This is the 3rd Pre-Conference Lesson for the 12th Kangaroo Care Conference

1. Susan M. Ludington CNM, CKC, PhD, FAAN
Walters Professor of Pediatric Nursing
Bolton School of Nursing Case Western Reserve University

2. •To understand the origins
of Kangaroo Care and
how it came to America
•Be able to name three
effects of Kangaroo Care
on infants, mothers, and
families

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

4. Non- sterile IV
bags; rinsed and
reused
Bogota Nursery

5. Shared Incubator;
unreliable electricity
source
Shared phototherapy

6. Intubated Infant on makeshift
ventilator:
only 3 vents /65 infants

7. Infant in heating pad for
warmth… NICU is 50°
Transitional Nursery…
waiting for mom to KC

8. Maintaining an upright position…
cold stess is common

9. Mom gets infant for KMC when neonatologist comes
from private practice…nurses could not handle babies

10. Infant with an NG tube because she doesn’t breastfeed
well… cannot go home until 3 days of weight gain
occurs

11. VLBW (999 gms) infant in KMC- being discharge
home in KC. KC to be done for 1-2 years at home

12. VLBW infant: note standard preemie diaper is too large.
Do NOT cover area from umbilicus to sternum with any thing
because it interferes with nerves on chest that create KC results

13. VLBW infant settles into KC.. (within 1-5 minutes) goes deeply
asleep which helps his brain mature.
Note frog-like position of infant which is best KC position for
maximum heat and prevention of Sudden Unexpected
Postnatal Collaps
Proper
positioning is
Extremely
important for
safe KC

14. Another VLBW sound asleep.
Self-regulatory consoling by holding his own hands.
KC improves self-regulation up to 10 years later (Feldman et al.
2014)

15. Dr. Hector Martinez,
Co-founder of ‘Kangaroo Mother Care’ Program which
reduced mortality by 70% in one year

16. Going home from follow-up clinic in KC- followed for two
years, doing 24/7 KC (day & night KC- baby sleeps in KC).
No reports of SIDS in >8000 babies.

17. And so, the Kangaroo Mother Care program of
Colombia was born- but KC started sooner…
•The first published randomized controlled study of a premature
being held skin-to-skin, chest-to-chest with mother, and first report
of mothers of preterms being taught and giving primary care to
their newborns was in 1970 in a study of ‘extended contact’.
Mothers starting contact & primary caregiving within 24 hours of
birth to contrast to mothers doing routine care – in 1970, routine
NICU care was mother could first touch infant at 21 days of life!
•Study was done at Rainbow Babies & Childrens Hospital in
Cleveland, OH by Drs. Klaus & Kennell. (Klaus & Kennell, 1971 Mothers
separated from their newborn infants. Clinics Obstetrics & Gynecology, 14(3), 926-954)

18. After 1st report of KMC program in 1983, Utrecht, Holland
embraced KMC with moms, dads, & infants with respiratory
distress.
Infant with
Blow by O2

19. Sweden began maternal and paternal Kangaroo Care ad lib in
1985.
Sweden has been doing 24/7 KC for >20 years. Moms & Dads
have own bed/own room with their infant

21. Dr. Susan Ludington, after learning about KC in Bogota for 3
weeks, brought the idea to USA and met TREMENDOUS
RESISTANCE getting permission to do a KC study to
determine preterm infant’s vital signs in a crib before KC
(pretest), during KC ( test period) & in a crib after KC
(posttest) design in infants nearing discharge
(Ludington, 1990, Energy conservation during skin-to-skin
contact between preterm infants and their mothers. Heart and
Lung, 19(5 Pt1),445-451.)

22. Beginning Descriptive Study – you see the design
below and the measured outcomes are on the right

23. The studies proceeded over the
years to include a control group
•Most of Dr. Ludington’s works and those of others
are Randomized Controlled Trials, which means
KC was being tested as a treatment to determine
KC’s effect on some outcome variable .
•Mothers volunteered to be in the KC group or the
NO KC group and were randomly assigned to
those groups after enrolling in the studies.
•Infants in incubators and micro-preemies were
eventually tested.

