Developmental Aspects of Kangaroo Care

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Developmental Aspects of Kangaroo Care Susan M. Ludington-Hoe,CNM, PhD, FAAN Joan Y. Swinth, RNC, BSN

Kangaroo care (skin-to-skinholding) is an intervention that meets development care criteria by fostering neurobehavioral development. The five dimensions of neurobehavioral development are autonomic, motor, state, attention/interaction, and self-regulation.Kangaroo care promotes stability of heart and respiratory function, minimizes purposeless movements, improves behavioral state profiles, offers maternal proximity for attention/interaction episodes, and permits self-regulatorybehavior expression. Kangaroo care satisfies in part the handling, self-consoling/soothing,nonnutritive sucking, and parenting interventions recommended by the National Association of Neonatal Nurses’Infant and FamilyCentered Developmental Care Gutdelines.JOGNN, 25,691-703; 1996.

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angaroo care (KC) is a synonym for skin-to-skin ontact in which the preterm infant, wearing only a diaper, is placed upright, chest-to-chest with h i d h e r parent. The emergence of KC (Martinez, Rey, & Marquette, 1992; Whitelaw & Sleath, 1985) and its use in developed and developing countries (Davanzo, 1993; Levin, 1994; Charpak, Ruiz-Pelaez,& Charpak, 1994) have prompted the use of a classification system that is based on how soon after birth KC is begun (Anderson, Marks, & Wahlberg, 1986). The classification system is as follows: birth, very early, early, intermediate, or late. Extensive testing with mothers (Anderson, 1991) and fathers (Ludington-Hoe, Hashemi, Argote, Medellin, & Rey, 1992) and each classification has been reported (Anderson, 1991, 1995, in press); the results of this testing provide empirical data of KC’s contribution as a developmental care intervention. This article discusses the research-based linkages between KC and developmental care using Als’ (1986) neurobehavioral framework. The article concludes with examples of how KC is an intervention for modifying the environment, individualizing care to the infant, and promoting closeness and confidence in the parents.

Neurobehavioral Organization The goal of developmental care is to support and promote the premature infant’s adaptability to external envi-

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ronmental events, known as neurobehavioral organization. The five dimensions of neurobehavioral organization are: autonomic, motor, state, attention/interaction, and self-regulatory (Als, 1986). For each dimension the goal is an “organized” infant, one who responds to environmental demands without disruption in physiologic and behavioral responses. “When developmentally supportive care is administered, the infant’s growth development can be facilitated. This care allows for stabilization of physiologic and behavioral functioning” (National Association of Neonatal Nurses, 1995, p. 2). Kangaroo care studies and findings relating to each dimension of neurobehavioral organization are discussed.

Autonomic Dimension of Neurobehavioral Organization The autonomic dimension is the first in which the infant must gain control. Preterm infants respond to environmental stressors with a wide variation in physiologic parameters. For example, if an alarm sounds, the infant’s heart and respiratory rates change, oxygen saturation levels drop, and color goes from pink to gray. This response reflects physiologic instability, with parameters slowly returning to baseline. Older, healthier infants demonstrate greater autonomic stability with less vacillation in basic physiologic functions. An autonomically organized infant is one who maintains autonomic stability in the presence of environmental disturbances.

Relationsb@ Between Kc and Autonomic Kangaroo care has been found to provide a milieu that supports autonomic stability and fosters improvement in basic physiologic functions (Table 1). Clearly, when implemented in the selected populations tested to date, KC promotes cardiorespiratory stabilization, as shown by decreased variation in heart and respiratory rates (Fig. l), improved oxygenation, less bradycardia, fewer and shorter apneic episodes, and fewer episodes of periodic breathing. “Events such as apnea and bradycardia can trigger or involve associated changes in cerebral autoregJ O G N N

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CLINICAL I S S U E S

Table 1. Kangaroo Care Research Findings Related to Autonomic Functioning Source

Metbod

Findings

Acolet et al., 1989

N=14KC 10 min KC vs 10 min supine horizontal position

Increased' by 6.5 beats/min, remained WNL

Ludington-Hoe et al., 1991

1 group only (N = 12 KC) 3 hr crib/3 hr KC/3 hr crib 3 hr KC total

Increased. by 9 beats/min, remained WNL

Ludington et al., 1992

N = 11 KC N = 13 crib 3 hr crib/3 hr KC/3 hr crib 3 hr KC total

Increased. significantly, remained WNL

Ludington-Hoe, Hashemi, et al. 1992

Descriptive (N = 11 KC) 2 hr KC within 17 hr of birth in Columbia Paternal KC

Increased* during KC, remained WNL

Bieret al., 1995

RCT N = 21 KC N = 13 swaddled Averaged 13 m i d d a y X 10 days

Lower. in KC (165) compared to swaddled (174)

Bosque, Brady, Atfonso, L Wahlberg, 1995

Weekly measures of 1 group N = 8 KC KC for 4 hr/day, 6 day/week X 3 weeks

Similar. between KC and incubator

d e Leeuw, Colin, Dunnebier, L Mirmiran, 1991

O n e group (N = 8 KC) 1 hr incubator/l hr KC/l hr incubator 1 hr KC total

Similar. between KC and incubator

Ludington-Hoe. Anderson, Rey, Argote, L Hosseini. 1992

RCT (N = 5 KC, 3 crib) First 6 hr postbirth KC = 6 hr total

Less variability in KC than in crib

Moeller-Jensen et al., 1987

Clinical report; Experience daily ad lib KC until discharge

Positive impact o n the heart rate during KC

Ludington-Hoe,Anderson, Simpson Lk Hollingsead,1993

1 group only (N = 6 KC) First 6 hr postbirth

Remained WNL

RCT N = 21 KC, 20 incubator

Remained WNL during KC for 5 days

Heart rate

Ludington, Swinth, Becker, Rao, L Hadeed, 1995

3 hr incubator/3 hr KC/3 hr incubator o n days 1 and 5 9 hr of KC over 5 days Ludington, Ferreira. L Wang, 1995

