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Notes on Guzzetta et al's article, "Massage Accelerates Brain Development and the Maturation of Visual Function", Introduction

Submitted by RST on Sun, 12/04/2011 - 10:08
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These notes are intended to serve as a guide to reading the article by Guzzetta et al. There is a great deal of scientific jargon in the article, and the style is telegraphic--factors which make the article less accessible to people who might otherwise like to read the research for themselves.

This post is intended to accompany a reading of that article, to demystify the jargon for a non-specialist reading audience, to expand the telegraphic style, and to make explicit the implicit knowledge contained within.

The article under study is:

Guzzetta A, Baldini S, Bancale A, Baroncelli L, Ciucci F, Ghirri P, Putignano E, Sale A, Viegi A, Berardi N, Boldrini A, Cioni G, Maffei L. Massage accelerates brain development and the maturation of visual function. Journal of Neuroscience. 2009 May 6;29(18):6042-51. PMID: 19420271 Free fulltext PDF of article available here.
 
Abstract: Environmental enrichment (EE) was shown recently to accelerate brain development in rodents. Increased levels of maternal care, and particularly tactile stimulation through licking and grooming, may represent a key component in the early phases of EE. We hypothesized that enriching the environment in terms of body massage may thus accelerate brain development in infants. We explored the effects of body massage in preterm infants and found that massage accelerates the maturation of electroencephalographic activity and of visual function, in particular visual acuity. In massaged infants, we found higher levels of blood IGF-1. Massage accelerated the maturation of visual function also in rat pups and increased the level of IGF-1 in the cortex. Antagonizing IGF-1 action by means of systemic injections of the IGF-1 antagonist JB1 blocked the effects of massage in rat pups. These results demonstrate that massage has an influence on brain development and in particular on visual development and suggest that its effects are mediated by specific endogenous factors such as IGF-1.
 
 

The first paragraph is pretty straightforward and relatively easily readable, although there are a few points worth remarking upon.

When you read their sentence "EE has remarkable effects on adult brain function in several species", this is a good opportunity to remember that we used to think the adult brain was far less plastic than it turns out to be in reality.

Here, I am using the word "plastic" as in "plastic surgery", meaning that it lends itself to being molded or shaped or formed. The fact that the adult brain is somewhat plastic means that negative experiences in the past that influenced the brain have at least a hope of being recovered from.

Let's review how the visual system works, to ensure that we're all on the same page.

  • Action item (AI) 1/Raven: review of the visual system: I'll post it in this discussion, and in the human systems e-Book, when it is finished--most likely, by end of day (EOD) Monday.

 

"Appreciable" means empirically detectable, measurable.

  • AI 2/Raven: put definition of "appreciable" in the wiki.
 
 
For many of us--not all, since massage education in the United States is so variable--one of the first things we learned in anatomy and physiology class was the various levels of analysis that we could look at in an anatomical structure and its physiological function. Even so, those we learned did not represent all possible levels, but just the ones most useful at the beginning, such as the gross anatomical level or the systems level.
 
  • Question 1: Can you give an example of a structure and its function at the behavioral level, at the electrophysiological level, and at the molecular level?
 

There is a lot of technical language in the 2nd paragraph, but it really refers to only a few foundational concepts. Once you know how, for example, a BDNF receptor works, you will understand how an NMDA receptor works when you come across it, because it's the same general idea--the specific molecule involved is the only change.

So don't let a skim of this paragraph discourage you--it's not nearly as hard as it looks at first glance.

  • Question 2: What seems to be the cause-and-effect connection between EE and improved function and behavior in pups?
  • Question 3: Can you think of an analogy in human behavior? Remember, we are not claiming that we know that this is true, but that it could possibly serve as a testable hypothesis for further study.
 
 
"[L]icking and grooming provided by the mother has been shown to influence [here, positive influence is implied]: 

 

Although there remains a lot that we don't know about what the hippocampus does, it is fairly well-established that it plays a major role both in memory and in spatial coding (mental representations of the spatial relations between objects). [1]

 

Guzzetta also states that the level of licking and grooming provided by the mother affects molecules crucial for plasticity, meaning the brain's ability to be shaped or formed in new ways and to form new connections, rather than being frozen and relatively unable to change.

In this context of the brain, this refers to proteins and other molecules that promote the growth and development of brain cells (a process called neurogenesis), since the dynamics governing that growth and development is where plasticity comes from.

BDNF, short for Brain-Derived Neurotrophic Factor, is:

  • is a protein expressed by the BDNF gene;
  • is a growth factor;
  • is involved in neurogenesis;
  • is suppressed in cases of depression;
  • increased by the neurotransmitter glutamate, exercise, caloric restriction, intellectual stimulation
  • active and present in high concentrations in brain areas vital to learning, memory, and higher thinking, such as the hippocampus and cortex. [2]
 
 

NMDA, short for N-Methyl-D-aspartic acid, is a molecule that mimics the action of the neurotransmitter glutamate, so it can stand in for glutamate when investigating the neurotransmitter's action under certain circumstances.

