The science of how Kangaroo care supports Neourodevelopment.

Keeping Kangaroo care going throughout the patient stay supports neurodevelopment in preterm infants. Implementing developmental care and family-centered care is a challenge that improves the outcome of every NICU and their patients.

The BABYBE SYSTEM® helps you to bring family-centered care to your hospital and provides you with an innovative developmental care approach.

Here you will find more information on how to implement developmental Care and the science behind the importance of keeping Kangaroo care available and effective.


Neural activity is critical for sculpting the intricate circuits of the nervous system from initially imprecise neuronal connections. Disrupting the formation of these precise circuits may underlie many common neurodevelopmental disorders, ranging from subtle learning disorders to pervasive developmental delay. The necessity for sensory- driven activity has been widely recognized as crucial for infant brain development. Recent experiments in neurobiology now point to a similar requirement for endogenous neural activity generated by the nervous system itself before sensory input is available. Here we use the formation of precise neural circuits in the visual system to illustrate the principles of activity-dependent development. Competition between the projections from lateral geniculate nucleus neurons that receive sensory input from the two eyes shapes eye-specific connections from an initially diffuse projection into ocular dominance columns. When the competition is altered during a critical period for these changes, by depriving one eye of vision, the normal ocular dominance column pattern is disrupted. Before ocular dominance column formation, the highly ordered projection from retina to lateral geniculate nucleus develops. These connections form before the retina can respond to light, but at a time when retinal ganglion cells spontaneously generate highly correlated bursts of action potentials. Blockade of this endogenous activity, or biasing the competition in favor of one eye, results in a severe disruption of the pattern of retinogeniculate connections. Similar spontaneous, correlated activity has been identified in many locations in the developing central nervous system and is likely to be used during the formation of precise connections in many other neural systems. Understanding the processes of activity-dependent development could revolutionize our ability to identify, prevent, and treat developmental disorders resulting from disruptions of neural activity that interfere with the formation of precise neural circuits.

  • Ruth Feldman* PhD, Department of Psychology, Bar-Ilan University, Ramat Gan;
  • Arthur I Eidelman MD, Department of Neonatology, Shaare Zedek Medical Center, Hebrew University School of Medicine, Jerusalem, Israel.


The effects of mother–infant skin-to-skin contact (Kangaroo Care; KC) on autonomic functioning, state regulation, and neurobehavioural status was examined in 70 preterm infants, half of whom received KC over 24.31 days (SD 7.24) for a total of 29.76 hours (SD 12.86). Infants were matched for sex (19 males and 16 females in each group); birthweight (KC, 1229.95g [SD 320.21]; controls, 1232.17g [SD 322.15]); gestational age (GA) (KC, 30.28 weeks [SD 2.54]; controls, 30.19 weeks [SD 2.65]); medical risk; and family demographics. Vagal tone was calculated from 10 minutes of heart rate before KC and again at 37 weeks’ GA. Infant state was observed in 10-second epochs during four consecutive hours before KC and again at 37 weeks’ GA. Neurobehavioural status was assessed at 37 weeks’ GA with the Neonatal Behavioral Assessment Scale (NBAS). Infants receiving KC showed a more rapid maturation of vagal tone between 32 and 37 weeks’ GA (p=0.029). More rapid improvement in state organization was observed in KC infants, in terms of longer periods of quiet sleep (p=0.016) and alert wakefulness (p=0.013) and shorter periods of active sleep (p=0.023). Neurodevelopmental profile was more mature for KC infants, particularly habituation (p=0.032) and orientation (p=0.007). Results underscore the role of early skin-to-skin contact in the maturation of the autonomic and circadian systems in preterm infants.

  • Mark S. Scher, MD *,1 ,
  • Susan Ludington-Hoe, PhD 3 ,
  • Farhad Kaffashi, PhD 2 ,
  • Mark W. Johnson, PhD 1 ,
  • Diane Holditch-Davis, PhD 4 , and
  • Kenneth A. Loparo, PhD 2


Objective: Skin-to-skin contact (SSC) promotes physiological stability and interaction between parents and infants. Analyses of EEG-sleep studies can compare functional brain maturation between SSC and non-SSC cohorts.

Methods: Sixteen EEG-sleep studies were performed on eight preterm infants who received eight weeks of SSC, and compared with two non-SSC cohorts at term (N=126), a preterm group corrected to term age and a full term group. Seven linear and two complexity measures were compared (Mann-Whitney U test comparisons p<.05).

