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1 http://ijcn.mainspringer.com Volume 2; Issue 12; December, 2015
Anitha Robert, Ruthrani Princely Jeyaraj and Sambavadas Kanchana, Effectiveness of Therapeutic Massage onLevel of Bilirubin among Neonates with Physiological Jaundice, IJCN, 2015, 2(12):1-6.
Effectiveness of Therapeutic Massage on Level of Bilirubin among Neonates withPhysiological Jaundice
Anitha Robert1*, Ruthrani Princely Jeyaraj2, and Sambavadas Kanchana3
1PG Scholar, Omayal Achi College of Nursing, Chennai.2HOD, Pediatric Nursing Department, Omayal Achi College of Nursing, Chennai.3Principal, 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
The present study was conducted to assess the effectiveness of therapeuticmassage on level of bilirubin among neonates with physiological jaundice atselected hospital, Chennai. A Quantitative approach, True-experimental -Pre test post test design was adopted for the present study. Thirty neonateseach in study and control group were selected by simple random samplingtechnique- lottery method. In study group each neonate was given thetherapeutic 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 ModifiedNeonatal Emergency and Transport Services (NETS) Guidelines Scale. Theresults concluded that there was high statistical significant reduction in levelof bilirubin among neonates in the study group who received the therapeuticmassage.
IntroductionPhysiological jaundice is the most common conditionrequiring medical attention in newborns. Jaundice is alsoa common reason for readmitting a newborn to thehospital after early discharge. Globally the incidence ofPhysiological jaundice is observed in almost 80% of thenormal neonates and 95% of the preterm.[1] The incidenceof neonatal hyperbilirubinemia in intramural live-birthsis 3.3% while in extramural admissions morbidity due tohyperbilirubinemia accounted for 22. 1%.[2] The incidenceof physiological jaundice in India varied from 15%-20%of neonates. In Tamil Nadu incidence of physiologicaljaundice varied from 20%-25%. [3]
Massage in neonates has the beneficial effects such as:relief from discomfort due to Gas, colic and constipation,regulates sleep/ wake cycle, infant parent attachment,promotes relief from pain improved blood circulation,aids in digestion, improves immune function andstimulates the neuro muscular development.[4]
Therapeutic Massage is the manipulation of superficialand deep layers of muscle and connective tissue usingvarious techniques to enhance their function and
Article History:Received 06 December 2015Received in revised form 22 De-cember 2015Accepted 25 December 2015Available online 30 December2015
Key words:Therapeutic massage, level ofbilirubin, NETS Guidelines, neo-nates with physiological jaundice.
*Corresponding author.E-mail: [email protected]
International Journal ofComprehensive Nursing
ISSN: 2349 - 5413
promotes relaxation and well being. Therapeutic massagestimuli can be directly sent to the exteroceptor the skin’ssensory terminal. The flow of blood, lymph and tissuefluid in the subcutaneous tissues, are induced. As a resultall elements essential to the body are adjusted and wasteproducts are collected and excreted. In addition itstimulates the vagus nerve and heightens the productionof food absorbing hormone which subsequently increasesthe secretion of gastric and pancreatic fluid. Thisincreases the amount of milk the infant suckles andenhances food digestion. This ultimately increasesfrequency of stool excretion and causes increasedexcretion of stercobilinogen.[5-6]
Some of the studies which showed effectiveness ofmassage were, Seyyedrasooli A, Jafarabadi M, et al., (2014)conducted a randomized controlled trial among 43 healthyterm infants at Tabriz Al-Zahra hospital to investigatethe effect of vimala massage on physiological jaundice.The jaundice level was assessed using transcutaneousbilirubinometer and frequency of defecation. The resultsindicated that 4 days of vimala massage has exceedednumber of defecation in the experimental group (p=0.449)and thus reduces the level of Transcutaneous bilirubinin neonates with physiological jaundice.[7]
3 http://ijcn.mainspringer.com Volume 2; Issue 12; December, 2015Figure - 2: Percentage distribution of pre-test and post-test level of bilirubin among neonates with physiologicaljaundice in the study group (N=30)
Figure – 3: Percentage distribution of pre-test and post-test level of bilirubin among neonates with physiologicaljaundice in the control group (N = 30)
December, 2015; Volume 2; Issue 12 http://ijcn.mainspringer.com 4
Moslem, Naghavi M, et al., (2014) conducted a clinicaltrial among 34 full term infants with physiological jaundiceundergoing phototherapy at hospital in Iran. Blood testswere done to assess the serum bilirubin levels. Theresults indicated that on the 4th day of intervention therewas a significant difference at 9.92±1.3mg/dl for themassage groups and 11.97±1.52mg/dl for the controlgroup demonstrating that massage therapy hassignificant effect in decreasing the bilirubin levels.[8]
Chen J and Sadakata M., (2011) conducted a quasirandomized trial in a Japanese hospital among 42 full termhealthy newborns selected using convenient samplingmethod. Bilirubin levels were assessed using serumbilirubin levels and transcutaneous bilirubinometer. Thefindings of the study were, the mean stool frequency ofmassaged infants (4.6) was significantly higher than thecontrol group (2.6) and the serum total bilirubin levelsand the transcutaneous bilirubin levels were significantlydecreased in the massaged group compared to thecontrol group. The study finding suggests that babymassage is beneficial for ameliorating neonatal jaundice.[9]
Thus the nurse investigator adopted the interventionTherapeutic massage as the intervention tool for thepresent study as it is a cost effective, easy and safelycan be performed by nurses and even the caregivers athome and health care settings.
