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Comparison of the effect of chewing gum with routine method on ileus after burns: a randomized clinical trial

BMC Research Notes volume 17, Article number: 261 (2024) Cite this article

Abstract

Background

Chewing gum is a healthy, cheap, and familiar solution for patients with premature irritation of the stomach and intestines. This study compared the effect of chewing gum and the routine method on ileus after burns.

Methods

This study is a randomized clinical trial conducted in Valiasr Hospital in Arak, Markazi Province, in the center of Iran, from December 2021 to February 2023. After the diagnosis of intestinal ileus in 83 patients hospitalized in the burn department by a general surgeon, with the available sampling method, these patients were evaluated based on the inclusion and exclusion criteria of the study. As a result, 66 patients were selected and divided into groups A (33 patients in the intervention group: routine care + gum chewing) and B (33 patients in the control group: routine care) by random allocation method. For the intervention group, from entering the ward until the beginning of oral feeding, gum (without sugar) was chewed four times a day for 15 min, while control groups received the routine diet of the department. Both groups’ condition of the bowel sounds, time of passing gas, and stool were recorded. The statistical analyses were performed using SPSS version 16. The chi-squared, Fisher’s exact, Independent t-test, and Mann-Whitney U tests were utilized.

Results

The results showed that the median bowel sound return time, time of the first gas discharge, earliest defecation time, and time to start the diet were significantly shorter in the intervention group than in the control group (P < 0.001).

Conclusion

This study showed the effect of chewing gum without sugar in shortening the symptoms of intestinal ileus after burns. However, it was not effective in reducing the hospitalization period of patients. According to these results, it is recommended to add chewing gum to the routine care of people hospitalized due to burns.

Trial registration

Iranian Registry of Clinical Trials IRCT20180715040478N1, 2021-07-27.

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Introduction

In the ileus, due to intestinal obstruction or paralysis, the passage of intestinal contents is prevented, leading to the accumulation of contents at the site of obstruction [1]. Accumulation of liquid and gas inside the intestine leads to distension, bloating, belching, nausea, vomiting, and constipation [2, 3]. In addition to causing a severe complication of complicated pulmonary aspiration, it can cause dehydration, electrolyte imbalance, or sepsis in patients [4]. The pathophysiology of ileus is related to multiple and complex causes that include pharmacological, neurological, and immune-mediated mechanisms. The initial nervous phase, caused by the activation of afferent nerves, has a shorter period than the subsequent inflammatory phase [2]. The release of corticotropin-releasing factor through the neurogenic phase plays a central role in neuroinflammation and affects both the central autonomic response and the hypothalamic-pituitary-adrenal axis [5]. Within a short time, endogenous luminal particles and bacterial products activate or replenish circulating leukocytes that eventually extravasate into the manipulated muscular [6]. Different causes, such as inflammation, infections, abdominal operations, drugs, and electrolyte imbalance (hyponatremia, hypokalemia, hypomagnesemia, etc.) can lead to ileus [7]. The general gastrointestinal tract is usually damaged in the initial stage of severe burns [8]. Intestinal sounds and disturbance in peristaltic movements are two symptoms of ileus after burn injuries [9].

Intravenous fluid treatment, using painkillers (including NSAIDs, prophylactic anti-emetics, and epidural and regional analgesia), restricting the consumption of food, and, if necessary, performing surgery are the usual methods in the treatment of this disease [10,11,12,13]. There are no definitive guidelines on the duration of conservative treatment, and the decision to perform surgery is not easy even for experienced surgeons [1, 14]. The effect of chewing gum in reducing the time of the first bowel movement in ileus patients has been confirmed [15]. Chewing gum is a non-medicinal, healthy, cheap, and familiar solution for patients with premature irritation of the stomach and intestines [16]. Chewing gum is considered a form of sham feeding [17]. The physiological mechanism of improved gut motility by gum chewing occurs by activating the cephalic-vagal pathway, which stimulates intestinal myoelectric activity to counteract the activation of gastrointestinal µ opioid receptors. In addition, this vagal stimulation appears to have an anti-inflammatory effect [17, 18]. Chewing gum has been investigated in various studies of gynecology and obstetrics, cesarean, colorectal, and appendectomy surgeries [19,20,21,22,23]. However, there has been no compelling study on the effect of chewing gum on the ileus after burns. In the conventional method of post-burn care, the start of the diet is delayed until bowel movements are resumed, which causes associated problems. The present study compared the effect of chewing gum and the routine method on ileus after burns.