RCT N = 6 KC, 3 incubator 3 hr incubator/3 hr KC/3 hr incubator 3 hr KC/day X 10 days

Remained WNL during KC for 10 days

Respiratoty rate Ludington-Hoe et al., 1991

Increased. by 3 breaths/min; remained WNL

Bier et al., 1995 Ludington, Swinth, et al., 1995

N o difference between KC and swaddled Remained WNL during KC for 5 days

Ludington, Ferreira. et al., 1995

Remained WNL during KC for 10 days

Ludington-Hoe, Hashemi, et al., 1992

Remained WNL during paternal KC

Ludington et al., 1992

Similar. between KC and open-air crib care

Bosque et al., 1995

Similar' between KC and incubator care

de Leeuw et al., 1991 Moeller-Jensen et al., 1987

Similar' between KC and incubator

Ludington-Hoe et al.. 1993

Remained WNL

Positive impact o n respiratory rate

Oxygenation Bier et al., 1995

Mean S a 0 2for KC 94% vs mean SaO, for control 92%; less likely to desaturate (SaO, < 88%) during KC

Ludington, Swinth, et al., 1995

Remained WNL for 5 days Remained WNL for 10 days

Ludington, Ferriera, et al., 1995 Ludington et al., 1992

Remained WNL and similar between groups

Ludington-Hoe et al., 1991 Gale et al., 1993

SaO, decreased. during KC; remained WNL KC group only (N = 25) ventilated infants ad lib time ranging to >20 hours total

S a 0 2 improved during KC

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Developmentally Based Care

Table 1 (continued). Kangaroo Care Researcb Findings Related to Autonomic Functioning Source

Metbod

Findings TcPO2rose by 1.0 kPa during KC; no hypoxia

Acolet et al., 1989 Ludington-Hoe,Hashemi, et al., 1992

Fluctuated little WNL during KC

de Leeuw et al., 1991

Similar. TcPO2between KC and incubator

Bosque et al., 1995 Ilamelin & Ramachandran, 1993

Similar. between KC and incubator Clinical report of experience with KC

O2 requirements stabilized or decreased. during KC

Lutlington-Hoe et al., 1993

No hypoxia in KC even with audible expiratory grunting

Luclington-Hoeet al., 1993

Stabilized in high 90s

Ludington-Hoe et al., 1993; Ludington-Hoe, Anderson, et al., 1992

Resolution of mild respiratory distress with KC and hood O2 within 6 hrs of birth

Apnea Whitelaw, 1986

Descriptive study, N = 20 KC Maternal/paternal KC to 3 hr/ day beginning as early as 3 days of age

No apnea during KC

Acolet et al., 1989

No serious apnea during KC

de Leeuw et al., 1991

Similar' number of apneic episodes > 10 secs plus similar total apnea time between the KC and control groups

Ludington, Swinth, et al., 1995

Sevenfold reduction in central apnea during KC on day 1 and day 5 @< 0.01); no change in central pattern for control infants Obstructive apnea rare occurrence

Ludington, Swinth, et al., 1995 Hadeed, Ludington, Ilr Siege], 1995

RCT; N = 20 KC, 21 incubator 3 hr incubator/3 hr KC/3 hr incubator 9 hr KC for 5 days

Similar' between KC and incubator care

Bosque et al., 1995 Hamelin Ilr Ramachandran, 1993 Ludington, Irwin, Swinth, Becker, Rao, & Hadeed, 1994

Frequency and duration of apnea reduced during KC

Less frequent episodes during KC RCT; N = 15 KC, 13 incubator 3 hr incubator/3 hr KC/3 hr incubator

Fewer central apneic spells and no obstructive apnea during KC N o prolonged apnea during KC for 10 days

Ludington, Ferreira, et al., 1995 Bradycardia Acolet et al., 1989

No serious bradycardia during KC

Bosque et al., 1995 de Leeuw et al., 1991

Similar. between KC and incubator care Increased' insignificantly in 2 of 8 infants during KC

Hamelin & Ramachandran, 1993

Less frequent episodes in KC

Periodic breathing Ludington, Ferreira, et al., 1995

Present in both groups in all periods

Ludington, Irwin, et al., 1994

Fewer episodes during KC

Temperature Positive impact on temperature

Moeller-Jensen et al., 1987 Mondlane, de Graca, & Ebrahim, 1989

Ludington-Hoe et al., 1991 Ludington et al., 1992

Descriptive (N = 132 KC) Two KC groups divided by start data ad lib KC until discharge

Warmed infants more than equipment after bath; KC at other than bath time maintained body temperature at higher level Increased. abdominal (abd) and rectal temperature (36.6'-37.2' C) Temperature increased. significantly during KC

Ludington, Swinth, et al., 1995; Ludington-Hoe, Anderson, et al., 1992

Increased. abdominal and toe temperature during KC

Ludington, Ferreira, et al., 1995

Increased. abdominal and axillary temperature during KC plus abdominal and axillary temperatures the same

Whitelaw, 1986

Body temperature "well maintained"

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CLINICAL ISSUES

Table 1 (continued).Kangaroo Care Researcb Findings Related to Autonomic Functioning Source

Method

Findings

Whitelaw, Heisterkamp, Sleath, Acolet, & Richards, 1988

RCT; N = 35 KC, 36 control Questionnaire at discharge and at 6 months of age Wt