Abstract
BACKGROUND AND PURPOSE:
Infants’ sleep disorders and parents’ insufficient sleep are common problems in the infant care. The current study was conducted to assess the effectiveness of infant massage on infants’ night-time sleep condition and mothers’ sleep quality.
PROCEDURES:
140 infants were randomly put into two different groups, experimental group with fifteen-minute bedtime messages for two weeks and the control group with normal infant routine care. The Brief Infant Sleep Questionnaire, a personal information submission form, and Pittsburgh Sleep Quality Index for the mothers were the tools used to gather data in this study.
RESULTS:
Infants in experimental group showed meaningful differences in variables such as, sleep latency (P < 0001, eta = 0.099), number of night waking (P = 0.03, eta = 0.027) and longest continuous sleep period (P = 0.03, eta = 0.026). As for other variables no meaningful differences were observed. There wasn’t meaningful difference in the mother’s overall night-time sleep quality between the two groups (P = 0.184, eta = 0.012) except for the duration of the mother’s night-time sleep (P = 0.028, eta = 0.026) and the reduction of maternal sleep disorder (P = 0.020 eta = 0.029).
CONCLUSION:
The findings indicated that infants’ bedtime massages would improve some of the sleep markers of mothers and infants, and therefore, can be suggested as a practical, harmless, and cost-free method to improve sleep.
Introduction
Infants’ sleep disorders, including sleep latency, constant waking up, and insufficient sleep are among the most common problems of parents [1] with a prevalence of about 20–30% [2]. The sleep pattern varies a lot in the first year of life. Newborns sleep about 16 hours a day on average [3], which reduces gradually as the infant grows older in a manner that the average becomes 12.1–14.6 hours for a one-month-old, 12.8–13.6 hours for a three-month-old, and 9.5–11 hours for a six-month-old infant [4–6]. The sleep condition of an infant can affect his/her health conditions. In a study, the infant’s sleep disorders were accompanied by mood problems such as nagging, restlessness, and an increase in crying [7]. In a different study, researchers observed abnormal cognitive development in 18 months old infants with sleep disorders [8]. In another study, socio-behavioral problems such as separation distress, anxiety, and depression, as well as a higher prevalence of childhood obesity, were seen in infants with less sleep [9, 10]. The infant’s sleep characteristics have an effect on the parents’ condition as well. This means that the fatigue caused by insomnia leads to mood changes in the parents, reduced motivation, impaired short-term memory, distorted emotional relationship with the infant, decreased quality of life, family problems, car accidents, postpartum depression, and stress [2, 10, 11]. These effects of sleep disorders that are harmful to babies and their families have led to numerous studies conducted with the aim of finding solutions to reduce or improve these effects. Regarding the effectiveness of using different bedtime routines, various studies have been conducted during which different methods have been used to improve the sleep quality of newborns, infants, and kids alone or together. Among these methods, educational-behavioral interventions that included the minimum parental involvement in the baby’s sleep [12], the use of routine bedtime procedures including bathing, singing or lullabies, swaddling, moving back and forth, and massaging were done together [2, 13]. However, the effects of each of these methods alone and on their own have not been accurately and vastly studied.
A method that has different uses in the field of health and treatment is massage therapy [14–16]. Massaging newborns and infants is an important part of the care system in different societies. For thousands of years, adults, kids, and infants were having massages in some East-Asian countries. However, it is only for the past few years that scientists have decided to study infant massages scientifically and identify the advantages and disadvantages of this traditional method [14]. Infant massages have numerous benefits for premature babies and sick infants. These benefits include enhancement of growth and development, reduction of pain, increase of awareness and learning capabilities, and reduction of the duration of hospital stay for premature or sick infants [17–19]. Despite the numerous above-mentioned advantages, the application of this method by itself to improve the sleep quality of newborns, infants, and their mothers is limited. Some studies performed in different situations with different races and age groups have shown contradictory results with some researchers considering it effective in the improvement of sleep quality of babies and their mothers [10, 14, 20], while others have not seen improvement in the sleep conditions of the infants that were being massaged [17, 21].
