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Kangaroo Mother Care

Kangaroo mother care (KMC) is a method of care of preterm or
low birth weight (LBW) neonates by placing them in skin-to-skin
(STS) contact with mother or other caregiver in order to
ensure their
1-4
optimum growth and development. Initially devised as an
alternative to conventional technology-based care, KMC is now
considered as the standard of care for LBW neonates in all
settings.

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Benefits of KMC: What is the evidence?
The Cochrane review on benefits of KMC demonstrated:
• Improved exclusive breast feeding at discharge or 40 to 41 weeks’
postmenstrual age (RR 1.16, 95% CI 1.07 to 1.25 and at 1 to 3
months’ follow-up (RR 1.20, 95% CI 1.01 to 1.43)
• Reduction in the risk of mortality (RR 0.60; 95% CI 0.39-0.92)
• Reduction in nosocomial infection/sepsis (RR 0.35, 95% CI 0.22 to
0.54 )
• Reduction in hypothermia
• Reduction in length of hospital stay (mean difference 2.4 days,
95% CI 0.7 to 4.1)
• Increase in:
Weight gain (mean difference [MD] 4.1 g/d, 95% CI 2.3 to 5.9)
Length gain (MD 0.21 cm/week, 95% CI 0.03 to 0.38)
Head circumference gain (MD 0.14 cm/week, 95% CI 0.06 to 0.22)

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Components of KMC
1. Kangaroo position
• The kangaroo position consists of skin-to-skin contact
(SSC) between the mother and the neonate in a vertical
position, between the mother’s breasts and under her
clothes
• The provider must keep herself in a semi- reclining
position to avoid the gastric reflux in the neonates
• The kangaroo position is maintained until the neonate
no longer tolerates it- as indicated by sweating or
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refusing to stay in KMC position

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 AIIMS Protocols in Neonatology

• When continuous care is not possible, the kangaroo

position can be used intermittently, providing the
proven emotional and breastfeeding promotion benefits
• The kangaroo position must be offered for as long as
possible (but at least 1-2 hr/sitting), provided the
neonate tolerates it well.
2. Kangaroo nutrition
• Kangaroo nutrition is the delivery of nutrition to
“kangarooed” neonates as soon as oral feeding is
possible.
• Goal is to provide exclusive or nearly exclusive
breastfeeding with fortification, if needed.
3. Kangaroo discharge and follow up
• Early home discharge in the kangaroo position from the
neonatal unit is one of the key components of KMC.
• Mothers at home require adequate support and follow-
up;
hence a follow-up program and access to emergency
services must be ensured.

KMC in different settings

KMC may be used in three different scenarios

1. No specialized care for LBW neonates
LBW neonates born at home or at first level health facility
with no specialized care and no possibility of being
transferred to a proper healthcare unit can be provided KMC
as the sole modality of care. In such cases, KMC including
skin-to-skin contact, breastfeeding and adequate follow-up
represent the best available means of survival of non-sick
premature infants.
2. Specialized care but limited resources
KMC represents an effective alternative which allows better
utilization of available resources in these settings
3. Specialized care and adequate resources
KMC is used as an adjunct to technology based care to
establish healthy bonding between mother and newborn and
to increase the breastfeeding rates. The intermittent
kangaroo position in hospital is the most widely used
component in such a setting.
 Kangaroo Mother Care

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Requirements for KMC implementation
KMC is feasible everywhere, because it is not based on
equipment, and it presents advantages for the organization of
health services provided the following requirements are met:
1. Appropriate health facility
a. The health facility should allow entry of the parents to
the neonatal unit at all times
b. A room near to or at the neonatal unit, furnished with
comfortable seats for mothers is needed for KMC
practice and for education of mothers and families
c. Reclining chairs in the nursery and postnatal wards, and
beds with adjustable back rest should be arranged
d. Mother can also provide KMC sitting on an ordinary
chair or in a semi-reclining posture on a bed with the
help of pillows
2. Appropriate supporting staff and professionals
a. Presence of a nurse available full time and trained in
assisting mothers in KMC is a must
b. Staff should receive adequate training on KMC.
Additional training is needed for expression and storage
of breast milk, using alternate methods of feeding, and
daily monitoring of growth of LBW neonates. The
training may best be done by exposing them to units
practicing KMC
c. Educational material such as information sheets, posters,
and video films on KMC in local language should be
available to the mothers, families and the community
3. Good quality follow-up
a. Early discharge in kangaroo position should be
attempted only if adequate and appropriate follow up
can be ensured
4. Institutional, social and community support
a. The requirement for a successful KMC program can be
summarized in three words: communication,
sensitiveness and education
b. Apart from supporting the mother, family members
should also be encouraged to provide KMC when the
mother wishes to take rest
c. Mother would need her family’s cooperation to deal with
 AIIMS Protocols in Neonatology

her conventional responsibilities of household chores till

the infant requires KMC
d. Community awareness about the benefits should be
created. This is particularly important when there are
social, economic or family constraints

