1. Integrative Pediatrics for Children with Special Health Care Needs Susie Gerik, MD Children’s Center for Restorative Care

2. 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

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

4. What is Integrative Pediatrics? Healthcare provider partners with patient and caregivers All interventions that are considered safe and potentially beneficial are offered/discussed

5. What is Integrative Pediatrics? Health and healing are emphasized more than disease and curing Prevention of disease and health optimization go hand-in-hand

6. What is Integrative Pediatrics? Healthcare provider is responsible for providing access to credible information and assisting people with encouraging habits to support wellness

7. What is Integrative Pediatrics? Attention is paid to all aspects of a child (holistic) Health professionals serve as role models for healthy living

8. Concerns Regarding CAM Use in Children Many therapies not well studied Dosages Safety Efficacy Delay of proven conventional therapy in favor of CAM

9. 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

10. Pediatrician’s Attitudes Over half would use CAM therapies personally Most were interested in CME on CAM

11. Realities about CAM Increasing CAM use Holistic practices Media coverage NCCAM

12. Increasing Use 199033% 199742% > $27 billion 75 out of 117 US Medical schools offer elective courses in CAM

13. 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

14. CAM Use Pediatric use of CAM is especially likely among children with chronic illness or disability.

15. 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)

16. 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

17. Increasing Prevalence and Incidence Increase in total population Decrease in mortality Shortened hospitalizations and more home care

18. 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.

19. 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

20. Common Ground The relationship between physician- healer and patient is integral to the success of treatments offered. The “art” of medicine.

21. What is NCCAM? National Center for Complementary and Alternative Medicine Established in 1998

22. 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

23. More about NCCAM… Director: Steven Strauss, MD Budget: $89.2 million (next year $100 million) 35% independent investigator initiated 10% training 23% for “Centers”

24. Major CAM Domains Alternative medical systems Mind-body interventions Biological-based therapies Manipulative or body-based therapies Energy therapies

25. Therapeutic Mountain A Model of Care Biochemical: medications, herbs, nutritional supplements Lifestyle and Mind-Body Therapies: nutrition, exercise, environment, mind- body

26. 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

27. 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

28. 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

29. 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

30. 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

31. Distraction Blowing bubbles Playing with pop-up toys Looking through a kaleidoscope Imagining a superhero Breathing techniques and guided imagery

32. Suggestion “Magic glove” technique Basic principles Willingness to be involved Trust in the coach Ability to participate

33. Breathing Techniques Rhythmic, deep-chest breathing Patterned, shallow breathing

34. Guided Imagery A form of relaxed, focused concentration Favorite place, favorite activity Not only produce distraction, but also enhance relaxation

35. Progressive Muscle Relaxation Recognize and reduce body tension associated with pain Decrease anxiety and discomfort

36. 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

37. Hypnosis Altered state of consciousness is used Concentration is focused, narrowed, absorbed

38. 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

39. Research Areas Gastrointestinal disorders Respiratory disorders Developmental disorders Oncology Mental health disorders Epidemiological studies of CAM

40. University of Arizona Fellowship in Integrative Medicine Research projects Abdominal pain Otitis media Cerebral palsy

41. 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

42. University of Rochester Adolescent use of CAM

43. University of Washington and Bastyr Echinacea for URI

44. University of Miami Massage in preterm infants

45. 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

46. 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

47. 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

48. 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 well- established and efficacious treatment for recurrent headaches

49. Vaccine-related Pain Jacobson et al Vaccine 2001 Attitude, empathy, instruction Distraction, hypnosis Sugar nipples Topical anesthetics (EMLA) 56 references

50. 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)

51. 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

52. Recurrent Abdominal Pain Gevirtz Journal of Pediatric Gastroenterology and Nutrition 2000 Fiber, Fiber-biofeedback, Fiber-biofeedback- cognitive/behavioral intervention, Fiber- biofeedback-cognitive/behavioral intervention-parental support All groups showed improvement, but treatment group showed more improvement

53. 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

54. 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

55. 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

56. Resources www.holistickids.org www.nccam.nih.gov/ UTMB Integrative Medicine Web Site HealthNotes Online Naz’s Special Needs Tips

57. Cases Asthma

58. http://www.holistickids.org/cases/asth ma/asthma_summary.shtml

59. Cases CP

60. HBO The principle effect of HBO therapy is hyperoxia. At 3 atmospheres of pressure Alveolar O 2 tension = 2180 mmHg PaO 2 = 1800 mmHg tissue concentration = 500 mmHg.

61. HBO After removal from the hyperbaric O 2 environment the PaO2 normalizes in minutes but the PtO 2 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.

62. 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

63. Hyperbaric Chamber

64. Cases ADHD

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

66. Other common ailments Constipation Reflux

67. http://www.holistickids.org/cases/consti pation/constipation_summary.shtml

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

69. 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.

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

71. 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.

72. 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.

74. 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