This document discusses recommendations from various national organizations for the use of Kangaroo Care. It begins by identifying organizations such as the WHO, CDC, AAP, and ACOG that recommend Kangaroo Care. It then reviews how evidence on the benefits of Kangaroo Care becomes guidelines that institutions can implement. Some key benefits discussed are improved breastfeeding rates, decreased infant pain and stress, and improved infant development. The document provides examples of guidelines from different organizations and reviews evidence from various studies on the positive outcomes of Kangaroo Care.

1. Susan M. Ludington CNM, CKC, PhD, FAAN
Kathy Morgan RN, NNP-E CKC

2. 1. To identify national organizations that recommend the use
of Kangaroo Care (KC)
2. To review the process of how the evidence behind KC
becomes national guidelines for practice
3. To review some of the most recent recommendations for
KC
4. To discuss how Kangaroo Care can help your institution
to achieve Baby Friendly Status
5. To identify recommendations of the Center for Disease
Control and Prevention for KC to increase exclusive
breast milk feedings
6. To identify your institution’s readiness to implement KC

3. Since the initial use of Skin-to-Skin contact
by Klaus and Kennell (1970) with preterm
infants in Cleveland, OH there has been a
multitude of research on the benefits of KC
Professional organizations have recognized
its’ value and have made recommendations
for the use of KC with both full term and
preterm infants
Kennell JH. Klaus MH. 1970.Care of the mother of the
high risk infant. Clin Obstet Gynecol.14(3):926-954

4. • World Health Organization
• Centers for Disease Control and Prevention USA
• American Academy of Pediatrics
• American Academy of Family Physicians
• Academy of Breastfeeding Medicine
• American College of Obstetricians and Gynecologists (ACOG)
• American Heart Association (NRP)
• Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN)
• American College of Nurse Midwives
• National Association of Neonatal Nursing
• National Perinatal Association
• United States Breastfeeding Committee
• United States Institute for Kangaroo Care / International Network of Kangaroo
Care
• New Zealand Ministry of Health

5. • Evidenced-based practice is mandated
• Evidence of positive benefits of KC has been shown through
research
• There have been many Cochrane Reviews of positive KC benefits.
Cochrane Reviews are the “Gold Standard “ for guiding practice
• Evidence is graded “A” through “E” by the US Preventive Services
Task Force
• Evidence for KC’s effects is predominantly “A”
• National Professional organizations publish guidelines/ protocols
/policy to guide institutional adoption of national recommendations
• Institution-specific policies reflecting national recommendations
are developed and implemented

6. In the syllabus that you will print to bring with you to the
KC course you will find a “Table of Recommendations for
KC” that is several pages long. It is too extensive to put in
this power point. It will be useful to you as a reference when
you are implementing KC in your institution. If there is a
guideline written it means that the evidence has been
established for the specific benefit of KC you are interested
in; i.e. breastfeeding the full term infant or diminishing pain
in the preterm infant in the NICU.
This is the title page of the handout in your syllabus materials
2018 USIKC Table of National Guidelines and Recommendations
(Ludington-Hoe & Morgan)

7. • Boundy, et al. Kangaroo Mother Care and Neonatal Outcomes: a
Meta-analysis. 2016. Pediatrics. 137 (1):e20152238.
• KMC infants: 36% lower mortality among low birth weight
newborns
• decreased risk of neonatal sepsis, hypothermia, hypoglycemia, and
hospital readmission
• increased exclusive breastfeeding.
• Newborns receiving KMC had lower mean respiratory rate and pain
measures and higher oxygen saturation, temperature, and head
circumference growth.
Conclusion :“Interventions to scale up KMC implementation
are warranted”. Not a Cochrane Meta-analysis

8. • Baley J and Committee on Fetus and Newborn.(2015-Augst 31). Skin-to-
Skin Care for Term and Preterm Infants in the Neonatal ICU. Pediatrics,
136(3):596-599 .doi:10.1542/peds.2015-2335 pii: peds.2015-2335
• “Because SSC has been shown to be feasible and safe in the NICU in
infants as young as 26 weeks’ gestations (cites Bier et al., 1996), with
benefits for both parents and infants, FACILITIES ARE ENCOURAGED
TO OFFER THIS CARE WHEN POSSIBLE.”(PG 598).”
• “It has been shown that skin to skin care results in improved breast
feeding, milk production, parental satisfaction and bonding”(pg. 598).
• Other effects associated with KC: decreased pain, improved sleep,
decreased stress, more alert, decreased crying, better Bayley scores at 6
and 12 months and at 10 years

9. AAP
Safe Sleep and Skin-to-Skin Care in the Neonatal
Period for Healthy Term Newborns
Feldman-Winter, Goldsmith, COMMITTEE ON FETUS AND NEWBORN,
TASK FORCE ON SUDDEN INFANT DEATH SYNDROME (2016)
This clinical report is intended for birthing centers and
delivery hospitals caring for healthy newborns to assist in
the establishment of appropriate SSC and safe sleep
policies.
Addresses rooming in

10. This International Joint Statement is endorsed by the American Academy of Pediatrics (AAP) Council of
International Neonatal Nurses (COINN), the International Council of Nurses (ICN), American College of
Obstetricians and Gynecologists (ACOG), the International Federation of Gynecology and Obstetrics (FIGO),
American College of Nurse-Midwives (ACNM), and the International Confederation of Midwives (ICM).

