1 http://ijcn.mainspringer.

com Volume 2; Issue 12; December, 2015

International Journal of
Comprehensive Nursing
ISSN: 2349 - 5413

Effectiveness of Therapeutic Massage on Level of Bilirubin among Neonates with

Physiological Jaundice

Anitha Robert1*, Ruthrani Princely Jeyaraj2, and Sambavadas Kanchana3

1
PG Scholar, Omayal Achi College of Nursing, Chennai.
2
HOD, Pediatric Nursing Department, Omayal Achi College of Nursing, Chennai.
3
Principal, Omayal Achi College of Nursing, Chennai.

A R T I C L E I N F O A B S T R A C T

Article History:
Received 06 December 2015
Received in revised form 22 De-
cember 2015
Accepted 25 December 2015
Available online 30 December
2015
Key words:
Therapeutic massage, level of
bilirubin, NETS Guidelines, neo-
nates with physiological jaundice.
The present study was conducted to assess the effectiveness of therapeutic
massage on level of bilirubin among neonates with physiological jaundice at
selected hospital, Chennai. A Quantitative approach, True-experimental -
Pre test post test design was adopted for the present study. Thirty neonates
each in study and control group were selected by simple random sampling
technique- lottery method. In study group each neonate was given the
therapeutic massage twice daily with 4 hours interval for a period of 5 days.
The pre and post test level of bilirubin was assessed by using Modified
Neonatal Emergency and Transport Services (NETS) Guidelines Scale. The
results concluded that there was high statistical significant reduction in level
of bilirubin among neonates in the study group who received the therapeutic
massage.

Introduction promotes relaxation and well being. Therapeutic massage

Physiological jaundice is the most common condition
requiring medical attention in newborns. Jaundice is also
a common reason for readmitting a newborn to the
hospital after early discharge. Globally the incidence of
Physiological jaundice is observed in almost 80% of the
normal neonates and 95% of the preterm.[1] The incidence
of neonatal hyperbilirubinemia in intramural live-births
is 3.3% while in extramural admissions morbidity due to
hyperbilirubinemia accounted for 22. 1%.[2] The incidence
of physiological jaundice in India varied from 15%-20%
of neonates. In Tamil Nadu incidence of physiological
jaundice varied from 20%-25%. [3]
stimuli can be directly sent to the exteroceptor the skins
sensory terminal. The flow of blood, lymph and tissue
fluid in the subcutaneous tissues, are induced. As a result
all elements essential to the body are adjusted and waste
products are collected and excreted. In addition it
stimulates the vagus nerve and heightens the production
of food absorbing hormone which subsequently increases
the secretion of gastric and pancreatic fluid. This
increases the amount of milk the infant suckles and
enhances food digestion. This ultimately increases
frequency of stool excretion and causes increased
excretion of stercobilinogen.[5-6]

Massage in neonates has the beneficial effects such as: Some of the studies which showed effectiveness of
relief from discomfort due to Gas, colic and constipation, massage were, Seyyedrasooli A, Jafarabadi M, et al., (2014)
regulates sleep/ wake cycle, infant parent attachment, conducted a randomized controlled trial among 43 healthy
promotes relief from pain improved blood circulation, term infants at Tabriz Al-Zahra hospital to investigate
aids in digestion, improves immune function and the effect of vimala massage on physiological jaundice.
stimulates the neuro muscular development.[4] The jaundice level was assessed using transcutaneous
bilirubinometer and frequency of defecation. The results
Therapeutic Massage is the manipulation of superficial indicated that 4 days of vimala massage has exceeded
and deep layers of muscle and connective tissue using number of defecation in the experimental group (p=0.449)
various techniques to enhance their function and and thus reduces the level of Transcutaneous bilirubin
in neonates with physiological jaundice.[7]
*Corresponding author.
E-mail: anitharobert2006@yahoo.com
Anitha Robert, Ruthrani Princely Jeyaraj and Sambavadas Kanchana, Effectiveness of Therapeutic Massage on
Level of Bilirubin among Neonates with Physiological Jaundice, IJCN, 2015, 2(12):1-6.
December, 2015; Volume 2; Issue 12 http://ijcn.mainspringer.com 2
3 http://ijcn.mainspringer.com Volume 2; Issue 12; December, 2015
Figure - 2: Percentage distribution of pre-test and post-test level of bilirubin among neonates with physiological
jaundice in the study group (N=30)

