Massage Therapy for neonatal hyperbilirubinemia-Stessel – Follow Up from RT1, WK3

Clinical Question: As in the past, please briefly outline the scenario and state your clinical question as concisely and specifically as possible 

3-day old female arrived at the ED for a bilirubin check. She was discharged from the hospital yesterday with a slightly elevated bilirubin. Her bilirubin comes back as 16 and she was sent to the NICU to receive Phototherapy.

 

SEARCH QUESTION: 

In neonates with hyperbilirubinemia, does massage therapy in conjunction with phototherapy reduce bilirubin levels faster than phototherapy alone?

 

PICO Question:

Identify the PICO elements – this should be a revision of whichever PICO you have already begun in a previous week

 

P	I	C	O
Neonates with hyperbilirubinemia	Massage therapy	Light therapy	Faster decrease in bilirubin
Neonates with jaundice	Massage therapy with phototherapy	Phototherapy alone	Shorter duration of phototherapy treatment
Jaundiced infants	Therapeutic massage	Light treatment	Decrease serum bilirubin
Infants with increased jaundice		UV light therapy
Neonatal hyperbilirubinemia

 

Search Strategy:

Outline the terms used, databases or other tools used, how many articles returned, and how you selected the final articles to base your CAT on.  This will likewise be a revision and refinement of what you have already done.

PubMed 

• Message therapy hyperbilirubinemia (within 5 years) —> 33 results
• Message therapy jaundice: 122 results
• Hyperbilirubinemia massage therapy à17 results
• Hyperbilirubinemia massage therapy, best match, within 5 years à 9

Cochrane

• Message therapy hyperbilirubinemia à 3 results
• Message therapy jaundice à 10 results

Google Scholar

• Message therapy hyperbilirubinemia à 1,260 results
• Message therapy hyperbilirubinemia (since 2015) à 304 results

Science Direct

• Hyperbilirubinemia massage therapy à 252 results
• Hyperbilirubinemia massage therapy (since 2015) (only review and research articles) à 18 results

 

Selection Method:

I started my search on PubMed where I got back many results. In addition to the filters I placed, I narrowed down the results by looking for articles that were Medline indexed, answered my PICO question, and I had access to the full article. Of the articles that I included in this PICO search the first time around, I only included two of them in this version. The other two studies were conducted in Iran and had very small ample sizes, making them not ideal.

The next database I looked at was Cochrane, although the search came up with 13 articles, none of them directly answered the question I was asking.

Google Scholar turned up many articles, but a significant number of them were either repeats of articles I’ve seen in the other databases, or I couldn’t get access to them. I was able to get my first article posted, the meta-analysis there.

Lastly, I checked science direct to try and find a 4th article, after the filters, it turned up 18 results, but none of them directly related to the question being asked.

 

Articles Chosen (3-5) for Inclusion (please copy and paste the abstract with link):

Please pay attention to whether the articles actually address your question and whether they are the highest level of evidence available.  If you cannot find high quality articles, be prepared to explain the extensiveness of your search and why there aren’t any better sources available. 

Article 1- Effects of massage on newborn infants with jaundice: A meta-analysis

Mengjie Lei Tingting Liu Yufeng Li Yaqian Liu Lina Meng Changde Jin

Abstract

Objective

This meta-analysis aims to systematically evaluate the effects of massage on infants with jaundice.

 

Methods

Multiple electronic databases, including Cochrane Library, PubMed, EMBASE, Web of Science, China Biology Medicine (CBM), Wan Fang Data, VIP Database for Chinese Technical Periodicals and China National Knowledge Infrastructure (CNKI), were used to search for studies on the effects of massage on infants with jaundice. Data were analyzed by Rev Man 5.3.

 

Results

A total of 14 randomized controlled trials with 1889 patients were included. Statistically significant difference in percutaneous bilirubin[MD = −1.21, 95% CI (−1.90, −0.52), P < 0.05; MD = −2.00, 95% CI (−2.68, −1.32), P < 0.05; MD = −2.00, 95% CI (2.56, −1.44), P < 0.05; MD = −1.93, 95% CI (−2.44, −1.43), P < 0.05] was found between two groups at 48, 72, 96 and 168 h. Studies on the serum total bilirubin level were divided into two subgroups according to sample size, and the results of subgroup analysis showed that the serum total bilirubin level in the intervention group was significantly lower than that in the control group [MD = −52.06, 95% CI (−57.76, −46.36), P < 0.05 and MD = −10.65, 95% CI (−14.66, −6.63), P < 0.05]. Statistically significant difference in defecation frequency was observed between the two groups at 48 h after birth [SMD = 0.44, 95%CI (0.02, 0.87), P < 0.05].

 

Conclusion

Massage can decrease serum total bilirubin and percutaneous bilirubin levels and increasing defecation frequency. However, due to heterogeneity among studies, numerous multi-centre, large-sample and high-quality randomized controlled trials are needed to verify the effects of massage.

