Tactile stimulation in low-risk infants: Results of a systematic
Review
Angela Underdown
Associate Professor in Early Childhood, University of Warwick
Jane Barlow
Associate Professor, Reader in Public Health, University of Warwick
Address for Correspondence:
Angela Underdown
Warwick Medical School
University of Warwick
Coventry
CV4 7AL
Tel: 02476 574884
Email: A.V.Underdown@warwick.ac.uk
Key words: tactile stimulation, infants, systematic review
Tactile stimulation in low-risk infants: Results of a systematic
Review
Abstract
Touch, an intrinsic part of caring for an infant, establishes powerful physical and
emotional connections, and plays an important role in supporting health and wellbeing, and in particular affect regulation. The objective of this study was to
investigate published research to ascertain whether tactile stimulation offers an
effective intervention to support infant mental and physical health. A systematic
review into the effects of infant massage on low-risk infants under 6 months
identified twenty-two studies (13 from China and 9 from elsewhere) that met our
inclusion criteria. Study criteria allowed only for randomised controlled trials to be
included. Study quality was variable. Beneficial effects for mother-infant
interaction, maternal warmth and reduction of intrusiveness, infant attentiveness,
liveliness and happiness were demonstrated in one study; other studies reported
no beneficial effect on infant temperament, attachment or development.
Individual studies reported beneficial effects on amount of crying, serum levels of
norepinephrine and epinephrine, and nocturnal urinary secretion of 6sulphatoxymelatonine and urinary cortisol. Beneficial effects on patterns and
quality of sleep were reported in two studies, and on length of sleep in studies
from China but not elsewhere in the world. Effects on weight, length and head
circumference were evident only in the meta-analysis of studies from China, and
in a large study from a Korean orphanage in which normal infant care was highly
atypical. It is concluded that there is some evidence that infant massage may
have beneficial effects on infants’ sleep and crying patterns, mother-infant
interaction and the infant’s physiological response to stress. There is also some
evidence that infant massage may be beneficial for infant growth, specifically in
situations where infants are deprived of sufficient adult contact, but all of these
findings require more robust studies. No evidence was presented that infant
massage does harm.
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Tactile stimulation in low-risk infants: Results of a systematic
Review
Introduction
Touch is an intrinsic part of caring for an infant that establishes powerful physical
and emotional connections between carer and baby, and plays a pervasive role
in communication and affect regulation (Moszkowski and Stack 2007). For most
infants, everyday routines involve many tactile interactions, communicating a
range of somatosensory messages including emotional feelings, pressure,
temperature, texture, softness or even pain. The amount of touch considered
appropriate between adults and infants varies between cultures with some
babies experiencing close contact with the mother’s body during most of the first
year while others experience extended periods of separation by being
encouraged to sleep alone in the nursery and through the use of day-care
(Rogoff 2003).
Maternal sensitivity has been identified as a significant component in the
development of an infant’s emotional attachment (Ainsworth 1973), and the
sensitivity (or otherwise) of a carers’ responses is transmitted to the infant
through a combination of touch, voice and facial movements. During the past
decade there has been increasing recognition about the specific role of touch or
tactile stimulation in the development of the infant’s capacity for affect regulation.
Affect Regulation and the Role of Touch
The formation of psychological attachments appears to be interlinked with
chemical changes and functional development in the infant neural system
(Schore 2003), and sensitive tactile stimulation during maternal nursing of the
infant, is thought to play a significant role in the growth of the dendrites that form
the crucial neural connections (Greenough and Black 1992 cited in Schore
2003). In primates, neurobiological research has shown that ‘critical levels of
tactile input of specific quality and emotional content is important for normal brain
maturation’ (Martin et al 1991:3355). At birth the primary somatosensory centre,
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which processes tactile and kinesthetic information in the brain’s cerebral
hemispheres, is metabolically active (Chugani 1996). The hypothalamicpituitary-adrenocorticol (HPA) system produces and regulates the glucocorticoid
cortisol in response to stress (Gunnar 1998) and for the first two months after
birth the infant’s HPA system is highly labile (Gunnar, Brodersen, Krueger and
Rigatuso 1996). However, from the age of about two months the infant’s stress
systems are becoming organised via transactions with the sensitive main carer
who acts as a ‘buffer’ to the reactivity of the HPA system (Nelson and Bosquet
2000).
