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
EPIGENETICS
ldquoexcept in the light
of motherrsquos bodyrdquo
NEURODEVELOPMENT
The DNA Behaviour
EVOLUTIONARY BIOLOGY
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
EXPECTED UNEXPECTED
ldquobuffering
protection of
adult supportrdquo
NEURODEVELOPMENT
The DNA Behaviour
EVOLUTIONARY BIOLOGY
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
BIRTH
SEPARATIONMOTHERBABY
BONDING Sensitization
Vulnerability
DISEASE
Disordered attachment
Toxic stress
Insensitiveparenting
ZERO
SEPARATION
NEURODEVELOPMENT
The DNA Behaviour
EVOLUTIONARY BIOLOGY
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
BIRTH
SEPARATIONMOTHERBABY
BONDING Sensitization
Disordered attachment
Toxic stress
Insensitiveparenting
NEURODEVELOPMENT
The DNA Behaviour
EVOLUTIONARY BIOLOGY
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
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
Doucet 2012
In the lsquolsquoscentless breastrsquorsquo
condition all infants were
exposed to the motherrsquos breast
fully covered with a perfectly
transparent and airtight plastic
film (polypropylene)
( the habitual visual scene of
the breast devoid of
corresponding odors )
(1) lsquolsquoBreastrsquorsquogroup (fully
uncovered motherrsquos breast)
(2) lsquolsquoNipplersquorsquogroup (all remaining
parts covered with plastic film)
(3) lsquolsquoAreolarsquorsquogroup (remainder of
the breast and nipple covered)
(4) lsquolsquoMilkrsquorsquogroup (milk smeared
on plastic covered breast)
5
lsquolsquoBreastrsquorsquogroup 0102
more than
lsquolsquoAreolarsquorsquogroup 0038
more than
lsquolsquoMilkrsquorsquogroup 0035
Grey bar ndash odourless
plastic film
Black ndash pooled odors
They displayed significantly longer global oral activity
when facing any of the odorous breast with opened
eyes the three other conditions being equivalent
odorous breast opened eyes 1327
odorous breast closed eyes 992
scentless breast opened eyes 663
scentless breast closed eyes 839
hellip only male newborns opened their eyes longer in
response to odorous breast conditions than to the
scentless condition
(0654 vs 0425 plt01)
Related experiments indicate however that the
chemical cues that attract rat pups to the nipples
are not produced in that region Rather initial
nipple orientation is elicited by the odor of
amniotic fluid and saliva that the mother spreads
on her ventrum while grooming herself during
parturition [7]
Babies more often spontaneously selected a breast
treated with a small amount of their own AF applied to
the nippleareola region than the alternative untreated
breast during tests beginning several minutes after
parturition [112]
These results are corroborated by a study in which 2-
day-old infants were offered a simultaneous choice
between two gauze pads the length of time oriented
to the odor of their AF was reliably greater than that
towards an odorless stimulus pad [92]
PSN envisions a community that embraces its mothers and babies and
values the unique
opportunity at birthto impact the physical and emotional
well-being of the newborn
Target 1 for 2005
Report that 65 of infants are placed and remain in
direct skin to skin contactwith their mothers
for at least one hourduring the first 3 hours after birth
6
Skin-to-skin and breastfeeding (4)
0
10
20
30
40
50
60
70
80
90
100
3Q05 4Q05 1Q06 2Q06 3Q06 4Q06 1Q07 2Q07
Breastfeeding intention Skin-to-skin one hour Breastfeeding at discharge
Used with permission Ruth Stanhiser MD
Babies breastfeeding
Mothers intending to breastfeed
Breastfeeding by the NeonateRegistration by skin-to-skin contact
More skin-to-skin more breastfeeding
Thomson 1979
E Early SSC first hourL Late contact next day2 2 hourly feeds from birth4 4 hourly feeds from birth
Group Brf at 12 w Brf duration (days)
2E 643 182 (14 - 392)4E 556 140 (14 ndash 322)2L 556 112 (10 ndash 294)4L 462 77 (11 ndash 280)
Salariya 1978
7
DEFENSE NUTRITION REPRODUCTION
HORMONES NERVES MUSCLES
DEFENSE NUTRITION REPRODUCTION
HORMONES NERVES MUSCLES
= BREASTFEEDING
SAFE
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
WIRE MOTHER
NEURODEVELOPMENTThe DNA Behaviour
EVOLUTIONARY BIOLOGY
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
BIRTH
BEYOND BREASTFEEDING Feed Sleep Cycling
MOTHERBABY
BONDING Sensitization
Secure attachment
Attuned parenting
SEPARATION
OXYTOCIN
8
OXYTOCIN
OXYTOCIN comes from
Cervical dilatation
Skin-to-skin contact
Breastfeeding
Eye-to-eye contact
Effects of doula care
No doula DoulaUSA (Kennell et al 1991)
Epidural 55 8Caesarean section 18 8Forceps delivery 26 8Fetal distress 24 10
ldquoIf a Doula was a drug it would be unethical
not to use itrdquoDr John Kennell
1922 -2013Marshall Klaus amp John Kenell
EARLY CHILDHOOD DEVELOPMENT ECD
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
BIRTH
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
WIRE MOTHER
OXYTOCIN
11
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDINGON-GOING
S S C
WIRE TOGETHER
OXYTOCIN
hellip infant cues - suckling vocalisation and tactile stimulation - stimulate
OXYTOCINrelease in the hypothalamus which may result in the activation of the dopaminergic reward pathway leading to behavioural reinforcement
key biological systems hellip that contribute to maternal caregiving behaviour hellip the oxytocinergic and dopaminergic systems
hellip dopamine pathways contribute to the processing of infant-related sensory cues leading to a behavioural response c
DISEASEHEALTH
CORTISOLOXYTOCIN
The psychology of human parent-infant relationships
Parenting is regulated by key hormones and neurotransmitters
Neuroanatomical circuits of parenting
Integrative physiology of normal parenting behaviours
Brain imaging of human parent-infant relationships
The neurobiology of empathy and parenting
Conclusions and critical summary
(Swain et al 2007)
12
FEARCONTROL
CENTRE
REWARDCONTROL
CENTRE
SOCIALCONTROL CENTRE
OXYTOCINDOPAMINE
CORTISOL
EMOTIONCONTROL CENTRE
WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY
DISEASEHEALTH
RESILIENCE VULNERABILITY
hellip there is considerable overlap in the brain structures associated with these neural mechanisms hellip functional interactions among the circuits
DOULA and KANGAROULA
-1000 min
BIRTH
+1000 min 1000 days
OXYTOCIN Zero separation
Protect OXYTOCINBefore and after
BIRTH
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDINGON-GOING
S S C
WIRE TOGETHER
Protect OXYTOCINBefore and after
BIRTH
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDINGON-GOING
S S C
WIRE SUCKLING
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
Alberts SUCKLING versus FEEDING
DUAL INGESTION SYSTEMS
13
300 mya 200 mya 100 mya 50 mya 300 mya 200 mya 100 mya 50 mya
Amniotes
Synapsids
Cynodonts
Mammaliaformes
PlacentalsMammals
ANCESTRAL STATE
hellip intoMATURE FEEDING
300 mya 200 mya 100 mya 50 mya
WATER
EGGS
Hatch withTEETH
ANCESTRAL STATE
hellip intoMATURE FEEDING
eg TURTLES
CROCODILES DINOSAURS
REPTILES
300 mya 200 mya 100 mya 50 mya
Epibubic bone = pouch care
hellip intoMATURE FEEDING
Amniotes
Synapsids
Cynodonts
Mammaliaformes
Smaller eggs longer in body
The AMNIOTE EGGextra membranes
Copes with AIR
PlacentalsMammals
Viviparity = immature
ENDOTHERMY
MOISTUREfor eggs
Diphyodontism
300 mya 200 mya 100 mya 50 mya
hellip intoMATURE FEEDING
Amniotes
Synapsids
Cynodonts
Mammaliaformes
PlacentalsMammals
ENDOTHERMY
MOISTUREfor eggs
LACTOSE added(apocrine glands)
NUTRIENTSAntimicrobials
LACTATION
SUCKLINGFEEDING
200 million years
Diphyodontism
300 mya 200 mya 100 mya 50 mya
hellip intoMATURE FEEDING
Amniotes
Synapsids
Cynodonts
Mammaliaformes
PlacentalsMammals
ENDOTHERMY
MOISTUREfor eggs
LACTOSE added(apocrine glands)
NUTRIENTSAntimicrobials
LACTATION
SUCKLINGFEEDING
200 million years
DUAL INGESTION SYSTEMS
100 million years
14
DUAL INGESTION SYSTEMS DUAL INGESTION SYSTEMS
SUCKLING WEANING FEEDING
Lactase Digestive enzymes
FEEDING SUCKLING
Influence of SMELL None Totally dependent
Motor mechanism Chewing ndash different
muscles
Suckling ndash different circuits
INSULIN Increases weight No effect
GHRELIN Increases weight No effect
LEPTIN Decreases intake No effect
CHOLECYSTOKININ Decreases intake No effect
AMPHETAMINE Decreases appetite Increases suckling
SEROTONIN Agonist improves feeding Antagonist improves suck
SATIETY Infant determined Maternal supply determine
FEEDING SUCKLING
DISRUPTION ROBUST VERY SENSITIVE
Must have right conditions
Pup-in-a- cup - And STIMULI
separated and fed by tube
From day 2 off life
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
14th century Tuscan text
Conceptual changeDyad careBreast first hour
even CaesareanContinuous SSC
DISCONTINUEGiving waterGlucose waterInfant formulaSeparationPacifier (dummy)
CHANGE POLICY Canrsquot change
biology
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
ON-GOING
S S C
WIRE NEURONS
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C WIRE
TIMING
(behavior)
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
ENTERIC NERVOUS SYSTEM
123
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
FEEDBACK LOOPS
CNS
ENS
ANS
InternalSomaticenvironment
124
125 126
22
Fetal stomach appears 4 weeks GABy 11 weeks wall capable of muscular
contraction
ldquoPatterns of antropyloric motilityin fed healthy preterm infantsrdquo
the neuroregulatory mechanisms responsible for the coordination of antro-pyloric motility and gastric emptying are
well developed by 30 weeks of PMAHassan 2002 127
Hydrochloric acidimportant for activation of pepsinogen
inactivation of microorganisms such as bacteria
Pepsinogenactivated by acid into active pepsin
responsible for the stomachs ability to initiate digestion of proteins
Chymosinis an enzyme whose role is to curdle or
coagulate milk in the stomach a process of considerable importance in the very young animal
128
Chymosinmakes the milk into ldquocheeserdquohalfway between liquid and solidstomach empties in 60 minutes
milk
129
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
FEEDBACK LOOPS
130
EVIDENCE FORFEEDING FREQUENCY
Edmond 2006 131
Breastfeeding and motherrsquos milkStrong and consistent evidence 132
23
Cup feeding versus bottle feedingCup feeding higher breastfeeding
greater stability133
Only case series Insufficient evidence
No mention of
stomach capacity134
EVIDENCE FORSTOMACH CAPACITY
Edmond 2006 135
0
05
1
15
2
25
3
35
4
0 10 20 30 40 50 60 70 80
volume ingested
fee
din
g f
req
ue
nc
y
Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml
StandardCARE3 hourlyschedule
136
KEY QUESTION
WHAT IS THE
STOMACHVOLUMEOF THE
NEONATE 137 Sase 2005
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
(Alliot) pressure)151
PROPOSAL
The CAPACITY of aweek old babyrsquos stomach is
approx 20 ml152
0
05
1
15
2
25
3
35
4
0 10 20 30 40 50 60 70 80
volume ingested
fee
din
g f
req
ue
nc
y
Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml
StandardCARE3 hourlyschedule
MOTHERNATURE
1 hourlyschedule
153
PHYSIOLOGICAL CAPACITY
RECEPTIVE CAPACITY of stomach
INGESTIVE CAPACITY of BABY
FUNCTIONAL CAPACITY
154
PROPOSAL
The FEEDINGFREQUENCY of theNEONATE is
approx 60 min155
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
BRAIN CYCLING
STOMACH FILLING amp EMPTYING
REMNR1NR2NR3NR4
156
27
Normal physiology of theEnteric Nervous System
ldquoSmall and frequent feeds according to the sleep cyclerdquo
The ldquonicherdquo (occupation) of a neonate (Alberts)
BOND FEED
SLEEP SLEEP
PLAY FEED
157
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
FEEDING SUCKLING
Influence of SMELL None Totally dependent
Motor mechanism Chewing ndash different
muscles
Suckling ndash different circuits
INSULIN Increases weight No effect
GHRELIN Increases weight No effect
LEPTIN Decreases intake No effect
CHOLECYSTOKININ Decreases intake No effect
AMPHETAMINE Decreases appetite Increases suckling
SEROTONIN Agonist improves feeding Antagonist improves suck
SATIETY Infant determined Maternal supply determine
FEEDING SUCKLING
Influence of SMELL None Totally dependent
Motor mechanism Chewing ndash different
muscles
Suckling ndash different circuits
INSULIN Increases weight No effect
GHRELIN Increases weight No effect
LEPTIN Decreases intake No effect
CHOLECYSTOKININ Decreases intake No effect
AMPHETAMINE Decreases appetite Increases suckling
SEROTONIN Agonist improves feeding Antagonist improves suck
SATIETY Infant determined Maternal supply determine
Current dogmaTHE BABY KNOWS
WHEN IT HAS HAD ENOUGH
PROBABLY NOT
WHAT IS THE
STOMACH VOLUME OF THE
PREMATURE
161
Assume low resilience
Assume proportionality
162
28
The CAPACITY of alow birthweight premfrom 20ml 3000g
= 0007 x BWt (g)
1kg x 0007 = 7mls2kg x 0007 = 14mls
163
Gastric overfilling syndrome
164
75 ml per feeding ASSUMPTION
IMMATURE OR OVERWHELMED
many aspects of gastrointestinalmotility are immature in the neonate
Zangen S et al Rapid maturation of gastric relaxation in newborns
A balloon in stomachcan fill to 76 mls
What does the stomach ndashwithout a balloon ndashdo to 76 mls
REFLUX PRESUME each feedapproximately 75 mls
GER
bull Sudden outbursts of crying
bull Awakens in pain
bull Related to feedings
bull Not easily comforted
bull ldquoI know baby hurtsrdquo
bull Sour burps throaty noises
bull Best when upright
Clues to GER
Dr W Sears
29
Mitchell 2001
Kerstin Uvnaumls-Moberg
Food in duodenum
AMYLINreleased
Closes pylorus
Duodenumempty
Pylorusopens
ldquoFeed intolerancerdquo hellip hellip or VOLUME intolerance
HYPOGLYCAEMIA
A babies stomach empties in60 minutes
Blood sugarmay fall hellip
after 90 minutes Options
30
METABOLIC ADAPTATION
SSC started in the first 20 minutes after birth
SSC CotBlood glucose (1 hr) 317 256Base excess drop 34 18
(Christenson 1992)0h 1h 2h 3h 4h 2 days
App
roxim
ate
GLUCOSE
SSC Glucose production = Glucose consumption
Separation
SNS stress Glucose consumption INCREASE
PSNS dissociation Glucose production DECREASE
HYPOGLYCEMIA
SSC Cot
Blood glucose (1 hr) 317 256
0h 1h 2h 3h 4h 2 days
App
roxim
ate
GLUCOSE
SSC Glucose production = Glucose consumption
Separation PSNS dissociation
Glucose production DECREASE
HYPOGLYCEMIA
SSC Cot
Blood glucose (1 hr) 317 256
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
NEURODEVELOPMENTThe DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
BONDING ATTACHMENT
MRI HRVEEG
STRESS RESPONES
RESILIENCE
DOHAD
(MAL) ADAPTATION
EPIGENETICS
GENE X ENVIRONMENT
GENETIC VARIANTS
HOSPITAL ACQUIRED INFECTIONIMMUNITY
SLEEP PHYSIOLOGY
GUT FUNCTIONMICROBIOTA
ldquoSTABILITYrdquo
TRANSITION
LONG TERM FOLLOW-UP
NEUROENDOCRINE BEHAVIOURS
MATERNAL NEUROPLASTICITY
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
MORTALITYMETABOLISM
0h 1h 2h 3h 4h
PSNS (vagal)
App
roxim
ate
GLUCOSE
1 HOURLY Milk feed
1 HOURLY Milk feed
1 HOURLY Milk feed
1 HOURLY Milk feed
LACTOSE
METABOLISM
31
0h 1h 2h 3h 4h
PSNS (vagal) SYMPATHETIC STRESS
App
roxim
ate
GLUCOSE
LACTOSE FATGLYCOGEN
METABOLISM
4 HOURLY Milk feed
0h 1h 2h 3h 4h
PSNS (vagal) SYMPATHETIC STRESS
App
roxim
ate
GLUCOSE
4 HOURLY ALLOSTATIC STATELACTOSE FATGLYCOGEN
METABOLISM
4 HOURLY Milk feed
HEALTH DISEASE
EXPECTED UNEXPECTED
NEURODEVELOPMENTThe DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
BONDING ATTACHMENT
MRI HRVEEG
STRESS RESPONES
RESILIENCE
DOHAD
(MAL) ADAPTATION
EPIGENETICS
GENE X ENVIRONMENT
GENETIC VARIANTS
HOSPITAL ACQUIRED INFECTIONIMMUNITY
SLEEP PHYSIOLOGY
GUT FUNCTIONMICROBIOTA
ldquoSTABILITYrdquo
TRANSITION
LONG TERM FOLLOW-UP
NEUROENDOCRINE BEHAVIOURS
MATERNAL NEUROPLASTICITY
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
MORTALITYMETABOLISM
Weight gain 1st week
predicts OBESITYat 30 years
Large volume feedsstretched stomach=
doubled absorptivecapacity as adult
Importance
Programming ndash early life chronic disease
32
RESISTANCE SENSITIVITY
PERCEPTIONSldquoNEUROCEPTIONrdquo
RESPONSESTRESS
ALLOSTATIC STATE
ALLOSTASIS
ANY STRESSPsychologicalNeurological
EndocrineImmune
ALLOSTATIC LOAD
ALLOSTATIC OVERLOAD
WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY
DISEASEHEALTH
RESILIENCE VULNERABILITY
RESISTANCE SENSITIVITY
PERCEPTIONSldquoNEUROCEPTIONrdquo
RESPONSESTRESS
ALLOSTATIC STATE
ALLOSTASIS
ANY STRESSPsychologicalNeurological
EndocrineImmune
ALLOSTATIC LOAD
HEALTH
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
Gastric overfilling syndrome
189
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
33
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
Only case series Insufficient evidence
No mention of
stomach capacity196
Baby weight freq reqrsquod size actual
2kg baby 4hrly ~ 320 ml6 = 53ml 14ml
15 baby 3hrly ~ 240 ml8 = 30ml 10ml
10 baby 2hrly ~ 160 ml12 = 13ml 7ml
Standardised from20ml capacityfor 3kg baby( x 0007)
197
0
10
20
30
40
50
60
70
80
90
13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w
LINEAR
TERM
PREM
198
34
0
10
20
30
40
50
60
70
80
90
13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w
LINEAR
TERM
PREM
199
Clues to GER
ldquoI know baby hurtsrdquo
Gastric overfilling syndrome
Excessive volumesreflux aspiration colic
Excessive time intervalhypoglycaemia
Adaptationsdiabetic diathesis obesity
200
Developmental Care of the Enteric Nervous System
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
Doucet 2012
In the lsquolsquoscentless breastrsquorsquo
condition all infants were
exposed to the motherrsquos breast
fully covered with a perfectly
transparent and airtight plastic
film (polypropylene)
( the habitual visual scene of
the breast devoid of
corresponding odors )
(1) lsquolsquoBreastrsquorsquogroup (fully
uncovered motherrsquos breast)
(2) lsquolsquoNipplersquorsquogroup (all remaining
parts covered with plastic film)
(3) lsquolsquoAreolarsquorsquogroup (remainder of
the breast and nipple covered)
(4) lsquolsquoMilkrsquorsquogroup (milk smeared
on plastic covered breast)
5
lsquolsquoBreastrsquorsquogroup 0102
more than
lsquolsquoAreolarsquorsquogroup 0038
more than
lsquolsquoMilkrsquorsquogroup 0035
Grey bar ndash odourless
plastic film
Black ndash pooled odors
They displayed significantly longer global oral activity
when facing any of the odorous breast with opened
eyes the three other conditions being equivalent
odorous breast opened eyes 1327
odorous breast closed eyes 992
scentless breast opened eyes 663
scentless breast closed eyes 839
hellip only male newborns opened their eyes longer in
response to odorous breast conditions than to the
scentless condition
(0654 vs 0425 plt01)
Related experiments indicate however that the
chemical cues that attract rat pups to the nipples
are not produced in that region Rather initial
nipple orientation is elicited by the odor of
amniotic fluid and saliva that the mother spreads
on her ventrum while grooming herself during
parturition [7]
Babies more often spontaneously selected a breast
treated with a small amount of their own AF applied to
the nippleareola region than the alternative untreated
breast during tests beginning several minutes after
parturition [112]
These results are corroborated by a study in which 2-
day-old infants were offered a simultaneous choice
between two gauze pads the length of time oriented
to the odor of their AF was reliably greater than that
towards an odorless stimulus pad [92]
PSN envisions a community that embraces its mothers and babies and
values the unique
opportunity at birthto impact the physical and emotional
well-being of the newborn
Target 1 for 2005
Report that 65 of infants are placed and remain in
direct skin to skin contactwith their mothers
for at least one hourduring the first 3 hours after birth
6
Skin-to-skin and breastfeeding (4)
0
10
20
30
40
50
60
70
80
90
100
3Q05 4Q05 1Q06 2Q06 3Q06 4Q06 1Q07 2Q07
Breastfeeding intention Skin-to-skin one hour Breastfeeding at discharge
Used with permission Ruth Stanhiser MD
Babies breastfeeding
Mothers intending to breastfeed
Breastfeeding by the NeonateRegistration by skin-to-skin contact
More skin-to-skin more breastfeeding
Thomson 1979
E Early SSC first hourL Late contact next day2 2 hourly feeds from birth4 4 hourly feeds from birth
Group Brf at 12 w Brf duration (days)
2E 643 182 (14 - 392)4E 556 140 (14 ndash 322)2L 556 112 (10 ndash 294)4L 462 77 (11 ndash 280)
Salariya 1978
7
DEFENSE NUTRITION REPRODUCTION
HORMONES NERVES MUSCLES
DEFENSE NUTRITION REPRODUCTION
HORMONES NERVES MUSCLES
= BREASTFEEDING
SAFE
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
WIRE MOTHER
NEURODEVELOPMENTThe DNA Behaviour
EVOLUTIONARY BIOLOGY
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
BIRTH
BEYOND BREASTFEEDING Feed Sleep Cycling
MOTHERBABY
BONDING Sensitization
Secure attachment
Attuned parenting
SEPARATION
OXYTOCIN
8
OXYTOCIN
OXYTOCIN comes from
Cervical dilatation
Skin-to-skin contact
Breastfeeding
Eye-to-eye contact
Effects of doula care
No doula DoulaUSA (Kennell et al 1991)
Epidural 55 8Caesarean section 18 8Forceps delivery 26 8Fetal distress 24 10
ldquoIf a Doula was a drug it would be unethical
not to use itrdquoDr John Kennell
1922 -2013Marshall Klaus amp John Kenell
EARLY CHILDHOOD DEVELOPMENT ECD
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
BIRTH
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
WIRE MOTHER
OXYTOCIN
11
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDINGON-GOING
S S C
WIRE TOGETHER
OXYTOCIN
hellip infant cues - suckling vocalisation and tactile stimulation - stimulate
OXYTOCINrelease in the hypothalamus which may result in the activation of the dopaminergic reward pathway leading to behavioural reinforcement
key biological systems hellip that contribute to maternal caregiving behaviour hellip the oxytocinergic and dopaminergic systems
hellip dopamine pathways contribute to the processing of infant-related sensory cues leading to a behavioural response c
DISEASEHEALTH
CORTISOLOXYTOCIN
The psychology of human parent-infant relationships
Parenting is regulated by key hormones and neurotransmitters
Neuroanatomical circuits of parenting
Integrative physiology of normal parenting behaviours
Brain imaging of human parent-infant relationships
The neurobiology of empathy and parenting
Conclusions and critical summary
(Swain et al 2007)
12
FEARCONTROL
CENTRE
REWARDCONTROL
CENTRE
SOCIALCONTROL CENTRE
OXYTOCINDOPAMINE
CORTISOL
EMOTIONCONTROL CENTRE
WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY
DISEASEHEALTH
RESILIENCE VULNERABILITY
hellip there is considerable overlap in the brain structures associated with these neural mechanisms hellip functional interactions among the circuits
DOULA and KANGAROULA
-1000 min
BIRTH
+1000 min 1000 days
OXYTOCIN Zero separation
Protect OXYTOCINBefore and after
BIRTH
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDINGON-GOING
S S C
WIRE TOGETHER
Protect OXYTOCINBefore and after
BIRTH
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDINGON-GOING
S S C
WIRE SUCKLING
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
Alberts SUCKLING versus FEEDING
DUAL INGESTION SYSTEMS
13
300 mya 200 mya 100 mya 50 mya 300 mya 200 mya 100 mya 50 mya
Amniotes
Synapsids
Cynodonts
Mammaliaformes
PlacentalsMammals
ANCESTRAL STATE
hellip intoMATURE FEEDING
300 mya 200 mya 100 mya 50 mya
WATER
EGGS
Hatch withTEETH
ANCESTRAL STATE
hellip intoMATURE FEEDING
eg TURTLES
CROCODILES DINOSAURS
REPTILES
300 mya 200 mya 100 mya 50 mya
Epibubic bone = pouch care
hellip intoMATURE FEEDING
Amniotes
Synapsids
Cynodonts
Mammaliaformes
Smaller eggs longer in body
The AMNIOTE EGGextra membranes
Copes with AIR
PlacentalsMammals
Viviparity = immature
ENDOTHERMY
MOISTUREfor eggs
Diphyodontism
300 mya 200 mya 100 mya 50 mya
hellip intoMATURE FEEDING
Amniotes
Synapsids
Cynodonts
Mammaliaformes
PlacentalsMammals
ENDOTHERMY
MOISTUREfor eggs
LACTOSE added(apocrine glands)
NUTRIENTSAntimicrobials
LACTATION
SUCKLINGFEEDING
200 million years
Diphyodontism
300 mya 200 mya 100 mya 50 mya
hellip intoMATURE FEEDING
Amniotes
Synapsids
Cynodonts
Mammaliaformes
PlacentalsMammals
ENDOTHERMY
MOISTUREfor eggs
LACTOSE added(apocrine glands)
NUTRIENTSAntimicrobials
LACTATION
SUCKLINGFEEDING
200 million years
DUAL INGESTION SYSTEMS
100 million years
14
DUAL INGESTION SYSTEMS DUAL INGESTION SYSTEMS
SUCKLING WEANING FEEDING
Lactase Digestive enzymes
FEEDING SUCKLING
Influence of SMELL None Totally dependent
Motor mechanism Chewing ndash different
muscles
Suckling ndash different circuits
INSULIN Increases weight No effect
GHRELIN Increases weight No effect
LEPTIN Decreases intake No effect
CHOLECYSTOKININ Decreases intake No effect
AMPHETAMINE Decreases appetite Increases suckling
SEROTONIN Agonist improves feeding Antagonist improves suck
SATIETY Infant determined Maternal supply determine
FEEDING SUCKLING
DISRUPTION ROBUST VERY SENSITIVE
Must have right conditions
Pup-in-a- cup - And STIMULI
separated and fed by tube
From day 2 off life
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
14th century Tuscan text
Conceptual changeDyad careBreast first hour
even CaesareanContinuous SSC
DISCONTINUEGiving waterGlucose waterInfant formulaSeparationPacifier (dummy)
CHANGE POLICY Canrsquot change
biology
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
ON-GOING
S S C
WIRE NEURONS
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C WIRE
TIMING
(behavior)
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
ENTERIC NERVOUS SYSTEM
123
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
FEEDBACK LOOPS
CNS
ENS
ANS
InternalSomaticenvironment
124
125 126
22
Fetal stomach appears 4 weeks GABy 11 weeks wall capable of muscular
contraction
ldquoPatterns of antropyloric motilityin fed healthy preterm infantsrdquo
the neuroregulatory mechanisms responsible for the coordination of antro-pyloric motility and gastric emptying are
well developed by 30 weeks of PMAHassan 2002 127
Hydrochloric acidimportant for activation of pepsinogen
inactivation of microorganisms such as bacteria
Pepsinogenactivated by acid into active pepsin
responsible for the stomachs ability to initiate digestion of proteins
Chymosinis an enzyme whose role is to curdle or
coagulate milk in the stomach a process of considerable importance in the very young animal
128
Chymosinmakes the milk into ldquocheeserdquohalfway between liquid and solidstomach empties in 60 minutes
milk
129
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
FEEDBACK LOOPS
130
EVIDENCE FORFEEDING FREQUENCY
Edmond 2006 131
Breastfeeding and motherrsquos milkStrong and consistent evidence 132
23
Cup feeding versus bottle feedingCup feeding higher breastfeeding
greater stability133
Only case series Insufficient evidence
No mention of
stomach capacity134
EVIDENCE FORSTOMACH CAPACITY
Edmond 2006 135
0
05
1
15
2
25
3
35
4
0 10 20 30 40 50 60 70 80
volume ingested
fee
din
g f
req
ue
nc
y
Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml
StandardCARE3 hourlyschedule
136
KEY QUESTION
WHAT IS THE
STOMACHVOLUMEOF THE
NEONATE 137 Sase 2005
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
(Alliot) pressure)151
PROPOSAL
The CAPACITY of aweek old babyrsquos stomach is
approx 20 ml152
0
05
1
15
2
25
3
35
4
0 10 20 30 40 50 60 70 80
volume ingested
fee
din
g f
req
ue
nc
y
Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml
StandardCARE3 hourlyschedule
MOTHERNATURE
1 hourlyschedule
153
PHYSIOLOGICAL CAPACITY
RECEPTIVE CAPACITY of stomach
INGESTIVE CAPACITY of BABY
FUNCTIONAL CAPACITY
154
PROPOSAL
The FEEDINGFREQUENCY of theNEONATE is
approx 60 min155
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
BRAIN CYCLING
STOMACH FILLING amp EMPTYING
REMNR1NR2NR3NR4
156
27
Normal physiology of theEnteric Nervous System
ldquoSmall and frequent feeds according to the sleep cyclerdquo
The ldquonicherdquo (occupation) of a neonate (Alberts)
BOND FEED
SLEEP SLEEP
PLAY FEED
157
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
FEEDING SUCKLING
Influence of SMELL None Totally dependent
Motor mechanism Chewing ndash different
muscles
Suckling ndash different circuits
INSULIN Increases weight No effect
GHRELIN Increases weight No effect
LEPTIN Decreases intake No effect
CHOLECYSTOKININ Decreases intake No effect
AMPHETAMINE Decreases appetite Increases suckling
SEROTONIN Agonist improves feeding Antagonist improves suck
SATIETY Infant determined Maternal supply determine
FEEDING SUCKLING
Influence of SMELL None Totally dependent
Motor mechanism Chewing ndash different
muscles
Suckling ndash different circuits
INSULIN Increases weight No effect
GHRELIN Increases weight No effect
LEPTIN Decreases intake No effect
CHOLECYSTOKININ Decreases intake No effect
AMPHETAMINE Decreases appetite Increases suckling
SEROTONIN Agonist improves feeding Antagonist improves suck
SATIETY Infant determined Maternal supply determine
Current dogmaTHE BABY KNOWS
WHEN IT HAS HAD ENOUGH
PROBABLY NOT
WHAT IS THE
STOMACH VOLUME OF THE
PREMATURE
161
Assume low resilience
Assume proportionality
162
28
The CAPACITY of alow birthweight premfrom 20ml 3000g
= 0007 x BWt (g)
1kg x 0007 = 7mls2kg x 0007 = 14mls
163
Gastric overfilling syndrome
164
75 ml per feeding ASSUMPTION
IMMATURE OR OVERWHELMED
many aspects of gastrointestinalmotility are immature in the neonate
Zangen S et al Rapid maturation of gastric relaxation in newborns
A balloon in stomachcan fill to 76 mls
What does the stomach ndashwithout a balloon ndashdo to 76 mls
REFLUX PRESUME each feedapproximately 75 mls
GER
bull Sudden outbursts of crying
bull Awakens in pain
bull Related to feedings
bull Not easily comforted
bull ldquoI know baby hurtsrdquo
bull Sour burps throaty noises
bull Best when upright
Clues to GER
Dr W Sears
29
Mitchell 2001
Kerstin Uvnaumls-Moberg
Food in duodenum
AMYLINreleased
Closes pylorus
Duodenumempty
Pylorusopens
ldquoFeed intolerancerdquo hellip hellip or VOLUME intolerance
HYPOGLYCAEMIA
A babies stomach empties in60 minutes
Blood sugarmay fall hellip
after 90 minutes Options
30
METABOLIC ADAPTATION
SSC started in the first 20 minutes after birth
SSC CotBlood glucose (1 hr) 317 256Base excess drop 34 18
(Christenson 1992)0h 1h 2h 3h 4h 2 days
App
roxim
ate
GLUCOSE
SSC Glucose production = Glucose consumption
Separation
SNS stress Glucose consumption INCREASE
PSNS dissociation Glucose production DECREASE
HYPOGLYCEMIA
SSC Cot
Blood glucose (1 hr) 317 256
0h 1h 2h 3h 4h 2 days
App
roxim
ate
GLUCOSE
SSC Glucose production = Glucose consumption
Separation PSNS dissociation
Glucose production DECREASE
HYPOGLYCEMIA
SSC Cot
Blood glucose (1 hr) 317 256
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
NEURODEVELOPMENTThe DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
BONDING ATTACHMENT
MRI HRVEEG
STRESS RESPONES
RESILIENCE
DOHAD
(MAL) ADAPTATION
EPIGENETICS
GENE X ENVIRONMENT
GENETIC VARIANTS
HOSPITAL ACQUIRED INFECTIONIMMUNITY
SLEEP PHYSIOLOGY
GUT FUNCTIONMICROBIOTA
ldquoSTABILITYrdquo
TRANSITION
LONG TERM FOLLOW-UP
NEUROENDOCRINE BEHAVIOURS
MATERNAL NEUROPLASTICITY
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
MORTALITYMETABOLISM
0h 1h 2h 3h 4h
PSNS (vagal)
App
roxim
ate
GLUCOSE
1 HOURLY Milk feed
1 HOURLY Milk feed
1 HOURLY Milk feed
1 HOURLY Milk feed
LACTOSE
METABOLISM
31
0h 1h 2h 3h 4h
PSNS (vagal) SYMPATHETIC STRESS
App
roxim
ate
GLUCOSE
LACTOSE FATGLYCOGEN
METABOLISM
4 HOURLY Milk feed
0h 1h 2h 3h 4h
PSNS (vagal) SYMPATHETIC STRESS
App
roxim
ate
GLUCOSE
4 HOURLY ALLOSTATIC STATELACTOSE FATGLYCOGEN
METABOLISM
4 HOURLY Milk feed
HEALTH DISEASE
EXPECTED UNEXPECTED
NEURODEVELOPMENTThe DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
BONDING ATTACHMENT
MRI HRVEEG
STRESS RESPONES
RESILIENCE
DOHAD
(MAL) ADAPTATION
EPIGENETICS
GENE X ENVIRONMENT
GENETIC VARIANTS
HOSPITAL ACQUIRED INFECTIONIMMUNITY
SLEEP PHYSIOLOGY
GUT FUNCTIONMICROBIOTA
ldquoSTABILITYrdquo
TRANSITION
LONG TERM FOLLOW-UP
NEUROENDOCRINE BEHAVIOURS
MATERNAL NEUROPLASTICITY
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
MORTALITYMETABOLISM
Weight gain 1st week
predicts OBESITYat 30 years
Large volume feedsstretched stomach=
doubled absorptivecapacity as adult
Importance
Programming ndash early life chronic disease
32
RESISTANCE SENSITIVITY
PERCEPTIONSldquoNEUROCEPTIONrdquo
RESPONSESTRESS
ALLOSTATIC STATE
ALLOSTASIS
ANY STRESSPsychologicalNeurological
EndocrineImmune
ALLOSTATIC LOAD
ALLOSTATIC OVERLOAD
WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY
DISEASEHEALTH
RESILIENCE VULNERABILITY
RESISTANCE SENSITIVITY
PERCEPTIONSldquoNEUROCEPTIONrdquo
RESPONSESTRESS
ALLOSTATIC STATE
ALLOSTASIS
ANY STRESSPsychologicalNeurological
EndocrineImmune
ALLOSTATIC LOAD
HEALTH
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
Gastric overfilling syndrome
189
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
33
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
Only case series Insufficient evidence
No mention of
stomach capacity196
Baby weight freq reqrsquod size actual
2kg baby 4hrly ~ 320 ml6 = 53ml 14ml
15 baby 3hrly ~ 240 ml8 = 30ml 10ml
10 baby 2hrly ~ 160 ml12 = 13ml 7ml
Standardised from20ml capacityfor 3kg baby( x 0007)
197
0
10
20
30
40
50
60
70
80
90
13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w
LINEAR
TERM
PREM
198
34
0
10
20
30
40
50
60
70
80
90
13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w
LINEAR
TERM
PREM
199
Clues to GER
ldquoI know baby hurtsrdquo
Gastric overfilling syndrome
Excessive volumesreflux aspiration colic
Excessive time intervalhypoglycaemia
Adaptationsdiabetic diathesis obesity
200
Developmental Care of the Enteric Nervous System
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
Doucet 2012
In the lsquolsquoscentless breastrsquorsquo
condition all infants were
exposed to the motherrsquos breast
fully covered with a perfectly
transparent and airtight plastic
film (polypropylene)
( the habitual visual scene of
the breast devoid of
corresponding odors )
(1) lsquolsquoBreastrsquorsquogroup (fully
uncovered motherrsquos breast)
(2) lsquolsquoNipplersquorsquogroup (all remaining
parts covered with plastic film)
(3) lsquolsquoAreolarsquorsquogroup (remainder of
the breast and nipple covered)
(4) lsquolsquoMilkrsquorsquogroup (milk smeared
on plastic covered breast)
5
lsquolsquoBreastrsquorsquogroup 0102
more than
lsquolsquoAreolarsquorsquogroup 0038
more than
lsquolsquoMilkrsquorsquogroup 0035
Grey bar ndash odourless
plastic film
Black ndash pooled odors
They displayed significantly longer global oral activity
when facing any of the odorous breast with opened
eyes the three other conditions being equivalent
odorous breast opened eyes 1327
odorous breast closed eyes 992
scentless breast opened eyes 663
scentless breast closed eyes 839
hellip only male newborns opened their eyes longer in
response to odorous breast conditions than to the
scentless condition
(0654 vs 0425 plt01)
Related experiments indicate however that the
chemical cues that attract rat pups to the nipples
are not produced in that region Rather initial
nipple orientation is elicited by the odor of
amniotic fluid and saliva that the mother spreads
on her ventrum while grooming herself during
parturition [7]
Babies more often spontaneously selected a breast
treated with a small amount of their own AF applied to
the nippleareola region than the alternative untreated
breast during tests beginning several minutes after
parturition [112]
These results are corroborated by a study in which 2-
day-old infants were offered a simultaneous choice
between two gauze pads the length of time oriented
to the odor of their AF was reliably greater than that
towards an odorless stimulus pad [92]
PSN envisions a community that embraces its mothers and babies and
values the unique
opportunity at birthto impact the physical and emotional
well-being of the newborn
Target 1 for 2005
Report that 65 of infants are placed and remain in
direct skin to skin contactwith their mothers
for at least one hourduring the first 3 hours after birth
6
Skin-to-skin and breastfeeding (4)
0
10
20
30
40
50
60
70
80
90
100
3Q05 4Q05 1Q06 2Q06 3Q06 4Q06 1Q07 2Q07
Breastfeeding intention Skin-to-skin one hour Breastfeeding at discharge
Used with permission Ruth Stanhiser MD
Babies breastfeeding
Mothers intending to breastfeed
Breastfeeding by the NeonateRegistration by skin-to-skin contact
More skin-to-skin more breastfeeding
Thomson 1979
E Early SSC first hourL Late contact next day2 2 hourly feeds from birth4 4 hourly feeds from birth
Group Brf at 12 w Brf duration (days)
2E 643 182 (14 - 392)4E 556 140 (14 ndash 322)2L 556 112 (10 ndash 294)4L 462 77 (11 ndash 280)
Salariya 1978
7
DEFENSE NUTRITION REPRODUCTION
HORMONES NERVES MUSCLES
DEFENSE NUTRITION REPRODUCTION
HORMONES NERVES MUSCLES
= BREASTFEEDING
SAFE
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
WIRE MOTHER
NEURODEVELOPMENTThe DNA Behaviour
EVOLUTIONARY BIOLOGY
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
BIRTH
BEYOND BREASTFEEDING Feed Sleep Cycling
MOTHERBABY
BONDING Sensitization
Secure attachment
Attuned parenting
SEPARATION
OXYTOCIN
8
OXYTOCIN
OXYTOCIN comes from
Cervical dilatation
Skin-to-skin contact
Breastfeeding
Eye-to-eye contact
Effects of doula care
No doula DoulaUSA (Kennell et al 1991)
Epidural 55 8Caesarean section 18 8Forceps delivery 26 8Fetal distress 24 10
ldquoIf a Doula was a drug it would be unethical
not to use itrdquoDr John Kennell
1922 -2013Marshall Klaus amp John Kenell
EARLY CHILDHOOD DEVELOPMENT ECD
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
BIRTH
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
WIRE MOTHER
OXYTOCIN
11
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDINGON-GOING
S S C
WIRE TOGETHER
OXYTOCIN
hellip infant cues - suckling vocalisation and tactile stimulation - stimulate
OXYTOCINrelease in the hypothalamus which may result in the activation of the dopaminergic reward pathway leading to behavioural reinforcement
key biological systems hellip that contribute to maternal caregiving behaviour hellip the oxytocinergic and dopaminergic systems
hellip dopamine pathways contribute to the processing of infant-related sensory cues leading to a behavioural response c
DISEASEHEALTH
CORTISOLOXYTOCIN
The psychology of human parent-infant relationships
Parenting is regulated by key hormones and neurotransmitters
Neuroanatomical circuits of parenting
Integrative physiology of normal parenting behaviours
Brain imaging of human parent-infant relationships
The neurobiology of empathy and parenting
Conclusions and critical summary
(Swain et al 2007)
12
FEARCONTROL
CENTRE
REWARDCONTROL
CENTRE
SOCIALCONTROL CENTRE
OXYTOCINDOPAMINE
CORTISOL
EMOTIONCONTROL CENTRE
WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY
DISEASEHEALTH
RESILIENCE VULNERABILITY
hellip there is considerable overlap in the brain structures associated with these neural mechanisms hellip functional interactions among the circuits
DOULA and KANGAROULA
-1000 min
BIRTH
+1000 min 1000 days
OXYTOCIN Zero separation
Protect OXYTOCINBefore and after
BIRTH
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDINGON-GOING
S S C
WIRE TOGETHER
Protect OXYTOCINBefore and after
BIRTH
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDINGON-GOING
S S C
WIRE SUCKLING
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
Alberts SUCKLING versus FEEDING
DUAL INGESTION SYSTEMS
13
300 mya 200 mya 100 mya 50 mya 300 mya 200 mya 100 mya 50 mya
Amniotes
Synapsids
Cynodonts
Mammaliaformes
PlacentalsMammals
ANCESTRAL STATE
hellip intoMATURE FEEDING
300 mya 200 mya 100 mya 50 mya
WATER
EGGS
Hatch withTEETH
ANCESTRAL STATE
hellip intoMATURE FEEDING
eg TURTLES
CROCODILES DINOSAURS
REPTILES
300 mya 200 mya 100 mya 50 mya
Epibubic bone = pouch care
hellip intoMATURE FEEDING
Amniotes
Synapsids
Cynodonts
Mammaliaformes
Smaller eggs longer in body
The AMNIOTE EGGextra membranes
Copes with AIR
PlacentalsMammals
Viviparity = immature
ENDOTHERMY
MOISTUREfor eggs
Diphyodontism
300 mya 200 mya 100 mya 50 mya
hellip intoMATURE FEEDING
Amniotes
Synapsids
Cynodonts
Mammaliaformes
PlacentalsMammals
ENDOTHERMY
MOISTUREfor eggs
LACTOSE added(apocrine glands)
NUTRIENTSAntimicrobials
LACTATION
SUCKLINGFEEDING
200 million years
Diphyodontism
300 mya 200 mya 100 mya 50 mya
hellip intoMATURE FEEDING
Amniotes
Synapsids
Cynodonts
Mammaliaformes
PlacentalsMammals
ENDOTHERMY
MOISTUREfor eggs
LACTOSE added(apocrine glands)
NUTRIENTSAntimicrobials
LACTATION
SUCKLINGFEEDING
200 million years
DUAL INGESTION SYSTEMS
100 million years
14
DUAL INGESTION SYSTEMS DUAL INGESTION SYSTEMS
SUCKLING WEANING FEEDING
Lactase Digestive enzymes
FEEDING SUCKLING
Influence of SMELL None Totally dependent
Motor mechanism Chewing ndash different
muscles
Suckling ndash different circuits
INSULIN Increases weight No effect
GHRELIN Increases weight No effect
LEPTIN Decreases intake No effect
CHOLECYSTOKININ Decreases intake No effect
AMPHETAMINE Decreases appetite Increases suckling
SEROTONIN Agonist improves feeding Antagonist improves suck
SATIETY Infant determined Maternal supply determine
FEEDING SUCKLING
DISRUPTION ROBUST VERY SENSITIVE
Must have right conditions
Pup-in-a- cup - And STIMULI
separated and fed by tube
From day 2 off life
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
14th century Tuscan text
Conceptual changeDyad careBreast first hour
even CaesareanContinuous SSC
DISCONTINUEGiving waterGlucose waterInfant formulaSeparationPacifier (dummy)
CHANGE POLICY Canrsquot change
biology
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
ON-GOING
S S C
WIRE NEURONS
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C WIRE
TIMING
(behavior)
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
ENTERIC NERVOUS SYSTEM
123
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
FEEDBACK LOOPS
CNS
ENS
ANS
InternalSomaticenvironment
124
125 126
22
Fetal stomach appears 4 weeks GABy 11 weeks wall capable of muscular
contraction
ldquoPatterns of antropyloric motilityin fed healthy preterm infantsrdquo
the neuroregulatory mechanisms responsible for the coordination of antro-pyloric motility and gastric emptying are
well developed by 30 weeks of PMAHassan 2002 127
Hydrochloric acidimportant for activation of pepsinogen
inactivation of microorganisms such as bacteria
Pepsinogenactivated by acid into active pepsin
responsible for the stomachs ability to initiate digestion of proteins
Chymosinis an enzyme whose role is to curdle or
coagulate milk in the stomach a process of considerable importance in the very young animal
128
Chymosinmakes the milk into ldquocheeserdquohalfway between liquid and solidstomach empties in 60 minutes
milk
129
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
FEEDBACK LOOPS
130
EVIDENCE FORFEEDING FREQUENCY
Edmond 2006 131
Breastfeeding and motherrsquos milkStrong and consistent evidence 132
23
Cup feeding versus bottle feedingCup feeding higher breastfeeding
greater stability133
Only case series Insufficient evidence
No mention of
stomach capacity134
EVIDENCE FORSTOMACH CAPACITY
Edmond 2006 135
0
05
1
15
2
25
3
35
4
0 10 20 30 40 50 60 70 80
volume ingested
fee
din
g f
req
ue
nc
y
Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml
StandardCARE3 hourlyschedule
136
KEY QUESTION
WHAT IS THE
STOMACHVOLUMEOF THE
NEONATE 137 Sase 2005
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
(Alliot) pressure)151
PROPOSAL
The CAPACITY of aweek old babyrsquos stomach is
approx 20 ml152
0
05
1
15
2
25
3
35
4
0 10 20 30 40 50 60 70 80
volume ingested
fee
din
g f
req
ue
nc
y
Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml
StandardCARE3 hourlyschedule
MOTHERNATURE
1 hourlyschedule
153
PHYSIOLOGICAL CAPACITY
RECEPTIVE CAPACITY of stomach
INGESTIVE CAPACITY of BABY
FUNCTIONAL CAPACITY
154
PROPOSAL
The FEEDINGFREQUENCY of theNEONATE is
approx 60 min155
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
BRAIN CYCLING
STOMACH FILLING amp EMPTYING
REMNR1NR2NR3NR4
156
27
Normal physiology of theEnteric Nervous System
ldquoSmall and frequent feeds according to the sleep cyclerdquo
The ldquonicherdquo (occupation) of a neonate (Alberts)
BOND FEED
SLEEP SLEEP
PLAY FEED
157
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
FEEDING SUCKLING
Influence of SMELL None Totally dependent
Motor mechanism Chewing ndash different
muscles
Suckling ndash different circuits
INSULIN Increases weight No effect
GHRELIN Increases weight No effect
LEPTIN Decreases intake No effect
CHOLECYSTOKININ Decreases intake No effect
AMPHETAMINE Decreases appetite Increases suckling
SEROTONIN Agonist improves feeding Antagonist improves suck
SATIETY Infant determined Maternal supply determine
FEEDING SUCKLING
Influence of SMELL None Totally dependent
Motor mechanism Chewing ndash different
muscles
Suckling ndash different circuits
INSULIN Increases weight No effect
GHRELIN Increases weight No effect
LEPTIN Decreases intake No effect
CHOLECYSTOKININ Decreases intake No effect
AMPHETAMINE Decreases appetite Increases suckling
SEROTONIN Agonist improves feeding Antagonist improves suck
SATIETY Infant determined Maternal supply determine
Current dogmaTHE BABY KNOWS
WHEN IT HAS HAD ENOUGH
PROBABLY NOT
WHAT IS THE
STOMACH VOLUME OF THE
PREMATURE
161
Assume low resilience
Assume proportionality
162
28
The CAPACITY of alow birthweight premfrom 20ml 3000g
= 0007 x BWt (g)
1kg x 0007 = 7mls2kg x 0007 = 14mls
163
Gastric overfilling syndrome
164
75 ml per feeding ASSUMPTION
IMMATURE OR OVERWHELMED
many aspects of gastrointestinalmotility are immature in the neonate
Zangen S et al Rapid maturation of gastric relaxation in newborns
A balloon in stomachcan fill to 76 mls
What does the stomach ndashwithout a balloon ndashdo to 76 mls
REFLUX PRESUME each feedapproximately 75 mls
GER
bull Sudden outbursts of crying
bull Awakens in pain
bull Related to feedings
bull Not easily comforted
bull ldquoI know baby hurtsrdquo
bull Sour burps throaty noises
bull Best when upright
Clues to GER
Dr W Sears
29
Mitchell 2001
Kerstin Uvnaumls-Moberg
Food in duodenum
AMYLINreleased
Closes pylorus
Duodenumempty
Pylorusopens
ldquoFeed intolerancerdquo hellip hellip or VOLUME intolerance
HYPOGLYCAEMIA
A babies stomach empties in60 minutes
Blood sugarmay fall hellip
after 90 minutes Options
30
METABOLIC ADAPTATION
SSC started in the first 20 minutes after birth
SSC CotBlood glucose (1 hr) 317 256Base excess drop 34 18
(Christenson 1992)0h 1h 2h 3h 4h 2 days
App
roxim
ate
GLUCOSE
SSC Glucose production = Glucose consumption
Separation
SNS stress Glucose consumption INCREASE
PSNS dissociation Glucose production DECREASE
HYPOGLYCEMIA
SSC Cot
Blood glucose (1 hr) 317 256
0h 1h 2h 3h 4h 2 days
App
roxim
ate
GLUCOSE
SSC Glucose production = Glucose consumption
Separation PSNS dissociation
Glucose production DECREASE
HYPOGLYCEMIA
SSC Cot
Blood glucose (1 hr) 317 256
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
NEURODEVELOPMENTThe DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
BONDING ATTACHMENT
MRI HRVEEG
STRESS RESPONES
RESILIENCE
DOHAD
(MAL) ADAPTATION
EPIGENETICS
GENE X ENVIRONMENT
GENETIC VARIANTS
HOSPITAL ACQUIRED INFECTIONIMMUNITY
SLEEP PHYSIOLOGY
GUT FUNCTIONMICROBIOTA
ldquoSTABILITYrdquo
TRANSITION
LONG TERM FOLLOW-UP
NEUROENDOCRINE BEHAVIOURS
MATERNAL NEUROPLASTICITY
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
MORTALITYMETABOLISM
0h 1h 2h 3h 4h
PSNS (vagal)
App
roxim
ate
GLUCOSE
1 HOURLY Milk feed
1 HOURLY Milk feed
1 HOURLY Milk feed
1 HOURLY Milk feed
LACTOSE
METABOLISM
31
0h 1h 2h 3h 4h
PSNS (vagal) SYMPATHETIC STRESS
App
roxim
ate
GLUCOSE
LACTOSE FATGLYCOGEN
METABOLISM
4 HOURLY Milk feed
0h 1h 2h 3h 4h
PSNS (vagal) SYMPATHETIC STRESS
App
roxim
ate
GLUCOSE
4 HOURLY ALLOSTATIC STATELACTOSE FATGLYCOGEN
METABOLISM
4 HOURLY Milk feed
HEALTH DISEASE
EXPECTED UNEXPECTED
NEURODEVELOPMENTThe DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
BONDING ATTACHMENT
MRI HRVEEG
STRESS RESPONES
RESILIENCE
DOHAD
(MAL) ADAPTATION
EPIGENETICS
GENE X ENVIRONMENT
GENETIC VARIANTS
HOSPITAL ACQUIRED INFECTIONIMMUNITY
SLEEP PHYSIOLOGY
GUT FUNCTIONMICROBIOTA
ldquoSTABILITYrdquo
TRANSITION
LONG TERM FOLLOW-UP
NEUROENDOCRINE BEHAVIOURS
MATERNAL NEUROPLASTICITY
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
MORTALITYMETABOLISM
Weight gain 1st week
predicts OBESITYat 30 years
Large volume feedsstretched stomach=
doubled absorptivecapacity as adult
Importance
Programming ndash early life chronic disease
32
RESISTANCE SENSITIVITY
PERCEPTIONSldquoNEUROCEPTIONrdquo
RESPONSESTRESS
ALLOSTATIC STATE
ALLOSTASIS
ANY STRESSPsychologicalNeurological
EndocrineImmune
ALLOSTATIC LOAD
ALLOSTATIC OVERLOAD
WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY
DISEASEHEALTH
RESILIENCE VULNERABILITY
RESISTANCE SENSITIVITY
PERCEPTIONSldquoNEUROCEPTIONrdquo
RESPONSESTRESS
ALLOSTATIC STATE
ALLOSTASIS
ANY STRESSPsychologicalNeurological
EndocrineImmune
ALLOSTATIC LOAD
HEALTH
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
Gastric overfilling syndrome
189
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
33
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
Only case series Insufficient evidence
No mention of
stomach capacity196
Baby weight freq reqrsquod size actual
2kg baby 4hrly ~ 320 ml6 = 53ml 14ml
15 baby 3hrly ~ 240 ml8 = 30ml 10ml
10 baby 2hrly ~ 160 ml12 = 13ml 7ml
Standardised from20ml capacityfor 3kg baby( x 0007)
197
0
10
20
30
40
50
60
70
80
90
13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w
LINEAR
TERM
PREM
198
34
0
10
20
30
40
50
60
70
80
90
13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w
LINEAR
TERM
PREM
199
Clues to GER
ldquoI know baby hurtsrdquo
Gastric overfilling syndrome
Excessive volumesreflux aspiration colic
Excessive time intervalhypoglycaemia
Adaptationsdiabetic diathesis obesity
200
Developmental Care of the Enteric Nervous System
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
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
Doucet 2012
In the lsquolsquoscentless breastrsquorsquo
condition all infants were
exposed to the motherrsquos breast
fully covered with a perfectly
transparent and airtight plastic
film (polypropylene)
( the habitual visual scene of
the breast devoid of
corresponding odors )
(1) lsquolsquoBreastrsquorsquogroup (fully
uncovered motherrsquos breast)
(2) lsquolsquoNipplersquorsquogroup (all remaining
parts covered with plastic film)
(3) lsquolsquoAreolarsquorsquogroup (remainder of
the breast and nipple covered)
(4) lsquolsquoMilkrsquorsquogroup (milk smeared
on plastic covered breast)
5
lsquolsquoBreastrsquorsquogroup 0102
more than
lsquolsquoAreolarsquorsquogroup 0038
more than
lsquolsquoMilkrsquorsquogroup 0035
Grey bar ndash odourless
plastic film
Black ndash pooled odors
They displayed significantly longer global oral activity
when facing any of the odorous breast with opened
eyes the three other conditions being equivalent
odorous breast opened eyes 1327
odorous breast closed eyes 992
scentless breast opened eyes 663
scentless breast closed eyes 839
hellip only male newborns opened their eyes longer in
response to odorous breast conditions than to the
scentless condition
(0654 vs 0425 plt01)
Related experiments indicate however that the
chemical cues that attract rat pups to the nipples
are not produced in that region Rather initial
nipple orientation is elicited by the odor of
amniotic fluid and saliva that the mother spreads
on her ventrum while grooming herself during
parturition [7]
Babies more often spontaneously selected a breast
treated with a small amount of their own AF applied to
the nippleareola region than the alternative untreated
breast during tests beginning several minutes after
parturition [112]
These results are corroborated by a study in which 2-
day-old infants were offered a simultaneous choice
between two gauze pads the length of time oriented
to the odor of their AF was reliably greater than that
towards an odorless stimulus pad [92]
PSN envisions a community that embraces its mothers and babies and
values the unique
opportunity at birthto impact the physical and emotional
well-being of the newborn
Target 1 for 2005
Report that 65 of infants are placed and remain in
direct skin to skin contactwith their mothers
for at least one hourduring the first 3 hours after birth
6
Skin-to-skin and breastfeeding (4)
0
10
20
30
40
50
60
70
80
90
100
3Q05 4Q05 1Q06 2Q06 3Q06 4Q06 1Q07 2Q07
Breastfeeding intention Skin-to-skin one hour Breastfeeding at discharge
Used with permission Ruth Stanhiser MD
Babies breastfeeding
Mothers intending to breastfeed
Breastfeeding by the NeonateRegistration by skin-to-skin contact
More skin-to-skin more breastfeeding
Thomson 1979
E Early SSC first hourL Late contact next day2 2 hourly feeds from birth4 4 hourly feeds from birth
Group Brf at 12 w Brf duration (days)
2E 643 182 (14 - 392)4E 556 140 (14 ndash 322)2L 556 112 (10 ndash 294)4L 462 77 (11 ndash 280)
Salariya 1978
7
DEFENSE NUTRITION REPRODUCTION
HORMONES NERVES MUSCLES
DEFENSE NUTRITION REPRODUCTION
HORMONES NERVES MUSCLES
= BREASTFEEDING
SAFE
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
WIRE MOTHER
NEURODEVELOPMENTThe DNA Behaviour
EVOLUTIONARY BIOLOGY
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
BIRTH
BEYOND BREASTFEEDING Feed Sleep Cycling
MOTHERBABY
BONDING Sensitization
Secure attachment
Attuned parenting
SEPARATION
OXYTOCIN
8
OXYTOCIN
OXYTOCIN comes from
Cervical dilatation
Skin-to-skin contact
Breastfeeding
Eye-to-eye contact
Effects of doula care
No doula DoulaUSA (Kennell et al 1991)
Epidural 55 8Caesarean section 18 8Forceps delivery 26 8Fetal distress 24 10
ldquoIf a Doula was a drug it would be unethical
not to use itrdquoDr John Kennell
1922 -2013Marshall Klaus amp John Kenell
EARLY CHILDHOOD DEVELOPMENT ECD
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
BIRTH
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
WIRE MOTHER
OXYTOCIN
11
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDINGON-GOING
S S C
WIRE TOGETHER
OXYTOCIN
hellip infant cues - suckling vocalisation and tactile stimulation - stimulate
OXYTOCINrelease in the hypothalamus which may result in the activation of the dopaminergic reward pathway leading to behavioural reinforcement
key biological systems hellip that contribute to maternal caregiving behaviour hellip the oxytocinergic and dopaminergic systems
hellip dopamine pathways contribute to the processing of infant-related sensory cues leading to a behavioural response c
DISEASEHEALTH
CORTISOLOXYTOCIN
The psychology of human parent-infant relationships
Parenting is regulated by key hormones and neurotransmitters
Neuroanatomical circuits of parenting
Integrative physiology of normal parenting behaviours
Brain imaging of human parent-infant relationships
The neurobiology of empathy and parenting
Conclusions and critical summary
(Swain et al 2007)
12
FEARCONTROL
CENTRE
REWARDCONTROL
CENTRE
SOCIALCONTROL CENTRE
OXYTOCINDOPAMINE
CORTISOL
EMOTIONCONTROL CENTRE
WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY
DISEASEHEALTH
RESILIENCE VULNERABILITY
hellip there is considerable overlap in the brain structures associated with these neural mechanisms hellip functional interactions among the circuits
DOULA and KANGAROULA
-1000 min
BIRTH
+1000 min 1000 days
OXYTOCIN Zero separation
Protect OXYTOCINBefore and after
BIRTH
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDINGON-GOING
S S C
WIRE TOGETHER
Protect OXYTOCINBefore and after
BIRTH
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDINGON-GOING
S S C
WIRE SUCKLING
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
Alberts SUCKLING versus FEEDING
DUAL INGESTION SYSTEMS
13
300 mya 200 mya 100 mya 50 mya 300 mya 200 mya 100 mya 50 mya
Amniotes
Synapsids
Cynodonts
Mammaliaformes
PlacentalsMammals
ANCESTRAL STATE
hellip intoMATURE FEEDING
300 mya 200 mya 100 mya 50 mya
WATER
EGGS
Hatch withTEETH
ANCESTRAL STATE
hellip intoMATURE FEEDING
eg TURTLES
CROCODILES DINOSAURS
REPTILES
300 mya 200 mya 100 mya 50 mya
Epibubic bone = pouch care
hellip intoMATURE FEEDING
Amniotes
Synapsids
Cynodonts
Mammaliaformes
Smaller eggs longer in body
The AMNIOTE EGGextra membranes
Copes with AIR
PlacentalsMammals
Viviparity = immature
ENDOTHERMY
MOISTUREfor eggs
Diphyodontism
300 mya 200 mya 100 mya 50 mya
hellip intoMATURE FEEDING
Amniotes
Synapsids
Cynodonts
Mammaliaformes
PlacentalsMammals
ENDOTHERMY
MOISTUREfor eggs
LACTOSE added(apocrine glands)
NUTRIENTSAntimicrobials
LACTATION
SUCKLINGFEEDING
200 million years
Diphyodontism
300 mya 200 mya 100 mya 50 mya
hellip intoMATURE FEEDING
Amniotes
Synapsids
Cynodonts
Mammaliaformes
PlacentalsMammals
ENDOTHERMY
MOISTUREfor eggs
LACTOSE added(apocrine glands)
NUTRIENTSAntimicrobials
LACTATION
SUCKLINGFEEDING
200 million years
DUAL INGESTION SYSTEMS
100 million years
14
DUAL INGESTION SYSTEMS DUAL INGESTION SYSTEMS
SUCKLING WEANING FEEDING
Lactase Digestive enzymes
FEEDING SUCKLING
Influence of SMELL None Totally dependent
Motor mechanism Chewing ndash different
muscles
Suckling ndash different circuits
INSULIN Increases weight No effect
GHRELIN Increases weight No effect
LEPTIN Decreases intake No effect
CHOLECYSTOKININ Decreases intake No effect
AMPHETAMINE Decreases appetite Increases suckling
SEROTONIN Agonist improves feeding Antagonist improves suck
SATIETY Infant determined Maternal supply determine
FEEDING SUCKLING
DISRUPTION ROBUST VERY SENSITIVE
Must have right conditions
Pup-in-a- cup - And STIMULI
separated and fed by tube
From day 2 off life
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
14th century Tuscan text
Conceptual changeDyad careBreast first hour
even CaesareanContinuous SSC
DISCONTINUEGiving waterGlucose waterInfant formulaSeparationPacifier (dummy)
CHANGE POLICY Canrsquot change
biology
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
ON-GOING
S S C
WIRE NEURONS
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C WIRE
TIMING
(behavior)
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
ENTERIC NERVOUS SYSTEM
123
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
FEEDBACK LOOPS
CNS
ENS
ANS
InternalSomaticenvironment
124
125 126
22
Fetal stomach appears 4 weeks GABy 11 weeks wall capable of muscular
contraction
ldquoPatterns of antropyloric motilityin fed healthy preterm infantsrdquo
the neuroregulatory mechanisms responsible for the coordination of antro-pyloric motility and gastric emptying are
well developed by 30 weeks of PMAHassan 2002 127
Hydrochloric acidimportant for activation of pepsinogen
inactivation of microorganisms such as bacteria
Pepsinogenactivated by acid into active pepsin
responsible for the stomachs ability to initiate digestion of proteins
Chymosinis an enzyme whose role is to curdle or
coagulate milk in the stomach a process of considerable importance in the very young animal
128
Chymosinmakes the milk into ldquocheeserdquohalfway between liquid and solidstomach empties in 60 minutes
milk
129
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
FEEDBACK LOOPS
130
EVIDENCE FORFEEDING FREQUENCY
Edmond 2006 131
Breastfeeding and motherrsquos milkStrong and consistent evidence 132
23
Cup feeding versus bottle feedingCup feeding higher breastfeeding
greater stability133
Only case series Insufficient evidence
No mention of
stomach capacity134
EVIDENCE FORSTOMACH CAPACITY
Edmond 2006 135
0
05
1
15
2
25
3
35
4
0 10 20 30 40 50 60 70 80
volume ingested
fee
din
g f
req
ue
nc
y
Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml
StandardCARE3 hourlyschedule
136
KEY QUESTION
WHAT IS THE
STOMACHVOLUMEOF THE
NEONATE 137 Sase 2005
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
(Alliot) pressure)151
PROPOSAL
The CAPACITY of aweek old babyrsquos stomach is
approx 20 ml152
0
05
1
15
2
25
3
35
4
0 10 20 30 40 50 60 70 80
volume ingested
fee
din
g f
req
ue
nc
y
Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml
StandardCARE3 hourlyschedule
MOTHERNATURE
1 hourlyschedule
153
PHYSIOLOGICAL CAPACITY
RECEPTIVE CAPACITY of stomach
INGESTIVE CAPACITY of BABY
FUNCTIONAL CAPACITY
154
PROPOSAL
The FEEDINGFREQUENCY of theNEONATE is
approx 60 min155
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
BRAIN CYCLING
STOMACH FILLING amp EMPTYING
REMNR1NR2NR3NR4
156
27
Normal physiology of theEnteric Nervous System
ldquoSmall and frequent feeds according to the sleep cyclerdquo
The ldquonicherdquo (occupation) of a neonate (Alberts)
BOND FEED
SLEEP SLEEP
PLAY FEED
157
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
FEEDING SUCKLING
Influence of SMELL None Totally dependent
Motor mechanism Chewing ndash different
muscles
Suckling ndash different circuits
INSULIN Increases weight No effect
GHRELIN Increases weight No effect
LEPTIN Decreases intake No effect
CHOLECYSTOKININ Decreases intake No effect
AMPHETAMINE Decreases appetite Increases suckling
SEROTONIN Agonist improves feeding Antagonist improves suck
SATIETY Infant determined Maternal supply determine
FEEDING SUCKLING
Influence of SMELL None Totally dependent
Motor mechanism Chewing ndash different
muscles
Suckling ndash different circuits
INSULIN Increases weight No effect
GHRELIN Increases weight No effect
LEPTIN Decreases intake No effect
CHOLECYSTOKININ Decreases intake No effect
AMPHETAMINE Decreases appetite Increases suckling
SEROTONIN Agonist improves feeding Antagonist improves suck
SATIETY Infant determined Maternal supply determine
Current dogmaTHE BABY KNOWS
WHEN IT HAS HAD ENOUGH
PROBABLY NOT
WHAT IS THE
STOMACH VOLUME OF THE
PREMATURE
161
Assume low resilience
Assume proportionality
162
28
The CAPACITY of alow birthweight premfrom 20ml 3000g
= 0007 x BWt (g)
1kg x 0007 = 7mls2kg x 0007 = 14mls
163
Gastric overfilling syndrome
164
75 ml per feeding ASSUMPTION
IMMATURE OR OVERWHELMED
many aspects of gastrointestinalmotility are immature in the neonate
Zangen S et al Rapid maturation of gastric relaxation in newborns
A balloon in stomachcan fill to 76 mls
What does the stomach ndashwithout a balloon ndashdo to 76 mls
REFLUX PRESUME each feedapproximately 75 mls
GER
bull Sudden outbursts of crying
bull Awakens in pain
bull Related to feedings
bull Not easily comforted
bull ldquoI know baby hurtsrdquo
bull Sour burps throaty noises
bull Best when upright
Clues to GER
Dr W Sears
29
Mitchell 2001
Kerstin Uvnaumls-Moberg
Food in duodenum
AMYLINreleased
Closes pylorus
Duodenumempty
Pylorusopens
ldquoFeed intolerancerdquo hellip hellip or VOLUME intolerance
HYPOGLYCAEMIA
A babies stomach empties in60 minutes
Blood sugarmay fall hellip
after 90 minutes Options
30
METABOLIC ADAPTATION
SSC started in the first 20 minutes after birth
SSC CotBlood glucose (1 hr) 317 256Base excess drop 34 18
(Christenson 1992)0h 1h 2h 3h 4h 2 days
App
roxim
ate
GLUCOSE
SSC Glucose production = Glucose consumption
Separation
SNS stress Glucose consumption INCREASE
PSNS dissociation Glucose production DECREASE
HYPOGLYCEMIA
SSC Cot
Blood glucose (1 hr) 317 256
0h 1h 2h 3h 4h 2 days
App
roxim
ate
GLUCOSE
SSC Glucose production = Glucose consumption
Separation PSNS dissociation
Glucose production DECREASE
HYPOGLYCEMIA
SSC Cot
Blood glucose (1 hr) 317 256
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
NEURODEVELOPMENTThe DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
BONDING ATTACHMENT
MRI HRVEEG
STRESS RESPONES
RESILIENCE
DOHAD
(MAL) ADAPTATION
EPIGENETICS
GENE X ENVIRONMENT
GENETIC VARIANTS
HOSPITAL ACQUIRED INFECTIONIMMUNITY
SLEEP PHYSIOLOGY
GUT FUNCTIONMICROBIOTA
ldquoSTABILITYrdquo
TRANSITION
LONG TERM FOLLOW-UP
NEUROENDOCRINE BEHAVIOURS
MATERNAL NEUROPLASTICITY
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
MORTALITYMETABOLISM
0h 1h 2h 3h 4h
PSNS (vagal)
App
roxim
ate
GLUCOSE
1 HOURLY Milk feed
1 HOURLY Milk feed
1 HOURLY Milk feed
1 HOURLY Milk feed
LACTOSE
METABOLISM
31
0h 1h 2h 3h 4h
PSNS (vagal) SYMPATHETIC STRESS
App
roxim
ate
GLUCOSE
LACTOSE FATGLYCOGEN
METABOLISM
4 HOURLY Milk feed
0h 1h 2h 3h 4h
PSNS (vagal) SYMPATHETIC STRESS
App
roxim
ate
GLUCOSE
4 HOURLY ALLOSTATIC STATELACTOSE FATGLYCOGEN
METABOLISM
4 HOURLY Milk feed
HEALTH DISEASE
EXPECTED UNEXPECTED
NEURODEVELOPMENTThe DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
BONDING ATTACHMENT
MRI HRVEEG
STRESS RESPONES
RESILIENCE
DOHAD
(MAL) ADAPTATION
EPIGENETICS
GENE X ENVIRONMENT
GENETIC VARIANTS
HOSPITAL ACQUIRED INFECTIONIMMUNITY
SLEEP PHYSIOLOGY
GUT FUNCTIONMICROBIOTA
ldquoSTABILITYrdquo
TRANSITION
LONG TERM FOLLOW-UP
NEUROENDOCRINE BEHAVIOURS
MATERNAL NEUROPLASTICITY
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
MORTALITYMETABOLISM
Weight gain 1st week
predicts OBESITYat 30 years
Large volume feedsstretched stomach=
doubled absorptivecapacity as adult
Importance
Programming ndash early life chronic disease
32
RESISTANCE SENSITIVITY
PERCEPTIONSldquoNEUROCEPTIONrdquo
RESPONSESTRESS
ALLOSTATIC STATE
ALLOSTASIS
ANY STRESSPsychologicalNeurological
EndocrineImmune
ALLOSTATIC LOAD
ALLOSTATIC OVERLOAD
WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY
DISEASEHEALTH
RESILIENCE VULNERABILITY
RESISTANCE SENSITIVITY
PERCEPTIONSldquoNEUROCEPTIONrdquo
RESPONSESTRESS
ALLOSTATIC STATE
ALLOSTASIS
ANY STRESSPsychologicalNeurological
EndocrineImmune
ALLOSTATIC LOAD
HEALTH
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
Gastric overfilling syndrome
189
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
33
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
Only case series Insufficient evidence
No mention of
stomach capacity196
Baby weight freq reqrsquod size actual
2kg baby 4hrly ~ 320 ml6 = 53ml 14ml
15 baby 3hrly ~ 240 ml8 = 30ml 10ml
10 baby 2hrly ~ 160 ml12 = 13ml 7ml
Standardised from20ml capacityfor 3kg baby( x 0007)
197
0
10
20
30
40
50
60
70
80
90
13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w
LINEAR
TERM
PREM
198
34
0
10
20
30
40
50
60
70
80
90
13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w
LINEAR
TERM
PREM
199
Clues to GER
ldquoI know baby hurtsrdquo
Gastric overfilling syndrome
Excessive volumesreflux aspiration colic
Excessive time intervalhypoglycaemia
Adaptationsdiabetic diathesis obesity
200
Developmental Care of the Enteric Nervous System
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
5
lsquolsquoBreastrsquorsquogroup 0102
more than
lsquolsquoAreolarsquorsquogroup 0038
more than
lsquolsquoMilkrsquorsquogroup 0035
Grey bar ndash odourless
plastic film
Black ndash pooled odors
They displayed significantly longer global oral activity
when facing any of the odorous breast with opened
eyes the three other conditions being equivalent
odorous breast opened eyes 1327
odorous breast closed eyes 992
scentless breast opened eyes 663
scentless breast closed eyes 839
hellip only male newborns opened their eyes longer in
response to odorous breast conditions than to the
scentless condition
(0654 vs 0425 plt01)
Related experiments indicate however that the
chemical cues that attract rat pups to the nipples
are not produced in that region Rather initial
nipple orientation is elicited by the odor of
amniotic fluid and saliva that the mother spreads
on her ventrum while grooming herself during
parturition [7]
Babies more often spontaneously selected a breast
treated with a small amount of their own AF applied to
the nippleareola region than the alternative untreated
breast during tests beginning several minutes after
parturition [112]
These results are corroborated by a study in which 2-
day-old infants were offered a simultaneous choice
between two gauze pads the length of time oriented
to the odor of their AF was reliably greater than that
towards an odorless stimulus pad [92]
PSN envisions a community that embraces its mothers and babies and
values the unique
opportunity at birthto impact the physical and emotional
well-being of the newborn
Target 1 for 2005
Report that 65 of infants are placed and remain in
direct skin to skin contactwith their mothers
for at least one hourduring the first 3 hours after birth
6
Skin-to-skin and breastfeeding (4)
0
10
20
30
40
50
60
70
80
90
100
3Q05 4Q05 1Q06 2Q06 3Q06 4Q06 1Q07 2Q07
Breastfeeding intention Skin-to-skin one hour Breastfeeding at discharge
Used with permission Ruth Stanhiser MD
Babies breastfeeding
Mothers intending to breastfeed
Breastfeeding by the NeonateRegistration by skin-to-skin contact
More skin-to-skin more breastfeeding
Thomson 1979
E Early SSC first hourL Late contact next day2 2 hourly feeds from birth4 4 hourly feeds from birth
Group Brf at 12 w Brf duration (days)
2E 643 182 (14 - 392)4E 556 140 (14 ndash 322)2L 556 112 (10 ndash 294)4L 462 77 (11 ndash 280)
Salariya 1978
7
DEFENSE NUTRITION REPRODUCTION
HORMONES NERVES MUSCLES
DEFENSE NUTRITION REPRODUCTION
HORMONES NERVES MUSCLES
= BREASTFEEDING
SAFE
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
WIRE MOTHER
NEURODEVELOPMENTThe DNA Behaviour
EVOLUTIONARY BIOLOGY
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
BIRTH
BEYOND BREASTFEEDING Feed Sleep Cycling
MOTHERBABY
BONDING Sensitization
Secure attachment
Attuned parenting
SEPARATION
OXYTOCIN
8
OXYTOCIN
OXYTOCIN comes from
Cervical dilatation
Skin-to-skin contact
Breastfeeding
Eye-to-eye contact
Effects of doula care
No doula DoulaUSA (Kennell et al 1991)
Epidural 55 8Caesarean section 18 8Forceps delivery 26 8Fetal distress 24 10
ldquoIf a Doula was a drug it would be unethical
not to use itrdquoDr John Kennell
1922 -2013Marshall Klaus amp John Kenell
EARLY CHILDHOOD DEVELOPMENT ECD
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
BIRTH
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
WIRE MOTHER
OXYTOCIN
11
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDINGON-GOING
S S C
WIRE TOGETHER
OXYTOCIN
hellip infant cues - suckling vocalisation and tactile stimulation - stimulate
OXYTOCINrelease in the hypothalamus which may result in the activation of the dopaminergic reward pathway leading to behavioural reinforcement
key biological systems hellip that contribute to maternal caregiving behaviour hellip the oxytocinergic and dopaminergic systems
hellip dopamine pathways contribute to the processing of infant-related sensory cues leading to a behavioural response c
DISEASEHEALTH
CORTISOLOXYTOCIN
The psychology of human parent-infant relationships
Parenting is regulated by key hormones and neurotransmitters
Neuroanatomical circuits of parenting
Integrative physiology of normal parenting behaviours
Brain imaging of human parent-infant relationships
The neurobiology of empathy and parenting
Conclusions and critical summary
(Swain et al 2007)
12
FEARCONTROL
CENTRE
REWARDCONTROL
CENTRE
SOCIALCONTROL CENTRE
OXYTOCINDOPAMINE
CORTISOL
EMOTIONCONTROL CENTRE
WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY
DISEASEHEALTH
RESILIENCE VULNERABILITY
hellip there is considerable overlap in the brain structures associated with these neural mechanisms hellip functional interactions among the circuits
DOULA and KANGAROULA
-1000 min
BIRTH
+1000 min 1000 days
OXYTOCIN Zero separation
Protect OXYTOCINBefore and after
BIRTH
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDINGON-GOING
S S C
WIRE TOGETHER
Protect OXYTOCINBefore and after
BIRTH
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDINGON-GOING
S S C
WIRE SUCKLING
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
Alberts SUCKLING versus FEEDING
DUAL INGESTION SYSTEMS
13
300 mya 200 mya 100 mya 50 mya 300 mya 200 mya 100 mya 50 mya
Amniotes
Synapsids
Cynodonts
Mammaliaformes
PlacentalsMammals
ANCESTRAL STATE
hellip intoMATURE FEEDING
300 mya 200 mya 100 mya 50 mya
WATER
EGGS
Hatch withTEETH
ANCESTRAL STATE
hellip intoMATURE FEEDING
eg TURTLES
CROCODILES DINOSAURS
REPTILES
300 mya 200 mya 100 mya 50 mya
Epibubic bone = pouch care
hellip intoMATURE FEEDING
Amniotes
Synapsids
Cynodonts
Mammaliaformes
Smaller eggs longer in body
The AMNIOTE EGGextra membranes
Copes with AIR
PlacentalsMammals
Viviparity = immature
ENDOTHERMY
MOISTUREfor eggs
Diphyodontism
300 mya 200 mya 100 mya 50 mya
hellip intoMATURE FEEDING
Amniotes
Synapsids
Cynodonts
Mammaliaformes
PlacentalsMammals
ENDOTHERMY
MOISTUREfor eggs
LACTOSE added(apocrine glands)
NUTRIENTSAntimicrobials
LACTATION
SUCKLINGFEEDING
200 million years
Diphyodontism
300 mya 200 mya 100 mya 50 mya
hellip intoMATURE FEEDING
Amniotes
Synapsids
Cynodonts
Mammaliaformes
PlacentalsMammals
ENDOTHERMY
MOISTUREfor eggs
LACTOSE added(apocrine glands)
NUTRIENTSAntimicrobials
LACTATION
SUCKLINGFEEDING
200 million years
DUAL INGESTION SYSTEMS
100 million years
14
DUAL INGESTION SYSTEMS DUAL INGESTION SYSTEMS
SUCKLING WEANING FEEDING
Lactase Digestive enzymes
FEEDING SUCKLING
Influence of SMELL None Totally dependent
Motor mechanism Chewing ndash different
muscles
Suckling ndash different circuits
INSULIN Increases weight No effect
GHRELIN Increases weight No effect
LEPTIN Decreases intake No effect
CHOLECYSTOKININ Decreases intake No effect
AMPHETAMINE Decreases appetite Increases suckling
SEROTONIN Agonist improves feeding Antagonist improves suck
SATIETY Infant determined Maternal supply determine
FEEDING SUCKLING
DISRUPTION ROBUST VERY SENSITIVE
Must have right conditions
Pup-in-a- cup - And STIMULI
separated and fed by tube
From day 2 off life
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
14th century Tuscan text
Conceptual changeDyad careBreast first hour
even CaesareanContinuous SSC
DISCONTINUEGiving waterGlucose waterInfant formulaSeparationPacifier (dummy)
CHANGE POLICY Canrsquot change
biology
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
ON-GOING
S S C
WIRE NEURONS
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C WIRE
TIMING
(behavior)
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
ENTERIC NERVOUS SYSTEM
123
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
FEEDBACK LOOPS
CNS
ENS
ANS
InternalSomaticenvironment
124
125 126
22
Fetal stomach appears 4 weeks GABy 11 weeks wall capable of muscular
contraction
ldquoPatterns of antropyloric motilityin fed healthy preterm infantsrdquo
the neuroregulatory mechanisms responsible for the coordination of antro-pyloric motility and gastric emptying are
well developed by 30 weeks of PMAHassan 2002 127
Hydrochloric acidimportant for activation of pepsinogen
inactivation of microorganisms such as bacteria
Pepsinogenactivated by acid into active pepsin
responsible for the stomachs ability to initiate digestion of proteins
Chymosinis an enzyme whose role is to curdle or
coagulate milk in the stomach a process of considerable importance in the very young animal
128
Chymosinmakes the milk into ldquocheeserdquohalfway between liquid and solidstomach empties in 60 minutes
milk
129
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
FEEDBACK LOOPS
130
EVIDENCE FORFEEDING FREQUENCY
Edmond 2006 131
Breastfeeding and motherrsquos milkStrong and consistent evidence 132
23
Cup feeding versus bottle feedingCup feeding higher breastfeeding
greater stability133
Only case series Insufficient evidence
No mention of
stomach capacity134
EVIDENCE FORSTOMACH CAPACITY
Edmond 2006 135
0
05
1
15
2
25
3
35
4
0 10 20 30 40 50 60 70 80
volume ingested
fee
din
g f
req
ue
nc
y
Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml
StandardCARE3 hourlyschedule
136
KEY QUESTION
WHAT IS THE
STOMACHVOLUMEOF THE
NEONATE 137 Sase 2005
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
(Alliot) pressure)151
PROPOSAL
The CAPACITY of aweek old babyrsquos stomach is
approx 20 ml152
0
05
1
15
2
25
3
35
4
0 10 20 30 40 50 60 70 80
volume ingested
fee
din
g f
req
ue
nc
y
Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml
StandardCARE3 hourlyschedule
MOTHERNATURE
1 hourlyschedule
153
PHYSIOLOGICAL CAPACITY
RECEPTIVE CAPACITY of stomach
INGESTIVE CAPACITY of BABY
FUNCTIONAL CAPACITY
154
PROPOSAL
The FEEDINGFREQUENCY of theNEONATE is
approx 60 min155
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
BRAIN CYCLING
STOMACH FILLING amp EMPTYING
REMNR1NR2NR3NR4
156
27
Normal physiology of theEnteric Nervous System
ldquoSmall and frequent feeds according to the sleep cyclerdquo
The ldquonicherdquo (occupation) of a neonate (Alberts)
BOND FEED
SLEEP SLEEP
PLAY FEED
157
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
FEEDING SUCKLING
Influence of SMELL None Totally dependent
Motor mechanism Chewing ndash different
muscles
Suckling ndash different circuits
INSULIN Increases weight No effect
GHRELIN Increases weight No effect
LEPTIN Decreases intake No effect
CHOLECYSTOKININ Decreases intake No effect
AMPHETAMINE Decreases appetite Increases suckling
SEROTONIN Agonist improves feeding Antagonist improves suck
SATIETY Infant determined Maternal supply determine
FEEDING SUCKLING
Influence of SMELL None Totally dependent
Motor mechanism Chewing ndash different
muscles
Suckling ndash different circuits
INSULIN Increases weight No effect
GHRELIN Increases weight No effect
LEPTIN Decreases intake No effect
CHOLECYSTOKININ Decreases intake No effect
AMPHETAMINE Decreases appetite Increases suckling
SEROTONIN Agonist improves feeding Antagonist improves suck
SATIETY Infant determined Maternal supply determine
Current dogmaTHE BABY KNOWS
WHEN IT HAS HAD ENOUGH
PROBABLY NOT
WHAT IS THE
