Card image cap

This report will examine the benefits of massage on preterm infants In the Special Care Nursery, predominantly that of weight gain and parent-child bonding. The Special Care Nursery supports preterm infants from 32 weeks gestation. Preterm Infants are going through a vast period of development outside of the womb and can face many challenges. Their growth and development needs to be supported by interventions that reduces stress and promotes normal neurological development. These interventions include:

   -   Attention to noise
   -   Attention to light
   -   Positioning
   -   Minimal Handling
   -   Cluster Care
   -   Skin to Skin 

Infant massage can be included as an intervention in the development of preterm infants in Special Care Nurseries. 


What are the benefits of infant massage on the preterm infant?

Touch is the first sense a foetus will develop and will be able to detect touch throughout its body from 12 weeks gestation (Lubbe, 2008).
Touch is crucial for the development, attachment and well-being of any newborn baby.  A lack of touch can have negative effects on the physical, and emotional development and limits their ability to form secure attachments (McClure, 2008)
Preterm infants have many people touching them. The touching can very often be stressful, uncomfortable and painful. Positive forms of touch, like Skin to Skin, massage, containment holding will negate the effects of negative touch. Positive forms of touch will support the preterm infant in remaining in a regulated state and will assist in the development of the central nervous system (Manzotti et al., 2019)
The effects of massage on the preterm infant have been researched for many years and reviewed by many. A narrative review by (Field 2019), reviewed 15 papers covering the past decade (2009- 2019). The benefits of preterm infants massage highlighted in these papers were:

   -   Increased Feed Tolerance
   -   Greater Weight Gain
   -   Less Infection Rates
   -   Shorter Hospital stays
   -   Developmental Gains
   -   Reduced Parental Stress
   -   Improved Parent-Child Bonding
   -   Higher Bone Density
   -   Reduction of Procedure-related Pain   



How does massage therapy promote greater weight gain?

Vagal Nerve Stimulation
We have 12 Cranial Nerves in the body responsible for various internal organ functions. One of these nerves is called the Vagus Nerve and has both sensory and motor functions. 
Responsibilities of the Vagal Nerve
- Digestion
- Heart Rate
- Breathing
- Cardiovascular Activity
- Reflex Actions

(Chang et al 2003).


A study review by Field and Diego (2008), in relation to Vagal activity in the preterm infant, reported that vagal activity increases when pressure receptors under the skin are stimulated through touch. In turn, preterm infants have lower Vagal activity than term infants and are more likely to exhibit sub-optimal neurodevelopment outcomes.
One study looked at autonomic functioning, state regulation, and neuro behaviour in preterm infants who received skin to skin over a 24 day period. Baseline Vagal activity was calculated initially then again at 37 weeks gestation. Infants receiving skin-skin showed more rapid vagal activity between 32 and 37 weeks gestation.
It is well documented that there is a correlation between Vagal activity and infant growth and development. Increased vagal activity stimulates:

   -   Gastric motility
   -   The release of food absorption hormones
   -   Food tolerance 

...therefore, greater weight gain. 
Vagal activity is also elevated during mother infant interactions (Field and Diego 2008).


Whose responsibility is it to carry out the massage? 

Preterm birth disrupts normal physical contact between mother and her baby.  This can cause the mother a great deal of stress and distress causing her to withdraw from her newborn.  Ineffective maternal responsiveness will cause lack of attachment, low self-esteem and unhealthy growth and development of the preterm infant (Lai 2016).
A systemic review into the effects of infant massage showed that mothers who were taught and who were able to perform infant massage, on their baby, in special care nurseries experienced stronger attachments with their baby (Mrljak et al., 2022).
Infant massage not only benefits the preterm infant but will also have positive benefits to the parent/caregivers who provide the massage.  Parental participation in the massage of their preterm infant has been shown to: 

- Reduce anxiety
- Increase their confidence in their parenting ability
- Assist with the transition into their new role
- Stronger attachment
- Lower risk of postpartum depression 

