Premature Infant Massage

in the NICU
Jodi M. Beachy, BSN, RNC, NNP

A THREE-WEEK-OLD, 32-WEEK GESTATION (35-WEEK

postconception) infant boy is in the neonatal intensive
care unit. He was on the ventilator for eight days and in an
NURSING EDUCATION
In 1998, the nurses in our NICU, with the support of our
neonatologist, began an infant massage program. The nurses
oxygen hood for five days; he is took a three-hour course on how
currently in room air. The patient to massage the premature infant.
has a history of Grade I intraven- ABSTRACT The course, taught by a neonatal
tricular hemorrhage, bradycar- Infant massage therapy is an inexpensive tool that
nurse who is a certified newborn
dia, and reflux. His weight gain should be utilized as part of the developmental care of the massage instructor, provided
has averaged 13 gm per day for preterm infant. Nurses have been hesitant to begin massage information about the risks and
the past seven days. His mother is therapy for fear of overstimulating the infant and because benefits of infant massage, out-
27 years old; this is her third child. there has been insufficient research to prove its safety. lined the types and techniques of
Her visits are less than a half- Recent research, however, has shown that the significant massage, and reviewed infant
hour long because she needs to care benefits of infant massage therapy far outweigh the minimal cues and states of aler tness.
for her other children. The mother risks. When infant massage therapy is properly applied to Guidelines were taken from
is experiencing sadness and help- preterm infants, they respond with increased weight gains, Baby’s First Massage: An
lessness; she states that she feels improved developmental scores, and earlier discharge from Instructor’s Manual by Teresa K.
the hospital. Parents of the preterm infant also benefit
“like a visitor, not a mom.” Ramsey.1 The nurses performed
because infant massage enhances bonding with their child
A neonatal nurse who is also a and increases confidence in their parenting skills. This arti-
a return demonstration of an
certified infant massage instruc- cle discusses the benefits and risks of massage for preterm infant massage and took a quiz
tor teaches the mother how to infants and their families and explains how to implement to show competency; they then
perform infant massage. She also massage therapy in the neonatal intensive care setting. began giving infant massages
reviews infant stress cues and and teaching parents how to
sleep states with the mother. The massage their infants.
mother successfully performs a return demonstration on her The massages were done for six minutes, one to two times
son and uses a flow sheet to keep track of the days she per- a day—once during each 12-hour shift. Pure, cold-pressed oil
forms massage. No other changes in care are noted. After two was used for all massages. All developmentally and medically
weeks of daily massages, the infant responds with a significant stable premature infants 1,360 gm and over were massaged.
increase in weight gain (averaging 27 gm per day). The Eligibility for massage was not limited by gestation or pres-
mother describes an increased feeling of wellness and ence of oxygen therapy; the average age was 32.5 weeks post-
improved attachment to the infant despite her short visits. As conception. If an infant showed signs of stress, such as color
she states it, “I really look forward to massaging my son.” change or arching of the back, the massage was discontinued

Accepted for publication April 2002. Revised May 2002.

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TABLE 1 ■ The Benefits of Infant Massage2,24–29
Increased weight gains (by 21% to 47%)
Increased elimination of waste products
Improved food digestion
Improvement in reflux symptoms
Improved performance on the Brazelton neurobehavioral assessment scale
Reduced secretion of stress hormones, such as cortisol, and increased
serotonin levels, leading to feelings of well-being
Increased pain tolerance
Accelerated maturation of the sympathetic nervous system
Increased alert states
Improved wake/sleep states
Decreased touch aversion
Improved circulation
Improved skin integrity
Improved skin tone
Enhanced parent-infant bonding
Improved parent-infant communication
Enhanced parent-child interaction
Improved parental understanding of infant’s cues
Improved tactile communication skills for parents
Increased prolactin levels in mother, stimulating nurturing feelings
until the next shift. We did not experience any repeated
episodes of intolerance.
