KANGAROO MOTHER CARE METHOD

TRAINING MANUAL
SCIENCE AND TENDERNESS

EPIDEMIOLOGY OF PRETERM AND LOW BIRTH

WEIGHT INFANTS
HISTORY AND PRINCIPLES
 KANGAROO MOTHER CARE LEARNING PORTAL
For the implementation, strengthening and updating of KMC programs

The Ministry of Health and Social Protection of Colombia, the World Food Program of the United Nations with the
technical support of the Kangaroo Foundation, prepared this training kit for all health professionals in charge of
preterm or /and low birth weight infants .

This tool summarizes the knowledge and experience gained by pediatricians, nurses, psychologists, social work-
ers, physiotherapists, ophthalmologists, optometrists in the management of these children.

The goals of this tool are to support the dissemination of the Kangaroo Mother Care Method, to decrease infant
morbidity and mortality worldwide and to improve the quality of survival of preterm and Low Birth Weight in-
fants. The original version was released in Spanish and can be found on this website.

Maternal and Child Health Integrated Program (MCHIP), and JSI Research & Training Inst. supported the
finalization of the English version. The coordination of this English version was assured by:

Dr. Nathalie Charpak,

Pediatrician, Kangaroo Foundation ‘ Scientific Director

Dr. Hélène Lefèvre-Cholay,

Neonatologist, senior advisor for KMC, JSI Research & Training Inst.

This Learning Portal is developed for professionals who have received a theoretical and a practical training in a
KMC implementing site.This training kit is prepared only for educational purposes, and should not be used for
profit activities.

All rights reserved. No part of this publication including videos may be reproduced, stored in a retrieval system,
or transmitted, in any form an by any means, electronic, mechanical, photocopying , recording or otherwise,
without the prior written permission of the Kangaroo Foundation, or the authors.

The videos and photographic material used in this Learning Portal received the appropriate authorization from
the parents and / or guardians of the preterm infants.

SCIENCE AND TENDERNESS

Contents
1. TARGET AUDIENCE AND OBJECTIVES OF THE KMC TRAINING KIT 4
2. Introduction 5
3. Epidemiology of prematurity and of low birth weight in the world 9
4. History of the Kangaroo Mother Care Method 12
5. Concept of the Kangaroo Mother Care Method 16
5.1 Characteristics of the Kangaroo Mother Care Method 16
5.1.1 Target population of KMC: 17
5.2 The Kangaroo Position (KP) is the “hallmark” of the KMC method. 17
5.2.1 Reference definition of kangaroo position 17
5.2.2 Variation of Kangaroo Position 18
5.3 The Kangaroo Feeding and Nutrition Strategy based on breastfeeding 19
5.3.1 Reference definition of the Kangaroo Feeding and Nutrition Strategy 20
5.3.2 Clinical objectives. 20
5.3.3 Variations: Kangaroo Mother Care Nutrition strategy. 21
5.4 Early Discharge and Outpatient Follow-up 21
5.4.1 Reference definition of “early discharge” 22
5.4.2 Objectives of “early discharge” 23
5.4.3 Variations and contrast with the definition of reference 23
5.4.4 Systematic outpatient follow-up 23
5.4.5 High-risk Follow-up 23
6.Different ways of implementing the KMC Method 24
6.1 As a complement to the incubator 24
6.2 As a substitute to the incubator 24
6.3 To limit the separation between mother and infant 25
7. Objectives of the Kangaroo Mother Care Method 26
BIBLIOGRAPHY 27
 1. TARGET AUDIENCE AND OBJECTIVES OF THE KMC
TRAINING KIT

I
n order to give every new-born the best quality of care—especially those born
prematurely or with a Low Birth Weight (LBW)— the practices and knowledge
of health workers and others caring for pregnant women, new mothers, and
new-borns babies must improve following the most recent evidence-based
technologies. At dawn of the 21th century it is necessary that we train every
neonatologist, paediatrician, nurse and other health professionals in charge of
preterm or LBW infants in the Kangaroo Mother Care (KMC) Method. This can
be achieved by training more perinatal health workers who, in turn, can update
the knowledge and skills of those caring for preterm or LBW infants immediately
after birth and during the post natal period, including a follow-up period up to
one year after birth for these high risk children.

The Kangaroo Mother Care Method
training Kit is developed to improve in
a comprehensive and dynamic way the
quality of care for preterm and LBW infants.
In particular, it pays special attention
to the harmonious development of the
underdeveloped brains of these children
and the importance of reinstating the role
of the mother and the family as the first
caretaker for their child.
4 KMC implementation.
It is developed specifically to be used by
health care professionals already trained
in Kangaroo Mother Care Method as a
tool to disseminate and transfer easily the
KMC knowledge to health professionals
working with preterm and small infants
in their own country (neonatologists,
pediatric nurses, midwives, in maternity,
in neonatal wards, in Neonatal Intensive
Care Units, as well as those in charge of
ambulatory care after hospital discharge).
If you are a heath care professional
interested in KMC this kit should not
be used as a self-learning tool as it is
important for trainees to be exposed to
successful KMC practice to understand
the dynamic of KMC under the guidance
of a trained multidisciplinary team. KMC
transfer knowledge is based on theoretical
knowledge but also on exposure to clinical
practice guided by an experienced staff in
The objective of the KMC training kit is
to improve the quality and outcome of
care for preterm or LBW infants and for
the mothers and their family by updating
and upgrading the professional and
managerial knowledge and skills of
health care providers at all levels.
The format of the training is based on
multidisciplinary collaboration, adult
learning methods, group work, case

