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The Effects of Field Massage Technique on Bilirubin Level and the Number of
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Karbandi et al 51

Evidence Based Care Journal

http://ebcj.mums.ac.ir/

The Effects of Field Massage

Technique on Bilirubin Level and the
Number of Defecations in Preterm
Infants
Soheila Karbandi, Maryam lotfi, Hasan Boskabadi, Habibollah Esmaily

The online version of this article can be found at

http://ebcj.mums.ac.ir/article_6057_616.html

Evidence Based Care Journal 2016 05:07 originally

published online 01 January 2016
Online ISSN: 2008-370X

Address: Mashhad Nursing and Midwifery School, Ebn-e-Sina St., Mashhad, Iran
P.O.Box: 9137913199
Tel.: (098 51) 38591511-294
Fax: (098 51) 38539775
Email: EBCJ@mums.ac.ir
7 Evidence Based Care Journal, 5 (4): 7-16

Original Article

The Effects of Field Massage Technique on Bilirubin Level

and the Number of Defecations in Preterm Infants
Soheila Karbandi1, Maryam lotfi2, Hasan Boskabadi3, Habibollah Esmaily4

Received: 12/07/2015
Evidence Based Care Journal, 5 (4): 7-16
Accepted: 01/12/2015

Abstract
Background: Hyperbilirubinemia is a common physiological problem in approximately 80% of
preterm infants during the first week after birth. Increase in bowel movements reduces enterohepatic
circulation and increases bilirubin excretion.
Aim: This study aimed to evaluate the effects of Field massage technique on bilirubin level and the
number of defecations in preterm infants
Method: This clinical trial was performed on 80 preterm infants aged 30-36 weeks, who were
hospitalized in neonatal intensive care units of Qaem, Imam Reza, and Ommolbanin hospitals of
Mashhad, Iran, in 2011. The enrolled infants were randomized into intervention and control groups.
The control group received the routine care, and the intervention group received a 15-minute massage
twice a day (morning and evening), for five consecutive days. Field massage technique was applied
by the researcher. The number of defecations and cutaneous bilirubin level were recorded on a daily
basis until the sixth day after birth. Independent t-test and Mann-Whitney U test were performed to
analyze the data, using SPSS version 14.
Results: The mean age of the intervention and control groups was 17.2±4.5 and 17.1±4.5 hours,
respectively. The mean level of cutaneous bilirubin in the intervention and control groups on the first
and sixth days were not significantly different (10.7±1.5, 10.8±1.4, 13.4±2.0, and 13.4±2.6,
respectively; the first day: P=0.67, the sixth day: P=0.98). The number of defecations on the fourth
(P=0.01), fifth (P<0.001), and sixth (P=0.005) days in the intervention group was significantly more
than the control group.
Implications for Practice: The five-day massage using the field technique could not reduce the level
of bilirubin in preterm infants; however, it increased the number of defecations during the bilirubin
peak days in preterm infants (fourth-sixth days), which can decrease bilirubin level in preterm infants.

Keywords: Field massage technique, Bilirubin, Defecation, Preterm infant

1. Evidence Based Care Research Centre, Instructor of Nursing, Department of Pediatric Nursing, School of Nursing and
Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran
2. MSc in Neonatal Intensive Care Nursing, Nursing and Midwifery School, Mashhad University of Medical Sciences,
Mashhad, Iran
3. Associate professor of Neonatology, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
4. Associate Professor of Biostatistics, Neonatal Research Center, Mashhad University of Medical Sciences, Mashhad, Iran