(Vincentes et al., 2017).
Evidence also suggests that maternal stress and distress will have a negative impact on milk supply and continued duration of breastfeeding (Nagel et al., 2021).
Therefore, strategies to help reduce maternal stress can have a positive outcome for lactation and breastfeeding, and therefore support weight gain in the preterm infant.
Infant massage also supports fathers in their new role.  We sometimes forget about the fathers, how difficult and stressful it can also be for them. Evidence does suggest that fathers performing infant massage reported lower stress levels (Cheng et al., 2011).
Neonatal nurses often hear Mothers say things like:-

"I feel useless."
"I don't feel like my baby is mine."
"I feel that you get to handle my baby more than I do."
"Why do you recognise my baby's cues and I do not?"

Infant massage instructors do not need to have a medical background to be able to undergo training however, neonatal nurses do have the training and expertise to enable them to read stress signals in the preterm infant. They can teach parents how to read their babies stress cues and whether or not it is a good time to massage their baby (Cooke 2015). 

With the evidence presented, it would be the role of the parents to provide the massage to their preterm infant. 
Parents can be empowered through the provission of support to learn the skills required so they feel that they are contributing and making a positive difference to their baby’s growth and development. Weight gain or lack of seems to be a factor that causes great stress and anxiety for parents. The first question that they tend to ask when they come to visit their baby in Special Care is ‘did s/he gain weight overnight’?  They take great pleasure in looking at their infants Growth Chart, especially when there has been a adequate weight gain.

Furthermore, using Mothers/Fathers/Caregivers to carry out massage on their preterm infant would be cost effective and promote wider use of massage in Special Care Nurseries (Field 2019).


When would massage take place and how often?

The when would purely depend on the stability of the infant. It is important to assess whether the baby is ready for massage and reading stress cues is vital. Stress cues can range from mild -severe. Some infants will show severe stress cues from the moment the portholes are opened on their isolette. They can experience:
- apnoea
- bradycardia
- desaturations
- cyanosis

The Infant will require stimulation and oxygen to aid in the recovery of these severe stress cues. 

Less severe stress cues can include:
- hiccups
- skin mottling
- gagging
- crying

If the baby is showing any of the severe stress cues either prior or during the massage, then it wouldn’t be a good time to massage. If the baby is relaxed and has no stress cues then it would be a good time to massage (White-Traut et al.,1998).

Two studies to mention in relation to frequency:

Impact of Massage Therapy on Stress and Activity Levels in Hospitalised Preterm Infants
Hospitalised preterm infants were randomly assigned to a massage therapy group or to the control group. The infants in the massage group received three 15-minute massages for 5 days, (the type of strokes and pressures will be discussed later).  Stress cues and activity were recorded on day 1 and day 5. The massage group showed fewer stress cues and less activity throughout the 5-day period. Thus, suggesting that massage does help settle and reduce stress in the preterm infant (Hernandez-Reif et al., 2007)  

Effects of Massage Therapy on Weight Gain and Sleep/Wake Patterns in Preterm Infants
This study examined the effects 5 days of massage therapy had on the infants weight and sleep/awake behaviours. Again, a massage group and a controlled group. The infants in the massage group received three 15-minute massages per day. Weight gain, milk intake, calories, bowel movements and sleep/wake patterns were compared with the control group. The infants in the massage group gained 53% more weight (Dieter et al., 2003). Evidence does suggest that a frequency of 3 times, for 15 minutes each time, during a 24 hour period has significant benefits to the preterm infant.


How is the massage done and what pressure is applied?

