INFANT BEHAVIOR AND DEVELOPMENT 136 i 167- I 88 119901

Massage Stimulates Growth in

Preterm Infants: A Replication
FRANK A. SCAFIDI, TIFFANY M. FIELD
University of Miami Medical School

SAUL M. SCHANBERG
Duke University Medical Center

‘CHARLES R. BAUER, KAREN Tuccr, JACQUELINE ROBERTS,

CONNIE MORROW
University of Miami Medical School

CYNTHIA M. KUHN
Duke University Medical School

Forty preterm infonts (M gestation01 oge = 30 weeks; M birth weight = 1 176 gms;
M duration KU core = 14 doysl were ossigned to treotment and control groups
once they were considered medicolly stoble. Assignments were bosed on o rondom
strotificotion of gestotionol age, birth weight, intensive core durotion, ond study
entrance weight. The treotment infants fn = 201 received tactile/kinesthetic stimulotion
for three 15min periods during 3 consecutive hours per doy for o IO-day period.
Sleep/woke behovior wos monitored and Brozelton assessments were performed
ot the beginning ond ot the end of the treotment period. The treoted infonts
overoged o 2 I % greater weight gain per day (34 vs. 28 gms) ond were discharged
5 doys eorlier. No significant differences were demonstroted in sleep/woke stotes
and activity level between the groups. The treated infonts’ performonce wos superior
on the hobituotion cluster items of the Brozelton stole. Finally, the treotment infonts
were more active during the stimulotion sessions than during the nonstimulotion
observation sessions (porticulorly during the tactile segments of the sessions). AI-
though these data confirm the positive effects of tactile/kinesthetic stimulation, the
underlying mechanisms remoin unknown.

stimulotion activity weight massage preterm infonts

Over the last 2 decades several researchers have examined the effects of
supplemental tactile/kinesthetic stimulation on the behavior and develop
The outhors thonk Lisa Eisen, Brian Heoly, ond Moshe Guthertz for their research ossistonce,
Herbert Quoy, Donald Routh, Debro Bendell, Anne Hogon, ond Annette Lo Greco for their critical
review, ond the staff of the Jackson Memorial Hospital neonotol nurseries and 011 the neonates
who porticipoted in this study. This research wos bosed on o doctoral dissertation by Frank
Scofidi ond wos supported in port by on NIMH Research Scientist Award #MH00331 ond NlMH
Basic Research Gront #MH40779 to Tiffony Field.
Correspondence and requests for reprints should be sent to Tiffany Field, Deportment of
Pediatrics, University of Miami Medical School, P.O. Box 016820, Miomi, FL 33101.

167
168 SCAFIDI, FIELD, SCHANBERG, BAUER, TUCCI, ROBERTS, MORROW, & KUHN

ment of the preterm infant (cf. Cornell & Gottfiied, 1976; Field, 1980;
Gaiter, 1985; Gottfiied, 1985; Masi, 1979, for reviews of the literature).
Generally, thesetypes of stimulation have facilitated the subsequentgrowth
and development of the infant (Barnard & Bee, 1983; Field et al., 1986;
Freedman, Boverman, & Freedman, 1966; Hasselmeyer, 1964; Rausch,
1981; Scafidi et al., 1986; Solkoff & Matuszak, 1975; White & LaBarba,
1976). Ottenbacher et al. (1987), for example, in a meta-analysis of 19
stimulation studies, estimated that 72% of infants receiving some form
of tactile stimulation were positively affected. However, several of the
studies are inconsistent with respectto specific effectsof the supplemental
stimulation.
One of the most inconsistent findings involves weight gain. Some
investigators have reported no differencesbetweentreatment and control
infants (Barnard, 1973;Freedman et al., 1966;Hasselmeyer,1964;Solkoff
& Matuszak, 1975), whereas others have reported a more rapid weight
gain for the treatment infants (Rausch, 1981; Scafidi et al., 1986; Scarr-
Salapatek & Williams, 1973; White & LaBarba, 1976). Activity level is
another variable for which contradictory findings have been reported.
Some investigators have observed greater activity in infants receiving
stimulation (Field et al., 1986; Scafidi et al., 1986;Scott, Cole, Lucas, &
Richards, 1983; Solkoff & Matuszak, 1975; Solkoff, Yaffe, Weintraub, dc
Blase, 1969).In contrast, Hasselmeyer(1964) reportedthat handled infants
were less active than control infants, and Barnard (1973) found no dif-
ferences in the amount of waking activity between the treatment and
control infants. As was noted in our earlier study on tactile/kinesthetic
stimulation of preterm neonates (Scafidi et al., 1986), the discrepant
findings may relate to this variability in the infants’ activity level. In-
tuitively, it would seem that increased activity would lead to greater
energy expenditure resulting in a lesserweight gain. However, in at least
three of the studies reporting weight gain, activity levels were also greater
(Scafidi et al., 1986; Scott et al., 1983; Solkoff et al., 1969). In contrast,
no significant weight gain was reported in studies in which activity level
was diminished in the treatment infants (Hasselmeyer, 1964) or similar
to that of the control infants (Barnard, 1973).
The strengthof the weight gain/activity level associationin the literature
is limited becauseactivity level has been measuredonly during brief time-
sampling observations. For example, in our earlier study (Scafidi et al.,
1986), activity level was based on a 45-min time-sampled sleep/wake
behavior observation conductedat the end of the study almost immediately
following a stimulation period. This observation was not only brief but
was also confounded by its occurrence immediately after a stimulation
session.Higher activity levels of the stimulated infants during this sleep/
wake observation could have been a carryover effect from the higher
activity levels noted during the previous stimulation period. In addition,
 MASSAGE STIMULATES GROWTH 169

