1 Dr Nils Bergman ”M.D., D.C.H., M.P.H., Ph.D.” Cape Town, South Africa www.skintoskincontact.com Neurodevelopmental Approach to “needed neural processes” NEURODEVELOPMENT The DNA Behaviour EVOLUTIONARY BIOLOGY The Neuroscience of Birth & Breastfeeding The Brain EPIGENETICS “except in the light of mother’s body.” NEURODEVELOPMENT The DNA Behaviour EVOLUTIONARY BIOLOGY ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESS ADAPTATION The Neuroscience of Birth & Breastfeeding The Brain EPIGENETICS EXPECTED UNEXPECTED “buffering protection of adult support” NEURODEVELOPMENT The DNA Behaviour EVOLUTIONARY BIOLOGY ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESS ADAPTATION The Neuroscience of Birth & Breastfeeding The Brain EPIGENETICS BIRTH SEPARATION MOTHER BABY BONDING Sensitization Vulnerability DISEASE Disordered attachment Toxic stress Insensitive parenting ZERO SEPARATION NEURODEVELOPMENT The DNA Behaviour EVOLUTIONARY BIOLOGY ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESS ADAPTATION The Neuroscience of Birth & Breastfeeding The Brain EPIGENETICS BIRTH SEPARATION MOTHER BABY BONDING Sensitization Disordered attachment Toxic stress Insensitive parenting NEURODEVELOPMENT The DNA Behaviour EVOLUTIONARY BIOLOGY ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESS ADAPTATION The Neuroscience of Birth & Breastfeeding The Brain EPIGENETICS BIRTH BEYOND BREASTFEEDING Feed Sleep Cycling SEPARATION MOTHER BABY BONDING Sensitization Secure attachment Attuned parenting Resilience Vulnerability DISEASE HEALTH Disordered attachment Toxic stress Insensitive parenting
39
Embed
Neurodevelopmental The Neuroscience of Birth ... · breastfeeding pattern, neonatal weight gain, and the dynamics of lactation. Doucet 2012 In the ‘‘scentless breast’’ condition,
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Transcript
1
Dr Nils BergmanrdquoMD DCH MPH PhDrdquo
Cape Town South Africa
wwwskintoskincontactcom
Neurodevelopmental Approach to
ldquoneeded neural
processesrdquo
NEURODEVELOPMENT
The DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth amp BreastfeedingThe Brain
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
BIRTH
BEYOND BREASTFEEDING Feed Sleep Cycling
SEPARATIONMOTHERBABY
BONDING Sensitization
Secure attachment
Attuned parenting
Resilience Vulnerability
DISEASEHEALTH
Disordered attachment
Toxic stress
Insensitiveparenting
2
BREASTFEEDING Feed Sleep Cycling
BONDING Sensitization
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C
BRAIN
WIRING
Neurodevelopmental Approach to
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C
BRAIN
WIRING
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
WIRE BABY There are ldquoneeded neural processesrdquo
these data indicate that pups have a unique learning circuit relying onthe olfactory bulb for
neural plasticity and on the hyperfunctioning noradrenergic locus coeruleus flooding the olfactory bulb with norepinephrine to support the neural changes
these data indicate that pups have a unique learning circuit relying onthe olfactory bulb for
neural plasticity and on the hyperfunctioning noradrenergic locus coeruleus flooding the olfactory bulb with norepinephrine to support the neural changes
3
Simulated birth (rat) Simulated birth (rat)
Simulated birth (rat)
No compression
Wrong smell
Nil In the 14 babies
older than 24 h
there was
no significant
difference
between the
changes in [Hb
O2] during control
and colostrum
exposure
Those babies
showing the
greatest
increase in
[Hb O2] were
between 6 and
24 h old at
testing
The first hours after birth are a
CRITICAL PERIOD
DOUCETThe secretion of Areolar (Montgomeryrsquos) Glands from Lactating Women Elicits Selective Unconditional Responses in Neonates
ldquohellip breast chemosignalsactivate oral activity on the nipple that releases a cascade of behavioral neural neuroendocrineand endocrine processes in the newborn and the motherrdquo
Doucet 2009 17
The secretion of Areolar(Montgomeryrsquos) Glands
ldquoIn early ontogeny the sleeping brain may thusremain sentient of an organismrsquos odor environmentrdquo
Doucet 2009 18
4
Fewer AG delayed grasp
Fewer AG Slower latch
Fewer AG Weaker suck
Fewer AG More weight loss day 3 of life
Fewer AG Delayed onset of lactation
Primip high AG 23 days Primip low AG 31 days
Difference p lt0001
An overlooked aspect of the human breast Areolar glands in relation with
breastfeeding pattern neonatal weight gain and the dynamics of lactation
ldquoFirst 1000 daysrdquo =gestation 270year one 365year two 365total 1000 days
Resilience Vulnerability
DISEASEHEALTH
EARLY CHILDHOOD DEVELOPMENT ECD
ldquoFirst 1000 daysrdquo =
Resilience Vulnerability
DISEASEHEALTH
First 1000 sec = 16 minutes = 1st hourFirst 1000 min = 166 hours = 1st day First 1000 hrs = 1st six weeks
DOULA-ldquoA WOMAN SERVING WOMENrdquo BIRTH SUPPORT COMPANION
KANGAROO CARE amp DOULA = ldquoKANGAROULArdquo
Resilience Vulnerability
DISEASEHEALTH
9
DOULA and KANGAROULA
DOULA protects
OXYTOCINduringlabour
KANGAROULA protects
OXYTOCINafter birth
lsquothe first 1000 minutesrsquolsquoprevious 1000 minutesrsquo
BIRTH
DOULA and KANGAROULA
-1000 min
BIRTH
+1000 min
DOULA and KANGAROULA
-1000 min
BIRTH
+1000 min 1000 days
OXYTOCIN Zero separation
Caesarean
Separation
Breastfeeding
Zero separation
DOULA and KANGAROULA
-1000 min
BIRTH
+1000 min 1000 days
OXYTOCIN Zero separation
CORTISOL Enemy of oxytocin Stress
White coat
Sarcasm
Hunger
thirst
SEPARATION
Bathing
Noise
Lights
LithotomyWeighing
Crowds
SEPARATION
Perfume
rdquogood nightrsquos sleeprdquo
Birth Transition ParentingLabourPregnancy
DOULA
KANGAROULA
Prematurity Attachment Parenting
MOTHERSUPPORT
NEWBORNSUPPORT
Counselling Counselling
Breastfeeding
During the first 24 hours of life newborns ingested 15 g of milk
10
Milk making NUTRITION
HypothalamusPituitaryPROLACTIN
Maternal ferocityPROTECTION
OXYTOCIN Gaze increase BONDING
OXYTOCINCingulate Suppressed
REGULATION
AmygdalaCHOLECYSTOKININ Emotion satiety
HypothalamusPituitary
Cingulate
Amygdala
ldquoThe newborn may
appear helpless but
skin-to-skin contactstimulates prolactin
ensures nutritionstimulates oxytocin
ensures protectionstimulates cholecystokinin
ensures wellbeing bonding
The first hours after birth are a
CRITICAL PERIOD
mutual psycho-neuro-physiological
caregivers
Critical period concept
ldquoWindows of opportunity in early life when a childrsquos brain is exquisitely primed to receive sensory input in order to develop more advanced neural systemsrdquo
a motherrsquos brain hellip
SENSITIZATION
DOULA and KANGAROULA
DOULA protects
OXYTOCINduringlabour
KANGAROULA protects
OXYTOCINafter birth
lsquothe first 1000 minutesrsquolsquoprevious 1000 minutesrsquo
Starts to feed normally d21 2 days gavage or other
no longer suckles
If starved for 24 hours pup
at d3 will feed food from
floor
(Can be maintained by
smell and other stimuli)
Pup-in-a- cup -
separated and fed by tube
From day 2 off life
Starts to feed normally d21
15
PMA 28 40 64 1y 2y
Nilsrsquo IDEALIZED VIEW
PMA 28 40 64 1y 2y
Nilsrsquo IDEALIZED VIEW
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
Reflections for practice
Suckling and Feeding areNOT THE SAME
16
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDINGON-GOING
S S C
WIRE SUCKLING
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
ON-GOING
S S C
WIRE NEURONS
Up to 6 months milk is 74 fat
96 of this is TRIGLYCERIDE
TRIGLYCERIDE Left glycerol Right palmitic acid oleic acid alpha-linolenic acid
In phosphoglycerides glycerol molecule same
two fatty acids esterified
Phospholipids area major component of all biological membranes
Sphingomyelin particularly concentrated in BRAIN major part of MYELIN
TRIGLYCERIDE
MYELIN
Dendirification and myelinisation peaks occurat 2 and 6 monthsis maximal at one year
At one year human milk has less proteinbut MORE TRIGLYCERIDE
FATTY ACIDS ARESPECIES SPECIFIC
Up to 6 months milk is 74 fat
but after 12 months it is 107
17
ldquocherry pickrdquo
Breastfeed time years school Incomelt 1 month 109 R$ 1238gt 6 month 121 R$ 1915
Group IQ 376 points higher from breatsfeeding
BREASTFEEDINGAND BREAST MILK
INCREASE IQ
BOTTLE FEEDINGamp FORMULA
DECREASE IQ
18
Be sure the wet nurse has plenty of milk because if she lacks it she may give the babymilk of a goat or sheep or some other animalbecause the child nourished on animal milkdoes not have perfect wits like one fed on womanrsquos milk and always looks stupid and vacant and not right in the head
In separation bull Dissociated statebull No cycling chaotic pattern
48 hour baseline chaotic pattern of
activity and quiet HR amp RR
SLEEP CYCLING ndashSeparation vs contact
In SSC bull Normal cyclingbull Non-chaotic pattern
48 hour baseline chaotic pattern of
activity and quiet HR amp RRPre-KC SSC
20
modulates state organisationelicits emotional behavioursactivates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour
SMELL
Schaal 2004 115
DOUCETThe secretion of Areolar (Montgomeryrsquos) Glands from Lactating Women Elicits Selective Unconditional Responses in Neonates
ldquohellip breast chemosignalsactivate oral activity on the nipple that releases a cascade of behavioral neural neuroendocrineand endocrine processes in the newborn and the motherrdquo
Doucet 2009 116
The secretion of Areolar(Montgomeryrsquos) Glands
ldquoIn early ontogeny the sleeping brain may thusremain sentient of an organismrsquos odor environmentrdquo
Doucet 2009 117
REM
NREM
A skin-to-skin contactsession SHOULD NOT be less than one hour
or 90 minutes
SLEEPING
amp
CONTAINING
FEEDING ampHANDLINGfeed
sleep
HO
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C WIRE
TIMING
(behavior)
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C WIRE
STOMACH
21
STATE organization
Feeding frequency
SLEEP cycling
BRAIN
WIRING
How often should a neonate feed
CNS
ENS
ANS
InternalSomaticenvironment
CNS cortical subcortical(also to PNS)
ANS emotional limbic brain(incl SNS)
ANS myelinated vagus (NA)
ANS unmyelinated vagus (DMC)sub-diaphragmatic
ENS submucous plexusmyenteric plexus
122
The digestive system is endowed with its own local nervous system referred to as the enteric or intrinsic nervous system
The magnitude and complexity of the enteric nervous system is immense - it contains as many neurons as the spinal cord
ldquoOntogeny of gastric emptying patternsin the human fetusrdquo
138
24
Goldstein 1987
ldquoGrowth of the Fetal Stomach in Normal Pregnanciesrdquo
139 Goldstein 1987
Length
Transverse
AP diameter
Using +2SD
140
Formula for calculation of stomach capacity (Charles Bradshaw UCT)Assumptions the stomach can be approximated by dividing into three sections namely a ellipsoidal hemisphere an ellipsoidal cylinder and a skewed ellipsoidal cone Variables a = anteroposterior radius t = transverse radius l = length stomachRelations the height of the cone and the hemisphere are both the same as lsquoarsquo
Ellipsoid = 43 Pi r1r2r3 = 43 Pi a a t therefore volume of hemisphere = 23 Pi a a t
Cylinder = Area of base height = (Pi a t ) ( l - 2a )Skewed cone = 13 base height = 13 Pi a t aTotal volume = 23 Pi aat + Pi a t (l- 2a) + 13 Pi a t a
=Pi atl -Pi a at= Pi a t(l-a)
Goldstein and Sase dataStomach capacity at term 10 - 15 ml
BRADSHAW formula
141
Assumption 25 kg baby 33w GA
requiring 150 mlkgday = 375 ml
45 MIN CYCLES ( 32 cyclesday)
12 ML PER CYCLE = 384 ml142
Newborn stomach volume
Gastric volumes at birthCorrelated with gastric pH
gastrin and somatostatin
ldquofetus drinks 10 ml portions of amniotic fluid helliprdquo
Widstrom 1988 143
Only recent study locatedldquoAutopsyrdquo capacity was determined
in Indian post-mortem studies
100 autopsies (63 SB 37 ENND)Tied at cardia and pylorus filled withwater emptied amp measured repeatedldquohellip obliteration of the gastric curvaturesrdquoldquodue care to minimize stretch artifactsrdquo
Naveed 1992
ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo
144
25
Infants above 2500g onlyAve Range
Stillborn (n 11) 196 ml (10-35)Early death (n 9) 178 ml (10-25)All cases (n 20) 188 ml
Naveed 1992
ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo
145 146
KERNESSUK 1997 (Russian)
Postmortem in situ measures(applied Bradshaw formula)
AveNewborn (n 11) 15 ml2 months (n 11) 35 ml2-4 m (n 10) 50 ml4-6 m (n 8) 100 ml
Known references with data
Scammon and Doyle 1920
Zuccarellirsquos method stomach filled at autopsy to ldquoa pressure of between
15 and 20 centimeters of waterrdquo
Scammon 1920
ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo
147
Anatomic capacity was determined in post-mortem studies
Main data set Alliot 1905 (n 25)Scammon own cases (n 13)
30 ndash 35 ml at birth ndashalmost regardless of birth weight
Scammon 1920
ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo
148
Zangen S et al Rapid maturation of gastric relaxation in newborns
Pressures (mmHg)
Balloon inflates to
15 ml no increase
functional capacity
149
Zangen S et al Rapid maturation of gastric relaxation in newborns
Pressures (mmHg)
Balloon inflates to
15 ml no increase20 ml pressure OK
physiologicalcapacity hellip 150
26
EVIDENCE (NBn 111009)
Author Capacity NoteSase 10-15 ml Live term fetusGoldstein 10-15 ml Live term fetusWidstrom 10 mls Live newbornZangen 20 mls Live (pressure)
Naveed 20 mls Autopsy (SB)20 mls Autopsy (ENND)
Kernessuk 15 mls Autopsy (in situ)Scammon 30-35 ml Autopsy (water
ldquoSmall and frequent feeds according to the sleep cyclerdquo
The ldquonicherdquo (occupation) of a neonate (Alberts)
BOND FEED
SLEEP SLEEP
PLAY FEED
201
Gastric overfilling syndrome
Proposed Management 202
Proposed Management
Babies should be fedEVERY TIME THEY WAKE
Stanley Graven 2006
REMNR1NR2NR3SWS
AS (20 mins) QS (40 mins)
A normal sleep cycle is ONE hourHow often should neonates feed
203
Proposed Management
All babies should be fedat least once an hour 204
35
Proposed Management
All babies should be fedat least once an hour
205
The first Milk Ejection Reflex (MER)
elicited in lt 2 minutesworks quicklyswallowed 1 minute
Feeding time (max)3 minutes
Repeat every 1 hour
Prime 2007
The ldquonormalrdquo or usual and common breastfeed
takes 15 minutesdiscomfort afterburping time 5 minutes
Feeding time 20 min
Repeat every 3 hours
Prime 2007
3 minute 20ml feeds x 24d = 72 minutes
20 minute 60ml feeds x 8d = 160 minutes
SMALL AND FREQUENT FEEDS ARE EFFICIENT
FEWER NURSES NEEDED
The calculated dailyrequirement for a 3kgbaby can be given without increase inpressure MINIMAL RISK
PARENTS CAN DOSAFELY
20 mls x 24 feeds= 480mls day
Zangen 2001 209
All babies should be fedat least once an hour
210
36
Infant feeding frequencyProposal based on available evidence and neuroscience
ldquoSmall and frequent feeds
adjusted to the sleep cyclerdquo
211
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C
STATE organization
Feeding frequency
SLEEP cycling
BRAIN
WIRING
How often should a neonate feeda neonate sleep
Infantsleep cycles
begin to block on diurnalrhythms
Mother-infant synchrony
hellip at 12 weeks
(circadian)
START at 3 months
Can be ldquoadult-likerdquo
at 6 months
Thomas 2014
STATE organization
Feeding frequency
SLEEP cycling
PLAY FEED
216
SLEEP SLEEP
SLEEP SLEEPPLAY
FEED
Infant sleep cycling and synchronicity with maternal sleep ensure development
Infantsleep cycles
begin to block on diurnalrhythms
37
BOND SUCKLE SLEEP SLEEP PLAY
FEED
217
SLEEP SLEEP SLEEP SLEEPPLAY
FEED
Infant sleep cycling and synchronicity with maternal sleep ensure development
modulates state organisationelicits emotional behaviours
activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour
SMELL(amp SKIN)
Schaal 2004 218
modulates state organisationelicits emotional behaviours
activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour
SMELL(amp SKIN)rdquoSLEEP-FEED CYCLINGrdquo
Schaal 2004 219
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C
WIRE
BRAIN
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C
BRAIN
WIRING
NEUROSCIENCE
The DNAEverything else
EVOLUTIONARYBIOLOGY
The Brain
EPIGENETICS
The PlaceENVIRONMENT
EXPERIENCEFITNESS ADAPTATION
ldquoScientific foundationrdquo hellip a synthesis
ZERO
SEPARATION
38
wwwninobirthorgwwwskintoskincontactcom
THE NEUROSCIENCE OFSKIN-TO-SKIN CONTACT
AND BREASTFEEDING
ARE THE SAME
SUMMARY SKIN-TO-SKIN
(Regulation)
SLEEP(Brain)
FEEDING(Stomach)
LOVE ( ldquomindrdquo )
REMNR1NR2NR3NR4
ACQUISITION CONSOLIDATION MEMORYFORMATION
poly-sensory input transfer information P wavesshort-term memory ldquoSNRrdquo strong signals returns infostored cortex amygdala to neocortex
hippocampus organizedAwake and REM NREM stage 4 REM
BRAIN WIRING
Stanley Graven 2006
PLAY
SLEEP
FEEDHOLDYOURPREM
httpswwwfacebookcomninobirth
39
Nelson Mandela
hellip in describing themeasure of a nation
he has argued that
ldquoThere can be no keener revelation of a societyrsquos soul than the way in which it treats its childrenrdquo
2
BREASTFEEDING Feed Sleep Cycling
BONDING Sensitization
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C
BRAIN
WIRING
Neurodevelopmental Approach to
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C
BRAIN
WIRING
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
WIRE BABY There are ldquoneeded neural processesrdquo
these data indicate that pups have a unique learning circuit relying onthe olfactory bulb for
neural plasticity and on the hyperfunctioning noradrenergic locus coeruleus flooding the olfactory bulb with norepinephrine to support the neural changes
these data indicate that pups have a unique learning circuit relying onthe olfactory bulb for
neural plasticity and on the hyperfunctioning noradrenergic locus coeruleus flooding the olfactory bulb with norepinephrine to support the neural changes
3
Simulated birth (rat) Simulated birth (rat)
Simulated birth (rat)
No compression
Wrong smell
Nil In the 14 babies
older than 24 h
there was
no significant
difference
between the
changes in [Hb
O2] during control
and colostrum
exposure
Those babies
showing the
greatest
increase in
[Hb O2] were
between 6 and
24 h old at
testing
The first hours after birth are a
CRITICAL PERIOD
DOUCETThe secretion of Areolar (Montgomeryrsquos) Glands from Lactating Women Elicits Selective Unconditional Responses in Neonates
ldquohellip breast chemosignalsactivate oral activity on the nipple that releases a cascade of behavioral neural neuroendocrineand endocrine processes in the newborn and the motherrdquo
Doucet 2009 17
The secretion of Areolar(Montgomeryrsquos) Glands
ldquoIn early ontogeny the sleeping brain may thusremain sentient of an organismrsquos odor environmentrdquo
Doucet 2009 18
4
Fewer AG delayed grasp
Fewer AG Slower latch
Fewer AG Weaker suck
Fewer AG More weight loss day 3 of life
Fewer AG Delayed onset of lactation
Primip high AG 23 days Primip low AG 31 days
Difference p lt0001
An overlooked aspect of the human breast Areolar glands in relation with
breastfeeding pattern neonatal weight gain and the dynamics of lactation
ldquoFirst 1000 daysrdquo =gestation 270year one 365year two 365total 1000 days
Resilience Vulnerability
DISEASEHEALTH
EARLY CHILDHOOD DEVELOPMENT ECD
ldquoFirst 1000 daysrdquo =
Resilience Vulnerability
DISEASEHEALTH
First 1000 sec = 16 minutes = 1st hourFirst 1000 min = 166 hours = 1st day First 1000 hrs = 1st six weeks
DOULA-ldquoA WOMAN SERVING WOMENrdquo BIRTH SUPPORT COMPANION
KANGAROO CARE amp DOULA = ldquoKANGAROULArdquo
Resilience Vulnerability
DISEASEHEALTH
9
DOULA and KANGAROULA
DOULA protects
OXYTOCINduringlabour
KANGAROULA protects
OXYTOCINafter birth
lsquothe first 1000 minutesrsquolsquoprevious 1000 minutesrsquo
BIRTH
DOULA and KANGAROULA
-1000 min
BIRTH
+1000 min
DOULA and KANGAROULA
-1000 min
BIRTH
+1000 min 1000 days
OXYTOCIN Zero separation
Caesarean
Separation
Breastfeeding
Zero separation
DOULA and KANGAROULA
-1000 min
BIRTH
+1000 min 1000 days
OXYTOCIN Zero separation
CORTISOL Enemy of oxytocin Stress
White coat
Sarcasm
Hunger
thirst
SEPARATION
Bathing
Noise
Lights
LithotomyWeighing
Crowds
SEPARATION
Perfume
rdquogood nightrsquos sleeprdquo
Birth Transition ParentingLabourPregnancy
DOULA
KANGAROULA
Prematurity Attachment Parenting
MOTHERSUPPORT
NEWBORNSUPPORT
Counselling Counselling
Breastfeeding
During the first 24 hours of life newborns ingested 15 g of milk
10
Milk making NUTRITION
HypothalamusPituitaryPROLACTIN
Maternal ferocityPROTECTION
OXYTOCIN Gaze increase BONDING
OXYTOCINCingulate Suppressed
REGULATION
AmygdalaCHOLECYSTOKININ Emotion satiety
HypothalamusPituitary
Cingulate
Amygdala
ldquoThe newborn may
appear helpless but
skin-to-skin contactstimulates prolactin
ensures nutritionstimulates oxytocin
ensures protectionstimulates cholecystokinin
ensures wellbeing bonding
The first hours after birth are a
CRITICAL PERIOD
mutual psycho-neuro-physiological
caregivers
Critical period concept
ldquoWindows of opportunity in early life when a childrsquos brain is exquisitely primed to receive sensory input in order to develop more advanced neural systemsrdquo
a motherrsquos brain hellip
SENSITIZATION
DOULA and KANGAROULA
DOULA protects
OXYTOCINduringlabour
KANGAROULA protects
OXYTOCINafter birth
lsquothe first 1000 minutesrsquolsquoprevious 1000 minutesrsquo
Starts to feed normally d21 2 days gavage or other
no longer suckles
If starved for 24 hours pup
at d3 will feed food from
floor
(Can be maintained by
smell and other stimuli)
Pup-in-a- cup -
separated and fed by tube
From day 2 off life
Starts to feed normally d21
15
PMA 28 40 64 1y 2y
Nilsrsquo IDEALIZED VIEW
PMA 28 40 64 1y 2y
Nilsrsquo IDEALIZED VIEW
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
Reflections for practice
Suckling and Feeding areNOT THE SAME
16
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDINGON-GOING
S S C
WIRE SUCKLING
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
ON-GOING
S S C
WIRE NEURONS
Up to 6 months milk is 74 fat
96 of this is TRIGLYCERIDE
TRIGLYCERIDE Left glycerol Right palmitic acid oleic acid alpha-linolenic acid
In phosphoglycerides glycerol molecule same
two fatty acids esterified
Phospholipids area major component of all biological membranes
Sphingomyelin particularly concentrated in BRAIN major part of MYELIN
TRIGLYCERIDE
MYELIN
Dendirification and myelinisation peaks occurat 2 and 6 monthsis maximal at one year
At one year human milk has less proteinbut MORE TRIGLYCERIDE
FATTY ACIDS ARESPECIES SPECIFIC
Up to 6 months milk is 74 fat
but after 12 months it is 107
17
ldquocherry pickrdquo
Breastfeed time years school Incomelt 1 month 109 R$ 1238gt 6 month 121 R$ 1915
Group IQ 376 points higher from breatsfeeding
BREASTFEEDINGAND BREAST MILK
INCREASE IQ
BOTTLE FEEDINGamp FORMULA
DECREASE IQ
18
Be sure the wet nurse has plenty of milk because if she lacks it she may give the babymilk of a goat or sheep or some other animalbecause the child nourished on animal milkdoes not have perfect wits like one fed on womanrsquos milk and always looks stupid and vacant and not right in the head
In separation bull Dissociated statebull No cycling chaotic pattern
48 hour baseline chaotic pattern of
activity and quiet HR amp RR
SLEEP CYCLING ndashSeparation vs contact
In SSC bull Normal cyclingbull Non-chaotic pattern
48 hour baseline chaotic pattern of
activity and quiet HR amp RRPre-KC SSC
20
modulates state organisationelicits emotional behavioursactivates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour
SMELL
Schaal 2004 115
DOUCETThe secretion of Areolar (Montgomeryrsquos) Glands from Lactating Women Elicits Selective Unconditional Responses in Neonates
ldquohellip breast chemosignalsactivate oral activity on the nipple that releases a cascade of behavioral neural neuroendocrineand endocrine processes in the newborn and the motherrdquo
Doucet 2009 116
The secretion of Areolar(Montgomeryrsquos) Glands
ldquoIn early ontogeny the sleeping brain may thusremain sentient of an organismrsquos odor environmentrdquo
Doucet 2009 117
REM
NREM
A skin-to-skin contactsession SHOULD NOT be less than one hour
or 90 minutes
SLEEPING
amp
CONTAINING
FEEDING ampHANDLINGfeed
sleep
HO
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C WIRE
TIMING
(behavior)
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C WIRE
STOMACH
21
STATE organization
Feeding frequency
SLEEP cycling
BRAIN
WIRING
How often should a neonate feed
CNS
ENS
ANS
InternalSomaticenvironment
CNS cortical subcortical(also to PNS)
ANS emotional limbic brain(incl SNS)
ANS myelinated vagus (NA)
ANS unmyelinated vagus (DMC)sub-diaphragmatic
ENS submucous plexusmyenteric plexus
122
The digestive system is endowed with its own local nervous system referred to as the enteric or intrinsic nervous system
The magnitude and complexity of the enteric nervous system is immense - it contains as many neurons as the spinal cord
ldquoOntogeny of gastric emptying patternsin the human fetusrdquo
138
24
Goldstein 1987
ldquoGrowth of the Fetal Stomach in Normal Pregnanciesrdquo
139 Goldstein 1987
Length
Transverse
AP diameter
Using +2SD
140
Formula for calculation of stomach capacity (Charles Bradshaw UCT)Assumptions the stomach can be approximated by dividing into three sections namely a ellipsoidal hemisphere an ellipsoidal cylinder and a skewed ellipsoidal cone Variables a = anteroposterior radius t = transverse radius l = length stomachRelations the height of the cone and the hemisphere are both the same as lsquoarsquo
Ellipsoid = 43 Pi r1r2r3 = 43 Pi a a t therefore volume of hemisphere = 23 Pi a a t
Cylinder = Area of base height = (Pi a t ) ( l - 2a )Skewed cone = 13 base height = 13 Pi a t aTotal volume = 23 Pi aat + Pi a t (l- 2a) + 13 Pi a t a
=Pi atl -Pi a at= Pi a t(l-a)
Goldstein and Sase dataStomach capacity at term 10 - 15 ml
