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J Pediatr (Rio J). 2015;91(3):213---233 www.jped.com.br REVIEW ARTICLE Application of tactile/kinesthetic stimulation in preterm infants: a systematic review , Vanessa C. Pepino a,, Maria Aparecida Mezzacappa b a Program in Child and Adolescent Health Science, Universidade Estadual de Campinas (UNICAMP), São Paulo, SP, Brazil b Division of Neonatology, Department of Pediatrics, Faculty of Medical Sciences, Universidade Estadual de Campinas (UNICAMP), São Paulo, SP, Brazil Received 19 September 2014; accepted 6 October 2014 Available online 9 February 2015 KEYWORDS Preterm infants; Massage; Review; Weight gain; Tactile/kinesthetic stimulation Abstract Objective: To verify the methods used by the clinical trials that assessed the effect of tac- tile/kinesthetic stimulation on weight gain in preterm infants and highlight the similarities and differences among such studies. Sources: This review collected studies from two databases, PEDro and PubMed, in July of 2014, in addition to bibliographies. Two researchers assessed the relevant titles independently, and then chose which studies to read in full and include in this review by consensus. Clinical trials that studied tactile stimulation or massage therapy whether or not associated with kinesthetic stimulation of preterm infants; that assessed weight gain after the intervention; that had a control group and were composed in English, Portuguese, or Spanish were included. Summary of the findings: A total of 520 titles were found and 108 were selected for manuscript reading. Repeated studies were excluded, resulting in 40 different studies. Of these, 31 met all the inclusion criteria. There were many differences in the application of tactile/kinesthetic stimulation techniques among studies, which hindered the accurate reproduction of the proce- dure. Also, many studies did not describe the adverse events that occurred during stimulation, the course of action taken when such events occurred, and their effect on the outcome. Conclusions: These studies made a relevant contribution towards indicating tactile/kinesthetic stimulation as a promising tool. Nevertheless, there was no standard for application among them. Future studies should raise the level of methodological rigor and describe the adverse events. This may permit other researchers to be more aware of expected outcomes, and a standard technique could be established. © 2015 Sociedade Brasileira de Pediatria. Published by Elsevier Editora Ltda. All rights reserved. Please cite this article as: Pepino VC, Mezzacappa MA. Application of tactile/kinesthetic stimulation in preterm infants: a systematic review. J Pediatr (Rio J). 2015;91:213---33. Study conducted at Department of Pediatrics, Faculty of Medical Sciences, Universidade Estadual de Campinas (UNICAMP), São Paulo, SP, Brazil Corresponding author. E-mail: [email protected] (V.C. Pepino). http://dx.doi.org/10.1016/j.jped.2014.10.005 0021-7557/© 2015 Sociedade Brasileira de Pediatria. Published by Elsevier Editora Ltda. All rights reserved.

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Page 1: Application of tactile/kinesthetic stimulation in preterm ... · Tactile kinesthetic stimulation in preterm infants 215 Inclusion criteria Two faster independent researchers preselected

J Pediatr (Rio J). 2015;91(3):213---233

www.jped.com.br

REVIEW ARTICLE

Application of tactile/kinesthetic stimulation inpreterm infants: a systematic review�,��

Vanessa C. Pepinoa,∗, Maria Aparecida Mezzacappab

a Program in Child and Adolescent Health Science, Universidade Estadual de Campinas (UNICAMP), São Paulo, SP, Brazilb Division of Neonatology, Department of Pediatrics, Faculty of Medical Sciences, Universidade Estadual de Campinas (UNICAMP),São Paulo, SP, Brazil

Received 19 September 2014; accepted 6 October 2014Available online 9 February 2015

KEYWORDSPreterm infants;Massage;Review;Weight gain;Tactile/kinestheticstimulation

AbstractObjective: To verify the methods used by the clinical trials that assessed the effect of tac-tile/kinesthetic stimulation on weight gain in preterm infants and highlight the similarities anddifferences among such studies.Sources: This review collected studies from two databases, PEDro and PubMed, in July of 2014,in addition to bibliographies. Two researchers assessed the relevant titles independently, andthen chose which studies to read in full and include in this review by consensus. Clinical trialsthat studied tactile stimulation or massage therapy whether or not associated with kinestheticstimulation of preterm infants; that assessed weight gain after the intervention; that had acontrol group and were composed in English, Portuguese, or Spanish were included.Summary of the findings: A total of 520 titles were found and 108 were selected for manuscriptreading. Repeated studies were excluded, resulting in 40 different studies. Of these, 31 metall the inclusion criteria. There were many differences in the application of tactile/kinestheticstimulation techniques among studies, which hindered the accurate reproduction of the proce-dure. Also, many studies did not describe the adverse events that occurred during stimulation,the course of action taken when such events occurred, and their effect on the outcome.Conclusions: These studies made a relevant contribution towards indicating tactile/kinestheticstimulation as a promising tool. Nevertheless, there was no standard for application amongthem. Future studies should raise the level of methodological rigor and describe the adverse

events. This may permit other researchers to be more aware of expected outcomes, and astandard technique could be established.© 2015 Sociedade Brasileira de Pediatria. Published by Elsevier Editora Ltda. All rights reserved.

� Please cite this article as: Pepino VC, Mezzacappa MA. Application of tactile/kinesthetic stimulation in preterm infants: a systematicreview. J Pediatr (Rio J). 2015;91:213---33.

�� Study conducted at Department of Pediatrics, Faculty of Medical Sciences, Universidade Estadual de Campinas (UNICAMP), São Paulo,SP, Brazil

∗ Corresponding author.E-mail: [email protected] (V.C. Pepino).

http://dx.doi.org/10.1016/j.jped.2014.10.0050021-7557/© 2015 Sociedade Brasileira de Pediatria. Published by Elsevier Editora Ltda. All rights reserved.

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214 Pepino VC, Mezzacappa MA

PALAVRAS-CHAVENeonatos prematuros;Massagem;Análise;Ganho de peso;Estimulacãotátil-cinestésica

Aplicacão da estimulacão tátil-cinestésica em neonatos prematuros: análisesistemática

ResumoObjetivo: Verificar quais metodologias foram utilizadas por ensaios clínicos que avaliaram oefeito da estimulacão tátil-cinestésica sobre o ganho de peso de neonatos prematuros e destacaras diferencas e semelhancas entre esses estudos.Fontes dos dados: Esta análise coletou estudos de duas bases de dados, PEDro e PubMed, emjulho de 2014, além de bibliografias. Dois pesquisadores avaliaram os títulos relevantes indepen-dentemente e, então, escolheram consensualmente quais estudos seriam lidos completamentee incluídos nesta análise. Foram incluídos os ensaios clínicos que estudaram a estimulacão tátilou a massagem terapêutica associada ou não à estimulacão cinestésica em neonatos prematurose avaliaram o ganho de peso após a intervencão, tiveram um grupo de controle e foram escritosem inglês, português ou espanhol.Síntese dos dados: Foram encontrados 520 títulos no total, e foram selecionados 108 paraleitura. Os estudos repetidos foram excluídos, resultando em 40 estudos diferentes. Destes,31 atenderam a todos os critérios de inclusão. Há muitas diferencas na aplicacão das técnicasde estimulacão tátil-cinestésica entre os estudos, o que prejudica a reproducão precisa do pro-cedimento. Além disso, muitos estudos não descreviam os eventos adversos ocorridos durantea estimulacão, o procedimento realizado quando esses eventos ocorriam e seu efeito sobre oresultado.Conclusões: Esses estudos fizeram uma contribuicão relevante ao incluir a estimulacão tátil-cinestésica como uma ferramenta promissora. Contudo, não houve padrão de aplicacão entreeles. Estudos futuros podem aumentar o nível do rigor metodológicos e descrever os eventosadversos. Isso pode permitir que outros pesquisadores tenham mais ciência do que esperar eassim estabelecer uma técnica padrão.© 2015 Sociedade Brasileira de Pediatria. Publicado por Elsevier Editora Ltda. Todos os direitosreservados.

