evidence behindRevealing the

the magic of

The magic of touch

For centuries, women have instinctively known about the magic of touch. Midwives arealso familiar with the benefits of a back rub during labour or letting newborn babies nestle upclose to their mothers.

Many studies have already shown clinical benefits to mothers and their babies. This bookletsummarises these studies – published, peer-reviewed trials that show benefits such as:

• A general reduction in stress and anxiety

• Pain relief during pregnancy and labour

• Helping newborns to stay warm, to feed and (in pre-terms) gain weight

This guide has been produced by JOHNSON’S® Baby in conjunction with the Royal College ofMidwives. Our goal is that every mother-to-be should understand the many benefits of touch,something that we can achieve only by working together. The evidence base and useful tips inthis booklet aim to support midwives in this, so that you can feel confident talking to mothersabout the magic of touch.

Of course, successful massage should be carried out in a safe, private environment.To make massage safe, mothers-to-be and their partners need advice from trained individuals.

We hope this booklet will be a useful aid to your clinical practice.

Cathy Warwick Kate HulattThe Royal College of Midwives Johnson & JohnsonGeneral Secretary Professional Communications Manager

Happier, more comfortable mothers-to-be

“Overall, the present findings suggest that massage therapy is

effective for reducing pregnant women’s anxiety levels, stress

hormones, sleep disturbance and back pain and for lessening

obstetric and postnatal complications.” Field, 1999

Massage during pregnancy can be calming and soothing for expectant mothers. Many practitioners are confidentit can relieve discomfort, promote restful sleep, reduce cramp and swelling in the legs and stimulate the circulation.

Field T et al.Journal of Psychosomatic Obstetrics and Gynaecology, 1999.

Pregnant women received twice-weekly, 20-minute massagetherapy or relaxation therapy. After five weeks, massagedwomen reported reduced anxiety and back pain and improvedmood and sleep compared with women who receivedrelaxation therapy. Both groups reported reduced anxiety andleg pain. Massaged women also had lowered urinary stresshormones and fewer labour complications than womenreceiving relaxation therapy.

Pregn

ancy

For full references of all studies used in this booklet, please see the inside back page.

Field T et al.Infant Behaviour and Development, 2009.

A study of 149 pregnant women diagnosed with major depression,88 of whom received 12 weeks of twice-weekly massage therapy lasting20 minutes. The placebo group received only standard treatment.Massage not only helped significantly reduce depression and back pain,it also led to significantly fewer premature births and low-birthweightbabies. Babies of massaged mothers had significantly lower cortisol levelsand higher Brazelton Neonatal Behaviour Assessment Scale Scores forhabituation, orientation and motor assessment.

Latisfes V et al.Journal of Bodywork and Movement Therapies, 2005.

175 expectant fathers carried out 20 minutes of either massageor relaxation therapy twice weekly for five weeks on their pregnantpartners. A third group performed no intervention. Self-reportedassessment revealed that massage lowered fathers’ self-reportedanxiety levels and improved their sense of marital adjustment.

Field T et al.Journal of Bodywork and Movement Therapies, 2008.

Prenatally depressed women received twice-weekly massagefrom their partners from 20 weeks’ gestation until term.Compared with a control group, who received no intervention,massaged mothers reported significantly less back and leg pain.There were also significant improvements in depression, anxiety,anger and the relationship with their partners by the end ofthe study. Their partners also felt significantly less depressionand an improved relationship than partners in the control group.

Pregnancy massage is also a good way for expectant mothers to stay close and intimate with their partner. It helpstheir partners feel involved in the pregnancy and brings couples closer together during a time of tremendous change.

