Kangaroo Care - University of Pittsburgh Medical Center 1... · •KC is a form of pleasing touch. ... BF in both pre-term and full-term infants. •BF in KC position achieves better

Kangaroo Care

Objectives

• Give the learner a history of Kangaroo Care

• Give the learner a good understanding of KC

• Give the learner enough knowledge of KC to promote the correct use of it in our NICU

• Give the learner enough knowledge of KC to teach parents and families to continue it at home

Definition

Kangaroo Care is a special way to hold an infant where the infant is held skin to skin and chest to chest so that the entire ventral surface from umbilicus to sternum of the infant is up against the mother’s ventral surface.

There are very sensitive cells in this area that can create a vagal-induced hormonal cascade that does not occur anywhere else in the body.

History of Kangaroo Care

• In the 1970’s, Dr. Edgar Rey and Dr. Hector Martinez from the Institito Maternal-Infantil in Bogota, Columbia visited a mountain village.

• They witnessed a grandmother carrying a small baby skin to skin between her breasts under clothing and wraps that made a pouch.

• They said it reminded them of how a kangaroo carries a baby in its pouch.


• They decided to try this in their unit where:

• average temperature was 50 degrees

• no formula was available

• mother often not available

• mortality rate was nearly 80%


• Mortality rate was primarily due to infections:

• nutrition- not mom’s own milk

• bed sharing- 2-3 infants per incubator

• inadequate cleansing capabilities

• lack of sterile supplies (rinse and reuse IV bags and tubing)

• nurse to baby ratio was 1:65


• Instituted Kangaroo Care in 1979.

• In first year, decreased their mortality rate by 70%

• Presented their findings to the world at the First Conference for Fetal and Neonatal Medicine in Bogota in 1983

• Attributed the success to a triad of milk, warmth, and bonding which is the conceptual model of Kangaroo Care


Practice still in place in Bogota:

• After delivery, mother and baby taken out in the hall and do Kangaroo Care

• After 2 hours, if mother not bleeding, and baby is alive, pink, and tries to suck, both go home.


• 1986- International Congress of Infant Studies convened in LA.

• 1996- WHO recommends every infant 28 weeks gestation or more has a right to KC.

• 1998- WHO’s International Network on KC: 1. All infants 28 weeks or greater should be given KC as

soon as possible.

2. Ideally, it should be started immediately after birth.

3. It should be done as much as possible.

4. It should be done for as long as possible.


• 2007- Save the Children Organization promotes KC as one of the 5 essential elements of NB care(resuscitation, BF, KC, small infant care, and thermoregulation).

• 2010- KC is practiced around the world in all levels of neonatal and home care.

Glossary of Terms

• Birth KC- begins within 5 minutes of birth

• Early KC- begins 5minutes to 24 hours of age

• End of Life KC- given when demise is anticipated

• Immediate KC- begins immediately after birth (less that 5 minutes)

• Kangaroo Care- Skin to skin placement of infant’s chest against the chest of another human being

Glossary of Terms

• Kangaroo Mother Care- KC 24/7

• Late KC- begins after discharge from hospital

• Palliative KC- another name for End of Life KC

• Paternal KC- given by father

• Shared KC- more that one infant held simultaneously

• Surrogate KC- held by someone other than biological mother or father

Glossary of Terms

• Ventilated KC- given to intubated infant

• INC- International Network on KMC- organization that began in Trieste, Italy in 1996

• Skin to Skin- any skin to skin contact, not necessarily KC- has to be chest to chest

• Kan Guru- someone certified in KC issued by the US division of WHO INK

Why Chest to Chest

The keratinocytes in the 7 epidermal layers of the skin in this ventral area are especially sensitive:

1. Seat of the vagus nerve

2. Nerve fibers very powerful in this area and release corticotropin releasing hormone

3. Make their own cortisol

4. Can initiate a vagal induced hormone cascade that does not occur anywhere else

Why Chest to Chest

Where do you think most of these cells are located?

Acronym for KC

Skin to Skin:

• S is for Survival

• K is for Kinder

• I is for Immunity

• N is for Nutrition

• T is for Thermoregulation and Transfer

• O is for Other Options for KC

Pneumonic for KC

• S is for State

• K is for “K”ardiorespiratory

• I is for Involvement of Parents

• N is for Neurobehavioral Developement

S is for Survival

• Hundreds of world-wide studies have repeatedly shown that KC decreases morbidity and mortality rates of both preterm and full term infants.

