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Neuro-endocrine Mechanisms
Providing the Benefits of
Kangaroo Mother Care
Dr Elise van Rooyen
Department of Paediatrics, University of Pretoria,
Kalafong Hospital, South Africa
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-toskin position and during breastfeeding
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 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
KMC vs Incubator Care
Teaching hospital, Lusaka, Zambia
80 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 hours
4 hours
SSC
30%
70%
90%
Incubator
21%
39%
60%
Adapted from Lancet 1998:352;1115
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 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 Synchrony
 A 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 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 - 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 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
Neurophysiologic Outcomes
 Sleep organisation
 Brain maturation
 Brain complexity
Sleep organisation: Sleep Phases
NREM (Quiet Sleep)




Stage 1
Stage 2
Stage 3
Stage 4
Drowsy
Light – onset of slow wave sleep
Deep slow sleep
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
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 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 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 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
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)
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
Oxytocin’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
K Reeta, et al. Regulatory Peptides 2006;135:85–90
produce tolerance
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. 2008;9(2)
• KMC reduces crying associated with painful procedures
(Weller & Feldman):
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
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 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 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 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. 1996;59(4/5):947-952
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 2005;120:73 – 79
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. 2003;284(6):2269-76.
Kerstin Uvnas-moberg. Acta Physiologica Scandinavica Supplementum.1997;640:38-42
KMC: 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:
Pro-social Behaviour
And
Disorders due to Aberrant
Social Interactions
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
KMC Effects on Early Mother-Infant
Relationship
Findings 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 MotherInfant 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 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!
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.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
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. 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 of
oxytocin in formalin-induced pain response in mice. Regulatory Peptides 2006;135:85–
90
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.
 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.
 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.
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