EFFECT OF MASSAGE ON HEALTH STATUS OF NEONATES WITH HYPERBILIRUBINEMIA

Abstract

Hyperbilirubinemia affects 60% of term and 80% of preterm infants in the 1st week of life. Massage is a
non-invasive therapeutic technique. It does not require any special technology or equipment; can easily be carried out alongside classical medicine and can result in a lowering of treatment costs, shortening of the length of the disease and its
side-effects.
The aim of this study was to assess the effect of massage on the health status of neonates with hyperbilirubinemia.
Methodology
A quasi-experimental design was utilized in this study, a purposeful sample of 64 neonates with
hyperbilirubinemia in El Monira Pediatric Hospital of Cairo University admitted to the Neonatal Intensive Care Unit.
Results
Mean of Total Serum Bilirubin (TSB) level in the 2nd, 3rd, and 4th day of the study was decreased among
the study group than the control group with statistically significant differences. During 72 hours of admission, more than
half of the study group and only six percent of the control group were discharged with a highly statistically significant difference.
Conclusions
Applying massage therapy combined with phototherapy in neonates with hyperbilirubinemia is effective in
reducing TSB levels, and hospital stays. Recommendation: apply baby massage as a routine care for full term neonates with hyperbilirubinemia under phototherapy.
KEYWORDS: Health Status, Hyperbilirubinemia, Massage, Neonates

Full text

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IMPACT: International Journal of Research in Applied,
Natural and Social Sciences (IMPACT: IJRANSS) ISSN(P): 2347-4580; ISSN(E): 2321-8851 Vol. 5, Issue 5, May 2017, 33-44 © Impact Journals
EFFECT OF MASSAGE ON HEALTH STATUS OF NEONATES WITH
HYPERBILIRUBINEMIA
AMNA NAGATY ABO EL-MAGD
1
, SOHEIR ABD EL-HAMID DABASH
2
,
SHADIA RIAD EL-GUINDY
3
, EMAN SAYED MASOED
4
& SALMA ZOHEIR EL HOUCHI
5
1
Assistant
Lecturer, Pediatric Nursing, Faculty of Nursing, Minia University, Egypt
2,3
Assistant
Professor, Pediatric Nursing, Faculty of Nursing, Cairo University, Egypt
4
Assistant
Professor, Pediatric Nursing, Faculty of Nursing, Minia University, Egypt
5
Assistant
Professor, Pediatric Medicine, Faculty of Medicine, Cairo University, Egypt
ABSTRACT
Background
Hyperbilirubinemia affects 60% of term and 80% of preterm infants in the 1
st
week of life. Massage is a
non-invasive therapeutic technique. It does not require any special technology or equipment; can easily be carried out
alongside classical medicine and can result in a lowering of treatment costs, shortening of the length of the disease and its
side-effects. The aim of this study was to assess the effect of massage on the health status of neonates with
hyperbilirubinemia.
Methodology
A quasi-experimental design was utilized in this study, a purposeful sample of 64 neonates with
hyperbilirubinemia in El Monira Pediatric Hospital of Cairo University admitted to the Neonatal Intensive Care Unit.
Results
Mean of Total Serum Bilirubin (TSB) level in the 2
nd
, 3
rd
, and 4
th
day of the study was decreased among
the study group than the control group with statistically significant differences. During 72 hours of admission, more than
half of the study group and only six percent of the control group were discharged with a highly statistically significant
difference.
Conclusions
Applying massage therapy combined with phototherapy in neonates with hyperbilirubinemia is effective in
reducing TSB levels, and hospital stays. Recommendation: apply baby massage as a routine care for full term neonates
with hyperbilirubinemia under phototherapy.
KEYWORDS:
Health Status, Hyperbilirubinemia, Massage, Neonates
INTRODUCTION
Hyperbilirubinemia is the most common problem in the newborn period requiring hospitalization and medical
attention (Alkalay, Breesee and Simmons, 2010). Approximately 60% of all newborns develop some degree of jaundice in
the 1
st
week of life (Bhutani, Stark and Lazzeroni, 2013).