Touch has been reported as an intrinsic factor in helping to regulate infant
behavioural states (Brazelton 1990) and de Chateau (1976) found that infants
who had extra bodily contact after birth smiled more and cried less at three
months observation. By 8 weeks post-natally the somatosensory connections to
the amygdala (the almond shaped group of neurons located deep within the
brain’s temporal lobes that have a major role in the processing and memory of
emotional reactions) are forming and Schore (2003) suggests that sufficient
levels of tactile stimulation releases early pro-attachment behaviour.
It is the security that most children experience within their attachment
relationships that is thought to impact upon the high neonatal cortisol responses,
so that by the age of one year infants are less likely to show an increase in
response to stressors (Gunnar and Donzella 2002). This appears to be due to
the development of functional glucocortoid hyporesponsiveness, as children
learn to feel secure and safe with caregivers who respond to their cues (Gunnar
and Donzella 2002). However, Gunnar and Donzella (2002) further report that
elevated cortisol levels have been noted when children are exposed to
moderately less sensitive and responsive care. These findings are supported by
ethological studies (Liu et al 1997) which have demonstrated that the amount of
tactile stimulation (maternal licking and grooming) experienced by rodent pups
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modulates cortisol production. Harlow’s famous studies also demonstrated the
importance of tactile experience by replacing the rhesus monkey mothers with
wire mesh dummies, one dispensing milk from a bottle and the other clad in terry
toweling cloth (Harlow 1958). The monkeys clung to the tactile surrogate mother
when fearful and were more confident to explore when it was present (Harlow
1958). In other studies Harlow (1965; 1971) demonstrated that isolated monkeys
developed abnormal social behaviour and later failed to care for their young.
Other studies (Mitchell 1970; Goosen 1981; Kraemer 1985) have produced
similar findings of abnormal social and motor behaviour in socially deprived
monkeys. More recent work (Martin et al 1991) investigating the neurobiological
mechanisms underlying the behaviour of socially deprived monkeys found that
social/sensory deprivation of non-human primates in the first year of life have
pronounced alterations in the organization and patterned arrangements of the
basal ganglia neurotransmitters. The basal ganglia are a group of subcortical
nuclei involved in motor control, cognition, and emotion (Carver and Carver
2003) and abnormalities in this region are characterised by abnormal movements
and a number of neuropsychiatric disorders (Carver and Carver 2003). Evidence
from neurobiological research on primates therefore suggests that “in early postnatal life, maintenance of critical levels of tactile input of specific quality and
emotional content is important for normal brain maturation” (Martin 1991:3355).
Research with human infants has been restricted to naturally occurring situations
where children have been raised in highly adverse conditions. Children living in
Romanian orphanages, who lacked social and physical stimulation and
opportunities to form emotional attachments with consistent care-givers had
complex ‘flattened’ cortisol profiles that did not show the expected daily rhythm,
with raised levels in the morning (Carlson et al 1995; Carlson et Earls 1997). This
finding suggests that HPA axis activity may have been adversely affected
(Gunnar and Vazquez 2001), and although no firm conclusions were possible
from this data (Gunnar and Donzella 2002), other evidence shows that children
5
raised in orphanages of this type have stunted growth (Johnson 2000). Elevated
corticotrophin-releasing hormones (CRH) are thought to be instrumental in this
type of faltering growth (Johnson et al 1992).
Intervening using tactile stimulation
Tactile stimulation or infant massage is widely practiced in many parts of the
world, especially Africa, Asia and the South Pacific (Field, Schanberg, Davalos,
Malphurs 1996). A survey of 332 primary caretakers of neonates in Bangladesh,
for example, found that 96% engaged in massage of the infant's whole body
between one and three times daily (Darmstadt et al 2002).
