Kangaroo Care REALLY Works

Susan M. Ludington, Ph.D., RN, CNM, CKC, FAAN

Walters Professor of Pediatric Nursing

Executive Director of U.S. Institute for Kangaroo Care

www.kangaroocareusa.org

Purposes of the Talk

Differentiate between skin to skin contact and kangaroo care

Understand mechanisms by which Kangaroo Care, not skin-to-skin contact, works

Identify benefits of Kangaroo Care to infants, mothers, fathers

Understand new findings about Kangaroo care for infants with congenital heart defects, NAS, and imminent maternal demise

Relate tenets of Zero Separation and the TOXIC incubator environment

Explain safe positioning

What Kangaroo Care Is

1st KC is “CHEST-to-CHEST”, skin-to-skin contact

2nd : KC is not “any” skin-to- skin contact.

3rd : Skin-to-skin can be cheek-to-cheek, head-to-breast, arm-in-hand, but these positions Do Not Do what the KC position does

Differentiating Kangaroo Care from Skin-to-Skin Contact

Skin to skin contact stimulates the brain through A-Afferent Tactile Nerve Stimulation

Kangaroo Care stimulates the brain through an entirely separate set of nerves that are only responsive to PLEASING TOUCH, and non-phasic stimulation of the chest stimulates the C-AFFERENT nerves.

KC Position Physiology

In KC, the c-afferent nerves (only on chest, from umbilicus to sternum & across infant’s back in newborn period and have greatest DENSITY here in newborn period) are stimulated (Morrison, I. et al. 2011, Reduced C-afferent fibre density affects perceived pleasantness and empathy for touch. Brain, 134, 1116-1126)

C-afferent nerves are exquisitely sensitive to chest-to-chest, nonphasic skin stimulation (Uvnas-Moberg, K., Arn, I., Magnusson, D. (2005). The psychobiology of emotion: the role of the oxytocinergic system. International Journal of

Behavioral Medicine. 12(2), 59-65. ) and encode it as PLEASANT TOUCH (Morrison, I. et al. 2011, Reduced C-afferent fibre density affects perceived pleasantness and empathy for touch. Brain, 134, 1116-1126)

C-Afferents

Message goes directly to insular cortex (limbic brain, seat of emotions & emotional memory)(Olausson HW et al., 2008.Unmyelinated tactile afferents have opposite effects on insular and somatosensory cortical processing. Neuroscience Letters, 436, 128-132)

In Mother, c-afferent stimulation and oxytocin release initiate MOTHERLINESS (protection, advocacy, bonding) and emotional COMMITMENT to take care and breast feed her infant – that sometimes is overcome by cortical decision making Bystrova, K. (2009). Medical Hypotheses, 72(2), 143-146. Henderson, A. (2011). Understanding the breast crawl: Implications for nursing practice. Nursing for Women’s Health ,15(4), 296-307.

C-Afferents

Message from C-Afferents goes directly to the insular cortex (limbic brain, seat of emotions and emotional memory) (Olausson HW et al., 2008.Unmyelinated tactile afferents have opposite effects on insular and somatosensory cortical processing. Neuroscience Letters, 436, 128-132)

C-Afferents

In Mother, c-afferent stimulation and oxytocin release initiate MOTHERLINESS (protection, advocacy, bonding)

and emotional COMMITMENT to Breast feed her infant – that sometimes is overcome by cortical decision making Bystrova, K. (2009). Medical Hypotheses, 72(2), 143-146. Henderson, A. (2011). Understanding the breast crawl: Implications for nursing practice. Nursing for Women’s Health ,15(4), 296-307. and

Ability of mother’s physiology to REGULATE the infant’s physiology (see Neu articles)

OXYTOCIN

Oxytocin is released from insular cortex to travel on nerves to 14 areas of mother’s and infant’s brain (as a neuropeptide) or to be released into the circulation (as a hormone) (Uvnas-Moberg, K., Arn, I., Magnusson, D. (2005). The psychobiology of emotion: the role of the oxytocinergic

system. International Journal of Behavioral Medicine. 12(2), 59-65. ) .

