Developmental Care - Considerations for Touch and Massage in the Neonatal Intensive Care Unit

Back to: New News

Developmental Care - Considerations for Touch and Massage in the Neonatal Intensive Care Unit

by Joy V. Browne, PhD, RN

First published in Neonatal Network, Vol. 19, No. 1, February 2000 and reproduced with permission.

Introduction

An expanding body of research has documented the short-term advantages of gentle touch and massage for healthy term infants and some growing and medically stable preterm infants. These findings have provided the impetus for extension of massage techniques to very small, fragile newborns, and have prompted the utilization of new personnel in NICUs specifically to provide massage therapy for newborns. It is important, before engaging in these approaches, for the professional in the NICU to consider the potential impact of massage on the infant and the family. It is also imperative that professionals in the NICU take into account the current growing knowledge base regarding developmental care and the implications for decision making with any provision of stimuli to fragile sick newborns in the NICU.

The Importance of Touch

Massage involves touch and handling, and can elicit cutaneous, proprioceptive, vestibular and/or sensory perceptions. These sensations are among the earliest to develop during gestation, and ultimately provide stimulation, organization, communication, and emotional exchange (1,2). Touch provides the foundation for complex and intimate interchange between the infant and caregiver, providing the infant with a beginning interpretation of the world and the relationships on which he or she will come to rely for survival (2,3). For term infants, touch is essential in establishing a nurturing, protective attachment relationship between the primary caregiver and the infant, which in turn establishes the foundation for learning, emotion regulation and social interactions (3,4).

The development of parent-infant relationships in the NICU is complex and include a progression of touch, stroking and holding of the infant (5,6). For term, stable infants, opportunities for touch, handling and holding by parents are essential. Most of these infants do well with handling episodes, and indeed these touching interactions are essential as they are integrated into an organized sensory interpretation of the world. However, the fragile, preterm and high-risk infant may not be able to withstand much touch and handling without physiological, motor and state compromise. Parents who deliver a premature or high risk infant tend to spontaneously touch the infant less frequently when the infant is under 28 weeks post conceptional age, and when the infant is not taken to the mother's room prior to transport (6,7). Studies have demonstrated that mothers of preterm infants stroked or held the infant's hand, backs and heads more than patting of preterm infants (7), but fathers stroked and patted equally. Sometimes infants who experience their parent's touch desaturate (8), a common occurrence which may prompt nurses to limit the tactile interactions between parents and infants.

Kangaroo, or skin-to-skin care, is an emerging practice in the NICU which does encourage touch and holding of the infant. It has been shown for the most part to have beneficial physiologic, state and attachment outcomes (9-15). However, in very small, fragile infants, handling during the movement from the bed to the mother's body may result in physiologic disorganization (16).

The negative behavioral responses to touch and handling of fragile, preterm infants can include reflexive responses such as the startle reflex, increased movement, agitation and/or crying, or other observable avoidance responses, and are well documented (17-21). Physiologic reactivity to touch and handling can include blood pressure changes, oxygen desaturations, heart rate changes, respiratory rhythm and rate changes, and neuroendocrine responses (21-27). These changes are particularly pronounced in the smaller and sicker infants. When the infant is already physiologically compromised because of medical or developmental fragility, underlying vulnerability to bradycardia and apnea to any kind of touch is pronounced (19). As massage techniques typically involve not only tactile, but kinesthetic stimulation, careful consideration of the consequences should be weighed.

Issues of touch stimulation in the NICU

In medically stable, growing preterm infants, massage is reported to have a variety of short-term benefits, including greater weight gain and shorter hospitalization (28-35). However, studies like these are difficult to interpret as a whole because of the variety of tactile and kinesthetic techniques that were implemented across studies, the variety of ages and weights of the infants included in the studies, the lack of physiologic measures to safeguard the welfare of the premature infants, and the lack of control for the infant's state (36). Several researchers document the sensitivity of preterm infants to stroking or massage (20, 37-41, 51) and urge caution in any program that implements massage in premature or ill infant. The rapidly growing and developing central nervous system of the immature infant is vulnerable to environmental effects, more so than we have ever known in the past (42). Therefore it is imperative that environmental stimuli such as touch and movement be carefully provided with constant monitoring of the infant's individual responses, and modified appropriately.

In response to the recognition that small, fragile preterm infants are reported to significantly react to tactile stimulation, several researchers have implemented a "gentle human touch" model of providing tactile interaction with infants (43-47). Harrison's technique includes providing containment with the experimenter's hands of the head and lower back and buttocks or abdomen, taking care to only provide supportive containment, and not intermittant stimulation (47). Their results indicate few detrimental effects, and show that the infants in the short term have less behavioral distress, more quiet sleep and less motor activity during the procedure as compared with baseline. This technique is still being investigated, and infants receiving this approach have not yet been followed long-term.

