PRESENTASI JURNAL

STASE KEPERAWATAN ANAK

PROGRAM STUDI PROFESI NERS
UNIVERSITAS MUHAMMADIYAH JEMBER

Oleh:

Dani Masita S Mei Dwi F Ibnu Rosyidi Yanita Dewi A Umul F

2001032015 2001032005 2001032013 2001032009 2001032014

PROGRAM STUDI PROFESI NERS

FAKULTAS ILMU KESEHATAN
UNIVERSITAS MUHAMMADIYAH JEMBER
Juni, 2021
 LEMBAR PERSETUJUAN

Presentasi Jurnal tentang “Effects of Massage Therapy on Indirect Hyperbilirubinemia in

Newborns Who Receive Phototherapy” telah dilaksanakan pada tanggal 13 Juni 2021.

Dilaksanakan oleh kelompok 14:

Mei Dwi Femila, S.Kep
Yanita Dewi Ayu W., S.Kep
Ibnu Rosyidi, S.Kep
Umul Farifatin, S.Kep
Dani Masita Sari, S.Kep
: NIM. 2001032005
: NIM. 2001032009
: NIM. 2001032013
: NIM. 2001032014
: NIM. 2001032015

Jember, 14 Juni 2021

Mengetahui,
Pembimbing Akademik PJMK Departemen Anak

(Dr. Nikmatul Rohmah, S.Kep., Ners., M.Kes) (Ns. Zuhrotul Eka Yulis, S.Kep., M.Kes)
NIP: 19720626 200501 2001 NPK. 1985071711503619
A. ANALISIS SITUASI
Masalah neonatus yang sering terjadi di ruang perinatologi adalah
tingginya angka kejadian bayi dengan peningkatan kadar bilirubin atau
hiperbilirubinemia yang dikenal di ruang perinatologi degan istilah ikterik
neonatus. Ikterus neonatorum adalah keadaan klinis pada bayi yang ditandai
oleh pewarnaan kuning pada kulit dan sklera akibat akumulasi bilirubin
indirek yang berlebih. Hiperbilirubinemia adalah terjadinya peningkatan
kadar plasma bilirubin 2 standar deviasi atau lebih dari kadar yang
diharapkan berdasarkan umur bayi atau lebih dari persentil 90. Bayi dengan
hiperbilirubinemia harus segera dilakukan perawatan karena kadar bilirubin
indirek yang sangat tinggi dapat menembus sawar otak dan sel-sel otak, hal
ini dapat menyebabkan terjadinya disfungsi saraf bahkan kematian.
Penatalaksanaan yang sering dilakukan pada bayi dengan hiperbilirubinemia
di ruang perinatologi adalah dengan pemberian fototerapi dengan tujuan
menurunkan kadar bilirubin bayi. Selain itu pemberian ASI juga dapat
menurunkan kadar bilirubin bayi. Namun tidak jarang terjadi ibu dari bayi
tidak dapat memberikan ASI dengan berbagai faktor. Kejadian
hiperbilirubinemia tidak hanya terjadi pada bayi dengan usia kehamilan
belum cukup bulan (bayi prematur), bayi dengan berat badan lahir rendah
bahkan hiperbilirubinemia dapat terjadi pada kasus bayi dengan berat badan
lahir cukup bahkan lebih. Hampir setiap hari terdapat bayi dengan kasus
hiperbilirubinemia di ruang perinatologi.

B. PERTANYAAN MASALAH
Pertanyaan masalah dalam telaah jurnal penelitian ini antara lain:
1. Apakah terapi pijat dapat menurunkan kadar bilirubin pada bayi baru lahir
dengan hiperbilirubinemia?
2. Apakah terapi pijat dapat menurunkan kadar bilirubin pada bayi baru lahir
dengan hiperbilirubinemia melalui peningkatan frekuensi buang air kecil
dan besar?
3. Bagaimana terapi pijat secara tepat dapat menurunkan hiperbilirubinemia?
C. PICO
1. POPULASI (P) : Icterus neonatorum, hyperbilirubinemia,
neonatal newborns
2. INTERVENTION (I) : Massage, phototerapy
3. COMPARISON (C) : Breastfeeding
4. OUTCOME (O) : Total Serum Bilirubin indirect, defecation
and urinary frequency
Populasi yang digunakan adalah neonatal newborns dengan
hyperbilirubinemia atau icterus neonatorum. Intervensi yang dipilih adalah
massage pada bayi serta phototerapy. Ada intervensi pembanding yang
digunakan pada kelompok kontrol, yaitu diberikan intervensi breastfeeding.
Outcome yang di ukur adalah total serum bilirubin (TSB) indirect, frekuensi
buang air besar, dan buang air kecil pada bayi setelah dilakukan massage.
Strategi pencarian studi yang relevan dengan topik dilakukan dengan
dengan menggunakan google. Keyword yang digunakan antara lain
“Neonatal newborns icterus neonatorum massage hyperbilirubinemia
breastfeeding total serum bilirubin indirect defecation and urinary
frequency”. Pencarian dengan kata kunci tersebut memunculkan kurang
lebih 27.900 jurnal.
icterus neonatorum massage hyperbilirubinemia
breastfeeding total serum bilirubin

578.000 jurnal

icterus neonatorum massage hyperbilirubinemia

breastfeeding total serum bilirubin defecation and urinary
frequency

430.000 jurnal
icterus neonatorum massage hyperbilirubinemia
breastfeeding phototerapy total serum bilirubin indirect
defecation and urinary frequency

299.000 jurnal

neonatal newborns icterus neonatorum massage

hyperbilirubinemia breastfeeding phototerapy total serum
bilirubin indirect defecation and urinary frequency

27.900 jurnal
D. ATRIBUT
Hasil
Penulis Tahun Judul jurnal Keywords Perlakuan Kontrol Sampel Metode Random Yang diukur
Temuan
Gulçin Tahun Effects of Massage defecation 25 bayi 25 bayi Bayi usia Randomize ya Kadar Kelompok
Korkm 2019 Therapy on Indirect massage menerima menerima (usia d bilirubin intervensi
az dan Hyperbilirubinemia in photothera terapi asuhan kehamilan controlled total memiliki
Figen Newborns Who py pijat di keperawat antara 37 trial kadar
Işsayak Receive Phototherapy total samping an rutin dan 42 bilirubin
Esenay serum asuhan yang minggu total yang
JOGNN, 49, 91–100; bilirubin keperawat diberikan selesai), jauh lebih
2020. urination an rutin untuk bayi berat lahir rendah (9,02
https://doi.org/10.1016/j frequency dan baru lahir antara mg/dl)
.jogn.2019.11.004 fototerapi yang 2.500 dan dibandingkan
dirawat 4.000 g, dengan
dengan skor kelompok
fototerapi. Apgar kontrol (
antara 7 11,04 mg/dl,
dan 10 p < .001).
pada 1
dan 5
menit
setelah
lahir
E. RESUME JURNAL
Bayi baru lahir terjadi hiperbilirubinemia tidak langsung atau tidak
terkonjugasi pada sel darah merah dan meningkat pada situasi seperti
prematuritas, malnutrisi, dan defisiensi glukosa fosfat yang menurunkan
metabolisme dan ekskresi bilirubin indirek. Secara global, hiperbilirubinemia
terjadi pada 80% bayi prematur dan 60% bayi cukup bulan selama minggu
pertama kehidupan. Bilirubin tidak langsung atau tidak terkonjugasi
terakumulasi dalam jaringan epitel tubuh, dan ikterus dapat terlihat pada kulit,
kuku, dan jaringan mukosa seperti sklera.
Fototerapi biasanya digunakan untuk mengobati penyakit tidak
langsung hiperbilirubinemia. Meskipun fototerapi adalah standar perawatan,
itu bukan tanpa risiko dan memiliki potensi efek samping untuk bayi baru
lahir, termasuk hipertermia, dehidrasi, diare, sindrom bayi perunggu, dan luka
bakar kulit Oleh karena itu, penggunaan fototerapi harus diminimalkan
selama perawatan bayi baru lahir. Salah satu metode yang murah dan ternyata
bebas efek samping adalah pijat.
Terapi pijat merangsang bayi baru lahir dan meningkatkan kesiapan
untuk menyusu dan frekuensi buang air besar meningkat seiring dengan
meningkatnya frekuensi menyusui. Akibatnya, siklus enterohepatik dari
resirkulasi bilirubin menurun, seperti halnya kadar TSB. Peneliti lain
menemukan bahwa pijat meningkatkan keberhasilan dan frekuensi menyusui.
Dalam pengalaman klinis kami, periode fototerapi biasanya 24 hingga
48 jam, dan terapi pijat bukan merupakan komponen perawatan klinis di
Turki. Oleh karena itu, tujuan dari penelitian kami adalah untuk mengevaluasi
efek terapi pijat pada tingkat TSB dan frekuensi buang air besar, buang air
kecil, dan makan di antara bayi baru lahir yang menerima fototerapi untuk
hiperbilirubinemia tidak langsung.
 F. TELAAH JURNAL (CRITICAL APPRAISAL)
CRITICAL POINT CRITICAL
YA TIDAK HASIL KRITISI JURNAL
APPRAISAL APPRAISAL
Pada jurnal ini, peneliti sudah mencantumkan abstrak di halaman
Apakah penelitian mencantumkan pertama. Di dalam abstrak ini sudah tercantum tujuan, desain