*Corresponding author, Email: Lotfim4@mums.ac.ir

Karbandi et al 8

Introduction
Prematurity is one of the major causes of mortality in infant and the development of new methods of
medicine has led to considerable increase in the survival rate of premature infants (1). Premature
infants experience numerous problems in all their vital organs. Hyperbilirubinemia is one of the most
common gastrointestinal problems in premature infants. This physiological problem occurs in 80% of
preterm and 60% of term infants during the first week of life (2)
Pathological jaundice is one of the major problems in the first week of life and one of the most
common causes of hospital readmission (51.8%) in neonates (3). Although neonatal icterus is usually
benign, but high levels of unconjugated bilirubin is potentially neurotoxic (2). Due to increased
toxicity of unconjugated bilirubin in the brain, timely diagnosis and treatment of neonatal
hyperbilirubinemia is crucial to prevent dangerous complications. Given the blood-brain barrier
permeability and susceptibility of brain cells to damage secondary to low serum bilirubin levels in
neonates, premature infants are at higher risk of kernicterus (2). Presentation of physiologic
hyperbilirubinemia in premature infants occurs three-four days after birth and it disappears seven-nine
days after birth, which is later than term infants (2).
Moreover, severity and complications of hyperbilirubinemia in premature infants is different from
term infants. Premature infants are at greater risk due to higher spinal-brain barrier permeability,
susceptibility of brain cells to damage caused by low levels of serum bilirubin, lack of sufficient
hepatic maturity, shortage of uridine diphosphate glucuronic acid enzyme, glucoroniel transferase,
more comorbidities, lower serum albumin level, albumin-binding capacity, and red blood cell
lifespan, gastroparesis, and several other medical problems (4).
The main methods of hyperbilirubinemia treatment are phototherapy, blood exchange, and therapeutic
treatment (2). The most common treatment of hyperbilirubinemia is phototherapy, which is safer and
more accessible as compared to other therapies, and it is the main intervention for prevention of
hyperbilirubinemia (5). However, there are the side effects attributable to phototherapy include
diarrhea, skin rashes, dehydration, hyperthermia, hypothermia caused by removing infants’ clothes,
Bronze baby syndrome, increased risk of melanoma later in life, and psychological stress on mothers
and infants (2, 5-7)
Therefore, finding a way to reduce the use of harmful drugs to maintain bilirubin level at a normal
range seems to be necessary (5). Massage is one of the most common complementary medicine
therapies and one of the most popular complementary therapies in nursing care (8). Many studies have
been done on the effects of massage on term and preterm infants.
Some of the effects of massage include: weight gain (9, 10), increased height (9, 11, 12), increased
head circumference (9, 12), bone density (13), sleep duration (14-16), easy breathing (16), reduced
incidence of late onset sepsis (17), reduced duration of hospital stay (9, 13, 14, 17), decreased hospital
costs (9, 13, 14), reduction of stressful behaviors in infants (18, 19), and reduced positive relationship
between mother and infant (9, 12, 20). The positive effects of massage on growth can be attributed to
stimulation of the vagus nerve activity, increased gastrointestinal motility, elevated levels of insulin
and insulin-like growth hormone (13, 14, 21, and 22).
Massage has positive effects on term neonates with icterus. Studies have shown the effects of massage
on physiological jaundice, low bilirubin levels, and fewer incidence of neonatal hyperbilirubinemia.
Studies have shown that massage leads to faster and shorter excretion of meconium and reduced
bilirubin reabsorption through enterohepatic circulation, which results in reduced neonatal jaundice
(23-25).
Chen et al. showed that massage might stimulate meconium excretion and increase the number of
defecations on the first and second days of life, and reduce bilirubin level in healthy term neonates
(5). Guiping (2002) demonstrated that defecation in newborn was improved by therapeutic touch,
which resulted in reduced neonatal hyperbilirubinemia (24). Basiri Moghaddam et al. (2012)
conducted a study on neonatal hyperbilirubinemia, the results indicated that massage for five days is
effective on reduction of serum bilirubin levels in newborns with hyperbilirubinemia who were
treated with phototherapy (26).
However, some studies did not confirm the effects of massage on bilirubin concentration in term
infants. The results of Seyyedrasooli et al. (2014) study did not show any positive effects for massage
on the cutaneous bilirubin concentration in term infants after four days of field massage (27).
Keshavarz et al. (2010) found that the incidence of neonatal icterus after the third day of receiving
9 Evidence Based Care Journal, 5 (4): 7-16

