Hilary McClafferty, MD, FAAP
Pediatric integrative medicine is a style of healthcare that prioritizes prevention and uses a blend of appropriate conventional and complementary therapies to expand treatment options.
It encompasses every aspect of the child’s wellbeing, including nutrition, physical activity, sleep, mind-body connection, relationships, environment, and emotional development as it relates to health. Parents seek out integrative options for a range of reasons, from being thoughtful and curious to the outright dangerous. For example, some parents are concerned about side effects of conventional medications, others are frustrated by the reactive nature of modern medicine and seek a more preventive focus to healthcare, while others are acting out of fear and are willing to try any therapy, proven or unproven, to help their child.
Probably the best way to use the field is to partner with a fully qualified integrative pediatrician, as early in a child’s life as possible. This is a step that can help maximize the child’s health and empower the family with education and resources targeted to the child’s needs. Another valuable approach is to have a fully qualified integrative pediatrician on the treatment team if a child has been diagnosed with a chronic illness. This pediatrician can partner with other pediatric specialists to help craft a treatment plan that expands the child’s treatment options while respecting the expertise of the specialists. One of the best examples of this nationally is the wide use of integrative therapies in the highly specialized world of pediatric hematology-oncology, where children face complex, extensive treatment and often benefit from support in every area of their lives (nutrition, sleep, gentle physical activity, and stress management for both child and family) with carefully vetted integrative approaches that are used in conjunction with conventional treatment plans as possible.
The field of pediatric integrative medicine has seen a significant evolution as research has accumulated showing its benefit in children. It has been endorsed by the American Academy of Pediatrics (AAP) since 2005 when the Provisional Section on Complementary and Alternative Medicine was formed. Since then the name of the AAP Section has changed to the Section on Integrative Medicine to mirror the name change of the National Institutes of Health (NIH) National Center for Complementary and Alternative Medicine (NCCAM) to the current National Center for Complementary and Integrative Health (NIH- NCCIH), dropping the word ‘alternative’.
Describing the naming and terms used to describe the field is important because it helps us understand the scope of the therapies used. Conventional medicine refers to Western medicine that most are familiar with: regular well-checks, immunizations, prescription medications if needed, urgent and emergent care if indicated, and hospital admission for longer term care.
Complementary therapies cover a wide range and have varying descriptions, making them harder to define. The NIH-NCCIH (National Center for Complementary and Integrative Health) has organized the therapies into three big buckets: Natural Products, Mind and Body Practices, and Other Complementary Approaches.
Within these buckets, Natural Products include dietary supplements which covers a wide range of herbs, botanicals, vitamins, minerals, and probiotics. Mind and Body Practices include a wide range of therapies including yoga, meditation, osteopathic manipulation, acupuncture, and a range of breathing exercises, guided imagery, clinical hypnosis, progressive muscle relaxation and associated relaxation techniques. Other Complementary Approaches includes categories such as Traditional Chinese Medicine, traditional healers, Ayurveda, Homeopathy and others.
In contrast, Alternative therapies are those that are used that are used in place of conventional medicine, and as such don’t fall into the widely agreed upon definition of integrative medicine, which refers to the blending of conventional and evidence-based complementary therapies. Many alternative therapies lack supporting evidence, especially for in children. Working from a base of evidence that supports a therapy’s safety and effectiveness in children is critical. No parent or health care professional wants to knowingly put a child in harm’s way by using an unproven therapy, or to delay needed care with a therapy recognized as ineffective.
This makes the designation of complementary therapies in pediatric integrative medicine important, meaning the therapy would only be recommended if supported by scientific evidence. Parents should carefully assess both the therapies and the health care professionals recommending them. Just as there are a wide range of complementary therapies, variation in training, credentialing and licensing among the different types of complementary medicine practitioners is significant. It is critically important for parents and caretakers to understand the training specifications of every type of health care professional working with their child, and to specifically ask about the amount and type of specific pediatric training the individual has received within that specialty. Many of the subsets of complementary practices lack a robust credentialing pathway for pediatric training, so always ask.
