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Touch Therapy With Infants and Their Mothers
The Effects of Massage in Neonatal Patients

By Carolyn Guenther Molloy

Originally published in Massage Bodywork magazine, December/January 2001.
Copyright 2003. Associated Bodywork and Massage Professionals. All rights reserved.


Author's note: With greater societal acceptance of complementary therapies, many more doors have opened for massage therapists. I went through one of those doors when I became a certified infant massage instructor in the Perinatal and Neonatal Units at St. Luke's Hospital in Kansas City, Mo., where I have practiced since 1992. This is my story.

Most massage therapists are used to working in relaxing and soothing surroundings. Therefore, making the transition into an impersonal environment typical of most hospitals requires patience. The venture can be challenging, particularly if you are the first massage therapist the hospital has brought on board, as was my case.

Integrating into a hospital setting can make any massage therapist feel like the Lone Ranger, yet those sentiments are quickly overcome by experiencing the impact one can have on the lives of patients and their families. This is compounded even more when working with expectant mothers and their newborns. Knowing you are able to bring comfort to these families through the simple act of touch is a great feeling.

However, though the role of the massage therapist in the perinatal and neonatal fields is rewarding, it can also be emotionally draining since you are working with people who are experiencing either a high-risk pregnancy or have a premature or ill infant. Because many of the patients I interact with are in the hospital for quite some time, it is easy to become emotionally involved. That can be difficult when working in a setting where life and death occur on a daily basis.


Perinatal Massage Therapy
For most women and families, pregnancy is a time of great joy and anticipation. Plans for the nursery and excitement about the upcoming birth abound. For some families, however, this is not the case. Approximately 20 percent of pregnancies are considered high-risk, and of those patients, many will be on bed rest either in the home or the hospital. This turn of events can be devastating - not only emotionally, but in many other ways. There may be financial concerns, issues regarding other children at home or the patient may live too great a distance from the hospital to have family and support people readily available.

My role in the High Risk Obstetrical Complications Unit (OB Comps) is to provide a weekly massage for the patients who are on long-term bed rest. Along with the physical act of massaging, however, comes the additional role of listening and being sensitive to the situation these mothers and their families are experiencing. Over the years, I have worked with scores of women who were on bed rest and had a happy outcome when they finally delivered their babies. I have also worked with many when the outcome was not as positive. Because St. Luke's has a Level III Nursery, they care for many women on the OB Comps unit who are at a stage in pregnancy where every day counts in the survival of the infant.

There have been times when women for whom I have provided massage deliver too early and the baby has died. There are also women whose babies have not died, but have experienced serious complications with potentially life-long effects. Since I often come to consider these women friends while working with them on the unit, this can be emotionally draining for me as well. Most health care workers learn how to separate themselves from their patients so as to remain objective when there is a sad outcome. However, my experience as a massage therapist had in no way prepared me for dealing with these types of situations.

As an example of the relationships I make with the patients, I recently had a fun experience while working with a woman named Shelly who was on bed rest because she was carrying triplets and had experienced pre-term labor. Shelly had been on the unit for about two weeks when we started talking about a project on which I was working with my sister-in-law who also was pregnant. I told Shelly I had done a belly casting of my relative as a remembrance of her pregnancy. Shelly said something she missed by being on bed rest in the hospital was not being able to do some of those fun things moms do in the last trimester. This was even more of an issue because this pregnancy would likely be her only pregnancy. Because I had grown very comfortable with her, I offered to do a casting of her belly while she was in the hospital. A few days later, with her doctor's blessing (and curiosity) we did a beautiful casting which she now cherishes as she looks back on the pregnancy.

With the help of many wonderful staff members in both the OB Comps Unit and the Intensive Care Nursery, I have learned to be sympathetic without being too empathetic. However, this is something I still struggle with on an almost daily basis. The emotional impact of the situations you experience working in this type of environment should not be underestimated, and should definitely be a consideration when evaluating your entry into this field of massage therapy.

All that said, however, I really enjoy the work I do on the Comps Unit, and feel massage makes a big difference in the quality of these patients' stay at the hospital. Women on bed rest can experience a lot of physical discomfort from being supine and having their movement restricted. Common complaints involve the upper and lower back and the hips. When providing massage to women on bed rest, I have them lie on their side, turning to the other side halfway through the massage. I use a paraffin-based, lavender-scented massage oil specially formulated to soak in quickly and not leave an oily residue. Depending on the reason for the bed rest, some women are unable to shower, so this oil keeps them from feeling greasy after their massage. The lavender scent is also nice for inducing relaxation and helping to lightly scent their hospital room.

