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Individual Enquiry
Research Paper 2013
Title: A critically appraised narrative review of the effects that manual therapy in the terms of neonatal massage has on the physiological and neuropsychological health of neonates and the subsequent effects on the mother’s health.
Author: James Alexander Rowland
Supervisor: Martin Collins PHD, MSC
The British School of Osteopathy
275, Borough High Street, London SE1 1JE
1
Acknowledgements
I would like to thank my supervisor Martin Collins for agreeing to supervise
this narrative review and for his continuous help, guidance and support which
was greatly appreciated.
Thanks also to James Barclay and Will Podmore for their advice and help with
locating some of the articles.
2
Abstract
Background – There are many reasons infants might be in distress. Labour
may be both traumatic for infant and mother alike. If birth stress remains
unresolved then the infant may adapt and accommodate resulting in the infant
to becoming uncomfortable and therefore unhappy, and to develop in an
asymmetrical way, (Hayden et al., 2000).
Regardless of age, people will alter their posture in response to pain or
inflammation. Facilitating the optimal function of the components of the
postural system will aid and support the child’s development by meeting the
demands of their environment (Carreiro et al., 2003).
Although infant massage might prove beneficial for neonates whose bodies
are under stress and strain, the mechanisms are not fully understood. Some
possible explanations for various outcomes have been suggested, though the
research is limited.
Objective – To assemble a narrative literature review on the effects that
manual therapy in the terms of neonatal massage that physiological and
neuropsychological on healthy neonates and the subsequent effects on
mothers.
Methods – Systematic computerised literature search of relevant up to date
citations and evaluation using methodological quality assessment and risk of
bias criteria.
3
Results – Eighteen studies were included in this review, all of these studies
scored acceptability for methodological quality and a moderately low
susceptibility of bias. Seven of these studies showed a positive outcome for
neonatal massage on growth and cortisol level, whilst other studies showed
evidence to suggest neonatal massage improves sleep, autonomic nervous
system function and metabolic function. However there was limited evidence
on the effects of behavioural states and cognitive function; effects of maternal
outcome.
Conclusion – In summary, the results of this review suggest that infant
massage, kinaesthetic and tactile stimulation can have a positive influence on
many physical and neuropsychological effects for both infant and mother.
There is little research into the effects that massage therapy may have on
infants. The understanding of how massage kinaesthetic and tactile
stimulation may have on the physical and neuropsychological effects of both
mother and infant is paramount. Further, long term studies are needed in
order to accurately determine the effectiveness that these have on mother
and infant.
Keywords – Infant; Neonate; Mother; Massage; Kinaesthetic Stimulation;
Tactile Stimulation.
4
1. Introduction
Massage therapy has been used for treatment and as a routine part of
neonatal care for hundreds of years in many cultures. It is one of the oldest
therapeutic techniques in the world (Field et al., 1996). Massage therapy has
been used in a wide range of occupations and along with osteopathy
represents one of the most used complementary alternative medicines
(CAMs) in the UK (NHS Careers, 2012).
It is a common misconception that children and infants have little, if no,
structural stresses and strains in their body. There are, however, many
reasons why labour may be both traumatic for infant and mother alike. As a
result if birth stress remains unresolved then the infant may adapt and
accommodate resulting in the infant to becoming uncomfortable and therefore
unhappy, and to develop in an asymmetrical way, (Hayden et al., 2000).
Regardless of age, people will alter their posture in response to pain or
inflammation. Facilitating the optimal function of the components of the
postural system will aid and support the child’s development by meeting the
demands of their environment (Carreiro et al., 2003).
Although infant massage might prove beneficial for neonates whose bodies
are under stress and strain, the mechanisms are not fully understood. Some
possible explanations for various outcomes have been suggested, though the
research is limited:
Field et al. (2008) and Lahat et al. (2007) both conducted randomised controls
to evaluate the effects that massage therapy has on growth in preterm infants.
5
The growth of the preterm neonates was evaluated by the insulin-like growth
factor 1 (IGF-1). It was suggested that massage increase levels of insulin and
IGF-1;
Field et al. (2008) came to the conclusion that healthy preterm infants showed
greater weight gain and greater increase in serum insulin and IGF-1 levels
after massage therapy;
Lahat et al. (2007) came to the conclusion that energy expenditure is
significantly lowered by massage therapy in healthy preterm neonates and
note “that this decrease in energy expenditure may be in part responsible for
the enhanced growth caused by massage therapy”;
Field et al. (2009) conducted a study that looked into the effects that massage
therapy and interpersonal psychotherapy had on prenatally depressed
women. The study looked at 112 pregnant women over a six week period.
The results show that psychotherapy therapy combined with massage therapy
has a significant effect in reducing prenatal depression.
A common critique is that relatively small sample sizes are used in the studies
and the period of study is short. A larger number of participants and a longer
time period over which the study is conducted could produce more accurate
findings.
6
A critically appraised narrative review of literature surrounding complementary
treatment of neonates would be beneficial from an osteopathic point of view
as it will provide any practitioner, who has an interest in treating neonates,
with accurate view and hence a greater understanding of the possible
physiological and neuropsychological changes which occur when utilising
such treatment approaches as massage. The rationale behind the different
treatment methods may also prove important for osteopaths enabling them to
determine which method of treatment to use.
Objective
The aim of this research is to critically assess the effects that manual therapy
in the terms of neonatal massage has on the physiological and
neuropsychological heath of neonates and the subsequent effects on the
mother’s health.
Ethical approval
Ethical approval for this review was gained from the British School of
Osteopathy Research Ethics Committee in July 2012.
7
2. Methods
The review protocol for this narrative review was devised in accordance with
the guidelines outlined by Greenhalgh (2006) and the Cochrane Handbook
(2009).
Literature search
A rigorous and extensive computerised literature search strategy, given the
time and resources available, was conducted covering traditional and
alternative medical literature. This was to identify relevant articles that were
specific to the neuropsychological and physiological effects that
complementary alternative medicine in the form of massage has on healthy
neonates under the age of one year, and the subsequent effects on the
mother.
