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Original Articles Indian Pediatrics 2001; 38: 1091-1098 |
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Effects of Tactile-Kinesthetic Stimulation in Preterms: A Controlled Trial |
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Manuscript received:
February 15, 2001, Initial review completed: April 18, 2001,
The sensations experienced in the intrauterine environment are ideal for the normal growth and neuro-behavioral development of the fetus(1). In contrast to this, the preterm "fetal" neonate is subjected to sensory experiences vastly different from those intended by nature. Excessive handling, ambient noise and light and poorly-timed social and care-giving activities all lead to stress. ‘Developmentally supportive care’(2) and ‘interventional stimulation’(3) aim at simulating the intrauterine environment. The aim is not to accelerate development but to put it back on track and, if possible, to maintain and facilitate it. A number of studies have shown positive effects of tactile-kinesthetic stimulation on the preterm infant(4-8). In most trials the stimulation was provided by nursing staff in a hospital environment without the involvement of the mother. Traditional infant massage incorporates tactile-kinesthetic stimulation. However, few scientific Indian studies have been carried out(4,6). A study was therefore undertaken to determine the effects of tactile-kinesthetic stimulation, given as a structured massage, with maternal involvement, on well, preterm infants. Methodology Study Design and Subjects A systematic allocation, non-blinded controlled trial was conducted on 48 inborn preterm babies admitted to the well pre-mature unit over a period of nine months, who met the following inclusion criteria after 2 days of stabilization. (a) Birth weight (BW) >1000 g and <2000g; (b) Gestational age (GA) ³32 weeks; (c) Apgar score ³7 at 1 and 5 minutes with no resuscitation required at birth; (d) Medically stable with no require-ment of drugs (other than mineral and vitamin supplements), or any interventions/proce-dures; (e) On breastfeeds or ‘spoon-wati’ feeds with expressed breast-milk or human banked milk (from the milk bank in the hospital) in adequate quantitites and ( f ) Presence of mother and adequate family support. The following babies were excluded: (a) Sick babies or those with congenital anomalies or neuromuscular disorders; and (b) Unreliable or socially isolated mother or staying far from the hospital. Allocation of Groups Twenty five babies were assigned to the treatment or test group and 23 to the control group. Systematic allocation was done in such a way that all babies born in weeks starting with an odd-number day were assigned to the test group and those born in other weeks to the control group. Thus at any given time mainly test or control infants were present in the ward, with minimal overlap. This was because during a pilot study it was found that mothers in the control group got concerned when they saw test babies in the unit receiving massage that was "denied" to their babies. They opted more often to leave the study in this situation. No blinding was done. General Measures Informed consent was taken from all mothers. A detailed obstetric hisotry was taken at the onset of the study using the Obstetric Complications Scale (OCS) of Littman and Parmalee(9) for comparison between the two groups. A social history was also taken. Gestational assessment was done by the New Ballard Score within 12 hours of delivery. In accordance with hospital proto-cols all neonates were given oral calcium, phosphorous and vitamin supplements and iron was started at 6 weeks of age. They were nursed in open cradles and mothers were allowed to touch and hold their infants as often as they wished in both groups. Mothers in the control group were specifically told not to administer any kind of massage to their babies during the study period. Method of Tactile-Kinesthetic Stimulation For the test group, tactile-kinesthetic stimulation in the form of a ‘baby massage’ was given by a trained person from day 3 of life for 5 consecutive days, and thereafter by the mother (who was taught the technique) until 40-42 weeks post-menstrual age. Stimulation was given three times a day. Sessions began 30-45 minutes after a feed in the morning, afternoon and evening. A small amount of mineral oil or powder was used to decrease friction and this was removed with cotton after the stimulation. The total duration of each session was 15 minutes (excluding time for recording physiologic parameters). If the baby started crying or passed urine or stools during the session it was temporarily stopped till the baby was comfortable again. Stimulation was given as follows: Phase I: This was done in the prone position. Twelve firm strokes with palms of the hands of 5 seconds