Transcript Hot Topics in Integrative Medicine - Pediatrics House Staff

HOT TOPICS IN
INTEGRATIVE
MEDICINE
Pediatric Residency Coaching
Program
Ann Ming Yeh, MD
Integrative Medicine Potpourri
•What is Integrative Medicine?
•Introduction to IM Modalities:
•Mind – Body Exercise
•Top 3 Herbs and Supplements
•Probiotics
•TCM/ Acupuncture/ Acupressure Demo
•3 minute Ted Talk on Gratitude 
Integrative Medicine is…
… healing oriented medicine that takes
account of the whole patient, including
all elements of lifestyle and family
health. It emphasizes the powerful
triad of patient-family-practitioner, is
informed by evidence, and makes use
of all appropriate therapies.
Good Medicine!
My journey/ My approach
•Intake – 90 min
•Standard H and P
•Deeper dive into
sleep, psychosocial,
nutrition
•Traditional Chinese
Medicine Eval - if
time allows
PIMR
http://integrativemedicine.arizona.ed
u/program/Pediatric_IMR_2017/mind
_body_medicine_in_practice/modalit
ies_overview/9.html
MIND BODY MEDICINE
http://integrativemedicine.arizona.ed
u/program/Pediatric_IMR_2017/mind
_body_medicine_in_practice/modalit
ies_overview/9.html
LET’S PRACTICE
HERBS AND
SUPPLEMENTS FOR
URI
Elderberry
Umckaloabo
Zinc
Case
While rotating in Urgent Care:
4 year old and 6 year old non vaccinated sibs with myalgia, runny
nose, cough, fever x 2 days.
Mom wants to know what she can do for the kids?
Elderberry
Sambucus nigra
Elderberry –
Mechanism of action
• BioFlavonoids
• Anthocyanins – water soluble pigments that appear red, purple or
blue depending on the pH
• Cyanidin-3-sambubiocide –
• Shown to bind influenza neuramidase (similar mechanism as oseltamivir/
Tamiflu)
• Antiviral, anti influenza effects
• Seen 2-4 days after starting therapy
Swaminathan. Anal Bioanal Chem 2013
Elderberry – The Evidence
• Three RCT’s in humans
• Zakay-Rones (n=40) adults and children (>2yo) of Influenza B
outbreak (1993)
• Placebo controlled RCT of Sambucol®
• Included patients (not vaccinated) with sx of myalgia, fever, nasal
discharge, cough of <24hrs
• Symptoms recorded x 6 days:
• Significant symptom improvement
• Control group – 92% improved in 6 days,
• Elderberry – 93% improved in 2 days
• Higher Influenza B titers in treatment group
• Limited by small n, high drop out (13/40) and no intention to treat
analysis
Zakay-Rones: J Altern Complement Med 1995
Elderberry – The Evidence
• Zakay-Rones – RCT of n= 60 non-vaccinated adults with flu A or
B
• 15mL elderberry syrup QID during first 24 hours of influenza
symptoms
• Symptoms relieved 4 days earlier in treatment group
• Use of rescue medication significantly less
Zakay-Rones. Journal of
Intern Med Res, 2004
Elderberry - Dose
• Sambucol – extract
• Adults: 15mL QID x 3-5 days
• Children: 15mL BID x 3 days
• Syrup – 38% of standardized elderberry extract
Elderberry - Safety
• COOKED / Ripe fruit is safe
• NO adverse effects reported in clinical trials (adults and children, age
2+)
• Uncooked leaves and other plant parts and Unripened,
uncooked green berries – NOT SAFE
• Contains cyanide-producing chemical - sambunigrin
• Causes nausea, vomiting, diarrhea
• Large volume ingestion  toxicity.
• COOKING eliminates toxicity
• Side effects: mild laxative, GI upset
Holst 2015; Zakey Rones 2004, 1995; Kong 2009
Contraindications
• Avoid in patients with known allergy or hypersensitivity to
elder or honeysuckle plants
• Use cautiously in patients with arrhythmias and on diuretics
and on immunosuppressive medications
• NO safety data in pregnancy (not recommended)
Case
At PAMF continuity clinic –
Mom comes in saying that she heard Umckaloabo was good for
URI’s. Her daughter gets frequent URI’s and she wants to know if
she can give it to her 12 y/o daughter who you are seeing for a
WCC.
