The biggest benefit I received from massage school, besides my career, was the ability to sleep. At 25, I went to massage school to learn a professional trade, but I also identified and addressed a problem I didn’t even realize I had at the time.
I assumed up to that point that everyone shared my two lifelong sleep strategies: either go, go, go until I just dropped and slept from exhaustion, or knowing it was time to sleep, completed the sleep preparation ritual, then lay in bed for 1–2 hours until my mind would stop (finally!). I would sleep until my wakefulness tormented me or until the alarm went off. What I found for myself was that after only a few weeks of regular massage during school, my ability to fall asleep improved, as did the overall quality of my sleep—and no, I’m not talking about sleeping on the massage table!
No longer would my mind swirl when I lay down to sleep at night. No longer would I find myself waking up multiple times each night or well before my alarm in the morning, only to lie in bed not sleeping and getting anxious about how tired I was going to be the next day. What I think happened was that regular massage “trained” my body and mind how to relax. My sleep has since benefited, even during times when I am not able to have regular massage. Now, when I lie horizontally on a comfortable surface, my body takes the cue to relax, restore, and sleep.
We sleep approximately one-third of our lives, and healthy sleep and sleep habits are critical for overall health. Sleep problems can be experienced at any time in life and can have multiple contributing factors, but sleep problems in early childhood have an impact on no less then two delicate health and well-being experiences—those of the child and the mother.
When I had children, I innately included massage as part of my babies’ bedtime preparation ritual. Massage is a practice my girls, ages 7 and 9, still enjoy, appreciate when they are unsettled, and benefit from due to the bond it has supported between us. While obvious for one trained in massage therapy, the practice of massage as part of a bedtime routine for infants with sleep problems may not be as evident to others; particularly, new mothers who are experiencing their own negative experiences with their child’s sleep issues. Infant sleep issues can include difficulty falling asleep, trouble staying asleep, or compromised waking mood due to tiredness. These issues are often mirrored in maternal sleep experiences in addition to increased stress levels, heightened anxiety, and compromised well-being for the mother. Massage for infant sleep has been examined in research with the work of Tiffany Field and colleagues, perhaps of most note for those in the massage field due to its inclusion in textbooks.1
Field’s research reported that massage decreased the time it took for children 8 months to 3 years to fall asleep2 and that newborns massaged with lotion have longer sleep durations and less night wakings.3 However, other research has been unable to demonstrate meaningful effect, whether due to potentially too little massage exposure (as in the case with a study that examined a single night of incorporating massage for preterm infants4) or due to the overall dearth of available high-quality research for inclusion in systematic review and analysis.5 With an expertise in pediatric sleep, and research history in the importance of bedtime sleep preparation routines, Jodi A. Mindell, PhD, and colleagues have published a paper reporting outcomes of a real-world approach to incorporating massage into the bedtime routine for infants with mild to moderate sleep issues.

