Kangaroo care originated in Bogota, Colombia in the 1970s as a way to improve outcomes for preterm infants born in hospitals lacking modern medical equipment and supplies. It involves skin-to-skin contact between a parent and infant. Kangaroo care has been shown to improve infant outcomes such as temperature regulation, breastfeeding rates, and bonding between parents and infants. It also reduces infant pain responses and improves sleep patterns which are important for brain development. Kangaroo care is now practiced worldwide and research continues to demonstrate its benefits.

1. Foundations of Kangaroo CareFoundations of Kangaroo Care
Susan Ludington, CNM, PhD, FAANSusan Ludington, CNM, PhD, FAAN
Walters Professor of Pediatric NursingWalters Professor of Pediatric Nursing
Bolton School of Nursing Case West.Res.UnivBolton School of Nursing Case West.Res.Univ
United States Institute for Kangaroo Care (United States Institute for Kangaroo Care (www.kangaroocareusa.org)www.kangaroocareusa.org),.,.
USIKC2010@gmail.comUSIKC2010@gmail.com
Susan.ludington@case.eduSusan.ludington@case.edu 216-368-5130216-368-5130

2. Pre-conference Power point # 1
Foundations of Kangaroo Care
Susan M. Ludington CNM, CKC, PhD, FAANSusan M. Ludington CNM, CKC, PhD, FAAN
Walters Professor of Pediatric NursingWalters Professor of Pediatric Nursing
Bolton School of Nursing Case Western Reserve UniversityBolton School of Nursing Case Western Reserve University

3. Objectives
• To understand theTo understand the
origins of Kangarooorigins of Kangaroo
Care and how it cameCare and how it came
to Americato America
• Be able to name threeBe able to name three
effects of Kangarooeffects of Kangaroo
Care on infants,Care on infants,
mothers, and familiesmothers, and families

4. Welcome to Bogota, ColombiaWelcome to Bogota, Colombia

5. Origins of Kangaroo Care
• Common wisdom is that Kangaroo Care was originatedCommon wisdom is that Kangaroo Care was originated
by Drs. Edgar Rey and Hector Martinez in Bogota,by Drs. Edgar Rey and Hector Martinez in Bogota,
Colombia to reduce preemie mortality & morbidity inColombia to reduce preemie mortality & morbidity in
resource-poor hospitals without heat, without formula,resource-poor hospitals without heat, without formula,
without supplies & limited sterilization capabilities.without supplies & limited sterilization capabilities.
• Mortality was ̴̴70%Mortality was ̴̴70%
due to infection.due to infection.

6. Labor RoomLabor Room

7. Immediate Post-partum CareImmediate Post-partum Care

8. The Neonatal Intensive CareThe Neonatal Intensive Care
UnitUnit

9. ““Clean” Supply Room in NICUClean” Supply Room in NICU

10. IV Bags in the NICUIV Bags in the NICU

11. Intubated infant in BogotaIntubated infant in Bogota

12. ““Co-Bedding” in NICUCo-Bedding” in NICU

13. Three infants sharing anThree infants sharing an
incubatorincubator

14. Sharing Phototherapy LightsSharing Phototherapy Lights

15. Bogota NurseryBogota Nursery

16. Baby with a heating pad forBaby with a heating pad for
warmthwarmth

17. Transitional NurseryTransitional Nursery

18. Maintaining an upright positionMaintaining an upright position

19. Use of Sling for PositioningUse of Sling for Positioning

20. Mom gets infant for KMCMom gets infant for KMC

21. Infant with an NG tubeInfant with an NG tube

22. VLBW infant in KMCVLBW infant in KMC

23. VLBW infant with standard preemie diaperVLBW infant with standard preemie diaper

24. Settling downSettling down

25. Sound AsleepSound Asleep

26. Dr. Hector Martinez,Dr. Hector Martinez,
Co-founder of Kangaroo CareCo-founder of Kangaroo Care

27. Getting ready to go homeGetting ready to go home

28. ““La Casita”: Kangaroo MotherLa Casita”: Kangaroo Mother
CareCare Follow-up ClinicFollow-up Clinic

