RESEARCH

1 57
2 58
3

Effects of Massage Therapy on Indirect

4 59
5 60
6 61
7
8 Hyperbilirubinemia in Newborns Who 62
63
9
Receive Phototherapy
64
10 65
11 66
12 Gülçin Korkmaz and Figen Is¸ık Esenay Q23
67
13 68
14 69
Correspondence
15 Gülçin Korkmaz, Ankara 70
16 University, Faculty of ABSTRACT
71
17 Nursing, Aktas¸ Mahallesi Objective: To evaluate the effects of massage therapy on total serum bilirubin (TSB) levels and frequency of defe-
Plevne, Caddesi No:5, PK 72
18 06080 Altındag, Ankara,
cation, urination, and feeding in newborns who receive phototherapy for indirect hyperbilirubinemia.
73
19 Turkey. Design: A randomized controlled clinical trial. 74
20 glcnkrkmz07@gmail.com; Setting: Ankara University Cebeci Research and Training Hospital and 29 May State Hospital in Ankara, Turkey. 75
glcnkorkmaz@ankara.edu.tr
21 Participants: Fifty full-term newborns with indirect hyperbilirubinemia who underwent phototherapy. 76
22 Keywords
defecation Methods: The newborns were randomly allocated to an intervention group (n ¼ 25) or a control group (n ¼ 25). 77
23 massage Newborns in the intervention group received massage therapy throughout the duration of phototherapy for 15 minutes 78
24 phototherapy
twice per day; newborns in the control group received routine care during phototherapy. Every 24 hours, TSB levels 79
25 total serum bilirubin
urination frequency were measured, and the mean values of frequency of defecation, urination, and feeding were also calculated for each 80
26 81
newborn.
27 82
Results: We found no differences in the characteristics of the newborns or in TSB levels between groups at enroll-
28 83
ment. After treatment, TSB levels were lower in the intervention group (p < .001). Frequencies of defecation, urination,
29 84
and feeding were significantly greater in the intervention group than in the control group.
30 85
31 Conclusion: Massage therapy had significant effects on TSB levels, feeding, breastfeeding, defecation, and urination
86
32 in newborns who received phototherapy for indirect hyperbilirubinemia. Massage therapy can be added as routine care
87
33 for full-term newborns with hyperbilirubinemia under phototherapy and may be an effective supplementary
88
34 intervention.
89
35 JOGNN, -, -–-; 2019. https://doi.org/10.1016/j.jogn.2019.11.004 90
36 Accepted November 2019
91
37 92

I
93
Q1 Gülçin Korkmaz is a
38 ndirect or unconjugated hyperbilirubinemia in shorter half-life and greater turnover (Dagoglu, 94
research assistant
in
39 newborns occurs as a result of catabolism of 2017; Erg ¨l & Sarıkaya, 2018; Maheshwari & 95
pediatric nursing, Faculty of
u

40 Nursing, Ankara University, red blood cells and is increased in situations such Carlo, 2019). Neonatal hyperbilirubinemia is 96
41 as prematurity, malnutrition, and glucose 6- usually harmless; it typically occurs after new- 97
42 Ankara, Turkey. phosphate deficiency that lower metabolism borns are 24 hours of age, and serum bilirubin 98
43 Figen Is¸ık Esenay is an and excretion of indirect bilirubin (Dagoglu, 2017; levels decrease in approximately 5 to 7 days 99
assistant professor in
44 Erg ¨l & Sarıkaya, 2018; Maheshwari & Carlo, (Erg ¨l & Sarıkaya, 2018). Direct bilirubin can be
u 100
pediatric nursing, Faculty of
u

45 Nursing, Ankara University, 2019). Globally, hyperbilirubinemia occurs in excreted via defecation, and higher levels of 101
46 80% of preterm and 60% of term infants during direct bilirubin indicate underlying disorders, 102
47 Ankara, Turkey. the first week of life (Begum & Afroze, 2018; such as hepatic or posthepatic pathologies 103
48 Dagoglu, 2017; Erg ¨l & Sarıkaya, 2018). Indirect
u (Dagoglu, 2017; Maheshwari & Carlo, 2019). 104
49 or unconjugated bilirubin accumulates in the 105
50 epithelial tissues of the body, and jaundice may In some cases, levels of indirect bilirubin may 106
51 become visible in skin, nail, and mucosal tissue increase beyond physiologic levels. If not diag- 107
52 such as the sclera (Erg ¨l & Sarıkaya, 2018;
u
nosed in a timely manner and treated adequately, 108
53 Maheshwari & Carlo, 2019). Newborns produce indirect hyperbilirubinemia may cross the blood– 109
54 more bilirubin than adults because they are born brain barrier and cause kernicterus (bilirubin en- 110
55 The authors report no con- with significantly more red blood cells with a cephalopathy), which presents with symptoms of 111
56 flict of interest or relevant 112
financial relationships.

