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Massage Today
March, 2004, Vol. 04, Issue 03

Spotlight on Research

Nurturing Touch in the Neonatal Intensive Care Unit (NICU) at Stony Brook University Hospital on Long Island, New York

By Editorial Staff

Editor's note: This periodic column keeps you abreast of the latest research documenting the benefits of massage and bodywork.

Recently, Massage Today spoke with Patricia Cadolino, LMT, CIMI, facilitator of the nurturing touch massage program in the neonatal intensive care unit at Stony Brook University Hospital in New York. Below is Patricia's poster session, which was presented at the 2002 and 2003 AMTA National Conventions, followed by the interview.

A parent education program for premature or medically fragile infants in a critical-care hospital setting. This is a supportive and developmental-care program that encourages and empowers parents to provide individualized touch for their high-risk infants.

Demonstration of hand containment on an infant. - Copyright – Stock Photo / Register Mark Hand containment involves gentle holding with moderate pressure. 1. Hand Containment: This is the first introduction of touch providing a safe, supportive environment. When the infant cannot be held, parents are instructed to hold their infants through the portholes in the incubator.

Benefits include: Enhanced family bonding, stabilizing infants' heart rates, improved breathing patterns, and decreased oxygen needs.

A baby held against a parent's bare chest. - Copyright – Stock Photo / Register Mark The benefits to a baby held against a parent's bare chest are numerous. 2. Skin-to-Skin or Kangaroo Care: With the parent sitting in a chair, the infant, in a diaper, is placed directly on the parent's bare chest and covered with a blanket.

Benefits include: Enhanced family bonding, improved heart rate and breathing patterns, increased weight gain, improved lactation, and helps regulate body temperature.

Additional benefits of positive touch: Minimizes the negative impact of hospitalization and helps infants avoid touch aversion; reduces pain and stress from the many necessary medical procedures.

A pre-term infant holds onto his parents hand. - Copyright – Stock Photo / Register Mark Medically stable pre-term infants can benefit greatly from a parent's touch. 3. Preemie Massage: This is the third phase of the touch program and is applied when the infant is more medically stable, weighing at least 1,000 grams or more.

Benefits include: Increased weight gain, decreased fussiness and crying, more organized sleep patterns, and earlier discharge from the hospital.

Depending on the infant's weight and gestational age, and with medical clearance, parents are advised on the best form of touch that will most benefit their babies. These techniques emphasize the variations in premature responses. Parents are taught to read the stress and behavioral cues to avoid putting additional stress on the infant while providing safe, positive and loving communication through touch!

Interview With Patricia Cadolino

Massage Today (MT): You've been at Stony Brook for five years?

Patricia Cadolino (PC): Almost six years.

MT: Can you tell us a little bit about how things have changed from the time you started your work at the hospital until now, and discuss the evolution of your work over that period of time?

PC: Sure. I started out part-time on a research grant. It was a Ryan White research grant. Ryan White was the boy who contracted AIDS through a blood transfusion. The hospital applied for an alternative medicine grant through the [Ryan White] foundation, and in that grant was massage and acupuncture. I was hired on that grant as a massage therapist, and that is when I was working with HIV and AIDS-infected infants, drug-addicted infants, pregnant women and adolescents. The hospital went on to open their own complementary center, but it did not work out and the center was shut down; however, there were administrators that were so supportive of me and my work, and they hired me as a state employee. I was the first in New York state. It was quite the venture [for a] government hospital. Once I became a state employee, I was on the professional line, and that is how I started. From that point, I kind of just made my own way. They gave me what I needed: an office, a treatment room...

MT: So, you were hired as a state employee of the hospital in the capacity of a massage therapist?

PC: Yes. They gave me a different title as a "clinical support specialist" under the nursing division, because everything [must be] listed within specific categories and titles. That is how the administrators got me into the position. Basically, I have just worked hard in lecturing and educating, and teaching medical students.

MT: What types of lecturing and educating are you doing?

PC: All about massage. When I am in the pediatric department, I discuss what I know from my pediatric background. Otherwise, it is reviewing the benefits and the research, and how massage can be used in a hospital setting and a home setting.

MT: How would you classify the differences between using massage in a hospital setting versus a private office setting?

PC: The benefits are great while the patient is in-house, but you never do any kind of deep work while they are in-patient. And with the younger children, we try to get the parents to massage the children at home. I don't treat many younger kids out-patient here. It is mostly adults.

