Throughout history and in many cultures, infant massage and similar "systematic" forms of touch have been an ingrained aspect of parent-infant bonding. In Africa and Asia especially, infants routinely receive massage from parents and other family members for several months after birth.

An increasing number of Western scientists, often with the aid of government and private moneys, are studying the clinical value of infant massage and examining the "biology of touch." The organization with the highest concentration of such work is the Touch Research Institute (TRI), which is based at the University of Miami Medical School. The Touch Research Institute is the world's leading center for scientific research on the effects of tactile stimulation. Modeled after the Monell Chemical Senses Center in Philadelphia (the only institute that specializes in the senses of taste and smell), the 40-member TRI has initiated a wide range of studies to elucidate the potential role of touch in healthcare.

GROUND-BREAKING STUDIES ON PRETERM INFANTS

Hospitals-aiming to help highly compromised premature infants via a range of medical interventions-must typically separate these babies from their parents at birth. Usually isolated in incubators that protect them, these preemies receive significantly less touch than full-term babies in the first days and weeks of life. In fact many intensive care nurseries have, in the past, discouraged any "unnecessary" touching of neonates, in part because some early reports claimed that certain procedures involving handling (e.g., intubation and diaper changes) led to physiological disruptions, such as decreases in oxygen tension. To some extent, the medical community interpreted these reports as cautions against touching neonates in any other-than-essential manner.

A 1986 study marked a turning point that has begun to change such protocols and has launched much of the current work in touch therapy. At the TRI, Field et al. documented the effects of touch on 40 premature infants. The researchers used a basic infant massage consisting of simple body strokes and passive limb movements for three 15-minute periods a day for 10 days. The study results showed that the preemies who received massage:

• averaged a 47 percent greater weight gain, even though the groups did not differ in average food intake (in calories or volume);

• were awake and active a greater percentage of the time;

• exhibited greater alertness, orientation, and responsiveness on the Brazelton Neonatal Behavior Assessment Scale; and,

• were hospitalized six days less than control-group infants, yielding an average cost savings of $3,000 per infant.²⁸

Other studies have supported these findings and defeated the "common wisdom" about preterm neonates' presumed hyperresponsiveness to touch. Acolet et al. showed, for example, that gentle massaging of the head and back of the ICU neonate does not increase the need for oxygen, but in fact helps the infant cope physiologically with stress.²⁹ Other studies showed greater weight gain, motor activity and alertness in preterm neonates who did not require intensive care.^30,31 A meta-analysis by Ottenbacher et al. of 19 stimulation studies illustrated that most preterm infants were positively affected by touch stimulation, typically with greater weight gain and better performance on developmental tests.^28,32

Field et al. discovered that in order to be effective, infant massage must entail a modicum of pressure. If the massage is too light, its potential physical benefits will not be realized.²⁸

Follow-up research has suggested that massage has long-term benefits for premature infants. Eight months after being massaged in the neonatal ICU, the stimulated babies continued to gain more weight and perform better on developmental tests than a control group.³³

Figure 1.
Mean daily weight²⁸

Results from the landmark 1986 study by Field et al. show enhanced weight gain in premature infants who received massage during transitional nursery care. The infants did not differ in caloric consumption from control infants on the same unit, who did not receive massage.

The tactile isolation that many premature infants face in intensive care may detract from their recovery. With massage, premature neonates grow more quickly and leave the hospital sooner.

MASSAGE AND TERM INFANTS

Other recent findings imply that the positive effects of massage are generalizable not just to preterm infants, but to all infants.

Growth and behavioral benefits. A TRI team selected a group of full-term infants, one to three months old, who were born to depressed adolescent mothers. Developmental literature has documented disturbed interactions between depressed mothers and their infants, as well as infant growth delays and inferior performance on developmental assessments.

The investigators compared these babies, who were massaged, to a control group of infants who were rocked in a rocking chair for comparable amounts of time. The massaged babies spent more time in active-alert and active-awake states, cried less and had lower salivary cortisol levels during massage, suggesting lower stress levels. Following the massage, they spent less time in an active awake-state and fell asleep when put to bed. In contrast, the rocked babies would often fall asleep during the rocking-but then wake up when put to bed. These findings suggested that massage may be effective in inducing sleep.

