The Importance of Healthy Touch

We all know that babies born with a visual or hearing impairment can, with the right support and services, develop healthily – without any negative developmental effects associated with missing out on sensory input through their eyes and ears. In contrast, healthy touch is crucial to the development of all babies.

Without sensory input through their skin, babies can experience serious complications. In the worst case scenarios – such as in poorly run overseas orphanages – lack of healthy touch results in serious, long term developmental delays and brain damage (Harmon, 2010). This is most likely associated with stress hormones which, when present in persistently high levels, are extremely toxic to the developing brain (American Academy of Pediatrics, 2011).

Although extreme forms of touch deprivation are far less common in Australia, it is believed that even mild to moderate absence of healthy touch can also have consequences for the baby’s developing brain. For example, a reduced level of healthy touch in infancy has been associated in animal and human studies with:

• Failure-to-Thrive (FTT) (Feldman, et al., 2004; Polan & Ward, 1994);
• the development of violent behaviours and lack of empathy (Field, 2002; Field, 1999; Prescott, 1996);
• development of body image and eating disorders (Gupta & Schork, 2006; Iwasaki, et al., 2000); and even
• predisposition to opioid addiction (Schwarz, Hutchison & Bilbo, 2011).

The studies and reviews included here do not provide enough evidence to conclusively say that adequate “healthy touch” in infancy either prevents or cures any particular illness. It is important to recognise these (and other conditions associated with low levels of touch) are not “caused” by any single trigger, but are multifactorial in their development. In addition, it is neither ethical nor practical to conduct studies which deprive infants of healthy touch (but not other forms of stimulation) to draw absolute conclusions about what specific conditions lack of touch may cause – we may never know the answer to this! Instead, together, these and other studies – as well as the field observations of children who have been deprived of touch – do confirm that healthy touch plays some sort of crucial role in healthy development of human babies.

More recently, scientists have become curious as to what that role might be, and have begun exploring exactly how healthy touch acts on infant (human) development and growth. The findings are quite surprising. Rather than simply providing an “emotionally nice” sensation for a baby, healthy touch appears to:

• directly reduce inflamation and vagus nerve activity (a key part of the body’s stress management system) (Feldman, Singer & Zagoory, 2010; Schore, 2001);
• help regulate and stimulate healthy brain growth and activity – particularly on the right side of the brain (Diego, et al., 2006; Guzetta, et al. , 2011; Jones, Field & Davalos, 1998; Schore, 2001); and
• set up a cascade of chemical processes which influence the activity and activation or suppression of genes ( Meaney, 2011; Schanberg, in Field, 2014).

What is “Healthy Touch”?

Some studies on infant touch, and particularly infant massage, have been poorly interpreted and applied. These studies do not, in any way, suggest that babies benefit simply from “being touched”. These studies do not imply that all babies should, for example, be massaged for a set amount of time each day before their bath (or whatever the fashionable advice is at any point in time). There is a vast difference between healthy touch, compared with touch that may be unhelpful…to say nothing of the forms of touch that are harmful or traumatising to babies.

At Baby in Mind we define “healthy touch” as being the sort of touch that helps a baby regulate their behavioural and neurological state. In simple terms, healthy touch is the sort that helps a baby to stay in, or return to, a focussed and calm state.

Although research can give us generalisations about what is true for some babies, some of the time, all babies can, and do, vary widely in their responses to different types of touch, under different circumstances and at different times. Pre-term babies, for example, often start off with much lower thresholds for moving touch than babies born at full-term (Warren & Bond, 2010). And even within groups of babies at similar developmental ages the impact of touch on behavioural and neurological regulation can vary widely (Harrison, Leeper & Yoon, 2006; Warren & Bond, 2010). There also appear to be gender and other genetically-driven differences in infant’s responses to touch.

As well as differences between babies there is, of course, great variation in the way each individual baby responds to touch. As any parent will know, a baby can be more responsive to interaction at different times of the day depending on their sleep needs, hunger, other activities happening, their growth spurts and other transitions.

In short, there is no one-size-fits all approach to healthy touch for babies.

Almost all of us as parents have interactions with our baby when we our touch does not help settle or calm our babies: for example when we inadvertently tickle our baby a for a bit longer than they can handle, or when we are still learning what works best to settle and soothe our baby and haven’t yet quite “got the touch”. This trial and error, or rupture and repair, is a normal part of the parent-baby relationship – and in fact is necessary and contributes to healthy development (Lewis, 2000; Tronick & Beeghly, 2011).

