Alternative Therapies in General Pediatrics and Pediatric

Report
Complementary and Alternative
Medicine (CAM) Resources for
the Practitioner:
Where to look and Who to Trust
John D. Mark MD
Clinical Assoc Professor of Pediatrics
Pediatric Pulmonary Medicine
Lucile Packard Children’s Hospital at
Stanford
CAM- Where is it?
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A 14 yr old athlete with moderate, persistent
asthma comes to clinic. He has an asthma action
plan and has been adherent with his controller
medication. Now he wants to try a breathing
technique (Buteyko) so he can “get off” his meds.
A 3 yr old comes to the clinic for a well-child
check-up. On exam you find a right otitis media.
She is asymptomatic and you recommend
watchful waiting. The parents would like to try a
homeopathic remedy because they had heard
that homeopathy worked better than placebo for
children with an ear infection.
Answer: Everywhere
CAM- every where you look
CAM in the News

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Dying Woman Loses Marijuana Appeal
March 14, 2007
Evidence Mounts That Coping Skills Can
Boost HIV Survival March 14, 2007
Omega-3 in Fish Oils Might Ease
Depression March 7, 2007
Insomnia: Alternative Medicine Popular
• 1.6 Million Adults Use Complementary Or
Alternative Medicine For Insomnia September
2006
Jennifer Aniston
Atkins diet
Madonna
Yoga, herbalism
Pamela Anderson
Homeopathy
Sir Paul McCartney
Alexander
Boris Becker
Homeopathy
Demi Moore
Lake algae
Cherie Blair
Acupuncture,
Kate Moss
Acupuncture
Tony Blair
Homeopathy
Martina Navratilova
Homeopathy
Dina Carroll
Reflexology
Olivia Newton-John
Homeopathy
Charles, Prince
Magnet therapy
Gwyneth Paltrow
herbalism
Cher
Homeopathy
Brad Pitt
Atkins diet
Cindy Crawford
Homeopathy
Sir Cliff Richard
Ginseng
Sheryl Crow
Eskimo diet
Sarah, Duchess of York
Bioenergy
Queen Elizabeth
Homeopathy
Arnold Schwarzenegger
Breathing
Jane Fonda
Homeopathy
Hugo Speer
Yoga
Richard Gere
Breathing therapy
Margaret Thatcher
Ayurveda
Whoopi Goldberg
Homeopathy
Uma Thurman
Gem therapy
Jerry Hall
Homeopathy
Tina Turner
Homeopathy
Geri Halliwell
Yoga
Kate Winslet
Acupuncture
Goldie Hawn
Ayurveda
Catherine Zeta-Jones
Homeopathy
Ernst MJA 2006; 185 (11/12): 680-681
Complementary and Alternative
Medicine (CAM)


Complementary and alternative medicine
• A group of diverse medical and health care
systems, practices, and products
• Not considered part of conventional medicine
• Some scientific evidence exists regarding CAM
therapies
• For most, questions of safety and efficacy
persist
Complementary medicine is used together with
conventional medicine. Alternative medicine is
used in place of conventional medicine.
http://nccam.nih.gov/health/whatiscam/
Integrative or Holistic Medicine


Integrative combines mainstream medical
therapies and CAM therapies for which
there is some high-quality scientific
evidence of safety and effectiveness.
“Healing-oriented medicine that takes account of
the whole person (body, mind, and spirit),
including all aspects of lifestyle. It emphasizes
the therapeutic relationship and makes use of all
appropriate therapies, both conventional and
alternative.”
http://nccam.nih.gov/health/whatiscam/
http://www.integrativemedicine.arizona.edu/about2.html
Major Classes of CAM
Enhance the
mind’s capacity
to affect bodily
function and
symptoms
Alternative
medical
systems
Homeopathic
Naturopathic
Traditional
Chinese and
Ayurvedic
treatments
Mind-body
interventions
Chiropractice
Osteopathy
Massage
Biologically
-based
therapies
Dietary supp
Herbs
Foods
Vitamins
Natural
substances
Manipulative
& body-based
methods
Energy
therapies
Biofield therapy
Bioelectromagnetic
therapy
http://nccam.nih.gov/
CAM Utilization
Reasons for using CAM:
 Consistent with patient’s and families
values: natural, and empowering
 CAM providers are “patient-centered”,
dedicated to promoting health.
 Conventional therapies are perceived to be
emotionally or spiritually without benefit
 Conventional therapies are not effective or
are associated with side effects.
 CAM use is a circular: usage determines
number of CAM practitioners
Archives of Disease in Childhood 2006;91:96-97
CAM Therapies
http://nccam.nih.gov/news/camsurvey_fs1.htm#domain
CAM Therapies
Pediatric Use of CAM