 
 
 
 
 
  • novelty reaction
  • exploratory behavior
 
Exploration is the act of making the unknown known and is a fundamental adaptive behavior across many species. A related adaptive behavior is novelty seeking, defined as a proclivity to approach unfamiliar situations. Abnormal exploratory behavior and novelty seeking are characteristic of many neuropsychiatric conditions, including excessive activity observed in bipolar mania, increased novelty seeking in substance use disorders, and prominent inactivity and withdrawal as observed in schizophrenia. For several decades, numerous animal paradigms of neuropsychiatric illness have assessed the multiple dimensions of exploratory behavior and novelty seeking. These models have been useful in elucidating underlying neurobiological mechanisms and testing novel psychotropic treatments. [3]
 
 
 
  • spatial learning and memory
  • level of glucocorticosteroid receptors in the hippocampus
Glucocorticoids are steroid hormones that play a role in reducing inflammation and in normal brain development. [4]
 
  • feedback control on hypothalamus-pituitary-adrenal axis
The hypothalamic–pituitary–adrenal (HPA) axis is a major system of hormonal control over many functions in the body. Much like a thermostat uses surrounding heat to tell if it needs to continue heating or to turn off the heat, the HPA axis checks blood levels of circulating hormones to determine whether to stimulate or stop stimulating hormone production in the glands in the system.
 
  • spine density and synaptic plasticity in hippocampus
This refers to the structure and plasticity of neurons in the hippocampus.
 
 
negative effects produced by maternal separation/deprivation or prenatal stress on:
  • pup growth
  • growth hormone (GH) secretion

Growth hormone, secreted by the anterior pituitary gland, plays a major role in structure growth and regulation of other hormonal systems in the body, such as the production of IGF-1.

 

 
 
 
 
 
  • HPA axis
  • BDNF expression
  • synaptophysin expression

Synaptophysin is a protein expressed by the SYP gene. The exact function of the protein is unknown...Recent research has shown, however, that elimination of synaptophysin in mice creates behavioral changes such as increased exploratory behavior, impaired object novelty recognition, and reduced spatial learning. [5]

 

 
"rescued": here it means "mitigated", or "alleviated"
 
"Working in preterm infants, Schanberg and Field (1987) found evidence that massage promoted a faster weight gain and a lower level of cortisol in massaged infants."
 
  • Question 4: What's wrong with this sentence?
 
 
Paragraph 3 is relatively straightforward and easy to understand.
 
 
Paragraph 4
 
Visual evoked potentials (VEPs) are measurements of electrical activity in the nervous system after some source of visual stimulation has occurred. For example, an investigator might use VEPs to trace the activity in the brain to see what happens when the subject is watching a flashing light.
 
Visual acuity is the sharpness or clearness of someone's vision--how clearly they can see.
 
Source: http://upload.wikimedia.org/wikipedia/commons/9/9f/Snellen_chart.svg accessed 4 December 2011
 
 
 
Electroencephalography (EEG) is the measurement of the brain's electrical activity
 
 
 
by means of electrodes placed along the scalp.
 
 
 
 
 
 
 

In paragraph 5, Guzzetta states that "IGF-1 mediates EE effects on visual cortical development". To "mediate" means to be in the middle of other things. Let's say the independent variable (roughly, the "cause") in the following figure is EE, and the dependent variable (roughly, the "effect") is visual cortical development.

Path C shows a connection where EE directly causes visual cortical effects. But here, Guzzetta is saying that that is not the case--instead, EE has an effect on IGF-1 (path A), and IGF-1 then has an effect on visual cortical effects (path B). IGF-1, then, mediates (is a mediator variable between) EE effects and visual cortical development.

 
 
 
 
So now that we've established the role that Guzzetta's team proposes it plays in mediating the effects of EE into visual cortex development, let's talk about what IGF-1 is.
 
IGF-1:
  • is a protein molecule, encoded by the IGF1 gene, that functions as a hormone;
  • is named Insulin-like Growth Factor 1:
    • "Insulin-like" because of its structural similarity to insulin;
    • "Growth Factor" because of its lifelong anabolic role;
    • "1" because it is a member of a family of structurally-related proteins, such as IGF-2;
  • is produced mostly by the liver;
  • is a primary mediator of Growth Hormone (GH);
  • appears to play a major role in biological aging and cancer, as well as in normal growth. [6]
 
 
 
How it works:
  1. the anterior pituitary in the brain produces GH, and releases it into the blood;
  2. GH goes to the liver, and stimulates it to produce IGF-1, and release it into the blood;
  3. IGF-1 causes growth in many different kinds of cells in the body, including the ones we're interested in here: the visual cortical cells in the occipital lobe.
     
Guzzetta also states that EE increases the number of IGF-1-positive neurons in the visual cortex; this is an example of neurogenesis.
 
They describe how increasing IGF-1 in the visual cortex of non-EE rats by means of osmotic minipumps mimics EE effects, accelerating visual acuity development.
 
An osmotic minipump is a tiny implantable device that delivers IGF-1, which the rat's cells then take up by osmosis.
  • AI 3/Raven: finish demonstration of diffusion, use that to lead into osmosis
 
 
The visual cortex is the part of the brain that processes information delivered from the eyes. This is the brain of a person whose hair, skin, and skull have been digitally removed from the image.
 
The person is facing away from you, so you are looking at the back of their head: the occipital lobe.
 
A funny thing is that--although the eyes are in the front of the head, the information they deliver has to travel all the way to the back to be processed, and then is projected all the way back up front to the eyes again, which gives the perception that vision is in our eyes.
 
 
The name "visual cortex" tells us that it's in the cortex, or outer layer of the cerebrum--the darker purple in this picture of a slice of brain tissue; the gray matter of the brain, as opposed to the inner layer of white matter.
 
 
 
 
 
Guzzetta observes that blocking IGF-1 action in the visual cortex of EE rats by means of the IGF-1 receptor antagonist JB1 blocks EE action on visual acuity development. JB-I blocks IGF-I signaling; in the following discussion of antagonists, we'll discuss in more detail how it does so.
 
