72 Report

Acupuncture for Treatment of Acute Vomiting inChildren with Gastroenteritis and Pneumonia
Akupunktur zur Therapie von Erbrechen im Kindesalter im Rahmen vonGastroenteritis und Pneumonie

AuthorsAﬃliations

Key words▶ acupuncture●▶ vomiting●▶ children●▶ gastroenteritis●▶ pneumonia●▶ individual therapy attempt●
Schlüsselwörter
▶ Akupunktur●▶ Erbrechen●▶ Kindesalter●▶ Gastroenteritis●▶ Pneumonie●▶ individueller●
Therapieversuch

Bibliography
DOI http://dx.doi.org/
10.1055/s-0031-1283144
Published online:
August 3, 2011
Klin Padiatr 2012; 224: 72–75© Georg Thieme Verlag KG
Stuttgart · New YorkISSN 0300-8630
Correspondence
Dr. Eric Falk Anders, MD
Ernst-Moritz-Arndt Universität
Pediatrics
Ferdinand-Sauerbruch-Straße
17487 Greifswald
Germany
Tel.: +49/173/6040 961
Fax: +49/38/34 86
eric.anders@uniklinikumdresden.de

E. F. Anders1, A. Findeisen1, H. N. Lode1, T. I. Usichenko2
12

Ernst-Moritz-Arndt-University, Pediatrics, Greifswald, Germany
Ernst-Moritz-Arndt-University, Anaesthesiology, Greifswald, Germany

Abstract▼

Zusammenfassung▼

Objective: Acupuncture is successfully used toalleviate vomiting in children after general anesthesia. However there is no data on treatment ofvomiting in children with gastroenteritis (GE)and pneumonia (PM).
Methods: Descriptive analysis of 18 cases,
where acupuncture was used as an individual
therapy attempt to treat vomiting in children
with GE or PM before starting the conventionalantiemetic therapy. Feasibility and acceptance bypatients and parents as well as the incidence ofvomiting and use of antiemetic drugs after acupuncture were recorded.
Results: Acupuncture was feasible in all children and application of the indwelling needles
was tolerated without fear. Side eﬀects were notobserved. 13 patients stopped vomiting immediately after the insertion of acupuncture needles,none of the patients required conventional antiemetic medication.
Conclusion: Acupuncture for the treatment ofvomiting is feasible and acceptable. Suggested
antiemetic eﬀect should be examined in a randomized multicenter controlled trial.

Hintergrund: Akupunktur wird bereits erfolgreich eingesetzt, um bei Kindern das Auftretenvon Übelkeit und Erbrechen nach Allgemeinanästhesie zu verhindern. Es existieren jedoch
noch keine Daten zur Behandlung von Erbrechen
im Rahmen von Gastroenteritis (GE) und Pneumonie (PM).
Methoden: Deskriptive Analyse von 18 Fällen, in welchen Akupunktur als individueller
Therapieversuch bei Kindern mit GE oder PM
eingesetzt wurde, bevor eine konventionelle antiemetische Therapie begonnen wurde. Durchführbarkeit und Akzeptanz der Akupunkturtherapie, Inzidenz von Erbrechen und Einsatz vonAntiemetika wurden erhoben.
Ergebnisse: Akupunktur konnte bei allen
Kindern angewendet werden, und die Applikation der Akupunkturpflaster wurde von den
Kindern angstfrei toleriert. Es wurden keine
Nebenwirkungen beobachtet. Bei 13 Patienten
sistierte das Erbrechen mit dem Beginn der Akupunkturbehandlung, und keiner der Patienten
benötigte Antiemetika.
Zusammenfassung: Akupunktur scheint bei
Erbrechen eﬀektiv zu sein und wird von Kindern
gut angenommen. Der vermutete antiemetische
Eﬀekt sollte im Rahmen einer randomisierten, kontrollierten Multicenterstudie untersucht werden.