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reterm infants (PI) are exposed daily to many stressorsn the neonatal intensive care unit (NICU) inherent to theritical care they need to survive. The manner and intensityf exposure vary according to the individual PI conditionnd response. It has already been shown that such expo-ure leads to structural and functional changes in specificreas of the brain, affecting its development,1 language,nd social-emotional and adaptive behavior.2

Tactile stimulation (TS) or massage therapy (MT), some-imes associated with kinesthetic stimulation (KS), is usedn PI along with the standard clinical treatment. TS haveeen the object of clinical studies since the 1960s,3 whent was proposed as a means of encouraging PI growthnd development.3---10 Additionally, recent studies havehown that interventions such as tactile/kinesthetic stim-lation (TKS) have the added benefit of reducing behavioralanifestations of stress.11

The objective of this systematic review was to verifyhich methodologies were used by clinical trials that study

he effects of some types of TS/MT, whether or not asso-iated with KS, on weight gain of PI. Clinical trials wereelected that studied the effects on weight gain, as this is a

eterminant variable for discharge from the NICU. The dif-erences and similarities between the methods used by theeviewed clinical trials were highlighted in an attempt tomprove the methodological quality of future trials.

sa

ethods

wo databases were searched for this systematic review: thehysiotherapy Evidence Database (PEDro)12 and the Unitedtates National Library of Medicine of the National Institutesf Health (PubMed).13 All studies listed on the date of searchere accessed.

The PEDro database was searched by specifying theollowing fields in the advanced search option: therapystretching, mobilization, manipulation, massage); subdis-ipline (pediatrics), and method (clinical trial).

PubMed was searched using six keyword combinations, asollows:

-- Search 1: massage premature newborn-- Search 2: tactile kinesthetic stimulation premature-- Search 3: tactile stimulation premature-- Search 4: massage premature growth-- Search 5: kinesthetic stimulation premature growth-- Search 6: tactile kinesthetic stimulation

premature growth

In addition to these searches, the references of the cho-en articles were also checked, and another 12 relevantrticles were selected for evaluation.

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Tactile kinesthetic stimulation in preterm infants

Inclusion criteria

Two independent researchers preselected the articlesaccording to their titles. In case of doubt, the article wasincluded in the selection process by consensus. The pres-elected titles were then stored in a file according to thedatabase they were found, and their abstracts or texts weredownloaded for assessment. Once downloaded, the articleswere thoroughly read to select those that met the inclusioncriteria detailed below.

The present review included all clinical trials that studiedthe provision of TS or MT, whether or not associated withKS, for PI in the NICU, assessed PI weight gain after theintervention, had a control group that did not receive anyintervention in addition to the standard treatment providedby the NICU, and were composed in English, Portuguese, orSpanish.

Results

A total of 508 articles were found in the two abovemen-tioned databases. Seventeen articles were fully read amongthe 206 articles found in the PEDro database, of whicheight met the inclusion criteria. The first search on PubMedresulted in 126 titles, of which 30 were selected and 18 metthe inclusion criteria. The second search on PubMed resultedin 16 titles, of which ten were selected and eight met theinclusion criteria. The third search on PubMed resulted in86 titles, of which 14 were selected and ten met the inclu-sion criteria. The fourth search on PubMed resulted in 49titles, of which 23 were selected and 16 met the inclu-sion criteria. The fifth search on PubMed resulted in 14titles, of which nine were selected and six met the inclusioncriteria. The sixth search on PubMed resulted in 11 titles,of which eight were selected and five met the inclusioncriteria.

However, another 12 titles found in the references of thearticles that met the inclusion criteria were analyzed, andof these, four were included, five were excluded, and threewere not found. Table 1 shows the titles and where theywere found.

In summary, 520 titles were found; the repeated stud-ies were eliminated, resulting in 31 that met the inclusioncriteria of the present review (Table 1).

TS/MT was done in many different ways,3,9,10,14---18 and themost of the studies did not provide a detailed descriptionof how to proceed during the stimulation if adverse eventsoccur, nor of the possible effects of these events on theoutcomes.

Analysis of the techniques used by different studiesshowed that older studies, such as Solkoff et al.,6 Krameret al.,7 and Solkoff & Matuszak8 did not specify which partsof the body were stimulated or how often. The pressureused during the intervention and its duration varied greatlybetween these studies.

White & Labarba3 were the first to combine TS and KS. In1981, Rausch9 divided TKS into three phases of five minuteseach and applied TKS only when the PI were awake, withoutchanging their position in the incubator. Both Lee19 and Fer-reira & Bergamasco20 followed these procedures. Rausch9

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uggested that new studies should provide the interventionor at least ten days, because weight gain increased afterhis period. Rausch’s9 study was the first to show significantlyaster weight gain in PI submitted to TKS and to describe theechnique used in detail.

Scafidi et al. 21 standardized the three five-minute phasesroposed by Rausch9 into prone TS + supine KS + prone TS.ourteen of the 31 studies that met the inclusion crite-ia for the present review used the technique describedy Field et al. 10 in 1986; 11 of the 14 were conductedy Field’s team10,21---30 in the same institution and threeere performed by other researchers, namely Lee,19 Mas-

aro et al.,31 and Ang et al. 32 The intervention wassually performed after the first feeding in the morning.n 1990, Field & Schanberg24 provided the intervention athe beginning of three consecutive hours, after the middayeeding.

Mathai et al. 14 introduced a new way of providingKS, as follows: the intervention was done after the morn-

ng, midday, and evening feeding in the prone (TS) + supineTS) + supine (KS) positions, which was repeated by Arorat al. 33 Like other studies, they also used some type of oilo reduce friction on the PI’s skin.14,17,33---35 In some studies,nly the mothers provided KTS.16,35,36

Ferber et al. 15 suggested that during the first ten secondsf TS, the caregiver should only rest his hand on the PI,voiding movements.

Dieter et al. 27 was the first to provide TKS for only fiveays, showing that this was enough to increase the rate ofeight gain significantly compared with the control group.

Diego et al. 28 demonstrated that moderate KTS pres-ure promoted better outcomes than the placebo group whoeceived light KTS pressure. Also, in another time, trained aew therapists and suggested that the technique was effec-ive, regardless of therapist.29

Massaro et al. 31 tested KTS and TS separately in differentroups of infants and found that KTS appears to be better,ut the difference was not significant.

Fucile & Gisel18 used the same trained researcher torovide the intervention and introduced oral stimulationOS) in addition to KTS. They found that OS did not increasehe rate of weight gain and attributed this result to thehorter period dedicated to each intervention, suggestinghat the duration of the sensoriomotor input is critical formproving defined outcomes.

Ferreira & Bergamasco20 used gentle techniques with noigid sequence, only when the PI was awake.

Moyer-Mileur et al. 37 used the Infant Massage USA pro-ocol, but they modified for PI, eliminating massage of thebdomen.

Kumar et al. 34 demonstrated that PI who received oilassage soon after birth had less weight loss in the firsteek, probably due to undetectable water loss through the

kin due to blockage of pores and sweat glands. Also, earlyil application probably leads to better temperature regu-ation and less caloric expenditure due to cold stress.

Abdallah et al. 35 used TS without KS and did notnd greater weight gain, but the pain scores on theremature Infant Pain Profile were favored in the mas-aged infants, being lower after the intervention and at

ischarge, in addition to demonstrating better cognitivecores.
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Table 1 Descriptions of the included studies.