First Stop is the brain stem to switch the brain from sympathetic (STRESS, flight, fight, fear, terror) to parasympathetic (CALM, contented, relaxed, affiliated not estranged) dominance

Autonomic Nervous System

http://www.taocontrol.com/images/Autonomic_nervous_system_main_figure_Blessing.gi

Parasympathetic Dominance during Kangaroo Care Confirmed in many studies by Cong that kangaroo care position

switches the brain to parasympathetic dominance. Cong, X., Cusson, R.M., Walsh, S., Hussain, N., Ludington-Hoe, S.M., Walsh, S., & Zhang, D. (2012). Effects of skin-to-skin contact on autonomic pain responses in preterm infants. Journal of Pain,13(7):636-645;

Cong X, Ludington-Hoe SM, McCain G, & Fu, P (2009). Kangaroo care modifies preterm infant heart rate variability in response to heel stick. Early Human Development, 85(9), 561-567. )

Parasympathetic dominance facilitates initiation and continuation of BF in first week of life, even in 26-28 weekers who will demonstrate sucking when in KC (Meier PP. (2001). Breastfeeding in the special care nursery: Prematures and infants with medical problems. Pediatric Clinics North American, 49(2), 425-443).

And many other things……..

Parasympathetic Importance & Stress

Stress hormones, especially aldosterone, are ten times higher at birth than they will ever be again in infant’s life (Bergman, N.J. (2014 – Nov 28). The neuroscience of birth - and the case for Zero Separation. Curationis, 37(2):1-4) ) (Morgan, B.E., Horn, A.R. & Bergman, N.J. (2011). Should neonates sleep alone? Biological Psychiatry 70, 817-825

So, oxytocin in brain stem switches the newborn’s brain from STRESS to CALM and helps INITIATE cardiorespiratory stability, readiness for breastfeeding, improved immunity, better brain development, less pain perception, 72% diminution of stress, and better sleep.

Parasympathetic Dominance Decreases STRESS

High stress levels impair premature infant brain development (Parsons,C.E., Young, K.S., Murray, L., Stein, A., & Kringelbach, M.L. (2010). The functional neuroanatomy of the evolving parent-infant relationship. Progress in Neurobiology, 91, 220-241. )

But, KC does not – it accelerates brain maturation, complexity, and connectivity. (Scher MS, Johnson MW, Ludington SM, Loparo K. (2011). Physiologic brain dysmaturity in late preterm infants. Pediatric Research,70(5), 524-528; Kaffashi ,F., Scher, M.S., Ludington-Hoe, S.M., & Loparo, K. (2013) An analysis of the Kangaroo Care intervention using neonatal EEG complexity: A preliminary study. Clinical Neurophysiology,124(2):238-246. )

Parasympathetic Dominance: Physiologic Stability and Improvement

physiologic stability ensues, HR & RR slow, MAP improves, SaO2 stabilizes (Park HK, Choi BS, Lee SJ, Son IA, Seol IJ, Lee HJ.(2014 March) Practical application of kangaroo mother care in preterm infants: clinical characteristics and safety of kangaroo mother care. Journal of Perinatal Medicine. 42(2): 239-245. Uvnas-Moberg, K., Arn, I., Magnusson, D. (2005). The psychobiology of emotion: the role of the oxytocinergic system. International Journal of Behavioral Medicine. 12(2), 59-65.)

Physiologic stability occurs faster in younger and smaller infants and they tolerate KC very well at 24 weeks postconceptional age onward (Park HK, Choi BS, Lee SJ, Son IA, Seol IJ, Lee HJ.(2014 March) Practical application of kangaroo mother care in preterm infants: clinical characteristics and safety of kangaroo mother care. Journal of Perinatal Medicine. 42(2): 239-245. )

Physiologic stability seen in KC immediately after birth with preterms ( Bergman, et al., 2004; Ludington-Hoe et al. 1993. J. Human Lactation 9(4): 241-242; Ludington-Hoe et al., (1998). JOGNN 28(1) 94-103.

