Kangaroo Mother Care (KMC) is the most efficient intervention to help in breastfeeding, provides warmth, sensory stimulation, safety, protection from infection and it also helps in bonding between the infant and mother. KMC is a cost effective easily available modality to address these issues and it can easily be continued at home. The present review intends to provide an insight into the benefits, the key components, the requirements, the initiation criteria, the procedure and the follow-up requirements of infants receiving KMC to help general practitioners understand, guide, and provide KMC to mothers and infants.
Kangaroo mother care (KMC) was first proposed by Dr. Edgar Rey in Colombia in 1978. KMC is an effective intervention for preterm/low birth weight infants by placing them in skin to skin contact with the mother or other caregiver, to ensure optimum growth and development of the infant.[1,2]
KMC has been widely studied and has shown several benefits for the infant, the mother, as well as the rest of the family. As KMC augments prolactin reflex it enhances breast milk production, it also significantly facilitates exclusive and prolonged breast feeding.[3-8] As breast milk and breastfeeding have significant long-term benefits, KMC indirectly benefits the infant and the mother simultaneously.[9,10] KMC helps in achieving necessary temperature regulation and prevents hypothermia.[11,13] KMC has been shown to be more effective in providing temperature stability than servo-controlled incubators.[14-15] KMC facilitates mother and infant bonding that has long lasting effects.[16-19] KMC also helps in strengthening infant-family bonding. KMC provides an opportunity for neurosensory stimulation. This might be responsible for better neurodevelopmental and behavioral outcomes as seen in research studies of infants who have received KMC. KMC decreases the incidence of infection by promoting healthy bacterial colonization of the infant’s skin from the mother’s skin.[23,24] KMC is widely studied and it also effectively reduces the pain response in neonates which is secondary to any painful stimuli or intervention.[25,26] Infants receiving KMC have better physical growth, which continues into early childhood and possibly beyond. Infants receiving KMC have fewer cardiorespiratory events such as apnea, bradycardia, desaturations and have a far more stable course as compared to controls. Maternal and infant stress is reduced as measured by salivary cortisol levels in both mother and the infant. KMC reduces infant mortality and morbidity.[30,31] KMC also reduces maternal morbidity and mortality and reduces maternal and infant length of hospitalization stays.[32,33]
The present review will provide further insight into the key components, the requirements, the initiation criteria, the procedure of KMC and the follow-up requirements of infants receiving KMC to help general practitioners understand and provide KMC.
KEY COMPONENTS OF KMC [34, 35]
KMC position consists of skin to skin contact between the mother and the infant in a vertical position, between the mother’s breasts and under her clothes in a semi-reclining position. Attempt to breast feed should be made as soon as oral feeding is possible and the goal should be to provide exclusive breastfeeding or expressed breast milk feeding as per the condition of the infant. Early home discharge and continuation of home based KMC is one of the important components of KMC. Mothers at home require adequate support and follow up, hence a follow-up program and access to emergency services must be ensured.
REQUIREMENTS FOR KMC IMPLEMENTATION [34, 35]
Hospitals should allow 24/7 access to the parents to the neonatal unit at all times. A room either adjacent to or in the neonatal unit, furnished with comfortable seats for the mothers should also be ensured. Reclining, comfortable chairs in the nursery and postnatal wards, and beds with adjustable back rests should be arranged. Mothers can provide KMC while sitting on an ordinary chair or in a semi-reclining posture on bed with help of pillows. Appropriate supporting staff and a nurse trained in assisting mothers in KMC should be available round the clock. All nursing staff should receive adequate training on KMC including nutrition of low birth weight (LBW) infants, expression and storage of breast milk, using alternate methods of feeding and daily growth monitoring of LBW infants. Educational material such as information sheets, posters, and video films on KMC (all in local languages) should be available to the mothers, families and the community. Early discharge with home based KMC should be attempted if adequate and appropriate follow up can be ensured. KMC should be provided as an in-hospital activity, allowing mothers and infants to room together for as long as needed. Family education initiatives about KMC should be ensured to help mothers be relieved of their household responsibilities while providing KMC. Community education and awareness about the benefits of KMC should be attempted. This is particularly important when there are social, economic and/or family constraints.
