Acupuncture for Pediatrics: An Educational Initiative

Abstract

Objective:

With the ongoing opioid crisis, the Centers for Disease Control and Prevention recommends nonpharmacologic therapies (e.g., acupuncture) for treating pain. Multiple agencies, such as the National Institutes of Health and World Health Organization, recognize acupuncture's effectiveness for treating pain, but acupuncture education for providers is scarce. A Workshop to Introduce Acupuncture for Pediatrics (AcuPeds-Workshop) was developed with support from American Academy of Pediatrics to educate providers. Additional funding was given by the Virginia Apgar Academy to evaluate the effects of attending this workshop.

Materials and Methods:

This prospective study used Immediate and 1-Month Post-Workshop (PWS) surveys. The AcuPeds-Workshop components included: history; a literature review; videos of patients receiving acupuncture; and hands-on experience. The workshop was presented at numerous conferences. Attendee survey completion was voluntary.

Results:

Of 327 attendees, the majority were female, non-Hispanic, and were physicians. At baseline, attendees had: heard of acupuncture, 96%; used it, 28%; and/or had a prior lecture, 13%. In the Immediate-PWS: 97% reported an increase in their knowledge and understanding of the indications for acupuncture; majority correctly addressed 3 clinical application scenarios and contraindications. With respect to attitude: 85% would use acupuncture for themselves and 88% would use it for patients. More than 80% rated the workshop components as useful or very useful. In the One-Month-PWS: majority addressed the same 3 clinical scenarios and contraindications correctly, and 11% considered referring patients for acupuncture.

Conclusions:

Attendance at this AcuPeds-Workshop had a positive impact on attendees' knowledge, application of, and attitude about acupuncture. This workshop supports efforts to educate medical providers on this nonpharmacologic pain therapy

INTRODUCTION

Pain is a common malady in the United States, most often treated with pharmaceuticals, including opioids.¹ Prescription opioid abuse has been associated with addiction and overdose deaths, especially during the COVID-19 pandemic, with a spike in numbers that have exacerbated and continued the epidemic in the United States.^2–4 In a national effort to combat this public health crisis, the U.S. Food and Drug Administration and Centers for Disease Control and Prevention recommend nonpharmacologic therapies for treating pain.^5,6 Since 2017, the Joint Commission has mandated that all of its hospitals offer nonpharmacologic therapies, such as acupuncture, to patients for pain.^7,8

Acupuncture was first developed in China.⁹ In 1998, a consensus statement was published by the National Institutes of Health (NIH) on the efficacy of acupuncture for treating pain.¹⁰ Since then, significant evidence has been published on the mechanism of action of acupuncture and its clinical efficacy for treating pain,^11–18 including research partnerships between the NIH and the U.S. Department of Defense and Department of Veterans Affairs^19–21 to advance scientific knowledge and clinical applications of acupuncture. Data from the U.S. Air Force in 2017 suggested that acupuncture treatment not only decreased the prescription of opioids by 45% but also improved patients' physical function and well-being.²²

The public has spent billions of dollars on integrative therapies, including acupuncture,²³ and numerous hospitals have incorporated acupuncture into their armamentariums.^24–27 Yet, despite the rise in public demand and federal agencies' call for using acupuncture to treat pain, there remains a paucity of educational curricula to introduce acupuncture to medical students, residents, and other medical providers.²⁸ To address this educational-knowledge gap, the Section on Integrative Medicine of the American Academy of Pediatrics awarded funding to support the development of a “Workshop to Introduce Acupuncture for Pediatrics” (AcuPeds-Workshop), an hour-long innovative educational presentation specifically designed to introduce acupuncture to health care providers, especially acupuncture as a nonpharmacologic therapy for pain in pediatric patients. There are full-length courses that prepare physicians to become certified in medical acupuncture.²⁹ These courses require hundreds of didactic and clinical hours designed to fulfill various state-specific regulations around physician practice of acupuncture, which are not standardized across the United States.³⁰

The goals of this AcuPeds-Workshop were to: (1) familiarize clinicians with the clinical indications and contraindications of acupuncture/acupressure; (2) review acupuncture literature for pediatrics; and (3) provide a hands-on opportunity to experience acupuncture needling. Additional funding support from the Virginia Apgar Academy of Medical Educators of the Vagelos College of Physicians & Surgeons was used to support this study. It was designed to evaluate the immediate and intermediate outcomes of attending the workshop by assessing the attendees' retention of contraindications and indications, perception changes regarding acupuncture, and any referrals of patient for acupuncture treatment. Feedback on this AcuPeds-Workshop was also solicited.