Results: Fewer REMs, more quiet sleep, increased respiratory regularity, longer cycles, and less spectral beta were noted for SSC preterm infants compared with both control cohorts. Fewer REMs, greater arousals and more quiet sleep were noted for SSC infants compared with the nonSSC preterms at term. Three right hemispheric regions had greater complexity in the SSC group. Discriminant analysis showed that the SSC cohort was closer to the non-SSC full-term cohort.

Conclusion: Skin to skin contact accelerates brain maturation in healthy preterm infants compared with two groups without SSC.

Significance: Combined use of linear and complexity analysis strategies offer complementary information regarding altered neuronal functions after developmental care interventions. Such analyses may be helpful to assess other neuroprotection strategies.

  • Kimberly A. Allen, MSN, RN. Duke University School of Nursing, Durham, NC.

Sleep is essential to brain development and maturation in infants. 1 Infants require extensive sleep for further development of the neurosensory systems; structural development of the hippocampus, pons, brainstem, and midbrain; 2 and optimizing physical growth. 3 Protecting infant sleep is a critical component of providing developmentally appropriate care for premature and full-term infants in the neonatal intensive care unit (NICU) because many of these infants are hospitalized during one of the most critical periods of brain development. 4 To best provide developmentally appropriate care, identification of sleep-wake states is necessary.

  • Perri S. Sutton, Family Health Division, Bill & Melinda Gates Foundation
  • Gary L. Darmstadt, Family Health Division, Bill & Melinda Gates Foundation


This review summarizes research findings to date on neurological and health outcomes following preterm birth, tools to identify children at risk for neurodevelopmental impairment and interventions to prevent preterm birth and improve outcomes. We bring together findings from research in high- and low-income countries, with an aim to provide a global perspective on the issues. Around the world, preterm birth is rising in importance as a cause of under-five morbidity and mortality, and we project that this trend will continue over time, particularly given the lack of interventions to prevent the condition. With the development of improved screening instruments, further identification and scale up of cost-effective interventions to optimize early childhood development and accelerated research on the underlying biological mechanisms, we have an opportunity to reduce rates of neurodevelopmental impairment, particularly in countries with the highest burden.

  • John Dobbing, Department of Child Health, University of Manchester.
  • Jean Sands, Department of Child Health, University of Manchester.


One hundred and thirty-nine complete human brains ranging in age from 10 weeks’ gestation to 7 postnatal years, together with 9 adult brains, have been analysed in order to describe the human brain growth spurt quantitatively. The three major regions were examined for weight, DNA, cholesterol, and water content. The growth spurt period is much more postnatal than has formerly been supposed. The cerebellum has special growth characteristics; and there is a separate period from 10 to 18 weeks’ gestation when adult neuronal cell number may largely be achieved. The implications of these findings for the vulnerability of developing brain are discussed.

  • Ann L Jefferies; Canadian Paediatric Society, Fetus and Newborn Committee


Kangaroo care (KC) is the practice of skin-to-skin contact between infant and parent. In developing countries, KC for low-birthweight infants has been shown to reduce mortality, severe illness, infection and length of hospital stay. KC is also beneficial for preterm infants in high-income countries. Cardiorespiratory and temperature stability, sleep organization and duration of quiet sleep, neurodevelopmental outcomes, breastfeeding and modulation of pain responses appear to be improved for preterm infants who have received KC during their hospital stay. No detrimental effects on physiological stability have been demonstrated for infants as young as 26 weeks’ gestational age, including those on assisted ventilation. Mothers show enhanced attachment behaviours and describe an increased sense of their role as a mother. The practice of KC should be encouraged in nurseries that care for preterm infants. Information is available to assist in developing guidelines and protocols.

  • Farin Soleimani, Pediatric Neurorehabilitation Research Center, University of Social Welfare and Rehabilitation Sciences, Tehran, IR Iran.
  • Farzaneh Zaheri, Department of Midwifery, Kurdistan University of Medical Sciences, Sanandaj, IR Iran.
  • Fatemeh Abdi, Students Research Committee, Shahid Beheshti University of Medical Sciences, Tehran. IR Iran.



All over the the world, preterm birth is a major cause of death and important neurodevelopmental disorders. Approximately 9.6% (12.9 million) births worldwide are preterm.

Evidence Acquisition:

In this review, databases such as PubMed, EMBASE, ISI, Scopus, Google Scholar and Iranian databases including Iranmedex, and SID were researched to review relevant literature. A comprehensive search was performed using combinations of various keywords.


Cerebral palsy especially spastic diplegia, intellectual disability, visual (retinopathy of prematurity) and hearing impairments are the main neurodevelopmental disorders associated with prematurity.


