Watch, listen and learn – your baby is your teacher!

Positive, nurturing touch is important in the Neonatal Intensive Care Unit (NICU) as premature babies often experience negative, painful touch by way of medical treatments. For an infant to interact socially, they must first be able to control their autonomic motor and behavioural state systems. Tactile support such as nurturing touch can help your baby to settle. Factors such as the environment, type and level of procedures along with the infants maturity will affect their ability to cope with stimulation. Environment can include noise from equipment, monitor alarms and other babies crying. The overall aim of positive, nurturing touch in the NICU is to reduce tactile sensitivity, to encourage bonding and attachment, to provide a pleasurable positive touch experience, to facilitate a positive interaction between parent and child, and to encourage an improved range of motion and relaxation for baby.

Parents and caregivers would ideally benefit in having an increased awareness and knowledge of their baby’s body language, or cues as it is otherwise known. It is important for parents to respect these ‘time out’ signals given by their baby. Through watching, listening and touching, parents become familiar of the individuality of their baby. This fosters a greater respect for their child, enhancing the parent-child bonding and communication (2).

 

Body language, stress cues and behavioural states

Premature babies at any time may display strong stress cues and body language associated with overstimulation. These cues include  a change in skin colour (pale or mottling), change in breathing, change in heart rate (bradycardia), apnea, change in oxygen levels and a sudden change in baby’s behavioural state. Why is it important for parents to observe their baby? As every baby and every situation is unique, observing how your newborn sleeps and wakes (their ‘infant’ or ‘behavioural’ states) will give you an idea of your baby’s maturity, nervous system functioning and how well your baby can manage their environment (so as not to become overstimulated) (10).

Parents and caregivers play a crucial role in helping their baby to control, or manage, his or her state.

Further more, look for ‘cluster’ cues, that is, if more than one cue is evident, take a break from positive touch or resting hands and try again later. Some avoidance cues include yawning, hiccups, sneezing, facial grimacing, squirming movements, the ‘salute’ (fingers over face), looking away, jerky movements, finger splaying, tremors or clenched fists. So what are positive ‘coping’ cues or behaviours that are a good sign? Hand to mouth, hands together, sucking, smooth movements (as opposed to jerky) and grasping/holding. These are examples of inborn behavioural patterns that help your baby to stay calm, pay attention and remain controlled.

NIDCAP essentially decreases infant disruption and individualises the care and handling of preterm infants. Premature infants often show an adverse response to procedural touch, designed to ensure an infant’s survival. Hypoxia, bradycardia and sleep disruptions are often observed in response to medical procedural touch. Parents providing appropriate nurturing touch is actually critical for promoting optimal growth and development of their newborn.

 

The importance of touch

Touch is the largest sensory organ and the first to develop in utero. Touch is critical for growth and development, communication and learning. A child’s first emotional bonds are built through touch, which lays the foundation for future emotional and intellectual development. Touch alters oxytocin, which, in turn, provides relaxation, encourages bonding between parent and child and lowers stress hormone levels (9). Touch produces vagal tone regulation, improves awake state and motor activity, enhances physiological responses and behavoural organisation. (1).The skin and nervous system develop from the same embryonic cell. The sensory system of touch is one of the earliest sensations to develop during gestation, ultimately providing stimulation and communication for your baby. Touch is an intimate exchange between caregiver and infant. In the NICU, the development of the parent-infant relationship is quite complex, as preterm, high risk infants are medically fragile (6). A preterm infant’s central nervous system is rapidly growing and developing and most vunerable to environmental effects. Containment holds such as cupping the feet and head, are favoured in this situation and have shown to produce less behavioural stress and more quiet sleep in preterm infants, as well as providing stability for the infant and enhanced parent-infant relationship.  Touch in the NICU should be supportive, sensitive, and the infant’s sleep/wake states and behavioural cues respected. Parents should monitor their baby’s response to touch and always look for avoidance cues.

Parents, being the primary nurturers, play a significant role in the continuity of touch interaction (6).

Another form of skin to skin contact is Kangaroo Care (KC), or Kangaroo Mother Care (KMC). KC originated in Colombia. Baby can be naked or partly naked with nappy on, lying on the parent’s chest, sometimes with a blanket placed over parent and baby. It has been shown that with KC, infants remain warm and have regular heartbeats, respiration and oxygenation. Research shows baby’s who experience Kangaroo Care sleep more deeply and cry less (9). Another study notes that in very preterm infants at twenty eight weeks, Kangaroo Mother Care (KMC) is an effective method for pain management, measured by the Prem Infant Pain Profile, or PIPP for short. After KMC, lance procedures were much lower than those babies without skin to skin contact, such as those babies who were in an incubator (4). In this study, skin to skin promoted a reduction in behavioural states and less physiological stress (7).