ELIGIBILITY CRITERIA [34-36]
- Infant: All stable LBW babies are eligible for KMC. KMC should be started as soon as the baby is hemodynamically stable. Short KMC sessions can be initiated during recovery with ongoing medical treatment (intravenous fluids, oxygen therapy). KMC can be provided even while the baby is being fed via orogastric tube.
- Mother: All mothers can provide KMC, irrespective of age, parity, education, culture and religion.  Any other family member can provide KMC if the mother is suffering from a communicable disease that can potentially be transmitted to the infant.
KMC INITIATION [34-36]
- Counselling: When the infant meets the KMC criteria, arrange a meeting time that is convenient to the mother and other family members. Discuss the benefits of KMC and the KMC procedure. Demonstrate KMC procedure to the mother in a caring and gentle manner, answering her queries and allay her anxieties.
- Mother’s clothing: Mother can wear any front-open dresses as per the local culture. This may include a sari, a blouse, front-open gown, a suit, or a simple shirt. KMC can even be done with gowns specially designed for KMC.
- Baby’s clothing: Baby is dressed in a cap, socks, diapers and front-open sleeveless shirt.
KMC PROCEDURE [34-36]
- Positioning: The baby should be placed between the mother’s breasts in an upright position and the head should be turned to one side and in a slightly extended position. This position keeps the airway open and allows eye to eye contact between the mother and baby. The hips and arms should be flexed and abducted in a frog-like position, with the baby’s abdomen at the level of the mother’s epigastrium. Support the baby’s bottom with a sling/blinder. The mother can sleep with her baby in the kangaroo position in a reclined or semi-recumbent position about 30 degrees from horizontal. This can be done with a back rest-adjustable bed, with pillows on an ordinary bed, or even a comfortable chair with an adjustable back.
- Monitoring: Infants should be monitored carefully especially during the initial stages. Nursing staff should make sure that infant’s neck position is neither too flexed nor too extended, airway is clear, breathing is regular, colour is pink and the baby is maintaining temperature. Mother should also be involved in observing the infant during KMC.
- Feeding: The mother should be instructed how to breastfeed while the infant is in the KMC position. If the infant requires, she may express milk and the infant could be fed with a paladai, spoon or tube while in KMC position depending on the infant’s condition.
- Duration: Skin to skin contact should start gradually in the nursery, with a smooth transition from conventional care to continuous KMC. Sessions that last less than one hour should be avoided however as frequent handling may be stressful for the infant. The length of skin to skin contact should be gradually increased up to 24 hours a day, interrupted only for changing diapers. When the infant does not require intensive care, he/she should be transferred to the postnatal ward where KMC should be continued.
DISCHARGE CRITERIA 
Infants can be discharged when general health is good and they show adequate weight gain of at least 15-20 gm/kg/day for at least three consecutive days and are feeding well while receiving exclusively or predominantly breast milk. The infant should maintain normal body temperature for at least three consecutive days in room temperature and the mother and family members should be confident in taking care of the infant.
DISCONTINUING KMC [34-36]
When the mother and infant are comfortable, KMC can be continued for as long as possible. It should be continued at least until the infant’s gestation reaches term or the weight is around 2500 grams. It can be discontinued if the infant starts wriggling and is repeatedly uncomfortable during KMC.
POST-DISCHARGE FOLLOW UP
Close follow up is a fundamental pre-requisite of KMC. The infant is followed once or twice a week till 37-40 weeks of gestation or till 2.5 to 3 kg of weight. Thereafter, a follow up once in 2-4 weeks may be enough till 3 months of post-conception age. Later the infant should be seen at an interval of 1-2 months during first year of life. The infant should gain adequate weight, 15-20gm/kg/day up to 40 weeks of post-conception age and 10 gm/kg/day subsequently. More frequent visits should be made if the infant is not growing well or there are other concerns.
- Charpak N, Ruiz JG, Zupan J, et al. Kangaroo Mother Care: 25 years after. Acta Paediatr. 2005;94(5):514–522.
