ArticlePDF AvailableLiterature Review


Behavioral and emotional outcomes for babies who experienced maternal separation due to prematurity or birth defects have not improved significantly for the last 20 years. Current theories and treatment paradigms based on neuroscience have not generated explanatory mechanisms that work, or provided testable hypotheses. This article proposes a new field of scientific investigation, “nurturescience” within which new hypotheses can be tested with novel instruments. Key distinctions between neuroscience and nurturescience are described. Our definition of nurturescience is based on the basic needs of all newborns and of the needs of mothers and their families. This understanding is drawn from biology, anthropology, sociology, physiological, and clinical research. Mechanisms are described from studies on microbiota, epigenetics, allostasis, brain imaging, and developmental origins of health and adult disease. The converging message from these and other fields is that the mother–infant dyad should not be separated. Ongoing emotional connection is the cornerstone of development, leading to life‐long resilience. This has implications for making the correct diagnosis (emotional disconnection vs. attachment disorder), providing the appropriate care (infant and family centered developmental care) in the biologically expected place (skin‐to‐skin contact), and potential for rehabilitation (calming cycle theory). Nurturescience has particular relevance to the care of “small and sick” infants, with profound potential for decreasing the “likelihood of developing developmental problems.”
Nurturescience versus neuroscience: A case for rethinking
perinatal motherinfant behaviors and relationship
Nils J. Bergman
| Robert Ludwig
| Björn Westrup
| Martha Welch
Department of Women's and Children's
Health, Karolinska Institute, Stockholm,
Department of Pediatrics, Columbia
University Irving Medical Center,
New York, New York
Department of Pathology and Cell Biology,
Columbia University Irving Medical Center,
New York, New York
Department of Psychiatry, Columbia
University Irving Medical Center,
New York, New York
Nils Bergman, Geijersgatan 16B, 75226
Uppsala, Sweden.
Behavioral and emotional outcomes for babies who experienced maternal separation
due to prematurity or birth defects have not improved significantly for the last
20 years. Current theories and treatment paradigms based on neuroscience have not
generated explanatory mechanisms that work, or provided testable hypotheses. This
article proposes a new field of scientific investigation, nurturesciencewithin which
new hypotheses can be tested with novel instruments. Key distinctions between neu-
roscience and nurturescience are described. Our definition of nurturescience is based
on the basic needs of all newborns and of the needs of mothers and their families.
This understanding is drawn from biology, anthropology, sociology, physiological,
and clinical research. Mechanisms are described from studies on microbiota, epige-
netics, allostasis, brain imaging, and developmental origins of health and adult dis-
ease. The converging message from these and other fields is that the motherinfant
dyad should not be separated. Ongoing emotional connection is the cornerstone of
development, leading to life-long resilience. This has implications for making the
correct diagnosis (emotional disconnection vs. attachment disorder), providing the
appropriate care (infant and family centered developmental care) in the biologically
expected place (skin-to-skin contact), and potential for rehabilitation (calming cycle
theory). Nurturescience has particular relevance to the care of small and sick
infants, with profound potential for decreasing the likelihood of developing devel-
opmental problems.
autonomic, development, life history, neonate, peripartum, resilience, separation, skin-to-skin contact,
toxic stress
Advances in neonatal care over the past 50 years, at least in
developed countries, have made it possible to save babies
with many birth defects, or who are born at earlier and ear-
lier gestational ages. Sadly, the same cannot be said about
overcoming short- and long-term adverse outcomes associ-
ated with these babies (Twilhaar et al., 2018). Since current
theories and practices surrounding perinatal care have failed
Abbreviations: ANS, Autonomic nervous system; BPD,
Bronchopulmonary dysplasia; CNS, Central nervous system; ECD, Early
childhood development; FNI, Family Nurture Intervention; IFCDC, Infant
and family centered developmental care; IQ, Intelligence quotient; KMC,
Kangaroo Mother Care; NFI, NIDCAP Federation International; NICU,
Neonatal intensive care unit; NIDCAP, Neonatal Individualized
Developmental Care and Assessment Program; NSP, Nurture Science
Program; SSC, Skin-to-skin contact; WAIMH, World Association of Infant
Mental Health; WECS, Welch Emotional Connection Scale.
Received: 10 May 2019 Accepted: 15 May 2019
DOI: 10.1002/bdr2.1529
Birth Defects Research. 2019;118. © 2019 Wiley Periodicals, Inc. 1
to make any major improvements in emotional and behav-
ioral disorders and developmental outcomes, a new approach
is indicated. We believe nurtureshould be the basis for
such a new approach. In fact, we consider that the impor-
tance and implications of this new approach, and the breadth
and scope of its promise, justify a new field of study, which
we call nurturescience.
What do we mean by the word nurture,and why use
it? We acknowledge that the word nurture has limitations.
The English word nurture cannot be easily translated into
other languages. In many languages, the translation narrowly
refers to breastfeeding,or keeping the infant alive. Further,
the word nurture has over the last four or five decades
acquired a wide array of political, psychological, and socio-
logical associations, and even negative connotations
(Tabery, 2015). The disparities of usage have resulted in a
rejection of the word in the basic sciences and an absence of
research aimed at understanding the biological mechanisms
of the phenomenon. Despite the word's limitations, and also
because of them, we have chosen to use nurture to identify
what we think is a long-neglected area of scientific investi-
gation, namely the biological mechanism underlying
motherinfant interactions that establish and maintain emo-
tional connection and physiologic coregulation.
This article arises out of a clinical research collaboration
between the Nurture Science Program (NSP) at the Colum-
bia University Medical Center in New York City and the
Karolinska Institute in Stockholm, Sweden, which has newly
launched a Nurturescience Program. The NSP at Columbia
has been expanding our knowledge of the biological under-
pinnings of nurture: Why and how does nurture work? And,
how can nurture be utilized to help children and families cur-
rently suffering from diagnosed emotional,behavioral, and
developmental problems? Over the past few years, the
Columbia program has proposed a new scientific explana-
tion for the mother/infant nurturephenomenon, together
with a new theoretical framework within which to study it
(Welch, 2016; Welch & Ludwig, 2017a, 2017b). The
Karolinska Institute has a long history of research elucidat-
ing mechanisms on the one hand, and of nurture-based inter-
ventions on the other. Interventions and behaviors studied
include very early skin-to-skin contact (SSC), breastfeeding,
and infant and family centered developmentally supportive
care (IFCDC).
Nurturescience addresses some very old questions in sci-
ence: Why and how does nurture work? How can a better
understanding of nurture be used to improve current neona-
tal care? And, how can the nurture phenomenon be utilized
to help families with infants and children suffering from
emotional and behavioral disorders and developmental
In this review, we will make the case that society in gen-
eral, and hospital healthcare professionals and researchers in
particular, must rethink some of the longest held assump-
tions, beliefs, and paradigms about perinatal behavior and
development. Our new field largely discards some of what
has been assumed about the perinatal motherinfant relation-
ship and biology, forming testable hypotheses within a new
theoretical framework. The Semmelweis reflex is a metaphor
for the reflex-like tendency to reject new evidence or new
knowledge because it contradicts established norms, beliefs,
or paradigms; Semmelweis could not explain the mechanism
for handwashing reducing maternal sepsis, which led to col-
leagues rejecting his evidence. Unlike Semmelweis, we can
present a scientific rationale for underlying mechanisms.
We will present our new theories on the origin and devel-
opment of perinatal motherinfant emotional behaviors that
explain why the perinatal motherinfant relationship is fun-
damental and critical to the health and well-being of both.
This article advocates for a fundamental change in how
health care systems and practitioners understand infant emo-
tional behavior, and the needs of mothers and infants, espe-
cially in the first day of life. Processes taking place in the
first 1,000 minutesprepare for the needs of mothers and
infants in the first 1,000 days(Panter-Brick & Leckman,
2013). We believe this will contribute considerably to the
effort to prevent and minimize the growing number of emo-
tional and behavioral disorders and developmental problems
in preterm and full-term infants.
There have been many theories proposed on the origin and
nature of perinatal emotional behaviors since Darwin pro-
vided his scientific theory 160 years ago (Ludwig & Welch,
2019). Many interventionists and researchers promoting the
benefits of SSC cite John Bowlby, claiming that SSC pro-
motes bonding and attachment. However, few contemporary
practitioners or researchers have critically read Bowlby's the-
ory, which has resulted in a number of misconceptions and
misunderstandings about what his theory actually says about
infant and child development. The following review of
Bowlby's theory will help clarify this point.
In his series of books on attachment (Bowlby, 1969,
1973, 1980), Bowlby created a new theoretical construct of
behavior, attachment, to explain and differentiate variations
in infant/child emotional behavior. Bowlby was not a theo-
rist, nor an infant clinician by training. He was a trained
Freudian psychoanalyst treating adult behavioral problems.
Instead of being a clearly reasoned philosophical argument,
Bowlby patched together a number of separate and some-
times contradictory theories that were popular in the mid-
twentieth century. To support his ideas about attachment, he
cited the imprinting theory of Konrad Lorenz (Lehrman,
1953), from whom he borrowed the term attachment.He
cited the control theory of Weiner, from which he got the
idea that the emotional behavior in humans is the same as a
machine, self-regulated via a system of feedback loops
(Cybernetics, 1948). He cited the behaviorist theories of
Harlow and Skinner (Skinner, 1938), from which derived
the ideas that the individual learns to control emotional
behavior through trial and error and reward and punishment.
He cited the drive theory of Freud, incorporating the idea
that infants are motivated by the instinct to survive (Freud,
1925). And, he slightly modified neo-Darwinist theory on
instincts, concluding that infants, rather than inheriting emo-
tional behavior itself, inherit the potentialfor adaptive
emotional behaviors.
Attachment, as formulated by Bowlby, is a psychological
behavioral construct, where the infant's emotional behavior is
self-regulatedvia the central nervous system (CNS) and
cortex (Bowlby, 1969). Although the mother may be present
at birth, other caregivers have a role equal to hers. This view
has resulted in the idea that the mother's relationship to the
infant, while it may be important at times, is not essential.
The mother, the father, the nanny, and the nurse all have an
equal role in helping the infant to self-regulateemotional
behavior. Within this attachment perspective, attention is
focused on the infant's signs of dysregulation. The caregiver's
emotional availability is often used to assess the ability of the
caregiver to help the infant self-regulate. Various treatment
methods have been devised that teach the caregiver how to be
sensitive and to identify infant needs and how to foster secure
attachment, that is, provide a secure base from which the child
can go off to explore (Saunders, Kraus, Barone, & Biringen,
2015; Welch & Ludwig, 2017b).
Based upon his theory, we can formulate how Bowlby
would answer basic questions about perinatal infant behav-
ior. These can be summarized as follows:
Q: Where does infant behavior originate? A:
The infant is born with the potentialto
respond to his surrounding environment in
emotional ways.
Q: Who does the infant respond to? A: The
infant attachesto the caregiver helping the
infant survive.
Q: What motivates the infant? A:The infant is
driven through self-interest and the need to
Q: How are the infant's emotions controlled? A:
Emotional behavior is controlled internally
within the cortex and central nervous system.
Q: How can maladaptive infant behavior be
identified in the hospital? A:An infant sepa-
rated from the attachment figure displays iden-
tifiable symptoms of grief and anxiety.
Q: When identified, how can maladaptive
behavior be changed to adaptive? A: Care-
givers should aim at meeting the infant's sur-
vival needs and help the infant self-regulate.
Bowlby's ideas were at first enthusiastically taken up in the
1970s and 1980s by a new generation of clinical psychologists,
initially influenced by Mary Ainsworth's new attachment cod-
ing system (Ainsworth, 1985; Ainsworth, Blehar, Werner, &
Werner, 1978). Two pediatricians, Klaus and Kennel, made
clinical observations and randomized controlled trials (Klaus
et al., 1972; Klaus, Kennell, Plumb, & Zuehlke, 1970), advo-
cating for early contact (Klaus, 2009). Their recommendations
were dismissed (Klaus & Kennell, 1982; Lamb, 1982a,
1982b), often on spurious grounds, and perhaps due to the
Semmelweis reflex, they lacked a plausible and scientifically
acceptable explanation, and Bowlby's ideas did not persuade
them. Bowlby's ideas came under increasing criticism by many
in the scientific community, who were critical of research
methods and skeptical of the claims made about the attachment
construct (Eyer, 1994). This resulted in a general skepticism
about attachment theory among pediatricians that exists to this
day, at least in the United States (Eyer, 1994). For neonatolo-
gists working with newborn and premature babies, survival
was first priority. As survival improved the measure of good
care shifted to the quality of survival, measured as long-term
developmental outcomes (White, 2004a, 2004b; White, 2011).
There is an increasing acceptance that bonding and attach-
mentin the newborn period is important. Nevertheless, the
prevailing paradigm of intensivist care remains, with Bowlby's
theories providing little direction or guidance.
As a result of the questions surrounding attachment theory,
there is no clear scientific rationale for changing hospital stan-
dard of care, especially if it requires an increase in funding. That
premature birth is associated with maladaptive behaviors and
socioemotional disorders is not disputed (Arpino et al., 2010;
Aylward, 2005; Roberts, Anderson, De, & Doyle, 2010;
Twilhaar et al., 2018), but that the high-quality medical care pro-
vided should be contributing to those problems has only lately
begun to be acknowledged. The general assumption is still that
it is just as likely that the poor outcomes are due to preceding
pathology and or intrinsic to the prematurity as such. When
change in practice does occur to include SSC, it typically occurs
because advocates point to the benefits of attachment-based
practice to mother and infant and not on potential positive effects
on infant physiologic homeostasis with long-term health effects.
Despite the criticism, Bowlby's attachment construct
remains the prevailing lens through which perinatal behavior
is viewed by society at large, including policy makers. Lac-
king any other construct, it also becomes the default for
researchers and practitioners of SSC, despite the fact that there
is yet to be demonstrated a biological mechanism underlying
the secure, avoidant, ambivalent, and disordered attachment
phenotypes (Hofer, 2006). As a result of this fact, or perhaps
because of this fact, there is yet to be generated a testable
hypothesis within attachment theory (Hofer, 2006).
