|Year : 2018 | Volume
| Issue : 3 | Page : 96-104
Pediatric massage for the treatment of anorexia in children: A meta-analysis
Li Gao, Chun-Hua Jia, Si-Si Ma, Tong Wu
Department of Jin Gui, School of Preclinical Medicine, Beijing University of Chinese Medicine, Beijing 100029, China
|Date of Submission||12-Apr-2018|
|Date of Acceptance||16-Aug-2018|
|Date of Web Publication||10-Oct-2018|
School of Preclinical Medicine, No. 11 North 3rd Ring East Road, Chaoyang District, Beijing 100029
Source of Support: None, Conflict of Interest: None
Objective: Anorexia is the long-term decreased sensation of appetite. Besides the pharmacotherapy, in China, massage therapy is also used by many traditional Chinese medicine physicians to treat anorexia in children. This paper conducted a meta-analysis to evaluate the efficacy of massage therapy for the treatment of anorexia in children. Methods: Seven databases were used in our research as follows: Cochrane Library, Web of Science, PubMed, Chinese Biomedical Literature Database, Chinese National Knowledge Infrastructure, Chinese Scientific Journal Database (VIP), and the Wan-fang Database. Search terms were as follows: (Massage OR tuina OR manipulation) AND (infant OR baby OR child OR pediatrics) AND (anorexia OR anorexias OR anorexia nervosas) AND (randomized controlled trial [RCTs]). Results: A total of 30 studies, including 2991 patients (1545 in the intervention group and 1446 in the control group), were included in this meta-analysis. The results showed that the relative risk was 1.31 regarding clinical effective rate with 95% confidence intervals from 1.24 to 1.38. Conclusions: Massage therapy was significantly better than pharmacotherapy in treating anorexia in children. However, the quality of evidence for this finding was low due to high risk of bias of the included studies. Thus, well-designed RCTs are still needed to further evaluate the efficacy of massage therapy.
Keywords: Anorexia, children, massage therapy, meta-analysis
|How to cite this article:|
Gao L, Jia CH, Ma SS, Wu T. Pediatric massage for the treatment of anorexia in children: A meta-analysis. World J Tradit Chin Med 2018;4:96-104
|How to cite this URL:|
Gao L, Jia CH, Ma SS, Wu T. Pediatric massage for the treatment of anorexia in children: A meta-analysis. World J Tradit Chin Med [serial online] 2018 [cited 2018 Oct 19];4:96-104. Available from: http://www.wjtcm.net/text.asp?2018/4/3/96/243018
| Introduction|| |
Anorexia is the long-term decreased sensation of appetite, which accompanied by reduction of food intake, and sometimes even refuses to eat. It was reported that about two million people were affected by anorexia, globally in 2013. The anorexia is a common disease in children especially for those younger than 15-year-old., Delayed treatment of anorexia may lead patients to be malnutrition, lack of vitamins and microelements, and even affect the growth of the children. The pathogenic factors for anorexia are mainly due to improper diet or psychological problems,, which result in the dysfunction of the spleen and stomach. Nowadays, the treatment for anorexia involves psychological therapy, zinc supplement therapy,, and pharmacotherapy to promote digestion. The treatment aims at restoring a healthy weight or treating the underlying psychological problems. In addition, Maudsley family therapy and cognitive behavioral therapy were also used by many parents and practitioners to improve regaining weight for the children.
Besides the pharmacotherapy, in China, massage therapy is also used by many traditional Chinese medicine (TCM) physicians to treat anorexia in children. The massage therapy is a complementary and alternative medicine, which can be dated back to ancient China in medical book Huangdi Neijing. In the massage treatment, TCM physicians use their fingers and hands to act on the bodies of the children with anorexia, promoting the flow of blood and Qi in the body. As a result, the digestive function of the children can be improved. There are many benefits for massage therapy such as enhancing immune function, unblocking meridians and collateral, and activating Qi and blood. Self-healing in the body will be promoted. For the treatment of anorexia, many clinical studies have reported the beneficial effects of massage therapy. Xia et al. conducted a meta-analysis to evaluate the efficacy of Tui Na (another name of massage therapy) in the treatment of childhood anorexia, the result showed that Tui Na could improve the effect compared with oral medicine for children with anorexia. However, the search date of this study was up to November 2011, and only three randomized controlled trials (RCTs) were involved in the meta-analysis, which restricted the quality of this study. In recent years, many new clinical RCTs using massage therapy for treating anorexia has been published. Therefore, in this study, an updated and extended meta-analysis was conducted to assess the efficacy of massage therapy for the treatment of anorexia in children.
| Methods|| |
This study protocol was registered in PROSPERO with a registration number CRD 42017056459.