STOMACH VOLUME OF THE
PREMATURE
161
Assume low resilience
Assume proportionality
162
28
The CAPACITY of alow birthweight premfrom 20ml 3000g
= 0007 x BWt (g)
1kg x 0007 = 7mls2kg x 0007 = 14mls
163
Gastric overfilling syndrome
164
75 ml per feeding ASSUMPTION
IMMATURE OR OVERWHELMED
many aspects of gastrointestinalmotility are immature in the neonate
Zangen S et al Rapid maturation of gastric relaxation in newborns
A balloon in stomachcan fill to 76 mls
What does the stomach ndashwithout a balloon ndashdo to 76 mls
REFLUX PRESUME each feedapproximately 75 mls
GER
bull Sudden outbursts of crying
bull Awakens in pain
bull Related to feedings
bull Not easily comforted
bull ldquoI know baby hurtsrdquo
bull Sour burps throaty noises
bull Best when upright
Clues to GER
Dr W Sears
29
Mitchell 2001
Kerstin Uvnaumls-Moberg
Food in duodenum
AMYLINreleased
Closes pylorus
Duodenumempty
Pylorusopens
ldquoFeed intolerancerdquo hellip hellip or VOLUME intolerance
HYPOGLYCAEMIA
A babies stomach empties in60 minutes
Blood sugarmay fall hellip
after 90 minutes Options
30
METABOLIC ADAPTATION
SSC started in the first 20 minutes after birth
SSC CotBlood glucose (1 hr) 317 256Base excess drop 34 18
(Christenson 1992)0h 1h 2h 3h 4h 2 days
App
roxim
ate
GLUCOSE
SSC Glucose production = Glucose consumption
Separation
SNS stress Glucose consumption INCREASE
PSNS dissociation Glucose production DECREASE
HYPOGLYCEMIA
SSC Cot
Blood glucose (1 hr) 317 256
0h 1h 2h 3h 4h 2 days
App
roxim
ate
GLUCOSE
SSC Glucose production = Glucose consumption
Separation PSNS dissociation
Glucose production DECREASE
HYPOGLYCEMIA
SSC Cot
Blood glucose (1 hr) 317 256
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
NEURODEVELOPMENTThe DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
BONDING ATTACHMENT
MRI HRVEEG
STRESS RESPONES
RESILIENCE
DOHAD
(MAL) ADAPTATION
EPIGENETICS
GENE X ENVIRONMENT
GENETIC VARIANTS
HOSPITAL ACQUIRED INFECTIONIMMUNITY
SLEEP PHYSIOLOGY
GUT FUNCTIONMICROBIOTA
ldquoSTABILITYrdquo
TRANSITION
LONG TERM FOLLOW-UP
NEUROENDOCRINE BEHAVIOURS
MATERNAL NEUROPLASTICITY
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
MORTALITYMETABOLISM
0h 1h 2h 3h 4h
PSNS (vagal)
App
roxim
ate
GLUCOSE
1 HOURLY Milk feed
1 HOURLY Milk feed
1 HOURLY Milk feed
1 HOURLY Milk feed
LACTOSE
METABOLISM
31
0h 1h 2h 3h 4h
PSNS (vagal) SYMPATHETIC STRESS
App
roxim
ate
GLUCOSE
LACTOSE FATGLYCOGEN
METABOLISM
4 HOURLY Milk feed
0h 1h 2h 3h 4h
PSNS (vagal) SYMPATHETIC STRESS
App
roxim
ate
GLUCOSE
4 HOURLY ALLOSTATIC STATELACTOSE FATGLYCOGEN
METABOLISM
4 HOURLY Milk feed
HEALTH DISEASE
EXPECTED UNEXPECTED
NEURODEVELOPMENTThe DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
BONDING ATTACHMENT
MRI HRVEEG
STRESS RESPONES
RESILIENCE
DOHAD
(MAL) ADAPTATION
EPIGENETICS
GENE X ENVIRONMENT
GENETIC VARIANTS
HOSPITAL ACQUIRED INFECTIONIMMUNITY
SLEEP PHYSIOLOGY
GUT FUNCTIONMICROBIOTA
ldquoSTABILITYrdquo
TRANSITION
LONG TERM FOLLOW-UP
NEUROENDOCRINE BEHAVIOURS
MATERNAL NEUROPLASTICITY
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
MORTALITYMETABOLISM
Weight gain 1st week
predicts OBESITYat 30 years
Large volume feedsstretched stomach=
doubled absorptivecapacity as adult
Importance
Programming ndash early life chronic disease
32
RESISTANCE SENSITIVITY
PERCEPTIONSldquoNEUROCEPTIONrdquo
RESPONSESTRESS
ALLOSTATIC STATE
ALLOSTASIS
ANY STRESSPsychologicalNeurological
EndocrineImmune
ALLOSTATIC LOAD
ALLOSTATIC OVERLOAD
WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY
DISEASEHEALTH
RESILIENCE VULNERABILITY
RESISTANCE SENSITIVITY
PERCEPTIONSldquoNEUROCEPTIONrdquo
RESPONSESTRESS
ALLOSTATIC STATE
ALLOSTASIS
ANY STRESSPsychologicalNeurological
EndocrineImmune
ALLOSTATIC LOAD
HEALTH
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
Gastric overfilling syndrome
189
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
33
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
Only case series Insufficient evidence
No mention of
stomach capacity196
Baby weight freq reqrsquod size actual
2kg baby 4hrly ~ 320 ml6 = 53ml 14ml
15 baby 3hrly ~ 240 ml8 = 30ml 10ml
10 baby 2hrly ~ 160 ml12 = 13ml 7ml
Standardised from20ml capacityfor 3kg baby( x 0007)
197
0
10
20
30
40
50
60
70
80
90
13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w
LINEAR
TERM
PREM
198
34
0
10
20
30
40
50
60
70
80
90
13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w
LINEAR
TERM
PREM
199
Clues to GER
ldquoI know baby hurtsrdquo
Gastric overfilling syndrome
Excessive volumesreflux aspiration colic
Excessive time intervalhypoglycaemia
Adaptationsdiabetic diathesis obesity
200
Developmental Care of the Enteric Nervous System
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
6
Skin-to-skin and breastfeeding (4)
0
10
20
30
40
50
60
70
80
90
100
3Q05 4Q05 1Q06 2Q06 3Q06 4Q06 1Q07 2Q07
Breastfeeding intention Skin-to-skin one hour Breastfeeding at discharge
Used with permission Ruth Stanhiser MD
Babies breastfeeding
Mothers intending to breastfeed
Breastfeeding by the NeonateRegistration by skin-to-skin contact
More skin-to-skin more breastfeeding
Thomson 1979
E Early SSC first hourL Late contact next day2 2 hourly feeds from birth4 4 hourly feeds from birth
Group Brf at 12 w Brf duration (days)
2E 643 182 (14 - 392)4E 556 140 (14 ndash 322)2L 556 112 (10 ndash 294)4L 462 77 (11 ndash 280)
Salariya 1978
7
DEFENSE NUTRITION REPRODUCTION
HORMONES NERVES MUSCLES
DEFENSE NUTRITION REPRODUCTION
HORMONES NERVES MUSCLES
= BREASTFEEDING
SAFE
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
WIRE MOTHER
NEURODEVELOPMENTThe DNA Behaviour
EVOLUTIONARY BIOLOGY
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
BIRTH
BEYOND BREASTFEEDING Feed Sleep Cycling
MOTHERBABY
BONDING Sensitization
Secure attachment
Attuned parenting
SEPARATION
OXYTOCIN
8
OXYTOCIN
OXYTOCIN comes from
Cervical dilatation
Skin-to-skin contact
Breastfeeding
Eye-to-eye contact
Effects of doula care
No doula DoulaUSA (Kennell et al 1991)
Epidural 55 8Caesarean section 18 8Forceps delivery 26 8Fetal distress 24 10
ldquoIf a Doula was a drug it would be unethical
not to use itrdquoDr John Kennell
1922 -2013Marshall Klaus amp John Kenell
EARLY CHILDHOOD DEVELOPMENT ECD
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
BIRTH
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
WIRE MOTHER
OXYTOCIN
11
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDINGON-GOING
S S C
WIRE TOGETHER
OXYTOCIN
hellip infant cues - suckling vocalisation and tactile stimulation - stimulate
OXYTOCINrelease in the hypothalamus which may result in the activation of the dopaminergic reward pathway leading to behavioural reinforcement
key biological systems hellip that contribute to maternal caregiving behaviour hellip the oxytocinergic and dopaminergic systems
hellip dopamine pathways contribute to the processing of infant-related sensory cues leading to a behavioural response c
DISEASEHEALTH
CORTISOLOXYTOCIN
The psychology of human parent-infant relationships
Parenting is regulated by key hormones and neurotransmitters
Neuroanatomical circuits of parenting
Integrative physiology of normal parenting behaviours
Brain imaging of human parent-infant relationships
The neurobiology of empathy and parenting
Conclusions and critical summary
(Swain et al 2007)
12
FEARCONTROL
CENTRE
REWARDCONTROL
CENTRE
SOCIALCONTROL CENTRE
OXYTOCINDOPAMINE
CORTISOL
EMOTIONCONTROL CENTRE
WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY
DISEASEHEALTH
RESILIENCE VULNERABILITY
hellip there is considerable overlap in the brain structures associated with these neural mechanisms hellip functional interactions among the circuits
DOULA and KANGAROULA
-1000 min
BIRTH
+1000 min 1000 days
OXYTOCIN Zero separation
Protect OXYTOCINBefore and after
BIRTH
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDINGON-GOING
S S C
WIRE TOGETHER
Protect OXYTOCINBefore and after
BIRTH
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDINGON-GOING
S S C
WIRE SUCKLING
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
Alberts SUCKLING versus FEEDING
DUAL INGESTION SYSTEMS
13
300 mya 200 mya 100 mya 50 mya 300 mya 200 mya 100 mya 50 mya
Amniotes
Synapsids
Cynodonts
Mammaliaformes
PlacentalsMammals
ANCESTRAL STATE
hellip intoMATURE FEEDING
300 mya 200 mya 100 mya 50 mya
WATER
EGGS
Hatch withTEETH
ANCESTRAL STATE
hellip intoMATURE FEEDING
eg TURTLES
CROCODILES DINOSAURS
REPTILES
300 mya 200 mya 100 mya 50 mya
Epibubic bone = pouch care
hellip intoMATURE FEEDING
Amniotes
Synapsids
Cynodonts
Mammaliaformes
Smaller eggs longer in body
The AMNIOTE EGGextra membranes
Copes with AIR
PlacentalsMammals
Viviparity = immature
ENDOTHERMY
MOISTUREfor eggs
Diphyodontism
300 mya 200 mya 100 mya 50 mya
hellip intoMATURE FEEDING
Amniotes
Synapsids
Cynodonts
Mammaliaformes
PlacentalsMammals
ENDOTHERMY
MOISTUREfor eggs
LACTOSE added(apocrine glands)
NUTRIENTSAntimicrobials
LACTATION
SUCKLINGFEEDING
200 million years
Diphyodontism
300 mya 200 mya 100 mya 50 mya
hellip intoMATURE FEEDING
Amniotes
Synapsids
Cynodonts
Mammaliaformes
PlacentalsMammals
ENDOTHERMY
MOISTUREfor eggs
LACTOSE added(apocrine glands)
NUTRIENTSAntimicrobials
LACTATION
SUCKLINGFEEDING
200 million years
DUAL INGESTION SYSTEMS
100 million years
14
DUAL INGESTION SYSTEMS DUAL INGESTION SYSTEMS
SUCKLING WEANING FEEDING
Lactase Digestive enzymes
FEEDING SUCKLING
Influence of SMELL None Totally dependent
Motor mechanism Chewing ndash different
muscles
Suckling ndash different circuits
INSULIN Increases weight No effect
GHRELIN Increases weight No effect
LEPTIN Decreases intake No effect
CHOLECYSTOKININ Decreases intake No effect
AMPHETAMINE Decreases appetite Increases suckling
SEROTONIN Agonist improves feeding Antagonist improves suck
SATIETY Infant determined Maternal supply determine
FEEDING SUCKLING
DISRUPTION ROBUST VERY SENSITIVE
Must have right conditions
Pup-in-a- cup - And STIMULI
separated and fed by tube
From day 2 off life
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
14th century Tuscan text
Conceptual changeDyad careBreast first hour
even CaesareanContinuous SSC
DISCONTINUEGiving waterGlucose waterInfant formulaSeparationPacifier (dummy)
CHANGE POLICY Canrsquot change
biology
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
ON-GOING
S S C
WIRE NEURONS
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C WIRE
TIMING
(behavior)
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
ENTERIC NERVOUS SYSTEM
123
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
FEEDBACK LOOPS
CNS
ENS
ANS
InternalSomaticenvironment
124
125 126
22
Fetal stomach appears 4 weeks GABy 11 weeks wall capable of muscular
contraction
ldquoPatterns of antropyloric motilityin fed healthy preterm infantsrdquo
the neuroregulatory mechanisms responsible for the coordination of antro-pyloric motility and gastric emptying are
well developed by 30 weeks of PMAHassan 2002 127
Hydrochloric acidimportant for activation of pepsinogen
inactivation of microorganisms such as bacteria
Pepsinogenactivated by acid into active pepsin
responsible for the stomachs ability to initiate digestion of proteins
Chymosinis an enzyme whose role is to curdle or
coagulate milk in the stomach a process of considerable importance in the very young animal
128
Chymosinmakes the milk into ldquocheeserdquohalfway between liquid and solidstomach empties in 60 minutes
milk
129
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
FEEDBACK LOOPS
130
EVIDENCE FORFEEDING FREQUENCY
Edmond 2006 131
Breastfeeding and motherrsquos milkStrong and consistent evidence 132
23
Cup feeding versus bottle feedingCup feeding higher breastfeeding
greater stability133
Only case series Insufficient evidence
No mention of
stomach capacity134
EVIDENCE FORSTOMACH CAPACITY
Edmond 2006 135
0
05
1
15
2
25
3
35
4
0 10 20 30 40 50 60 70 80
volume ingested
fee
din
g f
req
ue
nc
y
Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml
StandardCARE3 hourlyschedule
136
KEY QUESTION
WHAT IS THE
STOMACHVOLUMEOF THE
NEONATE 137 Sase 2005
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
(Alliot) pressure)151
PROPOSAL
The CAPACITY of aweek old babyrsquos stomach is
approx 20 ml152
0
05
1
15
2
25
3
35
4
0 10 20 30 40 50 60 70 80
volume ingested
fee
din
g f
req
ue
nc
y
Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml
StandardCARE3 hourlyschedule
MOTHERNATURE
1 hourlyschedule
153
PHYSIOLOGICAL CAPACITY
RECEPTIVE CAPACITY of stomach
INGESTIVE CAPACITY of BABY
FUNCTIONAL CAPACITY
154
PROPOSAL
The FEEDINGFREQUENCY of theNEONATE is
approx 60 min155
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
BRAIN CYCLING
STOMACH FILLING amp EMPTYING
REMNR1NR2NR3NR4
156
27
Normal physiology of theEnteric Nervous System
ldquoSmall and frequent feeds according to the sleep cyclerdquo
The ldquonicherdquo (occupation) of a neonate (Alberts)
BOND FEED
SLEEP SLEEP
PLAY FEED
157
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
FEEDING SUCKLING
Influence of SMELL None Totally dependent
Motor mechanism Chewing ndash different
muscles
Suckling ndash different circuits
INSULIN Increases weight No effect
GHRELIN Increases weight No effect
LEPTIN Decreases intake No effect
CHOLECYSTOKININ Decreases intake No effect
AMPHETAMINE Decreases appetite Increases suckling
SEROTONIN Agonist improves feeding Antagonist improves suck
SATIETY Infant determined Maternal supply determine
FEEDING SUCKLING
Influence of SMELL None Totally dependent
Motor mechanism Chewing ndash different
muscles
Suckling ndash different circuits
INSULIN Increases weight No effect
GHRELIN Increases weight No effect
LEPTIN Decreases intake No effect
CHOLECYSTOKININ Decreases intake No effect
AMPHETAMINE Decreases appetite Increases suckling
SEROTONIN Agonist improves feeding Antagonist improves suck
SATIETY Infant determined Maternal supply determine
Current dogmaTHE BABY KNOWS
WHEN IT HAS HAD ENOUGH
PROBABLY NOT
WHAT IS THE
STOMACH VOLUME OF THE
PREMATURE
161
Assume low resilience
Assume proportionality
162
28
The CAPACITY of alow birthweight premfrom 20ml 3000g
= 0007 x BWt (g)
1kg x 0007 = 7mls2kg x 0007 = 14mls
163
Gastric overfilling syndrome
164
75 ml per feeding ASSUMPTION
IMMATURE OR OVERWHELMED
many aspects of gastrointestinalmotility are immature in the neonate
Zangen S et al Rapid maturation of gastric relaxation in newborns
A balloon in stomachcan fill to 76 mls
What does the stomach ndashwithout a balloon ndashdo to 76 mls
REFLUX PRESUME each feedapproximately 75 mls
GER
bull Sudden outbursts of crying
bull Awakens in pain
bull Related to feedings
bull Not easily comforted
bull ldquoI know baby hurtsrdquo
bull Sour burps throaty noises
bull Best when upright
Clues to GER
Dr W Sears
29
Mitchell 2001
Kerstin Uvnaumls-Moberg
Food in duodenum
AMYLINreleased
Closes pylorus
Duodenumempty
Pylorusopens
ldquoFeed intolerancerdquo hellip hellip or VOLUME intolerance
HYPOGLYCAEMIA
A babies stomach empties in60 minutes
Blood sugarmay fall hellip
after 90 minutes Options
30
METABOLIC ADAPTATION
SSC started in the first 20 minutes after birth
SSC CotBlood glucose (1 hr) 317 256Base excess drop 34 18
(Christenson 1992)0h 1h 2h 3h 4h 2 days
App
roxim
ate
GLUCOSE
SSC Glucose production = Glucose consumption
Separation
SNS stress Glucose consumption INCREASE
PSNS dissociation Glucose production DECREASE
HYPOGLYCEMIA
SSC Cot
Blood glucose (1 hr) 317 256
0h 1h 2h 3h 4h 2 days
App
roxim
ate
GLUCOSE
SSC Glucose production = Glucose consumption
Separation PSNS dissociation
Glucose production DECREASE
HYPOGLYCEMIA
SSC Cot
Blood glucose (1 hr) 317 256
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
NEURODEVELOPMENTThe DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
BONDING ATTACHMENT
MRI HRVEEG
STRESS RESPONES
RESILIENCE
DOHAD
(MAL) ADAPTATION
EPIGENETICS
GENE X ENVIRONMENT
GENETIC VARIANTS
HOSPITAL ACQUIRED INFECTIONIMMUNITY
SLEEP PHYSIOLOGY
GUT FUNCTIONMICROBIOTA
ldquoSTABILITYrdquo
TRANSITION
LONG TERM FOLLOW-UP
NEUROENDOCRINE BEHAVIOURS
MATERNAL NEUROPLASTICITY
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
MORTALITYMETABOLISM
0h 1h 2h 3h 4h
PSNS (vagal)
App
roxim
ate
GLUCOSE
1 HOURLY Milk feed
1 HOURLY Milk feed
1 HOURLY Milk feed
1 HOURLY Milk feed
LACTOSE
METABOLISM
31
0h 1h 2h 3h 4h
PSNS (vagal) SYMPATHETIC STRESS
App
roxim
ate
GLUCOSE
LACTOSE FATGLYCOGEN
METABOLISM
4 HOURLY Milk feed
0h 1h 2h 3h 4h
PSNS (vagal) SYMPATHETIC STRESS
App
roxim
ate
GLUCOSE
4 HOURLY ALLOSTATIC STATELACTOSE FATGLYCOGEN
METABOLISM
4 HOURLY Milk feed
HEALTH DISEASE
EXPECTED UNEXPECTED
NEURODEVELOPMENTThe DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
BONDING ATTACHMENT
MRI HRVEEG
STRESS RESPONES
RESILIENCE
DOHAD
(MAL) ADAPTATION
EPIGENETICS
GENE X ENVIRONMENT
GENETIC VARIANTS
HOSPITAL ACQUIRED INFECTIONIMMUNITY
SLEEP PHYSIOLOGY
GUT FUNCTIONMICROBIOTA
ldquoSTABILITYrdquo
TRANSITION
LONG TERM FOLLOW-UP
NEUROENDOCRINE BEHAVIOURS
MATERNAL NEUROPLASTICITY
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
MORTALITYMETABOLISM
Weight gain 1st week
predicts OBESITYat 30 years
Large volume feedsstretched stomach=
doubled absorptivecapacity as adult
Importance
Programming ndash early life chronic disease
32
RESISTANCE SENSITIVITY
PERCEPTIONSldquoNEUROCEPTIONrdquo
RESPONSESTRESS
ALLOSTATIC STATE
ALLOSTASIS
ANY STRESSPsychologicalNeurological
EndocrineImmune
ALLOSTATIC LOAD
ALLOSTATIC OVERLOAD
WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY
DISEASEHEALTH
RESILIENCE VULNERABILITY
RESISTANCE SENSITIVITY
PERCEPTIONSldquoNEUROCEPTIONrdquo
RESPONSESTRESS
ALLOSTATIC STATE
ALLOSTASIS
ANY STRESSPsychologicalNeurological
EndocrineImmune
ALLOSTATIC LOAD
HEALTH
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
Gastric overfilling syndrome
189
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
33
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
Only case series Insufficient evidence
No mention of
stomach capacity196
Baby weight freq reqrsquod size actual
2kg baby 4hrly ~ 320 ml6 = 53ml 14ml
15 baby 3hrly ~ 240 ml8 = 30ml 10ml
10 baby 2hrly ~ 160 ml12 = 13ml 7ml
Standardised from20ml capacityfor 3kg baby( x 0007)
197
0
10
20
30
40
50
60
70
80
90
13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w
LINEAR
TERM
PREM
198
34
0
10
20
30
40
50
60
70
80
90
13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w
LINEAR
TERM
PREM
199
Clues to GER
ldquoI know baby hurtsrdquo
Gastric overfilling syndrome
Excessive volumesreflux aspiration colic
Excessive time intervalhypoglycaemia
Adaptationsdiabetic diathesis obesity
200
Developmental Care of the Enteric Nervous System
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
7
DEFENSE NUTRITION REPRODUCTION
HORMONES NERVES MUSCLES
DEFENSE NUTRITION REPRODUCTION
HORMONES NERVES MUSCLES
= BREASTFEEDING
SAFE
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
WIRE MOTHER
NEURODEVELOPMENTThe DNA Behaviour
EVOLUTIONARY BIOLOGY
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
BIRTH
BEYOND BREASTFEEDING Feed Sleep Cycling
MOTHERBABY
BONDING Sensitization
Secure attachment
Attuned parenting
SEPARATION
OXYTOCIN
8
OXYTOCIN
OXYTOCIN comes from
Cervical dilatation
Skin-to-skin contact
Breastfeeding
Eye-to-eye contact
Effects of doula care
No doula DoulaUSA (Kennell et al 1991)
Epidural 55 8Caesarean section 18 8Forceps delivery 26 8Fetal distress 24 10
ldquoIf a Doula was a drug it would be unethical
not to use itrdquoDr John Kennell
1922 -2013Marshall Klaus amp John Kenell
EARLY CHILDHOOD DEVELOPMENT ECD
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
BIRTH
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
WIRE MOTHER
OXYTOCIN
11
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDINGON-GOING
S S C
WIRE TOGETHER
OXYTOCIN
hellip infant cues - suckling vocalisation and tactile stimulation - stimulate
OXYTOCINrelease in the hypothalamus which may result in the activation of the dopaminergic reward pathway leading to behavioural reinforcement
key biological systems hellip that contribute to maternal caregiving behaviour hellip the oxytocinergic and dopaminergic systems
hellip dopamine pathways contribute to the processing of infant-related sensory cues leading to a behavioural response c
DISEASEHEALTH
CORTISOLOXYTOCIN
The psychology of human parent-infant relationships
Parenting is regulated by key hormones and neurotransmitters
Neuroanatomical circuits of parenting
Integrative physiology of normal parenting behaviours
Brain imaging of human parent-infant relationships
The neurobiology of empathy and parenting
Conclusions and critical summary
(Swain et al 2007)
12
FEARCONTROL
CENTRE
REWARDCONTROL
CENTRE
SOCIALCONTROL CENTRE
OXYTOCINDOPAMINE
CORTISOL
EMOTIONCONTROL CENTRE
WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY
DISEASEHEALTH
RESILIENCE VULNERABILITY
hellip there is considerable overlap in the brain structures associated with these neural mechanisms hellip functional interactions among the circuits
DOULA and KANGAROULA
-1000 min
BIRTH
+1000 min 1000 days
OXYTOCIN Zero separation
Protect OXYTOCINBefore and after
BIRTH
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDINGON-GOING
S S C
WIRE TOGETHER
Protect OXYTOCINBefore and after
BIRTH
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDINGON-GOING
S S C
WIRE SUCKLING
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
Alberts SUCKLING versus FEEDING
DUAL INGESTION SYSTEMS
13
300 mya 200 mya 100 mya 50 mya 300 mya 200 mya 100 mya 50 mya
Amniotes
Synapsids
Cynodonts
Mammaliaformes
PlacentalsMammals
ANCESTRAL STATE
hellip intoMATURE FEEDING
300 mya 200 mya 100 mya 50 mya
WATER
EGGS
Hatch withTEETH
ANCESTRAL STATE
hellip intoMATURE FEEDING
eg TURTLES
CROCODILES DINOSAURS
REPTILES
300 mya 200 mya 100 mya 50 mya
Epibubic bone = pouch care
hellip intoMATURE FEEDING
Amniotes
Synapsids
Cynodonts
Mammaliaformes
Smaller eggs longer in body
The AMNIOTE EGGextra membranes
Copes with AIR
PlacentalsMammals
Viviparity = immature
ENDOTHERMY
MOISTUREfor eggs
Diphyodontism
300 mya 200 mya 100 mya 50 mya
hellip intoMATURE FEEDING
Amniotes
Synapsids
Cynodonts
Mammaliaformes
PlacentalsMammals
ENDOTHERMY
MOISTUREfor eggs
LACTOSE added(apocrine glands)
NUTRIENTSAntimicrobials
LACTATION
SUCKLINGFEEDING
200 million years
Diphyodontism
300 mya 200 mya 100 mya 50 mya
hellip intoMATURE FEEDING
Amniotes
Synapsids
Cynodonts
Mammaliaformes
PlacentalsMammals
ENDOTHERMY
MOISTUREfor eggs
LACTOSE added(apocrine glands)
NUTRIENTSAntimicrobials
LACTATION
SUCKLINGFEEDING
200 million years
DUAL INGESTION SYSTEMS
100 million years
14
DUAL INGESTION SYSTEMS DUAL INGESTION SYSTEMS
SUCKLING WEANING FEEDING
Lactase Digestive enzymes
FEEDING SUCKLING
Influence of SMELL None Totally dependent
Motor mechanism Chewing ndash different
muscles
Suckling ndash different circuits
INSULIN Increases weight No effect
GHRELIN Increases weight No effect
LEPTIN Decreases intake No effect
CHOLECYSTOKININ Decreases intake No effect
AMPHETAMINE Decreases appetite Increases suckling
SEROTONIN Agonist improves feeding Antagonist improves suck
SATIETY Infant determined Maternal supply determine
FEEDING SUCKLING
DISRUPTION ROBUST VERY SENSITIVE
Must have right conditions
Pup-in-a- cup - And STIMULI
separated and fed by tube
From day 2 off life
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
14th century Tuscan text
Conceptual changeDyad careBreast first hour
even CaesareanContinuous SSC
DISCONTINUEGiving waterGlucose waterInfant formulaSeparationPacifier (dummy)
CHANGE POLICY Canrsquot change
biology
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
ON-GOING
S S C
WIRE NEURONS
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C WIRE
TIMING
(behavior)
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
ENTERIC NERVOUS SYSTEM
123
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
FEEDBACK LOOPS
CNS
ENS
ANS
InternalSomaticenvironment
124
125 126
22
Fetal stomach appears 4 weeks GABy 11 weeks wall capable of muscular
contraction
ldquoPatterns of antropyloric motilityin fed healthy preterm infantsrdquo
the neuroregulatory mechanisms responsible for the coordination of antro-pyloric motility and gastric emptying are
well developed by 30 weeks of PMAHassan 2002 127
Hydrochloric acidimportant for activation of pepsinogen
inactivation of microorganisms such as bacteria
Pepsinogenactivated by acid into active pepsin
responsible for the stomachs ability to initiate digestion of proteins
Chymosinis an enzyme whose role is to curdle or
coagulate milk in the stomach a process of considerable importance in the very young animal
128
Chymosinmakes the milk into ldquocheeserdquohalfway between liquid and solidstomach empties in 60 minutes
milk
129
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
FEEDBACK LOOPS
130
EVIDENCE FORFEEDING FREQUENCY
Edmond 2006 131
Breastfeeding and motherrsquos milkStrong and consistent evidence 132
23
Cup feeding versus bottle feedingCup feeding higher breastfeeding
greater stability133
Only case series Insufficient evidence
No mention of
stomach capacity134
EVIDENCE FORSTOMACH CAPACITY
Edmond 2006 135
0
05
1
15
2
25
3
35
4
0 10 20 30 40 50 60 70 80
volume ingested
fee
din
g f
req
ue
nc
y
Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml
StandardCARE3 hourlyschedule
136
KEY QUESTION
WHAT IS THE
STOMACHVOLUMEOF THE
NEONATE 137 Sase 2005
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
(Alliot) pressure)151
PROPOSAL
The CAPACITY of aweek old babyrsquos stomach is
approx 20 ml152
0
05
1
15
2
25
3
35
4
0 10 20 30 40 50 60 70 80
volume ingested
fee
din
g f
req
ue
nc
y
Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml
StandardCARE3 hourlyschedule
MOTHERNATURE
1 hourlyschedule
153
PHYSIOLOGICAL CAPACITY
RECEPTIVE CAPACITY of stomach
INGESTIVE CAPACITY of BABY
FUNCTIONAL CAPACITY
154
PROPOSAL
The FEEDINGFREQUENCY of theNEONATE is
approx 60 min155
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
BRAIN CYCLING
STOMACH FILLING amp EMPTYING
REMNR1NR2NR3NR4
156
27
Normal physiology of theEnteric Nervous System
ldquoSmall and frequent feeds according to the sleep cyclerdquo
The ldquonicherdquo (occupation) of a neonate (Alberts)
BOND FEED
SLEEP SLEEP
PLAY FEED
157
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
FEEDING SUCKLING
Influence of SMELL None Totally dependent
Motor mechanism Chewing ndash different
muscles
Suckling ndash different circuits
INSULIN Increases weight No effect
GHRELIN Increases weight No effect
LEPTIN Decreases intake No effect
CHOLECYSTOKININ Decreases intake No effect
AMPHETAMINE Decreases appetite Increases suckling
SEROTONIN Agonist improves feeding Antagonist improves suck
SATIETY Infant determined Maternal supply determine
FEEDING SUCKLING
Influence of SMELL None Totally dependent
Motor mechanism Chewing ndash different
muscles
Suckling ndash different circuits
INSULIN Increases weight No effect
GHRELIN Increases weight No effect
LEPTIN Decreases intake No effect
CHOLECYSTOKININ Decreases intake No effect
AMPHETAMINE Decreases appetite Increases suckling
SEROTONIN Agonist improves feeding Antagonist improves suck
SATIETY Infant determined Maternal supply determine
Current dogmaTHE BABY KNOWS
WHEN IT HAS HAD ENOUGH
PROBABLY NOT
WHAT IS THE
STOMACH VOLUME OF THE
PREMATURE
161
Assume low resilience
Assume proportionality
162
28
The CAPACITY of alow birthweight premfrom 20ml 3000g
= 0007 x BWt (g)
1kg x 0007 = 7mls2kg x 0007 = 14mls
163
Gastric overfilling syndrome
164
75 ml per feeding ASSUMPTION
IMMATURE OR OVERWHELMED
many aspects of gastrointestinalmotility are immature in the neonate
Zangen S et al Rapid maturation of gastric relaxation in newborns
A balloon in stomachcan fill to 76 mls
What does the stomach ndashwithout a balloon ndashdo to 76 mls
REFLUX PRESUME each feedapproximately 75 mls
GER
bull Sudden outbursts of crying
bull Awakens in pain
bull Related to feedings
bull Not easily comforted
bull ldquoI know baby hurtsrdquo
bull Sour burps throaty noises
bull Best when upright
Clues to GER
Dr W Sears
29
Mitchell 2001
Kerstin Uvnaumls-Moberg
Food in duodenum
AMYLINreleased
Closes pylorus
Duodenumempty
Pylorusopens
ldquoFeed intolerancerdquo hellip hellip or VOLUME intolerance
HYPOGLYCAEMIA
A babies stomach empties in60 minutes
Blood sugarmay fall hellip
after 90 minutes Options
30
METABOLIC ADAPTATION
SSC started in the first 20 minutes after birth
SSC CotBlood glucose (1 hr) 317 256Base excess drop 34 18
(Christenson 1992)0h 1h 2h 3h 4h 2 days
App
roxim
ate
GLUCOSE
SSC Glucose production = Glucose consumption
Separation
SNS stress Glucose consumption INCREASE
PSNS dissociation Glucose production DECREASE
HYPOGLYCEMIA
SSC Cot
Blood glucose (1 hr) 317 256
0h 1h 2h 3h 4h 2 days
App
roxim
ate
GLUCOSE
SSC Glucose production = Glucose consumption
Separation PSNS dissociation
Glucose production DECREASE
HYPOGLYCEMIA
SSC Cot
Blood glucose (1 hr) 317 256
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
NEURODEVELOPMENTThe DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
BONDING ATTACHMENT
MRI HRVEEG
STRESS RESPONES
RESILIENCE
DOHAD
(MAL) ADAPTATION
EPIGENETICS
GENE X ENVIRONMENT
GENETIC VARIANTS
HOSPITAL ACQUIRED INFECTIONIMMUNITY
SLEEP PHYSIOLOGY
GUT FUNCTIONMICROBIOTA
ldquoSTABILITYrdquo
TRANSITION
LONG TERM FOLLOW-UP
NEUROENDOCRINE BEHAVIOURS
MATERNAL NEUROPLASTICITY
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
MORTALITYMETABOLISM
0h 1h 2h 3h 4h
PSNS (vagal)
App
roxim
ate
GLUCOSE
1 HOURLY Milk feed
1 HOURLY Milk feed
1 HOURLY Milk feed
1 HOURLY Milk feed
LACTOSE
METABOLISM
31
0h 1h 2h 3h 4h
PSNS (vagal) SYMPATHETIC STRESS
App
roxim
ate
GLUCOSE
LACTOSE FATGLYCOGEN
METABOLISM
4 HOURLY Milk feed
0h 1h 2h 3h 4h
PSNS (vagal) SYMPATHETIC STRESS
App
roxim
ate
GLUCOSE
4 HOURLY ALLOSTATIC STATELACTOSE FATGLYCOGEN
METABOLISM
4 HOURLY Milk feed
HEALTH DISEASE
EXPECTED UNEXPECTED
NEURODEVELOPMENTThe DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
BONDING ATTACHMENT
MRI HRVEEG
STRESS RESPONES
RESILIENCE
DOHAD
(MAL) ADAPTATION
EPIGENETICS
GENE X ENVIRONMENT
GENETIC VARIANTS
HOSPITAL ACQUIRED INFECTIONIMMUNITY
SLEEP PHYSIOLOGY
GUT FUNCTIONMICROBIOTA
ldquoSTABILITYrdquo
TRANSITION
LONG TERM FOLLOW-UP
NEUROENDOCRINE BEHAVIOURS
MATERNAL NEUROPLASTICITY
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
MORTALITYMETABOLISM
Weight gain 1st week
predicts OBESITYat 30 years
Large volume feedsstretched stomach=
doubled absorptivecapacity as adult
Importance
Programming ndash early life chronic disease
32
RESISTANCE SENSITIVITY
PERCEPTIONSldquoNEUROCEPTIONrdquo
RESPONSESTRESS
ALLOSTATIC STATE
ALLOSTASIS
ANY STRESSPsychologicalNeurological
EndocrineImmune
ALLOSTATIC LOAD
ALLOSTATIC OVERLOAD
WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY
DISEASEHEALTH
RESILIENCE VULNERABILITY
RESISTANCE SENSITIVITY
PERCEPTIONSldquoNEUROCEPTIONrdquo
RESPONSESTRESS
ALLOSTATIC STATE
ALLOSTASIS
ANY STRESSPsychologicalNeurological
EndocrineImmune
ALLOSTATIC LOAD
HEALTH
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
Gastric overfilling syndrome
189
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
33
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
Only case series Insufficient evidence
No mention of
stomach capacity196
Baby weight freq reqrsquod size actual
2kg baby 4hrly ~ 320 ml6 = 53ml 14ml
15 baby 3hrly ~ 240 ml8 = 30ml 10ml
10 baby 2hrly ~ 160 ml12 = 13ml 7ml
Standardised from20ml capacityfor 3kg baby( x 0007)
197
0
10
20
30
40
50
60
70
80
90
13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w
LINEAR
TERM
PREM
198
34
0
10
20
30
40
50
60
70
80
90
13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w
LINEAR
TERM
PREM
199
Clues to GER
ldquoI know baby hurtsrdquo
Gastric overfilling syndrome
Excessive volumesreflux aspiration colic
Excessive time intervalhypoglycaemia
Adaptationsdiabetic diathesis obesity
200
Developmental Care of the Enteric Nervous System
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
8
OXYTOCIN
OXYTOCIN comes from
Cervical dilatation
Skin-to-skin contact
Breastfeeding
Eye-to-eye contact
Effects of doula care
No doula DoulaUSA (Kennell et al 1991)
Epidural 55 8Caesarean section 18 8Forceps delivery 26 8Fetal distress 24 10
ldquoIf a Doula was a drug it would be unethical
not to use itrdquoDr John Kennell
1922 -2013Marshall Klaus amp John Kenell
EARLY CHILDHOOD DEVELOPMENT ECD
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
BIRTH
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
WIRE MOTHER
OXYTOCIN
11
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDINGON-GOING
S S C
WIRE TOGETHER
OXYTOCIN
hellip infant cues - suckling vocalisation and tactile stimulation - stimulate
OXYTOCINrelease in the hypothalamus which may result in the activation of the dopaminergic reward pathway leading to behavioural reinforcement
key biological systems hellip that contribute to maternal caregiving behaviour hellip the oxytocinergic and dopaminergic systems
hellip dopamine pathways contribute to the processing of infant-related sensory cues leading to a behavioural response c
DISEASEHEALTH
CORTISOLOXYTOCIN
The psychology of human parent-infant relationships
Parenting is regulated by key hormones and neurotransmitters
Neuroanatomical circuits of parenting
Integrative physiology of normal parenting behaviours
Brain imaging of human parent-infant relationships
The neurobiology of empathy and parenting
Conclusions and critical summary
(Swain et al 2007)
12
FEARCONTROL
CENTRE
REWARDCONTROL
CENTRE
SOCIALCONTROL CENTRE
OXYTOCINDOPAMINE
CORTISOL
EMOTIONCONTROL CENTRE
WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY
DISEASEHEALTH
RESILIENCE VULNERABILITY
hellip there is considerable overlap in the brain structures associated with these neural mechanisms hellip functional interactions among the circuits
DOULA and KANGAROULA
-1000 min
BIRTH
+1000 min 1000 days
OXYTOCIN Zero separation
Protect OXYTOCINBefore and after
BIRTH
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDINGON-GOING
S S C
WIRE TOGETHER
Protect OXYTOCINBefore and after
BIRTH
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDINGON-GOING
S S C
WIRE SUCKLING
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
Alberts SUCKLING versus FEEDING
DUAL INGESTION SYSTEMS
13
300 mya 200 mya 100 mya 50 mya 300 mya 200 mya 100 mya 50 mya
Amniotes
Synapsids
Cynodonts
Mammaliaformes
PlacentalsMammals
ANCESTRAL STATE
hellip intoMATURE FEEDING
300 mya 200 mya 100 mya 50 mya
WATER
EGGS
Hatch withTEETH
ANCESTRAL STATE
hellip intoMATURE FEEDING
eg TURTLES
CROCODILES DINOSAURS
REPTILES
300 mya 200 mya 100 mya 50 mya
Epibubic bone = pouch care
hellip intoMATURE FEEDING
Amniotes
Synapsids
Cynodonts
Mammaliaformes
Smaller eggs longer in body
The AMNIOTE EGGextra membranes
Copes with AIR
PlacentalsMammals
Viviparity = immature
ENDOTHERMY
MOISTUREfor eggs
Diphyodontism
300 mya 200 mya 100 mya 50 mya
hellip intoMATURE FEEDING
Amniotes
Synapsids
Cynodonts
Mammaliaformes
PlacentalsMammals
ENDOTHERMY
MOISTUREfor eggs
LACTOSE added(apocrine glands)
NUTRIENTSAntimicrobials
LACTATION
SUCKLINGFEEDING
200 million years
Diphyodontism
300 mya 200 mya 100 mya 50 mya
hellip intoMATURE FEEDING
Amniotes
Synapsids
Cynodonts
Mammaliaformes
PlacentalsMammals
ENDOTHERMY
MOISTUREfor eggs
LACTOSE added(apocrine glands)
NUTRIENTSAntimicrobials
LACTATION
SUCKLINGFEEDING
200 million years
DUAL INGESTION SYSTEMS
100 million years
14
DUAL INGESTION SYSTEMS DUAL INGESTION SYSTEMS
SUCKLING WEANING FEEDING
Lactase Digestive enzymes
FEEDING SUCKLING
Influence of SMELL None Totally dependent
Motor mechanism Chewing ndash different
muscles
Suckling ndash different circuits
INSULIN Increases weight No effect
GHRELIN Increases weight No effect
LEPTIN Decreases intake No effect
CHOLECYSTOKININ Decreases intake No effect
AMPHETAMINE Decreases appetite Increases suckling
SEROTONIN Agonist improves feeding Antagonist improves suck
SATIETY Infant determined Maternal supply determine
FEEDING SUCKLING
DISRUPTION ROBUST VERY SENSITIVE
Must have right conditions
Pup-in-a- cup - And STIMULI
separated and fed by tube
From day 2 off life
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
14th century Tuscan text
Conceptual changeDyad careBreast first hour
even CaesareanContinuous SSC
DISCONTINUEGiving waterGlucose waterInfant formulaSeparationPacifier (dummy)
CHANGE POLICY Canrsquot change
biology
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
ON-GOING
S S C
WIRE NEURONS
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C WIRE
TIMING
(behavior)
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
ENTERIC NERVOUS SYSTEM
123
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
FEEDBACK LOOPS
CNS
ENS
ANS
InternalSomaticenvironment
124
125 126
22
Fetal stomach appears 4 weeks GABy 11 weeks wall capable of muscular
contraction
ldquoPatterns of antropyloric motilityin fed healthy preterm infantsrdquo
the neuroregulatory mechanisms responsible for the coordination of antro-pyloric motility and gastric emptying are
well developed by 30 weeks of PMAHassan 2002 127
Hydrochloric acidimportant for activation of pepsinogen
inactivation of microorganisms such as bacteria
Pepsinogenactivated by acid into active pepsin
responsible for the stomachs ability to initiate digestion of proteins
Chymosinis an enzyme whose role is to curdle or
coagulate milk in the stomach a process of considerable importance in the very young animal
128
Chymosinmakes the milk into ldquocheeserdquohalfway between liquid and solidstomach empties in 60 minutes
milk
129
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
FEEDBACK LOOPS
130
EVIDENCE FORFEEDING FREQUENCY
Edmond 2006 131
Breastfeeding and motherrsquos milkStrong and consistent evidence 132
23
Cup feeding versus bottle feedingCup feeding higher breastfeeding
greater stability133
Only case series Insufficient evidence
No mention of
stomach capacity134
EVIDENCE FORSTOMACH CAPACITY
Edmond 2006 135
0
05
1
15
2
25
3
35
4
0 10 20 30 40 50 60 70 80
volume ingested
fee
din
g f
req
ue
nc
y
Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml
StandardCARE3 hourlyschedule
136
KEY QUESTION
WHAT IS THE
STOMACHVOLUMEOF THE
NEONATE 137 Sase 2005
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
(Alliot) pressure)151
PROPOSAL
The CAPACITY of aweek old babyrsquos stomach is
approx 20 ml152
0
05
1
15
2
25
3
35
4
0 10 20 30 40 50 60 70 80
volume ingested
fee
din
g f
req
ue
nc
y
Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml
StandardCARE3 hourlyschedule
MOTHERNATURE
1 hourlyschedule
153
PHYSIOLOGICAL CAPACITY
