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Ko, Robert / Leung, Kelvin Sze-Yin / Tamayo, Carmen / Zhang, Zhang-Jin

Journal of Complementary and Integrative Medicine

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Developing an in-patient acupuncture treatment in a pediatric hospital

1Children’s Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, WI, USA

2Medical College of Wisconsin, Milwaukee, WI, USA

Citation Information: Journal of Complementary and Integrative Medicine. Volume 10, Issue 1, Pages 205–210, ISSN (Online) 1553-3840, ISSN (Print) 2194-6329, DOI: 10.1515/jcim-2012-0056, June 2013

Publication History

Received:
2012-12-04
Accepted:
2013-02-01
Published Online:
2013-06-12

Abstract: Little is known about the broad application of acupuncture as adjuvant treatment for in-patient pediatric populations. We review a series of cases involving acupuncture for conditions ranging from insomnia to cyclic vomiting. The details of the protocol for each are included. This case series illustrates the benefits of an in-patient acupuncture treatment service, as well as the subtleties of an acupuncture protocol when treating children and adolescents.

Keywords: pediatric acupuncture; complementary and alternative medicine; in-patient treatment services; pediatric pain

Introduction

While interest in acupuncture for pediatric populations is increasing, pediatricians rarely think of acupuncture as a therapeutic option, perhaps due to minimal exposure in traditional medical schools. Often, patients benefit substantially from the use of acupuncture when traditional medical therapies fail to address the need(s). This case series provides examples of the broad usage of acupuncture in pediatrics and importantly, provides examples of solutions to particular issues that may arise when working with children.

Although a small number of studies involving the use of acupuncture in pediatric populations exists in the literature [1,2,3,4,5], including case details on a small number of neonates and infants [1], there are no reports detailing the range of potential applications in hospitalized children and adolescents. Despite occasional reports of adverse effects associated with acupuncture therapy, acupuncture is reasonably safe in the hands of experienced and qualified individuals, as shown by two large, prospective studies in adult patients [6] and by reviews of studies involving pediatric patients [7, 8]. While interest in acupuncture for children is growing, not enough is known about treatment logistics [8] or about the broad usage potential for acupuncture therapy in pediatric samples. This article presents a series of cases that describe how acupuncture is now being used on hospitalized pediatric patients. Cases include specific details for each case/diagnosis. The hospital’s Institutional Review Board approved review and preparation for publication of the cases.

Case 1: perioperative nausea and vomiting

Problem: post-anesthetic nausea with impending spinal fusion surgery

A 14-year-old boy with cerebral palsy presented with a history of protracted nausea and vomiting after general anesthesia. He had undergone multiple minor outpatient surgical procedures for lower extremity tendon repair; the side effects were causing prolonged hospitalizations. The nausea and vomiting episodes were not responsive to traditional antiemetic medications or to the use of anesthetic techniques tailored to prevent these effects. The patient was facing an impending anterior and posterior spinal fusion to correct neuromuscular scoliosis. Both parents and patient were extremely anxious about the expectation of post-surgical nausea. The patient was a wheelchair bound, nervous teenager, with upper and lower extremity spasticity present. He was appropriately fasted for surgery. Vital signs: BP 110/82, P 100, R 16, a febrile.

Acupuncture protocol

The acupuncture protocol was undertaken in the operating room holding area the day of anterior spinal fusion. Bilateral PC 6 and ST 34 Needle type Serin No. 5(0.25)×30 mm needles were placed with low-frequency electrical stimulation (4 Hz) applied for 25 minutes before the patient was brought to operating room. The anesthetic was tailored to be non-emetogenic and the acupuncture procedure was repeated in the recovery room. The patient was allowed to recover two days from anterior fusion, with no signs of postoperative nausea. He then presented to the operating room for the posterior portion of his spinal fusion. Acupuncture treatment was repeated in the holding area and in the recovery room with no subsequent postoperative nausea or vomiting.

Case 2: myofascial pain and opioid-induced nausea

Problem: fibromyalgia pain requiring hospitalization

A 14-year-old female patient was admitted for pain control secondary to fibromyalgia and failed outpatient pain management. She complained of pain in the upper back, and was given intravenous patient controlled analgesia (PCA) with morphine to control the pain. She had nausea with use of the intravenous medication. The patient had surface fascia nodules with ropey muscle bands present in the sterncleidomastoid and trapezious musculature bilaterally. Vital signs: BP 115/72, P 95, R 18, a febrile.