The following online databases and journals were used:
PubMed
AMED
The Cochrane Central Register of Systematic Reviews and Controlled
Trials
Physiotherapy Evidence Database (PEDro)
Online journals also searched include:
British Medical Journal (BMJ)
Journal of the American Osteopathic Association (JAOA)
8
There were certain criteria for considering studies to be used on this narrative
review, with an aim to gain the relevant papers:
Types of studies – Randomised clinical controlled trials, systematic
reviews, intervention reviews, case studies and medical guidelines.
Studies and articles included:
manual therapy versus placebo treatment;
manual therapy versus another manual therapy; or
manual therapy versus no treatment;
that had been published in peer-reviewed journals or as full-text articles
between 2000 to 2012. Only articles relating to the treatment of healthy
neonates up to the age of one year by terms of massage, kinaesthetic
stimulation and tactile stimulation were included.
Types of participants – Full-term healthy neonates of any gender under
the ages of one year old. Studies were excluded if the participants were of
low birth weight, had been in an intensive care unit or suffered from any
illness or disability which may have lead to a subjective bias in the studies
or articles.
Types of intervention – studies were included if they evaluated the
effectiveness of infant massage, irrespective of theoretical basis. For the
purpose of the narrative review complementary alternative medicine is
defined as massage, kinaesthetic and tactile stimulation.
9
Beider et al. (2008) described paediatric massage as being a “manual
manipulation of soft tissue intended to promote health and well-being in
children.”
Either professionals or non-professionals could perform the massage
techniques.
Types of outcome measures – One or more standardised instruments
for measuring the effects of paediatric massage on the physiological or
neuropsychological on ether neonate, mother or both.
Limitations - Full articles had to be written in English - this is to ensure
there are no incorrect translations/interpretations of the studies and
articles. Articles also had to be published in the last 12 years to ensure
that the results and findings correlate with recent research. All the studies
had to be human studies.
The databases searched and the numerous combinations of keywords are
outlined in table 1 as well as the ‘number of hits’ being described as an
articles or papers found. A manual search was also carried out using the
references cited in the online studies located
10
Table 1
Database MeSH Term Limits Number of
Hits
Articles
Included
AMED Infant AND
Massage
Human/English 35 7
AMED Infant AND
Touch
Human/English 12 9
AMED Infant AND
Tactile
Stimulation
Human/English 2 0
AMED Infant AND
Kinaesthetic
Stimulation
Human/English 1 0
Cochrane Infant AND
Massage
None 135 11
Cochrane Infant AND
Touch
None 153 5
Cochrane Infant AND
Tactile
Stimulation
None 4 0
Cochrane Infant AND
Kinaesthetic
None 4 0
11
Stimulation
PEDro Infant AND
Massage
None 42 10
PubMed Infant AND
Massage
Human/English/Full
Text
Available/2000-
2012
123 6
PubMed Infant AND
Touch
Human/English/Full
Text
Available/2000-
2012/RCT/Review
164 12
PubMed Infant AND
Kinaesthetic
Stimulation
Human/English/Full
Text Available
20 9
PubMed Infant AND
Tactile
Stimulation
Human/English/Full
Text Available
120 13
PubMed Infant AND
Osteopathy
Human/English/Full
Text
Available/2000-
2012/RCT
364 10
JAOA Infant AND None 4 0
12
Massage
BMJ Infant AND
Massage
None 28 0
BMJ Infant AND
Kinaesthetic
Stimulation
English/2000-2012 0 0
BMJ Infant AND
Tactile
Stimulation
English/2000-2012 3 0
Selection of studies
The 1066 citations that were identified by the different databases were
screened and either rejected or selected in accordance with the inclusion and
exclusion criteria previously stated. Closer examination was then applied to
the full text of the remaining 67 citations to confirm the studies and articles
were deemed appropriate for this study. Consequently a further 49 citations
were excluded for the following reasons:
Tactile stimulation, Kinaesthetic stimulation or massage were not the
primary intervention;
Studies included low birth weights;
Studies had been in an intensive care unit or included children with an
illness or disability which may have lead to a subjective bias;
13
Mean age of infants was over 12 months.
14
Figure 2 Flow chart of database search
After the retrieval of relevant studies and articles, from the
search strategy stated above, they were put into category
types according to the Hierarchy of Evidence Scale
(Greenhalgh, 2006). (Figure 1)
Citations Identified (n= 1066)
AMED (n= 50)
Cochrane (n=296)
PEDro (n= 42)
PubMed (n= 791)
JAOA (n= 4)
BMJ (n= 31)
Citations Excluded (n= 974) Irrelevant studies Duplicates
Citations Excluded (n = 63) Study conducted in neonatal
intenice care unit. Included children with an
illness or disability Massage/kenestetic
stimulation/tactile stimulation not the primary intervension
Citations abstracts selected for screening (n=92)
Full text of citations retrieved for further assessment (n=29)
Full citations excluded (n=11) Mean age of infant over 12
months Citations eligible for review
(n=18)
Agarwal et al. 2000
Diego et al. 2009
Dieter et al. 2003
Feng et al. 2007
Ferber et al. 2002
Field et al. 2006
Field et al. 2008
Fujita et al. 2006
Guzzetta et al. 2011
Huhtala et al. 2000
Lahat et al. 2007
Moore et al. 2012
O’Higgins et al. 2007
Onozawa et al. 2001
Osborn et al. 2009
Smith et al. 2013
Underdown et al. 200615
Figure 1
Data extraction
Due to the varying array of papers selected for review in this narrative study,
each different type of citation was being appraised with a pre-chosen set of
criteria appropriate for that type of study shown in table 2. Throughout the
different criteria of review, the same system was used for scoring the criteria.
One point would be awarded to every ‘yes’ answer (indicating the study had
matched that particular criteria) and a score of zero for every answer that was
a ‘no’ or ‘unsure’.
Table 2
Type of Study Criteria Used Appendix
Systematic review Greenhalgh (2006) A
RCTs Furlan et al. (2009) B
Systematic reviews of RCT’s
RCTs
Clinical controlled trials
Observational studies
Case studies, letters, and opinion based literature
16
Inter-rater and intra-rater reliability.
