Physiologic and Neurophysiologic Outcomes of Kangaroo Care

1. Physiologic and Neurophysiologic Outcomes of Kangaroo Care Susan M. Ludington, CNM, Ph.D., FAAN Walters Professor of Pediatric Nursing Susan.ludington@case.edu

2. Evolution of KMC Science Case Studies Descriptive Studies Experimental Studies Meta-Analyses Policies

3. Physiologic Outcomes • Heart rate, stability, variability • Respiratory rate, stability, SaO2, apnea, PB • Temperature • Pain responses • All results cited in Ludington-Hoe et al., 2008. A Clinical Guideline for Implementation of Kangaroo Care with Premature Infants of 30 or More Weeks Postmenstrual Age. Advances in Neonatal Care 8(3S), S3-S23. ( Supplement)

4. Heart Rate variables • HR may not change or be different from incubator, or may rise 5 beats/min in KC • HR usually higher in 2nd KC hour than 1st • Bradycardia is rare during KC • HR variability shows increased sympathetic activity and overall predominance of parasympathetic activity during KC as compared to incubator

5. Respiratory Variables • RR may be lower, or no different than in incubator or rise 10 breaths/min with KC • RR usually more stable in KC (2nd sleep) • SaO2 may rise or drop 0.6 -1.0% with KC • Desats (Sao2<80%) increase in 2nd KC hr in one study (Bohnhorst et al. 2004)

6. Breathing Patterns • Apneas may not change or may decrease by 75% during KC • A decrease in apneas is expected because apneas occur during arousals from sleep and sleep arousals drop during KC (Lehtonen & Martin, 2004). • Periodic breathing decreases during KC

7. Temperature Changes • Infant body temperature rises. • The coldest an infant will be is when he is in an incubator or under a radiant warmer or swaddled • In tropical environments, infant temps can exceed 38.0C with paternal KC. • Each breast acts independently to keep a twin warm

8. Case Study #1

9. Case Study # 1 Baby A Baby B

10. Pain Responses • Heart rate is much less likely to rise with KC during pain as without KC or with sucrose • Respiratory rate does not fluctuate so widely with KC during pain as without KC or with sucrose • Crying may not occur with heelstick in KC, and crying time is greatly diminished with KC

11. Other physiologic responses • Cortisol levels (sign of stress) decrease during as little as 20 minutes of KC compared to incubator period • Weight gain is increased with KC • Head circumference is increased with KC • Body length is increased by 0.99 cm with KC • Fewer infections, probably due to increased hydration, decreased water loss, and the dermal pathway of antigen/antibody transfer using D-squam (Case and Rainbow study in progress).

12. Neurophysiologic Outcomes • Sleep indices • Brain Maturation • Brain Complexity • Cerebral Oxygenation

13. Neurophysiologic Outcomes

14. Neuroplasticity • In first 3 years, the components of the brain and central nervous system can be changed by environmental events (internal and external environment). • MALLEABILITY/FLEXIBILITY of the neurons, dendrites, axons, wiring, firing, and structure/function of brain.

16. Brain Growth Spurt • During first and last trimesters of pregnancy brain grows very fast and is more receptive to environmental influences than at other times. • Over 1st 3 years of life, brain reaches 75% of adult size • Genetic contributions made by DNA which is laid down in neurons up to 12 months age, not after that.

