The following references and resources support the evidence base for Unrestricted Kangaroo Care (uKC). They are organized by topic to guide clinicians, administrators, and families in expanding access and sustaining safe practice.
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Global Standards
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WHO guidelines¹
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Infant and Family-Centered Developmental Care Standards, Competencies, and Recommended Best Practices²–⁴
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European Standards of Care for Newborn Health⁵,⁶
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Growth and Neurodevelopment
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Evidence linking KC to improved infant growth and brain development⁷
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Milk Production and Breastfeeding
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Studies showing KC improves milk supply, breastfeeding initiation, and exclusivity⁸–¹³
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Physiologic Stability
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Preterm infant regulation of temperature, oxygenation, and vital signs¹⁴
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Clinical Outcomes
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Reduced morbidity, mortality, sepsis, and NICU length of stay¹⁵,¹⁶
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Parental Health
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Maternal and paternal mental health and well-being benefits¹⁷
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Safety Considerations
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Risks to monitor include:
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Accidental falls¹⁸–²⁰
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Sudden unexpected postnatal collapse²¹,²²
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Dislodgement of equipment or unplanned extubation²³–²⁵
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KC in Complex and Critically Ill Infants
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Increasing evidence supports KC for:
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Extremely low birth weight infants²⁶–³⁶
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Intubated infants³³,³⁵,³⁷–³⁹
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Surgical infants⁴⁰,⁴¹
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Infants with central lines⁴²
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Barriers and Risk Management
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Barriers to KC⁴³–⁴⁷
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Evidence-based strategies for risk management⁴⁸–⁵⁰
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48. Weber AM, Jackson YC, Elder MR, et al. Application of a Risk Management Framework to Parent Sleep During Skin-to-Skin Care in the NICU. J Obstet Gynecol Neonatal Nurs JOGNN. 2022;51(3):336-348. doi:10.1016/j.jogn.2022.02.004 https://pubmed.ncbi.nlm.nih.gov/35288109/
49. Weber A, Elder M, Voos KC, Lambert JW, Kaplan HC, Jackson YC. Clinician Opinions and Approaches to Manage Risk Related to Safe Sleep During Skin-to-Skin Care. J Obstet Gynecol Neonatal Nurs JOGNN. 2020;49(5):464-474. doi:10.1016/j.jogn.2020.07.001 https://pubmed.ncbi.nlm.nih.gov/32726581/
50. Weber A, Jackson Y. A Survey of Neonatal Clinicians’ Use, Needs, and Preferences for Kangaroo Care Devices. Adv Neonatal Care Off J Natl Assoc Neonatal Nurses. 2021;21(3):232-241. doi:10.1097/ANC.0000000000000790 https://pubmed.ncbi.nlm.nih.gov/32858546/
REFERENCES
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2. Phillips R, Smith K, First Consensus Conference on Standards, Competencies and Recommended Best Practices for Infant and Family Centered Developmental Care in the Intensive Care Unit. IFCDC- Recommendations for Skin-to-Skin Contact with Intimate Family Members. NICU Recommended Standards. 2020. Accessed March 17, 2020. https://nicudesign.nd.edu/nicu-care-standards/ifcdc--recommendations-for-skin-to-skin-contact-with-intimate-family-members/
3. Browne JV, Jaeger CB, Kenner C, Gravens Consensus Committee on Infant and Family Centered Developmental Care. Executive summary: standards, competencies, and recommended best practices for infant- and family-centered developmental care in the intensive care unit. J Perinatol Off J Calif Perinat Assoc. 2020;40(Suppl 1):5-10. doi:10.1038/s41372-020-0767-1
4. Browne JV, Jaeger CB, Arvedson JC, et al. Developmental Care Standards for Infants in Intensive Care.; 2020:1-139. Accessed March 17, 2020. https://nicudesign.nd.edu/nicu-care-standards/
5. Bergman NJ, Westrup B, Kuhn P, et al. Infant- & family-centered developmental care: Very early and continuous skin-to-skin contact. In: European Standards of Care for Newborn Health (ESCNH). European Standards of Care for Newborn Health; 2018. Accessed May 7, 2025. https://newborn-health-standards.org/standards/standards-english/infant-family-centred-developmental-care/very-early-and-continuous-skin-to-skin-contact/
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21. Davanzo R, De Cunto A, Paviotti G, et al. Making the first days of life safer: preventing sudden unexpected postnatal collapse while promoting breastfeeding. J Hum Lact Off J Int Lact Consult Assoc. 2015;31(1):47-52. doi:10.1177/0890334414554927
22. Shipstone R, Young J, Kearney L. New Frameworks for Understanding Sudden Unexpected Deaths in Infancy (SUDI) in Socially Vulnerable Families. J Pediatr Nurs Nurs Care Child Fam. 2017;37:35-41. doi:10.1016/j.pedn.2017.06.022
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24. Ludington-Hoe SM, Ferreira C, Swinth J, Ceccardi JJ. Safe criteria and procedure for kangaroo care with intubated preterm infants. J Obstet Gynecol Neonatal Nurs JOGNN NAACOG. 2003;32(5):579-588.
