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To evaluate the efficacy of massage on the short- and long-term outcomes of preterm infants. A search was conducted using the PRISMA framework. Validity of included studies was assessed using criteria defined by the Cochrane Collaboration that was carried out independently by two reviewers with a third reviewer to resolve differences. Thirty-four studies met the inclusion criteria, 3 were quasi-experimental, 1 was a pilot study, and the remaining 30 were randomized controlled trials (RCTs). The outcomes that could be used in the meta-analysis and found in more than three studies noted that massage improved daily weight gain by 0.53 g (95% CI = 0.28-0.78), p < 0.0001, and resulted in a significant improvement in mental scores by 7.89 points (95% CI = 0.96-14.82), p < 0.03. There were no significant effects on length of hospital stay, caloric intake, or weight at discharge. Other outcomes were not analyzed either because the units of measurement varied or because means and standard deviations were not provided by the authors. These included vagal activity and heart rate variability (5 studies), neurobehavioral states (7 studies), pain responses (2 studies), maternal outcomes (2 studies), breastfeeding (2 studies), and physiologic parameters: bone formation (2 studies), immunologic markers (1 study), brain maturity (1 study), and temperature (1 study). The quality of the studies was variable with methods of randomization and blinding of assessment unclear in 18 of the 34 studies. Massage therapy could be a comforting measure for infants in the NICU to improve weight gain and enhance mental development. However, the high heterogeneity, the weak quality in some studies, and the lack of a scientific association between massage and developmental outcomes preclude making definite recommendations and highlight the need for further RCTs to contribute to the existing body of knowledge.
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Objective: To evaluate the effi cacy of massage on
the short- and long-term outcomes of preterm
Methods: A search was conducted using the
PRISMA framework. Validity of included studies was
assessed using criteria defi ned by the Cochrane
Collaboration that was carried out independently
by two reviewers with a third reviewer to resolve
Results: Thirty-four studies met the inclusion criteria,
3 were quasi-experimental, 1 was a pilot study,
and the remaining 30 were randomized controlled
trials (RCTs). The outcomes that could be used
in the meta-analysis and found in more than
three studies noted that massage improved daily
weight gain by 0.53 g (95% CI = 0.28–0.78),
p < 0.0001, and resulted in a signifi cant improve-
ment in mental scores by 7.89 points (95%
CI = 0.96–14.82), p < 0.03. There were no signifi -
cant effects on length of hospital stay, caloric intake,
or weight at discharge. Other outcomes were not
analyzed either because the units of measurement
varied or because means and standard deviations
were not provided by the authors. These included
vagal activity and heart rate variability (5 studies),
neurobehavioral states (7 studies), pain responses
(2 studies), maternal outcomes (2 studies), breast-
feeding (2 studies), and physiologic parameters:
bone formation (2 studies), immunologic markers
(1 study), brain maturity (1 study), and temperature
(1 study). The quality of the studies was variable
with methods of randomization and blinding of as-
sessment unclear in 18 of the 34 studies.
Conclusions: Massage therapy could be a comfort-
ing measure for infants in the NICU to improve
weight gain and enhance mental development.
How ever, the high heterogeneity, the weak quality in
some studies, and the lack of a scientifi c associa-
tion between massage and developmental out-
comes preclude making defi nite recommendations
and highlight the need for further RCTs to contribute
to the existing body of knowledge.
Key words: Massage; Meta-analysis; Preterm
infants; Systematic review; Tactile stimulation.
An Ancient Practice With Contemporary Applications
Lina Kurdahi Badr, PhD, RN, CPNP, FAAN, Bahia Abdallah, MPH, RN,
IBCLC, and Lara Kahale, MPH, RN
A Meta-Analysis of
Andia / Alamy
344 volume 40 | number 6 November/December 2015
November/December 2015 MCN 345
therapy (MT) is defi ned by the American Massage Therapy
Association (AMTF) as “the manipulation of the soft tis-
sue structures of the body to prevent and alleviate pain,
discomfort, muscle spasm, and stress; and, to promote
health and wellness” (AMTF, 2005).
Why Review of Massage is
Important by Aims of the Review
Reducing stress in the NICU and promoting growth is
necessary for the favorable developmental outcome of
preterm infants. Although the effectiveness of massage
therapy has been reported in a few reviews (Bennett, Un-
derdown, & Barlow, 2013; Smith, 2012; Vickers et al.,
2004; Wang et al., 2013), these reviews were either fo-
cused on full-term infants (Bennett et al.), are outdated
(Vickers et al.), or have omitted several recent RCT stud-
ies (e.g., Smith; Wang et al.). Thus, the primary aim of
this review was to evaluate the effi cacy of massage on
several short- and long-term outcomes of premature in-
fants not addressed in previous studies. The review was
conducted based on the PRISMA (Preferred Reporting
Terms for Systematic Reviews and Meta-Analysis) (Libe-
rati et al., 2009a, 2009b) and the Cochrane guidelines
(Higgins et al., 2011). The history, types of massage, and
mechanisms of action are also discussed.
History of Massage
Massage therapy is an old practice that has evolved into
a science over the centuries. The word “massage” comes
from the Arabic root “mass’h” which means to touch or
squeeze or the Greek word meaning to knead. The oldest
written record of massage is approximately 4,000 years old
and was noted in Chinese medical literature. The ancient
Egyptians developed their own form of massage therapy
in 2500 B.C. that focused on specifi c points of the body to
heal and rejuvenate. In ancient Greece, massage therapy
was used in the medical world where Hippocrates (460
to 380 B.C.) advocated that the physician must be experi-
enced in the art of rubbing or massage (Yapijakis, 2009).
Although the western world turned away from the tradi-
tional healing practices including massage during the dark
ages, the practice gained popularity in Sweden in the 19th
century through Pehr Ling, who is regarded as the “father
of modern massage” (Arnould-Taylor, 1997). Mothers
in several cultures massage their infants for a number of
months as an integral part of parenting. For example, a
survey conducted in Bangladesh found that 96% of moth-
ers give their babies whole body massages between one and
three times daily (Darmstadt & Saha, 2002). In Western
India, mothers massage their infants because they believe
it enhances circulation and promotes strong bones (Darm-
stadt & Saha, 2003). During the past 3 decades, especially
with the work of Montagu, an English anthropologist who
championed the humanizing effects of touch in the 1970s,
the Western world has adopted massage therapy (MT) as
an intervention aimed at reducing stress in premature
The increased incidence of preterm, low birth
weight (LBW), and very low birth weight (VLBW)
infants in the last few decades is a worldwide
heath concern. This is attributed to several factors
such as assisted conception, higher maternal age
at fi rst childbirth, an increase in multiple births,
and induction of labor and cesarean birth before 37 weeks
gestation (American College of Obstetricians and Gyne-
cologists [ACOG], 2007; Badr, Abdallah, & Mahmoud,
2005; Beck et al., 2010; Bettegowda et al., 2008; Engle &
Kominiarek, 2008; Fuchs & Wapner, 2006). In 2010, an
estimated 11.1% of all live births worldwide were preterm,
ranging from approximately 5% in a number of European
countries, to 18% in some African countries (Blencowe et
al., 2012). Mortality rates of LBW and preterm infants are
three times that of full-term infants and account for 90%
of neonatal mortality, while morbidity is three to four times
that of full-term infants (Mathews & MacDorman, 2010;
Moreira, Magalhães, & Alves, 2014). Although improved
technology and treatment modalities have decreased
mortality and morbidity rates, long-term developmental
and cognitive outcomes remain suboptimal (Behrman &
Butler, 2007; Mathews & MacDorman, 2010). Delayed
motor and mental development, behavioral problems,
academic performance impairment, social and emotional
developmental diffi culties, and sensory abnormalities such
as impaired vision and hearing are common long-term con-
sequences, especially for infants born less than 24 weeks
gestation (Arpino et al., 2010; Roberts & Cheong, 2014;
Robertson, Howarth, Bork, & Dinu, 2009).
Due to the extended stay in the neonatal intensive care
unit (NICU), preterm infants are exposed to varying han-
dling and touch stimuli, which are often painful and stress-
ful. Several studies have made consistent observations on
the adverse effects of such handling procedures, including
hypoxia, bradycardia, sleep disruptions, increased intracra-
nial pressure, and behavioral agitation (Abdallah, Badr, &
Hawwari, 2013; Roofthooft, Simons, Anand, Tibboel, &
van Dijk, 2014). To minimize the stress of the NICU and
optimize the developmental outcomes of infants, several
interventions in the past 2 decades have been researched.
Some of these interventions have included (but are not been
limited to): kangaroo care (KC), massage therapy, cluster
care, nonnutritive sucking, positioning, swaddling, unlim-
ited parental visitation, and decreasing light and noise (Au-
cott, Donohue, Atkins, & Allen, 2002; Conde-Agudelo,
Belizán, & Diaz-Rossell, 2011; van Sleuwen et al., 2007).
To date, only two of these interventions have provided
conclusive evidence regarding their effi cacy: KC and non-
nutritive sucking (Conde-Agudelo et al.; Stevens, Yamada,
Lee, & Ohlsson, 2013). Massage therapy remains a con-
troversial intervention with inconclusive evidence related to
its clinical effectiveness (Vickers, Ohlsson, Lacy, & Hors-
ley, 2004; Wang, He, & Zhang, 2013). For the purposes
of this review, the term preterm infant is used to refer to
infants born before 37 completed weeks of gestation, LBW
infants are those born at less than 2500 grams and VLBW
infants are those born at less than 1500 grams. Massage
346 volume 40 | number 6 November/December 2015
(3) from the upper back to the waist, (4) from the
thigh to the foot to the thigh on both legs, and (5) from
the shoulder to the hand to the shoulder on both arms.
For the KS phase, fi ve, 1-minute segments of six pas-
sive fl exion/ extension movements lasting approxi-
mately 10 seconds apiece for each arm, then each leg,
and fi nally both legs together.
2) Vaivre-Douret (2003, 2009) in France described MPM
as a form of TS with the hands moving from the abdo-
men to the thorax and shoulders, followed by one half
of the body to cover the arm, hand, leg and foot, and
then the other half of the body and a ventral reversal
to massage the back, shoulders, and nape of the neck,
ending with a dorsal reversal to touch the head and
face with KS.
