The effect of massage on weight gain in very low birth weight neonates

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96 © 2015 Journal of Clinical Neonatology | Published by Wolters Kluwer - Medknow
The Effect of Massage on Weight Gain in Very Low Birth
Weight Neonates
Zahra Akbarian Rad, Mohsen Haghshenas, Yahya Javadian, Mahmoud Hajiahmadi, Fahimeh Kazemian1
Non‑Communicable Pediatric Diseases Research Center, Babol University of Medical Sciences, 1Department of Physiotherapy, Faculty of Medicine, Babol
University of Medical Sciences, Babol, Iran
ABSTRACT
Background: Achieving optimal weight is one of the factors that takes into consideration in the discharge of preterm infants from
the hospital. The aim of this study was to assess the effect of massage therapy on weight gain in very low birth weight neonates.
Methods: This study is a nonrandomized blocking clinical trial in Neonatal Intensive Care Unit. Forty neonates who had inclusion criteria,
were divided into two groups of case (n = 20) and control (n = 20). Both groups received standard care of preterm neonates. Additionally,
case group received the massage therapy 3 times daily for 15 min for each time at 7 days. During the study, the weight of neonates
was measured every day at 12 a.m. Results:Averageweightofneonates betweentwogroupshadnostatisticallysignicant difference
until 4thday ofstudy.However,this differencebecame signicantafter 4thdaybecamemoreand mostsignicant (P = 0.04, 0.02, 0.01
respectively). The mean duration of hospital stay in the massage group (34/1 days ± 7/5) was less than the control group (41/7 days ± 9/1)
signicantly(P = 0.007). Conclusion: The massage therapy can promote weight gain in very low birth weight neonates and also leads to
earlier discharge.
Key words:
Massage, neonate, preterm, very low birth weight
INTRODUCTION
Preterm birth rate has increased over the past 20years.[1]
Today, there has been a considerable decline in neonatal
mortality due to advances in antenatal, obstetric, and
neonatal care.[2] More attention has been devoted to
optimize the growth and development of premature infants.
[3] e infant explores most of its world in the early months
by touching.[4] e touch in neonates can be active or passive
that passive touch can be delivered as a care touch(feeding,
changing diapers, handling, holding, kangaroo mother
care(KMC), and examination of newborn) and massage.[5]
Massage has been described as “a mechanical manipulation
of body tissues with rhythmical pressure and stroking for
Address for correspondence:
Miss. Fahimeh Kazemian,
Non‑Communicable Pediatric Diseases Research Center,
No 19, Amirkola Children’s Hospital, Amirkola, Babol,
Mazandaran Province, 47317‑41151, Iran.
E‑mail: f.kazemian@mubabol.ac.ir
the purpose of promoting health and well‑being.”[6] ere
is generally a notion that massage improves circulation and
sooth the peripheral and central nervous system.[7] Infants
who received massage also showed less clinical signs of
stress and lower level of plasma cortisol concentration
than controls.[8] Massage of neonate can be performed
with a lubricant to reduce the friction between the surface.
[5] Trials on the eect of massage on growth in premature
infants have used either massage alone as a form of tactile
stimulation or massage with some type of vegetable oil.[9] It
is not clear yet whether oil has any prot on the growth of
preterm infants.[7] e present study was designed to test
the eect of massage therapy on weight gain in very low
birth weight neonates during 7days of massage compared
to standard care of very low birth weight neonates without
massage.
METHODS
is study is a nonrandomized blocking clinical trial in the
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How to cite this article: Rad ZA, Haghshenas M, Javadian Y,
Hajiahmadi M, Kazemian F. The effect of massage on weight gain
in very low birth weight neonates. J Clin Neonatol 2016;5:96‑9.
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Rad, et al.: Effect of massage on weight in neonates
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Journal of Clinical Neonatology | Vol. 5 | Issue 2 | April-June 2016
Neonatal Intensive Care Unit(NICU) of the level III hospital
from October 2012 to November 2014. Inclusion criteria
were birth weight between 1000 and 1500 g, gestational
age between 28 and 32weeks, birth weight appropriate for
their gestational age, gavage feeding, age between 10 and
20days, medical stabilization, and receive KMC. Calories
intake and time or duration of KMC in two groups were
equal. Infants with congenital anomalies, central nervous
system dysfunction, or medical conditions related to
immaturity(such as respiratory distress syndrome, apnea,
and hyperbilirubinemia), infant surgery, maternal history
of alcohol or illicit drug exposure, and syphilis or hepatitis
B were excluded. Prior to recruitment, informed consent
was obtained from parents of eligible infants and attending
physician. Forty neonates, who were selected for this study,
were divided into two groups(20 massages and 20controls).