The Impact of Bedtime Massage on Infants

Mindell’s research was published in Sleep Medicine in early 2018 and examined the impact of a massage-based bedtime routine on sleep and mood in infants and mothers.6 Researchers hypothesized that bedtime routines that incorporated massage would improve sleep and mood for both children and mothers. Study eligibility required mother identification of a mild to severe child sleep problem that did not exceed three or more wakings per night, nightly wakefulness of 60 or more minutes, or less than nine hours of nightly sleep duration. Children with acute or chronic illness were excluded from the study, as were those whose parents did not speak or read English or who routinely bathe or apply lotion to their child within one hour of bedtime four or more times per week. Study participants were randomly assigned to either a control group who performed their usual bedtime routine and completed assessments for three weeks, or an intervention group who followed their usual bedtime routine for a week and then incorporated a massage with lotion and other quiet and soothing activities (lullabies and cuddles) for two weeks with assessments.
Participants in the intervention group were instructed to turn the lights off no longer than 30 minutes after the intervention. Bedtime routines in both groups included both those who put their babies to bed awake and those who rocked their children to sleep, and both groups were asked not to change their routine during the study unless to add the intervention if randomized to that group.
Measures were collected at three time points for baseline (after the no-treatment first week for both groups), week 1 (after the second no-treatment week for the control group and the first week of the introduced massage-based bedtime routine for the intervention group), and week 2 (end of the three-week study term and second week of the massage-based bedtime routine for the intervention group). Several self-report survey tools were used for the study and collected online to assess child and maternal sleep. The Brief Infant Sleep Questionnaire is a validated and reliable tool for pediatric sleep assessment that asks respondents about sleeping arrangements and positioning, duration of day and night sleep and wakefulness, how and how long it takes to put the child to sleep, and the extent to which the child’s sleep is considered a problem by the respondent. The rest of the study measures related to adult assessment of sleeping and sleep quality (Pittsburgh Sleep Quality Index and Epworth Sleepiness Scale), mood (Edinburgh Postnatal Depression Scale and Brief Mood Introspection Scale), and anxiety and stress (Parenting Stress Index and State-Trait Anxiety Inventory).
One hundred and twenty-three (N=123) families participated, with 52 percent (n=64) randomized to the massage-based bedtime intervention group. Children participants’ average age was 9 months and ranged from 3–18 months old. Maternal age ranged from 18–45 and averaged 30.6 years old. Infants were both girls (54 percent) and boys (46 percent), were majority White (53 percent), and included Hispanic (2 percent), Black or African American (31 percent), Asian (5 percent), and other self-reported racial and ethnic descriptors (6 percent). Both groups were similar at baseline, except that those in the intervention group woke up an average 34 minutes earlier than those in the control group. The number of night wakings was significantly better for children in the massage-based bedtime routine group at the end of the study, and those children decreased their number of nightly wakings while those in the control group did not. While no significant reductions in sleep onset occurred for either group during the study, mothers in the massage group reported declining bedtime difficulty, improved child mood, and decreased perception of infant sleep difficulty throughout and at the end of the study. Reported sleep quality and mood improved for mothers in the massage-based bedtime routine group over the course of the study, with 69 percent and 80 percent reporting more connection with their children after one and two weeks of the massage-based bedtime routine intervention, respectively.
Study findings were not incredibly robust but were positive overall with a massage-based bedtime routine resulting in fewer nighttime waking episodes, improved infant mood, and less difficulty at bedtime. The authors acknowledge several limitations, including the broad age range of the children, the lack of a long-term follow-up, and the introduction of only one bedtime routine intervention. However, other limitations exist that are not reported. As far as I can tell, there is no description of the actual instruction materials for study replication or to share with those who would like to try the intervention for themselves. The authors do not indicate the materials are proprietary, but may be open to sharing the information with those who contact them (the article indicates that first author Jodi Mindell is the corresponding author: jmindell@sju.edu). In addition, there is no reporting of intervention compliance, and the extent to which participants did the massage-based bedtime routine is unclear. While the study appears to take a pragmatic, intent-to-treat approach (pragmatic meaning that analysis is run as planned regardless of intervention adherence and/or compliance), that design specification is not stated, so the rationale for the exclusion of compliance reporting should not be assumed. The duration of the massage application is also missing, both in relation to the instructions given and how long provided massages actually lasted; no rationale or explanation as to why these items are not reported are given. Despite the work’s limitations, there is a key practice-related takeaway discussion point.

The massage in this study was not provided by trained massage therapists and it isn’t clear what the massage actually entailed. How does this study and its results even relate to massage therapy as practiced by massage therapists?

