Challenges and enhancement of health: a dual impact of kangaroo care on parents and infants—systematic review

Introduction

The neonatal period, especially for preterm infants, presents unique challenges for parental bonding and infant well-being (1). One challenge is the limited opportunity for physical closeness in a hospital setting, where medical equipment and procedures can often keep parents at a distance from their newborns. This physical separation can delay the initial bonding process that is critical for both the infant’s emotional development and the parent’s psychological well-being (2). Skin-to-skin contact (SSC), often facilitated through kangaroo mother care (KMC), has emerged as a valuable intervention in promoting maternal-infant attachment and addressing various outcomes in neonatal care units. For example, KMC promotes more frequent and easier breastfeeding, and increased milk volume, which is important for infants in the neonatal intensive care unit (NICU), who typically have a lower birth weight (3). Also, the mother (or other caregiver) also plays a key role in temperature regulation of the infant, which is key to positive health outcomes in premature infants who may not yet be able to regulate their own temperature (4).

Despite the numerous benefits of KMC, its implementation faces several challenges such as space constraints and hospital policies (5). Structurally, the lack of space in facilities poses a challenge to KMC, leading to early discharges or limited visiting policies (6). Additionally, some hospitals have limited rooms where patients often share a space. Those shared spaces often feel crowded and lack privacy screens, which limits the implementation of KMC since it can cause discomfort from undressing around strangers (7,8).

In order to better support KMC practice in hospital settings, it is important to review existing knowledge to highlight what is known and identify existing needs and challenges. Given that, this literature review aims to synthesize existing research on the effects of KMC on maternal attachment (9,10), physiological functions of preterm infants (11), parental sleep quality and mood (12) in the NICU. Additionally, we aim to explore how technological advancements can be leveraged to extend the benefits of kangaroo care (KC) to more diverse settings, especially remote and rural areas. By examining the evidence supporting the use of KMC, our study presents data to support its use, and opportunities for future interventions.

Background

KMC involves continuous SSC between the mother and infant, promoting thermal regulation, breastfeeding, and emotional bonding. Studies have shown that KMC positively affects maternal attachment, as reflected in higher attachment scale scores and increased maternal responsiveness to preterm infants (9,10). Additionally, KMC has been associated with physiological benefits for preterm infants, including improved respiratory stability, temperature regulation, physiological stability, blood glucose, and weight gain (11,13-16). Furthermore, KMC has been shown to facilitate parental attachment even in high-risk populations, such as neonates with congenital heart disease (17). KMC practice among low birth weight infants’ (LBWIs’) mothers starts at hospital and continues at home, with the support from health workers. After discharge, LBWI’s mothers struggle to practice KMC at home, due to both internal and external factors. Some internal factors are the mother’s lack of confidence or fear of harming the baby and postpartum depression (18). And as for external factors that interfere with the practice of KMC at home are household chores, looking after a baby’s siblings, and lack of support from family (19-21).

In addition to household chores, caring for a baby’s siblings, and lack of familial support, safe sleeping practices recommended to prevent sudden infant death syndrome (SIDS), such as the ‘back to sleep’ position, also influence the home practice of KMC. These practices, while critical for infant safety, may pose additional challenges for continuous SSC, especially in environments not specifically adapted for safe KMC implementation (22).

In addition, the feasibility of continuous SSC can be hindered by hospital policies (23), staffing limitations (24), and the physical condition of both the mother and the infant which may often require medical interventions making it difficult to provide consistent KMC (25). In many NICUs, space constraints are also a barrier since KMC requires a special environment in healthcare settings, such as private, comfortable spaces where parents can remain with their newborns for extended periods (5,26). In order to address these limitations, it is important to reflect on how to adapt hospital policies and environments to better support KMC.

KC, originally developed as an innovative approach to neonatal care, has now become a well-established practice in NICUs worldwide. Supported by extensive research demonstrating its benefits for both infants and parents (27), KC is a standard of care that promotes early parental involvement, enhanced bonding, and significant improvements in infant health outcomes. This method involves parents as primary caregivers, engaging them in continuous SSC that supports the physiological and emotional development of their newborns (28). Today, KMC is recognized not just as an innovative care practice but as a standard of care recommended by leading health organizations, including the World Health Organization (WHO), for its critical role in enhancing the quality of care for newborns, especially those born preterm or with low birth weight (29).

