Acupuncture for children

Translation- Evidence Based Acupuncture Evidence Summary – Pediatric Acupuncture

Authors: Saunders N. Lic.Ac. BA (Hons) Traditional Acupuncture, and Berry K. BHSc TCM Acupuncture, MSc Research (addictions)

Introduction
The prevalence of chronic conditions in children is increasing: 13-27% of children are now suffering from chronic conditions [1]. These conditions can persist into adulthood and have a significant impact on the family and the affected child. It is therefore not surprising that many families are turning to Complementary and Alternative Medicine (CAM)* and Integrative Medicine (IM)*, including acupuncture and related therapies, for their children's conditions [2,3].

*Complementary and Alternative Medicine (CAM) is a term used worldwide. IM is the English abbreviation for Integrative Medicine.

Acupuncture-related therapies include the non-invasive stimulation of acupuncture points with moxibustion and manual pressure (Tui Na), lasers, TENS devices, and similar devices.

From various studies, it has been shown that acupuncture and related therapies are promising in the treatment of pain in children, cerebral palsy, bedwetting, tics, lazy eye, nausea and vomiting, digestive disorders, autism spectrum disorder, and respiratory disorders [4,5,6]. Additionally, acupuncture is considered safe and well-tolerated [7,8] with a very low risk of serious side effects.

Pain
One of the conditions most commonly treated with acupuncture in people of all ages is pain. According to a 2014 review [9], an estimated 30.8% of children suffer from chronic pain, and acupuncture can be effective in relieving migraine and tension headaches, abdominal pain, acute postoperative pain, and painful menstruation (dysmenorrhea) in adolescent girls.

A retrospective study [10] showed that children visiting a clinic experienced significant improvements in various types of pain, including headaches and migraines, back pain, and painful limbs after acupuncture. When children rated their pain on a scale of 1-10 (VAS), they reported an average decrease in pain from 5.5 to 2.2 points, and 40% of patients reported the complete disappearance of symptoms.

Further studies suggest that acupuncture may also be beneficial in the treatment of costochondritis [11,12] and acute pain from appendicitis [13].

Nausea and Vomiting
Another promising area for pediatric acupuncture is the relief of nausea and vomiting, especially postoperative nausea and vomiting and chemotherapy-induced nausea and vomiting.

From a double-blind prospective study on laser acupuncture for nausea and vomiting after eye surgery [14], it was found that 'real' laser acupuncture significantly reduced vomiting compared to a sham treatment, with only 5/20 patients experiencing these symptoms compared to 17/20 in the control group. Additionally, only two patients in the real acupuncture group required intervention with anti-nausea and vomiting medication (antiemetics), compared to 14 in the control group.

These results are supported by a 2015 review [15] which concluded that acupuncture was effective in relieving postoperative conditions, including nausea and vomiting, and delirium after general anesthesia.

Another review from 2016 [16] of seven different pediatric studies involving 727 patients concluded that acupuncture can reduce the risk of nausea and vomiting and decrease the need for antiemetic medication. The side effects were found to be mild and self-limiting, including skin irritation, redness, and pain. However, the quality of evidence in most studies was low with a high risk of bias.

In studies on acupuncture for chemotherapy-induced nausea and vomiting, it was found that acupuncture reduced the severity and duration of symptoms [17] and also increased patients' alertness [18].

Stomach Aches
From a large study involving 913 babies [19] aged 0-12 weeks, it was found that acupuncture provided a significant improvement in symptoms such as bloated stomach and bowel problems for 690 of the infants, while 201 patients experienced more subtle improvements. However, other symptoms, such as regurgitation, increased after an acupuncture treatment.

Another study from 2016 [20] showed that acupuncture reduced crying time in babies with colic abdominal pain, with more infants crying less than three hours a day after acupuncture (crying more than three hours a day is one of the diagnostic criteria for colic abdominal pain).

A systematic review from 2018 [21] of three randomized controlled trials and 307 infants found that although there were no differences after treatment, during treatment, babies treated with acupuncture cried 27 minutes less and the results were statistically significant.

Bedwetting
From a 2017 study [22] involving 20 patients aged 6-22 years, it was found that acupuncture was beneficial for bedwetting (nocturnal enuresis) and also improved sleep and quality of life.

These results were supported by a review from 2015 [23] of 21 studies and 1590 children, which showed encouraging results for acupuncture as a treatment for bedwetting. Outcome measures included the number of wet nights per week and the maximum voided volume. However, only one of the studies examined was considered to be of high quality.

A more recent review from 2017 [24] of seven studies involving children aged 7-15 years concluded that acupuncture was more effective for nocturnal enuresis than placebo or drug therapy.

Cerebral Palsy
A meta-analysis from 2018 of randomized controlled trials [25] examined 21 studies and 1718 patients comparing acupuncture plus rehabilitation to rehabilitation alone. The meta-analysis showed that acupuncture led to improvements in gross motor function and fine motor function with enhanced scores on assessment scales measuring muscle tone and spasticity. Furthermore, there was a high overall effectiveness score with only mild side effects reported. Of the 21 studies included in the analysis, three were classified as grade A for quality (strong evidence) while the rest were classified as grade B (reasonably strong evidence).

Autism Spectrum Disorder
A systematic review from 2009 [26] of new and emerging treatments for Autism Spectrum Disorder (ASD) ranked acupuncture as a grade C treatment, meaning its use is supported by at least one non-randomized controlled trial or two case series. Additionally, a review from 2011 [27] involving 10 studies and 390 children aged 3-18 years suggests that acupuncture may improve functioning in children with ASD. Six of the studies examined showed improvements in both cognitive and overall functioning, while another two studies suggested improvements in communication, language skills, cognitive, and overall functioning.