Considering the various harmful effects of sleep disorders in babies and their parents, the benefits of massages for infants and the fact that they are free and safe, and the contradictory results of previous studies, the current research has been conducted with the aim to assess the effectiveness of infant massages on infants’ night-time sleep condition and mothers’ sleep quality.
Design and methodology
Design
The current study is a clinical trial with a study population comprised of 15–20-day-old infants.
Data collection
The data was collected for ten months, from September 2019 to June 2020.
Subjects
Samples of this research are comprised of 140 15–20-day-old infants that have been randomly put into two groups, one receiving infant massages (Intervention group) and the other, being the control group.
The study’s inclusion criteria include: Term infant weighing 2500–4000 G at the time of birth, Singleton and firstborn, Breastfed exclusively, No record of hospitalization due to sickness, Infant not separated from mother, Lack of obvious sickness and/or infant abnormalities, Minimum educational level-of mother: high school diploma, No postpartum depression experienced
A convenience sampling of eligible infants was put into two groups, the intervention group “with infant massage” and the control group “no massage” using a simple random method.
Data collection tools
The Brief Infant Sleep Questionnaire, a personal information submission form, and the Pittsburgh Sleep Quality Index for mothers were tools used for gathering data in this study. The information submission form included infants’ personal information (height, weight, head circumference, chest circumference] as well as their parents’ age, level of education, job, etc.
The Brief Infant Sleep Questionnaire is a tool for assessing newborns’ sleep conditions, which has been proved valid and reliable for ages 0–36 months [22]. This questionnaire is made of 13 items in 3 main sections: Night-time sleep duration Number of wake-up times in the middle of the night Infants’ method of falling asleep
In this questionnaire, infants’ sleep condition during the past week was reported by their parents. To determine the validity of the questionnaire, the translated Persian version was matched to the original and given to 10 university faculty members for review. Changes were made based on their suggestions prior to the final form being submitted. The test method was used one more time to determine its reliability and was determined reliable with a Cronbach’s alpha of 0.80.
Pittsburgh Sleep Quality Index is one of the best tools designed to assess sleep quality. The questionnaire is made up of 19 items that are graded on a 4-point Likert scale from 0 to 3. Achieving an overall point greater than 5 is an indicator of poor sleep quality. This questionnaire was designed and introduced for the first time by Doctor Buysse et al., (1989). They determined 0.83 as the internal consistency of the questionnaire using Cronbach’s alpha [23]. In the Iranian version of the questionnaire, the validity was measured to be 0.86 and the reliability 0.89 [24].
Procedures
The information form was completed by all eligible infants. The assistant researcher held in-person meetings for both for the control group and experimental group separately. For the experimental group, the method of massaging infants was explained by a professional masseuse, practiced first on a doll and then on an actual infant. Mothers were then asked to give a return demonstration. An educational video file containing necessary instructions for providing infant massages and how to complete the questionnaire was provided to parents. The control group was too provided with an educational file containing instructions on how and when to fill out the questionnaire was also provided to the control group and all of their questions were answered. Both control and experimental group members were asked to, without any intervention, fill out the infant and mother sleep condition questionnaire for the duration of one week. In the intervention group, the usual bedtime routines such as changing diapers and breastfeeding was completed followed by a 15minute massage prior to bedtime for a two week period. Only the usual bedtime routines as mentioned above were followed in the control group. The same questionnaire was again completed by both groups after the intervention began and at the end of the first and second weeks. In case an infant, in any of the groups, was sick or on medication during the study, an infant was excluded from the study if they became ill or were prescribed medications.