SCIENCE AND TENDERNESS


studies, exercises, plenary sessions
and videos. It is mandatory to organize
supervised clinical practical sessions
during which participants will learn
how to place infants in the Kangaroo
position, assess breastfeeding, and to
attend outpatient follow-up visits.
The material contained in the KMC
training Kit is arranged in modular
form and can be adapted to meet the
needs of any professionals who care for
preterm and or LBW infants at time of
birth, during the neonatal period, or
during the outpatient care period. It
is a flexible tool that can be adapted to
the local conditions.
The training kit is composed of7
modules; each contains a narrative section
and a “ready-made” training component,
including specific slides and comments
on the most important topics of each
module. We recommend that future
facilitators carefully read the narrative
part and complete with few slides the
“ready-made” part. Each module can be
used individually, but ideally facilitators
should use all of them in the proposed
order.
Several videos were developed to support
different modules, such as the Kangaroo
position, the Kangaroo nutrition, and
specific topics such a massage or nasal
cleaning. The kit indicates the ideal time
to use each video during the learning
process.
The special module#7 was developed
TARGET AUDIENCE AND OBJECTIVES OF THE KMC
TRAINING KIT
for the administrative personnel of
health institutions, describing how to
implement and support the KMC.
Psychologists working with this category
of children will also find a specific
module (# 6) detailing the different neuro
psychomotor assessment tools, and
the solutions to the different problems
identified.
The KMC training kit is based on
existing materials developed and used
by the Kangaroo Foundation in Bogotá
Colombia since 1994and the experience
gained in several countries in the past
decade.
Updating and upgrading skills is not always
enough to improve outcomes, therefore,
the KMC training kit also includes tools
which allow the health care providers
to question ,and in some cases discard,
routine practices which were previously
considered to be appropriate or even
essential. The process of changing and
discarding old and familiar methods of
practice takes courage and an open mind.
Moving from a rigid health care system 5
to one that is more open and infant¬-
mother-centered is a strenuous process,
but it breeds hope for the future. This
course is designed to encourage health
professionals and policy-makers to enter
this questioning process.
This kit is open, and each facilitator is invited
to upload videos from his or her own KMC
program and participate actively in the
forum
SCIENCE AND TENDERNESS
 2. INTRODUCTION

W
e would like to initiate this training kit by quoting Drs. N. Charpak and J.G.
Ruiz: “The arrival of the new millennium is an excellent pretext to take a
step back and assess what we are doing and the way in which things are
becoming our own life projects. In our case, it refers to the care of the premature
and/or low birth weight infant)”. i

struggle for survival of a sick infant and

his mother to a gradual and progressive
capacity to understand and help the
immature and altered physiology of
the newborn with increasing success.
Too often along the way, parents were
physically and emotionally separated
from their sick babies. Children were
progressively placed in an increasingly
complex technical environment. All
this was, of course, done with the
most altruistic intentions, to improve
the babies’ condition with the pseudo
support of “science and technology.”

The progress of the 20th Century has

not been uniformly disseminated.
6 Improvement in quality of life is
clearly concentrated in industrialized
countries, while conditions have
changed very little in many developing
countries. It has been estimated that
approximately 90% of LBW infant births
During the past century medical occur in less developed countries, while
technologies have experienced 90% of the investment to care for high
exponential and explosive risk infants takes place in industrialized
development. During this period, countries. These fragile neonates, born
the role of the health care providers, in economically powerful societies,
including physicians, has gone from seemed doomed to a strange destiny:
being an almost helpless witness of the in order to survive they had to be

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separated from their parents and placed
in the efficient but inhuman environment
of medical technology. Preoccupation
with biomedical factors obscured
common sense to extremes which are
hard to believe. Painful procedures are
routinely performed without regard
for the “nightmare” experienced by a
completely defenseless child. In order
to receive care-temperature regulation,
prevention of infection, monitoring of
vital signs and support of physiological
functions-the infant is submerged in
noisy, harshly lit, aggressive and invasive
environments.
The fate of preterm and/or low birth
weight infants in developing countries
has been even stranger. Access to
sophisticated and costly technology
was and continues to be difficult. In
many cases, neonatal care units, having
few health staffs and limited medical
equipment, could not circumvent deadly
traps: overcrowded incubators, deficient
monitors, nosocomial infection, etc.
Fragile children in developing countries
are not experiencing the true and
complete advantages of technology,
because good quality technology is
rarely available.
The ghost of dehumanized medical
care, associated with technological
advances is also spreading widely to
developing countries, regardless of
how scarce technology may be. It is
INTRODUCTION
essential to merge the best practices
of both worlds.
Newborns, regardless of their place of
birth, must have the right to receive
the best possible quality of care from
biomedical technology, psychological,
emotional and “human” perspectives.
In many places and times, health care
professionals paid attention to the
need to provide humanized care to
infants and families. In 1907,Budin ii
defended the active involvement of
mothers caring for their hospitalized,
sick newborns. Miller, in 1948, provided
home care to preterm infants in the
United Kingdom (UK). Klaus & Kennel
in 1976, among others, emphasized the
importance of physical and emotional
contact between the mother and the
baby immediately after delivery to
support the development of a strong
and healthy bond.
Knowledge about newborns
experiencing pain is relatively recent
and has led to questions regarding the 7
need for sedation and analgesia during
exhausting and/or painful procedures.
In developing countries, there have
been efforts to create methods
appropriate to limiting conditions,
while providing adequate care. For
example, in 1978, Edgar Rey, in Bogotá,
Colombia began what is now known
as the Kangaroo Mother Care Method
SCIENCE AND TENDERNESS
 INTRODUCTION
(KMC), as a response to a shortage
of incubators and to the separation
of mothers and infants. Continued
and prolonged skin-to-skin contact,
breastfeeding, and early discharge
constituted the foundation of this
intervention, which allowed mothers
to return to their role as primary
provider for their fragile babies’
physical and emotional needs. His
work, a pioneer in this field, has been
carried out and developed by others,
and today, different modalities of the
KMC are provided both in developed
and developing countries.
Interventions such as KMC have been
conceived and implemented initially
in countries where technical resources
for appropriate care were neither
available nor accessible. For this
reason, it was mistakenly considered
as an alternative for the “poor”. This is
no longer true. KMC is physiologically,
humanly and emotionally appropriate
for the newborn needs; it has already
8 been integrated in initiatives such
as family-centered care or NIDCAP 1 ,
which have been created in wealthy
countries with the same aim. These
interventions are not merely medical,
but an intro d uc t i o n to a s ys te m o f
hu man val ues, moved b a ck ward s
by s cientif i c k nowled g e, i n t h e
hig hly tech ni ca l ro ut i n e ca re o f t h e
you ngest o f o ur s p eci es.
SCIENCE AND TENDERNESS
These modalities of care for preterm
newborns are not against medical
care based on technology, nor are
proposed as alternatives to it. They
are their allies, and their authors
and promoters are scientifically well
trained physicians, who recognize and
value the role of highly sophisticated
neonatal units and technology in the
neonate’s survival and quality of life.
Advances in neonatal medicine have
notoriously contributed to the increased
survival of children born prematurely
and or with LBW.
Critical stages of respiratory, metabolic,
and infectious disorders tend to resolve
with greater success each time; however,
recovery periods following these crises
tend to be prolonged and it is then that
the environmental impact of neonatal
units is inadequate for the integral
development of the infant and his
family. In this manual, we will cover the
KMC from the time it may begin—which
varies according to the infants, their
families and the institutions—until the
child has a corrected age of one year.
1
The care system for newborns known as NIDCAP
(Neonatal Individualized Developmental Care and
Assessment Program), places parents as their baby’s
primary caretakers and promotes the treatment of the
baby according to his developmental level. It also im-
proves the prognosis of low birth weight neonates and
reinforces their attachment with their parents.
 3. EPIDEMIOLOGY OF PREMATURITY AND OF LOW
BIRTH WEIGHT IN THE WORLD