becauseactivity level was not assessedat the beginning of the study, there
was no baseline control for the initial group differencesin activity level.
Similar methodological problems have beennoted in other studies. Sohff
et al. (1969), for example, assessedactivity level based on polygraph
readings after handling and during crying periods which would affect
activity level. Similarly, although Barnard and Bee (1983) used 24-hour
time-lapse video recordings,they scored activity in a rather gross manner
on a global 3-point scale. Activity level is more accurately assessedusing
continuous monitoring and more precise coding.
In addition to monitoring activity level, more attention should be
focused on sleep/wake state behaviors as an index of central nervous
system maturation. Disorganization of sleep/wake states in the neonatal
period is related to difficult parent-infant interactions and later devel-
opmental problems (Thoman, 1975;Thoman, Denenberg,Sievel, Zeidner,
& Becker, 1981). In one of the only stimulation studies monitoring sleep/
wake behaviors, Barnard and Bee (1983) reported no differencesbetween
the sleeppatternsof the treatment and control infants. In contrast, Barnard
(1973) had reported earlier development of distinct sleep patterns and
more quiet sleep time in the stimulated infants, whereas Scafidi et al.
(1986) noted increasedamounts of alertness.The results of these studies,
however, have limited inferential power becausethey were based on brief
time-sampling observations.Additionally, Barnard and Bee (1983)assessed
sleep/wakepatterns by having mothers keep a daily diary of their infants’
behaviors after discharge. The use of time-lapse video recordings or
continuous recordings of behavior at multiple times would provide a
more accurate indication of the amount of time spent in each state as
well as the organization of the infants’ state patterns.
A related issue is the immediate versus long-term effects of the stim-
ulation. Intuitively, massagewould induce quiescence.Some have noted
increasedepisodesof quiet sleep in handled infants (Hasselmeyer, 1964).
In contrast, others showed increasedactivity and alertness (Scafidi et al.,
1986).However, as has been noted, these results could be directly related
to the timing of the behavioral observation, that is, the observations being
conductedimmediately after the last stimulation session.State and activity
should be assessedprior to, during, and immediately following tactile/
kinesthetic stimulation. Baseline and follow-up observations would help
determine if massageis soothing or activating to the infant.
The present investigation was designed to correct for these method-
ological weaknessesand to provide a replication of our previous study
by providing tactile/kinesthetic stimulation to preterm infants after their
stay in the NICU (Field et al., 1986; Scafidi et al., 1986).Like our earlier
study, we expectedto show (a) greaterdaily weight gain for the treatment
group with no significant group differences in caloric intake; (b) superior
performance of the treatment infants on the Brazelton Neonatal Behavior
170 SCAFIDI, FIELD, SCHANBERG, BAUER, TUCCI, ROBERTS, MORROW, & KUHN

AssessmentScale; and (c) a shorter hospital stay for the treatment infants
following the stimulation period. In addition, the study was designedto
assess(a) the immediate and long-term effects of the stimulation on the
sleep/wake behaviors and motor activity levels of the infants; (b) the
differential effectsof the tactile and kinesthetic stimulation; and (c) whether
the 45min behavior observationswererepresentativeof the infants’ overall
state patterns as assessedby the &hour time-lapse video recordings.

METHOD
Subjects
The total sample was comprised of 40 premature infants from the inter-
mediate care units of our hospital. These nurseriesprovide treatment for
approximately 2000 neonatesper year who are predominantly from lower
socioeconomic backgrounds.Criteria for inclusion in the study were: (a)
a gestational ageless than 36 weeksas determined by the Dubowitz Scale
(Dubowitz, Dubowitz, & Goldberg, 1970); (b) a birth weight less than
1500 gms; (c) the absenceof genetic anomalies, congenital heart malfor-
mations, gastrointestinal disturbances, and central nervous system dys-
functions; (d) an NICU duration of less than 45 days; and (e) an entry
weight into the study between 1000 and 1450 gms. Infants of substance-
abusing mothers were not used in this study. Infants eligible for the study
were not enrolled until they were considered to be medically stable, were
free from ventilatory assistance,and were receiving no intravenous med-
ications or feedings.
The neonateswere assignedto the treatment and control groups based
upon a stratification of gestational age (GA; < or > 30 weeks), birth
weight (< or > 1100 gms), duration of intensive care treatment (< or
> 20 days), and entry weight into the study (< or > 1300gms). These
stratification criteria were selectedbased upon the mean values of these
measuresin our pilot study (Scafidi et al., 1986).Treatment and control
infants were enrolled on alternating weeks.Therefore, only one treatment
infant and one control infant were in the study at any given time.
The final sample averaged 30 weeks gestational age, 1176 gms birth
weight, 14 days intensive care treatment, and 1313 gms upon entry into
the study. The control and treatment infants did not differ on any of the
perinatal measures(seeTable 1). The control group was comprised of 14
female and 6 male neonates(5 Hispanic, 12 black, 3 Caucasian),and the
treatment group consisted of 11 females and 9 males (2 Hispanic, 15
black, 3 Caucasian). The sample was primarily a black, inner city pop-
ulation. Although this appearsto be an ethnically restricted sample, it is
represent.ative of the population served by our university hospital special
care units. These demographic characteristicsare prevalent in births less
than 2500 gms (National Center for Health Statistics, 1984).
 MASSAGE STIMULATES GROWTH 171

Procedure
Stundurd Nursery Cure. During the study period, all infants continued
to receive standard nursery care including: (a) daily examination by a
physician; (b) feeding by a nurse, nurse’s assistant, or “grandmother”
volunteer; and (c) weaning from the isolette at 1700 gms. Infants were
discharged at a weight of 1800 gms contingent upon self-regulation of
temperature and metabolites. In accord with hospital protocol, parents
were encouragedto visit, touch, hold, and feed their infants.

