Journal of Perinatology (2009) 29, 352–357
r 2009 Nature Publishing Group All rights reserved. 0743-8346/09 $32
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ORIGINAL ARTICLE
Massage with kinesthetic stimulation improves weight gain in
preterm infants
AN Massaro1,2, TA Hammad3, B Jazzo2 and H Aly1,2
1
Department of Neonatology, Children’s National Medical Center, Washington DC, USA; 2Newborn Services, The George Washington
University Medical Center, Washington DC, USA and 3Department Epidemiology and Biostatistics, The George Washington University
School of Public Health and Health Services, Washington DC, USA
Objective: The aim of this study was to evaluate the effects of massage
with or without kinesthetic stimulation on weight gain and length of
hospital stay in the preterm infant.
Study Design: A prospective randomized clinical trial was conducted
evaluating the effects of massage with or without kinesthetic stimulation
(KS) on weight gain and length of stay (LOS) in medically stable
premature (<1500 g and/or p32 weeks gestational age) neonates.
Infants were randomized either to receive no intervention (control),
massage therapy alone (massage), or massage therapy with KS (M/KS).
Linear regression analysis was performed to evaluate differences in the
primary outcomes between the groups after controlling for covariates. Post
hoc analysis with stratification by birthweight (BW> and <1000 g) was
also performed.
Result: A total of 60 premature infants were recruited for this study; 20
infants in each group. Average daily weight gain and LOS were similar
between the groups after controlling for covariates. For infants with
BW>1000 g, average daily weight gain was increased in the intervention
groups compared to control. This effect was mainly attributable to the
M/KS group.
Conclusion: Massage with KS is a relatively simple and inexpensive
intervention that can improve weight gain in selected preterm infants.
Length of hospital stay is not impacted by massage with or without KS.
Further studies are needed to evaluate the effect of massage in the
extremely low BW(<1000 g) infant.
Journal of Perinatology (2009) 29, 352–357; doi:10.1038/jp.2008.230;
published online 15 January 2009
Keywords: preterm infants; very low birthweight; massage; kinesthetic
stimulation; exercise
Correspondence: Dr AN Massaro, Department of Neonatology, Children’s National Medical
Center, 111 Michigan Avenue, NW, Washington DC 20010, USA.
E-mail: anguyenm@cnmc.org
Received 30 June 2008; revised 27 October 2008; accepted 8 December 2008; published online
15 January 2009
Introduction
The management and outcome of premature infants have changed
in the postsurfactant era. With more premature infants surviving
past the peripartum period, more focus has been devoted to
optimizing the growth and development of this population. In
addition to the physiologic consequences of preterm birth, the
stressful environment and lack of tactile stimulation associated
with care in the neonatal intensive care unit (NICU) may further
compromise these vulnerable neonates. In the past two decades a
number of studies have been conducted to examine the impact that
tactile and kinesthetic stimulation (KS) has on the growth and
development of premature babies.
Preliminary studies have suggested that massage therapy with
KS may have positive effects on preterm infants including greater
weight gain,1–7 improved bone mineralization,8 earlier
hospital discharge,1–3 and more optimal behavioral and motor
responses2–4,9,10 compared to controls. However, there is inconsistency
of these findings across studies and methodological concerns with
previous trials have led some authors to caution widespread and
routine use of preterm infant massage.11 Previous studies have also
varied in the type of intervention used, ranging from gentle ‘still
touch’ to programs including physical activity. It has not been
distinguished whether potential benefits are associated with massage
alone or the combination of massage and KS or exercise.
We conducted a randomized controlled clinical trial to test the
hypothesis that infant massage with or without KS (or exercise)
can improve weight gain and decrease length of hospital stay in
preterm infants.
Patients and methods
Overview
A prospective randomized controlled clinical trial evaluating the
effects of massage with or without KS on preterm infants was
performed at the George Washington University NICU between
August 2003 and March 2007. This study was approved by the
George Washington University Committee on Human Research
Institutional Review Board and registered at www.clinicaltrials.gov.