24. Control condition for first RCT- infants in open air crib, getting
ready for discharge, Note measurement of air temp near baby’s
nose and that baby was wearing head cap, t-shirt, and was
swaddled beneath two blankets.

25. The control group stayed in incubator throughout the _9_ hours
and got no KC. The KC group spent 3 hours in OC*, 3 hours in
KC and 3 hours back in OC
* Open Crib

26. Experimental condition: Mom being filmed during KC and seated
in stationary chair. Note the black & white checkerboard on crib-
because infants only see black & white for first 6 months of life
because rods and cones in eyes are not polarized yet for color
vision –but only nurses can see this checkerboard!

27. Find the baby! Technology took over as Dr. Ludington’s studies
continued. Infant with mother is in lower right and research-
grade recording is done by Gould Physiograph on left side of the
baby! U.S. technology (circa 1989)

28. Results of all Randomized
controlled trials were:
•All values were within acceptable clinical limits
•HR increased by 10 bpm due to warming in KC
(p=0.05)
•RR increased by 5 breaths/min due to warming(p=0.02)
•Skin Temp increased by 1°C (p=0.004) in KC, rectal
temps same during KC, & skin temp dropped once taken
off KC (p-0.03)
•No change in SaO2 during 4 hours of KC.

29. Conclusion - 1

30. Thermal Synchrony between Mother
and Infant was examined next
•As soon as infant placed on mother’s chest, her
breasts heated up 1-2° C within 1-2 minutes even
though breast temp started at 34° C!
•Breasts heat infant up to 37.4°C and then drop to
prevent temperature at or above 37.5°C temp- the
temp at which apnea occurs due to warmth

31. Maternal-Neonatal Thermal Synchrony
•One breast with cold baby on it will increase its temp
simultaneously while the other with a warm baby on it
will decrease its temperature (Ludington-Hoe et al.
2007)
•Breasts make 100 times more temperature adjustments
than any incubator does and keeps infant(s) in their
neutral thermal environment (Ludington-Hoe et al., 2000).

32. Thermal Synchrony during Shared Kangaroo Care

33. So, I next looked at sleep during KC compared to when in crib. 6
states from quiet sleep to active sleep to drowsy to quiet awake
to active awake and to fussy/cry were measured. The yellow bar
is in incubator, the middle bar is in KC, and the plain blue bar is
back in incubator Babies doubled quiet sleet during KC.

34. When using 12 states, you clearly see how QS (Quiet
Sleep)doubled during KC compared to incubator time before and
after KC. Brain matures only in QS state. The BEST sleep is KC
sleep, not incubator or swaddled sleep. We need to
encourage sleep during KC, not prohibit it!!!

35. In the next slide:
•These are randomized controlled trial results
showing amount of quiet sleep in KC group
on left (middle column) and in control group
(stayed only in incubator) on the right. The
columns show incubator-KC-incubator
amounts of sleep.
•Again, quiet sleep doubles during KC

37. •The next slide is very important for all newborns
placed in KC immediately after birth because it shows
in the left picture of blood flow from placenta to infant
(the blue and yellow squares) is enhanced when infant
is NOT crying, because crying stops blood flow from
placenta to infant (right picture).
•Knowing that the last 20% of placental blood flow
through the umbilicus goes only to the respiratory
tract, getting all of this blood is VITAL to an infant,
and in KC the infant does not CRY while the cord
continues to pulsate.

38. Crying is very rare in KC, and this in itself, improves
placenta to infant transfusion
Venous flow from placenta to infant
Blue= flow; * = flow stops
Blood flow velocity decreases with
short, large inspiration of cry
Blood flow STOPS with expiration of
cry AND
Red= reversal of flow back to baby
Boere I, et al., 2015. Umbilical
blood flow patterns directly
after birth before delayed cord
clamping Arch Dis Child Fetal
Neontal Ed, 100: F121-F125

39. So, with continuous crying you get two times flow from baby to
placenta and one time flow placenta to baby, so over time you deplete
baby’s blood volume
If infant is crying immediately after birth. Boere et al., 2015 Arch Dis
Child Fetal Neonatal Ed, 100: pg. F 124

40. • In the next slide, you see pneumographs (HR
and breathing patterns)in an incubator before
KC (far left), during KC (middle) and when
back in the incubator after KC (far right).
• The top line is Heart Rate: before KC it varies
greatly, stabilizes during KC,and then becomes
unstable when put back into incubator. Do you
want your baby to have an unstable heart rate?
IF not, why do you leave him in the incubator
so much, even when mother is present.