abstrak di dalam jurnal? penelitian, lokasi penelitian, populasi, metode penlitian, hasil hingga
kesimpulan.
ABSTRAK
Pada jurnal ini, peneliti sudah menyebutkan tujuan penelitiannya ,
sehingga pembaca mengerti tentang pentingnya penelitian ini
Apakah tujuan penelitian dilaksanakan. Tujuan dalam penelitian ini adalah untuk

disebutkan? mengevaluasi efek terapi pijat pada kadar bilirubin serum total
(TSB) dan frekuensi buang air besar, buang air kecil, dan makan
pada bayi baru lahir yang menerima fototerapi untuk
hiperbilirubinemia tidak langsung.

Judul pada penelitian ini sudah memenuhi kaidah penulisan judul

Apakah judul memenuhi kaidah 
yaitu terdiri dari 12 kata. Dimana jumlah kata maksimun dalam
penulisan judul?
judul adalah 20 kata.
JUDUL
Penulisan judul pada jurnal ini tidak mengunakan tanda baca
Apakah penulisan judul
tanda tanya (?), tanda baca perintah (!), atau tanda hubung (-)
menggunakan tanda baca (?) (!)
 karena judul pada jurnal ini merupakan sebuah pernyataan dan
atau tanda hubung (-)
tidak ada kata yang diulang.

Pada jurnal ini nama penulis dicantumkan tepat di bawah judul

Apakah nama penulis penelitian. Sehingga jurnal ini dapat dipertanggungjawabkan dan
dicantumkan?  merupakan hak paten bahwa Gulcin Korkmaz dan Figen Isik Esenay
merupakan peneliti dari jurnal ini.

PENULIS Pada jurnal ini telah mencantumkan asal institusi penulis yang
terletak tepat disamping abstrak dan masih dapat terlihat oleh
pembaca. Asal institusi penulis yaitu Fakultas Keperawatan
Apakah asal institusi penulis
Universitas Aktas Mahallesi Plevne, Caddesi No.5, PK 06080
dicantumkan? 
Altsaya ndag, Ankara Turki.
 CRITICAL POINT CRITICAL
YA TIDAK HASIL KRITISI JURNAL
APPRAISAL APPRAISAL
Asal institusi penulis dalam jurnal ini yaitu berasal dari fakultas
Apakah asal institusi penulis
keperawatan dan hal ini sesuai dengan topik penelitian yang disusun
sesuai dengan topik penelitian? 
merupakan di bidang keperawatan.

Bidang ilmu penelitian dalam jurnal ini sesuai dengan judul

Apakah bidang ilmu penelitian
penelitian yaitu di bidang kesehatan khususnya keperawatan
BIDANG ILMU sesuai dengan judul penelitian? 
sehingga dalam penelitian ini tidak terjadi banyak bias.

Peneliti telah mencantumkan literatur review dalam jurnal penelitian

Apakah peneliti mencantumkan ini. Peneliti menggunakan literature review dari berbagai sumber
LITERATUR literatur review dalam yang menunjukkan bahwa penelitian ini sangat perlu untuk diulas

REVIEW penelitiannya? dan literature review yang dicantumkan dapat memperkuat hasil
penelitian.

Apakah peneliti menampilkan Dalam jurnal ini peneliti sudah menampilkan kerangka konsep
KERANGKA kerangka konsep dalam  dalam penelitiannya yang dipaparkan secara narasi dan alur
KONSEP penelitiannya? kepesertaan penelitian. Dengan adanya kerangka konsep ini,
pembaca dapat lebih mudah memahami isi dari jurnal.

Dalam jurnal penelitian ini peneliti telah mencantumkan definisi

Apakah peneliti mencantumkan
operasional, dimana definisi operasional ini penting untuk
DEFINISI definisi operasional pada menjelaskan apa dan bagaimana penelitian ini akan dilakukan,
OPERASIONAL penelitiannya? dengan indikator yang seperti apa dan hasil penelitian akan dianalisis
 dengan metode yang bagaimana. Dalam jurnal penelitian ini, peneliti
menjelaskan alat pengukuran, indikator pengukuran dan proses
pengukuran yang digunakan dalam penelitian, serta bagaimana
outcome penelitian itu akan dianalisis.

Penelitian dalam jurnal ini dilakukan dengan melakukan uji klinis

Apakah desain penelitian sesuai
dengan model penelitian?
METODE
PENELITIAN Apakah sesuai level of evidence
(fakta) dari desain penelitian?
secara acak dimana terdapat kelompok intervensi dan kelompok
kontrol. Penentuan sample dalam penelitian ini ditentukan sesuai
dengan kriteria inklusi yang telah ditetapkan oleh peneliti.

Level of evidence pada jurnal penelitian ini berada pada derajat
 “Ib”, yaitu
 evidence yang berasal dari minimal satu uji klinik acak dengan
kontrol/kelola (randomized controlled trial).

CRITICAL POINT CRITICAL

YA TIDAK HASIL KRITISI JURNAL
APPRAISAL APPRAISAL
Dalam penelitian ini, peneliti sudah menerapkan langkah evidence
based medicine. Langkah evidence based medicine adalah:
1. Memformulasikan pertanyaan ilmiah yang berkaitan dengan
masalah penyakit yang diderita oleh pasien.
2. Penelusuran informasi ilmiah (evidence) yang berkaitan
dengan masalah yang dihadapi.
3. Penelaahan terhadap bukti-bukti ilmiah yang ada.
4. Menerapkan hasil penelaahan bukti-bukti ilmiah ke dalam
praktek pengambilan keputusan.
5. Melakukan evaluasi terhadap efikasi dan efektivitas intervensi.
Dalam jurnal penelitian ini sudah dijelaskan terkait pertanyaan
masalah tentang efek terapi pijat pada tingkat TSB dan frekuensi
buang air besar, buang air kecil, dan makan diantara bayi baru lahir
yang menerima fototerapi untuk hiperbilirubinemia tidak langsung.
Peneliti juga telah menerapkan hasil literatur review ke dalam
pembahasan hasil penelitian hingga melakukan evaluasi terhadap
efektivitas intervensi.

Pemilihan sampel dalam penelitian ini sudah sesuai dengan diagram

Apakah sesuai pemilihan sampel alur penentuan sampel yang dicantumkan peneliti dalam jurnal
dalam penelitian tersebut?  penelitian ini dan sudah sesuai dengan kriteria inklusi yang
dietapkan oleh peneliti .