• Dramatically increases the survival rate of premature infants

• Reduces severity of illnesses

• Decreases length of stay/costs

• Fewer complications at 1 year follow-ups

K is for Kinder and Gentler Environment

• Responses to KC have been so positive that is has been called an integral part of the foundation of contemporary developmental care.

• It provides an appropriate balance between under stimulated tactile and proprioceptive systems and the overwhelmed later developing systems such as vision and auditory. (provides low intensity stimulation to the developing senses)


• Meets NANN’s criteria as a developmental intervention:

1. Modifies the environment

2. Individualizes care

3. Promotes relief from inappropriate elements of the environment

4. Promotes attachment and confidence in the parents


Some developmental outcomes of KC include the following:

1. Increased duration and frequency of quiet sleep/ Less crying

2. Improved organizational state

3. Encourages self regulatory behaviors

4. Provides rest period from often noxious environment


5. Better arousal modulation at 3 months when presented with increasingly complex stimulation

6. Higher scales at 6 months on Bayley Scales of Infant Development - mental and psychomotor index

I Stands For Immunity

The evidence linking KC to immunity is just beginning to appear in literature, but the majority of studies show that infants who receive KC have no increased risk for infection and have fewer infections that require hospitalizations up to 1 year of age than infants who did not receive KC.


There is decreased trans-epidermal water loss from the skin for the following reasons:

1. Infant is contained in a warm and often flexed environment.

2. Humidity with KC is >50%.

3. Infant spends more time asleep than awake. Trans-epidermal water loss is greater in awake states.


4. Less trans-epidermal water loss means more water is retained in the stratum corneum. This enables it to maintain better integrity against injury and organisms and enables it to stay smooth and flexible.

5. Less trans-epidermal water loss also means energy conservation and growth.

6. Improved skin hydration causes improved barrier function of the skin.


• KC is a form of pleasing touch. Pleasing touch sensations go straight to the limbic area of the brain, which is the seat of emotion. This in turn, decreases the release of the stress hormone cortisol. High circulating levels of cortisol impair the body’s immune function.

• Pleasing touch also causes the release of neuropeptides, especially opioids. This calms, reduces cortisol release, and thus reduces stress.

I Stands for Immunity

• KC is also a form of warm touch. This stimulates cytokine expression in the stratum corneum, which further enhances the barrier function. (Warm environments improve cytokine expression more than cold environments.)


• When the hair follicles of the mother and infant touch each other, both secrete cutaneous corticotrophin releasing hormone. This hormone causes vasodilation of the skin blood vessels, making mother and infant skin warmer. Warm skin enhances cytokine expression.

• When the infant moves against the mother’s skin, the movement and touch improve the immune function of the keratinocytes in the infant’s skin.


The entero-mammary pathway theory:

• Infant comes in contact with pathogens, and they enter the skin through the skin, mucous membranes, and air. Once there, they are antigens.

• The antigens are transferred to the mother by mucus with breastfeeding and through the skin during KC.


• The mother’s mature immune system produces antibodies against the antigens.

• The antibodies enter the infant’s system in breastmilk and by passing through the mother’s skin then through the infant’s skin with KC.

• The theory is that the more skin to skin contact that occurs, more antibodies will be inherited, and the better the infant’s immunity will be.


• This provides species specific antimicrobial action.

• The entero-mammary pathway is supposed to be especially efficient in protecting preterm babies from nosocomial infections.

N is for Nutrition

KC has long been known to promote and enhance BF in both pre-term and full-term infants.

• BF in KC position achieves better latch, nutritional and weight gain outcomes than a swaddled infant.

• KC allows self-regulatory and on-demand feeding. (more hunger cues, more feeding organization, more weight gain, shorter hospitalization)

N is for Nutrition

• Infants held in KC are more likely to initiate BF, continue BF, BF more frequently, BF longer, and exclusively BF.

• Milk production increases with KC. KC mothers reported being warmer, sleepier, and thirstier than mothers without KC.

• Lack of early contact with infants is a cause of BF failure.

• Infant’s physiology is more stable while breastfeeding in KC.

N is for Nutrition

• Infants fed in KC were warmer than those swaddled, and fed better.

• Both mothers and infants become calmer in KC, activity in the sympathoadrenal axis decreased, and some aspects of vagal nerve activity linked to increased GI function and anabolic metabolism are enhanced.