Method

Study design

This randomized clinical trial was conducted on patients admitted to the burn department of Valiasr Hospital in Arak, Markazi Province, in the center of Iran from December 2021 to February 2023.

Participants

After the diagnosis of intestinal ileus in 83 patients hospitalized in the burn department by a general surgeon, with the available sampling method, these people were evaluated based on the inclusion and exclusion criteria of the study. As a result, 66 patients were selected.

The inclusion criteria included: the research units have 2nd-degree, 3rd-degree, or combined burns, and the percentage of burns is more than 40% of total body surface area (TBSA); No more than 6 h have passed from the time of getting a burn to the time of entering the research; The need for hospitalization according to the doctor’s opinion; Willingness to participate in research; Absence of facial injuries, inhalation injury, and psychological problems. The exclusion criteria included a history of diabetes, hypothyroidism, hypoparathyroidism, electrolyte disorder, prominent muscular and nervous diseases, and drug addiction; History of taking drugs affecting bowel movements (anticholinergic drugs, etc.); Unwillingness to continue participating in the study; The use of drugs that affect intestinal motility during the intervention period; Intolerance of gum chewing.

Randomization and blindness

The participants were divided into two groups, A (33 patients in the intervention group: routine care + gum chewing) and B (33 patients in the control group: routine care), by random allocation method (using a table of random numbers).

Due to the nature of the intervention, it was impossible to blind the subjects in the study about chewing gum. Therefore, blinding was performed on those who collected and recorded the data and those who conducted the analysis. The physician who examined the patient and the nurse who collected the data were unaware of whether the subjects belonged to the intervention or control groups. Also, the people who analyzed the data statistically were unaware of the people belonging to the intervention and control groups. This research was designed and implemented according to the CONSORT guidelines (Diagram 1).

Diagram 1
figure 1

Consort -flow- diagram

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Protocol

The study protocol can be viewed at https://irct.behdasht.gov.ir/trial/32595.

Plan of study

The patients were divided into two treatment groups for randomized clinical trial study:

  • Group A (Intervention Group): gum chewing.

  • Group B (Control Group): routine method.

For Group A patients (gum chewing), from entering the ward until the beginning of oral feeding, chewing gum was done four times a day for 15 min. The gums given were gum without sugar [24].

Group B patients (control group) received the routine diet of the department, including breakfast: bread and cereal group, oil group and meat group; Snacks: fruit group and bread and cereal group; Lunch: bread and grain group, meat group, oil group, vegetable group, dairy group; In the evening: fruit group, dairy group, grain group, meat group; Dinner: bread and grain group, meat group, oil group, vegetable group, dairy group.

Treatment was prescribed for patients by a specialist physician, and painkillers were also prescribed by a specialist physician routinely and based on the patient’s conditions. The researchers of the present study had no involvement in these cases.

Data Collection

This study’s data collection was meticulously carried out to ensure accuracy and consistency across the intervention and control groups. The study focused on both qualitative and quantitative variables. Qualitative variables, such as gender, marital status, education level, occupation, underlying medical conditions, type of burns, and accompanying injuries, were recorded using structured questionnaires.

Quantitative variables were recorded with precision, including the timing metrics related to bowel movement improvement (e.g., Bowel Sound Return Time, Time of First Gas Discharge, Earliest Defecation Time, Time to Start the Diet, and Time to Get Out of Bed). Every two hours, the condition of bowel sounds in both groups was assessed and recorded using a medical phone by the project’s associate physician. Additionally, a trained nurse documented the time of passing gas and stool in the evaluation checklist. These nurses received one-hour training sessions conducted by the researchers to ensure the accurate recording and reporting of these variables.

