Holding Helps: How Skin-to-Skin Care Improved Survival for Premature Babies with Breathing Trouble

A large 2025 study from Egypt tested whether "kangaroo care" is safe and helpful for premature babies who still need help breathing — with striking results

A new study of 240 premature babies found that holding them skin-to-skin against a parent's chest for several hours a day — a practice called kangaroo mother care — was linked to far better survival, fewer infections, and faster recovery from breathing problems, even while the babies were still receiving breathing support. The finding is important because doctors had long been cautious about this kind of close contact for the sickest premature babies, and this trial suggests that caution may have been holding back a simple, low-cost intervention that helps.

Why This Question Matters

Babies born too early often struggle to breathe because their lungs are not yet ready. This condition, called respiratory distress syndrome (RDS), happens when a baby's lungs lack enough of a soapy substance called surfactant that keeps the tiny air sacs open. Without it, the air sacs collapse and the baby has to work very hard for each breath. In wealthy countries, treatments such as surfactant given directly into the lungs, gentle air pressure through the nose, and steroids given before birth have made RDS far more survivable, as summarized in international treatment guidelines [1]. But in many parts of the world, those treatments are scarce, and RDS is still one of the most common reasons premature babies die.

Kangaroo mother care offers something different — and something almost any family and hospital can provide. A baby, wearing only a diaper and hat, is placed upright against a parent's bare chest, held in place by a wrap, with a blanket over the back. The parent's body warms the baby, steadies the heartbeat and breathing, and encourages breastfeeding and bonding. Researchers had already shown that this practice saves lives in stable premature babies: a major international trial found that starting skin-to-skin care early reduced deaths among small babies [2]. The idea itself is not new — it was developed in Colombia in the late 1970s when hospitals ran short of incubators, and decades of research have refined it since [3].

The Problem This Study Set Out to Solve

Here is the gap the new study addressed. Almost all of that earlier, encouraging research was done with babies who were already stable and no longer needed help breathing. Doctors and nurses were understandably nervous about lifting a baby who was still on a breathing machine onto a parent's chest, worried it might tire the baby out, cause pauses in breathing, or let the baby get too cold. So the babies who might have the most to gain — those in the thick of breathing trouble — were often the ones left in the incubator. For years, in other words, kangaroo care was treated as a reward for getting better rather than a tool to help babies get better. This study set out to test whether that thinking was wrong.

What the Researchers Did

A team led by Ramadan and colleagues carried out the study across four newborn intensive care units in Tanta, Egypt, over about a year and a half [4]. They enrolled 240 premature babies who weighed less than 2000 grams (about 4.4 pounds) and had RDS, but who were stable and needing only gentle breathing support such as low-flow oxygen or nasal air pressure. Babies who were very unstable or needed the most intensive breathing machines were not included — an important point, because the results apply to stable babies, not the very sickest.

The babies were randomly assigned, like a coin flip, into two groups of 120. One group received a carefully structured kangaroo care program: at least six hours of skin-to-skin contact each day until they went home, with nurses teaching parents how to hold their baby safely, watch for warning signs, and breastfeed. The nurses themselves completed 40 hours of special training. The other group received the hospital's usual care, with the same amount of nurse and parent contact time so the comparison would be fair. Throughout, the babies' breathing was scored using a simple, well-tested checklist that watches for signs of effort like flaring nostrils and grunting [5], and infections were carefully tracked. Assigning babies randomly and measuring outcomes with staff who did not know which group a baby was in helps make sure the results reflect the treatment and not wishful thinking.

What They Found

The results were striking. Babies in the kangaroo care group were much more likely to survive their first 28 days — the study reported their risk of dying was reduced by more than half compared with the usual-care group [4]. They also had 55% fewer hospital-acquired infections [4], a benefit that fits with earlier research showing kangaroo care lowers serious infections in newborns [6]. This makes sense: babies held by their parents are handled less by many different caregivers, stay warmer, and are far more likely to be breastfed, and breast milk carries natural protection against infection.

Their breathing recovered faster, too. Instead of being tired out by being held, the kangaroo care babies improved more quickly and came off their nasal breathing support about two days sooner [4]. And many more of them were breastfeeding fully by the time they went home — about 74% compared with 48% in the usual-care group [4] — echoing a large body of research linking kangaroo care to better breastfeeding [7]. Parents in the program also grew noticeably more skilled and confident in caring for their babies, a benefit that keeps giving after the family leaves the hospital and that reflects the close bonding kangaroo care encourages [8].

It also helps to understand why holding might do so much. When a baby lies skin-to-skin, the parent's own body acts like a living incubator, keeping the baby at a steady temperature so the baby does not have to burn precious energy staying warm — energy that can instead go toward growing and healing. Close contact tends to calm the baby, steadying the heart rate and breathing, and it makes breastfeeding far easier, which in turn delivers antibodies that help fight off infection. Being on a parent's chest also means the baby is handled less by rotating staff and spends less time exposed to the germs that circulate in a busy unit. None of these effects is dramatic on its own, but together they add up, and researchers believe this combination is why kangaroo care shows up as fewer infections, faster breathing recovery, and better survival rather than as a single isolated benefit. In this trial, the babies and parents were also carefully watched the whole time, with monitors tracking heart rate and oxygen and nurses ready to step in — a reminder that early kangaroo care for a baby who still needs breathing help is done alongside close medical supervision, not instead of it.

