Integrative Pediatricsfor Children with Special

Health Care Needs

Susie Gerik, MDChildren’s Center for Restorative Care

What is CAM?Broad range of healing philosophiesNot commonly used, accepted, studied, understood, or made available in Western (conventional) medicineTo promote well-being or treat health conditions

What is Holistic Medicine?An approach that considers the whole person, including physical, mental, emotional, and spiritual aspects

What is Integrative Pediatrics?

Healthcare provider partners with patient and caregiversAll interventions that are considered safe and potentially beneficial are offered/discussed

What is Integrative Pediatrics?

Health and healing are emphasized more than disease and curingPrevention of disease and health optimization go hand-in-hand

What is Integrative Pediatrics?

Healthcare provider is responsible for providing access to credible information and assisting people with encouraging habits to support wellness

What is Integrative Pediatrics?

Attention is paid to all aspects of a child (holistic)Health professionals serve as role models for healthy living

Concerns Regarding CAM Use in Children

Many therapies not well studiedDosagesSafetyEfficacy

Delay of proven conventional therapy in favor of CAM

Pediatrician’s AttitudesJAMA article my Sikand and Laken of a survey of 860 pediatriciansFindings:

Majority believed only a small percent of patients used CAMWould refer for therapies such as biofeedback, self-help, relaxation, hypnosis, and acupuncture or acupressure

Pediatrician’s AttitudesOver half would use CAM therapies personallyMost were interested in CME on CAM

Realities about CAMIncreasing CAM useHolistic practicesMedia coverageNCCAM

Increasing Use1990 33%1997 42%> $27 billion75 out of 117 US Medical schools offer elective courses in CAM

CAM UseLimited knowledge about the prevalence of use of CAM in pediatric population (estimated 10-15% overall)40% of adults use CAMMost adults do not discuss their use of CAM with their physicians

CAM UsePediatric use of CAM is especially likely among children with chronic illness or disability.

Prevalence of Use of CAM Therapies in Pediatrics

Up to 70% of children with severe, chronic, or recurrent illness

Cystic fibrosisJuvenile rheumatoid arthritsCancer

Use of CAM in acute illnesses not well studied but most likely related to parental use of therapies (over 40% in US surveys)

How Many Children?31% of children have one or more chronic physical condition at some time during their youth20% of children have developmental delays, behavioral and emotional problems, and/or learning disabilities6% of children have a severe chronic illness

Increasing Prevalence and Incidence

Increase in total populationDecrease in mortalityShortened hospitalizations and more home care

BiomedicineDisease is explained by pathophysiologic processes.Treatments are designed to affect these processes.

Many accepted biomedical treatments lack evidence of effectiveness from peer-reviewed scientific literature.

Alternative TherapiesBased on a variety of non-biomedical beliefsMany have not been subjected to clinical researchMost are supported by anecdotal evidenceSome have proven effectiveness

Common GroundThe relationship between physician-healer and patient is integral to the success of treatments offered.

The “art” of medicine.

What is NCCAM?National Center for Complementary and Alternative MedicineEstablished in 1998

What is NCCAM?To stimulate, develop, and support research on CAM for the benefit of the publicMission: to give the American public reliable information about the safety and effectiveness of CAM practices

More about NCCAM…Director: Steven Strauss, MDBudget: $89.2 million (next year $100 million)

35% independent investigator initiated10% training23% for “Centers”

Major CAM DomainsAlternative medical systemsMind-body interventionsBiological-based therapiesManipulative or body-based therapiesEnergy therapies

Therapeutic Mountain A Model of Care

Biochemical: medications, herbs, nutritional supplementsLifestyle and Mind-Body Therapies: nutrition, exercise, environment, mind-body

Therapeutic Mountain A Model of Care

Biomechanical Therapies: massage and physical therapy, chiropractic, osteopathic, surgeryBioenergetic Therapies: acupuncture, therapeutic touch, healing touch, laying on of hands, reiki, qi gong, prayer and ritual, homeopathy

Some examples of commonly used CAM

therapies Echinacea for URIChamomile for colic (remember Peter Rabbit), also fennel, licoriceHomeopathy for colds, flu, diarrheaAcupuncture/acupressure for headache other painGinger for nauseaVitamins for about everything

Some examples of commonly used CAM

therapiesImagery for wartsMassage, therapeutic touch, relaxation therapy for insomniaEssential fatty acids, evening primrose oil for eczemaAddress food allergies for recurrent AOMWitch hazel, chamomile, other herbs topically for diaper rash

Some examples of commonly used CAM

therapiesOlive oil for cradle capMassage for stimulating growth in premature infantsGarlic and honey for coughsHypnosis and biofeedback for encopresisVitamin C and Zinc lozenges for coldsAloe vera for burns

Some examples of commonly used CAM

therapiesTea tree oil for skin infectionsMind-body approaches like biofeedback, hypnotherapy for enuresisHypnosis, autogenic training, biofeedback, family support, prayer in asthmaticsReduce food allergens in those with inhalant allergies (cross rxn?)Vitamin A (from food), zinc, B6 for acne

DistractionBlowing bubblesPlaying with pop-up toysLooking through a kaleidoscopeImagining a superheroBreathing techniques and guided imagery

Suggestion“Magic glove” techniqueBasic principles

Willingness to be involvedTrust in the coachAbility to participate

Breathing TechniquesRhythmic, deep-chest breathingPatterned, shallow breathing

Guided ImageryA form of relaxed, focused concentrationFavorite place, favorite activity

Not only produce distraction, but also enhance relaxation

Progressive Muscle Relaxation

Recognize and reduce body tension associated with painDecrease anxiety and discomfort

BiofeedbackUses instruments to detect and amplify specific physical states in the body and help bring them under one’s voluntary controlMechanism of pain relief is based on specific physiologic changes caused by the biofeedback

