compared times of initiation (immediate less than 10 minutes post birth versus early 10 minutes or more post birth) or lengths of contact time (60 minutes or less contact versus more than 60 minutes contact).

Authors' Conclusions: Evidence supports the use of SSC to promote breastfeeding. Studies with larger sample sizes are necessary to confirm physiological benefit for infants during transition to extra-uterine life and to establish possible dose-response effects and optimal initiation time. Methodological quality of trials remains problematic, and small trials reporting different outcomes with different scales and limited data limit our confidence in the benefits of SSC for infants. Our review included only healthy infants, which limits the range of physiological parameters observed and makes their interpretation difficult.
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http://dx.doi.org/10.1002/14651858.CD003519.pub4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6464366PMC
November 2016

Hypothesis on supine sleep, sudden infant death syndrome reduction and association with increasing autism incidence.

Authors:
Nils J Bergman

World J Clin Pediatr 2016 Aug 8;5(3):330-42. Epub 2016 Aug 8.

Nils J Bergman, School of Child and Adolescent Health, University of Cape Town, Rondebosch 7700, South Africa.

Aim: To identify a hypothesis on: Supine sleep, sudden infant death syndrome (SIDS) reduction and association with increasing autism incidence.

Methods: Literature was searched for autism spectrum disorder incidence time trends, with correlation of change-points matching supine sleep campaigns. A mechanistic model expanding the hypothesis was constructed based on further review of epidemiological and other literature on autism.

Results: In five countries (Denmark, United Kingdom, Australia, Israel, United States) with published time trends of autism, change-points coinciding with supine sleep campaigns were identified. The model proposes that supine sleep does not directly cause autism, but increases the likelihood of expression of a subset of autistic criteria in individuals with genetic susceptibility, thereby specifically increasing the incidence of autism without intellectual disability.

Conclusion: Supine sleep is likely a physiological stressor, that does reduce SIDS, but at the cost of impact on emotional and social development in the population, a portion of which will be susceptible to, and consequently express autism. A re-evaluation of all benefits and harms of supine sleep is warranted. If the SIDS mechanism proposed and autism model presented can be verified, the research agenda may be better directed, in order to further decrease SIDS, and reduce autism incidence.
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http://dx.doi.org/10.5409/wjcp.v5.i3.330DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4978628PMC
August 2016

Kangaroo Mother Care in African countries.

Authors:
Nils J Bergman

Acta Paediatr 2015 Dec;104(12):1208-10

Department of Human Biology, University of Cape Town, Western Cape, South Africa.

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http://dx.doi.org/10.1111/apa.12933DOI Listing
December 2015

Newly born low birthweight infants stabilise better in skin-to-skin contact than when separated from their mothers: a randomised controlled trial.

Acta Paediatr 2016 Apr 15;105(4):381-90. Epub 2015 Oct 15.

Department of Human Biology, University of Cape Town, Cape Town, Western Cape, South Africa.

Aim: Routine care of low birthweight (LBW) neonates relies on incubators for stabilisation. An earlier study suggested that skin-to-skin contact achieves better physiological stability in the transition period when compared to incubator care. The aim of this study was to replicate that study with a larger sample.

Methods: A randomised controlled trial with LBW infants (1500-2500 g) randomised at birth, 50 to routine care and 50 to skin-to-skin contact, with stabilisation using the Stability of Cardio-Respiratory system in Preterms (SCRIP) score measured repeatedly over the first six hours of life as the primary outcome.

Results: Newly born infants in skin-to-skin contact showed better transition to extra-uterine life (p < 0.02), with the SCRIP score at 360 minutes in skin-to-skin contact being 5.82 (SD 0.66) and in maternal infant separation 5.24 (SD 0.72), p < 0.0001. In extended skin-to-skin contact care, infants had significantly less need for respiratory support, intravenous fluids and antibiotic use during the remainder of the hospital stay.

Conclusion: Skin-to-skin contact was likely to be an optimal environment for neonates without life-threatening conditions who weighed 1500-2500 g at birth. By preventing instability that requires subsequent medical treatment, it may be life-saving in low-income countries.
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http://dx.doi.org/10.1111/apa.13164DOI Listing
April 2016

The neuroscience of birth--and the case for Zero Separation.

Authors:
Nils J Bergman

Curationis 2014 11 28;37(2):e1-e4. Epub 2014 Nov 28.

Department of Human Biology, University of Cape Town.

Currently, Western maternal and neonatal care are to a large extent based on routine separation of mother and infant. It is argued that there is no scientific rationale for this practice and a body of new knowledge now exists that makes a case for Zero Separation of mother and newborn. For the infant, the promotion of Zero Separation is based on the need for maternal sensory inputs that regulate the physiology of the newborn. There are harmful effects of dysregulation and subsequent epigenetic changes caused by separation. Skin-to-skin contact is the antithesis to such separation; the mother's body is the biologically 'normal' place of care, supporting better outcomes both for normal healthy babies and for the smallest preterm infants. In the mother, there are needed neural processes that ensure enhanced reproductive fitness, including behavioural changes (e.g. bonding and protection) and improved lactation, which are supported by the practice of Zero Separation. Zero Separation of mother and newborn should thus be maintained at all costs within health services.
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http://dx.doi.org/10.4102/curationis.v37i2.1440DOI Listing
November 2014

Proposal for mechanisms of protection of supine sleep against sudden infant death syndrome: an integrated mechanism review.