They also observe that massage led to increased levels of blood IGF-1 and IGF1BP3 in human infants. IGFBP-3 is a carrier or a binding protein for IGF-1, preventing the kidney from quickly clearing it from the blood, as it normally would. [6]
 
Guzzetta states that massage led to increased number of IGF-1 positive neurons in the cortex in rat pups.
  • Question 5: Why didn't they test this in human infants?
 
 
Guzzetta also observes that antagonizing IGF-1 action blocked the effects of massage in rat pups. You can think of an antagonist at a molecular level as being both similar to and different from an antagonist at the muscular level.
 
Like a muscular antagonist, a molecular antagonist works against, or opposes, another molecule. But the way in which it opposes that other molecule is not like how an antagonist muscle works.
 
A molecular antagonist is similar enough to the other molecule that it can slip into the "lock-and-key" receptor, and block it off, so that when the other molecule arrives, it cannot find a receptor to take it up.
 
So Guzzetta is saying that they hypothesize that the effects of massage are mediated by IGF-1, and the fact that an IGF-1 antagonist blocked the effects of massage reinforces the hypothesis that massage affects the visual cortical neurons in a way that is mediated by IGF-1.
  • Question 6: Why didn't they test this in human infants?
 
  • Question 7: What is the purpose of Guzzetta's study?
Imagine you're explaining it to someone you just met at a party, or on the bus, not in the lab or clinic--use that level of language, rather than Guzzetta's jargon.
 
  • Question 8: What did they say about their results in this paragraph?
 
 
 

References

[1] Wikipedia: Hippocampus accessed 4 December 2011

[2] Wikipedia: BDNF accessed 4 December 2011

[3] Minassian A, Henry BL, Young JW, Masten V, Geyer MA, Perry W. Repeated assessment of exploration and novelty seeking in the human behavioral pattern monitor in bipolar disorder patients and healthy individuals. PLoS One. 2011;6(8):e24185. PMID: 21912623

[4] Wikipedia: Glucocorticoid accessed 4 December 2011

[5] Wikipedia: Synaptophysin accessed 4 December 2011

[6] Wikipedia: IGF-1 accessed 4 December 2011

 

In their own words: Ashley Montagu on Old Anna

Submitted by RST on Mon, 10/17/2011 - 09:19
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There was also Old Anna. Before World War I, Dr. Fritz Talbot of Boston was escorted through the Children’s Hospital in Dusseldorf by the Director, Dr. Arthur Schlossmann. The wards were very neat and tidy, but Dr. Talbot’s curiosity was piqued by the sight of a squat old lady waddling ahead of them down the corridor, carrying a baby on her hip. “Who’s that?” inquired Dr. Talbot. “Oh,” said Dr. Schlossmann, “that is Old Anna. When we have done everything medically we can for a baby, and it is still not doing well, we turn it over to Old Anna, and she is always successful in restoring it to vigor.” When Dr. Talbot returned to his duties in Boston he instructed the nurses and interns on his wards to pick up and hold the babies. The ensuing improvement in the welfare of the babies would have gratified Old Anna. It is not often that the Old Annas of this world have been appreciated. It gives me special pleasure to think of her and how much we owe her.

--Ashley Montagu, from Touch in Early Development [1]

 

 

[1] Montagu, A. "Animadversions on the Development of a Theory of Touch", Touch in early development, ed. Tiffany M. Field. Lawrence Erlbaum Associates, Inc., Mahwah, NJ. ISBN 0-8058-1890-1. 1995.

Oil massage for newborns in developing countries

Submitted by RST on Sun, 10/02/2011 - 11:16
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Hi, and welcome to the 2nd monthly Journal Club at POEM.

Before we start into this month's article, I'd like to thank rchunco for doing such a good and thorough job leading the discussion last month. It's never easy being the very first one in a new venture, and she really stepped up to the plate with it. I appreciate all the thought and work she put into it, and I enjoyed the discussion that resulted.

I'd also like to thank Christopher Moyer, the first author of the paper, for being so generous with his time, answering questions and contributing to the discussion.

This month, we are going to look at a very different kind of article, but that just goes to show the diversity of massage research--it spans a wide, multidisciplinary range of topics and approaches.

The article I've chosen to kick off this month's Journal Club is:

Mullany LC, Darmstadt GL, Khatry SK, Tielsch JM. Traditional massage of newborns in Nepal: implications for trials of improved practice. Journal of Tropical Pediatrics. 2005 Apr;51(2):82-6.

 

Click here to access a free fulltext PDF of the article.

Source: http://www.dfid.gov.uk/Images/250x190/MDG5-nepal-maternal-health-250-190.jpg accessed 2 October 2011

 

Describe WHY you picked this paper

Not to put too fine a point on it, I fell deeply in love with the work they are doing from the moment I learned about it. For one thing--the most important--they are working to save infant lives in the developing world, and that is absolutely foundational.

For another, this team's work is multifaceted--there are so many different issues contained in what they are studying. It touches on all aspects of the biopsychosocial model of massage. There are the strictly biological issues of skin development and barrier-function enhancement, as well as the development of temperature regulation in full-term and premature babies.

There are the psychological aspects of promoting bonding between mothers/other caregivers and children, the meaning of performing traditional massage in the self-image of the parent, and--in saving infant lives--sparing some families form having to grieve due to the risk of high infant mortality in the developing world.

And there are the social issues of what massage means in particular cultures, and how people from outside a culture can work with people inside that culture to implement positive change in traditional healthcare practices--encouraging them with sensitivity, respect, and cooperation to keep what works, and modify what doesn't work, or is even actively harmful.

