Full Term Article 2-10-2012

A Comprehensive Evidence-Based Review of Skin-to-Skin (Kangaroo) Care with Fullterm Infants

 

 

 

Susan M. Ludington-Hoe, R.N., CNM, Ph.D., FAAN

 

Barbara Morrison, R.N., CNM, FNP, Ph.D.

 

Gene Cranston Anderson, R.N., Ph.D., FAAN

 

 

 

This report has been supported in part by NIH-NINR 5RO1 NR04926 and NIH-NINR RO3 NR08587 to the first author and a Case Western Reserve University Frances Payne Bolton School of Nursing Research Incentive Grant to the second author.

 

 

Abstract

 

Kangaroo Care (KC), skin-to-skin chest-to-chest contact between an infant and his/her parent, has been shown to be beneficial for preterm and fullterm infants.  The infant and mother must have full skin-to-skin contact, without any clothing or materials being present in the ventral are (no bras are allowed!) because fabric in the ventral area will impeded all brain-mediated responses to KC (Kress, Minati, Ferraro, & Critchley, 2011).  Evidence regarding KC’s effects (physiological, psychosocial, behavioral, and breastfeeding outcomes) on fullterm infants and their mothers and fathers was reviewed according to KC nomenclature that characterizes KC by its “starting” time.  This comprehensive review covers 39 years of research and includes all types of studies, from qualitative through meta-analysis.  Based on the evidence presented, anticipated outcomes and recommendations for practice conclude the review.

 

 

Introduction

The new Maternity Care Practices in Infant Nutrition and Care (mPINC) criteria published by the Centers for Disease (CDC) Control and Prevention in the United States describe skin-to-skin contact (SSC) as a supportive hospital practice and mandate beginning SSC with the mother immediately after birth to improve breastfeeding outcomes (Centers for Disease Control and Prevention, 2009a, 2009b). Thus health professionals are eager to learn more about the evidence supporting the use of SSC.  Another name for SSC is Kangaroo Care (KC), defined as skin-to-skin, chest-to-chest contact between infants and their mothers and fathers. The use of KC with preterm infants has become common because its safety and benefits for these infants and their parents have been established through meta-analyses (Conde-Agudelo, Diaz-Rosello, & Belizan, 2000, 2003, 2007; Ludington-Hoe & Dorsey, 1998; Mori, Khanna, Pledge, & Nakayama, 2010).

Extension of KC to the care of fullterm neonates has begun (Anderson, Dombrowski, & Swinth, 2001; Anderson, Moore, Hepworth, & Bergman, 2003; Cash & O’Quinn, 1996), but is not so widely practiced because KC by this name is predominantly known as an intervention for infants born prematurely and/or undergoing intensive care. Two classic publications, Kangaroo Mother Care: A Practical Guide (Department of Reproductive Health and Research of the World Health Organization [WHO], 2003) and Kangaroo Care: The Best You Can Do For Your Premature Infant (Ludington-Hoe & Golant, 1993) illustrate this point because their focus is on KC with premature and low birth weight infants.

Evidence with fullterm infants is rich and dates from the early 1970s when KC was called “extra contact” and was used as an intervention to enhance maternal-infant bonding and breastfeeding.  More recent investigations reinforce earlier bonding and breastfeeding advantages, and augment the data base with more recently discovered physiologic benefits of KC for fullterm infants Utilization of KC depends upon the health professional’s awareness of documented outcomes attributable to KC.   In 1997, health professionals were advised “to learn the basics of Kangaroo Care” (Richardson, 1997, p. 51) and implement KC with healthy fullterm infants.  Thus, the purpose of this manuscript is to review the nomenclature used in the literature and summarize the state of the science of KC with healthy fullterm infants beginning at birth and continuing through the first year of life.  Recommendations for maternal-newborn practice of KC conclude the

Research reporting results of KC with fullterm infants were identified from a literature search of Medline, Pubmed, CINAHL, EBSCOT, OVID, ERIC, PsychInfo, SCOPUS, Google Scholar, and the International Network of Kangaroo Mother Care Bibliography developed and maintained by one of the authors (SL-H), reference lists in published articles and manuscripts, and from personal contact with researchers and clinicians in the field.  Years searched were 1970 (appearance of first publication of skin-to-skin extra contact) to July 2010. Search words were skin contact, skin-to-skin contact, skin-to-skin care, kangaroo care, kangaroo mother care, K-care, fullterm infants, newborns, touch, extra contact, and mother-infant contact.  Articles that specified fullterm infants and skin-to-skin placement with their mothers or fathers or others after birth were included.  A total of 947 manuscripts about skin-to-skin parent-infant contact (Kangaroo Care/Kangaroo Mother Care/Skin-to-Skin Contact or Care) were identified by February 10, 2012, of which 302 pertained to fullterm infants.  Review of the manuscripts was conducted independently by the authors to distinguish clinical reports, reviews, and guideline manuscripts from systematic research studies.All manuscripts are reported here and studies have been classified as to their type of research design.

Review of the Literature

Kangaroo Care Nomenclature

Generic to a discussion of KC studies is an understanding of the nomenclature used to describe when KC begins post-birth. In 1985 three nurses visited Bogota, Colombia, in part to investigate how soon KC began (Anderson, Marks, & Wahlberg, 1986). In 1988, funded primarily by UNICEF, Anderson visited 11 cities in Europe to learn more about KC research and implementation. After witnessing KC being practiced in many settings and beginning at various times throughout the postpartum period (Anderson 1989), she developed four temporal categories based on the timing of initiation of KC for preterm infants (Anderson, 1991); later she added a fifth category “Birth” (Anderson, 1995).  These temporal categories are important because the reasons for implementing KC and the physiological, psychosocial, behavioral, and breastfeeding benefits and outcomes vary with the age of the infant upon initiation of KC.  The same five categories, with some modifications in their descriptors, were soon being used to describe the experiences of fullterm infants (e.g., Anderson, et al., 2003; Walters, Boggs, Ludington-Hoe, Price, & Morrison, 2007). The categories related to fullterm infants are as follows:

Birth KC (BKC) begins by placing the newborn infant on the recumbent mother’s abdomen or chest immediately (within one to two minutes) after birth.  Birth KC is also known as “immediate KC” or “immediate skin-to-skin contact” (Lutter & Chaparro, 2009). The recumbent mother has the infant placed prone on a warm blanket on her belly.  The blanket is used to dry the infant and is then discarded so the infant can then be maintained in skin-to-skin contact. If the mother gives birth in the squatting position, she picks her infant up and holds him/her on her chest as she relaxes back in the bed and as the infant is dried.   With Birth KC, pharyngeal suction (a practice that has no evidence base and is not considered necessary [Widstrom, et al., 1987), drying, and APGARs can be completed while the infant lies quietly on the mother’s abdomen or chest immediately after birth (Ludington-Hoe, et al., 1999; Walters, et al., 2007; Righard, 2008).  In fact, the American College of Obstetricians and Gynecologists’ recommendations that were approved in 2006 state:

“The immediate postpartum period should allow the woman and her newborn to experience optimal bonding with immediate physical contact, preferably skin-to-skin. The initial feeding should occur as soon after birth as possible, preferably in the first hour when the baby is awake, alert, and ready to suck. Newborn eye prophylaxis, weighing, measuring, and other such examinations can be done after the feeding.  Such procedures usually can be performed later in the woman’s room” (American College of Obstetricians & Gynecologists, 2006, p. 279). Similar guidelines have been issued by the American Academy of Pediatrics (2005), the American Academy of Family Physicians (2001), the Academy of Breastfeeding Medicine (ABM, 2002, 2008), the Pan American Health Organization (Chaparro & Lutter, 2007; Lutter & Chaparro, 2009), the World Health Organization (Puig & Sguassero, 2007), and the Baby Friendly initiative (UNICEF & WHO, 2006; WHO, UNICEF, & Wellstart, 2009).  Most recently, the Joint Commission issued new perinatal core measures, one of which is “exclusive breast milk feeding during the newborn’s entire hospitalization” (Joint Commission, 2009), and this measure is greatly facilitated with immediate KC (Lutter & Chaparro, 2007).

Very Early KC (VEKC) has meant that the infant is returned to the mother 10-30 minutes post-birth after being under a radiant warmer or resuscitation unit.  In the past (Anderson, 1991), Very Early KC began after the pharynx had been suctioned, skin and head had been dried, and APGARS had been completed on a warming unit.  Given the new recommendations that all newborn care be delayed until the end of the first feeding and until the end of skin-to-skin contact, the term Very Early KC now means that KC begins sometime between 3-30 minutes following birth when the infant is first given to the mother.

Early KC (EKC) is defined as KC beginning 30 minutes-24 hours post-birth.  Early KC is commonly used with infants who need some medical intervention or close observation to achieve and assure stabilization.  KC can then begin as soon as the infant is stable or is stabilizing, because KC has been reported to facilitate stabilization (Cattaneo, Davanzo, Uxa, & Tamburlini, 1998; Puig & Sguaserro, 2007; SAREC, 1985; Schrod & Walter, 2002). This has been documented for preterm infants in a randomized trial of KC beginning by 5 minutes post-birth and continuing for the next 6 hours (Bergman, Linley, & Fawcus, 2004). These infants were by definition unstable and weighed between 1200 and 2199 g at birth. “Newborn care provided by KC on the mother’s chest results in better physiological outcomes and stability than the same care provided in closed servo-controlled incubators. Cardiorespiratory instability seen in separated infants in the first six hours is consistent with mammalian “protest-despair” biology, and with  “hyperarousal & dissociation” response patterns described in human infants.  Newborns should not be separated from their mothers” (Bergman, et al., 2004, pp.779; Bergman, Carney, & Ludington-Hoe, 2010).  Cardiorespiratory stability is expected during KC because oxytocin secretion occurs during KC in the infant, and oxytocin increases glucose uptake of muscle cells, especially the heart muscle cells, so that the muscle functions optimally (Florian, Jankowski, & Gutkowska, 2010; Uvnas-Moberg, Arn, & Magnusson, 2005).

Intermediate KC (IKC) for fullterm infants begins after the first day post-birth and continues until discharge from the hospital.  Because discharge times change with insurance practices and the availability of community-based follow-up, intermediate KC is KC from 24-96 hours post-birth for this review.

Late KC (LKC) begins after the infant and mother have been discharged home from the birth hospitalization.

The majority of investigations have evaluated Birth KC and Very Early KC.  When KC begins within five minutes of birth even better outcomes occur than when KC begins later (Bramson et al., 2010; Takahashi, Tamakoshi, Matsushima, & Kawabe, 2011).  Outcomes of all found studies on KC with fullterm infants are reported below.

Birth Kangaroo Care (begins immediately after birth, infant remains with mother).

Bonding. From the early 1970s through the early 1980s, skin-to-skin contact between mother and infant was being used and tested to enhance bonding during the “sensitive period” of the first two hours after birth.  In these early studies, KC was called “close contact”, “extended contact”, “extra contact”, and “skin-to-skin contact”.  Carlsson et al. completed five analyses from the same randomized controlled trial comparing 42 mothers who gave KC for 60 minutes after birth to 20 mothers who held their infants for five minutes after birth (Carlsson et al., 1978; 1979; Carlsson, Larsson, & Schaller, 1980; Schaller, Carlsson, & Larsson, 1979).  Birth KC mothers showed more contact behaviors (rubbing, holding, touching, rocking, patting) and spent more time in contact with their infants during postpartum hospitalization (Carlsson et al., 1978; Carlsson, Larsson, & Schaller, 1980), and during feedings at 1 week post-birth (Schaller, Carlsson, & Larsson, 1979) than did mothers who held their infants for only five minutes.  No differences in contact time were seen between the groups at 6 weeks post-birth (Carlsson et al., 1979; Carlsson, Larsson & Schaller, 1980). Hwang (1981) reported the same results as Carlsson and colleagues.

            Anisfeld and Lipper (1983) conducted a quasi-experiment with 29 mothers who provided Birth KC for 45-60 minutes prior to transferring the infants to a nursery.  Control group infants were taken to a warmer immediately after delivery and then were briefly shown to the mother before going to the nursery.  Mothers and infants were reunited every 3-4 hours for feeds, which were mostly bottle feeds.  A feeding at 48 hours post-birth was observed for contact behaviors.  Birth KC mothers had higher affectionate contact scores, smiled and vocalized more, kissed more, inspected more, and attempted to elicit responses more than control group mothers.  More Birth KC mothers appeared for follow-up appointments than control mothers, and Birth KC infants fretted and cried less and for shorter periods than control infants (Anisfeld & Lipper, 1983).  Mothers who provide Birth KC have reported an intense need to gaze at the infant and an instinctual drive to touch and hold the infant on the maternal chest (Finigan & Davies, 2004). Positive maternal behaviors were also observed by Odent (1989) who gave 70 infants Birth KC after home birth.  New Zealand midwives use Birth KC to support parent-infant discovery in the third stage of labor (Begley, Gilliland, Dixon, Reilly, & Keegan, 2011).

Breastfeeding.  The result of many Birth KC studies was that KC became a routine treatment for fullterm infants in Scandinavia (Widstrom et al., 1987; Widstrom et al., 1990), Russia (Bystrova, et al., 2003;  Bystrova, Matthiesen, et al., 2007; Bystrova, Widstrom et al., 2007), and Poland (Mazur & Mikiel-Kostyra, 2000; Mikiel-Kostyra & Mazur, 1998). As KC became routine, investigations shifted focus so that observations were made on treatments that occurred simultaneously with KC.  An example is a randomized trial of experimental infants (Birth KC for the first 45 minutes post-birth and placed at the breast within 30 minutes of birth for early suckling) and control infants (Birth KC for the first 45 minutes post-birth and placed at the breast 2-12 hours post-birth for late suckling).   All infants in both groups who touched or licked the areola and nipple spent more time in their mothers’ rooms and their mothers talked with them more during breastfeeding compared to infants who had not caressed the breast. Also, maternal serum gastrin levels were lower (better metabolic adaptation) four days after birth in the KC mothers. No differences were found between the groups when compared on total number of breast feedings, milk yield, amount of supplementation, breast engorgement, and maternal mood at four days, and 2-, 4-, 6- and 10 months post-birth (Widstrom et al., 1990). Further, no differences in type of crying, neonatal reactivity, and time between birth and exposure to the breast were found between newborns exposed to epidural or not when all infants were given Birth KC (Gizzo et al., 2011)

The routine use of uninterrupted Birth KC has also permitted observation of spontaneous infant behaviors that precede feeding.  Widstrom et al. first reported that infants crawl to the mother’s breast (Widstrom, et al. 1987).  Righard and Alade (1990) completed a descriptive study of infants who received Birth KC on their mother’s abdomen for 20 minutes (n=34) or at least 60 minutes (n=38).  Infants who remained in Birth KC for the first postpartum hour began spontaneously crawling to the breast at 20 minutes post-birth, began rooting, and were suckling at the breast around 50 minutes post-birth.  Instinctual movement toward the breast during Birth KC was facilitated by the presence of familiar amniotic-like scent present on the unwashed breast after being produced by areolar tissue (Varendi, Porter & Winberg, 1996).  Uninterrupted Birth KC for the first hour also resulted in more infants having correct sucking technique (Righard & Alade, 1990).   Even as little as 15 minutes of Birth KC resulted in KC infants demonstrating more feeding behaviors and breastfeeding longer (98 days) than infants who did not have Birth KC (36 days) (Wimmer-Puchinger & Nagel, 1982).  About twenty years later, video studies showed more hand, finger, mouth, and tongue movements in Birth KC than in non-Birth KC infants (Matthiesen, Ransjo-Arvidson, Nissen, & Uvnas-Moberg, 2001; Ransjo-Arvidson, et al., 2001).  Fullterm infants who were not exposed to maternal analgesia and who experienced Birth KC had very coordinated patterns of preparing the breast – by using their hands to explore and stimulate the breast prior to the feed.  The first lick occurred at 27 minutes post-birth; the first sucking occurred at 52 minutes post-birth. All hand movements stopped during sucking.  Sucking increased maternal oxytocin levels as did infant hand movements over the breast (Matthiesen et al., 2001).  Infants who received 64 minutes of Birth KC demonstrated more mouthing and feeding movements at one and four days post-birth, and breastfed two months longer than infants who had not been given Birth KC (Mizuno, Mizuno, Shonohara  & Noda, 2004).  A recent implementation study of Birth KC revealed that all but one infant spontaneously crawled to the breast and latched on, and all infants had excellent breastfeeding effectiveness scores for the first feeding in the KC position (Walters et al., 2007).  Thus, use of Birth KC is recommended to allow infants to express an innate sequence of nine pre-feeding and self-regulation behaviors.  The nine behaviors are:

1)  Birth cry (intense crying just after birth),

2)  Relaxation (infant resting/recovering, no activity of mouth, head, arms, legs or body),

3)  Awakening (begins to show signs of activity, small thrust of head up, down, side-to-side.

