Massage is a skill which was once mainstream in nursing practice (Barclay 1994) but was generally lost
to it some time between the world wars in the 1930s. Recently there has been a gradual, if limited reintroduction into clinical
practice (Rankin-Box 1997). This paper considers massage in the context of neonatology concentrating on the knowledge, skills,
research, practice and evaluation of massage, with particular focus on its use with premature infants.
Since 1988, there have been many changes in the N.H.S which have a bearing on the
introduction of massage in the neonatal unit, not least being the dual factors of accountability and duty of care, as laid
down in the U.K.C.C. Guidelines for Professional Practice (U.K.C.C.1996). Although
in 1907 it was maintained that a massage certificate was essential as part of a nursing qualification, (Hughes 1907) and back
in 1925 the massage department of the famous Guys Hospital, London showed photographs
of its baby massage activity in the hospital magazine, massage today is regarded as one of many complementary and alternative
therapies (Vickers 1996). As such, mechanisms must be in place to ensure the safety and best interests of patients, whilst
the practitioners use of evidence based and reflective practice is essential.
The registered (nurse) practitioner must be convinced of the relevance and accountability of the therapy being used, and must
be able to justify using it in a particular circumstance (U.K.C.C 1996), by way of evidence based practice. (Department of
Health White Paper 1997).
The White Paper prescribed a system of clinical governance to underpin the delivery
of health services, so ensuring that quality and clinical standards are central to health service decision making, and that
managers are legally accountable for the quality of N.H.S care. The Prime Minister, Mr. Tony Blair, saw this as part of turning
point for the N.H.S (Department of Health White Paper 1997), as the internal market was replaced with integrated care and
guaranteed national standards. The manner of delivery of neonatal/ pre-term baby massage must have cognisance of the new quality
imperative and be placed securely within the UKCC Code of Professional Conduct and the Scope of Professional Practice. (UKCC
Position Statement 1992).
Vickers tell us that it is impossible to give a single definition for complementary
therapies (Vickers 1996), as they do not share a single common body of knowledge;
rather that each therapys role and scope should be defined on its own merits. Pietroni further notes that complementary therapies
are defined in a sense by what they are not, (Pietroni 1992), that is they are not conventional or standard practice. Vickers
quotes massage as such a practice, defining it technically as the therapeutic manipulation of soft tissues (Vickers 1996).
The widespread use of complementary therapies is acknowledged in numerous publications, by the early 1990s, Graham
reporting massage as one of the most common complementary therapies used in the NHS (Graham et al 1998)
Description of the four main massage movements has been fairly constant since Prof.
Per Henrik Ling systematised and developed the movements of the ancient art of massage in the 19th century and
which were fully quoted by Kathryn Jensen in The Fundamentals in Massage for Students of Nursing) (Jensen 1938), one of the
last books published for nurses on massage prior to its absorption into physiotherapy in 1943 (Barclay 1994).
Beards Massage (de Domenico and Wood 1997), now in its fifth edition since 1964 and
widely acknowledged as the massage bible still gives these movements and
their effects as:
1. Effleurage--where the hands skim over the surface of the tissues to promote relaxation
and improve muscle tone.
2. Petrissage--where the hands press down and lift and squeeze the tissues, thus increasing
lymph flow, warming tissues and improving skin elasticity.
3. Tapotement--where the hands strike the tissues, with its variations of hacking and
cupping, so increasing local circulation and stimulating reflex contraction of muscle fibres.
4. Friction-- where deep localised movements against the bone increase local circulation,
break down adhesions and mobilise fibrous tissue.
(Note that massage in the context of this paper excludes the use of essential oils
as in aromatherapy)
Of what then should pre-term baby massage comprise? Beard suggests that massage techniques
need modification to accommodate the baby and cannot be rigidly prescribed, and the movement applied should vary between light
tickling, gentle stroking and gentle firm pressure as necessary, each babys position
adapted to wherever the baby is most comfortable at any given time (de Domenico and Wood 1997).
This clearly represents a subset of the more general adult massage previously described.
