Paula M. Gardiner, Caitlin M. Neri
Integrative medicine focuses on promoting physical, mental, emotional, spiritual, social, and educational well-being in the context of a medical home in a healthy family and community. The foundations of integrative medicine are health-promoting practices such as optimal nutrition and dietary supplements to prevent deficiencies, avoidance of addictive substances (e.g., nicotine, illicit drugs), physical activity, adequate sleep, a healthy environment, and supportive social relationships. Evidence-based complementary therapies such as dietary supplements, massage, chiropractic, other forms of bodywork, yoga, meditation practices, hypnosis, guided imagery, biofeedback, and acupuncture may also be used. Although prayer and healing rituals are sometimes included under the rubric of complementary and integrative therapies, they are not covered in this chapter.
Not including multivitamins and mineral supplements such as iron and calcium, an estimated 10–40% of healthy children and >50% of children with chronic conditions use integrative medicine in the United States. The prevalence could be even higher because these treatments usually occur without disclosure to the children's primary care physician. Common therapies include dietary supplements, deep breathing, guided imagery, mediation, biofeedback, hypnosis, yoga, acupuncture, massage, and aromatherapy.
Use of complementary therapies is most common among youth with chronic, incurable, or recurrent conditions such as cancer, depression and other mental health conditions, asthma, autism, headaches, abdominal pain, and other chronic painful conditions. Children's hospitals and pediatric subspecialty programs are increasingly offering integrative medicine strategies alongside traditional medicine, as part of the care of children in both inpatient and outpatient settings. In a 2014 survey the American Pain Society identified 48 pediatric chronic pain clinics, with most offering some type of integrative medicine or behavioral health strategies with conventional medicine. For example, integrative therapies are increasingly being used in pediatric chronic pain clinics to treat functional bowel disorders. Recent reviews include supplements (e.g., ginger, peppermint oil) and mind-body techniques (e.g., hypnotherapy, biofeedback, acupuncture/acupressure) with traditional medical management for these common pediatric conditions.
Under the 1994 U.S. Dietary Supplement Health and Education Act, a dietary supplement is a product taken by mouth that contains a dietary ingredient intended to supplement the diet. These may include vitamins, minerals, herbs or other botanicals, amino acids, and substances such as enzymes, organ tissues, glands, and metabolites. Dietary supplements are the most frequently used complementary therapies for children and adolescents (Table 78.1 ). Some uses are common and recommended, such as vitamin D supplements for breastfed infants and probiotics to prevent antibiotic-associated diarrhea, whereas other uses are more controversial, such as using herbal products to treat otitis media.
Table 78.1
Commonly Used Dietary Supplements in Pediatrics
| PRODUCT | USES |
|---|---|
| VITAMINS | |
| B2 (riboflavin) | Migraine headache prophylaxis |
| B6 (pyridoxine) | Pyridoxine-dependent epilepsy; neuropathy; nausea associated with pregnancy |
| B9 (folate) | Prevention of neural tube defects |
| D | Prevention of rickets; treatment of vitamin D deficiencies |
| Multivitamins | General health promotion |
| MINERALS | |
| Iodine (salt) | Prevent goiter and mental retardation |
| Iron | Prevent and treat iron-deficiency anemia |
| Magnesium | Constipation, asthma, migraine prevention |
| Zinc | Diarrhea in nutrient-poor populations |
| HERBS | |
| Aloe vera | Mild burns |
| Chamomile | Mild sedative, dyspepsia |
| Echinacea | Prevention of upper respiratory infections |
| Ginger | Nausea |
| Lavender (aromatherapy) | Mild sedative |
| Peppermint | Irritable bowel syndrome |
| Tea tree oil | Antibacterial (acne remedies), pediculicide (lice) |
| OTHER | |
| Melatonin | Insomnia |
| Omega-3 fatty acids | ADHD, allergies, inflammation, anxiety and mood disorders |
| Probiotics | Antibiotic-associated diarrhea; Clostridium difficile –associated diarrhea; constipation; irritable bowel syndrome; pouchitis; inflammatory bowel disorders |
ADHD, Attention-deficit/hyperactivity disorder.
In the United States, dietary supplements do not undergo the same stringent evaluation and postmarketing surveillance as prescription medications. Although they may not claim to prevent or treat specific medical conditions, product labels may make structure-function claims. For example, a label may claim that a product “promotes a healthy immune system,” but it may not claim to cure the common cold.