Small movements of limbs and shoulders),

4)  Activity (moves limb, head, is more determined in movements, rooting, pushing with

limbs without shifting body),

5)  Crawling (‘pushing’ that results in shifting body),

6)  Resting (infant rests with some activity, such as mouth activity, sucks on hand),

7)  Familiarization (infant has reached areola/nipple with mouth positioned to brush and lick

areola/nipple),

8)  Suckling (Nipple in mouth and  sucks),

9)  Sleeping (Baby closes his eyes) (Widstrom et al., 2011).

These nine behaviors are joined by innate ‘soliciting vocalizations’ (short ringing sounds) by infants about 15 minutes after birth (Velandia,  Matthiesen, Uvnas-Moberg, & Nissen (2010).    Soliciting vocalizations occur after the infant hears the parents’ voices which activate the speech motor areas of the newborn’s brain (Gentilucci & Dalla Volta, 2008) and the mirror neurons for imitating maternal sounds (Lepage & Theoret, 2007).  Some of these behaviors start immediately after birth, but others may not be manifested until 30 or more minutes post-birth (Rowe-Murray & Fisher, 2003).  Infants should be left in Birth KC for at least 90-120 minutes to allow full physiologic stability benefits of the breast crawl (Henderson, 2011) and full expression of all innate behaviors so optimal self-regulation by the infant occurs (Widstrom et al., 2011). Optimal self-regulation counteracts birth stress, extensive crying, and sustained peripheral vasoconstriction.

Spontaneous movements toward the breast and the prefeeding behaviors are less likely to be seen in infants during Birth KC who have been exposed to maternal medication.  Infants who had been exposed to pudendal block or more than one type of analgesia had less frequent hand and finger movements, and less touching, licking, and sucking of the nipple, and none sucked in the first two hours after birth compared to infants who had not been exposed to labor analgesia.  Analgesic-exposed infants also had higher temperatures and cried more than infants who were not exposed to maternal analgesia (Ransjo-Arvidson, et al., 2001).

Physiology. Seventeen infants who received KC at birth and day and night thereafter for the first three days of life, demonstrated more physiologic stability, no greater birth weight loss, and the same rate of birth weight recovery as 30 infants kept in cots by the mother’s bedside (Bouloumie, 2008).  Thirty-three percent of the Birth KC infants did not lose any birth weight at all, while those who had restricted KC regularly lost birth weight (Odent, 1989).  Thus, birth weight loss may not be a physiologic necessity, and sustained KC in the familiar home environment may be one way to achieve retention of birth weight.  Sustained KC has been credited with supporting elimination of all signs of transient respiratory distress in a fullterm infant who started KC at birth (Trotter, 2005).  While continuing KC the infant developed breathing difficulty about 24 hours post-birth.  Kangaroo Care was then continued with the consent of the physician and respiratory distress disappeared by 36 hours of age (Trotter, 2005).

Birth KC’s physiologic effects are being studied too, because VEKC’s effects on cardiorespiratory status are so profound (see discussion below).  A comparison of KC starting  time (less than five minutes versus more than five minutes post-birth) and duration (≤ 60 minutes versus > 60 minutes of KC in the first two hours post-birth) revealed that heart rate stability occurred significantly sooner in infants who started KC within five minutes of birth (Takahashi et al., 2011).  The infants who received KC for more than 60 minutes had lower cortisol levels at two hours post-birth than infants who received less KC, regardless of KC starting time.  Takahashi and associates concluded that starting KC earlier and continuing KC longer benefitted cardiorespiratory stability and reduction of stress post-birth.

Birth Kangaroo Care Summary. In summary, the effects of Birth KC on maternal-infant interactions and expression of spontaneous infant behaviors have been studied. Mother-infant dyads who received Birth KC showed more affectionate contact behaviors than dyads who did not received Birth KC.  Birth KC infants had more mouthing movements, went to the breast spontaneously if the mother had not received analgesia or anesthesia during labor, and spent more time with their mothers than infants who did not receive Birth KC.  In fact, placement of the infant on the mother’s abdomen right after birth has been identified by mothers as an advantage to breastfeeding that occurs in Baby Friendly Hospitals (Abolyan, 2006).  Further, the 383 mothers interviewed by Abolyan (2006) reported that “having less than 30 minutes of Birth KC was too short to support (their) breastfeeding plans” (p.71).  Though labor and delivery nurses generally know that KC immediately after birth is important, few understand the significance of “continuous uninterrupted” KC to facilitate correct attachment and effective sucking (Cantrill, Creedy, & Cooke, 2004).  Nurses’ understanding was measured by a valid and reliable KC Knowledge and Practices questionnaire (Creedy, Cantrill, & Cooke, 2008).   In conclusion, Birth KC has been associated with predominantly positive outcomes when accompanied by routine assessment of infant adaptation and is recommended because of its “kind” nature and benefits (Bouloumie, 2008; Chalmers, 2009; Klaus, 2009) and its ability to support a hormone-enhancing postnatal environment conducive to breastfeeding (Colson, 2008).

Very Early KC –KC begins 10-30 minutes post-birth when infant returned to mother

Studies of Very Early Kangaroo Care (VEKC) also began in the mid 70s and can be categorized into four outcomes:  attachment, breastfeeding,  maternal physiology, and infant physiology and behavior.

Attachment and Maternal-Infant Interaction Outcomes.  Very Early KC studies also investigated attachment outcomes.  Twenty mothers in the “early contact” group were given their infants for VEKC during episiotomy repair and were then taken to a private room where VEKC continued under a heat panel for 45 minutes (Hales et al., 1975; Hales, Kennell, & Sosa, 1976; Hales, Lozoff, Sosa, & Kennell, 1977).  “Delayed contact” mothers began Early KC at 12 hours post-delivery. “Control” mothers glanced at their infants before infants were taken to the nursery for 12 hours, returning to their mothers all wrapped-up. All infants stayed with their mothers from 9-5 each day and were breastfed throughout the two-day hospital stay. Maternal behavior during breastfeeding, observed at 36 hours post-birth, was more affectionate in VEKC than control mothers.  Early KC mothers (late contact) had an intermediate amount of affection behavior; the earlier KC occurred, the more behaviors were demonstrated.

De Chateau and Wiberg (1977a) conducted a longitudinal randomized trial of VEKC, assigning mothers to one of two groups:  the VEKC group consisted of 22 primiparas who received their infants for VEKC after the infants had been under a warmer for the first 6-10 minutes post-birth.  Five minutes later infants were moved to the breast and stayed there 10-15 minutes.  Afterwards, routine care was continued.  The control group mothers (20 primiparas and 20 multiparas) received routine care:  swaddled infants were kept at the mothers’ bedside for the first two hours post-birth, and then put in the observation nursery, except during feedings which occurred every four hours.  At 36 hours post-birth the primiparous VEKC mothers held their infants longer and more of their behaviors were similar to the multiparous mothers in the control group than to the primiparous mothers.  VEKC infants cried less frequently than controls. At three months of age VEKC mothers spent more time kissing and looking en-face than controls and VEKC infants smiled more often and cried less frequently. A greater proportion of VEKC infants were breastfeeding at three months. The influence of extra skin contact was more pronounced in boy-mother dyads than girl-mother dyads (de Chateau & Wiberg, 1977b).  At one year post-birth, VEKC mothers held and touched their infants more frequently, and more often spoke positively to their infants than control mothers (de Chateau & Wiberg, 1984).  Fewer VEKC mothers returned to work.  VEKC infants were ahead of control infants in social, linguistic, and fine and gross motor development at one year (de Chateau & Wiberg, 1984) and had earlier day continence and stubbornness –findings that were more pronounced in male than female infants by three years of age (Wiberg, Humble, & de Chateau, 1989).   Twenty-five years after de Chateau and Wiberg began their studies, Bystrova and colleagues (2003) began a similar longitudinal  randomized controlled trial. At one year post-birth infants who had VEKC from 25 to 120 minutes post-birth had better self-regulation, dyadic mutuality, and reciprocity (signs of interaction), and less irritability than infants who were dressed or swaddled or separated from the mother at birth (Bystrova et al., 2009).  VEKC mothers showed greater interaction, interest in the infant, and reciprocity than other mothers (Bystrova et al., 2009).  The determinant of increased affectionate behaviors in both studies and better interaction was KC contact.  The increase in affectionate behaviors in humans is similar to findings in other mammals in which affectionate behaviors are a function of oxytocin release that occurs in response to maternal-infant contact (Cozolino, 2006;  Feldman, Gordon, & Zagoory-Sharon, 2011; Uvnas-Moberg, 2003; Uvnas-Moberg et al.,2005

In contrast, no differences in maternal attachment behaviors or in maternal perceptions of the infant at 36 hours, 48 hours, and 1-and 3-months after VEKC have been reported (Craig, Tyson, Samson, & Lasky, 1982; Curry, 1979, 1982; Gewirtz, Hollenbeck, Sebris, & Manniello, 1989; Svejda, Campos, & Emde, 1980). In these studies, KC mothers gave 15-60 minutes of VEKC while control mothers received routine post-delivery care, briefly viewing, and either briefly holding or holding for up to 60 minutes the wrapped infant before being separated until the first feeding four-to-ten hours later.  No between group differences were found in maternal attachment behaviors or self-concept scores taken prenatally and at 3-months post-birth (Curry 1979, 1982), or maternal perception of infant difficultness (Craig et al., 1982).  Nonetheless, mothers report being very satisfied with VEKC (Carfoot,Williamson, & Dickson, 2005).

Breastfeeding.  Sosa and colleagues (Sosa, Kennell, Klaus, & Urrutia, 1976), in a randomized controlled trial (RCT), had mothers provide KC up against the nipple (a position now referred to as KC Breast Feeding [KCBF]) on the delivery table and for 45 minutes in the delivery recovery room once episiotomy repair was complete.  Control infants were separated immediately after delivery for the next 12-24 hours.  VEKC mothers breastfed nearly 50% longer and their infants had fewer infections at 6 and 12 months post-birth than control infants.  In a randomized trial of primiparous women (Thomson, Hartsock, & Larson, 1979), the mother was given her unwrapped infant at 15-30 minutes post-birth.  Breastfeeding was attempted during the 15-20 minutes of VEKC.  Control infants were placed in a heated crib for post-delivery care and then were wrapped and held briefly by mom (less than five minutes) before going to the observation nursery for the next 12 hours.  More VEKC than control mothers demonstrated happy reactions to the infant as they were leaving the delivery room, and more were exclusively breastfeeding successfully at two months post-birth.  “Skin-to-skin contact seemed to make an outwardly unresponsive mother more confident and happy.  Two women said ‘not now’ when asked if they would like to breastfeed, but after skin-to-skin contact each proceeded to put the baby to breast without further intervention and appeared excited as the infant nursed.  The infants seemed to ‘teach’ the mothers how to breastfeed” (Thomson et al., 1979, p. 1378).  Mothers who did not have happy reactions were solely in the control group and were not breastfeeding two months post-birth.  The presence of unhappy reactions was significantly related to breastfeeding failure (Thomson et al., 1979).

The early positive breastfeeding outcomes ascribed to VEKC have been supported by more recent reports.  When 533 infants were given VEKC for up to two hours (Mean = 49 minutes) (Gomez-Papi et al., 1998), 99% stayed awake during VEKC, and those who breastfed during VEKC stayed in VEKC longer than those who did not breastfeed.  Thus, 50 minutes or more of VEKC led to eight times the probability of spontaneous breastfeeding (Gomez-Papi et al., 1998).  Spontaneous breastfeeding occurs after fullterm infants spontaneously crawl to a breast (Righard & Alade,1990; Varendi, Porter, & Winberg, 1994; Widstrom et al., 1987), initiate pre-feeding behaviors that prepare the areola, nipple, and milk ducts for feeding (Ransjo-Arvidson et al., 2001; Widstrom et al., 2011), and spontaneously latch (Widstrom et al., 1987).  Some pre-feeding behaviors, especially rooting, mouth movements, and sucking occur when VEKC is given by the father (Erlandsson, Dsilna, Fagerberg, & Christensson., 2007).  In another randomized controlled trial, infants who received 1.5-3.0 hours of VEKC had more and earlier hunger cues, better breastfeeding effectiveness at the first breast feeding, and effective nippling in half the time of swaddled infants (Moore & Anderson, 2007).  In another clinical trial, more infants who received 45 minutes of VEKC than swaddled infants demonstrated effective first breastfeeding and were exclusively breastfeeding at 4 months post-birth. Though the number of VEKC infants was greater, this difference failed to meet significance (Carfoot, Williamson, & Dickson, 2004, 2005). Thus, VEKC promotes the breast crawl, pre-feeding behaviors, spontaneous latch, and first breastfeeding effectiveness, all signs of breastfeeding success (Carfoot, Williamson, & Dickson, 2003).

