EVIDENCE SUMMARY - PEDIATRIC ACUPUNCTURE

[email protected]
 PEDIATRIC ACUPUNCTURE
Natalie Saunders Lic.Ac. BA(Hons) Traditional Acupuncture
Katherine Berry BHSc TCM Acupuncture, MSc Research (Addictions)

INTRODUCTION

The prevalence of chronic childhood conditions Various reviews have found acupuncture and
is increasing with 13–27% of children now being acupuncture-related therapies to show particular
affected by chronic conditions. (1) These conditions promise in the treatment of pediatric pain, cerebral
may last into adulthood and can have a significant palsy, nocturnal enuresis, tic disorders, amblyopia,
impact on the whole family as well as the affected nausea and vomiting, digestive disorders, autistic
child. Therefore, it is unsurprising that many families spectrum disorder (ASD), and respiratory disorders.
are now seeking complementary and alternative (4) (5) (6)

medicine (CAM) therapies and integrative medicine Furthermore, acupuncture is considered safe and
including acupuncture and related therapies for well-tolerated (7) (8) with a very low risk of serious
their children’s conditions. (2) (3) adverse effects.

Acupuncture-related therapies include the non-

invasive stimulation of acupoints with moxibustion
and manual pressure (tui na), lasers, TENS
machines, and similar devices.

1
PEDIATRIC NAUSEA
ACUPUNCTURE: AND VOMITING
THE EVIDENCE
Another promising area in pediatric acupuncture is
the relief of nausea and vomiting, specifically post-
PAIN operative nausea and vomiting and chemotherapy-
induced nausea and vomiting.

One of the conditions most commonly treated with

A double-blind prospective study on laser acupuncture
acupuncture in people of all ages is pain. According
for nausea and vomiting following eye surgery (13)
to a 2014 review (9), an estimated 30.8% of children
found that genuine laser acupuncture significantly
suffer from chronic pain and acupuncture may be
reduced vomiting compared with sham treatment, with
effective in the relief of migraines and tension type
symptoms occurring in just 5/20 patients compared
headaches, abdominal pain, acute post-operative
with 17/20 in the control group. Furthermore, just two
pain, and dysmenorrhea in adolescent girls.
patients in the genuine acupuncture group required
rescue antiemetic therapy compared with 14 in the
A retrospective review (10) found that children
control group.
attending an outpatient service experienced
significant improvements in various types of pain
These results are supported by a review conducted
including headaches and migraines, back pain, and
in 2015 (14) which concluded that acupuncture was
painful extremities following acupuncture. When
effective in the relief of post-operative conditions
children rated their pain on a scale of 1-10 (VAS),
including nausea and vomiting and delirium
they reported average reductions in pain from
following general anesthetic.
5.5 to 2.2 points, and 40% of patients reported a
complete resolution of symptoms.
A further 2016 review (15) of seven different pediatric
trials comprising 727 patients concluded that
Further studies suggest that acupuncture may also
acupuncture may reduce the risk of nausea and
be helpful in the treatment of costochondritis (11)
vomiting and decrease the need for anti-emetic
and acute pain due to appendicitis. (12)
medication. Side effects were found to be mild and
self-limiting and included skin irritation, blistering,
redness, and pain. However, the quality of the
evidence in most trials was deemed to be of low-
quality with a high risk of bias.

Trials on acupuncture for chemotherapy-induced

nausea and vomiting found that acupuncture
reduced the severity and duration of symptoms (16)
and also increased alertness among patients. (17)

2
 Cortex
STRENGTH OF EVIDENCE

Smooth
muscle
Brain Stem

REVIEWS & Cardiac

META-ANALYSES muscle

Spinal Cord

Glands

RANDOMISED
CONTROLLED
TRIALS Cutaneo-visceral Reflex

Interneuron Pathways

MANY
REPORTS

Sensory Nerve Ending

SINGLE
REPORTS

Sensory Nerve Ending

ANIMAL MODELS
(Mechanisms)