Inter-rater reliability was examined by a four randomly selected blinded
studies from the final list of articles found for use in this study, after screening
with the inclusion and exclusion criteria. The author, institution, publication
date and sponsor were removed. The four articles were then assessed by two
alternative reviewers using the same criteria as used by the author (Appendix
A-D). There was a 90% agreement found between the two reviewers and the
author with regards to the four randomly selected papers. The disagreements
between the secondary reviewers were discussed and a conclusion
determined, of which both reviewers agreed.
3. Results
Four systematic reviews were identified; they were assessed for their
methodological quality as seen in table 2. The articles were assessed using
criteria from Greenhalgh (2006) (Appendix A). An article was deemed to be of
17
significant methodological quality if it scored 3/5 or above, and of insignificant
methodological quality if it scored 2/5 or below.
Table 2
Assessment of methodological quality (Adapted from Greenhalgh, 2006)
A B C D E Overall Score
Rank
Diego et al. 2009 N N Y Y Y 3 2nd
Moore et al. 2012 Y Y Y Y Y 5 1st
Osborn et al. 2009 Y Y Y Y Y 5 1st
Underdown et al. 2006 Y Y Y Y Y 5 1st
A summary of the articles can be found in table 3.
18
Table 3
Author Classification of Method Used
Classification of Study
Number of Participants
Type of Participant
Age Interventions Used
Outcome Measured
Period of Study
Diego et al. 2009
Systematic review of RCT
Physiological and Neuropsychological
348 Full term healthy neonates.
Gestational age of 1 week, 1 month and 3 month old infants of depressed and non-depressed mothers.
Numerous databases were searched for studies which looked into the effects of maternal depression on infant development previously reported by Diego et al.
Demographic questionnaire was administered answers to the occupation and education questions were used to compute the socioeconomic status (SES) based on Hollingshead (1975)
Centre of Epidemiological Studies-Depression scale were used.
Unknown
19
EEG was recorded and data graphically displayed.
Moore et al. 2012
Systematic Review of RCT
Physiological and Neuropsychological
2177 Mothers and their healthy full term neonates.
Gestational age of 34-37 weeks.
The Cochrane Pregnancy and Childbirths Group’s Trial Register.
Early skin to skin (SSC) contact were divided into several subcategories:
In birth SSC the infant is placed prone skin-to-skin on the mother abdomen or chest during the first minute
Trail Quality and Extraction of Data.
1 year.
20
postbirth.
Very early SSC begging around 30 to 40 minutes postbirth.
Early SSC can begin anytime between 1 and 24 hours postbirth.
Osborn et al. 2009
Systematic Review of RCT
Physiological and Neuropsychological
154 Healthy neonates at risk of developing recurrent apnoea.
Median Gestational age 30 weeks.
Cochrane Neonatal Group was searched.
Kinesthetic stimulation used as prophylaxis for recurrent
Separate evaluation of trial and quality and data extraction by each author and synthesis of the data using relative risk.
9 years
21
apnea.
Underdown et al. 2006
Systematic Review of RCT
Physiological and Neuropsychological
66 studies were reviewed.
Full term healthy neonates.
Healthy full term neonates under the age of 6 months.
Numerous electronic databases were searched with key MeSH headings.
Reference lists of articles identified and bibliographies of systematic and non-systematic review articles were examined to identify further and relevant studies .
Studies had to include at least one standardized instrument measuring the effects of infant massage on either infant mental health or on physical health.
1 year
22
Randomised Control Trial (RCT)
There were fourteen RCTs identified, they were assessed for their methodological quality and risk of bias as seen in Table 4. They
were assessed using criteria from Furlan et al. (2009) (Appendix B) a score of 8/15 or above were deemed to be significant.
Table 4
Assessment of methodological quality and risk of bias (Furlan et al. 2009)
Author 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Total Rank
Agarwal et al. 2000
Y Y N Y Y N/A N Y Y Y N Y N Y Y Y N Y 13 2nd
Dieter et al. 2003
Y Y N Y Y N/A N Y U Y N N N Y Y Y Y Y 11 4th
Feng et al. 2007
Y Y U Y Y N/A N N N Y U Y N Y Y Y U Y 10 5th
Ferber et al. 2002
Y Y N Y Y N/A N Y Y Y U Y N Y Y Y N Y 12 3rd
Field et Y Y Y Y Y N/A N Y Y Y N Y N Y Y Y Y Y 15 1st
23
al. 2006
Field et al. 2008
Y Y N Y Y N/A N Y Y Y N Y U Y Y Y N Y 12 3rd
Fujita et al. 2006
Y Y Y Y Y N/A N Y U Y N N N Y Y Y N Y 11 4th
Guzzetta et al. 2011
Y U N Y Y N/A N Y N Y N Y U Y Y Y N Y 10 5th
Huhtala et al. 2000
Y U N Y Y N/A N N N Y N N N Y Y Y N Y 8 6th
Lahat et al. 2007
Y Y U Y Y N/A U Y Y Y N Y N Y Y Y N Y 12 3rd
O’Higgins et al. 2007
Y N N Y Y N/A N Y N Y Y Y N N Y Y N Y 10 5th
Onozawa et al. 2001
Y Y N Y Y N/A N Y N Y N N N Y Y Y Y Y 11 4th
Smith et al. 2013
Y Y Y Y Y N/A N Y Y Y Y Y N Y Y Y U Y 15 1st
White- Y Y U Y Y N/A N Y Y Y Y Y N Y Y Y N Y 12 3rd
24
Traut et al. 2009
A summary of the article can be found in table 7
25
Table 7
Author Classification of Method Used
Classification of Study
Number of Participants
Type of Participant
Age Interventions Used
Outcome Measured
Period of Study
Agarwal et al. 2000
RCT Physiological 125 Healthy, full term neonates
1 week Full term neonates were split into five groups.
1. herbal oil and massaged by the mother for 10 minutes daily over four weeks
2. sesame oil and massaged by the mother for 10 minutes daily over four weeks
Anthropometric measurements: weight (g) length (cm) head circumference (cm). Mid arm and leg circumference (cm).
Sleep pattern.
Microhaematocrit.
Serum proteins, serum albumin, serum creatine phosphokinase.
Blood flow using colour doppler.
4 weeks
26
3. mustard oil and massaged by the mother for 10 minutes daily over four weeks
4. mineral oil and massaged by the mother for 10 minutes daily over four weeks
5. control group which received no treatment.