Breastfeeding initiation and duration are also enhanced by VEKC (Anderson, Moore, Hepworth, & Bergman, 2003) and mothers have recognized that VEKC helps initiate breastfeeding (Byaruhanga, Bergstrom, Tibemanya, Nakitto & Okong, 2008).   A trial with 375 primiparous women showed that 45 minutes of VEKC increased initiation of breastfeeding (Lindenberg, Cabrera-Artola, & Jimenez, 1990).  A randomized controlled trial of 137 mothers in Spain showed that more VEKC than non-VEKC mothers were exclusively breastfeeding at discharge (Marin et al., 2010).   In a survey of 427 Polish hospitals, data on factors related to breastfeeding initiation during hospitalization were collected for 11,750 newborns (Mikiel-Kostyra & Mazur, 1998).  Lack of skin-to-skin contact in the first two hours after birth was associated with artificial feeding:  the risk of artificial feeding was 60.9% in the absence of Birth KC or VEKC.   Kangaroo Care in the first two hours after birth was a strong predictor of breastfeeding initiation (Mikiel-Kostyra & Mazur, 1998) and was a strong predictor of breastfeeding duration for both fullterm and low-birth- weight infants (Mikiel-Kostyra & Mazur, 2000).  VEKC in the first two hours after birth did not predict exclusivity of breastfeeding by discharge (Mazur & Mikiel-Kostyra, 2000), but did when mothers were followed for three years (Mikiel-Kostyra, Mazur, & Boltruszko, 2002). Vaidya and colleagues’ findings were similar:  VEKC powerfully influenced exclusive breastfeeding for 4-6 months and was a more important contributor to exclusive breastfeeding than breastfeeding within two hours of birth (Vaidya, Sharma, & Dhungel. 2005).  A prospective study of 1250 newborns who either had less than 30 minutes or 30 – 120 minutes of VEKC were followed until three years of age (Mikiel-Kostyra, Boltruszko, Mazur, & Zielenska, 2001).  Even a very short duration of VEKC (less than 10 minutes) significantly increased the mean exclusive breastfeeding duration by 0.4 months and overall breastfeeding duration by 1.4 months.  Infants who had more than 30 minutes of VEKC exclusively breastfed 1.2 months longer and were weaned 1.7 months later than infants who had less than 30 minutes of VEKC. VEKC was a significant and independent predictor of exclusive breastfeeding continuation (Mikiel-Kostyra, et al., 2001).  Another three-year follow-up of the same infants showed slightly different findings when data were analyzed according to those who had at least 20 minutes of VEKC within the first two hours post-birth versus those who did not have any VEKC at that time.  VEKC infants exclusively breastfed for 1.35 months longer and were weaned 2.10 months later than infants with no VEKC (Mikiel-Kostyra, et al., 2002).  In 2005, VEKC was affirmed as contributing to exclusive breastfeeding and a lack of VEKC contributed to non-exclusive breastfeeding in 11,422 newborns (Mikiel-Kostyra, Mazur, & Wojdan-Godek, 2005).   A meta-analysis of 1,925 fullterm infants showed that infants who received VEKC were more likely to breastfeed and breastfed longer than infants who did not receive VEKC (Moore, Anderson, & Bergman, 2007).  In summary, even a short period of VEKC, i.e. 20 minutes, when given within 30 minutes of birth positively impacts exclusivity and duration of breastfeeding.  The results of Mikiel-Kostyra and colleagues’ alert us “to the importance of this early postpartum period. The events surrounding labor and delivery can have long-lasting effects on breastfeeding…” (McGrath & Kennell, 2002, p. 1288).

Whe                 When one reviews all the literature available rather than a few select reports, as recommended (Carfoot et al., 2003), compelling evidence shows that breastfeeding performance, exclusivity, and duration are determined in part by beginning KC within a half hour of birth (the sooner the better), having the infant remain in KC for at least 50 minutes, and feeding in the KC position (Mahmood,  Jamal, & Khan, 2011).  Uninterrupted and continuous KC from birth is a good predictor of breastfeeding success (Kroeger & Smith, 2004; Moore, et al., 2007; Simkiss, 1999). and a dose response study of 21,842 women in California showed that the longer the baby is with the mother in the first 2 hours post-birth, the more likely the infant is to be exclusively breastfed upon discharge two days later (Bramson et al., 2010).  Thus, the Baby Friendly Initiative updated the interpretation of Step 4 to now mean “Place babies in skin-to-skin contact with their mothers immediately following birth for at least an hour.  Encourage mothers to recognize when their babies are ready to breastfeed and offer help if needed.” (UNICEF/WHO, 2009, p. 3-36).  Even though the Baby Friendly Initiative recommends breastfeeding within 30 minutes of birth, many United States hospitals do not initiate breastfeeding even within one hour of birth.  Adopting Birth KC or VEKC and then breastfeeding as soon as the infant gives feeding cues will assist in attainment of Baby Friendly status and promote durable breastfeeding success (Centers for Disease Control and Prevention, 2011b).  A survey of physicians and nurses from 82 neonatal intensive care units across the United States revealed that the most prevalent supplemental stimulation practice was “skin-to-skin contact following birth in the delivery room” (Field, Hernandez-Reif, Feijo, & Freedman, 2006, p. 27), suggesting that incorporation of KC soon after birth may be more widely acknowledged now than before.  Yet, practice of VEKC is still far too limited, according to the Centers for Disease Control and Prevention survey of 2700 birth facilities in the United States in 2007 and 2009 (Centers for Disease Control and Prevention, 2007, 2011b).  Birth facilities were asked to report how often they encouraged mothers to hold their healthy full-term infants skin-to-skin for at least 30 minutes within an hour of birth, if routine newborn procedures (e.g. APGAR, cord clamping, foot printing) after uncomplicated vaginal birth were done while mothers held the healthy full-term infant skin-to-skin, and approximately how many mothers (regardless of feeding method) were encouraged to hold their healthy full-term infants skin- to-skin for at least 30 minutes within two hours after delivery for uncomplicated vaginal and cesarean births (Centers for Disease Control and Prevention, 2007). In 2009, the question about how many mothers were encouraged to hold their infants skin-to-skin was changed to “how many patients experience mother-infant skin to skin contact for at least 30 minutes within one hour of uncomplicated vaginal birth? (Centers for Disease Control and Prevention, 2011a).  Most facilities were not using VEKC to support breastfeeding in 2008 (Centers for Disease Control and Prevention, 2008) and now only 3.5% of all maternity hospitals in the US conform to this recommendation (Centers for Disease Control and Prevention, 2011b).  Each hospital’s mPINC score is available to the public and the lowest scores are from hospitals in Mississippi, West Virginia, Alabama, and Kentucky; highest scores (best performance of all mPINC recommendations) were in Oregon, Washington, California, and Vermont facilities (Centers for Disease Control and Prevention, 2011b).  Clearly, Birth KC and VEKC are now acknowledged practices that positively support breastfeeding, leading to the updated Baby Friendly guidelines of 2009 stating “STEP 4, Help mothers initiate breastfeeding within a half-hour of birth, is now interpreted as: Place babies in skin-to-skin contact with their mothers immediately following birth for at least an hour” (World Health Organization et al., 2009, pg. 34).  And even this guideline is not quite good enough because infants who remain in KC more than an hour are  more likely to breastfeed (Gomez-Papi et al., 1998), be exclusively breastfed (Bramson et al., 2010), and have better cardiorespiratory stability and less stress (Takahashi et al., 2011) than infants who have less than one hour of KC.  VEKC also increases maternal satisfaction and sense of breastfeeding success (Mahmood et al., 2011).

Maternal physiology.   Dordevic and colleagues (Dordevic, Jovanovic, & Dordevic, 2008) conducted a randomized controlled trial of 216 mothers who provided VEKC and breastfeeding within one hour of birth and 216 mothers who did not.  On postpartum Day 3 significantly fewer VEKC mothers than controls had poor involution and anemia (as measured by hemoglobin and erythrocyte count).  Very Early KC mothers also used fewer sanitary napkins and had a shorter postpartum stay.  Another randomized controlled trial of 137 mothers in VEKC and no-VEKC groups revealed that placental expulsion occurred significantly earlier in VEKC mothers than in those without VEKC (Marin Gabriel et al., 2010).  Additionally, VEKC has been reported by mothers (Byaruhanga, et al., 2008) and by physicians (Walters, et al., 2007) to distract mothers from episiotomy repair, reducing anesthetic needs, and maternal restlessness, and facilitating the repair process.  These episiotomy effects probably do exist even though another clinical trial found no difference in maternal perception of episiotomy pain between VEKC and no-VEKC mothers, probably due to different physicians doing the repairs of VEKC and no-VEKC mothers (Marin Gabriel et al., 2010).

Infant physiology and behavior.    In studies of VEKC effects on infant physiology and behavior, routine care was removal of the infant from the delivery area to a warming unit for foot printing, eye treatment, and measurements, followed by swaddling in multiple blankets and 5-10 minutes of holding by the mother.  After this brief holding, infants were taken to nurseries for the remainder of the recovery period.  Because the primary safety concern has been loss of body temperature, many investigators measured temperature to determine if KC was safe during the first hours post-birth.

Temperature (axillary, rectal, thigh, abdominal, back, or foot) during 10-15 minutes of VEKC was similar to that of control infants who were under radiant warmers (Vaughans, 1990), or in warming beds (Newport, 1984).  Temperature during 10-15 minutes of VEKC did not differ from temperature during two hours of VEKC (Gomez-Papi et al., 1998), or 4 hours of VEKC (Villalon & Alvarez, 1993; Villalon et al. 1992), or during 50 minutes of swaddled holding immediately post-birth (Curry, 1979, 1982).  Temperature during VEKC was higher than in swaddled holding at 60 minutes post-birth (Carfoot et al., 2005), and higher than in swaddled placement in a cot throughout the first 60 minutes (Bystrova et al., 2003; Chwo & Huang, 2002; Marin Gabriel et al., 2010), 75 minutes (Bystrova et al., 2003; Mazurek, et al., 1999), 90 minutes (Bystrova et al., 2003; Christensson, 1996; Christensson, Siles, et al., 1992), and 120 minutes (Bystrova et al., 2003; Durand et al., 1997) post-birth.  Temperature was higher even when VEKC was given by fathers to cesarean section infants (Christensson, 1996).  During VEKC body temperature dropped less than temperatures did under radiant warmers within the first 15 minutes post-birth (Gardner, 1979; Moore et al., 2009). For body temperature maintenance, VEKC was as effective as traditional mustard oil massage or swaddling in plastic (Johanson, Spencer, Rolfe, Jones, & Malla, 1992).  More VEKC infants than cot infants have temperatures that remain within the neutral thermal zone (Fardig, 1980) and better stabilization of temperature during KC has been established  for a long time (Britton, 1980).

Bystrova and associates’ (2003) randomized controlled trial of eight groups to compare VEKC with swaddling, rooming-in, being dressed in clothes, and combinations of these options, revealed that peripheral warming as measured by foot temperature occurred within 90 minutes of VEKC initiation, but took several days to occur in the other groups.  Further, stress related effects of birth on peripheral circulation in the newborn were reversed more swiftly with VEKC (Bystrova et al., 2003), leading others to conclude that “swaddling was more stressful and potentially harmful than allowing the infant to remain skin-to-skin with his mother” (Kennell & McGrath, 2003, p. 273).  Fullterm infants also warm up after a bath faster in KC than under warmers (Byaruhanga, Bergstrom, & Okong, 2005). Temperature studies clearly show that fullterm infants given VEKC have significantly higher temperatures and faster rises in temperature than infants who are swaddled or under radiant warmers – findings that have been confirmed by meta-analyses (Moore et al.,2007).

Other physiologic outcomes have also been studied.  Clinical trials of VEKC have yielded differing heart and respiratory rate effects.  No differences in heart and respiratory rates existed between VEKC and swaddled infants who remained in their cribs in some studies (Chwo & Huang, 2002; Newport, 1984, Villlalon et al., 1992), and in other studies heart and respiratory rates were more favorable in VEKC infants (Christensson et al., 1992; Mazurek et al., 1999).  Even paternal KC starting soon after cesarean delivery has been shown in a randomized controlled trial to improve infant breath volume and gaseous exchange (Erlandsson, Christensson, Dsilna, & Jonsson, 2008).

Across all studies, heart and respiratory rates remained within clinically acceptable ranges during VEKC.  Oxygen saturation levels also did not differ between VEKC and crib infants (Chwo & Huang, 2002), nor did blood gas levels differ between groups (Christensson, 1996).  Infants who had 90 minutes of VEKC had higher blood glucose levels than infants in cribs or incubators, even though the infants were not fed during those 90 minutes (Christensson et al., 1992), and even if they were held by their fathers (Christensson, 1996).  Mazurek and associates (1999) also found that blood glucose was higher in VEKC infants than in those who were swaddled and lying beside or away from their mothers. In Durand’s trial (Durand et al., 1997), all infants had normal blood glucose levels, but formula-fed infants increased their blood glucose by 3mg/dl after being fed 15 ml of D5W and 15 ml of formula.  VEKC infants, fed only breast milk, experienced a drop in blood glucose of 14 mg/dl (Durand et al., 1997).  Birth weight loss did not differ between VEKC and swaddled newborns in one clinical trial (possibly a randomized controlled trial) of VEKC (Newport, 1984) and in another, a randomized controlled trial, birth weight loss recovery was not delayed in VEKC infants but was delayed in dressed  or swaddled infants  (Bystrova, Matthiesen et al., 2007).  Newport (1984) also noted that no VEKC infant experienced diarrhea or ketonuria.

An additional direction in research with fullterm infants has been to evaluate the effectiveness of VEKC on infant state and neurobehavioral regulation.  The crying state has been extensively studied.  Crying is a generally accepted behavioral indicator of stress and is a modified Valsalva maneuver. As such, crying is especially harmful during the vulnerable early hours and days post-birth (Anderson, 1989; Ludington-Hoe, Cong, & Hashemi, 2001, 2002).  In a randomized controlled trial (N=224), fullterm infants who were separated from their mothers at 60 minutes post-birth cried twice as mulch between 60 minutes and 300 minutes (1 and 5 hours),compared to infantswho remained with their mothers.  The separated infants also had salivary cortisol levels that were twice as high at 5 hours (Anderson, Chang, Behnke, Conlon & Eyler, 1995).    Minimal crying occurs during VEKC (Christensson, Cabrera, Christensson, Uvnas-Moberg, & Winberg, 1995; Chwo & Huang, 2002).  Less frequent crying (Mazurek et al., 1999) and shorter durations of crying (Christensson et al., 1992; Mazurek et al., 1999) occurred in VEKC compared to swaddled infants, even with paternal VEKC (Erlandsson et al., 2007, 2008).  Michelsson and associates (Michelsson, Christensson, Rothganger & Winberg, 1996) found that infants in cribs cried 10 times more frequently than VEKC infants, a finding similar to that of Chwo & Huang (2002).  The cry of infants in a crib has all the characteristics of a separation distress cry, while the cry of VEKC infants does not (Christensson et al.,1995; Michelsson, et al., 1996).  In fact, after the initial birth cry, newborns in VEKC rarely cry at all (Widstrom, et al., 2011), as demonstrated by 19 out of 20 infants who received a hepatitis B vaccine while inVEKC  (Vivancos, Leite, Scochi, & dos Santos, 2010).   Meta-analyses of more than 30 trials have confirmed that infants receiving VEKC cry significantly less than infants not receiving VEKC (Moore et al., 2007).

In relation to neurobehavioral development, 25 full-term infants who received 60 minutes of VEKC (starting 15-20 minutes after delivery) were compared in a randomized trial to 25 infants who were kept in the observation nursery for two hours following birth.  At four hours post-birth, VEKC infants slept longer, had more quiet sleep than any other type of sleep, spent less time in fussy, crying, and alert states, and showed more flexor and fewer extensor movements. VEKC positively influenced state organization and motor system modulation shortly after delivery, leading the authors to conclude that

“KC seems to result in better central nervous system control by reduction in stress

experience for the infants, as reflected in the smoother and more flexed movements.

KC may act to facilitate the first phases of neurologic adaptation after birth to the

extra-uterine world.  KC may be particularly beneficial to the regulation of motor

activity in the newborn period” (Ferber & Makhoul, 2004, pg. 861).

Interacting with the mother is a form of neurobehavioral control, and a Cochrane meta-analysis concluded that infants who had received VEKC interacted more with their mothers than infants who had not received VEKC (Moore et al., 2007).