- Whitelaw A, Heisterkamp G, Sleath K, Acolet D, Richards M. Skin to skin contacts for very low birth weight infants and their mothers. Arch Dis Child1988; 63(11):1377-81.
- Hake-Brooks SJ, Anderson GC. Kangaroo care and breastfeeding of mother-preterm infant dyads 0-18 months: a randomized, controlled trial. Neonatal Network 2008;27(3):151-9.
- Beiranvand S, Valizadeh F, Hosseinabadi R, Pournia Y. The effects of skin-to-skin contact on temperature and breastfeeding successfulness in full-term newborns after cesarean delivery. International Journal of Pediatrics 2014;2014:846486.
- Mahmood I, Jamal M, Khan N. Effect of mother-infant early skin-to-skin contact on breastfeeding status: A randomized controlled trial. Journal of the College of Physicians and Surgeons Pakistan 2011;21(10):601-5.
- Vaidya K, Sharma A, Dhungel S. Effect of early mother-baby close contact over the duration of exclusive breastfeeding. Nepal Medical College Journal: NMCJ 2005;7:138-40.
- Lindenberg CS, Artola RC, Jimenez V. The effect of early postpartum mother-infant contact and breastfeeding promotion on the incidence and continuation of breastfeeding. International Journal of Nursing Studies 1990;27:179-86.
- Mikiel-Kostyra K, Mazur J, Boltruszko I. Effect of early skin-to-skin contact after delivery on duration of breastfeeding: a prospective cohort study. Acta Paediatrica 2002;91(12):1301-6.
- Agency for Healthcare Research and Quality; U. S. Department of Health and Human Services. Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries. Publication No. 07-E007, April 2007.
- Zhou J, Shukla VV, John D, Chen C. Human milk feeding as a protective factor for retinopathy of prematurity: a meta-analysis. Pediatrics. 2015 Dec 1;136(6):e1576-86.
11.Nimbalkar SM, Patel VK, Patel DV, Nimbalkar AS, Sethi A, Phatak A. Effect of early skin-to-skin contact following normal delivery on incidence of hypothermia in neonates more than 1800 g: randomized control trial. Journal of Perinatology 2014;34(5):364-8.
12.Gabriel MAM, Martin IL, Escobar AL, Villalba EF, Blanco IR, Pol PT. Randomized controlled trial of early skin-to-skin contact: effects on the mother and the newborn. Acta Paediatrica2010;99(11):1630-4.
- Srivastava S, Gupta A, Bhatnagar A, Dutta S. Effect of very early skin to skin contact on success at breastfeeding and preventing early hypothermia in neonates. Indian Journal of Public Health 2014;58(1):22-6.
14.Christensson K, Bhat GJ, Amadi BC. Randomised study of skin-to-skin versus incubator care for rewarming low-risk hypothermic neonates. Lancet 1998;352:1115.
15.Ibe OE, Austin T, Sullivan K, Fabanwo O, Disu E, Costello AM. A comparison of kangaroo mother care and conventional incubator care for thermal regulation of infants <2000g in Nigeria using continuous ambulatory temperature monitoring. Annals of Tropical Pediatrics 2004;24:245-51.
16.Bigelow A, Littlejohn M, Bergman N, McDonald C. The relation between early mother-infant skin-to-skin contact and later maternal sensitivity in South African mothers of low birth weight infants. Infant Mental Health Journal 2010;31(3):358-77.
17.Bystrova K, Ivanova V, Edhborg M, Matthiesen AS, Ransjo-Arvidson AB, Mukhamedrakhimov R, et al. Early contact versus separation: effects on mother-infant interaction one year later. Birth2009;36(2):97-109.
18.Dumas L, Lepage M, Bystrova K, Matthiesen AS, Welles-Nystrom B, Widstrom AM. Influence of skin-to-skin contact and rooming-in on early mother-infant interaction: a randomized controlled trial. Clinical Nursing Research 2013;22(3):310-36.
19.Carfoot S, Williamson P, Dickson R. A randomised controlled trial in the north of England examining the effects of skin-to-skin care on breast feeding. Midwifery2005;21(1):71-9.