RECEPTIVE CAPACITY of stomach
INGESTIVE CAPACITY of BABY
FUNCTIONAL CAPACITY
154
PROPOSAL
The FEEDINGFREQUENCY of theNEONATE is
approx 60 min155
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
BRAIN CYCLING
STOMACH FILLING amp EMPTYING
REMNR1NR2NR3NR4
156
27
Normal physiology of theEnteric Nervous System
ldquoSmall and frequent feeds according to the sleep cyclerdquo
The ldquonicherdquo (occupation) of a neonate (Alberts)
BOND FEED
SLEEP SLEEP
PLAY FEED
157
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
FEEDING SUCKLING
Influence of SMELL None Totally dependent
Motor mechanism Chewing ndash different
muscles
Suckling ndash different circuits
INSULIN Increases weight No effect
GHRELIN Increases weight No effect
LEPTIN Decreases intake No effect
CHOLECYSTOKININ Decreases intake No effect
AMPHETAMINE Decreases appetite Increases suckling
SEROTONIN Agonist improves feeding Antagonist improves suck
SATIETY Infant determined Maternal supply determine
FEEDING SUCKLING
Influence of SMELL None Totally dependent
Motor mechanism Chewing ndash different
muscles
Suckling ndash different circuits
INSULIN Increases weight No effect
GHRELIN Increases weight No effect
LEPTIN Decreases intake No effect
CHOLECYSTOKININ Decreases intake No effect
AMPHETAMINE Decreases appetite Increases suckling
SEROTONIN Agonist improves feeding Antagonist improves suck
SATIETY Infant determined Maternal supply determine
Current dogmaTHE BABY KNOWS
WHEN IT HAS HAD ENOUGH
PROBABLY NOT
WHAT IS THE
STOMACH VOLUME OF THE
PREMATURE
161
Assume low resilience
Assume proportionality
162
28
The CAPACITY of alow birthweight premfrom 20ml 3000g
= 0007 x BWt (g)
1kg x 0007 = 7mls2kg x 0007 = 14mls
163
Gastric overfilling syndrome
164
75 ml per feeding ASSUMPTION
IMMATURE OR OVERWHELMED
many aspects of gastrointestinalmotility are immature in the neonate
Zangen S et al Rapid maturation of gastric relaxation in newborns
A balloon in stomachcan fill to 76 mls
What does the stomach ndashwithout a balloon ndashdo to 76 mls
REFLUX PRESUME each feedapproximately 75 mls
GER
bull Sudden outbursts of crying
bull Awakens in pain
bull Related to feedings
bull Not easily comforted
bull ldquoI know baby hurtsrdquo
bull Sour burps throaty noises
bull Best when upright
Clues to GER
Dr W Sears
29
Mitchell 2001
Kerstin Uvnaumls-Moberg
Food in duodenum
AMYLINreleased
Closes pylorus
Duodenumempty
Pylorusopens
ldquoFeed intolerancerdquo hellip hellip or VOLUME intolerance
HYPOGLYCAEMIA
A babies stomach empties in60 minutes
Blood sugarmay fall hellip
after 90 minutes Options
30
METABOLIC ADAPTATION
SSC started in the first 20 minutes after birth
SSC CotBlood glucose (1 hr) 317 256Base excess drop 34 18
(Christenson 1992)0h 1h 2h 3h 4h 2 days
App
roxim
ate
GLUCOSE
SSC Glucose production = Glucose consumption
Separation
SNS stress Glucose consumption INCREASE
PSNS dissociation Glucose production DECREASE
HYPOGLYCEMIA
SSC Cot
Blood glucose (1 hr) 317 256
0h 1h 2h 3h 4h 2 days
App
roxim
ate
GLUCOSE
SSC Glucose production = Glucose consumption
Separation PSNS dissociation
Glucose production DECREASE
HYPOGLYCEMIA
SSC Cot
Blood glucose (1 hr) 317 256
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
NEURODEVELOPMENTThe DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
BONDING ATTACHMENT
MRI HRVEEG
STRESS RESPONES
RESILIENCE
DOHAD
(MAL) ADAPTATION
EPIGENETICS
GENE X ENVIRONMENT
GENETIC VARIANTS
HOSPITAL ACQUIRED INFECTIONIMMUNITY
SLEEP PHYSIOLOGY
GUT FUNCTIONMICROBIOTA
ldquoSTABILITYrdquo
TRANSITION
LONG TERM FOLLOW-UP
NEUROENDOCRINE BEHAVIOURS
MATERNAL NEUROPLASTICITY
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
MORTALITYMETABOLISM
0h 1h 2h 3h 4h
PSNS (vagal)
App
roxim
ate
GLUCOSE
1 HOURLY Milk feed
1 HOURLY Milk feed
1 HOURLY Milk feed
1 HOURLY Milk feed
LACTOSE
METABOLISM
31
0h 1h 2h 3h 4h
PSNS (vagal) SYMPATHETIC STRESS
App
roxim
ate
GLUCOSE
LACTOSE FATGLYCOGEN
METABOLISM
4 HOURLY Milk feed
0h 1h 2h 3h 4h
PSNS (vagal) SYMPATHETIC STRESS
App
roxim
ate
GLUCOSE
4 HOURLY ALLOSTATIC STATELACTOSE FATGLYCOGEN
METABOLISM
4 HOURLY Milk feed
HEALTH DISEASE
EXPECTED UNEXPECTED
NEURODEVELOPMENTThe DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
BONDING ATTACHMENT
MRI HRVEEG
STRESS RESPONES
RESILIENCE
DOHAD
(MAL) ADAPTATION
EPIGENETICS
GENE X ENVIRONMENT
GENETIC VARIANTS
HOSPITAL ACQUIRED INFECTIONIMMUNITY
SLEEP PHYSIOLOGY
GUT FUNCTIONMICROBIOTA
ldquoSTABILITYrdquo
TRANSITION
LONG TERM FOLLOW-UP
NEUROENDOCRINE BEHAVIOURS
MATERNAL NEUROPLASTICITY
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
MORTALITYMETABOLISM
Weight gain 1st week
predicts OBESITYat 30 years
Large volume feedsstretched stomach=
doubled absorptivecapacity as adult
Importance
Programming ndash early life chronic disease
32
RESISTANCE SENSITIVITY
PERCEPTIONSldquoNEUROCEPTIONrdquo
RESPONSESTRESS
ALLOSTATIC STATE
ALLOSTASIS
ANY STRESSPsychologicalNeurological
EndocrineImmune
ALLOSTATIC LOAD
ALLOSTATIC OVERLOAD
WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY
DISEASEHEALTH
RESILIENCE VULNERABILITY
RESISTANCE SENSITIVITY
PERCEPTIONSldquoNEUROCEPTIONrdquo
RESPONSESTRESS
ALLOSTATIC STATE
ALLOSTASIS
ANY STRESSPsychologicalNeurological
EndocrineImmune
ALLOSTATIC LOAD
HEALTH
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
Gastric overfilling syndrome
189
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
33
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
Only case series Insufficient evidence
No mention of
stomach capacity196
Baby weight freq reqrsquod size actual
2kg baby 4hrly ~ 320 ml6 = 53ml 14ml
15 baby 3hrly ~ 240 ml8 = 30ml 10ml
10 baby 2hrly ~ 160 ml12 = 13ml 7ml
Standardised from20ml capacityfor 3kg baby( x 0007)
197
0
10
20
30
40
50
60
70
80
90
13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w
LINEAR
TERM
PREM
198
34
0
10
20
30
40
50
60
70
80
90
13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w
LINEAR
TERM
PREM
199
Clues to GER
ldquoI know baby hurtsrdquo
Gastric overfilling syndrome
Excessive volumesreflux aspiration colic
Excessive time intervalhypoglycaemia
Adaptationsdiabetic diathesis obesity
200
Developmental Care of the Enteric Nervous System
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
BIRTH
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
WIRE MOTHER
OXYTOCIN
11
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDINGON-GOING
S S C
WIRE TOGETHER
OXYTOCIN
hellip infant cues - suckling vocalisation and tactile stimulation - stimulate
OXYTOCINrelease in the hypothalamus which may result in the activation of the dopaminergic reward pathway leading to behavioural reinforcement
key biological systems hellip that contribute to maternal caregiving behaviour hellip the oxytocinergic and dopaminergic systems
hellip dopamine pathways contribute to the processing of infant-related sensory cues leading to a behavioural response c
DISEASEHEALTH
CORTISOLOXYTOCIN
The psychology of human parent-infant relationships
Parenting is regulated by key hormones and neurotransmitters
Neuroanatomical circuits of parenting
Integrative physiology of normal parenting behaviours
Brain imaging of human parent-infant relationships
The neurobiology of empathy and parenting
Conclusions and critical summary
(Swain et al 2007)
12
FEARCONTROL
CENTRE
REWARDCONTROL
CENTRE
SOCIALCONTROL CENTRE
OXYTOCINDOPAMINE
CORTISOL
EMOTIONCONTROL CENTRE
WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY
DISEASEHEALTH
RESILIENCE VULNERABILITY
hellip there is considerable overlap in the brain structures associated with these neural mechanisms hellip functional interactions among the circuits
DOULA and KANGAROULA
-1000 min
BIRTH
+1000 min 1000 days
OXYTOCIN Zero separation
Protect OXYTOCINBefore and after
BIRTH
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDINGON-GOING
S S C
WIRE TOGETHER
Protect OXYTOCINBefore and after
BIRTH
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDINGON-GOING
S S C
WIRE SUCKLING
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
Alberts SUCKLING versus FEEDING
DUAL INGESTION SYSTEMS
13
300 mya 200 mya 100 mya 50 mya 300 mya 200 mya 100 mya 50 mya
Amniotes
Synapsids
Cynodonts
Mammaliaformes
PlacentalsMammals
ANCESTRAL STATE
hellip intoMATURE FEEDING
300 mya 200 mya 100 mya 50 mya
WATER
EGGS
Hatch withTEETH
ANCESTRAL STATE
hellip intoMATURE FEEDING
eg TURTLES
CROCODILES DINOSAURS
REPTILES
300 mya 200 mya 100 mya 50 mya
Epibubic bone = pouch care
hellip intoMATURE FEEDING
Amniotes
Synapsids
Cynodonts
Mammaliaformes
Smaller eggs longer in body
The AMNIOTE EGGextra membranes
Copes with AIR
PlacentalsMammals
Viviparity = immature
ENDOTHERMY
MOISTUREfor eggs
Diphyodontism
300 mya 200 mya 100 mya 50 mya
hellip intoMATURE FEEDING
Amniotes
Synapsids
Cynodonts
Mammaliaformes
PlacentalsMammals
ENDOTHERMY
MOISTUREfor eggs
LACTOSE added(apocrine glands)
NUTRIENTSAntimicrobials
LACTATION
SUCKLINGFEEDING
200 million years
Diphyodontism
300 mya 200 mya 100 mya 50 mya
hellip intoMATURE FEEDING
Amniotes
Synapsids
Cynodonts
Mammaliaformes
PlacentalsMammals
ENDOTHERMY
MOISTUREfor eggs
LACTOSE added(apocrine glands)
NUTRIENTSAntimicrobials
LACTATION
SUCKLINGFEEDING
200 million years
DUAL INGESTION SYSTEMS
100 million years
14
DUAL INGESTION SYSTEMS DUAL INGESTION SYSTEMS
SUCKLING WEANING FEEDING
Lactase Digestive enzymes
FEEDING SUCKLING
Influence of SMELL None Totally dependent
Motor mechanism Chewing ndash different
muscles
Suckling ndash different circuits
INSULIN Increases weight No effect
GHRELIN Increases weight No effect
LEPTIN Decreases intake No effect
CHOLECYSTOKININ Decreases intake No effect
AMPHETAMINE Decreases appetite Increases suckling
SEROTONIN Agonist improves feeding Antagonist improves suck
SATIETY Infant determined Maternal supply determine
FEEDING SUCKLING
DISRUPTION ROBUST VERY SENSITIVE
Must have right conditions
Pup-in-a- cup - And STIMULI
separated and fed by tube
From day 2 off life
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
14th century Tuscan text
Conceptual changeDyad careBreast first hour
even CaesareanContinuous SSC
DISCONTINUEGiving waterGlucose waterInfant formulaSeparationPacifier (dummy)
CHANGE POLICY Canrsquot change
biology
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
ON-GOING
S S C
WIRE NEURONS
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C WIRE
TIMING
(behavior)
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
ENTERIC NERVOUS SYSTEM
123
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
FEEDBACK LOOPS
CNS
ENS
ANS
InternalSomaticenvironment
124
125 126
22
Fetal stomach appears 4 weeks GABy 11 weeks wall capable of muscular
contraction
ldquoPatterns of antropyloric motilityin fed healthy preterm infantsrdquo
the neuroregulatory mechanisms responsible for the coordination of antro-pyloric motility and gastric emptying are
well developed by 30 weeks of PMAHassan 2002 127
Hydrochloric acidimportant for activation of pepsinogen
inactivation of microorganisms such as bacteria
Pepsinogenactivated by acid into active pepsin
responsible for the stomachs ability to initiate digestion of proteins
Chymosinis an enzyme whose role is to curdle or
coagulate milk in the stomach a process of considerable importance in the very young animal
128
Chymosinmakes the milk into ldquocheeserdquohalfway between liquid and solidstomach empties in 60 minutes
milk
129
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
FEEDBACK LOOPS
130
EVIDENCE FORFEEDING FREQUENCY
Edmond 2006 131
Breastfeeding and motherrsquos milkStrong and consistent evidence 132
23
Cup feeding versus bottle feedingCup feeding higher breastfeeding
greater stability133
Only case series Insufficient evidence
No mention of
stomach capacity134
EVIDENCE FORSTOMACH CAPACITY
Edmond 2006 135
0
05
1
15
2
25
3
35
4
0 10 20 30 40 50 60 70 80
volume ingested
fee
din
g f
req
ue
nc
y
Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml
StandardCARE3 hourlyschedule
136
KEY QUESTION
WHAT IS THE
STOMACHVOLUMEOF THE
NEONATE 137 Sase 2005
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
(Alliot) pressure)151
PROPOSAL
The CAPACITY of aweek old babyrsquos stomach is
approx 20 ml152
0
05
1
15
2
25
3
35
4
0 10 20 30 40 50 60 70 80
volume ingested
fee
din
g f
req
ue
nc
y
Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml
StandardCARE3 hourlyschedule
MOTHERNATURE
1 hourlyschedule
153
PHYSIOLOGICAL CAPACITY
RECEPTIVE CAPACITY of stomach
INGESTIVE CAPACITY of BABY
FUNCTIONAL CAPACITY
154
PROPOSAL
The FEEDINGFREQUENCY of theNEONATE is
approx 60 min155
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
BRAIN CYCLING
STOMACH FILLING amp EMPTYING
REMNR1NR2NR3NR4
156
27
Normal physiology of theEnteric Nervous System
ldquoSmall and frequent feeds according to the sleep cyclerdquo
The ldquonicherdquo (occupation) of a neonate (Alberts)
BOND FEED
SLEEP SLEEP
PLAY FEED
157
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
FEEDING SUCKLING
Influence of SMELL None Totally dependent
Motor mechanism Chewing ndash different
muscles
Suckling ndash different circuits
INSULIN Increases weight No effect
GHRELIN Increases weight No effect
LEPTIN Decreases intake No effect
CHOLECYSTOKININ Decreases intake No effect
AMPHETAMINE Decreases appetite Increases suckling
SEROTONIN Agonist improves feeding Antagonist improves suck
SATIETY Infant determined Maternal supply determine
FEEDING SUCKLING
Influence of SMELL None Totally dependent
Motor mechanism Chewing ndash different
muscles
Suckling ndash different circuits
INSULIN Increases weight No effect
GHRELIN Increases weight No effect
LEPTIN Decreases intake No effect
CHOLECYSTOKININ Decreases intake No effect
AMPHETAMINE Decreases appetite Increases suckling
SEROTONIN Agonist improves feeding Antagonist improves suck
SATIETY Infant determined Maternal supply determine
Current dogmaTHE BABY KNOWS
WHEN IT HAS HAD ENOUGH
PROBABLY NOT
WHAT IS THE
STOMACH VOLUME OF THE
PREMATURE
161
Assume low resilience
Assume proportionality
162
28
The CAPACITY of alow birthweight premfrom 20ml 3000g
= 0007 x BWt (g)
1kg x 0007 = 7mls2kg x 0007 = 14mls
163
Gastric overfilling syndrome
164
75 ml per feeding ASSUMPTION
IMMATURE OR OVERWHELMED
many aspects of gastrointestinalmotility are immature in the neonate
Zangen S et al Rapid maturation of gastric relaxation in newborns
A balloon in stomachcan fill to 76 mls
What does the stomach ndashwithout a balloon ndashdo to 76 mls
REFLUX PRESUME each feedapproximately 75 mls
GER
bull Sudden outbursts of crying
bull Awakens in pain
bull Related to feedings
bull Not easily comforted
bull ldquoI know baby hurtsrdquo
bull Sour burps throaty noises
bull Best when upright
Clues to GER
Dr W Sears
29
Mitchell 2001
Kerstin Uvnaumls-Moberg
Food in duodenum
AMYLINreleased
Closes pylorus
Duodenumempty
Pylorusopens
ldquoFeed intolerancerdquo hellip hellip or VOLUME intolerance
HYPOGLYCAEMIA
A babies stomach empties in60 minutes
Blood sugarmay fall hellip
after 90 minutes Options
30
METABOLIC ADAPTATION
SSC started in the first 20 minutes after birth
SSC CotBlood glucose (1 hr) 317 256Base excess drop 34 18
(Christenson 1992)0h 1h 2h 3h 4h 2 days
App
roxim
ate
GLUCOSE
SSC Glucose production = Glucose consumption
Separation
SNS stress Glucose consumption INCREASE
PSNS dissociation Glucose production DECREASE
HYPOGLYCEMIA
SSC Cot
Blood glucose (1 hr) 317 256
0h 1h 2h 3h 4h 2 days
App
roxim
ate
GLUCOSE
SSC Glucose production = Glucose consumption
Separation PSNS dissociation
Glucose production DECREASE
HYPOGLYCEMIA
SSC Cot
Blood glucose (1 hr) 317 256
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
NEURODEVELOPMENTThe DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
BONDING ATTACHMENT
MRI HRVEEG
STRESS RESPONES
RESILIENCE
DOHAD
(MAL) ADAPTATION
EPIGENETICS
GENE X ENVIRONMENT
GENETIC VARIANTS
HOSPITAL ACQUIRED INFECTIONIMMUNITY
SLEEP PHYSIOLOGY
GUT FUNCTIONMICROBIOTA
ldquoSTABILITYrdquo
TRANSITION
LONG TERM FOLLOW-UP
NEUROENDOCRINE BEHAVIOURS
MATERNAL NEUROPLASTICITY
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
MORTALITYMETABOLISM
0h 1h 2h 3h 4h
PSNS (vagal)
App
roxim
ate
GLUCOSE
1 HOURLY Milk feed
1 HOURLY Milk feed
1 HOURLY Milk feed
1 HOURLY Milk feed
LACTOSE
METABOLISM
31
0h 1h 2h 3h 4h
PSNS (vagal) SYMPATHETIC STRESS
App
roxim
ate
GLUCOSE
LACTOSE FATGLYCOGEN
METABOLISM
4 HOURLY Milk feed
0h 1h 2h 3h 4h
PSNS (vagal) SYMPATHETIC STRESS
App
roxim
ate
GLUCOSE
4 HOURLY ALLOSTATIC STATELACTOSE FATGLYCOGEN
METABOLISM
4 HOURLY Milk feed
HEALTH DISEASE
EXPECTED UNEXPECTED
NEURODEVELOPMENTThe DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
BONDING ATTACHMENT
MRI HRVEEG
STRESS RESPONES
RESILIENCE
DOHAD
(MAL) ADAPTATION
EPIGENETICS
GENE X ENVIRONMENT
GENETIC VARIANTS
HOSPITAL ACQUIRED INFECTIONIMMUNITY
SLEEP PHYSIOLOGY
GUT FUNCTIONMICROBIOTA
ldquoSTABILITYrdquo
TRANSITION
LONG TERM FOLLOW-UP
NEUROENDOCRINE BEHAVIOURS
MATERNAL NEUROPLASTICITY
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
MORTALITYMETABOLISM
Weight gain 1st week
predicts OBESITYat 30 years
Large volume feedsstretched stomach=
doubled absorptivecapacity as adult
Importance
Programming ndash early life chronic disease
32
RESISTANCE SENSITIVITY
PERCEPTIONSldquoNEUROCEPTIONrdquo
RESPONSESTRESS
ALLOSTATIC STATE
ALLOSTASIS
ANY STRESSPsychologicalNeurological
EndocrineImmune
ALLOSTATIC LOAD
ALLOSTATIC OVERLOAD
WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY
DISEASEHEALTH
RESILIENCE VULNERABILITY
RESISTANCE SENSITIVITY
PERCEPTIONSldquoNEUROCEPTIONrdquo
RESPONSESTRESS
ALLOSTATIC STATE
ALLOSTASIS
ANY STRESSPsychologicalNeurological
EndocrineImmune
ALLOSTATIC LOAD
HEALTH
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
Gastric overfilling syndrome
189
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
33
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
Only case series Insufficient evidence
No mention of
stomach capacity196
Baby weight freq reqrsquod size actual
2kg baby 4hrly ~ 320 ml6 = 53ml 14ml
15 baby 3hrly ~ 240 ml8 = 30ml 10ml
10 baby 2hrly ~ 160 ml12 = 13ml 7ml
Standardised from20ml capacityfor 3kg baby( x 0007)
197
0
10
20
30
40
50
60
70
80
90
13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w
LINEAR
TERM
PREM
198
34
0
10
20
30
40
50
60
70
80
90
13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w
LINEAR
TERM
PREM
199
Clues to GER
ldquoI know baby hurtsrdquo
Gastric overfilling syndrome
Excessive volumesreflux aspiration colic
Excessive time intervalhypoglycaemia
Adaptationsdiabetic diathesis obesity
200
Developmental Care of the Enteric Nervous System
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
BIRTH
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
WIRE MOTHER
OXYTOCIN
11
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDINGON-GOING
S S C
WIRE TOGETHER
OXYTOCIN
hellip infant cues - suckling vocalisation and tactile stimulation - stimulate
OXYTOCINrelease in the hypothalamus which may result in the activation of the dopaminergic reward pathway leading to behavioural reinforcement
key biological systems hellip that contribute to maternal caregiving behaviour hellip the oxytocinergic and dopaminergic systems
hellip dopamine pathways contribute to the processing of infant-related sensory cues leading to a behavioural response c
DISEASEHEALTH
CORTISOLOXYTOCIN
The psychology of human parent-infant relationships
Parenting is regulated by key hormones and neurotransmitters
Neuroanatomical circuits of parenting
Integrative physiology of normal parenting behaviours
Brain imaging of human parent-infant relationships
The neurobiology of empathy and parenting
Conclusions and critical summary
(Swain et al 2007)
12
FEARCONTROL
CENTRE
REWARDCONTROL
CENTRE
SOCIALCONTROL CENTRE
OXYTOCINDOPAMINE
CORTISOL
EMOTIONCONTROL CENTRE
WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY
DISEASEHEALTH
RESILIENCE VULNERABILITY
hellip there is considerable overlap in the brain structures associated with these neural mechanisms hellip functional interactions among the circuits
DOULA and KANGAROULA
-1000 min
BIRTH
+1000 min 1000 days
OXYTOCIN Zero separation
Protect OXYTOCINBefore and after
BIRTH
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDINGON-GOING
S S C
WIRE TOGETHER
Protect OXYTOCINBefore and after
BIRTH
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDINGON-GOING
S S C
WIRE SUCKLING
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
Alberts SUCKLING versus FEEDING
DUAL INGESTION SYSTEMS
13
300 mya 200 mya 100 mya 50 mya 300 mya 200 mya 100 mya 50 mya
Amniotes
Synapsids
Cynodonts
Mammaliaformes
PlacentalsMammals
ANCESTRAL STATE
hellip intoMATURE FEEDING
300 mya 200 mya 100 mya 50 mya
WATER
EGGS
Hatch withTEETH
ANCESTRAL STATE
hellip intoMATURE FEEDING
eg TURTLES
CROCODILES DINOSAURS
REPTILES
300 mya 200 mya 100 mya 50 mya
Epibubic bone = pouch care
hellip intoMATURE FEEDING
Amniotes
Synapsids
Cynodonts
Mammaliaformes
Smaller eggs longer in body
The AMNIOTE EGGextra membranes
Copes with AIR
PlacentalsMammals
Viviparity = immature
ENDOTHERMY
MOISTUREfor eggs
Diphyodontism
300 mya 200 mya 100 mya 50 mya
hellip intoMATURE FEEDING
Amniotes
Synapsids
Cynodonts
Mammaliaformes
PlacentalsMammals
ENDOTHERMY
MOISTUREfor eggs
LACTOSE added(apocrine glands)
NUTRIENTSAntimicrobials
LACTATION
SUCKLINGFEEDING
200 million years
Diphyodontism
300 mya 200 mya 100 mya 50 mya
hellip intoMATURE FEEDING
Amniotes
Synapsids
Cynodonts
Mammaliaformes
PlacentalsMammals
ENDOTHERMY
MOISTUREfor eggs
LACTOSE added(apocrine glands)
NUTRIENTSAntimicrobials
LACTATION
SUCKLINGFEEDING
200 million years
DUAL INGESTION SYSTEMS
100 million years
14
DUAL INGESTION SYSTEMS DUAL INGESTION SYSTEMS
SUCKLING WEANING FEEDING
Lactase Digestive enzymes
FEEDING SUCKLING
Influence of SMELL None Totally dependent
Motor mechanism Chewing ndash different
muscles
Suckling ndash different circuits
INSULIN Increases weight No effect
GHRELIN Increases weight No effect
LEPTIN Decreases intake No effect
CHOLECYSTOKININ Decreases intake No effect
AMPHETAMINE Decreases appetite Increases suckling
SEROTONIN Agonist improves feeding Antagonist improves suck
SATIETY Infant determined Maternal supply determine
FEEDING SUCKLING
DISRUPTION ROBUST VERY SENSITIVE
Must have right conditions
Pup-in-a- cup - And STIMULI
separated and fed by tube
From day 2 off life
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
14th century Tuscan text
Conceptual changeDyad careBreast first hour
even CaesareanContinuous SSC
DISCONTINUEGiving waterGlucose waterInfant formulaSeparationPacifier (dummy)
CHANGE POLICY Canrsquot change
biology
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
ON-GOING
S S C
WIRE NEURONS
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C WIRE
TIMING
(behavior)
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
ENTERIC NERVOUS SYSTEM
123
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
FEEDBACK LOOPS
CNS
ENS
ANS
InternalSomaticenvironment
124
125 126
22
Fetal stomach appears 4 weeks GABy 11 weeks wall capable of muscular
contraction
ldquoPatterns of antropyloric motilityin fed healthy preterm infantsrdquo
the neuroregulatory mechanisms responsible for the coordination of antro-pyloric motility and gastric emptying are
well developed by 30 weeks of PMAHassan 2002 127
Hydrochloric acidimportant for activation of pepsinogen
inactivation of microorganisms such as bacteria
Pepsinogenactivated by acid into active pepsin
responsible for the stomachs ability to initiate digestion of proteins
Chymosinis an enzyme whose role is to curdle or
coagulate milk in the stomach a process of considerable importance in the very young animal
128
Chymosinmakes the milk into ldquocheeserdquohalfway between liquid and solidstomach empties in 60 minutes
milk
129
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
FEEDBACK LOOPS
130
EVIDENCE FORFEEDING FREQUENCY
Edmond 2006 131
Breastfeeding and motherrsquos milkStrong and consistent evidence 132
23
Cup feeding versus bottle feedingCup feeding higher breastfeeding
greater stability133
Only case series Insufficient evidence
No mention of
stomach capacity134
EVIDENCE FORSTOMACH CAPACITY
Edmond 2006 135
0
05
1
15
2
25
3
35
4
0 10 20 30 40 50 60 70 80
volume ingested
fee
din
g f
req
ue
nc
y
Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml
StandardCARE3 hourlyschedule
136
KEY QUESTION
WHAT IS THE
STOMACHVOLUMEOF THE
NEONATE 137 Sase 2005
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
(Alliot) pressure)151
PROPOSAL
The CAPACITY of aweek old babyrsquos stomach is
approx 20 ml152
0
05
1
15
2
25
3
35
4
0 10 20 30 40 50 60 70 80
volume ingested
fee
din
g f
req
ue
nc
y
Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml
StandardCARE3 hourlyschedule
MOTHERNATURE
1 hourlyschedule
153
PHYSIOLOGICAL CAPACITY
RECEPTIVE CAPACITY of stomach
INGESTIVE CAPACITY of BABY
FUNCTIONAL CAPACITY
154
PROPOSAL
The FEEDINGFREQUENCY of theNEONATE is
approx 60 min155
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
BRAIN CYCLING
STOMACH FILLING amp EMPTYING
REMNR1NR2NR3NR4
156
27
Normal physiology of theEnteric Nervous System
ldquoSmall and frequent feeds according to the sleep cyclerdquo
The ldquonicherdquo (occupation) of a neonate (Alberts)
BOND FEED
SLEEP SLEEP
PLAY FEED
157
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
FEEDING SUCKLING
Influence of SMELL None Totally dependent
Motor mechanism Chewing ndash different
muscles
Suckling ndash different circuits
INSULIN Increases weight No effect
GHRELIN Increases weight No effect
LEPTIN Decreases intake No effect
CHOLECYSTOKININ Decreases intake No effect
AMPHETAMINE Decreases appetite Increases suckling
SEROTONIN Agonist improves feeding Antagonist improves suck
SATIETY Infant determined Maternal supply determine
FEEDING SUCKLING
Influence of SMELL None Totally dependent
Motor mechanism Chewing ndash different
muscles
Suckling ndash different circuits
INSULIN Increases weight No effect
GHRELIN Increases weight No effect
LEPTIN Decreases intake No effect
CHOLECYSTOKININ Decreases intake No effect
AMPHETAMINE Decreases appetite Increases suckling
SEROTONIN Agonist improves feeding Antagonist improves suck
SATIETY Infant determined Maternal supply determine
Current dogmaTHE BABY KNOWS
WHEN IT HAS HAD ENOUGH
PROBABLY NOT
WHAT IS THE
STOMACH VOLUME OF THE
PREMATURE
161
Assume low resilience
Assume proportionality
162
28
The CAPACITY of alow birthweight premfrom 20ml 3000g
= 0007 x BWt (g)
1kg x 0007 = 7mls2kg x 0007 = 14mls
163
Gastric overfilling syndrome
164
75 ml per feeding ASSUMPTION
IMMATURE OR OVERWHELMED
many aspects of gastrointestinalmotility are immature in the neonate
Zangen S et al Rapid maturation of gastric relaxation in newborns
A balloon in stomachcan fill to 76 mls
What does the stomach ndashwithout a balloon ndashdo to 76 mls
REFLUX PRESUME each feedapproximately 75 mls
GER
bull Sudden outbursts of crying
bull Awakens in pain
bull Related to feedings
bull Not easily comforted
bull ldquoI know baby hurtsrdquo
bull Sour burps throaty noises
bull Best when upright
Clues to GER
Dr W Sears
29
Mitchell 2001
Kerstin Uvnaumls-Moberg
Food in duodenum
AMYLINreleased
Closes pylorus
Duodenumempty
Pylorusopens
ldquoFeed intolerancerdquo hellip hellip or VOLUME intolerance
HYPOGLYCAEMIA
A babies stomach empties in60 minutes
Blood sugarmay fall hellip
after 90 minutes Options
30
METABOLIC ADAPTATION
SSC started in the first 20 minutes after birth
SSC CotBlood glucose (1 hr) 317 256Base excess drop 34 18
(Christenson 1992)0h 1h 2h 3h 4h 2 days
App
roxim
ate
GLUCOSE
SSC Glucose production = Glucose consumption
Separation
SNS stress Glucose consumption INCREASE
PSNS dissociation Glucose production DECREASE
HYPOGLYCEMIA
SSC Cot
Blood glucose (1 hr) 317 256
0h 1h 2h 3h 4h 2 days
App
roxim
ate
GLUCOSE
SSC Glucose production = Glucose consumption
Separation PSNS dissociation
Glucose production DECREASE
HYPOGLYCEMIA
SSC Cot
Blood glucose (1 hr) 317 256
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
NEURODEVELOPMENTThe DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
BONDING ATTACHMENT
MRI HRVEEG
STRESS RESPONES
RESILIENCE
DOHAD
(MAL) ADAPTATION
EPIGENETICS
GENE X ENVIRONMENT
GENETIC VARIANTS
HOSPITAL ACQUIRED INFECTIONIMMUNITY
SLEEP PHYSIOLOGY
GUT FUNCTIONMICROBIOTA
ldquoSTABILITYrdquo
TRANSITION
LONG TERM FOLLOW-UP
NEUROENDOCRINE BEHAVIOURS
MATERNAL NEUROPLASTICITY
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
MORTALITYMETABOLISM
0h 1h 2h 3h 4h
PSNS (vagal)
App
roxim
ate
GLUCOSE
1 HOURLY Milk feed
1 HOURLY Milk feed
1 HOURLY Milk feed
1 HOURLY Milk feed
LACTOSE
METABOLISM
31
0h 1h 2h 3h 4h
PSNS (vagal) SYMPATHETIC STRESS
App
roxim
ate
GLUCOSE
LACTOSE FATGLYCOGEN
METABOLISM
4 HOURLY Milk feed
0h 1h 2h 3h 4h
PSNS (vagal) SYMPATHETIC STRESS
App
roxim
ate
GLUCOSE
4 HOURLY ALLOSTATIC STATELACTOSE FATGLYCOGEN
METABOLISM
4 HOURLY Milk feed
HEALTH DISEASE
EXPECTED UNEXPECTED
NEURODEVELOPMENTThe DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
BONDING ATTACHMENT
MRI HRVEEG
STRESS RESPONES
RESILIENCE
DOHAD
(MAL) ADAPTATION
EPIGENETICS
GENE X ENVIRONMENT
GENETIC VARIANTS
HOSPITAL ACQUIRED INFECTIONIMMUNITY
SLEEP PHYSIOLOGY
GUT FUNCTIONMICROBIOTA
ldquoSTABILITYrdquo
TRANSITION
LONG TERM FOLLOW-UP
NEUROENDOCRINE BEHAVIOURS
MATERNAL NEUROPLASTICITY
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
MORTALITYMETABOLISM
Weight gain 1st week
predicts OBESITYat 30 years
Large volume feedsstretched stomach=
doubled absorptivecapacity as adult
Importance
Programming ndash early life chronic disease
32
RESISTANCE SENSITIVITY
PERCEPTIONSldquoNEUROCEPTIONrdquo
RESPONSESTRESS
ALLOSTATIC STATE
ALLOSTASIS
ANY STRESSPsychologicalNeurological
EndocrineImmune
ALLOSTATIC LOAD
ALLOSTATIC OVERLOAD
WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY
DISEASEHEALTH
RESILIENCE VULNERABILITY
RESISTANCE SENSITIVITY
PERCEPTIONSldquoNEUROCEPTIONrdquo
RESPONSESTRESS
ALLOSTATIC STATE
ALLOSTASIS
ANY STRESSPsychologicalNeurological
EndocrineImmune
ALLOSTATIC LOAD
HEALTH
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
Gastric overfilling syndrome
189
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
33
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
Only case series Insufficient evidence
No mention of
stomach capacity196
Baby weight freq reqrsquod size actual
2kg baby 4hrly ~ 320 ml6 = 53ml 14ml
15 baby 3hrly ~ 240 ml8 = 30ml 10ml
10 baby 2hrly ~ 160 ml12 = 13ml 7ml
Standardised from20ml capacityfor 3kg baby( x 0007)
197
0
10
20
30
40
50
60
70
80
90
13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w
LINEAR
TERM
PREM
198
34
0
10
20
30
40
50
60
70
80
90
13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w
LINEAR
TERM
PREM
199
Clues to GER
ldquoI know baby hurtsrdquo
Gastric overfilling syndrome
Excessive volumesreflux aspiration colic
Excessive time intervalhypoglycaemia
Adaptationsdiabetic diathesis obesity
200
Developmental Care of the Enteric Nervous System
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
11
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDINGON-GOING
S S C
WIRE TOGETHER
OXYTOCIN
hellip infant cues - suckling vocalisation and tactile stimulation - stimulate
OXYTOCINrelease in the hypothalamus which may result in the activation of the dopaminergic reward pathway leading to behavioural reinforcement
key biological systems hellip that contribute to maternal caregiving behaviour hellip the oxytocinergic and dopaminergic systems
hellip dopamine pathways contribute to the processing of infant-related sensory cues leading to a behavioural response c
DISEASEHEALTH
CORTISOLOXYTOCIN
The psychology of human parent-infant relationships
Parenting is regulated by key hormones and neurotransmitters
Neuroanatomical circuits of parenting
Integrative physiology of normal parenting behaviours
Brain imaging of human parent-infant relationships
The neurobiology of empathy and parenting
Conclusions and critical summary
(Swain et al 2007)
12
FEARCONTROL
CENTRE
REWARDCONTROL
CENTRE
SOCIALCONTROL CENTRE
OXYTOCINDOPAMINE
CORTISOL
EMOTIONCONTROL CENTRE
WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY
DISEASEHEALTH
RESILIENCE VULNERABILITY
hellip there is considerable overlap in the brain structures associated with these neural mechanisms hellip functional interactions among the circuits
DOULA and KANGAROULA
-1000 min
BIRTH
+1000 min 1000 days
OXYTOCIN Zero separation
Protect OXYTOCINBefore and after
BIRTH
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDINGON-GOING
S S C
WIRE TOGETHER
Protect OXYTOCINBefore and after
BIRTH
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDINGON-GOING
S S C
WIRE SUCKLING
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
Alberts SUCKLING versus FEEDING
DUAL INGESTION SYSTEMS
13
300 mya 200 mya 100 mya 50 mya 300 mya 200 mya 100 mya 50 mya
Amniotes
Synapsids
Cynodonts
Mammaliaformes
PlacentalsMammals
ANCESTRAL STATE
hellip intoMATURE FEEDING
300 mya 200 mya 100 mya 50 mya
WATER
EGGS
Hatch withTEETH
ANCESTRAL STATE
hellip intoMATURE FEEDING
eg TURTLES
CROCODILES DINOSAURS
REPTILES
300 mya 200 mya 100 mya 50 mya
Epibubic bone = pouch care
hellip intoMATURE FEEDING
Amniotes
Synapsids
Cynodonts
Mammaliaformes
Smaller eggs longer in body
The AMNIOTE EGGextra membranes
Copes with AIR
PlacentalsMammals
Viviparity = immature
ENDOTHERMY
MOISTUREfor eggs
Diphyodontism
300 mya 200 mya 100 mya 50 mya
hellip intoMATURE FEEDING
Amniotes
Synapsids
Cynodonts
Mammaliaformes
PlacentalsMammals
ENDOTHERMY
MOISTUREfor eggs
LACTOSE added(apocrine glands)
NUTRIENTSAntimicrobials
LACTATION
SUCKLINGFEEDING
200 million years
Diphyodontism
300 mya 200 mya 100 mya 50 mya
hellip intoMATURE FEEDING
Amniotes
Synapsids
Cynodonts
Mammaliaformes
PlacentalsMammals
ENDOTHERMY
MOISTUREfor eggs
LACTOSE added(apocrine glands)
NUTRIENTSAntimicrobials
LACTATION
SUCKLINGFEEDING
200 million years
DUAL INGESTION SYSTEMS
100 million years
14
DUAL INGESTION SYSTEMS DUAL INGESTION SYSTEMS
SUCKLING WEANING FEEDING
Lactase Digestive enzymes
FEEDING SUCKLING
Influence of SMELL None Totally dependent
Motor mechanism Chewing ndash different
muscles
Suckling ndash different circuits
INSULIN Increases weight No effect
GHRELIN Increases weight No effect
LEPTIN Decreases intake No effect
CHOLECYSTOKININ Decreases intake No effect
AMPHETAMINE Decreases appetite Increases suckling
SEROTONIN Agonist improves feeding Antagonist improves suck
SATIETY Infant determined Maternal supply determine
FEEDING SUCKLING
DISRUPTION ROBUST VERY SENSITIVE
Must have right conditions
Pup-in-a- cup - And STIMULI
separated and fed by tube
From day 2 off life
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
14th century Tuscan text
Conceptual changeDyad careBreast first hour
even CaesareanContinuous SSC
DISCONTINUEGiving waterGlucose waterInfant formulaSeparationPacifier (dummy)
CHANGE POLICY Canrsquot change
biology
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
ON-GOING
S S C
WIRE NEURONS
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C WIRE
TIMING
(behavior)
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
ENTERIC NERVOUS SYSTEM
123
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
FEEDBACK LOOPS
CNS
ENS
ANS
InternalSomaticenvironment
124
125 126
22
Fetal stomach appears 4 weeks GABy 11 weeks wall capable of muscular
contraction
ldquoPatterns of antropyloric motilityin fed healthy preterm infantsrdquo
the neuroregulatory mechanisms responsible for the coordination of antro-pyloric motility and gastric emptying are
well developed by 30 weeks of PMAHassan 2002 127
Hydrochloric acidimportant for activation of pepsinogen
inactivation of microorganisms such as bacteria
Pepsinogenactivated by acid into active pepsin
responsible for the stomachs ability to initiate digestion of proteins
Chymosinis an enzyme whose role is to curdle or
coagulate milk in the stomach a process of considerable importance in the very young animal
128
Chymosinmakes the milk into ldquocheeserdquohalfway between liquid and solidstomach empties in 60 minutes
milk
129
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
FEEDBACK LOOPS
130
EVIDENCE FORFEEDING FREQUENCY
Edmond 2006 131
Breastfeeding and motherrsquos milkStrong and consistent evidence 132
23
Cup feeding versus bottle feedingCup feeding higher breastfeeding
greater stability133
Only case series Insufficient evidence
No mention of
stomach capacity134
EVIDENCE FORSTOMACH CAPACITY
Edmond 2006 135
0
05
1
15
2
25
3
35
4
0 10 20 30 40 50 60 70 80
volume ingested
fee
din
g f
req
ue
nc
y
Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml
StandardCARE3 hourlyschedule
136
KEY QUESTION
WHAT IS THE
STOMACHVOLUMEOF THE
NEONATE 137 Sase 2005
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
(Alliot) pressure)151
PROPOSAL
The CAPACITY of aweek old babyrsquos stomach is
approx 20 ml152
0
05
1
15
2
25
3
35
4
0 10 20 30 40 50 60 70 80
volume ingested
fee
din
g f
req
ue
nc
y
Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml
StandardCARE3 hourlyschedule
MOTHERNATURE
1 hourlyschedule
153
PHYSIOLOGICAL CAPACITY
RECEPTIVE CAPACITY of stomach
INGESTIVE CAPACITY of BABY
FUNCTIONAL CAPACITY
154
PROPOSAL
The FEEDINGFREQUENCY of theNEONATE is
approx 60 min155
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
BRAIN CYCLING
STOMACH FILLING amp EMPTYING
REMNR1NR2NR3NR4
156
27
Normal physiology of theEnteric Nervous System
ldquoSmall and frequent feeds according to the sleep cyclerdquo
The ldquonicherdquo (occupation) of a neonate (Alberts)
BOND FEED
SLEEP SLEEP
PLAY FEED
157
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
FEEDING SUCKLING
Influence of SMELL None Totally dependent
Motor mechanism Chewing ndash different
muscles
Suckling ndash different circuits
INSULIN Increases weight No effect
GHRELIN Increases weight No effect
LEPTIN Decreases intake No effect
CHOLECYSTOKININ Decreases intake No effect
AMPHETAMINE Decreases appetite Increases suckling
SEROTONIN Agonist improves feeding Antagonist improves suck
SATIETY Infant determined Maternal supply determine
FEEDING SUCKLING
Influence of SMELL None Totally dependent
Motor mechanism Chewing ndash different
muscles
Suckling ndash different circuits
INSULIN Increases weight No effect
GHRELIN Increases weight No effect
LEPTIN Decreases intake No effect
CHOLECYSTOKININ Decreases intake No effect
AMPHETAMINE Decreases appetite Increases suckling
SEROTONIN Agonist improves feeding Antagonist improves suck
SATIETY Infant determined Maternal supply determine
Current dogmaTHE BABY KNOWS
