Rudolph's Pediatrics, 22nd Ed.

CHAPTER 14. Complementary and Alternative Medicine (CAM)

Anju Sawni

Complementary and alternative medicine (CAM) encompasses a large range of therapies outside the domain of mainstream conventional or Western medicine that are used for the purpose of medical intervention, health promotion, or disease prevention. A distinct trend toward the integration of CAM therapies with the practice of conventional medicine is occurring. Hospitals are offering CAM therapies, health maintenance organizations (HMOs) are covering such therapies, a growing number of physicians are using CAM therapies in their practices, and insurance coverage for CAM therapies is increasing. Integrative medicine centers and clinics are being established, many with close ties to medical schools and teaching hospitals. As a result of increasing interest in CAM and the realization of our limited understanding of these modalities, the National Center for Complementary and Alternative Medicine (NCCAM) was established by a mandate in 1998 to facilitate and conduct research and education on CAM.

The NCCAM at the National Institutes of Health defines CAM as “a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine,”¹ Many terms are used to describe CAM. Complementary medicine describes CAM when it is used in conjunction with conventional medicine. Alternative medicine is used in place of conventional medical care. Integrative medicine is becoming more popular and is the preferred term because it incorporates all appropriate approaches, both conventional medicine and CAM therapies, to achieve optimal health and healing. The Consortium of Academic Health Centers for Integrative Medicine, which consists of 36 prominent medical schools, further defines integrative medicine as “the practice of medicine that reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches, health care professionals, and disciplines to achieve optimal health and healing.”²

CAM therapies include alternative/whole medical systems (homeopathy, naturopathy, ayurveda, and traditional oriental medicine), mind-body interventions (meditation, prayer for healing, biofeedback, yoga, and art and music therapy), biologically based therapies (megavitamins, nutritional supplements, and herbs), manipulative and body-based methods (chiropractic manipulations, osteopathy, massage), and energy therapies (Reiki and therapeutic touch).¹

The use of CAM is prevalent among adults in the United States.³ In 2002, the National Center for Health Statistics (part of the Centers for Disease Control and Prevention) conducted the National Health Interview Survey of 31,044 adults and found that 62% used some form of CAM in the past 12 months when prayer for health reasons was included.⁴ Total visits to CAM providers exceeded total visits to all primary care physicians. Out-of-pocket expenditures for CAM are greater than for hospitalization.³

CAM use among parents is the number-one predictor of CAM use among children, which is increasing.⁵ Studies of CAM use in primary care and in healthy children in the United States show a prevalence of 12% to 21%.^5-8 CAM use among children from special populations or with chronic, recurrent, and incurable conditions such as cystic fibrosis, cancer, asthma, attention deficit hyperactivity disorder, and cerebral palsy, is even higher, ranging from 11% to 80%.^9-17 Most patients use CAM in conjunction with conventional medical care. Patients use CAM not because they are dissatisfied with conventional medicine but more likely because they find CAM therapies to be more congruent with their own culture, values, beliefs, and philosophical orientation toward health and life.¹⁸ Parents may seek CAM use for their children because of fear of side effects of drugs, chronic medical problems for which they are seeking a “cure,” dissatisfaction with conventional medicine, word of mouth recommendations, referral from family members, and need for more personal attention.^5,7

CAM appears to be gaining acceptance among pediatricians. In 2001 and 2004, the American Academy of Pediatrics surveyed fellows, looking specifically at pediatricians’ attitudes, beliefs, and use of CAM in the United States. Most believed CAM therapies could enhance recovery or relieve symptoms (66%) and would consider referring for CAM (71%) but were concerned about the side effects (75%) and that CAM use might delay mainstream care (74%). However, less than 40% of pediatricians asked about CAM use as part of routine pediatric history, and over 80% wanted education on CAM so they could counsel families appropriately.^19,20

Patients are increasingly seeking pediatricians who are knowledgeable about both conventional medicine and CAM. Pediatricians recognize this and want more education in CAM. Thus, medical schools and postgraduate medical training centers have to consider developing new competencies regarding CAM that include inquiring about CAM use, counseling on CAM from an evidence-based approach, and referring to and partnering with CAM practitioners.^21-24 This chapter describes CAM modalities, provides some evidence-based approaches to CAM, and suggests how to counsel about and refer for CAM.