 

Containment Holds

In the NICU, still touch such as containment holds are recommended, this is especially so for medically fragile infants. Why? Because massage and stroking may be overstimulating to your baby’s immature nervous system and cause further distress. Only when your baby is ‘well’, that is, physiologically or medically stable, that stroking and massage be recommended. One study recommends hand containment (hold) is safe for medically fragile infants (3). This study also noted high levels of satisfaction amongst caregivers and nurses. The important point to note is that with any form of positive, nurturing touch, it is crucial to respect your infant’s body language. S. Tribotti, 1990, suggests fifteen minutes for three time per day. Containment holds include placing one hand on your baby’s head with the other on their lower back in the prone position (that is, lying face down on their tummy). S.Jay, 1982, recommends one hand placed on baby’s head with the other hand on your baby’s abdomen for twelve minutes, four times per day. It was noted that infants who received regular positive, nurturing touch became habituated to touch, and that infants who were physiologically fragile required less oxygen and had higher hematocrit levels. Another form of containment hold includes right hand on the coccyx and left hand on the top of baby’s head OR right hand cupping baby’s feet with left hand placed on top of baby’s head.

Premature babies in NICU respond positively to nurturing touch and massage (if medically stable), losing hyperflexia (contraction of the body) and withdrawing from touch behaviour. For parents, nurturing touch provides a change of focus from negative ‘medical’ touch intervention to empowerment and a sense of control. Some babies can only cope with one sensory stimulation, that is, touch or talking or eye contact, so find what your baby prefers by just being with them. Responsive, sensitive parenting promotes a secure attachment; this is important for your child’s psychological development in later life and their ability to cope with stress (10).

 

Resting Hands (Still Touch)

1)     Breathe deeply and relax.

2)       Warm the massage oil in your hands. [Massage oil recommendations for premature babies – the IAIM recommends a cold pressed, organic vegetable (edible) oil. C.Bond suggests refined, cold pressed, organic sunflower oil (5)].

3)     Rest your hands on your baby’s body on an area that has been the least invaded with medical touch, for example, the back (if baby is lying on their tummy, or prone position).

4)     Ensure that the room is warm; try to reduce noise and lights if possible (environmental stimulation).

5)     Let your hands go heavy and relax your body.

6)     Slow your breathing.

7)     Enjoy this precious moment together!

Remember to watch your baby’s body language, or cues, paying attention for a cluster of ‘avoidance’ cues. At this point, take a break from positive nurturing touch and begin again later.

 

Massaging your premature baby

Massaging and touching your baby’s skin enhances and improves communication between your child’s brain and body. This skin stimulation is transmitted to the brain which regulates our body systems through the vagus nerve. The vagus nerve is the only nerve in the body that branches out to the various systems in our bodies, for example, the circulatory, respiratory and digestive systems. A Touch Research Institute (TRI) study found premature babies gained an average 47% weight, were more active and alert and showed more mature neurological development than infants who did not receive massage.

Observe your baby’s alert cycles and behavioural states to decide the best time to begin or cease massage. Your baby may avoid eye contact as premature babies body and brain organisation is immature and still developing. Eye contact will slowly eventuate as they grow and mature. At 27 weeks gestation, vision is  not usually a sense that your baby will use; it is around 35 weeks onwards that the visual system is rapidly developing as they attempt to follow and fix on objects (10).

When massaging your baby, it is suggested that moderate pressure is more relaxing for the preterm infant and less arousing as compared to light pressure, which may contribute to greater weight gain. Light/feathery touch can be overstimulating and irritating to baby.

Moderate pressure also was noted to have a positive effect on behavioural observations (8). If your baby is medically stable and growing, it has been recommended you can massage your baby up to three times per day. Remember to take into consideration your baby’s body language, or behavioural cues, and what infant state they are in, as massage and touch for any baby revolves around cue-based care.

 

Positioning

Having your baby close to you whilst you massage and interact, is important for premature babies. You may use a pillow for your baby to lie on in front of you, or, if you are sitting down with your back supported, bring your legs up together and baby can nestle on your lap. Giving your baby a secure boundary will help settle and relax them, for example, tuck your baby’s arms and chest with a blanket, allowing you to massage the lower half of their body. Before you begin to massage your baby, it is recommended that you 1) prepare 2) observe 3) ask permission 4) observe baby’s behavioural states/body language and 5) remember to pace the massage slowly.

Massage and gentle movement exercises for medically stable preterm infants have noted benefits, including enhanced body weight gain and improved developmental outcomes. Long term effects such as the quality of the mother-infant attachment and the child’s future behaviour and development are another positive benefit. In other research findings, babies cried less, had lower cortisol levels and regulated sleep after massage, and improved emotionally, socially and soothability. It is important to go slow. Environment is also important, to help baby feel relaxed and comfortable, for example, take note of your light and noise levels. Other long term benefits noted of massage provided to physiologically stable preterm infants, include an improvement in social development, enhanced motor development and an increase in alertness.