I work on as much of the patient's body as I am able to, for an average of 45-55 minutes. A physician's order is required before I can begin massaging a patient, but is not generally a problem since the physicians are supportive of this service. Perinatologist Dr. Jim Thorp explained, "In my experience, massage therapy has been valuable in high-risk obstetrical patients requiring long-term hospitalization. Patients uniformly vocalize very positive experiences and frequently state they 'live for the next massage treatment.' I have consistently observed patients' spirits be dramatically lifted by massage therapy and their outlooks and expectations are enhanced. However, published medical literature regarding the effects of massage therapy on perinatal outcome is very limited."

Most of the stroking I do is gentle effleurage with a focus on the areas where patients are experiencing discomfort. I work on their feet and hands, being careful not to put pressure on the reflexology points which could potentially induce uterine contractions. I tell patients before we start that this is their time to relax and focus on themselves and not to feel like they have to talk. For some, however, talking is a way of expressing their fears and concerns.

Training in pregnancy massage is available for massage therapists through several different providers. Working in the perinatal environment is not for everyone, but for those inclined to investigate it, I encourage the effort. There is a tremendous amount of job satisfaction when working with this population and it is an area I believe will continue to increase in popularity as awareness regarding its benefits grows in the general population and medical community.


Neonatal Massage Therapy
My work in the Intensive Care Nursery (ICN) at St. Luke's Hospital evolved from the work I was doing on the OB Comps Unit. One of the mothers I had been working with delivered her baby at 35 weeks (40 weeks is the normal gestation period). Having experienced the benefits of massage therapy for herself, she was anxious to provide her baby with massage as well. At that time, I had been certified in infant massage instruction by Deanna Elliott and the International Association of Infant Massage, but I was only trained to work with well-term babies. Although I was familiar with the research conducted at Touch Research Institute regarding the many benefits of massage therapy for pre-term infants, I had yet to work with a pre-term infant, and wasn't quite sure how to proceed with this tiny, 5-pound baby.

With the help of the wonderful ICN staff at the hospital, I was given information about premature infant behavior and behavioral cues. By combining this with my knowledge of touch and massage therapy, I modified the massage I would do on a term infant into one that was physically and developmentally appropriate for a pre-term infant. Thus began what is now known as the Tender Touch Program(TM). Tender Touch is a parent education touch therapy program that provides instruction in hand containment, skin-to-skin care and infant massage therapy. Tender Touch began in 1992 as a pilot program serving a small percentage of the patients in the ICN. It has evolved into a comprehensive touch therapy program that includes 75 percent-85 percent of the ICN patient population. Of that group, approximately 50 percent-60 percent will participate in infant massage during their hospital stay.

Tender Touch is funded by the ICN and is available to all patients who come through the ICN. Parents are contacted shortly after admission and given information about the program and the weekly educational class I instruct, and are encouraged to attend as soon after their baby's arrival as possible. The class covers such topics as the importance of touch for hospitalized and premature infants, research supporting touch therapy, and sensory development. We also talk about stress and overstimulation, its effect on their baby, and how they can help the infant cope with his new environment.

Touch therapy is very important for these babies, yet it is still considered to be a more progressive approach than traditional care. It is important parents understand their pre-term baby's particular needs and abilities to ensure good interaction.

Remember, the third trimester is a period of immense growth and development for the fetus. When a baby arrives prematurely, it still has to do those big jobs of growing and developing, but now it has to do them in an environment that is hugely different than its mother's uterus. If parents are educated, they are more able to help their baby cope and to be an advocate for their baby's care.

When babies are hospitalized, they experience several different types of touch. One of those is negative touch -- anything that is painful, invasive or uncomfortable. Most of this negative touch comes in the form of procedures that are necessary for the infant's health and survival, and are performed by someone other than the parents. The other main type of touch the baby receives is positive touch. This is generally provided by the parents and is any touch that is loving, nurturing, soothing or comforting. Because a baby is hospitalized, he will necessarily experience negative touch. However, by balancing the negative touch interventions with positive touch, the baby is less likely to suffer long-term problems, such as tactile defensiveness or touch aversion. Both of these are conditions that arise when there is an overabundance of negative touch without the balance of positive touch; it basically means the baby or child does not like to be touched. This can be in a specific area, such as the heels or around the mouth, and is caused because of negative experiences in these areas - heel sticks, being ventilated or in extreme cases, a total dislike of touch on any part of their body. As one can imagine, this can be a problem with lifelong consequences for the baby and his family.

