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Reducing stress in infants: Kangaroo Care.

Stress can be defined as a biological and psychological response to a given action or situation (Contrada, 2011). Many factors may produce a biological or psychological response and the presence of ongoing stress may result in disease or illness (Cohen, Kessler, & Gordon, 1997). However, most empirical literature emphasizes that stress is when an action or situation exceeds the ability to adapt to or to find balance (Contrada, 2011). In the matter of labor, delivery, and post-delivery, infants are exposed to many different types of stressors including but are not limited to the burden of labor, environment (internal or external), and/or medical needs. The burden of labor includes length and intensity of the labor, the mother's physical abilities or limitations, and the fetal development of the baby. The environment may include the mother's physical changes in labor (e.g., contractions), pushing, visceral changes (e.g., blood pressure, heart rate, oxygenation), or stress hormone changes. After delivery, the environment may include medical procedures imme diately performed on the infant, lights and sounds in the room, or the separation from the mother. These factors occur in healthy "normal" births as well as in births with complications or illness. Stress on the infant will be present in all situations regardless of the health of the infant. In matters of premature, ill, or complicated deliveries, the stressors will exceed the "average." It is important to incorporate antistress methods in efforts to calm an infant, one such natural method, and the subject of this article, is known as Kangaroo Care (KC).

KC is a technique in which the clothing of the infant is removed (except the diaper) allowing their body, legs, arms, and face to have direct skin contact to the parent's bare chest or torso. The term "parent" regarding direct skin contact refers to maternal, paternal, and surrogate (Ludington-Hoe, 2011). The skin-to-skin contact of chest to chest has been found to increase the release of oxytocin, a neuronal hormone that reduces stress, increases bonding, and trust (Gianaros & O'Connor, 2011; Uvnas-Moberg, 1998) and has been reported to have pain-relieving effects in infants (Ludington-Hoe & Hosseini, 2005). In addition, oxytocin has been found to decrease the stress hormone cortisol, and stimulate the vagus nerve, which connects with various organs and muscles in the body.

KC incorporates multisensory aspects including but not limited to touch and proprioception (the body's ability to feel the parent holding the infant), hearing (exposure to the sound of the parent's heartbeat), positioning (laying against the chest and skin of the parent), movement or vestibular (feel of the rhythmic breathing of the parent), and thermal or temperature (Cong, Ludington-Hoe, & Walsh, 20ii). KC is a natural behavioral technique (e.g., placing the infant on the parent via skin-to-skin), found to aid in parent bonding and infant calming rather than administering medicine or the need for invasive procedures.

History of KC

KC was originally studied in 1970 (Ludington-Hoe, 20ii). The initial research included the mother and full-term infant, focusing on the mother's behaviors toward the infant and parent-child attachment (Barnett, Leiderman, Grobstein, & Klaus, 1970). The research resulted in a positive change in healthcare by creating rooming-in (i.e., the infant sleeping in the same room as the parent) with the focus on child-parent attachment, however the element and potential benefits of skin-to-skin were initially disregarded (Ludington-Hoe, 20ii). In 1983, researchers from Colombia began investigating skin-to-skin contact between pre-term infants and maternal parents which resulted in an increase in research by European and Scandinavian neonatal specialists (Ludington-Hoe, 20ii). Through this expanded research, by 20ii, KC was endorsed by the American Academy of Pediatrics, American Heart Association, American College of Obstetricians and Gynecologists, Association of Women's Health, Obstetric and Neonatal Nurses, as well as the United States Centers of Disease Control for full term infants (Ludington-Hoe, 20ii).

Benefits of KC

The benefits of KC include biological and psychological elements for both the parent and infant. For the parent, gains center on eight themes in the research literature: confidence, physical effects on the parent and infant, bonding, constructing parental role, information and communication between parents and nurses, support of family/partner, parents' physical needs, and the NICU environment (Gabriels, Brouwer, Maat, & van den Hoogen, 2015). Ultimately, the primary gains were identified as increased parent involvement in the care of the infant, increased confidence of the parent, a sense of purpose and role as a primary caregiver, and "special" connections between the parent and infant (Gabriels et al., 2015).

