INTRODUCTION — Many Americans integrate complementary therapies into overall health strategies for themselves and their children. Pediatric clinicians should have some knowledge regarding complementary and lifestyle therapies because they may be asked to advise patients regarding these therapies or provide referrals to complementary practitioners such as massage therapists or acupuncturists. Clinicians should ask about the complementary therapies their patients are using (such as herbs and other dietary supplements) and know where to turn for additional information when questions arise (table 1) [1].
This topic will provide an overview of the integration of complementary therapies in pediatrics. The use of such therapies for specific disorders, such as autism spectrum disorder, is discussed in the relevant treatment topics. As an example, (see "Autism spectrum disorder in children and adolescents: Complementary and alternative therapies").
DEFINITIONS
●Integrative medicine – Integrative medicine is relationship-based care that makes use of all appropriate therapeutic approaches, health care professionals, and disciplines to promote optimal health and healing for the whole person – body, mind, emotions, spirit, and relationships [2]. It integrates complementary therapies into mainstream medical practice based upon evidence of safety and effectiveness within the context of relationship-based care promoting optimal health and well-being (table 2) [3]. As an example, a pediatric clinician may recommend ginger or acupuncture as a treatment for nausea for a patient who does not want to take an antiemetic medication [4]. In an increasing number of specialty settings (eg, neonatal intensive care units, gastroenterology clinics), conventional clinicians advise patients to use therapies formerly considered alternative, such as omega-3 fatty acid and probiotic supplements [5,6].
Integrative medicine encompasses some common basic values that reflect the importance of individual rights and the increasing education levels and access to information that characterize modern society:
•Recognition of the primary importance of treating the patient as an individual within a family and community, rather than a constellation of symptoms (patient-centered care)
•Recognition that the family has the primary role in providing care and that the role of the clinician is one of counselor, teacher, and advice giver rather than issuer of orders
•Recognition that family-clinician relationships are partnerships as opposed to hierarchies
•Recognition of the importance of a sustainable healing environment
•Recognition of the inherent healing ability of the individual
•Recognition of the importance of prevention and health promotion
●Complementary – Complementary therapies are a subset of integrative medicine; they are used as adjuncts to conventional care. Complementary therapies do not replace conventional medicine for serious medical problems but are offered to support the patient and family. Examples include massage, support groups, guided imagery, biofeedback, and hypnosis [7].
The list of practices that are considered to be complementary or alternative changes as practices and therapies become part of mainstream medicine over time and in different cultures.
●Alternative – Alternative medicine refers to therapies that are used in place of conventional care.
●Folk – Folk medicine refers to therapies that are provided by family or group members as part of a family or cultural tradition. Examples include using "cold" foods for "hot" illnesses, religious or ritual healing practices (eg, coining or sand painting), and using chicken soup to treat upper respiratory infections [8].
●Holistic – Holistic medicine refers to the care of the whole patient (eg, body, mind, emotions, spirit, and relationships) in the context of their values, beliefs, culture, and community. Holistic medicine is closely related to comprehensive care. Examples of holistic medicine include promotion of literacy, screening for social and environmental determinants of health such as for depression or alcohol use in family members, assessment of spirituality, and promotion of housecleaning to reduce allergic symptoms [9,10].
EPIDEMIOLOGY — The annual number of outpatient visits to CAM professionals is greater than the number of outpatient visits to mainstream clinicians in the United States. In addition, out-of-pocket expenditures for CAM are greater than those spent for hospitalization [11-13].
Approximately 12 percent of children <18 years use some form of complementary therapy each year, excluding the use of prayer and multivitamins [13]. The percentage may be greater than 50 percent for children and families who have chronic, recurrent, or fatal conditions (eg, rheumatoid arthritis, cancer), depending upon age, cultural background, and access to services [1,14-22]. As an example, oncology patients accounted for 63 percent of the consultations to a holistic medicine consultation service in an urban tertiary-care pediatric hospital [23]. (See "Complementary and alternative therapies for cancer" and "Complementary and alternative therapies for rheumatic disorders".)