The increased survival of preterm infants was not associated with lower complications. There is now increasing evidence of sustained adverse outcomes into school age and adolescence, for preterm infants.

  • By Karen D. Hendricks-Muñoz, MD, MPH, FAAP,
  • Carol C. Prendergast, EdD,
  • Martha C. Caprio, MD, and
  • Randi S. Wasserman, MD

From the Department of Pediatrics, Neonatology Program, New York University Medical Center and Bellevue Hospital Center, New York, NY.


shortened hospitalizations and improved medical, as well as neurodevelopmental outcomes, have recently been observed with the use of individualized developmental care for premature infants in the neonatal intensive care unit (NICU). 1–6 Accounting for over 10% of all babies born in the United States, 7 premature infants make up greater than 70% of admissions to the NICU, which provides high level and expensive critical care. For the very low birth weight infant, less than 1,500 g, in which 90% survival is expected, the duration of stay in the NICU can be greater than 2 to 3 months, and discharge is associated with an increased risk of developmental delay and disabilities. 8–10 After discharge from the NICU, ambulatory care costs for these infants are high and at least half of the children will require special education classes. Over the past 10 years, medical research has provided evidence that premature infants with a developmentally appropriate environment, through individualized developmental care, can have improved medical outcome. This is associated with decreased intraventricular hemorrhage, decreased numbers of oxygen and ventilator days, decreased development of chronic lung disease, and decreased days of hospitalization. 11–14 It is controversial, however, if these medical improvements translate to decreased long-term disabilities.

  • Stanley N. Graven, MD, Department of Community and Family Health, College of Public Health University of South Florida, Tampa, FL
  • Joy V. Browne, PhD, CNS-BC, Department of Community and Family Health, College of Public Health University of South Florida, Tampa, FL



Sleep and sleep cycles begin at around 26 to 28 weeks’ gestational age. They were originally recognized by observing infant behaviors. This observation of behaviors and changes in physiology has now added electoenchephalography (EEG) and continuous electoenchephalography (aEEG) to the studies of sleep and sleep cycles. Sleep partitions from indeterminate sleep EEG patterns to quiet sleep or non–rapid eye movement (REM) sleep, REM sleep, and quiet awake intervals. The REM sleep follows the quiet or slow wave sleep in the cycles. Sleep and sleep cycles are essential for the development of the neurosensory and motor systems in the fetus and neonate. They are essential for the creation of memory and long-term memory circuits, and they are essential for the maintenance of brain plasticity over the lifetime of the individual. The importance of sleep and preservation of sleep cycles in infants has been known for more than 40 years. They are critical for the fetus in utero and the preterm infant in the newborn intensive care unit (NICU). The infants’ state and sleep-wake cycles have been studied as part of developmental care since the 1980s. A major part of the implementation of developmentally appropriate care involves using the infant state and cues to plan care and interventions. This is also essential for the preservation of sleep and sleep cycles that are essential for early neurosensory development. Interference with sleep and disruption of sleep cycles can significantly interfere with the early processes of sensory development. Parents are playing an increasingly important role in supporting early development.

  • Annica Örtenstrand, Karolinska University Hospital
  • Björn Westrup, Karolinska University Hospital
  • Lene Lindberg, Karolinska Institutet
  • Ihsan Sarman



Parental involvement in the care of preterm infants in NICUs is becoming increasingly common, but little is known about its effect on infants’ length of hospital stay and infant morbidity. Our goal was to evaluate the effect of a new model of family care (FC) in a level 2 NICU, where parents could stay 24 hours/day from admission to discharge. A randomized, controlled trial was conducted in 2 NICUs (both level 2), including a standard care (SC) ward and an FC ward, where parents could stay from infant admission to discharge. In total, 366 infants born before 37$$\raisebox{1ex}{$0$}\!\left/ \!\raisebox{-1ex}{$7$}\right.$$ weeks of gestation were randomly assigned to FC or SC on admission. The primary outcome was total length of hospital stay, and the secondary outcome was short-term infant morbidity. The analyses were adjusted for maternal ethnic background, gestational age, and hospital site. Total length of hospital stay was reduced by 5.3 days: from a mean of 32.8 days (95% confidence interval [CI]: 29.6-35.9) in SC to 27.4 days (95% CI: 23.2-31.7) in FC (P = .05). This difference was mainly related to the period of intensive care. No statistical differences were observed in infant morbidity, except for a reduced risk of moderate-to-severe bronchopulmonary dysplasia: 1.6% in the FC group compared with 6.0% in the SC group (adjusted odds ratio: 0.18 [95% CI: 0.04-0.8]). Providing facilities for parents to stay in the neonatal unit from admission to discharge may reduce the total length of stay for infants born prematurely. The reduced risk of moderate-to-severe bronchopulmonary dysplasia needs additional investigation.

