Taiwanese Journal of Obstetrics & Gynecology 54 (2015) 116e121

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Taiwanese Journal of Obstetrics & Gynecology

journal homepage: www.tjog-online.com

Review Article

Usefulness of chewing gum for recovering intestinal function

after cesarean delivery: A systematic review and meta-analysis
of randomized controlled trials
Hua-Ping Huang*, Mei He
Department of Nursing Administration, Mianyang Central Hospital, Sichuan, China

a r t i c l e i n f o a b s t r a c t

Article history: Chewing gum has been reported to enhance bowel function. However, the efficacy remains unclear for
Accepted 15 October 2014 women undergoing cesarean delivery. The aim of this meta-analysis is to evaluate the efficacy of chewing
gum for recovering intestinal function following cesarean delivery in the early postoperative period.
Keywords: Electronic databases including MEDLINE, EMBASE, Cochrane Library were searched to identify English
bowel function language randomized controlled trials comparing chewing gum with other procedures for promoting the
cesarean delivery
recovery of intestinal function after cesarean delivery. Two of the authors independently extracted data
chewing gum
from the eligibility studies, and Review Manager Version 5.2 was used to pool the data. Finally, five
postoperative period
randomized controlled trials involving 882 patients were included and all the trials were considered as at
high risk of bias. The pooled findings showed that chewing gum after cesarean delivery can significantly
shorten the time to first flatus [standardized mean difference (SMD) ¼ 0.73; 95% confidence interval
(CI) ¼ 1.01 to 0.14; p < 0.001]; time to first hearing of normal intestinal sounds (SMD ¼ 0.69; 95%
CI ¼ 1.20 to 0.17; p ¼ 0.009; I2 ¼ 92%). Time to the first defecation (SMD ¼ 0.53; 95% CI ¼ 1.61
to 0.07; p ¼ 0.07; I2 ¼ 92%) and length of hospital stay (SMD ¼ 0.59; 95% CI ¼ 1.18 to 0.00; p ¼ 0.05;
I2 ¼ 93%) were also reduced in the chewing gum group; however, these results were not statistically
significant. The current evidence suggests that chewing gum has a positive effect on intestinal function
recovery following cesarean delivery in the early postoperative period. However, more large-scale and
high-quality randomized controlled trials are needed to confirm these results.
Copyright © 2015, Taiwan Association of Obstetrics & Gynecology. Published by Elsevier Taiwan LLC. All
rights reserved.

Introduction
The rate of cesarean delivery, one of the most common opera-
tions worldwide, has increased in many parts of the world over the
last decade, especially in developed countries [1]. Physicians
traditionally forbid oral feeding until normal intestinal function
returns after cesarean delivery. However, this procedure may lead
to intestinal ileus, which can prolong the length of hospital stay and
increase financial burden [2,3].
In recent years, with the development of enhanced recovery
after surgery, the safe and effective promotion of the recovery of
gastrointestinal function after surgery and prevention of post-
operative complications have caused widespread concern among
medical staff. The use of chewing gum to simulate bowel move-
ment has been reported in several randomized clinical trials in
patients following cesarean delivery [4e8]. The results of some
previous meta-analysis reviews in patients undergoing gastroin-
testinal surgery have shown that chewing gum can shorten the
time to bowel movement and the length of hospital stay [9e12].
We conducted this meta-analysis of randomized clinical trials to
assess the efficacy of chewing gum for intestinal function recovery
in the early postoperative period after cesarean delivery. We
assumed that chewing gum has a beneficial effect on bowel func-
tion recovery after cesarean delivery.
Material and methods

Search strategy
* Corresponding author. Number 12 Changjia Alley, Jingzhong Street, Fucheng
District, Mianyang 621000, China. The Preferred Reporting Items for Systematic Reviews and
E-mail address: jrzhou26@aliyun.com (H.-P. Huang). Meta-Analyses statement was utilized to report this meta-analysis