Use of complementary therapies is particularly common among pediatric patients with pain and with mental health challenges such as anxiety, attention deficit hyperactivity disorder, autism, and depression [24-28]. (See "Autism spectrum disorder in children and adolescents: Complementary and alternative therapies".)
Chiropractors, acupuncturists, naturopaths, and massage therapists are the CAM professionals most often used by children, and many of these professional recommend natural health products such as vitamins, minerals, and herbal remedies [29-31]. The complementary therapies most often sought include prayer and spiritual healing, vitamins and minerals (which are so common they are no longer included in some surveys), herbs and other dietary supplements, special diets, and mind/body techniques, such as relaxation training, hypnosis, and biofeedback [32,33].
RELATIONSHIP BETWEEN INTEGRATIVE AND MAINSTREAM MEDICINE — Patients and families may or may not discuss their use of complementary therapies with their mainstream health care professionals [1,11,32,34,35]. However, the percentage of caregivers who inform their child's clinician about use of such therapies appears to be increasing [36,37]. It is important for the pediatric clinician to routinely obtain a complete history, including complementary therapies, products, and services (table 3), because some complementary and mainstream medical therapies may have adverse interactions [38,39].
Pediatric clinicians may be concerned that families who use complementary therapies are unsatisfied with mainstream medical care and will abandon effective therapies for unproven alternatives, which has been associated with adverse outcomes [39,40]. However, families who use complementary therapies rarely abandon their mainstream pediatric clinicians, and adverse effects associated with complementary and complementary/conventional interactions appear to be less frequent than known adverse effects from conventional therapies. Complementary therapies are typically used as adjuncts rather than alternatives to mainstream medical care [23,41,42]. As examples:
●In a random sample of children admitted to a general pediatric service, the proportion of children who had seen their primary care pediatrician during the acute illness did not differ according to use of complementary treatments [41]
●The majority of consultations with a holistic medicine team in a tertiary-care pediatric hospital were for management of symptoms rather than cure (70 versus 9 percent) [23]
Families seek care from professionals who respect them as individuals and who offer them time and attention. They also seek information on healthy lifestyle choices, dietary supplements, and environmental therapies over which they may exert some control [43]. Thus, they turn to therapists who offer them personal attention, hope, time, and therapies consistent with their values, world view, and culture [44,45].
DISCUSSING COMPLEMENTARY THERAPIES WITH PATIENTS AND FAMILIES
Overview — Pediatric clinicians may find it helpful to use a structured approach when discussing therapeutic options, including complementary therapies, with their patients or families (table 3). Such an approach permits the clinician to obtain a complete history, a better understanding of the values and belief systems of their patients, and a better framework from which to offer advice regarding potential adverse effects [46].
The American Academy of Pediatrics has established recommendations for pediatric clinicians who discuss CAM therapies with their families [1]:
●Seek information for yourself and be prepared to share it with families
●Evaluate the scientific merits of specific therapeutic approaches
●Identify risks or potential harmful effects
●Provide families with information on a range of treatment options
●Educate families to evaluate information about all treatment approaches
●Avoid dismissal of families' choices in ways that communicate a lack of sensitivity or concern for the family's perspective
●Recognize when the family feels threatened, and guard against becoming defensive
●If the integrative approach is endorsed, offer to assist in monitoring, and evaluate the response
●Actively listen to the family and the child with chronic illness
When discussing complementary therapies with families, evidence about efficacy and safety can be used to guide recommendations [47,48]:
●Medical evidence supports efficacy and safety (eg, probiotics for antibiotic-associated diarrhea) – The therapy can be recommended; efficacy should be monitored.
●Medical evidence supports safety, but evidence regarding efficacy is negative or inconclusive (eg, chicken soup for a cold) – The therapy can be tolerated; efficacy should be monitored.
●Medical evidence supports efficacy, but the therapy has side effects (eg, St John's wort for depression) – The response to therapy should be monitored closely or discouraged.
●Medical evidence indicates risk or side effects and inefficacy (eg, St John's wort for attention deficit hyperactivity disorder) – The therapy should be avoided and actively discouraged.
