Complementary Therapies in Medicine Volume 41 (2018) 10-22
Pediatric Tui Na for acute diarrhea in children under 5 years old: A systematic review and meta-analysis of randomized clinicalBao-yong Lai (a), Ning Liang (a), Hui-juan Cao (a), Guo-yan Yang (b), Li-yan Jia (a), Rui-xue Hu (a), Chun-li Lu (a), Nan-qi Zhao (a), Sai-nan Fang (a), Xue-han Liu (a), Ya-jing Zhang (a), Yu-tong Fei (a), Da-rong Wu (c), Jian-ping Liu (a)
a Centre for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, Beijing, 100029, China
b NICM Health Research Institute, Western Sydney University, Penrith, NSW, 2751, Australia
c The 2nd Affiliated Hospital of Guangzhou Universality of Chinese Medicine, Guangzhou, 510000, China
Abstract
Objective: To evaluate the benefits and harms of pediatric Tui Na as a non-pharmaceutical Chinese medicine therapy for acute diarrhea in children under 5 years of age.
Design: Systematic review and meta-analysis of randomized clinical trials.
Methods: We searched seven major English and Chinese databases from their inception to January 2018 for randomized clinical trials (RCTs) comparing pediatric Tui Na therapy with conventional medicine (montmorillonite/diosmectite or probiotics used alone or in combination). Two authors extracted data and assessed the Cochrane risk of bias, independently. The primary outcomes are clinical cure rate and diarrhea duration from admission to the cessation of diarrhea. ‘Clinical cure’ is defined as the frequency, timing and character of stool back to normal status, as well as disappearance of diarrhea symptoms. We present dichotomous data as risk ratio (RR), and continuous data as mean difference (MD) with their 95% confidence interval (CI). We used the Cochrane’s Revman software (v.5.3) for data analysis. Trial sequential analysis (TSA) was applied to calculate the required sample size in a meta-analysis and detect the robustness of the results. The GRADEpro was used to generate a summary of finding table.
Results: Totally 26 RCTs were included, involving 2410 children with acute diarrhea. Most of the included trials had high or unclear risk of bias in terms of random sequence generation, blinding, and incomplete outcome reporting. The pooled results demonstrated that pediatric Tui Na was superior to montmorillonite after three-session treatment (RR 1.45, 95% CI 1.29–1.62, n=772, 10 trials), and also superior to montmorillonite combined with probiotics after three-session treatment (RR 2.04, 95% CI 1.49–2.78, n=533, 7 trials) and after six-session treatment (RR 1.52, 95% CI 1.34–1.73, n=631, 5 trials) in improving clinical cure rate. Pediatric Tui Na significantly decreased the duration of acute diarrhea (hrs) (MD -0.40 h, 95% CI -15.31 to -5.48 h, n=410, 6 trials) and daily stool frequency (MD -1.71times, 95% CI -2.37 to -1.04, n=217, 3 trials, after three-session treatment). No adverse event related to pediatric Tui Na was reported in the included trials. The quality of evidence of included trials was generally moderate to low. TSA for cure rate demonstrated that the pooled data reached a sufficient power regarding both numbers of trials and participants.
Conclusions: This review shows pediatric Tui Na appears to be effective and safe in improving clinical cure rate and shortening diarrhea duration in childhood aged less than five years of age with acute diarrhea. However, rigorously designed well-reported RCTs are warranted to confirm the findings.
https://www.sciencedirect.com/science/article/pii/S0965229918303716Excerpts:
"Pediatric Tui Na, as one of the traditional Chinese medicine (TCM) therapies, is a therapeutic massage for children. When give pediatric Tui Na, the practitioner may stimulate specific acupoints in the fingers, palms, arms or other areas of children’s body, as well as Tui Na manipulations in Du meridian (Governor vessel) or the abdomen. The frequently used acupoints and treating areas are shown in Appendix Fig. A1 . Pediatric Tui Na has been used for a long time in infants and children in China, especially when oral or intravenous administration of medication is not well-tolerated. One 2012 and 2016 systematic reviews , involving 15 trials and 16 trails separately demonstrated that pediatric Tui Na on childhood diarrhea had beneficial effect on total effect rate in children with diarrhea. However, the two systematic reviews did not specify the course of diarrhea, age of the children, details of control treatment, which increase the difficulty of interpreting the findings. In addition, the outcome assessment is only total effect rate, which is not internationally recognized outcome. Therefore, this systematic review aims to evaluate the effects and safety of pediatric Tui Na for the treatment of acute diarrhea in children less than 5 years of age."
"The top 10 acupoints or treating areas applied in the 26 included trials include: Spleen Meridian (located on the radial side of the thumb or the helicoid of thumb) (88.4%, 23/26 trials, 30–500 times), Abdomen/Abdominal Rubbing (by rubbing the abdomen with the whole palm) (84.6%, 22/26 trials, 30–500 times), Large Intestine Meridian (at the radial side of the index finger, a straight line between the index fingertip to the root of the finger) (76.9%, 20/26 trial, 90–300 times), Seven Segment Bone ( Qi Jie Gu) (located in the back midline, the fourth lumbar vertebra to the upper end of the caudal vertebra, into a straight line) (73.1%, 19/26 trials, 20–300 times), Gui wei/ Chang Qiang (DU1)) (located in the lower center of the tail of the caudal bone, clinically around Chang qiang acupoint) (69.2%, 18/26 trials, 9–300 times), Spine Pinching/Knead Ridge (the straight line between the Da Zhui (DU14) and Chang Qiang (DU1)) (61.5%, 16/26 trials, 3–15 times), Ban Men (The center area of thenar plane) (46.2%, 12/26 trials, 30–200 times), Zu San Li (ST36) (42.3%, 11/26 trials, 50–300 times), Shen Que (CV8) (38.4%, 10/26 trials, 100–500 times), and Small Intestine Meridian (located in the ulnar margin side of small finger, from small fingertip to the root of the finger, into a straight line) (38.4%, 10/26 trials, 100–200 times)."
"Pediatric Tui Na seems to be more effective than conventional treatment in treating acute diarrhea for children under 5 years old. However, the level of the evidence for all outcomes were assessed as 'moderate' or 'low' due to high risk of bias and considerable clinical and statistical heterogeneity among included studies. Pediatric Tui Na appears to be safe for children with acute diarrhea; however, there is still insufficient evidence allowing us to draw a conclusion on safety of this therapy."
"There are some limitations of this review. Firstly, the correspondent therapeutic method of pediatric Tui Na is traditionally conducted under guidance of the syndrome differentiation based on TCM theory. Syndrome differentiation (bian zheng) is performed base on the causative factors, symptoms and property of stools. It serves as guidance for pediatric Tui Na therapeutic methods. However, the causative factors of acute diarrhea and syndrome differentiation of TCM were not fully reported. As a result, it is difficult for us to draw conclusions based on TCM syndrome differentiation and for specific type of acute diarrhea."
"Due to the application characteristics, it is difficult to implement blinding to the practitioners and patients in trials on Pediatric Tui Na therapy. However, it is possible to apply blinding in outcome assessors."
"This review suggest that pediatric Tui Na therapy is potentially effective in children under five years old with acute diarrhea. No serious adverse events were reported related to pediatric Tui Na. However, there is still insufficient, convincing evidence allowing us to draw a conclusive conclusion on effectiveness and safety of pediatric Tui Na therapy."
"This work is supported by the fund from Beijing University of Chinese Medicine for the project on research and development of evidence-based medicine of clinical scientific research Capacity and international development in TCM (No. 2016-ZXFZJJ-011 )."