41. Cardio Respiratory Changes
Pre-KC KC
Post KC
Pre KC KC period Post KC

42. In the previous picture of HR and
breathing pattern…
•Look at the lower line, the breathing pattern line. It
represents inspiration and expiration and you see in
the incubator how irregular the breathing is and that 3
times the breathing stops (a straight line).
• Now look at the breathing during KC, it is regular,
easy(no big inspirations, no big expirations), and
then it becomes irregular and the work of breathing
increases when put in incubator again.
• So, to help babies breathe, KC is the BEST place,
not the incubator!!!!

43. And in the next slide you will see….
•Just above the white flash circle, a tracing that
looks like a series of “w”s, all very even and
regular. This is the breathing pattern of an infant
in quiet sleep – so when you see regular
respirations on the baby’s monitor, the baby is in
quiet sleep and SHOULD NOT BE
DISTURBED!.
•Quiet sleep RARELY occurs (for up to 10
seconds only) when in an incubator, but occurs
for 23 consecutive minutes per hour when in KC.

44. Gould Cardio-Respiratory Patterns
Quiet Sleep Pattern

45. When studying one baby, I saw he was warm all over
(pink) and collapsed in sleep. I worried that the deep
sleep might constrict his chest and impair breathing , so
I did an apnea study.

46. Apnea Study
Mom with foot support
to prevent blood clots
during first 6 weeks
after birth

47. Edentech nasal thermistor measures temp of air going in and air
coming out. If air coming out is same temp as air going in, there
is obstructive apnea; if air coming out is warmer than air going
in, it is a central (brain-based) apnea

48. Apnea in incubator was compared to apnea during KC.
Apnea decreased by 75% during KC
Ludington-Hoe et al
Neonatal
Network 1994

49. But when KC was given by either mother or father to a ventilated
infant, no breathing improvements were seen. Parents really
loved doing KC but fathers were not in the study
Ludington-Hoe et al
Acta Paediatrica 1998

50. For the 1st paternal KC study, Susie and team
went to Cali, Colombia.
The NICU was
same as Good
Samaritan NICU in
Los Angeles. All
staff trained in Los
Angeles and all
supplies
/equipment were
the same.

51. This is where all women labored…
No air conditioning

52. One year’s supplies for all deliveries

53. The KC Research Team
Dr. Jaime Bastitas, Dr. Susan Ludington
Mrs. Luz Angela Argote

54. This was 1st study of prematures put in KC
immediately after birth-Apgars taken in KC

55. Already warm after 3 minutes of KMC, preterms were put
immediately into KC, and stayed if 1 and 5 minute apgars were 6
or more. (Ludington-Hoe, et al. 1993, 1999)

56. Post-delivery research room where KC continued for 6
hours, and in one study, Daddy Did KC, too

57. One mother had twins & we learned both babies
were kept warm

58. We learned that 30 wk GA preemies went right to breast
when put in KC immediately after delivery

59. We learned that some did not feed (dstick<40) for 1.5
hours & they sucked DW10 well when in KC

60. KC continued for 6 hours when we transferred the dyad to our research
room. The father is standing far left, Dr. Gene Anderson is doing the
minute-by-minute data collection as head of WHO maternal-child
health looks on. He flew to Colombia to see this study in action

61. Peaceful, warm slumber 1 hour after birth for 34 wk
GA. No head cap, no blanket cover needed in tropical
environment without air conditioning. Abdominal temp
is 36.8 - 37.4

62. KC Beginning in Delivery Room for preterm infants &
continuing for 1st 6 hours post birth: KC babies had higher
abdominal and toe temperatures than preterms kept in cot beside
mother

63. After 6 hours in research room, mother-infant dyad sent to
postpartum to continue KC for 48 hours. Here is one subject (36
wks GA) at discharge at 48 hours after birth. No KC baby was
readmitted for 6 months when Mom continued 24/7 KC at home

64. 14 infants demonstrated transient respiratory distress within one minute of
birth while in KC. We put them in oxygen hood at 65%, and all stopped all
signs of respiratory distress before 6 hours of age when in KC. The first baby
went to fully advantaged NICU, was put under oxygen hood at 65% & was
still there at 4 days of age. Separation from mom did NOT help him, so we
started keeping them in KC.

