Incubators out - how many babies have died unnecessarily?

So I blogged back in July about Kangaroo Mother Care, and it seems on this front things are really hotting up!  A story hit the media last week that finally got the world's attention; a baby born at 27 weeks, was declared dead after doctors spent 20 minutes unsuccessfully battling to get him to breathe.   with no vital signs, they broke the news and mum asked to say goodbye to her baby.  Two hours of kangaroo mother care (KMC)  later, he began to breathe.  His mother (luckily) followed her instincts and gave him some colostrum on her finger - he took it and his breathing became regular...

Whilst this is a lovely heart warming story, it inevitably makes you wonder - how many prematures pronounced as stillborn, got two hours of skin to skin?  how many prematures are rushed away from their mothers under the false belief artificial high powered technology can do a better job?  Even when Jamie began to breathe, doctors dismissed this as a reflex action - how many other infants have done this and it's been dismissed as a reflex?  As someone on an internet list pointed out, perhaps its fortunate for this baby that those early signs were dismissed as a reflex, as he may not have survived further resus.  I for one find this terrifying!

My own son was only 6 weeks early, had agpars of 9/10 and yet was rushed with urgency to the SCBU where they immediately wanted to supplement with artificial breastmilk substitute and put him under a heated cot.  When I declined the panic was tangible, but this is what we do?!?  ok well on your head be it! I endured 13 days of sheer hell for daring to defy, question, seek alternative advice (for which I still owe Annalisa and Nils so much!) and decision make myself.  Change from this norm will NOT come easily.

Whilst some are stunned by this story, Nils Bergman has hardly batted an eye:

This is an emotive story, but hardly original!
Unusual, but occurs ... actually right here in Cape Town just two weeks ago !

Susan Ludington-Hoe opens one of her books on Kangaroo Care with a similar anecdote.

Nils Bergman

Nils believes it is all down to the protest despair response I discussed in my first blog post:

To almost all newborn mammals, separation from mother is life-threatening. This activates a very powerful defence response, which is to shut down and immobilise

He hypothesises that because the nervous system of prematures is so immature, if there is stress during delivery the only way their body can cope is to "shut down" to survive. 

It is "skin-to-skin contact" which is the key, because the deep sensory fibres from the skin go to the "emotional processing unit" of the brain (amygdala), and tells the brain "you are safe". This de-activates the dissociation (un-safe mode), and restores the regulation (safe mode) - which is the real function of the vagal nerve.

Nils Bergman

So why then are we still taking babies away from their mothers and putting them in an artificial womb like environment?  As I mentioned before, not a single study has shown adverse outcome with KMC - yet women still have to endure being separated from their babies, why?  I wonder if the decision makers have ever taken a call from the mum of a premature infant, desperately trying to produce enough breastmilk in an environment so removed from normal, she may struggle even to express enough for a small feed.  To hear her sob she has never even held her baby, she's only allowed to stroke a finger through a hole in the side of his incubator.  We sometimes forget that incubators are as artificial to a mother as they are to baby; she may be in shock her baby has come early, may feel grief for the end of her pregnancy and then has her baby taken from her.

These mothers are extremely vulnerable during what can be a traumatic experience, and as it stands women cannot even sleep on the same ward as their baby!  In our SCBU & NICU unit (which were together) there was around 26 cots and 6 mother's rooms.  Many are discharged home without their infant (yes really whilst supposedly trying to establish breastfeeding!) and end up in a frantic pattern of trying to express enough, get milk to the ward in time, sterilise everything required and then visit their baby - which of course is made a whole lot more interesting if you already have another child or few at home! 

So  many people fund raise for SCBU, yet I only ever hear about the next 15k required for a snazzy incubator.  I know if people feel that saved their baby, they feel they are doing the right thing in helping others to also have access to technology; but just think what a profound difference this money could make if it was spent keeping babies and mothers together - not only in terms of health outcome in the short term, but breastfeeding rates would soar!  there would be a real longterm gain.

