Introduction
If you have listened to my podcast previously or follow Empowering NICU Parents on social media, you likely know that I am a huge advocate for skin-to-skin care or kangaroo care! You also might know that I often speak to the importance of parental involvement and engagement in the NICU!
For today’s episode, we are going to review some recent research studies that not only show the importance of frequent skin-to-skin care, but you’ll quickly notice how the two topics impact one another. Now, before you get stressed or stop reading on just because I mentioned research, give it a chance! I promise that this topic is not boring or too advanced, and you will find it completely relatable and interesting, so keep reading!
We will review many of the ways skin-to-skin care can positively affect infants, their parents – yes both parents – not just mothers and not just in the immediate period of the NICU journey, but for many years in the future! So get ready to be blown away by the amazingness of what our human bodies can do!
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Episode 30
Our previous episodes on kangaroo care
As I previously stated, we are going to dive into some of the recent, amazing findings from several research studies on the benefits of kangaroo care. For this episode, I am not going to cover the basics of kangaroo care, because we already did that…so I strongly recommend if you have not already to head back to episode 14: Kangaroo Care in the NICU: How Does it Benefit the Infant and Parents?
But also consider checking out episode 15: where I specifically discuss Kangaroo Care in the NICU: How to address the barriers, assess for readiness, and transfer the infant safely.
Today we will review some of the commonly known positive effects of skin-to-skin care, but also dive a bit deeper into the topic as well. If you are a visual person like me, sometimes it’s helpful to see an image to really understand something, so I put together a graphic that displays all of the benefits of kangaroo care in a visually appealing way. Go grab your copy now!
Sequelae of prematurity
As you likely know, NICU infants are at risk for complications including feeding difficulties, suboptimal growth, gastrointestinal reflux, eye complications, bronchopulmonary dysplasia, long-term neurodevelopmental abnormalities plus more short and long-term morbidities. And unfortunately, they are also at risk for cognitive and behavior abnormalities including variations in social and emotional development.
Frontal lobe development and the impact of our environment
Without getting too deep into neonatal development, it’s important to understand that the frontal region of the brain develops late and continues to grow into early adulthood. The left frontal region of the brain is responsible for higher level cognitive and emotional regulatory function which means that it helps us to problem-solve, it regulates our impulse control and how we respond to situations, and it assists us with social interactions. Since it develops late, its growth is very sensitive to individual insults or differences in a child’s environment.
I bring this point up to remind us all that what we do either as clinicians in the NICU, even with our tiniest of patients or our involvement as parents in the first hours and years to follow is all very impactful! We have the ability to change the trajectory of our high risk NICU patients with positive experiences. Not only is an infant’s environment the physical objects and noises around them, it also includes the people and how we as caregivers and parents interact with them is so impactful. And once you listen to some of the findings from our literature review today, I think that the importance of our involvement will be even more apparent.
Our personal experience with kangaroo care
One of the reasons I love to discuss skin-to-skin or kangaroo care is because it provides so many benefits and not just to the baby, but the parents as well! I will admit that I knew kangaroo care was beneficial when I was a NICU nurse, but it wasn’t until I had my son William that I really understood its impact. I truly believe it was our daily kangaroo care that we did with him for hours each day that contributed to his success. It was also one of the few ways my husband and I could truly bond with him when he was so small. But, despite my personal experience, I also continue to learn more and more by reading and researching and it blows my mind how advantageous kangaroo care is in several ways that we will discuss today.
I believe and many others do as well that the standing transfer is the best way to transfer an infant for kangaroo care. At one point my friend recorded me doing a standing transfer with my son to share with some nurses. Go watch it now!
NICU stress and trauma
Before we dive into the studies further, I think it’s important to address the stress and trauma that our NICU patients endure as well as the parents because as you will see skin-to-skin care helps to negate much of that stress and trauma.
According to Smith et al. in a 2011 study, they discussed how the premature infant’s brain is very vulnerable to stressful exposures. With increased exposures to stressors and trauma in the NICU, they found an associated decrease in brain size, which will impact neurodevelopmental outcomes later in childhood.
The body’s physiological response to stress
We all know some of the common stressors NICU patients encounter including their separation from their parents, especially their mother, pain during cares and procedures, and the overstimulating and noxious environment. There is alot of pathophysiology to understand when it comes to the infant’s physiological responses to stress, but simply stated, heightened levels of stress initially cause the body to release hormones, one of which is cortisol which we discuss further momentarily. Two of the other hormones released are epinephrine and norepinephrine which results in increased arousal or suboptimal sleep patterns, anxiety, and an elevated heart rate plus additional responses. The secondary response to excessive stress causes our infants to become disengaged, hypotonic, apneic, and have bradycardia episodes.