WHEN IT HAS HAD ENOUGH
PROBABLY NOT
WHAT IS THE
STOMACH VOLUME OF THE
PREMATURE
161
Assume low resilience
Assume proportionality
162
28
The CAPACITY of alow birthweight premfrom 20ml 3000g
= 0007 x BWt (g)
1kg x 0007 = 7mls2kg x 0007 = 14mls
163
Gastric overfilling syndrome
164
75 ml per feeding ASSUMPTION
IMMATURE OR OVERWHELMED
many aspects of gastrointestinalmotility are immature in the neonate
Zangen S et al Rapid maturation of gastric relaxation in newborns
A balloon in stomachcan fill to 76 mls
What does the stomach ndashwithout a balloon ndashdo to 76 mls
REFLUX PRESUME each feedapproximately 75 mls
GER
bull Sudden outbursts of crying
bull Awakens in pain
bull Related to feedings
bull Not easily comforted
bull ldquoI know baby hurtsrdquo
bull Sour burps throaty noises
bull Best when upright
Clues to GER
Dr W Sears
29
Mitchell 2001
Kerstin Uvnaumls-Moberg
Food in duodenum
AMYLINreleased
Closes pylorus
Duodenumempty
Pylorusopens
ldquoFeed intolerancerdquo hellip hellip or VOLUME intolerance
HYPOGLYCAEMIA
A babies stomach empties in60 minutes
Blood sugarmay fall hellip
after 90 minutes Options
30
METABOLIC ADAPTATION
SSC started in the first 20 minutes after birth
SSC CotBlood glucose (1 hr) 317 256Base excess drop 34 18
(Christenson 1992)0h 1h 2h 3h 4h 2 days
App
roxim
ate
GLUCOSE
SSC Glucose production = Glucose consumption
Separation
SNS stress Glucose consumption INCREASE
PSNS dissociation Glucose production DECREASE
HYPOGLYCEMIA
SSC Cot
Blood glucose (1 hr) 317 256
0h 1h 2h 3h 4h 2 days
App
roxim
ate
GLUCOSE
SSC Glucose production = Glucose consumption
Separation PSNS dissociation
Glucose production DECREASE
HYPOGLYCEMIA
SSC Cot
Blood glucose (1 hr) 317 256
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
NEURODEVELOPMENTThe DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
BONDING ATTACHMENT
MRI HRVEEG
STRESS RESPONES
RESILIENCE
DOHAD
(MAL) ADAPTATION
EPIGENETICS
GENE X ENVIRONMENT
GENETIC VARIANTS
HOSPITAL ACQUIRED INFECTIONIMMUNITY
SLEEP PHYSIOLOGY
GUT FUNCTIONMICROBIOTA
ldquoSTABILITYrdquo
TRANSITION
LONG TERM FOLLOW-UP
NEUROENDOCRINE BEHAVIOURS
MATERNAL NEUROPLASTICITY
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
MORTALITYMETABOLISM
0h 1h 2h 3h 4h
PSNS (vagal)
App
roxim
ate
GLUCOSE
1 HOURLY Milk feed
1 HOURLY Milk feed
1 HOURLY Milk feed
1 HOURLY Milk feed
LACTOSE
METABOLISM
31
0h 1h 2h 3h 4h
PSNS (vagal) SYMPATHETIC STRESS
App
roxim
ate
GLUCOSE
LACTOSE FATGLYCOGEN
METABOLISM
4 HOURLY Milk feed
0h 1h 2h 3h 4h
PSNS (vagal) SYMPATHETIC STRESS
App
roxim
ate
GLUCOSE
4 HOURLY ALLOSTATIC STATELACTOSE FATGLYCOGEN
METABOLISM
4 HOURLY Milk feed
HEALTH DISEASE
EXPECTED UNEXPECTED
NEURODEVELOPMENTThe DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
BONDING ATTACHMENT
MRI HRVEEG
STRESS RESPONES
RESILIENCE
DOHAD
(MAL) ADAPTATION
EPIGENETICS
GENE X ENVIRONMENT
GENETIC VARIANTS
HOSPITAL ACQUIRED INFECTIONIMMUNITY
SLEEP PHYSIOLOGY
GUT FUNCTIONMICROBIOTA
ldquoSTABILITYrdquo
TRANSITION
LONG TERM FOLLOW-UP
NEUROENDOCRINE BEHAVIOURS
MATERNAL NEUROPLASTICITY
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
MORTALITYMETABOLISM
Weight gain 1st week
predicts OBESITYat 30 years
Large volume feedsstretched stomach=
doubled absorptivecapacity as adult
Importance
Programming ndash early life chronic disease
32
RESISTANCE SENSITIVITY
PERCEPTIONSldquoNEUROCEPTIONrdquo
RESPONSESTRESS
ALLOSTATIC STATE
ALLOSTASIS
ANY STRESSPsychologicalNeurological
EndocrineImmune
ALLOSTATIC LOAD
ALLOSTATIC OVERLOAD
WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY
DISEASEHEALTH
RESILIENCE VULNERABILITY
RESISTANCE SENSITIVITY
PERCEPTIONSldquoNEUROCEPTIONrdquo
RESPONSESTRESS
ALLOSTATIC STATE
ALLOSTASIS
ANY STRESSPsychologicalNeurological
EndocrineImmune
ALLOSTATIC LOAD
HEALTH
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
Gastric overfilling syndrome
189
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
33
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
Only case series Insufficient evidence
No mention of
stomach capacity196
Baby weight freq reqrsquod size actual
2kg baby 4hrly ~ 320 ml6 = 53ml 14ml
15 baby 3hrly ~ 240 ml8 = 30ml 10ml
10 baby 2hrly ~ 160 ml12 = 13ml 7ml
Standardised from20ml capacityfor 3kg baby( x 0007)
197
0
10
20
30
40
50
60
70
80
90
13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w
LINEAR
TERM
PREM
198
34
0
10
20
30
40
50
60
70
80
90
13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w
LINEAR
TERM
PREM
199
Clues to GER
ldquoI know baby hurtsrdquo
Gastric overfilling syndrome
Excessive volumesreflux aspiration colic
Excessive time intervalhypoglycaemia
Adaptationsdiabetic diathesis obesity
200
Developmental Care of the Enteric Nervous System
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
12
FEARCONTROL
CENTRE
REWARDCONTROL
CENTRE
SOCIALCONTROL CENTRE
OXYTOCINDOPAMINE
CORTISOL
EMOTIONCONTROL CENTRE
WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY
DISEASEHEALTH
RESILIENCE VULNERABILITY
hellip there is considerable overlap in the brain structures associated with these neural mechanisms hellip functional interactions among the circuits
DOULA and KANGAROULA
-1000 min
BIRTH
+1000 min 1000 days
OXYTOCIN Zero separation
Protect OXYTOCINBefore and after
BIRTH
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDINGON-GOING
S S C
WIRE TOGETHER
Protect OXYTOCINBefore and after
BIRTH
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDINGON-GOING
S S C
WIRE SUCKLING
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
Alberts SUCKLING versus FEEDING
DUAL INGESTION SYSTEMS
13
300 mya 200 mya 100 mya 50 mya 300 mya 200 mya 100 mya 50 mya
Amniotes
Synapsids
Cynodonts
Mammaliaformes
PlacentalsMammals
ANCESTRAL STATE
hellip intoMATURE FEEDING
300 mya 200 mya 100 mya 50 mya
WATER
EGGS
Hatch withTEETH
ANCESTRAL STATE
hellip intoMATURE FEEDING
eg TURTLES
CROCODILES DINOSAURS
REPTILES
300 mya 200 mya 100 mya 50 mya
Epibubic bone = pouch care
hellip intoMATURE FEEDING
Amniotes
Synapsids
Cynodonts
Mammaliaformes
Smaller eggs longer in body
The AMNIOTE EGGextra membranes
Copes with AIR
PlacentalsMammals
Viviparity = immature
ENDOTHERMY
MOISTUREfor eggs
Diphyodontism
300 mya 200 mya 100 mya 50 mya
hellip intoMATURE FEEDING
Amniotes
Synapsids
Cynodonts
Mammaliaformes
PlacentalsMammals
ENDOTHERMY
MOISTUREfor eggs
LACTOSE added(apocrine glands)
NUTRIENTSAntimicrobials
LACTATION
SUCKLINGFEEDING
200 million years
Diphyodontism
300 mya 200 mya 100 mya 50 mya
hellip intoMATURE FEEDING
Amniotes
Synapsids
Cynodonts
Mammaliaformes
PlacentalsMammals
ENDOTHERMY
MOISTUREfor eggs
LACTOSE added(apocrine glands)
NUTRIENTSAntimicrobials
LACTATION
SUCKLINGFEEDING
200 million years
DUAL INGESTION SYSTEMS
100 million years
14
DUAL INGESTION SYSTEMS DUAL INGESTION SYSTEMS
SUCKLING WEANING FEEDING
Lactase Digestive enzymes
FEEDING SUCKLING
Influence of SMELL None Totally dependent
Motor mechanism Chewing ndash different
muscles
Suckling ndash different circuits
INSULIN Increases weight No effect
GHRELIN Increases weight No effect
LEPTIN Decreases intake No effect
CHOLECYSTOKININ Decreases intake No effect
AMPHETAMINE Decreases appetite Increases suckling
SEROTONIN Agonist improves feeding Antagonist improves suck
SATIETY Infant determined Maternal supply determine
FEEDING SUCKLING
DISRUPTION ROBUST VERY SENSITIVE
Must have right conditions
Pup-in-a- cup - And STIMULI
separated and fed by tube
From day 2 off life
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
14th century Tuscan text
Conceptual changeDyad careBreast first hour
even CaesareanContinuous SSC
DISCONTINUEGiving waterGlucose waterInfant formulaSeparationPacifier (dummy)
CHANGE POLICY Canrsquot change
biology
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
ON-GOING
S S C
WIRE NEURONS
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C WIRE
TIMING
(behavior)
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
ENTERIC NERVOUS SYSTEM
123
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
FEEDBACK LOOPS
CNS
ENS
ANS
InternalSomaticenvironment
124
125 126
22
Fetal stomach appears 4 weeks GABy 11 weeks wall capable of muscular
contraction
ldquoPatterns of antropyloric motilityin fed healthy preterm infantsrdquo
the neuroregulatory mechanisms responsible for the coordination of antro-pyloric motility and gastric emptying are
well developed by 30 weeks of PMAHassan 2002 127
Hydrochloric acidimportant for activation of pepsinogen
inactivation of microorganisms such as bacteria
Pepsinogenactivated by acid into active pepsin
responsible for the stomachs ability to initiate digestion of proteins
Chymosinis an enzyme whose role is to curdle or
coagulate milk in the stomach a process of considerable importance in the very young animal
128
Chymosinmakes the milk into ldquocheeserdquohalfway between liquid and solidstomach empties in 60 minutes
milk
129
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
FEEDBACK LOOPS
130
EVIDENCE FORFEEDING FREQUENCY
Edmond 2006 131
Breastfeeding and motherrsquos milkStrong and consistent evidence 132
23
Cup feeding versus bottle feedingCup feeding higher breastfeeding
greater stability133
Only case series Insufficient evidence
No mention of
stomach capacity134
EVIDENCE FORSTOMACH CAPACITY
Edmond 2006 135
0
05
1
15
2
25
3
35
4
0 10 20 30 40 50 60 70 80
volume ingested
fee
din
g f
req
ue
nc
y
Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml
StandardCARE3 hourlyschedule
136
KEY QUESTION
WHAT IS THE
STOMACHVOLUMEOF THE
NEONATE 137 Sase 2005
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
(Alliot) pressure)151
PROPOSAL
The CAPACITY of aweek old babyrsquos stomach is
approx 20 ml152
0
05
1
15
2
25
3
35
4
0 10 20 30 40 50 60 70 80
volume ingested
fee
din
g f
req
ue
nc
y
Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml
StandardCARE3 hourlyschedule
MOTHERNATURE
1 hourlyschedule
153
PHYSIOLOGICAL CAPACITY
RECEPTIVE CAPACITY of stomach
INGESTIVE CAPACITY of BABY
FUNCTIONAL CAPACITY
154
PROPOSAL
The FEEDINGFREQUENCY of theNEONATE is
approx 60 min155
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
BRAIN CYCLING
STOMACH FILLING amp EMPTYING
REMNR1NR2NR3NR4
156
27
Normal physiology of theEnteric Nervous System
ldquoSmall and frequent feeds according to the sleep cyclerdquo
The ldquonicherdquo (occupation) of a neonate (Alberts)
BOND FEED
SLEEP SLEEP
PLAY FEED
157
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
FEEDING SUCKLING
Influence of SMELL None Totally dependent
Motor mechanism Chewing ndash different
muscles
Suckling ndash different circuits
INSULIN Increases weight No effect
GHRELIN Increases weight No effect
LEPTIN Decreases intake No effect
CHOLECYSTOKININ Decreases intake No effect
AMPHETAMINE Decreases appetite Increases suckling
SEROTONIN Agonist improves feeding Antagonist improves suck
SATIETY Infant determined Maternal supply determine
FEEDING SUCKLING
Influence of SMELL None Totally dependent
Motor mechanism Chewing ndash different
muscles
Suckling ndash different circuits
INSULIN Increases weight No effect
GHRELIN Increases weight No effect
LEPTIN Decreases intake No effect
CHOLECYSTOKININ Decreases intake No effect
AMPHETAMINE Decreases appetite Increases suckling
SEROTONIN Agonist improves feeding Antagonist improves suck
SATIETY Infant determined Maternal supply determine
Current dogmaTHE BABY KNOWS
WHEN IT HAS HAD ENOUGH
PROBABLY NOT
WHAT IS THE
STOMACH VOLUME OF THE
PREMATURE
161
Assume low resilience
Assume proportionality
162
28
The CAPACITY of alow birthweight premfrom 20ml 3000g
= 0007 x BWt (g)
1kg x 0007 = 7mls2kg x 0007 = 14mls
163
Gastric overfilling syndrome
164
75 ml per feeding ASSUMPTION
IMMATURE OR OVERWHELMED
many aspects of gastrointestinalmotility are immature in the neonate
Zangen S et al Rapid maturation of gastric relaxation in newborns
A balloon in stomachcan fill to 76 mls
What does the stomach ndashwithout a balloon ndashdo to 76 mls
REFLUX PRESUME each feedapproximately 75 mls
GER
bull Sudden outbursts of crying
bull Awakens in pain
bull Related to feedings
bull Not easily comforted
bull ldquoI know baby hurtsrdquo
bull Sour burps throaty noises
bull Best when upright
Clues to GER
Dr W Sears
29
Mitchell 2001
Kerstin Uvnaumls-Moberg
Food in duodenum
AMYLINreleased
Closes pylorus
Duodenumempty
Pylorusopens
ldquoFeed intolerancerdquo hellip hellip or VOLUME intolerance
HYPOGLYCAEMIA
A babies stomach empties in60 minutes
Blood sugarmay fall hellip
after 90 minutes Options
30
METABOLIC ADAPTATION
SSC started in the first 20 minutes after birth
SSC CotBlood glucose (1 hr) 317 256Base excess drop 34 18
(Christenson 1992)0h 1h 2h 3h 4h 2 days
App
roxim
ate
GLUCOSE
SSC Glucose production = Glucose consumption
Separation
SNS stress Glucose consumption INCREASE
PSNS dissociation Glucose production DECREASE
HYPOGLYCEMIA
SSC Cot
Blood glucose (1 hr) 317 256
0h 1h 2h 3h 4h 2 days
App
roxim
ate
GLUCOSE
SSC Glucose production = Glucose consumption
Separation PSNS dissociation
Glucose production DECREASE
HYPOGLYCEMIA
SSC Cot
Blood glucose (1 hr) 317 256
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
NEURODEVELOPMENTThe DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
BONDING ATTACHMENT
MRI HRVEEG
STRESS RESPONES
RESILIENCE
DOHAD
(MAL) ADAPTATION
EPIGENETICS
GENE X ENVIRONMENT
GENETIC VARIANTS
HOSPITAL ACQUIRED INFECTIONIMMUNITY
SLEEP PHYSIOLOGY
GUT FUNCTIONMICROBIOTA
ldquoSTABILITYrdquo
TRANSITION
LONG TERM FOLLOW-UP
NEUROENDOCRINE BEHAVIOURS
MATERNAL NEUROPLASTICITY
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
MORTALITYMETABOLISM
0h 1h 2h 3h 4h
PSNS (vagal)
App
roxim
ate
GLUCOSE
1 HOURLY Milk feed
1 HOURLY Milk feed
1 HOURLY Milk feed
1 HOURLY Milk feed
LACTOSE
METABOLISM
31
0h 1h 2h 3h 4h
PSNS (vagal) SYMPATHETIC STRESS
App
roxim
ate
GLUCOSE
LACTOSE FATGLYCOGEN
METABOLISM
4 HOURLY Milk feed
0h 1h 2h 3h 4h
PSNS (vagal) SYMPATHETIC STRESS
App
roxim
ate
GLUCOSE
4 HOURLY ALLOSTATIC STATELACTOSE FATGLYCOGEN
METABOLISM
4 HOURLY Milk feed
HEALTH DISEASE
EXPECTED UNEXPECTED
NEURODEVELOPMENTThe DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
BONDING ATTACHMENT
MRI HRVEEG
STRESS RESPONES
RESILIENCE
DOHAD
(MAL) ADAPTATION
EPIGENETICS
GENE X ENVIRONMENT
GENETIC VARIANTS
HOSPITAL ACQUIRED INFECTIONIMMUNITY
SLEEP PHYSIOLOGY
GUT FUNCTIONMICROBIOTA
ldquoSTABILITYrdquo
TRANSITION
LONG TERM FOLLOW-UP
NEUROENDOCRINE BEHAVIOURS
MATERNAL NEUROPLASTICITY
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
MORTALITYMETABOLISM
Weight gain 1st week
predicts OBESITYat 30 years
Large volume feedsstretched stomach=
doubled absorptivecapacity as adult
Importance
Programming ndash early life chronic disease
32
RESISTANCE SENSITIVITY
PERCEPTIONSldquoNEUROCEPTIONrdquo
RESPONSESTRESS
ALLOSTATIC STATE
ALLOSTASIS
ANY STRESSPsychologicalNeurological
EndocrineImmune
ALLOSTATIC LOAD
ALLOSTATIC OVERLOAD
WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY
DISEASEHEALTH
RESILIENCE VULNERABILITY
RESISTANCE SENSITIVITY
PERCEPTIONSldquoNEUROCEPTIONrdquo
RESPONSESTRESS
ALLOSTATIC STATE
ALLOSTASIS
ANY STRESSPsychologicalNeurological
EndocrineImmune
ALLOSTATIC LOAD
HEALTH
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
Gastric overfilling syndrome
189
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
33
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
Only case series Insufficient evidence
No mention of
stomach capacity196
Baby weight freq reqrsquod size actual
2kg baby 4hrly ~ 320 ml6 = 53ml 14ml
15 baby 3hrly ~ 240 ml8 = 30ml 10ml
10 baby 2hrly ~ 160 ml12 = 13ml 7ml
Standardised from20ml capacityfor 3kg baby( x 0007)
197
0
10
20
30
40
50
60
70
80
90
13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w
LINEAR
TERM
PREM
198
34
0
10
20
30
40
50
60
70
80
90
13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w
LINEAR
TERM
PREM
199
Clues to GER
ldquoI know baby hurtsrdquo
Gastric overfilling syndrome
Excessive volumesreflux aspiration colic
Excessive time intervalhypoglycaemia
Adaptationsdiabetic diathesis obesity
200
Developmental Care of the Enteric Nervous System
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
13
300 mya 200 mya 100 mya 50 mya 300 mya 200 mya 100 mya 50 mya
Amniotes
Synapsids
Cynodonts
Mammaliaformes
PlacentalsMammals
ANCESTRAL STATE
hellip intoMATURE FEEDING
300 mya 200 mya 100 mya 50 mya
WATER
EGGS
Hatch withTEETH
ANCESTRAL STATE
hellip intoMATURE FEEDING
eg TURTLES
CROCODILES DINOSAURS
REPTILES
300 mya 200 mya 100 mya 50 mya
Epibubic bone = pouch care
hellip intoMATURE FEEDING
Amniotes
Synapsids
Cynodonts
Mammaliaformes
Smaller eggs longer in body
The AMNIOTE EGGextra membranes
Copes with AIR
PlacentalsMammals
Viviparity = immature
ENDOTHERMY
MOISTUREfor eggs
Diphyodontism
300 mya 200 mya 100 mya 50 mya
hellip intoMATURE FEEDING
Amniotes
Synapsids
Cynodonts
Mammaliaformes
PlacentalsMammals
ENDOTHERMY
MOISTUREfor eggs
LACTOSE added(apocrine glands)
NUTRIENTSAntimicrobials
LACTATION
SUCKLINGFEEDING
200 million years
Diphyodontism
300 mya 200 mya 100 mya 50 mya
hellip intoMATURE FEEDING
Amniotes
Synapsids
Cynodonts
Mammaliaformes
PlacentalsMammals
ENDOTHERMY
MOISTUREfor eggs
LACTOSE added(apocrine glands)
NUTRIENTSAntimicrobials
LACTATION
SUCKLINGFEEDING
200 million years
DUAL INGESTION SYSTEMS
100 million years
14
DUAL INGESTION SYSTEMS DUAL INGESTION SYSTEMS
SUCKLING WEANING FEEDING
Lactase Digestive enzymes
FEEDING SUCKLING
Influence of SMELL None Totally dependent
Motor mechanism Chewing ndash different
muscles
Suckling ndash different circuits
INSULIN Increases weight No effect
GHRELIN Increases weight No effect
LEPTIN Decreases intake No effect
CHOLECYSTOKININ Decreases intake No effect
AMPHETAMINE Decreases appetite Increases suckling
SEROTONIN Agonist improves feeding Antagonist improves suck
SATIETY Infant determined Maternal supply determine
FEEDING SUCKLING
DISRUPTION ROBUST VERY SENSITIVE
Must have right conditions
Pup-in-a- cup - And STIMULI
separated and fed by tube
From day 2 off life
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
14th century Tuscan text
Conceptual changeDyad careBreast first hour
even CaesareanContinuous SSC
DISCONTINUEGiving waterGlucose waterInfant formulaSeparationPacifier (dummy)
CHANGE POLICY Canrsquot change
biology
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
ON-GOING
S S C
WIRE NEURONS
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C WIRE
TIMING
(behavior)
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
ENTERIC NERVOUS SYSTEM
123
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
FEEDBACK LOOPS
CNS
ENS
ANS
InternalSomaticenvironment
124
125 126
22
Fetal stomach appears 4 weeks GABy 11 weeks wall capable of muscular
contraction
ldquoPatterns of antropyloric motilityin fed healthy preterm infantsrdquo
the neuroregulatory mechanisms responsible for the coordination of antro-pyloric motility and gastric emptying are
well developed by 30 weeks of PMAHassan 2002 127
Hydrochloric acidimportant for activation of pepsinogen
inactivation of microorganisms such as bacteria
Pepsinogenactivated by acid into active pepsin
responsible for the stomachs ability to initiate digestion of proteins
Chymosinis an enzyme whose role is to curdle or
coagulate milk in the stomach a process of considerable importance in the very young animal
128
Chymosinmakes the milk into ldquocheeserdquohalfway between liquid and solidstomach empties in 60 minutes
milk
129
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
FEEDBACK LOOPS
130
EVIDENCE FORFEEDING FREQUENCY
Edmond 2006 131
Breastfeeding and motherrsquos milkStrong and consistent evidence 132
23
Cup feeding versus bottle feedingCup feeding higher breastfeeding
greater stability133
Only case series Insufficient evidence
No mention of
stomach capacity134
EVIDENCE FORSTOMACH CAPACITY
Edmond 2006 135
0
05
1
15
2
25
3
35
4
0 10 20 30 40 50 60 70 80
volume ingested
fee
din
g f
req
ue
nc
y
Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml
StandardCARE3 hourlyschedule
136
KEY QUESTION
WHAT IS THE
STOMACHVOLUMEOF THE
NEONATE 137 Sase 2005
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
(Alliot) pressure)151
PROPOSAL
The CAPACITY of aweek old babyrsquos stomach is
approx 20 ml152
0
05
1
15
2
25
3
35
4
0 10 20 30 40 50 60 70 80
volume ingested
fee
din
g f
req
ue
nc
y
Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml
StandardCARE3 hourlyschedule
MOTHERNATURE
1 hourlyschedule
153
PHYSIOLOGICAL CAPACITY
RECEPTIVE CAPACITY of stomach
INGESTIVE CAPACITY of BABY
FUNCTIONAL CAPACITY
154
PROPOSAL
The FEEDINGFREQUENCY of theNEONATE is
approx 60 min155
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
BRAIN CYCLING
STOMACH FILLING amp EMPTYING
REMNR1NR2NR3NR4
156
27
Normal physiology of theEnteric Nervous System
ldquoSmall and frequent feeds according to the sleep cyclerdquo
The ldquonicherdquo (occupation) of a neonate (Alberts)
BOND FEED
SLEEP SLEEP
PLAY FEED
157
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
FEEDING SUCKLING
Influence of SMELL None Totally dependent
Motor mechanism Chewing ndash different
muscles
Suckling ndash different circuits
INSULIN Increases weight No effect
GHRELIN Increases weight No effect
LEPTIN Decreases intake No effect
CHOLECYSTOKININ Decreases intake No effect
AMPHETAMINE Decreases appetite Increases suckling
SEROTONIN Agonist improves feeding Antagonist improves suck
SATIETY Infant determined Maternal supply determine
FEEDING SUCKLING
Influence of SMELL None Totally dependent
Motor mechanism Chewing ndash different
muscles
Suckling ndash different circuits
INSULIN Increases weight No effect
GHRELIN Increases weight No effect
LEPTIN Decreases intake No effect
CHOLECYSTOKININ Decreases intake No effect
AMPHETAMINE Decreases appetite Increases suckling
SEROTONIN Agonist improves feeding Antagonist improves suck
SATIETY Infant determined Maternal supply determine
Current dogmaTHE BABY KNOWS
WHEN IT HAS HAD ENOUGH
PROBABLY NOT
WHAT IS THE
STOMACH VOLUME OF THE
PREMATURE
161
Assume low resilience
Assume proportionality
162
28
The CAPACITY of alow birthweight premfrom 20ml 3000g
= 0007 x BWt (g)
1kg x 0007 = 7mls2kg x 0007 = 14mls
163
Gastric overfilling syndrome
164
75 ml per feeding ASSUMPTION
IMMATURE OR OVERWHELMED
many aspects of gastrointestinalmotility are immature in the neonate
Zangen S et al Rapid maturation of gastric relaxation in newborns
A balloon in stomachcan fill to 76 mls
What does the stomach ndashwithout a balloon ndashdo to 76 mls
REFLUX PRESUME each feedapproximately 75 mls
GER
bull Sudden outbursts of crying
bull Awakens in pain
bull Related to feedings
bull Not easily comforted
bull ldquoI know baby hurtsrdquo
bull Sour burps throaty noises
bull Best when upright
Clues to GER
Dr W Sears
29
Mitchell 2001
Kerstin Uvnaumls-Moberg
Food in duodenum
AMYLINreleased
Closes pylorus
Duodenumempty
Pylorusopens
ldquoFeed intolerancerdquo hellip hellip or VOLUME intolerance
HYPOGLYCAEMIA
A babies stomach empties in60 minutes
Blood sugarmay fall hellip
after 90 minutes Options
30
METABOLIC ADAPTATION
SSC started in the first 20 minutes after birth
SSC CotBlood glucose (1 hr) 317 256Base excess drop 34 18
(Christenson 1992)0h 1h 2h 3h 4h 2 days
App
roxim
ate
GLUCOSE
SSC Glucose production = Glucose consumption
Separation
SNS stress Glucose consumption INCREASE
PSNS dissociation Glucose production DECREASE
HYPOGLYCEMIA
SSC Cot
Blood glucose (1 hr) 317 256
0h 1h 2h 3h 4h 2 days
App
roxim
ate
GLUCOSE
SSC Glucose production = Glucose consumption
Separation PSNS dissociation
Glucose production DECREASE
HYPOGLYCEMIA
SSC Cot
Blood glucose (1 hr) 317 256
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
NEURODEVELOPMENTThe DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
BONDING ATTACHMENT
MRI HRVEEG
STRESS RESPONES
RESILIENCE
DOHAD
(MAL) ADAPTATION
EPIGENETICS
GENE X ENVIRONMENT
GENETIC VARIANTS
HOSPITAL ACQUIRED INFECTIONIMMUNITY
SLEEP PHYSIOLOGY
GUT FUNCTIONMICROBIOTA
ldquoSTABILITYrdquo
TRANSITION
LONG TERM FOLLOW-UP
NEUROENDOCRINE BEHAVIOURS
MATERNAL NEUROPLASTICITY
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
MORTALITYMETABOLISM
0h 1h 2h 3h 4h
PSNS (vagal)
App
roxim
ate
GLUCOSE
1 HOURLY Milk feed
1 HOURLY Milk feed
1 HOURLY Milk feed
1 HOURLY Milk feed
LACTOSE
METABOLISM
31
0h 1h 2h 3h 4h
PSNS (vagal) SYMPATHETIC STRESS
App
roxim
ate
GLUCOSE
LACTOSE FATGLYCOGEN
METABOLISM
4 HOURLY Milk feed
0h 1h 2h 3h 4h
PSNS (vagal) SYMPATHETIC STRESS
App
roxim
ate
GLUCOSE
4 HOURLY ALLOSTATIC STATELACTOSE FATGLYCOGEN
METABOLISM
4 HOURLY Milk feed
HEALTH DISEASE
EXPECTED UNEXPECTED
NEURODEVELOPMENTThe DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
BONDING ATTACHMENT
MRI HRVEEG
STRESS RESPONES
RESILIENCE
DOHAD
(MAL) ADAPTATION
EPIGENETICS
GENE X ENVIRONMENT
GENETIC VARIANTS
HOSPITAL ACQUIRED INFECTIONIMMUNITY
SLEEP PHYSIOLOGY
GUT FUNCTIONMICROBIOTA
ldquoSTABILITYrdquo
TRANSITION
LONG TERM FOLLOW-UP
NEUROENDOCRINE BEHAVIOURS
MATERNAL NEUROPLASTICITY
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
MORTALITYMETABOLISM
Weight gain 1st week
predicts OBESITYat 30 years
Large volume feedsstretched stomach=
doubled absorptivecapacity as adult
Importance
Programming ndash early life chronic disease
32
RESISTANCE SENSITIVITY
PERCEPTIONSldquoNEUROCEPTIONrdquo
RESPONSESTRESS
ALLOSTATIC STATE
ALLOSTASIS
ANY STRESSPsychologicalNeurological
EndocrineImmune
ALLOSTATIC LOAD
ALLOSTATIC OVERLOAD
WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY
DISEASEHEALTH
RESILIENCE VULNERABILITY
RESISTANCE SENSITIVITY
PERCEPTIONSldquoNEUROCEPTIONrdquo
RESPONSESTRESS
ALLOSTATIC STATE
ALLOSTASIS
ANY STRESSPsychologicalNeurological
EndocrineImmune
ALLOSTATIC LOAD
HEALTH
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
Gastric overfilling syndrome
189
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
33
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
Only case series Insufficient evidence
No mention of
stomach capacity196
Baby weight freq reqrsquod size actual
2kg baby 4hrly ~ 320 ml6 = 53ml 14ml
15 baby 3hrly ~ 240 ml8 = 30ml 10ml
10 baby 2hrly ~ 160 ml12 = 13ml 7ml
Standardised from20ml capacityfor 3kg baby( x 0007)
197
0
10
20
30
40
50
60
70
80
90
13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w
LINEAR
TERM
PREM
198
34
0
10
20
30
40
50
60
70
80
90
13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w
LINEAR
TERM
PREM
199
Clues to GER
ldquoI know baby hurtsrdquo
Gastric overfilling syndrome
Excessive volumesreflux aspiration colic
Excessive time intervalhypoglycaemia
Adaptationsdiabetic diathesis obesity
200
Developmental Care of the Enteric Nervous System
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
14
DUAL INGESTION SYSTEMS DUAL INGESTION SYSTEMS
SUCKLING WEANING FEEDING
Lactase Digestive enzymes
FEEDING SUCKLING
Influence of SMELL None Totally dependent
Motor mechanism Chewing ndash different
muscles
Suckling ndash different circuits
INSULIN Increases weight No effect
GHRELIN Increases weight No effect
LEPTIN Decreases intake No effect
CHOLECYSTOKININ Decreases intake No effect
AMPHETAMINE Decreases appetite Increases suckling
SEROTONIN Agonist improves feeding Antagonist improves suck
SATIETY Infant determined Maternal supply determine
FEEDING SUCKLING
DISRUPTION ROBUST VERY SENSITIVE
Must have right conditions
Pup-in-a- cup - And STIMULI
separated and fed by tube
From day 2 off life
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
14th century Tuscan text
Conceptual changeDyad careBreast first hour
even CaesareanContinuous SSC
DISCONTINUEGiving waterGlucose waterInfant formulaSeparationPacifier (dummy)
CHANGE POLICY Canrsquot change
biology
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
ON-GOING
S S C
WIRE NEURONS
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C WIRE
TIMING
(behavior)
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
ENTERIC NERVOUS SYSTEM
123
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
FEEDBACK LOOPS
CNS
ENS
ANS
InternalSomaticenvironment
124
125 126
22
Fetal stomach appears 4 weeks GABy 11 weeks wall capable of muscular
contraction
ldquoPatterns of antropyloric motilityin fed healthy preterm infantsrdquo
the neuroregulatory mechanisms responsible for the coordination of antro-pyloric motility and gastric emptying are
well developed by 30 weeks of PMAHassan 2002 127
Hydrochloric acidimportant for activation of pepsinogen
inactivation of microorganisms such as bacteria
Pepsinogenactivated by acid into active pepsin
responsible for the stomachs ability to initiate digestion of proteins
Chymosinis an enzyme whose role is to curdle or
coagulate milk in the stomach a process of considerable importance in the very young animal
128
Chymosinmakes the milk into ldquocheeserdquohalfway between liquid and solidstomach empties in 60 minutes
milk
129
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
FEEDBACK LOOPS
130
EVIDENCE FORFEEDING FREQUENCY
Edmond 2006 131
Breastfeeding and motherrsquos milkStrong and consistent evidence 132
23
Cup feeding versus bottle feedingCup feeding higher breastfeeding
greater stability133
Only case series Insufficient evidence
No mention of
stomach capacity134
EVIDENCE FORSTOMACH CAPACITY
Edmond 2006 135
0
05
1
15
2
25
3
35
4
0 10 20 30 40 50 60 70 80
volume ingested
fee
din
g f
req
ue
nc
y
Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml
StandardCARE3 hourlyschedule
136
KEY QUESTION
WHAT IS THE
STOMACHVOLUMEOF THE
NEONATE 137 Sase 2005
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
(Alliot) pressure)151
PROPOSAL
The CAPACITY of aweek old babyrsquos stomach is
approx 20 ml152
0
05
1
15
2
25
3
35
4
0 10 20 30 40 50 60 70 80
volume ingested
fee
din
g f
req
ue
nc
y
Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml
StandardCARE3 hourlyschedule
MOTHERNATURE
1 hourlyschedule
153
PHYSIOLOGICAL CAPACITY
RECEPTIVE CAPACITY of stomach
INGESTIVE CAPACITY of BABY
FUNCTIONAL CAPACITY
154
PROPOSAL
The FEEDINGFREQUENCY of theNEONATE is
approx 60 min155
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
BRAIN CYCLING
STOMACH FILLING amp EMPTYING
REMNR1NR2NR3NR4
156
27
Normal physiology of theEnteric Nervous System
ldquoSmall and frequent feeds according to the sleep cyclerdquo
The ldquonicherdquo (occupation) of a neonate (Alberts)
BOND FEED
SLEEP SLEEP
PLAY FEED
157
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
FEEDING SUCKLING
Influence of SMELL None Totally dependent
Motor mechanism Chewing ndash different
muscles
Suckling ndash different circuits
INSULIN Increases weight No effect
GHRELIN Increases weight No effect
LEPTIN Decreases intake No effect
CHOLECYSTOKININ Decreases intake No effect
AMPHETAMINE Decreases appetite Increases suckling
SEROTONIN Agonist improves feeding Antagonist improves suck
SATIETY Infant determined Maternal supply determine
FEEDING SUCKLING
Influence of SMELL None Totally dependent
Motor mechanism Chewing ndash different
muscles
Suckling ndash different circuits
INSULIN Increases weight No effect
GHRELIN Increases weight No effect
LEPTIN Decreases intake No effect
CHOLECYSTOKININ Decreases intake No effect
AMPHETAMINE Decreases appetite Increases suckling
SEROTONIN Agonist improves feeding Antagonist improves suck
SATIETY Infant determined Maternal supply determine
Current dogmaTHE BABY KNOWS
WHEN IT HAS HAD ENOUGH
PROBABLY NOT
WHAT IS THE
STOMACH VOLUME OF THE
PREMATURE
161
Assume low resilience
Assume proportionality
162
28
The CAPACITY of alow birthweight premfrom 20ml 3000g
= 0007 x BWt (g)
1kg x 0007 = 7mls2kg x 0007 = 14mls
163
Gastric overfilling syndrome
164
75 ml per feeding ASSUMPTION
IMMATURE OR OVERWHELMED
many aspects of gastrointestinalmotility are immature in the neonate
Zangen S et al Rapid maturation of gastric relaxation in newborns
A balloon in stomachcan fill to 76 mls
What does the stomach ndashwithout a balloon ndashdo to 76 mls
REFLUX PRESUME each feedapproximately 75 mls
GER
bull Sudden outbursts of crying
bull Awakens in pain
bull Related to feedings
bull Not easily comforted
bull ldquoI know baby hurtsrdquo
bull Sour burps throaty noises
bull Best when upright
Clues to GER
Dr W Sears
29
Mitchell 2001
Kerstin Uvnaumls-Moberg
Food in duodenum
AMYLINreleased
Closes pylorus
Duodenumempty
Pylorusopens
ldquoFeed intolerancerdquo hellip hellip or VOLUME intolerance
HYPOGLYCAEMIA
A babies stomach empties in60 minutes
Blood sugarmay fall hellip
after 90 minutes Options
30
METABOLIC ADAPTATION
SSC started in the first 20 minutes after birth
SSC CotBlood glucose (1 hr) 317 256Base excess drop 34 18
(Christenson 1992)0h 1h 2h 3h 4h 2 days
App
roxim
ate
GLUCOSE
SSC Glucose production = Glucose consumption
Separation
SNS stress Glucose consumption INCREASE
PSNS dissociation Glucose production DECREASE
HYPOGLYCEMIA
SSC Cot
Blood glucose (1 hr) 317 256
0h 1h 2h 3h 4h 2 days
App
roxim
ate
GLUCOSE
SSC Glucose production = Glucose consumption
Separation PSNS dissociation
Glucose production DECREASE
HYPOGLYCEMIA
SSC Cot
Blood glucose (1 hr) 317 256
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
NEURODEVELOPMENTThe DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
BONDING ATTACHMENT
MRI HRVEEG
STRESS RESPONES
RESILIENCE
DOHAD
(MAL) ADAPTATION
EPIGENETICS
GENE X ENVIRONMENT
GENETIC VARIANTS
HOSPITAL ACQUIRED INFECTIONIMMUNITY
SLEEP PHYSIOLOGY
GUT FUNCTIONMICROBIOTA
ldquoSTABILITYrdquo
TRANSITION
LONG TERM FOLLOW-UP
NEUROENDOCRINE BEHAVIOURS
MATERNAL NEUROPLASTICITY
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
MORTALITYMETABOLISM
0h 1h 2h 3h 4h
PSNS (vagal)
App
roxim
ate
GLUCOSE
1 HOURLY Milk feed
1 HOURLY Milk feed
1 HOURLY Milk feed
1 HOURLY Milk feed
LACTOSE
METABOLISM
31
0h 1h 2h 3h 4h
PSNS (vagal) SYMPATHETIC STRESS
App
roxim
ate
GLUCOSE
LACTOSE FATGLYCOGEN
METABOLISM
4 HOURLY Milk feed
0h 1h 2h 3h 4h
PSNS (vagal) SYMPATHETIC STRESS
App
roxim
ate
GLUCOSE
4 HOURLY ALLOSTATIC STATELACTOSE FATGLYCOGEN
METABOLISM
4 HOURLY Milk feed
HEALTH DISEASE
EXPECTED UNEXPECTED
NEURODEVELOPMENTThe DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
BONDING ATTACHMENT
MRI HRVEEG
STRESS RESPONES
RESILIENCE
DOHAD
(MAL) ADAPTATION
EPIGENETICS
GENE X ENVIRONMENT
GENETIC VARIANTS
HOSPITAL ACQUIRED INFECTIONIMMUNITY
SLEEP PHYSIOLOGY
GUT FUNCTIONMICROBIOTA
ldquoSTABILITYrdquo
TRANSITION
LONG TERM FOLLOW-UP
NEUROENDOCRINE BEHAVIOURS
MATERNAL NEUROPLASTICITY
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
MORTALITYMETABOLISM
Weight gain 1st week
predicts OBESITYat 30 years
Large volume feedsstretched stomach=
doubled absorptivecapacity as adult
Importance
Programming ndash early life chronic disease
32
RESISTANCE SENSITIVITY
PERCEPTIONSldquoNEUROCEPTIONrdquo
RESPONSESTRESS
ALLOSTATIC STATE
ALLOSTASIS
ANY STRESSPsychologicalNeurological
EndocrineImmune
ALLOSTATIC LOAD
ALLOSTATIC OVERLOAD
WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY
DISEASEHEALTH
RESILIENCE VULNERABILITY
RESISTANCE SENSITIVITY
PERCEPTIONSldquoNEUROCEPTIONrdquo
RESPONSESTRESS
ALLOSTATIC STATE
ALLOSTASIS
ANY STRESSPsychologicalNeurological
EndocrineImmune
ALLOSTATIC LOAD
HEALTH
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
Gastric overfilling syndrome
189
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
33
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
Only case series Insufficient evidence
No mention of
stomach capacity196
Baby weight freq reqrsquod size actual
2kg baby 4hrly ~ 320 ml6 = 53ml 14ml
15 baby 3hrly ~ 240 ml8 = 30ml 10ml
10 baby 2hrly ~ 160 ml12 = 13ml 7ml
Standardised from20ml capacityfor 3kg baby( x 0007)
197
0
10
20
30
40
50
60
70
80
90
13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w
LINEAR
TERM
PREM
198
34
0
10
20
30
40
50
60
70
80
90
13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w
LINEAR
TERM
PREM
199
Clues to GER
ldquoI know baby hurtsrdquo
Gastric overfilling syndrome
Excessive volumesreflux aspiration colic
Excessive time intervalhypoglycaemia
Adaptationsdiabetic diathesis obesity
200
Developmental Care of the Enteric Nervous System
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
14th century Tuscan text
Conceptual changeDyad careBreast first hour
even CaesareanContinuous SSC
DISCONTINUEGiving waterGlucose waterInfant formulaSeparationPacifier (dummy)
CHANGE POLICY Canrsquot change
biology
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
ON-GOING
S S C
WIRE NEURONS
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C WIRE
TIMING
(behavior)
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
ENTERIC NERVOUS SYSTEM
123
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
FEEDBACK LOOPS
CNS
ENS
ANS
InternalSomaticenvironment
124
125 126
22
Fetal stomach appears 4 weeks GABy 11 weeks wall capable of muscular
contraction
ldquoPatterns of antropyloric motilityin fed healthy preterm infantsrdquo
the neuroregulatory mechanisms responsible for the coordination of antro-pyloric motility and gastric emptying are
well developed by 30 weeks of PMAHassan 2002 127
Hydrochloric acidimportant for activation of pepsinogen
inactivation of microorganisms such as bacteria
Pepsinogenactivated by acid into active pepsin
responsible for the stomachs ability to initiate digestion of proteins
Chymosinis an enzyme whose role is to curdle or
coagulate milk in the stomach a process of considerable importance in the very young animal
128
Chymosinmakes the milk into ldquocheeserdquohalfway between liquid and solidstomach empties in 60 minutes
milk
129
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
FEEDBACK LOOPS
130
EVIDENCE FORFEEDING FREQUENCY
Edmond 2006 131
Breastfeeding and motherrsquos milkStrong and consistent evidence 132
23
Cup feeding versus bottle feedingCup feeding higher breastfeeding
greater stability133
Only case series Insufficient evidence
No mention of
stomach capacity134
EVIDENCE FORSTOMACH CAPACITY
Edmond 2006 135
0
05
1
15
2
25
3
35
4
0 10 20 30 40 50 60 70 80
volume ingested
fee
din
g f
req
ue
nc
y
Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml
StandardCARE3 hourlyschedule
136
KEY QUESTION
WHAT IS THE
STOMACHVOLUMEOF THE
NEONATE 137 Sase 2005
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
(Alliot) pressure)151
PROPOSAL
The CAPACITY of aweek old babyrsquos stomach is
approx 20 ml152
0
05
1
15
2
25
3
35
4
0 10 20 30 40 50 60 70 80
volume ingested
fee
din
g f
req
ue
nc
y
Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml
StandardCARE3 hourlyschedule
MOTHERNATURE
1 hourlyschedule
153
PHYSIOLOGICAL CAPACITY
RECEPTIVE CAPACITY of stomach
INGESTIVE CAPACITY of BABY
FUNCTIONAL CAPACITY
154
PROPOSAL
