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.