Preparing the preterm infant for massage is important. Developmental care interventions need to be implemented to support the baby prior, during and following the massage. Lights can be dimmed, noise levels reduced and maintaining the ideal body temp of the infant is paramount.   
Two phases as described by Field et al. (1986):
  1. Tactile phase
  2. Kinaesthetic phase

Some studies suggest that moderate pressure as opposed to light pressure massage therapy on preterm infants will have a better impact and weight gain and reduced hospital stays by 3-6 days. Preterm Infants who received moderate pressure stroking gained more weight, 26% more than Infants who received light pressure (Field et al., 2006).
Field et al., (2010) documents that upon reviews of Randomised Controlled studies, greater weight gain was observed in preterm infants receiving passive limb movements (kinaesthetic). 
NB: Neonatal Nurses would need to attend a training course with the Infant Massage Information Service to be able to teach parents how to massage their preterm infant.


Can products be used on the preterm infant’s skin during the massage?

With caution. Not all oils are suitable for the skin of a preterm infants. Sunflower oil seems to be the choice of oil for preterm skin.
Sunflower Oil

   -   No odour
   -   Full of vitamins
   -   Easily absorbed
   -   Edible
   -   Nourishing
   -   Anitbacterial propoerties

   -   Healing properties

   -   Restructuring properties

   -   Strengthes the stratum corneum
       (immature in preterm infants)

(De Meza 2013)

Coconut oil can be a good choice instead of Sunflower oil and has been shown to be more effective in preterm infants. However, more research is needed (Valizadeh et al., 2013).
A Neonatologist, Professor Tobias Strunk, a Neonatologist at King Edward Memorial Hospital, conducted research in 2016 on the benefits of using coconut oil on a preterm infant’s skin. His findings: 

   -   Less infection
   -   Fewer bad bacteria on their skin
   -   Increased good bacteria on their skin
   -   Better overall skin condition

Resulting from this study, since 2017 over 1500 babies at King Edward memorial Hospital, weighing less that 1kg, have had coconut oil applied to their skin as part of their routine daily care. Research is ongoing and this practice could very likely be replicated in other states.

What we do know is that using medium-chain triglyceride oil has resulted in greater weight gain (Saeadi et al., 2015).
Evidence does suggest that using oil decreases stress cues, increases vagal activity, increases salivary cortisol levels and decreases motor activity (Madhu et al., 2021).
The use of heavily scented oil is contra-indicated heavily scented oil will prevent the baby from smelling its parents and interfere with the attachment process (Alparslan 2021).
Oils must be organic and cold pressed to preserve beneficial lipids and reduce irritating by-products (Vaughn et al., 2018).
Oils must always be tested for sensitivity to avoid allergic reactions.  A patch test can be carried out and the oil left on the skin for 24 hours. If any reaction is noted then the oil should not be used (Michalak 2019).



There is a wealth of research on the effects of massage on preterm infants. Infant massage has positive effects on both the infants and their parents and can be easily implemented in Special Care Nurseries. 
Neonatal nurses can obtain specialised training through the Infant Massage information Service which will certify them to teach parents these valuable skills.  
By teaching parents how to perform massage on their infants, infant massage instructors are empowering them in the care of their newborn. 
Cheng H, Mashimo H, Goyal R. (2003) ‘Musings on the wanderer: What’s new in our understanding of vago-vagal reflex? Current concepts of vagal efferent projections to the gut’. American Journal of Physiology and Gastrointestinal Liver Physiology, 284, pp. 357-366.
Cheng C, Volk A, Mariniz Z. (2011) ‘Supporting fathering through infant massage’. The Journal of Perinatal Education, 20(4), pp. 200-209.
Cook A. (2015) ‘Infant Massage: The practice and evidence base to support it’. British Journal of Midwifery, 23(3), pp. 166-170.
De Meza T. (2013) ‘Should we use olive oil or sunflower oil on a preterm infant’s skin? Infant, 9(5), pp. 170-172.
Dieter JN, Field T, Hernandez-Reif M, Emory EK, Redzepi M. (2003) ‘Stable preterm infants gain more weight and sleep less after 5 days of massage therapy’. Journal of Paediatric Psychology, (6), pp. 403-411.
Field T. (2019) ‘Paediatric Massage Therapy Research: A Narrative Review’. Children, 6 (78).