Tactile/Kinesthetic Stimulation. Tactile/kinesthetic stimulation was pro-

vided to 20 of the infants for three 15-min periods during 3 consecutive
hours each day for a lo-day period. No stimulation was provided on the
intervening weekend. The first stimulation session began approximately
60 min prior to the noon feed. The second sessionbegan a l/2 hour after
TABLE I
Means land Standard Deviations) far the Perinatal Data

Treatment Control

Measures M LSDI M LSD)

Maternal age 27.0 (6.11 26.0 (7.11

Parity 2.3 (1.9) 2.5 (2.2)

Gestational age (weeks.1 30.0 (2.11 30.0 (2.0)

Birth weight (grams.1 1 172.9 (176.2) I 180.0 (176.2)

Birth length (cm1 38.5 (2.4) 37.8 12.1)

Head circumference fcml 26.6 (1.6) 26.6 (1.31

Panderal Index0 2.1 (0.3) 2.2 (0.31

APGAR
1 -min 4.7 (2.7) 4.6 (2.71
5min 7.2 11.71 7.1 (1.61

Obstetric camplicatiansb 78.5 (19.01 76.4 116.81

Postnatal camplicatiansb 70.9 (6.6) 69.5 (10.8)

Brazy Scalec 3.9 (3.51 3.2 (1.51

N days in KU 12.9 I1 1.41 15.0 (10.6)

Hospital days prior to study 21.9 (1 I.81 24.5 (9.51

Weight at study onset (grams) 1322.3 (76.2) 1303.5 I1 22.8)

Note. All comparisons were nonsignificant.

aPonderal Index = birth weight/length3 X 100.
bHigher score is optimal.
<Lower score is optimal.
172 SCAFIDI, FIELD, SCHANBERG, BAUER, TUCCI, ROBERTS, MORROW, & KUHN

the noon feed, and the third session began 45 min after completion of
the second stimulation session.The 15min stimulation sessionwas com-
prised of three standardized 5-min phases.The first and third phaseswere
tactile stimulation, and the middle phase was kinesthetic stimulation.
For the tactile stimulation phase, the infant was placed in a prone
position. The person providing the stimulation gently stroked the infant
with the flats of the fingers of both hands for five 1-min segmentsover
each region of the infant’s body in the following sequence:(a) six strokes
from the top of the infant’s head, down the side of the face to the neck
and back up to the top of the head (each of these strokes lasted 10 s);
(b) six 10-s strokes from the back of the neck across the shoulders and
back to the neck; (c) six 10-s strokes from the upper back down to the
waist and back to the upper back (for this segment, the stimulator’s
fingertips were placed on either side of the spine while the flats of the
fingers were on the back); (d) six 10-sstrokes from the thigh to the foot
to the thigh on both legs simultaneously; and (e) six 10-s strokes from
the shoulder to the wrist to the shoulder on both arms simultaneously.
During the stroking motions, the stimulator’s fingers never lost contact
with the infant’s skin.
For the kinesthetic phase, the infant was placed in a supine position.
This middle phase was also comprised of five 1-min segments. Each
segment consisted of six passive flexion/extension motions lasting ap-
proximately 10 s apiece. Each 1-min segment used a different body part
and was performed in the following sequence:(a) right arm, (b) left arm,
(c) right leg, (d) left leg, and (e) both legs simultaneously. For each
segment, the stimulator gently contained the long bones of the infant’s
limbs, avoiding the palms of the hands and the soles of the feet so as
not to elicit a reflex response.The infant was then returned to a prone
position for the final phase of tactile stimulation as described above.
The stimulation was conducted by the investigator or a nurse trained
in the procedure. For the entire intervention, the infant remained in a
temperature-controlled isolette, and the stimulator handled the infant
through the opened portholes located on the sides of the isolette. The
stimulator warmed his/her hands prior to touching the infant and remained
silent throughout the procedure.

Measures
Severalassessmentswere conductedthroughout the study period asfollows.

Obsiet*ic Da&. Obstetric complications were quantified using the Ob-

stetric Complications Scale (OCS; Littman & Parrnelee,1978).This scale
consists of 41 items that are obtained from the medical record and rated
as optimal or nonoptimal. The summary score provides an index of the
number of optimal conditions present during the gestational period.
 MASSAGE STIMULATES GROWTH 173

Postnaiul Data. Postnatal complications were quantified using the Post-

natal Complications Scale(PCS; Littman & Parmelee, 1978)and the Brazy
Perinatal Biological Scoring System (Brazy, 1985). The PCS consists of
10 items rated as optimal or nonoptimal. A summary score provides an
index of the number of complications during the perinatal period. In
contrast, the Brazy is a 12-item scale which weights complications on a
4-point scaleaccording to severity and duration. Items include respiratory
difficulties, metabolic disturbances, central nervous system insults, and
hyperbilirubinemia. Two scores were calculated for each of these scales
for each infant, one for the period prior to the study and one for the
period during the study.

Clinical D&z. Data recorded daily from the nursing notes included:
(a) volumetric and caloric intake; (b) frequency of urination and stooling;
(c) averagerespiration rate, heart rate, and body temperature; (d) number
of apneic episodes; and (e) parental visits including touching, holding,
and feeding by the parents. In addition, the infant was weighed daily by
the experimenter or researchassistantimmediately prior to the 3:00 p.m.
feeding.

Neonurul Behuviorul AssessmentScale. The Brazelton Neonatal Behav-

ioral Assessment Scale (BNBAS; Brazelton, 1973) was administered to
each infant immediately prior to and following the lo-day stimulation
period. These examinations were conductedby a trained graduate student
in psychology who was “blind” to the infant’s group assignment. The
scale consists of 27 items, each scored on a g-point scale, and 20 elicited
reflexes, each scored on a 3-point scale. Behaviors assessedinclude the
infant’s state organization, motor behavior, affect, responsiveness,and
reflexes. The infant’s performance was summarized according to seven
factors: habituation, orientation, motor behavior, rangeof state,regulation
of state, autonomic stability, and abnormal reflexes (Lester, Als, & Bra-
zelton, 1982).