Database and search strategies
Relevant studies were searched in the following electronic databases: Cochrane Library, Web of Science, PubMed, Chinese Biomedical Literature Database, Chinese National Knowledge Infrastructure, Chinese Scientific Journal Database, and Wan-fang Database up to January 31, 2017. The following search terms were used: (Massage OR tuina OR manipulation) AND (infant OR baby OR child OR pediatrics) AND (anorexia OR anorexias OR anorexia nervosas) AND (RCT). There was no language limitation.
Studies were included if the following criteria were fulfilled: (1) studies must be RCTs; (2) interventions using massage therapy alone were chosen; (3) and control groups received pharmacotherapy or no treatment.
Studies were excluded if the following criteria were fulfilled: (1) non-RCTs, case studies, qualitative studies, and experience summary and (2) unpublished or repeated literature.
Data extraction and quality assessment
Four reviewers (Gao, Jia, Ma, and Wu) independently did the work of data extraction and quality assessments. The statistical analysis was conducted using software RevMan 5.3, and the risk of bias was assessed using the Cochrane tool. Any disagreement was resolved by discussions between all reviewers.
| Results|| |
Description of included studies
In this review, 221 potentially eligible studies were identified, of which 191 were excluded as follows: 129 repeated publications, 19 irrelevant studies, 37 studies were not massaged therapy alone in the intervention group (including 13 studies combined Chinese medicine, 7 studies combined western medicine, 4 studies combined external application therapy, and 13 studies combined acupuncture), 5 studies did not receive pharmacotherapy or no treatment in the control group, and 1 study was systematic review. Finally, a total of 30 studies,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, including 2991 participants (1545 in the intervention group and 1446 in the control group), were included in the meta-analysis, and all published in Chinese Journal Literature Databases. The screening process is summarized in a flow diagram [Figure 1].
Details of the 30 studies are summarized in [Table 1]. All the children were under 15 years old. In the intervention group, massage therapy was used alone to treat anorexia, and details of the interventions of the included studies were shown in [Appendix 1]. In the control group, all the studies used pharmacotherapy, including 11 studies,,,,,,,,,, used TCM Jianwei Xiaoshi alone, 6 studies,,,,, used TCM Changweikang alone, 3 studies,, used other TCM prescriptions, 9 studies,,,,,,,, used western medicine, and 1 study used integrated Chinese and Western medicines.
Risk of bias
The risk of bias was high in the included studies [Figure 2]. All the studies described using randomization, but only two studies, reported using an appropriate method of random sequence generation, five studies,,,, reported using inappropriate methods. None of the studies described the method for allocation concealment and blinding of the outcome assessment. Most of the included studies had a high risk of performance bias because both the physicians and the patients clearly knew which treatment was been given.
|Figure 2: Risk of bias graph (a) risk of bias of all included studies; (b) risk of bias summary|
Click here to view
Efficacy criteria for the treatment of anorexia in the included studies can be described as follows: cure (significant improvement in appetite and food intake, return to the normal level), marked effective (significant improvement in appetite and food intake, but not return to the normal level), effective (improvement in appetite and food intake), and no effect (no improvement in appetite and food intake). The clinical effective rate is the accumulation of cure rate, marked effective rate, and effective rate. All the studies showed that massage therapy has a higher clinical effective rate compared with pharmacotherapy. Since high heterogeneity was observed in the meta-analysis (I2 = 59%, which is higher than 50%), a model of random effects was used to calculate the pooled estimation with the analysis of dichotomous data using relative risk (RR) including 95% confidence intervals (CIs). The total meta-analysis showed favorable effects of massage therapy in clinical effective rate (n = 2991, RR = 1.31, 95% CI: 1.24–1.38, P < 0.01) compared with control group [Figure 3].