29. KMC follow-upKMC follow-up

30. A 16 year old mom leavingA 16 year old mom leaving
“La Casita”“La Casita”

31. Dr. Gene Anderson with KMC babyDr. Gene Anderson with KMC baby
on her lapon her lap

32. Utrecht, Holland embracesUtrecht, Holland embraces
KMCKMC
Infant with
Blow by O2

33. Sweden embraces maternal andSweden embraces maternal and
paternal Kangaroo Carepaternal Kangaroo Care

35. Beginning descriptive studyBeginning descriptive study

36. Progressed to Randomized trialProgressed to Randomized trial

37. RCT over 5 daysRCT over 5 days

38. 10 days in KC versus:10 days in KC versus:

39. 10 days in incubator10 days in incubator

40. Control condition for first RCTControl condition for first RCT

41. Experimental conditionExperimental condition

42. Find the baby! U.S. technologyFind the baby! U.S. technology

46. Thermal Synchrony BetweenThermal Synchrony Between
Mother and Infants DuringMother and Infants During
Kangaroo CareKangaroo Care
Susan M. Ludington, CNM, PhDSusan M. Ludington, CNM, PhD
Gene C. Anderson, RN, PhD,Gene C. Anderson, RN, PhD,
FAANFAAN
Anthony Hadeed, MD, FAAPAnthony Hadeed, MD, FAAP

47. Descriptive crib study- 6 statesDescriptive crib study- 6 states

48. More refined State MeasuresMore refined State Measures

50. Cardio Respiratory ChangesCardio Respiratory Changes
Pre-KC KC Post KC

51. Gould Cardio-Respiratory Patterns

52. Chaotic modeling of cardio-Chaotic modeling of cardio-
respiratory pattern in anrespiratory pattern in an
incubatorincubator

