2. • Interest in complementary and alternative medicine (CAM) has
increased significantly
• The Cochrane Collaboration describes CAM as “a broad domain of
healing resources that encompasses all health systems, modalities
and practices and their accompanying theories and beliefs, other
than those intrinsic to the politically dominant health systems in a
particular society or culture in a given historical period”
• As of 1997, 64% of United States medical schools included elective
or required CAM courses.
• Between 1994 and 2010, the number of CAM practitioners in the
United States is projected to increase by 88%, and the number of
conventional physicians who incorporate CAM into their practices
will increase by 16%
3. • The National Institutes of Health established the Office of
Alternative Medicine in 1993.
• In 1998, this agency was elevated to the level of a center
and renamed the National Center for Complementary
and Alternative Medicine (NCCAM), with the mission of
sponsoring research in the various CAM fields.
• The NCCAM research budget increased from $2 million
in 1993 to $68.7 million in 2000
4. • Adolescent use of CAM ranges from 10% to 70%,
depending on where the adolescent lives or what illness
he/she has.
• CAM use is considerably higher in specific groups of
children and adolescents, such as those who have cystic
fibrosis, cancer, or arthritis, and in those undergoing
surgery.
• Guidelines on CAM use have been published by the
American Academy of Pediatrics Committee on Children
with Disabilities
5. • According to a 2001 study, although most parents in the Washington
D.C. area reported being satisfied with their children's conventional
medical care, 21% had treated their children and adolescents with
some form of CAM; vitamins, herbs, supplements, and dietary
modifications were the most common treatments reported.
• A separate study reported that 81% of parents indicated that they
would have liked to discuss CAM with their pediatricians, although
only 36% had done so.
• Pediatric pain management centers in the United States and Canada
that offer CAM use biofeedback (63%), imagery (60%), relaxation
therapy (60%), massage (49%), hypnosis (44%), meditation (44%)
and acupuncture (40%).
• Primary care providers are resources for advice and
recommendations about using CAM. Many adult and pediatric
primary care providers maintain an open attitude toward CAM, make
referrals to CAM providers, and use CAM themselves.
6. “ La principal obligación de cada nueva era es
formar a los nuevos hombres para que
establezcan sus libertades, logren el éxito
material y así rompan los candados y cadenas
oxidadas de las costumbres muertas que evitan
el crecimiento próspero. ¡Es posible que las
teorías e ideas que para nuestros antepasados
representaron vida, esperanza y libertad sean
ahora, para nosotros, destrucción, esclavitud y
deshonor¡” ASL
7. ACUPUNCTURE
• Acupuncture has increased in popularity and is used extensively in
adults and children.
• Recent studies have shown that between 1990 and 1997, a large
proportion of the population paid out-of-pocket for acupuncture.
• Approximately 11,000 acupuncturists are licensed in the United
States.
• A review of pain treatment services at North American children's
hospitals reported that one third offered acupuncture services.
8. • In 1997, a National Institutes of Health consensus conference concluded
that acupuncture was effective for treating certain types of pain in adults,
such as dental pain, migraine headaches, back pain, and dysmenorrhea.
• The conference also concluded that acupuncture was effective in treating
adult postoperative and chemotherapy-related nausea and vomiting, and
would probably be effective for nausea associated with pregnancy
• Postoperative nausea or vomiting (PONV) remains one of the most common
side effects in children and adolescents after outpatient surgery.
• Much has been reported about the effectiveness of acupuncture at the P6
point for adult PONV and chemotherapeutic nausea.
• One study indicated that laser stimulation of P6 in children undergoing eye
muscle surgery decreases the incidence of PONV.
• A separate study did not show a decrease in PONV in tonsillectomy
subjects or after strabismus surgery. A study of acupressure versus
acupuncture in a pediatric population undergoing tonsillectomy showed no
diminution of PONV in either group
9. • One study looked at the usefulness of acupuncture for
upper respiratory infections (URI); acupressure at a
nasal point was not statistically significantly better than a
control when looking at nasal airway resistance scores,
although the subjective sensation of symptoms improved
significantly.
