Overview of Complementary, Holistic and Integrative

Medicine Kathi J. Kemper, MD, MPH

Caryl J Guth Chair for Holistic and Integrative Medicine

Professor of Pediatrics, Public Health Sciences, Family and

Community MedicineWake Forest University Health

Sciences

OBJECTIVES. By the end of this session:

1. Name the new provisional Section within the AAP and be able to join.

2. Apply an ethical framework for recommending, avoiding, tolerating or monitoring a therapy

3. Describe a model integrating CAM and mainstream care into 4 major categories

4. List four resources for answering clinical questions about CAM

NIH NCCAM DefinitionComplementary and

alternative medicine (CAM) is a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine. …

Resource: http://nccam.nih.gov/

Resource 1: NIH NCCAM

• Patient information sheets in English and Spanish

• Ongoing research projects/clinical trials

• Education and Training opportunities

http://nccam.nih.gov

NCCAM Clearinghouse:1-888-644-6226

Resource 2: NCI OCCAM

• Health information for patients

http://www.cancer.gov/cam/health_understanding.html

• Clinical trial information• Grant funding for research

projects

Complementary, Alternative and Mainstream Therapies

Alternative Mainstream

Complementary

CAM Use in Kids• 1992-2005, 66 pediatric

utilization studies US, Canada, UK, Australia, Turkey, Norway…

• General and subspecialty populations

• Use increasing

Complementary and Alternative Research and Education Program

Pediatric Epidemiology• Spiegelblatt ’94 Pediatrics ; 11% used prof. CAM• Ottolini, et al, W, DC, ‘98: 20% of kids in 4 practices• Taylor, et al, Seattle, ‘98: 30% -50% use echinacea or

vitamin C for kids’ colds• Indiana teens ‘98: 20-30% of athletes take supplements• Crow, et al. Ped Res, ’03: 46% w/vitamins; 15%

wo/vitamins in Chicago PPRG• Wilson, et al AmbPeds ’02: 53% of Rochester teens • Lin, et al J Clin Anesth ’04: 30% pediatric pre-op pts use

herbs• Breuner APAM ‘98: 70% homeless teens

Children with other conditions

• Autism: 30%; • Asthma: 72%-81% of minority (H and Af.A.) families; • Cancer: 47% of kids at WFUSM in 2003; 73% of kids in

Washington state in 2001; • CF: 65%, mostly prayer• Cerebral palsy: 56% of 235 families in Ann Arbor• ED: 53% used herbs, Atlanta• IBD: 41% of kids in Boston, Detroit, London• Rheumatology: 64% of 141 in Toronto, 2003• Special needs: 24% for kids with correctable condition vs.

76% for kids with non-correctable condition

Which CAM therapies most commonly used?

• Prayer – most common, least worrisome to MDs• Herbal therapies, vitamins, minerals and other dietary

supplements – most worrisome to MDs• Chiropractic – most common professionally provided to

adults; historical competitive threat• Massage – most common professionally provided to kids;

often taught to parents or provided informally• Homeopathy – not well enumerated; confusion with herbs• Yoga, Tai Chi• Acupuncture/acupressure• Biofeedback, hypnosis

What are pediatricians most often asked about CAM?

• Herbs, dietary supplements (67%)• Chiropractic (59%)• Nutrition and special diets, vegetarian,

macrobiotic diets (46%)• Homeopathy (36%)• Therapeutic exercise, yoga (34%)• Hypnosis, biofeedback or meditation

(23%)• Massage or other bodywork (17%) ….• Prayer (13%)

Kemper, O’Connor. Amb Peds, 2004

Only 40% tell docs about CAM• “Natural”, not medical; irrelevant , “not

important for the doctor to know” 61%• Docs not interested; “the doctor never

asked” 60%• “None of the doctor’s business” 31%• “Doctor would not understand” 20%• Cultural practice - embarrassing or private,

<20%• Fear of physician reaction (disapproval,

abandonment, worse medical care) < 15%Eisenberg DM, et al. Arch Intern Med, 2001; 135:

344-51

How do you know what your patients are doing?

• <50% tell• Doctors need to ask!• Give examples• Ask in context (more later

on this)

Holistic

Caring for whole person - body, mind, emotions, spirit, relationships -- in the context of family, culture and community = Contextual pediatrics;

= Patient – centered care

Integrative Medicine

Integrative Medicine is the practice of medicine that reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches, healthcare professionals and disciplines to achieve optimal health and healing.