Mothers provided the massage in this study and very little detail is given in the article about what the massage entailed, making it unclear in what ways the intervention reflected massage practice. What we do know, however, is that a massage product (given the funder and prior research from these authors, I expect it was an unlabeled Johnson & Johnson lotion or oil) and instructional materials for possible massage techniques and application instruction for the infant’s chest, tummy, back, arms, hands, legs, and feet were provided. Even though the intervention massage is not provided by a massage therapist, this intervention is reflective of how a majority of massage for infants, particularly right before bedtime, is applied and accessed, making it rather “real-world” in that regard, and the practice of mothers massaging their infants should be supported by the massage field. The fact that large effects were not necessarily seen in the study with regard to infant sleep outcomes is likely due to the combined impact of the short study duration and minimal parent preparation, training, and support for the intervention’s application. This leads me to speculate that infant sleep outcomes could potentially be magnified or further improved if a massage-based bedtime routine was continued beyond just two weeks and/or if mothers or other caregivers are given more instructional resources or follow-up support.
For instance, I imagine a mother, particularly a first-time mother or caregiver, would value being able to watch a professional infant massage provided to their child, and then have an opportunity to demonstrate and practice observed and learned techniques on their child with the therapist there to supervise, guide, reinforce, and encourage the work. This one-on-one instruction and supportive approach is used and is very successful with regard to related health behaviors and skills acquisition such as breastfeeding education. Mothers or caregivers providing massage as part of a bedtime routine is appropriate, and massage therapists can have a role in helping clients feel confident in providing this for their children to help with sleep issues or to support a healthy bedtime routine.

Three strong indicators

Though relatively small, the positive results from this study can be seen as a good indication that even in bare minimum situations there is a signal of massage’s benefit for infant and maternal sleep outcomes. The next question is how to optimize and improve that benefit signal through a more enhanced training and delivery approach. For me, regular massage over an extended time period was what supported my development of healthy sleep ability, but to my knowledge, no massage-related sleep research has examined the effect of regular massage over an extended period of time on infants or otherwise. Mindell and colleagues did publish one-year follow-up data on a similar study in 2011 for which an internet training delivery approach was used to prepare mothers to incorporate a bath, massage, and cuddle routine into bedtime practices.7 In this study, similar infant and maternal sleep benefit occurred using the same three-week study design, but at one-year follow-up, 50 percent of participants indicated they still used the routine “most of the time” or “always” with continued benefit. Another 36 percent indicated they continued using the routine “about half the time,” suggesting massage can be incorporated by the mother long-term for infants and toddlers to the benefit of both. It is a practice I promote and share with others, and the work of Mindell and others support it.
I imagine all massage therapists can site anecdotal evidence from their practice and experiences similar to mine about how massage therapy is beneficial for sleep and promoting healthy sleep habits. Such evidence is an important part of the three-legged evidence-based practice “stool” as clinical experience. Just as with sitting on a stool, the other two stool legs for evidence-based practice, research and patient values, are just as important. Just as it is important to sit on a stool with three strong legs, massage therapists should have three strong indicators to inform their evidence-based practice. “Massage-Based Bedtime Routine: Impact of Sleep and Mood in Infants and Mothers” provides another strengthening component to the research leg of the evidence-based practice stool when infant and maternal sleep promotion are wanted and valued by the massage client.

Notes

1. Tiffany Field, “Massage Therapy Research Review,” Complementary Therapies in Clinical Practice 24 (2016): 19–31.
2. Tiffany Field and Maria Hernandez‐Reif, “Sleep Problems in Infants Decrease Following Massage Therapy,” Early Child Development and Care 168, no. 1 (2001): 95–104.
3. Tiffany Field, Gladys Gonzalez, Miguel Diego, and Jodi Mindell, “Mothers Massaging Their Newborns with Lotion Versus No Lotion Enhances Mothers’ and Newborns’ Sleep,” Infant Behavior and Development 45 (2016): 31–7.
4. Charlotte C. Yates et al., “The Effects of Massage Therapy to Induce Sleep in Infants Born Preterm,” Pediatric Physical Therapy: The Official Publication of the Section on Pediatrics of the American Physical Therapy Association 26, no. 4 (2014): 405.
5. Cathy Bennett, Angela Underdown, and Jane Barlow, “Massage for Promoting Mental and Physical Health in Typically Developing Infants Under the Age of Six Months,” Cochrane Database of Systematic Reviews 4 (2013).
6. Jodi A. Mindell et al., “Massage-Based Bedtime Routine: Impact on Sleep and Mood in Infants and Mothers,” Sleep Medicine 41 (2018): 51–7.
7. Jodi A. Mindell et al., “Long-Term Efficacy of an Internet-Based Intervention for Infant and Toddler Sleep Disturbances: One Year Follow-up,” Journal of Clinical Sleep Medicine 7, no. 5 (2011): 507–11.