Pediatric integrative medicine can be defined as the blending of conventional and complementary therapies. The field emphasizes preventive health and addresses the diverse dimensions of health including physical, mental, and emotional factors. Although still a relatively new field, it was recognized as a specialty by the American Academy of Pediatrics (AAP) in 20051 and has an accruing wealth of robust supporting literature. Main principles of integrative medicine include the use of evidence-based therapies, support of the child's innate healing potential, and a collaborative therapeutic relationship between parent, child, and health care team.
What are the Primary Drivers of Interest in the Field?
One of the most important reasons for the general pediatrician to remain updated on this field is a high prevalence of patient use—often without disclosure to their clinician. Data from the 2012 National Health Interview Survey (NHIS) showed that 12% of children (about 1 in 9) used complementary therapies in the prior year, similar to the prevalence documented in the 2007 NHIS survey.2 Prevalence jumps to approximately 50% in children living with a chronic illness.2
Reasons for the use of integrative therapies vary and can range from a desire to improve child's baseline health to the goal of reducing exposure to prescription medications. The ability to offer expanded treatment options in cases where conventional therapies have been exhausted or can be augmented with complementary approaches are further arguments for the field.
To clarify, use of the term complementary refers to treatments used in conjunction with conventional medicine, as opposed to the term “alternative,” which historically describes treatments used in place of conventional medicine that typically lack robust supporting evidence for their use.
An example of varying approaches to a child with asthma may help define terms. Whereas a conventional approach to a child with chronic asthma includes regular primary care visits, preventive and rescue medications, emergency visits as needed, and pulmonary consult as appropriate, an integrative approach would add a selection of evidence-based therapies to further support the child's well being and potentially reduce medication exposure. Evidence-based complementary therapy approaches in pediatric asthma include nutrition, with emphasis on the Mediterranean diet to reduce systemic inflammation, and mind-body therapy approaches such as guided imagery, mindfulness, clinical hypnosis, or biofeedback to promote lower stress. Other approaches include breathing-related relaxation skills and yoga for its combined benefits of strength, breath control, and harnessing of the powerful mind-body connection.3
Many complementary therapies can be used on their own, although historically the term “integrative” implies their use in conjunction with conventional therapies.
Scope of the Field
The scope of the field of integrative medicine is quite broad and has been organized by the National Institutes of Health National Center for Complementary and Integrative Health to include three main categories: Natural Products, Mind and Body Practices, and Other Complementary Health Approaches.4 Although the list of included therapies is long (Table 1),4 the amount of supporting research varies between modalities, especially in pediatrics.
Commonly Used Complementary Products and Practices
In children and adolescents, the field traditionally includes the foundations of health—whole foods, restorative sleep, physical activity, healthy social connections, stress management, emotional growth, and prioritizing an environmentally healthy life whenever possible in the form of clean air, water, and food.
What are the Most Common Types of Integrative Therapies Used in Children?
The 2012 NHIS showed an increase from 3.9% in 2007 to 4.9% of children using dietary supplements, and a significant increase in the pediatric use of yoga, fish oil, and melatonin.2 Therapies used most frequently were reported as natural products (3.9%), chiropractic and osteopathic (2.8%), deep breathing (2.2%), yoga (2.1%), homeopathy (1.3%), traditional healers (1.1%), massage (1%), diet-based therapies (0.8%), and progressive relaxation (0.5%).2 Use was higher in children whose parents used complementary or alternative therapies themselves; this was evident in children with more than one health condition, and in children whose families could not afford conventional care. Fish oil was the most commonly used supplement in 2012, as compared to echinacea in 2007.2 Melatonin was the second most commonly used supplement in 2012.2 The conditions most commonly treated with complementary therapies remained constant from 2007 and included back or neck pain (6.7%), head or chest cold (6.6%), anxiety/stress (4.8%), other types of musculoskeletal (4.2%), attention-deficit/hyperactivity disorder (2.5%), and insomnia (1.8%).5
Strengths and Challenges of the Field
One of the main strengths of integrative medicine is its inherent flexibility, providing the ability to tailor treatments to children of nearly any age and those living with chronic health conditions. The field also promotes the child's inherent capacity for self-regulation, resiliency, and healing—even in cases when a cure is not possible. Elements of the field can be practiced in a wide variety of settings including outpatient, inpatient, acute care, and in palliative care.
