CHAPTER 15

Complementary and Integrative Medicine in Pediatric Primary Care

Miriam T. Stewart, MD, FAAP, and Erica M.S. Sibinga, MD, MHS, FAAP

Complementary and Integrative Medicine

Complementary and integrative medicine (CIM) refers to a wide variety of therapies that are not typically part of “conventional” medical approaches. Conventional medicine (sometimes called Western medicine) is the general approach of medical doctors, doctors of osteopathy, and allied health professionals. The specific therapies thought of as CIM when compared with conventional medicine may change over time as research on CIM practices grows and those that are found to be of benefit are incorporated into evidence-based conventional medicine.

CIM therapies may be used in a number of different ways. When CIM therapies are used by patients in addition to the therapies recommended by conventional medical providers, they are termed complementary; this is by far the most common way CIM therapies are used. Alternative medicine refers to therapies used instead of conventional care. Increasingly, health professionals are incorporating both conventional approaches and evidence-based nonconventional approaches into their practice, a practice referred to as integrative medicine. Complementary and alternative medicine has been used as the umbrella term to describe CIM, but in view of the rare use of these modalities in place of conventional medicine and the increasing use of an integrative approach, integrative medicine is replacing alternative medicine in many settings, including the National Institutes of Health (NIH) National Center for Complementary and Integrative Health (NCCIH), formerly known as the National Center for Complementary and Alternative Medicine (NCCAM).

Pediatricians are learning about and using integrative therapies in a variety of ways. Many pediatric clinicians review evidence in the medical literature for specific therapies in certain clinical scenarios and integrate approaches into their clinical practice that show potential for benefit and safety. Interested clinicians may also attend continuing education courses and/or trainings in integrative approaches to gain knowledge and skills that can be incorporated into direct patient care. At many institutions, exposure to integrative medicine has expanded during residency training, including didactic and experiential instruction. In addition, a small but growing number of pediatric clinicians have received extensive training in integrative medicine at the fellowship level. Thus, a broad spectrum of approaches to pediatric integrative medicine currently exists.

Epidemiology

The use of CIM has risen steadily over the past several decades and now comprises a significant subset of health-related visits and expenditures. In 2012, 33.2% of American adults surveyed reported having used some form of CIM in the previous 12 months. Out-of-pocket expenditures for CIM totaled $30.2 billion in 2012, up from $27 billion in 1997. These statistics demonstrate the importance of physician awareness of CIM and support the routine inclusion of questions about CIM in the medical history.

A growing body of evidence reveals that the pediatric population is also using CIM. A large-scale survey of caregivers revealed that approximately 1 in 9 children uses CIM (11.6%). Higher prevalence, up to 60%, has been found among certain populations, such as children with cancer, epilepsy, sickle cell disease, or another chronic disease. The most commonly used CIM modalities are dietary supplements, chiropractic or osteopathic manipulation, yoga, and deep breathing exercises. A survey in 2017 revealed that use of yoga by children and use of meditation by children had increased over the previous 5 years from 3.1% to 8.4% and from 0.6% to 5.4%, respectively. Complementary and integrative medicine therapies are most likely to be used for back or neck pain, head or chest cold, anxiety or stress, and other musculoskeletal conditions. Adolescents are more likely to use CIM than younger children. Other factors associated with CIM use by children include parental education beyond high school; higher household income; coverage by private health insurance; use of prescription medications; and number of health conditions, doctor visits, or school days missed for illness in the past year. Non-Hispanic white patients are more likely to use CIM than Hispanic patients or black patients, although the strength of this association diminishes when data are adjusted for confounding factors. When worry about cost prevents the receipt of conventional medical care, children are more likely to use CIM. The strongest predictor of CIM use by children is CIM use by a parent; children whose parents use CIM are 5 times more likely to use CIM. When discussing CIM with families who are using it for their children, pediatricians need to be aware that parents may also be using CIM.

Motivations for Using CIM

Complementary and integrative medicine can be used for health maintenance; for symptomatic relief, as an adjunct to curative conventional medical care; for relief from adverse effects of conventional medical care; or in place of conventional medical care. Families choose to use CIM for many reasons. Word of mouth and belief in the efficacy of the treatment can be strong motivators. Some parents express a desire for more options and feel a sense of empowerment in their parental role as a result of CIM use. Complementary and integrative medicine may also be more congruous with a family’s values, philosophies about health, and understanding of the basis of disease. Parents may fear the adverse effects of conventional medications or be dissatisfied with the care their child receives in conventional medical settings. Families may seek the additional personal attention afforded by CIM providers. For some families, CIM offers additional hope when conventional medical care fails. Underlying all these motivations is the desire for the child’s health and well-being and the quest for safe and effective treatments of disease. Physicians and families can find common ground in this most basic of motivations, which can inform conversations about CIM and conventional medical care.

