This study examined the effect of Swedish massage on sleep quality and quantity in hospitalized children aged 4-12 years. 70 children were randomly assigned to a control or massage group. The massage group received 30 minutes of Swedish massage nightly for 3 nights. Sleep quality was measured using the CSHQ questionnaire completed by parents, and sleep quantity was measured via daily logs. Massage significantly improved scores on all CSHQ subscales and total sleep quality, but did not significantly impact sleep quantity. The study concluded that massage is an effective non-pharmacological intervention to improve children's sleep quality during hospitalization.

1. THE EFFECT OF SWEDISH MASSAGE ON CHILDREN’S
SLEEP DURING HOSPITALIZATION; A CLINICAL TRIAL
STUDY
YOSRA RAZIANI
KOMAR UNIVERSITY OF SCIENCE AND TECHNOLOGY, KURDISTAN REGION, IRAQ

2. BACKGROUND
• Sleep is essential to repairing and optimizing the physiological and psychological function of the body by the endocrine,
nervous, and cardiovascular systems. Patient-related factors, such as pain, and hospital-related factors, such as the sound of
an alarm or interruption of sleep due to medical procedures, may cause sleep disorders. Patients with poor sleep quality
show demonstrate physical and psychological symptoms, including difficulty concentrating, fatigue, a low pain threshold,
loss of appetite, nervousness, depression, and anxiety (1). Interventions targeting sleep disturbances in hospitals may
accelerate patients' recovery. At present, a common treatment for insomnia is drug therapy and the use of hypnotics such as
benzodiazepines. Nevertheless, due to the side effects of these drugs and the nurse's inability to prescribe drugs, the use of
non-pharmacological methods seems necessary (2).

3. BACKGROUND
• Massage therapy is one such non-pharmacological method to relieve sleep disorders. It also
increases blood circulation, reduces stress, improves gastrointestinal tract function, stimulates the
lymphatic system, improves the function of the autonomic nervous system, and reduces heart rate
and blood pressure. Massage therapy releases endorphins, thereby reducing patients' pain and
insomnia.
• Massage can be effective in balancing one's nervous system and physical aspects. The skin and
muscles contain huge nerve connections. Therefore, a gentle massage of the nerves relieves and
restores health in every part of the body.

4. METHODOLOGY
• Study population
The participants included girls aged 4-12 years who were selected from eligible patients and assigned to intervention and control
groups using stratified random blocking method from January 2020 to October 2020. After selecting the eligible patients and
obtaining informed consent to participation, they were assigned to the study groups using a stratified randomized block design. The
patients within the classes were assigned to the study groups using four-block random blocks. The random sequence list was
extracted by the Statistics Adviser from https://www.sealedenvelope.com and, was provided to the researcher after identifying the
above items (blocks and classes) with special codes (to conceal random assignment); finally, the participants were assigned to the
control and intervention groups (n = 35 per group).

5. METHODOLOGY
Inclusion and exclusion criteria
• Inclusion Criteria
At least three days of hospitalization, age of 4-12 years, absence of intellectual disabilities or Autism spectrum disorder, not taking sleeping pills, being fully alert, the
child's and parents' willingness to participate, no wounds or specific skin conditions on the body, scoring 41 and more on the Sleep Disorders Questionnaire, and female
sex.
• Exclusion Criteria
Mother's unwillingness to continue participation, the child's refusal to continue participation, the child being discharged earlier than three days, prescription of any
hypnotic or sedative medication, the child's participation in other complementary medicine programs (meditation, relaxation, etc).

6. QUESTIONNAIRE AND DATA COLLECTION
• The data were collected using a demographic information questionnaire, the CSHQ questionnaire to assess sleep quality, and a sleep log
table to assess sleep quantity. The CSHQ questionnaire (Owens, Esperito et al., 2000) includes 45 items to assess children’s sleep quality and
sleep habits. This questionnaire is completed by the parents and is designed for children aged 4 to 12 years. Owens et al. (2000) conceptually
grouped the items into eight subscales:1) sleep resistance; 2) delay in the onset of sleep; 3) sleep time; 4) sleep anxiety; 5) night awakenings;
6) parasomnia (pseudo-sleep); 7) respiratory sleep disorders; 8) daily sleepiness. Items are scored on a three-point scale from 1 = rarely to 3 =
usually. The final four questions about the child's drowsiness during the day are scored from 1 = not sleepy to 3 = falling asleep (20). The
score ranges from 33 to 99. This questionnaire was used twice in the research, once on the first day of hospitalization to assess sleep quality in
the previous month, and once at the end of the third day. The cut-off score with the best diagnostic confidence, as determined by the intersect
point of sensitivity and specificity, was 41; children scoring 41 or above entered the study.