Dieter et al. 2003
RCT Physiological 42 Healthy full term neonates
Mean gestational age of 30.1 weeks
Full term neonates were randomly assigned to either the
Weight gain and kilocalories consumed were recorded daily.
5days
27
massage therapy group or a standard treatment control group. The massage therapy group received treatment from the attending neonatologist and three 15 minutes massage of both kinaesthetic and tactile stimulation per day. The standard control group only received treatment from the neonatologist
Observation and sleep/awake pattern were recorded via live observation.
28
attending.
Feng et al. 2007
RCT Physiological and Neuropsychological
206 Full term, healthy neonates
Gestational age of 0-6 months and 6-12 months
Full term neonates were randomly assigned to four groups depending on their age.
0 month group – Experimental group received massage 1-2 times daily, the duration of massage lasted 15 minutes and 5 minutes of motion training. Control group
The status of growth was evaluated every month for infants under 6 months, every two months from 6 to 12 months, and every three months for infants over 12 months.
1 year
29
received no treatment.
6-12 month group - group received massage 1-2 times daily the duration for massage lasted for 8 minutes and motion training for 12 minutes.
Ferber et al. 2002
RCT Physiological 57 Mothers and their full term healthy neonates.
Gestational age between 26-34 weeks.
Participants were randomly assigned to three groups.
Two massage groups – one of which the
Weight gain and kilocalories consumed were recorded daily.
Two questionnaires CIRB and Nursery Neurobiological Risk Score were
10 days
30
mothers performed the massage, and the other in which the professional female figure unrelated to the infant of administered the treatment.
Control group - which received no treatment.
completed.
Field et al. 2006
RCT Physiological 68 Full term healthy neonates
Median Gestational age 30 weeks
Full term neonates were randomly assigned to either the moderate massage therapy group
Sleep-wake behaviour adapted from Thoman’s sleep state criteria in addition to hiccupping, clenching fists, yawning, sneezing, startles, tremors
5 days
31
or light massage therapy group.
Treatment provided was three fifteen minute treatments per day, for five days.
and mouthing.
Electrocardiograms were collected.
Field et al. 2008
RCT Physiological 42 Healthy full term neonates
Mean gestational age of 29.5 weeks
Full term neonates were randomly assigned to either the massage therapy group or a standard treatment control group.
Anthropometeric measurements: weight (g) length (cm) head circumference (cm). On days 1 and 5, blood serum was collected by clinical heel sticks and assayed for insulin and insulin-like
5 days
32
The massage therapy group received treatment from the attending neonatologist and three 15 minutes massage of both kinaesthetic and tactile stimulation per day.
The standard control group only received treatment from the neonatologist attending.
growth factor. Weight gain and kilocalories consumed were recorded daily.
33
Fujita et al. 2006
RTC Mother 57 Full term healthy neonates and there mothers
5-6 weeks Participants were randomly assigned into two groups.
Infant massage - 10 minutes of massage was performed daily by the mother until 3 months after delivery as outlined by Field.
Control group - which received no treatment.
Profile of mood states questionnaire and salivary cortisol samples twice (5–6 weeks after delivery, and 3 months after delivery).
3 months
34
Both were asked to reply to a questionnaire and to take salivary cortisol samples twice - 5–6 weeks after delivery, and 3 months after delivery.
Guzzetta et al. 2011
RCT Neuropsychological & Physiological
22 Healthy full term neonates
Gestational age between 30 and 33 weeks.
Full term neonates were randomly assigned into the massage or comparison groups. Intervention consisted of standard care
Spectral EEG analysis was performed on 80 seconds of sleep activity, applying the fast Fourier transform on the signal obtained from eight monopolar devises.
2 years
35
only (comparison group) or standard care plus infant massage (massage group). Massage was started at around 10 days after birth and was provided for 12 days during a 2 week period. EEG was performed at around 1 and 4 weeks i.e before and after intervention. Spectral EEG analysis was
Statistics were analysed using the Statistical Package for the Social Sciences (SPSS). Within group differences were analysed by a paired sample t-test, unadjusted.
Between group differences were also analysed. Levine’s test was used to assess equality of variances. The level of significant was set at p<0.05.
36
performed on 80 seconds of sleep activity, applying the fast Fourier transform on the signal obtained from eight monopolar devices.
Huhtala et al. 2000
RCT Neuropsychological 85 Healthy full term neonates with ‘colicky’ symptoms
3-7 weeks Full term neonates were randomly assigned into two groups:
Massage group – parents performed whole body massage, 3
Parent recorded the length of ‘colicky’ crying and sleeping, averaged to around 15 minutes.
Interviews were also conducted with the parents.
3 weeks
37
times daily for the length of the study.
Crib vibrator group –crib vibrators were used as a control group as it has been proven ineffective in previous studies.
Lahat et al. 2007
RCT Physiological 10 Healthy full term neonates
Gestational age between 29-34 weeks.
Full term neonates were randomly assigned to either the massage therapy group or a standard treatment
Metabolic measurements were performed by indirect calorimetry, using the Deltatrac 2 Metabolic chart.
12 days
38
control group.
The massage therapy group received treatment from the attending neonatologist and three 15 minutes massage of both kinaesthetic and tactile stimulation per day.
The standard control group only received treatment from the
39
neonatologist attending.
Each neonate was studied twice.
O’Higgins et al. 2007
RCT Mother 64 Full term healthy neonates and there mothers who scored above 12 on the Edinburgh Postnatal Depression Scale (EPDS)
4 weeks of age
The study used a prospective block-controlled randomised design.
Mothers with and EPDS of above 12 were randomly assigned to two groups.
EPDS
Mothers were filmed by a concealed camera interacting with their infant and rated using the Global-Rating for mother infant interactions.
5 weeks
40
Infant massage classes – where the mothers were asked to attend six, one hour classes.
Support group sessions – where the mothers were asked to attend six, one hour classes.
Non-depressed control
41
received no intervention.
Onozawa et al. 2001
RCT Mother 56 Mothers of healthy full term neonates with an EPDS ≥ 13
Gestational age of 1-3 months
Randomly assigned to two groups:
Massage group – mothers massaged their infants for 30 minutes daily.
