Transition to at-Breast Feeding

Skin-to-skin care – Transition to at-breast feeding interventions

Time to read: 4 min.

Skin-to-skin care is an intervention that empowers mothers to express and provide their milk to their infants and supports transition to breastfeeding by offering access and early opportunities for non-nutritive and nutritive sucking at the breast.

What is skin-to-skin care?

Skin-to-skin care (also known as kangaroo mother care - KMC) is a well-known practice of holding the naked infant vertically between the mother’s breasts and below her clothes.1

Skin-to-skin care is recommended for all infants globally.2

Skin-to-skin care, when possible, can be continuous 24h a day. Intermittent skin-to-skin care (alternating periods of time between a NICU incubator and a minimum of 1 hour with a parent) several times a day is recommended to give therapeutic benefits, and enables the infant to stabilise and regulate core physiological and behavioural functions following transfer.3

NICU infants can commence skin-to-skin care as soon as the infant is physiologically stable after birth; this applies to extremely low birthweight and ventilated infants.1,2,4

Why is skin-to-skin care important?

Skin-to-skin care supports a significant reduction in infant mortality and morbidity globally.3

Regular skin-to-skin care empowers mothers to

  • Express and provide their milk for their infants, resulting in significantly longer duration, exclusive breastfeeding5-7 and earlier discharge from hospital.8
  • Express milk during or after skin-to-skin care, significantly increasing expressed milk volumes.5

Regular skin-to-skin care supports the NICU infant to transition from enteral to oral feeding through

  • Access and early opportunities for non-nutritive sucking (NNS) and nutritive sucking (NS) at the breast.
  • Early sensory stimuli enable infants to touch, smell, and taste their mother’s milk.9
  • Oxytocin stimuli10 (crucial for milk ejection11) to support bonding and relationship building, specifically in a challenging NICU environment.12

How to implement skin-to-skin care

  • Stipulate skin-to-skin care for all physiologically and behaviourally stable infants
  • Recommend uninterrupted skin-to-skin care for a minimum duration of one hour
  • Inform parents to wear clothing that supports skin-to-skin care with the infant
  • Encourage and support the mother to express breast milk whilst in skin-to-skin care with the infant, or immediately after.
  • Enable the mother to offer the breast for NNS whilst in skin-to skin care (recently expressed breast).
  • Document all skin-to-skin care specifying frequency, duration and reasons why the practice was not performed in breastfeeding supportive practices (BFSP) logbook
  • Enable a NICU environment that supports parents to participate in extended skin-to-skin care at each parental visit through comfortable seating, space, and visitation access.

How to monitor skin-to-skin care

Collect data on frequency and duration of skin-to-skin care

Carry out a monthly audit of the data to measure:

• Percentage of infants receiving skin-to-skin care at least once per day.

• Daily frequency and duration of skin-to-skin care.

• Reasons for sub-optimal provision of skin-to-skin care.

Audit records monthly to review progress, identify challenges and implement interventions to improve skin-to-skin care practice and support lactation outcomes.


1. Nyqvist KH et al. Towards universal Kangaroo Mother Care: recommendations and report from the First European conference and Seventh International Workshop on Kangaroo Mother Care. Acta Paediatr. 2010; 99(6):820–826.

2. World Health Organization (WHO). Kangaroo mother care to reduce morbidity and mortality in low-birth-weight infants. 2020.

3. Nyqvist KH et al. State of the art and recommendations. Kangaroo mother care: application in a high-tech environment. Acta Paediatr. 2010; 99(6):812–819.

4. Ludington-Hoe SM et al. Safe criteria and procedure for kangaroo care with intubated preterm infants. J Obstet Gynecol Neonatal Nurs. 2003; 32(5):579–588.

5. Acuña-Muga J et al. Volume of milk obtained in relation to location and circumstances of expression in mothers of very low birth weight infants. J Hum Lact. 2014; 30(1):41–46.

6. Nyqvist KH et al. Expansion of the baby-friendly hospital initiative ten steps to successful breastfeeding into neonatal intensive care: expert group recommendations. J Hum Lact. 2013; 29(3):300–309.

7. Baley J. Skin-to-skin care for term and preterm infants in the neonatal ICU. Pediatrics. 2015; 136(3):596–599.

8. Assad M et al. Decreased cost and improved feeding tolerance in VLBW infants fed an exclusive human milk diet. J Perinatol. 2016; 36(3):216–220.

9. Spatz DL. Ten steps for promoting and protecting breastfeeding for vulnerable infants. J Perinat Neonatal Nurs. 2004; 18(4):385–396.

10. Uvnäs-Moberg K. Neuroendocrinology of the mother-child interaction. Trends Endocrinol Metab. 1996; 7(4):126–131.

11. Prime DK. Dynamics of milk flow and milk ejection during breast expression in women [PhD Thesis]: The University of Western Australia; 2010.

12.  Flacking R et al. Closeness and separation in neonatal intensive care. Acta Paediatr. 2012; 101(10):1032–1037.

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