Introduction

Infancy is a critical period, requiring special and thorough handling to achieve development and growth.1 Growth and development are a continuous process in human life, starting from the baby in the womb and one of the developments in infants is the early stages of gross motor and motor development.2

Problems that often occur in infants are growth, development and motor delays.3 Failure to thrive (FTT) in infants is defined as suboptimal physical growth, weight failure, or lack of growth.4 Low body weight or failure to thrive is a baby’s condition that triggers health problems. The consequences of child growth broadly impact mortality, morbidity, and impaired cognitive development.5 Therefore, it is essential to pay attention to the quality of life of infants and young children so that children can develop to their full physical and mental potential.6

Child growth is internationally recognized as the best global indicator of physical well-being and mental development. Globally, health goals are assessed based on weight gain in children under five years,6 including growth-related targets for stunting, wasting, and overweight.5 Optimal weight is significant for a baby’s life and long-term health. However, simultaneous changes in body length, lean tissue, fat mass, and motor and sensory development are critical to optimal health in children.3

One of the interventions to potentially increase growth in babies is massage therapy (MT). This therapy is associated with increased body weight and infant mental and motor development.7 Human touch strongly affects a baby’s life and is essential in helping them reach their optimal potential.8 As such, baby massage is a new trend in caring for babies to optimize baby growth and development.2 Massaging the baby can have a calming effect and encourage bone growth, stimulate movement and coordination of the limbs, and increase the baby’s weight.9 Research has shown that massage therapy can help improve and stimulate infant motor development.3 In line with other research, massage affects the growth of premature babies as a form of stimulation, helps improve the physical growth and digestive function of premature babies, and stimulates motor development.3,10 Infant massage is a type of tactile stimulation that can improve the performance of muscles, bones and organ systems. Massage will activate the valgus nerve to increase the capacity of intestinal peristalsis, which will speed up the emptying of the stomach and cause the infant to feel more hungry. In addition, infant massage can also improve blood circulation and metabolism.11

Previous research stated that the obstacles experienced in infant massage therapy include parents having obstacles to be involved in infant massage therapy, such as financial constraints, infant and mother health, having other children, transportation constraints, personal commitment, assessment of health workers who demean parents, and the view of parents’ lack of ability.12 There may be some side effects due to negligence or accidents such as applying too hot oil or improper techniques such as solid massage, exposure to cold, and allergies to massage oils resulting in skin rashes.13

The reasons for not massaging babies are the unavailability of experts to provide baby oil massage, having heard of other people’s negative experiences, perceptions about the dangers of massage, advice from health service providers who forbid massage, and lack of time.13 Another study revealed that massage therapy in infants was considered to take a long time.12 However, previous studies have not provided comprehensive information related to massage therapy for infants under nine month. A systematic scoping review is needed to provide conclusive information about massage therapy in infants under nine months regarding the types of massage interventions, techniques, and outcomes. This conclusive information can optimize their growth and development. Therefore, this study aims to conduct a systematic scoping review regarding the potential of massage therapy for growth and development among infants under nine months.

Materials and Methods Study Design

This study uses Arksey and O’Malley’s systematic review framework to present comprehensive research following a Preferred Reporting Item for Systematic Review and Meta-analysis (PRISMA-ScR).14 This method is suitable for the subject of this study to comprehensively explore one specific topic.15 The framework consists of five stages, including identifying research questions, identifying relevant studies, selecting studies, analyzing articles and compiling, summarizing, and reporting.16

Search Strategy

Search studies using the PRISMA framework, including PubMed, Scopus, and CINAHL, with full text. The criteria in this study using the PICOS question framework included: (1) population: infant; (2) intervention: massage; (3) comparison: not applicable; (4) outcomes: growth and development; and (5) study: RCTs. Mendeley software was used to eliminate duplicates. Medical Subject Heading (MeSH) was used to search for articles using Boolean operators OR and AND, thus including “massage therapy, baby massage, baby, infant, babies, newborn, neonate, growth, development, and progression”.

Eligibility Criteria

The inclusion criteria were studies on subjects less than 12 months, full-text articles, randomized controlled trials, and those which reported the impact of massage on an infant’s growth and development. Studies were excluded if they were not in English. Nine researchers independently screened and selected the titles, abstracts, and full texts. Any disputes were discussed to reach a consensus between researchers.

Data Extraction

Data extraction used a tabular outcome with the following columns: (1) study characteristics, including author and year of publication, study location and study design, intervention, population, sample size, age, weight at study, and gender; (2) Intervention and study outcome, including the name of the group or intervention, the assessment tool used, and outcomes; and (3) the method of massage therapy, including the intervention, duration, and technique.

Critical Appraisal

Study quality was assessed using the Joanna Briggs Institute (JBI) critical appraisal checklist tool for a Randomized Controlled Trial (RCT),17 consistent with 13 questions and four categories: yes, no, unclear, and not applicable. Score 0 for “No” and 1 for “Yes” for a total score of 0–13 (See Table 1).