CIM Categories

Complementary and integrative medicine therapies can be thought of as falling into 5 categories: whole medical systems, mind-body therapies, biomechanical therapies, bioenergetic therapies, and biochemical therapies (Table 15.1). Besides whole medical systems, these categories are chosen to reflect purported similarities in the underlying mechanism of effect. A particular therapy may be used as part of a whole medical system approach or on its own. For example, acupuncture may be part of an individualized, comprehensive traditional Chinese medicine (TCM) treatment approach, also consisting of herbs and lifestyle recommendations, or a standardized acupuncture treatment may be used without evaluation and treatment by a TCM provider, in which case it can be thought of as a bioenergetic therapy. In addition, a particular therapy may belong to more than 1 category; for example, herbal preparations may have a biochemical and placebo (mind-body) effect.

Whole Medical Systems

Whole medical systems, including conventional medicine, are whole-system approaches to treatment, consisting of an underlying theory of healing, standardized training, and diagnostic and treatment approaches reflective of the underlying theory. For instance, TCM is based on the theory that illness and symptoms result from yin-yang energy imbalances. These energy imbalances are diagnosed through history and physical examination and treated by altering the energy balance using acupuncture (or other mechanical or thermal stimuli), herbs, and lifestyle changes (eg, diet, sleep, physical activity).

Mind-Body Therapies

Mind-body therapies are intended to enhance the mind’s ability to benefit health. A number of mind-body therapies are integrated into conventional medical treatment, such as psychotherapy, group therapy, imagery, and biofeedback. Others are still considered CIM, such as meditation and hypnotherapy.

Biomechanical Therapies

Biomechanical therapies aim to improve health through physical manipulation of the body. This may involve working with muscles (as with massage) or spinal alignment (as with chiropractic and osteopathic approaches). Massage therapies range from relatively light muscle work to deep tissue massage and may be incorporated into physical therapy to work with muscles and joints. Spinal manipulation therapies are used commonly in the United States and are most often practiced by chiropractors or doctors of osteopathy.

Abbreviations: BCE, before the Common Era; CIM, complementary and integrative medicine; DC, doctor of chiropractic; DO, doctor of osteopathy; FDA, Food and Drug Administration; LAc, licensed acupuncturist; MD, medical doctor; NCCIH, National Center for Complementary and Integrative Health; ND, naturopathy doctor; NIH, National Institutes of Health; NMD, naturopathy medical doctor; TCM, traditional Chinese medicine.

Information in this table is adapted from the health topics pages at the NCCIH website (https://nccih.nih.gov) and the American Cancer Society “Complementary and Alternative Medicine” page (www.cancer.org/Treatment/TreatmentsandSideEffects/ComplementaryandAlternativeMedicine/index).

Bioenergetic Therapies

Bioenergetic therapies are directed at improving health through altering the body’s energy as it runs through, on, or around the body. Because conventional training does not include the concept of energy in this way, bioenergetic therapies tend to draw skepticism from conventional medical providers. With increasing scientific evidence of its beneficial effects, acupuncture is purported to affect the body’s vital energy (chi) as it courses through energy channels called meridians. In 1997, an NIH consensus panel declared the evidence sufficient for integration of acupuncture into a number of conventional treatments, including treatment of chemotherapy-associated nausea and emesis, anesthesia-associated nausea and emesis, and pain syndromes. Homeopathic remedies are theoretically bioenergetic therapies, as the “ingredients” are successively diluted beyond the point of significant molecular presence; therefore, it is the resulting change in the energy of the diluents (sometimes called the “memory of the molecule”) that is responsible for the therapeutic effect. In addition, a number of therapies aim to affect energy at or near the surface of the body, including therapeutic touch and Reiki, both of which involve a trained practitioner identifying the energy imbalance and directing the patient’s own energy to improve the patient’s energy balance and promote healing.

Biochemical Therapies

Biochemical therapies are intended to improve health through their biochemical effects and include nutritional approaches, herbal remedies, and dietary supplements. Nutrition is an important part of many CIM approaches, such as Ayurveda, TCM, and naturopathy, and is also an accepted part of the conventional medicine approach to disease prevention and treatment. As the body of research on integrative nutritional approaches has grown, some interventions that originated as integrative approaches, such as the Mediterranean diet, have become part of evidence-based conventional medicine. Herbal remedies and dietary supplements are conceptually related to the biochemical mechanism of effect of conventional medications but have a few important differences. First, herbal remedies are by nature complex mixtures of chemicals, so their effects are likely caused by multiple biochemical reactions. Second, there is currently no federal regulation or oversight of the production of herbs or supplements in the United States, as there is with pharmaceuticals, so quality control is extremely variable. Third, safety concerns are addressed not before they are available commercially to consumers, as with pharmaceuticals, but only after products are on the market and adverse events are reported to the US Food and Drug Administration. Because of the lack of oversight of production and premarket safety, it is important for practitioners to research not only the evidence of an herb’s effect and potential adverse effects but also the particular formulation’s production and quality control.

