Infant Behavior & Development 29 (2006) 476–480

Brief report

Mothers’ depressed mood and anxiety levels are reducedafter massaging their preterm infants

Larissa Feijo a,b, Maria Hernandez-Reif a,∗, Tiffany Field a,c,William Burns b, Sarah Valley-Gray b, Edward Simco b

a Touch Research Institutes, University of Miami School of Medicine, USAb Nova Southeastern University, USAc Fielding Graduate University, USA

Received 7 November 2005; received in revised form 10 February 2006; accepted 21 February 2006

Abstract

Forty mothers whose preterm infants were about to be discharged from the Neonatal Intermediate Care Nursery (NICU) wererandomly assigned to two groups: the first group of mothers conducted preterm infant massage and the second group only observedtheir preterm infants receiving massage. Both groups of mothers had lower depressed mood scores following the session. However,only the group who massaged their infants had lower anxiety scores after the session.© 2006 Elsevier Inc. All rights reserved.

Keywords: Preterm infants; Mothers; Massage; Depression; Anxiety

Maternal depression and anxiety are of special concern because of their adverse effects on infant development(see Field, 2002a; Pierrehumbert, Nicole, Muller-Nix, Forcada-Guex, & Ansermet, 2003). Mothers of preterm infantsreport feeling anxious and depressed at the time of their infants’ hospital discharge (Doering, Moser, & Dracup, 2000;Zanardo, Freato, & Zacchello, 2003). Thus, interventions that ameliorate depressed and anxious maternal mood wouldbenefit both the mother and the infant.

Previous studies have reported numerous benefits for adults from massaging infants, including improved mood. Inone study, elderly depressed individuals who massaged infants at a nursery school for 3 weeks showed a reduction indepressed mood and anxiety scores and lower cortisol levels (Field, Hernandez-Reif, Quintino, Schanberg, & Kuhn,1998). In another study, mothers who massaged their preterm infants reported less depressed mood and had improvedmother-infant interactions at 3 months post-birth (Goldstein-Ferber et al., 2005). In a third study, mothers who massagedtheir preterm infants reported feeling closer to their infants, less fearful of handling and touching them and less guiltyabout their infants’ preterm status (Feijo & Piccinini, 1998). Similar results have also been reported for postnatallydepressed mothers of full-term infants, including reduced depressed mood and improved mother–infant interactionsafter learning infant massage (Onozawa, Glover, Adams, Modi, & Kumar, 2001). Massage has also been shown tobenefit preterm infants, including greater weight gain, earlier hospital discharge and greater gastric motility (Diego,

∗ Corresponding author at: Touch Research Institutes, Department of Pediatrics, University of Miami School of Medicine, P.O. Box 016820(D-820), Miami, FL 33101, USA. Tel.: +1 305 243 6781; fax: +1 305 243 6488.

E-mail address: mhernan4@med.miami.edu (M. Hernandez-Reif).

0163-6383/$ – see front matter © 2006 Elsevier Inc. All rights reserved.doi:10.1016/j.infbeh.2006.02.003

L. Feijo et al. / Infant Behavior & Development 29 (2006) 476–480 477

Field, & Hernandez-Reif, 2005; Field, 2002b; Field, Hernandez-Reif, & Freedman, 2004) and for full-term infants,massage improves orientation and sleep and reduces excitability (Field, Hernandez-Reif, Diego et al., 2004). Takentogether, these studies highlight the bidirectional effects of giving and receiving infant massage for both the motherand the infant.

The current study validates and extends previous research on the benefits of performing infant massage with thefocus on mothers whose infants were born preterm and were about to be discharged from the hospital. Based on theliterature, the mothers were expected to be experiencing depressed symptoms and/or anxiety. One objective of the studywas to assess preterm infant massage as an intervention for improving maternal mood. Another aim was to examineif the mothers’ improvement was associated with the physical act of massaging her infant. Mothers of preterm infantswere assigned to either “observe” their preterm infant receive a massage or to “perform” the massage on their preterminfants. The mothers assigned to perform the preterm infant massage were expected to show a greater reduction in theirdepressed mood and anxiety scores.