Such massage therefore can be seen as a natural extension of touch, as described by the Lippincott Manual of Paediatric Nursing,
which prescribes within the confines of minimal handling caressing stroking and gentle handling of the premature baby, in
order to provide essential sensory stimulation (Weller 1986). Watson notes that where touch has formerly been an undervalued
aspect of general care it has a longer history in paediatric nursing (Watson 1999) and touch as a primary need for healthy
baby development is discussed fully by Adamson (Adamson 1993).
Lopes concludes that recent studies of premature infants receiving daily massage show physical
and neurological gains in excess of non-recipients (Lopes 1993), and other sources also report the evidence from randomised
trials, that premature infant massage is associated with more rapid weight gain and development (Scafidi and Field 1996; Phillips 1996; Vickers and Zollman 1999). It may also be that whilst tactile stimulation enhances weight
gain and responsiveness, later growth and development of the baby is also positively affected (Field et al. 1987).
However there is evidence that not all premature babies are suitable for massage and
that nurses need the knowledge to identify suitable infants, as such stimulation can cause initial responses of slight body
temperature decrease, and slight increase in heart and respiratory rate (White-Traut and Goldman 1988). Nevertheless whilst
Vickers also maintains evidence of decreased hospital stay amongst massaged premature infants (Vickers et al. 1998), the need
for care in choice of subject is also stressed, massage being decided on the basis of individual assessment as to when touch/massage
therapy might be counterproductive (Vickers 1996). The nurse practitioners knowledge and skill would thus determine such treatment
in unstable pre-term infants.
Strong noted that whilst pre-term infants did demonstrate changes in arousal and activity,
seen in varied behaviour and vital sign differences for a short period after massage, they did not show any stress related
behaviour during the same period (Strong 1999), and indeed displayed calmer, less irritable signs than non-recipients (Phillips 1996).
Caution is however expressed as to the value of these behavioural assessments, which
are technically extremely limited in very immature or ill neonates, although blood chemistry changes, including objective,
positive hormonal alterations can be detected following massage therapy, (here described as a non-therapeutic intervention)
(Acolet et al. 1993). Whilst such medical findings should not be overlooked, of more relevance to the nurse practitioner is
the TAC-TIC therapy researched in healthy pre-term and high-risk ventilated premature neonates (Hayes 1998) defined as Touching
and Caressing, Tender in Caring (TAC-TIC) Therapy. The preliminary findings of stabilised cardio-vascular responses, enhanced
secretory immunity and increased episodes of comfort actions seem to denote beneficial outcomes of such a therapy.
Beard recognised that baby massage promotes communication, strengthening the bonding
process, and so helping to establish warm, positive, parent-child relationships. Studies by neonatal nurses, midwives and
health visitors indicate that the use of massage for pre-term babies requiring special care has a positive bonding outcome
not only for the baby, but inspires confidence in parents and family, effecting pleasure and relaxation. (de Domenico and
Wood 1996; Porter 1996; Lim 1996).
The issue arising here is who teaches the mother/family to carry out the massage given
the special considerations of physical condition of, and relationship between the premature baby and its new mother, which
may differ from the relationship between full-term baby and mother. Adamson however has cast doubt on the qualification of
those individuals, including nurses, offering baby massage classes in health centres (Adamson 1996). Clearly this problem
applies even more so to the premature baby unit and two questions evolve: -
1. who teaches the carer , and
2. who is teaching the teachers, where nurses and midwives are most likely to be the
teachers.
Therefore training in massage for midwives and nurses, together with development of
protocols for the use of massage in the premature baby unit become significant issues. Graham found that only 32% of N.H.S
Trusts currently have a protocol for any complementary therapy in place (Graham et al. 1998), a figure closely in agreement
with Rankin-Box (Rankin-Box 1997).
A survey of all U.K universities, medical schools and faculties of nurse education
(Foundation for Integrated Medicine, London 1997) showed that only 37 nurse education departments provided courses for complementary
practitioners, some being awareness courses only. Clearly training in massage for premature babies is not widely available.
Those courses in universities are normally approved by the Nursing and Midwifery Council (e.g. E.N.B A49), are about complementary
therapies and not specifically designed for massage of pre-term infants (Graham et al. 1998).
