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Massage Today
January, 2012, Vol. 12, Issue 01

Nurturing Touch in the NICU

By Tina Allen, LMT, CPMMT, CPMT, CIMT

When a baby is born prematurely, parents and caregivers of babies in the Neonatal Intensive Care Unit (NICU) may face some serious challenges. One of the main challenges is likely providing appropriate tactile stimulation.

This can be difficult given the number of doctors rounds, medical equipment and requirements for medical interventions. Not only are there the physical limitations, but also consider the emotional component of seeing your baby covered in medical tubes, much smaller in size than you imagined, and the insecurity of not knowing what would be appropriate or might cause harm. When baby does become stable enough for touch, what can a parent or caregiver do to provide comfort to their child? One of the best approaches can be infant massage.

Touch therapy research has demonstrated that nurturing touch for an infant is critical in establishing the foundation of their psychological well-being. When it comes to babies born prematurely, this can become even more important. Evidence has shown that massage therapy provided for neonates:

  • Facilitates weight gain in preterm infants.
  • Lowers levels of cortisol (stress hormone).
  • Increases muscle tone.
  • Improves sleep and wake patterns.
  • Shortens length of stay in hospitals.
  • Improves cognitive and motor development (measured at eight months of age).

These recent research findings show there are significant benefits to infant massage that out weigh over-stimulation. Even a simple intervention of massaging a baby's leg prior to a heel stick might decrease pain responses. A nurse I trained at the Sutton's Children's Hospital used this very technique. With the parent's permission, she provided a gentle massage to a neonates lower extremities prior to rounds for blood draw. When the healthcare provider "poked" baby's heels and began to take the sample, he commented about how quickly it worked, and the need to only "poke" once. The nurse shared with me, how she smiled and let the healthcare provider in on her secret. A little massage goes a long way! Now, the healthcare provider plans to massage each baby's legs before administering a heel stick. Not only did it make his job easier, the baby cried less. Sounds like a win-win for all involved. Properly applied techniques produce increased benefits and should be used safely to ensure effectiveness.

Due to the baby's immaturity at birth, it is not appropriate to immediately begin providing massage therapy, but rather to implement nurturing techniques employed by parents and healthcare providers. Once the infant is stable enough, skin-to-skin contact should be utilized to provide appropriate stimulation and encourage bonding between parent and child. This skin-to-skin contact might be in the form of placing the baby securely on the parent's chest as is done with the technique of Kangaroo Care. Kangaroo Care can be a very simple, but powerful intervention providing the infant with stability in regulating heart rate, respiration and body temperature.

Specific Protocols

There are specific guidelines and protocols to follow prior to introducing infant massage in the neonatal intensive care unit. In addition to providing regular attentive care such as cuddling, holding and comforting, massage should be introduced slowly and with extra care. The baby must meet minimal weight and neurological requirements prior to introducing infant massage. However, as the baby shows stability in response to Kangaroo Care, nurturing touch and containment holds are the next steps to safely progress towards the introduction of infant massage therapy.

Containment holds are performed while always being mindful of the baby's states, cues and all verbal and non-verbal communication. Caregivers are encouraged to watch the baby closely for physiological cues (color changes, tremors, startles), motor state (tone, reflexes), behavioral state (alertness) and skin state (response to stimulation) responses. Whenever the baby exhibits any stress cues or overstimulation cues, it is time for the baby to have a break from tactile stimulation.

The best way to perform containment holds is to first ask the caregiver to relax and then proceed slowly. It is always optional for parents and caregivers to provide nurturing touch, as opposed to outside healthcare providers. This is due to the fact that the caregivers need to feel competent caring for their baby, as well as to encourage bonding to take place between parent and child.

The caregiver should always ask the baby's permission prior to beginning, by speaking gently, warming their hands and asking if it is okay to continue. Throughout the hands-on session, caregivers must watch baby's cues and follow their lead. Mindful of any medical apparatus, hands placed in two safe locations on baby's body. Common places to begin include head and feet, both arms/shoulders, and back/abdomen.

First, caregivers consider each baby's individual touch history and medical intervention history, and caution is used in areas where we believe the baby may have experienced discomfort. Especially on the heels, time must be taken before ever touching the heels. Due to the repetitive heel sticks these infants receive, touching this area might not immediately be well received.

It is imperative that any and all monitors are watched for changes, and that direct placement over medical apparatus is avoided. No lubricant is used on the hands while performing containment holds, as doing so may cause hands to slip, increase possibilities of infection or possible dislodgement of medical lines.

Parents are reminded to always watch baby's cues and make eye contact. Due to an infant's compact sensory receptors and their developmental immaturity, a little touch goes a long way. It can be very easy to cause over stimulation. This is never our goal. Sometimes, just placing your hands on two areas, then pausing and starting again another time, is the best route to safely introduce nurturing touch and containment holds without overstimulation.

Safety and precaution is always the best way to introduce touch in the NICU. Due to their baby's compromised health, many families with babies in the NICU have some delays in bonding. Delays in the bonding process might occur for a variety of reasons, and nurturing touch, along with infant massage, can be very beneficial in contributing to establishing the bond between parent and child.