53. Chaotic modeling in KMCChaotic modeling in KMC

54. All over warm and collapsed inAll over warm and collapsed in
sleepsleep

55. KMC apnea studyKMC apnea study

56. Apnea StudyApnea Study
Mom with foot support

57. Apnea Study, Edentech nasalApnea Study, Edentech nasal
thermistorthermistor

58. Nasal thermistor close-upNasal thermistor close-up

59. Apnea reduction by 75% during KMCApnea reduction by 75% during KMC
Ludington-Hoe et al
Neonatal
Network 1994

60. Paternal KC during ventilationPaternal KC during ventilation
Ludington-Hoe et al
Acta Paediatrica 1998

61. PKC and KMC Research TeamPKC and KMC Research Team

64. High Risk Labor UnitHigh Risk Labor Unit

65. Scrub in area for deliveriesScrub in area for deliveries

66. The KMC TeamThe KMC Team
Dr. Jaime Bastitas, Dr. Susan Ludington
Mrs. Luz Angela Argote

67. Six minutes oldSix minutes old

68. Already warm after 3 minutes ofAlready warm after 3 minutes of
KMCKMC

69. Post-delivery research roomPost-delivery research room

70. Subject #1: Pilot studySubject #1: Pilot study

71. TwinsTwins

72. Breastfeeding in KCBreastfeeding in KC

73. D-stick < 40 ; D10W feedD-stick < 40 ; D10W feed

74. KC during immediate post-partumKC during immediate post-partum
transitiontransition

75. Peaceful slumber 1 hour after birthPeaceful slumber 1 hour after birth

76. KC Beginning in Delivery RoomKC Beginning in Delivery Room

77. Discharge at 48 hours afterDischarge at 48 hours after
birthbirth

78. Transient respiratory distress inTransient respiratory distress in
KCKC

80. Beginning ofBeginning of
PKCPKC

81. Note theNote the
infant’s smile ininfant’s smile in
PKCPKC

82. PKC in ColombiaPKC in Colombia

85. TemperatureTemperature changes in PKCchanges in PKC
Ludington-Hoe et al Developmental Physiology 1992

87. Pre-test period for PKC inPre-test period for PKC in
BakersfieldBakersfield

88. Dad prepping for PKCDad prepping for PKC

89. Dad’s temperature gaugeDad’s temperature gauge

90. Samoan Dad for PKCSamoan Dad for PKC

91. Feet up for PKCFeet up for PKC

92. Pacifier afterPacifier after
relentless non-relentless non-
nutritivenutritive
sucking on dadsucking on dad

93. Searching outSearching out
the nipplethe nipple

94. What is sheWhat is she
doing?doing?

95. She finds theShe finds the
breastbreast

96. Asleep andAsleep and
still on thestill on the
breastbreast

97. Dad is happy!Dad is happy!

98. More PKCMore PKC

99. 24 hour/day KC in Heidelberg24 hour/day KC in Heidelberg

100. NICU: HeidelbergNICU: Heidelberg

101. Step-down NICU: HeidelbergStep-down NICU: Heidelberg

102. KC in the NICUKC in the NICU

103. KC in Step-downKC in Step-down

104. KC room inKC room in
HeidelbergHeidelberg

105. 24 hour KMC24 hour KMC

106. KC supplies in Heidelberg…note theKC supplies in Heidelberg…note the
strollerstroller

107. Heidelberg River from NICUHeidelberg River from NICU

108. Going out withGoing out with
DaddyDaddy

110. Baby in KC with a fiber-opticBaby in KC with a fiber-optic
bili-blanketbili-blanket

111. KMC SLEEP OutcomesKMC SLEEP Outcomes
 EEG sleep for 3 hours (Pediatrics, MayEEG sleep for 3 hours (Pediatrics, May
2006, e 909-923) shows many fewer2006, e 909-923) shows many fewer
arousals during AS and QS andarousals during AS and QS and
lengthening of QS.lengthening of QS.
 BECAUSE QUIET SLEEP IS BEST FORBECAUSE QUIET SLEEP IS BEST FOR
BRAIN DEVELOPMENT, best place forBRAIN DEVELOPMENT, best place for
sleep is in Kangaroo Caresleep is in Kangaroo Care

112. In NICU
graduates,
abnormal
sleep patterns
commonly
appear
Up to 2 year
(Scher 2007s)

114. KC SLEEP OUTCOMESKC SLEEP OUTCOMES
 Over 8 weeks of 1.5 of KC/day for at leastOver 8 weeks of 1.5 of KC/day for at least
5 days per week showed that sleep was5 days per week showed that sleep was
always better in KC than in incubator, andalways better in KC than in incubator, and
that is why infants had better brainthat is why infants had better brain
maturation, complexity, connectivity, andmaturation, complexity, connectivity, and
sensitivity at term age than infants who didsensitivity at term age than infants who did
not get KC (Scher et al., 2009; Kaffashi etnot get KC (Scher et al., 2009; Kaffashi et
al., 2013)al., 2013)

115. KC and PainKC and Pain
Heelstick done in KMC as compared to inHeelstick done in KMC as compared to in
incubator:incubator:
-Reduces crying time (Ludington-Hoe et al.,-Reduces crying time (Ludington-Hoe et al.,
2005. Skin-to-skin contact (KC) analgesia for2005. Skin-to-skin contact (KC) analgesia for
preterm infant heel stick. AACN Clinical Issues,preterm infant heel stick. AACN Clinical Issues,
vol.16 #3. 373-387vol.16 #3. 373-387
-Promotes better parasympathetic control-Promotes better parasympathetic control
(McCain et al., 2005, KC effects on HRV: A case(McCain et al., 2005, KC effects on HRV: A case
study. JOGNN 34(6), 689-694.study. JOGNN 34(6), 689-694.

116. KC and PainKC and Pain
 2014 Cochrane Meta-analysis confirms2014 Cochrane Meta-analysis confirms
that KC reduces procedural pain wellthat KC reduces procedural pain well
(Johnston, Campbell-Yeo et al., 2014)(Johnston, Campbell-Yeo et al., 2014)
 Maternal KC reduces pain better thanMaternal KC reduces pain better than
paternal KC and better than Nurse KCpaternal KC and better than Nurse KC
 KC alone reduces pain better thanKC alone reduces pain better than
swaddling, rocking, and enhanced (music,swaddling, rocking, and enhanced (music,
rocking + KC) KCrocking + KC) KC

117. KC with MultiplesKC with Multiples
 The outcomes are very positive with up toThe outcomes are very positive with up to
five infants on one maternal chest at afive infants on one maternal chest at a
timetime
 Temperatures are maintained by theTemperatures are maintained by the
chest/breastschest/breasts
 Look at the descriptive studies byLook at the descriptive studies by
Anderson et al.; Ludington-Hoe, Lewis etAnderson et al.; Ludington-Hoe, Lewis et
al., and Ludington-Hoe & Albouelfettoh.al., and Ludington-Hoe & Albouelfettoh.