MIND-BODY MEDICINE

Mind-body medicine is a philosophy and a system of health practices based on the concept that the mind and the body work together for healing. Mind-body medicine includes meditation and relaxation training, guided imagery, hypnosis, yoga, art and music therapy, biofeedback, prayer, and tai chi. These therapies can be used by individuals and support groups and incorporated into psychological therapies, such as cognitive behavioral therapy, that enlist the mind in improving emotional well-being and physical health. Children experiencing emotional stress often complain of chronic physical symptoms that respond poorly to medications. Evidence suggests that higher cognitive centers and limbic emotional centers are capable of regulating virtually all aspects of the immune system and therefore have a profound effect on health and illness.^18,25-27 Mind-body approaches show great potential for improving the quality of life by reducing the pain and symptoms associated with a variety of chronic disorders, and to improve function. They may reduce stress, reduce symptom burden, and also may improve self-monitoring and coping skills. The physical and emotional risk of using these techniques is minimal, cost is low; and many techniques can be taught by paraprofessionals. Most can easily be applied along with conventional medical care.

Mind-body therapies have been shown to be safe and effective for many pediatric conditions, including headaches, asthma, enuresis, sleep disorders, pain, and stress-related symptoms.²⁸

YOGA AND MEDITATION

Meditation is a self-directed practice for relaxing the body and stilling the mind. It is a form of concentration that nurtures the development of focused attention and personal awareness. Nearly all religions include some form of meditative practice. Examples of meditations include transcendental meditation, Tibetan meditation, mindfulness meditation (being in the moment), and walking meditation. Teaching children approaches that calm the mind may be particularly helpful in children with attention deficit hyperactivity disorder or mood disorders.²⁹

Yoga is an ancient practice from India that aims to unify body and mind with universal spirit, thereby encouraging physical and mental well-being. Yoga seeks to alter the body’s physiology through breathing techniques, postures, and meditation that activate the parasympathetic autonomic system and decrease the sympathetic system. An increase in parasympathetic activity leads to a decrease in blood pressure, heart rate, and respiratory rate and an increase in galvanic skin resistance as well as psychological benefits such as improving concentration, attention, mood, well-being, memory, mind-body neuroconnections, somatic and kinesthetic awareness, and self-actualization and cognitive functions. Studies have shown yoga’s benefit in improving cognitive functions, heart rate, and focus in children and adults.^30-34 The possible central nervous system effects, as well as yoga’s perceived benefits in stress reduction and improved concentration, provide the rationale for yoga as a treatment modality. A few preliminary studies have looked at the benefits of yoga in children with attention deficit hyperactivity disorder and eating disorders.^35-37 These studies suggest that yoga may have a role as an adjunct to conventional treatment. Meditation and yoga classes increasingly are being offered in summer camps and after-school programs for children.

HYPNOSIS

Self-hypnosis is an altered state of consciousness within a relaxed physical state of intense, focused concentration aimed at improving mental or physical health. It is an internal, imaginative process (using the imagination to see, hear, touch, smell, and taste things) to focus attention and become absorbed so that a hypnotic state is entered into in which perceptions and sensations can be enhanced, modified, or changed to decrease anxiety, stress, or discomfort and increase self-esteem. While in this state of deep concentration, children are highly responsive to therapeutic suggestions, thus coining the term hypnotherapy. School-aged children and adolescents can enter into the hypnotic trance far more easily and rapidly than adults. All hypnosis is self-hypnosis. Hypnotherapy allows the child to gain a sense of control, increase self-esteem and competence, and reduce stress. Children usually readily accept the suggestion, and hypnosis bridges the child’s inner world of imagination and therapeutic change.³⁸ Self-hypnosis is a teachable coping skill that most children are able to learn with minor effort. Hypnosis can be useful in treating pain (chronic pain related to disease, eg, malignancy, sickle cell, chronic headaches, abdominal pain, or acute pain associated with procedures such as lumbar puncture, needle sticks, suturing, and injuries),³⁹ behavioral problems (tics, habit problems, enuresis, encopresis, smoking, weight control, nightmares, attention deficit hyperactivity disorder),⁴⁰ anxiety associated with procedures or illness, performance anxiety (tests, athletes), and nausea and vomiting.⁴¹

Hypnotherapy’s benefits are enhanced by the use of biofeedback to induce physiological changes. Biofeedback is a mind-body therapy that uses visual and auditory stimuli to give the participant information about autonomic nervous system functions (heart rate, blood pressure, skin temperature, muscle contraction) using a computerized feedback system.^41,42 By using mind-body techniques such as self-hypnosis, relaxation, meditation, and yoga, we can teach children and adolescents how to manage anxiety by creating a sense of relaxation and thus increase their capacity to focus as well as their self-esteem.

