PREMM: preterm early massage by the mother: protocol of a randomised controlled trial of massage therapy in very preterm infants

Sensitivity and specificity of the Neonatal Visual Assessment to predict motor and cognitive outcomes in infants born very preterm

BACKGROUND

Very preterm infants are at increased risk of neurodevelopmental impairments. The Neonatal Visual Assessment (NVA) assesses visual function and outcomes and has been used to assess early neurodevelopmental outcomes. This study aimed to compare NVA results of very preterm and term-born infants and to calculate the sensitivity and specificity of the NVA at term equivalent age (TEA) and three months corrected age (CA) to predict motor and cognitive outcomes at 12 months CA in very preterm infants.

METHODS

This prospective observational cohort study recruited infants born before 31 weeks gestation and a healthy term-born control group. The NVA was assessed at TEA and three months CA, and neurodevelopmental outcomes (Bayley Scales of Infant and Toddler Development, Third Edition; Neurosensory Motor Developmental Assessment; Alberta Infant Motor Scale) were performed at 12 months CA. The sensitivity and specificity of the NVA to predict outcomes were calculated based on a previously published optimality score.

RESULTS

248 preterm (54 % male) and 46 term-born infants (48 % male) were analysed. The mean NVA scores of preterm and term-born infants were significantly different at TEA (preterm 3.1±2.1; term-born 1.2±1.7, p < 0.001). The NVA had moderate sensitivity (59-78 %) and low specificity (25-27 %) at TEA, and low sensitivity (21-28 %) and high specificity (86-87 %) at three months CA for the prediction of preterm infants' outcomes at 12 months CA.

CONCLUSION

The NVA at TEA and three months CA was not a strong predictor of motor and cognitive impairments in this contemporary cohort of very preterm infants.

The effect of participation education on maternal role adaptation in mothers with premature infants in the neonatal intensive care unit

BACKGROUND

The birth of a premature infant, hospitalization, and separation from the family cause disruption on maternal role adaption. This study was conducted with the aim of investigating the effect of participation education on maternal role adaption in mothers of premature infants hospitalized in the neonatal intensive care unit.

MATERIALS AND METHODS

This semiexperimental study was conducted with the participation of 129 eligible mothers with premature infants into three groups of 43 (face-to-face education, virtual education, and control). Data collection was done using a checklist measuring adaptation to the maternal role. Data were analyzed by descriptive statistical and multiple linear regression tests at a significance level of P < 0.05.

RESULTS

The mean age of mothers was 30.8 years, the mean gestational age of infants was 31.7 weeks, the mean birth weight was 1781.4 g, and the most common (84.5%) reason for hospitalization of infants was respiratory distress. Multiple linear regression analysis showed that the total score of maternal role adaptation at the time of discharge was significantly different in the two groups of virtual education (134.362 ± 0.925) (P < 0.001) and face-to-face education (132.421 ± 0.928) (P = 0.005) with the control group (128.286 ± 0.924).

CONCLUSION

The implementation of educational programs is a suitable solution to improve maternal role adaption. Therefore, it is recommended that managers and healthcare planners consider codified and regular educational programs in order to increase the ability of mothers, in order to adapt to the maternal role.

A follow up study on the effects of massage on preterm infants: A randomized controlled research

BACKGROUND

Preterm infants who leave the intrauterine environment early are deprived of tactile stimuli. This affects the physical, emotional and social developments of infants and their physical growth parameters such as weight, height and head circumference negatively.

AIM

This research was conducted to determine the effects of massage on the development of preterm infants.

MATERIAL-METHOD

This research was conducted as randomized controlled research with two groups (massage-control). The infants in the intervention group received massage for 30 days. Height, weight and head circumference values of the infants were recorded on days 5, 10, 20 and 30. Amount of feeding was recorded before intervention, on day 15 after intervention and on day 30 after intervention. Discharge times of the infants were recorded according to groups.

RESULTS

A significant difference was found in height and weight of the preterm infants on days 20 and 30 when compared with the control group. Discharge time of the infants in the massage group was found to be 10 days shorter on average when compared with the control group. Significant difference was also found between day 15 and 30 in terms of amount of feeding.

CONCLUSION

Massage was found to have significant effects on physical growth parameters such as height, weight and head circumference. It was found that massage increased amount of feeding and weight intake in infants and decreased discharge time. In this case, hospital cost per infant may be reduced.