118. 20142014

119. Data collection time
13:10
13:05
13:00
12:55
12:50
12:45
12:40
12:35
12:30
12:25
12:20
12:15
12:10
12:05
12:00
11:55
11:50
11:37
Temperature
38.0
37.5
37.0
36.5
36.0
35.5
35.0
Subject #1
Maternal breast A
Baby A

120. Data collection time
13:10
13:05
13:00
12:55
12:50
12:45
12:40
12:35
12:30
12:25
12:20
12:15
12:10
12:05
12:00
11:55
11:50
11:37
Temperature
38.0
37.5
37.0
36.5
36.0
35.5
35.0
Subject #1
Maternal Breast B
Baby B

121. Data collection time
14:35
14:30
14:25
14:20
14:15
14:10
14:05
14:00
13:55
13:50
13:45
13:40
13:35
13:30
13:25
13:20
13:15
13:10
13:05
13:00
12:55
12:50
Temperature
38.0
37.5
37.0
36.5
36.0
35.5
35.0
34.5
34.0
33.5
33.0
Subject #2
Maternal Breast A
Baby A

122. Data collection time
14:35
14:30
14:25
14:20
14:15
14:10
14:05
14:00
13:55
13:50
13:45
13:40
13:35
13:30
13:25
13:20
13:15
13:10
13:05
13:00
12:55
12:50
Temperature
38.0
37.5
37.0
36.5
36.0
35.5
35.0
34.5
Subject #2
Maternal Breast B
Baby B

125. Birth KCBirth KC
 AAP (2005, 2009, 2013) stated that all fullterm newbornsAAP (2005, 2009, 2013) stated that all fullterm newborns
should be placed in KMC immediately after birth andshould be placed in KMC immediately after birth and
remain there until completion of first breastfeeding (2005remain there until completion of first breastfeeding (2005
ref is under Gardner et al., 2005. Pediatrics.)ref is under Gardner et al., 2005. Pediatrics.)
 The Centers for Disease Control also published thisThe Centers for Disease Control also published this
(CDCP 2011b, 2013)(CDCP 2011b, 2013)
 In 2013 the United States Breast feeding CommitteeIn 2013 the United States Breast feeding Committee
identified birth KC as the first strategy to increase BF.identified birth KC as the first strategy to increase BF.

130. Immediate KC SummaryImmediate KC Summary
 Mother-infant dyads who received KCMother-infant dyads who received KC
immediately after birth showed:immediately after birth showed:
 more affectionate contact behaviors,more affectionate contact behaviors,
 more infants went to breastmore infants went to breast
spontaneously,spontaneously,
 more time spent with their mothers.more time spent with their mothers.
 only positive outcomes to date as noonly positive outcomes to date as no
adverse findings have been reported.adverse findings have been reported.

131. AT BIRTH,AT BIRTH,
the brain hasthe brain has
TWOTWO
CRITICALCRITICAL
SENSORYSENSORY
NEEDS:NEEDS:
SMELL & CONTACTSMELL & CONTACT
connect direct to the amygdalaconnect direct to the amygdala

132. Oxytocin Effects of Birth KC
 Gordon and Zagoory-Sharon and Feldman,
2010 – 10 studies:
 Oxytocin in 1st
3 hrs persists for days,
 oxytocin in 1st
3 hrs after birth predicts positive
interactions at 1 yr (Bystrova, 2009)
 Oxytocin in 1st
3 days predicts disclosure and
closeness at 16 yrs of age
 Fathers have oxytocin surges too and oxytocin
increases sense of responsibility for infant.