Control group – received no treatment
Maternal confidence questionnaire. Parenting stress index questionnaire. Beck Depression Inventory 2 and a questionnaire about physical contact
2 months
Smith et al. 2013
RCT Physiological 37 Full term healthy neonates.
Gestational age of 29 – 32 weeks.
Full term neonates were randomly assigned either
Massage
ECG data was acquired with Mortara H12 + Holter monitors.
ECG data was collected continuously
4 weeks
42
group, (17 neonates) of which licensed massage therapists provided the massage twice daily for 4 weeks.
Control group, (20 neonates) of which received no massage treatment.
beginning 10 minutes pre-massage and control, continuing during the massage or control, and for 10 min post massage or control at weeks 0,1,2,3 and 4.
Data analysis was done by various computer programs.
White-Traut et al. 2009
RCT Physiological and Neuropsychological
40 Full term healthy neonates
1-2 days Infants were randomly assigned to experimental groups.
Group T, receiving 15 minutes of
Saliva cortisol samples were collected before, immediately following, and 10 minutes post-intervention. Behavioral state
3 months.
43
tactile-only stimulation
Group ATVV, receiving 15 minutes of ATVV stimulation
Group C, 15 minutes of no stimulation (control group)
Intervention or control group observation was administered in a quiet room away from the mother’s room yet near
was judged every minute.
44
the nursery 30 minutes before the next anticipated feed
45
4. Discussion
The aim of this study was to critically assess a range of relevant published
studies, reviews and articles, to improve understanding of the effects that
manual therapy, in the terms of neonatal massage, kinaesthetic and tactile
stimulation, has on the physiological and neuropsychological heath of
neonates and whether it has any subsequent effects on the mother’s health.
They were positioned in a hierarchy of evidence in order to give weight and
potentially more significance to those which were deemed to have a greater
methodological quality.
Physiological Outcomes That Neonatal Massage Has on the Infants.
The physiological outcomes that result following neonatal massage were
investigated by ten randomised control studies, seven of which consider the
effects that neonatal massage has on growth.
Argawal et al. (2000); Dieter et al. (2003); Field et al. (2006) looked into the
possible outcomes that neonatal massage might have on growth and sleep
patterns.
Argawal et al. (2000) found that neonatal massage improved the weight of the
neonates with statistically relevant results for the increase in length (p=<0.05),
mid-arm circumference (p=<0.01) and mid-leg circumferences (0.05)
compared to the control group which did not receive any neonatal massage.
The femoral artery blood velocity, diameter and flow improved significantly by
12.6 cm/sec, 0.6 cm and 3.55 cm³/sec respectively in the neonatal massage
46
group, compared to the control group. It was also noted that neonatal
massage statistically improved the amount of sleep, post massage - the
maximum being 1.62 hours (P=<0.0001).
Dieter et al. (2003) statistically showed that after five days of neonatal
massage, the weight of the neonates improved (p=<0.03). However the
reduction in sleep state being investigated was not significantly relevant.
Virtually all the p values of the behaviours observed were over p=<0.05 apart
from drowsiness (p=<0.007). However in the conclusion it stated that the
reduction in sleep noted in the massage group can be viewed as a positive
effect, therefore showing a risk of bias.
Field et al. (2006) statistically showed that light pressure compared to
moderate pressure neonatal massage improved the weight of the neonates
(p=<0.02). Behavioural observations also had some statistical relevance,
showing a decrease in deep sleep by (p=<0.05) and a lesser increase in
active sleep by (p=0.02) in light pressured neonatal massage compared to
moderate neonatal massage.
In the studies conducted by both Field et al. (2006) and Agarwal et al. (2000)
there seemed to be adequate methodological quality and a relatively low risk
of bias, whilst that of Dieter et al. (2003) had a reasonably inadequate
methodological quality and a reasonably high risk of bias.
Feng et al. (2007) found that neonatal massage can accelerate the physical
development of the neonates. The effects are more prominent in the first 6
47
months of life - weight and length enhancement in the 0-6 month group
(p=<0.01). There is little statistical significant evidence that suggests that
neonatal massage has an effect on neonates over the age of 6 months.
However the RCT conducted by Feng et al. (2007) is shown to have a
reasonably inadequate methodological quality and a high risk of bias.
The RCT conducted by Field et al. (2008) statistically showed the positive
effects that neonatal massage has on insulin and insulin-like growth factor 1
(IGF-1). It was found that Vagal activity increased suggesting that massage
therapy increased the parasympathetic activity (p=<0.01). Correlation analysis
suggested significant relations between these growth variables following
neonatal massage therapy, and these two variables in turn relate to weight
gain: weight gain related to increased insulin (p=<0.05); weight gain related to
increased IGF-1 (p=<0.05).
Lahat et al., (2007) found that energy expenditure was significantly lower in
infants after 5 days of massage therapy than those in the control group
(p=<0.05). However, in contradiction there was found to be no statistical
significance in weight gain after 5 days of neonatal massage compared to that
of the control group (p=<0.2).
Like previous studies of which looked into the effects that neonatal massage
has on infant growth there seems to be a common correlation of relatively
poor methodological quality with a relatively high risk of bias.
48
Ferber et al. (2002) replicated previous studies that had a positive result of
increase weight gain following neonatal massage, with an aim to produce a
cost-effective application of this method by comparing maternal to nonmaterial
administration of therapy. The study consisted of 57 healthy neonates split
into three groups, over a ten day period. The two treatment groups gained
significantly more weight than the control group. However the calorie intake
and weight gain didn’t differ between the two groups. The author concluded
that mothers are able to achieve the same effect in neonatal growth as that of
trained professionals. However even though this is applicable to osteopathy in
that it showed a positive outcome to the effects that neonatal massage has on
the neonate, on assessment of methodological quality the study scored the
lowest out of all the papers suggesting a relatively high possibility of bias.
Unlike the previous studies, which considered how massage affected the
growth of the neonate, Smith et al. (2013) tested the hypothesis that massage
would improve autonomic nervous system (ANS) function as measured by
heart rate variability (HRV) in preterm infants. They tested the effect on
medically stable 29 – 32 week preterm infants twice a day over a four week
period and measured HRV before, during and after the massage as an
indicator of ANS development and function.