P
reterm and LBW infants represent a public health burden, especially in develo-
ping countries. In 2007 UNICEFiii studies on LBW infants report that every year
more than 20 million of infants are born prematurely or at term with a low birth
weight. This represents 17% of all births in the developing world, double as compared
to the rate of industrialized countries (7%).

A LBW infant is defined by the World Health Organization (WHO) as an infant born with
a weight of 2,500 g or less. This definition is based on the epidemiologic observation
that children weighing ≤ 2,500 g at birth have 20 times more probability of dying than
heavier children.

WHO has identified the main causes of low
birth weight as the following:
- Premature delivery before 37 week of
gestation(idiopathic in50% of case)
- Intrauterine growth retardation
- Maternal poor nutrition including vitamin
A, iron, folic acid, and zinc deficiecy
- Maternal arterial hypertension
- Multiple pregnancy ( twin, triplets)
- Teenage pregnancy
- Mother exposed to intensive workload.
- Stress, anxiety, and other psychological
factors including domestic violence
- Active and passive smoking
- Acute and chronic infection during
pregnancy: malaria, bacterial bacteriuria
In reality60% of infants born around the
world are not weighed, and the lack of
comparable data makes it difficult to
evaluate progress. No precise data have
been published on the global incidence of
preterm birth, but in 2010 WHO estimated
that premature births represents 9.6 % of
all births in the world, 85% of them being
concentrated in Africa and Asia.
As the gestational age is sometimes
unknown, WHO uses the term small infant
both for preterm and LBW infants.
Data from some developed countries
(United Kingdom, the United States, and
Scandinavian countries) show a dramatic
rise of LBW infants over the past 20 years.
Factors possibly contributing this upward
trend include:
• Increased proportion of births among
women over 34 years of age
• Greater use of assisted reproduction
techniques leading to more multiple births
9
• Changes in clinical practices (greater use
of elective Caesarean section, increasing
use of early ultrasonography to estimate
gestational age and resulting in larger
numbers of births being classified as
preterm).
• Changes in the definitions of fetal loss,
stillbirth and early neonatal death.

SCIENCE AND TENDERNESS

 EPIDEMIOLOGY OF PREMATURITY AND OF LOW
BIRTH WEIGHT IN THE WORLD

Percentage of LBW infants in some regions (1999-2006)

The map of premature and LBW births is superimposed to the world map of poverty.
90 % of these children are born in developing countries, with higher risk for presenting
physical, neuro-psychomotor and neurosensory sequels, as well as chronic illness, such
as cardiovascular diseases and diabetes in the adult years and risk of early death. Their
Intellectual Quotient (IQ) is usually 5 to 10 points below the standard, and they may
develop long term hearing and visual impairments.

Every year, around 4 million children die before reaching 28 days of life (neonatal
period). LBW infants are40 times more likely to die before reaching one month of age
and account for 1/3 of infant deaths.

10

2
CEE: Central and Eastern European Countries; CIS: Commonwealth of Independent
States (former soviet countries)

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 EPIDEMIOLOGY OF PREMATURITY AND OF LOW
BIRTH WEIGHT IN THE WORLD

Infant mortality

Almost 40% of all deaths in children younger than 5 years of age occur during the
neonatal period during the first year of life. Therefore, improving neonatal survival is
essential to reduce infant and child mortality.

The interventions listed below, were selected based on current scientific evidence and
on the analysis of their feasibility and potential for reducing neonatal morbidity. These
interventions could be included in the different levels of care offered in different health
systems.KMC has been proposed as one of the low cost interventions to decrease
infant mortality.

