Tuesday, April 10, 2012

Keeping Baby Massage Honest


Back in November 2010 my son, Evan was born. My wife was very proactive and was always looking to do whatever she could to improve his well-being and development. Water Babies was an obvious choice of activity because we were keen on getting him used to water and able to swim as soon as possible (for family holidays abroad etc). My wife also chose baby massage as an activity for them in the first few months. She enjoyed attending the sessions and felt that they were of value because Evan enjoyed massage and she felt it strengthened the bond between them.

However, she mentioned in passing some very interesting claims of benefits that were being touted by the massage instructor and associated literature. Now, being a skeptic, I could help myself and had to go and check on some of the more dubious ones such as that massage boosts the immune system and aids digestion. I also found these claims being made on the International Association of Infant Massge (UK Chapter) website.

I found no such support for these claims in any scientific studies and so felt that it was up to me to bring it to the attention of the IAIM that they may be in breach of ASA advertising codes. I was also open to the possibility that I was wrong and simply hadn't looked hard enough so I suggested that they cite the evidence on their website. This was around the time when many in the skeptic community were scrubbing UK web pages of woo and homeopathy.

I didn't hear back from them directly, however I did notice that the specific claims of benefits to immune and digestive systems had been removed and some wording changed. Recently I revistited their web site to take another look at the claims and investigate some of the other ones a little more. Included was a claimed benefit to infant development which was not only unsupported, but had also been concluded to be not true by a Cochrane review.

Here's the email I sent to the IAIM (UK Chapter):


From: Johnathan Stabler [mailto:john.stabler@gmail.com]
Sent: 05 April 2012 16:17
To: info@iaim.org.uk
Subject: Massage Benefit Claims on IAIM Website

Sir/Madam,
I sent you an email on 25/072011 pointing out that some of the claimed benefits of infant massage on your website were not supported by clinical evidence. I have noticed that the claim of "boosts immune system" has now been removed and "helps digestion" has been changed to "stimulation of...digestion...systems". While I am still concerned about your use of the word "stimulation" and the implication of benefits, I'd like to draw your attention to another statement on your website at http://www.iaim.org.uk/what_benefits.htm that claims "helping with language development, memory and concentration". I took the liberty of, once again, checking medical publication websites for trials/studies related to infant massage and this specific claim and once again drew a blank. In fact, a Cochrane systematic review concluded that there was no evidence of effects on cognitive and behavioural outcomes.
If there is evidence for the efficacy of infant massage in such matters then I suggest you update your website and literature to cite such studies. If there are none then you are likely to be in breach of ASA advertising codes. Currently it would seem that the Wikipedia article on Infant Massage is better able to substantiate claims and cite sources than your organisation.
In my previous email I also sought assurances that massage instructors were not making unsubstantiated claims of benefits. However, I was disappointed that my email was not even acknowledged, let alone information provided on how your members were being educated about the importance of evidence-based practise.
Kind Regards,
John Stabler

And here is the reply:


Dear Jonathan
Many thanks for writing to the IAIM. Your enquiry has been referred to our committee board who will reply back to you shortly. Please do not hesitate to contact us if you have any other queries in the meantime.

Kind regards

Nina Allen

Administration Assistant
International Association of Infant Massage (UK) Chapter
Suite 10, 96 George Lane
South Woodford
London
E18 1AD
Tel : 020 8989 9597
Registered Company : 6832002

Some people may ask me why I bothered? It's a helpful activity that provides mother and baby with many emotional benefits and there is nothing to suggest it causes any harm. However, baby massage courses cost money and are sources of income for the massage instructors. Also, the promotional literature tells parents that the course is of value and provides benefits that they wouldn't get otherwise. It could even be (indirectly) construed that you'd be denying youself and child something if you didn't do it. I believe all claims should be substantiated, no matter the potential for harm or the amount of money being made.

I will keep you up to date!

14 comments:

  1. Completely agree. Why isn't it enough to do something just because it's nice? Why do they have to add all this useless nonsense about boosting immune systems etc?
    It's the same with a lot of woo aimed at women, instead of just saying "this is lovely and relaxing and makes you feel special" they have to harp on about a load of "health benefits", none of which can be proven!

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  2. So the "committee board who will reply back to you shortly".
    Sounds like this story has a happy ending.


    ...

    What?

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  3. Your comments are absolutely justified. I can absolutely see how - as a lay person - you have come to these conclusions - and I totally agree the organisation should help you understand the basis for their claims. So I'll have a go instead.

