For The Management
Of Pediatric Pain: A Pilot Study
Yuan-Chi Lin, MD
Aimee B. Bioteau, BS
Anne C. Lee, MD
Background Acupuncture is used for pain management increasingly
more often in children.
Objective To evaluate the effects of acupuncture in pediatric pain management.
Design, Setting, and Patients A total of 112 acupuncture treatments
were performed in 53 children aged 2-18 years presenting with a variety
of pain conditions.
Intervention Acupuncture points were needled to alleviate patient
Main Outcome Measure Change in visual analog scale (VAS) pain
scores (before-after acupuncture).
Results The mean (SD) VAS score before acupuncture was 6.5 (1.6),
and after acupuncture, was 3.6 (1.8) (P<.01). No adverse effects
or complications were related to the acupuncture treatment.
Conclusions Acupuncture can significantly reduce pediatric patients
pain. Further prospective randomized studies are needed to evaluate
the short- and long-term effects of acupuncture therapy in the pediatric
Pediatric Pain Management, Acupuncture, Abdominal Pain, Limb Pain
Untreated pain-related conditions in pediatric patients can have long-term
physiological and psychological consequences.1 In the United States,
using acupuncture as a complementary therapeutic modality in the treatment
of pediatric pain and various illnesses is becoming more accepted.2
We report our experience in integrating acupuncture as a complementary
medical therapy in pain management for pediatric patients.
This study was approved by the institutional review board and written
informed consent from parents was obtained prior to the treatment. We
included patients aged 18 years or younger. Patients received acupuncture
treatment either because they had persistent pain despite a range of
conventional medical therapy or the patient/patients family requested
it. A visual analog scale (VAS) from 0-10 was used to assess pain. A
research assistant acting as an independent observer obtained the VAS
score from the
patient immediately before and immediately after each acupuncture treatment.
The duration of pain relief was inquired on the following visit. VAS
scores were averaged within each subject for comparison. The Shapiro-Wilk
test and paired t test were used for statistical analysis.
Of the patients in our study, 24% presented with abdominal pain. Chronic
recurrent abdominal pain is not uncommon, occurring in approximately
10%-17% of school-aged children. Only a small percentage of cases of
recurrent chronic abdominal pain have organic causes. Most pediatricians
reassure parents that the discomfort of recurrent abdominal pain will
resolve spontaneously; however, no research data support this. A 5-year
longitudinal study of recurrent abdominal pain in children revealed
that one-third had resolution of the pain, one-third had persistence
of pain, and one-third had a different pain complaint at follow-up.6
According to Traditional Chinese Medicine (TCM), the causes of abdominal
pain in children include the invasion of external cold, accumulation
disorder, organ deficiency from chronic illness, Qi obstruction from
injury or surgery, or parasites. External cold invasion is usually of
sudden onset and is a colicky type of abdominal pain. Heat accumulation
disorder is often associated with distension and pain.
Chronic illness may cause exhaustion, Spleen Qi deficiency, and intermittent
pain. Surgery or injury-related problems may have Qi obstruction and
more sharp and fixed discomfort. Parasitic disorder leads to blockage
of the intestine, resulting in pain and swelling. In addition to conventional
therapies, CV 12 (Zhong Wan), ST 25 (Tian Shu), ST 36 (Zusanli), and
SP 4 (Gong Sun) acupuncture points, along with moxibustion for deficiency
state, are commonly used.
Limb and Back Pain
Chronic limb pain (24%) and back pain (17%) were common complaints in
our patient group. In a study of 539 school-aged children, 27% had limb
pain.7 These symptoms included pain secondary to arthritis, fibromyalgia,
knee pain, complex regional pain syndrome, and sport-related overuse
injuries. In addition to meridian therapy, according to the anatomical
location of the limb pain, common acupuncture points include shoulder:
LI 15 (Jian Yu), GB 21 (Jian Jing), LI 11 (Qu Chi), TE 5 (Wai Guan);
elbow: LI 11 (Qu Chi), LI 4 (Hogu), LI 10 (Shousanli); wrist: LI 5 (Yang
Shi), TE 4 (Yang Chi), LI 11 (Qu Chi); hip: GB 30 (Huan Tiao), BL 40
(Wei Chung), GB 34 (Yang Ling Chuan), BL 54 (Zhi Bian); knee: M-LE 16
(Xi Yan), GB 34 (Yang Ling Chuan), SP 6 (Sanyinjiao), ST 34 (Liang Qui);
and ankle: ST 41 (Jie Xi), BL 60 (Kun Lung), GB 39 (Xuan Zhung).
Headaches are among the most common health complaints in adolescents.
The cumulative annual incidence was estimated at 11%-26% among 10- to
17-year-old Swedish children.8 The most common types of recurrent headaches
in children and adolescents are migraine and tension-type. Of the pediatric
patients in our series, 15% had headache as the chief complaint. The
characteristics of migraine headache include pulsating throbbing quality,
moderate or severe intensity prohibiting daily activities, unilateral
location, and/or aggravation during routine physical activities. During
the attack, the patient usually experiences nausea, vomiting, photophobia,
or phonophobia. The attack lasts for 4-72 hours.9 The characteristics
of chronic tension-type headaches include pressing or tightening quality,
mild or moderate intensity that may inhibit but not prohibit everyday
activities, bilateral or variable location, not aggravated during routine
physical activities, and usually not associated with vomiting.10
Acupuncture management of headache depends on its nature and location.