Figure 3: Percentage distribution of pre-test and post-test level of bilirubin among neonates with physiological
jaundice in the control group (N = 30)
 December, 2015; Volume 2; Issue 12 http://ijcn.mainspringer.com 4
Table - 1: Effectiveness of therapeutic massage on level of bilirubin among neonates with physiological jaundice
between the study and control group (N=30)

Groups Bilirubin Mean S.D Unpaired t Test

Study Group Pre test 12.95 0.71
Post test 10.00 1.03 t = 6.868
Control Group Pre test 12.95 0.71 p = 0.000 , S***
Post test 11.59 0.74
***p<0.001, S Significant
Table - 2: Association of demographic variables with the mean differed score level of bilirubin among neonates with
physiological jaundice in study group (N = 30)
Pretest Post Test Mean Diff ANOVA/
Demographic Variables Unpaired t
Mean S.D Mean S.D Mean S.D Test
Maternal GDM t = 3.584
Yes 13.07 0.77 9.21 0.80 3.86 0.71 p = 0.008
12.93 0.71 10.20 0.99 2.72 0.65 S**
No

Moslem, Naghavi M, et al., (2014) conducted a clinical
trial among 34 full term infants with physiological jaundice
undergoing phototherapy at hospital in Iran. Blood tests
were done to assess the serum bilirubin levels. The
results indicated that on the 4th day of intervention there
was a significant difference at 9.921.3mg/dl for the
massage groups and 11.971.52mg/dl for the control
group demonstrating that massage therapy has
significant effect in decreasing the bilirubin levels.[8]
Chen J and Sadakata M., (2011) conducted a quasi
randomized trial in a Japanese hospital among 42 full term
healthy newborns selected using convenient sampling
method. Bilirubin levels were assessed using serum
bilirubin levels and transcutaneous bilirubinometer. The
findings of the study were, the mean stool frequency of
massaged infants (4.6) was significantly higher than the
control group (2.6) and the serum total bilirubin levels
and the transcutaneous bilirubin levels were significantly
decreased in the massaged group compared to the
control group. The study finding suggests that baby
massage is beneficial for ameliorating neonatal jaundice.
[9]
Thus the nurse investigator adopted the intervention
Therapeutic massage as the intervention tool for the
present study as it is a cost effective, easy and safely
can be performed by nurses and even the caregivers at
home and health care settings.
Objectives
1. To assess and compare the pre and post test level
of bilirubin among neonates with physiological
jaundice in the study and control group.
2. To assess the effectiveness of therapeutic massage
on level of bilirubin among neonates with
physiological jaundice between study and
control group.
3.To associate the selected demographic variables
with the mean differed score level of bilirubin
among study and control group.
Null Hypotheses
NH1- There is no significant difference between pre and
post test level of bilirubin between study and control
group at p < 0.05 level.
NH2- There is no significant association of the selected
demographic variables with mean differed level of
bilirubin in study and control group at p < 0.05 level.
Conceptual framework
The conceptual framework adopted for this study was
based on Modified Kolcobas theory of comfort [10] as
shown in Figure 1. The present study was aimed to reduce
the level of bilirubin among neonates with physiological
jaundice. The nurse investigator identified the health care
need of the neonate (increased level of bilirubin), provided
the comfort measure (therapeutic massage) with ultimate
aim of promoting the enhanced comfort (decreased level
of bilirubin). Thus this best practice was appreciated and
was incorporated into the institutional policy
Methodology
A true experimental research design was adopted to
assess the effectiveness of therapeutic massage on level
of bilirubin among neonates with physiological jaundice.
The independent variable of this study was therapeutic
massage and the dependent variable was level of bilirubin.