In addition, the massage-group infants gained more weight; had more optimal temperament on emotionality, sociability and soothability dimensions; and performed better in face-to-face interaction assessments.³⁴

The quiet alert state. Researchers have described several states of consciousness in newborns. In an important state known as the "quiet alert" state, the neonate shows many signs of being alert: the baby is very receptive to touch and holding, is bright-eyed and attentive, remains still, makes direct eye contact with parents, responds to voices more and interacts more spontaneously with parents. The kind and amount of handling a neonate receives in the first seconds and minutes of life is known to affect whether or not the infant achieves a quiet alert state. Many experts believe that it is during the quiet alert state that infants learn best and start to communicate.³⁵

Figure 2.
Effects of infant massage³⁴

After massage therapy, full-term infants of depressed mothers had lower levels of cortisol, implying a reduction in stress. In addition, the massaged infants fell asleep more quickly after receiving massage.

Massage may be one way in which parents can increase the amount of quiet alert time a baby experiences. Many term infants who receive regular massage typically move into the quiet alert state during the massage session. Infants' greater alertness is consistent with data on adults, which show EEG changes that conform to a pattern of alertness during massage. In addition, researchers have shown that vagal activity increases in infants during massage. The vagus is one of the ten cranial nerves, and increases in vagal tone usually accompany greater attentiveness.³³

The mechanism behind the effects of infant massage has been largely unknown in the past. However, researchers now hold viable theories about these mechanisms and are beginning to find answers in their clinics and laboratories.

At a very basic "mechanical" level, massage directly stimulates the musculoskeletal, nervous and circulatory systems-thereby affecting the biochemical and physiological processes regulated by those systems as well. Many current touch studies thus focus on measuring the physiological and chemical effects of massage stimulation.

For the newborn, intimate contact with the mother during the first hours and days of life has long been known to contribute to the mother's milk production. In addition, human research has confirmed findings of animal studies showing that early and regular parental touch moderates infants' levels of stress hormones (such as norepinephrine and cortisol), promotes weight gain and enhances immune system function.

An increase in epinephrine and norepinephrine is normal for newborns and is considered a healthy, adaptive response to the stress of the neonatal period. Kuhn et al. found that massage in preterm infants facilitates this normal increase.36 However, excessive stress appears to elevate these catecholamines abnormally. In these instances, touch serves the broader role of a natural mediator of this response. Studies on babies of depressed mothers-infants who commonly exhibit abnormally high stress patterns-show that massage decreases epinephrine, norepinephrine and cortisol, and increases serotonin.³⁴

Increases in infants' vagal activity during massage may lead to an increase in food absorption hormones such as insulin - and may account, in part, for the enhanced weight gain these infants experience.

As noted earlier, massage has been shown to increase activity of the vagus nerve, one of the ten cranial nerves. Preliminary data suggest that increases in vagal activity in massaged preterm infants may lead to an increase in food absorption hormones such as insulin-a phenomenon which may account, at least in part, for the infants' significant weight gain.^37,33 Because massage was the only differing variable in these studies (the massaged preemies ate no more, in terms of calories or volume, than the control groups) the implications for weight gain-especially in populations where food sources may be limited-are promising. Due to its hormonal effects, massage alone may help infants overcome the detriments of low birthweight.

As in animal studies, massage has shown immune-system benefits in humans. In a study of HIV-positive men given massage for 45 minutes, five times a week for one month, results showed that the subjects experienced:

• significantly reduced levels of anxiety and distress;

• increased serotonin levels during massage; and

• an increase in the number and cytoxicity of natural killer cells.³⁸

OTHER APPLICATIONS OF INFANT MASSAGE

Massage has been used to improve-or prevent-a range of health problems not only in infants, but in all age groups. Following are highlights of recent and ongoing massage studies, many of which are being conducted at the Touch Research Institute.

Promoting parent-infant bonding. Clinicians and social workers may see the benefits of infant massage for teenage parents, parents who do not feel connected to their babies, adoptive parents, and (under supervision) abusive parents. An early massage session can also be helpful in bringing mother and baby together to bond after the separation engendered by a C-section.

Colic. A recently refined definition of colic describes the condition as a distinctive, high-pitched "pain crying" with paroxysmal onset, signs of hypertonia and inconsolability.³⁹ Currently prominent theories of colic's etiology include: an imbalance of the dynamic interplay of the autonomic nervous system; a disturbance in the development of sleep-wake control mechanisms; and desynchronization and other problems in the parent-infant interaction.⁴⁰

Colic has also long been associated with digestive and feeding problems. At some health care centers, infant massage may include stroking the stomach of infants who have colic or gas. Either instinctively or through experimentation, many parents resort to this technique naturally.