25. Azevedo VMG de O, Xavier CC, Gontijo F de O. Safety of Kangaroo Mother Care in intubated neonates under 1500 g. J Trop Pediatr. 2012;58(1):38-42. doi:10.1093/tropej/fmr033
26. Nation H, Sanlorenzo L, Lebar K, Brandon D. A Quality Improvement Project to Increase Frequency of Skin-to-Skin Contact for Extreme Low-Birth-Weight Infants in the Neonatal Intensive Care Unit. J Perinat Neonatal Nurs. 2021;35(3):247-257. doi:10.1097/JPN.0000000000000556
27. Fathi O, Nelin LD, Shepherd EG, Reber KM. Development of a small baby unit to improve outcomes for the extremely premature infant. J Perinatol Off J Calif Perinat Assoc. 2022;42(2):157-164. doi:10.1038/s41372-021-00984-0
28. Collados-Gómez L, Esteban-Gonzalo L, López-López C, et al. Lateral Kangaroo Care in Hemodynamic Stability of Extremely Preterm Infants: Protocol Study for a Non-Inferiority Randomized Controlled Trial CANGULAT. Int J Environ Res Public Health. 2022;19(1):293. doi:10.3390/ijerph19010293
29. Sharma D, Murki S, Pratap OT. To compare growth outcomes and cost-effectiveness of “Kangaroo ward care” with “intermediate intensive care” in stable extremely low birth weight infants: randomized control trial. J Matern Fetal Neonatal Med. 2017;30(14):1659-1665. doi:10.1080/14767058.2016.1220531
30. Span LC, van Dokkum NH, Ravensbergen AG, Bos AF, Jaschke AC. Combining Kangaroo Care and Live-Performed Music Therapy: Effects on Physiological Stability and Neurological Functioning in Extremely and Very Preterm Infants. Int J Environ Res Public Health. 2021;18(12):6580. doi:10.3390/ijerph18126580
31. Obaid M, Igawa T, Maxwell A, et al. “Liquid Gold” Lactation Bundle and Breastfeeding Rates in Racially Diverse Mothers of Extremely Low-Birth-Weight Infants. Breastfeed Med Off J Acad Breastfeed Med. 2021;16(6):463-470. doi:10.1089/bfm.2020.0322
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33. Pavlek LR, Mueller C, Jebbia MR, et al. Perspectives on developing and sustaining a small baby program. Semin Perinatol. 2022;46(2):151548. doi:10.1016/j.semperi.2021.151548
34. Xie X, Chen X, Sun P, et al. Kangaroo Mother Care Reduces Noninvasive Ventilation and Total Oxygen Support Duration in Extremely Low Birth Weight Infants. Am J Perinatol. 2021;38(8):791-795. doi:10.1055/s-0039-3402717
35. Bisanalli S, Nesargi S, Govindu RM, Rao SP. Kangaroo Mother Care in Hospitalized Low Birth-Weight Infants on Respiratory Support: A Feasibility and Safety Study. Adv Neonatal Care Off J Natl Assoc Neonatal Nurses. 2019;19(6):E21-E25. doi:10.1097/ANC.0000000000000666
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38. Klugman D, Melton K, Maynord PO, et al. Assessment of an Unplanned Extubation Bundle to Reduce Unplanned Extubations in Critically Ill Neonates, Infants, and Children. JAMA Pediatr. 2020;174(6):e200268. doi:10.1001/jamapediatrics.2020.0268