each, were provided in each area as follows: (a) Head from forehead hariline over scalp down to neck with alternate hands; (b) Neck from midline outwards with both hands simultaneously; (c) Shoulders from midline outwards with both hands simul-taneously; and (d) Back from nape of neck down to buttocks with firm, long stroke with alternate hands. Phase-II: This was done in the supine position. Twelve firm stroke with palms of the hands, of 5 seconds each, were provided in each area as follows: (a) Forehead - From midline, outwards with both hands simultaneously; (b) Cheeks - From side of nose, with both hands simultaneously in rotating and clockwise direction; (c) Chest - ‘butterfly’ stroking from midline upwards, outwards, downwards and inwards back to initiating point; (d) Abdomen - From the appendix, in a clock wise direction around abdomen avoiding the epigastrium and probes, with gentle strokes; (e) Upper limbs (each separately) - from shoulders to wrist using alternate hands for stroking; ( f ) Lower limbs (each separately) - from hips to ankles using alternate hands for stroking; (g) Palms - from wrist to finger tips using alternate hands for stroking; and (h) Soles - from heel to toe tips using alternate hands for stroking. Phase-III: This was done in the supine position and consisted of passive flexion and extension movements of the limbs at each large joint (shoulder, elbow, hip, knee and ankle) as 5 events of 2 seconds each in each area. The control infants were not given any specific stimulation but were monitored for parameters as in the test group. Measurement of Outcome Variables Primary Variables Physiologic Parameters: During massage room temperature was maintained at 32-33º C. Infant were naked and attached to skin probe (Zeal), a pulse oximeter (Novametrix 515 C), and apnea and respiratory rate monitor (Meditrin Apnea Monitor). Sites were chosen to avoid interference with the massage in the test group. Readings were recorded of heart rate, respiratory rate, temperature and oxygen saturation in both groups before, during and immediately after the stimulation during the first 5 days aof the study only. For the purpose of analysis the readings before the stimulation was compared with the average of the readings during and after the stimulation. In the control group the babies were monitored for heart rate, respiratory rate, temperature and oxygen saturation on pulse oximeter for a period of 15 minutes three times a day for five days under similar conditions to which the test babies were exposed - they were nursed naked in a room temperature of 32-34ºC, 45 minutes after food and were subjected to routine handling like changing diapers, etc. Secondary Variables 1. Anthropometric Parameters Weight of infants was taken without clothes on an electronic weighing scale (Phillips) with an accuracy of ± 5 grams. Head circumference was measured with a non-stretchable cloth-tape and length with an infantometer. All measurements were taken before and after the completion of the study on the same equipment and by the same observer. 2. Neonatal Behavioral Assessment The Brazelton Neonatal Behavioral Assessment Scale (BNBAS)(10) was administered to each infant in the study on three occasions - between day 2-3 (before onset of the study - BI), between day 7-10 (after at least 5 days of stimulation - BII) and on follow-up (at 40-42 weeks post menstrual age - BIII). All the tests were done by a trained person. Infants were tested mid-way between feeds in a quiet, semi-darkened room with an ambient temperature of 32-34ºC. The supplementary items specifically meant for preterms were also scored in the recommended manner. For the purpose of analysis the items scored were grouped as recommended by Lester(10), with modifica-tions to include the supplementary items for preterms. The groups included ‘habituation’, ‘orientation’, ‘motor’, ‘range of state’, ‘regulation of state’, autonomic stability’, ‘reflexes’ and ‘interactive behavior’. The last was a new group made to include certain of the supplementary items. Statistical Analysis All values were tabulated as averages (means) with standard deviations (SD). Comparisons were done using ‘t’ test for parametric data and Chi-Square test for non-parametric data. Yates correction was used with the latter when the value in any group was <5. Intra-group comparisons were done by the paired ’t’ test and inter-group comparisons by unpaired ‘t’-test. Pearson’s correlation test was used where required. Results Mothers and infants in both the test and the control groups were matched evenly for all parameters. The average birth weight was 1598 grams and 1588 grams in the test and control groups, respectively and the average gestational age was 34.36 weeks and 34.35 weeks in the test and control groups, respectively. The average number of feeds per day was the same in the two groups (9.0 