Infant Behavior and Development 49 (2017) 31–36

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Infant Behavior and Development

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Full length article

The lowering of bilirubin levels in patients with neonatal jaundice MARK

using massage therapy: A randomized, double-blind clinical trial
⁎
Fatemeh Eghbaliana, , Haneyeh Rafienezhada, Javad Farmalb
a
Department of Pediatrics, Hamadan University of Medical Sciences, Hamadan, Iran
b
Department of Biostatistics and Epidemiology, Hamadan University of Medical Sciences, Hamadan, Iran

AR TI CLE I NF O AB S T R A CT

Keywords: Objective: Due to the effects of massage on various laboratory parameters (including those related
Neonatal jaundice to jaundice) in infants and the expansion of existing studies to achieve effective and safe therapy
Massage therapy in the treatment of neonatal jaundice, this study aimed to investigate the effect of massage on
Phototherapy bilirubin levels in cases of neonatal jaundice.
Pediatrics
Methods: In this study, 134 patients were randomly assigned to either an intervention group
Billirubin
(massage combined with phototherapy, n = 67) or a control group (phototherapy only, n = 67).
In both groups, serum total bilirubin level and frequency of daily bowel movements were mea-
sured and compared during each of the first four days of treatment.
Results: Baseline levels of bilirubin were similar between the two groups (P > 0.05). During the
measurements obtained post-intervention, significant differences surfaces between the two
groups in bilirubin levels and frequency of daily bowel movements (P < 0.05 for both). No
significant relationship was observed during days 1 and 2 of massage therapy between daily
frequency of bowel movements and serum bilirubin level (P > 0.05); this relationship became
significant during the third and fourth days (P < 0.05).
Conclusion: Massage therapy combined with phototherapy is an effective method for reducing
serum total bilirubin in infants with neonatal jaundice.

1. Introduction

Neonatal hyperbilirubinemia refers to an excess of more than 5 mg/dl bilirubin above the normal level. Icterus (jaundice)
appears as a result of the deposition of bilirubin in the skin and mucosa. Unconjugated (indirect) hyperbilirubinemia is usually
benign, but severe cases can lead to kernicterus. Diagnosis and treatment of neonatal hyperbilirubinemia is of great im-
portance in the prevention of encephalopathy. Increased bilirubin occurs in infants between 3 and 7 days of age. However, it is
possible for jaundice to occur at birth or any time during infancy (Maisels & Newman, 2007; McGillivray, Polverino,
Badawi, & Evans, 2016).
Researchers have considered different treatment methods ranging from phototherapy to neonatal blood transfusion to prevent the
effects of hyperbilirubinemia. Each method has positive effects and drawbacks. Watery diarrhea, increased insensible water loss, skin
rashes, blue baby syndrome, and temporary skin tanning are some of the effects of phototherapy. It is also a matter of debate whether
phototherapy can cause melanoma in treating neonatal jaundice (Dennery & Lorch, 2007; Sharif et al., 2016). Complications asso-
ciated with blood transfusion include allergic reactions and possible infections. Also, separation of the baby from the mother during

⁎
Corresponding author at: Fatemeh Eghbalian, Department of Pediatrics, Hamadan University of Medical Sciences, Hamadan, Iran.
E-mail addresses: eghbalian_fa@yahoo.com (F. Eghbalian), Hhamidi50@gmail.com (H. Rafienezhad).

http://dx.doi.org/10.1016/j.infbeh.2017.05.002
Received 21 January 2017; Received in revised form 2 May 2017; Accepted 4 May 2017
0163-6383/ © 2017 Elsevier Inc. All rights reserved.
F. Eghbalian et al. Infant Behavior and Development 49 (2017) 31–36

phototherapy emotionally affects both the mother and the baby. Therefore, it seems necessary to simultaneously maintain the normal
range of circulating bilirubin and control possible side effects.
Massage in infants after birth is a method that, in addition to inducing relaxation in the mother and baby, has also been proven to
improve parameters such as height, weight, head circumference, bone density, sleep duration, and breathing patterns while reducing
the incidence of infant colic (Field, Diego, & Hernandez-Reif, 2010; Hernandez-Reif, Diego, & Field, 2007) As is well-known, defe-
cation is a mechanism whereby bilirubin is removed, decreasing the probability of jaundice (Diego, Field, & Hernandez-Reif, 2005).
Published studies have reported that baby massage can ameliorate neonatal jaundice (Chen, Sadakata, Ishida, Sekizuka, & Sayama,
2011). In another study, Vimala massage did not have an effect on the processing of bilirubin (Seyyedrasooli, Valizadeh, Hosseini,
Jafarabadi, & Mohammadzad, 2014). The conflicting results of these and other studies led to this study, in which the use of massage
in tandem with phototherapy is investigated for its impact on increasing the frequency of daily bowel movements in neonates and
thereby reducing neonatal jaundice.

