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 the healthy infants.
As we discussed in Part I of this article (see Nov-Dec issue of JMS) the best way for massage practitioners to be involved in this category of clients is to train the parents in the regular application of massage. Of course, the practitioner may work on the healthy babies as well and there is nothing wrong with that. However, as many studies have confirmed the application of regular massage to the healthy babies by parents, especially mothers, greatly enhances the bond between parent(s) and child (Underdown, et al., 2006; Serrano et al., 2010). Also, it has great impact on the psychological state and further mental and physical development of the child. Additionally it greatly helps mother to reduce stress and anxiety especially after labor (Livingston et al., 2007).
Mother or practitioner should conduct full body massage in the comfort environment while constantly maintaining verbal contact with the baby. Usually the very basic techniques are used: repetitive effleurage and gentle kneading. These techniques are easy to teach and performed by the parents.
I expect to hear angry comments from the practitioners who practice and advertise baby massages. They may express their disapproval on the ground that professional massage is much more effective when compared to the massage conducted by trained parents. I don’t have anything against the practitioners conducting baby massage on healthy infants. However as Touch Research Institute studies as well as other authors have confirmed the massage conducted by previously trained mothers is equally effective while enhances the bond between parents and child.
Considering health interests of the client as a major priority for each health practitioner I would like on behave of our Editorial Board to state following: we are against practicing baby massage without informing parents about health benefits of regular massages they may give to their son or daughter and offering the parents a chance to get trained to do that. If the parents are informed and still would like to use professional massage conducted by the practitioners alone or in the combination with massage by parents it is completely acceptable for the therapists to be involved.
2. Massage for the 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 application. The only similarity with the first group is full body application. We will discuss this subject below.
3. Massage for the term or pre-term infants who suffer from various medical conditions.
These conditions are results of various inborn abnormalities or complications developed during the labor (e.g., cerebral palsy, torticollis, Erb’s palsy, etc.). These babies need specially designed MEDICAL MASSAGE PROTOCOLs which are unique for each infant, and this treatment specifically addresses various medical conditions. There is no full body relaxing massage for these infants.
In this article we will concentrate on the clinical application of Infant Massage for generally healthy, but prematurely born, babies. After reviewing the various DVDs, textbooks and description of several seminars which are used as teaching tools for the practitioners who would like to be trained in the baby massage for the pre-term infants I concluded that the current established views on the clinical application of baby massage for the pre-term infant is based on the personal opinion of the instructors rather than on the solid scientific ground. Thus I see the major goal of this article as an attempt to inform practitioners about the clinically correct way to work with pre-term infants.
In the beginning 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) a gentle touch only. This common sense thinking is what the majority of modern educational materials about baby massage are based on. In such case the ‘cuchee-cuchee-coo’ approach used to massage healthy babies is applied to the pre-term infants. Of course it is better than nothing but it is a definite sign of professional underperformance on the therapists’ part.
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 achieved dramatic percent of surviving among those pre-mature babies which didn’t have any chance to live even 10 years ago. However these babies still have very difficult uphill battle which they fight on a daily basis, first trying to survive and later trying to catch up with those healthy babies who are now far ahead in their physical and psychological development. In these cases the massage practitioners’ job is to assist in this uphill battle to enhance the babies development and to help to close the gap between pre-mature and full time babies as soon as possible. For these reasons gentle caressing massage strokes are mostly a wasted effort.
Thus one should know that prematurely born infants would need deeper and faster strokes – to address their health conditions. Yes, your hands should be moving intensely in order to enhance functions of different systems in those babies. Clearly, there is a time for a loving and nurturing touch only but for the pre-mature babies it is a time to show your love through the science of saving a baby’s life!
Before I discuss the scientific background of this statement I would like to offer the readers more insight into the science of baby massage and its clinical application. I would like to share with you one of my recent experiences.
While we were conducting research on Pediatric Massage and for this article particularly I was invited to observe the work of massage therapists in several pediatric hospitals in the Ukraine. I had found the striking difference from Infant Massage currently recommenced and widely practiced on the pre-term infants in the U.S. I should mentioned that medical massage in general and Pediatric Massage in particular is a routine procedure in every hospital there and it has more than a 100 years of history of clinical application.
In this part of the world the massage had 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 wide spectrum of disorders in children. In fact, physicians prescribe various methods of massage therapy the same way they prescribe pharmaceutical medications and they actively helping the practitioners to formulate ideal massage protocol for each child. They indicate a precise dosage of massage therapy, as with pills or IV drugs. Otherwise, the positive effects of massage would be diminished or, in some cases, would even become negative.
Another aspect of clinical reality there is how well parents are educated in the medical impact of massage therapy and role the therapist plays in their child development or recovery. This is a result of a widely spread system of education and clinical practice which greatly helps to optimize the treatment outcomes. Ordinary people see these results on the daily basis on 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 the Ukraine I filmed as many of the cases of Pediatric Massage as I could. Also I interviewed physicians, massage practitioners and parents. Filming progress of children who were treated by Pediatric Massage was the most incredible professional experience I had. The case I would like to discuss I filmed in Ivano-Frankovsk Regional Children Hospital.
Each hospital department (e.g, neonatal, neurological orthopedy, 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 neonatal unit never work with children in the orthopedy department and vice versa. On the day I filmed one of the treatment sessions there was line of almost 20 mothers with their babies from those who were just released from neonatal care unit to those who for the past 6 months already went through several therapy courses.