MT: Has the scope of what you're doing shifted from infant massage to other types of patients?

PC: It is such a mix; I wear many, many hats. My love is working with the children because I went on for further training. I have been certified for 11 years to teach baby massage, but I went on for further training to work with the premature babies. I went to the University of New Mexico, and St. Luke's Hospital in Kansas City, Mo., in the Tender Touch program. So, since I had been trained to do that, I went to my bosses and supervisors and said, "This is what I would love to do," and they allowed me to do it.

MT: Do you have the support you need from other staff members, or do you find that some staff members are still a bit reluctant to embrace the benefits of massage?

PC: A little bit, but it is getting so much better. I really do see a shift. I see a change happening.

MT: Do you see massage evolving into a regular practice in hospitals everywhere?

PC: Yes, I do. I'm quite proud because I worked really hard to make a lot of positive connections with some key people in the hospital, and I've made my way. I think perseverance, a lot of courage, and consistency has really catapulted me into such a different arena, such a professional arena. I'm like a fixture now, and it's really quite nice, so I will get more referrals now, but you have to remember, the hospital's huge - about 3,000 employees - so it's a very big place; still, I have made great strides over a short period of time to incorporate massage into the [hospital program].

MT: If there were a couple of areas where you wish you had more support or more feedback from your work colleagues, what would those be?

PC: Definitely more referrals. It is a state hospital, so there is always a financial piece that comes into play, and a lot of the patients can't afford it. There are a lot of services that the hospital provides for free, so I see that the staff wishes that it [were] just part of the hospital stay. [Massage] is a fee-for-service.

MT: How much does that fee usually run?

PC: It is $40 per half hour, which is very reasonable. I worked in another hospital where it was $100 a massage.

MT: Are any of these patients able to get your services covered with their insurance?

PC: Only a few. The New York State No-Fault Insurance Law states that insurance companies must pay for massage; unfortunately, you have to get into a car accident to get massage [covered].

MT: Are you still working in the NICU (Neonatal Intensive Care Unit)?

PC: Yes. In fact, I implemented a nurturing touch program, which is a parent-education program that deals with developmental care. Each baby is assessed, and I work with the parents on the form of touch each baby is ready for. Initially, I used to have to charge parents for this class, and I used to feel so guilty, so I again went to my administrators, presented this, and they decided to make it a part of the baby's hospital stay, so it is free of charge. That is one service that I'm really pleased with.

MT: In some regards then, at least financially, the hospital seems to be trying to work with you in as much capacity as it can. With any program, money always seems an issue.

PC: Always, right.

MT: Making massage part of the baby's stay, does the hospital incorporate the extra fees into the overall charges, or does it absorb the fees?

PC: They added it under parent education. Also, there is the staff support issue, which is how I presented it to the administrators. It's not only a beautiful benefit to the parents. There is so much involved - it's very intense. When you're dealing with the parent of a premature baby, touch-and-go. And what happens is, instinctively, the parents really shut down. There is the fear of attaching. They don't want to become attached, and it's very scary because the baby is very sick, and in that fear, they refrain from touching. There are a lot of studies that have been done on this and it's phenomenal.

So, the parents are afraid. Or, on the flipside, you'll have a parent ever so gently stroke their baby with the tips of their fingers, but neurologically the baby can't handle that and can't process it, so the baby responds in a negative way: the monitors start flaring, the baby's oxygen saturation levels drop, and the nurse will come over and say, "Mom, please don't touch the baby." Because when you touch the baby, the baby gets upset and it becomes a very negative dynamic.

Now, the mother feels more depressed because the baby didn't respond well. So, with my program, pressure is everything. You have to have moderate pressure; it's relaxed, but moderate. And it's more like just holding and containing, not so much stroking, right away. And the baby processes that beautifully; they can handle that. It's comforting to them.

MT: What is the reason for that? Why is holding and containing ok, versus stroking?

PC: It takes the baby a while to process that hold and that's why we do it in stages: because some babies can handle the stroking right away, but others can't - they get overstimulated. A full-term baby at birth is not neurologically complete. So, as you can imagine, a premature baby is way under the gun. That is why it is such a blessing that I'm there, because I'm able to work with the parents early on. They get the confidence and the know-how of how to interact with their baby in a positive way. The baby responds better and the parents feel better, and it creates a wonderful family dynamic that is a little bit healthier.

Not that this is a cure-all, obviously. And I have worked with a lot of parents that have lost their babies. But the positive note on that is, at least the parents have some time to connect with the baby in a positive way before the passing.

