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Infant Massage Compared With Crib Vibrator in the Treatment of Colicky
Virpi Huhtala, Liisa Lehtonen, Riitta Heinonen and Heikki Korvenranta DOI: 10.1542/peds.105.6.e84 The online version of this article, along with updated information and services, is located on the World Wide Web at: PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthlypublication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, ElkGrove Village, Illinois, 60007. Copyright 2000 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275. Infant Massage Compared With Crib Vibrator in the Treatment of
Virpi Huhtala, MD; Liisa Lehtonen, MD; Riitta Heinonen, RN; and Heikki Korvenranta, MD To evaluate the effectiveness
of infant massage compared with that of a crib vibrator in
crying is typical of infantile colic.1–4 The phe- the treatment of infantile colic.
nomenon is associated with considerable pa- Infants <7 weeks of age and perceived as
rental distress5,6 and still lacks a safe and effective colicky by their parents were randomly assigned to an
therapy. Dicyclomine was effective in the treatment infant massage group (n ⴝ 28) or a crib vibrator group
of colicky infants7,8 but is now contraindicated be- (n ⴝ 30). Three daily intervention periods were recom-
cause of the possible life-threatening side effects.9 mended in both groups. Parents recorded infant crying
Herbal tea10 and sucrose11 may also be useful, but and given interventions in a structured cry diary that was
kept for 1 week before (baseline) and for 3 weeks during
more evidence for their effectiveness is needed. The the intervention. Parents were interviewed after the first
benefit of cow's milk elimination has been shown in and third weeks of intervention to obtain their evalua-
several studies,12,13 and a 1-week trial with a hypoal- tion of the effectiveness of the given massage or crib
lergenic formula has been suggested for colicky in- fants.14 However, no consensus about the role of At baseline, the mean amount of total crying
cow's milk allergy or intolerance in colic has so far was 3.6 (standard deviation: 1.4) hours/day in the mas-
been reached. Parental counseling is beneficial15,16 sage group infants and 4.2 (2.0) hours/day in the vibrator
and is considered important in the current manage- group infants. The mean amount of colicky crying was
ment of colic.
2.1 (standard deviation: 1.1) hours/day and 2.9 (1.5) hours/
Infant massage has been suggested for treatment day, respectively. The mean number of daily interven-
of colic,17 and it may be widely used for this purpose; tion periods was 2.2 in both groups. Over the 4-week
50% of mothers were reported to use massage to study, the amount of total and colicky crying decreased
soothe their excessively crying infants in a multicul- significantly in both intervention groups. The reduction
tural Dutch population.18 Infant massage provides a in crying was similar in the study groups: total crying
decreased by a mean 48% in the massage group and by
lot of sensory stimulation, which has been shown to 47% in the vibrator group, and colicky crying decreased
have pacifying effects on infants generally.19,20 Mas- by 64% and 52%, respectively. The amount of other cry-
sage therapy has been reported to promote growth ing (total crying minus colicky crying) remained stable in
and development in premature infants21,22 and to both groups over the intervention. Ninety-three percent
improve early mother–infant interaction.23 Human of the parents in both groups reported that colic symp-
toms decreased over the 3-week intervention, and 61% of
exposed infants and infants of depressed mothers the parents in the massage group and 63% of the parents
have also been suggested to benefit from massage in the crib vibrator group perceived the 3-week interven-
therapy.24 However, increased sensory stimulation in tion as colic reducing.
the form of carrying or crib vibration25,26 has not been Infant massage was comparable to the
effective in the treatment of colicky infants. Instead, use of a crib vibrator in reducing crying in colicky in-
colicky infants may benefit from decreased stimula- fants. We suggest that the decrease of total and colicky
crying in the present study reflects more the natural
To our knowledge, there was no controlled study course of early infant crying and colic than a specific
effect of the interventions. Pediatrics 2000;105(6). URL:
of infant massage in the treatment of colic. Thus, we evaluated the effects of infant massage on crying in fantile colic, massage, crib vibrator, treatment, sensory
colicky infants in a randomized, controlled trial. Use of a crib vibrator was chosen for control interventionor placebo treatment, because it had been ineffectivein a previous study.26 ABBREVIATION. SD, standard deviation.