Stages Interventions
Pre-conception Folic acid supplementation to prevent neural tube defects

Antenatal Screening and treatment of syphilis

Prevention of pre eclampsia and eclampsia
Tetanus immunization
Preventive treatment for intermittent Malaria
Treatment of anemia
Diagnostic and treatment of asymptomatic bacteriuria

Intrapartum Antibiotic for premature rupture of membranes

Corticosteroids during preterm labor
Recognition and management of breech delivery
Early diagnosis of birth complications
Aseptic delivery procedures 11

Post-partum Adequate adaptation and resuscitation of the newborn

Prevention and management of hypothermia
Breastfeeding
Kangaroo Mother Care (for Low Birth Weight infants)
Pneumonia case management in the community

Table 1.Efficient low cost interventions to decrease mortality in low birth weight
infants, Lancet 2005

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 HISTORY OF THE KANGAROO MOTHER
CARE METHOD
For over 30 years, the KMC has proposed to
the world a new alternative to care for preterm
and/or LBW infants. The comprehensive or
limited use of its different components (skin-
to-skin contact, kangaroo position, kangaroo
nutrition - exclusive breastfeeding, and policy
of early discharge in kangaroo position
under strict outpatient follow-up), is based
on scientific evidence of their benefits—
effectivivity in decreasing morbidity and
mortality in preterm and LBW. KMC creates
a hope for many newborns in settings with
limited resources.
4. HISTORY OF THE KANGAROO MOTHER CARE
METHOD
12
I
t is very likely that isolated cases of
managing preterm infants through skin-
to-skin contact existed in some native
SCIENCE AND TENDERNESS
The KMC has thus challenged the traditional
practices by returning parents to a central
role in the physical and emotional recovery
of their baby and healing the parents’
trauma of having given birth to a preterm
infant. The motto of not separating a mother
from her infant, even immediately following
delivery, continues to question multiple
aspects of medical care in delivery rooms
and neonatal units around the world.
Go to video: Kangaroo
Mother Care Method.
populations of the African or American
continents, most likely with good results.
Nevertheless, it was onlyin 1978 in Bogotá,
Colombia in the Instituto Materno Infantil–
(IMI)—the biggest public maternity in the
country, with 20,000 deliveries per year—
that Dr. Edgar Rey Sanabria, Chief of the
Neonatology Department and professor of
Pediatrics at the Universidad Nacional de
Colombia, facing a shortage of incubators,
decided to use mothers routinely as a source
of warmth. He initiated what became known
as the Kangaroo Mother Care Method, for
all “healthy” newborns with birth weight
less than 2 000g.

In addition to the shortage of incubators,
several different factors influenced the
creation of KMC:
- A high morbidity/mortality rates in preterm
and LBW infants hospitalized in overcrowded
departments and subsequent innumerable
nosocomial infections.
- A high incidence of infant abandonment
likely due to prolonged mother-infant
separation.
- An intimate conviction of the benefits of
breast milk for hospitalized preterm and/
or LBW infants. Breast milk for hospitalized
infants was not available due to the prolonged
separation from their mothers.
- The conviction that the incubator’s warmth
could be replaced, in a natural way, by the
direct contact with the body the infant’s
mother.
- The observation of LBW infants who survived
due to the care of mothers or grandmothers
who placed them skin-to-skin on their laps.
Guided by these thoughts, Dr.E Rey Sanabria
decided to establish an outpatient program
for LBW infants that he called “Kangaroo
Mother Program.”In this program, regardless
of weight or gestational age, once a preterm
or LBW infant was stable and did not need
any treatment except to be kept warm and
fed, he was sent home with permanent skin to
skin contact on his mother’s chest, ideally day
and night, fed at will, tobe monitored through
frequent outpatient consultations.
In1979 and 1982, Drs. Hector Martinez and Luis
Navarrete systematized outpatient follow-up
visits for this new and revolutionary method.
They were concerned about the necessity
to train mothers to give proper care to their
HISTORY OF THE KANGAROO MOTHER
CARE METHOD
infants. They organized daily group lectures
on breastfeeding, nutrition, infant stimulation
and prevention of illnesses. Fathers and any
interested family members were invited to
these lectures. It was clear that in addition
to training these groups, gatherings create
solidarity and warm, humane feelings
towards the family, often facing difficult
socioeconomic situation as it was the case of
most of the population consulting with the
Instituto Materno Infantil, Bogota, Colombia.
From this experience, the three principles of
the method emerge: i) love: emotional contact,
sensory stimulation; ii) warmth: through the
Kangaroo Position and iii) exclusive mother´s
milk: providing nutrition and protection.
In 1981, after a visit to Bogotá, WHO conveyed
the message to European countries, and
several European experts traveled to Bogotá,
motivated and intrigued by the amazing
results on reduction of mortality rate reported
by the Instituto Materno Infantil group.
Following their visit, these professionals
exported the kangaroo position or skin-to-
skin contact component, which appeared in
Anglo-Saxon literature as Kangaroo Care.
Dr. Susan Wahlberg from Sweden, Dr. Andrew 13
Whitelaw, neonatologist and Kathy Sleath,
a neonatologist nurse both from United
Kingdom were the first to visit the KMC
program.
The first reports on the Colombian experience
were initially inspiring because of the
dramatic drop in mortality and abandonment
rates; however, upon further review the
data were not as precise as initially thought.
Even so, Whitelaw and Sleath considered
SCIENCE AND TENDERNESS
 HISTORY OF THE KANGAROO MOTHER
CARE METHOD
this “Kangaroo care” to be innovative
and very soon, reports on Kangaroo Care
implementations appeared in Europe. iv
National and international criticisms for
KMC were strong due to the lack of a formal
systematization of the method and the
absence of strict evaluation tools. Many
questions regarding this methodology
prevented neonatologists inside and outside
of Colombia to accept KMC.
In 1991, during the WHO 44th Plenary
Assembly, Doctors Rey Sanabria and Martinez
from Colombia received the Sasakawa Health
Prize3 for the Kangaroo Mother Program as
an appropriate method for the protection of
infancy.
In 1989, researcher Dr. N. Charpak initiated the
scientific evaluation of KMC and conducted a
prospective, observational study, following
two cohorts of LBW children for two years.
KMC was implemented for the first cohort,
the second one was using “traditional” care.
The main result was that KMC did not increase
the vital risk of preterm infants.
Between1993 and 1996, the same team
14 conducted a controlled random study using
new written guidelines for KMC—both for
hospital and outpatient management. This
study demonstrated that the KMC is effective
and justified as an alternative to incubators
once the baby is stabilized and adapted to
extra uterine life.
3 The Sasakawa Health Prize is given to one or more people,
institutions or non-governmental organizations that have
done outstanding work to foster health.
SCIENCE AND TENDERNESS
Dr Zita Figueroa and Dr Nathalie Charpak.
In 1994 the Fundación Canguro
(Kangaroo Foundation) was created in
Bogotá, Colombia, led by pediatricians
Dr. NCharpak and Z Figueroa and
epidemiologist J G Ruiz, with the
mission to humanize neonatal care.
The “Foundation”, continues the
systematic scientific evaluation of
the KMC. Moreover, the “Foundation”
facilitates the transfer of knowledge
regarding KMC, shares the results
through publications, and trains health
professionals who promote around the
world the high-quality management
of high risk newborns in a humane,
scientific, efficient manner, making
rational use of cost and resources.
In 2007, the Kangaroo Foundation and
The University Javeriana in Bogotá,
Colombia, published “Practical Clinical
Guide based on evidence for the
optimal use of the Kangaroo Mother
Care Method in the preterm and/or low
birth weight infant”. This publication,
with the objective of standardizing
the growing use of this methodology,
was translated to English and provided
freely to interested professionals.