MT: As far as the staff education is concerned, when you begin to develop these patterns of the baby responding to the parents, does the staff respond, as well? Is the staff learning along with these parents?

PC: I have done separate work with the staff. I just offer the research and my knowledge, and offer hands-on practice. One time, one of the neonatalogists had a grandchild in the unit, and he had me go in and work with his daughter-in-law; he thought that would be a great way to get the staff to see how it works. I've seen it evolve through just the perseverance and commitment and consistency, and people see [the benefits] over time. Now, the staff is starting to show the parents hand containment as a tool.

MT: Dedication seems to be a good word to describe what you have done because you have dedicated your time and yourself to this endeavor, no matter how long it has taken.

PC: Right. And I am really quite pleased. The hospital is going to be expanding and building a brand new unit that is state-of-the-art. They have called me in to be on the steering committee to make sure that things are done for developmental care for my areas of touch [with the] lighting and sound, all for the developmental care for the babies. I am so proud of that because this program will then be a part of the team. It will be a standard of care. I am really pleased with that.

MT: It has to be really stressful for you personally, working with these distraught parents and ill babies. Do you ever find yourself becoming emotionally involved? How do you find your balance to avoid emotional burnout?

PC: I am a very sensitive person to begin with, and I, initially, would cry when the mothers cried - I couldn't help it. I have children and I was able to relate. But I knew eventually, I would have to become strong to be able to deal with this, and I have. I have gained a lot of strength over the years, and breathing and meditation gets me through it, to be honest. I have to take care of myself and replenish the energy. That's what I have found works really well for me. Over time, just developing confidence has helped, too.

I'm not going to deny that, initially, it was scary to be in the position that I was in and have that type of placement. Once I gained confidence and strength, I found it a lot easier, and now I'm a lot stronger for the parents and I'm a good support for them.

MT: Do you have any advice for those wishing to pursue something along the same lines, especially in working with a hospital? How would you advise a massage therapist to get started?

PC: Every hospital is unique. They have different financial needs. A lot of the hospitals are in trouble, so it's hard to start adding new programs, but I would say to start with the Hospital-Based Massage Network, which is run by Laura Coke. There are many wonderful books on the market on how to begin a hospital-based massage program. Just research and know your stuff before you approach the hospital administrators.

MT: And certainly persistence, as you have been very persistent and that has led greatly to your success.

PC: Right, but I also know that a lot of people that have been persistent are still finding closed doors because of financial and insurance crises. There is a crisis, right now. Hospitals are losing money and laying off employees. Here in Nassau County alone, they were laying off a couple of hundred thousand people.

MT: And yet, in the midst of some of these layoffs, you have managed to sustain. That speaks to the validity and importance of your work.

PC: Right. I also think it's [because this is] a teaching, research hospital, and I made my own way to get money for research. I've worked very hard to get positive anchors.

MT: It's almost as though you have done most of the footwork. You've taken away the responsibility from the administrators to find the resources. You've come up with the've done it all!

PC: Yes, and I think that is why they feel so blessed with me as well, because they're so overwhelmed. They work 24/7 and they're overwhelmed with it; that's how the dance has been successful.

MT: Do you have any current research projects underway?

PC: Yes, I still have the research working with pediatric oncology patients, and we are teaching the parents how to massage them at home. And we're also working with the parents to do mind/body work - we're taking a look at reducing the parents' anxiety and stress, as well as that of the child. We'll be looking at pain and sleep scales to reduce the anxiety, and we'll be looking at cortisol levels for both parents and children.

We are working on another [project], as well, looking to work with cardiac patients, since the hospital has a heart center. We're currently in the discussion stages and planning, and it's looking good.

MT: Do you have anything else you'd like to add?

PC: Well, I'll just continue to make my way. The only thing I would really like to do this year is more in-services, more grand rounds. The more that I can educate the staff, nurses and doctors, the better off I feel that I'll be.

My favorite is the medical students. I find that working with the med students so early on really gives them a positive twist on massage. It is all going to roll and hopefully, they'll incorporate it into their practices, so that massage will become a standard of care. That's what I find rewarding: working with the medical students before they go out into private practice. I would like to see massage become the standard of care, and get it into more hospitals. And the same thing applies to the nurturing touch program. I'd like to see more intensive care units around the country have these programs for the parents and for parent education.

MT: Thank you so much for your time, Patti.

PC: You are so welcome!


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