Subjects and Procedure
From the Department of Pediatrics, Turku University Hospital, Turku, The colicky infants were enrolled in the study by giving infor- mation about the study to the mothers of newborn infants on the Received for publication Jul 26, 1999; accepted Jan 17, 2000.
postpartum wards of the Turku University Hospital and at the Reprint requests to (V.H.) Department of Pediatrics, Turku University well-infant clinics in the Turku town district. In the study infor- Hospital, Kiinamyllynkatu 4-6, 20520 Turku, Finland. E-mail: virpi.susanna.
mation, colic was described as intensive infant crying of at least 3 hours a day on 3 or more days a week in an otherwise healthy PEDIATRICS (ISSN 0031 4005). Copyright 2000 by the American Acad- infant. The mothers were asked to contact us if their infant had emy of Pediatrics.
shown these symptoms of colic during the first month of the PEDIATRICS Vol. 105 No. 6 June 2000 infant's life, for at least 1 week. The inclusion criteria for study entry were ⬍6 weeks of age, born at ⱖ37 weeks of gestation, not The parents were interviewed after the first and third weeks of small for gestational age, Apgar scores ⱖ7 at 5 minutes and ⱖ8 at intervention. The first interview was conducted by phone and the 15 minutes, healthy from birth on, and parental perception of the second 1 at the control visit. Both interviews included an evalua- colic of the infant according to the description in the study infor- tion of the amount of colic symptoms (crying) compared with the mation. If the parents were willing to participate, they received a amount at baseline and an evaluation of the perceived effect of the 1-week diary for recording the crying, sleeping, and feedings of given intervention on these symptoms. The amount of colic symp- the infant and an informed consent form. At a visit to the re- toms was rated as: 1) decreased, 2) not changed, or 3) increased.
searcher, the infant was then given a physical examination and an The effect of the intervention was rated as: 1) colic decreasing, 2) abdominal ultrasound. The families were randomly assigned to an no effect, 3) colic increasing, or 4) cannot say.
infant massage or to a crib vibrator group. The use of a cribvibrator was considered a control intervention based on an earlierstudy in which a similar device was as effective as parental edu- cation or reassurance and support26 and was chosen instead of Analysis of variance of repeated measures was used in the nothing to improve parental compliance. Both of our interven- analysis of the percentage change in the amount of crying from the tions, however, were given equal value in discussions with the baseline level over the study weeks. In addition, 2-sample t test parents. After 1 week of diary recording (baseline), the families was applied in comparison of the study groups. Categorical data started a 3-week intervention according to the randomization and were analyzed using ␹2 statistics. SPSS for Windows, Release 6.1 continued to keep the diary in which they also recorded the given (SPSS, Chicago, IL) was used for data analysis. The level of sta- intervention. After 1 and 3 weeks, the parents were interviewed to tistical significance was defined as P ⬍ .05.
obtain their evaluation of the effectiveness of the given interven-tion. After the 3-week intervention, at a control visit, the infant was physically examined and the parents returned the completeddiaries.
All participating families gave written informed consent. The Between June 1995 and December 1997, 85 families study protocol was approved by the joint commission on ethics of with colicky infants were enrolled in the study. Of the University of Turku and the Turku University Hospital.
these, 25 (29%) did not eventually participate forvarious reasons: perceived improvement of colic (11), disease of the infant (3), or that of the mother (2), The diary was based on that used in previous studies.28,29 disapproval of the study protocol (5), and unknown Diaries have been validated as a method for measuring infant (4). Of the 60 participating infants randomized to the crying, using audiorecordings as a golden standard.30,31 In the intervention groups, 2 infants in the massage group diary, each page corresponded to 1 week and contained 7 rows.
were excluded, 1 because of maternal disapproval of Each row corresponded to 1 day and was divided into 24 squares, the randomized intervention and 1 because of the each square corresponding to 1 hour. Parents recorded the colickycrying, other crying, and sleeping of the infant, to an accuracy of infant's respiratory infection requiring hospitaliza- 15 minutes, and feedings as events in the lower half of the row by using specific symbols for each behavior. Colicky crying was At baseline, 83% of the infants had 3 or more hours defined as intensive crying with no identifiable cause and contin- of total crying on 3 or more days (79% in the massage uous despite efforts to console the infant. The given interventions group and 87% in the vibrator group; P ⫽ .41) and were recorded by drawing a line in the upper half of the row, thelength of the line corresponding to the duration of the interven- 47% of the study infants had 3 or more hours of tion. Continuous intervention with no interruption of ⬎15 min- colicky crying on 3 or more days (43% in the massage utes was interpreted as a single intervention period.