BRADSHAW formula
141
Assumption 25 kg baby 33w GA
requiring 150 mlkgday = 375 ml
45 MIN CYCLES ( 32 cyclesday)
12 ML PER CYCLE = 384 ml142
Newborn stomach volume
Gastric volumes at birthCorrelated with gastric pH
gastrin and somatostatin
ldquofetus drinks 10 ml portions of amniotic fluid helliprdquo
Widstrom 1988 143
Only recent study locatedldquoAutopsyrdquo capacity was determined
in Indian post-mortem studies
100 autopsies (63 SB 37 ENND)Tied at cardia and pylorus filled withwater emptied amp measured repeatedldquohellip obliteration of the gastric curvaturesrdquoldquodue care to minimize stretch artifactsrdquo
Naveed 1992
ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo
144
25
Infants above 2500g onlyAve Range
Stillborn (n 11) 196 ml (10-35)Early death (n 9) 178 ml (10-25)All cases (n 20) 188 ml
Naveed 1992
ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo
145 146
KERNESSUK 1997 (Russian)
Postmortem in situ measures(applied Bradshaw formula)
AveNewborn (n 11) 15 ml2 months (n 11) 35 ml2-4 m (n 10) 50 ml4-6 m (n 8) 100 ml
Known references with data
Scammon and Doyle 1920
Zuccarellirsquos method stomach filled at autopsy to ldquoa pressure of between
15 and 20 centimeters of waterrdquo
Scammon 1920
ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo
147
Anatomic capacity was determined in post-mortem studies
Main data set Alliot 1905 (n 25)Scammon own cases (n 13)
30 ndash 35 ml at birth ndashalmost regardless of birth weight
Scammon 1920
ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo
148
Zangen S et al Rapid maturation of gastric relaxation in newborns
Pressures (mmHg)
Balloon inflates to
15 ml no increase
functional capacity
149
Zangen S et al Rapid maturation of gastric relaxation in newborns
Pressures (mmHg)
Balloon inflates to
15 ml no increase20 ml pressure OK
physiologicalcapacity hellip 150
26
EVIDENCE (NBn 111009)
Author Capacity NoteSase 10-15 ml Live term fetusGoldstein 10-15 ml Live term fetusWidstrom 10 mls Live newbornZangen 20 mls Live (pressure)
Naveed 20 mls Autopsy (SB)20 mls Autopsy (ENND)
Kernessuk 15 mls Autopsy (in situ)Scammon 30-35 ml Autopsy (water
ldquoSmall and frequent feeds according to the sleep cyclerdquo
The ldquonicherdquo (occupation) of a neonate (Alberts)
BOND FEED
SLEEP SLEEP
PLAY FEED
201
Gastric overfilling syndrome
Proposed Management 202
Proposed Management
Babies should be fedEVERY TIME THEY WAKE
Stanley Graven 2006
REMNR1NR2NR3SWS
AS (20 mins) QS (40 mins)
A normal sleep cycle is ONE hourHow often should neonates feed
203
Proposed Management
All babies should be fedat least once an hour 204
35
Proposed Management
All babies should be fedat least once an hour
205
The first Milk Ejection Reflex (MER)
elicited in lt 2 minutesworks quicklyswallowed 1 minute
Feeding time (max)3 minutes
Repeat every 1 hour
Prime 2007
The ldquonormalrdquo or usual and common breastfeed
takes 15 minutesdiscomfort afterburping time 5 minutes
Feeding time 20 min
Repeat every 3 hours
Prime 2007
3 minute 20ml feeds x 24d = 72 minutes
20 minute 60ml feeds x 8d = 160 minutes
SMALL AND FREQUENT FEEDS ARE EFFICIENT
FEWER NURSES NEEDED
The calculated dailyrequirement for a 3kgbaby can be given without increase inpressure MINIMAL RISK
PARENTS CAN DOSAFELY
20 mls x 24 feeds= 480mls day
Zangen 2001 209
All babies should be fedat least once an hour
210
36
Infant feeding frequencyProposal based on available evidence and neuroscience
ldquoSmall and frequent feeds
adjusted to the sleep cyclerdquo
211
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C
STATE organization
Feeding frequency
SLEEP cycling
BRAIN
WIRING
How often should a neonate feeda neonate sleep
Infantsleep cycles
begin to block on diurnalrhythms
Mother-infant synchrony
hellip at 12 weeks
(circadian)
START at 3 months
Can be ldquoadult-likerdquo
at 6 months
Thomas 2014
STATE organization
Feeding frequency
SLEEP cycling
PLAY FEED
216
SLEEP SLEEP
SLEEP SLEEPPLAY
FEED
Infant sleep cycling and synchronicity with maternal sleep ensure development
Infantsleep cycles
begin to block on diurnalrhythms
37
BOND SUCKLE SLEEP SLEEP PLAY
FEED
217
SLEEP SLEEP SLEEP SLEEPPLAY
FEED
Infant sleep cycling and synchronicity with maternal sleep ensure development
modulates state organisationelicits emotional behaviours
activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour
SMELL(amp SKIN)
Schaal 2004 218
modulates state organisationelicits emotional behaviours
activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour
SMELL(amp SKIN)rdquoSLEEP-FEED CYCLINGrdquo
Schaal 2004 219
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C
WIRE
BRAIN
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C
BRAIN
WIRING
NEUROSCIENCE
The DNAEverything else
EVOLUTIONARYBIOLOGY
The Brain
EPIGENETICS
The PlaceENVIRONMENT
EXPERIENCEFITNESS ADAPTATION
ldquoScientific foundationrdquo hellip a synthesis
ZERO
SEPARATION
38
wwwninobirthorgwwwskintoskincontactcom
THE NEUROSCIENCE OFSKIN-TO-SKIN CONTACT
AND BREASTFEEDING
ARE THE SAME
SUMMARY SKIN-TO-SKIN
(Regulation)
SLEEP(Brain)
FEEDING(Stomach)
LOVE ( ldquomindrdquo )
REMNR1NR2NR3NR4
ACQUISITION CONSOLIDATION MEMORYFORMATION
poly-sensory input transfer information P wavesshort-term memory ldquoSNRrdquo strong signals returns infostored cortex amygdala to neocortex
hippocampus organizedAwake and REM NREM stage 4 REM
BRAIN WIRING
Stanley Graven 2006
PLAY
SLEEP
FEEDHOLDYOURPREM
httpswwwfacebookcomninobirth
39
Nelson Mandela
hellip in describing themeasure of a nation
he has argued that
ldquoThere can be no keener revelation of a societyrsquos soul than the way in which it treats its childrenrdquo
3
Simulated birth (rat) Simulated birth (rat)
Simulated birth (rat)
No compression
Wrong smell
Nil In the 14 babies
older than 24 h
there was
no significant
difference
between the
changes in [Hb
O2] during control
and colostrum
exposure
Those babies
showing the
greatest
increase in
[Hb O2] were
between 6 and
24 h old at
testing
The first hours after birth are a
CRITICAL PERIOD
DOUCETThe secretion of Areolar (Montgomeryrsquos) Glands from Lactating Women Elicits Selective Unconditional Responses in Neonates
ldquohellip breast chemosignalsactivate oral activity on the nipple that releases a cascade of behavioral neural neuroendocrineand endocrine processes in the newborn and the motherrdquo
Doucet 2009 17
The secretion of Areolar(Montgomeryrsquos) Glands
ldquoIn early ontogeny the sleeping brain may thusremain sentient of an organismrsquos odor environmentrdquo
Doucet 2009 18
4
Fewer AG delayed grasp
Fewer AG Slower latch
Fewer AG Weaker suck
Fewer AG More weight loss day 3 of life
Fewer AG Delayed onset of lactation
Primip high AG 23 days Primip low AG 31 days
Difference p lt0001
An overlooked aspect of the human breast Areolar glands in relation with
breastfeeding pattern neonatal weight gain and the dynamics of lactation
ldquoFirst 1000 daysrdquo =gestation 270year one 365year two 365total 1000 days
Resilience Vulnerability
DISEASEHEALTH
EARLY CHILDHOOD DEVELOPMENT ECD
ldquoFirst 1000 daysrdquo =
Resilience Vulnerability
DISEASEHEALTH
First 1000 sec = 16 minutes = 1st hourFirst 1000 min = 166 hours = 1st day First 1000 hrs = 1st six weeks
DOULA-ldquoA WOMAN SERVING WOMENrdquo BIRTH SUPPORT COMPANION
KANGAROO CARE amp DOULA = ldquoKANGAROULArdquo
Resilience Vulnerability
DISEASEHEALTH
9
DOULA and KANGAROULA
DOULA protects
OXYTOCINduringlabour
KANGAROULA protects
OXYTOCINafter birth
lsquothe first 1000 minutesrsquolsquoprevious 1000 minutesrsquo
BIRTH
DOULA and KANGAROULA
-1000 min
BIRTH
+1000 min
DOULA and KANGAROULA
-1000 min
BIRTH
+1000 min 1000 days
OXYTOCIN Zero separation
Caesarean
Separation
Breastfeeding
Zero separation
DOULA and KANGAROULA
-1000 min
BIRTH
+1000 min 1000 days
OXYTOCIN Zero separation
CORTISOL Enemy of oxytocin Stress
White coat
Sarcasm
Hunger
thirst
SEPARATION
Bathing
Noise
Lights
LithotomyWeighing
Crowds
SEPARATION
Perfume
rdquogood nightrsquos sleeprdquo
Birth Transition ParentingLabourPregnancy
DOULA
KANGAROULA
Prematurity Attachment Parenting
MOTHERSUPPORT
NEWBORNSUPPORT
Counselling Counselling
Breastfeeding
During the first 24 hours of life newborns ingested 15 g of milk
10
Milk making NUTRITION
HypothalamusPituitaryPROLACTIN
Maternal ferocityPROTECTION
OXYTOCIN Gaze increase BONDING
OXYTOCINCingulate Suppressed
REGULATION
AmygdalaCHOLECYSTOKININ Emotion satiety
HypothalamusPituitary
Cingulate
Amygdala
ldquoThe newborn may
appear helpless but
skin-to-skin contactstimulates prolactin
ensures nutritionstimulates oxytocin
ensures protectionstimulates cholecystokinin
ensures wellbeing bonding
The first hours after birth are a
CRITICAL PERIOD
mutual psycho-neuro-physiological
caregivers
Critical period concept
ldquoWindows of opportunity in early life when a childrsquos brain is exquisitely primed to receive sensory input in order to develop more advanced neural systemsrdquo
a motherrsquos brain hellip
SENSITIZATION
DOULA and KANGAROULA
DOULA protects
OXYTOCINduringlabour
KANGAROULA protects
OXYTOCINafter birth
lsquothe first 1000 minutesrsquolsquoprevious 1000 minutesrsquo
Starts to feed normally d21 2 days gavage or other
no longer suckles
If starved for 24 hours pup
at d3 will feed food from
floor
(Can be maintained by
smell and other stimuli)
Pup-in-a- cup -
separated and fed by tube
From day 2 off life
Starts to feed normally d21
15
PMA 28 40 64 1y 2y
Nilsrsquo IDEALIZED VIEW
PMA 28 40 64 1y 2y
Nilsrsquo IDEALIZED VIEW
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
Reflections for practice
Suckling and Feeding areNOT THE SAME
16
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDINGON-GOING
S S C
WIRE SUCKLING
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
ON-GOING
S S C
WIRE NEURONS
Up to 6 months milk is 74 fat
96 of this is TRIGLYCERIDE
TRIGLYCERIDE Left glycerol Right palmitic acid oleic acid alpha-linolenic acid
In phosphoglycerides glycerol molecule same
two fatty acids esterified
Phospholipids area major component of all biological membranes
Sphingomyelin particularly concentrated in BRAIN major part of MYELIN
TRIGLYCERIDE
MYELIN
Dendirification and myelinisation peaks occurat 2 and 6 monthsis maximal at one year
At one year human milk has less proteinbut MORE TRIGLYCERIDE
FATTY ACIDS ARESPECIES SPECIFIC
Up to 6 months milk is 74 fat
but after 12 months it is 107
17
ldquocherry pickrdquo
Breastfeed time years school Incomelt 1 month 109 R$ 1238gt 6 month 121 R$ 1915
Group IQ 376 points higher from breatsfeeding
BREASTFEEDINGAND BREAST MILK
INCREASE IQ
BOTTLE FEEDINGamp FORMULA
DECREASE IQ
18
Be sure the wet nurse has plenty of milk because if she lacks it she may give the babymilk of a goat or sheep or some other animalbecause the child nourished on animal milkdoes not have perfect wits like one fed on womanrsquos milk and always looks stupid and vacant and not right in the head
In separation bull Dissociated statebull No cycling chaotic pattern
48 hour baseline chaotic pattern of
activity and quiet HR amp RR
SLEEP CYCLING ndashSeparation vs contact
In SSC bull Normal cyclingbull Non-chaotic pattern
48 hour baseline chaotic pattern of
activity and quiet HR amp RRPre-KC SSC
20
modulates state organisationelicits emotional behavioursactivates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour
SMELL
Schaal 2004 115
DOUCETThe secretion of Areolar (Montgomeryrsquos) Glands from Lactating Women Elicits Selective Unconditional Responses in Neonates
ldquohellip breast chemosignalsactivate oral activity on the nipple that releases a cascade of behavioral neural neuroendocrineand endocrine processes in the newborn and the motherrdquo
Doucet 2009 116
The secretion of Areolar(Montgomeryrsquos) Glands
ldquoIn early ontogeny the sleeping brain may thusremain sentient of an organismrsquos odor environmentrdquo
Doucet 2009 117
REM
NREM
A skin-to-skin contactsession SHOULD NOT be less than one hour
or 90 minutes
SLEEPING
amp
CONTAINING
FEEDING ampHANDLINGfeed
sleep
HO
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C WIRE
TIMING
(behavior)
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C WIRE
STOMACH
21
STATE organization
Feeding frequency
SLEEP cycling
BRAIN
WIRING
How often should a neonate feed
CNS
ENS
ANS
InternalSomaticenvironment
CNS cortical subcortical(also to PNS)
ANS emotional limbic brain(incl SNS)
ANS myelinated vagus (NA)
ANS unmyelinated vagus (DMC)sub-diaphragmatic
ENS submucous plexusmyenteric plexus
122
The digestive system is endowed with its own local nervous system referred to as the enteric or intrinsic nervous system
The magnitude and complexity of the enteric nervous system is immense - it contains as many neurons as the spinal cord
ldquoOntogeny of gastric emptying patternsin the human fetusrdquo
138
24
Goldstein 1987
ldquoGrowth of the Fetal Stomach in Normal Pregnanciesrdquo
139 Goldstein 1987
Length
Transverse
AP diameter
Using +2SD
140
Formula for calculation of stomach capacity (Charles Bradshaw UCT)Assumptions the stomach can be approximated by dividing into three sections namely a ellipsoidal hemisphere an ellipsoidal cylinder and a skewed ellipsoidal cone Variables a = anteroposterior radius t = transverse radius l = length stomachRelations the height of the cone and the hemisphere are both the same as lsquoarsquo
Ellipsoid = 43 Pi r1r2r3 = 43 Pi a a t therefore volume of hemisphere = 23 Pi a a t
Cylinder = Area of base height = (Pi a t ) ( l - 2a )Skewed cone = 13 base height = 13 Pi a t aTotal volume = 23 Pi aat + Pi a t (l- 2a) + 13 Pi a t a
=Pi atl -Pi a at= Pi a t(l-a)
Goldstein and Sase dataStomach capacity at term 10 - 15 ml
BRADSHAW formula
141
Assumption 25 kg baby 33w GA
requiring 150 mlkgday = 375 ml
45 MIN CYCLES ( 32 cyclesday)
12 ML PER CYCLE = 384 ml142
Newborn stomach volume
Gastric volumes at birthCorrelated with gastric pH
gastrin and somatostatin
ldquofetus drinks 10 ml portions of amniotic fluid helliprdquo
Widstrom 1988 143
Only recent study locatedldquoAutopsyrdquo capacity was determined
in Indian post-mortem studies
100 autopsies (63 SB 37 ENND)Tied at cardia and pylorus filled withwater emptied amp measured repeatedldquohellip obliteration of the gastric curvaturesrdquoldquodue care to minimize stretch artifactsrdquo
Naveed 1992
ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo
144
25
Infants above 2500g onlyAve Range
Stillborn (n 11) 196 ml (10-35)Early death (n 9) 178 ml (10-25)All cases (n 20) 188 ml
Naveed 1992
ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo
145 146
KERNESSUK 1997 (Russian)
Postmortem in situ measures(applied Bradshaw formula)
AveNewborn (n 11) 15 ml2 months (n 11) 35 ml2-4 m (n 10) 50 ml4-6 m (n 8) 100 ml
Known references with data
Scammon and Doyle 1920
Zuccarellirsquos method stomach filled at autopsy to ldquoa pressure of between
15 and 20 centimeters of waterrdquo
Scammon 1920
ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo
147
Anatomic capacity was determined in post-mortem studies
Main data set Alliot 1905 (n 25)Scammon own cases (n 13)
30 ndash 35 ml at birth ndashalmost regardless of birth weight
Scammon 1920
ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo
148
Zangen S et al Rapid maturation of gastric relaxation in newborns
Pressures (mmHg)
Balloon inflates to
15 ml no increase
functional capacity
149
Zangen S et al Rapid maturation of gastric relaxation in newborns
Pressures (mmHg)
Balloon inflates to
15 ml no increase20 ml pressure OK
physiologicalcapacity hellip 150
26
EVIDENCE (NBn 111009)
Author Capacity NoteSase 10-15 ml Live term fetusGoldstein 10-15 ml Live term fetusWidstrom 10 mls Live newbornZangen 20 mls Live (pressure)
Naveed 20 mls Autopsy (SB)20 mls Autopsy (ENND)
Kernessuk 15 mls Autopsy (in situ)Scammon 30-35 ml Autopsy (water
ldquoFirst 1000 daysrdquo =gestation 270year one 365year two 365total 1000 days
Resilience Vulnerability
DISEASEHEALTH
EARLY CHILDHOOD DEVELOPMENT ECD
ldquoFirst 1000 daysrdquo =
Resilience Vulnerability
DISEASEHEALTH
First 1000 sec = 16 minutes = 1st hourFirst 1000 min = 166 hours = 1st day First 1000 hrs = 1st six weeks
DOULA-ldquoA WOMAN SERVING WOMENrdquo BIRTH SUPPORT COMPANION
KANGAROO CARE amp DOULA = ldquoKANGAROULArdquo
Resilience Vulnerability
DISEASEHEALTH
9
DOULA and KANGAROULA
DOULA protects
OXYTOCINduringlabour
KANGAROULA protects
OXYTOCINafter birth
lsquothe first 1000 minutesrsquolsquoprevious 1000 minutesrsquo
BIRTH
DOULA and KANGAROULA
-1000 min
BIRTH
+1000 min
DOULA and KANGAROULA
-1000 min
BIRTH
+1000 min 1000 days
OXYTOCIN Zero separation
Caesarean
Separation
Breastfeeding
Zero separation
DOULA and KANGAROULA
-1000 min
BIRTH
+1000 min 1000 days
OXYTOCIN Zero separation
CORTISOL Enemy of oxytocin Stress
White coat
Sarcasm
Hunger
thirst
SEPARATION
Bathing
Noise
Lights
LithotomyWeighing
Crowds
SEPARATION
Perfume
rdquogood nightrsquos sleeprdquo
Birth Transition ParentingLabourPregnancy
DOULA
KANGAROULA
Prematurity Attachment Parenting
MOTHERSUPPORT
NEWBORNSUPPORT
Counselling Counselling
Breastfeeding
During the first 24 hours of life newborns ingested 15 g of milk
10
Milk making NUTRITION
HypothalamusPituitaryPROLACTIN
Maternal ferocityPROTECTION
OXYTOCIN Gaze increase BONDING
OXYTOCINCingulate Suppressed
REGULATION
AmygdalaCHOLECYSTOKININ Emotion satiety
HypothalamusPituitary
Cingulate
Amygdala
ldquoThe newborn may
appear helpless but
skin-to-skin contactstimulates prolactin
ensures nutritionstimulates oxytocin
ensures protectionstimulates cholecystokinin
ensures wellbeing bonding
The first hours after birth are a
CRITICAL PERIOD
mutual psycho-neuro-physiological
caregivers
Critical period concept
ldquoWindows of opportunity in early life when a childrsquos brain is exquisitely primed to receive sensory input in order to develop more advanced neural systemsrdquo
a motherrsquos brain hellip
SENSITIZATION
DOULA and KANGAROULA
DOULA protects
OXYTOCINduringlabour
KANGAROULA protects
OXYTOCINafter birth
lsquothe first 1000 minutesrsquolsquoprevious 1000 minutesrsquo
Starts to feed normally d21 2 days gavage or other
no longer suckles
If starved for 24 hours pup
at d3 will feed food from
floor
(Can be maintained by
smell and other stimuli)
Pup-in-a- cup -
separated and fed by tube
From day 2 off life
Starts to feed normally d21
15
PMA 28 40 64 1y 2y
Nilsrsquo IDEALIZED VIEW
PMA 28 40 64 1y 2y
Nilsrsquo IDEALIZED VIEW
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
Reflections for practice
Suckling and Feeding areNOT THE SAME
16
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDINGON-GOING
S S C
WIRE SUCKLING
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
ON-GOING
S S C
WIRE NEURONS
Up to 6 months milk is 74 fat
96 of this is TRIGLYCERIDE
TRIGLYCERIDE Left glycerol Right palmitic acid oleic acid alpha-linolenic acid
In phosphoglycerides glycerol molecule same
two fatty acids esterified
Phospholipids area major component of all biological membranes
Sphingomyelin particularly concentrated in BRAIN major part of MYELIN
TRIGLYCERIDE
MYELIN
Dendirification and myelinisation peaks occurat 2 and 6 monthsis maximal at one year
At one year human milk has less proteinbut MORE TRIGLYCERIDE
FATTY ACIDS ARESPECIES SPECIFIC
Up to 6 months milk is 74 fat
but after 12 months it is 107
17
ldquocherry pickrdquo
Breastfeed time years school Incomelt 1 month 109 R$ 1238gt 6 month 121 R$ 1915
Group IQ 376 points higher from breatsfeeding
BREASTFEEDINGAND BREAST MILK
INCREASE IQ
BOTTLE FEEDINGamp FORMULA
DECREASE IQ
18
Be sure the wet nurse has plenty of milk because if she lacks it she may give the babymilk of a goat or sheep or some other animalbecause the child nourished on animal milkdoes not have perfect wits like one fed on womanrsquos milk and always looks stupid and vacant and not right in the head
In separation bull Dissociated statebull No cycling chaotic pattern
48 hour baseline chaotic pattern of
activity and quiet HR amp RR
SLEEP CYCLING ndashSeparation vs contact
In SSC bull Normal cyclingbull Non-chaotic pattern
48 hour baseline chaotic pattern of
activity and quiet HR amp RRPre-KC SSC
20
modulates state organisationelicits emotional behavioursactivates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour
SMELL
Schaal 2004 115
DOUCETThe secretion of Areolar (Montgomeryrsquos) Glands from Lactating Women Elicits Selective Unconditional Responses in Neonates
ldquohellip breast chemosignalsactivate oral activity on the nipple that releases a cascade of behavioral neural neuroendocrineand endocrine processes in the newborn and the motherrdquo
Doucet 2009 116
The secretion of Areolar(Montgomeryrsquos) Glands
ldquoIn early ontogeny the sleeping brain may thusremain sentient of an organismrsquos odor environmentrdquo
Doucet 2009 117
REM
NREM
A skin-to-skin contactsession SHOULD NOT be less than one hour
or 90 minutes
SLEEPING
amp
CONTAINING
FEEDING ampHANDLINGfeed
sleep
HO
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C WIRE
TIMING
(behavior)
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C WIRE
STOMACH
21
STATE organization
Feeding frequency
SLEEP cycling
BRAIN
WIRING
How often should a neonate feed
CNS
ENS
ANS
InternalSomaticenvironment
CNS cortical subcortical(also to PNS)
ANS emotional limbic brain(incl SNS)
ANS myelinated vagus (NA)
ANS unmyelinated vagus (DMC)sub-diaphragmatic
ENS submucous plexusmyenteric plexus
122
The digestive system is endowed with its own local nervous system referred to as the enteric or intrinsic nervous system
The magnitude and complexity of the enteric nervous system is immense - it contains as many neurons as the spinal cord
ldquoOntogeny of gastric emptying patternsin the human fetusrdquo
138
24
Goldstein 1987
ldquoGrowth of the Fetal Stomach in Normal Pregnanciesrdquo
139 Goldstein 1987
Length
Transverse
AP diameter
Using +2SD
140
Formula for calculation of stomach capacity (Charles Bradshaw UCT)Assumptions the stomach can be approximated by dividing into three sections namely a ellipsoidal hemisphere an ellipsoidal cylinder and a skewed ellipsoidal cone Variables a = anteroposterior radius t = transverse radius l = length stomachRelations the height of the cone and the hemisphere are both the same as lsquoarsquo
Ellipsoid = 43 Pi r1r2r3 = 43 Pi a a t therefore volume of hemisphere = 23 Pi a a t
Cylinder = Area of base height = (Pi a t ) ( l - 2a )Skewed cone = 13 base height = 13 Pi a t aTotal volume = 23 Pi aat + Pi a t (l- 2a) + 13 Pi a t a
=Pi atl -Pi a at= Pi a t(l-a)
Goldstein and Sase dataStomach capacity at term 10 - 15 ml
BRADSHAW formula
141
Assumption 25 kg baby 33w GA
requiring 150 mlkgday = 375 ml
45 MIN CYCLES ( 32 cyclesday)
12 ML PER CYCLE = 384 ml142
Newborn stomach volume
Gastric volumes at birthCorrelated with gastric pH
gastrin and somatostatin
ldquofetus drinks 10 ml portions of amniotic fluid helliprdquo
Widstrom 1988 143
Only recent study locatedldquoAutopsyrdquo capacity was determined
in Indian post-mortem studies
100 autopsies (63 SB 37 ENND)Tied at cardia and pylorus filled withwater emptied amp measured repeatedldquohellip obliteration of the gastric curvaturesrdquoldquodue care to minimize stretch artifactsrdquo
Naveed 1992
ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo
144
25
Infants above 2500g onlyAve Range
Stillborn (n 11) 196 ml (10-35)Early death (n 9) 178 ml (10-25)All cases (n 20) 188 ml
Naveed 1992
ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo
145 146
KERNESSUK 1997 (Russian)
Postmortem in situ measures(applied Bradshaw formula)
AveNewborn (n 11) 15 ml2 months (n 11) 35 ml2-4 m (n 10) 50 ml4-6 m (n 8) 100 ml
Known references with data
Scammon and Doyle 1920
Zuccarellirsquos method stomach filled at autopsy to ldquoa pressure of between
15 and 20 centimeters of waterrdquo
Scammon 1920
ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo
147
Anatomic capacity was determined in post-mortem studies
Main data set Alliot 1905 (n 25)Scammon own cases (n 13)
30 ndash 35 ml at birth ndashalmost regardless of birth weight
Scammon 1920
ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo
148
Zangen S et al Rapid maturation of gastric relaxation in newborns
Pressures (mmHg)
Balloon inflates to
15 ml no increase
functional capacity
149
Zangen S et al Rapid maturation of gastric relaxation in newborns
Pressures (mmHg)
Balloon inflates to
15 ml no increase20 ml pressure OK
physiologicalcapacity hellip 150
26
EVIDENCE (NBn 111009)
Author Capacity NoteSase 10-15 ml Live term fetusGoldstein 10-15 ml Live term fetusWidstrom 10 mls Live newbornZangen 20 mls Live (pressure)
Naveed 20 mls Autopsy (SB)20 mls Autopsy (ENND)
Kernessuk 15 mls Autopsy (in situ)Scammon 30-35 ml Autopsy (water
ldquoFirst 1000 daysrdquo =gestation 270year one 365year two 365total 1000 days
Resilience Vulnerability
DISEASEHEALTH
EARLY CHILDHOOD DEVELOPMENT ECD
ldquoFirst 1000 daysrdquo =
Resilience Vulnerability
DISEASEHEALTH
First 1000 sec = 16 minutes = 1st hourFirst 1000 min = 166 hours = 1st day First 1000 hrs = 1st six weeks
DOULA-ldquoA WOMAN SERVING WOMENrdquo BIRTH SUPPORT COMPANION
KANGAROO CARE amp DOULA = ldquoKANGAROULArdquo
Resilience Vulnerability
DISEASEHEALTH
9
DOULA and KANGAROULA
DOULA protects
OXYTOCINduringlabour
KANGAROULA protects
OXYTOCINafter birth
lsquothe first 1000 minutesrsquolsquoprevious 1000 minutesrsquo
BIRTH
DOULA and KANGAROULA
-1000 min
BIRTH
+1000 min
DOULA and KANGAROULA
-1000 min
BIRTH
+1000 min 1000 days
OXYTOCIN Zero separation
Caesarean
Separation
Breastfeeding
Zero separation
DOULA and KANGAROULA
-1000 min
BIRTH
+1000 min 1000 days
OXYTOCIN Zero separation
CORTISOL Enemy of oxytocin Stress
White coat
Sarcasm
Hunger
thirst
SEPARATION
Bathing
Noise
Lights
LithotomyWeighing
Crowds