Sleep/Woke Behavior. To obtain an index of daily motor activity level

and state organization, the infants were time-lapse videotaped for an 8-
hour period (7:30a.m.-3:30 p.m.) on the first and last days of the treatment
period. The video recorder was placed as close as possible to the infant’s
isolette so that the infant was in full view. The time-lapse recorder was
activated in the 1Zhour mode so that real time could be reduced by a
ratio of 6:l (6 hours of actual time was coded in 1 hour).
In addition, four 45-min sleep/wakeobservationswere conducted across
the study period. These observations were conducted on Days 1, 5, 6,
and 10 of the study period between 8:00 and 1O:OOa.m. Observations
were done approximately 1 hour before the infants’ feedings to control
174 SCAFIDI, FIELD, SCHANBERG, BAUER, TUCCI, ROBERTS, MORROW, 8. KUHN

for feeding-inducedstatesand behaviors. These observationsalso occurred

prior to any assessments(e.g., Brazelton), procedures(e.g., heelsticks),or
stimulation sessions. A single observer who was blind to the infant’s
group assignment sat next to the isolette and recordedin a lap computer
each state change and all movements that occurred during the 45-min
period. The observers(psychology graduatestudents) were trained to an
overall 94% reliability criterion level, exceedingthe 80% to 90% criterion
frequently employed in studies (Bums, Deddish, Bums, & Hatcher, 1982;
Scafidi et al., 1986; Watt & Strongman, 1985).The reliability on specific
behaviors is shown in Table 2. Reliability was determined in the following
manner. A minimum of 10 infants were observed for 10 min each. The
trainer and trainee discussed the infants’ states and movements as they
occurred.Ten infants were then observedfor a 15-min period. The trainer
and trainee independently coded the predominant state and movements
(seebelow) occurring within every 10-speriod. Reliability was calculated
by dividing the number of agreementsby the number of agreementsplus
disagreements(see Brazelton, 1973; Scafidi et al., 1986). Reliability was
also calculated by Cohen’s kappa to correct for chanceagreements(Cohen,
1986).
Finally, to determine the immediate effects of stimulation on sleep/
wake behavior, the 20 treatment infants were observedduring stimulation
and no-stimulation sessions.Two sets of stimulation/no-stimulation ses-
sions were observed during the first and second weeks of the treatment
period. The stimulation/no-stimulation observations were conducted on
Day 2 and Day 9 of the stimulation period during the first and second
stimulation sessions.In order to assessthe immediate and delayed effects
of the stimulation, the infants’ states and movements were recorded
immediately following the first stimulation sessionand during the 15-min
precedingthe secondsession.During the stimulation sessions,one research
assistantprovided the stimulation while the other assistantrecordedsleep/
wake states and behaviors.
An adaptation of Thoman’s (1975) criteria was used to define state
categories.The criteria were as follows: (a) No-REM sleep-the infant’s
eyes are closed and still, and there is no motor activity other than an
occasional startle, rhythmic mouthing, or a slight limb movement; (b)
active deep without REM-the infant’s eyes are closed and still, motor
activity is present; (c) REM sleep-the infant’s eyesare closed, although
they may open briefly, rapid eye movements can be detected through
closed eyelids, and motor activity may or may not be present;(d) drowsy-
the infant’s eyes may be opening and closing but have a dull, glazed
appearance,motor activity is minimal; (e) inactive alert-the infant is
relatively inactive, although there may be occasional limb movements,
the eyesare wide open and bright and shiny; (f) active awake-the infant’s
eyes are open and there is motor activity; and (g) crying-the infant’s
 MASSAGE STIMULATES GROWTH 175

eyes can be open or closed, and motor activity is present, agitated vo-
calizations are also present. In addition to coding behavioral states, the
observeralso recorded(a) single-limb movements, (b) multiple-limb move-
ments, (c) gross body movements, (d) head-turning, (e) facial grimaces,
(f) startles, (g) mouthing, (h) smiles, and (i) clenched fists.

B-Hour Videotapes.The videotapes were played back at normal speed

(i.e., 2-hour mode). Thus an &hour observation was played back in
approximately 90 min. Minor modifications of the state definitions were
necessarybecausenot all seven of the Thoman states used in the live
45-min observations were easily discernible on time-lapsed recordings.
The following states were coded from the tapes: (a) inactive sleep, (b)
active sleep, (c) inactive awake, (d) active awake, and (e) crying. Single-
and multiple-limb movements, grossbody movements, head-turns, facial
grimaces, smiles, startles, mouthing, and clenched fists were also coded.
The length of time the infant was out-of-crib as well as the duration of
nursing/medical interventions, assessments,and stimulation periods were
also recorded. State and motor activity during nursing/medical interven-
tions, assessments,and stimulation sessionswas not included in the final
analyses. If at any time the infant’s eyes were out of view from the
camera, only motor activity was recorded and the state was coded as
unclassifiable.

State Reduction. The infant’s states and behaviors were continuously

recordedon a Tandy lap computer for both the 45-min and 8-hour state
observations. The use of continuous monitoring and the general disor-
ganization of neonatal states resulted in artifactual state transitions (i.e.,
states that lasted for less than 30 s). Therefore, a state was considered
“real” only if the infant remained in that state for a minimum of 30 s.
The use of a 30-s state criterion was based on previous research(Anders,
1978; Gunnar, Malone, Vance, & Fisch, 1985).
This 30-s requirement was implemented by a computer program (de-
signedspecifically for this project) that automatically smoothed and scored
the data. The computer program eliminated extraneousvariability in state
transitions in a purely objective and consistent manner, resulting in a
revised data stream having fewer state transitions, clean and unambiguous
transitions, and longer within-state epochs. Those states not fitting the
30-s criterion were incorporated into the previous state epoch. The com-
puter output was a flow chart displaying state transitions, time length of
each epoch, and movements. Additionally, the output provided infor-
mation on the percentageof time spent in each state during the entire
observation period. A matrix of movement by state was also generated.
Information provided by this matrix included total percentageof each
176 SCAFIDI, FIELD, SCHANBERG, BAUER, TUCCI, ROBERTS, MORROW, & KUHN

movement and each state that occurredthroughout the observation period

as well as percentageof each movement occurring in a particular state.

