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Impact de trois interventions: Méthode Mère Kangourou, Massage en
Incubateur et Massage en Position Kangourou sur la croissance et le
développement des enfants prématurés nés à moins de 33 semaines d’âge
gestationnel
Thèse
Andrea Carolina Aldana Acosta
Doctorat en psychologie
Philosophiae doctor (Ph.D.)
Québec, Canada
© Andrea Carolina Aldana Acosta, 2016
Impact de trois interventions: Méthode Mère Kangourou, Massage en
Incubateur et Massage en Position Kangourou sur la croissance et le
développement des enfants prématurés nés à moins de 33 semaines d’âge
gestationnel
Thèse
Andrea Carolina Aldana Acosta
Sous la direction de:
Réjean Tessier, directeur de recherche
iii
Résumé
Cette recherche vise à étudier l’impact d’interventions réalisées par les parents
dans l’unité néonatale de soins intensifs. Plus spécifiquement, le premier objectif est
de documenter les effets différentiels de la Méthode Mère Kangourou « MMK »
accompagnée ou non du Massage en incubateur «MI » ou du Massage en Position
Kangourou « MPK » et des Soins Traditionnels «ST » accompagnés ou non du
massage dans l’incubateur sur la croissance physique mesurée par le poids, la taille et
le périmètre crânien pendant une période de 5 et 15 jours dans l’unité néonatale et
l’impact à 40 semaines d’âge gestationnel. Le second objectif est de comparer, chez
des enfants qui bénéficient de la « MMK » la valeur ajoutée du « MPK » ou du «MI »
sur le neuro-développement à 6 et 12 mois d’âge corrigé de l’enfant.
Un échantillon total de 198 enfants et leur famille a été recruté de la façon
suivante dans trois hôpitaux de Bogota. Dans chaque hôpital, 66 sujets ont été répartis
aléatoirement à deux conditions. Ces hôpitaux ont été choisis afin de tester les effets
de diverses conditions expérimentales et de diminuer les bais de sélection. Dans
chaque hôpital, deux techniques ont été assignées aléatoirement. Il s’agit, dans le
premier, de la « MMK & MPK » vs « MMK & MI ». Dans le second, « MMK sans
massage » vs « MMK & MI ». Dans le troisième, « MI » a été comparé aux « ST » ce
qui implique une absence de contact physique continu des bébés avec leurs parents.
Les résultats rapportés dans le premier article sont à l’effet que, dans le premier
hôpital, il y a un effet compensatoire de l’intervention « MMK & MPK » sur la perte
physiologique du poids de l’enfant prématuré dans les 15 premiers jours de vie avec
un impact sur le poids à 40 semaines d’âge gestationnel, sur la durée du portage
kangourou et sur la durée d’hospitalisation totale. Aucun effet sur le périmètre
crânien ou la taille n’est apparu.
Dans le deuxième hôpital, aucune différence significative n’est rapportée pour le
poids sauf quand l’intervention est commencée après le 10ième jours de vie alors que
l’enfant « MPK» semble grossir mieux que le «MMK avec MI». Finalement, dans le
troisième hôpital il n’y a aucun effet du massage sur les variables anthropométriques,
iv
le groupe avec MI grossissant moins vite avec un léger impact sur le poids à 40
semaines. Cela pourrait être dû à la perte de chaleur due à l’ouverture de l’incubateur
quand l’enfant est très immature.
Dans le second article, les 66 enfants de l’hôpital sont répartis aléatoirement dans
le groupe « MMK & MPK» vs le groupe « MMK & MI», ont complété, à 6 et 12
mois d’âge corrigé, un test de neuro-développement, le Griffiths. Les résultats à 6
mois ne montrent aucune différence entre les 2 interventions, mais a 12 mois le IQ
semble dépendant du nombre de jours d’hospitalisation de l’enfant, cette durée
d’hospitalisation correspond au temps que met l’enfant à se stabiliser physiquement
et correspond également au temps que mettent la mère et l’enfant à s’adapter à la
méthode kangourou. Une fois, l’adaptation kangourou réussie, la dyade mère enfant
sort avec l’enfant toujours en position kangourou. Le temps d’hospitalisation
correspond au temps que met l’enfant à être éligible à l’apprentissage de la MMK par
la mère. À 12 mois les deux groupes montrent des résultats équivalents, mais des
différences positives sont apparues pour le groupe « MMK & MPK» dans les sous
échelle Coordination Oculo Manuelle et Audition et Langage du test Grffiths.
Dans l’ensemble, les résultats suggèrent que la pratique des deux interventions non
traditionnelles peut contribuer à une meilleure croissance physique dans nos cohortes.
Le gain de poids du bébé, notamment, est affecté par l’intervention MPK (Hôpital 1)
ou sans l’ajout du Massage (Hôpital 2). Par ailleurs, le massage en incubateur n’a pas
de différence significative en comparaison aux soins traditionnels, ces interventions
ont toutefois un impact mineur (tendances) sur le neuro développement à 6 et 12 mois
d’âge corrigé dans cette étude.
v
Abstract
This research aims to study the impact of interventions by parents in the
neonatal intensive care unit. More specifically, the first objective is to document the
differential effects of the Kangaroo Mother Care «KMC» with or without the
Massage Incubator «MI» or Massage Kangaroo Position «MKP» and Traditional
Care «TC» with or without Massage in the Incubator «MI» on physical growth as
measured by the weight, height and head circumference during a period of 5 to 15
days in the neonatal unit and impact at 40 weeks gestational age. The second
objective is to compare, in children who benefit from the «KMC» value added «
MKP» or «MI» on neurodevelopment at 6 and 12 months corrected age of the child.
A total sample of 198 children and their families was recruited as follows in
three hospitals in Bogota. In each hospital, 66 subjects were randomly assigned to
two conditions. These hospitals were selected to test the effects of various
experimental conditions and reduce bais selection. In each hospital, two techniques
were randomly assigned. In the first hospital, « KMC & MKP» vs. «KMC& MI». In
the second, «KMC without massage» vs. « KMC & MI»." In the third, «MI» was
compared to «TC» which implies a lack of continuous physical contact babies with
their parents.
The results reported in the first article are the effect that in the first hospital,
there is a compensatory effect of the intervention «KMC & MKP» on the
physiological loss of the child's weight early in the first 15 days of life with an impact
on weight at 40 weeks of gestational age, the duration of the kangaroo carry and the
total hospital stay. No effect on head circumference or size is not appeared.
In the second hospital, no significant difference was reported for the weight
except when the intervention is started after the 10th day of life while «MMK» child
seems to grow better than the «MMK with MI». Finally, in the third hospital there is
no effect of massage on anthropometric variables, the group with «MI» slower
vi
magnifying a slight impact on weight at 40 weeks. This could be due to the heat loss
due to the opening of the incubator when the child is very immature.
In the second article, the 66 children from the hospital were randomly
assigned to the group « KMC & MKP» vs. the group «KMC & MI », completed at 6
and 12 months corrected age, a neuro-development test, Griffiths. The 6-month
results show no difference between the 2 interventions, but 12 months on IQ seems
dependent on the number of days of hospitalization of the child, the hospital stay is
the time it takes for the child to stabilize physically and also corresponds to the time
taken by the mother and child to adapt to the kangaroo method. Once the successful
adaptation kangaroo, the mother child dyad out with the child still in the kangaroo
position. The hospitalization time is the time it takes for the child to learning the
MMK by the mother. At 12 months both groups showed equivalent results, but
positive differences emerged for the group «KMC & MKP'' in the subscale
Coordination Oculo Manual and Hearing and Language Test Grffiths.
Overall, the results suggest that the practice of two non-traditional
interventions may help improve physical growth in our cohort. The baby's weight
gain in particular is affected by the intervention MKP (Hospital 1) or without the
addition of massage (2 Hospital). Moreover, the incubator massage has no significant
difference compared to «TC», these interventions, however, have a minor impact
(trends) on the neuro development at 6 and 12 months corrected age in this study.
vii
Table des matières
Résumé ................................................................................................................................. iii
Abstract ................................................................................................................................. v
Table des matières .............................................................................................................. vii
Liste de tableaux ................................................................................................................... x
Liste de figures .................................................................................................................... xi
Liste des abréviations ......................................................................................................... xii
Remerciements .................................................................................................................. xiv
Avant-propos .................................................................................................................... xvii
1. Chapitre 1 ..................................................................................................................... 1
1.1. Introduction générale ...................................................................................... 1
1.2. Description des interventions ......................................................................... 3
1.2.1. Protocole de Massage en Incubateur (MI) .............................................. 3
1.2.2. Méthode Mère Kangourou (MMK) ........................................................ 6
1.3. Objectifs et hypothèses ................................................................................... 9
1.3.1. Organisation des milieux de recherche................................................... 9
1.3.2. Article 1 : Perspective à court terme : mesures anthropométriques ...... 10
1.3.3. Article 2. Perspective longitudinale : effets à 6 et à 12 mois d’âge
corrigé 11
2. Chapitre 2 - Premier Article: Impact on growth of the Massage therapy
delivered in Kangaroo Position as compared to other alternative intervention. ......... 12
2.1. Introduction .................................................................................................. 16
2.2. Interventions ................................................................................................. 18
2.2.1. Kangaroo Mother Care (KMC) ............................................................. 18
2.2.2. Massage Therapy in incubator (MI) ...................................................... 21
2.2.3. Massage Therapy in Kangaroo Position (MKP) ................................... 22
2.2.4. Traditional care (TC)............................................................................. 23
2.3. Method .......................................................................................................... 23
2.3.1. Design ................................................................................................... 23
2.3.2. Procedure............................................................................................... 25
viii
2.3.3. Analysis ................................................................................................. 28
2.4. Results .......................................................................................................... 28
2.4.1. «KMC & MKP » vs «KMC &MI» – First Cohort (Hospital one) ........ 28
2.4.2. «KMC »Vs «MI & KMC» –Second Cohort (Hospital two) ................. 29
2.4.3. « MI » VS « TC » – Third cohort (Hospital three) ............................... 29
2.5. Discussion .................................................................................................... 29
2.5.1. Limitations and Advantages of the study: ............................................. 32
2.5.2. Implications for application in the neonatal intensive care unit: .......... 32
2.5.3. Clinical and practice concerns for future studies .................................. 33
2.6. References .................................................................................................... 34
3. Chapitre 3 Deuxième article: Effects of Massage in Kangaroo Care Position
at birth on infant’s neurodevelopmental outcomes at 6 and 12 months of
corrected age. ...................................................................................................................... 46
3.1. Introduction .................................................................................................. 49
3.1.1. Kangaroo Mother care ( KMC) and neurodeveleopmental outcomes .. 50
3.1.2. Massage Therapy and neurodevelopmental outcomes .......................... 51
3.1.3. Benefits of Massage Therapy in Kangaroo Position (MKP) ............... 51
3.2. Method .......................................................................................................... 52
3.2.1. Design ................................................................................................... 52
3.2.2. Partipants ............................................................................................... 53
3.2.3. Procedure............................................................................................... 53
3.3. Analysis ........................................................................................................ 55
3.4. Results .......................................................................................................... 55
3.5. Discussion .................................................................................................... 56
3.5.1. Clinical concerns ................................................................................... 59
3.5.2. Limits and strengths .............................................................................. 59
3.6. References .................................................................................................... 61
4. Conclusions générales ................................................................................................ 70
4.1.1. Retour sur les objectifs et contributions de la thèse .............................. 70
4.2. Limites et directions futures ......................................................................... 73
4.3. Avantage méthodologique : .......................................................................... 74
ix
Bibliographie ...................................................................................................................... 75
Annexes ............................................................................................................................... 79
x
Liste de tableaux
CHAPITRE 2
Tableau 2.1 Experimental design for the three cohorts. ............................................ 37
Tableau 2.2 Neonatal clinical characteristics of the infants and parental demographic
information .................................................................................................................. 38
Tableau 2.3 Clinical neonatal outcomes .................................................................... 39
Tableau 2.4 Weight Gain in grams per day 5. 15 and 40 wks GA ............................ 40
Tableau 2.5 Neonatal clinical characteristics of infants categorized by days of life at
the moment of intervention ......................................................................................... 41
Tableau 2.6 Effect of the age at the beginning of the intervention on outcomes at 5
and 15 days post intervention and at 40 weeks of GA ................................................ 43
Tableau 2.7 Effect of the age at the beginning of the intervention 6 to 10 days of life
on outcomes at 5 and 15 days post intervention and at 40 weeks of GA .................... 44
Tableau 2.8 Effect of the age at the beginning of the intervention >10 days of life on
outcomes at 5 and 15 days post intervention and at 40 weeks of GA ......................... 45
CHAPITRE 3
Tableau 3.1 Medical information of infants at birth .................................................. 69
Tableau 3.2 The global IQ and general quotients Griffiths scales at 6 and 12 months
of corrected age ............................................................................................................ 69
xi
Liste de figures
CHAPITRE 1
Figure 1.1Position Kangourou Original ....................................................................... 8
CHAPITRE 3
Figure 3.1 Study flow chart ........................................................................................ 68
xii
Liste des abréviations
KMC: Kangaroo Mother Care
MI: Massage Incubator
MKP: Massage in Kangaroo Position
TC: Traditional Care
MMK : Méthode Mère Kangourou
MI: Massage en Incubateur
MPK: Massage en Position Kangourou.
ST: Soins Traditionnels
xiii
À Dios y a mis padres
“12 a fin de que no os hagáis perezosos, sino imitadores de aquellos que por la fe y la
paciencia heredan las promesas”
Hebreos 6 :12
.
A Dieu et mes parents
« 12 En sorte que vous ne vous relâchez pas, et que vous imitiez ceux qui par la foi et
la persévérance, héritent des promesses »
Hébreux 6 :12
xiv
Remerciements
La unica parte de mi tesis que puedo escribir en mi lengua materna que alegria se
siente !!!!
Quiero en primer lugar dar gracias a Dios fue a través de Él que logre este
doctorado. No fue un camino fácil pero hoy en día doy gracias a Él por estar siempre
a mi lado darme la sabiduría y persistencia para continuar. Gracias a su compañía fue
más claro para mi el amor y apoyo de todos.
Pero bueno todo este proceso de formación académica se logró gracias a mi
director de investigación REJEAN !! Solo tengo palabras de agradecimiento y
admiración por su calidad humana, por motivarme a hacer proyectos fuera de la zona
de confort y aprender que en la vida se tienen que disfrutar cada una de las etapas,
también porque en estos años de estudio siempre hubo palabras sabias y claras en el
momento adecuado gracias por darme esta oportunidad.
A mi fiel codirectora en Colombia Nathalie, gracias por nuestras jornadas de
trabajo siempre agradables, por los chocolates y bocadillos traídos de Colombia que
me llenaban de energía y alegría. Por dar lo mejor para sacar este proyecto, por
guiarme, respaldarme y creer en mi trabajo Gracias !
También un agradecimiento muy especial a George siempre encontré palabras de
ánimo, seguridad y admiración por el trabajo que estaba realizado muchas gracias.
A mi familia en Quebec nana tu amor, apoyo, paciencia y el crecer juntas
nuevamente lejos de casa son cosas que siempre llevo conmigo GRACIAS !!! A mis
primos adorados nati y matel !!! llegaron en la etapa final a motivarme aún más.,
hacerme reír.. Bailar y disfrutar mis cortos descansos en casa.LOS QUIERO!!
A mis familias en Colombia Acosta y Aldana... gracias por siempre consentirme
cuando regresaba a Colombia por estar ahí con su alegría, apoyo y amor.
xv
A mis amigos colombianos en Quebec Ana María, mi compañía, amiga, hermana
santandereana mi todo incluido... gracias por nuestras noches de trabajo del primer
año del doctorado por luego aprender juntas a llevar un equilibrio y tener las mejores
pausas activas de trabajo, por nuestras miles de conversaciones sobre lo que soñamos
y sobre todo por siempre cuidar de mi GRACIAS!!!
Pablo, Nati, lo logramos !!!!! Acabamos nuestro doctorado y el camino lo
recorrimos juntos fue mas fácil y agradable gracias a su apoyo y compañía.
A mis amigas Quebecoise !!!! Caroline y Angele su amistad me acerco a su país y
me permitió disfrutar el invierno las quiero mucho !!!
Tais !! Minha amiga … gracias por todo tu apoyo desde que iniciamos este
doctorado tu fuerza y perseverancia me inspiraron siempre…
À mi amiga de vida Lina; miles de aventuras, sueños y retos hemos vivido juntas
los mas dificiles o faciles siempre ha estado ahi. La palabra amistad tiene significado
cuando recuerdo todas las cosas que hemos vivido juntas gracias por acompanarme
en este camino.
Lina Callejas, te quiero… desde nuestra epoca Vallera motivandome a seguir
adelante. Xime, amiga tambien de la vida siempre peresente aun en la distancia.
Cata, gracias por esucharme por estar pendiente de mi por tu amistad. Jennifer, su
honestidad y sensatez es necesaria en mi vida la quiero montones. Pame, Lili, Pipe,
Chiqui, Nicolas lejos pero siempre presentes muchos sueños cumplidos al lado de
ustedes y muchos más por venir.
Y Timm !!! Siempre estuviste presente y al final de este gran camino lo
celebramos juntos con la gran alegria de iniciar un nuevo camino pero ahora juntos
gracias por estar a mi lado.
xvi
Pero las personas que me permitieron llegar hasta acá fueron MAMA y PAPA
GRACIAS !!!! Ustedes nunca han dudado en apoyarme son muestra de ese amor que
lo da todo sin medida que me permite apasionarme por lo que me gusta, que me
permite soñar cosas imposibles y proyectarme más allá de lo que yo imagine. Este
doctorado es el resultado de todo ese amor y apoyo que me dan día a día este título es
para ustedes !!!
Lore !! MI HERMANA !!! Te admiro y amo con todo mi corazón gracias por tu
consejos siempre sabios y claros, por disfrutar y viajar conmigo en estos 6 anos fuera
del país. Mis encuentros contigo siempre fueron llenos de alegría, buenas
conversaciones, sueños cumplidos, deliciosos restaurantes y maravillosas compras
eres la mejor compañía para disfrutar aun mas esta vida.
Ustedes TRES han sido el motor y gracias a ustedes he logrado las mejores cosas
que me han pasado en mi vida los amo !!!
xvii
Avant-propos
Les contributions de la thèse seront présentées dans quatre chapitres. La présente
introduction en constitue le premier et couvre le contexte théorique dans lequel elle
s’inscrit, en énonce la problématique, les objectifs et les hypothèses de recherche. Le
corps de la thèse est constitué de deux chapitre qui présentent chacun les articles de la
thèse. Les articles sont rédigés en langue anglaise. L’auteure de la thèse est l’auteure
principale de chacun des articles et a assumé ce rôle pour la révision de littérature, la
cueillette de données, l’analyse et l’interprétation de résultats. Le premier article
s’intitule : Impact on growth development of the Massage therapy delivered in
Kangaroo Position as compared to other alternative interventions. Les co-auteurs pour
cet article sont Rejean Tessier (directeur de recherche), Nathalie Charpak (pédiatre),
George Tarabulsy. Le deuxieme article est intitulé Effects of Massage in Kangaroo
care Position and neurodevelopmental outcomes. Les coauteurs pour cet article sont
Rejean Tessier (directeur de thèse), Nathalie Charpak (pédiatre), et George Tarabulsy.