Authors:
Nils J Bergman

Pediatr Res 2015 Jan 30;77(1-1):10-9. Epub 2014 Sep 30.

Department of Human Biology, University of Cape Town, Western Cape, South Africa.

Unlabelled: Supine sleep decreases sudden infant death syndrome (SIDS) incidence, however the mechanisms for this are unclear. The triple risk model for SIDS requires that one or more underlying abnormalities of breathing or autonomic control are present; these are rare, but brainstem defects are found in most SIDS cases. Supine sleep increases sympathetic nervous system tone, and level of state organization, and may therefore act as a stressor. This is evidenced by physiological arousal, and by delayed neurodevelopment in supine compared to prone sleepers. It is argued here that prone sleep position is the biological normative standard in healthy infants, supporting autonomic regulation. During rapid eye movement (REM) sleep (and other circumstances), a parasympathetic-mediated adverse autonomic event (AAE) may be spontaneously triggered. In healthy infants, gasping initiates autoresuscitation and recovery.

Hypothesis: The underlying vulnerability to SIDS is specific to autoresuscitation from an AAE, the initial serotonin-dependent gasp is commonly compromised. Serotonin metabolism defects also influence sleep architecture, increasing the likelihood of AAE. The mechanism whereby supine sleep decreases SIDS may therefore be a stressor effect, disturbing sleep architecture to decrease REM and AAEs, and increasing sympathetic tone, which may prevent and counteract the purely parasympathetic-mediated AAE, thereby decreasing the risk of SIDS.
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http://dx.doi.org/10.1038/pr.2014.140DOI Listing
January 2015

Whose Choice? Advocating Birthing Practices According to Baby's Biological Needs.

J Perinat Educ 2013 ;22(1):8-13

Modern western society and media often present the mother's choices for her birth as paramount. Various gurus provide the mother with often conflicting advice. But the reality is that childbirth often becomes a medicalized event with many interventions and less than ideal outcomes. In many instances, the choices are made to suit health professionals and hospital routines rather than the mother. All the aforementioned are based on ideas and assumptions which predate evidence-based medicine and recent neuroscience. In reproductive biology, the newborn is an active participant and agent in birthing (Alberts, 1994). Based on this, the perspective which has been lacking is what is best for the baby; our choices should be primarily based on the basic biological needs of the infant.
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http://dx.doi.org/10.1891/1058-1243.22.1.8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3647724PMC
January 2014

Neonatal stomach volume and physiology suggest feeding at 1-h intervals.

Authors:
Nils J Bergman

Acta Paediatr 2013 Aug 3;102(8):773-7. Epub 2013 Jun 3.

Department of Human Biology, Department of Paediatrics, University of Cape Town, Cape Town, South Africa.

Unlabelled: There is insufficient evidence on optimal neonatal feeding intervals, with a wide range of practices. The stomach capacity could determine feeding frequency. A literature search was conducted for studies reporting volumes or dimensions of stomach capacity before or after birth. Six articles were found, suggesting a stomach capacity of 20 mL at birth.

Conclusion: A stomach capacity of 20 mL translates to a feeding interval of approximately 1 h for a term neonate. This corresponds to the gastric emptying time for human milk, as well as the normal neonatal sleep cycle. Larger feeding volumes at longer intervals may therefore be stressful and the cause of spitting up, reflux and hypoglycaemia. Outcomes for low birthweight infants could possibly be improved if stress from overfeeding was avoided while supporting the development of normal gastrointestinal physiology. Cycles between feeding and sleeping at 1-h intervals likely meet the evolutionary expectations of human neonates.
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http://dx.doi.org/10.1111/apa.12291DOI Listing
August 2013

Early skin-to-skin contact for mothers and their healthy newborn infants.

Cochrane Database Syst Rev 2012 May 16(5):CD003519. Epub 2012 May 16.

School of Nursing, Vanderbilt University,Nashville, Tennessee, USA.

Background: Mother-infant separation postbirth is common in Western culture. Early skin-to-skin contact (SSC) begins ideally at birth and involves placing the naked baby, head covered with a dry cap and a warm blanket across the back, prone on the mother's bare chest. According to mammalian neuroscience, the intimate contact inherent in this place (habitat) evokes neurobehaviors ensuring fulfillment of basic biological needs. This time may represent a psychophysiologically 'sensitive period' for programming future physiology and behavior.

Objectives: To assess the effects of early SSC on breastfeeding, physiological adaptation, and behavior in healthy mother-newborn dyads.

