Integrative Pediatrics

Art, Science, and Clinical Application

Hilary McClafferty

• Editorial: Routledge
• Año: 2017
• ISBN:
  9781315353944
• Edición: 1
• Categoría: Médecine
• Categoría: Pédiatrie

Pediatric integrative medicine is a rapidly evolving field with great potential to improve the quality of preventive health in children and expand treatment options for children living with chronic disease. Many families actively use integrative therapies making familiarity with the field essential for clinicians working with pediatrics patients.

This book provides a clear, evidence-based overview of the field. Foundations of pediatric health are covered with a goal of reviewing classic information and introducing emerging research in areas such as nutrition science, physical activity and mind-body therapies. Complementary medicine therapies are reviewed with an eye to expanding the conventionally trained clinician's awareness about traditional healing approaches. Clinical applications explored include:

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• Allergy

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• Asthma

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• Mental health

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• IBS

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• Bullying

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• Obesity

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• Environmental health

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• ADHD

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• Autism

The book provides an excellent introduction to a relatively young field and will help the reader understand the scope of current evidence for integrative therapies in children and how to introduce integrative concepts into clinical practice. Integrative Pediatrics is a refreshing must-read for all students and health professionals focused on pediatrics, especially those new to the field or studying at graduate level.

Part 1

Integrative Medicine: A New Frontier in Pediatrics

1	Introduction to Pediatric Integrative Medicine

Children are born with a natural capacity to thrive, ideally supported by parents who provide food, shelter, companionship, education, and unconditional love. The clinician’s role has historically been that of trusted guide and dedicated child advocate in the medical arena. Rapid changes in the business of medicine and an emphasis on productivity over patient-centered care have stripped pediatric practice of some of its richness, resulting in a lost sense of collaboration for many clinicians. Parents have been similarly affected by the “commercialization” of medicine and seek a deeper connection with providers who can deliver more personalized care, expanded treatment options, and accurate information about emerging therapies that may improve their child’s health. Pediatric integrative medicine can serve to reconnect clinician, child, and parent and can be defined as a modern approach to children’s health in that it respects the strengths of conventional medicine while embracing emerging research in preventive health and management of chronic illness. The field includes topics such as nutrition, physical activity, sleep, stress management, mental health, environmental influences, and social relationships across every stage of development. One of the newest concepts in the field is inter-professionalism, which emphasizes the value of an interdisciplinary team approach. The practice of pediatric integrative medicine has potential to bring the heart back to pediatric practice by creating a child-centered model of care, infusing the medical encounter with forward looking, evidence-based therapies, and prioritizing health across the lifespan.

Some of the principles of integrative medicine practice include:

• Emphasis on preventative health and lifestyle

• Support of the individual’s innate healing response

• Focus on the therapeutic relationship between patient, family, and clinician

• Consideration of health in all dimensions (body, mind, and spirit)

• Family-centered care

• Cultural competency

• Use of all appropriate evidence-based therapies

(Maizes, Rakel, and Niemiec 2009)

These principles are well aligned with the medical home model and will hopefully pave the way for creation of an “integrative medical home,” a model that places whole childcare squarely in the mainstream of healthcare.

Historically, expansion of the field of integrative medicine has been hampered by those preying on the fears of parents willing to accept any therapy, no matter how unscientific, in the effort to help their child. A guiding principle of this book will be to convey a balanced approach to the field and to stress the importance of evidence-based therapies. The goal is to raise awareness about the field of integrative pediatrics and its enormous potential to improve healthcare for children. The title of the book reflects three important elements that together can help clinicians maximize whole child health. These include: the art of medicine practiced with compassion and awareness, a firm foundation of scientific evidence, and the skillful clinical application of all appropriate therapies. When combined, these elements exceed the sum of their parts and describe a modern approach to pediatrics that blends appropriate conventional and complementary therapies in a child-centered model with the potential to optimize children’s health from preconception through adulthood.

What’s in a Name?

As the field of integrative medicine has evolved, the language used to define it has adapted accordingly. Here the term integrative will be used to reflect an evidence-based blending of conventional and complementary approaches. Popularity of the term complementary and alternative therapy (CAM) is waning as concerns have mounted about the lack of evidence underpinning alternative therapies, defined as treatments used in place of conventional medicine. This change is reflected in the name change of the former National Center for Complementary and Alternative Medicine (NCCAM) to the National Center for Complementary and Integrative Health (NCCIH) in 2014 (National Institutes of Health 2014; NCCIH 2014).

The following example compares conventional, complementary, integrative, and alternative approaches in a child with migraine headache.

Examples of Treatment Approaches for an Adolescent with Migraine Headache

• Conventional: Traditional history and physical by an MD or DO, prescription medication as needed, comprehensive physical once per year, ‘sick’ visits as needed, hospital admission if necessary.

• Complementary: “Complements” conventional treatment. May include nutrition counseling, judicious use of dietary supplements such as butterbur, vitamin D, and omega-3 fatty acids, mind–body therapies such as guided imagery, yoga, clinical hypnosis, or biofeedback, probiotics, and bioenergetics treatments such as acupuncture.

• Integrative: Emphasis on preventive health, conventional treatment as needed, evidence-based complementary therapies as appropriate. In the integrative model, complementary therapies might be appropriately used alone, but openness to blending both conventional and evidence-based complementary therapies for the highest benefit of the patient is the overarching theme. This approach might include dietary review, possible symptom-driven elimination diet, stress management skills, and counseling on sleep and environmental triggers. All evidence-based therapies would be considered.