Massaging the infant was performed in three 5-minute cycles. A mother first moisturizes her hands with baby lotion to prevent skin friction and begins massaging their infant according to the following procedure: In the first 5 minute cycle, the mother lays the baby on his/her stomach; the massage then begins by applying, in a pat-like manner, moderate pressure on the head, shoulders, back, arms, and legs (each part massaged for 6–10 seconds). In the second cycle, the baby lays on his/her back for 5 minutes, ten extensions and flexions of the arms and legs are first provided, then both hands and feet. In the third 5 minute cycle, a massage is given in similar conditions to the first 5 minute cycle.
Ethical consideration
After receiving approval from the university’s ethics committee, the researcher spoke with the parents of eligible infants, explained the goals of the research, and asked them if they were willing to participate in the research. For those who were willing to participate, the researcher explained the research procedure and asked them to sign a written consent form. In addition, they were assured that their information would remain confidential and that if they wanted, they could exit the study at any time.
Statistical analysis
Demographic and infant sleep variables
Demographic and infant sleep variables
Initially, the premise of the natural distribution of data was assessed with the help of the K.S test. Next, descriptive statistics were done based on Mean and Standard Deviations of continuous quantitative variables, frequency, and frequency percentages for nominal variables. The repeated measurement test was used to evaluate the meaningful difference between the mean of the number of measurements of the intended variables. First, the sphericity condition was investigated with the help of Mauchly’s test of sphericity, if the conditions were met, the results would be reported with the assumption of sphericity, and if not, greenhouse would be reported.
In this study, 138 infants between the ages of 15–20 days old were studied and put into two groups, one group receiving bedtime massages (the experimental group n = 70] and the other receiving only bedtime routine care (control group n = 68 with 2 people withdrawing from the study). Sleep characteristics, sex, and demographic information of infants in both groups are shown in Table 1. No significant differences were seen between the two groups in terms of the mothers’ average age, career status, sex, position, and infants’ place of sleep and the method they fall asleep (Table 1).
Infants’ sleep condition
Infants in the experimental and the control groups showed significant differences in variables including sleep latency (P < 0001, eta = 0.099), number of night waking (P = 0.03, eta = 0.027), and longest continuous sleep period (P = 0.03, eta = 0.026). As for the other variables related to the infants’ sleep conditions, no significant differences were seen during the study (Table 2).
Sleep-wake patterns (BISQ) at three time points
Sleep-wake patterns (BISQ) at three time points
In this study, there was no indication of a significant difference in the mothers’ overall night- time sleep quality between the two groups, (P = 0.184, eta = 0.012) except for the duration of the night-time sleep (P = 0.028, eta = 0.026) and maternal sleep disorder (P = 0.020 eta = 0.029) As for other sub-factors of maternal sleep quality, no significant differences were observed. The results demonstrate that during the study, night-time sleep duration was longer in the experimental group, while no differences were seen in the control group. Also, sleep disorders were reduced in the experimental group compared to the control group (Table 3).
Mother Sleep quality and its subscales at three time points
Mother Sleep quality and its subscales at three time points
Additionally, continuity of breastfeeding in the two groups and at the age of 6 months was meaningfully different (P = 0.010). 62% of parents in the experimental group were still giving massages as part of their infant’s bedtime routine up until the infant was six months old.
The results of this study indicated that among infants ‘sleep condition markers, bedtime massages have meaningfully reduced sleep latency as well as the number of night waking, and has increased the longest continuous sleep period (first episode of sleep after the massage). Even though the duration of each night waking had decreased in the experimental group, the reduction was not significant. Also, mothers’ night-time sleep duration increased, and sleep disorders were significantly reduced. Continuity of breastfeeding in the first 6-months showed a meaningful difference in the experimental group.
