The Effects of Massage on Brain Maturation

Using an EEG as an objective way to measure brain function, previous research has established that preterm infants have an altered neurodevelopmental trajectory compared to term infants. However, research has also found that positive tactile experiences such as skin-to-skin holding, maternal touch, and infant massage can increase brain activity and maturation. This randomized controlled trial (RCT) aimed to investigate the effects of a maternally administered massage on brain maturation.

This Australian based team studied 45 preterm infants born 28 to 32+6 weeks GA, with no congenital anomalies or IVH over grade I, who were randomly assigned to an experimental group (maternal massage) or a standard care group (no massage). Mothers provided massage to their infants 2x/day for 15 minutes from 34 to 40 weeks. Between 39-42 weeks an EEG was performed during sleep to record and calculate the global relative power. Researchers found the massage group had significantly higher alpha central relative power compared to standard care group (p=0.03). This finding was also dose dependent, with infants demonstrating more brain maturation across all EEG bands with higher doses of massage.

This study is a great reinforcement of the importance of parental provided positive tactile experiences. Teaching massage to parents in the NICU can foster brain maturation and empower parents that they can help to improve their baby’s neurodevelopment!

Lai, M., D’Acunto, G., Guzzetta, A., Finnigan, S., Ngenda, N., Ware, R., Boyd, R., & Colditz, P. (2022). Infant massage and brain maturation measured using EEG: A randomized controlled trial. Early Human Development, 172, 105632. https://doi.org/10.1016/J.earlhumdev.2022.105632

All Care is Brain Care: Neuro-Focused Quality Improvement in the Neonatal Intensive Care Unit

Vast improvements have been made to decrease mortality in the NICU, however, the rates of neurodevelopmental impairments have remained stagnant.  In the NICU, brain development and maturation are impacted by the following factors:

  • Prenatal Factors: Infection, Drugs, IUGR
  • Sensory: Over or under stimulation, changes in mobility, pain
  • Brain Damage: HIE, IVH, inflammation
  • Neonatal Factors: PDA, BPD, hemodynamic instability, altered nutrition, drugs
  • Family: Parental separation, impaired bonding, anxiety, depression

While all care in the NICU has the potential to be harmful, care can also be neuroprotective and improve outcomes—if protocols, standardized care, and care bundles are utilized. Authors outlined 3 main areas, including Best Practices and Potentially Better Practices to help mitigate the negative impact of the NICU on neurodevelopment and long-term outcomes.

The 3 Pillars: Prevent Injury, Protect, Promote

I. Prevention of Acquired Injury

  • Best Practices
    • Antenatal steroids have shown a decrease in IVH
    • Antenatal magnesium reduces CP by reducing apoptosis and inflammation
    • Delayed cord clamping eases the transition to extrauterine life by preventing dramatic changes in VS, reducing mortality and IVH
    • Therapeutic hypothermia at the targeted temperature with early identification and referral by 6 hours of age improves outcomes
  • Potentially Better Practices
    • IVH and Golden Hour Bundles are effective in QI projects to reduce IVH, focusing especially on the first 72 hours of life
      • Optimize care during this time by maintaining a normal temperature, effectively ventilate, normalize CO2 and PO2, and start TPN in a timely manner
      • Gentle ventilation, slow blood draws and IV boluses, increased HOB, avoid elevating the legs, and head in midline
      • Minimize handling, skin-to-skin, 2-person care
    • Seizure management bundles may reduce the seizures and prevent further brain injury

II. Protection of Normal Brain Maturation and Development

  • Best Practices
    • Provide Skin-to-Skin Holding– Proven benefits even for unstable or ELBW infants and families, decreases mortality rates
    • Decrease Opiate Use – Untreated pain alters brain structure, but opiate use can lead to poor neurodevelopmental outcomes. Create standards of practice, identify and prevent pain, utilize non-pharmacologic methods.
    • Minimize noxious interventions – Limit procedures and skin breaks to protect the thalamus, and white and gray matter
  • Potentially Better Practices
    • Infant Driven Feeding – Supports normal feeding progression with decreased length of stay

III. Promotion of Positive Environment

  • Best Practices
    • Promote Families as Partners – Intentionally acknowledge the families as a critical part of the care team to improve short-term and long-term outcomes, during the NICU stay and beyond.
    • Refer to Early Intervention – Early and continued developmental monitoring, referrals and therapy improve outcomes with a smoother transition to home.
  • Potentially Better Practices
    • Utilize NIDCAP – Standardized approach for assessment, stimulation and developmental support, shown to decrease length of stay.
    • Utilize SENSE – Dose-specific positive sensory experiences to offset negative experiences, with parents as the center of care and shown to improve language skills.