massage therapy was not significantly different in cutaneous contact (kangaroo care) and routine care
groups (28).
A study was conducted on the effect of abdominal massage on icterus in premature infants in China;
the results of this study, which was performed by Xiaoli et al. (2007), showed that abdominal massage
can improve the performance of premature infants’ digestive system, accelerate meconium excretion,
reduce intestinal absorption of bilirubin, and decrease the risk of severe icterus (29).
In studies on term neonates with icterus, different massage techniques were used and it is not clear
which technique is more suitable for clinical use. The applied techniques include: Vimala technique
(the first phase in supine position facial massage to the legs, and the second phase prone, neck
massage to waist and vice versa), Field technique (the first and third phases prone and massage from
head to legs, and the second phase supine with flexion and extension of the limbs), therapeutic touch
technique from Miami University of United States (facial, chest, abdomen, limbs, and back massage),
and abdominal massage (clockwise, circular massage around the navel, alternating flexion and
extension movements of legs) (29). The possibility of increased calorie consumption during massage
should be taken into account in preterm infants; in field massage technique that is suitable for
premature infants, energy is maintained and additional calorie is not required (13).
Considering the absence of studies on the effects of massage on neonatal icterus in Iran, and given the
fact that the study performed in China used abdominal massage, while based on the previous studies
Field technique is suitable for premature infants (13), this study was conducted to evaluate the effect
of Field massage technique on bilirubin concentration level and the number of defecations in
premature infants.

Methods
This randomized, clinical trial was carried out on 80 premature infants, who were admitted to the
neonatal intensive care units (NICU) of Qaem, Imam Reza, and Omolbanin hospitals of Mashhad
during October-March, in 2011. Since the main variables of this study were quantitative, the sample
size was calculated using comparison of the average of the two communities' formula.
Mean and standard deviation of cutaneous bilirubin variable in the intervention and control groups
were put into the formula based on similar studies (Chen et al., on neonatal icterus) (5). The mean
cutaneous bilirubin level on the last day of intervention in the treatment and control groups was
calculated to be 9.5±3.1 and 11.6±23.2, respectively. Moreover, coefficient of accuracy and power
were 95% and 80 %, respectively. The sample size was calculated to be 26; however, to ensure the
adequacy of the participants, 40 newborns were allocated to each group.
The inclusion criteria included: gestational age 30-36 weeks, birth weight over 1250 g, Apgar score of
7 and above (fifth minute), no prohibition of massage (such as ulcers, cutaneous lesions, burns,
ecchymosis, fracture, dislocation, infection-associated rash, and hyperthermia), no obvious congenital
anomalies, and absence of congenital infections.
The exclusion criteria included: presentation of clinical hyperbilirubinemia during the first 24 hours of
birth, having the known causes of hyperbilirubinemia (including: lack of glucose-6-phosphate
dehydrogenase, hypothyroidism, or ABO and Rh incompatibility, and evidence of globular lysis),
receiving phototherapy, blood transfusion, and therapeutic treatment (drugs such as intravenous
immunoglobulin, metalloporphyrin, and clofibrate) for hyperbilirubinemia during the first 24 hours of
birth, placing the newborn on ventilation, transferring the baby to another hospital, and the risk of
infection during the study (blood culture or cerebrospinal fluid positive culture).
At the end of the study, out of the 80 samples, 30 cases were excluded (15 neonates from the massage
group and 15 infants from the control group). The main cause of exclusion was receiving
phototherapy during the first 24 hours of birth (six infants in each group). Other reasons for exclusion
included: parents’ willingness to leave the study (two infants from the intervention group), discharge
of patients younger than five days (two infants from the intervention group and three infants from the
control group), septicemia (one infant from the control group), ventilation (one infant from the control
group), transferring the baby to other hospitals (one infant from the control group), deficiency in
glucose-6-phosphate dehydrogenase enzyme (three infants from the intervention group), and
incompatibility of ABO (two infants from the intervention group and three infants from the control
group).
Karbandi et al 01