34
Amna Nagaty Abo El-Magd , Soheir Abd El-Hamid Dabash,
Shadia Riad El-Guindy , Eman Sayed Masoed & Salma Zoheir El Houchi
NAAS Rating: 3.00 - Articles can be sent to editor@impactjournals.us
Massage is a non-invasive therapeutic technique. It does not require any special technology or equipment; can
easily be carried out alongside classical medicine and can result in a lowering of treatment costs, shortening of the length
of the disease and its side-effects. It can also lead to a better emotional relationship – which could have been disturbed by
hospitalization –between mother and infant. It has been linked to several benefits, including stimulation of the vagus nerve,
increasing gastric fluids, aiding digestion, increasing appetite, increasing blood flow and stimulating of the lymphatic
system. It aids in the collection, excretion of waste products from the body, and early defecation stimulation
(Click et al. 2013).
Early defecation may decrease entero-hepatic bilirubin circulation, which may translate into decreased rate and
severity of neonatal hyperbilirubinemia (Bagshaw and Fox, 2005). Baby massage may improve quality of care provided by
the nurses and decrease length of hospital costs.
Operational Definition
Health status was assessed through the level of hyperbilirubinemia, hospital stay, stool frequency, and weight
gain.
Significance of the Study
Ministries of Health (MOH) survey done during 2005 in 21 hospitals in 12 governorates. All admissions over 15
months were collected, it was reported that 31.39% of the final diagnosis of hospitalized neonates were having neonatal
jaundice in Egyptian governmental NCUs (Fahmy, 2007)
According to health statistics of Neonatal Intensive Care Unit (NICU) at the Cairo University Pediatric Hospital
(EL Monira Pediatric Hospital) (2014), number of neonates admitted with hyperbilirubinemia was 624 cases (69.5%) from
the 898 total number of admissions.
Aim of the Study
To assess the effect of massage on the health status of neonates with hyperbilirubinemia.
RESEARCH HYPOTHESES
• Applying massage to neonates with hyperbilirubinemia will decrease bilirubin level in the study group than the
control group.
• Applying massage to neonates with hyperbilirubinemia will decrease hospital stay duration in the study group
than the control group.
SUBJECT AND METHODS
Research Design
A quasi-experimental design was utilized for this study.
Setting
This study was conducted at the Neonatal Intensive Care Unit (NICU) in El Monira Pediatric Hospital of Cairo
University.

Effect of Massage on Health Status of Neonates with Hyperbilirubinemia
35
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Sample
A purposeful sample of 64 neonates with hyperbilirubinemia admitted to NICU. Neonates were divided into two
equal groups (study & control groups). The determination of the sample size based upon the following sample calculation
formula
t
2
x p (1-p)
N =
m
2
(1.96)
2
x 0.69 (1- 0.69)
N =
0.05
2
N = 32 neonates
Inclusion criteria
• Full term neonates with unconjugated hyperbilirubinemia,
• Bilirubin level above 12 mg/dl,
• Under phototherapy, & not requiring exchange transfusion
• Birth weight ≥ 2.500 kg.
Tool for Data Collection
Neonatal characteristics sheet developed by the researcher included two parts:
• Part I: Personal data of the neonate were included: code, gender, birth weight, mode of delivery, onset and history
of hyperbilirubinemia.
• Part II: Medical data: total serum bilirubin level (TSB), hospital stay, stool frequency and daily weight.
Tool Validity and Reliability
Validity
The tool was submitted to a panel of five experts in Pediatric Nursing and Medicine neonatologist to confirm its
validity.
Reliability
Reliability of the tools was performed to confirm validity of tool and was calculated statistically. Reliability of the
study's tool was done by alpha Cronbach test 0.82.
Pilot Study
The pilot study was done on 10% of the sample size (6 neonates). Neonates who shared in
the pilot were included in the study sample.