Those social issues, informed by anthropological and sociological considerations, also intersect with the medical ethics values of beneficence, non-maleficence, autonomy, dignity, and others. As well, there are the basic science issues involved with the biology of the skin, the medical issues involved in the treatment of any one infant, and the public health issues of populations and preventive health.

This team's research is very rich, as the bibliography at the end of this post shows, and for these reasons, I have chosen the Mullany 2005 article to lead into a discussion of this research.

 

Explain how you came across the article

I found this article in a berry-picking way (not to be confused with cherry-picking).

Cherry-picking is a kind of bias where you choose only the evidence that puts your issue in a positive light, in order to make it look better than it is.

Berry-picking is very different, even though the names sound so similar. It's a description of how we find information, by analogy with going into the woods or meadows to look for berries.

You don't know before you get there where the best berries will be, so you set out with a general idea of where you are going to start looking. Then, based on what you find, you modify that start to take you to where the best berries turn out to be. You wander from bush to bush, rather than proceeding in a straight line, and what you find influences where you go next--the initial plan continually evolves.

My process unfolded in a similar way. I was looking through PubMed for articles on massage, and I came across one of this team's articles. Intrigued, I followed that one to find others on the topic, and ended up with a body of work that was very interesting and unexpected, and that I had had no idea even existed.

 

BRIEFLY describe the study

Mullany's team is exploring the practice of traditional infant massage among groups of people in Nepal to determine what they practice, what reasons they perceive lie behind their practice, and what factors would need to be taken into account to make oils other than mustard oil be considered as acceptable alternatives.

They administered a questionnaire to caretakers of 8580 newborns and conducted focus group discussions to understand and explore these issues. 

In these ways, they found:

  • Approximately 99 per cent of newborns were massaged at least once with mustard oil in the 2 weeks after birth, and
  • 80 per cent were massaged at least twice daily.
  • Most commonly cited reasons for application of mustard oil:
    • promotion of strength,
    • maintenance of health, and
    • provision of warmth.
  • Important contextual factors involved in the practice:
    • smell,
    • oiliness,
    • mode of pre-massage preparation, and
    • perceived absorptive potential on the skin.
  • Caretakers are willing to consider adaptation of established traditions for the promotion of positive health outcomes if essential contextual criteria are met.
  • An understanding of cultural, social, and economic factors that shape the context of traditional healthcare practices is essential to the design and implementation of intervention trials examining the relative efficacy of application of oils in reducing neonatal mortality and morbidity.

 

 

Describe the research question using the 4 basic components of the question (PICO):

Population  (who was studied?)

Caregivers of infants in Nepal

Intervention (what therapy was applied, tests etc?)

Exploratory, through questionnaire and focus groups

Comparison or control (how was the intervention controlled?)

N/A: questionnaire and focus groups don't have controls as such

Outcome

Findings as summarized above

 

What is the importance or relevance of the question asked?

The traditional practice of massage clearly provides benefits to both the mother and the baby. However, the use of mustard oil as a lubricant in the traditional massage poses a risk to the baby's life and health, because it compromises the integrity of the skin, which serves both as a barrier to infection and as insulation for self-thermoregulation.

Because of the infrastructure and resources available to these populations, the children are already at high risk of dying or being disabled. Improving the traditional practice of infant massage to protect the skin more reliably can make a real, tangible difference in giving these children every chance possible for survival.

However, an intervention only works if it is actually used. To give this intervention the maximal chance of success, the researchers asked the caregivers to tell them about how they practiced traditional infant massage, what their reasons for doing it were, what factors played into their choice of oil, and what considerations they would take into account when thinking about whether to use an alternative to mustard oil.

 

State your questions (and answers, if you wish) on the threats to validity in the study.

This investigation was designed to examine those socio-cultural and behavioral factors that would be essential to consider within the design of an intervention trial to determine the impact of behavior change to modify and enhance the benefits of newborn oil massage.

When you're administering a questionnaire, you have to remember that respondents always have their own motivations. The higher the stakes in the culture of the practice you're asking about, the more you have to keep that in mind, because they have a real investment in their place in the society.

You shouldn't think of this type of intervention as a 1-transaction event, but as one that gets refined and added to, as the issues are identified and examined.

I did not see any explanation of what steps they took to validate their questionnaire--to make sure that it tested for what they thought, within the context of the cultures that the respondents are part of. That is one possible threat to validity.

I think that a good way to proceed would be for you to read the study now, available by clicking this link.

As questions and ideas occur to you, please post them in the comments for discussion. I'll also start putting some questions out there, as well.

The articles immediately following this post are more articles on related aspects of traditional oil massage for infants, by the same group of researchers. Feel free to look at them to get ideas if you like, but for right now, don't worry about trying to read them (unless, of course, you're really motivated to). If it's appropriate, we'll bring some of them into the discussion as well, but let's get comfortable with this one article first, before trying to being in any additional material.

I hope you enjoy this topic even a fraction as much as I do, and I look forward to hearing what you think of it.

