In the second part of this article, I would like to concentrate on the practical aspects of Infant Massage. Clinically, we can separate Infant Massage into three major categories:
1. MASSAGE FOR HEALTHY INFANTS
As we discussed in Part I of this article (Nov-Dec issue of JSM: https://www.scienceofmassage.com/2010/11/infant-massage-part-i/), the best way for massage practitioners to engage with this category of clients is to train parents in the regular application of massage. Of course, the practitioner may also work with healthy babies, and there is nothing wrong with that. However, as many studies have confirmed, the application of regular massage to healthy babies by parents, especially mothers, significantly enhances the bond between parent(s) and child and has a profound impact on the child’s psychological state and subsequent mental and physical development. (Underdown et al., 2006; Serrano et al., 2010). Additionally, it greatly helps mothers to reduce stress and anxiety, especially after labor (Livingston et al., 2007).
A mother or practitioner should conduct a full-body massage in a comfortable environment, maintaining constant verbal contact with the baby throughout. Typically, the basic techniques are employed: repetitive effleurage and gentle kneading. These techniques are easy to teach and can be performed by parents.
I expect to hear angry comments from the practitioners who practice and advertise baby massages. They may express their disapproval because professional massage is much more effective than massage conducted by trained parents. I don’t have anything against the practitioners conducting baby massage on healthy infants. However, as studies by the Touch Research Institute in Florida and other authors have confirmed, massage performed by previously trained mothers on healthy infants is equally effective and enhances the bond between parents and their child.
Considering the health interests of the client as a priority for each health practitioner, I would like, on behalf of our Editorial Board, to state the following: we are against practicing infant massage without informing parents about the health benefits of regular massages they may give to their son or daughter. Additionally, the parents must be informed of the opportunity to receive training from the therapist to receive regular massages at home from a very young age. If informed parents still wish to use professional massage, conducted by practitioners alone or in combination with massage by parents. In that case, it is completely acceptable for the therapists to be involved.
2. MASSAGE FOR PRE-TERM INFANTS
This category includes prematurely born but generally healthy infants. For these babies, the application of massage has completely different goals and clinical applications. The only similarity with the first group is full-body application. This group is the subject of this article, and we will discuss it below.
3. MASSAGE FOR THE PRE-TERM INFANTS WHO SUFFER FROM VARIOUS MEDICAL CONDITIONS
These pathological conditions are results of various inborn abnormalities or complications developed during labor (e.g., cerebral palsy, torticollis, Erb’s palsy, etc.). These babies require specially designed medical massage protocols, which are unique for each infant, and this treatment specifically addresses various medical conditions. There is no full-body massage for these infants.
As I mentioned above, in this article, we will concentrate on the clinical application of Infant Massage for generally healthy, but prematurely born, babies. After reviewing various DVDs, textbooks, and descriptions of several seminars that offer training for practitioners who wish to practice Infant Massage with pre-term infants, I concluded that the current established views on its clinical application are mostly based on personal opinions rather than on solid scientific evidence. Thus, I view the primary goal of this article as an attempt to inform practitioners about the clinically correct approach to working with pre-term infants.
At the outset, I would like to separate myth from medical reality, or differentiate between thinking and knowing. One might think that infants, in general, and pre-term infants, in particular, need (or can handle) gentle touch only. This common-sense thinking is what the majority of modern educational materials about Infant Massage are based on. In such cases, the ‘cuchee-cuchee-coo’ approach, typically used to massage healthy babies, is applied to pre-term infants. Of course, it is better than nothing, but it is a definite sign of professional underperformance on the part of the therapists.
The premature infant is exposed to the hostile environment out of the womb early, when all of his or her systems and organs aren’t ready yet. Of course, modern neonatal care has achieved a dramatic percentage of survival among pre-mature babies who didn’t have any chance to live even 10 years ago. However, these babies still have a tough uphill battle, which they fight daily, first trying to survive and later trying to catch up with those healthy babies who are now far ahead in their physical, psychological, and mental development. In these cases, the massage practitioner’s role is to support the baby’s development and help close the gap between premature and full-term babies as soon as possible. For these reasons, gentle caressing massage strokes are a wasted effort.
Thus, one should know that prematurely born infants would need more intense and faster strokes to address their health conditions. The therapists’ hands should move intensely to enhance the functions of different systems in those babies, as the time for full-body massage for premature babies is limited. Clearly, there is a time for a loving and nurturing touch only for premature babies, but it is the parents’ job. The therapist must show love and compassion by assisting in the future normal development of a pre-mature baby.