The FEEDINGFREQUENCY of theNEONATE is
approx 60 min155
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
BRAIN CYCLING
STOMACH FILLING amp EMPTYING
REMNR1NR2NR3NR4
156
27
Normal physiology of theEnteric Nervous System
ldquoSmall and frequent feeds according to the sleep cyclerdquo
The ldquonicherdquo (occupation) of a neonate (Alberts)
BOND FEED
SLEEP SLEEP
PLAY FEED
157
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
FEEDING SUCKLING
Influence of SMELL None Totally dependent
Motor mechanism Chewing ndash different
muscles
Suckling ndash different circuits
INSULIN Increases weight No effect
GHRELIN Increases weight No effect
LEPTIN Decreases intake No effect
CHOLECYSTOKININ Decreases intake No effect
AMPHETAMINE Decreases appetite Increases suckling
SEROTONIN Agonist improves feeding Antagonist improves suck
SATIETY Infant determined Maternal supply determine
FEEDING SUCKLING
Influence of SMELL None Totally dependent
Motor mechanism Chewing ndash different
muscles
Suckling ndash different circuits
INSULIN Increases weight No effect
GHRELIN Increases weight No effect
LEPTIN Decreases intake No effect
CHOLECYSTOKININ Decreases intake No effect
AMPHETAMINE Decreases appetite Increases suckling
SEROTONIN Agonist improves feeding Antagonist improves suck
SATIETY Infant determined Maternal supply determine
Current dogmaTHE BABY KNOWS
WHEN IT HAS HAD ENOUGH
PROBABLY NOT
WHAT IS THE
STOMACH VOLUME OF THE
PREMATURE
161
Assume low resilience
Assume proportionality
162
28
The CAPACITY of alow birthweight premfrom 20ml 3000g
= 0007 x BWt (g)
1kg x 0007 = 7mls2kg x 0007 = 14mls
163
Gastric overfilling syndrome
164
75 ml per feeding ASSUMPTION
IMMATURE OR OVERWHELMED
many aspects of gastrointestinalmotility are immature in the neonate
Zangen S et al Rapid maturation of gastric relaxation in newborns
A balloon in stomachcan fill to 76 mls
What does the stomach ndashwithout a balloon ndashdo to 76 mls
REFLUX PRESUME each feedapproximately 75 mls
GER
bull Sudden outbursts of crying
bull Awakens in pain
bull Related to feedings
bull Not easily comforted
bull ldquoI know baby hurtsrdquo
bull Sour burps throaty noises
bull Best when upright
Clues to GER
Dr W Sears
29
Mitchell 2001
Kerstin Uvnaumls-Moberg
Food in duodenum
AMYLINreleased
Closes pylorus
Duodenumempty
Pylorusopens
ldquoFeed intolerancerdquo hellip hellip or VOLUME intolerance
HYPOGLYCAEMIA
A babies stomach empties in60 minutes
Blood sugarmay fall hellip
after 90 minutes Options
30
METABOLIC ADAPTATION
SSC started in the first 20 minutes after birth
SSC CotBlood glucose (1 hr) 317 256Base excess drop 34 18
(Christenson 1992)0h 1h 2h 3h 4h 2 days
App
roxim
ate
GLUCOSE
SSC Glucose production = Glucose consumption
Separation
SNS stress Glucose consumption INCREASE
PSNS dissociation Glucose production DECREASE
HYPOGLYCEMIA
SSC Cot
Blood glucose (1 hr) 317 256
0h 1h 2h 3h 4h 2 days
App
roxim
ate
GLUCOSE
SSC Glucose production = Glucose consumption
Separation PSNS dissociation
Glucose production DECREASE
HYPOGLYCEMIA
SSC Cot
Blood glucose (1 hr) 317 256
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
NEURODEVELOPMENTThe DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
BONDING ATTACHMENT
MRI HRVEEG
STRESS RESPONES
RESILIENCE
DOHAD
(MAL) ADAPTATION
EPIGENETICS
GENE X ENVIRONMENT
GENETIC VARIANTS
HOSPITAL ACQUIRED INFECTIONIMMUNITY
SLEEP PHYSIOLOGY
GUT FUNCTIONMICROBIOTA
ldquoSTABILITYrdquo
TRANSITION
LONG TERM FOLLOW-UP
NEUROENDOCRINE BEHAVIOURS
MATERNAL NEUROPLASTICITY
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
MORTALITYMETABOLISM
0h 1h 2h 3h 4h
PSNS (vagal)
App
roxim
ate
GLUCOSE
1 HOURLY Milk feed
1 HOURLY Milk feed
1 HOURLY Milk feed
1 HOURLY Milk feed
LACTOSE
METABOLISM
31
0h 1h 2h 3h 4h
PSNS (vagal) SYMPATHETIC STRESS
App
roxim
ate
GLUCOSE
LACTOSE FATGLYCOGEN
METABOLISM
4 HOURLY Milk feed
0h 1h 2h 3h 4h
PSNS (vagal) SYMPATHETIC STRESS
App
roxim
ate
GLUCOSE
4 HOURLY ALLOSTATIC STATELACTOSE FATGLYCOGEN
METABOLISM
4 HOURLY Milk feed
HEALTH DISEASE
EXPECTED UNEXPECTED
NEURODEVELOPMENTThe DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
BONDING ATTACHMENT
MRI HRVEEG
STRESS RESPONES
RESILIENCE
DOHAD
(MAL) ADAPTATION
EPIGENETICS
GENE X ENVIRONMENT
GENETIC VARIANTS
HOSPITAL ACQUIRED INFECTIONIMMUNITY
SLEEP PHYSIOLOGY
GUT FUNCTIONMICROBIOTA
ldquoSTABILITYrdquo
TRANSITION
LONG TERM FOLLOW-UP
NEUROENDOCRINE BEHAVIOURS
MATERNAL NEUROPLASTICITY
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
MORTALITYMETABOLISM
Weight gain 1st week
predicts OBESITYat 30 years
Large volume feedsstretched stomach=
doubled absorptivecapacity as adult
Importance
Programming ndash early life chronic disease
32
RESISTANCE SENSITIVITY
PERCEPTIONSldquoNEUROCEPTIONrdquo
RESPONSESTRESS
ALLOSTATIC STATE
ALLOSTASIS
ANY STRESSPsychologicalNeurological
EndocrineImmune
ALLOSTATIC LOAD
ALLOSTATIC OVERLOAD
WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY
DISEASEHEALTH
RESILIENCE VULNERABILITY
RESISTANCE SENSITIVITY
PERCEPTIONSldquoNEUROCEPTIONrdquo
RESPONSESTRESS
ALLOSTATIC STATE
ALLOSTASIS
ANY STRESSPsychologicalNeurological
EndocrineImmune
ALLOSTATIC LOAD
HEALTH
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
Gastric overfilling syndrome
189
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
33
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
Only case series Insufficient evidence
No mention of
stomach capacity196
Baby weight freq reqrsquod size actual
2kg baby 4hrly ~ 320 ml6 = 53ml 14ml
15 baby 3hrly ~ 240 ml8 = 30ml 10ml
10 baby 2hrly ~ 160 ml12 = 13ml 7ml
Standardised from20ml capacityfor 3kg baby( x 0007)
197
0
10
20
30
40
50
60
70
80
90
13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w
LINEAR
TERM
PREM
198
34
0
10
20
30
40
50
60
70
80
90
13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w
LINEAR
TERM
PREM
199
Clues to GER
ldquoI know baby hurtsrdquo
Gastric overfilling syndrome
Excessive volumesreflux aspiration colic
Excessive time intervalhypoglycaemia
Adaptationsdiabetic diathesis obesity
200
Developmental Care of the Enteric Nervous System
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
14th century Tuscan text
Conceptual changeDyad careBreast first hour
even CaesareanContinuous SSC
DISCONTINUEGiving waterGlucose waterInfant formulaSeparationPacifier (dummy)
CHANGE POLICY Canrsquot change
biology
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
ON-GOING
S S C
WIRE NEURONS
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C WIRE
TIMING
(behavior)
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
ENTERIC NERVOUS SYSTEM
123
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
FEEDBACK LOOPS
CNS
ENS
ANS
InternalSomaticenvironment
124
125 126
22
Fetal stomach appears 4 weeks GABy 11 weeks wall capable of muscular
contraction
ldquoPatterns of antropyloric motilityin fed healthy preterm infantsrdquo
the neuroregulatory mechanisms responsible for the coordination of antro-pyloric motility and gastric emptying are
well developed by 30 weeks of PMAHassan 2002 127
Hydrochloric acidimportant for activation of pepsinogen
inactivation of microorganisms such as bacteria
Pepsinogenactivated by acid into active pepsin
responsible for the stomachs ability to initiate digestion of proteins
Chymosinis an enzyme whose role is to curdle or
coagulate milk in the stomach a process of considerable importance in the very young animal
128
Chymosinmakes the milk into ldquocheeserdquohalfway between liquid and solidstomach empties in 60 minutes
milk
129
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
FEEDBACK LOOPS
130
EVIDENCE FORFEEDING FREQUENCY
Edmond 2006 131
Breastfeeding and motherrsquos milkStrong and consistent evidence 132
23
Cup feeding versus bottle feedingCup feeding higher breastfeeding
greater stability133
Only case series Insufficient evidence
No mention of
stomach capacity134
EVIDENCE FORSTOMACH CAPACITY
Edmond 2006 135
0
05
1
15
2
25
3
35
4
0 10 20 30 40 50 60 70 80
volume ingested
fee
din
g f
req
ue
nc
y
Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml
StandardCARE3 hourlyschedule
136
KEY QUESTION
WHAT IS THE
STOMACHVOLUMEOF THE
NEONATE 137 Sase 2005
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
(Alliot) pressure)151
PROPOSAL
The CAPACITY of aweek old babyrsquos stomach is
approx 20 ml152
0
05
1
15
2
25
3
35
4
0 10 20 30 40 50 60 70 80
volume ingested
fee
din
g f
req
ue
nc
y
Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml
StandardCARE3 hourlyschedule
MOTHERNATURE
1 hourlyschedule
153
PHYSIOLOGICAL CAPACITY
RECEPTIVE CAPACITY of stomach
INGESTIVE CAPACITY of BABY
FUNCTIONAL CAPACITY
154
PROPOSAL
The FEEDINGFREQUENCY of theNEONATE is
approx 60 min155
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
BRAIN CYCLING
STOMACH FILLING amp EMPTYING
REMNR1NR2NR3NR4
156
27
Normal physiology of theEnteric Nervous System
ldquoSmall and frequent feeds according to the sleep cyclerdquo
The ldquonicherdquo (occupation) of a neonate (Alberts)
BOND FEED
SLEEP SLEEP
PLAY FEED
157
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
FEEDING SUCKLING
Influence of SMELL None Totally dependent
Motor mechanism Chewing ndash different
muscles
Suckling ndash different circuits
INSULIN Increases weight No effect
GHRELIN Increases weight No effect
LEPTIN Decreases intake No effect
CHOLECYSTOKININ Decreases intake No effect
AMPHETAMINE Decreases appetite Increases suckling
SEROTONIN Agonist improves feeding Antagonist improves suck
SATIETY Infant determined Maternal supply determine
FEEDING SUCKLING
Influence of SMELL None Totally dependent
Motor mechanism Chewing ndash different
muscles
Suckling ndash different circuits
INSULIN Increases weight No effect
GHRELIN Increases weight No effect
LEPTIN Decreases intake No effect
CHOLECYSTOKININ Decreases intake No effect
AMPHETAMINE Decreases appetite Increases suckling
SEROTONIN Agonist improves feeding Antagonist improves suck
SATIETY Infant determined Maternal supply determine
Current dogmaTHE BABY KNOWS
WHEN IT HAS HAD ENOUGH
PROBABLY NOT
WHAT IS THE
STOMACH VOLUME OF THE
PREMATURE
161
Assume low resilience
Assume proportionality
162
28
The CAPACITY of alow birthweight premfrom 20ml 3000g
= 0007 x BWt (g)
1kg x 0007 = 7mls2kg x 0007 = 14mls
163
Gastric overfilling syndrome
164
75 ml per feeding ASSUMPTION
IMMATURE OR OVERWHELMED
many aspects of gastrointestinalmotility are immature in the neonate
Zangen S et al Rapid maturation of gastric relaxation in newborns
A balloon in stomachcan fill to 76 mls
What does the stomach ndashwithout a balloon ndashdo to 76 mls
REFLUX PRESUME each feedapproximately 75 mls
GER
bull Sudden outbursts of crying
bull Awakens in pain
bull Related to feedings
bull Not easily comforted
bull ldquoI know baby hurtsrdquo
bull Sour burps throaty noises
bull Best when upright
Clues to GER
Dr W Sears
29
Mitchell 2001
Kerstin Uvnaumls-Moberg
Food in duodenum
AMYLINreleased
Closes pylorus
Duodenumempty
Pylorusopens
ldquoFeed intolerancerdquo hellip hellip or VOLUME intolerance
HYPOGLYCAEMIA
A babies stomach empties in60 minutes
Blood sugarmay fall hellip
after 90 minutes Options
30
METABOLIC ADAPTATION
SSC started in the first 20 minutes after birth
SSC CotBlood glucose (1 hr) 317 256Base excess drop 34 18
(Christenson 1992)0h 1h 2h 3h 4h 2 days
App
roxim
ate
GLUCOSE
SSC Glucose production = Glucose consumption
Separation
SNS stress Glucose consumption INCREASE
PSNS dissociation Glucose production DECREASE
HYPOGLYCEMIA
SSC Cot
Blood glucose (1 hr) 317 256
0h 1h 2h 3h 4h 2 days
App
roxim
ate
GLUCOSE
SSC Glucose production = Glucose consumption
Separation PSNS dissociation
Glucose production DECREASE
HYPOGLYCEMIA
SSC Cot
Blood glucose (1 hr) 317 256
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
NEURODEVELOPMENTThe DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
BONDING ATTACHMENT
MRI HRVEEG
STRESS RESPONES
RESILIENCE
DOHAD
(MAL) ADAPTATION
EPIGENETICS
GENE X ENVIRONMENT
GENETIC VARIANTS
HOSPITAL ACQUIRED INFECTIONIMMUNITY
SLEEP PHYSIOLOGY
GUT FUNCTIONMICROBIOTA
ldquoSTABILITYrdquo
TRANSITION
LONG TERM FOLLOW-UP
NEUROENDOCRINE BEHAVIOURS
MATERNAL NEUROPLASTICITY
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
MORTALITYMETABOLISM
0h 1h 2h 3h 4h
PSNS (vagal)
App
roxim
ate
GLUCOSE
1 HOURLY Milk feed
1 HOURLY Milk feed
1 HOURLY Milk feed
1 HOURLY Milk feed
LACTOSE
METABOLISM
31
0h 1h 2h 3h 4h
PSNS (vagal) SYMPATHETIC STRESS
App
roxim
ate
GLUCOSE
LACTOSE FATGLYCOGEN
METABOLISM
4 HOURLY Milk feed
0h 1h 2h 3h 4h
PSNS (vagal) SYMPATHETIC STRESS
App
roxim
ate
GLUCOSE
4 HOURLY ALLOSTATIC STATELACTOSE FATGLYCOGEN
METABOLISM
4 HOURLY Milk feed
HEALTH DISEASE
EXPECTED UNEXPECTED
NEURODEVELOPMENTThe DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
BONDING ATTACHMENT
MRI HRVEEG
STRESS RESPONES
RESILIENCE
DOHAD
(MAL) ADAPTATION
EPIGENETICS
GENE X ENVIRONMENT
GENETIC VARIANTS
HOSPITAL ACQUIRED INFECTIONIMMUNITY
SLEEP PHYSIOLOGY
GUT FUNCTIONMICROBIOTA
ldquoSTABILITYrdquo
TRANSITION
LONG TERM FOLLOW-UP
NEUROENDOCRINE BEHAVIOURS
MATERNAL NEUROPLASTICITY
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
MORTALITYMETABOLISM
Weight gain 1st week
predicts OBESITYat 30 years
Large volume feedsstretched stomach=
doubled absorptivecapacity as adult
Importance
Programming ndash early life chronic disease
32
RESISTANCE SENSITIVITY
PERCEPTIONSldquoNEUROCEPTIONrdquo
RESPONSESTRESS
ALLOSTATIC STATE
ALLOSTASIS
ANY STRESSPsychologicalNeurological
EndocrineImmune
ALLOSTATIC LOAD
ALLOSTATIC OVERLOAD
WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY
DISEASEHEALTH
RESILIENCE VULNERABILITY
RESISTANCE SENSITIVITY
PERCEPTIONSldquoNEUROCEPTIONrdquo
RESPONSESTRESS
ALLOSTATIC STATE
ALLOSTASIS
ANY STRESSPsychologicalNeurological
EndocrineImmune
ALLOSTATIC LOAD
HEALTH
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
Gastric overfilling syndrome
189
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
33
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
Only case series Insufficient evidence
No mention of
stomach capacity196
Baby weight freq reqrsquod size actual
2kg baby 4hrly ~ 320 ml6 = 53ml 14ml
15 baby 3hrly ~ 240 ml8 = 30ml 10ml
10 baby 2hrly ~ 160 ml12 = 13ml 7ml
Standardised from20ml capacityfor 3kg baby( x 0007)
197
0
10
20
30
40
50
60
70
80
90
13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w
LINEAR
TERM
PREM
198
34
0
10
20
30
40
50
60
70
80
90
13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w
LINEAR
TERM
PREM
199
Clues to GER
ldquoI know baby hurtsrdquo
Gastric overfilling syndrome
Excessive volumesreflux aspiration colic
Excessive time intervalhypoglycaemia
Adaptationsdiabetic diathesis obesity
200
Developmental Care of the Enteric Nervous System
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
14th century Tuscan text
Conceptual changeDyad careBreast first hour
even CaesareanContinuous SSC
DISCONTINUEGiving waterGlucose waterInfant formulaSeparationPacifier (dummy)
CHANGE POLICY Canrsquot change
biology
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
ON-GOING
S S C
WIRE NEURONS
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C WIRE
TIMING
(behavior)
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
ENTERIC NERVOUS SYSTEM
123
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
FEEDBACK LOOPS
CNS
ENS
ANS
InternalSomaticenvironment
124
125 126
22
Fetal stomach appears 4 weeks GABy 11 weeks wall capable of muscular
contraction
ldquoPatterns of antropyloric motilityin fed healthy preterm infantsrdquo
the neuroregulatory mechanisms responsible for the coordination of antro-pyloric motility and gastric emptying are
well developed by 30 weeks of PMAHassan 2002 127
Hydrochloric acidimportant for activation of pepsinogen
inactivation of microorganisms such as bacteria
Pepsinogenactivated by acid into active pepsin
responsible for the stomachs ability to initiate digestion of proteins
Chymosinis an enzyme whose role is to curdle or
coagulate milk in the stomach a process of considerable importance in the very young animal
128
Chymosinmakes the milk into ldquocheeserdquohalfway between liquid and solidstomach empties in 60 minutes
milk
129
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
FEEDBACK LOOPS
130
EVIDENCE FORFEEDING FREQUENCY
Edmond 2006 131
Breastfeeding and motherrsquos milkStrong and consistent evidence 132
23
Cup feeding versus bottle feedingCup feeding higher breastfeeding
greater stability133
Only case series Insufficient evidence
No mention of
stomach capacity134
EVIDENCE FORSTOMACH CAPACITY
Edmond 2006 135
0
05
1
15
2
25
3
35
4
0 10 20 30 40 50 60 70 80
volume ingested
fee
din
g f
req
ue
nc
y
Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml
StandardCARE3 hourlyschedule
136
KEY QUESTION
WHAT IS THE
STOMACHVOLUMEOF THE
NEONATE 137 Sase 2005
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
(Alliot) pressure)151
PROPOSAL
The CAPACITY of aweek old babyrsquos stomach is
approx 20 ml152
0
05
1
15
2
25
3
35
4
0 10 20 30 40 50 60 70 80
volume ingested
fee
din
g f
req
ue
nc
y
Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml
StandardCARE3 hourlyschedule
MOTHERNATURE
1 hourlyschedule
153
PHYSIOLOGICAL CAPACITY
RECEPTIVE CAPACITY of stomach
INGESTIVE CAPACITY of BABY
FUNCTIONAL CAPACITY
154
PROPOSAL
The FEEDINGFREQUENCY of theNEONATE is
approx 60 min155
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
BRAIN CYCLING
STOMACH FILLING amp EMPTYING
REMNR1NR2NR3NR4
156
27
Normal physiology of theEnteric Nervous System
ldquoSmall and frequent feeds according to the sleep cyclerdquo
The ldquonicherdquo (occupation) of a neonate (Alberts)
BOND FEED
SLEEP SLEEP
PLAY FEED
157
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
FEEDING SUCKLING
Influence of SMELL None Totally dependent
Motor mechanism Chewing ndash different
muscles
Suckling ndash different circuits
INSULIN Increases weight No effect
GHRELIN Increases weight No effect
LEPTIN Decreases intake No effect
CHOLECYSTOKININ Decreases intake No effect
AMPHETAMINE Decreases appetite Increases suckling
SEROTONIN Agonist improves feeding Antagonist improves suck
SATIETY Infant determined Maternal supply determine
FEEDING SUCKLING
Influence of SMELL None Totally dependent
Motor mechanism Chewing ndash different
muscles
Suckling ndash different circuits
INSULIN Increases weight No effect
GHRELIN Increases weight No effect
LEPTIN Decreases intake No effect
CHOLECYSTOKININ Decreases intake No effect
AMPHETAMINE Decreases appetite Increases suckling
SEROTONIN Agonist improves feeding Antagonist improves suck
SATIETY Infant determined Maternal supply determine
Current dogmaTHE BABY KNOWS
WHEN IT HAS HAD ENOUGH
PROBABLY NOT
WHAT IS THE
STOMACH VOLUME OF THE
PREMATURE
161
Assume low resilience
Assume proportionality
162
28
The CAPACITY of alow birthweight premfrom 20ml 3000g
= 0007 x BWt (g)
1kg x 0007 = 7mls2kg x 0007 = 14mls
163
Gastric overfilling syndrome
164
75 ml per feeding ASSUMPTION
IMMATURE OR OVERWHELMED
many aspects of gastrointestinalmotility are immature in the neonate
Zangen S et al Rapid maturation of gastric relaxation in newborns
A balloon in stomachcan fill to 76 mls
What does the stomach ndashwithout a balloon ndashdo to 76 mls
REFLUX PRESUME each feedapproximately 75 mls
GER
bull Sudden outbursts of crying
bull Awakens in pain
bull Related to feedings
bull Not easily comforted
bull ldquoI know baby hurtsrdquo
bull Sour burps throaty noises
bull Best when upright
Clues to GER
Dr W Sears
29
Mitchell 2001
Kerstin Uvnaumls-Moberg
Food in duodenum
AMYLINreleased
Closes pylorus
Duodenumempty
Pylorusopens
ldquoFeed intolerancerdquo hellip hellip or VOLUME intolerance
HYPOGLYCAEMIA
A babies stomach empties in60 minutes
Blood sugarmay fall hellip
after 90 minutes Options
30
METABOLIC ADAPTATION
SSC started in the first 20 minutes after birth
SSC CotBlood glucose (1 hr) 317 256Base excess drop 34 18
(Christenson 1992)0h 1h 2h 3h 4h 2 days
App
roxim
ate
GLUCOSE
SSC Glucose production = Glucose consumption
Separation
SNS stress Glucose consumption INCREASE
PSNS dissociation Glucose production DECREASE
HYPOGLYCEMIA
SSC Cot
Blood glucose (1 hr) 317 256
0h 1h 2h 3h 4h 2 days
App
roxim
ate
GLUCOSE
SSC Glucose production = Glucose consumption
Separation PSNS dissociation
Glucose production DECREASE
HYPOGLYCEMIA
SSC Cot
Blood glucose (1 hr) 317 256
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
NEURODEVELOPMENTThe DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
BONDING ATTACHMENT
MRI HRVEEG
STRESS RESPONES
RESILIENCE
DOHAD
(MAL) ADAPTATION
EPIGENETICS
GENE X ENVIRONMENT
GENETIC VARIANTS
HOSPITAL ACQUIRED INFECTIONIMMUNITY
SLEEP PHYSIOLOGY
GUT FUNCTIONMICROBIOTA
ldquoSTABILITYrdquo
TRANSITION
LONG TERM FOLLOW-UP
NEUROENDOCRINE BEHAVIOURS
MATERNAL NEUROPLASTICITY
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
MORTALITYMETABOLISM
0h 1h 2h 3h 4h
PSNS (vagal)
App
roxim
ate
GLUCOSE
1 HOURLY Milk feed
1 HOURLY Milk feed
1 HOURLY Milk feed
1 HOURLY Milk feed
LACTOSE
METABOLISM
31
0h 1h 2h 3h 4h
PSNS (vagal) SYMPATHETIC STRESS
App
roxim
ate
GLUCOSE
LACTOSE FATGLYCOGEN
METABOLISM
4 HOURLY Milk feed
0h 1h 2h 3h 4h
PSNS (vagal) SYMPATHETIC STRESS
App
roxim
ate
GLUCOSE
4 HOURLY ALLOSTATIC STATELACTOSE FATGLYCOGEN
METABOLISM
4 HOURLY Milk feed
HEALTH DISEASE
EXPECTED UNEXPECTED
NEURODEVELOPMENTThe DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
BONDING ATTACHMENT
MRI HRVEEG
STRESS RESPONES
RESILIENCE
DOHAD
(MAL) ADAPTATION
EPIGENETICS
GENE X ENVIRONMENT
GENETIC VARIANTS
HOSPITAL ACQUIRED INFECTIONIMMUNITY
SLEEP PHYSIOLOGY
GUT FUNCTIONMICROBIOTA
ldquoSTABILITYrdquo
TRANSITION
LONG TERM FOLLOW-UP
NEUROENDOCRINE BEHAVIOURS
MATERNAL NEUROPLASTICITY
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
MORTALITYMETABOLISM
Weight gain 1st week
predicts OBESITYat 30 years
Large volume feedsstretched stomach=
doubled absorptivecapacity as adult
Importance
Programming ndash early life chronic disease
32
RESISTANCE SENSITIVITY
PERCEPTIONSldquoNEUROCEPTIONrdquo
RESPONSESTRESS
ALLOSTATIC STATE
ALLOSTASIS
ANY STRESSPsychologicalNeurological
EndocrineImmune
ALLOSTATIC LOAD
ALLOSTATIC OVERLOAD
WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY
DISEASEHEALTH
RESILIENCE VULNERABILITY
RESISTANCE SENSITIVITY
PERCEPTIONSldquoNEUROCEPTIONrdquo
RESPONSESTRESS
ALLOSTATIC STATE
ALLOSTASIS
ANY STRESSPsychologicalNeurological
EndocrineImmune
ALLOSTATIC LOAD
HEALTH
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
Gastric overfilling syndrome
189
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
33
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
Only case series Insufficient evidence
No mention of
stomach capacity196
Baby weight freq reqrsquod size actual
2kg baby 4hrly ~ 320 ml6 = 53ml 14ml
15 baby 3hrly ~ 240 ml8 = 30ml 10ml
10 baby 2hrly ~ 160 ml12 = 13ml 7ml
Standardised from20ml capacityfor 3kg baby( x 0007)
197
0
10
20
30
40
50
60
70
80
90
13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w
LINEAR
TERM
PREM
198
34
0
10
20
30
40
50
60
70
80
90
13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w
LINEAR
TERM
PREM
199
Clues to GER
ldquoI know baby hurtsrdquo
Gastric overfilling syndrome
Excessive volumesreflux aspiration colic
Excessive time intervalhypoglycaemia
Adaptationsdiabetic diathesis obesity
200
Developmental Care of the Enteric Nervous System
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
14th century Tuscan text
Conceptual changeDyad careBreast first hour
even CaesareanContinuous SSC
DISCONTINUEGiving waterGlucose waterInfant formulaSeparationPacifier (dummy)
CHANGE POLICY Canrsquot change
biology
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
SENSORY BRAINstimulation nutrition
ON-GOING
S S C
WIRE NEURONS
BIRTH
S S C
Breastfeeding behaviour
Breastfeeding WIRING
BREASTFEEDING
STATE organization
Feeding frequency
SLEEP cycling
ON-GOING
S S C WIRE
TIMING
(behavior)
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
ENTERIC NERVOUS SYSTEM
123
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
FEEDBACK LOOPS
CNS
ENS
ANS
InternalSomaticenvironment
124
125 126
22
Fetal stomach appears 4 weeks GABy 11 weeks wall capable of muscular
contraction
ldquoPatterns of antropyloric motilityin fed healthy preterm infantsrdquo
the neuroregulatory mechanisms responsible for the coordination of antro-pyloric motility and gastric emptying are
well developed by 30 weeks of PMAHassan 2002 127
Hydrochloric acidimportant for activation of pepsinogen
inactivation of microorganisms such as bacteria
Pepsinogenactivated by acid into active pepsin
responsible for the stomachs ability to initiate digestion of proteins
Chymosinis an enzyme whose role is to curdle or
coagulate milk in the stomach a process of considerable importance in the very young animal
128
Chymosinmakes the milk into ldquocheeserdquohalfway between liquid and solidstomach empties in 60 minutes
milk
129
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
FEEDBACK LOOPS
130
EVIDENCE FORFEEDING FREQUENCY
Edmond 2006 131
Breastfeeding and motherrsquos milkStrong and consistent evidence 132
23
Cup feeding versus bottle feedingCup feeding higher breastfeeding
greater stability133
Only case series Insufficient evidence
No mention of
stomach capacity134
EVIDENCE FORSTOMACH CAPACITY
Edmond 2006 135
0
05
1
15
2
25
3
35
4
0 10 20 30 40 50 60 70 80
volume ingested
fee
din
g f
req
ue
nc
y
Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml
StandardCARE3 hourlyschedule
136
KEY QUESTION
WHAT IS THE
STOMACHVOLUMEOF THE
NEONATE 137 Sase 2005
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
(Alliot) pressure)151
PROPOSAL
The CAPACITY of aweek old babyrsquos stomach is
approx 20 ml152
0
05
1
15
2
25
3
35
4
0 10 20 30 40 50 60 70 80
volume ingested
fee
din
g f
req
ue
nc
y
Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml
StandardCARE3 hourlyschedule
MOTHERNATURE
1 hourlyschedule
153
PHYSIOLOGICAL CAPACITY
RECEPTIVE CAPACITY of stomach
INGESTIVE CAPACITY of BABY
FUNCTIONAL CAPACITY
154
PROPOSAL
The FEEDINGFREQUENCY of theNEONATE is
approx 60 min155
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
BRAIN CYCLING
STOMACH FILLING amp EMPTYING
REMNR1NR2NR3NR4
156
27
Normal physiology of theEnteric Nervous System
ldquoSmall and frequent feeds according to the sleep cyclerdquo
The ldquonicherdquo (occupation) of a neonate (Alberts)
BOND FEED
SLEEP SLEEP
PLAY FEED
157
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
FEEDING SUCKLING
Influence of SMELL None Totally dependent
Motor mechanism Chewing ndash different
muscles
Suckling ndash different circuits
INSULIN Increases weight No effect
GHRELIN Increases weight No effect
LEPTIN Decreases intake No effect
CHOLECYSTOKININ Decreases intake No effect
AMPHETAMINE Decreases appetite Increases suckling
SEROTONIN Agonist improves feeding Antagonist improves suck
SATIETY Infant determined Maternal supply determine
FEEDING SUCKLING
Influence of SMELL None Totally dependent
Motor mechanism Chewing ndash different
muscles
Suckling ndash different circuits
INSULIN Increases weight No effect
GHRELIN Increases weight No effect
LEPTIN Decreases intake No effect
CHOLECYSTOKININ Decreases intake No effect
AMPHETAMINE Decreases appetite Increases suckling
SEROTONIN Agonist improves feeding Antagonist improves suck
SATIETY Infant determined Maternal supply determine
Current dogmaTHE BABY KNOWS
WHEN IT HAS HAD ENOUGH
PROBABLY NOT
WHAT IS THE
STOMACH VOLUME OF THE
PREMATURE
161
Assume low resilience
Assume proportionality
162
28
The CAPACITY of alow birthweight premfrom 20ml 3000g
= 0007 x BWt (g)
1kg x 0007 = 7mls2kg x 0007 = 14mls
163
Gastric overfilling syndrome
164
75 ml per feeding ASSUMPTION
IMMATURE OR OVERWHELMED
many aspects of gastrointestinalmotility are immature in the neonate
Zangen S et al Rapid maturation of gastric relaxation in newborns
A balloon in stomachcan fill to 76 mls
What does the stomach ndashwithout a balloon ndashdo to 76 mls
REFLUX PRESUME each feedapproximately 75 mls
GER
bull Sudden outbursts of crying
bull Awakens in pain
bull Related to feedings
bull Not easily comforted
bull ldquoI know baby hurtsrdquo
bull Sour burps throaty noises
bull Best when upright
Clues to GER
Dr W Sears
29
Mitchell 2001
Kerstin Uvnaumls-Moberg
Food in duodenum
AMYLINreleased
Closes pylorus
Duodenumempty
Pylorusopens
ldquoFeed intolerancerdquo hellip hellip or VOLUME intolerance
HYPOGLYCAEMIA
A babies stomach empties in60 minutes
Blood sugarmay fall hellip
after 90 minutes Options
30
METABOLIC ADAPTATION
SSC started in the first 20 minutes after birth
SSC CotBlood glucose (1 hr) 317 256Base excess drop 34 18
(Christenson 1992)0h 1h 2h 3h 4h 2 days
App
roxim
ate
GLUCOSE
SSC Glucose production = Glucose consumption
Separation
SNS stress Glucose consumption INCREASE
PSNS dissociation Glucose production DECREASE
HYPOGLYCEMIA
SSC Cot
Blood glucose (1 hr) 317 256
0h 1h 2h 3h 4h 2 days
App
roxim
ate
GLUCOSE
SSC Glucose production = Glucose consumption
Separation PSNS dissociation
Glucose production DECREASE
HYPOGLYCEMIA
SSC Cot
Blood glucose (1 hr) 317 256
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
NEURODEVELOPMENTThe DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
BONDING ATTACHMENT
MRI HRVEEG
STRESS RESPONES
RESILIENCE
DOHAD
(MAL) ADAPTATION
EPIGENETICS
GENE X ENVIRONMENT
GENETIC VARIANTS
HOSPITAL ACQUIRED INFECTIONIMMUNITY
SLEEP PHYSIOLOGY
GUT FUNCTIONMICROBIOTA
ldquoSTABILITYrdquo
TRANSITION
LONG TERM FOLLOW-UP
NEUROENDOCRINE BEHAVIOURS
MATERNAL NEUROPLASTICITY
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
MORTALITYMETABOLISM
0h 1h 2h 3h 4h
PSNS (vagal)
App
roxim
ate
GLUCOSE
1 HOURLY Milk feed
1 HOURLY Milk feed
1 HOURLY Milk feed
1 HOURLY Milk feed
LACTOSE
METABOLISM
31
0h 1h 2h 3h 4h
PSNS (vagal) SYMPATHETIC STRESS
App
roxim
ate
GLUCOSE
LACTOSE FATGLYCOGEN
METABOLISM
4 HOURLY Milk feed
0h 1h 2h 3h 4h
PSNS (vagal) SYMPATHETIC STRESS
App
roxim
ate
GLUCOSE
4 HOURLY ALLOSTATIC STATELACTOSE FATGLYCOGEN
METABOLISM
4 HOURLY Milk feed
HEALTH DISEASE
EXPECTED UNEXPECTED
NEURODEVELOPMENTThe DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
BONDING ATTACHMENT
MRI HRVEEG
STRESS RESPONES
RESILIENCE
DOHAD
(MAL) ADAPTATION
EPIGENETICS
GENE X ENVIRONMENT
GENETIC VARIANTS
HOSPITAL ACQUIRED INFECTIONIMMUNITY
SLEEP PHYSIOLOGY
GUT FUNCTIONMICROBIOTA
ldquoSTABILITYrdquo
TRANSITION
LONG TERM FOLLOW-UP
NEUROENDOCRINE BEHAVIOURS
MATERNAL NEUROPLASTICITY
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
MORTALITYMETABOLISM
Weight gain 1st week
predicts OBESITYat 30 years
Large volume feedsstretched stomach=
doubled absorptivecapacity as adult
Importance
Programming ndash early life chronic disease
32
RESISTANCE SENSITIVITY
PERCEPTIONSldquoNEUROCEPTIONrdquo
RESPONSESTRESS
ALLOSTATIC STATE
ALLOSTASIS
ANY STRESSPsychologicalNeurological
EndocrineImmune
ALLOSTATIC LOAD
ALLOSTATIC OVERLOAD
WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY
DISEASEHEALTH
RESILIENCE VULNERABILITY
RESISTANCE SENSITIVITY
PERCEPTIONSldquoNEUROCEPTIONrdquo
RESPONSESTRESS
ALLOSTATIC STATE
ALLOSTASIS
ANY STRESSPsychologicalNeurological
EndocrineImmune
ALLOSTATIC LOAD
HEALTH
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
Gastric overfilling syndrome
189
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
33
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
Only case series Insufficient evidence
No mention of
stomach capacity196
Baby weight freq reqrsquod size actual
2kg baby 4hrly ~ 320 ml6 = 53ml 14ml
15 baby 3hrly ~ 240 ml8 = 30ml 10ml
10 baby 2hrly ~ 160 ml12 = 13ml 7ml
Standardised from20ml capacityfor 3kg baby( x 0007)
197
0
10
20
30
40
50
60
70
80
90
13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w
LINEAR
TERM
PREM
198
34
0
10
20
30
40
50
60
70
80
90
13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w
LINEAR
TERM
PREM
199
Clues to GER
ldquoI know baby hurtsrdquo
Gastric overfilling syndrome
Excessive volumesreflux aspiration colic
Excessive time intervalhypoglycaemia
Adaptationsdiabetic diathesis obesity
200
Developmental Care of the Enteric Nervous System
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
ENTERIC NERVOUS SYSTEM
123
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
FEEDBACK LOOPS
CNS
ENS
ANS
InternalSomaticenvironment
124
125 126
22
Fetal stomach appears 4 weeks GABy 11 weeks wall capable of muscular
contraction
ldquoPatterns of antropyloric motilityin fed healthy preterm infantsrdquo
the neuroregulatory mechanisms responsible for the coordination of antro-pyloric motility and gastric emptying are
well developed by 30 weeks of PMAHassan 2002 127
Hydrochloric acidimportant for activation of pepsinogen
inactivation of microorganisms such as bacteria
Pepsinogenactivated by acid into active pepsin
responsible for the stomachs ability to initiate digestion of proteins
Chymosinis an enzyme whose role is to curdle or
coagulate milk in the stomach a process of considerable importance in the very young animal
128
Chymosinmakes the milk into ldquocheeserdquohalfway between liquid and solidstomach empties in 60 minutes
milk
129
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
FEEDBACK LOOPS
130
EVIDENCE FORFEEDING FREQUENCY
Edmond 2006 131
Breastfeeding and motherrsquos milkStrong and consistent evidence 132
23
Cup feeding versus bottle feedingCup feeding higher breastfeeding
greater stability133
Only case series Insufficient evidence
No mention of
stomach capacity134
EVIDENCE FORSTOMACH CAPACITY
Edmond 2006 135
0
05
1
15
2
25
3
35
4
0 10 20 30 40 50 60 70 80
volume ingested
fee
din
g f
req
ue
nc
y
Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml
StandardCARE3 hourlyschedule
136
KEY QUESTION
WHAT IS THE
STOMACHVOLUMEOF THE
NEONATE 137 Sase 2005
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
(Alliot) pressure)151
PROPOSAL
The CAPACITY of aweek old babyrsquos stomach is
approx 20 ml152
0
05
1
15
2
25
3
35
4
0 10 20 30 40 50 60 70 80
volume ingested
fee
din
g f
req
ue
nc
y
Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml
StandardCARE3 hourlyschedule
MOTHERNATURE
1 hourlyschedule
153
PHYSIOLOGICAL CAPACITY
RECEPTIVE CAPACITY of stomach
INGESTIVE CAPACITY of BABY
FUNCTIONAL CAPACITY
154
PROPOSAL
The FEEDINGFREQUENCY of theNEONATE is
approx 60 min155
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
BRAIN CYCLING
STOMACH FILLING amp EMPTYING
REMNR1NR2NR3NR4
156
27
Normal physiology of theEnteric Nervous System
ldquoSmall and frequent feeds according to the sleep cyclerdquo
The ldquonicherdquo (occupation) of a neonate (Alberts)
BOND FEED
SLEEP SLEEP
PLAY FEED
157
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
FEEDING SUCKLING
Influence of SMELL None Totally dependent
Motor mechanism Chewing ndash different
muscles
Suckling ndash different circuits
INSULIN Increases weight No effect
GHRELIN Increases weight No effect
LEPTIN Decreases intake No effect
CHOLECYSTOKININ Decreases intake No effect
AMPHETAMINE Decreases appetite Increases suckling
SEROTONIN Agonist improves feeding Antagonist improves suck
SATIETY Infant determined Maternal supply determine
FEEDING SUCKLING
Influence of SMELL None Totally dependent
Motor mechanism Chewing ndash different
muscles
Suckling ndash different circuits
INSULIN Increases weight No effect
GHRELIN Increases weight No effect
LEPTIN Decreases intake No effect
CHOLECYSTOKININ Decreases intake No effect
AMPHETAMINE Decreases appetite Increases suckling
SEROTONIN Agonist improves feeding Antagonist improves suck
SATIETY Infant determined Maternal supply determine
Current dogmaTHE BABY KNOWS
WHEN IT HAS HAD ENOUGH
PROBABLY NOT
WHAT IS THE
STOMACH VOLUME OF THE
PREMATURE
161
Assume low resilience
Assume proportionality
162
28
The CAPACITY of alow birthweight premfrom 20ml 3000g
= 0007 x BWt (g)
1kg x 0007 = 7mls2kg x 0007 = 14mls
163
Gastric overfilling syndrome
164
75 ml per feeding ASSUMPTION
IMMATURE OR OVERWHELMED
many aspects of gastrointestinalmotility are immature in the neonate
Zangen S et al Rapid maturation of gastric relaxation in newborns
A balloon in stomachcan fill to 76 mls
What does the stomach ndashwithout a balloon ndashdo to 76 mls
REFLUX PRESUME each feedapproximately 75 mls
GER
bull Sudden outbursts of crying
bull Awakens in pain
bull Related to feedings
bull Not easily comforted
bull ldquoI know baby hurtsrdquo
bull Sour burps throaty noises
bull Best when upright
Clues to GER
Dr W Sears
29
Mitchell 2001
Kerstin Uvnaumls-Moberg
Food in duodenum
AMYLINreleased
Closes pylorus
Duodenumempty
Pylorusopens
ldquoFeed intolerancerdquo hellip hellip or VOLUME intolerance
HYPOGLYCAEMIA
A babies stomach empties in60 minutes
Blood sugarmay fall hellip
after 90 minutes Options
30
METABOLIC ADAPTATION
SSC started in the first 20 minutes after birth
SSC CotBlood glucose (1 hr) 317 256Base excess drop 34 18
(Christenson 1992)0h 1h 2h 3h 4h 2 days
App
roxim
ate
GLUCOSE
SSC Glucose production = Glucose consumption
Separation
SNS stress Glucose consumption INCREASE
PSNS dissociation Glucose production DECREASE
HYPOGLYCEMIA
SSC Cot
Blood glucose (1 hr) 317 256
0h 1h 2h 3h 4h 2 days
App
roxim
ate
GLUCOSE
SSC Glucose production = Glucose consumption
Separation PSNS dissociation
Glucose production DECREASE
HYPOGLYCEMIA
SSC Cot
Blood glucose (1 hr) 317 256
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
NEURODEVELOPMENTThe DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
BONDING ATTACHMENT
MRI HRVEEG
STRESS RESPONES
RESILIENCE
DOHAD
(MAL) ADAPTATION
EPIGENETICS
GENE X ENVIRONMENT
GENETIC VARIANTS
HOSPITAL ACQUIRED INFECTIONIMMUNITY
SLEEP PHYSIOLOGY
GUT FUNCTIONMICROBIOTA
ldquoSTABILITYrdquo
TRANSITION
LONG TERM FOLLOW-UP
NEUROENDOCRINE BEHAVIOURS
MATERNAL NEUROPLASTICITY
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
MORTALITYMETABOLISM
0h 1h 2h 3h 4h
PSNS (vagal)
App
roxim
ate
GLUCOSE
1 HOURLY Milk feed
1 HOURLY Milk feed
1 HOURLY Milk feed
1 HOURLY Milk feed
LACTOSE
METABOLISM
31
0h 1h 2h 3h 4h
PSNS (vagal) SYMPATHETIC STRESS
App
roxim
ate
GLUCOSE
LACTOSE FATGLYCOGEN
METABOLISM
4 HOURLY Milk feed
0h 1h 2h 3h 4h
PSNS (vagal) SYMPATHETIC STRESS
App
roxim
ate
GLUCOSE
4 HOURLY ALLOSTATIC STATELACTOSE FATGLYCOGEN
METABOLISM
4 HOURLY Milk feed
HEALTH DISEASE
EXPECTED UNEXPECTED
NEURODEVELOPMENTThe DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
BONDING ATTACHMENT
MRI HRVEEG
STRESS RESPONES
RESILIENCE
DOHAD
(MAL) ADAPTATION
EPIGENETICS
GENE X ENVIRONMENT
GENETIC VARIANTS
HOSPITAL ACQUIRED INFECTIONIMMUNITY
SLEEP PHYSIOLOGY
GUT FUNCTIONMICROBIOTA
