A Randomized Controlled Trial Examining the Effects of Reflexology on Children With Functional Constipation

The effect of listening to music and foot reflexology on nausea, pain and anxiety in children during perioperative period: A randomized controlled study

AIM

The purpose of this research was to examine the effects of listening to music and foot reflexology during the perioperative period on nausea, pain and anxiety in children aged 7-12 years.

MATERIAL AND METHOD

The sample for the randomized controlled experimental study included children who underwent outpatient surgery in the Pediatric Surgery Clinic. Research data were collected. A total of 99 children were included in the study with 33 in the music group, 33 in the foot reflexology group, and 33 in the control group.

RESULTS

In the preoperative and postoperative periods, Children's Perioperative Multidimensional Anxiety Scale (CPMAS) scores for the music listening and reflexology groups were significantly lower than the control group (p < 0.05). In the postoperative period, the Children's Emotional Manifestation Scale (CEMS) scores for the reflexology and music listening groups after the application were significantly lower than the control group (p < 0.001). Postoperative Baxter Retching Faces (BARF) scores were found to be significantly lower in children who listened to music compared to the control group (p = 0.002). The Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) scores for children in the control group were found to be significantly higher in the postoperative period than for children in the music and reflexology groups (p < 0.001).

CONCLUSIONS

As a result, listening to music and reflexology during the perioperative period were effective in reducing anxiety, pain and nausea in children.

PRACTICE IMPLICATIONS

In the perioperative period, listening to music and reflexology for children can be recommended as non-pharmacological nursing interventions with low cost and easy implementation.

Strategies used for childhood chronic functional constipation: the SUCCESS evidence synthesis

Background

Up to 30% of children have constipation at some stage in their life. Although often short-lived, in one-third of children it progresses to chronic functional constipation, potentially with overflow incontinence. Optimal management strategies remain unclear.

Objective

To determine the most effective interventions, and combinations and sequences of interventions, for childhood chronic functional constipation, and understand how they can best be implemented.

Methods

Key stakeholders, comprising two parents of children with chronic functional constipation, two adults who experienced childhood chronic functional constipation and four health professional/continence experts, contributed throughout the research. We conducted pragmatic mixed-method reviews. For all reviews, included studies focused on any interventions/strategies, delivered in any setting, to improve any outcomes in children (0-18 years) with a clinical diagnosis of chronic functional constipation (excluding studies of diagnosis/assessment) included. Dual reviewers applied inclusion criteria and assessed risk of bias. One reviewer extracted data, checked by a second reviewer. Scoping review: We systematically searched electronic databases (including Medical Literature Analysis and Retrieval System Online, Excerpta Medica Database, Cumulative Index to Nursing and Allied Health Literature) (January 2011 to March 2020) and grey literature, including studies (any design) reporting any intervention/strategy. Data were coded, tabulated and mapped. Research quality was not evaluated. Systematic reviews of the evidence of effectiveness: For each different intervention, we included existing systematic reviews judged to be low risk of bias (using the Risk of Bias Assessment Tool for Systematic Reviews), updating any meta-analyses with new randomised controlled trials. Where there was no existing low risk of bias systematic reviews, we included randomised controlled trials and other primary studies. The risk of bias was judged using design-specific tools. Evidence was synthesised narratively, and a process of considered judgement was used to judge certainty in the evidence as high, moderate, low, very low or insufficient evidence. Economic synthesis: Included studies (any design, English-language) detailed intervention-related costs. Studies were categorised as cost-consequence, cost-effectiveness, cost-utility or cost-benefit, and reporting quality evaluated using the consensus health economic criteria checklist. Systematic review of implementation factors: Included studies reported data relating to implementation barriers or facilitators. Using a best-fit framework synthesis approach, factors were synthesised around the consolidated framework for implementation research domains.

Results

Stakeholders prioritised outcomes, developed a model which informed evidence synthesis and identified evidence gaps.

Scoping review

651 studies, including 190 randomised controlled trials and 236 primary studies, conservatively reported 48 interventions/intervention combinations.

Effectiveness systematic reviews

studies explored service delivery models (n = 15); interventions delivered by families/carers (n = 32), wider children's workforce (n = 21), continence teams (n = 31) and specialist consultant-led teams (n = 42); complementary therapies (n = 15); and psychosocial interventions (n = 4). One intervention (probiotics) had moderate-quality evidence; all others had low to very-low-quality evidence. Thirty-one studies reported evidence relating to cost or resource use; data were insufficient to support generalisable conclusions. One hundred and six studies described implementation barriers and facilitators.