According to the 2012 National Health Interview Survey, 5% of U.S. children used non-vitamin/mineral dietary supplements. (e.g., fish oil, melatonin, prebiotics, probiotics) Use of dietary supplements is most common among children whose families have higher income and education and whose parents use supplements, among older children, and among those with chronic conditions.
Despite this widespread use, many patients and their parents who use dietary supplements do not talk with their physician about their use. Several guidelines have called for more complete dietary supplement history taking by healthcare professionals. The Joint Commission recommends that clinicians routinely ask patients about their use of dietary supplements and include this information as part of the medication reconciliation process.
Dietary supplements may have safety issues in children, but toxicity is much less common with nonprescription dietary supplements than with prescription medications (Table 78.2 ). Toxicity depends on dose, use of other therapies, and the child's underlying medical condition. Current use of a dietary supplement (e.g., ephedra for weight loss) may not reflect its traditional use (e.g., ephedra as a component of a traditional Chinese medicine tea in small doses to improve allergic or respiratory symptoms). Moreover, herbs that are apparently safe for most adults may be more hazardous in specific conditions (e.g., newborns, patients with impaired renal or hepatic function), under special circumstances (e.g., after organ transplantation or other surgery), or when combined with prescription medications. Some natural products are toxic in and of themselves. Even when a product is safe when used correctly, it can cause mild or severe toxicity when used incorrectly. For example, although peppermint is a commonly used and usually benign gastrointestinal spasmolytic included in after-dinner mints, it can exacerbate gastroesophageal reflux.
Table 78.2
Clinical Toxicity of Selected Herbs
| COMMON NAME | BOTANICAL NAME | THERAPEUTIC USES | POTENTIAL TOXICITY |
|---|---|---|---|
| Aconite (monkshood, wolfsbane) | Aconitum spp. | Sedative, analgesic, antihypertensive | Cardiac arrhythmias |
| Aloe | Aloe spp. | Burns, skin diseases | Nephritis, GI upset |
| Betel nut | Areca catechu | Mood elevation | Bronchoconstriction, oral cancers |
| Bloodroot | Sanguinaria canadensis | Emetic, cathartic, eczema | GI upset, vertigo, visual disturbances |
| Chaparral (greasewood) | Larrea tridentata | Aging, free radical scavenging | Hepatitis |
| Compound Q | Trichosanthes kirilowii | Anthelmintic, cathartic | Diarrhea, hypoglycemia, CNS toxicity |
| Dandelion | Taraxacum officinale | Diuretic, heartburn remedy | Anaphylaxis |
| Figwort (xuan shen) | Scrophularia spp. | Antiinflammatory, antibacterial | Cardiac stimulation |
| Ginseng | Panax quinquefolium | Antihypertensive, aphrodisiac, stimulant, mood elevation, digestive aid | Ginseng abuse syndrome |
| Goldenseal | Hydrastis canadensis | Digestive aid, mucolytic, anti-infective | Uterine, cardiac stimulation; GI upset, leukopenia |
| Hellebore | Veratrum spp. | Antihypertensive | Vomiting, bradycardia, hypotension |
| Hyssop | Hyssopus officinalis | Asthma, mucolytic | Seizures |
| Juniper | Juniperus communis | Hallucinogen | GI upset, seizures, renal injury, hypotension, bradycardia |
| Kava kava | Piper methysticum | Sedative | Inebriation |
| Kombucha | Stimulant | Metabolic acidosis, hepatotoxicity, death | |
| Licorice | Glycyrrhiza spp. | Indigestion | Mineralocorticoid effects |
| Lily of the valley | Convallaria spp. | Cardiotonic | GI (nausea, vomiting), cardiac arrhythmias |
| Linn (willow) | Salix caprea | Purgative | Hemolysis with glucose-6-phosphate dehydrogenase deficiency |
| Lobelia (Indian tobacco) | Lobelia spp. | Stimulant | Nicotine intoxication |
| Ma Huang | Ephedra sinica | Stimulant | Sympathetic crisis, especially with monamine oxidase inhibitors |
| Mandrake | Mandragora officinarum | Hallucinogen | Anticholinergic syndrome |
| Mormon tea | Ephedra nevadensis | Stimulant, asthma, antipyretic | Hypertension, sympathomimetic |
| Nutmeg | Myristica fragrans | Hallucinogen, abortifacient | Hallucinations, GI upset |
| Oleander | Nerium oleander | Cardiac stimulant | Cardiac arrhythmias |