Analisa data yang digunakan pada penelitian ini sudah sesuai

Apakah peneliti menggunakan dengan rancangan penelitian yang digunakan dimana hasil
ANALISA analisa data yang tepat atau pengumpulan data digunakan untuk menguji adanya perbedaan

DATA tidak? efek terapi pijat pada kelompok intervensi dan kelompok kontrol.
 CRITICAL POINT CRITICAL
YA TIDAK HASIL KRITISI JURNAL
APPRAISAL APPRAISAL
 Peneliti mencantumkan jenis uji statistik yang digunakan dalam
penelitian yaitu menggunakan SPSS (Versi 20) untuk menganalisis
Apakah peneliti mencantumkan data. Tes Chi-kuadrat digunakan untuk membandingkan karakteristik
jenis uji statistik yang digunakan? demografi bayi baru lahir pada kelompok kontrol dan intervensi.
ANCOVA digunakan untuk menentukan perbedaan berdasarkan
kelompok untuk kadar bilirubin. Mann– Whitney tes digunakan
untuk jumlah makan dan frekuensi buang air besar, karena jumlah
makan dan frekuensi buang air besar tidak normal.

Dalam bentuk apa hasil penelitian

Hasil penelitian dalam jurnal ini disajikan dapat bentuk tabel dan
disajikan? 
urain

Hasil penelitian pada jurnal ini dapat diimplementasikan dalam

Apakah hasil penelitian dapat
diimplementasikan di
HASIL keperawatan?
PENELITIAN
Apakah ada rekomendasi khusus
terkait hasil penelitian?
Apakah daftar pustaka yang
digunakan up to date?
DAFTAR
PUSTAKA
Apakah daftar pustaka yang
digunakan sesuai?
keperawatan karena intervensi dan outcome yang dilakukan dalam
penelitian ini sesuai dengan bidang ilmu keperawatan.

Dalam jurnal penelitian ada rekomendasi khusus terkait hasil
penelitian yaitu terapi pijat dapat dijadikan sebagai intervensi
tambahan yang efektif untuk menurunkan kadar TSB untuk bayi
baru lahir dengan hiperbilirubinemia dengan fototerapi.

Pada jurnal ini terdapat 28 daftar pustaka. Dari 28 daftar pustaka
tersebut, 23 up to date (dengan kurun waktu jurnal 5 tahun dan buku
 10 tahun dari tahun penelitian) dan 5 out of date (dengan kurun
waktu jurnal lebih dari 5 tahun dan buku lebih dari 10 tahun dari
tahun penelitian).
Daftar pustaka dalam jurnal ini sudah sesuai dengan topik penelitian

dan isi dari penelitian yaitu tentang terapi pijat pada bayi,
hiperbilirubinemia dan sistem pencernaan neonatus
 CRITICAL POINT CRITICAL
YA TIDAK HASIL KRITISI JURNAL
APPRAISAL APPRAISAL
Apakah daftar pustaka yang Daftar pustaka yang digunakan sudah terpercaya, yaitu
digunakan dari sumber yang menggunakan jurnal serta buku yang sesuai dengan bidang ilmu

terpercaya? penelitian serta daftar pustaka yang tercantum dapat menunjukkan
dengan jelas penulis, judul, kota hingga di halaman berapa peneliti
mengutip jurnal atau buku yang digunakan.

Dalam jurnal ini telah mencantumkan kesimpulan hasil penelitian

dan kalimat yang dijelaskan dalam kesimpulan telah menjelaskan
KESIMPULAN hasil dari tujuan penelitian.

Jurnal ini tidak mencantumkan saran. Alangkah baiknya jika dalam
jurnal ini mencantumkan saran karena saran sangat penting baik
bagi instansi yang digunakan sebagai tempat penelitian, tenaga
profesional yang diharapkan dapat menerapkan hasil penelitian

maupun bagi peneliti selanjutnya, mengingat dalam penelitian ini
SARAN
masih banyak keterbatasan-keterbatasan yang perlu diperbaiki saat
dilakukan penelitian selanjutnya.
G. PROSEDUR INTERVENSI
Terapi pijat bayi baru lahir berdurasi selama 15 menit dua kali sehari
(pijat dilakukan dua kali pada 30 menit setelah makan di pagi dan sore selama
5 hari. Perangkat fototerapi dimatikan selama terapi pijat, dan pemanas
berseri digunakan untuk mencegah kehilangan panas pada bayi baru lahir.
Pemanas dinyalakan selama 5 menit sebelum pemijatan untuk
menghangatkan lingkungan, dan perangkat tetap menyala selama pemijatan.
Suhu ruangan dipertahankan antara 26 dan 28 C.
Prosedur pemijatan yang digunakan sudah sesuai dengan pedoman
International Association Of Infant Massage (2013) yaitu :
1. Mencuci tangan secara menyeluruh
2. Mengoleskan baby oil antialergi yang biasa digunakan
3. Melakukan tes kulit sebelum memulai prosedur terapi pijat pertama .
4. Untuk tes kulit, mengoleskan baby oil ke sisi palmar pergelangan tangan
bayi baru lahir .
5. Setelah 30 menit, memeriksa kulit untuk kemerahan, ruam, atau tanda-
tanda reaksi alergi lainnya.
6. Setelah dipastikan tidak ada alergi baby oil dioleskan.
7. Pijat dimulai dengan wajah.
8. Pijat menggunakan dua ibu jari untuk memijat area sekitar mata dan pipi
dengan lembut dan perlahan, kemudian dilanjutkan dari area dada bagian
bawah ke atas. Pemijat kemudian melakukan beberapa gerakan lembut
dan setengah lingkaran pada perut bayi yang baru lahir, diikuti dengan
pemijatan pada tungkai atas dan bawah dengan tekanan sedang. Terakhir,
punggung dipijat dengan dua ibu jari dari atas ke bawah dan dari leher ke
bokong. Bayi yang baru lahir ditempatkan di bawah fototerapi setelah
dipijat.
9. Bayi diberikan pijat selama 15 menit dua kali sehari (pijat dilakukan dua
atau tiga kali tergantung pada durasi fototerapi pada 30 menit setelah
makan di pagi dan sore hari.
10. Perangkat fototerapi dimatikan selama terapi pijat, dan pemanas berseri
digunakan untuk hipotermia.
 11. Pemanas dinyalakan selama 5 menit sebelum pemijatan untuk
menghangatkan lingkungan, dan perangkat tetap menyala selama
pemijatan. Suhu ruangan dipertahankan antara 26 dan 28 C.
12. Fototerapi diberikan dengan lampu dioda pemancar cahaya (Novos,
Bilied Maxi, Turki) pada jarak 30 cm dari bayi baru lahir.
Kadar TSB secara rutin dianalisis dari sampel darah vena bayi baru
lahir setiap 24 jam setelah dimulainya fototerapi; analisis dilakukan di
laboratorium rumah sakit, yang disetujui dan disertifikasi oleh Kementerian
Kesehatan Turki. TSB dianalisis sekali di satu pusat dan dua kali di pusat
lainnya setiap 24 jam. menggunakan kadar bilirubin pada saat rawat inap dan
pulang.

H. KESIMPULAN
Jurnal penelitian ini merupakan jurnal dengan derajat evidence “Ib”
yaitu evidence yang berasal dari minimal satu uji klinik acak dengan
kontrol/kelola (randomized controlled trial). Hal ini ditunjukkan dalam
jurnal yang menjelaskan bahwa rancangan penelitian ini yaitu sebuah uji
klinis terkontrol secara acak dan dalam uji klinis ini tidak ada blinding.
Hasil dari penelitian ini menyimpulkan bahwa penggunaan pijat untuk
bayi baru lahir yang dirawat dengan fototerapi untuk hiperbilirubinemia
tidak langsung dapat meningkatkan frekuensi buang air besar, buang air
kecil, dan makan dan mengurangi kadar TSB.