Early developmental intervention programmes provided post hospital discharge to prevent motor and cognitive impairment in preterm infants

BACKGROUND

Infants born preterm are at increased risk of cognitive and motor impairments compared with infants born at term. Early developmental interventions for preterm infants are targeted at the infant or the parent-infant relationship, or both, and may focus on different aspects of early development. They aim to improve developmental outcomes for these infants, but the long-term benefits remain unclear. This is an update of a Cochrane review first published in 2007 and updated in 2012 and 2015.

OBJECTIVES

Primary objective To assess the effect of early developmental interventions compared with standard care in prevention of motor or cognitive impairment for preterm infants in infancy (zero to < three years), preschool age (three to < five years), and school age (five to < 18 years). Secondary objective To assess the effect of early developmental interventions compared with standard care on motor or cognitive impairment for subgroups of preterm infants, including groups based on gestational age, birthweight, brain injury, timing or focus of intervention and study quality.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO and trial registries in July 2023. We cross-referenced relevant literature, including identified trials and existing review articles.

SELECTION CRITERIA

Studies included randomised, quasi-randomised controlled trials (RCTs) or cluster-randomised trials of early developmental intervention programmes that began within the first 12 months of life for infants born before 37 weeks' gestational age (GA). Interventions could commence as an inpatient but had to include a post discharge component for inclusion in this review. Outcome measures were not prespecified, other than that they had to assess cognitive outcomes, motor outcomes or both. The control groups in the studies could receive standard care that would normally be provided.

DATA COLLECTION AND ANALYSIS

Data were extracted from the included studies regarding study and participant characteristics, timing and focus of interventions and cognitive and motor outcomes. Meta-analysis using RevMan was carried out to determine the effects of early developmental interventions at each age range: infancy (zero to < three years), preschool age (three to < five years) and school age (five to < 18 years) on cognitive and motor outcomes. Subgroup analyses focused on GA, birthweight, brain injury, time of commencement of the intervention, focus of the intervention and study quality. We used standard methodological procedures expected by Cochrane to collect data and evaluate bias. We used the GRADE approach to assess the certainty of evidence.

MAIN RESULTS

Forty-four studies met the inclusion criteria (5051 randomly assigned participants). There were 19 new studies identified in this update (600 participants) and a further 17 studies awaiting outcomes. Three previously included studies had new data. There was variability in the focus and intensity of the interventions, participant characteristics, and length of follow-up. All included studies were either single or multicentre trials and the number of participants varied from fewer than 20 to up to 915 in one study. The trials included in this review were mainly undertaken in middle- or high-income countries. The majority of studies commenced in the hospital, with fewer commencing once the infant was home. The focus of the intervention programmes for new included studies was increasingly targeted at both the infant and the parent-infant relationship. The intensity and dosages of interventions varied between studies, which is important when considering the applicability of any programme in a clinical setting. Meta-analysis demonstrated that early developmental intervention may improve cognitive outcomes in infancy (developmental quotient (DQ): standardised mean difference (SMD) 0.27 standard deviations (SDs), 95% confidence interval (CI) 0.15 to 0.40; P < 0.001; 25 studies; 3132 participants, low-certainty evidence), and improves cognitive outcomes at preschool age (intelligence quotient (IQ); SMD 0.39 SD, 95% CI 0.29 to 0.50; P < 0.001; 9 studies; 1524 participants, high-certainty evidence). However, early developmental intervention may not improve cognitive outcomes at school age (IQ: SMD 0.16 SD, 95% CI -0.06 to 0.38; P = 0.15; 6 studies; 1453 participants, low-certainty evidence). Heterogeneity between studies for cognitive outcomes in infancy and preschool age was moderate and at school age was substantial. Regarding motor function, meta-analysis of 23 studies showed that early developmental interventions may improve motor outcomes in infancy (motor scale DQ: SMD 0.12 SD, 95% CI 0.04 to 0.19; P = 0.003; 23 studies; 2737 participants, low-certainty evidence). At preschool age, the intervention probably did not improve motor outcomes (motor scale: SMD 0.08 SD, 95% CI -0.16 to 0.32; P = 0.53; 3 studies; 264 participants, moderate-certainty evidence). The evidence at school age for both continuous (motor scale: SMD -0.06 SD, 95% CI -0.31 to 0.18; P = 0.61; three studies; 265 participants, low-certainty evidence) and dichotomous outcome measures (low score on Movement Assessment Battery for Children (ABC) : RR 1.04, 95% CI 0.82 to 1.32; P = 0.74; 3 studies; 413 participants, low-certainty evidence) suggests that intervention may not improve motor outcome. The main source of bias was performance bias, where there was a lack of blinding of participants and personnel, which was unavoidable in this type of intervention study. Other biases in some studies included attrition bias where the outcome data were incomplete, and inadequate allocation concealment or selection bias. The GRADE assessment identified a lower certainty of evidence in the cognitive and motor outcomes at school age. Cognitive outcomes at preschool age demonstrated a high certainty due to more consistency and a larger treatment effect.

