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Table of Contents
ORIGINAL ARTICLE
Year : 2018  |  Volume : 4  |  Issue : 3  |  Page : 96-104

Pediatric massage for the treatment of anorexia in children: A meta-analysis


Department of Jin Gui, School of Preclinical Medicine, Beijing University of Chinese Medicine, Beijing 100029, China

Date of Submission12-Apr-2018
Date of Acceptance16-Aug-2018
Date of Web Publication10-Oct-2018

Correspondence Address:
Chun-Hua Jia
School of Preclinical Medicine, No. 11 North 3rd Ring East Road, Chaoyang District, Beijing 100029
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/wjtcm.wjtcm_12_18

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  Abstract 


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 Dec 15];4:96-104. Available from: http://www.wjtcm.net/text.asp?2018/4/3/96/243018




  Introduction Top


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.[1] The anorexia is a common disease in children especially for those younger than 15-year-old.[2],[3] 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,[4],[5] which result in the dysfunction of the spleen and stomach. Nowadays, the treatment for anorexia involves psychological therapy,[6] zinc supplement therapy,[7],[8] and pharmacotherapy to promote digestion. The treatment aims at restoring a healthy weight or treating the underlying psychological problems. In addition, Maudsley family therapy[9] and cognitive behavioral therapy[10] 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.[11] 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[12] 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.[2] 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 Top


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.

Inclusion criteria

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.

Exclusion criteria

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 Top


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,[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33],[34],[35],[36],[37],[38],[39],[40],[41],[42] 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].
Figure 1: Flowchart of study selection process

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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[14],[20],[28],[29],[30],[31],[36],[38],[39],[40],[41] used TCM Jianwei Xiaoshi alone, 6 studies[16],[21],[26],[35],[37],[42] used TCM Changweikang alone, 3 studies[23],[24],[33] used other TCM prescriptions, 9 studies[13],[15],[18],[19],[22],[25],[27],[32],[34] used western medicine, and 1 study[17] used integrated Chinese and Western medicines.
Table 1: Details of the 30 included studies

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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[24],[29] reported using an appropriate method of random sequence generation, five studies[13],[15],[25],[32],[38] 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

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Outcome measurements

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].
Figure 3: Forest plot of clinical effective rate

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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 Top


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.[43] 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.[44] Second, in the 30 included studies, only 11 studies[13],[15],[17],[21],[24],[32],[34],[35],[36],[38],[39] had sample sizes >100 patients, small sample sizes in most studies made it hard to draw a meaningful conclusion.[45] 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 Top


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.

Acknowledgments

This study was funded by the National Natural Science Foundation of China (Grant No. 81373770).

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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