More striking are the benefits for the infant. These are noted in the physiological and biological changes such as temperature, heart rate, sleep-wake cycles, reduction of pain, and oxytocin release (Bystrova et al., 2003; Cong et al., 20ii; Feldman, Gordon, Schneiderman, Weisman, & ZagoorySharon, 2010; Ludington-Hoe, 20ii; McCain, LudingtonHoe, Swinth, & Hadeed, 2005).

Temperature

Bystrova et al. (2003) evaluated full term infants maintaining or increasing body temperature given either KC (skin-to-skin), mother's arms (infant clothed but in the mother's arms), or in the nursery (clothed and in a bassinet or swaddled in a bassinet). The infants who were in the skin-to-skin group demonstrated a higher temperature rectally as well as in the feet. The feet temperatures remained throughout the hospitalization in the skin-to-skin group while in other groups, temperatures were lower (Bystrova et al., 2003). The authors speculated that the sensory system was activated by the skin-to-skin contact through the proprioceptive aspects of KC, which resulted in temperature regulation (Bystrova et al., 2003). In other words, the way the infant's body interpreted the sensations in KC created a neurological chain reaction resulting in benefits of regulating and maintaining the infant's body temperature. Even with preterm infants (e.g., birth prior to 36 weeks), skin-to-skin contact resulted in temperature elevation (Bauer et al., 1997). In addition, Bauer et al. O997) noted that the change in air temperature during the transition from the nursery to the skin-to-skin contact did not affect the rise in the infant's temperature elevation when skin-to-skin on the parent. In both full-term and preterm infants, the use of skin-to-skin contact resulted in a rise in the infant's body temperature, maintenance of the temperature, and positively influenced distal blood flow to the extremities (i.e., arms and legs).

Heart Rate, Sleep-Wake Cycle, and Oxygenation

The measurement of the heart rate provides the healthcare team with information related to the heart contraction rate over a set period of time (e.g., a minute). Physiologically, with each breath, a neurological signal is sent to the heart to increase or decrease the rate of contraction (i.e., pumping). The nervous system is regulated by two competing systems, one that excites (i.e., speeds up) and one that depresses (i.e., slows) activity. The heart works together with the respiratory system through the nervous system signals by means of the excitation system (i.e., sympathetic) and depressive (i.e., parasympathetic) system (Feld & Eidelman, 2003; McCain et al., 2005). Few studies have looked at the benefits of KC on heart rate variability (HRV), yet the results are consistent. Infants who used KC demonstrated better neurodevelopmental growth as demonstrated by improved HRV (Feld & Eidelman, 2003; McCain et al., 2005). Additional study is warranted, however; current results of KC research indicate significant positive outcomes as it relates to decreasing stress and improving HRV.

Infants have a series of "states," or levels of consciousness (Gottesman, 1999; White, Simon, & Bryan, 2002). These include quiet sleep, active sleep, drowsiness, quiet alert, active alert, and crying (Gottesman, 1999). The sleep states, including quiet and active sleep, typically last 60 minutes in length and transition to drowsiness prior to the infant awakening (Gottesman, 1999; White et al., 2002). A conscious/awake infant can also move through the alert states (e.g., quiet alert, active alert, and crying) and transition to drowsiness then into the sleep states. These states and the progression between states is normal infant behavior. However, environmental stimuli can alter or rapidly change an infant's state (e.g., heel stick, bright lights, and loud sounds) which can create additional stress and a disruption in the infant's ability to regulate sleep-wake cycles as they relate to state.