Field T, Diego M. (2008) ‘Vagal Activity: Early growth and emotional development’. Infant Behaviour Development, 31(3), pp. 361-373.

Field T, Schanberg SM, Scafidi F, Bauer CR, Vega-Lahr N, Garcial R. (1986). ‘Tactile/kinesthetic stimulation, effects on preterm neonates. Paediatrics, 77(5), pp. 654-658.

Field, T, Diego, MA, Hernandez-Reif, M, Deeds, O & Figuereido, B (2006), ‘Moderate versus light pressure massage therapy leads to greater weight gain in preterm infants’, Infant Behavior and Development, vol. 29, no. 4, pp. 574–578. Field T, Diego M, Hernandez-Reif M. (2010) ‘Preterm infant massage therapy research: A review’. Infant Behaviour and Development, 33(2), pp. 115-124.‌

Hernandez-Reif M, Diego M, Field T. (2007) ‘Preterm infants show reduced stress behaviours and activity after 5 days of massage therapy’. Infant Behaviour and Development, 30(4), pp. 557-561.

Lai M et al. (2016) ‘Premm: Preterm early massage by the mother: Protocol of a randomised control trial of massage therapy in very preterm infants’. BMC Paediatrics, 16:146.

Lubbe, W. (2008). ‘Prematurity, Adjusting your dream’. Pretoria: Little Steps.

Madhu R, Vijayabhaskar C, Anandan V. (2021) ‘Guidelines for Paediatric Skin Care’. Indian Academy of Paediatrics, 58(2), pp.153-161.

Manzotti, A, Cerritelli, F, Esteves, JE, Lista, G, Lombardi, E, La Rocca, S, Gallace, A, McGlone, FP & Walker, SC (2019), ‘Dynamic touch reduces physiological arousal in preterm infants: A role for c-tactile afferents?’, Developmental Cognitive Neuroscience, vol. 39, p. 100703.

McClure V. (2008) cited in Campbell, M, Jacobs L. (2021) ‘The effect of parent administered infant massage on the developmental outcomes of premature infants’. South African Journal of Occupational Therapy, 51(1).

Michalak M. (2019) ‘The use of carrier oils in aromatherapy massage and their effect on skin’. Physiotherapy Global Research, 22(3), pp 23-31.

Mrljak R, Arnsteg-Danielsson A, Hedov G, Garmy P. (2022) ‘Effects of infant massage: A Systemic Review’. International Journal of Environmental Research and Public Health, 19, 6378.

Nagel M et al., (2021) ‘Maternal psychological distress and lactation and breastfeeding outcomes: A Narrative Review’. Online Publication, Dec 20th.

Saeadi,R, Ghorbani Z, Shapouri Moghaddam, A. (2015) ‘The effects of massage with medium-chain triglyceride oil on weight gain in premature neonates’. Acta Med, Iran, 53, pp. 134-138.

Valizadeh S, Hosseini MB, Asghari Jafarabadi M Ajoodanian N. (2012) ‘The effects of massage with coconut and sunflower oils on oxygen saturation of premature infants with respiratory distress syndrome treated with nasal continuous positive airway pressure’. Journal of Caring Science, 1, pp. 191-199.

Vaughn AR, Clark AK, Sivamani RK, Shi VY. (2018) ‘Natural oils for skin barrier repair: Ancient compounds now backed by modern science’. American Journal of Clinical Dermatology, 19(1), pp.103-117.

Vincente S, Verissimo M, Dinize E. (2017) ‘Infant massage improves attitudes toward childbearing, maternal satisfaction and pleasure in parenting’. Infant Behaviour and Development, 49, pp. 114-119.

White-Traut RC, Carrier Goldman MB. (1998) ‘Premature Infant Massage: Is it safe’? Paediatric Nursing, 14(4), pp. 285-288.