VEKC Summary.  To sum, because of the positive benefits of VEKC documented above, VEKC is routinely practice in Russia (Bystrova, Matthiesen et al., 2007), Sweden (Matthiesen et al., 2001; Widstrom et al., 1987), and Poland (Mazur & Mikiel-Kostyra, 2000; Mikiel-Kostyra & Mazur, 1998, 2000).  Routine use of VEKC in the United States has not yet been reported even though recommendations for its use exist (____, 2007; European Commission Directorate of Public Health, Karolinska Institutet, Institute for Child Health, & WHO Unit for Health Services Research and International Health,  2006; Davanzo, 2004;  Demott et al., 2006; Forster & McLachlan, 2007; Keister, Roberts, & Werner, 2008;  Kroeger & Smith, 2004; Mercer, Erickson-Owens, Graves, & Haley, 2007; Sinusas & Gagliardi, 2001; Trotter, 2005).  Use of VEKC is a “best practice” and the substantial evidence showing so many benefits would be burgeoning with even more and stronger benefits if KC actually had begun immediately after delivery rather than after being taken to warmers for routine care, being separated and manipulated before the dose of VEKC because “the  compulsory care dictated by tradition is harmful and disruptive to mother and infant ” (Romano, 2009, p. 53), meaning that the VEKC studies have actually been measuring maternal and infant adaptation to disruptive behaviors rather than the outcome of undisturbed and prolonged KC (Romano, 2009).

 Early KC – KC begins between 30 minutes-to-24 hours post-birth.

The early studies of skin-to-skin contact was structured similarly to the “extra contact” studies conducted by Klaus and colleagues in 1972 (Klaus et al., 1972).  In their quasi- experimental study 14 clothed mothers were given their nude infant to hold for one hour within the first 3 hours post-birth and then had five extra hours of contact each afternoon for the next three days.  Control mothers glimpsed their baby at birth, had brief contact 6-12 hours later, and then saw the infant for 20-30 minutes every four hours for bottle feeding.  Differences between control and extra contact mothers were readily apparent as extra contact mothers were more attentive, responded readily to crying, and spent more time fondling and “en face” with their infants one month later.  Studies that followed in which the mother gave Early KC produced similar outcomes.  Namely, the outcomes of Early KC studies confirm that Early KC mothers, even those who had a cesarean birth, show more attachment behaviors at 36 hours (McClellan & Cabianca, 1980), one month (McClellan & Cabianca, 1980; Kontos, 1978), and three months (Kontos, 1978) post-birth than mothers who did not experience Early KC (McClellan & Cabianca, 1980; Kontos, 1978).  A study of infants receiving Early KC over the first month of life (i.e. 5 hrs/day in week 1 and then 2 hrs/day for weeks 2, 3 and 4) showed that they responded to their mother’s still face (affectless and unanimated and not vocalizing to the infant) as early as 1 week age and responded with bids for their mother’s  attention at one month and  increased their non-distress vocalizations to their mother at three months.  Control infants lagged by a month or more in demonstrating the same behaviors (Bigelow & Power, 2012). Early KC accelerated infant’s social expectations for their mother’s behavior and enhanced their awareness of themselves as active participants in social interactions.

Most of the Early KC trials also support benefits to breastfeeding initiation and duration.  In a study of 119 fullterm newborns, more Early KC infants were breastfeeding at 24 hours, discharge, and 14 days post-birth than infants who spent the first four hours after birth in a nursery (Villalon & Alvarez, 1993). Maternal self-confidence about breastfeeding was also greater for the Early KC mothers (Villalon & Alvarez, 1993).   Taiwanese mothers who had rooming-in and started KC within four hours of birth and continued it (8 hours-per-day for three days) were closer to exclusive breastfeeding and breastfed longer (91.1 days vs. 24.8 days) than control mothers who did not have rooming in and Early KC.  Further, more Early KC mothers had less anxiety and less breast engorgement and were breastfeeding longer (at one year post-birth, than control mothers (Shiau, 1997). Bigelow’s (2012) randomized trial revealed that Early KC of 5 hours per day in the first week and 2 hours/day for the first month resulted in significantly more KC than control mothers continuing exclusive breastfeeding at1 week,  and at 2,  3, and 4 months; the number of KC mothers exclusively breastfeeding did not decline over 4 months whereas it significantly declined in the control group.  None of Bigelow’s mothers experienced Birth KC.  Even though mothers have identified Early KC as being a positive breastfeeding promotion strategy (Tofteland, 2006), one study of 50 primiparous mothers revealed that Early KC alone is not as effective as Early KC plus infant suckling.  The more KC in the first two hours after birth, the more likely the infant will be exclusively breastfed (Bramson et al., 2010).

The effect of Early KC on breastfeeding for mothers experiencing difficulty has also been examined.  Mothers whose infants had not started traveling to the breast by 30 minutes post-birth were put in a warm water bath with their newborns.  Serial photos showed infants journeying to the breast and spontaneously latching, leading the author to conclude that Early KC in a warm bath facilitated spontaneous breastfeeding (Harris, 1994).  In a case report one infant who had not breastfed successfully by 20 hours post-birth, spontaneously sought out and latched onto the nipple during 60 minutes of Early KC; two subsequent infants who were having difficulty received Early KC and also spontaneously latched (Meyer & Anderson, 1999) and were exclusively breastfeeding at discharge and one week later.  This phenomenon was then studied systematically in a pilot study of 50 mothers identified within 24 hours post-birth as experiencing breastfeeding difficulties; the intervention was a KC experience beginning when each of the next three breastfeeding times was anticipated and continuing through the feeding.  Findings were that these mothers had a high rate of breastfeeding success at discharge and at 1-and 4-weeks later.  The more frequently mothers provided KC thereafter on their own, the more successful they were (Anderson, Chiu, Morrison, Burkhammer, & Ludington-Hoe, 2004), even when a mother recalled previous pregnancy loss while Kangarooing (Burkhammer, Anderson, & Chiu, 2004).  A separate analysis revealed that mothers of any race/ethnicity in this sample were equally successful in their breast feedings (Chiu, Anderson, & Burkhammer, 2008).  For mothers who have been separated from their term infants, KC is considered the first step in encouraging the infants to suckle and latch-on (Clarke & Deutsch, 1997).

            Many physiological studies of Early KC were retrieved.  In a study of heat loss in newborns after birth, thermograms were taken three times: immediately after birth, after newborn care, and after a session of Early KC or radiant warmer care.  Immediately after birth the thermogram showed heat dissipation from the skin (a sign of heat loss).  Following newborn care (drying, AGPAR, and foot printing), arms and legs were cooler than the trunk.  After a session of Early KC within the first hour post-birth, the thermogram showed uniform warmth throughout the body. Uniform warmth was not seen in infants who had been under a radiant warmer (Christidis et al., 2003).  When Early KC began 4-8 hours post-birth, peripheral (foot) temperatures rose quickly) and abdominal skin temperatures increased, indicating a heat gain when infants were in Early KC compared to being in an open-air crib wearing a diaper, cotton vest and romper beneath a blanket (Fransson, Karlsson, & Nilsson, 2005).  Infants in Early KC had a 1.5° C difference between rectal and foot temperatures whereas infants in open-air cribs had a 7.5° C difference.  A difference of 7.0-8.0° C between body parts is a sign of heat loss (Fransson et al., 2005).  In fact, fullterm mothers generate heat quickly, causing their breast and axillary temperatures to rise 0.5°C or more within 2 minutes after KC began, and causing their skin to conduct heat to the infant during KC (Bergstrom, Okong, & Ransjo-Arvidson, 2007; Bystrova, Matthiesen, Vorontsov et al., 2007; Bystrova, Matthiesen, Widstrom et al., 2007; Karlsson, 1996), as originally found with preterm mothers (Ludington, 1990; Ludington-Hoe, Nguyen, Swinth, & Satyshur, 2000; Ludington-Hoe et al., 2004).  Conduction of maternal heat to the infant has also prevented hypothermia following the first infant bath (Bergstrom, Byaruhanga, & Okong, 2005;  Byaruhanga et al., 2005). Newborns bathed by their mothers and then held in KC stayed just as warm as newborns placed in a warmer after being bathed in the nursery (Medves & O’Brien, 2004), and maternal KC re-warmed infants three times faster than a radiant warmer (Bergstrom et al.,, 2005).

In another physiologic study, temperatures of 48 fullterm infants were assessed during simultaneous Early KC and breastfeedings. Temporal artery temperatures taken before, during and after three consecutive feedings remained within neutral thermal range, indicating that infants can safely breastfeed in KC without concern about temperature loss (Chiu, Anderson, & Burkhammer, 2005).  A randomized trial (RCT) of Early KC (78 mothers given their infants while still on the cesarean section table) versus radiant warmer for newly-delivered cesarean section infants showed that significantly more Early KC than radiant warmer infants had reached normal body temperature by four hours post-birth (Huang, Huang, Lin & Wu, 2006).  In another RCT prolonged uninterrupted KC (and other non-separation elements such as en face positioning of the infant immediately after birth, intraoperative cheek-to-cheek contact between mother and newborn, and having the newborn within eight feet of the mother) began in post-surgical recovery and was compared to a control group experiencing no KC.  The KC infants had better heart rate, respiratory rate and temperature stabilization and lower cortisol levels than control infants and KC mothers had less anxiety and more satisfaction with their care (Nolan & Lawrence, 2009).  In another RCT of Early KC with cesarean section mothers, mothers did or did not give 2 hours of Early KC beginning when they were in their postpartum rooms at a mean 51 minutes post-birth.  No infants in either group were at risk of hypothermia at all.  The Early KC infants latched sooner and more were breastfeeding at discharge, and maternal satisfaction with KC after cesarean section was better than in the no-Early KC group (Gouchon et al., 2010).  These last two studies provide new evidence that infants delivered by cesarean section will not become cold during KC, and that mothers can enjoy experiencing KC even if they have just had a cesarean section.  Additional information about KC during cesarean section birth is provided in a separate section.

A randomized controlled trial in Taiwan revealed that infants who received 8 hours of KC each of the first three days post-birth had less crying, less wakefulness, and more sleep than infants who received routine cot-based nursery care (Shiau, 1999).  Another randomized trial, this one with 640 term newborns, showed better and longer pain reduction with KC than with dextrose water, and that dextrose water combined with KC had greater analgesic effect than either KC or dextrose water alone for intramuscular injection of hepatitis B vaccine at 12-72 hours post-birth (Chermont, Falcao, de Souza Silva, de Cassia Xavier, & Guinsburg, 2009).   Chermont et al.’s finding have been clinically observed, too (Long, 2010), even when the hepatitis B vaccine was given 15 minutes post-birth (Vivancos et al. 2010).  Less crying, reduced pain, lower mean HR and higher SaO2 were found in a randomized controlled trial of 10 minutes of KC before an injection given to 100 newbornws (Kashaninia, Sajedi, Rahgozar, & Noghabi, 2008; Sajedi, Kashaninia, Rahgozar, & Noghabi, 2007). Thus, KC effects on state that are evident with VEKC also appear with later onset and/or later practice of KC.  Thus, randomized controlled trials have confirmed that Early KC effects are a decrease in crying, an increase in sleep, and a decrease in procedural pain in infants.

Early KC has also been practiced in home births in third world countries.  In rural India, 971 fullterm newborns who were given Early KC had no adverse events during Early KC and hypothermia was prevented.  Further, Early KC was well accepted because mothers believed KC protected the infants from evil spirits, as evidenced by the infants being calm and contented in KC (Darmstadt et al., 2006).  The practice of Early KC in India has saved infant lives (Darmstadt et al., 2005), prevented neonatal infections (Darmstadt, Black, & Santosham, 2000; Darmstadt et al., 2005), and has been cost-effective.  Early KC in homebirths has been readily and popularly accepted, and is practiced 24 hours per day in most of South America (Quasem et al., 2003) and is considered a program of excellence in primary health care of newborns (Bhutta, Darmstadt, Hasan  & Haws, 2005;  Torjesen & Olness, 2009).

Intermediate KC (KC beginning between 24 hrs post-birth and discharge)

Several studies of Intermediate KC were found.  In one study, back temperatures on the second day post-birth increased more during 30 minutes of Intermediate KC and simultaneous breastfeeding than temperatures in infants who breastfed without KC (Jonas, Wiklund, Nissen, Ransjo-Arvidson, & Uvnas-Moberg, 2007).  Jonas and colleagues’ temperature findings are similar to temperature changes seen during Birth KC.  In another study, nine healthy term neonates were given 70 minutes of Intermediate KC during which their backs and extremities were covered with a double layer of terry cloth toweling.   Infant skin and rectal temperatures, and maternal chest temperature were taken 10 and 70 minutes into Intermediate KC. Infant rectal temperatures increased by 0.7° C, going up to 37.0° C.  Heat was gained from areas in contact with the mother’s skin, reducing heat loss in infants during Intermediate KC and allowing heat to be conserved (Karlsson, 1996).  Karlsson concluded that mothers conduct heat to the infant and that no increase in oxygen consumption nor basal metabolic rate occurs during KC regardless of when KC begins.

A randomized trial of Intermediate KC examined the pain response of newborns to a heel stick that was performed either in KC or while the infant lay swaddled in a crib (Gray, Watt, & Blass, 2000).  Intermediate KC reduced crying by 82% and grimacing by 65% -infants in Intermediate KC cried on average 1 second and grimaced 2 seconds; control infants cried 23 seconds and grimaced 30 seconds.  No infant receiving Intermediate KC cried after the 30 seconds immediately following heel stick, whereas 11 of 15 control infants kept crying for the remaining 20 minutes of the recovery period. Pain was measured after 10-15 minutes of KC had passed so that mothers would be relaxed during the infant’s heel stick. Data collection terminated early for the 11 control infants because of excessive crying. Intermediate KC also prevented the rise in heart rate that normally accompanies heel lance and that was present in control infants.  In Gray and associates’ (Gray, Miller, Phillip, & Blass, 2002) follow-up study, Intermediate KC with breastfeeding was even more effective in significantly reducing crying and grimacing responses to heel stick pain.  Infants in Intermediate KC cried for 8.77 seconds and grimaced for 17.25 seconds, whereas control infants cried for 72.07 seconds and grimaced for 80.31 seconds. Sixty-six percent of Intermediate KC infants did not cry nor grimace at all during heel lance, and these effects extended well into the recovery phase.   When in KC, heart rate was less variable and rose less (only six beats per minute) than when not in KC (heart rates rose 29 beats per minute) (Gray et al., 2002).   Heart rate variability, a sign of sympathetic autonomic activity, or stress, rose 176% when 2 day old newborns slept in a cot beside the mother rather than in KC, indicating that sleeping away from mother is a very stressful event for newborns that is not seen when the infant sleeps in KC; sleeping away from mother also decreased quiet sleep by 86%  (Morgan, Horn, & Bergman, 2011).  These results were similar to those found in  the randomized controlled trial of Early KC (Kashaninia et al., 2008) reported earlier, and another randomized controlled trial of 68 infants receiving Hepatitis B vaccine (Kostandy & Anderson, 2003).   Heart rate response was more stable and less crying occurred when the Hepatitis B vaccine was given in KC rather than in a bassinet. The seventh study was a RCT of three groups receiving a heel stick at about 33 hours of age.  The three groups were Intermediate KC coupled with breastfeeding, KC without breastfeeding, and infant lying on a mattress with no pain intervention.  Heart rate and oxygen saturation changes and crying duration were less in both KC groups, and the KC without breastfeeding group had less grimacing than the group without interventions (Okan, Ozdil, Bulbul, Yapici, & Nuhoglu, 2010).  Reduced pain and less crying occurred in a case of clustered painful procedures (two heel sticks and injection) given during KC on the second day of life (Kostandy & Ludington-Hoe, in press).    The consistently positive reduction in pain response in fullterm infants has led to general agreement that KC is a safe and effective pain-reduction treatment (Harrison, Yamada & Stevens, 2010; Hunseler & Roth, 2008; Lago et al.,2009; Tsao, Evans, Meldrum, Altman & Zeltzer, 2008; Warnock, et al., 2010).  However, most practitioners still do not know that KC reduces pain (Mallet et al., 2007; Schultz,  Loughran-Fowlds & Spence,  2009), even though it has been recommended in the United States by the Academy of Breastfeeding Medicine (2010) and  in both the United States and Canada by the American Academy of Pediatrics  and Canadian Pediatric Society since 2006 (AAP & Canadian Pediatric Society, 2006).  Physiologic stability of all vital signs was present during ambulance and helicopter transport in Intermediate KC to- and – from neonatal special care units (Sontheimer, Fischer, & Buch, 2004), supporting earlier reports of improved cardiorespiratory stability during KC that have been reviewed above. Thus, Intermediate KC appears to foster physiologic stability and minimize pain during heel sticks and injections in healthy term infants.