While we here in USA are just discussing incorporation of massage in the clinical setting our Ukrainian colleagues work in the completely different professional environment. On many occasions I witnessed conversations between massage practitioners and physicians as well as with parents. It was stunning to observe the degree of professional respect and cooperation other health practitioners and parents exhibited toward massage practitioners. Physicians regularly stop by to discuss with the massage therapists progress of patients and their response to the therapy. Together they correct and adjust treatment protocols and pediatricians rely greatly 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 made as a result of massage therapists efforts. In many cases, parents even trying to have their kids hospitalized (thanks to free healthcare) as a way to securing those massage and remedial gymnastics sessions. Also, I witnessed how deeply parents were moved by therapists’ work. The therapists I talked with told me that in many occasions parents keep in touch with them and stop by with their grown up children even years after the therapist stopped working on the child.
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 weighted 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 a two weeks period (5 daily sessions per week) – in order to further stimulate his physical and mental development.
At the time of my filming massage had been performed with consistently increasing fast pace and pressure fluctuated from the initial superficial to the moderate. Each session lasted about 20-25 minutes, with 4-5 min. per each arm, 5-6 min. per each leg and 5-6 min on his back. (Usually, massage of chest and stomach are not a part of a general massage application for pre term infants.) After the first introductory sessions the practitioners start to increase intensity and duration of the treatment until it reaches maximum. Here are I composed short exerts from the treatment session I filmed. However. before you will watch the video I would like emphasize several important aspects you should pay attention.
1. Please pay attention to the babys’ physique and development. At the moment of filming the baby boy is 3 month old. Pre-mature babies catch up with full term infants later. As you may see in the video the Infant Massage greatly helped the pre-term baby to catch up the development of full term babies.
2. What initially catches the eye of the viewer is speed of massage strokes applied during the session. What you see in the video is a real time speed of massage strokes without any fast forwarding added. The practitioner starts each segment with slower speed but in 30-40 seconds speed reaches its maximum and it stays 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 she elevated pressure to the moderate level while speed remained very fast. During the filming it was especially noticeable during application of friction. Also pay attention to the babys’ reaction to the application of intense strokes.
4. Notice the fluidity of the strokes: friction to friction-kneading, to vibration, to percussion and to passive movements. Also, notice how techniques are constantly changing.
5. Notice how detailed the practitioner works on the small areas of the body.
6. Full range of massage techniques are used during massage session on pre-term infants. As you can see the techniques are ranged from effleurage to intense friction, percussion and passive stretching.
7. Pay attention on how relaxed massage therapist’s hands are during the strokes while they perform high energy, sophisticated strokes. Clearly, this is an important skill to develop – stay relaxed and energetic while performing a vigorous massage application.
I was also struck by how calm and relaxed babies were during treatment sessions. I asked the supervising physician Dr. Alferova about that. She told me that pre-mature babies routinely exposed to the gentle touch after first 24 hours of their lives. At this time they are still under a lot of stress after the labor and massage helps them to recover quicker. What is more important that their body which when exposed earlier in life to touch therapy becomes in some degree dependent to the regular application of massage strokes. In a sense the body and brain accepts the regular massage sessions as a part of regular environment. Mothers very quickly learn that the child reacts very negatively (sleep disturbances, agitation, decrease of appetite, etc.) to each missed appointment.
Dr Alferova also told me that the Hospital continues to provide healthcare for local children until the age of 16. The pediatricians routinely observe that the children who were exposed to touch therapy and exercise at the very young age show better physical and mental development as well as more social skills later in life.
Why does the Infant Massage requires 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 segments in the pre-term infant body which require immediate attention: immaturity of central nervous system and immune system. The immaturity of central nervous system affects functions of all other system and organs (digestive, respiratory, etc.) while immaturity of immune system make child vulnerable to various infectious agents.
The main goal of intense application of massage strokes on pre-term infant is creation of massive sensory input to the spinal cord and brain which greatly speeds up maturation of central nervous system which must process this increased amount of sensory information and form proper motor response. This is why the practitioner must to use full range of massage techniques with fast speed and moderate pressure to engage and stimulate all peripheral receptors in the soft tissue. Simultaneous stimulation of touch, pressure, temperature, vibration receptors as well as muscle spindle receptors and Golgi tendon organ receptors create this powerful flow of sensory information to the central nervous system which requires processing of this information and formation of the proper motor response. As a result the central nervous system matures quicker and it helps to normalize 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 quicker.
The equally important subject for the pre-term infant is immaturity of immune system which normally develops as the fully sustain defense mechanism when full term babies reach age 3. The stimulating impact on immune system is well documented fact. Despite that majority of studies concentrated on the adults (Ironson et al., 1996; Kuznetsov 1998; Jemmon et al, 1998; Diego et al, 2001) there are some studies reported the stimulating effect of massage on the immune system of children as well (Field et al., 2001; Shor-Posner.et al., 2006).
An issue I would like to discuss separately is the necessity of intensive application of massage for the pre-term infants. I don’t want that readers see this approach as some exotic concept which is used in the different part of the world and completely foreign to the American scientists. 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 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 the recent study of the similar subject by the same group of scientists (Field et al., 2010) concluded that only moderate pressure appears to be necessary for massage therapy effects in pre-term 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 you would like really help your patients don’t waste your time and their money on ‘cuchee-cuchee-coo’ massage for the pre-term infants.
My sincere hope is that you are getting exhilarated at the thought of new possibilities for application of your natural talents, which would come with you embracing this newly obtained knowledge.
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