Medicolegal considerations — Medicolegal considerations are listed in the table (table 4) [49]. In addition to the standard documentation of the history, physical examination, diagnostic test results, and reports from consultants, the documentation in the medical record should include [50]:
●The conventional medical therapies that have been discussed, offered, tried, or refused
●Discussion of the risks and benefits of the recommended complementary treatment
●That the clinician has determined the extent to which the complementary therapy could interfere with any other recommended or ongoing treatment
●Appropriate informed consent
●Treatments and medications (including date, type, dose, and quantity prescribed)
●Instructions and agreements
●Periodic reviews
COMPLEMENTARY THERAPIES — The number and types of complementary therapies (table 2) and professionals include:
●Chiropractors (DC)
●Acupuncturists (LicAc)
●Biofeedback therapists (usually psychologists)
●Biofield therapists such as Reiki Masters, Healing Touch, and Therapeutic Touch practitioners
●Guided Imagery professionals (usually psychologists)
●Naturopathic doctors (ND)
●Licensed massage therapists (LMT) and bodyworkers
●Registered yoga teachers (RYT)
●Meditation instructors (often psychologists)
Chiropractic — Chiropractors believe that malalignment of the spine is a major source of morbidity. Spinal manipulation is their principal therapeutic option; chiropractors cannot legally prescribe drugs but may provide counseling about nutrition or refer patients to massage therapists or acupuncturists. Chiropractors are licensed in all 50 states [51]. In the United States, there are >70,000 active chiropractors [52].
The chiropractic community is divided into two professional organizations [53]:
●The International Chiropractic Association promotes chiropractic as essential to health promotion and is opposed to mandatory childhood immunizations.
●The American Chiropractic Association tends to focus upon treatment of low back pain and other musculoskeletal disorders and includes exercise, dietary, and nutritional supplement counseling among their therapeutic maneuvers.
Chiropractors are the complementary therapists most often used by adults and children in Canada and the United States [54]. Chiropractors see an average of 120 to 150 patients per week [53]. Initial visits typically last 45 minutes. Patients with acute conditions are scheduled for follow-up two to three times per week. Follow-up visits generally are 15 to 20 minutes long. Nearly one-half of chiropractor fees are covered by third-party payers, including Medicare and most major medical insurance carriers. Medicaid also pays for chiropractic visits in some states.
Children and adolescents account for 10 to 20 percent of chiropractor visits, and most chiropractic schools offer courses in pediatric care [53]. When treating children, chiropractors tend to take fewer radiographs, to use lighter force when making adjustments, and to use a device called an activator to make adjustments. They treat children in the caregivers' laps or use special pediatric tables.
Many chiropractors, particularly members of the International Chiropractic Association, promote regular chiropractic care for children as an essential part of pediatric health promotion. However, children receiving chiropractic care may not receive recommended childhood immunizations [55].
In addition to health promotion, some chiropractors claim to treat otitis media, asthma, allergies, infantile colic, and enuresis [56]. Few randomized trials have evaluated the chiropractic treatment of these acute conditions [57-60]. No well-designed prospective double-blind randomized studies have shown that chiropractic care is as effective or more effective than mainstream care for these conditions, nor have studies demonstrated the effectiveness of chiropractic care in preventing mild or serious pediatric disorders. On the other hand, significant adverse effects from chiropractic adjustments are rare [61], and the rate of malpractice claims against chiropractors is much lower than the rate of suits against medical doctors [62].
Acupuncture — Acupuncture, a component of traditional Chinese medicine, is based upon the theory of a vital energy or chi (qi) that circulates through the body in channels called meridians. Disease occurs when the flow of vital energy is disrupted or blocked. Health returns when the flow is restored, balanced, and harmonized. Acupuncture restores the flow of vital energy through stimulation of specific points along the energy meridians.