SEPARATION
Perfume
rdquogood nightrsquos sleeprdquo
Birth Transition ParentingLabourPregnancy
DOULA
KANGAROULA
Prematurity Attachment Parenting
MOTHERSUPPORT
NEWBORNSUPPORT
Counselling Counselling
Breastfeeding
During the first 24 hours of life newborns ingested 15 g of milk
10
Milk making NUTRITION
HypothalamusPituitaryPROLACTIN
Maternal ferocityPROTECTION
OXYTOCIN Gaze increase BONDING
OXYTOCINCingulate Suppressed
REGULATION
AmygdalaCHOLECYSTOKININ Emotion satiety
HypothalamusPituitary
Cingulate
Amygdala
ldquoThe newborn may
appear helpless but
skin-to-skin contactstimulates prolactin
ensures nutritionstimulates oxytocin
ensures protectionstimulates cholecystokinin
ensures wellbeing bonding
The first hours after birth are a
CRITICAL PERIOD
mutual psycho-neuro-physiological
caregivers
Critical period concept
ldquoWindows of opportunity in early life when a childrsquos brain is exquisitely primed to receive sensory input in order to develop more advanced neural systemsrdquo
a motherrsquos brain hellip
SENSITIZATION
DOULA and KANGAROULA
DOULA protects
OXYTOCINduringlabour
KANGAROULA protects
OXYTOCINafter birth
lsquothe first 1000 minutesrsquolsquoprevious 1000 minutesrsquo
Starts to feed normally d21 2 days gavage or other
no longer suckles
If starved for 24 hours pup
at d3 will feed food from
floor
(Can be maintained by
smell and other stimuli)
Pup-in-a- cup -
separated and fed by tube
From day 2 off life
Starts to feed normally d21
15
PMA 28 40 64 1y 2y
Nilsrsquo IDEALIZED VIEW
PMA 28 40 64 1y 2y
Nilsrsquo IDEALIZED VIEW
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
Reflections for practice
Suckling and Feeding areNOT THE SAME
16
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDINGON-GOING
S S C
WIRE SUCKLING
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
ON-GOING
S S C
WIRE NEURONS
Up to 6 months milk is 74 fat
96 of this is TRIGLYCERIDE
TRIGLYCERIDE Left glycerol Right palmitic acid oleic acid alpha-linolenic acid
In phosphoglycerides glycerol molecule same
two fatty acids esterified
Phospholipids area major component of all biological membranes
Sphingomyelin particularly concentrated in BRAIN major part of MYELIN
TRIGLYCERIDE
MYELIN
Dendirification and myelinisation peaks occurat 2 and 6 monthsis maximal at one year
At one year human milk has less proteinbut MORE TRIGLYCERIDE
FATTY ACIDS ARESPECIES SPECIFIC
Up to 6 months milk is 74 fat
but after 12 months it is 107
17
ldquocherry pickrdquo
Breastfeed time years school Incomelt 1 month 109 R$ 1238gt 6 month 121 R$ 1915
Group IQ 376 points higher from breatsfeeding
BREASTFEEDINGAND BREAST MILK
INCREASE IQ
BOTTLE FEEDINGamp FORMULA
DECREASE IQ
18
Be sure the wet nurse has plenty of milk because if she lacks it she may give the babymilk of a goat or sheep or some other animalbecause the child nourished on animal milkdoes not have perfect wits like one fed on womanrsquos milk and always looks stupid and vacant and not right in the head
In separation bull Dissociated statebull No cycling chaotic pattern
48 hour baseline chaotic pattern of
activity and quiet HR amp RR
SLEEP CYCLING ndashSeparation vs contact
In SSC bull Normal cyclingbull Non-chaotic pattern
48 hour baseline chaotic pattern of
activity and quiet HR amp RRPre-KC SSC
20
modulates state organisationelicits emotional behavioursactivates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour
SMELL
Schaal 2004 115
DOUCETThe secretion of Areolar (Montgomeryrsquos) Glands from Lactating Women Elicits Selective Unconditional Responses in Neonates
ldquohellip breast chemosignalsactivate oral activity on the nipple that releases a cascade of behavioral neural neuroendocrineand endocrine processes in the newborn and the motherrdquo
Doucet 2009 116
The secretion of Areolar(Montgomeryrsquos) Glands
ldquoIn early ontogeny the sleeping brain may thusremain sentient of an organismrsquos odor environmentrdquo
Doucet 2009 117
REM
NREM
A skin-to-skin contactsession SHOULD NOT be less than one hour
or 90 minutes
SLEEPING
amp
CONTAINING
FEEDING ampHANDLINGfeed
sleep
HO
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C WIRE
TIMING
(behavior)
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C WIRE
STOMACH
21
STATE organization
Feeding frequency
SLEEP cycling
BRAIN
WIRING
How often should a neonate feed
CNS
ENS
ANS
InternalSomaticenvironment
CNS cortical subcortical(also to PNS)
ANS emotional limbic brain(incl SNS)
ANS myelinated vagus (NA)
ANS unmyelinated vagus (DMC)sub-diaphragmatic
ENS submucous plexusmyenteric plexus
122
The digestive system is endowed with its own local nervous system referred to as the enteric or intrinsic nervous system
The magnitude and complexity of the enteric nervous system is immense - it contains as many neurons as the spinal cord
ldquoOntogeny of gastric emptying patternsin the human fetusrdquo
138
24
Goldstein 1987
ldquoGrowth of the Fetal Stomach in Normal Pregnanciesrdquo
139 Goldstein 1987
Length
Transverse
AP diameter
Using +2SD
140
Formula for calculation of stomach capacity (Charles Bradshaw UCT)Assumptions the stomach can be approximated by dividing into three sections namely a ellipsoidal hemisphere an ellipsoidal cylinder and a skewed ellipsoidal cone Variables a = anteroposterior radius t = transverse radius l = length stomachRelations the height of the cone and the hemisphere are both the same as lsquoarsquo
Ellipsoid = 43 Pi r1r2r3 = 43 Pi a a t therefore volume of hemisphere = 23 Pi a a t
Cylinder = Area of base height = (Pi a t ) ( l - 2a )Skewed cone = 13 base height = 13 Pi a t aTotal volume = 23 Pi aat + Pi a t (l- 2a) + 13 Pi a t a
=Pi atl -Pi a at= Pi a t(l-a)
Goldstein and Sase dataStomach capacity at term 10 - 15 ml
BRADSHAW formula
141
Assumption 25 kg baby 33w GA
requiring 150 mlkgday = 375 ml
45 MIN CYCLES ( 32 cyclesday)
12 ML PER CYCLE = 384 ml142
Newborn stomach volume
Gastric volumes at birthCorrelated with gastric pH
gastrin and somatostatin
ldquofetus drinks 10 ml portions of amniotic fluid helliprdquo
Widstrom 1988 143
Only recent study locatedldquoAutopsyrdquo capacity was determined
in Indian post-mortem studies
100 autopsies (63 SB 37 ENND)Tied at cardia and pylorus filled withwater emptied amp measured repeatedldquohellip obliteration of the gastric curvaturesrdquoldquodue care to minimize stretch artifactsrdquo
Naveed 1992
ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo
144
25
Infants above 2500g onlyAve Range
Stillborn (n 11) 196 ml (10-35)Early death (n 9) 178 ml (10-25)All cases (n 20) 188 ml
Naveed 1992
ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo
145 146
KERNESSUK 1997 (Russian)
Postmortem in situ measures(applied Bradshaw formula)
AveNewborn (n 11) 15 ml2 months (n 11) 35 ml2-4 m (n 10) 50 ml4-6 m (n 8) 100 ml
Known references with data
Scammon and Doyle 1920
Zuccarellirsquos method stomach filled at autopsy to ldquoa pressure of between
15 and 20 centimeters of waterrdquo
Scammon 1920
ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo
147
Anatomic capacity was determined in post-mortem studies
Main data set Alliot 1905 (n 25)Scammon own cases (n 13)
30 ndash 35 ml at birth ndashalmost regardless of birth weight
Scammon 1920
ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo
148
Zangen S et al Rapid maturation of gastric relaxation in newborns
Pressures (mmHg)
Balloon inflates to
15 ml no increase
functional capacity
149
Zangen S et al Rapid maturation of gastric relaxation in newborns
Pressures (mmHg)
Balloon inflates to
15 ml no increase20 ml pressure OK
physiologicalcapacity hellip 150
26
EVIDENCE (NBn 111009)
Author Capacity NoteSase 10-15 ml Live term fetusGoldstein 10-15 ml Live term fetusWidstrom 10 mls Live newbornZangen 20 mls Live (pressure)
Naveed 20 mls Autopsy (SB)20 mls Autopsy (ENND)
Kernessuk 15 mls Autopsy (in situ)Scammon 30-35 ml Autopsy (water
ldquoFirst 1000 daysrdquo =gestation 270year one 365year two 365total 1000 days
Resilience Vulnerability
DISEASEHEALTH
EARLY CHILDHOOD DEVELOPMENT ECD
ldquoFirst 1000 daysrdquo =
Resilience Vulnerability
DISEASEHEALTH
First 1000 sec = 16 minutes = 1st hourFirst 1000 min = 166 hours = 1st day First 1000 hrs = 1st six weeks
DOULA-ldquoA WOMAN SERVING WOMENrdquo BIRTH SUPPORT COMPANION
KANGAROO CARE amp DOULA = ldquoKANGAROULArdquo
Resilience Vulnerability
DISEASEHEALTH
9
DOULA and KANGAROULA
DOULA protects
OXYTOCINduringlabour
KANGAROULA protects
OXYTOCINafter birth
lsquothe first 1000 minutesrsquolsquoprevious 1000 minutesrsquo
BIRTH
DOULA and KANGAROULA
-1000 min
BIRTH
+1000 min
DOULA and KANGAROULA
-1000 min
BIRTH
+1000 min 1000 days
OXYTOCIN Zero separation
Caesarean
Separation
Breastfeeding
Zero separation
DOULA and KANGAROULA
-1000 min
BIRTH
+1000 min 1000 days
OXYTOCIN Zero separation
CORTISOL Enemy of oxytocin Stress
White coat
Sarcasm
Hunger
thirst
SEPARATION
Bathing
Noise
Lights
LithotomyWeighing
Crowds
SEPARATION
Perfume
rdquogood nightrsquos sleeprdquo
Birth Transition ParentingLabourPregnancy
DOULA
KANGAROULA
Prematurity Attachment Parenting
MOTHERSUPPORT
NEWBORNSUPPORT
Counselling Counselling
Breastfeeding
During the first 24 hours of life newborns ingested 15 g of milk
10
Milk making NUTRITION
HypothalamusPituitaryPROLACTIN
Maternal ferocityPROTECTION
OXYTOCIN Gaze increase BONDING
OXYTOCINCingulate Suppressed
REGULATION
AmygdalaCHOLECYSTOKININ Emotion satiety
HypothalamusPituitary
Cingulate
Amygdala
ldquoThe newborn may
appear helpless but
skin-to-skin contactstimulates prolactin
ensures nutritionstimulates oxytocin
ensures protectionstimulates cholecystokinin
ensures wellbeing bonding
The first hours after birth are a
CRITICAL PERIOD
mutual psycho-neuro-physiological
caregivers
Critical period concept
ldquoWindows of opportunity in early life when a childrsquos brain is exquisitely primed to receive sensory input in order to develop more advanced neural systemsrdquo
a motherrsquos brain hellip
SENSITIZATION
DOULA and KANGAROULA
DOULA protects
OXYTOCINduringlabour
KANGAROULA protects
OXYTOCINafter birth
lsquothe first 1000 minutesrsquolsquoprevious 1000 minutesrsquo
Starts to feed normally d21 2 days gavage or other
no longer suckles
If starved for 24 hours pup
at d3 will feed food from
floor
(Can be maintained by
smell and other stimuli)
Pup-in-a- cup -
separated and fed by tube
From day 2 off life
Starts to feed normally d21
15
PMA 28 40 64 1y 2y
Nilsrsquo IDEALIZED VIEW
PMA 28 40 64 1y 2y
Nilsrsquo IDEALIZED VIEW
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
Reflections for practice
Suckling and Feeding areNOT THE SAME
16
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDINGON-GOING
S S C
WIRE SUCKLING
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
ON-GOING
S S C
WIRE NEURONS
Up to 6 months milk is 74 fat
96 of this is TRIGLYCERIDE
TRIGLYCERIDE Left glycerol Right palmitic acid oleic acid alpha-linolenic acid
In phosphoglycerides glycerol molecule same
two fatty acids esterified
Phospholipids area major component of all biological membranes
Sphingomyelin particularly concentrated in BRAIN major part of MYELIN
TRIGLYCERIDE
MYELIN
Dendirification and myelinisation peaks occurat 2 and 6 monthsis maximal at one year
At one year human milk has less proteinbut MORE TRIGLYCERIDE
FATTY ACIDS ARESPECIES SPECIFIC
Up to 6 months milk is 74 fat
but after 12 months it is 107
17
ldquocherry pickrdquo
Breastfeed time years school Incomelt 1 month 109 R$ 1238gt 6 month 121 R$ 1915
Group IQ 376 points higher from breatsfeeding
BREASTFEEDINGAND BREAST MILK
INCREASE IQ
BOTTLE FEEDINGamp FORMULA
DECREASE IQ
18
Be sure the wet nurse has plenty of milk because if she lacks it she may give the babymilk of a goat or sheep or some other animalbecause the child nourished on animal milkdoes not have perfect wits like one fed on womanrsquos milk and always looks stupid and vacant and not right in the head
In separation bull Dissociated statebull No cycling chaotic pattern
48 hour baseline chaotic pattern of
activity and quiet HR amp RR
SLEEP CYCLING ndashSeparation vs contact
In SSC bull Normal cyclingbull Non-chaotic pattern
48 hour baseline chaotic pattern of
activity and quiet HR amp RRPre-KC SSC
20
modulates state organisationelicits emotional behavioursactivates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour
SMELL
Schaal 2004 115
DOUCETThe secretion of Areolar (Montgomeryrsquos) Glands from Lactating Women Elicits Selective Unconditional Responses in Neonates
ldquohellip breast chemosignalsactivate oral activity on the nipple that releases a cascade of behavioral neural neuroendocrineand endocrine processes in the newborn and the motherrdquo
Doucet 2009 116
The secretion of Areolar(Montgomeryrsquos) Glands
ldquoIn early ontogeny the sleeping brain may thusremain sentient of an organismrsquos odor environmentrdquo
Doucet 2009 117
REM
NREM
A skin-to-skin contactsession SHOULD NOT be less than one hour
or 90 minutes
SLEEPING
amp
CONTAINING
FEEDING ampHANDLINGfeed
sleep
HO
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C WIRE
TIMING
(behavior)
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C WIRE
STOMACH
21
STATE organization
Feeding frequency
SLEEP cycling
BRAIN
WIRING
How often should a neonate feed
CNS
ENS
ANS
InternalSomaticenvironment
CNS cortical subcortical(also to PNS)
ANS emotional limbic brain(incl SNS)
ANS myelinated vagus (NA)
ANS unmyelinated vagus (DMC)sub-diaphragmatic
ENS submucous plexusmyenteric plexus
122
The digestive system is endowed with its own local nervous system referred to as the enteric or intrinsic nervous system
The magnitude and complexity of the enteric nervous system is immense - it contains as many neurons as the spinal cord
ldquoOntogeny of gastric emptying patternsin the human fetusrdquo
138
24
Goldstein 1987
ldquoGrowth of the Fetal Stomach in Normal Pregnanciesrdquo
139 Goldstein 1987
Length
Transverse
AP diameter
Using +2SD
140
Formula for calculation of stomach capacity (Charles Bradshaw UCT)Assumptions the stomach can be approximated by dividing into three sections namely a ellipsoidal hemisphere an ellipsoidal cylinder and a skewed ellipsoidal cone Variables a = anteroposterior radius t = transverse radius l = length stomachRelations the height of the cone and the hemisphere are both the same as lsquoarsquo
Ellipsoid = 43 Pi r1r2r3 = 43 Pi a a t therefore volume of hemisphere = 23 Pi a a t
Cylinder = Area of base height = (Pi a t ) ( l - 2a )Skewed cone = 13 base height = 13 Pi a t aTotal volume = 23 Pi aat + Pi a t (l- 2a) + 13 Pi a t a
=Pi atl -Pi a at= Pi a t(l-a)
Goldstein and Sase dataStomach capacity at term 10 - 15 ml
BRADSHAW formula
141
Assumption 25 kg baby 33w GA
requiring 150 mlkgday = 375 ml
45 MIN CYCLES ( 32 cyclesday)
12 ML PER CYCLE = 384 ml142
Newborn stomach volume
Gastric volumes at birthCorrelated with gastric pH
gastrin and somatostatin
ldquofetus drinks 10 ml portions of amniotic fluid helliprdquo
Widstrom 1988 143
Only recent study locatedldquoAutopsyrdquo capacity was determined
in Indian post-mortem studies
100 autopsies (63 SB 37 ENND)Tied at cardia and pylorus filled withwater emptied amp measured repeatedldquohellip obliteration of the gastric curvaturesrdquoldquodue care to minimize stretch artifactsrdquo
Naveed 1992
ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo
144
25
Infants above 2500g onlyAve Range
Stillborn (n 11) 196 ml (10-35)Early death (n 9) 178 ml (10-25)All cases (n 20) 188 ml
Naveed 1992
ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo
145 146
KERNESSUK 1997 (Russian)
Postmortem in situ measures(applied Bradshaw formula)
AveNewborn (n 11) 15 ml2 months (n 11) 35 ml2-4 m (n 10) 50 ml4-6 m (n 8) 100 ml
Known references with data
Scammon and Doyle 1920
Zuccarellirsquos method stomach filled at autopsy to ldquoa pressure of between
15 and 20 centimeters of waterrdquo
Scammon 1920
ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo
147
Anatomic capacity was determined in post-mortem studies
Main data set Alliot 1905 (n 25)Scammon own cases (n 13)
30 ndash 35 ml at birth ndashalmost regardless of birth weight
Scammon 1920
ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo
148
Zangen S et al Rapid maturation of gastric relaxation in newborns
Pressures (mmHg)
Balloon inflates to
15 ml no increase
functional capacity
149
Zangen S et al Rapid maturation of gastric relaxation in newborns
Pressures (mmHg)
Balloon inflates to
15 ml no increase20 ml pressure OK
physiologicalcapacity hellip 150
26
EVIDENCE (NBn 111009)
Author Capacity NoteSase 10-15 ml Live term fetusGoldstein 10-15 ml Live term fetusWidstrom 10 mls Live newbornZangen 20 mls Live (pressure)
Naveed 20 mls Autopsy (SB)20 mls Autopsy (ENND)
Kernessuk 15 mls Autopsy (in situ)Scammon 30-35 ml Autopsy (water
ldquoFirst 1000 daysrdquo =gestation 270year one 365year two 365total 1000 days
Resilience Vulnerability
DISEASEHEALTH
EARLY CHILDHOOD DEVELOPMENT ECD
ldquoFirst 1000 daysrdquo =
Resilience Vulnerability
DISEASEHEALTH
First 1000 sec = 16 minutes = 1st hourFirst 1000 min = 166 hours = 1st day First 1000 hrs = 1st six weeks
DOULA-ldquoA WOMAN SERVING WOMENrdquo BIRTH SUPPORT COMPANION
KANGAROO CARE amp DOULA = ldquoKANGAROULArdquo
Resilience Vulnerability
DISEASEHEALTH
9
DOULA and KANGAROULA
DOULA protects
OXYTOCINduringlabour
KANGAROULA protects
OXYTOCINafter birth
lsquothe first 1000 minutesrsquolsquoprevious 1000 minutesrsquo
BIRTH
DOULA and KANGAROULA
-1000 min
BIRTH
+1000 min
DOULA and KANGAROULA
-1000 min
BIRTH
+1000 min 1000 days
OXYTOCIN Zero separation
Caesarean
Separation
Breastfeeding
Zero separation
DOULA and KANGAROULA
-1000 min
BIRTH
+1000 min 1000 days
OXYTOCIN Zero separation
CORTISOL Enemy of oxytocin Stress
White coat
Sarcasm
Hunger
thirst
SEPARATION
Bathing
Noise
Lights
LithotomyWeighing
Crowds
SEPARATION
Perfume
rdquogood nightrsquos sleeprdquo
Birth Transition ParentingLabourPregnancy
DOULA
KANGAROULA
Prematurity Attachment Parenting
MOTHERSUPPORT
NEWBORNSUPPORT
Counselling Counselling
Breastfeeding
During the first 24 hours of life newborns ingested 15 g of milk
10
Milk making NUTRITION
HypothalamusPituitaryPROLACTIN
Maternal ferocityPROTECTION
OXYTOCIN Gaze increase BONDING
OXYTOCINCingulate Suppressed
REGULATION
AmygdalaCHOLECYSTOKININ Emotion satiety
HypothalamusPituitary
Cingulate
Amygdala
ldquoThe newborn may
appear helpless but
skin-to-skin contactstimulates prolactin
ensures nutritionstimulates oxytocin
ensures protectionstimulates cholecystokinin
ensures wellbeing bonding
The first hours after birth are a
CRITICAL PERIOD
mutual psycho-neuro-physiological
caregivers
Critical period concept
ldquoWindows of opportunity in early life when a childrsquos brain is exquisitely primed to receive sensory input in order to develop more advanced neural systemsrdquo
a motherrsquos brain hellip
SENSITIZATION
DOULA and KANGAROULA
DOULA protects
OXYTOCINduringlabour
KANGAROULA protects
OXYTOCINafter birth
lsquothe first 1000 minutesrsquolsquoprevious 1000 minutesrsquo
Starts to feed normally d21 2 days gavage or other
no longer suckles
If starved for 24 hours pup
at d3 will feed food from
floor
(Can be maintained by
smell and other stimuli)
Pup-in-a- cup -
separated and fed by tube
From day 2 off life
Starts to feed normally d21
15
PMA 28 40 64 1y 2y
Nilsrsquo IDEALIZED VIEW
PMA 28 40 64 1y 2y
Nilsrsquo IDEALIZED VIEW
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
Reflections for practice
Suckling and Feeding areNOT THE SAME
16
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDINGON-GOING
S S C
WIRE SUCKLING
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
ON-GOING
S S C
WIRE NEURONS
Up to 6 months milk is 74 fat
96 of this is TRIGLYCERIDE
TRIGLYCERIDE Left glycerol Right palmitic acid oleic acid alpha-linolenic acid
In phosphoglycerides glycerol molecule same
two fatty acids esterified
Phospholipids area major component of all biological membranes
Sphingomyelin particularly concentrated in BRAIN major part of MYELIN
TRIGLYCERIDE
MYELIN
Dendirification and myelinisation peaks occurat 2 and 6 monthsis maximal at one year
At one year human milk has less proteinbut MORE TRIGLYCERIDE
FATTY ACIDS ARESPECIES SPECIFIC
Up to 6 months milk is 74 fat
but after 12 months it is 107
17
ldquocherry pickrdquo
Breastfeed time years school Incomelt 1 month 109 R$ 1238gt 6 month 121 R$ 1915
Group IQ 376 points higher from breatsfeeding
BREASTFEEDINGAND BREAST MILK
INCREASE IQ
BOTTLE FEEDINGamp FORMULA
DECREASE IQ
18
Be sure the wet nurse has plenty of milk because if she lacks it she may give the babymilk of a goat or sheep or some other animalbecause the child nourished on animal milkdoes not have perfect wits like one fed on womanrsquos milk and always looks stupid and vacant and not right in the head
In separation bull Dissociated statebull No cycling chaotic pattern
48 hour baseline chaotic pattern of
activity and quiet HR amp RR
SLEEP CYCLING ndashSeparation vs contact
In SSC bull Normal cyclingbull Non-chaotic pattern
48 hour baseline chaotic pattern of
activity and quiet HR amp RRPre-KC SSC
20
modulates state organisationelicits emotional behavioursactivates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour
SMELL
Schaal 2004 115
DOUCETThe secretion of Areolar (Montgomeryrsquos) Glands from Lactating Women Elicits Selective Unconditional Responses in Neonates
ldquohellip breast chemosignalsactivate oral activity on the nipple that releases a cascade of behavioral neural neuroendocrineand endocrine processes in the newborn and the motherrdquo
Doucet 2009 116
The secretion of Areolar(Montgomeryrsquos) Glands
ldquoIn early ontogeny the sleeping brain may thusremain sentient of an organismrsquos odor environmentrdquo
Doucet 2009 117
REM
NREM
A skin-to-skin contactsession SHOULD NOT be less than one hour
or 90 minutes
SLEEPING
amp
CONTAINING
FEEDING ampHANDLINGfeed
sleep
HO
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C WIRE
TIMING
(behavior)
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C WIRE
STOMACH
21
STATE organization
Feeding frequency
SLEEP cycling
BRAIN
WIRING
How often should a neonate feed
CNS
ENS
ANS
InternalSomaticenvironment
CNS cortical subcortical(also to PNS)
ANS emotional limbic brain(incl SNS)
ANS myelinated vagus (NA)
ANS unmyelinated vagus (DMC)sub-diaphragmatic
ENS submucous plexusmyenteric plexus
122
The digestive system is endowed with its own local nervous system referred to as the enteric or intrinsic nervous system
The magnitude and complexity of the enteric nervous system is immense - it contains as many neurons as the spinal cord
ldquoOntogeny of gastric emptying patternsin the human fetusrdquo
138
24
Goldstein 1987
ldquoGrowth of the Fetal Stomach in Normal Pregnanciesrdquo
139 Goldstein 1987
Length
Transverse
AP diameter
Using +2SD
140
Formula for calculation of stomach capacity (Charles Bradshaw UCT)Assumptions the stomach can be approximated by dividing into three sections namely a ellipsoidal hemisphere an ellipsoidal cylinder and a skewed ellipsoidal cone Variables a = anteroposterior radius t = transverse radius l = length stomachRelations the height of the cone and the hemisphere are both the same as lsquoarsquo
Ellipsoid = 43 Pi r1r2r3 = 43 Pi a a t therefore volume of hemisphere = 23 Pi a a t
Cylinder = Area of base height = (Pi a t ) ( l - 2a )Skewed cone = 13 base height = 13 Pi a t aTotal volume = 23 Pi aat + Pi a t (l- 2a) + 13 Pi a t a
=Pi atl -Pi a at= Pi a t(l-a)
Goldstein and Sase dataStomach capacity at term 10 - 15 ml
BRADSHAW formula
141
Assumption 25 kg baby 33w GA
requiring 150 mlkgday = 375 ml
45 MIN CYCLES ( 32 cyclesday)
12 ML PER CYCLE = 384 ml142
Newborn stomach volume
Gastric volumes at birthCorrelated with gastric pH
gastrin and somatostatin
ldquofetus drinks 10 ml portions of amniotic fluid helliprdquo
Widstrom 1988 143
Only recent study locatedldquoAutopsyrdquo capacity was determined
in Indian post-mortem studies
100 autopsies (63 SB 37 ENND)Tied at cardia and pylorus filled withwater emptied amp measured repeatedldquohellip obliteration of the gastric curvaturesrdquoldquodue care to minimize stretch artifactsrdquo
Naveed 1992
ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo
144
25
Infants above 2500g onlyAve Range
Stillborn (n 11) 196 ml (10-35)Early death (n 9) 178 ml (10-25)All cases (n 20) 188 ml
Naveed 1992
ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo
145 146
KERNESSUK 1997 (Russian)
Postmortem in situ measures(applied Bradshaw formula)
AveNewborn (n 11) 15 ml2 months (n 11) 35 ml2-4 m (n 10) 50 ml4-6 m (n 8) 100 ml
Known references with data
Scammon and Doyle 1920
Zuccarellirsquos method stomach filled at autopsy to ldquoa pressure of between
15 and 20 centimeters of waterrdquo
Scammon 1920
ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo
147
Anatomic capacity was determined in post-mortem studies
Main data set Alliot 1905 (n 25)Scammon own cases (n 13)
30 ndash 35 ml at birth ndashalmost regardless of birth weight
Scammon 1920
ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo
148
Zangen S et al Rapid maturation of gastric relaxation in newborns
Pressures (mmHg)
Balloon inflates to
15 ml no increase
functional capacity
149
Zangen S et al Rapid maturation of gastric relaxation in newborns
Pressures (mmHg)
Balloon inflates to
15 ml no increase20 ml pressure OK
physiologicalcapacity hellip 150
26
EVIDENCE (NBn 111009)
Author Capacity NoteSase 10-15 ml Live term fetusGoldstein 10-15 ml Live term fetusWidstrom 10 mls Live newbornZangen 20 mls Live (pressure)
Naveed 20 mls Autopsy (SB)20 mls Autopsy (ENND)
Kernessuk 15 mls Autopsy (in situ)Scammon 30-35 ml Autopsy (water
ldquoFirst 1000 daysrdquo =gestation 270year one 365year two 365total 1000 days