| Passionflower | Passiflora caeruliea | Hallucinogen | Hallucinations, seizures, hypotension |
| Periwinkle | Vinca spp. | Antiinflammatory, diabetes | Alopecia, seizures, hepatotoxicity |
| Pokeweed | Phytolacca spp. | Arthritis, chronic pain | GI upset, seizures, death |
| Sabah | Sauropus androgynus | Weight loss, vision | Pulmonary injury |
| Sage | Salvia spp. | CNS stimulant | Seizures |
| Snakeroot | Rauwolfia serpentina | Sedative, antihypertensive | Bradycardia, coma |
| Squill | Urginea maritima | Arthritis, cardiac stimulant | Seizures, arrhythmias, death |
| Thorn apple (jimsonweed) | Datura stramonium | Hallucinations | Anticholinergic |
| Tonka bean | Dipteryx odorata | Anticoagulant | Bleeding diathesis |
| Valerian root | Valeriana spp. | Sedative | Sedation, obtundation |
| Wild (squirting) cucumber | Ecballium elaterium | Constipation, antiinflammatory, rheumatic disease | Airway obstruction |
| Wormwood (mugwort) | Artemisia spp. | Stimulant, hallucinogen | Hallucinations, seizures, uterine stimulation |
| Yohimbine | Corynanthe yohimbe | Aphrodisiac, stimulant | Hypertension, sympathetic crisis |
CNS, Central nervous system; GI, gastrointestinal.
From Kingston RL, Foley C: Herbal, traditional, and alternative medicines. In Haddad and Winchester's clinical management of poisoning and drug overdose, ed 4, Philadelphia, 2007, Saunders/Elsevier, p 1081.
Although there are good manufacturing practices for dietary supplements in the United States, dietary supplement labels might not accurately reflect the contents or concentrations of ingredients. Because of natural variability, variations of 10-1,000–fold have been reported for several popular herbs, even across lots produced by the same manufacturer. Herbal products may be contaminated with pesticides, microbial agents or products, or the wrong herb misidentified during harvesting. Products from developing countries (e.g., Ayurvedic products from South Asia) might contain toxic levels of mercury, cadmium, arsenic, or lead, either from unintentional contamination during manufacturing or from intentional additions by producers who believe that these metals have therapeutic value. Approximately 30–40% of Asian patent medicines include potent pharmaceuticals, such as analgesics, antibiotics, hypoglycemic agents, or corticosteroids; typically the labels for these products are not written in English and do not note the inclusion of pharmaceutical agents. Even conventional mineral supplements, such as calcium, have been contaminated with lead or had significant problems with product variability.
Many families use supplements concurrently with medications, posing hazards of interactions (Table 78.3 ). Using the same principles of drug-drug interactions can help determine if a supplement-drug interaction is a concern. For example, St. John's wort induces CYP3A4 activity of the cytochrome P450 enzyme system and thus can enhance elimination of most drugs that use this pathway, including digoxin, cyclosporine, protease inhibitors, oral contraceptives, and numerous antibiotics, leading to subtherapeutic serum levels.
Table 78.3
Common Herbal Dietary Supplement (HDS)–Drug Interactions
| HDS | DRUGS | POTENTIAL CONSEQUENCES/REACTIONS |
|---|---|---|
| Aloe vera | Glibenclamide (glyburide) | ↑ Oral aloe vera gel can cause additive glycemic-lowering effects when taken concurrently with a hypoglycemic agent. |
| Bitter orange | Phenelzine | ↑ Risk of hypertensive crisis |
| Garlic | Ritonavir | ↓ Effect of ritonavir |
| Saquinavir | ↓ Effect of saquinavir | |
| Licorice | Warfarin | ↑ Risk of bleeding |
| Grapefruit | Calcium channel blockers | Grapefruit juice has been found to increase bioavailability of certain drugs by inhibition of cytochrome P450 (CYP) 3A4 isozyme in liver and gut wall. |
| Melatonin | Zolpidem | ↑ Sedative effects |
| Valerian | Alprazolam, phenobarbital | ↑ Central nervous system depression |
| Goldenseal | Inhibition of CYP2D6 and CYP3A4 | May affect approximately 50% of common pharmaceutical agents |
| St. John's wort | Cyclosporine, tacrolimus, warfarin, protease inhibitors, digoxin, theophylline, venlafaxine, oral contraceptives | May decrease drug effectiveness |
↓, Decreasing; ↑, increasing.
