Original Articles

Iranian Journal of Neonatology Vol. 33, No.2, Summer 2012

Effect of Massage on Weight Gain in Premature Infants

*Zohreh Badiee1, Shiva Samsamshariat2, Pegah Pourmorshed2
1
Department of Pediatrics, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
Iran.
2
General Physician, Faculty
aculty of Medicine,
edicine, Isfahan University of Medical Sciences, Isfahan, Iran
Iran.

Abstract

Introduction:
After the introduction of surfactant, the survival rate of preterm neonates has increased
significantly. This issue attracted much attention towards this fragile population. Many studies have
demonstrated that massage plays a role in the weight gain of preterm infants. This study compares
the effect of massage therapy on infants who were massaged by a nurse or their mother with those
who did not receive massage therapy at all.

Materials and Methods:

This randomized clinical trial was conducted on three groups.
groups (1) The infants who only received
routine care and no massage (2)), those who received massage by an expert nurse and (3) those who
received massage by their mothers. We recorded daily weight gain, the length of hospital stay and
fluid intake of infants. Kruskal
ruskal Wallis test and SPSS software were used for statistical analysis.

Results:
The gestational age of infants ranged between 28 to 34 weeks. At the end of the fifth day the group
massaged by a nurse had significantly more weight gain compared to the other
other two groups (6.5+1.5
in the nurse group, 4.6 +1 in the mother group and 3.7 +1.5 in the control group
group, P= 0.001). Those
who were massaged by their mothers also gained weight significantly more than the control group
(P =0.05). There was no significant difference in the length of hospital stay among the understudy
groups.

Conclusion:
Our study showed that the five-day
five day massage therapy is a safe technique mothers can perform for
stable preterm infants to facilitate weight gain in neonate.

Keywords:
Premature infant, Newborn, Massage therapy.
therapy

Introduction
1
At present, improved care of preterm and specialists have focused on improving
infants especially with the use of the growth and development of this
surfactant has resulted in increased population (1). According to tthe definition
number of premature infants who survive by the World Health Organization
(WHO), an infant born prior to 37 weeks
*Corresponding Author: Zohreh Badiee Division of gestation is considered preterm (2).
of Neonatology, Department of Pediatrics, Isfahan Various studies have demonstrated that
University of Medical Sciences, Isfahan, Iran. infants leaving the uterus too early can
E-mail: [email protected] have many health complications (3).
Received: 14 March 2012; Accepted:
Accepted 24 June 2012