Resilience Vulnerability
DISEASEHEALTH
EARLY CHILDHOOD DEVELOPMENT ECD
ldquoFirst 1000 daysrdquo =
Resilience Vulnerability
DISEASEHEALTH
First 1000 sec = 16 minutes = 1st hourFirst 1000 min = 166 hours = 1st day First 1000 hrs = 1st six weeks
DOULA-ldquoA WOMAN SERVING WOMENrdquo BIRTH SUPPORT COMPANION
KANGAROO CARE amp DOULA = ldquoKANGAROULArdquo
Resilience Vulnerability
DISEASEHEALTH
9
DOULA and KANGAROULA
DOULA protects
OXYTOCINduringlabour
KANGAROULA protects
OXYTOCINafter birth
lsquothe first 1000 minutesrsquolsquoprevious 1000 minutesrsquo
BIRTH
DOULA and KANGAROULA
-1000 min
BIRTH
+1000 min
DOULA and KANGAROULA
-1000 min
BIRTH
+1000 min 1000 days
OXYTOCIN Zero separation
Caesarean
Separation
Breastfeeding
Zero separation
DOULA and KANGAROULA
-1000 min
BIRTH
+1000 min 1000 days
OXYTOCIN Zero separation
CORTISOL Enemy of oxytocin Stress
White coat
Sarcasm
Hunger
thirst
SEPARATION
Bathing
Noise
Lights
LithotomyWeighing
Crowds
SEPARATION
Perfume
rdquogood nightrsquos sleeprdquo
Birth Transition ParentingLabourPregnancy
DOULA
KANGAROULA
Prematurity Attachment Parenting
MOTHERSUPPORT
NEWBORNSUPPORT
Counselling Counselling
Breastfeeding
During the first 24 hours of life newborns ingested 15 g of milk
10
Milk making NUTRITION
HypothalamusPituitaryPROLACTIN
Maternal ferocityPROTECTION
OXYTOCIN Gaze increase BONDING
OXYTOCINCingulate Suppressed
REGULATION
AmygdalaCHOLECYSTOKININ Emotion satiety
HypothalamusPituitary
Cingulate
Amygdala
ldquoThe newborn may
appear helpless but
skin-to-skin contactstimulates prolactin
ensures nutritionstimulates oxytocin
ensures protectionstimulates cholecystokinin
ensures wellbeing bonding
The first hours after birth are a
CRITICAL PERIOD
mutual psycho-neuro-physiological
caregivers
Critical period concept
ldquoWindows of opportunity in early life when a childrsquos brain is exquisitely primed to receive sensory input in order to develop more advanced neural systemsrdquo
a motherrsquos brain hellip
SENSITIZATION
DOULA and KANGAROULA
DOULA protects
OXYTOCINduringlabour
KANGAROULA protects
OXYTOCINafter birth
lsquothe first 1000 minutesrsquolsquoprevious 1000 minutesrsquo
Starts to feed normally d21 2 days gavage or other
no longer suckles
If starved for 24 hours pup
at d3 will feed food from
floor
(Can be maintained by
smell and other stimuli)
Pup-in-a- cup -
separated and fed by tube
From day 2 off life
Starts to feed normally d21
15
PMA 28 40 64 1y 2y
Nilsrsquo IDEALIZED VIEW
PMA 28 40 64 1y 2y
Nilsrsquo IDEALIZED VIEW
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
Reflections for practice
Suckling and Feeding areNOT THE SAME
16
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDINGON-GOING
S S C
WIRE SUCKLING
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
ON-GOING
S S C
WIRE NEURONS
Up to 6 months milk is 74 fat
96 of this is TRIGLYCERIDE
TRIGLYCERIDE Left glycerol Right palmitic acid oleic acid alpha-linolenic acid
In phosphoglycerides glycerol molecule same
two fatty acids esterified
Phospholipids area major component of all biological membranes
Sphingomyelin particularly concentrated in BRAIN major part of MYELIN
TRIGLYCERIDE
MYELIN
Dendirification and myelinisation peaks occurat 2 and 6 monthsis maximal at one year
At one year human milk has less proteinbut MORE TRIGLYCERIDE
FATTY ACIDS ARESPECIES SPECIFIC
Up to 6 months milk is 74 fat
but after 12 months it is 107
17
ldquocherry pickrdquo
Breastfeed time years school Incomelt 1 month 109 R$ 1238gt 6 month 121 R$ 1915
Group IQ 376 points higher from breatsfeeding
BREASTFEEDINGAND BREAST MILK
INCREASE IQ
BOTTLE FEEDINGamp FORMULA
DECREASE IQ
18
Be sure the wet nurse has plenty of milk because if she lacks it she may give the babymilk of a goat or sheep or some other animalbecause the child nourished on animal milkdoes not have perfect wits like one fed on womanrsquos milk and always looks stupid and vacant and not right in the head
In separation bull Dissociated statebull No cycling chaotic pattern
48 hour baseline chaotic pattern of
activity and quiet HR amp RR
SLEEP CYCLING ndashSeparation vs contact
In SSC bull Normal cyclingbull Non-chaotic pattern
48 hour baseline chaotic pattern of
activity and quiet HR amp RRPre-KC SSC
20
modulates state organisationelicits emotional behavioursactivates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour
SMELL
Schaal 2004 115
DOUCETThe secretion of Areolar (Montgomeryrsquos) Glands from Lactating Women Elicits Selective Unconditional Responses in Neonates
ldquohellip breast chemosignalsactivate oral activity on the nipple that releases a cascade of behavioral neural neuroendocrineand endocrine processes in the newborn and the motherrdquo
Doucet 2009 116
The secretion of Areolar(Montgomeryrsquos) Glands
ldquoIn early ontogeny the sleeping brain may thusremain sentient of an organismrsquos odor environmentrdquo
Doucet 2009 117
REM
NREM
A skin-to-skin contactsession SHOULD NOT be less than one hour
or 90 minutes
SLEEPING
amp
CONTAINING
FEEDING ampHANDLINGfeed
sleep
HO
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C WIRE
TIMING
(behavior)
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C WIRE
STOMACH
21
STATE organization
Feeding frequency
SLEEP cycling
BRAIN
WIRING
How often should a neonate feed
CNS
ENS
ANS
InternalSomaticenvironment
CNS cortical subcortical(also to PNS)
ANS emotional limbic brain(incl SNS)
ANS myelinated vagus (NA)
ANS unmyelinated vagus (DMC)sub-diaphragmatic
ENS submucous plexusmyenteric plexus
122
The digestive system is endowed with its own local nervous system referred to as the enteric or intrinsic nervous system
The magnitude and complexity of the enteric nervous system is immense - it contains as many neurons as the spinal cord
ldquoOntogeny of gastric emptying patternsin the human fetusrdquo
138
24
Goldstein 1987
ldquoGrowth of the Fetal Stomach in Normal Pregnanciesrdquo
139 Goldstein 1987
Length
Transverse
AP diameter
Using +2SD
140
Formula for calculation of stomach capacity (Charles Bradshaw UCT)Assumptions the stomach can be approximated by dividing into three sections namely a ellipsoidal hemisphere an ellipsoidal cylinder and a skewed ellipsoidal cone Variables a = anteroposterior radius t = transverse radius l = length stomachRelations the height of the cone and the hemisphere are both the same as lsquoarsquo
Ellipsoid = 43 Pi r1r2r3 = 43 Pi a a t therefore volume of hemisphere = 23 Pi a a t
Cylinder = Area of base height = (Pi a t ) ( l - 2a )Skewed cone = 13 base height = 13 Pi a t aTotal volume = 23 Pi aat + Pi a t (l- 2a) + 13 Pi a t a
=Pi atl -Pi a at= Pi a t(l-a)
Goldstein and Sase dataStomach capacity at term 10 - 15 ml
BRADSHAW formula
141
Assumption 25 kg baby 33w GA
requiring 150 mlkgday = 375 ml
45 MIN CYCLES ( 32 cyclesday)
12 ML PER CYCLE = 384 ml142
Newborn stomach volume
Gastric volumes at birthCorrelated with gastric pH
gastrin and somatostatin
ldquofetus drinks 10 ml portions of amniotic fluid helliprdquo
Widstrom 1988 143
Only recent study locatedldquoAutopsyrdquo capacity was determined
in Indian post-mortem studies
100 autopsies (63 SB 37 ENND)Tied at cardia and pylorus filled withwater emptied amp measured repeatedldquohellip obliteration of the gastric curvaturesrdquoldquodue care to minimize stretch artifactsrdquo
Naveed 1992
ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo
144
25
Infants above 2500g onlyAve Range
Stillborn (n 11) 196 ml (10-35)Early death (n 9) 178 ml (10-25)All cases (n 20) 188 ml
Naveed 1992
ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo
145 146
KERNESSUK 1997 (Russian)
Postmortem in situ measures(applied Bradshaw formula)
AveNewborn (n 11) 15 ml2 months (n 11) 35 ml2-4 m (n 10) 50 ml4-6 m (n 8) 100 ml
Known references with data
Scammon and Doyle 1920
Zuccarellirsquos method stomach filled at autopsy to ldquoa pressure of between
15 and 20 centimeters of waterrdquo
Scammon 1920
ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo
147
Anatomic capacity was determined in post-mortem studies
Main data set Alliot 1905 (n 25)Scammon own cases (n 13)
30 ndash 35 ml at birth ndashalmost regardless of birth weight
Scammon 1920
ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo
148
Zangen S et al Rapid maturation of gastric relaxation in newborns
Pressures (mmHg)
Balloon inflates to
15 ml no increase
functional capacity
149
Zangen S et al Rapid maturation of gastric relaxation in newborns
Pressures (mmHg)
Balloon inflates to
15 ml no increase20 ml pressure OK
physiologicalcapacity hellip 150
26
EVIDENCE (NBn 111009)
Author Capacity NoteSase 10-15 ml Live term fetusGoldstein 10-15 ml Live term fetusWidstrom 10 mls Live newbornZangen 20 mls Live (pressure)
Naveed 20 mls Autopsy (SB)20 mls Autopsy (ENND)
Kernessuk 15 mls Autopsy (in situ)Scammon 30-35 ml Autopsy (water
ldquoSmall and frequent feeds according to the sleep cyclerdquo
The ldquonicherdquo (occupation) of a neonate (Alberts)
BOND FEED
SLEEP SLEEP
PLAY FEED
201
Gastric overfilling syndrome
Proposed Management 202
Proposed Management
Babies should be fedEVERY TIME THEY WAKE
Stanley Graven 2006
REMNR1NR2NR3SWS
AS (20 mins) QS (40 mins)
A normal sleep cycle is ONE hourHow often should neonates feed
203
Proposed Management
All babies should be fedat least once an hour 204
35
Proposed Management
All babies should be fedat least once an hour
205
The first Milk Ejection Reflex (MER)
elicited in lt 2 minutesworks quicklyswallowed 1 minute
Feeding time (max)3 minutes
Repeat every 1 hour
Prime 2007
The ldquonormalrdquo or usual and common breastfeed
takes 15 minutesdiscomfort afterburping time 5 minutes
Feeding time 20 min
Repeat every 3 hours
Prime 2007
3 minute 20ml feeds x 24d = 72 minutes
20 minute 60ml feeds x 8d = 160 minutes
SMALL AND FREQUENT FEEDS ARE EFFICIENT
FEWER NURSES NEEDED
The calculated dailyrequirement for a 3kgbaby can be given without increase inpressure MINIMAL RISK
PARENTS CAN DOSAFELY
20 mls x 24 feeds= 480mls day
Zangen 2001 209
All babies should be fedat least once an hour
210
36
Infant feeding frequencyProposal based on available evidence and neuroscience
ldquoSmall and frequent feeds
adjusted to the sleep cyclerdquo
211
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C
STATE organization
Feeding frequency
SLEEP cycling
BRAIN
WIRING
How often should a neonate feeda neonate sleep
Infantsleep cycles
begin to block on diurnalrhythms
Mother-infant synchrony
hellip at 12 weeks
(circadian)
START at 3 months
Can be ldquoadult-likerdquo
at 6 months
Thomas 2014
STATE organization
Feeding frequency
SLEEP cycling
PLAY FEED
216
SLEEP SLEEP
SLEEP SLEEPPLAY
FEED
Infant sleep cycling and synchronicity with maternal sleep ensure development
Infantsleep cycles
begin to block on diurnalrhythms
37
BOND SUCKLE SLEEP SLEEP PLAY
FEED
217
SLEEP SLEEP SLEEP SLEEPPLAY
FEED
Infant sleep cycling and synchronicity with maternal sleep ensure development
modulates state organisationelicits emotional behaviours
activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour
SMELL(amp SKIN)
Schaal 2004 218
modulates state organisationelicits emotional behaviours
activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour
SMELL(amp SKIN)rdquoSLEEP-FEED CYCLINGrdquo
Schaal 2004 219
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C
WIRE
BRAIN
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C
BRAIN
WIRING
NEUROSCIENCE
The DNAEverything else
EVOLUTIONARYBIOLOGY
The Brain
EPIGENETICS
The PlaceENVIRONMENT
EXPERIENCEFITNESS ADAPTATION
ldquoScientific foundationrdquo hellip a synthesis
ZERO
SEPARATION
38
wwwninobirthorgwwwskintoskincontactcom
THE NEUROSCIENCE OFSKIN-TO-SKIN CONTACT
AND BREASTFEEDING
ARE THE SAME
SUMMARY SKIN-TO-SKIN
(Regulation)
SLEEP(Brain)
FEEDING(Stomach)
LOVE ( ldquomindrdquo )
REMNR1NR2NR3NR4
ACQUISITION CONSOLIDATION MEMORYFORMATION
poly-sensory input transfer information P wavesshort-term memory ldquoSNRrdquo strong signals returns infostored cortex amygdala to neocortex
hippocampus organizedAwake and REM NREM stage 4 REM
BRAIN WIRING
Stanley Graven 2006
PLAY
SLEEP
FEEDHOLDYOURPREM
httpswwwfacebookcomninobirth
39
Nelson Mandela
hellip in describing themeasure of a nation
he has argued that
ldquoThere can be no keener revelation of a societyrsquos soul than the way in which it treats its childrenrdquo
9
DOULA and KANGAROULA
DOULA protects
OXYTOCINduringlabour
KANGAROULA protects
OXYTOCINafter birth
lsquothe first 1000 minutesrsquolsquoprevious 1000 minutesrsquo
BIRTH
DOULA and KANGAROULA
-1000 min
BIRTH
+1000 min
DOULA and KANGAROULA
-1000 min
BIRTH
+1000 min 1000 days
OXYTOCIN Zero separation
Caesarean
Separation
Breastfeeding
Zero separation
DOULA and KANGAROULA
-1000 min
BIRTH
+1000 min 1000 days
OXYTOCIN Zero separation
CORTISOL Enemy of oxytocin Stress
White coat
Sarcasm
Hunger
thirst
SEPARATION
Bathing
Noise
Lights
LithotomyWeighing
Crowds
SEPARATION
Perfume
rdquogood nightrsquos sleeprdquo
Birth Transition ParentingLabourPregnancy
DOULA
KANGAROULA
Prematurity Attachment Parenting
MOTHERSUPPORT
NEWBORNSUPPORT
Counselling Counselling
Breastfeeding
During the first 24 hours of life newborns ingested 15 g of milk
10
Milk making NUTRITION
HypothalamusPituitaryPROLACTIN
Maternal ferocityPROTECTION
OXYTOCIN Gaze increase BONDING
OXYTOCINCingulate Suppressed
REGULATION
AmygdalaCHOLECYSTOKININ Emotion satiety
HypothalamusPituitary
Cingulate
Amygdala
ldquoThe newborn may
appear helpless but
skin-to-skin contactstimulates prolactin
ensures nutritionstimulates oxytocin
ensures protectionstimulates cholecystokinin
ensures wellbeing bonding
The first hours after birth are a
CRITICAL PERIOD
mutual psycho-neuro-physiological
caregivers
Critical period concept
ldquoWindows of opportunity in early life when a childrsquos brain is exquisitely primed to receive sensory input in order to develop more advanced neural systemsrdquo
a motherrsquos brain hellip
SENSITIZATION
DOULA and KANGAROULA
DOULA protects
OXYTOCINduringlabour
KANGAROULA protects
OXYTOCINafter birth
lsquothe first 1000 minutesrsquolsquoprevious 1000 minutesrsquo
Starts to feed normally d21 2 days gavage or other
no longer suckles
If starved for 24 hours pup
at d3 will feed food from
floor
(Can be maintained by
smell and other stimuli)
Pup-in-a- cup -
separated and fed by tube
From day 2 off life
Starts to feed normally d21
15
PMA 28 40 64 1y 2y
Nilsrsquo IDEALIZED VIEW
PMA 28 40 64 1y 2y
Nilsrsquo IDEALIZED VIEW
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
Reflections for practice
Suckling and Feeding areNOT THE SAME
16
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDINGON-GOING
S S C
WIRE SUCKLING
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
ON-GOING
S S C
WIRE NEURONS
Up to 6 months milk is 74 fat
96 of this is TRIGLYCERIDE
TRIGLYCERIDE Left glycerol Right palmitic acid oleic acid alpha-linolenic acid
In phosphoglycerides glycerol molecule same
two fatty acids esterified
Phospholipids area major component of all biological membranes
Sphingomyelin particularly concentrated in BRAIN major part of MYELIN
TRIGLYCERIDE
MYELIN
Dendirification and myelinisation peaks occurat 2 and 6 monthsis maximal at one year
At one year human milk has less proteinbut MORE TRIGLYCERIDE
FATTY ACIDS ARESPECIES SPECIFIC
Up to 6 months milk is 74 fat
but after 12 months it is 107
17
ldquocherry pickrdquo
Breastfeed time years school Incomelt 1 month 109 R$ 1238gt 6 month 121 R$ 1915
Group IQ 376 points higher from breatsfeeding
BREASTFEEDINGAND BREAST MILK
INCREASE IQ
BOTTLE FEEDINGamp FORMULA
DECREASE IQ
18
Be sure the wet nurse has plenty of milk because if she lacks it she may give the babymilk of a goat or sheep or some other animalbecause the child nourished on animal milkdoes not have perfect wits like one fed on womanrsquos milk and always looks stupid and vacant and not right in the head
In separation bull Dissociated statebull No cycling chaotic pattern
48 hour baseline chaotic pattern of
activity and quiet HR amp RR
SLEEP CYCLING ndashSeparation vs contact
In SSC bull Normal cyclingbull Non-chaotic pattern
48 hour baseline chaotic pattern of
activity and quiet HR amp RRPre-KC SSC
20
modulates state organisationelicits emotional behavioursactivates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour
SMELL
Schaal 2004 115
DOUCETThe secretion of Areolar (Montgomeryrsquos) Glands from Lactating Women Elicits Selective Unconditional Responses in Neonates
ldquohellip breast chemosignalsactivate oral activity on the nipple that releases a cascade of behavioral neural neuroendocrineand endocrine processes in the newborn and the motherrdquo
Doucet 2009 116
The secretion of Areolar(Montgomeryrsquos) Glands
ldquoIn early ontogeny the sleeping brain may thusremain sentient of an organismrsquos odor environmentrdquo
Doucet 2009 117
REM
NREM
A skin-to-skin contactsession SHOULD NOT be less than one hour
or 90 minutes
SLEEPING
amp
CONTAINING
FEEDING ampHANDLINGfeed
sleep
HO
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C WIRE
TIMING
(behavior)
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C WIRE
STOMACH
21
STATE organization
Feeding frequency
SLEEP cycling
BRAIN
WIRING
How often should a neonate feed
CNS
ENS
ANS
InternalSomaticenvironment
CNS cortical subcortical(also to PNS)
ANS emotional limbic brain(incl SNS)
ANS myelinated vagus (NA)
ANS unmyelinated vagus (DMC)sub-diaphragmatic
ENS submucous plexusmyenteric plexus
122
The digestive system is endowed with its own local nervous system referred to as the enteric or intrinsic nervous system
The magnitude and complexity of the enteric nervous system is immense - it contains as many neurons as the spinal cord
ldquoOntogeny of gastric emptying patternsin the human fetusrdquo
138
24
Goldstein 1987
ldquoGrowth of the Fetal Stomach in Normal Pregnanciesrdquo
139 Goldstein 1987
Length
Transverse
AP diameter
Using +2SD
140
Formula for calculation of stomach capacity (Charles Bradshaw UCT)Assumptions the stomach can be approximated by dividing into three sections namely a ellipsoidal hemisphere an ellipsoidal cylinder and a skewed ellipsoidal cone Variables a = anteroposterior radius t = transverse radius l = length stomachRelations the height of the cone and the hemisphere are both the same as lsquoarsquo
Ellipsoid = 43 Pi r1r2r3 = 43 Pi a a t therefore volume of hemisphere = 23 Pi a a t
Cylinder = Area of base height = (Pi a t ) ( l - 2a )Skewed cone = 13 base height = 13 Pi a t aTotal volume = 23 Pi aat + Pi a t (l- 2a) + 13 Pi a t a
=Pi atl -Pi a at= Pi a t(l-a)
Goldstein and Sase dataStomach capacity at term 10 - 15 ml
BRADSHAW formula
141
Assumption 25 kg baby 33w GA
requiring 150 mlkgday = 375 ml
45 MIN CYCLES ( 32 cyclesday)
12 ML PER CYCLE = 384 ml142
Newborn stomach volume
Gastric volumes at birthCorrelated with gastric pH
gastrin and somatostatin
ldquofetus drinks 10 ml portions of amniotic fluid helliprdquo
Widstrom 1988 143
Only recent study locatedldquoAutopsyrdquo capacity was determined
in Indian post-mortem studies
100 autopsies (63 SB 37 ENND)Tied at cardia and pylorus filled withwater emptied amp measured repeatedldquohellip obliteration of the gastric curvaturesrdquoldquodue care to minimize stretch artifactsrdquo
Naveed 1992
ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo
144
25
Infants above 2500g onlyAve Range
Stillborn (n 11) 196 ml (10-35)Early death (n 9) 178 ml (10-25)All cases (n 20) 188 ml
Naveed 1992
ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo
145 146
KERNESSUK 1997 (Russian)
Postmortem in situ measures(applied Bradshaw formula)
AveNewborn (n 11) 15 ml2 months (n 11) 35 ml2-4 m (n 10) 50 ml4-6 m (n 8) 100 ml
Known references with data
Scammon and Doyle 1920
Zuccarellirsquos method stomach filled at autopsy to ldquoa pressure of between
15 and 20 centimeters of waterrdquo
Scammon 1920
ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo
147
Anatomic capacity was determined in post-mortem studies
Main data set Alliot 1905 (n 25)Scammon own cases (n 13)
30 ndash 35 ml at birth ndashalmost regardless of birth weight
Scammon 1920
ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo
148
Zangen S et al Rapid maturation of gastric relaxation in newborns
Pressures (mmHg)
Balloon inflates to
15 ml no increase
functional capacity
149
Zangen S et al Rapid maturation of gastric relaxation in newborns
Pressures (mmHg)
Balloon inflates to
15 ml no increase20 ml pressure OK
physiologicalcapacity hellip 150
26
EVIDENCE (NBn 111009)
Author Capacity NoteSase 10-15 ml Live term fetusGoldstein 10-15 ml Live term fetusWidstrom 10 mls Live newbornZangen 20 mls Live (pressure)
Naveed 20 mls Autopsy (SB)20 mls Autopsy (ENND)
Kernessuk 15 mls Autopsy (in situ)Scammon 30-35 ml Autopsy (water
ldquoSmall and frequent feeds according to the sleep cyclerdquo
The ldquonicherdquo (occupation) of a neonate (Alberts)
BOND FEED
SLEEP SLEEP
PLAY FEED
201
Gastric overfilling syndrome
Proposed Management 202
Proposed Management
Babies should be fedEVERY TIME THEY WAKE
Stanley Graven 2006
REMNR1NR2NR3SWS
AS (20 mins) QS (40 mins)
A normal sleep cycle is ONE hourHow often should neonates feed
203
Proposed Management
All babies should be fedat least once an hour 204
35
Proposed Management
All babies should be fedat least once an hour
205
The first Milk Ejection Reflex (MER)
elicited in lt 2 minutesworks quicklyswallowed 1 minute
Feeding time (max)3 minutes
Repeat every 1 hour
Prime 2007
The ldquonormalrdquo or usual and common breastfeed
takes 15 minutesdiscomfort afterburping time 5 minutes
Feeding time 20 min
Repeat every 3 hours
Prime 2007
3 minute 20ml feeds x 24d = 72 minutes
20 minute 60ml feeds x 8d = 160 minutes
SMALL AND FREQUENT FEEDS ARE EFFICIENT
FEWER NURSES NEEDED
The calculated dailyrequirement for a 3kgbaby can be given without increase inpressure MINIMAL RISK
PARENTS CAN DOSAFELY
20 mls x 24 feeds= 480mls day
Zangen 2001 209
All babies should be fedat least once an hour
210
36
Infant feeding frequencyProposal based on available evidence and neuroscience
ldquoSmall and frequent feeds
adjusted to the sleep cyclerdquo
211
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C
STATE organization
Feeding frequency
SLEEP cycling
BRAIN
WIRING
How often should a neonate feeda neonate sleep
Infantsleep cycles
begin to block on diurnalrhythms
Mother-infant synchrony
hellip at 12 weeks
(circadian)
START at 3 months
Can be ldquoadult-likerdquo
at 6 months
Thomas 2014
STATE organization
Feeding frequency
SLEEP cycling
PLAY FEED
216
SLEEP SLEEP
SLEEP SLEEPPLAY
FEED
Infant sleep cycling and synchronicity with maternal sleep ensure development
Infantsleep cycles
begin to block on diurnalrhythms
37
BOND SUCKLE SLEEP SLEEP PLAY
FEED
217
SLEEP SLEEP SLEEP SLEEPPLAY
FEED
Infant sleep cycling and synchronicity with maternal sleep ensure development
modulates state organisationelicits emotional behaviours
activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour
SMELL(amp SKIN)
Schaal 2004 218
modulates state organisationelicits emotional behaviours
activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour
SMELL(amp SKIN)rdquoSLEEP-FEED CYCLINGrdquo
Schaal 2004 219
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C
WIRE
BRAIN
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C
BRAIN
WIRING
NEUROSCIENCE
The DNAEverything else
EVOLUTIONARYBIOLOGY
The Brain
EPIGENETICS
The PlaceENVIRONMENT
EXPERIENCEFITNESS ADAPTATION
ldquoScientific foundationrdquo hellip a synthesis
ZERO
SEPARATION
38
wwwninobirthorgwwwskintoskincontactcom
THE NEUROSCIENCE OFSKIN-TO-SKIN CONTACT
AND BREASTFEEDING
ARE THE SAME
SUMMARY SKIN-TO-SKIN
(Regulation)
SLEEP(Brain)
FEEDING(Stomach)
LOVE ( ldquomindrdquo )
REMNR1NR2NR3NR4
ACQUISITION CONSOLIDATION MEMORYFORMATION
poly-sensory input transfer information P wavesshort-term memory ldquoSNRrdquo strong signals returns infostored cortex amygdala to neocortex
hippocampus organizedAwake and REM NREM stage 4 REM
BRAIN WIRING
Stanley Graven 2006
PLAY
SLEEP
FEEDHOLDYOURPREM
httpswwwfacebookcomninobirth
39
Nelson Mandela
hellip in describing themeasure of a nation
he has argued that
ldquoThere can be no keener revelation of a societyrsquos soul than the way in which it treats its childrenrdquo
10
Milk making NUTRITION
HypothalamusPituitaryPROLACTIN
Maternal ferocityPROTECTION
OXYTOCIN Gaze increase BONDING
OXYTOCINCingulate Suppressed
REGULATION
AmygdalaCHOLECYSTOKININ Emotion satiety
HypothalamusPituitary
Cingulate
Amygdala
ldquoThe newborn may
appear helpless but
skin-to-skin contactstimulates prolactin
ensures nutritionstimulates oxytocin
ensures protectionstimulates cholecystokinin
ensures wellbeing bonding
The first hours after birth are a
CRITICAL PERIOD
mutual psycho-neuro-physiological
caregivers
Critical period concept
ldquoWindows of opportunity in early life when a childrsquos brain is exquisitely primed to receive sensory input in order to develop more advanced neural systemsrdquo
a motherrsquos brain hellip
SENSITIZATION
DOULA and KANGAROULA
DOULA protects
OXYTOCINduringlabour
KANGAROULA protects
OXYTOCINafter birth
lsquothe first 1000 minutesrsquolsquoprevious 1000 minutesrsquo
Starts to feed normally d21 2 days gavage or other
no longer suckles
If starved for 24 hours pup
at d3 will feed food from
floor
(Can be maintained by
smell and other stimuli)
Pup-in-a- cup -
separated and fed by tube
From day 2 off life
Starts to feed normally d21
15
PMA 28 40 64 1y 2y
Nilsrsquo IDEALIZED VIEW
PMA 28 40 64 1y 2y
Nilsrsquo IDEALIZED VIEW
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
Reflections for practice
Suckling and Feeding areNOT THE SAME
16
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDINGON-GOING