17. Brain Maturation • Development of the brain that occurs over time: • Nerves become covered with myelin sheath • Neurons grow larger (dendritic growth) (# is set by term age) • Neurons connect with thousands of others to produce thoughts, actions, feelings • Redundant neurons die off • Neurons travel from central germinal matrix to periphery to form cortex in lobes and areas of brain • Communication between R and L hemispheres occurs  intelligence

18. Frontal LOBE • Area of LIMBIC system –the emotional system of the human being • The site for memory retention in the first 3 years of life – emotional memories establishing self-esteem, love, compassion, empathy, sympathy, importance, sense of belonging. • Pleasing TOUCH is best stimulator of LIMBIC system. ( Ollauson et al., 2003)

19. Signs of Brain Maturation • Enlarging head size due to dendritic and cell body expansion and migration • Increasing control over bodily functions, ie. -respiratory rate becomes more regular, - heart rate becomes more regular - HR and RR become more cohesive(↓ RSA- respiratory sinus arrhythmia) - less physiologic and behavioral disruption with distrubance -sleep becomes more organized -brain firing patterns change and do so without damage -brain structure changes without damage (Scher 1997, Scher et al., 2002)

20. How to Measure Brain Maturation • SLEEP PATTERNS • HEART RATE/RESPIRATORY RATE PATTERNS • BRAIN ACTIVATION by EEG patterns by regular EEG (expensive) or by aEEG (amplitude EEG - using new bed side brain monitor) and by Near Infrared Sprectroscopy

21. Not so much duration, or density of any sleep stage, or number of sleep stage episodes, but, cycling between quiet sleep and active sleep is what is important what is important in SLEEP

22. Active sleep=REM=Dream sleep=continuous EEG patternQuiet sleep=Non REM=NREM=No dreamsSynaptogenesis between neurons occurs in =discontinuous EEG patternCycles take about 60 minutes to completeThink of your pet, watching him sleep

23. REM REM REM NREM NREM This is a healthy sleep pattern This is a very good cycling pattern

24. So in every hour, you would like to see an EEG pattern that shows: REM REM NREM NREM 2nd hour 1 hour

25. But,In the NICU, infants demonstrate a very chaotic version of this cycling pattern.Cycling is needed for normal development. Quiet Sleep is needed to produce Active Sleep.

26. In any 3 hour period you should see 3 cycles between REM (dreaming) sleep & NREM (quiet) sleep completed:

27. REM Sleep is supposed to be somewhat active, so HR increases and RR is irregular REM State REM REM NREM NREM NREM HR RR

28. What do we see during Kangaroo Care?

29. KC chaotic pattern of activity, quiet HR & RR Pre-KC Pre-KC: • Same as baseline pattern In KC: • Normal cycling & less magnitude in 2nd cycle • Few, if any, tachycardic/bradycardic • HR-variation is within normal limits • Non-chaotic pattern

30. In the cerebal cortex: Synapses between the 3 levels of neurons are occurring and synapses are becoming reinforced for longevity and complexity as needed to provide regular cycling What does this mean?

31. Cycling is needed for normal growth Neuronal Synapses & Growth Sleep Cycling

32. But preemies are demonstrating 48 hours of non-cycled sleep patterns • Does this continue thru hospitalization? YES • Does the lack of cycling or delay in cycling affect post-discharge sleep? No normal sleep pattern for two years post discharge (Scher, 1997)

33. Maturation changes are reflected in the spectral characteristics of • Respiration, • ECG/Heart rate, • Pulse oximetry, • Chin EMG, • Eye movements, • EEG. CALLED DYSMATURITY INDEX and DIMENSIONAL ANALYSIS OF COMPLEXITY

34. Test Conditions Incubator Group SSC Group

35. Results Pediatrics 2006 report: Arousals were lower in SSC group than controls (p<.01) over entire study period as well as during test-pretest matched segments of QS (p<.0001) and AS (p<.007). REMs were lower in SSC period in SSC group (p <.01) and in AS segments (p < .02)

36. Results with N=109Continued • Indeterminate sleep lower in SSC (p < .03) when confounders were included in the regression. • QS increased during SSC • State transitions decreased during SSC

39. Dysmaturity Index Findings • When studied over 32-40 weeks: • Respiratory Regularity better than term & 44 wks • AS time better than term and 44 wks • Arousals the same as term • QS time better than term and 44 wks • Cycle length better than term and same as 44 wks • Spectral beta and spectral correlation better than term and 44 wks • 5 areas of right hemisphere (the one that responds to sensory stimulation) more mature than non-KC preterms