Evidence about the effectiveness of dietary supplements to prevent or treat pediatric problems is mixed, depending on the product used and condition treated. Some herbal products may be helpful adjunctive treatments for common childhood problems; some herbs have proved helpful for colic (fennel and the combination of chamomile, fennel, vervain, licorice, and balm mint), nausea (ginger), irritable bowel syndrome (peppermint), and diarrhea (probiotics).
Massage is usually provided at home by parents and in clinical settings by professional massage therapists, physical therapists, and nurses. Infant massage is routinely provided in many neonatal intensive care units to promote growth and development in preterm infants. Massage also has been demonstrated to be beneficial for pediatric patients with asthma, insomnia, colic, cystic fibrosis, or juvenile arthritis and patients undergoing cancer therapy. Massage therapy is generally safe. Professional massage practice is regulated by state government and may be in the form of a license, registration, or certification. More than 40 states license massage therapists, with licensure being the strictest form of regulation, making it illegal for any nonlicensed professional to practice massage therapy.
Chiropractic healthcare deals with the diagnosis, treatment, and prevention of disorders of the neuromusculoskeletal system and their effects on general health. Currently, >60,000 chiropractors have licensure in the United States, with licensure in all 50 states. Most medical insurance companies cover chiropractic funding. Children and families seek chiropractic care for common childhood conditions such as asthma, infantile colic, nocturnal enuresis, constipation, and headache. A recent consensus update on chiropractic care in children overall found limited support in a small number of high-quality studies for effectiveness of chiropractic care for such common childhood conditions. With respect to safety, the evidence is also limited; however, published cases of serious adverse events in infants and children receiving chiropractic care are rare. If children and families are seeking chiropractic care, it is appropriately done in collaboration with the child's pediatric primary care provider to ensure patient safety.
Mind-body therapies such as slow, deep breathing, meditation, guided imagery, biofeedback, hypnosis, tai chi, and yoga are also frequently used complementary therapies in pediatrics. These practices can be learned informally through books, YouTube videos, compact discs, digital video discs, smartphone apps, or classes, as well as in therapeutic sessions with health professionals, such as psychologists and social workers (Table 78.4 ). Substantial research suggests that such practices can aid in reducing anxiety, insomnia, and stress-related conditions, including migraine headaches and functional abdominal pain. These therapies can also help patients struggling with chronic pain.
Table 78.4
ADHD, Attention-deficit/hyperactivity disorder.
Modern acupuncture incorporates treatment traditions from China, Japan, Korea, France, and other countries. In the United States, acupuncturists are licensed to practice in 45 states. Acupuncture can be delivered to pediatric patients in hospital and clinic settings to treat a variety of ailments. Acupuncture is particularly useful for children experiencing pain, and acupuncture services are offered alongside conventional medicine and psychology by >50% of North American academic pediatric chronic pain programs. The technique that has undergone most scientific study involves penetrating the skin with thin, solid, metallic needles manipulated by hand or by electrical stimulation. Variants include rubbing (shiatsu ), heat (moxibustion ), lasers, magnets, pressure (acupressure ), or electrical currents.
Although pediatric patients may be averse to needles, when approached in a developmentally appropriate way by an acupuncturist trained in pediatrics, children are often amenable to acupuncture and report that it is helpful. Acupuncture can offer significant benefits in the treatment of recurrent headache, anxiety, back and other types of pain, depression, abdominal pain, and nausea. As with any needle therapy, infections and bleeding are rare but can occur, and more serious complications, such as pneumothorax, occur in <1 in 30,000 treatments.
Because marijuana has been legalized in many states for both recreational (adult) use and medical use, caregivers and families have inquired about the potential health benefits of cannabis for both children and adults. At this time, no pediatric studies support any health benefit of cannabis for children. Furthermore, significant safety concerns remain, since detrimental effects of marijuana on the developing brain have been documented.
It is important to note that in some children with severe refractory epilepsy , oral cannabidiol , a nonpsychoactive component in marijuana, has provided improvement in seizure control. On a case-by-case basis, this is a reasonable consideration for families facing this rare and difficult challenge, and additional research is required in this area, especially since the purity and regulation of marijuana and its commercially available component products are variable. Most of the recent pediatric literature on cannabis describes an increase in accidental ingestions in young children, presumably in association with the increase in products now available for adult use; this is an additional safety risk for pediatricians to consider.