Most American acupuncturists are trained in America. Acupuncturists are licensed in almost all states and the District of Columbia according to data from the National Certification Commission for Acupuncture and Oriental Medicine. Approximately 80 percent of licensed acupuncturists also recommend dietary changes, herbs and other supplements, massage, and changes in lifestyle, exercise, rest, and relationships to enhance health. Acupuncture visits increasingly are covered by insurance. The Affordable Care Act section 2706 mandates nondiscrimination in payment to licensed health care professionals. Thus, pediatricians are likely to see increased availability of affordable acupuncture services for their patients.
In 2015, approximately 34,000 acupuncturists were licensed in the United States, predominantly in New York, California, and Florida [63]. Acupuncturists typically see 30 to 60 patients per week. Initial visit length is approximately 90 minutes, and follow-up visits last approximately one hour. Acute conditions typically are treated two to three times per week for two to three weeks, after which the visit frequency gradually is reduced until treatment is no longer needed [64]. Benefits of therapy, when they occur, usually are evident within the first five treatments.
Few acupuncturists regularly treat children; less than 10 percent of acupuncturists see three or more children per week. Most acupuncturists who treat children use special techniques, including nonneedle methods (eg, heat, magnets, lasers, and vigorous massage or tapping) to stimulate points along the energy meridians. In addition, they may use the Japanese style of acupuncture, which is gentler and uses thinner needles than the Chinese style.
Acupuncture commonly is recommended by clinicians; over one-third of North American pediatric pain treatment programs provide acupuncture services [65]. Many of the major teaching hospitals with a pediatric pain service offer acupuncture to treat chronic pain in children. The National Institutes of Health Consensus Conference on Acupuncture concluded that it was effective in treating several kinds of pain and nausea in adults [66]. It also appears to be effective for certain conditions in children [67]. As examples:
●A 2020 meta-analysis of 16 studies involving 1773 patients concluded that acupuncture was effective in preventing postoperative nausea and vomiting in children [68]. An earlier meta-analysis limited to clinical studies of acupuncture for postoperative nausea and vomiting in children after tonsillectomy supported these findings [69].
●A 2022 systematic review of randomized controlled trials of scalp-based acupuncture and moxibustion as adjunctive treatments for children with cerebral palsy found that scalp acupuncture significantly improved children's symptoms, mental development, and motor ability [70].
●In a randomized trial, laser acupuncture was more effective than placebo in reducing headache frequency and severity in 43 children with migraine and tension type headaches [71].
An analysis of 24 systematic reviews involving 142 randomized trials and over 12,000 pediatric participants concluded that needle acupuncture is safe for children when it is performed by appropriately trained practitioners who follow detailed protocols [72]. Among 1422 patients treated with acupuncture, there were 279 adverse events. Most adverse events (91 percent) were mild (eg, pain, bruising, worsening of symptoms). Serious adverse events may have been related to substandard practice.
Naturopathy — Naturopathic medicine is based upon the belief that the body has an innate power to heal and that symptoms are the manifestation of the body's attempt to achieve wholeness in the face of internal and external stress. Treatment is focused on restoring healthy balance and resilience. Similar to mainstream clinicians, naturopaths help patients to avoid unhealthy habits (eg, smoking, excessive alcohol use, illicit drug use). In addition, naturopathic doctors (NDs) focus on health promotion, including:
●Healthy diet (low in fat, high in fiber and micronutrients, and free of pesticides, herbicides, and antimicrobials)
●Exercise
●Rest
●Positive mental and emotional state (enhanced by meditation, imagery, and counseling)
Naturopathic therapies include hot and cold baths, steam baths, massage, and dietary supplements such as herbs and vitamins. Some naturopaths incorporate elements of other CAM therapies into their practice (eg, chiropractic, acupuncture, homeopathy, and midwifery).
According to the American Association of Naturopathic Physicians and the Canadian Association of Naturopathic Doctors, in 2020, 22 states, the District of Columbia, the United States territories of Puerto Rico and the United States Virgin Islands, and five Canadian provinces having licensing or registration laws for NDs. The seven accredited schools of naturopathy in the United States and Canada require four years of training. Internship and residency are not required. NDs are certified by the North American Board of Naturopathic Examiners (Naturopathic Physicians Licensing Examinations) [46,51]. Third-party coverage of ND services varies by state, but most pediatric care is paid out of pocket by families; this may change with the implementation of the Affordable Care Act, which includes a clause about nondiscrimination against licensed health professionals for payment.