Parasympathetic Dominance Decreases STRESS

High stress levels destabilize physiologic functions (Morgan, Horn & Bergman, 2011 above), BUT KC does NOT: look at the slide on basic HR and RR and APNEAs during incubator vs. KC

So, better cardiorespiratory stabilization and 75% reduction in APNEAs (Ludington-Hoe, et al., 1994 Kangaroo

care: Research results and practice implications and guidelines. Neonatal Network, 13(1), 19-27)

.

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Cardio Respiratory Changes

Pre-KC KC Post KC

Parasympathetic Dominance Improves CR

Function Cerebral oxygenation improves during KC in several pretest-

test-posttest studies (Begum EA, Bonno M, Ohtani N, Yamashita S, Tanaka S, Yamamoto H, Kawai M, & Komada Y. (2008). Cerebral oxygenation responses during kangaroo care in low birth weight infants. BMC Pediatrics 8(1)(Nov. 7, 2008), 51- 60; Begum EA, Bonno M, Ohtani N, Yamashita S, Tanaka S, Yamamoto H, Kawai M, & Komada Y. (2009). Cerebral oxygenation responses during kangaroo care in low birth weight infants. Neonatal Intensive Care 2(2), 2-25; Martin, J.B., & Ludington-Hoe, S.M. (2010). Near infrared spectroscopy measure of brain activation in premature infants in an incubator and during kangaroo care. Advances in Neonatal Care, 19(4), 214-215.)

If it is YOUR baby in an incubator, and you know oxygen supply to brain

can increase from 57% to 88%, which oxygen level do you want your baby’s brain to have?

Parasympathetic Dominance Decreases STRESS

High stress levels delay immune functions of stratum corneum

particularly in the keratinocytes,

and impair infant’s resistance to infection by impairing maternal antigen-specific antibody development and conveyance through maternal skin to neonatal skin (Bergman, N.J. (2014 – Nov 28). The neuroscience of birth - and the case for Zero Separation. Curationis, 37(2):1-4; Abouelfettoh A., Ludington-Hoe, S.M., Burant, C., & Visscher, M. (2011). Effect of skin-to-skin contact on preterm infant skin barrier function and hospital-acquired infection. Journal of Clinical Medicine Research, 3(1), 36-46; Schanler RJ. (2001). The use of human milk for premature infants.Pediatr Clin North Am 2001, 48(1), 207-219. )

NEWBORN INFANT NEEDS MATERNAL CONTACT TO BUILD UP HIS OWN GOOD BACTERIAL AND SEED HIS GI TRACK WITH GOOD BACTERIA – IF NOT BORN VAGINALLY, THE INFANT IS AT

HIGH RISK OF ASTHMA, OBESITY, TYPE 1 DM, AND CELIAC DISEASE, so VAGINAL SWABS are being done now (see Neena MODI’s studies)

Parasympathetic Dominance: Weight

Gain and Crying Purposeless activity/agitation decrease, minimizing wasted energy expenditure and then

better weight gain (Conde-Agudelo, A., Belizan, J.M., & Diaz-Rosello, J. (2011). Kangaroo mother care to reduce morbidity and mortality in low birthweight infants. Cochrane Database Systematic Review, (3): CD002771 )

Central oxytocin also increases growth hormone and digestive enzymes to improve utilization of nutrients and better weight gain. (Uvnas-Moberg, K., Arn, I., Magnusson, D. (2005). The psychobiology of emotion: the role of the oxytocinergic system. International Journal of Behavioral Medicine. 12(2), 59-65; Wahlberg, V. (1991). The “kangaroo method” and breastfeeding in low birth weight babies. NU Nytt on U-landshalsovard,5(3), 22-26

Crying is rare, so foramen ovale seals over properly and likelihood of heart attack due to patent foramen ovale decreases (Ludington-Hoe, S.M., Cong, X., & Hashemi, F. (2002). Infant crying: Nature, physiologic consequences, and select interventions. Neonatal Network 21(2), 29-36)

Central Oxytocin Goes to Hypothalamus: Heat Control

Healthy newborns heat up throughout the body (down to toes) within 10 minutes of onset of KC (Christidis ) and mother’s body makes 10 times more adjustments to keep baby in NTZ than any incubator (Ludington-Hoe, S.M, Nguyen, N, Swinth, J., & Satyshur, R. (2000). Kangaroo Care compared to incubators in maintaining body warmth in preterm infants. Biologic Research for Nursing, 2(1), 60-73.