SPIRITUALITY

Prayer focused on healing is one of the most prevalent complementary therapies used by adults in United States. The 2002 National Health Interview Survey found that 62% of adults used prayer specifically for healing/health and that faith and spiritual practice is one of the most frequent CAM therapies used in the this country.⁴ Spirituality may or may not involve formal religion. Spiritual beliefs are important in medical decisions, and may be associated with better coping, faster recovery, and better quality of life.^43-45 Most pediatricians believe that spirituality impacts on illness but few ask their patients about it.^46,47

CREATIVE ARTS THERAPY

The National Coalition of Creative Arts Therapies Associations (NCCATA) states that creative arts therapies include art therapy, dance and movement, drama therapy, music therapy, psychodrama, and poetry therapy. These therapies use arts modalities and therapeutic, rehabilitative, community, or educational settings to foster health, communication, and expression and to promote the integration of physical, cognitive, and social functioning, emotional self-awareness, and change.⁴⁸ Music therapy is an example of a creative arts intervention that can be integrated into daily or weekly activities, and which may be beneficial for children, who naturally respond to music and rhythm. Music therapy has been shown to increase oxygen saturation and weight gain and to decrease salivary cortisol and distress behaviors in premature infants.⁴⁹ In pediatric oncology patients, music therapy can reduce pain and suffering and also improve both mood and attitude.⁵⁰

MANIPULATIVE AND BODY-BASED PRACTICES

Manipulative and body-based practices such as chiropractic, osteopathy, massage, reflexology, and a host of others focus primarily on the structures and systems of the body, including the bones, joints, soft tissues, and circulatory and lymphatic systems. All examples incorporate touch and are based on the principles that the human body is self-regulating and has the ability to heal itself and that the parts of the human body are interdependent.

MASSAGE

Massage therapy (the laying on of hands for health purposes) dates back thousands of years. Massage, which involves manipulation, compression, and stretching of the skin, muscle, and joints, activates a variety of mechanisms that lead to enhanced blood flow to the muscles and soft tissues and also enhance lymphatic flow and a sense of well-being. Massage techniques include Swedish massage, deep-tissue massage, trigger-point massage, and shiatsu massage. Massage can also include many different techniques and forms such as rolfing, movement integration (Feldenkrais method, Alexander technique), pressure-point techniques (acupressure), cranial sacral therapy, reflexology, and many others.

Massage is used to promote relaxation and to reduce stress. Clinical studies of selected physiological parameters suggest that massage can alter various neurochemical, hormonal, and immune markers.^51-53Several small studies in infants and children have shown benefits of massage therapies for various conditions, such as attention deficit hyperactivity disorder and cystic fibrosis, for improving weight gain in premature infants, for decreasing pain and anxiety in people with rheumatoid arthritis and in burn victims, and enhancing mood and decreasing anxiety in depressed children and adolescents.^52,54,55

The massage experience is sometimes enhanced through the use of clinical aromatherapy–therapeutic application of oils distilled from plants. Topical oils that enhance blood flow and engender a sense of warmth (called rubefacients) are also often used. Massage may be provided by parents or other family members as well as by professional massage therapists. Massage therapists are licensed in fewer than 40 states. The largest professional national organization of body workers and massage therapists is the American Massage Therapy Association.

