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Original paper

Acupuncture for treatment of hospital-induced
constipation in children: a retrospective case series
study
Eric Falk Anders,1 Annette Findeisen,2 Andreas Nowak,3 Mario Rüdiger,1Taras Ivanovich Usichenko4
1Department of Paediatrics, Carl
Gustav Carus University,
Hospital TU Dresden, Dresden,
Germany2
Department of Paediatrics,
University Medicine ofGreifswald, Greifswald, Germany
3
Department ofAnaesthesiology & Intensive
Care Medicine, Emergency
Medicine & Pain Management,
Dresden Friedrichstadt Hospital,Dresden, Germany
4Department ofAnaesthesiology and Intensive
Care Medicine, University
Medicine of Greifswald,
Greifswald, Germany
Correspondence toDr Eric Falk Anders, Departmentof Paediatrics, Carl Gustav
Carus—TU Dresden, Fetscher
Str. 74, 01307, Dresden,
Germany;
eric.anders@uniklinikumdresden.de
Accepted 30 July 2012

Abstract
Objective Acupuncture is a promising option in
the treatment of functional bowel disorders. The
aim of this study was to evaluate the feasibility andacceptance of acupuncture for the treatment ofhospital-induced constipation (HIC) in children.
Methods Bilateral stimulation of acupuncture point
LI11 was applied in 10 children with HIC using ﬁxed
indwelling acupuncture needles (0.9 mm long) before
considering starting conventional local constipation
therapy with laxative suppositories. The clinicalrecords were studied retrospectively for feasibility,acceptance and effectiveness of acupuncture.
Results Acupuncture was feasible in all children andapplication of the indwelling needles was tolerated
without fear. Side effects were not observed. After amedian of 3 days of HIC, all children defaecated within
2 h after LI11 stimulation. No patient required
conventional local constipation therapy.
Conclusions Acupuncture for the treatment of HIC
is feasible and acceptable. Its effect should be veriﬁed
in a randomised controlled trial.

INTRODUCTION
Constipation is one of the most common digestive disorders of childhood, with 10–45% of children visiting paediatric gastroenterologists withconstipation-related complaints.1 The pathophysiology of childhood constipation can originate from a number of factors. The vast majorityof patients do not have any inﬂammatory, anatomical, metabolic or neoplastic underlying
causes and a diagnosis of functional constipation is made.2 Functional constipation in childhood usually results in frequent absence fromschool, social isolation and feelings of depression.3 Common treatments for constipation arelaxatives, enemas and other invasive procedures
including manual removal of impacted faeces.
Standard therapy is usually accompanied byunwanted side effects such as cramping, bloating, dehydration and faecal incontinence.4
Recent research has therefore focused on milder
methods to treat constipation.
Acupuncture is one of the most frequently
applied methods of complementary medicine
in countries of the western world for a large
Acupunct Med 2012;0:1–3. doi:10.1136/acupmed-2012-010192

spectrum of clinical conditions.5 Although theneurohumoral mechanisms of needling areclearly shown in experimental studies, the clinical application of acupuncture is limited to theprevention and treatment of nausea and vomiting after general anaesthesia, during chemotherapy and pregnancy and the adjunctive
treatment of acute pain.6–9
Acupuncture is a promising treatment forfunctional bowel disorders in adults and children.10 11 To date, acupuncture for constipation
has only been used in paediatric patients withchronic constipation.12 There are no trials
evaluating acupuncture in acute hospitalinduced constipation (HIC), which occurs in
10–20% of children during inpatient treatmentof other diseases.13 We used acupuncture totreat HIC in children to evaluate the feasibility
and acceptance of this treatment modality andto generate preliminary data for a subsequent
randomised controlled trial.

METHODSThis was a retrospective case series investigation performed at the Department ofPaediatrics of the University Medicine ofGreifswald. The parents of children who
developed HIC between November 2008 andFebruary 2009 were invited to try acupuncture instead of standard therapy using laxative suppositories. HIC was deﬁned as nostool within 72 h after hospital admission.
We did not offer acupuncture to children who
had clinical symptoms of an acute abdomen
or massive coprostasis. The parents of all children agreed to have acupuncture performedon their children and gave their signed
informed consent. The ethics committee ofthe University of Greifswald retrospectively
approved the study design.
Fixed indwelling New Pyonex acupunctureneedles (Seirin Corporation, Japan) with adiameter of 0.22 mm and a length of 0.9 mm(ﬁgure 1) were applied by a paediatrician
licensed for acupuncture. The children weretold that they were going to receive ‘a sticker’
to relieve their complaints and were shown
the needle immediately before its application.

Copyright 2012 by British Medical Journal Publishing Group.

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Original paper

Figure 1 Fixed indwelling acupuncture needle New Pyonex (Seirin Corporation, Japan). (A) The needle embedded in adhesiveskin-coloured material with diameter 0.22 mm and length 0.9 mm (arrow). (B) The needle in situ with a plastic hemisphere (between
the two arrows), enhancing the effect of stimulation by massage.
The needles were applied unilaterally or bilaterally
depending on the placement of intravenous lines to acupuncture point LI11 (Qu Chi). LI11 is located at the lateralend of the transverse cubital crease midway between LU5(Chi Ze) and the lateral epicondyle of the humerus (ﬁgure2). LI11 was chosen as the most frequently used point for
constipation according to the recommendations publishedin text books on acupuncture.14 15
Indwelling needles were left in situ until the production of a stool. Patients, parents and nurses were encouraged to perform needle stimulation by means of massage
for 2–3 min twice an hour. If no stool had been produced
6 h after acupuncture, the child was given conventional
laxative therapy using rectal suppositories. The time
between acupuncture and defaecation was documented
in patient charts, and parents and older children wereasked about their opinion of the effectiveness of acupuncture as well as whether they would like to repeat thistreatment in case of recurrence of constipation.