I. REKOMENDASI
Intervensi terapi pijat dalam jurnal penelitian ini adalah Recommended
atau direkomendasikan, yang artinya terapi pijat ini dapat digunakan sebagai
intervensi tambahan yang efektif untuk menurunkan kadar TSB untuk bayi
baru lahir dengan hiperbilirubinemia dengan fototerapi.
 RESEARCH

Effects of Massage Therapy on Indirect

Hyperbilirubinemia in Newborns Who
Receive Phototherapy
Gülçin Korkmaz and Figen Is¸ık Esenay

Correspondence
Gülçin Korkmaz, Ankara
University, Faculty of
Nursing, Aktas¸ Mahallesi
Plevne, Caddesi No:5, PK
06080 Altındağ, Ankara,
Turkey.
glcnkrkmz07@gmail.com;
glcnkorkmaz@ankara.edu.tr
Keywords
defecation
massage
phototherapy
total serum bilirubin
urination frequency
ABSTRACT
Objective: To evaluate the effects of massage therapy on total serum bilirubin (TSB) levels and frequency of defe-
cation, urination, and feeding in newborns who receive phototherapy for indirect hyperbilirubinemia.
Design: A randomized controlled clinical trial.
Setting: Ankara University Cebeci Research and Training Hospital and 29 May State Hospital in Ankara, Turkey.
Participants: Fifty full-term newborns with indirect hyperbilirubinemia who underwent phototherapy.
Methods: The newborns were randomly allocated to an intervention group (n ¼ 25) or a control group (n ¼ 25).
Newborns in the intervention group received massage therapy throughout the duration of phototherapy for 15 minutes
twice per day; newborns in the control group received routine care during phototherapy. Every 24 hours, TSB levels
were measured, and the frequencies of defecation, urination, and feeding were also calculated for each newborn.
Results: We found no differences in the characteristics of the newborns or in TSB levels between groups at enroll-
ment. After treatment, TSB levels were lower in the intervention group (p < .001). Frequencies of defecation, urination,
and feeding were significantly greater in the intervention group than in the control group.

Conclusion: Massage therapy had significant effects on TSB levels, feeding, breastfeeding, defecation, and urination
in newborns who received phototherapy for indirect hyperbilirubinemia. Massage therapy can be added as routine care
for full-term newborns with hyperbilirubinemia under phototherapy and may be an effective supplementary
intervention.
JOGNN, 49, 91–100; 2020. https://doi.org/10.1016/j.jogn.2019.11.004
Accepted November 2019

Gülçin Korkmaz, MSc, is a
research assistant in
pediatric nursing, Faculty of
Nursing, Ankara University,
Ankara, Turkey.
Figen Is¸ık Esenay, PhD, is
an assistant professor in
pediatric nursing, Faculty of
Nursing, Ankara University,
Ankara, Turkey.
The authors report no con-
flict of interest or relevant
financial relationships.
I ndirect or unconjugated hyperbilirubinemia in
newborns occurs as a result of catabolism of
red blood cells and is increased in situations such
as prematurity, malnutrition, and glucose 6-
phosphate deficiency that lower metabolism
and excretion of indirect bilirubin (Dağoğlu, 2017;
Ergül & Sarıkaya, 2018; Maheshwari & Carlo,
2019). Globally, hyperbilirubinemia occurs in
80% of preterm and 60% of term infants during
the first week of life (Begum & Afroze, 2018;
Dağoğlu, 2017; Ergü l & Sarıkaya, 2018). Indirect
or unconjugated bilirubin accumulates in the
epithelial tissues of the body, and jaundice may
become visible in skin, nail, and mucosal tissue
such as the sclera (Ergü l & Sarıkaya, 2018;
Maheshwari & Carlo, 2019). Newborns produce
more bilirubin than adults because they are born
with significantly more red blood cells with a
shorter half-life and greater turnover (Dağoğlu,
2017; Ergül & Sarıkaya, 2018; Maheshwari &
Carlo, 2019). Neonatal hyperbilirubinemia is
usually harmless; it typically occurs after new-
borns are 24 hours of age, and serum bilirubin
levels decrease in approximately 5 to 7 days
(Ergü l & Sarıkaya, 2018). Direct bilirubin can be
excreted via defecation, and higher levels of
direct bilirubin indicate underlying disorders,
such as hepatic or posthepatic pathologies
(Dağoğlu, 2017; Maheshwari & Carlo, 2019).
In some cases, levels of indirect bilirubin may
increase beyond physiologic levels. If not diag-
nosed in a timely manner and treated adequately,
indirect hyperbilirubinemia may cross the blood–
brain barrier and cause kernicterus (bilirubin en-
cephalopathy), which presents with symptoms of
lethargy, hypoglycemia, decreased feeding, res-
piratory distress, and opisthotonos (Maheshwari