Handlin et al. (2009) explored the effects of Intermediate KC and breastfeeding on patterns of release of maternal stress hormones (adrenocorticotrophic hormone [ACTH], and cortisol) during a breastfeeding session on postpartum Day 2.  Both hormone levels fell significantly during the breastfeeding session and both had a significant positive relationship to each other.  Further, ACTH was significantly and negatively related to amount of synthetic oxytocin that was administered to the mothers.  The length of KC contact before suckling began was significantly and negatively related to cortisol level, meaning that the more KC the lower the cortisol level.  KC did not have the same influence on maternal ACTH, suggesting that KC has selective effects on pituitary hormones. Length of suckling, on the other hand, was associated with a significant decrease in ACTH (Handlin et al., 2009).  Reduction in ACTH (a central nervous system marker of physiologic stress) during KC is due to the increased presence of oxytocin; oxytocin enables the muscle cells to increase their glucose uptake to maintain optimal functioning (especially in heart muscle cells) and to prevent metabolic stress (Florian et al., 2010; Uvnas-Moberg et al., 2005). Recently, Handlin et al. (2012) reported that Intermediate KC before breastfeeding was associated with lower maternal systolic blood pressure in mothers who did not have epidurals and who received oxytocin only by injection.  Infant stress, as measured by sympathetic and parasympathetic control over heart rate, was 176% higher when 2 day old cesarean birth infants were sleeping in a cot beside their mother’s postpartum bed as compared to sleeping in KC (Morgan et al., 2011).  Sleeping in the cot decreased quiet sleep duration by 86%, showing that separation had a profoundly negative impact on quiet sleep and greatly increased the level of stress exhibited by the autonomic nervous system (Morgan et al., 2011).   So, KC reduces central nervous system stress responses and also reduces stress responses generated by the skin.  The skin itself contacts all the elements of the hypothalamic-pituitary-adrenal axis.  The infant’s skin produces corticotrophin releasing hormone (CRH); CRH activates ACTH production,  ACTH and CRH then jointly lead to increases in cortisol and corticosterone (Narendran, Visscher, Abril, Hendrix, & Hoath, 2010).   The hair follicles of the newborn’s skin serve as an extra-adrenal site of cortisol synthesis; cortisol synthesis occurs when the peripheral skin senses stress, like a noxious touch.  Clearly, KC attenuates stress responses in infants (Feldman, Singer, & Zagoory, 2010) and in mothers (Handlin et al., 2009; Nissen, Gustavsson, Widstrom, & Uvnas-Moberg, K. (1998); Nolan & Lawrence, 2009; Uvnas-Moberg et al., 2005).

Late KC – KC begins after discharge from hospitalization for birth. 

Two Late KC studies tested the efficacy of KC in reducing colic. One was a case report of

Two infants with colic.  One infant cried a mean of 14 minutes over two weeks and the other

cried a mean of 605 minutes.  Late KC decreased the minutes of daily crying in both infants

(Ellett, Bleah, & Parris, 2004). The second colic study was a randomized controlled trial of 7

days of Late KC for 3-12 week old term infants (N=70) who were having a mean of 3.5 hours of

inconsolable crying each day.  Infants given several hours of KC each day had only 1.7 hr/day of

crying at the end of Late KC and had more hours of awake content time and longer sleep periods

than controls. Control infants who had no KC were still crying more than three hours/day at the

end of the seven day period (Saeidi et al., 2010).  Additional randomized controlled trials are

needed to confirm Late KC’s role as an effective intervention for infant colic. An experimental

trial of Late KC in combination with simultaneous breastfeeding during a 12-month

immunization showed that Late KC + breastfeeding lowered heart rate response and induced

less crying than receiving the shot without KC + breastfeeding (Abdel Razak & Az El Dein,

2009).  A case study of a term newborn with Down’s Syndrome who received maternal KC for

one hour at 12 days post-birth before repair of a ventricular septal defect demonstrated stability

of heart rate, respiratory rate and temperature during KC as was seen during an open air crib

period, but oxygen saturation was consistently 3-4% higher during KC (Ludington-Hoe &

Harrison, under review).  The infant did not sleep as well in KC as he had in the crib, due in part

to his vigorous arousing in KC for feeding even though feeding was not allowed.  Feedings were

being given in small portions every two hours to minimize the cardiac challenge that

accompanies feeding infants with congenital heart defects. Cardiorespiratory (heart rate and

oxygen saturation) stability was also seen in two other cases studies of fullterm infants with

hypoplastic left heart defects.  One infant received KC for one hour each day for 14 days after

stage 1 repair (Harrison, 2010) and the other the infant received KC for one hour three days

before first stage repair was conducted at Children’s Hospital of Philadelphia (Torowicz, under

review)..  In all three of these cases, ardiorespiratory stability was a positive finding because the

better and more stable the infant’s physiology is, the sooner corrective surgery can be performed.

Children’s Hospital of Philadelphia also uses KC (at least one hour/day once infant tolerates

transfer out of crib/incubator) to assist in transitioning fullterm infants with complex surgical

anomalies from bottle to breast feedings (Edwards & Spatz, 2010).

A quasi-experiment of 50 infants who were readmitted to the hospital for clinically

diagnosed jaundice on days 3-5 of life.received at least 3 hours/day of KC and intermittent

phototherapy during hospitalization; KC infants had 40 fewer hours of phototherapy than

control infants who had continuous phototherapy and no KC (Samra, El Taweel, &

Cadwell, 2011).

If and how long mothers practice KC with fullterm infants after discharge is not known even though a contact tool has been developed (Anderson, Radjenovic, Chiu, Conlon, & Lane, 2004).  One recommendation for Late KC with fullterm infants exists and that is for KC to be used to support continuance of breastfeeding (Academy of Breastfeeding Medicine, 2007).  Fullterm infants who experience KC for 3 months or more may show better developmental outcomes as preterm infants experiencing months of KC do (Ludington-Hoe, 2010; Ludington-Hoe Morgan, & Abouelfettoh, 2008).

Kangaroo Care with Cesarean Birth

The use of KC with cesarean birth of fullterm infants has been addressed by many researchers because cesarean section mothers have less pulsatile oxytocin secretion (Uvnas-Moberg, 2003) and are more at risk of inadequate oxytocin, prolactin, and milk production than women who deliver vaginally.  Beginning KC as soon as possible after cesarean birth has been recommended to improve breastfeeding outcomes (Gouchon et al., 2010; Nissen t al., 1998; Nyqvist et al., 2010; Nyqvist, Sjoden, & Ewald, 1994; Price & Johnson, 2005; Puig & Sguassero, 2007; Rowe-Murray & Fisher, 2003) and the transition to motherhood (Nissen et al., 1998; Uvnas-Moberg, 2003).  Mothers who gave birth by cesarean have related that KC needs to start as soon as the mother is able to respond if KC is to help with breastmilk production (Lazarov, 1994) and breastfeeding (Nyqvist et al., 1994). Hung and Berg (2011) found that mothers who started KC on the operating table had better LATCH scores, less supplementation, and greater likelihood of breastmilk feedings throughout hospitalization than mothers who began KC during cesarean recovery. Hung and Berg also reported that one mother ceased having surgical sensation discomfort during the cesarean once her infant had been placed on her chest. Recognizing that oxytocin , when released in the maternal brain, acts like an opiate, maternal pain and perception of pain should be less during the remainder of the section as well as during recovery and might be able to decrease the amount of analgesic medication needed as suggested with episiotomy repair (Walters et al., 2007). Kangaroo care during cesarean section helps improve breastfeeding exclusivity at discharge, and decrease maternal stress and increase satisfaction with the cesarean experience (Crenshaw et al., 2012). Two randomized controlled trials of mothers providing KC in the recovery room following completion of the cesarean section have been reported in addition to Gouchon et al’s randomized controlled trial that has been reviewed earlier. One revealed that mothers had better perceptions of their infants and a greater number of positive maternal behaviors towards their infants than mothers who did not provide KC (McClelland & Cabianca, 1980) and the other that mothers were able to warm their infants faster than a radiant warmer (Huang et al., 2006), a finding confirmed during cesarean KC in the operating room (Gouchon et al., 2010; Singh, 2010).

The effects of paternal KC after cesarean birth are so numerous that researchers enthusiastically endorse adoption of paternal KC beginning within 1-3 minutes of cesarean birth if the mother cannot start KC on the operating table (Colonna, Robieux, Santin, Camper  & Nadalin, 2009; Velandia et al., 2010).  Infants who received paternal KC starting within five minutes of cesarean birth were effectively calmed and relaxed by their fathers.  The infants also responded by initiating soliciting vocalizations with the father within the first 15 minutes post-birth and did not do so if the infant was not in KC (Velandia, et al., 2010).  In the first two hours after elective cesarean section newborns demonstrated pre-feeding behaviors, cried little, and rapidly fell asleep as paternal KC was administered in the newborn nursery (Erlandsson, Dsilna, Fagerberg & Christensson, 2007).  Fullterm infants also showed greater breath volumes, less crying and swifter physiological adaptation to extra-uterine life when given paternal KC as compared to being wrapped and placed in cots (Erlandsson, Christensson, Dsilna, & Jonsson, 2008).  Fathers have commented that they felt increased “connectedness” and responsibility for the newborn to whom they gave KC (Erlandsson et al., 2008) and that KC could be given by them without difficulty (Colonna, et al., 2009).

Based on the cesarean birth evidence described above, strategies to facilitate implementation of KC with cesarean birth have been offered.  A pictorial step-by-step procedure for the cesarean section and placement of the infant in maternal KC after the one-minute APGAR is available (Smith, Plaat, & Fisk, 2008).  In India, the practice of cesarean Birth KC includes putting the newborn cheek-to-cheek with the mother for kissing and blessing (Gangal, 2007).   Further evaluation of cesarean Birth KC procedures on maternal and infant outcomes is needed.  Picture posters of Birth KC in the operating and postpartum rooms has facilitated adoption of cesarean Birth KC (Price & Johnson, 2005) in spite of numerous labor and delivery barriers that continue to exist 26 years after they were first identified (Lazarov, 1994).  Thus, the practice of Birth KC with cesarean sections is expected to increase.

Sudden Infant Collapse.  Though case studies of Kangaroo Care helping infants who are having respiratory distress have been reviewed above and are encouraging, sudden infant collapse has been documented in healthy fullterm infants within 48 hours of birth (Baker, 2011; Gatti et al., 2004; Grylack & Williams, 1996) and up to 9 weeks post-birth (Byard & Burnell, 1995). Sudden infant collapse means that the healthy infant with good APGARS is observed to be pale or cyanotic, flaccid or limp, and not breathing (asphyxia) – conditions constituting what is also known as an Apparent Life Threatening Events.  Sudden infant deaths have been reported in infants in KC (Aboudiab, Vue-Droy, Al Hawan, Attier, & Chouraki, 2007; Andres, Garcia, Rimet, Nicaise, & Simeoni, 2011; Becher, Bhustan, & Lyon,2011;  Branger, Savagner, Roze, Winer, & Pediatries des Maternites des Pays-de-la-Loire, 2007;  Espagne, Hamon, Thiebaugeorges, & Hascoet, 2004; Hayes et al., 2006;  Melchor Marcus, 2010;  Nakamura, 2007; Nakamura & Sano, 2008; Poets . Steinfeldt, & Poets, 2011; Rodriguez Alarcon Gomez et al., 2010), in the delivery room’s warming unit (Branger et al. 2007), in a crib (Becher et al., 2011),  on a bed (Dageville, Pignol & De Smet, 2008; Fleming, 2011; Poets et al., 2011), and when swaddled in parental arms (Becher et al., 2011; Byard & Burnell, 1995; Gatti et al., 2004; Poets et al., 2011) while the mother was awake (Peters, Becher, Lyon, & Midgley,2009; Poets et al., 2011) or asleep (Andres et al., 2011; Foran et al., 2009; Poets et al., 2011) and when breastfeeding the swaddled infant (Gatti et al., 2004; Radtke, 2010; Toker-Mainmon, Joseph, Bromiker, & Schimmel, 2006).  Sudden infant collapse occurs more often in the evening or at night than during the day (Leow & Platt, 2011; Rodriguez Alarcon Gomez et al., 2011) and in mothers who are overweight or obese (Poets et al., 2011). The cause of sudden infant collapse can be prenatal brain injury (Becher et al., 2004; Foran et al., 2009), failure of ductus arteriosus and/or foramen ovale to close (Grylack & Williams,1996), genetic predisposition (Becher., Bell, Keeling,  McIntosh, & Wyatt, 2004), the immediate postpartum drop in the infant’s sympathetic nervous system activity (Poets et al.., 2011), vulnerability in the infant such that the infant does not respond to developing hypoxia (Byard, 2011; Gatti, et al., 2004) which has been seen in late preterm and fullterm infants during breastfeeding (Andres et al., 2011; Becher, Bhushan, & Lyon, 2011; Byard, 2011; Foran et al., 2009; Radtke, 2010), and the most common cause is positional asphyxia (Gatti et al., 2004; Toker-Mainmon et al., 2006). And, sudden infant collapse was observed in an infant who had excessive abdominal fluid for unknown reasons (Eklund, 2012), so it is not always KC per se that causes the collapse.  (Branger et al., 2007; Melchor Marcos, 2010;).  The incidence of sudden infant collapse in KC may be less than it is for infants not in KC (Dageville et al., 2008) or may be more (Becher et al, 2011), depending on hospital policies about the frequency of observing the mother-infant dyad.  Most of the collapses in KC have occurred in primiparous mothers (who are less experienced in knowing how an infant should look and act), during the second hour of life when mothers and infants tend to fall asleep (due to fatigue from labor and birth, brain-based oxytocin induces sleep, and satiety after feeding) (Poets et al., 2011), when the infant embeds his nose in breast tissue or slips beneath the breast (Byard & Burnell, 1995; Foran et al., 2009; Gatti et al., 2004; Krous, Chadwick, & Stanley, 2005; Poets et al., 2011), when the infant’s flexes his neck thereby occluding the airway (Byard & Burnell, 1995), and when the dyad is unsupervised by health professionals (Leow & Platt, 2011).  Sudden collapse has occurred during episiotomy repair when no one assessed the mother and infant during the repair (Peters et al., 2009).   Also, many collapses have been discovered six-to-seven minutes after the last observation of the healthy infant (Poets et al., 2011), indicating that the standard of care for newborn observation should be continuous for the first two hours of life  instead of every 15 or 30 minutes as is now  practiced so  new families have some private bonding time.  Sudden infant collapses can occur after the first two hours of life and are no uncommon 1 to 3 days post-birth (Weber, Ashworth, & Risdon, 2009).  Once an infant has experienced a sudden collapse, he or she is prone to recurrent collapse, especially in the first week of life (Grylack & Williams, 1996), so vigilant monitoring of the mother-infant dyad and their positions is necessary for fullterm infants throughout the postpartum hospitalization (Fleming, 2011; Rodriguez Alarcon Gomez et al., 2010).  Still, collapse is a rare event (Espagne etal., 2004; Fleming, 2011; Leow & Platt, 2011) and has existed for many years (Polberger & Svenningsen, 1985; Gatti et al., 2004; Pryce, et al., 2011).  The majority of investigators recommend continuation of skin-to-skin contact beginning at birth because not doing KC would jeopardize the establishment of adaptive cardiorespiratory and neural physiology in the dyad as well as establishment of normal dyadic  interactions and breastfeeding (Dageville, Casagrande, DeSmet, & Boutte, 2011; Fleming, 2011; Foran et al., 2009; Rodriguez Alarcon Gomez e al., 2011). Establishing breastfeeding is important because delay in breastfeeding initiation after the first two hours post-birth increases the risk of neonatal death (Edmond et al., 2006) and decreases the likelihood of exclusivity and long duration of breastfeeding (Bramson et al., 2010).