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 RESEARCH Massage Therapy and Phototherapy for Hyperbilirubinemia

113 169
the enterohepatic cycle of bilirubin recirculation
114 Phototherapy for newborns with hyperbilirubinemia has decreases, as do TSB levels (Hassan & 170
115 some potential adverse effects, such as hyperthermia, Zakerihamidi, 2018). Researchers hypothesized 171
116 dehydration, diarrhea, bronze baby syndrome, and skin that massage accelerated vagal stimulation and 172
117 burns. reduced bilirubin levels by increasing food intake 173
118 and defecation frequency (Dalili et al., 2016; 174
119 Eghbalian et al., 2017; El-Magd & Dabash, 175
120 lethargy, hypoglycemia, decreased feeding, res- 2017; Kianmehr et al., 2014; Lin et al., 2015; 176
121 piratory distress, and opisthotonos (Maheshwari Moghadam et al., 2012; Novianti, Mediani, & 177
122 & Carlo, 2019; Woodgate & Jardine, 2015). Pho- Nurhidayah, 2018). Other researchers found that 178
123 totherapy is commonly used to treat indirect massage increased the success and frequency 179
124 hyperbilirubinemia. The recommended total of breastfeeding. For example, in a study by Polat 180
125 serum bilirubin (TSB) level at which to begin (2010), mean LATCH (L ¼ latch, A ¼ audible Q3 181
126 phototherapy depends on the newborn’s gesta- swallowing, T ¼ type of nipple, C ¼ comfort, H ¼ 182
127 tional age, weight, postnatal age, and risk factors hold) Assessment Tool scores were higher in 183
128 such as Rh and ABO incompatibility (American newborns in the massage intervention group than 184
129 Academy of Pediatrics [AAP], 2004). in those in the control group (mean [M] ¼ 8.80 □ 185
130 0.957 vs. M ¼ 7.78 □ 1.59, p < .001). Xuelan, 186
131 Qingling, and Changhong (2005) found that 187
Although phototherapy is the standard of care, it
132 newborns in the massage intervention group 188
is not without risks and has potential adverse ef-
133 breastfed more frequently in 24 hours than those 189
fects for newborns, including hyperthermia,
134 in the control group (M ¼ 8.9 times □ 1.6 times vs. 190
dehydration, diarrhea, bronze baby syndrome,
135 M ¼ 5.7 times □ 1.3 times, p < .01). Kianmehr 191
and skin burns (Dagoglu, 2017; Erg ¨l & Sarıkaya,
136
u

et al. (2014) found no such relationship. 192

2018; Maheshwari & Carlo, 2019; Woodgate &
137 193
Jardine, 2015). Therefore, the use of photo-
138 194
therapy should be minimized during the treat- Phototherapy is generally discontinued based on
139 195
ment and care of newborns. the age at which it was initiated and the cause of
140 196
the indirect hyperbilirubinemia. The AAP recom-
141 197
mended that “for infants who are readmitted after
142 Different methods can be used to accelerate the 198
their birth hospitalization (usually for TSB levels of
143 excretion of bilirubin and prevent severe indirect 199
18 mg/dL or greater), phototherapy may be dis-
144 hyperbilirubinemia, including sponge bath ( ¸ ınar 200
continued when the serum bilirubin level falls
C

145 & K ¨ ¸ ¨koglu, 2018) and skin-to-skin care ( ¸ ınar 201

below 13 to 14 mg/dL” (AAP, 2004, p. 315). The
u c u C

146 & K ¨ ¸ ¨koglu, 2018). One method that is inex- 202

AAP did not provide recommendations about
u c u

147 pensive and apparently free of adverse effects is 203

duration of phototherapy (e.g., 3 days, 5 days,
148 massage. Researchers reported on massage for 204
etc.; AAP, 2004). Likewise, the Turkish Neona-
149 newborns with indirect hyperbilirubinemia who 205
tology guideline for phototherapy, which is based
150 received phototherapy for different lengths of 206
on the AAP guidelines, does not include a
151 time, such as for 3 days (Lin, Yang, Cheng, & Yen, 207
recommendation for a specific duration of pho-
152 2015), 4 days (Dalili, Sheikhi, Shariat, & 208
totherapy ( ¸ oban, T ¨rkmen, & G ¨rsoy, 2014). In
Haghnazarian, 2016; Eghbalian, Rafienezhad, &
C