Results indicated significant gender differences, with massage males
demonstrating improved parasympathetic function over time compared with
49
males in the control group and females in both groups. It is understood that
preterm male infants have higher morbidities and mortality than females.
In addition, preterm male infants have a dysfunctional microvasculature that
contributes to hypotension and there is some evidence to suggest prolonged
stress may lead to metabolic perturbations, immune response and growth
abnormalities. This study suggests that a well-delivered massage intervention
may improve the ANS development in preterm male infants who are more
vulnerable to stress response. Although the long-term effects of massage and
the effects of this therapy on preterm male or female infant morbidity and
outcomes are unknown, Smith et al. (2013) suggests that if massage
intervention improves the male infant’s ability to respond to stressful events,
there may be prolonged effects on minimising morbidity and chronic disease.
Smith et al. (2013) study is shown to have high methodological quality with a
low risk of bias, scoring 1st in the assessment of methodological quality and
risk of bias analysis.
Osborn et al. (2010) considered the effect of prophylactic kinaesthetic
stimulation on apnoea and bradycardia and use of intermittent positive
pressure ventilation (IPPV) in preterm infants at risk of apnoea.
Recurrent apnoea is common in preterm infants, frequent episodes may be
accompanied by respiratory failure of such severity as to lead to intubation
and the use of intermittent positive pressure ventilation (IPPV). As physical
stimulation is often used to restart breathing it was decided to carry out
50
research in to whether repeated stimulation, such as with an oscillating
mattress (kinaesthetic stimulation), might prevent apnoea.
Osborn et al. used a variety of criteria when considering studies as a basis for
their review. These included:
Types of study: all trials utilising random or quasi-random patient
allocation;
Types of participants: preterm or low birth weight infants at risk of
developing recurrent apnoea/bradycardia;
Types of intervention: kinaesthetic stimulation (various forms of oscillating
mattresses or other repetitive stimulation involving moving the baby) used
as prophylaxis for recurrent apnoea.
Although studies included were from 1966 to 2009, there are limitations in the
review and meta-analysis of the results of trials as:
different forms of kinaesthetic stimulation were used;
different measures of apnoea/bradycardia were used;
relatively small numbers of subjects were involved.
The authors summarised that the results of the trials reviewed did not indicate
prophylactic kinaesthetic stimulation to be of benefit to preterm infants in the
prevention of recurrent apnoea and bradycardia. They therefore concluded
that prophylactic use of kinaesthetic stimulation cannot be recommended to
reduce apnoea/bradycardia in preterm infants.
51
The aim of Underdown’s, (2009) study was to assess the effectiveness of
infant massage in promoting physical and mental health in infants aged six
months or under. 23 studies were included in this systematic review, the only
evidence of significant impact of massage on growth was obtained from a
group of studies of which were deemed to be at a high risk of bias. However
some evidence on mother-infant interaction, sleeping and crying, and on
hormones influencing stress levels. The author summarised the results to be
sufficient, despite the suspected high risk of bias, to support the use of infant
massage in the community especially in context where infant’s stimulation is
low. On review of this study there is little evidence of bias, and therefore the
conclusion is deemed accurate.
Physiological And Neuropsychological Outcomes That Neonatal
Massage Has On The Infant.
There were three cross-over studies conducted by Guezzetta et al., (2011),
Moore et al., (2012) and White-Traut et al., (2009) which looked into
physiological and neuropsychological outcomes that result following neonatal
massage.
Moore et al., (2012) carried out a review on early skin-to-skin contact (SSC)
for mothers and their healthy newborn infants to assess the effects of early
SSC on breastfeeding, physiological adaptation, and behaviour in healthy
mother-newborn dyads.
52
Post-birth separation of mother and infant is fairly commonplace within
Western culture. However, early skin-to-skin contact begins ideally at birth
and involves placing the naked baby, head covered with a dry cap and a
warm blanket across the back, prone on the mother’s bare chest. Mammalian
neuroscience indicates that this intimate contact evokes neurobehaviours
ensuring fulfilment of basic biological needs. Indeed, this time may represent
a psychophysiologically sensitive period whereby future physiology and
behaviour is programmed.
The objective of the review was to assess the effects of early skin-to-skin
contact for healthy newborn infants compared to standard contact, that is
infants held wrapped or dressed in their mothers arms, placed in open cribs or
placed under radiant warmers.
The three main outcome categories included:
establishment and maintenance of breastfeeding/lactation;
infant physiology - thermoregulation, respiratory, cardiac, metabolic
function, neurobehaviour;
The review included 34 randomised studies involving 2177 mothers and their
babies. All the studies reviewed were randomised controlled trials. However,
difficulties were encountered in interpreting the findings during this review as
a consequence of the large number of outcomes reported in the included
studies and also the inconsistency in the way outcomes were measured.
Nevertheless, the authors did reach some conclusions.
Breastfeeding outcomes
53
SSC practised for a short time at birth should have positive measurable
breastfeeding effects one to four months afterbirth;
Infant outcomes
SSC results in a significant increase in blood glucose and maintenance of
infant temperature in the neutral thermal range as well as reduced crying;
Attachment outcomes
SSC has at least a small effect on maternal neurobehaviour in relation to
her infant.
In summary the review by Moore et al. (2012) on early skin-to-skin contact
(SSC) for mothers and their healthy newborn infants to assess the effects of
early SSC on breastfeeding, physiological adaptation, and behaviour in
healthy mother-newborn dyads concludes that the intervention appears to
benefit breastfeeding outcomes, cardio-respiratory stability and decrease
infant crying, whilst having no apparent short or long-term negative effects.
However, further investigations are recommended due to limitations including
methodological quality, variations in intervention implementation, and
outcomes observed.
Guzzetta et al. (2011) carried out a study to test the hypothesis that massage
determines changes in EEG spectral activity, a highly sensitive index of brain
maturation.
Early intervention programmes based on the manipulation of the extra-uterine
environment have been used in preterm infants with the aim of improving
54
development and functional outcome. Infant massage has proved effective for
weight gain and reduced length of stay in the neonatal intensive care unit.