  • Nathalie Charpak, MD, a Rejean Tessier, PhD, b Juan G. Ruiz, MD, MSc, c,d Jose Tiberio Hernandez, PhD, e Felipe Uriza, MD, MSc, Julieta Villegas, MD, MSc, a Line Nadeau, PhD, b Catherine Mercier, PhD, b Francoise Maheu, PhD, f Jorge Marin, MD, g Darwin Cortes, PhD, h Juan Miguel Gallego, PhD, h Dario Maldonado, PhD e




Kangaroo mother care (KMC) is a multifaceted intervention for preterm and low birth weight infants and their parents. Short- and mid-term benefits of KMC on survival, neurodevelopment, breastfeeding, and the quality of mother-infant bonding were documented in a randomized controlled trial (RCT) conducted in Colombia from 1993 to 1996. The aim of the present study was to evaluate the persistence of these results in young adulthood.


From 2012 to 2014, a total of 494 (69%) of the 716 participants of the original RCT known to be alive were identified; 441 (62% of the participants in the original RCT) were re-enrolled, and results for the 264 participants weighing ≤1800 g at birth were analyzed. The KMC and control groups were compared for health status and neurologic, cognitive, and social functioning with the use of neuroimaging, neurophysiological, and behavioral tests.


The effects of KMC at 1 year on IQ and home environment were still present 20 years later in the most fragile individuals, and KMC parents were more protective and nurturing, reflected by reduced school absenteeism and reduced hyperactivity, aggressiveness, externalization, and socio-deviant conduct of young adults. Neuroimaging showed larger volume of the left caudate nucleus in the KMC group.

CONCLUSIONS:This study indicates that KMC had significant, long-lasting social and behavioral protective effects 20 years after the intervention. Coverage with this efficient and scientifically based health care intervention should be extended to the 18 million infants born each year who are candidates for the method.

  • Karel O’Brien, Kate Robson, Marianne Bracht, Melinda Cruz, Kei Lui, Ruben Alvaro, Orlando da Silva, Luis Monterrosa, Michael Narvey, Eugene Ng, Amuchou Soraisham, Xiang Y Ye, Lucia Mirea, William Tarnow-Mordi, Shoo K Lee, for the FICare Study Group and FICare Parent Advisory Board*




Despite evidence suggesting that parent involvement was beneficial for infant and parent outcomes, the Family Integrated Care (FICare) programme was one of the first pragmatic approaches to enable parents to become primary caregivers in the neonatal intensive care unit (NICU). We aimed to analyse the effect of FICare on infant and parent outcomes, safety, and resource use.


In this multicentre, cluster-randomised controlled trial, we stratified 26 tertiary NICUs from Canada, Australia, and New Zealand by country and size, and assigned them, using a computer-generated random allocation sequence, to provide FICare or standard NICU care. Eligible infants were born at 33 weeks’ gestation or earlier, and had no or low-level respiratory support; parents gave written informed consent for enrolment. To be eligible, parents in the FICare group had to commit to be present for at least 6 h a day, attend educational sessions, and actively care for their infant. The primary outcome, analysed at the individual level, was infant weight gain at day 21 after enrolment. Secondary outcomes were weight gain velocity, high frequency breastfeeding (≥6 times a day) at hospital discharge, parental stress and anxiety at enrolment and day 21, NICU mortality and major neonatal morbidities, safety, and resource use (including duration of oxygen therapy and hospital stay). This trial is registered with, number NCT01852695.


From Oct 1, 2012, 26 sites were randomly assigned to provide FICare (n=14) or standard care (n=12). One site assigned to FICare discontinued because of poor site enrolment. Parents and infants were enrolled between April 1, 2013, and Aug 31, 2015, with 895 infants being eligible in the FICare group and 891 in the standard care group. At day 21, weight gain was greater in the FICare group than in the standard care group (mean change in Z scores -0·071 [SD 0·42] vs -0·155 [0·42]; p<0·0002). Average daily weight gain was significantly higher in infants receiving FICare than those receiving standard care (mean daily weight gain 26·7 g [SD 9·4] vs 24·8 g [9·5]; p<0·0001). The high-frequency exclusive breastmilk feeding rate at discharge was higher for infants in the FICare group (279 [70%] of 396) than those in the standard care group (394 [63%] of 624; p=0·016). At day 21, parents in the FICare group had lower mean stress scores than did parents in the standard care group (2·3 [SD 0·8] vs 2·5 [0·8]; p<0·00043), and lower mean anxiety scores (70·8 [20·1] vs 74·2 [19·9]; p=0·0045). There were no significant differences between groups in the rates of the secondary outcomes of mortality, major morbidity, duration of oxygen therapy, and duration of hospital stay. Although the safety assessment was not completed, there were no adverse events.


