1 Kangaroo Mother Care: Restoring the Original Paradigm for Infant Care Dr Nils Bergman ”M.D., D.C.H., M.P.H., Ph.D.” Cape Town, South Africa www.skintoskincontact.com WHAT IS A PARADIGM ?? Kangaroo Mother Care: Restoring the Original Paradigm for Infant Care PARADIGM SHIFT !! What is a paradigm ? The American Heritage® Dictionary of the English Language: Fourth Edition. 2000. paradigm 3. A set of assumptions, concepts, values, and practices that constitutes a way of viewing reality for the community that shares them, especially in an intellectual discipline. What is a paradigm ? [Kuhn, T S; The Structure of Scientific Revolutions, 2nd Ed., Univ. of Chicago Press, Chicago & London, 1970, p.175]. Kuhn defines a paradigm as: “an entire constellation of beliefs, values and techniques, and so on, shared by the members of a given community” PARADIGM CONSTRUCT Paradigm: “in the philosophy of science, a generally accepted model of how ideas relate to one another, forming a conceptual framework within which scientific research is carried out” MSN Encarta FOUNDATION / PLATFORM / BASE BASIC ASSUMPTIONS:
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1
Kangaroo Mother Care:Restoring the Original
Paradigm for Infant Care
Dr Nils Bergman”M.D., D.C.H., M.P.H., Ph.D.”
Cape Town, South Africa
www.skintoskincontact.com
WHAT IS A
PARADIGM ??
Kangaroo Mother Care:Restoring the Original
Paradigm for Infant Care
PARADIGM SHIFT !! What is a paradigm?
The American Heritage® Dictionary of the English
Language: Fourth Edition. 2000.
paradigm 3. A set of
assumptions, concepts, values, and
practices that constitutes a way of
viewing reality for the community
that shares them, especially in an
intellectual discipline.
What is a paradigm?
[Kuhn, T S; The Structure of Scientific
Revolutions, 2nd Ed., Univ. of Chicago Press,
Chicago & London, 1970, p.175].
Kuhn defines a paradigm as:
“an entire constellation of beliefs,
values and techniques, and so on,
shared by the members of a given
community”
PARADIGM CONSTRUCT
Paradigm: “in the philosophy of science, a generally accepted model of how ideas relate to one another,
forming a conceptual framework
within which scientific research is carried out”
MSN Encarta
FOUNDATION / PLATFORM / BASE
BASIC ASSUMPTIONS:
2
WHAT IS THECURRENT PARADIGMFOR INFANT CARE?
Kangaroo Mother Care:Restoring the Original
Paradigm for Infant Care
child helpless
OLD PARADIGM
Restoring the Original Paradigm for Infant Care
mother clueless
father useless
Clinics in Perinatology,
June 2004, Vol 31(2) p293
Robert White
“Mothers’ arms – the past and
future locus of neonatal care ?”
“(Our care) still views the
infant as a solitary
individual who sleeps
most of the time in a bed."
Culture Producing Science Producing Culture:
How A Folk Myth Achieved Scientific Validation
“Scientific”
validation of solitary
infant sleep as
“normal” and
“healthy”
#1: Initial test condition—
infant sleeps alone, is bottle fed,
and has little or no parental contact
#2: Derive
measurements
of infant sleep
under these
conditions
#3: Repeat measurements across ages,
creating an “infant sleep model”
#4: Publish
clinical model
on what
constitutes
desirable,
healthy infant
sleep.
#5: To produce
“healthy” infant
sleep, replicate the
test condition
From James McKenna
• CIRCULAR
SCIENCE -
A SELF-
FULFILLING
PROPHECY
What determines a paradigm ??
Tradition Culture
ExperienceResearch
Science
3
BASIC ASSUMPTIONS:
= INFANT SLEEPS ALONE
FOUNDATION / PLATFORM / BASE
Culture Producing Science Producing Culture:
How A Folk Myth Achieved Scientific Validation
“Scientific”
validation of
solitary infant sleep
as “normal” and
“healthy”
#1: Initial test condition—infant
sleeps alone, is bottle fed, and has
little or no parental contact
#2: Derive
measurements
of infant sleep
under these
conditions
#3: Repeat measurements across ages,
creating an “infant sleep model”
#4: Publish
clinical model
on what
constitutes
desirable,
healthy infant
sleep.
