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Part 2 - The Use of Comforting Touch and Massage to Reduce Stress in Preterm Infants in the Neonatal Intensive Care Unit

By Lynda Law Harrison, RN, PhD, FAAN

Longer Term Effects

Four studies were reviewed that examined longer term effects of supplemental stroking/massage interventions. The sample sizes in these studies ranged from 10 to 62 infants. The reported GAs and birth weights of the infants suggest that the infants were physiologically stable at the time of the intervention, although it is recognized that physiological stability cannot be assumed based on GA and birth weight alone. Solkoff and colleagues 36 provided 5 minutes of stroking each hour during the first 10 days of life to 10 preterm infants. Compared with group C infants, those who received the supplemental stroking regained their birth weights faster, were more active during the hospitalization period, and had fewer developmental abnormalities 7 to 8 months after discharge. In a later study, infants received 7.5 minutes of stroking per hour, 16 hours per day, for 10 days.37 Group E infants showed more rapid habituation to light and sound, improved body tone, increased alertness, and more consolability than did group C infants. Kramer and colleagues 38 provided 48 minutes of extra touch daily to 8 preterm infants, and found that those in the extra touch group had enhanced motor development, as measured by the Bayley Motor Developmental Index, compared with group C infants. Adamson Macedon 35 provided supplemental stroking for 10 minutes twice a day during the first week of life to 31 preterm infants (with a mean GA of 32 weeks), and reported that group E infants lost significantly less weight than did group C infants. These findings may suggest that supplemental stroking/massage interventions that are provided to physiologically stable preterm infants have long term benefits, including improved weight gain and social development.

Studies of Stroking/Massage Combined With Kinesthetic or Vestibular Stimulation

Studies that examine the combined effects of stroking with kinesthetic (passive movement or range of motion) or vestibular (rocking) stimulation have generally included infants who were physiologically stable at the time of the intervention. Results from these studies have suggested that such combined intervention programs have positive long term outcomes, including increased daily weight gain, increased secretion of urinary epinephrine or norepinephrine, increased levels of alertness, and more optimal scores on the Brazelton Neonatal Behavioral Assessment 43 examination. 44–56

Several of these researchers have examined infants’ immediate responses to the tactile and kinesthetic or vestibular components of the intervention programs. Morrow and colleagues 46 examined responses over 4 days to 15 minute interventions that consisted of 5 minutes of massage followed by 5 minutes of kinesthetic stimulation (passive range of motion of limbs) and then a further 5 minutes of massage. During the first day, there were decreased TcPO2 levels during the first tactile period and during the kinesthetic period. By the fourth day, there were no changes during both the tactile and kinesthetic phases of the intervention. This finding is consistent with the finding by Tribotti 32 reported earlier that suggests that infants are able to habituate over time to tactile stimuli. White Traut et al 54 compared preterm infants’ responses to 4 types of stimulation : tactile only (T); auditory only (A); auditory, tactile, and visual (ATV); and auditory, tactile, visual, and vestibular (ATVV). Infants in the T group had a higher percentage of heart rates greater than 180 beats per minute (bpm) (7.1%), compared with infants in the ATVV group (4.5%). The authors concluded that the findings suggested that the vestibular stimulation provided at the end of the massage had a modulating effect, and that tactile stimulation without such rocking might lead to unacceptably high levels of arousal in some infants. There is a need for further research to examine this possibility.

Studies of Skin-to-Skin Holding (Kangaroo Care)

The historical development of the practice of Kangaroo Care (KC) in NICUs was summarized by Gayle, Franck, and Lund,57 who noted that this method of holding preterm infants was initially described in 1983 in Bogota, Columbia. The practice was introduced to prevent infections associated with sharing of incubators, and it involved placing stable preterm infants (less than 1500 g birth weight) in ski to ski contact with their mothers for prolonged periods, beginning shortly after birth. During the 1980s and 1990s, hospitals in Europe and the United States also began to incorporate this method of care, and a number of studies were conducted to evaluate its effects. Although a comprehensive review of these studies is beyond the scope of this paper, the reader is referred to several comprehensive reviews of the research related to KC that have been published in recent years.57–60

Findings from studies to date suggest that during KC infants maintain stable skin temperatures, respiratory rates, and oxygen saturation levels.61,62 Other researchers have re ported an increase in quiet sleep during KC.60,62 For example, Ludington-Hoe et al 60 randomly assigned 25 preterm infants who were in open cribs to either a KC group ( = 11) or a control group ( = 13). Infants spent twice as much time in quiet sleep during KC, compared with pretest and post test periods, and achieved quiet sleep within 5 to 10 minutes, compared with the 30 minutes usually needed to move from active to quiet sleep.