3) Vimala McClure (1978, 2009) in the United States
combined ancient Indian practice with modern Swed-
ish methods. It was fi rst used with term infants and
then preterm infants. This massage includes systematic
very gentle and slow stroking of the whole body (head-
to-toe, supine-to-prone, and midline-to-periphery
progression), divided into six anatomic regions with
Resting Hands beginning at each session and ends with
stretching of all limbs. The speed and order of MPM is
adapted to the individual infant’s cues.
4) Mathai (2001) from India described MPM as a form of
TS that can begin at day 3 of life for 5 consecutive days,
and thereafter can be provided by trained mothers until
40 to 42 weeks postmenstrual age with small amount of
mineral oil. This MPM includes three phases: in the fi rst
phase, 12 fi rm strokes in the prone position with palms
of the hands; in the second phase, 12 fi rm strokes with
palms of the hands with the infant in the supine position,
including the abdomen; and in the third phase, KS in the
supine position at each large joint.
Underlying Mechanism
of Massage Therapy
Touch is one of the fi rst developed senses in the fetus and
at birth. It is particularly important for the psychological,
infants. However, despite what has been published about the
benefi ts of infant massage, controversy remains about the
strength of evidence and possible adverse effects (Kulkarni,
Kaushik, Gupta, Sharma, & Agrawal, 2010).
Types of Massage
Used With Premature Infants
Different types of massage therapies have been used;
however, for this review only studies that used Moder-
ate Pressure Massage (MPM) or Tactile Stimulation (TS)
combined with or without Kinaesthetic Stimulation (KS)
(passive fl exion and extension movements of the limbs)
are included. Nevertheless, within MPM, researchers
have used various techniques as summarized below.
1) Field (1986) in the United States was the fi rst to de-
scribe a technique for MPM employing both TS and
KS. The massage consists of 15 minutes of three stan-
dardized 5-minute phases given after feeding. Tactile
stimulation is given during the fi rst and third phase
while infant is in prone position, and KS is given dur-
ing the middle phase while infant is in supine position.
For TS, 12 gentle strokes are applied at approximately
5 seconds per stroking motion on the infant’s body in
the following sequence: (1) from the top of the head
to the neck, (2) from the neck across the shoulders,
Massage therapy could be a comforting
measure for infants in the NICU to
improve weight gain and enhance
mental development.
Phanie / Alamy
November/December 2015 MCN 347
and if the results were questionable or unclear (Liberati
et al., 2009a, 2009b). Separate folders for each database
were created and close duplicates were removed. Two
reviewers evaluated the abstracts of each article indepen-
dently for eligibility of study inclusion/exclusion. From
the 1,145 abstracts found, 42 studies were evaluated in
detail by full text to determine their relevance for inclu-
sion criteria by two reviewers, with a third reviewer to re-
solve differences. Eight studies were excluded because of
poor or insuffi cient information on methods or outcomes
and one was excluded due to redundancy, resulting in 34
studies (Figure 1).
Data Extraction
Data were extracted using standardized data extrac-
tion tables adapted from the Cochrane handbook
(Higgins et al., 2011). Two reviewers independently
reviewed the studies with any disagreements resolved
by discussion or by the third reviewer. The main data
extracted included author, year, place where study
was conducted, year of publication, number of par-
ticipants, study design, intervention, primary and sec-
ondary outcomes, and results. The complete data with
mental, and physiological development of preterm infants
(Blackwell, 2000; Bystrova et al., 2009). Several research-
ers have postulated that infant massage may help mature
the central nervous system by normalizing its function,
increasing the secretion of neuroendocrine substances
necessary for growth; it moderates cortisol production
and promotes glucocorticoid receptors in the hippocam-
pus and increases vagal activity that aids the secretion of
gastrointestinal hormones important for food absorption,
particularly insulin and gastrin (Ang et al., 2012; Diego,
Field, & Hernandez-Reif, 2005; Diego, Field, Sanders, &
Hernandez-Reif, 2004; Field, Diego, & Hernandez-Reif,
2011; Field, Diego, Hernandez-Reif, Deeds, & Figuereido,
2006; McGrath, 2009; Procianoy, Mendes, & Silveira,
2010; Smith, 2012; Uvnas-Moberg, 2004). However, the
exact mechanisms of action have not yet been confi rmed
since the evidence is limited to animal studies. Further re-
search with human infants is required to ascertain exact
mechanism of action.
Search Strategy
A systematic review of the literature was undertaken us-
ing PRISMA guidelines including studies in the English
language published between 2000 and 2014 in peer-
reviewed journals (Liberati et al., 2009a, 2009b). Stud-
ies before 2000 were not included as they were reviewed
in an earlier systematic Cochrane review (Vickers et al.,
2004). The PICOS approach was used in searching the
literature. The population (P) of interest was preterm and
LBW infants in neonatal units; the intervention (I) was
massage (MPM, TS with or without KS, and touch); the
comparisons (C) were no intervention, standard/routine
care or other forms of intervention, the outcomes (O) of
interest were any infant physiological measures (heart
rate, temperature, caloric/formula intake, vagal activity/
tone, gastric motility, insulin, bone density, and immuno-
logic measures), behavioral responses, neurodevelopment,
clinical outcomes (length of stay), and anthropometric
measures (weight, length, head circumference, skinfold
thickness, & Ponderal Index), the study design (S) includ-
ed randomized controlled trials (RCTs), or concurrent
comparisons before/after studies.
The electronic databases MEDLINE, EMBASE, CI-
NAHL Plus, The Cochrane Library, Dissertation Ab-
stracts, Wiley Online Library, and Google scholar were
searched using the one or more of the following key
words: massage (MPM, TS with or without KS, and
touch), tactile stimulation, premature, preterm, LBW,
and VLBW infants. “Snowballing” by reference and cita-
tion tracking was performed using the citation databases.
Exclusion Criteria
Studies were excluded if they used gentle massage,
Touching and Caressing, Tender in Caring (TAC-TIC)
therapy, or massage to one area of the body, if there was
an unclear description of how participants were random-
ized or allocated to the intervention and control groups
Figure 1. Method of data extraction
Total titles and abstracts screened
by 2 reviewers (n = 1145)
Duplicate studies excluded (n = 659)
Excluded studies because they did
not focus on massage as the main
intervention (n = 397)
Studies excluded (Total = 47) because
massage was not moderate pressure
(n = 26)
Not original study (n = 21)
Potentially relevant studies identifi ed by
2 reviewers Total (n = 89)
Primary studies meeting all inclusion
criteria (n = 34)
Studies excluded if
there was insuffi cient
information on methods
or outcome, and one was
redundant (n = 8)
Studies evaluated in detail
by full text to
determine relevance
for inclusion criteria by
2 reviewers (n = 42)
348 volume 40 | number 6 November/December 2015
Table 1b. Characteristics of included studies with means and standard deviations (SD) reported if noted in the studies, a ?
indicates that the information was not found in the publication
Author (Date)/
Location Design Participants
Abdallah et al.
N = 50, IG = 27, CG = 23,
GA = 26–36 w, BW = 750–2,500 g
Age at enrolment: ?
Medically stable
Aliabadi &
Askary (2013)
RCT N = 40, IG = 20, CG = 20,
GA = 33.65 (±1.93) w.
BW = >1,500–2,499 g
Age at enrolment: ?
Medically stable
Aly et al.
N = 30, IG = 15, CG = 15
GA = 28–35 w, BW = 1,200–1,700 g
Age at enrolment: < 2 w
Medically stable
Ang et al.
RCT Triple
Block Design
N = 120, IG = 58, CG = 62
GA: 28–33 w, BW: 685–1,790 g
Age at enrolment: 11–13 days PNA
Medically stable
Arora et al.
RCT N = 62, IG1 = 20, IG2 = 19, CG = 23
BW = <1,500 g, GA = <37 w
Age at enrolment: 3.5–4.5 days PNA
Medically stable
Diego et al.
RCT with strat-
ifi ed randomiz-
N = 48, IGI = 16, IG2 = 16,CG = 16
GA = 22–33 w, BW = 560–1,800 g
Age at enrolment: 29–34 w
Medically stable
Diego et al.
RCT with strat-
ifi ed randomiz-
N = 70, IG = 36,CG = 34
GA: 26 = 32 w, BW: 900 = 1,400 g
Age at enrolment: ?
Medically stable
Diego et al.
RCT with strat-
ifi ed randomiz-
N = 48, IG = ?, CG = ?
GA mean = 29.4 w,
BW mean = 1,206 g
Age at enrolment:?
Medically stable
Diego et al.
RCT with strat-
ifi ed randomiz-
N = 56, IG1 = 20, IG2 = 16, CG = 16
BW mean = 1,212 g, GA = 29.8 w
Age at enrolment: 34.7 w
Medically stable
Diego et al.
RCT with strat-
ifi ed randomiz-
N = 30, IG1 = 15, IG2 = 15,
BW = 1,000–1,500 g, GA = 28–32 w
Age at enrolment: 15–60 PNA days;
Medically stable
Dieter et al.
RCT with strat-
ifi ed randomiz-
N = 32, IG = 16, CG = 16
GA = 25–34 w, BW = 750–1,600 g
Age at enrolment = 22–25 PNA days
Medically stable
Fallah et al.
parallel group
N = 54, IG1 = 27, IG2 massage
with oil
GA = 33–37 w, BW = 1,500–1,999 g,
Age at enrolment: ?
Medically stable
Author (Date)/
Location Design Participants
Ferber et al.
Cluster design
N = 57, IG1 = mothers, IG2 =
research assistant, CG = 19
GA 26–34 w, BW >600–<2,200 g
Age at enrolment: 12–17 PNA days
Medically stable
Ferber et al.
Cluster design
N = 57, IG1 21, IG2 = 16, CG = 19
GA 26–34 w, BW >600–<2,200 g
Age at enrolment = 10–12 PNA days
Medically stable
Ferreira &
N = 32, IG = 16, CG = 16
GA = 33.38 (+1.9)–33.28 (+2.1),
BW 1,872.81 (±407.85)–1,910.31 ± 30.86)
Age at enrolment: ?
Medically stable
Field et al.
Parallel design
N = 42, Number in each arm not
specifi ed
GA mean = 29.5, BW mean = 1,236 g
Age at enrolment = 34.6 w.
Medically stable
Field et al.
