Improving neonatal care with neuroscience
The incubator was invented 100 years ago, but modern neonatal care only started taking shape about 50 years ago. This care assumed the incubator was the only possible PLACE such care could be given. The care was focused on improving survival, and it was partly based on a belief that as long as the heart and the lungs and the stomach was working, then the brain would be fine, as it develops so much later in the human being. As a result, we now have amazing survival rates, however, these survivors have physical and psychological problems, the more so the lower the gestation. In fact we now know that even late preterm infants perform poorly when they start school, and economically cost more to support (there are more of them!). For the last twenty years these developmental outcomes have not improved.
For the same twenty years there has been an explosion of knowledge in neuroscience, and this explains why these problems are there. The fetal brain development with respect to its anatomy is complete at 20 weeks, and all its basic connections are complete at 28 weeks. Development is now about collecting sensory information about the world, and that fires and wires pathways that adapt or mould the brain to be suited or adjusted to the world. Good sensations provide a platform for higher level development and approach behaviours. Bad sensations fire more lower level defensive or avoidance pathways, and when these are overused, there is “wear and tear” on basic pathways. Future stresses and “knocks in life” later trigger pathway failures that show themselves in the various physiological and behavioural problems we later see.
One of the most basic abilities, and that appears early in development, is to determine whether a sensation (or even constellation of such) is safe, dangerous or life threatening. This is seen in early fetal life, and is fully competent from 28 weeks. All the sensations in the uterus tell the fetus it is SAFE. At birth the baby is highly stressed, and this birthing stress is necessary to activate the systems that make for breathing air and coping with “life outside”. But once outside, the need for being SAFE is primary, and essentially it is only mother’s presence providing familiar sensations that achieve this. The chest of the mother is to the newborn its PLACE of care. Care means the three basic biological needs are met: mother skin-to-skin contact ensures warmth, her breasts provide nutrition, and her arms cover baby for protection. The baby is wired to respond to this place in many different ways, the two we can easily see we call self-attachment and breastfeeding. After feeding, sleep cycling is essential to establish the pathways that were fired.
When mother is absent, the newborn brain feels unsafe, it perceives danger and threat to life, and its basic needs are not provided. The brain kicks in a powerful defence reaction, which first makes a short burst of crying before shutting that down and lowering heart rate and temperature, and then shuts down all activity, reverting to the immobilization defence, similar to that of frogs and reptiles. This looks like sleep! But it is not, and it is maintained by high levels of cortisol, which make the “wear and tear” which is the primary first cause of all subsequent problems preterm infants suffer from. This is not actually sleep, so the pathways are not established. Instead, when stress is prolonged, the cortisol disrupts brain architecture, unless there is “buffering protection of adult support”.
This new understanding of the brain and its development can profoundly improve neonatal care. Mother’s presence is an absolute requirement for OPTIMAL development. This is the underlying scientific rationale for Kangaroo Mother Care, which is defined as continuous or prolonged maternal-infant skin-to-skin contact (supplemented by father or other attachment figure). The definition includes breastfeeding, which must alternate with protecting sleep cycles. And so, mother and father must be central to the care team, not just in theory but physically central as well! Premature infants have brains that are ready, but bodies that are not. They may need technology, but this was not designed with the thought that mother should be the PLACE of care. Ingenious solutions are usually required. Then, even with mother present, the sensations from the environment must not be intrusive or stressful. Bright light and noise are the most common stressors. When by circumstance and necessity parents cannot be present, then the environment must be made as “womblike” as possible.
Should Neonates sleep alone?
Article published in Biological Psychiatry November 2011.
Barak E. Morgan, Alan R. Horn, and Nils J. Bergman
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.
Comment from Nils
This is possibly the first paper published that provides any kind of research evidence on the effects of separation on the brain of the human newborn. What it shows is that babies that are sleeping in cots three or four feet from their mothers are in a state of “anxious arousal”, meaning that they are stressed. This stress can influence their earliest development. Brain development also requires one hourly sleep cycles: the separated babies were not sleep cycling, and their “Quiet Sleep” was one seventh of the babies in skin-to-skin contact. So this paper shows two separate pathways – probably interlinked – whereby early separation may have an adverse effect of good development.