In 2001, we tracked all of the massaged and nonmassaged
infants treated in our unit in the previous two years. There
were 21 infants in each group. Three infants from the non-
masssaged group and 1 infant from the massaged group were
disqualified from the study because they had been transferred
out of the unit. We assessed medical records to acquire weight
gain data from the time during which the infants went from
1,360 to 1,810 gm, and we found that average daily weight
gain among massaged infants was 9 gm higher than among
the nonmassaged infants. The massaged infants gained an
average of 26.6 gm per day; the nonmassaged infants gained
an average of 17 gm per day. These results were similar to
those found in studies by Scafidi and colleagues.2
The improved weight gain and the positive feedback from
the parents and nurses in the NICU solidified our belief that
infant massage is a positive addition to the plan of care. We
found that although infant massage therapy is somewhat
time-consuming, the benefits greatly outweigh the extra time
and effort expended.
BENEFITS
In reviewing the nursing and medical literature, we found
30 physical and psychological benefits of infant massage thera-
py, 20 of which particularly benefit the neonate (Table 1).
These include faster weight gain, improved skin integrity, and
improved sympathetic nervous system development; the
majority of the studies included infants 37 weeks and younger.
The only cited risk factors found were slight heat loss3,4
and possible periods of disorganization after massage,5 as
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40
demonstrated by periods of eye aversion and restlessness.
Current research literature supports massage therapy for the
premature infant.
The mechanisms behind the benefits of massage are not
fully understood. However, it is known that the positive
effects of massage on the infant’s weight gain are related to
the increased secretion of growth hormone and its effect on
the sympathetic nervous system.5 Also, massage stimulates the
vegetative branch of the vagus nerve (tenth cranial nerve),
which increases the release of insulin.6 Increased insulin avail-
ability may enhance glucose uptake and improve weight
gain.7 Increased vagal activity also stimulates gastric motility,
which can contribute to more efficient absorption of food.6
The improvement in skin quality is due to the combination
of massage and oil. Massage helps remove dead cells and
encourages the secretion of sebum (the baby’s natural oil),
which improves the skin’s resilience. The oil can help prevent
drying, cracking, and fissures; it also hydrates the skin by con-
serving the water within.8
Infant development is hastened by the effect of massage on
the autonomic nervous system. When an infant is massaged,
the secretion of catecholamine (norepinephrine and
epinephrine) is increased. This enhances the overall develop-
ment of the sympathetic nervous system by improving the
infant’s level of arousal and attention.6,9
Infant massage therapy is noninvasive, inexpensive, and
easy to learn and provides pleasant interaction between care-
giver and child. Massage given by parents involves them inti-
mately in their infant’s care, allowing them an active role in
helping their child gain weight and heal.10
Parents and nurses may be concerned about overstimulat-
ing the premature or sick infant; it is important to instruct the
nurses and family about how the stable newborn tolerates
touch. Fortunately, studies have shown that the infant who
has experienced the most difficult obstetric and perinatal his-
tories will actually benefit more from massage than one whose
course has been less complicated.11,12 This may be because
massage reduces stress levels, as frequently evidenced by
decreased grimaces and less clenching of fists.11 Infants with
difficult histories may begin with higher stress levels and
therefore benefit more from the massage.
MASSAGE THERAPY GUIDELINES
Eligibility for infant massage therapy is best determined on
a case-by-case basis (Table 2). Massage has the most beneficial
impact on weight gain when the premature infant has the first
massage by 48 hours of age.13 Infants as small as 1,100 gm
benefit from massage if they are medically and physiologically
stable. The premature infant should not be massaged during a
time of active sepsis or painful skin disorders (Table 3). The
assessment must be completed before massage begins.
The best time to do infant massage is when the patient is
in a quiet alert state. The person giving the massage should
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TABLE 2 ■ Patient Care Procedure for Infant Massage
Procedure
1. Assess infant for eligibility:
a. Infants should be more than 31 weeks
postconception.
b. Assess for contraindications: active sepsis, contagious
or painful skin disorders, suspicious abdomen,
necrotizing enterocolitis, apnea, bradycardia
requiring stimulation in last 24 hours.
2. Assess infant for readiness.
3. Gather oil and warming lights.
4. Assess temperature.
5. Massage on lap with warming lights overhead, in
incubator, or on warmer bed.
6. Using warm oil, massage the legs and then the arms and
body. Avoid oil on the face and ECG lead area.
7. Use firm, slow, smooth strokes.
8. If infant becomes disorganized, use hand containment
until infant calms before continuing massage.
9. Document the infant’s response.
be in a calm, relaxed state. Refrain from abdomi-
nal massage during the half-hour after feeding to
avoid possible emesis or discomfort. Do not
wake a baby for a massage.