• In an observational study of 46 infants treated with mild
moxibustion over acupuncture points, there was a slight
reduction in symptoms, including rhinorrhea, fever, and
sore throat.
10. • In one small crossover study, acupuncture may be
helpful in treating sickle crisis pain.
• Ten subjects who had sickle cell anemia received either
acupuncture point or sham site treatments during 16
painful crises in two extremities.
• In 15 of these 16 cases, equal pain relief was obtained
by subjects receiving sham or real acupuncture.
• The conclusion was that needling of either acupuncture
or sham site may be an effective tool for pain relief.
11. • Acupuncture and hypnotherapy were compared in one study looking
at chronic pain in children. Thirty-one children received
acupuncture, along with a 20-minute hypnotherapy session, over a
6-week period of time.
• Reports of pain-associated disability (in physical activity and social
interactions) from subjects and parents and the subjects' pain
ratings were assessed before and after each of the six weekly
sessions.
• The study subjects experienced an average 46% reduction in pain
and a 32% reduction in pain-related disability. This study was limited
in that acupuncture and hypnotherapy were not evaluated
individually, and there was no control group.
12. • When perceived efficacy and acceptance of acupuncture in 47 pediatric
subjects was reviewed, it was found that 70% of subjects (average age 16,
79% female) reported that the treatments helped the symptoms, and 67%
rated the therapies as pleasant.
• The predominant problems presenting in this population were migraines,
endometriosis, and reflex sympathetic dystrophy.
• Helms compared real acupuncture, placebo acupuncture, weekly MD visits,
and no treatment in 43 women who had primary dysmenorrhea.
• After 1 year, improvement was seen in 90.9% (10/11) of the real
acupuncture group. Pain relief was noted in 36.4% (4/11) of the placebo
acupuncture group. In the no-treatment group, pain improvement was noted
in 18.2% (2/11). Only 10% (1/10) experienced pain relief in the physician
visit only group.
• Analgesic medication use was reduced by 41% in the real acupuncture
group, with no change or increased use of medication in the other groups.
13. • A recent Cochrane review of 26 trials supported the use of
acupuncture for headache.
• For tension headaches, a single case design study compared true
with sham acupuncture in 14 subjects; no significant difference was
noted in this study, although there was a trend toward reduction in
pain scores in those who received true acupuncture.
• Acupuncture can provide relief for depression, as noted in a study of
adult women. Thirty-eight women were assigned randomly to one of
three groups: (1) “specific to depression” acupuncture; (2)
“nonspecific to depression” acupuncture; and (3) wait list.
• Those who received specific acupuncture treatments improved
significantly more than those who received nonspecific acupuncture
treatments, and slightly more that those on the wait list
14. • In the United States, acupuncture is a treatment option for those
with a diagnosis of substance abuse.
• Two adult studies, one of chronic alcoholics and the other of illegal
substance abusers, reported more abstinence in those groups that
received acupuncture as an adjunctive treatment. However, in a
randomized, single-blind, controlled study looking at cocaine
addiction, acupuncture was no more effective than a sham needle
insertion or relaxation training in reducing cocaine use.
• Acupuncture has been evaluated as a possible treatment option for
other conditions.
• Laser acupuncture, more applicable to adults than to children, has
unpublished pilot data for attention deficit hyperactivity disorder
(ADHD).
• Multiple studies have looked at the effect of acupuncture on
nocturnal enuresis in children, some with promising results
15. COMPLICATIONS
• Acupuncture has lower adverse effects than many drugs
used for similar.
• The single death reported from acupuncture was caused
by toxic shock syndrome.
• In a prospective study involving 32,000 acupuncture
treatments, only 11 serious adverse events occurred,
including pneumothorax, angina, septic sacroiliitis, and
epidural and temporomandibular abscess.
• These occurred at a rate of 684 adverse events per
10,000 treatments.
• Ernst revealed the most common adverse effects from
acupuncture to be pain, fatigue, and bleeding. More
adverse events may occur when those performing
acupuncture are poorly trained, as reported in a
Japanese paper
16. • Hippocrates wrote, “The physician must be experienced in many
things, most especially in rubbing”.
• The western world has become knowledgeable in massage therapy
only recently, although touch therapies, such as those practiced in
China and in Indian Ayurvedic medicine, have a long and renowned
history.