153
u u

our clinical experience, the period of photo- 209

154 Farmal, 2017; El-Magd & Dabash, 2017; 210
therapy is usually 24 to 48 hours, and massage
155 Kianmehr et al., 2014), and 5 days (Moghadam, 211
therapy is not a component of clinical care in
156 Moghadam, Kianmehr, Jomezadeh, & Davoudi, 212
Turkey. Therefore, the purpose of our study was to
157 2012), and at different frequencies, such as two 213
evaluate the effects of massage therapy on TSB
158 times per day (Eghbalian et al., 2017; Lin et al., 214
levels and the frequencies of defecation, urina-
159 2015) and three times per day (Dalili et al., 215
tion, and feeding among newborns who received
160 2016; El-Magd & Dabash, 2017; Kianmehr et al., 216
phototherapy for indirect hyperbilirubinemia.
161 2014; Moghadam et al., 2012). Findings from 217
162 these studies included decreased bilirubin levels 218
163 and increased frequency of defecation; fre- 219
Methods
164 quency of urination was not evaluated. 220
Design
165 We conducted a randomized controlled trial be- 221
166 Massage therapy stimulates the newborn and tween January 15 and July 15, 2018. In this trial 222
167 increases readiness to feed (G ¨rol & Polat, 2010),
u there was no blinding. Simple randomization was 223
168 Q2 and the frequency of defecation increases as the done according to the gestational age in weeks of Q4 224
frequency of breastfeeding increases. As a result,
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 Korkmaz, G., and Esenay, F. I. RESEARCH

225 281
226 282
Ankara University Cebeci Research (n = 75) Training Hospital and
227 283
228 284
229 29 May State (n = 65)
230 Excluded (n = 84)
231
- Newborns did not meet th
232
233 inclusion criteria (n = 60)
234 - Researcher could not con
235 mothers (n = 24)
236
237 Randomization
238 285
e
act 286
287
288
289
290
291
292
293
294
239 Intervention group Control group
Allocation 295
(n = 27) (n = 29)
240 296
241 297
242 298
243 299
Reasons for leaving the group Reasons for leaving the group -
244 300
- Onset of fluid infusion (n = 1) Onset of fluid infusion (n = 2) -
245 301
246 - Left the hospital before completion Massage by the mother (n = 2) 302
247 of the treatment (n = 1) 303
248 304
249 305
250 306
251 307
252 Massage therapy in addition to 308
253 phototherapy (n= 25) Phototherapy (n= 25)
309
254 310
255 311
256 Analyzed (n = 25) 312
Analyzed (n = 25)
257 313
258 Figure 1. Consolidated Standards for Reporting Trials (CONSORT) participant flow diagram. 314
259 315
260 316
261 317
262 the newborns. The trial complied with the hospital had a Level 2 NICU. Because of their 318
263 Consolidated Standards for Reporting Trials central locations, these hospitals provide ser- 319
264 (CONSORT) guidelines (Schulz, Altman, Moher, & vices to individuals with different sociocultural 320
265 the CONSORT Group, 2010; see Figure 1) and characteristics. Both hospitals implemented 321
266 was approved by the Ethics Committee at the standardized phototherapy in accordance with 322
267 Faculty of Medicine at Ankara University for the the recommendations of the AAP (2004). 323
268 province of Ankara (institutional review board 324
269 number 19-1200-17). The mothers of the new- The inclusion criteria for the newborns included 325
270 borns were informed about the aim, plan, and the following: born at term (gestational age be- 326
271 duration of the study, and mothers’ written con- tween 37 and 42 completed weeks), birth weight 327
272 sent was obtained by the first author (G.K.). between 2,500 and 4,000 g, Apgar scores be- 328
273 tween 7 and 10 at 1 and 5 minutes after birth, 329
274 Setting and Sample receiving phototherapy, indirect hyper- 330
275 Our study participants were newborns who were bilirubinemia diagnosed 24 hours or longer after 331
276 admitted for treatment of indirect hyper- birth, and fed breast milk or formula. The 332
277 bilirubinemia at two centers: Ankara University exclusion criteria for newborns were ABO blood 333
278 Cebeci Research and Training Hospital and 29 type incompatibility, Rh incompatibility, blood 334
279 May State Hospital in Ankara. The university transfusion therapy, intravenous fluid treatment, 335
280 hospital had a Level 3 NICU, whereas the public infection, congenital anomaly, asphyxia, biliary 336