In different studies, bedtime massages on their own or alongside other bedtime routines have caused different changes in the sleep markers of mothers and infants, which could occur for a variety of reasons such as the combination of all bedtime routines together or differences in the age of infants. In a study, bedtime massages have improved sleep latency significantly but had no effect on the infants’ overall sleep condition [25]. In a similar study, results indicated that sleep latency, the number of night waking, and infants’ night-time sleep duration were reduced, and also improved mothers’ sleep condition by lowering their sleep disorders [20]. In another study, researchers realized that bedtime massages led to a meaningful reduction of the number of night waking in infants and their mothers. They observed that massages had improved the sleep quality of mothers, their morning mood, and their feeling about the infants’ sleep problems, while they had no significant effects on other infants’ sleep variables [10]. In two other studies, bedtime massages improved the sleep patterns of infants and their mothers, infants’ sleep quality, and reduced night waking [26, 27]. In a review article, applying bedtime routines (swaddling, massaging, bathing) collectively or alone have reduced sleep latency, the number of night waking, and improved the overall sleep conditions [28]. In similar research, the same results were obtained [13], which are relatively consistent with the results of our study, indicating positive effects of massages on the sleep condition of infants. Massages reduce cortisol levels and increase serotonin levels in infants and parents and inhibit the impacts of environmental stressors to a great deal. This sedative effect probably improves the sleep pattern [13, 14]. Massaging stimulates the secretion of melatonin hormone, which impacts the body’s biological clock and sleep conditions [9, 17]. Also, massages stimulate the autonomic nervous system and blood circulation and relaxes muscles and connective tissue, which can bring peace and a more effective sleep [29]. Bedtime massages improve night-time behaviors of mothers and infants and reduces crying, nagging, and body movements while sleeping [20].
Improved infant sleep conditions have a positive effect on mothers’ sleep conditions because as the infant’s sleep markers are improved, mother’s sleep conditions also improve [14]. On the other hand, massages can be effective on both the giver and the receiver, with the giver experiencing a reduction in stress levels leading to peaceful and comfortable sleep [11, 20]. Massaging the infant increases, the mother’s self- confidence in managing and adjusting the infant’s bedtime and improves his/her mood. Also, massages improve the way mothers and infants interact with each other, which can affect their night waking and the quality of sleep [10].
However, the effects of massages on the sleep of infants depend on various factors. In one study, bedtime massages were given to preterm infants for five days, causing an increase in waking hours of infants [30]. In a similar study conducted on 32–48 weeks old premature infants, researchers found that not only did massages have no effects on sleep latency, but they actually increased awareness of the infants. These researchers believe that massages increase the sleep markers of term infants, but they can have the exact opposite effect on premature infants because of an increase in the electrical activity of the brain [21]. The results of a review article indicate that massages were ineffective on the sleep condition of 0–6 month old infants. However, in this review, the age of infants, intensity, method, and duration of the massage varied across studies [17].
The method of giving massages seems to have an important role in the sleep patterns of infants. Massaging with moderate pressure as opposed to low-pressure increases vagal activity, reduces heart rate, cortisol levels, stress, and as a result, brings a sense of relaxation, achieving a better sleep pattern [21, 31, 32].
The frequency of giving massages is also important. By giving massages more frequently, sleep patterns have improved [20, 21]. Applying lotions or lubricants such as sesame oil or sunflower oil while giving massages affects improves sleep patterns [11, 14, 20].
In this study, breastfeeding at the age of 6 months was significantly higher for infants in the experimental group compared to those in the control group. Although no similar research in this field is available, it seems that infant massages may boost mothers’ self-confidence, improve their mood and the way they interact with their babies, and increases a sense of attachment towards the infant [10, 16], which can prolong breastfeeding. An interesting point here is that six months later, more than half (62%)of the mothers in the control group kept giving massages to the babies as part of their bedtime routines and were satisfied with it.
Conclusion
The result of this research indicates that giving infants bedtime massages improves some sleep markers of infants and their mothers (infants’ falling asleep time, reduction of night waking, longest continuous sleep period of infants, enhancement of the mothers’ night-time sleep duration, mothers’ sleep disorders), and also, prolongs breastfeeding until the age of 6 months; suggesting that massage is a practical, harmless, and free method of improving sleep.
Footnotes
Acknowledgments
The authors would like to express their gratitude to all the participants in this research
Conflict of interest
The authors have no conflicts of interest to declare.