Effect of Abdominal Massage on Gastric Residual Volume and Weight Gain of Premature Infants Admitted in NICU

Document Type: Original Article

Authors

1 Department of nursing and midwifery, Tehran Medical Sciences Branch, Islamic Azad University, Tehran, Iran

2 Department of Pediatrics, Faculty of Medicine, Baqiyatallah University of Medical Sciences, Tehran, Iran

3 International Otorhinolaryngology Research Association (IORA), Universal Scientific Education and Research Network (USERN), Tehran, Iran.

Abstract

Introduction: One of the most important problems of premature infants and main reason of hospitalization in neonatal intensive care unit (NICU) is their low birth weight. They need gavage for feeding which has several side effects. Thus choosing appropriate nutritional interventions in premature infants decreases gavage-related complications and results in lower duration of hospitalization.
Methods: In this clinical trial study premature infants were randomly allocated to two intervention and control groups. Both groups underwent routine care. Intervention group infants received abdominal massage 15 minutes twice a day for five days by a trained physiotherapist using moisturizing lotion based on the method described in previous studies.
Results: Eventually 28 infants (15 male and 13 female) with a mean gestational age of 32.43±1.16 weeks in intervention and 33±0.88 weeks in control group underwent analysis (p=0.15). Mean gastric residual volume was 0.71±1.13 ml in intervention and 1.43±1.55 ml in control group prior to intervention (p=0.2). It was 1.93±2.43 ml in intervention and 4.71±4.25 ml in control group in the fifth day of intervention (p=0.04). Before intervention, mean weight was 1830±330 gr in intervention and 1870±370 gr in control group (p=0.82). In the fifth day of intervention mean weight was 1871±323.15 gr in intervention group and 1767±347.24 gr in control group (p=0.001).
Conclusion: In conclusion our findings suggest that abdominal massage efficiently decreases gastric residual volume and helps with weight gain in preterm infants.

Keywords


Introduction:

Preterm birth consists 5-9% of all births in developing countries and 12.8 % of births in United States. Out of 40 million mortalities in the first 28 days of life, more than one million infantile mortalities are related to prematurity complications each year (1). Nowadays, significantly increasing number of premature infants is saved due to improvement in neonatal care and this has drawn specialists’ attention to growth and development of this population. 

One of the most important problems of premature infants and main reason of hospitalization in neonatal intensive care unit (NICU) is their low birth weight. Previous studies have indicated that low birth weight (LBW) is a determining factor of infantile mortality worldwide (2). Premature infants need special and long-term care for overcoming their growth failure and preventing neurological disorders. During this period, there are a remarkable number of nutritional problems. Infants with gestational ages of less than 34 weeks have higher risks of aspiration because of discrepancies between sucking, swallowing and respiration; so feeding should be through gavage (3). This method has several complications such as vague nerve stimulation and bradycardia, increased respiratory effort, aspiration, perforation of gastrointestinal tract and necrotizing enterocolitis. Oral feeding intolerance in premature infants is a main concern which influences duration of hospitalization. This intolerance is determined by abdominal distension and increased gastric residue which is considered as a visible criteria for gastric depletion (3).

Thus choosing appropriate nutritional interventions in premature infants decreases gavage-related complications and results in lower duration of hospitalization, lower costs and more effective emotional relation between infants and mothers (4). Enteral nutrition intolerance is a major problem in premature infants which leads to higher risks of sepsis because of long-term application of parenteral nutrition (5).

In the last two decades abovementioned problems has made researchers to provide a variety of complementary stimulations for premature infants to help with their development (6). Providing touching stimulations such as massage are among complementary interventions which are effective on growth and development trend. Massaging infants has been an important part of care in different communities and especially India and it has been evaluated scientifically in recent years (2).

Endearment and touching have important roles in physical and emotional growth of infants. Massage is the best way which not only empowers emotional relation of mother and infant but also helps with relieving colic pains and gastrointestinal system development. It is also considered that massage improves blood circulation and relieves central and peripheral nervous system pains.

Therefore, regarding that a few related studies have been conducted in Iran we aimed to evaluate the effect of abdominal massage on gastric residue in NICU-admitted premature infants.