Perhaps we need a campaign to provoke change?  Anyone feel strongly enough to hop on board and help organise something?  If so email me!

Incubators out - Mums in!

If this is the first time you have heard this suggestion, you are probably thinking either that I've just landed from another planet; or am some radical, hippified, Neo-Luddite who has clearly lost it.  Not true, honest!

As this is a rather large topic due to it's impact on many different areas -I thought I might tackle it over more than one blog post, with this being an introduction to.  So it's mainly aimed at those not too familiar with the concept of using mothers instead of incubators - often called Kangaroo Mother Care (KMC) which includes Skin to Skin (STS)

Let's start by jumping back to pre-incubators.  Premature baby care was at this time poor; the majority of infants were born at home, often without a doctor readily available.  Preemies were just considered "weak" babies, and as a result many were considered too small to survive.  In general doctors were "in no position to extend their direct responsibility for the newborn", so perhaps not surprisingly death rates were as high as 85%.

Around the turn of the 20th century, America's first incubator hospitals for premature infants were built.  Alexandre Lion had developed the first incubator suitable for hospital use; but they were complicated, expensive, and the technology was hard to sell to hospitals.  To get round this Lion displayed the incubators and their premature residents at fairs and amusement parks, charging an admission fee to offset the cost of running the equipment.

Survival rates soared; in part because of the clean, warm environment and appropriate medical care - but also because after seeing the techniques used at the hospitals, parents were better able to care for their own premature infants.  Incubator hospitals challenged many of the social norms of the time, but ultimately were designed to make a very large profit.

From this point,  research surrounding vulnerable infants, (and the development of incubators) was based on one fundamental assumption; that the incubator was the best way to care for a premature or sick infant. Today developments are still constantly underway to try and create an ever more womb like environment; controlling oxygen levels and other vital systems, with an array of sensors, monitors and alarms. Nowadays they are highly advanced pieces of equipment, costing in the region of £30,000.

But what if this initial assumption was wrong? What if the whole foundation was based upon an assumption that was massively flawed? What if, creating a womb like environment wasn't the
optimum way to care for a baby that had been born and something else could increase survival rates more?

Dr Nils Bergman has been researching, practising and lecturing on KMC for twenty years and firmly believes an infant should not be separated from his mother.   What Bergman discovered is that separation causes something called the "protest - despair response"; the protest response is one of intense activity seeking reuniting, the despair response that follows, is a withdraw and survive response - temperature and heart rate decrease, caused by a massive rise in stress hormones.  When reunited with mother, there is conversley a rapid rise in heart rate and temperature.

The "protest-despair response" was first described in human orphans after WWII, and was subsequently studied in monkeys and then in many other mammals. "Separation distress calls" have been documented in rats and very similar distress calls have been identified in human infants.  Cot babies make ten times as many cry signals as babies held skin to skin, and Bergman believes there is not only physical but neurological implications to separating the dyad.

There is compelling evidence a baby should be with mum, and that in fact she is the perfect incubator.  The infant's temperature sits within a very narrow range, because mum's core temperature rises and fall as her baby requires - so much so STS has been proven better than an incubator for rewarming hypothermic infants.  KMC has also been shown to improve oxygenation, to the extent that STS is used successfully to treat respiratory distress.  Baby's breathing becomes regular, stable, and is coordinated with heart rate.

Despite all this, KMC is not about shunning technology; on the contrary all the usual modern technological equipment should be used alongside the mother. It is purely about keeping mum and baby as one unit.

Isn't this risky? is the first question people ask.  The fact is that in over seventy studies. not a single adverse outcome has been reported for KMC. On the contrary, time and again KMC infants have improved outcome over traditional methods of care - something widely recognised in available scientfic literature.

Why isn't it practised? is usually the next.  But, as I promised to keep this a short introduction - I think that's for another blog entry!