Numerous studies of preterm birth over the last three
decades have documented the negative cognitive (Allotey
et al., 2018; Brydges et al., 2018; Twilhaar et al., 2018) and
socioemotional (Johnson et al., 2010; Pinto-Martin et al.,
2011) outcomes on the preterm infant and devastating socio-
emotional impact on families (Prouhet, Gregory, Russell, &
Yaeger, 2018; Pugliese et al., 2013). A review by Twilhaar
et al. concludes: extremely or very preterm children born in
the antenatal corticosteroids and surfactant era show large
deficits in intelligence. No improvement in cognitive out-
come was observed between 1990 and 2008(Twilhaar
et al., 2018). This review makes a significant observation:
poor cognitive outcomes are strongly correlated to severity
of bronchopulmonary dysplasia (BPD), and outcomes for
BPD have also not improved. A review on BPD states not
all of the mechanisms that lead to lung damage are
completely understood, which explains why therapeutic
approaches that are theoretically effective have been only
partly satisfactory or useless and, in some cases, potentially
negative(Principi, Di Pietro, & Esposito, 2018).
Our current paradigms have led us to a cul-de-sac; the
current paradigms fail to provide us with mechanisms that
actually work to improve outcomes. To date, attempts to
identify underlying mechanisms implicated in adverse pre-
term outcomes have been made from a brain-based theoreti-
cal framework, mostly within the field of neuroscience
(Ludwig & Welch, 2019). The context has been an inten-
sively mechanistic and technological approach, in which
separation of infants from parents was seen as unavoidable
and even necessary. As described elsewhere in this issue
(Bergman, 2019), that such separation could have an adverse
impact was not even considered.
With reference to above-mentioned poor cognitive out-
comes correlating to BPD, Westrup et al. reported a reduction
of BPD and improved behavioral outcome at 5 years by the
Newborn Developmental Care and Assessment Program
(NIDCAP), which has a constructive nurture approach
(Westrup, Bohm, Lagercrantz, & Stjernqvist, 2004). Simi-
larly, Ortenstrand et al. implemented another nurture
intervention (continuous day and night family presence), and
showed a reduction in BPD and length of hospital stay
(Ortenstrand et al., 2010). In these two studies from
Karolinska, it is primarily the nurtureaspect that distin-
guishes them from the studies reporting poorer outcomes.
Since current theories and practices have failed to make a dif-
ference, a new approach is indicated. We believe nurture
should be the basis for such a new approach. We consider that
the importance and implications of this new approach, and the
breadth and scope of the contents, justify a new field of study,
which we call nurturescience.
Nurture includes defining ecological elements, specifically
the interactions between organisms (plural) and their physical
environment. For the newly born human that physical environ-
ment is the mother's body, as expressed in immediate and con-
tinuous SSC. The mother's ecology includes the family, itself a
neglected aspect necessary for better outcomes (Mercer,
Erickson-Owens, Graves, & Haley, 2007). The antithesis of
SSC is maternalinfant separation. In the absence of mother
(or family member), there is no nurture. It is noteworthy that the
original Kangaroo Mother Method from Colombia never
questioned the need or necessity of separation, or the prevailing
paradigms of care (Rey & Martinez, 1981). Inadequate techni-
cal resources led to a poor man's alternative,it was rec-
ommended for developing countries, but certainly not an
alternative for developed countries(Whitelaw, 1990;
Whitelaw & Sleath, 1985), where separation of preterm infants
from their mothers was seen as necessary. This prevailing para-
digm remains among neonatologists, and even a majority of
Kangaroo Care proponents. And yet, it is from careful and close
observations of nonseparated neonates and their mothers after
birth that an alternative paradigm has crystallized.
Since Bowlby formulated his theory in the 1960s, there
has been growing evidence from fields outside psychology
that contradicts his picture of mother/infant physiology and
biology. This new evidence supports a radically different
view of the perinatal mother/infant emotional relationship,
one that should provide a clear and convincing rationale for
why the care for critically ill infants should shift from
treating the infant in isolation to treating the infant and
mother together (Ludwig & Welch, 2019; Welch, 2016). A
critical assumption that underlies this new view is that the
mother's emotional relationship with the infant in particular
has special relevance to the development and health of the
infant as well as to her own health and well-being.
The fundamental element of nurturescience is maternal
infant emotional connection. The NSP conducts preclinical
and clinical studies to establish a scientific link between
family emotional connection and healthy child development.
A new explanation for why the reciprocal emotional rela-
tionship between infant and mother should be the primary
focus of monitoring and intervention in the hospital is pro-
vided by emotional connection theory and calming cycle
theory (Welch, 2016; Welch & Ludwig, 2017a). These two
theories offer a view of perinatal mother/infant emotional
behaviors that is actionable and scalable. Emotional connec-
tion is distinct from the currently accepted attachment con-
struct in important ways. Rather than a static process of
attaching to a caregiver, which brings to mind the image of a
chemical bond, emotional connection is described as being
analogous to the force between two magnets. When the
forces align (i.e., biologically expected sensory inputs such
as endocrine, smell, sight, touch, hearing), as occurs with
normal pregnancy and birth, the mother and infant are
attractedto one another. When the normal biological
forces do not align, as occurs with preterm birth or from
early separation, the force is broken and the mother and
infant are likely to display avoidant behaviors toward one
another (Welch & Ludwig, 2017a, 2017b).
The validated Welch Emotional Connection Screen
(WECS) makes it relatively easy to measure and assess emo-
tional connection (Frosch et al., 2019; Hane et al., 2018).
This has both clinical and research implications for hospital
care of critically ill infants. The time to make a WECS
assessment can be as little as 310 min, as opposed to the
hours necessary to assess attachment behaviors. Assessing
the degree of emotional connection can be charted in less
than a minute at the end of a 3-min assessment.
A more explicit theory and framework has been evolving in
the ColumbiaKarolinska collaboration, and some of this is
summarized in Table 1. In contrasting nurturescience and
neuroscience, the intention is not to dismiss or negate neuro-
science in any way, but to highlight essential assumptions
and beliefs, that are taken for granted in current
TABLE 1 Comparison of nurturescience and neuroscience
Nurturescience Neuroscience
Relevant time period Perinatal, conception to birth to 1 year,
the first 1,000 minutes
1 month, 3 years (ECD), the first
1,000 days
Critical periods (brief) Brain maturation, sensitive periods (long)
Autonomic objective Homeorhesis Homeostasis; allostasis
Emotions regulatory mechanism Viscera/ANS/limbic Limbic brain/neocortex
Fetus/neonate acutely aware of threat Infant and toddler develop threat
Coregulation, buffering of stress Self-regulation of stress (within self)
Emotional learning mechanism ANS primary influence on behavior CNS primary influence on behavior
Autonomic learning or conditioning CNS conditioning, operant
Fetal & neonatal connectome Prolonged infant brain maturation
Maternal peripartum neuroplasticity Maternal learning of competence
Open feedback loop (with others) Closed feedback loop (within self)
Dyadic/family (plural) Individual (singular)
Theoretical roots Dynamic systems theory, ecology Reductionistic logic, isolationist
Biology, ethology, anthropology Sociology (Maslow, Dunbar)
Physiology, polyvagal theory Psychology
Epigenetics Geneticsepigenetics
Epigenetic adaptation/maladaptation Toxic stress, allostatic load
Intervention target Boost parasympathetic, calming ANS,
and emotional behavior
Counter sympathetic, excitability CNS,
and cognition
Key outcomes Emotional connection and resilience Attachment and cognition
Key objectives Relational health
Self-actualization (Maslow)
Abbreviations: ANS, autonomic nervous system; CNS, central nervous system; ECD, early childhood development.
neuroscience, but differ in nurturescience. Nurturescience is
at present engulfed or embedded in current neuroscience par-
adigms, and requires dissecting out. Perhaps the most obvi-
ous is the relevant time period.Essentially, we see
nurturescience for neonates and infants as a necessary pre-
cursor to neuroscience for toddlers until adulthood.
The neuroscience behind Early Childhood Development
emphasizes the importance of the early years. The First
1,000 daysrecognize explicitly that development begins at
conception, but the first 2 years are decisive. Karolinska
nurturescience emphasizes the first 1,000 minutesafter
birth, essentially the first day of life. Preceding parturition
profoundly influences birth behavior, and all antenatal care
and preparation for labor applies, deserving more emphasis
than current first 1,000 dayspolicies provide.
It is, however, in the first 1,000 seconds(16.7 min, but
practically the first hour of life) that critical coregulatory
processes are initiated.
The first breath is critical, and ensuring it is often given
as a reason for separation; however, the normal full-term
baby does not need the help (Lind, 1960). The baby's crying
is seen as a goodthing from a neuroscience paradigm,
filling the lungs with air.This is erroneous. The lungs fill
with air from the first breath, and a catecholamine activated
pump clears the rest of the fluid in the first hour (de Luca,
Boulvain, Irion, Berner, & Pfister, 2009; Pfister, Ramsden,
Neil, Kyriakides, & Berger, 2001). Crying is a distress signal
(Christensson, Cabrera, Christensson, Uvnas-Moberg, &
Winberg, 1995), probably elicited by sudden bright light
(babies born in the dark hardly cry), and prolonged by
maternalneonate separation (Michelsson, Christensson,
Rothganger, & Winberg, 1996). Crying is not helpful for
breathing, rather the opposite as it restores the fetal circula-
tion (Baba et al., 2012; Ludington-Hoe, Cong, & Hashemi,
2002). Transition to extrauterine life begin in the first sec-
onds of life, and includes an array of physiological adjust-
ments, including using the lungs for the first time. The
critical requirement is regulation, provided by all the sensory
inputs from mother's body (Hofer, 2006), not least the
In the first hour, newborns exhibit typical behaviors that
achieve suckling at the breast, these are necessary for
achieving subsequent breastfeeding (Widstrom et al., 2010).
Only in the first hour, after birth is there significant volume
of colostrum in the breast (Parker, Sullivan, Krueger, &
Mueller, 2015). Healthy babies swallow this and those that
do not suckle should receive it after early maternal expres-
sion (Parker, Sullivan, Krueger, Kelechi, & Mueller, 2013).
Perhaps, the most obvious and most easily overlooked
critical process is the race for the surface(Dominguez-
Bello et al., 2010), the colonization of the newborn with
maternal microbiota (Diaz Heijtz et al., 2011; Neu, 2014),
that is now recognized as essential for health (Zhang
et al., 2015).
Maternal olfactory signals activate olfactory bulb
(Raineki et al., 2010) and amygdala activity (Numan, 1994;
Raineki et al., 2010) that lead to integration of emotional
systems for social affectin the infant (Nelson & Panksepp,
1998). However, these systems are bidirectional, it is during
the first seconds of life that newborn smell and suckling acti-
vate critical parenting brain circuits (Strathearn, 2011;
Strathearn, Fonagy, Amico, & Montague, 2009).
The reader may react to the nurturescientifichyperbole
and excessive use of the word criticalin the above para-
graph. On this point, Karolinska nurturescience has a posi-
tion that differs slightly from the Columbia NSP. Columbia
is focused on the restorative nature of emotional connection.
The Family Nurture Intervention (FNI) trials have shown
dramatic and impressive benefits from an intervention that
started an average of 7 days following preterm birth, despite
protocol designed to begin FNI as soon as possible after
birth (Porges et al., 2019; Welch et al., 2015; Welch et al.,
2016; Welch & Myers, 2016). Columbia NSP is testing the
hypothesis that it is not too late to reestablish the healing
powers of emotional connection in children 05 years of
age. Karolinska does not dispute that such healing is likely,
as indeed the FNI results show (Hane et al., 2018).
Karolinska nurturescience takes the view that such restor-
ative healing may not be necessary if it is possible to prevent
adverse outcomes. Guided by life history theory and a
broader nurturescience view, applying nurturescience princi-
ples immediatelyupon birth has been the focus of interest.
The nurturescience rationale begins with the paradigm that
separation is the potentially harmful intervention. From this
starting point, the research question can be phrased as What
is the effect of maternal absence on neonatal...?where the
question can be completed for almost any imaginable out-
come, since the paradigm for asking it in this way is new.
In neuroscience, there is a defensive position around the
neonate and infant that the brain is so immature and devel-
oping so slowly and surelythat short-term adverse events
will not be remembered and will not matter, that the baby
will catch up its development and no harm will follow. If
evidence is presented that it may matter, neuroscience may
concede that there is a sensitiveperiod, and appeal to neu-
roplasticity for recovery. As used in developmental neurosci-
ence, the development of vision is proffered as an example;
it is a complex matter with a sensitive period of 2 years
(Graven, 2004; Lewis & Maurer, 2005).
Rather, the needed neural processestaking place in the
first hour are critical (Graven, 2006), because if they do not
happen then, alternative developmental adaptations may take
place and the preferred option compromised. It may not be
lost but function suboptimally; it may be totally recoverable,
but we do not know. The critical period is a window of
opportunity (Gabbard, 1998) during which a specific sensory
input leads to fire and wireof a specific neural circuit
(Shatz, 1992) and repeated firing followed by sleep cycling
consolidates the circuit (Peirano & Algarin, 2007; Peirano,
Algarin, & Uauy, 2003). Any alternative signal will consoli-
date contingency plan circuits that will ensure that the neo-
nate will survive,but at the expense of thrive.
Events begun in the first hour of life consolidate during the
first 1,000 min,essentially the first day of life. An analogy
could be launching a rocket into space, the good launch is
criticaland the booster rocket cannot compensate for a poor
or failed launch. The developmental trajectory of the neonate
and infant is enhanced by ensuring ecologically salient sensa-
tions and experiences. It matters how we are born.
Physiological transition is complete after 6 hr (Bergman,
Linley, & Fawcus, 2004). Sleep cycling requires maternal
smell (Doucet, Soussignan, Sagot, & Schaal, 2007; Schaal,
Hummel, & Soussignan, 2004), and development of neural
circuits takes place during sleep cycles (Graven, 2006).
A single expression of colostrum in the first hour is not
enough for establishing lactation. The suckling should con-
tinue between sleep cycles (Klaus, 1987; Salariya, Easton, &
Cater, 1978). For small and sick infants, frequent expression
is necessary. During the first day of life, a healthy and robust
regular rhythmic cycle of feed and sleep is established.
Bartocci et al. measured the frontal lobe activation of attrac-
tion to olfactory stimuli in healthy neonates, comparing
vanilla and colostrum (Bartocci et al., 2000). Both odors
elicited a strong response in the first day of life, but in the
second day of life only vanilla elicited a response. The life
history theory interpretation is that if there was no colostrum
in the first day, it is likely the mother died, and survival
requires rapid adaptation in the form of accepting other
foods than mothers' milk. Maternal smell is the necessary
salient input for regulation of state organization: the
capacity to appropriately regulate the level of sleep and
arousal (Graven, 2006).