Ultimately, the cascade of stressful events causes the infant’s body to divert resources away from the gastrointestinal tract to the more important organs like the brain, heart, and lungs. The diversion from the GI tract results in a decrease of digestion and motility, plus it may cause feeding intolerance and it can ultimately affect the infant’s body and brain growth.
Now Cortisol, which is a glucocorticoid, is released once the infant experiences short-term stress. But, if the infant is exposed to prolonged elevated levels of Cortisol, it can be detrimental to an infant’s body. Once Cortisol levels are elevated for prolonged periods, it over-stimulates neurons in the brain, can cause neuronal cell death, poor brain growth and structural changes. These negative changes contribute to negative long-term neurodevelopmental outcomes including learning, behavioral, mental, and physical abnormalities .
Prolonged elevated levels of cortisol also lead to an inflammatory cascade that plays a role in necrotizing entercolitis (NEC), bronchopulmonary dysplasia BPD), and retinopathy of prematurity (ROP) – which are all common morbidities for preterm infants.
Some of the stress our NICU patients experience is difficult to manage, but we as caregivers and parents need to attempt to minimize prolonged periods of excessive or repetitive stress when possible. Obviously, we need to care for the infant and many of the procedures are medically necessary, but we need to try to mitigate the amount of stress with non-pharmacological or pharmacological measures as much as possible to minimize the negative long-term effects. One of the most effective ways to do this is with skin-to-skin care.
Maternal-child separation
Infants admitted to the NICU also experience a separation from their mother in the initial moments followed by the extended time while they are in the NICU. Obviously, the separation impacts the parent-infant attachment and ability to bond in the early moments and days and months that follow. But, studies have also shown that when touch is limited or eliminated, it may lead to touch starvation and result in adverse physical and psychological outcomes. What better way to prevent touch starvation and promote parent-infant attachment than with kangaroo care?
Additionally, parents who have a baby in the NICU often experience parental role alteration and do not feel like parents. Between their loss of identity as a parent coupled with their trauma from the NICU experience, it can affect their ability to bond with and nurture their baby. NICU mothers are also at an increased risk for postpartum stress, depression, and PTSD, which may impact their ability to become involved and nurture their baby. We know that all babies need love and attachment, so it is crucial that we minimize parental fears, encourage their involvement and engagement, and minimize the risk of postpartum depression. And one of the most prominent ways we can accomplish this is with kangaroo care.
NICU pain
And Sadly, despite previous thoughts that infants, especially those born prematurely, do not experience or remember pain, we now know this to be inaccurate. The nerve pathways of infants mature more slowly, so infants may not withdraw in response to pain or may not display the typical pain signals, but you will note a physiologic response including an elevated heart rate, fast breathing, or an elevated blood pressure.
In a 2021 cross-sectional study by Assefa and colleagues, they found that on average, each infant in the NICU experiences 7.5 to 17.3 painful procedures per day! Most of those procedures are considered to be moderately to severely painful. What better way to help manage mild to moderate pain than with skin-to-skin care!
NICU environment and the impact of kangaroo care
Additionally, the NICU environment itself is very stressful and traumatic for our patients. The mismatch between the infant’s underdeveloped coping skills with the intensely stimulating NICU environment may cause physiologic instability, adversely affect growth and development, and ultimately impact long-term neurodevelopmental outcomes
It is not my intent to bring up these statistics or findings to scare NICU parents, but to acknowledge that our NICU infants do have many known stressors placed on them especially in the early NICU days that may affect their short and long-term outcomes. I also bring these stressors up because as we review some of the findings from the studies here shortly, you will learn that practicing kangaroo care not only helps to minimize the negative effects of the parent-child separation, the stressors from the NICU environment including painful cares and procedures, but it also has many additional positive benefits.
And we do know that despite all of the stress endured in the NICU, that positive experiences can negate the negative trauma and redirect the child’s developmental trajectory and benefit the entire family as a whole.
Oxytocin – the love hormone
Now before we move on to some of the findings, it is important to also discuss the hormone oxytocin as well, which is often referred to as the “love hormone.” Oxytocin is released in response to activation of the sensory nerves in women during labor and breastfeeding, with adults during sexual activity and in adults and infants in response to low intensity stimulation of the skin with touch and as we will see, with skin-to-skin care.
