Neuro-endocrine%20Mechanisms%20Providing%20the%20Benefits%20of%20Kangaroo%20Mother%20Care

1
Neuro-endocrine Mechanisms Providing the Benefits
of Kangaroo Mother Care

• Dr Elise van Rooyen
• Department of Paediatrics, University of
  Pretoria,
• Kalafong Hospital, South Africa

2
Neuro-endocrine Mechanism

• Many benefits of KMC are related to oxytocin
  secretion which is released by touch, light
  pressure and warmth experienced by the infants in
  the skin-to-skin position and during breastfeeding

3
KMC Effect on Body Temperature

• KMC maintains adequate temperature for preterm
  and/or LBW infants
• Infant body temperature rises in KMC
• Fewer episodes of hypo- and hyperthermia occurs
  during KMC
• It is safe to take care of infants as small as
  700g in warm environment with cap
• Mothers are able to maintain their babys
  temperature within a very narrow temperature
  range which is not the case in incubator care
• WHO KMC practical guide, PEP unit 43
  Principles of KMC

4
Rewarming Infants with Hypothermia KMC vs
Incubator Care
Teaching hospital, Lusaka, Zambia 80 babies with
templt36ºC (low risk hypothermia) 41 treated with
skin-to-skin contact (SSC) 39 treated in
incubator
Reaching 36.5ºC at 2 hours 3 hours 4 hours
SSC 30 70 90
Incubator 21 39 60

• Adapted from Lancet 19983521115

5
Role of Oxytocin in Temperature Regulation

• Circulation in the skin overlying the breast is
  increased during suckling resulting in increased
  skin temperature - this makes suckling more
  pleasant for pups Kerstin
  Uvnäs-Moberg TEM 1996
• Circulating oxytocin and neurological triggered
  vasoactive peptides mediates this cutaneous
  vasodilation Eriksson et al
  1996ab
• Temperature of breasts and chest increases not
  only during breastfeeding but also when milk
  ejection is triggered psychologically
  Lind et al. 1971

6
KMC Thermal Synchrony

• A thermal synchrony develops between mom and baby
• The mothers core temperature may rise 2ºC or
  drop one degree in a short period of time, in
  order to maintain this narrow range

7
Thermal Synchrony in Twins

• Mothers breasts have the ability to thermally
  accommodate multiple infants simultaneously
• Each breast acts independently to keep a twin
  warm
• Case studies by S Ludington

8
KMC Behavioural Effects - Crying

• Infants cry for a variety of reasons Separation
  from mother, hunger, and in response to pain
• There was a reduction in crying during KMC
  compared to incubator care (Cochrane
  meta-analysis)
• KMC reduces crying in response to pain (Weller
  Feldman) (Ludington-Hoe et al. AACN Clin Issues
  2005 16(3) 373387)
• No crying at all when transporting sick infants
  in KMC position to a distant NICU (Sontheimer et
  al)

9
Research on Crying

• Compared babies in KMC with babies in cots
• Number of crying babies at observation periods
  performed every 15 minutes for the first 90
  minutes after birth
• There was a significant absence or reduction in
  crying in infants receiving KMC compared to
  infants in cots
• Christensson et al. Acta Paediatr 81488-93. 1992

10
KMC Effect on Neurophysiologic Outcomes

• Sleep organisation
• Brain maturation
• Brain complexity

11
Sleep organisation Sleep Phases

• NREM (Quiet Sleep)
• Stage 1 Drowsy
• Stage 2 Light onset of slow wave sleep
• Stage 3 Deep slow sleep
• Stage 4 Deep slow wave sleep
• Crucial for creation of long term memories
  learning
• REM (Active Sleep, Dream Sleep)
• Paradoxical sleep rapid eyelid muscle
  movements
• ? Heart rate Resp rate
• Critical component associated with the
  development of the sensory systems

12
Sleep and Sleep Cycles

• Sleep and sleep cycles are essential for
• Sensory system development in the fetus and young
  infant
• Creation of long-term memory and learning
• Preservation of brain plasticity
• Sleep deprivation in foetus and neonate has
  profound effects on early sensory development and
  creation of permanent neural circuits for the
  primary sensory systems

13
Sleep Continue

• Sleeping is not a passive process
• Sleep is driven by cholinergic cells which
  stimulate sleep actively (can be inhibited by
  depressant drugs)
• Each specific EEG wave that occur during REM
  sleep plays a specific role in sensory system
  development (smell, taste, visual, auditory,
  touch, motion, position, emotion, or memory)
• REM sleep deprivation between 30 wks GA and 4-5
  mnths results in delayed or disordered
  development of any or all of the systems above