A study from 2010 [28] found significant improvements in language comprehension and self-care after 'real' electro-acupuncture compared to a sham treatment. Parents also reported improvements in sociability, receptive language, motor skills, coordination, and attention span. A review from 2018 [29] found improvements in CARS and ABC scores when acupuncture was combined with behavioral and educational interventions, with an 'acceptable' risk of side effects. Another study from 2018 [30] found that the greatest improvements were in verbal communication. This latter study also suggests that the effectiveness of acupuncture for ASD may decrease with age.

Asthma
A study from 2013 [31] involving 52 children aged 6 months to 6 years found significant improvements in asthma symptoms after acupuncture treatment. However, these improvements were not sustained after treatment cessation, suggesting that long-term acupuncture therapy may be necessary. These findings are supported by a 2015 systematic review of seven studies and 410 patients [32]. Two of the reviewed studies reported improvements in expiratory peak flow (PEF) after acupuncture, while another study showed a reduction in asthma-related anxiety.

Neonatal Care
Newborns are often subjected to painful procedures [33] for which acupuncture can provide relief [34]. Another condition for which acupuncture may be useful is neonatal abstinence syndrome (NAS), where the baby experiences withdrawal symptoms due to fetal exposure to drugs or medications such as opioids and benzodiazepines.

A randomized, controlled, blinded study [35] from 2015 showed that babies receiving acupuncture treatments for NAS needed less morphine and had shorter hospital stays compared to the control group, resulting in approximately 26.4% lower hospital costs. A retrospective study [36] demonstrated that babies with NAS showed improved feeding, were calmer, and slept better during and immediately after treatment.

These findings are supported by a pilot study from 2015 involving 20 babies with NAS [37] in which acupuncture was recommended as a safe, feasible, and effective treatment. Another review conducted in 2018 [38] confirms these results.

Biological Mechanisms of Pediatric Acupuncture
Several mechanisms underlie the physiological effects of acupuncture. The most thoroughly researched indication area is pain. It has been established that numerous nerve pathways and biochemicals are involved in the pain-relieving effects of acupuncture. These include Aδ, Aβ, and C nerve fibers, opioid neuropeptides including enkephalins, endorphins, dynorphins, endomorphins, and nociceptins, and non-opioid neuropeptides including substance P (SP), vasoactive intestinal peptide (VIP), and calcitonin gene-related peptide (CGRP). Various neurotransmitters are also involved, including serotonin, noradrenaline, dopamine, cytokines, glutamate, nitric oxide, and gamma-aminobutyric acid (GABA). [39,40]

There have been many other pathways identified that help explain how acupuncture has such a diverse range of effects. Perhaps the most important of these is known as purinergic signaling, a system in which adenosine triphosphate (ATP) plays a role in the signaling and regulation of all tissues and organs [41,42]. ATP is not only important in energy metabolism but is also required for nerve transmission. Animal studies showed that mice bred with an inability to bind adenosine did not experience analgesia from acupuncture while normal mice did [43,44]. This effect has also been replicated in human studies [45].

Purinergic signaling appears to play a role in various clinical areas, including migraine and headache [46], immunity and inflammation [47], cancer [48], autism [49], Alzheimer's disease [50], cardiovascular diseases [51,52], and endocrine functions [53]. While pharmaceutical companies are currently trying to develop drugs that inhibit or enhance purinergic signaling [54], safety is a point of concern. Because it involves a delicate balance of substances and compounds at the cellular level, both excessive and insufficient adenosine and ATP can be associated with disease. Self-regulation of purinergic signaling, as promoted by acupuncture treatments, is likely to be both effective and safe.

In addition to biochemical actions, studies also demonstrate the direct effects of acupuncture on the central nervous system. These influence spinal reflexes, with acupuncture causing muscle relaxation and changes in the intestines. In the brain, acupuncture has been shown to alter functional connectivity and reduce activity in limbic structures associated with stress and illness. Acupuncture simultaneously enhances the regulation of the hypothalamic-pituitary-adrenal (HPA) axis, the primary system the body uses to regulate hormones and the physiological stress response [55]. Additionally, acupuncture modulates activity in the parasympathetic nervous system associated with rest, relaxation, digestion, and healing [56].

Treatment Options for Children: Approach and Concerns
An important point of concern regarding pediatrics is that off-label prescribing is a common practice, with approximately half of all medications in 2012 being inadequately labeled for pediatric use [57]. While off-label use of medications does not necessarily mean they are dangerous, it does indicate a lack of evidence regarding their safety and efficacy. This reality poses significant and complex issues, especially concerning newborns, infants under two years old, and children with rare or chronic conditions [58]. In contrast, acupuncture has been tried and tested over many centuries, proving to be safe and effective, even for very young children.

Epilogue
In September 2022, a study was initiated in the Netherlands from the AMC to investigate the experiences and attitudes of children, parents, and pediatricians regarding Complementary Medicine (CAM), including specifically acupuncture, in children with gastrointestinal disorders. Functional gastrointestinal disorders, known as FGIDs, are common in children. The study will contact parents and pediatricians of children (0-18 years) with four common gastrointestinal diagnoses (functional constipation, functional abdominal pain, gastroesophageal reflux disease, and excessive crying) to complete a digital questionnaire. Despite conventional treatment, a large number of children remain symptomatic, and many parents turn to complementary and alternative medicine (CAM). One of the CAM modalities of particular interest is acupuncture, which has been shown to be effective in treating adults with FGIDs. Children, parents, and pediatricians from 5 participating medical centers will receive a digital questionnaire as part of the study. It is expected that a follow-up study (interview study) will commence in 2024. Attitude towards the use of Complementary and Alternative Medicine in children with gastrointestinal symptoms (ATCAM)

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