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 RESEARCH Massage Therapy and Phototherapy for Hyperbilirubinemia

337 atresia or glucose dehydrogenase-6 phosphate turned off during the massage therapy, and a 393
338 deficiency, glucuronosyl transferase enzyme radiant heater (BNT 2000, Drager, Luebeck, Q5 394
339 deficiency, and/or bronze baby syndrome. Germany) was used to prevent heat loss of the 395
340 newborn. The heater was turned on for 5 minutes 396
341 Fifty-six newborns met the inclusion criteria and before the massage to warm the environment, 397
342 were admitted to the study (intervention group, n ¼ and the device remained on during the massage. 398
343 27; control group, n ¼ 29). In total, six newborns The room temperature was maintained between 399
344 were excluded, including one newborn whose 26 and 28 □C. 400
345 parents wanted to leave the hospital before 401
346 completion of the treatment, three newborns who The massage techniques used were in accor- 402
347 received intravenous fluid treatment because of dance with the guidelines of the International 403
348 dehydration, and two newborns in the control Association of Infant Massage (2013). The first 404
349 group whose mothers performed massages. The author (G.K.) provided the massage therapy to 405
350 final sample was 50 newborns (intervention group, all newborns in the study; she thoroughly 406
351 n ¼ 25; control group, n ¼ 25). We used analysis of washed her hands, applied the antiallergenic 407
352 covariance (ANCOVA) to compare the pretreat- baby oil that was routinely used, and performed 408
353 ment and posttreatment TSB values by group. With a skin test before starting the first massage 409
354 the partial eta squared value of 0.0320, the calcu- therapy procedure. For the skin test, we applied 410
355 lated effect size was 0.68, and the power of the test baby oil to the palmar side of the newborn’s 411
356 conducted with 50 newborns with a Type I error wrist and, after 30 minutes, checked the skin for 412
357 value of 0.05 was 0.99 (99%). Our calculation was redness, rash, or other signs of allergic reaction. 413
358 made with the use of the G Power software pro- None of the newborns had an allergic reaction 414
359 gram (Version 3.1.9.2). or experienced adverse effects from the baby 415
360 oil. The massage began with the face, and baby 416
361 oil was applied. The massager applied two 417
362 Procedures 418
thumbs to massage the area around the eyes
363 Pilot study. We conducted a preliminary 419
and cheeks gently and slowly. This action then
364 implementation of the study protocol at the uni- 420
continued from the bottom to the top of the
365 versity hospital with two newborns who met the 421
chest area. The massager then performed some
366 inclusion criteria to test the operability of the data 422
soft and semicircular movements on the new-
367 collection forms. No change was made in the 423
born’s abdomen, followed by massaging of the
368 data collection forms. Because only two new- 424
upper and lower limbs with moderate pressure.
369 borns could be recruited within a month at the 425
Finally, the spine was massaged with two
370 university hospital, the second hospital was 426
thumbs from the top to the bottom and from the
371 included as a study site to increase recruitment. 427
neck to the buttocks. Newborns were placed
372 under phototherapy after the massage. 428
373 429
Implementation. Before newborns who quali-
374 430
fied for the study were assigned to groups by
375 Measures 431
simple randomization, the first author (G.K.) met
376 Tools for data collection. A neonatal char- 432
the mothers of the newborns, explained the pur-
377 acteristics sheet was developed by the first 433
pose and procedures of the study, and obtained
378 author (G.K.) and had two parts: Part I, which 434
written consent from the mothers who agreed to the
379 recorded personal data of the newborn, including 435
admission of their newborns to the study. The
380 gestational age at birth, route of birth, sex, birth 436
control group received routine nursing care pro-
381 weight, Apgar score, type of feeding, photo- 437
vided for newborns being treated with photo-
382 therapy duration, hospitalization duration, and 438
therapy at both hospitals. The newborns in the
383 maternal age; and Part II, which included medical 439
intervention group received massage therapy in
384 data and data contributed by the health care 440
addition to routine nursing care and phototherapy.
385 providers, including TSB levels and frequencies 441
386 of feeding, defecation, and urination. 442
387 Massage procedure. The newborns in the 443
388 intervention group were given massages for 15 444
389 minutes twice a day (the massage was applied Phototherapy device. The same photo- 445
390 two or three times depending on the duration of therapy device was used for the treatment of the 446
391 phototherapy [M ¼ 41 hours, range ¼ 24–49 newborns in the intervention and control groups 447
392 hours]) at 30 minutes after feeding in the morning at both hospitals. Phototherapy was provided 448
and the evening. The phototherapy device was with a light-emitting diode lamp (Novos, Bilied
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 Korkmaz, G., and Esenay, F. I. RESEARCH