FICare improved infant weight gain, decreased parent stress and anxiety, and increased high-frequency exclusive breastmilk feeding at discharge, which together suggest that FICare is an important advancement in neonatal care. Further research is required to examine if these results translate into better long-term outcomes for families.


Canadian Institutes of Health Research Partnerships for Health System Improvement, and Ontario Ministry of Health and Long-Term Care

  • Ruth Feldman, PhD



Parent-infant skin-to-skin contact (Kangaroo Care, KC) has recently become a method of choice in several Neonatal Infant Care Units (NICUs), where parents and preterm infants in stable condition spend a portion of their day in the kangaroo position. This article reviews research on the benefits of the KC intervention in stabilizing the infant’s physiological systems, increasing lactation, and promoting parent-infant attachment. Data from our longitudinal KC project are reviewed in relation to 4 topics: effects of maternal proximity on infant self-regulation, the role of motherinfant contact in accelerating neuromaturation, KC effects on maternal mood and perceptions, and the contribution of KC to the mother-infant, father-infant, and family relationship. Findings demonstrate the positive effect of KC on infants’ cognitive development across infancy. In addition to its clinical significance, the kangaroo intervention provides a unique research paradigm into central issues in early development, including maternal proximity and separation, brain-behavior relationship, the centrality of early experience, and the reversibility of early trauma. Clinical implications and directions for future research are also discussed. Key words: breastfeeding, emotional regulation, Kangaroo Care, maternal depression, neurobehavioral maturation, premature infants

  • Sahar Saliba, Laboratoire Ethologie, Cognition, Developpement, Univiversite Paris Nanterre, Nanterre, France
  • Rana Esseily, Laboratoire Ethologie, Cognition, Developpement, Univiversite Paris Nanterre, Nanterre, France
  • Manuela Filippa, Universit  a della Valle d’Aosta, Italy; Universite de Geneve, Suisse.
  • Pierre Kuhn, Institut de Neurosciences Cellulaires et Integratives, CNRS, Universite de Strasbourg, Strasbourg, France
  • Maya Gratier, Laboratoire Ethologie, Cognition, Developpement, Univiversite Paris Nanterre, Nanterre, France



We reviewed the literature up to March 2016 on the effects of nonmaternal voices on preterm infants’ clinical outcomes. Of the 11 studies that met the inclusion criteria, 10 focused on short-term outcomes and one looked at long-term effects. The studies mainly showed that vocal stimuli increased preterm infants’ stability in terms of heart rate, respiratory rate, oxygen saturation and behavioural measures. Improvements in feeding skills were also reported. The methods and the measures used in the studies were heterogeneous, making it difficult to draw reliable conclusions.

Conclusion: Vocal stimuli increased preterm infants’ stability, but further studies are needed.

  • Laura Doheny, Department of Newborn Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA,
  • Shelley Hurwitz, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA,
  • Robert Insoft, Department of Newborn Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA,
  • Steven Ringer, Department of Newborn Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA,
  • Amir Lahav, Department of Newborn Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA. Department of Pediatrics, Mass General Hospital for Children, Boston, MA, USA



Preterm infants experience frequent cardiorespiratory events (CREs) including multiple episodes of apnea and bradycardia per day. This physiological instability is due to their immature autonomic nervous system and limited capacity for self-regulation. This study examined whether systematic exposure to maternal sounds can reduce the frequency of CREs in NICU infants. Fourteen preterm infants (26-32 weeks gestation) served as their own controls as we measured the frequency of adverse CREs during exposure to either Maternal Sound Stimulation (MSS) or Routine Hospital Sounds (RHS). MSS consisted of maternal voice and heartbeat sounds recorded individually for each infant. MSS was provided four times per 24-h period via a micro audio system installed in the infant’s bed. Frequency of adverse CREs was determined based on monitor data and bedside documentation. There was an overall decreasing trend in CREs with age. Lower frequency of CREs was observed during exposure to MSS versus RHS. This effect was significantly evident in infants ≥ 33 weeks gestation (p=0.03), suggesting an effective therapeutic window for MSS when the infant’s auditory brain development is most intact. This study provides preliminary evidence for short-term improvements in the physiological stability of NICU infants using MSS. Future studies are needed to investigate the potential of this non-pharmacological approach and its clinical relevance to the treatment of apnea of prematurity.