2. Materials and methods

The infants were randomly divided into the intervention study group (67 infants undergoing massage with phototherapy) and the
control group (67 undergoing phototherapy only). Infants in the intervention study group (under treatment) received massage and
phototherapy 2 times a day for 15–20 min. The inclusion criteria were: 1–14 days after birth, gestational age of 38–40 weeks, no
congenital anomalies, absence of maternal addiction to alcohol, cigarettes, or other drugs, no neonatal surgery, mother was ex-
clusively breastfeeding (Jalali et al., 2016; Lotfi et al., 2016; Saba, Valeh, Ehteram, Haddad, & Ghazi, 2017). Each infant was carefully
examined, and the related demographic and clinical data were registered in the checklist. Information recorded included gender,
gestational age, mode of delivery, birth weight, Apgar score, maternal parity, delivery duration, mean birth weight during the first
4 days, defecation, the time of the first bowel movement (meconium) during the first 4 days, and total bilirubin within the first 4 days
(Chen et al., 2011).
Infant massage was performed by mothers under the supervision of trained nurses. Infants were massaged an hour after waking up
in the morning and at noon in a place with a room temperature between 24 °C and 28 °C. The mother would rub his/her hands
together after washing and drying her hands so as to bring his/her body temperature close to the temperature of the infant’s skin.
Massaging began with the face; baby oil was applied. The massager applied her two thumbs to gently and slowly massage the area
around the eyes and cheeks. This action then continued from the bottom to the top of the chest area. Then, the massager performed
some soft and semi-circular movements on the infant’s abdomen, followed by massaging with moderate pressure of the upper and
lower limbs. Eventually, the spine was massaged using the two thumbs from top to bottom and from the neck to buttock. Terms and
the method of massage were the same for all infants in the study group. The infants in the control group were given routine care.
The number of bowel movements in the first 4 days was recorded based on the reports of mothers and nurses. Using venous
sampling and testing, we measured serum total bilirubin level for 4 consecutive days (once daily) (Ferdosian et al., 2015).

2.1. Ethical considerations

This clinical trial study has been approved as a research project by the Vice Chancellor for Research and Technology of Hamadan
University of Medical Sciences under the project number C.16.359.631. The study was conducted in 2015 on 134 infants admitted to
the pediatric ward of Besat Hospital in Hamadan after approval by the ethics committee and registration in the Iranian Registry of
Clinical Trials (IRCT2014121610933N4). All procedures involving human participants were in accordance with the ethical standards
of the institutional and national research committee and with the 1964 Helsinki declaration and its later amendments.

2.2. Statistical methods

The Kolmogorov-Smirnov test was applied to determine the normal distribution of variables (Hosseini, Moniri, Goli, & Kashani,
2016; Kashani & Moniri, 2015; Kashani, Nikzad, Mobaseri, & Hoseini, 2012; Nikzad, Kashani, Kabir-Salmani, Akimoto, & Iwashita,
2013). Analyses were carried out based on the intent-to-treat population and performed using the analysis of variance (ANOVA)
method (Dehghani, Sharif, Moniri, Sharif, & Kashani, 2016; Kashani et al., 2013). We applied one-way, but two-tailed Student’s t tests
and Chi-square test with independent samples to compare between-group ratios. As the bilirubin levels were nor normally distributed
in the two groups, the Mann-Whitney was used for the comparison of bilirubin levels between them; P < 0.05 was considered
statistically significant (Dehghani, Sharif, Assadi, Kashani, & Sharif, 2016). All statistical analyses were done using the Statistical
Package for the Social Sciences, version 19 (SPSS Inc., Chicago, Illinois, USA) (Dehghani, Sharif, Madani, Kashani, & Sharif, 2016).

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F. Eghbalian et al. Infant Behavior and Development 49 (2017) 31–36

3. Result

In this study, no significant differences in gender distribution, gestational age, type of delivery, birth weight, and Apgar score
were noted in infants with neonatal jaundice between the two groups (massage plus phototherapy; control group) (P > 0.05)
(Table 1).
Bilirubin levels at the beginning of the study were similar between the two groups (P > 0.05). Significant differences surfaced in
the first two days post-intervention (P < 0.05) (Table 2 and Fig. 1) (Graph 1).
Significant differences existed in the frequency of daily bowel movements daily between the two groups (Table 3) (P < 0.05).
No significant relationship existed between the frequency of daily bowel movements and serum bilirubin levels during the first
and second day in massage group (P > 0.05). A significant statistical relationship existed between frequency of daily bowel
movements and serum bilirubin level during the third and fourth days in massage group (P < 0.05); this relationship was not
statistically significant on any of the four days in the control group (Table 4) (P > 0.05).