RESULTS
To ensure that the stratification procedure yielded similar data for the
two groups,all perinatal and maternal data were subjectedto a Hotelling’s
T” test. Univariate t tests were then performed for each of the variables.
Becausemultiple contrasts were performed, the alpha level for this and
all subsequent analyses was corrected using the Bonferroni procedure
(Rosenthal & Rubin, 1984).This procedureprovides a stringent criterion
for significance becauseit takes into account the number of contrasts
being done in any given analysis. Therefore, chancesignificant effectsare
minimized.

Perinatal Data
The means and standard deviations for the perinatal data are presented
in Table 1. The groupsdid not significantly differ on any of thesevariables
including gestational age, obstetric and perinatal complications, intensive
care duration, and length of hospitalization prior to the study.

Clinical Data
The means and standard deviations for these measuresare presentedin
Table 2. Except for the frequency of stooling, which was greater in the
control group, t (1,38) = 2.25, p < .05, the groups were similar on all
clinical measuresincluding body temperature,heart rate, respiration rate,
frequency of urination, and number of complications during the study
period. In addition, the number of parent visits and the incidence of
touching, holding, and feeding their infants did not vary across groups.
Finally, the treatment infants were hospitalized 5 days (M = 19 days) less
than the control infants (M = 24 days) after the onset of the treatment
period, t( 1,38)= 2.14, p < .05.

Intake and Weight Gain Data

A multivariate Hotelling’s P test performed on the group of formula
intake and weight gain variablesyielded a significant P: P (2,37)= 412.27,
p < .Ol. The means and standard deviations are presented in Table 3.
No significant differences were demonstrated between the groups on the
baseline data collected 3 days prior to the study period. Furthermore, no
differenceswere noted on number of feeds per day or averagevolume of
formula, and averagecaloric intake during the study period did not differ
between groups. However, the treatment infants averageda greaterdaily
weight gain (M = 33.6 gms) than the control infants (M = 28.4 gms) over
the treatment period, t( 1,38)= 3.07, p < .003. Also, it should be noted
 MASSAGE STIMULATES GROWTH 177

TABLE 2
Means (and Standard Deviations) for the Clinical Measures Throughout the Study Period

Treatment Control

Measures M LSD) M lSDl

Respiration rate 53.3 12.4) 53.6 (2.2)

Heart rate 159.8 (3.0) 159.8 13.41

Averoge temperature 98.1 (0.11 98.1 (0. I I

Frequency of stooling” 1.2 10.51 I .6 10.7)

Frequency of urination 8.5 10.61 8.8 Il.21

Postnatal complications 129.7 133.3) 125.2 (33.71

Brazy score 0.4 10.71 0.5 (I.01

N parental visits 2.4 (3.2) 2.0 12.11

with touching 2.3 13.21 1.9 (2.01
with holding 1.7 (2.5) 1.3 (1.7)
with feedina 1 .o 12.11 0.8 il.81

OGroup difference at p = .05.

that the averageweight gain was significantly greaterduring the stimulation

period as comparedto the prestudy period for the treatment group (M = 14
gms vs. 4 gms, respectively, p < .OOl) in contrast to the control group
which did not change.
A 2 (Group) X 12 (Days) repeated-measuresanalysis of variance was
performed on the weight gain data. A significant repeated-measureseffect
suggestedthat the linear increasein weight gain was significant for both
groups, F(12,372)= 535.11, p < .OOl. However, a significant Group by
Day interaction revealeda greaterincreasein daily weight for the treatment
group, F(12,372)= 1.94, p < .03. This greater increase in daily weight
gain for the treatment group became statistically significant on Day 9 of
the study. An analysis of covariance was performed using daily average
weight gain as the dependent variable and average formula and caloric
intake as the covariates.The treatment group still averageda greater daily
weight gain (adjusted M= 33.4 gms) than the control group (adjusted
M= 28.6 gms), F(1,38) = 13.66,p -c .OOl.

Brazelton Neonatal Behavior Assessment Data

Performance on the BNBAS on the first and last days of the study was
subjectedto a 2 (Group) X 2 (Day) repeated-measuresanalysis of variance
(see Table 4). No differences were noted between the groups on the
baseline data (Day 1). Significant repeated-measureseffects suggestedma-
turation in both groups for motor maturity (JI < .005) and number of
abnormal reflexes(p < .OOl). The treatment group showed better perfor-
178 SCAFIDI, FIELD, SCHANBERG, BAUER, TUCCI, ROBERTS, MORROW, 8 KUHN

TABLE 3
Means (and Stondord Deviations1 for the Formula lntoke and Weioht Goin Doto

Treotment Control
Measures M EDI M fSDl

Average doily weight

gain prior to study
13 doysl 19.6 110.51 24.5 I1 1.1)

Averoge doily weight

goin during study 33.6 (5.4) 28.4 L5.5P

N of feeds
per day 8.6 (0.7) 8.9 (I.41

Averoge fluid intoke

&/kg/day) 161.8 113.2) 163.7 (8.9)

Colories per kg/day I 18.9 (11.4) 121.1 (14.5)

Colories per ounce 21.5 il.711 21.5 il.761

-Group difference ot p = .003.

TABLE 4
Meons fond Stondord Deviotionsl for the Brozelton Cluster Scores
on First ond lost Doys of the Study

First Doy lost Day

Treotment Control Treotment Control

Meosures M LiDI M lSDl M (SD1 M lSDl

Hobituotion 5.4 (1.1) 5.2 (I.21 5.3 (1.71 4.4 lO.8P

Orientotion 3.4 (I.51 3.7 (I.81 3.8 (I.41 3.9 (I.51

Motor moturity 2.9 10.81 3.1 (1.01 3.3 (1.1) 3.7 (I.21

Ronge of stote 4.2 Il.11 4.3 (1.1) 4.2 il.11 3.9 Il.21

Regulotion of stote 5.1 (1.91 5.5 I I .61 5.5 I I .9) 5.6 il.51

Autonomic stability 6.4 il.21 6.3 II .2) 6.7 (I.21 6.7 11.11

N obnormol 8.1 (2.31 9.0 12.3) 5.9 (2.91 6.1 (2.3)

“Group difference at p = .05.

mance than the control group on the habituation cluster following the
treatment period, t(1,38) = 2.05, p < .05.