Link: https://www.sciencedirect.com/science/article/pii/S2352013217303198

Citation:

Mengjie Lei, Tingting Liu, Yufeng Li, Yaqian Liu, Lina Meng, Changde Jin, Effects of massage on newborn infants with jaundice: A meta-analysis, International Journal of Nursing Sciences, Volume 5, Issue 1, 2018, Pages 89-97, ISSN 2352-0132, https://doi.org/10.1016/j.ijnss.2018.01.004.

 

Article 2- Effects of infant massage on jaundiced neonates undergoing phototherapy

Chien-Heng Lin1,2, Hsiu-Chuan Yang3 , Chien-Sheng Cheng4 and Chin-En Yen3

 

Abstract

 

Background:

Infant massage is a natural way for caregivers to improve health, sleep patterns, and reduce colic. We aimed to investigate the effects of infant massage on neonates with jaundice who are also receiving phototherapy.

 

Methods:

Full-term neonates with jaundice, admitted for phototherapy at a regional teaching hospital, were randomly allocated to either a control group or a massage group. The medical information for each neonate, including total feeding amount, body weight, defecation frequency, and bilirubin level, was collected and compared between two groups.

 

Results:

A total of 56 patients were enrolled in the study. This included 29 neonates in the control group and 27 in the experimental group. On the third day, the massage group showed significantly higher defecation frequency (p = 0.045) and significantly lower bilirubin levels (p = 0.03) compared with the control group. No significant differences related to feeding amount or body weight were observed between the two groups.

 

Conclusion:

Infant massage could help to reduce bilirubin levels and increase defecation frequency in neonates receiving phototherapy for jaundice. Keywords: Infant massage, Jaundice, Neonates, Phototherapy, Bilirubin

Link: https://ijponline.biomedcentral.com/track/pdf/10.1186/s13052-015-0202-y

 

Article 3- The lowering of bilirubin levels in patients with neonatal jaundice using massage therapy: A randomized, double-blind clinical trial.

Eghbalian F1, Rafienezhad H2, Farmal J3.

 

Abstract

OBJECTIVE:

Due to the effects of massage on various laboratory parameters (including those related to jaundice) in infants and the expansion of existing studies to achieve effective and safe therapy in the treatment of neonatal jaundice, this study aimed to investigate the effect of massage on bilirubin levels in cases of neonatal jaundice.

METHODS:

In this study, 134 patients were randomly assigned to either an intervention group (massage combined with phototherapy, n=67) or a control group (phototherapy only, n=67). In both groups, serum total bilirubin level and frequency of daily bowel movements were measured and compared during each of the first four days of treatment.

RESULTS:

Baseline levels of bilirubin were similar between the two groups (P>0.05). During the measurements obtained post-intervention, significant differences surfaces between the two groups in bilirubin levels and frequency of daily bowel movements (P<0.05 for both). No significant relationship was observed during days 1 and 2 of massage therapy between daily frequency of bowel movements and serum bilirubin level (P>0.05); this relationship became significant during the third and fourth days (P<0.05).

CONCLUSION:

Massage therapy combined with phototherapy is an effective method for reducing serum total bilirubin in infants with neonatal jaundice.

Link: https://www.ncbi.nlm.nih.gov/pubmed/28688960

Citation: Fatemeh Eghbalian, Haneyeh Rafienezhad, Javad Farmal, The lowering of bilirubin levels in patients with neonatal jaundice using massage therapy: A randomized, double-blind clinical trial, Infant Behavior and Development, Volume 49, 2017, Pages 31-36, ISSN 0163-6383, https://doi.org/10.1016/j.infbeh.2017.05.002.

 

Summary of Evidence

 

