Clinical observation of pediatric Tuina plus oral Chinese medication for pediatric anorexia due to spleen failing in transportation

XIE Tao (解濤), JIANG Hua (江華), ZHANG Chengyan (張成燕)

Jimo District Qingdao Hospital of Traditional Chinese Medicine, Shandong 266200, China

Abstract

Keywords: Pediatric Tuina; Massage; Yun Shui Ru Tu; Drugs, Chinese Herbal; Anorexia; Spleen Failing in Transportation

Anorexia in children is a common pediatric disease characterized by long-term reluctance to eat and reduced food intake. The incidence of this disease is increasing year by year. There is no obvious discomfort in children except for poor appetite. However, it can lead to a lack of transformation of Qi and blood in long-term uncured children, with a low resistance to diseases, and even affect children’s growth and development. Therefore, early treatment should be the key. Western medicine treatment of this disease is mainly based on symptomatic treatment such as gastrointestinal motility drugs[1]and supplementation of trace elements[2-3]. Modern traditional Chinese medicine (TCM) treatment includes acupuncture, Tuina(Chinese therapeutic massage) such as Nie-Pinching spine therapy[4-7], and Chinese herbal decoction[8-10].Pediatric Tuina has been widely used in the treatment of anorexia in children, and the curative effect is definite.

Tuina manipulation of Yun Shui Ru Tu is a compound manipulation of pediatric Tuina, belonging to the regulating-reinforcing method. It can treat chronic diseases and deficiency syndromes. Children are delicate in Zang-Fu organs and insufficient in the shape and Qi, usually deficient in the kidney and inadequate in the spleen. The kidney is the congenital origin and the spleen is the acquired foundation. The kidney is full because of the continuous replenishment of the essence from water and food transported and transformed by the spleen. And the reason why the spleen can transport and transform the essence from water and food is due to the encouragement of kidney Yang. Tuina manipulation of Yun Shui Ru Tu can invigorate primordial Yang in the kidney to tonify the spleen Yang and dispel spleen dampness. Therefore, in this study, we applied Tuina manipulation of Yun Shui Ru Tu plus Chinese medication in treating children with anorexia due to spleen failing in transportation.

1 Clinical Materials

1.1 Diagnostic and syndrome differentiation criteria

1.1.1 Diagnostic criteria

The diagnostic criteria in this study referred to the diagnostic criteria for pediatric anorexia in theCriteria of Diagnosis and Therapeutic Effects of Diseases and Syndromes in Traditional Chinese Medicine[11].

1.1.2 Criteria for syndrome differentiation of traditional Chinese medicine (TCM)

According to thePediatrics of Chinese Medicine[12],the criteria for the syndrome of spleen failing in transportation in this study were established: poor appetite, less intake or reluctant to eat, feeling tasteless when eating, significant less intake than before,belching, and acid regurgitation; emaciation and weakness; unformed stools; lusterless complexion or pale complexion; a pale tongue with white coating; slow and moderate pulse.

1.2 Inclusion criteria

Those who met the above diagnostic criteria and the criteria for syndrome differentiation; aged 1-9 years old;were able to cooperate with the treatment; whose guardians agreed to undergo the clinical study and signed informed consent.

1.3 Exclusion criteria

Children with liver or kidney dysfunction; who took oral medications or had other therapies in the past week; malnutrition led by long-term diseases; those who were allergic to Chinese medication decoction;those with other severe organic diseases; who had anorexia nervosa; who had a loss of appetite caused by other conditions.

1.4 Elimination and dropout criteria

The children or their guardians dropped out voluntarily; those who presented with discomfort during treatment and were stopped by the physician.

1.5 Statistical methods

All data were statistically analyzed by the IBM SPSS version 26.0 statistical software. The measurement data in normal distribution and having homogeneous variance were expressed as mean ± standard deviation(±s. The independent samplest-test was applied for the comparison between the groups. The pairedt-test was applied to the intra-group comparisons. The measurement data in non-normal distribution or without homogeneous variance were processed by the non-parametric rank-sum test. Rank-sum test was applied for the comparison of ranked data. Counting data were analyzed by Chi-square test.P＜0.05 was considered to indicate a significant difference.