7. Questionnaire and data collection
• The sleep quantity index included the time of onset of sleep, the time of waking up and daily naps,
and the total hours of sleep per day. Behroozifar et al. translated the sleep quantity survey form to
Persian, and its content and formal validity was confirmed. This checklist is designed as a table that
measures the amount of sleep a child has during 24 hours. In this study, this checklist was used four
times; first, at the time of administration, and then at the end of each night for three nights at 8:00 AM.

8. MASSAGE TECHNIQUE AND PROCEDURE
• The massage was performed in a quiet environment and on the patient’s bed. The direct pressure on the bones,
and massage on damaged, pimple-prone skin or areas where there was a possibility of infection was avoided. All
the rooms were double-bed. The temperature was maintained between 20 and 24 °C. The walls of all the rooms
were pink. The bed had the same features for all children. During the intervention, wherever a crying or restless
child caused the participant to fall asleep, the bed was changed with the permission and consent of the parents.
The child's privacy was protected by a screen during the intervention.
• The child lay on her back on the bed, and bitter almond oil was used to reduce friction. The massage began
systematically from the arms to the neck and head, and then progressed to the legs, thighs, hips, and back. The
massage was performed for each child for 30 minutes for 3 nights after receiving the night medication.

9. MASSAGE TECHNIQUE AND PROCEDURE
• The main movements of the Swedish massage therapy were performed as
follows:
Effleurage: long rubs with the palms of both hands
Tapping with the palms and fingers to stimulate muscles and relieve tension
Vibration performed by hands to create a rapid movement that relaxes the
muscles
Friction in a circular motion that releases muscle knots.

10. DATA ANALYSIS
• Sleep quality was measured twice, on the first day of admission and after three
days. Moreover, sleep quantity was measured four times: at the time of
admission; and 24, 48, and 72 hours after hospitalization. SPSS 22.0 (SPSS, Inc.),
was used for data analysis. Independent t-test, paired t-test, and repeated
measures analysis of variance were used to analyze the data. To investigate the
effect of the intervention on changes in sub-domains and the total score of sleep
quality by modulating the background variables, the generalized linear model
(GLM) was adopted.

11. PARTICIPANT FLOW
Figure 1. The participant flow of the present study

12. RESULTS AND DISCUSSION
Table 1. Frequency distribution of sleep problems in hospitalized children reported by parents
Reported problems of sleeping
(By mothers)
Control group
N (F%)
Intervention group
N (F%)
Insomnia due to the absence of the father 8 (9) 6 (5)
Medication while sleeping 14 (15) 15 (14)
Cannula related problems 13 (14) 12 (11)
Environmental noise 11 (12) 17 (16)
Fear of injections while sleeping 9(10) 6 (5)
The crying and restlessness of the child next
to her
6 (7) 11 (11)
Change (environment) of sleeping place 4 (5) 12 (12)
Environmental lightening 15 (16) 14 (13)
Clinical problems of the disease 11 (12) 13 (12)

13. RESULTS AND DISCUSSION
Table 2. T-tests for comparison of the mean sleep quantity of inpatients in the control and massage
group
Group Home 1st
night 2nd
night 3rd
night
Intragroup
P value
Between groups p
value
Control 10.88±1.65 8.22±1.26 8.17±1.09 8.11±1.19 .00
.09
Intervention 9.71±1.46 7.42±1.52 8.08±1.13 8.74±1.44 .00

