I welcome your responses to my thoughts. “As steel sharpens steel”, I welcome challenges to my views as much as support.
I am happy to advise on research anyone likes to undertake relating to skin-to-skin contact, and even more to collaborate !
On these pages I provide a brief overview of my own research.
Manama – start of birth skin-to-skin contact
My first encounter with skin-to-skin contact (SCC) was in 1988, at Manama Mission Hospital. In the beginning this was not done as research, but as a novel form of care. The key departure point was to use mother’s chest as the place to stabilise low birthweight babies, rather than the incubator. The published paper is based on a comparison to the outcomes from the previous four years, when care was otherwise pretty much the same, apart from the addition of skin-to-skin contact. There was a dramatic improvement in survival, from 10% to 50% for infants below 1500g.
University of the Western Cape – MPH
From Zimbabwe I went to Cape Town South Africa, where I was able to read more deeply into the possible explanations for what I had observed. As the thesis component of my Masters in Public Health at University of the Western Cape, I did a systematic review of the relationship between skin-to-skin contact and breastfeeding, and based on this a protocol for a randomized controlled trial. It was during this time that I drew a simple model I now call the “Place Model”, which has had other names during the years.
Mowbray Maternity Hospital – first randomized controlled trial
With support and encouragement from experienced researchers, I was awarded a research grant from the Thrasher Foundation, which made possible a Randomized Controlled Trial to test the Place Model, at Mowbray Maternity Hospital. At this time, I was also appointed as Medical Superintendent at the same hospital, which allowed for better support. Using experienced neonatal nurse researchers, infants below 1200g and 2200g were randomized to spend the first six hours of life either in skin-to-skin contact, or in standard incubator care. Recruitment was very difficult, ethical approval required fully informed consent prior to birth, which in “premature” birth is challenging. Based on a pre-defined cardio-respiratory monitor based algorithm of *stable* – all skin-to-skin babies were fully stable at 6 hours. Less than half the standard care incubator babies were stable, and the smallest were even more unstable.
Acta Paediatr. 2004 Jun;93(6):779-85 (abstract)
This paper states in the conclusion: “Newborn care provided by skin-to-skin contact on the mother’s chest results in better physiological outcomes and stability than the same care provided in closed servo-controlled incubators.” Since servo-controlled incubators were state of the art at the time, this was the standard of reference. Biologically, SSC is the standard of reference, and the conclusion should be better stated as: “Newborn care provided by closed servo-controlled incubators results in worse physiological outcomes and stability than the same care provided in skin-to-skin contact on the mother’s chest.” The editor could hardly allow such a statement to be published. The article stimulated no interest whatever, and was not cited. But two years later, John Kennell wrote in an editorial:
“Publication of the report of Bergman et al. should stimulate replications by others. If these investigators’ findings are confirmed, and clear guidelines for the care of premature infants in the kangaroo method in the first 6 h and beyond are published, with particular attention to warm coverings for the babies’ backs, this research could benefit large numbers of premature infants in the Third World. Conclusion: As the authors indicate, skin-to-skin contact from the birth of premature infants may also be a good alternative in First World settings”.
University of Cape Town – the neuroscience of SSC
In a small part prompted by this experience, I resigned my post at Mowbray Maternity in order to take this matter on in a more focused way. In primate studies, maternal separation causes HARM! Humans are primates – are we causing harm by separating them? I was fortunate to meet Barak Morgan in 2006, and start a research collaboration at the Department of Human Biology, University of Cape Town, where I am now an Honorary Research Associate. The underlying neuroscience of our thinking can be found on pages in this website under WHAT IS SSC. In brief: the harm that separation makes in primates is effected or mediated by cortisol, and this is released by stress, which also releases autonomic nervous system ANS activations. This ANS activity we hypothesized can be detected in Heart Rate Variability. Our first paper was published November 2011, and concludes:
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.
Biological Psychiatry Biol Psychiatry 2011 Nov 1;70(9):817-25. Epub 2011 Jul 29.
November 2011 – feeding research
Along with our cultural paradigm, the medical establishment has some difficulty with this idea that what we are doing might be harmful. Getting research funding has been a frustrating failure !!
The Place Model provides a simple scoping lens for re-examining not only our clinical care, but also our parenting culture. I have researched effects of infant crying, strict infant scheduling, fathers’ hormones, as well as effects of the NICU care environment. Physiology Honours students have done great projects. What is really needed are long-term follow-up studies, which have to be rigorous and time consuming, and hence costly.
Skin-to-skin contact and breastfeeding are “a whole” to the newborn brain. In my thinking around this I have formulated an hypothesis around infant feeding frequency, which should be linked to brain cycling and sleep cycling. The neuroscience suggests that Homo sapiens should feed approximately every hour. Infants are able to feed as often as adults determine they should … but what evidence is there? I suggest the stomach capacity is the clue to an answer on this.
August 2016 – SIDS and autism
Disclosure: the views expressed here are those of myself only. They challenge a “holy cow” – a firmly held belief and dogma of my medical colleagues.
The “holy cow” that I am questioning concerns supine sleep for young infants.
The following is based on two publications, which have been through peer-review. The first was accepted almost immediately, an hypothesis for how supine sleep protects from SIDS. The second was rejected by 5 high profile journals. In each instance, reviewers made thoughtful and helpful comments and wished me luck, in each instance editors very politely found some (seemingly spurious) reason to reject! The 6th editor obviously had more courage!
The first paper states that supine sleep prevents SIDS by acting as a stressor. The second paper argues that when the whole population experiences this stressor, the incidence of autism increases.
The two articles present one single coherent and cohesive argument: taking any piece of it in isolation and making an issue out of it is doing me and my argument a disservice, as well as potentially be a disservice to all newborns and our society.
My intention is not to make simplistic public health recommendations, but to provide the correct scientific information. This will allow parents to make an informed choice, and to guide scientists in more fruitful avenues of research.
On the linked page is a summarised layman’s version of the “story line” from both the articles. There are links to more details ( I shall add more in future), and I refer to the actual articles for further details. There are no references, readers wanting such should read the full articles for the proper context. The two articles cover very complicated and difficult concepts, and in making this everyday language explanation some important detail gets left out. I also have to assume that you the reader have some prior knowledge of SIDS and autism, explaining every concept in greater detail would make this into a book.
2017 to 2020 Immediate KMC study
With collaboration from Björn Westrup, a neonatologist from Karolinska Institute, Stockholm (ans many others) we got a hearig from Bill & Melinda Gates Foundation, and a planning grant for an Immediate SSC study. This was essentally approved, but was cinducted by the WHO who revised details and changed the name to Immediate KMC Study. We were extremely happy, even though it became “early” and not immediate, and KMC should still have been SSC, as only that was the intervention, other parts of KMC were the same for both groups.
We put all other work aside and focused fully on supporting the iKMC study in Ghana, India, Malawi, Nigeria and Tanzania. The study was stopped early (at 3100 instead of the planned 4200) because of overwhelming benefit from SSC.
2021 to present – in Sweden
The final recruitment was completed end of January 2020, and the pandemic lockdown followed just 4 weeks later! We have been supporting processes for manuscripts, publications and policy preparation.