#5: To produce
“healthy” infant
sleep, replicate the
test condition
Culture Producing Science Producing Culture:
How A Folk Myth Achieved Scientific Validation
#1: Initial test condition—
infant sleeps in INCUBATOR,
is FORMULA fed, SEPARATED
#2: Derive
measurements
NEONATES
under these
conditions
#3: Repeat measurements across ages,
defining “NEONATAL PHYSIOLOGY”
#4: Publish
TEXTBOOKS
DESCRIBING
“NORMAL”
NEONATES
#5: “replicate
the test
condition”
SEPARATED
NEONATES
ARE NORMAL
From James McKenna
“Scientific”
validation of
SEPARATED
NEONATE
as “normal” and
“healthy”
PARADIGM CONSTRUCT
Paradigm: “in the philosophy of science, a generally accepted model of how ideas relate to one another,
forming a conceptual framework
within which scientific research is carried out”
MSN Encarta
FOUNDATION / PLATFORM / BASE
BASIC ASSUMPTION:
= INCUBATORS STABILIZE
PARADIGM CONSTRUCT
Specifically, all the recommendations involving clinical medicine in a CME activity must be based on evidence
that is accepted within the professionof medicine as adequate justification
for their indications and contra-indications in the care of patients.
FOUNDATION / PLATFORM / BASE
BASIC ASSUMPTION:
= INCUBATORS STABILIZE
PARADIGM CONSTRUCTParadigm has internal
IntelligenceHonestyIntegrity
Consistency
FOUNDATION / PLATFORM / BASE
What determines a paradigm ??What determines a paradigm ??
Tradition Tradition CultureCulture
ExperienceExperienceResearchResearch
ScienceScience
BASIC ASSUMPTION:
= INCUBATORS STABILIZE
SEPARATION= CURRENTROUTINE !!
4
(Positive Tolerable )
Toxic Stress
• Strong and prolonged activation of the body’s
stress management systems in the absence of
the buffering protection of adult support.
• Disrupts brain architecture and leads to stress
management systems that respond at relatively
lower thresholds, thereby increasing the risk of
stress-related physical and mental illness.Jack P. Shonkoff, M.D.
HYPERAROUSAL -DISSOCIATION (Schore 2001)
“in this state both sympathetic and parasympathetic components are hyperactivated … Creating
Pushed handwashing, cleanliness & standards:Maternal death ratefrom 12% to 1% in 2 years
Ostracised by peers,Died insane
Stephane TARNIER 1828 -97
French obstetrician
Saw a warmed box forhatching chickens, hadone designed for “weaklings” …
… invented incubator
5
Pierre BUDIN 1846 - 1907
Friend of Tarniers …took Incubators, made centresfor the care of weaklings,wrote book on subject.
Political support …France versus Germany
BUDIN was very particular to includemother, reason for the glass window ….
Martin COUNEY 1860 - 1950
Born in Germany
claims he learnedthe techniques forBudin ....
Berlin Exhibition 1896, success !
Photograph: Pan-American Exhibition in Buffalo, New York, 1901.
Martin COUNEY 1860 - 1950
Berlin 1896, success
to USA: Buffalo Omaha 1902-4,
Chicago Fair 1932 2nd highest receipts,Last show New York 1940.
New York Worlds Fair, 1939
Martin COUNEY 1860 - 1950
... famous for “preemie road show”.
MONEY MAKING SHOW
PERMANENT pavilion in Dreamland
Dreamland delivered novel and fantastic diversions of the odd and unusual ... Catering to the public's endless fascination with oddities and freaks . It was the home to scientific, ethnological and cultural exhibits, including Dr. Couney's Baby Incubator pavilion ...
Martin COUNEY 1860 - 1950
Born in Germany
claims he learnedthe techniques forBudin ....
Berlin Exhibition 1896, success !London World fair 1898, fiasco!
ALL THE BABIES DIED ....“MOTHERS TO BLAME”
6
Martin COUNEY 1860 - 1950
Couney succesfullyraised 5000 prems!
BUT –used wet-nurses, excluded mothers
(mother got free pass to the shows !)
Mothers were excluded – “germs” …
Sarah Morris Hospital, Chicago 1923, others followed –
KANGAROO MOTHER CARE:RESTORING THE ORIGINAL PARADIGM
7
MATERNAL-INFANTSEPARATION
HAS NO SCIENTIFIC
FOUNDATION.
KANGAROO MOTHER CARE:RESTORING THE ORIGINAL PARADIGM
WHAT IS
“SCIENCE” ??
Kangaroo Mother Care:Restoring the Original
Paradigm for Infant Care
“TRUTH” CREATION
BIOLOGY - ANTHROPOLOGY - SOCIOLOGY
“SCIENCE”KNOWLEDGE
EXPERIENCE
EVIDENCE
“TRUTH” CREATION
BIOLOGY - ANTHROPLOGY - SOCIOLOGY
“SCIENCE”KNOWLEDGE
EXPERIENCE
EVIDENCE PRACTICE
GUIDELINESPOLICIES
PROTOCOLS
8%“MYTHS”
ASSUMPTIONS
“MYTHS”ASSUMPTIONS
PRACTICE ?