Where do you go to learn how to massage your premature baby? Contact the I.A.I.M (the International Association of Infant Massage) to find your nearest certified infant massage instructor. Idibidi Kids www.kidsmassage.com.au teach the I.A.I.M course in Perth. Their website contains a large amount of research studies, information and website links for those wanting to know more about massage and touch for premature infants.

 

What is the role of a Certified Infant Massage Instructor (CIMI)?

A CIMI acts as a facilitator. They facilitate communication between parent and infant in the IAIM parent education (infant massage) course as well as parental awareness of infant behavioural cues; CIMI’s also promote parental sensitivity during interaction with your infant. CIMI’s  demonstrate on their baby dolls how to massage your baby using a series of strokes and techniques. In the I.A.I.M. infant massage course, you will learn to understand  your baby’s body language (or cues), why babies cry, respect, bonding, relaxation, when to massage, what oil is best, parent empowerment, behavioural states (sleep and awake cycles), touch relaxation, colic massage routine, gentle yoga based movements and more. The I.A.I.M. offers the most comprehensive infant massage course within Australia and developed the only internationally accredited infant massage training program. The international program is endorsed by well-known and respected people in the fields of psychology, perinatal psychobiology, occupational therapy and neonatology in the United Kingdom.

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By Natalie Garmson
Cert. Infant Massage Instructor, West Australian State Representative (IAIM).
Natalie is a mother of two boys, and is passionate about research and education into the effects of positive, nurturing touch, infant massage and raising awareness of the benefits in the community.
www.idibidikids.com.au
Ph: 0411 615 641

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REFERENCES
1. Nurturing Touch in NICU at Stony Brook University Hospital, Dept. Nursing, Korea, 2005
2. “How Little You Are”, I.Hartrlius, M.A. L. Rasmussen, R.N, Denmark (article c/- IAIM instructor manual)
3. Touch and Massage for Medically Fragile Infants, 2007, K.Livingston, S.Beider et al
4. Kangaroo Mother Care diminishes pain from heel lance in very preterm neonates: A crossover trial, 2008. C. C Johnston et al, McGill University, Canada.
5. Oil for the Neonatal Unit, Cherry Bond, 2007 www.cherrybond.com
6. Developmental Care considerations for Touch and Massage in the NICU, J.Browne, 2000 www.preemie-l.org/massage.html
7. The Effects of skin to skin contact during acute pain in preterm newborns. T. Castral et al, 2007.
8. Moderate versus Light pressure massage therapy leads to greater weight gain in preterm infants. T. Field et al, 2006.
9. Touch, T.Field, 2003 (book).
10. The preterm Infant: NICU experience and beyond (notes from C.Bond workshop, Sydney 2009).

Gosh where has the time gone? I can’t believe that Ronan will start pre-school next year! I am sure many parents are thinking the same thing but when you have a child who was born too early (13wks too early for us), fighting for life it is certainly something you don’t really think about when you sit by their humidicrib watching them grow. You really only focus on them reaching the next milestone. We never thought Ronan was ever going to be weaned off CPAP as he was attached to it for so long, well it felt like 8 long weeks to us. Then the excitment of finally being able to bring them home was so joyus but we were so fearful at the same time.

As the years have gone on we have grown with him so we don’t really notice how much he has grown but a few weeks ago he was playing with his friends and it hit me, there wasn’t any any height differences, he was actually as tall as his peers! It was actually a shock to the system because he has always been behind with everything.

It is funny how you seem to fall into a routine with them and it’s not until a stranger or a family member point out how well they are doing. Ronan attends child care 2 days a week and whilst we paint and play at home whenever i pick him up his carers tell me all about his day. He has progressed so much and over the past 6 months his fine motor skills have excelled in leaps and bounds.

Ronan has been attending early intervention for the past 2 years after being assessed with Sensory Intergration problems due to his prematurity. We have been attending weekly for years and now that he has settled down and can actually focus on the task at hand we truly believe that this is a major factor as to why he is excelling and learning so much. Before he started early intervention i was going out of my mind daily. I was constantly frustrated and struggling to come to terms with a toddler that just wouldn’t sit down! Now he will sit for up to 30mins to read a book with us, stand and paint for hrs on end, he doesn’t sensory seek anywhere near as much as he did and he doesn’t walk into doors anymore as his body awarness is catching up. The only real issue we are trying to tackle is potty training which sadly isn’t going too well. He just has NO idea about when he is needing to go to the toilet as he can’t feel the sensation. I have been told on many occassions that this is very normal for children with sensory issues and to just hang in there, be patient so that is what we are doing. We are also waiting on grommets in the hope that it helps with his speech but we are hopeful that he will have an aid in pre-school that will be able to help him if needed.

Our little boy who we sat beside in hospital waiting to grow big enough to come home has grown into a toddler who is about to reach his 4th birthday. We still can’t believe that he is about to start pre-school and we will be excited & proud to see him standing there with his little uniform on walking through those doors for the first time.

Are there many other ex-prems who are starting pre-school next year?

Tristan & Ronan