Lengths of visits are typically 60 to 90 minutes for an initial visit and 30 to 45 minutes for follow-up. Some families rely upon their ND as the only source of primary care. Children and adolescents account for 20 to 30 percent of NDs' patient loads.
Massage and bodywork — Massage therapists focus on muscles and connective tissues. Hundreds of types of bodywork and massage exist because almost every cultural group has a tradition of massage therapy. Massage is often provided along with relaxing music and may be accompanied by aromatherapy. The most common types of bodywork and massage practiced in the United States include:
●Swedish massage (long, gliding strokes; kneading; and stroking)
●Deep tissue massage (eg, Rolfing and Hellerwork)
●Craniosacral therapy
●Infant massage
●Pressure-point techniques (eg, shiatsu and acupressure)
●Movement integration (eg, Feldenkrais and Alexander techniques)
●Sports massage
●Neuromuscular massage
●Aromatherapy massage
Massage therapy is regulated by the municipality in some areas and by the state in others. A certifying examination may or may not be required [51]. According to the National Certification Board for Therapeutic Massage and Bodywork, massage therapy is licensed in most states, within the health care field by some states and within the entertainment field by others [73]. Nurses and physical therapists provide massage therapy for children in some hospital settings.
The American Massage Therapy Association is the largest national professional organization of bodyworkers. Membership in this association requires training in an accredited school and hundreds of hours of supervised practice. Most massage schools provide little training in pediatrics, and therapists rarely treat children.
A survey of licensed massage therapists in the Boston area revealed that practitioners received 1000 hours of training in massage therapy [74]. Typical visits lasted approximately one hour; the cost of the visit was rarely covered by insurance. Most therapists saw an average of 20 patients per week, with less than one visit per week from a child or adolescent [74].
Substantial and growing evidence indicates that massage helps children and adolescents who suffer from a wide range of conditions. It can ease suffering from anxiety and depression in adolescents who are hospitalized for psychiatric disorders, reduce the severity of asthma in school-age children, and may enhance the growth rate of premature infants [75-84]. Massage therapy also is helpful in relieving pain, improving circulation, loosening tight joints, decreasing levels of stress hormones, enhancing endogenous levels of serotonin, and enhancing an overall sense of relaxation and well-being [85,86].
Yoga — An increasing number of pediatric patients use yoga as a form of exercise or stress management [87]. A review of 34 studies in pediatrics, including 19 randomized controlled trials, concluded that yoga is generally safe, and preliminary data suggest positive health outcomes [88]. Yoga teachers are registered with the national Yoga Alliance, which provides credentialing for teachers. A minimum of 200 hours of training are needed for beginner teacher certification; many experienced teachers have over 500 hours of training.
Meditation — Meditation is a mind-body therapy that is intended to enhance focus, attention, or moment-to-moment nonjudgmental awareness, lovingkindness, compassion, or gratitude [87,89]. Meditation practices are commonly used to promote health or to relieve stress, anxiety, insomnia, depression, chronic pain, or fatigue. In a 2012 survey, approximately 3 percent of children reported using meditation and other relaxation therapies for health purposes [90]. Resources related to meditation for children are provided in the table (table 5).
Major types of meditation practice used for health purposes include [87]:
●Concentration on a word, thought, sensation, emotion (such as compassion or gratitude) or image (eg, transcendental meditation, breathing awareness, including relaxation response)
●Mindfulness (the intention to notice without judgment the experiences that arise in each moment)
●Movement (eg, yoga, mindful walking, tai chi, qi gong, Sufi dancing)
A growing body of research supports the effectiveness of several kinds of meditation practice [91-95]. There is some evidence to suggest that one or more of these meditation techniques may be beneficial in reducing blood pressure and improving attention, behavior, academic performance, sleep, and psychological functioning in children and adolescents [88,89,91,96-100]. Meditation practices are rarely harmful [87].
