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.

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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.

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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.

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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.

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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.

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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.

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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)

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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.

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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

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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;

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Mean age of infants was over 12 months.

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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

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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

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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.

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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

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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.

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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

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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

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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

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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

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Traut et al. 2009

A summary of the article can be found in table 7

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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

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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.

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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.

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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.

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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

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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.

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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.

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the nursery 30 minutes before the next anticipated feed

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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

63

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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