At the end of 2010, the ”Technical
Guidelines for the Implementation
of a Kangaroo Mother Program
in Colombia” was published by
the Colombian Ministry of Social
Protection, together with the United
Nations World Food Program( WFP),as
an institutional support tool for health
providing institutions and hospitals
caring for preterm and LBW infants.
The KMC continues to be disseminated,
not only in Colombia but in the world
with a wide range of researchers in
developed and developing countries,
producing an ever-growing body of
scientific evidence to support a better
use of its components with preterm
and/or LBW infants as well as full-term
babies.
Asthis happens in Colombia, the
kangaroo position is also being
implemented in Europe and North
America. In Europe, implementation
of the KMC Method began with
descriptive and systematic studies of
the kangaroo position conducted by
Dr. A Whitelaw and K. Sleath. R. de
Leew followed this experiment and
started using the kangaroo position at
different times after birth. These first
studies confirmed that implementing
KMC was safe for preterm infants and
full term babies and beneficial for
parents, allowing positive emotional
bonding and parental empowerment
in infant care.
HISTORY OF THE KANGAROO MOTHER
CARE METHOD
In 1988, in the United States, Dr. G.
Anderson and S. Ludington v began the
first study of the effects of kangaroo
care in the neonatal care unit in Los
Angeles. Since then, they have been
investigating the kangaroo position
component. They are great advocates
of the position, not only for preterm
but also for full term babies.
Finally, in the 1990s, studies focused
back on the infant and his need to
interact with his parents. A wide
review made by G. Anderson in 1999
compiles these studies.
In 1996 the 1stInternational KMC
Meeting was held in Trieste, Italy. This
was the origin of the International
Network in Kangaroo Mother Care
(INK). Since then, bi-annual meetings
have been held in different countries
about various topics of world interest
with the aim of further developing the
Kangaroo Mother Care Method.
In 2008 Ludington developed guides
based on evidence to implement 15
Kangaroo Care in preterm infants of
less than 30 weeks gestational age.
In 2010, The United Nations Program
for Development (UNDP) recognized
KMC as an efficient tool to decrease
infant mortality in the world and to
achieve the Millennium’s Goal .
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 5. CONCEPT OF THE KANGAROO MOTHER CARE
METHOD

T
he Kangaroo Mother Care Method is primarily targeting the preterm and/or LBW
infants. This method has some degree of heterogeneity manifested from the
diversity of names by which it is identified in the literature such as: i) kangaroo
care, ii) kangaroo mother care, iii) Kangaroo Method, iv) Kangaroo Mother Care
Method, v) kangaroo mother intervention, vi) kangaroo technique, vii) Kangaroo
Program, viii) Kangaroo Mother Program, and ix) skin-to-skin contact.
The term “skin-to-skin contact” in particular has been frequently employed in Anglo-
Saxon literature to describe the kangaroo position.

5.1 CHARACTERISTICS OF THE KANGAROO MOTHER CARE METHOD 5

Since its creation in the 1970s, the method has evolved from the initial concepts,
incorporating modifications originated in practice and scientific research.

16 In order to characterize and understand Based on the specification of these

what the KMC is, it becomes necessary to
define some basic items such as: i) what
is the target population of the KMC, ii)
what is the kangaroo position (KP), iii)
how breastfeeding-based feeding and
nutrition is understood and iv) what are
the kangaroo discharge policies and
ambulatory follow-up.
characteristic elements of the KMC, a
typical, basic, or reference scenario is
defined, which characterizes the elements
and circumstances of implementation
of the KMC. This scenario contains the
components considered fundamental in
KMC.

5This part has also been adapted and modified from the document “Practical Clinical Guides based on evidence for
the optimal use of the Kangaroo Mother Care Method in the preterm and/or low birth weight infant.

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5.1.1 TARGET POPULATION OF KMC:

Kangaroo Mother Intervention is offered to preterm (<37 weeks gestational age)and/

or LBW infants (≤ 2500g), as soon as it is possible and prudent to do so and if the child
is able to tolerate it, meaning that they have stable vital signs, no bradycardia, no
hypoxemia when manipulated and no primary apnea or, if present, apnea is controlled.

Kangaroo intervention does not replace neonatal care units, but rather
complements health intervention performed with the newborn.

Observation of nearly12.000 “kangaroo” children, shows that when they reach 2,500
grs, nearly 95% of children rejected the kangaroo position(Kangaroo Foundation,
unpublished data).

Full term babies6 with weight adequate for gestational age may benefit from the
kangaroo position for a limited duration during day time and for a limited number of
days, as long as he tolerates being placed and maintained in skin-to-skin contact.