 

Patients and methods:

This clinical trial study was conducted between March and September 2016 at NICU ward of Najmiyeh University hospital, Tehran, Iran. This study was registered at ethics committee of Tehran medical sciences branch of Islamic Azad University (reference no: IR.IAU.TMU.REC.1394.77). Figure 1 shows a flowchart of the study. Premature infants in NICU ward were assessed for eligibility. Samples were selected using simple random sampling method. Infants with birthweight of less than 2500 gr and gestational ages of lower than 34 weeks were included in the study.  Infants with congenital anomalies, unstable condition, contraindication for abdominal massage and those not willing to participate in the study were excluded from the study. Demographic information as well as primary weight, type of feeding, daily weight gain and vomiting, gavage and defecation frequencies was recorded in a predesigned check list.

Infants were randomly allocated to two intervention and control groups using random number table. Both groups underwent routine care. Intervention group infants received abdominal massage 15 minutes twice a day for five days by a trained physiotherapist using moisturizing lotion based on the method described in Tekgündüz et al. study (5).

Data was analyzed using SPSS software version 21 (SPSS Inc., Chicago, IL) for Microsoft Windows. Normal distributed variables (approved by 1-sample Kolmogorov-Smirnov test) were compared using independent sample t test between the groups. The chi square test was used to compare categorical variables in the 2 groups. Mean and standard deviation (SD) were used for describing categorical variables.

 

Results:

Eventually 28 infants (15 male and 13 female) with a mean gestational age of 32.43±1.16 weeks in intervention and 33±0.88 weeks in control group underwent analysis (p=0.15). Demographic information has been summarized in Table 1. Most of the infants in both intervention (71.4%) and control (85.7%) groups were conceived by cesarean section (p=0.32). Prematurity was the most prevalent cause of admission in both intervention (57.1%) and control (35.7%) groups followed by tachypnea and respiratory distress. There was no significant difference between two groups for cause of admission (p=0.79). Mean birthweight was 1892.14±318.22 gr in intervention and 1930.71±379.36 gr in control group (p=0.77). Mothers had a mean age of 29.36±4.86 years in intervention and 31.57±5.61 years in control group (p=0.28). In intervention group 4(28.6%) and in control group 6(42.8%) had an underlying disease (p=0.35).

 

Table 1.Demographic information of study individuals

Variable

Intervention group (N=14)

Control group (N=14)

p Value

Male, N (%)

9(64.3%)

6(42.9%)

0.25

Gestational age, weeks (mean±SD)

32.43±1.16

33±0.88

0.15

Birthweight, gr (mean±SD)

1892.14±318.22

1930.71±379.36

0.77

Height, cm

43.96±3.04

43.61±2.39

0.73

Head circumflex, cm (mean±SD)

30.57±2.15

30.90±3.33

0.76

Abdominal circumflex, cm (mean±SD)

27.61±1.62

27.18±2.83

0.63

 

Mother’s milk was the most common (42.9%) type of feeding in intervention group; while it was formula (64.3%) in control group (p=0.06). Mean gastric residual volume was 0.71±1.13 ml in intervention and 1.43±1.55 ml in control group prior to intervention (p=0.2). It was 1.93±2.43 ml in intervention and 4.71±4.25 ml in control group in the fifth day of intervention (p=0.04). Changes in mean gastric residual volume during intervention has been shown in table 2. Mean frequency of vomiting was 0.07±0.27 times in intervention and no vomiting was recorded for control group prior to intervention. During intervention no vomiting was recorded for abdominal massage group; while mean frequency of vomiting was 0.36±0.50 times in control group in fifth day of intervention (p=0.02).

 

Table 2. Mean gastric residual volume during different days of intervention

Day of intervention

Intervention group (N=14)

Control group

(N=14)

p value

1st  day, ml (mean±SD)

1.21±2.25

3.56±6.36

0.150

2nd day, ml (mean±SD)

1.21±1.42

5.07±4.27

0.004

3rd day, ml (mean±SD)

0.71±1.90

4.86±3.94

0.002

4th day, ml (mean±SD)

0.86±2.41

6.07±7.36

0.020

5th day, ml (mean±SD)

1.93±2.43

4.71±4.25

0.040

Mean abdominal circumference was 26.21±1.92 cm in intervention and 26.29±2.42 cm in control group before intervention (p=0.93). In the fifth day of study, intervention group had a mean abdominal circumference of 24.32±1.32 cm and it was 26.43±2.18 cm in control group (p=0.005). Before intervention, mean weight was 1830±330 gr in intervention and 1870±370 gr in control group (p=0.82). In the fifth day of intervention mean weight was 1871±323.15 gr in intervention group and 1767±347.24 gr in control group (p=0.001). Table 3 and figure 2 visualize the changing trend of mean weight in study individuals.