Infants were alternatively assigned in 10 blocks of four cases
of control and massage. First neonate with the inclusion
criteria was randomly assigned to the control block. e
study on any case started when intravenous therapy was
discontinued and neonate had a condition of medical
stabilization.
e Field’s protocol for massage was used[10] but in our
study, whereas the lymph ow in the body is from distal
to proximal,[11] the direction of massage only was done
from distal to proximal. In massage group, the intervention
was done 3 times/day for 15 min for each time during
7consecutive days.[12] e interval of any session of massage
therapy was at least 4 h and it was done 1h aer feeding.
During the study, massage of all cases in the intervention
group was done by one special nurse who was trained by the
licensed physiotherapist.
Each session of massage consisted of 5 min of tactile
stimulation in a prone position, followed by 5 min of
kinesthetic stimulation in the supine position, and another
5min period of tactile stimulation again. e nurse warmed
and lubricated(with 1 cc olive oil) her hands before starting
of massage and remained silent during intervention. During
tactile stimulation, the infant was placed under warmer set
that regulated with infant body temperature in a prone
position and was given moderate pressure stroking with
the ats of the ngers of both hands. Five 1‑min intervals,
consisting of 12 5‑s periods of stroking, were applied to
the following body regions:(a) From the top of the infant’s
head, down the back of the head to the neck,(b) from the
back of the neck across the shoulders,(c) from the buttocks
to the upper back,(d) simultaneously on both legs from the
feet to the hips, and(e) both arms from the wrist to the
shoulders synchronously.
For the kinesthetic phase, each of the ve 1‑min segments
consisted of six passive exions and extension movements
lasting approximately 10 s. ese “bicycling‑like” movements
of the limbs occurred in the following sequence:(a) Right
arm, (b) le arm, (c) right leg, (d) le leg, and (e) both
legs synchronously. Infant was monitored continuously
for heart rate, respiratory rate, and percutaneous oxygen
saturation during massage by monitoring set(S1800‑made
in England). None of the neonates showed an adverse eect
due to massage during the study.
e weight of neonate was measured every day (at 12 a.m.)
by digital balance (Seca 334‑made in Germany) with a
standard deviation of±5 g. Head circumference and length
of neonates was measured at before and aer of study.
Measuring and recording the data was carried out by one
nurse who was not aware of the purpose of our study.
e homogeneity of the massage and control groups was
tested with independent t‑test and Chi‑square test, and
comparison of the weight gain between the two groups
was done using the repeated measurement test with SPSS
version21.Number of hospitalization days in NICU for all
cases was calculated aer discharging.
RESULTS
None of the 40 neonates who were enrolled in the study
were excluded during the study. Demographic data of two
groups are showed in Table1. Two groups were matched in
terms of confounding variables such as birth weight, weight
at enrollment, gestational age, age at enrollment, sex and
Apgar score at 5min of birth.
Results of our study demonstrated that average weight of
neonates between massage group and control group had
no statistically signicant dierence until 4thday of study
(P > 0/05). However, this dierence became signicant
from 5th day of the study and the following days became
more and more signicant[Table2]. Infants in the massage
group compared to baseline had 11/3% overweight but this
range in the control group was 7/7% that this dierence
between two group was signicant too (P = 0.000). e
dierence of head circumference and length between two
groups was not statistically signicant at the beginning and
end of study (P>0.05). e mean duration of hospital stay
Table 1: Demographic data of two groups
Parameter X
_±SD P
Massage group Control group
Birth weight (g) 1299/5±137/8 1275/3±137/4 0/33
Weight at enrollment 1257/25±137/2 1211±125/3 0/16
Age at enrollment (days) 15/7±7/35 15/7±7/3 0/8
Gestational age (weeks) 29/5±1/5 29/6±1/9 0/8
Apgar score (5 min) 8/6±0/9 8/65±1 0/8
Sex (male (%)) 40 35 0/7
SD – Standard deviation
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Rad, et al.: Effect of massage on weight in neonates
98 Journal of Clinical Neonatology | Vol. 5 | Issue 2 | April-June 2016
in the massage group(34/1days±7/5) was shorter than the
control group(41/7days±9/1) for 7days(P=0.007). e
prevalence of retinopathy of prematurity requiring surgery
at 1‑month‑old in the control group was more than massage
group (45% vs. 20%) but this dierence was not statistically
signicant(P=0.18).
DISCUSSION
e present study demonstrates signicantly more weight
gain in the massage group compared to the control group
over 4 days of massage. In this study, massage therapy
causes more weight gain in very low birth weight neonates
aer 5days. Duration of each massage session was 15 min
for 3times/day until 7days and the distance between each
massage had at least 4 h in our study. In Massaro etal., Kumar
etal., Alizadeh etal. and Field’ studies that had results similar
to our study about eect of massage on weight in preterm
neonates, the direction of massage was from proximal to
distal,[3,7,13,14] but in this study, the direction of massage was
from distal to proximal. In our study, the massage began on
an average of 15 days aer birth. Additionally, all infants
massage performed by one specic nurse. Neonates of the
intervention group were discharged from hospital earlier
than the control group for 7 days on average. Kumar et al.