Objectives1. To assess and compare the pre and post test level
of bilirubin among neonates with physiologicaljaundice in the study and control group.
2. To assess the effectiveness of therapeutic massageon level of bilirubin among neonates withphysiological jaundice between study andcontrol group.
3.To associate the selected demographic variableswith the mean differed score level of bilirubinamong study and control group.
Null HypothesesNH1- There is no significant difference between pre andpost test level of bilirubin between study and controlgroup at p < 0.05 level.
NH2- There is no significant association of the selecteddemographic variables with mean differed level ofbilirubin in study and control group at p < 0.05 level.
Conceptual frameworkThe conceptual framework adopted for this study wasbased on Modified Kolcoba’s theory of comfort [10] asshown in Figure 1. The present study was aimed to reducethe level of bilirubin among neonates with physiologicaljaundice. The nurse investigator identified the health careneed of the neonate (increased level of bilirubin), providedthe comfort measure (therapeutic massage) with ultimateaim of promoting the enhanced comfort (decreased levelof bilirubin). Thus this best practice was appreciated andwas incorporated into the institutional policy
MethodologyA true experimental research design was adopted toassess the effectiveness of therapeutic massage on levelof bilirubin among neonates with physiological jaundice.The independent variable of this study was therapeuticmassage and the dependent variable was level of bilirubin.The study was conducted in Andhra Mahila Sabha,Durgabai Deshmukh General Hospital and ResearchCentre Adyar, Chennai. The study population includesneonates with 37-41 weeks of gestation withphysiological jaundice admitted in AMS, Adyar. Thesample size consisted of 60 neonates (who fulfils theinclusion and exclusion criteria) selected by simplerandom sampling technique – lottery method, pairmatching was done for selected demographic variablesand homogeneity of the groups were maintained. Thestudy included the neonates with 37-41weeks andneonates categorized to have Zone 3 & 4 level of jaundiceaccording to Modified NETS Guidelines and who arereceiving intermittent phototherapy. The study excludedparents of neonates who were not willing to participatein this study and neonates who are critically ill or withsevere congenital anomalies.
The instrument used in this study was Modified NETSGuidelines which included the Serum bilirubin andKramer’s Rule for the assessment of level of bilirubin.Neonates with serum bilirubin level of 12-15 mg/dl andneonates within the Zone 3 & 4 in the Kramer’s Rulewere taken into as study samples.
Groups Bilirubin Mean S.D Unpaired ‘t’ Test Study Group
Pre test 12.95 0.71 t = 6.868 p = 0.000 , S***
Post test 10.00 1.03 Control Group
Pre test 12.95 0.71 Post test 11.59 0.74
***p<0.001, S – Significant
Table - 1: Effectiveness of therapeutic massage on level of bilirubin among neonates with physiological jaundicebetween the study and control group (N=30)
Table - 2: Association of demographic variables with the mean differed score level of bilirubin among neonates withphysiological jaundice in study group (N = 30)
Demographic Variables Pretest Post Test Mean Diff ANOVA/
Unpaired ‘t’ Test Mean S.D Mean S.D Mean S.D
Maternal GDM t = 3.584 p = 0.008 S**
Yes 13.07 0.77 9.21 0.80 3.86 0.71
No 12.93 0.71 10.20 0.99 2.72 0.65
5 http://ijcn.mainspringer.com Volume 2; Issue 12; December, 2015After thorough hand washing the investigator by placingher warm hands began the procedure by applying mildpressure onto the neonate’s skin. Massage starts on theface using two thumbs gently rubbing the peri-orbitaland cheek region; and then moving to the chest andabdomen using the two hands from the lower margin ofthe chest slide to opposite upper edges alternatively thento the abdomen in a half circle position gently; nextmoving towards the limbs using hand by hand fashionwith moderate pressure on the external sides of the upperand lower limbs and finally moved to the back performingthe massage with two hands from vertebra to both thesides from the neck to the buttock. The investigatorperformed the intervention 1 hour after the feed twicedaily with an interval of 4 hours for 5 days.