Umcka-wah?
Lane.stanford.edu  peds portal
Natural Medicines Database
Pelargonium sidoides- Umckaloabo
Umckaloabo –
mechanism of action
• Pelargonium sidoides root –
• African geranium
• Historical uses for sinusitis, bronchitis, pharyngitis
• In vitro:
• Release of antibacterial cytokines (TNF-alpha, interferon-beta)
• Enhances phagocytosis and NK cell activity
Evidence
• Cochrane Database Review 2012 for acute bronchitis
• 12 clinical trials, 10 included for analysis
• Placebo controlled RCT’s
• In children – 2 RCT’s (n= 200, n=220), using liquid extract on
treating acute bronchitis
• Decreased bronchitis specific symptoms (BSS) from day 0 to Day 7
• RCT (n-143) children >6y/o with non-strep pharyngitis:
• Reduced severity and duration of symptoms by 2 days compared to
placebo
Timmer. Cochrane Database Sys Rev. 2012
Berenznoy 2003
• Relative effect (RR = 0.82) for failure to recover by day 7
Timmer. Cochrane Database Sys Rev. 2012
Safety/ Contraindications
• No published adverse effects except for rare hypersensitivity/
allergy reactions
• Some GI upset side effects:
• nausea, vomiting, diarrhea
• CAUTION with:
• Antiplatelet medications
• Coumarin - May have mild anti platelet aggregation effect
• No effect on platelet aggregation in animal models
• Immunosuppressive medications
• Allergy to pelargonium or ethanol
Dosing
• Dosing: (extraction 1:8-10; ethanol solvent)
100g of finished product = 80 g pelargonium extract
corresponding to 8 gram of dry material + 20g glycerol (85%)
bronchitis
• 1-6 y/o:
• 6-12y/o
• 12-18 y/o
10 drops TID
20 drops TID
30 drops TID
pharyngitis
3mL TID
3mL TID
on bottle
5ml TID
7.5ml TID
Zinc (Zn)
Ods.od.nih.gov
Zn – Mechanism of action
• Important for immune cell function
• Deficiency causes imbalance between TH1 and TH2 functions 
• Decreased production of TNF-alpha, IFN-g, IL-2
• Zinc may help regenerate new CD4+ T cells
• Intestinal barrier function
• Improves duration, severity and volume of diarrhea in acute
gastroenteritis (Developing countries)
• Human rhinoviruses attach to nasal epithelium via intracellular
adhesion molecule 1 (ICAM-1).
• Zn ion blocks ICAM-1 receptor, exerting an antiviral effect
Zn – Evidence
• Randomized, double-blind, placebocontrolled trials on Zn in common cold
• for at least 5 days to treat or
• for at least 5 months to prevent
• 16 therapeutic trials (n=1387)
• 2 preventive trials (n=394)
• Both in children
Cochrane Review 2013
Zn –Evidence for Common Cold
Treatment
• If administered within 24 hours of
symptoms Zn:
• Lower duration of sick days
(P=0.003)
• Does not reduce severity of
symptoms (P= 0.11)
• Less of those symptomatic after 7
days of treatment (P=0.05)
Prevention (x 5 mo)
• Lower Incidence Rate Ratio (IRR)
of developing a cold (IRR 0.64, 95%
CI 0.47-0.88)
• School absence less in Zn group (P
= 0.0003)
• Prescription of antibiotics lower in
Zn group (P < 0.00001)
Adverse effects higher in Zn group
• Bad taste (OR 2.31, 95% CI 1.71 to 3.11) (P <
0.00001)
• Nausea (OR 2.15, 95% CI 1.44 to 3.23) (P = 0.002)
Cochrane Review 2013
Zn –Evidence
JAMA 2014
Zn – Dose
• RDA
• ~2mg infants, ~5mg children, ~10mg adults
• In studies:
• 10-15mg in children
• ~75mg in adults
Zn - Safety
• Oral generally safe if don’t exceed tolerable upper limit
• 4mg/d (<6 mos) to 34mg/d (14-18 yrs)
• Side effects:
• Bad taste
• Nausea
• Long-term high dose (450-1600mg/d) may lead to copper
deficiency
• Intranasal Zn may cause irreversible loss of sense of smell and
should not be used.
