Transcript Integrative Pediatrics

Integrative Pediatrics
for Children with Special
Health Care Needs
Susie Gerik, MD
Children’s Center for Restorative Care
What is CAM?
Broad range of healing philosophies
Not commonly used, accepted, studied,
understood, or made available in
Western (conventional) medicine
To 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 caregivers
All interventions that are considered
safe and potentially beneficial are
offered/discussed
What is Integrative Pediatrics?
Health and healing are emphasized
more than disease and curing
Prevention 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 studied
Dosages
Safety
Efficacy
Delay of proven conventional therapy in
favor of CAM
Pediatrician’s Attitudes
JAMA article my Sikand and Laken of a
survey of 860 pediatricians
Findings:
Majority believed only a small percent of
patients used CAM
Would refer for therapies such as
biofeedback, self-help, relaxation,
hypnosis, and acupuncture or acupressure
Pediatrician’s Attitudes
Over half would use CAM therapies
personally
Most were interested in CME on CAM
Realities about CAM
Increasing CAM use
Holistic practices
Media coverage
NCCAM
Increasing Use
1990 33%
1997 42%
> $27 billion
75 out of 117 US Medical schools offer
elective courses in CAM
CAM Use
Limited knowledge about the
prevalence of use of CAM in pediatric
population (estimated 10-15% overall)
40% of adults use CAM
Most adults do not discuss their use of
CAM with their physicians
CAM Use
Pediatric 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 fibrosis
Juvenile rheumatoid arthrits
Cancer
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 youth
20% of children have developmental
delays, behavioral and emotional
problems, and/or learning disabilities
6% of children have a severe chronic
illness
Increasing Prevalence and
Incidence
Increase in total population
Decrease in mortality
Shortened hospitalizations and more
home care
Biomedicine
Disease 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 Therapies
Based on a variety of non-biomedical
beliefs
Many have not been subjected to
clinical research
Most are supported by anecdotal
evidence
Some have proven effectiveness
Common Ground
The relationship between physicianhealer and patient is integral to the
success of treatments offered.
The “art” of medicine.
What is NCCAM?
National Center for Complementary and
Alternative Medicine
Established in 1998
What is NCCAM?
To stimulate, develop, and support
research on CAM for the benefit of the
public
Mission: to give the American public
reliable information about the safety
and effectiveness of CAM practices
More about NCCAM…
Director: Steven Strauss, MD
Budget: $89.2 million (next year $100
million)
35% independent investigator initiated
10% training
23% for “Centers”
Major CAM Domains
Alternative medical systems
Mind-body interventions
Biological-based therapies
Manipulative or body-based therapies
Energy therapies
Therapeutic Mountain
A Model of Care
Biochemical: medications, herbs,
nutritional supplements
Lifestyle and Mind-Body Therapies:
nutrition, exercise, environment, mindbody
Therapeutic Mountain
A Model of Care
Biomechanical Therapies: massage and
physical therapy, chiropractic,
osteopathic, surgery
Bioenergetic 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 URI
Chamomile for colic (remember Peter
Rabbit), also fennel, licorice
Homeopathy for colds, flu, diarrhea
Acupuncture/acupressure for headache
other pain
Ginger for nausea
Vitamins for about everything
Some examples of commonly
used CAM therapies
Imagery for warts
Massage, therapeutic touch, relaxation
therapy for insomnia
Essential fatty acids, evening primrose oil for
eczema
Address food allergies for recurrent AOM
Witch hazel, chamomile, other herbs topically
for diaper rash
Some examples of commonly
used CAM therapies
Olive oil for cradle cap
Massage for stimulating growth in
premature infants
Garlic and honey for coughs
Hypnosis and biofeedback for
encopresis
Vitamin C and Zinc lozenges for colds
Aloe vera for burns
Some examples of commonly
used CAM therapies
Tea tree oil for skin infections
Mind-body approaches like biofeedback,
hypnotherapy for enuresis
Hypnosis, autogenic training, biofeedback,
family support, prayer in asthmatics
Reduce food allergens in those with inhalant
allergies (cross rxn?)