group and 50% in the vibrator group; P ⫽ .59). Othercharacteristics of the 58 study infants and those oftheir parents are presented in Tables 1 and 2. Before intervention, the groups differed significantly from At the beginning of the massage intervention, a trained nurse each other only in the amount of daily colicky crying, taught the massage technique21 to the parents (mothers) and gavethem a brochure with written illustrated instructions. Massage the infants in the vibrator group having more colicky included gentle stroking of the skin over the different parts of the crying than those in the massage group (P ⫽ .021).
head, body, and limbs. The palms of the hands or fingertips were The age of the infants at the beginning of the inter- used, according to the area that was massaged. Similarly, the vention ranged from 23 to 48 days in both study pressure of the stroking/massage varied; for example, less pres- groups. There was 1 single-parent family in the mas- sure was applied on the face than on the soles of the feet. How-ever, the parents were encouraged not to massage the areas where sage group and the father's employment data are the infant did not like to be touched. Olive oil was used with the missing for this family. All mothers were home full- massage, and an attempt was made to maintain eye-to-eye contact time during the study weeks.
and an uninterrupted touch between the infant and the masseuse Complete diaries (minimum of 6 days per week) of during the procedure. At the end of the massage period, the infant the baseline week and parental evaluations were re- was swaddled in a towel and was rocked gently a few times. Threedaily massage periods were recommended: twice daily a whole ceived from 28 families in the massage group and 30 body massage (estimated duration: 20 –30 minutes) and once daily families in the crib vibrator group. Complete diaries a belly massage (15 minutes). Parents were advised to give the for all 4 study weeks were received from 26 families massage when the infant was calm and satisfied, but the belly in the massage group and 28 families in the crib massage could also be tried during symptoms of colic.
vibrator group and were included in the analysis of The families in the crib vibrator group received the device with oral and written instructions at the beginning of the intervention the diary data over the intervention. The 4 infants period. The crib vibrator (EP 88, Enerpoint Oy, Rauma, Finland) with incomplete diary data had more total (P ⫽ .018) consisted of a vibrating unit that also produced some white sound and colicky (P ⫽ .001) crying at baseline than the and a control unit for regulating the intensity and duration (5–25 other infants. They were also younger (P ⫽ .040) and minutes) of the vibration period. The vibrating unit was installed all 4 were boys (P ⫽ .062). Otherwise, these infants at the bottom of the infant's crib. The parents were advised to usethe vibrator at least 3 times a day in 25-minute periods during and their parents did not differ from the rest of the spells of colic or in advance, during the usual daily colic period.
infants and parents.
INFANT MASSAGE IN THE Characteristics of the Study Infants Infant Massage Group Crib Vibrator Group (n ⫽ 28) n (%) (n ⫽ 30) n (%) Feeding type before intervention Exclusively breastfed Mostly formula fed Exclusively formula fed Birth weight (g)* Gestational age (wk)* At the beginning of intervention Crying at baseline (h/d)* Colicky crying† * Data are presented as means (SD).
† P ⫽ .021, 2-sample t test for independent samples.
Characteristics of Study Parents amount of total daily crying decreased signifi-cantly (P ⬍ .001) but similarly (P ⫽ .27) in the Group (n ⫽ 28) Group (n ⫽ 30) study groups (Fig 1), the mean decrease being 48% (SD: 30) in the massage group and 47% (27) in the crib vibrator group (P ⫽ .87). The amount of colicky crying tended to be lower in the massage Father's employment* group than in the vibrator group during all 4 study weeks. The difference between the groups was significant at baseline (mean: 1.9; SD: .9 hours/day Age at child's birth (y)† of colicky crying in the massage group vs 2.7 [1.4] hours/day in the vibrator group; P ⫽ .017).
