AAP Addresses Use of Complementary and Alternative Medicine

News Author: Laurie Barclay, MD
CME Author: Penny Murata, MD

Posted: 12/5/2008

December 5, 2008 — The American Academy of Pediatrics (AAP) has issued a clinical report that addresses the use of complementary and alternative medicine (CAM) in children and has published it in the December issue of Pediatrics.

"The National Center for Complementary and Alternative Medicine (NCCAM) of the National Institutes of Health (NIH) defines...CAM as a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional Western medicine," write Kathi J. Kemper, MD, MPH, and colleagues from the Task Force on Complementary and Alternative Medicine and the Provisional Section on Complementary, Holistic, and Integrative Medicine. "Complementary medicine is used in conjunction with conventional medicine; for example, massage, guided imagery, and acupuncture may be used in addition to analgesic medications to help decrease pain. Alternative medicine is used in place of conventional Western medicine; for example, some adolescents use herbs rather than antidepressant medications to treat depression."

Recognizing the increasing use of CAM in children, the AAP also saw the need to provide information and support for pediatricians regarding this field of practice. From 2000 to 2002, the AAP convened the Task Force on Complementary and Alternative Medicine to address issues related to the pediatric use of CAM and to develop resources to educate clinicians, patients, and families.

The present AAP clinical report describes CAM services, current levels of utilization and costs, and related legal and ethical issues. Given the breadth and range of CAM, the task force concluded that an in-depth review of each modality was beyond the scope of this report.

The aims of the report were therefore to define terms; to review the epidemiology; to list frequently used CAM modalities; to discuss medicolegal, ethical, and research implications; to describe education and training for CAM providers; to offer resources for additional learning regarding CAM; and to suggest communication strategies that clinicians may find helpful when discussing CAM with patients and families.

Now that many CAM modalities, such as guided imagery and massage for pain treatment, have been formally tested and integrated into standard practice, the distinction between CAM and mainstream medicine has become less apparent. The terms holistic medicine or integrative medicine is being increasingly substituted for CAM.

"Holistic medicine refers to patient-centered care that includes consideration of biological, psychological, spiritual, social, and environmental aspects of health," the Task Force writes. "Integrative medicine is relationship-based care that combines mainstream and complementary therapies for which there is some high-quality scientific evidence of safety and effectiveness to promote health for the whole person in the context of his or her family and community. Integrative medicine also reaffirms the importance of the relationship between the practitioner and the patient, emphasizes wellness and the inherent drive toward healing, and focuses on the whole person, using all appropriate therapies to achieve the patient's goals for health and healing."

The Kemper model of holistic care recognizes 4 main components of therapy. Biochemical components include medications, dietary supplements, vitamins, minerals, and herbal remedies. Lifestyle and nutritional interventions include recommendations for exercise and/or rest; environmental therapies including heat, ice, music, vibration, and light; and mind-body treatments such as behavior management, meditation, hypnosis, biofeedback, and counseling.

Biomechanical components include massage and bodywork, chiropractic and osteopathic adjustment, and surgery. Bioenergetic therapies may include acupuncture, radiation therapy, magnets, Reiki, healing touch, qi gong, therapeutic touch, prayer, and homeopathy.

Clinicians caring for children need to advise and counsel patients and their families about appropriate, safe, and effective health services and treatments regardless of whether they are considered mainstream or CAM. Clinicians should specifically ask about all treatments the family is administering to the child because most families use CAM services without spontaneously notifying their clinician.

To provide useful counsel regarding use of CAM and integrating these therapies into the child's treatment plan, pediatricians should stay informed and updated regarding therapeutic options available to their patients. Clinicians should address and counsel their patients' families regarding the safety, appropriateness, and advisability of specific CAM services used by individual patients.

A common-sense approach to advising families regarding use of CAM modalities is that those treatments shown to be safe and effective should be encouraged, those treatments that are safe but ineffective may be tolerated, those modalities that are effective but raise safety issues should be closely monitored or discouraged, and those therapies that are neither safe nor effective should be discouraged.

For patients being treated by a CAM provider, the pediatrician should seek permission of the patient and family to include the CAM provider in the overall management plan.

Helpful communication strategies may include asking about different therapies the patient is using; recognizing and respecting the family's perspectives, values, and cultural beliefs; working together with the parents as a team; and actively listening to families and patients.

The patient's response to treatment should be monitored with use of measurable outcomes, such as specific goals for symptom relief and remembering to "first do no harm."

"A growing number of pediatric generalists and subspecialists have begun to offer complementary therapies and advice as part of their practice," the task force concludes. "In addition, there is a growing number of academic pediatric integrative medicine programs and new initiatives to promote systematic sharing, support, and dissemination of information to improve collaborative and comprehensive care."