One of the safest approaches is to work with a Board-certified physician who has additional training in integrative medicine, especially in pediatric integrative medicine. Many integrative pediatricians partner with well- qualified complementary medicine practitioners to expand their treatment teams. Key words to look for when searching for an integrative physician include Board certification in integrative medicine, which is offered through the American Board of Integrative Medicine. Various integrative medicine fellowship training programs exist for physicians seeking training beyond standard residency, however the only pediatric specific one at present is offered through Stanford University’s Lucille Packard Children’s Hospital.
Examples of how pediatric integrative medicine can be used in practice include adding mind-body skills training such as breathing exercises paired with progressive muscle relaxation into the regular care of a child with asthma to help them identify early triggers of stress that may play a part in precipitating an asthma flare. This helps them by building their resilience skills with simple, age-appropriate tools to use both in the moment and to address long-term chronic stress. Many children with chronic health conditions or disabilities are relentlessly bullied, learning mind-body skills can help buffer the child while developing self-confidence and a greater sense of self-efficacy. Another useful addition to this child’s treatment plan would be nutrition education and providing practical guidance to help upgrade the overall quality of the child’s nutrition with emphasis on the anti-inflammatory or Mediterranean diet, shown to help reduce inflammation in the body that is associated with many chronic illnesses, including asthma.
A second example would be a child with obesity, where lifestyle education and guidance paired with concrete steps to reinforce, educate and coach a child and family towards better health can literally impact the child’s health over the lifespan. Elements of integrative pediatrics directed at enhancing self-efficacy through motivational interviewing for example, once mastered become lifelong skills. Pediatric integrative medicine can also be very useful in a child experiencing disruption in sleep. Development of a personalized sleep hygiene plan with help in implementation and follow thought has helped many children of different ages regain a pattern of healthy restorative sleep, and to experience an enhanced sense of self-efficacy by mastering a new approach that they have helped create.
Another example where integrative pediatrics has been shown to be effective is enuresis or bed-wetting where clinical hypnosis (after correctable causes such as infection or a congenital malformation of the kidney or ureter) tailored to the child’s age and developmental stage can be highly effective. Similar success has been seen with gut-directed hypnotherapy in children experiencing the symptoms of irritable bowel syndrome, again once other conditions such as inflammatory bowel disease have been ruled out with conventional approaches.
Although pediatric integrative medicine has many strengths, pitfalls do exist. Perhaps the most common is reluctance on the part of parents to disclose the use of any and all therapies they are using on their child. This could lead to dangerous unwanted interactions, or delay of needed care. Similarly, physicians who are biased against even hearing about the potential benefits of an integrative approach put parents in a difficult position if they fear derision from the doctor, or worse, dismissal from the practice. Ultimately it is the child who suffers when extreme bias in adults is present. Ideally the common goal should be creation of a respectful, evidence-based dialogue that allows consideration of all appropriate therapies to maximize the child’s health.
Another potentially serious outfall is the avoidance of conventional therapies simply on principle, for example declining the use of an antibiotic for strep throat, or avoidance of emergency care for diagnosis and treatment of appendicitis, or new onset of symptoms worrisome for cancer or other equally serious illness in a child. This approach places the child’s life at risk and often results in very delayed care with multiple missed windows of opportunity for effective treatment. Use of unvetted treatments, for example an untested dietary supplement, also raise concern and reinforce the need for guidance from properly licensed health care professionals to help evaluate choices.
In summary, pediatric integrative medicine has significant potential to help maximize children’s health and maintains a strong focus on prevention and increasing sense of self-efficacy in both patient and caretaker. It is a field that lends itself to tailored treatment plans and has been formally endorsed by the American Academy of Pediatrics since 2005. It has been used in hospital, outpatient and home settings and comprises a wide range of therapies including mind and body medicine, natural products, and traditional treatments such as acupuncture- in ways that have been researched and found to be safe and effective in the pediatric population. Pitfalls in the use of pediatric integrative medicine do exist, and the best course of action for parents is to partner with a fully trained and licensed pediatrician or other similarly qualified health care professional who has specific training in the field. More training programs are needed, which is one of the main drivers behind the development of the Academy of Pediatric Integrative Medicine, a continuing medical education driven educational resource for health care professionals. www.apim.org