5.2 THE KANGAROO POSITION (KP) IS THE “HALLMARK” OF THE KMC METHOD.

5.2.1 REFERENCE DEFINITION OF KANGAROO POSITION

17

6There is evidence about the positive effect of the kangaroo position on breastfeeding and on the mother-infant relationship. These effects
are similar in direction, although not necessarily in magnitude, to that obtained in preterm or LBW infants. This manual does not offer recom-
mendations for the use of the KMC in healthy full term babies.

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The infant is placed almost naked (except a cap, diaper, and socks) in a strict, upright
ventral position between the mother´s breasts, in direct contact with her skin, under
her clothes, 24 hours a day. Mothers in KP maintain the infant’s temperature; they are
also the main source of nutrition and stimulation. A cloth support (cotton or elastic
material) is used to allow the provider of the kangaroo position to relax or even sleep
while the baby is permanently kept in KP.

The cloth support helps to prevent the child’s airway from being obstructed by changes
in position (e.g. flexion or hyper-extension of the neck). This is particularly important
as usually preterm infants are hypotonic.

• The baby may be fed at any time, while and still in KP.

• Any other person (e.g. the father), can share the mother role, carrying the baby in KP.
The provider must sleep in a semi-sitting position (30°).

• The KP is maintained until the baby no longer tolerates it. The child will show he
no longer tolerates it by sweating, scratching, screaming or by any other clear
demonstration of discomfort, each time his mother places him in KP.

In Kangaroo position the child finds in his mother as a permanent source of heat, kinetic
and tactile stimulation, while maintaining his air way open. The position stimulates
and improves breastfeeding. Moreover, the intimate and prolonged contact between
mother and infant seeks to establish or reinforce a healthy biologic and affective bond
that should exist between every newborn and his mother. The establishment of this
bond is hampered by the child´s prematurity and/or illness and by traditional practice
where mother and preterm child are separate.

The Kangaroo Position must be:

a) As continuous as possible, with minimum possible interruption,
18
b) Prolonged for the longest possible time, if possible day and night,
c) Lasting for as many days or weeks as the child needs it.

5.2.2 VARIATION OF KANGAROO POSITION

Different health institutions, facing different problems, are using KP in different ways.
The differences concern3 aspects:

Time of initiation:
The initiation of KP has been described at different periods once the preterm infant has

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 CONCEPT OF THE KANGAROO MOTHER
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been stabilized, including from few minutes afterbirth up to the time of hospital discharge. The
kangaroo position has also been described as part of the early stabilization maneuvers.

Continuity of the position:

While some seek the position to be maintained 24 hours a day, others place the infant on
the mother´s chest intermittently (alternating with incubator) for periods of minutes to a few
hours. This intermittent mode is mostly employed with fragile but stable children, looking to
strengthen the mother¬¬-infant bond and breastfeeding.

Duration of Kangaroo position :

There are different scenarios: only during hospitalization; others maintain KP after hospital
discharge.

Regardless of the time of initiation, continuity and duration of the kangaroo position, all these
alternatives may be identified as variations of the KMC, as long as the previously described
definition is satisfied: carrying the baby in kangaroo position. It is not possible to talk about
Kangaroo Mother Care Method, if the baby is never placed in kangaroo position.

Other approaches that involve parents in caring for their fragile newborns or efforts done to
humanize neonatology—for example, by changing the micro-environment (e.g. carrying the
baby, breastfeeding, NIDCAP, massage, etc.)—but in which the baby is not held in kangaroo
position, are not part of the range of variables identified as Kangaroo Mother Care Method.

5.3 THE KANGAROO FEEDING AND NUTRITION STRATEGY BASED ON BREAST-

FEEDING

with adequate weight or preterm infants

with intra-uterine growth retardation.
Additionally, within the ”preterm category”
are included almost mature, near full term
(e.g. 35-36 weeks) infants, moderately 19
preterm infants, and very preterm infants
(23-28 gestational weeks with birth weight
less than 1,000 g). The nutritional needs
and capacity to be fed can also change in
cases of illnesses or complications during
the transitional period.

It is generally accepted to recognize 3

The nutritional needs of a preterm and a LBW periods in the post natal period for preterm
infant are different. Newborns with the same infants. Each period determines the feeding
birth weight may be full term babies with and nutrition strategies for the preterm, low
intra-uterine retardation, preterm infants birth, and/or sick infant.

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- The transitional period, from birth until adaptation to extra uterine life has been
completed (usually 7-10 days).During this time it may be necessary to use parenteral
nutrition and/or to use adaptive strategies to use enteral feeding.

- The period of “stable growth”, from the end of the transition period to 40 weeks of GA.
Similar to the period of intrauterine growth, this may have occurred if the newborn was
not preterm. During this period, enteral feeding is usually, predominantly oral.

- The post-discharge period, from term (or hospital discharge, usually 4-8 weeks after birth)
to 1 year of corrected age.

5.3.1 REFERENCE DEFINITION OF THE KANGAROO FEEDING AND NUTRITION

STRATEGY

The child´s feeding and nutrition strategy within the KMC framework is based on the
following key points:

- Target population. The kangaroo feeding strategy is designed for children who are
in the”stable growth period.”The feeding strategies in the transition period are not
considered in this manual. Similarly, the feeding strategies during the post-discharge
period, even though they are in continuity with the feeding process initiated during the
period of stable growth, exceed the scope of this document.

- Feeding source. The child’s fundamental source of nutrition is the milk of the child’s mother,
and it should be used whenever possible. The mother´s milk is always supplemented with
A, D and K vitamins. Mother’s milk may also be fortified or supplemented when necessary.
The use of human milk from a donor with similar gestational age, may be considered as
long as it is collected, pasteurized, and its benefits and nutritional value are preserved.

20 - Feeding modalities. Feeding may be done through direct suction or through the
administration of the mother´s milk, previously extracted. If extracted, it can be administered
orally or through gavage more often through intermittent gavage.