This is a form of systematic tactile stimulation consisting in a gentle, slow
stroking of each part of the body in turn. It is often combined with other forms
of stimulation such as kinaesthetic stimulation. However, little is known about
the effect of massage on early brain development although Guzzetta et al.
(2011) reported a significant effect of massage on the maturation of visual
function.
In this study, 20 newborns with a gestational age between 30 – 33 weeks
were studied.
Results showed that there was no change in spectral power in infants
receiving massage therapy although it decreased significantly in the
comparison group. The authors propose that massage intervention affects the
maturation of brain electrical activity and favouring a process more similar to
that observed in utero in term infants.
White-Traut et al. (2009) carried out a study to compare changes in stress
reactivity and behavioural state in healthy newborn infants following tactile-
only stimulation or a multisensory, auditory, tactile, visual, and vestibular
stimulation (ATVV) with a control group.
Elevated cortisol, a measure of stress reactivity has been found to have a
detrimental effect on brain development affecting infant learning and memory.
The research involved comparing the changes in stress reactivity by
measuring the biomarker salivary cortisol.
55
In this study, the researchers wanted to expand on these previous findings by
examining responsiveness to the ATVV intervention in healthy newborn
infants receiving standard nursing care and by adding the measurement of
salivary cortisol to quantify infant stress reactivity. Forty infants took part in the
study.
The researchers found stress reactivity increased as evidenced by elevated
salivary cortisol levels for the control and tactile-only group infants, while the
stress reactivity of infants assigned to the ATVV group exhibited a steady
decline in salivary cortisol over the course of the intervention. Whilst the
increase in cortisol for the control and tactile-only groups cannot be explained,
the infants in both groups were removed from their mothers’ room and did not
experience human social interaction (or any additional nursing care) over the
short data collection session.
The authors note the limitations of the study as a result of the small numbers
of infants taking part in the study and state that results should be interpreted
with caution and that the research should be replicated with a larger sample
size. Nevertheless, they conclude that whilst interventions appeared to have
minimal effect on stress reactivity based on behavioural state, Tactile-only
stimulation may increase infant stress reactivity whilst multisensory auditory,
tactile, visual, and vestibular intervention appears to reduce infant stress
reactivity.
56
The Neuropsychological Outcomes for Infants.
Huhtala et al. (2000) carried out a study to evaluate the effectiveness of infant
massage compared with that of a crib vibrator in the treatment of infantile
colic.
Inconsolable crying is typical in a child with infantile colic and results in
considerable parental stress. Dicyclomine was previously used as an effective
method of treatment but is now contraindicated because of possible life-
threatening side effects. There is some suggestion that sucrose and herbal
tea may be useful but more evidence regarding their effectiveness is needed.
Similarly there is a suggestion that cow’s milk elimination may be beneficial
but there is no consensus about the role of a cow’s milk allergy or intolerance
in colic.
Infant massage has been suggested for the treatment of colic but at the time
of this study there had been no controlled study of infant massage in the
treatment of colic. The study evaluated the effects of infant massage on crying
in infants in a randomised, controlled trial. Use of a crib vibrator was chosen
for control intervention or placebo treatment, because it had been shown to be
ineffective in a previous study.
58 infants <7 weeks old who were perceived to be colicky by their parents
took part in the study. They were randomly assigned to the massage group
(28 infants) or the control crib vibration group (30 infants). Three daily
intervention periods were recommended for both groups and parents
recorded observations in a diary for 1 week prior to the study and for 3 weeks
during the intervention. Parents were also interviewed after the first and third
57
week of intervention to determine their views with regard to the effectiveness
of the intervention.
Huhtala et al. found 93% of parents in both groups reported that colic
symptoms decreased over the three week period but that there was no
significant difference between the massage group and the use of the crib
vibrator. They suggest that the reduction in crying reflects the natural course
of colic and conclude that massage cannot be recommended for the treatment
of infant colic.
Outcomes on the Mothers Health Following Neonatal Massage.
The effect of mother-infant interaction following neonatal massage was
investigated by both O’Higgins et al. (2008) and Onozawa et al. (2001). The
two studies investigating mother-infant dyads used the global rating scales for
assessing the mother-infant interactions in order to collect the relevant data.
Onozawa et al. (2001) reported a highly statistically significant result in:
the improvement of the mothers attitude towards the neonate (p=<0.01);
the infant response (p=<0.001);
the overall mother infant interactions (p=<0.0004)
by attending a neonatal massage class, compared to the control group.
However O’Higgins et al. (2008) reported there to be no statistically relevant
data portraying the effects that neonatal massage has on mother-infant
interactions to remain the same in all groups.
58
Both O’Higgins et al. (2008) and Onozawa et al. (2001) investigated maternal
depression and how this was subsequently affected by neonatal massage,
data collected was analysed using the Edinburgh Postnatal Depression Scale
(EPDS).
O’Higgins et al. found that significantly more of the infant massage group had
achieved a clinically significant reduction in the EPDS score compared to the
support group over the study period (p=<0.05). However there was a
substantial drop in the baseline scores between recruitment and pre-
treatment, though at the one year follow up study the EPDS score of the infant
massage group was still statistically lower. O’Higgins et al. also used the
Spielberger State Anxiety Inventor (SSAI) reporting low statistically relevant
data which was not discussed suggesting the outcome of the study to be
selective and suggestible bias.
Onozawa et al. (2001) showed there to be even more of a significant
decrease in the EPDS score following the massage therapy programme
(p=0.03), however it should be noted that mothers in the intervention group
had a greater drop in their EPDS score between recruitment and pre-
treatment.
Fujita et al. (2006) also assessed the possible outcomes that neonatal
massage has on the mother’s health following neonatal massage. Unlike
O’Higgins et al. (2008) and Onozawa et al. (2001) the questionnaire was
conducted using the profile of mood states (POMS) as a psychological
measurement. Salivary cortisol levels were also analysed measuring any
59
proposed physical outcomes that neonatal massage has on the mother’s
health.
The randomised control trial conducted by Fujita et al. (2006) showed
statistically significant results and a positive outcome for reducing the levels of
depression in the mothers following neonatal massage. With the subscales
depression-dejection and vigour scoring a p value of 0.02. These were the
only two subscales of the POMS to have relevant statistically significant value,
which was left out of the conclusion suggesting a possible bias of results.