Birth weight

<1200 g 1200 to 1800 g >1800 g

Most suffer from serious Many suffer from

Generally stable at birth
morbidities serious morbidities
Transfer to a specialized centre, if possible
Best transported in STS with mother / family member

May take days to weeks KMC can be initiated

May take days before
before KMC can be initiated immediately after birth
KMC can be initiated

Figure 54.1: Timing of KMC initiation for

different birth weight categories

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Criteria for eligibility of KMC
1. Neonates
All stable LBW neonates are eligible for KMC. However, sick
and very small neonates (<1200 g) needing special care need
to be cared under radiant warmer initially. KMC need to
started once the neonate is hemodynamically stable. Short
KMC sessions can be initiated during recovery. KMC can be
provided while the neonate is being fed via orogastric tube
or on oxygen therapy. Figure 50.1 shows the timing of KMC
initiation for different birth weight categories.
 Kangaroo Mother Care

2. Mother/relatives
All mothers can provide KMC, irrespective of age, parity,
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education, culture and religion.
The following points must be taken into consideration when
counselling on KMC:
1. Willingness: The mother must be willing to provide
KMC. Healthcare providers should counsel and motivate
her. Once the mother realizes the benefits of KMC, she
will learn and undertake KMC
2. General health and nutrition: The mother should be
free from serious illness to be able to provide KMC. She
should receive adequate diet and supplements
recommended by her physician
3. Hygiene: The mother should maintain good hygiene:
daily bath/sponge, change of clothes, hand washing,
short and clean finger nails

Initiation of KMC
1. Counseling
a. When the neonate is ready for KMC, arrange a time that
is convenient to the mother and her baby
b. Demonstrate to her the KMC procedure in a caring and
gentle manner and with patience. Answer her queries
and allay her anxieties
c. Encourage her to bring her mother/mother in law,
husband or any other member of the family. This helps
in building positive attitude of the family and ensuring
family support to the mother which is particularly
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crucial for post-discharge home-based KMC
d. It is helpful that the mother starting KMC interacts with
someone already practicing KMC
2. Mother’s clothing
a. Mother can wear any front-open dresses as per local
culture. This may include sari, a blouse, front open
gown, a suit, or a simple shirt (Figure 50.2)
b. KMC can be done with special apparel (such as KEM
bag or AIIMS KMC jacket) designed to suit the needs of
mothers
c. Any other suitable apparel that can retain the neonate
for extended period of time can be used
 AIIMS Protocols in Neonatology

3. Baby’s clothing
Baby is dressed with cap, socks, nappy, and a front-open
sleeveless shirt

A B

C D

Figure 54.2: Mother (A) and father (B) practicing KMC in front open
gown and shawl. AIIMS KMC jacket (C) and mother performing
KMC using AIIMS KMC jacket (D)

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KMC procedure
1. Kangaroo positioning (Figure 54.3)
a. The neonate should be placed between the mother’s breasts
in an upright position
b. The head should be turned to one side and kept in a slightly
extended position. This position keeps the airway open and
allows eye to eye contact between the mother and her baby
c. The hips should be flexed and abducted in a “frog” position;
the arms should also be flexed. Baby’s abdomen should be at
the level of the mother’s epigastrium. Mother’s breathing
stimulates the baby, thus reducing the occurrence of apnea
d. Support the baby’s bottom with a sling/binder
 Kangaroo Mother Care

Head turned
Baby between to one side
mother’s breasts

Frog-leg
Support baby’s position
bottom

Figure 54.3: Positioning in KMC

2. Monitoring
a. Neonates receiving KMC should be monitored carefully.
b. Nursing staff should make sure that neonate’s neck
position is neither too flexed nor too extended, airway is
clear, breathing is regular, color is pink and the neonate
is maintaining temperature
c. Mother should be involved in observing the neonate
during KMC so that she herself can continue monitoring
at home
3. Feeding
a. The mother should be explained how to breastfeed while
the neonate is in KMC position.
b. Holding the neonate near the breast stimulates milk
5,6
production
c. She may express milk while the neonate is still in KMC
position. The neonate could be fed with paladai, spoon or
tube, depending on his/her clinical condition
4. Duration
a. Skin-to-skin contact should start gradually in the
nursery, with a smooth transition from conventional
care to continuous KMC
b. Sessions that last less than one hour should be avoided
because frequent handling may be stressful for the
neonate
c. The length of skin-to-skin contacts should be gradually
increased up to 24 hours a day, interrupted only for
changing diapers
 AIIMS Protocols in Neonatology

d. When the neonate does not require intensive care, she

should be transferred to the post-natal ward where
KMC should be continued
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Can the mother continue KMC during sleep and resting?
The mother can sleep with her baby in kangaroo position in
reclined or semi recumbent position about 30 degrees from
horizontal (Figure 54.4). This can be done with an adjustable bed
or with pillows on an ordinary bed. A comfortable chair with an
adjustable back may be used for resting during the day (Figure
54.4).