Thus nurses and midwives seeking education in this area have little alternative to
enrolling in private massage schools where quality assurance and standards are unaccredited (Adamson 1996; Fulder 1997).
The introduction of massage into the premature baby unit will not be without potential
difficulties and constraints. The relationship of massage to nursing practice needs full understanding, and parental attitudes
and fears must also be considered. Opportunity and the cost factors combined with all the constraints that time, attitude
and competing demands put on the nurse practitioner are likely to compound the overall difficulties that lack of training
in evaluating and implementing research already present.
This might be addressed by planning a strategy which would include in-house education
and training for potential massage practitioners within the premature baby unit, with opportunity to attend relevant external
courses. The creation of an action learning environment which introduces and monitors new practices, and evaluates and modifies
them as appropriate would be essential to ongoing development. Discussions conducted with appropriate colleagues/committees
on any ethical issues associated with the introduction of a new therapy are essential, including considerations of parental
consent. Finally a protocol/written procedure governing the use of massage would need to be developed.
The balance of evidence would suggest that massage for the pre-term infant can be
a useful and enhancing therapy particularly to accelerate weight gain and strengthen the bonding process. To varying degrees
there is also evidence that a self-calming benefit occurs, as well as a number of physiological reactions, such as a stabilised
cardiac response, and that no stress-related behaviour ensues after this therapy. However caution combined with knowledge
is advocated as some initial responses e.g. lowered body temperature increased heart and lung activity, as well as some behavioural,
arousal and activity changes have been reported, so that the nurse practitioner must make informed decisions as to the suitability
of each patient as a potential beneficiary of massage. If massage is to be introduced to the premature baby unit, suitably
trained nurse practitioners are essential, and the professional environment would need to be prepared. Practitioners would need to bear in mind the need for accountability
and quality, with full reference to the U.K.C.C. Guidelines for Professional Practice (1996) and the use of reflective practice,
as a means of developing practice knowledge so that it can be on a level with scientific knowledge (Wilson 1996).
REFERENCES
Acolet D, Modi N, Giannakoulopoulos
X, Bond C, Weg W, Clow A, Glover V 1993
Changes in Plasma Cortisol and Catecholamine Concentrations in Response to Massage in Pre-Term Infants Archives of Diseases in Childhood 68(1)
De Domenico G and Wood E
1997 BEARDS MASSAGE 4th edition
Philadephia: W.B. Saunders & P144-144
Field T, Scafidi F, Schanberg
S 1987 Massage of Pre-Term
Newborns to Improve Growth and Development
Paediatric Nursing 13(6):P 385-387
Hayes JA 1998 TAC-TIC Therapy:
a Non-Pharmacological Stroking Intervention for Premature Infants
Complementary Therapies in
Nursing and Midwifery 4(1): P25-27
Lim P 1996 Baby Massage British Journal of Midwifery 4(8) P439-441
Lopes M 1993
The Healthy Touch! In M.Lopes (Ed) Care Giver News National Network for Child Care Amherst M.A. www.nncc.org/Child.Dev/health.touch.html
Phillips RB, Moses HA 1996 Skin Hunger Effects on Pre-Term Neonates
Infant-Toddler Intervention-The Transdisciplinary Journal 6(1)p39-46
Porter SJ 1996 The Use
of Massage for Neonates Requiring Special Care Complementary
Therapies in Nursing and Midwifery 2(4) p93-96
Scafidi F, Field T 1996 Massage Therapy Improves Behaviour in Neonates Born to
HIV_Positive Mothers Journal of Paediatric Psychology 21(6) P897-897
Strong CB 1989 The Effect
of Massage on Premature Infants University
of Arizona PhD Thesis
Vickers A, Ohlsson A, Lacy
JP, Horsley A 1999 Massage
to Promote Development in Pre-Term and/or Low Birthweight Infants
The Cochrane Library Oxford Issue 3
Vickers A, Zollman C 1999 Massage Therapies British Medical Journal 319: P1254-1257
Watson S 1998 Using Massage in the Care of Children Paediatric Nursing
10(10)P27-29
White-Traut RC Goldman MBC 1988
Premature Infant Massage: Is it Safe?
Paediatric Nursing 14(4)
P285-289
