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CAM offers lens on health care.ppt


									Overview of Complementary,
  Holistic and Integrative
           Kathi J. Kemper, MD, MPH
          Caryl J Guth Chair for Holistic
            and Integrative Medicine
          Professor of Pediatrics, Public
           Health Sciences, Family and
              Community Medicine
          Wake Forest University Health
OBJECTIVES. By the end of this session:
         1. Name the new provisional Section
            within the AAP and be able to join.
         2. Apply an ethical framework for
            recommending, avoiding, tolerating or
            monitoring a therapy
         3. Describe a model integrating CAM and
            mainstream care into 4 major
         4. List four resources for answering
            clinical questions about CAM
NIH NCCAM Definition
     Complementary and
      alternative medicine
      (CAM) is a group of
      diverse medical and
      health care systems,
      practices, and products
      that are not presently
      considered to be part of
      conventional medicine. …
         Resource 1: NIH NCCAM
                 • Patient information sheets in
                   English and Spanish
NCCAM            • Ongoing research
Clearinghouse:     projects/clinical trials
                 • Education and Training
Resource 2: NCI OCCAM
        • Health information for
        • Clinical trial information
        • Grant funding for
          research projects
Complementary, Alternative and
   Mainstream Therapies

Alternative                   Mainstream

               CAM Use in Kids
                        • 1992-2005, 66 pediatric
                          utilization studies US,
                          Canada, UK, Australia,
                          Turkey, Norway…
                        • General and subspecialty
                        • Use increasing

Complementary and Alternative Research and Education Program
           Pediatric Epidemiology
• Spiegelblatt ‟94 Pediatrics ; 11% used prof. CAM
• Ottolini, et al, W, DC, „98: 20% of kids in 4 practices
• Taylor, et al, Seattle, „98: 30% -50% use echinacea or
  vitamin C for kids‟ colds
• Indiana teens „98: 20-30% of athletes take supplements
• Crow, et al. Ped Res, ‟03: 46% w/vitamins; 15%
  wo/vitamins in Chicago PPRG
• Wilson, et al AmbPeds ‟02: 53% of Rochester teens
• Lin, et al J Clin Anesth ‟04: 30% pediatric pre-op pts use
• Breuner APAM „98: 70% homeless teens
          Children with other
• Autism: 30%;
• Asthma: 72%-81% of minority (H and Af.A.) families;
• Cancer: 47% of kids at WFUSM in 2003; 73% of kids in
  Washington state in 2001;
• CF: 65%, mostly prayer
• Cerebral palsy: 56% of 235 families in Ann Arbor
• ED: 53% used herbs, Atlanta
• IBD: 41% of kids in Boston, Detroit, London
• Rheumatology: 64% of 141 in Toronto, 2003
• Special needs: 24% for kids with correctable condition vs.
  76% for kids with non-correctable condition
      Which CAM therapies most
          commonly used?
• Prayer – most common, least worrisome to MDs
• Herbal therapies, vitamins, minerals and other dietary
  supplements – most worrisome to MDs
• Chiropractic – most common professionally provided to
  adults; historical competitive threat
• Massage – most common professionally provided to kids;
  often taught to parents or provided informally
• Homeopathy – not well enumerated; confusion with herbs
• Yoga, Tai Chi
• Acupuncture/acupressure
• Biofeedback, hypnosis
  What are pediatricians
most often asked about CAM?
    • Herbs, dietary supplements (67%)
    • Chiropractic (59%)
    • Nutrition and special diets, vegetarian,
      macrobiotic diets (46%)
    • Homeopathy (36%)
    • Therapeutic exercise, yoga (34%)
    • Hypnosis, biofeedback or meditation
    • Massage or other bodywork (17%) ….
    • Prayer (13%)
                    Kemper, O‟Connor. Amb Peds, 2004
Only 40% tell docs about CAM
     • “Natural”, not medical; irrelevant , “not
       important for the doctor to know” 61%
     • Docs not interested; “the doctor never
       asked” 60%
     • “None of the doctor‟s business” 31%
     • “Doctor would not understand” 20%
     • Cultural practice - embarrassing or private,
     • Fear of physician reaction (disapproval,
       abandonment, worse medical care) < 15%
        Eisenberg DM, et al. Arch Intern Med, 2001; 135:
How do you know what your
   patients are doing?

