PRELIMINARY

Neonates younger than 10 days has a phase of bilirubin or Hyperbilirubinemia

increased levels. The maturity of organ system function is a requirement to be able to adapt
outside the womb. This is due to the liver maturity factor so the conjugation bilirubin indirec
into direct bilirubin comes rudimentary (Surasmi et al, 2003). If the bilirubin level isnt
controlled, it can cause the dysfunction of the central nervous system and chance of death
(Steffensrud, 2004).
Several references have been proven scientifically about touch therapy in infants
which has many benefits in physiological changes. Kind of touch stimulation which is known
in society is a massage (Widyastuti & Widyani, 2009).
Based on observations that have been conducted by researchers dr. Moewardi
Hospital

in Surakarta, neonates whose indicated of hyperbilirubinemia pathological got

Hospital stimulation or massage that aims to reduce levels of bilirubin to normal numbers.
Based on the backround above and effects of massage stimulation in reducing
bilirubin levels, the researcher is interested to take "Effects of Massage Stimulation
Against Neonatal Bilirubin Levels Decline in Hospital Dr. Moewardi Surakarta " as the title
of research.

THEORETICAL BASIC
Caring for a child is an obligation that must be done by every parent in order to make
their children becomes health future generation. Caring for children has been stated in the
Qur'an letter Al-Baqarah paragraph 233 which reads "Allah commanded mothers to
breastfeed their children for whole two years. If wants to wean before 2 years, should be
consulted at first and must have a mutually willing ".
Neonates is a phase where infants aged 0-28 days after birth (WebMD, 2010). In this
phase the baby's organ systems are still in the process of establishment and refinement, so
they still require a special care from parents and medical (Paembonan, 2014).
Indonesia Demographic Health Survey (SKDI) states that neonatal mortality rate in
Indonesia in 2014 reached 32/1000 live births. Still far from the Millennium Development
Goals (MDGs) 4th 2020 targets, namely 24/1000 life birth. The numbers was affected by the
infants conditions with low birth weight by 26%, 9% of jaundice, 0.8% of hypoglycemia and
1.8% of neonatal infections (Ministry of Health Indonesia, 2015).
There is a relationship between hyperbilirubinemia condition in neonates with
physiological changes in the body. This condition can cause a yellow discoloration of the
skin called jaundice babies. Normal levels of serum total bilirubin in newborns is 0.3-1 mg/dl
(Angraini, 2014). Maturity of organ system function is a requirement to be able to adapt to a
a life outside the womb. This is due to the liver maturity factor so that conjugation of
indirect bilirubin into directt isnt perfect (Surasmi et al, 2003). If the bilirubin level is not
controlled, it can cause to dysfunction of the central nervous system and the likelihood of
death (Steffensrud, 2004).
A touch massage is one type of stimulation to stimulate the organ system to work
more optimally. Several references have been proven scientifically about touch therapy in
infants which has many benefits in physiological changes. Kind of touch stimulation which is
known in society is a massage (Widyastuti & Widyani, 2009).
Roesli (2008) explains that massage has a biochemical effect and the positive clinical
impact, so it can stimulate digestion and increase metabolism in the body. Mojtaba Kianmehr,
et al (2014) in his study adds, massage with field methods can reduce the excess bilirubin
levels in naonatus. This was cause because the stimulation can stimulate the metabolism so
that toxins in the body can easily disassemble and removes through fases and urine.

Field massage method is a massage on infants or neonates that focused in giving

stimulation on the chest and abdomen area. Field et al (in Kianmehr, 2014) mentions that
massage can improve the activity of digestion organs and ingestion proccess in neonates so it
can increased metabolism system in the body.
Dose or movement stimulation which used was refers to the research of Kianmehr et
al (2014). He explained that the difference of field massage methode with general
massage method is in the area of stimulation were given. Field massage is stimulating the
face areas, abdomen and chest. It aims to activate the vagus nervus to increase metabolism so
the function of the digestive organs work better.