Le chapitre quatre de la thèse conclut par une discussion des résultats en lien avec les
objectifs poursuivis et les hypothèses énoncées. Les limites sont aussi mentionnées.
1
1. Chapitre 1
1.1. Introduction générale
Annuellement, 12,9 millions de naissances, soit 9,6 % de la natalité mondiale
totale, survient avant terme. Environ 11 millions (85 %) de ces naissances
prématurées sont concentrés en Afrique et en Asie, tandis que l’Europe et l’Amérique
du Nord (Mexique inclus) accueillent chacune 0,5 million de naissances de ce type et
l’Amérique latine et les Caraïbes 0,9 million. Les taux de prématurité les plus élevés
se retrouvent en Afrique et en Amérique du Nord (11,9 % et 10,6 % de l’ensemble
des naissances, respectivement) et les plus bas sont en Europe (6,2 %) (Beck et al.,
2010).
Les enfants qui naissent prématurément présentent des risques à différents
niveaux : à court terme il y a une immaturité du système neurologique qui affecte le
système de régulation des processus physiologiques et psychologiques de base tels
que la succion et l’alimentation, le stress, la croissance, les capacités d’attention et
d’autorégulation (Mally, Bailey, & Hendricks-Muñoz, 2010). Les conséquences en
sont multiples et apparaissent de différentes façons. Les risques les plus communs
sont la détérioration sensorielle et la paralysie cérébrale lesquels, à long terme,
causent des problèmes au niveau cognitif, comportemental et des difficultés sociales à
l’âge scolaire. Les enfants qui sont le plus à risque de présenter ce type de
complication sont ceux qui ont eu, dans l’unité de soins intensifs, une chirurgie, une
sepsis, ou l’utilisation postnatale de corticostéroïdes (P. J. Anderson & Doyle, 2008).
Le syndrome de détresse respiratoire, la cause majeure de mortalité et de morbidité
chez les prématurés, est causé par une déficience de surfactant pulmonaire dont la
production débute vers la fin du second trimestre de grossesse et se développe jusqu’à
la 37ième semaine. Les grands prématurés nés avant 32 semaines présentent une très
forte probabilité d‘en être atteints et, dans certaines situations, le traitement par
ventilation mécanique est nécessaire à la survie (Mally et al., 2010). Au plan visuel,
ces enfants sont à risque de développer une rétinopathie, ce dommage infligé aux
vaisseaux sanguins de la rétine, laquelle se développe au cours des 12 dernières
2
semaines de la grossesse. Bien que la rétinopathie puisse être traitée avec succès, elle
demeure un risque important pour une réduction de la capacité visuelle. La présence
de ce type de maladie est corrélée négativement à l’âge gestationnel de l’enfant
(Fielder, Blencowe, O’Connor, & Gilbert, 2015).
Également, à long terme, on note des risques élevés de troubles du comportement,
des problèmes d’hyperactivité, une faible tolérance à la frustration, de même qu’une
immaturité sociale chez les prématurés. Ces conséquences sont d’autant plus
importantes que l’enfant est né plus tôt (Nadeau, Boivin, Tessier, Lefebvre, &
Robaey, 2001).
En réponse à ces différents impacts sur la santé physique des enfants prématurés,
une première solution au niveau des soins intra hospitaliers fut la création d ‘unités de
soins intensifs et l’introduction de l’incubateur. Au départ, plusieurs études ont
montré les avantages de son utilisation car l’enfant prématuré y était dans une
condition médicale stable. Toutefois, les médicaments administrés pendant la période
d’hospitalisation ont souvent causé des effets secondaires au niveau de l’audition et
de la vision ce qui a augmenté l’incidence et la gravité des complications (Mally et
al., 2010) . A partir de ces observations, les recherches médicales ont produit des
avancés technologiques permettant une meilleure surveillance de l’enfant en unité de
soins intensifs et ont contribuées à l’augmentation du taux de survie de ces derniers
(Richardson, Gray, & Gormaker, 1999).
Cependant, si les études récentes rapportent une augmentation du taux de survie
des prématurés, les problèmes liés au développement cognitif, comportemental et
moteur n’ont pas diminués pas à long terme (Ehrenkranz et al., 2015). Sur la base de
ces travaux et, dans le but d’améliorer la qualité de soins donnés immédiatement
après la naissance, nous avons voulu évaluer et comparer les effets à court terme de
deux interventions sur le développement des enfants tant sur le plan de la croissance
que du développement cognitif et moteur : il s’agit d’un protocole de Massage en
Incubateur (MI) , ajouté ou non à la Méthode Mère Kangourou (MMK).
3
La MMK est maintenant une routine dans la plupart des unités néonatales en
Colombie où la méthode a d’abord été développée par le dr Edgar Rey Sanabria en
1978 dans une grande maternité publique de Bogota. Elle a ensuite été évaluée en
Colombie (Charpak & Ruiz-pela, 1997) et disséminée dans la plupart des unités
néonatales d’abord dans les pays en voie de développement et rapidement par la suite
dans les pays à haute technologie. Une technique de massage en position kangourou a
graduellement été ajoutée à la MMK originale ; elle sera comparée dans ce projet à la
méthode de MI développée par l’équipe de Tiffany Field en Floride (Tiffany Field,
2001). Ces deux interventions, pratiquées par les parents, ont montré un impact si
elles sont appliquées très tôt dans l’unité de soins intensifs (Scafidi et al., 1986) C’est
une période sensible où le système nerveux de l’enfant prématuré est immature et
réceptif à toute stimulation (Casey, Kraemer, & Bernbaum, 2000). Ces interventions
répondent aux besoins des enfants prématurés en ce qu’ils aident à la stabilisation
physiologique pendant la période d’hospitalisation et réduisent les risques à moyen et
long terme associés au développement moteur, cognitif et comportemental.
1.2. Description des interventions
1.2.1. Protocole de Massage en Incubateur (MI)
Dans les travaux de Tiffany Field le premier objectif des massages visait l’un des
problèmes les plus fréquents chez les enfants prématurés soit leur difficulté à prendre
du poids quotidiennement (Scafidi,. Field, 1993). Le massage est une intervention
non nutritionnelle, mais il vise le même objectif que les interventions basées sur
l’amélioration de la nutrition (Ferber et al., 2002).Les résultats obtenus dans
l’ensemble des travaux de l’équipe de chercheurs montrent une augmentation du
poids de l’enfant mais on ne connaissait pas bien le mécanisme impliqué au début de
ces interventions. Par la suite, on a tenté d’obtenir les mêmes résultats chez d’autres
populations présentant des conditions instables comme une exposition à la cocaïne
pendant la période de grossesse et au virus du V.I.H. Les résultats ont aussi montré
une augmentation significative de poids.
4
Les travaux de Tiffany Field ont par la suite visé à mieux comprendre les
mécanismes physiologiques engendrés par le massage. Ses premières recherches ont
porté sur les facteurs responsables de l’augmentation de poids. Au début, cette
augmentation était expliquée par l’hypothèse d’une plus grande consommation de
calories, mais une fois cette condition contrôlée, les observations montrent quand
même une augmentation de poids plus grande dans le groupe qui a reçu le protocole
de massage par comparaison au groupe non-massage ( Field, 2001). La deuxième
hypothèse était l’activation physique due au massage qui contribuerait à une
augmentation du poids. L’effet de recevoir un contact physique pendant une période
de 15 minutes 3 fois par jour serait associé à une meilleure activation chez l’enfant
pendant et après l’intervention, raison pour laquelle des études suivantes ont eu pour
but d’observer les systèmes physiologiques qui sont activés dans l’intervention par
massage. (Tiffany Field, Diego, & Hernandez-Reif, 2010a; Tiffany Field & Diego,
2008). Une troisième hypothèse en lien avec la croissance physique a porté sur le role
de la pression exercée sur certaines parties du corps pendant le massage. Cette
hypothèse suggère qu’une pression modérée stimule le nerf vague (l’un des 12 nerfs
crâniens du cerveau) conduisant à une augmentation de l’activité vagale qui stimule
l’activité gastrique, le mouvement des voies gastro-intestinales, la libération de
l'insuline (une hormone pour l’absorption alimentaire) et l’action de l'IGF-1 Insuline
grow factor (une hormone de croissance). ( Field, Diego, & Hernandez-Reif, 2010b)
Afin d’évaluer ce processus, une étude a été réalisée où les mesures de l’activité
vagale et gastrique, ont été prises chez 80 enfants, assignés par hasard dans deux
groupes : un groupe massage et un groupe témoin. Les résultats montrent que
l’augmentation de poids est associée à une plus grande activité vagale et gastrique
dans le groupe massage (Diego et al., 2007). Toutefois, les études faites avec des
pressions plus légères pendant le massage ne montrent pas de changements dans
l’activité vagale ni dans l’augmentation du poids (Harrison, 2001). Ainsi la pression
exercée pour le massage jouerait un rôle déterminant (Diego & Field, 2009).
Une dernière hypothèse porte sur les effets du massage sur le développement du
cerveau et sur la maturation de la fonction visuelle. La stimulation tactile favoriserait
5
l’augmentation du factor IGF-1, hormone de la croissance libérée dans la circulation
sanguine. Celle-ci régule la croissance du cerveau et plus spécifiquement le
développement du cortex visuel (Guzzetta et al., 2009).
En résumé, toutes les études nous montrent que les interventions auprès des bébés
prématurés avec le protocole de MI mis en place par Tiffany Field et son équipe
favorisent une augmentation du poids et une maturation du cerveau ce qui penche en
faveur des effets bénéfiques que peut apporter cette technique.
Autres effets du massage selon la personne qui fait le massage.
Parallèlement aux effets physiques à court terme chez l’enfant durant la période
d’hospitalisation, d’autres études comparatives sont faites avec les différentes
personnes qui font le massage dans l’unité de soins intensif selon qu’il s’agit d’un
professionnel de la santé ou des parents. Les résultats montrent qu’il n’y a pas de
différence (Ferber et al., 2002). Les effets sur le gain de poids et sur le nombre de
semaines d’hospitalisation sont les mêmes. Toutefois, chez les personnes qui font le
massage, on peut constater un effet significatif chez les mères: ces dernières
présentent plus de facilité à établir des interactions avec l’enfant, un meilleur
sentiment de compétence ainsi que de meilleurs liens affectifs avec les enfants âgés
de 3 mois (Ferber et al., 2005a).
Le protocole du MI de cette étude
Le protocole de massage comporte plusieurs étapes : dans la première, l’enfant
doit être en position « face à face »; il est doucement caressé avec les mains pendant
cinq périodes de 1 minute (12 mouvements d’environ 5 secondes) sur différentes
régions du corps dans l'ordre suivant : (1) du haut de la tête au cou en aller-retour; (2)
du cou vers les épaules en aller-retour ; (3) des épaules vers la taille en aller-retour;
(4) des fesses aux pieds en aller-retour et finalement (5) de l'épaule à la main en aller-
retour sur les deux bras. Dans la deuxième étape, le bébé est placé dans une position
« couchée sur le ventre » pour une phase de stimulation kinesthésique antérieure.
Cette phase contient les 5 mêmes périodes, plus 1 segment de six flexions passives.
Ces flexions sont constituées par différents mouvements d'extension d’environ 10
6
secondes chacun et cela pour chaque bras, chaque jambe et une dernière fois avec les
jambes. Enfin, le bébé est mis en position de départ pour la phase de stimulation
tactile finale dans laquelle la procédure initiale est répétée. Pour avoir des résultats
significatifs, les protocoles doivent être répétés trois fois par jour, pendant 5 jours
(Tiffany Field et al., 2004). Des réplications de cette procédure ont donné les mêmes
résultats en Iran (Aliabadi & Askary, 2013) en Israël (Ferber et al., 2005b) et à
Taiwan (Moyer-Mileur, Luetkemeier, Boomer, & Chan, 1995).
1.2.2. Méthode Mère Kangourou (MMK)
Cette méthode a été créée en 1978 à l’Instituto Materno Infantil à Bogota en
Colombie, par le médecin Edgar Rey Sanabria. Au cours des 30 dernières années,
cette méthode a évoluée à partir des concepts initiaux et des modifications ont été
faites dans la pratique et dans la recherche scientifique développée par la fondation
kangourou en Colombie (Charpak et al., 2005)(Charpak et al., 2005)
Effets à court terme de la MMK
Une étude extensive des travaux ayant évaluée la méthode dans le but de comparer
les soins traditionnels versus la MMK chez les enfants prématurés a produit des
résultats convaincants tels que une diminution de la mortalite et du risque d’infection
nosocomiale avant la sortie de l’hôpital, qui était plus élevée dans le groupe contrôle
(7.8% vs 3,8%, p = .026) et également une réduction de 5 jours dans la période
d’hospitalisation ainsi qu’une meilleure croissance à l’âge de 40 semaines (Charpak
& Ruiz-Pelaez, 1997). La croissance de la taille et du perimètre cranien a également
été meilleure dans la première année de suivi (Rojas et al., 2003). Cette technique
montre aussi que durant la période d’hospitalisation il y a une meilleure régulation
physiologique, une meilleure capacité d’orientation ainsi que d’autorégulation.
(Feldman, Weller, Sirota, & Eidelman, 2002).
7
Effets à long terme
À long terme, la MMK favorise, chez les mères, les sentiments de compétence,
l’adaptation à son rôle et le bonding (Tessier et al., 2003) diminuent la dépression
des mères et l’anxiété autour de la santé de l’enfant. De la même façon il y a des
avantages sur le développement cognitif, le tempérament chez l’enfant et l’ambiance
familiale (Feldman, Rosenthal, & Eidelman, 2014). Ainsi la MMK telle que
développée puis améliorée durant ces 30 dernières années, montre des impacts
positifs tant du point de vue du développement physique de l’enfant et de sa santé,
que de son développement psychologique. De plus, la méthode s’avère également
bénéfique pour la mère de l’enfant et présente donc de nombreux avantage à être
pratiquée et développée.
Le protocole original de la MMK
La méthode mère kangourou comprend cinq postulats principaux (Charpak, 2009):
le premier est d’établir la population vers laquelle elle sera dirigée : enfants avec
moins de 37 semaines de gestation et ayant un poids inférieur à 2,500 gr. Le
deuxième est la position kangourou, telle que pratiquée en Colombie consiste en un
contact peau à peau entre la mère (et/ou le père) et l’enfant pendant la plus la plus
longue période de temps possible. La position de l’enfant est verticale (60 degrés). Le
bébé est placé sur la poitrine du donneur de soins, sous ses vêtements. Ces derniers
ont comme rôle de maintenir la température, d’alimenter l’enfant et de le stimuler.
(Figure 1.1).
Le troisième postulat est l’alimentation et la nutrition au lait maternel qui satisfait
les besoins nutritionnels chez l’enfant prématuré. Une fois que l’enfant se trouve dans
la période de croissance stable, il est recommandé jusqu’à l’âge de 6 mois de
favoriser l’allaitement maternel exclusif afin d’obtenir une augmentation de poids
selon les paramètres médicaux.
8
Figure 1.1Position Kangourou Original
Le quatrième correspond au processus d’adaptation entre les soins hospitaliers et
les soins ambulatoires à la maison. Une fois que l’enfant est stable et capable de
sucer, avaler et respirer d’une façon coordonnée et que la famille est consciente de la
nécessité du suivi strict du protocole et des recommandations du programme, les
enfants sortent de l’hôpital avec un suivi strict journalier au début puis hebdomadaire
jusqu’à au terme présumé. La cinquième étape est la phase de suivi ambulatoire de
l’enfant a risque. Un des grands avantages de la phase ambulatoire est qu’elle permet
de garder le contact de l’enfant et de sa famille et en même temps de faire un suivi
avec l’équipe des professionnels (médecins, physiothérapeute, infirmiers et
psychologues) qui donnent une consultation mensuelle jusqu’à 12 mois d’âge corrigé,
ce qui permet une mesure adéquate de la croissance de l’enfant.
Un protocole modifié de massage : le massage en position kangourou
Le massage en position kangourou a été introduit dans la MMK il y a environ une
dizaine d’années pour permettre à la mère de connaitre mieux son bébé, ce massage
se fait en position kangourou pour éviter la perte de chaleur. Le « Massage en
9
Position Kangourou » est effectué selon le même protocole que celui donné en
incubateur mais la différence entre les deux est que, dans ce protocole MMK modifié,
le bébé est porté par le parent, sur son ventre, ce qui permet de maintenir le contact
physique en permanence alors que, dans l’autre cas, le parent doit déplacer le bébé
dans l’incubateur pendant une durée d’environ une heure si on inclut le temps des
transitions de l’incubateur à la maman.
1.3. Objectifs et hypothèses
On a vu que le protocole de massage développé par Tiffany Field sur les bébés
prématurés permet une meilleure prise de poids que les interventions
conventionnelles et réduit ainsi la durée d’hospitalisation du bébé. De même, la
Méthode Mère Kangourou développée par la fondation Kangourou en Colombie
favorise un meilleur développement physique, favorise l’allaitement maternel,
améliore le lien mère-enfant et donne des ressources à la mère pour diminuer les
effets de la dépression et de l’anxiété (Field, Grizzle, Scafidi, & Abrams, 1996).
Deux aspects complémentaires de recherche seront considérés, la première
(Article 1) a trait aux effets physiques (anthropométriques) à court terme de
l’introduction du massage dans le protocole de soins et la seconde (Article 2) inclut
une perspective longitudinale du développement cognitif conséquent à deux
différentes modalités d’interventions.
1.3.1. Organisation des milieux de recherche
Afin d’évaluer l’efficience de l’association des deux méthodes (massage et soins
kangourou), ces dernières seront comparées dans le cadre de 3 essais cliniques
indépendants randomisés dans 3 hôpitaux de la ville de Bogota. Pour des raisons
d’éthique, dans les deux hôpitaux où les soins kangourou sont un standard, le
protocole vise à comparer des modalités de massage qui sont ajoutés aux soins
10
kangourou standard. Dans le troisième hôpital, où les soins kangourou ne sont pas un
standard, les massages donnés en incubateur seront comparés aux soins traditionnels,
sans soin kangourou. Ainsi, l’écologie des soins varie d’un hôpital à l’autre : dans les
deux premiers hôpitaux, il n’y a pas de restriction quant aux horaires de visite et les
parents y circulent librement 24h/24. L’allaitement maternel y est favorisé et les
bébés peuvent être en contact peau à peau pendant tout ce temps. Par contre, dans le
troisième hôpital les parents ne sont pas encouragés à participer activement à des
routines de soins pendant la période d’hospitalisation, la méthode mère kangourou
n’est pas pratiquée à l’hôpital et les visites ne sont autorisées que quatre heures par
jour. Pour ces raisons, chaque hôpital représente un milieu de recherche indépendant
et les sujets y seront randomisés selon des protocoles différents.