NCCIH 2015
Cochrane 2013
JAMA 2014
BUGS AND GUTS AND
PROBIOTICS
Intestinal Gut Microbiota
• 100 trillion bacterial cells, most are anaerobes
• GI tract sterile at birth
• In infancy, gut flora varies greatly
• Vaginal vs. C Section
• More bacteroides and bifidobacterium in vaginal birth
• Premature birth – more staph species
• Formula fed vs. breastfed
•  Breastfed – more bifidobacterium, more diverse microbiome
• Neonatal antibiotic use
Impact of Diet on Gut Microbiome
Worldatlas.com
Fecal Microbiota Transplantation
•Stool from donor transplanted into recipient
•Routes:
• From below (via colonoscopy or enema)
• Or Above (via NG-tube)
• Capsules PO
•Only indication currently IN ADULTS:
• recalcitrant C. difficile infection
• failed standard antimicrobial therapy
•Research underway
• recurrent Cdiff, for IBD, diabetes, etc … …
Probiotics - “the good bacteria”
“Live microorganisms, which,
when administered in
adequate amounts, confer
health benefits to the host.”
<nourishedkitchen.com>
Functional Food
•a modified food or food ingredient that
has potential benefits on the health
beyond basic nutrition
•Examples:
•Baby formula with probiotics
•Yogurt with probiotic cultures
•Kefir
Probiotics in foods
<theguardian.com>
<theguardian.com>
<realsimple.com>
<simple.wikipedia.org>
<allrecipes.com>
<en.wikipedia.org>
... Not to be confused with
Prebiotics
Prebiotics – nondigestible
ingredients
stimulate growth of
beneficial microorganisms
– ferment in the colon.
•Inulins (bananas, agave,
wild yams, jerusalem
artichokes, jicama)
•Fructooligosaccharides
(FOS)
•Galactooligosaccharides
(GOS) – human milk
<en.wikipedia.org>
… not to be confused with Synbiotics
• Nutritional supplements that combine both probiotics and
prebiotics.
• Ex: Lactobaccillus acidophilus and inulins
Quality Control
• http://Consumerlabs.com
• May not contain viable organisms
• Microbial contamination
• Potential for transmission of antibacterial resistant plasmids
• Effectiveness of different formulations • Actual amount advertised is present
• “active cultures”
• Ability to survive gastric acid
Side Effects and Contraindications
• Abdominal discomfort and allergic reactions
• diarrhea, nausea, vomiting, gassiness, bloating
• Invasive infections of immunocompromised Host
• Case Reports of Saccharomyces fungemia and death
• >100 cases of fungemia in literature
• Indwelling Catheters/ Central Lines
• Lactobacillus line infections
• Patients with short gut
• Case report of lactobacillemia
<surgery.med.umich.edu>
Handout/ Reference from probiotic review
In urgent care, you diagnose a 9
month old female with acute
otitis media. You prescribe
amoxicillin.
The mom asks: “I heard
antibiotics can give babies
diarrhea. Can I do anything to
prevent this?”
On the ward, you admit a 2 year
old previously healthy boy for
dehydration. He was found to
have norovirus on stool antigen.
After giving hydration and
supportive care…
“What else do you want to do
for this patient?”
Your 6 y/o patient ex-premie with a
history of short gut due to NEC and
is TPN dependent. He just finished
a course of antibiotics for line
sepsis. He also has a history of
recurrent clostridium difficile.
The parents are asking about
starting probiotics to prevent
recurrent c. diff.
What do you think?
