know your premmie
Skin to Skin Contact

Skin-to-skin care, also known as Kangaroo Mother Care (KMC) is an innovative method of taking care of premature and low birth weight (LBW) babies. With KMC the baby is dressed only in a small nappy and then placed on the mother’s naked chest, between her breasts with the head of the baby underneath her chin. The baby can also be placed on the father’s chest and he can provide skin-to-skin care.

KMC improves the outcome of the premature babies, humanise the general care, help the baby with temperature regulation, reduce the length of hospitalisation and infection and improve parent-to-infant bonding. KMC further establishes exclusive breastfeeding.

Why do we call it Kangaroo Mother Care? KMC reminds us of how marsupials or kangaroos take care of their young. The infant kangaroo is always born prematurely. When the little kangaroo is born, it crawls into the maternal pouch where it receives warmth, safety and food, until maturation. Similar to the kangaroo mother, the human mother provides a safe, warm environment and frequent feeding opportunities for her premature or LBW infant, when she cares for her baby, using the KMC method.

Continuous KMC is skin-to-skin care practiced for 24 hours, day and night. The baby is removed from the position, only when the mother takes a bath. Alternatively, intermittent KMC can be practiced. The infant is held skin-to-skin for a shorter period of time when the mother or father is unable to be with their infant for 24 hours. In this case parents can practice KMC for a few hours per day and still experience the benefits of skin-to-skin contact.

Kangarooing is beneficial to all

Many research studies have been done comparing KMC to incubator care. These studies have shown that KMC has numerous benefits. The benefits have been divided into 3 categories namely benefits to the baby, parents and hospital.

Benefits to the baby include maintenance of adequate body temperature, less crying and more quiet sleep periods. The baby will also show less energy consuming movements resulting in satisfactory weight gain. Breastfeeding initiation and duration is increased with more babies receiving exclusive breastfeeding, babies experience no additional risk of infection and a reduction of the occurrence and severity of hospital acquired infections is a major benefit for the baby. KMC babies can also be discharged to home sooner.

Benefits to the parents include an increased sense of bonding with their baby, an increased confidence in caring for their baby, continuation of the interrupted nurturing role as a mother and the empowerment to become the primary caregiver again. Skin-to-skin care also enables both fathers and mothers to participate in their baby’s care.

Benefits to the hospital include significant cost-savings, since babies go home sooner and staff experienced improved moral, due to better infant survival and improved quality care.

How to do KMC?

The naked baby (except for a nappy) is placed in a curled up position between the mother’s breasts or on dad’s chest and supported by a wrap or snug shirt. The baby’s head need to be supported to keep the airway open and hands close to the face will support self-regulation. Even babies that are stable on a ventilator and babies on CPAP can be cared for in skin-to-skin care. Do not delay until the baby is stable, since skin-to-skin care helps to reach this physiological stability.

Kangaroo discharge refers to the fact that many LBW infants can be discharged earlier (if KMC is continued at home). Discharge irrespective of weight is possible once the baby is feeding satisfactorily and weight gain is maintained. KMC is continued at home until the baby reaches a weight of 2 – 3 kg or when the baby becomes restless and protests when tied in the KMC position. KMC should not be seen as an alternative, but rather as the gold standard of care.


KMC and tube feeding

Sleeping in the KMC position

KMC and Technology

 KMC twins

Dad doing KMC 

Premmie Stimulation

Stimulating a preterm infant is always a hot topic. The question is not how to stimulate, but rather when?

The whole environment offers stimulation for these little persons: sound, touch, light, smell and movement, so even the linen the preterm baby lies on acts as a ‘stimulator’. It is important to provide interaction activities as described earlier in the section ‘ready to interact’. Baby massage is usually seen as very beneficial, but may also be very over stimulating for the premmie. We therefore suggest that baby stimulation as we traditionally know it is not provided before the infant is 36 weeks gestational age.

Dr Rosemary White-Traut developed a program known as the ATVV program: Auditory, Tactile, Vestibular and Vision. You can download the document here.

Dr Welma Lubbe shares on how the womb environment guides us on what stimulation will be best for baby after birth

Behavioural Stages

While your preterm baby is in the NICU you may experience a lot of emotions such as loss, guilt, self-blame, anger, anxiety, depression and many more.  These are all normal emotions, since the birth of a preterm baby is similar to the loss of a baby.  As parents of a preterm baby, you’ve lost the opportunity to experience a normal pregnancy and birth, as well as the joy of taking a healthy, full term baby home.  One of the main challenges parents of preterm babies experience is that they do not know how to interact with their babies while they are still in the NICU.  Before even touching or interacting with your baby it is important to observe her and read the cues that she gives you.  Your baby has different behavioural stages and behavioural cues that will help you give her the appropriate care at the right time. A behavioural stage (turning-in, coming out or reciprocity) will tell you whether your baby is ready for interaction or whether you should rather not handle her at the time, since she is already experiencing stress.