14
Sleep Pattern in NICU

• In the NICU, infants demonstrate a very chaotic
  version of this cycling pattern
• Incubator Infants only have 10-20 seconds of
  quiet sleep. (HR and RR also does not change)
• Disrupted sleep due to
• separation from mother
• and care giving environment

15
KMC Effect on Sleep Organization

• Increases quantity of Quiet Sleep
• Non-chaotic sleep pattern
• Normal sleep cycling
• Less sleep arousals
• HR and RR variation according to sleep cycles
• Preterm sleep cycles generally require 60 minutes
  to complete and within 5 minutes of the onset of
  KMC, cycling begins

16
Cycling is needed for Normal Growth

• Formation of Neuronal Synapses and Growth

Sleep Cycling

• Preemies in incubators demonstrate non-cycled
  sleep patterns throughout hospitalization
• Result of delay in sleep cycling affect
  post-discharge sleep for up to 2 yrs (Scher,
  1997)

17
Brain Maturity by Complexity

• Preterm infants who received KMC from 32-40 weeks
  PMA had better brain maturation in all measures
  of complexity
• Brain maturation was better compared to preemies
  who did not receive KMC
• Brain maturation was even better compared to full
  term infants

Kaffashi, Scher, Ludington-Hoe et al. Complexity
analysis of neonatal EEG. J Electroencephalography
18
Oxytocins Analgesic Effects

• Oxytocin administered in mice has an analgesic
  effect in response to (formalin-induced) pain
• Oxytocin acts on the ?- d-opioid receptors in
  the brain
• Chronic (X 7 days) administration of oxytocin did
  not produce tolerance

K Reeta, et al. Regulatory Peptides 20061358590
KMC Effect on painful procedures

• Preterm infants exhibit less audible and
  inaudible (facial grimacing, eye squeezing and
  brow bulging) crying during and after heel pricks
  when in KMC compared to incubator R
  Kostandy, et al. 20089(2)
• KMC reduces crying associated with painful
  procedures (Weller Feldman)

19
KMC Effects on Nosocomial Infections

• Infants who received 24/7 KMC had ? infections by
  discharge (3 randomized trials)
• ? Infections in infants who received KMC
  (Cochrane meta-analysis)
• ? Nosocomial infections may be due to
• Enhanced stratum corneum barrier function when
  hydration increases and trans-epidermal water
  loss decreases
• Improved immunity
• Oxytocin
• Less stress
• Breastmilk

20
KMC reduces Mortality?

• A meta-analysis shows that KMC reduces neonatal
  mortality amongst preterm babies (birth weight
  lt2000 g) in hospital, and is highly effective in
  reducing severe morbidity, particularly from
  infection
• Joy Lawn et al. International Journal of
  Epidemiology 201039i144i154
• Cochrane meta-analysis

21
KMC Effect on Desaturation Events

• During KMC the number of desaturation events
  decreased in breastfed infants
• Relationship between desaturation events and
  method of feeds
• 20 desaturation events occured after bottle
  feeding during KMC
• None occured during breastfeeding (Chen)

22
Oxytocin Effects on Growth

• Suckling, massage and warm temperature influence
  the release of GI hormones
  (Uvnas-Moberg et al. 1992)
• Oxytocin stimulates digestion, weight gain and
  growth by activation of the endocrine system of
  the GIT
• One study showed that oxytocin injections caused
  increased weight gain in mice

Kerstin Uvnas-Moberg. Massage, Relaxation
Well-being A possible role for Oxytocin E
Bjorkstrand, K. Uvnas-Moberg. Physiol Behav.
199659(4/5)947-952
23
Effects on Growth

• Another study showed that increased levels of
  oxytocin after massage coincided with a rise of
  GI hormones in the blood
• A third study suggested that the weight gain
  observed in preterm infants who received massage
  therapy was related to an increase in vagal tone

Kerstin Uvnas-Moberg. E Bjorkstrand, K.
Uvnas-Moberg.. Physiol Behav. 199659(4/5)947-952

24
Weight gain associated with Massage Oxytocin
release

• Increased weight gain was not associated with
  increased food consumption
• This suggests that the treatments had induced a
  higher metabolic efficiency and that energy was
  used for anabolic metabolism

S Holst, et al. Autonomic Neuroscience Basic and
Clinical 200512073 79
25
Oxytocin Cardiovascular Effects