http://dx.doi.org/10.1016/j.tjog.2014.10.004
1028-4559/Copyright © 2015, Taiwan Association of Obstetrics & Gynecology. Published by Elsevier Taiwan LLC. All rights reserved.
 H.-P. Huang, M. He / Taiwanese Journal of Obstetrics & Gynecology 54 (2015) 116e121
[13]. The electronic databases MEDLINE, EMBASE, and Cochrane
Library were systematically searched from their inception to
December 31, 2013. The searches were restricted to English lan-
guage publications. The following Medical Subject Headings
(MeSH) terms or key words were used: sham or chewing gum or
gum chewing or gum and caesarean section or postoperative. The
reference lists of the original and related reviews were also scanned
to identify any additional relevant studies.
Study selection
All studies included in the analysis met the following criteria:
(1) a randomized control trial design; (2) compared chewing gum
with usual care after cesarean delivery; (3) evaluated at least one of
the outcomes of intestinal function (time to first flatus; time to first
sounds; time to the first defecation); and (4) reported the sample
size, mean difference, and other appropriate data. Studies were
excluded if they: (1) were not randomized clinical trials; (2) did not
report the outcomes of intestinal function; (3) did not use chewing
gum as an intervention method; (4) were letter, comments, cor-
respondence, editorials, reviews, or gray literature; and (5) had
considerable overlap between authors, centers, and participants in
the published articles.
Data extraction
Data from each study were independently extracted by the two
authors. Any disagreements were resolved by discussion and
Fig. 1. Flowchart of studies selection.
117
consensus. The following information was extracted: first author,
year of publication, country, sample size, participant characteristics
(age, mean, and standard deviation), intervention methods, and
primary outcomes included intestinal function and length of hos-
pital stay (days).
Study quality assessment
The quality of included studies was assessed by using the
assessment tool described in the Cochrane Handbook for Systematic
Reviews of Interventions [14]. All studies were assigned a judgment
of low, unclear or high risk of bias for the following items: random
sequence generation; allocation concealment; blinding (perfor-
mance bias, detection bias); incomplete outcome data (attrition
bias); selective reporting (reporting bias); and other sources of bias.
Studies with low risk of bias for all key domains were considered as
at low risk of bias. Studies with low or unclear risk for all key do-
mains were considered as at unclear risk of bias. Studies with high
risk of bias for any one or more key domains were considered as at
high risk of bias [15].
Statistical analysis
All of the data analyses were performed using Review Manager
5.2 (Cochrane Collaboration, Oxford, UK) following recommenda-
tions from the Cochrane handbook (http://handbook.cochrane.org/
). Continuous variables were analyzed using standardized mean
difference (SMD) and expressed with 95% confidence intervals (CI).
118 H.-P. Huang, M. He / Taiwanese Journal of Obstetrics & Gynecology 54 (2015) 116e121

We used Cochrane's Q test and the I2 statistic to assess heteroge-

neity among the combined study results [16]. A p-value for
Cochrane's Q test at < 0.1 with an I2 value > 50% indicating the
existence of heterogeneity between included trials. If there was
significant heterogeneity, the random effects model was applied to
pool the data; otherwise, the fixed effects model was used. If the
results were presented as median and range values, the means and
standard deviation were calculated using the formulas described by
Hozo et al [17]. We conducted sensitivity analysis to assess the
results of this meta-analysis if there is significant heterogeneity.
Publication bias was assessed using a funnel plot. A p value < 0.05
was considered statistically significant.

Ethics approval
Ethics approval was not needed because this is a meta-analysis
of previous published literature.

Results

Fig. 1 shows a detailed flowchart of the literature search and

selection results. Of the 105 publications that were searched using
MeSH terms, 98 clinical studies were removed after reading of the
title and abstract. Seven full-text articles were assessed for eligi-
bility. One duplicated study [18] and one correspondence [19] were
excluded. Ultimately, five randomized clinical trials involving 882 Fig. 2. Summary for risk of bias assessment.
participants were included in this study [4e8].

personnel were not blinded. Outcome assessment was not blinded

Characteristics of the included studies
The baseline and design characteristics of the included studies
are presented in Table 1. All studies were published after 2008. One
study each was conducted in Egypt [4], Turkey [5], China [6], Iran
[7], and Thailand [8]. The sample size ranged from 50 to 388. Of the
882 patients, 437 were in the chewing gum group and 445 in the
control group. Patients were required to chew sugar-free gum three
times daily in four studies [5e8], while patients in another study
chewed sugarless gum every 2 hours but not during sleep [4]. The
chewing duration was 15e60 minutes. All studies reported at least
one of the outcomes of intestinal function.
Study quality assessment
Fig. 2 shows the details of the study quality assessment by using
the risk of bias tool. Among all the selected studies, participants and
in three studies. Overall, all the included studies were considered as
at high risk of bias.
Chewing gum and intestinal function recovery
Fig. 3 presents the efficacy of chewing gum on time to first
flatus, defecation, hearing of bowel sounds, and duration of hos-
pitalization. The pooled results using the random effects model
showed that time to first flatus was significantly shorter after the
use of chewing gum (SMD ¼ 0.73; 95% CI ¼ 1.01 to 0.14;
p < 0.001); time to first hearing of normal intestinal sounds
(SMD ¼ 0.69; 95% CI ¼ 1.20 to 0.17; p ¼ 0.009; I2 ¼ 92%); There
was no significant difference in time to the first defecation
(SMD ¼ 0.53; 95% CI ¼ 1.61 to 0.07; p ¼ 0.07; I2 ¼ 92%) and
length of hospital stay (SMD ¼ 0.59; 95% CI ¼ 1.18 to 0.00;
p ¼ 0.05; I2 ¼ 93%) between the groups.

Table 1
Characteristics of included studies.

