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Infant Massage as a Stress Management Technique for Parents of Extremely Preterm Infants

Rachel Silver, SPT

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Before beginning PT school, I already knew that my heart was in pediatrics from my experiences shadowing and experiences working with children (camp counselor, babysitter, school volunteer, dance teacher, assistant for a teenager with cerebral palsy). This passion has only been further strengthened through our coursework in the DPT program and my clinical rotation in outpatient pediatrics at Atrium Health Cabarrus Pediatric Therapy in the second year. During this rotation, I was able to work with children of all ages and with a wide array of diagnoses and gained invaluable experience and mentorship from Erin Degrauw, PT, DPT that I will continue to carry with me throughout my career. During this rotation, I also completed a patient education assignment targeted at parents as part of PHYT 765 which emphasized the importance of involving the family in the physical therapy plan of care, particularly for younger children, to optimize therapeutic outcomes and strengthen the therapeutic alliance.

I had also always had a particular interest in neonatal physical therapy, as my father is a neonatologist, and I have always loved hearing him talk about the patients he has worked with and the strides he has seen them make, keeping in touch with many of them after their discharge from the NICU. I could not have been more fortunate to be at a school with a neonatal specialist like Dana McCarty, PT, DPT which allowed me to continue learning more about NICU physical therapy through course content and shadowing opportunities. On my acute care rotation, I gained my first real exposure to NICU physical therapy as my CI (Erin Fenner, PT, DPT) often treated this patient population. I was amazed seeing how PTs could work with even the youngest and smallest infants to begin improving their gross motor development, and I knew I wanted to learn more about this.

Additionally, as a psychology major in undergrad, I have always enjoyed learning about the impact that different psychological conditions can have on therapeutic outcomes, which I have been glad to see woven throughout the curriculum. I did research related to anxiety/stress disorders throughout undergrad and even presented research centered around postpartum women, specifically related to the role of stress in the development of obsessive-compulsive symptoms in the perinatal period. I also investigated the role that health anxiety can have on physical activity levels among college students and am passionate about learning more about the ways that mental health barriers can be navigated to improve physical wellbeing and overall health.

Therefore, when Dana presented this project to me, I was thrilled as it combined so many of my current interests. It allowed me to continue learning about pediatric therapy, parent education methods, neonatal therapeutic techniques, and the role of psychological variables on patient outcomes. Throughout the fall, I extracted data, wrote up a standardized operating procedure, explored literature, and prepared a conference abstract to assist with the research process and begin organizing the data in a way that could be disseminated. With this capstone, I have greatly expanded my knowledge of what infant massage looks like, how it can be implemented in the NICU, and how it can improve outcomes for both the parent and infant.

Statement of Need

Parents of extremely preterm infants experience increased stress and anxiety as a result of their child’s condition and their decreased ability to interact with their children during a prolonged NICU stay.1-4  This has been shown to negatively influence long-term development and behavior in these infants even as late as middle childhood.5-8 Therefore, there is a need to develop strategies to both improve parental psychological variables and increase parent-infant interaction in the neonatal intensive care unit to promote improved developmental outcomes for these infants and wellbeing among their parents.

Participation in infant massage sessions has previously been explored as a possible technique to help decrease stress among mothers of hospitalized infants and has been found to have promising results for a number of psychological variables.9-13 The auditory-tactile-visual-vestibular (ATVV) massage technique, developed by White-Traut et al., has been the most widely studied and utilized technique within the NICU.14 Additionally, research has shown improved outcomes for infants (improved feeding, improved weight gain, decreased pain, decreased hospital length of stay) and improved parent-infant attachment after ATVV.14-18 However, all studies to date utilize self-report measures rather than biological markers, which indicates the need for more objective testing measures.

Existing literature is focused on preterm infants rather than extremely preterm infants (infants born at less than 28 weeks gestation).1 Given that these children are at particularly increased risk for lengthy NICU stays and developmental complications, there is a pressing need to evaluate the safety, feasibility, and effectiveness of therapeutic techniques for these individuals.1

Lastly, there is a lack of clinical guidance in the literature for neonatal therapy. For example, the APTA does not have any clinical practice guidelines related to preterm infants, indicating a need for continued research in the field.19 Therefore, there is a need to educate both neonatal health care providers and parents on how to implement infant massage in neonatal intensive care units through the use of written research/conference presentations and educational handouts/demonstrations, respectively, in order to help improve outcomes. A variety of educational formats should be utilized in order to meet the learning needs of all individuals in the target audience, which is why written materials are needed to supplement presentation, discussion, and demonstration.20


This study aimed to meet the needs listed above. All of the data collected and analyzed in my capstone was a part of the TEMPO (Therapist Education and Massage for Parent-Infant Outcomes) Study completed at UNC Children’s Hospital, which is focused on improving therapeutic outcomes for extremely preterm infants and their parents through infant massage and educational techniques. Therefore, it addresses current needs by assessing possible benefits for infant massage utilizing biological markers of stress (salivary cortisol) in parents of extremely preterm infants.