RCT N = 60, Did not specify the number
in each arm
GA: 28–32 w, BW: 550–1,800 g
Age at enrolment: 34.6 w
Medically stable
Fucile & Gisel
N = 75, IG1 = 19, IG2 = 18,
IG3 = 18, CG = 20
GA stratifi ed (26–29 and 30–32 w),
BW mean = 1,340 ± 52.5 g
Age at enrolment: 31–32 w
Medically stable
Fucile et al.
N = 75, G1 = 19, IG2 = 18, IG3 = 18,
CG = 20
GA stratifi ed (26–29 and 30–32 w),
BW mean = 1,340 ± 52.5 g
Age at enrolment: 31–32 w
Medically stable
Gonzalez et
al. (2009)
Parallel design
N = 60, IG = 30, CG = 30
GA 30–35 w, BW = ??
Age at enrolment: ?
Medically stable
Guzetta et al.
Parallel design
N = 20, IG = 10, CG = 10
GA 30–33 w, BW = ?
Age at enrolment = PNA 10 days.
Haley et al.
N = 40, IG = 20, CG = 20
GA 29–32 w, BW = 1,300–1,900 g
Age at enrolment = 32–33 w
Medically stable
Reif et al.
RCT N = 32, IG = 16, CG = 16
GA = 28–32 w, BW = 800–1,400 g
Age at enrolment = ?
Medically stable
Ho et al.
Hong Kong
RCT (pilot) N = 20, IG = 10, CG = 10
GA = 25–34 w, stratifi ed by birth wt
21,000 g vs. 1,001–1,500 g
Age at enrolment: ?
Medically stable
November/December 2015 MCN 349
all of the information is Table 1A that can be found
at, Table 1B here, pro-
vides abbreviated information of the studies reviewed.
Quality Assessment/Risk of Bias
Risk of bias was assessed using the Cochrane Collabora-
tion’s “Risk of Bias” tool (Higgins & Green, 2008). Two
review authors independently assessed the methodologi-
cal quality of each included study and resolved any dis-
agreements by discussion with a third reviewer. Method-
ological criteria were used to summarize the quality of the
studies into: low risk of bias, high risk of bias, and unclear
risk of bias (Table 2 can be found at Supplemental Digital
Statistical Analysis
The Cochrane review manager (2011) was used to ana-
lyze any three or more studies that measured the same
outcome using the same unit of measurement, these in-
cluded: weight at discharge, average weight gain, caloric
intake, length of stay (LOS), and mental development
(Bayley Scales). Total number of participants and number
of participants who were massaged, as well as the means
and standard deviations (SD) of each study were extract-
ed when available. Studies that did not report means and
standard deviations (despite attempts to contact the au-
thors) and/or who did not have a control group (no mas-
sage) had to be excluded from the meta-analysis; however,
they were included in the review. Heterogeneity between
trials was tested by the Q statistic and the I2 metric using
the random effect model. Forest plots were generated by
using the RevMan 5.2 software (Higgins & Green, 2008).
Classifi cation of studies for Heterogeneity was as follows: a
value of I2: 0 to 30 = low; 30 to 60 = moderate; 60 to 100 =
high. For studies with more than one intervention, only the
rst arm intervention was entered in the analysis.
A total of 34 studies were identifi ed meeting the inclusion
criteria (Table 1), 3 were quasi-experimental (Abdallah
et al., 2013; Ferreira & Bergamasco, 2010; Rangey &
Sheth, 2014), 1 was a pilot RCT study (Ho, Lee, Chow,
& Pang, 2010), and the remaining 30 were RCTs. Studies
were conducted in four continents: Asia (Middle-East =
6, Hong Kong = 1, and India = 5), South America (N =
5), Europe (N = 2), and North America (N = 15). Studies
were heterogeneous in terms of design, participants, inter-
vention, and outcomes measures. All the studies included
medically stable infants, 22 studies included VLBW in-
fants, and 5 focused exclusively on VLBW infants. All of
the studies provided Moderate Pressure Massage (MPM);
however, 25 used the massage therapy described by Field
(1986), some with and some without KS for different pe-
riods of time, 2 used the massage therapy described by
Mathai, 4 used the McClure method, 2 described their
own technique of MPM and 1 used the Vaive-Douret
Author (Date)/
Design Participants
Kumar et al.
RCT N = 48, IG = 25, CG = 23
GA < 35 w, BW = <1,800 g
Age at enrolment: 25–27 w
Medically stable
Massaro et al.
RCT N = 60, G1 20, IG2 = 20, CG = 20
BW = <1,500 g, GA = 3 2 w
Age at enrolment: 7–15 PNA days
Medically stable
Mendes & Pro-
cianoy (2008)
RCT blinded N = 104, IG = 46, CG = 47,
GA 32 w, mean = 29.7 BW 750
1,500 g,.
Age at enrolment: 2 days
Medically stable
et al. (2013)
N = 44, IG = 22, CG = 22
GA = 28 4/7 and 32 3/7 w, BW = IG =
1,574 ± 232 & CG = 1,618 ± 231 g
Age at enrolment: 32–33 w
Age at enrolment:
Medically stable
Procianoy et al.
RCT blinded
N = 73, IG = 35, GC = 38
GA mean = 29.7 w, BW = 750 and
1,500 g
Age at enrolment: 2 days
Medically stable
Rangey &
N = 30, IG1 = 15, IG2 = 15
GA < 37 weeks, BW= <2,500 g
Age at enrollment = ?
Medically stable
et al. (2005)
RCT with
block ran-
N = 112, IG1 = 38, IG2 = 37,CG = 37
GA = >32 w, BW 1,500–2,000 g
Age at enrolment: ?
Medically stable
Smith et al.
RCT N = 37, IG = 17, CG = 20,
GA 29–32 w, BW mean IG = 1,615.5 ±
220.3 g mean CG = 1,641 ± 311.2 g
Age at enrolment: 32–33 w
Medically stable
Teti et al.
N = 138, IG = 66, CG = 72,
GA < 37 w (Mean = 30.12± 3.45), BW
= 1,409.15, ± 557.52),
Age at enrolment: 32–36 w PCA
Medically stabile
et al. (2009)
N = 49, IG1 = 12, IG2 = 12, IG3 = 12,
CG = 13
GA 31–34 w, Wt 1,543–1,933 g
Age at enrolment = ?
Medically stabile
N = Number
W = Weeks
Wt = wt
M = Mean
IG = Intervention group
CG = Control group
GA = Gestational age
BW = Birth weight
RCT = Randomized Controlled Trail
DC = Discharge
LOS = Length of stay
NS = Nonsignifi cant
PNA = Postmenstrual age
PCA = Postconceptual age
350 volume 40 | number 6 November/December 2015
or during NICU stay. Weight gain was reported as either
total mean weight gain or daily mean weight gain in g/kg/
day or g/day. Sixteen studies reported the benefi ts of mas-
sage on weight gain and nine did not fi nd any relationship
between massage and weight gain. Six of the eight studies
that used oil in the massage had positive results; however,
only four of those could be used in the meta-analysis as
there was no control group in four studies (Diego, Field, &
Hernandez-Reif, 2014; Fallah, Akhavan Karbasi, Golestan,
& Fromandi, 2013; Rangey & Sheth, 2014; Sankaranaray-
anan et al., 2005). Due to missing data or lack of a control
group, 13 studies were analyzed for daily weight gain and
10 studies analyzed for weight at discharge or the end of
the intervention. Of the 13 studies eligible for analysis for
method. Outcomes varied; while the majority of studies
mentioned that weight gain was the primary outcome,
others did not mention the primary outcome. The vari-
ous outcomes included neurodevelopment, LOS, mother
and infant behaviors, breastfeeding, pain, caloric intake,
adverse events, and physiologic variables (vagal activity,
gastric motility, brain maturation, bone formation, insu-
lin and immunologic markers, and temperature).
Massage and Weight Gain
Twenty-fi ve studies assessed weight gain using different
units of measurement: 9 studies reported both weight gain
and weight at discharge, 3 reported weight gain at dis-
charge, and 13 reported weight gain after the intervention
Figure 2. Forest plots for the association between massage and daily weight gain (weight in grams), standard mean
difference and the 95% CI of each study are indicated
Massage Control
Std. Mean
Difference Std. Mean Difference
Study or
Subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI
Abdallah (2013) 7.8 9 27 8.7 12.2 23 8.4% -0.08 [-0.64, 0.47]
–2 –1012
Ang (2012) 15.4 3.8 58 14.9 2.9 62 11.1% 0.15 [-0.21, 0.51]
Arora (2005) 10.9 4.4 20 8.3 4.9 23 7.7% 0.55 [-0.07, 1.16]
Deiter (2003) 48.7 36.9 16 22.7 12.2 16 6.4% 0.92 [0.19, 1.66]
Diego (2005) 19.6 3.7 16 15.5 3.6 16 6.2% 1.09 [0.35, 1.84]
Feild (2008) 13.6 16 20 -0.47 24.1 20 7.4% 0.67 [0.04, 1.31]
Ferrreira (2010) 6.09 13.8 16 4.53 26.6 16 6.8% 0.07 [-0.62, 0.76]
Fucile (2010) 17.6 3.8 18 12.6 5.9 20 7.0% 0.98 [0.30, 1.65]
Gonzalez (2011) 29.2 5.3 30 20.9 7.6 30 8.4% 1.25 [0.69, 1.81]
Ho (2012) 36.4 11 10 32.6 6 10 5.1% 0.41 [-0.48, 1.30]
Massarro (2009) 30 1.2 20 28.9 1 20 7.2% 0.98 [0.32, 1.64]
Mendez (2008) 15.4 3.8 46 14.4 3.5 47 10.4% 0.27 [-0.14, 0.68]
Moyer-Milier (2013) 16.8 4.8 22 16.4 5.5 22 8.0% 0.08 [-0.52, 0.67]
Total (95% CI) 319 325 100.0% 0.53 [0.28, 0.78]
Heterogeneity: Tau2 = 0.11; Chi2 = 27.34, df = 12 (P = 0.007); I2 = 56%
Test for overall effect: Z = 4.18 (P < 0.0001)
CI = Confi dence interval, df = degrees of freedom, Std = Standard
Favors[control] Favors[massage]
November/December 2015 MCN 351
Massage and Length of Stay (LOS)
Eleven studies assessed LOS with four providing posi-
tive results related to the effi cacy of massage in reducing
days spent in the NICU (Gonzalez et al., 2009; Massaro,
Hammad, Jazzo, & Aly, 2009; Rangey & Sheth, 2014;
Vaivre- Douret et al., 2009) and one reported earlier hos-
pital discharge for infants with low motor scores before
massage (Ho et al., 2012). Three studies reported LOS
in medians (Massaro et al.; Mendes & Procianoy, 2008;
Vaivre-Douret et al.), one study reported postconceptual
age at discharge and not LOS (Ho et al., 2010), and one
study did not have a control group (Rangey & Sheth) that
excluded them from the meta-analysis. Thus, six studies
with 332 participants were analyzed. The results found
that massaged infants did not have signifi cant reduction
in LOS -0.90 (95% CI -2.47–0.67), p = 0.26, with a low
heterogeneity of I2 = 26% (Figure 4).
daily weight gain there were a total of 644 participants. Due
to different units of measurement (g/day and g/kg/day) and
different gestational ages when the weight was obtained the
standard mean deviation (SMD) was used in the analysis.