What This Means for Families

For a parent whose baby is in the NICU with breathing trouble, the encouraging message is that holding your baby is not just comforting — it may be genuinely therapeutic, and this study suggests it can be done safely even while a baby still needs some breathing help, as long as the medical team confirms the baby is stable and monitors closely. Kangaroo care costs almost nothing, and it puts parents at the center of their baby's care rather than at the edge of it. Global health leaders have called for newborn care to be reorganized around exactly this kind of parent-baby closeness [9], partly because it also eases the stress that both babies and parents feel in intensive care [10].

A few honest cautions are worth keeping in mind. This was one study, done in a setting where many babies did not have access to the advanced breathing treatments common in wealthier hospitals, so the dramatic survival difference may be larger than it would be in a well-equipped unit. The babies were stable ones on gentle support, not the most critically ill. And because everyone could see which babies were being held, some of the benefit might come from the extra attention and breastfeeding help that came bundled with the program. Researchers will now want to repeat the study in other places to confirm the findings.

What Comes Next

Scientists are working to confirm these results in larger trials across different countries and to pin down practical questions — how many hours of skin-to-skin contact are enough, and how hospitals can rearrange busy units and support nurses to make it happen, including lighter-touch versions of the program [11]. What this study has already changed is the starting assumption. Rather than asking whether a premature baby with breathing trouble is well enough to be held, the better question may now be whether there is any good reason not to offer that closeness — because for these families, holding appears to help.

References

  1. Sweet DG, Carnielli VP, Greisen G, Hallman M, Klebermass-Schrehof K, Ozek E, et al. European consensus guidelines on the management of respiratory distress syndrome: 2022 update. Neonatology. 2023;120(1):3–23. doi:10.1159/000528914 ↩
  2. WHO Immediate KMC Study Group. Immediate "Kangaroo Mother Care" and survival of infants with low birth weight. N Engl J Med. 2021;384(21):2028–2038. doi:10.1056/NEJMoa2026486 ↩
  3. Charpak N, Ruiz JG, Zupan J, Cattaneo A, Figueroa Z, Tessier R, et al. Kangaroo Mother Care: 25 years after. Acta Paediatr. 2005;94(5):514–522. doi:10.1080/08035250510027381 ↩
  4. Ramadan OME, Alshammari AM, Alruwaili AN, Elsharkawy NB, Alhaiti A, Baraka NIM. Transforming neonatal nursing: a randomized controlled trial comparing kangaroo care and standard protocols for survival in preterm infants with respiratory distress syndrome. BMC Nurs. 2025;24:430. doi:10.1186/s12912-025-03088-8 ↩
  5. Setty SG, Batra M, Hedstrom AB. The Silverman Andersen respiratory severity score can be simplified and still predicts increased neonatal respiratory support. Acta Paediatr. 2020;109(6):1273–1275. doi:10.1111/apa.15142 ↩
  6. Arya S, Chhabra S, Singhal R, Kumari A, Wadhwa N, Anand P, et al. Effect on neonatal sepsis following immediate kangaroo mother care in a newborn intensive care unit: a post-hoc analysis of a multicentre, open-label, randomised controlled trial. EClinicalMedicine. 2023;60:102006. doi:10.1016/j.eclinm.2023.102006 ↩
  7. Narciso LM, Beleza LO, Imoto AM. The effectiveness of Kangaroo Mother Care in hospitalization period of preterm and low birth weight infants: systematic review and meta-analysis. J Pediatr (Rio J). 2022;98(2):117–125. doi:10.1016/j.jped.2021.06.004 ↩
  8. Feldman R, Eidelman AI, Sirota L, Weller A. Comparison of skin-to-skin (kangaroo) and traditional care: parenting outcomes and preterm infant development. Pediatrics. 2002;110(1):16–26. doi:10.1542/peds.110.1.16 ↩
  9. Darmstadt GL, Kirkwood B, Gupta S, Adejuyigbe E, Bahl R, Batra M, et al. WHO Global Position Paper and Implementation Strategy on kangaroo mother care call for fundamental reorganisation of maternal–infant care. Lancet. 2023;401(10390):1751–1753. doi:10.1016/S0140-6736(23)00674-800674-8) ↩
  10. Cañadas DC, Perales AB, Martínez RG, Casado-Belmonte MDP, Carreño TP. Effects of Kangaroo Mother Care in the NICU on the physiological stress parameters of premature infants: a meta-analysis of RCTs. Int J Environ Res Public Health. 2022;19(1):583. doi:10.3390/ijerph19010583 ↩
  11. Ouyang X, Ye X, Liu X, Zhang H, Huang S, Fan Y, et al. Effects of kangaroo mother care combined with nurse-assisted mindfulness training for reducing stress among mothers of preterm infants hospitalized in the NICU: a randomized controlled trial. BMC Pediatr. 2024;24:628. doi:10.1186/s12887-024-05098-y ↩