Behaviour stages of the preterm baby

Your baby will react or behave differently depending on the age she was born.  Even though all babies are unique, research has shown that they can normally be categorised into certain stages of behaviour.  A baby born before 32 weeks gestation will not be able to communicate with the environment or her caretakers at all. This baby will need intensive care nursing, will be physiologically unstable and will be unable to come into and maintain the quiet alert state.  This is called the turning-in stage.  The baby’s behaviour is similar to that of a porcupine, since she reacts on pain (or touch) by turning in to herself and trying to protect herself from possible harm.

Between 32 and 35 weeks gestation your baby will become physiologically stable, start to communicate and interact, breathe comfortably and absorb calories when fed by mouth.  This is the coming-out stage and the baby is similar to a tortoise, since she will shyly start to explore the environment, but as soon as it becomes too much she will withdraw to try to recover.

When your baby is 36 weeks or older she will be able to actively interact with the environment and her parents.  She will be able to recover from agitation by using self-quieting behaviours (which the staff and her parents taught her).  This stage is the reciprocity (interaction) stage and similar to a puppy.  During this stage she mainly sleeps and feed — just like a newborn full term baby does.

Keep these stages in mind when starting to interact with and getting to learn your baby.  It is important to remember that your baby may be outside the womb environment, but the development will be at the same level than that of her counterparts who are still in the womb, receiving the protection they need.  Preterm babies may also be compromised from over stimulation that is too must for her fragile system.

As mentioned earlier, all babies are unique and you might find that your 30 week old baby will be in the coming out stage.  It is more important to look at how your baby reacts to interaction than at the gestational age.  Chapter four of Prematurity – Adjusting your Dream explains the different stages and also provides you with activities that you can do during each stage to get to know your baby.

Sleep and Awake Stages

Babies have two sleep stages, namely quiet sleep and active (rapid eye movement or REM) sleep. They also experience awake stages that can be categorised in quite alert, drowsiness, active alert and then crying.  Understanding the different sleep and awake stages is important for parents to know, as the baby will be ready for interaction only in one of these stages. Sleep and awake stages

Quiet Sleep

Quiet Sleep is when your baby’s eyes are tightly shut and still. Her breathing is regular and almost no activity is seen except for startles or mouthing. Babies rest the most and gain the most weight when they remain in this sleep stage.

Active sleep is when the eyes are closed, but slow rolling movements or REM (rapid eye movement) can be seen.  She  may briefly open her eyes, has irregular breathing and make sucking movements. She may also have movement of the limbs from minor twitches to stretching movements and your baby may respond to voices and other noises.

Active sleep


Drowsy is when your baby’s eyes open and close, but have a glazed appearance.  It might look like dull eyes with droopy eyelids when the eyes are open.  Her breathing is faster and shallower than in quiet sleep and she has increased movement with mild startles.  Response to voices and other noises may be delayed.

Quiet alert babies have wide-open eyes with a bright and shining look.  They can focus attention on face or objects, and have little or no body or facial movements.  During this awake stage, the baby will also have regular breathing.  This is a good time to feed, talk, look at or hold your baby.  Premature babies may spend time in quiet alert normally only after 32 weeks gestation, and before this time only be awake for a maximum of two minutes a day.

Quiet Alert

Active alert

Active alert is the stage when the baby’s eyes are generally open. Generalised movements are often accompanied by grimacing and / or brief vocalizations and the baby has regular breathing.  It may be difficult to get the baby to interact, since she is struggling to cope with her environment.

Fussing/Crying is a stage that any parent or caregiver wants to avoid, since it is so stressful to the parent and the baby.  During crying or fussing the baby shows generalised movement with agitated vocalization, which ranges from mild fussing to continuous crying.  She also has irregular breathing and colour changes (red or pale).


Stress Cues

Since your baby cannot talk to you, her only way of communication is through non-verbal (body) language.  When someone, either you or the nurse, is handling your baby, your little one will tell you through her body language whether she is ready for the activity or not.  Your baby may show either readiness or avoidance (or stress) cues.

Readiness cues, also known as self-regulatory behaviour is the techniques a baby use to interact with her environment and if the environment is unsupportive, these techniques help her to cope.  Some of this self-regulatory behaviour includes non-nutritive sucking, foot bracing, hands to chin, grasping and hands to face.  You can help your premmie to reach self-regulation by supporting her with lots of skin-to-skin contact, positive touch techniques, positioning and protection from the harsh NICU environment. 

