Full title: “Shonishin as a Non-Pharmacologic Approach in Pediatric Pain Management”
Related: NPR feature story with Dr. Adcock, Pain Rescue Team Helps Seriously Ill Kids Cope In Terrible Times
Pediatric pain is often under diagnosed, under treated, and difficult to manage. Hospitals, now mandated to offer non-pharmacologic pain management options in response to the opioid epidemic, are seeking solutions from integrative therapies, including acupuncture. The practice of Shonishin, a form of no-needle acupuncture, offers a safe, effective and pleasant option for pediatric patients of all ages.
The Opioid Crisis was declared a “public health emergency” in 2017 by the U.S. Department of Health and Human Services (HHS), which cited an unprecedented 47,600 opioid-related deaths in 2017 alone.1 In 2018, the Joint Commission on Accreditation of Healthcare Organization, which accredits 77% of all U.S. hospitals, took action to fight against the opioid crisis within hospitals by creating new standards for “Pain Assessment and Management” and included a requirement that all “accredited hospitals provide non-pharmacologic pain treatment modalities.”2
In the search for new pain treatment options, U.S. hospitals have begun introducing, into both ambulatory and inpatient care settings, such integrative modalities as: meditation, biofeedback, hypnotherapy, breathing techniques, gentle movement such as tai chi or qigong, aromatherapy, massage and acupuncture. For pediatric patients, the list of integrative modalities often grows smaller based on a patient’s age, development, physical ability, cognitive level, or medical condition. 3,4
Although acupuncture research demonstrates clear therapeutic value in pediatric pain management, acupuncture needles can be formidable or inappropriate to administer in certain pediatric populations.5,6,7 Such patients can include neonates, toddlers, children in intensive care units (ICU), those requiring palliative care, or patients with neutropenia or thrombocytopenia. Additionally, a fear of needles, hypersensitivity to touch due to allodynia, hyperalgesia, or cognitive or behavioral conditions such as ADHD or Autism Spectrum Disorders, or past trauma (medical or otherwise) may deter such patient care.
Parents often decline acupuncture treatment for their child under the assumption that the insertion of acupuncture needles may create more pain for their child. However, when parents are offered a non-invasive acupuncture option for their child, many are willing to consent to treatment. Fortunately, recent studies suggest that non-invasive forms of acupuncture are also highly effective in pediatric pain management.8
Perhaps the most specialized form of non-invasive pediatric acupuncture hails from 17th century Japan and is called Shonishin, which translates as “children’s needle.”9 While Shonishin is rooted in the same theories of Traditional Chinese Medicine and classical acupuncture, it differs in a few key ways.
Shonishin does not use regular acupuncture needles which are inserted into the body, employing instead a variety of handheld tools that are designed to treat the surface of the skin. Techniques include gentle, rhythmic tapping, rubbing, pressing, scratching or scraping.
These tools offer a mix of smooth, round, multi-tipped or ridged edges to provide different kinds of stimulus or “dosing,” and often are creatively shaped like tiny brushes, miniature wands, or even little people or animals, as a means of disarming young patients. The most common materials used are stainless steel, pure gold, pure silver, copper, brass or, more recently, plastic.
Despite their pointy look, these tools touch the skin with light contact, at steep angles and rarely perpendicularly, and with the practitioner’s fingertips as a close guide at or very near the surface of the skin. Moreover, practitioners use their non-tool hand to gently brush over the skin after each application of a tool to create greater comfort for the child, while enhancing both diagnostic and therapeutic results.
Image 1.A. and 1.B. Modern Metal Shonishin Tools (2019).
Image 2.A., 2.B and 2.C. Examples of Shonishin Tool Hand Positions (2019).
Shonishin rarely targets specific acupuncture points, which are located at precise anatomical landmarks, but rather focuses on specific stroking directions over general regions of the body. For example, instead of using one or two specific acupoints to treat the lungs, Shonishin strokes would move distally over the posterior region of the forearm, or Lung channel, or caudally along the upper thoracic area of the back, over the Lung organ itself and the corresponding paraspinal nerves.