5.3.2 CLINICAL OBJECTIVES.

Feeding is based on the milk of the infant’s motherto take advantage of all benefits
of non-modified human milk, especially its immunological properties, its balanced
composition of essential nutrients, and its safety profile with respect to the risk for
enterocolitis. To start, breast milk is administered at fixed intervals, to ensure minimum
nutritional intake.

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 CONCEPT OF THE KANGAROO MOTHER
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The goal is to reach a weight gain similar to the usual growth during the intra
uterine life (15 g/kg/ day until full term).

If this goal is not reached through exclusive breastfeeding (supported by intensive

intervention - kangaroo adaptation - including strategies for initiation and
establishment of breastfeeding), it is necessary to identify and to correct conditions
which may explain inadequate weight gain (e.g. anemia, infection, hypothermia, non-
adherence to kangaroo position, etc.).

Once the abnormal condition is corrected, growth must improve. If not, or if there
was no secondary cause for inadequate growth, breast milk should be fortified or
supplemented with special preterm formula, administered with dropper, cup, or
spoon so as not to interfere with breastfeeding. The goal is to supplement 30% of
the theoretical daily caloric intake. After at least one week of adequate growth, it is
recommended to decrease progressively the supplementation in order to reach 40
weeks gestational age, ideally with exclusive breastfeeding.

5.3.3 VARIATIONS: KANGAROO MOTHER CARE NUTRITION STRATEGY.

In some case, infants are placed in the KP despite the fact that they cannot benefit
from the kangaroo feeding strategy based on breast milk. It is the case for infants
unable to suck and swallow, or those receiving parenteral or gastric gavage, or in those
cases where lactation is not a possiblility (an adopted child kept in kangaroo position
by the adoptive parents, death of the mother, absolute or relative contraindications
for breast milk). In such cases this component of the KMC Method cannot be applied,
but it is still a Kangaroo Mother Care Intervention, if the kangaroo position is being
employed correctly.

21
5.4 EARLY DISCHARGE AND OUTPATIENT FOLLOW-UP

“Early,” timely discharge in kangaroo position is one of the basic components of the
KMC Care Method. This early discharge, accompanied by a close and strict outpatient
follow-up program, is a safe and efficient alternative to keeping infants in Neonatal
Units during the phase of “stable growth.”7 The child, though discharged, continues to
receive care of similar quality to that received in the minimal neonatal care unit. Early
discharge prevents undue exposure to nosocomial risk and allows the infant to be fully
integrated into his family, physically and emotionally.

7 as defined in 1.5.2 in this module

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5.4.1 REFERENCE DEFINITION OF “EARLY DISCHARGE”

KMC Method is a continuous process. Both kangaroo position and feeding are initiated
at some point during hospitalization; it is the beginning of the kangaroo adaptation
and it continues for as long as the child requires it, independent of whether or not
child is still in the hospital. In fact, when mother and child successfully adapt to the
kangaroo position and feeding, there is little the hospital can offer that cannot be
provided in an appropriate outpatient environment. Therefore, in-hospital kangaroo
adaptation can be seen as a preparation process for the mother and child to have a
timely, safe, and successful discharge, and to be able to maintain the kangaroo care at
home for as long as the child requires it.

A “kangaroo” child is eligible for home-based kangaroo care as soon as the following
conditions are achieved:

• Kangaroo adaptation is achieved, including kangaroo position and kangaroo nutrition

for mother and infant.
22 • The child is able to coordinate sucking, swallowing and breathing.
Some Kangaroo Mother Programs are discharging to outpatient care children fed
through “gavage” given by the mother after proper training, or by oral administration
(cup, spoon, and dropper).
• The family is willing and able to follow the protocols and recommendations of the
program as well as the follow-up policy.
• The child and family have access to a systematic, rigorous and well established
outpatient management and kangaroo follow-up program.

Children are discharged from the hospital regardless of their weight or gestational
age. Once at home, children are maintained in kangaroo position 24 hours a day,
until they reject it.

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5.4.2 OBJECTIVES OF “EARLY DISCHARGE”

The Kangaroo Mother Care Method allows a gradual transfer of the responsibilities of
the physical and emotional care of the child from the health personnel to the family,
particularly the mother (and any other kangaroo position provider accepted by the
family, such as the father, grandparents, etc.).

5.4.3 VARIATIONS AND CONTRAST WITH THE DEFINITION OF REFERENCE

DESTINATION AT DISCHARGE
Discharge criteria for home kangaroo care:
Regardless of weight or gestational age, the mother and child can be discharged as
soon as they achieve successful kangaroo adaptation (kangaroo position and nutrition).

Likewise, at home the family should be willing and able to strictly follow the
recommendations, protocols, and follow-up policies, and the KMC Program must
guarantee close and timely follow-up visits and be able to provide emergency care to
the child in outpatient care.

Discharge criteria to be admitted to Kangaroo ward (mother and “kangaroo” child

accommodation): Upon discharge from Neonatal Units, the child may be referred
to special department where mother and child are together or going directly home.

5.4.4 SYSTEMATIC OUTPATIENT FOLLOW-UP

After discharge, children are reviewed daily with weight monitoring until they reach a
daily weight gain of 15 g/Kg/day. Then, they are reviewed weekly until they reach full
term (40 weeks gestational age) and 2,500 g.
23
Care provided in a outpatient KMC program is similar to care received in a “minimal-
care neonatal unit” and could be called “minimal outpatient neonatal care”. This care
includes systematic prophylactic treatment such as anti-reflux and prophylaxis of
primary apnea, and vitamins, etc. During this follow-up, ophthalmologic and neurologic
screening is conducted, including a brain echography.

5.4.5 HIGH-RISK FOLLOW-UP

It is necessary to complete this final stage of the KMC Method with a description of the
follow-up program of these high-risk newborns, which is done at least until the child has a
corrected age of1 year.

