Kangaroo Care REALLY
Works
Susan M. Ludington, Ph.D., RN, CNM, CKC, FAAN
Walters Professor of Pediatric Nursing
Executive Director of U.S. Institute for Kangaroo Care
www.kangaroocareusa.org
Purposes of the Talk

Differentiate between skin to skin contact and kangaroo care

Understand mechanisms by which Kangaroo Care, not skin-to-skin contact,
works

Identify benefits of Kangaroo Care to infants, mothers, fathers

Understand new findings about Kangaroo care for infants with congenital
heart defects, NAS, and imminent maternal demise

Relate tenets of Zero Separation and the TOXIC incubator environment

Explain safe positioning
What Kangaroo Care Is

1st KC is “CHEST-to-CHEST”,
to-skin contact
skin-

2nd : KC is not “any” skin-tocontact.
skin

3rd : Skin-to-skin
can be
cheek-to-cheek, head-tobreast, arm-in-hand, but
these positions Do Not Do
what the KC position does
Differentiating Kangaroo Care from
Skin-to-Skin Contact

Skin to skin contact stimulates the brain through A-Afferent Tactile Nerve
Stimulation

Kangaroo Care stimulates the brain through an entirely separate set of nerves
that are only responsive to PLEASING TOUCH, and non-phasic stimulation of
the chest stimulates the C-AFFERENT nerves.
KC Position Physiology

In KC, the c-afferent nerves (only on chest, from umbilicus to sternum &
across infant’s back in newborn period and have greatest DENSITY here in
newborn period) are stimulated (Morrison, I. et al. 2011, Reduced C-afferent fibre density
affects perceived pleasantness and empathy for touch. Brain, 134, 1116-1126)

C-afferent nerves are exquisitely sensitive to chest-to-chest, nonphasic skin
stimulation (Uvnas-Moberg, K., Arn, I., Magnusson, D. (2005). The psychobiology of emotion:
the role of the oxytocinergic system. International Journal of Behavioral Medicine. 12(2), 59-65. )
and encode it as PLEASANT TOUCH (Morrison, I. et al. 2011, Reduced C-afferent fibre
density affects perceived pleasantness and empathy for touch. Brain, 134, 1116-1126)
C-Afferents

Message goes directly to insular cortex (limbic brain, seat of emotions &
emotional memory)(Olausson HW et al., 2008.Unmyelinated tactile afferents have opposite
effects on insular and somatosensory cortical processing. Neuroscience Letters, 436, 128-132)

In Mother, c-afferent stimulation and oxytocin release initiate MOTHERLINESS
(protection, advocacy, bonding) and emotional COMMITMENT to take care and
breast feed her infant – that sometimes is overcome by cortical decision
making Bystrova, K. (2009). Medical Hypotheses, 72(2), 143-146. Henderson, A. (2011).
Understanding the breast crawl: Implications for nursing practice. Nursing for Women’s Health
,15(4), 296-307.
C-Afferents
Message from C-Afferents goes directly to the insular cortex
(limbic brain, seat of emotions and emotional memory) (Olausson HW et
al., 2008.Unmyelinated tactile afferents have opposite effects on insular and somatosensory cortical
processing. Neuroscience Letters, 436, 128-132)
C-Afferents

In Mother, c-afferent stimulation and oxytocin release initiate MOTHERLINESS
(protection, advocacy, bonding)

and emotional COMMITMENT to Breast feed her infant – that sometimes is
overcome by cortical decision making Bystrova, K. (2009). Medical Hypotheses, 72(2),
143-146. Henderson, A. (2011). Understanding the breast crawl: Implications for nursing practice.
Nursing for Women’s Health ,15(4), 296-307. and

Ability of mother’s physiology to REGULATE the infant’s
physiology (see Neu articles)
OXYTOCIN

Oxytocin is released from insular cortex to travel on nerves to 14 areas of
mother’s and infant’s brain (as a neuropeptide) or to be released into the
circulation (as a hormone) (Uvnas-Moberg, K., Arn, I., Magnusson, D. (2005). The
psychobiology of emotion: the role of the oxytocinergic system. International Journal of
Behavioral Medicine. 12(2), 59-65. ) .