• Lower blood pressure
• Lower pulse rate

CARDIOVASCULAR PROTECTIVE EFFECT
LC Michelini, MC Marcelo, J Amico, M Morris..
American Journal of Physiology - Heart
Circulatory Physiology. 2003284(6)2269-76. Kerst
in Uvnas-moberg. Acta Physiologica Scandinavica
Supplementum.199764038-42
26
KMC Effect on Physiological Stress

• Cortisol levels has been studied as a sign of
  physiological stress in preterm infants
• gt60 reduction in cortisol levels in stable
  preterms receiving KMC (gt20 min)

KMC reduces stress in preterm infants most likely
due to the secretion of oxytocin
Mooncey S, Giannakoulopoulos X, Glover V, Acolet
D, Modi N, 1997. Infant Behaviour and development
20(4) 553-557.
27
Role of Oxytocin in

• Pro-social Behaviour And Disorders due to
  Aberrant Social Interactions

28
Oxytocin Mediates Pro-social Behaviour

• Oxytocin receptors are distributed in various
  brain regions responsible for the formation of
  normal social attachments and affiliation
• Oxytocin promotes bonding (maternal, paternal
  pairing)
• ? the subjective experience of attachment
  security
• ? trusting trustworthy behaviour (NOT risk
  taking behaviour)
• ? ability to infer mental state of others from
  facial cues
• Oxytocin suppresses fear-related activation of
  amygdala in healthy individuals in social
  situations

M Heinrichs et al. Frontiers in
Neuroendocrinology 30 (2009) 548-557
29
KMC Effects on Early Mother-Infant
RelationshipFindings from a Canadian Sample of
Full-Term Infants

• Newborn infants use much of their energy making
  physiological adjustments to postnatal life
• Many of their physiological states crying
  sleeping does not allow for taking in information
  from the external world
• The one exception is the quiet alert state
• Early skin-to-skin contact increases the infants
  ability to regulate their state organization
• KMC facilitates infants ability to move into and
  maintain the quiet alert state
• Researcher Ann Bigelow, Antigonish, Nova
  Scotia

30
KMC Effects on Early Mother-Infant Relationship
Cont.

• The quiet alert state allow infants to be aware
  of external stimulation from the mother
• It allows them to participate more actively in
  interactions with their mothers
• Facilitates the infants own growth and
  development
• Also fosters early social relations
• KMC influence mothers to enhance their maternal
  behaviours
• Mothers demonstrate more sensitivity to their
  infants signals and to their early social
  behaviour

31
Prevent Separation

• If possible no baby should be separated from
  their mother
• If there is separation introduce skin-to-skin
  care as soon as possible and as often as possible
• Commence continuous KMC as soon as infant is
  stable
• Keep Mothers Babies together!

32
Literature

• Susan M. Ludington-Hoe, Kathy Morgan, Amel
  Abouelfettoh, A Clinical Guideline for
  Implementation of Kangaroo Care With Premature
  Infants of 30 or More Weeks Postmenstrual Age.
  Advances in Neonatal Care 2008 Vol. 8, No. 3S
• Evidence-based clinical practice guidelines for
  an optimal use of the kangaroo mother method in
  preterm and/or low birthweight infants at birth.
  Fundación Canguro and Department of Clinical
  Epidemiology and Biostatistics, School of
  Medicine Pontificia, Universidad Javeriana,
  Bogotá, 2005 2007, Juan Gabriel Ruiz P,
  Nathalie Charpak
• World Health Organization. Kangaroo mother care
  a practical guide. Geneva World Health
  Organization, Department of Reproductive Health
  and Research 2003
• Kerstin Uvnas-moberg. Oxytocin Linked Antistress
  Effects The Relaxation And Growth Response.
  Acta Physiologica Scandinavica Supplementum.19976
  4038-42
• K Uvnas-moberg. Oxytocin A Possible Mediator Of
  Anti-stress Effects Induced By Acupuncture.
  Journal Of Acupuncture In Medicine.
  200220109-110
• M Hernandez-Reif, M Diego, T Field. Preterm
  Infants Show Reduced Stress Behaviors And
  Activity After 5 Days Of Massage Therapy. Infant
  Behavior Development. 200730 557561