The study was conducted in Andhra Mahila Sabha,
Durgabai Deshmukh General Hospital and Research
Centre Adyar, Chennai. The study population includes
neonates with 37-41 weeks of gestation with
physiological jaundice admitted in AMS, Adyar. The
sample size consisted of 60 neonates (who fulfils the
inclusion and exclusion criteria) selected by simple
random sampling technique lottery method, pair
matching was done for selected demographic variables
and homogeneity of the groups were maintained. The
study included the neonates with 37-41weeks and
neonates categorized to have Zone 3 & 4 level of jaundice
according to Modified NETS Guidelines and who are
receiving intermittent phototherapy. The study excluded
parents of neonates who were not willing to participate
in this study and neonates who are critically ill or with
severe congenital anomalies.
The instrument used in this study was Modified NETS
Guidelines which included the Serum bilirubin and
Kramers Rule for the assessment of level of bilirubin.
Neonates with serum bilirubin level of 12-15 mg/dl and
neonates within the Zone 3 & 4 in the Kramers Rule
were taken into as study samples.
5 http://ijcn.mainspringer.com
After thorough hand washing the investigator by placing
her warm hands began the procedure by applying mild
pressure onto the neonates skin. Massage starts on the
face using two thumbs gently rubbing the peri-orbital
and cheek region; and then moving to the chest and
abdomen using the two hands from the lower margin of
the chest slide to opposite upper edges alternatively then
to the abdomen in a half circle position gently; next
moving towards the limbs using hand by hand fashion
with moderate pressure on the external sides of the upper
and lower limbs and finally moved to the back performing
the massage with two hands from vertebra to both the
sides from the neck to the buttock. The investigator
performed the intervention 1 hour after the feed twice
daily with an interval of 4 hours for 5 days.
Results and Discussion
The study findings were analyzed by means of Pairedt
and Unpairedt test. Chi square test was used for
association. Homogeneity of the group was maintained
for 3 selected demographic variables: 10(33.34%) were
with the gestational age of 38 weeks, 10(33.33%) were
with the gestational week of 39 and 10(33.33%) were with
the gestational age of 40, 17(56.67%) had serum bilirubin
of 12-13mg/dl, 8(26.67%) with serum bilirubin 13-14 mg/
dl, 4(13.33%) mg/dl with serum bilirubin of 14-15 mg/dl
and 1(3.33%) with serum bilirubin level of 15-16 mg/dl,
with a birth weight of 2500-3000gm 20(66.67%), 7(23.33%)
with the birth weight of 3001-3500 gm and 3(10.00%) with
the birth weight of >3500gm.
The demographic variables in the study group as derived
from the statistical interpretation depicts, 17(56.67%) were
male neonates, majority 19(63.33%) were first born,
22(73.33%) had no history of previous child with
physiological jaundice of which 14(46.67%) were born
with normal vaginal delivery and 14(46.67%) were born
by caesarean section. Almost all 30(100%) were on breast
feeding with on demand feeding and all of them had
exposure to phototherapy with the duration of 4 hours /
day and none of the neonates had any birth injuries and
no neonates had exposure to sunlight. Majority of the
neonates 26(86.67%) had APGAR score of 9 at 5th minute
of birth. The maternal factors include age of the mother
of which 16(53.33%) had mothers with the age group
between 20-25 years, none of the neonates 30(100%) had
Rh incompatibility, 29(96.67%) had no history of ABO
incompatibility and 24(80.00%) had no history of maternal
GDM.
Figure 2 presents the findings of the pre test and post
level of bilirubin among neonates with physiological
jaundice in the study group. Figure 3 presents the pre
test and post test level of bilirubin among neonates with
physiological jaundice in the control group. Table 1
presents the findings of the effectiveness of therapeutic