This study was approved by the Columbia University institutional review board.

MATERIALS AND METHODS

The AcuPeds-Workshop was developed and conducted by the principal investigator (PI), who is a pediatric emergency-medicine physician and a medical acupuncturist. The AcuPeds-Workshop was presented at multiple medical forums, including grand rounds at medical institutions and national conferences with attendees including students, nurses, and practicing physicians (Box 1). This was a prospective study utilizing an Immediate Post-Workshop-Survey (Immediate-PWS) and a One-Month Post-Workshop-Survey (One-Month-PWS). The Immediate-PWS was distributed on paper at the end of the workshop and filled out by the attendees. The One-Month-PWS was collected via Survey Monkey and e-mailed to each conference coordinator, who then sent out the link to the attendees. Attendance at the AcuPeds-Workshop and survey completion were all voluntary. The survey and data from this study were stored on a password-protected Survey Monkey account, accessible only to the authors. Data analysis was performed with statistical programs provided by Survey Monkey and Microsoft Excel.

Box 1.

Forums Where Workshop to Introduce Acupuncture for Pediatrics Were Presented

• 2015 North East Bangladesh Medical Conference. New York, NY

• Medical Grand Rounds at Saint Joseph's Medical Center. Paterson, NJ

• Chief of Service at Department of Pediatrics, Columbia University Medical Center, NewYork–Presbyterian Hospital. New York, NY

• Nursing Grand Rounds at NewYork–Presbyterian–Morgan Stanley Children's Hospital. New York, NY

• Division of Pediatric Emergency Medicine, Cornell Medical Center. New York, NY

• Division of Pediatric Emergency Medicine, Montefiore Medical Center. Bronx, NY

• Division of Pediatric Emergency Medicine, Columbia University Medical Center. New York, NY

• Residency Conference, Department of Emergency Medicine, Columbia University Medical Center. New York, NY

• Residency Conference, Department of Pediatrics, Columbia University Medical Center, NewYork–Presbyterian–Morgan Stanley Children's Hospital. New York, NY

• Integrative Health Symposium, Children's Hospital of Philadelphia. Philadelphia, PA

• New York Regional Pediatric Hospital Medicine, Columbia University Medical Center, NewYork–Presbyterian Hospital. New York, NY

• Medical Grand Round at Department of Pediatrics, Rutgers University Hospital. Newark, NJ

Workshop Components

The AcuPeds-Workshop consisted of the following components: (1) history of acupuncture; (2) a review of the literature; (3) videos of patients receiving acupuncture; and (4) a hands-on experiential segment.

The history segment introduced the principles of Traditional Chinese Medicine, and the philosophy of how acupuncture is used to treat diseases and promote health. The review of literature segment provided an overview of published studies on the mechanism of acupuncture for treating pain, including functional magnetic resonance imaging changes in the brain, endogenous endorphin analgesia, and connective-tissue histophysiology resulting from acupuncture needling. Studies on pediatric pain were also included, as well as a review of acupuncture contraindications and indications—taken from the World Health Organization (WHO) and American Society of Acupuncture—according to general safety guidelines. For this introductory workshop, and to provide the safest guidelines for health care providers, pregnancy was listed as a contraindication, as well as cellulitis and stainless-steel allergy.^31,32

Clinical case scenarios of acupuncture for treating pediatric pain were presented, interspersed with videos of patients receiving treatment with acupuncture in the pediatric emergency department (PED) of NewYork–Presbyterian–Morgan Stanley Children's Hospital, in New York City. Real cases from the PED were used because the PI is a pediatric emergency-medicine physician and this is where her clinical practice is located, and where the current authors had conducted published acupuncture studies previously. These videos were shown throughout the workshop to demonstrate the clinical application of acupuncture in pediatric patients and to counter the notion that children are fearful of acupuncture needles. The videos often included the following: interviews of the patients and their preacupuncture pain levels; physical examinations; acupuncture administration; postacupuncture pain levels and physical examinations; and feedback from the families and patients about the patients' acupuncture experiences.