Recent reports show that pediatric healthcare has started to use digital technology to keep providing care safely (30). This includes more telemedicine using video calls to see patients at home and mobile apps to track health data (31). For example, in the study by Park et al. (31), they developed and supported a healthcare service using a mobile personal health record (PHR) app specifically to investigate the effects of video-based telehealth services for vulnerable workers with metabolic risk factors like high blood pressure, reduction in body weight and more. While these advances have improved care and the sharing of medical knowledge, they have also shown wider gaps in who has access to the needed technology and the need for infrastructure to support its implementation such as reliable internet connection (30,31).

Given that, our literature review aims to provide a comprehensive understanding of the effects of KMC on maternal-infant attachment and other outcomes in the NICU. By systematically reviewing the existing literature, our results identified major challenges and limitations through which KMC implementation is impacted. Finally, we provide discussion points on how to promote a nurturing environment that supports the health and well-being of both mother and child during the NICU stay. We present this article in accordance with the PRISMA reporting checklist (available at https://mhealth.amegroups.com/article/view/10.21037/mhealth-24-80/rc).

Methods

Search algorithm

A comprehensive review of the literature identified a total of 28,039 publications related to the NICU in PubMed and a total of 674 publications in the Institute of Electrical and Electronics Engineers (IEEE) database with a search range from 1993 to 2024, using the keywords “neonatal intensive care unit (NICU)”. The search was conducted on 14 March 2024. Refining the search to include only articles discussing KC in NICU settings yielded 380 articles in PubMed and 13 articles in IEEE, using the keywords “neonatal intensive care unit (NICU)” and “kangaroo care”. Now to focus on the involvement of mothers in KC practices, we have used the keywords “neonatal intensive care unit (NICU)”, “kangaroo care”, “mothers”, and obtained 319 articles in PubMed and 13 articles in IEEE. Narrowing the focus to the attachment between the mother and preterm infants resulted in 36 articles in PubMed and 0 articles in IEEE, on using the keywords “neonatal intensive care unit (NICU)”, “kangaroo care”, “mothers”, and “attachment”. Exclusion criteria included review and systematic reviews (n=3), studies without information on attachment (n=16), and surveys (n=1). On excluding the articles based on the exclusion criteria above, 16 articles were considered for this study. PRISMA flow chart (Figure 1) depicts the systematic progression of search algorithm through various stages of filtering and selection. Table 1 presents the key aspects and findings of each selected paper.

Figure 1 Flow diagram demonstrating literature search according to PRISMA guidelines. IEEE, Institute of Electrical and Electronics Engineers.

Data extraction and analysis

In conducting this literature review, we employed a thematic analysis (43) approach to systematically extract and analyze data from the identified articles. This method involved a thorough review of each study to identify and code key themes based on the most common and unique topics discussed. The process began with an initial reading of each article to gain an understanding of its content and context. Key themes emerged through repeatedly categorizing the data, allowing us to group similar topics and identify patterns across the studies.

The primary themes identified were maternal-infant attachment, physiological benefits for preterm infants, parental well-being, and innovative interventions to enhance KMC effectiveness. For maternal-infant attachment, themes such as attachment scale scores, maternal responsiveness, and emotional bonding were prevalent. Physiological benefits were highlighted through improved respiratory stability, weight gain, and growth metrics like head circumference and height. Themes related to parental well-being included reduced postpartum depression, improved sleep quality, and mood enhancement. Additionally, innovative interventions such as maternal audio recordings and music therapy were noted for their unique contributions to enhancing KMC practices. This thematic approach helped us to systematically capture a wide range of topics in the literature and gain a good understanding of the impacts of KMC in the NICU.

Results

Our literature review identified a total of 16 articles that met the inclusion criteria for this study, from an initial pool of 28,713 publications across PubMed and IEEE databases. These studies consistently demonstrate the significant positive impact of KMC on various outcomes in the NICU. Specifically, 10 out of the 16 articles reported enhanced maternal-infant attachment, as reflected in higher attachment scale scores and increased maternal responsiveness. The physiological benefits for preterm infants, documented in six articles, include improved respiratory stability, weight gain, and growth metrics such as head circumference and height. Additionally, three studies linked KMC to reduced levels of postpartum depression among mothers, and two articles highlighted improvements in parental sleep quality and mood for those engaging in SSC.