ldquoSTABILITYrdquo
TRANSITION
LONG TERM FOLLOW-UP
NEUROENDOCRINE BEHAVIOURS
MATERNAL NEUROPLASTICITY
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
MORTALITYMETABOLISM
Weight gain 1st week
predicts OBESITYat 30 years
Large volume feedsstretched stomach=
doubled absorptivecapacity as adult
Importance
Programming ndash early life chronic disease
32
RESISTANCE SENSITIVITY
PERCEPTIONSldquoNEUROCEPTIONrdquo
RESPONSESTRESS
ALLOSTATIC STATE
ALLOSTASIS
ANY STRESSPsychologicalNeurological
EndocrineImmune
ALLOSTATIC LOAD
ALLOSTATIC OVERLOAD
WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY
DISEASEHEALTH
RESILIENCE VULNERABILITY
RESISTANCE SENSITIVITY
PERCEPTIONSldquoNEUROCEPTIONrdquo
RESPONSESTRESS
ALLOSTATIC STATE
ALLOSTASIS
ANY STRESSPsychologicalNeurological
EndocrineImmune
ALLOSTATIC LOAD
HEALTH
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
Gastric overfilling syndrome
189
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
33
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
Only case series Insufficient evidence
No mention of
stomach capacity196
Baby weight freq reqrsquod size actual
2kg baby 4hrly ~ 320 ml6 = 53ml 14ml
15 baby 3hrly ~ 240 ml8 = 30ml 10ml
10 baby 2hrly ~ 160 ml12 = 13ml 7ml
Standardised from20ml capacityfor 3kg baby( x 0007)
197
0
10
20
30
40
50
60
70
80
90
13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w
LINEAR
TERM
PREM
198
34
0
10
20
30
40
50
60
70
80
90
13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w
LINEAR
TERM
PREM
199
Clues to GER
ldquoI know baby hurtsrdquo
Gastric overfilling syndrome
Excessive volumesreflux aspiration colic
Excessive time intervalhypoglycaemia
Adaptationsdiabetic diathesis obesity
200
Developmental Care of the Enteric Nervous System
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
ENTERIC NERVOUS SYSTEM
123
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
FEEDBACK LOOPS
CNS
ENS
ANS
InternalSomaticenvironment
124
125 126
22
Fetal stomach appears 4 weeks GABy 11 weeks wall capable of muscular
contraction
ldquoPatterns of antropyloric motilityin fed healthy preterm infantsrdquo
the neuroregulatory mechanisms responsible for the coordination of antro-pyloric motility and gastric emptying are
well developed by 30 weeks of PMAHassan 2002 127
Hydrochloric acidimportant for activation of pepsinogen
inactivation of microorganisms such as bacteria
Pepsinogenactivated by acid into active pepsin
responsible for the stomachs ability to initiate digestion of proteins
Chymosinis an enzyme whose role is to curdle or
coagulate milk in the stomach a process of considerable importance in the very young animal
128
Chymosinmakes the milk into ldquocheeserdquohalfway between liquid and solidstomach empties in 60 minutes
milk
129
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
FEEDBACK LOOPS
130
EVIDENCE FORFEEDING FREQUENCY
Edmond 2006 131
Breastfeeding and motherrsquos milkStrong and consistent evidence 132
23
Cup feeding versus bottle feedingCup feeding higher breastfeeding
greater stability133
Only case series Insufficient evidence
No mention of
stomach capacity134
EVIDENCE FORSTOMACH CAPACITY
Edmond 2006 135
0
05
1
15
2
25
3
35
4
0 10 20 30 40 50 60 70 80
volume ingested
fee
din
g f
req
ue
nc
y
Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml
StandardCARE3 hourlyschedule
136
KEY QUESTION
WHAT IS THE
STOMACHVOLUMEOF THE
NEONATE 137 Sase 2005
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
(Alliot) pressure)151
PROPOSAL
The CAPACITY of aweek old babyrsquos stomach is
approx 20 ml152
0
05
1
15
2
25
3
35
4
0 10 20 30 40 50 60 70 80
volume ingested
fee
din
g f
req
ue
nc
y
Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml
StandardCARE3 hourlyschedule
MOTHERNATURE
1 hourlyschedule
153
PHYSIOLOGICAL CAPACITY
RECEPTIVE CAPACITY of stomach
INGESTIVE CAPACITY of BABY
FUNCTIONAL CAPACITY
154
PROPOSAL
The FEEDINGFREQUENCY of theNEONATE is
approx 60 min155
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
BRAIN CYCLING
STOMACH FILLING amp EMPTYING
REMNR1NR2NR3NR4
156
27
Normal physiology of theEnteric Nervous System
ldquoSmall and frequent feeds according to the sleep cyclerdquo
The ldquonicherdquo (occupation) of a neonate (Alberts)
BOND FEED
SLEEP SLEEP
PLAY FEED
157
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
FEEDING SUCKLING
Influence of SMELL None Totally dependent
Motor mechanism Chewing ndash different
muscles
Suckling ndash different circuits
INSULIN Increases weight No effect
GHRELIN Increases weight No effect
LEPTIN Decreases intake No effect
CHOLECYSTOKININ Decreases intake No effect
AMPHETAMINE Decreases appetite Increases suckling
SEROTONIN Agonist improves feeding Antagonist improves suck
SATIETY Infant determined Maternal supply determine
FEEDING SUCKLING
Influence of SMELL None Totally dependent
Motor mechanism Chewing ndash different
muscles
Suckling ndash different circuits
INSULIN Increases weight No effect
GHRELIN Increases weight No effect
LEPTIN Decreases intake No effect
CHOLECYSTOKININ Decreases intake No effect
AMPHETAMINE Decreases appetite Increases suckling
SEROTONIN Agonist improves feeding Antagonist improves suck
SATIETY Infant determined Maternal supply determine
Current dogmaTHE BABY KNOWS
WHEN IT HAS HAD ENOUGH
PROBABLY NOT
WHAT IS THE
STOMACH VOLUME OF THE
PREMATURE
161
Assume low resilience
Assume proportionality
162
28
The CAPACITY of alow birthweight premfrom 20ml 3000g
= 0007 x BWt (g)
1kg x 0007 = 7mls2kg x 0007 = 14mls
163
Gastric overfilling syndrome
164
75 ml per feeding ASSUMPTION
IMMATURE OR OVERWHELMED
many aspects of gastrointestinalmotility are immature in the neonate
Zangen S et al Rapid maturation of gastric relaxation in newborns
A balloon in stomachcan fill to 76 mls
What does the stomach ndashwithout a balloon ndashdo to 76 mls
REFLUX PRESUME each feedapproximately 75 mls
GER
bull Sudden outbursts of crying
bull Awakens in pain
bull Related to feedings
bull Not easily comforted
bull ldquoI know baby hurtsrdquo
bull Sour burps throaty noises
bull Best when upright
Clues to GER
Dr W Sears
29
Mitchell 2001
Kerstin Uvnaumls-Moberg
Food in duodenum
AMYLINreleased
Closes pylorus
Duodenumempty
Pylorusopens
ldquoFeed intolerancerdquo hellip hellip or VOLUME intolerance
HYPOGLYCAEMIA
A babies stomach empties in60 minutes
Blood sugarmay fall hellip
after 90 minutes Options
30
METABOLIC ADAPTATION
SSC started in the first 20 minutes after birth
SSC CotBlood glucose (1 hr) 317 256Base excess drop 34 18
(Christenson 1992)0h 1h 2h 3h 4h 2 days
App
roxim
ate
GLUCOSE
SSC Glucose production = Glucose consumption
Separation
SNS stress Glucose consumption INCREASE
PSNS dissociation Glucose production DECREASE
HYPOGLYCEMIA
SSC Cot
Blood glucose (1 hr) 317 256
0h 1h 2h 3h 4h 2 days
App
roxim
ate
GLUCOSE
SSC Glucose production = Glucose consumption
Separation PSNS dissociation
Glucose production DECREASE
HYPOGLYCEMIA
SSC Cot
Blood glucose (1 hr) 317 256
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
NEURODEVELOPMENTThe DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
BONDING ATTACHMENT
MRI HRVEEG
STRESS RESPONES
RESILIENCE
DOHAD
(MAL) ADAPTATION
EPIGENETICS
GENE X ENVIRONMENT
GENETIC VARIANTS
HOSPITAL ACQUIRED INFECTIONIMMUNITY
SLEEP PHYSIOLOGY
GUT FUNCTIONMICROBIOTA
ldquoSTABILITYrdquo
TRANSITION
LONG TERM FOLLOW-UP
NEUROENDOCRINE BEHAVIOURS
MATERNAL NEUROPLASTICITY
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
MORTALITYMETABOLISM
0h 1h 2h 3h 4h
PSNS (vagal)
App
roxim
ate
GLUCOSE
1 HOURLY Milk feed
1 HOURLY Milk feed
1 HOURLY Milk feed
1 HOURLY Milk feed
LACTOSE
METABOLISM
31
0h 1h 2h 3h 4h
PSNS (vagal) SYMPATHETIC STRESS
App
roxim
ate
GLUCOSE
LACTOSE FATGLYCOGEN
METABOLISM
4 HOURLY Milk feed
0h 1h 2h 3h 4h
PSNS (vagal) SYMPATHETIC STRESS
App
roxim
ate
GLUCOSE
4 HOURLY ALLOSTATIC STATELACTOSE FATGLYCOGEN
METABOLISM
4 HOURLY Milk feed
HEALTH DISEASE
EXPECTED UNEXPECTED
NEURODEVELOPMENTThe DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
BONDING ATTACHMENT
MRI HRVEEG
STRESS RESPONES
RESILIENCE
DOHAD
(MAL) ADAPTATION
EPIGENETICS
GENE X ENVIRONMENT
GENETIC VARIANTS
HOSPITAL ACQUIRED INFECTIONIMMUNITY
SLEEP PHYSIOLOGY
GUT FUNCTIONMICROBIOTA
ldquoSTABILITYrdquo
TRANSITION
LONG TERM FOLLOW-UP
NEUROENDOCRINE BEHAVIOURS
MATERNAL NEUROPLASTICITY
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
MORTALITYMETABOLISM
Weight gain 1st week
predicts OBESITYat 30 years
Large volume feedsstretched stomach=
doubled absorptivecapacity as adult
Importance
Programming ndash early life chronic disease
32
RESISTANCE SENSITIVITY
PERCEPTIONSldquoNEUROCEPTIONrdquo
RESPONSESTRESS
ALLOSTATIC STATE
ALLOSTASIS
ANY STRESSPsychologicalNeurological
EndocrineImmune
ALLOSTATIC LOAD
ALLOSTATIC OVERLOAD
WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY
DISEASEHEALTH
RESILIENCE VULNERABILITY
RESISTANCE SENSITIVITY
PERCEPTIONSldquoNEUROCEPTIONrdquo
RESPONSESTRESS
ALLOSTATIC STATE
ALLOSTASIS
ANY STRESSPsychologicalNeurological
EndocrineImmune
ALLOSTATIC LOAD
HEALTH
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
Gastric overfilling syndrome
189
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
33
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
Only case series Insufficient evidence
No mention of
stomach capacity196
Baby weight freq reqrsquod size actual
2kg baby 4hrly ~ 320 ml6 = 53ml 14ml
15 baby 3hrly ~ 240 ml8 = 30ml 10ml
10 baby 2hrly ~ 160 ml12 = 13ml 7ml
Standardised from20ml capacityfor 3kg baby( x 0007)
197
0
10
20
30
40
50
60
70
80
90
13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w
LINEAR
TERM
PREM
198
34
0
10
20
30
40
50
60
70
80
90
13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w
LINEAR
TERM
PREM
199
Clues to GER
ldquoI know baby hurtsrdquo
Gastric overfilling syndrome
Excessive volumesreflux aspiration colic
Excessive time intervalhypoglycaemia
Adaptationsdiabetic diathesis obesity
200
Developmental Care of the Enteric Nervous System
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
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
ENTERIC NERVOUS SYSTEM
123
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
FEEDBACK LOOPS
CNS
ENS
ANS
InternalSomaticenvironment
124
125 126
22
Fetal stomach appears 4 weeks GABy 11 weeks wall capable of muscular
contraction
ldquoPatterns of antropyloric motilityin fed healthy preterm infantsrdquo
the neuroregulatory mechanisms responsible for the coordination of antro-pyloric motility and gastric emptying are
well developed by 30 weeks of PMAHassan 2002 127
Hydrochloric acidimportant for activation of pepsinogen
inactivation of microorganisms such as bacteria
Pepsinogenactivated by acid into active pepsin
responsible for the stomachs ability to initiate digestion of proteins
Chymosinis an enzyme whose role is to curdle or
coagulate milk in the stomach a process of considerable importance in the very young animal
128
Chymosinmakes the milk into ldquocheeserdquohalfway between liquid and solidstomach empties in 60 minutes
milk
129
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
FEEDBACK LOOPS
130
EVIDENCE FORFEEDING FREQUENCY
Edmond 2006 131
Breastfeeding and motherrsquos milkStrong and consistent evidence 132
23
Cup feeding versus bottle feedingCup feeding higher breastfeeding
greater stability133
Only case series Insufficient evidence
No mention of
stomach capacity134
EVIDENCE FORSTOMACH CAPACITY
Edmond 2006 135
0
05
1
15
2
25
3
35
4
0 10 20 30 40 50 60 70 80
volume ingested
fee
din
g f
req
ue
nc
y
Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml
StandardCARE3 hourlyschedule
136
KEY QUESTION
WHAT IS THE
STOMACHVOLUMEOF THE
NEONATE 137 Sase 2005
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
(Alliot) pressure)151
PROPOSAL
The CAPACITY of aweek old babyrsquos stomach is
approx 20 ml152
0
05
1
15
2
25
3
35
4
0 10 20 30 40 50 60 70 80
volume ingested
fee
din
g f
req
ue
nc
y
Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml
StandardCARE3 hourlyschedule
MOTHERNATURE
1 hourlyschedule
153
PHYSIOLOGICAL CAPACITY
RECEPTIVE CAPACITY of stomach
INGESTIVE CAPACITY of BABY
FUNCTIONAL CAPACITY
154
PROPOSAL
The FEEDINGFREQUENCY of theNEONATE is
approx 60 min155
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
BRAIN CYCLING
STOMACH FILLING amp EMPTYING
REMNR1NR2NR3NR4
156
27
Normal physiology of theEnteric Nervous System
ldquoSmall and frequent feeds according to the sleep cyclerdquo
The ldquonicherdquo (occupation) of a neonate (Alberts)
BOND FEED
SLEEP SLEEP
PLAY FEED
157
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
FEEDING SUCKLING
Influence of SMELL None Totally dependent
Motor mechanism Chewing ndash different
muscles
Suckling ndash different circuits
INSULIN Increases weight No effect
GHRELIN Increases weight No effect
LEPTIN Decreases intake No effect
CHOLECYSTOKININ Decreases intake No effect
AMPHETAMINE Decreases appetite Increases suckling
SEROTONIN Agonist improves feeding Antagonist improves suck
SATIETY Infant determined Maternal supply determine
FEEDING SUCKLING
Influence of SMELL None Totally dependent
Motor mechanism Chewing ndash different
muscles
Suckling ndash different circuits
INSULIN Increases weight No effect
GHRELIN Increases weight No effect
LEPTIN Decreases intake No effect
CHOLECYSTOKININ Decreases intake No effect
AMPHETAMINE Decreases appetite Increases suckling
SEROTONIN Agonist improves feeding Antagonist improves suck
SATIETY Infant determined Maternal supply determine
Current dogmaTHE BABY KNOWS
WHEN IT HAS HAD ENOUGH
PROBABLY NOT
WHAT IS THE
STOMACH VOLUME OF THE
PREMATURE
161
Assume low resilience
Assume proportionality
162
28
The CAPACITY of alow birthweight premfrom 20ml 3000g
= 0007 x BWt (g)
1kg x 0007 = 7mls2kg x 0007 = 14mls
163
Gastric overfilling syndrome
164
75 ml per feeding ASSUMPTION
IMMATURE OR OVERWHELMED
many aspects of gastrointestinalmotility are immature in the neonate
Zangen S et al Rapid maturation of gastric relaxation in newborns
A balloon in stomachcan fill to 76 mls
What does the stomach ndashwithout a balloon ndashdo to 76 mls
REFLUX PRESUME each feedapproximately 75 mls
GER
bull Sudden outbursts of crying
bull Awakens in pain
bull Related to feedings
bull Not easily comforted
bull ldquoI know baby hurtsrdquo
bull Sour burps throaty noises
bull Best when upright
Clues to GER
Dr W Sears
29
Mitchell 2001
Kerstin Uvnaumls-Moberg
Food in duodenum
AMYLINreleased
Closes pylorus
Duodenumempty
Pylorusopens
ldquoFeed intolerancerdquo hellip hellip or VOLUME intolerance
HYPOGLYCAEMIA
A babies stomach empties in60 minutes
Blood sugarmay fall hellip
after 90 minutes Options
30
METABOLIC ADAPTATION
SSC started in the first 20 minutes after birth
SSC CotBlood glucose (1 hr) 317 256Base excess drop 34 18
(Christenson 1992)0h 1h 2h 3h 4h 2 days
App
roxim
ate
GLUCOSE
SSC Glucose production = Glucose consumption
Separation
SNS stress Glucose consumption INCREASE
PSNS dissociation Glucose production DECREASE
HYPOGLYCEMIA
SSC Cot
Blood glucose (1 hr) 317 256
0h 1h 2h 3h 4h 2 days
App
roxim
ate
GLUCOSE
SSC Glucose production = Glucose consumption
Separation PSNS dissociation
Glucose production DECREASE
HYPOGLYCEMIA
SSC Cot
Blood glucose (1 hr) 317 256
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
NEURODEVELOPMENTThe DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
BONDING ATTACHMENT
MRI HRVEEG
STRESS RESPONES
RESILIENCE
DOHAD
(MAL) ADAPTATION
EPIGENETICS
GENE X ENVIRONMENT
GENETIC VARIANTS
HOSPITAL ACQUIRED INFECTIONIMMUNITY
SLEEP PHYSIOLOGY
GUT FUNCTIONMICROBIOTA
ldquoSTABILITYrdquo
TRANSITION
LONG TERM FOLLOW-UP
NEUROENDOCRINE BEHAVIOURS
MATERNAL NEUROPLASTICITY
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
MORTALITYMETABOLISM
0h 1h 2h 3h 4h
PSNS (vagal)
App
roxim
ate
GLUCOSE
1 HOURLY Milk feed
1 HOURLY Milk feed
1 HOURLY Milk feed
1 HOURLY Milk feed
LACTOSE
METABOLISM
31
0h 1h 2h 3h 4h
PSNS (vagal) SYMPATHETIC STRESS
App
roxim
ate
GLUCOSE
LACTOSE FATGLYCOGEN
METABOLISM
4 HOURLY Milk feed
0h 1h 2h 3h 4h
PSNS (vagal) SYMPATHETIC STRESS
App
roxim
ate
GLUCOSE
4 HOURLY ALLOSTATIC STATELACTOSE FATGLYCOGEN
METABOLISM
4 HOURLY Milk feed
HEALTH DISEASE
EXPECTED UNEXPECTED
NEURODEVELOPMENTThe DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
BONDING ATTACHMENT
MRI HRVEEG
STRESS RESPONES
RESILIENCE
DOHAD
(MAL) ADAPTATION
EPIGENETICS
GENE X ENVIRONMENT
GENETIC VARIANTS
HOSPITAL ACQUIRED INFECTIONIMMUNITY
SLEEP PHYSIOLOGY
GUT FUNCTIONMICROBIOTA
ldquoSTABILITYrdquo
TRANSITION
LONG TERM FOLLOW-UP
NEUROENDOCRINE BEHAVIOURS
MATERNAL NEUROPLASTICITY
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
MORTALITYMETABOLISM
Weight gain 1st week
predicts OBESITYat 30 years
Large volume feedsstretched stomach=
doubled absorptivecapacity as adult
Importance
Programming ndash early life chronic disease
32
RESISTANCE SENSITIVITY
PERCEPTIONSldquoNEUROCEPTIONrdquo
RESPONSESTRESS
ALLOSTATIC STATE
ALLOSTASIS
ANY STRESSPsychologicalNeurological
EndocrineImmune
ALLOSTATIC LOAD
ALLOSTATIC OVERLOAD
WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY
DISEASEHEALTH
RESILIENCE VULNERABILITY
RESISTANCE SENSITIVITY
PERCEPTIONSldquoNEUROCEPTIONrdquo
RESPONSESTRESS
ALLOSTATIC STATE
ALLOSTASIS
ANY STRESSPsychologicalNeurological
EndocrineImmune
ALLOSTATIC LOAD
HEALTH
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
Gastric overfilling syndrome
189
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
33
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
Only case series Insufficient evidence
No mention of
stomach capacity196
Baby weight freq reqrsquod size actual
2kg baby 4hrly ~ 320 ml6 = 53ml 14ml
15 baby 3hrly ~ 240 ml8 = 30ml 10ml
10 baby 2hrly ~ 160 ml12 = 13ml 7ml
Standardised from20ml capacityfor 3kg baby( x 0007)
197
0
10
20
30
40
50
60
70
80
90
13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w
LINEAR
TERM
PREM
198
34
0
10
20
30
40
50
60
70
80
90
13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w
LINEAR
TERM
PREM
199
Clues to GER
ldquoI know baby hurtsrdquo
Gastric overfilling syndrome
Excessive volumesreflux aspiration colic
Excessive time intervalhypoglycaemia
Adaptationsdiabetic diathesis obesity
200
Developmental Care of the Enteric Nervous System
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
22
Fetal stomach appears 4 weeks GABy 11 weeks wall capable of muscular
contraction
ldquoPatterns of antropyloric motilityin fed healthy preterm infantsrdquo
the neuroregulatory mechanisms responsible for the coordination of antro-pyloric motility and gastric emptying are
well developed by 30 weeks of PMAHassan 2002 127
Hydrochloric acidimportant for activation of pepsinogen
inactivation of microorganisms such as bacteria
Pepsinogenactivated by acid into active pepsin
responsible for the stomachs ability to initiate digestion of proteins
Chymosinis an enzyme whose role is to curdle or
coagulate milk in the stomach a process of considerable importance in the very young animal
128
Chymosinmakes the milk into ldquocheeserdquohalfway between liquid and solidstomach empties in 60 minutes
milk
129
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
FEEDBACK LOOPS
130
EVIDENCE FORFEEDING FREQUENCY
Edmond 2006 131
Breastfeeding and motherrsquos milkStrong and consistent evidence 132
23
Cup feeding versus bottle feedingCup feeding higher breastfeeding
greater stability133
Only case series Insufficient evidence
No mention of
stomach capacity134
EVIDENCE FORSTOMACH CAPACITY
Edmond 2006 135
0
05
1
15
2
25
3
35
4
0 10 20 30 40 50 60 70 80
volume ingested
fee
din
g f
req
ue
nc
y
Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml
StandardCARE3 hourlyschedule
136
KEY QUESTION
WHAT IS THE
STOMACHVOLUMEOF THE
NEONATE 137 Sase 2005
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
(Alliot) pressure)151
PROPOSAL
The CAPACITY of aweek old babyrsquos stomach is
approx 20 ml152
0
05
1
15
2
25
3
35
4
0 10 20 30 40 50 60 70 80
volume ingested
fee
din
g f
req
ue
nc
y
Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml
StandardCARE3 hourlyschedule
MOTHERNATURE
1 hourlyschedule
153
PHYSIOLOGICAL CAPACITY
RECEPTIVE CAPACITY of stomach
INGESTIVE CAPACITY of BABY
FUNCTIONAL CAPACITY
154
PROPOSAL
The FEEDINGFREQUENCY of theNEONATE is
approx 60 min155
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
BRAIN CYCLING
STOMACH FILLING amp EMPTYING
REMNR1NR2NR3NR4
156
27
Normal physiology of theEnteric Nervous System
ldquoSmall and frequent feeds according to the sleep cyclerdquo
The ldquonicherdquo (occupation) of a neonate (Alberts)
BOND FEED
SLEEP SLEEP
PLAY FEED
157
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
FEEDING SUCKLING
Influence of SMELL None Totally dependent
Motor mechanism Chewing ndash different
muscles
Suckling ndash different circuits
INSULIN Increases weight No effect
GHRELIN Increases weight No effect
LEPTIN Decreases intake No effect
CHOLECYSTOKININ Decreases intake No effect
AMPHETAMINE Decreases appetite Increases suckling
SEROTONIN Agonist improves feeding Antagonist improves suck
SATIETY Infant determined Maternal supply determine
FEEDING SUCKLING
Influence of SMELL None Totally dependent
Motor mechanism Chewing ndash different
muscles
Suckling ndash different circuits
INSULIN Increases weight No effect
GHRELIN Increases weight No effect
LEPTIN Decreases intake No effect
CHOLECYSTOKININ Decreases intake No effect
AMPHETAMINE Decreases appetite Increases suckling
SEROTONIN Agonist improves feeding Antagonist improves suck
SATIETY Infant determined Maternal supply determine
Current dogmaTHE BABY KNOWS
WHEN IT HAS HAD ENOUGH
PROBABLY NOT
WHAT IS THE
STOMACH VOLUME OF THE
PREMATURE
161
Assume low resilience
Assume proportionality
162
28
The CAPACITY of alow birthweight premfrom 20ml 3000g
= 0007 x BWt (g)
1kg x 0007 = 7mls2kg x 0007 = 14mls
163
Gastric overfilling syndrome
164
75 ml per feeding ASSUMPTION
IMMATURE OR OVERWHELMED
many aspects of gastrointestinalmotility are immature in the neonate
Zangen S et al Rapid maturation of gastric relaxation in newborns
A balloon in stomachcan fill to 76 mls
What does the stomach ndashwithout a balloon ndashdo to 76 mls
REFLUX PRESUME each feedapproximately 75 mls
GER
bull Sudden outbursts of crying
bull Awakens in pain
bull Related to feedings
bull Not easily comforted
bull ldquoI know baby hurtsrdquo
bull Sour burps throaty noises
bull Best when upright
Clues to GER
Dr W Sears
29
Mitchell 2001
Kerstin Uvnaumls-Moberg
Food in duodenum
AMYLINreleased
Closes pylorus
Duodenumempty
Pylorusopens
ldquoFeed intolerancerdquo hellip hellip or VOLUME intolerance
HYPOGLYCAEMIA
A babies stomach empties in60 minutes
Blood sugarmay fall hellip
after 90 minutes Options
30
METABOLIC ADAPTATION
SSC started in the first 20 minutes after birth
SSC CotBlood glucose (1 hr) 317 256Base excess drop 34 18
(Christenson 1992)0h 1h 2h 3h 4h 2 days
App
roxim
ate
GLUCOSE
SSC Glucose production = Glucose consumption
Separation
SNS stress Glucose consumption INCREASE
PSNS dissociation Glucose production DECREASE
HYPOGLYCEMIA
SSC Cot
Blood glucose (1 hr) 317 256
0h 1h 2h 3h 4h 2 days
App
roxim
ate
GLUCOSE
SSC Glucose production = Glucose consumption
Separation PSNS dissociation
Glucose production DECREASE
HYPOGLYCEMIA
SSC Cot
Blood glucose (1 hr) 317 256
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
NEURODEVELOPMENTThe DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
BONDING ATTACHMENT
MRI HRVEEG
STRESS RESPONES
RESILIENCE
DOHAD
(MAL) ADAPTATION
EPIGENETICS
GENE X ENVIRONMENT
GENETIC VARIANTS
HOSPITAL ACQUIRED INFECTIONIMMUNITY
SLEEP PHYSIOLOGY
GUT FUNCTIONMICROBIOTA
ldquoSTABILITYrdquo
TRANSITION
LONG TERM FOLLOW-UP
NEUROENDOCRINE BEHAVIOURS
MATERNAL NEUROPLASTICITY
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
MORTALITYMETABOLISM
0h 1h 2h 3h 4h
PSNS (vagal)
App
roxim
ate
GLUCOSE
1 HOURLY Milk feed
1 HOURLY Milk feed
1 HOURLY Milk feed
1 HOURLY Milk feed
LACTOSE
METABOLISM
31
0h 1h 2h 3h 4h
PSNS (vagal) SYMPATHETIC STRESS
App
roxim
ate
GLUCOSE
LACTOSE FATGLYCOGEN
METABOLISM
4 HOURLY Milk feed
0h 1h 2h 3h 4h
PSNS (vagal) SYMPATHETIC STRESS
App
roxim
ate
GLUCOSE
4 HOURLY ALLOSTATIC STATELACTOSE FATGLYCOGEN
METABOLISM
4 HOURLY Milk feed
HEALTH DISEASE
EXPECTED UNEXPECTED
NEURODEVELOPMENTThe DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
BONDING ATTACHMENT
MRI HRVEEG
STRESS RESPONES
RESILIENCE
DOHAD
(MAL) ADAPTATION
EPIGENETICS
GENE X ENVIRONMENT
GENETIC VARIANTS
HOSPITAL ACQUIRED INFECTIONIMMUNITY
SLEEP PHYSIOLOGY
GUT FUNCTIONMICROBIOTA
ldquoSTABILITYrdquo
TRANSITION
LONG TERM FOLLOW-UP
NEUROENDOCRINE BEHAVIOURS
MATERNAL NEUROPLASTICITY
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
MORTALITYMETABOLISM
Weight gain 1st week
predicts OBESITYat 30 years
Large volume feedsstretched stomach=
doubled absorptivecapacity as adult
Importance
Programming ndash early life chronic disease
32
RESISTANCE SENSITIVITY
PERCEPTIONSldquoNEUROCEPTIONrdquo
RESPONSESTRESS
ALLOSTATIC STATE
ALLOSTASIS
ANY STRESSPsychologicalNeurological
EndocrineImmune
ALLOSTATIC LOAD
ALLOSTATIC OVERLOAD
WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY
DISEASEHEALTH
RESILIENCE VULNERABILITY
RESISTANCE SENSITIVITY
PERCEPTIONSldquoNEUROCEPTIONrdquo
RESPONSESTRESS
ALLOSTATIC STATE
ALLOSTASIS
ANY STRESSPsychologicalNeurological
EndocrineImmune
ALLOSTATIC LOAD
HEALTH
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
Gastric overfilling syndrome
189
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
33
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
Only case series Insufficient evidence
No mention of
stomach capacity196
Baby weight freq reqrsquod size actual
2kg baby 4hrly ~ 320 ml6 = 53ml 14ml
15 baby 3hrly ~ 240 ml8 = 30ml 10ml
10 baby 2hrly ~ 160 ml12 = 13ml 7ml
Standardised from20ml capacityfor 3kg baby( x 0007)
197
0
10
20
30
40
50
60
70
80
90
13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w
LINEAR
TERM
PREM
198
34
0
10
20
30
40
50
60
70
80
90
13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w
LINEAR
TERM
PREM
199
Clues to GER
ldquoI know baby hurtsrdquo
Gastric overfilling syndrome
Excessive volumesreflux aspiration colic
Excessive time intervalhypoglycaemia
Adaptationsdiabetic diathesis obesity
200
Developmental Care of the Enteric Nervous System
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
23
Cup feeding versus bottle feedingCup feeding higher breastfeeding
greater stability133
Only case series Insufficient evidence
No mention of
stomach capacity134
EVIDENCE FORSTOMACH CAPACITY
Edmond 2006 135
0
05
1
15
2
25
3
35
4
0 10 20 30 40 50 60 70 80
volume ingested
fee
din
g f
req
ue
nc
y
Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml
StandardCARE3 hourlyschedule
136
KEY QUESTION
WHAT IS THE
STOMACHVOLUMEOF THE
NEONATE 137 Sase 2005
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
(Alliot) pressure)151
PROPOSAL
The CAPACITY of aweek old babyrsquos stomach is
approx 20 ml152
0
05
1
15
2
25
3
35
4
0 10 20 30 40 50 60 70 80
volume ingested
fee
din
g f
req
ue
nc
y
Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml
StandardCARE3 hourlyschedule
MOTHERNATURE
1 hourlyschedule
153
PHYSIOLOGICAL CAPACITY
RECEPTIVE CAPACITY of stomach
INGESTIVE CAPACITY of BABY
FUNCTIONAL CAPACITY
154
PROPOSAL
The FEEDINGFREQUENCY of theNEONATE is
approx 60 min155
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
BRAIN CYCLING
STOMACH FILLING amp EMPTYING
REMNR1NR2NR3NR4
156
27
Normal physiology of theEnteric Nervous System
ldquoSmall and frequent feeds according to the sleep cyclerdquo
The ldquonicherdquo (occupation) of a neonate (Alberts)
BOND FEED
SLEEP SLEEP
PLAY FEED
157
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
FEEDING SUCKLING
Influence of SMELL None Totally dependent
Motor mechanism Chewing ndash different
muscles
Suckling ndash different circuits
INSULIN Increases weight No effect
GHRELIN Increases weight No effect
LEPTIN Decreases intake No effect
CHOLECYSTOKININ Decreases intake No effect
AMPHETAMINE Decreases appetite Increases suckling
SEROTONIN Agonist improves feeding Antagonist improves suck
SATIETY Infant determined Maternal supply determine
FEEDING SUCKLING
Influence of SMELL None Totally dependent
Motor mechanism Chewing ndash different
muscles
Suckling ndash different circuits
INSULIN Increases weight No effect
GHRELIN Increases weight No effect
LEPTIN Decreases intake No effect
CHOLECYSTOKININ Decreases intake No effect
AMPHETAMINE Decreases appetite Increases suckling
SEROTONIN Agonist improves feeding Antagonist improves suck
SATIETY Infant determined Maternal supply determine
Current dogmaTHE BABY KNOWS
WHEN IT HAS HAD ENOUGH
PROBABLY NOT
WHAT IS THE
STOMACH VOLUME OF THE
PREMATURE
161
Assume low resilience
Assume proportionality
162
28
The CAPACITY of alow birthweight premfrom 20ml 3000g
= 0007 x BWt (g)
1kg x 0007 = 7mls2kg x 0007 = 14mls
163
Gastric overfilling syndrome
164
75 ml per feeding ASSUMPTION
IMMATURE OR OVERWHELMED
many aspects of gastrointestinalmotility are immature in the neonate
Zangen S et al Rapid maturation of gastric relaxation in newborns
A balloon in stomachcan fill to 76 mls
What does the stomach ndashwithout a balloon ndashdo to 76 mls
REFLUX PRESUME each feedapproximately 75 mls
GER
bull Sudden outbursts of crying
bull Awakens in pain
bull Related to feedings
bull Not easily comforted
bull ldquoI know baby hurtsrdquo
bull Sour burps throaty noises
bull Best when upright
Clues to GER
Dr W Sears
29
Mitchell 2001
Kerstin Uvnaumls-Moberg
Food in duodenum
AMYLINreleased
Closes pylorus
Duodenumempty
Pylorusopens
ldquoFeed intolerancerdquo hellip hellip or VOLUME intolerance
HYPOGLYCAEMIA
A babies stomach empties in60 minutes
Blood sugarmay fall hellip
after 90 minutes Options
30
METABOLIC ADAPTATION
SSC started in the first 20 minutes after birth
SSC CotBlood glucose (1 hr) 317 256Base excess drop 34 18
(Christenson 1992)0h 1h 2h 3h 4h 2 days
App
roxim
ate
GLUCOSE
SSC Glucose production = Glucose consumption
Separation
SNS stress Glucose consumption INCREASE
PSNS dissociation Glucose production DECREASE
HYPOGLYCEMIA
SSC Cot
Blood glucose (1 hr) 317 256
0h 1h 2h 3h 4h 2 days
App
roxim
ate
GLUCOSE
SSC Glucose production = Glucose consumption
Separation PSNS dissociation
Glucose production DECREASE
HYPOGLYCEMIA
SSC Cot
Blood glucose (1 hr) 317 256
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
NEURODEVELOPMENTThe DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
BONDING ATTACHMENT
MRI HRVEEG
STRESS RESPONES
RESILIENCE
DOHAD
(MAL) ADAPTATION
EPIGENETICS
GENE X ENVIRONMENT
GENETIC VARIANTS
HOSPITAL ACQUIRED INFECTIONIMMUNITY
SLEEP PHYSIOLOGY
GUT FUNCTIONMICROBIOTA
ldquoSTABILITYrdquo
TRANSITION
LONG TERM FOLLOW-UP
NEUROENDOCRINE BEHAVIOURS
MATERNAL NEUROPLASTICITY
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
MORTALITYMETABOLISM
0h 1h 2h 3h 4h
PSNS (vagal)
App
roxim
ate
GLUCOSE
1 HOURLY Milk feed
1 HOURLY Milk feed
1 HOURLY Milk feed
1 HOURLY Milk feed
LACTOSE
METABOLISM
31
0h 1h 2h 3h 4h
PSNS (vagal) SYMPATHETIC STRESS
App
roxim
ate
GLUCOSE
LACTOSE FATGLYCOGEN
METABOLISM
4 HOURLY Milk feed
0h 1h 2h 3h 4h
PSNS (vagal) SYMPATHETIC STRESS
App
roxim
ate
GLUCOSE
4 HOURLY ALLOSTATIC STATELACTOSE FATGLYCOGEN
METABOLISM
4 HOURLY Milk feed
HEALTH DISEASE
EXPECTED UNEXPECTED
NEURODEVELOPMENTThe DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
BONDING ATTACHMENT
MRI HRVEEG
STRESS RESPONES
RESILIENCE
DOHAD
(MAL) ADAPTATION
EPIGENETICS
GENE X ENVIRONMENT
GENETIC VARIANTS
HOSPITAL ACQUIRED INFECTIONIMMUNITY
SLEEP PHYSIOLOGY
GUT FUNCTIONMICROBIOTA
ldquoSTABILITYrdquo
TRANSITION
LONG TERM FOLLOW-UP
NEUROENDOCRINE BEHAVIOURS
MATERNAL NEUROPLASTICITY
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
MORTALITYMETABOLISM
Weight gain 1st week
predicts OBESITYat 30 years
Large volume feedsstretched stomach=
doubled absorptivecapacity as adult
Importance
Programming ndash early life chronic disease
32
RESISTANCE SENSITIVITY
PERCEPTIONSldquoNEUROCEPTIONrdquo
RESPONSESTRESS
ALLOSTATIC STATE
ALLOSTASIS
ANY STRESSPsychologicalNeurological
EndocrineImmune
ALLOSTATIC LOAD
ALLOSTATIC OVERLOAD
WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY
DISEASEHEALTH
RESILIENCE VULNERABILITY
RESISTANCE SENSITIVITY
PERCEPTIONSldquoNEUROCEPTIONrdquo
RESPONSESTRESS
ALLOSTATIC STATE
ALLOSTASIS
ANY STRESSPsychologicalNeurological
EndocrineImmune
ALLOSTATIC LOAD
HEALTH
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
Gastric overfilling syndrome
189
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
33
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
Only case series Insufficient evidence
No mention of
stomach capacity196
Baby weight freq reqrsquod size actual
2kg baby 4hrly ~ 320 ml6 = 53ml 14ml
15 baby 3hrly ~ 240 ml8 = 30ml 10ml
10 baby 2hrly ~ 160 ml12 = 13ml 7ml
Standardised from20ml capacityfor 3kg baby( x 0007)
197
0
10
20
30
40
50
60
70
80
90
13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w
LINEAR
TERM
PREM
198
34
0
10
20
30
40
50
60
70
80
90
13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w
LINEAR
TERM
PREM
199
Clues to GER
ldquoI know baby hurtsrdquo
Gastric overfilling syndrome
Excessive volumesreflux aspiration colic
Excessive time intervalhypoglycaemia
Adaptationsdiabetic diathesis obesity
200
Developmental Care of the Enteric Nervous System
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
(Alliot) pressure)151
PROPOSAL
The CAPACITY of aweek old babyrsquos stomach is
approx 20 ml152
0
05
1
15
2
25
3
35
4
0 10 20 30 40 50 60 70 80
volume ingested
fee
din
g f
req
ue
nc
y
Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml
StandardCARE3 hourlyschedule
MOTHERNATURE
1 hourlyschedule
153
PHYSIOLOGICAL CAPACITY
RECEPTIVE CAPACITY of stomach
INGESTIVE CAPACITY of BABY
FUNCTIONAL CAPACITY
154
PROPOSAL
The FEEDINGFREQUENCY of theNEONATE is
approx 60 min155
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
BRAIN CYCLING
STOMACH FILLING amp EMPTYING
REMNR1NR2NR3NR4
156
27
Normal physiology of theEnteric Nervous System
ldquoSmall and frequent feeds according to the sleep cyclerdquo
The ldquonicherdquo (occupation) of a neonate (Alberts)
BOND FEED
SLEEP SLEEP
PLAY FEED
157
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
FEEDING SUCKLING
Influence of SMELL None Totally dependent
Motor mechanism Chewing ndash different
muscles
Suckling ndash different circuits
INSULIN Increases weight No effect
GHRELIN Increases weight No effect
LEPTIN Decreases intake No effect
CHOLECYSTOKININ Decreases intake No effect
AMPHETAMINE Decreases appetite Increases suckling
SEROTONIN Agonist improves feeding Antagonist improves suck
SATIETY Infant determined Maternal supply determine
FEEDING SUCKLING
Influence of SMELL None Totally dependent
Motor mechanism Chewing ndash different
muscles
Suckling ndash different circuits
INSULIN Increases weight No effect
GHRELIN Increases weight No effect
LEPTIN Decreases intake No effect
CHOLECYSTOKININ Decreases intake No effect
AMPHETAMINE Decreases appetite Increases suckling
SEROTONIN Agonist improves feeding Antagonist improves suck
SATIETY Infant determined Maternal supply determine
Current dogmaTHE BABY KNOWS
WHEN IT HAS HAD ENOUGH
PROBABLY NOT
WHAT IS THE
STOMACH VOLUME OF THE
PREMATURE
161
Assume low resilience
Assume proportionality
162
28
The CAPACITY of alow birthweight premfrom 20ml 3000g
= 0007 x BWt (g)
1kg x 0007 = 7mls2kg x 0007 = 14mls
163
Gastric overfilling syndrome
164
75 ml per feeding ASSUMPTION
IMMATURE OR OVERWHELMED
many aspects of gastrointestinalmotility are immature in the neonate
Zangen S et al Rapid maturation of gastric relaxation in newborns
A balloon in stomachcan fill to 76 mls
What does the stomach ndashwithout a balloon ndashdo to 76 mls
REFLUX PRESUME each feedapproximately 75 mls
GER
bull Sudden outbursts of crying
bull Awakens in pain
bull Related to feedings
bull Not easily comforted
bull ldquoI know baby hurtsrdquo
bull Sour burps throaty noises
bull Best when upright
Clues to GER
Dr W Sears
29
Mitchell 2001
Kerstin Uvnaumls-Moberg
Food in duodenum
AMYLINreleased
Closes pylorus
Duodenumempty
Pylorusopens
ldquoFeed intolerancerdquo hellip hellip or VOLUME intolerance
HYPOGLYCAEMIA
A babies stomach empties in60 minutes
Blood sugarmay fall hellip
after 90 minutes Options
30
METABOLIC ADAPTATION
SSC started in the first 20 minutes after birth
SSC CotBlood glucose (1 hr) 317 256Base excess drop 34 18
(Christenson 1992)0h 1h 2h 3h 4h 2 days
App
roxim
ate
GLUCOSE
SSC Glucose production = Glucose consumption
Separation
SNS stress Glucose consumption INCREASE
PSNS dissociation Glucose production DECREASE
HYPOGLYCEMIA
SSC Cot
Blood glucose (1 hr) 317 256
0h 1h 2h 3h 4h 2 days
App
roxim
ate
GLUCOSE
SSC Glucose production = Glucose consumption
Separation PSNS dissociation
Glucose production DECREASE
HYPOGLYCEMIA
SSC Cot
Blood glucose (1 hr) 317 256
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
NEURODEVELOPMENTThe DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
BONDING ATTACHMENT
MRI HRVEEG
STRESS RESPONES
RESILIENCE
DOHAD
(MAL) ADAPTATION
EPIGENETICS
GENE X ENVIRONMENT
GENETIC VARIANTS
HOSPITAL ACQUIRED INFECTIONIMMUNITY
SLEEP PHYSIOLOGY
GUT FUNCTIONMICROBIOTA
ldquoSTABILITYrdquo
TRANSITION
LONG TERM FOLLOW-UP
NEUROENDOCRINE BEHAVIOURS
MATERNAL NEUROPLASTICITY
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
MORTALITYMETABOLISM
0h 1h 2h 3h 4h
PSNS (vagal)
App
roxim
ate
GLUCOSE
1 HOURLY Milk feed
1 HOURLY Milk feed
1 HOURLY Milk feed
1 HOURLY Milk feed
LACTOSE
METABOLISM
31
0h 1h 2h 3h 4h
PSNS (vagal) SYMPATHETIC STRESS
App
roxim
ate
GLUCOSE
LACTOSE FATGLYCOGEN
METABOLISM
4 HOURLY Milk feed
0h 1h 2h 3h 4h
PSNS (vagal) SYMPATHETIC STRESS
App
roxim
ate
GLUCOSE
4 HOURLY ALLOSTATIC STATELACTOSE FATGLYCOGEN
METABOLISM
4 HOURLY Milk feed
HEALTH DISEASE
EXPECTED UNEXPECTED
NEURODEVELOPMENTThe DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
BONDING ATTACHMENT
MRI HRVEEG
STRESS RESPONES
RESILIENCE
DOHAD
(MAL) ADAPTATION
EPIGENETICS
GENE X ENVIRONMENT
GENETIC VARIANTS
HOSPITAL ACQUIRED INFECTIONIMMUNITY
SLEEP PHYSIOLOGY
GUT FUNCTIONMICROBIOTA
ldquoSTABILITYrdquo
TRANSITION
LONG TERM FOLLOW-UP
NEUROENDOCRINE BEHAVIOURS
MATERNAL NEUROPLASTICITY
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
MORTALITYMETABOLISM
Weight gain 1st week
predicts OBESITYat 30 years
Large volume feedsstretched stomach=
doubled absorptivecapacity as adult
Importance
Programming ndash early life chronic disease
32
RESISTANCE SENSITIVITY
PERCEPTIONSldquoNEUROCEPTIONrdquo