N is for Nutrition

Some hormones that specifically affect metabolism and weight gain have been studied with regards to KC.

• Gastrin, a vagally controlled hormone that improves GI function and utilization of nutrients, is released in the mother and infant during KC resulting in improved GI function and anabolic metabolism.

N is for Nutrition

• KC increases release of oxytocin in both mother and infant. This in turn aids in the production of GI hormones gastrin, somatostatin, and cholescystokinin which help food absorption by elongating intestinal villae and increasing enzyme secretions.

• Infants fed with a feeding tube while held in KC have increased levels of cholecystokinin than infants gavaged without KC.

N is for Nutrition

• Blood glucose levels were higher in KC infants than those held while swaddled.

• There is a quicker return to birth weight and increased weight gain per day with KC infants.

T is for Thermoregulation and Transfer

Thermoregulation is the process of maintaining an infant’s temperature within a normal range.

With KC the mechanism is simple. When the infant’s skin touches the skin of the KC giver, the sympathetic nervous system is activated causing vasodilation and increased skin blood flow. This causes skin temperatures to increase and in turn body and core temperatures increase also.


• Body warming will occur faster and in a more physiologically appropriate manner than with a heater. This includes immediately after a bath.

• Infants are warmer while BF in KC than while being swaddled.


• A mother’s breasts and chest will regulate temperatures independently to keep infant’s temperature in a normal range. (increase or decrease temperatures as needed)

• A father’s chest will increase temperatures, but not decrease.


Recommendations to help maintain thermoregulation with KC and premature infants:

• Do not preform under air currents or vents.

• Always cover infant’s back with a blanket.

• May need a blanket during transfer into KC.

• A hat is recommended for infants <1000g.

• Monitor temperature q3h during KC.


• Infants <28wks and <1000g, may require a heat lamp to help maintain body temperatures.

• Any fabric between the skin of the mother and infant will interfere with thermoregulation. This includes a bra.

Fewer episodes of hypothermia and hyperthermia occur with KC than with incubator care.


Transfer can be done in 2 ways:

• Sitting- Mother sits in chair and nurse transfers baby and tubing.

• Standing- Mother stands at bedside, leans over infant, and picks infant up to her chest, and then sits. Nurse gives full attention to tubing.

O is for Other Options for KC

• Ventilated Patient

• Multiples

• Surrogate

• Hyperbilirubinemia

• Post partum Depression

• KC Transport

• KC for Congenital Heart Defects

• KC for NAS

S is for State (Sleep, Wakefulness, and Crying)

Sleep is a state of restoration, learning, memory, growth.

Sleep is a continuous and dynamic process. The brain may be more active during sleep than wakefulness.

Sleep is divided into two stages in the preterm infant:

• Active sleep

• Quiet sleep


Quiet Sleep:

• Non REM, discontinuous EEG pattern

• The quality of active sleep requires a predominance of quiet sleep in a premature infant.

• Some memories are laid down and some forms of learning only occur here.

• Resembles sleep in the womb, more natural.

• Provides a respite from the noisy NICU.


Quiet Sleep Continued:

• Blunts release of glucocorticoids (cortisol) better than active sleep. High levels of these cause neuronal cell death.

• Associated with lower levels of stress as measures by hypothalamo-pituitary-adrenal axis activity.

• It is restorative and anabolic in nature.

• Oxygen consumption is lowest in quiet sleep.


Quiet Sleep Continued:

• Necessary for the emergence of attentiveness thus permits interaction with parents (amount of time in quiet sleep parallels time in attention later)

• Necessary for brain development (optimal conditions for brain organization)

• The more quiet sleep an infant has the less likely they are to have SIDS.


Active Sleep:

• REM sleep, continuous EEG pattern

• Most memory and learning occurs here. Information is actively processed and put into memory>

• Synapses are reconstructed to create memory and learning.

• Increased protein synthesis in brain cells here.

• Higher levels associated with better mental development at 1 and 2 years of age

• Promotes brain maturation


• One of the first observations made was that infants in KC appear relaxed, calm, and fall asleep.

• Infants in the hospital, especially NICU, have chaotic, fragmented sleep due to interruptions.

• Infants require both active and quiet sleep for normal neurodevelopment, but increased amounts of quiet sleep promotes brain maturation and complexity of active sleep.