36
Amna Nagaty Abo El-Magd , Soheir Abd El-Hamid Dabash,
Shadia Riad El-Guindy , Eman Sayed Masoed & Salma Zoheir El Houchi
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Ethical Consideration
Acceptance of ethical committee at Faculty of Nursing, Cairo University was gained. The confidentiality of
information was assured and the parents had the right to withdraw from the study at any time during the study without any
effect on the care provided for their infants.
DATA COLLECTION PROCEDURE
The official permissions were obtained from the Director of the Pediatric Hospital and the Head of Neonatology
Unit, up on letters issued from the Faculty of Nursing, Cairo University. A formal written consent was obtained from
one of the parents of the neonates who were admitted to the unit and fulfilling the inclusion criteria.
Data were collected between June to November, 2015. The neonates in the study group were received Vimala
Massage Technique, "International Association of Infant Massage" (IAIM) (McClure, 2012) by the researcher for 15- 20
minutes twice/ day, 1- 2 hours in the morning shift (11.00 am – 12.00 pm) and midday feed (2.00 – 3.00 pm).
The neonates were following the routine care of the unit. Every morning, TSB, hospital stay, stool frequency, and daily
weight were measured as the routine care until discharge up to 7 days for both groups as illustrated in Figure 1& 2.
Figure 1: For the Study Group (Massage Group)
Figure 2: For the Control Group (Routine Care)
STATISTICAL
ANALYSIS
Data were summarized, tabulated, and presented using descriptive statistics in the form of frequency distribution,
percentages, means and the standard deviations as a measure of dispersion.
A statistical package for the social science (SPSS), version (20) was used for statistical analysis of the data, as it
contains the test of significance given in standard statistical books. Numerical data were expressed as mean and SD.
Qualitative data were expressed as frequency and percentage. For quantitative data, comparison between two variables was
done using student's t-test. Probability (P-value) is the degree of significance, less than 0.05 was considered significant.

Effect of Massage on Health Status of Neonates with Hyperbilirubinemia
37
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RESULTS
Table 1 described the characteristics of the neonates participating in this study. It was found that, more than half
of neonates of the study group and half of neonates of the control group were males (56.2 %, 50% respectively), the mean
birth weight of study and control groups was 3.04 ± .48 Kg & 3.02 ± .43 Kg respectively. 68.8% of the study group
compared to 75% of the control group delivered by caesarian section. The mean onset of hyperbilirubinemia in study and
control groups was 2.9 ± .56 day & 2.9 ± .49 day respectively. There was no statistically significance differences between
study and control groups as regards neonatal characteristics.
Table 2 determinates that, mean of TSB between study and control groups before the study denoted near to equal
mean scores related to TSB level between both groups (22.1 ± 1.9 vs 22.5 ± 1.8 respectively). No statistical significant
differences between both groups (t = -.841=, p = .404), while the mean TSB level in the 2
nd
, 3
rd
, and 4
th
day of the study
was decreased among the study group than the control group (15.9 ± 1.5 vs 18.5 ± 1.9, 11.6 ± 1.2 vs 16.1 ± 2.0 and 9.8 ± .6
vs 13.2 ± 2.2 respectively) with statistical significant differences between both groups (p = .0001 respectively).
Table 3 demonstrated during 72 hours of admission, more than half (56.3%) of the study group compared to only
six percent (6.2%) of the control group were discharged with highly statistically significant difference (t = 8.194, p = .000).
Table 4 showed the mean number of stool frequency increased among study group than the control group (5.8 ± .8
vs 4.1 ± .8 and 6.0± 1.0 vs 4.2 ± 1.7 respectively) with statistical significant differences between both groups (p = .0001
respectively) in the 2
nd
, and 3
rd
day of the study.
Table 5 illustrated before the study no association was detected between total serum bilirubin level & stool
frequency among both groups, while in the 2
nd
, 3
rd
, 4
th
day of the study there was negative significant association among
the study group (r = -.388, p = .03*, r = -.399, p = .02* & r = -.495, p = .02* respectively), and no significant association
was detected among the control group.
No statistical significant differences between both groups regarding weight gain as observed in table 6