11. Kangaroo Care is
recommended as a
non-pharmacological
method of pain
reduction and/or
elimination

12. Note the
tourniquet

14. Zaichkin, J., & Weiner, GM. (2011). Neonatal
Resuscitation Program (NRP) 2011: New Science, New
Strategies. Neonatal Network 30(1), 5-13.
”If the newborn is term, breathing, and has good muscle
tone, the baby SHOULD STAY with his mother for routine
care. This includes the vigorous infants with meconium-
stained fluid” Page 10
There is 2015 update. 7th update effective Jan 2017; I have
only seen 2 pg newsletter for resuscitation of depressed
infant

15. Delivery Room
Guidelines for healthy,
vigorous infant
recommend Kangaroo
Care immediately after
delivery (NRP 2011)

16. JOGNN AWHONN Practice Brief # 5 (2016)
Immediate and Sustained Skin-to-Skin Contact for
the Healthy Term Newborn After Birth
 Recommended for Vaginal and Caesarian deliveries
 KC until the 1st breastfeeding complete
 Emphasis on safety and monitoring by health care
professional to prevent SUPC (sudden unexpected
postnatal collapse)

17.  Defines immediate postnatal period as the first one –two hours
post birth…may be longer
 All mothers and infants must receive active and ongoing
assessment in immediate postnatal period. For 1 hour minimum,
up to 2 hours
 Mother and baby should never be left alone
 Promote skin-to-skin contact
 Ongoing assessment of baby’s color, tone and respiratory status
 Identify infants who are at increased risk; (long, complicated labor
and delivery, exposure to medications, drugs, alcohol, cigarette
smoke, inexperienced mothers,

18. Hynan MT, Hall SL. 2015. Psychosocial program standards for NICU
parents. J Perinatol.35 : supplement 1-4. doi: 10.1038/jp.2015.141.
Provides a rationale for and brief description of the process of
developing recommendations for program standards for
psychosocial support of parents with babies in the neonatal
intensive care unit (NICU).
•“early, frequent and prolonged skin-to-skin contact is
medically appropriate” (supports parents’ roles as primary
caregiver)
•“Skin-to-skin care to provide neuroprotection of their babies”

19. Kangaroo Care is mentioned throughout the document for
“In-Hospital Care” of late preterm
• Stabilization after birth
• Reducing risk of respiratory distress
• Reducing risks of hypothermia
• First breastfeeding
Access at:
http://nationalperinatal.org/latepreterm

20. Craig et al. 2015.Recommendations for involving family in developmental
care of the NICU infant. J of Perinatology 35, S5-S8;doi:10.1038/jp.2015.142
• Separation of parents from NICU babies results in adverse outcomes
for baby’s social, emotional development, and behavioral and
cognitive functioning.
• Stress in NICU results in change in brain structure and function
• Support parents as primary caregivers and integral part of NICU team
• Early, frequent and prolonged skin-to-skin contact as medically
appropriate
• Kangaroo Care is component of Developmental Care which
includes parents

21. Seven components of Neuroprotective care
• Healing Environment
• Partnering with families
• Positioning and handling
• Safeguarding sleep
• Minimizing stress and pain
• Protecting skin
• Optimizing nutrition
Altimier LB. 2015. Neuroprotective Core Measurre 1: The
Healing Environment. Newborn & Infant Nursing Reviews .
15pg 91-96

22. Kangaroo Care is Optimal care for the preterm infant; it
provides:
• Thermosynchrony
• Fulfills need for touch
• Needed proprioceptive sensory input to developing brain (pg93)
Recommended interventions for neuroprotective / neurosupportive
care for the tactile system include:
•“Facilitate early, frequent, and prolonged skin-to-skin
contact”(p93)

23. Pregnancy, Childbirth, Postpartum and Newborn Care:
A Guide for Essential Practice (Revised 2015)
•Place baby on abdomen in mother’s arms in skin-to-skin (pg
D11)
•Keep the baby warm in skin-to-skin care with mother (pg D19)
•Monitor mother at 1,3, and4 hours; then every 4 hours
•Keep mother and infant together
•Never leave mother and infant alone