         •   <50% tell
         •   Doctors need to ask!
         •   Give examples
         •   Ask in context (more later
             on this)
Caring for whole person - body,
  mind, emotions, spirit,
  relationships -- in the context of
  family, culture and community
  = Contextual pediatrics;
   = Patient – centered care
Integrative Medicine
    Integrative Medicine is the practice of
       medicine that reaffirms the importance
       of the relationship between
       practitioner and patient, focuses on the
       whole person, is informed by
       evidence, and makes use of all
       appropriate therapeutic approaches,
       healthcare professionals and
       disciplines to achieve optimal health
       and healing.
     Consortium of Academic Health Centers
                for Integrative Medicine, 5/05
Resource 3

 •   Founded in 2000
 •   Now has over 30 academic health centers
 •   International Conference
 •   Collaborative research
 •   Developing “best practices” models
 •   Education (residency and undergrad)
Resource 4: AAP Provisional Section
 for Complementary, Holistic, and
       Integrative Medicine
          • Formed 7/05
          • Dr. Larry Rosen organized
             – NYC PIM 10/05;
             – Pangea in Chicago 10/06
          • Dr. Sunita Vohra (CARE) leads PIR
            reviews; developing questions for
            ABP; international liaison
AAP ps CHIM continued
 • Dr. Richard Walls‟ committee approved
   CPS Statement on Herbs and Supplements
 • Dr. Susan Hyman – autism statement
 • Dr. Joy Weydert – Liaisons
 • Dr. Hilary McLafferty – newsletter
 • OJ Sahler – liaison to PAS
 • Junelle Speller – staffer, web site
 • TO JOIN, email Junelle:
AAP ps CHIM continued
     • NCE 2007 (SF) and beyond
       –   Acupuncture
       –   Herbs and supplements
       –   Nutrition
       –   Massage
       –   Clinical practice, billing, coding,
           time management
     • Collaboration with PAS,
     • TFOCAM report (Periodic
• CAM use is common
• Pediatricians need to be aware
  of this and ASK about use of all
  kinds of therapies
• Pediatricians need to coordinate
  care, continue to learn about
  diverse therapies
• Ethical approach to treatments
    Ethical framework

               Yes                     No

Safe Yes Use/Recommend              Tolerate

     No   Monitor closely      Advise against

                            Cohen M. Pediatrics, 2005
Effective? Safe?
  – What therapy?
  – For whom?
  – For what condition? (cancer,
  – Under what circumstances?
  – For what desired outcome?
  – When? immediate versus long-

               Kemper. Arch Dis Child, 2001
     Nausea: Does CAM work?

               Yes                No

Safe Yes Use/Recommend          Tolerate

     No   Monitor closely    Advise against
    Chemotherapy for Cancer

               Yes                   No

Safe Yes Use/Recommend           Tolerate

     No   Monitor closely   Advise against

                            Cohen M. Pediatrics, 2005
      Chicken soup for colds

               Yes           No/Unknown

Safe Yes Use/Recommend           Tolerate

     No   Monitor closely   Advise against

                            Cohen M. Pediatrics, 2005
   Surgery for Common Cold

               Yes             No/Unknown

Safe Yes Use/Recommend            Tolerate

     No   Monitor closely   Advise against

                            Cohen M. Pediatrics, 2005
Patients‟ only goals are to cure
  disease, reduce symptoms
  and prevent serious illness or
  injury. If you can do that,
  you‟re done!
What’s the desired outcome?
      • Patients may have more than
        one goal
      • Non-articulated goals are often
        as important as spoken goals
      • Patients/families may have
        goals they aren‟t consciously
        aware of
Goals for Healing
YANG-type/ Specific        YIN-type/Global, unstated
Cure                       Connection/Support/
Manage symptoms              Trust
Prevent specific disease   Meaning/Transcendence
Reduce or manage           Harmony
  specific toxin           Peace
                           Well-being/ Resilience
                           Reduce dependence
         Models for Treatment
                Disease in                  QOL
    Treatment   Organ or      Symptoms    Well-being