Tips on massage during pregnancy:

• Massage should only be performed from the second trimester onward

• Mothers should be in a comfortable position before massage, such as on their side with good supportfor the back and legs, or sitting down

• Head and neck massages have been shown to be effective – massaging the scalp in small circlesalong the hairline, then kneading the neck from the base up

• Back massages are really effective too (with mothers on their side). There are several techniques, for examplemassaging the lower back from the backbone across the waistline using the hands to make large circles

• A foot or hand massage is a good alternative to the head, back or torso and means mothers don’thave to be lying down

Helping couples stay close during pregnancy

“Just being able to do something positive in this pregnancy

means a lot to me.”Quote from a father who learnt how

to massage his pregnant partner, Latisfes, 2005

Making labour shorter and less painful

Labou

r

“In this study we found that massage therapy reduces

medical interventions and need for pain relief

during labour.” Khodakarami et al. 2006

Massage has been used for centuries during labour and you have probably witnessed its benefits first hand.Many midwives also acknowledge that massage can give the birth partner an active and supportive role during labour.

Tips on massage during labour:

• Slow, rhythmic long-stroke massages, primarily on the lower back, the upper and lower limbs can be effective

• These strokes can be combined and synchronised with slow, rhythmic breathing – massaging hands movingupwards with inspiration and downwards with expiration

Khodakarami N et al.European Journal of Pain, 2006.

Research midwives massaged the back and limbs of women in labour anticipatinga normal delivery. Visual analogue scale pain scores of women’s perception of theirpain during labour revealed significantly lower pain levels than non-massagedwomen. The duration of the first stage of labour was also reduced.

Yildirim G et al.Pain Research and Management, 2004.

Nurse- and self-administered massage was conducted on women in labour;levels of pain were compared with non-massaged women at different phasesof labour. Pain levels at every phase of labour were significantly lower in massagedwomen, compared with non-massaged women. Several common features oflabour (such as crying, complaining and screaming) were also significantly reducedin massaged women.

Chang M-Y et al.Journal of Advanced Nursing, 2002.

Women received 30 minutes of massage from the primary researcher during thelatent, active and transitional phase of labour. Compared with non-massagedwomen, significantly lower pain intensity was reported by massaged womenduring all three phases of labour. Anxiety was also reduced in the first labour phase.87% of massaged women reported that massage was more than moderately helpfulduring their labour.

Field T et al.Journal of Psychosomatic Obstetricsand Gynaecology, 1997.

Women received 20 minutes of head,shoulder/back, hand and foot massage fromtheir partners during labour every hour forfive hours. Massaged women reportedsignificantly lower stress levels and labourpain than non-massaged women. They alsospent significantly shorter time in labour andin hospital.

Kimber L et al.European Journal of Pain, 2008.

A UK pilot study examined the effect of30–45 minutes of regular massage, music orno intervention in women from 35 weeks’gestation until they attended hospital inlabour/for induction. Although too smallto reach statistical significance, the studyobserved trends for reduced self-reportedpain and more positive views of labourpreparedness and sense of control fromwomen in the massage group, comparedwith control groups.

Keeping baby warm and content

“There is a large body of evidence supporting the

need to keep all babies warm immediately after birth.

Even vigorous newborn babies, exposed to cold delivery

rooms, may have a marked drop in temperature…

…skin contact with the mother will reduce this loss

of temperature.”RCM Midwifery Practice Guidelines,

‘Immediate Care of the Newborn’, May 2008

The first few hours after birth are recognised as an important time for the development of the relationshipbetween mothers and their new babies. RCM guidelines recommend early skin-to-skin contact between mothersand their healthy newborn babies to help reduce loss of temperature. The guidelines also point to evidencethat this, along with early suckling, has a positive effect on breastfeeding success.