INFANT ASSESSMENT
Each individual has a unique reaction to mas-
sage, and infants should receive a massage only
when they are able to benefit from it. The
patient should be physiologically stable enough
to tolerate the massage; assess for readiness
before beginning.14,15 Most infants older than
31 weeks postconception are stable enough to
benefit from infant massage. At 32–33 weeks
gestation, the infant’s skin is still fragile and very
sensitive to touch, but he does begin to tolerate
more touch times.16 Monitor the infant for signs
of overstimulation and stress before, during, and
after the massage. The caregivers, both nurses
and parents, must have a clear understanding of
infant stress signals and states of organization
(asleep, quiet alert, active alert) before giving a
massage.
The infant will show stress cues if overstimu-
lated. These include grimacing, arching the
back, crying, vomiting, splaying the fingers, gag-
ging, and fisting. Other signs of disorganization
include eye aversion, frowning, yawning, color
changes, hiccups, irritability, bradycardia, and
apnea. Discontinue the infant massage therapy if
any stress cues are present. To help the patient
organize if stressed, firmly rest your hands on
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Points to Remember
Infant should be in a quiet alert state.
Use additive-free oil. Do not use baby oil or petrolatum.
Axillary temperature must be 97.9 to 99.9°F.
Legs are the least vulnerable part of the newborn’s body.
Firm strokes enhance weight gain.
the head and the trunk until the infant is again
relaxed.
In addition to watching for stress cues,
observe for levels of alertness prior to beginning
a massage. Massage is most successful when the
infant is in a quiet alert state because at this time
he is best able to interact with others and toler-
ate a variety of stimuli—tactile, auditory, and
kinesthetic. The infant is in a quiet alert state
when he has a bright look on his face and is able
to focus on a stimulus.
The final step in minimizing risks is regulating
the infant’s temperature. In order to prevent heat
loss, make sure the temperature is above 97.9°F
(36.5°C) axillary before beginning the massage.
Use heating lights overhead if the massage takes
TABLE 3 ■ When Massage May Not Be Appropriate
Do not perform massage:
Over a fracture or incision site
Within 48 hours after immunization (can cause local
reaction at site)
If infant presents with any of the following:
• Active infection or fever over 100°F (37.8°C)
• Painful or contagious skin disorders such as
epidermolysis bullosa or staphylococcal scalded skin
syndrome
• Gastroschisis or omphalocele
• Hemophilia or malignancy
• Apnea and bradycardia requiring stimulation in last
24 hours
• Necrotizing enterocolitis
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FIGURE 1 ■ Opening stretch. FIGURE 2 ■ Leg massage—”milking”.
place on your lap. Massage can also be done with the infant in
an incubator or on a warmer bed. If the caregiver understands
and responds to the infant’s cues, temperature needs, and
states of alertness, the risks of massage are minimized.
MASSAGE STROKES
If the massage will be given on your lap, place warming
lights in position. Next, dim the overhead lights, remove any
sharp jewelry from your fingers, and wash hands with warm
water. Have a soft blanket or pillow available for your lap; soft
music may be played as tolerated. Take several deep, relaxing
breaths and get comfortable. Speak to the infant in a soft voice
before you begin in order to make your presence known.
Use oil on all the infant’s body parts except the face and
the ECG lead area. Use a product that has no added per-
fumes, dyes, or preservatives.8 Cold-pressed oil (almond,
sesame, safflower, apricot kernel, grape seed) or Aquaphor
ointment are both appropriate choices because they are water
miscible, which allows them to be absorbed without clogging
the pores, and they rarely cause contact dermatitis.17 Do not
use baby oil (mineral oil) or straight petrolatum because they
are not water miscible.
Cold-pressed oil has natural vitamin E, which preserves the
oil and nourishes the skin.18 It has also been shown to effect
better infant weight gains than mineral oil.19 Aquaphor pre-
vents excess drying of the skin.17 Monitor the infant’s skin for
intolerance whenever you switch to a new oil or ointment.
Maintain physical contact with the baby at all times in
FIGURE 4 ■ Toe massage. FIGURE 5 ■ Abdominal massage.