Introduction▼

during chemotherapy and pregnancy has been
evaluated and was found eﬀective when applied▶ Fig. 1) [6, 11, 14].
to the acupuncture point P6 (●P6 stimulation for prevention of postoperative
N&V was described as eﬀective as conventionalantiemetic drugs including metoclopramide, ondansetron and dexamethasone [13]. In the treatment of the incidence and severity of nausea, thestimulation of P6 was superior to serotonin(5-HT3) –receptor antagonist ondansetron: theincidence of nausea in the P6 group was 19 %Acupuncture is a traditional Chinese treatment
method using needle insertion at distinct sites ofthe body surface. It became one of the most frequently applied methods of complementary andalternative medicine (CAM) in countries of thewestern world for a large spectrum of clinicalconditions [16]. In this respect, the use of acupuncture in prevention and treatment of nausea
and vomiting (N&V) after general anesthesia,

Anders EF et al. Acupuncture for treatment of … Klin Padiatr 2012; 224: 72–75

Report 73

compared to 40 % in the ondansetron group and 79 % in the placebo group [8]. The use of acupuncture against postoperative
N&V at the P6 location was also evaluated in pediatric patientsand it was found as eﬀective as in adults [4, 14]. So far, the antiemetic properties of P6 stimulation in pediatric patients were
only used for N&V prevention in the perioperative setting and its
treatment during chemotherapy [4, 10], although acupuncture isa safe treatment modality for children [12]. There are no trials
evaluating acupuncture for treatment of N&V in the context ofcommon infectious pediatric diseases such as gastroenteritis
and pneumonia. In these conditions, vomiting is one of the key
symptoms accounting for reduced oral fluid intake and therefore
requiring hospitalization [5, 9]. Based on these considerations,
we analyzed feasibility and acceptance of acupuncture used as
an individual therapy attempt to treat vomiting in children withacute gastroenteritis and pneumonia and collected preliminary
outcome data in order to prepare for a controlled randomized trial.

Methods▼
Descriptive analysis of clinical records
The clinical records of children who received acupuncture as individual therapy attempt to treat acute vomiting between November 2008 and February 2009 at the Department of Pediatricsof the Ernst-Moritz-Arndt University Greifswald were studied.
The parents of the children, who were admitted to the hospital
because of acute vomiting, were all asked if they wanted to try
antiemetic acupuncture in addition to standard therapy. We did
not oﬀer acupuncture to children who revealed hemodynamic
instability, clinical symptoms of severe dehydration or who revealed symptoms of increased intracranial pressure upon admission. The parents of all children agreed to have acupuncture
performed on their children and signed the informed consent.

Fig. 1 Fixed indwelling acupunctureneedle. The indwelling
auricular acupunctureneedle (AA) from Seirin“NEW PYONEX”
auricular Japan wasused. The needle has adiameter of 0.22 mm
and a length of
1.5 mm.

M. flexor carpi
radialis

M. palmaris
longusP6

Fig. 2 Schematic location of stimulation point
Pericardium 6 (P6).
P6 (Neiguan) is locatedbetween the tendonsof the M. palmaris
longus and M. flexor
carpi radialis twice thewidth of an individual’s
thumb proximal to the
distal wrist crease.

Application of acupuncture
Fixed indwelling “NEW PYONEX” auricular acupuncture needles(AA) from Seirin, Japan, with a diameter of 0.22 mm and a length▶ Fig. 1) were applied by a pediatrician licensed forof 1.5 mm (●acupuncture before beginning the conventional antiemetic
therapy. Needles were applied uni- or bilaterally depending on theplacement of iv-lines to acupuncture point P6 (Pericardium 6,
Neiguan). P6 is located twice the width of an individual’s thumbproximal to the distal wrist crease, between the tendons of the▶ Fig. 2). The
M. palmaris longus and M. flexor carpi radialis (●needles were fixed with skin-colored adhesive tape and patients, parents and nurses were instructed how to stimulate theneedles in case of nausea and vomiting. The children were toldthat they will receive “a sticker”, which is going to relieve theircomplaints and the child was shown the needle immediately be▶ Fig. 3).
fore its application (●Indwelling needles were left in situ for about 2–3 days and patients,
parents and nurses were encouraged to perform needle stimulation by the means of massage for 2–3 min in the case of N&V.

Outcome analysis
Acceptance of acupuncture and subjective experience with thistherapy was analyzed using an interview at the end of each individual therapy attempt. The data on the incidence of nausea andvomiting and the frequency of the use of antiemetic medication
were extracted from patient’s chart and presented in a descriptive manner using median and range where appropriate. The

Fig. 3 Illustration of the indwelling acupuncture needle in situ.
The indwelling acupuncture needle is illustrated in relation to a penny(diameter: 18 mm).

sample size calculation for subsequent randomized controlled
trial was performed using the incidence of vomiting after initiation of therapy as a primary outcome endpoint.

