Treatment For Cyclic Vomiting Syndrome
Yuan-Chi Lin, MD
Brenda Golianu, MD
Background Gastrointestinal symptoms such as cyclic vomiting
are commonly encountered in children with mitochondrial disorders. The
value of acupuncture as a complimentary therapy in controlling nausea
and vomiting in this setting is not well known.
Objective To describe the use of acupuncture as a complementary
modality for a case of mitochondrial DNA deletion disorder and cyclic
Patient A 11/2-year-old girl with mitochondrial DNA deletion
disorder was evaluated for the treatment of severe cyclic vomiting syndrome.
Intervention Points ST 36 and PC 6 were needled for a 10-minute
period; initially, 2 times weekly, then, 1 time weekly.
Main Outcome Measure Reduction in vomiting episodes and additional
hospitalizations to manage severe vomiting.
Results The patient's symptoms improved after the initial acupuncture
treatment. She has been followed up for 3 years, receiving weekly outpatient
acupuncture treatment for controlling cyclic vomiting syndrome. Since
the initial treatment, the patient has not required any additional hospitalizations
to manage complications secondary to severe vomiting.
Conclusions This report demonstrates the efficacy of acupuncture
as a complementary therapy for managing a patient with severe cyclic
vomiting syndrome and a mitochondrial deletion disorder.
Cyclic Vomiting, Acupuncture, Mitochondrial Deletion Disorder
Gastrointestinal symptoms such as cyclic vomiting, gastroesophageal
reflux, and intestinal dysmotility are common in children with mitochondrial
disorders.1-4 Children with frequent emesis and retching, resulting
in lethargy and fluid and electrolyte imbalance, may require hospitalization.
Acupuncture was integrated in the treatment of a patient with intractable
nausea and vomiting with a mitochondrial deletion defect.
A 11/2-year-old girl with a mitochondrial DNA deletion disorder and
severe cyclic vomiting syndrome presented in the pediatric intensive
care unit because of severe dehydration and fluid and electrolyte imbalance
secondary to her cyclic vomiting. Despite a maximal multi-pharmacological
regimen, the patient required several hospital admissions.
Initial physical examination revealed that the patient was lethargic,
both hands and feet were cold to touch, she was afebrile, blood pressure
was 86/42 mm Hg, and heart rate was 120/min. Auscultation of the chest
was clear, and the heart had a regular rhythm without murmur. Abdominal
examination showed the bowel sound was reduced and there was no organomegaly.
The patient ingested nothing by mouth and depended on total parenteral
Acupuncture points ST 36 (Zu San Li) and PC 6 (Nei Guan) were utilized
to treat cyclic vomiting syndrome. According to Traditional Chinese
Medicine (TCM), PC 6 can be used for controlling nausea and vomiting,
and ST 36 can regulate stomach function; PC 6 is located 2 inches above
the transverse crease of the wrist, between the tendons of the long
palmar muscle and the radial flexor muscle; ST 36 is located 3 inches
below the patella and 1 inch lateral to the crest of the tibia. Acupuncture
needles (0.20 mm) were inserted for 10 minutes. Parental consent was
The patient's symptoms improved after the initiation of acupuncture.
Outpatient acupuncture treatment included 2 times weekly initially,
then 1 time weekly. The effect of each treatment lasted 6-7 days. An
attempt to decrease the frequency of acupuncture treatment to less than
1 time weekly resulted in the recurrence of severe vomiting. For the
past 3 years, the patient's cyclic vomiting syndrome has been successfully
controlled with weekly acupuncture. Since its initiation, the patient
has not required any additional hospitalizations to manage complications
secondary to severe vomiting.
Mutations of mitochondrial DNA are increasingly recognized as a cause
of human disease. Inherited mitochondrial fatty acid oxidation disorders
represent a relatively new group of inborn errors of metabolism. In
recent years, our understanding of the biochemical and molecular bases
of these disorders has improved dramatically. However, many cases remain
undetected or are given other diagnoses, cyclic vomiting syndrome being
one of them.2 Boles and Williams5 described 6 unrelated children with
mitochondrial DNA mutation causing migraine (n=6), cyclic vomiting syndrome
(n=5), developmental delay (n=3), seizures (n=3), and poor growth (n=3).
Age at onset for vomiting episodes was younger than 1 year in 5 of the
cases. An elevated level of body fluid lactate was found in 5 cases.
A mitochondrial DNA mutation was confirmed in 1 child with the finding
of a large rearrangement. Mitochondrial disease should be considered
in cases of cyclic vomiting, especially those with additional pathology
or possible maternal inheritance.
Initial screening should include plasma lactate and urine organic acid
samples obtained during an episode.5
Cyclic vomiting syndrome remains poorly understood and management is
often frustrating for the pediatrician. Children with severe cyclic
vomiting may experience dehydration and electrolyte abnormalities. Medical
management for cyclic vomiting commonly includes supportive measures,
abortive strategies, and prophylactic therapies. These approaches include
intravenous fluids, a non-stimulating environment, antiemetic agents
(e.g., promethazine, ondansetron), anxiolytic agents, antimigraine compounds,
antiepileptic agents, and gastrointestinal prokinetic agents.
There is growing interest among the general public in complementary
and alternative therapies.6 A recent study revealed that use of alternative
therapy is not limited to children with life-threatening illness, but
is commonly practiced in children with routine medical problems.7 Acupuncture
is one of the alternative therapies frequently utilized in children.8
promising results support the efficacy of acupuncture in adult postoperative
and chemotherapy-induced nausea and vomiting and in postoperative dental
pain;9 PC 6 has produced a highly significant reduction of perioperative
emesis sequelae10,11 and vomiting produced by chemotherapeutic agents.12
Acupuncture is also being used for various gastrointestinal disorders;13
ST 36 can regulate and harmonize the stomach and gastrointestinal function.
Clinical use of acupuncture is supported by the evidence of acupuncture
effects on gastric motility14 and basal acid output.15
This report demonstrates that acupuncture can be a useful therapy to
complement the conventional treatment of cyclic vomiting syndrome in
a child with a mitochondrial deletion disorder.
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JW, Ghaly RG, Bill KM, Chestnutt WN, Fitzpatrick KT, Lynas AG. Effect
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Dr Yuan-Chi Lin is a Pediatrician, Anesthesiologist, and Pain Specialist.
Dr Lin is the Director of Medical Acupuncture Service at Children's
Hospital Boston, Harvard Medical School, Boston, Massachusetts.
Yuan-Chi Lin, MD, MPH, DABMA*
Medical Acupuncture Service
Dept of Anesthesia
Children's Hospital Boston
300 Longwood Ave
Boston, MA 02115
Phone: 617-355-4158 o Fax: 617-739-2599 o E-mail: firstname.lastname@example.org
Dr Brenda Golianu is a Pediatric Anesthesiologist at Lucile Packard
Children's Hospital at Stanford University, and Assistant Professor
of Anesthesia at Stanford University School of Medicine, Stanford, California.
Brenda Golianu, MD, DABMA
Dept of Anesthesia
Stanford University Hospital
Stanford, CA 94305
*Address all correspondence and reprint requests to Dr Yuan-Chi Lin
at the above address.