38
Amna Nagaty Abo El-Magd , Soheir Abd El-Hamid Dabash,
Shadia Riad El-Guindy , Eman Sayed Masoed & Salma Zoheir El Houchi
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Table 1: Characteristics of the Study & Control Groups as
Regards Personal Data of the Neonates (N= 64)
Characteristics of the neonates Groups Test P
Study (n=32) Control (n=32)
No % No %
Gender Male 18 56.2 16 50 χ
2
= .251 .616 NS
Female 14 43.8 16 50
Birth weight /kilogram 2.500- 14 43.8 14 43.8 t=.110 .792 NS
3.000- 10 31.2 12 37.5
3.500- 3.999 8 25 6 18.8
Mean ± SD 3.04 ± .48 Kg 3.02 ± .43 Kg
Mode of delivery
S.V.D 10 31.2 8 25 χ
2
= .309 .578 NS
C.S 22 68.8 24 75
Family history of hyperbilirubinemia
χ
2
=
2.286
.131 NS
+ ve 2 6.2 6 18.8
-ve 30 93.8 26 81.2
Onset of hyperbilirubinemia / days
2 6 18.8 6 18.8 t=.472 .686 NS
3 22 68.7 24 75
4 4 12.5 2 6.2
Mean ± SD 2.9 ± .56 days 2.9 ± .49 days
NS= No Significant difference S.V.D = Spontaneous Vaginal Delivery
C.S = Cesarean Section
Table 2: Comparison of Daily Mean and Standard Deviation of Total Serum Bilirubin Between Study &Control Groups
TSB Groups t P
Study Control
Mean ± SD Mean ± SD
Before study
22.1
± 1.9
22.5
± 1.8
-
.841
.404
2
nd
day
of the study
15.9
± 1.5
18.5
± 1.9
-
5.8
.0001*
3
rd
day
of the study
11.6
± 1.2
16.1
± 2.0
-
10.8
.0001*
4
th
day
of the study
9.8
± .6
13.2
± 2.2
-
7.7
.0001*
5
th
day
of the study
…………
11.9
± 1.9
……
……
6
th
day
of the study
…………
11.2
± 1.2
……
……
7
th
day
of the study
…………
10.4
± .9
……
……
*statistical significance difference

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Table 3: Comparison of the Hospital Stay (Hours)
Between Study &Control Groups (N= 64)
Hospital Stay
/ Hours
Groups t P Study (N= 32) Control (N= 32)
No % No %
Length of hospital stay/hours
48 - 18 56.3 2 6.2
8.194 .000*
72 - 12 37.5 4 12.5
96 - 2 6.2 10 31.3
120 - 0 0 12 37.5
144- 168 0 0 4 12.5
Mean ± SD 50.98± 1.74 hrs 96.76 ± 2.98 hrs
*statistical significance difference
Table 4: Comparison of Daily Mean and Standard Deviation of
Stool Frequency Between Study &Control Groups
Stool frequency
Groups
t P
Study Control
Mean ± SD Mean ± SD
Before
study
3.5 ± .9
3.0 ± .9
.458
.357
2
nd
day
of the
study
5.8
± .8
4.1 ± .8
8.430
.0001*
3
rd
day
of the study
6.0 ± 1.0
4.2 ± 1.7
8.522
.0001*
4
th
day of the study 4.2 ± 1.7 4.1 ± .4 .553 .583
5
th
day of the study ………… 3.8 ± .9 …… ……
Table 4: Condt.,
6
th
day
of the study
…………
4.0
± .8
……
……
7
th
day
of the study
…………
3.0
± 1.2
……
……
*statistical significance difference
Table 5: Correlations Between Total Serum Bilirubin Level & Stool Frequency Between
Study &Control Groups at Before, 2
nd
, 3
rd
, & 4
th
Day of Study
TSB Level
Stool Frequency
Study group Control group
r P r P
Before study .220 .225 .182 .319
2
nd
day of the study
-.388 .03* -.293 .104
3
rd
day of the study -.399 .02* -.311 .217
4
th
day of the study -.495 .02* .393 .197
5
th
day of the study .487 .01*
6
th
day of the study -.036 .889
7
th
day of the study .353 .260
*Correlation is significant at the 0.05 level (2-tailed)