The integration of emotional systems for social affectis
a critical need (Nelson & Panksepp, 1998), and it qualifies as
critical in terms of timing in that the window of opportunity is
in the first 1,000 min. It qualifies as critical also in terms of
importance. The limbic brain with the amygdala is regarded
as the emotional brain, and in the first hour and first day, it
connects to the orbitoprefrontal lobe, the social brain
(Nelson & Panksepp, 1998). Similar connections are taking
place in the maternal brain; this now also includes dopamine
centers, which are fundamental to all other parenting circuits
(Strathearn, 2011). The neural circuitry of mothering is com-
plex and intricate, with a number of neural and hormonal sys-
tems needing to harmonize and integrate into a symphonic
whole (Buckley, 2015). Ongoing sensory inputs and contin-
gent interactions with the infant are required. Any stressors
during this time may lead to suboptimal circuitry, separation
removes the necessary sensory inputs to activate the needed
neural processes(Graven, 2006). The critical nature of the
emotionalsocial connection is evidenced also by several
layers of redundancy. The connection can be achieved in vari-
ous ways and finally consolidates at 6 weeks (Schore, 2001).
Further evidence of this is described in detail elsewhere in this
issue (Bergman, 2019). The maternal dose of SSC during the
first 24 hr (and not the first 6 hr) was predictive of emotional
and cognitive support for her infant several months later
(Bigelow, Littlejohn, Bergman, & McDonald, 2010).
Feldman suggests another underlying mechanism for a
critical period. In a case control study of preterm infants
receiving SSC or not (Feldman & Eidelman, 2003), a variety
of outcomes were measured at term age, 1, 5, and 10 years
(Feldman, 2009; Feldman, Rosenthal, & Eidelman, 2014;
Feldman, Weller, Sirota, & Eidelman, 2002). At term age,
vagal tone was higher in the SSC group, and when repeat-
edly measured, differences in vagal tone increased over the
years. Feldman suggests that maternal regulation may set the
oscillators or clocks of the neonate's physiology, with vagal
tone being a millisecond oscillator, stress reactivity (cortisol)
being over some minutes, and the sleep cycling oscillator a
1-hr rhythm (Feldman et al., 2014). These rhythms are fun-
damental to development, and the early setting of them
allows a continued trajectory of better outcomes and
decreased developmental problems. We could add that the
capacity for learning these is innate, but that learning or
entraining at the level of the autonomic nervous system
(ANS) has to take place. On this platform, emotional con-
nection maintains the optimal developmental trajectory.
This message may be distressing for mothers to hear after
the birth of their infants. It is a fact that many mothers do expe-
rience such distress, which may be evidence that they have a
parenting expectation in their neural circuitry that they sud-
denly identify with when they hear it, but which has not been
fulfilled. Karolinska nurturescience seeks to prevent distress
from separation, Columbia seeks to remediate it and help and
support in such situations when separation is unavoidable.
We highlight here the positive value of homeostasisin
neuroscience, whereby the ANS maintains physiological
equilibrium in the self-regulating adult. In nurturescience,
more than homeostasis is needed for optimal development,
and homeorhesisconveys the need to maintain balance of
physiological systems within changing energy dynamics
over time of development (Casey et al., 2009), specifically
to allocate resources for growth. The ANS has a more prom-
inent role in nurturescience than in neuroscience. The syn-
active model of Als is an example, in her iconic diagram it is
the ANS which is at the core of development (Als, 1986).
The ANS plays a key role in the development of emotion
regulation systems, and functions to bridge visceral function
with the limbic brain. Basic visceral needs must be met, and
the majority (90%) of neural fibers in the vagus are from the
gut to the brain. Interoception is an early or primary level of
sensory communication, and in nurturescience, the neonate's
regulation is entirely or totally dependent on mother. Later
in development, the dependence can shift to other care-
givers, and the term buffering protection of adult support
conveys this.
Neuroscience assumes the infant settles and self-regulates
when it calms down following separation, and that in any
case it is still developing capacity for threat recognition and
appraisal, (stranger dangercomes after some months).
Nurturescience recognizes the absence of maternal buffering
and regulation as acutely distressing to the neonate. The
calming downoften observed in the neonatal intensive
care unit (NICU) is in many instances not what is happening
in the infant's ANS. As predicted by nurturescience, and as
evidenced from actual measures of the ANS during such epi-
sodes (Morgan, Horn, & Bergman, 2011), the very opposite
of calm is occurring: a state of fear-induced freeze, followed
by panic-induced dissociation (Als, 2015; Perry, Pollard,
Blakely, Baker, & Vigilante, 1995).
Neuroscience sees the CNS as the primary influence on
behavior and also emotion. There is increasing recognition on
the importance of the emotional system as a whole. This was,
however, slow in coming. Panksepp published Affective
Neuroscience,the title was an oxymoron to many
(Panksepp, 1998). At a deeper level, the autonomic is per-
ceived as automatic without interfering with important mat-
ters. Acquisition of emotional competence is operant,
experience of behavior as good or bad is learned by the infant
at a cortical level by experience during development. That
development was perceived as having a component of matu-
ration independent of learning, influenced by the genome.
Current views focus on the connectome,the integrity
and interconnectivity of the total wiring of all connections in
the brain (Crossley et al., 2014; van den Heuvel et al.,
2014). The quality of the early hubs of the connectome,
established in fetal and neonatal period, depend on the qual-
ity of early experiences in emotional connection with
mother, and this in turn determines resilience and capacity
for development.
Affective neuroscience, that emotion regulation underpins
neuroscience, is fully embraced by nurturescience. The emo-
tional system is deeply and profoundly rooted in the viscera
and the ANS, and these are functional and operational in the
fetus and fully developed at full-term birth. The regulation
of this system is the necessary platform for subsequent corti-
cal development. The neural axis could be conveyed as vis-
ceral, autonomic, emotional, and social. Emotional
connection is never singular or individual, it is dyadic
between mother and infant at first, anchored in family next
and translated to the school and community at large. A neuro-
science core value for development has been astrongand
independent individual; in nurturescience that is an oxymo-
ron: alone is vulnerable. Independent individuals can be very
strong, but they got there by early adult buffering, and later
are invariably anchored in a socioemotional base. Maslow's
pyramid presents self-actualizationas the pinnacle of devel-
opment (Lester, Hvezda, Sullivan, & Plourde, 1983). In the
light of recent developments at the interface of life history the-
ory, anthropology, and psychology, Kenrick et al have reno-
vated the pyramid, and self-actualization has been replaced
by mate acquisition, mate retention, and parenting
(Kenrick, Griskevlelus, Neuberg, & Schaller, 2010).
Detailed elaboration on the tabled theoretical roots would
exceed the scope and intent of this article. We have identified
above that biological and physiological roots inform
nurturescience. Neuroscience is more influenced by psychol-
ogy and sociology. Most obviously, nurtureis difficult to
pin down from a reductionist and scientific point of view,
where the randomized controlled trial requires that all alterna-
tive conditions are controlled and only two variables com-
pared. Ecology deals with the interactions of organisms
(plural) and the environment, and the environment alone pro-
foundly impacts outcomes. The interactions as such are
unpredictable. Motherinfant interaction is not static, it can be
chaotic. Dynamic systems theory measures such outcomes in
a more appropriate way: since circumstances vary (instead of
being static), outcomes are variable. However, repeated events
can become canalized (Tronick & Hunter, 2016). The cana-
lizedis more purposefully accomplished by epigenetics,
where benefit appropriate to a circumstance is remembered
in the DNA. In nurturescience, epigenes allow for the first
encountered environment to be formative, expressing predic-
tive adaptive responses (Gluckman & Hanson, 2005). Health
is adversely impacted when those predictions do not match
the future environment (Hochberg et al., 2011). This is not
quite the same as the allostatic load concept,whereby a
healthy adaptation can become altered later in development
(Ellis & Del Giudice, 2019; McEwen, 1998).
Neuroscience assumes that attachmentis the underlying
development outcome of socioemotional development, but
above all measures success in terms of cognitive outcomes,
ultimately intelligence quotient (IQ) in the adolescent
(Horwood & Fergusson, 1998; Kramer et al., 2008; Orton,
Spittle, Doyle, Anderson, & Boyd, 2009; Twilhaar et al.,
2018), or beyond that academic achievement or adult income
(Victora et al., 2015). A few studies have indeed shown a cor-
relation between secure attachment at 2 years with school age
IQ (Dimitrijevic, Dimitrijevic & Marjanovic, 2013). Though
avenues for explanatory research are suggested, practically no
such research has followed, and the underlying mechanisms
remain speculative.
In nurturescience, it is emotional connection that is the
primary and immediate developmental outcome, and the
long-term objective is resilience. Connection may seem
semantically similar to attachment, but is grounded in well-
known neuroanatomical circuitry amenable to mechanistic
study, and to observable behavior in motherneonate and
motherinfant interactions (Hofer, 2006). This connection is
primarily emotional, and emotionalsocialin contrast to
socioemotional attachment.
A key departure point in nurturescience is that the cogni-
tion is not the primary validity measureof early optimal
development, but rather optimal emotional connection and
autonomic regulation leading to resilience. Resilience has
been defined as the capacity to restore healthy emotional
functioning after a stressful experience(Parker, Buckmaster,
Sundlass, Schatzberg, & Lyons, 2006). Fitness in the most
general sense requires an appropriate and adequate response
to stress, and then restoration to equilibrium. In other terms,
maintaining allostasis requires restoring all stress systems to
baseline, without accumulating an allostatic load that raises
that baseline to a higher level of ongoing metabolic demand,
with wear and tear and impact on health over the life span
(McEwen, 1998). Nurturescience begins here, fundamentally
ensuring the nurturance of buffering protection of adult sup-
port, establishing healthy stress neurobiology and competent
threat appraisal (Loman & Gunnar, 2010), and from this
secure platform subsequent emotionalsocial function. The
iconic experiment of Meaney was titled maternal care as a
model for experience-dependent plasticity(Meaney & Szyf,
2005). He showed that the quality of maternal carenur-
turedetermined the expression of cortisol receptors: the
more care, the more receptor expression, the more rapid the
lowering of cortisol, the greater the resilience.
We point out that emotional connection is observable and
measurable (Hane et al., 2018), and resilience likewise
(Bazhenova, Plonskaia, & Porges, 2001; Bigelow & Power,
2012; Premji, 2014; Scheinkopf et al., 2007). Further, both
can be measured early in the neonatal period and infancy.
Attachment can best be measured at 2 years, cognition at
5 years. Nurturescience clinical trials are underway to corre-
late measures of emotional connection and autonomic cor-
egulation to well-known neuroscience outcomes (Frosch
et al., 2019; Hane et al., 2015). The important advance of
nurturescience is that it provides new hypotheses and instru-
ments that can be used to measure mechanisms and develop-
mental pathways. More importantly, with a properand
correctunderstanding of the underlying mechanisms, our
care of preterm and full-term neonates can profoundly
improve, with less risk for developmental problems.
The above concepts are visually presented in Figures 1
and 2, conveying the same information from different angles.
The Karolinska perspective in Figure 1 focuses on the birth
period, and contrasts infantmother togetherness against
FIGURE 1 Key concepts of nurturescience,
from a perinatal perspective
separation. The Columbia perspective in Figure 2 has a longer
perspective for development, with more focus on the role of
emotion connection and the element of remediation. Nothing
in these two perspectives contradict each other.
Based upon nurturescience principles, the answers for-
mulated within Bowlby's attachment principles on perinatal
behavior and development can be rephrased as follows:
Q: Where do infant instinctive behaviors origi-
nate? A: Autonomic co-conditioning that
develops between mother and fetus/infant that
assures the two will to be emotionally connected.
Q: Who does the infant respond to? A:The
infant responds emotionally to the mother,
assuring healthy development.
Q: What motivates the infant? A:The infant is
driven by the need for emotional connection.
Q: How are the infant's emotions controlled? A:
Emotional behavior is co-regulated between
mother and infant at the autonomic nervous system
Q: How can maladaptive infant behavior be
identified in the hospital? A:An infant and
mother separated from one another display
identifiable symptoms of grief and anxiety.
Q: When identified, how can maladaptive behavior
be changed to adaptive? A: Caregivers should aim
at helping mother and infant restore emotional
connection to promote the well-being of both.
As stated above, developmental outcomes for very preterm
babies have not improved over 20 years (Twilhaar et al.,
2018), and our current paradigms based on neuroscience are
not providing us with mechanisms that work. Nurturescience
takes a fresh view, incorporating recent developments in sev-
eral fields of science, providing a novel and practical
approach. This has implications for making the correct diag-
nosis (emotional connection, as described above), providing
the appropriate care in the biologically expected place (SSC),
improved maternal care and the potential for rehabilitation.
One such example of appropriate care is IFCDC. IFCDC is
a descriptive term for a framework of newborn care that incor-
porates the theories and concepts of neurodevelopment, neuro-
behavior, parentinfant interaction, parental involvement,
breastfeeding promotion, environmental adaptation, and
change of hospital systems, that is, incorporates the principles
of nurturescience. It is based on the pioneering work of Als
et al. in the NIDCAP Federation International (Als, 1986; Als,
2015) and Brazelton (Brazelton & Nugent, 1995), and on the
World Association for Infant Mental Health Declaration of
Infants' Rights (WAIMH, 2016). The core pillars of IFCDC
are: sensitive care based on infant behavioral communication
and cues gives the infant a voice (Als, 1986) and is beneficial
for brain growth (Als et al., 2012), parent engagement supports
parental well-being and infant development (Als et al., 2003;
Gilkerson & Als, 1995; McAnulty et al., 2012; Westrup,
2015), and customized adaptations of the NICU environment
and hospital system as a whole (Smith, Buehler, & Als, 2015).
Nurturescience has particular relevance to the care of
small and sick infants, with profound potential for decreasing
likelihood of developmental problems.It must be noted
that our understanding of nurture is based on the basic needs
of all newborns; nurturescience has implications for newborn
care, but also for the needs of mothers and their families.
SSC can be regarded as an important and obvious part of
IFCDC, but it has a unique salience that requires it be
highlighted. Some definition of terms is necessary. The
FIGURE 2 Key concepts of
nurturescience, from a developmental
Kangaroo Mother Method was the original term as first
described from Bogota, Colombia (Rey & Martinez, 1981).