massage on level of bilirubin among neonates with
physiological jaundice between the study and control
group with t test values which showed high statistical
significance of massage on neonatal jaundice.
Table 2 showed the significant association of
demographic variables with the mean differed score level
of bilirubin among neonates with physiological jaundice
in study group. The only variable which got associated
was maternal gestational diabetes mellitus, where
neonates with mothers having GDM had high level of
serum bilrubin compared with neonates with mothers not
having GDM.
Volume 2; Issue 12; December, 2015
Apart from the study objectives the investigator had
monitored for any improvement in the weight gain and
stool frequency as background variables. The
background variables of the study included assessment
of pre test and post test weight gain and stool frequency.
The post test stool frequency mean score was found to
have highly significant value indicating that therapeutic
massage was found to increase stool frequency in
neonates in the study group with the mean of 6.30 and
SD 0.59 and t value was calculated as 11.200, thus
enhanced the reduction in level of bilirubin.
Recommendations
The pediatric nurses can adopt therapeutic massage as
an easy, efficient and safe method employed in care of
neonates with physiological jaundice at their clinical
areas of practice. The researcher recommends use of
therapeutic massage in the hospital and also recommends
that the postnatal mothers can be trained for the use of
therapeutic massage as part of routine newborn care at
home care settings.
Conclusion
Thus the study findings provided evidence that
therapeutic massage was effective in reducing the level
of bilirubin among neonates with physiological jaundice.
Therefore the investigator recommends that therapeutic
massage can be utilized by the pediatric health care
providers in their day to day practice at the maternity
and newborn wards.
Source of Support: NIL
Conflict of Interest: NIL
References
1. South East Asian Region (SEAR) Neonatal-Perinatal
Database (NPD) Network report on newborn Available at
http://www.searo.who.int/entity/child_adolescent/
docum en t s/ r epor t _r egi on a l _n et wor k_m eet i n g
_on_newborn_2011.pdf
2. National Neonatal Perinatal Database (NNPD) report
2002 2003 available at http://www.newbornwhocc.org/
pdf/nnpd_report_2002-03.PDF
3. PHFI, AIIMS, and SC- State of Indias Newborns
(SOIN) 2014- a report. (Eds) Zodpey S and Paul VK. Public
Health Foundation of India, All India Institute of Medical
Sciences and Save the Children. New Delhi, India available
a t h t t p : / / w ww. n e w b o r n w h oc c . or g /
SOIN_PRINTED%2014-9-2014.pdf
4. Infant Massage Lessens Risk of Neonatal Jaundice,
Online article available at https://www.massagemag.com/
infant-massage-lessens-risk-of-neonatal-jaundice-8604/
5. Massage therapy study guide available online at https:/
/www.studyblue.com/notes/note/n/massage-therapy-
study-guide-2015-16-laura-gordon/deck/15344103
6. Field T, Diego M, Hernandez-Reif M (2010) Preterm
infant massage therapy research: a review. Infant Behav
Dev 33: 115-124. Avilabale at http://
www.ncbi.nlm.nih.gov/pmc/articles/PMC2844909/
7. Moslem, Naghavi M, et al., (2014). The effect of massage
on serum bilirubin levels in term neonates with
hyperbilirubinemia undergoing phototherapy. Iranian
journal of pediatric nursing, 128(1), 36-41.
December, 2015; Volume 2; Issue 12 http://ijcn.mainspringer.com 6

8. Seyyedrasooli, A., Jafarabadi ,M., et al., (2014). Effect

of vimala massage on physiological jaundice in infants:
A randomized controlled trial. Journal of caring sciences,
3(3), 165-173.
9. Chen, J., & Sadakata, M. (2011). Baby massage
ameliorates neonatal jaundice in full term newborn
infants. Tohoku Journal of experimental medicine. 223(2),
97-102.
10. Kolcaba, K. Y., & Kolcaba, R. J. (1991). An analysis of
the concept of comfort. Journal of Advanced Nursing,
16(11), 1301-1310.