Massaged infants had a modest improvement in weight gain
of 0.53 g (95% CI, 0.28–0.78), p = 0.0001. The heterogene-
ity in this comparison was moderate (I2 = 56%) (Figure 2).
In terms of difference in weight at discharge or at the end
of the intervention, 10 studies with 545 participants were
included. The results note a slight improvement in weight
favoring the massaged group by 51.04 g (95% CI, 7.34–
109.45, p = 0.09) that was not signifi cant and had moderate
heterogeneity of I2 = 55% (Figure 3). Subgroup analysis for
mean weight gain and weight at discharge selecting stud-
ies using the Field technique only (10 studies) and the ones
where the mothers provided the massage (8 studies) did not
improve the heterogeneity that remained above 50%.
Figure 3. Forest plots for the association between massage and weight at discharge (weight in grams), mean
difference and the 95% CI of each study are indicated
Massage Control Mean Difference Mean Difference
Study or
Subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI
Abdallah (2013) 1,842 174.34 27 1,772 143.65 23 14.3% 70.00 [-18.15, 158.15]
–500 –250 0 250 500
Aliabadi (2013) 1,930 338.5 20 1,945 299.8 20 6.2% -15.00 [-213.17, 183.17]
Ang (2012) 2,178 548 58 1,999 284 62 8.3% 179.00 [21.24, 336.76]
Arora (2005) 1,626 210 23 1,545 195.9 23 11.4% 81.00 [-36.37, 198.37]
Ho (2012) 1,636 258.6 10 1,536 233.6 10 5.4% 100.00 [-115.99, 315.99]
Kumar (2013) 1,946 252 25 1,773 217 23 10.1% 173.00 [40.25, 305.75]
Massarro (2009) 2,375 93 20 2,289 82 20 17.9% 86.00 [31.66, 140.34]
Mendez (2008) 1,973 140 46 2,051 270 47 14.4% -78.00 [-165.15, 9.15]
Moyer-Milier (2013) 2,186 352 22 2,265 338 22 5.9% -79.00 [-282.92, 124.92]
Procianoy (2010) 2,186 352 22 2,265 337 22 5.9% -79.00 [-282.63, 124.63]
Total (95% CI) 273 272 100.0% 51.04 [-7.34, 109.43]
Heterogeneity: Tau2 = 4177.24; Chi2 = 19.87, df = 9 (P = 0.02); I2 = 55%
Test for overall effect: Z = 1.71 (P < 0.09)
CI = Confi dence interval, df = degrees of freedom, SD = Standard deviation
Favors[control] Favors[massage]
352 volume 40 | number 6 November/December 2015
opment (Abdallah et al., 2013; Procianoy et al., 2010;
Teti et al., 2009), two using the Test for Infant Motor
performance (TIMP) scale (Fucile & Gisel, 2010; Ho
et al., 2010), and one using psychomotor development
(Vaivre-Douret et al., 2009). Comparing the three stud-
ies that used the Bayley scales with 261 participants,
the results note that mental development, but not mo-
tor, was signifi cantly enhanced by 7.89 points in mas-
saged infants (95% CI = 0.96–14.82, p < 0.03, I2 =
88%) (Figure 6). One of the two studies that used the
TIMP, found higher motor scores for massaged infants
(Fucile & Gisel) and Ho et al. (2010) noted higher
motor scores only for infants with low TIMP scores
at baseline. The study by Vaivre-Douret et al. (2009)
noted better neurologic and motor scores for infant
massaged with blended oil.
Massage and Maternal Outcomes
Two studies assessed the benefi ts of massage provided by
mothers on maternal behaviors (Ferber et al., 2005; Teti
et al., 2009). Ferber et al. (2005) noted that mothers of
massaged infants manifested more reciprocal behaviors
Massage, Caloric Intake/Gastric Motility/Digestion
Eight studies assessed caloric intake (Diego et al., 2005,
2014, 2007, 2003; Dieter et al., 2003; Ferber et al., 2002;
Field et al., 2008; Moyer-Mileur, Haley, Slater, Beachy, &
Smith, 2013). Of those, three were not analyzed because
Diego et al., (2003, 2014) did not have a control group and
Field et al. (2008) did not specify the number of infants in
each group. Due to the different methods used in calculating
caloric intake, the standard mean difference was used. There
were 224 total participants. Caloric intake favored the mas-
saged group by 7.70 calories (95% CI -3.03–18.44, p < 0.16,
but the difference was not signifi cant with high heterogene-
ity (74%) between studies (Figure 5). Two studies measured
gastric motility (Diego et al., 2005, 2007), one measured
time to attainment of oral feeding (Fucile et al., 2011), and
one measured age at oral feedings (Mendes & Procianoy,
2008). All but the study by Mendes and Procianoy found
signifi cant improvements for the massaged infants.
Massage and Infant Development
Six studies assessed infant development, with three us-
ing the Bayley scales of infant mental and motor devel-
Figure 4. Forest plots for the association between massage and LOS. Days in the NICU, mean difference and the
95% CI of each study are indicated
Massage Control Mean Difference Mean Difference
Study or
Subgroup Mean SD Total Mean SD Total Weight IV, Fixed, 95% CI IV, Fixed, 95% CI
Abdallah (2013) 27.21 18.67 27 25.04 18.54 23 2.3% 2.17 [-8.17, 12.51]
–20 –10 0 10 20
Ang (2012) 26 16 58 26 11 62 10.1% 0.00 [-4.94, 4.94]
Diego (2005) 20.1 11.2 16 25.5 11.1 16 4.1% -5.40 [-13.13, 2.33]
Ferrreira (2010) 13.44 8.57 16 18.19 13.8 16 3.9% -4.75 [-12.71, 3.21]
Fucile (2010) 55.7 3.7 18 55.3 2.6 20 58.5% 0.40 [-1.65, 2.45]
Gonzanlez (2011) 15.63 5.4 30 19.33 7.9 30 21.1% -3.70 [-7.12, 0.28]
Total (95% CI) 165 167 100.0% -0.90 [-2.47, 0.67]
Heterogenity: Chi2 = 6.77, df = 5 (P = 0.24); l2 = 26%
Test for overall effect: Z = 1.13 (P = 0.26)
CI = Confi dence interval, df = degrees of freedom, SD = Standard deviation
Favors[control] Favors[massage]
November/December 2015 MCN 353
and activity from the fi rst to the fi fth day of the massaged
Massage and Pain
Two studies assessed the relationship between massage
and pain responses in preterm infants. Diego, Field, and
Hernandez-Reif (2009) noted that preterm infants who
received 15 minutes of massage therapy 15 minutes prior
to the removal of surgical tape, exhibited less of an in-
crease in heart rate than infants who did not receive mas-
sage therapy and thus had lower heart rates following the
surgical tape removal. Abdallah et al. (2013) found that
infants who were massaged had signifi cantly lower pain
scores on the Premature Infant Pain Profi le (PIPP) during
a heel stick, compared to nonmassaged infants and had
lower PIPP scores at discharge.
Massage and Physiologic Measures
Physiologic parameters measured included heart rate
variability (HRV), vagal activity, immunologic markers,
bone formation temperature, and insulin levels. Four
studies measured vagal activity, one vagal tone (Diego
et al., 2005, 2014, 2007; Field et al., 2006, 2008), and
one measured HRV (Smith et al., 2013) with signifi cant
and were less intrusive while Teti et al. found that moth-
ers who massaged their infants had higher maternal
self- effi cacy scores. Two studies that assessed duration
of breastfeeding at 6 months corrected age (Abdallah et
al., 2013; Procianoy et al., 2010) found no difference be-
tween the massaged and the control group.
Massage and Infant Behavioral Responses
Six studies assessed the effects of massage on the behavior-
al states of infants. Three used the Brazelton Neonatal Be-
havioral Assessment Scale (BNBAS) (Aliabadi & Askary,
2013; Arora, Kumar, & Ramji, 2005; Sankaranarayanan
et al., 2005); and three used various scales to assess stress,
sleep, and wake behaviors (Dieter, Field, Hernandez-Reif,
Emory, & Redzepi, 2003; Field et al., 2006; Hernandez-
Reif, Diego, & Field, 2007). A meta-analysis could not be
performed on the three studies that used the BNBAS since
Sankaranarayanan et al. did not provide any data for
comparison. Nevertheless, the three latter studies did not
report signifi cant differences in the behaviors of infants.
Two studies, which assessed sleep wake states, found that
massaged infants slept less and were more relaxed (Dieter
et al.; Field et al., 2006). Hernandez-Reif et al. reported
signifi cant reduction in the duration of stress behaviors
Figure 5. Forest plots for the association between massage and caloric intake (kg/day), standard mean difference
and the 95% CI of each study are indicated
Massage Control Mean Difference Mean Difference
Study or
Subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI
Deiter (2003) 160.6 36.9 16 154.8 26.9 16 14.0% 5.80 [-16.58, 28.18]
–100 –50 0 50 100
Diego (2005) 111 11.4 16 111 12.4 16 29.5% 0.00 [-8.25, 8.25]
Diego (2007) 158 29.71 36 153 29.88 34 22.2% 5.00 [-8.97, 18.97]
Ferber (2002) 1,709 432 27 1,737 585 19 0.1% -28.00 [-337.43, 281.43]
(2013) 117 5 22 100 7.4 22 34.2% 17.00 [13.27, 20.73]
Total (95% CI) 117 107 100.0% 7.70 [-3.03, 20.73]
Heterogeneity. Tau2= 84.08, Chi2=15.60, df=4 (P=0.0004); l2=74%
Test for overall effect: Z=1.41.23 (P=0.16)
CI = Confi dence interval, df = degrees of freedom, SD = Standard deviation
Favors[control] Favors[massage]
354 volume 40 | number 6 November/December 2015
previous meta-analysis by Vickers et al. (2004) and Wang
et al. (2013) concluded that the evidence for the benefi ts
of massage for preterm infants is weak, and the associa-
tion between neurodevelopment and massage is elusive.