1. Method

1.1. Participants

The participants were 40 mothers and their preterm infants (23 boys and 17 girls) who were scheduled for dischargefrom a Neonatal Intermediate Care Nursery (NICU) at a University Hospital. Mothers of preterm infants visiting thenursery were referred by the preterm infants’ attending physician, who was aware of the study criteria. The motherswere approached and informed about the study and asked to sign an informed consent. Subsequently, the motherswere interviewed for background information and their preterm infants’ medical charts were reviewed for study entrycriteria (born <37 weeks gestation, medically stable, scheduled to be discharged within 24 h). All of the mothers whosigned consent form and their infants met the study criteria, and thus none had to be removed from the study. Themothers were randomly assigned to one of the two groups: Performing the Infant Massage (n = 20) or Observing theInfant Massage (n = 20).

On average, the preterm infants had been hosptialized for 54 days (S.D. = 39 days). The two groups did not differ onnumber of days in the NICU (p > .10). The mothers assigned to “performing” infant massage versus “observing” infantmassage did not differ on maternal age (29 years versus 29 years old, respectively), ethnicity (Caucasian: 10% versus15%; Black: 30% versus 25%; Hispanic: 45% versus 50%; Other: 15% versus 10%, respectively), education (13.5years versus 13.3 years, respectively) or socioeconomic status (3.3 versus 3.4, respectively, on the Hollingshead). Thepreterm infants assigned to the performing massage versus the observing massage group were comparable on gender(males: 60% versus 55%, respectively) and gestational age at birth (28 weeks versus 30 weeks gestation, respectively).

1.2. Procedure

A researcher trained on preterm infant massage met the mother at the preterm infant’s bedside at an appointed time,explained the group assignment and then asked the mother to complete baseline anxiety (STAI) and depressed mood(POMS) questionnaires prior to the massage session. After the massage session, the same researcher asked the motherto again complete the brief anxiety and mood scales and answer questions related to the infant massage session.

1.3. Assessments

The State Anxiety Inventory (Spielberger, Gorsuch, Lushene, Vagg, & Jacobs, 1970) was used to assess the mothers’anxiety levels before and after the massge session. This 20-question inventory is scored on a 4-point Likert scale withscores ranging from 20 to 80 (higher scores indicating greater anxiety). The State Anxiety Inventory is comprised ofitems on how the subject “feels right now.” Characteristic items include statements such as “I feel calm” and “I feelsecure.” The State Anxiety Inventory has adequate concurrent validity and internal consistency (r = .83).

The Profile of Mood States (POMS) Depression Subscale (McNair, Lorr, & Droppleman, 1992) was used to assessthe mothers’ depressed mood before and after the massage session. The POMS Depression Subscale consists of 15items rated on a 5-point Likert scale ranging from (0) “not at all” to (4) “extremely.” Characteristic items include “blue,”“hopeless,” and “sad.” The scale has adequate concurrent validity (r = .95; McNair, Lorr, & Droppleman, 1992).

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The Infant Massage Questionnaire was designed for this study and contained one pre-massage question (“Howrelaxed do you feel right now?”) and five post-massage questions as follows: (1) present relaxed feelings; (2) how wellthe mother felt she learned the massage; (3) the effectiveness of the massage; (4) whether the mother felt the babyenjoyed the massage; and (5) whether the mother enjoyed watching the massage. Mothers assigned to perform themassage were also asked to rate whether they enjoyed massaging their preterm infants. The mothers responded to thequestions using a Likert scale format from 0 (not at all) to 1 (somewhat) to 2 (moderately) to 3 (very much).

1.4. Infant Massage groups

1.4.1. Performing the Infant Massage: Group 1Mothers assigned to this group observed their preterm infant receive a massage by a researcher and were then asked

to imitate the infant massage techniques on their preterm infants. Specifically, the 8-min massage session consistedof two identical standardized 4-min segments without removing the infant from the bassinet. The first 4 min involvedthe researcher demonstrating the massage and for the second 4 min, the mother perfomed the massage. The researcherwarmed her hands by rubbing them together. Using the palms of her hands, and with the infant in a prone position,she firmly stroked with moderate pressure for four 1-min periods (12 strokes at approximately 5 s per stroking motion)the infant’s head and the back in the following sequence: (1) from the top of the head to the neck and back to the topof the head; and (2) from the upper back to the waist and back to the upper back. The mother then repeated the samemoderate pressure stroking procedure modeled by the researcher.