      Yang                                Secondary

B                              Peace
    Treatment    Person      Connection
How (not) to ask
      “You‟re not using any
        alternative medicines, are

      Using written checklists that
        don‟t include common

      Failing to provide examples.
Colic Case
You are in clinic seeing a tired-
 appearing mother with her one
 month old infant who will not
 stop screaming. After performing
 a careful history and physical,
 you diagnose colic.
What do you ask?
A.   You haven‟t tried any CAM therapies,
     have you?
B.    Have you given your baby any medicine?
C.   Mothers of babies who cry a lot try many
     different things to help, such as rides in
     the car, bouncy seats, Mylicon, Tylenol,
     homeopathy, chamomile, prayer, tummy
     rubs, changing formulas, homeopathy and
     other things. What have YOU tried so far?
     And how has that worked?
              The Mother asks

I was in the grocery store last
      week and saw these
     HOMEOPATHIC colic
   tablets. What do you think
     about homeopathy for
The highly educated physician
      I know that many homeopathic
         products are marketed for children,
         but actually none has undergone
         any randomized, controlled clinical
         trials except for some 3rd world
         studies on diarrhea and one early
         study on otitis media. You‟d
         probably just be wasting your
         money or doing an uncontrolled
         experiment, using your baby as a
         guinea pig.
The confused mother replies…
     Well, actually, since it was so cheap and
      it was right there and everything, I
      bought it and gave it. It settled the
      baby right down, and I‟ve tried it a
      couple of times since then and it works
      great. I just wanted to know if you
      thought it was safe and if you had any
      particular brands you recommend.
        Lesson 1:

     – What have you tried so far (give
     – How has that worked? (Do NOT
       give your opinion until you hear
                 Case 2
A 13 year old recently diagnosed with
 osteogenic sarcoma says she‟s having
 trouble sleeping. She doesn‟t want any more
The teenager asks
    I just don‟t want any more meds,
         but I do want to get some
       sleep. I‟ve heard that valerian
       and kava kava may be helpful.
       What do you think? I might go
             on-line to find out.
Have you already gone on line?
             What have you learned so far?
         Have you brought any printouts with
         Have you tried any products so far?
              Do you have any with you?
       I‟d like to see them and check them out.
          Please bring everything you take for
          your health so I can see it and write it
            down accurately for your records.
          More resources:

• MD Anderson Cancer Center:
Natural Standard Review: Kava
        Memorial Sloan Kettering
The girls responds
      Yes, I‟ve brought some
       valerian and kava kava,
       but I haven‟t started taking
       them yet, because I wanted
       to ask your opinion first.
       Do they work?
     The knowledgeable clinician
Several randomized controlled trials in adults have
  shown that valerian, 400 mg before bed, can help
  reduce sleep latency, that‟s the time it takes to fall
  asleep. And it doesn‟t seem to cause a morning
  hangover. It appears to be safe, but then again,
  herbal products aren‟t well regulated, so you may
  just be wasting your money. Valerian smells like
  sweaty gym socks, so if you do decide to try it,
  make sure you‟ve got a really smelly product to
  ensure you‟ve got one that has the active
       And responds some more
Now kava kava is an herb that‟s been used in Polynesia for a
  long time, mostly for social occasions, kind of the way
  wine is used in Europe and the US. If you take it three
  times a day every day for three weeks, it can significantly
  improve anxiety that may be affecting your sleep.
  However, there are several recent reports of serious
  hepatotoxicity with kava, so if you decide to take it, we
  have to monitor your liver function very closely. Any
      The impressed teen replies,
Well, actually my mom
 thought it might be helpful
 just to take a hot bath and
 have a glass of milk or a
 turkey sandwich before bed.
 And my grandmother told
 me I should pray and count
 my blessings. What do you
 think about that?
        Lesson: Be systematic
  Do not jump in with an answer
  until you have assessed ALL the
         therapies of interest