AUTHORS' CONCLUSIONS

Early developmental intervention programmes for preterm infants probably improve cognitive and motor outcomes during infancy (low-certainty evidence) while, at preschool age, intervention is shown to improve cognitive outcomes (high-certainty evidence). Considerable heterogeneity exists between studies due to variations in aspects of the intervention programmes, the population and outcome measures utilised. Further research is needed to determine which types of early developmental interventions are most effective in improving cognitive and motor outcomes, and in particular to discern whether there is a longer-term benefit from these programmes.

A randomized-controlled trial of parent-administered interventions to improve short-term motor outcomes in hospitalized very low birthweight infants

BACKGROUND

Premature infants are at increased risk for cerebral palsy (CP). Early interventions with a motor focus and administered by parents may improve motor outcomes.

AIMS

Secondary study evaluating the short-term motor outcomes and risk for CP in very low birthweight (VLBW) infants randomized to multimodal interventions with a motor focus provided by parents versus usual care.

STUDY DESIGN

Randomized controlled trial (intervention vs. usual care (control group)).

SUBJECTS

Infants (<32 weeks' gestational age (GA) and/or <1500 grams birthweight) born between March 2019 and October 2020.

OUTCOME MEASURES

Short-term motor outcomes and risk for CP was evaluated using the Hammersmith Infant Neurological Evaluation (HINE, primary motor outcome), the General Movement Assessment (GMA) and the Test of Infant Motor Performance (TIMP) at 3 months' postmenstrual age (PMA).

RESULTS

70 participants were enrolled (GA 28.3±2.7 weeks, birthweight 1139.2±376.6 grams, 64.3% male). The in-person follow-up rate was 73%, lower than expected, in part due to COVID-19 restrictions, resulting in 25 infants (intervention) and 26 infants (control) with outcome data available for analysis. There was not a significant difference in the HINE, GMA or TIMP at 3 months' PMA between groups.

CONCLUSION

Multimodal interventions with a motor focus and provided by parents need further investigation to determine if they can improve short-term motor outcomes in VLBW infants. These interventions are evidence-based and the evaluation of broader implementation into routine care is also needed.

Effects of massage therapy on preterm infants and their mothers: a systematic review and meta-analysis of randomized controlled trials

Background

Massage therapy for preterm newborns has received increasing attention in recent years due to its beneficial clinical outcomes. However, disagreements persist in different investigations.

Method

We performed a systematic literature search in the Cochrane Library, Embase, PubMed, Web Science, and CINAHL to retrieve randomized controlled trials of premature infants receiving massage therapy and its impact on maternal and infant outcomes. Outcomes were mother-infant attachment, oxygen saturation, motor funtion, reflex, temperature, and calorie intake. The tool developed by the Cochrane collaboration assessed risk bias. With a 95% confidence interval (CI), the integration's results were presented as the mean difference or standardized mean difference. The registration number was CRD42022337849.

Results

Of 940 records retrieved, 15 trials were included. Massage therapy increased oxygen saturation (standardized mean difference (SMD) = 2.00, 95% CI [1.17 to 2.83], P < 0.0001). Massage therapy can strengthen mother-infant attachment [SMD = 2.83, 95% CI (2.31 to 3.35), P < 0.00001]. Other outcomes, including motor activity, relaxation, caloric intake, and temperature, did not differ significantly.