The data collection tools included forms of the research unit, demographic information questionnaire,
daily information forms, and transcutaneous bilirubin meter. Content validity of the demographics
questionnaire and daily information form, which were designed school based on the latest books,
articles, and research objectives, was established by ten faculty members of nursing and midwifery of
Mashhad. Then, the final survey forms were developed using the comments and proposed
amendment.
Several studies carried out in Iran and other countries performed transcutaneous bilirubin
measurement, especially in infants with serum bilirubin less than 15 mg/dl, and its validity was
confirmed for screening (2, 30-37). In this study, criterion validity was established using ten infants
gestational aged 30-36 weeks, who were admitted to NICU and required serum bilirubin measurement
according to physician advice. Blood sampling was conducted along with cutaneous bilirubin
measurement. The results were compared using the Pearson correlation coefficient (r=0.72).
The infants admitted to the NICUs were randomized into massage and control groups. Using a table
of random numbers, 40 numbers were randomly selected from 0 to 9; for each selected number
between 0-4 and 5-9, AB and BA were assigned, respectively. Therefore, we had a string of 40 pairs
of AB and BA. The As and Bs were allocated to the control and intervention groups, respectively. In
the intervention group, massage was performed by a researcher, twice a day in the morning and
evening (same time in each hospital, 12 hours interval between each massage) during five consecutive
days (according to the same study(5)).
The intervention was performed as followed: in the massage group, 12-24 hours after birth and after
stabilization of the infants (stabilizing characteristics included open airway, adequate ventilation, pink
skin and lips, pulse of 120-140 beats per minute, axillary temperature 36.5 - 37° C, modified
metabolic disorders, and management of special problems), the infants were placed in a relatively
peaceful environment under radiant heaters one hour after being fed, and cutaneous bilirubin level
was determined using JAUNDICE DETECTOR JH20-1A (China).
The bilirubin level was measured from glabella twice using a cutaneous bilirubin meter and the mean
value was considered. Before initiating the massage, the researcher’s hands were washed and warmed,
and lubricated with maximum 1 ml sunflower oil (for better lubrication). Massage was done with the
soft parts of the fingers of both hands with light pressure by the researcher using field technique.
Massage duration was 15 minutes, and included three steps each lasting five minutes, according to the
same study (23).
During the first and final stages, the infant was placed in prone position, and each minute one of the
following areas was massaged: A) 12 massage moves (every five seconds one move) from head
downwards (both sides of the face to neck and reversely); B) 12 massage motions from the neck to the
shoulders and reversely; C) 12 massage moves from the upper back down to the waist and reversely; D) 12
massage moves from the thighs down to the ankles and reversely; E) 12 massage motions from the
shoulders to the wrists and reversely, in the middle phase, the infant was put in supine position and six
extension and flexion moves were done (10 seconds for each) in the right arm, left arm, right leg, left leg,
and both legs.
On the sixth day, the routine care was provided for the intervention group. In the control group, the
routine care was provided since the beginning of the intervention. In the intervention and control
groups, the number of daily defecation and coetaneous serum bilirubin level were recorded until the
sixth day. The number of daily defecations was recorded in the infants’ profiles based on the intake
and output forms.
This study did not hinder the newborns’ treatment, and all the medical procedures were controlled
since the second day of birth to assess the effects of massage on the need for other treatments (i.e.,
phototherapy, blood transfusion, and therapeutic treatment). During the course of intervention, the
infants did not require blood transfusion and therapeutic treatment. From the second day, the hours of
receiving phototherapy were controlled and recorded in the daily information form. When cutaneous
bilirubin concentration was higher than the physiological rate or according to physician advice, serum
bilirubin level was measured by the personnel and the results were recorded and controlled by the
researcher in the daily information form.
All the ethical codes regarding clinical trials were observed, the most important of which are as
follows: obtaining permission from the Ethics Committee of the university, receiving a written letter
of introduction from the School of Nursing for the hospitals, introducing the researcher and
 55 Evidence Based Care Journal, 5 (4): 7-16

explaining the objectives and methods of the study, obtaining parents’ permission to participate in the
study, ensuring the participants of non-invasiveness and safety of the study, ensuring the parents of
the right to quit participating in the study at any time, respect for scientific integrity in presenting
results, and notifying the ability to perform routine treatment at every stage of the study. Finally, the
data were analyzed using SPSS version 14.
After determining the normal distribution of variables, Kolmogorov-Smirnov test, independent t-test,
Mann-Whitney U test, Chi-square, and Fisher’s exact test were used. In all the tests, accuracy
coefficient and statistical power were 95% and 80%, respectively.