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FIGURE 3 ■ Legs, wrist twist.
order to help him feel secure and comfortable; the infant will
show signs of stress if the person giving the massage frequent-
ly loses physical contact. Flow gently from one body part to
another, using a smooth, gentle rhythm. Each body part takes
about one minute, with 12–16 strokes per minute.20
The majority of the massage will consist of the effleurage
stroke. Effleurage is a smooth, relaxing stroke and can be
used on the entire body; it relaxes the soft tissue such as mus-
cles and tendons.21 Apply effleurage with firm pressure; light
stroking alone does not enhance weight gain.18 Effleurage is
responsible for stimulating circulation, eliminating waste
products through the lymphatic system, speeding up recovery
from injuries, and decreasing stress hormones.22
Pettrisage, a gentle kneading, rolling stroke, uses the fin-
gers and thumb or the palm of the hand; it is applied primari-
ly to the arms and legs. 23 The therapeutic ef fects of
pettrissage are improved muscle tone, improved circulation,
and removal of waste products that are released by the cells.22
Infant massage therapy should be firm enough to pene-
trate the subcutaneous tissues, similar to giving an adult mas-
sage without the vigorous kneading of the muscles. Use slow,
steady, gentle movements; avoid fluttery or ticklish strokes.
Increase the intensity of the massage as the infant matures
and becomes accustomed to the massage therapy.
TECHNIQUE
1. To begin: Place the infant on a soft pillow or blanket on
your lap in the supine position. Place your hands on the
FIGURE 6 ■ Finger massage.
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FIGURE 7 ■ Ear massage. FIGURE 8 ■ Head massage.
infant to make your presence known. Looking in the
baby’s face, place your hands under the hips and gently
raise the hips up with a rolling motion. Lift about 2 inches.
This elicits an opening stretch. Repeat this three to four
times. Then move on to the least sensitive area, the legs
(Figure 1).18
2. Legs: Use your index finger and thumb to circle the 6.
baby’s thigh. Use your other hand to hold the ankle.
Move the first hand over the buttocks and down the leg.
Repeat twice (Figure 2). Next, wrap your hands around
the thigh and gently glide down the leg, twisting your
wrists as you go (Figure 3). Repeat twice. Move your
thumb over the top and bottom of the foot, being careful 7.
to avoid heelstick areas. Squeeze and roll the toes individ-
ually. Stabilize the foot with both hands, and move your
thumbs in a circle around the ankle (Figure 4). Repeat
with the other leg.
3. Abdomen: Rub from the umbilicus to the groin using the
entire palm of your hand. Keep one hand in contact with
the skin at all times. Next, massage from the upper left side
under the ribs, making the letters I, L, and U. Form the
letter I following the descending colon and glide your
hand from the right to the left under the ribs, forming an 8.
upside down L and then U following the ascending trans-
verse and descending colon. Repeat three to four times.
This is helpful for infants with constipation and gas because
the hand movement along the large intestine to the
descending colon stimulates the elimination of waste.
Lastly, start at the umbilicus and make an ever-increasing
clockwise, circular stroke around the abdominal area
(Figure 5). 9.
4. Arms: Hold the baby’s wrist or hand with one hand, and
rub down the arm with your other hand, molding your
hand around the arm and sliding down from shoulder to
hands. Repeat three to four times, keeping the infant’s
arm in midline. Open the baby’s hands, and massage the
palm with small circles; also massage the wrist with small
circles. Massage the fingers individually (Figure 6).
Repeat with the other arm.
5. Face: Do not put oil on the face because it may get
into the eyes. Rub the face with your fingertips or
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FIGURE 9 ■ Back integration massage.
thumbs. Move your fingers from the top of the head to
the chin, and then across the cheeks. With your
thumbs, push on the bridge of the nose and stroke
down across the sinus area. Next, stroke across the
upper lip. Make tiny circles over the cheeks and jaw.
Massage the ears (Figure 7).
Scalp: Rub the head, using one hand to cradle it and the
other to rub. Make small circles covering the entire scalp;
then rub from the top of the head down to the base of
the skull. Avoid the front of the neck because massaging
there may cause a cough reflex; also avoid swollen and
bruised areas on the head (Figure 8).
Back: Slowly turn the baby over. Using your entire hand,
stroke from the neck, down the shoulders and arms, to
the fingertips. Place your right hand on the buttocks and
your left hand over the shoulders. Move your left hand
down the back, then your right hand. Alternate, repeat-
ing twice; then make small circles along the sides of the
spine from the neck downward. Avoid direct pressure
over the spine because it is uncomfortable to the infant.
