This chapter provides general information on a number of commonly used complementary modalities. The authors and publishers do not offer this discussion as a recommendation or endorsement of any of these approaches. Instead, the intention is to familiarize the reader with methods patients might already be using. Providers need to assess the use of complementary medicines as part of the patient’s history, because such therapies may impact conventional treatments. Patients may not volunteer such information unless specifically asked. The efficacy of many complementary approaches is less well documented than that of conventional therapies. Providers should read the literature before suggesting any complementary approaches. The bibliography at the end of this chapter supports the material here and in the appendices and provides further readings for interested clinicans. Display 4-1 is a list of common pediatric problems and various modalities discussed in this chapter that sometimes are used to treat them.

Traditional Chinese medicine (TCM) refers to the Chinese herbal tradition, certain therapeutic massage techniques (eg, tui na), and the kind of acupuncture practiced in China. Many would argue that these practices are “traditional” in name only, because Communist ideology intentionally excludes many concepts from other schools of thought that conflict with current political doctrine. TCM in North America, which derives from the contemporary Chinese system, also excludes these other schools of thought. One of the best known pre-Communist systems is five elements acupuncture, also known as traditional acupuncture. J. R. Worsley, who has established schools in Miami, Maryland, and Great Britain, has popularized this method, which focuses more on the emotional and spiritual dimensions of health.

Chinese herbal medicine generally does not use individual herbs alone but combines herbs in various formulas. Diagnosis in TCM is empirical; symptoms for physical ailments include emotional components. TCM practitioners rely on physical diagnostic signs to ascertain patterns of disharmony, including pulses, tongue, body odor, and sweat patterns. The wide variety of schools of training in TCM makes regulation difficult.

Acupuncture is one commonly used modality of TCM. Although children may find the needles frightening, they usually tolerate their actual use quite well. For young or scared children, acupressure (tui na) or laser acupuncture may be more appropriate. Practitioners trained in different methodologies have different beliefs about point locations, depth of needling, and applications. Still, some movement has been made toward comprehensive, standardized licensure. In many states, the title LAc connotes licensure by a state regulatory board. NCCA certification is the national board examination, which several states recognize as a prerequisite for licensure. NCCA-certified individuals are entitled to practice acupuncture without another medical degree.

Medical acupuncture is the term used when conventionally trained practitioners, such as medical doctors (MDs), osteopaths (DOs), and nurse practitioners, complete basic training in acupuncture. Several states have mandated that physicians complete a minimum number of hours of additional training to practice acupuncture among the therapies they offer. As of this writing, however, most states do not require any specific training for physicians practicing acupuncture.

A doctorate in Chinese medicine is signified by the letters OMD, which indicates training in both acupuncture and Chinese herbal medicine. Currently, the only training programs that offer this degree are in Asia and the Pacific.

Kanpo, traditional Japanese medicine, is similar to TCM in using the practices of acupuncture, herbs, and physical manipulation. Typically the depth of needling in Kanpo acupuncture is less than in TCM, which may make Kanpo easier for children to tolerate. Meridian therapy, also developed in Japan, emphasizes working with the channels of energy flow or meridians to restore or maintain health.

Aromatherapy is a branch of healing that uses essential oils and perfumes for physical therapeutics, spiritual development, and cosmetic purposes. This ancient practice was described in the oldest of Sanskrit Vedic documents about 5000 years ago. Ancient Egyptians, Chinese, Greeks, and Romans, as well as Medieval and Arabic physicians, religious authorities, and perfumers, were familiar with the properties of essential oils.

The term “aromatherapy” is relatively recent, coined by a French perfumer, Rene-Maurice Gattefosse, in the 1920s. Gattefosse became interested in the dermatologic and especially antiseptic properties of essential oils after burning his hand during a laboratory explosion. To treat the burn, he immediately immersed his hand in pure lavender essential oil. He found that the injury healed in hours rather than days without scarring or infection. Dr. Jean Valnet, a surgeon, later studied Gattefosse’s work and used essential oils to treat injured soldiers during World War II. These therapies were so effective that Valnet continued to use aromatic oils in all areas of his medical practice after the war. In 1964 he published The Practice of Aromatherapy, which is still available in English translation.

The biochemist Marguerite Maury, Valnet’s student, later published her own text that expanded the range of aromatherapy to include spiritual and emotional balancing. She incorporated much traditional knowledge of aromatics in massage. Since that time, the body of knowledge has continued to grow. A wide variety of books on numerous aspects of aromatherapy is available, including well-known works by Robert Tisserand and Shirley Price.

Production of essential oils occurs through a steam distillation process (usually of flowers or leafy plant matter). The oils are very concentrated extractions from the oil fraction of plants and usually are not used without the guidance of an
experienced practitioner. Very few essential oils are taken internally; most are diluted in a neutral oil (eg, olive or sesame) and are applied topically in small amounts or inhaled with a diffuser or steam.

