Download Physiologic and Neurophysiologic Outcomes of Kangaroo Care

Physiologic and
Neurophysiologic Outcomes of
Kangaroo Care
Susan M. Ludington, CNM, Ph.D.,
FAAN
Walters Professor of Pediatric Nursing
[email protected]
Evolution of KMC Science
Case Studies
Studies
Descriptive Studies
Experimental
Meta-Analyses
Policies
Physiologic Outcomes
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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)
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
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)
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
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
Case Study #1
Case Study # 1
38.0
38.0
37.5
37.5
Baby A
37.0
37.0
36.5
36.0
36.0
Subject #1
35.5
Temperature
36.5
Maternal breast A
35.0
Baby A
Subject #1
35.5
Maternal Breast B
35.0
Baby B
0
:1
13:05
13:00
13:55
12 50
:
12 45
:
12:40
12:35
12:30
12 :25
12:20
12:15
12:10
12:05
12:00
12:55
11:50
11
7
:3
11
0
:1
13:05
13:00
13:55
12:50
12 :45
12:40
12:35
12:30
12 :25
12:20
12:15
12:10
12:05
12:00
12:55
11:50
11
7
:3
11
Data collection time
Baby B
Data collection time
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
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 Dsquam (Case and Rainbow study in progress).
Neurophysiologic Outcomes
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Sleep indices
Brain Maturation
Brain Complexity
Cerebral Oxygenation
Neurophysiologic Outcomes
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.
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.
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
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)
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(↓ RSArespiratory 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)
How to Measure Brain Maturation
1. SLEEP PATTERNS
2. HEART RATE/RESPIRATORY RATE
PATTERNS
3. 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
what is important in SLEEP
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
Active sleep
=REM=Dream sleep
=continuous EEG pattern
Quiet sleep
=Non REM=NREM=No dreams
Synaptogenesis between neurons occurs in
=discontinuous EEG pattern
Cycles take about 60 minutes to complete
Think of your pet, watching him sleep
REM
REM
NREM
REM
NREM
This is a healthy sleep pattern
This is a very good cycling pattern
So in every hour, you would like to
see an EEG pattern that shows:
REM
REM
NREM
1 hour
NREM
2nd hour
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.
In any 3 hour period you should see 3
cycles between REM (dreaming)
sleep & NREM (quiet) sleep
completed:
REM Sleep is supposed to be somewhat active, so
HR increases and RR is irregular
REM
REM
NREM
State
REM
NREM
NREM
HR
RR
What do we see during
Kangaroo Care?
chaotic pattern of activity,
quiet HR & RR
Pre-KC
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
What does this mean?
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
Neuronal Synapses
& Growth
Sleep Cycling
Cycling is needed for normal growth
But preemies are demonstrating 48
hours of non-cycled sleep patterns
a) Does this continue thru hospitalization? YES
b) Does the lack of cycling or delay in cycling
affect post-discharge sleep? No normal sleep
pattern for two years post discharge (Scher,
1997)
• 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

Test Conditions
Incubator Group
SSC Group
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)
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
Dysmaturity Index Findings
• When studied over 32-40 weeks:
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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
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 eightweek trial of skin contact with preterm infants.
Sleep Medicine, 2008
Maturity by COMPLEXITY
• Complexity is called Dimensional Analysis
• There are 3 measures we look at (sample
entropy, approximate entropy,
probabalistic complexity, and deterministic
complexity)
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. )
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 NONINVASIVELY
• When brain tissue is activated, changes in blood
flow cause change in oxygenation and this is
picked up by machine
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).
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)
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.
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.)
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!!
This is the Best quiet time in the NICU for brain
maturation
Kangaroo and Hand Touch
For the Limbic Brain!!!
Brain Outcomes
• Kangaroo Care is the best NONSEPARATION. Separation from mother
during stressful periods/painful procedures
during the first two weeks of life
permanently alters µOpioid receptor
binding capacity in the brain in rats and is
expected to do so in humans – a
PERMANENTLY BAD change in the brain
(Weaver SA, Diorio J, Meaney MJ. 2007. Maternal separation leads
to persistent reductions in pain sensitivity in female rats. J. of Pain
8(12), 962-969.)