HypnosisAltered state of consciousness is usedConcentration is focused, narrowed, absorbed

AcupunctureBased on a theory that energy (Chi) flows through the body along channels (meridians) which are connected by acupuncture pointsPain results when flow of energy is obstructedAcupuncture restores that flow and eliminates or reduces pain

Research AreasGastrointestinal disordersRespiratory disordersDevelopmental disordersOncologyMental health disordersEpidemiological studies of CAM

University of ArizonaFellowship in Integrative MedicineResearch projects

Abdominal painOtitis mediaCerebral palsy

Boston Children’s HospitalCenter for Holistic Pediatric Education and ResearchResearch projects:

Herbs and supplements in cancerAcupuncture for several conditionsEchinacea for URIAlternative treatments for otitis media

University of RochesterAdolescent use of CAM

University of Washington and Bastyr

Echinacea for URI

University of MiamiMassage in preterm infants

Key Principles in CAM Research

Consistency of design and outcome instruments is essentialRCT is still the gold standard (hierarchy of evidence)Some CAM cannot be blendedStudies of whole systems require creativity

Key Principles in CAM Research

Rigorous designs are imperativeCAM experts and patient advocates should be included in study oversightRole of CAM for given health conditions must be clarified

HeadacheDuckro and Cantwell-Simmons Headache 1989 Biofeedback and Relaxation in the Management of Pediatric HeadacheSummary and interpretation of controlled studies supports behavioral approach as a potent alternative

HeadacheHolden, Deichmann, and Levy Journal of Pediatric Psychology 1999Review of research on behavioral treatments for recurrent headachesRelaxation and self-hypnosis is a well-established and efficacious treatment for recurrent headaches

Vaccine-related PainJacobson et al Vaccine 2001Attitude, empathy, instructionDistraction, hypnosisSugar nipplesTopical anesthetics (EMLA)56 references

Fracture ReductionIserson Journal of Emergency Medicine 1998Hypnosis used to diminish pain and anxiety in patients with angulated forearm fractures (no other form of sedation or analgesia available)

Postoperative PainPolkki et al Journal of Advanced Nursing 2001Emotional support, helping with activities, creating a comfortable environment used routinelyOther nonpharmacologic measures used less frequentlyRelated to background of the nurses

Recurrent Abdominal PainGevirtz Journal of Pediatric Gastroenterology and Nutrition 2000Fiber, Fiber-biofeedback, Fiber-biofeedback-cognitive/behavioral intervention, Fiber-biofeedback-cognitive/behavioral intervention-parental supportAll groups showed improvement, but treatment group showed more improvement

Rheumatic IllnessesField et al Journal of Pediatric Psychology 1997Massage helpful for JRA – marked decrease in subjective pain, observed pain, and tender trigger points

The Holistic PediatricianAuthor Kathy Kemper, MD, MPH of HarvardA parent’s guide to therapy for 25 most common childhood ailmentsProvides an integrative approach: the best of modern medical science with proven alternative therapies Well referenced. Clear recommendations, prescriptions, and proscriptions

Healthy Child, Whole ChildIntegrating the Best of Conventional and Alternative Medicine to Keep Your Kids HealthyAuthors: Stuart Ditchek, MD and Russell Greenfield, MD

Resourceswww.holistickids.orgwww.nccam.nih.gov/UTMB Integrative Medicine Web SiteHealthNotes OnlineNaz’s Special Needs Tips

CasesAsthma

http://www.holistickids.org/cases/asthma/asthma_summary.shtml

CasesCP

HBOThe principle effect of HBO therapy is hyperoxia.At 3 atmospheres of pressure

Alveolar O2 tension = 2180 mmHg

PaO2 = 1800 mmHg

tissue concentration = 500 mmHg.

HBOAfter removal from the hyperbaric O2 environment the PaO2 normalizes in minutes but the PtO2 may remain elevated for a variable period.Potentially important physiologic effects of HBO include:

stimulation of angiogenesis in hypoxic soft tissues

enhanced leukocyte function reduction of edema in injured tissue.

HBOStudies have been generated that suggest HBO may ameliorate reperfusion injury and systemic inflammation.Mink & Dutka (Dec. 1995) revealed:

HBO administered after global cerebral ishemia promoted BBB integrityHBO also reduced cerebral blood flow

Hyperbaric Chamber

CasesADHD

http://www.holistickids.org/cases/adhd/adhd_summary.shtml

Other common ailmentsConstipationReflux

http://www.holistickids.org/cases/constipation/constipation_summary.shtml

http://library.utmb.edu/HealthNotes/

AAP RecommendationsSeek information for yourself and be prepared to share it with families.Evaluate the scientific merits of specific therapeutic approaches.Identify risks or potential harmful effects.

AAP RecommendationsProvide families with information on a range of treatment options.Educate family to evaluate information about all treatment approaches.

AAP RecommendationsAvoid dismissal of CAM in ways that communicate lack of sensitivity or concern for family’s perspective.Recognize feeling threatened and guard against becoming defensive.

AAP RecommendationsIf the CAM approach is endorsed, offer to assist in monitoring and evaluating the response.Actively listen to the family and the child with chronic illness.

Thank you for the privilege of being a doctor, for letting me serve as your instrument in ministering to the sick and afflicted. 

May I always treat with reverence the human life, which you have brought into being. 

Keep me constantly alert to see that the sacred right to live is never violated for even the least individual. 

Deepen my love for people, so that I will always give of myself gladly and generously

to those stricken with illness and suffering.  Help me to listen patiently, diagnose carefully. 

Teach me to blend gentleness with skill; to be a doctor with a heart as well as a head.

A PHYSICIAN'S PRAYER