Sleep/Wake State and Activity Data

No differences were noted between the groups on the baseline (Day 1)
observations. A 2 (Group) X 4 (Observation) repeated-measuresanalysis
of variance yielded no significant group differencesor time changeson
the 45min observations. A 2 (Group) X 2 (Observation) repeated-meas-
 MASSAGE STIMULATES GROWTH 179

uresanalysisof varianceon the 8-hour time-lapse video recordingsrevealed

no group differencesor time changes.
Repeated-measuresanalysesof variance were conducted to determine
whether the 4%min and 8-hour observations were representative of the
S-hour videotaped sleep/wake behaviors. Becausethe coding systems for
the two data sets were slightly different, minor modifications were made
in the summary data for the 45min observations to make them com-
parable. Active sleep without REM and REM sleep were combined into
a single category called active sleep. Likewise, drowsiness and inactive
alertness were combined into a single category called inactive alertness,
resulting in five sleep/wakecategoriesand 10 behaviors. Several significant
differenceswere yielded by the repeated-measuresANOVA (seeTable 6).
The 8-hour video recordings tended to yield lower estimates of quiet
sleep, active sleep, single-limb movements on the first day, startles, and
stillness (no movement) than the 4%min observations. In contrast, the
TABLE 5
Means for the 45Min Sleep/Wake Observation Behaviors for the Treatment ond
Control Groups on First and Last Days of the Study

First Day Last Day

Measure” Treotment Control Treatment Control

Quiet sleep 196) 62.0 54.9 63.8 59.3

Active sleep 191 I 15.9 17.5 10.6 16.1

REM sleep 1911 23.5 21.8 23.6 21.2

Drowsy (91 I 2.4 1.9 0.7 0.6

Inactive alert (981 0.1 1.4 0.0 0.3

Active olert 198) 0.0 1.1 0.0 0.0

Fussing/crying (991 0.7 0.9 1.2 0.9

Single limb (88) 12.5 11.9 7.2 8.3

Multiple limb (86) 13.0 15.4 11.0 13.6

Head-turns (801 2.6 4.3 4.8 5.8

Gross body (881 2.1 2.7 4.3 7.7

Startles 177) 0.9 0.9 1.4 1.6

Smiles 1701 0.5 0.5 0.9 1 .o

Mouthing (861 4.0 4.7 2.9 5.6

Facial grimaces 198) 6.8 6.0 6.2 10.3

No movement (99) 66.2 60.4 73.0 65.0

Clenched Rsts (83) 5.1 3.0 0.4 6.7

“Values in parentheses ore interobserver reliability coefficients.

180 SCAFfDf, FIELD, SCHANBERG, BAUER, TUCCI, ROBERTS, MORROW, & KUHN

TABLE 6
Means for the 45Min and 8-Hour Sleep/Woke Observotion Behaviors
on First ond lost Days of the Study

First Doy Lost Doy

Measure 45Min 8-Hour 45Min 8-Hour P

Quiet sleep 58.0 37.5 63.3 37.0 .OOlo

Active sleep 39.4 22.5 34.6 20.5 .OOlo

Inactive alert 1.7 I .6 0.7 3.2 .002b

Active alert 0.0 1.1 0.0 1.1 .OOl*

Fussing/crying 0.7 1.1 0.7 0.5 n.s.

Single limb 12.6 6.9 6.6 6.5 .OOlb

Multiple limb 14.7 15.6 12.4 13.7 n.s.

Heod-turns 2.6 3.8 4.6 6.1 n.s.

Gross body 2.1 3.1 1.7 2.3 n.s.

Stortles 0.9 0.3 1.1 0.0 .OOl~

Smiles 0.5 0.7 0.1 0.0 n.s.

Mouthing/yawning 3.5 2.7 3.3 2.8 “.S.

Facial grimaces 6.4 3.9 6.7 4.5 n.s.

No movement 63.0 51.1 73.6 50.3 .OOla

Clenched fists 4.5 1.6 2.9 I .5 n.s.

“p values represent type of observation effects.

“p values represent type of observation by day interaction effects.

video recordings provided higher estimates of the inactive alert state on

the last day and the active alert state than the 45min observations.

Immediate Effects of Stimulation on the Sleep/Wake Behaviors

To determine the immediate effects of stimulation, the four stimulation
and no-stimulation periods were subjectedto a 2 (Week) X 4 (Stimulation/
No Stimulation) repeated-measuresanalysis of variance. No significant
Time or Time by Stimulation/No-Stimulation interaction effects were
present. However, several Stimulation/No-Stimulation repeated-measures
effectswere significant (seeTable 7). During the stimulation periods, the
infants experienced:(a) more active sleep; (b) less REM sleep; (c) more
activity, in particular more multiple-limb movements and more head-
turns; and (d) fewer periods with no movement. These patterns appeared
to be stableover the 2-weekperiod. Subsequentt testsperformed separately
on the two stimulation and the two no-stimulation sessionsdid not reveal
any significant differences between the observations.
 MASSAGE STIMULATES GROWTH 181

TABLE 7
Means (Collapsed Across Weeks) for the Proportion of Time the Stotes ond Behaviors Occurred
During the Stimulation (Stim) and No-Stimulation (No-Stim) Periods

Session 1 Session 2

Measure Stim No-Stim Stim No-Stim P”

Quiet sleep 49.9 53.3 50.7 60.2 n.s.

Active sleep 30.8 11.5 30. I 14.0 .OOl

REM sleep 4.6 19.6 3.2 13.5 .004

Drowsy 1.9 5.3 3.8 2.6 n.s.

lnoctive olert 3.9 4.1 1.8 1.7 n.s.

Active ofert 1 .o 1 .o 2.2 3.9 n.s.

Fussing/crying 7.7 1.2 8.0 4.1 n.s.

Single limb 14.6 16.5 13.6 11.8 ns.