Humidity between breasts is good and Transepidermal Water Loss is minimized (Abouelfettoh A., Ludington-Hoe, S.M., Burant, C., & Visscher, M. (2011). Effect of skin-to-skin contact on preterm infant skin barrier function and hospital-acquired infection. Journal of Clinical Medicine Research, 3(1), 36-46. et al., 2013)

Central Oxytocin…. Promotes BETTER SLEEP Quiet Sleep is BEST sleep for any newborn.

Sleep in NICU in incubator is fractured, chaotic sleep

Complete sleep cycles is best for brain development and sleep cycle is 60 minutes duration up to 52 weeks pma.

IN KC: SLEEP CYCLES Improve, arousals decrease, sleep behaviors and physiology are organized so that NO INDETERMINANT SLEEP is seen, and QUIET SLEEP is much longer than active sleep (Ludington-Hoe SM, et al. (2006). Neurophysiologic assessment of neonatal sleep organization: preliminary results of a randomized controlled trial of skin contact with preterm infants. Pediatrics, 112, e909-e923)

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Incubator Sleep is Fragmented and Chaotic

Cyclical Sleep occurs in Kangaroo Care

Parasympathetic Dominance & BF

So, oxytocin in brain stem switches the newborn’s brain from STRESS to CALM and helps INITIATE BF by facilitating prolactin production and eliminating the delay in feeding at the breast.

coordination of vital signs and feeding occurs, allowing the infant to breastfeed without respiratory compromise – coupling feed and VS.

Facilitates transition to NIPPLE feedings

So, maintaining chest-to-chest position when infant is at breast, allows INITIATION and CONTINUATION OF BREAST FEEDING (Winberg, 2005)

Thus you will be meeting NICU-Baby Friendly Hospital Initiative designation criteria

Many Maternal Benefits of KC:

Improved bonding and interactions with infant Enhanced exclusivity and longer duration Breastfeeding Decreased involution time Decreased lochia and preventative for Postpartum Hemorrhage Decrease Postpartum depression and may prevent it altogether Decreased Blood pressure – adjunct/preventative treatment for

HTN or pre-eclampsia/eclampsia Can prevent maternal mortality – 5 cases at Grant Medical

Center and Hershey Medical Center –”only thing it could be that saved her is Kangaroo Care” (MD at Grant Med Ctr in Columbus, OH, Contact Mary Walters at Mwalters@OhioHealth.com)

Paternal Benefits

Greater sense of responsibility to infant (Erlandsson, K., Christensson, K., & Fagerberg, I. (2008). Fathers’ lived experiences of getting to know their baby while acting as primary caregivers immediately following birth. Journal of Perinatal Education, 17(2), 28-36)

Enhanced bonding (Erlandsson, K., Christensson, K., & Fagerberg, I. (2008). Fathers’ lived experiences of getting to know their baby while acting as primary caregivers immediately following birth. Journal of Perinatal Education, 17(2), 28-36)

Greater sense of family development Enhanced interactions with infant (Ludington-Hoe et al., 1992. J.

Dev. Physiology, 18(5) 223-232)

Zero Separation

Holding a clothed baby over mother’s clothes is NOT KC and is a form of separation that prevents KC physiology from occurring

Stress hormones rise rapidly in the newborn and destabilize the baby when separated from mother or father (Morgan, B.E., Horn, A.R. & Bergman, N.J. (2011). Should neonates sleep alone? Biological Psychiatry 70, 817-825)

Newborn has short period to be exposed to maternal bacteria and seed his GI system with them to prevent many later health problems: ie obesity, asthma, celiac disease, type I diabetes, and metabolic syndrome as an adult. So give infant as much KC as possible for better life span health (Dahlen H. 2015. Being born is good for you. Practicing Midwife, 18(4): 10-13.)