CHIROPRACTIC AND OSTEOPATHY

Doctors of osteopathy are mainstream physicians and are fully licensed in all 50 states to practice medicine (prescribe drugs, perform surgery) but are also trained in musculoskeletal manipulation. Osteopathic philosophy is holistic, focusing on the mind, body, and spirit, and emphasizes the promotion of health and illness prevention. On a musculoskeletal level, osteopaths are primarily concerned with barriers to normal physiologic motion. Doctors of chiropractic are trained only in chiropractic spinal manipulation and do not prescribe drugs or do surgery. Chiropractors are licensed in all 50 states⁵⁶ and are the most commonly utilized CAM practitioners in the United States.^3,57Chiropractic is based on the belief that spinal problems are the cause of health problems and that spinal manipulations (“adjustments”) can restore and maintain health. According to chiropractic concepts, the nervous system coordinates all of the body’s functions, and disease results from a lack of normal nerve function due to displacement (subluxation) of a spinal vertebral body. This subluxation, misalignment, and nerve pressure can cause problems not only in the local area but also at some distance from it. Subluxations cause nerve irritability, which leads to ineffective nervous system function and agitation, decreased concentration, and abnormal behavior.^58,59

Chiropractic is one of the most common alternative therapies sought by families, but there is an absence of randomized controlled clinical trials suggesting that it is a significantly helpful or cost-effective therapy for any major pediatric disease.^61,62 Considerable numbers of children and adolescents receive chiropractic care for musculoskeletal conditions as well as for chronic illness such as asthma, allergies, infant colic, otitis media, and enuresis.⁶⁰ Some adult studies suggest that chiropractic manipulation may be beneficial for acute back pain.¹ Serious adverse events may also be associated with spinal manipulation in children.⁶³ Further studies are required to determine the safety and benefits of chiropractic care in children.

ENERGY HEALING THERAPIES

Energy healing therapies are based on the concept that human beings are infused with a subtle form of biophysical energy. This vital energy or life force is known by different names in different cultures such as qi (Chi) in Chinese medicine, ki in the Japanese Kampo system, doshas/prana in ayurvedic medicine, etheric energy, and energy or life force. Therapists claim that they can work with this subtle energy, see it with their own eyes, and use it to effect changes and influence health in the physical body.¹ Practitioners of energy medicine believe that illness results from disturbances of the biofield, an energy field that is proposed to surround and flow throughout the human body. Biofields have not been measured by conventional instruments. Healing or therapeutic touch, Reiki, and qigong are examples of therapies that involve movement of the practitioner’s hands over the patient’s body to become attuned to the condition of the patient, with the idea that by so doing, the practitioner can strengthen and reorient the patient’s energies. Even though energy therapies are among the most controversial of CAM practices, because neither the external energy fields nor their therapeutic effects have been demonstrated convincingly by any biophysical means, they are gaining popularity in the United States. A recent National Center for Health Statistics survey indicated that approximately 1% of the participants had used Reiki, 0.5% had used qigong, and 4.6% had used some kind of healing ritual.^4,64 More have used acupuncture which could be considered a variant of energy therapy and is discussed later in this chapter.

Therapeutic touch was developed in the 1970s by Dolores Krieger, a nurse, and Dora Kunz, a lay healer. It is taught in nursing schools and in many hospitals, including children’s hospitals, in the United States.^65,66 In a recent meta-analysis of 11 controlled therapeutic touch studies, 7 controlled studies had positive outcomes, and 3 showed no effect.⁶⁷ Therapeutic touch has shown potential efficacy for wound healing, osteoarthritis, migraine headaches, and anxiety in burn patients.

Reiki, an energy practice similar to therapeutic touch, comes from a Japanese tradition based on a belief that an invisible energy may be transmitted from healer to patient through intention; the energy is focused by placing the hands on particular parts of the patient’s body or even from distant healing through intention. Practitioners are trained by a Reiki master through apprenticeship and spiritual/energetic initiation. Neither therapeutic touch nor Reiki have national certifying examinations or state licensure. While there are no good studies evaluating the effectiveness of these energy therapies, there are no reported side effects from such treatments.