Study population
Subjects consisted of healthy preterm infants born at the George
Washington University Hospital. Inclusion criteria for study
participation were (1) birthweight (BW) <1500 g and/or
gestational agep32 weeks, (2) postnatal age>7 days and current
weight>1000 g and (3) relative medical stability (that is, ‘feeders
and growers’ that were no longer deemed at a critical stage in their
care, including patients on nasal continuous positive airways
pressure or naso/orogastric enteral feeds). Infants were excluded if
they had a major congenital anomaly (including chromosomal
abnormalities, neuromuscular disorders, congenital heart disease,
neural tube defects and gastrointestinal malformations), or were
restricted in their movement or ability to undergo the intervention
(including those infants with pathological fractures, bony
deformities, contractures). Informed consent was obtained from the
parents of each patient enrolled in the study.
Study design
Enrolled patients were randomly assigned to receive no intervention
(control), massage therapy alone (massage) or massage with
exercise (M/KS) by a computer-generated random number table
sequence. Treatment allocation was concealed in opaque,
sequentially numbered, sealed envelopes until study entry.
Informed consent was obtained from parents of eligible infants by
the investigators or on-service neonatologists. Once enrolled,
participants were assigned to their group by a research assistant.
Clinical and demographic information were recorded including
daily weight (measured by NICU nurses) and caloric and
volumetric intake. Infants were fed with fortified breast milk or
premature formula. Enteral feeding protocol consists of
advancement by 20 ml kg
1 per day after initial stabilization. A
period of trophic feeding is used in the extremely low birthweight
(ELBW<1000 g) infant with target of achieving full feeds at
approximately 14 days of life.
The massage group underwent a protocol that consisted of
application of six strokes, each lasting 10 s, to the following areas
of the baby in prone position: (1) head from crown to neck, (2)
shoulders from middle of back to arms, (3) back from neck to
waist, (4) legs from top of thighs to ankles and (5) arms from
shoulder to wrist. The M/KS group received the massage protocol as
described with the addition of KS, which consisted of transitioning
the baby to a supine position and six movements of each arm at
the elbow and leg at the knee. Infants were monitored continuously
for heart rate, respiratory rate and percutaneous oxygen saturation
throughout the intervention.
Massage and KS were performed by bedside registered nurses in
the NICU who were trained by the same licensed massage therapist
(BJ). This therapist trained all incoming staff nurses during the
study period. Training included instruction on the study design as
well as intervention techniques and procedures for each study
group. All efforts were made to assign study infants to trained staff
Massage in preterm infants
AN Massaro et al
353
nurses. In the event that a study infant was assigned to an agency
or traveling nurse, the charge nurse would perform the
intervention during that shift. The LMT continued to visit the NICU
1 to 2 times per week during day and evening shifts to
supervise the technique of massage performed by trained nurses.
Additionally, an instructional video was available and encouraged
to refresh training for nurses who had not performed the
intervention regularly. The intervention was done two times per day
for 15 min at a time from the time of study entry until discharge.
The control group infants were managed via the nursery standard
of care. Primary outcomes of average daily weight gain during the
study period and length of stay (LOS) were assessed at discharge.
Secondary outcomes of change in head circumference (HC) and
length were also noted. Besides the bedside nurses performing the
actual intervention, all other NICU personnel, including managing
physicians, were not aware of the randomization code or the group
orientation of their infants.
Sample-size calculation and statistical analysis
Our historical data showed that average daily weight gain in our
NICU was 25±5 g per day and average LOS in our NICU was
45±6 days for <1500 g preterm infants. We proposed that the
infants exposed to massage therapy±KS would gain an average of
20% more per day and have a shortened LOS by 15% when
compared to controls. To detect this difference, we calculated that it
would be adequate (power ¼ 0.8) to test both primary outcomes
with a sample size of 60 infants: 20 infants in the control group
and 20 infants in each intervention group.
Demographic and clinical information for the patients are
described as means±standard error of the mean (s.e.m.) for
continuous data and rates for categorical variables. Differences
between the control and intervention groups were evaluated by the
w2-test for categorical variables and analysis of variance (ANOVA)
for continuous variables. Posterior testing was performed by
Tukey’s test to evaluate mean differences between individual
groups. Nonparametric analysis was also performed with the
Kruskal–Wallis test (KW). Multiple regression analysis was
performed to evaluate differences between the groups after
controlling for effects of covariates. Due to the observed
overrepresentation of more immature infants randomly
assigned to the control group, post hoc analysis was performed
evaluating effects of massage on infants stratified by BW
(< or >1000 g). Data were analyzed using SPSS 12.0 for windows
(Chicago, IL, USA).
Results
There were 147 very low BW infants admitted to our NICU during
the study period. Of these infants, 2 were excluded because of
congenital anomalies, 20 expired and 21 were transferred to
another institution for surgical reasons. Of the remaining
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Table 1 Patient demographic and clinical information