Statistical analysis

The present study conducted a comprehensive statistical analysis to assess the demographic characteristics and crucial timing metrics related to bowel movement improvement in burn patients within the intervention and control groups. The statistical analyses were performed using SPSS version 16.

Before proceeding with additional analyses, the normality of the data was evaluated using the Kolmogorov-Smirnov test. The test results indicated that the data distribution for most variables did not follow a normal distribution, necessitating non-parametric tests for those variables. Consequently, the decision to employ both the independent t-test (for normally distributed quantitative variables) and the Mann-Whitney U test (for non-normally distributed variables) was made based on these results.

The chi-squared test was primarily used to compare qualitative variables in the intervention and control groups. However, Fisher’s exact test was utilized for variables with small expected frequencies as it provides a more accurate assessment in such cases. This approach ensured the robustness of the findings. The significance level was set at 0.05. Additionally, Excel 2013 was used for graph construction.

Results

During the study, 66 patients with intestinal ileus after burns were included; three from the intervention group and one from the control group were excluded because of non-referral for treatment. Also, two people from the control group were excluded from the study because of withdrew written consent. The mean age of participants in the survey was 34.63 ± 18.45. Of the total, 34 (56.7%) were male, and 32 (53.3%) had underlying medical conditions. Furthermore, 32 individuals (53%) exhibited fuel consumption exceeding 40%, and 55 individuals (91.7%) presented with thermal burns. Additionally, visceral lacerations were identified in 33 individuals (55%). Treatment, including dressing, antibiotic therapy, debridement, and graft, was administered to 46 individuals (76.7%) (Table 1).

The intervention and control groups showed no significant differences in terms of age, gender, occupation, education, underlying medical conditions, intake drugs (vancomycin hydrochloride, cephalosporin, histamine H2-blocker), percentage of burns, burn type, accompanying injuries, and treatment type (p > 0.05) (Table 1).

The median Bowel Sound Return Time was significantly shorter in the intervention group (22 h, IQR: 9) compared to the control group (38 h, IQR: 20), with a P-value less than 0.001. Similarly, the Time of the First Gas Discharge demonstrated a notable reduction in the intervention group (32 h, IQR: 9) compared to the control group (45 h, IQR: 25), with a P-value less than 0.001. The earliest defecation time showed a significant decrease in the intervention group (48 h, IQR: 14) compared to the control group (56 h, IQR: 25) with a P-value less than 0.001. Additionally, the Time to Start the Diet was markedly shorter in the intervention group (1 h, IQR: 0) compared to the control group (3 h, IQR: 2), with a P-value less than 0.001. However, the Time to Get Out of Bed did not exhibit a statistically significant difference between the intervention and control groups (2 h, IQR: 2 for both groups, P-value: 0.177) (Table 2).

These findings highlight the positive impact of the intervention on bowel movement-related metrics, emphasizing the potential benefits of the implemented approach in facilitating the recovery of burn patients (Fig. 1).

Table 1 Comparison of demographic variables in intervention and control groups before the intervention
Full size table
Table 2 Comparative analysis of bowel movement improvement in burn patients: key timing metrics between intervention and control groups
Full size table
Fig. 1
figure 2

Comparison of bowel sound resumption, first gas passage, earliest defecation, and diet commencement times in burn patients in intervention versus control groups

Full size image

Discussion

This study compared the effect of chewing gum and the routine method on post-burn ileus. The comparison between the intervention and control groups showed no significant difference in demographic variables, type and severity of burns, and type of treatment. Visceral lacerations were observed in more than half of the people. Burn treatment measures, including dressing, antibiotic therapy, debridement, and grafting, were performed for 76.7%.