Title/Author/Year/Database

Sample Size Objectives andstarting conditions

Description of thetechnique

Main variables Measured weightgain

Description ofadverse eventsduring theprocedure

Results achievedstatistical significance

Effects of handlingon the subsequentdevelopments ofpremature infants6

Solkoff et al., 1969Bibliography ofarticle

Total: 20MBW = 1360 gMBW = 1369 g

Verify immediate andsubsequent effects ofhandling on thebehavior and physicaldevelopment 12 hafter delivery,randomly assigned.

5 min each hour, for24 h, 10 days.While awake, theinfant’s neck, backand arms were gentlyrubbed by a nurse oraide.

1) Activity (polygraphreading, from arecorder)2) WG3) Temperature4) Startle responses5) Crying6) Frequency ofurination anddefecation7) Physicaldevelopment

Body weight takendaily with normalnursery routine,approximately thesame time.

Not described Was not performedstatistically becauseof the small sample.It appeared that theTG was more active,cried less, and gainedweight faster.

Extra tactilestimulation of thepremature infant7

Kramer et al., 1975PubMed search 3and PEDro

Total: 14TG: 8GAM = 33 wBWM = 1441 gCG: 6GAM = 33 wBWM = 1418 gAfter the randomstart, subjectswere alternatelyassigned to TG orCG.

Verify if touch such asextra tactilestimulation couldresult in fasterphysical and socialdevelopment and agreater degree ofsocial development ofPI.Beginning when theinfants were at least2 weeks in theisolletes.

Gentle, nonrhythmicstroking of thegreatest possible skinarea of the infant’sbody, by trainednurse, 48 min/day,2 min before and2 min after eachfeeding (if two in 2 h)or 3 min before and3 min after (if threein 3 h). Stop watcheswere used foraccurate timing.

1) Daily WG2) Social (Geselldevelopmentschedule) andphysical development(Bayley scale)3) Plasma cortisollevel

Body weight takedaily with normalnursery routine.Scales used toweigh infantswere checked andcalibrated once aweek by theresearchers usingOhaus weights.

Not described TG appears to havedemonstrated ahigher degree ofmotor skill.

Tactile stimulationand behavioraldevelopmentamong low-birthweight infants8

Solkoff Matuszak,1975PubMed search 3

Total: 11TG: 6GAM = 31.2 wBWM = 1375.3 gCG: 5GAM = 31 wBWM = 1564.5 g

To check the effectTS on WG andbehavioral byNeonatal behavioralassessment scale.The mean age of startof stimulation was 14days.

7.5 min ofextra-handling, forten days, in the formof stroking, duringeach hour of16 h/day, total of1,200 min.Applied by twonurses.

1) Temperamental,reflex, and ‘‘early’’social behavior -Neonatal behavioralassessment scale.2) WG

Not described Not described Was not performedstatistically becauseof small sample size.

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Table 1 (Continued)

Title/Author/Year/Database

Sample Size Objectives andstarting conditions

Description of thetechnique

Main variables Measured weightgain

Description ofadverse eventsduring theprocedure

Results achievedstatistical significance

The effects of tactileand kinestheticstimulation onneonataldevelopment in thepremature infant3

White Labarba, 1976PubMed searches 2,3, 5, 6

Total: 12TG: 6GAM = 34.3 wBWM = 1910 gCG: 6GAM = 34.2 wBWM = 1911 g

Investigate someimmediate effectssuch as WG and thedevelopment of lowbirth weight infantsthat received T/KS ina typical hospitalnursery.Beginning after 48 h ofage.

15 min periods everyhour for fourconsecutive hours, forten days. Rubbing theinfant’s neck,shoulder, arms, legs,chest, and back; andKS. Performed byresearcher.

1) WG, number offeedings, amount offormula intake.2) Body temperature3) HR, RR4) Frequency ofvoiding and stooling.

All infants wereroutinely weighedthree days eachweek by thenursery staff.

Not described 1) TG: More WGstimulation effect(p < 0.05) andstimulation x daysinteraction (p < 0.001)TG: Greater amount offormula intake(p < 0.025)TG: Fewer number offeedings/day (p < 0.05)

Effects of tactile andkinestheticstimulation onpremature infants9

Rausch, 1981PubMed searches 2,3, 5, 6

Total: 40TG: 20CG: 20BW = 1000-2000 gNot randomized

To determine theeffects of a 10-dayregimen of T/KS oncaloric intake,stooling, and WG.Beginning at 24-48 h ofage.

15 min, 3x/day, at thebeginning of threeconsecutive hours,starting 30 min afterthe first morningfeeding, for tenweekdays;non-treatment onweekend. Performedby researcher.With the infant awakeand keeping the babyin position.

1) WG2) Frequency ofstooling3) Caloric intake

Body weight takendaily with normalnursery routine.

Not described 2)TG: Increase offormula intake on days6-10 (p < 0.0001)3) TG: Increasestooling frequency(p < 0.004)

Effects oftactile/kinestheticstimulation on theclinical course andsleep/wakebehavior of pretermneonates21

Scafidi et al., 1986PEDro

Total: 40TG: 20GAM = 31 wBWM = 1280 gCG: 20GAM = 31 wBWM = 1268 g

It was designed tocomplement thealready existingliterature of theeffects of T/KS in PI.Beginning whenclinically stable.

T/KS: 15 min, 3x/day,at the beginning ofthree consecutivehours, starting 30 minafter the first morningfeeding, for tenweekdays;non-treatment onweekend.Performed byresearcher.Phase 1 and 3 in proneposition and phase 2 insupine.

1) Daily WG2) Formula intake,frequency of voiding,stooling3) HR, RR, bodytemperature4) Number of apneicepisodes5) Parents visiting andtouch6) Brazelton scale7) Sleep-wakebehavioral (ThomasScale of 1975)8) Length of hospitalstay

Body weight takendaily with normalnursery routine.

Not described 1) TG: Better WG perday (8 g/day more)(p < 0.0005)2) More weight percalories of intake perkg of body weight6) TG: More matureorientation, motorhabituation, and rangeof state behaviors onBrazelton Scales7) TG: More timeawake (p < 0.04) andactive (p < 0.05)8) TG: 6 days earlierdischarge (p < 0.05)

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Table 1 (Continued)

Title/Author/Year/Database

Sample Size Objectives andstarting conditions

Description of thetechnique

Main variables Measured weightgain

Description ofadverse eventsduring theprocedure

Results achievedstatistical significance

Tactile/kinestheticstimulation effectson pretermsneonates10

Field et al., 1986PubMed search2,3,5,6

Total: 40TG: 20GAM = 31 wBWM = 1280 g20 GC:GAM = 31 wBWM = 1268 g

Evaluate the effectsof T/KS on growth,sleep-wake behavior,and Brazelton scale inPIBeginning whenclinically stable

T/KS: 15 min, 3x/day,at the beginning ofthree consecutivehours, starting 30 minafter the firstmorning feeding, forten weekdays;non-treatment onweekend.Not clear who appliedthe technique.

1) Daily WG, formulaintake, frequency ofvoiding and stooling,and parent visits2) Length of hospitalstay3) Sleep-wakebehavior4) Brazelton scale5) Physiologicalparameters

Body weight takendaily with normalnursery routine.