With the release of oxytocin, it helps support muscle tone throughout the body so infants are more able to engage with their caregivers which promotes bonding. With the release of oxytocin, infants are also able to more effectively feed, and it improves digestion and overall growth.
Overall, it’s important to remember that oxytocin is the hormone associated with affectionate behavior, bonding, and the ability to nurture relationships whereas cortisol is released in response to stress.
Literature Review
Okay, now let’s look at some of the findings in the literature!
Parent-Training with Kangaroo Care Impacts Infant Neurophysiologic Development & Mother-Infant Neuroendocrine Activity
In a 2020 study by Hardin and colleagues, they conducted a randomized-control trial to review the effects of skin-to-skin care on brain activity, the associated release of neurohormones on the mother and infant, and the neurodevelopment in full-term infants. They measured the levels of Oxytocin and Cortisol in both the mothers and infants and they measured EEG activity on the infants to examine a potential association between kangaroo care and brain development.
They found that infants who received kangaroo care had significant effects on the left frontal portion of their brain which is associated with neuro-maturation, language skills, problem solving and positive emotions. In regards to the bio-mechanism and the levels of oxytocin and cortisol, they found moderate to large increases in oxytocin levels in the mothers and infants and a moderate decrease in cortisol. Overall, the trial showed that full-term infants respond to kangaroo care with a decrease in stress reactivity and with a favorable influence on neurodevelopmental trajectories and neurobiological functions.
Parent Engagement Correlates With Parent and Preterm Infant Oxytocin Release During Skin-to-Skin Contact
In a 2019 study by Vittner and colleagues, they examined the relationship between parental engagement and oxytocin and cortisol levels for parents who participated in skin-to-skin care. They included 28 stable preterm infants, mothers, and fathers in their randomized crossover study. Saliva samples of oxytocin and cortisol were collected in the infants and parents 15 minutes before skin-to-skin care was initiated, 60 minutes into it and 45 minutes following skin-to-skin care.
They found that oxytocin levels increased and cortisol levels decreased for the infants, mothers and fathers compared with the baseline. The results also revealed that the changes in the levels of oxytocin and cortisol were associated with an increase in parental engagement. With the study, they speculated that changes in the levels of hormones during skin-to-skin care allowed the infants and parents to develop a more synchronous relationship. With the responsive and positive interaction during skin-to-skin care, it increases the feelings of comfort and attachment leading to enhanced bonding, even for patients in the NICU. Isn’t that amazing – yet it makes total sense! Once we are relaxed and able to bond with and nurture our baby, we begin to become engaged, which enhances the attachment and promotes further involvement!
Systematic Review of the Effects of Skin-to-Skin Care on Short-term Physiologic Stress Outcomes in Preterm Infants in the Neonatal Intensive Care Unit
A 2019 systematic review by Pados and Hess, they evaluated the evidence for improvements in short-term physiologic stress outcomes with skin-to-skin care. They reviewed several studies and although there were some mixed findings, they found that overall the research supports that skin-to-skin care has a stress-reducing effect on physiologic cardiorespiratory variables. With the findings, they recommended that skin-to-skin care should be considered an essential component of providing optimal care for our NICU patients.
Kangaroo Care and Postpartum Depression: The Role of Oxytocin
Badr and Zauszniewski conducted a literature review and published it in 2017. They reviewed evidence that linked the effects of kangaroo care with the release of oxytocin and its association with postpartum depression. They consistently found that kangaroo care has a positive effect on preventing postpartum depression.
As we previously reviewed, with kangaroo care, oxytocin is released which stimulates maternal behaviors like attachment which positively affects the mother’s mood so oxytocin has an antidepressent-like property and decreases maternal stress. They concluded that kangaroo care should be used as a non-pharmacologic intervention to prevent or decrease the incidence of postpartum depression.
The Effects of Kangaroo Care in the Neonatal Intensive Care Unit on the Physiological Functions of Preterm Infants, Maternal-Infant Attachment, and Maternal Stress
Okay, next up we are going to review a study done by Cho and colleagues that was published in 2016. Their goal was to identify the effects of kangaroo care on the physiologic functions of preterm infants, maternal-infant attachment, and maternal stress. The data they evaluated for physiologic functioning included body weight, heart rate, respiratory rate, and oxygen saturations. Although there were some changes, the only function that showed statistical significance was a decrease in the respiratory rate of infants in the experimental group who received kangaroo care whereas those in the control group had an increase in their respiratory rate. Additionally they found that maternal-infant attachment scores were higher in the experimental group who practiced kangaroo care as well as an improvement in maternal stress. Their findings support that kangaroo care not only promotes emotional bonding between mothers and their babies, but it also reduces maternal stress and helps to stabilize the infant’s respirations leading it to be one of the most effective nursing interventions in the NICU.
