The Effect of Massage on Bilirubin Level in Infants
The Effect of Massage on Bilirubin Level in Infants
Jaundice (hyperbilirubinemia) which is one of the common causes of repeated hospitalizations
 in the neonatal period, is a physiological condition seen in 60% of term babies and 80% of
 premature babies in the first week of life . Premature babies are more susceptible
 tobilirubin neurotoxicity. Death and severe sequelae due to hyperbilirubinemia can be
 prevented by early diagnosis and treatment. Massage is one of the applications that can be
 used to reduce bilirubin levels in newborn infants. Baby massage facilitates bowel movements
 and bilirubin excretion by reducing enterohepatic circulation. This study was designed as a
 randomized controlled trial to investigate the effect of massage on bilirubin levels in
 premature infants.
Neonatal jaundice is a physiological condition seen in 60% of infants and 80% of preterm
 infants in the first week of life. There is no clear data on the frequency of jaundice in
 newborns in our country. Jaundice is one of the common causes of 75% of hospitalizations in
 the first week after birth and the recurrence of hospitalizations in the neonatal period.
 Neonatal jaundice is a non-hazardous and transient condition that can usually resolve
 spontaneously without treatment. Although it is a transient condition, high bilirubin levels
 can cause kernicterus which causes severe neurological damage if not diagnosed and treated
 early .

 The severity and complications of hyperbilirubinemia in premature infants are different from
 term infants. Premature infants are more susceptible to damage caused by serum bilirubin,
 even at low levels of brain cells. Hyperbilirubinemia in preterm infants is more prevalent,
 severe, and protracted than that in term infants because of the immaturity of their red blood
 cells, livers, and gastrointestinal tracts. There also is often a delay in enteral feeds,
 which may limit intestinal flow and bacterial colonization, resulting in further enhancement
 of the enterohepatic circulation of bilirubin. Preterm neonates are more susceptible to
 bilirubin neurotoxicity. Almost all preterm infants less than 35 weeks gestational age have
 elevated total serum/plasma bilirubin levels, which results in neonatal jaundice, the
 yellowish discoloration of the skin and conjunctiva caused by bilirubin deposition. The major
 complication of an elevated total serum (hyperbilirubinemia) is bilirubin-induced neurologic
 dysfunction (BIND), which occurs when circulating bilirubin crosses the blood-brain barrier
 and binds to brain tissue . Jaundice is an important problem in newborn infants and death and
 severe sequelae due to hyperbilirubinemia can be prevented by early diagnosis and treatment.
 Various treatment methods have been developed to reduce bilirubin levels. The most commonly
 used methods are; blood exchange, phototherapy and pharmacological agents. Therapeutic
 interventions prevent BIND and thus kernicterus by lowering the level of bilirubin in the
 blood. Phototherapy is a common treatment for both treatment and prevention of increased
 bilirubin levels. Phototherapy has been widely used in the treatment of hyperbilirubinemia of
 the newborn for more than fifty years. Phototherapy has various side effects, such as damage
 to the retina and genitalia, loss of body water, skin rashes, watery stools and Bronze Baby
 Syndrome.

 Nowadays, studies on new treatment methods and different applications are being made which
 support the treatment of jaundice and shorten the length of hospital stay. Kangaroo care
 reduces the exposure of newborns to phototherapy, swimming, wiping and bathtub bathing have
 been reported to reduce bilirubin levels. Baby massage is one of the alternative and
 complementary therapies that can be used to reduce bilirubin levels.

 While there are many studies investigating the effect of infant massage on bilirubin levels
 in term neonates with healthy and hyperbilirubinemia, a limited number of studies
 investigating the effect of massage on bilirubin levels in premature infants were found.

 It is suggested that baby massage can be performed by trained nurses and mothers trained by
 nurses. Infant massage stimulates defecation by increasing bowel movements, thus decreasing
 enterohepatic circulation and increasing bilirubin excretion. Bilirubin excretion decreases
 the speed and severity of hyperbilirubinemia. In some studies investigating the effect of
 massage on bilirubin levels, transcutaneous bilirubin (TcB) levels or TSB levels were found
 to be significantly lower, also no significant difference was found in some studies.

 In our country, the studies on the benefits of baby massage for infants are quite new. There
 are two studies investigating the effect of massage on bilirubin levels in newborn infants.
 However, in one of these studies, the effect of infant massage on bilirubin levels in
 newborns who received phototherapy was investigated, while the effect of abdominal massage on
 TcB bilirubin levels in newborns was investigated in the other study. TSB levels are the gold
 standard in the evaluation of bilirubin levels in newborn infants. However, the blood needs
 to be taken from the baby, and taking blood is a painful procedure, and it may not always
 possible to get enough blood. Measurement of bilirubin level from the skin surface is both
 noninvasive, painless and simple. In this study, the effect of infant massage on bilirubin
 level in premature infants not receiving phototherapy was evaluated by transcutaneous
 bilirubin measurement method. This study was designed as a randomized controlled trial to
 investigate the effect of massage on bilirubin levels in premature infants.
Inclusion Criteria:

 -  families being voluntary to participate in the study

 -  infants being born between 32 and 37 weeks plus 6 days of gestation

 -  infants having a birth weight of ≥1500 g

 -  infants having a fifth-minute Apgar score of more than seven

 -  infant's bilirubin level is not sufficient to require phototherapy

 -  the vital signs of the baby are within normal limits

 -  the absence of congenital major malformation of the infants

 -  the lack of patent ductus arteriosus requiring treatment

 -  no proven sepsis diagnosis

 Exclusion Criteria:

 -  neonates with disease disrupting skin integrity (epidermolysis bullosa, ichthyosis,
 collodion baby)

 -  need for phototherapy

 -  infants with gastrointestinal obstruction and biliary atresia

 -  infants with congenital major deformations