There is no national or state certification for meditation teachers, but meditation is generally considered a safe form of mental-emotional self-management training.
Homeopathy — Homeopathy is a system of medical treatment invented in the 1800s that remains popular in Europe, Russia, India, and South America [101] (see "Homeopathy", section on 'Foundations of homeopathy'). It is based upon two principles:
●The law of similars
●The law of dilutions
According to the law of similars, a remedy that would cause a symptom in a healthy person is used to treat the same symptom in a sick person ("like cures like"). As an example, poison ivy (rhus toxicum) might be used to treat a child suffering from eczema. Serious side effects from homeopathic treatments rarely occur. The safety of homeopathy is attributed to its second principle. According to the law of dilutions, the more the remedy is diluted, the more powerful it becomes. Homeopaths believe that dilute remedies contain energy or information that is used by the patient to heal their symptoms. In contrast, most mainstream clinicians believe that dilute homeopathic remedies contain no active molecules and that the remedies have a placebo effect that triggers the patient's psycho-neuro-immunologic healing systems. However, randomized controlled trials suggest that homeopathic remedies are more effective than placebo for several pediatric conditions including colds [102-104], cough [105], otalgia [106], and diarrhea [107]. In a 2016 meta-analysis of 28 trials of homeopathy, treatment with homeopathic remedies and placebo treatments had the same rate of side effects [108].
An estimated 5 million adults and 1 million children in the United States use homeopathic products annually [109]. Approximately 50 percent of homeopathy practitioners are lay practitioners, 35 percent are chiropractors, and 10 percent are clinicians; the remainder includes naturopaths, nurses, and other health professionals [110]. Practitioners of homeopathy are licensed in fewer than 10 states [46]. Insurance coverage for homeopathic care varies by state, carrier, and the professional status of the practitioner. Homeopathic services provided by clinicians and chiropractors are covered more often than are services provided by nonclinicians.
Homeopathic remedies are available over the counter, through mail-order catalogs, and over the internet without a prescription. Homeopathic visits are scheduled approximately every four to six weeks [111]. The initial visit usually lasts 90 minutes, and follow-up visits 30 to 45 minutes. Children and adolescents account for 20 to 30 percent of the patient load of the typical homeopathic practitioner. In addition to homeopathic remedies, many practitioners of homeopathy discuss and recommend dietary therapies, dietary supplements, and relaxation techniques.
Studies evaluating homeopathic remedies in children and adults are discussed separately. (See "Homeopathy", section on 'Limited evidence supporting the use of homeopathy'.)
Biofield therapy — Therapeutic Touch, Healing Touch, and Reiki are forms of biofield therapy in which healing energy is transferred from the healer to the patient through the healer's hands.
Therapeutic Touch — Therapeutic Touch can be performed without touching the patient. The process was developed in the 1970s by a nursing professor and a lay healer and does not require a specific religious faith or belief. The process has five steps:
●Having a clear and conscious intent to be helpful and heal
●Being centered in a peaceful state of mind
●Using the hands to assess the patient's energy (typically moving the hands 1 to 3 inches away from the body in a slow downward sweep from the head to the toes)
●Using the hands to help restore the patient's energy to a balanced, harmonious, peaceful state (again, slowly moving the hands a few inches away from the body)
●Releasing the patient to complete their healing process while the healer returns to their own centered, peaceful state of mind
Therapeutic Touch is taught in nursing schools across the United States. Nursing practice in many hospitals includes policies and procedures for performing Therapeutic Touch. Credentialing is provided through Therapeutic Touch International Association. Most practitioners are nurses practicing under the professional nurses' scope of practice.
Studies in adults report that Therapeutic Touch is effective in reducing pain and anxiety and for enhancing sleep and a sense of well-being. Few studies have been performed in children [112,113]. Side effects are rare.
Healing Touch — Healing Touch grew out of Therapeutic Touch and other energy-based healing traditions. It uses a variety of nontouch or light touch techniques to affect the patient's bioenergy. Nurses are the largest professional group of Healing Touch practitioners; there are several levels of training to become a certified Healing Touch Practitioner. Practitioners of Healing Touch may be certified through various Healing Touch groups.