Technological advances in neonatalogy are enabling smaller and sicker infants to survive being born prematurely or being born very ill. However, the philosophies regarding the best way to socially and developmentally care for the infants are still areas of great debate. Premature births also continue to rise as fertility drugs create multiple births. Also, the overall stress of our society can be a contributing factor in the occurrence of pre-term labor and other complications. According to the National Center for Health Statistics, the rate of twin births since 1980 has risen 37 percent and the rate of triplets, quads, etc. has increased by 312 percent. When you consider most of these multiple births will not go to term, it is easy to understand why this area is one of many important discussions in the medical community.

St. Luke's unit is based on the philosophy of Family Centered Care (FCC) that states the family is the constant in the baby's life and therefore needs to be as actively involved as possible, depending on the infant's size and medical condition. For a number of parents, the only type of touch they will be able to initially experience with their baby will be hand containment because their baby will not be able to be picked up and held. By learning the proper hand positioning, pressure and timing of the hand containment, parents are much more likely to have good interaction with their baby, in turn helping to increase their parental confidence and promoting the bonding process.

The issue of bonding concerns most parents of a hospitalized infant. Because they are physically separated from their baby, they may have a difficult time bonding and attaching to the infant. If the infant is critically ill, there may be a delayed bonding on the part of the parent because of the fear the infant might die, making the experience much harder to bear. Working with parents of hospitalized infants is very different because of issues such as these. Learning about the dynamics of parenting a premature or ill infant is critical to anyone who is going to be in the ICN environment. For many parents, this is the worst thing ever to happen to them and understanding this can help the therapist have better communication with the families.

Being able to educate families about these aspects of parenting a premature infant means a therapist who chooses to work in this environment must also be educated in many areas of premature infant behavior. The therapist must be aware of how different types of touch impact these hospitalized infants and how to touch them appropriately. When I was beginning my work at St. Luke's, there was very limited information available regarding how to touch pre-term infants. Much of my knowledge was gained as I worked together with the developmental specialists in determining the optimal touch therapy interventions. As a result, part of my work now involves teaching a two-day workshop called "The Nurturing NICU" which addresses why touch therapy is important, how to administer the different types of touch therapy, and how to implement a touch therapy program in the medical setting.

Most of the time, the first type of touch a parent has with their infant is hand containment. In hand containment, the parent is able to surround the baby with their hands; in essence, recreating the boundaries the baby had in utero, while helping the baby maintain the fetal position that is so important in maintaining stability. Hand containment is a multi-sensory experience for the baby, because they are able to experience the warmth of the parent's touch, smell the parent's scent and depending on the maturity of the baby, possibly see their parents' hands. Hand containment is also something the parents can provide to the baby after a procedure or any time the infant needs help in getting calmed or soothed. Almost all of our infants receive hand containment, with the length of the intervention depending on the baby's maturity and medical stability.

Skin-to-skin, or Kangaroo Care, is the next step in the progression of touch. Protocols at St. Luke's require the infant be 1,000 grams (approximately 2 1/2 pounds) and medically stable. Skin-to-skin occurs when the infant is wearing only a diaper and is placed on the parents' bare chest and covered with a blanket. The benefits to the baby and parent of this simple method of holding are enormous. Babies have improved oxygenation, better quality sleep and easier temperature regulation than when they are held in a blanket. A recent study conducted by Legault and Goulet compared blanket holding and skin-to-skin holding with isolette (incubated) babies and found the skin-to-skin method was the preferred method of holding in regard to infant stability and maternal satisfaction. Mothers report feeling an increased sense of well-being and fulfillment; this in turn leads to increased feelings of parental competency. In addition, if the mother is breastfeeding, it also helps to increase milk production and length of breastfeeding.

Infant massage therapy is the final step in the Tender Touch progression of touch and is started once a baby has reached 1,000 grams (2 1/2 pounds) and is medically stable. A physician's order is required before beginning massage and parental readiness is also a consideration. Until the point of initiating infant massage, most of the touch the parent has with the infant involves their whole hands on the baby's whole body. Once they begin infant massage, they begin touching the baby in a very body specific manner, which previously tended to be associated with procedures. By replacing the negative connotation of this specific touch, the massage also helps to reduce any tactile aversion the baby may have developed during the course of his hospitalization. A recent study published in The American Journal of Maternal/Child Nursing featured a photo essay of an infant receiving massage therapy and showed his progression from touch aversion to touch acceptance during the course of the massage treatment.