Control (n ¼ 20) Massage (n ¼ 19) M/KS (n ¼ 20)

Birthweight (g) 959±44 1097±68 1124±75

Gestational age (weeks) 27±0.45 29±0.46 29±0.55
Gender (% male) 45 61 35

Age at start of study

Day of life (median/range) 15 (7–46) 7 (7–46) 9 (7–48)
Post menstrual age (weeks) 30±0.4 30±0.3 30±0.3

Study days (median/range) 40 (14–62) 30 (12–98) 35 (12–76)

Caloric intake (g kg
1 per day) 121±2.2 118±2.4 118±1.4

Weight (g)
At start of study 1174±30 1216±44 1263±194
At discharge 2298±82 2176±88 2375±93

Head circumference (cm)

At start of studya 25±0.4 26±0.4 27±0.7
At discharge 31±0.4 30±0.4 31±0.3

Length (cm)
At start of study 37±1.0 38±0.6 38±0.6
At dischargea 44±0.7 43±0.6 45±0.6

Culture proven sepsis (%) 10 22 0

Bronchopulmonary dysplasiab (%) 5 10 15
Necrotizing enterocolitis (%) 0 0 0
Intraventricular hemorrhage (%) 0 0 0
Presented as mean±s.e.m. except where noted.
a
None of the differences are statistically significant except for starting head circumference (P ¼ 0.035) and length at discharge (ANOVA P ¼ 0.008).
b
Bronchopulmonary dysplasia defined as infants with oxygen requirement (n ¼ 3) or nasal continuous positive airway pressure (n ¼ 3) at 36 weeks postmenstrual age.

eligible infants, 44 families declined consent and 60 infants
were enrolled in the study, 20 in each group. Infants
participating in the study were slightly smaller than those not
enrolled (mean BW 1054±290 vs 1179±268 g, respectively,
P ¼ 0.027, gestational age 28±2 vs 29±3 weeks, P ¼ 0.009), but
gender distribution was similar. Two infants in the massage group
were excluded after enrollment (one diagnosed with congenital
cytomegalovirus requiring contact isolation and removal from the
massage protocol, one with congenital hydrocephalus transferred to
another hospital for neurosurgical intervention). The intervention
was well tolerated and there were otherwise no withdrawals from
the study. Demographic and clinical characteristics of the study
patients are presented in Table 1. Postmenstrual age and weight at
study entry were similar between the groups. The majority of
infants (80%) had regained BW at time of study entry. No infants
were more than 10% below BW at the start of study. There were no
infants with necrotizing enterocolitis or severe (grades III or IV)
intraventricular hemorrhage so these variables were not included
in the regression models. Bronchopulmonary dysplasia (BPD) was
defined per NICHD criteria as infants requiring oxygen (n ¼ 3) or
nasal continuous positive airway pressure (n ¼ 3) at 36 weeks
postmenstrual age.12
Average daily weight gain over the study period was 28.9±1,
27.1±1.4 and 30±1.2 g for the control, massage and M/KS
groups, respectively. These values were not significantly different by
univariate analysis with ANOVA and KW or multiple linear
regression controlling for the effects of gestational age, gender,
caloric intake, BPD and sepsis. After stratification by BW, average
daily weight gain was significantly higher in infants with BW
>1000 g (ANOVA P ¼ 0.008, KW P ¼ 0.012; Figure 1). This
difference was attributable to the M/KS group according to Tukey’s
probability table (mean difference 6.7 g kg
1 per day compared to
control). This remained significant after controlling for the
covariates in a regression model (Table 2). Average weight gain
was not significantly different in the infants with BW <1000 g after
controlling for covariates.
Median LOS was not significantly different between the groups
(Figure 2). The two outliers in the massage group both required
transfer to subacute facility for oromotor dysfunction, all other
infants were discharged to home. After excluding these outliers,

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 Massage in preterm infants
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355

40 All Infants * 120 22

BW >1000g 25
*
100

Length of Hospital stay (Days)

Average Daily Weight Gain (gm Kg –1 per day)

35
80
*

30 60

40

25
20

0
20

Control Massage M/KS

Figure 2 Length of stay by group.