At that time, the method was started on very small and very
premature babies that were clinically stableafter some
days in incubators. The method involved nearly continuous
SSC with a parent, support for achieving early exclusive
breastfeeding and early discharge. In 1996, the definition of
this three-part strategy was codified under the auspices of
World Health Organization (WHO, 2003), and the term
Kangaroo Mother Care (KMC) agreed on. To distinguish the
components, recommended terms were Kangaroo Position
for SSC, Kangaroo nutrition for the breastfeeding support,
and Kangaroo discharge. For the latter, a crucial requirement
is an intensive follow-up program (Charpak, Ruiz, & Figue-
roa de Calume, 2001), starting with daily visits in early days,
then weekly, and continued to ensure early identification of
any developmental delays or defects.
When introduced to the United States, it was the skin-to-
skin component that was emphasized, and the term Kanga-
roo care was introduced (Anderson, 1989). The original
focus on mother, feeding, and early discharge was set aside.
Further, in the United States, the term is generally used as an
adjunct to care, with 1- or 2-hr periods of SSC, usually
started just prior to discharge (Anderson, 1990). When actu-
ally practiced and described globally, the term KMC is gen-
erally used, but referring only to the SSC component
without the awareness of the other parts of the original KMC
definition. This discordance between the original definition
and practice was compounded by a later differentiation
between intermittent KMC and continuous KMC, where
SSC was being discussed (Nyqvist et al., 2010). The end
result is considerable confusion as to what we actually mean
by the term KMC, and Kangaroo care.
In translating health program language to the research
arena, we need more precise definitions. The word care
correctly conveys that this is a strategy with several compo-
nents or interventions. The key component of KMC is in fact
the first, which we feel should correctly be called SSC. A
fundamentally important concept is that when the infant is
naked on mother's bare chest, it is in a different placeadif-
ferent environment or habitat. The medical and nursing
carerequired does not change. SSC is therefore a place of
care; it is not itself the care.The fundamental importance
of this is elaborated in another article in this issue (Bergman,
2019). Though the term SSC has no official sanction, nor
does any other term, it is used in both Cochrane reviews on
the topic (Conde-Agudelo & Díaz-Rossello, 2016; Moore,
Bergman, Anderson, & Medley, 2016).
Both these reviews then deal with more detailed dimen-
sions of SSC. The first is initiation time,how soon after
birth is the intervention initiated: for mortality outcome there
is indicative evidence that initiation must occur before 2 hr
(Conde-Agudelo & Díaz-Rossello, 2016), and possibly
immediately. For healthy full-term infants, there is evidence
of improved breastfeeding even from 2 hr a day (Moore et al.,
2016); one epidemiological study reports a doseresponse
effect of SSC in the first 3 hr of life, measured in exclusive
breastfeeding at discharge (Bramson et al., 2010). Both
reviews consider subsequent daily dose,and available evi-
dence suggests survival benefit only when given more than
20 hr a day (Conde-Agudelo & Díaz-Rossello, 2016). The
duration or dose of SSC while in hospital and after discharge
is a factor, on which there are very few studies. Further, safe
technique is an important but often neglected factor. Gener-
ally, it is agreed that a garment that protects against obstruc-
tive apnea is essential (WHO, 2003). Care does not change,
but staff competence in providing sophisticated technological
supportive care in this new place must change. Another con-
sideration is the SSC provider: though the mother should be
emphasized, fathers and surrogates are necessary both for
immediate and continuous SSC. Bringing parents into the
NICU has in itself brought about developments such as fam-
ily centered care (Lee, Carter, Stevenson, & Harrison, 2014;
Ortenstrand et al., 2010) and increasing awareness of devel-
opmentally supportive sensory environments (Als &
Gilkerson, 1995; White, 2004a, 2004b).
The latter make us more aware that no single factor is a
silver bullet,many components of care matter. The key
concept, as elaborated in another article in this issue
(Bergman, 2019), is that place or environment is fundamen-
tally much more important than we have appreciated in the
past. In our life history theory (Ellis & Del Giudice, 2019),
or from our evolutionary biology (McKenna, Ball, & Gettler,
2007), any other alternative than SSC would have been
totally unimaginable. Our underlying biology is dealing with
this unimaginable and unexpected reality, maternalneonate
separation is the opposite of SSC with mother. Therefore,
immediate and continuous SSC does deserve prominence in
what we should prioritize for neonatal care.
Returning then to the theme of this issue: what is the role
of SSC in preventing and minimizing preterm and term
infants' likelihood of developing developmental problems?
The benefits of SSC for the mother and infant are well
documented throughout this special edition. Indeed, the
number of those who argue against the merits of SSC has
substantially decreased over the past 50 years. Yet, there
remains a considerable amount of skepticism within the
medical profession about many of the claims made by advo-
cates of SSC practice (Goldsmith, 2013), especially in the
universal context of expending scarce resources to accom-
plish its goals (Miles, Cowan, Glover, Stevenson, & Modi,
2006). This is not due to lack of data, there are Cochrane
and other systematic reviews (Boundy et al., 2016; Carfoot,
Williamson, & Dickson, 2003; Lawn, Mwansa-Kambafwile,
Horta, Barros, & Cousens, 2010; Mori, Khanna, Pledge, &
Nakayama, 2010), and an extensive bibliography of all
known publications (USIKC). Skepticism of SSC due to the
absence of biological plausibility or scientific rationale is
legitimate. However, a scientific rationale is presented in this
issue, focusing as much on what SSC does but also on how
its absence potentially could jeopardize optimal infant devel-
opment. These data and explanations have not, thus far, con-
vinced practitioners to change the place in which the
neonate receives standard of care.
SSC is not a kind of care or intervention, but the
expected environment for the human neonate. In the words
of the anthropologist James McKenna: Nothing an infant
can or cannot do makes sense, except in the light of mother's
body.Separation from SSC on mother results in genetic
and epigenetic changes, in altered neural circuitry and neuro-
behavioral adaptations that highly likely contribute to devel-
opmental problems, even in the presence of all optimal care.
Life history theory suggests some simple and practical inter-
ventions for maternal care. Almost all mammals give birth
alone; the human is the exception. In all societies, another
woman is in constant and uninterrupted attendance during
labor (Trevathan, 1993, 1996). The birth companion, or doula,
has an evidence base even in modern and sophisticated set-
tings (Brown, Hofmeyr, Nikodem, Smith, & Garner, 2007;
Kennell, Klaus, McGrath, Robertson, & Hinkley, 1991;
Paterno, Van Zandt, Murphy, & Jordan, 2012; Steel, Frawley,
Adams, & Diezel, 2015). Nurturescience attributes this to
highly conserved neuroendocrine behaviors, in which parturi-
tion requires a sense of safety for oxytocin to perform its
important multiple roles (Carter, Altemus, & Chrousos, 2001;
Uvnas-Moberg, 1999). The doula makes the mother feel safe.
From a neuroscience paradigm, that is totally unimportant,
only the midwife is necessary and the doula not always wel-
comed. Nurturescience affirms the midwife, and that the
mother must be safe. However, the mother's sense of feeling
safeis engendered by the doula that never leaves her to be
alone, and has a profound health enhancement effect. Our
health systems behave as if mother's feelings do not matter,
and safety is almost entirely about risk reduction (Welch et al.,
2016). Birth is seen as a dangerous clinical condition, and
managed as a disease. Being safe is necessary, but equally so
is feeling safe, and having active support during and after birth.
Nurturescience suggests also that the father be present during
birth. In MRI and other studies, fathers have been shown to
have the same parenting brain circuitry as mothers (Fleming,
Corter, Stallings, & Steiner, 2002; Gloppestad, 1996; Swain,
Lorberbaum, Kose, & Strathearn, 2007). Professor John Lind
stated, The family is born in the labor ward.Behind this sen-
timental sounding statement lies a depth of nurturescience still
to be researched and explored. Parental neurobehavior has
been described in detail, but very few studies have focused on
the time of birth.
The first day of life with critical periods for key events is
described in detail above; nurturescience makes another
observation and recommendation from life history theory:
after birth, the mother should never be alone. Western cul-
ture might value solitude, but reproductive behaviors are
based on oxytocin, which has an element of sociality. There
is additional safety in never being alone, but it is not for risk
reduction but fundamentally for optimal outcome that doula
and family support is vital. In non-Western cultures, there is
an almost universal period of cloistering for 6 weeks, when
mother is pampered and cared for by others. Postpartum
behaviors are embedded in ceremony and in memory of
other women, and this includes doing safe SSC. Since our
culture has lost this, we propose a new health cadre: the
Kangaroula. Early SSC, early support for breastfeeding, and
ensuring optimal emotional connection are all so vital and
essential that they deserve to be the dedicated task of a
health professional, with no other distracting responsibility.
Preterm and term infants may be born with a wide variety of
pathological conditions, and to families with many other
issues and problems that make IFCDC and SSC not happen.
Calming cycle theory describes the process by which an
emotional connection and autonomic coregulation can be
reestablished between mother and infant utilizing the natural
learning mechanism that makes it possible for the two to
connect upon birth. Calming cycle theory extends polyvagal
theory by providing a learning mechanism by which the
vagus nerve controls heart rate and vagal tone (Ludwig &
Welch, 2019; Porges et al., 2019). It proposes that an associ-
ation is formed between the autonomic states of infant and
mother during gestation via Pavlovian coconditioning (auto-
nomic learning), which leads to a cardiac calming reflex and
emotional connection following normal birth (Welch &
Ludwig, 2017b). An association forms between autonomic
states of infant and mother due to the daily ebb and flow
between sympathetic activities (awake, arousal) and para-
sympathetic activities (sleep, calming). This calming cycle
forms a basis for the coregulatory effects seen in healthy
mother/infant dyads. It also provides the basis for rec-
onnecting a mother and infant emotionally following a
period of separation.
Calming cycle theory is first and foremost a theory of
change. Following births with complications, which are
often accompanied by hospitalization and maternalinfant
separation, a break in autonomic coregulation and emotional
connection between mother and infant often occurs. This
can be assessed using the WECS assessment tool. Once a
break in emotional connection is observed, action can be
taken immediately to help facilitate a maternalinfant
Nurturescience therefore encompasses more than just the infant
and any single intervention. It is ecological, including the
mother, their emotional connection, and interactions with fam-
ily, always mindful of the physical and social environment.
This provides a better understanding of the dynamic and devel-
oping needs of the motherinfant dyad. Nurturescience is
drawn from biology, anthropology, sociology, physiological,
and clinical research. Mechanisms are described from studies
on microbiota, epigenetics, allostasis, brain imaging, and devel-
opmental origins of health. The converging message from these
and other fields is that the motherinfant dyad should not be
separated at birth or thereafter. Ongoing emotional connection
is the cornerstone of development, leading to life-long resil-
ience. Given that SSC is both a physical and social environ-
ment, that it connects infant and mother, that it directly
supports neural connections for emotion and sociality, we do
believe that immediate and continuous SSC does indeed have a
role in preventing and minimizing preterm and term infants'
likelihood of developing developmental problems.
The authors thank Jill Bergman for inputs and proofreading.
The authors declare that they have no conflict of interest.
Ainsworth, M. D. (1985). Patterns of infant-mother attachments: Ante-
cedents and effects on development. Bulletin of the New York Acad-
emy of Medicine,61(9), 771791.
Ainsworth, M. D., Blehar, M., Werner, D., & Werner, D. (1978). Pat-
terns of attachment: A psychological study of the strange situation.
Hillsdale, NJ: Lawrence Erlbaum Associates.
Allotey, J., Zamora, J., Cheong-See, F., Kalidindi, M., Arroyo-
Manzano, D., Asztalos, E., Thangaratinam, S. (2018). Cognitive,
motor, behavioural and academic performances of children born
preterm: A meta-analysis and systematic review involving 64 061
children. BJOG,125(1), 1625.
Als, H. (1986). A synactive model of neonatal behavioral organization:
Framework for the assessment of neurobehavioral development in
the premature infant and for support of infants and parents in the
neonatal intensive care environment. Physical & Occupational
Therapy in Pediatrics,6(3/4), 353.
Als, H. (2015). Program Guide -Newborn Individualized Developmen-
tal Care and Assessment Program (NIDCAP): An education and
training program for health care professionals. Retrieved from
Als, H., Duffy, F. H., McAnulty, G., Butler, S. C., Lightbody, L.,
Kosta, S., Warfield, S. K. (2012). NIDCAP improves brain func-
tion and structure in preterm infants with severe intrauterine growth
restriction. Journal of Perinatology,32(10), 797803. https://doi.
Als, H., & Gilkerson, L. (1995). Developmentally supportive care in
the neonatal intensive care unit. Zero to Three,15(6), 110.
Als, H., Gilkerson, L., Duffy, F. H., McAnulty, G. B., Buehler, D. M.,
Vandenberg, K., Jones, K. J. (2003). A three-center, random-
ized, controlled trial of individualized developmental care for very
low birth weight preterm infants: Medical, neurodevelopmental,
parenting, and caregiving effects. Journal of Developmental and
Behavioral Pediatrics,24(6), 399408.
Anderson, G. C. (1989). Kangaroo care and breastfeeding for preterm
infants. Breastfeeding Abstracts,9,78.
Anderson, G. C. (1990). Overview of current knowledge about skin-to-
skin (kangaroo) care for preterm infants (lit review). UNICEF,3
(371), 390.
Arpino, C., Compagnone, E., Montanaro, M. L., Cacciatore, D.,
De, L. A., Cerulli, A., Curatolo, P. (2010). Preterm birth and
neurodevelopmental outcome: A review. Child's Nervous System,
26(9), 11391149.
Aylward, G. P. (2005). Neurodevelopmental outcomes of infants born
prematurely. Journal of Developmental and Behavioral Pediatrics,
26(6), 427440.
Baba, A., Ishida, T., Okada, M., Akazawa, Y., Hirabayashi, K.,
Saida, K., Koike, K. (2012). Right-to-left shunting in the ductus
arteriosus is induced readily by intense crying and rapid postural
change in neonates with meconium-stained amniotic fluid. Pediat-
ric Critical Care Medicine,13(1), 6065.
Bartocci, M., Winberg, J., Ruggiero, C., Bergqvist, L. L., Serra, G., &
Lagercrantz, H. (2000). Activation of olfactory cortex in newborn
infants after odor stimulation: A functional near-infrared spectros-
copy study. Pediatric Research,48(1), 1823.
Bazhenova, O. V., Plonskaia, O., & Porges, S. W. (2001). Vagal reac-
tivity and affective adjustment in infants during interaction chal-
lenges. Child Development,72(5), 13141326.