However, a history of unethical promotion of alternative therapies to concerned parents, for example to those raising children with autism, has created a stigma that has slowed the legitimate progress of pediatric integrative medicine.6
A paucity of educational and training opportunities has further impeded understanding and acceptance, although this is slowly changing. Gaps in outcomes research is another challenge. Skeptical colleagues and complementary practitioners who take extreme positions (for example anti-vaccination) have polarized the field on both sides, slowing progress on research, educational, and clinical fronts. Ethical and legal considerations are a legitimate concern in integrative medicine. A full discussion of this important aspect of the field is beyond the scope of this article, although it has been thoroughly considered as the field has evolved in a range of published works in respected pediatric journals.7–11
Variability in credentialing, training, and licensure are further challenges and often vary state-to-state. Full understanding of the evidence surrounding individual therapies is critical for clinicians to guide parents in solid decision-making about appropriate therapies.
The fundamental questions of safety and efficacy should underlie any treatment decision in pediatrics. A decision algorithm developed by Kemper and Cohen is useful in this regard.12
How Can Integrative Medicine be Used in Pediatric Practice?
There are several ways to approach the question of how (and why) one might introduce integrative medicine into practice. For example, desire to introduce nonpharmacological approaches to stress, or to introduce effective programs for lifestyle change in patients who are overweight or obese that include evidence-based approaches to motivational interviewing, improved nutrition, increased physical activity, stress management, and increase in the sense of self-efficacy, all which can be integral to patient outcome.
Another way to approach the field consists of following personal interests and curiosity about a selected therapy. One example is an exploration of the of mind-body medicine that includes tools such as guided imagery and clinical hypnosis. Narrowing the approach to one area and identifying high-quality references and resources can reassure both practitioner and parent that the therapy has high potential value and make the introduction of a new treatment approach more successful. The AAP published its first Clinical Policy Statement on the use of mind-body therapies in children and youth in 2016.13
In Whom Should I Avoid Use of Integrative Medicine?
Integrative medicine therapies should be avoided in cases where their use would delay a straightforward cure; for example, treatment of strep throat with antibiotic treatment. Similarly, integrative medicine should not stand in the way of life-saving treatment; for example, urgent treatment of a new oncology diagnosis (although complementary therapies are being offered in many tertiary pediatric oncology and surgery centers as adjunctive care to standard treatment). As in conventional medicine, each integrative therapy has a potential downside and must be carefully considered for its risk/benefit ratio. Certain situations call for greater caution; for example, use of clinical hypnosis or guided imagery in a survivor of physical, sexual, or emotional abuse is not recommended without clearance from a credentialed mental health professional. Any use of an integrative therapy should be accompanied by a full understanding of its pros and cons.
How Can I Learn More About this Field?
A good place to begin is the AAP Pediatrics Section on Integrative Medicine, which offers educational resources, clinical policy guidelines, and national presentations on a wide range of integrative topics.14
Other useful resources include a series of special editions on pediatric integrative medicine with a range of contributions from national and international experts, with a deeper exploration of mind-body therapies in pediatrics and examples of the implementation into a wide range of clinical practice.15–18
- Esparham A, Misra S, Sibinga E, et al. Pediatric integrative medicine: vision for the future. Children (Basel). 2018;5(8):E111. doi:10.3390/children5080111 [CrossRef].
- Black LI, Clarke TC, Barnes PM, Stussman BJ, Nahin RL. Use of complementary health approaches among children aged 4–17 years in the United States: National Health Interview Survey, 2007–2012. Natl Health Stat Report. 2015;78:1–19.