Several studies have found that the use of skin-toskin contact aided in calming a crying or excited infant (Bohnhorst, Heyne, Peter, & Poets, 2001; Feldman et al., 2010; Feldman et al., 2002; McCain et al., 2005). For example, a stressed infant in a crying state was placed skin-to-skin to the mother resulting in a change in the infant's respiratory and heart rate (within 30 seconds) and the infant was able to maintain a calm resting state for 40 minutes (McCain et al., 2005). Feldman et al. (2002) assessed premature infants and the impact of KC on the sleep-wake cycle. Results found those infants who utilized KC demonstrated an improved rhythm of sleep wake cycle and those with a medical risk showed a greater benefit overall in which the infant was able to stay awake and rest in the normal sleep wake patterns. These findings support the infant's ability to improve his or her regulation of sleep and periods of wakefulness. In contrast to many studies related to heart rate, oxygen consumption, and temperature, Bohnhorst et al. (2001) noted that in preterm infants (e.g., ages 24-31 weeks), bradycardia (i.e., slow heart rate) and hypoxemia (i.e., low oxygen intake) with less regular breathing was noted. Considerations of infant head positioning and placement on the parent was a noted limitation, however, for purposes of infant safety, heart rates and oxygen saturations are recommended to be monitored on preterm infants when engaging in KC.

Reduction of Pain and Crying Time

Infants are likely to undergo various procedures to ensure health after birth and while in the hospital. The most common is a heel stick for purposes of obtaining blood. The use of KC for pain regulation or remediation was studied in both preterm and full-term infants. Ludington-Hoe and Hosseini (2005) assessed the impact of KC on preterm infants (aged 37 weeks) during heel sticks. Heart rates, states of alertness and duration of crying was noted throughout the study (Ludington-Hoe & Hosseini, 2005). Results indicated that given the use of KC, infants demonstrated reduced heart rates and crying duration (Ludington-Hoe & Hosseini, 2005). In addition, several infants in a deep sleep state did not cry at all despite the needle stick (Ludington-Hoe & Hosseini, 2005). However, the timing of the KC prior to the heel stick is important. Using KC within 30 minutes prior to the heel stick has demonstrated the greatest results in decreasing pain (Cong et al., 2011).

The theory that skin-to-skin contact between the infant and parent provides pain-relieving methods continues to be explored in infant populations with disorders, difficulties, or discomfort. Infants with colic (i.e., fussiness and crying in otherwise healthy infants) are another group in which KC may provide comfort or calming of symptoms (Rad et al., 2015). In a quasi-experimental study, infants aged 15-60 days were evaluated with KC and the potential impact on their crying duration and fussiness (Rad et al., 2015). Prior to initiating KC, colicky infants presented with an average crying duration of 2.21 [+ or -] 1.54 hours per day. After the use of KC, crying durations decreased to 1.16 [+ or -]1.3 hours per day (Rad et al., 2015). Similar to the work of Bystrova et al. (2003), the theory of sensory system activation due to skin-to-skin contact through the proprioceptive aspects of KC, warrant ongoing study.

Summary

The impact of kangaroo care on temperature, heart rate, sleep-wake cycle, and oxygenation, and pain reduction is being universally studied. KC has consistently demonstrated positive calming effects on the full-term and preterm infant. The benefits extend far beyond the parent child bonding, and researchers have hypothesized KC may positively influence the neurological system and aid in cognitive and physical development. Additional research is needed in this area, however, based on the literature to date and the overall positive results of KC over the past 40 years of research, doulas, nurses, and midwives can quickly teach parents how to use KC and explain the general benefits with very few contraindications found in current literature.

References

Barnett, C. R., Leiderman, P. H., Grobstein, R., & Klaus, M. (1970). Neonatal separation: The maternal side of interactional deprivation. Pediatrics, 45(2l 197.

Bauer, K., Uhrig, C., Sperling, P., Pasel, K., Wieland, C., & Versmold, H. T. (1997). Body temperatures and oxygen consumption during skin-to-skin (kangaroo) care in stable preterm infants weighing less than 1500 grams. The Journal of Pediatrics, 130(2), 240-244. doi: http://dx.doi.org/10.1016/S00223476(97)70349-4

Bohnhorst, B., Heyne, T., Peter, C. S., & Poets, C. F. (2001). Skin-to-skin (kangaroo) care, respiratory control, and thermoregulation. The Journal of Pediatrics, 138(2), 193-197. doi: http://dx.doi.org/10.1067/mpd.2001.110978

Bystrova, K., Widstrom, A. M., Matthiesen, A. S., Ransjo-Arvidson, A. B., Welles-Nystrom, B., Wassberg, C., ... Uvnas-Moberg, K. (2003). Skinto-skin contact may reduce negative consequences of "the stress of being born": A study on temperature in newborn infants, subjected to different ward routines in St. Petersburg. Acta Paediatrica, 92(3), 320-326. DOI: 10.1111/j.1651-2227.2003.tb00553.x

Cohen, S., Kessler, R. C., & Gordon, L. U. O997). Strategies for measuring stress in studies of psychiatric and physical disorders. In S. Cohen, R. C. Kessler, & L. U. Gordon (Eds.), Measuring stress: A guide for health and social scientists (pp. 3-26). New York: Oxford University Press.