Figure 2 Location of acupuncture point LI11. The indwelling
acupuncture needle in situ at LI11 (arrow). Acupuncture point
LI11 is located in the depression of the lateral end of thetransverse cubital crease when the elbow is ﬂexed.
2The data are presented in a descriptive manner using
median and range where appropriate. The sample size
calculation for a subsequent randomised controlled trial
was performed using the incidence of defaecation after
acupuncture as a primary endpoint.

RESULTS
Ten children (eight girls) of median age 5.5 years (range0.5–15) with HIC received acupuncture of LI11. All of
the children tolerated the insertion of the acupunctureneedles well and none developed anxiety before needling.
All children received acupuncture only once. No adverse
effects during and after acupuncture were recorded. There
were no skin complaints caused by acupuncture therapy
with indwelling acupuncture needles. All children defaecated within 2 h after acupuncture (table 1) and nopatient required conventional local constipation therapy.
Using the data from this investigation we calculated
the sample size for a subsequent randomised controlled
trial. Thirty-nine patients in each study group arerequired in order to detect a 30% difference in the incidence of defaecation between acupuncture and standard
therapy groups with a power of 80% and α=0.05.
DISCUSSION
The use of acupuncture for the treatment of HIC has
been analysed for the ﬁrst time in this retrospective
study. We demonstrate that the procedure of insertionand stimulation of ﬁxed indwelling acupuncture needles
was well accepted by both children and their parents.
The stimulation of acupuncture point LI11 was associated with defaecation within 2 h of application in allpatients without the need for administration of conservative local constipation therapy.
Acupuncture was shown to be a safe treatment modality in paediatric patients,16 although its application may
be complicated by fear of needles in children.17 However,in our investigation none of the children reported fear ofacupuncture needles. This observation is most likely associated with the design of the needles, which were
Acupunct Med 2012;0:1–3. doi:10.1136/acupmed-2012-010192

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Original paper
Table 1

Patient characteristics and clinical observations following acupuncture treatment
Parents’ opinion*

Patient
numberAge(years)

GenderConstipation
since (days)

Time fromacupuncture
to defecation (h)

12
3
4
5
6
7
8
910

3.75
8
2.5
0.5
15
4.5
2.25
15
6.25
8.75

FFMFFFFFFM

3
3
3
3
3
3
3
33
3

1
2
1.5
122
2
0.5
1
0.5

Acupuncture
helped?

Acupuncture
again?

11
1
1×××1×1

1
1
11×××1×1*0, no; 1, yes; ×, no reply.

originally created for auricular acupuncture. Theseneedles resemble a small ‘sticker’ with a length of
0.9 mm, in contrast to the long standard acupunctureneedles used for body acupuncture. Similar observations
were reported in a survey of children with severe chronic
pain in which the children described acupuncture treatment as pleasant and helpful.18 Acupuncture at LI11 isan easy, reproducible and safe intervention. In our pilot
series there was no necessity for additional conservative
local constipation therapies. Furthermore, we experienced
a high acceptance rate compared with laxatives in theform of enemas or rectal tubes, especially in older
children.
In a future randomised controlled investigation we aim
to compare LI11 stimulation with a standard therapy
regimen using conventional local constipation therapy.
This type of design will allow an evaluation of the entire
clinical effect of acupuncture including non-speciﬁc andspeciﬁc physiological effects.19

CONCLUSION
Stimulation of acupuncture point LI11 using ﬁxed
indwelling needles of 0.9 mm length is safe, has a highacceptance rate and may be an effective and supportive
therapy for HIC in children. This study provides important information for the design of an adequately powered
randomised controlled trial.

Summary points▸ 10 children had acupuncture for intercurrent constipation.
▸ All defaecated within 2 hours.

Acknowledgements The authors thank Marlies Rosenfeld, University Medicine ofGreifswald, for her assistance in the preparation of ﬁgure 1.
Contributors EFA: conception and design of study, acquisition of data, analysis andinterpretation of data, drafting and revision of the manuscript. AF: design of study,acquisition of data, approval of the manuscript. AN: interpretation of data, revision of
the manuscript, technical support. MR: analysis and interpretation of data, drafting
Acupunct Med 2012;0:1–3. doi:10.1136/acupmed-2012-010192

and revision of the manuscript. TIU: design of study, analysis and interpretation ofdata, drafting and revision of the manuscript.
Competing interests None.
Patient consent Obtained.
Ethics approval Ethics approval was obtained from the ethics committee ofUniversity Medicine Greifswald.
Provenance and peer review Not commissioned; externally peer reviewed.

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Downloaded from aim.bmj.com on September 3, 2012 - Published by group.bmj.com

Acupuncture for treatment of
hospital-induced constipation in children: aretrospective case series study
Eric Falk Anders, Annette Findeisen, Andreas Nowak, et al.
Acupunct Med published online August 21, 2012

doi: 10.1136/acupmed-2012-010192

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