Table 1 Critical Appraisal Tool

Results Study Selection

Three databases provided 197 articles from the year 2013 to October 2022. After duplicates, inclusion and exclusion criteria, and those not with full text, 38 articles remained. Twenty-seven excluded articles were not designed RCTs, leaving 11 studies as included and acceptable for a review (See Figure 1).

Figure 1 PRISMA Flow diagram.

Adapted from: Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated :guideline for reporting systematic reviews. BMJ. 2021;372:n71. Creative Commons.

Characteristic Study

Analysis of studies were conducted on 11 RCTs, yielding 676 participants, consisting, 356 males and 320 females, including preterm infants, neonates, infants, infants with Down’s syndrome, and infants with HIV-infected mothers. The research was conducted in many countries: South Africa (n=2), USA (n=2), India (n=2), Egypt (n=1), Taiwan (n=1), Spain (n=1), Iran (n=1), China (n=1), and published from 2013 to 2022.

The range of weight of the participants in the study was 1000 and >2500 grams, and the range age of the participants from 10 studies was 3–9 months, and one study was <28 days. The populations in the study analyzed were preterm infants (n=7), infants with HIV-infected mothers (n=1), infants with Down’s syndrome (n=1), infants (n=1), and neonates (n=1). In addition, 676 participants were further randomized into an intervention group of 333 and a control group of 343. Interventions consisted of massage interventions.

Outcomes were measured using standardized instruments of pediatric growth and development, such as anthropometric, infant medical charts, infantometer, digital scale, Griffiths Mental Development Scales (GMDS), the Brunet-Lezine Early Childhood Psychomotor Development revised scale (BLR scale), dual X-ray absorptiometry (DXA) scan, Bayley Scales of Infant and Toddler Development Third Edition (BSID-III), and Peabody Developmental Motor Scales Second Edition (PDMS-2) (See Table 2).

Table 2 Characteristics of Included Studies

Study Outcomes The Summary Analysis of Massage Intervention Among Infants

The intervention of massages for infants’ growth and development utilizes various techniques, including medium-chain triglyceride oil massage (MCT oil massage), masked massage, oil massage, Dabur Lal Tail massage, parent-administered infant massage, and just massage therapy without any additives.3,7,9,10,18–24

Overall, the 11 studies analyzed were grouped by demographics. The majority of findings from the analysis included age 7–9 months (37.84%), preterm infants (52.26%), Europe, the Middle East and Africa region (50.15%), massage without oil (66.67%), duration 5–15 minutes (68.17%), growth (88.29%) and development (33.63%) (See Table 3). This study shows that massage therapy is more effective in increasing the growth and development of infants’ than those who do not apply massage. In addition, massage therapy has a positive effect on infants with various conditions, including growth and development in preterm infants and infants with HIV-infected mothers, growth in neonates and infants, and development in infants with Down’s syndrome. The efficacy of massage therapy for each intervention and technique is shown in Table 4.

Table 3 Summary Analysis of Intervention Massage by Demographic Variable in Selected Studies

Table 4 Intervention and Outcome

Efficacy of Massage Intervention for the Growth Domain

Ten studies revealed that massage therapy could improve growth domains, including body weight and length of infants receiving massage therapy. In addition, one study found that the efficacy of massage can increase total body-less head (TBLH) tissue mass. Techniques used to enhance this growth domain include medium chain triglyceride oil massage (MCT oil massage), Dabur Lal Tail massage, oil massage, massage by their mothers, and massage therapy without additives. Overall, these nine studies demonstrated the significant efficacy of the massage intervention for the growth domain (See Table 4).

Efficacy of Massage Intervention for the Development Domain

Five studies showed that massage therapy could improve the developmental domains of infants who receive massage, between smooth motoric and rough motoric development, such as visual-motor coordination, visual-motor integration, hand-eye, hearing/speech, social, vagal activity, language, locomotion, stationary, and reflexes. Techniques that effectively improve an infant’s development include massage therapy and massage by parents (See Table 4).

The Technique of Massage Therapy

The 11 analyzed articles found that massage therapy was carried out with a short duration of 5–45 minutes per day, according to several techniques. Overall, massage therapy has excellent efficacy in promoting infant growth and development. An impressive finding from this systematic scoping review is that many massage techniques applied to infants have efficacy in enhancing infant development and growth without the addition of pharmacological interventions (See Table 5).