WHOLE MEDICAL SYSTEMS

Whole medical systems, as defined by NCCAM, involve complete systems of theory and practice that have evolved independently from or parallel to allopathic (conventional) medicine. Many are traditional systems of medicine that are practiced by individual cultures throughout the world. Major Eastern whole medical systems include traditional Chinese medicine (TCM) and ayurvedic medicine (a whole medical system that originated in India). Major Western whole medical systems include homeopathy and naturopathy (both originated in Europe). Other systems have been developed by Native American, African, Middle Eastern, Tibetan, and Central and South American cultures.¹

HOMEOPATHY

Homeopathy is a whole medical system that was founded by a German physician, Samuel Christian Hahnemann (1755–1843) in the late 18th and early 19th centuries. Homeopathy is based on 2 principles: (1) the law of similars, or “like cures like,” and (2) the law of dilutions. The law of similars means that a remedy that would cause a symptom in a healthy person is used to treat the same symptom in a sick person: Like cures like. Hahnemann gave repeated doses of many common remedies to healthy volunteers and carefully recorded the symptoms they produced. This procedure is called a proving, or in modern homeopathy, a human pathogenic trial. Based on his experiments with healthy people, Hahnemann developed his treatments for sick patients by matching the symptoms produced by a drug to symptoms in sick patients.⁶⁸ For example, a treatment (remedy) made from an onion skin (Allium cepa) might be used to treat a child with rhinorrhea and watery eyes caused by allergies or a cold.

Homeopathic remedies are made from plant, animal, and mineral substances, which are diluted to extremely small doses so that only the “medicinal energy,” not the actual substance, remains in the end product. The law of dilutions states that the more a remedy is diluted, the more powerful it becomes, a concept that is counterintuitive to conventional medications, where the larger the dose, the more powerful the effects. But in homeopathy, the most powerful remedies are those that have been diluted hundreds, thousands, or even millions of times. Serious side effects from homeopathic treatment are very rare, far less common than side effects from standard over-the-counter and prescription medications. Homeopaths also believe that illness results from disrupted “vital energies,” and these very dilute solutions contain an energy, or information, that is used by the patient to heal his or her symptoms. The right remedy sometimes may worsen symptoms briefly before they improve. The concept of homeopathy is hard for mainstream physicians to understand, and many believe that the remedies are nothing more than placebos that trigger the patient’s psychoneuroimmunologic healing systems. Five systematic reviews and meta-analyses evaluated clinical trials of the effectiveness of homeopathic remedies compared with placebo and found an effect over placebo.^69-72Homeopathic remedies have been shown to provide improvement in some common conditions (eg, allergic rhinitis, diarrhea, and attention deficit hyperactivity disorder) in children.^73-76 Homeopathic remedies are available over the counter, through mail-order catalogs, and over the Internet without a prescription. Common over-the-counter remedies include combination products for colds, teething, colic, allergies, injuries, and bedwetting. Practitioners of homeopathy are licensed in fewer than 10 states in the United States and can be lay practitioners, chiropractors, physicians, naturopaths, nurses, and other health professionals.⁷⁷ Homeopathic visits are generally scheduled every 4 to 6 weeks. The initial visit is usually 90 minutes, and follow-up visits are 30 to 45 minutes. Children and adolescents comprise between 20% and 30% of the patient load of the typical homeopathic practitioner.⁷⁸

NATUROPATHIC MEDICINE

Naturopathy is a whole medical system that has its roots in Germany. A central belief in naturopathy is that nature has a healing power (a principle called vis medicatrix naturae). Another belief is that living organisms (including the human body) have the power to maintain (or return to) a state of balance and health and to heal themselves. Practitioners of naturopathy prefer to use treatment approaches that they consider to be the most natural and least invasive instead of using drugs and more invasive procedures. The core modalities supporting these principles include diet modification and nutritional supplements, herbal medicine, acupuncture and Chinese medicine, hydrotherapy, massage, and lifestyle counseling. Naturopathic physicians are educated and trained in a 4-year, graduate-level program at one of the four U.S. naturopathic medical schools accredited by the Council on Naturopathic Medical Education and receive the degree of Doctor of Naturopathic Medicine (ND). Naturopathy is not a complete substitute for conventional medical care. Some therapies used in naturopathy have the potential to be harmful if not used properly or under the direction of a trained practitioner. For example, herbs can cause side effects on their own or by interaction with prescription or over-the-counter medicines. Restrictive or other unconventional diets can be unsafe for some people. Some practitioners of naturopathy do not recommend using all or some of the childhood vaccinations that are standard practice in conventional medicine. Naturopathy as a whole medical system is challenging to study. A large pediatric study showed that echinacea was not effective in treating colds.⁷⁹ In contrast, a smaller, double-blind trial of an herbal extract solution containing echinacea, propolis (a resinous product collected from beehives), and vitamin C concluded that the extract may be beneficial for ear pain associated with acute otitis media.⁸⁰ A naturopathic extract known as Otikon Otic Solution (containing Allium sativum, Verbascum thapsus, Calendula flores, and Hypericum perforatum in olive oil) was found as effective as anesthetic ear drops and was proven appropriate for the management of acute otitis media–associated ear pain.⁸¹ Overall studies of naturopathic treatments show mixed results.