 

 

Related articles to this study

2002

  • Darmstadt GL, Mao-Qiang M, Chi E, Saha SK, Ziboh VA, Black RE, Santosham M, Elias PM. Impact of topical oils on the skin barrier: possible implications for neonatal health in developing countries. Acta Paediatr. 2002;91(5):546-54.
    Department of International Health, Bloomberg School of Public Health, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA.
    PMID: 12113324
Abstract:
Topical therapy to enhance skin barrier function may be a simple, low-cost, effective strategy to improve outcome of preterm infants with a developmentally compromised epidermal barrier, as lipid constituents of topical products may act as a mechanical barrier and augment synthesis of barrier lipids. Natural oils are applied topically as part of a traditional oil massage to neonates in many developing countries. We sought to identify inexpensive, safe, vegetable oils available in developing countries that improved epidermal barrier function. The impact of oils on mouse epidermal barrier function (rate of transepidermal water loss over time following acute barrier disruption by tape-stripping) and ultrastructure was determined. A single application of sunflower seed oil significantly accelerated skin barrier recovery within 1 h; the effect was sustained 5 h after application. In contrast, the other vegetable oils tested (mustard, olive and soybean oils) all significantly delayed recovery of barrier function compared with control- or Aquaphor-treated skin. Twice-daily applications of mustard oil for 7 d resulted in sustained delay of barrier recovery. Moreover, adverse ultrastructural changes were seen under transmission electron microscopy in keratin intermediate filament, mitochondrial, nuclear, and nuclear envelope structure following a single application of mustard oil. Conclusion: Our data suggest that topical application of linoleate-enriched oil such as sunflower seed oil might enhance skin barrier function and improve outcome in neonates with compromised barrier function. Mustard oil, used routinely in newborn care throughout South Asia, has toxic effects on the epidermal barrier that warrant further investigation.

 

 
  • Darmstadt GL, Saha SK. Traditional practice of oil massage of neonates in Bangladesh. J Health Popul Nutr. 2002 Jun;20(2):184-8.
    Department of International Health, Bloomberg School of Public Health, The Johns Hopkins Medical Institutions, Baltimore, MD, USA
    PMID: 12186200
Abstract:
Topical application of natural oils is practised routinely in many countries and may either improve skin barrier function and health or have detrimental cutaneous and systemic effects, depending on the composition of the oil. Little literature on the epidemiology, practice, and perceptions of traditional neonatal oil massage is available. This study was undertaken to gain insights into the epidemiology, practice, and perceptions regarding traditional oil massage of Bangladeshi neonates. A questionnaire was administered verbally to the primary caretaker of 332 outpatients at the Dhaka Shishu Hospital, and to 20 women with children encountered at the Matlab Health Complex in Bangladesh. More than 96% (340/352) of the caregivers practised oil massage, irrespective of socioeconomic status and place of residence. Among those at the Dhaka Shishu Hospital who practised oil massage, mustard oil was used alone or in combination by 95% (303/320) over the entire body, 1-3 time(s) daily (96%), starting in the first three days of life (72%) in both term and preterm neonates. Perceived benefits included prevention of infections (69%) and hypothermia (2%). Oil massage is an important traditional domiciliary practice used annually on more than three million newborns in Bangladesh. Given its potential for beneficial and harmful effects, further research is needed on the value of this practice, and ways to optimize its beneficial effects.

 

 

2003

  • Darmstadt GL, Saha SK. Neonatal oil massage. Indian Pediatr. 2003 Nov;40(11):1098-9.
    PMID: 14660847 Free full text

 

2005

  • Darmstadt GL, Saha SK, Ahmed AS, Chowdhury MA, Law PA, Ahmed S, Alam MA, Black RE, Santosham M. Effect of topical treatment with skin barrier-enhancing emollients on nosocomial infections in preterm infants in Bangladesh: a randomised controlled trial. Lancet. 2005 Mar 19-25;365(9464):1039-45.
    Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA.
    PMID: 15781099

Abstract:
BACKGROUND:
Infections and complications of prematurity are main causes of neonatal mortality. Very low birthweight premature infants have compromised skin barrier function, and are at especially high risk for serious infections and mortality. Our aim was to ascertain whether topical application of emollients to enhance skin barrier function would prevent nosocomial infections in this population.

 

METHODS:

We randomly assigned infants born before week 33 of gestation after admission to Dhaka Shishu Hospital, Bangladesh, to daily massage with sunflower seed oil (n=159) or Aquaphor (petrolatum, mineral oil, mineral wax, lanolin alcohol; n=157). We then compared incidence of nosocomial infections among infants in these two groups with an untreated control group (n=181) by an intention-to-treat analysis.

 

FINDINGS:

20 patients in the control group, and 22 in each of the treatment groups left the hospital early, but were included in the final analysis. Overall, infants treated with sunflower seed oil were 41% less likely to develop nosocomial infections than controls (adjusted incidence rate ratio [IRR] 0.59, 95% CI 0.37-0.96, p=0.032). Aquaphor did not significantly reduce the risk of infection (0.60, 0.35-1.03, p=0.065). No adverse events were seen.

 

INTERPRETATION:

Our findings confirm that skin application of sunflower seed oil provides protection against nosocomial infections in preterm very low birthweight infants. The low cost, availability, simplicity, and effect of treatment make it an important intervention for very low birthweight infants admitted to hospital in developing countries.