• Efficient
• Comprehensive; avoid missing the key
• Example: differential diagnosis; organ
  system approach in ICU
Integrative Approach

          •   Biochemical
          •   Lifestyle
          •   Biomechanical
          •   Bioenergetic

      • Medications
      • Dietary Supplements,
        such as herbs,
        vitamins, minerals,
        glucosamine, etc.
Be specific
      Do YOU use herbs
       regularly, ie. 4 or more
       days a week?
Be persistent; give sound advice
            • Don‟t stop at the first positive
            • Don‟t stop at the first denial;
              give examples that fit the
              clinical situation
            • Discourage use of remedies
              KNOWN to have high risks,
              e.g. aristolochic acid, Patent
              Medicines from China, herbs
              imported from developing
More Resources on Herbs and
   Dietary Supplements
        • Natural Medicines Comprehensive Database:

        • ConsumerLabs:
        • Natural Standard

        • NIH NCCAM and OCCAM
        • MedLinePlus:

NIH Office of Dietary Supplements
   • Nutrition, Diet, Habits to
     avoid (tobacco, xs EtOH,
   • Exercise and Rest
   • Mind-Body Therapies
   • Environment
  • No smoking; Clean house;
    lead, allergens, air filters
  • Minimize exposure to sick
  • Read; Avoid guns
  • Heat, cold, mist, sound,
    magnets, color,
    phototherapy, etc.
Mind-Body Therapies
          • Hypnosis
          • Guided imagery
          • Meditation
          • Journaling
          • Social Support
          • Psychological
          • Peer support
   • Surgery
   • Massage and bodywork
   • Cranial, spinal or joint
       • Acupuncture
       • Healing
       • Prayer/Spirituality
       • Homeopathy
  • Licensed in 43 states
  • NIH strong evidence – post-op
    nausea and dental pain;
    promising for many other kinds
    of pain; JAMA– turn breech
Non-contact healing
    •   Like cures like
    •   Law of dilutions
    •   Licensed in only 2 states
    •   Most is OTC
    •   Few pediatric studies –
        diarrhea; otitis media;
Integrative Medicine Model

   Biochemical         Lifestyle


   Bioenergetic   Biomechanical
• Ask
• Give examples when you ask
• Ask systematically –
  biochemical, lifestyle,
  biomechanical, bioenergetic
• Consider using self-
  administered questionnaires
Remember your ethical framework
          for advice

               Yes                No

Safe Yes Use/Recommend          Tolerate

     No   Monitor closely    Advise against
Remember your resources
        • AAP
        • NIH NCCAM
        • NIH NLM Medline Plus
        • Natural Standard, NMCD,
        • Academic Centers
        • Professional Journals (PIR,
          Contemporary Pediatrics)
        Opportunities for fellowship
   Complementary and       • CARE (Edmonton, Alberta)
Alternative Research and
   Education Program

                           • University of Arizona
                             (Tucson) – not pediatric
                             oriented, but many
                             pediatricians have done it.
  A Short History of Medicine
2000 B.C.   Here, eat this root
1000 A.D.   That root is heathen.
                  Here, say this prayer.
1850 A.D.   That prayer is superstition.
                  Here, drink this potion.
1940 A.D.   That potion is snake oil.
                  Here, swallow this pill.
1985 A.D.   That pill is ineffective.
                  Here, take this antibiotic.
2000 A.D.   That antibiotic is artificial.
                  Here, eat this root.

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