Les deux modalités de massage
Pour évaluer les effets du massage ajouté à la méthode mère kangourou nous
avons, dans un des hôpitaux (appelé hôpital 2 ci-après), randomisé les sujets selon
qu’ils reçoivent ou non le massage en incubateur (selon la technique de Field décrite
ci avant) en plus des soins kangourou, permettant la comparaison des groupes
« Méthode Mère Kangourou » vs « Méthode Mère Kangourou avec massage en
incubateur ». L’objectif est de vérifier la valeur de l’ajout du massage en incubateur
(méthode de Tiffany Field) aux soins kangourou standard. Dans l’autre hôpital
(hôpital 1) où les soins kangourou sont aussi un standard, nous avons créé un
protocole où le massage est donné alors que le bébé est en position kangourou. Dans
ce dernier hôpital, l’objectif est de comparer le massage intégré aux soins kangourou
à celui du massage ajouté en incubateur aux soins kangourou. Enfin, à l’hôpital 3 le
groupe massage (méthode Field) sera comparé au groupe avec soins traditionnels en
incubateur. L’objectif est ici de répliquer les études de l’équipe de Tiffany Field et de
son équipe.
1.3.2. Article 1 : Perspective à court terme : mesures
anthropométriques
Dans les trois hôpitaux les hypothèses portent sur les variations des mesures
anthropométriques de poids, de taille et de périmètre crânien au cours du séjour à
11
l’hôpital et à maturité, soit 40 semaines de gestation. Les groupes sont randomisés par
hôpital et les données sont traitées indépendamment pour chaque milieu. Dans tous
les cas on prévoit que le massage représente une valeur ajoutée aux soins kangourou
standard ou encore aux soins traditionnels. Ainsi, le massage intégré aux soins
kangourou (en position kangourou) serait préférable au massage en incubateur ajouté
aux soins kangourou (hôpital 1); le massage en incubateur ajouté aux soins
kangourou produirait de meilleurs résultats (croissance) que les soins kangourou sans
massage (hôpital 2); enfin les massages en incubateur seraient préférables aux soins
traditionnels en incubateur (hôpital 3).
1.3.3. Article 2. Perspective longitudinale : effets à 6 et à 12 mois
d’âge corrigé
Le deuxième article est une étude longitudinale à 6 et 12 mois d’âge corrigé de
l’enfant et le but est d’évaluer l’impact de deux interventions sur le développement
cognitif des enfants. L’hypothèse principale pour le deuxième article repose
uniquement sur les résultats obtenus à l’hôpital 1 :
Hypothèse : Les enfants qui ont reçu le « Massage en Position
Kangourou » auront un meilleur développement neurocognitif à 6 et 12
mois d’âge corrigé comparé au groupe qui ont reçu le « Massage en
Incubateur » tout en bénéficiant, dans les 2 groupes, de la « Méthode
Mère Kangourou ».
Le protocole de massage intégré aux soins kangourou (en position kangourou) est
le plus susceptible de produire des effets à long terme étant donné qu’il y a plus de
temps en position kangourou et qu’il n’y a pas de coupure dans l’intervention comme
c’est le cas pour le massage en incubateur. Comme il est prévu que ce groupe
d’enfants tirera de meilleurs bénéfices sur le plan anthropométrique, il est également
prévu que ces derniers obtiennent de meilleurs résultats à l’examen du développement
cognitif mesuré au Griffiths.
12
2. Chapitre 2 - Premier Article: Impact on growth
of the Massage therapy delivered in Kangaroo
Position as compared to other alternative
intervention.
13
Résumé du premier article
Les bébés prématurés sont à risque élevé de développer des complications à la
naissance, avec complications dans la croissance postnatale comme principale
préoccupation au cours des premières semaines de vie. Dans un effort pour faciliter la
croissance adéquate des nouveau-nés prématurés, un certain nombre d’interventions
précoces complémentaires aux soins traditionnels sont mis en œuvre au cours de la
période néonatale, comme la méthode mère kangourou (MMK) et Massage Therapy
dans l'incubateur (MI). L’objectif principal de cet article est d'évaluer l'efficacité
d'une nouvelle intervention précoce impliquant un massage thérapie livré dans la
position Kangaroo (MPK) par rapport à la thérapie de massage dans l’incubateur (MI)
sur la croissance postnatale chez les nourrissons nés avant 33 semaines de gestation
dans un échantillon que pratique couramment Kangaroo Mother Care (KMC).
14
Abstract
Background:
Preterm infants are at high risk of developing complications at birth, with postnatal
growth as a primary concern during the first weeks of life. In an effort to facilitate
adequate growth in premature newborns, a number of early interventions
complementary to Traditional Care (TC) are implemented during the neonatal period,
such as Kangaroo Mother Care (KMC) and Massage Therapy in Incubator (MI).
Objectives:
Primary objective of this study is to assess the effectiveness of a new early
intervention involving a Massage Therapy delivered in the Kangaroo Position (MKP)
compared with Massage Therapy in incubator (MI) on postnatal growth in infants
born before 33 weeks of gestation in an entire sample that practices routinely
Kangaroo Mother Care (KMC).
Secondary objectives are to assess the effectiveness of standard « KMC vs MI plus
KMC » and «MI vs TC» on postnatal growth in two additional cohorts of infants
born at ≤33 weeks of gestation in 2 different institutions during the same period.
Patients and methods: Three cohorts of infants born before 33 weeks of gestation
were recruited from three different teaching hospitals. The first cohort included 66
infants randomly assigned to one of two groups: «KMC & MKP » or «KMC & MI».
The second cohort included 66 infants randomly assigned to either a «KMC & MI»
group vs a group of standard «KMC» only. The third cohort included 66 infants
randomly assigned to either a «MI» group vs a group of «TC». In each cohort parents
were responsible for delivering the interventions with the exception of the TC group.
For the first cohort the practice of «KMC & MKP» was associated with greater
weight gain (g/day) than group “KMC & MI on day 5 (9.7 ±1.6 vs 3.4 ±3.5, p = .01)
and day 15 (11.8 ±0.7 vs 9.66 ±0.9, p = 0.07). For the second cohort there were no
significant group differences, and for the third cohort there was a trend in greater
15
weight gain on day 15 for the MI group over the TC group of children. For the
variables head circumference and length no differences were found.
A second analisis found an effect of the interaction between days of life at the
begining of intervention and the interventions in the 3 hospitals. To determine if there
is an impact of this varibale in weight, length and HC the infants were distributed for
each hospital in 3 categories: <5 days of life, 6 to 10 days of life and > 10 days of
life. Where in the first hospital for the group « KMC & MKP » there is a greater
Weight Gain in the preterms with less than 5 days of life at 5 days of the intervention
(.02 ±6.9 Vs -12.7 ± 25.37 p .012) and 15 days (10.06 ± 5.60 Vs 7.3 ± 4.2 p.013) and
at 40 wks (2951 ± 510 Vs 2618 ± 337 p .014).
Conclusion:
We can conclude that in the first cohort the practice of MKP in addition to KMC
decrease the initial physiological weigth characteristic of this population at 5 and 15
days post intervention, in preterms with 5 or less days of life nevertheless in the
second cohort for the group of preterms between >10 days of life there is also a
positive effect in weigth gain at 5 and 15 days for the KMC group. For the third
cohort the results no difference were found in antropometric measures the only
important result found were similar to other published studies, were MI intervention
have a trend on the gain weight at 15 days.
16
2.1. Introduction
Approximately 12.9 million of infants die during or shortly after birth due to
complications, whilst a large proportion are reported to die post discharge from
hospital, with inadequate care in the home environment believed to be a significant
contributor (Beck et al., 2010; Zanardo, Freato, & Zacchello, 2003). For those
preterm infants who do survive, they are at increased risk of neurodevelopmental
difficulties, which have been shown to impair longer term functioning (Howard, Sc,
& Inder, 2006).
There are a number of perinatal complications that may contribute to the altered
developmental trajectories reported in infants born prematurely, including breathing
problems caused by the immature respiratory system and its associated pulmonary
dysplasia (Angio & Maniscalco, 2004), brain injuries such as intraventricular
haemorrhage, and thermoregulation complications such as hypothermia . However,
one of the most commonly reported medical complications in infants born
prematurely, particularly those infants weighing ≤1500g at birth, is growth failure,
characterised as a growth rate below the appropriate growth velocity for the infant’s
gestational age.
Providing adequate postnatal nutrition to infants born prematurely and addressing
deficits in much needed energy and protein is an ongoing challenge. Despite the
protocols of nutrition and supplements delivered in today’s standard neonatal care
practice, growth failure remains a significant concern that is associated with low
neurodevelopmental and growth outcomes at 18 and 22 months (R. A. Ehrenkranz et
al., 2006). Furthermore, post discharge from hospital, the growth of preterm infants
continues to lag behind that of their full term peers, and across early childhood,
approximately 30% of preterm infants are identified as underweight (Rose, Susan A,
Feldman F. Judith, 2012)
An infant with slower growth velocity has higher incidence of morbidities that
affect provision and use of the adequate nutritional support (Ehrenkranz et al.,
2006). Also, for those infants who present higher morbidities weight gain is slow in
17
comparison with that of a group without morbidities. (Elirenkranz et al., 1948). It has
also been suggested that malnutrition is associated with poor neurocognitive
symptoms (Hay et al., 1999).
In addition to its impact on infant growth and developmental outcomes, it has been
found that preterm birth can have an ongoing negative influence on parental mental
health and family functioning (Treyvaud et al., 2009) which is in turn associated with
poorer child developmental outcomes (Nomura, 2007). According to Treyvaud
(2009) and Davis (2003), parents of preterm infants experience significantly higher
rates of depression and anxiety compared with parents of children born at term, with
up to 63% of mothers of infants born ≤34 weeks’ reporting symptoms of depression
in the first few months post birth. Also, studies by Schmucker and collaborators
(2005) and Singer and collaborators (2003) have found that parental separation is a
common environmental stressor for parents of infants born prematurely, which
potentially mediates their poor growth during the neonatal period and contributes
significantly to parental symptoms of anxiety, depression, pain, and short period of
sleep present during the following weeks after the delivery, further affecting the
adequate process of care once the neonate is discharged from the hospital.
Previous studies have described the powerful contribution parents make to their
child’s development when a first physical contact is established (Kennell & Klaus,
1984). These findings have led to the establishment of early interventions such as
Kangaroo Mother Care (KMC), characterised mainly by skin-to-skin contact with the
mother, Massage Therapy in Incubator (MI), physical touch with the hands over the
skin of the preterm, both of them seek to complement Traditional Care (TC). By
modifying the physical and emotional environment of the parents and infants, they
may reduce the inherent stress associated with the separation of parents from their
premature child and growth development. This type of intervention is being
increasingly used in neonatal care.
The central challenge for these early interventions in the context of growth is to
accelerate growth velocity (gain weight in grams per Kg per day) during care at the
neonatal intensive care unit, in order to match the corresponding intrauterine growth.
18
The aim of this study is to assess the effectiveness of early interventions KMC,
MI and Massage Therapy in Kangaroo Position (MKP) delivered by parents in the
neonatal intensive care unit in reducing incidence of initial weight lost. The last one
is a new intervention that could improve growth by the combination of massage
therapy with skin to skin contact.
The Following 3 hypotheses are developed in the present paper.
1. For infants born ≤33 weeks GA, postnatal growth (weight, length and head
circumference) will be significantly greater in infants receiving 5 days of «KMC
and MKP» compared to infants receiving 5 days of «KMC and MI» measured on
day 5 and day 15 post intervention and at 40 weeks of GA.
2. For infants born ≤33 weeks of GA, postnatal growth (weight, length and head
circumference) will be significantly greater in infants receiving 5 days of «MI and
KMC» compared to infants receiving 5 days of «KMC» without massage when
measured on day 5 and day 15 post intervention and at 40 weeks of GA.
3. For infants born ≤33 of GA, postnatal growth (weight, length, and head
circumference) will be significantly greater in infants receiving 5 days of «MI»
compared to infants receiving 5 days of «TC» when measured on day 5 and day 15
post intervention and at 40 weeks of GA.
2.2. Interventions
2.2.1. Kangaroo Mother Care (KMC)
KMC was developed in Bogota, Colombia in the late 1970’s where its initial aim
was to support the thermoregulation of the low birth weight / preterm infant through
skin-to-skin contact with the parent, breastfeeding and early discharge from hospital
in kangaroo position. Earlier studies examining the effects of KMC compared with
traditional incubator care reported a decrease in the length of hospitalization and a
decreased morbi-mortality rate in infants receiving KC (Conde-Agudelo, 2000). In 2
more recent reviews investigating the mortality and morbidity outcomes for low birth
weight (LBW), infants receiving KMC compared with traditional incubator care
19
showed reduction in neonatal mortality (relative risk 0.49, 95% (Johnston, 2014)CI
0.29-0.82) and serious morbidity (relative risk 0.34, 95% CI 0.17 – 0.65) (Johnston,
2014; Lawn, Mwansa-Kambafwile, Horta, Barros, & Cousens, 2010).
Other studies have demonstrated a relationship with KMC and improved outcomes
across a number of domains. They include reduced nosocomial and severe
infection/sepsis, improved thermoregulation, (Bohnhorst, Heyne, Peter, & Poets,
2001), reduced oxygen requirements and improved autonomic maturity (Feldman &
Eidelman, 2003), and a reduced psychological and behavioural pain response during
heel stick procedures when delivered to the infant in Kangaroo Position (KP)
(Johnston, 2014).
Impact of KMC on neurodevelopment
An inherent challenge for the infant born prematurely is the regulation of
autonomic, motor, state, and attentional / interactive systems whilst in constant
interaction with an environment that does not correspond with their developmental
maturation. The preterm infants’ early neuro behaviour demonstrates the maturation
and regulation of these multiple systems, and at term equivalent age, preterm infants
have shown to differ significantly from infants born at full term.
An infant’s capacity to regulate these systems can be observed in their early neuro
behaviour with the Autonomic System displayed through the infant’s breathing
pattern, skin fluctuations, temperature control, visceral function. Their motor System
is displayed through the degree of muscle tone and movements of the face, trunk,
limbs, and extensor and flexor postures. The State Regulation System becomes
evident by their robustness and modulation, and in the pattern of transition from sleep
to quiet awake, to active awake and aroused, and to upset and crying. The system for
attention and interaction can be observed when the infant is able to reach a calm alert
state. At shorter gestational age, more severe disturbances in state organization are
more severe and the rate of maturation is poorer in comparison with a term neonate
(Holditch-Davis, 2003)
20
The KMC intervention develops better performance of the Autonomic System,
there is a better breathing pattern that regulates with the heart rate of the person that
delivered the KP and also better thermoregulation where the skin-skin contact allows
the preterm to not lose heat and regulates the temperature with the person that does
the KP .There is no evidence of the effects during the neonatal period in the motor
system. Furthermore, in the State Regulation System preterm infants who recieved
KMC during the neonatal period showed more organized sleep-wake cyclicity and at
3 months of corrected age more efficient arousal modulation while attending complex
stimuli in comparison with the control group (Ruth Feldman, Weller, Sirota, &
Eidelman, 2002).
Based on those results in an early stage during the neonatal period new long-term
studies have showed evidence of how at the age of 10 years of life the effect of being
in KP during the NICU period showed more mature autonomic functioning,
organized sleep and better cognitive control. All of them were individually stable
across the years. (Feldman, Rosenthal, & Eidelman, 2014).
Positive impact on family interactions
In addition to improved infant outcomes, KMC has been shown to have a positive
influence on parenting sense of competency and the parent-infant relationship.
Feldman and colleagues (2003) demonstrated that the practice of KP for as little as
1hr/day for 14 consecutive days significantly improved maternal sensitivity and
infant responsivity. During a parent-interaction task at 3 months of corrected age,
mothers who had provided early KP to their infants engaged in more nurturing touch
and their infants displayed less negative effects compared to infants who received
standard incubator care (Feldman, Weller, Sirota, & Eidelman, 2003). Mothers in the
hospital claim that during KP, feelings of need and reciprocity to their infants
emerged/arouse (Johnson, 2007; Neu, 1999; Roller, 2005). In relation to the fathers,
the opportunity to practice skin-skin contact develops paternal competence and ability
to handle unexpected situations and increase their participation in infant care
(Blomqvist, Rubertsson, Kylberg, Jöreskog, & Nyqvist, 2012).
21
2.2.2. Massage Therapy in incubator (MI)
The intervention was created to respond to the needs of physical contact between
mother and child in the NICU and to complement other less invasive mechanisms as
a means to contribute to weight gain in this population when KMC is not
implemented in the NCIU. A protocol of tactile stimulation was created based on
continued stimulation for three 15-min periods at the beginning of three consecutive
hours during a 10 – day period. The massage therapy session began approximately 30
minutes before the noon feed. (Scafidi et al., 1986)
The most relevant results after the practice of this intervention were found to be
associated/associated with weight gain in the intervention group. After those results
were suggested, different studies were conducted to measure the same variable and
some changes were made in the protocol in order to improve the results. Those
changes involve: moderate pressure, number of series and time, benefits from the use
of oils (vegetal oil) (Tiffany Field et al., 2010a) and kinaesthetic stimulation on the
limbs, revealing an impact in weight gain and bone density (Moyer-Mileur et al.,
2011).
Tiffany Field (2001) describes a hypothesis that explains the above
mentioned weight gain by a specific physiological path. The moderate pressure
during the Massage Therapy in Incubator activates receptors under the skin that
stimulate vagal activity associated with infant growth and socio-emotional
development in addition to higher levels of the hormone IGF-1 which plays an
important role in infant growth. Those results are associated with a greater weight
gain in the preterm who received massage with moderate pressure in comparison with
those who received it with light pressure (Diego, Field, & Hernandez-Reif, 2005).
Effects on visual function and brain development
Other studies reveal an impact in visual function. Those results were evident at 2
months where, higher levels of IGF-1 were found to be a mediator in visual
development (Guzzetta et al., 2009). Those results confirm the hypothesis described
22
by Field, where there is a mechanism that accelerates the production of the hormone
IGF-1 and in this case contributes not only to the gain weight but also to the visual
development. Other study suggests the practice of massage therapy favours the
maturation of brain electrical activity due at the minimization the differences between
the extra and intra uterine environments (Guzzetta et al., 2011).
Impact on growth development and family interactions
The role of the father during the post-partum period is associated with activities
like bath and more support to the mother than getting involved in daily care routines
that imply care of the baby. One intervention program was created to improve father-
infant relationship based on the practice of massage therapy during the same
period. The results show more enjoyment of parenthood, more involvment in
touching their infant and more time spent in practicing the daily routine learned in the
intervention program (Scholz & Samuels, 1992).
2.2.3. Massage Therapy in Kangaroo Position (MKP)
Based on the evidence of the interventions described above, a new protocol of
intervention was created taking into account the benefits from each intervention.
From KMC the skin-skin contact or Kangaroo Position helps to the thermoregulation
and stabilization of the preterm and increases parents-infants behaviours of
reciprocity and comfort (Ruth Feldman, Weller, Sirota, & Eidelman, 2003) in the
other hand, from the MT the stimulation received causes a physiological response in
weight gain and the mothers express behaviours of security and reciprocity with their
child during the practice in the sequence of movements (Ferber et al., 2005).
The practice of the Massage Therapy in Kangaroo position (MKP) integrates the 2
interventions, which are expected to lead positive outcomes in growth development at
short term.
23
2.2.4. Traditional care (TC)
Traditional care for Low Birth Weight Infants (LBWI) includes keeping the infant
in an incubator until the premature infant/premature infant is able to regulate
temperature and is adequately growing. Infants are discharged according to current
hospital practice. Parents are not allowed to establish any kind of physical contact
and this medical procedure showed long terms effects on growth (Allen, 2008).