However, if intrusive touch (such as poking or overwhelming a baby with sensory stimulation) or other types of touch which irritate (dysregulate) a baby’s stress responses, begins to occur frequently and persistently, development can be impacted (Stack, in Field, 2004; Tronick & Beeghly, 2011).

Persistent, dysregulating touch is usually unintentional. It is sometimes seen when a caregiver is experiencing depression or other mental health difficulty, is overwhelmed, or is simply still working out how to help their baby manage their reactions (Stack, in Field, 2004). It is also sometimes seen when approaches to care of fragile babies focus only on procedures and technology, and does not provide care in a way that helps the baby achieve a state of neurological regulation and relaxation.

Therefore, a crucial part of the Baby in Mind First Touch infant massage program, focuses on supporting parents to recognise, understand and respond to their baby’s cues. These cues are the (sometimes subtle) signs a baby gives to a parent. These cues tell a parent whether the touch, massage or interaction is helping them regulate their neurological state, or whether the baby is asking their caregiver to to adapt, modify or change what they are doing. In this context, each and every baby is different. This is why Cue Recognition is an equally important element of our program as touch itself.

Cue Recognition is the core, defining feature of the Baby in Mind First Touch program.

This element of our program supports parents in their ability to recognise the different body signals (cues) that signal the baby’s relative state of arousal, and to view these cues as a conversation.

Most parents are already familiar with the idea of cues: postnatal and early childhood health services now routinely provide information about tired and hunger cues used by some babies.

However, babies display many different (often subtle) cues to communicate many other internal experiences besides tiredness and hunger. The approach used by Baby in Mind to understand and work with infant cues comes from, and is based on the Neonatal Behavioural Assessment Scale (NBAS) developed by Dr. T. Berry Brazelton. The NBAS identifies six distinct patterns of behaviours, or cues, that babies display. Each pattern or grouping of cues provides clues as to the neurological state, or level of regulation (or dysregulation), the baby is experiencing.

By observing a baby’s distinct cues at any point in time, parents can make inferences about what is happening for their baby. In the First Touch Program we support parents to observe and notice their baby’s cues. We then support parents to test-out their assumptions about those cues, by modifying and adapting the way they are using massage, touch, voice or other interactions. Parents then watch how, in turn, their babies respond, and how their baby’s regulatory state changes.

In this way, high-quality cue-based education is based on the assumption that babies and parents interact with each other in a complex backwards-and-forwards conversation, in which both continue to modify their actions in response to each other, until they reach a level of synchronicity. Therefore, high-quality cue-based education consists of a whole lot more than providing parents with a list of “baby signs”, but instead involves managing the activities in the group in such a way that allows parents and babies to achieve this interactive synchronicity.

To do this, our Educators pay attention to the parent’s response to the baby’s cues and to how the baby “answers” their parent…and then again how the parent notices and replies with modifications or changes in their behaviour. Using a variety of evidence-based parent education approaches, the Educator then supports the parent to also notice their baby’s cues, to make some meaning of these cues, and to develop their own repertoire of responses.

Therefore, good quality cue-based education will have as both a method an aim, shifting the focus of expertise from the instructor to the parent, and the task of teaching to the baby. The Educator’s role is simply to facilitate and guide. An infant massage educator who has received high-quality training in cue-based approaches will avoid issuing blanket rules about “all babies” (such as “babies should never be massaged after a bath”) and will also avoid telling a parent what (they think) their baby’s cues mean – approaches that both place the instructor in the position of the expert who holds “all the answers”. Instead, an Educator who has received high-quality infant massage training will support the parent, using a range of evidence-based approaches, to discover and recognise their own expertise and knowledge about the cues and language of their own baby.

Good quality cue-based education has very significant benefits, especially when families have been exposed to early stresses that can interfere with early bonding and relationship development (Bakermans-Kranenburg, van IJzendoorn & Juffer, 2005; Barnard & Summer in Gomes-Pedro, et al., 2002; Hotelling, 2004; Milgrom, et al., 2010; Norhov, et al, 2011; White, Simon & Bryant, 2002). The benefits have also been noted specifically in the infant massage setting, where high-quality cue-based infant massage education appears to maximise potential outcomes (Underdown & Barlow, 2011).

Child development experts describe the communication that occurs between parents as a type of dance, in which different babies and parents engage in a two-way exchange of various interactions. It is believed these high quality, two-way conversations form the very basis of brain development. These interactions help babies make meaning of their experience and, when repeated over and over, forge the connections in the brain that will come to make up their neural circuitry.