Search Methods: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 November 2011), made personal contact with trialists, and consulted the bibliography on kangaroo mother care (KMC) maintained by Dr. Susan Ludington.

Selection Criteria: Randomized controlled trials comparing early SSC with usual hospital care.

Data Collection And Analysis: We independently assessed trial quality and extracted data. Study authors were contacted for additional information.

Main Results: Thirty-four randomized controlled trials were included involving 2177 participants (mother-infant dyads). Data from more than two trials were available for only eight outcome measures. For primary outcomes, we found a statistically significant positive effect of early SSC on breastfeeding at one to four months postbirth (13 trials; 702 participants) (risk ratio (RR) 1.27, 95% confidence interval (CI) 1.06 to 1.53, and SSC increased breastfeeding duration (seven trials; 324 participants) (mean difference (MD) 42.55 days, 95% CI -1.69 to 86.79) but the results did not quite reach statistical significance (P = 0.06). Late preterm infants had better cardio-respiratory stability with early SSC (one trial; 31 participants) (MD 2.88, 95% CI 0.53 to 5.23). Blood glucose 75 to 90 minutes following the birth was significantly higher in SSC infants (two trials, 94 infants) (MD 10.56 mg/dL, 95% CI 8.40 to 12.72).The overall methodological quality of trials was mixed, and there was high heterogeneity for some outcomes.

Authors' Conclusions: Limitations included methodological quality, variations in intervention implementation, and outcomes. The intervention appears to benefit breastfeeding outcomes, and cardio-respiratory stability and decrease infant crying, and has no apparent short- or long-term negative effects. Further investigation is recommended. To facilitate meta-analysis, future research should be done using outcome measures consistent with those in the studies included here. Published reports should clearly indicate if the intervention was SSC with time of initiation and duration and include means, standard deviations and exact probability values.
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http://dx.doi.org/10.1002/14651858.CD003519.pub3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3979156PMC
May 2012

Should neonates sleep alone?

Biol Psychiatry 2011 Nov 29;70(9):817-25. Epub 2011 Jul 29.

MRC Medical Imaging Research Unit, University of Cape Town, Western Cape, South Africa.

Background: Maternal-neonate separation (MNS) in mammals is a model for studying the effects of stress on the development and function of physiological systems. In contrast, for humans, MNS is a Western norm and standard medical practice. However, the physiological impact of this is unknown. The physiological stress-response is orchestrated by the autonomic nervous system and heart rate variability (HRV) is a means of quantifying autonomic nervous system activity. Heart rate variability is influenced by level of arousal, which can be accurately quantified during sleep. Sleep is also essential for optimal early brain development.

Methods: To investigate the impact of MNS in humans, we measured HRV in 16 2-day-old full-term neonates sleeping in skin-to-skin contact with their mothers and sleeping alone, for 1 hour in each place, before discharge from hospital. Infant behavior was observed continuously and manually recorded according to a validated scale. Cardiac interbeat intervals and continuous electrocardiogram were recorded using two independent devices. Heart rate variability (taken only from sleep states to control for level of arousal) was analyzed in the frequency domain using a wavelet method.

Results: Results show a 176% increase in autonomic activity and an 86% decrease in quiet sleep duration during MNS compared with skin-to-skin contact.

Conclusions: Maternal-neonate separation is associated with a dramatic increase in HRV power, possibly indicative of central anxious autonomic arousal. Maternal-neonate separation also had a profoundly negative impact on quiet sleep duration. Maternal separation may be a stressor the human neonate is not well-evolved to cope with and may not be benign.
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http://dx.doi.org/10.1016/j.biopsych.2011.06.018DOI Listing
November 2011

The relation between early mother-infant skin-to-skin contact and later maternal sensitivity in South African mothers of low birth weight infants.

Infant Ment Health J 2010 May;31(3):358-377

Colchester-East Hants Health Authority, Truro, Nova Scotia, Canada.

The relation between early mother-infant skin-to-skin contact (SSC) and mothers' subsequent sensitivity to their low birth weight infants was investigated in a study of 12 mother-infant dyads who participated in a South African randomized control study of early SSC. The dyads were visited in the home when infants were under 1 year. Amounts of SSC were taken from hospital records and home interviews. Videotapes of mother-infant interactions in the home were scored for maternal sensitivity on the Maternal Behavior Q-Sort (D.R. Pederson, G. Moran, & S. Bento, 1999) and the Maternal Behavior subscale of the Nursing Child Assessment Teaching Scale (G. Sumner & A. Spietz, 1994). Amount of SSC in infants' first 24 hr correlated with amount of SSC through the first month. Amount of SSC in infants' first 24 hr independently accounted for maternal sensitivity on both measures, indicating that early mother-infant SSC predicted subsequent maternal sensitivity.
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http://dx.doi.org/10.1002/imhj.20260DOI Listing
May 2010

More than a cuddle: skin-to-skin contact is key.

Authors:
Nils Bergman

Pract Midwife 2005 Oct;8(9):44

Mowbray Maternity Hospital, Cape Town, South Africa.

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October 2005
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