1.6 General data

This study was reviewed and approved by the Ethics Committee of the Jimo District Qingdao Hospital of Traditional Chinese Medicine (Approval No. 043-KY,2018). A total of 94 children with anorexia due to spleen failing in transportation, aged 1-9 years old, were selected from the Jimo District Qingdao Hospital of Traditional Chinese Medicine, between June 2019 and June 2020. All children were randomized into a control group and an observation group by the random number table method, with 47 cases in each group. There were no significant differences in the general data between the two groups (P＞0.05), indicating that they were comparable (Table 1).

2 Treatment Methods

2.1 Control group

The control group was treated with modified Bu Huan Jin Zheng Qi San.

Primary prescription components:Cang Zhu(Rhizoma Atractylodis) 6 g,Pei Lan(Herba Eupatorii) 6 g,Ban Xia(Rhizoma Pinelliae) 3 g,Chen Pi(Pericarpium Citri Reticulatae) 6 g,Zhi Ke(Fructus Aurantii) 6 g,Huo Xiang(Herba Agastaches) 6 g,Chao Mai Ya(Fructus Hordei Germinatus) 6 g,Jiao Shan Zha(Fructus Crataegi)6 g,Jiao Shen Qu(Massa Medicata Fermentata) 6 g,andGan Cao(Radix Glycyrrhizae Preparata) 3 g.

Modifications: For significant abdominal bloating,Mu Xiang(Radix Aucklandiae) andLai Fu Zi(Semen Raphani)were added to activate Qi flow for dispelling bloating;for significant summer-heat dampness obstruction,Bian Dou Hua(Flos Lablab Album) was added to eliminate dampness and activate Qi flow; for those with irregular defecation,Zhi Shi(Fructus Aurantii Immaturus),Lai Fu Zi(Semen Raphani),Shan Yao(Rhizoma Diosscoreae), andYi Yi Ren(Semen Coicis)were added to benefit Qi and invigorate the spleen for drying dampness.

Method: Decocted with water till about 100 mL. For 1-3 years old, 30 mL/time, twice a day; 4-6 years old,40 mL/time, twice a day; 7-9 years old, 50 mL/time,twice a day. Took the decoction for four consecutive weeks.

2.2 Observation group

The observation group was treated with additional Tuina manipulation of Yun Shui Ru Tu based on the oral medication in the control group.

The points included Shenshui, Zhanghengwen,Xiaotianxin and Pitu. The child took a sitting position during the Tuina treatment.

2.2.1 Single-finger Yun-Circular pushing manipulation

The physician held the child’s index finger, middle finger, ring finger and little finger with the left hand, to make the child’s palm upward. Then, with force on the radial side of the thumb, the physician’s right thumb Yun-Circularly pushed from the thread surface of the child’s little finger (Shenshui), along the palm edge,through Zhanghengwen and Xiaotianxin, till Pitu at the tip of the child’s thumb (Figure 1a). Yun-Circularly pushed 100 times in one direction.

2.2.2 Double-finger Yun-Circular pushing manipulation

The physician’s left hand performed as same as in the thumb Yun-Circular pushing manipulation. The right hand focused on the index and middle fingers, with the other three fingers flexing naturally, and Yun-Circular pushed from the thread surface of the child’s little finger,along the palm edge, through Zhanghengwen and Xiaotianxin, till Pitu at the tip of the child’s thumb(Figure 1b). Yun-Circularly pushed 100 times in one direction.

2.2.3 Triple-finger Yun-Circular pushing manipulation The physician’s left hand performed as same as in the thumb Yun-Circular pushing manipulation. The right hand performed the manipulation at the abovementioned points with the index, middle, and ring fingers (Figure 1c). Yun-Circularly pushed 100 times in one direction.

2.2.4 Hypothenar Yun-Circular pushing manipulation The physician’s left hand still performed as same as in the thumb Yun-Circular pushing manipulation. The right hand, half clasped, performed manipulation at the above-mentioned points with the hypothenar (at the base of the fifth metacarpal bone), (Figure 1d).Yun-Circularly pushed 100 times in one direction.