Not described 1) TG: 47% more WGper day (p < 0.0005)2) TG: 6 days earlierdischarge (p < 0.05)3) TG: More timeawake and active(p < 0.04)4) TG: More matureorientation, motorhabituation, andrange of statebehaviors onBrazelton Scales

Massage of pretermnewborns toimprove growthand development22

Field et al., 1987Bibliography---Touchresearch institute

Total: 40TG = 20CG = 20Overall averageGA = 31 weeksBW = 1274 g

To describe aneffective massageprocedure forfacilitating WG in PI,reviewing data thatsupport it.Beginning whenclinically stable andbottle-fed.

T/KS: 15 min, 3x/day,at the beginning ofthree consecutivehours, starting 30 minafter the firstmorning feeding, forten weekdays;non-treatment onweekend.Not clear who appliedthe technique.

1) Daily WG2) Formula intake andnumber of feedings3) Brazelton scale atend of treatment4) Sleep-wakebehavior---recordedfor 45 min at end oftreatment5) After six months:half of the samplereceived ratingpediatric (weight,height, and headcircumference) andBayley scales ofinfant development(1969)

Not described Not described 1) TG: more daily WG(p < 0.0005)3) Betterperformance4) More active5) Greater WG aftersix months (p < 0.05),better performance(p < 0.05)

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Table 1 (Continued)

Title/Author/Year/Database

Sample Size Objectives andstarting conditions

Description of thetechnique

Main variables Measured weightgain

Description ofadverse eventsduring theprocedure

Results achievedstatistical significance

Effects of earlymultimodalstimulation onpreterm newborninfants39

Benavides-Gonzálezet al., 1989PubMed searches 2,5, 6

Total: 18GAM = 31.5 wBWM = 1296 gGC:GAM = 32.4 wBWM = 1211 g

To study if thesupplementalstimulation of PIresponses improvesneurobehavioralorganization,achieving greater WGand a reduction inlength of hospitalstay.

Intrahospital T/KS:15 min, 2x/day, forten days,non-treatment onweekend.Period 1: TS,vestibular andproprioceptive(15 min)Period 2: lateralwedge-shapedcrescent (15 min)Performed by threetrained people,30 min before feedingat 7 am and 10 am.Extra-hospital:T/KS + visual, auditorystimulation for 5 min

1) Daily WG2) Formula intake3) Length of hospitalstay4) Postural reflexesand neurobehavioralperformance wereassessed at the timethe child left thehospital and onemonth afterwards.

Body weight takendaily with normalnursery routine.Only one scale wasused.

Not described 1)TG: 3.2 g/day more3) TG: 3 days less4) Betterneurobehavioralperformance andpostural reflexes

Massage stimulatesgrowth in preterminfants: areplication23

Scafidi et al., 1990PEDro

Total: 40TG: 20GAM = 30wBWM = 1179 gCG: 20GAM = 30wBWM = 1180 gStratification:< or > 30 weeks GA< or >1100 g BW< or >20 days NICU< or > 1300 g atbeginning of study

Designed to correctpreviousmethodologicalweaknesses andprovide a replicationof the previous study.Not randomized,alternative weeks.Beginning whenclinically stable.

T/KS: 15 min, 3x/day,at the beginning ofthree consecutivehours, starting 60 minafter the noonfeeding, for 10weekdays;non-treatment onweekends.Not clear who appliedthe technique.Never lost contactwith the infant’s skinduring strokingmotions.

1) Daily WG2) Formula intake,frequency of voidingand stooling3) HR, RR, bodytemperature4) Number of apneicepisodes6) Parents visiting andtouch7) Brazelton scale(day 1 and 10)8) Sleep/wakebehavior---videotapedduringstimulation/no-stimulation period9) Length of hospitalstay

The infant wasweighed daily bythe experimenteror researchassistantimmediately priorto the 3 pmfeeding.

Not described 1)TG: Greater dailyWG (p < 0.003)Greater WG in finalperiod (p < 0.001)2) Frequency ofstooling was lower inTG (p < 0.05)7) TG: Betterhabituation (p < 0.05);motor maturity(p < 0.005), andnumber of abnormalreflexes (p < 0.001)8)TG: tactile phase:more active sleep,fewer periods withoutmovement (p = 0.001)9) 5 days lesshospitalization(p < 0.05)

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Table 1 (Continued)

Title/Author/Year/Database

Sample Size Objectives andstarting conditions

Description of thetechnique

Main variables Measured weightgain

Description ofadverse eventsduring theprocedure

Results achievedstatistical significance

Massage alters growthand catecholamineproduction inpreterm newborns24

Field Schanberg,1990Bibliography---Touchresearch institute

Total: 40BWM = 1176 gGAM = 30 wNICU = 14 daysRandomized

To replicate thestimulation procedureand findings of theearlier study, and toadd severalunder-the-skinvariables such asgrowth hormone,cortisol, andcathecolamine activitythat might providemore information onthe relationshipbetween TS and WG.

T/KS: 15 min, 3x/day,at the beginning ofthree consecutivehours, starting 60 minafter the noonfeeding, for tenweekdays;non-treatment onweekends.Not clear who appliedthe technique.

1) Formula intake,daily WG2) Frequency ofurination3) Frequency ofstooling4) HR, RR, bodytemperature5) Number of apneicepisodes6) Parents visiting (andif touching, holding,and feeding)7) Sleep---wakebehavior8) Plasma growthhormone and cortisol9)Urine-norepinephrine,epinephrine,dopamine, cortisol,and creatinine10) Length of hospitalstay

Not described Not described 1) TG: 21% greater WG(p = 0.003).3) Better performanceon the habituationcluster following thetreatment period, lesstime in active sleep,and less facialgrimacing,mouthing/yawning,and clenched fists10) 5 days lesshospitalization

Massage effects oncocaine-exposedpreterm neonates25

Wheeden et al.,1993PEDro and PubMedsearches 1, 4

Total: 30TGGAM = 29.7wBWM = 1158.3 gCGGAM = 30.8 wBWM = 1265.4 g

To observe the effectsof MT in WG ofcocaine-exposed PI.Beginning whenclinically stable.

T/KS: 15 min, 3x/day,at the beginning ofthree consecutivehours, for ten days. Allperformed by thesame trainedresearcher.During TS phase neverlost contact with theskin, keeping pressureeven if there was somereaction from theinfant, such as tickle.

1) Daily WG2) Formula intake,frequency of voidingand stooling3) HR, RR, bodytemperature4) Number of apneicepisodes5) Parents visiting andtouch6) Brazelton Scale7) Postnatalcomplications

Body weight takendaily with normalnursery routine.

Not described1) TG: 28% greater WG2) More daily WG,p < 0.016) Brazelton scale:better motor maturity(p < 0.005), orientation(p < 0.06), and stressbehaviors (p < 0.05)

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Table 1 (Continued)

Title/Author/Year/Database

Sample Size Objectives andstarting conditions

Description of thetechnique

Main variables Measured weightgain

Description ofadverse eventsduring theprocedure

Results achievedstatistical significance

Factors that predictwhich preterminfants benefitmost from massagetherapy26

Scafidi et al., 1993Bibliography---Touchresearch institute

Total: 93GAM = 30 wBWM = 1204 gNICU = 15 daysWeight at start ofstudy = 1353 g

This study examinedindividual differencesto identify infant andclinicalcharacteristics thatwould predictmaximal WG incontrol andMT-receiving infants.Beginning whenclinically stable.

T/KS: 15 min, 3x/day,at the beginning ofthree consecutivehours, for ten days;never lost contactwith the skin, orlightened thepressure.Trained researchassistant or nurse.

1) WG and volumetricand caloric intake2) Frequency ofvoiding3) HR, RR, bodytemperature4) Number of apneas5) Frequency ofvisiting (includingtouch, feeding, andholding)6) Sleep-wake7) Brazelton scale

Data collectedfrom the nursesnotes and dailyweighing by aresearch assistant.