39. Marvin MM, Gardner FC, Sarsfield KM, Travagli RA, Doheny KK. Increased Frequency of Skin-to-Skin Contact Is Associated with Enhanced Vagal Tone and Improved Health Outcomes in Preterm Neonates. Am J Perinatol. 2019;36(5):505-510. doi:10.1055/s-0038-1669946
40. Levesque V, Johnson K, McKenzie A, Nykipilo A, Taylor B, Joynt C. Implementing a Skin-to-Skin Care and Parent Touch Initiative in a Tertiary Cardiac and Surgical Neonatal Intensive Care Unit. Adv Neonatal Care Off J Natl Assoc Neonatal Nurses. 2021;21(2):E24-E34. doi:10.1097/ANC.0000000000000770
41. Kelley-Quon LI, Kenney BD, Bartman T, et al. Safety and feasibility of skin-to-skin care for surgical infants: A quality improvement project. J Pediatr Surg. 2019;54(11):2428-2434. doi:10.1016/j.jpedsurg.2019.02.016
42. Catherine ZG, Béatrice P, Fabrice L, Claire H, Alain D. Skin-to-skin contact with an umbilical venous catheter: prospective evaluation in a level 3 unit. Eur J Pediatr. 2016;175(4):551-555. doi:10.1007/s00431-015-2665-7
43. Fluharty M, Nemeth LS, Logan A, Nichols M. What Do Neonatal Intensive Care Unit Policies Tell Us About Kangaroo Care implementation? A Realist Review. Adv Neonatal Care Off J Natl Assoc Neonatal Nurses. 2021;21(4):E76-E85. doi:10.1097/ANC.0000000000000808
44. Chan GJ, Labar AS, Wall S, Atun R. Kangaroo mother care: a systematic review of barriers and enablers. Bull World Health Organ. 2016;94(2):130-141J. doi:10.2471/BLT.15.157818
45. Smith ER, Bergelson I, Constantian S, Valsangkar B, Chan GJ. Barriers and enablers of health system adoption of kangaroo mother care: a systematic review of caregiver perspectives. BMC Pediatr. 2017;17(1):35. doi:10.1186/s12887-016-0769-5
46. Hull WL, Gongora P. Implementing Early Kangaroo Mother Care: A Quality Improvement Initiative. Adv Neonatal Care Off J Natl Assoc Neonatal Nurses. 2025;25(1):46-54. doi:10.1097/ANC.0000000000001231
47. Beaumont L, Mullaney D, Eklund W, DeGrazia M. Kangaroo Care in the Neonatal Intensive Care Unit-A Practice Change Initiative. Adv Neonatal Care Off J Natl Assoc Neonatal Nurses. 2025;25(2):129-137. doi:10.1097/ANC.0000000000001252
48. Weber AM, Jackson YC, Elder MR, et al. Application of a Risk Management Framework to Parent Sleep During Skin-to-Skin Care in the NICU. J Obstet Gynecol Neonatal Nurs JOGNN. 2022;51(3):336-348. doi:10.1016/j.jogn.2022.02.004
49. Weber A, Elder M, Voos KC, Lambert JW, Kaplan HC, Jackson YC. Clinician Opinions and Approaches to Manage Risk Related to Safe Sleep During Skin-to-Skin Care. J Obstet Gynecol Neonatal Nurs JOGNN. 2020;49(5):464-474. doi:10.1016/j.jogn.2020.07.001
50. Weber A, Jackson Y. A Survey of Neonatal Clinicians’ Use, Needs, and Preferences for Kangaroo Care Devices. Adv Neonatal Care Off J Natl Assoc Neonatal Nurses. 2021;21(3):232-241. doi:10.1097/ANC.0000000000000790