Table 1
Comparison of gender, gestational age, type of delivery, birth weight, and Apgar scores of infants with neonatal jaundice in two groups.

Variable Group P-value

Massage Control

Gender 0.167
Boy 37 (55.2%) 29 (43.3%)
Girl 30 (44.8%) 38 (56.7%)

Gestational Age 0.236

Mean (SD) 38.61 (1.27) 38.89 (1.6)

Delivery 0.603
Natural 34 (50.7%) 38 (56.7%)
Caesarean 33 (49.3%) 29 (43.3%)

Birth Weight 0.06

Mean (SD) 3.04 (0.19) 3.07 (0.19)

Apgar score 0.282

8 39 (58.2%) 46 (68.7%)
9 28 (41.8%) 21 (31.3%)

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F. Eghbalian et al. Infant Behavior and Development 49 (2017) 31–36

Table 2
Descriptive characteristics of total bilirubin in infants with neonatal jaundice for days 1 through 4 in the massage/phototherapy and control groups.

Time Group P-value

Massage Control

Mean SD Mean SD

First Day (n1 = 67, n2 = 67) 18.44 1.9 18.33 1.84 0.742
Second Day (n1 = 67, n2 = 67) 13.52 2 14.93 1.64 < 0.001
Third Day (n1 = 55, n2 = 61) 9.66 1.78 11.62 1.98 < 0.001
Fourth Day (n1 = 8a, n2 = 21) 6.94 0.59 9.36 1.41 < 0.001

a
The reason for early discharge in infants in the massage group was the early improvement in the signs of jaundice.

Massage
20 Control

15
Mean+-SD

10

0
1 2 3 4

Day
Fig. 1. Mean total bilirubin in infants with neonatal jaundice for days 1 through 4 of hospitalization in the massage group and the control group.

Table 3
Comparison of the frequency of daily bowel movements in infants with neonatal jaundice between the two groups.

Variable Group P-value

Massage Control

Mean SD Mean SD

Frequency of defecation daily 5.41 1.46 3.62 1.08 < 0.001

Table 4
The relationship between frequency of daily bowel movements and serum bilirubin levels in infants with neonatal jaundice in the massage/
phototherapy and control groups.

Time Group Frequency of defecation each day

Correlation P-value

First Day Massage 0.098 0.432

Control 0.078 0.53
Second Day Massage 0.135 0.267
Control −0.608 0.58
Third Day Massage −0.329 0.58
Control −0.207 0.1
Fourth Day Massage −0.309 0.021
Control 0.035 0.78

4. Discussion

Notably, no significant differences existed among the background variables of gender, gestational age, mode of delivery, birth
weight, and Apgar score of newborns with neonatal jaundice in the massage therapy and the control groups. Hence, the randomi-
zation process has been done appropriately, and these confounding factors cannot be considered to influence the differences between
the treatment results of the two groups.

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F. Eghbalian et al. Infant Behavior and Development 49 (2017) 31–36