- McClafferty H. An overview of integrative therapies in asthma treatment. Curr Allergy Asthma Rep. 2014;14(10):464. doi:. doi:10.1007/s11882-014-0464-2 [CrossRef]
- National Institutes of Health National Center for Complementary and Integrative Health. Complementary, alternative, or integrative health: what's in a name? https://nccih.nih.gov/health/integrative-health. Accessed May 15, 2019.
- Birdee GS, Phillips RS, Davis RB, Gardiner P. Factors associated with pediatric use of complementary and alternative medicine. Pediatrics. 2010;125(2):249–256. doi:. doi:10.1542/peds.2009-1406 [CrossRef]
- Polevoy T. Complementary medicine: risks to infants and children. J Clin Med. 2018;7(6):E149. doi:. doi:10.3390/jcm7060149 [CrossRef]
- McClafferty H, Vohra S, Bailey M, et al. Pediatric integrative medicine. Pediatrics. 2017;140(3):e20171961. doi:. doi:10.1542/peds.2017-1961 [CrossRef]
- Gilmour J, Harrison C, Asadi L, Cohen MH, Vohra S. Complementary and alternative medicine practitioners' standard of care: responsibilities to patients and parents. Pediatrics. 2011;128(suppl 4):S200–S205. doi:. doi:10.1542/peds.2010-2720J [CrossRef]
- Gilmour J, Harrison C, Asadi L, Cohen MH, Vohra S. Hospitals and complementary and alternative medicine: managing responsibilities, risk, and potential liability. Pediatrics. 2011;128(suppl 4):S193–S199. doi:. doi:10.1542/peds.2010-2720I [CrossRef]
- Gilmour J, Harrison C, Asadi L, Cohen MH, Vohra S. Informed consent: advising patients and parents about complementary and alternative medicine therapies. Pediatrics. 2011;128(suppl 4):S187–S192. doi:. doi:10.1542/peds.2010-2720H [CrossRef]
- Gilmour J, Harrison C, Asadi L, Cohen MH, Vohra S. Referrals and shared or collaborative care: managing relationships with complementary and alternative medicine practitioners. Pediatrics. 2011;128(suppl 4):S181–S186. doi:. doi:10.1542/peds.2010-2720G [CrossRef]
- Kemper KJ, Cohen M. Ethics meet complementary and alternative medicine: new light on old principles. Contemp Pediatr. 2004;21(3):61–72.
- Section on Integrative Medicine. Mind-body therapies in children and youth. Pediatrics. 2016;138(3):e20161896. doi:. doi:10.1542/peds.2016-1896 [CrossRef]
- American Academy of Pediatrics. Section on integrative medicine. https://www.aap.org/en-us/about-the-aap/Sections/Section-on-Integrative-Medicine/Pages/SOIM.aspx. Accessed May 15, 2019.
- McClafferty H. Mind-body medicine in pediatrics. Pediatrics. Children (Basel). 2017;4(9):E76. doi:10.3390/children4090076 [CrossRef].
- Hall M, Bifano SM, Leibel L, Golding LS, Tsai S-L. The elephant in the room: the need for increased integrative therapies in conventional medical settings. Children (Basel). 2018;5(11):E154. doi:10.3390/children5110154 [CrossRef].
- Esparham A, Herbert A, Pierzchalski E, et al. Pediatric headache clinic model: implementation of integrative therapies in practice. Children (Basel). 2018;5(6):E74. doi:10.3390/children5060074 [CrossRef].
- Ramesh G, Gerstbacher D, Arruda J, Golianu B, Mark J, Yeh AM. Pediatric integrative medicine in academia: Stanford Children's Experience. Children (Basel). 2018;5(12):E168. doi:10.3390/children5120168 [CrossRef].
Commonly Used Complementary Products and Practices
| Vitamins and minerals|
| Guided imagery|
| Clinical hypnosis|
| Massage therapy|
| Relaxation techniques (breathing, progressive muscle relaxation)|
| Osteopathic manipulation|
| Tai chi|
| Feldenkrais method|
| Alexander technique|
|Other complementary health approaches|
| Traditional Chinese medicine|
| Ayurvedic medicine|
| Functional medicine|