40. BETTER BRAIN MATURATION • THIS SINGLE NURSING INTERVENTION IMPROVES BRAIN MATURATION. NO other single nursing intervention has been shown to do this (Scher M, Ludington-Hoe, SM, Kaffashi, F., Johnson, M, Holditch-Davis, D, & Loparo KA. Neurophysiologic assessment of brain maturation: preliminary results of an eight-week trial of skin contact with preterm infants. Sleep Medicine, 2008

41. Maturity by COMPLEXITY • Complexity is called Dimensional Analysis • There are 3 measures we look at (sample entropy, approximate entropy, probabalistic complexity, and deterministic complexity)

43. Complexity Results • In all measures of complexity, preterm infants who received KC from 32-40 weeks pma had better brain maturation than fullterm infants and similar healthy preterms who did not get Kangaroo Care. (Kaffashi F, Scher M, Ludington-Hoe SM, & Loparo, KA. Complexity analysis of neonatal EEG. In press for J. Electroencephalography. )

44. Effect of Nursing Care on Brain Activation • Near Infrared Reflective Spectroscopy is a measure taken by a machine that can be used at the bedside. • It measures cerebral blood volume, blood flow, cerebral oxygenation, cerebral oxygenated and deoxygenated hemoglobin – all NON-INVASIVELY • When brain tissue is activated, changes in blood flow cause change in oxygenation and this is picked up by machine

45. Effect of Nursing • Opening incubator doors • Handling • Heel Stick • Conversation • Blanket tucking • Overhead paging Each reduced cerebral blood volume by 17-40% for 5-60 seconds These occurred 28-45 times in a 2 hour period Spectrometry picked up 63% more desaturation events than SaO2 monitoring does (Gagnon, Leung & Macnab, 1999. A J Perinatol 16(1), 7-11).

46. Effects of Nursing • Vital Signs are very disruptive to cerebral blood flow and • -Reduce blood flow by 14% • -Reduce blood volume by 8% • -Reduce oxygenation by 7-56% • CHANGING DIAPERS is Similarly Disruptive (Adcock et al., 1999, Neonatal intensive care applications of near-infrared spectroscopy. Clin Perinatol 26(4), 893-903)

47. Effects of Nursing • Weighing the infant with lowered lights, sound, and containment of extremities vs. no change in environment- measured Pain, HR, SaO2, salivary cortisol, and cerebral oxygenation • Weighing with environment change resulted in less pain, lower HR increase, no change in cortisol, and increased cerebral oxygenation levels. Better than no environment change. Cateline, Tordjman, Morin, Oger, Sizun, 2005. Clinical, physiologic, and biologic impact of environmental and behavioral interventios in neonates during a routine nursing procedure. J Pain 6(12), 791-797.

48. Effect of Environment • The Loud and Well Nursery is still bad, because it prevents/minimizes quiet sleep, sustains active sleep, minimizes good quality cycling. • Though changes proposed in 1985 (Gottfried et al., Infant Stress Under Intensive Care), sound levels continue to be above recommended levels despite physical redesign of nurseries and staff training. Equipment, alarms, staff talking and infant fussiness contribute to even higher sound levels (Byers et al., 2006. Sound level exposure of high risk infants in different environmental conditions, Neonatal Network, 25(1), 25-32.)

49. Jackie Martin – Roanoke, VA NICU • Comparing brain activation during incubator care and during KC • Similar to heart rate variability, there appears to be increased activation of the brain during KC (improved cerebral blood flow and cerebral oxygenation probably mediated by stabilized cardiorespiratory parameters during sleep) as compared to incubator. • So, if it were your infant, would you want the baby to have better or lesser brain blood flow and oxygenation? THIS IS A NO-BRAINER!!

50. This is the Best quiet time in the NICU for brain maturation