Subgroup analysis was also performed for different pharmacotherapies. For subgroup massage versus TCM Jianwei Xiaoshi, n = 1040, RR = 1.18, 95% CI: 1.13–1.24, and I2 = 1%. For subgroup massage versus TCM Changweikang, n = 546, RR = 1.23, 95% CI: 1.14–1.33, and I2 = 0%. For subgroup massage versus other TCM prescriptions, n = 253, RR = 1.22, 95% CI: 1.10–1.36, and I2 = 0%. For subgroup massage versus Western medicine, n = 950, RR = 1.50, 95% CI: 1.34–1.67, and I2 = 56%. For subgroup massage versus combined therapy, n = 202, RR = 1.52, and 95% CI: 1.28–1.80. The subgroup analysis showed that the massage therapy was more efficient than the pharmacotherapies especially in the subgroup of massage versus Western medicine. However, there was a high heterogeneity in the subgroup of massage versus Western medicine, with I2 = 56%, while heterogeneities in other subgroups were low (I2 ≤ 1%), resulting that there was a significant subgroup difference, with I2 = 80.5%.
| Discussion|| |
It is considered that anorexia in children is a manifestation of functional dyspepsia in modern medicine. The common treatments for this disease include diet, medication treatment, psychotherapy, etc. The medication treatments may have a good therapeutic effect in a short period, however, disadvantages such as side effects, easy recurrence, and limit their benefits. As a result, more and more people are seeking for a complementary and alternative therapy.
In TCM theory, spleen and stomach play the role of digesting water and food and nourishing other organs. This function made them to be called the foundation of acquired constitution. Therefore, anorexia in children is mainly caused by the dysfunction of the spleen and stomach. Pediatric massage in China is an ancient therapy, which has been used for treating anorexia for thousands of years. Massage therapy can effectively improve the function of spleen and stomach by stimulating corresponding acupoints.
In many TCM books, there are many records of the massage therapy for the treatment of anorexia. For example, the spine pinching can play the role of adjusting Yin and Yang, harmonizing qi and blood, invigorating the meridians, and restoring the vitality of the viscera. Kneading the Zusanli (ST36) has the effect of strengthening the spleen and stomach. Pushing Sihengwen has the effect of strengthening spleen and eliminating food accumulation in the stomach, which can effectively increase the digestive fluid in the body and promote digestion. These methods are simple, effective, and safe, which play an important role in the treatment of anorexia. Nowadays, many clinical RCTs have reported a superiority in using massage therapy for treating anorexia compared with pharmacotherapy. For assessing their clinical efficacy and safety, this study reported a meta-analysis of massage therapy for the treatment of anorexia in children.
A total of 30 studies, including 2991 children patients, were included in the meta-analysis, the result showed that there was a superiority of massage therapy over pharmacotherapy regarding the clinical effective rate. However, high heterogeneity was found in clinical effective rate, with I2 = 59%. Reasons may be as follows:First, different massage therapies were utilized by different TCM physicians [Appendix 1]. In these studies, some basic manipulations were utilized by all the physicians such as pinch spine, rub abdomen, and knead Zusanli (ST36), but more manipulations were conducted in different ways. In addition, the anorexia is classified into different types by TCM physicians such as impairment by overeating, or heat accumulation in spleen and stomach, and different massage therapies were applied to the different types of anorexia. Second, different pharmacotherapies were used in different control groups. These different therapies make the efficacy of massage therapy hard to be assessed.
The methodological quality for this finding was low because of high risk of bias. There are several limitations in the systematic review. First, for most of the included studies, the methods for randomization, allocation concealment, and blinding were not reported clearly. Due to the characteristics of TCM, both the physicians and the patients clearly knew which treatment was been given, making the blinding methods at a high risk. Second, in the 30 included studies, only 11 studies,,,,,,,,,, had sample sizes >100 patients, small sample sizes in most studies made it hard to draw a meaningful conclusion. Third, the clinical effective rate was the main outcome measurement for most of the studies, bias from the physicians might make the reliability and validity of the studies decreased. Fourth, limited information about adverse effect has been reported by the included studies, therefore, the conclusion on the safety of massage therapy on treatment of anorexia should be seriously considered. Five, all the studies were conducted in China, which may limit the generalization of the finding.
| Conclusions|| |
A total of 30 studies, including 2991 children patients (1545 in the intervention group and 1446 in the control group), were included in this meta-analysis, with comparison between massage therapy and pharmacotherapy for treating anorexia in children. The results of a meta-analysis suggest that there was a superiority of massage therapy over pharmacotherapy regarding clinical effective rate (RR = 1.31, 95% CI: 1.24–1.38). However, the studies analyzed to date are of relatively low quality. More rigorous RCTs with large sample sizes are recommended to further evaluate the clinical efficacy and adverse effects of massage therapy in treating anorexia in children.