New

bornbabies

Tips on skin-to-skin contact following birth:

• Make sure the mother has sufficiently recovered from the birthing process to provide safe skin-to-skin contact

• Once informed consent has been sought, babies should have skin-to-skin contact within the first hour after birth,while they are alert and willing to feed

• Following birth, baby should be dried with a warm towel, placed onto the mother’s chest and coveredwith a blanket for warmth

• Non-essential procedures (like weighing or vitamin K administration) should be carried out after this first hour,to let the mother and baby adjust to their new environment

• Check the personal or cultural preferences of mothers as this may affect whether their baby is cleanedbefore placing it on their chest

• Another term for skin-to-skin contact is ‘kangaroo care’ where baby is placed in a frontal/prone positiondirectly against the mother’s skin

• Baby’s arms and legs should be flexed, in a frog-like position and the head turned upright to maintainan open airway

• Babies are obligatory nose breathers and should be positioned to minimise obstruction to the nasal airways

• If partners are well prepared about skin-to skin contact before the birth they can step in when mothersare unable to hold the baby immediately, for example after a particularly long or traumatic labour, or aftera Caesarean section

• Some guidelines recommend extended periods of skin-to-skin contact with pre-term or low birthweight babies

Goldstein Ferber S & Makhoul IR. Paediatrics, 2004.

The study investigated the effects of an hour of `kangaroo care’between mothers and their newborn babies 15–20 minutesafter birth, compared with keeping the newborn in the nursery.Between four and five hours’ postnatal age, babies who hadundergone `kangaroo care’ slept longer, were in a quietersleep state, exhibited more flexor movements and postures andshowed less extensor movements.

Johanson RB et al. Acta Paediactrica, 1992.

Temperature was maintained in 300 deliveries by one ofthree methods – `kangaroo care’, oil massage or a plasticswaddler. All three were effective at maintaining neonatalbody temperatures.

Erlandsson K et al. Birth, 2007.

The effect of skin-to-skin contact between newborn babiesand their fathers was investigated following Caesarean section.Compared with newborn babies kept in a cot near their fathers,infants with skin-to-skin contact cried significantly less, withpositive impacts on wakefulness and rooting behaviour.

Moore ER et al. Cochrane Database of systematic reviews, 2007.

A systematic review of 30 studies into the benefits of earlyskin-to-skin contact for mothers and their newborn babies.The plain-language summary stated that skin-to-skin contactbetween mother and baby at birth reduces crying, improvesmother-baby interaction, keeps the baby warmer and helpswomen breastfeed successfully.

Tips for extended skin-to-skin contact (recommended for pre-term or low birthweight babies):

• Make sure mother has no negative effects from birth (like pain, fatigue, nausea, vomiting and pyrexia) that mayprevent optimal skin-to-skin contact (and place extra burden on the mother)

• Monitor and record baby’s temperature prior to feeding by comparing baby’s abdomen with arm or leg

• Baby should wear a nappy and hat, cocooned inside the mother’s clothing firmly and comfortably in a safe position

• The mother should not be lying flat when providing skin-to-skin contact (she should be upright and/orwalking around). This is in line with policy and reduces the incidence of sudden infant death

• Baby should be returned back to its cot in a supine position, hat removed and dressed in multiple layerswhenever the mother wishes to sleep

• For extended skin-to-skin contact, make sure mothers are aware of the behavioural language of the baby,so that they can adapt their handling to minimise stress to the baby

Healthier, happier babies

Baby

massage

“These findings support previous studies showing

that massage therapy promotes weight gain and

alters the distribution of sleep/awake states in

preterm neonates.” Dieter, 2003

There is plenty of anecdotal evidence to show regular baby massage helps babies recover from birth, develop goodsleep patterns, obtain relief from colic and even, in the case of pre-term babies, gain weight. Many mothers alsobelieve that massaging their baby helps them to form a relationship more quickly and see it as part of theirbaby’s daily routine. Fathers can participate in baby massage too and many say it helps them feel more involved,particularly during the early months if the mother is breastfeeding.

Many midwives acknowledge the benefits of baby massage and touch in the bonding process as well as helpingto establish a good bedtime routine and sleep pattern. With fathers increasingly enjoying a more hands-onapproach to parenting, baby massage can help paternal bonding too.