Conclusion

Massage therapy can significantly improve oxygen saturation and strengthen maternal-infant attachment. However, prior to making a recommendation, additional research with a larger sample size and more rigorous design should be conducted due to the heterogeneity of studies in several outcomes.

Diagnostic accuracy of the Hammersmith Neonatal Neurological Examination in predicting motor outcome at 12 months for infants born very preterm

AIM

To evaluate the predictive validity of the Hammersmith Neonatal Neurological Examination (HNNE) performed early (at 32 weeks postmenstrual age) and at term-equivalent age (TEA) for 12-month motor outcomes in infants born very preterm.

METHOD

This was a diagnostic study using data from a prospective birth cohort. A total of 104 infants born preterm at less than 31 weeks gestational age (males n = 61; mean = 28 weeks 1 day [SD 1 week 6 days], range 23 weeks 1 day-30 weeks 6 days) underwent HNNE early and at TEA, which were scored by comparison with term data. Motor outcomes at 12 months corrected age were determined using the Bayley Scales of Infant and Toddler Development, Third Edition (scores ≤85). Cut-off points were determined using receiver operating characteristic curves.

RESULTS

Sixteen (15%) infants born preterm had motor impairment at 12 months corrected age. The HNNE total score cut-off points with the best combination of sensitivity and specificity at early and TEA assessments were 15.2 or lower (sensitivity 77%, 95% confidence interval [CI] = 46%-95%; specificity 74%, 95% CI = 63%-83%) and 23.5 or lower (sensitivity 67%, 95% CI = 38%-88%; specificity 66%, 95% CI = 54%-76%) respectively. The most predictive subscale at the early assessment was reflexes (sensitivity 86%, 95% CI = 57%-98%; specificity 62%, 95% CI = 51%-72%; cut-off point ≤3); at TEA, it was spontaneous movements (sensitivity 73%, 95% CI = 45%-92%; specificity 60%, 95% CI = 48%-70%; cut-off point ≤2).

INTERPRETATION

The HNNE provides moderate predictive accuracy for motor outcome at 12 months corrected age in infants born very preterm. Although modest at both time points, early assessment had stronger predictive ability for motor outcomes than TEA when scored using term data, highlighting the value of performing the HNNE earlier in the neonatal period. Performing HNNE earlier may assist risk stratification when planning follow-up services.

Neurological examination at 32-weeks postmenstrual age predicts 12-month cognitive outcomes in very preterm-born infants

BACKGROUND

To determine the diagnostic accuracy of Hammersmith Neonatal Neurological Examination (HNNE) at 30-32 weeks postmenstrual age (PMA, 'Early') and term equivalent age (TEA) in infants born <31 weeks PMA to predict cognitive outcomes at 12 months corrected age (CA).

METHODS

Prospective cohort study of 119 infants (73 males; median 28.4 weeks gestational age at birth) who underwent Early and TEA HNNE. At 12 months CA, 104 participants completed Bayley Scales of Infant and Toddler Development, 3rd Edition, (Bayley-III). Optimum cut-off points for each HNNE subscale were determined to establish diagnostic accuracy for predicting adverse cognitive outcomes on the Bayley-III Cognitive Composite Scale (≤85).

RESULTS

The best diagnostic accuracy for HNNE total score at 30-32 weeks PMA predicting cognitive impairment occurred at cut-off ≤16.7 (sensitivity (Se) = 71%, specificity (Sp) = 51%). The Abnormal Signs subscale demonstrated the best balance of sensitivity/specificity combination (Se = 71%, Sp = 71%; cut-off ≤1.5). For HNNE at TEA, the total score at cut-off ≤24.5 had Se = 71% and Sp = 47% for predicting cognitive impairment. The Tone Patterns subscale demonstrated the strongest diagnostic accuracy at TEA (Se = 71%, Sp = 63%; cut-off ≤3).

CONCLUSIONS

Early and TEA HNNE demonstrated moderate diagnostic accuracy for cognitive outcomes at 12-months CA in infants born <31 weeks gestational age.

CLINICAL TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry; Trial Registration Number: ACTRN12613000280707; web address of trial: http://www.ANZCTR.org.au/ACTRN12613000280707.aspx .