This study was funded by the National Natural Science Foundation of China (Grant No. 81373770).
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Vos T, Barber RM, Bell B, Bertozzi-Villa A, Biryukov S, Bolliger I, et al
. Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990–2013: A systematic analysis for the Global Burden of Disease Study 2013. Lancet 2015;386:743-800.
Xia QC, Feng ZX, Ping CX. Evaluating the efficacy of Tui Na in treatment of childhood anorexia: A meta-analysis. Altern Ther Health Med 2014;20:45-52.
Akdemir D, Şahin M, Sinir H, Derman O, Pehlivantürk B, Çeliker A. Anorexia nervosa in a young, sportive male with severe bradycardia. Hong Kong J Paediatr 2010;15:224-9.
Espie J, Eisler I. Focus on anorexia nervosa: Modern psychological treatment and guidelines for the adolescent patient. Adolesc Health Med Ther 2015;6:9-16.
Polivy J, Herman CP. Causes of eating disorders. Annu Rev Psychol 2002;53:187-213.
Zainal KA, Renwick B, Keyes A, Lose A, Kenyon M, DeJong H, et al.
Process evaluation of the MOSAIC trial: Treatment experience of two psychological therapies for out-patient treatment of anorexia nervosa. J Eat Disord 2016;4:2.
Su JC, Birmingham CL. Zinc supplementation in the treatment of anorexia nervosa. Eat Weight Disord 2002;7:20-2.
Wang CH, Ma XL, Shi LP. Zinc deficiency dermatitis in premature infants with necrotising enterocolitis. Hong Kong J Paediatr 2014;19:240-3.
Rhodes P. The maudsley model of family therapy for children and adolescents with anorexia nervosa: Theory, clinical practice, and empirical support. Aust N
Z J Fam Ther 2003;24:191-8.
Hay P. A systematic review of evidence for psychological treatments in eating disorders: 2005-2012. Int J Eat Disord 2013;46:462-9.
Veith I. Chinese medical history. Book Reviews: Huang Ti Nei Ching Su Wen. The yellow emperor's classic of internal medicine. Science 1967;156:53-4.
Kose F, Ozcan E, Sonmez K, Turkyilmaz C, Karabulut R, Turkyilmaz Z. A rare cause of neonatal breast abscess and mastitis: Foeniculum vulgare
and powerfull massage. Hong Kong J Paediatr 2016;21:131.
Cao Y. Chiropractic and abdominal massage therapy for 52 cases of anorexia with spleen qi deficiency. Guangxi J Tradit Chin Med 2000;23:15-6.
Cui X, Li M, Li M. Massage therapy for treatment of 47 cases of anorexia in children. Chin J Integr Tradit West Med Digestion 2012;20:375-6.
Cui Y. Massage therapies for childhood anorexia: A clinical observation. Jilin J Tradit Chin Med 2006;26:39-40.
Dong L. Clinical study of pediatric massage in treating children anorexia. Health Care Today 2016;9:262.
Gao Z, Bu X, Bu X. Clinical efficacy observation of six-step massage therapy in treating 122 cases of childhood anorexia. Guide China Med 2012;10:269.
Hao H. Efficacy observation of chiropractic and massage in treating serious functional dyspepsia with anorexia. J Sichuan Tradit Chin Med 2016;34:194-6.
He R. Clinical study of pediatric massage in traditional Chinese medicine for treatment of anorexia in children. Womens Health Res 2016;22:137-9.
He X. Clinical effect observation of pediatric massage in traditional Chinese medicine for treatment of anorexia in children. Med Inf 2015;28:114.