Results▼
Description of the patients’ collective
The descriptive analysis of clinical records revealed 18 children(8 girls), aged from 0.5 to 10 years (mean 3.3 years), who received antiemetic acupuncture in addition to standard therapy.
The underlying disease was gastroenteritis (GE) in 10 patients,
Anders EF et al. Acupuncture for treatment of … Klin Padiatr 2012; 224: 72–75

74 Report

Table 1 Patient characteristics and clinical observations following acupuncture treatment.
Nr

Age

Sex

Dg. #

[yr]
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18

0.5
1.25
1.5
1.5
3.0
1.25
8.0
5.0
0.75
3.25
6.25
3.5
3.5
5.25
2.25
1.25
0.5
10.0

m
m
m
m
m
f
m
f
m
f
f
f
f
m
f
m
m
f

GE
GE
PM
PM
GE
PM
PM
GE
GE+PM
GE
GE
GE
GE+PM
GE
PM
GE
GE+PM
GE

Duration

Incidence ofTime to V after

Length of

Parents interview:

Parents interview:of V† [d]V after

acupuncture

Hospitalization“Acupuncture“Acupuncture

acupuncture

[d]

[d]

helped?”*treatment again?”*

4.0
2.0
11.0
4.0
1.0
4.0
5.0
2.0
3.0
1.0
2.0
1.0
2.0
1.0
9.0
2.0
2.0
3.0

0
1
0
1
X
1
1
X
1
X
1
0
1
X
X
X
1
1

0
1
0
1
X
1
1
X
1
X
1
1
1
X
X
X
1
1

0.0
4.0
1.0
1.0
3.0
0.0
1.0
2.0
0.0
1.0
3.0
3.0
1.0
1.0
0.0
1.0
1.0
2.0

0
0
1
1
1
0
0
0
0
1
0
0
0
0
0
0
1
0

5.0
3.0
1.0

1.0

1.0

#Diagnosis of individual patients: GE = Gastroenteritis, PM = Pneumonia†Duration of Vomiting before admission*0 = no, 1 = yes, X = no attendancepneumonia (PM) in 5 patients and 3 were diagnosed with both
▶ Table 1).
GE and PM (●Acceptance and safety of acupuncture
The application of the AA needles was feasible and well tolerated
in all children (18/18). None of the patients revealed signs ofanxiety before and during insertion of the needles. All patients
received acupuncture at the beginning of the therapy immediately after admission to the hospital. Indwelling needles remained at P6 for 2–3 days. 9 of 12 parents declared that acupuncture helped to stop vomiting and that 10 out of 12 would
choose acupuncture in the future to treat vomiting. 3 parents
did not indicate that acupuncture relieved vomiting and 2 ofthem would not use acupuncture again for the treatment ofvomiting. The children (n = 3) of parents indicating that acupuncture did not help had the following outcome: one childwith PM vomited once on the 5th day after application of theneedle and in 2 children with GE vomiting stopped immediately
after application of the needles. No adverse eﬀects during acupuncture were registered. There were no skin lesions under theacupuncture therapy with indwelling acupuncture needles.

Clinical eﬀects
In 13 out of 18 patients vomiting ceased immediately following
the first acupuncture treatment and did not reappear▶ Table 1). In 5 other patients, vomiting was observed only(●
once after acupuncture. In 3/5 (2 GE; 1 GE + PM) vomiting
occurred once on the 1st day after initiation of acupuncture, in
1/5 (PM) on the 3rd day and in 1/5 (PM) on the 5th day after acupuncture. None of the patients required conventional antiemetic
medication. The development of severe dehydration requiring
intensive therapy or invasive monitoring was not observed. Patients were discharged from the hospital on the 4th (3–5) day(median (range)). For patients with GE, the length of stay was
shorter: 2 (1–4) days (median (range)).

Anders EF et al. Acupuncture for treatment of … Klin Padiatr 2012; 224: 72–75

Sample size calculation for randomized controlled trial
Based on these observations we calculated the sample size for acontrolled trial with the null-hypothesis that acupuncture stimulation of P6 is not better than standard therapy with conventional antiemetic drugs using the cessation of vomiting within
8 h after the initial administration of either intervention. Assumptions for the calculation of the sample size are based on
this descriptive data and on results of previously publishedstudies [1]. A 30 % diﬀerence between the groups in the incidenceof vomiting after intervention is considered clinically relevant.
Based on the primary endpoint, 39 patients per group had to be
included to detect this diﬀerence with a power of 80 % and α = 0.05.