Acupuncture protocol

In prone position, tender painful trigger points typical for fibromyalgia were identified with palpation. Needle type Serin No. 1(0.14)×30 mm. needles were advanced directly into the painful points until resistance in the tissue was felt. Each needle was advanced a bit further until Qi was appreciated and release of the muscle tension was felt. A slight red circle of skin was present around the needle. Fifteen needles were used. These were peppered across her upper back in the trigger points. She remained prone and a heat lamp was applied above the needles. The needles were left in place for 40 minutes, with occasional manual twisting done under the heat lamp. The mild red coloration of the skin around the needles slowly disappeared and after 45 minutes, the needles were removed. The patient had improvement of muscle pain and no longer needed intravenous medication for pain. She was discharged and followed up in chronic outpatient pain clinic for continued acupuncture therapy. She continued maintenance acupuncture twice per month for two months, then once per month for two months preceded by a treatment about every eight to nine weeks thereafter.

Case 3: pain associated with Herpez Zoster

Problem: chest pain with shingles

Aear-old boy, 60 kg, with acute lymphocytic leukemia (ALL), was hospitalized for chemotherapy and radiation therapy prior to living-related bone marrow transplant. His course was complicated by chest wall shingles (Herpes Zoster). He presented with pain in his chest, followed a day later by the appearance of a pustular rash in T1–2 distribution. His absolute neutrophil white cell count was 1,000/mm3, and platelet count was 55,000/mm3. Acupuncture was suggested but the white count was low and it was felt infection was a risk. Treatment was postponed until white cell count recovery. Pain scores were 8–9/10. He had poor sleep due to pain. The pain was being treated by PCA with intravenous morphine. Therapy also included calamine lotion locally and antiviral acyclovir at doses of 200 mg three times per day. The patient was drowsy. Vital signs: BP 121/70, P89, R 8/minute, T 101 F. Oxygen saturation 94% There was a pustular rash on the right chest in the distribution of the T1-T2 dermatone. Vesicles were draining and causing severe pain. He was unable to wear a shirt on his chest. Self-rated pain intensity was 9/10. He was using the PCA to the hourly maximum. He was on nasal prong oxygen 1 L, due to sedation and shallow breathing.

Acupuncture protocol

Tendinomuscular Meridian (TMM) was chosen in the face of an acute onset of the rash. Meridians involved were determined to be right heart and stomach. A concern was his low white cell count. Skin was prepped with alcohol and betadine prior to needling and he was informed that he might have some bruising on the basis of his low platelets. The rash on right chest was surrounded with eight Sterile, Serin No. 5 (0.25×30 mm) needles. Pustules were avoided. Gathering Point used SI 18 for Stomach meridian and GB 22 for Heart Meridian on right face and chest. Ting (extremity) points used were ST 45 in the foot and Ht 9 on the fifth digit on right. The patient was instructed to cough at the same time as placement of extremity points to distract from pain of needle placement.

Points were left in for 25 minutes, to allow erythematic reaction at the site of needle insertion to dissipate. Chest needles were rotated intermittently during this time. Pain level significantly improved to scores of 6/10. He slept well that night, with continued PCA and basal.

Acupuncture treatment was repeated daily for three successive days. PCA use declined and the doses were lowered on the first day after treatment. On treatment day 2, basal opioid infusion was discontinued when pain intensity was rated as 3–5/10. Oxygen was discontinued as breathing improved and the patient was less somnolent. After treatment day 3, the PCA was discontinued and the patient converted to an oral regimen for pain using morphine, which was weaned after two days.

Case 4: insomnia

Problem: insomnia in a chronically ill child with Crohn’s disease

A four-year-old boy with Crohn’s disease and a chronic history of fistulating enterocolitis was found to have genetic XIAP deficiency. One month after matched stem cell transplant, he was hospitalized for cerebral inflammation, confusion and insomnia. MRI showed hipocampal swelling consistent with HHV6 infection. An EEG showed slowing but no epileptogenic foci. He was on gancyclovir. Insomnia was not responsive to lorazepam, diphenhydramine, melatonin or aromatherapy. The treating team was reluctant to continue sedating medications due to worsening confusion. He had been awake continuously for six days. The patient was not oriented to place or time. Vital signs: BP 96/40, P 97, R 22, afebrile

Acupuncture protocol

Treatment was designed for manic states, insomnia, stress and parasympathetic calming. Needle type Serin No. 5 (0.25)×30 mm, sterile skin prep with alcohol Si Shen Cong, a cluster of four points was used, each approximately one Cun radius from GV-20, overlying and perpendicular to Du Mo., GV-20, P6, K6 bilaterally, with tonification of scalp points. Treatment was for 45 minutes with patient playing cards happily in bed. That evening, six hours of sleep were recorded. Treatment was repeated the next two days, with continued improvements in sleep hygiene.