133. Oxytocin EffectsOxytocin Effects
 Oxytocin goes to 14 different places in theOxytocin goes to 14 different places in the
brain and the first place it goes to is thebrain and the first place it goes to is the
MEDULLA OBLONGATA to STABILIZEMEDULLA OBLONGATA to STABILIZE
vital signs and Switch the brain fromvital signs and Switch the brain from
stress functioning to parasympatheticstress functioning to parasympathetic
(contentment, calm, safety, security)(contentment, calm, safety, security)
functioning (Uvnas-Moberg, et al. 2005)functioning (Uvnas-Moberg, et al. 2005)

136. Oxytocin and the AmygdalaOxytocin and the Amygdala
 Two sides of amygdala: right and leftTwo sides of amygdala: right and left
 Right is seat of contentment, calm, compassion,Right is seat of contentment, calm, compassion,
sympathy, empathy, love, and reading faces ofsympathy, empathy, love, and reading faces of
others to know to approach or withdraw - KCothers to know to approach or withdraw - KC
starts these pathwaysstarts these pathways
 Left is seat of anger, hostility, fear, violence,Left is seat of anger, hostility, fear, violence,
poor attachments, inability to read facespoor attachments, inability to read faces

137. Long-term effects ofLong-term effects of
OXYTOCINOXYTOCIN
 Anxiolytic-like effectAnxiolytic-like effect
 Increased pain thresholdIncreased pain threshold
 Decreased inflammationDecreased inflammation
 Lowered bloodpressureLowered bloodpressure
 Lowered cortisol levelsLowered cortisol levels
 Increased vagal nerve tone (GI hormones)Increased vagal nerve tone (GI hormones)
 Facilitated learning (conditioned avoidance)Facilitated learning (conditioned avoidance)
 Increased weight gain (females)Increased weight gain (females)
 Increased rate of wound healingIncreased rate of wound healing
With permission from Kerstin Uvnäs Moberg

138. Baby with desire to nestBaby with desire to nest

139. Artificial nestingArtificial nesting

140. Artificial nestingArtificial nesting

141. Blanket nestingBlanket nesting

142. Nesting and flexionNesting and flexion

143. Natural nestingNatural nesting

145. Research moves at a snails paceResearch moves at a snails pace

146. Original KC in AmericaOriginal KC in America

147. Original KC in AmericaOriginal KC in America

148. Newspaper report in 1989Newspaper report in 1989

149. Anne Geddes’ view of KCAnne Geddes’ view of KC

150. Mother and baby togetherMother and baby together

151. Mom
and
baby

152. My babiesMy babies

153. Co-Bedding in the NAVYCo-Bedding in the NAVY

155. Nurses Were to:Nurses Were to:
“Put the Patient in the Best“Put the Patient in the Best
Position for Nature to ActPosition for Nature to Act
Upon Him”Upon Him”
Florence NightingaleFlorence Nightingale
(1859/1969)(1859/1969)

159. Israeli mom in KCIsraeli mom in KC

160. Columbia: RDS and KCColumbia: RDS and KC

161. Maternal cortisols before and after KCMaternal cortisols before and after KC

162. Mom sleepingMom sleeping
in KCin KC

163. AAP Breastfeeding GuidelinesAAP Breastfeeding Guidelines
 For PRETERM infants:For PRETERM infants:
 Recommendation #3, pg. 500 relates:Recommendation #3, pg. 500 relates:
““Additional recommendations for high risk infants. Hospitals andAdditional recommendations for high risk infants. Hospitals and
physicians should recommend human milk for premature and otherphysicians should recommend human milk for premature and other
high risk infants either by direct breastfeeding and/or using thehigh risk infants either by direct breastfeeding and/or using the
mother’s own expressed milk. Maternal support and education onmother’s own expressed milk. Maternal support and education on
BF and milk expression should be provided from the earliest time.BF and milk expression should be provided from the earliest time.
Mother-infant skin-to-skin contactMother-infant skin-to-skin contact and direct breastfeedingand direct breastfeeding
should be encouraged as early as feasibleshould be encouraged as early as feasible .”.”
American Academy of Pediatrics, Section on Breastfeeding. 2005. Breastfeeding and the Use of Human Milk Policy Statement. PediatricsAmerican Academy of Pediatrics, Section on Breastfeeding. 2005. Breastfeeding and the Use of Human Milk Policy Statement. Pediatrics
115(2), 496-506.115(2), 496-506.

