An Integrative Approach to Pediatrics Rachel Busse MD

An Integrative Approach to Pediatrics Rachel Busse, MD Integrative Medicine Fellow January 6, 2010

Learning objectives: part 1 Holistic pediatric history n Preventative recommendations n Herbs in children n Introduction to homeopathy n Food allergy and sensitivity n Probiotics n

Learning objectives: part 2 n Common pediatric complaints: n n n Otitis Media Asthma Colic Eczema Headache Allergic rhinitis

Holistic history taking Goal of the visit n Herbs or supplements n Prior CAM providers n Detailed dietary history n Detailed activity history n Spirituality/stress reduction/hobbies n What do you think is going on? n

Preventative care n n TV with clear risk of obesity Screen time of <2 hours per day Environmental exposures Co-sleeping: n n n attachment parenting 2 studies in NZ only found increased risk of SIDS if mother smoked education around bed safety: no co-sleeping if waterbed, soft bedding, bed rails

Preventative care n Highest pesticides: n n n Peaches Apples Bell peppers Celery Nectarines Strawberries Cherries Lettuce Grapes Pears Spinach Potatoes n Lowest pesticides: n n n Onions Avocadoes Frozen corn Pineapples Mangoes Frozen peas Asparagus Kiwis Bananas Cabbage Broccoli Eggplant

Frequently used herbs n n n Echinacea for colds Astragalus for colds Ginger for nausea Garlic for mild infections Elderberry for flu Chamomile for colic, teething, anxiety Peppermint for upset stomach Slippery elm for sore throat Calendula for diaper rash Aloe for burns Eucalyptus for congestion

Assessing alternatives for children Evaluate potential level of harm n Then evaluate level of evidence n

Homeopathy Developed in the late 1700 s by Dr Samuel Hahnemenn in Germany n Minute amounts of plant, mineral and animal substances n Law of Similars: “like cures like” n

Homeopathy continued n n The more dilute the substance the more powerful the medicines Dilutions are described as ‘C’ or ‘X’ n n For example 9 C = 1/1009 9 X = 1/109 No contraindications or interactions – safe for children, pregnant women Acute and chronic (or constitutional) remedies

Homeopathy first aid kit n n n n Oscillococcinum – influenza Chamomilla – teething, insomnia, colic Arnica – bruises and injuries Allium cepa – colds , hay fever Euphrasia – irritated eyes, hay fever Apis – bee stings, burns, hives Hypericum – toothache, sinus pain Gelsemium – summer colds, fever, headache Rhus toxicodendron – sprains, strains when worse after rest Ruta graveolens – sprains, strains when better with rest Aconite – sudden acute inflammation/fright Nux vomica – indigestion, nausea, stomachache Pulsatilla – ear infections, URI

Food allergy and sensitivity n Elimination diet n n n Elimination phase Reintroduction phase Common foods: n dairy, soy, eggs, corn, wheat, citrus, nuts, shellfish, pork, and chocolate

Food allergy and sensitivity n Elimination diet in kids n n Difficult in children under age 6 Picky eaters – one food at a time Screen for eating disorders in adolescents Ig. G antibody testing controversial

Probiotics intestines protect from disease using mucosal barrier, local immune system (including GALT), microflora n intestines are initially sterile n culture of live microbes that alter environment in a beneficial way n activity n

Probiotics n Foods with naturally occurring probiotics: n n n Yogurt – danactive 10 billion cfu, activia 5 -10 billion cfu per serving Buttermilk Sauerkraut Kefir Kim chi

Probiotics n Some of the strains which have been studied: n n n n n lactobacillus GG lactobacillus casei lactobacillus acidophilus lactobacillus plantarum 299 V lactobacillus reuteri bifidobacterium longum streptococcus thermophilus saccharomyces boulardii (yeast)

Probiotics n Dosing: n n 1 -10 billion cfu for infants and young children 10 -20 billion cfu for adults Generally take on an empty stomach n Prebiotics n Synbiotics n

Probiotics n Strong evidence: n n Moderate evidence: n n n Viral or antibiotic associated diarrhea Eczema Prevention of necrotizing enterocolitis in preterm infants Food allergies IBS IBD Lactose intolerance Generally safe, caution with immunocompromised patients, patients with short-gut syndrome, and those with central venous access.

Otitis Case A 2 year old boy is brought in by his mother with a fever of 100, fussiness, and tugging at his right ear. You note a red, bulging tympanic membrane on the right. What treatment might you offer? a) Naturopathic ear drops b) Amoxicillin 80 mg/kg/day c) Probiotics d) Cranial osteopathy

Otitis media Most acute cases resolve n Increased risk with pacifier, cigarette smoke or wood burning stove, dairy in some children n Decreased risk with breastfeeding n

Otitis media summary Most OM resolves spontaneously n Naturopathic drops as effective as anesthetic drops n Homeopathy research is limited n OMT evidence with recurrent OM n

Asthma case n A 10 year old girl presents to establish care and has a history of mild intermittent asthma. She uses an albuterol inhaler with flare-ups, has never been hospitalized. Her parents want to know if there any vitamins which might help.