15
Table 3 Regression analysis for length of stay
Control Massage M/KS
b 95% CI s.e. P
Figure 1 Average daily weight gain by group.
Study group 0.067
3.02 to 3.15 1.15 0.965
Gestational age
7.48
8.65 to
6.31 0.58 0.000*
Table 2 Regression analysis for average daily weight gain in infants with Gender
4.49
9.50 to 0.52 2.50 0.078
BW>1000 g Bronchopulmonary dysplasia
27.8 18.55 to 37 4.59 0.000*
Sepsis 3.08
5.69 to 11.8 4.38 0.485
b 95% CI s.e. P
*Statistically significant.
Study group 3.38 0.87–5.57 1.14 0.009*
Gestational age 0.12
1.28–1.52 0.68 0.863 the group exposed to massage with KS. This is the first randomized
Gender
2.07
5.86–1.72 1.84 0.271 clinical trial to demonstrate a difference in outcome for preterm
Caloric intake 0.06
0.12–0.24 0.09 0.506
infants that are exposed to massage with KS compared to massage
Bronchopulmonary dysplasia
3.51
10.5–3.49 3.40 0.312
alone. Although previous studies have demonstrated that massage
Sepsis
0.67
7.80–6.47 3.46 0.849
in combination with KS is associated with improved weight gain
*Statistically significant. compared to controls,1–7 our results suggest that this difference is
mostly attributable to the effects of KS. This is consistent with
LOS was significantly shorter in the intervention groups results of other trials that have evaluated gentle still touch13 or
(ANOVA P ¼ 0.021, KW P ¼ 0.033). However this difference lost massage alone and found no difference in weight gain between
significance after controlling for gestational age, gender, sepsis and intervention groups and controls.10,14 However, when massage has
BPD in a regression model (Table 3). Likewise, LOS was not been combined with KS or physical activity, benefits have been
different between the groups after stratification by BW. more consistently demonstrated.
Change in HC and linear growth over the study period was similar The importance of KS is clear when considering the proposed
between the groups (HC: 1±0.1, 0.8±0.1, and 0.9±0.1 cm per mechanisms by which massage improves growth and weight gain.
week; Length: 1.1±0.1, 0.9±0.4, 1.3±0.1 cm per week for the Evidence suggests that improvements in weight gain are related to
control, massage, M/KS groups, respectively, P>0.05). improved metabolic efficiency leading to acquisition of body mass.
Infants receiving M/KS do not consume or retain more calories
than controls, as ours and previous studies have shown similar
Discussion caloric intake patterns between the groups.2,3,6,7 Similarly, M/KS
In selected preterm infants, there appears to be a demonstrable infants do not appear to conserve more calories by spending more
effect on weight gain and this effect seems to be most notable in time in the sleep state, because studies have actually shown