Conclusions

Management of childhood chronic functional constipation is complex. The available evidence remains limited, with small, poorly conducted and reported studies. Many evidence gaps were identified. Treatment recommendations within current clinical guidelines remain largely unchanged, but there is a need for research to move away from considering effectiveness of single interventions. Clinical care and future studies must consider the individual characteristics of children.

Study registration

This study is registered as PROSPERO CRD42019159008.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 128470) and is published in full in Health Technology Assessment; Vol. 28, No. 5. See the NIHR Funding and Awards website for further award information.

The effects of foot reflexology on symptoms of discomfort in palliative care: a feasibility study

BACKGROUND

In palliative care, the relief of discomfort is sought by an overall approach, combining prescribed medication and additional therapies, such as foot reflexology (FR). The main objective of this study was to assess the feasibility of FR in a population of inpatients in a palliative care unit (PCU).The precariousness of the patients led us to perform a feasibility study and not a cohort study from the outset. Its secondary objective was to assess the impact of an FR session on some symptoms of discomfort (anxiety, pain, troubled sleep, and psychological distress).

METHODS

This is a feasibility study designed as a randomized controlled two-arm therapeutic trial. One arm tested FR, the other an active control, massage therapy (MT). The evaluators were blinded.

RESULTS

FR was feasible for 14 patients out of the 15 included in the FR group (95% CI [68%; 100%]). These patients were in the palliative care phase of cancer, motor neuron disease, or terminal organ failure. Concerning the symptoms of discomfort, ESAS sleep quality score was on average 3.9 (± 2.5) before a session in the FR group. It was improved to an average of 3 (± 2.3) on the day after the session (effect-size = 0.38 [0.03; 0.73]).

CONCLUSION

This study confirms the feasibility of an FR session for patients hospitalized in a PCU. It resulted in a slight improvement in sleep quality. For other discomfort symptoms such as anxiety, pain and distress, FR yielded a non-significant improvement. Significant results would have needed a larger cohort.

Nonpharmacologic Treatment for Children with Functional Constipation: A Systematic Review and Meta-analysis

OBJECTIVE

To evaluate the effectiveness and safety of nonpharmacologic interventions for the treatment of childhood functional constipation.

STUDY DESIGN

Randomized controlled trials (RCTs) evaluating nonpharmacologic treatments in children with functional constipation which reported at least 1 outcome of the core outcome set for children with functional constipation.

RESULTS

We included 52 RCTs with 4668 children, aged between 2 weeks and 18 years, of whom 47% were females. Studied interventions included gut microbiome-directed interventions, other dietary interventions, oral supplements, pelvic floor-directed interventions, electrical stimulation, dry cupping, and massage therapy. An overall high risk of bias was found across the majority of studies. Meta-analyses for treatment success and/or defecation frequency, including 20 RCTs, showed abdominal electrical stimulation (n = 3), Cassia Fistula emulsion (n = 2), and a cow's milk exclusion diet (n = 2 in a subpopulation with constipation as a possible manifestation of cow's milk allergy) may be effective. Evidence from RCTs not included in the meta-analyses, indicated that some prebiotic and fiber mixtures, Chinese herbal medicine (Xiao'er Biantong granules), and abdominal massage are promising therapies. In contrast, studies showed no benefit for the use of probiotics, synbiotics, an increase in water intake, dry cupping, or additional biofeedback or behavioral therapy. We found no RCTs on physical movement or acupuncture.

CONCLUSIONS

More well-designed high quality RCTs concerning nonpharmacologic treatments for children with functional constipation are needed before changes in current guidelines are indicated.

Distinct Basal Brain Functional Activity and Connectivity in the Emotional-Arousal Network and Thalamus in Patients With Functional Constipation Associated With Anxiety and/or Depressive Disorders

OBJECTIVE

Functional constipation (FC) is a common gastrointestinal disorder. Anxiety and/or depressive disorders are common in patients with FC (FCAD). Brain dysfunction may play a role in FC, but the contribution of comorbid anxiety and/or depression in patients with FC is poorly understood.