AYURVEDA

Ayurveda, which means “the science of life,” is a natural healing system developed in India. It is a comprehensive system of medicine that places equal emphasis on the body, mind, and spirit and strives to restore the innate harmony of the individual. Some of the primary ayurvedic treatments include diet, exercise, meditation, herbs, massage, exposure to sunlight, and controlled breathing. Ayurveda also has some basic beliefs about the body’s constitution. Constitution refers to a person’s general health, how likely he or she is to become out of balance, and the person’s ability to resist and recover from disease or other health problems. The constitution is called the prakriti. Three qualities, called doshas (vata, pitta, and kapha), form important characteristics of the constitution and control the activities of the body. Each dosha is made up of 1 or 2 of the 5 basic elements: space, air, fire, water, and earth; each has a particular relationship to body functions and can be upset for different reasons. Doshas are constantly being formed and reformed by food, activity, and bodily processes. In summary, it is believed that a person’s chances of developing certain types of diseases are related to the way doshas are balanced. There is very little research done on ayurvedic medicine and its benefits in children.

TRADITIONAL CHINESE MEDICINE AND ACUPUNCTURE

Traditional Chinese medicine is a complete system of healing that dates back to 200 BC in written form. Korea, Japan, and Vietnam each has developed its own unique versions of traditional medicine based on practices originating in China. In the traditional Chinese medicine view, the body is a delicate balance of two opposing and inseparable forces: yin and yang. Yin represents cold, slow, or passive aspects of the person, while yang represents hot, excited, or active aspects. Health is achieved through balancing yin and yang, and disease is caused by an imbalance leading to a blockage in the flow of qi (the vital energy or life force proposed to regulate a person’s spiritual, emotional, mental, and physical health and to be influenced by the opposing forces of yin and yang and of blood along pathways known as meridians). Traditional Chinese medicine practitioners typically use herbs, massage, and acupuncture to help unblock qi and blood in patients in an attempt to bring the body back into harmony and wellness. Acupuncture is the most common form of traditional Chinese medicine practiced in the United States.

Acupuncture, a component of traditional Chinese medicine, originated over 2000 years ago as a therapeutic treatment. In traditional Chinese medicine, acupuncture, the stimulation of specific points on the body along the energy meridians, is intended to remove blockages in the flow of chi (qi, vital energy). Disease occurs when the flow of vital energy is disrupted or blocked. Health returns when the flow is restored, balanced, and harmonized. It is believed that there are 12 main meridians and 8 secondary meridians and over 2000 acupuncture points on the human body that connect these meridians. Acupuncture techniques used to stimulate these points include insertion of thin metal needles that are manipulated by the hand or by electrical stimulation, heat (moxibustion), laser, or vigorous massage (shiatsu). In the Western system of medicine, it is proposed that acupuncture produces its effects by the conduction of electromagnetic signals at a greater-than-normal rate, thus aiding the activity of pain-killing biochemicals, such as endorphins, and immune system cells at specific sites in the body. In addition, studies have shown that acupuncture may alter brain chemistry by changing the release of neurotransmitters and neurohormones and by affecting the parts of the central nervous system related to sensation and involuntary body functions, such as immune reactions and processes by which blood pressure, blood flow, and body temperature are regulated.⁸²

In 1997, a National Institutes of Health consensus conference concluded that acupuncture was effective for treating pain in adults, such as postoperative pain, chemo-related nausea and vomiting, and dental pain. There is also some promising evidence that the use of acupuncture as an alternative to or in conjunction with conventional medical care is beneficial in headaches, back pain, dysmenorrhea, fibromyalgia, myofascial pain, tennis elbow, carpal tunnel syndrome, and tendonitis.⁸³ Acupuncture is used in pediatric patients as well. Nearly one third of the major teaching hospitals with a pediatric pain service offer acupuncture to treat chronic pain in children.⁸⁴ Children are open and receptive to acupuncture despite the perception that children fear needles.^84,85 Most acupuncturists who treat children use special techniques, including nonneedle methods (eg, heat, magnets, lasers, and vigorous massage or tapping) to stimulate points along the energy meridians. Studies show that acupuncture has potential benefits for recurrent headaches, nausea, pain (acute and chronic), and allergy.^86-89

