Perspective: A Dedication to Integrative Pediatric Care
Kathi J. Kemper, M.D., M.P.H., holds the Caryl J. Guth Chair for Holistic and Integrative Medicine at Wake Forest University School of Medicine, where she is also Professor of Pediatrics and Public Health Sciences and Director of the Program for Holistic and Integrative Medicine. Dr. Kemper received her M.D. degree from the University of North Carolina at Chapel Hill School of Medicine; her M.P.H. from that university's School of Public Health; and her postdoctoral training at Chapel Hill, the University of Wisconsin-Madison, and Yale University. Author of many papers on pediatric topics and the book The Holistic Pediatrician, she chairs the American Academy of Pediatrics' Provisional Section on Complementary, Holistic, and Integrative Medicine. Dr. Kemper answered a few questions from CAM at the NIH.
Q: How long have you been an NCCAM grant recipient, and what have you studied?
A: I have been an NCCAM grantee since April 2000. My first project was a pilot study on providing an Internet educational program on herbs and supplements to a diverse group of health professionals. We found that all participants (over 500) who completed the online program and the followup showed significant, sustained improvements in their knowledge, confidence, and communication practices on this topic.
The two major questions I am now researching are
- What is the most cost-effective strategy for providing clinical education online about integrative medicine?
- What is the impact of noninvasive therapies such as music, Healing Touch, and biofeedback on the physical function and well-being of pediatric patients, as measured in patterns of heart rate variability?
Q: According to the evidence, what are the CAM therapies most used by children and adolescents?
A: It depends somewhat on how one defines CAM. If one includes prayer (although investigators have defined prayer in different ways), then that is number one. After prayer, it varies by age. In newborn infants, it is massage, which has become nearly routine in neonatal intensive care units and many pediatric practices. In teenagers, it is dietary supplements. Over a third of pediatric pain treatment centers use acupuncture, and even more use hypnosis/guided imagery and biofeedback. Many therapies that might have been considered CAM 10 years ago have now become mainstream.
Q: Can you describe your ideal model of integrative pediatric care?
A: At its best, it's good pediatric care--period. Good care is patient centered and takes into account a family's values, cultural perspectives, goals, and preferences. It is informed by evidence, but tailored to individuals. It is comprehensive and coordinates with care provided by others. It has a very strong focus on health promotion and disease prevention. It doesn't matter whether this care is provided by a pediatrician, family doctor, nurse practitioner, or physician assistant; a generalist or specialist; or in what setting. What matters more is its quality--reflected in things like attention to and focus on the patient, humility to ask for help from others with more expertise in other therapies, and passion to advocate for patients and families to help improve systems of care.
Q: What are a few examples of CAM (or integrative medicine) therapies that parents often ask you about for their children, and for which you think there is at least some evidence of effectiveness?
A: Some examples are various dietary supplements (the ones I am asked about vary over time and by condition), massage, nutrition, exercise, and social support. Much of what is done in pediatrics is inferred from data that comes from studies on adults. We need more studies in the pediatric population--particularly on supplements, mind-body approaches, and whether improving support and healthy lifestyles for parents improves kids' health. We need more input from economists when we consider the costs and benefits of therapies--and we need that perspective on the next 20 years, not the next 6 weeks.
In my pediatric practice, I usually focus mostly on lifestyle--for example, good nutrition, exercise, social support, educational opportunities, strategies to manage stress, and the practice of gratitude. Everyone also needs to look at social and environmental forces in the community. Are there sidewalks and bike paths to promote exercise? Are the streets safe to walk? What's happening in the schools to promote optimal eating? Do they ban smoking? What's the TV tuned to? How much TV? Are we being positive role models that kids will want to emulate?
Q: Chronic pain is a reason that many people of all ages turn to CAM. While there are many types of pain, are there any interventions that appear especially helpful for pain, generally, in children and adolescents?
A: Yes--several mind-body approaches such as hypnosis, biofeedback, and guided imagery; optimal nutrition and exercise, to help create endorphins [morphine-like chemicals made naturally in the brain that relieve pain]; and acupuncture, massage, Therapeutic Touch, and Healing Touch.
Q: When a parent asks you about a therapy for use in a child and there is no evidence from controlled clinical trials, how do you respond?
A: I use the "2x2 table" developed by Michael Cohen and David Eisenberg at Harvard Medical School.1 It can be summed up as follows.
If the evidence reported in the scientific and medical literature on a therapy:
- Supports the therapy's safety and effectiveness--recommend it and continue to monitor it
- Supports the therapy's safety but is inconclusive on effectiveness--tolerate it, provide caution, and closely monitor its effectiveness
- Supports the therapy's effectiveness but is inconclusive on safety--consider tolerating it, provide caution about it, and closely monitor its safety
- Indicates either serious risk or ineffectiveness--avoid the therapy and actively discourage it.
1Cohen MH, Eisenberg DM. Potential physician malpractice liability associated with complementary and integrative medical therapies. Annals of Internal Medicine. 2002;136(8):596-603.
That said, there are a lot of gray areas. Many parents ask what I would do if it were my child. Here, a clinician has to tread very carefully. It's important to be respectful without either giving up one's own values or imposing them on someone else.Q: Pediatricians and other health care providers may find it challenging (for example, because of time limitations) to be informed on the evidence on CAM therapies they are asked about. What can they do?
A: Read, ask patients, and ask colleagues about these therapies. Go to lunch with a chiropractor, acupuncturist, or massage therapist to find out more about what they do. Ask patients who go online for health information to bring in what they find. Be willing to ask others who know more about a therapy. Join the American Academy of Pediatrics' Provisional Section on Complementary, Holistic, and Integrative Medicine. There are also other, similar groups elsewhere in the world. Some fellowship programs exist that provide in-depth training. Online education programs are available from (to name a few sources) the Northwest Area Health Education Center, the University of Minnesota's Center for Spirituality and Healing, NCCAM, and an increasing number of medical schools and academic health centers in the Consortium of Academic Health Centers for Integrative Medicine.