In this systematic review we included an additional 14
studies not reviewed in the previous 2 meta- analysis and
evaluated risk of bias based on Cochrane Collaboration
guidelines (Higgins et al., 2011). Our fi ndings are sup-
ported by previous reviews indicating high risk for bias in
most studies with moderate-to-high heterogeneity between
studies. As noted in Table 2 (Supplemental Digital Content,, 13 studies are con-
sidered at low risk of bias based on 4 or more of the 6
criteria evaluated at low risk while 21 studies are high
risk or unclear risk (Higgins et al.). The main reasons
for high risk are due to inadequate or lack of allocation
concealment, blinding of personnel and participants,
and blinding of outcome assessments. It is worth not-
ing that studies with premature infants in the NICU
setting are diffi cult if not impossible to blind personnel
as they are present in the unit and will observe the in-
tervention unless the infant is taken to another room or
the curtains around the crib or incubator are closed for
both the intervention and control sessions. This was the
case in a few studies, but may not have been possible in
all NICU settings. Blinding of participants is automatic
since infants are not aware of group assignment. When
mothers perform the massage as was the case in 8 stud-
ies, efforts were made to conceal the intervention such
as using the washout procedure (Ferber et al., 2005),
improvements in vagal activity, tone, and HRV. Diego et
al. (2014) noted that the increase in vagal activity was
for infants who were massaged using TS and not KS
(there was no control group).Only Field et al. (2008) of-
fered means for vagal activity with no SDs; thus, a meta-
analysis could not be performed.Two studies assessed
bone formation or density (Aly et al., 2004; Haley et al.,
2012), one assessed immunologic markers (Ang et al.,
2012), one assessed brain maturity using EEG (Guzzetta
et al., 2011), one assessed temperature (Diego, Field, &
Hernandez-Reif, 2008), and one assessed insulin levels
(Field et al., 2008). While all these studies reported sig-
nifi cant gains in massaged infants, none could be pooled
for analysis due to various units of measurement.
Massage and Adverse Events
Three studies (Ang et al., 2012; Fallah et al., 2013; San-
karanarayanan et al., 2005) assessed adverse events of
massage and reported minor or no adverse events. Ang
et al. noted minor adverse events in the control group.
Sankaranarayanan et al. noted a mild rash in six preterm
infants, which were divided equally between the control
and the intervention group and Fallah et al. (2013) re-
ported no adverse events.
The majority of empirical studies conducted in the last 30
years on the effects of massage on the growth and develop-
ment of premature report positive results. However, both
CI = Confi dence interval, df = degrees of freedom, SD = Standard deviation
Figure 6. Forest plots for the association between massage and mental development on the Bayley scale. Bayley
MDI scores, Standard mean difference and the 95% CI of each study are indicated
Massage Control Mean Difference Mean Difference
Study or
Subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI
Adballh (2013) 120.43 15.73 27 106.25 11.76 23 26.8% 14.18 [6.54, 21.82]
–50 –25 0 25 50
Procianoy (2010) 85.1 1.99 35 82.9 5.61 38 38.7% 2.20 [0.30, 4.10]
Teti (2009) 97.21 12.31 66 87.83 13.6 72 34.5% 9.38 [5.06, 13.70]
Total (95% CI) 128 133 100.0% 7.89 [0.96, 14.82]
Heterogeneity: Tau2 = 31.38; Chi2 = 16.21, df = 2 (P = 0.0003); I2 = 88%
Test for overall effect: Z = 2.23 (P = 0.03)
Favors[control] Favors[massage]
November/December 2015 MCN 355
When physiologic measures were considered, mas-
saged infants were noted to have better bone formation
and bone strength in two studies. That is especially criti-
cal for preterm infants whose bone mineralization is low
despite dietary supplementation (Haley et al., 2012).
Massage was noted to increase serum insulin, which in
turn stimulates bone formation, brain regulation, and
weight gain (Field et al., 2008, Diego et al., 2014). The
rise in temperature during the massage therapy period is
consistent with fi ndings with Kangaroo care (Ludington-
Hoe et al., 2000) and is most likely due to the therapist’s
hands transferring heat to the infant or may be because
massage facilitates neurological regulation of temperature
(Diego et al., 2008).
The increase in vagal activity, tone, and HRV noted in
the studies reviewed here could result in an increased au-
tonomic functioning and in enhanced growth and develop-
ment in preterm infants. A few studies have suggested that
an increase in vagal activity may improve mother–infant
attachment and mental development (Feldman, Rosenthal,
& Eidelman, 2014; Field & Diego, 2008). Field et al. (2011).
Deigo et al. (2008) suggest that moderate pressure massage
stimulates vagal activity and leads to increased weight gain
through two mechanisms (1) increased vagal activity and
gastric motility leading to increased food absorption and
increased weight gain; and (2) release of insulin and Insulin-
like growth factor 1 directly leading to greater weight gain.
These relationships, however, are hypothetical and remain to
be tested empirically.
Seven studies assessed the long-term effects of massage
(Abdallah et al., 2013; Fallah et al., 2013; Ferber et al.,
2005; Moyer-Mileur et al., 2013; Procianoy et al., 2010;
Teti et al., 2009; Vaivre-Douret et al., 2009). Of those,
only three assessed both mental and motor development.
Abdallah et al. assessed infants at 12 months corrected age,
Procianoy et al. assessed infants at 2 years corrected age,
and Teti et al. assessed infants at 4 months corrected age.
Effect of massage on mental development was impressive
where the pooled effect of the three studies was 7.89 points.
Although the exact mechanism of how massage can infl u-
ence infant development is not clear, animal studies have
shown that higher frequency licking and grooming is asso-
ciated with improved cognitive development in rats (Liu,
Diorio, Day, Francis, & Meaney, 2000). An explanation
may be that mothers who massage their infants provide a
more sensitive and appropriately stimulating home envi-
ronment increasing the infant’s attention, and exploratory
skills, leading ultimately to better mental skills. This fi nd-
ing is in line with extensive previous research that points
to the contribution of maternal involvement to cognitive
development (Feldman et al., 2014; Saint-Georges et al.,
Neurobehavioral outcomes assessed by the Brazelton
NBAS were not signifi cant in three studies (Aliabadi &
Askary, 2013; Arora et al., 2005; Mathai et al., 2001),
consistent with the review by Wang et al. (2013). How-
ever, sleep/awake and stress behaviors favored massaged
infants in four studies (Dieter et al., 2003; Field et al.,
2006; Ferreira & Bergamasco, 2010; Hernandez-Reif
completing the control before the intervention was in-
troduced (Abdallah et al., 2013; Ferreira & Bergamasco,
2010), or using a separate room for the intervention
(Ferber et al., 2002). Nonetheless, the possibility of
contamination cannot be ruled out due to the possible
observation or communication between mothers in the
NICU. Blinding of outcome assessments is another area
of concern as most studies collected the outcome data
in the NICU with research personnel who may have
knowledge of group assignment. There were four stud-
ies that collected data after the infants were discharged
with only two that specifi ed that the outcome measures
were done by an individual blinded to group assignment
(Abdallah et al.; Procianoy et al., 2010). It is worth not-
ing that 9 of the 34 studies reviewed were conducted
by researchers at the Touch Institute in Miami. This
could also present a bias in reporting. Although all but
one study (Ferreira & Bergamasco, 2010) documented
power calculations for sample size, larger samples are
recommended to validate generalizations.
There was a wide range of massage techniques used for
the intervention. Even though the majority of studies (n
= 24) used the Field technique (1986), many have modi-
ed the technique in terms of duration (10–20 minutes
per session), frequency (1–4 times a day), length of total
days (5 days to 20 weeks), by whom it is applied (physi-
cal therapists, trained doctors, nurses, mothers), with or
without KS, and with or without oil application. These
variations in the intervention protocol make conclusions
related to effi cacy and clinical application challenging.
Most studies assessed weight gain, weight at dis-
charge, caloric intake, and LOS; however, the methods
used to assess weight differed between studies with some
reporting g/day, others g/kg/day, and still others provid-
ing total weight gain during the study period or during
NICU stay. When we controlled for these variations us-
ing the SMD, effectiveness of massage was signifi cant
in terms of improving daily weight gain only with high
heterogeneity. Effect of massage on weight at discharge
and caloric intake showed no signifi cant difference be-
tween groups. These fi ndings could be explained by the
different birthweights and gestational ages (GAs) of the
infants and the timing or when the massage was provided
and the duration of the massage. Weight at discharge,
weight gain during NICU stay, caloric intake, and LOS
are highly confounded by GA and comorbidities. That is
also a limitation in terms of generalizing the results. In
addition, what could be effective and tolerated for a 24-
week infant may be very different than what is effective
for a 34-week infant, yet this issue was not mentioned in
most of the studies. Only two studies (Ferrieria & Berga-
masco, 2010; Vaivre-Douret et al., 2009) indicated that
the massage provided was based on infant cues.
Unlike the results by Wang et al. (2013) we found no
effect on length of hospital days. This may be due to the
inclusion of different studies in the 2 meta-analysis or
may be explained by the fact that several infant and care-
giver variables may infl uence the health outcomes of in-
fants in the NICU such as comorbidities and GA at birth.
356 volume 40 | number 6 November/December 2015
efi ts of massage. Infants included in this review were
all medically stable; therefore, generalizations cannot be
made to fragile or sick infants. Despite the limitations of
this review, nurses could consider massage as a method
of improving the outcomes of preterm infants especially
in the absence of known adverse effects.