Table 5 The Technique of Massage Therapy

Discussion

The findings of this study revealed that infants under nine months of age with various conditions, such as preterm infants, neonates, infants, infants with HIV-infected mothers, and infants’ with Down’s syndrome, can increase growth and develop better by applying massage therapy than was observed in the group that did not get treatment. The results showed a significant increase in the daily growth rate of children who received massage compared to those not involved in the treatment.7 Another meta-analysis study by Li et al (2016) revealed that oil massage effectively promotes the baby’s physical growth.25 This study added the previous systematic review, which revealed that massage could increase head circumference and total body weight in premature infants and did not affect length gain.26

Infants’ massage can meet four basic needs of infants, namely physical-biological needs, emotional needs, love needs, and stimulation needs. Infant massage is one of the treatments that stimulate infants’ motor movements, which affects their growth and development.1 Infant massage also stimulates the brain’s core work structure and function.2 According to this study, infants’ massage can improve the growth and motor development of infants aged 3 and 9 months. Another study found that infants’ massage is effective for weight growth and for infants’ length aged 3–12 months.27

Based on the analyzed studies, another finding is that massage therapy can be used in stimulating the growth and development of infants in conditions other than normal, such as preterm infants, infants with Down’s syndrome, and infants with HIV-infected mothers. A previous study revealed that massage therapy has been shown to have beneficial effects on a variety of conditions, including prenatal depression, premature infants, preterm infants, autism, skin diseases, autoimmune conditions, asthma, and immune conditions, including HIV and cancer.24 This study adds to the literature by reporting on the benefits of massage therapy to promote infants’ growth and development, including preterm infants, neonates, infants, infants with HIV-infected mothers, and infants with Down’s syndrome.

Another finding from this study is that the intervention type used to increase infant growth and development is only massage and massage with oil. Other studies show that various massage interventions are used, including flexion and extension movements,24 MCT oil massage therapy,23 sunflower oil massage,10,28 and Qigong massage, to improve motor development and reduce disability.29

Our study found several techniques used in infant massage to increase growth and development in infants under nine months of age. Several research results have shown different percentage increases in weight and development, mostly due to differences in the use of massage technique protocols. Several decades ago, several iterations in the development of tactile-kinesthetic protocols were applied in research studies, including variations in kinesthetic stimulation, tactile stimulation, variations in stimulation, amount of pressure, duration, and frequency of the protocol.24 The Touch Research Institute in Miami used a 15-minute protocol, three times a day, for ten days in healthy premature infants less than 30 weeks gestation and found increased weight gain after massage compared with those who did not receive it.7,30 Two meta-analysis studies with the same protocol showed daily weight increases of 5.1 g and 5.07 g/day in children who received massage.31,32

The pressure in tactile stimulation is essential to massage because only infants who receive strokes with moderate pressure rather than light pressure show more significant weight gain and vagal activity. Apart from that, frequency and duration are also essential components in getting optimal results from massage.24 Previous studies revealed an increase in the daily growth of infants who received massage. However, there was no difference in outcomes in the group that received massage and regular care, which may be related to the short-term intervention protocol.7 Given the importance of the massage technique, pediatric nurses and parents can be given a demonstration and stimulation session.

Implication and Limitations

This study has limitations. The article search was limited to three databases, and the literature search excluded non-English studies, making it possible that there was still literature that needed to be included from other databases and causing the literature to be incomplete. The sample in this scoping review was small, so the findings cannot be generalized to different populations.

However, despite its limitations, several strengths of this study must also be recognized. The clinical implication of this study is that this scoping review examines types of massage interventions, techniques, and outcomes in a population of children under nine months of age. However, the literature analyzed represents four country regions, including Europe, the Middle East and Africa, North America, and Asia-Pacific so these findings can be used as information for relevant countries as a clinical basis for implementing interventions to increase the growth and development of infants under nine months. This study has the potential to provide insight into massage interventions and techniques used to help improve the weight of premature infants, neonates, infants with HIV-infected mothers, and infants with Down’s syndrome under nine months, both at home and in the hospital.

Conclusion

This systematic review found that the therapy massages effectively increased infants’ growth and development. Through the massages, it can improve the performance of muscles, bones and organ systems. Massage will activate the valgus nerve to increase the capacity of intestinal peristalsis, which will speed up the emptying of the stomach and cause the infant to feel hungrier. In addition, infant massage can also improve blood circulation and metabolism. The interventions include medium chain triglyceride oil massage (MCT oil massage), Dabur Lal Tail massage, oil massage, massage by the mothers, and massage therapy without additives. A therapy massage finding shows that the technique’s benefits can improve growth and development domains, such as body weight, length, visual-motor coordination, visual-motor integration, hand-eye, hearing/speech, social, and vagal activity locomotion, stationary, and reflexes.

Our findings highlight that infants receiving massage therapy were significantly more likely to increase growth and development than the population who were not given massage therapy. In the future, a comprehensive approach to improving quality of life-related to growth and development is needed, starting with increasing awareness, educating patients and families, and offering information to increase massage as an effective and efficient alternative therapy. In addition, further investigation on the prevention of severity in infants who are already experiencing developmental problems is urgently needed.

Acknowledgments

The authors appreciate Universitas Padjadjaran, Bandung, West Java, Indonesia, for facilitating the search database for this systematic review. The Ministry of Education, Culture, Research and Technology, the Republic of Indonesia, supports this study.

Disclosure

The authors declare no conflicts of interest in this work.

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