449 505
Maxi, Turkey) at a distance of 30 cm from the
450 newborns. Massage therapy for newborns with hyperbilirubinemia 506
451 reduced the total serum bilirubin levels and increased the 507
452
TSB value. The sum of direct and indirect
frequencies of defecation, urination, and feeding. 508
453 509
bilirubin equals TSB (Ganji, Kasagani, Revupalli,
454 510
Kavali, & Chidugulla, 2015), and TSB is
455 breast milk and formula were documented from 511
measured for indirect hyperbilirubinemia (AAP,
456 the mothers’ parenting logs and the nursing re- 512
2004; ¸ oban et al., 2014). TSB levels were
C

457 cords and were calculated as the feeding quan- 513

routinely analyzed from venous blood samples of
458 tity and frequency during a 24-hour period. The 514
the newborns every 24 hours after the beginning
459 mothers could feed their newborns for any dura- Q7 515
of phototherapy; analysis was performed in the
460 tion and frequency that they desired in both 516
hospitals’ laboratories, which are approved and
461 research sites. In situations in which the mothers 517
Q6 certified by the Turkish Ministry of Health. The
462 could not breastfeed their newborns (at night, 518
devices used to measure TSB are calibrated
463 when the newborn could not hold the nipple, or 519
weekly by laboratory specialists. TSB was
464 when the mother had to leave the hospital), the 520
analyzed once in one center and twice in the
465 newborns were fed by the nurses with breast milk 521
other every 24 hours. Therefore, we used bilirubin
466 obtained by pumping or with formula. 522
levels at time of hospitalization and discharge.
467 523
468 524
469 Frequencies of defecation and uri- Analysis 525
470 nation. The first author (G.K.) recorded the We used SPSS (Version 20) to analyze the data. 526
471 defecation and urination frequencies of the new- Chi-square tests and Student t tests were used to 527
472 borns during the phototherapy period from the compare the demographic characteristics of 528
473 nursing notes and calculated the number of times newborns in the control and intervention groups. 529
474 the newborn defecated and urinated during a 24- ANCOVA was used to determine differences by 530
475 hour period. group for bilirubin levels. Student t tests were used 531
476 to investigate the differences between the control 532
477 Feeding quantity and frequency. The and intervention groups with regard to frequency 533
478 feeding frequency and quantity of feeding with of urination and feeding. Mann–Whitney U tests 534
479 535
480 536
481 Table 1: Characteristics of Newborns (N [ 50) 537
482 Intervention Control Group 538
483 Variable Item Group (n ¼ 25) (n ¼ 25) Test Statistic p 539
484 540
Q19
Sex, n (%) Female 18 (72) 13 (52) c ¼ 2.12
2
.14
485 541
Male 7 (28) 12 (48)
486 542
487 543
487 Age Gestational age at birth, 38 (37–40) 38 (37–40) U ¼ 312.50 1.000
544
488 weeks, median (range)
545
489
490 Maternal age, years, M □ SD 27.48 □ 6.71 28.12 □ 6.13 t ¼ –0.352 .726 JOG
NN
491 Weight, g Birth weight 3,289 □ 369.94 3,141.60 □ 349.18 t ¼ 1.45 .154 2019
492 ; Vol
Apgar score, 1 minute 9 (7–10) 9 (7–10) U ¼ 295.000 .722
. -, Is
493 sue -
median (range) 5 minutes 10 (9–10) 10 (7–10) U ¼ 286.000 .41
494
Treatment period, Phototherapy period 29 (20–37) 29 (14–52) U ¼ 308.50 .938
495
496 hours, median(range ) Hospitalization period 41 (24–49) 42.3 (15.5–54) U ¼ 282.000 .553 FLA
497 Type of feeding, Breast milk 5 (20) 9 (36) c ¼ 1.587
2
.208 GN
cem
498
n (%) Breast milk and formula 20 (80) 16 (64) pm
499
500 Mode of birth, Vaginal 11 (44) 15 (60) c ¼ 2.122
2
.145

501 n (%) Cesarean 14 (56) 10 (40)

502 Note. Chi-square, Mann–Whitney U, and Student t tests were used to compare the demographic characteristics of the newborns in the
503 groups. M ¼ mean; SD ¼ standard deviation.
504
546 547 548 549 550 551 552 553 554 555 556 557 558 559 560
 RESEARCH Massage Therapy and Phototherapy for Hyperbilirubinemia