Bergman, N. J. (2019). Birth practices: Maternal-neonate separation as
a source of toxic stress. Birth Defects Research,2019,123. https://
Bergman, N. J., Linley, L. L., & Fawcus, S. R. (2004). Randomized
controlled trial of skin-to-skin contact from birth versus conven-
tional incubator for physiological stabilization in 1200- to
2199-gram newborns. Acta Paediatrica,93(6), 779785.
Bigelow, A. E., Littlejohn, M., Bergman, N., & McDonald, C. (2010).
The relation between early motherinfant skin-to-skin contact and
later maternal sensitivity in south African mothers of low birth
weight infants. Infant Mental Health Journal,31(3), 358377.
Bigelow, A. E., & Power, M. (2012). The effect of motherinfant skin-
to-skin contact on infants' response to the still face task from
newborn to three months of age. Infant Behavior and Development,
35(2), 240251.
Boundy, E. O., Dastjerdi, R., Spiegelman, D., Fawzi, W. W.,
Missmer, S. A., Lieberman, E., Chan, G. J. (2016). Kangaroo
mother care and neonatal outcomes: A meta-analysis. Pediatrics,
137(1), e20152238.
Bowlby, J. (1969). Attachment and loss. Vol 1. Attachment. New York,
NY: Hogarth Press.
Bowlby, J. (1973). Attachment and loss. Vol 2. Separation: Anxiety
and anger. New York, NY: Hogarth Press.
Bowlby, J. (1980). Attachment and loss. Vol 3 loss: Sadness and
depression. New York, NY: Hogarth Press.
Bramson, L., Lee, J. W., Moore, E., Montgomery, S., Neish, C.,
Bahjri, K., & Melcher, C. L. (2010). Effect of early skin-to-skin
mother--infant contact during the first 3 hours following birth on
exclusive breastfeeding during the maternity hospital stay. Journal
of Human Lactation,26(2), 130137.
Brazelton, T. B., & Nugent, J. K. (1995). Neonatal behavioral assess-
ment scale (No. 137 (3rd ed.). London, England: Mac Keith Press.
Brown, H., Hofmeyr, G. J., Nikodem, V. C., Smith, H., & Garner, P.
(2007). Promoting childbirth companions in South Africa: A
randomised pilot study. BMC Medicine,5,7.
Brydges, C. R., Landes, J. K., Reid, C. L., Campbell, C., French, N., &
Anderson, M. (2018). Cognitive outcomes in children and adoles-
cents born very preterm: A meta-analysis. Developmental Medicine
and Child Neurology,60, 452468.
Buckley, S. (2015). Hormonal Physiology of Childbearing: Evidence
and Implications for Women, Babies, and Maternity Care (Vol.
January 2015). 1875 Connecticut Avenue NW, Suite 650, Washing-
ton, DC: Childbirth Connection.
Carfoot, S., Williamson, P. R., & Dickson, R. (2003). A systematic
review of randomised controlled trials evaluating the effect of
mother/baby skin-to-skin care on successful breast feeding. Mid-
wifery,19(2), 148155. doi:10.1054/midw.2002.0338
Carter, C. S., Altemus, M., & Chrousos, G. P. (2001). Neuroendocrine
and emotional changes in the post-partum period. In J. A. Russell,
A. J. Douglas, R. J. Windle, & C. D. Ingram (Eds.), Progress in
Brain Research. Vol. 133, pp. 241249.
Casey, T., Patel, O., Dykema, K., Dover, H., Furge, K., & Plaut, K.
(2009). Molecular signatures reveal circadian clocks may orches-
trate the homeorhetic response to lactation. PLoS One,4(10),
Charpak, N., Ruiz, J. G. F., & Figueroa de Calume, Z. (2001). What is
the issue when discharging "premies": Early discharge from hospi-
tal or early integration with the family? Acta Paediatrica,90(10),
Christensson, K., Cabrera, T., Christensson, E., Uvnas-Moberg, K., &
Winberg, J. (1995). Separation distress call in the human neonate in
the absence of maternal body contact. Acta Paediatrica,84(5),
Conde-Agudelo, A., & Díaz-Rossello,J.L.(2016).Kangaroomother
care to reduce morbidity and mortality in low birthweight infants.
The Cochrane Library, (8).
Crossley, N. A., Mechelli, A., Scott, J., Carletti, F., Fox, P. T.,
McGuire, P., & Bullmore, E. T. (2014). The hubs of the human
connectome are generally implicated in the anatomy of brain
disorders. Brain,137(Pt 8), 23822395.
Cybernetics. (1948). On control and communication in the animal and
the machine. Cambridge, MA: MIT Press.
de Luca, R., Boulvain, M., Irion, O., Berner, M., & Pfister, R. E.
(2009). Incidence of early neonatal mortallity and morbidity after
late-preterm and term cesarean delivery. Pediatrics,123(6),
Diaz Heijtz, R., Wang, S., Anuar, F., Qian, Y., Bjorkholm, B.,
Samuelsson, A., Pettersson, S. (2011). Normal gut microbiota
modulates brain development and behavior. Proceedings of the
National Academy of Sciences of the United States of America,108
(7), 30473052.
Dimitrijevic, A., Dimitrijevic, A. A., Marjanovic, Z. J. (2013). An Exam-
ination of the Relationship between Intelligence and Attachment in
Adulthood. Retrieved from http://www.inpact-psychologyconference.
Dominguez-Bello, M. G., Costello, E. K., Contreras, M., Magris, M.,
Hidalgo, G., Fierer, N., & Knight, R. (2010). Delivery mode shapes
the acquisition and structure of the initial microbiota across multi-
ple body habitats in newborns. Proceedings of the National Acad-
emy of Sciences of the United States of America,107(26),
Doucet, S., Soussignan, R., Sagot, P., & Schaal, B. (2007). The
"smellscape" of mother's breast: Effects of odor masking and selec-
tive unmasking on neonatal arousal, oral, and visual responses.
Developmental Psychobiology,49(2), 129138.
Ellis, B. J., & Del Giudice, M. (2019). Developmental adaptation to
stress: An evolutionary perspective. Annual Review of Psychology,
70, 111139.
Eyer, D. E. (1994). Mother-infant bonding : A scientific fiction. Human
Nature,5(1), 6994.
Feldman, R. (2009). The development of regulatory functions from
birth to 5 years: Insights from premature infants. Child Develop-
ment,80(2), 544561.
Feldman, R., & Eidelman, A. I. (2003). Skin-to-skin contact (kangaroo
care) accelerates autonomic and neurobehavioural maturation in
preterm infants. Developmental Medicine and Child Neurology,45
(4), 274281.
Feldman, R., Rosenthal, Z., & Eidelman, A. I. (2014). Maternal-
preterm skin-to-skin contact enhances child physiologic organiza-
tion and cognitive control across the first 10 years of life. Biologi-
cal Psychiatry,75(1), 5664.
Feldman, R., Weller, A., Sirota, L., & Eidelman, A. I. (2002). Skin-to-
skin contact (kangaroo care) promotes self-regulation in premature
infants: Sleep-wake cyclicity, arousal modulation, and sustained
exploration. Developmental Psychology,38(2), 194207. https://
Fleming, A. S., Corter, C., Stallings, J., & Steiner, M. (2002). Testos-
terone and prolactin are associated with emotional responses to
infant cries in new fathers. Hormones and Behavior,42(4),
Freud, S. (1925). An autobiographical study. London, England:
Hogarth Press.
Frosch, C. A., Fagan, M. A., Lopez, M. A., Middlemiss, W.,
Chang, M., Hane, A. A., & Welch, M. G. (2019). Validation study
showed that ratings on the Welch emotional connection screen at
infant age six months are associated with child behavioural prob-
lems at age three years. Acta Paediatrica,108, 889895. https://
Gabbard, C. (1998). Windows of opportunity for early brain and motor
development. Journal of Physical Education, Recreation and
Dance,69(8), 5455.
Gilkerson, L., & Als, H. (1995). Role of reflective process in the imple-
mentation of developmentally supportive care in the newborn inten-
sive care nursery. Infants and Young Children: An Interdisciplinary
Journal of Special Care Practices,7(4), 2028.
Gloppestad, K. (1996). Parents' skin to skin holding of small premature
infants: Differences between fathers and mothers. Nordic Journal
of Nursing Research,16(1), 2227.
Gluckman, P., & Hanson, M. (2005). The fetal matrix evolution, devel-
opment and disease. Cambridge, Great Britain: The Press Syndicate
of the University of Cambridge.
Goldsmith, J. P. (2013). Hospitals should balance skin-to-skin contact
with safe sleep policies. AAP News,34,2222.
Graven, S. N. (2004). Early neurosensory visual development of the
fetus and newborn. Clinics in Perinatology,31(2), 199216.
Graven, S. N. (2006). Sleep and brain development. Clinics in Perina-
tology,33, 693706.
Hane, A. A., LaCoursiere, J. N., Mitsuyama, M., Wieman, S.,
Ludwig, R. J., Kwon, K. Y., Welch, M. G. (2018). The Welch
emotional connection screen: Validation of a brief mother-infant
relational health screen. Acta Paediatrica,108, 615625. https://
Hane, A. A., Myers, M. M., Hofer, M. A., Ludwig, R. J.,
Halperin, M. S., Austin, J., Welch, M. G. (2015). Family nurture
intervention improves the quality of maternal caregiving in the neo-
natal intensive care unit: Evidence from a randomized controlled
trial. Journal of Developmental and Behavioral Pediatrics,36(3),
Hochberg, Z., Feil, R., Constancia, M., Fraga, M., Junien, C.,
Carel, J. C., Albertsson-Wikland, K. (2011). Child health,
developmental plasticity, and epigenetic programming. Endo-
crine Reviews,32(2), 159224.
Hofer, M. A. (2006). Psychobiological roots of early attachment. Cur-
rent Directions in Psychological Science,15(2), 8488.
Horwood, L. J., & Fergusson, D. M. (1998). Breastfeeding and later
cognitive and academic outcomes. Pediatrics,101(1), E9.
Johnson, S., Hollis, C., Kochhar, P., Hennessy, E., Wolke, D., &
Marlow, N. (2010). Psychiatric disorders in extremely preterm chil-
dren: Longitudinal finding at age 11 years in the EPICure study.
Journal of the American Academy of Child and Adolescent Psychi-
atry,49(5), 453463 e451.
Kennell, J., Klaus, M., McGrath, S., Robertson, S., & Hinkley, C.
(1991). Continuous emotional support during labor in a US hospi-
tal. Jama,265(17), 21972201.
Kenrick, D. T., Griskevlelus, V., Neuberg, S. L., & Schaller, M.
(2010). Renovating the pyramid of needs: Contemporary extensions
built upon ancient foundations. Perspective on Psychological Sci-
ence,5(3), 292314.
Klaus, M., & Kennell, J. (1982). The bonding phenomenon: Misinter-
pretations and their implications. The Journal of Paediatrics,101
(4), 555557.
Klaus, M. H. (1987). The frequency of suckling. A neglected but essen-
tial ingredient of breast-feeding. Obstetrics and Gynecology Clinics
of North America,14(3), 623633.
Klaus, M. H. (2009). Commentary: An early, short, and useful sensitive
period in the human infant. Birth,36(2), 110112.
Klaus, M. H., Jerauld, R., Kreger, N. C., McAlpine, W., Steffa, M., &
Kennel, J. H. (1972). Maternal attachment. Importance of the first
post-partum days. New England Journal of Medicine,286(9),
Klaus, M. H., Kennell, J. H., Plumb, N., & Zuehlke, S. (1970). Human
maternal behavior at the first contact with her young. Pediatrics,46
(2), 187192.
Kramer, M. S., Aboud, F., Mironova, E., Vanilovich, I., Platt, R. W.,
Matush, L., Shapiro, S. (2008). Breastfeeding and child cogni-
tive development: New evidence from a large randomized trial.
Archives of General Psychiatry,65(5), 578584.
Lamb, M. E. (1982a). The bonding phenomenon: Misinterpretations
and their implications. The Journal of Pediatrics,101(4), 555557.
Lamb, M. E. (1982b). Early contact and maternal-infant bonding: One
decade later. Pediatrics,70(5), 763768.
Lawn, J. E., Mwansa-Kambafwile, J., Horta, B. L., Barros, F. C., &
Cousens, S. (2010). 'Kangaroo mother care' to prevent neonatal
deaths due to preterm birth complications. International Journal of
Epidemiology,39(Suppl. 1), i144i154.
Lee, L. A., Carter, M., Stevenson, S. B., & Harrison, H. A. (2014).
Improving family-centered care practices in the NICU. Neonatal
Network,33(3), 125132.
Lehrman, D. S. (1953). A critique of Konrad Lorenz's theory of instinc-
tive behavior. Quarterly Review of Biology,28(4), 337363.
Lester, D., Hvezda, J., Sullivan, S., & Plourde, R. (1983). Maslow's
hierarchy of needs and psychological health. Journal of General
Psychology,109(1), 8385.
Lewis, T. L., & Maurer, D. (2005). Multiple sensitive periods in human
visual development: Evidence from visually deprived children.
Developmental Psychobiology,46(3), 163183.
Lind, J. (1960). Changes in the circulation and lungs at birth. Acta
Paediatrica Supplementum,49(Suppl. 122), 3952.
Loman, M. M., & Gunnar, M. R. (2010). Early experience and the
development of stress reactivity and regulation in children. Neuro-
science and Biobehavioral Reviews,34(6), 867876.
Ludington-Hoe, S. M., Cong, X., & Hashemi, F. (2002). Infant crying:
Nature, physiologic consequences, and select interventions. Neona-
tal Network,21(2), 2936.
Ludwig, R. J., & Welch, M. G. (2019). Darwin's other dilemmas and
the theoretical roots of emotional connection. Frontiers in Psychol-
ogy,10, 683.
McAnulty, G., Duffy, F. H., Kosta, S., Weisenfeld, N. I.,
Warfield, S. K., Butler, S. C., Als, H. (2012). School age effects
of the newborn individualized developmental care and assessment
program for medically low-risk preterm infants: Preliminary
findings. Journal of Clinical Neonatology,1(4), 184194. https://
McEwen, B. S. (1998). Protective and damaging effects of stress medi-
ators. New England Journal of Medicine,338(3), 171179.
McKenna, J. J., Ball, H. L., & Gettler, L. T. (2007). Mother-infant cos-
leeping, breastfeeding and sudden infant death syndrome: What
biological anthropology has discovered about normal infant sleep
and pediatric sleep medicine. American Journal of Physical Anthro-
pology Supplement,45, 133161.