[7] found that massage therapy of premature infant increases
the weight gain aer 28 days of massage. In their study,
intervention group received the massage from the 1stday of
birth until 28days by mothers in hospital or aer discharging
at home. Alizadeh etal.[13] studied 44 infants with birth weight
of 1000 to 2500g for 5days and their study showed massage
resulted in a signicant dierence in weight gain between
intervention and control groups(P=0.001). Number of daily
massage in this study was similar to our study (3 times for
15min at each time) except that the distance between each
massage time was 2 h. In this study, infants who received
massage were discharged earlier from the hospital on an
average 12days. Another study by Badiee etal.[15] used the
massage(5min 3times a day for 5days), similar to our study,
resulted in increasing the rate of weight gain in preterm
infants. eir study included three groups of massage by
mother, massage by nurses, and without massage(control)
that showed massage by mother or nurses increased weight in
preterm infant with gestational age between 28 and 34weeks
without reference to birth weight when compared to control
group. Unlike our study, the massage was performed by
several nurses in the second group and each massage session
was only 5min in the intervention groups. Astudy in Iran
by Hosseinzadeh et al.[16] presented that massage increases
the rate of weight gain in infants but infants who were
enrolled had weight of 2000 to 2500g whereas our inclusion
criteria were weight of 1000 to 1499g. In another study in
America by Massaro etal.[3] on infants<33weeks and birth
weight<1500g, weight gain was signicantly higher than the
control group infants who were 1000 and 1499g(P<0.05).
In their study, massage had no eect on weight gain in
infants<1000 g. Infants who received massage, duration of
hospital stay did not show signicant dierences from the
control group in its study. e result of another study in
Iran to determine the eect of therapeutic touch on weight
premature infants was conducted by Keshavarz et al.[17]
showed a moderate pressure massage for 5days(3times a
day for 20min) due to signicant dierence on weight gain
in preterm infants with birth weight of more than 1500 g
between the intervention and control groups(P=0.01).e
massage was done in right and le lateral positions in this
study but we massaged the infants in supine and prone
positions. Golchin et al.[18] studied the eects of massage
on weight gain in infants with birth weights <2500 g and
the results showed that massage increases the speed of their
weight; the average birth weight of the massaged infants was
1709g whereas in our study, it was 1275g. Field etal.[14] in a
study of 5‑day(15min 3times a day) demonstrated that the
massage increased the rate of weight gain in preterm infants
was similar to the results obtained in the present study. As
regards, the mean birth weight and weight gain entry to the
study were 1789 and 1292 g, respectively, whereas in our
study those were 1275and 1238g, respectively.
Amini etal.[19] examined 10‑day massage eect on weight
gain in preterm infants and the results showed that weight
gain was not signicantly dierent between the two groups
at the end of the study, while like our study, intervention
group was massaged commonly by a trained massage
therapist. Age of enrollment in their study was 2 to 7days
aer birth. Mendes and Procianoy conducted a study in
Brazil,[20] contrary to the results of this study showed that
massage therapy by mothers had no signicant eect on the
increase in weight gain in infants<1500g but the hospital
stay in the intervention group was 7 days less than the
control group (P=0.007).Because of their result did not
show a signicant eect of massage on weight gain, perhaps
the mothers cannot use moderate pressure during massage
therapy because of their intense emotions about their small
baby.However, based on our idea the massage can be more
Table 2: Comparison of daily weight in two groups
during study
Days of study X
_
±SD P
Massage Control
First day 1282/7±119/1 1219±124/7 0/1
Second day 1300±123/3 1233±122/4 0/09
Third day 1321/7±127/5 1247/25±124/8 0/07
Fourth day 1346±131/7 1263/75±130 0/054
Fifth day 1369/7±136/1 1282/75±130/5 0/04
Sixth day 1394±132/4 1297/7±131/6 0/02
Seventh day 1428±135/8 1312/7±135/5 0/01
SD – Standard deviation
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Journal of Clinical Neonatology | Vol. 5 | Issue 2 | April-June 2016
eective if it was done by nurses or other trained ones. We
propose to study the eect of massage by trained fathers on
weight gain in preterm infants for future studies.
CONCLUSION
is study showed that the massage or deep tactile
stimulation can promote weight gain in hospitalized, very
low birth weight infants in the NICU. Infant massage that
has also led to earlier discharge and reduced hospital costs
will follow. As one of the measures of the quality of nursing
care in the NICU is neonatal weight gain, we suggested
that the massage can be used as an eective method in
conjunction with other treatments.
Acknowledgments
We are grateful to the Clinical Research Development
Committee of Amirkola Children’s Hospital, NICU
personal of Ayatollah Rouhani Hospital and Mrs. Fatemeh
Rahmaanpour for their contribution to this study.
Financial support and sponsorship
Nil.
Conicts of interest
ere are no conicts of interest.
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