In the West, tactile stimulation has until recently been largely restricted to highrisk infants often in intensive care settings, in which the amount of handling that
an infant received was thought to be suboptimal (Field 2000 cited in Zeanah
2000; Vickers 2000). Increasingly, however, parents in western cultures are
being taught the techniques of tactile stimulation or infant massage (Underdown
cited in Barlow and Svanberg in press) often by attending a weekly class. Claims
for the effects of such stimulation are wide and include benefits for parent-infant
interaction, sleep, respiration, elimination and the reduction of colic and wind
(Blackwell 2000; Field 2000 cited in Zeanah 2000). The aim of this review was to
address whether tactile stimulation in medically low-risk infants could be shown
to have an impact on either the mental well-being of infants or the relationship
between the mother and the baby. Data on infant growth has also been
included, due to the complexity of the relationship between growth and other
aspects of mental health.
Method
A systematic review of randomised controlled trials was conducted. Searches
were undertaken of a range of electronic databases including CENTRAL 2005
(Issue 3), MEDLINE (1970 to 2005), PsycINFO (1970 to 2005), CINAHL (1982 to
2005), EMBASE (1980 to 2005), and a number of other Western and Chinese
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databases. We only included studies that had examined the impact of any form
of tactile stimulation on low-risk infants under the age of six months. The
intervention was defined as ‘systematic tactile stimulation by human hands’
(Vickers 2004) and low-risk infants were defined as having no apparent physical
health adversities. Studies comprising infants of post-natally depressed mothers
(Field et al 1996; Onozawa et al 2001) and those being cared for in an
orphanage (Kim et 2003) were included (i.e. as they were reported on healthy
full-term infants, whereas infants who were HIV exposed (Scafidi et al 1996)
were excluded. Studies were included if infants were randomised to either a
tactile stimulation group or a control group that received no intervention or
standard care. No language restrictions were applied.
Data management
Data were extracted, checked and entered into RevMan version 4.2 (Cochrane
Collaboration, 2003) by two reviewers independently. Discrepancies were
discussed with a third reviewer.
Assessment of quality and risk of bias
Trials were assigned a quality category based on allocation concealment.
Aspects of study design that may increase bias were also appraised (sample
size, number of infants lost to follow-up, the method of dealing with attrition/drop
out, use of blinding to assess outcomes, and whether there was any assessment
of the distribution of confounders).
Data synthesis
Using a random effect model we report the differences in continuous outcomes
between the treatment and control groups as weighted mean differences with
95% confidence interval. In the case of measures where data were reported on
incompatible scales, we present the standardised mean difference and 95%
confidence intervals. Where it was not possible to synthesise the data, effect
7
sizes and 95% confidence intervals have been calculated for individual outcomes
in each study. In the absence of data with which to calculate effect sizes we
report the significance level presented in the primary study. A minus sign
indicates a result favouring the intervention group.
Due to concerns about uniformly positive results, inadequate information about
the design and conduct, and the absence of any reported dropout, a post hoc
decision was taken to analyse separately the results of thirteen studies
undertaken in China (Liu Chun Li 2005; Liu 2005; Lu Jiao, Li Ju Zhan, Wu Li
Fang 2005; Na Zhuo Hua, Xie Hui Yun, Huang Jian Hua 2005; Shao L et
al.2005; Sun Hai Yun, Gao Xiang Yu, Zhao Xue Mei 2005; Ye Hong Yun 2004;
Xua Li Shuan, Qing Gui Romg, Ye Mei Yan et al 2004; Duan Lihong, Li Weihong,
Shi Fentao 2002; Shi Li, Xue, Rong 2002; Ke, Ling, Li. 2001; Zhai, Pan Xian,
Hua et al 2001; Wang Bin, Shen Yue Hua, Jin Run Yan et al 1999).
Sensitivity Analysis
A sensitivity analysis was undertaken to assess the impact on the findings of one
large Korean study (Kim, Shin, White-Traut 2003) of infants receiving orphanage
care.