2.2.5 Thenar Yun-Circular pushing manipulation

The performance of the physician’s left hand remained the same as in the thumb Yun-Circular pushing manipulation. The right hand performed manipulation at the above-mentioned points with the thenar (at the base of the first metacarpal bone),(Figure 1e). Yun-Circularly pushed 100 times in one direction.

All children were treated with the thumb Yun-Circular pushing manipulation at the beginning of the treatment.Children under 3 years old were treated with additional double-finger Yun-Circular pushing manipulation.Children aged between 3 and 5 years old were treated with additional triple-finger Yun-Circular pushing manipulation. Children from 6 to 7 years old were treated with additional hypothenar Yun-Circular pushing manipulation. And children from 7 to 9 years old were treated with additional thenar Yun-Circular pushing manipulation. The above manipulations were performed once every other day, for four consecutive weeks.

3 Observation of Curative Efficacy

3.1 Observation items

3.1.1 TCM symptom score

The symptom score was mainly based on the children's diet, nausea and vomiting, abdominal pain and bloating, complexion, defecation, and spiritual state.These 6 aspects were scored 0-3 points at 4 grades[13].

Diet: Good appetite was scored 0 point; general appetite and slow eating were scored 1 point; poor appetite and slow eating were scored 2 points; very poor appetite, and inability to swallow or refusal to eat were scored 3 points.

Nausea and vomiting: No nausea or vomiting was scored 0 point; occasional nausea but no vomiting was scored 1 point; severe nausea and occasional vomiting were scored 2 points; severe nausea and vomiting was scored 3 points.

Abdominal pain and bloating: No abdominal pain or bloating was scored 0 point; slightly pain and bloating in abdomen but not reaching the chest when lying down was scored 1 point; abdominal bloating pain, which reached the chest when lying down, was scored 2 points; significant pain and bloating in abdomen,which was higher than the chest level when lying down,was scored 3 points.

Figure 1. Yun-Circular pushing manipulation

Complexion: Normal ruddy complexion was scored 0 point; slightly sallow complexion but still glossy was scored 1 point; sallow complexion and barely glossy was scored 2 points; sallow complexion or withered complexion was scored 3 points.

Defecation: 0 point for normal stools; 1 point for a little dry but basically formed stools; 2 points for dry stools that could only be discharged with exertion, and occasionally mixed with undigested food; 3 points for dry and hard stools like sheep feces, sometimes with blood or mixed with undigested food.

Spiritual state: 0 point for good spirits; 1 point for poor spirits ad unwilling to move; 2 points for tired, lack of words, and sleepy; 3 points for indifferent expressions and reluctant to speak or move.

3.1.2 Serum leptin, neuropeptide Y, zinc, and calcium levels

Five milliliters of fasting venous blood was taken from each child, and centrifuged at 2 000 r/min for 15 min.The supernatant was collected, and stored in -20 ℃low-temperature refrigerator for later use. Serum leptin and neuropeptide Y levels were measured by radioimmunoassay. The contents of serum zinc and calcium were detected by flame atomic absorption spectrometry.

3.2 Criteria of curative efficacy

According to the criteria of curative efficacy for pediatric anorexia in theCriteria of Diagnosis and Therapeutic Effects of Diseases and Syndromes in Traditional Chinese Medicine[11], the clinical curative efficacy was assessed.

Markedly effective: The appetite returned to normal,and there was no nausea or vomiting, with a ruddy complexion, and a soft and flat abdomen.

Effective: The appetite was improved, with occasional nausea, lusterless complexion, and occasional abdominal bloating.

Invalid: The appetite was not recovered, still with nausea and vomiting, a sallow complexion, abdominal bloating, and discomfort.

3.3 Treatment results

3.3.1 Comparison of clinical efficacy

After 4 weeks of treatment, the total effective rate of the observation group was 87.2%, and that of the control group was 74.5%. The between-group difference was statistically significant (P＜0.05), (Table 2).