Meaney, M. J., & Szyf, M. (2005). Maternal care as a model for
experience-dependent chromatin plasticity? Trends in Neurosci-
ences,28(9), 456463.
Mercer, J. S., Erickson-Owens, D. A., Graves, B., & Haley, M. M.
(2007). Evidence-based practices for the fetal to newborn transition.
Journal of Midwifery and Women's Health,52(3), 262272. https://
Michelsson, K., Christensson, K., Rothganger, H., & Winberg, J.
(1996). Crying in separated and non-separated newborns: Sound
spectrographic analysis. Acta Paediatrica,85(4), 471475.
Miles, R., Cowan, F., Glover, V., Stevenson, J., & Modi, N. (2006). A
controlled trial of skin-to-skin contact in extremely preterm infants.
Early Human Development,82(7), 447455.
Moore, E. R., Bergman, N., Anderson, G. C., & Medley, N. (2016).
Early skin-to-skin contact for mothers and their healthy newborn
infants. Cochrane Database of Systematic Reviews,11, Cd003519.
Morgan, B. E., Horn, A. R., & Bergman, N. J. (2011). Should neonates
sleep alone? Biological Psychiatry,70(9), 817825.
Mori, R., Khanna, R., Pledge, D., & Nakayama, T. (2010). Meta-
analysis of physiological effects of skin-to-skin contact for new-
borns and mothers. Pediatrics International,52(2), 161170.
Nelson, E. E., & Panksepp, J. (1998). Brain substrates of infant-mother
attachment: Contributions of opioids, oxytocin and norepinephrine.
Neuroscience and Biobehavioral Reviews,22(3), 437452.
Neu, J. (2014). The developing intestinal microbiome: Probiotics and
prebiotics. World Review of Nutrition and Dietetics,110, 167176.
Numan, M. (1994). A neural circuitry analysis of maternal behavior in
the rat. Acta Paediatrica Supplement,397,1928.
Nyqvist, K. H., Anderson, G. C., Bergman, N., Cattaneo, A.,
Charpak, N., Davanzo, R., Widstrom, A. M. (2010). Towards
universal kangaroo mother care: Recommendations and report from
the First European conference and Seventh International Workshop
on Kangaroo Mother Care. Acta Paediatrica,99(6), 820826.
Ortenstrand, A., Westrup, B., Brostrom, E. B., Sarman, I.,
Akerstrom, S., Brune, T., Waldenstrom, U. (2010). The Stock-
holm neonatal family centered care study: Effects on length of stay
and infant morbidity. Pediatrics,125(2), e278e285. https://doi.
Orton, J., Spittle, A., Doyle, L., Anderson, P., & Boyd, R. (2009). Do
early intervention programmes improve cognitive and motor out-
comes for preterm infants after discharge? A systematic review.
Developmental Medicine and Child Neurology,51(11), 851859.
Panksepp, J. (1998). Affective neuroscience. New York, NY: Oxford
University Press.
Panter-Brick, C., & Leckman, J. F. (2013). Resilience in child
developmentInterconnected pathways to wellbeing. Journal of
Child Psychology and Psychiatry and Allied Disciplines,54(4),
Parker, K. J., Buckmaster, C. L., Sundlass, K., Schatzberg, A. F., &
Lyons, D. M. (2006). Maternal mediation, stress inoculation, and
the development of neuroendocrine stress resistance in primates.
PNAS,103(8), 30003003.
Parker, L. A., Sullivan, S., Krueger, C., Kelechi, T., & Mueller, M.
(2013). Strategies to increase milk volume in mothers of VLBW
infants. MCN: American Journal of Maternal Child Nursing,38(6),
Parker, L. A., Sullivan, S., Krueger, C., & Mueller, M. (2015). Associa-
tion of timing of initiation of breastmilk expression on milk volume
and timing of lactogenesis stage II among mothers of very low-
birth-weight infants. Breastfeeding Medicine,10(2), 8491. https://
Paterno, M. T., Van Zandt, S. E., Murphy, J., & Jordan, E. T. (2012).
Evaluation of a student-nurse doula program: An analysis of doula
interventions and their impact on labor analgesia and cesarean birth.
Journal of Midwifery & Women's Health,57(1), 2834.
Peirano, P., Algarin, C., & Uauy, R. (2003). Sleep-wake states and their
regulatory mechanisms throughout early human development. Jour-
nal of Pediatrics,143(4), S70S79.
Peirano, P. D., & Algarin, C. R. (2007). Sleep in brain development.
Biological Research,40(4), 471478.
Perry, B. D., Pollard, R. A., Blakely, T. L., Baker, W. L., &
Vigilante, D. (1995). Childhood trauma, the neurobiology of adap-
tation and "use-dependent" development of the brain. How"states"
become "traits". Infant Mental Health,16(4), 271291.
Pfister, R. E., Ramsden, C. A., Neil, H. L., Kyriakides, M. A., &
Berger, P. J. (2001). Volume and secretion rate of lung liquid in the
final days of gestation and labour in the fetal sheep. Journal of
Physiology,535(Pt 3), 889899.
Pinto-Martin, J. A., Levy, S. E., Feldman, J. F., Lorenz, J. M.,
Paneth, N., & Whitaker, A. H. (2011). Prevalence of autism spec-
trum disorder in adolescents born weighing <2000 grams. Pediat-
rics,128(5), 883891.
Porges, S. W., Davila, M. I., Lewis, G. F., Kolacz, S., Okonmah-
Obazee, A. A., Kwon, K. Y., Welch, M. G. (2019). Autonomic
regulation of preterm infants is enhanced by family nurture inter-
vention. Developmental Psychobiology,111.
Premji, S. (2014). Perinatal distress in women in low- and middle-
income countries: Allostatic load as a framework to examine the
effect of perinatal distress on preterm birth and infant health. Mater-
nal and Child Health Journal,18(10), 23932407.
Principi, N., Di Pietro, G. M., & Esposito, S. (2018). Bron-
chopulmonary dysplasia: Clinical aspects and preventive and thera-
peutic strategies. Journal of Translational Medicine,16(1), 36.
Prouhet, P. M., Gregory, M. R., Russell, C. L., & Yaeger, L. H. (2018).
Fathers' stress in the neonatal intensive care unit: A systematic
review. Advances in Neonatal Care,18(2), 105120. https://doi.
Pugliese, M., Rossi, C., Guidotti, I., Gallo, C., Della Casa, E.,
Bertoncelli, N., Ferrari, F. (2013). Preterm birth and
developmental problems in infancy and preschool age part II:
Cognitive, neuropsychological and behavioural outcomes. The
Journal of Maternal-Fetal and Neonatal Medicine,26(16),
Raineki, C., Pickenhagen, A., Roth, T. L., Babstock, D. M.,
McLean, J. H., Harley, C. W., Sullivan, R. M. (2010). The neu-
robiology of infant maternal odor learning. Brazilian Journal of
Medical and Biological Research,43(10), 914919.
Rey, S. E., & Martinez, G. H. (1981). Maejo racional del nino pre-
maturo. Proceedings of the Conference 1 Curso de Medicina Fetal
y Neonatal, Bogota, Colombia: Fundacion Vivar, 1983. (Spanish).
(Manuscript available in English from UNICEF, 3 UN Plaza,
New York, NY: 10017).
Roberts, G., Anderson, P. J., De, L. C., & Doyle, L. W. (2010).
Changes in neurodevelopmental outcome at age eight in geographic
cohorts of children born at 22-27 weeks' gestational age during the
1990s. Archives of Disease in Childhood. Fetal and Neonatal Edi-
tion,95(2), F90F94.
Salariya, E. M., Easton, P. M., & Cater, J. I. (1978). Duration of breast-
feeding after early initiation and frequent feeding. Lancet,2(8100),
Saunders, H., Kraus, A., Barone, L., & Biringen, Z. (2015). Emotional
availability: Theory, research, and intervention. Frontiers in Psy-
chology,6, 1069.
Schaal, B., Hummel, T., & Soussignan, R. (2004). Olfaction in the fetal
and premature infant: Functional status and clinical implications.
Clinics in Perinatology,31(2), 261285.
Scheinkopf, S. J., Lagasse, L. L., Lester, M., Liu, J., Seifer, R.,
Bauer, C. R., Das, A. (2007). Vagal tone as a resilience factor in
children with prenatal cocaine exposure. Development and Psycho-
pathology,19(03), 649673.
Schore, A. N. (2001). Effects of a secure attachment relationship on
right brain development, affect regulation, and infant mental health.
Infant Mental Health Journal,22(12), 766.
Shatz, C. J. (1992). The developing brain. Scientific American,267(3),
Smith, K., Buehler, D. M., & Als, H. (Producer). (2015). Nursery
Assessment Manual, NIDCAP Nursery Program. Retrieved from
Steel, A., Frawley, J., Adams, J., & Diezel, H. (2015). Trained or pro-
fessional doulas in the support and care of pregnant and birthing
women: A critical integrative review. Health & Social Care in the
Community,23(3), 225241.
Strathearn, L. (2011). Maternal neglect: Oxytocin, dopamine and the
neurobiology of attachment. Journal of Neuroendocrinology,23
(11), 10541065.
Strathearn, L., Fonagy, P., Amico, J., & Montague, P. R. (2009). Adult
attachment predicts maternal brain and oxytocin response to infant
cues. Neuropsychopharmacology,34(13), 26552666.
Swain, J. E., Lorberbaum, J. P., Kose, S., & Strathearn, L. (2007).
Brain basis of early parent-infant interactions: Psychology, physiol-
ogy, and in vivo functional neuroimaging studies. Journal of Child
Psychology & Psychiatry,48(3/4), 262287.
Tabery, J. (2015). Why is studying genetics of intelligence so contro-
versial? The Hastings Center Report,45(Suppl. 5), S9S14. https://
Trevathan, W. R. (1993). The evolutionary history of childbirth: Biol-
ogy and cultural practices. Human Nature,4(4), 337350.
Trevathan, W. R. (1996). The evolution of bipedalism and assisted
birth. Medical Anthropology Quarterly,10(2), 287290.
Tronick, E., & Hunter, R. G. (2016). Waddington, dynamic systems,
and epigenetics. Frontiers in Behavioral Neuroscience,10, 107.
Twilhaar, E. S., Wade, R. M., de Kieviet, J. F., van Goudoever, J. B.,
van Elburg, R. M., & Oosterlaan, J. (2018). Cognitive outcomes of
children born extremely or very preterm since the 1990s and associ-
ated risk factors: A meta-analysis and meta-regression. JAMA Pedi-
atrics,172, 361367.
Skinner, B. F. (1938). The behaviour of organisms: An experimental
analysis. Oxford, England: Appleton-Century.
Uvnas-Moberg, K. (1999). Effects on mother and infant of oxytocin
released in the postpartum period. In The role of early experience
in infant development (pp. 283290). New Brunswick, NJ: Johnson
and Johnson Pediatric Institute.
van den Heuvel, M. P., Kersbergen, K. J., de Reus, M. A., Keunen, K.,
Kahn, R. S., Groenendaal, F., Benders, M. J. (2014). The neona-
tal connectome during preterm brain development. Cerebral Cor-
tex,25(9), 30003013.
Victora, C. G., Horta, B. L., Loret de Mola, C., Quevedo, L.,
Pinheiro, R. T., Gigante, D. P., Barros, F. C. (2015). Association
between breastfeeding and intelligence, educational attainment, and
income at 30 years of age: A prospective birth cohort study from
Brazil. The Lancet Global Health,3(4), e199e205.
WAIMH. (2016). WAIMH position paper on the rights of infants. Per-
spectives on Infant Mental Health, Winter-Spring, 35. http://www. https://perspectives.
corr/ [Accessed 23rd May 2019].
Welch, M. G. (2016). Calming cycle theory: The role of visceral/-
autonomic learning in early mother and infant/child behaviour and
development. Acta Paediatrica,105(11), 12661274. https://doi.
Welch, M. G., Firestein, M. R., Austin, J., Hane, A. A., Stark, R. I.,
Hofer, M. A., Ludwig, R. J. (2015). Family nurture intervention
in the neonatal intensive care unit improves social-relatedness,
attention, and neurodevelopment of preterm infants at 18 months in
a randomized controlled trial. Journal of Child Psychology and
Psychiatry,56(11), 12021211.
Welch, M. G., Halperin, M. S., Austin, J., Stark, R. I., Hofer, M. A.,
Hane, A. A., & Myers, M. M. (2016). Depression and anxiety
symptoms of mothers of preterm infants are decreased at 4 months
corrected age with family nurture intervention in the NICU.
Archives of Women's Mental Health,19(1), 5161.
Welch, M. G., & Ludwig, R. J. (2017a). Calming cycle theory and the
co-regulation of oxytocin. Psychodynamic Psychiatry,45(4),
Welch, M. G., & Ludwig, R. J. (2017b). Mother/infant emotional com-
munication through the lens of visceral/autonomic learning and
calming cycle theory. In M. Filippa, P. Kuhn, & B. Westrup (Eds.),
Early vocal contact and preterm infant brain development:
Bridging the gaps between research and practice. New York, NY:
Springer International Publishing.
Welch, M. G., & Myers, M. M. (2016). Advances in family-based
interventions in the neonatal ICU. Current Opinion in Pediatrics,
28(2), 163169.
Westrup, B. (2015). Family-centered developmentally supportive care:
The Swedish example. Archives de Pédiatrie,22(10), 10861091.
Westrup, B., Bohm, B., Lagercrantz, H., & Stjernqvist, K. (2004).
Preschool outcome in children born very prematurely and cared
for according to the newborn individualized developmental care
and assessment program (NIDCAP). Acta Paediatrica,93(4),
White, R. D. (2004a). Mothers' arms--the past and future locus of neo-
natal care? Clinics in Perinatology,31(2), 383387, ix. https://doi.
White, R. D. (2004b). The sensory environment of the NICU: Scientific
and designed-related aspects. Clinics in Perinatology,31(2),
White, R. D. (2011). Designing environments for developmental care.
Clinics in Perinatology,38(4), 745749.
Whitelaw, A. (1990). Kangaroo baby care: Just a nice experience or
an important advance for preterm infants? Pediatrics,85(4),
Whitelaw, A., & Sleath, K. (1985). Myth of the marsupial mother:
Home care of very low birth weight babies in Bogota, Colombia.
Lancet,1(8439), 12061208.
WHO. (2003). Kangaroo mother care - A practical guide. Geneva,
Switzerland: WHO.