Strengths and Weaknesses
The strength of this systematic review is that it included
all studies from 2000 to 2014 that used massage as an
intervention to improve all the outcomes of preterm in-
fants including 14 studies not included in previous re-
views. Nevertheless, there are few limitations that merit
attention: 1) the review was limited to studies published
only in the English language which may have excluded
good quality studies in other languages (e.g., 2 Irani-
an, 2 Chinese, 1 German, and 1 Portuguese); 2) data
on outcome measures were missing from a few stud-
ies and could not be obtained despite efforts to contact
the authors; 3) the massage intervention varied among
studies making the association between massage and
positive outcomes diffi cult; and 4) the outcome mea-
sures were also varied precluding accuracy in the meta-
analysis. Due to these limitations, effi cacy of massage
on outcomes such as behavioral states, mother–infant
interaction, and LOS cannot be established.
There is low quality evidence from the 34 studies re-
viewed in this meta-analysis that preterm infant massage
is associated with better infant outcomes. Conclusive
evidence cannot be established due to the relatively small
effect sizes and moderate-to-high heterogeneity between
studies. Nevertheless, in this vulnerable population, even
small effect sizes should be considered as they may have
long term benefi ts. This may be due to the fact that mas-
sage techniques vary between studies, outcome variables
are inconsistent, and the majority of studies are high risk
for bias. Most signifi cantly, there is limited knowledge
on the physiological mechanisms by which massage is ef-
fective. There is a need to further investigate the effi cacy
of massage using larger, more rigorous RCTs that assess
physiological, behavioral, and psychosocial short- and
long-term benefi ts. Only when such studies are conduct-
ed, a convincing argument can be made to the benefi ts of
preterm infant massage.
The authors wish to thank Professors Martyn Jones and
Dr. Heather Whitford, University of Dundee and Dr.
Caroline Bradbury-Jones, University of Birmingham
for their valuable contribution in the conception and
design of this review.
Supplemental digital content is available for this article.
Direct URL citations appear in the printed text and are
provided in the HTML and PDF versions of this article on
the journal’s Web site (
et al., 2007). Since premature infants generally are
disorganized behaviorally, application of massage ther-
apy may have pacifying effects as it moderates cortisol
production and increases glucocorticoid receptors in the
hippocampus reducing stress and allowing better self-
regulation. None of the studies reported any adverse ef-
fects of massage.
Two studies assessed duration of breastfeeding at 6
months corrected age (Abdallah et al., 2013, Procianoy
et al., 2010) and found no difference between the mas-
saged and the control group, which could be explained
by the fact that several sociocultural factors affect the
duration of breastfeeding that cannot be ameliorated by
infant massage alone.
The signifi cant effect of massage in reducing pain
responses noted in two studies (Abdallah et al., 2013; Di-
ego et al., 2009) is supported by the gate control theory
that postulates that massage may be effective in “closing
the gate”—or inhibiting the transmission of noxious stim-
uli by stimulating large nerve fi bers that have been shown
to alter pain perception (Mendell, 2014). Since only two
studies assessed this outcome, the need for more studies
measuring the effi cacy of massage on pain is recommend-
ed before meaningful recommendations are made.
Massage therapy could be a comforting measure
in the NICU to enhance weight gain, improve neuro-
development, and reduce stress especially when KC is
not feasible in countries or cultures where women are
modest. For example in many Arab countries, the Is-
lamic religion mandates certain behavioral and dress
codes that make it impossible for a woman to expose
her body to provide KC (Azaiza & Cohen, 2008). Fur-
thermore, nurses may be ambivalent to facilitate KC
due to the time, space, and effort it requires (Kymre,
2014). A recent study comparing KC to massage con-
cluded that both interventions are equally effective in
improving weight and reducing hospital stay and can be
used interchangeably (Rangey & Sheth, 2014). Based
on this review, however, it is not possible to make defi -
nite recommendations on the benefi ts of massage or to
predict whether the benefi ts are long-lasting. This is due
to the fact that both the massage intervention and the
outcome measures varied between studies making it dif-
cult to make conclusions. It is strongly recommended
that future studies use more uniform outcome measures
such as weight gain, LOS, and mental development to
enable quality meta analyses to be conducted. In addi-
tion, longitudinal, high-quality studies are essential to
be able to provide evidence about the long-term ben-
Massage can have a pacifying effect on preterm infants that
could improve their health outcomes and enhance their mental
Massage can be of special benefi t in communities where skin-to-
skin contact may not be feasible or culturally acceptable.
Suggested Clinical Implications
November/December 2015 MCN 357
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Lina Kurdahi Badr is a Professor, Azusa Pacifi c Univer-
sity, Azusa, CA. The author can be reached via e-mail at
Bahia Abdallah is a Lecturer, Faculty of Health Sciences,
University of Balamand, Ashrafi eh, Beirut, Lebanon.
The author can be reached at bahia.abdallah@balamand.
Lara Kahale, is a Research assistant, the Clinical Re-
search Institute, American University of Beirut, Beirut,
The authors declare no confl ict of interest.
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... The massaged premies also displayed longer wake times (Dieter et al., 2003) and reduced stress behaviors (crying, grimacing, jerking, startle; Hernandez-Reif et al., 2007). Subsequent longitudinal studies revealed reduced hospital stays (Badr et al., 2015) as well as reduced stress hormone levels and increased immune competence in the massage group (Badr et al., 2015). Dr. Field's own daughter was born prematurely and served as a "guinea pig" for this study. ...
... The massaged premies also displayed longer wake times (Dieter et al., 2003) and reduced stress behaviors (crying, grimacing, jerking, startle; Hernandez-Reif et al., 2007). Subsequent longitudinal studies revealed reduced hospital stays (Badr et al., 2015) as well as reduced stress hormone levels and increased immune competence in the massage group (Badr et al., 2015). Dr. Field's own daughter was born prematurely and served as a "guinea pig" for this study. ...
Full-text available
The quality of one’s adult health and the chances of maintaining cognitive ability in aging stem directly from the quality of care one receives as an infant. Formal studies of maternal care can be traced back at least a century. Revelations of behavioral outcomes after maternal deprivation in primates were followed by discoveries of systemic and brain growth factors mediated by the caregiver–offspring relationship in rodents. More recently, much of the genetic/epigenetic bases of maternal care has been defined and positively linked to adult health and cognitive ability in senescence. The history of this field is both tragic and fascinating. The early primate work, while informative, was abusive. The initial rodent work was ridiculed before its importance was recognized. The final lesson learned is that infant/toddler care matters a lot. Today, we have a better understanding of the biology underlying maternal care and its transmission across generations as well as a scientific basis for massaging premature infants and hugging our children.
... La diferencia de ganancia promedio de peso (3,159 g) hallada en el estudio, aunque no fue significativa entre ambos grupos, es similar a la publicada en otras investigaciones 19-21 realizadas en UCIN en Estados Unidos, en las que los recién nacidos también aumentaron de peso, al realizar el ETK 3 veces al día durante 5 días consecutivos. Estos resultados que describen la ganancia de peso permiten reiterar que la inclusión del ETK en el cuidado del RNP 19 en condiciones hemodinámicamente estables favorece el incremento del peso [22][23][24][25] . ...
... La evidencia señala que la ganancia de peso es significativa cuando se utiliza el estímulo kinestésico asociado al estímulo táctil 9 ; asimismo, confirma que la fase táctil debe realizarse con una presión moderada para que la probabilidad de aumento de peso sea mayor, ya que se observan diferencias cuando sólo se realiza a un grupo de recién nacidos y al otro no 20,21,[23][24][25] . ...
Full-text available
Objetivo: Determinar el efecto de la práctica repetida del estímulo táctil kinestésico (ETK) en la curva de peso del recién nacido prematuro (RNP). Metodología: El estudio tuvo un enfoque cuantitativo, de diseño cuasi experimental, realizado en una muestra de RNP (entre ≥29 y ≤35 semanas de gestación), hemodinámicamente estables, hospitalizados en la Unidad de Cuidado Neonatal del Hospital Simón Bolívar (Bogotá, Colombia). La muestra fue agrupada aleatoriamente; la enfermera practicó el ETK 3 veces al día (grupo experimental) y 1 vez al día (grupo control) durante 5 días consecutivos. La curva de peso y la relación peso/calorías ( se evaluaron mediante análisis de la varianza (ANOVA), ajuste de curva polinomial y test de la U de Mann-Whitney (p <0,05). Resultados: Se incluyeron en el estudio 38 RNP. Se calculó el peso en función del tiempo, y el porcentaje de aumento de peso frente a curvas de tiempo de ambos grupos no mostró diferencias estadísticas (p <0,05), con una varianza (F= 3,2208; p= 0,090) y un ajuste lineal similar (r2= 0,99; p= 5,6.10–6), pero la razón peso/calorías muestra una diferencia significativa con los valores más altos para el grupo experimental (13,69 ± 0,2–1) frente al grupo control (13,4 ± 0,09–1; U de Mann-Whitney, p= 0,008). Conclusión: Estos resultados sugieren que la práctica repetida de ETK, durante al menos 5 días 3 veces al día, promueve el equilibrio anabólico, favoreciendo un mayor aumento de peso, evaluado por la proporción peso/calorías en los RNP.
... Updated meta-analyses by Badr et al. (5) and Lu et al. (6) confirmed data on increased daily weight gain in massaged preterm infants medically stable compared with controls. Badr also added data on higher neurodevelopmental scores (assessed with structured developmental scales) in infants that received IM in the NICU compared with controls treated with standard care (7). ...
... The home-based nature of the IM early intervention, ongoing for 8 weeks, significantly differs from the other programs proposed in the vast majority of the studies in literature. These studies mainly investigate the short-term clinical benefits of a usually brief cycle of massage administration in the NICU before discharge from hospital (1,4,5,7,8). ...