First Stop is the brain stem to switch the brain from sympathetic (STRESS,
flight, fight, fear, terror) to parasympathetic (CALM, contented, relaxed,
affiliated not estranged) dominance
Autonomic Nervous System
http://www.taocontrol.com/images/Autonomic_nervous_system_main_figure_Blessing.gi
Parasympathetic Dominance
during Kangaroo Care

Confirmed in many studies by Cong that kangaroo care position switches the
brain to parasympathetic dominance. Cong, X., Cusson, R.M., Walsh, S., Hussain, N.,
Ludington-Hoe, S.M., Walsh, S., & Zhang, D. (2012). Effects of skin-to-skin contact on autonomic
pain responses in preterm infants. Journal of Pain,13(7):636-645;

Cong X, Ludington-Hoe SM, McCain G, & Fu, P (2009). Kangaroo care modifies preterm infant heart
rate variability in response to heel stick. Early Human Development, 85(9), 561-567. )

Parasympathetic dominance facilitates initiation and continuation of BF in
first week of life, even in 26-28 weekers who will demonstrate sucking
when in KC (Meier PP. (2001). Breastfeeding in the special care nursery:
Prematures and infants with medical problems. Pediatric Clinics North
American, 49(2), 425-443).

And many other things……..
Parasympathetic Importance & Stress

Stress hormones, especially aldosterone, are ten times higher at birth than
they will ever be again in infant’s life (Bergman, N.J. (2014 – Nov 28). The neuroscience
of birth - and the case for Zero Separation. Curationis, 37(2):1-4) ) (Morgan, B.E., Horn, A.R. &
Bergman, N.J. (2011). Should neonates sleep alone? Biological Psychiatry 70, 817-825

So, oxytocin in brain stem switches the newborn’s brain from STRESS to CALM
and helps INITIATE cardiorespiratory stability, readiness for breastfeeding,
improved immunity, better brain development, less pain perception, 72%
diminution of stress, and better sleep.
Parasympathetic Dominance Decreases
STRESS

High stress levels impair premature infant brain
development (Parsons,C.E., Young, K.S., Murray, L., Stein, A., & Kringelbach, M.L. (2010). The
functional neuroanatomy of the evolving parent-infant relationship. Progress in Neurobiology, 91, 220-241. )
But, KC does not – it accelerates brain
maturation, complexity, and connectivity.
(Scher MS,
Johnson MW, Ludington SM, Loparo K. (2011). Physiologic brain dysmaturity in late
preterm infants. Pediatric Research,70(5), 524-528; Kaffashi ,F., Scher, M.S.,
Ludington-Hoe, S.M., & Loparo, K. (2013) An analysis of the Kangaroo Care
intervention using neonatal EEG complexity: A preliminary study. Clinical
Neurophysiology,124(2):238-246. )
Parasympathetic Dominance:
Physiologic Stability and Improvement

physiologic stability ensues,

Physiologic stability occurs faster in younger and smaller infants and
they tolerate KC very well at 24 weeks postconceptional age onward
HR & RR slow, MAP improves, SaO2 stabilizes (Park HK,
Choi BS, Lee SJ, Son IA, Seol IJ, Lee HJ.(2014 March) Practical application of kangaroo mother care in
preterm infants: clinical characteristics and safety of kangaroo mother care. Journal of Perinatal Medicine.
42(2): 239-245. Uvnas-Moberg, K., Arn, I., Magnusson, D. (2005). The psychobiology of emotion: the role
of the oxytocinergic system. International Journal of Behavioral Medicine. 12(2), 59-65.)
(Park HK, Choi BS, Lee SJ, Son IA, Seol IJ, Lee HJ.(2014 March) Practical application of kangaroo mother
care in preterm infants: clinical characteristics and safety of kangaroo mother care. Journal of Perinatal
Medicine. 42(2): 239-245. )

Physiologic stability seen in KC immediately after birth
with preterms ( Bergman, et al., 2004; Ludington-Hoe et al. 1993. J. Human Lactation 9(4):
241-242; Ludington-Hoe et al., (1998). JOGNN 28(1) 94-103.
.
Parasympathetic Dominance Decreases STRESS