    What the Cochrane review actually found was that there was insufficient evidence to support that infant massage promotes *weight gain*. This finding was based on research up until 2005 (i.e. seven years ago) - so the Cochrane Review is now quite old (in research terms). Nevertheless, I am not aware of any new studies that would dramatically challenge this conclusion - so I would believe this is still a "current" finding.

    However, with regard to the actual claims made, there is a good deal of justification for them.

    For example, the abstract from the Cochrane review you cite actually says there was some evidence on "levels of hormones influencing stress responses"...if you check the full review, you'll see these hormones are actually immune system hormones (the "stress" response is an immune system function). I don’t imagine they are claiming "baby massage prevents or cures colds and sniffles" (though there is some evidence that baby massage reduces infections in preterm babies who are hospitalised, and reduces length of hospital stays - see Tiffany Field's extensive body of research for this) - but the Cochrane Review does provide a “gold standard” evidence that baby massage overall helps to regulate and maintain healthy levels of hormones and other functions involved in immune system function.

    The evidence linking baby massage and digestion is indirect – but nevertheless quite strong. The autonomic nervous system is profoundly affected by touch and baby massage (again, see the research of Field, and also Schore). The autonomic nervous system also regulates digestion. So, as clinicians we have a good basis for believing that some forms of baby massage almost certainly help digestive functioning. This is further supported by studies that focus on specific outcomes - for example a study by Aly and colleagues (2004) found that infant massage (along with movement) improved bone density in pre-term infants - a good indication that touch/ massage most likely plays a role in the absorption aspects of digestive function.

    With regard to infant development, there is a substantial body of research to support that *some forms of infant massage* (but not all) play a critical role in infant development. To understand this research, you firstly need to understand that probably the most critical element/ influence on infant development is the quality of the relationship a baby has with their parent (what your wife experienced as "bonding"). For evidence of the importance of this for the child's physical/ social/ emotional/ behavioural/ mental health development - see the work of Allan Schore, and also the Harvard University Centre for the Developing Child. What *some* forms of baby massage do, is enhance this relationship, and in turn, the basis for most infant development outcomes. In fact, two authors of the Cochrane Review you mention (Underdown & Barlow), in 2011 published a study that actually found the IAIM program is one of the highest quality programs for establishing this foundation for long-term developmental outcomes. This is also supported by studies such as O'Higgins (2006) and Onozawa et al (2001), that found the IAIM program enhanced (motor skill, social, mental health) developmental outcomes for babies in high-risk groups. More recent research (e.g. see Guzetta et al, 2011) has used brain scan studies to show that infant massage affects the way the developing brain organises itself and grows over time (i.e. “infant development”).

    So, I think the issue you have identified is one of poor website writing and referencing - not of mischievous or misleading claims.

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  4. Thanks for taking the time to comment, Anon. I made it clear in my blog post that my search of the literature was not exhaustive and I was open to evidence for these claims. I may not be an expert, but even as a "lay-person" I have a good understanding of the scientific method and the critical thinking skills that requires me to address a few points in your post:

    "What the Cochrane review actually found was that there was insufficient evidence to support that infant massage promotes *weight gain*."

    If you read it all it says other things. Right there in the Main Results: "There was no evidence of effects on cognitive and behavioural outcomes, infant attachment or temperament."

    As per my email to the IAIM, my main concern was about the claim of "Helping with language development, memory and concentration", but I would just like to address this:

    "The autonomic nervous system is profoundly affected by touch and baby massage (again, see the research of Field, and also Schore). The autonomic nervous system also regulates digestion. So, as clinicians we have a good basis for believing that some forms of baby massage almost certainly help digestive functioning."
    Unless you have evidence this is a non sequitur and an incredible leap of logic.

    "for example a study by Aly and colleagues (2004) found that infant massage (along with movement) improved bone density in pre-term infants - a good indication that touch/ massage most likely plays a role in the absorption aspects of digestive function."

    I don't seem to be able to find the paper you reference as it has been removed from the Nature journal. However, I believe that your conclusion that massage helps improve absorption is another leap in so much that the current understanding of massage/exercise of pre-term infants increases mineralisation, not absorption and therefore has nothing to do with digestion. If you are able to link to evidence specific to absorption and massag/excercise then I would be very interested.

    "you firstly need to understand that probably the most critical element/ influence on infant development is the quality of the relationship a baby has with their parent"

    Please provide evidence for this statement because the rest of your paragraph is contigent upon it and it needs to be well substantiated.

    What you've done is provided theories/mechanisms with some studies supporting some outcomes (not the ones I seek to address) and extrapolated from there. Your citing of the endocrine system is a good example and (not wanting to lump you in with them) is very similar to chiropractic in that it suggests a mechanism and has a small amount of evidence supporting some positive outcomes, but fails to provide evidence for the bulk of the others.