GUIDELINESPOLICIES
PROTOCOLS
8%
DO INCUBATORSIMPROVE SURVIVAL ??
Or is it …Surfactant ??Ventilation / CPAP ??Antibiotics ??
http://apps.who.int/rhl/en/index.html
Neuroscience
Evolutionary biologyprimatology
EpigeneticsTOXIC STRESS
DOHAD
THE SCIENCE BEHINDSKIN-TO-SKIN CONTACT
8
NEUROSCIENCE
The DNAEverything else
EVOLUTIONARYBIOLOGY
The PlaceENVIRONMENT
EXPERIENCEFITNESS ADAPTATION
SPECTRUM of expression in POPULATION
HEALTH DISEASE
“Scientific foundation” … a synthesis
Platform for better understanding of PUBLIC HEALTH.… policy and practice that impacts the care of mothers and babies.
The Brain
EPIGENETICS
EXPECTED UNEXPECTED
0 10 20 30 40w 1y 3 5 7 9 13 23 53
Birth Puberty
MATERNAL D
EPE
NDENCE
100%
MATERNAL DEPENDENCEPREMATURITY
DEPRIVATION
CORTISOL
SEPARATION
ADVERSE OUTCOMES
0 10 20 30 40w 1y 3 5 7 9 13 23 53
Birth Puberty
MATERNAL D
EPE
NDENCE
100%
MATERNAL DEPENDENCEPREMATURITY
DEPRIVATION
SENSORY
SOCIAL
STIMULATION
BASIC
BIOLOGICAL
NEEDS
0 10 20 30 40w 1y 3 5 7 9 13 23 53
Birth Puberty
MATERNAL D
EPE
NDENCE
100%
MATERNAL DEPENDENCEPREMATURITY
KC (Kangaroo Care)
TOO LITTLE,TOO LATE ..
Mother-infant skin-to-skin contact after extremely preterm birth results in
neither benefit nor adverse consequences.Although there is no reason to dissuade mothers who wish to provide STS contact, we are unable to recommend resource allocation for the implementation of STS programmes for extremely preterm infants in a neonatal intensive care unit setting.
Miles et al 20060 10 20 30 40w 1y 3 5 7 9 13 23 53
Stabilisation first 6 hours, average hourly SCRIP score
5.1
5.2
5.3
5.4
5.5
5.6
5.7
5.8
5.9
6
6.1
2nd 3rd 4th 5th 6th
KMC all
KMC <1800
CMC all
CMC <1800
Hourly average of SCRIP score, 2nd to 6th hour
Stabilization 1200g – 1800g
Skin-to-skin
Incubator
INCUBATORS DE-STABILISE
NEWBORNSStabilisation first 6 hours, average hourly SCRIP score
5.1
5.2
5.3
5.4
5.5
5.6
5.7
5.8
5.9
6
6.1
2nd 3rd 4th 5th 6th
KMC all
KMC <1800
CMC all
CMC <1800
18
BREAST- VAGALMOTHER FEEDING (PSNS) GROWTH
OTHER PROTEST- STRESS SURVIVAL orDESPAIR (SNS)
SKIN-TO-SKIN CONTACT
SEPARATION
THE PLACE MODEL
DYS-REGULATION
STABILISATION
CORTISOL
Premature babies are not in incubators because they are unstable.
Premature babies are unstable because they are in incubators.
Skin-to-skin
contact
IS MORE
essential for
premature
newborns!
Our NORMAL biology
PARADIGM CONSTRUCT
Specifically, all the recommendations involving clinical medicine in a CME activity must be based on evidence
that is accepted within the professionof medicine as adequate justification
for their indications and contra-indications in the care of patients.
FOUNDATION / PLATFORM / BASE
BASIC ASSUMPTION:
= INCUBATORS STABILIZE
Scientific Validation of a False Assumption
#5: “replicate
the test
condition”
SEPARATED
NEONATES
ARE NORMAL
FOUNDATION / PLATFORM / BASE
BASIC ASSUMPTION:
= INCUBATORS STABILIZE
PARADIGM CONSTRUCT
All scientific research referred to, reported or used in CME in support or justification of a patient care recommendation must conform to the generally
accepted standards of experimental design, data collection and analysis.
19
NORMAL
Perceived harm: NO
SSC
Incubator
What is a paradigmWhat is a paradigm??
The American HeritageThe American Heritage®® Dictionary of the English Dictionary of the English