High stress levels destabilize physiologic functions
(Morgan, Horn & Bergman, 2011 above), BUT KC does NOT: look at
the slide on basic HR and RR and APNEAs during incubator vs. KC

.
So, better cardiorespiratory stabilization and 75%
reduction in APNEAs (Ludington-Hoe, et al., 1994 Kangaroo care: Research results and
practice implications and guidelines. Neonatal Network, 13(1), 19-27)
Cardio Respiratory Changes
Pre-KC
KC
Post KC
Parasympathetic Dominance
Improves CR Function

Cerebral oxygenation improves
during KC in several pretest-test-
posttest studies
(Begum EA, Bonno M, Ohtani N, Yamashita S, Tanaka S, Yamamoto H, Kawai M, &
Komada Y. (2008). Cerebral oxygenation responses during kangaroo care in low birth weight infants.
BMC Pediatrics 8(1)(Nov. 7, 2008), 51- 60; Begum EA, Bonno M, Ohtani N, Yamashita S, Tanaka S,
Yamamoto H, Kawai M, & Komada Y. (2009). Cerebral oxygenation responses during kangaroo care in
low birth weight infants. Neonatal Intensive Care 2(2), 2-25; Martin, J.B., & Ludington-Hoe, S.M.
(2010). Near infrared spectroscopy measure of brain activation in premature infants in an incubator and
during kangaroo care. Advances in Neonatal Care, 19(4), 214-215.)

If it is YOUR baby in an incubator, and you know oxygen supply to brain can
increase from
to have?
57% to 88%,
which oxygen level do you want your baby’s brain
Parasympathetic Dominance Decreases STRESS

High stress levels delay immune functions

particularly in the keratinocytes,

and impair infant’s resistance to infection by impairing maternal antigenspecific antibody development and conveyance through maternal skin to
neonatal skin (Bergman, N.J. (2014 – Nov 28). The neuroscience of birth - and the case for Zero
of stratum corneum
Separation. Curationis, 37(2):1-4; Abouelfettoh A., Ludington-Hoe, S.M., Burant, C., & Visscher, M.
(2011). Effect of skin-to-skin contact on preterm infant skin barrier function and hospital-acquired
infection. Journal of Clinical Medicine Research, 3(1), 36-46; Schanler RJ. (2001). The use of
human milk for premature infants.Pediatr Clin North Am 2001, 48(1), 207-219. )

NEWBORN INFANT NEEDS MATERNAL CONTACT TO BUILD UP HIS OWN GOOD BACTERIAL AND SEED
HIS GI TRACK WITH GOOD BACTERIA – IF NOT BORN VAGINALLY, THE INFANT IS AT HIGH RISK OF
ASTHMA, OBESITY, TYPE 1 DM, AND CELIAC DISEASE, so VAGINAL SWABS are being done now
(see Neena MODI’s studies)
Parasympathetic Dominance:
Weight Gain and Crying

Purposeless activity/agitation decrease, minimizing wasted energy expenditure and then
better weight gain (Conde-Agudelo, A., Belizan, J.M., & Diaz-Rosello, J. (2011). Kangaroo
mother care to reduce morbidity and mortality in low birthweight infants. Cochrane
Database Systematic Review, (3): CD002771 )

Central oxytocin also increases growth hormone and digestive enzymes to improve
utilization of nutrients and better weight gain. (Uvnas-Moberg, K., Arn, I., Magnusson, D.
(2005). The psychobiology of emotion: the role of the oxytocinergic system. International
Journal of Behavioral Medicine. 12(2), 59-65; Wahlberg, V. (1991). The “kangaroo method”
and breastfeeding in low birth weight babies. NU Nytt on U-landshalsovard,5(3), 22-26

Crying is rare, so foramen ovale seals over properly and likelihood of heart attack due to
patent foramen ovale decreases (Ludington-Hoe, S.M., Cong, X., & Hashemi, F. (2002). Infant
crying: Nature, physiologic consequences, and select interventions. Neonatal Network 21(2),
29-36)
Central Oxytocin Goes to Hypothalamus:
Heat Control

Healthy newborns heat up throughout the body (down to toes) within 10 minutes of
onset of KC (Christidis ) and mother’s body makes 10 times more adjustments to
keep baby in NTZ than any incubator (Ludington-Hoe, S.M, Nguyen, N, Swinth, J., & Satyshur, R.
(2000). Kangaroo Care compared to incubators in maintaining body warmth in preterm infants. Biologic
Research for Nursing, 2(1), 60-73.

