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The importance of skin to skin contact for every newborn

Modern childbirth has become a medical condition requiring delivery in a hospital with doctors and nurses in attendance. Our neonatal mortality has decreased in the last 200 years which is a wonderful thing. However recent studies of neuroscience of the newborn have shown that our modern care may well be at some cost to the baby’s brain. What we now know is that newborn brain development is dependent on mother’s presence! Inside mother the fetus was held warm and safe, loved and protected by mother’s body. Sounds are muffled and mum’s familiar heart beat and voice reassure the baby. His heart rate and oxygen saturation are optimal. The moment of birth then is a huge transition, but his development has prepared him for this change. After the actual birth he is able to get his systems regulated because he is in the safe place which mother’s chest provides (1-3). However our modern care often takes the newborn into the world of lights that are too bright for his sensitive eyes, loud sounds that he cannot block out, and strange new smells(4). Often a newborn is taken and weighed on a cold scale, or bathed or routinely suctioned. But worst of all for his adapting brain is that he is taken away from his mother, his SAFE place. Separation from mother is highly stressful, and is enough to make a baby unstable(2;5). He feels unsafe, his brain send “danger” signals to the body. His brain releases the stress hormone cortisol which increases the heart rate and breathing in a basic “fight or flight” instinct(5-7). Somatostatin (which counteracts the growth hormone) is also released and acts in the gut to decrease absorption of food and thus inhibit growth(8;9). These stress hormones will stay in the body while the baby is separated from Mum. When returned to Mum, the stress hormones still take 30 minutes or even an hour to wash out of his system. The separated baby will protest and cry to call for Mum. His arms and legs will wave or jerk to get Mum to come back. The crying can also open the foramen ovale, a flap between the two sides of the heart, thus restoring fetal circulation, which now pumps deoxygenated blood to the brain(10). This crying increases the heart rate and blood pressure in the baby’s brain which can damage the tiny capillaries, maybe even causing an intraventricular hemorrhage (IVH)(11). All of this intense protest activity uses up vital calories which should be used for growth(12). If the baby’s protest signals are not heeded, the baby may go into an energy-conserving defense mode which lowers heart rate and temperature for prolonged survival(5). This state of “freeze” may look like the baby is asleep, but recent neuroscience research has shown that baby can be firing avoidance pathways in the brain. A final stage of defense is called “dissociation” in which the baby essentially “tunes out”(7). The ominous part is that the brain of the baby is wiring emotional pathways, adapting to cope with “a dangerous world, where nobody loves me”. This can cause lasting emotional complications which can have major effects later in life for the emotional and mental health of the baby. Adult mental health is based on infant mental health, but now we know that this starts really early, even in the first hour after birth(5). In summary, separation of the newborn baby from the mother is the primary cause of stress. This can show itself in increased heart rate, blood pressure and decreased oxygen saturation in the blood. This often causes a cascade of problems and complications requiring ever more intervention from the neonatal health system. Most of this could be avoided by the mind-blowingly simple practice of putting every newborn baby naked onto Mum’s bare chest, drying him and covering both of them. All of the observations and tests can be done while leaving the newborn in his SAFE place. This alternative to separation-stress is called “skin-to-skin contact”(4).

So what are the positive effects of skin to skin contact?

