Neonatal Cardiometabolic Palpation: A New Paradigm in Biodynamic Practice

http://www.cranio.co.uk/craniosacral-advanced-courses/birthtransition.shtml

Introduction

The first year of life after birth is the most metabolically active time in the entire human lifespan. Extensive remodeling of the brain, lungs, heart and gut must begin within moments after birth. Microcirculation increases dramatically in the brain as the endothelium changes function to accommodate the intensive growth of neurons. High levels of cortisol and catecholamines are necessary for the lungs to begin their powerful operation of converting carbon dioxide to oxygen. The gut goes through intensive microcirculation to accommodate breast-feeding. The metabolic engine of life starts with the gut microbiome and includes the functions of urinating and defecating or more properly the filling of diapers. Finally the heart goes through the most extensive remodeling as the endocardial cells change function and especially the way in which glucose is converted. Glucose is no longer stored in the neonatal heart and therefore it must switch from glycolysis to lipid conversion from the fatty molecules in breastmilk or formula that is hopefully sugar free. From the beginning of life after birth, the conversion of high quality fats to glucose for the use in our anabolic metabolism becomes vitally important throughout the lifespan.

A Metabolic Protocol

In order to support such dramatic metabolic growth throughout the body and especially those four organ systems, I have developed a 10 step protocol to evaluate and support the metabolism of a newborn baby, specifically the cardiovascular system. The basic principles of the Long Tide Model of Biodynamic Craniosacral Therapy are being applied to the cardiovascular system of the baby. This simply means that the practitioner has embodied Primary Respiration in their mind, body and heart.

This is not so much of a protocol in terms of clinical practice although it can be used in that fashion. It is more like a buffet to choose from when treating a family. I teach it in a linear sequence in class but as most pediatric therapists know, once the infant comes in in the arms of a worried mother, adaptation is always necessary. Thus, it is helpful to know the metabolic logic behind each palpation skill. What is happening inside this baby’s body at a deep level? The deep level is the metabolic level. I will now go through the sequence as I teach it in class knowing that the reader must adapt to the immediate environment of the family system that is presented to you in your office. There are certainly other skills that can be blended and at times must be blended. What follows basically starts at the feet and heads to the top.

The Extremities

The most basic principle in biodynamic cardiovascular work is to work from periphery to center. Step one when possible with an infant is contact with either or both of the anterior and posterior tibial arteries. This is especially valuable with infants who have had their umbilical cord cut prematurely. It is estimated that there is a loss of approximately 20% blood volume coming from the placenta and the cord that does not get to reach the babies cardiovascular system. This can lead to what is called hypovolemic shock. Since there is extensive remodeling happening in the entire cardiovascular system more centrally in the core of the body, the extremities experience a loss of blood volume and consequently the central core metabolism is working harder especially since the normal infant heart rate is:

Neonate (less than 28 days) Awake: 100-205 BPM, Sleep: 90-160 BPM
Infant (1 month-1 year) Awake: 100-190 BPM, Sleep: 90-160 BPM
Toddler (1-2 year) Awake: 98-140 BPM, Sleep: 80-120 BPM

Contact with the tibial arteries and the brachial arteries supports the resolution of hypovolemic shock and relaxation of the vascular tree when practiced in conjunction with the other skills mention below. At another level one of the most important metabolic functions happening in a newborn is thermal regulation. The function of skin to skin contact (SSC) with a caregiver supports this function. Metabolically, there are two interconnected thermal systems. One is in the core of the body and the other is in the extremities. They get connected via the cardiovascular system and the sympathetic nervous system regulating blood flow and vessel wall dilation and contraction especially in the capillary. Working biodynamically with the arteries in a newborn supports proper development of thermal regulation and the metabolism of the autonomic nervous system. Thus, the contact with the tibial and brachial arteries supports the extremities and later the contact with the gut arteries supports the core. Together they support thermal regulation.