Humidity between breasts is good and Transepidermal Water Loss is minimized
(Abouelfettoh A., Ludington-Hoe, S.M., Burant, C., & Visscher, M. (2011). Effect of skin-to-skin contact on
preterm infant skin barrier function and hospital-acquired infection. Journal of Clinical Medicine
Research, 3(1), 36-46. et al., 2013)
Central Oxytocin….
Promotes BETTER SLEEP

Quiet Sleep is BEST sleep for any newborn.

Sleep in NICU in incubator is fractured, chaotic sleep
.
Complete sleep cycles is best for brain development and sleep cycle is 60
minutes duration up to 52 weeks pma.


IN KC: SLEEP CYCLES Improve, arousals decrease, sleep behaviors and
physiology are organized so that NO INDETERMINANT SLEEP is seen, and
QUIET SLEEP is much longer than active sleep (Ludington-Hoe SM, et al. (2006).
Neurophysiologic assessment of neonatal sleep organization: preliminary results of a
randomized controlled trial of skin contact with preterm infants. Pediatrics, 112, e909-e923)
Incubator Sleep is Fragmented and Chaotic
Cyclical Sleep occurs in Kangaroo Care
Parasympathetic Dominance & BF

So, oxytocin in brain stem switches the newborn’s brain from STRESS to CALM
and helps INITIATE BF by facilitating prolactin production and eliminating the
delay in feeding at the breast.

coordination of vital signs and feeding occurs,
allowing the infant to breastfeed without respiratory compromise – coupling
feed and VS.

Facilitates transition to NIPPLE feedings
So, maintaining chest-to-chest position when infant is at breast, allows INITIATION
and CONTINUATION OF BREAST FEEDING (Winberg, 2005) Thus you will be meeting
NICU-Baby Friendly Hospital Initiative designation criteria
Many Maternal Benefits of KC:

Improved bonding and interactions with infant

Enhanced exclusivity and longer duration Breastfeeding

Decreased involution time

Decreased lochia and preventative for Postpartum Hemorrhage

Decrease Postpartum depression and may prevent it altogether

Decreased Blood pressure – adjunct/preventative treatment for HTN
or pre-eclampsia/eclampsia

Can prevent maternal mortality – 5 cases at Grant Medical Center and
Hershey Medical Center –”only thing it could be that saved her is
Kangaroo Care” (MD at Grant Med Ctr in Columbus, OH, Contact Mary
Walters at Mwalters@OhioHealth.com)
Paternal Benefits

Greater sense of responsibility to infant

Enhanced bonding

Greater sense of family development

Enhanced interactions with infant
(Erlandsson, K., Christensson,
K., & Fagerberg, I. (2008). Fathers’ lived experiences of getting to know their baby while acting as
primary caregivers immediately following birth. Journal of Perinatal Education, 17(2), 28-36)
(Erlandsson, K., Christensson, K., & Fagerberg, I. (2008). Fathers’
lived experiences of getting to know their baby while acting as primary caregivers immediately
following birth. Journal of Perinatal Education, 17(2), 28-36)
Physiology, 18(5) 223-232)
(Ludington-Hoe et al., 1992. J. Dev.
Zero Separation

Holding a clothed baby over mother’s clothes is NOT KC and is a form of
separation that prevents KC physiology from occurring

Stress hormones rise rapidly in the newborn and destabilize the baby when
separated from mother or father (Morgan, B.E., Horn, A.R. & Bergman, N.J. (2011). Should
neonates sleep alone? Biological Psychiatry 70, 817-825)

Newborn has short period to be exposed to maternal bacteria and seed his GI
system with them to prevent many later health problems: ie obesity, asthma,
celiac disease, type I diabetes, and metabolic syndrome as an adult. So give
infant as much KC as possible for better life span health (Dahlen H. 2015. Being born is
good for you. Practicing Midwife, 18(4): 10-13.)