Widstrom, A. M., Lilja, G., Aaltomaa-Michalias, P., Dahllof, A.,
Lintula, M., & Nissen, E. (2010). Newborn behaviour to locate the
breast when skin-to-skin: A possible method for enabling early
self-regulation. Acta Paediatrica,100(1), 7985.
Zhang, Y. J., Li, S., Gan, R. Y., Zhou, T., Xu, D. P., & Li, H. B.
(2015). Impacts of gut bacteria on human health and diseases. Inter-
national Journal of Molecular Sciences,16(4), 74937519. https://
How to cite this article: Bergman NJ, Ludwig R,
Westrup B, Welch M. Nurturescience versus
neuroscience: A case for rethinking perinatal mother
infant behaviors and relationship. Birth Defects
Research. 2019;118.
... Parents report feelings of guilt, shame and high levels of stress, mood, and anxiety symptoms [1,4]. This is associated with an elevated risk for subsequent impaired child development and poorer family functioning [5][6][7][8][9]. A multi-layered approach to support parents in the NICU with particular attention to mental health has been recently highlighted [10,11]. ...
... We can observe a strong relational as well as emotional connotation in the parental stress emerging from this study. Prolonged separation from the newborn interferes with the parent/child relationship, a fundamental and neurobiologically founded factor for infant development and health [2,6]. The need of closeness, contact and interaction between parent and child is rooted in instincts programmed by evolution for the safety of the mammalian offspring, and separation may induce distress and fear in both [2,6]. ...
... Prolonged separation from the newborn interferes with the parent/child relationship, a fundamental and neurobiologically founded factor for infant development and health [2,6]. The need of closeness, contact and interaction between parent and child is rooted in instincts programmed by evolution for the safety of the mammalian offspring, and separation may induce distress and fear in both [2,6]. During the pandemic, parental visits in NICU are limited and nurturing experiences including breastfeeding, kangaroo care, or parents' talking with their infant, which are routinely employed to mitigate stress, are less frequent or not feasible [3,12,13]. ...
Full-text available
The current SARS-CoV-2 disease (COVID-19) pandemic is a sudden major stressor superimposed on pre-existing high distress in parents of infants admitted to the neonatal intensive care unit (NICU). This study aimed to investigate the psychological wellbeing of NICU parents during the COVID-19 pandemic. Forty-four parents of 25 inpatients of the Padua University Hospital NICU were included from June 2020 to February 2021. At 7–14 days postpartum parents completed the Edinburgh Postnatal Depression Scale (EPDS), State-Trait Anxiety Inventory (STAI), Parental Stressor Scale: NICU (PSS:NICU) and an ad-hoc questionnaire measuring parental COVID-19 related stress. About one third of parents reported extreme/high stress and a relevant negative impact on parenthood experience. Less time (82%) and less physical contact (73%) with infants due to COVID-19 preventive measures were the most frequent negative factors. Higher COVID-19 related parental stress was positively associated with anxiety, depression, NICU parental stress, stress related to NICU environment, and parental role alterations. Depression symptoms, stress related to infant condition and parental role alterations were higher in mothers. The pandemic affected parental emotional and relational wellbeing directly through additional stress due to COVID-19 concerns and indirectly through the impact of restrictions on the experience of becoming parents.
... Mother-infant connection is related to attachment, described by Bowlby as a relationship whereby children are strongly disposed to seek proximity and contact with their primary caregiver, and who do so in stressful situations [8,9]. In full-term infant populations, infant breastfeeding is associated with more secure mother-child attachment and greater maternal responsiveness [10]. ...
... Children 2022, 9, 296 ...
Full-text available
Maternal milk (MM) intake during neonatal intensive care unit (NICU) hospitalization is associated with improved neurodevelopment in preterm infants. Underlying mechanisms may include stronger mother–infant emotional connection. This paper examines associations between MM provision in the NICU with maternal connection to her infant using three factors validated in our sample: maternal sensitivity, emotional concern, and positive interaction/engagement. We studied 70 mothers of infants born <1500 g and/or <32 weeks’ gestation. Associations between MM provision and mother–infant connection were modeled using median regression adjusted for clustering. Mothers who provided exclusive MM (i.e., 100% MM, no other milk) reported higher levels of maternal sensitivity by a median score of 2 units (β = 2.00, 95% CI: 0.76, 3.24, p = 0.002) than the mixed group (i.e., MM < 100% days, other milk ≥1 days), as well as greater emotional concern (β = 3.00, 95% CI: −0.002, 6.00, p = 0.05). Among mothers of very preterm infants, greater milk provision was associated with greater maternal sensitivity, but also with greater emotional concern about meeting the infant’s needs. These findings highlight the importance of supporting MM provision and early infant care as an integrated part of lactation support. The findings may also provide insight into links between MM provision in the NICU and infant neurodevelopment.
... Parent-infant attachment is essential for infant development. Evidence points to the avoidance of separation [37] and that parents' presence and involvement benefit both infants and their families [38]. The presence and involvement of parents may ameliorate their infants' neuroendocrine stress responses, accordingly mitigating or even preventing toxic stress, and may influence long-term outcomes [37][38][39][40]. ...
... Evidence points to the avoidance of separation [37] and that parents' presence and involvement benefit both infants and their families [38]. The presence and involvement of parents may ameliorate their infants' neuroendocrine stress responses, accordingly mitigating or even preventing toxic stress, and may influence long-term outcomes [37][38][39][40]. ...
Full-text available
Background Worldwide, strict infection control measures including visitation regulations were implemented due to the COVID-19 pandemic at Neonatal Intensive Care Units (NICUs). These regulations gave restricted access for parents to their hospitalized infants. The consequence was limited ability to involve in the care of their infants. At Oslo University Hospital entry to NICU was denied to all except healthy mothers in March 2020. The absolute access ban for fathers lasted for 10 weeks. The aim of this study was to explore parental experiences with an infant hospitalized in the NICU during this absolute visitation ban period. Methods We invited post discharge all parents of surviving infants that had been hospitalized for at least 14 days to participate. They were interviewed during autumn 2020 using an explorative semi-structured interview approach. Data were analyzed via inductive thematic analysis. Results Nine mothers and four fathers participated. The COVID-19 regulations strongly impacted the parent’s experiences of their stay. The fathers’ limited access felt life-impacting. Parents struggled to become a family and raised their voices to be heard. Not being able to experience parenthood together led to emotional loneliness. The fathers struggled to learn how to care for their infant. The regulations might lead to a postponed attachment. On the other hand, of positive aspect the parents got some quietness. Being hospitalized during this first wave was experienced as exceptional and made parents seeking alliances by other parents. Social media was used to keep in contact with the outside world. Conclusions The regulations had strong negative impact on parental experiences during the NICU hospitalization. The restriction to fathers’ access to the NICU acted as a significant obstacle to early infant-father bonding and led to loneliness and isolation by the mothers. Thus, these COVID-19 measures might have had adverse consequences for families.
... This approach was widespread in Italy in the last decades, when "positioning a baby at the breast" was considered a professional competence, according to the educational programs available at that time [45]. More recently, in light of the evolving evidence, a different paradigm has emerged, considering the newborn and the mother's competencies and relationship as the core for breastfeeding success [46][47][48]. In this vision, the mother-newborn dyad should be supported in "doing it themselves", with the goal being to create an environment that allows instinctive behaviour that facilitate breastfeeding to be expressed without interference [49]. ...
Full-text available
Background Emergencies have a great impact on infant and young child feeding. Despite the evidence, the recommended feeding practices are often not implemented in the emergency response, undermining infant and maternal health. The aim of this study was to explore the experiences of pregnant and lactating women during the earthquake emergency that occurred in L’Aquila on 6 April 2009. Methods The study design was qualitative descriptive. Data were collected by individual semi-structured interviews, investigating the mother’s experiences of pregnancy, childbirth, breastfeeding, infant formula or complementary feeding during the emergency and the post emergency phase. Data analysis was categorical and was performed by using N-Vivo software. Results Six women who were pregnant at the time of the earthquake were interviewed in January 2010. In addition to the essential needs of pregnant and lactating women, such as those related to the emergency shelters conditions, the main findings emerged from this study were: the reconfiguration of relationships and the central role of partners and family support; the need of spaces for sharing experiences and practices with other mothers; the lack of breastfeeding support after the hospital discharge; the inappropriate donations and distribution of Breast Milk Substitutes. Conclusions During and after L’Aquila earthquake, several aspects of infant and young child feeding did not comply with standard practices and recommendations. The response system appeared not always able to address the specific needs of pregnant and lactating women. It is urgent to develop management plans, policies and procedures and provide communication, sensitization, and training on infant and young child feeding at all levels and sectors of the emergency response.
... Altricial animals require parental care during the neonatal period. Nurturing physical and emotional interactions between offspring and caregivers are instrumental in the processes of early postnatal growth and brain maturation (Bergman et al., 2019). Neglected or abused offspring often display developmental disturbances including weight loss, stunted growth, gastrointestinal disorders, impaired brain development and cognitive control, and immune incompetence (Homan, 2016;Wade et al., 2018;Park et al., 2021). ...
Full-text available
The quality of one’s adult health and the chances of maintaining cognitive ability in aging stem directly from the quality of care one receives as an infant. Formal studies of maternal care can be traced back at least a century. Revelations of behavioral outcomes after maternal deprivation in primates were followed by discoveries of systemic and brain growth factors mediated by the caregiver–offspring relationship in rodents. More recently, much of the genetic/epigenetic bases of maternal care has been defined and positively linked to adult health and cognitive ability in senescence. The history of this field is both tragic and fascinating. The early primate work, while informative, was abusive. The initial rodent work was ridiculed before its importance was recognized. The final lesson learned is that infant/toddler care matters a lot. Today, we have a better understanding of the biology underlying maternal care and its transmission across generations as well as a scientific basis for massaging premature infants and hugging our children.
... Examples include limitations in allowing only the parent who gave birth to stay with the newborn at the postnatal ward, or that a newborn in need of neonatal care may be separated from the parents completely until they recover, resulting in the parents missing out on the important first days of bonding with their newborn. 24 Similarly, severe maternal morbidity may aggravate emotional distress 25 and may be linked to a higher risk of post-traumatic stress disorder in both the mother 26 and the partner. 27 This, in turn, may negatively influence the parent-infant bond and affect subsequent child development. ...
Full-text available
Introduction There is limited knowledge on how the SARS-CoV-2 affects pregnancy outcomes. Studies investigating the impact of COVID-19 in early pregnancy are scarce and information on long-term follow-up is lacking. The purpose of this project is to study the impact of COVID-19 on pregnancy outcomes and long-term maternal and child health by: (1) establishing a database and biobank from pregnant women with COVID-19 and presumably non-infected women and their infants and (2) examining how women and their partners experience pregnancy, childbirth and early parenthood in the COVID-19 pandemic. Methods and analysis This is a national, multicentre, prospective cohort study involving 27 Swedish maternity units accounting for over 86 000 deliveries/year. Pregnant women are included when they: (1) test positive for SARS-CoV-2 (COVID-19 group) or (2) are non-infected and seek healthcare at one of their routine antenatal visits (screening group). Blood, as well as other biological samples, are collected at different time points during and after pregnancy. Child health up to 4 years of age and parent experience of pregnancy, delivery, early parenthood, healthcare and society in general will be examined using web-based questionnaires based on validated instruments. Short- and long-term health outcomes will be collected from Swedish health registers and the parents’ experiences will be studied by performing qualitative interviews. Ethics and dissemination Confidentiality aspects such as data encryption and storage comply with the General Data Protection Regulation and with ethical committee requirements. This study has been granted national ethical approval by the Swedish Ethical Review Authority (dnr 2020-02189 and amendments 2020-02848, 2020-05016, 2020-06696 and 2021-00870) and national biobank approval by the Biobank Väst (dnr B2000526:970). Results from the project will be published in peer-reviewed journals. Trial registration number NCT04433364 .
... Our proposed approach incorporates several important theories and overall concepts of infant neurobehavioral functioning and neurodevelopment that are particularly applicable to the infant affected by NAS/NOWS (Als, 1982(Als, , 1986(Als, , 2006Brazelton and Nugent, 1995;Brazelton and Robey, 1965;Lester et al., 2004;Lester et al., 2011), also including information regarding Sensory Integration Theory® (Ayers, 2005), behavioral epigenetics (Lester et al., 2011), early life stressors and programming of the stress response system (Kundakovic and Champagne, 2015), the "window of tolerance" (Siegel, 1999), polyvagal theory (Porges, 1995;Porges, 2009), maternal psychological functioning, mother-infant interaction (Mayes et al., 2012;Suchman et al., 2010;Welch, 2016), and environmental adaptation (Smith et al., 2015). Lastly, taken together, the comprehensive model derived from these theories and concepts and described below incorporates several principles of what some researchers call "nurturescience" (Bergman et al., 2019). ...
Discussions about non-pharmacologic interventions for Neonatal Abstinence Syndrome and Neonatal Opioid Withdrawal Syndrome (NAS/NOWS) have been minor compared with wider attention to pharmacologic treatments. Although historically under-recognized, non-pharmacologic interventions are of paramount importance for all substance-exposed infants and remains as a first line therapy for the care of infants affected by NAS. Here we examine the role of non-pharmacologic interventions for NAS/NOWS by incorporating theoretical perspectives from different disciplines that inform the importance of individualized assessment of the mother-caregiver/infant dyad and interventions that involve both individuals. NAS/NOWS is a complex, highly individualized constellation of signs/symptoms that vary widely in onset, duration, severity, expression, responses to treatment and influence on long-term outcomes. NAS/NOWS often occurs in infants with multiple prenatal/postnatal factors that can compromise neurobiological self-regulatory functioning. We propose to rethink some of the long-held assumptions, beliefs, and paradigms about non-pharmacologic care of the infant with NAS/NOWS, which is provided as non-specific or as “bundled” in current approaches. This paper is Part I of a two-part series on re-conceptualizing non-pharmacologic care for NAS/NOWS as individualized treatment of the dyad. Here, we set the foundation for a new treatment approach grounded in developmental theory and evidence-based observations of infant neurobiology and neurodevelopment. In Part II, we provide actionable, individually tailored evaluations and approaches to non-pharmacologic NAS/NOWS treatment based on measurable domains of infant neurobehavioral functioning.