The session wasdiscontinued ifbehavioral signsof stress orcrying persistedfor longer than60 scontinuously.

1) TG: Greater dailyWG (p < 0.01)2) Separate t-testanalyses wereperformed for thelow and high weightgainers: 70% of theTG was classified ashigh weight gain and40% of the of CG(p < 0.01)Low weight gainers ofthe TG gained moreweight (p < 0.005)

Effects oftactile-kinestheticstimulation inpreterms: acontrolled trial14

Mathai et al., 2001PubMed searches 1,2, 3, 4, 5, 6

Total: 45TG: 25GAM = 34.6 wBWM = 1598 gCG: 23GAM = 34.3 wBWM = 1588 gNot randomized-systematicallocation

Determine the effectsof T/KS in PI onphysiologicalparameters, physicalgrowth, andbehavioraldevelopment(Brazelton Scale).Beginning after twodays clinically stable.

T/K: 3x/day, 15 min,for five days,30-45 min aftermorning, afternoon,and night feeding, bya trainedprofessional.After this period themothers performeduntil 40-42 wpost-menstrual age.Prone and supineposition.Used talc or mineraloil, excess removedwith cotton afterfinish.

1) Anthropometricdata at the beginningand end of the study2) Physiologicparameters3) Brazelton scalebefore and after fivedays of T/KS and atthe end of the study.

Body weight takendaily with normalnursery routine,on an electronicscale (Phillips®,Amsterdam,Netherlands) withan accuracyof ± 5 g.

If the babystarted crying orpassed urine orstools during thesession, it wastemporarilystopped until thebaby wascomfortableagain.

1) TG: Greater WG(21.9%, 4.24 g/day)2) TG: Higher HRduring stimulation(p < 0.005)3) Improvedneurobehavior duringdays 5-7 inorientation, range ofstate, supplementsregulations, andautonomic stability

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Table 1 (Continued)

Title/Author/Year/Database

Sample Size Objectives andstarting conditions

Description of thetechnique

Main variables Measured weightgain

Description ofadverse eventsduring theprocedure

Results achievedstatistical significance

Massage therapy bymothers andtrainedprofessionalsenhances weightgain in preterminfants15

Ferber et al., 2002PEDro and PubMedsearches 1, 4

Total: 571) TG mother: 21GAM = 30.9 wBWM = 1318 g2) TG prof: 17GAM = 31.8 wBWM = 1527 g3) CG: 19GAM = 31.52 wBWM = 1375 g

Compare the resultsof MT performed bymothers and bytrained professionalson WG in PI.Beginning whenclinically stable.

Only TS prone andsupine, moderatepressure, 15 min,3x/daily, early 3hsconsecutive for 10days. One groupreceived from theprof, the other frommothers.Each 7.5 min: Bothhands were laid onthe baby’s head for10 s withoutmovement, then theinfant was strokedslowly by handmovement from thehead towards thelegs, back and forth.No massages on chestand stomach.Between day 7 andday 9: one daywithout MT.

1) WG2) Calorie intake

Not described Not described

1) TG mother and TGprof: Greater WG(p = 0.03) moreevident after fivedays of intervention

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223Table 1 (Continued)

Title/Author/Year/Database

Sample Size Objectives andstarting conditions

Description of thetechnique

Main variables Measured weightgain

Description ofadverse eventsduring theprocedure

Results achievedstatistical significance

Stable preterminfants gain moreweight and sleepless after five daysof massagetherapy27

Dieter et al., 2003PubMed searches 1,4

Total: 32TG: 16GAM = 30.1 wBWM = 1359 gCG: 16GAM = 31.1 wBWM = 1421 g

To evaluate the effectof five days of MT inWG and sleep-wakebehavior in PI.Beginning whenclinically stable.

T/KS: 15 min for fivedays, 3x/day.Performed by atrained therapist.

1) Daily WG2) Formula intake,kilocalories, stooling3) Sleep-wakebehavior

Daily WG wasmeasured in theearly morning bynurses on thepreceding nightshift.

At the sign ofphysiologicdistress (HRgreater than 200bpm), massagewas discontinuedfor 15 s, or untila return tobaseline levelswas observed.Massage wasthen resumed.The occurrenceof five periods ofphysiologic overreactivity wasarbitrarilychosen as thecriterion fordiscontinuing aninfant from thestudy. No infantdiscontinued.

1) TG: 53% greaterdaily WG (p = 0.001)3) TG: Less sleepingtime (p = 0.04) anddrowsy longer(p = 0.007)

Effect of oil massageon growth andneurobehavior invery low birthweight pretermneonates33

Arora et al., 2005PEDro and PubMedsearches 1, 4

Total: 621) TG with oil: 20GAM = 33.9 wBWM = 1280.2 g2) TG without oil:19GAM = 34.6 wBWM = 1298.6 g3) CG: 23GAM = 34.7 wBWM = 1327.1 g

Studying the effect ofMT with oil on growthand behavior PI withBW < 1500 g.Beginning as soon asthey received enteralfeeds of at least100 mL/kg/day,provided they wereless than 10 days ofage.

20 gentle strokes ineach area, byprofessionals andmothers.Prone position: bothshoulders startingfrom the neck, upperback to the waist.Supine position: thelimbs.28 days, 4x/day for10 min.After dischargeperformed bymothers.Used sunflower oil.

1) WG2) Anthropometricdata3) Serum triglyceridelevels

Body weight takenwith normalnursery routine atthe time ofregistration andweekly for thenext four weeks.

Temporaryinterruption inthe trial: apnea,sepsis, and IVH.Minor problems:oral thrush,pyoderma, andhyperbilirubine-mia

There were three PIwho had more than20% interruption intheir procedure; allwere in the oil TG.After exclusion,observed more WG inTG with oil.

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Table 1 (Continued)

Title/Author/Year/Database

Sample Size Objectives andstarting conditions

Description of thetechnique

Main variables Measured weightgain

Description ofadverse eventsduring theprocedure

Results achievedstatistical significance

Vagal activity, gastricmotility, andweight gain inmassaged pretermneonates28

Diego et al., 2005PubMed searches 1,4

Total: 481) TG: 16GAM = 29.8 wBWM = 1091 g2) Gsham: 16GAM = 30.3 wBWM = 1184 g3) CG: 16GAM = 29.6 wBWM = 1265 g

Assess whether therealteration in VA, GM,and WG in responseto MT.Beginning whenclinically stable.

T/KS: 15 min 3x/dayfor five days, 1 h afterfeeding.Applied by variousprofessionals.The Gsham receivedthe same sequence ofT/KS with lightpressure.

1) WG2) Days ofhospitalization3) VA and GM on day 1(15 min before,during the 15 min oftreatment, and15 min after T/KS)

Data collected bya blindedresearcher.Body weight takenwith normalnursery routine

Not described 1) GM greater WG (p <0.01), with no greatercaloric intake.3) Increased VA andGM during and shortlyafter MT.

The effect of infantmassage on weightgain, physiologicaland behavioralresponses inprematureinfants19

Lee, 2005PubMed searches 1,2, 3, 4, 5

Total: 26TG: 13GAM = 224.2 daysBWM = 1508.5 gCG: 13GAM = 217.4 daysBWM = 1377.7 g

Evaluate the responseof infants whoreceived MT in WG,includingphysiological andbehavioralparameters.Beginning whenclinically stable, twodays after start ofenteral feeding.

T/KS: 15 min 2x/dayfor ten days, 1 h afterfeeding in themorning andafternoon, withinfant’s eyes open.Data collected 10 minbefore and 10 minafter the T/KS daily.Use of oil to reducefriction.Performed by nurses.