All the studies reviewed in relation to the effects of infant massage on the well
being of the mother, showed statistically significant results and a positive
outcome for the mother’s health. Nevertheless, on assessment using the
scale adapted by Furlan et al. (2009) and the Cochrane Handbook (2009),
(Figure 4), the three reviews showed relatively high susceptibility of bias.
However it should be noted that research conducted on pre-term infants such
as that conducted by Feijo et al. (2006) and Diego et al. (2009), provides
statistically relevant data with a relatively low bias. It indicates a reduction of
depression in mothers when performing neonatal massage and also when
watching their infants being massaged by professionals. This therefore has
particular significant relevance to osteopathic therapists as it proposes the
subsequent effects that neonatal massage might have on the mother.
60
Limitations
There were two main types of citations used in this narrative review study:
randomised control trials (RCT) and systematic reviews of randomised control
trials. All systematic reviews are open to an element of subjective bias. (Bias
is an extremely important factor to consider when reviewing both systematic
reviews and RCT articles.) By using various appraisal tools, often unfamiliar to
the reviewer, for different types of studies can sometimes result in possible
reviewer bias. This is mainly apparent when certain criteria may not be fully
clear as to whether a ‘yes’ or ‘no’ score should be given and instead an
‘unknown’ score is given. This subsequently creates a subjective decision for
the reviewer regarding scoring leading to a suggestible bias.
There are a variety of approaches used in massage therapy, kinaesthetic and
tactile stimulation of the neonate, in situ there are various different types of
papers each intern reviewing and trialling different treatment modalities. Even
though there are many different modalities, there are extremely few articles on
the subject, with even fewer that are valid for comparison with each other due
to factors such as different measurable outcomes, sample sizes and
timeframes. The quality of the older RCTs used in the systematic reviews
were said to be extremely poor in terms of methodological quality and with a
high suggestibility of bias, leading to insufficient evidence and lack of a
statically significant outcome.
This narrative review was limited to studies that were only in English (or
professionally translated by original authors) and so there may have been
61
numerous other articles with statistically significant results, there was a
considerable amount of literature which was not included (Underdown et al.,
2006), in turn this may have affected the overall findings of this narrative
review.
It should also be noted that only one individual carried out this review, and
although there were no conflicting views, the decisions and opinions made in
this review are only that of one individual and as such are susceptible to bias.
Implications to Osteopathy
There has been limited research conducted into the effects that osteopathic
treatment might have on neonates and subsequent effects on the mother.
Osteopaths use both massage and touch as one of their primary techniques
when treating infants. It is believed that osteopaths “maintain or restore the
circulation of body fluids” (Philippi et al., 2006).
Understanding how massage, kinaesthetic and tactile stimulation influences
outcomes on both physiological and neuropsychological heath in neonates is
fundamental for osteopaths, in order for them to assess the extent of how they
might be able to help the parent and their child. This review offers a greater
understanding with regard to the effects that various forms of infant massage
might have on both mother and infant.
62
5. Conclusion
In summary, the results of this review suggest that infant massage,
kinaesthetic and tactile stimulation can have a positive influence on many
physical and neuropsychological effects for both infant and mother. The
studies with a lower suggestive risk of bias demonstrated accurate statistically
significant results on physical factors such as growth of the neonate and
reduction in level of salivary cortisol. Therefore such studies are deemed to
have a higher weighting in the provocation and application that infant
massage might have in complementary alternative medicine. However the
evidence has been obtained from a relatively small sample number and more
conclusive and accurate results may be obtained by meta-analysis of a wider
sample.
To conclude there is little research into the effects that massage therapy may
have on infants. However understanding how massage kinaesthetic and
tactile stimulation may have on the physical and neuropsychological effects of
both mother and infant is paramount. Further, long term studies are needed in
order to accurately determine the effectiveness that these have on mother
and infant.
Word count : 5500
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Appendices
70
Appendix ‘A’ – For assessing systematic reviews (adapted from Greenhalgh, 2006).
a Did the systematic review address an important clinical question?
Yes / No / Unsure
b Was a in-depth and thorough search done of the appropriate database(s) and were other potentially important sources explored?
Yes / No / Unsure
c Was methodological used quality assessed and the trials weighted accordingly to this?
Yes / No / Unsure
d Have the numerical results been interpreted accurately?
Yes / No / Unsure
e How sensitive are the results to the way the review has been carried out?
Yes – very sensitive
No – not sensitive
Unsure
Appendix ‘B’ – For assessing RCTs (adapted from Furlan et al., 2009)
PATIENT SELECTION
1 Were the eligibility criteria specified? Yes/No/Unsure
TREATMENT GROUP ALLOCATION
2 Was the method of randomization
adequate?
Yes/No/Unsure
3 Was the treatment allocation blinded? Yes/No/Unsure
4 Were the groups similar at baseline
regarding the most important prognostic
indicators?
Yes/No/Unsure
INTERVENTIONS USED
71
5 Were the index and control interventions
explicitly described?
Yes/No/Unsure
6 Was the patient blinded to the
intervention?
Yes/No/Unsure
7 Was the care provider blinded to the
intervention?
Yes/No/Unsure
8 Was the compliance acceptable in all
groups?
Yes/No/Unsure
9 Were co-interventions avoided or
similar?
Yes/No/Unsure
OUTCOME MEASUREMENT
10 Were the outcome measures relevant? Yes/No/Unsure
11 Was the outcome assessor blinded to
the intervention?
Yes/No/Unsure
12 Was the drop-out rate described and
acceptable?
Yes/No/Unsure
13 Were all randomised participants
analysed in the group to which they were
allocated?
Yes/No/Unsure
14 Are reports of the study free of
suggestion of selective outcome
reporting?
Yes/No/Unsure
15 Was the timing of the outcome
assessment similar in all groups?
Yes/No/Unclear
STATISTICS
72
16 Was the sample size for each group
described?
Yes/No/Unsure
17 Did the analysis include an intention-to-
treat analysis?
Yes/No/Unsure
18 Were point estimates and measures of
variability presented for the primary
outcome measures?
Yes/No/Unsure
73
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