... This approach was widespread in Italy in the last decades, when "positioning a baby at the breast" was considered a professional competence, according to the educational programs available at that time (40). More recently, in light of the evolving evidence, a different paradigm has emerged, considering the newborn and the mother's competencies and relationship as the core for breastfeeding success (41)(42)(43). In this vision, the mother-newborn dyad should be supported in "doing it themselves", with the goal being to create an environment that allows instinctive behaviour that facilitate breastfeeding to be expressed without interference (44). ...
Full-text available
Background: Emergencies have a great impact on infant and young child feeding. Although the evidence, the recommended feeding practices are often not implemented in the emergency response, undermining infant and maternal health. The aim of this study was to explore the experiences of pregnant and lactating women during the earthquake emergency that occurred in L’Aquila on April 6, 2009. Methods: The study design was qualitative descriptive. Data were collected by individual semi-structured interviews, investigating the mother’s experiences of pregnancy, childbirth, breastfeeding, infant formula or complementary feeding during the emergency and the post emergency phase. Data analysis was categorical and was performed by using N-Vivo software. Results: Six women who were pregnant at the time of the earthquake were interviewed in January 2010. In addition to the essential needs of pregnant and lactating women, such as those related to the emergency shelters conditions, the main findings emerged from this study were: the reconfiguration of relationships and the central role of partners and family support; the need of spaces for sharing experiences and practices with other mothers; the lack of breastfeeding support after the hospital discharge; the inappropriate donations and distribution of Breast Milk Substitutes. Conclusions: During and after L’Aquila earthquake, several aspects of infant and young child feeding did not comply with standard practices and recommendations. The response system appeared not always able to address the specific needs of pregnant and lactating women. It is urgent to develop management plans, policies and procedures and provide communication, sensitization, and training on infant and young child feeding at all levels and sectors of the emergency response.
El presente artículo tiene como objetivo revisar literatura científica existente sobre los efectos a largo plazo en la infancia cuando se produce una separación materna temprana. Los resultados muestran que las separaciones tempranas de las madres y sus bebés en la primera infancia producen efectos a largo plazo en los niños y adolescentes, en sus capacidades de autorregulación emocional (afectando a la función del eje hipotálamo-hipofisario-adrenal), en su paradigma de vinculación adulta, capacidades cognitivas, sociales y emocionales. Igualmente se muestra la relación entre la falta de disponibilidad materna en los primeros años y un patrón de apego desorganizado, lo que se relaciona con mayor vulnerabilidad a la psicopatología infantil y adulta. La posibilidad de ofrecer un sostén adecuado para establecer, mejorar y reparar el vínculo en la díada, junto con la intervención temprana interdisciplinar, se hace imprescindible para ofrecer unas posibilidades adecuadas para estas familias. Invertir en la promoción del bienestar familiar en las primeras etapas es una prevención eficaz para la psicopatología infantil posterior. De la revisión también se constata que se hacen necesarios más estudios longitudinales frente a retrospectivos, para evaluar los efectos a largo plazo de las separaciones.
Full-text available
Modern scientific theories of emotional behavior, almost without exception, trace their origin to Charles Darwin, and his publications On the Origin of Species (1859) and The Expression of the Emotions in Man and Animals (1872). The most famous dilemma Darwin acknowledged as a challenge to his theory of evolution through natural selection was the incomplete Sub-Cambrian fossil record. However, Darwin struggled with two other rarely referenced theoretical and scientific dilemmas that confounded his theories about emotional behavior. These included (1) the origin of social instincts (e.g., altruism, empathy, reciprocity and cooperation) and the reasons for their conservation in evolution and (2) the peripheral control of heart rate vis-à-vis emotional behavior outside of consciousness. Darwin acknowledged that social instincts are critical to the survival of some species, but had difficulty aligning them with his theory of natural selection in humans. Darwin eventually proposed that heart rate and emotions are controlled via one's intellect and cortical mechanisms, and that instinctive behavior is genetically programmed and inherited. Despite ongoing efforts, these two theoretical dilemmas are debated to this day. Simple testable hypotheses have yet to emerge for the biological mechanisms underlying instinctive behavior or the way heart rate is controlled in infants. In this paper, we review attempts to resolve these issues over the past 160 years. We posit that research and theories that supported Darwin's individualistic brain-centric and genetic model have become an "orthodox" Western view of emotional behavior, one that produced the prevailing behavioral construct of attachment as developed by John Bowlby. We trace research and theories that challenged this orthodoxy at various times, and show how these challenges were repeatedly overlooked, rejected, or misinterpreted. We review two new testable theories, emotional connection theory and calming cycle theory, which we argue resolve the two dilemmas We show emerging scientific evidence from physiology and a wide variety of other fields, as well from clinical trials among prematurely born infants, that supports the two theories. Clinical implications of the new theories and possible new ways to assess risk and intervene in emotional, behavioral and developmental disorders are discussed.
Full-text available
Aim The Welch Emotional Connection Screen (WECS), a new instrument, assesses mother‐infant Emotional Connection in clinical settings. It includes: Attraction, Vocal Communication, Facial Communication, Sensitivity/Reciprocity, and clinical decision of Emotional Connection (yes/no). We tested concurrent and construct validity of the WECS and associations with behavioral and physiological measures in preterm infants. Methods Videos from 76 mothers‐infants (gestational age 36 weeks) during an in‐NICU caregiving paradigm were coded for maternal caregiving behavior. Videos of mothers‐infants were also obtained at 4‐months during 10‐min of face‐to‐face play (coded with WECS and for maternal positivity and infant social engagement) and the still‐face paradigm (coded for infant behavioral approach toward mother, infant electrocardiogram acquired in‐vivo). Results WECS maternal scores positively associated with maternal sensitivity and quality of vocal contact at 36‐weeks(caregiving) and maternal positivity at 4 months(face‐to‐face). WECS infant scores positively correlated with infant social engagement and maternal positivity during face‐to‐face interactions at 4‐months. Infants from emotionally not connected dyads (vs emotionally connected dyads) displayed autonomic dysregulation and less approach‐seeking behavior toward mother during interactive/play sessions of the still‐face paradigm. Conclusion This preliminary evidence supports the WECS as a valid screen for rating mother‐preterm infant emotional connection associated with healthier infant biobehavioral stress responding. This article is protected by copyright. All rights reserved.
Full-text available
The assumption that early stress leads to dysregulation and impairment is widespread in developmental science and informs prevailing models (e.g., “toxic stress”). An alternative evolutionary-developmental approach, which complements the standard emphasis on dysregulation, proposes that early stress may prompt the development of costly but adaptive strategies that promote survival and reproduction in adverse conditions. Here we survey this growing theoretical and empirical literature, highlighting recent developments and outstanding questions. We review concepts of adaptive plasticity and conditional adaptation, introduce the life history framework and the Adaptive Calibration Model, and consider how physiological stress response systems and related neuroendocrine processes may function as plasticity mechanisms. We then address the evolution of individual differences in susceptibility to the environment, which engenders systematic person-environment interactions in the effects of stress on development. Finally, we discuss stress-mediated regulation of pubertal development as a case study of how an evolutionary-developmental approach can foster theoretical integration.
Full-text available
Background Bronchopulmonary dysplasia (BPD) is the result of a complex process in which several prenatal and/or postnatal factors interfere with lower respiratory tract development, leading to a severe, lifelong disease. In this review, what is presently known regarding BPD pathogenesis, its impact on long-term pulmonary morbidity and mortality and the available preventive and therapeutic strategies are discussed. Main bodyBronchopulmonary dysplasia is associated with persistent lung impairment later in life, significantly impacting health services because subjects with BPD have, in most cases, frequent respiratory diseases and reductions in quality of life and life expectancy. Prematurity per se is associated with an increased risk of long-term lung problems. However, in children with BPD, impairment of pulmonary structures and function is even greater, although the characterization of long-term outcomes of BPD is difficult because the adults presently available to study have received outdated treatment. Prenatal and postnatal preventive measures are extremely important to reduce the risk of BPD. Conclusion Bronchopulmonary dysplasia is a respiratory condition that presently occurs in preterm neonates and can lead to chronic respiratory problems. Although knowledge about BPD pathogenesis has significantly increased in recent years, not all of the mechanisms that lead to lung damage are completely understood, which explains why therapeutic approaches that are theoretically effective have been only partly satisfactory or useless and, in some cases, potentially negative. However, prevention of prematurity, systematic use of nonaggressive ventilator measures, avoiding supraphysiologic oxygen exposure and administration of surfactant, caffeine and vitamin A can significantly reduce the risk of BPD development. Cell therapy is the most fascinating new measure to address the lung damage due to BPD. It is desirable that ongoing studies yield positive results to definitively solve a major clinical, social and economic problem.
Full-text available
Importance: Despite apparent progress in perinatal care, children born extremely or very preterm (EP/VP) remain at high risk for cognitive deficits. Insight into factors contributing to cognitive outcome is key to improve outcomes after EP/VP birth. Objective: To examine the cognitive abilities of children of EP/VP birth (EP/VP children) and the role of perinatal and demographic risk factors. Data Sources PubMed, Web of Science, and PsycINFO were searched without language restriction (last search March 2, 2017). Key search terms included preterm, low birth weight, and intelligence. Study Selection: Peer-reviewed studies reporting intelligence scores of EP/VP children (<32 weeks of gestation) and full-term controls at age 5 years or older, born in the antenatal corticosteroids and surfactant era, were included. A total of 268 studies met selection criteria, of which 71 covered unique cohorts. Data Extraction and Synthesis: MOOSE guidelines were followed. Data were independently extracted by 2 researchers. Standardized mean differences in intelligence per study were pooled using random-effects meta-analysis. Heterogeneity in effect size across studies was studied using multivariate, random-effects meta-regression analysis. Main Outcomes and Measures: Primary outcome was intelligence. Covariates included gestational age, birth weight, birth year, age at assessment, sex, race/ethnicity, socioeconomic status, small for gestational age, intraventricular hemorrhage, periventricular leukomalacia, bronchopulmonary dysplasia (BPD), necrotizing enterocolitis, sepsis, and postnatal corticosteroid use. Results: The 71 included studies comprised 7752 EP/VP children and 5155 controls. Median gestational age was 28.5 weeks (interquartile range [IQR], 2.4 weeks) and the mean age at assessment ranged from 5.0 to 20.1 years. The median proportion of males was 50.0% (IQR, 8.7%). Preterm children had a 0.86-SD lower IQ compared with controls (95% CI, −0.94 to −0.78, P < .001). Results were heterogeneous across studies (I² = 74.13; P < .001). This heterogeneity could not be explained by birth year of the cohort. Multivariate meta-regression analysis with backward elimination revealed that BPD explained 65% of the variance in intelligence across studies, with each percent increase in BPD rate across studies associated with a 0.01-SD decrease in IQ (0.15 IQ points) (P < .001). Conclusions and Relevance: Extremely or very preterm children born in the antenatal corticosteroids and surfactant era show large deficits in intelligence. No improvement in cognitive outcome was observed between 1990 and 2008. These findings emphasize that improving outcomes after EP/VP birth remains a major challenge. Bronchopulmonary dysplasia was found to be a crucial factor for cognitive outcome. Lowering the high incidence of BPD may be key to improving long-term outcomes after EP/VP birth.
Maternal-neonate separation for human newborns has been the standard of care since the last century; low birth weight and preterm infants are still routinely separated from their mothers. With advanced technology, survival is good, but long-term developmental outcomes are very poor for these especially vulnerable newborns. The poor outcomes are similar to those described for adversity in childhood, ascribed to toxic stress. Toxic stress is defined as the absence of the buffering protection of adult support. Parental absence has been strictly enforced in neonatal care units for many reasons and could lead to toxic stress. The understanding of toxic stress comes from discoveries about our genome and epigenetics, the microbiome, developmental neuroscience and the brain connectome, and life history theory. The common factor is the early environment that gives (a) signals to epigenes, (b) sensory inputs to neural circuits, and (c) experiences for reproductive fitness. For human newborns that environment is direct skin-to-skin contact from birth. Highly conserved neuroendocrine behaviors determined by environment are described in this review. The scientific rationale underlying skin-to-skin contact is presented: autonomic development and regulation of the physiology leads to emotional connection and achieving resilience. Maternal-neonate separation prevents these critical neural processes from taking place, but also channel development into an alternative developmental strategy. This enables better coping in a stressful environment in the short term, but with permanently elevated stress systems that negatively impact mental and physical health in the long term. This may explain the increasing incidence of developmental problems in childhood, and also Developmental Origins of Health and Disease. Arguments are presented that maternal-neonate separation is indeed a source of toxic stress, and some suggestions are offered toward a "zero separation" paradigm.
The relation between early mother–infant skin‐to‐skin contact (SSC) and mothers' subsequent sensitivity to their low birth weight infants was investigated in a study of 12 mother–infant dyads who participated in a South African randomized control study of early SSC. The dyads were visited in the home when infants were under 1 year. Amounts of SSC were taken from hospital records and home interviews. Videotapes of mother–infant interactions in the home were scored for maternal sensitivity on the Maternal Behavior Q‐Sort (D.R. Pederson, G. Moran, & S. Bento, 1999) and the Maternal Behavior subscale of the Nursing Child Assessment Teaching Scale (G. Sumner & A. Spietz, 1994). Amount of SSC in infants' first 24 hr correlated with amount of SSC through the first month. Amount of SSC in infants' first 24 hr independently accounted for maternal sensitivity on both measures, indicating that early mother–infant SSC predicted subsequent maternal sensitivity.
Background: Admission to the neonatal intensive care unit (NICU) is stressful for parents. Nurses often focus on maternal well-being and fail to acknowledge the stress of fathers. Research on fathers' psychological stress is limited. Purpose: A systematic review of the literature was completed to examine the extent of psychological stress and types of stressors in fathers with infants admitted to the NICU. Methods/search strategy: A search of Ovid MEDLINE, Cochrane Library, PsycINFO, CINAHL, and EMBASE was conducted to identify descriptive and observational studies reporting father-specific stress in the NICU. Studies using observational and descriptive designs, published in English, and reporting father-specific stress outcomes during a NICU admission were eligible for inclusion. Strengthening the Reporting of Observational Studies in Epidemiology guidelines were used for quality assessment. Results: Fifteen studies met inclusion criteria. Fathers find the NICU environment stressful and are more stressed than fathers of full-term, healthy infants. Parental role alteration, infant appearance, NICU environment, and staff communication are stressors. Implications for practice/research: By recognizing the extent and types of psychological stress in fathers, nurses can provide better support for fathers in their new role. Younger fathers and those with very low birth-weight premature infants may need additional support and resources. Future research on fathers' stress should include larger sample sizes, diverse populations, and tool development and evaluation.