Innovative interventions, such as playing maternal audio recordings and facilitating visual connections via cloud platforms, have shown effectiveness in enhancing maternal-infant bonds during restrictive periods, such as the coronavirus disease 2019 (COVID-19) pandemic. One study by Wang et al. [2021] noted a significant increase in premature infant-parent attachment scores from 64.6 to 74.4 following such interventions (32). Furthermore, the integration of complementary therapies like music therapy was found to significantly increase the level of attachment between mothers and premature neonates, as demonstrated by Vahdati et al. [2017] (33). Observational data from the study indicated that SSC not only reduces parental heart rate and blood pressure but also potentially alleviates stress, depression, and anxiety, underscoring KMC as a crucial family-centered care practice in the NICU (34).

Maternal attachment and KMC

Research indicates that KMC positively influences maternal attachment (9,10), as reflected in higher attachment scale scores and increased maternal responsiveness to preterm infants. This highlights the importance of KMC as a supportive intervention for promoting bonding between mothers and their infants in the NICU. KC facilitates bonding and enhances maternal-infant acquaintance, calming both mothers and newborns (35). KMC significantly enhanced mother-baby attachment in LBWIs compared to standard care (36). KMC promotes a positive perception in mothers and a state of readiness to detect and respond to infant’s cues, contributing to a subjective “bonding effect” and enhancing maternal competence and resilience (37).

Physiological benefits of KMC and parental engagement

KMC has been associated with various physiological benefits for preterm infants (11), including improved respiratory stability and weight gain. These findings underscore the importance of KMC as a holistic approach to neonatal care, addressing both emotional, and physiological needs. Premature infants in the KC group showed higher height and larger head circumference compared to the control group (38). Maternal attachment scores were higher in the KC group, and both groups showed reduced levels of postpartum depression after 3 weeks (38). A significant negative correlation between paternal engagement and paternal oxytocin levels (r=−0.43; P=0.03) and a significant negative correlation between infant oxytocin levels and maternal engagement (r=−0.54; P=0.004) were present (39).

Parental sleep quality and mood

Preliminary evidence suggests that KMC may have positive effects on parental sleep quality and mood (12), potentially reducing stress and promoting parental well-being in the NICU setting. Further research is needed to elucidate the mechanisms underlying these effects and optimize the implementation of KMC to support parental mental health. The study only follows the participants for 4 days (12), which may not be long enough to observe long-term effects or sustainability of benefits from continuous SSC. Furthermore, the study is confined to a few hospitals in Sweden (12), which may limit its applicability in different cultural or healthcare settings.

Cognitive development and early SSC

Ongoing research aims to investigate the impact of early SSC on cognitive development in preterm infants and aims at evaluating the safety of SSC immediately after delivery and its effects on physiological stability, prematurity complications, and maternal mental health (40). Understanding how this intervention influences cognitive outcomes can inform early intervention strategies and support optimal neurodevelopment in vulnerable infants. Targets very preterm infants (40) who are at significant risk for neurodevelopmental issues. While outcomes like physiological stability and maternal mental health are directly measurable, the impact on cognitive development will only be assessable long-term, making it challenging to link immediate SSC with outcomes at 2 years of age definitively.

Integration of music therapy

Music therapy has gained attention as a complementary intervention in the NICU, with the study exploring its effects on physiological stability and stress reduction in preterm infants (33). The group receiving both KC and music therapy showed a significant improvement in the overall attachment scores compared to the group that received only KC (33). The study (33) concluded that combining KC with music could be beneficial, low-cost, and easily implementable intervention in NICUs to enhance maternal-neonatal attachment, suggesting a promising area for further research. Further research is needed to elucidate the mechanisms underlying these effects and optimize music therapy protocols for neonatal populations.

Innovative attachment strategies in NICU

A study employed an intervention where nurses played maternal audio recordings to premature infants and facilitated visual connections via a cloud platform (32). Expressive arts therapy and phone interviews provided additional maternal support. The goal was to increase the attachment score by 10% from an average of 64.6 to 71.1 (32). This innovative approach raised attachment scores from 64.6 to 74.4, surpassing the initial target and demonstrating its effectiveness in enhancing maternal-infant bonds during restrictive periods (32). Additionally, mothers received emotional support and information through expressive arts therapy and phone interviews.