1) WG2) Physiological data3) Behavioralresponses:10 min evaluationpre- and post-MT -videotaped4) Electrocardiogram

Nurses on thepreceding nightshift measureddaily WG in theearly morning.

Study would bediscontinued forat least one hourif: HR less than100 bpm orgreater than 200bpm for 12 s ormore, or bloodoxygensaturation levelsless than 90% forlonger than 30 s.Infant showed nosigns of stressduring the study.

1) Higher in VA in TG:days 1, 2, 6, 7, 8, and92) Increased O2 Saton the 9th day in TG3) Significant increasein alertness andmotor activity4) There was asignificant effect fordays (p = 0.001) bothgroups increased inWG, on the average,over the ten-dayexperimental period

Preterm infantmassage elicitsconsistentincreases in vagalactivity and gastricmotility that areassociated withgreater weightgain29

Diego et al., 2007PubMed searches 1,4

Total: 70

TG: 34CG: 36

Determine whetherthe MT in PI is relatedto the increase in VAand GM and if itinterferes with WG.Beginning whenclinically stable andgavage-fed.

T/KS: 15 min 3x/dayfor five days, onehour after feeding,early of 3hsconsecutivePerformed byprofessional

1) Daily WG2) Caloric intake3) ECGs and EGGscollected on day oneand day five, 15 minbefore, during the15 min, and 15 minafter the procedure.MT was performed at12 am.

Body weight takenwith normalnursery routine.

Not described 1) TG: Increased WG(30% more)3) TG: Increased VAand GM during MTperiod, on days oneand five (p < 0.001)

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225Table 1 (Continued)

Title/Author/Year/Database

Sample Size Objectives andstarting conditions

Description of thetechnique

Main variables Measured weightgain

Description ofadverse eventsduring theprocedure

Results achievedstatistical significance

Insulin and insulin-likegrowth factor 1increased inpreterm neonatesfollowing massagetherapy 30

Field et al., 2008PubMed searches 1,4

Total: 42TG: 95GAM = 29.3 wBWM = 1178.5 gCG: 42GAM = 2.8 wBWM = 1292.5 g

Determine if the MTincreased seruminsulin and insulin-likegrowth factor 1(IGF-1) in PI.Beginning whenclinically stable.

T/KS: 15 min 3x/dayfor five days, one hourafter the morningfeeding (12 am), earlyof 3hs consecutive.Conducted by atherapist.

1) Daily WG2) Daily caloric intake3) Vital signs before,during, and after theMT4) Serum insulin andIGF-1 on days one andfive5) VA measured atintervals

Body weight takenwith normalnursery routine(weighed dailyprior to the 8 amfeeding)

Not described 1) TG: Greater WG(p = 0.02)4) TG: Increase ininsulin (p = 0.001) andgreater increase inIGF-1 (p = 0.05)5) TG: greater VA(p < 0.001)

Massage therapyreduces hospitalstay and occurrenceof late-onset sepsisin very pretermneonates16

Mendes Procianoy,2008PubMed search 1

Total: 104TG: 52GAM = 29.7 wBWM = 1186.8 gCG: 52GAM = 29.4 wBWM = 1156.7 g

Studying the effects ofmassage on maternalhospital stay in verylow birth weight(VLBW) who werealready submitted toskin-to-skin care.Beginning after48 hours of life.

MT applied only bymothers, 4x/day for15 min each time,intervals of 6 h. TS:temporal, frontal,periorbital, nasal, andperilabial regions ofthe face and theexternal side of theupper and lowerlimbs + KS (3x each:wrist, elbow, ankle,and knee)

1) Length of hospitalstay2) Growth3) Age of start ofpartial or total enteralfeeding4) Age which partialand total oral feedingstarted5) Occurrence of lateonset sepsis---clinicaland blood andor/cerebrospinal fluid6) Presence ofnecrotizingenterocolitis and7) Bronchopulmonarydysplasia

Body weight takenwith normalnursery routine,always verified by ablinded researcher,in the afternoonand using the samedigital baby scaleequipment

Not described 1) TG: Fewer days ofhospitalization(p = 0.084)2) TG: Lesser rate oflate-onset sepsis(p < 0.01)

Weight gain inpreterm infantsfollowing parent-administeredVimala massage: arandomizedcontrolled trial17

Gonzalez et al.,2009PEDro and PubMedsearches 1, 4

Total: 60TG: 30GAM = 31.4 wBWM = 1235 gCG: 30GAM = 31.7 wBWM = 1220 g

Evaluate the WG in PIreceiving MT, correlatewith length of hospitalstay and check forother effects.Beginning whenclinically stable, withorogastric tubefeeding.

Vimala massage2x/day for ten days,1 h after feeding.Conducted by themother or father,trained andsupervised: face,upper limbs, chest,abdomen, lowerlimbs, and back,without ever losingtouch, even in casesof PI discomfort.Used oil or cream.

1) Daily WG2) Daily caloric intake3) Length ofhospitalization

Body weight takenwith normalnursery routinewith a digital scale,(Seca®, Hamburg,Germany). At 8 amevery day, 1 hbefore the nextscheduled feeding.The nurse wasblinded.

Not described 1) TG: Greater WGover 10 days and dailyWG (p < 0.001)3) TG: Shorter hospitalstay (p = 0.03)

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Table 1 (Continued)

Title/Author/Year/Database

Sample Size Objectives andstarting conditions

Description of thetechnique

Main variables Measured weightgain

Description ofadverse eventsduring theprocedure

Results achievedstatistical significance

Massage withkinestheticstimulationimproves weightgain in preterminfant31

Massaro et al., 2009PEDro and PubMedsearches 1, 4

Total: 60TS G: 20GAM = 29 wBWM = 1097 gT/KSG: 20GAM = 29 wBWM = 1124 gCG: 20GAM = 27 wBWM = 959 g

To evaluate theeffect of MT with andwithout kinestheticphase in WG and inthe length of PIhospitalization.Beginning whenclinically stable.

TS (only phase 1 and3) or T/KS 2x/day for15 min, performed bytrained nurses, fromthe beginning of thestudy until discharge.

1) Daily WG2) Daily caloric intake3) Length ofhospitalization

Body weight takenwith normalnursery routine.

Not described T/KS G: with birthweight > 1000g = higher daily WG(stratification by BW)

Massage therapyimprovesneurodevelopmentoutcome at twoyears corrected agefor very low birthweight infants36

Procianoy et al.,2010PubMed searches 1,4

Total: 73TG: 35GAM = 30 wBWM = 1192 gCG: 38GAM = 29.7 wBWM = 1151 gboth groupsSkin-skin care

Assess the outcome ofMT growth andneurodevelopment ofPI assessed at 2 yearscorrected age.Beginning after 48 hof life.

MT applied only bymothers, 4x/day for15 min, intervals of6 hours of TS:temporal, frontal,periorbital, nasal,and perilabial regionsof the face and theexternal side of theupper and lowerlimbs + KS (3x each:wrist, elbow, ankle,and knee)

1) Anthropometric2) Bayley scales ofinfant development,second edition(BSID-II).Measured at 2 yearsof corrected age

Body weight takenwith normalnursery routine.

Mothers of theTG wereinstructed toobserve thenewborns’tolerance signs,avoidingexcessivestimulations.

2) TG: Greatermental developmentindex (p = 0.035)

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Title/Author/Year/Database

Sample Size Objectives andstarting conditions

Description of thetechnique

Main variables Measured weightgain

Description ofadverse eventsduring theprocedure

Results achievedstatistical significance

Sensorimotorinterventionsimprove growthand motor functionin preterminfants18

Fucile & Gisel, 2010PubMed searches 1,2, 3, 4, 5, 6

Total: 75OS G: 19T/KS G: 18OS + T/KS G: 18CG: 20

To evaluate the effectof OS and T/KS aloneon WG and motorfunction in PI and ifOS + T/KS havegreater influence onthese parameters.Beginning whenclinically stable,receiving all feedingsby tube.