Consortium of Academic Health Centers for Integrative Medicine, 5/05

Resource 3

• Founded in 2000• Now has over 30 academic health centers• International Conference• Collaborative research• Developing “best practices” models• Education (residency and undergrad)• http://www.imconsortium.org/cahcim/about/

home.html

Resource 4: AAP Provisional Section for Complementary, Holistic, and

Integrative Medicine• Formed 7/05• Dr. Larry Rosen organized

– NYC PIM 10/05; – Pangea in Chicago 10/06

• Dr. Sunita Vohra (CARE) leads PIR reviews; developing questions for ABP; international liaison

• http://www.aap.org/sections/chim/default.htm

AAP ps CHIM continued

• Dr. Richard Walls’ committee approved CPS Statement on Herbs and Supplements

• Dr. Susan Hyman – autism statement• Dr. Joy Weydert – Liaisons • Dr. Hilary McLafferty – newsletter• OJ Sahler – liaison to PAS• Junelle Speller – staffer, web site• TO JOIN, email Junelle: jspeller@aap.org

AAP ps CHIM continued

• NCE 2007 (SF) and beyond presentations– Acupuncture– Herbs and supplements– Nutrition– Massage– Clinical practice, billing, coding, time

management• Collaboration with PAS, TFOMH• TFOCAM report (Periodic survey)

TFOCAM Report

• CAM use is common• Pediatricians need to be aware

of this and ASK about use of all kinds of therapies

• Pediatricians need to coordinate care, continue to learn about diverse therapies

• Ethical approach to treatments

Ethical frameworkEffective

Yes No

Safe Yes Use/Recommend Tolerate

No Monitor closely Advise against

Cohen M. Pediatrics, 2005

Effective? Safe?

– What therapy? – For whom? – For what condition? (cancer,

colds)– Under what circumstances?– For what desired outcome?– When? immediate versus long-

term

Kemper. Arch Dis Child, 2001

Nausea: Does CAM work? Acupuncture

Yes No

Safe Yes Use/Recommend Tolerate

No Monitor closely Advise against

Effective

Chemotherapy for Cancer

Yes No

Safe Yes Use/Recommend Tolerate

No Monitor closely Advise against

Cohen M. Pediatrics, 2005

Effective

Chicken soup for colds

Yes No/Unknown

Safe Yes Use/Recommend Tolerate

No Monitor closely Advise against

Cohen M. Pediatrics, 2005

Effective

Surgery for Common Cold

Yes No/Unknown

Safe Yes Use/Recommend Tolerate

No Monitor closely Advise against

Cohen M. Pediatrics, 2005

Effective

TRUE/FALSE

Patients’ only goals are to cure disease, reduce symptoms and prevent serious illness or injury. If you can do that, you’re done!

What’s the desired outcome?

• Patients may have more than one goal

• Non-articulated goals are often as important as spoken goals

• Patients/families may have goals they aren’t consciously aware of

Goals for Healing

YANG-type/ Specific

Cure

Manage symptoms

Prevent specific disease

Reduce or manage specific toxin

YIN-type/Global, unstated

Connection/Support/

Trust

Meaning/Transcendence

Harmony

Peace

Well-being/ Resilience

Reduce dependence

Models for Treatment

TreatmentDisease inOrgan orTissue

SymptomsQOL

Well-being

Treatment PersonPeace

ConnectionTrust

Harmony

Symptoms or

Disease

PrimarySecondary

PrimarySecondary

B

Yang

Yin

How (not) to ask

“You’re not using any alternative medicines, are you?”

Using written checklists that don’t include common alternatives.

Failing to provide examples.

Colic Case

You are in clinic seeing a tired-appearing mother with her one month old infant who will not stop screaming. After performing a careful history and physical, you diagnose colic.

What do you ask?

A. You haven’t tried any CAM therapies, have you?

B. Have you given your baby any medicine?

C. Mothers of babies who cry a lot try many different things to help, such as rides in the car, bouncy seats, Mylicon, Tylenol, homeopathy, chamomile, prayer, tummy rubs, changing formulas, homeopathy and other things. What have YOU tried so far? And how has that worked?

The Mother asks

I was in the grocery store last week and saw these

HOMEOPATHIC colic tablets. What do you think

about homeopathy for colic?

The highly educated physician responds…..

I know that many homeopathic products are marketed for children, but actually none has undergone any randomized, controlled clinical trials except for some 3rd world studies on diarrhea and one early study on otitis media. You’d probably just be wasting your money or doing an uncontrolled experiment, using your baby as a guinea pig.

The confused mother replies…

Well, actually, since it was so cheap and it was right there and everything, I bought it and gave it. It settled the baby right down, and I’ve tried it a couple of times since then and it works great. I just wanted to know if you thought it was safe and if you had any particular brands you recommend.

Lesson 1: THE TWO MOST IMPORTANT

QUESTIONS IN CLINICAL MEDICINE:

– What have you tried so far (give examples)?

– How has that worked? (Do NOT give your opinion until you hear theirs)

Case 2

A 13 year old recently diagnosed with osteogenic sarcoma says she’s having trouble sleeping. She doesn’t want any more meds.

The teenager asks

I just don’t want any more meds, but I do want to get some

sleep. I’ve heard that valerian and kava kava may be helpful. What do you think? I might go

on-line to find out.

Have you already gone on line?

What have you learned so far?Have you brought any printouts with

you?Have you tried any products so far?

Do you have any with you?I’d like to see them and check them out.

Please bring everything you take for your health so I can see it and write it

down accurately for your records.

