Kangaroo mother care works, and fathers can do it too

Kangaroo mother care means holding your small baby skin to skin on your bare chest for many hours a day, along with breast milk feeding. It is one of the most effective treatments we have for premature and low birth weight babies. It costs almost nothing, and fathers and other family members can do it too.

What is kangaroo mother care?

Kangaroo mother care (KMC) is long, close skin to skin contact between a baby and a parent, together with breast milk feeding and good follow-up. The baby wears only a nappy and a cap and lies upright on the parent's bare chest.

It began in Bogota, Colombia, when a hospital did not have enough incubators. Today it is studied all over the world. Reviews describe three parts: skin to skin contact, frequent breastfeeding, and going home early with close follow-up once the baby is stable.¹

Does kangaroo care really work?

Yes. In pooled trials, low birth weight babies who received KMC were about 40 percent less likely to die before discharge than babies cared for in the usual way.¹

The same Cochrane review found less serious infection and much less hypothermia (low body temperature), better weight gain, and more mothers breastfeeding at discharge.¹ A second large review, which also included observational studies, found lower rates of sepsis, low body temperature, low blood sugar and readmission to hospital.² Very few things we do in a NICU have evidence this strong.

What did the iKMC trial show?

The iKMC trial showed that starting skin to skin care straight after birth, instead of waiting for the baby to become stable, saved more lives.³

The trial was published in the New England Journal of Medicine in 2021. It included 3211 babies weighing 1.0 to 1.799 kg in five hospitals in Ghana, India, Malawi, Nigeria and Tanzania. Mothers stayed with their babies in a special unit and gave skin to skin care for a median of about 17 hours a day. In the usual care group, it was about 1.5 hours.³

Deaths in the first 28 days fell from 15.7 percent to 12.0 percent. The trial was stopped early because the benefit was clear.³

How soon after birth can kangaroo care start?

WHO now advises starting KMC as soon as possible after birth, even before a small baby is fully stable.⁴

The baby's heart rate, breathing, colour, temperature and oxygen level should be watched while this happens. WHO lists three exceptions: babies who cannot breathe on their own after resuscitation, babies in shock, and babies who need a ventilator.⁴ For these babies, skin to skin care starts once they are out of danger. Ask your nurse each day whether today can be the first day.

How many hours a day should we do kangaroo care?

WHO recommends 8 to 24 hours a day, as many hours as possible.⁴ More is better.

Long sessions are better than many short ones, because moving a tiny baby in and out of an incubator is stressful in itself. Many Indian families share the work. The mother does long stretches, and the father, grandmother or an aunt takes over while she eats, bathes or sleeps.

Can fathers do kangaroo care?

Yes. WHO says the mother should give KMC when she can, and that a father, partner or another relative can take her place when she cannot.⁴

A review of seven trials found that babies held by their fathers had stress hormone levels similar to babies held by their mothers, and fathers' stress and anxiety were similar too.⁵ After a caesarean, or when a mother is unwell, the father can often start on the first day.

Some fathers feel shy about sitting shirtless in a ward. Most units have screens or curtains. Ask for one. A clean chest, no strong perfume and no smoking beforehand are all that is needed.

How do I hold my baby in the kangaroo position?

Place your baby upright on your bare chest, between the breasts, with the head turned to one side and slightly tilted up so the airway stays open.

1. Wash your hands and sit in a comfortable chair with a back, slightly reclined.
2. Your baby wears only a nappy, a cap and socks.
3. Hold the baby chest to chest in a frog position, hips bent and legs tucked up.
4. Support the bottom with one hand.
5. Tie a KMC binder or soft cloth around both of you, firm enough that the baby cannot slip. WHO advises securing the baby with a binder that keeps the airway open.⁴
6. Cover both of you with your shirt, a shawl or a light blanket.

You should always be able to see your baby's face.

What should I wear for kangaroo care?

Wear something that opens at the front, such as a button shirt, a front-open kurti or a hospital gown. This lets your baby lie directly on your skin.

Use the toilet first and keep water and your phone nearby, because once your baby settles you will not want to move. In winter, a shawl over both of you is enough. In a hot Kolkata summer, a thin cotton cover is plenty.

Will my baby get cold during kangaroo care?

No, not if it is done properly. Babies in KMC are much less likely to get cold than babies cared for in cots or incubators.

Pooled trials found hypothermia was about 70 percent less common with KMC.¹ A parent's chest is a very good heater. Keep the cap on, keep your baby's back covered, and keep the room comfortably warm, especially in an air conditioned ward.

Does kangaroo care help with breastfeeding?

Yes. Mothers who give KMC are more likely to be exclusively breastfeeding when the baby goes home.^1,2

Being close to the breast helps a small baby find it, smell the milk and practise sucking. Many mothers also find they express more milk after a long session. Keep the pump or a clean container nearby.

Can my baby have kangaroo care while on CPAP or a drip?

Often yes. CPAP, drips and feeding tubes do not by themselves stop skin to skin care, as long as the baby is watched closely.⁴

The nurse will help you lift your baby with all the tubes and wires. Once settled, monitors stay on and the nurse checks on you. WHO lists a baby who needs a ventilator as an exception to starting KMC straight away, so for these babies the team decides when it is safe to begin.⁴

Can we continue kangaroo care at home?

Yes, and you should. KMC can start in hospital or at home, and WHO recommends it in both places.⁴

A large trial in Haryana, India, supported mothers of babies weighing 1.5 to 2.25 kg to do KMC at home. Deaths in the first 28 days fell by about 30 percent, and the benefit lasted to six months.⁶ Most babies tell you when they have had enough. They start wriggling, kicking and getting too warm on your chest.

Should we oil or massage the baby before kangaroo care?

Please do not use mustard oil on a small baby. If you want to use oil, ask your doctor about a mild one such as sunflower oil.

In a laboratory study, mustard oil damaged the skin barrier, while sunflower seed oil helped it recover.⁷ That was a mouse study, so it is not the whole story. WHO says applying oil to the body of premature or low birth weight babies may be considered.⁴ Skin to skin contact itself needs no oil at all.

Why does kangaroo care work so well?

It keeps babies warm, steadies their breathing and helps them feed. It also brings mother and baby close all day.

Studies show babies in KMC have a lower breathing rate, higher oxygen levels, a steadier temperature and better head growth.² Being on a parent's skin also means the baby meets the family's own skin bacteria rather than hospital ones, which may help explain the lower infection rates. Parents who hold their baby for hours stop feeling like visitors. They become the people who know this baby best.

When should I stop kangaroo care and call for help?

Stop and call the nurse, or your doctor if you are at home, if your baby shows any sign of being unwell.

• Blue or grey colour around the lips or face.
• A pause in breathing that does not stop on its own quickly, or very fast or hard breathing.
• Feels cold, or feels hot.
• Floppy, very sleepy or hard to wake.
• Not feeding, or vomiting.
• Any jerking or stiffening.

These signs need a doctor whether or not you were doing KMC.