Mitigation of infant medical trauma

Mothers initially experienced preoccupation and fear, but by the third week, they reported increased meaning, mastery, and self-esteem. Respite from SSC was requested to manage emotional crises. SSC through the KC method of care facilitated maternal emotional adaptation and reconciliation over the study period (41). With a small sample size of eight mother-infant dyads participating, the findings may have limited generalizability and may not represent wider populations in similar settings. Still, the study (41) provides valuable insights into the emotional dynamics and potential benefits of the KC in a tertiary intensive care setting, such as SSC through the KC method not only helped mothers cope with their initial emotional responses to childbirth and the condition of their adaptation over time (41).

SSC benefits

Observational data from The Royal Women’s Hospital in Melbourne indicated that SSC not only reduces heart rate and blood pressure among parents but also potentially alleviates their stress, depression, and anxiety (34). These findings highlight SSC as a crucial family-centered care practice that enhances physical health and strengthens parental bonding with neonates, advocating for its broader implementation in similar healthcare settings (34).

KC in pediatric cardiac intensive care unit

With no adverse events reported across 60 sessions involving 25 neonates, KC shows promise not only as a safe practice but also as a potentially beneficial one for enhancing maternal-neonatal bonding in this high-risk group (17). The findings pave the way for future research to explore the long-term neurodevelopmental benefits of KC, suggesting the need for larger, quasi-experimental studies to deepen our understanding of its impact (17). The study focuses on the immediate safety and feasibility of KC but does not provide data on long-term neurodevelopmental outcomes, which are critical for evaluating the full impact of KC on this vulnerable population.

Father providing KC

Fathers identified that they were passing a silent language of love and connecting with their baby by the act of KC in a challenging environment (42). KC enhances the bonding and attachment between fathers and infants (42). The conceptualization of the parental role in caregiving to a newborn is evolving as a contemporary practice. Further research is warranted to confirm or refute the study findings (42). With only 10 participants, the study’s findings are limited in representing fathers experiencing KC in NICUs. A larger sample would provide a more robust understanding of diverse experiences.

Discussion

The findings of our review give insights on the multifaceted nature of mother-infant attachment within the NICU, emphasizing the important role of early parental involvement, SSC, and emotional support in fostering this bond. Our literature review demonstrates the importance of comprehensive support services for parents, addressing their stress and providing guidance to promote positive developmental outcomes for vulnerable newborns. These insights demonstrate the ongoing need for research and innovation in neonatal care to enhance the quality of support provided to infants and families in the NICU setting.

However, despite the substantial evidence supporting the benefits of KMC, several research gaps remain. While short-term benefits of KMC are well-documented (28,44), more research is needed to understand the long-term developmental outcomes for infants and the sustained impact on parental mental health (45). Research into this area is crucial for establishing whether KMC can contribute to sustained developmental benefits such as enhanced emotional development, and whether it can provide long-lasting psychological benefits for parents, reducing the risk of postpartum depression and anxiety.

In the context of NICU environment adaptations, the shift towards single-family rooms (SFRs) has been significant. These rooms are designed to foster a better KC experience by allowing families private space to engage in prolonged SSC. However, as evidenced by Liu et al. [2019] (46), while SFRs facilitate greater parental presence and involvement, they also require careful consideration of support dynamics. The design must ensure that families do not feel isolated and have adequate access to medical and nursing staff. Incorporating these elements into NICU design can significantly impact the effectiveness of KC by ensuring parents feel supported by their child’s care team.

Research on the effects of KMC in socio-economic contexts is also necessary to generalize findings broadly. Such studies would help determine how different practices, and economic conditions influence the implementation and outcomes of KMC. However, in contexts that depend more on hospitals and less on close contact between caregivers and infants, KMC might not be as easily accepted. For example, in hospitals that rely heavily on technology and less on direct contact, KMC might not be as easily accepted because these settings often prefer using medical equipment and have different practices that do not stress close physical contact between mothers and their infants. As mentioned by Hassan et al., the research highlights how socio-economic factors significantly influence the adoption and effectiveness of KMC in managing preterm infant health outcomes (47). This study indicates that socio-economic disparities, such as differences in income, education levels and access to healthcare, can affect how widely and effectively KMC is implemented (47).