40
Amna Nagaty Abo El-Magd , Soheir Abd El-Hamid Dabash,
Shadia Riad El-Guindy , Eman Sayed Masoed & Salma Zoheir El Houchi
NAAS Rating: 3.00 - Articles can be sent to editor@impactjournals.us
Table 6: Comparison of Daily Mean and Standard Deviation of
Weight Gain between Study &Control Groups
Weight Gain
Groups
t P
Study Control
Mean ± SD Mean ± SD
Before study 3.0 ± .476 3.0 ± .442 .212 .533 NS
2
nd
day 3.1 ± .472 3.0 ± .441 .186 .548 NS
3
rd
day 3.0 ± .471 3.0 ± .444 .246 .644 NS
4
th
day 3.0 ± .485 3.0 ± .434 .377 .455 NS
5
th
day ………… 3.1 ± .437 …… ……
6
th
day ………… 3.1 ± .409 …… ……
7
th
day ………… 3.1 ± 350 …… ……
NS= No Significant difference
DISCUSSIONS
There was no statistically significance differences between study and control groups as regards neonatal
characteristics. This confirms that these two groups were homogenous groups during to the study.
Total serum bilirubin level on the 2
nd
, 3
rd
, and 4
th
day was lower among the study group than the control group
with statistically significant difference. These results supported by Lin, et al. (2015), Kianmehr, et al. (2014),
Basiri-Moghadam, et al. (2012), they found that, bilirubin level of the massage group neonates was significantly lower than
that of the control group on the third and four day of massage therapy difference may be due to type of techniques used,
time of starting massage techniques and person who did massage (experience).
There was no statistically significant difference in stool frequency (times\24 hours) between both groups before
the study. On the 2
nd
, and 3
rd
day the stool frequency increased in the study group. Similar results were reached by
Basiri-Moghadam, et al. (2015), Chen, et al. (2011), who reported that, the stool frequency increased from day 1- 4 after
intervention. The increase in stool frequency in the newborns receiving massage could be due to the stimulation of the
vagal nerve which can be caused by a stimulation of the peripheral nerves. The later reduces the re-absorption of
conjugated bilirubin that is secreted in the intestines and thus prevents an increase in bilirubin.
Concerning about the potential effect of massage on gaining weight demonstrated no significant difference among
the study and control groups. The same findings were reported by Lin, et al. (2015), Basiri-Moghadam, et al. (2012),
Serrano, Doren, and Wilson, (2010), Yilmaz and Conk, (2009), and Lee (2006) who showed that, 5 days of massage
therapy cannot cause significant differences in weight gain, while Diego, Field and Hernandez- Reif, (2014) and an
Egyptian recent study conducted by El Said, et al. (2013), who illustrated that, babies with oil massage had significantly
higher weight on day 4 (P = 0.02). These differences may be related to the age of neonates ranged between 4
th
to 5
th
day
after life. In addition, it is possible that the duration of massage therapy was too short to increase weight gain and normally
newborn lose 10% of total weight during 1
st
week of life.

Effect of Massage on Health Status of Neonates with Hyperbilirubinemia
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After 72 hours of admission, more than half of the study group and only 6% of the control group were discharged
with highly statistically significant difference in which p – value < .000. This result was in the same line with Zhang,
(2012) who evaluated the effect of touching in infants with different degrees of hyperbilirubinemia, who are undergoing
phototherapy, who mentioned that, touching together with phototherapy can significantly shorten the length of hospital
stay in experimental groups (P < 0.05) and Underdown et al. (2006) also, Vickers, et al. (2004) found that, massage
reduced the length of hospital stay by 4.5 days.
On 2
nd
day of the study there was a negative significant association between the study and control groups as
regards TSB level and number of stool frequency. This finding supported and explained by Huang (2009) carried out in
China, indicated that by adding to the bowel movements, massage facilitates the excretion of meconium, and shortens the
bilirubin change time and its re-absorption to blood via liver-port system resulting in a lower incidence of
hyperbilirubinemia. Also, Semmekrot, de Vries, Gerrits, & van Wieringen, (2004) and Gourley, Kreamer, and Arend,
(1992) who demonstrated that, there were a negative relationship between stool production and bilirubin levels in healthy
term infants during the first 3 weeks of life.
In the light of study results, the researchers concluded that, applying massage therapy combined with
phototherapy on neonates with hyperbilirubinemia effective in reducing TSB levels, hospital stay, and increase stool
frequency.
RECOMMENDATIONS
Applying baby massage as a routine care for full term neonates with hyperbilirubinemia under phototherapy and
evaluate efficacy of Vimala massage on preterm neonates with hyperbilirubinemia.
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