My capstone project specifically focused on increasing the dissemination of information about infant massage, its benefits, and its impact on salivary cortisol levels to practicing therapists and parents through a written manuscript, parent education handout, and other products discussed below. It is my hope that these products will empower both neonatal health care providers and parents of extremely preterm infants to interact with these infants more regularly (via infant massage) in order to improve gross motor outcomes for these infants in addition to psychological variables in their parents and attachment in the parent-infant dyad.


As a starting point for this project, I screened and reviewed over 80 articles, 60 of which are included in the literature review below. These articles were centered around infant massage (feasibility/acceptability, use, benefits, etc.) and salivary cortisol (feasibility, gender/pregnancy differences, clinical change, etc.), and my findings are organized with an interactive table of contents. I have included summaries of findings for each subtopic at the end of each respective section.

Infant Massage and Salivary Cortisol Literature Review

I used this information from my literature review and the data I extracted and then analyzed with Dana’s assistance to prepare a manuscript that we will submit for publication to an academic journal. This manuscript discusses the possible benefits of infant massage, the use of salivary cortisol as a biological marker of cortisol, and our research findings and their significance.

Infant Massage and Salivary Cortisol Manuscript

I also created a parent education handout covering the benefits of infant massage, possible risks, and frequency for performing infant massage that can be used by health care providers in the NICU as a supplement to an existing parent education handout covering the “how to” for infant massage.

Infant Massage Parent Education Handout

I am preparing to present our research findings at UNC’s 2022 Human Movement Science Research Symposium on April 29 and plan to submit this poster for presentation at CSM or another physical therapy conference in the upcoming year. I have included the abstract for this presentation in addition to the poster.

Infant Massage Abstract

Infant Massage Poster Final


I have created an evaluation form for parents to submit after receiving the parent education handout. Unfortunately, this handout has not yet been distributed in the NICU, so I have not been able to obtain any feedback from parents about my handout, although I did seek feedback from all members of my committee. Despite this, I will continue to monitor the feedback form as the handout is distributed so that I can continue to improve the handout even after this course has ended to improve parent education in the NICU. I have also left a place on the form for parents to submit any other questions they still have after reviewing the handout and contact information if they would like me to follow up with them to answer those questions.

Here is the link to the evaluation form (anyone else is welcome to submit feedback regarding my handout here as well!):

Parent Education Handout Feedback Form

Also, before uploading this form, I utilized the Fry Readability Index in order to assess the grade level of my document to ensure that it is at an appropriate level being mindful of health literacy concepts and recommendations. Here are my findings:

     Sample 1: 9 sentences, 138 syllables –> 6th grade

     Sample 2: 10 sentences, 136 syllables –> 5th grade

     Sample 3: 10 sentences, 139 syllables –> 5th grade

     Approximate grade level of handout: 5th/6th grade

I also sought detailed feedback from all of my committee members at two time points throughout the semester and have incorporated that feedback into my final products.


Reflecting back on my research experience over the past year and my work on my capstone this spring, I feel as though I have not only met my learning objectives but improved a number of skills that will continue to benefit me beyond my time in the DPT program. I was able to continue exploring the literature to add meaning to the results of our study and have written a manuscript that is in the final stages of preparation for submission to an academic journal. Additionally, I have strengthened my peer and patient/parent education skills which will prove invaluable throughout my career. I am proud of the work that I have done to take this manuscript from the initial planning stages to its completion and am excited to share the results that I have found with other therapists and my future patients/their families.

As I mentioned above, I participated in research for three years in undergrad and developed and completed by own research study over the course of my senior year. Participating in a research elective in the fall and continuing my work over the course of the spring semester has reignited my passion for research and excitement for sharing and presenting my research with others. This project has also allowed me to combine my academic interests (physical therapy and psychology) into one. I have always been a big advocate for considering a patient’s mental health in order to optimize their physical health, and this project has shown me the ways I can continue to meld these interests in the future through additional research. Additionally, completing this capstone has taught me to also consider the impact of the family and their health on a patient’s progress in therapy. There a number of items I would have liked to investigate (ex. investigating parent demographic variables to see if there is a correlation with responders vs. non-responders to treatment), but this was not feasible given the time frame for completion of the project. I hope to remain involved in research to maintain my intellectual curiosity and help advance our field.

