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REVIEW ARTICLE
Nurturescience versus neuroscience: A case for rethinking
perinatal mother–infant behaviors and relationship
Nils J. Bergman
1
| Robert Ludwig
2
| Björn Westrup
1
| Martha Welch
2,3,4
1
Department of Women's and Children's
Health, Karolinska Institute, Stockholm,
Sweden
2
Department of Pediatrics, Columbia
University Irving Medical Center,
New York, New York
3
Department of Pathology and Cell Biology,
Columbia University Irving Medical Center,
New York, New York
4
Department of Psychiatry, Columbia
University Irving Medical Center,
New York, New York
Correspondence
Nils Bergman, Geijersgatan 16B, 75226
Uppsala, Sweden.
Email: nils@kangaroomothercare.com
Abstract
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 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 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 devel-
opmental problems.”
KEYWORDS
autonomic, development, life history, neonate, peripartum, resilience, separation, skin-to-skin contact,
toxic stress
1|INTRODUCTION
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;1–18. wileyonlinelibrary.com/journal/bdr2 © 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 “nurture”should 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
mother–infant 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 “nurture”phenomenon, 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
problems?
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 mother–infant 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 mother–infant emotional behaviors that
explain why the perinatal mother–infant 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 minutes”prepare 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.
2|THEORIES UNDERLYING
CURRENT CARE
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-
2BERGMAN ET AL.
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 “potential”for adaptive
emotional behaviors.
Attachment, as formulated by Bowlby, is a psychological
behavioral construct, where the infant's emotional behavior is
“self-regulated”via 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-regulate”emotional
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 “potential”to
respond to his surrounding environment in
emotional ways.
Q: Who does the infant respond to? A: The
infant “attaches”to the caregiver helping the
infant survive.
Q: What motivates the infant? A:The infant is
driven through self-interest and the need to
survive.
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-
ment”in 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
BERGMAN ET AL.3
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).
3|TIME TO RETHINK THE
PERINATAL MOTHER–INFANT
BEHAVIORS AND RELATIONSHIP
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 “nurture”aspect that distin-
guishes them from the studies reporting poorer outcomes.
4|INTRODUCING
NURTURESCIENCE
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 maternal–infant 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
4BERGMAN ET AL.
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
“attracted”to 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 3–10 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.
5|DISTINGUISHING
NURTURESCIENCE FROM
NEUROSCIENCE
A more explicit theory and framework has been evolving in
the Columbia–Karolinska 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
awareness
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 Genetics–epigenetics
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
Sociality
Interdependence
Self-actualization (Maslow)
Individualistic
Independence
Abbreviations: ANS, autonomic nervous system; CNS, central nervous system; ECD, early childhood development.
BERGMAN ET AL.5
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.
6|RELEVANT TIME PERIOD
The neuroscience behind Early Childhood Development
emphasizes the importance of the early years. The “First
1,000 days”recognize explicitly that development begins at
conception, but the first 2 years are decisive. Karolinska
nurturescience emphasizes the “first 1,000 minutes”after
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 days”policies 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 “good”thing 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
maternal–neonate 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
warmth.
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 affect”in 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).
7|CRITICAL PERIOD
The reader may react to the “nurturescientific”hyperbole
and excessive use of the word “critical”in 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 0–5 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 “immediately”upon 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 surely”that 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 “sensitive”period, and appeal to neu-
roplasticity for recovery. As used in developmental neurosci-
ence, the development of vision is proffered as an example;
6BERGMAN ET AL.
it is a complex matter with a sensitive period of 2 years
(Graven, 2004; Lewis & Maurer, 2005).
Rather, the “needed neural processes”taking 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 wire”of 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
“critical”and 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 affect”is
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
emotional–social 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.
8|AUTONOMIC OBJECTIVE
We highlight here the positive value of “homeostasis”in
neuroscience, whereby the ANS maintains physiological
BERGMAN ET AL.7
equilibrium in the self-regulating adult. In nurturescience,
more than homeostasis is needed for optimal development,
and “homeorhesis”conveys 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 danger”comes after some months).
Nurturescience recognizes the absence of maternal buffering
and regulation as acutely distressing to the neonate. The
“calming down”often 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).
9|EMOTIONAL LEARNING
MECHANISM
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-actualization”as 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).
10 |THEORETICAL ROOTS
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, “nurture”is 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. Mother–infant 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-
lized”is 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
8BERGMAN ET AL.
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).
11 |KEY OUTCOMES AND
OBJECTIVES
Neuroscience assumes that “attachment”is 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 mother–neonate and
mother–infant interactions (Hofer, 2006). This connection is
primarily emotional, and “emotional–social”in contrast to
socioemotional attachment.
A key departure point in nurturescience is that the cogni-
tion is not the “primary validity measure”of 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 emotional–social 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 care—nur-
ture—determined 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 proper—and
correct—understanding 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 infant–mother togetherness against
FIGURE 1 Key concepts of nurturescience,
from a perinatal perspective
BERGMAN ET AL.9
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
level.
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.
12 |IMPLICATIONS OF
NURTURESCIENCE
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, parent–infant 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.
13 |SKIN-TO-SKIN CONTACT
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
perspective
10 BERGMAN ET AL.
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 “stable”after 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 place—adif-
ferent environment or habitat. The medical and nursing
“care”required 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 dose–response
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, maternal–neonate
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,
BERGMAN ET AL.11
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.
14 |IMPLICATIONS FOR
MATERNAL 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
safe”is 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.
15 |CALMING CYCLE THEORY
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 maternal–infant
12 BERGMAN ET AL.
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 maternal–infant
reconnection.
16 |CONCLUSION
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 mother–infant 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 mother–infant 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.
ACKNOWLEDGMENT
The authors thank Jill Bergman for inputs and proofreading.
CONFLICT OF INTEREST
The authors declare that they have no conflict of interest.
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How to cite this article: Bergman NJ, Ludwig R,
Westrup B, Welch M. Nurturescience versus
neuroscience: A case for rethinking perinatal mother–
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