State-of-the-Art Pediatrics

Auricular Neurostimulation: Modulating the Gut Feeling through the Ear for Irritable Bowel Syndrome

Co-author: Amornluck “Pang” Krasaelap, MD | Pediatric Gastroenterologist, Section of Neurogastroenterology and Motility | Assistant Professor of Pediatrics, UMKC School of Medicine | Education Assistant Professor of Pediatrics, University of Kansas Medical Center

Co-author: Gracielle Bahia, DO | Pediatric Gastroenterologist, Section of Neurogastroenterology and Motility | Associate Program Director, Pediatric Gastroenterology Fellowship | Assistant Professor of Pediatrics, UMKC School of Medicine

Column Editor: Amita R. Amonker, MD, FAAP | Pediatric Hospitalist | Assistant Professor of Pediatrics, UMKC School of Medicine 

Sixteen-year-old Maddie had been dealing with abdominal pain, alternating diarrhea, and constipation for years before being diagnosed with irritable bowel syndrome (IBS). She had tried multiple medications, diet modification, and cognitive behavioral therapy with no success. She had missed school, was miserable and hopeless.

Irritable bowel syndrome (IBS): The brain-gut axis dysregulation

Do you know that we all have two brains? One brain in the head (central nervous system) and the other in the digestive system (enteric nervous system). The two brains are inextricably linked, sending signals back and forth continually. This connection is responsible for “feeling butterflies in your stomach” when nervous, or “trusting your gut” when making a decision.

Dysfunction of this connection plays a major role in a group of disorders known as functional gastrointestinal disorders, including IBS.¹ With dysregulated brain-gut signaling, patients with IBS often have visceral hypersensitivity and altered bowel habits at the gut level, and enhanced sensory perception and psychological disturbances at the brain level.¹

IBS treatment options

Treatment options for IBS have long been limited to symptom management at the gut level such as antispasmodics, laxatives, antidiarrheal agents and diet modifications. Additional treatments that work at the brain level, such as antidepressants/anti-anxiety medications can come with side effects. Psychological interventions can take time to work and deep brain stimulation and spinal cord stimulation are invasive.

Auricular neurostimulation: The brain-gut axis modulation

A novel, FDA-cleared auricular neurostimulator device has been developed to deliver percutaneous electrical stimulation to the brain via cranial nerve branches around the ear.^1,2 The device delivers alternating frequencies below sensation threshold such that most people cannot feel it. The device is worn continuously for five consecutive days each week, followed by a two-day break by removal in the home setting. A typical treatment course consists of four to eight weeks of therapy but can be shorter or longer based on an individual child’s needs.

Data from a randomized, double-blind trial showed that patients who received this therapy achieved ≥ 30% reduction in worst abdominal pain scores, when compared with patients in the control group (59% vs. 26%; P = .024).² The number needed to treat for one patient to reach this goal was only 3. Furthermore, researchers observed significantly more patients receiving this therapy reporting an improvement in overall symptoms with a symptom response scale score of 2 or more, when compared with the control group (82% vs. 26%; P≤0.001).² This therapy is well-tolerated with an excellent safety profile.

In light of poor efficacy of pharmacological therapies and a need for safer treatment options, the auricular neurostimulator is an effective, safe and non-pharmacological alternative therapy for adolescents with functional abdominal pain disorders. Ongoing research studies have also shown that auricular neurostimulation may also be beneficial for patients with other functional gastrointestinal disorders as well.  

This treatment option is available for patients through the Neuromodulation Program, Section of Neurogastroenterology and Motility, Department of Gastroenterology at Children’s Mercy Kansas City.

Maddie decided to “go with her gut” and joined the auricular neurostimulation journey at Children’s Mercy. Her abdominal pain significantly improved. Maddie was able to go back to school and live her life as she wanted.

References:

1. Hyams JS, Di Lorenzo C, Saps M, Shulman RJ, Staiano A, van Tilburg M. Functional disorders: Children and adolescents. Gastroenterology. 2016 Feb 15:S0016-5085(16)00181-5. doi: 10.1053/j.gastro.2016.02.015. Epub ahead of print. PMID: 27144632.
2. Krasaelap A, Sood MR, Li BUK, Unteutsch R, Yan K, Nugent M, Simpson P, Kovacic K. Efficacy of auricular neurostimulation in adolescents with irritable bowel syndrome in a randomized, double-blind trial. Clin Gastroenterol Hepatol. 2020 Aug;18(9):1987-1994.e2. doi: 10.1016/j.cgh.2019.10.012. Epub 2019 Oct 14. PMID: 31622740.
3. Kovacic K, Hainsworth K, Sood M, Chelimsky G, Unteutsch R, Nugent M, Simpson P, Miranda A. Neurostimulation for abdominal pain-related functional gastrointestinal disorders in adolescents: a randomised, double-blind, sham-controlled trial. Lancet Gastroenterol Hepatol. 2017 Oct;2(10):727-737. doi: 10.1016/S2468-1253(17)30253-4. Epub 2017 Aug 18. PMID: 28826627.