Use this article for changes in care practices to improve the neurodevelopmental outcomes of the infant’s in your NICU!

Liebowitz, M., Kramer, K., & Rogers, E. (2023). All care is brain care: Neuro-focused quality improvement in the neonatal intensive care unit. Clinics Perinatology, 50(2), 399-420.  https://doi.org/10.1016/j.clp.2023.01.004

Hypothermia at Admission

Study: The Department of Pediatrics in a Level III NICU in Korea studied the short- and long-term effects of hypothermia on ELBW infants.  Hypothermia may increase respiratory distress, PPHN, increase oxygen consumption, metabolic acidosis and hypoglycemia leading to hemodynamic instability.

Subjects: 208 ELBW infants with a weight of 400-999g between 2012-2017 were studied with clinical data collected retrospectively.  Infants who were transported to this center or with major congenital anomalies were excluded.

Methods: A standardized approach to delivery was maintained with an admission room temp, radiant warmer, cap and plastic bag applied to all ELBW infants.  Admission axillary temperatures were recorded upon admission to the NICU and classified as moderate hypothermia (32.0-35.9°C), mild hypothermia (36.0-36.4°C) and normothermia (36.5-37.5°C).

Outcomes: Short-term outcomes were identified as mortality before discharge, hemodynamically significant PDA requiring treatment, moderate to severe BPD, grade III or IV IVH, and NEC.  Long-term outcomes were assessed utilizing the Bayley Scale II at 18-24 months corrected age (abnormal results were a PDA or MDI <70), and the incidence of blindness, deafness, and CP were evaluated.

The median admission temperature was 36.1°C, with 0.6% normothermic, 61.5% with mild hypothermia, 32.3% with moderate hypothermia, and no infants with severe hypothermia.

In short-term outcomes, only a hemodynamically significant PDA was statistically significant.  All other short-term variables were not significantly associated with lower admission temperatures.

In long-term outcomes, a motor delay (MDI) was significant at 18-24 months corrected age, but all other variables did not show a significant correlation with lower admission temperatures.

Conclusion: The incidence of a hemodynamically significant PDA and lower Bayley motor scores at 18-24 months corrected age shows that moderate hypothermia at admission has short-term and long-term consequences.  Although the other short and long-term outcome variables were more prevalent in hypothermic infants, the outcomes were not statistically significant.

Does all of your NICU team understand the short- and long-term implications of hypothermia? What can you do to educate your team or modify your team’s care practices to minimize these adverse outcomes? 

Kim, S. H., Hwang, J. H., Jeong, J., Lee, J. M., Lee, H. N., Park, S. H., Lee, B. S., & Jung, E. (2023). Association of moderate hypothermia at admission with short-term and long-term outcomes in extremely low birth weight infants. Neonatal Medicine, 301(2),28-33. https://doi.org/10.5385/nm.2023.30.2.28

Know Better. Do Better.

If you are intentional each moment in the NICU with the knowledge that ALL CARE is BRAIN CARE, you will change HOW you do what you do and make a huge difference in the lives of infants and families. From ensuring neuroprotection through appropriate thermoregulation, environmental adaptation, cord clamping, positioning and handling, flushing slowly, to neuropromotion through neonatal massage, skin-to-skin holding, non-pharmacological pain management and parent engagement, you can reduce brain injuries and maximize developmental outcomes.

Want to advance your knowledge and skills in this area? Join our Neonatal Touch & Massage Certification (NTMC) Family! ALL of NTMC is BRAIN CARE! You’ll learn valuable skills in positioning, handling, 2-person care, skin-to-skin transfers, neonatal massage, swaddled bathing, non-pharmacological care, parent education and much more! 

We hope you use these CTC Newsletter article reviews to change your daily practice, advocate for practice changes in your unit, further your knowledge through NTMC or other CTC Education opportunities and support parents in the care of their infants! Together we can make a difference in the lives of infants and their families.

Your Friends in Neonatal Care,

The NTMC Team