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Infant massage (IM) can be considered an early intervention program that leads to the environmental enrichment framework. The effectiveness of IM to promote neurodevelopment in preterm infants has been proved, but studies on infants with early brain damage are still lacking. The main aim of this study was to assess the feasibility, acceptability and usability of IM, carried out by parents at home, on infants at high risk for Cerebral Palsy. An IM daily diary and an ad hoc questionnaire, called Infant Massage Questionnaire Parent-Infant Experiences (IMQPE), were developed. IMQPE consisted of a total of 30 questions, divided into 5 areas. The parents were trained to carry out the IM with a home-based course, conducted by an expert therapist. The intensive IM program was set according to a defined daily length of at least 20 min, with a frequency of at least 5 days per week for a total of 8 weeks. Data collection consisted in the selection of the variables around the characteristics, both of the infants and the mothers, IM dosage and frequency, different body parts of the infants involved and IMQPE scores. Variable selection was carried out by minimizing the Bayesian Information Criteria (BIC) over all possible variable subsets. Nineteen high-risk infants, aged 4.83 ± 1.22 months, received IM at home for 8 weeks. The massage was given by the infants' mothers with a mean daily session dose of 27.79 ± 7.88 min and a total of 21.04 ± 8.49 h. 89.74% and 100% of mothers performed the IM for the minimum daily dosage and the frequency recommended, respectively. All the families filled in the IMQPE, with a Total mean score of 79.59% and of 82.22% in General Information on IM, 76.30% in Infant's intervention-related changes, 76.85% in IM Suitability, 79.07% in Infant's acceptance and 83.52% in Time required for the training. Different best predictors in mothers and in infants have been found. These data provide evidence of the feasibility of performing IM at home on infants at high risk for CP. Study registration: (NCT03211533 and NCT03234959).
... Massage therapy is practiced in some neonatal intensive care units or intermediate care units in developed and developing countries [19][20][21][22][23][24][25][26][27][28][29][30][31][32][33], where the most consistently reported benefit among infants receiving massage therapy is greater weight gain for preterm infants [21-25, 29, 34, 35]. Massage may result in a variety of other potential benefits including reduced length of hospital stay and cost savings, increased bone mineralization, and improvement in a variety of functional neurodevelopmental indicators, although with variable results [20, 21, 25, 27-30, 32, 36]. ...
... . At up to 30 months of follow-up,30.5% (29/95) and 36.8% (35/95) of children had disability on the MDI and PDI scales, respectively (Table 3). ...
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Background Topical treatment with sunflower seed oil (SSO) or Aquaphor® reduced sepsis and neonatal mortality in hospitalized preterm infants <33 weeks’ gestational age in Bangladesh. We sought to determine whether the emollient treatments improved neurodevelopmental outcomes during early childhood. Methods 497 infants were randomized to receive SSO, Aquaphor®, or neither through the neonatal period or hospital discharge. 159 infant survivors were enrolled in the longitudinal follow-up study using a validated Rapid Neurodevelopmental Assessment tool and the Bayley Scales of Infant Development II (BSID II) administered at three-monthly intervals for the first year and thereafter at six-monthly intervals. Lowess smoothing was used to display neurodevelopmental status across multiple domains by age and treatment group, and Generalized Estimating Equations (GEE) were used to compare treatment groups across age points. Results 123 children completed at least one follow-up visit. Lowess graphs suggest that lower proportions of children who received massage with either SSO or Aquaphor® had neurodevelopmental delays than control infants in a composite outcome of disabilities. In GEE analysis, infants receiving SSO showed a significant protective effect on the development of fine motor skills [odds ratio (OR) 0.92, 95% confidence interval (CI) 0.86–0.98, p =0.006]. The Psychomotor Development Index (PDI) in the BSID II showed significantly lower disability rates in the Aquaphor group (23.6%) compared to the control (55.2%) (OR 0.21, 95% CI 0.06–0.72, p =0.004). Conclusions Emollient massage of very preterm, hospitalized newborn infants improved some child neurodevelopmental outcomes over the first 2 years of follow-up. Findings warrant further confirmatory research. Trial registration (98-04-21-03-2) under weblink
... The weight gain in the CG of our study is consistent with the findings of other authors, who showed weight gain in preterm infants who received massage [37][38][39][40] , and in contrast to Eliakim et al. 2002 31 , who found weight improvements in favour of PMC compared to caresses and tactile stimulation. ...
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Preterm infants have a low level of bone mineralization compared to those born at term. The purpose of the present study was to investigate the effect of reflex locomotion therapy (RLT) on bone mineralization and growth in preterm infants and compare its effect to other physiotherapy procedures. Forty-six preterm infants born at 29–34 weeks were randomized into three groups: one group received RLT (n = 17); the other group received passive movements with gentle joint compression (n = 14); and the control group received massages (n = 15). All the treatments were performed at the neonatal unit for one month. The main outcome measure was bone mineralization, which was measured using the tibial speed of sound (Tibial-SOS). All the groups were similar in terms of gestational age (31.8 ± 1.18), birth weight (1,583.41 ± 311.9), and Tibia-SOS (1,604.7 ± 27.9) at the beginning of the intervention. At the end of the study, significant differences were found among the groups in the Tibial-SOS [F(4,86) = 2.77, p = 0.049, ηp² = 0.114] in terms of the benefit to the RLT group. In conclusion, RLT has been effective at improving Tibial-SOS levels and has been more effective than other physical therapy modalities; therefore, it could be considered an effective physiotherapeutic modality for the prevention and treatment of osteopenia from prematurity.
The aim of the current review was to assess whether parent-performed infant massage (PPIM) could effectively improve the mental state of parents during the postpartum period. Several international electronic databases were thoroughly searched for relevant articles. Included studies observed the influence of PPIM on the mental state of parents of healthy full-term infants within 18 months postpartum or medically stable preterm infants during hospitalization after birth. Nine studies were included, which observed one or more aspects of parental mental state, including depression, anxiety, parental stress, or general mood state. Characteristics of participants, massage protocols, and outcome measures were heterogenous; hence, results regarding the influence of PPIM on parental mental state were inconsistent. Upon further investigation, 10-minute, home-based PPIM for at least 4 weeks is advisable for maternal depression within 5 months postpartum. Moreover, PPIM in a neonatal intensive care unit is advisable for improving the general mood of mothers of preterm infants. Additional methodologically rigorous studies are needed to provide stronger evidence. [Journal of Psychosocial Nursing and Mental Health Services, xx(x), xx-xx.].
Background Very preterm (VPT) infants develop adverse neurological sequelae from early exposure of the immature brain to the extrauterine environment. Aims To determine the effects of infant massage on brain maturation in low-risk VPT infants. Study design A randomised controlled trial of VPT infants, who received standard care or daily massage therapy, administered by the mother, from 34 weeks' to 40 weeks' corrected age (CA). Subjects VPT infants (born at 28 weeks to 32 + 6 weeks' gestational age, G.A.) and a healthy at term cohort for comparison. Outcome measures At term equivalent age (39 weeks' to 42 weeks' CA), EEG was recorded to calculate global relative power (GRP), using power spectral analysis. Results Sixty infants were recruited, and EEGs of 25 massage and 20 standard care infants were analysable. There was no difference between groups in primary outcome (beta GRP). There was a significantly higher central alpha relative power measured in the intervention group infants, compared to standard care (SC) group (mean difference = 1.42, 95 % confidence interval (CI): 0.12 to 2.73; p = 0.03). A massage dose effect was shown by a positive correlation between, massage dose and beta, alpha and theta GRP (r = 0.42, 95%CI = 0.12 to 0.64, r = 0.45; 95%CI = 0.16 to 0.66, r = 0.39; 95%CI = 0.10 to 0.62 respectively) and a negative correlation between massage dose and delta GRP (r = −0.41, 95%CI = −0.64 to −0.12), suggesting that a higher dose of massage is associated with more favourable brain maturation. Conclusions Central alpha regional relative power was greater in massaged infants compared to SC group infants, suggesting relatively greater brain maturation in this area. A measurable massage dose effect in favour of greater brain maturation, shows promise for verification in a larger clinical trial.
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Background: Oil massage versus only massage can increase preterm newborn development, especially weight gain, via a supposed percutaneous absorption of oil lipids, but data are contradictory. Aims: Investigating whether massage with a vegetable oil balanced in essential fatty acids improves neonatal weight gain, and digestive autonomy as proxy for neuro-development outcomes. Methods: A prospective monocentric randomized study was conducted in very premature newborns who received massage with oil (isio4 10 mL/kg/day, n = 18) versus with no oil (n = 18) for five consecutive days (10-min session twice daily) at a corrected gestational age of 34-35 weeks. Anthropometrics and clinical characteristics were recorded. Plasma triglyceride and total cholesterol concentrations were analyzed with an enzymatic kit. The fatty acid composition (weight%, mg/mL) of total plasma lipids and of red blood cell (RBC) membrane was analyzed by gas chromatography. Results: Weight gain velocity at the end of massage period was 12.3 ± 1.4 g/kg/day with oil vs. 9.8 ± 1.4 g/kg/day with no oil (p = 0.1). Digestive autonomy, plasma lipid parameters, polyunsaturated fatty acids in plasma total lipids or in RBC were comparable. The no oil group displayed a higher RBC level in nervonic acid at discharge (4.3 ± 0.2 vs. 3.4 ± 0.2%; p = 0.025) and in C18:1n-9 plasmalogen species at the end of the massage period and at discharge (0.73 ± 0.06 vs. 0.48 ± 0.06; 0.92 ± 0.06 vs. 0.69 ± 0.06%; p < 0.01), two molecules that are involved in neurodevelopment. Conclusions: The use of isio4 oil did not provide additional benefits for the development of very premature newborns, neither changed lipid metabolism nor polyunsaturated fatty acid biological status, which did not corroborate the existence of a percutaneous route for oil lipid absorption. The reason for different levels of nervonic acid and plasmalogen in RBC remains to be explored.