 

 

  • Mullany LC, Darmstadt GL, Khatry SK, Tielsch JM. Traditional massage of newborns in Nepal: implications for trials of improved practice. J Trop Pediatr. 2005 Apr;51(2):82-6.
    Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA
    PMID: 15677372 PMCID: PMC1317296 Free PMC Article
Abstract
Mustard oil massage of newborns is an integral component of traditional care practices in many communities. Recent evidence suggests that this practice may have detrimental effects, particularly for preterm infants or for those whose skin barrier function is otherwise sub-optimal. Other natural oils such as sunflower, sesame or safflower seed oil may have a beneficial impact on newborn health and survival. Little is known, however, about cultural and other factors related to the acceptance and uptake of alternative, more beneficial oils for massage of the newborn. A questionnaire concerning the usage and reasons for application of mustard and other oils to newborn skin was administered to the caretakers of 8580 newborns in Sarlahi district of rural Nepal. Four focus group discussions among representative groups were conducted to describe the perceived benefits of oil massage and the factors involved in the decision to apply oil. The potential for the introduction of alternative natural oils was explored. Approximately 99 per cent of newborns were massaged at least once with mustard oil in the 2 weeks after birth, and 80 per cent were massaged at least twice daily. Promotion of strength, maintenance of health, and provision of warmth were the most commonly cited reasons for application of mustard oil. Focus group discussion participants noted that smell, oiliness, mode of pre-massage preparation, and perceived absorptive potential on the skin are important contextual factors involved in the practice. Caretakers are willing to consider adaptation of established traditions for the promotion of positive health outcomes if essential contextual criteria are met. An understanding of cultural, social, and economic factors that shape the context of traditional healthcare practices is essential to the design and implementation of intervention trials examining the relative efficacy of application of oils in reducing neonatal mortality and morbidity.
 
 

2007

  • Ahmed AS, Saha SK, Chowdhury MA, Law PA, Black RE, Santosham M, Darmstadt GL. Acceptability of massage with skin barrier-enhancing emollients in young neonates in Bangladesh. J Health Popul Nutr. 2007 Jun;25(2):236-40.
    Department of Neonatology, Bangladesh Institute of Child Health, Dhaka Shishu Hospital, Dhaka, Bangladesh.
    PMID: 17985826 PMCID: PMC2754003 Free PMC Article
Abstract
Oil massage of newborns has been practised for generations in the Indian sub-continent; however, oils may vary from potentially beneficial, e.g. sunflower seed oil, to potentially toxic, e.g. mustard oil. The study was carried out to gain insights into oil-massage practices and acceptability of skin barrier-enhancing emollients in young, preterm Bangladeshi neonates. Preterm infants of <33 weeks gestational age were randomized to high-linoleate sunflower seed oil, Aquaphor Original Emollient Ointment, or the comparison group (usual care). A survey was administered at admission to assess routine skin-care practices prior to admission and at discharge to assess acceptability of emollient therapy during hospitalization. Oil massage was given to 83 (21%) of 405 babies before hospital admission, 86% (71/83) of whom were delivered at home. Application of oil, most commonly mustard oil (88%, 73/83), was started within one hour of birth in 51 cases (61%) and was applied all over the body (89%, 74/83) one to six (mean 2.2) times before admission. Of infants who received emollient therapy in the hospital, 42% (n=32) of mothers reported that the emollient applied in the hospital was better than that available at home, and only 29% would use the same oil (i.e. mustard oil) in the future as used previously at home. No problems resulted from use of emollient in the hospital. Topical therapy with sunflower seed oil or Aquaphor was perceived by many families to be superior to mustard oil. If caregivers and health professionals can be motivated to use inexpensive, available emollients, such as sunflower seed oil that are beneficial, emollient therapy could have substantial public-health benefit.
 
 
 

2008

  • Alam MA, Ali NA, Sultana N, Mullany LC, Teela KC, Khan NU, Baqui AH, El Arifeen S, Mannan I, Darmstadt GL, Winch PJ. Newborn umbilical cord and skin care in Sylhet District, Bangladesh: implications for the promotion of umbilical cord cleansing with topical chlorhexidine. J Perinatol. 2008 Dec;28 Suppl 2:S61-8.
    Child Health Unit, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh.
    PMID: 19057570 PMCID: PMC2929163 Free PMC Article
Abstract
Newborn cord care practices may directly contribute to infections, which account for a large proportion of the four million annual global neonatal deaths. This formative research study assessed current umbilical and skin care knowledge and practices for neonates in Sylhet District, Bangladesh, in preparation for a cluster-randomized trial of the impact of topical chlorhexidine cord cleansing on neonatal mortality and omphalitis. Unstructured interviews (n=60), structured observations (n=20), rating and ranking exercises (n=40) and household surveys (n=400) were conducted to elicit specific behaviors regarding newborn cord and skin care practices. These included hand-washing, skin and cord care at the time of birth, persons engaged in cord care, cord cutting practices, topical applications to the cord at the time of birth, wrapping/dressing of the cord stump and use of skin-to-skin care. Overall 90% of deliveries occurred at home. The umbilical cord was almost always (98%) cut after delivery of the placenta, and cut by mothers in more than half the cases (57%). Substances were commonly (52%) applied to the stump after cord cutting; turmeric was the most common application (83%). Umbilical stump care revolved around bathing, skin massage with mustard oil and heat massage on the umbilical stump. Overall 40% of newborns were bathed on the day of birth. Mothers were the principal provider for skin and cord care during the neonatal period and 9% of them reported umbilical infections in their infants. Unhygienic cord care practices are prevalent in the study area. Efforts to promote hand-washing, cord cutting with clean instruments and avoiding unclean home applications to the cord may reduce exposure and improve neonatal outcomes. Such efforts should broadly target a range of caregivers, including mothers and other female household members.
 