Reiki — Reiki is a practice similar to Therapeutic Touch that is based on Japanese tradition. The practice of Reiki relies upon a belief in an invisible energy that may be transmitted from healer to patient through intention; the energy is focused by placing the hands on particular parts of the patient's body. Reiki healers perform long-distance healing in some cases: the patient is visualized, and energy is transmitted through intention rather than direct physical contact.
Practitioners of Reiki are trained by a Reiki master through apprenticeship and spiritual/energetic initiation. It has no national certifying examinations and no state licensure requirements.
Reiki training for caregivers has been offered in at least one children's hospital in the United States [114,115].
Guided imagery, hypnosis, and biofeedback — Guided imagery, hypnosis, and biofeedback are mind-body therapies that are part of mainstream medical practice. They are used by clinicians, psychologists, social workers, and other mainstream health professionals. Training in these techniques is available through workshops sponsored by the Society for Behavioral and Developmental Pediatrics, the American Society for Clinical Hypnosis, the Biofeedback Certification International Alliance, and others.
Guided imagery, hypnosis, and biofeedback have been shown to be useful in promoting optimal performance and in treating pain, behavior problems, and a variety of other pediatric conditions when used as an adjunct to other therapies [89,116-121].
The use of biofeedback in the management of specific conditions is discussed separately. (See "Tension-type headache in children", section on 'Preventive treatment' and "Management of bladder dysfunction in children", section on 'Biofeedback and pelvic floor muscle training' and "Preventive treatment of migraine in children", section on 'Behavioral therapy' and "Complementary, alternative, and integrative therapies for asthma", section on 'Biofeedback and functional relaxation'.)
Herbs/supplements — Herbs, vitamins, minerals, and other dietary supplements are used by families of children and adolescents for a variety of indications (table 6) [4,122].
●Multivitamins and minerals are promoted as therapies for children who have attention deficit hyperactivity disorder, autism spectrum disorder, bipolar and mood disorders, Down syndrome, and other developmental/behavioral disabilities and mental health concerns. (See "Autism spectrum disorder in children and adolescents: Complementary and alternative therapies", section on 'Classification according to benefits and risks'.)
●Fish oils, antioxidants, and herbs are marketed for children with attention deficit hyperactivity disorder. (See "Attention deficit hyperactivity disorder in children and adolescents: Overview of treatment and prognosis", section on 'Dietary interventions' and "Attention deficit hyperactivity disorder in children and adolescents: Overview of treatment and prognosis", section on 'Other alternative therapies'.)
●Vitamin B2, magnesium, feverfew, and butterbur are increasingly recommended by conventional neurologists to prevent migraine headaches. (See "Preventive treatment of episodic migraine in adults", section on 'Other agents' and "Preventive treatment of migraine in children", section on 'Nutraceuticals'.)
●Magnesium and a variety of Asian herbs are sought as a natural approach to management of asthma [123].
●Adolescents spend money on dietary supplements to lose weight, build strength, enhance mood, clear skin blemishes, and provide energy [124,125].
●Gastroenterologists may recommend probiotics to ease symptoms of irritable bowel syndrome (IBS) and inflammatory bowel disease [126], and neonatologists may recommend probiotics to reduce the risk of necrotizing enterocolitis [127]. (See "Chinese herbal medicine for the treatment of allergic diseases" and "Probiotics for gastrointestinal diseases" and "Neonatal necrotizing enterocolitis: Prevention", section on 'Probiotics'.)
Pediatric clinicians should advise caution about potential toxicities from herbs and dietary supplements (table 7) [124,128]. Natural products (eg, digitalis, hemlock, tobacco) can have potent physical effects, some of which are obvious after one dose, others of which occur over years of accumulated exposure [129]. Probiotics rarely can cause bacteremia; predisposing factors include intensive care unit admission, immunosuppression, short gut syndrome, prolonged hospitalization, and preceding surgery [130-132]. Dietary supplements used for energy, weight loss, and muscle building are associated with more frequently reported adverse events than vitamins [124]. (See "Overview of herbal medicine and dietary supplements", section on 'Safety' and "Hepatotoxicity due to herbal medications and dietary supplements".)