Based on the results of this study, the program of massage plus phototherapy, conducted for 4 days, had a significant impact on
the reduction of total bilirubin in newborns with neonatal jaundice. In a study correlated with our study, was found that the bilirubin
level in the massage plus phototherapy group was less than that in the control group (Dalili, Sheikhi, Shariat, & Haghnazarian, 2016).
Similarly, in another study bilirubin reduction within 4 days of treatment in the massage group was greater than in the control group
(Basiri-Moghadam, Basiri-Moghadam, Kianmehr, & Jani, 2015). In a different study performed in 60 infants with jaundice, it was
revealed (similar to our study) that bilirubin levels in the massage therapy and control groups were the same during the first and
second days, but on the third day were significantly lowered in the massage therapy group compared to the control group (Lin, Yang,
Cheng, & Yen, 2015). In another study by Chen et al. (2011) in 69 infants with jaundice, the level of total serum bilirubin on the
fourth day in the massage therapy group was also significantly lower than in the control group (Chen et al., 2011), a finding (that is,
lower serum bilirubin with massage) that is also supported by other studies (Moghadam, Moghadam, Kianmehr,
Jomezadeh, & Davoudi, 2012).
The results of our study are consistent with the aforementioned studies in the field; however, other studies have arrived at
different conclusions. In a study with results incompatible with the results of the present study, it was found that the levels of
bilirubin within four days of treatment were the same in the massage therapy group and the control group (Seyyedrasooli et al.,
2014). Likewise, a different study reported no significant difference between the control group and the massage plus phototherapy
group in terms of the amount of bilirubin (Karbandi et al., 2016 Karbandi, Boskabadi, Esmaeily, & Kalateh, 2016). The lack of
compatibility between these studies with our research could be due to differences in sample size, massage therapy methods, and
different incidences of jaundice.
Several studies have reported on the mean daily bowel movements in infants receiving massage plus phototherapy, specifically
asserting that the incidence was higher in this group versus control groups. In a study similar to ours, Dalili et al., (2016) observed
more frequent defecation in the massage therapy group versus a control group on the first day of treatment (Dalili et al., 2016).
Another study found that the frequency of bowel movements during the 4 days of treatment was higher in the massage group than in
the control group (Basiri-Moghadam et al., 2015). Furthermore, Lin et al. (2015) realized that frequency of bowel movements on the
first and second days in their massage therapy and control groups were the same, but that on the third day that frequency of bowel
movements was higher (and serum bilirubin levels) significantly lower in the massage plus phototherapy group than in the control
group (Lin et al., 2015). Other researchers have found that the frequency of bowel movements within four days of treatment was
greater in the massage therapy group than in the control group (Seyyedrasooli et al., 2014). Similarly, others have shown a significant
between the frequency of defecation on the first and second days in the massage therapy group and the control group (Chen et al.,
2011). However, in another study no significant difference was observed between the frequency of daily bowel movements in the
message therapy and the control groups within the first 4 days. Such an incompatibility can be attributed to the difference in the kind
of massage therapy used by each study (Seyyedrasooli et al., 2014).
In this study, no significant difference was seen in the massage plus phototherapy group regarding the frequency of daily bowel
movements and serum bilirubin level on the first and second days; this difference only appeared on the third and fourth days. No
significant relationship emerged at any point in time in the control group. Serum bilirubin levels can therefore be reduced through
increasing the number of daily bowel movements using a program of massage plus phototherapy. Lin et al. (2015) have suggested
that massage therapy can lead to early reduction in bilirubin levels, which may shorten treatment with phototherapy and thus lead to
earlier discharge (Lin et al., 2015). Moreover, Chen et al. (2011) have indicated a mechanism of jaundice reduction in massage
therapy group that is primarily related to the stimulation of bowel movements, as increasing defecation enables infants to discharge a
greater amount of meconium (which contains bilirubin). Others have reported fecal production and bilirubin levels in healthy infants
are negatively correlated during the first week of life (Gourley, Kreamer, & Arend, 1992). In addition, massage therapy may stimulate
the vagus nerve through peripheral nerve stimulation, which in turn increases the frequency of bowel movements and reduces
enterohepatic circulation of bilirubin, resulting in excretion of bilirubin (Chen et al., 2011). In the subcutaneous tissue, physiological
massage therapy can enhance blood flow, lymph nodes, and interstitial fluids (tissue fluids), increasing the collection and disposal of
waste products such as bilirubin (Seyyedrasooli et al., 2014). More frequent defecation can also occur due to increased gastric
motility after massage (Diego et al., 2005).
Several limitations exist in this study. First, this study was conducted over 4 days; it is recommended that such a study be
continued for a longer period of time to investigate the long-term effect of massage and phototherapy on serum bilirubin levels.
Second, the sample size in this study was relatively small (N = 134); the lack of significance regarding differences in the variables of
interest in this study could be due to the low sample size. We suggest that future studies be designed with larger sample sizes. Third,
since the method of massage therapy plus phototherapy is an influential factor on neonatal bilirubin levels, and because this study has
not dealt with the role of the type of a given massage therapy in neonatal bilirubin level, we propose that further research be
conducted with respect to the impact of different massage methods.

5. Conclusion

Massage therapy combined with phototherapy is an effective method for reducing serum total bilirubin within 4 days in infants
with neonatal jaundice. The frequency of daily bowel movements increased through the application of this program, likely leading to
the consequent reduction of serum bilirubin levels.

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F. Eghbalian et al. Infant Behavior and Development 49 (2017) 31–36

Conflict of interest

The authors declared that they have no competing interests.

Ethical responsibilities of authors

This paper is our original unpublished work and it has not been submitted to any other journal for reviews.

Acknowledgment

The authors would like to acknowledge the Research Deputy of Hamadan University of Medical Sciences for financial support of
this study.

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