164. KC for BF in PretermsKC for BF in Preterms
 The AAP website has a Hospital Policy, which is aThe AAP website has a Hospital Policy, which is a
sample hospital policy for integration of the newsample hospital policy for integration of the new
recommendations by the CDC for KC to begin within 1recommendations by the CDC for KC to begin within 1
minute of birth and continue for 60 minutes for all healthyminute of birth and continue for 60 minutes for all healthy
term infants, and for healthy preterm infants. Thisterm infants, and for healthy preterm infants. This
recommendation is assumed to be part of the 2014recommendation is assumed to be part of the 2014
exclusive breast milk feeding mandate for healthy infantsexclusive breast milk feeding mandate for healthy infants
by the Joint Commission(JCAHO 2009, 2013)by the Joint Commission(JCAHO 2009, 2013)
(AWHONN< 2013; Romano, 2010;The Joint(AWHONN< 2013; Romano, 2010;The Joint
Commission, 2012)Commission, 2012)
(See also the mPINC materials from CDCP on KC Bib).(See also the mPINC materials from CDCP on KC Bib).

165. Academy of Breastfeeding Medicine,Academy of Breastfeeding Medicine,
Protocol #12: BF the PrematureProtocol #12: BF the Premature
 V: “A. Support mother to initiate kangarooV: “A. Support mother to initiate kangaroo
care as early as possible in hospital(ABM,care as early as possible in hospital(ABM,
2004c, p. 8)2004c, p. 8)
 ““B. Skin-to-skin contact…may facilitateB. Skin-to-skin contact…may facilitate
the establishment of the milk supply” (p.8-the establishment of the milk supply” (p.8-
9)9)
 ““C. Educate mothers that early feedingC. Educate mothers that early feeding
behaviors will emerge during skin-to-skinbehaviors will emerge during skin-to-skin
holding…” p. 9)holding…” p. 9)
 www.bfmed.org/ace-files/protocol/NICUGradProtocol.pdfwww.bfmed.org/ace-files/protocol/NICUGradProtocol.pdf

166. Pain Guidelines: AAP Prevention andPain Guidelines: AAP Prevention and
Management of Pain in the Neonate: AnManagement of Pain in the Neonate: An
Update (2007)Update (2007)
Reducing pain from bedside careReducing pain from bedside care
procedures:procedures:
 ““2. Use of …non-pharmacologic pain-2. Use of …non-pharmacologic pain-
reduction methods (nonnutritive sucking,reduction methods (nonnutritive sucking,
kangaroo care, facilitated tucking,kangaroo care, facilitated tucking,
swaddling, developmental care) should beswaddling, developmental care) should be
used for minor routine procedures”used for minor routine procedures”(2007, ___ New(2007, ___ New
Neonatal AAP Pain Management Recommendations, Neonatal Netw 26(2), p 135). Based onNeonatal AAP Pain Management Recommendations, Neonatal Netw 26(2), p 135). Based on
AAP & Canadian Pediatric Society (2006), Pediatrics, 118(15), 2231-2241.AAP & Canadian Pediatric Society (2006), Pediatrics, 118(15), 2231-2241.

167. AAP Pain Guidelines 2007AAP Pain Guidelines 2007
 ““Inclusion of the family in painInclusion of the family in pain
management is encouraged.”management is encouraged.”
American Academy of Pediatrics &American Academy of Pediatrics &
American Pain Society, 2001. TheAmerican Pain Society, 2001. The
assessment and management of acuteassessment and management of acute
pain in infants, children, and adolescents.pain in infants, children, and adolescents.
Pediatrics 108(3), 793-797.Pediatrics 108(3), 793-797.

168. 2011 ARP2011 ARP
 Healthy infants who do not needHealthy infants who do not need
resuscitationresuscitation shouldshould (NOT CAN, as it(NOT CAN, as it
was in 2006) be placed in skin-to-skinwas in 2006) be placed in skin-to-skin
contact for thermoregulation and non-contact for thermoregulation and non-
separation. Zaichkin, 2011, Feb. issue ofseparation. Zaichkin, 2011, Feb. issue of
Neonatal Network; Kattwinkel, 2011,Neonatal Network; Kattwinkel, 2011,
Circulation).Circulation).