 
 

2009

  • Thatte N, Mullany LC, Khatry SK, Katz J, Tielsch JM, Darmstadt GL. Traditional birth attendants in rural Nepal: knowledge, attitudes and practices about maternal and newborn health. Glob Public Health. 2009;4(6):600-17.
    Department of International Health, International Centre for Advancing Neonatal Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
    PMID: 19431006 PMCID: PMC2762492 Free PMC Article
Abstract
Efforts to formalise the role of traditional birth attendants (TBAs) in maternal and neonatal health programmes have had limited success. TBAs' continued attendance at home deliveries suggests the potential to influence maternal and neonatal outcomes. The objective of this qualitative study was to identify and understand the knowledge, attitudes and practices of TBAs in rural Nepal. Twenty-one trained and untrained TBAs participated in focus groups and in-depth interviews about antenatal care, delivery practices, maternal complications and newborn care. Antenatal care included advice about nutrition and tetanus toxoid (TT) immunisation, but did not include planning ahead for transport in cases of complications. Clean delivery practices were observed by most TBAs, though hand-washing practices differed by training status. There was no standard practice to identify maternal complications, such as excessive bleeding, prolonged labour, or retained placenta, and most referred outside in the event of such complications. Newborn care practices included breastfeeding with supplemental feeds, thermal care after bathing, and mustard seed oil massage. TBAs reported high job satisfaction and desire to improve their skills. Despite uncertainty regarding the role of TBAs to manage maternal complications, TBAs may be strategically placed to make potential contributions to newborn survival.
 
 
  • Maulik PK, Darmstadt GL. Community-based interventions to optimize early childhood development in low resource settings. J Perinatol. 2009 Aug;29(8):531-42. Epub 2009 Apr 30.
    Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA.
    PMID: 19404276
Abstract
OBJECTIVE:
Interventions targeting the early childhood period (0 to 3 years) help to improve neuro-cognitive functioning throughout life. Some of the more low cost, low resource-intensive community practices for this age-group are play, reading, music and tactile stimulation. This research was conducted to summarize the evidence regarding the effectiveness of such strategies on child development, with particular focus on techniques that may be transferable to developing countries and to children at risk of developing secondary impairments.
 
STUDY DESIGN:
PubMed, PsycInfo, Embase, ERIC, CINAHL and Cochrane were searched for studies involving the above strategies for early intervention. Reference lists of these studies were scanned and other studies were incorporated based on snow-balling.
 
RESULT:
Overall, 76 articles corresponding to 53 studies, 24 of which were randomized controlled trials, were identified. Sixteen of those studies were from low- and middle-income countries. Play and reading were the two commonest interventions and showed positive impact on intellectual development of the child. Music was evaluated primarily in intensive care settings. Kangaroo Mother Care, and to a lesser extent massage, also showed beneficial effects. Improvement in parent-child interaction was common to all the interventions.
 
CONCLUSION:
Play and reading were effective interventions for early childhood interventions in low- and middle-income countries. More research is needed to judge the effectiveness of music. Kangaroo Mother Care is effective for low birth weight babies in resource poor settings, but further research is needed in community settings. Massage is useful, but needs more rigorous research prior to being advocated for community-level interventions.
 
 
  • Falle TY, Mullany LC, Thatte N, Khatry SK, LeClerq SC, Darmstadt GL, Katz J, Tielsch JM. Potential role of traditional birth attendants in neonatal healthcare in rural southern Nepal. J Health Popul Nutr. 2009 Feb;27(1):53-61.
    Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, E8646, Baltimore, MD 21205, USA.
    PMID: 19248648 PMCID: PMC2650835 Free PMC Article
Abstract
The potential for traditional birth attendants (TBAs) to improve neonatal health outcomes has largely been overlooked during the current debate regarding the role of TBAs in improving maternal health. Randomly-selected TBAs (n=93) were interviewed to gain a more thorough understanding of their knowledge, attitudes, and practices regarding maternal and newborn care. Practices, such as using a clean cord-cutting instrument (89%) and hand-washing before delivery (74%), were common. Other beneficial practices, such as thermal care, were low. Trained TBAs were more likely to wash hands with soap before delivery, use a clean delivery-kit, and advise feeding colostrum. Although mustard oil massage was a universal practice, 52% of the TBAs indicated their willingness to consider alternative oils. Low-cost, evidence-based interventions for improving neonatal outcomes might be implemented by TBAs in this setting where most births take place in the home and neonatal mortality risk is high. Continuing efforts to define the role of TBAs may benefit from an emphasis on their potential as active promoters of essential newborn care.
 
 
 

2010

  • LeFevre A, Shillcutt SD, Saha SK, Ahmed AS, Ahmed S, Chowdhury MA, Law PA, Black R, Santosham M, Darmstadt GL. Cost-effectiveness of skin-barrier-enhancing emollients among preterm infants in Bangladesh. Bull World Health Organ. 2010 Feb;88(2):104-12.
    Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, United States of America.
    PMID: 20428367 PMCID: PMC2814477 Free PMC Article
Abstract
OBJECTIVE:
To evaluate the cost-effectiveness of topical emollients, sunflower seed oil (SSO) and synthetic Aquaphor, versus no treatment, in preventing mortality among hospitalized preterm infants (< 33 weeks gestation) at a tertiary hospital in Bangladesh.
 
METHODS:
Evidence from a randomized controlled efficacy trial was evaluated using standard Monte Carlo simulation. Programme costs were obtained from a retrospective review of activities. Patient costs were collected from patient records. Health outcomes were calculated as deaths averted and discounted years of life lost (YLLs) averted. Results were deemed cost-effective if they fell below a ceiling ratio based on the per capita gross national income of Bangladesh (United States dollars, US$ 470).
 