http://jognn.org ª 2020 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses. 91
Published by Elsevier Inc. All rights reserved.
RESEARCH
Phototherapy for newborns with hyperbilirubinemia has
some potential adverse effects, such as hyperthermia,
dehydration, diarrhea, bronze baby syndrome, and
skin burns.
& Carlo, 2019; Woodgate & Jardine, 2015). Pho-
totherapy is commonly used to treat indirect
hyperbilirubinemia. The recommended total
serum bilirubin (TSB) level at which to begin
phototherapy depends on the newborn’s gesta-
tional age, weight, postnatal age, and risk factors
such as Rh and ABO incompatibility (American
Academy of Pediatrics [AAP], 2004).
Although phototherapy is the standard of care, it
is not without risks and has potential adverse ef-
fects for newborns, including hyperthermia,
dehydration, diarrhea, bronze baby syndrome,
and skin burns (Dağoğlu, 2017; Ergü l & Sarıkaya,
2018; Maheshwari & Carlo, 2019; Woodgate &
Jardine, 2015). Therefore, the use of photo-
therapy should be minimized during the treat-
ment and care of newborns.
Different methods can be used to accelerate the
excretion of bilirubin and prevent severe indirect
hyperbilirubinemia, including sponge bath (Ç ınar
& Kü ç ü koğlu, 2018) and skin-to-skin care (Samra,
El Taweel, & Cadwell, 2012). One method that is
inexpensive and apparently free of adverse ef-
fects is massage. Researchers reported on
massage for newborns with indirect hyper-
bilirubinemia who received phototherapy for
different lengths of time, such as for 3 days (Lin,
Yang, Cheng, & Yen, 2015), 4 days (Dalili,
Sheikhi, Shariat, & Haghnazarian, 2016;
Eghbalian, Rafienezhad, & Farmal, 2017; El-
Magd, Dabash, Guindy, Masoed, & Houchi, 2017;
Kianmehr et al., 2014), and 5 days (Moghadam,
Moghadam, Kianmehr, Jomezadeh, & Davoudi,
2012), and at different frequencies, such as two
times per day (Eghbalian et al., 2017; Lin et al.,
2015) and three times per day (Dalili et al.,
2016; El-Magd et al., 2017; Kianmehr et al.,
2014; Moghadam et al., 2012). Findings from
these studies included decreased bilirubin levels
and increased frequency of defecation;
frequency of urination was not evaluated.
Massage therapy stimulates the newborn and
increases readiness to feed (Gürol, 2010), and
the frequency of defecation increases as the
frequency of breastfeeding increases. As a result,
the enterohepatic cycle of bilirubin recirculation
92 JOGNN, 49, 91–100; 2020. https://doi.org/10.1016/j.jogn.2019.11.004
Massage Therapy and Phototherapy for Hyperbilirubinemia
decreases, as do TSB levels (Hassan &
Zakerihamidi, 2018). Researchers hypothesized
that massage accelerated vagal stimulation and
reduced bilirubin levels by increasing food intake
and defecation frequency (Dalili et al., 2016;
Eghbalian et al., 2017; El-Magd et al., 2017;
Kianmehr et al., 2014; Lin et al., 2015; Moghadam
et al., 2012; Novianti, Mediani, & Nurhidayah,
2018). Other researchers found that massage
increased the success and frequency of breast-
feeding. For example, in a study by Gürol (2010),
mean LATCH (L ¼ latch, A ¼ audible swallowing,
T ¼ type of nipple, C ¼ comfort, H ¼ hold)
Assessment Tool scores were higher in newborns
in the massage intervention group than in those in
the control group (mean [M] ¼ 8.80 0.957 vs.
M ¼ 7.78 1.59, p < .001). Xuelan, Qingling, and
Changhong (2005) found that newborns in the
massage intervention group breastfed more
frequently in 24 hours than those in the control
group (M ¼ 8.9 times 1.6 times vs. M ¼ 5.7
times 1.3 times, p < .01). Kianmehr et al. (2014)
found no such relationship.
Phototherapy is generally discontinued based on
the age at which it was initiated and the cause of
the indirect hyperbilirubinemia. The AAP recom-
mended that “for infants who are readmitted after
their birth hospitalization (usually for TSB levels of
18 mg/dL or greater), phototherapy may be dis-
continued when the serum bilirubin level falls
below 13 to 14 mg/dL” (AAP, 2004, p. 315). The
AAP did not provide recommendations about
duration of phototherapy (e.g., 3 days, 5 days,
etc.; AAP, 2004). Likewise, the Turkish Neona-
tology guideline for phototherapy, which is based
on the AAP guidelines, does not include a
recommendation for a specific duration of pho-
totherapy (Ç oban, Tü rkmen, & Gürsoy, 2014). In
our clinical experience, the period of photo-
therapy is usually 24 to 48 hours, and massage
therapy is not a component of clinical care in
Turkey. Therefore, the purpose of our study was to
evaluate the effects of massage therapy on TSB
levels and the frequencies of defecation, urina-
tion, and feeding among newborns who received
phototherapy for indirect hyperbilirubinemia.
Methods
Design
We conducted a randomized controlled trial be-
tween January 15 and July 15, 2018. In this trial
there was no blinding. Simple randomization was
done according to the gestational age in weeks of
the newborns. The trial complied with the
http://jognn.org
Korkmaz, G., and Esenay, F. I.
Ankara University Cebeci Research (n = 75) Training Hospital and
29 May State (n = 65)
Randomization
Intervention group
(n = 27)
Reasons for leaving the group
- Onset of fluid infusion (n = 1)
- Left the hospital before completion
of the treatment (n = 1)
Massage therapy in addition to
phototherapy (n = 25)
Analyzed (n = 25)
Figure 1. Consolidated Standards for Reporting Trials (CONSORT) participant flow diagram.
Consolidated Standards for Reporting Trials
(CONSORT) guidelines (Schulz, Altman, Moher, &
the CONSORT Group, 2010; see Figure 1) and
was approved by the Ethics Committee at the
Faculty of Medicine at Ankara University for the
province of Ankara (institutional review board
number 19-1200-17). The mothers of the new-
borns were informed about the aim, plan, and
duration of the study, and mothers’ written con-
sent was obtained by the first author (G.K.).
Setting and Sample
Our study participants were newborns who were
admitted for treatment of indirect hyper-
bilirubinemia at two centers: Ankara University
Cebeci Research and Training Hospital and 29
May State Hospital in Ankara. The university
hospital had a Level 3 NICU, whereas the public
hospital had a Level 2 NICU. Because of their
JOGNN 2020; Vol. 49, Issue 1
RESEARCH
Excluded (n = 84)
- Newborns did not meet the
inclusion criteria (n = 60)
- Researcher could not contact
mothers (n = 24)
Control group
Allocation (n = 29)
Reasons for leaving the group
- Onset of fluid infusion (n = 2)
- Massage by the mother (n = 2)
Phototherapy (n = 25)
Analyzed (n = 25)
central locations, these hospitals provide ser-
vices to individuals with different sociocultural
characteristics. Both hospitals implemented
standardized phototherapy in accordance with
the recommendations of the AAP (2004).
The inclusion criteria for the newborns included
the following: born at term (gestational age be-
tween 37 and 42 completed weeks), birth weight
between 2,500 and 4,000 g, Apgar scores be-
tween 7 and 10 at 1 and 5 minutes after birth,
receiving phototherapy, indirect hyper-
bilirubinemia diagnosed 24 hours or longer after
birth, and fed breast milk or formula. The
exclusion criteria for newborns were ABO blood
type incompatibility, Rh incompatibility, blood
transfusion therapy, intravenous fluid treatment,
infection, congenital anomaly, asphyxia, biliary
atresia or glucose dehydrogenase-6 phosphate
93
RESEARCH
deficiency, glucuronosyl transferase enzyme
deficiency, and/or bronze baby syndrome.
Fifty-six newborns met the inclusion criteria and
were admitted to the study (intervention group, n ¼
27; control group, n ¼ 29). In total, six newborns
were excluded, including one newborn whose
parents wanted to leave the hospital before
completion of the treatment, three newborns who
received intravenous fluid treatment because of
dehydration, and two newborns in the control
group whose mothers performed massages. The
final sample was 50 newborns (intervention group,
n ¼ 25; control group, n ¼ 25). We used analysis of
covariance (ANCOVA) to compare the pretreat-
ment and posttreatment TSB values by group. With
the partial eta squared value of 0.0320, the calcu-
lated effect size was 0.68, and the power of the test
conducted with 50 newborns with a Type I error
value of 0.05 was 0.99 (99%). Our calculation was
made with the use of the G Power software pro-
gram (Version 3.1.9.2).
Procedures
Pilot study. We conducted a preliminary
implementation of the study protocol at the uni-
versity hospital with two newborns who met the
inclusion criteria to test the operability of the data
collection forms. No change was made in the
data collection forms. Because only two new-
borns could be recruited within a month at the
university hospital, the second hospital was
included as a study site to increase recruitment.
Implementation. Before newborns who quali-
fied for the study were assigned to groups by
simple randomization, the first author (G.K.) met
the mothers of the newborns, explained the pur-
pose and procedures of the study, and obtained
written consent from the mothers who agreed to the
admission of their newborns to the study. The
control group received routine nursing care pro-
vided for newborns being treated with photo-
therapy at both hospitals. The newborns in the
intervention group received massage therapy in
addition to routine nursing care and phototherapy.
Massage procedure. The newborns in the
intervention group were given massages for 15
minutes twice a day (the massage was applied two
or three times depending on the duration of pho-
totherapy [M ¼ 41 hours, range ¼ 24–49 hours]) at
30 minutes after feeding in the morning and the
evening. The phototherapy device was turned off
during the massage therapy, and a radiant heater
94 JOGNN, 49, 91–100; 2020. https://doi.org/10.1016/j.jogn.2019.11.004
Massage Therapy and Phototherapy for Hyperbilirubinemia
(BNT 2000, Drager, Lü beck, Germany) was used
to prevent heat loss of the newborn. The heater was
turned on for 5 minutes before the massage to
warm the environment, and the device remained
on during the massage. The room temperature was
maintained between 26 and 28 ◦ C.
The massage techniques used were in accor-
dance with the guidelines of the International
Association of Infant Massage (2013). The first
author (G.K.) provided the massage therapy to
all newborns in the study; she thoroughly
washed her hands, applied the antiallergenic
baby oil that was routinely used, and performed
a skin test before starting the first massage
therapy procedure. For the skin test, we applied
baby oil to the palmar side of the newborn’s
wrist and, after 30 minutes, checked the skin for
redness, rash, or other signs of allergic reaction.
None of the newborns had an allergic reaction
or experienced adverse effects from the baby
oil. The massage began with the face, and baby
oil was applied. The massager applied two
thumbs to massage the area around the eyes
and cheeks gently and slowly. This action then
continued from the bottom to the top of the
chest area. The massager then performed some
soft and semicircular movements on the new-
born’s abdomen, followed by massaging of the
upper and lower limbs with moderate pressure.
Finally, the spine was massaged with two
thumbs from the top to the bottom and from the
neck to the buttocks. Newborns were placed
under phototherapy after the massage.
Measures
Tools for data collection. A neonatal char-
acteristics sheet was developed by the first
author (G.K.) and had two parts: Part I, which
recorded personal data of the newborn, including
gestational age at birth, route of birth, sex, birth
weight, Apgar score, type of feeding, photo-
therapy duration, hospitalization duration, and
maternal age; and Part II, which included medical
data and data contributed by the health care
providers, including TSB levels and frequencies
of feeding, defecation, and urination.
Phototherapy device. The same photo-
therapy device was used for the treatment of the
newborns in the intervention and control groups
at both hospitals. Phototherapy was provided
with a light-emitting diode lamp (Novos, Bilied
Maxi, Turkey) at a distance of 30 cm from the
newborns.
http://jognn.org
Korkmaz, G., and Esenay, F. I. RESEARCH