57 Iranian Journal of Neonatology Vol.3, No.2, Summer 2012

Badiee Z, et al

Whatever the fetus feels and experiences in Materials and Methods

the uterus environment are necessary and This randomized clinical trial was
ideal for his physical growth and conducted on 28-34 week infants
behavioral development (4). In case of hospitalized at the NICU of Beheshti
premature birth, the preterm neonate loses Hospital during 2009-2010. The inclusion
the calm uterus environment that was full criteria were: Gestational age of 28-34
of sensory stimulations required for his weeks and complete oral feeding or gavage
growth and development and is placed in of 150 ml/kg/day. Infants in all study
the NICU; a place full of light, noise and groups were fed with milk and did not
stress (4,5). Impairment in growth at early receive fluid infusion. Infants older than 7
infancy, which is an important time for days were selected if they had stable vital
cellular hyperplasia and hypertrophy, can signs. The exclusion criteria were:
have permanent impacts on the future Important congenital disorders, congenital
health of the infant. The restriction caused heart disease, gastrointestinal disorders and
in growth of premature infants can stay need for mechanical ventilation during
with them till puberty (6). During the past 2 massage therapy. The number of infants
decades the abovementioned problems receiving nutritional supplementation of
have compelled researchers to seek various mother’s milk was similar in all 3 groups.
methods to provide premature infants with The number of breastfed or formula-fed
complementary stimuli to help growth and infants was also similar in the 3 groups. All
development of newborns in the NICU (3). the study phases and consent forms
The supportive care and interventional provided by parents were approved by the
stimulations aim to imitate the uterus Ethics Committee of Isfahan University of
environment and assist and facilitate Medical Sciences. The study was
infant’s normal development (4-8). Various thoroughly explained to the parents and
studies have demonstrated that massage written informed consent was obtained. A
therapy can improve weight gain, code was allocated to each infant qualified
mineralization of bones, shorten the for the study. These codes were written on
hospital stay and result in earlier discharge small pieces of paper and placed in a box.
and tactile-kinesthetic responses in infants A person not aware of the study randomly
(5). In a study by field et al, 63 clinically drew pieces of paper out of the box and this
stable preterm newborns with a mean way all infants were randomly divided into
gestational age of 30 weeks were randomly 3 groups. Each group consisted of 20
divided into 2 groups; massage and infants. The first group received massage
control. Newborns in the test group were therapy by their mothers, and the second
massaged three times a day for 15 minutes group by a nurse. The 3rd group did not
for a total of 10 days. Test group infants receive massage therapy and only routine
gained significantly more weight daily care was given to them. Massage therapy
compared to controls (32g versus29 g). was started on the first day of the study and
The same result was obtained in similar continued for 5 consecutive days, each time
studies conducted by the same researchers for 5 minutes. The first session was one
(9,10). hour after the morning feeding, the second
The present study aimed to evaluate the session was 30 minutes after the mid-day
effect of massage therapy by the mother feeding, and the 3rd session was 45
on the weight gain of premature minutes after the completion of the 2nd
newborns and comparing it with the session. Each session consisted of 5
result of massage therapy by a trained minutes of tactile stimulation. The infant
nurse and controls during a 5-day period. would be placed in prone position. The

58 Iranian Journal of Neonatology Vol.3, No.2, Summer 2012

Effect of Massage on Weight Gain in Premature Infants

massage therapists would warm up their Mothers received necessary information

hands first and were quiet during therapy. and training in this respect. The head nurse
Massaging was gentle using the ventral supervised the massaging by the mothers
part of the fingers. The whole massage was and nurses. Data were entered via SPSS
divided into 5 sections of 1 minute each version 15 software and one way analysis
and each section to 6 fractions of 10 of variance (ANOVA) and Kruskal Wallis
seconds each. In the first section, massage test were used for data analysis.
was started from the head to the posterior
neck and back to the head. In the second Results
and third sections, massage started from the A total of 60 infants 28 to 34 weeks were
posterior neck to the shoulders and back to studied. The mean gestational age in the 3
the posterior neck. In the 4th section, groups of control, massage by the mother
massage started from the shoulders down and massage by a nurse was 31±2.4,
to the buttocks and back to shoulders 30±2.3 and 32±2, respectively. The mean
except for the vertebral area which was left percentage of weight gain is listed in
untouched. The fifth section included Table 1. The mean percentage of weight
simultaneous massage of both legs from gain in infants during the study days
the hip down to the soles and back. The compared to day 1 in the group of
sixth section included both hands from the massage by nurse was higher than in the
shoulders to the wrists and back to other 2 groups (P<0.001). Between the
shoulders simultaneously. The phases of other 2 groups, the massage by the mother
each 5-minute session of massage included group had 0.5% more weight gain
5 times repeating of the 1 minute massage compared to controls and this difference
which contained head and neck massage was also statistically significant (P=0.04).
for 10 seconds, 20 seconds shoulders Comparing the mean weight gain in each
massage, 10 seconds back massage, and 10 day of study compared to the previous
seconds massage of both legs. A special day, this rate was significantly higher in
questionnaire was filled out daily for each the massage by nurse group compared to
infant containing daily weight, amount of the other groups (P=0.0001). Also the
fluid intake, number of defecations, group of massage by mother had a
medications, and amount of calories significantly higher weight gain compared
received (kcal/kg/d). Before initiation of to controls (P=0.04). The mean hospital
study, the mothers and nurses who were stay in the 3 groups was not significantly
going to massage the infants received different (P=0.1).
necessary instructions and training. For According to one-way ANOVA test,
accurate recording of information, a mean percentage of weight gain in the
fulltime nurse was recruited to supervise massage by the nurses group was
the whole process. significantly higher than the other 2 groups.
Physiologic responses were controlled by The remaining 2 groups had 0.5%
measuring the heart rate and respiration difference which is the minimal significant
rate per minute. In case of emergence of difference. Mean number of defecations
signs or symptoms of physiologic distress was significantly higher in the group of
such as the heart rate over 200 beats/min, massage by nurse (P=0.001). No
the massaging would be stopped for 15 significant difference was observed
seconds or until reaching the baseline between the other 2 groups in this regard.
values. A warning alert sound would warn The mean percentage of fluid intake was
the therapist about the presence of significantly lower in the group of massage
unfavorable physiologic responses. by nurse (P=0.05) but the other 2 groups