IMPACT

Early Hammersmith Neonatal Neurological Examination (HNNE) assessment at 30-32 weeks postmenstrual age has moderate diagnostic accuracy for cognitive outcomes at 12 months corrected age in infants born <31 weeks gestation. Early HNNE at 30-32 weeks has stronger predictive validity than HNNE at term equivalent age. Early HNNE may provide an early marker for risk-stratification to optimise the planning of post-discharge support and follow-up services for infants born preterm.

A feasibility randomized controlled trial of a NICU rehabilitation program for very low birth weight infants

Motor disability is common in children born preterm. Interventions focusing on environmental enrichment and emotional connection can positively impact outcomes. The NICU-based rehabilitation (NeoRehab) program consists of evidence-based interventions provided by a parent in addition to usual care. The program combines positive sensory experiences (vocal soothing, scent exchange, comforting touch, skin-to-skin care) as well as motor training (massage and physical therapy) in a gestational age (GA) appropriate fashion. To investigate the acceptability, feasibility and fidelity of the NeoRehab program in very low birthweight (VLBW) infants. All interventions were provided by parents in addition to usual care. Infants (≤ 32 weeks' GA and/or ≤ 1500 g birthweight) were enrolled in a randomized controlled trial comparing NeoRehab to usual care (03/2019-10/2020). The a priori dosing goal was for interventions to be performed 5 days/week. The primary outcomes were the acceptability, feasibility and fidelity of the NeoRehab program. 36 participants were randomized to the intervention group and 34 allocated to usual care. The recruitment rate was 71% and retention rate 98%. None of the interventions met the 5 days per week pre-established goal. 97% of participants documented performing a combination of interventions at least 3 times per week. The NeoRehab program was well received and acceptable to parents of VLBW infants. Programs that place a high demand on parents (5 days per week) are not feasible and goals of intervention at least 3 times per week appear to be feasible in the context of the United States. Parent-provided motor interventions were most challenging to parents and alternative strategies should be considered in future studies. Further studies are needed to evaluate the relationship between intervention dosing on long term motor outcomes.

Feasibility of Early Intervention Through Home-Based and Parent-Delivered Infant Massage in Infants at High Risk for Cerebral Palsy

Infant massage (IM) can be considered an early intervention program that leads to the environmental enrichment framework. The effectiveness of IM to promote neurodevelopment in preterm infants has been proved, but studies on infants with early brain damage are still lacking. The main aim of this study was to assess the feasibility, acceptability and usability of IM, carried out by parents at home, on infants at high risk for Cerebral Palsy. An IM daily diary and an ad hoc questionnaire, called Infant Massage Questionnaire Parent-Infant Experiences (IMQPE), were developed. IMQPE consisted of a total of 30 questions, divided into 5 areas. The parents were trained to carry out the IM with a home-based course, conducted by an expert therapist. The intensive IM program was set according to a defined daily length of at least 20 min, with a frequency of at least 5 days per week for a total of 8 weeks. Data collection consisted in the selection of the variables around the characteristics, both of the infants and the mothers, IM dosage and frequency, different body parts of the infants involved and IMQPE scores. Variable selection was carried out by minimizing the Bayesian Information Criteria (BIC) over all possible variable subsets. Nineteen high-risk infants, aged 4.83 ± 1.22 months, received IM at home for 8 weeks. The massage was given by the infants' mothers with a mean daily session dose of 27.79 ± 7.88 min and a total of 21.04 ± 8.49 h. 89.74% and 100% of mothers performed the IM for the minimum daily dosage and the frequency recommended, respectively. All the families filled in the IMQPE, with a Total mean score of 79.59% and of 82.22% in General Information on IM, 76.30% in Infant's intervention-related changes, 76.85% in IM Suitability, 79.07% in Infant's acceptance and 83.52% in Time required for the training. Different best predictors in mothers and in infants have been found. These data provide evidence of the feasibility of performing IM at home on infants at high risk for CP. Study registration: www.clinicaltrial.com (NCT03211533 and NCT03234959).

A Maternal-Administered Multimodal Neonatal Bundle in Hospitalized Very Preterm Infants: A Pilot Study

BACKGROUND

Premature infants are at an increased risk for developing cerebral palsy (CP). Evidence-based strategies designed to promote healthy brain development and facilitate adaptation after brain injury in infants still admitted to the neonatal intensive care unit (NICU) represent a novel approach that may lead to improved long-term outcomes.