The skin-to-skin contact will help the baby to keep an even temperature. If the baby is cold, the mother’s chest is a shield area that can heat up to warm her baby, or cool if her baby is too hot(13). The Autonomic Nervous System (ANS) of the mother and baby coordinate to establish healthy and stable set points of blood pressure, temperature, heart rate and glucose(2). This allows the baby to “self-regulate” better when stressful events rock his equilibrium. But until the baby has established those set points he needs the “buffering protection of adult support”(14). In the absence of this support, metabolic set points may not be properly established and this can increase problems of hypertension, obesity and diabetes in later life(15). Most readers will be familiar with the “self-attachment” behavior of the newborn on mother’s chest in the first hour of life(16). The baby’s small movements on the mother’s chest in moving his way to the nipple and touching it stimulates a wonderful interaction of hormones in both mother and baby’s brain and body as follows. The baby stimulates the mother’s breast and areola(17), and the ANS fires from here to her hypothalamus and pituitary to release the hormone prolactin(18). This reaches the breast to start milk production (mammogenesis II). Note that it is the behavior of the baby which ensures that milk will be produced by the breast;the baby is in effect making his next meal! In the baby prolactin stimulates oligodendrocite cells which make the myelin which will coat the nerves and speed up the sending of messages in the brain, thus increasing intelligence(19). The prolactin in the baby also stimulates production of surfactant, which helps the newborn baby’s lungs to breathe better. Oxytocin is well-known as the “love hormone” and also for its action in the Milk Ejection Reflex(20;21). However it is also a neurotransmitter in the brain, and is released primarily by skin-to-skin contact. In the mothers brain the oxytocin suppresses the “cingulate gyrus”, which is the fear centre of the brain, thus making the mother fearless to protect her baby(22;23). Oxytocin in the baby stimulates the brain pathways for approach, and the response is to open his eyes and to gaze at mother(22) . This is the beginning of bonding, the vital first bond on which foundation all other relationships are formed. The baby suckling also releases cholecystokinin, which in the mother’s amygdala gives the emotion of contentment and well-being. In the baby this same hormone aids self-regulation of digestion and it calms the amygdala, the emotional centre of the baby’s brain(24;25). These three powerful hormones have thus worked in both mother and baby to wire neural circuits for a well-bonded, well-regulated mother-infant pair. The basic biological needs for warmth, nutrition and protection are thus provided from the very beginning.This early bonding fires security in the baby and instinctive protection behavior in the mother, and sets the mother-baby pair on a course of healthy development, and secure relationships. Skin-to-skin contact at birth for stabilization of EVERY newborn is a simple yet profound intervention which increases the physical, mental, emotional and social stability and well-being of the baby. This is every baby’s right. The number of hours of skin-to-skin contact baby receives in the first day of life will determine his mother’s sensitivity to his cognitive development and emotional security even a year later(26;27). This also predicts the attachment relationship and social intelligence. These are just a few reasons for adjusting and modifying our health care practices(4); to give every baby the best start. All of the above are valid benefits for EVERY newborn baby. For a fragile and sensitive preterm baby, skin-to-skin contact at birth is even more important for stabilization and minimizing stress. If technology needs to be added, it should be done on mother’s chest, the baby’s SAFE place.

Summary of benefits of skin-to-skin contact for baby

Physical: heart rate, breathing and temperature better. Emotional: feels safe so less stress and crying. Mental: better sleep and brain wiring for development. Breastfeeding: gains weight, home sooner. For Parents: less stress, better bonding. More details on the neuroscience of newborns can be found in “HOLD YOUR PREMIE, A workbook on skin to skin contact for parents of premature babies,”(28) and in the DVD “Hold your Prem” available from www.kangaroomothercare.com.

