Effects of Tactile-Kinesthetic Stimulation in Preterms: A Controlled Trial

Sheila Mathai, Armida Fernandez, Jayshree Mondkar and Wasundhara Kanbur

From the Department of Neonatology, Lokmanya Tilak Municipal Medical College and General Hospital,
Sion, Mumbai, India.
Indian Pediatrics 2001; 38: 1091-1098

Correspondence to: Dr. S.S. Mathai, 50, Gangotri, Near Afghan Church, Colaba, Mumbai
400 005, India. Email: ssmathai@vsnl.net
Manuscript received: February 15, 2001, Initial review completed: April 18, 2001,
Revision accepted: June 6, 2001.
Background: To determine the effects of tactile-kinesthetic stimulation to preterms on
physiologic parameters, physical growth and behavioral development. Design: Controlled
trial. Setting: The premature unit (growing nursery) of a large, teaching hospital. Subjects:
48 well preterms with birth weights between 1000-2000 grams. Intervention: The neonates
were systematically allocated into test and control groups. Test babies received tactilekinesthetic stimulation in the form of a structured baby massage from day 3 to term
corrected age. They were observed for changes in vital parameters (heart rate, respiration,
temperature and oxygen saturation) during the first few days of stimulation in hospital.
Thereafter, massage was continued at home. Changes in weight, length and head
circumference and neuro-behavior (Brazelton Neuro-Behavioral Assessment Scale) were
assessed in both groups before, during and after the study period. Results: An increase in
heart rate (within physiologic range) was seen in the test group during stimulation. This
group also showed a weight gain of 4.24 g/day more than controls, which was statistically
significant. On the Brazelton Scale the test group showed statistically significant improved
scores on the orientation, range of state, regulation of state and autonomic stability
clusters at follow-up. No significant complications were noted. A positive correlation was
found between the duration of stimulation in days and the weight gain in grams but this did
not reach statistical significance. Conclusions: Tactile-kinesthetic stimulation when
administered to well, preterm infants has a beneficial effect on growth and behavioral
development with no adverse effects on physiologic parameters.
Key words: Preterms, Massage, Tactile-kinesthetic stimulation.
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 tactilekinesthetic 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) 32 weeks; (c) Apgar score 7 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 simultaneously; 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 32-33 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 32-34C, 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 clothtape 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 32-34C. 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 ttest. Pearsons 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

Parameter
Test (n=25)
Control (n=25)
Before
After
Before
After
p
p
stimulation stimulation
observation observation
Heart rate

129.96

133.24

(per min)
Respiratory
rate
(per min)

(5.61)

(6.1)

37.52

37.08

(6.55)

Temperature

36.43

<0.005 132.75

132.17

(5.92)

(4.39)

NS

35.08

35.88

(6.43)

(4.04)

(2.90)

36.40

NS

36.39

(0.34)

(0.26)

NS

95.33

(1.86)

(1.63)

(C)
(0.29)
(0.31)
Oxygen
96.16
95.52
saturation
(%)
(1.55)
(1.45)
Value are as averages (standard deviation).
NS = Not significant

Table II - Comparison of BNBAS sector in test and controls

Parameter
Test
Control

36.34

94.83

P value

NS
NS

NS

NS

BI (before study)
(n=25)
Habituation
7.50 (1.25)
Orientation
3.14 (0.63)
Motor
3.18 (0.47)
Range of state
2.60 (0.52)
Regulation of state 2.71 (0.50)
Automatic stability 2.70 (0.40)
Reflexes
6.88 (1.09)
Interactive
2.34 (0.55)
BII (7-10 days)
(n=25)
Habituation
7.01 (1.22)
Orientation
4.05 (0.71)
Motor
3.48 (0.77)
Range of state
3.24 (0.67)
Regulation of state 3.42 (0.66)
Automatic stability 3.31 (0.54)
Reflexes
5.28 (1.2)
Interactive
3.00 (0.94)
BIII (40-42 weeks) (n=16)
Habituation
5.80 (1.28)
Orientation
5.14 (0.57)
Motor
4.94 (0.78)
Range of state
4.66 (0.62)
Regulation of state 4.67 (0.52)
Automatic stability 4.91 (0.70)
Reflexes
2.38 (0.62)
Interactive
4.03 (0.59)
Value are as averages (standard deviation).
NS = Not significant.

(n=23)
7.77 (0.62)
2.8 (5.2)
3.17 (0.46)
2.85 (0.50)
2.72 (0.44)
2.76 (0.26)
7.48 (1.81)
2.25 (0.42)
(n=23)
7.44 (0.98)
3.75 (0.48)
3.52 (0.28)
3.27 (0.48)
2.99 (0.40)
2.94 (0.46)
5.83 (1.52)
2.70 (0.43)
(n=17)
5.35 (1.02)
4.25 (0.40)
4.57 (0.60)
3.79 (0.50)
4.00 (0.38)
3.77 (0.63)
2.67 (0.49)
3.75 (0.46)

NS (0.39)
NS (0.17)
NS (0.48)
NS (0.054)
NS (0.47)
NS (0.28)
NS (0.08)
NS (0.29)
NS (0.18)
NS (0.07)
NS (0.42)
NS (0.41)
<.05 (0.005)
<.005 (0.001)
NS (0.08)
NS (0.07)
NS (0.15)
<0.001 (0.0004)
NS (0.06)
<0.005 (0.005)
<0.005 (0.001)
<0.005 (0.001)
NS (0.07)
NS (0.06)

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 parents availability during the infants 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
Competing interests: None declared.

Key Messages
Tactile-kinesthetic stimulation given in the form of a structured baby massage has
no adverse effects on well, preterm infants.
Tactile-kinesthetic stimulation may positively impact short-term growth and
neuro- behavior in preterms.
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