This is because acupuncture points and acupuncture channels develop in alignment with anatomical growth and sensorimotor development. Theories state that young children, especially infants, have less developed acupoints than older children and adults, and thus respond better to treatments that enliven a broad area of the body, or an entire channel, along which those specific acupoints will ultimately mature.
Shonishin employs the body’s largest sensory organ, the skin, to communicate with babies and children. The pressure, rhythm, vibration, softness, direction, pattern, and speed of Shonishin techniques are all forms of stimulation that deliver unique information into the nervous system, brain and spirit of a child. The child processes that information, and then sends back communication in the form of reaction through the skin itself which will demonstrate changes in temperature, tone, texture, and moisture, oftentimes after only a few strokes.
A few common responses heard from parents and bedside nurses alike, after a hospitalized child receives Shonishin, is how “relaxed” and “calm” a child becomes after being treated. This is because, among other therapeutic results, Shonishin triggers the release of oxytocin through the stimulation of the free nerve endings known as C-nerve fibers.10
Indeed, a 2018 study, conducted at the University of Oxford and Liverpool John Moores University, showed that gentle stroking of a baby’s skin reduced the activity in the brain commonly associated with pain. From a group of 32 infants who all required medically-necessary heel lance blood tests, 16 were lightly stroked with a soft brush, just prior to the lancing, at the exact rate of 3 cm/second, while being monitored with an EEG.
While all 32 of the infants exhibited the same limb reflex withdrawal, the experimental group showed greatly reduced noxious-evoked brain activity on the EEG.11 Furthermore, the experimental group that received the gentle brushing showed a 50% decrease in duration of facial grimacing after the heel lance. The research suggests that the brushing reduces pain perception through the stimulation of C-tactile (CT) afferent nerve fibers.
Shonishin affects not only C-nerve fibers of the skin, but also many of the other neuroanatomical structures contained within the epidermis and dermis, such as Merkel cells, Ruffini corpuscles, hair-follicle receptors, Pacinian corpuscles, Golgi tendon organs, and muscle spindles. Shonishin stimulates these structures to create a unique neurophysiological response which therapeutically influences the sympathetic and parasympathetic nervous system, muscle tone, fascial tone, lymphatic function, proprioception, and pain modulation.1,11
Shonishin is an easy and effective intervention to deliver in an inpatient setting. It requires no special accommodations, other than a trained practitioner, usually a Licensed Acupuncturist (LAc), plus a small tool, and about 5-10 minutes of treatment time, depending upon the age of the child. For most children, including babies, two or three short Shonishin treatments per week create a maximum therapeutic result, with positive outcomes often witnessed in the very first treatment.
In addition to treating pain, and because of its varied effects on the nervous system, Shonishin can be used effectively for many of the other issues commonly faced by patients in pediatric hospitals such as: opiate-induced constipation, diarrhea, feeding intolerance, poor appetite, bloating, colic, fussiness, restlessness, excessive crying, anxiety, behavioral disorders, hypersensitivity to touch, sleep disorders, hypoxic-ischemic brain damage, hypertonicity, tachycardia, frequent infection, low oxygen saturation levels, and asthma.
For inpatient care, only simple Shonishin tools with flat surfaces should be selected for use and must be disinfected before and after each use with 70% isopropyl alcohol, in the same manner as a stethoscope. However, for immunocompromised patients or patients suffering from infectious disease that can be spread via the skin, a newly developed, single-use, sterile, disposable Shonishin tool made by the Japanese-based Seirin Corporation is recommended.
Image 3. Seirin Shonishin Box (2019).
Image 4. Seirin Shonishin Tool (2019).
Contraindications for Shonishin treatment include: fever over 100F (37.8C), skin rash, open wounds, lesions, and immediately after bath. Indications of Shonishin over-treatment include: increased fussiness, hyperactivity, excessive fatigue or sweaty skin though a mild increase in skin moisture is a positive indication of treatment. Because of its extremely mild approach, adverse events from Shonishin treatment are rare.