Asthma case n Questions you might ask: n n Smoking at home Pets History of allergies Breathing/relaxation techniques

Asthma case n Which of the following supplements have evidence for asthma in children: n n n A) Omega 3 fatty acids B) Zinc C) Vitamin C D) Vitamin B 6 E) Vitamin E

Asthma case n The following supplements have evidence for asthma in children: n n n A) Omega 3 1000 mg daily B) Zinc 15 mg daily C) Vitamin C 200 mg daily

Asthma case Good evidence for daily yoga or massage in children (but time consuming) n Insufficient evidence for psychological interventions or smoking cessation for parents n

Allergic rhinitis n n n n Vitamin E does not reduce symptoms Probiotics may be helpful Butterbur as effective as fexofenadine or cetirizine Stinging nettle lacks sufficient evidence Chinese herbal formulations in adults Acupuncture Environmental exposures

Colic case n A 7 week old baby cries for 3 hours most days for the last 3 weeks. The mother wants to know what homeopathy is and whether it could help. Also she has heard from a friend that she should try giving her chamomile tea.

Colic case n Questions you could ask: n n n Breastfeeding? Find out more about mom’s diet Symptoms of reflux Amount of stimulation

Colic case n Which of the following do you recommend? n n n A) abdominal massage with lavender oil B) increasing play time with the infant using board books, mobiles, music C) trial of avoiding dairy/eggs/nuts/wheat D) chiropractic manipulation E) herbal tea with chamomile, fennel, lemon balm F) homeopathy

Colic case n You recommend the following: n C) trial of avoiding dairy/eggs/nuts/wheat n F) homeopathy

Colic case Homeopathy is safe n Little evidence n Combination preparations most often sold for colic, teething etc which may help, but likely not perfectly matched to symptoms n

Eczema case n A 4 year old boy has had severe eczema since he was several months old. His parents have been limiting his bathing, using a mild soap, and applying Eucerin after each bath. He requires a lot of topical steroids and they are wanting to find another approach.

Eczema case n Which CAM therapies have evidence? n n n A) Probiotics B) Primrose oil C) DHA D) Elimination diet E) Chinese herbal cream, such as Wau Wa F) Vitamin E 400 IU daily

Eczema case n n n Probiotics – cochrane review 2008 insufficient evidence, recent new trial, also in perinatal period Primrose oil - ineffective DHA – evidence in adults Elimination diet – only evidence is eliminating eggs in eggallergic children Chinese herbal creams – no! many found to contain high dose steroids. Can try chamomile, calendula or hyperformin Vitamin E 400 IU daily – evidence in adults, but takes months to see benefit

Eczema case n Other measures: n n n Washing bedding at 131 degrees F kills 100% of mites Bedding covers Wet wraps increase skin infections and offers no added benefit

Headache case n An 8 year old boy is brought in for intermittent migraines. His mother also gets migraines and takes magnesium, which seems to help her. She asks about this and any other integrative therapies you might recommend.

Headache case n Additional questions: n n n Stress School association Sleep pattern Skipping meals? Food triggers in 10 -20% of cases n n Aged cheeses Chocolate Nuts Processed meats

Headache case Which of the following have been studied for prevention of migraines in children? n A) Feverfew n B) Magnesium oxide 9 mg/kg/day n C) Butterbur n D) Coenzyme Q 10 n

Headache case The following have been studied for prevention of migraines in children: n B) Magnesium n C) Butterbur n

Headache case n n n Feverfew lacking sufficient evidence for migraine prevention in adults, co. Q 10 shows benefit in adults Magnesium oxide at 9 mg/kg/day does not reduce frequency of migraines in children, but decreases severity Butterbur has been studied as Petadolex 50 mg qd-tid in children and decreased frequency of headaches

Headache case Biofeedback n Acupuncture or acupressure n Guided visualization n Cognitive behavioral therapy n

References n n n Integrative Medicine, David Rakel, (Saunders/Elsevier 2007) Integrative Medicine: Principles for Practice, Kligler and Lee (Mc. Graw Hill 2004). Healthy Child, Whole Child, Stuart Ditchek and Russ Greenfield (Harper Collins 2009) Smart Medicine for a Healthier Child, Zand, Walton and Rountree (Avery Publishing) Dynamed Natural Medicines Comprehensive Database Arch Pediatric Adol Med 2001 Jul; 155 (7): 796 (naturopathic ear drops) Br J Dermatology 2008 Apr; 158 (4): 786 (DHA for eczema) Ann Allergy Asthma Immunol 2008 Nov; 101(5): 508 (probiotics in eczema) Br J Nutr 2009 Jun (probiotics for reducing URI) Headache 2003 Jun; 43 (6): 601 (magnesium for pediatric migraine prevention)

Additional online resources n Probiotics – aafp 2008 overview n n Integrative medicine in residency n n www. besthealth. com/Integrated+Medicine Memorial Sloan Kettering Cancer Center n n http: //www. drweil. com/drw/ecs/pyramid/press-foodpyramid. html Wake Forest Holistic and Integrative Medicine n n http: //dime. arizona. edu/imr Anti-inflammatory food pyramid n n http: //www. aafp. org/afp/2008/1101/p 1073. html www. mskcc. org/mskcc/html/11570. cfm University of Maryland Herbal Database n http: //www. umm. edu/altmed/index. htm