24. •World Health Organization
•10 Steps to Baby Friendly Status
•Step 4. Help mothers initiate breastfeeding
within a half-hour of birth (pgs 31-39)
•Reviews many studies related to successful
breast feeding
•Many recommendations for “early skin contact”
to promote successful breastfeeding

25. Access @ http://www.healthypeople.gov/
Every 10 years this organization produces a national health
promotion and disease prevention initiative bringing together many
individuals and agencies to improve the health of all Americans ;
etc
The following slide notes the Healthy People 2020 initiatives
related to breastfeeding (BF)
Kangaroo Care has been identified by many organizations to
initiate, promote, and maintain exclusive BF
Thus KC helps to achieve Healthy People Goal of increased
number of infants who are BF

26. MICH-21: Increase the proportion of infants who are breastfed
MICH-21.1 Ever 81.9%
MICH-21.2 At 6 months 60.6%
MICH-21.3 At 1 year 34.1%
MICH-21.4 Exclusively through 3 months 46.2%
MICH-21.5 Exclusively through 6 months 25.5%
MICH-22: Increase the proportion of employers that have work site
lactation support programs.
38%
MICH-23: Reduce the proportion of breastfed newborns who receive
formula supplementation within the first 2 days of life.
14.2%
MICH-24: Increase the proportion of live births that occur in facilities
that provide recommended care for lactating mothers and their
babies.
8.1%
Healthy People 2020 Objectives

27. Healthy People produce health
goals for the nation every ten
years. The previous slide shows
that a national goal is to increase
exclusive breast milk feeds.
To assist in the achievement of
this goal, in 2007 the CDCP
developed a “survey” for
hospitals to complete every two
years. It is called the “mPINC
Survey”

28. • In U.S., most infants born in hospital or free-standing birth center.
• Typically stay is short, but events during this time have lasting effects.
• Many experiences of mothers and newborns in the hospital affect
breastfeeding.(BF)
• These experiences reflect routine practices at the facility; patients
rarely request care different from that offered them by health
professionals.
• Experiences with BF in the first hours and days of life significantly
influence an infant’s later feeding.
• Due to the relationship with the birth experience, BF must be
established during maternity hospital stay.
• The mPINC looks at these practices and scores the facility on the
“Report Card”. This report identifies areas which need improvement
and areas of excellence pertaining to successful BF

29. mPINC (2007 ) CDCP National Survey of Maternity
Care Practices in Infant Nutrition and Care
Who participates in the mPINC survey?
All hospitals with maternity services and all free-standing birth centers in
the US are invited to participate in CDC’s mPINC survey every two
years.
The survey produces a “report card” for each state
This report summarizes results from all Ohio facilities* that participated in
the 2015 mPINC Survey and identifies opportunities to improve mother-
baby care at hospitals and birth centers and related health outcomes
throughout Ohio. (*Sample Report Card for Ohio in your syllabus)
Access mPINC report card for your state, city and hospital at:
http://www.cdc/gov/breastfeeding/data/reportcard.htm

30. mPINC (2007 )
Areas assessed with the mPINC survey
(this is only a few of areas assessed)
L & D Care •Initial skin-to-skin contact (Note the very first area assessed)
•Initial breastfeeding opportunity
•Routine procedures performed in skin-to-skin
Post-partum
Care
Feeding of Breastfed
Infants
•Initial feeding received after birth
•Supplementary feedings
Breastfeeding
Assistance
•Documentation of feeding decision
•Breastfeeding advise and counseling
•Assessment & observation of breastfeeding
•Pacifier use
Contact Between
Mother and Infant
Should be sustained
by:
• No separation of mother and newborn during
transition to receiving patient care units
• Infant rooms in with mother 24/7
• Minimize mother infant separation throughout
the intrapartum stay
• Encourages transfer to PP in Kangaroo Care

31. Breastfeeding Report Card Progressing Toward
National Breastfeeding Goals United States, 2016
This report gives statistics for each state as
identified by mPINC
http://www.cdc/gov/breastfeeding/data/reportcard.htm

32. Conclusions of the CDCP
after 2007 mPINC National Results
• Steady increase in exclusivity at 3 and at 6 months
• < 5% of US births occur in Baby Friendly hospitals
• “Maternity practices in US hospitals and birth
centers must be changed to improve breastfeeding,
thereby helping to improve maternal and child
health” [MMWR 2008; 57(23):621-625].