S S C
WIRE SUCKLING
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
ON-GOING
S S C
WIRE NEURONS
Up to 6 months milk is 74 fat
96 of this is TRIGLYCERIDE
TRIGLYCERIDE Left glycerol Right palmitic acid oleic acid alpha-linolenic acid
In phosphoglycerides glycerol molecule same
two fatty acids esterified
Phospholipids area major component of all biological membranes
Sphingomyelin particularly concentrated in BRAIN major part of MYELIN
TRIGLYCERIDE
MYELIN
Dendirification and myelinisation peaks occurat 2 and 6 monthsis maximal at one year
At one year human milk has less proteinbut MORE TRIGLYCERIDE
FATTY ACIDS ARESPECIES SPECIFIC
Up to 6 months milk is 74 fat
but after 12 months it is 107
17
ldquocherry pickrdquo
Breastfeed time years school Incomelt 1 month 109 R$ 1238gt 6 month 121 R$ 1915
Group IQ 376 points higher from breatsfeeding
BREASTFEEDINGAND BREAST MILK
INCREASE IQ
BOTTLE FEEDINGamp FORMULA
DECREASE IQ
18
Be sure the wet nurse has plenty of milk because if she lacks it she may give the babymilk of a goat or sheep or some other animalbecause the child nourished on animal milkdoes not have perfect wits like one fed on womanrsquos milk and always looks stupid and vacant and not right in the head
In separation bull Dissociated statebull No cycling chaotic pattern
48 hour baseline chaotic pattern of
activity and quiet HR amp RR
SLEEP CYCLING ndashSeparation vs contact
In SSC bull Normal cyclingbull Non-chaotic pattern
48 hour baseline chaotic pattern of
activity and quiet HR amp RRPre-KC SSC
20
modulates state organisationelicits emotional behavioursactivates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour
SMELL
Schaal 2004 115
DOUCETThe secretion of Areolar (Montgomeryrsquos) Glands from Lactating Women Elicits Selective Unconditional Responses in Neonates
ldquohellip breast chemosignalsactivate oral activity on the nipple that releases a cascade of behavioral neural neuroendocrineand endocrine processes in the newborn and the motherrdquo
Doucet 2009 116
The secretion of Areolar(Montgomeryrsquos) Glands
ldquoIn early ontogeny the sleeping brain may thusremain sentient of an organismrsquos odor environmentrdquo
Doucet 2009 117
REM
NREM
A skin-to-skin contactsession SHOULD NOT be less than one hour
or 90 minutes
SLEEPING
amp
CONTAINING
FEEDING ampHANDLINGfeed
sleep
HO
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C WIRE
TIMING
(behavior)
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C WIRE
STOMACH
21
STATE organization
Feeding frequency
SLEEP cycling
BRAIN
WIRING
How often should a neonate feed
CNS
ENS
ANS
InternalSomaticenvironment
CNS cortical subcortical(also to PNS)
ANS emotional limbic brain(incl SNS)
ANS myelinated vagus (NA)
ANS unmyelinated vagus (DMC)sub-diaphragmatic
ENS submucous plexusmyenteric plexus
122
The digestive system is endowed with its own local nervous system referred to as the enteric or intrinsic nervous system
The magnitude and complexity of the enteric nervous system is immense - it contains as many neurons as the spinal cord
ldquoOntogeny of gastric emptying patternsin the human fetusrdquo
138
24
Goldstein 1987
ldquoGrowth of the Fetal Stomach in Normal Pregnanciesrdquo
139 Goldstein 1987
Length
Transverse
AP diameter
Using +2SD
140
Formula for calculation of stomach capacity (Charles Bradshaw UCT)Assumptions the stomach can be approximated by dividing into three sections namely a ellipsoidal hemisphere an ellipsoidal cylinder and a skewed ellipsoidal cone Variables a = anteroposterior radius t = transverse radius l = length stomachRelations the height of the cone and the hemisphere are both the same as lsquoarsquo
Ellipsoid = 43 Pi r1r2r3 = 43 Pi a a t therefore volume of hemisphere = 23 Pi a a t
Cylinder = Area of base height = (Pi a t ) ( l - 2a )Skewed cone = 13 base height = 13 Pi a t aTotal volume = 23 Pi aat + Pi a t (l- 2a) + 13 Pi a t a
=Pi atl -Pi a at= Pi a t(l-a)
Goldstein and Sase dataStomach capacity at term 10 - 15 ml
BRADSHAW formula
141
Assumption 25 kg baby 33w GA
requiring 150 mlkgday = 375 ml
45 MIN CYCLES ( 32 cyclesday)
12 ML PER CYCLE = 384 ml142
Newborn stomach volume
Gastric volumes at birthCorrelated with gastric pH
gastrin and somatostatin
ldquofetus drinks 10 ml portions of amniotic fluid helliprdquo
Widstrom 1988 143
Only recent study locatedldquoAutopsyrdquo capacity was determined
in Indian post-mortem studies
100 autopsies (63 SB 37 ENND)Tied at cardia and pylorus filled withwater emptied amp measured repeatedldquohellip obliteration of the gastric curvaturesrdquoldquodue care to minimize stretch artifactsrdquo
Naveed 1992
ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo
144
25
Infants above 2500g onlyAve Range
Stillborn (n 11) 196 ml (10-35)Early death (n 9) 178 ml (10-25)All cases (n 20) 188 ml
Naveed 1992
ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo
145 146
KERNESSUK 1997 (Russian)
Postmortem in situ measures(applied Bradshaw formula)
AveNewborn (n 11) 15 ml2 months (n 11) 35 ml2-4 m (n 10) 50 ml4-6 m (n 8) 100 ml
Known references with data
Scammon and Doyle 1920
Zuccarellirsquos method stomach filled at autopsy to ldquoa pressure of between
15 and 20 centimeters of waterrdquo
Scammon 1920
ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo
147
Anatomic capacity was determined in post-mortem studies
Main data set Alliot 1905 (n 25)Scammon own cases (n 13)
30 ndash 35 ml at birth ndashalmost regardless of birth weight
Scammon 1920
ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo
148
Zangen S et al Rapid maturation of gastric relaxation in newborns
Pressures (mmHg)
Balloon inflates to
15 ml no increase
functional capacity
149
Zangen S et al Rapid maturation of gastric relaxation in newborns
Pressures (mmHg)
Balloon inflates to
15 ml no increase20 ml pressure OK
physiologicalcapacity hellip 150
26
EVIDENCE (NBn 111009)
Author Capacity NoteSase 10-15 ml Live term fetusGoldstein 10-15 ml Live term fetusWidstrom 10 mls Live newbornZangen 20 mls Live (pressure)
Naveed 20 mls Autopsy (SB)20 mls Autopsy (ENND)
Kernessuk 15 mls Autopsy (in situ)Scammon 30-35 ml Autopsy (water
Starts to feed normally d21 2 days gavage or other
no longer suckles
If starved for 24 hours pup
at d3 will feed food from
floor
(Can be maintained by
smell and other stimuli)
Pup-in-a- cup -
separated and fed by tube
From day 2 off life
Starts to feed normally d21
15
PMA 28 40 64 1y 2y
Nilsrsquo IDEALIZED VIEW
PMA 28 40 64 1y 2y
Nilsrsquo IDEALIZED VIEW
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
Reflections for practice
Suckling and Feeding areNOT THE SAME
16
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDINGON-GOING
S S C
WIRE SUCKLING
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
ON-GOING
S S C
WIRE NEURONS
Up to 6 months milk is 74 fat
96 of this is TRIGLYCERIDE
TRIGLYCERIDE Left glycerol Right palmitic acid oleic acid alpha-linolenic acid
In phosphoglycerides glycerol molecule same
two fatty acids esterified
Phospholipids area major component of all biological membranes
Sphingomyelin particularly concentrated in BRAIN major part of MYELIN
TRIGLYCERIDE
MYELIN
Dendirification and myelinisation peaks occurat 2 and 6 monthsis maximal at one year
At one year human milk has less proteinbut MORE TRIGLYCERIDE
FATTY ACIDS ARESPECIES SPECIFIC
Up to 6 months milk is 74 fat
but after 12 months it is 107
17
ldquocherry pickrdquo
Breastfeed time years school Incomelt 1 month 109 R$ 1238gt 6 month 121 R$ 1915
Group IQ 376 points higher from breatsfeeding
BREASTFEEDINGAND BREAST MILK
INCREASE IQ
BOTTLE FEEDINGamp FORMULA
DECREASE IQ
18
Be sure the wet nurse has plenty of milk because if she lacks it she may give the babymilk of a goat or sheep or some other animalbecause the child nourished on animal milkdoes not have perfect wits like one fed on womanrsquos milk and always looks stupid and vacant and not right in the head
In separation bull Dissociated statebull No cycling chaotic pattern
48 hour baseline chaotic pattern of
activity and quiet HR amp RR
SLEEP CYCLING ndashSeparation vs contact
In SSC bull Normal cyclingbull Non-chaotic pattern
48 hour baseline chaotic pattern of
activity and quiet HR amp RRPre-KC SSC
20
modulates state organisationelicits emotional behavioursactivates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour
SMELL
Schaal 2004 115
DOUCETThe secretion of Areolar (Montgomeryrsquos) Glands from Lactating Women Elicits Selective Unconditional Responses in Neonates
ldquohellip breast chemosignalsactivate oral activity on the nipple that releases a cascade of behavioral neural neuroendocrineand endocrine processes in the newborn and the motherrdquo
Doucet 2009 116
The secretion of Areolar(Montgomeryrsquos) Glands
ldquoIn early ontogeny the sleeping brain may thusremain sentient of an organismrsquos odor environmentrdquo
Doucet 2009 117
REM
NREM
A skin-to-skin contactsession SHOULD NOT be less than one hour
or 90 minutes
SLEEPING
amp
CONTAINING
FEEDING ampHANDLINGfeed
sleep
HO
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C WIRE
TIMING
(behavior)
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C WIRE
STOMACH
21
STATE organization
Feeding frequency
SLEEP cycling
BRAIN
WIRING
How often should a neonate feed
CNS
ENS
ANS
InternalSomaticenvironment
CNS cortical subcortical(also to PNS)
ANS emotional limbic brain(incl SNS)
ANS myelinated vagus (NA)
ANS unmyelinated vagus (DMC)sub-diaphragmatic
ENS submucous plexusmyenteric plexus
122
The digestive system is endowed with its own local nervous system referred to as the enteric or intrinsic nervous system
The magnitude and complexity of the enteric nervous system is immense - it contains as many neurons as the spinal cord
ldquoOntogeny of gastric emptying patternsin the human fetusrdquo
138
24
Goldstein 1987
ldquoGrowth of the Fetal Stomach in Normal Pregnanciesrdquo
139 Goldstein 1987
Length
Transverse
AP diameter
Using +2SD
140
Formula for calculation of stomach capacity (Charles Bradshaw UCT)Assumptions the stomach can be approximated by dividing into three sections namely a ellipsoidal hemisphere an ellipsoidal cylinder and a skewed ellipsoidal cone Variables a = anteroposterior radius t = transverse radius l = length stomachRelations the height of the cone and the hemisphere are both the same as lsquoarsquo
Ellipsoid = 43 Pi r1r2r3 = 43 Pi a a t therefore volume of hemisphere = 23 Pi a a t
Cylinder = Area of base height = (Pi a t ) ( l - 2a )Skewed cone = 13 base height = 13 Pi a t aTotal volume = 23 Pi aat + Pi a t (l- 2a) + 13 Pi a t a
=Pi atl -Pi a at= Pi a t(l-a)
Goldstein and Sase dataStomach capacity at term 10 - 15 ml
BRADSHAW formula
141
Assumption 25 kg baby 33w GA
requiring 150 mlkgday = 375 ml
45 MIN CYCLES ( 32 cyclesday)
12 ML PER CYCLE = 384 ml142
Newborn stomach volume
Gastric volumes at birthCorrelated with gastric pH
gastrin and somatostatin
ldquofetus drinks 10 ml portions of amniotic fluid helliprdquo
Widstrom 1988 143
Only recent study locatedldquoAutopsyrdquo capacity was determined
in Indian post-mortem studies
100 autopsies (63 SB 37 ENND)Tied at cardia and pylorus filled withwater emptied amp measured repeatedldquohellip obliteration of the gastric curvaturesrdquoldquodue care to minimize stretch artifactsrdquo
Naveed 1992
ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo
144
25
Infants above 2500g onlyAve Range
Stillborn (n 11) 196 ml (10-35)Early death (n 9) 178 ml (10-25)All cases (n 20) 188 ml
Naveed 1992
ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo
145 146
KERNESSUK 1997 (Russian)
Postmortem in situ measures(applied Bradshaw formula)
AveNewborn (n 11) 15 ml2 months (n 11) 35 ml2-4 m (n 10) 50 ml4-6 m (n 8) 100 ml
Known references with data
Scammon and Doyle 1920
Zuccarellirsquos method stomach filled at autopsy to ldquoa pressure of between
15 and 20 centimeters of waterrdquo
Scammon 1920
ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo
147
Anatomic capacity was determined in post-mortem studies
Main data set Alliot 1905 (n 25)Scammon own cases (n 13)
30 ndash 35 ml at birth ndashalmost regardless of birth weight
Scammon 1920
ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo
148
Zangen S et al Rapid maturation of gastric relaxation in newborns
Pressures (mmHg)
Balloon inflates to
15 ml no increase
functional capacity
149
Zangen S et al Rapid maturation of gastric relaxation in newborns
Pressures (mmHg)
Balloon inflates to
15 ml no increase20 ml pressure OK
physiologicalcapacity hellip 150
26
EVIDENCE (NBn 111009)
Author Capacity NoteSase 10-15 ml Live term fetusGoldstein 10-15 ml Live term fetusWidstrom 10 mls Live newbornZangen 20 mls Live (pressure)
Naveed 20 mls Autopsy (SB)20 mls Autopsy (ENND)
Kernessuk 15 mls Autopsy (in situ)Scammon 30-35 ml Autopsy (water
Starts to feed normally d21 2 days gavage or other
no longer suckles
If starved for 24 hours pup
at d3 will feed food from
floor
(Can be maintained by
smell and other stimuli)
Pup-in-a- cup -
separated and fed by tube
From day 2 off life
Starts to feed normally d21
15
PMA 28 40 64 1y 2y
Nilsrsquo IDEALIZED VIEW
PMA 28 40 64 1y 2y
Nilsrsquo IDEALIZED VIEW
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
Reflections for practice
Suckling and Feeding areNOT THE SAME
16
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDINGON-GOING
S S C
WIRE SUCKLING
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
ON-GOING
S S C
WIRE NEURONS
Up to 6 months milk is 74 fat
96 of this is TRIGLYCERIDE
TRIGLYCERIDE Left glycerol Right palmitic acid oleic acid alpha-linolenic acid
In phosphoglycerides glycerol molecule same
two fatty acids esterified
Phospholipids area major component of all biological membranes
Sphingomyelin particularly concentrated in BRAIN major part of MYELIN
TRIGLYCERIDE
MYELIN
Dendirification and myelinisation peaks occurat 2 and 6 monthsis maximal at one year
At one year human milk has less proteinbut MORE TRIGLYCERIDE
FATTY ACIDS ARESPECIES SPECIFIC
Up to 6 months milk is 74 fat
but after 12 months it is 107
17
ldquocherry pickrdquo
Breastfeed time years school Incomelt 1 month 109 R$ 1238gt 6 month 121 R$ 1915
Group IQ 376 points higher from breatsfeeding
BREASTFEEDINGAND BREAST MILK
INCREASE IQ
BOTTLE FEEDINGamp FORMULA
DECREASE IQ
18
Be sure the wet nurse has plenty of milk because if she lacks it she may give the babymilk of a goat or sheep or some other animalbecause the child nourished on animal milkdoes not have perfect wits like one fed on womanrsquos milk and always looks stupid and vacant and not right in the head
In separation bull Dissociated statebull No cycling chaotic pattern
48 hour baseline chaotic pattern of
activity and quiet HR amp RR
SLEEP CYCLING ndashSeparation vs contact
In SSC bull Normal cyclingbull Non-chaotic pattern
48 hour baseline chaotic pattern of
activity and quiet HR amp RRPre-KC SSC
20
modulates state organisationelicits emotional behavioursactivates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour
SMELL
Schaal 2004 115
DOUCETThe secretion of Areolar (Montgomeryrsquos) Glands from Lactating Women Elicits Selective Unconditional Responses in Neonates
ldquohellip breast chemosignalsactivate oral activity on the nipple that releases a cascade of behavioral neural neuroendocrineand endocrine processes in the newborn and the motherrdquo
Doucet 2009 116
The secretion of Areolar(Montgomeryrsquos) Glands
ldquoIn early ontogeny the sleeping brain may thusremain sentient of an organismrsquos odor environmentrdquo
Doucet 2009 117
REM
NREM
A skin-to-skin contactsession SHOULD NOT be less than one hour
or 90 minutes
SLEEPING
amp
CONTAINING
FEEDING ampHANDLINGfeed
sleep
HO
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C WIRE
TIMING
(behavior)
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C WIRE
STOMACH
21
STATE organization
Feeding frequency
SLEEP cycling
BRAIN
WIRING
How often should a neonate feed
CNS
ENS
ANS
InternalSomaticenvironment
CNS cortical subcortical(also to PNS)
ANS emotional limbic brain(incl SNS)
ANS myelinated vagus (NA)
ANS unmyelinated vagus (DMC)sub-diaphragmatic
ENS submucous plexusmyenteric plexus
122
The digestive system is endowed with its own local nervous system referred to as the enteric or intrinsic nervous system
The magnitude and complexity of the enteric nervous system is immense - it contains as many neurons as the spinal cord
ldquoOntogeny of gastric emptying patternsin the human fetusrdquo
138
24
Goldstein 1987
ldquoGrowth of the Fetal Stomach in Normal Pregnanciesrdquo
139 Goldstein 1987
Length
Transverse
AP diameter
Using +2SD
140
Formula for calculation of stomach capacity (Charles Bradshaw UCT)Assumptions the stomach can be approximated by dividing into three sections namely a ellipsoidal hemisphere an ellipsoidal cylinder and a skewed ellipsoidal cone Variables a = anteroposterior radius t = transverse radius l = length stomachRelations the height of the cone and the hemisphere are both the same as lsquoarsquo
Ellipsoid = 43 Pi r1r2r3 = 43 Pi a a t therefore volume of hemisphere = 23 Pi a a t
Cylinder = Area of base height = (Pi a t ) ( l - 2a )Skewed cone = 13 base height = 13 Pi a t aTotal volume = 23 Pi aat + Pi a t (l- 2a) + 13 Pi a t a
=Pi atl -Pi a at= Pi a t(l-a)
Goldstein and Sase dataStomach capacity at term 10 - 15 ml
BRADSHAW formula
141
Assumption 25 kg baby 33w GA
requiring 150 mlkgday = 375 ml
45 MIN CYCLES ( 32 cyclesday)
12 ML PER CYCLE = 384 ml142
Newborn stomach volume
Gastric volumes at birthCorrelated with gastric pH
gastrin and somatostatin
ldquofetus drinks 10 ml portions of amniotic fluid helliprdquo
Widstrom 1988 143
Only recent study locatedldquoAutopsyrdquo capacity was determined
in Indian post-mortem studies
100 autopsies (63 SB 37 ENND)Tied at cardia and pylorus filled withwater emptied amp measured repeatedldquohellip obliteration of the gastric curvaturesrdquoldquodue care to minimize stretch artifactsrdquo
Naveed 1992
ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo
144
25
Infants above 2500g onlyAve Range
Stillborn (n 11) 196 ml (10-35)Early death (n 9) 178 ml (10-25)All cases (n 20) 188 ml
Naveed 1992
ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo
145 146
KERNESSUK 1997 (Russian)
Postmortem in situ measures(applied Bradshaw formula)
AveNewborn (n 11) 15 ml2 months (n 11) 35 ml2-4 m (n 10) 50 ml4-6 m (n 8) 100 ml
Known references with data
Scammon and Doyle 1920
Zuccarellirsquos method stomach filled at autopsy to ldquoa pressure of between
15 and 20 centimeters of waterrdquo
Scammon 1920
ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo
147
Anatomic capacity was determined in post-mortem studies
Main data set Alliot 1905 (n 25)Scammon own cases (n 13)
30 ndash 35 ml at birth ndashalmost regardless of birth weight
Scammon 1920
ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo
148
Zangen S et al Rapid maturation of gastric relaxation in newborns
Pressures (mmHg)
Balloon inflates to
15 ml no increase
functional capacity
149
Zangen S et al Rapid maturation of gastric relaxation in newborns
Pressures (mmHg)
Balloon inflates to
15 ml no increase20 ml pressure OK
physiologicalcapacity hellip 150
26
EVIDENCE (NBn 111009)
Author Capacity NoteSase 10-15 ml Live term fetusGoldstein 10-15 ml Live term fetusWidstrom 10 mls Live newbornZangen 20 mls Live (pressure)
Naveed 20 mls Autopsy (SB)20 mls Autopsy (ENND)
Kernessuk 15 mls Autopsy (in situ)Scammon 30-35 ml Autopsy (water
Starts to feed normally d21 2 days gavage or other
no longer suckles
If starved for 24 hours pup
at d3 will feed food from
floor
(Can be maintained by
smell and other stimuli)
Pup-in-a- cup -
separated and fed by tube
From day 2 off life
Starts to feed normally d21
15
PMA 28 40 64 1y 2y
Nilsrsquo IDEALIZED VIEW
PMA 28 40 64 1y 2y
Nilsrsquo IDEALIZED VIEW
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
Reflections for practice
Suckling and Feeding areNOT THE SAME
16
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDINGON-GOING
S S C
WIRE SUCKLING
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
ON-GOING
S S C
WIRE NEURONS
Up to 6 months milk is 74 fat
96 of this is TRIGLYCERIDE
TRIGLYCERIDE Left glycerol Right palmitic acid oleic acid alpha-linolenic acid
In phosphoglycerides glycerol molecule same
two fatty acids esterified
Phospholipids area major component of all biological membranes
Sphingomyelin particularly concentrated in BRAIN major part of MYELIN
TRIGLYCERIDE
MYELIN
Dendirification and myelinisation peaks occurat 2 and 6 monthsis maximal at one year
At one year human milk has less proteinbut MORE TRIGLYCERIDE
FATTY ACIDS ARESPECIES SPECIFIC
Up to 6 months milk is 74 fat
but after 12 months it is 107
17
ldquocherry pickrdquo
Breastfeed time years school Incomelt 1 month 109 R$ 1238gt 6 month 121 R$ 1915
Group IQ 376 points higher from breatsfeeding
BREASTFEEDINGAND BREAST MILK
INCREASE IQ
BOTTLE FEEDINGamp FORMULA
DECREASE IQ
18
Be sure the wet nurse has plenty of milk because if she lacks it she may give the babymilk of a goat or sheep or some other animalbecause the child nourished on animal milkdoes not have perfect wits like one fed on womanrsquos milk and always looks stupid and vacant and not right in the head
In separation bull Dissociated statebull No cycling chaotic pattern
48 hour baseline chaotic pattern of
activity and quiet HR amp RR
SLEEP CYCLING ndashSeparation vs contact
In SSC bull Normal cyclingbull Non-chaotic pattern
48 hour baseline chaotic pattern of
activity and quiet HR amp RRPre-KC SSC
20
modulates state organisationelicits emotional behavioursactivates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour
SMELL
Schaal 2004 115
DOUCETThe secretion of Areolar (Montgomeryrsquos) Glands from Lactating Women Elicits Selective Unconditional Responses in Neonates
ldquohellip breast chemosignalsactivate oral activity on the nipple that releases a cascade of behavioral neural neuroendocrineand endocrine processes in the newborn and the motherrdquo
Doucet 2009 116
The secretion of Areolar(Montgomeryrsquos) Glands
ldquoIn early ontogeny the sleeping brain may thusremain sentient of an organismrsquos odor environmentrdquo
Doucet 2009 117
REM
NREM
A skin-to-skin contactsession SHOULD NOT be less than one hour
or 90 minutes
SLEEPING
amp
CONTAINING
FEEDING ampHANDLINGfeed
sleep
HO
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C WIRE
TIMING
(behavior)
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C WIRE
STOMACH
21
STATE organization
Feeding frequency
SLEEP cycling
BRAIN
WIRING
How often should a neonate feed
CNS
ENS
ANS
InternalSomaticenvironment
CNS cortical subcortical(also to PNS)
ANS emotional limbic brain(incl SNS)
ANS myelinated vagus (NA)
ANS unmyelinated vagus (DMC)sub-diaphragmatic
ENS submucous plexusmyenteric plexus
122
The digestive system is endowed with its own local nervous system referred to as the enteric or intrinsic nervous system
The magnitude and complexity of the enteric nervous system is immense - it contains as many neurons as the spinal cord
ldquoOntogeny of gastric emptying patternsin the human fetusrdquo
138
24
Goldstein 1987
ldquoGrowth of the Fetal Stomach in Normal Pregnanciesrdquo
139 Goldstein 1987
Length
Transverse
AP diameter
Using +2SD
140
Formula for calculation of stomach capacity (Charles Bradshaw UCT)Assumptions the stomach can be approximated by dividing into three sections namely a ellipsoidal hemisphere an ellipsoidal cylinder and a skewed ellipsoidal cone Variables a = anteroposterior radius t = transverse radius l = length stomachRelations the height of the cone and the hemisphere are both the same as lsquoarsquo
Ellipsoid = 43 Pi r1r2r3 = 43 Pi a a t therefore volume of hemisphere = 23 Pi a a t
Cylinder = Area of base height = (Pi a t ) ( l - 2a )Skewed cone = 13 base height = 13 Pi a t aTotal volume = 23 Pi aat + Pi a t (l- 2a) + 13 Pi a t a
=Pi atl -Pi a at= Pi a t(l-a)
Goldstein and Sase dataStomach capacity at term 10 - 15 ml
BRADSHAW formula
141
Assumption 25 kg baby 33w GA
requiring 150 mlkgday = 375 ml
45 MIN CYCLES ( 32 cyclesday)
12 ML PER CYCLE = 384 ml142
Newborn stomach volume
Gastric volumes at birthCorrelated with gastric pH
gastrin and somatostatin
ldquofetus drinks 10 ml portions of amniotic fluid helliprdquo
Widstrom 1988 143
Only recent study locatedldquoAutopsyrdquo capacity was determined
in Indian post-mortem studies
100 autopsies (63 SB 37 ENND)Tied at cardia and pylorus filled withwater emptied amp measured repeatedldquohellip obliteration of the gastric curvaturesrdquoldquodue care to minimize stretch artifactsrdquo
Naveed 1992
ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo
144
25
Infants above 2500g onlyAve Range
Stillborn (n 11) 196 ml (10-35)Early death (n 9) 178 ml (10-25)All cases (n 20) 188 ml
Naveed 1992
ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo
145 146
KERNESSUK 1997 (Russian)
Postmortem in situ measures(applied Bradshaw formula)
AveNewborn (n 11) 15 ml2 months (n 11) 35 ml2-4 m (n 10) 50 ml4-6 m (n 8) 100 ml
Known references with data
Scammon and Doyle 1920
Zuccarellirsquos method stomach filled at autopsy to ldquoa pressure of between
15 and 20 centimeters of waterrdquo
Scammon 1920
ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo
147
Anatomic capacity was determined in post-mortem studies
Main data set Alliot 1905 (n 25)Scammon own cases (n 13)
30 ndash 35 ml at birth ndashalmost regardless of birth weight
Scammon 1920
ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo
148
Zangen S et al Rapid maturation of gastric relaxation in newborns
Pressures (mmHg)
Balloon inflates to
15 ml no increase
functional capacity
149