65. A 31 4/7 weeker at 2 minutes age under oxygen hood at 65% in
KC. All 14 subjects ceased all signs of respiratory distress within
6 hours of birth while in KC. All then went to Postpartum unit
for 24/7 KC til discharge. No admits to NICU

66. Beginning of Paternal
Kangaroo Care (PKC)- after
having this father in
Richland, WA demand a
chance to hold his daughter
in KC, paternal KC was
born, but we had to go to
Colombia to study it because
no one would allow a father
to take off his shirt in US
NICUs. (Ludington-Hoe, et al.,
J. Developmental Physiology
19192)

67. Note the infant’s
smile in PKC and
holding onto Daddy’s
hair

68. 1st Paternal KC Study in the world
•Within 1st 6 hours of preterm birth, immediately after mom
fed infant, infant was given to father for 2 hours of KC.
Fathers warmed up the infant too much and 8/11 went
>38°C. No apneas occurred.
•Fathers got tired of KC after 90 minutes just when infant
temp was 37.5°C
•Babies had typical quiet sleep in KC and had good
interactions with their fathers.
• (Ludington-Hoe, et al., 1992 in J. Developmental Physiology).

69. Paternal KC in Colombia

71. •Look at the next slide which is a graph of the
abdominal, tympanic and toe temperatures of
preterm infants during paternal KC.
•All temperatures continue to rise as paternal KC
continues….. Thus, paternal breasts do NOT
thermoregulate (keep the infant’s temp within
his/her neutral thermal zone) and can cause some
infants to have temperatures in the APNEIC zone (>
37.5C)

72. Temperature changes in PKC
Ludington-Hoe et al Developmental Physiology 1992

73. And in the next slide….
•You see a table of types of sleep (across the
bottom) and duration of sleep (along the left
vertical axis).
•QRS is quiet regular sleep (the best kind of
sleep)
•QIS is quiet irregular sleep (no movements),
(RR is irregular), sleep (eyes closed)
•AS is Active sleep (many movements)(eyes
closed).

75. So, during Paternal KC, sleep is….
•Predominantly Quiet Regular Sleep (QRS) (you lay
down some memories in QRS sleep and other
memories in Active Sleep (AS), but to have good
quality AS, you must have good quality and
predominant Quiet Regular Sleep
•The brain matures in Quiet Regular Sleep
•In incubator, QRS occurs in 10 second epochs for a
total of 2 hours/day when infant should get 20-22 hours
of QRS/24 hrs.

76. After Colombia, paternal KC was
studied in Bakersfield, CA
•The design was a 2-3 hour pre-KC period in the
incubator depending on infants feeding schedule
•Then an equal time in paternal KC
•Then an equal time (post-KC) back in incubator.
•Fathers had to scrub their chests for 2 minutes
before doing Paternal KC because they may have
been in agricultural fields

77. Pre-test period for Paternal KC in Bakersfield –
Preterm in typical incubator

78. Dad prepping for Paternal KC

79. Samoan Dad for Paternal KC –
we studied many ethnicities

80. Feet up for PKC so Dad does not get a
thrombus either

82. A Green Bay
Packer dad doing
PKC, his daughter
searches for his
nipple

83. Dad wonders:
What is she
doing? She is
massaging his
breast.

84. She finds his
nipple and
starts to suck

85. Dad falls asleep
and she’s still
sucking on the
nipple, wondering
where the heck the
milk is. Note the
whiteness where
she sucks

86. Dad wakes up and
is happy & she is
still sucking for
milk! Dad wrote
that he loved this
girl more than his
other 2

87. More PKC for
picture only.
Baby should
have blanket
around the back

88. Invited to do a 24/7 KC study at
University. of Heidelberg, we went….
•And encountered a common problem.
•The nurses said there was no room for mother to be there
holding her baby 24/7. Nurses had said this for 5
months.
•Finally, Dr Sontheimer, Chief of Neonatology (right in
following picture) asked housekeeping to put a Zero
Gravity lounger beside each incubator and 24/7 KC in
Germany was born.
•In 1996, 97% of all German NICUS practiced 24/7
KC!!!