AS MUCH KC AS POSSIBLE – follow Scandinavian Sample of 24/7 KC – mother’s chest
is the PLACE of care throughout hospitalization and for three months post term
age. (Nyqvist et al., 2010 – referred to earlier in this lecture)
With KC

When there is ZERO SEPARATION between mom and newborn, and the feed –
sleep -wake up -and feed again cycle, in KC, does not allow separation.

Start KC ASAP, recommendation is within 24 hours of birth, even with 24 wk
gestation birth, and continue as much as possible for entire postpartum
hospitalization (Nyqvist KH, Anderson GC, Bergman N, Cattaneo A, Charpak N, Ewald U, Ibe O., Ludington-Hoe
SM, Mondoza S, Pallas K, Ruiz-Pelaez JG, Sizun J., & Widstrom A-M. (2010b). Towards universal Kangaroo Mother Care:
Recommendations and report from the First European Conference and 7 th International Workshop on Kangaroo Mother
Care. Acta Paediatrica, 99(6), 820-826;. Nyqvist, K (actually listed as Hedberg Nyqvist, K) & Heinemann, A-B. (2011).
Kangaroo Mother Care: Optimal support of preterm infant’s transition to extra-uterine life in the high tech NICU
environment. Current Women’s Health Reviews, 7(3), 278-287 .

Keep REPEATING KC, the more you do it the more likely the preterm infant
will be breastfeeding and doing so (90% likely) exclusively at discharge
(Bergman, NJ (2014 – Nov 28). The neuroscience of birth - and the case for Zero Separation.
Curationis, 37(2):1-4. )
Kangaroo Care- Fights TOXIC stress

SEPARATION from mother is TOXIC

The INCUBATOR is a TOXIC environment

The American Academy of Pediatrics relates that separation toxicity sets the
infant up for many and most of the developmental delays and biological
diseases that are common in NICU graduates (Garner & Shonkoff 2010;
Shonkoff & Garner 2010).

For example, little TOUCH is clearly associated with MOTOR DEFICITS (Multino
DC & Crumpsty P. 1984. Tactile aversion in infancy. South African Medical
Journal,, 65(19): 773-774.
So, what’s not to like about KC?
It’s association with SUPC

Sudden Unexpected postnatal collapse has been
documented in the literature with breastfeeding
since 1981.
Identifying Potential Events that May
Occur During Birth KC
Sudden Infant
Collapse
Acute LifeThreatening Event
Sudden Unexpected
Postnatal Collapse
SUPC
Postnatal adaption
appeared normal
with 5 min Apgar >
8
Reports say: Occurs within minutes of birth up to 24 hours of life ..can
occur up to 7 days post natal. Ludington-Hoe,SM & Morgan K, (2014). Infant assessment and reduction of sudden
unexpected postnatal collapse risk during skin-to-skin contact. Newborn and Infant Nursing Reviews, 14(1), 28-33
Assessment of Mother-Infant KC Dyad
While in KC infant should be
assessed continually
(document /your policy)

Remember: breathing,
activity, color, & tone
assessment should be
ongoing and continuous by
health care professional
(AHA & AAP, NRP, 2011)

The USIKC recommends the
RAPPT
“RAPPT” Assessment

R = Respiratory Effort (easy respirations, RR,
grunting, nasal flaring,)
tachypnea, retractions,

A = Activity / State ( quiet alert, active alert,

P = Perfusion / Color (pink, grey, blue, mottled)]

P = Position for minimizing asphyxia (Position of head, neck and face,
nares visible, well flexed)

T = tone (limp, flaccid vs responsive)

Ludington-Hoe SM & Morgan K. (2014 April). Assessing the Infant during
Kangaroo Care and Breastfeeding. Newborn and Infant Nursing Reviews)
and Ludington-Hoe, Morgan & Morrison-Wilford, 2015. USIKC: Cleveland,
OH.
asleep, crying, BF)
© 2012 USIKC. Safe Position poster available from susan.Ludington@case.edu
One of many wraps designed to hold
infant in position during KC