Acupuncture for the treatment of childhood anorexia: A systematic review and meta-analysis

# Acupuncture for the Treatment of Childhood Anorexia: A Comprehensive Analysis of Benefits and Limitations

Childhood anorexia represents one of the most common symptoms in childhood, characterized by prolonged loss of appetite, decreased food intake, or even outright refusal to try or consume certain foods. This condition primarily affects children between one and six years of age, with incidence ranging from 14% to 50% in infants and preschoolers, decreasing to 7% to 27% in older children. Although it generally has a good prognosis, prolonged anorexia can result in malnutrition, compromise growth and development, cause low immunity, and lead to the development of various diseases. Causes may include inadequate eating habits, negative feeding experiences, parental attitudes during feeding, family dietary influences, as well as factors related to illness, seasonal changes, or other environmental elements.

This study aimed to systematically review the available literature on the efficacy and safety of acupuncture for the treatment of childhood anorexia. The researchers conducted a comprehensive analysis of 12 electronic databases from database inception through June 2021, including Medline, EMBASE, the Cochrane Central Register of Controlled Trials, and several Asian databases. The search was designed broadly, including not only studies published in journals but also gray literature such as doctoral theses and conference proceedings. Only randomized controlled clinical trials evaluating different types of acupuncture-related therapies were included, encompassing manual acupuncture, electroacupuncture, auriculotherapy, acupressure, application of herbal patches to acupoints, and moxibustion, either as monotherapy or as adjunctive therapy to conventional treatment.

The analysis included 32 randomized controlled trials with 3,518 participants, all conducted in China. The studies compared acupuncture with conventional treatment, with no treatment, or acupuncture combined with conventional treatment versus conventional treatment alone. Manual acupuncture was the most frequently used modality, followed by application of herbal patches to acupoints. The most commonly used acupuncture point was EX-UE-10 (Sifeng), located at the midpoint of the transverse creases of the proximal interphalangeal joints of the index, middle, ring, and little fingers.

Treatment was typically delivered once a week for approximately one month.

Results demonstrated that, whether acupuncture was used as monotherapy or as adjunctive therapy, there was significant improvement in the total effectiveness rate based on anorexia symptoms, hemoglobin levels, abdominal subcutaneous fat, and body weight. Acupuncture proved superior to conventional treatment for improvement of anorexia symptoms, with a risk ratio of 1.30 and a 95% confidence interval of 1.25 to 1.36. Subgroup analyses showed that all acupuncture-related techniques, including manual acupuncture, herbal patch application, acupressure, moxibustion, and combinations of these methods, produced significant results compared with conventional treatment. In addition, hemoglobin and serum leptin levels were significantly higher in the acupuncture group than in the control group.

For patients and clinicians, these findings suggest that acupuncture may offer a promising therapeutic option for children with anorexia, especially considering that current conventional treatments such as prokinetic drugs, zinc, probiotics, vitamins, or iron-containing supplements often have insufficient evidence of effectiveness and the possibility of side effects such as abdominal cramping and skin rashes. Acupuncture proved relatively safe, with few serious adverse events reported. Reported adverse events included superficial skin burns in the moxibustion group, dermal pruritus in the herbal patch group, and nausea and constipation in some control groups receiving conventional treatments. Importantly, the recurrence rate of anorexia was significantly lower in the acupuncture group.

However, this study has several important limitations that should be considered in the interpretation of the results. First, all included studies were conducted in China and published in Chinese, which may introduce publication bias and affect the external validity of the results. This suggests the need for similar research in other countries that actively use acupuncture for the treatment of childhood anorexia. Second, the methodological quality of the included studies was rated as low to moderate, with unclear risk of bias in several domains, including random sequence generation, allocation concealment, and blinding of participants, personnel, and outcome assessors.

The quality of evidence for the main findings was rated as low to moderate using the GRADE tool, with no high-quality evidence identified.

Third, high statistical heterogeneity was observed in some meta-analysis results, the cause of which could not be fully determined even with subgroup analyses based on acupuncture treatment type. This heterogeneity may be attributable to the clinical diversity of the included studies, such as differences in baseline participant characteristics, diagnostic criteria for childhood anorexia, and acupuncture treatment methods. In addition, diagnostic criteria for childhood anorexia were diverse and heterogeneous across studies, highlighting the need to establish appropriate diagnostic standards for the entire pediatric age range.

Results were also inconsistent regarding nutritional indices, suggesting that more research is needed to fully understand the effects of acupuncture on the nutritional status of children with anorexia. Although mechanistic studies of acupuncture for the treatment of anorexia remain limited, experimental research suggests that treatment at point EX-UE-10 may regulate gastric acid secretion, increase intestinal trypsin and pancreatic amylase levels, improve gastrointestinal motility and gastric emptying rate, thereby promoting digestion and absorption.

In conclusion, although current evidence suggests that acupuncture may improve symptoms of childhood anorexia without serious adverse events, the low methodological quality and heterogeneity of the included studies, as well as the low quality of the evidence, indicate that rigorously designed, high-quality clinical trials should be conducted to definitively establish the efficacy and safety of this treatment. A clinically meaningful acupuncture treatment strategy for childhood anorexia needs to be developed, and its effectiveness and safety evaluated in prospective clinical trials. Future research should also focus on the development of pr