METHODS

Sixty-five FC patients and 42 healthy controls (HCs) were recruited, and a hierarchical clustering algorithm was used to classify FC patients into FCAD and patients without anxiety/depressive status (FCNAD) based on neuropsychological assessment. Resting-state functional magnetic resonance imaging measures including fractional amplitude of low-frequency fluctuation (fALFF) and functional connectivity were used to investigate brain functional differences.

RESULTS

Thirty-seven patients were classified as FCAD, and 28 patients were classified as FCNAD; as compared with HC, both groups showed decreased activity (fALFF) in the perigenual anterior cingulate cortex (pACC), dorsomedial prefrontal cortex (DMPFC), and precuneus; enhanced precentral gyrus-thalamus connectivity and attenuated precuneus-thalamus connectivity in FCAD/FCNAD highlighted the thalamus as a critical connectivity node in the brain network (pFWE < .05). In comparison with FCNAD/HC, the FCAD group also had decreased fALFF in the orbitofrontal cortex (OFC) and thalamus, and increased OFC-hippocampus connectivity. In the FCNAD group, brain activities (pACC/DMPFC) and connection (precuneus-thalamus) had correlations only with symptoms; in the FCAD group, brain activities (OFC, pACC/DMPFC) and connectivities (OFC-hippocampus/precentral gyrus-thalamus) showed correlations with both constipation symptoms and anxiety/depressive status ratings. Mediation analysis indicated that the relationship between abdominal distension and OFC activity was completely mediated by anxiety in FCAD.

CONCLUSIONS

These findings provide evidence of differences in brain activity and functional connectivity between FCAD and FCNAD, potentially providing important clues for improving treatment strategies.

Clinical Acupoint Selection for the Treatment of Functional Constipation by Massage and Acupuncture Based on Smart Medical Big Data Analysis

With the development of society and economy, people's lifestyle and eating habits have undergone great changes, such as spending a long time behind desks, sitting for a long time, drinking and staying up late, and emotional depression; functional constipation, a disease of the digestive system, has changed. It is extremely common, and the age of onset is gradually decreasing. The development of the medical and health industry is also accompanied by the rapid development of technologies such as the Internet of Things, big data, and artificial intelligence, which penetrates into all aspects of the medical and health field and has entered the stage of smart medical care. This article proposes a study on the clinical acupoint selection rules of massage and acupuncture treatment of functional constipation based on smart medical big data analysis. This article adopts a variety of methods such as literature data method and experimental research method to carry out related theoretical research and promotion of massage and acupuncture treatment under the background of smart medical big data and design a clinical experiment of massage and acupuncture treatment based on big data analysis for functional constipation. The advantages of big data algorithms, the law of selecting acupoints in massage and acupuncture treatment, and the comparison of CCS symptom score and PAC-QOL score are analyzed. From the frequency of acupuncture treatment of functional constipation, the top 5 acupoints are Tianshu, Shangjuxu, Dachangshu, Zusanli, and Zhigou. In this paper, the total effective rate of treatment in the experimental group reached 96.56%, while the total effective rate of treatment in the control group was only 75.02%. Tuina and acupuncture treatment of functional constipation has a good therapeutic effect and is worthy of extensive clinical application.

Non-pharmacologic approach to pediatric constipation

Functional constipation (FC) is a pervasive problem in pediatrics. Although pharmaceuticals are commonly used for FC, parents and patients show reluctance or find dissatisfaction with available medications at times. Further, patients often have interest in utilizing nutraceutical supplements and botanicals that are available over the counter. This literature review aims to summarize research studies performed on non-pharmacologic approaches to constipation and to evaluate the safety and efficacy of these modalities. Overall data on non-pharmacologic treatments for childhood constipation were sparse, and though some studies were available for adult populations, pediatrics studies were generally limited, lacking or flawed. Certain supplements, such as prebiotics, probiotics and fiber, are safe and are without significant side effects. Though fiber supplements such as glucomannan, green banana mass, cocao husk and various fiber blends have emerging evidence in children, evidence for psyllium, cellulose and flaxseed only have supportive studies in adults. Other than senna, studies of botanicals indicate significant safety concerns (in particular with Aloe vera with aloin and Cascara sagrada) and insufficient evidence. For patients with a significant behavioral or anxiety component to their FC and exhibit dyssynergia, mind-body interventions (e.g. diaphragmatic breathing, biofeedback, cognitive behavioral therapy, and behavioral modifications) are certainly safe and effective. Finally, movement and manipulative interventions such as abdominal massage, reflexology, acupuncture and transcutaneous nerve stimulation show promise in the field of pediatric constipation, and data is accumulating for efficacy. These modalities require further study to determine mechanisms of action and which populations may benefit the most from these therapies.