Based on our data, we argue that there is a need for continued investigation on innovative intervention strategies that can overcome the challenges of implementing KMC. For example, integrating mobile technology into KMC aligns with prior research (48), which is focused on developing a remote healthcare monitoring system for NICUs. This approach not only enhances caregiver comfort and privacy but also supports the scaling of KMC in community settings and remote areas broadening its impact (48). As we reported, with the integration of mobile, remote monitoring systems, healthcare providers could equip the mother with a wearable device that continuously tracks vital signs like heart rate, temperature, and oxygen levels.

As presented in study by Smith et al. (5), one of the enablers for better implementation of KMC would be the use of technology. Our research corroborates with this line of research and we suggest that future work should focus on the design of technology to support remote participation to facilitate the involvement of family members who cannot join hospital visits such as grandparents or older siblings. In addition, based on our analysis, we suggest developing community-based support programs to enhance emotional and practical support for caregivers, which can improve the overall health outcomes of both infants and their families by increasing their access to resources and shared experiences.

Finally, we observed that fathers perceived that their responsibility was limited to finding money for health care and buying clothes for their families, instead of spending time with the baby in the hospital (49). We recommend future research to address this practice by educating fathers and other caregivers to understand their roles and impacts in KC, specifically KMC, as their active participation could improve the continuity and effectiveness of these practices in the hospital and at home. KC as the general method of SSC and KMC as continuous SSC initiated by the mother can help ensure that all caregivers are aware of the specific interventions and their potential benefits. By continuing to explore ways to optimize these care practices, healthcare providers might significantly enhance the quality of neonatal care, supporting the health and development of preterm infants and their families in the NICU setting. Future work could also involve changing rules to focus more on family-centered care. For example, to support continuous and integral family involvement, hospitals should ensure unrestricted parental access to the NICU. This approach recognizes parents as essential caregivers rather than visitors, facilitating their constant presence and active participation in the care of their babies, which is very important for effective KC and the overall well-being of the infants. To support KMC, hospitals could hire more staff by partnering with volunteer organizations or nursing training programs, where trainees can gain experience by assisting with KMC under supervision. Also redesigning NICU spaces to make them more private and comfortable for parents to stay close to their babies (50). This could include adding movable privacy screens, more comfortable seating options for parents, and facilities for parents to rest and refresh themselves within the NICU area. Training hospital staff on the benefits of KMC can also encourage more widespread use (5). Future research could also explore the efficacy and benefits of KC across a broader range of family structures, including adoptive parents, parental surrogates, and lesbian, gay, bisexual, transgender, and queer (LGBTQ) families with two mothers or fathers.

Conclusions

Based on our analysis, we argue that KMC is an important intervention in the NICU that can significantly enhance maternal-infant attachment, support infant physiological functions, and improve parental well-being. The consistent findings across various studies show the importance of SSC in fostering a positive and nurturing environment for both mothers and infants. However, there are still significant challenges to implement KMC in hospital settings. This includes navigating hospital policies to ensure the broader implementation of KC and KMC. Recent studies acknowledge significant barriers such as staff resistance, inadequate facilities, and rigid NICU policies that often limit the practice of KC (51-53). These awarenesses are important for understanding the full scope of challenges that influence the adoption of KMC in hospital settings. Furthermore, considering the physical condition of both mother and infant is essential (54,55). By addressing these barriers, outlined in the literature, we can enhance strategies to support the health and development of preterm infants and their families in the NICU setting. Addressing the challenges related to identifying best practices for the integration of KMC in NICUs is crucial (56). Moreover, the integration of affordable, advanced technology into KMC practices, such as mobile, remote monitoring systems, offers a promising avenue to extend the benefits of KMC to remote and rural areas. Developing and integrating these technologies could make KMC more effective and accessible, ensuring the benefits of KC might reach more families.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the PRISMA reporting checklist. Available at https://mhealth.amegroups.com/article/view/10.21037/mhealth-24-80/rc

Peer Review File: Available at https://mhealth.amegroups.com/article/view/10.21037/mhealth-24-80/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://mhealth.amegroups.com/article/view/10.21037/mhealth-24-80/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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