Gut-Directed Hypnotherapy versus Standard Medical Treatment for Nausea in Children with Functional Nausea or Abdominal Pain
By Dr. Pamela D. Browne
Chronic idiopathic nausea (CIN) and functional dyspepsia (FD) affect approximately 0.5% and 4.5%–7.6% children worldwide,1 respectively, and are associated with substantial physical and psychosocial distress, school absences and decreased social functioning.2–4 Moreover, it has a considerable negative financial impact on healthcare.5 According to the Rome IV criteria, when no evidence of organic disease is found, the disorders are considered functional. Children meet the Rome IV criteria for CIN when they suffer from chronic nausea without abdominal pain, when symptoms are not related to meals, and not consistently associated with vomiting. Children are diagnosed with FD when they have chronic symptoms of epigastric pain/burning, symptoms of postprandial fullness and/or early satiation.6
The treatment of CIN and FD with prominent nausea in paediatric patients is mostly symptomatic and not well defined. Most clinicians individualise the patient’s medical treatment, including prokinetics, antiemetics, antacids and herbal products, according to their symptoms and associated comorbidities.3 4 The major disadvantage of this approach is that this treatment is symptomatic, and thus drugs often need to be used as long as patients suffer from nausea, which may take years.7 8 Hence, there is a need for additional effective treatments for nausea in children with CIN or FD.
Several pathophysiological mechanisms have been proposed to play a role in the aetiology of CIN and FD, including delayed gastric emptying, impaired gastric motility and/or abnormal central nervous system processing of gastric stimuli through the gut–brain axis.3 Additionally, there are indications that psychological factors, including anxiety and stress, may increase the severity of nausea (SON) through the gut–brain axis.9 10
Gut-directed hypnotherapy (HT) may have the potential to reduce symptoms of nausea in children with CIN or FD. HT is a form of therapy in which a therapist, by using suggestions, can induce a hypnotic state in an individual to positively modify physiological, cognitive and affective processes, as well as behaviour in that individual.11 It has been shown to be very effective in the treatment of adults and children with functional abdominal pain12 13 and children with chemotherapy-induced nausea and vomiting.14 Therefore we hypothesise that HT, by its ability to influence gut motility,15 psychological well-being16 and visceral hypersensitivity,17–19 might alleviate symptoms of nausea in children with CIN or FD as well. To date, however, no studies have examined the potential effect of HT in children with CIN or FD.
The main goal of this multicentre randomised controlled trial (RCT) is to evaluate the effectiveness of HT in reducing symptoms of nausea in children with CIN or FD. Six sessions of gut-direct HT will be compared with six sessions of standard medical treatment (SMT) plus supportive therapy in 100 children with CIN or FD between 8 and 18 years. Additionally, we will investigate the potential influence on abdominal pain, dyspeptic symptoms, quality of life (QoL), anxiety, depression, school absences, parental absence of work and healthcare costs. We hypothesize that HT will be more effective in reducing symptoms of nausea than SMT. Furthermore, we expect that children receiving HT will report more relief of symptoms (eg, less abdominal pain, less dyspeptic symptoms), better QoL, less symptoms of anxiety and depression, less absence from school, compared with children receiving SMT. We also expect that parents of children in the HT group will report less parental absences from work and lower healthcare costs, compared the medical treatment group.
Individual HT consists of six sessions of 50–60 min, given over a period of 3 months by a qualified hypnotherapist (weeks 1, 2, 3, 5, 7 and 11). Twelve hypnotherapist affiliated to the recruiting hospitals will offer the HT to children. All hypnotherapists have years of experience in performing HT in children. The hypnotherapists will use an adapted version of our previously used HT protocol.13 20 The HT protocol contains exercises focusing on normalisation of the gut motility, stress reduction and ego strengthening. The hypnotherapists will be instructed to use the same scripts, but are allowed to adapt the content to the child’s needs. The same protocol is used for children of all ages. However, the language used will be adjusted to the child’s developmental age.
In the first session, an introduction to HT will be given to the child and parents, including an explanation of what HT is and how it may help in reducing symptoms of nausea. Furthermore, the hypnotherapist will take a full history and children and parents are instructed to not talk about the nausea during the treatment period. The hypnotherapist will then start with a breathing exercise and introduce a progressive relaxation, in which children imagine floating on a big cloud. Positive suggestions to increase the child’s belly comfort will also be provided. For instance, the child will be instructed to make hands warm and place both hands on the belly, imagining warmth spreading through their abdomen and especially the stomach.
In the second session, the therapist will repeat the exercise on progressive relaxation. Additionally, the therapist will introduce an exercise focusing on reduction of anxiety and stress which is called ‘the favourite place exercise’.
The third session focuses on ego strengthening and a new exercise will be introduced: ‘the rainbow planet exercise’ for children attending primary school, and ‘the air balloon exercise’ for children in secondary school. In the first exercise, children choose a personal need from a rainbow that contains different needs, for example, a healthy stomach, courage, tranquillity or confidence.
In the fourth session, children are encouraged to release stress during the ‘the beach without worries exercise’ and additional ego strengthening suggestions are made.
The fifth session focuses on reduction of anxiety, stress and ego strengthening, as well as improved functioning of the digestive system. For the digestive system, children visualise a well working digestive system with food sliding through the stomach and bowel in a comfortable way.
In the sixth session, the previous sessions will be evaluated, remaining gastrointestinal problems may be addressed and preceding exercises may be repeated, if requested by children. If no improvement has taken place, an exercise will be introduced in which the child is instructed to look inside the stomach to see ‘what the stomach needs’.
After the first session, all children will receive a compact disc containing standard scripts of the exercises used during the sessions. The hypnotherapist will advise children to self-practice these exercises on a daily basis. Additionally, the therapist will encourage children to practice breathing exercises a few time a day.
Chronic nausea is a highly disabling symptom for children with CIN or FD, and poses a risk for negative health outcomes and decreased psychosocial functioning.2–4 To date large randomised placebo controlled trials evaluating the effect of any drug in children with either CIN or FD are lacking.37 Current medical treatment is experienced based, however these treatments are symptomatic and often used for months or years.7 8 For these reasons, new effective treatment options to reduce nausea in children with CIN or FD are warranted.
There are indications that HT can decrease symptoms of functional nausea and dyspepsia in adults,35 and functional abdominal pain (FAP)13 and chemotherapy induced nausea in children.14 Calvert et al 35 found that adult patients with FD receiving 12 sessions of HT had significantly less dyspeptic symptoms (59%, n=26) compared with patients receiving medical treatment (33%, n=29) (p=0.02).35 These beneficial effects were maintained for more than a year: 56 weeks after the first treatment, 73% of the patients in the HT group reported symptom improvement compared with 43% in the medical treatment group (p<0.01). In children with FAP, Vlieger et al found that HT was highly superior compared with SMT to reduce abdominal pain. At 1 year follow-up, 85% of the children in the HT group (n=26) were in clinical remission compared with 25% of the children in the SMT group (n=24) (p<0.001).13 Additionally, a systematic review including six RCTs evaluating the effectiveness of HT to reduce chemotherapy-induced nausea found HT was most effective when compared with SMT to reduce complaints (D=0.99).14