2.3. Method
2.3.1. Design
A randomized trial was conducted within each of three cohorts from three different
teaching hospitals in Bogotá, Colombia. Preterm infants were randomized using a
computer random number generator and opaque sealed envelopes were used for
hospital allocation. This research design was conducted with the aim of reducing the
bias that could occur if four interventions were carried out simultaneously at the same
hospital and practice by their parents. Also, comparing two interventions by hospital
allowed the team of researchers to enforce more strict and punctual interventions as
well as more efficient and accurate data collection.
However, this design did not allow for a posteriori comparison across the
hospitals, due to three differences in their practices. The first of them is that KMC is a
standard practice in two hospitals but not in the third. This introduces differences in
the involvement of parents in daily care routines and in the practice of breastfeeding,
which may contribute to a better growth development. Comparison of results of the
study on the first two hospitals with the third would then be inconclusive where the
KMC it is not a standard practice.
The second difference is the restriction on visiting hours ; in the first two hospitals
the neonatal care unit is open 24 hours, so parents are allowed to stay as long as they
want without any restriction. In contrast, the third hospital restricted visiting hours for
parents to 4 hours per day, which represents a disadvantage compared to other
hospitals. Lasty, there were large differences in the expected socio-economic status of
24
patients attending the three hospitals, the first hospital being known for receiving
patients predominantly from wealthier classes compared to the other two.
Participants
Participants in the three cohorts (one per hospital) included Hispanic infants born
≤33 weeks of gestation, recruited between January 2012 and July 2013. The
participants were allowed to participate in the study if they met the inclusion criteria :
(a) Having a gestational age between 29 and 33 weeks, (b) weight ≤1500 grams, (c)
stable health condition (d) no congenital anomalies, (e) no more than 15 days of
chronological age, (f) approval from the paediatrician or neonatologist, and (g)
having a mother and father who are open to communication and agree to
cooperate. Student’s T-test did not show significant differences between parents’ and
infants’ general characteristics between groups in each cohort (Table 2.1).
All the participants from the first two hospitals practiced KMC. As for the third
hospital, at the moment of the study the professionnals did not practice KMC, which
allowed us to have a 4th group of patients that were treated with TC exclusively.
In the three cohort’s parents mean age varied between 27 and 30 years old.
Sample Size
66 infants were enrolled per cohort (hospital) and were randomly assigned in two
interventions. In the second cohort (Hospital 2), 3 preterm infants were dismissed
from the study due to medical complications. In the third cohort (Hospital 3), 3
preterms were dismissed from the study in the TC group because of parents’ refusal
to continue with the TC intervention. Table 2.1 explains the experimental design for
each hospital.
25
Insert Table 2.1 about hear
The study was approved by the ethics committee at Laval University and by the
ethics review boards of the three teaching hospitals. Informed parental consent was
obtained within 3 days postpartum
2.3.2. Procedure
Stage of training prior to the study
Prior to the start of the study a group of 12 psychologists, 50 nurses and 27
paediatricians who work in each of the hospitals received training on the methods of
intervention, patient selection for the study and data collection. A pilot study which
assessed the knowledge acquired during training was done upon its completion.
Recruitment
For the first and second cohort :
The families were enrolled the study if the following conditions were met ; (1)
mothers agree to perform KMC at least 5 consecutives days and at least 2 hours per
day, (2) parents agree to perform an specific care routine (MI or MKP) during 5 days,
3 times per day. Thus, KMC, MKP and MI, were targeted to a period when the
premature infant would otherwise be deprived of full maternal contact. Parents were
trained by the researchers to perform KMC. Infants were taken out of the incubator,
were undressed (except for a diaper), and were placed against their mother/father
chest. In the same manner, a trained researcher explained the protocol for MKP or MI
when necessary. During these interventions, the infant’s reaction was always
monitored using a pulse oximeter and a cardiac monitor. At any signs of alarm, (heart
rate greater that 200 bpm or oxygen saturation under 90%) the intervention was
suspended for 25 seconds until the preterm infant was stable. None of the babies
experienced any distress signals. The intervention was always performed one hour
after the baby was fed.
26
For the third cohort : The families were enrolled the study if the following
conditions were met. (1) mothers agree to perform MI during 5 days, 3 times per day
or the traditional care routine establish in the hospital where the preterm infant spend
most of the time in the incubator. (2) During these interventions, the infant’s reaction
was always monitored using a pulse oximeter and a cardiac monitor. At any signs of
alarm, (heart rate greater that 200 bpm or oxygen saturation under 90%) the
intervention was suspended for 25 seconds until the preterm infant was stable. None
of the babies experienced any distress signals. For the MI group the intervention was
always performed one hour after the baby was fed.
Procedure of the Interventions carried out during 5 consecutive days
Massage therapy in a incubator (MI) : The infant was placed in prone position and
was given moderate pressure stroking with the flats of the fingers. Five 1-minute
intervals, consisting of six 10-s periods of stroking, were applied to the following
body regions : Head, back, both legs and both arms. The same protocol was repated
in supine position. The last part was flexion of the extremities. (Field, 1984).
In most of the studies the protocol has been held three times a day for 5 or 10
consecutives days, in both cases all the studies have reported greater Weight Gain for
the interventions group : Massage Therapy Incubator group versus Control group
(Traditional Care). These differences in the duration or number of periods do not
seemed to affect the positive outcomes found in the intervention group (Diego et al.,
2007; Tiffany Field et al., 2010b).
Massage In Kangaroo Position : (MKP) : The infant was placed in prone position
in vertical position on the chest of the mother or father in direct skin-skin contact. In
this position an adjustable cotton and lycra band is placed around the baby and the
mother or father to maintain the position. The researchers supervise the adequacy of
the baby’s head, arms and legs position. Once the position is correct, the massage
begins with moderate pressure stroking with the fingertips of the right hand while the
left hand holds the baby’s head. The massage therapy is applied following the same
27
procedure as in MI, except that it is applied in kangaroo postion described above for
the Prone position.
Kangaroo mother Care(KMC) : The infant is placed in vertical position on the
chest of the mother or father in direct skin- skin contact. In this position, a band of
cotto lycra around the baby and the mother or father is placed to maintain the
position. The researchers supervise the adequacy of the baby’s head, arms and legs
position of the baby. The hips should be flexed and extended in a “frog” position ; the
arms should also be flexed. This position is practiced 10 hours minimum per day.
Measures
Antropometric : Weight and Head Circumference were measured at birth, the
day preceding the intervention and every day at 7 :00 am from the first day of
the intervention until the 5th day, at two weeks post intervention and at 40
weeks of GA. Length was measured at birth, the day preceding the
intervention, the first day of the intervention and at 40 weeks of GA.
Time spent in skin-skin contact (KMC) : For all participants the number of
hours in KMC position was measured by the research assistant at the NICU
during 15 days from the beginning of the intervention.
Growth velocity : The following formulas are used to measure the growth velocity for
each of the antropometric measures.
The Weight gain (WG) was measured in grams per day per kg with the same
formula at 5, 15 days and 40 weeks Gestational Age.
𝑊𝐺5 = [(Weight fifth day – weight first day)
Weight fifth day × 1000] ÷ 4
28
Length was measured in cm per week at 15 days and 40 weeks GA with the
same formula.
𝐿𝐸𝑁𝐺𝑇𝐻15 =( length at 15 day − length 1 day )
2
Head circumeference (HC) was measured in cm per week at 15 and 40 weeks
of gestational age with the same formula.
𝐻𝐶15 =( HC 15 day − HC 1 day)
2
2.3.3. Analysis
Univariate analyses of variance were conducted to measure the differences
between groups at the beginig of the interventions per hospital no differences were
found Table 2.2 and Table 2.5.
A second univariate analysis was conducted to measure the effects of the different
interventions in function of days of life when the intervention begins ; < 5 days, 6 to
10 and > 10. The same analysis was repeated for each cohort of the study Table 2.6,
Table 2.7 and Table 2.8.
2.4. Results
2.4.1. «KMC & MKP » vs «KMC &MI» – First Cohort (Hospital
one)
The univariate test revealed that infants in the « MKP & KMC » group gained
significantly more weight than those in the « MI & KMC » group at 5 days (9.7 ±1.6
Vs 3.4 ± 3.5p =.0.1) and day 15 (11.8 ±0.7gr vs 9.6 ±0.9 gr p = 0.07). There was no
difference between the 2 interventions for length and head circumference growth at
any moment during and after the intervention Table 2.4.
For the second analysis the group of preterms « MKP & KMC» with <5 days of
life, the group are loosing significantly less weight than those in the « MI & KMC» at
29
5 days (.02 ±6.9 Vs -12.7 ± 25.37 p .012) and 15 days (10.06 ± 5.6 Vs 7.3 ±4.2 p
.013) of intervention. (Table 2.6) And the group of preterms with 6 to 10 days of life
there was also a greater Weight Gain at 40 wks in kg (3052± 271.5 Vs 2755±390.9. p
016) Table 2.6 and Table 2.7.
2.4.2. «KMC »Vs «MI & KMC» –Second Cohort (Hospital two)
In the second cohort, the univariate test shows no significant difference between
the groups in anthropometric data. Only the gain weight during the 15 days post
intervention is better when the intervention began after 10 days of life. There were no
differences in other anthropometrics data Table 2.7.
2.4.3. « MI » VS « TC » – Third cohort (Hospital three)
There was a trend of the intervention «MI » at 15 days with higher gain weight (10.26
± 4.11 vs 8.57 ± 5.49, p = .10) no differences were found in head circumference and
length. For the analyses in function of the days of life when the intervention starts
there was no difference between groups in any of the antropometric measures at any
moment of the intervention Table 2.6, Table 2.7 and Table 2.8.
2.5. Discussion
To accomplish the objectives, we studied the effects of the interventions on three
indicators of growth; weight gain in grams per Kg per day at 5 and 15 days and the
weight in kg at 40 wks, head circumference and length gain in cm per week in order
to evaluate the growth differences between the interventions at 5 and 15 days post
intervention and at 40 weeks of GA. And then analyse the same outcomes in fuction
of days of life at the beginig of intervention in 3 categories of preterms infants with
< 5 days, 6 to 10 days and > 10 days.
Based on these results, we claim the practice of early interventions by parents
could improved better growth velocity during the hospitalization at the neonatal
intensive care unit where the goal is to obtain a Weight, Head perimeter and Length
gain velocity similar to the foetus in the mother`s womb, causing less negative
outcomes.
30
Based on these positive results, the «MKP» intervention acts as a complementary
technique in order to maintain the benefits of KMC (breastfeeding, thermoregulation
through skin-skin contact with the chest of the mother) and contributes to faster
recovery of the physiological loss of initial weight specifically in preterm infants with
less than 5 days of life, evident in the greater weight gain at 5 and 15 days post
intervention and 40 wks. This result is associated with two positive outcomes in the
preterm infant; better growth, more hours in kangaoo position and shorter stay at
hospital. As reported in the literature these results might be linked to further brain
maturation. A study by Ehrenkranz (2005) describes how adequate weight gain while
in the hospital is a predictor of neurodevelopmental and growth outcomes at 18 to 22
months.
A group of 600 preterms were evaluated and the incidence of cerebral palsy,
neurodevelopmental impairment and need for rehospitalization fell significantly.
Conversely, another study states that lower growth measurements (weight, length and
head circumference) during the hospitalization period is associated with greater
neurodevelopmental disability (R. a Ehrenkranz et al., 2006). These data support the
idea that a follow up of this study would be mandatory to evaluate the brain impact of
this MKP intervention. Another result found was a shorter hospitalization period that
benefits the preterm decreasing the risk of phsycial sickness got during the stay at
hospital. (N Charpak, Ruiz-Peláez, Figueroa de C, & Charpak, 1997)
The last contribution of the practice of «MKP» was the increased time spent in
KMC. One of the great challenges of this method is to increase the practice during the
hospitalization period. In our study this objective is achieved if parents are invited to
perform «MKP»; as the massage is performed while the baby is carried in the
Kangaroo Position it increases the lenght of time of skin to skin contact as compared
to the massage in incubator. (Table 2.3)
In the second cohort (hospital 2), though there was a tendency for a weight gain in
the KMC group, in prterms with moree than 10 days of life. Until now there is not
enough evidence of a significant effect from studies that compare these interventions
«KMC» and «KMC+MI» in terms of growth development, but in a long-term study at
31
2 years of age, better neurodevelopmental scores were found for the group were the
combination of both interventions, «KMC+MI», was delivered in the neonatal period,
(Procianoy, Mendes, & Silveira, 2010). It is then important to replicate studies that
consider the combination of both techniques and study the outcomes in order to
establish more clearly the benefits that could be obtained in terms of improved
growth development and neurodevelopmental outcomes.
In the third cohort, we compared «MI» Vs «TC» in a cohort of preterm infants that
did not receive KMC. There was no differences even if other studies published by
Scadafi (1986), and others (Tiffany Field et al., 2004; Tiffany Field, Diego, &
Hernandez-Reif, 2011; Moyer-Mileur et al., 1995; White & Labarba, 1976) showed
that the intervention group presented greater weight gain in grams per day compared
to the control group. It was not our case in ifants with < 5 days, 6 to 10 and > 10 days
of life.
Moreover, it seems that the parents as well as the medical professionals produces
equivalent results. Ferber (2002) attempted to measure weight gain due to «MI»
practice, and she seeked to measure if its effect is the same independently of the
group of people that performs the intervention. To do this she compares a group of
parents, a group of health care professionals, and a control group with no
intervention, finding that the benefits of the intervention are the same regardless of
who performs it. Considering these results and the positive impact of this intervention
in other studies, we suggest that parents should perform it. Performing the
intervention evidenced showed positive results in other outcomes ilike better
confidence while taking care of their infant in the hospital, which will be a great
conribution after discharge when they will be fully in charge of care. Moreover, in
this way the intervention does not represent an additional work load for professionals,
who further approved increased parent involvement in child care as a result of the
intervention.
32
2.5.1. Limitations and Advantages of the study:
One of the Limitations was due to the differences in the three hospitals mentioned
previously (standard KMC practice, visiting hours etc.), it was not possible to
conduct a study with the application of five different interventions in the same
hospital. Also the KMC it is a standardize practice in the first and second hospital.
For those reasons, a randomized experimental design was conducted in each hospital,
and statistical analyzes were performed independently.
Two advantages were possible to identify. The first positive aspect of the study is
the randomization of patients in two conditions of intervention by hospital that
allowed avoiding the bias of the researcher in the allocation of cases to the groups and
ensure that statistical tests are valid significance values. This is the best scientific
design to demonstrate the effectiveness of interventions.
The second was the possibility of having a researcher per patient during the 5 days
of the intervention, with the aim of reducing bias during the due process that had to
be done by parents three times a day. The last advantage was having a team of health
professionals blind to our research hypotheses and blind to the parent’s experimental
group allocation.
2.5.2. Implications for application in the neonatal intensive care
unit:
The results of this study suggest that practice of KMC and MKP contribute in
growth and development of preterm infants especially if the intervenvion starts with
less than 5 days of life. In turn is evidenced the capabilities of parents to practice each
of these interventions in the neonatal care unit when the premature is in a medical
stable condition. Other studies have reported similar outcomes of each of these
methods where parents also delivered the intervention (Conde-Agudelo, 2000;
Tiffany Field et al., 2011).
Based on the evidence from these studies the numbers of health professionals
trained in those interventions around the world are increasing. However, these
interventions are not considered as standard practice in many neonatal intensive care
33
units. The results of this study may help make a case for the introduction of these
interventions because it is a strategy of low-cost option, it improves the quality of
hospitalization of the newborn, and the health professionals include the parents in the
caring process, which contributes to an optimal development in newborn.
2.5.3. Clinical and practice concerns for future studies
The importance of parental care in the neonatal intensive care unit and how this is
associated to a better development is already known (Kennell & Klaus, 1984). In this
study we suggest that the early alternative interventions practiced in the NICU need
to focus in a continued contact between parents-preterm as the only source that could
complement the medical procedures delivered during the period of hospitalization.
This could have an impact not only in the growth of the preterm as found in this
study but also in the mental health of parents that are exposed to stress (Tommiska,
Ostberg, & Fellman, 2002), depression (O’brien, Asay, & McCluskey-fawcett, 2007)
and anxiety (Miles, 1991). The physical contact given by the parents to the preterm
could have an impact in decreasing those symptoms, associated with posttraumatic
stress disorders (Kersting et al, 2004).
For this reason, further studies should take into account the mental hearlth of
parents before, during and after the practice of these interventions, to evaluate if there
is a positive impact not only in the preterms but also in the mental health fo the
parents.
34
2.6. References
Allen, M. C. (2008). Neurodevelopmental outcomes of preterm infants. Current
Opinion in Neurology, 21(2), 123–8. doi:org/10.1097/WCO.0b013e3282f88bb4
Angio, C. T. D., & Maniscalco, W. M. (2004). Bronchopulmonary Dysplasia in
Preterm Infants Pathophysiology and Management Strategies, V(5), 303–330.
Beck, S., Wojdyla, D., Say, L., Betran, A. P., Merialdi, M., Requejo, J. H., … Van
Look, P. F. a. (2010). The worldwide incidence of preterm birth: a systematic
review of maternal mortality and morbidity. Bulletin of the World Health
Organization, 88(1), 31–8. doi:org/10.2471/BLT.08.062554
Charpak, N., Ruiz-Peláez, J. G., Figueroa de C, Z., & Charpak, Y. (1997). Kangaroo
mother versus traditional care for newborn infants </=2000 grams: a
randomized, controlled trial. Pediatrics (Vol. 100, pp. 682–688). doi :/10.1542/peds.100.4.682
Conde-Agudelo, A. (2000). Kangaroo mother care to reduce morbidity and mortality
in low birthweight infants. Review. The Cochrane …, (3). Retrieved from
doi:10.1002/14651858.CD002771.pub3/pdf/standard
Diego, M. a, Field, T., Hernandez-Reif, M., Deeds, O., Ascencio, A., & Begert, G.
(2007). Preterm infant massage elicits consistent increases in vagal activity and
gastric motility that are associated with greater weight gain. Acta Paediatrica
(Oslo, Norway : 1992), 96(11), 1588–91. doi:org/10.1111/j.1651-
2227.2007.00476.x
Ehrenkranz, R. a, Dusick, A. M., Vohr, B. R., Wright, L. L., Wrage, L. a, & Poole,
W. K. (2006). Growth in the neonatal intensive care unit influences
neurodevelopmental and growth outcomes of extremely low birth weight infants.