Author (date)	Level of Evidence	Sample/Setting (# of subjects/ studies, cohort definition etc. )	Outcomes Studied	Key Findings	Limitations and biases
Mengjie Lei Tingting Liu Yufeng Li Yaqian Liu Lina Meng Changde Jin (2018)	Meta-Analysis	14 RCTs- 1889 participants in total	-percutaneous bilirubin levels (on days 1, 2, 3, 4, 7 after birth) -serum bilirubin levels- total bilirubin and direct bilirubin -jaundice duration -defecation frequency (on days 1, 2, 3, and 4 after birth)	-effects on bilirubin levels: no statistically significant difference in percutaneous bilirubin on day 1 between intervention and control. Statistically significant differences were found on days 2, 3, 4, 7 between the control group and the massage group.   – the effects of message on indirect bilirubin and jaundice duration were unclear.   -Effects of message on defecation frequency:  different studies arrived at many different outcomes. The study did not arrive at a specific conclusion on the outcomes studied.   Conclusions: massage therapy is an effective intervention for neonatal jaundice; however, further research is needed.	-Both English and Chinese databases were searched to avoid a language barrier   -Even though 14 studies were included, for each outcome assessed, there for 6 of less studies that examined that particular outcome.   -As per the authors: due to the low number of studies included, test efficiency was too low to distinguish between opportunity and true asymmetry.
Chien-Heng Lin, Hsiu-Chuan Yang, Chien-Sheng Cheng and Chin-En Yen (2015)	RCT	56 participants	Primary outcome: termination of phototherapy   Secondary outcome: discharge after completion of the procedure   The study also examined total feeding amount, body weight, defecation frequency and microbilirubin levels	-there was no difference between the two groups in feeding amount, body weight.   -the defecation frequency was not significantly different between the two groups on day 1 and 2 of life, but the defecation frequency was significantly higher in the massage group on the third day of life (p=0.04)   -The bilirubin levels were not significantly different between the two groups on day 1 and 2, but on the third day, the microbilirubin levels were significantly lower in the massage group when compared to the control group (p=0.03)	The number of participating neonates was very small, making the results less reliable.   The study only examined the outcomes for the first 3 days of life and improvement was only seen on day 3. Longer studies are needed to support the conclusion.   This study was conducted in Taiwan which may not have the same rigorous research regulations as the U.S.
Eghbalian F, Rafienezhad H, Farmal J. (2017)	RCT	134 participants.	-Defecation -Time of meconium passage -mean birth weight during first 4 days -Total bilirubin during the first 4 days.	-there were significant differences in bilirubin levels during the first two days post-intervention onset between the massage and control group (p<0.05).   -There was no significant different in daily bowel movements between the two groups.   -there was no relationship between frequency of defecation and serum bilirubin levels during the first and second day. There was a statistically significant difference between daily bowel movements and serum bilirubin during the third and fourth days in the massage group (p< 0.05). The relationship was not statistically significant at any time in the control group.   Conclusion: massage therapy + phototherapy conducted for 4 days has a statistically significant difference on bilirubin levels and neonatal jaundice.	The number of neonates participating is the study is small making the results less reliable.   This study was conducted in Iran which may not have the same rigorous regulations as the U.S.

 

 

Conclusions:

• Mengjie et al concluded that massage therapy can decrease both total serum bilirubin and percutaneous bilirubin levels. While that is the case, they still recommended that more studies be done, specifically a “numerous multi-centre, large-sample and high-quality randomized controlled trials” in order to verify the effects of massage on bilirubin levels in jaundiced neonates.
• Chien-Heng et al concluded that neonatal massage can both lower bilirubin levels and increase defecation frequency in jaundiced neonates. Additionally, this study found that neonatal massage did not affect feeding amount or body weight.
• Eghbalian et al concluded that during days 3 and 4 after birth, phototherapy combined with massage therapy is more effective at decreasing bilirubin levels and increasing defecation frequency than phototherapy alone.
• All three studies arrived at the same conclusion: phototherapy in conjunction with massage therapy is more effective than phototherapy alone in decreasing serum bilirubin levels.

 

Clinical Bottom line:

There weren’t many high-quality studies that examined the use of massage therapy as a treatment for neonatal hyperbilirubinemia, for this reason, I included 2 lower quality RCTs with few participants. We had learned that the more times a study can be repeated with similar outcomes, the stronger the evidence. For this reason, I think the small RCTs still add value to the Mini-cat. Both of them arrive at the same conclusions as the large meta-analysis.

 

I weighed the evidence from Mengjie et al the most, and then the data from Eghbalian et al and Chien-Heng et al. The Mengjie et al study is the only meta-analysis and included the largest number of participants (n=1889). Both of the other studies were RCTs, with a small number of participants (n=134 and n=56). Generally, the two RCTs would carry very little weight, because of the small number of participants. In this case, the clinical bottom lines do not differ dramatically based on which data is weighed the most, because all three studies arrived at the same conclusions.

All three studies are from foreign countries, despite that, I chose to include them because they were the highest levels of evidence I was able to find on the topic. This might be the case because Asian countries are likely to be more open to alternative therapies such as massage therapy as a treatment for medical conditions. Mengjie et al did a great job at compensating for any cultural or language bias by searching both Chinese and English databases for the meta-analysis.

 

Although all three studies show positive results, more data is needed to verify these studies. The optimal study would be a large double blinded RCT. this would allow control for all variables, increasing the reliability of the results. The studies included in this Mini-Cat ended on days 3-5 after birth. A study is needed that would continue beyond that time period, preferably until the bilirubin is back to a healthy level. This would allow verification that the effects of massage therapy persist beyond 4 days.

 

Clinical Significance: based off of the data, I would say that massage therapy can be initiated in neonates with hyperbilirubinemia. Even though more research is needed and there isn’t a lot of data yet, massage therapy, if done correctly is pretty benign, and the available studies have not reported any adverse effects.

 

Other considerations to keep in mind: It is important to keep in mind that to initiate massage therapy on a large scale, such as in a NICU, manpower would be needed to massage all the neonates. Although this may not be a large hinderance, it is likely to pose a financial burden. A separate study can be done to assess exactly how steep the financial burden would be. Considering the results we have seen in the studies available, it is likely that the benefit would still outweigh the cost, but it is something to keep in mind when considering the benefits of phototherapy in neonates with hyperbilirubinemia.