Both practitioners and patients should be very careful with essential oils. Almost all are toxic in large doses. In the home, families should keep essential oils out of children’s reach. Because essential oils smell good, children are naturally attracted to them, yet ingestion can cause serious morbidity and might even be fatal.

Essential oils should never be applied in the noses of children younger than 5 years. Practitioners should not use undiluted essential oils (except a bit of lavender or tea tree oil) on a child’s skin. They must use all oils cautiously on sensitive or broken skin. Oils for a child’s bath should be much more diluted than for an adult’s. Typically, not more than four to five drops are used. Similarly, oils for massage on a child should be one-quarter to one-half the strength of those massaged on an adult. Practitioners should give inhalations to children only briefly, initially around 30 seconds. If well tolerated, they can repeat these brief inhalation treatments several times. They should use essential oils orally only with extreme caution and preferably not at all. When used with children, oils should be extremely dilute and given under the guidance of an experienced practitioner.

Appendix 4-1 provides brief and general guidelines for some essential oils commonly used in the pediatric population. Training in aromatherapy is urged before prescribing any of these oils; reading these guidelines does not constitute training. These notes are not intended to provide instruction in aromatherapy or to advocate the use of these agents.

Ayurveda, the traditional medicine of India, is an ancient, complex, and complete medical system that involves diet and nutrition, herbal medicine, massage and bodywork, meditation, and contemplation. Students of Ayurveda usually train for practice over 4 years. Many brief courses and popular books, however, provide a sampling of the wisdom of this healing tradition. Currently, no board in the United States certifies or licenses Ayurvedic practitioners. Most Ayurvedic practitioners have either trained in India or studied with a teacher who trained in India.

Ayurveda has its roots in the Vedas, the revered ancient scriptures of Hinduism. The major written texts that are the foundation of Ayurvedic practice are the Charaka Samita and the Sushruta Samita. The underlying principles are the three dosas (pronounced “doshas”) or constitutional types that are the foundation for each individual’s unique physiology. They are Pitta (eg, oil, heat, fire), Vata (eg, air, nervous system), and Kapha (eg, water, muscles). Though each person is thought to possess elements of all three dosas, typically one or two predominate. Ayurvedic therapy focuses on harmonizing the elements while respecting each individual’s unique constitution.

In children as in adults, any dosa may predominate, but children are believed to have a healthy predominance of Kapha that supports their growth and development. Many Ayurvedic approaches are effective for children; application of the dietary principles of Ayurveda may be particularly helpful.

Pancha karma, thought to be among the oldest of Ayurvedic practices, is a system of cleansing and restorative therapies. It includes ways to support, cleanse, purge, and nurture the body to achieve balance and eliminate excess dosas. Pancha karma practice pays attention to the individual’s homeostasis, the seasons, the phases of the moon, and the times of day. It can be quite extreme; a qualified practitioner should guide anyone undergoing this healing method, especially children and adolescents.

Every traditional society has an herbal pharmacopoeia; herbal medicines have been around about as long as humans. For most of history, herbal medicines were virtually the only available treatments. Many botanicals commonly used today were used hundreds and even thousands of years ago. For example, the ancient Egyptian Ebers Papyrus (1552 BC) lists more than 700 prescriptions, including aloes, opium, caraway, coriander, dill, juniper berries, gentian, and peppermint. The Bible mentions many botanicals. In his writings, Hippocrates discusses about 400 single herbs used as medicinal substances. According to Galen, Hippocrates prepared his own medicines and practiced pharmacy as well as medicine. He also believed strongly in diet as essential to recovery. Galen himself wrote more than 500 medical works; several of his surviving texts discuss 141 herbal remedies and their actions.

Pharmacognosy, the earliest scientific approach to botanical medicine, arose in the 18th and 19th centuries both in Europe and North America. It grew out of western thought and paradigms, stressing an analytical approach, seeking a mechanism of action, and applying active principles for each medicinal substance. Its reductionistic model was similar to contemporary orthodox medicine. The basic work from this tradition led to the isolation of many current botanically derived drugs, such as digitalis, cocaine, and morphine. The major texts of pharmacognosy include Felter and Lloyd’s King’s American Dispensatory and Ellingwood’s American Materia Medica Therapeutics and Pharmacognosy, both of which have been in continuous publication since the late 19th century.

Asia has a rich, unbroken written herbal tradition. Chinese herb books are known as Bun Cao, the first of which was the Shun Nun Bun Cao (approximately 150 AD). This text discusses the actions of 365 herbs. By 600 to 700 AD, various Chinese Materia Medica listed 800 medicinal herbs. In 1596, Li Sher Chen published a Materia Medica listing approximately 2000 herbs. As recently as 1972, approximately 5700 herbs were in the various Chinese Materia Medica; however, fewer than 1000 of these are commonly used. Most practitioners typically use 300 to 500 herbs.