More resources:

• MD Anderson Cancer Center: http://www.mdanderson.org/departments/CIMER/

Natural Standard Review: Kava

Memorial Sloan Ketteringhttp://www.mskcc.org/mskcc/html/11570.

cfm

The girls responds

Yes, I’ve brought some valerian and kava kava, but I haven’t started taking them yet, because I wanted to ask your opinion first. Do they work?

The knowledgeable clinician responds,

Several randomized controlled trials in adults have shown that valerian, 400 mg before bed, can help reduce sleep latency, that’s the time it takes to fall asleep. And it doesn’t seem to cause a morning hangover. It appears to be safe, but then again, herbal products aren’t well regulated, so you may just be wasting your money. Valerian smells like sweaty gym socks, so if you do decide to try it, make sure you’ve got a really smelly product to ensure you’ve got one that has the active compound.

And responds some more

Now kava kava is an herb that’s been used in Polynesia for a long time, mostly for social occasions, kind of the way wine is used in Europe and the US. If you take it three times a day every day for three weeks, it can significantly improve anxiety that may be affecting your sleep. However, there are several recent reports of serious hepatotoxicity with kava, so if you decide to take it, we have to monitor your liver function very closely. Any questions?

The impressed teen replies,

Well, actually my mom thought it might be helpful just to take a hot bath and have a glass of milk or a turkey sandwich before bed. And my grandmother told me I should pray and count my blessings. What do you think about that?

Lesson: Be systematicDo not jump in with an answer until you have assessed ALL the

therapies of interest

• Efficient

• Comprehensive; avoid missing the key

• Example: differential diagnosis; organ system approach in ICU

Integrative Approach

• Biochemical• Lifestyle• Biomechanical• Bioenergetic

Biochemical

• Medications• Dietary Supplements,

such as herbs, vitamins, minerals, glucosamine, etc.

Be specific

Do YOU use herbs regularly, ie. 4 or more days a week?

Be persistent; give sound advice

• Don’t stop at the first positive answer

• Don’t stop at the first denial; give examples that fit the clinical situation

• Discourage use of remedies KNOWN to have high risks, e.g. aristolochic acid, Patent Medicines from China, herbs imported from developing countries

More Resources on Herbs and Dietary Supplements

• Natural Medicines Comprehensive Database: http://www.naturaldatabase.com/

• ConsumerLabs: http://www.consumerlab.com/ • Natural Standard

http://www.naturalstandard.com/• NIH NCCAM and OCCAM• http://www.nlm.nih.gov/medlineplus/

druginformation.html• MedLinePlus:

http://www.nlm.nih.gov/medlineplus/druginformation.html

NIH Office of Dietary Supplements http://ods.od.nih.gov/factsheets/Diet

arySupplements.asp

Lifestyle

• Nutrition, Diet, Habits to avoid (tobacco, xs EtOH, drugs)

• Exercise and Rest• Mind-Body Therapies• Environment

Environment

• No smoking; Clean house; lead, allergens, air filters

• Minimize exposure to sick people

• Read; Avoid guns• Heat, cold, mist, sound,

magnets, color, phototherapy, etc.

Mind-Body Therapies

• Hypnosis• Guided imagery• Meditation• Journaling• Social Support• Psychological

counseling• Peer support

Biomechanical

• Surgery• Massage and bodywork• Cranial, spinal or joint

adjustment

Bioenergetic• Acupuncture• Healing

Touch/TT/Reiki/Qi Gung

• Prayer/Spirituality• Homeopathy

ACUPUNCTURE

• Licensed in 43 states• NIH strong evidence – post-op

nausea and dental pain; promising for many other kinds of pain; JAMA– turn breech babies?

• http://nccam.nih.gov/health/acupuncture/

Non-contact healing

HOMEOPATHY

• Like cures like• Law of dilutions• Licensed in only 2 states• Most is OTC• Few pediatric studies –

diarrhea; otitis media; allergies

Integrative Medicine Model

Biochemical Lifestyle

BiomechanicalBioenergetic

Patient

Remember:

• Ask

• Give examples when you ask

• Ask systematically – biochemical, lifestyle, biomechanical, bioenergetic

• Consider using self-administered questionnaires

Remember your ethical framework for advice

Effective

Yes No

Safe Yes Use/Recommend Tolerate

No Monitor closely Advise against

Remember your resources

• AAP• NIH NCCAM• NIH NLM Medline Plus• Natural Standard, NMCD,

ConsumerLabs• Academic Centers• Professional Journals (PIR,

Contemporary Pediatrics)

Opportunities for fellowship training

• CARE (Edmonton, Alberta)• http://www.care.ualberta.ca/ • University of Arizona

(Tucson) – not pediatric oriented, but many pediatricians have done it.

http://www.integrativemedicine.arizona.edu/index.html

Complementary and Alternative Research and

Education Program

A Short History of Medicine2000 B.C. Here, eat this root1000 A.D. That root is heathen. Here, say this prayer.1850 A.D. That prayer is superstition. Here, drink this potion.1940 A.D. That potion is snake oil. Here, swallow this pill.1985 A.D. That pill is ineffective. Here, take this antibiotic.2000 A.D. That antibiotic is artificial. Here, eat this root.