• Preterm infants in incubators spend 15-17% of sleep in quiet sleep. Preterm infants in KC spend 45-65% of sleep in quiet sleep.

• Quiet sleep is a sign of and precursor to nervous system maturation.

• Learn to observe for quiet sleep and don’t interrupt it! (no movement and even respirations on monitor)


The ideal amount of Kangaroo Care (at one time) necessary to promote quiet sleep:

• In the full term infant and infants > 32 weeks gestation: at least 60-70 minutes

• In infants < 32 weeks gestation: at least 90 minutes

Takes about 60-75 minutes to complete 1 full sleep cycle in a premature or sick infant.


There is less crying with KC. Crying:

• Keeps PFO open (opening between right and left atria) (25% adults have PFO- causes clots)

• Increases intra-thoracic pressure

• Obstructs venous return to the heart

• Increased air in the intestinal tract

• Increases intra-abdominal pressure


Effects of Crying Continued:

• Decreases oxygenation to hypoxia

• Increases BP

• Depletes energy reserves

• Increases cortisol levels

• Inverted T waves and tachycardia

• Increases leukocyte count


• Positive correlation with pCO2 and negative correlation with pH

• Can cause a pneumothorax

• Can delay closure of ductus arteriosus

• Increased BP and hypoxemia can lead to intracranial hemorrhage

• Reestablishment of fetal circulation


KC has been shown to minimize pain during painful procedures.

K is for “K”ardiorespiratory

Overall, the effects of KC have been positive in regards to:

• Heart rates stabilize

• Respiratory rates stabilize

• Oxygen saturations increase

• FiO2 needs decrease (except with BPD)

• Less A and B

These effects are dependent on maintaining an adequate airway during KC.

I is for Involvement of Parents

KC has been proven to enhance the attachment/bonding process. The simple version- some things parents report: • Feel relaxed • Feel like I know my baby better • Feel closer to my baby • Feel in more control • Less anxiety over infant’s appearance • Look forward to doing it again


The more complex version- what studies show:

• More positive interactions- talk, touch, kiss, and adaptation to infant cues

• Rated feelings of love higher

• More confident, more involved, more protective

• Increased release of oxytocin (the only positive feedback loop in the body- more oxytocin begets more oxytocin)


Effects of Oxytocin

• Feelings of relaxation and well being

• Lower rates of depression

• Resolution of grief

• Alleviation of negative feelings

• Causes release of other hormones such as endogenous opiods, vasopressin, norepinephrerine, and prolactin


Together with oxytocin, these hormones:

• Modulate pain

• Promote calm and relaxation

• Makes mother feel good, increases enjoyment of infant, and causes them to seek out further interactions

• Increases number of nurturing behaviors

• Increased role in care giving


• Physiologically changes mother’s brain increasing their sense of mothering and developing a strong connection to infant

• Physiologically changes infant’s brain by promoting social brain development and causes increased actions to seek further interaction with parents

I is for Parent Involvement

Follow up studies at 3 months and 1 year show continued increase in positive interactions such as smiling, touching, contact behaviors and less crying in the baby than that of non KC infants/parents.

Findings support the presence of a “sensitive period” during which contact between mother and infant may induce a long-term positive effect on maternal infant interactions.

N is for Neurobehavioral Development

KC provides brain care:

• Accelerates neurobehavioral development

• Faster maturation of vagal tone (parasympathetic nervous system)

• Faster maturation of state organization

• Better brain complexity (more synapses)

• 5 distinct areas of higher brain development (2-4 weeks faster that non KC infants)

N is for Neurobehavioral Development

• No different or improved motor development

• When had improved motor performance, had higher scores on the Bayley Motor Scale at 6 and 12 months.

• KC infants had earlier day continence.

Cues with KC

• If the infant is craning his/her neck for interaction, you may stroke, touch, and talk softly.

• If the infant is sleeping, let the infant sleep.

Other Countries

KC is widely practiced around the world, including 3rd world countries.

• It is a federal law in South Africa.

• In Sweden, if families don’t provide KC 24/7, insurance companies will not pay any of the hospital bill.

So far, the US has been very slow in initiating KC, let alone adopting it.

Proposed Studies

• NAS

• Postpartum Depression

• Long Term Behavioral Studies

Documents

Kangaroo Care - University of Pittsburgh Medical Center 1... · •KC is a form of pleasing touch. ... BF in both pre-term and full-term infants. •BF in KC position achieves better