561 617
562 Table 2: ANCOVA Results and Descriptive Statistics for TSB Levels of Newborns (N [ 50) 618
563 Before and After Randomization by Group 619
564 620
565 Group TSB–Before, mg/dl, Mean □ SD TSB–After, mg/dl, Mean □ SD n 621
566 Intervention 17.91 □ 1.55 18.64 □ 1.42 25 622
567 Control 9.02 □ 1.27 11.04 □ 1.57 25 623
568 624
569 Source SS df MS F p Partial h 2
Effect Size 625
570 TSB–before 0.212 1 0.212 0.101 .752 0.002 — Q20
626
571 Group 46.238 1 46.238 22.163 .000 *
0.320 0.68 627
572 628
Error 98.055 47 2.086 — — — —
573 629
574 Note. Analysis of covariance (ANCOVA; F) was used to compare the total serum bilirubin (TSB) levels of the newborns in the groups. In 630
ANCOVA, the controlled variable was TSB–before. The TSB–before values of newborns were controlled (covariated), and TSB–after
575 values were compared in the intervention and control groups. MS ¼ mean squared; SD ¼ standard deviation; SS ¼ sum of squared.
631
576 *p < .001. 632
577 633
578 634
579 635
580 were used for feeding amounts and defecation newborns were greater in the intervention group 636
581 frequency, because the feeding amounts and fre- (p <.001). There were no differences between the 637
582 quency of defecation were not normally distrib- breast milk (M ¼ 130 ml, range ¼ 25–310 ml vs. 638
583 uted. The results were considered significant for p M ¼ 130 ml, range ¼ 20–402 ml) and formula 639
584 values of less than .05 and are presented as (M ¼ 87.5 ml, range ¼ 30–350 ml vs. M ¼ 75 ml, 640
585 means plus or minus standard deviation. range ¼ 20–402 ml) quantities received by the 641
586 newborns in the intervention and control groups 642
587 Results (p > .05), but the feeding frequencies in the 643
588 Participant Characteristics intervention group (M ¼ 10.97 times □ 1.62 times) 644
589 The demographic information of the 50 partici- were significantly greater than in the control 645
590 pants by group is shown in Table 1. We observed group (M ¼ 9.05 times □ 1.82 times, p < .001). 646
591 no significant differences between the two groups 647
592 in terms of sex, gestational age at birth, birth 648
593 weight, Apgar score, route of birth, type of Discussion
649
594 feeding, duration of phototherapy, duration of There were no statistically significant differences
650
595 hospitalization, and maternal age. between the intervention and control groups with
651
596 regard to neonatal characteristics, which in-
652
597 dicates that the two groups were similar before
Serum Bilirubin Levels randomization. The feeding frequency was
653
598 The total bilirubin levels of the intervention and 654
599 significantly greater in the intervention group; this
control groups are shown in Table 2 and Figure 2. 655
600 finding contrasts with those of previous re-
When the effects of admission TSB levels were 656
601 searchers, who reported similar breastfeeding
controlled for, TSB levels at hospital discharge 657
602 frequencies between intervention and control
were significantly different between the two 658
603 groups with massage therapy (Kianmehr et al.,
groups. The newborns in the intervention group 659
604 2014). Consistent with our findings, Xuelan et al.
had significantly lower levels of total bilirubin (M ¼ 660
605 (2005) also found greater breastfeeding fre-
9.02 □ 1.27) compared with the infants in the 661
606
Q8
quencies in their intervention group. Massage
control group (M ¼ 11.04 □ 1.57, p < .001). 662
607 therapy is proposed to stimulate the newborn and
663
608 increase activity (Pepino & Mezzacappa, 2015)
Frequencies of Defecation, Urination, 664
609 and willingness and readiness to feed (G ¨rol &
665
u

and Feeding Polat, 2010). Newborns who were stimulated Q9

610 666
The mean daily frequencies of defecation, urina- through massage and exhibited increased will-
611 667
tion, feeding, breastfeeding, and breast milk and ingness to be fed had more active feeding ses-
612 668
formula quantities are presented in Table 3. Uri- sions. Massage therapy also stimulates the vagus
613 669
nation (M ¼ 9.29 times □ 1.04 times vs. M ¼ 7.81 nerve and increases gastrin secretion (Field,
614 670
times □ 1.51 times) and defecation (M ¼ 8 times, 2017), which increases gastric motility, gastric
615 671
range ¼ 6.48–11.86 times vs. M ¼ 5 times, secretion of hydrochloric acid, food digestion,
616 672
range ¼ 2.57–9 times) frequencies of the and gastric emptying (Hall, 2015), leading to
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 Korkmaz, G., and Esenay, F. I. RESEARCH