 

Table 3. Mean weight of study individuals during different days of intervention.

Day of intervention

Intervention group (N=14)

Control group

(N=14)

p value

1st  day, gr (mean±SD)

1815±331.68

1827±343.48

0.200

2nd day, gr (mean±SD)

1816±321.93

1814±337.75

0.120

3rd day, gr (mean±SD)

1836±322.70

1805±344.96

0.008

4th day, gr (mean±SD)

1847±328.5

1795±345.48

0.001

5th day, gr (mean±SD)

1871±323.15

1767±347.24

0.001

 

Mean defecation frequency was 1±0.78 times in intervention and 1.79±1.25 times in control group prior to intervention (p=0.06). In the fifth day of intervention it was 4.36±0.84 times in intervention and 1±0.78 times in control group infants (p=0.001).

 

  

Discussion:

We found that abdominal massage significantly improves weight gaining of premature infants admitted in NICU ward and decreases gastric residual volume (GRV). We also realized that infants in control group had vomiting more frequently than infants who underwent abdominal massage. In addition, it was concluded that abdominal massage increased defecation frequency in intervention group.

Comparison of gastric residual volume in different days of intervention showed that there is a significant difference between intervention and control groups from second day of intervention on; infants who had underwent abdominal massage had a significantly lower gastric residual volume. This is in agreement with Tekgündüz et al. study; however in their study gastric residual volume had decreased in the last day of intervention(5). In another study by Valizadeh et al. they have mentioned that gastric residual volume had decreased in infants receiving Kangaroo mother care. Results of Törnhage et al. study showed that massage and Kangaroo mother care significantly increases plasma Cholecystokinin level in preterm infants with Nasogastric tube feeding which results in more peristaltic movements of gastrointestinal tract (7).

Vomiting is one of the most important complications of feeding which increases the risk of pneumonia and aspiration (8). In concordance with Tekgündüz et al. study, infants in abdominal massage group had less vomiting in comparison with baseline in the present study (5). As an indicator of abdominal distention, abdominal circumference was significantly lower in abdominal massage group in fourth day of the trial which confirms the results of Tekgündüz et al. study (5).

In the present study, body weight showed a decrease in control group infants during study; while it was significantly increased in infants undergoing abdominal massage which is in accordance with Tekgündüz et al. study (5). In Badiee et al. study, abdominal massage for five consecutive days (three times a day) was resulted in higher weight gain of premature infants (6). In another similar study by Hosseinzadeh et al., mean weight gain of infants in abdominal massage group was 56 gr more than control group (9). Additionally, abdominal massage with coconut oil has been shown to be effective on weight gaining of infants (10).

It has been proved that abdominal massage increases vagal tone and gastric motility leading to higher frequency of defecation and weight gain (11-13). It accelerates peristaltic movements through effects on intra-abdominal pressure and stimulation of reflexive movements of intestines (14, 15). Frequency of defecation is a determining factor which decreases the abdominal distension and results in more Bilirubin excretion. In our study, frequency of defecation was significantly higher in infants who received abdominal massage from third day of intervention on which is in line with Lin et al., Tekgündüz et al. and Badiee et al. studies (5, 6, 16).

In conclusion our findings suggest that abdominal massage efficiently decreases gastric residual volume and helps with weight gain in preterm infants. We also found that abdominal massage decreases vomiting and increases frequency of defecation in enterally fed infants. Further studies are recommended to evaluate the effect of simultaneous abdominal massage and Kangaroo mother care on duration of hospitalization in preterm infants. Also the effects of abdominal massage on reducing Bilirubin levels, infections and increasing arterial blood saturation in preterm infants should be investigated in future researches.

 

Authors’ Contributions:

MG collected the data and drafted the manuscript. BN helped with data collection and drafting manuscript. MHK analyzed the data and edited the manuscript critically. MN designed the study and helped with final approval of the manuscript. All authors approved the final version of the manuscript. 

 

Conflict of Interest Disclosures:

There are no conflicts of interest in terms of the present manuscript.

 

Ethical approval/Consideration:

A written informed consent was taken from the patients’ guardians. Their information was kept confidential and if they were interested in knowing the interpretation of their results, they were informed about it. No cost posed to the participants for their participation in this study.

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