Massage therapy is proposed as a non-medical treatment intervention for infants in NICUs. Vulnerable infants often respond to touch and handling with significant physiologic and behavioral disorganization. There is reason to believe that small, fragile infants could be at significant risk for tachypnea, tachycardia, apnea, bradycardia, desaturations, agitation, flaccidity and/or hyperextension, and other potentially compromising effects when subjected to massage. Massage is a complex and intimate interaction, which in all the reviewed studies has been done to infants by strangers rather than with their parents.

As a non-invasive, non-medical technique, massage may be construed as providing developmentally appropriate, family centered care in the NICU. It behooves those practitioners of developmental and family centered care to determine if, when, why, and by whom massage might be provided to fragile newborns. If the practitioner comes from a perspective that infants are initiators of and participants in their own caregiving; that parents are primary and consistent co-regulators of their infants in efforts to build nurturing relationships; and that there are individual differences in infants' receptivity, tolerance and energy levels so that they deserve individualized approaches, then proscribed massage delivered by strangers is not an intervention that should be utilized.

With our current knowledge base, the following recommendations for thoughtful decision making regarding touch and massage in the NICU are offered.

	Modify all handling/touch to be supportive, sensitive, calm and in synchrony with the infant's sleep-wake states as well as behavioral cues Infants can indicate through their arousal and state availability when touch interaction may be optimal. Awakening an infant from sleep for routine handling or caregiving may not be supportive of emerging organized sleep-wake cycles, a critical component of infant development. Provision of touch, handling and/or massage should be titrated to the infant's responses, and diminished, modified, or withdrawn when they are exhibited. This requires that the full attention of the practitioner be available to the interaction, and that there are minimal interruptions in the caregiving to attend to other tasks or conversations.
	Monitor autonomic and behavioral responses during all handling/touch procedures and modify interactions appropriately Behavioral avoidance cues, such as physiologic disorganization, motor hypertonia or hypotonia, and flailing, squirming or jerky movements can signify an inability to deal with the touch and handling that is being provided. A familiarity with infant communication responses such as those offered by Als, (48) should assist the practitioner in being able to determine if the infant is unable to deal with the touch intervention. The caregiving interaction requires close, second-by-second monitoring and responsiveness to the infant's communication of needs and strengths.
	Individualize touch and handling based on the infant's responses, timing and continuity needs, as well as parent preference Infants respond to tactile stimulation in different ways, and to different caregivers' ways of communicating through touch and handling. Consistency of caregivers is not only necessary, but essential for the infant's developmental agenda. The infant should be able to become familiar and rely on a small number of caregivers' styles and ways of providing touch interaction. As the parents are the most consistent people in their infant's lives, and the primary nurturers and cherishers of their infant, they should have a significant role in providing the continuity of touch interactions.
	Avoid massage in all small fragile infants Infants who are medically unstable, on ventilators and who may have significant post operative or post procedural discomfort should be provided as gentle handling as possible. As massage can produce both physiologic and behavioral disorganization, potentially adding to their distress, it should be avoided. Smaller and less mature infants (less than 32 weeks weeks post conceptional age) may not benefit from massage, and could potentially be at risk from this type of interaction. Others who are older, but who show similar disorganization should not be provided with massage intervention. Those infants with chronic illness such as bronchopulmonary dysplasia and cardiac involvement have been shown to have physiologic and behavioral disorganization as well, and massage should be carefully weighed against the potential risks (39, 40, 41).
	Assist parents in identifying the type of touch and handling that is most appropriate for the infant Parents themselves, as the consistent observers and holders of their infant, may be able to identify the unique responses of their infant. These observations should be incorporated into the infant's twenty-four hour plan of care.
	Engage parents as the primary providers of touch interaction Of all of the potential caregivers who could provide touch intervention, the parents are the most appropriate. Even when the infant is fragile, there are methods of providing touch that can be promoted for parents. Supportive holding, with a hand to the infant's head and feet or body may be an intervention that is not distressing to the infant (49, 50). Not only does this approach assist the infant in stabilization, but also serves as a significant factor in the development of the parent-infant relationship.
	Provide massage and other stress reduction resources for parents Parents, whose infant is born sick or preterm, experience some of the most stressful events of their lives. They continue to experience stressful events throughout their infant's hospitalization. Assisting them with stress reduction resources, may help them cope with the experience of having a sick, hospitalized infant.
	Provide massage and other stress reduction resources for staff Professionals who work in NICUs have more responsibility and fewer resources than ever before. The NICU, with its high acuity, responsibility and emotional expenditures can take its toll on all those who work there. Provision of resources to assist them in coping with such a high-pressure environment could assist them, in turn, to be more responsive to the infants and families with whom they work.