673 729
674 20 730
675 731
676 18 732
677 733
16
678 734
679 14 735
680 736
12
681 737
682 10 738
683 739
8
684 740
685 6 741
686 742
687 4 743
688 2 744
689 745
690 0 746
691 TSB before, mg/dl TSB a□er, mg/dl 747
692 748
693 Interven□on Control 749
694 750
Figure 2. Total serum bilirubin (TSB) levels of newborns before and after randomization by group.
695 751
696 more active and more frequent feeding sessions. so if the passage of stool from the intestines is 752
697 Thus, food intake increases, and the digestion of slow, an increase in bilirubin level may occur 753
698 food is facilitated because of increased gastric (Dalili et al., 2016; Kianmehr et al., 2014). Mas- 754
699 motility and gastric secretion of hydrochloric acid. sage therapy increases intestinal peristalsis, fa- 755
700 These mechanisms may explain the increase in cilitates stool passage from the intestines, and 756
701 feeding frequency observed in our study. An in- increases the frequency of defecation. This may 757
702 crease in feeding frequency in newborns with explain the greater defecation frequency in the 758
703 indirect hyperbilirubinemia is important because intervention group, a finding that is consistent 759
704 it may increase the frequency of urination and with those reported by other researchers who 760
705 defecation and accelerate the excretion of bili- found greater defecation frequencies in massage 761
706 rubin from the body. groups compared with control groups (Dalili 762
707 et al., 2016; El-Magd & Dabash, 2017; Lin et al., 763
708 The stools of newborns with indirect hyper- 2015; Seyyedrasooli, Valizadeh, Hosseini, Jafar- 764
709 bilirubinemia include significant levels of bilirubin, abadi, Mohammadzad, 2014). Seyyedrasooli 765
710 766
711 767
712 Table 3: Findings Associated With Newborn Defecation, Urination, and Feeding
713 Frequencies (N [ 50) FLA
714 Variable Intervention Group (n ¼ 25) Control Group (n ¼ 25) TS p GN
715 cem
Feeding frequency, times, M □ SD 10.97 □ 1.62 9.05 □ 1.82 t ¼ –3.931 .000 * Q21
pm
716
717 Breastfeeding frequency, times, M □ SD 10.16 □ 0.46 6.94 □ 0.5 t ¼ 4.498 .000 *

718 Total breastfeedin g duration, minutes, M (range) 273.7 (100.3–480) 172.3 (15–403) U ¼ 159.000 .003 **

719 Breastfeeding duration for each time, minutes, M □ SD 29.91 □ 3.15 24.91 □ 2.21 t ¼ 1.297 .201
720
Breast milk volume, ml, median (range) 130 (25–310) 130 (20–402) U ¼ 143.000 .573
721
722 Formula volume, ml, median (range) 87.5 (30–350) 75 (20–402) U ¼ 176.000 .708

723 Urinatio n frequency, times, M □ SD 9.29 □ 1.04 7.81□1.51 t ¼ 4.036 .000 *

724 Defecation frequency, times, M □ SD 8 (6.48–11.86) 5 (2.57–9) U ¼ 38.500 .000 *

725
726 Note. Mann–Whitney U and Student t tests were used to compare the feeding, urination, and defecation frequencies of newborns in the
group. M ¼ mean; SD ¼ standard deviation; TS ¼ test statistic.
727 *p < .001. **p <. 005.
728

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768 769 770 771 772 773 774 775 776 777 778 779 780 781 782 783 784
 RESEARCH Massage Therapy and Phototherapy for Hyperbilirubinemia