Approaching CIM Use From a Conventional Medicine Perspective

As with any treatment option, the safety (risks) and efficacy (benefits) of a CIM modality must form the basis for therapeutic decision-making about its use. Table 15.2 can be a helpful guide in directing physician responses to a particular CIM therapy.

Assessing Efficacy

Data on the efficacy of CIM treatments are increasingly available as CIM becomes a greater focus of research effort and funding in the United States and worldwide. When searching the medical literature for CIM evidence, international and foreign-language articles can be useful, as certain CIM modalities may have been studied in greater depth or over a longer period in other countries. As with any research data, it is important to consider study design, outcome measures, sources of bias, methods of data analysis, and applicability of results for a given indication, patient, or patient population. With herbal remedies and supplements, it is also important to acknowledge that formulations differ, so efficacy as reported in a clinical trial may be altered if a different formulation is used.

Assessing Safety

The huge diversity of CIM makes it difficult to discuss safety in general terms. Each CIM modality has its own unique risk profile. However, awareness of broad categories of risk can help physicians prevent bad outcomes.

•Delay of conventional care: In studies of CIM risks for the pediatric population, the risk associated with the highest morbidity and mortality rates is delay of conventional care. This delay can come about for a number of reasons, including a family’s perception that care from a CIM provider obviates the need for conventional care, a family’s inability to afford conventional care, or a family’s belief that conventional care will be harmful. It may be helpful to contract with families that they will seek conventional care before or in conjunction with CIM care for a new symptom or acute illness to rule out disease processes that require conventional treatment.

•Drug-drug interactions: Certain supplements and herbal remedies may interfere with or alter the effects of conventional medications. Particular attention has been given to substances that are inhibitors or inducers of hepatic drug metabolism by the cytochrome P-450 enzymes, with St. John’s wort (used for depression; known botanically as Hypericum perforatum) and grapefruit juice being the most well-known examples. See the Resources for Physicians section for online resources for checking drug-drug interactions with herbal remedies and supplements.

•Adverse reactions: Allergic reactions, adverse effects, and idiosyncratic reactions are possible with CIM therapies as well as conventional therapies. Close follow-up is helpful in monitoring response to therapy.

Regulation and Licensure

Licensure and accreditation for CIM providers varies from state to state. Chiropractic care, massage therapy, acupuncture, naturopathy, and homeopathy have licensing bodies in some states. In states where licensing exists for a CIM modality, it is incumbent on the physician to ensure that any referrals are made to licensed practitioners. None of these licenses authorizes the practitioner to practice medicine. Other CIM modalities may have a national organization that supervises training and certifies practitioners. Although these are not subject to government oversight, there still may be value in preferentially seeking out providers who are approved by their national organization, as these providers have had to meet a standard established by their colleagues.

Regulation of herbal remedies and supplements is the subject of ongoing scrutiny and debate. Currently, the US Food and Drug Administration does not regulate production or marketing of these products, so it is often difficult to verify their composition, safety, or efficacy unless they have been independently studied. The burden of researching products and manufacturers falls to the consumer.

Communication About CIM Use

Most caregivers of children who use CIM do not disclose this use to their pediatrician despite that most report a desire to discuss it. The high rate of nondisclosure is alarming, as it places patients at risk for drug-drug interactions with conventional medications, robs physicians of the opportunity to monitor for adverse reactions, and interferes with the development of trust in the patient-physician relationship. Reasons cited by patients and caregivers for nondisclosure include

•Negative experiences with past disclosures to physicians.

•Fear of disapproval or judgment on the part of physicians.

•Belief that physicians do not need to know.

•Lack of time with physicians.

•Physicians do not ask.

Many of these barriers can be addressed by the physician.

Physicians may be reticent to discuss CIM, as evidenced by the fact that CIM discussions are patient initiated in most cases. Physicians may worry about legal liability if there is a bad outcome. They may fear conflict with families over use of CIM. They may be afraid to reveal their lack of knowledge about CIM and may worry that this lack of knowledge will threaten a family’s trust in their abilities. They may feel pressured by time constraints and overwhelmed by the need to acquire new knowledge. There is often a disconnect between the meaning that patients and families attribute to CIM use (more options and a greater sense of empowerment) and the meaning that physicians may attribute to it (irrationality given lack of evidence and the threat of interference with conventional medical care). This disconnect can influence patients and physicians to avoid the subject of CIM.

Communication Tips

Effective communication about CIM use is a wonderful opportunity to improve rapport and better understand a patient and family (Box 15.1). Communication can be a powerful tool for ensuring safety and reducing harm, as well as for broadening physician knowledge and building trust with families. Even if they do not initiate or recommend a CIM treatment, pediatricians can play an important role by monitoring a child’s response to the treatment over time and engaging the family in a discussion about risks and benefits if adverse reactions arise. Discussion about CIM may also bring about a greater understanding of families’ explanatory models of illness as well as their expectations of health care professionals and their beliefs about conventional medications. Deeper insight into a family’s health beliefs and values can facilitate a more successful patient-physician partnership and better patient care.

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