Tips on baby massage:

• Babies should be massaged in a warm, draught-free room

• Oil or lotion, suitable for baby massage, should be warmed in the parent’s hands first

• Encourage parents to make plenty of eye contact and talk to their baby during a massage

• Remind parents to avoid the stomach area straight after feeding

• Sticking to a set massage routine is reassuring for babies because they know what to expect

• Other carers (like grandparents) can be involved in baby massage, bringing their own massage techniques

Dieter JNI et al. Journal of Paediatric Psychology, 2003.

Pre-term hospitalised babies received thrice-daily, 15-minutemassages for five days. Compared to the control group(that received no massage) massaged babies gained 53% moreweight every day.

Field T. Current Directions in Psychological Science, 2001.

A review paper discussing how massage increases weight gainin pre-term infants. Includes prior data showing significantweight gain in massaged pre-term infants, versus unmassagedbabies. The evidence for potential underlying mechanisms(including protein synthesis, increased motor or vagal activityor involvement of oxytocin and IGF-1) are reviewed.

Field T et al. Journal of Developmental and BehaviouralPaediatrics, 2008.

The effects of thrice-daily 15-minute massages on pre-terminfant weight gain were investigated. Despite similar calorieintake, massaged babies had significantly higher weight gain,insulin and IGF-1 levels than non-massaged babies.

Lahat S et al. Journal of the American College of Nutrition, 2007.

A crossover study examining five days of massage followedby five days of no massage (or vice-versa). Massage comprisedthree 15-minute sessions per day. During the period of massage,energy expenditure was significantly lower than when massagetherapy did not occur.

Mendes EW. Procianoy RS. Journal of Perinatology, 2008.

Mothers massaged their very pre-term (≤32 weeks, ≥750 g and≤1500 g) babies for 15 minutes, four times a day. Compared withunmassaged babies, massaged babies had significantly lowerincidences of late-onset sepsis and were discharged from hospitala median of seven days sooner than non-massaged babies.Caloric intake did not differ between the two groups.

Guzetta A et al. The Journal of Neuroscience, 2009.

Pre-term neonates received 15 minutes of massage three timesa day from postnatal day ten for ten days (with two non-massagedays). Massage accelerated maturation of EEG activity, particularlyvisual acuity. It also increased circulating IGF-1 levels.

The final word on the magic of touch

The studies included here are all from published, peer-reviewed journals. Their overwhelming conclusion is thatmassage and touch can bring many benefits to pre- and postnatal women, their partners and babies, including:

• reduced stress and anxiety at all stages (Field, 1999 & 2007)

• relief from pain during pregnancy and labour (Chang, 2002; Field, 1997; Khodakarami, 2006; Yildrim, 2004)

• reduction in prematurity and low birth weight (Field, 2009)

• reduction in loss of temperature in newborn babies (RCM guidelines, 2008)

• increased breastfeeding success (RCM guidelines, 2008)

• faster weight gain in preterm babies (Field, 2001 & 2008; Dieter, 2003)

• accelerated brain and visual development in newborn babies (Guzetta, 2009)

• reduced sepsis and hospital stay in very preterm newborn babies (Mendes, 2008)

Acknowledgements:

The Royal College of Midwives.Stephanie Michaelides for advice on skin-to-skin contact.Linda Kimber, Mary McNabb and Anne Haines from Childbirth Essentials (www.childbirthessentials.co.uk)

An

yqu

estions?

Frequently asked questions

Which oils should be used for baby massage?

Many oils used for baby massage, such as olive oil and other vegetable oils, have a very high oleic acid content(up to 85%). Oleic acid has been shown to disrupt the structure of skin cells which weakens the skin barrier,and may actually damage the skin. For that reason, it is better to choose oils with a very low oleic acid content,such as jojoba oil (10–13%), coconut oil (5%) or mineral oil (0%).1 In babies and adults, mineral oil penetratesand is absorbed as effectively as vegetable oils (like sweet almond and jojoba oil).2

Are there any handouts about touch and massage that I can give to expectant mothers?