for test and 9.60 for controls). The average duration (standard deviation) of stimulation in the test and control groups was 40.94 (7.51) and 38.72 (9.65) days respectively. In the primary outcome variables, the change in heart rate was significantly greater in the test group during the stimulation. However, values were within physiologic limits and were not associated with changes in the other vital parameters (i.e., respiratory rate, temperature or oxygen saturation) or apnea (Table I). In the anthropometric parameters the weight gain in the test group was 4.24 grams or 21.92% more per day as compared to the control group, which was highly significant. There was no significant difference in the rate of growth of the head circumference or length in the two groups. In the neurobehavioral parameters the test group showed better scores on the ‘orientation’, ‘range of state’ ‘regulation of state’ and ‘autonomic stability’ clusters (Table II). The improvement in latter two was seen as early as 5-7 days after commencement of stimulation. The duration of stimulation in days and the weight gain showed a positive correlation which, however, did not reach statistical significance. Complications No significant complications were seen during the study. One baby in the test group developed an asymptomatic PDA which responded to Indomethacin and did not require stopping the intervention. Lost to Folow-up Cases Sixty nine per cent of the study infants came back for follow-up. Those lost to follow up were evenly matched in initial parameters as compared to infants who were brought back for follow up.
Table I - Change in physiologic parameters in the two groups
Table II - Comparison of BNBAS sector in test and controls
Discussion The effect of touch on growth and development of infants has long fascinated researchers. Sensory interventional studies on preterms began with Hasselmeyer, a research nurse(11). Some studies have shown that stimulation may adversely affect physiologic parameters in preterms and produce apnea(12) while others have shown no adverse response to the stimulation(13). In our study, except for heart rate, physiologic parameters were unaffected by the stimula-tion. A number of studies have shown better weight gain in stimulated preterm infants(4-6). Ornithine decarboxylase, an important enzyme involved in protein synthesis, has been shown to increase with stimulation in preterm pups(14). A Cochrane meta-analysis has shown an average greater weight gain of 5 g/day than controls(8). However, the authors have commented that the quality of the studies was a cause for concern. In our study the test infants averaged an increase in weight gain of 4.24 grams (21.9%) more per day as compared to controls (23.58 g/day in the test group compared to 19.34 grams/day in the control group) which was highly significant. The follow-up was only till 40-42 weeks post-menstrual age. Hence, the effect on head circumference and length may not have become apparent by then. A number of studies have shown better state regulation with tactile-kinesthetic stimulation in preterms (15-19). Kuhn, Schanberg and associates (15) found that urine norepiphrine and epinephrine levels increased significantly only in stimulated preterms. This was thought to reflect the maturation of the sympathetic system and could suggest better stress handling. Greater activity levels and more mature sleep-wake patterns have also been demonstrated(6,17). It has been suggested that a premature infant who achieves a more robust neurophysiological development would elicit responses of a more confident nature from the mother. Our study showed that ‘orientation’ ‘range and regulation of state’ and ‘autonomic stability’ were the most significantly affected parameters. We wish to follow-up these infants at 1 year of age to confirm if this is indeed a predictor of better developmental outcome. A unique aspect of our study was that all stimulation, except for the first five days, was provided by mothers and it is well known that maternal touch differs from others(20). This study has important implications in the NICU care of premature infants and takes advantage of the parent’s availability during the infant’s hospitalization to initiate a simple, no-cost, culturally acceptable, mother-focused, home-based program to foster preterm infant development. Acknowledgement The authors acknowledge the contribution of Varsha who helped teach the mothers the technique of massage. Contributors: SM supervized the stimulation, did the Brazelton tests and data collection and drafted the paper. AR designed and coordinated the study. JM helped in designing the study and supervised data collection and analysis. WK supervised the randomization and method of stimulation. SM will act as the guarantor for the manuscript. Funding: None
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