Altered Functional Connectivity Within and Between Salience and Sensorimotor Networks in Patients With Functional Constipation

Functional constipation (FCon) is a common functional gastrointestinal disorder. A considerable portion of patients with FCon is associated with anxiety/depressive status (FCAD). Previous neuroimaging studies mainly focused on patients with FCon without distinguishing FCAD from FCon patients without anxiety/depressive status (FCNAD). Differences in brain functions between these two subtypes remain unclear. Thus, we employed resting-state functional magnetic resonance imaging (RS-fMRI) and graph theory method to investigate differences in brain network connectivity and topology in 41 FCAD, 42 FCNAD, and 43 age- and gender-matched healthy controls (HCs). FCAD/FCNAD showed significantly lower normalized clustering coefficient and small-world-ness. Both groups showed altered nodal degree/efficiency mainly in the rostral anterior cingulate cortex (rACC), precentral gyrus (PreCen), supplementary motor area (SMA), and thalamus. In the FCAD group, nodal degree in the SMA was negatively correlated with difficulty of defecation, and abdominal pain was positively correlated with nodal degree/efficiency in the rACC, which had a lower within-module nodal degree. The salience network (SN) exhibited higher functional connectivity (FC) with the sensorimotor network (SMN) in FCAD/FCNAD, and FC between these two networks was negatively correlated with anxiety ratings in FCAD group. Additionally, FC of anterior insula (aINS)-rACC was only correlated with constipation symptom (i.e., abdominal pain) in the FCNAD group. In the FCAD group, FCs of dorsomedial prefrontal cortex-rACC, PreCen-aINS showed correlations with both constipation symptom (i.e., difficulty of defecation) and depressive status. These findings indicate the differences in FC of the SN-SMN between FCAD and FCNAD and provide neuroimaging evidence based on brain function, which portrays important clues for improving new treatment strategies.

Efficacy of Non-pharmacologic Auxiliary Treatments in Improving Defecation Function in Children With Chronic Idiopathic Constipation: A Systematic Review and Network Meta-analysis

Background: Non-pharmacologic auxiliary treatments have been considered crucial therapies for treating chronic idiopathic constipation (CIC) during the past decades worldwide. Several treatment patterns are available, but their relative efficacy is obscure because there are no head-to-head randomized controlled trials, especially in children. We conducted this network meta-analysis to evalute the effectiveness of these therapies in improving defecation function based on their direct comparisons with standard medical care. Methods: Medline, Embase, and Cochrane Central were searched for randomized controlled trials (RCTs) published in English from inception to October 2020, assessing the efficacy of auxiliary therapies (behavior therapy, physiotherapy, biofeedback, or anorectal manometry) in children with CIC. We extracted data for endpoints, risk of bias, and evidence quality. Eligible studies in the meta-analysis reported the data of a dichotomous assessment of overall response to treatment (response or not) or defecation frequency per week after treatment. The hierarchical Bayesian network meta-analysis was used in the study. We chose a conservative methodology, random effects model, to pool data which could handle the heterogeneity well. The relative risk (RR) with 95% confidence intervals (CIs) was calculated for dichotomous outcomes. For continuous results, weighted mean difference (WMD) with related CIs was calculated. The included treatments were ranked to define the probability of being the best treatment. Results: Seven RCTs (838 patients) met inclusion and endpoint criteria. Based on an endpoint of the absence of constipation (Rome criteria) with laxatives allowed, physiotherapy plus standard medical care (SMC) had the highest probability (84%) to bethe most effective therapy. When the treatment response was defined as an absence of constipation with not laxatives allowed, biofeedback plus SMC ranked first (probability 52%). Physiotherapy plus SMC ranked first when the endpoint was based on defecation frequency per week with laxatives allowed (probability 86%). Conclusion: Almost all auxiliary therapies are effective complementary therapies for treating CIC, but they needed to be used simultaneously with SMC. Nevertheless, because of the small number of eligible studies and their small sample sizes, the differences in treatment duration and the endpoints, large sample RCTs with long-term follow-up are required for further investigation.