Results
We identified 809 abstracts in Western databases, of which 35 were obtained for
review. Ten studies met the inclusion criteria, one (Koniak Griffin, Ludington-Hoe
et al 2001) of which reported follow-up of one of the other nine and one of which
was carried out in China (Duan Lihong, Li Weihong, Shi Fentao 2002). A handsearch of references resulted in the identification of one further study (Ke, Ling,
Li 2001).
Of the abstracts reviewed from the Chinese databases,12 studies were identified
as suitable for inclusion, producing in total 13 Chinese studies (Liu Chun Li 2005;
Liu 2005; Lu Jiao, Li Ju Zhan, Wu Li Fang 2005; Na Zhuo Hua, Xie Hui Yun,
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Huang Jian Hua 2005; Shao L et al.2005; Sun Hai Yun, Gao Xiang Yu, Zhao Xue
Mei 2005; Ye Hong Yun 2004; Xua Li Shuan, Qing Gui Romg, Ye Mei Yan et al
2004; Duan Lihong, Li Weihong, Shi Fentao 2002; Shi Li, Xue, Rong 2002; Ke,
Ling, Li. 2001; Zhai, Pan Xian, Hua et al 2001; Wang Bin, Shen Yue Hua, Jin
Run Yan et al 1999)
In addition to the Chinese studies, one Korean (Kim, Shin, White-Traut 2003),
one Israeli (Goldstein Ferber et al 2002), one British (Onozawa, Glover et al
2001) one Indian (Argawal, Ashish et al 2000), and five North American (Elliot,
Reilly 2002; Cigales, Field et al 1996; Jump 1998; Field, Grizzle et al 1996;
Koniak Griffin, Ludington-Hoe 1988) studies were included. One follow-up study
was also included (Koniak Griffin, Ludington-Hoe et al 1995).
Table one shows the characteristics of the included studies.
Table 1
Types of studies
A range of tactile stimulation or massage methods were reviewed. In four studies
(Argawal 2000; Elliott 2002; Goldstein Ferber 2002; Koniak-Griffin 1988) parents
were taught massage techniques prior to them conducting massage on their
infants in the home. In two studies massage was offered by research associates
(Cigales 1997; Field 1996). In the Kim (2003) study, orphans received a multimodal intervention of massage, talking and eye contact from research associates
who were trained to be responsive to the infants’ responses. Although it was not
possible to isolate the effects of eye contact and talking, this study was included
because both these components are an intrinsic part of some included infant
massage programmes. In the 13 Chinese studies the massage was mostly
administered by a nurse with specialist training in infant massage, following
which the technique was taught to the parents who continued the massage at
home.
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Types of massage
The massage programmes evaluated in the included studies varied in terms of
duration and frequency. In one study, infants received a daily 30 minutes
intervention over 14 days (Goldstein Ferber 2002). In the Kim (2003) study
infants were massaged 15 minutes, twice daily for 4 weeks. In further studies,
infants received 10 minutes of massage daily over a four week period (Argawal
2000) or a minimum of 10 minutes massage daily over 16 weeks (Elliott 2002). In
the Field (1996) study infants received 15 minutes of massage twice weekly over
a period of six weeks and in the Koniak-Griffin (1988) study infants received 5-7
minutes of massage daily over 3 months. In two studies (Jump 1998 and
Onozawa 2001) mothers were taught massage techniques for approximately an
hour per week as part of four, weekly, group-based sessions, following which the
continuation of this practice at home varied according to parental motivation. In
the 13 Chinese studies infants were mostly massaged for fifteen minute periods
up to three times a day over a period extending up to 6 weeks (Liu 2005; Liu
Chun 2005; Lu 2005; Na 2005; Shao 2005; Sun 2004; Ye 2004; Xua 2004; Duan
2002; Shi 2002; Ke 2001; Zhai 2001; Wang 1999). In the Cigales study (1997)
massage was administered only once prior to the conducting of an experimental
task to assess the impact of massage on cognitions.
