neuro-endocrine mechanisms providing the benefits of kangaroo mother care dr elise van rooyen...
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Neuro-endocrine Mechanisms Neuro-endocrine Mechanisms Providing the Benefits of Providing the Benefits of Kangaroo Mother Care Kangaroo Mother Care
Dr Elise van RooyenDr Elise van RooyenDepartment of Paediatrics, University of Pretoria,
Kalafong Hospital, South Africa
Neuro-endocrine MechanismNeuro-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
KMC: Effect on Body TemperatureKMC: 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 baby’s 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
Rewarming Infants with Hypothermia Rewarming Infants with Hypothermia
KMC vs Incubator CareKMC vs Incubator Care
Adapted from Lancet 1998:352;1115
Teaching hospital, Lusaka, Zambia80 babies with temp<36ºC (low risk hypothermia)41 treated with skin-to-skin contact (SSC)39 treated in incubator
Reaching 36.5ºC at 2 hours 3 hours3 hours 4 hours
SSC 30% 70%70% 90%
Incubator 21% 39%39% 60%
Role of Oxytocin in Temperature Role of Oxytocin in Temperature RegulationRegulation
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 1996a&b
Temperature of breasts and chest increases not only during breastfeeding but also when milk ejection is triggered psychologically Lind et al. 1971
KMC: Thermal SynchronyKMC: Thermal Synchrony
A thermal synchrony thermal synchrony develops between mom and baby
The mother’s core temperature may rise 2ºC or drop one degree in a short period of time, in order to maintain this narrow range
Thermal Synchrony in TwinsThermal Synchrony in Twins
Mother’s breasts have the ability to thermally accommodate multiple infants simultaneously
Each breast acts independently to keep a twin warm
Case studies by S Ludington
KMC: Behavioural Effects - CryingKMC: 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): 373–387)
No crying at all when transporting sick infants in KMC position to a distant NICU (Sontheimer et al)
Research on CryingResearch 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 81:488-93. 1992
KMC: Effect on KMC: Effect on Neurophysiologic OutcomesNeurophysiologic Outcomes
Sleep organisation
Brain maturation
Brain complexity
Sleep organisation: Sleep PhasesSleep organisation: Sleep Phases
NREM (Quiet Sleep)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)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
Sleep and Sleep Cycles 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
Sleep ContinueSleep 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
Sleep Pattern in NICUSleep 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
KMC: Effect on Sleep OrganizationKMC: Effect on Sleep Organization
Increases quantity of Quiet SleepQuiet 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
Cycling is needed for Normal GrowthCycling is needed for Normal Growth
Formation of Formation of Neuronal Neuronal
Synapses and Synapses and GrowthGrowth
Sleep Sleep CyclingCycling
• 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)
Brain Maturity by ComplexityBrain 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
Oxytocin’s Analgesic EffectsOxytocin’s Analgesic Effects Oxytocin administered in mice has an analgesic effect in
response to (formalin-induced) pain
Oxytocin acts on the κ- & δ-opioid receptors in the brain
Chronic (X 7 days) administration of oxytocin did not produce tolerance K Reeta, et al. Regulatory Peptides 2006;135:85–90
KMC: Effect on painful proceduresKMC: 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. 2008;9(2)
• KMC reduces crying associated with painful procedures (Weller &
Feldman):
KMC: Effects on Nosocomial InfectionsKMC: 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
KMC reduces Mortality?KMC reduces Mortality?
A meta-analysis shows that KMC reduces neonatal mortality amongst preterm babies (birth weight <2000 g) in hospital, and is highly effective in reducing severe morbidity, particularly from infection
Joy Lawn et al. International Journal of Epidemiology 2010;39:i144–i154
Cochrane meta-analysis
KMC Effect on Desaturation EventsKMC 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)
Oxytocin Effects on GrowthOxytocin 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. 1996;59(4/5):947-952
Effects on GrowthEffects 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
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 2005;120:73 – 79
Weight gain associated with Weight gain associated with Massage & Oxytocin releaseMassage & Oxytocin release
Oxytocin: Cardiovascular EffectsOxytocin: 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. 2003;284(6):2269-76.
Kerstin Uvnas-moberg. Acta Physiologica Scandinavica Supplementum.1997;640:38-42
KMC: Effect on Physiological StressKMC: Effect on Physiological Stress
Cortisol levels has been studied as a sign of physiological stress in preterm infants
>60% reduction in cortisol levels in stable preterms receiving KMC (>20 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.
Role of Oxytocin in:Role of Oxytocin in:
Pro-social Behaviour
And
Disorders due to Aberrant
Social Interactions
Oxytocin Mediates Pro-social BehaviourOxytocin 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
KMC Effects on Early Mother-Infant KMC Effects on Early Mother-Infant RelationshipRelationship
Findings from a Canadian Sample of Full-Term InfantsFindings 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
KMC Effects on Early Mother-KMC Effects on Early Mother-Infant Relationship Cont.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
Prevent SeparationPrevent 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!
LiteratureLiterature 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.1997;640:38-42
K Uvnas-moberg. Oxytocin – A Possible Mediator Of Anti-stress Effects Induced By Acupuncture. Journal Of Acupuncture In Medicine. 2002;20:109-110
M Hernandez-Reif, M Diego, T Field. Preterm Infants Show Reduced Stress Behaviors And Activity After 5 Days Of Massage Therapy. Infant Behavior & Development. 2007;30: 557–561
ReferencesReferences 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. 1996;59(4/5):947-952 S Holst, I Lund, M Petersson, K Uvna¨s-Moberg. Massage-like stroking influences
plasma levels of gastrointestinal hormones, including insulin, and increases weight gain in male rats. Autonomic Neuroscience: Basic and Clinical 2005;120:73 – 79
R Kostandy, et al. Pain Management Nursing. Kangaroo care (skin contact) reduces crying response to pain in preterm neonates: pilot results. 2008;9(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. 2003;284(6):2269-76.
R Kostandy, et al. Pain Management Nursing. Kangaroo care (skin contact) reduces crying response to pain in preterm neonates: pilot results. 2008;9(2):
K Reeta, et al. Role of κ- and δ-opioid receptors in the antinociceptive effect ofoxytocin in formalin-induced pain response in mice. Regulatory Peptides 2006;135:85–90
References cont.References cont. S HolstT, I Lund, M Petersson, K Uvna¨s-Moberg. Massage-like stroking influences
plasma levels of gastrointestinal hormones, including insulin, and increases weight gain in male rats. Autonomic Neuroscience: Basic and Clinical 2005;120:73 – 79
Trends Endicrinol Metab 1996;7:126-131 M Heinrichs, B von Dawans, G Domes. Oxytocin, vasopressin, and human social
behavior. Frontiers in Neuroendocrinology 30 (2009) 548-557 Brain Research. 2005;1049:234 – 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. 2005;1049:234 – 239
E Bjorkstrand, K. Uvnas-Moberg. Central oxytocin increases food intake and daily weight gain in rats. Physiol Behav. 1996;59(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,
References cont.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 2006;117(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. 2008:Volume 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 Medicine Reviews, Vol. 7, No. 4, p.
321±334, 2003
References cont.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.