Colicky crying decreased significantly from the * n ⫽ 27 in the massage group.
baseline level (P ⬍ .001) but not differently (P ⫽ † Data are presented as means (SD).
.53) in the intervention groups over the course ofthe study. The mean decrease of colicky crying by Crying and Given Interventions Over the Study Weeks
the third intervention week was 64% (SD: 37) in the massage group and 52% (40) in the crib vibrator The amount of intervention given during the in- group (P ⫽ .24). This decrease in colicky crying tervention weeks is presented in Table 3. Massage contributed to most of the decrease in total crying, was performed a mean 2.2 (standard deviation [SD]: because other crying did not change significantly .5) times a day and the crib vibrator was used 2.2 (P ⫽ .17). Other crying decreased by a mean 17% (1.1) times a day during the 3-week intervention. The (SD: 63) in the massage group and by 15% (115) in mean duration of the intervention was .9 (SD: .3) the vibrator group (P ⫽ .93).
hours/day in the massage group and 1.2 (.7) hours/ Thirty-three infants (33/54; 15 infants in the day in the vibrator group.
massage group and 18 infants in the vibrator The mean amount of total crying at baseline was group; P ⫽ .62) were ⬍6 weeks of age at the 3.5 (SD: 1.4) hours/day in the massage group in- beginning of the intervention. In these infants, as fants and 4.0 (1.9) hours/day in the vibrator group well as in those who were older, total and colicky infants (P ⫽ .25). Over the 4-week study, the crying decreased significantly from the baseline Number and Duration of Daily Interventions Infant Massage Group Crib Vibrator Group (n ⫽ 26) Mean (SD) (n ⫽ 28) Mean (SD) Number of intervention periods/d Duration of intervention (h/d) Fig 1. Mean (standard error) daily duration of the total, colicky, and other crying at baseline (0) and during the 3 intervention weeks
(1–3). Total and colicky crying decreased significantly but similarly in the study groups over the intervention. At the beginning of the
study, the infants in the crib vibrator group had significantly more colicky crying than the infants in the massage group (* P ⫽ .017; **
P ⫽ .045). The amount of other crying remained comparable in the study groups.
level over the intervention (both P ⬍ .001), Parental Evaluation of the Effectiveness of Intervention
whereas the amount of other crying remained sta- ble (P ⫽ .27). The percentage changes in total, The parents rated the amount of colic symptoms colicky, and other crying over the intervention and the effect of the interventions similarly in the weeks were similar in these 2 age groups (all P ⬎ study groups at both interviews (all P ⬎ .38; Table 4).
Ninety-three percent of the parents in both groups Twenty-four infants (92%) in the massage group reported that colic symptoms decreased over the and 26 infants (93%) in the vibrator group had less 3-week intervention. Sixty-one percent of the fami- total crying in the third intervention week than at lies in the massage group and 63% of the families in baseline. The amount of colicky crying decreased in the crib vibrator group perceived the 3-week inter- 92% of the infants (24/26) and in 89% of the infants vention as colic decreasing. However, 21% of the (25/28; P ⫽ .70), respectively. During the third inter- parents in the massage group and 30% of the parents vention week, 19% of the infants (5/26) in the mas- in the crib vibrator group considered that the given sage group and 25% of the infants (7/28) in the crib intervention had no effect on colic symptoms. No vibrator group (P ⫽ .61) had no colicky crying. These families in either group reported that the interven- infants (12/54) did not differ significantly from the tion increased colic symptoms, neither after 1 week rest of the infants as to age at the beginning of the nor after 3 weeks of intervention.
intervention (P ⫽ .19) or as to amount of total,colicky, or other crying at baseline (all P ⬎ .31).
Seven of these infants with no colicky crying in the Sample Size
last intervention week (7/12) had reached the 8 This study had a power of 94% (at a significance weeks of age by the beginning of the third interven- level of .05) to detect an intergroup difference of 30% in the reduction of daily total crying. The power was INFANT MASSAGE IN THE Parental Evaluation of Colic Symptoms and the months of life.28 It may be difficult to distinguish a Effect of Intervention colic cry from a hunger cry on an audible basis only,35 but our definitions take into consideration Group (n ⫽ 28) Group (n ⫽ 30) both the audible quality and the context of crying.