Results
The mean age of the infants was 17.2±4.5 and 17.1±4.5 hours in the intervention and control groups
(P=0.90), respectively. The results showed that both groups were quite the same in terms of
gestational age, birth weight, head circumference, Apgar score of five minutes after birth, and
maternal age (P>0.05). The samples’ demographics are demonstrated in Table 1.
Table 1: Comparison of demographic characteristics of the samples in the intervention and control groups
Mean ± SD Results of the statistical tests
Variable
Intervention group Control group
Chronological age (hour) 17.2 ± 4.5 17.1 ± 4.5 * 0.90
Gestational age (week) 33.1 ± 1.4 33.1 ± 1.5 ** 0.97
Birth weight (gr) 1893.7 ± 440.4 2000.2 ± 433.3 * 0.28
Infant’s height (cm) 43.5 ± 3.5 43.7 ± 3.3 * 0.77
Head circumference (cm) 31.0 ± 2.0 30.9 ± 2.4 * 0.84
Five-minute Apgar score 8.6 ± 0.8 8.5 ± 0.9 ** 0.77
Maternal age (years) 25.5 ± 5.0 26.6 ± 6.5 * 0.39
*independent t-test
**Mann-Whitney U test

In the intervention group, 12 (48%) and 13 (52%) samples were female and male, respectively. In the
control group, 5 (20%) and 20 (80%) cases were female and male, respectively. Chi-square test
reflected a significant difference between the two groups in terms of gender, and the two groups were
not homogeneous regarding this variable (P=0.009, x²= 6.76).
The two groups were homogeneous in terms of mode of delivery, maternal diabetes, previous history
of child hospitalization due to icterus, induction of labor with oxytocin, maternal blood type and Rh,
and infant blood type and Rh (P˃0.05).
The mean cutaneous bilirubin concentration of the first day (before the intervention) was 10.7±1.5
and 10.8±1.4 in the intervention and control groups, respectively; independent t-test did not show
statistically significant differences between the two groups (P=0.67).
The mean bilirubin concentration on the sixth day (the day after the intervention) was 13.4±2.0 and
13.4±2.6 in the intervention and control groups, respectively; there was no statistically significant
difference the two groups (P=0.98).
The mean level of cutaneous bilirubin on the other days (second, third, fourth) did not show
significant differences between the intervention and control groups (P>0.05). Comparison of the
differences between the sixth and first days in the level of cutaneous bilirubin showed no significant
differences between the two groups (P=0.82; Table 2).
Table 2: Comparison of daily cutaneous bilirubin in the intervention and control groups
Intervention n= 51 control n= 51 Results
Days of study Mean ± SD cutaneous mean±SD of t-test
bilirubin (mg/dl) cutaneous bilirubin (mg/dl)
First 10.7± 1.5 10.8 ± 1.4 P=0.67
Second 13.6± 1.6 13.2 ± 1.7 P=0.36
Third 13.7± 2.3 13.1 ± 2.1 P=0.31
4th 13.5± 2.2 13.4 ± 2.0 P=0.86
5th 14.3± 2.5 14.0 ± 2.3 P=0.68
6th 13.4± 2.0 13.4 ± 2.6 P=0.98
Difference between the first and sixth days 2.7± 2.4 2.5 ± 2.5 P=0.82
regarding bilirubin
 Karbandi et al 01

Due to ethical considerations, blood sample was not taken to measure serum bilirubin concentration,
but the results of the tests prescribed by the treating physicians were recorded in the form. After
evaluating 19 infants on the third and fourth days, the results were analyzed using t-test. The results
showed that there was no statistically significant difference between the two groups in terms of serum
bilirubin level on the third (P=049.) and fourth (P=0.15) days (Table 3).

Table 3: Comparison of daily serum bilirubin in the intervention and control groups
Group
Intervention Control Results
Variable No. Mean ± SD cutaneous No. Mean ± SD cutaneous of t-test
bilirubin (mg/dl) bilirubin (mg/dl)

Serum bilirubin on the third day (mg/dl) 9 8.1±1.8 10 8.1 ± 2.2 P=0.94
Serum bilirubin of 4th day (mg/dl) 8 8.1±1.8 11 9.7 ± 2.2 P=0.12

T-test and Mann-Whitney U test reflected no statistically significant differences between the
intervention and control groups in the number of daily defecation of the premature infants on the first
(P=0.94), second (P=0.37), and third (P=0.10) days. However, a statistically significant difference
was observed between the two groups on the fourth (P=0.01), fifth (P<0.001), and sixth (P=0.005)
days (Table 4).
Repeated measures ANOVA (dependent variable was cutaneous bilirubin and independent variable
was massage with controlling gender and the total hours of receiving phototherapy after the first day)
was performed for the second and sixth days. The results did not show any statistically significant
differences between the two groups in terms of cutaneous bilirubin (P=0.93); the same test
demonstrated that gender did not affect bilirubin concentration (P=0.41; Figure 1).