RESPONSESTRESS
ALLOSTATIC STATE
ALLOSTASIS
ANY STRESSPsychologicalNeurological
EndocrineImmune
ALLOSTATIC LOAD
ALLOSTATIC OVERLOAD
WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY
DISEASEHEALTH
RESILIENCE VULNERABILITY
RESISTANCE SENSITIVITY
PERCEPTIONSldquoNEUROCEPTIONrdquo
RESPONSESTRESS
ALLOSTATIC STATE
ALLOSTASIS
ANY STRESSPsychologicalNeurological
EndocrineImmune
ALLOSTATIC LOAD
HEALTH
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
Gastric overfilling syndrome
189
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
33
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
Only case series Insufficient evidence
No mention of
stomach capacity196
Baby weight freq reqrsquod size actual
2kg baby 4hrly ~ 320 ml6 = 53ml 14ml
15 baby 3hrly ~ 240 ml8 = 30ml 10ml
10 baby 2hrly ~ 160 ml12 = 13ml 7ml
Standardised from20ml capacityfor 3kg baby( x 0007)
197
0
10
20
30
40
50
60
70
80
90
13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w
LINEAR
TERM
PREM
198
34
0
10
20
30
40
50
60
70
80
90
13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w
LINEAR
TERM
PREM
199
Clues to GER
ldquoI know baby hurtsrdquo
Gastric overfilling syndrome
Excessive volumesreflux aspiration colic
Excessive time intervalhypoglycaemia
Adaptationsdiabetic diathesis obesity
200
Developmental Care of the Enteric Nervous System
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
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
(Alliot) pressure)151
PROPOSAL
The CAPACITY of aweek old babyrsquos stomach is
approx 20 ml152
0
05
1
15
2
25
3
35
4
0 10 20 30 40 50 60 70 80
volume ingested
fee
din
g f
req
ue
nc
y
Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml
StandardCARE3 hourlyschedule
MOTHERNATURE
1 hourlyschedule
153
PHYSIOLOGICAL CAPACITY
RECEPTIVE CAPACITY of stomach
INGESTIVE CAPACITY of BABY
FUNCTIONAL CAPACITY
154
PROPOSAL
The FEEDINGFREQUENCY of theNEONATE is
approx 60 min155
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
BRAIN CYCLING
STOMACH FILLING amp EMPTYING
REMNR1NR2NR3NR4
156
27
Normal physiology of theEnteric Nervous System
ldquoSmall and frequent feeds according to the sleep cyclerdquo
The ldquonicherdquo (occupation) of a neonate (Alberts)
BOND FEED
SLEEP SLEEP
PLAY FEED
157
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
FEEDING SUCKLING
Influence of SMELL None Totally dependent
Motor mechanism Chewing ndash different
muscles
Suckling ndash different circuits
INSULIN Increases weight No effect
GHRELIN Increases weight No effect
LEPTIN Decreases intake No effect
CHOLECYSTOKININ Decreases intake No effect
AMPHETAMINE Decreases appetite Increases suckling
SEROTONIN Agonist improves feeding Antagonist improves suck
SATIETY Infant determined Maternal supply determine
FEEDING SUCKLING
Influence of SMELL None Totally dependent
Motor mechanism Chewing ndash different
muscles
Suckling ndash different circuits
INSULIN Increases weight No effect
GHRELIN Increases weight No effect
LEPTIN Decreases intake No effect
CHOLECYSTOKININ Decreases intake No effect
AMPHETAMINE Decreases appetite Increases suckling
SEROTONIN Agonist improves feeding Antagonist improves suck
SATIETY Infant determined Maternal supply determine
Current dogmaTHE BABY KNOWS
WHEN IT HAS HAD ENOUGH
PROBABLY NOT
WHAT IS THE
STOMACH VOLUME OF THE
PREMATURE
161
Assume low resilience
Assume proportionality
162
28
The CAPACITY of alow birthweight premfrom 20ml 3000g
= 0007 x BWt (g)
1kg x 0007 = 7mls2kg x 0007 = 14mls
163
Gastric overfilling syndrome
164
75 ml per feeding ASSUMPTION
IMMATURE OR OVERWHELMED
many aspects of gastrointestinalmotility are immature in the neonate
Zangen S et al Rapid maturation of gastric relaxation in newborns
A balloon in stomachcan fill to 76 mls
What does the stomach ndashwithout a balloon ndashdo to 76 mls
REFLUX PRESUME each feedapproximately 75 mls
GER
bull Sudden outbursts of crying
bull Awakens in pain
bull Related to feedings
bull Not easily comforted
bull ldquoI know baby hurtsrdquo
bull Sour burps throaty noises
bull Best when upright
Clues to GER
Dr W Sears
29
Mitchell 2001
Kerstin Uvnaumls-Moberg
Food in duodenum
AMYLINreleased
Closes pylorus
Duodenumempty
Pylorusopens
ldquoFeed intolerancerdquo hellip hellip or VOLUME intolerance
HYPOGLYCAEMIA
A babies stomach empties in60 minutes
Blood sugarmay fall hellip
after 90 minutes Options
30
METABOLIC ADAPTATION
SSC started in the first 20 minutes after birth
SSC CotBlood glucose (1 hr) 317 256Base excess drop 34 18
(Christenson 1992)0h 1h 2h 3h 4h 2 days
App
roxim
ate
GLUCOSE
SSC Glucose production = Glucose consumption
Separation
SNS stress Glucose consumption INCREASE
PSNS dissociation Glucose production DECREASE
HYPOGLYCEMIA
SSC Cot
Blood glucose (1 hr) 317 256
0h 1h 2h 3h 4h 2 days
App
roxim
ate
GLUCOSE
SSC Glucose production = Glucose consumption
Separation PSNS dissociation
Glucose production DECREASE
HYPOGLYCEMIA
SSC Cot
Blood glucose (1 hr) 317 256
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
NEURODEVELOPMENTThe DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
BONDING ATTACHMENT
MRI HRVEEG
STRESS RESPONES
RESILIENCE
DOHAD
(MAL) ADAPTATION
EPIGENETICS
GENE X ENVIRONMENT
GENETIC VARIANTS
HOSPITAL ACQUIRED INFECTIONIMMUNITY
SLEEP PHYSIOLOGY
GUT FUNCTIONMICROBIOTA
ldquoSTABILITYrdquo
TRANSITION
LONG TERM FOLLOW-UP
NEUROENDOCRINE BEHAVIOURS
MATERNAL NEUROPLASTICITY
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
MORTALITYMETABOLISM
0h 1h 2h 3h 4h
PSNS (vagal)
App
roxim
ate
GLUCOSE
1 HOURLY Milk feed
1 HOURLY Milk feed
1 HOURLY Milk feed
1 HOURLY Milk feed
LACTOSE
METABOLISM
31
0h 1h 2h 3h 4h
PSNS (vagal) SYMPATHETIC STRESS
App
roxim
ate
GLUCOSE
LACTOSE FATGLYCOGEN
METABOLISM
4 HOURLY Milk feed
0h 1h 2h 3h 4h
PSNS (vagal) SYMPATHETIC STRESS
App
roxim
ate
GLUCOSE
4 HOURLY ALLOSTATIC STATELACTOSE FATGLYCOGEN
METABOLISM
4 HOURLY Milk feed
HEALTH DISEASE
EXPECTED UNEXPECTED
NEURODEVELOPMENTThe DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
BONDING ATTACHMENT
MRI HRVEEG
STRESS RESPONES
RESILIENCE
DOHAD
(MAL) ADAPTATION
EPIGENETICS
GENE X ENVIRONMENT
GENETIC VARIANTS
HOSPITAL ACQUIRED INFECTIONIMMUNITY
SLEEP PHYSIOLOGY
GUT FUNCTIONMICROBIOTA
ldquoSTABILITYrdquo
TRANSITION
LONG TERM FOLLOW-UP
NEUROENDOCRINE BEHAVIOURS
MATERNAL NEUROPLASTICITY
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
MORTALITYMETABOLISM
Weight gain 1st week
predicts OBESITYat 30 years
Large volume feedsstretched stomach=
doubled absorptivecapacity as adult
Importance
Programming ndash early life chronic disease
32
RESISTANCE SENSITIVITY
PERCEPTIONSldquoNEUROCEPTIONrdquo
RESPONSESTRESS
ALLOSTATIC STATE
ALLOSTASIS
ANY STRESSPsychologicalNeurological
EndocrineImmune
ALLOSTATIC LOAD
ALLOSTATIC OVERLOAD
WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY
DISEASEHEALTH
RESILIENCE VULNERABILITY
RESISTANCE SENSITIVITY
PERCEPTIONSldquoNEUROCEPTIONrdquo
RESPONSESTRESS
ALLOSTATIC STATE
ALLOSTASIS
ANY STRESSPsychologicalNeurological
EndocrineImmune
ALLOSTATIC LOAD
HEALTH
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
Gastric overfilling syndrome
189
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
33
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
Only case series Insufficient evidence
No mention of
stomach capacity196
Baby weight freq reqrsquod size actual
2kg baby 4hrly ~ 320 ml6 = 53ml 14ml
15 baby 3hrly ~ 240 ml8 = 30ml 10ml
10 baby 2hrly ~ 160 ml12 = 13ml 7ml
Standardised from20ml capacityfor 3kg baby( x 0007)
197
0
10
20
30
40
50
60
70
80
90
13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w
LINEAR
TERM
PREM
198
34
0
10
20
30
40
50
60
70
80
90
13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w
LINEAR
TERM
PREM
199
Clues to GER
ldquoI know baby hurtsrdquo
Gastric overfilling syndrome
Excessive volumesreflux aspiration colic
Excessive time intervalhypoglycaemia
Adaptationsdiabetic diathesis obesity
200
Developmental Care of the Enteric Nervous System
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
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
(Alliot) pressure)151
PROPOSAL
The CAPACITY of aweek old babyrsquos stomach is
approx 20 ml152
0
05
1
15
2
25
3
35
4
0 10 20 30 40 50 60 70 80
volume ingested
fee
din
g f
req
ue
nc
y
Assumption 3kg baby requiring 160 mlkgdaydaily requirement = 480ml
StandardCARE3 hourlyschedule
MOTHERNATURE
1 hourlyschedule
153
PHYSIOLOGICAL CAPACITY
RECEPTIVE CAPACITY of stomach
INGESTIVE CAPACITY of BABY
FUNCTIONAL CAPACITY
154
PROPOSAL
The FEEDINGFREQUENCY of theNEONATE is
approx 60 min155
CEPHALIC PHASEGASTRIC PHASE
INTESTINAL PHASE
BRAIN CYCLING
STOMACH FILLING amp EMPTYING
REMNR1NR2NR3NR4
156
27
Normal physiology of theEnteric Nervous System
ldquoSmall and frequent feeds according to the sleep cyclerdquo
The ldquonicherdquo (occupation) of a neonate (Alberts)
BOND FEED
SLEEP SLEEP
PLAY FEED
157
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
FEEDING SUCKLING
Influence of SMELL None Totally dependent
Motor mechanism Chewing ndash different
muscles
Suckling ndash different circuits
INSULIN Increases weight No effect
GHRELIN Increases weight No effect
LEPTIN Decreases intake No effect
CHOLECYSTOKININ Decreases intake No effect
AMPHETAMINE Decreases appetite Increases suckling
SEROTONIN Agonist improves feeding Antagonist improves suck
SATIETY Infant determined Maternal supply determine
FEEDING SUCKLING
Influence of SMELL None Totally dependent
Motor mechanism Chewing ndash different
muscles
Suckling ndash different circuits
INSULIN Increases weight No effect
GHRELIN Increases weight No effect
LEPTIN Decreases intake No effect
CHOLECYSTOKININ Decreases intake No effect
AMPHETAMINE Decreases appetite Increases suckling
SEROTONIN Agonist improves feeding Antagonist improves suck
SATIETY Infant determined Maternal supply determine
Current dogmaTHE BABY KNOWS
WHEN IT HAS HAD ENOUGH
PROBABLY NOT
WHAT IS THE
STOMACH VOLUME OF THE
PREMATURE
161
Assume low resilience
Assume proportionality
162
28
The CAPACITY of alow birthweight premfrom 20ml 3000g
= 0007 x BWt (g)
1kg x 0007 = 7mls2kg x 0007 = 14mls
163
Gastric overfilling syndrome
164
75 ml per feeding ASSUMPTION
IMMATURE OR OVERWHELMED
many aspects of gastrointestinalmotility are immature in the neonate
Zangen S et al Rapid maturation of gastric relaxation in newborns
A balloon in stomachcan fill to 76 mls
What does the stomach ndashwithout a balloon ndashdo to 76 mls
REFLUX PRESUME each feedapproximately 75 mls
GER
bull Sudden outbursts of crying
bull Awakens in pain
bull Related to feedings
bull Not easily comforted
bull ldquoI know baby hurtsrdquo
bull Sour burps throaty noises
bull Best when upright
Clues to GER
Dr W Sears
29
Mitchell 2001
Kerstin Uvnaumls-Moberg
Food in duodenum
AMYLINreleased
Closes pylorus
Duodenumempty
Pylorusopens
ldquoFeed intolerancerdquo hellip hellip or VOLUME intolerance
HYPOGLYCAEMIA
A babies stomach empties in60 minutes
Blood sugarmay fall hellip
after 90 minutes Options
30
METABOLIC ADAPTATION
SSC started in the first 20 minutes after birth
SSC CotBlood glucose (1 hr) 317 256Base excess drop 34 18
(Christenson 1992)0h 1h 2h 3h 4h 2 days
App
roxim
ate
GLUCOSE
SSC Glucose production = Glucose consumption
Separation
SNS stress Glucose consumption INCREASE
PSNS dissociation Glucose production DECREASE
HYPOGLYCEMIA
SSC Cot
Blood glucose (1 hr) 317 256
0h 1h 2h 3h 4h 2 days
App
roxim
ate
GLUCOSE
SSC Glucose production = Glucose consumption
Separation PSNS dissociation
Glucose production DECREASE
HYPOGLYCEMIA
SSC Cot
Blood glucose (1 hr) 317 256
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
NEURODEVELOPMENTThe DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
BONDING ATTACHMENT
MRI HRVEEG
STRESS RESPONES
RESILIENCE
DOHAD
(MAL) ADAPTATION
EPIGENETICS
GENE X ENVIRONMENT
GENETIC VARIANTS
HOSPITAL ACQUIRED INFECTIONIMMUNITY
SLEEP PHYSIOLOGY
GUT FUNCTIONMICROBIOTA
ldquoSTABILITYrdquo
TRANSITION
LONG TERM FOLLOW-UP
NEUROENDOCRINE BEHAVIOURS
MATERNAL NEUROPLASTICITY
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
MORTALITYMETABOLISM
0h 1h 2h 3h 4h
PSNS (vagal)
App
roxim
ate
GLUCOSE
1 HOURLY Milk feed
1 HOURLY Milk feed
1 HOURLY Milk feed
1 HOURLY Milk feed
LACTOSE
METABOLISM
31
0h 1h 2h 3h 4h
PSNS (vagal) SYMPATHETIC STRESS
App
roxim
ate
GLUCOSE
LACTOSE FATGLYCOGEN
METABOLISM
4 HOURLY Milk feed
0h 1h 2h 3h 4h
PSNS (vagal) SYMPATHETIC STRESS
App
roxim
ate
GLUCOSE
4 HOURLY ALLOSTATIC STATELACTOSE FATGLYCOGEN
METABOLISM
4 HOURLY Milk feed
HEALTH DISEASE
EXPECTED UNEXPECTED
NEURODEVELOPMENTThe DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
BONDING ATTACHMENT
MRI HRVEEG
STRESS RESPONES
RESILIENCE
DOHAD
(MAL) ADAPTATION
EPIGENETICS
GENE X ENVIRONMENT
GENETIC VARIANTS
HOSPITAL ACQUIRED INFECTIONIMMUNITY
SLEEP PHYSIOLOGY
GUT FUNCTIONMICROBIOTA
ldquoSTABILITYrdquo
TRANSITION
LONG TERM FOLLOW-UP
NEUROENDOCRINE BEHAVIOURS
MATERNAL NEUROPLASTICITY
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
MORTALITYMETABOLISM
Weight gain 1st week
predicts OBESITYat 30 years
Large volume feedsstretched stomach=
doubled absorptivecapacity as adult
Importance
Programming ndash early life chronic disease
32
RESISTANCE SENSITIVITY
PERCEPTIONSldquoNEUROCEPTIONrdquo
RESPONSESTRESS
ALLOSTATIC STATE
ALLOSTASIS
ANY STRESSPsychologicalNeurological
EndocrineImmune
ALLOSTATIC LOAD
ALLOSTATIC OVERLOAD
WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY
DISEASEHEALTH
RESILIENCE VULNERABILITY
RESISTANCE SENSITIVITY
PERCEPTIONSldquoNEUROCEPTIONrdquo
RESPONSESTRESS
ALLOSTATIC STATE
ALLOSTASIS
ANY STRESSPsychologicalNeurological
EndocrineImmune
ALLOSTATIC LOAD
HEALTH
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
Gastric overfilling syndrome
189
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
33
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
Only case series Insufficient evidence
No mention of
stomach capacity196
Baby weight freq reqrsquod size actual
2kg baby 4hrly ~ 320 ml6 = 53ml 14ml
15 baby 3hrly ~ 240 ml8 = 30ml 10ml
10 baby 2hrly ~ 160 ml12 = 13ml 7ml
Standardised from20ml capacityfor 3kg baby( x 0007)
197
0
10
20
30
40
50
60
70
80
90
13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w
LINEAR
TERM
PREM
198
34
0
10
20
30
40
50
60
70
80
90
13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w
LINEAR
TERM
PREM
199
Clues to GER
ldquoI know baby hurtsrdquo
Gastric overfilling syndrome
Excessive volumesreflux aspiration colic
Excessive time intervalhypoglycaemia
Adaptationsdiabetic diathesis obesity
200
Developmental Care of the Enteric Nervous System
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
27
Normal physiology of theEnteric Nervous System
ldquoSmall and frequent feeds according to the sleep cyclerdquo
The ldquonicherdquo (occupation) of a neonate (Alberts)
BOND FEED
SLEEP SLEEP
PLAY FEED
157
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
FEEDING SUCKLING
Influence of SMELL None Totally dependent
Motor mechanism Chewing ndash different
muscles
Suckling ndash different circuits
INSULIN Increases weight No effect
GHRELIN Increases weight No effect
LEPTIN Decreases intake No effect
CHOLECYSTOKININ Decreases intake No effect
AMPHETAMINE Decreases appetite Increases suckling
SEROTONIN Agonist improves feeding Antagonist improves suck
SATIETY Infant determined Maternal supply determine
FEEDING SUCKLING
Influence of SMELL None Totally dependent
Motor mechanism Chewing ndash different
muscles
Suckling ndash different circuits
INSULIN Increases weight No effect
GHRELIN Increases weight No effect
LEPTIN Decreases intake No effect
CHOLECYSTOKININ Decreases intake No effect
AMPHETAMINE Decreases appetite Increases suckling
SEROTONIN Agonist improves feeding Antagonist improves suck
SATIETY Infant determined Maternal supply determine
Current dogmaTHE BABY KNOWS
WHEN IT HAS HAD ENOUGH
PROBABLY NOT
WHAT IS THE
STOMACH VOLUME OF THE
PREMATURE
161
Assume low resilience
Assume proportionality
162
28
The CAPACITY of alow birthweight premfrom 20ml 3000g
= 0007 x BWt (g)
1kg x 0007 = 7mls2kg x 0007 = 14mls
163
Gastric overfilling syndrome
164
75 ml per feeding ASSUMPTION
IMMATURE OR OVERWHELMED
many aspects of gastrointestinalmotility are immature in the neonate
Zangen S et al Rapid maturation of gastric relaxation in newborns
A balloon in stomachcan fill to 76 mls
What does the stomach ndashwithout a balloon ndashdo to 76 mls
REFLUX PRESUME each feedapproximately 75 mls
GER
bull Sudden outbursts of crying
bull Awakens in pain
bull Related to feedings
bull Not easily comforted
bull ldquoI know baby hurtsrdquo
bull Sour burps throaty noises
bull Best when upright
Clues to GER
Dr W Sears
29
Mitchell 2001
Kerstin Uvnaumls-Moberg
Food in duodenum
AMYLINreleased
Closes pylorus
Duodenumempty
Pylorusopens
ldquoFeed intolerancerdquo hellip hellip or VOLUME intolerance
HYPOGLYCAEMIA
A babies stomach empties in60 minutes
Blood sugarmay fall hellip
after 90 minutes Options
30
METABOLIC ADAPTATION
SSC started in the first 20 minutes after birth
SSC CotBlood glucose (1 hr) 317 256Base excess drop 34 18
(Christenson 1992)0h 1h 2h 3h 4h 2 days
App
roxim
ate
GLUCOSE
SSC Glucose production = Glucose consumption
Separation
SNS stress Glucose consumption INCREASE
PSNS dissociation Glucose production DECREASE
HYPOGLYCEMIA
SSC Cot
Blood glucose (1 hr) 317 256
0h 1h 2h 3h 4h 2 days
App
roxim
ate
GLUCOSE
SSC Glucose production = Glucose consumption
Separation PSNS dissociation
Glucose production DECREASE
HYPOGLYCEMIA
SSC Cot
Blood glucose (1 hr) 317 256
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
NEURODEVELOPMENTThe DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
BONDING ATTACHMENT
MRI HRVEEG
STRESS RESPONES
RESILIENCE
DOHAD
(MAL) ADAPTATION
EPIGENETICS
GENE X ENVIRONMENT
GENETIC VARIANTS
HOSPITAL ACQUIRED INFECTIONIMMUNITY
SLEEP PHYSIOLOGY
GUT FUNCTIONMICROBIOTA
ldquoSTABILITYrdquo
TRANSITION
LONG TERM FOLLOW-UP
NEUROENDOCRINE BEHAVIOURS
MATERNAL NEUROPLASTICITY
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
MORTALITYMETABOLISM
0h 1h 2h 3h 4h
PSNS (vagal)
App
roxim
ate
GLUCOSE
1 HOURLY Milk feed
1 HOURLY Milk feed
1 HOURLY Milk feed
1 HOURLY Milk feed
LACTOSE
METABOLISM
31
0h 1h 2h 3h 4h
PSNS (vagal) SYMPATHETIC STRESS
App
roxim
ate
GLUCOSE
LACTOSE FATGLYCOGEN
METABOLISM
4 HOURLY Milk feed
0h 1h 2h 3h 4h
PSNS (vagal) SYMPATHETIC STRESS
App
roxim
ate
GLUCOSE
4 HOURLY ALLOSTATIC STATELACTOSE FATGLYCOGEN
METABOLISM
4 HOURLY Milk feed
HEALTH DISEASE
EXPECTED UNEXPECTED
NEURODEVELOPMENTThe DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
BONDING ATTACHMENT
MRI HRVEEG
STRESS RESPONES
RESILIENCE
DOHAD
(MAL) ADAPTATION
EPIGENETICS
GENE X ENVIRONMENT
GENETIC VARIANTS
HOSPITAL ACQUIRED INFECTIONIMMUNITY
SLEEP PHYSIOLOGY
GUT FUNCTIONMICROBIOTA
ldquoSTABILITYrdquo
TRANSITION
LONG TERM FOLLOW-UP
NEUROENDOCRINE BEHAVIOURS
MATERNAL NEUROPLASTICITY
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
MORTALITYMETABOLISM
Weight gain 1st week
predicts OBESITYat 30 years
Large volume feedsstretched stomach=
doubled absorptivecapacity as adult
Importance
Programming ndash early life chronic disease
32
RESISTANCE SENSITIVITY
PERCEPTIONSldquoNEUROCEPTIONrdquo
RESPONSESTRESS
ALLOSTATIC STATE
ALLOSTASIS
ANY STRESSPsychologicalNeurological
EndocrineImmune
ALLOSTATIC LOAD
ALLOSTATIC OVERLOAD
WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY
DISEASEHEALTH
RESILIENCE VULNERABILITY
RESISTANCE SENSITIVITY
PERCEPTIONSldquoNEUROCEPTIONrdquo
RESPONSESTRESS
ALLOSTATIC STATE
ALLOSTASIS
ANY STRESSPsychologicalNeurological
EndocrineImmune
ALLOSTATIC LOAD
HEALTH
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
Gastric overfilling syndrome
189
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
33
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
Only case series Insufficient evidence
No mention of
stomach capacity196
Baby weight freq reqrsquod size actual
2kg baby 4hrly ~ 320 ml6 = 53ml 14ml
15 baby 3hrly ~ 240 ml8 = 30ml 10ml
10 baby 2hrly ~ 160 ml12 = 13ml 7ml
Standardised from20ml capacityfor 3kg baby( x 0007)
197
0
10
20
30
40
50
60
70
80
90
13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w
LINEAR
TERM
PREM
198
34
0
10
20
30
40
50
60
70
80
90
13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w
LINEAR
TERM
PREM
199
Clues to GER
ldquoI know baby hurtsrdquo
Gastric overfilling syndrome
Excessive volumesreflux aspiration colic
Excessive time intervalhypoglycaemia
Adaptationsdiabetic diathesis obesity
200
Developmental Care of the Enteric Nervous System
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
28
The CAPACITY of alow birthweight premfrom 20ml 3000g
= 0007 x BWt (g)
1kg x 0007 = 7mls2kg x 0007 = 14mls
163
Gastric overfilling syndrome
164
75 ml per feeding ASSUMPTION
IMMATURE OR OVERWHELMED
many aspects of gastrointestinalmotility are immature in the neonate
Zangen S et al Rapid maturation of gastric relaxation in newborns
A balloon in stomachcan fill to 76 mls
What does the stomach ndashwithout a balloon ndashdo to 76 mls
REFLUX PRESUME each feedapproximately 75 mls
GER
bull Sudden outbursts of crying
bull Awakens in pain
bull Related to feedings
bull Not easily comforted
bull ldquoI know baby hurtsrdquo
bull Sour burps throaty noises
bull Best when upright
Clues to GER
Dr W Sears
29
Mitchell 2001
Kerstin Uvnaumls-Moberg
Food in duodenum
AMYLINreleased
Closes pylorus
Duodenumempty
Pylorusopens
ldquoFeed intolerancerdquo hellip hellip or VOLUME intolerance
HYPOGLYCAEMIA
A babies stomach empties in60 minutes
Blood sugarmay fall hellip
after 90 minutes Options
30
METABOLIC ADAPTATION
SSC started in the first 20 minutes after birth
SSC CotBlood glucose (1 hr) 317 256Base excess drop 34 18
(Christenson 1992)0h 1h 2h 3h 4h 2 days
App
roxim
ate
GLUCOSE
SSC Glucose production = Glucose consumption
Separation
SNS stress Glucose consumption INCREASE
PSNS dissociation Glucose production DECREASE
HYPOGLYCEMIA
SSC Cot
Blood glucose (1 hr) 317 256
0h 1h 2h 3h 4h 2 days
App
roxim
ate
GLUCOSE
SSC Glucose production = Glucose consumption
Separation PSNS dissociation
Glucose production DECREASE
HYPOGLYCEMIA
SSC Cot
Blood glucose (1 hr) 317 256
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
NEURODEVELOPMENTThe DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
BONDING ATTACHMENT
MRI HRVEEG
STRESS RESPONES
RESILIENCE
DOHAD
(MAL) ADAPTATION
EPIGENETICS
GENE X ENVIRONMENT
GENETIC VARIANTS
HOSPITAL ACQUIRED INFECTIONIMMUNITY
SLEEP PHYSIOLOGY
GUT FUNCTIONMICROBIOTA
ldquoSTABILITYrdquo
TRANSITION
LONG TERM FOLLOW-UP
NEUROENDOCRINE BEHAVIOURS
MATERNAL NEUROPLASTICITY
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
MORTALITYMETABOLISM
0h 1h 2h 3h 4h
PSNS (vagal)
App
roxim
ate
GLUCOSE
1 HOURLY Milk feed
1 HOURLY Milk feed
1 HOURLY Milk feed
1 HOURLY Milk feed
LACTOSE
METABOLISM
31
0h 1h 2h 3h 4h
PSNS (vagal) SYMPATHETIC STRESS
App
roxim
ate
GLUCOSE
LACTOSE FATGLYCOGEN
METABOLISM
4 HOURLY Milk feed
0h 1h 2h 3h 4h
PSNS (vagal) SYMPATHETIC STRESS
App
roxim
ate
GLUCOSE
4 HOURLY ALLOSTATIC STATELACTOSE FATGLYCOGEN
METABOLISM
4 HOURLY Milk feed
HEALTH DISEASE
EXPECTED UNEXPECTED
NEURODEVELOPMENTThe DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
BONDING ATTACHMENT
MRI HRVEEG
STRESS RESPONES
RESILIENCE
DOHAD
(MAL) ADAPTATION
EPIGENETICS
GENE X ENVIRONMENT
GENETIC VARIANTS
HOSPITAL ACQUIRED INFECTIONIMMUNITY
SLEEP PHYSIOLOGY
GUT FUNCTIONMICROBIOTA
ldquoSTABILITYrdquo
TRANSITION
LONG TERM FOLLOW-UP
NEUROENDOCRINE BEHAVIOURS
MATERNAL NEUROPLASTICITY
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
MORTALITYMETABOLISM
Weight gain 1st week
predicts OBESITYat 30 years
Large volume feedsstretched stomach=
doubled absorptivecapacity as adult
Importance
Programming ndash early life chronic disease
32
RESISTANCE SENSITIVITY
PERCEPTIONSldquoNEUROCEPTIONrdquo
RESPONSESTRESS
ALLOSTATIC STATE
ALLOSTASIS
ANY STRESSPsychologicalNeurological
EndocrineImmune
ALLOSTATIC LOAD
ALLOSTATIC OVERLOAD
WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY
DISEASEHEALTH
RESILIENCE VULNERABILITY
RESISTANCE SENSITIVITY
PERCEPTIONSldquoNEUROCEPTIONrdquo
RESPONSESTRESS
ALLOSTATIC STATE
ALLOSTASIS
ANY STRESSPsychologicalNeurological
EndocrineImmune
ALLOSTATIC LOAD
HEALTH
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
Gastric overfilling syndrome
189
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
33
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
Only case series Insufficient evidence
No mention of
stomach capacity196
Baby weight freq reqrsquod size actual
2kg baby 4hrly ~ 320 ml6 = 53ml 14ml
15 baby 3hrly ~ 240 ml8 = 30ml 10ml
10 baby 2hrly ~ 160 ml12 = 13ml 7ml
Standardised from20ml capacityfor 3kg baby( x 0007)
197
0
10
20
30
40
50
60
70
80
90
13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w
LINEAR
TERM
PREM
198
34
0
10
20
30
40
50
60
70
80
90
13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w
LINEAR
TERM
PREM
199
Clues to GER
ldquoI know baby hurtsrdquo
Gastric overfilling syndrome
Excessive volumesreflux aspiration colic
Excessive time intervalhypoglycaemia
Adaptationsdiabetic diathesis obesity
200
Developmental Care of the Enteric Nervous System
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
29
Mitchell 2001
Kerstin Uvnaumls-Moberg
Food in duodenum
AMYLINreleased
Closes pylorus
Duodenumempty
Pylorusopens
ldquoFeed intolerancerdquo hellip hellip or VOLUME intolerance
HYPOGLYCAEMIA
A babies stomach empties in60 minutes
Blood sugarmay fall hellip
after 90 minutes Options
30
METABOLIC ADAPTATION
SSC started in the first 20 minutes after birth
SSC CotBlood glucose (1 hr) 317 256Base excess drop 34 18
(Christenson 1992)0h 1h 2h 3h 4h 2 days
App
roxim
ate
GLUCOSE
SSC Glucose production = Glucose consumption
Separation
SNS stress Glucose consumption INCREASE
PSNS dissociation Glucose production DECREASE
HYPOGLYCEMIA
SSC Cot
Blood glucose (1 hr) 317 256
0h 1h 2h 3h 4h 2 days
App
roxim
ate
GLUCOSE
SSC Glucose production = Glucose consumption
Separation PSNS dissociation
Glucose production DECREASE
HYPOGLYCEMIA
SSC Cot
Blood glucose (1 hr) 317 256
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
NEURODEVELOPMENTThe DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
BONDING ATTACHMENT
MRI HRVEEG
STRESS RESPONES
RESILIENCE
DOHAD
(MAL) ADAPTATION
EPIGENETICS
GENE X ENVIRONMENT
GENETIC VARIANTS
HOSPITAL ACQUIRED INFECTIONIMMUNITY
SLEEP PHYSIOLOGY
GUT FUNCTIONMICROBIOTA
ldquoSTABILITYrdquo
TRANSITION
LONG TERM FOLLOW-UP
NEUROENDOCRINE BEHAVIOURS
MATERNAL NEUROPLASTICITY
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
MORTALITYMETABOLISM
0h 1h 2h 3h 4h
PSNS (vagal)
App
roxim
ate
GLUCOSE
1 HOURLY Milk feed
1 HOURLY Milk feed
1 HOURLY Milk feed
1 HOURLY Milk feed
LACTOSE
METABOLISM
31
0h 1h 2h 3h 4h
PSNS (vagal) SYMPATHETIC STRESS
App
roxim
ate
GLUCOSE
LACTOSE FATGLYCOGEN
METABOLISM
4 HOURLY Milk feed
0h 1h 2h 3h 4h
PSNS (vagal) SYMPATHETIC STRESS
App
roxim
ate
GLUCOSE
4 HOURLY ALLOSTATIC STATELACTOSE FATGLYCOGEN
METABOLISM
4 HOURLY Milk feed
HEALTH DISEASE
EXPECTED UNEXPECTED
NEURODEVELOPMENTThe DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
BONDING ATTACHMENT
MRI HRVEEG
STRESS RESPONES
RESILIENCE
DOHAD
(MAL) ADAPTATION
EPIGENETICS
GENE X ENVIRONMENT
GENETIC VARIANTS
HOSPITAL ACQUIRED INFECTIONIMMUNITY
SLEEP PHYSIOLOGY
GUT FUNCTIONMICROBIOTA
ldquoSTABILITYrdquo
TRANSITION
LONG TERM FOLLOW-UP
NEUROENDOCRINE BEHAVIOURS
MATERNAL NEUROPLASTICITY
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
MORTALITYMETABOLISM
Weight gain 1st week
predicts OBESITYat 30 years
Large volume feedsstretched stomach=
doubled absorptivecapacity as adult
Importance
Programming ndash early life chronic disease
32
RESISTANCE SENSITIVITY
PERCEPTIONSldquoNEUROCEPTIONrdquo
RESPONSESTRESS
ALLOSTATIC STATE
ALLOSTASIS
ANY STRESSPsychologicalNeurological
EndocrineImmune
ALLOSTATIC LOAD
ALLOSTATIC OVERLOAD
WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY
DISEASEHEALTH
RESILIENCE VULNERABILITY
RESISTANCE SENSITIVITY
PERCEPTIONSldquoNEUROCEPTIONrdquo
RESPONSESTRESS
ALLOSTATIC STATE
ALLOSTASIS
ANY STRESSPsychologicalNeurological
EndocrineImmune
ALLOSTATIC LOAD
HEALTH
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
Gastric overfilling syndrome
189
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
33
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
Only case series Insufficient evidence
No mention of
stomach capacity196
Baby weight freq reqrsquod size actual
2kg baby 4hrly ~ 320 ml6 = 53ml 14ml
15 baby 3hrly ~ 240 ml8 = 30ml 10ml
10 baby 2hrly ~ 160 ml12 = 13ml 7ml
Standardised from20ml capacityfor 3kg baby( x 0007)
197
0
10
20
30
40
50
60
70
80
90
13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w
LINEAR
TERM
PREM
198
34
0
10
20
30
40
50
60
70
80
90
13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w
LINEAR
TERM
PREM
199
Clues to GER
ldquoI know baby hurtsrdquo
Gastric overfilling syndrome
Excessive volumesreflux aspiration colic
Excessive time intervalhypoglycaemia
Adaptationsdiabetic diathesis obesity
200
Developmental Care of the Enteric Nervous System
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
30
METABOLIC ADAPTATION
SSC started in the first 20 minutes after birth
SSC CotBlood glucose (1 hr) 317 256Base excess drop 34 18
(Christenson 1992)0h 1h 2h 3h 4h 2 days
App
roxim
ate
GLUCOSE
SSC Glucose production = Glucose consumption
Separation
SNS stress Glucose consumption INCREASE
PSNS dissociation Glucose production DECREASE
HYPOGLYCEMIA
SSC Cot
Blood glucose (1 hr) 317 256
0h 1h 2h 3h 4h 2 days
App
roxim
ate
GLUCOSE
SSC Glucose production = Glucose consumption
Separation PSNS dissociation
Glucose production DECREASE
HYPOGLYCEMIA
SSC Cot
Blood glucose (1 hr) 317 256
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
NEURODEVELOPMENTThe DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
BONDING ATTACHMENT
MRI HRVEEG
STRESS RESPONES
RESILIENCE
DOHAD
(MAL) ADAPTATION
EPIGENETICS
GENE X ENVIRONMENT
GENETIC VARIANTS
HOSPITAL ACQUIRED INFECTIONIMMUNITY
SLEEP PHYSIOLOGY
GUT FUNCTIONMICROBIOTA
ldquoSTABILITYrdquo
TRANSITION
LONG TERM FOLLOW-UP
NEUROENDOCRINE BEHAVIOURS
MATERNAL NEUROPLASTICITY
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
MORTALITYMETABOLISM
0h 1h 2h 3h 4h
PSNS (vagal)
App
roxim
ate
GLUCOSE
1 HOURLY Milk feed
1 HOURLY Milk feed
1 HOURLY Milk feed
1 HOURLY Milk feed
LACTOSE
METABOLISM
31
0h 1h 2h 3h 4h
PSNS (vagal) SYMPATHETIC STRESS
App
roxim
ate
GLUCOSE
LACTOSE FATGLYCOGEN
METABOLISM
4 HOURLY Milk feed
0h 1h 2h 3h 4h
PSNS (vagal) SYMPATHETIC STRESS
App
roxim
ate
GLUCOSE
4 HOURLY ALLOSTATIC STATELACTOSE FATGLYCOGEN
METABOLISM
4 HOURLY Milk feed
HEALTH DISEASE
EXPECTED UNEXPECTED
NEURODEVELOPMENTThe DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
BONDING ATTACHMENT
MRI HRVEEG
STRESS RESPONES
RESILIENCE
DOHAD
(MAL) ADAPTATION
EPIGENETICS
GENE X ENVIRONMENT
GENETIC VARIANTS
HOSPITAL ACQUIRED INFECTIONIMMUNITY
SLEEP PHYSIOLOGY
GUT FUNCTIONMICROBIOTA
ldquoSTABILITYrdquo
TRANSITION
LONG TERM FOLLOW-UP
NEUROENDOCRINE BEHAVIOURS
MATERNAL NEUROPLASTICITY
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
MORTALITYMETABOLISM
Weight gain 1st week
predicts OBESITYat 30 years
Large volume feedsstretched stomach=
doubled absorptivecapacity as adult
Importance
Programming ndash early life chronic disease
32
RESISTANCE SENSITIVITY
PERCEPTIONSldquoNEUROCEPTIONrdquo
RESPONSESTRESS
ALLOSTATIC STATE
ALLOSTASIS
ANY STRESSPsychologicalNeurological
EndocrineImmune
ALLOSTATIC LOAD
ALLOSTATIC OVERLOAD
WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY
DISEASEHEALTH
RESILIENCE VULNERABILITY
RESISTANCE SENSITIVITY
PERCEPTIONSldquoNEUROCEPTIONrdquo
RESPONSESTRESS
ALLOSTATIC STATE
ALLOSTASIS
ANY STRESSPsychologicalNeurological
EndocrineImmune
ALLOSTATIC LOAD
HEALTH
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
Gastric overfilling syndrome
189
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
33
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
Only case series Insufficient evidence
No mention of
stomach capacity196
Baby weight freq reqrsquod size actual
2kg baby 4hrly ~ 320 ml6 = 53ml 14ml
15 baby 3hrly ~ 240 ml8 = 30ml 10ml
10 baby 2hrly ~ 160 ml12 = 13ml 7ml
Standardised from20ml capacityfor 3kg baby( x 0007)
197
0
10
20
30
40
50
60
70
80
90
13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w
LINEAR
TERM
PREM
198
34
0
10
20
30
40
50
60
70
80
90
13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w
LINEAR
TERM
PREM
199
Clues to GER
ldquoI know baby hurtsrdquo
Gastric overfilling syndrome
Excessive volumesreflux aspiration colic
Excessive time intervalhypoglycaemia
Adaptationsdiabetic diathesis obesity
200
Developmental Care of the Enteric Nervous System
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
31
0h 1h 2h 3h 4h
PSNS (vagal) SYMPATHETIC STRESS
App
roxim
ate
GLUCOSE
LACTOSE FATGLYCOGEN
METABOLISM
4 HOURLY Milk feed
0h 1h 2h 3h 4h
PSNS (vagal) SYMPATHETIC STRESS
App
roxim
ate
GLUCOSE
4 HOURLY ALLOSTATIC STATELACTOSE FATGLYCOGEN
METABOLISM
4 HOURLY Milk feed
HEALTH DISEASE
EXPECTED UNEXPECTED
NEURODEVELOPMENTThe DNA Behaviour
EVOLUTIONARY BIOLOGY
The Neuroscience of Birth amp BreastfeedingThe Brain
EPIGENETICS
ENVIRONMENT EXPERIENCE REPRODUCTIVE FITNESSADAPTATION
BONDING ATTACHMENT
MRI HRVEEG
STRESS RESPONES
RESILIENCE
DOHAD
(MAL) ADAPTATION
EPIGENETICS
GENE X ENVIRONMENT
GENETIC VARIANTS
HOSPITAL ACQUIRED INFECTIONIMMUNITY
SLEEP PHYSIOLOGY
GUT FUNCTIONMICROBIOTA
ldquoSTABILITYrdquo
TRANSITION
LONG TERM FOLLOW-UP
NEUROENDOCRINE BEHAVIOURS
MATERNAL NEUROPLASTICITY
ENVIRONMENTWHAT IS THE EFFECT OF MATERNAL ABSENCE ON hellip
MORTALITYMETABOLISM
Weight gain 1st week
predicts OBESITYat 30 years
Large volume feedsstretched stomach=
doubled absorptivecapacity as adult
Importance
Programming ndash early life chronic disease
32
RESISTANCE SENSITIVITY
PERCEPTIONSldquoNEUROCEPTIONrdquo
RESPONSESTRESS
ALLOSTATIC STATE
ALLOSTASIS
ANY STRESSPsychologicalNeurological
EndocrineImmune
ALLOSTATIC LOAD
ALLOSTATIC OVERLOAD
WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY
DISEASEHEALTH
RESILIENCE VULNERABILITY
RESISTANCE SENSITIVITY
PERCEPTIONSldquoNEUROCEPTIONrdquo
RESPONSESTRESS
ALLOSTATIC STATE
ALLOSTASIS
ANY STRESSPsychologicalNeurological
EndocrineImmune
ALLOSTATIC LOAD
HEALTH
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
Gastric overfilling syndrome
189
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
33
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
Only case series Insufficient evidence
No mention of
stomach capacity196
Baby weight freq reqrsquod size actual
2kg baby 4hrly ~ 320 ml6 = 53ml 14ml
15 baby 3hrly ~ 240 ml8 = 30ml 10ml
10 baby 2hrly ~ 160 ml12 = 13ml 7ml
Standardised from20ml capacityfor 3kg baby( x 0007)
197
0
10
20
30
40
50
60
70
80
90
13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w
LINEAR
TERM
PREM
198
34
0
10
20
30
40
50
60
70
80
90
13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w
LINEAR
TERM
PREM
199
Clues to GER
ldquoI know baby hurtsrdquo
Gastric overfilling syndrome
Excessive volumesreflux aspiration colic
Excessive time intervalhypoglycaemia
Adaptationsdiabetic diathesis obesity
200
Developmental Care of the Enteric Nervous System
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
32
RESISTANCE SENSITIVITY
PERCEPTIONSldquoNEUROCEPTIONrdquo
RESPONSESTRESS
ALLOSTATIC STATE
ALLOSTASIS
ANY STRESSPsychologicalNeurological
EndocrineImmune
ALLOSTATIC LOAD
ALLOSTATIC OVERLOAD
WELL-BEING SUSCEPTIBILITY MORBIDITY MORTALITY
DISEASEHEALTH
RESILIENCE VULNERABILITY
RESISTANCE SENSITIVITY
PERCEPTIONSldquoNEUROCEPTIONrdquo
RESPONSESTRESS
ALLOSTATIC STATE
ALLOSTASIS
ANY STRESSPsychologicalNeurological
EndocrineImmune
ALLOSTATIC LOAD
HEALTH
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
Gastric overfilling syndrome
189
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip NICU context
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
33
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
Only case series Insufficient evidence
No mention of
stomach capacity196
Baby weight freq reqrsquod size actual
2kg baby 4hrly ~ 320 ml6 = 53ml 14ml
15 baby 3hrly ~ 240 ml8 = 30ml 10ml
10 baby 2hrly ~ 160 ml12 = 13ml 7ml
Standardised from20ml capacityfor 3kg baby( x 0007)
197
0
10
20
30
40
50
60
70
80
90
13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w
LINEAR
TERM
PREM
198
34
0
10
20
30
40
50
60
70
80
90
13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w
LINEAR
TERM
PREM
199
Clues to GER
ldquoI know baby hurtsrdquo
Gastric overfilling syndrome
Excessive volumesreflux aspiration colic
Excessive time intervalhypoglycaemia
Adaptationsdiabetic diathesis obesity
200
Developmental Care of the Enteric Nervous System
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
33
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
PMA 28 40 64 1y 2y
Nilsrsquo QUESTIONS hellip full term
SUCKLING IS
COMPETENT
FEEDING IS
IMMATURE
elevated activity ndashsustained over time
or severe hellip changes the ldquoset
pointsrdquo for homeostasis(eg increasing blood pressure change in cholesterol level)
Only case series Insufficient evidence
No mention of
stomach capacity196
Baby weight freq reqrsquod size actual
2kg baby 4hrly ~ 320 ml6 = 53ml 14ml
15 baby 3hrly ~ 240 ml8 = 30ml 10ml
10 baby 2hrly ~ 160 ml12 = 13ml 7ml
Standardised from20ml capacityfor 3kg baby( x 0007)
197
0
10
20
30
40
50
60
70
80
90
13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w
LINEAR
TERM
PREM
198
34
0
10
20
30
40
50
60
70
80
90
13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w
LINEAR
TERM
PREM
199
Clues to GER
ldquoI know baby hurtsrdquo
Gastric overfilling syndrome
Excessive volumesreflux aspiration colic
Excessive time intervalhypoglycaemia
Adaptationsdiabetic diathesis obesity
200
Developmental Care of the Enteric Nervous System
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
34
0
10
20
30
40
50
60
70
80
90
13w 16w 19w 22w 25w 28w 31w 34w 37w 40w 43w 46w 49w 52w
LINEAR
TERM
PREM
199
Clues to GER
ldquoI know baby hurtsrdquo
Gastric overfilling syndrome
Excessive volumesreflux aspiration colic
Excessive time intervalhypoglycaemia
Adaptationsdiabetic diathesis obesity
200
Developmental Care of the Enteric Nervous System
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
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
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
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
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
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