1.4.2. Observing the Infant Massage: Group 2 (control)The duration of the massage session for this group was identical to that of the Performing the Infant Massage group.

However, the mothers in this group merely observed while the researcher demonstrated the preterm infant massage for8 min (two repetitions of the 4-min massage).

2. Results

2.1. Background data and infant medical chart data

The mothers’ and infants’ background data were analyzed via chi-square and t-tests between groups. No groupdifferences were observed on these variables (see Section 1.1).

2.2. Self-report measures

Repeated measures ANOVAs were conducted on the anxiety (STAI) and depressed mood (POMS) scores with Time(pre- and post-massage) as the repeated measure and Group (Performing Massage versus Observing Massage) as thebetween groups variable to determine the effects of massaging versus observing massage on maternal anxiety andmood. A significant Time by Group interaction effect was noted for the anxiety measure (STAI), F(1, 38) = 10.36,p < .01, indicating that only the mothers who conducted the preterm infant massage reported decreased anxiety. Asignificant main effect of Time was noted for the depressed mood scale (POMS), F(1, 38) = 13.51, p < .001, indicatingthat both groups experienced a decrease in depressed mood (see Table 1). No group differences were found on theInfant Massage Questionnaire.

3. Discussion

Mothers of preterm infants have reported being anxious and depressed at the time of their infants’ hospital discharge(Doering et al., 2000; Zanardo et al., 2003). The results of this study suggest that “observing” their preterm infantreceive a massage as well as “performing” a massage on their preterm infant reduces the mothers’ depressed symptoms.One reason for this might be that mothers perceived their infants as benefiting from the massage, inasmuch as bothgroups rated their infants as enjoying the massage on the Infant Massage Questionnaire. The pivotal finding, however,was that only the mothers who massaged their preterm infants reported both reduced depression and reduced anxiety.This may have derived from the physical act of massaging their preterm infants or feeling less helpless (Franck, Cox,

L. Feijo et al. / Infant Behavior & Development 29 (2006) 476–480 479

Table 1Means (and standard deviations in parentheses) for the Conducting Massage versus Observing Massage groups on Maternal Mood scales

Variables Massage groups

Conducting Observing

Pre Post Pre Post

Maternal distressSTAI (anxiety) 32.9 (7.3)a 27.9 (7.1)b 34.9 (7.4)a 33.7 (7.2)a

POMS (depressed mood) 2.4 (3.0)a 1.0 (2.1)b 2.5 (2.9)a .9 (1.8)b

Note: Different letter subscripts indicate means that differ at p < .05.

Allen, & Winter, 2004), similar to the reduced anxiety reported by parents who have been used as massage therapists inother studies involving children with chronic problems like diabetes (Field et al., 1997), cystic fibrosis (Hernandez-Reifet al., 1999) and sleep problems (Field & Hernandez-Reif, 2001).

In sum, the findings from this study support the use of preterm infant massage as an intervention for reducingdepressed mood and anxiety in mothers of preterm infants prior to the infants’ hospital discharge. Infant massagehas been reported to facilitate growth and development in preterm infants (Field, Hernandez-Reif, & Freedman,2004). The bidirectional effects of “giving” and “receiving” massage support its use as a safe and cost-effectiveintervention for mothers and their infants. Future studies may focus on bidirectional massage effects for fathers ofpreterm infants.

Acknowledgments

We thank the mothers and infants who participated in this study. We also thank Karla Gil, Yanexy Vera and WendyCisneros for their assistance with recruitment and data collection. This research was supported by an NIMH SeniorResearch Scientist Award (#MH00331) and an NIMH Merit Award (#MH46586) to Tiffany Field, an NIH/NCCAMgrant (AT 000370) to Maria Hernandez-Reif and funding from Johnson & Johnson Pediatric Institute to the TouchResearch Institutes.

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