A B

Figure 54.4: Mother practicing KMC in reclining

posture (A) and KMC chair (B)

Discharge criteria
The standard policy of the unit for discharge from the hospital
should be followed. Generally the following criteria are used at
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most centres:
• Baby’s general health is good
• Gaining weight (at least 15-20 g/kg/day for three
consecutive days)
• Maintaining body temperature satisfactorily for at least three
consecutive days in room temperature.
• Feeding well and receiving exclusively or predominantly
breast milk.
• The mother and family members are confident to take care of
the baby
 Kangaroo Mother Care

When to discontinue KMC?

KMC is continued for as long as possible at the health facility &
then at home. Often this is desirable until the gestation reaches
term or the weight is around 2500 g. The time when the infant
starts wriggling to show that she is uncomfortable, pulls her
limbs out, cries and fusses every time the mother tries to put her
back skin-to- skin is the time to wean her from KMC. Even after
weaning, mothers can provide skin-to-skin contact occasionally
after giving the baby a bath or during cold nights.

Post-discharge follow-up
Close follow up is a fundamental pre-requisite of KMC. The
infant is followed once or twice a week till 37-40 weeks of
gestation or till he/she reaches 2.5 to 3 kg of weight. Thereafter,
a follow up once in 2-4 weeks may be enough till 3 months of
post-conception age. Later the baby should be seen at an interval
of 1-2 months during first year of life. The baby should gain
adequate weight (15-20 gm/kg/day up to 40 weeks of post-
conception age and 10 gm/kg/ day subsequently). More
frequent visits should be made if the infant is not growing well
or his condition demands.

Barriers and enablers of kangaroo mother care

To support kangaroo mother care implementation, one needs
context-specific materials, including guidelines, sociocultural
norms and behaviour change materials. In addition, systematic
training curriculums for health care professionals and mothers,
and bed side job aids are needed.
The stress associated with birth of a preterm neonate is
compounded by lack of knowledge about KMC among parents,
families and health-care workers. This eventually leads to
hindrance in ‘buy-in’ and support from parents and families for
practicing KMC. These barriers can be overcome by clear
articulation of the benefits for mothers, newborns, caregivers and
health-care workers. Engagement of fathers in childcare can help
overcome these barriers. In addition, team work and
collaboration amongst health care providers can work wonders.

Kangaroo mother care should be practiced systematically and

consistently with motivated trained staff, targeted education of
 AIIMS Protocols in Neonatology

staff and parents, clear eligibility criteria, and improved referral

practices and creation of community group in kangaroo mother
9,10
care participants through support groups.

References
1. Ludington-Hoe SM, Hadeed AJ, Anderson GC. Physiological
response to skin to skin contact in hospitalized premature infants. J
Perinatol.1991; 11: 19-24
2. Whitelaw A, Heisterkamp G, Sleath K, Acolet D, Richards M. Skin
to skin contact for very low birthweight infants and their mothers.
Arch Dis Child 1988; 63(11):1377-81.
3. Sloan NL, Camacho LW, Rojas EP, Stern C. Kangaroo mother
method: randomized controlled trial of an alternative method of
care for stabilized low-birthweight infants. Maternidad Isidro
Ayora Study Team. Lancet 1994; 344(8925):782-5.
4. Charpak N, Ruiz-Pelaez JG, Charpak Y. Rey-Martinez Kangaroo
Mother Program: an alternative way of caring for low birth weight
infants? One year mortality in a two cohort study. Pediatrics 1994;
94(6 Pt 1):804-10.
5. Conde-Agudelo A, Belizán JM, Diaz-Rossello J, Jose L. Kangaroo
mother care to reduce morbidity and mortality in low birthweight
infants. Cochrane Database Syst Rev. 2016August 16; (3):CD002771.
6. Udani RH, Nanavati RN. Training manual on Kangaroo mother
care. Published by the Department of neonatology. KEM Hospital
and Seth GS medical college Mumbai. September 2004.
7. Website of KMC India Network. Guidelines for parents and health
providers are available online at www.kmcindia.org17.
8. World Health Organization. Kangaroo mother care: a practical
guide. Department of Reproductive Health and Research, WHO,
Geneva.2003.
9. Johnson AN. Factors influencing implementation of kangaroo
holding in a Special Care Nursery.MCN Am J Matern Child Nurs.
2007. Jan-Feb;32(1):25–9.
10. Eichel P. Kangaroo care: Expanding our practice to critically III
neonates. Newborn Infant Nurs Rev. 2001;1(4):224–8.