AS MUCH KC AS POSSIBLE – follow Scandinavian Sample of 24/7 KC – mother’s chest is the PLACE of care throughout hospitalization and for three months post term age. (Nyqvist et al., 2010 – referred to earlier in this lecture)

With KC

When there is ZERO SEPARATION between mom and newborn, and the feed –sleep -wake up -and feed again cycle, in KC, does not allow separation.

Start KC ASAP, recommendation is within 24 hours of birth, even with 24 wk gestation birth, and continue as much as possible for entire postpartum hospitalization (Nyqvist KH, Anderson GC, Bergman N, Cattaneo A, Charpak N, Ewald U, Ibe O., Ludington-Hoe SM, Mondoza S, Pallas K, Ruiz-Pelaez JG, Sizun J., & Widstrom A-M. (2010b). Towards universal Kangaroo Mother Care: Recommendations and report from the First European Conference and 7th International Workshop on Kangaroo Mother Care. Acta Paediatrica, 99(6), 820-826;. Nyqvist, K (actually listed as Hedberg Nyqvist, K) & Heinemann, A-B. (2011). Kangaroo Mother Care: Optimal support of preterm infant’s transition to extra-uterine life in the high tech NICU

environment. Current Women’s Health Reviews, 7(3), 278-287 .

Keep REPEATING KC, the more you do it the more likely the preterm infant will be breastfeeding and doing so (90% likely) exclusively at discharge (Bergman, NJ (2014 – Nov 28). The neuroscience of birth - and the case for

Zero Separation. Curationis, 37(2):1-4. )

Kangaroo Care- Fights TOXIC stress

SEPARATION from mother is TOXIC

The INCUBATOR is a TOXIC environment

The American Academy of Pediatrics relates that separation toxicity sets the infant up for many and most of the developmental delays and biological diseases that are common in NICU graduates (Garner & Shonkoff 2010; Shonkoff & Garner 2010).

For example, little TOUCH is clearly associated with MOTOR DEFICITS (Multino DC & Crumpsty P. 1984. Tactile aversion in infancy. South African Medical Journal,, 65(19): 773-774.

So, what’s not to like about KC? It’s association with

SUPC

Sudden Unexpected postnatal collapse has been documented in the literature with breastfeeding since 1981.

Identifying Potential Events that May Occur During Birth KC

Acute Life-Threatening

Event

Postnatal adaption appeared

normal with 5 min Apgar > 8

Sudden Infant Collapse

Sudden Unexpected Postnatal Collapse

SUPCReports say: Occurs within minutes of birth up to 24 hours of life ..can occur up to 7 days post natal. Ludington-Hoe,SM & Morgan K, (2014). Infant assessment and reduction of sudden unexpected postnatal collapse risk during skin-to-skin contact. Newborn and Infant Nursing Reviews, 14(1), 28-33

Assessment of Mother-Infant KC Dyad

While in KC infant should be assessed continually (document /your policy)

Remember: breathing, activity, color, & tone assessment should be ongoing and continuous by health care professional (AHA & AAP, NRP, 2011)

The USIKC recommends the RAPPT

“RAPPT” Assessment

R = Respiratory Effort (easy respirations, RR, tachypnea, retractions, grunting, nasal flaring,)

A = Activity / State ( quiet alert, active alert, asleep, crying, BF)

P = Perfusion / Color (pink, grey, blue, mottled)]

P = Position for minimizing asphyxia (Position of head, neck and face, nares visible, well flexed)

T = tone (limp, flaccid vs responsive)

Ludington-Hoe SM & Morgan K. (2014 April). Assessing the Infant during Kangaroo Care and Breastfeeding. Newborn and Infant Nursing Reviews) and Ludington-Hoe, Morgan & Morrison-Wilford, 2015. USIKC: Cleveland, OH.

© 2012 USIKC. Safe Position poster available from susan.Ludington@case.edu

One of many wraps designed to hold infant in position during KC