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 DIFFERENT WAYS OF IMPLEMENTING THE KMC METHOD

Often kangaroo children belong to the category of biologic high risk related to
inadequate somatic growth and/or for neuro psychomotor and sensory development
problems. While it is not exactly “kangaroo follow-up” as the child is no longer in
kangaroo position, it is considered essential that an appropriate follow-up be carried
out for high risk children, after completing the “normal” kangaroo follow-up (40 weeks
post conception age and 2,500 g). It is for these reasons that this training kit describes
the minimum activities that a follow-up program for high risk children should perform
on these very preterm or and or very LBW infants.

6. DIFFERENT WAYS OF IMPLEMENTING THE KMC

METHOD

T
aking into account the expectations and the level of development of the
institution or country, the KMC method may be used to achieve at once, one or
several goals. KMC may be implemented in 3 different ways.

6.1 AS A COMPLEMENT TO THE INCUBATOR

The few available incubators are used in addition to KMC. This approach is of special
interest to middle income countries as these countries do have, although in a limited
way, access to economic, technical, and human resources and are concerned with the
consequences of separating a mother from her infant. It has the enormous advantage
24
of having families actively participating in the baby´s care.

This is the most complete use of the KMC, since it achieves2 objectives: i) optimize the
use of the available human and technological resource and ii) allow the newborn to be
with his mother and his family as soon as possible.

6.2 AS A SUBSTITUTE TO THE INCUBATOR

In countries with no incubators, KMC represents a survival possibility for LBW infants.
We refer to poor countries, where there is no option apart from the KMC Care Method
for thermoregulation and nutrition of the LBW infant. We consider this implementation
of the KMC as a transitional alternative.

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Developing countries must insist on having adequate referral centers to receive these fragile
children, aiming not just for their survival but for the quality of their lives in order to deliver,
to their families and their countries, citizens who can contribute to its development. This
modality of the KMC is a first stage to decrease neonatal and infant mortality. KMC Method
does not treat illness; it is only implemented for caring for LBW and/or preterm infants,
without pathologies or with mild immaturity. Other children, with associated pathologies
will be at risk for death if they do not receive the specialized clinical care they may need.

6.3 TO LIMIT THE SEPARATION BETWEEN MOTHER AND INFANT

Where there is no limitation to access to high technology neonatal care, the KMC Method
and specifically the kangaroo position were introduced in order to foster the development
of the maternal-infant bond and breastfeeding.

Modern neonatology is usually quite aggressive for small infants admitted to a high
technology environment, where, in spite their vulnerability, they must face their first stage
of life overwhelmed by stress. NICU’s are rooms where small patients experience frequent
aggressive procedures, indiscriminate manipulation, interruption of sleep, unpleasant oral
medication, and excessive light and noise.

Immediate and long term effects of being placed under such stress vary. A 26 week-old
infant must tolerate in average 400 painful procedures before going home and will not
have slept more than 19 straight minutes during his hospitalization. The effects of such
cumulative stress is probably critical for brain formation, since several studies show that
some of the brain disorders of these children (in learning, behavior and motor problems)
can be attributed to the stress and pain suffered in neonatal unit.

The visiting schedule in most neonatal units does not depend on the mother’s or the
25
family´s wishes, but rather on what the medical staff of the hospital decides. The child
is nearly kidnapped in order to be cared for by ever rotating health teams. The mother,
though recognized as the child´s guardian, comes to be treated as a visitor, and, in many
cases physicians can even overlook the need to obtain her consent to order a procedure
that may prove traumatic or even unnecessary.

Key steps proposed that seek to humanize the care of LBW infants, promote breastfeeding
and the establishment of an early mother-infant bond, and propose several changes
in maternity wards around the world. These changes include early mother-infant
contact, kangaroo position when needed, joint accommodation, exclusive and frequent
breastfeeding and minimal contact with rotating health teams.

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Parents are a constant presence throughout any child´s life. Moreover, the family is one
of the most influential factors for the children´s future; and more so when there is a
developmental disorder.

7. OBJECTIVES OF THE KANGAROO MOTHER CARE

METHOD

The objectives of the KMC Method are to improve the health of preterm and/or LBW
infants in a global and comprehensive way and to humanize the care in neonatal units
both for children and their families. Therefore the following benefits are expected:

- Humanized hospital and outpatient care - Improved life prognosis, fostering an

for preterm and or LBW infants.
- Offer of specialized care, oriented toward
the quality of survival and the preservation
of adequate brain development.
adequate physical, neurological and psycho
social development in these children.
- Exclusive breastfeeding is promoted and
protected, as much as possible.

- Support of the development of attachment - Contribution to the decrease of child

between the infant and his parents as soon
as possible after birth.
26
- Empowerment through training of mothers
or caregivers by gradually transferring to
them the ability and responsibility of being
the baby´s caregivers, satisfying his physical
and emotional needs.
- Timely detection and treatment of any
sequels inherent to prematurity and low
birth weight during high risk follow-up (up
to a minimum of 1 year corrected age).
abandonment and abuse
Neonatology requires a change in the
paradigm concerning the care of LBW
infants regarding the participation and
leading role of the parents in their care.
The introduction of the KMC Method
allows this change in practice, since, in
order to implement it, units must not
only open their doors to parents but offer
a holistic approach: integrating parents
and transferring responsibility to them for
caring for their baby during his treatment.

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 Bibliography
i Charpak , Ruiz, Acta Pediatrica , Humanization of neonatal care 2000

ii Budin, P. (1907). Infant Nutrition. The nursling: the feeding and hygiene of premature
& full-term infants.

iii UNICEF, 207, State of the World, Statistical exam of an appropriate world for boys
and girls. Progress in infancy

iv Whitelaw, A., Heisterkamp, G., Sleath, K., Acolet, D., & Richards, M. (1988). Skin-to-skin
contact for very low birth weight infants and their mothers. Arch Dis Child 63, 1377-81.

v Ludington-Hoe, S. (2008). A Clinical Guideline for Implementation of Kangaroo Care

With Premature Infants of 30 or More Weeks Postmenstrual Age. Advances in Neonatal
Care Vol. 8, No. 3S , S3–S23.

27

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