Before I discuss the scientific background of this statement, I would like to provide readers with more insight into the science of Infant Massage and its clinical applications. I want to share with you one of my recent experiences.
While conducting research on Infant Massage for this article, I was specifically invited to observe the work of massage therapists in several pediatric hospitals in Ukraine. I had found a striking difference between Infant Massage, as currently recommended and widely practiced on pre-term infants in the U.S. I should mention that medical massage, in general, and Pediatric Massage are routine procedures in every hospital, with a history of more than 100 years of clinical application.
In this part of the world, the massage has been both recognized and used as an integrative part of the traditional Western (not an Alternative) medicine. Massage goes far beyond stress reduction and muscle aches, but is used for the treatment of a broad spectrum of disorders in children. In fact, physicians prescribe various methods of massage therapy in the same way they prescribe pharmaceutical medications, and they actively help the practitioners to formulate ideal massage protocols for each child. They indicate a precise dosage of massage therapy, in the same way as with pills or IV drugs.
Another aspect of clinical reality is how well parents are educated in the medical impact of massage therapy and the role the therapist plays in their child’s development or recovery. This is a result of a widely spread system of education and clinical practice, which helps to optimize the treatment outcomes. Ordinary people see these results daily in their friends and relatives. This is why parents must make sure that massage therapy is always included as an integral part of their children’s treatment.
While I was in Ukraine, I filmed as many of the cases of Pediatric Massage as I could. Also, I interviewed physicians, massage practitioners, and parents. Observing and filming the progress of children treated by Infant or Pediatric Massage was the most incredible professional experience I’ve had. The case I would like to discuss was filmed in Ivano-Frankovsk Regional Children’s Hospital.
Each hospital department (e.g, neonatal, neurological, orthopedic, etc.) employs 7-8 full-time massage practitioners who have extensive and highly specialized training. Their training and clinical expertise are so specialized that there is no rotation between massage practitioners who work in the different departments. Those therapists who work in the neonatal unit never work with children in the orthopedic department, and vice versa. On the day I filmed one of the treatment sessions, there was a line of almost 20 mothers with their babies, ranging from those who had just been released from the neonatal care unit to those who, over the past six months, had already completed several Infant Massage courses.
While we in the USA are discussing the incorporation of massage into the clinical setting, our Ukrainian colleagues work in a completely different professional environment. On many occasions, I witnessed conversations between massage practitioners and physicians as well as with parents. It was striking to observe the level of professional respect and cooperation that other healthcare practitioners and parents showed toward massage practitioners. Physicians regularly stop by to discuss the progress of patients with the massage therapists and their response to the therapy. Together, they correct and adjust treatment protocols, and pediatricians rely significantly on the therapists’ reports when deciding if patients may be discharged from the hospital.
The attitude of the parents toward the practitioners is even more striking. The parents observe treatments and see the progress their children have made as a result of the therapist’s efforts. In many cases, parents are even trying to have their kids hospitalized (thanks to free healthcare) as a way to secure those massage and remedial gymnastics sessions. Also, I witnessed how deeply the therapists’ work moved parents. The therapists I spoke with told me that on many occasions, parents keep in touch with them and stop by with their grown children, and that therapists may witness the results of their work.
As an illustration, I would like to share with our readers one of the typical cases I observed in the Regional Hospital. A baby boy was delivered prematurely at 7 months. He weighed 3.5 pounds and was 15.3 inches long. At the time of my observation, he was back for another 10 sessions course of Infant Massage (see video below) done within two weeks (5 daily sessions per week) – in order to further stimulate his physical and mental development.
During my filming, a massage was performed at a consistently increasing pace, with pressure fluctuating from superficial to moderate. Each session lasted about 20-25 minutes, with a 4-5 minute break in between. per arm, 5-6 min. per leg and 5-6 min on his back. (Usually, massage of the chest and stomach is not a part of a general massage application for pre-term infants.) After the initial introductory sessions, which involve soothing strokes, the practitioners gradually increase the intensity and duration of the treatment until it reaches its maximum. Here are some short excerpts from the treatment session I filmed. However, before watching the video, I would like to highlight several key aspects to keep in mind.