TSB value. The sum of direct and indirect

bilirubin equals TSB (Ganji, Kasagani, Revupalli, Massage therapy for newborns with hyperbilirubinemia
Kavali, & Chidugulla, 2015), and TSB is reduced the total serum bilirubin levels and increased the
measured for indirect hyperbilirubinemia (AAP, frequencies of defecation, urination, and feeding.
2004; Çoban et al., 2014). TSB levels were
routinely analyzed from venous blood samples of
quantity and frequency during a 24-hour period.
the newborns every 24 hours after the beginning
The mothers could feed their newborns for any
of phototherapy; analysis was performed in the
duration and frequency that they desired in both
hospitals’ laboratories, which are approved and
research sites. In situations in which the mothers
certified by the Turkish Ministry of Health. The
could not breastfeed their newborns (at night,
devices used to measure TSB are calibrated
when the newborn could not hold the nipple, or
weekly by laboratory specialists. TSB was
when the mother had to leave the hospital), the
analyzed once in one center and twice in the
newborns were fed by the nurses with breast milk
other every 24 hours. Therefore, we used bilirubin
obtained by pumping or with formula.
levels at time of hospitalization and discharge.

Frequencies of defecation and uri- Analysis

nation. The first author (G.K.) recorded the
defecation and urination frequencies of the new-
borns during the phototherapy period from the
nursing notes and calculated the number of times
the newborn defecated and urinated during a 24-
hour period.
Feeding quantity and frequency. The
feeding frequency and quantity of feeding with
breast milk and formula were documented from
the mothers’ parenting logs and the nursing re-
cords and were calculated as the feeding
We used SPSS (Version 20) to analyze the data.
Chi-square tests and Student t tests were used to
compare the demographic characteristics of
newborns in the control and intervention groups.
ANCOVA was used to determine differences by
group for bilirubin levels. Student t tests were used
to investigate the differences between the control
and intervention groups with regard to frequency
of urination and feeding. Mann–Whitney U tests
were used for feeding amounts and defecation
frequency, because the feeding amounts and fre-
quency of defecation were not normally

Table 1: Characteristics of Newborns (N [ 50)

Intervention Control Group

Variable Item Group (n ¼ 25) (n ¼ 25) Test Statistic p
Sex, n (%) Female 18 (72) 13 (52) c2 ¼ 2.12 .14

Male 7 (28) 12 (48)

Age Gestational age at birth, 38 (37–40) 38 (37–40) U ¼ 312.50 1.000

weeks, median (range)

Maternal age, years, M SD 27.48 6.71 28.12 6.13 t ¼ –0.352 .726

Weight, g Birth weight 3,289 369.94 3,141.60 349.18 t ¼ 1.45 .154

Apgar score, 1 minute 9 (7–10) 9 (7–10) U ¼ 295.000 .722

median (range) 5 minutes 10 (9–10) 10 (7–10) U ¼ 286.000 .41

Treatment period, Phototherapy period 29 (20–37) 29 (14–52) U ¼ 308.50 .938

hours, median(range) Hospitalization period 41 (24–49) 42.3 (15.5–54) U ¼ 282.000 .553

Type of feeding, Breast milk 5 (20) 9 (36) c2 ¼ 1.587 .208

n (%) Breast milk and formula 20 (80) 16 (64)

Mode of birth, Vaginal 11 (44) 15 (60) c2 ¼ 2.122 .145

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

Note. Chi-square, Mann–Whitney U, and Student t tests were used to compare the demographic characteristics of the newborns in the
groups. M ¼ mean; SD ¼ standard deviation.

JOGNN 2020; Vol. 49, Issue 1 95

RESEARCH Massage Therapy and Phototherapy for Hyperbilirubinemia

Table 2: ANCOVA Results and Descriptive Statistics for TSB Levels of Newborns (N [ 50)
Before and After Randomization by Group

Group TSB–Before, mg/dl, Mean SD TSB–After, mg/dl, Mean SD n

Intervention 17.91 1.55 18.64 1.42 25

Control 9.02 1.27 11.04 1.57 25

Source SS df MS F p Partial h2 Effect Size

TSB–before 0.212 1 0.212 0.101 .752 0.002 —

Group 46.238 1 46.238 22.163 .000* 0.320 0.68

Error 98.055 47 2.086 — — — —

Note. Analysis of covariance (ANCOVA; F) was used to compare the total serum bilirubin (TSB) levels of the newborns in the groups. In
ANCOVA, the controlled variable was TSB–before. The TSB–before values of newborns were controlled (covariated), and TSB–after
values were compared in the intervention and control groups. MS ¼ mean squared; SD ¼ standard deviation; SS ¼ sum of squared.
*p < .001.

distributed. The results were considered signifi-
cant for p values of less than .05 and are pre-
sented as means plus or minus standard
deviation.
Results
Participant Characteristics
The demographic information of the 50 partici-
pants by group is shown in Table 1. We observed
no significant differences between the two groups
in terms of sex, gestational age at birth, birth
weight, Apgar score, route of birth, type of
feeding, duration of phototherapy, duration of
hospitalization, and maternal age.
Serum Bilirubin Levels
The total bilirubin levels of the intervention and
control groups are shown in Table 2 and Figure 2.
When the effects of admission TSB levels were
controlled for, TSB levels at hospital discharge
were significantly different between the two
groups. The newborns in the intervention group
had significantly lower levels of total bilirubin (M ¼
9.02 mg/dl 1.27 mg/dl) compared with the in-
fants in the control group (M ¼ 11.04 mg/dl
1.57 mg/dl, p < .001).
Frequencies of Defecation, Urination,
and Feeding
The mean daily frequencies of defecation, urina-
tion, feeding, breastfeeding, and breast milk and
formula quantities are presented in Table 3. Uri-
nation (M ¼ 9.29 times 1.04 times vs. M ¼ 7.81
times 1.51 times) and defecation (M ¼ 8 times,
range ¼ 6.48–11.86 times vs. M ¼ 5 times,
range ¼ 2.57–9 times) frequencies of the new-
borns were greater in the intervention group
(p <.001). There were no differences between the
breast milk (M ¼ 130 ml, range ¼ 25–310 ml vs.
M ¼ 130 ml, range ¼ 20–402 ml) and formula
(M ¼ 87.5 ml, range ¼ 30–350 ml vs. M ¼ 75 ml,
range ¼ 20–402 ml) quantities received by the
newborns in the intervention and control groups
(p > .05), but the feeding frequencies in the
intervention group (M ¼ 10.97 times 1.62 times)
were significantly greater than in the control
group (M ¼ 9.05 times 1.82 times, p < .001).
Discussion
There were no statistically significant differences
between the intervention and control groups with
regard to neonatal characteristics, which in-
dicates that the two groups were similar before
randomization. The feeding frequency was
significantly greater in the intervention group; this
finding contrasts with those of previous re-
searchers, who reported similar breastfeeding
frequencies between intervention and control
groups with massage therapy (Kianmehr et al.,
2014). Consistent with our findings, Xuelan et al.
(2005) also found greater breastfeeding fre-
quencies in their intervention group. Massage
therapy is proposed to stimulate the newborn and
increase activity (Pepino & Mezzacappa, 2015)
and willingness and readiness to feed (Gürol,
2010). Newborns who were stimulated through
massage and exhibited increased willingness to
be fed had more active feeding sessions. Mas-
sage therapy also stimulates the vagus nerve and
increases gastrin secretion (Field, 2017), which
increases gastric motility, gastric secretion of
hydrochloric acid, food digestion, and gastric
emptying (Hall, 2015), leading to more active and
more frequent feeding sessions. Thus, food