Each Native American tribe has an herbal tradition. Many such traditions are oral, but some are written texts, such as the Badianus manuscript of the ancient Incas. Coca, chinchona (quinine), wintergreen, bloodroot, lobelia, goldenseal, mayapple (podophyllum), and echinacea are among significant North American medicinal plants.

Scientific evidence of the safety and efficacy of commonly used herbs is mounting. The chemical constituents of many commonly used herbs have long been established. A great deal of research is being done regarding specific herbs and specific phytochemical constituents. Popular herbs, such as gingko and echinacea, have quite a bit of literature supporting their use. Ayurvedic herbs are among the most well studied,
because the Indian government has long supported solid research about their use. In Europe, phytomedicine (plant medicine) is widely accepted. For example German physicians wrote over 2 million prescriptions for echinacea alone in 1998.

No independent licensure exists for herbalists anywhere in North America. For lay herbalists, a peer review guild, the American Herbalist Guild, has fairly high standards for admission, and members can exhibit the title AHG with their names. Primary care providers should check carefully into the training and experience of herbalists. Although many lay herbalists are outstanding, others claim titles like “master herbalist” after only a few weekends of classes. Herbs are potentially wonderful allies in healing patients, but some are dangerous and toxic as well. Practitioners should be sure to understand the nuances of herbal therapeutics, just as they would understand medications before prescribing them.

Appendix 4-2 provides brief general guidelines for some herbs commonly used in the pediatric population. Training in herbal medicine is urged before any of these herbs are prescribed. Reading these guidelines does not constitute training. These notes are not intended to provide instruction in herbal medicine or to advocate the use of these agents.

The term chiropractic, derived from the Greek, refers to treatment by manipulation. David Daniel Palmer developed this therapeutic and preventive system of healing around 1895. He discovered that manipulation of the spinal vertebrae could improve health not only in people with back pain, but also for those with conditions as diverse as heart disease, asthma, and headaches. He theorized these effects resulted from the existence of spinal subluxations, or subtle vertebrae displacements, that affected nerve conduction. Because spinal nerves innervate every body tissue and organ, even partial disruption of flow could have wide-ranging effects. Optimal health, then, would depend on unrestricted nerve impulse conduction. Later, other chiropractors devoted much study and research to the manipulation of peripheral joints to alleviate more distal structural problems.

Today, most chiropractors use a number of modalities. Some advise patients about diet and nutritional supplements and provide in-office massage, ultrasound treatment, acupuncture, and hydrotherapy. Many order laboratory tests, and most use x-rays in diagnosis.

Chiropractic is quite popular throughout the United States. Every state has independent professional licensure boards regulating who may practice chiropractic. They restrict the title to those who have completed a 4-year chiropractic college and passed proficiency examinations. Most states, however, do not regulate additional training required for the practice of other modalities under a chiropractic license, such as acupuncture and nutritional counseling.

Much research has validated the effectiveness of chiropractic for structural problems, such as back pain. Early studies by the Workman’s Compensation Administration found that patients treated by chiropractors for job-related injuries healed twice as quickly as patients who received orthodox medical care. Recent studies regarding chiropractic for other conditions, such as asthma, have failed to demonstrate any benefits. Because chiropractic traditionally was unpopular with the medical establishment, some animosity exists between conventional physicians and chiropractors. This situation, however, has been shifting toward greater cooperation in recent years.

Flower essence therapy is a safe and gentle form of treatment thought to be particularly suitable for children. Dr. Edward Bach, a London physician, developed flower essence therapy. He had a successful private practice in bacteriology and homeopathy; throughout the 1920s, however, he became disillusioned with both allopathic and homeopathic medicine, because he felt that both dealt with the results and not the causes of disease. In 1930, Bach left his home, family, and medical practice to embark on a period of itinerant wandering. During this time, he lived very simply, mostly in nature, and gave his services away for free. He relied greatly on his intuition and observations of personality and illness. Bach felt the true cause of disease was conflict between the soul and the mind. Over several years, he developed a system of healing that relied on inner attunement to the energy of flowers. The 38 remedies he developed are called the Bach flower remedies; they address the emotional and spiritual causes that Bach believed were responsible for all physical and emotional illnesses. Many still enthusiastically use these original remedies today; other providers have expanded this body of knowledge.

In making flower essences, practitioners first connect with the vibration of the plant and ask permission to take a few flowers. Generally they choose flowers in full bloom, often at midsummer. Then providers are intuitively guided to the appropriate flowers that wish to become medicine. Practitioners infuse them in pure water in the sunlight, until they feel that the essence is ready (usually when the flowers wilt). They then decant the essence and add food-grade alcohol as a preservative. They then dilute the essence in a manner similar to homeopathic dilution. A few drops of a flower essence are enough for one dose.