Background: The aim of this study was to investigate the influence of early-life pain/stress and medical characteristics on neurobehavioral outcomes in preterm infants. Methods: A prospective cohort study was conducted with 92 preterm infants (28-32 weeks gestational age [GA]). Early-life pain/stress was measured via the Neonatal Infant Stressor Scale (NISS) during the first 28 days of NICU hospitalization. Neurobehavioral outcomes were evaluated using the NICU Network Neurobehavioral Scale at 36-38 weeks post-menstrual age. Functional regression and machine learning models were performed to investigate the predictors of neurobehavioral outcomes. Results: Infants experienced daily acute pain/stress (24.99 ± 7.13 frequencies) and chronic events (41.13 ± 17.81 h). Up to 12 days after birth, both higher acute and chronic NISS scores were associated with higher stress scores; and higher chronic NISS scores were also related to lower self-regulation and quality of movement. Younger GA predicted worse neurobehavioral outcomes; GA < 31.57 weeks predicted worse stress/abstinence, self-regulation, and excitability; GA < 30.57 weeks predicted poor quality of movement. A higher proportion of maternal breastmilk intake predicted better self-regulation, excitability, and quality of movement in older GA infants. Conclusions: Preterm infants are vulnerable to the impact of early-life pain/stress. Neurobehavioral outcomes are positively associated with increased GA and higher maternal breastmilk intake. Impact: During the first 12 days of life, preterm infant neurobehavioral outcomes were vulnerable to the negative impact of acute and chronic pain/stress. Future research is warranted to investigate the long-term effects of early-life pain/stress on neurobehavioral outcomes. Gestational age remains one of the critical factors to predict neurobehavioral outcomes in preterm infants; older gestational age significantly predicted better neurobehavioral outcomes. Feeding with a higher proportion of maternal breastmilk predicted better neurobehavioral outcomes. Future research is warranted to investigate how maternal breastmilk may buffer the negative effects of early-life pain/stress on neurobehavioral outcomes.
BACKGROUND: Baby spa is useful for baby’s growth and development. The previous research has shown that when the baby is massaged by the mother, a bond is formed between the mother and the baby compared to other people who do the massage. However, in its implementation, baby spas are often carried out by health workers. AIM: The purpose of this research is to determine the mother’s ability to do baby massage with the guidance of medical personnel. METHODS: This method of writing systematic reviews refers to the Preferred Reporting Items for Systematic Reviews guidelines. Articles were searched in several databases ; ScienceDirect, EBSCO, PubMed, Scinapse, Google Scholar from 2011-2021. The search strategy uses the keywords Infant OR Infant Preterm OR Very Low Birth Weight infants AND Massage OR Oil Massage AND Attachment AND Growth. RESULTS: The results show the chances of success of mothers doing baby massage with the help of medical personnel, the baby massage learning media used were baby phantoms, brochures, pamphlets, and baby massage videos, and the frequency of massage for 10–15 min each time the massage. The results obtained after the mother did the baby massage were the increase in body weight, body length, arm circumference of the baby, better bonding between mother and baby, improvement in mother’s mood, and increase in mother’s positive attitude in caring for the baby. CONCLUSION: This study proves that the role of medical personnel in training baby massage to mothers is proven to be effective in increasing the ability of mothers to do baby massage.
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Systematic reviews and meta-analyses are essential to summarize evidence relating to efficacy and safety of health care interventions accurately and reliably. The clarity and transparency of these reports, however, is not optimal. Poor reporting of systematic reviews diminishes their value to clinicians, policy makers, and other users.Since the development of the QUOROM (QUality Of Reporting Of Meta-analysis) Statement--a reporting guideline published in 1999--there have been several conceptual, methodological, and practical advances regarding the conduct and reporting of systematic reviews and meta-analyses. Also, reviews of published systematic reviews have found that key information about these studies is often poorly reported. Realizing these issues, an international group that included experienced authors and methodologists developed PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) as an evolution of the original QUOROM guideline for systematic reviews and meta-analyses of evaluations of health care interventions.The PRISMA Statement consists of a 27-item checklist and a four-phase flow diagram. The checklist includes items deemed essential for transparent reporting of a systematic review. In this Explanation and Elaboration document, we explain the meaning and rationale for each checklist item. For each item, we include an example of good reporting and, where possible, references to relevant empirical studies and methodological literature. The PRISMA Statement, this document, and the associated Web site ( should be helpful resources to improve reporting of systematic reviews and meta-analyses.
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Objective To examine the effects of 5 days of massage therapy on the weight gain and sleep/wake behavior of hospitalized stable preterm infants. Methods Massage therapy (body stroking/passive limb movement for three 15-minute periods per day) was provided to 16 preterm neonates (mean gestational age, 30.1 weeks; mean birth weight, 1359 g), and their weight gain, formula intake, kilocalories, stooling, and sleep/wake behavior were compared with a group of 16 control infants (mean gestational age, 31.1 weeks; mean birth weight, 1421 g). Results The massage group averaged 53% greater daily weight gain than the control group. The massage group spent less time sleeping at the end of 5 treatment days than the control group and more time in the drowsy state. Conclusions Healthy, low-risk preterm infants gained more weight and slept less with just 5 days of massage, in contrast to 10 days in previous studies. Results support the continued use of massage as a cost-effective therapy for medically stable preterm infants.
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Background. Massage therapy (MT) and kangaroo mother care (KMC) are both effective in increasing the weight and reducing length of hospital stay in low birth weight preterm infants but they have not been compared. Aim. Comparison of effectiveness of MT and KMC on body weight and length of hospital stay in low birth weight preterm (LBWPT) infants. Method. 30 LBWPT infants using convenience sampling from Neonatal Intensive Care Unit, V.S. hospital, were randomly divided into 2 equal groups. Group 1 received MT and Group 2 received KMC for 15 minutes, thrice daily for 5 days. Medically stable babies with gestational age < 37 weeks and birth weight < 2500 g were included. Those on ventilators and with congenital, orthopedic, or genetic abnormality were excluded. Outcome measures, body weight and length of hospital stay, were taken before intervention day 1 and after intervention day 5. Level of significance was 5%. Result. Data was analyzed using SPSS16. Both MT and KMC were found to be effective in improving body weight (P = 0.001, P = 0.001). Both were found to be equally effective for improving body weight (P = 0.328) and reducing length of hospital stay (P = 0.868). Conclusion. MT and KMC were found to be equally effective in improving body weight and reducing length of hospital stay. Limitation. Long term follow-up was not taken.
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This article illuminates the essence of Neonatal Intensive Care Unit (NICU) nurses' attitudes in skin-to-skin care (SSC) practice for preterm infants and their parents. Health care providers are in a unique position to influence the dynamic between infants and parents, and SSC affects both partners in the dyad. The design is descriptively phenomenological in terms of reflective lifeworld approach. Eighteen Swedish, Danish, and Norwegian nurses from NICUs offering varied possibilities and extents of SSC participated. NICU nurses' attitudes in SSC practice are ambivalent. The nurses consider the sensory, wellness, and mutuality experiences to be primary and vital and enact SSC as much as possible. But "as much as possible" is a broad and varied concept, and their attitudes are ambivalent in terms of not always facilitating what they consider to be the optimal caring conditions. The source of NICU nurses' ambivalent attitudes in SSC practice is a complex interplay of beliefs, norms, and evidence, which have a multidisciplinary basis. The ambivalent attitudes are, to a great extent, the result of the need to balance these multidisciplinary concerns. This needs to be acknowledged in considering SSC practice, as well as acknowledging that clinical judgments concerning optimal SSC depend on parents and infants unlimited access to each other, which NICU nurses can influence.
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Objective: To study whether new pharmacological and nonpharmacological guidelines lowered numbers of painful procedures in neonates and changed the amount and frequency of analgesic therapy as compared to the results of our previous study in 2001. Design: A prospective observational study. Setting: Level III NICU of the Erasmus MC-Sophia Children's Hospital, Rotterdam. Participants: Neonates admitted at postnatal ages less than 3 days with length of stay at least 72 h. Main outcome measures: Number of all potentially painful procedures and analgesic therapy recorded at the bedside during the first 14 days of NICU stay. Results: A total number of 21,076 procedures were performed in the 175 neonates studied during 1,730 patient-days (mean 12.2). The mean number of painful procedures per neonate per day was 11.4 (SD 5.7), significantly lower than the number of 14.3 (SD 4.0) in 2001 (p < 0.001). The use of analgesics was 36.6% compared to 60.3% in 2001. Sixty-three percent of all peripheral arterial line insertions failed versus 37.5% in 2001 and 9.1% venipunctures failed versus 21% in 2001. Conclusions: The mean number of painful procedures per NICU patient per day declined. Nonpharmacological pain- or stress-reducing strategies like NIDCAP and sucrose were fully embedded in our pain management. As further reduction of the number of painful procedures is unlikely, we should apply more nonpharmacological interventions and explore newer pharmacological agents.
OBJECTIVE: To analyse preterm birth rates worldwide to assess the incidence of this public health problem, map the regional distribution of preterm births and gain insight into existing assessment strategies. METHODS: Data on preterm birth rates worldwide were extracted during a previous systematic review of published and unpublished data on maternal mortality and morbidity reported between 1997 and 2002. Those data were supplemented through a complementary search covering the period 2003-2007. Region-specific multiple regression models were used to estimate the preterm birth rates for countries with no data. FINDINGS: We estimated that in 2005, 12.9 million births, or 9.6% of all births worldwide, were preterm. Approximately 11 million (85%) of these preterm births were concentrated in Africa and Asia, while about 0.5 million occurred in each of Europe and North America (excluding Mexico) and 0.9 million in Latin America and the Caribbean. The highest rates of preterm birth were in Africa and North America (11.9% and 10.6% of all births, respectively), and the lowest were in Europe (6.2%). CONCLUSION: Preterm birth is an important perinatal health problem across the globe. Developing countries, especially those in Africa and southern Asia, incur the highest burden in terms of absolute numbers, although a high rate is also observed in North America. A better understanding of the causes of preterm birth and improved estimates of the incidence of preterm birth at the country level are needed to improve access to effective obstetric and neonatal care.
The increasing prevalence of preterm birth in the United States is a complex public health problem that requires multifaceted solutions. Preterm birth is a cluster of problems with a set of overlapping factors of influence. Its causes may include individual-level behavioral and psychosocial factors, sociodemographic and neighborhood characteristics, environmental exposure, medical conditions, infertility treatments, and biological factors. Many of these factors co-occur, particularly in those who are socioeconomically disadvantaged or who are members of racial and ethnic minority groups. While advances in perinatal and neonatal care have improved survival for preterm infants, those infants who do survive have a greater risk than infants born at term for developmental disabilities, health problems, and poor growth. The birth of a preterm infant can also bring considerable emotional and economic costs to families and have implications for public-sector services, such as health insurance, educational, and other social support systems. Preterm Birth assesses the problem with respect to both its causes and outcomes. This book addresses the need for research involving clinical, basic, behavioral, and social science disciplines. By defining and addressing the health and economic consequences of premature birth, this book will be of particular interest to health care professionals, public health officials, policy makers, professional associations and clinical, basic, behavioral, and social science researchers. © 2007 by the National Academy of Sciences. All rights reserved.