59 Iranian Journal of Neonatology Vol.3, No.2, Summer 2012

Badiee Z, et al

had no significant difference in this respect coefficient failed to find a significant

with each other. The Apgar score at 1 and 5 association between education level of
minutes for infants in different groups was mothers and percentage of weight gain at
not significantly different. Kruskal Wallis different times in the massage by mother
test demonstrated that educational level of group (P>0.05). No complication occurred
mothers in the 3 groups was not in any of the understudy groups and heart
significantly different from each other rate and respiration rate of infants remained
(P=0.71). Spearman’s rank correlation normal.

Table 1: Comparison of the mean percentage of weight gain among the infants of 3 groups during
the study period.
Massage by mother Massage by nurse Controls
Percentage of weight gain Mean±SD Mean±SD Mean±SD P-value

Day 2 compared to day 1 1 (3.4) 1.4 (0.9) 0.9 (0.4) 0.03

Day 3 compared to day 2 2.1 (0.6) 2.8 (1.2) 1.8 (0.6) 0.001

Day 4 compared to day 3 3.3 (0.8) 4.4 (1.7) 2.8 (0.9) <0.001
Day 5 compared to day 4 4.6 (1) 6.5 (2.5) 3.7 (1.5) <0.001

Discussion
Dieter et al, in 2003 conducted a study on groups. The first group only received
32 premature infants. The newborns were supportive routine care; the second group
randomly divided into 2 groups of test was massaged by their mothers and the
(massage) and controls. Since the previous third group by a nurse. The intervention
10 day studies had demonstrated that continued for 10 days. At the end of study
gaining weight usually starts from day 5 of period, both groups receiving massage
intervention, the test group infants were therapy gained significantly more weight
massaged for 5 days. At the end of compared to the control group (10).
massage therapy, the test group gained Matthias and coworkers performed a study
53% more weight compared to controls (3). on 48 immature infants weighing 1 to 2 kg.
Safety and efficacy of massage therapy for Massage therapy was performed by a nurse
premature infants have been confirmed in from day 3 to day 8 and from day 8 on by
several studies. Researchers have the mother and continued until the infant
demonstrated that kinesthetic stimulation in was full-term. Weight gain in the group
infants by mothers improves the parent- receiving massage therapy was 4.2 g per
child relationship. Massage therapy can day more than the control group (13). In
also improve this relationship by the literature review we found only one
facilitating the development of preterm study evaluating the weight gain of
newborn (12). Therefore, it was suggested premature infants receiving massage
that massaging be performed by the therapy only by their mothers or nurses. If
mother. Apart from the above mentioned massage therapy is effective, the adverse
benefits, if applicable, this can help in complications of premature birth will be
reducing the costs to a great extent because compensated for to a great extent. If
hiring a nurse to do the massage therapy massage therapy is done by the mother, in
would be expensive and time consuming. spite of the resultant weight gain, the
In a study by Ferber and colleagues 57 mother-child relationship will also become
healthy preterm infants were divided into 3 stronger. The high cost of NICU will