96 JOGNN, 49, 91–100; 2020. https://doi.org/10.1016/j.jogn.2019.11.004 http://jognn.org

Korkmaz, G., and Esenay, F. I. RESEARCH

20

18

16

14

12

10

0
TSB before, mg/dl TSB after, mg/dl

Intervention Control

Figure 2. Total serum bilirubin (TSB) levels of newborns before and after randomization by group.

intake increases, and the digestion of food is
facilitated because of increased gastric motility
and gastric secretion of hydrochloric acid. These
mechanisms may explain the increase in feeding
frequency observed in our study. An increase in
feeding frequency in newborns with indirect
hyperbilirubinemia is important because it may
increase the frequency of urination and defeca-
tion and accelerate the excretion of bilirubin from
the body.
The stools of newborns with indirect hyper-
bilirubinemia include significant levels of bilirubin,
so if the passage of stool from the intestines is slow,
an increase in bilirubin level may occur (Dalili et al.,
2016; Kianmehr et al., 2014). Massage therapy
increases intestinal peristalsis, facilitates stool
passage from the intestines, and increases the
frequency of defecation. This may explain the
greater defecation frequency in the intervention
group, a finding that is consistent with those re-
ported by other researchers who found greater
defecation frequencies in massage groups
compared with control groups (Dalili et al., 2016;
El-Magd et al. 2017; Lin et al., 2015; Seyye-
drasooli, Valizadeh, Hosseini, Jafarabadi,

Table 3: Findings Associated With Newborn Defecation, Urination, and Feeding

Frequencies (N [ 50)

Intervention Group Control Group

Variable (n ¼ 25) (n ¼ 25) TS p
Feeding frequency, times, M SD 10.97 1.62 9.05 1.82 t ¼ –3.931 .000*

Breastfeeding frequency, times, M SD 10.16 0.46 6.94 0.5 t ¼ 4.498 .000*

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

Breastfeeding duration for each time, minutes, M SD 29.91 3.15 24.91 2.21 t ¼ 1.297 .201

Breast milk volume, ml, median (range) 130 (25–310) 130 (20–402) U ¼ 143.000 .573

Formula volume, ml, median (range) 87.5 (30–350) 75 (20–402) U ¼ 176.000 .708

Urination frequency, times, M SD 9.29 1.04 7.81 1.51 t ¼ 4.036 .000*

Defecation frequency, times, median (range) 8 (6.48–11.86) 5 (2.57–9) U ¼ 38.500 .000*

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.
*p < .001. **p <. 005.