Asthma
80%

Adolescents
54-69%

Special Needs
64%
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Rheumatology
64%

ADHD
54%

Emergency
13-45%
Reznik, 2003
(Bronx, NY)
Wilson, 2002 (NY)
Braun, 2005 (MN)
Sanders, 2003
(Tucson, AZ)
Hagen, 2003
(Toronto)
Chan et al, 2003
(Boston Children’s)
Losier, 2005 (Ottawa)
Lanski, 2003 (Atlanta)
Pediatric Use of CAM

Oncology
47-84%

Cerebral Palsy
56%
IBD
41%


Autism Spectrum 30%

Preoperative
29.5%
Primary Care
12-21%

McCurdy, 2003 (WFU)
Neuhouser, 2001 (Seattle)
Kelly, 2000 (NYC)
Hurvitz, 2003
Ann Arbor, MI
Heuschkel, 2002
London, Boston, Detroit
Levy, 2003
CHOP, PA
Lin, 2004
Boston Children’s
Sawni, 2002 (Detroit)
Ottolini, 2001 (Wash D.C.)
Evidence Based CAM Therapies in
Pediatrics

Effectiveness well documented:
• Acupuncture for nausea and vomiting
• Biofeedback for constipation
• Biofeedback for headache
• Hypnotherapy for headache
• Hypnotherapy for irritable bowel
syndrome
• Lemon balm for herpes simplex
• Massage for constipation
Archives of Disease in Childhood 2006;91:96-97
CAM Treatments Commonly
Thought Effective in Pediatrics

Effectiveness
uncertain
• Acupuncture for asthma
• Acupuncture for hay
fever
• Acupuncture for
rheumatoid arthritis
• Chromium for diabetes
• Echinacea for common
cold prevention or
treatment
• Evening primrose for
eczema

Effectiveness unlikely
• Acupuncture for body
weight reduction
• Acupuncture for
smoking cessation
• Flower remedies for
anxiety
• Homeopathy for anxiety
• Spinal manipulation for
asthma
• Spinal manipulation for
infantile colic
Archives of Disease in Childhood 2006;91:96-97
Use of Herbs- Evidence?
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Alternative Health supplement of the 2002
National Health Interview Survey: data on
10 common herbs
Of 30,616 adults, 19% used herbs in past
12 mo, 57% for a specific condition
Approximately 2/3 used herbs (except
Echinacea) not in accordance with
evidence based indications
Mayo Clin Proc, May 2007;82(5): 561-566
Conventional Medicine, Evidence?
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Most conventional physicians believe in unconventional
medicine because it is not scientific
What is evidence-based medicine? Treatment that will
improve patient outcomes by well-designed, appropriately
powered, randomized, controlled clinical trials.
There is not good evidence (Grade A) that many of the
commonly used therapies in conventional medicine are
effective (ex: heparin, aspirin, and warfarin).
The principal distinguishing characteristic of unconventional
and conventional medicine therapies is the source of
introduction.
Conventional therapies are introduced by mainstream
Western physicians and scientists, whereas most
unconventional modalities are introduced by "outsiders."
One of the reasons that most unconventional modalities are
not evidence based is that the majority of them were
introduced prior to the 20th Century
Arch Intern Med. 1998;158:2179-2181
CAM & Pediatric Care

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Evidence is lacking even for the most popular, if
there is evidence, most is in adults
However, the Institute of Medicine states: “the
same principles and standards of evidence of
treatment effectiveness apply to all treatments
whether currently labeled as conventional
medicine or CAM”.
Only 1/3-1/3 of patients or their parents reported
CAM use to their doctors. Indicates a need to
promote dialogue about CAM use between
patients and their health care providers.
Physician’s Attitudes



Survey sent to 660 physicians at the Mayo
Clinic (233 responded)
Three areas: utilization, familiarity and
attitudes
Utilization:
• 75% had never referred to CAM practitioner
• 44% said they would consider if available at
the Mayo (<46 years or female more likely)
• Less 25% discussed benefits or risks with CAM
• 57% thought incorporation of CAM would be
have a positive impact on pt satisfaction
Physician’s Attitudes