Discussion▼
The use of acupuncture for the treatment of vomiting associatedwith common infectious diseases was for the first time evaluated in this descriptive analysis [2]. The procedure of insertion andstimulation of fixed indwelling acupuncture needles was feasible and well accepted by both children and their parents. Interestingly, the stimulation of acupuncture point P6 was associatedwith immediate cessation of vomiting in the majority of patients
without the need for administration of antiemetic medication.
In recent controlled trials the eﬀectiveness of P6 stimulation forprevention of postoperative nausea and vomiting was evaluatedsuggesting the antiemetic eﬀect of P6 stimulation, which wascomparable to the eﬀect of antiemetic medication [3, 14, 16, 24].
Importantly, the eﬀect of antiemetic medication including ondansetron and dimenhydrinate reported in the literature appears not superior to our observation with acupuncture. In placebo-controlled clinical trials in pediatric patients with GE,
14–49 % of the children with GE vomited once after ondansetron
administration, 30 % vomited after dimenhydrinate, in comparison to 35–67 % vomiting in the placebo control [7, 18–20, 23, 25].
In our descriptive analysis, the single treatment with P6 stimula-Report 75

tion was associated with the immediate cessation of vomiting in
the majority of the children. Only 2 out of 10 (20 % ) children diagnosed with GE vomited once after acupuncture, postulating
the long-term eﬀect of P6 stimulation due to the insertion of theindwelling fixed needles. This might be a potential advantage
over other non-invasive psychological therapies (e. g. clown visits to hospitalized pediatric patients), which demonstrated only
short-term eﬀect to improve the psychological well-being ofchildren [17].
Moreover, none of our patients required antiemetic drugs after
acupuncture therapy. Furthermore, it is postulated, that the application of acupuncture in the pediatric population is complicated by the children’s fear of needles [21]. However, none of thechildren in our study reported fear of the acupuncture needles.
This observation is most likely associated with the design of the
AA needles, which were originally designed for so-called auricular acupuncture. These needles resemble a small “sticker” with alength of 1.5 mm in contrast to the long standard acupunctureneedle, used for body acupuncture. Indwelling needle “stickers”
can be safely applied for 2–3 days, so children experienced needle insertion only once at the beginning of the antiemetic acupuncture therapy. Most children hardly notice needle insertion
while the “sticker” was placed on the skin. Similar observations
were reported in a survey of children with severe chronic pain,
showing that children in pain found acupuncture treatment
pleasant and helpful [13]. Although this descriptive observation
analyzed only a small number of patients with N&V of diﬀerent
etiology without using a control group, several valuable observations were made useful to design a randomized trial. Importantly, the immediate cessation of vomiting in the majority ofthe patients, the absence of additional use of antiemetic therapies and the high acceptance rate with complete absence of thefear of needles provide an important base line for the design of arandomized multicenter clinical trial. Since a site-specific antiemetic eﬀect of P6 was already demonstrated in a variety of
randomized clinical trials [4, 6, 10, 13, 14], the design of our future trial will not implement a question related to the location ofneedle placement. Therefore we aim to compare P6 stimulation
with standard therapy regimen, using conventional antiemetic
drugs, which constitute an accepted and established method inclinical acupuncture research [15]. This type of design will allow
an evaluation of the entire clinical eﬀect of acupuncture including, non-specific and specific physiological eﬀects.
In case of acupuncture benefit for children on chemotherapy[10], N&V definitely had anticipatory pathophysiological component [22], which might have been sensitive to psychological(placebo) eﬀect of acupuncture. However, in the context of infectious diseases the type, origin and mechanism of N&V are notcompletely understood. In this case the placebo arm would be
helpful to distinguish the psychological eﬀect of acupuncture.

Conclusion▼
Stimulation of the P6 acupuncture point using indwelling fixedneedles was feasible and revealed a high acceptance rate. Thismethod may be an eﬀective supportive therapy for vomiting inchildren with common infectious diseases, such as GE. Our
descriptive data provide the sample size calculation for thedesign of an adequately powered, randomized multicenter controlled trial.

Conflict of interest: The authors have no conflict of interest to
disclose.
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