FINDINGS:
Aquaphor and SSO were both highly cost-effective relative to control, reducing neonatal mortality by 26% and 32%, respectively. SSO cost US$ 61 per death averted and US$ 2.15 per YLL averted (I$ 6.39, international dollars, per YLL averted). Aquaphor cost US$ 162 per death averted and US$ 5.74 per YLL averted (I$ 17.09 per YLL averted). Results were robust to sensitivity analysis. Aquaphor was cost-effective relative to SSO with 77% certainty: it cost an incremental US$ 26 more per patient treated, but averted 1.25 YLLs (US$ 20.74 per YLL averted).
 
CONCLUSION:
Topical therapy with SSO or Aquaphor was highly cost-effective in reducing deaths from infection among the preterm neonates studied. The choice of emollient should be made taking into account budgetary limitations and ease of supply. Further research is warranted on additional locally available emollients, use of emollients in community-based settings and generalizability to other geographic regions.
 
 
 

2011

  • Duffy JL, Ferguson RM, Darmstadt GL. Opportunities for Improving, Adapting and Introducing Emollient Therapy and Improved Newborn Skin Care Practices in Africa. J Trop Pediatr. 2011 May 10.
    Family Health Division, Global Health Program, Bill and Melinda Gates Foundation, Seattle, WA, USA.
    PMID: 21558307
Abstract
Infections and complications from prematurity cause a majority of global neonatal deaths. Recent evidence has demonstrated the life-saving ability of topical emollient therapy in resource-poor settings. With the potential to reduce infection and neonatal mortality by 41 and 26%, respectively, emollient therapy is a promising option for improving newborn care. While application of oil to the newborn is nearly universal in South Asia, little is known about this behavior in Africa. This article draws on literature regarding neonatal skin care in Africa to describe behaviors, motivations and potential for introducing topical emollients. Oil massage does not appear to be universal. When oil massage occurs, substances of unknown toxicity and possibly damaging massage practices are used; thus, there is scope for introduction of improved therapeutic practices. Overall, more research is needed to develop the evidence base of current neonatal skin care behaviors in Africa, and to determine emollient therapy effectiveness there.
 
 
  • Karas DJ, Mullany LC, Katz J, Khatry SK, Leclerq SC, Darmstadt GL, Tielsch JM. Home Care Practices for Newborns in Rural Southern Nepal During the First 2 weeks of Life. J Trop Pediatr. 2011 Jun 24.
    Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
    PMID: 21705765
Abstract
The provision of essential newborn care through integrated packages is essential to improving survival. We analyzed data on newborn care practices collected among infants who participated in a community-based trial in rural Nepal. Analysis focused on feeding, hygienic, skin/cord care and thermal care practices. Data were analyzed for 23 356 and 22 766 newborns on Days 1 and 14, respectively. About 56.6% of the babies were breastfed within 24 h and 80.4% received pre-lacteal feeds within the first 2 weeks of life. Only 13.3% of the caretakers always washed their hands before caring for their infant. Massage with mustard oil was near universal, 82.2% of the babies slept in a warmed room and skin-to-skin contact was rare (4.5%). Many of these commonly practiced behaviors are detrimental to the health and survival of newborns. Key areas to be addressed when designing a community-endorsed care package were identified.
 
 

 

 

Journal Club for October: Traditional oil massage for newborn babies in India, Nepal, and Bangladesh

Submitted by RST on Sat, 10/01/2011 - 08:48
Posted in
 
 
 
If you want to start reading the first article before Monday, click here to access a free, fulltext PDF of the following:
 
Mullany LC, Darmstadt GL, Khatry SK, Tielsch JM. Traditional massage of newborns in Nepal: implications for trials of improved practice. J Trop Pediatr. 2005 Apr;51(2):82-6. PMID: 15677372 PMCID: PMC1317296 
 
Abstract: Mustard oil massage of newborns is an integral component of traditional care practices in many communities. Recent evidence suggests that this practice may have detrimental effects, particularly for preterm infants or for those whose skin barrier function is otherwise sub-optimal. Other natural oils such as sunflower, sesame or safflower seed oil may have a beneficial impact on newborn health and survival. Little is known, however, about cultural and other factors related to the acceptance and uptake of alternative, more beneficial oils for massage of the newborn. A questionnaire concerning the usage and reasons for application of mustard and other oils to newborn skin was administered to the caretakers of 8580 newborns in Sarlahi district of rural Nepal. Four focus group discussions among representative groups were conducted to describe the perceived benefits of oil massage and the factors involved in the decision to apply oil. The potential for the introduction of alternative natural oils was explored. Approximately 99 per cent of newborns were massaged at least once with mustard oil in the 2 weeks after birth, and 80 per cent were massaged at least twice daily. Promotion of strength, maintenance of health, and provision of warmth were the most commonly cited reasons for application of mustard oil. Focus group discussion participants noted that smell, oiliness, mode of pre-massage preparation, and perceived absorptive potential on the skin are important contextual factors involved in the practice. Caretakers are willing to consider adaptation of established traditions for the promotion of positive health outcomes if essential contextual criteria are met. An understanding of cultural, social, and economic factors that shape the context of traditional healthcare practices is essential to the design and implementation of intervention trials examining the relative efficacy of application of oils in reducing neonatal mortality and morbidity.
 
Additionally, since we are all coming together along very different paths, and we are such an interdisciplinary group, I'm not making implicit assumptions that we all have been exposed to the same knowledge.
 
If you'd like an introduction or a refresher to the scientific method, and how it relates to the structure of a research article, my article on that topic has kindly been made available by clicking on the following link, thanks to Massage & Bodywork Magazine and the Massage Therapy Foundation:
 

Infant massage

Submitted by RST on Thu, 02/24/2011 - 07:35
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