RESEARCH METHODOLOGY
Type of research is descriptive analytic and used one group pre and post design as
research design.. This study took place at the dr. Moewardi Hospital of Surakarta. Sampling
was done by using total sampling. The research was conducted in November-December,
2015. The number of respondents in this study were 8 babies and are all used as experiment
group.
Independent variables in this study is the massage stimulation, and the dependent
variable is the decrease of bilirubin levels.

RESEARCH RESULT
This research was implemented by one group pre and post design. Respondents
were 8 people who fall into one control group. This study was implemented at dr. Moewardi
Hospital in November-December 2015. Respondents are neonates with total bilirubin levels
exceed 10 mg/dl. The average age of neonates in this study starting from 5 days of birth. The
data were collected in a month, while the treatment of each respondent was given 1-2 days
after hyperbilirubinemia neonates diagnosed by the doctor.
The first data retrieval is to categorize respondents who comply the inclusion and
exclusion criteria. After that the respondents parents fill the informed concent. Researchers
simply categorize the respondents in one group. Within this group, bilirubin levels of
respondents will be measured before giving treatment (pre test). In the end of the study,
bilirubin levels of respondents will be re-measured to determine the changes of bilirubin level
(post test).

Table 1. Distribution of respondents based birthweight

No

variable

.
1.
2.
3.

(Birth weight)
<2500 g
2500 - 4000 gr
> 4000 g

treatment group
Frequency

percentage

5
3
0

62.5%
37.5%
0%

This study found that the previous theory about low birth weight (LBW) can influence
bilirubin levels in neonates correctly prove based on the research that has been conducted by
researchers. There are several factors that can affect of bilirubin levels increasing such as low
birth weight, premature rupture of membranes, breast-fed infants, neonatal infection, drugs
consumption in conception, the use of aids childbirth, and a history of bleeding in the first
trimester of birth (Lubis, 2013). The most age that have a high risk of increase of bilirubin
levels into pathological hyperbilirubinemia in this study occurred at an average age of 5
days.
Massage stimulation on the chest and abdomen area will stimulate the vagus nerv. The
nerve can increase the production of digestive enzymes so it can maximally absorb the
foods. This is what can decrease bilirubin levels towards normal. The more often the
stimulation of massage administered to infants, it will affect a good digestive process, and
increasing metabolism.
Based on the results of research on reducing bilirubin levels in responder after
stimulation it provides massage. Here are the results from the stimulation provided.
a. baby A
A baby is female respondents, Having a history of low birth weight (LBW) is 1750
grams. At the age of six babies a day to get the doctor's diagnosis form Hiperbilirubin with
total bilirubin levels 15.66 mg / dl, the rate is classified in Hiperbilirubinemia pathological
conditions heavy and require basic medical measures to decrease levels of bilirubin in the
form of light or phototherapy terpi. On the same day weight (BW) 1790 or heavier than 40
grams of birth weight (BBL).
The next day after a baby massage stimulation, combined with light therapy or
phototherapy, bilirubin levels down to 9.70 mg / dl or decreased by 5.96 mg / dl, this
figure is an indicator of where the bilirubin levels have returned to normal as a physiologic
respondents. But the weight of respondents over baby name A also decreased by 240
grams, which is initially at age 4 days 1790 grams to 1550 grams in the next day.

b. baby B
Baby B is the female respondents, Having BBL amounted to 2830 grams. At the
age of 4 days Baby B get a doctor's diagnosis form Hiperbilirubin with total bilirubin
levels 16.650 mg / dl, the rate is classified in Hiperbilirubin pathological conditions heavy
and require basic medical measures to decrease levels of bilirubin in the form of light or
phototherapy terpi. On the same day weight (BW) in 2730, down 100 grams of BBL.
The next day after a baby massage and stimulation, combined with light therapy or
phototherapy, bilirubin levels down to 12.83 mg / dl or decreased by 3.67 mg / dl. This
means that the respondent has entered the category Hiperbilirubin pathological conditions
were the previous day. But the weight of respondents in the name of the baby B increased
by 90 grams, initially at age 4 days 1790 grams to 1550 grams in the next day.
c. baby C
Baby C was the respondents were female, history Having a baby with low birth
weight is equal to 2000 grams. At the age of 4 days Baby C get a doctor's diagnosis form
Hiperbilirubin with total bilirubin level that is equal to 16.00 mg / dl, this figure is an
indicator of where Hiperbilirubin pathological condition has occurred in neonates. In these
conditions already require medical measures in the form of phototherapy to prevent
increased levels to the higher numbers, at the same weight (BW) in 2730, down 20 grams
of BBL.
The next day after the baby's getting massage stimulation, combined with light
therapy or phototherapy, bilirubin levels decreased to 12.10 mg / dl or decreased by 3.90
mg / dl. This means that the respondent has entered the category Hiperbilirubin
pathological conditions were the previous day. But the weight of respondents over baby
name C decreased by 130 grams, which is initially at age 4 days 1980 grams to 1850
grams in the next day.