3.3.2 Comparison of TCM symptom score before and after treatment

There were no statistical differences in the TCM symptom scores between the two groups before treatment (P＞0.05). After 4 weeks of treatment, the scores for diet, abdominal bloating, and nausea and vomiting decreased in both groups, and the intra-group differences were statistically significant (P＜0.05). The scores of these three items in the observation group were all lower than those in the control group, and the between-group differences were statistically significant(P＜0.05), (Table 3).

3.3.3 Comparison of serum leptin, neuropeptide Y,zinc, and calcium levels before and after treatment

Before treatment, there were no statistical differences in the levels of serum leptin, neuropeptide Y,zinc, and calcium between the two groups (P＞0.05).After 4 weeks of treatment, the serum leptin levels in both groups decreased (P＜0.05), and the serum leptin level in the observation group was lower than that in the control group (P＜0.05). After treatment, the serum levels of neuropeptide Y, zinc, and calcium in both groups increased (P＜0.05), and the levels in the observation group were higher than those in the control group (P＜0.05), (Table 4).

Table 2. Comparison of clinical efficacy between the two groups (case)

xTable 3. Comparison of TCM symptom score between the two groups ( ±s, point)

Table 4. Comparison of serum leptin, neuropeptide Y, zinc, and calcium levels between the two groups ( ±s)

Table 4. Comparison of serum leptin, neuropeptide Y, zinc, and calcium levels between the two groups ( ±s)

Note: Compared with the same group before treatment, 1) P＜0.05; compared with the control group after treatment, 2) P＜0.05

Group n Time Serum leptin(g/L)Neuropeptide Y(ng/L)Serum zinc(μmol/mL)Serum calcium(mmol/mL)Observation 47 Before treatment 30.68±4.79 86.46±9.42 61.27±8.44 1.52±0.16 After treatment 21.32±4.231)2) 132.16±12.191)2) 85.88±9.121)2) 1.94±0.261)2)Control 47 Before treatment 29.76±4.77 87.27±9.45 62.38±7.49 1.54±0.23 After treatment 25.24±4.341) 107.45±11.441) 74.76±8.831) 1.78±0.221)

4 Discussion

Modern medical study believes that the etiology of pediatric anorexia is rather complex and results from multiple factors[14]. These factors include diet and environmental influences. Poor eating habits and improper diet can lead to weakened digestive ability in children[15]. If the gastric acid secretion of children is excessive, it will cause gastric mucosal injuries or loss of appetite, which further affects digestion[16]. Chronic gastritis is one of the most common causes of anorexia in children. Dietary bias or improper diet can cause gastric mucosal injuries in children and form inflammatory responses[17].Helicobacter pyloriinfection,which can be caused by infection between families, may be another important cause of anorexia in children[18].Some children have abnormal gastrointestinal motility,insufficient gastrointestinal digestion, slow digestion,and loss of appetite[19]. In addition, emotional factors such as fright[20]can also cause loss of appetite in children. Some other gastrointestinal disorders should also be considered in children’s anorexia[21].

Serum leptin is an important hormone in regulating dietary behaviors by acting on the central nervous system. When leptin level increases, it inhibits eating behavior. Meanwhile, the increased leptin will act on the hypothalamus, combine with the receptor, promote the expression of fibroblast growth factor 2, and then excite neurons, and regulate the secretion of neuroendocrine hormones, resulting in loss of appetite[22]. Neuropeptide Y is a hormone that maintains the homeostasis of the internal environment.It can induce vasoconstriction and smooth muscle cell proliferation, and release adipokines to promote appetite[23]. Therefore, the increased neuropeptide Y can stimulate appetite. This study found that pediatric Tuina plus oral Chinese medication can reduce the level of leptin, increase the level of serum neuropeptide Y,and improve the appetite of children, which is consistent with the results of other studies[24]. It is found that the levels of zinc and calcium in children with anorexia are lower than those in normal children.The insufficient zinc and calcium contents may lead to the disorder of ribozyme protein formation, affect the production of taste hormones, promote mucosal hyperplasia and keratinization, and affect taste buds,thereby affecting appetite and leading to anorexia[25].The results of this study showed that pediatric Tuina plus oral administration of Chinese medication can increase the serum zinc and calcium levels, and improve appetite and symptoms in children.