The results showed that the return of bowel sounds in the intervention group (gum chewing) was significantly shorter in the control group (routine method). Similarly, the time to the first gas evacuation was considerably shorter in the intervention group than in the control group. In line with these results, Altraigey’s [25] and Manzoor’s [26] studies showed that chewing gum effectively returned bowel sounds and expelled gas after a cesarean section. The results of Ya-Chuan’s study showed that chewing gum positively affects the time of the first gas evacuation and bowel movement after surgery [27]. Also, Bhatti’s study showed that chewing gum is associated with a shorter passage of flatus [28].

According to the results, the earliest defecation time was significantly reduced in the intervention group compared to the control group. In addition, the time to start the diet was considerably shorter in the intervention group compared to the control group. Wen’s meta-analysis showed that chewing gum after a cesarean section can significantly accelerate the earliest defecation time and shorten the hospital stay [29]. The results of some studies on the effects of chewing gum after colorectal cancer surgery concluded that it may improve bowel function [30]. On the other hand, a meta-analysis focused on the impact of chewing gum on postoperative ileus showed that chewing gum is beneficial for an apparent reduction in time to passage of flatus and time to excretion. Still, it does not reduce the length of hospital stay [31]. In the present study, the time of getting out of bed did not significantly improve in the intervention group compared to the control group.

Regarding these contradictions, it should be said that the mentioned studies were conducted on patients with different reasons for hospitalization, so the type of disease and the action taken for the patient can be considered adequate on the effectiveness of chewing gum in reducing the duration of ileus.

The strength of the current study was the proper cooperation of the hospital staff to carry out the intervention and complete supervision in implementing the intervention by the researchers.

One of the limitations of the study was the various injuries caused by burns in the patients, which made it challenging to perform examinations and collect information.

Conclusion

This study showed the effect of chewing gum without sugar in shortening the symptoms of intestinal ileus after burns. However, it was not effective in reducing the hospitalization period of patients. According to these results, it is recommended to add chewing gum to the routine care of people hospitalized due to burns. Of course, conducting more clinical trials in this field seems necessary for people hospitalized due to burns.

Data availability

The datasets generated and analyzed during the current study are not publicly available because they contain raw data from study participants, and sharing these data requires participants’ permission. But are available from the corresponding author on reasonable request.

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Acknowledgements

We thank all the patients who participated in this study.

Funding

This research was supported by Khomain University of Medical Sciences (No:400000008).

Author information

Authors and Affiliations

  1. Department of Nursing, Khomein University of Medical Sciences, Khomein, Iran

    Azam Malek Hosseini

  2. Department of Medicine, Faculty of Medicine, Arak University of Medical Sciences, Arak, Iran

    Sina Abdi & Siavash Abdi

  3. Department of Public Health, Torbat Jam Faculty of Medical Sciences, Torbat Jam, Iran

    Vahid Rahmanian

  4. Department of Public Health, Khomein University of Medical Sciences, Khomein, Iran

    Nader Sharifi

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  1. Azam Malek Hosseini
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Contributions

Conceptualization: A M K, Sin A, N SH; Data curation: A M K, Sia A; Formal analysis: A M K, V R, N SH; Methodology: A M K, N SH; Project administration: A M K, Sin A; Writing–original draft: N SH, A M K, V R; Writing–review & editing: all authors.

Corresponding author

Correspondence to Nader Sharifi.

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Competing interests

The authors declare no competing interests.

Ethical approval and consent to participate

Ethical approval was obtained from the Human Research Ethics Committee at the Khomeini University of Medical Sciences (Code IR.KHOMEIN.REC.1400.014). All study participants provided written informed consent. For illiterate subjects, informed consent to participate was obtained from their literate legal guardian. All participants in this study were over 18 years of age. Confidentiality and anonymity were ensured. All procedures performed in studies involving human participants were by the ethical standards of the institutional and national research committee and with the 1964 Helsinki Declaration.

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All participants provided written informed consent.

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Malek Hosseini, A., Abdi, S., Abdi, S. et al. Comparison of the effect of chewing gum with routine method on ileus after burns: a randomized clinical trial. BMC Res Notes 17, 261 (2024). https://doi.org/10.1186/s13104-024-06929-y

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BMC Research Notes

ISSN: 1756-0500

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