OS: 15 min 2x/day forten days (7 min:cheek, chin, lips,5 min on gum andtongue, and 3 min ofnon-nutritive pacifiersucking).T/KS for 15 min2x/day. TS: Prone andsupine, stroking thebody starting fromthe head, followed bythe neck, shoulders,back, legs, andarms + KS.Performed byresearcher.

1) Daily WG(g/kg/day)2) Motor Function.Test of Infant MotorPerformance-1969(TIMP)

Body weight takenwith normalnursery routine,nurse was blindedand always usedthe same scale.

Stop procedure:if fussing,vomiting,growing oxygendemand,frequentepisodes ofapnea,bradycardia, ordesaturation inthe 24 h thatpreceded theintervention; orinterventionssuch as sight orhearing testsperformed 30 minbefore T/KS.

1) OS G andT/KS G: greater WG(p = 0.014)2) T/KS G and OS+T/KS G: greater TIMPscores (p < 0.003)

Behavioral analysis ofpreterm neonatesincluded in a tactileand kinestheticstimulationprogram duringhospitalization20

FerreiraBergamasco, 2010PubMed searches 2,3

Total: 32TG: 16GAM = 33.4 wBWM = 1910.3 gCG: 16GAM = 33.3 wBWM = 1872.8 gNot randomized

To evaluate the effectof T/KS evolutionbehavioral andclinical newborn PIduringhospitalization.Beginning whenclinically stable.

8 min/week filminguntil discharge:behavioralevaluation.TS: performed4-5x/week for5-15 min, focusing onalertness. Softtouches, slow andcontinuous, no rigidsequence, withcerebrospinal flowdirection on thetrunk, andproximal-distaldirection on thelimbs, supine orlateral position.KS: flexion andextension of thelimbs.Conducted byresearcher.

1) Daily WG2) Length ofhospitalization3) Behavioralevaluation: adaptedfrom the Manual forthe NaturalisticObservation ofNewborn Behavior(Pre-term andFull-term)

Body weight takenwith normalnursery routine.

Not described.Cites someinternal eventsinherent to thenursery that caninterfere withbehavioralresponses, suchas time after thelast feeding,sleep, pain,noise, light, andtemperature.

3) TG: Greater % timewith:Regular respiration(p = 0.002)State active warning(p = 0.036)Postures mixed(p = 0.013)Balanced tone(p < 0.001)TG: Higher number ofmovements handside, suction, grip andsupport (p = 0.013),more coordinatedmovements and morefrequent (p < 0.001)CG: More frequentextensor posture(p = 0.001) andhypotonia (p < 0.001)

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Table 1 (Continued)

Title/Author/Year/Database

Sample Size Objectives andstarting conditions

Description of thetechnique

Main variables Measured weightgain

Description ofadverse eventsduring theprocedure

Results achievedstatistical significance

A randomizedplacebo-controlledtrial of massagetherapy on theimmune system ofpreterm infants32

Ang et al., 2012PubMed searches 1,4

Total: 120TG: 58GAM = 30 wBWM = 1389 gCG: 62GAM = 30 wBWM = 1286 gRandomized

To investigate theeffects of MT on theimmune system of PI.Beginning whenclinically stable.

T/KS: 15 min, 3x/day,at the beginning ofthree consecutivehours, behind twowide screens, for aminimum of five daysand maximum of fourweeks or untilhospital discharge.CG: nurse remainedbehind the two widescreens the sameamount of time.

1) Immunologicevaluation (absoluteNK cells, T and Bcells, T cell subsets,and NK cytotoxicity2) WG3) Number ofinfections4) Length of hospitalstay

Not described Not described 1) TG: NK cytotoxicityhigher (p = 0.05)2) TG: Greater dailyWG (p = 0.01) andhigher final weight(p = 0.05)

Massage improvesgrowth quality bydecreasing body fatdeposition in malepreterm infants37

Moyer-Mileur et al.,2013PubMed searches 1,4

Total: 44TG: 22GAM = 31.4 wBWM = 1574 gCG: 22GAM = 31 wBWM = 1618 gRandomized

To assess the effect ofMT on WG and bodyfat deposition in PI.Beginning whentolerating enteralfeeding vol-umes > 100 mL/kg/day.

20 min 2x/day at 7am and 7 pm, 6days/week (exceptSunday), performedbehind a privacyscreen by a licensedmassage therapist.The MT was modeledafter the InfantMassage USA protocoland modified for PI byeliminating massageof the abdomen.

1) WG2) Length of hospitalstay3) Ponderal index4) Bodycircumferences5) Skinfold thickness6) Insulin-like growthfactor I, leptin,adiponectin levels7) Daily dietary intake

Body weight on anelectronic infantscale (Air shields-vickers®, Ohio,USA) was recordedto the nearestgram.

All massagetherapists weretrained torecognizeclinical signs ofdistress.

3) TG: Male infantshad smaller ponderalindex5)TG: Male infantshad triceps,subscapular, andmid-thigh skinfoldthickness increases(p < 0.05)TG: Female hadlarger subscapular(p < 0.05)6) Circulatingadiponectin increasedover time in GC maleinfants (p < 0.01) andwas correlated toponderal index(p < 0.01)

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Table 1 (Continued)

Title/Author/Year/Database

Sample Size Objectives andstarting conditions

Description of thetechnique

Main variables Measured weightgain

Description ofadverse eventsduring theprocedure

Results achievedstatistical significance

Effect of oil massageon growth inpreterm neonatesless than 1800 g: arandomized controltrial34

Kumar et al., 2013

PubMed searches 1,4

Total: 48TG: 25GAM = 32.9 wBWM = 1466.6 gCG: 23GAM = 32.6 wBWM = 1416.6 gRandomized

To study the effect ofoil massage on growthin preterm babies lessthan 1800 g.Beginning < 48 h ofage and on at least100 mL/kg/d of feedoral or tube feed.

10 min, 4x/day, 4 wmassage was carriedout first over bothshoulders startingfrom the neck withthe baby in proneposition. Then it wascarried out from theupper back to thewaist. Each of thetwo upper and lowerlimbs was separatelymassaged in thesupine position.Twenty gentle strokesin each area.Massage was providedwith 2.5 mL/kg(10 mL/kg/day) ofsunflower oil, byresearcher or mother(if discharged before4 w)

1) WG after 28 days

2) Length and headcircumference after28 days

3) Loss of weightafter 7 days

4) Difference inserum triglyceridelevels after 28 days

Were measuredusing standardtechniques, atenrollment andthen weekly fornext 4 weeks.

Not described 1) TG: Greater WGover 28 days (p < 0.05)

3) TG: Less weightloss after 7 days(p = 0.003)

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Table 1 (Continued)

Title/Author/Year/Database

Sample Size Objectives andstarting conditions

Description of thetechnique

Main variables Measured weightgain

Description ofadverse eventsduring theprocedure

Results achievedstatistical significance

The efficacy ofmassage on shortand long termoutcomes inpreterm infants35

Abdallah et al.,2013

PubMed searches 1,3, 4

Total: 66TG: 32GAM = 32.2 wBWM = 1747 gCG: 34GAM = 32.6wBWM = 1684 g

The first 34 infantswere assigned forthe CG and then32 for the TG

To assess the shortand long termbenefits of MT onstable PI.

TS, without KS, for10 min, for at least 10days, 1x/day,performed by trainedmothers, using 2 mLof olive oil (6 drops).

