Baby Friendly neonatal special: Q&A with Dr Nils Bergman
Dr Nils Bergman developed and implemented Kangaroo Mother Care (KMC) for premature infants right from birth, with dramatic improvement in survival of premature babies. He spoke at our 2015 neonatal conference, and below shares insight from his work.
How did you first get involved with Kangaroo Mother Care (KMC)?
Dr Bergman: I first heard of KMC in 1987 during a diploma course, then implemented it in 1988. Since we had no incubators at the remote mission hospital in which I started working, we started the skin-to-skin contact immediately after birth, and this had a profound effect on well-being, with an improvement in survival of very low-birth weight babies from 10% to 50%. Skin-to-skin contact was profoundly effective in supporting stabilisation during transition.
Why is separation such an issue for preterm babies?
Dr Bergman: In primate research, separation is used a well-established measure of extreme stress. It is well-established that a limbic brain response produces both upstream cortical (psychological) and downstream physical (physiological) changes in the short term, which leads to long term adaptive changes through epigenetic mechanisms. The adaptation translates to long term harm, as is now being described by Developmental Origins of Health and Adult Disease (DOHAD). Separation dys-regulates, preventing or delaying transition and stabilisation. This applies to full term babies, who do have some inbuilt resilience (stress resistance) – not every separated baby experiences harmful change. Preterm babies however have less resilience, and therefore are greatly more at risk for developing adaptive (potentially harmful) changes.
Where does breastfeeding fit in?
Dr Bergman: The parent’s body (yes father, but primarily mother) provides regulation of basic physiological set-points (also through epigenetic mechanisms), providing the necessary neural process in the limbic brain. This early biological regulation Myron Hofer defines as the neural substrate of ‘bonding’. Over time this leads to a secure attachment, but the breastfeeding is the ongoing “engine’ that ensures the continued sensory and socio-emotional exchanges that cement this secure attachment. I consider that feeding is of secondary importance in this behaviour.
What can parents do?
Dr Bergman: Parents can be present. In fact they must be present. There is research that shows that they do not need to do anything at all, their mere presence in the Neonatal Intensive Care Unit (NICU) improves outcomes, with a dose response. But they can also, and should, do skin-to-skin contact. This is the biologically expected environment for newborns, where optimal development takes places without (mal)adaptation. Skin-to-skin contact is actually a place of care, it is not something we “do” in the active or interventionist sense of the word, it is something we provide by being totally and physically the place/environment for the preterm.
How much difference do you see in neonatal units today compared with when you started?
Dr Bergman: 20 years ago, all NICUs were pretty much the same: high tech, strict visiting hours, no parental touch allowed. The change is that there is now great variability, there are many units that have not changed at all, but increasingly parents are being allowed and welcomed, and even allowed to touch their infants. But I do not see the change that our basic neuroscience expects: skin-to-skin contact uptake of any degree over the globe is less than 5%, and as the default place of care it is almost non-existent.
What element of that progress excites you most?
Dr Bergman: The key progress is that the neuroscience is now providing the necessary biological rationale for skin-to-skin contact and “zero separation” that was absent in the past, along with new evidence from the microbiome, maternal reproductive neuroplasticity, epigenetics and life sciences theory. Almost paradoxically, I see progress in the fact the we now see that the long-term outcomes of our current care are indeed poor with respect to “quality of survival” as opposed to “quantity of survival”: and the nature of this poor quality is fully in support of expected consequences of separation in early life programming and from life sciences theory (and DOHAD). The need for change is there, and will hopefully reach a tipping point.