Findings
Stress hormones
One US study (Field et al 1996) showed reduced levels of norepinephrine
(weighted mean difference -60.30 ng/gm creatinine 95% confidence intervals 111.88 to -8.72) and epinephrine (weighted mean difference -13.00 ng/gm
creatinine 95% confidence intervals -20.08 to -5.29) among massaged infants,
but no effect on levels of serotonin (weighted mean difference -295.50 ng/gm
creatinine 95% confidence interval -705.25 to 114.25). This study also measured
salivary cortisol levels 20-minutes post-intervention and showed no difference
between groups (weighted mean difference -0.20 ng/dl 95% confidence interval
10
-4.60 to 4.20) (Field et al 1996). However, urinary cortisol levels measured later
using radioimmune assay, were lower in the massage group (weighted mean
difference -360.40 ng/gm creatinine 95% confidence intervals -633.79 to -87.01).
Circadian Rhythms
An Israeli study (Goldstein Ferber et al 2001) measured the nocturnal secretion
of 6-sulphatoxyymelatonin in urine and showed higher levels in the massaged
group (weighted mean difference -523.03 ng/night 95% confidence interval 664.51 to -381.55), suggesting that massage enhances circadian rhythms by
promoting the secretion of melatonin.
Infant sleep/wake behaviours
The above study also showed at 8-weeks postnatal peak activity during the time
period 3 - 7 a.m. in the massaged group compared with 11 p.m. - 3 a.m. in the
control group. A secondary peak of activity was observed in the treated subjects
between 3 p.m. and 7 p.m. while in the control group a secondary peak occurred
between 11 a.m. to 3 p.m. This suggests a delay in peak activity in massaged
infants and that the treated infants achieved a more favourable adjustment of
their rest-activity cycle. An interaction between treatment and timing of peak
activity was observed (p=0.042). No differences were found between groups in
total movement. No differences were found for measurements performed 1-day
before and 1-day after the intervention, and at 6-weeks of age.
One US study (Field et al 1996) showed less crying (weighted mean difference 8.20 episodes 95% confidence interval -12.24 to -4.16) and increased active
sleep in the massaged group (weighted mean difference -37.00 95% confidence
interval -50.86 to -23.14). Infants in the control group spent more time in an
inactive alert state 12.70 (6.02 to 19.38). A non-significant increase in measures
of quiet sleep 6.30 (-7.56 to 20.16) was also observed in this group. There was
no difference between massage and control groups in the amount of drowsiness
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-2.00 (-4.19 to 0.19) (Field et al 1996). One further study that assessed duration
of sleep and number of naps after four weeks of massage showed no difference
between the two groups (Argawal et al 2002).
One of the Chinese studies (Xua, Shuan et al 2003) measured the frequency and
duration of bouts of crying and found the massaged group to have fewer bouts of
crying -0.34 (-0.56 to -0.12) that lasted for shorter periods of time (hrs) -0.30 (0.54 to -0.06).
Three of the thirteen Chinese studies (Zhai, Pan et al 2001; Sun etal 2004; Xua
el al 2004) including 434 infants (216 intervention and 218 in the control group)
measured hours of sleep. Meta-analysis showed massaged infants to sleep
longer -0.62 hrs (-1.12 to -0.12).
One Chinese study (Xua el al 2004) also measured the frequency and duration of
night waking and found the massaged group woke fewer times -0.48 (-0.81 to 0.15) for significantly shorter periods -0.27hrs (-0.51 to -0.03)
Infant Interactions
A British study (Onozawa, Glover et al 2001) showed improvements in the
intervention group for three aspects of infant interaction including attentiveness
(standardised mean difference -1.31 95% confidence interval -2.26 to -0.37);
liveliness (standardised mean difference -1.30 95% confidence interval -2.24 to 0.36) and happiness (standardised mean difference -0.95 95% confidence
interval -1.85 to -0.06).
This study also showed an impact on mother-infant interaction using an
independent assessment of outcome (standardised mean difference -1.32 95%
confidence interval -2.27 to -0.38). Differences favouring the intervention group
were also observed for the amount of warmth (standardised mean difference 2.17 95% confidence interval -3.27 to -1.07) and intrusiveness (standardised
12
mean difference -0.97 95% confidence interval -1.87 to -0.08) of maternal
interactions in the massage group.