Familiarity:
• Biofeedback, massage, chiropractic and
relaxation therapies were the most familiar
• 59% were unfamiliar with energy healing, 53%
with naturopathic medicine
• Of the 13 herbs listed, only 3 were commonly
listed as familiar
• 66% were not familiar with feverfew and 52%
were not familiar with Kava
• 49% of the physicians felt it was difficult or
very difficult to find reliable information about
herbs
Physician’s Attitudes
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41% of the physicians neither agreed or
disagreed that physician knowledge had an
impact on patient’s health
52% felt physician’s spiritual beliefs were
important and 87% felt patients spiritual beliefs
and practices were important
67% agreed some CAM therapies hold promise
but 70% felt current practices of CAM was a
“threat” to the public health
Most important factors in changing physician’s
attitudes were RCT’s and evidence demonstrating
mechanism
70% of the physicians felt Mayo clinic should
provide proven CAM therapies
eCAM 2006;3(4) 495-501
Federation of State Medical Board
Guidelines (excerpts)
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Patient evaluation: Includes the use of nonconventional methods of diagnosis and treatment
Consultation and/or referral to licensed or
otherwise state-regulated health care
practitioner- the Physician is responsible for
monitoring the results
Medical records should also document: What
conventional medical options have been
discussed, offered, tried, or refused
Education- All physicians must be "able to
demonstrate a basic understanding of the
medical scientific knowledge" connected with any
CAM therapy
www.fsmb.org
What to do……….
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Be aware of the growing scientific evidence
concerning the safety and effectiveness of
relevant complementary, as well as mainstream,
therapies.
Balance the risks and benefits of any therapy
before recommending a course of action, and
continue to monitor patients appropriately.
Discuss and document with patients and their
families any information regarding treatment
decisions, conventional or CAM.
Know professional guidelines including ethics
CAM Education in Pediatrics
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CAM education in medical schools
American Academy of Pediatrics (AAP)
Pediatric Integrative Medicine Leadership
Initiative and Pediatric Integrative
Medicine Conference (PIMC)
International Pediatric Integrative
Medicine Network (IPIM-N)
Canadian network linking pediatric CAM
researchers & educators (PedCAM)
CAM Education in Medical Schools


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1998 survey found 75 medical schools (out of 125) offered
CAM electives or including these topics in required courses
81% of the schools that included CAM in the curriculum did
so by adding stand alone courses or electives, 41% used
required courses, and 23% had both stand-alone and in
required courses JAMA. 1998;280:784-7
Barriers included: lack of money, lack of time to plan and
prepare, and outright animosity on the part of faculty.
• …unscientific, lack of mechanistic explanation or demonstrated
clinical efficacy….if taught could be viewed as advocacy

Change is occurring:
• Harvard: Division for Research and Education in
Complementary and Integrative Medical Therapies
• Albert Einstein, Columbia, Duke, Mount Sinai, Stanford,
Arizona, Maryland, Pennsylvania, and several branches of the
University of California have included CAM in the curriculum
How to Include CAM in Education
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Teach One Medicine
Create Opportunities for Cross-Fertilization
Develop Support and Commitment from the
Institution
Offer a Well-Designed Electives
Include an Experiential Component (acupuncture,
massage, homeopathy, craniosacral etc)
Plan across the Curriculum from Undergraduate
to Graduate and Continuing Medical Education
(often a void during residency and fellowships)
Wetzel MS, et al. Ann Intern Med 2003; 138: 191–6
Current Status - AAP

Provisional Section on Complementary,
Holistic & Integrative Medicine (CHIM)
• Kathi Kemper, Chair for Holistic and Integrative Medicine
and Professor of Pediatrics, Wake Forest University
• Section will promote policies to enhance patientcentered care, integrating evidence-based, safe and
effective complementary therapies

Meetings:
• Super CME Courses
• AAP National Conference October 2007

Four sessions by CHIM members
Current status - PIMC


Pediatric Integrative Medicine
Conference
Collaboration of academic faculty at multiple
pediatric integrative medical centers in
US/Canada
• 1st-2000, University of Arizona, Tucson
• 2nd-2001, University of Minnesota, Minneapolis
• 3rd- 2005, New York Academy of Medicine, NYC
• 4th- 2006 October, 27-29th, Chicago
• 5th- 2007, October 26-27th, San Francisco
http://www.pangeaconference.com/index.asp
Current Status - IPIM-N


International Pediatric Integrative
Medicine Network
List serve connecting PIM practitioners
and organizations
• Facilitates communication and collaboration
• Promotes clinical, educational and research
initiatives
• Provides resources and links

Secure electronic network

[email protected]
Resource Evaluation
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Introduction
Who runs this site?
Who pays for the site?
What is the purpose of the site?
Where does the information come from?
What is the basis of the information?
How is the information selected?
How current is the information?
How does the site choose links to other sites?
What information about you does the site collect,
and why?
How does the site manage interactions with
visitors?
A Guide for Providers Using CAM
Government sites