Acupuncturists are licensed in more than 40 states.^56,77 Approximately 80% of licensed acupuncturists also recommend dietary changes, herbs and other supplements, and changes in lifestyle, exercise habits, rest patterns, and relationships to enhance health. Acupuncture may be covered by insurance; most patients pay out-of-pocket for these services unless they are provided by a physician acupuncturist. Initial visit length is approximately 90 minutes, and follow-up visits last approximately 30 to 60 minutes. Several large, prospective studies have demonstrated acupuncture to be a reasonably safe therapy in the hands of experienced and qualified practitioners.^90,91

NUTRITIONAL AND DIETARY SUPPLEMENTS

Herbs, vitamins, minerals, and other dietary supplements are among the most commonly used CAM therapies. Data from the 2002 National Health Interview Survey showed that 19% of US adults had used herbs and other naturally occurring nonbotanical supplements, such as fish oils and melatonin in the previous year.⁴ Dietary supplements are now at least a $19 billion a year industry. Use among children is also common; research indicated that 20% to 40% of children and adolescents have used dietary supplements,^8,92-94 and use is even higher in subpopulations of children, especially among children with chronic medical problems.^{5,7,9,10,12,94-96} In 2002, an online survey showed that 46% of adolescents had used dietary supplements, and 29% had used a supplement in the previous month. Nearly 10% of adolescents reported using supplements with prescription medications in the previous month. Commonly used supplements included ginseng, zinc, echinacea, ginkgo biloba, creatine, and weight-loss supplements.⁹⁷Table 14-1 lists some herbs commonly used among children and adolescents. Nutritional supplements such as vitamin C, zinc, omega-3 fatty acids (fish oils, flaxseed oil), and melatonin are also being used with increasing frequency. It is important to understand the reasons families and patients use herbs (eg, cultural practices, parental beliefs about health, disease prevention, and chronic or acute illness treatment). Also, with the explosion of the Internet, mass media, and multilevel marketing companies for herbs and dietary supplements, parents are inundated with information and proposed claims of herbal supplements for various medical conditions. Many patients take herbs, believing they are safe because they are natural. Safety and efficacy remain largely unknown: Many herbal remedies have been associated with adverse effects, as have herb-drug interactions. Some herbal remedies have been found to contain lead, arsenic, and other heavy metals, as well as steroids and benzodiazepines.⁹⁸

The Dietary Supplement Health and Education Act of 1994 defines herbal medicines supplements.⁹⁹ They are neither food nor drugs and are regulated by the Food and Drug Administration (FDA) but with less stringent requirements than drugs. They are not tested according to the same safety and efficacy requirements and regulations as are prescription and over-the-counter drugs. Under the Dietary Supplement Health and Education Act, herbal supplements can be sold for “stimulating, maintaining, supporting, regulating, and promoting health” rather than for treating disease. Herbs may not claim to restore normal or to correct abnormal function and may not claim to “treat, prevent, or cure.” For example, herbal supplement companies can claim on the bottle that their product supports bone health but not that it treats osteopenia. Supplements can be removed from the market only if the FDA can prove them unsafe under ordinary conditions of use. In 2003, the FDA proposed requiring Good Manufacturing Practices for the dietary supplement industry.¹⁰⁰ The proposed practices would require that herbal medicines be properly labeled, free of adulterants, and manufactured according to specified standards for personnel and equipment. Despite this effort, there is substantial variation in the quality of herbal products in the United States and elsewhere, and this inconsistency can impact the product’s efficacy and safety. The clinical usefulness of an herbal supplement for a particular patient or condition therefore depends on its evidence for quality, efficacy, and safety. Families do not always disclose their use of herbal and nutritional supplements to their pediatrician because they do not think of them as “medications;” thus, it is critical that pediatricians have an open dialog and ask specifically about their use as part of the routine pediatric history.