• Massage therapy may release muscle tension, remove toxic
metabolites, and facilitate oxygen transport to cells and tissues.
• The four different massage therapy techniques include: traditional
European or Swedish massage , performed on a massage table or
chair, which is the most common; sports massage, which is deep-
muscle or deep-tissue massage; body work, which integrates
movement and structure, and uses deep-tissue massage to correct
posture problems and movement imbalances; and reflexology, an
energy form of massage, which focuses on the hands, feet and
ears.
MASSAGE
17. RESEARCH EVIDENCE
• Numerous studies have looked at the efficacy of massage in children and
adolescents. In a benchmark study, 20 preterm infants who received
massage therapy gained 47% more weight, became more socially
responsive, and were discharged 6 days earlier at a hospital cost savings of
$3,000 per infant, in comparison with 20 matched controls.
• In another study, 24 children and adolescents who had diabetes were
assigned to receive either massage or relaxation therapy. Over a 30-day
period, mean blood glucose decreased from 159 to 118 in the massage
group. In a study of pediatric asthma, 32 subjects were assigned randomly
to receive either massage or relaxation therapy. Forced expiratory flow
improved from 25% to 75% in those who received massage.
• The younger population who received massage therapy showed an
immediate decrease in behavioral anxiety and cortisol levels after massage,
and the older subjects reported lower anxiety after the massage. A
Cochrane review of three randomized control trials in adults and children
produced insufficient evidence in favor of, or opposed to, massage for
asthma.
•
18. • One study showed that children and adolescents who had mild to
moderate juvenile rheumatoid arthritis, massaged daily by their
parents, had less anxiety, pain, and lower stress hormone levels
over a 30-day period.
• In atopic dermatitis, affect and activity levels improved after
massage therapy, as did skin redness, lichenification, excoriation,
and pruritus.
• Cystic fibrosis patients may also benefit from massage therapy. For
children and adolescents who are depressed, massaged patients
have reported less anxiety and had lower saliva cortisol levels.
• Massage may be helpful in a variety of medical conditions. Different
studies have shown that massage may also enhance attempts at
smoking cessation.
• A study of adult gay men showed that massage may improve the
numbers of natural killer T cells.
• Eating disorder patients seem to be affected positively by the
addition of massage therapy to their treatment regimens.
•
19. • Massage and aquatherapy were used by approximately 25% of 213
pediatric cerebral palsy subjects seen in the University of Michigan
rehabilitation medical clinic.
• Spasticity and muscle tightness were the most commonly cited reasons for
which families of these patients sought CAM. Similarly, a survey conducted
by the University of Arizona revealed that, of 376 children seen at a facility
serving those with special health care needs, those who had cerebral palsy
and spina bifida were the most likely to seek out physical manipulation that
included massage.
• In one study of pain treatment in adults with cerebral palsy, out of 19 pain
interventions listed, only massage and a hip dislocation procedure were
rated as optimally helpful.
• In the one trial of massage in children who had cerebral palsy, 20 children
were randomized to either massage or to the attention control of being read
to by an adult for 30 minutes twice weekly for 12 weeks.
• Conclusions were that massage decreased spasticity, and improved muscle
tone, range of motion, cognition, fine and gross motor skills, and social
functioning.
20. • Four randomized, controlled, clinical trials have been conducted in which
massage was tested as a monotherapy for low back pain.
• A meta-analysis of these studies concluded that methodological flaws
existed in all of the trials and that too few trials of massage therapy exist for
a reliable evaluation of its efficacy. However, massage does seem to be an
effective therapy for low back pain.
• In depressed adolescent mothers and in their infants, massage improved
the mothers' moods, enhanced parent–child interactions, and had fewer
reported pediatric complications.
• Infants of depressed mothers were randomized to receive either an
intervention, conducted from 3 to 6 months, consisting of free daycare for
the infants, and a rehab program (social, educational, and vocational) plus
several mood induction interventions for the mothers, including relaxation
therapy, music mood induction, massage therapy, or mother–infant
interaction coaching. Although the mothers who received the intervention
continued to have more depressive symptoms than the nondepressed
mothers, their interactions improved significantly and their biochemical
values and vagal tone normalized.