Vitamin A (from food), zinc, B6 for acne
Distraction
Blowing bubbles
Playing with pop-up toys
Looking through a kaleidoscope
Imagining a superhero
Breathing techniques and guided
imagery
Suggestion
“Magic glove” technique
Basic principles
Willingness to be involved
Trust in the coach
Ability to participate
Breathing Techniques
Rhythmic, deep-chest breathing
Patterned, shallow breathing
Guided Imagery
A form of relaxed, focused
concentration
Favorite place, favorite activity
Not only produce distraction, but also
enhance relaxation
Progressive Muscle Relaxation
Recognize and reduce body tension
associated with pain
Decrease anxiety and discomfort
Biofeedback
Uses instruments to detect and amplify
specific physical states in the body and
help bring them under one’s voluntary
control
Mechanism of pain relief is based on
specific physiologic changes caused by
the biofeedback
Hypnosis
Altered state of consciousness is used
Concentration is focused, narrowed,
absorbed
Acupuncture
Based on a theory that energy (Chi)
flows through the body along channels
(meridians) which are connected by
acupuncture points
Pain results when flow of energy is
obstructed
Acupuncture restores that flow and
eliminates or reduces pain
Research Areas
Gastrointestinal disorders
Respiratory disorders
Developmental disorders
Oncology
Mental health disorders
Epidemiological studies of CAM
University of Arizona
Fellowship in Integrative Medicine
Research projects
Abdominal pain
Otitis media
Cerebral palsy
Boston Children’s Hospital
Center for Holistic Pediatric Education
and Research
Research projects:
Herbs and supplements in cancer
Acupuncture for several conditions
Echinacea for URI
Alternative treatments for otitis media
University of Rochester
Adolescent use of CAM
University of Washington and
Bastyr
Echinacea for URI
University of Miami
Massage in preterm infants
Key Principles in CAM
Research
Consistency of design and outcome
instruments is essential
RCT is still the gold standard (hierarchy
of evidence)
Some CAM cannot be blended
Studies of whole systems require
creativity
Key Principles in CAM
Research
Rigorous designs are imperative
CAM experts and patient advocates
should be included in study oversight
Role of CAM for given health conditions
must be clarified
Headache
Duckro and Cantwell-Simmons
Headache 1989
Biofeedback and Relaxation in the
Management of Pediatric Headache
Summary and interpretation of
controlled studies supports behavioral
approach as a potent alternative
Headache
Holden, Deichmann, and Levy Journal
of Pediatric Psychology 1999
Review of research on behavioral
treatments for recurrent headaches
Relaxation and self-hypnosis is a wellestablished and efficacious treatment
for recurrent headaches
Vaccine-related Pain
Jacobson et al Vaccine 2001
Attitude, empathy, instruction
Distraction, hypnosis
Sugar nipples
Topical anesthetics (EMLA)
56 references
Fracture Reduction
Iserson Journal of Emergency Medicine
1998
Hypnosis used to diminish pain and
anxiety in patients with angulated
forearm fractures (no other form of
sedation or analgesia available)
Postoperative Pain
Polkki et al Journal of Advanced Nursing
2001
Emotional support, helping with
activities, creating a comfortable
environment used routinely
Other nonpharmacologic measures used
less frequently
Related to background of the nurses
Recurrent Abdominal Pain
Gevirtz Journal of Pediatric Gastroenterology
and Nutrition 2000
Fiber, Fiber-biofeedback, Fiber-biofeedbackcognitive/behavioral intervention, Fiberbiofeedback-cognitive/behavioral interventionparental support
All groups showed improvement, but
treatment group showed more improvement
Rheumatic Illnesses
Field et al Journal of Pediatric
Psychology 1997
Massage helpful for JRA – marked
decrease in subjective pain, observed
pain, and tender trigger points
The Holistic Pediatrician
Author Kathy Kemper, MD, MPH of Harvard
A parent’s guide to therapy for 25 most
common childhood ailments
Provides an integrative approach: the best of
modern medical science with proven
alternative therapies
Well referenced. Clear recommendations,
prescriptions, and proscriptions
Healthy Child, Whole Child
Integrating the Best of Conventional
and Alternative Medicine to Keep Your
Kids Healthy
Authors: Stuart Ditchek, MD and
Russell Greenfield, MD
Resources
www.holistickids.org
www.nccam.nih.gov/
UTMB Integrative Medicine Web Site
HealthNotes Online
Naz’s Special Needs Tips
Cases
Asthma
http://www.holistickids.org/cases/asthm
a/asthma_summary.shtml
Cases
CP
HBO
The principle effect of HBO therapy is
hyperoxia.
At 3 atmospheres of pressure
Alveolar O2 tension = 2180 mmHg
PaO2 = 1800 mmHg
tissue concentration = 500 mmHg.
HBO
After 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.
HBO
Studies 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 integrity
HBO also reduced cerebral blood flow
Hyperbaric Chamber
Cases
ADHD
http://www.holistickids.org/cases/adhd/
adhd_summary.shtml
Other common ailments
Constipation
Reflux
http://www.holistickids.org/cases/consti
pation/constipation_summary.shtml
http://library.utmb.edu/HealthNotes/
AAP Recommendations
Seek 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 Recommendations
Provide families with information on a
range of treatment options.
Educate family to evaluate information
about all treatment approaches.
AAP Recommendations
Avoid 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 Recommendations
If 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.
A PHYSICIAN'S PRAYER
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.