Chinese medicine believes that the main cause of anorexia includes a variety of factors. Acquired factors include improper feeding, long-term diseases that damage the spleen, and emotional disorders. The disease is located in the spleen and stomach, and the basic pathogenesis is the dysfunction of the spleen and stomach, and the disharmony of receiving and transforming. The function of the stomach is to receive and decompose food, and the spleen is to govern transportation and transformation. The harmony of the spleen and stomach and unobstructed Qi flow guarantee the normal transportation and transformation of water and food and proper diet. If the spleen and stomach fail in the transportation and transformation of the water and food essence, then the ascending and descending Qi movements will lose control, and Qi will stagnate in the stomach, causing poor appetite. The treatment of this disease should be based on the principle of invigorating the spleen and appetite. The spleen prefers dryness to dampness. With the flavoring agent to solve the stagnancy in spleen and stomach assisted with formula for activating Qi flow to recover their activities, the spleen and stomach will then be harmonized, and spleen transportation will be recovered, the Qi flow will be regulated, leading to the increase of appetite.

In this study, modified Bu Huan Jin Zheng Qi San was selected. In this prescription,Cang Zhu, drying dampness for spleen transportation, andPei Lan,resolving dampness with aroma for invigorating the spleen, were the sovereign drugs.Chen Pi,Ban Xia,Zhi KeandHuo Xiangcan not only regulate Qi flow, activate the spleen and regulate the stomach, but also assist the sovereign drugs to increase the power of invigorating the spleen with aroma, serving as minister drugs.Assisted withJiao Shen Qu,Chao Mai YaandJiao Shan Zhato resolve food for harmonizing the stomach, help the stomach with receiving and transforming. In addition,Gan Caowas used to harmonize the above herbs. The whole prescription can achieve the effects of activating the spleen with aroma, transporting the spleen and invigorating appetite. The results of this study showed that the TCM symptom scores decreased and the children’s appetite improved in both the observation group and the control group.

Tuina manipulation of Yun Shui Ru Tu is a unique treatment for this disease. Children’s kidney is usually deficient and the spleen is usually insufficient. The spleen and stomach are not fully developed, the organs are formed but immature, and Qi is complete but not strong. In addition, improper diet in children can easily damage the spleen and stomach, causing dysfunction of receiving and decomposing food and failing in transformation of the essence, resulting in spleen diseases such as anorexia. The spleen and kidney are closely related, and the two are taken as congenital and acquired foundations that mutually promote and assist each other. Kidney Qi can promote the spleen to transport and transform water and food. Tuina manipulation of Yun Shui Ru Tu can help with this mutual promotion and assistance, and enhance the ability of transportation and transformation.

Tuina manipulation of Yun Shui Ru Tu was added in the observation group, which was to Yun-Circularly push from Shenshui to Pitu. This Tuina manipulation involves multiple manipulations such as Bu-Reinforcing Shenjing,Tui-Pushing Banmen and Qing-Clearing Pijing. Among them, Bu-Reinforcing Shenjing can reinforce congenital kidney Qi. Tui-Pushing Banmen can invigorate the spleen for digesting food. Qing-Clearing Pijing can invigorate the spleen for resolving dampness.Furthermore, Tuina manipulation of Yun Shui Ru Tu can stimulate children’s own resistance by physically stimulating specific body parts. Children have high compliance and can easily accept this Tuina manipulation. The results showed that the serum leptin was significantly decreased and neuropeptide Y was increased in the observation group, with enhanced foraging behaviors and appetite, and improvements of anorexia symptoms. The increase of food intake in turn further promoted the increase of zinc and calcium.

In summary, Tuina manipulation of Yun Shui Ru Tu plus Chinese medication is significantly effective in treating pediatric anorexia. This approach can improve the symptoms of the children and increase their appetite, and thus is worthy of clinical promotion.

Conflict of Interest

There is no potential conflict of interest in this article.

Acknowledgments

There was no project fund support for this study.

Statement of Informed Consent

Informed consent was obtained from the guardians of the recruited children in this study.

Received: 30 January 2021/Accepted: 13 May 2021