Practice Implications

Practice implications include six maternal and infant outcomes that can be expected with KC and guidelines for practicing in a way that is safe and yields the anticipated outcomes.

Anticipated Practice Outcomes.  Studies of KC’s effects on fullterm infants began in the 1970’s, long before KC was applied to preterm infants, but the practice with fullterm infants did not spread at that time. Now, the more substantial foundation of evidence enables us to recommend KC’s use with all healthy term infants – in developed and developing countries.  The evidence reviewed here spans the breadth of scientific methods.  Descriptive studies enabled researchers to progress to experimental studies, randomized controlled clinical trials, and meta-analyses.  Even if one were to formulate opinions based only on randomized controlled trials and meta-analyses, the data clearly show that KC should be practiced with healthy fullterm infants with anticipation of many benefits (Table 1), including the following:

1)  Prevention of hypothermia and more stable infant temperature following birth than when separated from the mother or not in maternal or paternal KC.  A heat panel is not necessary for temperature maintenance as fullterm mothers quickly increase their breast temperatures when the infant is placed in KC, creating a heat sink in which the infant lies (Bergstrom et al., 2007).  Body heat is transmitted from the mother to the infant, insuring infant warmth (Karlsson, 1996).  Nonetheless, a head cap (for first 2-4 hours post-birth) and back covering (at all times) may be needed to maintain temperature in the infant’s neutral thermal zone.  Kangaroo Care’s effectiveness in warming infants after birth has led to skin-to-skin placement being a thermoregulatory option for all newborns who do not require resuscitation according to the Neonatal Resuscitation Program (American Academy of Pediatrics &American Heart Association, 2006) and others (Mance, 2008).  Kangaroo Care’s effectiveness in re-warming hypothermic infants has also been demonstrated.  Reviews of KC’s temperature effects in fullterm infants (Bowden, Greenberg, & Donaldson, 2000; Dzukou, et al., 2004; Galligan, 2006; Winberg, 2005) support Kennell and McGrath’s (2003) conclusion that “skin-to-skin contact with the mother is the most effective way to maintain the newborn’s body temperature” (p. 273).

2)  Increased initiation and duration of breastfeeding (United States Department of Health and Human Services, 2000), and increased duration of exclusive breastfeeding are high priority national health goals (United States Department of Health and Human Services, 2007).  Kangaroo Care consistently contributes to meeting, if not surpassing, these breastfeeding goals (Moore & Anderson, 2007; Moore et al., 2009; Bramson et al., 2010), even in women who have had adverse experiences with breastfeeding in the first 12 hours post-birth (Anderson, et al., 2004).  Kangaroo Care needs to start immediately after birth according to the American Academy of Pediatrics (2005), American College of Obstetricians and Gynecologists (2006, 2007), Academy of Breastfeeding Medicine (2002), American Academy of Family Practice (2001), the U.S. Center for Disease Control and Prevention (2007), and the World Health Organization (Puig & Sguassero, 2007).  Infants should be left undisturbed on the mother’s chest until completion of the first feed (AAP, 2005; ABM, 2002; Cadwell & Turner-Maffei, 2009; European Commission et al., 2006; Kent, Prime, & Garbin, 2012).  One can expect the healthy term infant to crawl towards a breast, demonstrate pre-feeding behaviors that prepare the nipple, areola, and milk ducts for feeding, and spontaneously latch within the first two hours post-birth (AAP, 2005; Dabrowski, 2007; European Commission et al., 2006; Gangal, 2007; Klaus, 1998, 2009; Righard, 2008).  Observations of 21,842 women giving birth in California revealed that Birth KC was associated with more women breastfeeding than the lack of Birth KC and that women who gave one hour or more of KC in the first 3 hours post-birth had 200% higher likelihood of exclusively breastfeeding than women who gave 1-15 minutes of KC, and doubled the likelihood of women who gave only 16-30 or 31-59 minutes of KC in the first three hours after birth (Bramson et al., 2010), leading to recognition that KC enhances breastfeeding exclusivity (Di Frisco et al., 2011; Moore & Anderson, 2007; Moore et al., 2007).   In Japan, KC beginning within the first half hour of birth was associated with initiation of breastfeeding that lasted until four months post-birth (Nakao, Moji, Honda, & Oishi, 2008). Thus, KC starting at birth is now recommended as the best standard of care for all labor and delivery room policies (European Commission et al., 2006; Forster & McLachlan, 2007; Komara et al., 2007; Mercer et al. 2007; Righard, 2008).

Continuing KC throughout the postpartum period also makes essential contributions to establishing and maintaining lactation (Kent, & Garbin, 2012; Vasquez &Berg, 2012), because breastfeeding is rarely learned and successfully implemented for a long duration based solely on what happens in the first two hours post-birth.  Early, frequent, unrestricted skin-to-skin contact throughout postpartum reinforces “baby led” instinctive feeding behaviors because postpartum KC calms and alleviates stress in dyads still learning breastfeeding skills (Kent, et al., 2012;    Vazquez & Berg, 2012).

3)  Cardiorespiratory and metabolic stability during KC and during feedings in KC.  Heart rate, respiratory rate and blood glucose remain within clinically acceptable ranges during KC over the first 90 minutes post-birth with or without feeding, and stability continues throughout KC during the postpartum period, leading to the recommendation to begin KC at birth (Nyqvist et al. 2010; Takahashi et al., 2011; Winberg, 2005) and provide KC as continuously as possible (Nyqvist et al., 2010; Takahashi et al., 2011). Reduction in or absence of hypoglycemia in the first two hours post-birth occurs in infants who are maintained in KC (____, 2006; Chantry, 2005). “Healthy infants who are maintained in Kangaroo Care maintain normal body temperature.  Normal body temperature prevents hypoglycemia.  Given the importance of thermoregulation, skin-to-skin contact should be promoted and “kangaroo care” encouraged in the first 24 hours after birth” (_____, 2006, pg. 13).

4)  Mitigation of infant and maternal pain and discomfort.  Reduced autonomic and behavioral responses to painful experiences, such as injections and heel sticks, have been documented during KC in preterm (Ludington-Hoe,2010) and in term infants (Abdel Razak & As El Dein, 2009; Belleini et al., 2002;  Chermont et al., 2009; Gray et al., 2000; 2002; Kashaninia et al., 2008; Okan et al. 2010; Sajedi et al.,2007; Tsao et al., 2008; Tsao, Meldrum, & Zeltzer,2007).  Kangaroo Care is now recommended as a pain management strategy for minor routine procedures like shots and heel sticks in fullterm neonates (American Academy of Pediatrics & Canadian Pediatric Society, 2006; Campbell-Yeo, Fernandes, & Johnston, C.(2011); Hardy, 2011;  Johnston, Fernandes, & Campbell-Yeo, 2011; Lago et al., 2009; Naughten, 2005).  Also, KC reduces infant crying (Anderson, et al., 2003; Moore et al., 2007; Shiau, 1999), and usually sleep until hungry.  Mothers have discomfort when they are not allowed to touch the newborn and bring their infant to their breast (Finigan & Davies, 2004), but find relief when allowed to do so (Ashmore, 2001).

5)  Reduction of infant infection.  Kangaroo Care has been found to reduce the number and severity of infections in infants (Sosa et al., 1976) and has been recommended as a way to prevent early onset neonatal sepsis (Ganatra, Stoll & Zaidi, 2010).  In fact, the United States Breastfeeding Committee encourages KC as a way in which parents and caretakers can help protect infants from swine flu and the spread of other germs (US Breastfeeding Committee, 2009).  KC’s use to prevent infection has been clearly stated:

“However, regardless of whether an infant is born by cesarean section or natural vaginal

delivery, skin-to-skin contact between a newborn and his mother should be established

immediately upon birth in the delivery room so that the mother’s beneficial Staphylococcus

 epidermis bacteria can be transferred to the child at the earliest possible moment.  This has

been referred to as Kangaroo Care and should be begun in the delivery room.  It could also be considered the first stage in infection control for a newborn  baby’s skin” (Kitajima, 2003, pg. 241).

6)  Enhancement of infant brain development.  The fullterm infant’s brain is still quite immature, and matures through changes to its connection patterns due to the environment in which is exists (Parsons, Young, Murray, Stein & Kringelbach, 2010).  The first brain structure to begin this maturation is the brain stem.  The brain stem is responsible for cardiorespiratory functions.   Because the infant’s brain stem requires skin contact for its optimal development (Geva & Feldman, 2008), both infant and mother intuitively seek skin contact with each other (Parsons et al., 2010).  “Kangaroo Care contact provides the expected sensations that define a ‘safe’ place.  Being safe makes the brain operate on a developmental program leading to physiologic regulation Physiologic regulation leads later to enhanced development. Separation from the mother leads to altered neurotransmitter systems in the brain, with depression and shortened life span” ” (Bergman et al., 2010, p. 165).

7)  Enhanced maternal-infant attachment behavior, bonding, relaxation, and pleasure.   Three mechanisms accounting for these maternal outcomes exist.  The major mechanism is oxytocin.  Kangaroo Care causes increased frequency of pulsatile oxytocin surges, leading to increased oxytocin in the maternal brain and in maternal and infant circulation.  Increased oxytocin in the brain enhances maternal bonding, sense of calm, and relaxation (Uvnas-Moberg, 1999; Uvnas-Moberg, 2003).  Increased oxytocin in the circulation fosters successful breastfeeding and postpartum physiologic stabilization (Uvnas-Moberg, et al., 2005).  The second mechanism is stimulation of C tactile afferent nerves by skin-to-skin contact.  Stimulation of the afferent nerves produces the sensation of pleasant touch in the limbic area of the brain (Olausson et al., 2002), acting as a source of maternal comments about their enjoyment of KC.  But, the stimulation of the C-afferent nerves goes beyond that.  Skin-to-skin contact stimulation of the lanugo hairs encased to some degree by vernix caseosa “activate highly sensitive mechanoreceptors connected to unmyelinated C-afferents which conduct impulses from all skin dermatoms via the spinal cord and which activate vagal sensory zone, hypothalamus, and insular cortex for concomitant promotion of the anti-stress effect through oxytocin release, and stimulation of growth by the incretin effect of gastrointestinal hormones” (Bystrova, 2009) (incretin is a contributing factor to the decreased birth weight loss seen in term infants receiving KC).  In fullterm infants in which ventral lanugo is gone, remnants usually remain across the shoulders at the base of the neck, just where mothers place their fingers to secure their infant’s head position during KC.  Most recently, the existence of unmyelinated C-afferent nerves were discovered (Narendran, Wicket, Pickens, & Hoath, 2000).  These unmyelinated C-afferent nerves are low-threshold mechanoreceptors that exist in the hair (thus in hairy skin) and have exclusive and exquisitely sensitivity to slow or constant, gentle, light touch and have the function of processing pleasant and socially relevant aspects of touch as well as pain inhibition (Olausson, Wessberg, Morrison, McGlone, & Vallbo, 2010; Bystrova, 2009).  The third mechanism is reduction of maternal cortisol secreted by the hypothalamic-pituitary-adrenal axis (Handlin et al., 2009) and by maternal epidermis (Narendran et al., 2010) during KC.

Guidelines for the Practice of Kangaroo Care.  In fact, the Centers for Disease Control and Prevention now ask hospitals to report their KC practices with fullterm infants and post the “report card grade” for each hospital on the internet so consumers can determine the extent to which KC is being provided (Centers for Disease Control and Prevention, 2007).  Also, all pediatricians, including neonatologists, have been advised to use Kangaroo Care because “KC is an intervention that is more than an excellent innovation.  It is real progress in modern neonatal assistance because KC can be implemented worldwide and has tested beneficial effects that are long-lasting, or better, last forever” (Martinez, 2007, p. e55).  The outcomes ascribed to KC are attainable with all healthy term infants if a few evidence-based guidelines are followed.  The guidelines are:

  1. Introduce Birth KC to the mother and her partner during the antenatal period so Birth KC can be included in the birth plan and so parents are ready to participate immediately after delivery. When mothers have had prenatal education about KC beginning at birth and continuing throughout their postpartum stay, satisfaction with their care increases (Calais, Dalbye, Nyqvist, & Berg, 2010). Expectant parents enjoy watching the newborn infant spontaneously crawl up to a breast and latch onto the nipple.  For example, the breast crawl can be seen by accessing www.breastcawl.org.
  2. Do not separate the mother from her neonate! Immediately after delivery, put the infant supine onto the mother’s body.  Because the infant’s cord should not be clamped for a minimum of two minutes post-birth to prevent infant anemia (Chaparro & Lutter, 2009; Hutton & Hassan, 2007; Lutter & Chaparro, 2009), the infant cannot go any further than the mother’s abdomen.  Record how soon after birth skin-to-skin contact begins so duration records will be accurate.  Dry the infant thoroughly.. Place a head cap on the infant’s dry head.  Conduct one minute APGAR.  Turn the infant prone for early and uninterrupted continuous skin-to-skin contact.  Replace the drying cloth with a warm receiving blanket to cover the infant’s back.  KC should be provided during the first two hours post-birth to support this sensitive period for establishment of breastfeeding (Demott et al., 2006; European Commission et al., 2006), physiologic stability (Begley, Guilliland, Dixon, Reilly, & Keegan, 2011), and the maternal-infant relationship (Chantry, 2005; Kennell & McGrath, 2003; McGrath & Kennell, 2002).  Immediate and uninterrupted placement in Birth KC enables the infant to express instinctual seeking and sucking behaviors within the first hour post-birth (Gangal, 2007; Righard & Allade, 1990; Matthiesen et al.,  2001; Mohrbacher, 2008; Widstrom, et al., 1990), which is part of the reason why the Baby Friendly Hospitals Initiative increased the time in BirthKC to at least one hour in 2010 (Vincent, 2011).. When all well infants are routinely placed in Birth KC as the evidence suggests, the nursing culture changes and nurses demonstrate “a deeper commitment to deliver high quality evidence-based care…”(Jablonski, 2011, pg. S25).  Record the duration of KC because the duration of KC is considered a new vital sign for good maternity care (Advance for Nurses, 2009; Centers for Disease Control & Prevention, 2011b; Romano, 2011).
  3. 3. If immediate KC is not possible after birth, return the infant to the mother as soon as possible. Ideally, the infant will be placed in KC within 15- 30 minutes of birth – the sooner the better (AWHONN, 2004; Demott et al., 2006; European Commission et al., 2006). Neonatal deprivation of maternal contact can lead to biological disorders in adulthood and alter the infant’s biological responses to stress, disturb learning behaviors, and impair social skills (Dageville et al., 2011).   Separating the newborn from his mother should rarely occur because separation is not harmless.
  4. Delay weighing, eye treatments, shots, and identification procedures until completion of the first feeding and conduct as many of these as possible in KC (American Academy of Pediatrics, 2005; Academy of Breastfeeding Medicine, 2002, 2008; European Commission et al., 2006; Righard, 2008). Doing so gives the infant a chance to spontaneously move toward and latch onto the nipple, nurse successfully, and establish eye-to-eye contact with mother.  Newborn care immediately after delivery significantly delays the onset of KC by 30 minutes or more (Awi & Alikor, 2004).  Immediate contact should take precedence over hospital routines according to the American Academy of Pediatrics  (American Academy of Pediatrics, 2005), the American College of Obstetricians and Gynecologists (2006, 2007), American Academy of Family Physicians (2001), the Academy of Breastfeeding Medicine (2002, 2008), the Association for Women’s Health, Obstetric and Newborn Nurses (AWHONN, 2000, 2004),  the European Union Infant and Young Child Feeding Standards (European Commission et al., 2006), and the National Collaborating Centre for Primary Care in the United Kingdom (Demott et al., 2006).