89. Seeing a crowded 3rd level NICU
in Heidelbe

90. Heidelberg Intensive ICU before lounge

91. Intensive NICU with 24/7 KC on
lounger

92. Step-down NICU in Heidelberg before loungers

94. Infants had:
fewer infections
gained weight faster
discharged 2 weeks
earlier than in U.S.,
KC rooms were
created – note
Kangaroos on door

95. 24 hour KMC-no need for monitor, bra should NOT
be there because it interferes with the stimulation of the
nerves which are responsible for the physiologic
responses to KMC

96. How did modern German mothers
accommodate 24/7 KC in NCU?
•Told by all MDs and RNs that 24/7 KC was
BEST for infant, that infant will get well sooner,
infant’s brain will be better developed, infant
will be less sick & have fewer problems and go
home sooner
•Told that if Mom and Dad did not do it, a
surrogate would have to be found.
•Nurses in USA do NOT advocate for KC

97. KC lounger and stroller supplies in Heidelberg…
to be discharged, all infants have to go outside for 2
days in stroller. Note the stroller

98. Going out with Daddy-
a 1994 gm infant is
going out for the day
because he is ready for
discharge if he does well
while outdoors for 8
hours. Dad takes no
chances and puts him in
KC
Does your NICU do this
prior to discharge?

99. KC for Phototherapy Infants
•Many times Dr. Ludington was told that an infant could
not come out of phototherapy for KC.
•So, she wrote a grant and tested use of fiberoptic blanket
during 1 hour of KC and it worked WELL as long as
mother presses it against the infant’s back while doing KC
• No statistical differences in serum bilirubin between 3
groups, so KC + fiberoptic blanket worked well
(Ludington-Hoe et al,1996)

100. Baby in KC with a fiber-optic bili-blanket

102. Sleep of the Newborn
•The infant’s brain matures during quiet sleep (QS)
•Sleep in a cot or incubator is poorly organized compared
to sleep in KC as determined by EEG.
•Leaving an infant in an incubator instead of in KC
contributes to poor cognitive and motor development up to
18 years of age (Charpak et al., 2016; Schneider et al.. 2012).

103. SLEEP During Kangaroo Care
•EEG sleep for 3 hours (Ludington-Hoe et al., Pediatrics,
May 2006, e 909-923) shows:
•Fewer arousals during Active Sleep and Quiet
Sleep
• Lengthening of Quiet Sleep and completed
CYCLES of sleep
•QUIET SLEEP and CYCLING IS BEST FOR
BRAIN DEVELOPMENT
• Best place for sleep is in Kangaroo Care!

104. Sleep in incubator-
interpreting the next slide
•On the top line, in green, are the arousals from sleep
during one interfeeding-interval. Baby is arousing a
lot, sleeping little
•The red marks on the 2nd line denote Active Sleep. A
lot of time, too much, is spent in Active Sleep.
•The blue marks are Quiet Sleep.
•Much more active sleep than quiet sleep is seen here –
so baby is in an INCUBATOR, sleeping poorly.
•In the bottom box, you see a very poor pattern of
cycles of sleep – little if any normal brain development
here.