Pediatrics, 117(4), 1253–61. doi:org/10.1542/peds.2005-1368
Ehrenkranz, R. A., Dusick, A. M., Vohr, B. R., Wright, L. L., Wrage, L. A., Poole,
W. K., & Carolina, N. (2006). Growth in the Neonatal Intensive Care Unit
Influences Neurodevelopmental and Growth Outcomes of Extremely Low Birth
Weight Infants, 117(4). doi:org/10.1542/peds.2005-1368
Feldman, R., Weller, A., Sirota, L., & Eidelman, A. I. (2002). Skin-to-skin contact
(kangaroo care) promotes self-regulation in prématuré infants: Sleep-wake
cyclicity, arousal modulation, and sustained exploration. Developmental
Psychology, 38(2), 194–207. doi:org/10.1037//0012-1649.38.2.194
35
Feldman, R., Weller, A., Sirota, L., & Eidelman, A. I. (2003). Testing a family
intervention hypothesis: The contribution of mother-infant skin-to-skin contact
(kangaroo care) to family interaction, proximity, and touch. Journal of Family
Psychology, 17(1), 94–107. doi:org/10.1037/0893-3200.17.1.94
Field, T., Diego, M., & Hernandez-Reif, M. (2010a). Moderate pressure is essential
for massage therapy effects. The International Journal of Neuroscience, 120(5),
381–5. doi:org/10.3109/00207450903579475
Field, T., Diego, M., & Hernandez-Reif, M. (2010b). Preterm infant massage therapy
research: a review. Infant Behavior & Development, 33(2), 115–24.
doi:org/10.1016/j.infbeh.2009.12.004
Field, T., Diego, M., & Hernandez-Reif, M. (2011). Potential underlying mechanisms
for greater weight gain in massaged preterm infants. Infant Behavior &
Development, 34(3), 383–9. doi:org/10.1016/j.infbeh.2010.12.001
Field, T., Hernandez-Reif, M., Diego, M., Feijo, L., Vera, Y., & Gil, K. (2004).
Massage therapy by parents improves early growth and development. Infant
Behavior and Development, 27(4), 435–442.
doi:org/10.1016/j.infbeh.2004.03.004
Hay, W. W., Md, J., Lucas, a., Heird, W. C., Ziegler, E., Levin, E., … Yaffe, S. J.
(1999). Workshop Summary: Nutrition of the Extremely Low Birth Weight
Infant. Pediatrics, 104(6), 1360–1368. doi:org/10.1542/peds.104.6.1360
Holditch-Davis, D. (2003). Posttraumatic Stress Symptoms in Mothers of Premature
Infants. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 32(2), 161–
171. doi:org/10.1177/0884217503252035
Howard, K., Sc, B., & Inder, T. E. (2006). Neonatal MRI to Predict
Neurodevelopmental Outcomes in Preterm Infants, 685–694.
Johnston, C. (2014). Skin-to-skin care for procedural pain in neonates. Status and
Date: New …, (1). Retrieved from
doi:10.1002/14651858.CD008435.pub2/pdf/standard
Kennell, J. H., & Klaus, M. H. (1984). Mother-infant bonding: Weighing the
evidence. Developmental Review, 4(3), 275–282. doi:org/10.1016/S0273-
2297(84)80008-8
Kersting, a, Dorsch, M., Wesselmann, U., Lüdorff, K., Witthaut, J., Ohrmann, P., …
Arolt, V. (2004). Maternal posttraumatic stress response after the birth of a very
36
low-birth-weight infant. Journal of Psychosomatic Research, 57(5), 473–6.
doi:org/10.1016/j.jpsychores.2004.03.011
Miles, M. S. (1991). The neonatal intensive care unit Enviroment - Sources of
stress.Journal Advanced Critical Care : 2(2), 346-354). doi: 10.4037/15597768-
1991-2022
Miles, M. S., Holditch-Davis, D., Schwartz, T. a, & Scher, M. (2007). Depressive
symptoms in mothers of prematurely born infants. Journal of Developmental
and Behavioral Pediatrics : JDBP, 28(1), 36–44.
doi:org/10.1097/01.DBP.0000257517.52459.7a
Moyer-Mileur, L., Luetkemeier, M., Boomer, L., & Chan, G. M. (1995). Effect of
physical activity on bone mineralization in premature infants. The Journal of
Pediatrics, 127(4), 620–5. Retrieved from doi: http://dx.doi.org/10.1016/S0022-
3476(95)70127-3
Rose, Susan A, Feldman F. Judith, J. . J. and V. R. R. (2012). Information Processing
from infancy to 11 years: Continuities and Prediction of IQ. National Intstitute
Of Health, 40(5), 445–457. doi:org/10.1016/j.intell.2012.05.007.Information
Scholz, K., & Samuels, C. a. (1992). Neonatal Bathing and Massage Intervention
with Fathers, Behavioural Effects 12 Weeks after Birth of the First Baby: The
Sunraysia Australia Intervention Project. International Journal of Behavioral
Development, 15(1), 67–81. doi:org/10.1177/016502549201500104
Tommiska, V., Ostberg, M., & Fellman, V. (2002). Parental stress in families of 2
year old extremely low birthweight infants. Archives of Disease in Childhood.
Fetal and Neonatal Edition, 86(3), F161–F164. doi:10.1136/fn.86.3.F161
Treyvaud, K., Sych, D. P., Anderson, V. A., Lee, K. J., Woodward, L. J., Newnham,
C., … Anderson, P. J. (2009). Parental Mental Health and Early Social-
emotional Development of Children Born Very Preterm, 1–10. doi:10.1093/jpepsy/jsp109
White, J., & Labarba, R. (1976). The effects of tactile and kinesthetic stimulation on
neonatal development in the premature infant. Developmental Psychobiology,
9(December 1975), 569–577. Retrieved from doi:
10.1002/dev.420090610/abstract
Zanardo, V., Freato, F., & Zacchello, F. (2003). Maternal anxiety upon NICU
discharge of high-risk infants. Journal of Reproductive and Infant Psychology,
doi:org/10.1080/0264683021000060093.
37
Tableau 2.1 Experimental design for the three cohorts.
Interventionsa
Cohort 1 (Hospital 1)
« KMC & MKP » « KMC & MI »
Cohort 2 (Hospital 2)
« KMC » « KMC & MI »
Cohort 3 (Hospital 3)
« MI » « TC »
a KMC: Kangaroo Mother Care: MKP: Massage therapy in Kangaroo Position; MI: Massage therapy in incubator
38
Tableau 2.2 Neonatal clinical characteristics of the infants and parental demographic information
Hospital 1 Hospital 2 Hospital 3
Kangaroo Mother Care for all Kangaroo Mother Care for all Traditional Care for all
MKP
n=33
MI
n=33
p
No MI
n=33
MI
n=33
p
MI
n=33
TC
n=33
p
Variables Means (±SD) Means (±SD) Means (±SD) Means (±SD) Means (±SD) Means (±SD)
Birth Weight 1708.2±330.3 1626±293.2 .87 1700.2±284.1 1617.1±272.5 .94 1738.1±223.0 1682.1±286.0 .38
Birth HC 30.39±2.0 31.11±1.5 .34 29.19±1.82 30.14±2.2 .79 30.92±1.4 29.59 ± 1.6 .66
Birth length 42.03± 2.9 42.11 ± 3.0 .32 43.37± 2.9 42.02 ± 3.7 .70 43.01 ± 2.5 42.07±3.09 .98
Gestational age at birth
(wk) 32.12±1.0 32.25±.83 .44 32.35±0.96 31.82±1.6 .06 32.39±1.1 31.88±1.1 .97
Age in days at the
beginning of the
intervention
7.66±4.34 7.21±4.38 .94 8.03±4.63 8.04±4.21 .49 6.09±5.26 5.84±4.53 .49
Mother Age 27.43 ± 7.3 28.75 ±7.8 .22 27.3±4.9 28.4±5.9 .22 26.7± 7.6 23.8 ± 7.4 .86
Father Age 30.78 ± 10.5 32.74 ± 8.5 .57 30.1±6.8 31.3 ± 6.9 .92 29.3 ± 8.1 26.9 ± 8.1 .55
39
Tableau 2.3 Clinical neonatal outcomes
Hospital 1 Hospital 2
Kangaroo Care Kangaroo Care
MKP
(n=33)
MI
(n=33)
p
No MI
(n=33)
MI
(n=33)
p
Variables Means (±SD) Means (±SD) Means (±SD) Means (±SD)
Total hours in KP during the first 5 days of
intervention.
25.4±13.6
20.86 ± 10.2
.05
35.6 ±20.6
22.57±11.00
.05
Total hours in KP during at 15 days post
intervention.
133.3 ± 64.9
110.0± 71.0
.00
138.9 ± 58.5
94.7± 43.24
.03
Duration of hospitalization
15.44±8.8
20.59±13.0
.095
28.55±24.3
27.71±16.6
.87
40
Tableau 2.4 Weight Gain in grams per day 5. 15 and 40 wks GA
Hospital 1 Hospital 2 Hospital 3
Kangaroo Care Kangaroo Care Traditional Care
MPK
(n =33)
MI
(n =33)
Control
(n =33)
MI
(n =33)
MI
(n =33)
TC
(n =33)
Variables Means (±SD) Means (±SD) p Means (±SD) Means (±SD) p Means (±SD) Means (±SD) p
5 days 9.7±1.6 3.4 ± 3.5 .01 11.86±14.08 10.21 ±9.69 .60 3.76 ± 14.36 6.08 ± 14.98 .52
15 days 11.8±0.7 9.60 ± 0.9 .07 10.68 ± 4.68 9.91± 3.90 .48 10.26 ± 4.11 8.57 ± .5.49 .10
40 weeks GA 2922 ± 418 2690 ± 327 .01 7.95 ± 1.69 7.17 ± 1.98 .092 7.67 ± 1.24 7.49 ± 2.01 .65
41
Tableau 2.5 Neonatal clinical characteristics of infants categorized by days of life at the moment of interventio
Hospital 1 Hospital 2 Hospital 3
Kangaroo Mother Care for all
Kangaroo Mother Care for all
Traditional Care for all
MKP
(n =33)
MI
(n =33)
Without Massage
(n =33)
MI
(n =33)
MI
(n =33)
TC
(n =33)
Variables Means (±SD) Means (±SD) p Means (±SD) Means (±SD) p Means(±SD) Means(±SD) p
<5 days
Number of Infants % 11 (16.6) 11 (16.6) 13 (21.31) 8(13.11) 7 (11.11) 4 (6.34)
Weight at birth 1851 1766 .40 1871 1832 .98 1619 1428 .82
HP at birth 31.38 31.14 .59 30.04 32.1 .08 29.98 28.87 .45
Length at birth 42.97 43.03 .85 44.46 44.44 .97 41.50 39.14 .58
6 to 10 days
Number f Infants % 13 (19.69) 14 (21.21) 11 (18.03) 11 (18.03) 20 (31.74) 20 (31.74)
Weight at birth 1736 1646 .54 1574 1505 .32 1822 1765 .43
HP at birth 30.45 29.74 .35 28.59 29.27 .33 31.46 29.86 .49
Length at birth 43.18 41.38 .51 45.0 40.9 .73 43.57 42.97 .32
42
MKP : Massage Therapy Kangaroo Position; MI: Massage Therapy Incubator; TC: Traditional Care
> 10 days
Number f Infants % 9 (13.63) 7 (10.60) 9(14.75) 9 (14.75) 7 (11.11) 5 (7.93)
Weight at birth 1492 1346 .21 1606 1562 .17 1565 1704 .26
HP at birth 29.09 29.09 .20 28.38 29.4 .49 28.9 29.7 .71
Length at birth 41.85 39.93 .15 42 42 1.0 42.2 42.6 .40
43
Tableau 2.6 Effect of the age at the beginning of the intervention on outcomes at 5 and 15 days post intervention and at 40 weeks of
GA
Hospital 1 Hospital 2 Hospital 3
Kangaroo Mother Care for all Kangaroo Mother Care for all Traditional Care for all
MKP
(n =33)
MI
(n =33)
Without Massage
(n =33)
MI
(n =33)
MI
(n =33)
TC
(n =33)
Variables Means (±SD) Means (±SD) p Means (±SD) Means (±SD) p Means (±SD) Means (±SD) p
Weight gain
(gr)
5 days .02 ±6.9 -12.7± 25.3 .012 3.95±10.95 3.55±12.05 .93 1.54±14.72 5.10±17.65 .44
15 days 10.06 ± 5.6 7.3 ±4.2 .013 8.35±4.43 8.56±3.46 .90 9.71±5.79 8.33±5.97 .33
Weight at 40
wks GA 2951±510. 2618±. 337 .014 3025±335.8 3091±441.6 .67 2870±329.8 3013±245.4 .09
HC gain (mm)
15 days .91±.40 .84±.32 .77 1.07±1.00 1.0±.44 .91 1.00±.79 .77±.38 .26
40 weeks .66±.26 .67±.17 .89 .90±.29 79±.24 .34 .0.88±.0.20 0.68±.0.34 .003
Length gain
(mm)
15 days .85± .99 1.86±2.29 .16 .45±.37 .66±.28 .71 .92±.83 1.64±197 .19
40wks GA .57±29 .61±.20 .75 .83±.36 .73±.41 .50 .80±.36 .98±.63 .26
44
Tableau 2.7 Effect of the age at the beginning of the intervention 6 to 10 days of life on outcomes at 5 and 15 days post intervention
and at 40 weeks of GA
Hospital 1 Hospital 2 Hospital 3
Kangaroo Mother Care for all Kangaroo Mother Care for all Traditional Care for all
MKP
(n =33)
MI
(n =33)
Without Massage
(n =33)
MI
(n =33)
MI
(n =33)
TC
(n =33)
Variables Means (±SD) Means (±SD) p Means (±SD) Means (±SD) p Means (±SD) Means (±SD) p
Weight gain (gr per day)
5 days 16,33±7.30 9.72±8.99 0.11 11.66±9.71 14.16±8.34 .60 9.69±11.01 7.00 ±8.99 .75
15 days 14.05± 4.05 10.00 ±4.65 0.11 9.90±3.80 10.78±4.39 .59 10.63±3.10 6.95±5.70 .17
Weight at 40
weeks (gr) 3052±271.5 2755±390.9 .016 2851±259.5 2667±337.1 .21 2966±441.3 2837±100.7 .39
HC gain (cm)
15 days 1.00±.30 1.16±.99 .52 .84±1.59 .87±.56 .91 1.24±.50 .66±.42 .13
40 weeks .80±17 .77±.27 .75 .82±.23 .63±.23 .074 .0.95±.0.30 0.68±0.16 .10
Length gain (cm)
15 days 1.05±..93 .99±.55 .92 .10±.22 .71±.65 .18 1.66±.76 1.13±1.05 .68
40 wks GA .65±.34 .75±.24 .42 76±.38 57±.34 .25 .55±.42 .98±.63 .70
45
Tableau 2.8 Effect of the age at the beginning of the intervention >10 days of life on outcomes at 5 and 15 days post intervention and
at 40 weeks of GA
Hospital 1 Hospital 2 Hospital 3
Kangaroo Mother Care for all Kangaroo Mother Care for all Traditional Care for all
MKP
(n =33)
MI
(n =33)
Without
Massage
(n =33)
MI
(n =33)
MI
(n =33)
TC
(n =33)
Variables Means (±SD) Means (±SD) p Means (±SD) Means (±SD) p Means (±SD) Means (±SD) p
Weight gain
(gr per day)
5 days 10.67 + 4.09 12.54± 7.04 .76 22.20±16.97 12.62±6.42 .074 3.53±16.00 8.75±8.94 .57
15 days 9.94 ±4.33 11.63 ± 4.64 .46 14.67±3.05 10.38±3.46 .023 6.65±2.31 8.18±4.53 .59
Weight at 40
weeks (gr) 2748 ± 343.7 2823 ± 142.7 .63 2787±286.2 2699±478±.8 .59 3036±384.9 2804±197.3 .19
HC gain (cm)
15 days 1.34±.65 1.02±46 .31 1.12±1.03 1.26±.70 .93 .91±.46 1.02±.53 .76
40 weeks .90±+31 .97±.07 .57 .96±.34 .75±.43 .068 .94±.28 .85±.44 .66
Length gain
(cm)
15 days .48±.43 1.12±.74 .46 1.22±.1.15 1.11±.82 .76 1.03±.06 1.58±1.89 .66
40 wks GA 0.76± 0.42 0.86± 0.39 .66 1.08±.34 0.74±.43 .08 .88±.59 1.01±.59 .70
46
3. Chapitre 3 Deuxième article: Effects of Massage
in Kangaroo Care Position at birth on infant’s
neurodevelopmental outcomes at 6 and 12 months
of corrected age.
47
Résumé du deuxième article
Contexte : Le Massage en Incubateur (MI) et la Methode Mère Kangourou
(MMK) ont été étudiés comme interventions indépendantes et ont montré des effets
positifs. Néanmoins, il n'y a aucune preuve sur les mesures neurolgiques de la mise
en œuvre de Massage en Posisition Kagourou (MPK).
Objectifs : comparer la pratique de MPK et la pratique de MI sur les mesures
neurologiques à 6 et 12 mois d'âge corrigé.
Méthode : Un groupe de prématurés ≤ 33 et faible poids ≤1500 g à la naissance ont
été répartis en deux groupes : «MPK» (n = 33) et «MI» (n = 33). Les interventions
étaient réalisées pendant 5 jours consécutifs. Le développement neurologique a été
mesuré avec le test Griffiths administré à 6 et 12 mois d'âge corrigé. Le soin
Kangarou (contecta peau a peau) était une pratique standardisée pour les deux
groupes et les protocoles de massage (en incubateur ou en position de kangourou) ont
été ajoutés comme les variations expérimentales.
Résultats : Les deux groupes étaient équivalents à la naissance. Il n'y avait pas
d'effet significatif des protocoles de massage à 6 et 12 mois sur le quotient de
développement global. De plus, il n'y avait pas de différence de groupe à 6 mois dans
aucune des cinq sous-échelles. À 12 mois, il y avait une différence positive sur la
coordination ocullo-manuelle et de l'ouïe- langage qui favorisant le groupe « MMK
&MKP ».
Conclusion : Le protocole de Massage en Position Kangourou lie a la pratique de la
méthode m’erre kangourou ont un impact à 12 mois d'âge corrigé sur les grands
prématurés. En outre, du point de vue clinique, le « MPK » augmente la quantité de
temps que le bébé est en contact peu à peu avec ses parents.
48
Abstract
Background: Massage therapy and Kangaroo Mother Care have been studied as
independent interventions and have shown positive neurodevelopmental outcomes.
Nevertheless, there is no evidence on neurodevelopmental outcomes of the
implementation of the «Massage Therapy in Kangaroo Care Position».
Objectives: To compare the practice of «Massage Therapy in Kangaroo Care
Position» (MKP) and the practice of «Massage Therapy in Incubator» (MI) on
neurodevelopmental outcomes at 6 and 12 months of corrected age.
Method: The sample is a group of premature (≤ 33wga) and low birthweight
Colombian infants (≤1500 g). They were randomly assigned at two groups : «
Massage Therapy in Kangaroo Care Position » (n=33) and « Massage Therapy in
Incubator » (n=33) and received the interventions during 5 consecutive days in their
inborn hospital. Neurodevelopment outcomes measured by the Griffiths test were
administered at 6 and 12 months of corrected age. The Kangaroo Care was a
standardized practice for both groups and the massage protocols (in incubator or in
kangaroo position) were added as the experimental variations.
Results: Both groups were equivalent at birth but the « Massage in Kangaroo Care
Position» group carried their baby for more hours (18%) than the other group of
mothers. There was no significant effect of the massage protocols at 6 and 12 months
on the global developmental quotient. Moreover, there were no group difference at 6
months on any of the five subscales. At 12 months, there was a positive difference on
the Hand-Eye coordination and Hearing and Speech groups favoring « Massage
Therapy in Kangaroo Care Position».