Table 4: Comparison of mean daily defecation in the control and intervention groups
Days of study Intervention n= 51 Control n= 51 P-value
First 0.5 ± 0.9 0.4± 0.6 *P=0. 94
Second 2.0± 1.4 1.6 ± 1.1 **P=0.37
Third 3.2 ± 1.4 2.6 ± 1.3 **P=0.10

4th 3.8 ± 1.5 2.7 ± 1.4 **P=0.01

5th 4.4 ± 1.0 3.2 ± 1.4 *P < 0.001

6th 4.2 ± 1.3 3.3 ± 1.2 *P=0.005

*Mann-Whitney U test
**independent t-test

Figure 1: Comparison of bilirubin concentration on the second-sixth days with controlling gender and total hours of
phototherapy variables in the intervention and control groups

Discussion
The results of the current study showed that the five-day Field massage technique could not affect
cutaneous bilirubin concentration in premature infants; however, it could increase the number of
defecations on the fourth, fifth, and sixth days. The mechanism of the effect of massage on the
concentration of bilirubin in other studies was proposed as vagus nerve stimulation, elevated
production of hormones affecting food digestion and absorption (gastrin and insulin) and as a result,
increasing intestinal peristalsis and excretion of meconium (5). Since meconium contains 1 mg/dl
51 Evidence Based Care Journal, 5 (4): 7-16

bilirubin, it may be deconjugated by intestinal glucoronidase and increase serum bilirubin

concentration (2); thus, increasing meconium excretion can prevent further increase of bilirubin
concentration in term infants. Massage can have varied effects on icterus in premature infants, due to
delayed excretion of meconium in pre-term infants (the first 48 hours after birth) and other factors
such as prematurity of muscular layers of the gastrointestinal tract, uncoordinated bowel movements,
gastroparesis, fasting infants in the first days of life for various reasons, low hormone secretion in the
gastrointestinal tract, and prolonged movement of food through the digestive tract (4).
In our study, the mean cutaneous bilirubin concentration level in the first (before the intervention),
second-fifth, and sixth day (the day after the intervention) showed no significant differences between
the intervention and control groups.
The results of a study performed by Chen et al. (2011) study showed that infant massage with
therapeutic touch from Miami University of America (modified version of field technique) reduced
cutaneous bilirubin level in the second-fifth days significantly in the treatment group, as compared to
the control group. Additionally, total serum bilirubin level in the fourth day was significantly lower in
the treatment group than the control group (5). The results of this study are not in agreement with
those of our study, which may be due to the fact that Chen et al. (2011) conducted their study on term
infants and that physiologic hyperbilirubinemia persists longer in preterm infants, as compared to
term neonates. Other differences of preterm infants from term ones may prevent massage to affect
bilirubin concentration in premature newborns.
A review of the literature done by Field et al. (2010) showed that the moderate pressure of massage
did not affect weight gain in infants (13). This result might apply to bilirubin concentration as well.
Measurement of serum bilirubin concentration is more precise than cutaneous bilirubin concentration;
however, due to ethical considerations this method was not used in this study. Moreover, the recorded
test results were not reliable due to lack of homogeneity. Earlier initiation of massage renders better
results, but in this study, massage was postponed to 12-24 hours after birth due to instability of the
preterm infants.
The results of a study by Basiri et al. (2012) exhibited that mean serum bilirubin concentration of
intervention group was significantly lower than control group on the fourth day (26). The results of
this study are inconsistent with the findings of ours. As mentioned earlier, this discrepancy might be
due to the fact that Basiri et al. (2012) conducted their study on term infants. Moreover, Basiri et al.
(2012) measured serum bilirubin; while in this study, cutaneous bilirubin level was determined.
Despite suitable correlation between measurement of serum and cutaneous bilirubin in the validity
section of the present study, in-vitro conditions of the measurement method can affect bilirubin level.
More importantly, the Basiri et al. (2012) study was conducted on infants with hyperbilirubinemia,
whereas in the present study not all the cases sustained hyperbilirubinemia. Excessive excretion of
meconium in neonates with hyperbilirubinemia may be more effective in reducing bilirubin. The
results of a study by Xiaoli et al. (2007) demonstrated that cutaneous bilirubin concentration in the
fourth-tenth days after abdominal massage was significantly lower in intervention group than control
group (29).
The abovementioned result is not in line with our results. This inconsistency might be due to the
differences in massage techniques between our study and the one by Xiaoli et al. (2007) (in the Xiaoli
study abdominal massage and in our study field massage techniques were used). In the field massage
technique no massage is performed on infants’ abdomen, but studies have shown that abdominal
massage increases intestinal peristalsis (38). In addition, duration of intervention in the study by
Xiaoli et al. (2007) was twice (ten days) as long as the current study.
In a study performed by Seyyedrasooli et al. (2014), no significant difference was observed between
intervention and control groups in terms of cutaneous bilirubin on the first-fourth days of intervention
(27). The results of this study are consistent with the findings of the present study. Although the study
groups and the intervention duration (4 vs. 5 days) were different, the two studies were the same in
terms of massage technique, and duration of massage (15 minutes).
The findings of the current study showed that massage increases the number of defecations in the
bilirubin concentration peak days (4-6th days) in premature infants, which can reduce bilirubin in
premature newborns. Chen et al. (2011) study showed that the number of defecations on the first and
second days was significantly higher in the intervention group, as compared to the control group (5).
These results are inconsistent with the findings of the current study, which might be due to different
Karbandi et al 01