Current research on colic involves teaching parents to massage their infants during colic episodes and before bedtime. The researchers anticipate that infants receiving massage will have more positive feeding interactions with their caregivers, be less irritable, exhibit fewer stress behaviors, and have more organized sleep-wake behaviors. In addition, their parents may report less anxiety about (i.e., more control over) infant care and perceive their infants' temperament more positively.³⁷

Asthma. Asthma is primarily associated with external, physical stimuli such as pollen or dust, but it is also related to intrinsic, psychological factors such as anxiety. Relaxation therapy has shown success with asthmatics who have large-airway obstruction.

Massage is a common type of relaxation therapy. Researchers are now looking at the effects of massage on children and adolescents whose asthma is at least partly intrinsic and concentrated in the large airways. Investigators project that, with massage, these individuals will report lower levels of anxiety and depression, and will have fewer and less severe asthma attacks and airway obstructions. Teaching parents to administer the massage will likely also reduce family anxiety, parental panic attacks and parental feelings of helplessness.⁴¹

Fetal cocaine exposure. A recent study of massage for newborns of mothers who had taken cocaine during pregnancy reported fewer postnatal complications, fewer stress behaviors, better weight gain and superior performance on developmental tests for the massaged infants.^37,38,42

Positive HIV status. Researchers are also now studying whether massage therapy improves immune functioning in HIV-exposed newborns and whether massage therapy given by parents can improve the mental, motor and social development of these infants. The research suggests that massaged HIV-positive infants showed: greater weight gain; better performance on the orientation and motor clusters of the Brazelton scale; and better scores on a stress-behavior scale that includes alert responsiveness, cost of attention, examiner persistence, state regulation, motor tone and excitability.⁴³

OTHER POPULATIONS NOW UNDER STUDY

Children. Researchers are looking at the possible physical and psychological benefits of massage on preschoolers and older children who have suffered such conditions as: neglect or abuse, autism, post-traumatic stress disorder, skin disorders, diabetes, juvenile rheumatoid arthritis, burns and cancer.³⁷

Adolescents. A 1992 study showed that massage lessened depression, anxiety and cortisol levels in children and adolescents hospitalized for depression and adjustment disorders.⁴⁴ The effects of massage on depressed teenage mothers, on the childbirth and labor of teenage mothers and on adolescents with eating disorders are now being studied.³⁷

Adults. Touch research is also addressing the effects of massage on adults experiencing problems such as hypertension, positive HIV status, spinal cord injury, fibromyalgia syndrome, migraine and tension headaches, chronic fatigue syndrome, rape or spousal abuse, sexual-performance problems, and job performance problems.³⁷

Elderly. Current massage research holds promise for elderly individuals who have arthritis or depression.³⁷

INFANT MASSAGE AND THE FAMILY

Fathers. Massage potentially benefits all infants and those close to them. Massage therapy can serve, for example, as an important way of facilitating father-infant bonding. Studies in Australia have shown that massaged babies gained more weight and enjoyed a better relationship with their fathers than babies in the non-massage group. Furthermore, those fathers tended to have better self-esteem as a result of feeling more involved with their babies.³³ The infants who were massaged starting at four-weeks postpartum showed considerably more responsiveness at a 12-week home observation: these infants greeted their fathers with more eye contact and more smiling, vocalizing, reaching and orienting responses, and showed less avoidance behaviors than did infants who were not massaged.⁴⁵

Grandparents. In one ongoing investigation, "grandparent" volunteers give infants massage and then receive a massage themselves. The study involves infants, aged three months to eighteen months, who have been neglected or abused.

Perhaps surprisingly, preliminary results have shown stronger positive effects for the "grandparents" after giving massage to infants than after receiving massage themselves.³³ The adults who gave massage reported less anxiety and fewer depressive symptoms; had decreased stress levels, indicated by lower urine cortisol; showed decreased resting pulse rates; and reported improved self-esteem and positive lifestyle changes (e.g., fewer doctor visits and more social contacts). Concurrently, the massaged infants have shown increased quiet sleep, alertness, tracking behaviors, activity, sociability and soothability.³⁸

Siblings. Some experts suggest that parents use massage to overcome the rivalry many siblings feel toward new infants in the family. By assisting a parent with a baby's massage, a young child enjoys a caregiving role, and discovers a way to demonstrate affection for the infant.

Parents can involve older siblings by asking them to help with the infant massage.