    It is bad science to make specific claims based on the assumptions of clinicians rather than controlled studies that actually measure what is being claimed. I believe the scientific community and the ASA understand this.

    "So, I think the issue you have identified is one of poor website writing and referencing - not of mischievous or misleading claims."

    I never claimed that the IAIM is intentionally misleading people or being mischievous, but in light of you not offering any direct evidence for the claims being made I can still only conclude that they are not substantiated and are therefore misleading.

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  5. oh boy Johnathon . What a shame you did not take the time to attend the IAIM course with your wife and son at the time.

    You would understand so much more .

    You have made a very important point as an outsider looking in .
    I know this organisation is a not for profit org. Committee who run the organisation may be be greatful for your talents in writing and researching websites.

    Have you offered to help ??

    If you are really serious about wanting evidence and research, try reading "keeping the baby in Mind . Infant Mental Health in Practice.
    Edited by Jane Barlow and PO Svanburg .

    see www.camharena .

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  6. Hi Johnathon

    (this is the "first" Anon replying, not the second person who posted as anon).

    I'm sorry as it seems some of my inital post was mis-intepreted. For example, I didn't set out to reply on behalf of the IAIM organisation or to defend their specific claims. I was simply commenting on some of the literature associated with infant massage - in specific response to your comment that you were not at all familiar with the body of knowledge in this regard.

    My response was also prompted by your inital comment where you said "claimed benefit to infant development which was not only unsupported, but had also been concluded to be not true by a Cochrane review". I felt this was inaccurate, as the Cochrane Review did not find it to be untrue - but at the time found there was insufficient evidence to support some claims. As someone who claims to be familiar with scientific method, I am sure you will appreciate the difference between a literature review that funds something does not have sufficient evidence to support it - versus a finding that something is "untrue". Some of these research gaps have begun to be filled (e.g. as I mentioned, brain scan studies have actually found there is a substantial impact of infant massage on the baby's developing brain).

    I have no "argument" with you questioning the way the claims were posed or written as you described them - I think you are well-justified in this regard. However, the title of your post did imply to that you did believe there was a bit of wickedness on behalf of this organisation (for my money - there is a vast difference between a poor interpretation and communication of research findings - compared with being "dishonest"). I have done my own bit of research into this organisation and have found they are mostly nurses, midwives and home visitors and it is entirely volunteer run. In this regard I agree with Anon #2, and your time and skill may be more constructively spent offering to work with them to develop a more accurate and sensible summary of the research - rather than implying that a bunch of people who are doing something to support new families - using a program based on reasonable foundations - are "dishonest".

    You are correct in pointing out that I mentioned a lot of mechanisms (rather than specific outcomes). In this respect I agree with you - it is dubious to claim that any particular intervention can "fix" things, on the basis of evidence about mechanisms. However, infant massage (just as swimming lessons, and many, many other programs) are "early intervention" and "preventative" in nature - and evidence about mechanisms (risk factors, protective factors) is a particularly valid form of evidence in these contexts. I respect your right to disagree with me, but I would suggest it is an *opinion* (not a "fact") that basing preventative and early interventions on our understanding of developmental pathways and trajectories is somehow "bad science".

    Likewise, I respect your right to advocate for the removal of "experience (assumptions) of clinicians" as a legitimate form of evidence or knowledge. I think many people would agree with you in theory (even myself on some levels, and in some contexts). It's funny though - if I had a loved one who was injured in a car accident - I would opt for them to be cared for by a paramedic with 20 years experience - not a newbie. I guess on a deep level some of us understand that experience and different forms of knowledge (other than just RCTs) do count in some contexts.

    Finally, if you want any evidence for the importance of the early relationships - as I said, spend some time visiting Allan Schore's research or the Harvard University Centre for the Developing child.

    I wish you all the best in your search for answers.

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  7. To the second anonymous poster:

    "oh boy Johnathon . What a shame you did not take the time to attend the IAIM course with your wife and son at the time.
    You would understand so much more ."

    I'm not sure how having a personal experience of infant massage would help me objectively evaluate claims of its effects. I will now assume that you understand why that is the case. If you don't know then please repost and I will be happy to point to some resources.

    "You have made a very important point as an outsider looking in ."

    That is the great thing about skepticism.

    "I know this organisation is a not for profit org. Committee who run the organisation may be be greatful for your talents in writing and researching websites.
    Have you offered to help ??"

    The fact that I already have a career and not much free time precludes me from doing this. However, I don't think that fact means I can't criticize.