REFERENCES

1 Barnard, K.E. & Brazelton, T.B. (Eds.). (1990). Touch: The Foundation of Experience. Madison: International Universities Press Inc.

2 Montagu, A. (1986) Touching. Second Edition, New York: Columbia University Press

3 Rose, S.A. (1990). Perception and cognition in preterm infants: The sense of touch In K. Barnard and T.B. Brazelton, (Eds.), Touch, the Foundation of Experience. Madison, CT: International Universities Press.

4 Reite, M. (1990). Touch, attachment and health: Is there a relationship? In K.Barnard and T.B. Brazelton (eds). Touch, the Foundation of Experience. Madison: International Universities Press.

5 Rubin, R. (1963). Maternal touch. Nursing Outlook 1, 828-831.

6 Klaus, M.H., and Kennell, J.H. (1982). Parent-Infant Bonding. Second Edition, St. Louis: C.V. Mosby Co.

7 Harrison, L.L. and Woods, S. (1991). Early parental touch and preterm infants. JOGNN, 2O(4), 299-306.

8 Harrison, L.L., Leeper, J.D., and Yoon, M. (1990). Effects of early parent touch on preterm infants' heart rates and arterial oxygen saturation levels. Journal of Advanced Nursing, 15, 877-885.

9 Afffonso, D, Bosque, E, Wahlberg, V and Brady, JP (l993). Reconciliation and healing for mothers through skin-to-skin contact provided in an American tertiary level intensive care nursery. Neonatal Network 12 (3), 25-32.

10 Bosque, EM (l995). Physiologic measures of kangaroo versus incuator care in a tertiary-level nursery. Journal of Obstetrical, Gynecological and Neonatal Nursing 24 (3), 219-26.

11 DeLeeuw, R, Colin, EM, Dunnebier, EA, and Mirmiran, M (l991). Physiological effects of kangaroo care in very small preterm infants. Biology of the Neonate, 59, l49-155.

12 Ludington, SM (l990). Energy conservation during skin-to-skin contact between premature infants and their mothers. Heart and Lung 19, 445-51.

13 Ludington-Hoe, SM, Hadeed, AJ, Anderson, GC (l991). Physiologic responses to skin-to-skin contact in hospitalized premature infants. Journal of Perinatology 11 (1), 19-24.

14 Ludington-Hoe, SM, Thompson, C., Swinth, J, Hadeed, AJ and Anderson, GC (l994). Kangaroo Care: Research results, and practice implications and guidelines. Neonatal Network 13 (1), 19-27.

15 Ludington-Hoe, SM and Swinth, JY (l996). Developmental aspects of kangaroo care. Journal of Obstetrical, Gynecological and Neonatal Nursing 25 (8), 691-703.

16 Neu, M and Browne, J. The impact of two transfer techniques on the physiologic and behavioral responses of preterm infants. Nursing Research (In press).

17 Barnard, K.E. (1973). The effect of stimulation on the sleep behavior of the premature infant. Communication Nursing Research, 6, 12-40.

18 Gorski, P.A. (1983). Premature infant behavioral and physiological responses to caregiving interventions in the intensive care nursery. In Call, J.D., Galenson, E., and Tyson, L. (Eds.), Frontiers of Infant Psychiatry. NY: Basic Books, Inc.

19 Gorski, P., Leonard, C.H., Sweet, D.M., Martin, J.A., and Sehring, S.A. (1990). Caregiver-infant interaction and the immature nervous system: A touchy subject. In K. Barnard and T.B. Brazelton (Eds.) Touch, the Foundations of Experience. Madison, CT: International Universities Press.

20 Oehler, J.M., Eckerman, C.O., & Wilson, W.H. (1988). Social stimulation and the regulation of premature infants' state prior to term age. Infant Behavior and Development, 11, 333-351.

21 Peters, K.L. (1992). Does routine nursing care complicate the physiologic status of the premature neonate with respiratory distress syndrome? Journal of Perinatal and Neonatal Nursing, 6 (2), 67-84.

22 Long, J.G., Philip, A.G.S., and Lucey, J.F. (1980). Excessive handling as a cause of hypoxemia. Pediatrics, 65(2), 203-207.

23 Harrison, L. (1997). Research utilization: Handling preterm infants in the NICU. Neonatal Network, 16(3), 65-69.

24 Evans, J.C. (1991). Incidence of hypoxemia associated with caregiving in premature infants. Neonatal Network, 10(2), 17-23.

25 Medvin, M.B. (1994). The influence of social stimulation on arterial oxygen saturation levels in very low birthweight neonates. Infant Behavior and Development, 17.

26 Norris, S., Campbell, L.A., and Brenkert, S. (1982). Nursing procedures and alterations in transcuteneous oxygen tension in premature infants. Nursing Research 31, 330-336.

