Disclosures. Complementary Medicine in Pediatrics: What are the Alternatives? Use of CAM in the U.S. is increasing.

Transcription

1 5/18/12 Disclosures Complementary Medicine in Pediatrics: What are the Alternatives? I have nothing to disclose Karen Sun, MD Assistant Clinical Professor Overview What is CAM? Use of CAM in the U.S. is increasing Definitions Utilization Case based discussion of some common alternative medical therapies and practices. 1

2 5/18/12 Audience Poll What percentage of the general pediatric population has used CAM therapies? A. <2% B. 10% C. 20% D. 50% Audience Poll What percentage of the general pediatric population has used CAM therapies? A. <2% B. 10% C. 20% D. 50% Audience Poll What percentage of patients with chronic and/or lifelimiting conditions utilize CAM therapies? A. 10% B. 25% C. 50% D. >70% Audience Poll What percentage of patients with chronic and/or lifelimiting conditions utilize CAM therapies? A. 10% B. 25% C. 50% D. >70% 2

3 5/18/12 Definitions Integrative Medicine CAM: a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine (NCCAM, 2002) Practice of integrating CAM therapies based on scientific evidence of safety and efficacy Child in context: family, environment, peers, school Maintaining good health, prevention, healing Personalized approach to patient care- individualized therapies Empowerment CAM utilization ½ medical schools now offer CAM Many alternative therapies now offered in children s hospitals More third party payers are reimbursing for services Increased research and scientific evidence of safety and efficacy of CAM therapies 3

4 5/18/12 Categories of CAM Therapies Biochemical therapies vitamins, herbs, dietary supplements Biomechanical Massage Chiropractic adjustments Bioenergetic Acupuncture/acupressure Healing touch/reiki Prayer/meditation Lifestyle Diet, exercise, environment (aromatherapy, music, pets, visual arts) Safety and efficacy Safety Category 1 Yes Yes Efficacy Category 2 Yes Inconclusive Category 3 Inconclusive Yes/Inconclusive Category 4 NO NO Category 1: recommend and monitor Category 2: tolerate, closely monitor effectiveness Category 3: provide caution, closely monitor safety Category 4: avoid and discourage Children s Hospital Minnesota, Integrative Medicine Program Case 1- Adam Audience poll Adam is a 7 year old boy with moderate-persistent asthma. His asthma is often emotionally triggered, primarily by anxiety. You have started him on an inhaled corticosteroid, but mom would like to get him off of it. She has a list of CAM therapies for asthma that she has found on the internet and would like your opinion. Mom s list: A. Biofeedback B. Dietary supplements omega3 fatty acid, probiotics, vitamin C C. Acupuncture Which of these would you advise her as being safe and potentially beneficial? 4

5 5/18/12 Mom s list: A. Biofeedback Audience poll B. Dietary supplements omega3 fatty acid, probiotics, vitamin C C. Acupuncture Mind-Body Techniques Techniques that facilitate a person s own ability to direct their own behavior and modulate physiologic changes in a desired direction for the purpose of symptom control and maintaining health and wellness. Yoga, meditation, biofeedback Which of these therapies would you advise her as being safe and potentially beneficial? Locus of control Children have a natural drive for mastery and autonomy Something they do for themselves as opposed to something that we do to them Conditions Biofeedback Asthma Anxiety Attention problems Enuresis/encopresis Irritable bowel syndrome Chronic/recurrent pain Sleep Migraines Sensory information collected Computer processes and displays information Attune to and modulate the process 5

6 5/18/12 Heart Rate Variability (Coherence): Neonates - HRV good predictor of illness Computer game or handheld device Heart Math Herbal Medicine Readily available Widely used Most commonly asked questions from parents. Rapid shifts in popularity of different supplements. Herbal Medicines-the BAD Herbal Medicines-the GOOD Scientific data on most herbal medications show varying degrees of efficacy. Potency and purity highly variable, poorly regulated FDA does not have to approve packaging Short-term safety does not guarantee safety of chronic exposure 30% of imports from developing countries are contaminated with other drugs, heavy metals Increasing amount of research Evidence showing efficacy in a handful of herbal medications Many dietary supplements are easily obtained through natural food sources. Potential for adverse herb-drug interactions More resources are becoming available: Consumerlab.com- regulatory testing on products 6

7 5/18/12 Asthma and Herbal Medicines Some data supporting efficacy SAFE: Vitamin C Probiotics Omega-3 Fatty Acids- More safety studies needed, but promising Ivy Leaf Bronchodilator, spasmolytic, mucolytic Butterbur Anti-inflammatory Ma huang = ephedra Used in China for over 5,000 years Active ingredient: ephedrine Tx of colds, congestion and as weight loss agent Potent bronchodilator, vasoconstriction, diuretic Side effects: hypertension, tachycardia, headache, anxiety Variability in potency and high contamination >50% of all FDA complaints of dietary supplements are related to ma huang. Case 2 Clarissa is a 15 year old teen, who you have been seeing in your practice for chronic migraines. 4-5 headaches/month +nausea/vomiting Misses a lot of school Multiple migraine medications some relief Resistant to starting daily prophylactic medication Which of these would you advise her as being SAFE and potentially beneficial? A. Biofeedback and relaxation therapy B. Acupuncture C. Homeopathic medicine D. Reiki 7