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increased arousal in massaged infants compared to controls.2,3
Thus, it remains that the increase in weight gain is most likely
related to hormonal alterations or changes in basal metabolic
function. Increased activity levels have been associated with
improved weight gain in both animal and human models.
Increased growth hormones following physical activity has been
shown in rat pups15,16 and humans.17 Increased vagal activity
inducing gastric motility has been demonstrated in infants exposed
to M/KS.18 Animal models of repeated exercise have revealed that
there is an overall anabolic effect on body protein metabolism
leading to somatic growth.19 Improved bone mineralization and
skeletal growth have been associated with programs of daily
physical activity in preterm infants.8,20–23 Thus physical activity
may improve weight gain through a variety of mechanisms
affecting body mass of all typesFadipose, muscle and bone.
Additional mechanisms have been proposed that provide a basis
for the benefits of massage alone in the promotion of growth. Non-
nutritive sucking leading to stimulation of proprioreceptors in the
oral mucosa have been shown to increase gastrin, insulin and
cholecystokinin release and similar hormonal changes have been
shown in animals exposed to tactile stimulation in other parts of
the skin.24 Stress behaviors may increase caloric expenditures
affecting weight gain. Massage and other modalities of
somatosensory input (for example, Kangaroo care) have been
associated with attenuated adverse reactions to stress.3,25 Decreasing
cortisol levels have been demonstrated in preterm infants following
massage.26 It is not clear whether these benefits would be observed
in infants only exposed to KS.
Our findings suggest that the effects of massage alone are not
sufficient to significantly impact weight gain, and that potential
metabolic changes require addition of KS. This is consistent with
other studies that evaluated daily physical activity programs alone,
without the additional periods of massage. Moyer-Mileur et al.,20,21
and others utilizing a similar protocol,22,23 demonstrated that
infants receiving 5 min of daily range-of-motion exercise had
improved weight gain compared to control infants who received a
5 min daily interactive period of holding and stroking. One might
argue that this ‘holding and stroking’ may not have the same
effects as a systematic protocol of moderate pressure massage.
Thus, our study included such a protocol for massage alone and a
control group receiving no intervention to further elucidate the
level of intervention required to promote weight gain.
These findings are important because recent meta-analyses11,27
raised important methodological concerns with previous studies
(for example, blinding of treatment allocation and control of
performance bias via blinding of managing neonatologists to
group assignment) that cast uncertainty on the benefits of massage
and physical activity in preterm infants. The authors concluded
that evidence was weak to support widespread routine use of these
interventions and questioned whether providing massage was a
cost-effective use of nursing and NICU staff time. Our findings
Journal of Perinatology
provide further evidence that M/KS improves weight gain in
selected preterm infants and demonstrate the importance of
inclusion of KS or range-of-motion exercise in any protocol used.
This may aid in defining the role of M/KS in NICU care. In
consideration of nursing time, perhaps focus on abbreviated
programs of physical activity without massage may be more
practical and just as beneficial. Ferber et al.6 demonstrated that
training of parents or caregivers is associated with similar effect
size on weight gain in preterm infants when compared to infants
massaged by trained professionals. Involvement of the parent may
also lead to other benefits such as decreased parental stress and
improved caregiver satisfaction, because there is evidence that
similar interventions lead to improved mother–infant
interaction.28 If parents and caregivers are to be trained in
massage, focus on KS should be included.
We did not find an effect of massage/KS on weight gain in the
overall study population. In post hoc analysis, this appeared to be
due to the wide variability of the primary outcomes in the lower
BW, more immature infants. Obviously, the most immature
preterm infants have a range of comorbidities that could not be
adequately controlled for in this study. At the time of study
conception, the entry criteria were designed to capture infants of
similar postmenstrual age at enrollment, allowing for evaluation of
weight gain over a comparable time period in all infants. However,
because weight gain and LOS are so highly variable in the smallest
of infants, stratification by BW at study entry, with adequate sample
size to account for this variability, would have lead to more
interpretable results in this population. Future studies are needed
targeting the ELBW population before conclusions can be made
regarding the effects of massage in this population.
We did not find a significant difference in LOS between our
intervention and control groups, in contrast with other studies.1–3
Similar to weight gain in the ELBW infant, this may be due to the
higher variance than expected in this outcome. LOS is a difficult
outcome to assess given that it depends not only on gestational age,
but also on the medical and social condition of the infant and is,
to some extent, parent and individual physician driven. These
factors are difficult to control for in any trial design, and may be
accountable for the variability in findings for this outcome.
Similarly, we did not detect a difference in linear growth or HC
between the groups. However, it should be noted that this study was
not powered to detect differences in this secondary outcome.
Although HC and linear growth may be a useful reflection of
postnatal growth, these are more prone to measurement error and
variability, making detection of meaningful differences more
problematic. For this reason, weight gain was chosen as the
primary outcome of interest.
Our findings add to previous evidence to support that preterm
infant M/KS is associated with an improvement in weight gain in a
subset of premature infants. The clinical impact of this benefit,
especially if it does not lead to earlier hospital discharge, is unclear.

Long-term follow up of patients is needed to evaluate if this effect
on weight gain is sustained and translates into accelerated
catch-up growth into childhood. Future studies evaluating other
outcomes such as neurobehavioral and developmental effects
should be undertaken with protocols that focus on KS with or
without massage. Additionally, focused trials targeting the ELBW
are needed.
Conclusions
Massage when combined with KS is associated with an
improvement in daily weight gain in selected preterm infants.
Length of stay is not impacted by massage.
Acknowledgments
We thank Adenike Oloade, Inderjeet Sandhu and Mary Rivas for their assistance
with patient enrollment and compiling and maintaining the dataset.
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