Case 5: cyclic vomiting

Problem: cyclic vomiting and chronic nausea

An 18-year-old female with postural orthostatic tachycardia syndrome, chronic migraines, and unable to attend school, presented with cyclic vomiting and chronic nausea unresponsive to antiemetic medications. The patient was on propranolol and amitriptyline for migraines. Upper endoscopy was performed with normal results. She was a well-groomed female, wearing makeup, calm in hospital bed, with reported severe nausea, and an emesis basin at her side. Vital signs: BP 110/80, P 87, R 20, a febrile.

Acupuncture protocol

Needles Serin No. 5(0.25)×30 mm. PC6 bilaterally, ST 36 with low frequency electrical stimulation between two points, 4 Hz. MU points CV 12, ST 25 bilaterally, CV 14, LR3 bilaterally. Treatment duration was 35 minutes with complete resolution of nausea.

Case 6: myofascial pain

Problem: muscular pain associated with prolonged ileus after colectomy for chronic constipation

The patient was a dishevelled teenage male with a nasogastric tube in place and a midline abdominal scar. Vital signs: BP 110/67, P 98, R 20, a febrile. There were multiple tense “muscle knots” from base of the scalp extending throughout sternocliedomastoid musculature. He had not responded to weekly physical therapist massage techniques and was utilizing PCA morphine for pain.

Acupuncture protocol

Needles Serin No. 01(0.14)×30 mm and Serin No. 5(0.25)×30 mm. The patient was unable to lay prone due to abdominal discomfort, so he was positioned in sitting position, with his arms and head on pillow on his bedside table. The back muscle knots were identified with gentle palpation. Serin No. 1 needles were used to pierce knots, with approximately 15 needles distributed from scalp to lower back muscles. Serin No. 5 along bilateral kidney meridian from T10-L4 was also used. Ming Men at L4–5 was supplemented to his first treatment session. Treatment duration was 25 minutes for the first session, with immediately improved pain. This was repeated in two days with the patient lying prone, on two pillows supporting abdomen as the pain was further improved. The treatment was repeated in the pain clinic two days later on an acupuncture table. Cups and heat lamp were added to the above treatment for 45 minutes. Pain symptoms improved such that he was able to be discharged from the hospital the next day.

Case 7: chemotherapeutic nausea

Problem: chemotherapeutic induced nausea

The patient was a 16-year-old boy treated for ALL, including living related bone marrow transplant. His treatment included cisplatinum, which caused severe nausea after each round of chemotherapy. He was unable to take oral nutrition, and was unresponsive to intravenous medications for nausea. He was a thin male with alopecia. A central line was present in the chest. He was holding an empty kidney basin at his side for vomiting. Vital signs: 124/65, 90, 22, a febrile.

Acupuncture protocol

Needles Serin No. 1(0.14)×30 mm. Skin prepped at points used with alcohol prep.

Bilateral Points PC6, ST 34, ST36. Low-frequency electrical stimulation from PC6 to ST 34 at 4 Hz for 25 minutes. Treatment was repeated daily for three days and resulted in slow recovery from nausea. Patient was able to eat solids after the third day.

Case 8: chemotherapeutic nausea and patient refusal

Problem: chemotherapeutic induced nausea

The patient was a 14-year-old male, with second relapse of ALL, on chemotherapy who presented with alopecia, chronic nausea, and depression. Nausea was unresponsive to prophylactic medications. His family was anxious about trying acupuncture therapy. LR was approached by the patient’s hematologist about offering acupuncture services.

On arrival, the room was dark, shades pulled, lights out. The patient was soft spoken, and was lying curled under many blankets. Vital signs: BP 125/70 P91, R 19, a febrile.

LR explained the use of acupuncture for nausea, showed needle sizes, and placed one in mother’s arm to demonstrate, but patient refused therapy. Reading materials were provided to the patient on the benefits of using acupuncture for chemotherapeutic nausea. He later told his psychologist that he felt pressured to do acupuncture and it made him angry. The patient continued to experience chronic retching. Two weeks later, the patient reluctantly agreed to try acupuncture after the attending hematologist insisted that patient try this therapy, as he had “nothing else to offer.”

Acupuncture protocol

Needles Serin No. 1(0.14)×30 mm. Skin prepped at points used with alcohol.

Bilateral Points PC6, ST 34. Low frequency electrical stimulation from PC6 to ST 34 at 4 Hz was applied for 30 minutes.