106. Sleep in KC /STS*- interpreting the next slide
•Now the infant is in KC, and you see that the arousals
have decreased a lot; that the red of Active sleep has
decreased and the blue of Quiet Sleep has increased.
•In the lower box, you can see a wave like pattern of sleep
markers, showing that the infant has good cycles of sleep.
Cycles of sleep are needed for NORMAL brain
development and they occur only in KC
* Skin-to-skin, aka KC

108. 8 weeks of 1.5 hours of KC
/day at least 5 days per week
•sleep was always better in
KC than in incubator,
•infants had better brain
maturation, complexity,
connectivity, and
sensitivity at term age than
infants who did not get KC
(Scher et al., 2009; Kaffashi et
al., 2013)

109. Cycling of Sleep
•Cycling of sleep (going from drowsy to
Active Sleep to Quiet Sleep and then
reversing the order is one cycle of sleep) is
MOST IMPORTANT feature needed for
good brain development
•In infants up to 54 weeks postmenstrual
age, one cycle takes 60 minutes, so KC
should be done for at least 60 minutes

110. KC Clearly Reduces Pain
Heelstick done in KMC as compared to in incubator:
• Reduces crying time (Ludington-Hoe et al., 2005),
• Reduces pain better than anything else but
breastfeeding (Johnston et al., 2014- A Cochrane
review)
•Promotes better parasympathetic control
(McCain et al., 2005)
•Works well for clustered pain (Kostandy et al., 2016)

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

112. AAP Pain Guidelines 2007
“Inclusion of the family in pain management is
encouraged.”
American Academy of Pediatrics & American Pain
Society, 2001. The assessment and management of
acute pain in infants, children, and adolescents.
Pediatrics 108(3), 793-797.
This means MOMs can do KC to decrease or alleviate
pain

113. Kangaroo Care and Pain
•Maternal KC reduces pain better than paternal KC
and better than Nurse KC
•KC alone reduces pain better than swaddling,
rocking, and enhanced (music, rocking + KC)
• American Academy of Pediatrics and Canadian Pediatric
Society RECOMMEND using KC for all procedural pain (AAP
& CPS, 2006; Baley et al., 2015) and have since 2002
•If you don’t use KC for pain, you are 14 years
BEHIND published best care!!!

114. Kangaroo Care with Multiples
•The outcomes are very positive with up to five infants
on one maternal chest at a time
•Temperatures are maintained by the chest/breasts
•Look at the descriptive studies by Anderson et al.;
Ludington-Hoe, Lewis et al., and Ludington-Hoe &
Albouelfettoh. (Can be found on KC Bibliography)

115. *

116. Kangaroo Care for Multiples
•Another set of
twins in our study.
• Note how the
twins hold each
other’s hand.
•Non-separation
from mother and
each other is really
the ideal.

117. Kangaroo Care beginning at birth
•AAP (2005, 2009, 2013) stated that all fullterm
newborns should be placed in KC immediately after
birth and remain there until completion of first
breastfeeding (2005 ref is under Gardner et al., 2005. Pediatrics.)
•The Centers for Disease Control also published this
recommendation (CDCP 2011b, 2013)
•In 2013 the United States Breast feeding Committee
identified birth KC as the first strategy to increase BF.
•In the next three slides, you see a term infant sleeping in
KC, scooting to, and latching on the nipple when in KC

121. Paternal KC with Term Infant
• Throughout the postpartum
hospital stay, the father
should be encouraged to
give KC alternately with the
mother, so each can get
some sleep and so the infant
receives 24/7 KC over the
first 2-3 days of life
• Here is what Paternal KC
with a Term infant looks
like:

122. Kangaroo Care at Birth Summary
•Mother-infant dyads who received KC immediately
after birth showed:
•more affectionate contact behaviors,
•more infants spontaneously breast fed,
•Mothers spent more time with infants,
•only positive outcomes to date as no adverse findings
have been reported.
•THE SOONER KC STARTS, THE BETTER
EVERYTHING IS

123. Because Physiologic Stability occurs in
KC, the 2011 Neonatal Resuscitation
Program states:
Healthy infants who do not need resuscitation
should (NOT CAN, as it was in 2006) be
placed in skin-to-skin contact for
thermoregulation and non-separation.
Zaichkin, 2011, Feb. issue of Neonatal
Network; Kattwinkel, 2011, Circulation).