THE CENTRAL NERVOUS SYSTEM

3
COLIC CEREBRAL PALSY

A large study of 913 infants (18) aged 0–12 weeks found A 2018 meta-analysis of randomized controlled
that acupuncture significantly improved symptoms trials (24) looked at 21 studies and 1718 patients
such as inflated stomach and defecation rates in 690 comparing acupuncture plus rehabilitation with
of its subjects, while 201 subjects saw more subtle rehabilitation alone. The meta-analysis found that
improvements. However, other symptoms such as acupuncture provided improvements in gross motor
regurgitation actually increased following function and fine motor function with improvements
acupuncture treatment. in scales measuring muscle tone and spasticity.
Furthermore, there was a high total effective rate,
A further 2016 study (19) found that acupuncture reduced with only mild adverse effects reported. Of the 21
crying time in infants with colic, with more of its studies included in the analysis, three were classed
subjects crying for less than three hours a day (one of as grade A for quality, while the remainder were
the diagnostic criteria for colic) following acupuncture. classed as grade B.

A 2018 systematic review (20) of three randomized

controlled trials and 307 patients found that while
AUTISTIC SPECTRUM DISORDER
there were no differences after treatment, during
treatment babies treated with acupuncture had a 27
A 2009 systematic review (25) of new and emerging
minute reduction in crying and that the results were
treatments for ASD ranked acupuncture as a grade
statistically significant.
C treatment, meaning that its use is supported by
at least one non-randomized controlled trial or two
NOCTURNAL case series.
ENURESIS
Additionally, a 2011 review (26) including 10 trials
(BEDWETTING) and 390 children aged 3–18 years suggests that
acupuncture may improve functioning in children
with ASD. Six of the reviewed trials indicated
A 2017 study (21) of 20 patients aged 6–22 years found
improvements in both cognitive and global function,
that acupuncture benefited nocturnal enuresis
while a further two suggested improvements in
symptoms, as well as improving sleep and quality of life.
communication, linguistic skills, cognitive and
global function.
These results were supported by a 2015 review
of 21 studies and 1590 patients, which showed
(22)
A 2010 study (27) found significant improvements in
encouraging results for acupuncture as a treatment language comprehension and self-care following
for nocturnal enuresis. Outcome measures genuine electro-acupuncture compared with sham
included number of weekly wet nights, and treatment. Parents also reported improvements
maximum voided volume. However, only one study in sociability, receptive language, motor skills,
was deemed to be high-quality. coordination, and attention span.

A further 2017 review (23) of seven studies A 2018 review (28) found improvements in CARS and
conducted on children aged 7–15 years concluded ABC scores when acupuncture was combined with
that acupuncture was more effective for nocturnal behavioral and educational interventions, with an
4
enuresis than either placebo or drug therapy. ‘acceptable’ risk of adverse effects.
A further 2018 study (29) found that the greatest
NEONATAL CARE
improvements were in verbal communication. The
latter study also suggests that the efficacy of
acupuncture for ASD may reduce with increased age.
Neonates are often subjected to painful procedures
(32)
for which acupuncture may offer relief. (33)
ASTHMA Another condition for which acupuncture may be
useful is neonatal abstinence syndrome (NAS),
a group of symptoms experienced by babies
A 2013 study (30) of 52 children aged 6 months to 6 withdrawing from fetal exposure to illicit drugs or
years found significant improvements in asthma prescription medications such as opioids
symptoms following acupuncture treatment. and benzodiazepines.
However, these were not maintained following
the cessation of treatment, suggesting long-term One 2015 randomized, controlled, blinded trial (34) found
acupuncture therapy could be necessary. that infants with NAS required a reduced duration of
morphine therapy and had a reduced length of hospital
These results are supported by a 2015 systematic stay compared with control subjects, resulting in
review of seven studies and 410 patients (31) Two of reduced costs to the hospital of around 26.4%. A
the reviewed studies found improvements in peak retrospective review (35) found that infants with NAS
expiratory flow (PEF) following treatment, while showed improved feeding following acupuncture
another showed a reduction in asthma-related anxiety. treatment, and were calmer and slept better during
and immediately after treatment.