Cong, X., Ludington-Hoe, S. M., & Walsh, S. (2011). Randomized crossover trial of Kangaroo Care to reduce biobehavioral pain responses in preterm infants: A pilot study. Biological Research for Nursing, 13(2), 204-216. doi:10.1177/1099800410385839

Contrada, R. J. (2011). Stress, adaptation, and health. In R. J. Contrada & A. Baum (Eds.), The handbook of stress sciences (pp. 1-9). New York: Springer Publishing Company, LLC.

Feld, R., & Eidelman, A. (2003). Skin-to-skin contact (Kangaroo Care) accelerates autonomic and neurobehavioral maturation in preterm infants. Developmental Medicine and Child Neurology, 45(4), 274-28i. DOI: 10.1111/j.14698749.2003.tb00343.x

Feldman, R., Gordon, I., Schneiderman, I., Weisman, O., & Zagoory-Sharon, O. (2010). Natural variations in maternal and paternal care are associated with systematic changes in oxytocin following parent-infant contact. Psychoneuroendocrinology, 35(8), 1133-1141. doi: http://dx.doi.org/10.1016/j. psyneuen.2010.01.013

Gabriels, K., Brouwer, A. J., Maat, J., & van den Hoogen, A. (2015). Kangaroo care: Experiences and needs of parents in neonatal intensive care: A systematic review 'parents' experience of kangaroo care. Pediatric Neonatal Nursing, 1(1), 8. Retrieved from http://dx.doi.org/10.16966/2470-0983.102

Gianaros, P., & O'Connor, M. (2011). Neuroimaging methods in human stress science. In R. J. Contrada & A. Baum (Eds.), The handbook of stress science. biology, psychology, and health (pp. 543-563). New York, NY: Springer Publishing Company, LLC.

Gottesman, M. O999). Enabling parents to "read" their baby. Journal of Pediatric Health Care, 13(3, Part i), 148-151. doi:http://dx.doi.org/10.1016/ S089i-5245(99)90080-9

Klaus, M. H., Kennell, J. H., Plumb, N., & Zuehlke, S. O970). Human maternal behavior at the first contact with her young. Pediatrics, 46(2), 187.

Ludington-Hoe, S. M. (2011). Thirty years of kangaroo care science and practice. Neonatal Network, 30(5), 357-362. doi:10.1891/0730-0832.30.5.357

Ludington-Hoe, S. M., & Hosseini, R. B. (2005). Skin-to-skin contact analgesia for preterm infant heel stick. AACN Clinical Issues, 16(3), 373-387.

McCain, G. C., Ludington-Hoe, S. M., Swinth, J. Y., & Hadeed, A. J. (2005). Heart rate variability responses of a preterm infant to Kangaroo care. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 34(6), 689-694. doi:10.1177/0884217505281857

Uvnas-Moberg, K. O998). Oxytocin may mediate the benefits of positive interactions and emotions. Psychoneuroendocrinology, 23(8), 819-835. doi: http://dx.doi.org/10.1016/S0306-4530(98)00056-0

White, C., Simon, M., & Bryan, A. (2002). Using evidence to educate birthing center nursing staff: About infant states, cues, and behaviors. The American Journal of Maternal/Child Nursing, 27(5), 294-298.

Meredith Baker-Rush is a speech-language pathologist with clinical experience of working in a neonatal intensive care unit and is completing her doctorate in health psychology. She has personal and professional experience with Kangaroo Care and continues to support stress reduction techniques across the life span.
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Author:Baker-Rush, Meredith
Publication:International Journal of Childbirth Education
Article Type:Report
Geographic Code:1USA
Date:Oct 1, 2016
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