Foot reflexology in the management of functional constipation: A systematic review and meta-analysis

BACKGROUND

Foot reflexology has been considered an important complementary therapy for many health-related symptoms, especially for some chronic conditions such as anxiety, stress, pain and fatigue. Some studies also showed that foot reflexology had a significant effect on functional constipation, whereas some studies did not. The effect of foot reflexology on functional constipation remains controversial. Therefore, an evidence-based systematic review and meta-analysis of randomised controlled trials were conducted to investigate the effect of foot reflexology on functional constipation.

METHODS

Randomised controlled trials were identified by searching five electronic databases and hand-searching eligible reference lists. Studies that reported the effect of foot reflexology on functional constipation were included. Two reviewers performed the study screening, quality assessment and data extraction. Any discrepancy was discussed with a third reviewer. Quantitative synthesis was conducted for the same outcome measurements by calculating weighted risk ratios.

RESULTS

A total of 203 records were identified, of which seven were eligible. Overall, foot reflexology significantly increased the curative ratio, with a pooled risk ratio of 1.27 (95% CI: 1.16, 1.40, p < 0.00001). Three trials compared the improvement of constipation-related symptoms after intervention in both the experimental and control groups by evaluating the constipation-related symptom scores. The results all showed that foot reflexology can effectively improve constipation-related symptoms. However, one trial reported that foot reflexology had no significant effect on stool frequency and stool consistency. Two studies indicated that foot reflexology significantly reduced the recurrence rate of functional constipation. One study reported the effect of foot reflexology on compliance with the toilet training, diet and motivation. Nevertheless, no significant improvement was detected.

CONCLUSION

Foot reflexology is an effective complementary therapy for treating functional constipation. However, because of the small number of included studies and their small sample sizes, the current evidence was insufficient to support the effectiveness of foot reflexology in reducing the recurrence rate, improving the constipation-related symptom, and compliance with toilet training, diet and motivation. Randomised controlled trials with long-term follow-up are needed for further investigation.

Effects of reflexology on child health: A systematic review

BACKGROUND

It is known that the parents of one of every two children who need health care seek at least one complementary health-care approach. Reflexology, which is one of these, increases well-being while maintaining the continuity of homeostasis. As studies with children are limited, there is a need for evidence that includes the positive as well as the negative effects of reflexology that can be transferred to clinical practice and recommendations for future studies.

AIM

The aim of this study was to examine the effects of reflexology on child health by systematically summarizing the results obtained.

METHOD

In this study, which was structured as a systematic review, data were obtained by scanning CINAHL, Cochrane Library, Academic Search Complete, WoS, Scopus, Science Direct, PubMed, and ProQuest. According to MeSH terminology, (zone therapy OR reflexology OR foot massage OR hand massage) AND (pediatrics OR child OR infant OR baby) were used. Randomized controlled studies (RCTs), systematic reviews, and meta-analyses conducted with a pediatric population and accessible in English and full text up to 07.08.2019 (with no time limitation) were included. Exclusion criteria for the present study included applying a massage procedure different from reflexology, the inclusion of an adult sample, or publication of the article in a predatory journal. The Cochrane guidelines (Handbook for Systematic Reviews of Interventions Version 5.2.0, 2017) were applied and the article reported on according to the PRISMA checklist.

RESULTS

In all six of the RCTs, which included a total of 277 infants and children, the only method used was foot reflexology. Regarding the results of nine investigated outcomes, reflexology was found to be effective in infancy for reducing pain level and regulating heart rate, for increasing oxygen saturation, for relieving infantile colic symptoms, and neonatal abstinence symptoms. Reflexology was also found to decrease spasticity and improve motor skills in children with cerebral palsy, but it failed to produce positive change in regard to constipation and quality of life. Four of the studies were performed in a nursing context, one in midwifery, and one in physiotherapy.

CONCLUSION

As a common result of the studies conducted with different sample groups, it is possible that reflexology had positive effects on children. However, the absence of standardization related to reflexology, inadequate use of a study protocol and guidelines, the heterogeneity of the data, and the determination that half the studies were conducted with high-risk groups according to the bias analysis with RoB 2.0 indicate that it is too soon to generalize the results. Well-structured, randomized controlled double-blind trials are required.