These findings are supported by a 2015 pilot study

of 20 infants with NAS (36) which recommended
acupuncture as a safe, feasible, and effective
treatment. Another review conducted in 2018 (37)
also confirms these results.

TREATMENT OPTIONS FOR CHILDREN: APPROACHES AND CONCERNS

One major concern regarding pediatric medicine is that off-label prescribing is a common practice, with
approximately half of all medicines insufficiently labelled for pediatric use as of 2012. (56) Although using
drugs off-label does not necessarily mean that they are dangerous, it does mean that there is insufficient
evidence regarding their safety and efficacy. This reality presents large and complex issues, especially
regarding neonates, infants under two years of age, and children with rare or chronic conditions. (57)
Conversely, acupuncture has been tried and tested over the course of many centuries and has proven safe
and effective, even for very young children. 5
BIOLOGICAL MECHANISMS OF PEDIATRIC ACUPUNCTURE

There are a number of different mechanisms and too little adenosine and ATP may be associated
underlying acupuncture’s physiological effects. with disease. However, self-regulation of purinergic
The most thoroughly researched area is pain. signaling as is promoted by acupuncture treatment
Numerous nerve pathways and biochemicals have is likely to be both effective and safe.
been identified as being involved in acupuncture’s
analgesic effects. These include Aδ, Aβ and C nerve In addition to biochemical actions, studies also
fibers, opioid neuropeptides including enkephalins, demonstrate the direct effects of acupuncture
endorphins, dynorphins, endomorphins, and on the central nervous system. These influence
nociceptin, and non-opioid neuropeptides including spinal reflexes, where acupuncture induces muscle
substance P (SP), vasoactive intestinal peptide relaxation and changes in visceral organs. In
(VIP) and calcitonin gene-related peptide (CGRP). the brain, acupuncture has been shown to alter
Several neurotransmitters are also involved functional connectivity and decrease activity in
including serotonin, norepinephrine, dopamine, limbic structures associated with stress and illness.
cytokines, glutamate, nitric oxide, and gamma-
amino-butyric-acid (GABA). (38) (39) Acupuncture simultaneously improves regulation of
the hypothalamus, pituitary, adrenal (HPA) axis, the
Many other pathways have been identified primary system that the body uses for regulating
which help to explain how acupuncture has such hormones and the physiological stress response. (54)
a diverse range of effects. Perhaps the most Additionally, acupuncture modulates activity in the
central of these is known as purinergic signaling, parasympathetic nervous system which is associated
a system in which adenosine triphosphate (ATP) with rest, relaxation, digestion and healing. (55)
plays a role in signaling and regulation of all
tissues and organs. (40) (41) ATP is required for nerve
transmission, and animal studies found that mice
bred with an inability to bind to adenosine did not
experience analgesia from acupuncture, while
normal mice did. (42) (43) This effect has also been
replicated in human studies. (44)

Purinergic signaling has been found to play a

role in diverse clinical areas including migraines
and headaches (45) immunity and inflammation
(46)
cancer, (47) autism, (48) Alzheimer’s, (49)
cardiovascular disease, (50) (51), and endocrine
function. (52)

While pharmaceutical companies are currently

attempting to develop drugs in these areas which
inhibit or enhance purinergic signaling, (53) safety is
an area of concern. As these compounds exist in a
delicate balance at the cellular level, both too much
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 ©2019

Saunders, N. Lic.Ac. BA(Hons) Traditional Acupuncture

Berry, K. BHSc TCM Acupuncture, MSc Research (Addictions) (2019).
Pediatric Acupuncture
Evidence Based Acupuncture.
EDITION 1