Nurturing touch and massage contain all of the elements necessary to begin the process of bonding, introduce appropriate tactile stimulation and encourage healthy development. When provided safely, infant massage might be just the nurturing intervention an infant needs to cope with medical interventions and encourage optimum development.

References:

  1. Adamsson-Macebo, E.N. (1985-86). Effects of tactile stimulation on low and very low birth weight infants during the first week of life. Current Physiological Research and Review 4 (4), 305-308.
  2. Barnard, K.E. (1973). The effect of stimulation on the sleep behavior of the premature infant. Communication Nursing Research, 6, 12-40.
  3. Bosque, EM (l995). Physiologic measures of kangaroo versus incubator care in a tertiary-level nursery. Journal of Obstetrical, Gynecological and Neonatal Nursing 24 (3), 219-26.
  4. DeLeeuw, R, Colin, EM, Dunnebier, EA, and Mirmiran, M (l991). Physiological effects of kangaroo care in very small preterm infants. Biology of the Neonate, 59, l49-155.
  5. Dieter, J. N. I., Field, T., Hernandez-Reif, M., Emory, E. K., Redzepi, M. (2003). Stable preterm infants gain more weight and sleep less after five days of massage therapy. Journal of Pediatric Psychology, 28, 403-411.
  6. Ferber, S. G., Feldman, R., Kohelet, D., Kuint, J., Dollberg, S, Arbel, E., et al. (2005). Massage therapy facilitates mother-infant interaction in premature infants. Infant Behavior and Development, 28, 74-81.
  7. Field, T., Hernandez-Reif, M., Diego, M., Feijo, L., Yanexy, V., Gil, K. (2004). Massage therapy by parents improves early growth and development. Infant Behavior and Development, 27, 435-442.
  8. Gorski, P., Leonard, C.H., Sweet, D.M., Martin, J.A., and Sehring, S.A. (1990). Caregiver-infant interaction and the immature nervous system: A touchy subject. In K. Barnard and T.B. Brazelton (Eds.) Touch, the Foundations of Experience. Madison, CT: International Universities Press.
  9. Harrison, L.L. and Woods, S. (1991). Early parental touch and preterm infants. JOGNN, 2O(4), 299-306.
  10. Harrison, L.L., Leeper, J.D., and Yoon, M. (1990). Effects of early parent touch on preterm infants' heart rates and arterial oxygen saturation levels. Journal of Advanced Nursing, 15, 877-885.
  11. Jay, S.S. (1982). The effects of gentle human touch on mechanically ventilated very-short-gestation infants. Maternal Child Nursing Journal 11 199-256.
  12. Jain, S., Kumar, P. and McMillan, D. D. (2006), Prior leg massage decreases pain responses to heel stick in preterm babies. Journal of Pediatrics and Child Health, 42: 505-508. doi: 10.1111/j.1440-1754.2006.00912.x
  13. Klaus, M.H., and Kennell, J.H. (1982). Parent-Infant Bonding. Second Edition, St. Louis: C.V. Mosby Co.
  14. Ludington-Hoe, SM, Hadeed, AJ, Anderson, GC (l991). Physiologic responses to skin-to-skin contact in hospitalized premature infants. Journal of Perinatology 11 (1), 19-24.
  15. Ludington-Hoe, SM, Thompson, C., Swinth, J, Hadeed, AJ and Anderson, GC (l994). Kangaroo Care: Research results, and practice implications and guidelines. Neonatal Network 13 (1), 19-27.
  16. Modricin-McCarthy (1993). The physiological and behavioral effects of gentle human touch nursing intervention on preterm infants. Doctoral Dissertation. University of Tennessee. Dissertation Abstracts International 54B (3), 1336.
  17. Onozawa, K., Glover, V., Adams, D., Modi, N., Kumar, R. C. (2001). Infant massage improves mother-infant interaction for mothers with postnatal depression. Journal of Affective Disorders, 63, 201-207.
  18. Ottenbacher, K.J., et al. (1987). The effectiveness of tactile stimulation as a form of early intervention: A quantitative evaluation. Developmental and Behavioral Pediatrics, 8(2), 68- 76.
  19. Rausch, P.B. (1981). Effects of tactile and kinesthetic stimulation on premature infants. Journal of Obstetrical, Gynecological and Neonatal Nursing. 34-37.
  20. Scafidi, F.A., et al. (1986). Effects of tactile/kinesthetic stimulation on the clinical course and sleep/wake behavior of preterm neonates. Infant Behavior and Development, 9, 91-105.
  21. Scafidi, F,A,, et al. (1990). Massage stimulates growth in preterm infants: a replication. Infant Behavior and Development, 13, 167-188.
  22. White-Traut, R.C., & Goldman, M.C. (1988). Premature infant massage: Is it safe? Pediatric Nursing, 14(4), 285-289.

Click here for more information about Tina Allen, LMT, CPMMT, CPMT, CIMT.

 

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