Results and DiscussionThe study findings were analyzed by means of Paired‘t’and Unpaired’t’ test. Chi square test was used forassociation. Homogeneity of the group was maintainedfor 3 selected demographic variables: 10(33.34%) werewith the gestational age of 38 weeks, 10(33.33%) werewith the gestational week of 39 and 10(33.33%) were withthe gestational age of 40, 17(56.67%) had serum bilirubinof 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/dland 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%) withthe birth weight of >3500gm.
The demographic variables in the study group as derivedfrom the statistical interpretation depicts, 17(56.67%) weremale neonates, majority 19(63.33%) were first born,22(73.33%) had no history of previous child withphysiological jaundice of which 14(46.67%) were bornwith normal vaginal delivery and 14(46.67%) were bornby caesarean section. Almost all 30(100%) were on breastfeeding with on demand feeding and all of them hadexposure to phototherapy with the duration of 4 hours /day and none of the neonates had any birth injuries andno neonates had exposure to sunlight. Majority of theneonates 26(86.67%) had APGAR score of 9 at 5th minuteof birth. The maternal factors include age of the motherof which 16(53.33%) had mothers with the age groupbetween 20-25 years, none of the neonates 30(100%) hadRh incompatibility, 29(96.67%) had no history of ABOincompatibility and 24(80.00%) had no history of maternalGDM.
Figure 2 presents the findings of the pre test and postlevel of bilirubin among neonates with physiologicaljaundice in the study group. Figure 3 presents the pretest and post test level of bilirubin among neonates withphysiological jaundice in the control group. Table 1presents the findings of the effectiveness of therapeuticmassage on level of bilirubin among neonates withphysiological jaundice between the study and controlgroup with t test values which showed high statisticalsignificance of massage on neonatal jaundice.
Table 2 showed the significant association ofdemographic variables with the mean differed score levelof bilirubin among neonates with physiological jaundicein study group. The only variable which got associatedwas maternal gestational diabetes mellitus, whereneonates with mothers having GDM had high level ofserum bilrubin compared with neonates with mothers nothaving GDM.
Apart from the study objectives the investigator hadmonitored for any improvement in the weight gain andstool frequency as background variables. Thebackground variables of the study included assessmentof pre test and post test weight gain and stool frequency.The post test stool frequency mean score was found tohave highly significant value indicating that therapeuticmassage was found to increase stool frequency inneonates in the study group with the mean of 6.30 andSD 0.59 and t value was calculated as 11.200, thusenhanced the reduction in level of bilirubin.
RecommendationsThe pediatric nurses can adopt therapeutic massage asan easy, efficient and safe method employed in care ofneonates with physiological jaundice at their clinicalareas of practice. The researcher recommends use oftherapeutic massage in the hospital and also recommendsthat the postnatal mothers can be trained for the use oftherapeutic massage as part of routine newborn care athome care settings.
ConclusionThus the study findings provided evidence thattherapeutic massage was effective in reducing the levelof bilirubin among neonates with physiological jaundice.Therefore the investigator recommends that therapeuticmassage can be utilized by the pediatric health careproviders in their day to day practice at the maternityand newborn wards.
Source of Support: NIL
Conflict of Interest: NIL
References1. South East Asian Region (SEAR) Neonatal-PerinatalDatabase (NPD) Network report on newborn Available athttp://www.searo.who.int/entity/child_adolescent/documents/ r epor t_regi onal_network_meet ing_on_newborn_2011.pdf
2. National Neonatal Perinatal Database (NNPD) report2002 – 2003 available at http://www.newbornwhocc.org/pdf/nnpd_report_2002-03.PDF
3. PHFI, AIIMS, and SC- State of India’s Newborns(SOIN) 2014- a report. (Eds) Zodpey S and Paul VK. PublicHealth Foundation of India, All India Institute of MedicalSciences and Save the Children. New Delhi, India availablea t h t t p : / / w w w . n e w b o r n w h o c c . o r 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) Preterminfant massage therapy research: a review. Infant BehavDev 33: 115-124. Avilabale at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2844909/
7. Moslem, Naghavi M, et al., (2014). The effect of massageon serum bilirubin levels in term neonates withhyperbilirubinemia undergoing phototherapy. Iranianjournal of pediatric nursing, 128(1), 36-41.
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8. Seyyedrasooli, A., Jafarabadi ,M., et al., (2014). Effectof 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 massageameliorates neonatal jaundice in full term newborninfants. Tohoku Journal of experimental medicine. 223(2),97-102.
10. Kolcaba, K. Y., & Kolcaba, R. J. (1991). An analysis ofthe concept of comfort. Journal of Advanced Nursing,16(11), 1301-1310.