The Workshop concluded with a hands-on segment, providing attendees the opportunity to handle differing types of acupuncture needles, including Seirin^® needles, Pyonex,^® and Aiguille Semi-Permanente^® (ASP) needles. Attendees were given oranges, into which they could insert the acupuncture needles. The attendees were also offered an opportunity to experience the actual sensations of administering and receiving acupuncture by inserting needles through guide tubes onto each other. The PI also demonstrated acupuncture by asking attendees to volunteer as patients so they could receive acupuncture needling. The volunteers would be asked to describe the sensations to the rest of the attendees as the acupuncture needled were inserted and manipulated. These experiences were important for demystifying acupuncture therapy, demonstrating the ease of application, and to familiarizing attendees with the sensations of acupuncture needling. This hands-on segment was also a time utilized for questions and answers; thus, rich discussions were encouraged.

Workshop Surveys

The workshop surveys were developed in collaboration with input from members of the Center for Education Research and Evaluation (CERE) at the Vagelos College of Physicians and Surgeons, experts in the field of medical-education research. CERE was consulted on workshop survey design and helped frame the survey questions in such a way as to assess attendees' baseline experiences with acupuncture from the Immediate-PWS only, without having an additional pre-workshop survey. Attendees completed the Immediate-PWS and One-Month PWS to assess the influence of attending the workshop.

The Immediate-PWS was administered to attendees and collected the following: (1) demographic information and baseline experience with acupuncture prior to the workshop; (2) knowledge acquisition and clinical application with 3 case scenarios appropriate for acupuncture along with 1 contraindication question; (3) change in perceptions regarding acupuncture; and (4) feedback on the usefulness of the individual workshop components (using a Likert Scale).

To assess attendees' knowledge acquisition, they were asked 1 question on contraindications to acupuncture. To assess knowledge application, the attendees' responses on the use of acupuncture were collected for 3 real and appropriate clinical scenarios: (1) Case A of a 4-year-old child with asthma who continued to have wheezing and increased work of breathing after having received albuterol nebulized treatments; (2) Case B of a 15-year-old girl with right lower-abdominal pain despite having received acetaminophen and ibuprofen with normal radiographic and laboratory workups; and (3) Case C of a 10-year-old girl with persistent pain and decreased range of motion from muscular torticollis whose mother refused all pharmaceuticals for her daughter, because she had already tried them and they did not work at home.

The One-Month-PWS assessed the intermediate-term effect on retention of acupuncture knowledge, indications, and contraindications; the appropriate application to the same 3 clinical scenarios; attitude changes; and any referrals for their patients to receive acupuncture.

RESULTS

A total of 327 Immediate-PWS and 102 One-Month-PWS responses were collected. Demographic and medical-education status of attendees are shown in Table 1. The majority of these participants were female and were physicians or physicians in training.

Table 1.

Demographics of Survey Respondents

Demographics	Immediate-Post-Workshop (n = 327)	One-Month-Post-Workshop (n = 102)
Ethnicity (%)a
Hispanic or Latinx	7	6
Not Hispanic or Latinx	79	84
Race (%)
Asian	24	19
Black or African American	3	2
Native Hawaiian or Pacific Islander	1	0
White	60	72
Choose not to answer	12	7
Sex (%)
Female	67	68
Medical-education status (%)
Medical student	12	11
Resident or fellow	31	28
Nurse or nurse–practitioner	13	10
Attending physician	30	34
Acupuncturist	2	0
Other	12	17

^a Total does not add up to 100% due to nonrespondents and respondents who identified with multiple categories.

Data from the Immediate-PWS on the attendees' baseline experiences with acupuncture showed that 96% of the participants had heard of acupuncture prior to attending the workshop. However, only 13% of the participants attended any formal class on acupuncture, despite 28% having received acupuncture for themselves. These data are depicted in Figure 1.

FIG. 1.

Attendees' baseline experiences with acupuncture.