60 Iranian Journal of Neonatology Vol.3, No.2, Summer 2012

Effect of Massage on Weight Gain in Premature Infants

decrease and the need for hiring a trained were massaged by a nurse. From day 2 on,
nurse will be obviated. infants massaged by the nurse had a
Our study results, similar to the findings significantly greater weight gain than those
of several previous studies revealed that in the other 2 groups. Infants massaged by
massage therapy can enhance weight gain the mothers did not gain weight as much as
of clinically stable preterm infants those in the nurse group but from day 3 on
(11-13,17). In the present study, infants had a significantly higher weight gain than
in the group of massage by nurse gained controls. This finding is in accord with
significantly more weight than the some other studies that confirm the ability
matched controls. At the end of 5-day of mothers to do the massage. However, a
study period, the massage by nurse group significant difference was found between
had significantly more weight gain infants massaged by the nurse and those
compared to the other 2 groups. Infants in massaged by their mothers in terms of
the group of massage by mother also weight gain. We believe this difference is
gained significantly more weight than the due to the difference in the amount of
controls. Different mechanisms have been pressure applied since mothers and nurses
proposed for the positive effects of had the same technique and the maneuvers
massage therapy. For the first time, Field were exactly the same. Also, a trained
and colleagues during the feeding of technician supervised both nurses and
preterm infants found that infants who had mothers. Although the mechanism
non-nutritive sucking gained 2.8 g more responsible for weight gain as the result of
weight than others. Based on this finding, a massage therapy is yet to be completely
mechanism was suggested stating that understood, it seems distant that the weight
stimulation of proprioceptors present in the gain be due to increased calorie intake
mouth has been the reason for this extra because Field and colleagues demonstrated
weight gain (11). In the mentioned study it that the infants who gained weight as the
was shown that stimulation of these result of massage therapy did not have
receptors results in increased secretion of more calorie intake or were not storing
Gastrin, Insulin and Cholecystokinin. Thus, more than others. The same results were
they concluded that stimulation of obtained by studies conducted on preterm
proprioceptors all over the body of infants infants and also in animal model studies.
may result in gaining more weight. Several Any weight gain as the result of massage
studies were performed by the same therapy is due to the higher food
researchers and others to test the accuracy conversion ratio (18). Another finding of
of this theory. They all reported that the present study was fewer defecations in
massage therapy with the technique the nurse group compared to the other 2
employed in our study enhances weight which can further confirms the increase in
gain. In all these studies massage therapy food conversion ratio. This group even had
with and without passive movement of less fluid intake compared to others. Some
limbs resulted in weight gain (11). studies have shown that massage therapy
According to the above mentioned studies can reduce the hospital stay (12). In our
although the immature infants can seem study and also in a study by Massaro et al,
very fragile, some pressure has to be no significant difference was observed in
applied in order for the massage to be the duration of hospital stay among the 3
effective. This fact was also confirmed in groups. It should be mentioned that in our
the present study. This study showed that hospital system, hospital stay is not a good
mean weight gain on day 1 was criterion to report because it is influenced
significantly greater among infants who by the medical and social status of infant