Growth
Meta-analysis of the effects of massage on infant weight was undertaken based
on findings from four non-Chinese studies (Kim et al 2003; Argawal et al 2000;
Field et al 1996; Koniak Griffin et al 1988). Based on a total sample of 264
infants the results showed a large but non-significant increase in infant weight (297.72 gms 95% confidence interval 859.26 to 263.81].
Figure 1 Meta-analysis of weight gain
This finding was heavily dependent on the data from a large study of Korean
orphanage infants (Kim et al 2003) and a sensitivity analysis was therefore
undertaken in which the data from this study were removed from the metaanalysis. The exclusion of this study resulted in a reduction in the weighted
mean difference to 4.12 gms (95% confidence interval 223.91 to 232.16).
Figure 2 Sensitivity analysis for weight
Ten of the 13 Chinese studies (Liu Chun Li 2005; Liu 2005; Lu Jiao et al 2005;
Na et al 2005; Sun et al 2005; Ye et al 2004; Duan et al 2002; Shi et al 2002; Ke,
et al 2001; Zhai 2001) evaluated the effectiveness of infant massage on weight
gain (based on results from 1570 infants); meta-analysis showed a significant
increase favouring the intervention group -378.12 (-511.02 to -245.22).
Figure 3 Meta-analysis of weight Chinese Studies
Two non-Chinese studies evaluated the impact of massage on infant length (Kim
et al 2003; Argawal et al 2000). They comprise a sample of 183 infants; meta-
13
analysis showed no impact (weighted mean difference 0.76 cms 95% confidence
interval -2.67 to 1.15).
Figure 4 Meta-analysis of length
Six of the thirteen Chinese studies (Liu 2005; Lu Jiao et al 2005; Na et al 2005;
Duan et al 2002; Shi et al 2002;) comprising a total of 1120 infants measured
infant length; meta-analysis showed massaged infants to be longer (cms) -0.93 (1.21 to -0.64).
Figure 5 Meta-analysis of length Chinese Studies
Two non-Chinese studies comprising 183 infants evaluated the impact of
massage on infant head circumference (Kim et al 2003; Argawal et al 2000).
Meta-analysis showed no impact (weighted mean difference -0.87 cms 95%
confidence interval -2.62 to 0.87).
Figure 6 Meta-analysis of head circumference
Five of the thirteen Chinese studies (Liu 2005; Lu Jiao et al 2005; Na et al 2005;
Duan et al 2002; Ke, et al 2001) including 1040 infants measured infant head
circumference and meta-analysis showed a benefit of 1.48 cms(-1.70 to -1.26) in
massaged infants.
Figure 7 Meta-analysis of head circumference Chinese Studies
Number of illnesses and clinic visits
Massaged Korean orphanage infants had fewer illnesses (weighted mean
difference -8.82 95% confidence interval -10.41 to -7.23) and clinic visits
(weighted mean difference -5.98 95% confidence interval -6.94 to -5.02) than
controls (Kim et al 2003).
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Other outcomes
One USA study showed an effect on habituation (Cigales et al 1997) but there
was no evidence in other USA studies of benefit on a range of measures of infant
temperament, (Elliot et al 2002; Jump 1998; Field et al 1996) infant
attachment,(Jump 1998) or psychomotor and mental development (Koniak Griffin
et 1995).
Discussion
The methodological quality of the included studies was variable, and has been
reported elsewhere (Underdown et al 2006). The largest number of studies were
conducted in China and they show significant effects on weight, length and head
circumference. Based on concerns about Chinese studies raised previously
(Vickers et al 1997) that were also apparent in these studies (uniformly significant
results, inadequate information about the design and conduct of the studies, and
absence of any reported dropout), we took the decision to present the results of
the Chinese studies in a separate meta-analysis. These studies examined the
effect of very similar amounts and durations of massage (i.e. fifteen minutes,
twice daily over around six weeks), but considerable statistical heterogeneity was
noted, even after taking account of the individual results and the sample sizes.
The reason for this is not clear. The results of these studies must therefore be
viewed with considerable caution.