(Sinusas & Gagliardi, 2001; Warren, 2008). Kangaroo Care increases oxytocin release in both mother and infant.  Oxytocin, in turn, facilitates breastfeeding, bonding, maternal relaxation, uterine contractions, and minization of stress (Dordevic et al., 2008; Uvnas -Moberg, 2003; Uvnas-Moberg et al., 2005). Suckling maintains development of the anterior pituitary’s prola ctin-secreting cells even when estrogen drops at birth – a condition that threatens prolactin cell integrity.  Suckling also induces prolactin surges in maternal blood, supporting normal lactation (Uvnas-Moberg, 1999; Uvnas-Moberg, 2003).  The colostrum delivered with the initial sucks is rich in T and B lymphocyctes, enhancing infant immunity.  Also, sending the infant to the observation5.  Keep the infant in KC at least until the first suckling at the breast has been accomplished nursery at any time during postpartum is detrimental because once the infant is in the nursery, treatments, physical assessments, and screenings get clustered together and result in prolonged separation from the mother (Vazquez & Berg, 2012). Conducting these procedures at the mother’s bedside is the best practice.

  1. 6. Have the mother provide continuous KC until discharge. Mother and infant should remain in KC as much as possible throughout the postpartum stay for improved interactions, development, and breastfeeding (Kent et al., 2012;Vasquez & Berg, 2012).  Continue KC as much as possible throughout the first three months of life (Chalmers, O’Brien, & Boscoe, 2009) and use KC as a FIRST intervention for breastfeeding problems (Vazquez & Berg, 2012).   Remember, Kangaroo Care is the newborn’s playground (Winberg, 2005).  Kangaroo Care’s continual use throughout the mother’s day can be accomplished using a tube top, slings, or wraps to position the infant near the breast while maintaining maternal modesty as the mother conducts routine postpartal activities.  Commercial wraps and tops are available (Table 2).  KC can be continued at home to support breastfeeding and promote infant development.
  2. 7. Distribute KC educational materials to patients during the prenatal, intrapartal, or early postnatal period because early and continuing education about KC is perceived by mothers as being helpful in initiation of and continuing KC (Calais et al., 2010) and is needed (Henderson, 2011). “Resources for Parents and Providers:  Book, Pamphlets, and Videos” are in Table 1; “Kangaroo Care Carriers and Designers/Merchants” are listed in Table 2.   Other educational materials are:  1) A trifold for parents to read on the topic of Kangaroo Care, called “Kangaroo Care For You and Your Baby”(United States Institute for Kangaroo Care, 2011), 2) the Massachusetts Breastfeeding Coalition’s informative sheet entitled “It’s my birthday, give me a hug.  Skin-to-skin contact for you and your baby” (Massachusets Breastfeeding Coalition, 2005), 3) the “How To Hold Your Baby Skin-to-Skin.  Skin-to-Skin: A Great Way to Begin” sheet (Health Education Associates, 2011a), 4) “The First Hour After Birth; A Baby’s 9 Instinctive Stages” which enumerates the stages infants go through during Birth KC.  There is a section on the benefits of Birth KC and all pictures are of Birth KC (Health Education Associates, 2011b), and 5) the book entitled “The Miracle of Kangaroo Mother Care. For Every Parent and Every Baby. Rare Inspirational Stories of Infant Survival” (Roos & Roos, 2011).
  3. 8. Monitor couplet for sudden infant collapse (life-threatening event) and safe positioning. Life-threatening events and death can occur in all fullterm infants within minutes, hours, and days of birth, whether they are in KC, in a crib, or in the mother’s or father’s  arms (Poets, et al., 2011).  Several reports of healthy fullterm infants having life threatening events during skin-to-skin contact within the first two  hours of birth are reviewed above, so the first two hours post-birth should be considered critical care hours with continuous one-on-one monitoring of the couplet by the nurse.  The majority of life-threatening events and sudden infant death in all newborns are associated with infants having their noses pressed against the mother’s breast or abdomen even when mothers are awake (Gatti et al., 2004) and especially during the second hour post-birth (Poets et al., 2011). Maternity nursing staff should be vigilant during skin-to-skin contact, especially if the mother is alone with her neonate or other risk factors are present. Thus, vigilant monitoring of the infant’s nose, head and neck positions is necessary to be sure that the infant’s airway does not become occluded.  Close examination of life-threatening events  in KC have led researchers to conclude “skin-to-skin contact (at birth) should be promoted.” (Rodriguez-Alarcon Gomez et al., 2010, Poets et al., 2011).  But, the incidence of life threatening events in KC is much less than it is for infants not in KC (Dageville et al., 2008), making Birth Kangaroo Care a factor contributing to reduced neonatal mortality over the first week of life (Carlo et al., 2010).
  4. 9. Maintain staff knowledge and competencies related to KC. by attending educational programs such as basic and advanced courses in KC (United States Institute for Kangaroo Care, 2012) and webinars.(AWHONN, 2012)
  5. 10. Make conducting Kangaroo Care part of a staff member’s performance review, because knowledge alone does little to change nursing behaviors (Ludington-Hoe, 2011; Weddig, Baker, Auld & Horodynski, 2011).

Conclusion

This comprehensive review of 302 publications produced over 41 years of investigation of the effects of KC on fullterm infants and their parents leads to the conclusions that KC is beneficial to breastfeeding, maternal-infant attachment and interaction, infant physiology, and infant neurobehavioral development.  Indeed, the beneficial outcomes of KC are greater the longer and the more frequently KC is conducted.  Benefits have been documented globally and through a substantial data-base of studies and randomized controlled trials and meta-analyses from each continent, indicating the universality of positive infant responses to KC.  Based on the numerous benefits of KC and overwhelmingly positive responses to KC in infants and their parents, health professionals need to realize that KC is the habitat in which healthy newborns and their parents thrive.  In the KC habitat all requirements for optimal growth and development of both infant and mother are being met; any place else is inferior. The time has come for KC to be the routine place and standard for newborn care..  KC is the gold standard of non-separation of mother and infant post-birth.  Any separation of mother and infant is not the best practice as demonstrated by the evidence comparing KC to being in crib, held swaddled, or in nurseries and under artificial warming devices.

The question should not be “Are the newborns in your maternity center in continuous KC?” but rather “Why aren’t all newborns in continuous KC beginning within one minute of birth?”  Kangaroo Care is readily available, accessible to all, inexpensive to initiate, cost-effective to continue (Adam et al., 2005) and has amazing benefits.  Kangaroo Care should begin at birth and continue throughout postpartum hospitalization and the first three months of life because Kangaroo Care during the early post-birth period has positive effects on later life functioning. Kangaroo Care is simply a BEST CARE practice and should be the standard of care in all healthy term birthing circumstances, including cesarean section.

 


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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.

 

Vaidya, K., Sharma, A., & Dhungel, S. (2005).  Effect of early mother-baby close contact on the duration of exclusive breastfeeding.  Nepal Medical College Journal.7(2), 138-140.

 

Varendi, H., Porter, R.H., & Winberg, J. (1994).  Does the newborn baby find the nipple by smell?  Lancet, 344(8928), 989-990.

 

Varendi, H., Porter, R.H., & Winberg, J. (1996). Attractiveness of amniotic fluid odour:  Evidence of prenatal olfactory learning?  Acta Paediatrica, 85, 1223-1227.

 

Vasquez, M.J. & Berg, O.R. (2012). The Baby-Friendly journey in a US public hospital.  Journal of Perinatal and Neonatal Nursing.  26(1), 37-46.

 

Vaughans, B. (1990). Early maternal-infant contact and neonatal thermoregulation. Neonatal Network, 8, 19-21.

 

Velandia, M., Matthisen, A-S, Uvnas-Moberg, K., & Nissen, E. (2010).  Onset of vocal interaction between parents and  newborns in skin-to-skin contact immediately after elective cesarean section.  Birth, 37, 192-201.

 

Villalon, U.H., Alvarez, C. P., Baria, H. E., Caneleo, H. D., Carrillo, M., L., Duragon, G. S., Luz Feres, R. C., Mansilla, A.P., Navarro, C.Z., Olivares, G.C., & Torres, R.V. (1992).  Effect of early skin-to-skin contact on temperature regulation, heart rate, and respiratory rate in healthy, full-term newborns. Review of Childhood and Pediatrics, 63, 140-144.

 

Villalon, U.H., & Alvarez, C.P. (1993). Short term effects of early skin-to-skin contact (kangaroo care) on breastfeeding in healthy fullterm newborns. Review of Childhood and Pediatrics. 64(2), 124-128.

 

Vincent, S., (2011).  Skin-to-skin contact. Part one:  Just an hour of your time.  Practicing Midwife, 14(5): 40-41.

 

Vivancos, R.B.Z., Leite, A.M., Scochi, C.G.S., & Dos Santos, C.B. (2010).  The skin to skin contact at birth and newborn crying during vaccination against Hepatitis B .  Acta Paulista de Enferemagem, 23(4), 461-465.

 

Walters, M., Boggs, K., Ludington-Hoe, S.M., Price, K., & Morrison, B. (2007).  Kangaroo Care at birth:  Temperature and blood glucose effects. MCN, American Journal of Maternal Child Nursing, 32(6), 375-381.

 

Warnock, F.F., Castral, T.C., Brant, R., Sekilian, M., Leite, A.D., Owens, de la P., & Scochi, C.G.S.

(2010).  Brief report.  Maternal  kangaroo care for neonatal pain relief:  A systematic

narrative review.  Journal of Pediatric Psychology, 35(9), 975-984.

 

Warren, R. (2008).  Breastfeeding in the delivery room.  British Journal of Midwifery,16(2), 119-

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Weber,M.A., Ashworth, M.T., Risdon, R.A et al., (2009).  Sudden unexpected neonatal death in the first week of life: autopsy findings from a specialist centre. J Maternal Fetal Neonatal Medicine, 22, 398-404.

 

Weddig, J., Baker, S., Auld, G., & Horodynski, M. (2011). Improving breastfeeding intiation practices through online theory-based education.  Journal of Obstetric, Gynecologic and Neonatal Nursing, 20(Suppl 1), S119.

 

Weller, A., & Feldman, R. (2003).  Emotion regulation and touch in infants:  The role of

cholescystokinin and opioids.  Peptides, 24, 779-788.

 

Wiberg, B., Humble, K., & de Chateau, P. (1989).  Long-term effect on mother-infant behaviour of extra contact during the first hour postpartum. V.  Follow-up at three years.  Scandinavian Journal of Social Medicine, 17(2), 181-191.

 

Widstrom, A-M,  Lilja G, Aaltomaa-Michalias P, Dahllof A, Lintual M, & Nissen E. (2011).  Newborn behaviour to locate the breast when skin-to-skin:  a possible method for enabling early self-regulation. Acta Paediatrica 100 (1), , 79-85 DOI:10.1111/j.1651-2227.2010.01983.x.

 

Widstrom, A.M., Ransjo-Arvidson, A.B., Christensson, K., Matthiesen, A.S., Winberg J., & Uvnas-Moberg, K. (1987). Gastric suction in healthy newborn infants. Effects on circulation and developing feedng behaviors. Acta Paediatrica Scandinavica, 76, 566-572.

 

Widstrom, A.M., Wahlberg, V., Matthiesen, A.S., Eneroth, P., Uvnas-Moberg, K., Werner, S., & Winberg, J. (1990). Short-term effects of early suckling and touch of the nipple on maternal behavior. Early Human Development, 21, 153-163.

 

Wimmer-Puchinger, B., & Nagel, M. (1982).  The importance of attitudes during pregnancy and early mother-child contact for breast-feeding behavior: An empirical study.  In Prill, H., & Stauber, M. (eds.) Advances in Psychosomatic Obstetrics and Gynaecology.  Berlin: Springer Verlag,  pp. 482-487.

 

Winberg, J. (2005).  Mother and newborn baby: Mutual regulation of physiology and behavior – a selective review. Developmental Psychobiology, 47, 217-229.

 

World Health Organization. Department of Reproductive Health and Research. (2003).  Kangaroo Mother Care.  A Practical Guide.  Geneva:  WHO.  Available from Marketing and Dissemination, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland, or by email at bookorders@who.int

 

World Health Organization (WHO), UNICEF & Wellstart International.  (2009). Section 1 Background and Implementation. Baby-Friendly Hospital Initiative. Revised, Updated, and Expanded for Integrated Care. Geneva, Switzerland:  WHO:  pp. 3-27 to 3-264.  Available from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel+41 22 791 3264, fax: +41 22 791 4857; email: bookorders@who.int).

 

 

 

 

 

 

 

 

Table 1:  Summary of Benefits of Kangaroo Care to Fullterm Newborns and Their Parents

 

Infant Benefits Mother Benefits Mother & Infant Benefits Father Benefits
Thermoregulation ↓ BP on PP day 2 ↑ Breastfeeding initiation ↑ attachment
↓Birth weight loss ↓anxiety ↑ Breastfeeding duration ↑ sense of

responsibility for infant

Better, longer sleep ↑ feelings of

Confidence

↑ Exclusivity of breast-

feeding

Enhanced sense

of fulfillment

↓ pain with shots,

Vaccinations, sticks

↑ feelings of

Competence

↑ Milk production
Cardiorespiratory

Stabilization

Enhanced satis-

faction with birth

experience

Optimal proximity for synchronizing develop-

mental patterns

↓ Crying Distraction from

surgical repairs

Better maternal-infant

Interactions thru 12 months and thru 3 years

↓ Severity of Colic Shorter involution Enhanced bonding
↓ Stress during

Extrauterine adaptation

↓  4th  stage of labor

Blood loss

Maintain Euglycemia better No shaking/shivering
↓ Infections ↑ Oxytocin  which calms  & ↑ love for infant & can

↓ postpartum hemorrhage

Shorter phototherapy ↑ Cholecystokinin to improve GI functions
Enhanced immunity
Better mental development
Better motor development
Better depth of

Respiration during

Paternal KC

Improved neurobehavioral control
Better emotion regulation

 

 

 

Table 2: Resources for parent- and provider- Kangaroo Care education: Books, pamphlets and videos.