d. baby D
Baby K respondents gender is male, having a normal BBL is equal to 2500 grams.
At the age of 4 days Baby D get a doctor's diagnosis form Hiperbilirubin with total
bilirubin level that is equal to 12.60 mg / dl, this figure is an indicator of where the
pathological condition Hiperbilirubin was already happening in neonates. In these

conditions already require medical measures in the form of phototherapy to prevent

increased levels to the higher numbers, at the same weight (BW) 2730 or have been up 50
grams of BBL.
The next day after a baby massage D stimulation, combined with light therapy or
phototherapy, bilirubin levels down to 7.36 mg / dl or decreased by 5.28 mg / dl, this
figure is an indicator of where the bilirubin levels have returned to normal as a physiologic
respondents. But the weight of respondents over baby name D decreased by 130 grams,
which is initially at age 4 days 1980 grams to 1850 grams in the next day.
e. baby E
Baby E is the respondents were female, with a history of low birth weight (LBW)
is 1900 grams. At the age of 5 days DS babies get a doctor's diagnosis form Hiperbilirubin
with total bilirubin levels 21.80 mg / dl, the rate is categorized in Hiperbilirubin conditions
are severe or critical, if the child is not promptly given medical action as soon as mngkin,
it will lead to death in less than 24 hour. On the same day or at the age of 5 days BB 2880
respondents or 980 grams heavier than the BBL.
The next day after a baby massage E stimulation, combined with light therapy or
phototherapy, bilirubin levels down to 15.51 mg / dl or decreased by 6.29 mg / dl, this
figure is an indicator of where the bilirubin level down or have been classified in
conditions Hiperbilirubin pathological weight. However, respondents' weight on the baby's
name E decreased by 80 grams, initially at age 5 days 2880 grams to 2800 grams in the
next day.
f. baby F
Baby F are the respondents were female, having a normal BBL is equal to 2700
grams. At the age of 5 days babies get the doctor's diagnosis form F Hiperbilirubin with
total bilirubin level that is equal to 12.82 mg / dl, this figure is an indicator of where the
pathological condition Hiperbilirubin was already happening in neonates. In these
conditions already require medical measures in the form of phototherapy to prevent
increased levels to the higher numbers, at the same weight (BW) has climbed 2910 or 210
grams of BBL.
The following day after a baby massage F stimulation, combined with light therapy
or phototherapy, bilirubin levels down to 7.21 mg / dl or decreased by 5.64 mg / dl, this