Acolet, Sleath, and Whitelaw 63 found that infants with chronic lung disease had improved oxygen saturation levels during KC, and suggested that the vertical position may result in improved pulmonary function. Gayle, Franck, and Lund 57 evaluated the responses to KC of 25 preterm infants who had respiratory distress syndrome and who were intubated. They also evaluated responses to KC of the infants’ parents and nurses. The nurses followed a special protocol, which was individualized based on the recommendations of a developmental care nurse specialist, and usually increased the infant’s fractional inspired oxygen (FiO2) level by 10% before the transfer to KC. During each transfer, one nurse managed the infant and the intravenous (IV) lines, and the other managed the infant’s endotracheal tube and other monitoring devices. In some cases the parent lifted the infant while standing by the incubator and was guided to a chair, and in other cases the nurses carried the infant to the seated parent. The researchers reported that the transfer was the most stressful part of the KC procedure, and that infants tolerated the standing procedure better than the procedure in which nurses carried the infant to the seated parent. Only 1 infant continued to require increased FiO2 levels during the KC procedure. For most other infants, the nurses were able to reduce the FiO2 level to at or below the level needed before KC once the infants were settled on the parent’s chest. Infants less than 1.2 kg tended to become “wriggly” after 15 to 20 minutes of KC, in contrast to the larger infants (older than 30 weeks PCA) who often slept for 10 to 15 minutes and then aroused as though they were attempting to visualize the parent’s face and interact reciprocally. Parents indicated that KC helped them to have a stronger identity with and knowledge about their infants, and that KC helped enhance their confidence in their ability to meet their infants’ needs. No parents expressed negative reactions during or after the KC experience, although the total amount of time spent in KC varied considerably among the parents. A total of 25% of mothers and 29% of fathers chose to use KC only 1 time with their infants. Many of these parents noted that they preferred to see the infant’s face during interaction times; this was not possible during KC. Nurses’ responses to KC varied, but the researchers reported that most nurses’ attitudes towards KC were positive after they participated in a KC session, and that many were encouraged by the empowerment of mothers that was promoted by KC.

Gayle and VandenBerg 59 reported that KC also promotes a sensory dialog between parents and infants and facilitates regulation of the infant’s autonomic, motor, and state systems; they noted observations of more regular respiratory and heart rates and more organized sleep states during KC. Although these authors acknowledged that there is still controversy about whether KC should be practiced with extremely small infants or with intubated infants, they suggested that the decision about whether to initiate KC should be based on an individual assessment of each infant and parent. Gayle and Van den Berg also proposed a protocol, based on results of research and clinical practice, that nurses might use when they implement KC in a NICU.

Summary and Implications for Practice

A recent report by Vickers, Ohlsson, and Horsley 64 included a meta analysis of randomized trials of human tactile stimulation provided to preterm infants. Only 13 studies met the criteria for inclusion in the review, which included studies of still, gentle touch; massage/stroking; and massage combined with kinesthetic or vestibular stimulation. Although positive effects were identified in many of the studies, Vickers addressed methodological concerns, including failure to blind the observers who assessed the outcomes, and failure to ensure that infants in groups E and C were treated similarly in all aspects other than the experimental intervention. Further research is needed to identify the most appropriate types and amounts of touch to provide to preterm infants of varying GAs and levels of morbidity.

The findings from the studies reported here suggest that preterm infants receive very little comforting, nonprocedural touch in the NICU. Gentle, still touch has immediate positive effects including reduced levels of motor activity and behavioral distress, which suggests that this type of touch might reduce energy expenditure and promote comfort. Gentle touch has no clinically significant effects on levels of heart rate or oxygen saturation, which suggests that this type of touch is safe for physiologically fragile infants. Findings from studies of supplemental stroking/massage, either alone or combined with kinesthetic or vestibular stimulation, suggest that this type of touch may have positive immediate and longer term effects on infants who are physiologically stable, including reduced apnea, improved TcPO2 levels, improved weight gain, and enhanced developmental outcomes. However, some infants may react to such stimulation with decreased TcPO2 levels, increased heart rate, or signs of behavioral distress. KC may have positive effects such as maintenance of stable temperatures, oxygen saturation , and heart rate levels, promotion of quiet sleep, and promotion of increased coregulation between infants and parents. However, transferring intubated infants from the incubator to the parent may be stressful, and infants less than 1.2 kg may not tolerate KC for prolonged periods.

Peters 65 recommended the use of “care milestones” to determine when individual infants are able to tolerate different types of stimulation. Nurses and parents can assess infants’ physiological and behavioral responses to determine the most appropriate types and amounts of touch to provide to promote comfort and reduce stress. Physiological cues that might indicate distress and a need to modify stimulation include decreased oxygen saturation or heart rate levels and increased heart rate or blood pressure levels. Behavioral cues that might indicate distress include increased agitation, facial grimace, finger splay, grunting, gaze aversion, and extension of arms and legs. Behaviors that suggest a positive response to stimulation include maintenance of a quiet alert state, relaxed body tone, eye to eye contact, and flexed posture. However, it must be recognized that infants’ behavioral responses may be influenced by many factors, including GA, morbidity status, behavioral state, and prior exposure to handling or painful procedures.66 The findings from research to date suggest that when infants are physiologically fragile, they may respond best to still, gentle touch. As these infants mature and become more stable, caregivers can begin to provide gentle stroking and massage, as well as KC, observing the infants’ responses and modifying their tactile stimulation accordingly.

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Article published in the Newborn and Infant Nursing Reviews, Vol 1, No4 (December), 2001: pp235-241. Reprinted on Comeunity with permission of the author and publisher.

Lynda Law Harrison is the Professor and Co-Deputy Director, World Health Organization Collaborating Center on International Nursing at the University of Alabama School of Nursing, in the University of Alabama at Birmingham.

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