We defined colicky crying as intensive, unsoothable crying with no identifiable cause. Thus, other crying After first wk of represented soothable crying related to hunger, need for company, or diaper change, etc. Because crying is suggested to have a function in securing the fulfill- ment of basic needs until other means of communi- After third wk of cation appear, it is reasonable that the amount of other crying remains stable in the early weeks of life.
The fact that parents recorded a stable amount of other crying also suggests that they were able to Effect of intervention recognize functionally relevant and excessive crying.
After first wk of The amount of colicky crying in our study infants is similar to that reported in our previous study,28 but it is greater than the amount reported in another study of excessive criers.36 Therefore, it is possible that the infants in this study had more severe colic After third wk of than the infants in some other studies. At baseline, the crib vibrator group infants had significantly more colicky crying than the massage group infants. This difference, however, is unlikely to bias the evalua- tion of the interventions, because we used the per-centage change in crying in the analysis.
Parental compliance in carrying out the interven- 77% to detect a similar difference in the reduction of tions was good. Infants received interventions ap- daily colicky crying.
proximately twice a day in both groups during the 3-week period. The mean duration per day of themassage was 54 minutes (.9 hours) and of crib vibra- Crying and colic decreased similarly over the tion 72 minutes (1.2 hours). Rice21 included four 15- 3-week intervention in colicky infants receiving ei- minute massage periods per day in her original in- ther massage or crib vibration. The 2 ways to eval-uate the effectiveness of the interventions were in structions for infant massage, but even a shorter daily duration of massage has been reported to be showed no difference between the study groups. The effective.24 It is unlikely that increasing the duration reduction of crying in our study infants is compara- of daily massage could increase its benefit in the ble to that in earlier studies in which a crib vibrator26 treatment of colicky infants. It would even be diffi- or supplemental carrying25 was used. In both of those cult to increase the amount because, in our experi- studies, the interventions were as effective as paren- ence, mothers perceived even the performed inter- tal counseling. Taken together, the reports of normal vention as strenuous, and some mothers also crying and the natural course of colic1,2,28,32 and our reported that their infant did not like the massage. It present findings suggest that neither infant massage may be speculated whether the massage would have nor the use of a crib vibrator modifies the natural been more effective if performed by someone else, course of crying in infantile colic.
not by the tired37 and distressed5,6 mother trying to Infant crying has been reported to peak during the cope with her colicky infant. In contrast, because first 6 weeks of life,2,33 and more than half of the colicky massage therapy has been shown to increase mater- infants are free from colic by the end of the second nal sensitivity to infant cues,23 a better response to month.1,34 Parkin et al26 also reported a significant de- massage, especially when performed by the mother, crease in crying only in colicky infants who were older could have been expected.
than 6 weeks, not in younger ones, when all their Parents of colicky infants desperately search for intervention groups, including the group using a crib something that would ameliorate the colic symp- vibrator, were evaluated together. In our study, the age toms. Massage is often tried as a method of sooth- of the infant did not influence the course of crying or ing18 and has even been recommended for treatment the disappearance of colic symptoms.
of colicky infants.17 We did not find any difference in The total amount of crying decreased in nearly all the reduction of colicky crying between infants re- infants over the intervention weeks. The evaluation ceiving massage and those with a crib vibrator over of 2 separate types of crying showed that the de- a 3-week intervention. We consider that the decrease crease in colicky crying contributed most to the re- of crying in our study reflects more the natural duction in total crying, whereas the amount of other course of early infant crying and colic1,2,28,32 than a crying remained stable. These findings are in accor- specific effect of the interventions. Thus, infant mas- dance with those reported earlier as a natural course sage cannot be recommended for treatment of infan- of crying in colicky infants over the first 2 or 3 17. Larsen J-H. Infants' colic and belly massage. Practitioner. 1990;234: This study was financially supported by grants from the Turku 18. Van der Wal MF, van den Boom DC, Pauw-Plomp H, de Jonge GA.
University Hospital and the Pediatric Research Foundation.
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Virpi Huhtala, Liisa Lehtonen, Riitta Heinonen and Heikki Korvenranta DOI: 10.1542/peds.105.6.e84 including high-resolution figures, can be found at: & Services
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