Multiple limb 33.5 13.3 31.1 15.6 .OOl

Head-turns 8.5 3.3 5.9 4.1 .OOl

Gross body 4.3 2.6 6.1 5.5 n.s.

Stortles 0.2 0.4 0.4 0.5 n.s.

Smiles 0.4 0.7 0.2 0.3 n.5.

Mouthing 6.4 4.9 6.0 4.2 n.5.

Facial grimaces 13.4 5.3 13.1 8.1 n.s.

No movement 41.3 61.9 43.6 62.4 .OOl

Clenched fists 2.8 3.8 3.6 5.4 n.s.

“p values represent stimulation/no-stimulation effects.

Effects of Tactile Versus Kinesthetic Stimulation on

Sleep/Wake Behaviors
Establishingthat the stimulation sessionsimmediately activated the infant
culminated in two final questions: (a) Were the tactile and kinesthetic
segmentsaffecting the infants differently? and (b) if so, was this pattern
of arousal the same for all the stimulation sessions?A 4 (Session)X 3
(Tactile/Kinesthetic/Tactile Segment) repeated-measuresanalysis of vari-
ance was performed on the stimulation periods. No significant Session
effects or Session by Stimulation Segment interaction effects were dem-
onstrated. Several significant repeated-measureseffects for Stimulation
Segment suggestedthat the tactile segments were more arousing for the
infants than the kinesthetic segments (see Table 8). During the tactile
stimulation segments,the infants experienced:(a) more periods of active
 182 SCAFIDL FIELD. SCHANBERG, BAUER, TUCCI, ROBERTS, MORROW, & KUHN

TABLE B
Meons (Collapsed Across Sessions ond Weeks1 for the Proportion of Time the States and Behaviors
Occurred During the Tactile ond Kinesthetic Segments

Segment

Meosure Tactile Kinesthetic Tactile P”

Quiet sleep 48.8 56.5 45.4 ns.

Active sleep 38.3 19.5 32.7 .oo 1

REM sleep 1.5 9.1 1.5 n.s.

Drowsy 0.7 4.0 4.1 fl.S.

lnoctive alert I .6 4.3 2.6 n.s.

Active olert 0.6 I .9 I .8 n.s.

Fussing/crying 8.5 4.3 11.9 “.S.

Single limb 13.4 16.3 13.0 n.s.

Multiple limb 38.5 26.2 33.0 ,001

Heod-turns 9.1 2.8 9.7 .oo I

Gross body 6.2 0.3 8.3 ,001

Startles 0.1 0.6 0.2 ns.

Smiles 0.1 0.4 0.1 n.s.

Mouthing 5.1 7.1 6.4 n.s.

Foci01 grimaces 17.5 8.5 15.6 n.s.

No movement 34.8 50.8 39.8 .oo I

Clenched fists 3.1 3.0 3.4 n.s.

op values represent type of segment (tactile/kinesthetic stimulotionl effects.

sleep; (b) more activity, including more multiple-limb movements, head-

turns, and gross body movements; and (c) fewer periods without move-
ment.

DISCUSSION
These results suggestthat supplemental tactile/kinesthetic stimulation can
improve the clinical course of healthy preterm infants. The stimulated
infants showed a 21% greater daily weight gain and were significantly
heavier at the end of the treatment period. Although this investigation
replicated the weight gain results of our previous study (Field et al., 1986;
Scafidi et al., 1986),there are three notable differencesbetweenthe earlier
and more recent studies. First, both the treatment and control infants
gained at least 10 gms more per day during the time period of this study
than they did 4 years ago during the time period of our earlier study.
 MASSAGE STIMULATES GROWTH 183

The reasonsfor this are unclear becausethere is no apparent difference

in volumetric or caloric intake levels of the earlier and present study
infants. Two possible reasons are changes in formula composition and
changesin types of stimulation on the unit. Formula changesare a likely
cause becausethere is some suggestionthat the addition of soybean oil,
vitamins, minerals, and medium chain triglycerides may be contributing
to the recent greaterdaily weight gain. Ways in which the infants’ stim-
ulation has changedinclude placing the infants in a prone versus supine
position, covering the isolettes with blankets (to reduce excessive light),
and adding bunting and nesting blanket rolls to the isolettes for tactile
stimulation and “containment” of the infants.
A second related finding was that the treatment infants in this study
demonstrated a 5-gm increase in daily weight gain as opposed to the 7-
gm increasethat occurred in our previous study. It should be noted that
the 33.6 gm/day weight gain seen in the current treatment group ap-
proximates the average35 gm/day weight gain for a normal fetus of this
gestationalage(Widdowson, 1982).Thus, both groupsare now approaching
the normal in utero weight gain.
The greaterweight gain of the treatment group versus the control group
could not be attributed to greater volumetric or caloric intake inasmuch
as the treatment infants did not have higher intakes than the control
infants even when the amount of formula intake was statistically con-
trolled. In fact, some infants gained less weight despite greater intake,
and vice versa. This finding of greater weight gain independent of intake
is consistentwith other studies (Bembaum, Perreira, Watkins, & Peckrnan,
1983; Field et al., 1982; Scafidi et al., 1986).
The similarity of overall sleep/wake state behaviors and activity levels
in the two groups was an unexpectedfinding. Greater activity levels and
more mature sleep/wakebehaviors were expectedfor the treatment group
becausethesefindings werepreviously reportedfor infants receiving similar
treatments (Barnard, 1973; Barnard & Bee, 1983; Scafidi et al., 1986;
Solkoff et al., 1969). These differences could be attributed to the meth-
odological flaws in the previous investigations, such as the absence of
baseline data and the timing of the observations (i.e., immediately after
the stimulation sessions;Scafidi et al., 1986),the use of brief time-sampling
measures(Scafidi et al., 1986; Solkoff et al., 1969),maternal report (Bar-
nard, 1973),and global rating scales(Barnard & Bee, 1983).The findings
of this investigation may indeed be more reflective of the actual proportion
of time the infants spent in the various sleep/wake states and of their
activity levels becauserepeated, continuous monitoring was employed.
However, these findings as well as those of previous investigations are
limited becauseonly proportions of sleep/wakebehaviors were examined.
Future studies may uncover more information if sleep/wakepatterns and
basic-rest-activity cycles are analyzed.
184 SCAFIDI. FIELD, SCHANBERG, BAUER, TUCCI, ROBERTS, MORROW, B KUHN