8 5/18/12 Chinese concept of Qi A. Biofeedback and relaxation therapy B. Acupuncture C. Homeopathic medicine D. Reiki Qi (pronounced chee) energy or vital life force. Circulates through the body in meridians Free-flowing and vigorous =health Insufficient or interrupted =illness Use and Popularity At present in US, over 6000 physicians and 11-12,000 nonphysicians practice acupuncture. American Academy of Medical Acupuncture trains almost 600 MDs yearly How it might work Release of Neurotransmitters Beta endorphin, enkephalins, dynorphins, seratonin, norepinephrine Inhibits transmission of pain Naloxone inhibits acupuncture analgesia. Mayer DJ et al. Brain Res 1977;121:

9 5/18/12 Migraines and acupuncture Nausea/vomiting 43 children with migraine, mean age 12.3 yrs Randomized true vs sham acupuncture- 4 weekly treatments True acupuncture showed clear reductions in migraine frequency and severity. 120 pts. Age 4-18 yrs. T&A. Randomly assigned acupuncture, sham acupuncture or control. Needles placed while pt anesthetized. Arms wrapped to prevent identification of treatment group. Headache severity and monthly hours with HA significantly lower than placebo group. Gottschling S, et al (2008) Pain. Nausea and vomiting Acupuncture for kids? PONV significant lower in acupuncture group (63%; OR 0.135, NNT 3.3, p<.001) compared with controls (93%), sham (88%). Rusy L, Hoffman G. Anesthesiology 2002;96:

10 5/18/12 Emma 10 year old girl s/p R ankle sprain while competing in a gymnastics meet 9 months ago. c/o sharp, burning pain of her right leg Unable to walk without crutches Has missed many days of school Pain unrelieved by acetaminophen, ibuprofen or acetaminophen/hydrocodone Extensive work-up: blood, X-rays, MRI: all negative Lives with both parents, younger brother. Previously happy child, now having angry outbursts directed towards parents. CRPS therapy- Multimodal Pharmacology and analgesia Paced physical therapy Psychosocial support CAM therapies Art, Music, Pet Therapies Counseling patient and family Mind-Body Techniques: Stress reduction and relaxation, biofeedback techniques Acupuncture or acupressure Music, art, and pet therapy Music and Art Therapy Decreased heart rate, BP, respiratory rate Reduces stress/anxiety Decreases isolation Decreases pain Motivation to ambulate or use gross motor movement 10

11 5/18/12 Pet Therapy Talking to Parents ASK parents may not bring it up. Fear of MD disapproval Don t consider it medically relevant Be non-judgemental, open minded. Avoid terms that might be perceived as derogatory. Ask how well they think the therapies are working Be an ally Offer to learn more and assist in monitoring and evaluating the therapy Find reliable resources Websites National Center for complementary and alternative Medicine National Institutes of Health Nccam.nih.gov AAP Section on Complementary and Integrative Medicine aap.org/sections/chim/default.chm Canadian Pediatric CAM Network Osher Center for Integrative Medicine UCSF Pedcam.ca osher.ucsf.edu Wake Forest Center for Integrative Medicine NIH Office of Dietary Supplements wakehealth.edu/center-for-integrative-medicine/ ods.od.nih.gov/ Consumerlab.com- regulatory testing on health and nutritional products Center for Mind-Body Medicine Cmbm.org 11

12 5/18/12 References References (cont) Spigelblatt L, Laine-Ammara G, Pless B, et al. The use of alternative medicine by children. Pediatrics 1994;94: Hofmann D, Hecker M, Volp A. Efficacy of dry extract of ivy leaves in children with bronchial asthma a review of randomized controlled trials. Phytomedicine. 2003;10: Bukutu C, et al. Asthma: A Review of Complementary and Alternative Therapies. Pediatrics in Review 2008;29;e44. Wilder R. Management of Pediatric Patients with Complex Regional Pain Syndrome. Clin J Pain 2006;22: Schechter N, Berde C, Yaster M. Pain in Infants, Children, and Adolescents. Philadelphia. Lippincott Williams and Wilkins, 2003, Kemper KJ. The holistic pediatrician: a parent s comprehensive guide to safe and effective therapies for the 25 most common childhood ailments. New York: Harper Perenniel, 1996:408 Rusy L, Hoffman G. Electroacupuncture prophylaxis of postoperative nausea and vomiting following pediatric tonsillectomy with or without adenoidectomy. Anesthesiology 2002;96: Kabalak A. et al. Transcutaneous Electrical Acupoint Stimulation Versus Ondansetron in the Prevention of Postoperative Vomiting Following Pediatric Tonsillectomy. J Alt Comp Med. 2005;11(3): Breuner CC. Complementary medicine in pediatrics: a review of acupuncture, homeopathy, massage, and chiropractic therapies. Current Problems in Pediatric and Adolescent Health Care. 2002;32(10): Davis MP, Darden PM. Use of complementary and alternative medicine by children in the United States. Archives of Pediatrics and Adolescent Medicine. 2003;157(4): Gardiner P, Kemper K. Herbs in Pediatric and Adolescent Medicine. Pediatrics in Review 2000;21;44. 12