The tendinomuscular meridian needs to be addressed for headache. In
addition, frontal location is yang-ming type of headache, temporal location
is shao-yang type of headache, occipital location is tai-yang type of
headache, and headache in the top of the head is jun-yin type. The common
acupuncture points include the following: yang-ming type of headache:
M-NH 3 (Ying Tang), LI 4 (Hogu), and ST 44 (Nei Ting); shao-yang type
of headache: M-NH 9 (Tai Yang), TE 5 (Wai Guan), and GB 41 (Lin Qi);
tai-yang type of headache: GB 20 (Feng Chi), SI 3 (Houshi) and BL 60
(Kun Lun); and jun-yin type of headache: GV 20 (Bai Hui) and LR 3 (Tai
Chest pain in children may originate from somatic structures or visceral
structures in the thorax and abdomen. Cardiac causes are not the most
common origin of chest pain in children and adolescents. Carefully reviewing
the patients history and examining the chest can reveal the possible
etiology of the chest pain. The majority of chest pain in the pediatric
population is found in cases of cystic fibrosis. The chest pain is related
to splinting of the chest wall muscles from prolonged reactive airway
disease, hypercarbia, and chronic hypoxia. Chest pain can originate
from acute or chronic lung infection, pneumothorax, and pleurisy. High
prevalence of low bone mineral density in patients with cystic fibrosis
can increase risk of rib fracture. Chest pain can further impair sputum
clearance and lead to exacerbation of pulmonary diseases.
Severity of lung disease can determine the quality and length of life.
According to TCM, chest pain can be caused by the stasis of Blood and
can be due to deficiency of Yang. Chest pain accompanied by cough and
yellowish sputum can be related to stagnation of Lung Qi. Distension
and stiffness of the hypochondrium can be related to stagnation of Liver
Qi. Severe pain is associated with stasis of Liver Blood. Depending
on the etiology of chest pain, acupuncture can be integrated as part
of the therapy. Acupuncture points commonly used include: TE 5 (Wai
Guan), BL 13 (Fei Shu), and LU 1 (Zhong Fu).
Promising results support the efficacy of acupuncture in other populations
and situations such as adult postoperative care, chemotherapy-induced
nausea and vomiting, and postoperative dental pain. Acupuncture may
be useful as an adjunct or alternative treatment or be included in a
comprehensive management program for conditions such as substance addiction,
stroke rehabilitation, headache, menstrual cramps, tennis elbow, fibromyalgia,
myofascial pain, osteoarthritis, low back pain, carpal tunnel syndrome,
Acupuncture treatments (112 consecutive) were performed in 53 pediatric
patients, 31 females and 22 males. The patients ages ranged from
2-18 years old (mean [SD], 13.3 [3.4] years). The chief complaints at
the time of consultation were abdominal pain (24%), limb pain (24%),
back pain (17%), headache (15%), chest pain (8%), neck pain (4%), and
others (8%). The Shapiro-Wilk test for normality showed that the distribution
of the data was not significantly different from normal (P=.51). The
mean VAS pain score for all patients immediately before the acupuncture
treatment was 6.5 (SD,1.6) and immediately after treatment, 3.6 (SD,
1.8). The average duration of acupuncture effect was 3.0 (SD, 1.1) days.
Acupuncture treatment significantly reduced the VAS pain scores by 3.1
(SD, 1.5) points (P<.01). There were no reported adverse effects
or complications related to the acupuncture treatment.
In our series, acupuncture reduced the VAS pain scores by a mean of
3.1 points. Complementary and alternative therapies have received considerable
attention by the public and health care providers.3 In the pediatric
population, acupuncture is a frequently used alternative therapy.4 Recent
studies reveal that use of alternative therapy is not limited to children
with life-threatening illness, but is commonly used in those with routine
Our findings suggest that acupuncture can significantly reduce patients
pain and be successfully incorporated into a pediatric pain management
practice. These data do not control for placebo effects of acupuncture
or dropout rates for those patients who did not continue treatment.
Prospective randomized controlled trials are needed to evaluate the
short- and long-term effects of acupuncture therapy in the pediatric
population, and changes in the requirements for pain medication, as
well as patients general well-being and daily activity level related
to the acupuncture treatment.
Anand K, Grunau R, Oberlander T. Developmental character and long-term
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Lin Y, Lee A, Kemper K, Berde C. Integrating complementary and alternative
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L, Laine-Ammara G, Pless IB, Guyver A. The use of alternative medicine
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Friedman T, Slayton WB, Allen LS, et al. Use of alternative therapies
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Magni G, Pierri M, Donzelli F. Recurrent abdominal pain in children:
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Larsson BS. Somatic complaints and their relationship to depressive
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Brattberg G, Wickman V. Prevalence of back pain and headache in
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MJ, Kay J, Jaron A. Epidemiology of headache and childhood migraine
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Dr Yuan-Chi Lin is a Pediatrician, Anesthesiologist, Pain Specialist,
and Medical Acupuncturist. He is the Director of the Medical Acupuncture
Service at the Childrens Hospital Boston, Harvard Medical School
in Boston, Massachusetts.
Yuan-Chi Lin, MD, MPH*
Medical Acupuncture Service
Dept of Anesthesia, Childrens Hospital Boston
Harvard Medical School
300 Longwood Ave
Boston, MA 02115
Aimee Bioteau is a Research Associate with Dr Lin.
Aimee Bioteau, BS
Dr Anne C. Lee is a Pediatrician and Research Associate with Dr Lin.
Anne C. Lee, MD
*Address all correspondence and reprint requests regarding this article
to Yuan-Chi Lin, MD, at the address listed at left.