The results of this study suggestthat the brief time-sampling of sleep/

wake statesand motor behavior may not be representativeof the infants’
daily sleep/wake behavior, that is, the 45-min live observations did not
provide the same information as the 8-hour time-lapse video recordings
in this study. The discrepanciesbetween the two observation types were
not surprising, and two possible explanations are considered. First, the
8-hour video recordingstended to provide lower estimatesof movements
such as smiles and startles. When one considers that these “subtle”
movements are often difficult to detect while actually observingthe infant,
it is not surprising that they would be even more difficult to see on
videotape. Second, 45 min is only a brief sampling of sleep/wake states
and behaviors. Considering that the averagequiet sleep/active sleepcycle
is 40 to 60 min (Stem, Par-melee,& Harris, 1972),an observation of this
length barely allows an accurate estimate of a single cycle. In addition,
hospitalized preterm infants sleep from 20 to 23 hours per day (Beckwith
& Cohen, 1978; Prechtl, Theorell, & Blair, 1973).It is unlikely that a 45
min observation would accurately estimate proportions of wakefulness.
Therefore, it was not unexpectedthat the 8-hour video recordingsprovided
higher estimates of wakefulnessand lower estimates of sleepthan the 45
min observations. The results of this study suggestthat 8-hour time-
lapsed video recordings offer more accurate estimates of the proportions
of sleep/wake behaviors. Additionally, 8-hour video recordings would
provide a means of accurately assessingrest/activity cycles in future
studies.
The only indication of stimulation-induced activity in this study was
the significantly greater activity noted during the stimulation sessions
compared to the no-stimulation sessions.Thus, the immediate effect of
the stimulation appears to be an increase in activity. This pattern of
arousal appearsto be stable across the 2-week stimulation period.
Although tactile and kinesthetic stimulation are frequently combined
in stimulation programs (Field et al., 1986; Rausch, 1981; Rice, 1977;
Scafidi et al., 1986; Solkoff et al., 1969; White & LaBarba, 1976), these
two forms of stimulation appear to have different immediate effects on
behavior. The tactile segmentsin this study were more arousing to the
infant, resulting in more episodesof active sleepand greatermotor activity.
Similar findings were demonstrated in Scafidi et al. (1986). In addition,
comparisons across studies in which one or the other form of stimulation
was employed suggestthat the tactile stimulation has an activating effect,
whereasthe kinesthetic stimulation has a quieting effect (Freedman et al.,
1966; Komer & Thoman, 1972;Solkoff & Matuszak, 1975).The possible
reason for the quieting effect of the kinesthetic stimulation in this study
is twofold: (a) The kinesthetic stimualtion involved passive movements
of the limbs, thereby physically limiting spontaneousmovements; and (b)
the infant was placed in a supine position for the kinesthetic stimulation.
 MASSAGE STIMULATES GROWTH 185

The increased quiescence may be a response to the novelty of this

positioning, that is, most preterm neonatesin the NICU are placed in a
prone position in the isolette.
Even though documentation of the differential effects of the tactile and
kinesthetic segmentsis noteworthy, the data from our study are limited.
These data only address the immediate effects of the tactile versus kin-
esthetic segments.The differential effects on weight gain are unknown,
although stimulation programs with rat pups (Schanberg, Evoniuk, &
Kuhn, 1984) showed that only tactile stimulation and not vestibular or
kinesthetic stimulation was effective in reversing the effects of maternal
deprivation on protein synthesis.For the purpose of developing the most
beneficial and least time-consuming program, future studies will need to
assessthe differential and additive effects of the tactile and kinesthetic
types of stimulation.
Developmental differencesbetween the stimulated and control infants
were minimal in this study. The treatment and control infants differed
only on the Brazelton Habituation Cluster Score. The present difference
between the groups seems to be a result of the control group becoming
worsein habituation after the treatment period. The reasonfor this pattern
of differencesremains unexplained. In addition, this finding is inconsistent
with previous research that reported differences on several Brazelton
clusters (Barnard & Bee, 1983; Scafidi et al., 1986; Solkoff & Matuszak,
1975).This discrepancy is possibly related to methodological differences
among the studies. The Barnard and Bee (1983) and Scafidi et al. (1986)
studies did not measurebaseline performance. Therefore, any differences
noted on the Brazelton Scalecould have existed prior to the intervention.
Although Solkoff and Matuszak (1975) included baseline performance,
they did not use the seven cluster scores to summarize the infants’
performancesbut did an item-by-item comparison. Their findings dem-
onstrated that the stimulated infants improved on 11 of the 26 individual
items. It is conceivable that similar results would be obtained if the
present investigation examined the individual test items.
Although the present investigation has demonstrated an inexpensive
treatment for improving the clinical course of premature infants, the
results of this study are limited by several factors. First, the reader must
keep in mind that the infants in this study were healthy preterm infants.
The intervention was administered only to medically stable infants in the
intermediate care nurseries. Future studies should investigate the use of
stimulation with smaller, sicker infants before adopting these programs
universally. Second,routine handling of sick premature infants has been
associatedwith hypoxemia (Long et al., 1980; Speidel, 1978). The effect
of tactile/kinesthetic stimulation on the oxygenation of the infant should
always be examined by monitoring transcutaneousoxygen. Finally, it is
unclear as to when in the infant’s development tactile/kinesthetic stim-
186 SCAFIDI, FIELD, SCHANBERG, BAUER, TUCCI, ROBERTS, MORROW, & KUHN

ulation would be most beneficial. Future studies should try to determine

the most appropriate time for implementing stimulation programs.

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6 March 1989; Revised 4 October 1989 n