14. RESULTS AND DISCUSSION
Figure 2. Changes in the sleep quantity of hospitalized children over time

15. RESULTS AND DISCUSSION
Table 3. Comparison of mean dimensions of sleep quality in children in intervention and control groups before and
after intervention.
Dimensions Groups
Before
Intervention
After
Intervention
Mean
Differences
Mean ±
Standard
Deviation
Intragrou
p
P Value
Between
Groups
P Value
Mean ±
Standard
Deviation
Mean ±
Standard
Deviation
Sleep resistance
Intervention 7.42 ± 1.14 5.68 ± 1.14 1.91 ± 1.74- 0.001<
0.001<
Control 7.65 ± 1.05 7.85 ± 1.28 -.20±1.58
.46
Sleep onset Delay
Intervention 2.28 ± 0.89 1.60±0.84 .68±1.62 .01
.02
Control 2.34 ± 0.68 2/37±0.64 -.02±.85
.84
Sleep duration
Intervention 6.08 ± 1.48 4.74±1.14 1.34±1.60 0.001<
0.001<
Control 5.77 ± 1.21 5.94±1.13 -.17±1.75
.56
Sleep anxiety
Intervention 8.40 ± 2.14 7.02±1.58 1.37±1.91 0.001<
0.001<
Control 8.48 ± 1.24 8.25±1.40 .22±1.47
.36
Nocturnal awakenings
Intervention 5.11 ± 1.18 3.54±0.56 1.57±1.37 0.001<
0.001<
Control 4.97 ± 0.98 5.08±1.37 -.11±1.77
.70
Parasomnia
Intervention 10.40 ± 1.86 9.80±2.01 .60±2.49 .16
.13
Control 9.54 ± 1.35 9.77±1.45 -.22±2.04
.51
Sleep-dsordered
Breathing
Intervention 3.54 ± 1.09 3.20±0.47 .34±1.10 .07
.01
Control 3.22 ± 0.73 3.68±1.32 -.45±1.44 .06
Daily drowsiness
Intervention 17.14 ± 2.62 14.82±2.66 2.31±3.21 0.001<
0.001<
Control 16.71 ± 2.73 18.05±2.88 -1.34±3.33
.02
Sleep quality
Intervention 60.40 ± 3.77 50.40±4.60 10.00±5.82 0.001<
0.001<
Control 58.71 ± 4.11 61.02±4.78 -2.31±6.28 . 3

16. RESULTS AND DISCUSSION
Table 4. Modeling the effect of massage on changes in the average sleep quality of children by adjusting
the underlying variables using the GLM model
Dimensions
Group
p. value
Age
p.value
Number of
children
p.value
Economic
status
p.value
Having
private
room
p.value
Living
place
p.value
Sleep resistance .00 .01 .92 .60 .04 .72
Sleep onset delay .00 .01 .01 .11 .29 .21
Sleep duration .00 .51 .00 .04 .01 .54
Sleep anxiety .00 .92 .55 .99 .05 .29
Nocturnal
awakenings
.00 .00 .27 .76 .51 .96
Parasomnia .20 .37 .05 .33 .35 .25
Sleep-disordered
breathing
.00 .23 .35 .20 .91 .30
Daily drowsiness .00 .72 .06 .52 .28 .08
Sleep quality .00 .10 .01 .82 .43 .43

17. LIMITATION
• Although the most important methods to know children's sleep quality is polysomnography and
Actigraphy, they come with some limitations. Actigraphy provides only a fair indication of the
level of arousal from sleep in children and polysomnography requires some special preparation
including the continuous presence of a sleep technologist, several EEG recorders that was not
available in our hospital and many other hospitals, so that we could not use theses methods to
evaluate the sleep. There were interfering factors beyond the control of the nurse and the
researcher, such as the noise of the outside environment (which was the same for both groups,
the hypnotic side effects of medications (which was the same for both groups), and nursing
measures during sleep. However, the nurses' cooperation was ensured to avoid any unnecessary
measures that would conflict with the child's sleep time. Moreover, only girls participated in this
study as the hospital wards were separate for male and female patients; thus, the results cannot
be generalized to boys.

18. CONCLUSION
• It was shown that hospitalization under the influence of environmental factors such as light,
noise, unfamiliar environment, and aggressive and painful procedures clearly affects sleep
quality and quantity and therefore, it is necessary to take measures to eliminate these factors.
Massage is an effective factor in improving children's sleep quality, and the better this massage
is performed, the better sleep children with experience. However, despite three sessions of
massage therapy, sleep quantity did not change considerably. Sleep deprivation impacts the
healing process, children's mood, and their relationship with their mother and the healthcare
personnel; therefore, we have to look for other solutions and control the environmental factors
as much as possible to improve the sleep quantity of hospitalized children.
• Based on the philosophy of massage therapy and the important role of anatomy and physiology
in its effect, this intervention should be performed by trained people. Nevertheless, since nurses
are busy and may not be able to perform this intervention every night, training sessions can be
held for the accompanying parent to perform the intervention when necessary.

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