PURPOSE

To investigate the feasibility of a maternal-administered early intervention bundle in very preterm infants prior to NICU discharge.

METHODS

A pilot trial evaluating a maternal-administered NICU-based bundle of interventions in preterm infants (≤32 weeks' gestational age and/or ≤1500 g birth weight). The impact of the bundle on short-term developmental outcomes of infants, as well as maternal stress, anxiety, and depression, is evaluated.

RESULTS

The intervention bundle was implemented in 11 mother-infant dyads (including 1 set of twins) for a median of 8 weeks and was overall well received. Vocal soothing, scent exchange, and comforting touch were feasible, performed at or above the predetermined goal of 71% of the time (5/7 days), while kangaroo care and infant massage were not. Maternal stress, anxiety, and depression were decreased during the study time.

IMPLICATIONS TO PRACTICE

A neonatal multimodal intervention bundle provided by mothers is feasible.

IMPLICATIONS TO RESEARCH

Additional randomized controlled studies are needed to determine whether this type of bundled interventions can (1) improve the neurodevelopmental outcomes of participating infants and (2) improve long-term parental outcomes, including decreased burden of anxiety and depression, as well as improved attachment and optimal patterns of social interaction.

Effects of massage on newborn infants with jaundice: A meta-analysis

Objective

This meta-analysis aims to systematically evaluate the effects of massage on infants with jaundice.

Methods

Multiple electronic databases, including Cochrane Library, PubMed, EMBASE, Web of Science, China Biology Medicine (CBM), Wan Fang Data, VIP Database for Chinese Technical Periodicals and China National Knowledge Infrastructure (CNKI), were used to search for studies on the effects of massage on infants with jaundice. Data were analysed by Rev Man 5.3.

Results

A total of 14 randomised controlled trials with 1889 patients were included. Statistically significant difference in percutaneous bilirubin [MD = −1.21, 95% CI (−1.90, −0.52), P < 0.05; MD = −2.00, 95% CI (−2.68, −1.32), P < 0.05; MD = −2.00, 95% CI (2.56, −1.44), P < 0.05; MD = −1.93, 95% CI (−2.44, −1.43), P < 0.05] was found between two groups at 48, 72, 96 and 168 h. Studies on the serum total bilirubin level were divided into two subgroups according to sample size, and the results of subgroup analysis showed that the serum total bilirubin level in the intervention group was significantly lower than that in the control group [MD = −52.06, 95% CI (−57.76, −46.36), P < 0.05 and MD = −10.65, 95% CI (−14.66, −6.63), P < 0.05]. Statistically significant difference in defecation frequency was observed between the two groups at 48 h after birth[SMD = 0.44, 95%CI (0.02, 0.87), P < 0.05].

Conclusion

Massage can decrease serum total bilirubin and percutaneous bilirubin levels and increasing defecation frequency. However, due to heterogeneity among studies, numerous multi-centre, large-sample and high-quality randomised controlled trials are needed to verify the effects of massage.

Bonding in neonatal intensive care units: Experiences of extremely preterm infants' mothers

BACKGROUND

The birth of an extremely preterm infant can disrupt normal mother-infant physical contact and the care provided by the mother. This situation has an impact on the process of bonding between the mother and the child.

AIM

The objective of this study was to describe and understand the experiences of mothers who have extremely preterm infants admitted in Neonatal Intensive Care Units with regard to their bonding process.

METHODS

An interpretive, qualitative research methodology using Gadamer's philosophical hermeneutics was carried out. A focus group and eleven in-depth, semi-structured interviews were conducted. Data were collected between June and September of 2016.

FINDINGS

Sixteen women with a mean age of 34.4 years participated in the study. Two themes emerged from the data analysis: (1) premature labour and technological environment, a distorted motherhood, with the subthemes 'feeling of emptiness and emotional crisis' and 'the complexity of the environment and care generate an emotional swing'; (2) learning to be the mother of an extremely preterm infant, with the subthemes "the difficulty of relating to a stranger" and 'forming the bond in spite of difficulties'.

CONCLUSIONS

The bonding with extremely preterm infants is interrupted after giving birth. The maternal emotional state and the environment of the neonatal intensive care unit limit its development. Nursing care can facilitate mother-infant bonding by encouraging communication, participation in care, massaging or breastfeeding.