124. Kangaroo Care Enhances Development
Because KC improves sleep quality and cycling,
enhancement of autonomic nervous system,
mental and motor development have been
documented

125. Autonomic Nervous System
Development
•Improved ANS functioning during 1st 3 iweeks of life
(Feldman & Eidelman, 2003)
•Improves development of vagal functioning and heart
rate variability, respiratory sinus arrhythmia (Porges &
Furman, 2011)
•By 10 years, children receiving KC showed attenuated
stress response & improved Respiratory Sinus
Arrythmia as signs of better ANS development than in
controls (Feldman, 2014),
•

126. Kangaroo Care Effects on Mental
Development
23 studies showing better mental
development at term age, 6, 12, 18, 24
months, and 6 years, 10 years and 18 years
of age when compared to preterm and term
infants who did not receive KC, usually 24/7
KC in Preterms for 8 weeks

127. KC Effect on Motor Development
•20 studies showing better motor skills/coordination,
smooth movements at birth, 10 minutes, 3 days, 21
days, term age, during breastfeeding, 3, 6, 12,18, 24
months, and 3, 6, 10, 16, and 18 years.
•The Kangaroo Position leads to a growing increase in
the electromyographic activity of preterm children's
biceps brachii after up to 96 hr of KC and this response
persists until at least the 21st day after this period (Diniz,
2013) and maturation of the biceps in KC group was
better than it was in full terms who did not get KC
(Miranda, 2014).

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

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

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

131. Other Kangaroo Care Effects
•Fewer infections, Shorter lengths of stay
•Swifter transition to nipple and breast feedings
•More stable physiology,
•Better cerebral blood flow, Higher SaO2,
•Less hypoglycemia, Rare hypothermia (Boundy et al., 2016)
•Better tolerance of blood transfusions, able to go for CHD
surgery sooner & shorter post-anesthesia recovery time
•Possibly less severe Neonatal Abstinence Syndrome
(Ludington-Hoe et al., 2015)
•Increases microbial diversity of infant

132. Maternal Effects of KC
•Decreases maternal stress
•Minimizes maternal depression; Prevents
depression,
•Hastens recovery from birth, decreases lochia,
enhances placental expulsion,
•Lowers maternal BP, helps prevention & recovery
from postpartum hemorrhage,
•Improves bonding
•Increases milk production, lengthens breastfeeding,
builds confidence and competence
•Improves interactions with child for years

133. Maternal cortisols before and after KC show that KC
reduces stress and within minutes, infant and mother
stress levels are the same, reduced greatly.

134. So, what’s not to like?
Why isn’t KC used
routinely, consistently
and continuously
every time mother is
there?

135. No matter your reasons for NOT doing
ROUTINE KC, think of these……
In the next few slides, you will see that infants
desire the cuddling and containment that comes
from Kangaroo Care, NOT from SWADDLED
HOLDING….

136. A preterm baby with desire to nest

137. Artificial nesting of a baby in NICU

138. Artificial nesting as done in Utrecht Holland

139. Blanket and roll nesting in USA

140. Swinging nest in USA

143. Original KC in America
KC should NEVER be like this!!!
Infant needs
hat, diaper
and blankets
across back to
prevent
hypothermia

144. Nor like this – this baby is STRESSED and COLD

146. In all species,
mother and newborn are together

147. Mom
and baby

150. Mother and baby
in KC with
comfortable
recliner

151. Florence Nightingale 1859 - 1969
•“The role of the nurse is to put the patient in the
best possible position and let Mother Nature run
her course”.
•Skin-to-skin contact
is the best place for
Nature to heal

152. Quality Family Time

154. Israeli mom in KC

156. ”Kangaroo mother care is a basic right of the
newborn and should be an integral part of the low
birth weight and full term newborn’s care, in all
settings, in all levels of care, and in all countries”
(pg. 1140)
Charpak N, de Calume, ZF, & Ruiz JG. (2000). “The Bogota Declaration on
kangaroo mother care.” Conclusions of the second international workshop on
the method. Second International Workshop of Kangaroo Mother Care. Acta
Paediatrica 89 (9): 1137-1140. The declaration that was adopted by all
attendees
Remember

157. •A subject who had multiple days of KC is saying
thank you to his mother at the end of Day 6 of KC
•I want all babies happy, just like this one, and not
separated from their moms but doing KC around the
clock to create a healthy life for the newborn.
•THANK YOU. Susie Ludington