Take Home to your Practice…
• Think Probiotic when prescribing antibiotic
• Saccharomyces Boulardii
• Lactobacillus rhamnosus GG
• Baby with Colic/ Reflux
• Lactobacillus Reuterii
• Teen with Ulcerative Colitis
• VSL#3
** Encourage breastfeeding, plant based diet, fiber and fermented
foods, yogurt, playing in the dirt, pets
<cartoonstock.com>
INTRO TO TCM
CONCEPTS AND
DEFINITIONS
WHAT ARE ACUPUNCTURE POINTS?
ACHIEVING BALANCE
• Lifestyle/ Diet/ Psychology
• Herbs
• Acupuncture can balance Qi
• Inserting thin sterile, stainless steel needles into the
points on the meridian pathways
• Needles are inserted to various depths but typically just
beneath the skin
• Needles are sometimes stimulated by manipulation,
moxibustion (‘Arternisia Vulgaris’, also called mugwort),
or with electrical stimulation
5 Elements Theory –
BiopsychoTypes
“Needlephobia in children before and after
experience with acupuncture
Acupuncture Analgesia Mechanism
Spinal cord level – Gate theory of pain
• Mechanisms in the spinal cord prevent pain fibers from
transmitting in the presence of competing sensory
information
ACUPUNCTURE – Central modulation
• Acupuncture modulates activities in the central
nervous system (CNS)
• Influences treatment areas via release of
neurotransmitters/hormones
• Normalize stress responses in the hypothalamicpituitary-adrenal (HPA) axis
• Acupuncture blocks cold stress induced increases in
HPA axis in rats
• Eshkevari, et al. J endocrinology. March 2013
FMRI STUDIES ON PC6 –
modulation of cerebellar
activities
Group activation map in
cerebellar ROIs (region of
interest)
(A) real acupuncture > sham
acupuncture condition
(B) real acupuncture > tactile
stimulation
Yoo et.al - Modulation of cerebellar
activities by acupuncture stimulation:
evidence from fMRI study. Neuroimage
2004
A
B
PC6 for Nausea/ Vomiting in Children
• Chemo induced nausea and vomiting –
• 3 small published clinical studies in Peds literature
• Show improvement in N/V scores (n=10-30)
• Post-operative N/V
• 1 clinical study – (n=120)
• Acupuncture improved incidence and timing of N/V significantly
compared to sham acupuncture (63% vs 88%)
Yeh, C.H. et al J. Altern. Complement. Med. 2012, 18, 334–340.
Gottschling, et all Klin. Pädiatr. 2008, 220, 365–370.
Reindl, et al. Support Care Cancer 2006, 14, 172–176.
Rusy, L.M. et al. Anesthesiology 2002, 96, 300–305.
GERD and Dyspepsia
• Points PC6, ST36 and CV 12 have in vitro and invivo effects on improving gastric motility and
decreasing basal acid production
• Study: Acupuncture vs. Double Dose PPI
• In 30 adults who failed standard PPI dosing (nl EGD)
• Acupuncture more effective at improving sx scores than
doubling PPI dose
• Dickman et.al, Aliment Pharm Therapy, Nov 2007
LET’S LEARN SOME POINTS
ACUPRESSURE
PC 6 – NEI GUAN: INDICATIONS
• Nausea/ vomiting
•
•
•
•
Post operative N/V
Chemotherapy induced N/V
Pregnancy induced N/V
Motion Sickness
• Contraindicated if cardiac arrhythmia
LI 4 – HE GU POINT
• Headache
• Sore throat
• Toothache
• Sinus Congestion
• Contraindicated in
pregnancy – increases
uterine contractions
LI-4: POINT LOCATION
• On dorsum of first
interosseus space of the
hand
• On the belly of the first
interosseus dorsalis
muscle
• At the level of the
midpoint of the shaft of
the 2nd metacarpal bone
BL 32 - LOCATION
• One index finger length
above the top of the
buttock crease
• Approximately one
thumb width either side
of the spine.
• Over the second sacral
foramen
Dimple = posterior superior iliac spine
BL32 - INDICATIONS
• Relieve labor contraction pain
• Use feedback from the laboring women – point may
move downward as baby descends
• Speeds up labor
GRATITUDE “TED TALK”
THANKYOU!