1) PIPP after MT2) PIPP at discharge3) Cognitive score(Bayley scales)4) WG5) Length of stay6) Breastfeedingduration7) Motor score(Bayley scales)

Not described The infant’sreaction to TSwas monitoredby a researchassistant for anyadverse physicalor behavioralsigns, Sat O2,HR, and RR. Atany sign ofphysiologicdistress (HRgreater than 200bpm or Sat O2

less than 95%),massage wasdiscontinued for15 s, or until areturn tobaseline levelsthen resumed.None of theinfantsexperienced anyof the abovesigns.

1) Lower scores onthe PIPP after MT(p = 0.041)2) Lower PIPP scoreson discharge(p = 0.011)3) Higher cognitivescores of TG at 12months corrected age(p = 0.004)

TS, tactile stimulation; T/KS, tactile and kinesthetic stimulation; KS, kinesthetic stimulation; HR, heart rate; RR, respiratory rate; BW, birth weight; BWM, birth weight-mean; GAM,gestational age-mean; GA, gestational age; NICU, Neonatal intensive care unit; MT, massage therapy; prof, professional; VA, vagal activity; GM, gastric motility; ECGs, electrocardiograms;EGGs-electrogastrograms; OS, oral stimulation; PIPP, Premature infant pain profile.

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Tactile kinesthetic stimulation in preterm infants

Discussion

Tactile stimulation has the advantages of being noninvasive,inexpensive, and safe, as was demonstrated by Livingstonet al. 38 based on physiological stability and no change inagitation/pain scores of the infants receiving massage. Themajority of the clinical trials studied herein (20 of the 31studies)3,10,14,15,17---19,21---32,34 described a significantly benefiton weight gain in the PI group that received the TS/TKS.This information places TS as a promising adjunctive tool inaddressing PI in the NICU. Some of the studies did not assessthe data statistically; part of them justified this because ofsmall sample size.6---8

Some correlations have been suggested to justify thefaster weight gain of PI submitted to TKS, such asgreater vagal stimulation and gastric activity,28,29 relation-ship with energy intake,3,10,15,17,22---31,39 sleep-wake behaviorand behavioral scales,6---8,10,14,19---27,36,39 serum insulin and IGF-1 levels,30,37 and use of oil.33,40,41 The results found by Diegoet al. 28 and Field et al. 42 on the effects of mild andmoderate pressure showed that moderate pressure providedgreater vagal stimulation. Diego et al. 29 also found greatergastric motility among the PI who were stimulated with mod-erate pressure and suggested that greater gastric activitymay explain their faster weight gain. Field et al. 42 addedthat the group of PI stimulated with moderate pressure weremore relaxed, characterized by their lower heart rates andby the assessment of their wake and sleep status, and behav-ior, as recommended by the Thomas Scale of 1975.21 Theythen suggested that the more relaxed state of the PI resultedin lower energy expenditure, which would then result infaster weight gain. This was confirmed by Lahat et al.,43

who used indirect calorimetry to show that a group of PIsubmitted to stimulation had lower energy expenditure.

Regarding energy intake, some studies have shownthat stimulated infants have higher daily weightgain.10,17,22,23,25---28,31,32,39 Other studies recorded stool-ing frequency and found that it increased significantly,together with an increased formula intake on days 6-10.9

Rausch9 suggested that increased stooling was a conse-quence of higher formula intake. On the other hand, Scafidiet al. 23 found that the frequency of stooling decreased,even when daily weight gain increased. White Labarba3

reported that the amount of formula consumed per feedingincreased while the number of daily feedings decreased,which the authors attributed to the nursery routine: PI whodid not consume the entire serving were fed more often.Other studies that reported faster weight gain did not findsignificant differences in energy intake.

Along with weight gain, other variables, somementioned above, have been analyzed after appli-cation of TKS in premature. All of the followingparameters were analyzed by clinical studies in PIwho received TS/MT whether or not associated withKS during their NICU stay: weight gain;3,6---10,14---37,39

length of hospital stay;10,16,17,20,21,23,24,28,31,32,35,37,39

behavioral responses;6---8,10,14,19---23,25,26,36,39 sleep/wakestage;10,21,23,24,26,27 stress behavior;11 energy expenditure;43

body temperature;3,6,21,23---26,44 variations in stimulationpressure;42 use or non-use of oil;33,40,41 speed of brainmaturation;38 vagal activity and gastric motility;28,29 seruminsulin and growth factor I levels;30,37 late-onset sepsis;16

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ody fat deposition;37 effect on the immune system;32 andone formation.45 The studies had very similar objectives;hat is, to identify the effects of TKS on these parametersnd the possible causes of its benefits.

Some studies using only KS obtained results not only inreater weight gain but also in bone mineralization.46---48

s for TKS with or without KS for bone weight gain ana-yzed herein, they found that there was no ideal levelf stimulation47 or optimal duration, frequency, and typef exercise for bone development.49 Further evaluation ofhis intervention (KS) was suggested to indicate for thisurpose.50 A more recent study demonstrated a signifi-ant improvement in bone formation and decrease of boneesorption, using a more rigorous methodological design.48

A few studies have described the adverse situationshat could occur during the procedure and the parame-ers that should encourage the therapist to interrupt theession.14,18,19,26,33 Certain signs during the application ofhe TKS, such as stress or uninterrupted crying for morehan 60 seconds,26 defecation or urination,14 increased heartate,19,27 or heart rate < 100 for 12 seconds and desaturationor more than 30 seconds,19 were some of the causes that ledhe therapists to interrupt the procedure or discontinue thetudy. Some therapists considered some signs in the 24 hourshat preceded the intervention to suspend the procedure,uch as fussing, vomiting, growing oxygen demand, frequentpisodes of apnea, bradycardia, desaturation, or interven-ions conducted within the 30 minutes that preceded TKS,uch as sight and hearing tests.18 Arora et al. 33 separatedhe adverse situations into temporary interruption and minorroblems that neither affected feeding nor required anynterruption in the trial.

Despite the information above, the majority of the stud-es did not mention adverse events and/or did not describe

course of action to deal with adverse events during thentervention. The studies that reported the occurrence ofvents that required the interruption of the procedure didot indicate how the procedure was resumed; for example,hether it was resumed from the start of the massage rou-

ine or whether it was continued from where it had stopped;lso, they did not indicate whether the procedure should beesumed on the same day or on the next day, or whetherhese interruptions could affect weight gain. The clinicalrials studied by this review made a relevant contributiono the scope of TS. Nevertheless, adding detailed dataighlighted by this review, such as adverse events, wouldmprove methodology and reliability for future studies.

imitations

his systematic review was performed using two databases,n addition to checking the bibliographic articles of thosehat met the inclusion criteria; however, the possibility ofot having included an article relevant to the topic thatould have been found in other databases cannot be ruledut.

onclusion

ssessment of the methodology of the studies reviewederein showed that there is no standard for application of

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S technique or recommended course of action if adversevents occur during the procedure. The effect of thesedverse events that can occur during the TKS procedure maynfluence the results.

Generally, some kind of benefit associated with TKS,uch as faster weight gain, shorter hospital stay, and bet-er behavior, among others, was reported by all studies thatsed TS or TKS in PI. Nurseries have many stressors and TKSas been shown to be helpful in this context. Therefore,KS should be considered as a possible therapy to be associ-ted with the standard medical treatment. Even discreteains in this population can result in long-term benefits.uture studies may raise the level of methodological rigornd describe the adverse events that can occur during therocedure. This may permit other researchers to be moreware of expect outcomes, and a standard TKS techniqueould be established.

onflicts of interest

he authors declare no conflicts of interest.

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