There is a tear-off hand-out pad to accompany this booklet that has been designed for you to use with mothers.

Where can mothers go for more information on baby massage?

There are often local massage groups in your area, some which you may already be aware of. For general advice,tips and techniques on baby massage visit www.johnsonsbaby.co.uk

Where can healthcare professionals find out more about JOHNSON’S® Baby products?

Email JOHNSON’S® Baby at jbhcpcontact@its.jnj.com, or call 0845 606 6091. A qualified midwife, who is alsoan expert on the JOHNSON’S® Baby range of products, is on hand to help with your query.

1. Johnson & Johnson, data on file.2. Stamatas G et al. Lipid intake and skin occlusion following topical application of oils on adult and infant skin. J Derm Sci 2008; 50: 135–42.

Where can I find more information on the studies cited in this booklet?

Chang M-Y et al. Effects of massage on pain and anxiety during labour: a randomised controlled trial in Taiwan. J Adv Nursing 2002; 38: 68–73.

Dieter J et al. Stable preterm infants gain more weight and sleep less after five days of massage therapy. J Ped Psychol; 28: 403–11.

Erlandsson K et al. Skin-to-skin care with the father after Caesarean birth and its effect on newborn crying and prefeeding behaviour.Birth 2007; 34: 105–14.

Field T et al. Labour pain is reduced by massage therapy. J Psychosom Obstet Gynecol 1997; 18: 286–91.

Field T et al. Pregnant women benefit from massage therapy. J Psychosom Obstet Gynecol 1999; 20: 31–8.

Field T et al. Massage therapy facilitates weight gain in preterm infants. Curr Dir Psycholog Sci 2001; 10: 51–4.

Field T et al. Massage therapy reduces pain in pregnant women, alleviates prenatal depression in both parents and improves their relationships.J Bodywork Movement 2008; 12: 146–50.

Field T et al. Insulin and insulin-like growth factor 1 (IGF-1) increased in preterm neonates. J Dev Behav Pediatr 2008; 29: 463–6.

Field T et al. Pregnancy massage reduces prematurity, low birth weight and postpartum depression. Infant Behav Devel 2009; 32: 454–60.

Goldstein Ferber S et al. The effect of skin-to-skin contact (kangaroo care) shortly after birth on the neurobehavioral responses ofthe term newborn: a randomised, controlled trial. Paeditrics 2004; 113: 858–65.

Guzzetta A et al. Massage accelerates brain development and the maturation of visual function. J Neurosci 2009; 29: 6042–51.

Khodakarami N et al. The effects of massage therapy on labour pain and pregnancy outcome. J Pain 2006; 10 (Suppl 1): E05–822.

Kimber L et al. Massage or music for pain relief in labour: A pilot randomised placebo controlled trial Eur J Pain 2008; 12: 961–9.

Lahat, Sharon et al. Energy expenditure in growing preterm infants receiving massage therapy. J Am Coll Nutri; 26: 356–9.

Latifses V et al. Fathers massaging and relaxing their pregnant wives lowered anxiety and facilitated marital adjustment.J Bodywork Movement Ther; 9: 277–82.

Mendes EW et al. Massage therapy reduces hospital stay and occurrence of late-onset sepsis in very preterm neonates. J Perinatol; 28: 815–20.

Moore ER et al. Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database Syst Rev 2007 Jul 18: CD003519.

Royal College of Midwives Midwifery Practice Guidelines, evidence-based guidelines for midwifery-led care in labour, 4th edition, May 2008.

Yildirim G et al. The effect of breathing and skin stimulation techniques on labour pain perception of Turkish women. Pain Res Manage; 9: 183–7.

evidence behindRevealing the

the magic of

Date of preparation: June 2010