“Less is more” is a guiding principle of Shonishin as over-stimulation of a child is an unwanted outcome. Shonishin treatments build on one another to create an entourage effect, so no singular physiological result is sought in any given treatment, rather the practitioner looks to create a greater sense of well-being, calmness and comfort in the child with each session.
Pediatric pain is often under diagnosed and undertreated and pain management options, especially integrative therapies, for pediatric patients can be limited. Shonishin offers pediatric patients and their families a gentle, safe and effective intervention that is a drug-free, needle-free, and even enjoyable approach in the treatment of pain.
- U.S. Department of Health & Human Services. “What is the U.S. Opioid Epidemic?” (2017) Retrieved on 3/1/2019 from https://www.hhs.gov/opioids/about-the-epidemic/index.html
- Joint Commission. (2017) Joint Commission Enhances Pain Assessment and Management Requirements for Accredited Hospitals. Retrieved from https://www.jointcommission.org/assets/1/18/Joint_Commission_Enhances_Pain_Assessment_and_Management_Requirements_for_Accredited_Hospitals1.PDF
- Hathaway, E., Luberto, C., Bogenschutz, L., Geiss, S., Wasson, R. and Cotton, S. (2019). Integrative Care Therapies and Physiological and Pain-related Outcomes in Hospitalized Infants.
- Mathews L. Pain in children: neglected, unaddressed and mismanaged. Indian J Palliat Care. 2011;17(Suppl):S70‐S73. doi:10.4103/0973-1075.76247
- Simons SH, van Dijk M, Anand KS, Roofthooft D, van Lingen RA, Tibboel D. Do we still hurt newborn babies? A prospective study of procedural pain and analgesia in neonates. Arch Pediatr Adolesc Med. 2003;157(11):1058‐1064. doi:10.1001/archpedi.157.11.1058.
- Tsai SL, Reynoso E, Shin DW, Tsung JW. Acupuncture as a Nonpharmacologic Treatment for Pain in a Pediatric Emergency Department [published online ahead of print, 2018 Sep 21]. Pediatr Emerg Care. 2018;10.1097/PEC.0000000000001619. doi:10.1097/PEC.0000000000001619.
- Wu S, Sapru A, Stewart MA, et al. Using acupuncture for acute pain in hospitalized children. Pediatr Crit Care Med. 2009;10(3):291‐296. doi:10.1097/PCC.0b013e318198afd6.
- Golianu B, Yeh AM, Brooks M. Acupuncture for Pediatric Pain. Children (Basel). 2014;1(2):134‐148. Published 2014 Aug 21. doi:10.3390/children1020134.
- Birch, S. (2011). Shonishin: Japanese Pediatric Acupuncture. 1st ed. Stuttgart: Thieme.
- Wernicke, T. and Michel, W. (2014). Shōnishin. 1st ed. London: Singing Dragon.
- Gursul D, Goksan S, Hartley C, et al. Stroking modulates noxious-evoked brain activity in human infants. Curr Biol. 2018;28(24):R1380‐R1381. doi:10.1016/j.cub.2018.11.014.
- Attarian S, Tran LC, Moore A, Stanton G, Meyer E, Moore RP. The neurodevelopmental impact of neonatal morphine administration. Brain Sci. 2014;4(2):321‐334. Published 2014 Apr 25. doi:10.3390/brainsci4020321.
Adcock, R. (Photograph). (2019). Examples of Shonishin Tool Hand Positions, San Francisco, CA.
Adcock, R. (Photograph). (2019). Modern Metal Shonishin Tools, San Francisco, CA.
Adcock, R. (Photograph). (2019). Seirin Shonishin Box, San Francisco, CA.
Adcock, R. (Photograph). (2019). Seirin Shonishin Tool, San Francisco, CA.