My capstone project required time management and initiative throughout the semester in order to meet my goals to complete a project of this breadth. Similar to physical therapy practice, we were given an outline of what we should do and then, in conjunction with our advisor, left to sort out the gray area and determine how to make our project take shape. I found that by creating a detailed timeline, I was able to hold myself accountable and gradually work on this project bit by bit even at times when the semester got busy with papers and projects. This has made me more confident in my abilities to manage outside or additional projects beyond my day to day responsibilities as a practicing therapist, perhaps by continuing to participate in research or contributing to the education of students in the DPT program at UNC even after graduation.


To Dana McCarty, PT, DPT, thank you so much for allowing me to work on this project with you and for all of your assistance with and support for my desire to pursue a career in pediatric therapy throughout the DPT program. I have enjoyed learning from you and gaining valuable exposure to neonatal therapy under your guidance. You have always gone above and beyond to connect me with any resources you have, and your dedication and commitment to pediatric therapy inspires me to keep my passion for learning and working with children alive throughout my career.

To Erin Fenner, PT, DPT, thank you for exposing me to the world of neonatal PT, for your skillful guidance throughout my acute care rotation, and for agreeing to serve on my capstone committee. You have allowed me to become a more confident clinician by seeming to always know exactly how much to push me out of my comfort zone. Additionally, I am so appreciative that you were willing to take on the extra time to provide such meaningful feedback to me on my project throughout the semester with such attention to detail.

To Kristen Dragotta, PT, DPT, thank you for agreeing to serve on my capstone committee while in the midst of your residency and for allowing me to tag along in the NICU last fall to gain firsthand exposure to the infant massage techniques utilized in this study. I so appreciate your willingness to help in any way possible throughout this project and am grateful for the valuable feedback you provided that helped improve the quality of my final products.

To the UNC DPT faculty, my clinical instructors, my classmates, family, and friends, thank you to all of you for your support throughout the last 3 years. I could not have asked for a better support system or group of people to learn and grow with, and I am confident I would not be where I am today without the support of each and every one of you!


  1. Glass HC, Costarino AT, Stayer SA, Brett CM, Cladis F, Davis PJ. Outcomes for extremely premature infants. Anesth Analg. 2015;120(6):1337-1351. doi:10.1213/ANE.0000000000000705
  2. Ionio C, Colombo C, Brazzoduro V, et al. Mothers and fathers in NICU: the impact of preterm birth on parental distress. Eur J Psychol. 2016;12(4):604-621. doi:10.5964/ejop.v12i4.1093
  3. Moura MRS, Araújo CGA, Prado MM, et al. Factors associated with the quality of life of mothers of preterm infants with very low birth weight: a 3-year follow-up study. Qual Life Res. 2017;26(5):1349-1360. doi:10.1007/s11136-016-1456-6
  4. Trumello C, Candelori C, Cofini M, et al. Mothers’ depression, anxiety, and mental representations after preterm birth: A study during the infant’s hospitalization in a neonatal intensive care unit.Front Public Health. 2018;6:359. doi:10.3389/fpubh.2018.00359
  5. Greene MM, Rossman B, Meier P, Patra K. Elevated maternal anxiety in the NICU predicts worse fine motor outcome in VLBW infants. Early Hum Dev. 2018;116:33-39. doi:10.1016/j.earlhumdev.2017.10.008
  6. Kleine I, Falconer S, Roth S, et al. Early postnatal maternal trait anxiety is associated with the behavioural outcomes of children born preterm <33 weeks. J Psychiatr Res. 2020;131:160-168. doi:10.1016/j.jpsychires.2020.09.010
  7. Huhtala M, Korja R, Lehtonen L, et al. Parental psychological well-being and behavioral outcome of very low birth weight infants at 3 years. Pediatrics. 2012;129(4):e937-44. doi:10.1542/peds.2011-2411
  8. Jaekel J, Wolke D, Chernova J. Mother and child behaviour in very preterm and term dyads at 6 and 8 years. Dev Med Child Neurol. 2012;54(8):716-723. doi:10.1111/j.1469-8749.2012.04323.x
  9. Welch MG, Halperin MS, Austin J, et al. Depression and anxiety symptoms of mothers of preterm infants are decreased at 4 months corrected age with Family Nurture Intervention in the NICU. Arch Womens Ment Health. 2016;19(1):51-61. doi:10.1007/s00737-015-0502-7 
  10. Holditch-Davis D, White-Traut RC, Levy JA, O’Shea TM, Geraldo V, David RJ. Maternally administered interventions for preterm infants in the NICU: effects on maternal psychological distress and mother-infant relationship. Infant Behav Dev. 2014;37(4):695-710. 
  11. Feijó L, Hernandez-Reif M, Field T, Burns W, Valley-Gray S, Simco E. Mothers’ depressed mood and anxiety levels are reduced after massaging their preterm infants. Infant Behav Dev. 2006;29(3):476-480. doi:10.1016/j.infbeh.2006.02.003 
  12. White-Traut R, Norr KF, Fabiyi C, Rankin KM, Li Z, Liu L. Mother-infant interaction improves with a developmental intervention for mother-preterm infant dyads. Infant Behav Dev. 2013;36(4):694-706. doi:10.1016/j.infbeh.2013.07.004 
  13. Afand N, Keshavarz M, Fatemi NS, Montazeri A. Effects of infant massage on state anxiety in mothers of preterm infants prior to hospital discharge. J Clin Nurs. 2017;26(13-14):1887-1892. doi:10.1111/jocn.13498
  14. White-Traut RC, Nelson MN, Silvestri JM, et al. Effect of auditory, tactile, visual, and vestibular intervention on length of stay, alertness, and feeding progression in preterm infants . Dev Med Child Neurol. 2002;44:91-97.
  15. Juneau AL, Aita M, Héon M. Review and critical analysis of massage studies for term and preterm infants. Neonatal Netw. 2015;34(3):165-177. doi:10.1891/0730-0832.34.3.165
  16. Newnham CA, Milgrom J, Skouteris H. Effectiveness of a modified Mother-Infant Transaction Program on outcomes for preterm infants from 3 to 24 months of age. Infant Behav Dev. 2009;32(1):17-26. doi:10.1016/j.infbeh.2008.09.004
  17. Kanagasabai PS, Mohan D, Lewis LE, Kamath A, Rao BK. Effect of multisensory stimulation on neuromotor development in preterm infants. Indian J Pediatr. 2013;80(6):460-464. doi:10.1007/s12098-012-0945-z
  18. Pineda R, Guth R, Herring A, Reynolds L, Oberle S, Smith J. Enhancing sensory experiences for very preterm infants in the NICU: an integrative review. J Perinatol. 2017;37(4):323-332. doi:10.1038/jp.2016.179
  19. Clinical Practice Guidelines and Resources. Academy of Pediatric Physical Therapy. Updated 2022.
  20. Byrne EM, Sweeney JK, Schwartz N, Umphred D, Constantinou J. Effects of instruction on parent competency during infant handling in a neonatal intensive care unit. Pediatr Phys Ther. 2019;31(1):43-49. doi:10.1097/PEP.0000000000000557

