Improving Provision of Skin-to-Skin Care in Preterm Neonates

John Hunter Children’s Hospital developed a step-by-step guide to encourage the delivery of Kangaroo Care to premature babies, and provided education to staff and parents on the topic.


To increase the proportion of babies born at less than 29 weeks gestation who receive Kangaroo Care (skin-to-skin care) by 72 hours of age, to 60 per cent by 31 December 2017.


  • Improves temperature and bodily function regulation for premature babies.
  • Enhances mother-baby bonding and parent confidence in caring for their baby.
  • Supports higher scores on the Bayley Scales of Infant Development.
  • Improves sleep, stress response, nervous system function and cognitive control later in life.
  • Encourages higher volumes of breast milk production, with longer and more exclusive breastfeeding times.
  • Strengthens the family’s role in the care of premature babies.


Kangaroo Care is a method of holding a baby that involves skin-to-skin contact. The baby, who is naked except for a nappy or piece of cloth covering their back, is placed in an upright position against the parent’s bare chest. Research has shown that Kangaroo Care can stabilise heart and respiratory rates, improve oxygen saturation rates, better regulate the baby’s body temperature, conserves calories for growth, and positively affect brain development.1

In NSW, Neonatal Intensive Care Units’ data on the provision of skin-to-skin care between 2013 and 2015 showed that babies born before 29 weeks often did not receive Kangaroo Care until late into their first week of life. For very premature babies, Kangaroo Care was first provided at 17 days.2 An audit of John Hunter Children’s Hospital practices from June 2016 to January 2017 showed a similar pattern, with only 18 per cent of babies born at less than 29 weeks receiving skin-to-skin care by 72 hours of age.

A survey of Neonatal Intensive Care Unit (NICU) staff and parents in March 2017 showed that parents often felt helpless in their ability to support their sick baby. This led to delayed expression of breast milk by the mother and delayed receipt of breast milk by the baby. There was an overwhelming willingness by staff and families to change the status quo and aim to deliver Kangaroo Care for 60 minutes or more per day to babies born before 29 weeks.


  • A project team was established, comprising two parents, neonatal consultants, fellows, senior and junior nursing staff, lactation consultants and midwifery staff.
  • Brainstorming sessions and multi-voting tools were used to identify the key barriers to delivering Kangaroo Care. These included parental fear and ignorance on the benefits of Kangaroo Care, apprehension by nursing staff about moving premature babies and dislodging catheters and tubes, and a lack of guidelines on Kangaroo Care for the NICU.
  • A comprehensive step-by-step guide was developed in collaboration with parent representatives, to help staff encourage and support safe Kangaroo Care by the mother’s bedside.
  • Staff were trained to use the guide in small group education sessions over an eight-week period (10 group sessions and some one-on-one education), capturing 57 per cent (118 out of 206) of NICU nursing staff.
  • Parent information sheets were developed by the project team and modified based on feedback from five parent sets. These were distributed to all parents as part of the NICU admission pack, to educate them on the benefits of Kangaroo Care and empower them to provide it to their babies during their hospital stay and at home.


Sustained – The project has been implemented and is sustained in standard business.


12 May 2017 – 31 December 2017

Implementation sites

Neonatal Intensive Care Unit, John Hunter Children’s Hospital, HNELHD


Clinical Excellence Commission Clinical Leadership Program


  • The proportion of babies born at less than 29 weeks who received Kangaroo Care within 72 hours increased from 19 per cent in January 2017, to 86 per cent in December 2017.
  • The median time taken to first deliver Kangaroo Care to babies born at less than 29 weeks reduced from 5.7 days in January 2017 to 1.9 days in December 2017.
  • The project aim has been achieved and maintained for eight months and is now a routine standard of care, with ongoing surveillance of practice and monitoring of data.

Lessons Learnt

  • Involving grass roots staff in the change can help achieve and sustain goals.
  • Consumer involvement and partnership is essential to deliver relevant healthcare outcomes.


  1. Cleveland Clinic. Kangaroo Care. Ohio USA: Cleveland Clinic; 2015.
  2. NSW Pregnancy and Newborn Services Network. NICUS Registry Data 2015. St Pauls NSW: NSW Pregnancy and Newborn Services Network; 2015.

Further reading

  • Boundy EO, Dastjerdi R, Spiegelman D et al. Kangaroo mother care and neonatal outcomes: a meta-analysis. Pediatrics 2016;137(1):e20152238.
  • Conde-Agudelo A, Díaz-Rossello JL. Kangaroo mother care to reduce morbidity and mortality in low birthweight infants. Cochrane Database of Systematic Reviews 2016;8:CD002771. DOI: 10.1002/14651858.
  • Feldman R, Eidelman AI, Sirota L et al. Comparison of skin-to-skin (Kangaroo) and traditional care: parenting outcomes and preterm infant development. Pediatrics 2002;110(1 pt 1):16-26.
  • Feldman R, Rosenthal Z, Eidelman AI. Maternal-preterm skin-to-skin contact enhances child physiologic organization and cognitive control across the first 10 years of life. Biological Psychiatry 2014;75(1):56-64.
  • Lee K, Bang K. The effects of Kangaroo Care on maternal self-esteem and premature infants’ physiological stability. Korean Journal of Women Health Nursing 2011;17(5):454-62.


Dr Javeed Travadi
Deputy Director, Newborn Services
John Hunter Children’s Hospital
Hunter New England Local Health District
Phone: 02 4921 4362


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