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  8. In reply to the first anonymous poster:

    "I didn't set out to reply on behalf of the IAIM organisation or to defend their specific claims. I was simply commenting on some of the literature associated with infant massage - in specific response to your comment that you were not at all familiar with the body of knowledge in this regard."

    I wasn't under the impression that you were representing the IAIM in any way. Unfortunately I am only interested in specific claims. Discussing any other claims as a "background" can muddy the waters.

    "I felt this was inaccurate, as the Cochrane Review did not find it to be untrue - but at the time found there was insufficient evidence to support some claims. As someone who claims to be familiar with scientific method, I am sure you will appreciate the difference between a literature review that funds something does not have sufficient evidence to support it - versus a finding that something is 'untrue'."

    I intentionally used the words "not true" for a reason. You seem to be interpreting them as meaning "false", which is definitely not the same as false. Given a specific claim (a theory) that predicts certain outcomes if it were true, if the expected evidence isn't found then it is safe to describe that claim as not true.

    "However, the title of your post did imply to that you did believe there was a bit of wickedness on behalf of this organisation (for my money - there is a vast difference between a poor interpretation and communication of research findings - compared with being 'dishonest')."

    A simple point of interpretation. However, I'm quite surprised that you'd think "Keeping x honest" implies that x is dishonest. Surely to keep something honest it must already be honest?

    I don't think the IAIM is dishonest and I don't think (except for your interpretation of the title of my blog post out of context) that I have said they are dishonest or intentionally misleading people. I would only describe them as dishonest if they knew their claims were not supported by evidence but continued to use them regardless. My email to them has highlighted this fact and it is now up to them.

    "I have done my own bit of research into this organisation and have found they are mostly nurses, midwives and home visitors and it is entirely volunteer run. In this regard I agree with Anon #2, and your time and skill may be more constructively spent offering to work with them to develop a more accurate and sensible summary of the research - rather than implying that a bunch of people who are doing something to support new families - using a program based on reasonable foundations - are 'dishonest'."

    Again, you put dishonest in scare quotes as if I have used it. I have not. Much as I would like to work within an organisation to fix things, there are plenty of other organisations that I'd consider are in more dire need of change. The Catholic Church would probably be the the first on the list.

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  9. ...continued:

    "...I would suggest it is an *opinion* (not a 'fact') that basing preventative and early interventions on our understanding of developmental pathways and trajectories is somehow 'bad science'."

    No, I said that basing claims based on the gut-feelings or intuition of people instead of controlled studies is bad science. In fact, it is the very opposite of science. Please do not play the "opinion" card because science is not opinion.

    "if I had a loved one who was injured in a car accident - I would opt for them to be cared for by a paramedic with 20 years experience - not a newbie."

    Your example conflates two concepts of "experience". I really don't want to have to explain how because it was my birthday yesterday and I have a hangover.

    "I guess on a deep level some of us understand that experience and different forms of knowledge (other than just RCTs) do count in some contexts."

    The skeptic/philosopher in me would like to ask you to explain what forms of knowledge there are apart from experience (RCTs are simply experiences which are designed to reduce bias) but that would not be relevant to the discussion.

    Once again, thanks for taking the time to reply."...I would suggest it is an *opinion* (not a 'fact') that basing preventative and early interventions on our understanding of developmental pathways and trajectories is somehow 'bad science'."

    No, I said that basing claims based on the gut-feelings or intuition of people instead of controlled studies is bad science. In fact, it is the very opposite of science. Please do not play the "opinion" card because science is not opinion.

    "if I had a loved one who was injured in a car accident - I would opt for them to be cared for by a paramedic with 20 years experience - not a newbie."

    Your example conflates two concepts of "experience". I really don't want to have to explain how because it was my birthday yesterday and I have a hangover.

    "I guess on a deep level some of us understand that experience and different forms of knowledge (other than just RCTs) do count in some contexts."

    The skeptic/philosopher in me would like to ask you to explain what forms of knowledge there are apart from experience (RCTs are simply experiences which are designed to reduce bias) but that would not be relevant to the discussion.

    Once again, thanks for taking the time to reply.

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  10. There is now a follow-up post: http://thinkrant.blogspot.co.uk/2012/04/follow-up-keeping-baby-massage-honest.html

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  11. Wow this guy clearly has way too much time on his hands

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    1. "Wow this guy clearly has way too much time on his hands"
      As opposed to people who post vacuous comments on year-old zombie blog posts?

      I'm sorry if you don't think that challenging inaccurate information is worthwhile. Although the intention of your comment was to make a judgement on me, I think it says a lot more about you.

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