Finish the back by rubbing your hands down the entire
body, including the legs (Figure 9).
Chest: Turn the baby faceup. Avoid getting oil on the
umbilical cord and ECG lead area. Place your hands on
the infant’s chest for a second, and then glide down from
shoulders to groin (Figure 10). Next, move your hands
in a heart-shaped pattern from the center of the chest out
and following the rib cage down. Finally, cross your
hands, moving one hand across the chest, then the other.
Repeat twice (Figure 11).
Kinesthetic stimulation: If the infant tolerates the mas-
sage well, you can begin gentle kinesthetic massage
movements. Do these at the rate of about six per minute.
Begin by holding the baby’s wrists and crossing them
over the chest, alternating them with one arm on top
first, then the other. Then stretch the arms out alongside
the body. Next, cross the legs and arms over the body:
First, bring the left arm across the chest to the bottom of
the ribs on the right side; then cross the left leg over the
stomach. Repeat on the opposite side. Then gently
stretch out the legs. End by “bicycling” the legs with
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FIGURE 10 ■ Chest massage. FIGURE 11 ■ Chest massage.
flexion and extension softly toward the stomach. Do not
let go of the extremities during these movements.
Kinesthetic stimulation should take no longer than 5
minutes (Figure 12).
10. You may repeat the entire massage if the infant has toler-
ated it well. All nurses should be taught by a qualified
infant massage instructor prior to showing parents how
to massage. The parents may want to view a massage
video before a hands-on demonstration is done.
IMPLICATIONS FOR NURSING PRACTICE
One goal of NICU care is to promote maximum individu-
al potential and appropriate developmental growth.
Immediately after birth, it is important to protect the prema-
ture infant from intracerebral/intraventricular injury by keep-
ing all stimulation to a minimum. Then, once the infant is
stable, it is important to incorporate nonpainful touch, such
as massage, into the care plan on an individualized basis in
order to improve the infant’s overall physical and emotional
state and to counteract the many negative stimuli experienced
in the NICU.
The neonatal nurse can greatly enhance the quality of care
for the infant and family by incorporating at least one massage
a day into care times. Experience and research show that the
benefits of infant massage greatly outweigh the minor risks.
Infant massage should become a standard for all stable
preterm infants in the NICU.
SUMMARY
Infant massage is a therapeutic tool that improves the
developmental outcome of the stable preterm infant in the
NICU. It leads to better feeding tolerance, significant increas-
es in weight gain, and improved skin texture. It also enhances
neurologic development, lowers stress hormone secretion lev-
els, improves tolerance to pain, aids sleep, and increases alert
awake times. Parents benefit from improved attachment, bet-
ter understanding of their infant’s cues, and an enhanced feel-
ing of confidence.
A successful massage therapy program in the NICU must
have the support of the neonatologist and nurses. Nursing
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FIGURE 12 ■ Bicycling of legs.
education must include these points: (1) understanding the
risks and benefits of infant massage, (2) determining when
massage is not an appropriate therapy, (3) being alert to the
stress cues and awake states of the premature infant, and (4)
understanding the massage strokes and techniques.
Massage therapy is easy to teach and simple to learn. It is
inexpensive and cost-effective when done by nurses and fami-
ly members. Research supports the institution of a massage
therapy program in the NICU. All individuals involved in this
program benefit: the premature infant, the family, and the
nurses.
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About the Author
Jodi Beachy has been interested in the developmental care of the
neonate for 16 years. She is a neonatal nurse practitioner and infant
massage instructor at Children’s Hospital Newborn Special Care unit at
Doctors West, Columbus, Ohio.
The author would like to express gratitude to Carl Backes, DO, and
Jeptha Hostetler, PhD, for their valuable input and encouragement. The
author would also like to thank Lisa Lyons and Grace Maxwell for their
photographs, as well as the entire staff of the Neonatal Special Care Unit
at Doctors Hospital West for their support and patience.
For further information, please contact:
Jodi M. Beachy, BSN, RNC, NNP
Doctors Hospital West
Newborn Special Care Unit
5100 West Broad Street
Columbus, OH 43228
E-mail: BeachyJodi@juno.com
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