1. Please pay attention to the baby’s physique and development. He appears to be a healthy, full-term baby boy. At the time of filming, the baby boy is 3 months old. Usually, pre-mature infants catch up with full-term infants later. As you may see in the video, regular application of Infant Massage greatly helped the pre-term baby catch up with the development of full-term babies at a very early age.
2. What initially catches the eye of the viewer is the speed of massage strokes applied during the session. What you see in the video is the real-time speed of massage strokes without any fast forwarding added. The practitioner starts each segment at a slower speed, but within 30-40 seconds, the speed reaches its maximum and remains constant until the segment is finished.
3. It is difficult to see in the video, but the practitioner increases applied pressure as well. The practitioner started with very superficial pressure and later increased the pressure to a moderate level while maintaining a very fast speed. During the filming, it was especially noticeable during the application of friction.
4. Notice the fluidity and variety of the strokes: friction to friction-kneading, to vibration, to percussion, and passive movements. Also, notice how techniques are constantly changing. The therapist even decompresses superficial and deep fascia separately!
5. Notice how detailed the practitioner works on the small areas of the body.
6. Pay attention to the baby’s reaction to the application of intense strokes. Why is the baby so calm? I asked the supervising physician, Dr. Alferova, about that. She told me that all pre-mature babies are routinely exposed to the gentle touch after the first 24 hours of their lives. In many cases, specially trained therapists work on them while they are in the incubator!
Babies are still under a lot of stress after labor, and massage helps them to recover quicker. What is more important is early exposure of their bodies to touch therapy. To some degree, they became dependent on the regular application of massage strokes, and the body and brain accepted the regular massage sessions as part of their regular environment.
Mothers very quickly learn that the child reacts very negatively (sleep disturbances, agitation, decrease of appetite, etc.) to each missed appointment. Thus, the baby grows and develops with the therapist’s touch since birth.
8. Pay attention to how relaxed the massage therapist’s hands are during the strokes while they perform high-energy, sophisticated strokes. The correct body mechanics allow therapists to perform this demanding work for 6-8 hours. This is an important skill to develop – stay relaxed with correct body mechanics, but work intensely.
Dr. Alferova also told me that the Hospital continues to provide healthcare for local children until the age of 16. Pediatricians routinely observe that children exposed to touch therapy and exercise at a very young age exhibit better physical and mental development, as well as enhanced social skills, later in life.
Why does Infant Massage require such intense application on pre-term infants? As we discussed above, the pre-term infants are exposed to the hostile environment earlier when their systems and organs are not completely ready. There are two weakest systems in the pre-term infant body that require immediate attention: immaturity of the central nervous system and the immune system. The immaturity of the central nervous system affects functions of all other systems and organs (digestive, respiratory, etc.). In contrast, immaturity of the immune system makes the child vulnerable to various infections.
Central Nervous System Development
The newborn visual analyzator starts to form after 3 months. After birth, a baby sees everything in black and white and has only near vision. Taste fully formed after 6 months, etc. Thus, in the early stages of our lives, the touch, pressure, vibration, and temperature receptors in the soft tissues are the primary sensory stimuli that govern brain development.
Thus, the primary goal of applying intense massage strokes to pre-term infants is to create a massive amount of sensory input to the spinal cord and brain, which significantly accelerates the maturation of the central nervous system. Excessive stimulation of the peripheral receptors in the soft tissues creates a massive amount of sensory input to the brain. At this age, it becomes a primary tool for enhancing brain development. This is why the practitioner must use the full range of massage techniques at a fast speed and moderate pressure to engage and stimulate all peripheral receptors in the soft tissues, thereby surprising the baby’s sensory cortex. Simultaneous stimulation of touch, pressure, temperature, vibration receptors, as well as muscle spindle receptors and Golgi tendon organ receptors, creates a powerful flow of sensory information to the central nervous system, which requires the processing of this information and the formation of the proper motor response. As a result, the central nervous system matures more quickly, which helps to normalize the function of other systems and organs (Guzzetta et al., 2009; Procianoy et al., 2010). As a result, pre-term infants close developmental gaps with full-term infants quickly.
Immune System Development
The equally important subject for the pre-term infant is the immaturity of the immune system, which normally develops into a fully sustained defense mechanism by the time full-term babies reach age 3. The stimulating impact on the immune system is a well-documented fact. Although the majority of studies concentrated on the adults (Ironson et al., 1996; Kuznetsov 1998; Jemmon et al, 1998; Diego et al, 2001), some studies have reported the stimulating effect of massage on the immune system of children as well (Field et al., 2001; Shor-Posner.et al., 2006).