 

TITLE AUTHOR SOURCE
PAMPHLETS
Kangaroo Care for You and Your Baby United States Institute for Kangaroo Care  (2010) www.kangaroocareusa.org
First Hug: Get to know your baby and let your baby know you Massachusetts Breastfeeding Coalition (2006) www.massbfc.org
It’s My Birthday, Give Me A Hug Massachusetts Breastfeeding Coalition (2005) www.massbfc.org
Hold me, Mom Ohio Department of Health (2008)
How to Hold Your Baby Skin-to-Skin. Health Education Associates (2011a) www.healthed.cc (under tear off pads)
The First Hour After Birth: A Baby’s 9 Instinctive Stages

(Enumerates stages infants go through during BKC. Benefits & pictures of BKC]

Health Education Associates (2011b) www.healthed.cc (under tear off pads)
BOOKS
The Miracle of Kangaroo Mother Care. For Every Parent and Every Baby. Rare Inspirational Stories of Infant Survival Tony and Nyrie Roos (2011) Themiracleofkangaroomothercare.com

 

VIDEOS – Parents
Enhancing Baby’s First Relationship: A Parents’ Guide for Skin-to-Skin Contact with their Infants (20 minutes) Dr. Anne Bigelow, PhD (2010) www.mystfx.ca/InfantSkinToSkinContact/

(free)

Initiation of Breastfeeding by Breast Crawl for Early Breastfeeding Initiation ( UNICEF Maharashtra www.breastcrawl.org (free & downloadable)
Kangaroo Care: Nature’s Best for Your Baby (20 minutes) Dr. Barbara Morrison, PhD (2007) DrBarbCNM.com ($25.00)
Kangaroo Mother Care for Your Newborn (8 minutes) Sylvia Houston with Dr. Barbara Morrison, PhD, (2010) www.PreciousImageCreations.com (Free, click on video of fashions)
The Magical Hour: Holding Your Baby Skin to Skin for the First Hour After Birth (30 minutes) The Healthy Children Project (2011) www.healthed.cc  (#39.99)
VIDEOS – Parents and Providers
Breastfeeding – Baby’s Choice (8 minutes) Widstrom, Ransjo-Arvidson & Christensson (2007) www.healthed.cc ($39.00)
Breast Feeding: Techniques That Work! First Attachment (Vol. 1) Kitty Frantz (2005) www.geddesproduction.com ($25.00, ISBN 1-885748-76-0)
Baby-Led Breastfeeding (16 minutes) Dr. Christina Smillie, MD (2007) www.geddesproduction.com ($39.95 ISBN 978-1-885748-79-9)
Dr. Lennart Righart’s Delivery Self-Attachment (6 minutes) Dr. Lennart Righart, MD (1995) www.geddesproduction.com ($22.95, ISBN 1-885748-69-8)

Healthed.cc ($19.95)

Enhancing Baby’s First Relationship: Results from a Study on Mother-Infant Skin-to-Skin Contact (28 minutes) Dr. Anne Bigelow (2010) www.mystfx.ca/InfantSkinToSkinContact/ (free)
Jumping into Kangaroo Care: A Comprehensive Educational Toolkit with KC Policies for Labor/Delivery, Postpartum, and Newborn Nursery Units D. Barbier and the University Hospital Center for Women & Infants
VIDEOS – Providers
Biological NurturingTM Laid-back Breastfeeding (20 minutes) Dr. Susan Colson, PhD (2008) www.geddesproduction.com (#39.95, ISBN 9781885748867)
Kangaroo Care: A Crash Course (multiple sections, ~4 hours) Dr. Barbara Morrison, PhD (2007) DrBarbCNM.com  or PreciousImageCreations.com ($75.00)
Kangaroo Care: An Overview (45 minutes) Dr. Barbara Morrison, PhD (2007) DrBarbCNM.com or PreciousImageCreations.com ($40.00)
Latch 1, 2, 3: Troubleshooting Breastfeeding the Early Weeks (17 minutes) The Healthy Children Project (2008) www.Healthed.cc ($29.95)

 

Skin-to-Skin in the First Hour After Birth: Practical Advice for Staff after Vaginal and Cesarean Birth (3 sections, 40 minutes) The Healthy Children Project (2010) www.Healthed.cc ($39.95)

 

 

 

 

Table 3:  Kangaroo Care Carriers and designers/merchants

Company Name Contact Information Device Descriptions
Nils Bergman

South Africa

www.kangaroomothercare.com KangaCarrier Shirts- holds infant against chest with ties
KamCare Designs

Uppsala, Sweden

Maria Jansdotter & Karin Holmgren, www.Kamcaredesign.se, info@kamcaredesign.se Wraps, tube tops, camisoles and others
Kanguru Wraps

United States

Susan Sczentmikllosky, 330-527-2623 in Hiram, Ohio. Tube Tops, pouches, and delivery room wraps
LennyLamb

Warszawie

En.lennylamb.com

+48 22 257 8882

Baby slings and carriers
Mei Tai Baby

United States

www.meitaibaby.com

info@meitaibaby.com

Asian style baby carrier, shoet ties for around waist, long ties go over shoulders, cross back and tie around or under baby.
Moby Wrap

United States

www.mobywrap.com

infor@mobywrap.com

888-629-9727

Wide piece of durable, one-way stretch cotton fabric that wraps around your waist and over both shoulders providing 3 sections of fabric for securely holding baby.
Nurtured by Me Ellen Shatzkin, 914-328-2226 A blouse with a pouch
Peppermint.com info@peppermint.com Dedicated to the art of baby wearing, Peppermint offers a wide variety of slings and carriers.
Precious Image Creations Sylvia Houston

www.preciousimagecreations.com

Blouses for ambulatory KC and breastfeeding in KC, delivery room wraps, KC wraps for multiples
Sleepy Wrap www.sleepywrap.com Wraps and slings
Zakeez, Inc. www.zakeez.com or orders@zakeez.com Kangaroo Zak – Simple chest wrap with zippers to adjust to size

 

 

 

 

 

 

 

 

 

 

Table 1:  Skin-to-skin effects in term infants and citations* 

 

EFFECT CITATION(S)
Better heart rate Nolan & Lawrence, 2009
Sooner heart rate stability Christensson et al., 1992; Mazurek et al., 1999; Takahashi et al., 2011
Better cardio-respiratory stability Bouloumie, 2008; Sontheimer et al., 2004
Better respiratory rate Nolan & Lawrence, 2009
Increased breath volume Erlandsson et al., 2008
Better gaseous exchange Erlandsson et al., 2008
Early cessation of respiratory distress (Case study only, no group comparisons) Trotter, 2005
Better blood glucose level thru-out first 90 mins post-birth Chirstensson et al., 1992, 1996; Mazurek et al., 1999
Decreased metabolic stress Christensson et al., 1996; Chantry, 2005
Better body temperature and temperature earlier in neutral thermal zone (Huang et al. 2006) Bystrova et al., 2003; Carfoot et al., 2005; Christensson et al., 1992, 1996; Chwo & Huang, 2002; Durand et al., 1997; Franssen et al., 2005; Gardner, 1979; Huang et al., 2006; Marin et al., 2010;  Mazurek et al., 1999; Moore et al., 2009
Prevents hypothermia Bergstrom et al., 2005;  Byaruhanga et al., 2005
Better temperature stability from 15 mins-4 hours post-birth Britten, 1980; Curry, 1979, 1982;  Fardig, 1980; Gomez-Papi, et al., 1998; Johanson et al., 1992; Villalon & Alvarez, 1992, 1993
Faster rewarming after bath Bergstrom et al., 2005; Byaruhanga eta l., 2005;Medves & O’Brien, 2004
Decreased # of infections, early post-birth, at 6 months and at 12 months Kitajima, 2003; Sosa et al., 1976
Decreased cortisol level-if >60 mins of Birth S2S Takahashi, et al., 2011
Decreased infant stress Feldman, 2009; Feldman et al., 2010; Morgan et al., 2011; Takahashi et al., 2011
Increases infant peace, contentment, happiness, satisfaction, well-being Dalbye, et al., 2011
Decreased birth weight loss (33% have no loss) Bouloumie, 2008; Odent, 1989
Faster recovery of birth weight loss Bystrova et al., 2007
Decreased crying episodes and duration Anderson et al., 1995; Anisfeld & Lipper, 1998; Christensson et al., 1992, 1995, 1996; Chwo & Huang, 2002; De Chateau & Wiberg, 1997a; Erlandsson et al., 2007, 2008; Mazurek et al., 1999; Michelsson et al., 1996; Widstrom, 2011
Increased smiling @ 3 months De Chateau & Wiberg, 1977a
Decreased pain perception Abdel-Razak et al., 2009; Belleini et al., 2002; Chermont et al., 2009; Gray et al., 2000, 2002; Kashaninia et al., 2008; Long, 2010; Moore et al., 2007; Okan et al., 2010; Sajeidi et al., 2007; Tsao et al., 2007, 2008; Vivancos et al., 2010
Fewer hours of phototherapy Samra, El Taweel, & Cadwell, 2011
Activates infant speech motor areas Gentilucci & Dalla Volta, 2008
Stimulates imitation of maternal sounds Lepage & Theoret, 2007

 

Better interactions with mother Moore, et al., 2007, Dalbye et al., 2011
Accelerated development in first year of life Bystrova, 2009; Bystrova et al., 2003; De Chateau & Wiberg, 1984; Wiberg et al., 1989
Crawl to breast Righard & Alade, 1990; Widstrom et al., 1987
Better preparation of the breast for breastfeeding by infant Carfoot et al., 2003; Erlandsson et al., 2007; Mathiesen, et al., 2001; Mizuno et al., 2004; Ransjo-Arvidson et al., 2001
Better latch Meyer & Anderson, 1999; Gouchon et al., 2010
Better sucking technique Righard & Alade, 1990
Better breastfeeding effectiveness Moore & Anderson, 2007
Increased likelihood of breastfeeding success Kroeger & Smith, 2004; Simkiss, 1999
Increased initiation of breastfeeding Anderson et al., 2003;  Gomez-Papi, et al., 1998; Lindenberg et al., 1990; Mathiesen et al., 2001; Mikiel-Kostyra & Mazur, 1998; Mizuno et al., 2004; Ransjo-Arvidson et al., 2001; Walters et al., 2007
Increased breastfeeding duration Anderson et al., 2003; De Chateau & Wiberg, 1977a; Mikiel-Kostyra & Mazur, 2000; Mikiel-Kostyra et al., 2001, 2002;Mizuno et al., 2004; Moore et al., 2007; Shiau, 1997; Sosa et al., 1976; Taylor et al., 1985;  Wimmer-Puchinger & Nagel, 1982
Increased breastfeeding exclusivity Bramson et al., 2010; Carfoot et al., 2004, 2005; Marin et al., 2010; Mikiel-Kostyra et al., 2001, 2002, 2005; Thomson et al., 1979; Vaidya et al., 2005

*compared to swaddled holding, swaddled in cot, under radiant warmer or in incubator or warming unit unless otherwise noted.

All citations are available free on KC Bib at www.kangaroocareusa.org

©2011 Ludington-Hoe and United States Institute for Kangaroo Care (www.kangaroocareusa.org)

 

 

 

 

 

 

 

Table 2:  Skin-to-skin effects in mothers of fullterm infants

 

EFFECT CITATION(S)
Increased infant contact and attachment behaviors Anisfeld & Lipper, 1983; Carlson et al.,  1978, 1979, 1980; Dalbye et al., 2011; De Chateau & Wiberg, 1977a; Klaus et al.,  1972; Kontos, 1978; McClellan & Cabianca, 1980; Odent, 1989; Schaller et al., 1979; Widstrom et al., 1990
More affectionate behaviors during breastfeeding Hales et al., 1975, 1976, 1977, Jonas
Increase time spent with infant throughout postpartum Carlson et al., 1978, 1980;  Dalbye et al., 2011;  Hwang, 1981; Schaller et al., 1979; Widstrom et al., 1990
Intense desire to gaze at, touch, hold  S2S Finigan & Davies, 2004
Increased maternal-infant attachment McClellan & Cabianca, 1980
Increased confidence in infant’s care Bouloumie, 2008
Better maternal-infant interaction over 1st year Bystrova et al., 2009; Dalbye et al., 2011; De Chateau & Wiberg, 1977a, 1984; Takahashi et al., 2011,
Distracts mothers from episiotomy repair or cesarean  sensations Byaruhanga et al., 2008; Hung & Berg, 2011; Walters et al., 2007
Decreased Blood pressure on Postpartum Day 2 Handlin et al., 2012
Decreases lochia amount Dordevic et al., 2008 (a randomized controlled trial of 216 mothers)
Decreases anemia on Postpartum Day 3 Dordevic et al., 2008 (a randomized controlled trial of 216 mothers)
Fewer cases of poor involution Dordevic et al., 2008 (a randomized controlled trial of 216 mothers)
Earlier placental expulsion Marin et al., 2010 (a randomized controlled trial of137 mothers)
Decreased serum gastrin (better metabolic adaptation) Widstrom et al., 1990
Decreased cortisol & ACTH Handlin et al., 2009, Feldman
Decreased anxiety Nolan & Lawrence, 2009; Shiau, 1997; Vasquez & Berg, 2012
Increased satisfaction and happiness with care Bouloumie, 2008; Carfoot et al., 2005; Gouchon et al., 2010; Thomson et al., 1979, Vasquez & Berg, 2012
Better appearance for post-partum follow-up Anisfeld & Lipper, 1983
Recognize that S2S helps breastfeeding Byaruhanga et al., 2008; Tofteland et al., 2006
Decreased engorgement Shiau, 1997
Increased success of BF Anderson et al., 2004; Bulfone et al., 2011; Burkhammer et al., 2004; Moore & Anderson, 2007

All citations are available free on the KC Bib (under resources) at www.kangaroocareusa.org

©2011 Ludington-Hoe and United States Institute for Kangaroo Care

 

Labor and Delivery

Wearing The Second Skin Swaddle Is The Perfect Way to Welcome your Baby into the World

Provides coverage during labor and Delivery. After your baby is born he will be dried, diapered and placed on your chest. He will then be covered with the Swaddle Section to keep him warm and secure. The Womb like Enclosure will comfort him as he hears your heart beat and the sound of your voice. Learn More

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Hands Free Hold

Step-by-step instructions on using the swaddle

Click below to learn all the steps on how to properly use your swaddle to effectively hold your baby skin-to-skin. Learn More

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For Dad's

Great Shirt for Dad to Hold and Bond With His Precious Gift

Skin to Skin Contact the first weeks of life have been proven to be a life changing event for you and your newborn. It is also great for Mom to have a break.

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Postpartum

The Second Skin Swaddle “patent pending” For Post Partum Wear Allows You to be Discreet While You Safely Hold your Baby In Skin to Skin Contact

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Moderate Hold

There are two identical sections to the Second Skin Swaddle. A Single Section is used for Labor and Delivery a second section is added for the moderate hold. The design and flexibility of the Swaddle provides all that is needed for Labor/ Delivery and Postpartum while mom is in bed.

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