Alternative medicine guidelines get an update

Pediatricians need to know what alternative treatments their patients are receiving, and need to start asking parents about complementary medicine without judgment, according to a new clinical report from the American Academy of Pediatrics’ (AAP) Section on Integrative Medicine.

“The primary takeaway is the importance of clinicians being well informed. The reality is that many families are using complementary medicine, yet they hesitate to discuss this with their child's clinician for fear of censure or even ridicule,” says lead author Hilary McClafferty, MD, FAAP, associate professor in the department of medicine, co-director of the fellowship in Integrative Medicine, and director of Pediatric Integrative Medicine in Residency at the University of Arizona College of Medicine, Tucson. “A well informed clinician can steer the family towards safe and effective therapies, both conventional and complementary, and help prevent unwanted or unintended treatment interactions.”

Complementary and alternative medicine (CAM) can include a variety of approaches, but is defined as evidence-based therapies developed outside of conventional Western medicine,. Few medical schools teach this approach, with the AAP report referencing just 16 out of 143 pediatric medicine programs teaching integrative medicine. Yet parents are using these therapies, with an estimated 12% of children aged younger than 18 years using some form of CAM, according to statistics from the 2012 National Health Interview Study. Additionally, the study revealed that parents spent nearly $2 billion on CAM for their children in 2012, accounting for 9.2% of out-of-pocket healthcare costs for that year.

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Complementary medicine is most often used to promote general wellbeing rather than to treat specific conditions, but it is often utilized for back or neck pain, colds, musculoskeletal conditions, anxiety or stress, and for the treatment of attention-deficit/hyperactivity disorders. Treatments can come in the form of vitamins and herbal or dietary supplements, or physical therapies like chiropractic care and yoga.

Complementary medicine use is particularly popular in children with chronic illness. More than half of children with chronic illness receive some sort of complementary therapy, and usage increases when multiple conditions are present.

Teenagers are the age group most likely to use complementary therapies. While teenagers with chronic conditions embrace these therapies, adolescents also use complementary medicine for weight loss, to increase energy, or to improve athletic performance. Supplements used may include ginseng, zinc, Echinacea, gingko, weight loss supplements, and creatine.

Children of parents who use complementary medicine for themselves are more likely to be offered these therapies, as well. Other predictors of complementary medicine use include parents with higher education levels and income, living in the Western United States, and having a high number of physician visits in the preceding year. Parents are willing to disclose CAM use when patient-centered communication is in place with their practitioner and if the clinician specifically asks.

Although usage rates of complementary medicine among minorities are low, it may be a matter of underreporting rather than low use.

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“Complementary medicine use among children may be underreported because certain ethnic populations are less likely to disclose the use of these practices to their providers, the report notes. “This may be in part because many cultures do not see their indigenous practices as ‘complementary;’ rather, they are viewed as traditional approaches to health and healthcare indigenous to their culture.”

There is also a high prevalence of CAM use among patients who delay traditional treatments for financial reasons.

Physicians are on board with the idea of complementary medicine use, but don’t know enough about it to offer good information. A 2001 study by AAP revealed that 72.8% of pediatricians wanted to provide patients information about complementary therapies, but reported having little or no knowledge about the many options. More than a third of the physicians polled in that study reported personally using some type of complementary medicine such as massage, chiropractic care, spiritual healing, or acupuncture.

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There are many uses in pediatric specialties and general practice for integrative medicine, McClafferty says.

“Integrative medicine emphasizes preventive health, so early counseling on nutrition, physical activity, and effective stress management are easy places to start. An emphasis on self-efficacy and self-regulation skills is another focus, and this provides a rich opportunity to introduce some of the evidence-based mind-body therapies,” she says.

In addition to the clinical report, McClafferty says the AAP Section on Integrative Medicine also published guidance on Mind-Body Therapies in Children and Youth in 2016 that provides clinicians with resources on therapies such as biofeedback, clinical hypnosis, guided imagery, yoga, mindfulness, and mindfulness based stress reduction. “An example of its use in the clinical setting might include introduction of gut-directed hypnotherapy for a child with irritable bowel syndrome. There is good supporting data for this, it encourages a child’s participation in their health and healing, is cost-effective, gentle, and non-invasive,” McClafferty says. “It is important to remember that most complementary therapies are used in conjunction with conventional medicine-to support an approach to the child that covers all elements of their health and well-being.”

Benefits of integrative medicine in pediatrics include its emphasis on preventive health, healthy nutrition, effective stress management, and attention to the full scope of the factors that influence a child’s well-being, McClafferty adds. “Many therapies help children and families cultivate self-efficacy, and are gentle, non-invasive, and non-pharmacologic. Benefits also include the fact that most therapies can and are used in conjunction with conventional care, and may help the child with the stress, pain, and fear that often accompany medical treatment."

The clinical report goes on to detail some of the most popular supplements and therapies used in children and teenagers, as well as safety guidance. Although support for the role of complementary therapies in traditional medicine is growing, the report notes that there is still more work and research to be done. Pediatricians agree that they should be the one to discuss alternative medicine with patients, but the report illustrates that this can only happen through open communication and regular inquiries about complementary medicine use by the clinician. Clinicians may have to do their own research and seek out information to provide their patients with the best guidance, but the wealth of courses and clinical resources available to providers is growing. The key to talking to patients about alternative medicine is to ask questions about CAM use; respect the family’s culture and values in regard to alternative therapies; monitor the the patient’s response and outcomes; and receive and disseminate education and evidence-based information about the various therapies that are recommended and available.

McClafferty says she hopes the report will raise awareness of the potential to expand treatment options for children in a safe, evidence-based manner, and that pediatricians will benefit from the report’s updated research and safety guidelines.