The Impact of Kangaroo Mother Care on Mother-Infant Dyads Affected by Neonatal Abstinence Syndrome

Background and Significance: Opioid use, both licit and illicit, is a growing public health concern in the United States (NIDA, 2016). Heroin use has increased among both men and women of all ages and across all socio-economic groups. Further, rates of heroin use have doubled in U.S. women (CDC, 2016). These national trends are reflected in the rising number of women who use opioids while pregnant. Between the year 2000 and 2009, the use of opioids during pregnancy increased fivefold (Patrick, et al., 2012). As a result, national rates of neonatal abstinence syndrome (NAS) have tripled since 2000 resulting in one U.S. child now being born every 25 minutes with this syndrome (NIDA, 2016). NAS is a withdrawal syndrome experienced by infants who are prenatally exposed to addicting substances, most commonly opioids, and is associated with inconsolable crying, sleep disturbance and seizures (Cleveland, in press). No universally agreed upon standard of care exists for infants impacted by NAS. Treatment is typically focused on symptom management using medications, such as morphine, and soothing techniques. Medications may alleviate some NAS symptoms; however, medication use prolongs an infant’s length and cost of hospital stay (Bio, et. al, 2011; Jansson, L., 2011). Soothing techniques are nonpharmacologic comfort measures and are considered the first line in the clinical management of infants with NAS. These techniques include swaddling, providing a quiet environment and skin-to-skin mother-infant holding [kangaroo mother care] (Sublett, 2013; Valez, 2008). Of these techniques, kangaroo mother care (KMC) is unique because it offers the potential to benefit both the mother and her infant (Ludington-Hoe & Swinth,1996). While KMC is often recommended for infants with NAS, no empirical evidence exists to support its use.

 

Study Purpose and Specific Aims: The purpose of this study was to determine the impact of KMC on attachment and stress-reactivity in mother-infant dyads impacted by NAS.

Methods: Institutional Review Board approval was obtained prior to the onset of data collection. All participants provided written consent to participate in this study. We used a sequential, embedded, mixed-methods design to conduct this study. Our participants were recruited prenatally from a non-residential treatment facility for pregnant and parenting women with opioid use disorders. They were enrolled in the study following informed consent and a brief educational intervention on KMC. The women then contacted our study personnel following delivery and we met with them during two separate sessions of KMC. Maternal attachment was assessed using the Maternal Attachment Inventory (MAI) at baseline and following the 2^nd KMC session. Stress was measured using the Parental Stressor Scale: Neonatal Intensive Care Unit (PSS: NICU). We also assessed mother and infant heart rate and salivary cortisol levels prior to and during each session of KMC. Qualitative interviews were conducted with the mothers following discharge of their infant from the hospital. All interviews were audio-recorded, transcribed verbatim and analyzed line by line using thematic analysis.

Findings: As of October 2016, 76 women have been enrolled in the study. Forty-nine mother-infant dyads have completed data collection; 14 women are still pending delivery and 13 have been lost to follow-up. Our target sample size is 60 complete data sets and we anticipate this study to be complete no later than spring of 2017. To date, the mean age of our study participants was 27 years and 79% self-identified as Latina. Sixty-three percent of the women were married and 71% indicated that their infant’s father was actively involved in their lives. Most women (67%) did not work outside of the home and 35% reported having an annual household income of less than $9,999. Further, 46% of the women reported have a previous mental illness diagnosis. The average gestational age for the infants who participated in this study was 38 weeks and the average birth weight was 2700 grams. Infants spent an average of 28 days on medications for management of their NAS symptoms.

Scores on the MAI indicated a high level of maternal attachment across both time points. Results from the PSS: NICU showed high scores on the “Relationship and Parental Role” subscale. The items scored as most stressful were: (a) being separated from my baby, (b) not being able to hold my baby when I want, (c) feeling helpless and unable to protect my baby from pain and painful procedures, and (d) feeling helpless about how to help my baby during this time. Further, a paired samples t-test revealed a significant decrease in mother’s heart rate, from an average of 76.41 (SD = 10.31) beats per minute prior to engaging in KMC, to an average of 70.62 (SD = 12.58) beats per minute during KMC; t(33) = 3.67, p < .01. Infant heart rate also decreased significantly from pre-KMC at an average of 144.76 (SD = 17.24) beats per minute to an average of 137.79 (SD = 18.11) beats per minute during KMC; t(33) = 2.33, p < .05. Both maternal and infant saliva analysis for cortisol are underway and will be completed by Spring of 2017.

To date, our qualitative findings indicate that KMC was very meaningful to the mothers. Thematic analysis revealed the following themes: (a) Barriers to KMC, (b) In our own world, (c) Healing together, and (d) Preparing to go home. Barriers to KMC reflected the busy and often crowded environment of the intensive care nursery as well as staff attitudes and stigma surrounding addiction. Yet mothers described feeling as though they were in their own world with their infant while doing KMC in-spite of this environment. They also explained how they felt they and their infant were healing together during KMC and that their infant was “forgiving” them. Finally, the mothers described preparing to go home and how many of them continued to do KMC with their infants following hospital discharge.