The Effects of Kangaroo Care Applied by Turkish Mothers Who Have Premature Babies and Cannot Breastfeed on Their Stress Levels and Amount of Milk Production
The next study by Coskun and Gunay from 2020 specifically looked at the effects of kangaroo care on Turkish mothers of premature infants who were not able to breastfeed and how that affected their stress levels and the amount of milk production. As we know, mothers who deliver their infant prematurely, or any mother whose baby is in the NICU will typically have delayed and/or decreased milk production. The stress and fatigue from having an infant in the NICU coupled with the maternal-infant separation and the inability to put the baby to the breast affects milk production.
The study performed a randomized control trial and had 84 couplets that practiced at least 15-20 minutes of kangaroo care for 5 days a week over 3 weeks. They found that the breast milk produced by the mothers who practiced kangaroo care gradually began to increase with statistical significance when compared to the mothers in the standard group. They also found that the increase in milk production of those mothers in the kangaroo care group positively affected the mother’s maternal feelings and decreased their stress. With the improved maternal mood and decreased stress, it allowed them to more effectively bond with and develop relationships with their infant. The authors concluded by saying that kangaroo care is a very important intervention for promoting bonding between mothers and premature infants and increasing the mother’s milk production.
Microbiome and skin-to-skin care
There are also a few studies that go beyond the scope of this podcast that focus on the infant’s microbiome or the microbial colonization of the surfaces of the body. The microbes play an essential role in the immune system, the development of the gastrointestinal tract plus much more. And according to Indrio and his colleagues, skin-to-skin care has the potential to positively contribute to the infant’s microbiome which has potential lifelong effects on health.
The benefits of skin-to-skin care when it comes to microbiomes is actually quite fascinating. While doing skin-to-skin care, the infant has direct contact with the parent’s skin microbes which will then help to colonize the infant with healthier microbiome. Additionally, if the mother is nursing or pumping breast milk, she is exposed to the infant’s microbes during skin-to-skin care and her milk will actually produce an immune response to those microbes and will then share the immune properties with the infant through her breast milk! Isn’t that so cool! Which is one of the many reasons that fresh breastmilk is best because if the infant has been exposed to something, it will receive natural antibodies against it from his or her mother’s milk! I find it all so fascinating!
Mother-Infant Skin-to-Skin Contact: Short and Long-Term Effects for Mothers and Their Children Born Full-Term
Okay, for our last study, Bigelow and Power published it in 2020 and they did a longitudinal study looking at skin-to-skin contact with mothers and full-term infants and did a follow-up when the children were 9 years old. I point this one out because most studies are over a few months or years, which is often a limitation to the results, but this one is unique because it looks at the positive influence of skin-to-skin care on mother-child interactions in infancy and into children’s middle childhood.
After following the children at 1 week, 1 month, 2 months, 3 months, and 9 years, they found that the mothers who practiced skin-to-skin care reported fewer depressive symptoms and a decrease in cortisol (remember, that stress hormone) in the first month. They also found that those mothers continued to breastfeed their infants through the first 3 months when compared with the control group. The skin-to-skin care dyads also displayed earlier mother-child reciprocity or the ability to recognize cues, signals and communicate. The mother-child dyads who practiced kangaroo care in the 9 year follow-up showed more engagement and reciprocity at that time as well. They concluded that release of oxytocin during skin-to-skin care is an underlying factor that helped the mother-child relationship have a positive trajectory with long-term benefits.
The value of research
So there you have it! There are so many researchers out there who are doing great work and I cannot thank them enough. It is through evidence found in research findings that help to drive the evidence-based care we provide in healthcare. Not that I doubted for one second all of the benefits of skin-to-skin care, but it’s a great reminder of just how valuable it is for the infant, the mother, the father, and the family’s long-term trajectory!
To help encourage you as parents or if you are a clinician, please share with your parents the kangaroo care log we put together. I feel that it helps to encourage and empower our parents to keep trying daily kangaroo care. If they are able to visually see how much time they’ve been able to invest in it, see the improvements in the infant’s tolerance, and document how they felt during skin-to-skin care, it can be very encouraging. Grab your copy of the kangaroo log now!