•
21. • Their infants also showed more positive
interactions, better growth, fewer pediatric
complications, and normalized biochemical
values, and by 12 months their mental and
motor scores were better than those of the
infants in the control group.
COMPLICATIONS
• None reported
22. YOGA
• Yoga, around for centuries, was developed in India as a spiritual, mental,
and physical practice.
• Originally made popular in the western world in the 1960s, interest waned
until its recent reemergence as a form of healing and mindfulness. The many
different types of yoga include: bhakti, a practice of devotion; guru, which
involves the dedication to a master; and hatha, a disciplined physical practice
that attempts to balance body and mind, with enlightenment as the ultimate
goal. Ashtanga is a more athletic form of hatha. Bikram followers practice in
rooms with temperatures near 100 degrees Fahrenheit. Jnana is a practice
of wisdom, karma is self-transcending action, mantra is practice of a powerful
sacred sound, raja is the royal eightfold path to enlightenment, and tantra is
the practice of continuity.
• Multiple studies have looked at evidence of improved cognitive function,
heart rate, and focus in children and adults who practice yoga.
• Boys who have ADHD improved behavior and attention was noted . These
important, but small, studies indicated significant improvement; however,
more extensive research needs to be performed.
• This is an important form of treatment with implications for children who have
epilepsy, asthma, and eating disorde
• rs.
23. SPIRITUALITY
• Faith and spiritual practices characterize the CAM therapy most
frequently used in the United States.
• Sixty two percent of adults have used prayer specifically for health
reasons, according to data obtained from the 2002 National Health
Interview Survey.
• In a study looking at pediatrician beliefs about spirituality, most
pediatricians believed that these issues might have important health
implications, yet few asked their patients about spirituality.
• Those who did appeared more comfortable with their patients' and
families' needs and requests for this intervention. Multiple studies
and papers have reviewed spirituality and its place in the health
model and the therapeutic relationship that practitioners build with
their patients.
• Further studies are warranted to evaluate the role of spirituality as a
source of support and positive health outcomes for adolescent
patients and their families.
24. HERBAL MEDICINE
• The use of herbal medicines has increased dramatically over the past
several years, with excellent reviews documented in the literature. Herbal
sales during the first quarter of 1998 increased by more than 100% over the
previous year.
• The Dietary Supplement Health and Education Act of 1994 defines herbal
medicines as supplements. They are not tested according to the same
safety and efficacy requirements and regulations as are prescription and
over-the-counter drugs. Supplements cannot be marketed for the diagnosis,
treatment, cure, or prevention of disease, and deceptive claims are not
allowed.
• Some herbal medicines have been associated with serious negative
outcomes, especially when used in conjunction with conventional
medications.
• People who have allergies may be sensitive to the flowers and oils of certain
herbal products. Chamomile, a member of the ragweed family, may induce
severe anaphylaxis in the susceptible patient.
25. • Herbal preparations may be contaminated with heavy metals,
bacteria, or fungal organisms while being manufactured or stored.
• The consumption of Chinese herbal medicine correlated significantly
with elevated blood lead levels in children who were screened for
increased blood lead concentrations in Taipei.
• Fungal contamination also may be a problem: 62 samples of
medicinal plant material and 11 samples of herbal tea were
examined in Croatia, 18% of the medicinal plant samples and 9% of
the herbal tea samples contained molds such as aspergillus,
penicillium, mucor or absidia.
26. • Documented contaminants and adulterants found in herbal
therapies
• Aluminum
Arsenic
Aspirin
Cadmium
Caffeine
Corticosteroids
Diazepam
Indomethacin
Lead
Mercury
Theophylline
Thiazide diuretics
Zinc
• Data from Ernst E. Harmless Herbs? A review of the recent
literature. Am J Med 1998;104(2):170–8.
27. ST. JOHN'S WORT
• Traditionally, St. John's wort has been used for depression.
• The predominant mechanism of action may be serotonin reuptake
inhibition, using two active ingredients, hypericin and hyperforin;
other mechanisms may include monoamine oxidase inhibition,
interference with melatonin secretion, and uptake of norepinephrine.