Next, bilateral contact is made with the femoral arteries at midthigh in the septum between the quadriceps and abductor muscles. In the adult I usually work ipsilaterally. This location is a Traditional Chinese Medicine (TCM) pulse location but in the case of a newborn baby it supports proper blood flow to the pelvic floor for the function of urinating and defecating. Remember that full diapers in an infant are a good thing. I typically make bilateral contact with my thumbs which is quite easy to do with the infant.

The Gut

The gut is really the new center of the body regarding health and disease. In order to support microcirculation in the small and large intestine, I like to place one hand palm up to feel the fluid body breathing on top of the umbilicus. I wait until I can sense Primary Respiration breathing through my hand and through the infant at the level of the umbilicus. This also supports the wound healing of the umbilicus. Then I make gentle contact with one finger on the superior mesenteric artery slightly above the umbilicus and another finger from the same hand can make contact with the inferior mesenteric artery just to the side of the umbilicus. The mesenteric arteries are linked to the sympathetic nervous system and especially the function of thermal regulation in the newborn metabolism as mentioned above. Thermal regulation in the abdomen is core thermal regulation. By supporting the microcirculation of the superior and inferior mesenteric arteries, two metabolic functions are being supported. One is core thermal regulation and the other is how the small and large intestine are remodeling with substantial amounts of blood being redirected into a vast new endothelium forming in the core of the body.

It must also be remembered that along with microcirculation, the gut microbiome of the baby is being constructed and the sub diaphragmatic vagus is initiating it’s communication from the gut microbiome to the brain and heart. This communication is founded on the generation of an internal sense of safety while the brain of the newborn is oriented to an external sense of safety via the social nervous system of the polyvagal system. In addition, the vagus nerve contributes to peeing and pooping for the proper and regular filling of diapers. The parasympathetic function of vagal immobilization plays an essential role in bladder and bowel function especially in the newborn.

Ipsilateral contact is then made with the renal arteries in order to support cardiometabolic function and the metabolic fluid body via the RAAS (Renin-Aldosterone-Angiotensin System) between the kidneys, liver, lungs and heart. Briefly, the RAAS regulates the function of the water molecule at the level of the capillary between those particular organs. The water molecule is a carrier molecule for red blood cells and immune system molecules through the endothelial wall of the capillary. I like to make ipsilateral contact with one finger in the general location of the renal artery and my other finger under the infant’s kidney. I simply use my thumb and index finger like a horseshoe shape for the contact. I recommend treating both sides of the renal artery remembering that the left kidney is slightly more superior than the right.

The Neck

The next possible contact is with the subclavian arteries. Since a baby’s body is small, it is possible to make bilateral contact with just a thumb and index finger. However most babies that I have ever worked with will try to take my hand away when I gets too close to the neck, face and head. I don’t like to approach an infant’s head and neck from behind. Consequently, I like to introduce myself to the infant and figure out a communication style in which I can negotiate permission to make contact and receive a yes or a no that is pretty clear. This could be anything from a nod of the head to a facial expression. As is the case with most adults, I now work ipsilaterally and just approach the subclavian artery one side at a time.

There is so much stress in our culture that it is important to approach that area of the body which is highly innervated by the autonomic nervous system, very gently and with great kindness. The subclavian artery can be approached around the mid clavicular area either with contact on the clavicle itself or simply on top and behind the clavicle in the soft tissue suspending the artery. It is quite easy to sense the artery through the bone of the clavicle. It just requires patience. The subclavian artery is very important in terms of the heart-brain communication system. It has an important sympathetic nerve wrapped around it called the inferior cervical sympathetic ganglion also known as the stellate ganglion.