61 Iranian Journal of Neonatology Vol.3, No.2, Summer 2012

Badiee Z, et al

and is also based on the opinion of parents 6. Hack M, Flannery DJ, Schluehter M,
and judgment of physicians. Controlling Carterl, Borawski E, Kelein N. Outcomes for
young adulthood for very-low-birth weight
these confounding factors is difficult in infants. N Engl J Med 2002; 346:149-57.
clinical trial settings (12). In our study, no 7. Field TM, Schanberg SM, Scafidi F, Bauer
significant difference was detected between CR, Vega-Lahr N, Garcia R. Tactile/
the infants of the 3 groups in terms of their kinesthetic stimulation effects on preterm
Apgar score at 0 and 5 minutes. Our study neonates. Pediatrics 1986; 77: 654-8.
8. Harrison L, Williams AK, Stem B, Leeper J.
demonstrated that mothers can significantly Physiologic and behavioral effects of gentle
enhance the weight gain of their newborns human touch on preterm infants. research in
by massaging them, but in contrast to the nursing and health, 2000; 23: 435-46.
findings of Ferber et al, (14), this weight 9. Tiffany field. Preterm infant massage
therapy studies: an American approach.semin
gain in our study was not as much as the neonatology, 2002; 7:487-94.
amount gainedby infants massaged by a 10. Ferber SG, Kuint J, Weller A, Feldman R,
trained nurse. As mentioned earlier, this Dollberg S, Arbel E. Massage therapy by
may be due to the lower amount of mothers and trained professionals enhances
pressure applied by the mothers since they weight gain in preterm infants. early human
development. 2002; 67: 37-45.
believe their newbornsare too fragile. No 11.Mendes EW, Procianoy RS. Massage
complication occurred in our study and therapy reduces hospital stay and occurrence
vital signs of infants were stable during the of late-onset sepsis in very preterm neonates.J
massage therapy. This study showed that Perinatol.2008 ; 28: 815-20.
massage therapy of preterm infants with 12. Massaro AN, Hammad TA, Jazzo B, Aly
H. massage with kinesthetic stimulation
gestational age over 28 weeks is a safe improves weight gain in preterm infants. J
technique to improve their weight gain and perinatal 2009; 29: 352-57.
mothers can learn and perform this 13.Mathia S, Frandes A. Effects of tactile-
effective procedure to enhance the weight kinesthetic stimulation in preterm :A
gain of their newborns and decrease the controlled trial .Indian pediatr 2001;38:1091-8.
14.Gonzalez AP, Vasquez-Mendoza G, García-
costs at the same time. However, further Vela A, Guzmán-Ramirez A, Salazar-Torres M,
investigations are required to improve the Romero-Gutierrez G. Weight gain in preterm
efficacy of massage therapy. infants following parent-administered Vimala
massage: a randomized controlled trial.Am J
References Perinatol. 2009; 26: 247-52.
1. White JL,Labarba RC.The effects of tactile 15. McGeheeI.J,Eckerman C.O. The preterm
and kinesthetic stimulation on neonatal infant as social partner: responsive but
development in the premature infants.Dev unreadable. Infant behavior and development.
psychobiol 1976; 9:569-77. 1983; 6: 461-70.
2. Kliegman RM. Behrman RE, Jenson HB, 16. Ohler JM, Eckerman C.O, Wilson W.H.
Stanton BF.High risk infant: Nelson textbook Examining the issue of tactile stimulation for
of pediatric: Philadelphia, Saunders, 2007. preterm infants.Neonatal network. 1985;4:25-33
3. Dieter J, Field T, Hernandez-reif M, Emory 17. Harrison L, Woods S. Early parental touch
E, Redzepi M. Stable preterm infants gain and preterm infants. J Obstet, Gynecolneonatl
more weight and sleep less after five days of Nursing,1991; 20:299-306.
massage therapy. Journal of pediatric 18. Diego MA, Field T, Hernandez-Reif M.
psychology 2003; 28:403-11. Preterm infant massage elicits consistent
4. Mathaish,Fernandez A, Mondkar J, Kanbur increase in vagal activity and gastric motility
W. Effects of tactile-kinesthetic stimulation in that are associated with greater weight gain.
preterms: A controlled trial. Indian pediatrics Acta Paediatr 2007; 96: 1588-91.
2001;38:1091-8. 19. Field T, Diego M, Hernandez-Reif, Dieter
5. Acolet D, Modi N, Giannakoulopoulos X, JN, Kumar AM, Schanberg S, et al. Insulin
Bond C, WegW,Clow A. Changes in plasma and Insulin like growth factor-1 increased in
cortisol and catecholamine concentrations in preterm neonates following massage therapy. J
response to massage in preterm infants. Arch Dev Behav Pediatr 2008; 29:463-6.
Dis Child 1993; 68: 29-31.

62 Iranian Journal of Neonatology Vol.3, No.2, Summer 2012