3 Responses to “Infant Massage as a Stress Management Technique for Parents of Extremely Preterm Infants”

  1. Dana B McCarty

    Rachel – your work on this project was stellar. You set objectives and met each one. I am impressed with your initiative and curiosity. Most of all, I am grateful for your hard work in getting these materials together so that we can get this work out into the world!

  2. mikalia

    As I am reading through your capstone project and exploring your products, I realized how little I know about NICU PT and can immensely appreciate how each student in our class has different interests and scopes of projects which allow the rest of us to explore new topics, ideas, projects, and populations. It made me realize the importance of having a website to post everyone’s capstones on and use as resources later if we were to need them. With that, great job on your capstone!
    Your products were organized and clearly written. I especially think the parent handout is meaningful as it allows the parents to get involved with their pre-term infant’s care in a hands-on and safe way. You mentioned there were other variables you would have liked to consider when analyzing data, is there an opportunity for you to do this after we graduate? Are there other research initiatives you’re interested in pursuing? I hope you can continue to fuel your research passion throughout your career.

  3. Cheyenne Gasper

    Ever since you mentioned your participation in this project in the pediatric elective class (PHYT880), I have been interested in viewing it in its entirety! I am also interested in pediatric physical therapy, and though I have not had clinical experience in the NICU, I had a feeling that viewing your project may be useful for my upcoming outpatient pediatric clinical rotation.

    I really enjoyed exploring your literature review, manuscript, abstract, and poster presentation, and think these will be excellent resources for practicing clinicians to view in an academic journal or at conferences. I was really impressed by the clarity with which you presented your findings, particularly in the succinct abstract and poster presentation. I was personally also really excited to see how compelling your findings were about the physiologic effects of just one session infant massage on parents of NICU infants. Throughout our pediatric coursework, providing family centered care has been emphasized, and your study re-affirms the profession’s commitment to this objective. I also thought your parent education handout was visually appealing, and could reinforce experiential learning of infant massage that therapists may perform during treatment sessions. If I were to practice in the NICU setting, I would find this resource clinically useful.

    Based on the background information you provided, this project seemed like a perfect fit for your personal, academic, and clinical interests. I am glad that you had the opportunity to participate in this research to further your education, and thank you for contributing to the knowledge base of the pediatric physical therapy profession as a whole!


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