Zangen S et al Rapid maturation of gastric relaxation in newborns
Pressures (mmHg)
Balloon inflates to
15 ml no increase20 ml pressure OK
physiologicalcapacity hellip 150
26
EVIDENCE (NBn 111009)
Author Capacity NoteSase 10-15 ml Live term fetusGoldstein 10-15 ml Live term fetusWidstrom 10 mls Live newbornZangen 20 mls Live (pressure)
Naveed 20 mls Autopsy (SB)20 mls Autopsy (ENND)
Kernessuk 15 mls Autopsy (in situ)Scammon 30-35 ml Autopsy (water
Starts to feed normally d21 2 days gavage or other
no longer suckles
If starved for 24 hours pup
at d3 will feed food from
floor
(Can be maintained by
smell and other stimuli)
Pup-in-a- cup -
separated and fed by tube
From day 2 off life
Starts to feed normally d21
15
PMA 28 40 64 1y 2y
Nilsrsquo IDEALIZED VIEW
PMA 28 40 64 1y 2y
Nilsrsquo IDEALIZED VIEW
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
Reflections for practice
Suckling and Feeding areNOT THE SAME
16
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDINGON-GOING
S S C
WIRE SUCKLING
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
ON-GOING
S S C
WIRE NEURONS
Up to 6 months milk is 74 fat
96 of this is TRIGLYCERIDE
TRIGLYCERIDE Left glycerol Right palmitic acid oleic acid alpha-linolenic acid
In phosphoglycerides glycerol molecule same
two fatty acids esterified
Phospholipids area major component of all biological membranes
Sphingomyelin particularly concentrated in BRAIN major part of MYELIN
TRIGLYCERIDE
MYELIN
Dendirification and myelinisation peaks occurat 2 and 6 monthsis maximal at one year
At one year human milk has less proteinbut MORE TRIGLYCERIDE
FATTY ACIDS ARESPECIES SPECIFIC
Up to 6 months milk is 74 fat
but after 12 months it is 107
17
ldquocherry pickrdquo
Breastfeed time years school Incomelt 1 month 109 R$ 1238gt 6 month 121 R$ 1915
Group IQ 376 points higher from breatsfeeding
BREASTFEEDINGAND BREAST MILK
INCREASE IQ
BOTTLE FEEDINGamp FORMULA
DECREASE IQ
18
Be sure the wet nurse has plenty of milk because if she lacks it she may give the babymilk of a goat or sheep or some other animalbecause the child nourished on animal milkdoes not have perfect wits like one fed on womanrsquos milk and always looks stupid and vacant and not right in the head
In separation bull Dissociated statebull No cycling chaotic pattern
48 hour baseline chaotic pattern of
activity and quiet HR amp RR
SLEEP CYCLING ndashSeparation vs contact
In SSC bull Normal cyclingbull Non-chaotic pattern
48 hour baseline chaotic pattern of
activity and quiet HR amp RRPre-KC SSC
20
modulates state organisationelicits emotional behavioursactivates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour
SMELL
Schaal 2004 115
DOUCETThe secretion of Areolar (Montgomeryrsquos) Glands from Lactating Women Elicits Selective Unconditional Responses in Neonates
ldquohellip breast chemosignalsactivate oral activity on the nipple that releases a cascade of behavioral neural neuroendocrineand endocrine processes in the newborn and the motherrdquo
Doucet 2009 116
The secretion of Areolar(Montgomeryrsquos) Glands
ldquoIn early ontogeny the sleeping brain may thusremain sentient of an organismrsquos odor environmentrdquo
Doucet 2009 117
REM
NREM
A skin-to-skin contactsession SHOULD NOT be less than one hour
or 90 minutes
SLEEPING
amp
CONTAINING
FEEDING ampHANDLINGfeed
sleep
HO
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C WIRE
TIMING
(behavior)
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C WIRE
STOMACH
21
STATE organization
Feeding frequency
SLEEP cycling
BRAIN
WIRING
How often should a neonate feed
CNS
ENS
ANS
InternalSomaticenvironment
CNS cortical subcortical(also to PNS)
ANS emotional limbic brain(incl SNS)
ANS myelinated vagus (NA)
ANS unmyelinated vagus (DMC)sub-diaphragmatic
ENS submucous plexusmyenteric plexus
122
The digestive system is endowed with its own local nervous system referred to as the enteric or intrinsic nervous system
The magnitude and complexity of the enteric nervous system is immense - it contains as many neurons as the spinal cord
ldquoOntogeny of gastric emptying patternsin the human fetusrdquo
138
24
Goldstein 1987
ldquoGrowth of the Fetal Stomach in Normal Pregnanciesrdquo
139 Goldstein 1987
Length
Transverse
AP diameter
Using +2SD
140
Formula for calculation of stomach capacity (Charles Bradshaw UCT)Assumptions the stomach can be approximated by dividing into three sections namely a ellipsoidal hemisphere an ellipsoidal cylinder and a skewed ellipsoidal cone Variables a = anteroposterior radius t = transverse radius l = length stomachRelations the height of the cone and the hemisphere are both the same as lsquoarsquo
Ellipsoid = 43 Pi r1r2r3 = 43 Pi a a t therefore volume of hemisphere = 23 Pi a a t
Cylinder = Area of base height = (Pi a t ) ( l - 2a )Skewed cone = 13 base height = 13 Pi a t aTotal volume = 23 Pi aat + Pi a t (l- 2a) + 13 Pi a t a
=Pi atl -Pi a at= Pi a t(l-a)
Goldstein and Sase dataStomach capacity at term 10 - 15 ml
BRADSHAW formula
141
Assumption 25 kg baby 33w GA
requiring 150 mlkgday = 375 ml
45 MIN CYCLES ( 32 cyclesday)
12 ML PER CYCLE = 384 ml142
Newborn stomach volume
Gastric volumes at birthCorrelated with gastric pH
gastrin and somatostatin
ldquofetus drinks 10 ml portions of amniotic fluid helliprdquo
Widstrom 1988 143
Only recent study locatedldquoAutopsyrdquo capacity was determined
in Indian post-mortem studies
100 autopsies (63 SB 37 ENND)Tied at cardia and pylorus filled withwater emptied amp measured repeatedldquohellip obliteration of the gastric curvaturesrdquoldquodue care to minimize stretch artifactsrdquo
Naveed 1992
ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo
144
25
Infants above 2500g onlyAve Range
Stillborn (n 11) 196 ml (10-35)Early death (n 9) 178 ml (10-25)All cases (n 20) 188 ml
Naveed 1992
ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo
145 146
KERNESSUK 1997 (Russian)
Postmortem in situ measures(applied Bradshaw formula)
AveNewborn (n 11) 15 ml2 months (n 11) 35 ml2-4 m (n 10) 50 ml4-6 m (n 8) 100 ml
Known references with data
Scammon and Doyle 1920
Zuccarellirsquos method stomach filled at autopsy to ldquoa pressure of between
15 and 20 centimeters of waterrdquo
Scammon 1920
ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo
147
Anatomic capacity was determined in post-mortem studies
Main data set Alliot 1905 (n 25)Scammon own cases (n 13)
30 ndash 35 ml at birth ndashalmost regardless of birth weight
Scammon 1920
ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo
148
Zangen S et al Rapid maturation of gastric relaxation in newborns
Pressures (mmHg)
Balloon inflates to
15 ml no increase
functional capacity
149
Zangen S et al Rapid maturation of gastric relaxation in newborns
Pressures (mmHg)
Balloon inflates to
15 ml no increase20 ml pressure OK
physiologicalcapacity hellip 150
26
EVIDENCE (NBn 111009)
Author Capacity NoteSase 10-15 ml Live term fetusGoldstein 10-15 ml Live term fetusWidstrom 10 mls Live newbornZangen 20 mls Live (pressure)
Naveed 20 mls Autopsy (SB)20 mls Autopsy (ENND)
Kernessuk 15 mls Autopsy (in situ)Scammon 30-35 ml Autopsy (water
ldquoSmall and frequent feeds according to the sleep cyclerdquo
The ldquonicherdquo (occupation) of a neonate (Alberts)
BOND FEED
SLEEP SLEEP
PLAY FEED
201
Gastric overfilling syndrome
Proposed Management 202
Proposed Management
Babies should be fedEVERY TIME THEY WAKE
Stanley Graven 2006
REMNR1NR2NR3SWS
AS (20 mins) QS (40 mins)
A normal sleep cycle is ONE hourHow often should neonates feed
203
Proposed Management
All babies should be fedat least once an hour 204
35
Proposed Management
All babies should be fedat least once an hour
205
The first Milk Ejection Reflex (MER)
elicited in lt 2 minutesworks quicklyswallowed 1 minute
Feeding time (max)3 minutes
Repeat every 1 hour
Prime 2007
The ldquonormalrdquo or usual and common breastfeed
takes 15 minutesdiscomfort afterburping time 5 minutes
Feeding time 20 min
Repeat every 3 hours
Prime 2007
3 minute 20ml feeds x 24d = 72 minutes
20 minute 60ml feeds x 8d = 160 minutes
SMALL AND FREQUENT FEEDS ARE EFFICIENT
FEWER NURSES NEEDED
The calculated dailyrequirement for a 3kgbaby can be given without increase inpressure MINIMAL RISK
PARENTS CAN DOSAFELY
20 mls x 24 feeds= 480mls day
Zangen 2001 209
All babies should be fedat least once an hour
210
36
Infant feeding frequencyProposal based on available evidence and neuroscience
ldquoSmall and frequent feeds
adjusted to the sleep cyclerdquo
211
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C
STATE organization
Feeding frequency
SLEEP cycling
BRAIN
WIRING
How often should a neonate feeda neonate sleep
Infantsleep cycles
begin to block on diurnalrhythms
Mother-infant synchrony
hellip at 12 weeks
(circadian)
START at 3 months
Can be ldquoadult-likerdquo
at 6 months
Thomas 2014
STATE organization
Feeding frequency
SLEEP cycling
PLAY FEED
216
SLEEP SLEEP
SLEEP SLEEPPLAY
FEED
Infant sleep cycling and synchronicity with maternal sleep ensure development
Infantsleep cycles
begin to block on diurnalrhythms
37
BOND SUCKLE SLEEP SLEEP PLAY
FEED
217
SLEEP SLEEP SLEEP SLEEPPLAY
FEED
Infant sleep cycling and synchronicity with maternal sleep ensure development
modulates state organisationelicits emotional behaviours
activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour
SMELL(amp SKIN)
Schaal 2004 218
modulates state organisationelicits emotional behaviours
activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour
SMELL(amp SKIN)rdquoSLEEP-FEED CYCLINGrdquo
Schaal 2004 219
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C
WIRE
BRAIN
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C
BRAIN
WIRING
NEUROSCIENCE
The DNAEverything else
EVOLUTIONARYBIOLOGY
The Brain
EPIGENETICS
The PlaceENVIRONMENT
EXPERIENCEFITNESS ADAPTATION
ldquoScientific foundationrdquo hellip a synthesis
ZERO
SEPARATION
38
wwwninobirthorgwwwskintoskincontactcom
THE NEUROSCIENCE OFSKIN-TO-SKIN CONTACT
AND BREASTFEEDING
ARE THE SAME
SUMMARY SKIN-TO-SKIN
(Regulation)
SLEEP(Brain)
FEEDING(Stomach)
LOVE ( ldquomindrdquo )
REMNR1NR2NR3NR4
ACQUISITION CONSOLIDATION MEMORYFORMATION
poly-sensory input transfer information P wavesshort-term memory ldquoSNRrdquo strong signals returns infostored cortex amygdala to neocortex
hippocampus organizedAwake and REM NREM stage 4 REM
BRAIN WIRING
Stanley Graven 2006
PLAY
SLEEP
FEEDHOLDYOURPREM
httpswwwfacebookcomninobirth
39
Nelson Mandela
hellip in describing themeasure of a nation
he has argued that
ldquoThere can be no keener revelation of a societyrsquos soul than the way in which it treats its childrenrdquo
15
PMA 28 40 64 1y 2y
Nilsrsquo IDEALIZED VIEW
PMA 28 40 64 1y 2y
Nilsrsquo IDEALIZED VIEW
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
Reflections for practice
Suckling and Feeding areNOT THE SAME
16
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDINGON-GOING
S S C
WIRE SUCKLING
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
ON-GOING
S S C
WIRE NEURONS
Up to 6 months milk is 74 fat
96 of this is TRIGLYCERIDE
TRIGLYCERIDE Left glycerol Right palmitic acid oleic acid alpha-linolenic acid
In phosphoglycerides glycerol molecule same
two fatty acids esterified
Phospholipids area major component of all biological membranes
Sphingomyelin particularly concentrated in BRAIN major part of MYELIN
TRIGLYCERIDE
MYELIN
Dendirification and myelinisation peaks occurat 2 and 6 monthsis maximal at one year
At one year human milk has less proteinbut MORE TRIGLYCERIDE
FATTY ACIDS ARESPECIES SPECIFIC
Up to 6 months milk is 74 fat
but after 12 months it is 107
17
ldquocherry pickrdquo
Breastfeed time years school Incomelt 1 month 109 R$ 1238gt 6 month 121 R$ 1915
Group IQ 376 points higher from breatsfeeding
BREASTFEEDINGAND BREAST MILK
INCREASE IQ
BOTTLE FEEDINGamp FORMULA
DECREASE IQ
18
Be sure the wet nurse has plenty of milk because if she lacks it she may give the babymilk of a goat or sheep or some other animalbecause the child nourished on animal milkdoes not have perfect wits like one fed on womanrsquos milk and always looks stupid and vacant and not right in the head
In separation bull Dissociated statebull No cycling chaotic pattern
48 hour baseline chaotic pattern of
activity and quiet HR amp RR
SLEEP CYCLING ndashSeparation vs contact
In SSC bull Normal cyclingbull Non-chaotic pattern
48 hour baseline chaotic pattern of
activity and quiet HR amp RRPre-KC SSC
20
modulates state organisationelicits emotional behavioursactivates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour
SMELL
Schaal 2004 115
DOUCETThe secretion of Areolar (Montgomeryrsquos) Glands from Lactating Women Elicits Selective Unconditional Responses in Neonates
ldquohellip breast chemosignalsactivate oral activity on the nipple that releases a cascade of behavioral neural neuroendocrineand endocrine processes in the newborn and the motherrdquo
Doucet 2009 116
The secretion of Areolar(Montgomeryrsquos) Glands
ldquoIn early ontogeny the sleeping brain may thusremain sentient of an organismrsquos odor environmentrdquo
Doucet 2009 117
REM
NREM
A skin-to-skin contactsession SHOULD NOT be less than one hour
or 90 minutes
SLEEPING
amp
CONTAINING
FEEDING ampHANDLINGfeed
sleep
HO
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C WIRE
TIMING
(behavior)
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C WIRE
STOMACH
21
STATE organization
Feeding frequency
SLEEP cycling
BRAIN
WIRING
How often should a neonate feed
CNS
ENS
ANS
InternalSomaticenvironment
CNS cortical subcortical(also to PNS)
ANS emotional limbic brain(incl SNS)
ANS myelinated vagus (NA)
ANS unmyelinated vagus (DMC)sub-diaphragmatic
ENS submucous plexusmyenteric plexus
122
The digestive system is endowed with its own local nervous system referred to as the enteric or intrinsic nervous system
The magnitude and complexity of the enteric nervous system is immense - it contains as many neurons as the spinal cord
ldquoOntogeny of gastric emptying patternsin the human fetusrdquo
138
24
Goldstein 1987
ldquoGrowth of the Fetal Stomach in Normal Pregnanciesrdquo
139 Goldstein 1987
Length
Transverse
AP diameter
Using +2SD
140
Formula for calculation of stomach capacity (Charles Bradshaw UCT)Assumptions the stomach can be approximated by dividing into three sections namely a ellipsoidal hemisphere an ellipsoidal cylinder and a skewed ellipsoidal cone Variables a = anteroposterior radius t = transverse radius l = length stomachRelations the height of the cone and the hemisphere are both the same as lsquoarsquo
Ellipsoid = 43 Pi r1r2r3 = 43 Pi a a t therefore volume of hemisphere = 23 Pi a a t
Cylinder = Area of base height = (Pi a t ) ( l - 2a )Skewed cone = 13 base height = 13 Pi a t aTotal volume = 23 Pi aat + Pi a t (l- 2a) + 13 Pi a t a
=Pi atl -Pi a at= Pi a t(l-a)
Goldstein and Sase dataStomach capacity at term 10 - 15 ml
BRADSHAW formula
141
Assumption 25 kg baby 33w GA
requiring 150 mlkgday = 375 ml
45 MIN CYCLES ( 32 cyclesday)
12 ML PER CYCLE = 384 ml142
Newborn stomach volume
Gastric volumes at birthCorrelated with gastric pH
gastrin and somatostatin
ldquofetus drinks 10 ml portions of amniotic fluid helliprdquo
Widstrom 1988 143
Only recent study locatedldquoAutopsyrdquo capacity was determined
in Indian post-mortem studies
100 autopsies (63 SB 37 ENND)Tied at cardia and pylorus filled withwater emptied amp measured repeatedldquohellip obliteration of the gastric curvaturesrdquoldquodue care to minimize stretch artifactsrdquo
Naveed 1992
ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo
144
25
Infants above 2500g onlyAve Range
Stillborn (n 11) 196 ml (10-35)Early death (n 9) 178 ml (10-25)All cases (n 20) 188 ml
Naveed 1992
ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo
145 146
KERNESSUK 1997 (Russian)
Postmortem in situ measures(applied Bradshaw formula)
AveNewborn (n 11) 15 ml2 months (n 11) 35 ml2-4 m (n 10) 50 ml4-6 m (n 8) 100 ml
Known references with data
Scammon and Doyle 1920
Zuccarellirsquos method stomach filled at autopsy to ldquoa pressure of between
15 and 20 centimeters of waterrdquo
Scammon 1920
ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo
147
Anatomic capacity was determined in post-mortem studies
Main data set Alliot 1905 (n 25)Scammon own cases (n 13)
30 ndash 35 ml at birth ndashalmost regardless of birth weight
Scammon 1920
ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo
148
Zangen S et al Rapid maturation of gastric relaxation in newborns
Pressures (mmHg)
Balloon inflates to
15 ml no increase
functional capacity
149
Zangen S et al Rapid maturation of gastric relaxation in newborns
Pressures (mmHg)
Balloon inflates to
15 ml no increase20 ml pressure OK
physiologicalcapacity hellip 150
26
EVIDENCE (NBn 111009)
Author Capacity NoteSase 10-15 ml Live term fetusGoldstein 10-15 ml Live term fetusWidstrom 10 mls Live newbornZangen 20 mls Live (pressure)
Naveed 20 mls Autopsy (SB)20 mls Autopsy (ENND)
Kernessuk 15 mls Autopsy (in situ)Scammon 30-35 ml Autopsy (water
ldquoSmall and frequent feeds according to the sleep cyclerdquo
The ldquonicherdquo (occupation) of a neonate (Alberts)
BOND FEED
SLEEP SLEEP
PLAY FEED
201
Gastric overfilling syndrome
Proposed Management 202
Proposed Management
Babies should be fedEVERY TIME THEY WAKE
Stanley Graven 2006
REMNR1NR2NR3SWS
AS (20 mins) QS (40 mins)
A normal sleep cycle is ONE hourHow often should neonates feed
203
Proposed Management
All babies should be fedat least once an hour 204
35
Proposed Management
All babies should be fedat least once an hour
205
The first Milk Ejection Reflex (MER)
elicited in lt 2 minutesworks quicklyswallowed 1 minute
Feeding time (max)3 minutes
Repeat every 1 hour
Prime 2007
The ldquonormalrdquo or usual and common breastfeed
takes 15 minutesdiscomfort afterburping time 5 minutes
Feeding time 20 min
Repeat every 3 hours
Prime 2007
3 minute 20ml feeds x 24d = 72 minutes
20 minute 60ml feeds x 8d = 160 minutes
SMALL AND FREQUENT FEEDS ARE EFFICIENT
FEWER NURSES NEEDED
The calculated dailyrequirement for a 3kgbaby can be given without increase inpressure MINIMAL RISK
PARENTS CAN DOSAFELY
20 mls x 24 feeds= 480mls day
Zangen 2001 209
All babies should be fedat least once an hour
210
36
Infant feeding frequencyProposal based on available evidence and neuroscience
ldquoSmall and frequent feeds
adjusted to the sleep cyclerdquo
211
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C
STATE organization
Feeding frequency
SLEEP cycling
BRAIN
WIRING
How often should a neonate feeda neonate sleep
Infantsleep cycles
begin to block on diurnalrhythms
Mother-infant synchrony
hellip at 12 weeks
(circadian)
START at 3 months
Can be ldquoadult-likerdquo
at 6 months
Thomas 2014
STATE organization
Feeding frequency
SLEEP cycling
PLAY FEED
216
SLEEP SLEEP
SLEEP SLEEPPLAY
FEED
Infant sleep cycling and synchronicity with maternal sleep ensure development
Infantsleep cycles
begin to block on diurnalrhythms
37
BOND SUCKLE SLEEP SLEEP PLAY
FEED
217
SLEEP SLEEP SLEEP SLEEPPLAY
FEED
Infant sleep cycling and synchronicity with maternal sleep ensure development
modulates state organisationelicits emotional behaviours
activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour
SMELL(amp SKIN)
Schaal 2004 218
modulates state organisationelicits emotional behaviours
activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour
SMELL(amp SKIN)rdquoSLEEP-FEED CYCLINGrdquo
Schaal 2004 219
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C
WIRE
BRAIN
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C
BRAIN
WIRING
NEUROSCIENCE
The DNAEverything else
EVOLUTIONARYBIOLOGY
The Brain
EPIGENETICS
The PlaceENVIRONMENT
EXPERIENCEFITNESS ADAPTATION
ldquoScientific foundationrdquo hellip a synthesis
ZERO
SEPARATION
38
wwwninobirthorgwwwskintoskincontactcom
THE NEUROSCIENCE OFSKIN-TO-SKIN CONTACT
AND BREASTFEEDING
ARE THE SAME
SUMMARY SKIN-TO-SKIN
(Regulation)
SLEEP(Brain)
FEEDING(Stomach)
LOVE ( ldquomindrdquo )
REMNR1NR2NR3NR4
ACQUISITION CONSOLIDATION MEMORYFORMATION
poly-sensory input transfer information P wavesshort-term memory ldquoSNRrdquo strong signals returns infostored cortex amygdala to neocortex
hippocampus organizedAwake and REM NREM stage 4 REM
BRAIN WIRING
Stanley Graven 2006
PLAY
SLEEP
FEEDHOLDYOURPREM
httpswwwfacebookcomninobirth
39
Nelson Mandela
hellip in describing themeasure of a nation
he has argued that
ldquoThere can be no keener revelation of a societyrsquos soul than the way in which it treats its childrenrdquo
16
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDINGON-GOING
S S C
WIRE SUCKLING
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
ON-GOING
S S C
WIRE NEURONS
Up to 6 months milk is 74 fat
96 of this is TRIGLYCERIDE
TRIGLYCERIDE Left glycerol Right palmitic acid oleic acid alpha-linolenic acid
In phosphoglycerides glycerol molecule same
two fatty acids esterified
Phospholipids area major component of all biological membranes
Sphingomyelin particularly concentrated in BRAIN major part of MYELIN
TRIGLYCERIDE
MYELIN
Dendirification and myelinisation peaks occurat 2 and 6 monthsis maximal at one year
At one year human milk has less proteinbut MORE TRIGLYCERIDE
FATTY ACIDS ARESPECIES SPECIFIC
Up to 6 months milk is 74 fat
but after 12 months it is 107
17
ldquocherry pickrdquo
Breastfeed time years school Incomelt 1 month 109 R$ 1238gt 6 month 121 R$ 1915
Group IQ 376 points higher from breatsfeeding
BREASTFEEDINGAND BREAST MILK
INCREASE IQ
BOTTLE FEEDINGamp FORMULA
DECREASE IQ
18
Be sure the wet nurse has plenty of milk because if she lacks it she may give the babymilk of a goat or sheep or some other animalbecause the child nourished on animal milkdoes not have perfect wits like one fed on womanrsquos milk and always looks stupid and vacant and not right in the head
In separation bull Dissociated statebull No cycling chaotic pattern
48 hour baseline chaotic pattern of
activity and quiet HR amp RR
SLEEP CYCLING ndashSeparation vs contact
In SSC bull Normal cyclingbull Non-chaotic pattern
48 hour baseline chaotic pattern of
activity and quiet HR amp RRPre-KC SSC
20
modulates state organisationelicits emotional behavioursactivates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour
SMELL
Schaal 2004 115
DOUCETThe secretion of Areolar (Montgomeryrsquos) Glands from Lactating Women Elicits Selective Unconditional Responses in Neonates
ldquohellip breast chemosignalsactivate oral activity on the nipple that releases a cascade of behavioral neural neuroendocrineand endocrine processes in the newborn and the motherrdquo
Doucet 2009 116
The secretion of Areolar(Montgomeryrsquos) Glands
ldquoIn early ontogeny the sleeping brain may thusremain sentient of an organismrsquos odor environmentrdquo
Doucet 2009 117
REM
NREM
A skin-to-skin contactsession SHOULD NOT be less than one hour
or 90 minutes
SLEEPING
amp
CONTAINING
FEEDING ampHANDLINGfeed
sleep
HO
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C WIRE
TIMING
(behavior)
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C WIRE
STOMACH
21
STATE organization
Feeding frequency
SLEEP cycling
BRAIN
WIRING
How often should a neonate feed
CNS
ENS
ANS
InternalSomaticenvironment
CNS cortical subcortical(also to PNS)
ANS emotional limbic brain(incl SNS)
ANS myelinated vagus (NA)
ANS unmyelinated vagus (DMC)sub-diaphragmatic
ENS submucous plexusmyenteric plexus
122
The digestive system is endowed with its own local nervous system referred to as the enteric or intrinsic nervous system
The magnitude and complexity of the enteric nervous system is immense - it contains as many neurons as the spinal cord
ldquoOntogeny of gastric emptying patternsin the human fetusrdquo
138
24
Goldstein 1987
ldquoGrowth of the Fetal Stomach in Normal Pregnanciesrdquo
139 Goldstein 1987
Length
Transverse
AP diameter
Using +2SD
140
Formula for calculation of stomach capacity (Charles Bradshaw UCT)Assumptions the stomach can be approximated by dividing into three sections namely a ellipsoidal hemisphere an ellipsoidal cylinder and a skewed ellipsoidal cone Variables a = anteroposterior radius t = transverse radius l = length stomachRelations the height of the cone and the hemisphere are both the same as lsquoarsquo
Ellipsoid = 43 Pi r1r2r3 = 43 Pi a a t therefore volume of hemisphere = 23 Pi a a t
Cylinder = Area of base height = (Pi a t ) ( l - 2a )Skewed cone = 13 base height = 13 Pi a t aTotal volume = 23 Pi aat + Pi a t (l- 2a) + 13 Pi a t a
=Pi atl -Pi a at= Pi a t(l-a)
Goldstein and Sase dataStomach capacity at term 10 - 15 ml
BRADSHAW formula
141
Assumption 25 kg baby 33w GA
requiring 150 mlkgday = 375 ml
45 MIN CYCLES ( 32 cyclesday)
12 ML PER CYCLE = 384 ml142
Newborn stomach volume
Gastric volumes at birthCorrelated with gastric pH
gastrin and somatostatin
ldquofetus drinks 10 ml portions of amniotic fluid helliprdquo
Widstrom 1988 143
Only recent study locatedldquoAutopsyrdquo capacity was determined
in Indian post-mortem studies
100 autopsies (63 SB 37 ENND)Tied at cardia and pylorus filled withwater emptied amp measured repeatedldquohellip obliteration of the gastric curvaturesrdquoldquodue care to minimize stretch artifactsrdquo
Naveed 1992
ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo
144
25
Infants above 2500g onlyAve Range
Stillborn (n 11) 196 ml (10-35)Early death (n 9) 178 ml (10-25)All cases (n 20) 188 ml
Naveed 1992
ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo
145 146
KERNESSUK 1997 (Russian)
Postmortem in situ measures(applied Bradshaw formula)
AveNewborn (n 11) 15 ml2 months (n 11) 35 ml2-4 m (n 10) 50 ml4-6 m (n 8) 100 ml
Known references with data
Scammon and Doyle 1920
Zuccarellirsquos method stomach filled at autopsy to ldquoa pressure of between