Finding: Both massage protocols linked to Kangaroo Mother Care have an impact
at 12 months of corrected age on the very premature babies. Moreover, from a
clinical perspective the «Massage Therapy in Kangaroo Care position» increases the
quantity of time the baby is in close contact to his/her mother.
49
3.1. Introduction
The survival rate of the very preterm infants is increasing (Beck et al., 2010) but
the morbidities are constant and the short and long term consequences are well known
to be devastating in many cases. Follow-up studies on preterm hospitalized infants
weighting less than 1500 grams in the NICU report neurodevelopmental impairments
in the motor area mainly attributable to cerebral palsy, the major disabling outcome
(Hay et al., 1999). This is reflected in fine motor static and dynamic imbalance,
transient dystonia, extension tone of the trunk and lower extremities, head lag on
traction and delayed supportive responses (Bracewell & Marlow, 2002)
In the cognitive area, almost all studies reported that IQ scores are positively
corassociated with gestational age and/or weight at birth. A meta analysis at school
age, based on 16 studies on ex-preterm children followed from 5 to 14 years, reported
that the differences in school performance were mainly associated to low overall IQ
(Adnan T. Bhutta, Mario A. Cleves, Casey, Cradock, & Anand, 2002). In addition,
recent studies in preterm infants with neurodevelopment impairment showed a greater
risk of abnormal language development, suggesting that the Broca’s and Wernicke’s
neural pathways have a delayed maturation in preterm infants (Adams-Chapman,
Bann, Carter, & Stoll, 2015)
Behavioural and social difficulties are also present in this population particularly
during adolescence were the parents of preterm infants reported less social
competence in boys and internalization and attention problems in girls (Dahl et al.,
2006). À meta-analysis including 35 studies had similar results regarding
internalization in adolescents born preterm (Aarnoudse-Moens, Weisglas-Kuperus,
van Goudoever, & Oosterlaan, 2009).
In summary, most results from meta-analyses and observational studies concluded
that premature or low birth weight subjects have cognitive deficits, poorer academic
performance, attention problems and are less socially competent than their full-term
peers, and that these consequences have long lasting impacts on adolescence and
adulthood (Moster, Lie, & Markestad, 2008) Could those negative impacts in the
50
development of the preterm neonates be changed? Are there early interventions,
which could reverse the process?
3.1.1. Kangaroo Mother care ( KMC) and neurodeveleopmental
outcomes
Kangaroo Mother Care was initiated in 1978 in Bogota, Colombia by Dr Edgar
Rey, a pediatrician. It has been developed and evaluated by a team of researchers of
the Kangaroo Foundation in Colombia. This intervention is now considered to be one
of the major contributors to the decrease in infant morbidity and mortality rate
(Nathalie Charpak et al., 2005). The intervention is based on the skin-to-skin contact
between the chest of the parent and their infant during the perinatal period. In this
position the parents give a physical presence and provision of warm interactions
during the postpartum period, which is known to promote psychological and
behavioural processes, which in turn have an impact on the infant’s brain systems that
manage stress and enhance social adaptation (Ruth Feldman et al., 2003). One of the
consequence is a more positive mother-infant interaction and maternal infant bonding
that contributes to a better auto-regulation and a higher score of attachment at 3 years
of age. There is also an improved coordination of attention to the mother and
sustained effortful exploration of the environment. (Ruth Feldman et al., 2002). In the
long term, during the schooling period at 5 and 10 years of age, there is a better
cognitive and executive function in infants who received Kangaroo Care during the
neonatal period. (Ruth Feldman, Rosenthal, & Eidelman, 2014b).
Physiologically, Kangaroo Care activates the autonomic nervous system (ANS),
which controls the regulation of heart rhythm. The ANS also matures through
thermal, tactile stimuli provided by the parent’s body. This system regulates the
body’s response to the external demands providing support to complex cognitive and
social skills helping to moderate the transition between the neonate and his
environment. It is also reported as lowering the pain response, increasing the
physiologic stability and regulating the sleep cycles (Ruth Feldman & Eidelman,
2003). It has also been reported as a predictor of early development in cognitive
outcomes. (Charpak et al., 2005)
51
3.1.2. Massage Therapy and neurodevelopmental outcomes
Until now there are no consistent results regarding the long term effects of
Massage therapy in incubator (MI) on preterm newborns. Some short term studies
have found interesting results concerning brain maturation. One of them describes
how MI accelerates the maturation of visual function, particularly visual acuity, and
suggests that its effects are mediated by specific endogenous factors such as IGF-1, a
growth hormone that regulates brain growth and in particular, the development of the
visual cortex. The effects of the massage are not permanent and differences between
massaged and control infants could no longer be detected at 7 months and 12 months
(Guzzetta et al., 2009).
A more recent study found that the maturation of brain electrical activity induces a
process more similar to that observed in utero in term infants (Guzzetta et al.,
2011). This study shows that receiving MI during the hospitalization period has a
positive effect on brain maturation. Other studies have evaluated outcomes in the
motor and cognitive development using neurodevelopmental assessments. One of
these studies evaluated 37 extremely premature babies of 1 year of corrected age,
which were randomly assigned to either the MI group or the control group. It was
hypothesized that a positive effect would be observed in the group receiving the
intervention, but the results did not show significant group differences on the Bayley
scores (Nelson et al., 2001). Contrarily to these findings, a follow-up study at 6
months of age on infants who received MI found evidence improvement in weight
gain and mental and motor development scores for the intervention group at the
Bayley Test (Field et al., 2004)
3.1.3. Benefits of Massage Therapy in Kangaroo Position (MKP)
No previous studies have measured the long-term effects of this intervention in the
neurodevelopment of the premature infant. However, studies on the two techniques
52
on which this intervention is based, Kangaroo Mother Care and Massage Therapy in
Incubator, show independently positive results.
Based on these results it can be asserted that there is a favorable impact of
performing the two techniques simultaneously, but the question arises of whether
further improved results could be achieved by applying the massage itself in
kangaroo position where the incubator would be replaced by the more favorable
environment of KMC and the continuous practice of the intervention would be
favored.
Research question and hypothesis
Based on the recognised positive impact of the Kangaroo Care intervention and
since the numerous publications on the short term positive impacts of the massage
therapy in incubator would the addition of the massage in position kangaroo promotes
higher neurodevelopmental outcomes?
Controlling for the parents’ and infants’ gender, and for the length of time the
baby is in kangaroo position, the hypothesis is that the massages therapy in Kangaroo
Care position during the neonatal period by the parents improves better
neurodevelopmental outcomes at 6 and 12 months of corrected age for the preterm
infants that received Massage Therapy in Kangaroo Position.
3.2. Method
3.2.1. Design
This study is a randomized controlled trial realized in Bogota, Colombia on a
group of 66 preterm infants randomly assigned at two types of early interventions
«MKP» vs «MI» delivered in the neonatal intensive care unit for 5 consecutive days’
period. A random number generator was used to assign infants to either «MKP n= 33
» or «MI n=33». Opaque sealed envelops were use to conceal allocation. Parents,
assistant researchers and health professionals in the NCU were blind to allocation
until the envelope was opened. Informed parental consent was signed before the
53
randomization. While not during the massage procedure both groups benefitted from
the regular Kangaroo Care intervention.
3.2.2. Partipants
The participants were allowed to participate in the study if they met the inclusion
criteria: (a) Having a gestational age at birth between 29 and 33 weeks, (b) weight
≤1500 grams, (c) stable health condition (d) no congenital anomalies, (e) 6 and 12
months of corrected age, (f) having a mother and father who are open to
communication and agree to cooperate. Student’s T-test did not show significant
differences between parents’ and infants’ general characteristics between groups.
3.2.3. Procedure
Interventions at birth
The parents were instructed by the researcher to performed the interventions as it
follows. The parents had been trained to do the intervention which is done 3 times per
day and under the supervision of an assistant. The infant’s reaction was always
monitored using a pulse oxymeter and cardiac monitor. At any signs of alarm, (heart
rate greater that 200 bpm or oxygen saturation under 90%) the intervention was
suspended for 25 seconds until the baby was stable. None of the babies experienced
any distress signal. The intervention was always performed one hour after the baby’s
feeding.
Interventions procedures
a) Massage Therapy in Incubator (MI): The infant is transferred from the kangaroo
position to the incubator by the parent helped by the medical personal. The parent is
the administrator of the massage. The infant is placed in a prone position and is given
moderate pressure stroking with the flats of the fingers of both arms. Five 1-min
intervals, consisting of six 10-s periods of stroking, were applied to the following
body regions: a) from the top of the infants’ head, down the back of the head to the
neck and back to the top of the head; b) from the back of the neck across the
shoulders and back to the neck; c) from the upper back down to the buttocks and
returning to the upper back (contact with the spine was avoided; d) simultaneously on
54
both legs from the hips to the feet and back to the feet and back to the hips; e) both
arms simultaneously from the shoulders to the wrist to the shoulders and flexion of
the extremities arms and legs for periods of 60 seconds 5 times in the right and left
side (Scafidi et al., 1986)
b) Massage Therapy in Kangaroo Care Position (MKP): The skin-to-skin contact
is required. The infant is placed in vertical position on the mother’s chest. A research
assistant supervised the adequate position head, arms and legs of the baby. In this
position a band of cotton adjustable stabilizes the baby and the mother or father was
asked to keep the position. Once the position is correct, the massage begins with
moderate pressure stroking with the flats of the fingers of the right hand with the left
hand holds the baby head. The same protocol as the one used in incubator is
performed.
Follow up at 6 and 12 months: Curent study -
All infants were contacted by telephone and appointments were assigned at 6 and
12 months of corrected age (see Flow Chart here after). Due to family difficulties, 4
children were lost to follow up in the MI group. During the assessment the father or
mother were present. All the assessments were done in the same room in the inborn
hospital.
Measures
Griffiths test
At 6 and 12 months of corrected age the Griffiths test was administrated to get a
general developmental quotient (DQ) obtained by combining the scores on five areas:
loco-motor, personal-social, hearing and speech, eye and hand coordination and
performance. Furthermore, subscale quotients for each area are derived
independently. We obtain a general score and five domain scores at 6 and 12 months
of corrected age Figure 3.1. The test was validated in Colombia and is commonly
used in preterm population (Christiansen & Ortiz, 1974)
55
Insert figure 3.1 about hear
3.3. Analysis
Univariate analyses of variance were conducted to measure the effects of the
interventions on the General developmental quotient at 6 and 12 months of corrected
age. We used the development quotient (DQ) at 12 months and 6 months, consisting
of the total Griffiths score and five subsacores, as the dependent variables and the
intervention groups as the main independent condition As the duration of
hospitalization was linked to the intervention it was used as a covariable. Statistical
analyses were performed with SPPS.
3.4. Results
Sixty-two infants were evaluated at 6 and 12 months of corrected age: 33 received
Massage in Kangaroo Care and 29 Massage in Incubator. They all received the
Kangaroo Care intervention but the number of hours in Kangaroo Position was higher
at 5 days for the group MKP (25.4 ± 13.6 vs 20.86 ± 10.2, p = .05).
At 6 months of corrected age the groups’ DQ means were not different (MKP:
78.44 ±12.36 vs MI: 80.71± 8.20 p = .44). At 12 months the groups’ mean was 3
points higher but not statistically significant (MTCK: 85.62 ± 12.93 vs MI: 82.95 ±
4.42, p = .22).
Analyses of the 5 subscales indicate a general trend at 6 months of corrected age
where the MI group obtains positive but not significant differences. At 12 months, the
mean subscores were not different with the exception of the Eye and Hand score (p =
,006) ( table 3.2) and Language and Hearing score (p = .038) Table 3.2 favouring
the group Massage in position Kangaroo.
56
Table 3.2 about hear
3.5. Discussion
Two interventions were practiced in the neonatal intensive care unit: Massage
Therapy in Kangaroo position (MKP) and Massage Therapy in Incubator (MI).
Moreover, the practice of regular Kangaroo Care was maintained daily in both groups
and followed the same protocol in the same hospital. The research question was then
the value of the massage applied in the Kangaroo position vs the Massage applied in
the incubator. The massage was given by the parent using the same technique but
adapted to each context.
The daily Kangaroo Care practice has regularly shown positive outcomes in the
development of the preterm infant on growth development, breasfeeding, decreases
risk of mortality (Conde-Agudelo, 2000). A study using Kangaroo Care in a neonatal
intensive care unit has shown higher DQ in low birth weight infants with fragile
health using the Griffiths developmental assessment (Réjean Tessier et al., 2003a).
This study also showed higher scores in three subscales, namely Hearing and Speech,
Personal Social, and Performance observed at 12 months of corrected age. Moreover,
a subsample of this group submitted to a neurological experiment at 15 years
(Transcranial Magnetic Stimulation) have shown enhanced synchronization,
conduction time and connectivity of cerebral motor pathways (Schneider, Charpak,
Ruiz-Peláez, & Tessier, 2012) reflecting a more mature brain organisation.
These studies support our first conclusion that the Kangaroo Care, applied
conjointly to both groups, might equally influence DQ outcomes. But at 6 months
both groups had a similar general quotient and subscales scores were also equivalent.
In the Field’s study (2001) which highlighted better scores in mental and motor
development at 6 months in a group of preterm infants who received massage therapy
57
in incubator the comparison group was premature without massage. Other massage
studies (without kangaroo care) were also conducted over a short period of time in the
neonatal period and showed evidence of better outcomes in relation to brain activity
and visual function at 7 months of corrected age (Guzzetta et al., 2011). But any of
these studies included kangaroo care. However, an other study has shown that 6-
month old infants in a Kangaroo Care group had higher Bayley developmental scores
in the mental (MDI) and motor (PDI) domains. Regression models point to the fact
that the mental score was predicted by infant’s alertness during early social
interaction with the mother in the neonatal period, highlighting the relationship
between infant attention span and cognitive skills (Feldman, Eidelman, Sirota, &
Weller, 2002).The same sample of 146 children (73 KMC and 73 Traditional care)
was observed at 10 years and concluded that cognitive capacity has been found in the
Kangaroo Mother Care group (Ruth Feldman et al., 2014b).
These two first studies compared a group of Massage therapy to a group without
Massage and confirmed that the massage produces higher weight gains. Ohter studies
compared a group who benefitted of KMC vs a group without Kangaroo Care.
Conclusion was that Kangaroo care increases the development, mostly cognitive. In
any case was there a comparison between 2 groups who benefitted of Kangaroo Care
added to a modality of massage. Our results have not shown group difference at 6
months suggesting that there is no early impact on cognitive development of the
modality of massage.
At 12 months of corrected age, the global Griffiths scores appear equivalent in
both groups. However, the Hand-Eye coordination (p < ,006) and the Hearing and
Speech subscales (p = ,038) indicate higher scores in the Massage in Kangaroo
position group. The Hand-Eye coordination subscale measures the capacity of the
preterm infant to maintain their attention on external stimuli and it evaluates
cognitive function. Other studies that compared Kangaroo Care intervention without
massage have demonstrated positive impact on infants development as compared to
those who received no physical contact (Tessier et al. 2003). The results were similar
in the Feldman et al.’s study where the intervention group of children looked more
58
frequently at the stimuli, for longer periods, with wider eyes and with more eye
movement indicating an improved attention span. These results indicate improved
cognitive skills, habituation performance and exploratory behaviour in later infancy.
There have been several studies other studies in this area. One of them reported that
the visual information processing in infancy is among the strongest predictors of
cognitive development during adolescence (Rose, Susan A, Feldman F. Judith, 2012)
Another study reported that highly efficient visual processing during the neonatal
period was a predictor for higher cognitive skills at 5 years of age (Cohen &
Parmelee, 1983). A further study reported improved functioning on tasks that require
a longer attention span at 18 years of age (Sigman, Cohen, & Beckwith, 1997). These
results suggest that the immediate benefits of the intervention Massage Therapy in
Kangaroo Care on the subscale concerning Hand-Eye coordination, are important as a
predictor of cognitive development.
The Hearing and Speech subscore is the social part of the Griffiths scores. It is the
expression of the children’s social capacities to interact with his/her caregiver. It has
already been documented that KMC impacts on the family’s involvement manifested
by an increase bonding effect as soon as the first days of life (Tessier et al. 1998).
This bonding is the expression of a reciprocal link between parents and children that
would be facilitated by the sensorial availability of the child observed in the Hearing
and Speech subscore. This is also part of the socio cognitive development which is
favoured by he Massage during the Kangoroo position rather than in the incubator. It
has been noted how efficient was the “looking-at-the-mother” of the KMC children
during the brastfeeding experience. In this study, it appears that the Massage in KMC
position enrich this close experience by touching in a systematic way the infant’s
body.
In summary, applied to very premature infants, the combination of massage and
Kangaroo care managed by the parents during the hospital stay produces an increase
of the Oculo-Manual coordination and Hearing and Speech ability at 12 months.
Massage therapy while in position kangaroo appears to support and enrich the
traditional Kangaroo Care protocol more than the massage given by the parent in
59
incubator. Both these subscales of the Griffiths neurodevelopmental test are markers
of neurological maturation. These effects are modest but given the randomized design
of the study they are significant. It has already published that the mechanisms by
which KMC acts is in the regulation of cortical organization though the process of
myelination (Tessier et al. 2003). Another part of the neurological hypothesis is the
added sensory stimulations given by the massages which is supported by the evidence
that specific environmental inputs are necessary for normal cortical development (Als
et al., 2015). The massage therapy provides the sensory information needed for basic
development of the sensorimotor body scheme which is manifested in the better
Hand-Eye coordination.
3.5.1. Clinical concerns
Furthermore, at 12 months of corrected age there is a clinical aspect that favours
the practice of the massage therapy in Kangaroo Care, one of them is more time in
Kangaroo Care as is reported in the Table 1. The group of parents who delivered the
massage in this position carried a longer time (more hours) in comparison to the
group Massage Therapy in incubator. This allows the parents to develop a stronger
attachment with their infants during a critical period. Also during the practice of the
massage in kangaroo position the parent might express feelings of security and
comfort toward the preterm infant. In comparison, the parents who deliver the
massage in the incubator might express insecurity when they have to transfer the baby
from the Kangaroo Care position to the incubator to deliver the massage therapy. In
conclusion, the massage in Kangaroo position might favour the parent’s feeling and
performance while it helps infants’ neurological maturation.
3.5.2. Limits and strengths
In relation to the methodology, there was a common factor in both groups, namely
that both groups were subject to some skin-skin contact. It is therefore difficult to
disentangle between the effects of the «Massage Therapy in Incubator» and «Massage
Therapy in Kangaroo Position». Future studies on neurodevelopmental outcomes
should therefore compare both interventions with a controlled group.
60
It would also be necessary to consider the perinatal and neonatal complications.
Even though the inclusion criteria were based on medically healthy infants in the
neonatal period up until 6 and 12 months of corrected age, other factors could play an
important role on the neurodevelopment subsequent to intervention.
One of the strengths of our study was that 90% of the preterm infants from the
initial group were followed up until 12 months of corrected age. Other strength was
that the psychologists who conducted the assessments at 6 and 12 months of
corrected age, were not aware which infants were subject to Massage Therapy in
Incubator and which infants were subject to Massage Therapy in Kangaroo Care.