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National Center for CAM:
http://nccam.nih.gov/
Office of Dietary Supplements:
http://ods.od.nih.gov/Research/CARDS_Database
.aspx
MedWatch:
http://www.fda.gov/medwatch
CAM on PubMed:
http://www.nih.gov/news/pr/feb2001/nccam05a.html
NCCAM Website


Acupuncture
Arthritis
Black Cohosh
Cancer
Chelation
Chiropractic
Chondroitin
Depression
Dietary Supplements
Echinacea
Ephedra
Ginkgo
Ginseng
Glucosamine
Herbs at a Glance
Homeopathy
Menopause
St. John's Wort

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Introduction to Naturopathy
New Herbs at a Glance: Grape
Seed Extract
AARP/NCCAM Report on Older
Americans
Past Highlights
News from NCCAM:
Subscribe to quarterly
newsletter
Monthly e-bulletin
A Guide for Providers Using CAM
Academic sites
 Boston-Longwood Herbal Task Force:

http://www.longwoodherbal.org/
University of Pittsburgh:
http://www.pitt.edu/~cbw/database.html
 Beth Israel Medical Center NYC:
http://www.healthandhealingny.org/
 Columbia University:
http://www.rosenthal.hs.columbia.edu/Botanicals
.html
 University of California, Berkeley
Newsletter:
http://www.wellnessletter.com/html/ds/dsSupple
ments.php
Longwood Website

ABC's of Herbal Medicine | Herbs | Dietary
Supplements | Vitamins & Minerals
In-depth Monographs (71) | Clinician
Information Summaries
Patient Fact Sheets | Articles by LHTF
Members
Interactions and Toxicity Information |
Resources & Links
About the LHTF | How to Support the LHTF
Courses and Websites

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Herbs and Dietary Supplements-Wake Forest
University
http://northwestahec.wfubmc.edu/learn/herbs/index.asp#
CurrDesc
Botanicals and Health series-University of Arizona
http://integrativemedicine.arizona.edu/online_courses/#b
otanicals
Botanical Medicine in Modern Clinical Practice (NYC)
http://cait.cpmc.columbia.edu:88/dept/rosenthal/Botanica
ls_CME.html
Consumer Labs
http://www.consumerlab.com
Natural Medicines Comprehensive Database
http://www.therapeuticresearch.net/(ctt54155qny2vs55ryi
v2d32)/home.aspx?li=0&st=0&cs=&s=ND
Quackwatch http://www.quackwatch.com.
Consumer Labs




ConsumerLab.com, is a provider of independent
test results and information to evaluate health,
wellness, and nutrition products.
2.5 millions visits/year and as a certification
company, CL enables companies of all sizes to
have their products voluntarily tested for
inclusion in its list of Approved Quality products
and bear the CL Seal.
In the past 7 years, tested more than 1,800
products, representing over 350 different brand
and supplements. One-year (12 months)
subscription is $27.00
Natural Products Encyclopedia and free
newsletter
Natural Medicine Database





Search - enter natural product name, disease or
condition, or drug name: objective product
information, Effectiveness Ratings, or potential
interactions with drugs
Natural Product Effectiveness Checker - tells you
the level of effectiveness for natural products
used for various medical conditions.
Natural Product / Drug Interaction Checker - tells
you potential interactions between any natural
product and any drug.
Disease / Medical Conditions Search - shows you
medical conditions, and allows you to see which
natural products might be effective.
Search Colleagues Interact - shows you
questions, answers, and comments posted by
other health professionals.
Fellowships and Residencies

University of Arizona Associate Fellowship
http://www.integrativemedicine.arizona.edu/af/i
ndex.html (residential and associate)

Family Practice and CAM residencies
• Albert Einstein College of Medicine
• Maine Medical Center
• Middlesex Hospital Family Practice Residency
Program
• Oregon Health & Science University
• University of Arizona College of Medicine
• University of Wisconsin – Madison
CAM –Local Resources
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Stanford Center for Integrative Medicine (SCIM)
• http://www.stanfordhospital.com/clinicsmedSe
rvices/clinics/complementaryMedicine/default
Osher Center for Integrative Medicine
• http://www.osher.ucsf.edu//
Five Branches Institute
• http://www.fivebranches.edu/
College of Botanical Healing
• http://www.cobha.org/
Ryan Ranch, Integrative Medicine
• http://www.ryanranchmedicalgroup.com/integr
ative_medicine.htm

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