Table 14-1. Common Herbs Used in Children and Adolescents

TALKING TO FAMILIES ABOUT CAM

With the increasing use of CAM, it is important that pediatricians obtain a complete CAM history from every patient and family as part of the routine pediatric history. This is best done in a culturally sensitive, open-minded, and nonjudgmental manner. Table 14-2 offers guidelines on talking with families about CAM. CAM typically is used as an adjunct rather than alternative to conventional, mainstream medical care, but patients and families may not discuss their use of CAM with their pediatrician and primary health care providers; thus, potential for both benefit and harm exists. If the pediatrician does not ask specifically about CAM, patients and families may not think to mention its use, or they may be uncomfortable or fearful that the pediatrician may disapprove or abandon care, especially if they perceive the pediatrician to be judgmental or antagonistic.^5,6,101,102 However, patients and families generally want and appreciate their pediatrician’s input, guidance, and professional recommendations regarding CAM.

CAM therapists offer personal attention, hope, time, and therapies consistent with their health beliefs, culture, and values. CAM providers may not discuss with pediatricians the care they are providing to patients. This lack of communication, coordination, and attention to safety issues are of particular concern when care is provided by acupuncturists and naturopathic physicians, who might prescribe herbs that interact with medications. When medical information is not obtained completely, the doctor-patient relationship is attenuated and medical care can be compromised. When communication is open and comprehensive, especially about CAM, it may strengthen the relationship and bridge the potential gaps in beliefs about health and illness.^103,104 In the best interest of children, it is important to provide balanced advice about therapeutic options, to guard against bias, and to establish and maintain a trusting relationship with families. In 2001, the American Academy of Pediatrics issued a policy statement, “Counseling Families Who Choose CAM for Their Children,” which recommends that pediatricians seek information, evaluate the scientific merits of specific therapeutic approaches, and identify risks or potential harmful effects.¹⁰⁵ These recommendations are summarized in eTable 14.1 .

Table 14-2. How to Talk with Patients about Complementary and Alternative Therapies

Source: Kemper K. Overview of complementary and alternative medicine in pediatrics. UpToDate Web site. Available at: http://www.uptodate.com/online/content/topic.do?topicKey=gen_pedi/16563&selectedTitle=1∼22&source=search_result. Last accessed June 16, 2009.

MEDIOLEGAL AND ETHICAL CONSIDERATIONS

For most pediatricians, the legal issues about CAM center on individual liability and integration of care. Pediatricians have an ethical responsibility to guard the welfare of children by ensuring that any treatment they endorse is in accordance with science and proven evidence and experience. They also have a duty not only to avoid harm but to do good—that is, to act in the patient’s best interests. This duty of beneficence takes precedence over any self-interest. Cohen and Kemper summarized the ethical issues of CAM, acknowledging the dilemmas: lack of pediatrician knowledge about the safety and effectiveness of CAM therapies, scope of practice, licensing requirements, credentialing of CAM practitioners, concerns about safety and legal liability, and how to translate principles of medical ethics into CAM.¹⁰⁶ They suggest a framework assessing liability risks regarding CAM therapies summarized in eTable 14.2 .

In the United States the Federation of State Medical Boards recommends that in addition to the standard medical history, physical examination, diagnostic test results, and reports from consultants, the medical record should include documented information about CAM (eTable 14.3 ). The weighing of risks and benefits sometimes is complicated by variables such as the family’s personal beliefs, cultural values and practices, therapeutic goals, and the type and severity of illness. Additionally, the efficacy and safety of a particular treatment may not be well studied in certain populations, such as children. While scientific evidence exists regarding some CAM therapies, for most, key questions remain to be answered through well-designed scientific studies, including whether these therapies are safe and whether they work for the disease or medical conditions in children. While the same principles and standards of evidence of treatment effectiveness should apply to all treatments, certain characteristics of some CAM and some conventional medical interventions make it difficult or impossible to conduct standard randomized controlled trials. For these therapies, innovative methods of evaluation are needed. Pediatricians should be aware of relevant professional licensing guidelines (see eTable 14.4 ) and the four basic principles of biomedical ethics: autonomy, nonmaleficence, beneficence, and justice.

A variety of CAM resources including information on CAM training for physicians is provided in eTable 14.5 .