Retching resolved immediately post-treatment. The treatment was repeated the next day and patient was able to eat chicken nuggets, and go on pass from the hospital for several hours. The managing hematologist reported that the patient was upright walking the halls, and had more energy than usual. LR repeated treatment every other day for five treatments, after which, the patient was able to be discharged from hospital.

Discussion

This case series extends the literature on the usefulness of acupuncture in pediatric samples in the hospital setting. These cases demonstrate that acupuncture may be helpful in a variety of cases, and can be tailored to the situation demanded by the case. With more families desiring complementary and alternative approaches for their child’s treatment [7], the use of acupuncture for inpatients meets those needs and increases the convenience for such families.

Acupuncture and other forms of alternative medicine have existed quietly in the United States for a number of years. Nonetheless, it was estimated that people were spending $14 billion out of pocket dollars for acupuncture therapy [9]. Studies have shown that between 1990 and 1997, increasing proportions of the population were seeking and paying for alternative therapy, including acupuncture [10]. Since 1997, when a consensus conference on Acupuncture held by the National Institutes of Health (NIH) found clear cut evidence for the benefits of acupuncture, particularly pain conditions, patients visits to acupuncturists have steadily increased and at least 600 more clinical trials have been published worldwide [11], however, challenges still remain. To incorporate acupuncture, with its extensive history into Western medicine, close accounting of how and when it is used, and resolving issues through the scientific method will be important. This is particularly true when treating children.

Fourteen years ago, the use of acupuncture for pediatric patients was slowly on the rise in the United States [12]. In a review of acupuncture at another pediatric centre, patients who had severe chronic pain found acupuncture treatment to be pleasant and helpful [13]. An increasing number of studies on acupuncture in children and adolescents can be found in the literature. For example, Schwartz et al. looked at the stress response in premature infants undergoing eye examination for retinopathy of prematurity. Patients with acupuncture showed a significantly blunted stress response as measured by salivary cortisol levels [14]. A review in Pediatric Clinics reported on the successful use of acupuncture for various pediatric chronic pain conditions, such as migraine headache, complex regional pain syndrome and endometriosis [15]. Eight treatments were used over a three-month period, on an outpatient basis. Most patients (70%) felt the treatments helped their condition.

While acupuncture is typically used in the outpatient setting, it can also be used in the inpatient setting, as exemplified by the successful use of acupuncture therapy in the above cases representing various medical dilemmas. Acupuncture therapy can also be used to treat nausea and vomiting associated with cancer chemotherapy, a typical in-patient medical problem [16].

With the increased use in children, the safety of acupuncture has been investigated. Adams et al. [7] reviewed 18 databases resulting in 37 reports. Of the adverse events reported, the majority were mild in nature, including bruising, and pain. More importantly, however, a small number of serious adverse events were reported, including cardiac rupture, pneumothorax, HIV, intestinal obstruction, overnight hospitalization and reversible coma. It is important to note that the authors identified substandard practice as the cause for many of the serious adverse effects. The authors conclude that overall, acupuncture is safe for children when performed by appropriately trained practitioners, which is similar to a prior report on the safety of acupuncture for children [8] and adults [6]. Knowledge of anatomy and surrounding structures is imperative as needle placement is crucial to success and avoidance of terrible consequences. In our series, in addition to being performed by a trained specialist, critical precautions specific to the patient’s condition were used. A leukemic patient with non-existent platelets was avoided, and sterile prep of skin was used in immune compromised patients. Sterile, single use needles were always employed.

Case 8 exemplifies the need to educate patients and their families about the benefits of acupuncture. Certainly, patient refusal is a legitimate reason not to pursue acupuncture. Often, there is substantial benefit when traditional measures for nausea have failed. In the case of refusal presented, the patient did see benefits after he allowed simple needle treatment. Proceeding cautiously with children and adolescents is key to success in many cases.

Pediatricians rarely think of acupuncture as a therapeutic option, perhaps due to lack of training and familiarity with acupuncture in traditional medical schools. While complications can occur, such as pneumothorax or infections [7], if trained personnel are available to use acupuncture on in-patients, it should be considered when traditional medical therapies are failing to address the problem(s). Risks are minimized if practitioners are adequately trained.

These cases support consideration of acupuncture by pediatricians as a helpful treatment tool for in-patients, when trained acupuncturists are available. While we found use of acupuncture to be beneficial in these specific case presentations, there is still substantial need for more acupuncture research targeted at children alone. Based on objective and standardized treatment principles and methods, the day may come when mechanisms of acupuncture are understood and applied in Western pediatric medicine.

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