Though the nurses often teach hand containment and skin-to-skin care to the parents, I am the only person who teaches infant massage at St. Luke's. I teach the parents one-on-one, working only with their baby during the lesson. This is important because it assures consistency in the training, and I am able to be at the bedside without interruption -- something a hospital staffer, who is on duty, would not be able to do because of other responsibilities in the unit. Massage therapy is usually taught in two, 25-30 minute lessons; the actual massage should only take the parents about 15 minutes to complete once they have learned the techniques. This is because a premature baby's threshold for stimulation is short, and we want to be sure the massage experience is a positive one -- not one that overstimulates the baby and negates any positive benefit of the massage.

The massage begins with the legs and feet, progresses to hand containment on the stomach and chest, then proceeds to stroking the arms, hands, head and face. We finish by turning the baby onto the tummy or side and stroking the back. When working with a premature infant who has an immature nervous system, we have to keep in mind their touch receptors are still developing and therefore we must be careful to use enough pressure so that the infant doesn't feel a tickle sensation. Conversely, we must be careful not to use so much pressure that the massage becomes uncomfortable for the baby. When I am instructing a parent, I demonstrate on their own hand what type of pressure they should be using when massaging their baby, and they are usually surprised. Our tendency with small babies is to touch or stroke lightly and we now know this is not the best type of touch for them. When a baby is in utero, he has a lot of pressure on his body, providing tactile stimulation -- critical for growth and development. When a baby is born early, he loses that tactile stimulation -- a reason preemies may lag behind developmentally. Most soon catch up and those who receive massage, helping to replicate the tactile stimulation in utero, are documented to progress more quickly toward maturity.

Research conducted at the Touch Research Institute has shown babies who are massaged consistently gain weight faster, have less apneas and bradychardias (pauses in breathing and heart rate), have better muscle tone and reduced levels of cortisol (a stress hormone, which among other things, inhibits the immune system). All of these physical pluses come with the additional benefits of helping bond parent and child, allowing for quality one-on-one time -- not to mention that it feels good, too. For a baby who has experienced negative touch, massage can be invaluable in helping him learn touch doesn't have to be painful or uncomfortable, but can be pleasurable, comfortable and soothing.

With few exceptions, the massage is performed by the parents during instruction; however, on occasion, I will massage a baby whose parents are unable to be involved. When we do this, it is because it is believed the baby will benefit from not only the massage, but also the positive touch and interaction with a person who does not "do procedures" on the baby. My role in the nursery is that of a part-time touch therapist, and I am contracted by the hospital to provide 10 hours a week working with the babies and families. This works well and provides me the opportunity to balance my experiences in this highly rewarding, but also highly stressful environment with more traditional work experiences. I feel good helping parents do something for their babies that they can do better than anyone else. I also enjoy teaching them a skill they can use indefinitely with their child.


Conclusion
Though working in the hospital setting is not for everyone, I have found it to be an incredible experience and feel honored I am allowed to be a part of a patient's stay during one of the most difficult periods in her or his life. Being able to provide a mother with compassionate touch so that she, in turn, can provide it to her baby, brings me a great deal of satisfaction, and I feel fortunate to be able to work in a hospital that embraces not only the high-tech world, but also that of high touch. Together, they make for an amazing combination in the care and well-being of their patients.

Carolyn Guenther Molloy, LMT, CIMI, is a Licensed Massage Therapist and Certified Infant Massage Instructor and director of the Tender Touch Program at St. Luke's Hospital in Kansas City, Mo. She is also the co-owner of Lasting Impressions Infant and Pediatric Massage Services and the author of a soon to be published book entitled, Lasting Impressions, The Power of Loving Touch for your Premature or Medically Fragile Infant. For more information, visit www.Lastingi.com, e-mail to Carolyn@Lastingi.com. or mail to 4627 Jarboe, Kansas City, MO 64112.

References
Legault, M. Goulet, C. (1995) "Comparison of Kangaroo and Traditional Methods of Removing Preterm Infants From Incubators," Journal of Obstetric, Gynecologic and Neonatal Nursing, 24:6, 501-506.
Lindrea, K.B., Stainton, M.C. (2000) "A Case Study of Infant Massage Outcomes," The American Journal of Maternal/Child Nursing, Vol. 25, No. 2, 95-99.
Field, T. Schanberg, S., et al. (1986) "Tactile/Kinesthetic Stimulation Effects on Preterm Neonates," Pediatrics, Vol. 77, No. 5, 654-658




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