• Alternative: Alternative medicine refers to use of non-evidence-based therapies in place of conventional medicine. This approach will not be covered in this text.

Functional medicine is an emerging field primarily based on molecular biology and metabolic pathways with an emphasis on laboratory testing and use of replacement supplements. There is currently a relative paucity of evidence supporting this approach in pediatrics, and for this reason functional medicine will not be covered in detail in this work. Research is active in this field and will be important for pediatricians and others caring for children to follow.

Table 1.1 National Center for Complementary and Integrative Health Classifications

Practice	Examples
Whole medical systems	Homeopathy, naturopathy, Ayurveda, traditional Chinese medicine
Mind–body medicine	Meditation, prayer, mental healing, creative therapy (art, music, dance)
Biologically based practices	Dietary supplements, botanical medicine
Manipulative and body-based practices	Chiropractic, osteopathy, massage
Energy therapies	Biofield therapies (Qi gong, reiki, therapeutic touch), Bioelectromagnetics (electromagnetic fields)

Many integrative therapies that have been gradually accepted into the Western biomedical model originated in long-established cultural healing traditions. A lack of standardized definitions associated with this rich history can create challenges to clear communication among conventionally trained health professionals. One approach historically used is the NIH NCCIH classification developed by the former NCCAM Advisory Board, noted in Table 1.1. This approach has recently been updated and streamlined to include three main categories: mind and body practices, natural products, and other complementary health approaches (https://nccih.nih.gov/health/integrative-health#types).

Organization and Overview

The main categories of integrative medicine discussed in the text include those with the current strongest evidence in children. Part 1 includes an overview of the field, and introduces the topic of clinician self-care and its important influence on patient outcome. Part 2 covers the foundations of healthy lifestyle habits in pediatrics including:

• Nutrition

• Selected dietary supplements

• Physical activity

• Mind–body therapies, spirituality in medicine

• Sleep

• Environmental health

Part 3 covers evidence-based complementary therapies including:

• Botanicals

• Manual medicine (therapeutic massage, osteopathy, craniosacral therapy)

• Aromatherapy

• Homeopathy

• Whole medical systems (traditional Chinese medicine, naturopathy)

• Bioenergetic therapies (acupuncture, therapeutic touch, healing touch)

Part 4 covers integrative approaches to a variety of common pediatric conditions in the areas of:

• Preventive care

• Allergy and asthma

• Dermatology

• Gastroenterology

• Infectious disease (URI and otitis media)

• Mental health

• Neurodevelopmental disorders

• Obesity and metabolic disorders

• Integrative intake

Why Do Parents Use Integrative Medicine for their Children?

Reasons for the use of integrative medicine vary and can include a desire to support the child’s natural healing process, a wish to explore all treatment options, preference for less invasive treatments, and reduction of pain, stress, and suffering. An increased range of cost-effective treatment options, cultural preference, and lack of access to conventional care may be other important reasons. Integrative medicine holds special potential to improve care in children by expanding treatment options, introducing new approaches to chronic conditions and prioritizing health and wellness from preconception through adulthood.

Why is Pediatric Integrative Medicine Relevant to Modern Pediatric Practice?

The use of integrative therapies is high in children and in adolescents, requiring awareness on the part of all practitioners caring for these patients. Data from the 2012 National Health Interview Survey (NHIS) found that nearly 12% of children used complementary therapies in the prior year (about one in nine), similar to the overall prevalence recorded in the 2007 NHIS survey. Prevalence increases to approximately 50% in children living with a chronic illness (Black et al. 2015).

Dietary supplements (other than vitamins and minerals) were again the most commonly used approaches. The 2012 survey showed an increase from 3.9% in 2007 to 4.9% of children using dietary supplements, and a significant increase in pediatric use of yoga, fish oil, and melatonin. Therapies used most frequently were reported as natural products (3.9%), chiropractic and osteopathic (2.8%), deep breathing (2.2%), yoga (2.1%), homeopathy (1.3%), traditional healers (1.1%), massage (1.0%), diet-based therapies (0.8%), and progressive relaxation (0.5%). Use remained higher in children whose parents had also used complementary or alternative therapies, in children with more than one health condition, and in children who did not use, or whose families could not afford, conventional care. Fish oil was the most commonly used supplement in 2012, as compared to echinacea in 2007. Melatonin was the second most commonly used supplement in 2012.The conditions where complementary therapies were most commonly used remained constant from 2007 and included back or neck pain (6.7%), head or chest cold (6.6%), anxiety/stress (4.8%), other types of musculoskeletal conditions (4.2%), ADHD (2.5%), and insomnia (1.8%) (Barnes, Bloom, and Nahin 2008; NCCIH 2012).

What do the Statistics Imply?

High prevalence of use of integrative and complementary therapies reinforces the need for pediatricians and other practitioners caring for children to be current on research in integrative medicine and familiar with reliable sources of information to best serve the needs of their patients. The statistics also suggest that children and their families, especially children living with chronic illness, may not be fully served in the conventional health model. Many turn to integrative therapies to fill the gap, citing concerns about medication side effects and lack of access to care that is consistent with their values (Birdee et al. 2010).

The relatively high use of integrative medicine in the pediatric population often goes unrecognized, in part because of low disclosure rates (less than 50% ...