A pilot study of parents' experiences of reflexology treatment for infants with colic in Finland

Background

Many infants under 4 months suffer from infantile colic. Infants with colic cry a lot, appear to be in pain, and it is difficult to sooth them. Colic is a painful condition for the infant and very stressful to parents. Parents in Finland get advice to try reflexology treatment for their infant, but there are no studies in Finland to support this advice.

Aim

The aim of the pilot study was to treat infants with reflexology and find out parents’ experiences of the effects of the treatment on colic symptoms and parental stress.

Method

A total of 33 parents of 35 infants diagnosed with colic participated to the pilot study. Three certified reflexologists with health care education background and extensive experience in infant reflexology were trained to give the reflexology treatment in a standardised manner. They treated each infant 3–4 times. The whole body reflexology treatment session consisted of gentle pressure treatment of soles and feet, hands, head, face, ears, back, neck and whole stomach area. One treatment session lasted about 20–30 minutes, and treatments were delivered within 8–12 days. The data were collected from the parents with semi‐structured questionnaires.

Results

The series of the treatments helped reduce the suffering of all the babies with infant colic. The colic symptoms disappeared on 43% of infants and decreased on the remaining 57%. The parents reported having pleasant experiences with the treatment, regardless whether the colic symptoms disappeared or continued. Parents stated that the treatment reduced the most typical colic symptoms; infants’ body tension, colic crying and restless movements, poor sleep quality and irregular bowel movements.

Conclusions

Reflexology treatment seems to be a safe and effective way to treat infants with colic when conducted by a health care professional with reflexology training and experience.

Traditional, complementary and alternative medicine in children constipation: a systematic review

OBJECTIVES

This review aims to evaluate the efficacy and safety of complementary and alternative medicine methods for constipation in the pediatric population.

EVIDENCE ACQUISITION

Medical literature search was performed in several databases for a variety of Traditional, Complementary and Alternative Medicine in childhood constipation. Databases included Web of Science, Scopus, Embase, Cochrane Library, PubMed, ScienceDirect, Google scholar and a number of Persian databases including IranDoc, Magiran and SID. No time limitation was determined. Clinical trials or case series that had evaluated the effectiveness of CAM therapies in functional constipation of 1-18 year old children were included. Papers not in English or Persian language were excluded. Related articles were screened independently by two reviewers according to their titles and abstracts. A data extraction form was filled in for each eligible paper. Quality assessment of eligible documents was also performed.

RESULTS

30 studies were included, comprising 27 clinical trials and 3 case series. Ten documents were on herbal medicine, nine on traditional medicine, ten on manual therapies and one on homeopathy. Except for two herbal and one reflexology interventions, all studies reported positive effects on childhood constipation, with the majority being statistically significant. As the number of studies in each method was limited, we could not perform a meta-analysis.

CONCLUSION

The scarcity of research on the efficacy and safety of different types of complementary and alternative medicine methods in children with constipation necessitates conducting more studies in each field. Graphical abstract.

The impact of motivational therapy in the management of enuretic children

OBJECTIVE

The aim of this study is to determine the impact of a motivational therapy (MT) on the outcomes for individuals diagnosed with nocturnal enuresis (NE).

MATERIAL AND METHODS

We enrolled 158 patients with NE referred to the Service of Pediatrics, Campus Bio-Medico University Hospital of Rome, from January 2013 to September 2017. Of these, 21 were excluded because they didn't meet the inclusion criteria. The study was carried out in compliance with the Helsinki Declaration.

RESULTS

A hundred and thirty seven enuretic patients [100 (72.9%) male and 37 (27.1%)] female patients with a median age of 8.8 years were included in the study. The patients were assigned to receive pharmacological therapy with desmopressin (dDAVP) (G1) (n=51), MT (G2) (n=33) and both of them (G3) (n=53). The three groups were homogeneous, with no significant differences in gender, age and family history of NE. In G1, 30/51 (58.82%) children achieved response vs. 1/33 (3.0%) children in G2 vs. 35/53 (66.04%) children in G3. About these results, The differences between G2 vs. G1 (p<0.01) and vs. G3 (p<0.01) were statistically significant while the difference between G1 vs G3 was not statistically significant (p=0.45).

CONCLUSION

Our study underlines the importance of MT in the management of NE and highlights the safety of treatment and the positive effect of MT on the compliance and the adherence to pharmacological therapy. Considering the importance of the impact of such evidence on children's lifestyle, we expect that further study with a larger sample size may confirm our hypothesis.