33. •The mPINC identifies your institution’s strengths and
weaknesses related to breastfeeding (BF) and includes
the practice of Kangaroo Care (KC)
•Results can be used to guide Quality Improvement
projects within your clinical areas
•Can help you to improve all areas of BF: initiation,
duration, and exclusivity
•Can provide you with information for education of
parents and staff from birth through discharge, which
includes KC, related to BF (see next slide)

34. 
 Skin-to-skin contact
–Doctors and midwives place newborns skin-to-skin with their mothers
immediately after birth, with no bedding or clothing between them,
allowing enough uninterrupted time (at least 30 minutes) for mother and
baby to start breastfeeding well.
 Teaching about breastfeeding
–Hospital staff teach mothers and babies how to breastfeed and to
recognize and respond to important feeding cues.
 Early and frequent breastfeeding-
Hospital staff help mothers and babies start breastfeeding as soon as
possible after birth, with many opportunities to practice throughout the
hospital stay. Pacifiers are saved for medical procedures.
http://www.cdc.gov/breastfeeding/pdf/mPINC/Maternity_Care_Practices.
pdf
What hospitals Can do…

35. Using the mPINC to improve BF
 Exclusive breastfeeding
 –Hospital staff only disrupt breastfeeding with supplementary
feedings in cases of rare medical complications.
 Rooming-in
 –Hospital staff encourage mothers and babies to room together and
teach families the benefits of this kind of close contact, including
better quality and quantity of sleep for both and more opportunities
to practice breastfeeding.
 Active follow-up after discharge
 –Hospital staff schedule in-person breastfeeding follow-up visits
for mothers and babies after they go home to check-up on
breastfeeding, help resolve any feeding problems, and connect
families to community breastfeeding resources
 Crenshaw J. 2007. Care Practice # 6: No separation of mother and baby, with
unlimited opportunities for breastfeeding. J Perinatal Education. 16(3)39-43

36. • Hospitals need to do more to support BF families.
• Hospitals can participate in the Maternity Practices in
Infant Nutrition and Care (mPINC) survey, and use their
results to improve maternity care practices.” All past
performances on Breastfeeding report cards can be
accessed
How can states use Report Card to improve BF rates?
• To access your state mPINC results log on to:
• http://www.cdc.gov/breastfeeding/data/mpinc/results.h
tm
mPINC Report Card is in 10th Year

37. Academy of Breastfeeding Medicine Protocol Committee. 2010.
ABM Clinical Protocol #7: Model breastfeeding policy
(Revision 2010). Breastfeeding Medicine, 5(4), 173-
177.Academy of Breastfeeding Medicine 2010

38. *Protocol #23: “Coordinating a breastfeeding session with the
timing of the (painful) procedure is best, but, if this is not
possible, skin-to-skin contact can comfort infants undergoing a
procedure such as heel lance. Skin- to-skin contact also gives
the mother a caretaking role during the procedure that is
unobtrusive, and by diminishing infant stress, it can increase
maternal confidence as to her value to the infant. ..Sucrose and
pacifier can both be combined with the skin-to-skin component
of parental contact” (Pg. 1). “Skin-to-skin contact provides
effective pain reduction for premature infants.”(Pg. 2)….

39. •Wrote the Bogota Declaration “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, at all levels of care, and in all
countries”.
•Charpak,N, deCalume, CF, Ruiz JG 2000. The Bogota
Declaration on Kangaroo Mother Care: conclusions of
the second international workshop on the methods. Acta
Pediatrica. 89(9); 1137-1140

40. United States Institute of Kangaroo Care

41. • Are your staff prepared to implement KC
safely?
• Are your patients/ clients ready to
implement KC?
• Have they been prepared?
• Does this mean that your institution is
ready to implement Kangaroo Care as a
standard of care?
• How do you know if you are ready and
how do you get ready to implement KC?

42. •Institutional Readiness
•Staff Readiness
•Parental Readiness
•Patient Readiness

43. •Includes physical, human, and educational resources.
•Is their physical space and chairs for KC
•Is their adequate nursing staff?
•Has staff been educated about benefits of, and skills
for KC. Standardized basic education r/t KC is essential
•Do you have educational material for parents?
•Do you have written policies pertaining to KC?
•Are physicians (NEOs, OBs, NNPs, RNs) supportive?

44. •Are parents aware of KC and
its’ benefits?
•Are the parents asking to
hold their infant in KC?
•Are they ready to provide KC
physically?
•Are they ready emotionally?
•Have they been given adequate
information to make informed
consent to provide KC

45. •Has staff received adequate training to offer KC
safely?
•Do they know all of the benefits of KC for full term
and preterm infants?
•Do they have support system for questions?
•Do they have needed policies ?
•Are they competent in the practice of KC?
•Are they competent in the assessment of the infant
while in KC?

46. • As you have learned, there are many recommendations for
Kangaroo Care for both full term and preterm infants.
• Having these guidelines does not mean that you are ready to
implement KC for your clinical are.
• Knowing these guidelines is the first step in implementing
KC.
• It takes team work, education, and commitment from all;
Doctors, RNs, NNPs, OB GYNs, along with
administrative support.

47. The Bogota Declaration is complete and concise. It states:
“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, at all levels of care, and in all countries”.
It is our responsibility as health care providers for
mothers and infants to educate ourselves so that we
may safely assure that this basic right is protected
and provided for all newborns