JOGNN 2020; Vol. 49, Issue 1 97

RESEARCH
Massage therapy may be an effective supplementary
intervention to lower total serum bilirubin levels in
combination with phototherapy for newborns with
hyperbilirubinemia.
Mohammadzad, 2014). Seyyedrasooli et al. (2014)
found that the frequency of defecation within
4 days was greater in the massage intervention
group than in the control group, and Lin et al.
(2015) determined that the frequency of defeca-
tion was significantly greater in the intervention
group on the third day. Dalili et al. (2016) observed
more frequent defecation in the intervention group
than the control group on the first day of massage
treatment. El-Magd et al. (2017) reported that the
frequency of defecation on the second and third
days of treatment was greater in the intervention
group than the control group. Because bilirubin is
discharged from the body in the stool, a negative
association exists between frequency of stool
discharge and TSB level (Gourley, Kreamer, &
Arend, 1992). Therefore, increased defecation in
the newborn diminishes the enterohepatic circu-
lation of bilirubin, leading to increased bilirubin
excretion (Kianmehr et al., 2014; Lin et al., 2015;
Seyyedrasooli et al., 2014). Moreover, massage
increases lymphatic flow and blood circulation,
which increases the excretion of the bilirubin that is
broken down by phototherapy (Kianmehr et al.,
2014; Lin et al., 2015; Seyyedrasooli et al., 2014).
Bilirubin also is excreted from the body in the
form of urobilin in the urine (Maheshwari &
Carlo, 2019). Therefore, frequency of urination
is also evaluated by researchers focusing on
the effects of massage on indirect hyper-
bilirubinemia. The mean urination frequency in
24 hours was significantly greater in the inter-
vention group than the control group in our
study. We found only one study on the effects
of massage therapy on bilirubin levels in which
researchers analyzed urinary output. Jeong
and Park (2018) found no statistically signifi-
cant differences between the 24-hour urine
volume levels between newborns in the mas-
sage therapy intervention and control groups,
but the urine volume in the intervention group
(M ¼ 426.87 ml 118.36 ml) was greater than
in the control group (M ¼ 372.35 ml
103.65 ml). Massage therapy increases perfu-
sion of the kidneys by increasing the blood
and lymph circulation in the tissues. Thus,
urination frequency might be expected to in-
crease. Furthermore, massage therapy could
98 JOGNN, 49, 91–100; 2020. https://doi.org/10.1016/j.jogn.2019.11.004
Massage Therapy and Phototherapy for Hyperbilirubinemia
increase the frequency of urination by
increasing the frequency of feeding. An in-
crease in urine excretion increases bilirubin
excretion in the form of urobilin and also di-
minishes the enterohepatic circulation of bili-
rubin i n a newborn.
The newborns in the intervention group in our
study had significantly lower TSB levels than
those in the control group after the massage
therapy intervention. This finding is consistent
with those of previous studies in which re-
searchers focused on the effects of massage
therapy on bilirubin levels (Eghbalian et al., 2017;
El-Magd et al., 2017; Kianmehr et al., 2014;
Moghadam et al., 2012; Novianti et al., 2018).
Massage may accelerate bilirubin excretion
through increased urination, defecation, and
feeding frequency, which may explain the signif-
icantly lower TSB levels in the intervention group.
In massage therapy studies conducted with
newborns under phototherapy for indirect hyper-
bilirubinemia, researchers showed that TSB
levels were significantly lower in the intervention
group at different time points than those in our
study (El-Magd et al., 2017; Kianmehr et al.,
2014; Moghadam et al., 2012). Similarly,
Moghadam et al. (2012) and Kianmehr et al.
(2014) found that, although initial bilirubin levels
were similar between groups, bilirubin levels were
significantly lower on the fourth day in newborns
whose mothers massaged them three times a day
for 4 and 5 days for 30 minutes after feeding.
Furthermore, Kianmehr et al. reported that bili-
rubin levels were similar between the intervention
and control groups on the first, second, and third
days. In contrast, El-Magd et al. (2017) reported
that bilirubin levels were significantly lower on the
first, second, and third days for newborns in the
intervention group, for whom a researcher
applied massage therapy in accordance with the
International Association of Infant Massage
guidelines twice a day for approximately 15 to 20
minutes. We applied fewer massage treatments
in our intervention group than the intervention
groups in other studies, but similar results were
obtained. Massage had effects within a short time
frame, helped reduce bilirubin levels, and helped
newborns recover from indirect hyper-
bilirubinemia. Study results may vary depending
on the type of massage, the techniques used
during the massage, the experience of the per-
sons who administer the massage, and the
massage duration and frequency.
http://jognn.org
Korkmaz, G., and Esenay, F. I.
Limitations
The most important limitation of our study was
that it was not blinded because the person who
implemented the massage intervention was the
researcher. Another limitation of our study may
be that the numbers of newborns from the two
centers were not equal. Bilirubin was analyzed
once in one center and twice in the other every
24 hours. Therefore, the use of bilirubin levels
at admission and discharge and lack of inter-
mittent measurements may be considered
limitations.
Conclusion
Use of massage for newborns who are treated
with phototherapy for indirect hyperbilirubinemia
may increase the frequency of defecation, urina-
tion, and feeding and reduce TSB levels. Thus,
massage therapy may be an effective supple-
mentary intervention to lower TSB levels in com-
bination with phototherapy for newborns with
hyperbilirubinemia.
REFERENCES
American Academy of Pediatrics, Subcommittee on Hyper-
bilirubinemia. (2004). Management of hyperbilirubinemia in the
newborn 35 or more weeks of gestation. Pediatrics, 114(1),
297–316. https://doi.org/10.1542/peds.114.1.297
Begum, N. A., & Afroze, S. (2018). An overview of neonatal unconju-
gated hyperbilirubinemia and it’s management. Bangladesh
Journal of Child Health, 42(1), 30–37. https://doi.org/10.3329/
bjch.v42i1.37048
Çınar, V., & Kü çü koğlu, S. (2018). Effects of sponge bath on bilirubin
levels of neonatals who underwent phototherapy. International
Journal of Innovative Research and Reviews, 2(2), 10–14.
Çoban, A., Turkmen, M., & Gursoy, T. (2014). Yenidoğan sarılıklarında
yaklas‚ ım, izlem ve tedavi rehberi [Guideline for understanding,
monitoring and treatment of neonatal jaundice]. Retrieved from
http://www.neonatology.org.tr/wp-content/uploads/2016/12/
sarilik.pdf
Dağoğlu, T. (2017). Yenidoğan sarılıkları [Newborn jaundice]. In T.
Dağoğlu & F. Ovalı (Eds.), Neonatoloji (pp. 540–600). Ankara,
Turkey: Günes‚ Kitabevi.
Dalili, H., Sheikhi, S., Shariat, M., & Haghnazarian, E. (2016). Effects of
baby massage on neonatal jaundice in healthy Iranian infants: A
pilot study. Infant Behavior and Development, 42, 22–26.
https://doi.org/10.1016/j.infbeh.2015.10.009
Eghbalian, F., Rafienezhad, H., & Farmal, J. (2017). The lowering of
bilirubin levels in patients with neonatal jaundice using mas-
sage therapy: A randomized, double-blind clinical trial. Infant
Behavior and Development, 49, 31–36. https://doi.org/10.1016/
j.infbeh.2017.05.002
El-Magd, A. N. A., Dabash, S. A. E. H., Guindy, S. R. E. G., Masoed,
E. S., & Houchi, S. Z. E. (2017). Effect of massage on health
status of neonates with hyperbilirubinemia. International Journal
of Research in Applied, Natural and Social Sciences, 5(5), 33–44.
JOGNN 2020; Vol. 49, Issue 1
RESEARCH
Ergü l, S., & Sarikaya, S. (2018). Yenidoğan hastalıkları ve hems‚ irelik
bakımı [Newborn jaundice and nursing care]. In Z. Conk, Z.
Bas‚ bakal, B. Bolıs‚ ık, & H. Bal Yılmaz (Eds.), Pediatri Hems‚ ireliği
(pp. 289–352. Ankara, Turkey: Akademisyen Kitabevi.
Field, T. (2017). Newborn massage therapy. International Journal of
Pediatrics and Neonatal Health, 1(12), 54–64.
Ganji, S. B., Kasagani, S., Revupalli, S., Kavali, S., & Chidugulla, S. K.
(2015). Bilirubin as an indirect measure of laboratory perfor-
mance of bilirubin determinations. Journal of Evolution of
Medical and Dental Sciences, 4(76), 13149–13155. https://doi.
org/10.14260/jemds/2015/1893
Gourley, G. R., Kreamer, B., & Arend, R. (1992). The effect of diet on
feces and jaundice during the first 3 weeks of life. Gastroen-
terology, 103(2), 660–667. https://doi.org/10.1016/0016-
5085(92)90862-S
Gürol, A. (2010). The effects of baby massage on mother infant
attachment and breastfeeding success (Doctoral thesis).
Erzurum, Turkey: Atatürk University. Retrieved from https://
www.atauni.edu.tr/bebek-masajinin-anne-bebek-baglanmasi-
veemzirme-basarisina-etkisi
Hall, J. E. (2015). General principle of gastrointestinal function, motility,
nervous control, and blood circulation. In Guyton and Hall
textbook of medical physiology (13th ed., pp. 789–797). Phila-
delphia, PA: WB Saunders.
Hassan, B., & Zakerihamidi, M. (2018). The correlation between fre-
quency and duration of breastfeeding and the severity of
neonatal hyperbilirubinemia. Journal of Maternal-Fetal &
Neonatal Medicine, 31(4), 457–463. https://doi.org/10.1080/
14767058.2017.1287897
International Association of Infant Massage. (2013). Handouts for
parents. Retrieved from https://cdn.shopify.com/s/files/1/1
921/1159/files/IAIM_Parent_Handouts-2017_-_chapter_13.pdf
Jeong, S. J., & Park, M. K. (2018). Effects of infant massage therapy on
transcutaneous bilirubin, feeding, and excretion in neonates
with jaundice undergoing phototherapy. Journal of the Korean
Society of Maternal and Child Health, 22(1), 25–34. https://doi.
org/10.21896/jksmch.2018.22.1.25
Kianmehr, M., Moslem, A., Moghadam, K. B., Naghavi, M., Noghabi,
S., & Moghadam, M. B. (2014). The effect of massage on serum
bilirubin levels in term neonates with hyperbilirubinemia un-
dergoing phototherapy. Nautilus, 128, 36–41.
Lin, C.-H., Yang, H.-C., Cheng, C.-S., & Yen, C.-E. (2015). Effects of
infant massage on jaundiced neonates undergoing photo-
therapy. Italian Journal of Pediatrics, 41(1), 94. https://doi.org/
10.1186/s13052-015-0202-y
Maheshwari, A., & Carlo, W. (2019). Diseases of the digestive system.
In R. M. Kliegman, B. M. Stanton, & J. S. Geme (Eds.), Nelson
textbook of pediatrics (21st ed., Vol. 2, pp. 603-612). Philadel-
phia, PA: Elsevier Health Science.
Moghadam, M. B., Moghadam, K. B., Kianmehr, M., Jomezadeh, A., &
Davoudi, F. (2012). Effects of massage on weight gain and
jaundice in term neonates with hyperbilirubinemia. Journal of
Isfahan Medical School, 30(183).
Novianti, N., Mediani, H. S., & Nurhidayah, I. (2018). Pengaruh field
massage sebagai terapi adjuvan terhadap kadar bilirubin
serum bayi hiperbilirubinemia [Effect of field massage as
adjuvant therapy on serum bilirubin levels neonatal hyper-
bilirubinemia]. Jurnal Keperawatan Padjadjaran, 5(3), 315–327.
Pepino, V. C., & Mezzacappa, M. A. (2015). Application of tactile/
kinesthetic stimulation in preterm infants: A systematic review.
Jornal de Pediatria, 91(3), 213–233. https://doi.org/10.1016/j.
jped.2014.10.005
Samra, N. M., El Taweel, A., & Cadwell, K. (2012). The effect of kan-
garoo mother care on the duration of phototherapy of infants
99
RESEARCH
re-admitted for neonatal jaundice. Journal of Maternal-Fetal &
Neonatal Medicine, 25(8), 1354–1357. https://doi.org/10.3109/
14767058.2011.634459
Schulz, K. F., Altman, D. G., Moher, D., & the CONSORT Group.
(2010). CONSORT 2010 statement: Updated guidelines for
reporting parallel group randomized trials. BMC Medicine,
152(11), 726–732.
Seyyedrasooli, A., Valizadeh, L., Hosseini, M. B., Jafarabadi, M. A., &
Mohammadzad, M. (2014). Effect of Vimala massage on
100 JOGNN, 49, 91–100; 2020. https://doi.org/10.1016/j.jogn.2019.11.004
Massage Therapy and Phototherapy for Hyperbilirubinemia
physiological jaundice in infants: A randomized controlled trial. Jour-
nal of Caring Sciences, 3(3), 165–173. https://doi.org/10.5681/jcs.
2014.018
Woodgate, P., & Jardine, L. A. (2015). Neonatal jaundice: Photo-
therapy. BMJ Clinical Evidence, 5(319), 1–21.
Xuelan, Q., Qingling, Y., & Changhong, S. (2005). Effect of acupoint
massage and breast-feeding frequency on serum bilirubin
levels of neonates with breast-feeding jaundice. Journal of Qilu
Nursing, 14(8), 28–32.
http://jognn.org