Many courses train practitioners to work with flower essences. No board or body, however, certifies competency or sets minimum standards for practice. This is as Bach himself would have preferred, because he conceived his healing system as one that would be quite accessible to lay people. Because the preparations are essentially homeopathic high dilutions, virtually no danger exists in using these remedies, even if one chooses an incorrect remedy. Flower remedies are considered to be safe for children and infants.

Homeopathy is a broad system of medicine practiced by numerous individuals from various backgrounds. Samuel Hahnemann, a German physician, was the founder of modern homeopathy. He expounded the “law of similars,” which is based on the principle that “like cures like.” That is, homeopathic doses that cause symptoms in a well person can cure the same symptoms in an ill person. So, for example, homeopaths might treat vomiting with ipecac (nux vomica), bee stings with apis mellifica (bee venom), and insomnia with coffea cruda (coffee).

Homeopaths believe that symptoms are the body’s attempt to restore homeostasis and thus should not be suppressed. In fact, the term “healing crisis” refers to the therapeutic activity of an appropriate remedy that temporarily exacerbates symptoms as the body corrects itself. In homeopathic thought, the suppression of symptoms by allopathic medicine actually may cause further imbalance.

Homeopathy is one of the most challenging types of complementary medicine for conventionally trained medical
practitioners to accept, because it is based on a different paradigm of health and illness. Practitioners discover and elaborate on remedies by “provings.” This method requires that practitioners give substances to be “proved,” some of which may be toxic (eg, mercury) to healthy individuals, who then meticulously record symptoms caused by their administration. Currently, Hahnemann and his successors have proven about 2000 remedies.

According to homeopathic principles, potentization occurs with increasing dilution, so the most dilute remedies are the most powerful. Frequently no actual molecules of the original substance remain in the remedy after successive dilutions. Remedies are prepared through decussation, which includes dilution and vigorous shaking at each stage. A 6x or 6c (the terms are used interchangeably) has been successively diluted and shaken six times. A 6x is a low potency, 30x is an average potency, and 100x, 200x, and 1 million x are high-potency extractions. Lower potencies typically are used for acute physical problems and many children’s remedies. Higher potencies are chosen more frequently for chronic or severe illness and psychological disturbance. Current homeopathic theory postulates that these remedies work by the principles of quantum physics rather than biochemistry, so efficacy is not ideally evaluated biochemically, especially initially.

Different forms of homeopathy are practiced worldwide. Classical homeopathy is an exacting and rigorous discipline that usually requires several years of training. Any individual, including a child, receives only one constitutional remedy at any given time. The homeopathic interview is painstaking and specific, eliciting broad information about symptoms, personality traits and preferences, food cravings, favorite colors, sleep patterns, and other diverse characterizations. Classical homeopaths also may advise patients to avoid all other therapies, including conventional medications, when using constitutional remedies. Homeopathy also is practiced as a form of first aid, where just a few matching symptoms are considered enough to select for an appropriate remedy. Other methodologies combine remedies simultaneously (combination remedies) or blend potencies of the same remedy (homaccords).

Because of the variety of approaches, some contention exists among practitioners about what constitutes homeopathy, who should be allowed to practice it, and what training is appropriate. Very few states license homeopathy, and in those, only medically trained practitioners (eg, MDs or DOs) may administer remedies. Nonetheless, in reality, most oral homeopathic remedies are available over the counter, and many lay people and practitioners prescribe them. In fact, relatively few physicians have embraced homeopathic prescribing, although recently the number has grown.

The literature contains some favorable studies of homeopathy. For example, a study of diarrhea in Nicaraguan children was done with randomization to two groups. One received appropriate hydration alone, while the other received identical hydration plus a homeopathic remedy. Although all the children recovered, those in the homeopathy group recovered twice as rapidly as those who received hydration alone.

Homeopathy is considered to be especially effective for children, because their constitutions are more pure and respond well to energetic medicine. In infants and young children, homeopathic remedies typically are given in liquid form. Pellets can be crushed and put into liquid for small children (usually hands should not touch them) if necessary. Older children, who can suck on small candies, can take the pellets, which typically are prepared in a pleasant lactose base. Homeopathy is considered to be extremely safe, precisely because, by Avogadro’s number, no molecules of the original substance actually are given. Thus, an incorrect remedy usually will have no effect rather than cause ill effects. This is especially true of milder remedies.

Display 4-2 lists some remedies commonly used for children, although many remedies might be appropriate in a variety of circumstances. The authors and publisher do not endorse homeopathy or these remedies. Training in homeopathy is urged before prescribing any of these remedies; reading these guidelines does not constitute training.