figure is an indicator of where the bilirubin levels have returned to normal as a physiologic
respondents. But the weight of respondents over baby name F decreased by 110 grams,
which is initially at age 5 days 2910 grams to 2800 grams in the next day.
g. baby G
Baby G are the respondents were female, history Having a baby with low birth
weight is equal to 2020 grams. At the age of 7 days baby G to get the doctor's diagnosis
form Hiperbilirubin with total bilirubin level that is equal to 19.80 mg / dl, this figure is an
indicator of where Hiperbilirubin pathological condition has occurred in neonates. In these
conditions already require medical measures in the form of phototherapy to prevent
increased levels to the higher numbers, at the same weight (BW) in 2020, down 180 grams
of BBL.
The next day after a baby massage G stimulation, combined with light therapy or
phototherapy, bilirubin levels down to 12.05 mg / dl or decreased by 7.75 mg / dl. This
means that the respondent has entered the category Hiperbilirubin pathological conditions
were the previous day. Weight on the baby name G respondents experienced an increase of
30 grams, which is initially at age 7 days 2020 grams to 2050 grams in the next day.
h. baby H
Baby H is the respondents were female, history Having a baby with low birth
weight is equal to 2380 grams. At the age of 4 days Baby H to get the doctor's diagnosis
form Hiperbilirubin with total bilirubin level that is equal to 15.50 mg / dl, this figure is an
indicator of where Hiperbilirubin pathological condition has occurred in neonates. In these
conditions already require medical measures in the form of phototherapy to prevent
increased levels to the higher numbers, at the same weight (BW) 2460 or lebib weight of
80 grams of BBL.
The next day after a baby massage H stimulation, combined with light therapy or
phototherapy, bilirubin levels decreased to 10.31 mg / dl or decreased by 5.19 mg / dl. This
means that the respondent has entered the category Hiperbilirubin pathological conditions
were the previous day. But the weight of respondents over baby name H decreased by 130
grams, which is initially at age 4 days 2460 grams to 2330 grams in the next day.
Table 2. Results of the difference in weight and bilirubin levels after given massage
stimulation

No
.
1.
2.
3.
4.
5.
6.
7.
8.

Nam
e
by A
by B
by C
by D
by E
by F
by G
by H

Typ

Age

BB

(day

Sex
P

)
6

P
P
L
L
P
L
P

BB (gram)

(gr)
175

H1

H2

179

155

0
283

0
273

0
200

BL (mg/dl)

Differenc

Differenc

H1

H2

-240

15.6

9.70

-5.96

0
282

+90

6
16.50

2.83

-3.67

0
198

0
185

-130

16.0

12.1

-3.90

0
250

0
255

0
256

+10

0
12.6

0
7.36

-5.24

0
190

0
288

0
280

-80

0
21.8

15.5

-6.29

0
270

0
291

0
280

-110

0
12.8

1
7.21

-5.64

0
220

0
202

0
205

+30

5
19.8

12.0

-7.75

0
238

0
246

0
233

-130

0
15,5

5
10.3

-5.19

4.9

0
228

0
241

0
234

-70

0
16.3

1
10.8

-5.48

The decreased levels of bilirubin for all respondents was 5.48 mg/dl. Children with
bilirubin levels of 10-15 mg/dl or pathological Hyperbilirubinemia category currently have a
decrease in bilirubin level of 5.13 mg/dl, the rate is greater than children who have bilirubin
levels of 15-20 mg/dl or severe pathological conditions, as 5.13 mg/dl.

Graph 1. Decreasing Levels of Bilirubin After Giving Massage Stimulation

>20 mg/dl

15,01-20,00 mg/dl
Kadar Bilirubin

10,01-15,00
mg/dl
post test

pre test

<10 mg/dl
0

Jumlah Responden

From the research that has been implemented on whole respondents with
Hyperbilirubinemia in dr. Moewardi Hospital in November-December 2015, shows that the
highest levels of bilirubin in the respondents amounted to 21.80 mg/dl,

and the lowest

bilirubin level was 12.60 mg/dl. Besides that, lowest bilirubin level after treatment was 7.75
mg/dl and lowest bilirubin level was of 3.67 mg/dl.

CONCLUSIONS AND RECOMMENDATIONS

Conclusion
Based on the descriptive results and analysis it can be concluded that there is an effect
of massage stimulation to decrease bilirubin levels in neonates with hyperbilirubinemia
condition.

Suggestion

1.

For neonatess Parents

That parents do the massage stimulation every day at home after bathing or before going
to bed in order to increase metabolism in children and increase a stong relationship
between parents and children.

2.

For physiotherapists and health agencies

Physiotherapist has its own record for the the massage stimulation for neonates with
hyperbilirubinemia.

3.

For Educational Institutions

This study can be an evidence based theory to stimulate the growth and development of
infants and pediatric physiotherapy scientific development.

4.

For Further Research

In the next researcher can make this study as a reference source and may develop it
better by adding a longer research,, larger number of samples, and more data captured.

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