study groups (term neonates), differences in massage technique and recording the number of
defecations (in the study by Chen et al. it was recorded according to the mother’s statements, and
adsorption and excretions recorded by nurses, but in current study due to the absence of the majority
of mothers in the NICUs, it was based on the numbers recorded by nurses in the infants’ profile),
depth of massage (gentle pressure in the present study, and in the Chen et al. study it was unknown),
and the time of massage initiation (immediately after birth).
The current study also shows the positive effects of massage on the number of defecations, but this
impact does not present in the early days of birth due to differences of premature infants and term
newborns. Jiang et al. (2014) found a statistically significant difference between intervention and
control groups in the number of defecations (39). The results of this study are not in agreement with
the current findings. The reason for this inconsistency may be the differences in the study groups
(neonates) and study method (in this study, swimming and massage once a day for ten days).
Field massage technique in the study by Seyyedrasooli et al. (2014) showed that the number of
defecations was not significantly different in the intervention and control groups on the first-fourth
days (27). This result is not in agreement with the findings of the present study, which might be due to
studying term infants and shorter duration of the intervention (four days) (4). Vimala massage
technique in the study by Seyyedrasooli et al. (2014) demonstrated that the number of defecations on
the fourth day in the massage group was more than the control group (40), which is consistent with
the findings of the present study.
The following limitations could affect the results of this study: not measuring serum bilirubin levels
due to impossibility of frequent blood sampling out of the course of treatment, phototherapy
administration during the first 24 hours of birth without testing and according to clinical diagnosis,
great loss of samples and having a smaller sample size than expected, lack of accurate fecal
measurement, several residents and neonatologists visiting the neonates (which resulted in frequent
starting and stopping the phototherapy).

Implications for Practice

Field massage for five days could not reduce cutaneous bilirubin levels in preterm infants. However,
the findings of this study indicate that massage increases the number of defecations on the bilirubin
peak days in preterm infants (4-6 days); which can in turn, reduce bilirubin level in preterm infants.
Due to the positive effects of massage on premature newborns and because of excretion of meconium,
which could prevent further increase in bilirubin concentration, massage as a complementary therapy
technique can be used to reduce the need for therapeutic treatment of icterus? Conducting further
studies on the effect of massage on serum bilirubin concentration in newborns is recommended.

Acknowledgments
This article is part of an NICU Nursing master's thesis (code: 910140 and registration number:
IRCT201206059949N1) approved by the Ethics Committee of Mashhad University of Medical
Sciences in 2012, which is recorded in the clinical trial center of Iran. We would like to thank the
officials of School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad,
Iran, NICU staff of Qaem, Imam Reza, and Omolbanin hospitals, and parents who contributed to this
study.

Conflict of interest
The authors declare that there is no conflict of interest.

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