27 Danford, D.A., Miske, S., Headley, J., and Nelson, R.M.(1983). Effects of routine care procedures on transcutaneous oxygen in neonates: A quantitative approach. Archives of Disease in Childhood 58, 20-23.

28 Field, T., and Schanberg, S.M.(1990). Massage alters growth and catecholamine production in preterm neonates. In N. Gunzenhauser (ed). Advances in Touch: New Implications in Human Development. New Jersey: Johnson and Johnson, 96- 104.

29 Scafidi, F.A., et al. (1986). Effects of tactile/kinesthetic stimulation on the clinical course and sleep/wake behavior of preterm neonates. Infant Behavior and Development,9, 91-105.

30 Scafidi, F,A,, et al. (1990). Massage stimulates growth in preterm infants: a replication. Infant Behavior and Development, 13, 167-188.

31 Rausch, P.B. (1981). Effects of tactile and kinesthetic stimulation on premature infants. Journal of Obstetrical, Gynecological and Neonatal Nursing. 34-37.

32 Rice, R.D. (1977). Neurophysiological development in premature infants following stimulation. Developmental Psychology, 13(l), 69-76.

33 Adamsson-Macebo, E.N. (1985-86). Effects of tactile stimulation on low and very low birth weight infants during the first week of life. Current Physiological Research and Review 4 (4), 305-308.

34 Solkoff, N., & Matuszak, D. (1975). Tactile stimulation and behavioral development among low birthweight infants. Child Psychiatry and Human Development. 6, 1-11.

35 White, J.L. and Labarba, R.C. (1976). The effects of tactile and kinesthetic stimulation on neonatal development in the premature infant. Developmental Psychobiology, 9(6), 569-577.

36 Ottenbacher, K.J., et al. (1987). The effectiveness of tactile stimulation as a form of early intervention: A quantitative evaluation. Developmental and Behavioral Pediatrics, 8(2), 68- 76.

37 White-Traut, R.C., & Goldman, M.C. (1988). Premature infant massage: Is it safe? Pediatric Nursing, 14(4), 285-289.

38 Eckerman, C.O., Oehler, J.M., Medvin, M.B., & Hannan, T.E. (1994). Premature newborns as social partners before term age. Infant Behavior and Development, 17, 55-70.

39 Medoff-Cooper, B. (1988). The effects of handling on preterm infants with bronchopulmonary dysplasia. IMAGE: Journal of Nursing Scholarship, 2O(3), 132-134.

40 Weiss, S.J. (1992). Psychophysiologic and behavioral effects of tactile stimulation on infants with congenital heart disease. Research in Nursing, 15(2), 93-101.

41 Weiss, S.J. (1993). Predictors of neurobehavioral response during tactile stimulation of infants with congenital heart disease. Infant Behavior and Development, 16, 261-264.

42 Als, H. (1997). Neurobehavioral development of the preterm infant. In A.A.Fanaroff, and R.J. Martin (eds). Neonatal-Perinatal Medicine. St. Louis: C.V. Mosby. 964-989.

43 White-Traut, R.C., Nelson, M.N., & Silvestri, J.M. , et al. (1997). Responses of preterm infants to unimodal and multimodal sensory intervention. Pediatric Nursing, 23(2), 169-176.

44 Jay, S.S. (1982). The effects of gentle human touch on mechanically ventilated very-short-gestation infants. Maternal Child Nursing Journal 11 199-256.

45 Modricin-McCarthy (1993). The physiological and behavioral effects of gentle human touch nursing intervention on preterm infants. Doctoral Dissertation. University of Tennessee. Dissertation Abstracts International 54B (3), 1336.

46 Tribotti, S. J. (1990). Effects of gentle human touch on the premature infant. In Ganzenhauser, N., (Ed.), Advances in Touch: New Implications in Human Development. N.J.: Johnson and Johnson, pp. 80-89.

47 Harrison, L., Olivet, L., Cunningham, K., Bodin, M.B., & Hicks, C. (1996). Effects of gentle human touch on preterm infants: Pilot study results. Neonatal Network, 15(2), 35-42.

48 Als, H. (1995). Newborn Individualized Developmental Care and Assessment Program (NIDCAP): Training Guide. (Rev. ed.). Boston: Childen's Medical Center Corporation.

49 Harrison, L., et al. (1992). Effects of gentle human touch on preterm infants: Results from a pilot study. Infant Behavior and Development, 15, 12.

50 Corff, K.E. (1993). An effective comfort measure for minor pain and stress in preterm infants: Facilitated tucking., Neonatal Network, 12(8), 74.

51 Oehler. J.M. (1985). Examining the issue of tactile stimulation for preterm infants. Neonatal Network, 4, 25-33.

Copyright 2000 Joy V. Browne/Neonatal Network

Home