Comparison of Skin-to-Skin (Kangaroo) and Traditional Care: Parenting Outcomes and Preterm Infant Development

PEDIATRICS Vol. 110 No. 1 July 2002, pp. 16-26 Ruth Feldman, PhD*, Arthur I. Eidelman, MD, Lea Sirota, MD and Aron Weller, PhD*

*Department of Psychology Bar-Ilan University, Ramat Gan, Israel Department of Neonatology, Shaare Zedek Medical Center, and Department of Pediatrics, Hebrew University School of Medicine, Jerusalem, Israel Schneider Children’s Hospital and Department of Pediatrics, Sackler School of Medicine, Tel-Aviv University, Israel

OBJECTIVE

To examine whether the kangaroo care (KC) intervention in premature infants affects parent-child interactions and infant development.

METHODS

Seventy-three preterm infants who received KC in the neonatal intensive care unit were matched with 73 control infants who received standard incubator care for birth weight, gestational age (GA), medical severity, and demographics. At 37 weeks’ GA, mother-infant interaction, maternal depression, and mother perceptions were examined. At 3 months’ corrected age, infant temperament, maternal and paternal sensitivity, and the home environment (with the Home Observation for Measurement of the Environment [HOME]) were observed. At 6 months’ corrected age, cognitive development was measured with the Bayley-II and mother-infant interaction was filmed. Seven clusters of outcomes were examined at 3 time periods: at 37 weeks’ GA, mother-infant interaction and maternal perceptions; at 3-month, HOME mothers, HOME fathers, and infant temperament; at 6 months, cognitive development and mother-infant interaction.

RESULTS

After KC, interactions were more positive at 37 weeks’ GA: mothers showed more positive affect, touch, and adaptation to infant cues, and infants showed more alertness and less gaze aversion. Mothers reported less depression and perceived infants as less abnormal. At 3 months, mothers and fathers of KC infants were more sensitive and provided a better home environment. At 6 months, KC mothers were more sensitive and infants scored higher on the Bayley Mental Developmental Index (KC: mean: 96.39; controls: mean: 91.81) and the Psychomotor Developmental Index (KC: mean: 85.47; controls: mean: 80.53).

CONCLUSIONS

KC had a significant positive impact on the infant’s perceptual-cognitive and motor development and on the parenting process. We speculate that KC has both a direct impact on infant development by contributing to neurophysiological organization and an indirect effect by improving parental mood, perceptions, and interactive behavior.

KEY WORDS

Kangaroo Care • parent-infant interaction • maternal depression • fathers • Bayley • infant development

ABBREVIATIONS

KC, kangaroo care • SD, standard deviation • GA, gestational age • NICU, neonatal intensive care unit • CRIB, Clinical Risk Index for Babies • BDI, Beck Depression Index • NPI, Neonate Parental Inventory • HOME, Home Observation for Measurement of the Environment • ICQ, Infant Characteristic Questionnaire • MDI, Mental Developmental Index • PDI, Psychomotor Developmental Index • MANOVA, multivariate analysis of variance

Received for publication July 26, 2001; accepted January 9, 2002.

The importance of skin-to-skin contact

There are now a multitude of studies that show that mothers and babies should be together, skin-to-skin (baby naked, not wrapped in a blanket), immediately after birth, as well as later. The baby is happier, the baby’s temperature is more stable and more normal, the baby’s heart and breathing rates are more stable and more normal, and the baby’s blood sugar is more elevated.

We now know that this is true not only for the baby born at term and in good health, but also even for the premature baby. Skin-to-skin contact and Kangaroo Mother Care can contribute much to the care of the premature baby. Even babies on oxygen can be cared for skin-to-skin, and this helps reduce their needs for oxygen, and keeps them more stable in other ways as well.

From the point of view of breastfeeding, babies who are kept skin-to-skin with the mother immediately after birth for at least an hour, are more likely to latch on without any help and they are more likely to latch on well, especially if the mother did not receive medication during the labour or birth. As mentioned in Breastfeeding - Starting out Right, a baby who latches on well gets milk more easily than a baby who latches on less well. When a baby latches on well, the mother is less likely to be sore. When a mother’s milk is abundant, the baby can take the breast poorly and still get lots of milk, though the feedings may then be long or frequent or both, and the mother is more prone to develop problems such as blocked ducts and mastitis. In the first few days, however, the mother does not have a lot of milk, and a good latch is important to help the baby get the milk that is available (yes, the milk is there even if someone has proved to you with the big pump that there isn’t any). If the baby does not latch on well, the mother may be sore, and if the baby does not get milk well, the baby will want to be on the breast for long periods of time worsening the soreness.

To recap, skin-to-skin contact immediately after birth, which lasts for at least an hour has the following positive effects on the baby:

• Are more likely to latch on
• Are more likely to latch on well
• Have more stable and normal skin temperatures
• Have more stable and normal heart rates and blood pressures
• Have higher blood sugars
• Are less likely to cry
• Are more likely to breastfeed exclusively longer

There is no reason that the vast majority of babies cannot be skin-to-skin with the mother immediately after birth for at least an hour. Hospital routines, such as weighing the baby, should not take precedence. The only reason this cannot be done is that "we’ve never done this before". Not a good enough reason!

The baby should be dried off and put on the mother. Nobody should be pushing the baby to do anything; nobody should be trying to help the baby latch on during this time. The mother and baby should just be left in peace to enjoy each other’s company. (The mother and baby should not be left alone, however, especially if the mother has received medication, and it is important that not only the mother’s partner, but also a nurse, or physician stay with them - occasionally, some babies do need medical help and someone qualified should be there "just in case"). The eyedrops and the injection of vitamin K can wait a couple of hours. By the way, immediate skin-to-skin contact can also be done after caesarean section, even while the mother is getting stitched up, unless there are medical reasons which prevent it.

Studies have shown that even premature babies, as small as 1200 g (2 lb 10 oz) are more stable metabolically (including the level of their blood sugars) and breathe better if they are skin-to-skin immediately after birth. The need for an intravenous infusion, oxygen therapy or a nasogastric tube, for example, or all the preceding, does not preclude skin-to-skin contact. Skin-to-skin contact is quite compatible with other measures taken to keep the baby healthy. Of course, if the baby is quite sick, the baby’s health must not be compromised, but any premature baby who is not suffering from respiratory distress syndrome can be skin-to-skin with the mother immediately after birth. Indeed, in the premature baby, as in the full term baby, skin-to-skin contact may decrease rapid breathing into the normal range.

Even if the baby does not latch on during the first hour or two, skin-to-skin contact is still good and important for the baby and the mother for all the other reasons mentioned.

If the baby does not take the breast right away, do not panic. There is almost never any rush, especially in the full term healthy baby. One of the most harmful approaches to feeding the newborn has been the bizarre notion that babies must feed every three hours. There is actually not a stitch of proof that this is true, but based on such a notion, many inexperienced hospital staff are pushing babies into the breast because "three hours have gone by". The baby not interested yet in feeding, may object strenuously, and thus is pushed even more, resulting, in many cases, in babies refusing the breast because we want to make sure they take the breast. And it gets worse. If the baby keeps objecting to being pushed into the breast and gets more and more upset, then the "obvious next step" is to give a supplement. And it is obvious where we are headed (see When a Baby Refuses to Latch On).

The importance of skin-to-skin contact. Revised January 2005 
Written by Jack Newman, MD, FRCPC. © 2005

This handout may be copied and distributed without further permission, on the condition that it is not used in any context in which the WHO code on the marketing of breastmilk substitutes is violated