For attendees' knowledge acquisition, on the Immediate-PWS, the majority of attendees selected Pregnancy (70%), Allergy to stainless steel (86%), and Cellulitis (84%) correctly as contraindications to acupuncture, and 13% chose thrombocytopenia incorrectly as a contraindication. The corresponding contraindication data from the One-Month-PWS and the Immediate-PWS are plotted side-by-side in Figure 2. There was a decline in knowledge retention on the One-Month-PWS for the question on thrombocytopenia as a noncontraindication, as well as in one-third of respondents who had identified pregnancy as a contraindication.

FIG. 2.

Attendees' knowledge of acupuncture contraindications.

Regarding acupuncture-knowledge application, a summary of participants' responses to the 3 cases collected from the Immediate-PWS and One-Month PWS are shown in Table 2. In the Immediate-PWS, only 40% of attendees answered correctly that acupuncture/acupressure would be a very appropriate or appropriate treatment option for the patient with asthma in respiratory distress, while 88% and 87% answered correctly for the abdominal pain and torticollis cases, respectively. A similar response pattern was observed in the One-Month-PWS.

Table 2.

Acupuncture Knowledge Application Immediate and One-Month-Post-Workshop

Responses	Case A 4-year-old with asthma		Case B 15-year-old with abdominal pain		Case C 10-year-old with torticollis
	Immediate-Post-Workshop	One-Month-Post Workshop	Immediate-Post-Workshop	One-Month Post Workshop	Immediate-Post-Workshop	One-Month Post Workshop
Very appropriate/Appropriate	40	29	88	90	87	89
Somewhat appropriate	24	25	6	5	7	2
Not appropriate	29	37	1	1	1	2
Did not respond/Don't know	7	9	5	4	16	7

For changes in attendees' knowledge and perception regarding acupuncture on the Immediate-PWS, 97% indicated that their knowledge of acupuncture/acupressure had increased: 59% “a lot” and 38% “somewhat.” Eighty-eight percent indicated that they were significantly/somewhat more likely to consider using acupuncture/acupressure therapy for patients, and 85% would consider using acupuncture for themselves. Figure 3 depicts the data on knowledge and perception regarding acupuncture usage from the Immediate PWS.

FIG. 3.

Perceptions of acupuncture knowledge, indications, and usage.

It also shows from the One-Month-PWS attendance, 50% of the respondents indicated that they had considered using acupuncture/acupressure for themselves, 40% had considered using acupuncture for their patients. 11% referred patients to receive acupuncture therapy. Obstacles to acupuncture referral are shown in Figure 4. The top 2 reasons chosen were not knowing where to refer patients and the lack of acupuncture availability at their institutions.

FIG. 4.

Obstacles to acupuncture referrals.

Figure 5 shows the attendees' feedback on the AcuPeds-Workshop. Participants rated the workshop components highly, with a Likert score of “very useful” or “useful” for all 4 segments of the workshop. Combining these 2 Likert scores, the highest workshop components were 81% for the videos and 80% for the literature review.

FIG. 5.

Workshop component feedback. EBM, evidence-based medicine.

DISCUSSION

In 2002, the WHO published a call for providers to learn about complementary medicine, which includes acupuncture.³³ More-recent data from Crawford et al.³⁴ suggested that physicians trained in acupuncture prescribed fewer opioids. Given the above, in conjunction with compelling evidence of acupuncture efficacy for pain and the urging of the former United State president's Commission to combat our nation's opioid crisis,³⁵ now is the time to educate medical providers broadly on nonpharmacologic pain therapies, such as acupuncture.

To the best of the authors' knowledge, this is one of the first studies to examine knowledge acquisition and attitude change among medical professionals after attending an educational workshop devoted to introducing acupuncture for pediatrics. This study suggests that attendance at this 1-hour AcuPeds-Workshop increased attendees' knowledge and influenced their attitudes positively toward acupuncture. While the majority of these participants did not attend prior formal lectures on acupuncture, this workshop was effective in imparting the necessary knowledge for most of the attendees to apply acupuncture correctly to the 3 clinical scenarios and to answer the question on contraindications correctly. This knowledge was mostly gained by the attendees immediately post-workshop, with some decline in retention of the contraindications surrounding pregnancy and thrombocytopenia at the One-Month-PWS time.