61
3.6. References
Aarnoudse-Moens, C. S. H., Weisglas-Kuperus, N., van Goudoever, J. B., &
Oosterlaan, J. (2009). Meta-analysis of neurobehavioral outcomes in very
preterm and/or very low birth weight children. Pediatrics, 124(2), 717–28.
doi:org/10.1542/peds.2008-2816
Adams-Chapman, I., Bann, C., Carter, S. L., & Stoll, B. J. (2015). Language
outcomes among ELBW infants in early childhood. Early Human Development,
91(6), 373–9. doi:org/10.1016/j.earlhumdev.2015.03.011
Adnan T. Bhutta, M., Mario A. Cleves, P., Casey, P. M., Cradock, M. P., & Anand,
K. J. S. (2002). Cognitive and Behavioral Outcomes, 288(6), 728–737.
doi.org/10.1001/jama.288.6.728
Aliabadi, F., & Askary, R. K. (2013). Effects of tactile-kinesthetic stimulation on low
birth weight neonates. Iranian Journal of Pediatrics, 23(3), 289–294.
doi.org/10.1097/00001577-199200420-00021
Allen, M. C. (2008). Neurodevelopmental outcomes of preterm infants. Current
Opinion in Neurology, 21(2), 123–8. doi:org/10.1097/WCO.0b013e3282f88bb4
Als, H., Duffy, F. H., Mcanulty, G. B., Rivkin, M. J., Vajapeyam, S., Mulkern, R. V,
Eichenwald, E. C. (2015). Early Experience Alters Brain Function and Structure,
113(4). doi.org/10.1542/peds.113.4.846
Anderson, P. J., & Doyle, L. W. (2008). Cognitive and educational deficits in
children born extremely preterm. Seminars in Perinatology, 32(1), 51–8.
doi:org/10.1053/j.semperi.2007.12.009
Angio, C. T. D., & Maniscalco, W. M. (2004). Bronchopulmonary Dysplasia in
Preterm Infants Pathophysiology and Management Strategies, V(5), 303–330.
doi:org/10.2165/00148581-200406050-00004
Beck, S., Wojdyla, D., Say, L., Betran, A. P., Merialdi, M., Requejo, J. H., … Van
Look, P. F. a. (2010). The worldwide incidence of preterm birth: a systematic
review of maternal mortality and morbidity. Bulletin of the World Health
Organization, 88(1), 31–8. doi:org/10.2471/BLT.08.062554
Bracewell, M., & Marlow, N. (2002). Patterns of motor disability in very preterm
children. Mental Retardation and Developmental Disabilities Research Reviews,
8(4), 241–8. doi:org/10.1002/mrdd.10049
62
Casey, P. H., Kraemer, H. C., & Bernbaum, J. (2000). Fetal and neonatal medicine
Growth status and growth rates of a varied sample of low birth weight , preterm
infants : A longitudinal cohort from birth to three years of
age.doi :org/10.1016/s0022-3476(05)82414-x
Charpak, N. (2009). Lineamientos Técnicos Para la Implementacion de Programas
Madre Canguro en Colombia. (L. A. Ochoa, Ed.) (Primera Ed, p. 121). Bogota,
Colombia.: Divergraficas Ltda.
Charpak, N., Ruiz, J. G., Zupan, J., Cattaneo, A., Figueroa, Z., Tessier, R., … Worku,
B. (2005). Kangaroo Mother Care: 25 years after. Acta Paediatrica (Oslo,
Norway : 1992), 94(5), 514–22. doi:org/10.1080/08035250510027381
Charpak, N., Ruiz-Peláez, J. G., Figueroa de C, Z., & Charpak, Y. (1997). Kangaroo
mother versus traditional care for newborn infants </=2000 grams: a
randomized, controlled trial. Pediatrics (Vol. 100, pp. 682–688).
doi :org/10.1542/peds.100.4.682
Christiansen, V., & Ortiz, N. (1974). Adaptacion de la prueba de desarrollo mental de
griffiths a la poblacion de bogota.reordenacion de los items, 6(3), 347–361.
Cohen, S. E., & Parmelee, A. H. (1983). Prediction of Five-Year Stanford-Binet
Scores in Preterm Infants. Society for Research in Child Development, 54(5),
1242–1253. doi:org/10.2307/1129679
Conde-Agudelo, A. (2000). Kangaroo mother care to reduce morbidity and mortality
in low birthweight infants. Review. The Cochrane …, (3). Retrieved from
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD002771.pub3/pdf/stand
ard
Dahl, L. B., Kaaresen, P. I., Tunby, J., Handegård, B. H., Kvernmo, S., & Rønning, J.
a. (2006). Emotional, behavioral, social, and academic outcomes in adolescents
born with very low birth weight. Pediatrics, 118(2), e449–59.
doi:org/10.1542/peds.2005-3024
Diego, M. a, Field, T., Hernandez-Reif, M., Deeds, O., Ascencio, A., & Begert, G.
(2007). Preterm infant massage elicits consistent increases in vagal activity and
gastric motility that are associated with greater weight gain. Acta Paediatrica
(Oslo, Norway : 1992), 96(11), 1588–91. doi:org/10.1111/j.1651-
2227.2007.00476.x
Ehrenkranz, R. a, Dusick, A. M., Vohr, B. R., Wright, L. L., Wrage, L. a, & Poole,
W. K. (2006). Growth in the neonatal intensive care unit influences
63
neurodevelopmental and growth outcomes of extremely low birth weight infants.
Pediatrics, 117(4), 1253–61. doi:org/10.1542/peds.2005-1368
Ehrenkranz, R. A., Dusick, A. M., Vohr, B. R., Wright, L. L., Wrage, L. A., Poole,
W. K., & Carolina, N. (2006). Growth in the Neonatal Intensive Care Unit
Influences Neurodevelopmental and Growth Outcomes of Extremely Low Birth
Weight Infants, 117(4). doi:org/10.1542/peds.2005-1368
Ehrenkranz, R. A., Dusick, A. M., Vohr, B. R., Wright, L. L., Wrage, L. A., Poole,
W. K., & Carolina, N. (2015). Growth in the Neonatal Intensive Care Unit
Influences Neurodevelopmental and Growth Outcomes of Extremely Low Birth
Weight Infants, 117(4). doi:org/10.1542/peds.2005-1368
Er, M., Gc, A., & Bergman, N. (2007). Early skin-to-skin contact for mothers and
their healthy newborn infants ( Review ), (4). doi.org/10.1046/j.1523-
536x.2003.00247.x
Feldman, R., Eidelman, a. I., Sirota, L., & Weller, a. (2002). Comparison of Skin-to-
Skin (Kangaroo) and Traditional Care: Parenting Outcomes and Preterm Infant
Development. Pediatrics, 110(1), 16–26. doi:org/10.1542/peds.110.1.16
Feldman, R., & Eidelman, A. I. (2003). Skin-to-skin contact (Kangaroo Care)
accelerates autonomic and neurobehavioural maturation in preterm infants.
Developmental Medicine & Child Neurology, null(04), 274–281.
doi:org/10.1017/S0012162203000525
Feldman, R., Rosenthal, Z., & Eidelman, A. I. (2014a). Maternal-preterm skin-to-skin
contact enhances child physiologic organization and cognitive control across the
first 10 years of life. Biological Psychiatry, 75(1), 56–64.
doi:org/10.1016/j.biopsych.2013.08.012
Feldman, R., Rosenthal, Z., & Eidelman, A. I. (2014b). Maternal-preterm skin-to-skin
contact enhances child physiologic organization and cognitive control across the
first 10 years of life. Biological Psychiatry, 75(1), 56–64.
doi:org/10.1016/j.biopsych.2013.08.012
Feldman, R., Weller, A., Sirota, L., & Eidelman, A. I. (2002). Skin-to-skin contact
(kangaroo care) promotes self-regulation in premature infants: Sleep-wake
cyclicity, arousal modulation, and sustained exploration. Developmental
Psychology, 38(2), 194–207. doi:org/10.1037//0012-1649.38.2.194
Feldman, R., Weller, A., Sirota, L., & Eidelman, A. I. (2003). Testing a family
intervention hypothesis: The contribution of mother-infant skin-to-skin contact
64
(kangaroo care) to family interaction, proximity, and touch. Journal of Family
Psychology, 17(1), 94–107. doi:org/10.1037/0893-3200.17.1.94
Ferber, S. G., Feldman, R., Kohelet, D., Kuint, J., Dollberg, S., Arbel, E., & Weller,
A. (2005). Massage therapy facilitates mother–infant interaction in premature
infants. Infant Behavior and Development, 28(1), 74–81.
doi:org/10.1016/j.infbeh.2004.07.004
Ferber, S. G., Kuint, J., Weller, A., Feldman, R., Dollberg, S., Arbel, E., & Kohelet,
D. (2002). Massage therapy by mothers and trained professionals enhances
weight gain in preterm infants. Early Human Development, 67(1-2), 37–45.
doi:org/10.1016/S0378-3782(01)00249-3
Field, T. (2001). Massage Therapy Facilitates Weight Gain in Preterm Infants.
Current Directions in Psychological Science, 10(2), 51–54.
doi:org/10.1111/1467-8721.00113
Field, T., Diego, M., & Hernandez-Reif, M. (2010a). Moderate pressure is essential
for massage therapy effects. The International Journal of Neuroscience, 120(5),
381–5. doi:org/10.3109/00207450903579475
Field, T., Diego, M., & Hernandez-Reif, M. (2010b). Preterm infant massage therapy
research: a review. Infant Behavior & Development, 33(2), 115–24.
doi:org/10.1016/j.infbeh.2009.12.004
Field, T., Diego, M., & Hernandez-Reif, M. (2010c). Preterm infant massage therapy
research: a review. Infant Behavior Development, 33(2), 115–124.
doi.org/10.1016/j.infbeh.2009.12.004
Field, T., Diego, M., & Hernandez-Reif, M. (2011). Potential underlying mechanisms
for greater weight gain in massaged preterm infants. Infant Behavior &
Development, 34(3), 383–9. doi:org/10.1016/j.infbeh.2010.12.001
Field, T., Grizzle, N., Scafidi, F., & Abrams, S. (1996). Massage theraphy for infants
of depressed mothers. Infant Behavior and, 107–112. doi.org/10.1016/s0163-
6383(96)90048-x
Field, T., Hernandez-Reif, M., Diego, M., Feijo, L., Vera, Y., & Gil, K. (2004).
Massage therapy by parents improves early growth and development. Infant
Behavior and Development, 27(4), 435–442
doi:org/10.1016/j.infbeh.2004.03.004
Fielder, A., Blencowe, H., O’Connor, A., & Gilbert, C. (2015). Impact of retinopathy
of prematurity on ocular structures and visual functions. Archives of Disease in
65
Childhood. Fetal and Neonatal Edition, 100(2), F179–84.
doi:org/10.1136/archdischild-2014-306207
Guzzetta, A., Baldini, S., Bancale, A., Baroncelli, L., Ciucci, F., Ghirri, P., … Maffei,
L. (2009). Massage accelerates brain development and the maturation of visual
function. The Journal of Neuroscience : The Official Journal of the Society for
Neuroscience, 29(18), 6042–51. doi:org/10.1523/JNEUROSCI.5548-08.2009
Guzzetta, A., D’Acunto, M. G., Carotenuto, M., Berardi, N., Bancale, A., Biagioni,
E., … Cioni, G. (2011). The effects of preterm infant massage on brain electrical
activity. Developmental Medicine and Child Neurology, 53 Suppl 4, 46–51.
doi:org/10.1111/j.1469-8749.2011.04065.x
Harrison, L. L. (2001). The use of comforting touch and massage to reduce stress for
preterm infants in the neonatal intensive care unit. Newborn and Infant Nursing
Reviews, 1(4), 235–241. doi:org/10.1053/nbin.2001.28103
Hay, W. W., Md, J., Lucas, a., Heird, W. C., Ziegler, E., Levin, E., … Yaffe, S. J.
(1999). Workshop Summary: Nutrition of the Extremely Low Birth Weight
Infant. Pediatrics, 104(6), 1360–1368. doi:org/10.1542/peds.104.6.1360
Holditch-Davis, D. (2003). Posttraumatic Stress Symptoms in Mothers of Premature
Infants. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 32(2), 161–
171. doi:org/10.1177/0884217503252035
Howard, K., Sc, B., & Inder, T. E. (2006). Neonatal MRI to Predict
Neurodevelopmental Outcomes in Preterm Infants, 685–694.
Johnston, C. (2014). Skin-to-skin care for procedural pain in neonates. Status and
Date: New …, (1). Retrieved from
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD008435.pub2/pdf/stand
ard
Kennell, J. H., & Klaus, M. H. (1984). Mother-infant bonding: Weighing the
evidence. Developmental Review, 4(3), 275–282. doi:org/10.1016/S0273-
2297(84)80008-8
Mally, P. V, Bailey, S., & Hendricks-Muñoz, K. D. (2010). Clinical issues in the
management of late preterm infants. Current Problems in Pediatric and
Adolescent Health Care, 40(9), 218–33. doi:org/10.1016/j.cppeds.2010.07.005
Moster, D., Lie, R. T., & Markestad, T. (2008). Long-Term Medical and Social
Consequences of Preterm Birth.
66
Moyer-Mileur, L., Luetkemeier, M., Boomer, L., & Chan, G. M. (1995). Effect of
physical activity on bone mineralization in premature infants. The Journal of
Pediatrics, 127(4), 620–5. Retrieved from
http://www.ncbi.nlm.nih.gov/pubmed/7562289
Nadeau, L., Boivin, M., Tessier, R., Lefebvre, F., & Robaey, P. (2001). Mediators Of
Behavioral Problems in 7-Year-Old Children Born after 24 To 28 Weeks of
Gestation. Journal of Developmental & Behavioral Pediatrics, 22(1), 1–10.
doi:org/10.1097/00004703-200102000-00001
Nelson, M. N., White-Traut, R. C., Vasan, U., Silvestri, J., Comiskey, E., Meleedy-
Rey, P., … Patel, M. (2001). One-Year Outcome of Auditory-Tactile-Visual-
Vestibular Intervention in the Neonatal Intensive Care Unit: Effects of Severe
Prematurity and Central Nervous System Injury. Journal Of Child Neurology,
16(07), 493. doi:org/10.2310/7010.2001.17044
Procianoy, R. S., Mendes, E. W., & Silveira, R. C. (2010). Massage therapy improves
neurodevelopment outcome at two years corrected age for very low birth weight
infants. Early Human Development, 86(1), 7–11.
doi:org/10.1016/j.earlhumdev.2009.12.001
Richardson, D. K., Gray, J. E., & Gormaker, S. L. (1999). Declining Severity
Adjusted Mortality: Evidence of Improving Neonatal Intensive Care. Pediatrics,
102(4), 893–899.
Rojas, M. A., Kaplan, M., Quevedo, M., Sherwonit, E., Foster, L. B., Ehrenkranz, R.
A., & Mayes, L. (2003). Somatic Growth of Preterm Infants During Skin-to-
Skin Care Versus Traditional Holding : A Randomized , Controlled Trial
Description of Subjects, 24(3).
Rose, Susan A, Feldman F. Judith, J. . J. and V. R. R. (2012). Information Processing
from infancy to 11 years: Continuities and Prediction of IQ. National Intstitute
Of Health, 40(5), 445–457. doi:org/10.1016/j.intell.2012.05.007.Information
Scafidi, F. a., Field, T. M., Schanberg, S. M., Bauer, C. R., Vega-Lahr, N., Garcia, R.,
… Kuhn, C. M. (1986). Effects of tactile/kinesthetic stimulation on the clinical
course and sleep/wake behavior of preterm neonates. Infant Behavior and
Development, 9(1), 91–105. doi:org/10.1016/0163-6383(86)90041-X
Scafidi, Frank a. Field, T. (1993). Factors that Predict which Preterm Infants benefit
Most from Massage Therapy, 14, 176–80.
Schneider, C., Charpak, N., Ruiz-Peláez, J. G., & Tessier, R. (2012). Cerebral motor
function in very premature-at-birth adolescents: A brain stimulation exploration
67
of kangaroo mother care effects. Acta Paediatrica, International Journal of
Paediatrics, 101(10), 1045–1053.
Scholz, K., & Samuels, C. a. (1992). Neonatal Bathing and Massage Intervention
with Fathers, Behavioural Effects 12 Weeks after Birth of the First Baby: The
Sunraysia Australia Intervention Project. International Journal of Behavioral
Development, 15(1), 67–81. doi:org/10.1177/016502549201500104
Sigman, M., Cohen, S. E., & Beckwith, L. (1997). Why does infant attention predict
adolescent intelligence? Infant Behavior and Development, 20(2), 133–140.
doi:org/10.1016/S0163-6383(97)90016-3
Tessier, R., Cristo, M. B., Velez, S., Giron, M., Nadeau, L., Figueroa de Calume, Z.,
… Charpak, N. (2003). Kangaroo Mother Care: A method for protecting high-
risk low-birth-weight and premature infants against developmental delay. Infant
Behavior and Development, 26(3), 384–397. doi:org/10.1016/S0163-
6383(03)00037-7
Tessier, R., Cristo, M., Velez, S., Giron, M., Ruiz-Palaez, J. G., Charpak, Y., &
Charpak, N. (1998). Kangaroo Mother Care and the Bonding Hypothesis.
Pediatrics, 102(2), e17–e17. doi:org/10.1542/peds.102.2.e17
Treyvaud, K., Sych, D. P., Anderson, V. A., Lee, K. J., Woodward, L. J., Newnham,
C., … Anderson, P. J. (2009). Parental Mental Health and Early Social-
emotional Development of Children Born Very Preterm, 1–10.
White, J., & Labarba, R. (1976). The effects of tactile and kinesthetic stimulation on
neonatal development in the premature infant. Developmental Psychobiology,
9(December 1975), 569–577. doi.org/10.1002/dev.420090610
Zanardo, V., Freato, F., & Zacchello, F. (2003). Maternal anxiety upon NICU
discharge of high-risk infants. Journal of Reproductive and Infant Psychology,
21(1), 69–75. doi:org/10.1080/0264683021000060093
68
Figure 3.1 Study flow chart
Griffiths at 6 and 12 months
Corrected age
Interventions in the NICU at birth
for 5 days
Patients randomised N= 66
n=33
Kangaroo care & Massage in
kangaroo position
n=33
Kangaroo care & Massage in incubator
n =33 (100%)
Kangaroo care + Massage in kangaroo position
n = 29 (88%)
Kangaroo care
+ Massage in
incubator
69
Tableau 3.1 Medical information of infants at birth
.
Kangaroo Care
Variables MKP MI P
Weight birth (gr +SD) 1708.2 ±330.9 1626 ±293,2 .87
HC Birth (cm +SD) 30.39 ±2.06 31.11 ±1,57 .34
Height at birth (cm +SD) 42.03 ±2.9 42.11 ±3,07 .32
Gestational age at birth (weeks +SD) 32.12±1.0 32.25 ± .83 .44
Hospital Stay (days +SD) 15.44±8.8 20.59 ±13.0 .09
Total hours in KP during the first 5
days of intervention. (days +SD) 25.4±13.6 20.86 ±10.2 .05
Mother Age (years +SD) 27.43 ±7.3 28.75 ±7.8 .22
Father Age (years +SD) 30.78 ±10.5 32.74 ±8.5 .57
Tableau 3.2 The global IQ and general quotients Griffiths scales at 6 and 12 months
of corrected age.