15 and 20 centimeters of waterrdquo
Scammon 1920
ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo
147
Anatomic capacity was determined in post-mortem studies
Main data set Alliot 1905 (n 25)Scammon own cases (n 13)
30 ndash 35 ml at birth ndashalmost regardless of birth weight
Scammon 1920
ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo
148
Zangen S et al Rapid maturation of gastric relaxation in newborns
Pressures (mmHg)
Balloon inflates to
15 ml no increase
functional capacity
149
Zangen S et al Rapid maturation of gastric relaxation in newborns
Pressures (mmHg)
Balloon inflates to
15 ml no increase20 ml pressure OK
physiologicalcapacity hellip 150
26
EVIDENCE (NBn 111009)
Author Capacity NoteSase 10-15 ml Live term fetusGoldstein 10-15 ml Live term fetusWidstrom 10 mls Live newbornZangen 20 mls Live (pressure)
Naveed 20 mls Autopsy (SB)20 mls Autopsy (ENND)
Kernessuk 15 mls Autopsy (in situ)Scammon 30-35 ml Autopsy (water
ldquoSmall and frequent feeds according to the sleep cyclerdquo
The ldquonicherdquo (occupation) of a neonate (Alberts)
BOND FEED
SLEEP SLEEP
PLAY FEED
201
Gastric overfilling syndrome
Proposed Management 202
Proposed Management
Babies should be fedEVERY TIME THEY WAKE
Stanley Graven 2006
REMNR1NR2NR3SWS
AS (20 mins) QS (40 mins)
A normal sleep cycle is ONE hourHow often should neonates feed
203
Proposed Management
All babies should be fedat least once an hour 204
35
Proposed Management
All babies should be fedat least once an hour
205
The first Milk Ejection Reflex (MER)
elicited in lt 2 minutesworks quicklyswallowed 1 minute
Feeding time (max)3 minutes
Repeat every 1 hour
Prime 2007
The ldquonormalrdquo or usual and common breastfeed
takes 15 minutesdiscomfort afterburping time 5 minutes
Feeding time 20 min
Repeat every 3 hours
Prime 2007
3 minute 20ml feeds x 24d = 72 minutes
20 minute 60ml feeds x 8d = 160 minutes
SMALL AND FREQUENT FEEDS ARE EFFICIENT
FEWER NURSES NEEDED
The calculated dailyrequirement for a 3kgbaby can be given without increase inpressure MINIMAL RISK
PARENTS CAN DOSAFELY
20 mls x 24 feeds= 480mls day
Zangen 2001 209
All babies should be fedat least once an hour
210
36
Infant feeding frequencyProposal based on available evidence and neuroscience
ldquoSmall and frequent feeds
adjusted to the sleep cyclerdquo
211
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C
STATE organization
Feeding frequency
SLEEP cycling
BRAIN
WIRING
How often should a neonate feeda neonate sleep
Infantsleep cycles
begin to block on diurnalrhythms
Mother-infant synchrony
hellip at 12 weeks
(circadian)
START at 3 months
Can be ldquoadult-likerdquo
at 6 months
Thomas 2014
STATE organization
Feeding frequency
SLEEP cycling
PLAY FEED
216
SLEEP SLEEP
SLEEP SLEEPPLAY
FEED
Infant sleep cycling and synchronicity with maternal sleep ensure development
Infantsleep cycles
begin to block on diurnalrhythms
37
BOND SUCKLE SLEEP SLEEP PLAY
FEED
217
SLEEP SLEEP SLEEP SLEEPPLAY
FEED
Infant sleep cycling and synchronicity with maternal sleep ensure development
modulates state organisationelicits emotional behaviours
activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour
SMELL(amp SKIN)
Schaal 2004 218
modulates state organisationelicits emotional behaviours
activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour
SMELL(amp SKIN)rdquoSLEEP-FEED CYCLINGrdquo
Schaal 2004 219
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C
WIRE
BRAIN
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C
BRAIN
WIRING
NEUROSCIENCE
The DNAEverything else
EVOLUTIONARYBIOLOGY
The Brain
EPIGENETICS
The PlaceENVIRONMENT
EXPERIENCEFITNESS ADAPTATION
ldquoScientific foundationrdquo hellip a synthesis
ZERO
SEPARATION
38
wwwninobirthorgwwwskintoskincontactcom
THE NEUROSCIENCE OFSKIN-TO-SKIN CONTACT
AND BREASTFEEDING
ARE THE SAME
SUMMARY SKIN-TO-SKIN
(Regulation)
SLEEP(Brain)
FEEDING(Stomach)
LOVE ( ldquomindrdquo )
REMNR1NR2NR3NR4
ACQUISITION CONSOLIDATION MEMORYFORMATION
poly-sensory input transfer information P wavesshort-term memory ldquoSNRrdquo strong signals returns infostored cortex amygdala to neocortex
hippocampus organizedAwake and REM NREM stage 4 REM
BRAIN WIRING
Stanley Graven 2006
PLAY
SLEEP
FEEDHOLDYOURPREM
httpswwwfacebookcomninobirth
39
Nelson Mandela
hellip in describing themeasure of a nation
he has argued that
ldquoThere can be no keener revelation of a societyrsquos soul than the way in which it treats its childrenrdquo
17
ldquocherry pickrdquo
Breastfeed time years school Incomelt 1 month 109 R$ 1238gt 6 month 121 R$ 1915
Group IQ 376 points higher from breatsfeeding
BREASTFEEDINGAND BREAST MILK
INCREASE IQ
BOTTLE FEEDINGamp FORMULA
DECREASE IQ
18
Be sure the wet nurse has plenty of milk because if she lacks it she may give the babymilk of a goat or sheep or some other animalbecause the child nourished on animal milkdoes not have perfect wits like one fed on womanrsquos milk and always looks stupid and vacant and not right in the head
In separation bull Dissociated statebull No cycling chaotic pattern
48 hour baseline chaotic pattern of
activity and quiet HR amp RR
SLEEP CYCLING ndashSeparation vs contact
In SSC bull Normal cyclingbull Non-chaotic pattern
48 hour baseline chaotic pattern of
activity and quiet HR amp RRPre-KC SSC
20
modulates state organisationelicits emotional behavioursactivates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour
SMELL
Schaal 2004 115
DOUCETThe secretion of Areolar (Montgomeryrsquos) Glands from Lactating Women Elicits Selective Unconditional Responses in Neonates
ldquohellip breast chemosignalsactivate oral activity on the nipple that releases a cascade of behavioral neural neuroendocrineand endocrine processes in the newborn and the motherrdquo
Doucet 2009 116
The secretion of Areolar(Montgomeryrsquos) Glands
ldquoIn early ontogeny the sleeping brain may thusremain sentient of an organismrsquos odor environmentrdquo
Doucet 2009 117
REM
NREM
A skin-to-skin contactsession SHOULD NOT be less than one hour
or 90 minutes
SLEEPING
amp
CONTAINING
FEEDING ampHANDLINGfeed
sleep
HO
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C WIRE
TIMING
(behavior)
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C WIRE
STOMACH
21
STATE organization
Feeding frequency
SLEEP cycling
BRAIN
WIRING
How often should a neonate feed
CNS
ENS
ANS
InternalSomaticenvironment
CNS cortical subcortical(also to PNS)
ANS emotional limbic brain(incl SNS)
ANS myelinated vagus (NA)
ANS unmyelinated vagus (DMC)sub-diaphragmatic
ENS submucous plexusmyenteric plexus
122
The digestive system is endowed with its own local nervous system referred to as the enteric or intrinsic nervous system
The magnitude and complexity of the enteric nervous system is immense - it contains as many neurons as the spinal cord
ldquoOntogeny of gastric emptying patternsin the human fetusrdquo
138
24
Goldstein 1987
ldquoGrowth of the Fetal Stomach in Normal Pregnanciesrdquo
139 Goldstein 1987
Length
Transverse
AP diameter
Using +2SD
140
Formula for calculation of stomach capacity (Charles Bradshaw UCT)Assumptions the stomach can be approximated by dividing into three sections namely a ellipsoidal hemisphere an ellipsoidal cylinder and a skewed ellipsoidal cone Variables a = anteroposterior radius t = transverse radius l = length stomachRelations the height of the cone and the hemisphere are both the same as lsquoarsquo
Ellipsoid = 43 Pi r1r2r3 = 43 Pi a a t therefore volume of hemisphere = 23 Pi a a t
Cylinder = Area of base height = (Pi a t ) ( l - 2a )Skewed cone = 13 base height = 13 Pi a t aTotal volume = 23 Pi aat + Pi a t (l- 2a) + 13 Pi a t a
=Pi atl -Pi a at= Pi a t(l-a)
Goldstein and Sase dataStomach capacity at term 10 - 15 ml
BRADSHAW formula
141
Assumption 25 kg baby 33w GA
requiring 150 mlkgday = 375 ml
45 MIN CYCLES ( 32 cyclesday)
12 ML PER CYCLE = 384 ml142
Newborn stomach volume
Gastric volumes at birthCorrelated with gastric pH
gastrin and somatostatin
ldquofetus drinks 10 ml portions of amniotic fluid helliprdquo
Widstrom 1988 143
Only recent study locatedldquoAutopsyrdquo capacity was determined
in Indian post-mortem studies
100 autopsies (63 SB 37 ENND)Tied at cardia and pylorus filled withwater emptied amp measured repeatedldquohellip obliteration of the gastric curvaturesrdquoldquodue care to minimize stretch artifactsrdquo
Naveed 1992
ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo
144
25
Infants above 2500g onlyAve Range
Stillborn (n 11) 196 ml (10-35)Early death (n 9) 178 ml (10-25)All cases (n 20) 188 ml
Naveed 1992
ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo
145 146
KERNESSUK 1997 (Russian)
Postmortem in situ measures(applied Bradshaw formula)
AveNewborn (n 11) 15 ml2 months (n 11) 35 ml2-4 m (n 10) 50 ml4-6 m (n 8) 100 ml
Known references with data
Scammon and Doyle 1920
Zuccarellirsquos method stomach filled at autopsy to ldquoa pressure of between
15 and 20 centimeters of waterrdquo
Scammon 1920
ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo
147
Anatomic capacity was determined in post-mortem studies
Main data set Alliot 1905 (n 25)Scammon own cases (n 13)
30 ndash 35 ml at birth ndashalmost regardless of birth weight
Scammon 1920
ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo
148
Zangen S et al Rapid maturation of gastric relaxation in newborns
Pressures (mmHg)
Balloon inflates to
15 ml no increase
functional capacity
149
Zangen S et al Rapid maturation of gastric relaxation in newborns
Pressures (mmHg)
Balloon inflates to
15 ml no increase20 ml pressure OK
physiologicalcapacity hellip 150
26
EVIDENCE (NBn 111009)
Author Capacity NoteSase 10-15 ml Live term fetusGoldstein 10-15 ml Live term fetusWidstrom 10 mls Live newbornZangen 20 mls Live (pressure)
Naveed 20 mls Autopsy (SB)20 mls Autopsy (ENND)
Kernessuk 15 mls Autopsy (in situ)Scammon 30-35 ml Autopsy (water
ldquoSmall and frequent feeds according to the sleep cyclerdquo
The ldquonicherdquo (occupation) of a neonate (Alberts)
BOND FEED
SLEEP SLEEP
PLAY FEED
201
Gastric overfilling syndrome
Proposed Management 202
Proposed Management
Babies should be fedEVERY TIME THEY WAKE
Stanley Graven 2006
REMNR1NR2NR3SWS
AS (20 mins) QS (40 mins)
A normal sleep cycle is ONE hourHow often should neonates feed
203
Proposed Management
All babies should be fedat least once an hour 204
35
Proposed Management
All babies should be fedat least once an hour
205
The first Milk Ejection Reflex (MER)
elicited in lt 2 minutesworks quicklyswallowed 1 minute
Feeding time (max)3 minutes
Repeat every 1 hour
Prime 2007
The ldquonormalrdquo or usual and common breastfeed
takes 15 minutesdiscomfort afterburping time 5 minutes
Feeding time 20 min
Repeat every 3 hours
Prime 2007
3 minute 20ml feeds x 24d = 72 minutes
20 minute 60ml feeds x 8d = 160 minutes
SMALL AND FREQUENT FEEDS ARE EFFICIENT
FEWER NURSES NEEDED
The calculated dailyrequirement for a 3kgbaby can be given without increase inpressure MINIMAL RISK
PARENTS CAN DOSAFELY
20 mls x 24 feeds= 480mls day
Zangen 2001 209
All babies should be fedat least once an hour
210
36
Infant feeding frequencyProposal based on available evidence and neuroscience
ldquoSmall and frequent feeds
adjusted to the sleep cyclerdquo
211
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C
STATE organization
Feeding frequency
SLEEP cycling
BRAIN
WIRING
How often should a neonate feeda neonate sleep
Infantsleep cycles
begin to block on diurnalrhythms
Mother-infant synchrony
hellip at 12 weeks
(circadian)
START at 3 months
Can be ldquoadult-likerdquo
at 6 months
Thomas 2014
STATE organization
Feeding frequency
SLEEP cycling
PLAY FEED
216
SLEEP SLEEP
SLEEP SLEEPPLAY
FEED
Infant sleep cycling and synchronicity with maternal sleep ensure development
Infantsleep cycles
begin to block on diurnalrhythms
37
BOND SUCKLE SLEEP SLEEP PLAY
FEED
217
SLEEP SLEEP SLEEP SLEEPPLAY
FEED
Infant sleep cycling and synchronicity with maternal sleep ensure development
modulates state organisationelicits emotional behaviours
activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour
SMELL(amp SKIN)
Schaal 2004 218
modulates state organisationelicits emotional behaviours
activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour
SMELL(amp SKIN)rdquoSLEEP-FEED CYCLINGrdquo
Schaal 2004 219
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C
WIRE
BRAIN
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C
BRAIN
WIRING
NEUROSCIENCE
The DNAEverything else
EVOLUTIONARYBIOLOGY
The Brain
EPIGENETICS
The PlaceENVIRONMENT
EXPERIENCEFITNESS ADAPTATION
ldquoScientific foundationrdquo hellip a synthesis
ZERO
SEPARATION
38
wwwninobirthorgwwwskintoskincontactcom
THE NEUROSCIENCE OFSKIN-TO-SKIN CONTACT
AND BREASTFEEDING
ARE THE SAME
SUMMARY SKIN-TO-SKIN
(Regulation)
SLEEP(Brain)
FEEDING(Stomach)
LOVE ( ldquomindrdquo )
REMNR1NR2NR3NR4
ACQUISITION CONSOLIDATION MEMORYFORMATION
poly-sensory input transfer information P wavesshort-term memory ldquoSNRrdquo strong signals returns infostored cortex amygdala to neocortex
hippocampus organizedAwake and REM NREM stage 4 REM
BRAIN WIRING
Stanley Graven 2006
PLAY
SLEEP
FEEDHOLDYOURPREM
httpswwwfacebookcomninobirth
39
Nelson Mandela
hellip in describing themeasure of a nation
he has argued that
ldquoThere can be no keener revelation of a societyrsquos soul than the way in which it treats its childrenrdquo
18
Be sure the wet nurse has plenty of milk because if she lacks it she may give the babymilk of a goat or sheep or some other animalbecause the child nourished on animal milkdoes not have perfect wits like one fed on womanrsquos milk and always looks stupid and vacant and not right in the head
In separation bull Dissociated statebull No cycling chaotic pattern
48 hour baseline chaotic pattern of
activity and quiet HR amp RR
SLEEP CYCLING ndashSeparation vs contact
In SSC bull Normal cyclingbull Non-chaotic pattern
48 hour baseline chaotic pattern of
activity and quiet HR amp RRPre-KC SSC
20
modulates state organisationelicits emotional behavioursactivates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour
SMELL
Schaal 2004 115
DOUCETThe secretion of Areolar (Montgomeryrsquos) Glands from Lactating Women Elicits Selective Unconditional Responses in Neonates
ldquohellip breast chemosignalsactivate oral activity on the nipple that releases a cascade of behavioral neural neuroendocrineand endocrine processes in the newborn and the motherrdquo
Doucet 2009 116
The secretion of Areolar(Montgomeryrsquos) Glands
ldquoIn early ontogeny the sleeping brain may thusremain sentient of an organismrsquos odor environmentrdquo
Doucet 2009 117
REM
NREM
A skin-to-skin contactsession SHOULD NOT be less than one hour
or 90 minutes
SLEEPING
amp
CONTAINING
FEEDING ampHANDLINGfeed
sleep
HO
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C WIRE
TIMING
(behavior)
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C WIRE
STOMACH
21
STATE organization
Feeding frequency
SLEEP cycling
BRAIN
WIRING
How often should a neonate feed
CNS
ENS
ANS
InternalSomaticenvironment
CNS cortical subcortical(also to PNS)
ANS emotional limbic brain(incl SNS)
ANS myelinated vagus (NA)
ANS unmyelinated vagus (DMC)sub-diaphragmatic
ENS submucous plexusmyenteric plexus
122
The digestive system is endowed with its own local nervous system referred to as the enteric or intrinsic nervous system
The magnitude and complexity of the enteric nervous system is immense - it contains as many neurons as the spinal cord
ldquoOntogeny of gastric emptying patternsin the human fetusrdquo
138
24
Goldstein 1987
ldquoGrowth of the Fetal Stomach in Normal Pregnanciesrdquo
139 Goldstein 1987
Length
Transverse
AP diameter
Using +2SD
140
Formula for calculation of stomach capacity (Charles Bradshaw UCT)Assumptions the stomach can be approximated by dividing into three sections namely a ellipsoidal hemisphere an ellipsoidal cylinder and a skewed ellipsoidal cone Variables a = anteroposterior radius t = transverse radius l = length stomachRelations the height of the cone and the hemisphere are both the same as lsquoarsquo
Ellipsoid = 43 Pi r1r2r3 = 43 Pi a a t therefore volume of hemisphere = 23 Pi a a t
Cylinder = Area of base height = (Pi a t ) ( l - 2a )Skewed cone = 13 base height = 13 Pi a t aTotal volume = 23 Pi aat + Pi a t (l- 2a) + 13 Pi a t a
=Pi atl -Pi a at= Pi a t(l-a)
Goldstein and Sase dataStomach capacity at term 10 - 15 ml
BRADSHAW formula
141
Assumption 25 kg baby 33w GA
requiring 150 mlkgday = 375 ml
45 MIN CYCLES ( 32 cyclesday)
12 ML PER CYCLE = 384 ml142
Newborn stomach volume
Gastric volumes at birthCorrelated with gastric pH
gastrin and somatostatin
ldquofetus drinks 10 ml portions of amniotic fluid helliprdquo
Widstrom 1988 143
Only recent study locatedldquoAutopsyrdquo capacity was determined
in Indian post-mortem studies
100 autopsies (63 SB 37 ENND)Tied at cardia and pylorus filled withwater emptied amp measured repeatedldquohellip obliteration of the gastric curvaturesrdquoldquodue care to minimize stretch artifactsrdquo
Naveed 1992
ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo
144
25
Infants above 2500g onlyAve Range
Stillborn (n 11) 196 ml (10-35)Early death (n 9) 178 ml (10-25)All cases (n 20) 188 ml
Naveed 1992
ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo
145 146
KERNESSUK 1997 (Russian)
Postmortem in situ measures(applied Bradshaw formula)
AveNewborn (n 11) 15 ml2 months (n 11) 35 ml2-4 m (n 10) 50 ml4-6 m (n 8) 100 ml
Known references with data
Scammon and Doyle 1920
Zuccarellirsquos method stomach filled at autopsy to ldquoa pressure of between
15 and 20 centimeters of waterrdquo
Scammon 1920
ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo
147
Anatomic capacity was determined in post-mortem studies
Main data set Alliot 1905 (n 25)Scammon own cases (n 13)
30 ndash 35 ml at birth ndashalmost regardless of birth weight
Scammon 1920
ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo
148
Zangen S et al Rapid maturation of gastric relaxation in newborns
Pressures (mmHg)
Balloon inflates to
15 ml no increase
functional capacity
149
Zangen S et al Rapid maturation of gastric relaxation in newborns
Pressures (mmHg)
Balloon inflates to
15 ml no increase20 ml pressure OK
physiologicalcapacity hellip 150
26
EVIDENCE (NBn 111009)
Author Capacity NoteSase 10-15 ml Live term fetusGoldstein 10-15 ml Live term fetusWidstrom 10 mls Live newbornZangen 20 mls Live (pressure)
Naveed 20 mls Autopsy (SB)20 mls Autopsy (ENND)
Kernessuk 15 mls Autopsy (in situ)Scammon 30-35 ml Autopsy (water
ldquoSmall and frequent feeds according to the sleep cyclerdquo
The ldquonicherdquo (occupation) of a neonate (Alberts)
BOND FEED
SLEEP SLEEP
PLAY FEED
201
Gastric overfilling syndrome
Proposed Management 202
Proposed Management
Babies should be fedEVERY TIME THEY WAKE
Stanley Graven 2006
REMNR1NR2NR3SWS
AS (20 mins) QS (40 mins)
A normal sleep cycle is ONE hourHow often should neonates feed
203
Proposed Management
All babies should be fedat least once an hour 204
35
Proposed Management
All babies should be fedat least once an hour
205
The first Milk Ejection Reflex (MER)
elicited in lt 2 minutesworks quicklyswallowed 1 minute
Feeding time (max)3 minutes
Repeat every 1 hour
Prime 2007
The ldquonormalrdquo or usual and common breastfeed
takes 15 minutesdiscomfort afterburping time 5 minutes
Feeding time 20 min
Repeat every 3 hours
Prime 2007
3 minute 20ml feeds x 24d = 72 minutes
20 minute 60ml feeds x 8d = 160 minutes
SMALL AND FREQUENT FEEDS ARE EFFICIENT
FEWER NURSES NEEDED
The calculated dailyrequirement for a 3kgbaby can be given without increase inpressure MINIMAL RISK
PARENTS CAN DOSAFELY
20 mls x 24 feeds= 480mls day
Zangen 2001 209
All babies should be fedat least once an hour
210
36
Infant feeding frequencyProposal based on available evidence and neuroscience
ldquoSmall and frequent feeds
adjusted to the sleep cyclerdquo
211
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C
STATE organization
Feeding frequency
SLEEP cycling
BRAIN
WIRING
How often should a neonate feeda neonate sleep
Infantsleep cycles
begin to block on diurnalrhythms
Mother-infant synchrony
hellip at 12 weeks
(circadian)
START at 3 months
Can be ldquoadult-likerdquo
at 6 months
Thomas 2014
STATE organization
Feeding frequency
SLEEP cycling
PLAY FEED
216
SLEEP SLEEP
SLEEP SLEEPPLAY
FEED
Infant sleep cycling and synchronicity with maternal sleep ensure development
Infantsleep cycles
begin to block on diurnalrhythms
37
BOND SUCKLE SLEEP SLEEP PLAY
FEED
217
SLEEP SLEEP SLEEP SLEEPPLAY
FEED
Infant sleep cycling and synchronicity with maternal sleep ensure development
modulates state organisationelicits emotional behaviours
activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour
SMELL(amp SKIN)
Schaal 2004 218
modulates state organisationelicits emotional behaviours
activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour
SMELL(amp SKIN)rdquoSLEEP-FEED CYCLINGrdquo
Schaal 2004 219
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C
WIRE
BRAIN
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C
BRAIN
WIRING
NEUROSCIENCE
The DNAEverything else
EVOLUTIONARYBIOLOGY
The Brain
EPIGENETICS
The PlaceENVIRONMENT
EXPERIENCEFITNESS ADAPTATION
ldquoScientific foundationrdquo hellip a synthesis
ZERO
SEPARATION
38
wwwninobirthorgwwwskintoskincontactcom
THE NEUROSCIENCE OFSKIN-TO-SKIN CONTACT
AND BREASTFEEDING
ARE THE SAME
SUMMARY SKIN-TO-SKIN
(Regulation)
SLEEP(Brain)
FEEDING(Stomach)
LOVE ( ldquomindrdquo )
REMNR1NR2NR3NR4
ACQUISITION CONSOLIDATION MEMORYFORMATION
poly-sensory input transfer information P wavesshort-term memory ldquoSNRrdquo strong signals returns infostored cortex amygdala to neocortex
hippocampus organizedAwake and REM NREM stage 4 REM
BRAIN WIRING
Stanley Graven 2006
PLAY
SLEEP
FEEDHOLDYOURPREM
httpswwwfacebookcomninobirth
39
Nelson Mandela
hellip in describing themeasure of a nation
he has argued that
ldquoThere can be no keener revelation of a societyrsquos soul than the way in which it treats its childrenrdquo
19
Not so much duration
or density of any sleep stage
or number of sleep stage episodes but
cycling between quiet sleep
and active sleepis what is important
REMREM REM
NREM NREM
This is a healthy sleep pattern
This is a very good cycling pattern
(thanks to Susan Ludington-Hoe)
REMREM REM
NREM NREM
1st hour 2nd hour
So in every hour you would like
to see an EEG pattern that shows this
REM
NREM
REM
NREM
REM
NREM
State
HR
RR
REM Sleep is supposed to be
somewhat active so
HR increases and RR is irregular
SLEEP CYCLING ndashSeparation vs contact
In separation bull Dissociated statebull No cycling chaotic pattern
48 hour baseline chaotic pattern of
activity and quiet HR amp RR
SLEEP CYCLING ndashSeparation vs contact
In SSC bull Normal cyclingbull Non-chaotic pattern
48 hour baseline chaotic pattern of
activity and quiet HR amp RRPre-KC SSC
20
modulates state organisationelicits emotional behavioursactivates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour
SMELL
Schaal 2004 115
DOUCETThe secretion of Areolar (Montgomeryrsquos) Glands from Lactating Women Elicits Selective Unconditional Responses in Neonates
ldquohellip breast chemosignalsactivate oral activity on the nipple that releases a cascade of behavioral neural neuroendocrineand endocrine processes in the newborn and the motherrdquo
Doucet 2009 116
The secretion of Areolar(Montgomeryrsquos) Glands
ldquoIn early ontogeny the sleeping brain may thusremain sentient of an organismrsquos odor environmentrdquo
Doucet 2009 117
REM
NREM
A skin-to-skin contactsession SHOULD NOT be less than one hour
or 90 minutes
SLEEPING
amp
CONTAINING
FEEDING ampHANDLINGfeed
sleep
HO
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C WIRE
TIMING
(behavior)
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C WIRE
STOMACH
21
STATE organization
Feeding frequency
SLEEP cycling
BRAIN
WIRING
How often should a neonate feed
CNS
ENS
ANS
InternalSomaticenvironment
CNS cortical subcortical(also to PNS)
ANS emotional limbic brain(incl SNS)
ANS myelinated vagus (NA)
ANS unmyelinated vagus (DMC)sub-diaphragmatic
ENS submucous plexusmyenteric plexus
122
The digestive system is endowed with its own local nervous system referred to as the enteric or intrinsic nervous system
The magnitude and complexity of the enteric nervous system is immense - it contains as many neurons as the spinal cord
ldquoOntogeny of gastric emptying patternsin the human fetusrdquo
138
24
Goldstein 1987
ldquoGrowth of the Fetal Stomach in Normal Pregnanciesrdquo
139 Goldstein 1987
Length
Transverse
AP diameter
Using +2SD
140
Formula for calculation of stomach capacity (Charles Bradshaw UCT)Assumptions the stomach can be approximated by dividing into three sections namely a ellipsoidal hemisphere an ellipsoidal cylinder and a skewed ellipsoidal cone Variables a = anteroposterior radius t = transverse radius l = length stomachRelations the height of the cone and the hemisphere are both the same as lsquoarsquo
Ellipsoid = 43 Pi r1r2r3 = 43 Pi a a t therefore volume of hemisphere = 23 Pi a a t
Cylinder = Area of base height = (Pi a t ) ( l - 2a )Skewed cone = 13 base height = 13 Pi a t aTotal volume = 23 Pi aat + Pi a t (l- 2a) + 13 Pi a t a
=Pi atl -Pi a at= Pi a t(l-a)
Goldstein and Sase dataStomach capacity at term 10 - 15 ml
BRADSHAW formula
141
Assumption 25 kg baby 33w GA
requiring 150 mlkgday = 375 ml
45 MIN CYCLES ( 32 cyclesday)
12 ML PER CYCLE = 384 ml142
Newborn stomach volume
Gastric volumes at birthCorrelated with gastric pH
gastrin and somatostatin
ldquofetus drinks 10 ml portions of amniotic fluid helliprdquo
Widstrom 1988 143