Then I like to approach the carotid arteries once again ipsilaterally. Remember that the left carotid artery arises directly from the aorta and the right carotid artery arises from the subclavian artery. Each artery has a very different sensibility and responsiveness to Primary Respiration. I like to differentiate three areas on the carotid artery: First is the common carotid artery close to the proximal head of the clavicle where the tendon of the sternocleidomastoid (SCM) muscle inserts. Again a simple finger pad contact with the head of the clavicle or the tendon of the SCM superior to it can be enough to sense the artery.

Then I differentiate the carotid sinus where the carotid artery bifurcates into its external and internal branches. There is an important mechanoreceptor called a baroreceptor of the autonomic nervous system associated with the glossopharyngeal nerve located at the bifurcation. It is important in the regulation of blood pressure since the carotid arteries provide 80% of blood volume going to the brain and face.

Finally, I like to make contact with my little finger close to the styloid process where the vagus nerve exits the cranium into the carotid sheath that contains the vagus, the carotid artery and the jugular vein. This structure is located directly underneath the SCM muscle and is consequently quite easy to palpate. Anyone of these three geographical areas of the carotid is good to make contact with ipsilaterally. Of course, some infants can tolerate bilateral contact.

The Cranium

If I’m going to approach an infant around their cranium and face it will be for contact with the temporal artery that goes over the temporomandibular (TMJ) joint space and branches up into the temporalis muscle. This is very supportive for the suck-swallow-breathe reflex in the infant. The TMJ of an infant is not a hinge joint until solid food begins being introduced. Breast-feeding or bottle feeding requires that the mandible be able to slide forward and not hinge down. In addition, the suck-swallow-breathe reflex is the biggest structural influence on the development of this sphenobasilar joint space (SBJ). Although it is most common for practitioners to approach the cranial base via the SBJ of an infant I have found that this is often distressing for the infant. I like to teach new moms how to stroke their baby’s head which when done consistently remolds the infant’s cranium including the SPJ. Certainly, there are occasions when the SBJ of an infant is very compressed requiring help from a qualified and experienced practitioner.

The Heart

Last but not least in this teaching protocol is the heart itself. The most common contact I make with the baby is with the palm of my hand centered around the fifth thoracic (T5) vertebrae in the back of the child. I have never had a child refuse this contact. I then hold the child’s heart with Primer Respiration until I feel the heart and myocardium breathing with Primary Respiration.

If an infant is being held by his mother or in some cases playing on the floor or lying supine, I like to place my hand palm up over the central portion of the sternum to feel the fluid body breathing. Sometimes this position feels as if a blessing is being offered to the child. Then I use my fingers to connect with the valves of the heart starting with the costosternal margin on the left third rib (R3) and finishing with the right costosternal margin of the fifth rib (R5). This contact is intended to synchronize with the potency of Primer Respiration in the pulmonary valve, aortic valve, bicuspid (mitral) valve and tricuspid valve. With fingers on the sternum in this diagonal line the other hand can be in the position described above supporting the T5 vertebrae.

I should mention in conclusion that if a mother or family hands the baby to me and the baby is comfortable being held by me, I will most often have one hand supporting the sacrum and the other hand supporting the occiput and in this way sense the whole craniosacral system breathing with Primer Respiration. This is how Biodynamic Craniosacral Therapy is applied to both the metabolic and physiological systems of the baby. It is potentially a complete stabilizing and normalization of the baby after birth.

Recently, a young family came in with a newborn baby. It became apparent that the mom needed a session rather than the baby. I would like to remind all of us who work in this field that mom and dad are the priority. If she is okay and supported by her partner, then treating the infant is the next step rather than the first. The relationship of the family system is the priority.

I will be teaching this course in London next spring, 2018.

THE METABOLIC HEART OF A NEWBORN: CLINICAL APPROACHES FOR BABIES IN BIODYNAMIC PRACTICE
With Dr. Michael Shea B.A., M.A., Ph.D, B.C.S.T.
Birth dynamics and transition physiology in babies and adults.
April 12th-15th 2018
For more details:
http://www.cranio.co.uk/craniosacral-advanced-courses/birthtransition.shtml