Dr Welma Lubbe shares on how the womb environment guides us on what stimulation will be best for baby after birth




Frequent handling and even routine procedures disturbs sleep, which leads to decreased weight gain, decreased state regulation and low oxygen levels in the blood.  Even noise and bright light can cause stress in the preterm infant.  The premmie will show her inability to cope with her environment through stress cues.  This will be her way of communication to you that something is bothering her.  Some stress cues you may see in your premmie are:

Physiologic/ autonomic (Automatic Functions)

  • Colour changes – pallor or flushing
  • Changes in vital signs (e.g. Heart rate, breathing)
  • Hiccups
  • Spitting up
  • Sneezing
  • Yawning

State subsystem (States of consciousness)



  • Irritability
  • Diffuse sleep states – grimacing, twitching
  • Glassy eyes
  • Gaze aversion (looking away)
  • Staring
  • Panicked look
  • Looking Away

Looking away

Gaze aversion


Motor subsystem (Muscle Movements)

  • Hyperextension of extremities – saluting, arching, airplane, sitting on air, “stop” sign
  • Frantic movements
  • Finger splaying
  • Generalised hypotonia – low muscle tone

Extension of Extremities

Finger Splaying



Toe Splaying

Sitting on Air

Attention/interaction (Awake stages, ability to interact)


Avoid interaction

“Stop sign”

A baby that is tired or over stimulated will send out a signal that says, “I need a break!” These time-out signals tell us to stop what we are doing and give the baby a rest.  You saw examples of these time-out signals or stress cues.  Look for these signals whenever you do an activity with your baby.  Ask your baby’s nurse to help you identify these signals.  Remember that it takes practice to learn to identify them, but it will help you understand your baby better.

Read more on stress cues and understanding your baby in Chapter 4 of Prematurity – Adjusting your Dream.

Calming your Premmie

Handling of the preterm baby must be based on two critical components: individualisation of care and timing.  Stress can be minimised for your baby if the caregiver is able to identify individual stress signals and respond appropriately, time interventions to allow for undisturbed rest periods, and provide “time-out” for your baby to re-organise during stressful procedures.  Your baby can be helped to re-organise by following the steps of positive touch, such as still touch, containment hold and skin-to-skin care.

Stroking is a natural and instinctive action for parents, but for a fragile baby it might be too much to tolerate, as the premature baby may experience stroking as painful.  Instead of stroking you can rest a hand on your baby. This is known as still or positive touch.
Containment hold is when you cup the premmie’s head and one other body area with a steady hand giving positive gentle pressure.  Movement should always be gentle, firm and rhythmical started on a body part the baby seems to like being touched.  E.g. hold your baby firmly against your chest and rock her body slowly.  This is only started when baby is physiological stable and seems to tolerate the touch.
Massage in premature babies should be done with extreme care, since it may have negative effects.  This should only be done with babies that are stable and seems to tolerate touch well.  Massage should preferably not be started before the baby is in the reciprocity stage.
You can also implement the following to prevent over stimulation:

  • Avoid more than one stimulus at a time – only talk or touch.
  • Prevent visual over-stimulation by using busy toys, eye contact, bright lights and colours.
  • Handle your premmie slow and gentle and keep her in a flexed position, with hands and feet in midline and while keeping the whole body contained.
  • Provide time-out when she seems stress while you are caring for her.  This can be done by stopping what you’re doing and providing still touch or containment hold untill she calms down.  You can continue with what you were busy with after she calmed down.

More ways to help calm your baby

  • Hold your baby firmly but gently in a curled (fetus) position.  Place your hand on your baby’s feet and on head or shoulders to help your baby curl up and relax.
  • Swaddle your baby in a blanket.  Bend the legs up and bring the arms to the middle of the body.  Leave your baby’s hands free to find the mouth.
Ready to Interact

Earlier we have discussed ways to calm your baby, but your little one may be very ill and you may very well be too scared to touch her. It is important to understand where she is in her development and then plan interactions with her accordingly.

We discussed that a preterm infant experience three distinctive developmental stages (Gorski stages). 

  • The first being the turning-in stage when the preterm infant is still very ill and unstable as she reacts similar to a porcupine. She may at first react negatively to touch, all the pens coming out to protect herself, but as she get to know the stimulation she will slowly relax.
  • At about 32 weeks you can expect that her development is in the coming-out stage where she will react by withdrawing when overstimulated, but slowly, like a tortuous she will start exploring her environment again.  If she is very ill, she may remain in turning-in for longer or until she is older.
  • Finally, she will move onto the reciprocity or interaction stage, which is similar to newborn reactions. At this stage she will start reacting like a puppy: sleep, feed and poop. When she is awake, for short periods at a time, she may make eye contact and she will be ready to start feeding on the breast or bottle.

In Prematurity – Adjusting your dream you will find some useful activities that you can do with your premmie according to the developmental stage she is in.



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