A parent’s use of touch to communicate with their baby rarely occurs on it’s own: many different senses are involved in this exquisite dance between parents and babies. Of particular importance appear to be eye contact, voice and movement. In the Baby in Mind First Touch Program, touch and massage is not taught in isolation of these interactions. Parents are supported to notice how their baby is using eye contact, how they might respond to different tones or ways of using voice, and also to notice what their baby “says” with their cues in in response to different types of movement.

Movement-based interactions include carrying, rocking, gentle bouncing and jiggling. Eventually, as the baby grows, this will extend to includes more vigorous movement that is enjoyable to the baby/ toddler: such as rough-and-tumble play (sometimes called “rough-housing”), lifting, swinging and spinning.

These movement-based interactions appear to be somewhat similar to touch, in that all babies appear to depend on the sensation of movement (such as that experienced whilst being carried) for healthy brain development. In 1977 a landmark study (Clark, Kreutzberg & Chee, 1977) made the first, definitive link between the sensation of movement and brain development – specifically, gross motor skill coordination.

Eye contact and voice are also important in many aspects of brain development. For example, eye contact is believed to help regulate and develop parts of the brain involved in social skills and face-recognition. A parent’s voice, particularly the higher-pitched speech with elongated vowels (known as “Infant Directed Speech” or the Sing-Song voice) has been shown to play a vital role in language development and, in some studies, also linked to social and mental health development.

However, unlike movement and touch, a baby’s brain seems more adaptable to greater variation in the way that eye contact and voice are used (e.g. in the case of a baby born with a visual or hearing impairment). We wonder if this may be because, in these cases, other types of interaction help to compensate? For example, perhaps in cultures where levels of eye contact with infants are not high, parents tend to use high levels of facial expresssion and infant-directed speech (Trehub, Unyk & Trainor, 1993), which may fulfil the baby’s needs?

While this is still unknown, what we do know is that low levels of attuned eye contact, combined with low levels of infant directed speech begin to impact on infant development when a parent is also experiencing significant stress, such as in postnatal depression. For example, parents with postnatal depression tend to use far fewer and less animated facial experssions with their babies and this has a long-term impact on a baby’s development (Cohn, et al., 2006).

The value of infant massage in postnatal depression has received growing attention in recent years. This interest was sparked after a Randomised Clinical Trial found that some depressed mothers who participated in the high-quality, cue-based Infant Massage program showed reduced symptoms of postnatal depression, and babies showed statistically significant improvements in developmental outcomes compared to the control group (whose mothers attended a support group only) (Onozawa, et al., 2001).

Unfortunately, the results of this study have been widely (and misleadingly) misinterpreted with claims along the lines that “infant massage eases/ cures/ relieves postnatal depression”. In both this study, and later trials, impacts of infant massage on postnatal depression were highly variable among women (e.g. O’Higgins, St. James Roberts & Glover, 2008), so it is still not clear which women, if any, are assisted by attending an infant massage program, or under what circumstances. In addition, these studies have been conducted using the high-quality cue-based infant massage program protocols, and the findings do not apply to all infant massage programs generally.

However, what these studies have consistently shown is that the IAIM infant massage program specifically, does appear to improve – and even normalise – developmental outcomes for babies of depressed mothers irrespective of their mother’s depression status. In other words, interest in the Baby in Mind program for families dealing with postnatal depression is justified, because it appears it may protect and buffer the baby from the long-term impacts of maternal depression and may be an important and useful intervention from the infant’s point of view, whilst their parent is undertaking treatment and recovery.

We don’t yet know why the First Touch program may help protect babies from the developmental consequences of postnatal depression. One possibility is that the use of touch alone appears to help a baby regulate their internal state, even when other interactions are withdrawn (Jean, Stack & Arnold, 2014; Stack & Muir, 1990). In this way, the “massage” component of the First Touch infant massage program may directly help the baby regulate the higher level of toxic stress hormones that may otherwise be present.

Another possibility is related to the focus on cue-recognition and responsiveness in the First Touch infant massage program. The difficulty experienced by a depressed parent in “attuning” to her baby’s cues and signals is believed to be one of the key mediators in the developmental consequences of postnatal depression for babies (Milgrom, Westley, Gemmil, 2004). The emphasis on supporting attuned (responsive) interactions between parents and babies in the First Touch program may therefore be another mechanism via which infants experience improved, long-term outcomes.