I don’t want readers to view intensity, degree of pressure, and varieties of strokes as an exotic concept used in different parts of the world and completely foreign to the USA. I think this topic is an excellent example of how detached American massage therapy is from American science and medicine. Let’s review some American publications on this subject.
In 2006 Dr. T. Field and her colleagues from Touch Research Institute conducted a study on 68 pre-term infants who received 15 massages three times per day for 5 days. In the clinical group, moderate pressure was used while in the control group, light pressure was used. Comparison of the obtained data allowed the authors to conclude that:
“Thus, the moderate pressure massage therapy group appeared to be more relaxed and less aroused than the light pressure massage group which may have contributed to the greater weight gain of the moderate pressure massage therapy group”.
In a recent study on a similar subject by the same group of scientists (Field et al., 2010), it was concluded that only moderate pressure appears to be necessary for massage therapy effects in preterm infants. The authors think that:
“…the stimulation of pressure receptors during massage therapy leads to increased vagal activity which, in turn, seems to mediate the diverse benefits noted for massage therapy”.
Thus, scientific data doesn’t support the commonly used application of gentle, relaxing massage for pre-term infants. If therapists would like to help their patients, don’t waste their time and their money on ‘cuchee-cuchee-coo’ massage courses for the pre-term infants.
My sincere hope is that readers will get excited about the prospect of new possibilities for applying their natural talents, which will emerge with the adoption of this clinical data.
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Diego, M.A., Hernandez-Reif, M., Field, T., Friedman, L. & Shaw, K. HIV adolescents show improved immune function following massage therapy.International Journal of Neuroscience, 106, 35-45. 2001.
Field, T., Cullen, C., Diego, M., Hernandez-Reif, M., Sprinz, P., Beebe, K., Kissel, B., & Bango-Sanchez. Leukemia immune changes following massage therapy. Journal of Bodywork and Movement Therapies, 5, 271-274, 2001.
Field T, Diego M, Hernandez-Reif M. Moderate pressure is essential for massage therapy effects. Int J Neurosci, May;120(5):381-5, 2010.
Field, T., Diego, M., Hernandez-Reif, M., Deeds, O., Figueiredo, B. & Ascencio, A. Moderate Versus Light Pressure Massage Therapy Leads to Greater Weight Gain in Preterm Infants. Infant Behavior and Development, 29, 574-578, 2006.
Guzzetta A, Baldini S, Bancale A. Massage Accelerates Brain Development and Maturation of Visual Function. J Neurosci, 29(18):6042-6051, 2009.
Ironson, G., Field, T., Scafidi, F., Hashimoto, M., Kumar, M., Kumar, A., Price, A., Goncalves, A., Burman, I., Tetenman, C., Patarca, R., & Fletcher, M. A. Massage therapy is associated with enhancement of the immune system’s cytotoxic capacity. International Journal of Neuroscience, 84, 205-217, 1996.
Livingston, Beider S, Kant A. Touch and massage for medically fragile infants.eCAM, 2007.
Procianoy RS, Mendes EW, Silveira RC. Massage therapy improves neurodevelopment outcome at two years corrected age for very low birth weight infants. Early Hum Dev, Jan;86(1):7-11, 2010.
Serrano, M. S.C., Doren, F.M., Wilson, L. Teaching Chilean Mothers to Massage Their Full-Term Infants: Effects on Maternal Breast-Feeding and Infant Weight Gain at Age 2 and 4 Months. Journal of Perinatal & Neonatal Nursing., 24(2), April/June, p 172-181, 2010.
Shor-Posner, G., Hernandez-Reif, M., Miguez, M. Fletcher, M., Quintero, N., Baez, J., Perez-Then, E. Soto, S., Mendoza, R., Castillo, R., Zhang, G.Impact of a massage therapy clinical trial on immune status in young Dominican children infected with HIV-1. Journal of Alternative and Complementary Medicine, 12, 511-516 2006.
Underdown A., Barlow J., Chung V. Massage intervention for promoting mental and physical health in infants aged under six months. Cochrane Database Syst Rev 4, (3): 1-28.2006.
Category: Pediatric Massage