In premature infants, weight gain becomes the main criterion for hospital discharge. Research has shown that massage therapy has led to weight gain in preterm infants when moderate pressure massage was provided (1,2). Moderate pressure may be an essential component of the infant massage, as a recent study by our group revealed that preterm infants who received moderate pressure stroking gained significantly more weight (26% more) than infants who received light pressure stroking (3).

Preterm infants are at risk for developing bone disease and bone fractures due to the limited formation of bone mass in utero and to limited activity (4). In studies on passive movement of the limbs, preterm infants also gained significantly more weight, and their bone density also increased (5). Oil massage for newborns is reported to improve weight gain by better thermoregulation. Transcutaneous absorption has also been suggested as a possible mechanism. (1)The use of oils including coconut oil and safflower oil enhanced the average weight gain, and the transcutaneous absorption of oil also increased triglycerides (6,7).

Mechanism of weight gain with massage in preterms (8)
Research has shown that massage in preterms is associated with increased vagal activity due to touch stimulation which leads to stimulation of the gastric branch of the vagus that leads to increased gastric motility which can enhance food digestion and can increase the availability of nutrients which, in turn, is related to greater weight gain. Greater nutrient availability can, in turn, increase Insulin like growth factor -1 (IGF-1) which leads to greater weight gain. Vagal stimulation also promotes the release of insulin via the celiac branch of the vagus and insulin has been shown to stimulate the synthesis and release of IGF-1 Insulin-like-growth-factor-I (IGF-1) plays a key role in regulating preterm infant growth.

Moderate massage in preterms (9)
The newborn is placed in a prone position and stroked with moderate pressure (sufficient to produce a slight skin color change from pink to white in a Caucasian neonate or slight indentations in the skin for all neonates). The newborn is massaged for five minutes as follows:

1. From the top of the head to the neck and back to the top of the head, and back to the neck;
   
   
2. From the neck across the shoulders;
   
   
3. From the upper back to the waist and back to the upper back;
   
   
4. From the thigh to the foot to the thigh on both legs; and
   
   
5. From the shoulder to the hand to the shoulder on both arms.

This is followed by passive movements of the limbs for 5 minutes. The newborn is placed in a supine position and each arm, then each leg, and finally both legs together are flexed and extended (as in a bicycling motion). Each flexion/extension motion lasts 10 seconds. This is again followed by 5 minute massage as depicted above.