• In a systematic review of St. John's wort for mild or moderate
depression, it was noted that St. John's wort was superior to
placebo and as effective as low doses of tricyclic antidepressants.
However, this herb was not as effective with major depression. Side
effects include gastrointestinal (GI) symptoms, confusion, and
dizziness.
• St John's wort has been shown to induce the cytochrome P450
system, and can increase the metabolism of drugs that use this
enzyme pathway, including indinavir, estradiol, oral anticoagulants,
and cyclosporine. The serotonin syndrome may be precipitated
when St. John's wort is used with conventional antidepressants.
• Use in pregnancy and lactation is contraindicated
28. VALERIAN ROOT
• Valerian root has been used for centuries as a sedative
agent and sleep aid. Recently, it has been used mainly
as an aid for insomnia and jet lag. It also is used for
migraine headaches, fatigue, and intestinal cramps.
• Valerian root, like kava, may affect GABA receptors,
which leads to its sedative effects. Several human trials
confirm a mild sedative effect.
• Few studies exist regarding the anxiolytic effects of
valerian root in vivo. Side effects may include headache,
excitability, uneasiness, and cardiac disturbances.
• Valerian root should not be combined with other
sedatives
29. CHAMOMILE
• Chamomile has been used historically for GI discomfort,
peptic ulcer disease, pediatric colic, and mild anxiety.
• It is felt that chamomile may act by binding to central
benzodiazepine receptors.
• Several small human trials have noted that chamomile
has hypnotic-sedative properties; however, none of
these trials have been randomized or controlled.
• Several cases of significant allergic reactions to
chamomile have been reported, no significant toxicity
has been reported.
30. GINSENG (PANAX GINSENG)
• Ginseng has been touted as enhancing mental and
physical strength. It may affect nitric oxide synthesis in
the endothelial tissue of the lung, heart, and kidney.
• Effects on serotonin and dopamine may be responsible
for its actions. Adverse effects may include irritability,
insomnia, and GI disturbance.
• Ginseng may interact with oral anticoagulants,
antiplatelet agents, corticosteroids, and hypoglycemic
agents.
•
31. HOMEOPATHIC MEDICINE
• Anecdotal support of the efficacy of homeopathy has been replaced with
more scientific evidence.
• The article, “Treatment of acute childhood diarrhea with homeopathic
medicine: a randomized clinical trial in Nicaragua,” by Jacobs and
colleagues , published in Pediatrics in 1994, was a randomized, double-
blind, clinical trial from 1991 where homeopathic remedies were compared
with placebo in children who had diarrhea.
• The treatment group had a statistically significant (P<.05) decrease in the
duration of diarrhea and number of stools.
• In a response to that article, Sampson and London had many concerns,
including: (1) the diagnostic scheme was unreliable and unproven; (2) the
product adulteration was not controlled; (3) the treatment selection was
arbitrary; (4) the data sets were grouped oddly, without explanation; (5) the
results were not clinically significant; (6) the inference of a public health
significance was not founded; (7) the selection of references was incomplete
and biased to support the claims of the article, and references were quoted
inaccurately; and, finally, (8) the editorializations were inaccurate.
32. • In a meta-analysis of 185 adult trials comparing the effects of homeopathic
treatments with the effects of placebo, 89 had adequate data for meta-
analysis, and two sets of trials were used to assess reproducibility.
• The results of this meta-analysis were not compatible with the hypothesis
that the clinical effects of homeopathy are caused completely by placebo.
However, these studies did not provide enough evidence on the efficacy of
homeopathy for any single clinical conclusion.
• A separate meta-analysis of 32 adult trials showed individualized
homeopathy to be significantly more effective than placebo. However, when
the analysis was restricted to methodologically sound trials, no significant
effect was seen.
• The results of the available randomized trials suggest that individualized
homeopathy has some effect over placebo, but the evidence is not
convincing because of methodological shortcomings and inconsistencies .
Reilly reproduced the evidence found in earlier trials, that homeopathy,
more than placebo, improved the daily symptom score in subjects who had
allergic asthma.