785 841
increase the frequency of urination by
786 Massage therapy may be an effective supplementary increasing the frequency of feeding. An in- 842
787 intervention to lower total serum bilirubin levels in crease in urine excretion increases bilirubin 843
788 combination with phototherapy for newborns with excretion in the form of urobilin and also di- 844
789 hyperbilirubinemia. minishes the exterohepatic circulation of bili- Q12 845
790 rubin in a newborn. 846
791 847
792 et al. (2014) found that the frequency of defeca- 848
793 The newborns in the intervention group in our 849
tion within 4 days was greater in the massage
794 study had significantly lower TSB levels than 850
intervention group than in the control group, and
795 those in the control group after the massage 851
Lin et al. (2015) determined that the frequency of
796 therapy intervention. This finding is consistent 852
defecation was significantly greater in the inter-
797 with those of previous studies in which re- 853
vention group on the third day. Dalili et al. (2016)
798 searchers focused on the effects of massage 854
observed more frequent defecation in the inter-
799 therapy on bilirubin levels (Eghbalian et al., 2017; 855
vention group than the control group on the first
800 El-Magd & Dabash, 2017; Kianmehr et al., 2014; 856
day of massage treatment. El-Magd and Dabash
801 Moghadam et al., 2012; Novianti et al., 2018). 857
(2017) reported that the frequency of defecation
802 Massage may accelerate bilirubin excretion 858
on the second and third days of treatment was
803 through increased urination, defecation, and 859
greater in the intervention group than the control
804 feeding frequency, which may explain the signif- 860
group. Because bilirubin is discharged from the
805 icantly lower TSB levels in the intervention group. 861
body in the stool, a negative association exists
806 between frequency of stool discharge and TSB 862
807 level (Gourley, Kreamer, & Arend, 1992). There- In massage therapy studies conducted with 863
808 fore, increased defecation in the newborn di- newborns under phototherapy for indirect hyper- 864
809 minishes the enterohepatic circulation of bilirubin, bilirubinemia, researchers showed that TSB 865
810 leading to increased bilirubin excretion levels were significantly lower in the intervention 866
811 (Kianmehr et al., 2014; Lin et al., 2015; group at different time points than those in our 867
812 Seyyedrasooli et al., 2014). Moreover, massage study (El-Magd & Dabash, 2017; Kianmehr et al., 868
813 increases lymphatic flow and blood circulation, 2014; Moghadam et al., 2012). Similarly, Basiri- 869
814 which increases the excretion of the bilirubin that Moghadam et al. (2012) and Kianmehr et al. Q13 870
815 is broken down by phototherapy (Kianmehr et al., (2014) found that, although initial bilirubin levels 871
816 2014; Lin et al., 2015; Seyyedrasooli et al., 2014). were similar between groups, bilirubin levels were 872
817 significantly lower on the fourth day in newborns 873
818 whose mothers massaged them three times a day 874
Bilirubin also is excreted from the body in the
819 for 4 and 5 days for 30 minutes after feeding. 875
form of urobilin in the urine (Maheshwari &
820 Furthermore, Kianmehr et al. reported that bili- 876
Q10 Carlo, 2015). Therefore, frequency of urination
821 rubin levels were similar between the intervention 877
is also evaluated by researchers focusing on
822 and control groups on the first, second, and third 878
the effects of massage on indirect hyper-
823 days. In contrast, El-Magd and Dabash (2017) 879
bilirubinemia. The mean urination frequency in
824 reported that bilirubin levels were significantly 880
24 hours was significantly greater in the inter-
825 lower on the first, second, and third days for 881
vention group than the control group in our
826 newborns in the intervention group, for whom a 882
study. We found only one study on the effects
827 researcher applied massage therapy in accor- 883
of massage therapy on bilirubin levels in which
828 dance with the International Association of Infant 884
researchers analyzed urinary output. Jeong
829 Massage guidelines twice a day for approxi- 885
Q11 and Park (2018) found no statistically signifi-
830 mately 15 to 20 minutes. We applied fewer mas- 886
cant differences between the 24-hour urine
831 sage treatments in our intervention group than the 887
volume levels between newborns in the mas-
832 intervention groups in other studies, but similar 888
sage therapy intervention and control groups,
833 results were obtained. Massage had effects 889
but the urine volume in the intervention group
834 within a short time frame, helped reduce bilirubin 890
(M ¼ 426.87 ml □ 118.36 ml) was greater than
835 levels, and helped newborns recover from indi- 891
in the control group (M ¼ 372.35 ml □
836 rect hyperbilirubinemia. Study results may vary 892
103.65 ml). Massage therapy increases perfu-
837 depending on the type of massage, the tech- 893
sion of the kidneys by increasing the blood
838 niques used during the massage, the experience 894
and lymph circulation in the tissues. Thus,
839 of the persons who administer the massage, and 895
urination frequency might be expected to in-
840 the massage duration and frequency. 896
crease. Furthermore, massage therapy could
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 Korkmaz, G., and Esenay, F. I. RESEARCH

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897 Limitations u s

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900 implemented the massage intervention was the Field, T. (2017). Newborn massage therapy. International Journal of 956
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