All AAP clinical reports automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time. Coauthor Sunita Vohra, MD, has received salary support from the Alberta Heritage Foundation for Medical Research and the Canadian Institutes of Health Research.

Pediatrics. 2008;122:1374-1386.

Clinical Context

CAM is described as a set of medical and healthcare practices that are not currently part of conventional Western medicine, according to the National Center for Complementary and Alternative Medicine of the National Institutes of Health. Complementary medicine is used with conventional medicine, whereas alternative medicine is used instead of conventional medicine.

Newer terms for CAM include holistic medicine to describe patient-centered care involving biological, psychological, spiritual, social, and environmental considerations and integrative medicine to describe relationship-based care combining mainstream and evidence-based complementary treatment.

The AAP convened the Task Force on Complementary and Alternative Medicine in 2000 and the Provisional Section on Complementary, Holistic, and Integrative Medicine in 2005. This report from the task force, with contributions from the provisional section, describes complementary and alternative medicine therapies in children; the medicolegal, ethical, and research issues; education and training for providers; and communication strategies for clinicians to use with patients and families.

Study Highlights

  • CAM is used in 20% to 40% of healthy children and in more than 50% of children with chronic, recurrent, and incurable conditions, including asthma, attention-deficit/hyperactivity disorder, autism, cancer, cerebral palsy, cystic fibrosis, inflammatory bowel disease, and juvenile rheumatoid arthritis.
  • 66% of caregivers did not tell their child's clinician about CAM use.
  • CAM is not consistently linked with parent income, sex, or usual source of care.
  • Reasons for CAM use include word of mouth, effectiveness, fear of drug adverse effects, dissatisfaction with conventional medicine, and more personal attention.
  • Barriers to health insurance coverage of CAM include variable credentialing, accounting issues, and lack of Current Procedural Terminology codes.
  • Dietary supplements do not need proven safety or efficacy for marketing.
  • Biologically based therapies include botanicals, animal-derived extracts, vitamins, minerals, fatty acids, amino acids, proteins, prebiotics, probiotics, whole diets, and functional foods:
    • Multivitamins are the most commonly used in children (up to 41%).
    • Of teenagers using CAM, approximately 75% use dietary supplements and herbs.
    • The ketogenic diet is an accepted treatment of seizure disorder.
    • Quality is affected by portion of plant, time of harvest, handling, and identification.
  • Manipulative and body-based therapies include chiropractic and osteopathic manipulation, massage, reflexology, Rolfing, Bowen technique, and Trager approach:
    • Chiropractors are the most common CAM providers for pediatric patients.
    • Massage is beneficial for preterm infants and alleviates symptoms of asthma, insomnia, colic, cystic fibrosis, and juvenile rheumatoid arthritis.
  • Common mind-body therapies in children are meditation, prayer, hypnosis, biofeedback, and progressive muscle relaxation:
    • Guided imagery, hypnosis, and biofeedback complement medical therapy for pain, anxiety/stress disorders, enuresis, encopresis, sleep disorders, autonomic nervous system dysregulation, habitual disorders, attention/learning disorders, asthma, cancer, and diabetes.
    • Two thirds of parents use prayer for their children.
  • Biofield therapies include acupuncture, homeopathy, polarity therapy, magnet, Japanese Reiki and Johrei, qi gong, therapeutic touch, healing touch, and spiritual healing:
    • Acupuncture is possibly effective for recurrent headaches, nausea, pain, and allergy.
    • 2% to 10% of children use homeopathic therapies for respiratory conditions, teething, or otitis media.
  • Special populations using CAM include adolescents, children with chronic illness or disability, and ethnic and cultural groups.
  • CAM research issues include the more likely publication of negative studies in well-known journals and positive studies in foreign-language journals, heterogeneous products and practices, need for more randomized controlled trials in children, few serious adverse effects in children, and lack of priority listing for children.
  • Pediatric CAM training for providers and clinicians is variable or lacking.
  • Clinicians should understand local and state regulations for CAM provider licensure and specific CAM therapies.
  • Ethical issues include need for evidence-based safety and effectiveness information about CAM therapies and therapists, risk/benefit analysis, respect for patient autonomy, nonmaleficence, beneficence, and justice.
  • Clinicians should routinely ask about specific CAM therapies and stress management; respect the family's values, perspectives, and cultural beliefs; reevaluate treatment if no or negative response; and maintain evidence-based knowledge about CAM therapies.

Pearls for Practice

  • Common types of CAM therapies used in children include multivitamins, herbs and other dietary supplements, chiropractic care, massage, prayer, progressive relaxation exercises, meditation, biofeedback, hypnosis, and acupuncture.
  • Strategies to use in discussing CAM with children and families include routinely asking whether the child uses vitamins, home remedies, or other services and about stress management; showing respect for values and cultural beliefs; reevaluating therapy if the measured outcome to treatment is inadequate; and maintaining knowledge about CAM therapies.