• Considerable controversy continues to exist, with several meta-analyses
demonstrating inconclusive or unfavorable results
33. • A randomized, placebo-controlled trial was initiated to
evaluate the efficacy of homeopathy in reducing
symptoms of otitis media in children.
• Seventy-five children, aged 18 months to 6 years,
entered into the study and received either an
individualized homeopathic medicine or placebo. After 5
days, 2 weeks, and 6 weeks, the group receiving
homeopathy had fewer treatment failures, although
these findings were not significant .
• In a separate case series of 24 children receiving
homeopathic remedies, 2% were considered treatment
failures. No adverse effects were reported
34. • The effect of homeopathic medicines on the daily burden of
symptoms, use of antibiotics, and need for adenoidectomy or
tonsillectomy in children and adolescents who had recurrent URIs
showed no statistically significant difference in the daily symptom
score between the treatment group and the placebo group.
• Both groups reduced their use of antibiotics and there was no
difference in the incidence of adenoidectomy or tonsillectomy.
• Forty-three children and adolescents who had ADHD were assigned
alternately to either placebo or homeopathic treatment in a double-
blind, partial crossover study, to determine the effectiveness of
homeopathy for this disorder.
• Statistically significant differences were found for both comparisons,
supporting the hypothesis that homeopathic treatment is superior to
placebo treatment for ADHD
35. • In a different study comparing homeopathy with methylphenidate on
children and adolescents who had ADHD, 86 (75%) responded to
homeopathy, reaching a clinical improvement rating of 73% after an
average treatment time of 3.5 months.
• COMPLICATIONS
• A review of the literature on homeopathic remedies reveals that
complications are reported rarely.
• These may include a transient aggravation of symptoms, occurring
in 10% to 20% of patients after taking a homeopathic medicine.
• Because of the dilute nature of the remedies, toxicity is not a
complication .
• However, one infant developed infantile botulism after being given
the natural homegrown chamomile tea colic remedy contaminated
with Clostridium botulinum spores .
36. SUMMARY
• The field of CAM is broad and diverse,
comprising numerous therapeutic modalities.
• CAM therapies are viewed as either an adjunct
or a complement to conventional treatment.
• Patients and their parents can make various
health care choices; physicians need to
understand and respect these options, and
support them if safe and effective.
37. Talking with your patients about CAM
• Be open-minded. Most patients are reluctant to share information about
their use of CAM therapies because they are concerned their physicians will
disapprove. By remaining open-minded, you can learn a lot about your
patients' use of unconventional therapies. These strategies will help foster
open communication:
• Ask the question.
• The author recommends asking every patient about his/her use of
alternative therapies during routine history taking. One approach is to
inquire simply, “Are you doing anything else for this condition?” It is an
open-ended question that gives the patient the opportunity to tell you about
his/her use of other health care providers or therapies. Another approach is
to ask, “Are you taking any over-the-counter remedies such as vitamins or
herbs?”
• Avoid using the words “alternative therapy,” at least initially, to help you to
avoid appearing judgmental or biased.
38. • Don't dismiss any therapy as placebo.
• If a patient tells you about a therapy that you are unaware of, make a note of
it in the patient's record and schedule a follow-up visit after you have
learned more, when you will be in a better position to negotiate the patient's
care. If you determine the therapy might be harmful, you will have to ask the
patient to stop using it. If it is not harmful and the patient feels better using it,
you may want to consider incorporating the therapy into your care plan.
• Discuss providers as well as therapies.
• Another way to help your patients negotiate the maze of alternative
therapies is by stressing that they see appropriately trained and licensed
providers and knowing whom to refer them to in your area. Encourage your
patients to ask alternative providers about their background and training and
the treatment modalities they use. By doing so, your patients will be better
equipped to make educated decisions about their health care.
• Discuss CAM therapies with your patients at every visit.
• Charting the details of their use will remind you to raise the issue. It may
also help alert you to potential complications before they occur.
39. “El separatismo, que ha nacido del orgullo, es
el error de un intelecto sin compasión. La
docta ignorancia de un saber que no sabe
nada de totalidades y por ello ha perdido su
integridad, surge en el contexto de una
autosuficiencia donde ya no hay lugar para la
humildad”
Jorge iván carvajal posada