The quality of the remaining studies was only fair with many not providing
specific details about the method of randomisation or about allocation
concealment. There was also some heterogeneity in the infant massage
interventions. For example, in some studies the massage was administered by
the mother, while in others it was administered by researchers/professionals.
The duration and frequency of massage also varied from one episode for 8
minutes to 15 minutes three times a day for 6 weeks. Although specific detail was
often not provided, it would appear that the approach to massage also varied
15
including the use of tactile and kinaesthetic stimulation in one and
responsiveness to infant cues in another. Synthesis of data was undertaken
using a random effect model despite this variation because we were not aware of
any evidence to indicate that any of these factors are influential in altering
outcomes. This variation, however, makes it very difficult to identify the core
components of effective massage intervention.
Bearing these limitations in mind, the evidence of significance effects of massage
on catecholamine (norepinephrine and epinephrine) and cortisol excretion are
potentially important given what we now know about the possible damaging
effects of stress hormones on the development of pathways in the infant brain
(Gunnar et al 1998 cited in: Zeanah 2000). Given the apparent effect of infant
massage on stress hormones it is not surprising to find some evidence of an
effect on sleep and crying and one study (Goldstein Ferber 2002) also reported
an effect on release of melatonin (6-sulphatoxymelatonin), which is involved in
the adjustment of circadian rhythms. As sleep deprivation is a very real problem
for many families with a young infant, the teaching of infant massage may be an
effective practical way of helping parents to support infants in establishing
sleeping patterns.
Meta-analyses of growth in weight, length and head circumference in the nonChinese studies showed non-significant differences favouring the intervention
group that disappeared following a sensitivity analysis in which the results of the
large Korean study of orphanage infants were removed. The highly significant
findings of the Korean study may have been due to severe deprivation of tactile
stimulation in the orphanage control group infants. Certainly there is research to
show that infants who are deprived of touch, such as those in orphanages with
low infant-adult ratios, do not achieve optimum growth (Mason and Narad 2005).
Field (1996) found a non-significant weight gain favouring the intervention group
of infants of depressed mothers. However, this study used researchers to
16
massage infants, which raises questions about the promotion of attachment in
combination with sensitive touch (Schore 2003). Ten of the 13 Chinese studies
reported a significant increase in weight following infant massage, although as
noted earlier more information is needed about these studies before any
conclusions can be drawn. There is a need for further studies to identify whether
learning infant massage may be an effective intervention in some home
situations where infant growth is faltering.
One UK study (Onozawa et al 2001) reported more effective interactions which
were warmer and less intrusive, between post-natally depressed mothers and
their infants following a five week infant massage course. This is an important
finding but raises questions about individual teaching methods and how much
attention was drawn to responding to infants’ cues. While massage may be an
effective medium for encouraging parental sensitivity and awareness of infant
communication, however this may be dependent on the training and aptitude of
the instructor.
Conclusions
Potentially valuable benefits on aspects of maternal behaviour and infant
behaviour, development and physiology were evident in a small number of
studies. No evidence of harm was identified. Robust trials are needed to confirm
these findings and to assess whether the geographical differences we observed
are attributable to study methodology, approaches to massage or to cultural
differences.
Meanwhile, the equivocal findings of this review provide insufficient evidence on
which to base decisions regarding either the development of new provision or the
discontinuation of existing provision of services to teach massage to parents of
low risk infants in community settings.
17
It would be beneficial to have more research into specific methods of teaching
infant massage and the possible role it can play as a medium for promoting infant
–parent communication.
Among the non-institutionalised low-risk infants who were the subject of this
review, massage was associated with benefits in growth only in studies at high
risk of bias. Further robust trials are clearly needed in different parts of the world
to confirm the positive findings of this review with regard to sleep, crying and
physiological effects which were based on a limited number of studies. These
trials should also measure growth to establish whether the discrepant results we
observed are attributable to methodological inadequacies or cultural differences
in either approaches to massage or normal infant care. Such research should
aim to distinguish effects in infants in homes where care is optimal from those
where it is less than optimal. There is also a need for further research on the
effect of infant massage on parent-infant interaction and infant temperament
where findings of this review were inconclusive.
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