20.Feldman R, Weller A, Sirota L, Eidelman AI. Testing a family intervention hypothesis: the contribution of mother-infant skin-to-skin contact (kangaroo care) to family interaction, proximity, and touch. Journal of Family Psychology 2003;17(1):94-107.
21.Ferber SG, Makhoul IR. The effect of skin-to-skin contact (kangaroo care) shortly after birth on the neurobehavioral responses of the term newborn: a randomized, controlled trial. Pediatrics2004;113(4):858-65.
22.Ohgi S, Fukuda M, Moriuchi H, Kusumoto T, Akiyama T, Nugent JK, et al. Comparison of kangaroo care and standard care: behavioral organization, development, and temperament in healthy, low-birth-weight infants through 1 year. Journal of Perinatology 2002;22(5):374-9.
- Sosa R, Kennell, JH, Klaus M, Urrutia JJ. The effect of early mother-infant contact on breastfeeding, infection and growth. In: Elliott K, Fitzsimons DW editor(s). Breastfeeding and the Mother: Ciba Foundation Symposium. Vol. 45, New York: Elsevier Excerpta Medica, 1976:179-93.
- Filho FL, de Sousa SH, Freitas IJ, Lamy ZC, Simoes VM, da Silva AA, et al. Effect of maternal skin-to-skin contact on decolonization of Methicillin-Oxacillin-Resistant Staphylococcus in neonatal intensive care units: a randomized controlled trial. BMC Pregnancy and Childbirth 2015;15(1):63.
- Ferber SG, Makhoul IR. Neurobehavioural assessment of skin-to-skin effects on reaction to pain in preterm infants: a randomized, controlled within-subject trial. Acta Paediatrica 2008;97(2):171-6.
- Nimbalkar SM, Chaudhary NS, Gadhavi KV, Phatak A. Kangaroo mother care in reducing pain in preterm neonates on heel prick. The Indian Journal of Pediatrics. 2013 Jan 1;80(1):6-10.
27.Gathwala G, Singh B, Singh J. Effect of Kangaroo Mother Care on physical growth, breastfeeding and its acceptability. Tropical Doctor 2010;40(4):199-202.
28.Ludington-Hoe SM, Anderson GC, Swinth JY, Thompson C, Hadeed AJ. Randomized controlled trial of kangaroo care: cardiorespiratory and thermal effects on healthy preterm infants. Neonatal Network – Journal of Neonatal Nursing 2004;23(3):39-48.
- Morelius E, Ortenstrand A, Theodorsson E, Frostell A. A randomised trial of continuous skin-to-skin contact after preterm birth and the effects on salivary cortisol, parental stress, depression, and breastfeeding. Early Human Development 2015;91(1):63-70.
- Ahmed S, Mitra SN, Chowdhury AM, Camacho LL, Winikoff B, Sloan NL. Community Kangaroo Mother Care: implementation and potential for neonatal survival and health in very low-income settings. Journal of Perinatology 2011;31(5):361-7.
31.Conde-Agudelo A, Díaz-Rossello JL, Belizan JM. Kangaroo mother care to reduce morbidity and mortality in low birthweight infants. Cochrane Database Syst Rev. 2003 Jun 1;2(2):CD002771.
32.Dordevic G, Jovanovic B, Dordevic M. An early contact with the baby – benefit for the mother. Medicina Preglio 2008;61(11- 12):576-9.
33.Figueiredo B, Canário C, Field T. Breastfeeding is negatively affected by prenatal depression and reduces postpartum depression. Psychological medicine. 2014 Apr;44(5):927-36.
34.World Health Organization. Kangaroo mother care: a practical guide. Department of Reproductive Health and Research, WHO, Geneva.2003
35.Website of KMC India network. Guidelines for parents and health providers, as assessed at www.kmcindia.org on 2017-06-26.
36.Udani RH, Nanavati RN. Training manual on Kangaroo mother care. Published by the Department of Neonatology. KEM Hospital and Seth GS Medical College (Mumbai). September 2004.