The Effect of Skin-to-Skin Contact (Kangaroo Care) Shortly After Birth on the Neurobehavioral Responses of the Term Newborn: A Randomized, Controlled Trial

Background. The method of skin-to-skin contact (kangaroo care [KC]) has shown physiologic, cognitive, and emotional gains for preterm infants; however, KC has not been studied adequately in term newborns. Aims. To evaluate the effect of KC, used shortly after delivery, on the neurobehavioral responses of the healthy newborn. Study Design. A randomized, controlled trial using a table of random numbers. After consent, the mothers were assigned to 1 of 2 groups: KC shortly after delivery or a no-treatment standard care (control group). Subjects. Included were 47 healthy mother-infant pairs. KC began at 15 to 20 minutes after delivery and lasted for 1 hour. Control infants and KC infants were brought to the nursery 15 to 20 and 75 to 80 minutes after birth, respectively. Results. During a 1-hour-long observation, starting at 4 hours postnatally, the KC infants slept longer, were mostly in a quiet sleep state, exhibited more flexor movements and postures, and showed less extensor movements. Conclusions. KC seems to influence state organization and motor system modulation of the newborn infant shortly after delivery. The significance of our findings for supportive transition from the womb to the extrauterine environment is discussed. Medical and nursing staff may be well advised to provide this kind of care shortly after birth. Pediatrics 2004;113:858–865; skin-to-skin contact, kangaroo care, birth, neurobehavior, newborn infant. ABBREVIATIONS. KC, kangaroo care; C-section, cesarean section; ANOVA, analysis of variance; CNS, central nervous system. The transition from fetal to neonatal life represents one of the most dynamic and potentially hazardous events in the human life cycle. The initial postnatal period is characterized by high levels of stress, as exemplified by levels of catecholamines and cortisol secretion1–3 and comparatively labile neurobehavioral regulation.4 Therefore, methods that may enhance stabilization of neural, behavioral, and state regulation and facilitate the adaptation of the infant to the outside world might be clinically useful. The current study was designed to test the effect of a behavioral method known as skin-to-skin contact (kangaroo care [KC]), used as a postdelivery facilitation of the neurobehavioral selfregulatory responses of the term infant. The 5 key dimensions of neurobehavioral adaptation described in the literature5–8 are autonomic, motor, state, attention/interaction, and self-regulation, each regarded as a subsystem interacting with the other, all of which the infant aims to regulate. The degree of a newborn’s effectiveness to modulate behavior at a given moment reflects the degree of differentiation and quality of modulation of interaction among the different subsystems. Eventually, the subsystems achieve a relative degree of stable integration and work as a modulated ensemble, which in turn serves as an index for maturation9,10 and the basis for the next step of differentiation. For example, Ludington et al11 found increased frequency of quite sleep and reduced activity level during skin-to-skin contact compared with preand posttreatment periods, suggesting a better energy conservation as a result of a modulated interplay between the 2 subsystems in the treated preterm infants. Self-regulation, the index for differences in the level of the neurobehavioral organization in newborns, is expressed in the observable strategies the infant appears to use. This is aimed to maintain a balanced, relatively effective equilibrium of subsystem integration; otherwise, the infant persists in more labile subsystem imbalance and fluctuation that is considered more costly both autonomically and interactively.4,10,12,13 The term “self-regulation” is widely used to identify infant adaptation to various internal and external stimuli and to unstable situations. The development of infant self-regulation involves the regulation of physiologic systems,14 information processes,15 and the formation of attachment bonds16 and ultimately determines how the infant responds cognitively and social-affectively to the environment. Self-regulation develops in the newborn within the womb and throughout the birth process, and it is especially challenged during the first hours and days after delivery.13 Skin-to-skin contact, the normal mammalian postnatal condition,17–23 has been found to improve infant state organization, thermal regulation, respiration, and oxygen saturation, reduce apnea and From the *Department of Nursing, Faculty of Social Welfare and Health Studies, University of Haifa, Haifa, Israel; and ‡Department of Neonatology, Meyer Children’s Hospital, Rambam Medical Center, and B. Rappaport Faculty of Medicine, Technion, Haifa, Israel. Received for publication Jul 3, 2003; accepted Dec 17, 2003. Address correspondence to Sari Goldstein Ferber, PhD, Department of Nursing, Faculty of Social Welfare and Health Studies, University of Haifa, Mount Carmel Haifa 31905, Israel. E-mail: [email protected] PEDIATRICS (ISSN 0031 4005). Copyright © 2004 by the American Academy of Pediatrics. 858 PEDIATRICS Vol. 113 No. 4 April 2004 bradycardia, increase milk production, accelerate weight gain, and quicken hospital discharge. Since the KC method was first introduced for preterm infants in Bogota, South America,24 this form of skinto-skin contact has been found furthermore to improve state regulation, neurobehavioral status, and autonomic maturation in preterm infants surviving to term age.25–34 KC is supposed to help the newborn regulate himself/herself in the presence of incoming information from the outside world,32,35–37 suggesting that maternal contact could establish a protective function by raising the infant’s regulatory threshold for aversive stimuli in the environment. This protective function in turn seems to promote attention and exploration. In support of this view, Feldman et al32 found that preterm infants, treated with KC before term, by 3 months of age cried only during the more aversive stimuli as compared with controls who did not experience KC. The effects of KC seem to persist beyond the time period of KC provision. After KC, preterm infants slept longer, their sleep was better organized and restful,38 and the sleep-wake cyclicity was more mature at term age.32 Infant alertness was also improved,39 which is rather important for the development of attention processes and intake of outside information in infancy. In addition, longer duration of breastfeeding was found in KC dyads.40 Few studies have reported the use of KC shortly after birth, and it is not being widely used with term infants. Compared with controls who were not held after birth, newborn infants treated with KC shortly after birth had their temperature more readily well maintained,40–43 had higher blood glucose levels while none of the subjects were fed,43 and significantly decreased crying 60 minutes postbirth.43 It was also found that KC functioned as an analgesic intervention in term newborns during the heel-lance procedure.44 Studies from another laboratory have shown that maternal touch by massage rather than by holding in the postnatal period also was beneficial in terms of improved weight gain in preterm infants45 and in maturation of circadian rhythms and melatonin secretion in term infants.46 In a recent review and meta-analysis on KC,47 it was concluded that KC after birth has a positive effect on long-term breastfeeding in term dyads and that the temperature of the healthy, newly delivered infant will remain in a safe range, provided ventralto-ventral KC is uninterrupted and the infant is thoroughly dried and covered across the back. To date, self-regulation and neurobehavioral responses in the term newborn infant after KC in the early postnatal period have not been reported yet. We hypothesized that KC would be superior to standard care in terms of neurobehavioral responses of newborns after birth. Thus, the aim of this study was to investigate the effect of KC experienced shortly after birth on self-regulation and neurobehavioral expression of the term newborn during the first postnatal hours. METHODS