Only recent study locatedldquoAutopsyrdquo capacity was determined
in Indian post-mortem studies
100 autopsies (63 SB 37 ENND)Tied at cardia and pylorus filled withwater emptied amp measured repeatedldquohellip obliteration of the gastric curvaturesrdquoldquodue care to minimize stretch artifactsrdquo
Naveed 1992
ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo
144
25
Infants above 2500g onlyAve Range
Stillborn (n 11) 196 ml (10-35)Early death (n 9) 178 ml (10-25)All cases (n 20) 188 ml
Naveed 1992
ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo
145 146
KERNESSUK 1997 (Russian)
Postmortem in situ measures(applied Bradshaw formula)
AveNewborn (n 11) 15 ml2 months (n 11) 35 ml2-4 m (n 10) 50 ml4-6 m (n 8) 100 ml
Known references with data
Scammon and Doyle 1920
Zuccarellirsquos method stomach filled at autopsy to ldquoa pressure of between
15 and 20 centimeters of waterrdquo
Scammon 1920
ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo
147
Anatomic capacity was determined in post-mortem studies
Main data set Alliot 1905 (n 25)Scammon own cases (n 13)
30 ndash 35 ml at birth ndashalmost regardless of birth weight
Scammon 1920
ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo
148
Zangen S et al Rapid maturation of gastric relaxation in newborns
Pressures (mmHg)
Balloon inflates to
15 ml no increase
functional capacity
149
Zangen S et al Rapid maturation of gastric relaxation in newborns
Pressures (mmHg)
Balloon inflates to
15 ml no increase20 ml pressure OK
physiologicalcapacity hellip 150
26
EVIDENCE (NBn 111009)
Author Capacity NoteSase 10-15 ml Live term fetusGoldstein 10-15 ml Live term fetusWidstrom 10 mls Live newbornZangen 20 mls Live (pressure)
Naveed 20 mls Autopsy (SB)20 mls Autopsy (ENND)
Kernessuk 15 mls Autopsy (in situ)Scammon 30-35 ml Autopsy (water
ldquoSmall and frequent feeds according to the sleep cyclerdquo
The ldquonicherdquo (occupation) of a neonate (Alberts)
BOND FEED
SLEEP SLEEP
PLAY FEED
201
Gastric overfilling syndrome
Proposed Management 202
Proposed Management
Babies should be fedEVERY TIME THEY WAKE
Stanley Graven 2006
REMNR1NR2NR3SWS
AS (20 mins) QS (40 mins)
A normal sleep cycle is ONE hourHow often should neonates feed
203
Proposed Management
All babies should be fedat least once an hour 204
35
Proposed Management
All babies should be fedat least once an hour
205
The first Milk Ejection Reflex (MER)
elicited in lt 2 minutesworks quicklyswallowed 1 minute
Feeding time (max)3 minutes
Repeat every 1 hour
Prime 2007
The ldquonormalrdquo or usual and common breastfeed
takes 15 minutesdiscomfort afterburping time 5 minutes
Feeding time 20 min
Repeat every 3 hours
Prime 2007
3 minute 20ml feeds x 24d = 72 minutes
20 minute 60ml feeds x 8d = 160 minutes
SMALL AND FREQUENT FEEDS ARE EFFICIENT
FEWER NURSES NEEDED
The calculated dailyrequirement for a 3kgbaby can be given without increase inpressure MINIMAL RISK
PARENTS CAN DOSAFELY
20 mls x 24 feeds= 480mls day
Zangen 2001 209
All babies should be fedat least once an hour
210
36
Infant feeding frequencyProposal based on available evidence and neuroscience
ldquoSmall and frequent feeds
adjusted to the sleep cyclerdquo
211
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C
STATE organization
Feeding frequency
SLEEP cycling
BRAIN
WIRING
How often should a neonate feeda neonate sleep
Infantsleep cycles
begin to block on diurnalrhythms
Mother-infant synchrony
hellip at 12 weeks
(circadian)
START at 3 months
Can be ldquoadult-likerdquo
at 6 months
Thomas 2014
STATE organization
Feeding frequency
SLEEP cycling
PLAY FEED
216
SLEEP SLEEP
SLEEP SLEEPPLAY
FEED
Infant sleep cycling and synchronicity with maternal sleep ensure development
Infantsleep cycles
begin to block on diurnalrhythms
37
BOND SUCKLE SLEEP SLEEP PLAY
FEED
217
SLEEP SLEEP SLEEP SLEEPPLAY
FEED
Infant sleep cycling and synchronicity with maternal sleep ensure development
modulates state organisationelicits emotional behaviours
activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour
SMELL(amp SKIN)
Schaal 2004 218
modulates state organisationelicits emotional behaviours
activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour
SMELL(amp SKIN)rdquoSLEEP-FEED CYCLINGrdquo
Schaal 2004 219
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C
WIRE
BRAIN
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C
BRAIN
WIRING
NEUROSCIENCE
The DNAEverything else
EVOLUTIONARYBIOLOGY
The Brain
EPIGENETICS
The PlaceENVIRONMENT
EXPERIENCEFITNESS ADAPTATION
ldquoScientific foundationrdquo hellip a synthesis
ZERO
SEPARATION
38
wwwninobirthorgwwwskintoskincontactcom
THE NEUROSCIENCE OFSKIN-TO-SKIN CONTACT
AND BREASTFEEDING
ARE THE SAME
SUMMARY SKIN-TO-SKIN
(Regulation)
SLEEP(Brain)
FEEDING(Stomach)
LOVE ( ldquomindrdquo )
REMNR1NR2NR3NR4
ACQUISITION CONSOLIDATION MEMORYFORMATION
poly-sensory input transfer information P wavesshort-term memory ldquoSNRrdquo strong signals returns infostored cortex amygdala to neocortex
hippocampus organizedAwake and REM NREM stage 4 REM
BRAIN WIRING
Stanley Graven 2006
PLAY
SLEEP
FEEDHOLDYOURPREM
httpswwwfacebookcomninobirth
39
Nelson Mandela
hellip in describing themeasure of a nation
he has argued that
ldquoThere can be no keener revelation of a societyrsquos soul than the way in which it treats its childrenrdquo
20
modulates state organisationelicits emotional behavioursactivates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour
SMELL
Schaal 2004 115
DOUCETThe secretion of Areolar (Montgomeryrsquos) Glands from Lactating Women Elicits Selective Unconditional Responses in Neonates
ldquohellip breast chemosignalsactivate oral activity on the nipple that releases a cascade of behavioral neural neuroendocrineand endocrine processes in the newborn and the motherrdquo
Doucet 2009 116
The secretion of Areolar(Montgomeryrsquos) Glands
ldquoIn early ontogeny the sleeping brain may thusremain sentient of an organismrsquos odor environmentrdquo
Doucet 2009 117
REM
NREM
A skin-to-skin contactsession SHOULD NOT be less than one hour
or 90 minutes
SLEEPING
amp
CONTAINING
FEEDING ampHANDLINGfeed
sleep
HO
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C WIRE
TIMING
(behavior)
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C WIRE
STOMACH
21
STATE organization
Feeding frequency
SLEEP cycling
BRAIN
WIRING
How often should a neonate feed
CNS
ENS
ANS
InternalSomaticenvironment
CNS cortical subcortical(also to PNS)
ANS emotional limbic brain(incl SNS)
ANS myelinated vagus (NA)
ANS unmyelinated vagus (DMC)sub-diaphragmatic
ENS submucous plexusmyenteric plexus
122
The digestive system is endowed with its own local nervous system referred to as the enteric or intrinsic nervous system
The magnitude and complexity of the enteric nervous system is immense - it contains as many neurons as the spinal cord
ldquoOntogeny of gastric emptying patternsin the human fetusrdquo
138
24
Goldstein 1987
ldquoGrowth of the Fetal Stomach in Normal Pregnanciesrdquo
139 Goldstein 1987
Length
Transverse
AP diameter
Using +2SD
140
Formula for calculation of stomach capacity (Charles Bradshaw UCT)Assumptions the stomach can be approximated by dividing into three sections namely a ellipsoidal hemisphere an ellipsoidal cylinder and a skewed ellipsoidal cone Variables a = anteroposterior radius t = transverse radius l = length stomachRelations the height of the cone and the hemisphere are both the same as lsquoarsquo
Ellipsoid = 43 Pi r1r2r3 = 43 Pi a a t therefore volume of hemisphere = 23 Pi a a t
Cylinder = Area of base height = (Pi a t ) ( l - 2a )Skewed cone = 13 base height = 13 Pi a t aTotal volume = 23 Pi aat + Pi a t (l- 2a) + 13 Pi a t a
=Pi atl -Pi a at= Pi a t(l-a)
Goldstein and Sase dataStomach capacity at term 10 - 15 ml
BRADSHAW formula
141
Assumption 25 kg baby 33w GA
requiring 150 mlkgday = 375 ml
45 MIN CYCLES ( 32 cyclesday)
12 ML PER CYCLE = 384 ml142
Newborn stomach volume
Gastric volumes at birthCorrelated with gastric pH
gastrin and somatostatin
ldquofetus drinks 10 ml portions of amniotic fluid helliprdquo
Widstrom 1988 143
Only recent study locatedldquoAutopsyrdquo capacity was determined
in Indian post-mortem studies
100 autopsies (63 SB 37 ENND)Tied at cardia and pylorus filled withwater emptied amp measured repeatedldquohellip obliteration of the gastric curvaturesrdquoldquodue care to minimize stretch artifactsrdquo
Naveed 1992
ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo
144
25
Infants above 2500g onlyAve Range
Stillborn (n 11) 196 ml (10-35)Early death (n 9) 178 ml (10-25)All cases (n 20) 188 ml
Naveed 1992
ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo
145 146
KERNESSUK 1997 (Russian)
Postmortem in situ measures(applied Bradshaw formula)
AveNewborn (n 11) 15 ml2 months (n 11) 35 ml2-4 m (n 10) 50 ml4-6 m (n 8) 100 ml
Known references with data
Scammon and Doyle 1920
Zuccarellirsquos method stomach filled at autopsy to ldquoa pressure of between
15 and 20 centimeters of waterrdquo
Scammon 1920
ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo
147
Anatomic capacity was determined in post-mortem studies
Main data set Alliot 1905 (n 25)Scammon own cases (n 13)
30 ndash 35 ml at birth ndashalmost regardless of birth weight
Scammon 1920
ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo
148
Zangen S et al Rapid maturation of gastric relaxation in newborns
Pressures (mmHg)
Balloon inflates to
15 ml no increase
functional capacity
149
Zangen S et al Rapid maturation of gastric relaxation in newborns
Pressures (mmHg)
Balloon inflates to
15 ml no increase20 ml pressure OK
physiologicalcapacity hellip 150
26
EVIDENCE (NBn 111009)
Author Capacity NoteSase 10-15 ml Live term fetusGoldstein 10-15 ml Live term fetusWidstrom 10 mls Live newbornZangen 20 mls Live (pressure)
Naveed 20 mls Autopsy (SB)20 mls Autopsy (ENND)
Kernessuk 15 mls Autopsy (in situ)Scammon 30-35 ml Autopsy (water
ldquoOntogeny of gastric emptying patternsin the human fetusrdquo
138
24
Goldstein 1987
ldquoGrowth of the Fetal Stomach in Normal Pregnanciesrdquo
139 Goldstein 1987
Length
Transverse
AP diameter
Using +2SD
140
Formula for calculation of stomach capacity (Charles Bradshaw UCT)Assumptions the stomach can be approximated by dividing into three sections namely a ellipsoidal hemisphere an ellipsoidal cylinder and a skewed ellipsoidal cone Variables a = anteroposterior radius t = transverse radius l = length stomachRelations the height of the cone and the hemisphere are both the same as lsquoarsquo
Ellipsoid = 43 Pi r1r2r3 = 43 Pi a a t therefore volume of hemisphere = 23 Pi a a t
Cylinder = Area of base height = (Pi a t ) ( l - 2a )Skewed cone = 13 base height = 13 Pi a t aTotal volume = 23 Pi aat + Pi a t (l- 2a) + 13 Pi a t a
=Pi atl -Pi a at= Pi a t(l-a)
Goldstein and Sase dataStomach capacity at term 10 - 15 ml
BRADSHAW formula
141
Assumption 25 kg baby 33w GA
requiring 150 mlkgday = 375 ml
45 MIN CYCLES ( 32 cyclesday)
12 ML PER CYCLE = 384 ml142
Newborn stomach volume
Gastric volumes at birthCorrelated with gastric pH
gastrin and somatostatin
ldquofetus drinks 10 ml portions of amniotic fluid helliprdquo
Widstrom 1988 143
Only recent study locatedldquoAutopsyrdquo capacity was determined
in Indian post-mortem studies
100 autopsies (63 SB 37 ENND)Tied at cardia and pylorus filled withwater emptied amp measured repeatedldquohellip obliteration of the gastric curvaturesrdquoldquodue care to minimize stretch artifactsrdquo
Naveed 1992
ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo
144
25
Infants above 2500g onlyAve Range
Stillborn (n 11) 196 ml (10-35)Early death (n 9) 178 ml (10-25)All cases (n 20) 188 ml
Naveed 1992
ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo
145 146
KERNESSUK 1997 (Russian)
Postmortem in situ measures(applied Bradshaw formula)
AveNewborn (n 11) 15 ml2 months (n 11) 35 ml2-4 m (n 10) 50 ml4-6 m (n 8) 100 ml
Known references with data
Scammon and Doyle 1920
Zuccarellirsquos method stomach filled at autopsy to ldquoa pressure of between
15 and 20 centimeters of waterrdquo
Scammon 1920
ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo
147
Anatomic capacity was determined in post-mortem studies
Main data set Alliot 1905 (n 25)Scammon own cases (n 13)
30 ndash 35 ml at birth ndashalmost regardless of birth weight
Scammon 1920
ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo
148
Zangen S et al Rapid maturation of gastric relaxation in newborns
Pressures (mmHg)
Balloon inflates to
15 ml no increase
functional capacity
149
Zangen S et al Rapid maturation of gastric relaxation in newborns
Pressures (mmHg)
Balloon inflates to
15 ml no increase20 ml pressure OK
physiologicalcapacity hellip 150
26
EVIDENCE (NBn 111009)
Author Capacity NoteSase 10-15 ml Live term fetusGoldstein 10-15 ml Live term fetusWidstrom 10 mls Live newbornZangen 20 mls Live (pressure)
Naveed 20 mls Autopsy (SB)20 mls Autopsy (ENND)
Kernessuk 15 mls Autopsy (in situ)Scammon 30-35 ml Autopsy (water
ldquoOntogeny of gastric emptying patternsin the human fetusrdquo
138
24
Goldstein 1987
ldquoGrowth of the Fetal Stomach in Normal Pregnanciesrdquo
139 Goldstein 1987
Length
Transverse
AP diameter
Using +2SD
140
Formula for calculation of stomach capacity (Charles Bradshaw UCT)Assumptions the stomach can be approximated by dividing into three sections namely a ellipsoidal hemisphere an ellipsoidal cylinder and a skewed ellipsoidal cone Variables a = anteroposterior radius t = transverse radius l = length stomachRelations the height of the cone and the hemisphere are both the same as lsquoarsquo
Ellipsoid = 43 Pi r1r2r3 = 43 Pi a a t therefore volume of hemisphere = 23 Pi a a t
Cylinder = Area of base height = (Pi a t ) ( l - 2a )Skewed cone = 13 base height = 13 Pi a t aTotal volume = 23 Pi aat + Pi a t (l- 2a) + 13 Pi a t a
=Pi atl -Pi a at= Pi a t(l-a)
Goldstein and Sase dataStomach capacity at term 10 - 15 ml
BRADSHAW formula
141
Assumption 25 kg baby 33w GA
requiring 150 mlkgday = 375 ml
45 MIN CYCLES ( 32 cyclesday)
12 ML PER CYCLE = 384 ml142
Newborn stomach volume
Gastric volumes at birthCorrelated with gastric pH
gastrin and somatostatin
ldquofetus drinks 10 ml portions of amniotic fluid helliprdquo
Widstrom 1988 143
Only recent study locatedldquoAutopsyrdquo capacity was determined
in Indian post-mortem studies
100 autopsies (63 SB 37 ENND)Tied at cardia and pylorus filled withwater emptied amp measured repeatedldquohellip obliteration of the gastric curvaturesrdquoldquodue care to minimize stretch artifactsrdquo
Naveed 1992
ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo
144
25
Infants above 2500g onlyAve Range
Stillborn (n 11) 196 ml (10-35)Early death (n 9) 178 ml (10-25)All cases (n 20) 188 ml
Naveed 1992
ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo
145 146
KERNESSUK 1997 (Russian)
Postmortem in situ measures(applied Bradshaw formula)
AveNewborn (n 11) 15 ml2 months (n 11) 35 ml2-4 m (n 10) 50 ml4-6 m (n 8) 100 ml
Known references with data
Scammon and Doyle 1920
Zuccarellirsquos method stomach filled at autopsy to ldquoa pressure of between
15 and 20 centimeters of waterrdquo
Scammon 1920
ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo
147
Anatomic capacity was determined in post-mortem studies
Main data set Alliot 1905 (n 25)Scammon own cases (n 13)
30 ndash 35 ml at birth ndashalmost regardless of birth weight
Scammon 1920
ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo
148
Zangen S et al Rapid maturation of gastric relaxation in newborns
Pressures (mmHg)
Balloon inflates to
15 ml no increase
functional capacity
149
Zangen S et al Rapid maturation of gastric relaxation in newborns
Pressures (mmHg)
Balloon inflates to
15 ml no increase20 ml pressure OK
physiologicalcapacity hellip 150
26
EVIDENCE (NBn 111009)
Author Capacity NoteSase 10-15 ml Live term fetusGoldstein 10-15 ml Live term fetusWidstrom 10 mls Live newbornZangen 20 mls Live (pressure)
Naveed 20 mls Autopsy (SB)20 mls Autopsy (ENND)
Kernessuk 15 mls Autopsy (in situ)Scammon 30-35 ml Autopsy (water
ldquoOntogeny of gastric emptying patternsin the human fetusrdquo
138
24
Goldstein 1987
ldquoGrowth of the Fetal Stomach in Normal Pregnanciesrdquo
139 Goldstein 1987
Length
Transverse
AP diameter
Using +2SD
140
Formula for calculation of stomach capacity (Charles Bradshaw UCT)Assumptions the stomach can be approximated by dividing into three sections namely a ellipsoidal hemisphere an ellipsoidal cylinder and a skewed ellipsoidal cone Variables a = anteroposterior radius t = transverse radius l = length stomachRelations the height of the cone and the hemisphere are both the same as lsquoarsquo
Ellipsoid = 43 Pi r1r2r3 = 43 Pi a a t therefore volume of hemisphere = 23 Pi a a t
Cylinder = Area of base height = (Pi a t ) ( l - 2a )Skewed cone = 13 base height = 13 Pi a t aTotal volume = 23 Pi aat + Pi a t (l- 2a) + 13 Pi a t a
=Pi atl -Pi a at= Pi a t(l-a)
Goldstein and Sase dataStomach capacity at term 10 - 15 ml
BRADSHAW formula
141
Assumption 25 kg baby 33w GA
requiring 150 mlkgday = 375 ml
45 MIN CYCLES ( 32 cyclesday)
12 ML PER CYCLE = 384 ml142
Newborn stomach volume
Gastric volumes at birthCorrelated with gastric pH
gastrin and somatostatin
ldquofetus drinks 10 ml portions of amniotic fluid helliprdquo
Widstrom 1988 143
Only recent study locatedldquoAutopsyrdquo capacity was determined
in Indian post-mortem studies
100 autopsies (63 SB 37 ENND)Tied at cardia and pylorus filled withwater emptied amp measured repeatedldquohellip obliteration of the gastric curvaturesrdquoldquodue care to minimize stretch artifactsrdquo
Naveed 1992
ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo
144
25
Infants above 2500g onlyAve Range
Stillborn (n 11) 196 ml (10-35)Early death (n 9) 178 ml (10-25)All cases (n 20) 188 ml
Naveed 1992
ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo
145 146
KERNESSUK 1997 (Russian)
Postmortem in situ measures(applied Bradshaw formula)
AveNewborn (n 11) 15 ml2 months (n 11) 35 ml2-4 m (n 10) 50 ml4-6 m (n 8) 100 ml
Known references with data
Scammon and Doyle 1920
Zuccarellirsquos method stomach filled at autopsy to ldquoa pressure of between
15 and 20 centimeters of waterrdquo
Scammon 1920
ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo
147
Anatomic capacity was determined in post-mortem studies
Main data set Alliot 1905 (n 25)Scammon own cases (n 13)
30 ndash 35 ml at birth ndashalmost regardless of birth weight
Scammon 1920
ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo
148
Zangen S et al Rapid maturation of gastric relaxation in newborns
Pressures (mmHg)
Balloon inflates to
15 ml no increase
functional capacity
149
Zangen S et al Rapid maturation of gastric relaxation in newborns
Pressures (mmHg)
Balloon inflates to
15 ml no increase20 ml pressure OK
physiologicalcapacity hellip 150
26
EVIDENCE (NBn 111009)
Author Capacity NoteSase 10-15 ml Live term fetusGoldstein 10-15 ml Live term fetusWidstrom 10 mls Live newbornZangen 20 mls Live (pressure)
Naveed 20 mls Autopsy (SB)20 mls Autopsy (ENND)
Kernessuk 15 mls Autopsy (in situ)Scammon 30-35 ml Autopsy (water
ldquoSmall and frequent feeds according to the sleep cyclerdquo
The ldquonicherdquo (occupation) of a neonate (Alberts)
BOND FEED
SLEEP SLEEP
PLAY FEED
201
Gastric overfilling syndrome
Proposed Management 202
Proposed Management
Babies should be fedEVERY TIME THEY WAKE
Stanley Graven 2006
REMNR1NR2NR3SWS
AS (20 mins) QS (40 mins)
A normal sleep cycle is ONE hourHow often should neonates feed
203
Proposed Management
All babies should be fedat least once an hour 204
35
Proposed Management
All babies should be fedat least once an hour
205
The first Milk Ejection Reflex (MER)
elicited in lt 2 minutesworks quicklyswallowed 1 minute
Feeding time (max)3 minutes
Repeat every 1 hour
Prime 2007
The ldquonormalrdquo or usual and common breastfeed
takes 15 minutesdiscomfort afterburping time 5 minutes
Feeding time 20 min
Repeat every 3 hours
Prime 2007
3 minute 20ml feeds x 24d = 72 minutes
20 minute 60ml feeds x 8d = 160 minutes
SMALL AND FREQUENT FEEDS ARE EFFICIENT
FEWER NURSES NEEDED
The calculated dailyrequirement for a 3kgbaby can be given without increase inpressure MINIMAL RISK
PARENTS CAN DOSAFELY
20 mls x 24 feeds= 480mls day
Zangen 2001 209
All babies should be fedat least once an hour
210
36
Infant feeding frequencyProposal based on available evidence and neuroscience
ldquoSmall and frequent feeds
adjusted to the sleep cyclerdquo
211
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C
STATE organization
Feeding frequency
SLEEP cycling
BRAIN
WIRING
How often should a neonate feeda neonate sleep
Infantsleep cycles
begin to block on diurnalrhythms
Mother-infant synchrony
hellip at 12 weeks
(circadian)
START at 3 months
Can be ldquoadult-likerdquo
at 6 months
Thomas 2014
STATE organization
Feeding frequency
SLEEP cycling
PLAY FEED
216
SLEEP SLEEP
SLEEP SLEEPPLAY
FEED
Infant sleep cycling and synchronicity with maternal sleep ensure development
Infantsleep cycles
begin to block on diurnalrhythms
37
BOND SUCKLE SLEEP SLEEP PLAY
FEED
217
SLEEP SLEEP SLEEP SLEEPPLAY
FEED
Infant sleep cycling and synchronicity with maternal sleep ensure development
modulates state organisationelicits emotional behaviours
activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour
SMELL(amp SKIN)
Schaal 2004 218
modulates state organisationelicits emotional behaviours
activates pre-feeding actionsanticipatory digestive physiologyregulates pace of ingestive behaviour
SMELL(amp SKIN)rdquoSLEEP-FEED CYCLINGrdquo
Schaal 2004 219
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C
WIRE
BRAIN
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C
BRAIN
WIRING
NEUROSCIENCE
The DNAEverything else
EVOLUTIONARYBIOLOGY
The Brain
EPIGENETICS
The PlaceENVIRONMENT
EXPERIENCEFITNESS ADAPTATION
ldquoScientific foundationrdquo hellip a synthesis
ZERO
SEPARATION
38
wwwninobirthorgwwwskintoskincontactcom
THE NEUROSCIENCE OFSKIN-TO-SKIN CONTACT
AND BREASTFEEDING
ARE THE SAME
SUMMARY SKIN-TO-SKIN
(Regulation)
SLEEP(Brain)
FEEDING(Stomach)
LOVE ( ldquomindrdquo )
REMNR1NR2NR3NR4
ACQUISITION CONSOLIDATION MEMORYFORMATION
poly-sensory input transfer information P wavesshort-term memory ldquoSNRrdquo strong signals returns infostored cortex amygdala to neocortex
hippocampus organizedAwake and REM NREM stage 4 REM
BRAIN WIRING
Stanley Graven 2006
PLAY
SLEEP
FEEDHOLDYOURPREM
httpswwwfacebookcomninobirth
39
Nelson Mandela
hellip in describing themeasure of a nation
he has argued that
ldquoThere can be no keener revelation of a societyrsquos soul than the way in which it treats its childrenrdquo
24
Goldstein 1987
ldquoGrowth of the Fetal Stomach in Normal Pregnanciesrdquo
139 Goldstein 1987
Length
Transverse
AP diameter
Using +2SD
140
Formula for calculation of stomach capacity (Charles Bradshaw UCT)Assumptions the stomach can be approximated by dividing into three sections namely a ellipsoidal hemisphere an ellipsoidal cylinder and a skewed ellipsoidal cone Variables a = anteroposterior radius t = transverse radius l = length stomachRelations the height of the cone and the hemisphere are both the same as lsquoarsquo
Ellipsoid = 43 Pi r1r2r3 = 43 Pi a a t therefore volume of hemisphere = 23 Pi a a t
Cylinder = Area of base height = (Pi a t ) ( l - 2a )Skewed cone = 13 base height = 13 Pi a t aTotal volume = 23 Pi aat + Pi a t (l- 2a) + 13 Pi a t a
=Pi atl -Pi a at= Pi a t(l-a)
Goldstein and Sase dataStomach capacity at term 10 - 15 ml
BRADSHAW formula
141
Assumption 25 kg baby 33w GA
requiring 150 mlkgday = 375 ml
45 MIN CYCLES ( 32 cyclesday)
12 ML PER CYCLE = 384 ml142
Newborn stomach volume
Gastric volumes at birthCorrelated with gastric pH
gastrin and somatostatin
ldquofetus drinks 10 ml portions of amniotic fluid helliprdquo
Widstrom 1988 143
Only recent study locatedldquoAutopsyrdquo capacity was determined
in Indian post-mortem studies
100 autopsies (63 SB 37 ENND)Tied at cardia and pylorus filled withwater emptied amp measured repeatedldquohellip obliteration of the gastric curvaturesrdquoldquodue care to minimize stretch artifactsrdquo
Naveed 1992
ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo
144
25
Infants above 2500g onlyAve Range
Stillborn (n 11) 196 ml (10-35)Early death (n 9) 178 ml (10-25)All cases (n 20) 188 ml
Naveed 1992
ldquoAn Autopsy Study of Relationship between Perinatal Stomach Capacity and Birth Weightrdquo
145 146
KERNESSUK 1997 (Russian)
Postmortem in situ measures(applied Bradshaw formula)
AveNewborn (n 11) 15 ml2 months (n 11) 35 ml2-4 m (n 10) 50 ml4-6 m (n 8) 100 ml
Known references with data
Scammon and Doyle 1920
Zuccarellirsquos method stomach filled at autopsy to ldquoa pressure of between
15 and 20 centimeters of waterrdquo
Scammon 1920
ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo
147
Anatomic capacity was determined in post-mortem studies
Main data set Alliot 1905 (n 25)Scammon own cases (n 13)
30 ndash 35 ml at birth ndashalmost regardless of birth weight
Scammon 1920
ldquoObservations of the capacity of the stomach in the first ten days of post natal liferdquo
148
Zangen S et al Rapid maturation of gastric relaxation in newborns
Pressures (mmHg)
Balloon inflates to
15 ml no increase
functional capacity
149
Zangen S et al Rapid maturation of gastric relaxation in newborns
Pressures (mmHg)
Balloon inflates to
15 ml no increase20 ml pressure OK
physiologicalcapacity hellip 150
26
EVIDENCE (NBn 111009)
Author Capacity NoteSase 10-15 ml Live term fetusGoldstein 10-15 ml Live term fetusWidstrom 10 mls Live newbornZangen 20 mls Live (pressure)
Naveed 20 mls Autopsy (SB)20 mls Autopsy (ENND)
Kernessuk 15 mls Autopsy (in situ)Scammon 30-35 ml Autopsy (water