He Y. Clinical analysis of massage therapy for treatment of anorexia in children. Chin Manipulation Qi Gong Ther 2008;24:18-9.
Huang S. Efficacy observation of massage therapy in treating childhood anorexia with spleen deficiency and liver hyperactivity. Gems Health 2012;11:78.
Ji L, Chen H, Chen Q, He Y, Huolian C, Qiaoling C, et al
. Applied research of massage trilogy in collaborative care of anorexia. Chin Med Mod Distance Educ China 2015;13:124-6.
Jia Y, Tang W, Li Z, Su S, Liu Y, Tang W, et al
. Clinical efficacy observation of Liu Shi five-meridian massage therapy in treating childhood anorexia. Chin Manipulation Rehabil Med 2015;6:41-3.
Jian Y, Wu G, Wu G. Chiropractic for infantile anorexia due to insufficiency of spleen-qi and stomach-qi: An observation of 45 cases. J Pediatri Tradit Chin Med 2007;3:50-1.
Li X, Shang Q, Shang Q. A clinical study on treating infantile anorexia in TCM. Clin J Chin Med 2014;6:20-1.
Luo H, Leng L, Pang P, Fei X, Peng Y, Leng L, et al
. Clinical efficacy observation of massage therapy in treating 80 cases of children anorexia. Uygur Med 2013;1:44-5.
Luo Q. Clinical observation of pediatric massage therapy in treating anorexia in children. Med Inf 2014;27:597.
Ning X. Clinical observation of massage therapy in treating 60 cases of children anorexia. Chin J Ethnomed Ethnopharmacy 2010;19:166-7.
Pan J. Clinical study of pediatric massage in traditional Chinese medicine for treatment of anorexia in children. Chin Baby 2015;3:115-6.
Wang L. Analysis of clinical efficacy and safety of pediatric massage in treating anorexia in children. Chin J Trauma Disabil Med 2015;23:135-6.
Wang X. Treatment of anorexia in children by massotherapy associated with digital acupoint pressure: A clinical observation of 70 cases. J New Chin Med 2004;36:42-3.
Wang Y, Zhang Y, Zhang Y. Observation of massage therapy for treatment of anorexia in children. Chin Manipulation Rehabil Med 2015;6:47-8.
Wu Q. Clinical observation of pediatric massage in treating anorexia in children. Herald Health Med Ed 2014;19:121.
Xia J. Efficacy observation of massage therapy in treating children anorexia. Contemp Med Symp 2015;13:21-2.
Xiao Y, Peng X, Su S. Liu Shi massages the therapy to treat the young child apositia (weakness of spleen and stomach) 128 example clinical observations. Chin Manipulation Rehabil Med 2010;1:63-4.
Xiao Z. Clinical study of pediatric massage in traditional Chinese medicine in treating anorexia in children. Guide China Med 2016;14:199.
Yang L. Clinical observation of pediatric massage therapy in treating childhood anorexia with spleen-qi and stomach-qi deficiency. J Frontiers Med 2015;5:315-6.
Yu J. Efficacy observation of Chinese massage in treating children anorexia. Health Care Today 2015;3:229.
Zhang J. Efficacy observation of chiropractic and massage in treating 30 cases of childhood anorexia. Zhejiang J Tradit Chin Med 2016;51:652-3.
Zhang W, Jiang K, Jiang K. Clinical observation of massage therapy for treatment of anorexia in children. Jilin Med J 2010;31:5124-5.
Zhu X. Clinical study of massage therapy in traditional Chinese medicine for treatment of anorexia in children. World Latest Med Inf 2016;16:202-5.
Pinna F, Sanna L, Carpiniello B. Alexithymia in eating disorders: Therapeutic implications. Psychol Res Behav Manag 2015;8:1-5.
Xia LM, Cui LL, Jiang YL, Qin Z, Luo MH. Meta-analysis of clinical efficacy of traditional Chinese medicine in the treatment of aplastic anemia. World J Tradit Chin Med 2017;3:46-50. [Full text]
Zhang Y, Xu LJ, Zheng Y, Xu FQ. Traditional Chinese herbal medicine for perimenopausal depression of Chinese women: A meta-analysis. World J Tradit Chin Med 2017;3:51-7. [Full text]
[Figure 1], [Figure 2], [Figure 3]