6 Months 12 Months
Kangaroo Care Kangaroo Care
MKP MI MKP MI
IQ 78.44 ±12.36 80.7±8.20 .44 85.62±12.93 82.95 ±4.42 .22
Locomotor 80.93 ± 21.78 85.3 ±14.61 .39 83.03 ±13.85 86.09 ± 9.31 .98
Personal-Social 80.45± 14.5 81.5 ±10.03 .75 82.8 ± 12.95 82.9 ± 4.35 .96
Hearing and language 75.73 ± 12.1 76.18 ± 8.6 .89 87.0± 14.23 81.55±4.85 .038
Eye and hand 88.69± 16.5 88.80 ±11.4 .97 91.91 ±14.23 85.53 ± 4.85 .006
Performance 76.42 ± 13.1 80.27 ±14.6 .16 84.63 ± 14.66 84.06 ± 3.93 .82
70
4. Conclusions générales
Cette thèse a été élaborée pour comparer les effets d’interventions non
conventionnelles dans l’unité néonatale de soins intensifs. Deux articles ont été
rédigés correspondant à deux objectifs généraux.
4.1.1. Retour sur les objectifs et contributions de la thèse
Le premier article est fondé sur la comparaison de deux interventions par hôpital
dans trois institutions différentes. Les interventions se sont étalées sur une période de
5 jours consécutifs dans l’unité néonatale de soins intensifs afin d’identifier quel type
d’intervention était le plus efficace à court terme pendant la période d’hospitalisation.
L’efficacité était observée par l’impact de chaque intervention sur la croissance
(poids, périmètre crânien, taille). Aucune étude préalable n’avait comparé les
interventions sous cet aspect.
Dans le premier hôpital les mesures ont montré un effet de la « Méthode
Kangourou & Massage en position Kangourou » uniquement pour la variable poids et
ce, après cinq et quinze jours d’intervention et à 40 semaines d’âge gestationnel et
uniquement pour les enfants qui ont débuté le programme hâtivement soit 5 jours ou
moins après la naissance. Dans ce groupe, de plus, les enfants ont été
significativement plus longtemps en contact peau à peau avec leur parent ce qui
pourrait avoir contribué à la différence du gain de poids rapide.
Ces deux résultats permettent de comprendre comment une quantité de temps
supplémentaire en contact peau à peau pourrait contribuer à une amélioration des
conditions de soins à l’hôpital. Comme démontré déjà dans d’autres études, le contact
peau à peau favorise la régulation de la température chez l’enfant prématuré, la
diminution de la douleur pendant des procédures médicales, une plus grande
autorégulation des comportements en relation à son environnement. Le fait d’exécuter
le massage en position kangourou favorise une récupération de poids plus rapide dans
un moment critique où les enfants sont réputés perdre du poids et où une des tâches
impérieuses des soins professionnels est d’aider ces derniers à récupérer le plus
71
rapidement possible le poids perdu suite aux dérèglements physiologiques lors d’une
naissance prématurée.
Dans le deuxième hôpital, aucun effet de ces deux groupes n’a été rapporté pour la
variable poids ni pour le périmètre cranien ni pour la taille. Ces résultats ne
permettent pas de déterminer quelle intervention du Massage en Incubateur ou de la
Méthode Kangourou (sans massage) a le meilleur effet sur la croissance au cours de
la période d'hospitalisation. Il serait pertinent de dupliquer la présente étude et
d’observer les résultats à long terme, car une autre étude qui a effectué le suivi de 35
enfants jusqu’à l’âge corrigé de deux ans a permis d’obtenir un meilleur effet de
l'intervention « Massage en Incubateur & Méthode Kangourou » sur le
développement mental et moteur en comparaison au groupe « Méthode Kangourou »
sans massage (Procianoy, Mendes, & Silveira, 2010). Cette dernière étude n’a
toutefois pas pris de mesures de croissance pendant la période d’intervention à
l’hôpital, mais a seulement mesuré les effets des interventions à 2 ans.
Finalement dans le troisième hôpital une tendance positive du « Massage en
incubateur » est importante à mentionner pour les variables poids et périmètre cranien
pour les enfants qui ont commencé le massage entre 6 et 10 jours depuis leur
naissance. Ces différences ne sont pas statistiquement significatives, mais constantes
et doivent être interprétées en comparaison de ceux obtenus dans d’autres études où la
randomisation des patients et les procédures de massage étaient exactement les
mêmes (Aliabadi & Askary, 2013; Tiffany Field et al., 2010a; Tiffany Field, 2001;
Scafidi et al., 1986; White & Labarba, 1976) et où le massage en incubateur
produisait des gains substantiels de poids.
L’unique différence qui peut être mise en évidence avec certaines études est la
durée de temps pendant laquelle l’intervention a été réalisée. Dans notre étude la
durée fut de 5 jours et dans les autres études, elle est de 10 jours. Dans une révision
de la littérature, Tiffany Field (2004) décrit qu’indépendamment de la durée de 5 à
10 jours d’intervention, les effets sur l’augmentation de poids sont identiques.
72
Il a par ailleurs été démontré que le massage en incubateur par comparaison aux
soins traditionnels augmente la synchronisation dans les réponses aux besoins de
l’enfant chez les parents qui pratiquent cette intervention à l’hôpital (Ferber et al.,
2002).
Dans le deuxième article, le but est de démontrer comment la pratique des
interventions non conventionnelles très tôt dans l’unité néonatale de soins intensifs
peut avoir un impact dans le développement neurologique de l’enfant à 6 et 12 mois
de l’âge corrigé. Pour atteindre cet objectif, nous avons limité l’étude au premier
hôpital où les groupes « Méthode Kangourou & Massage en position kangourou »
vs « Méthode Kangourou & Massage en Incubateur » sont comparés. Plusieurs
études ont démontré comment les interventions chez une population d’enfants
prématurés hospitalisés dans l’unité néonatale de soins intensifs sont corrélées à long
terme avec un meilleur développement cognitif et moteur (Orton, Spittle, Doyle,
Anderson, & Boyd, 2009). Pour cette raison la question à laquelle nous avons cherché
à répondre est celle d’un effet à long terme au niveau neuro cognitif attribuable à
l’une des interventions.
Les résultats obtenus au test de développement Griffiths démontrent qu’il y a une
tendance, mais non significative à 6 mois le dans groupe « Massage en Incubateur »
pour le QI général. À 12 mois d’âge corrigé nous avons observé des différences
significatives de l’intervention « Massage en Position Kangourou » dans les sous tests
de la Coordination oculo — Manuelle et Audition et Langage, lesquels sont associés
à un meilleur développement cognitif à long terme (R. Feldman et al., 2002).
À partir de ce résultat, il est possible de conclure que la pratique du massage, soit
en Incubateur ou en Position Kangourou, ajoute une différence dans un milieu
hospitalier qui pratique la Méthode Mère Kangourou comme soin standardisé. Les
résultats nous autorisent à suggérer qu’il y a un avantage positif à la pratique
d’intervention comme le Massage pendant la période d’hospitalisation des enfants
prématurés de moins de 33 semaines, et ce, le plus rapidement possible. Ces résultats
font ressortir une question : celle d’identifier quel type de massage est le plus efficace
à court et long terme.
73
4.2. Limites et directions futures
Une des limites de notre premier article était de faire une comparaison entre les 6
interventions à cause des différences qu’il y avait entre les différents milieux
hospitaliers des trois hôpitaux. Cependant, cela nous a permis de faire une distinction
entre les milieux qui pratiquent la « Méthode Mère Kangourou » comme soin
standardisé dans l’unité de soins intensifs néonatale (premier et deuxième hôpital) et
les autres, qui pratiquent exclusivement les « Soins traditionnels » (troisième hôpital).
Cette différence peut amener à la réalisation de futures études, car elle favorise la
pratique d’une intervention plutôt qu’une autre. Un cas particulier se trouve dans le
premier Hôpital, qui pratique la « Méthode Kangourou » comme soin standardisé où
l’intervention « Méthode Mère kangourou & Massage Thérapie en Position
Kangourou » a démontré un effet positif sur la pratique de la « Méthode Kangourou »
avec une plus grande quantité d’heures de portage en contact peau à peau.
De plus, dans le troisième hôpital, qui pratique exclusivement « Soins
traditionnels » l’intervention « Massage en Incubateur » peut favoriser une
augmentation de poids à 15 jours, dans un milieu hospitalier dans lequel les soins
donnés effectuent un minimum de manipulation de l’enfant et une restriction de
visites des parents à leurs enfants.
Les futures études devront prendre en considération le contexte dans lequel les
interventions sont réalisées, car cela peut favoriser l’impact des interventions pendant
la période d’hospitalisation.
74
4.3. Avantage méthodologique :
Deux grands avantages de notre étude peuvent être identifiés. Le premier est que la
randomisation des sujets par l’hôpital nous a permis d’identifier des effets de chacune
des interventions comparées par hôpital, ainsi que d’avoir un plus grand contrôle sur
la procédure à suivre par les parents dans l’hôpital et sur le recrutement de données
par les professionnels de la santé. Le deuxième avantage était la période de formation
de 6 mois des professionnels de la santé dans chaque étape de l’étude, ce qui a facilité
le recrutement des patients ainsi qu’un suivi très ponctuel du protocole d’intervention.
75
Bibliographie
Aliabadi, F., & Askary, R. K. (2013). Effects of tactile-kinesthetic stimulation on
low birth weight neonates. Iranian Journal of Pediatrics, 23(3), 289–294.
doi.org/10.1097/00001577-199200420-00021
Anderson, J. (n.d.). Sensory Intervention With the Pretertn Infant in the Neonatal
Intensive Care Unit. doi.org/10.5014/ajot.40.1.19
Anderson, P. J., & Doyle, L. W. (2008). Cognitive and educational deficits in
children born extremely preterm. Seminars in Perinatology, 32(1), 51–8.
doi:org/10.1053/j.semperi.2007.12.009
Beck, S., Wojdyla, D., Say, L., Betran, A. P., Merialdi, M., Requejo, J. H., … Van
Look, P. F. a. (2010). The worldwide incidence of preterm birth: a systematic
review of maternal mortality and morbidity. Bulletin of the World Health
Organization, 88(1), 31–8. doi:org/10.2471/BLT.08.062554
Casey, P. H., Kraemer, H. C., & Bernbaum, J. (2000). FETAL AND NEONATAL
MEDICINE Growth status and growth rates of a varied sample of low birth
weight , preterm infants : A longitudinal cohort from birth to three years of age.
Charpak, N. (2009). Lineamientos Técnicos Para la Implementacion de Programas
Madre Canguro en Colombia. (L. A. Ochoa, Ed.) (Primera Ed, p. 121). Bogota,
Colombia.: Divergraficas Ltda.
Charpak, N., Ruiz, J. G., Zupan, J., Cattaneo, A., Figueroa, Z., Tessier, R., … Worku,
B. (2005). Kangaroo Mother Care: 25 years after. Acta Paediatrica (Oslo,
Norway : 1992), 94(5), 514–22. doi:org/10.1080/08035250510027381
Charpak, N., & Ruiz-pela, J. G. (2000). Kangaroo Mother Versus Traditional Care
for Newborn Infants, 100(4). doi.org/10.1542/peds.100.4.682
Diego, M. a, & Field, T. (2009). Moderate pressure massage elicits a parasympathetic
nervous system response. The International Journal of Neuroscience, 119(5),
630–8. doi:org/10.1080/00207450802329605
Diego, M. a, Field, T., Hernandez-Reif, M., Deeds, O., Ascencio, A., & Begert, G.
(2007). Preterm infant massage elicits consistent increases in vagal activity and
gastric motility that are associated with greater weight gain. Acta Paediatrica
(Oslo, Norway : 1992), 96(11), 1588–91. doi:org/10.1111/j.1651-
2227.2007.00476.x
76
Ehrenkranz, R. A., Dusick, A. M., Vohr, B. R., Wright, L. L., Wrage, L. A., Poole,
W. K., & Carolina, N. (2015). Growth in the Neonatal Intensive Care Unit
Influences Neurodevelopmental and Growth Outcomes of Extremely Low Birth
Weight Infants, 117(4). doi:org/10.1542/peds.2005-1368
Feldman, R., Rosenthal, Z., & Eidelman, A. I. (2014). Maternal-preterm skin-to-skin
contact enhances child physiologic organization and cognitive control across the
first 10 years of life. Biological Psychiatry, 75(1), 56–64.
doi:org/10.1016/j.biopsych.2013.08.012
Ferber, S. G., Feldman, R., Kohelet, D., Kuint, J., Dollberg, S., Arbel, E., & Weller,
A. (2005a). Massage therapy facilitates mother–infant interaction in premature
infants. Infant Behavior and Development, 28(1), 74–81.
doi:org/10.1016/j.infbeh.2004.07.004
Ferber, S. G., Feldman, R., Kohelet, D., Kuint, J., Dollberg, S., Arbel, E., & Weller,
A. (2005b). Massage therapy facilitates mother–infant interaction in premature
infants. Infant Behavior and Development, 28(1), 74–81.
doi:org/10.1016/j.infbeh.2004.07.004
Ferber, S. G., Kuint, J., Weller, A., Feldman, R., Dollberg, S., Arbel, E., & Kohelet,
D. (2002). Massage therapy by mothers and trained professionals enhances
weight gain in preterm infants. Early Human Development, 67(1-2), 37–45.
doi:org/10.1016/S0378-3782(01)00249-3
Field, T. (2001). Massage Therapy Facilitates Weight Gain in Preterm Infants.
Current Directions in Psychological Science, 10(2), 51–54.
doi:org/10.1111/1467-8721.00113
Field, T., & Diego, M. (2008). Vagal activity, early growth and emotional
development. Infant Behavior & Development, 31(3), 361–73.
doi:org/10.1016/j.infbeh.2007.12.008
Field, T., Diego, M., & Hernandez-Reif, M. (2010a). Moderate pressure is essential
for massage therapy effects. The International Journal of Neuroscience, 120(5),
381–5. doi:org/10.3109/00207450903579475
Field, T., Diego, M., & Hernandez-Reif, M. (2010b). Preterm infant massage therapy
research: a review. Infant Behavior Development, 33(2), 115–124.
doi.org/10.1016/j.infbeh.2009.12.004
Field, T., Diego, M., & Hernandez-Reif, M. (2010c). Preterm infant massage therapy
research: a review. Infant Behavior & Development, 33(2), 115–24.
doi:org/10.1016/j.infbeh.2009.12.004
77
Field, T., Grizzle, N., Scafidi, F., & Abrams, S. (1996). Massage theraphy for infants
of depressed mothers. Infant Behavior and, 107–112. doi.org/10.1016/s0163-
6383(96)90048-x
Field, T., Hernandez-Reif, M., Diego, M., Feijo, L., Vera, Y., & Gil, K. (2004).
Massage therapy by parents improves early growth and development. Infant
Behavior and Development, 27(4), 435–442.
doi:org/10.1016/j.infbeh.2004.03.004
Fielder, A., Blencowe, H., O’Connor, A., & Gilbert, C. (2015). Impact of retinopathy
of prematurity on ocular structures and visual functions. Archives of Disease in
Childhood. Fetal and Neonatal Edition, 100(2), F179–84.
doi:org/10.1136/archdischild-2014-306207
Guzzetta, A., Baldini, S., Bancale, A., Baroncelli, L., Ciucci, F., Ghirri, P., … Maffei,
L. (2009). Massage accelerates brain development and the maturation of visual
function. The Journal of Neuroscience : The Official Journal of the Society for
Neuroscience, 29(18), 6042–51. doi:org/10.1523/JNEUROSCI.5548-08.2009
Harrison, L. L. (2001). The use of comforting touch and massage to reduce stress for
preterm infants in the neonatal intensive care unit. Newborn and Infant Nursing
Reviews, 1(4), 235–241. doi:org/10.1053/nbin.2001.28103
Mally, P. V, Bailey, S., & Hendricks-Muñoz, K. D. (2010). Clinical issues in the
management of late preterm infants. Current Problems in Pediatric and
Adolescent Health Care, 40(9), 218–33. doi:org/10.1016/j.cppeds.2010.07.005
Moyer-Mileur, L., Luetkemeier, M., Boomer, L., & Chan, G. M. (1995). Effect of
physical activity on bone mineralization in premature infants. The Journal of
Pediatrics, 127(4), 620–5. doi.org/10.1016/s0022-3476(95)70127-3
Nadeau, L., Boivin, M., Tessier, R., Lefebvre, F., & Robaey, P. (2001). Mediators Of
Behavioral Problems in 7-Year-Old Children Born after 24 To 28 Weeks of
Gestation. Journal of Developmental & Behavioral Pediatrics, 22(1), 1–10.
doi:org/10.1097/00004703-200102000-00001
Procianoy, R. S., Mendes, E. W., & Silveira, R. C. (2010). Massage therapy improves
neurodevelopment outcome at two years corrected age for very low birth weight
infants. Early Human Development, 86(1), 7–11.
doi:org/10.1016/j.earlhumdev.2009.12.001
Richardson, D. K., Gray, J. E., & Gormaker, S. L. (1999). Declining Severity
Adjusted Mortality: Evidence of Improving Neonatal Intensive Care. Pediatrics,
102(4), 893–899. doi.org/10.1542/peds.102.4.893
78
Rojas, M. A., Kaplan, M., Quevedo, M., Sherwonit, E., Foster, L. B., Ehrenkranz, R.
A., & Mayes, L. (2003). Somatic Growth of Preterm Infants During Skin-to-
Skin Care Versus Traditional Holding : A Randomized , Controlled Trial
Description of Subjects, 24(3). doi.org/10.1097/00004703-200306000-00006
Scafidi, F. a., Field, T. M., Schanberg, S. M., Bauer, C. R., Vega-Lahr, N., Garcia, R.,
… Kuhn, C. M. (1986). Effects of tactile/kinesthetic stimulation on the clinical
course and sleep/wake behavior of preterm neonates. Infant Behavior and
Development, 9(1), 91–105. doi:org/10.1016/0163-6383(86)90041-X
Scafidi, Frank a. Field, T. (1993). Factors that Predict which Preterm Infants benefit
Most from Massage Therapy, 14, 176–80. doi.org/10.1097/00004703-
199306010-00008
Tessier, R., Cristo, M. B., Velez, S., Giron, M., Nadeau, L., Figueroa de Calume,
Z.,Charpak, N. (2003). Kangaroo Mother Care: A method for protecting high-
risk low-birth-weight and premature infants against developmental delay. Infant
Behavior and Development, 26(3), 384–397. doi:org/10.1016/S0163-
6383(03)00037-7
White, J., & Labarba, R. (1976). The effects of tactile and kinesthetic stimulation on
neonatal development in the premature infant. Developmental Psychobiology,
9(December 1975), 569–577. Retrieved from
http://onlinelibrary.wiley.com/doi/10.1002/dev.420090610/abstract
79
Annexes
Annexe A : Tableau mesures de croissence
80
Annexe B : Histoire clinique