Lifestyle therapies — Lifestyle therapies include special diets, exercise, and environmental manipulation.
Diet — Diet is a lifestyle therapy that is used commonly by families who pursue complementary and alternative approaches because diet, particularly for young children, is controlled by the family. Diet typically is discussed by pediatric clinicians as part of routine health supervision visits. However, families also may seek advice regarding diet from other health professionals (eg, registered dietitians, NDs, chiropractors, and licensed acupuncturists) or lay advisers within their cultural communities. Increasingly, special diets, such as the low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAP) diet and exclusive enteral nutrition are recommended by conventional gastroenterologists to treat IBS and inflammatory bowel diseases, such as Crohn disease. (See "Functional abdominal pain in children and adolescents: Management in primary care", section on 'Dietary triggers' and "Overview of the management of Crohn disease in children and adolescents", section on 'Exclusive enteral nutrition'.)
Caregivers may choose vegetarian, macrobiotic, or other special diets for religious, ethical, or health reasons. They may choose to purchase only organically grown meat and produce. They may wish to have their children avoid possible allergens (eg, wheat, dairy products, tree nuts, shellfish, corn, soy, and peanuts). (See "Vegetarian diets for children" and "Organic foods and children".)
Severely restrictive diets, particularly for infants, may result in poor weight gain, malnutrition, and, occasionally, death [39]. Caregivers may not be aware of the potential nutritional deficiencies of restrictive diets for their children or of the means to address these deficiencies within their dietary framework. They should be referred to a qualified pediatric dietitian for specific advice before restricting gluten, dairy, or other commonly consumed foods.
Exercise — In addition to making dietary recommendations, pediatric clinicians also encourage physical activity as part of routine health supervision. Pediatric clinicians should be aware that certain exercise therapies may be useful in the management of specific conditions. As an example, yoga may be particularly useful for children suffering from asthma [123].
Environmental — Environmental therapies have long been used in children's health care. Examples include phototherapy for jaundice, vibration for colic, cold for pruritus, music for anxiety, and mattress and pillow covers for children with allergy to dust mites. Environmentally based complementary therapies include lights, sounds, magnets, ionizers, and aromatherapy. These therapies are marketed as being safe and effective for children. Although data to evaluate some of these claims are lacking, most of them appear to be benign. Increasingly, pediatricians and pediatric integrative clinicians have expressed concern about the negative impact of climate change on children's physical and mental health [133-135].
SUMMARY
●Definitions – Integrative medicine is relationship-based care that focuses on the whole person; is informed by evidence; and makes use of all appropriate therapeutic approaches, health care professionals, and disciplines to promote optimal health and healing. Complementary therapies are a subset of integrative medicine. (See 'Definitions' above.)
●Relationship with mainstream medicine – Complementary therapies typically are used as adjuncts rather than alternatives to mainstream medical care. Families may turn to therapists who offer them personal attention, hope, time, and therapies consistent with their values, world view, and culture. (See 'Relationship between integrative and mainstream medicine' above.)
●Complementary therapies – Complementary therapies include acupuncture, massage and other types of bodywork, chiropractic, prayer, homeopathy, bioenergetic therapies (Therapeutic Touch, Healing Touch, Reiki), guided imagery and biofeedback, herbs and supplements, and lifestyle therapies (diet, exercise, and environmental manipulation) (table 2). (See 'Complementary therapies' above.)
●Discussing complementary therapies with patients and families – Pediatric clinicians may find it helpful to use a structured approach when discussing therapeutic options, including complementary therapies, with their patients or families (table 3). (See 'Discussing complementary therapies with patients and families' above.)
●Medicolegal considerations – Medicolegal considerations related to the use of both conventional and complementary therapies are listed in the table (table 4). (See 'Medicolegal considerations' above.)