The attendees reported a high likelihood of using acupuncture for themselves and for their patients both at the immediate-post and 1-month post-workshop timepoints, suggesting that their attitudes were changed positively. These findings are similar to those found in the Quartey et al. study that summarized educational interventions in complementary and alternative medicine.³⁶ In terms of the effect on attendees' referral considerations after their attendance at this AcuPeds-Workshop, there were a number of obstacles identified that may have negatively affected the number of actual acupuncture referrals. Given that a baseline rate of referral was not captured in the Immediate-PWS, the 11% referral rate during the 1-month post-workshop is difficult to interpret. Furthermore, considerations to refer are different from actual referral of patients—not necessarily reflecting a change in clinical practice.

This study showed that the AcuPeds-Workshop was well developed and conducted, based on the high Likert-scale scores given by the attendees on all 4 components of the workshop. Another strength of this study was that the AcuPeds-Workshop was attended by a broad interprofessional audience, from students to nurses to faculty members and practicing physicians; therefore, the data collected reflect a wide spectrum of medical providers. Given the national impetus to utilize nonpharmacologic therapies for pain, the current authors believe attendance at this workshop can empower medical providers with knowledge about acupuncture that will enable them to engage in thoughtful conversations with patients about this treatment option for pain, and to know when to refer patients appropriately for acupuncture.

Beyond the nation's opioid abuse crisis, other developing countries face the same pain crisis with very limited resources and opioids access for children, including specialties such as palliative care.³⁷ Acupuncture could provide pain relief in world regions where environmental and financial constraints often prevent people from accessing other pharmaceutical treatments. The Acupuncturists Without Borders organization has been providing acupuncture therapy across the world to people caught in wars and natural disasters.³⁸ This attests further to the need for acupuncture-education initiatives, to promote a more-broad integration of this nondrug therapy into standard of care in mainstream health care within the United States and in resource-poor regions around the world.

Limitations

The study had a number of limitations. While the Immediate-PWS was collected easily in person, achieving a nearly 100% response rate, it was not possible to be certain of the exact number of attendees given that they were allowed to walk in and out freely during the workshop. The actual number of attendees was likely slightly above 327. The One-Month-PWS was sent via e-mail and difficult to collect responses; thus there was a low response rate of just <50%. Both surveys collected self-reported changes in behavioral intent but lacked the ability to actually assess objective behavior changes. To do this, actual interviews of participants would have been necessary. Future research could also include a control group of providers who did not attend this workshop. This kind of study would provide more-robust outcome comparison data. It is also possible that the presenter's perceptions might have introduced biases into the study's findings in unknown ways. This could not be assessed with the current study's methodology.

Overall, the data suggest that attendance at the AcuPeds-Workshop was effective for achieving the aims of familiarizing medical providers with the indications and contraindications for acupuncture/acupressure in children, seeing its clinical application especially for pain, and providing a hands-on experiential opportunity. The results from this study suggest that there is much interest from medical professionals in gaining knowledge of acupuncture for pediatrics. The study also provided information on barriers to referral, that there is a need to provide resources to facilitate the acupuncture referral process to augment integration of this therapy into the U.S. medical system. An earlier implementation of this acupuncture workshop educational initiative at the medical-school level may be valuable, as it supports the national agenda of promoting nonpharmacologic therapies for pain. This AcuPeds Workshop could contribute positively as a solution in response to the U.S. national pain and opioid crisis.

CONCLUSIONS

This 1-hour AcuPeds Workshop was effective and informative for influencing attendees' attitudes about, and knowledge of, acupuncture positively. This educational acupuncture initiative supports the national call for health care providers to use nonpharmaceutical therapies to treat patients with pain.

AUTHOR DISCLOSURE STATEMENT

No competing financial interests exist.

FUNDING INFORMATION

This study received funding support from the Section on Integrative Medicine(s) of the American Academy of Pediatrics to develop this acupuncture for pediatrics workshop. Additional funding from the Virginia Apgar Academy of Medical Educators of the Columbia University Vagelos College of Physicians and Surgeons was provided to evaluate the impact of attending this workshop.