References below
Closing
I hope you found our literature review on the many benefits of kangaroo care helpful! It is just astounding how amazing our bodies are and how one simple practice between an infant and their parent can cause this beautiful, virtuous, positive cycle of unending benefits for everyone involved! With both the physical, mental, and neurobiological benefits, kangaroo care is one of the most effective non-pharmacological nursing interventions used in the NICU for the care of infants and their family. With its ability to decrease pain in infants, minimize stress in infants and mothers, promote parental engagement, positively influence the infant’s microbiome, stabilize an infant’s physiologic functioning, improve an infant’s neuromaturation, decrease the risk of postpartum depression, and improve maternal-child engagement for years down the road, it is an integral component of the neuroprotective and developmental care we provide in the NICU.
Not only is skin-to-skin care beneficial for the infant, but in turn it can increase a mother’s milk supply, positively affect the mother’s emotions, minimize the risk of postpartum depression, and decrease their stress which promotes their ability to bond with their infant. With parent-child attachment and bonding, parents are more likely to remain involved and engaged with their infant while they are in the NICU which allows them to learn their infant’s behavioral cues and how to care for their infant in the future. Therefore, parents are able to confidently care for their infant after discharge which continues to promote a nurturing environment and ultimately improves the infant’s long-term outcomes.
Parents, do not underestimate the power of skin-to-skin care with your infant and if you are a clinician, please continue to encourage it as much as possible!
We ask that you please consider sharing this podcast episode with someone who would gain some value from it!
References
Assefa, E., Dinkiye, M. Geleta, T., Tantu, T. Wondwosen, M., & Zewdu, D. (2022). The practice of procedural pain assessment and management in neonatal intensive care unit in Ethiopia: Cross-sectional study. Health Science Reports, 5(2), e533-e540.
Badr, H. & Zauszniewski, J. (2017). Kangaroo Care and Postpartum Depression: The Role of Oxytocin. International Journal of Nursing Sciences, 4(2):179-183.
Begelow, A. & Power, M. (2020). Mother-Infant Skin-to-Skin Contact: Short and Long-Term Effects for Mothers and Their Children Born Full-Term. Frontiers in Psychology, 8, 1-9. https://doi.org/10.3389/fpsyg.2020.01921
Cho, E., Kim, S., Kwon, M., Cho, H., Kim, E., Jun, E., & Lee, S. (2016). The Effects of Kangaroo Care in the Neonatal Intensive Care Unit on the Physiological Functions of Preterm Infants, Maternal-Infant Attachment, and Maternal Stress. Journal of Pediatric Nursing, 31, 430-438.
Coskun, D. & Gunay, U. (2020). The Effects of Kangaroo Care Applied by Turkish Mothers Who Have Premature Babies and Cannot Breastfeed on Their Stress Levels and Amount of Milk Production. Journal of Pediatric Nursing, 50, e26-e32.
Hardin, J., Jones, N., Mize, K., & Platt, M. (2020). Parent-Training with Kangaroo Care Impacts Infant Neurophysiologic Development & Mother-Infant Neuroendocrine Activity. Infant Behavior and Development, 58, https://doi.org/10.1016/j.infbeh.2019.101416
Indrio, F., Martini, S., Francavilla, R., Corvaglia, L., Cristofori, F., Mastrolia, S., Neu, J., Rautava, S., Spena, G., Raimondi, F., & Loverro, G. (2017). Epigenetic Matters: The Link Between Early Nutrition, Microbiome, and Long-Term Health Development. Frontiers in Pediatrics, 5(178), https://doi.org/10.3389/fped.2017.00178
Pados, B. (2019). Physiology of Stress and Use of Skin-to-Skin Care as Stress-Reducing Intervention in the NICU. Nursing for Women’s Health, 23(1), 59-70.
Pados, B. & Hess, F. (2019). Systematic Review of the Effects of Skin-to-Skin Care on Short-term Physiologic Stress Outcomes in Preterm Infants in the Neonatal Intensive Care Unit. Advances in Neonatal Care, 20(1), 48-58.
Smith, G., Gutovich, J., Smyser, C., Pineda, R., Newnham, C., Tjoeng, T., Vavasseur, C., Wallendorf, M., Neil, J., & Inder, T. (2011). Neonatal Intensive Care Unit Stress is Associated with Brain Development in Preterm Infants. American Neurology Association, 70(4), 541-549.
Vintner, D. Butler, S., Smith, K., Makris, N., Brownell, E., Sara, H., & McGrath, J. (2018). Parent Engagement Correlates With Parent and Preterm Infant Oxytocin Release During Skin-to-Skin Contact.
Advances in Neonatal Care, 19(1), 73-79.
Remember, once empowered with knowledge, you have the ability to change the course.
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