33
References

• Kerstin Uvnas-Moberg. Touch - Chapter 12
  Massage, Relaxation And Well-being A Possible
  Role For Oxytocin
• E Bjorkstrand, K. Uvnas-Moberg. Central oxytocin
  increases food intake and daily weight gain in
  rats. Physiol Behav. 199659(4/5)947-952
• S Holst, I Lund, M Petersson, K Uvnas-Moberg.
  Massage-like stroking influences plasma levels of
  gastrointestinal hormones, including insulin, and
  increases weight gain in male rats. Autonomic
  Neuroscience Basic and Clinical 200512073 79
• R Kostandy, et al. Pain Management Nursing.
  Kangaroo care (skin contact) reduces crying
  response to pain in preterm neonates pilot
  results. 20089(2)
• LC Michelini, MC Marcelo, J Amico, M Morris.
  Oxytocinergic regulation of cardiovascular
  function studies in oxytocin-deficient mice.
  American Journal of Physiology - Heart
  Circulatory Physiology. 2003284(6)2269-76.
• R Kostandy, et al. Pain Management Nursing.
  Kangaroo care (skin contact) reduces crying
  response to pain in preterm neonates pilot
  results. 20089(2)
• K Reeta, et al. Role of ?- and d-opioid receptors
  in the antinociceptive effect ofoxytocin in
  formalin-induced pain response in mice.
  Regulatory Peptides 20061358590

34
References cont.

• S HolstT, I Lund, M Petersson, K Uvnas-Moberg.
  Massage-like stroking influences plasma levels of
  gastrointestinal hormones, including insulin, and
  increases weight gain in male rats. Autonomic
  Neuroscience Basic and Clinical 200512073 79
• Trends Endicrinol Metab 19967126-131
• M Heinrichs, B von Dawans, G Domes. Oxytocin,
  vasopressin, and human social behavior. Frontiers
  in Neuroendocrinology 30 (2009) 548-557
• Brain Research. 20051049234 239
• Review of medical physiology. 20th ed. Publisher
  Lang Medical Books. W Ganong
• M Peterssona. Oxytocin increases the density of
  high affinity a2-adrenoceptors within the
  hypothalamus, the amygdala and the nucleus of the
  solitary tract in ovariectomized rats. Brain
  Research. 20051049234 239
• E Bjorkstrand, K. Uvnas-Moberg. Central oxytocin
  increases food intake and daily weight gain in
  rats. Physiol Behav. 199659(4/5) 947-952
• Juan Gabriel Ruiz P, Nathalie Charpak.
  Evidence-based clinical practice guidelines for
  an optimal use of the kangaroo mother method in
  preterm and/or low birthweight infants at birth.
  Fundación Canguro and Department of Clinical
  Epidemiology and Biostatistics, School of
  Medicine Pontificia, Universidad Javeriana,
  Bogotá, 2005 2007,

35
References cont.

• World Health Organization. Kangaroo mother care
  a practical guide. Geneva World Health
  Organization, Department of Reproductive Health
  and Research 2003
• Ludington-Hoe SM, Johnson MW, Morgan K, Lewis T,
  Gutman J, Wilson D, Scher MS. Neurophysiologic
  assessment of neonatal sleep organization
  Preliminary results of a randomized controlled
  trial of skin contact with preterm infants.
  Pediatrics 2006117(5) e909-e923.
• Woods DL, Principles of Kangaroo Mother Care unit
  43 in Woods DL (ed) Mother and baby friendly
  care, Cape Town Perinatal education programme
  2005
• World Health Organization. Kangaroo mother care
  a practical guide. Geneva World Health
  Organization, Department of Reproductive Health
  and Research 2003
• Mirmiran Ariagno Role of REM sleep in brain
  development and plasticity)
• Graven SN, Browne JV. 2008Volume 8(4),
  www.nainr.com
• Scher MS, Ludington-Hoe S, et al Clinical
  Neurophysiology 120 (2009) 1812-1818
• Development of fetal and neonatal sleep and
  circadian rhythms
• M Mirmiran, YG.H. Maas, RL. Ariagno Sleep
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36
References cont.

• Stanley N. Graven, J V. Browne, Sleep and Brain
  Development The Critical Role of Sleep in Fetal
  and Early Neonatal Brain Development. Newborn
  Infant Nursing Reviews, December 2008 Vol 8,
  Number 4 173-179
• Mooncey S, Giannakoulopoulos X, Glover V, Acolet
  D, Modi N, 1997. The Effect of Mother-Infant
  Skin-to-Skin Contact on Plasma Cortisol and
  beta-endorphin Concentrations in Preterm
  Newborns. Infant Behaviour and development 20(4)
  553-557.