Reference list

(1) Bergman NJ, Linley LL, Fawcus SR. Randomized controlled trial of skin-to-skin contact from birth versus conventional incubator for physiological stabilization in 1200- to 2199-gram newborns. Acta Paediatr 2004 June;93(6):779-85. (2) Hofer MA. Early relationships as regulators of infant physiology and behaviour. Acta Paediatr 1994;Suppl 397:9-18. (3) Hofer MA. The psychobiology of early attachment. Clinical Neuroscience Research 2005;15(2):84-7. (4) Kroeger M, Smith LJ. Impact of Birthing Practices on Breastfeeding. First ed. Jones and Bartlett Publishers, Sudbury, Massachusetts; 2004. (5) Schore AN. Attachment and the regulation of the right brain. Attach Hum Dev 2000 April;2(1):23-47. (6) McEwen BS. Protective and Damaging Effects of Stress Mediators. New England Journal of Medicine 1998 January 15;338(3):171-9. (7) Perry BD, Pollard RA, Blakely TL, Baker WL, Vigilante D. Childhood trauma, the neurobiology of adaptation and “use-dependent” development of the brain. How”states” become “traits”. Infant Mental health 1995;16(4):271-91. (8) Marchini G, Lagercrantz H, Feuerberg Y, Winberg J, Uvnas-Moberg K. The effect of non-nutritive sucking on plasma insulin, gastrin, and somatostatin levels in infants. Acta Paediatr Scand 1987 July;76(4):573-8. (9) Widstrom AM, Christensson K, Ransj+¦-Arvidson AB, Matthiesen AS, Winberg J, Uvn+ñs-Moberg K. Gastric aspirates of newborn infants: pH, volume and levels of gastrin- and somatostatin-like immunoreactivity. Acta Paediatrica Scandinavica 1988 July;77(4):502-8. (10) Ludington-Hoe SM, Cong X, Hashemi F. Infant crying: nature, physiologic consequences, and select interventions. Neonatal Network: NN 2002 March;21(2):29-36. (11) Als H, Lawhon G, Duffy FH, McAnulty GB, Gibes-Grossman R, Blickman JG. Individualized developmental care for the very low-birth-weight preterm infant. Medical and neurofunctional effects. JAMA: The Journal Of The American Medical Association 1994 September 21;272(11):853-8. (12) Ludington SM. Energy conservation during skin-to-skin contact between preterm infants and their mothers. Heart Lung 1990 September;19(5 Pt 1):445-51. (13) Ludington-Hoe SM, Lewis.T., Morgan K, Cong X, Anderson L, Reese S. Breast-infant temperature synchrony with twins during shared kangaroo care. JOGNN: Journal of Obstetric, Gynecologic & Neonatal Nursing 2006;35(2):223-31. (14) Shonkoff JP. Building a new biodevelopmental framework to guide the future of early childhood policy. Child Dev 2010 January;81(1):357-67. (15) Barker DJ. Fetal programming of coronary heart disease. Trends Endocrinol Metab 2002 November;13(9):364-8. (16) Widstrom AM, Lilja G, Aaltomaa-Michalias P, Dahllof A, Lintula M, Nissen E. Newborn behaviour to locate the breast when skin-to-skin: a possible method for enabling early self-regulation. Acta Paediatr 2010;100(1):79-85. (17) Doucet S, Soussignan R, Sagot P, Schaal B. The secretion of areolar (Montgomery’s) glands from lactating women elicits selective, unconditional responses in neonates. PLoS One 2009 October 23;4(10):e7579. (18) Grattan DR, Steyn FJ, Kokay IC, Anderson GM, Bunn SJ. Pregnancy-induced adaptation in the neuroendocrine control of prolactin secretion. J Neuroendocrinol 2008 April;20(4):497-507. (19) Gregg C, Shikar V, Larsen P, Mak G, Chojnacki A, Yong VW et al. White matter plasticity and enhanced remyelination in the maternal CNS. J Neurosci 2007 February 21;27(8):1812-23. (20) Matthiesen AS, Ransjo-Arvidson AB, Nissen E, Uvnas-Moberg K. Postpartum maternal oxytocin release by newborns: effects of infant hand massage and sucking. Birth 2001 March;28(1):13-9. (21) Uvnas-Moberg K. Neuroendocrinology of the mother-child interaction. Trends In Endocrinology And Metabolism: TEM 1996 May;7(4):126-31. (22) Ross HE, Young LJ. Oxytocin and the neural mechanisms regulating social cognition and affiliative behavior. Front Neuroendocrinol 2009 October;30(4):534-47. (23) Leng G, Meddle SL, Douglas AJ. Oxytocin and the maternal brain. Curr Opin Pharmacol 2008 December;8(6):731-4. (24) Tornhage CJ, Serenius F, Uvnas-Moberg K, Lindberg T. Plasma somatostatin and cholecystokinin levels in preterm infants during kangaroo care with and without nasogastric tube-feeding. J Pediatr Endocrinol Metab 1998 September;11(5):645-51. (25) Weller A, Feldman R. Emotion regulation and touch in infants: the role of cholecystokinin and opioids. Peptides 2003 May;24(5):779-88. (26) Bigelow AE. Infants’ sensitivity to familiar imperfect contingencies in social interaction. Infant Behavior & Development 1998;21(1):149-62. (27) Bigelow AE, Littlejohn M, Bergman N, McDonald C. The relation between early mother-infant skin-to-skin contact and later maternal sensitivity in South African mothers of low birth weight infants. Infant Mental Health Journal 2010 May;31(3):358-77. (28) Bergman J, Bergman N. Hold your prem. 1st ed. New Voices Publication (available from www.kangaroomothercare.com); 2010.