Author (y, country) Number Age (y), Mean (SD) Interventions Main outcomes
(gum/control)
Gum Control
a,b,c,d
Abd-El-Maeboud et al 200 (93/107) 26.2 (4.1) 26.4 (4.6) Giving sugar-free gum for 15 min every 2 h after surgery,
(2009, Egypt) every 2 h thereafter during daytime. There was no chewing
gum during overnight sleep.
a,b,d
Kafali et al (2010, Turkey) 150 (74/76) 29.3 (3.8) 29.2 (4.8) Chewing sugar-free gum 3 times daily and lasting 1 h except
initial 1, which lasted 15 min, beginning 2 h after surgery
a,b,c,d
Shang et al (2010, China) 386 (195/191) 29.4 (5.4) 29.9 (6.4) Chewing gum at least 30 min each time, 3 times daily after
returning to ward.
a,b,c
Ledari et al (2012, Iran) 100 (50/50) 27.9 (6.4) 28.5 (6.2) Patients received sugarless gum for 1 h, 3 times/
d immediately after recovery from anesthesia.
b,d
Jakkaew et al 50 (25/25) 31.2 (6.3) 29.5 (5.9) Patients chewed sugar free gum for 1 h each time, 3 times
(2013, Thailand) daily until discharge.

SD ¼ standard deviation.
a
Time to first hearing of normal bowel sounds.
b
Time to first flatus.
c
Time to first defecation.
d
Length of hospital stay.
 H.-P. Huang, M. He / Taiwanese Journal of Obstetrics & Gynecology 54 (2015) 116e121 119

Fig. 3. Meta-analysis of evaluating effects of chewing gum on intestinal function and length of hospital stay. CI ¼ confidence interval; IV ¼ inverse variance; SD ¼ standard deviation.

Results of sensitivity analysis Discussion

Given the heterogeneity among the studies included in our
meta-analysis, sensitivity analysis was performed by removing in-
dividual study and the data of the remaining studies were chosen
and pooled. After excluding the small-scale study (number < 100)
[8], the pooled results about time to first flatus (SMD ¼ 0.73; 95%
CI ¼ 1.06 to 0.40) and length of hospital stay (SMD ¼ 0.65; 95%
CI ¼ 1.38 to 0.07) were stable (Fig. 4).
Publication bias
The funnel plot for the five studies on time to first flatus is
shown in Fig. 5. All studies distributed around the vertical, which
indicated that there was no obvious publication bias.
With increasing pressure on limited medical resources and the
need to improve patient satisfaction worldwide, strategies to
reduce the postoperative sequelae and hospitalization length are of
significant importance. Postoperative ileus is the most common
complication after abdominal surgery and is a major contributing
factor to postoperative discomfort associated with abdominal
distension, nausea and vomiting, and persistent abdominal pain
[20]. Early postoperative feeding may stimulate bowel motility and
many rehabilitation approaches such as oral hydration [21] and
systemic prokinetic pharmacologic treatments [22] have been
applied to resolve this problem. However, not all patients can
tolerate these feedings [23]. Therefore, many gynecologic doctors
are very reluctant to use early feeding.
120 H.-P. Huang, M. He / Taiwanese Journal of Obstetrics & Gynecology 54 (2015) 116e121

Fig. 4. Sensitivity analyses of chewing gum for intestinal function recovery and length of hospital stay based on large scale trials (n > 100). CI ¼ confidence interval; IV ¼ inverse
variance; SD ¼ standard deviation.

and passing flatus than those who do not chew gum, which is
consistent with some previous meta-analysis reference to abdom-
inal surgery [9e12]. Postoperative length of stay was also reduced
in the chewing gum group; however, this result was not statistically
significant (p ¼ 0.05). This result is inconsistent with previous
studies [10e12]. One potential reason is that a well-designed trial
[6] included in this meta-analysis has large proportion and
convincingly negative outcomes. In this meta-analysis, no adverse
effects were recorded in all selected studies, although some in-
gredients in gum can cause adverse effects such as headaches,
vasculitis, and diarrhea [10].
Several limitations of our meta-analysis need to be considered.
Firstly, its nature was heterogeneous and the quality of all trials in
this study was poor, possibly because the nature of this interven-
tion does not allow a double-blinded design. Secondly, the sample
size and number of included studies are small, which may influence
the accuracy of the outcomes. Third, the fact that our search was
limited to publications in English may have led us to miss some
important trials.
Fig. 5. Funnel plot analysis for time to first flatus.

Conclusions
Chewing gum as a form of sham feeding has been approved as a
safe and tolerated method to enhance intestinal function and In conclusion, the findings of this study suggest that chewing
decrease the duration of hospital stay after gastrointestinal surgery gum is certainly a useful strategy in reducing the recovery time of
[9e12]. The presumed mechanism of this action is the vagal bowel function after cesarean delivery. However, additional well-
cholinergic stimulation and triggering the release of saliva and designed clinical trials are needed to confirm these findings.
gastrointestinal tract hormones [24]. However, evidence of the
benefits of chewing gum on intestinal function after cesarean de-
Conflicts of interest
livery is rarely presented.
We conducted this meta-analysis including five randomized
The authors have no conflicts of interest relevant to this article.
controlled trials to evaluate the effect of chewing gum on intestinal
function after cesarean delivery. The findings from our study sup-
port the hypothesis that chewing gum can significantly reduce the Acknowledgments
recovery time following cesarean delivery. Women who chew gum
after surgery experience a faster return of normal bowel sounds All authors thank Mr Meng-Jun Zhou for his useful suggestions.
 H.-P. Huang, M. He / Taiwanese Journal of Obstetrics & Gynecology 54 (2015) 116e121 121

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