Abdominal Massage for Newborn Jaundice

Neonatal jaundice is a common condition during the early postnatal period and is associated with immature bilirubin metabolism, increased red blood cell breakdown, limited hepatic conjugation and excretion, and increased enterohepatic circulation. Although most cases are physiologic, markedly elevated bilirubin levels may lead to serious neurologic complications if not identified and treated promptly. Standard newborn care therefore includes jaundice assessment, feeding support, bilirubin monitoring, and phototherapy when clinically indicated.

Abdominal massage is a non-pharmacological and non-invasive nursing intervention that may stimulate intestinal motility, increase stool passage, promote meconium excretion, and reduce intestinal reabsorption of bilirubin. Previous studies have suggested that infant massage may lower bilirubin levels and increase stool frequency; however, evidence from standardized clinical protocols in healthy full-term newborns remains limited. This study will evaluate the effectiveness, feasibility, and safety of a standardized abdominal massage intervention for neonatal jaundice.

This study is a two-arm, parallel-group randomized controlled trial. A total of 84 eligible full-term newborns will be randomly assigned in a 1:1 ratio to either an intervention group or a control group. Block randomization with a fixed block size of four will be used to maintain balanced enrollment between groups. Allocation concealment will be maintained using sequentially numbered, opaque, sealed envelopes prepared by a researcher who is not involved in participant recruitment, intervention delivery, or outcome measurement.

Because the abdominal massage procedure is readily identifiable, the nurses providing the intervention cannot be blinded. However, the nurses responsible for bilirubin measurement and data collection will not participate in randomization or massage delivery and will remain unaware of group assignment. Data analysis will also be conducted using coded group labels until the primary statistical analyses have been completed.

Both groups will receive the same routine newborn care, including feeding support, clinical observation for jaundice, transcutaneous or serum bilirubin assessment, phototherapy when medically indicated, and discharge education. The control group will not receive abdominal massage during the study period.

Newborns assigned to the intervention group will receive routine care plus standardized abdominal massage. The massage will be administered twice daily for 10 to 15 minutes during hospitalization for 2 to 5 days. It will begin after medical assessment confirms that the newborn is clinically stable and at least 1 hour after feeding. The newborn must be awake and calm before the intervention begins.

The standardized massage procedure includes gentle clockwise circular massage over the abdomen following the direction of intestinal movement, gentle flexion of the knees toward the abdomen, and light circular massage across the lower abdomen and groin area from right to left. Excessive pressure over the liver, spleen, or unhealed umbilical area will be avoided. The procedure will be performed by trained nurses who have completed infant massage education and standardized intervention training. Each session will be documented to monitor intervention fidelity.

Transcutaneous bilirubin will be measured on the forehead using a standardized bilirubin meter at approximately 0-6, 24, 48, 72, 96, and 120 hours after birth. If a transcutaneous bilirubin value approaches the clinical treatment threshold, total serum bilirubin will be measured according to routine clinical practice. Additional clinical data will include stool frequency, time to first stool passage, feeding frequency and amount, diaper frequency, daily weight change, use and duration of phototherapy, length of hospital stay, and adverse events. Medical records will also be reviewed for jaundice-related outpatient visits or readmissions within 7 days after discharge.

The primary analysis will evaluate differences in transcutaneous bilirubin trends over time between the two groups. Generalized estimating equations will be used to examine the effects of group, time, and the group-by-time interaction. Potential confounding variables, such as gestational age, birth weight, feeding method, delivery mode, percentage of weight loss, and baseline bilirubin level, may be included in adjusted analyses when necessary. Secondary outcomes will be analyzed using appropriate parametric, nonparametric, categorical, or regression methods according to the distribution and type of the data. All statistical tests will be two-sided, with statistical significance set at p < 0.05.

Safety will be assessed before, during, and after each massage session. Nurses will observe skin color, respiratory pattern, crying, abdominal distension, vomiting, activity, feeding tolerance, and vital signs. Massage will be stopped immediately if the newborn develops persistent crying, vomiting, marked abdominal distension, skin changes, respiratory abnormalities, unstable vital signs, or any other sign of discomfort. A pediatrician will evaluate the newborn when clinically indicated. Any newborn who reaches the threshold for phototherapy or other treatment will receive standard medical care without delay, regardless of group assignment.

Inclusion criteria

• Full-term newborns with a gestational age of 37 weeks or greater
• Birth weight of 2,500 grams or greater
• Apgar score of 7 or greater at 5 minutes after birth
• Stable vital signs
• No significant abnormal findings following examination by a physician after birth
• Eligible to begin the study procedures at least 1 hour after the first feeding
• Written informed consent provided by a parent or legal guardian

Exclusion criteria

• Preterm newborns or newborns with very low birth weight
• Congenital gastrointestinal abnormalities, abdominal wall defects, or conditions requiring surgery
• Major congenital diseases or chromosomal abnormalities
• Admission to a neonatal intensive care unit
• Sepsis, respiratory distress, or other acute or critical medical conditions
• Pathologic jaundice, including hemolytic jaundice or biliary atresia
• Bilirubin levels meeting the criteria for immediate phototherapy or exchange transfusion
• Abdominal skin infection, skin damage, or any condition making abdominal massage unsuitable
• Considered unsuitable for participation by the attending physician