The UseofComplementary and Alternative Medicine in Pediatrics

CLINICAL REPORT
The Use of Complementary and
Guidance for the Clinician in Rendering
Pediatric Care
Alternative Medicine in Pediatrics
Kathi J. Kemper, MD, MPH, Sunita Vohra, MD, Richard Walls, MD, PhD, the Task Force on Complementary
and Alternative Medicine, the Provisional Section on Complementary, Holistic, and Integrative Medicine
ABSTRACT
The American Academy of Pediatrics is dedicated to optimizing the well-being of
children and advancing family-centered health care. Related to these goals, the
www.pediatrics.org/cgi/doi/10.1542/
peds.2008-2173
American Academy of Pediatrics recognizes the increasing use of complementary
and alternative medicine in children and, as a result, the need to provide infor-
doi:10.1542/peds.2008-2173
mation and support for pediatricians. From 2000 to 2002, the American Academy
All clinical reports from the American
Academy of Pediatrics automatically expire
of Pediatrics convened and charged the Task Force on Complementary and Alter-
5 years after publication unless reaffirmed,
native Medicine to address issues related to the use of complementary and alter-
revised, or retired at or before that time.
native medicine in children and to develop resources to educate physicians,
The guidance in this report does not
patients, and families. One of these resources is this report describing complemen-
indicate an exclusive course of treatment
tary and alternative medicine services, current levels of utilization and financial
or serve as a standard of medical care.
Variations, taking into account individual
expenditures, and associated legal and ethical considerations. The subject of com-
circumstances, may be appropriate.
plementary and alternative medicine is large and diverse, and consequently, an
Key Words
in-depth discussion of each method of complementary and alternative medicine is
complementary, alternative, patient-
beyond the scope of this report. Instead, this report will define terms; describe
centered, communication, ethics,
epidemiology; outline common types of complementary and alternative medicine
epidemiology, health services, integrative
therapies; review medicolegal, ethical, and research implications; review educa-
Abbreviations
NCCAM—National Center for
tion and training for complementary and alternative medicine providers; provide
Complementary and Alternative Medicine
resources for learning more about complementary and alternative medicine; and
NIH—National Institutes of Health
suggest communication strategies to use when discussing complementary and
CAM— complementary and alternative
alternative medicine with patients and families. Pediatrics 2008;122:1374–1386
medicine
AAP—American Academy of Pediatrics
TCM—traditional Chinese medicine
FDA—Food and Drug Administration
DSHEA—Dietary Supplements Health and
INTRODUCTION
Education Act
The National Center for Complementary and Alternative Medicine (NCCAM) of
RCT—randomized, controlled trial
the National Institutes of Health (NIH) defines complementary and alternative
PEDIATRICS (ISSN Numbers: Print, 0031-4005;
medicine (CAM) as a group of diverse medical and health care systems, practices,
Online, 1098-4275). Copyright © 2008 by the
American Academy of Pediatrics
and products that are not presently considered to be part of conventional Western
medicine.1 Complementary medicine is used in conjunction with conventional
medicine; for example, massage, guided imagery, and acupuncture may be used in
addition to analgesic medications to help decrease pain. Alternative medicine is used in place of conventional
Western medicine; for example, some adolescents use herbs rather than antidepressant medications to treat
depression.
The distinction between CAM and mainstream medicine has lessened as many practices have undergone rigorous
research and have been integrated increasingly into mainstream care. For example, guided imagery and massage
have been proven to be effective in the treatment of pain and are now included in many tertiary care settings.2–5 Since
the American Academy of Pediatrics (AAP) convened the Task Force on Complementary and Alternative Medicine
in 2000 and since the creation of the NCCAM, these complexities inherent in the definition of CAM have become
more problematic. Given the wide usage and general understanding of the term “CAM,” it will be used throughout
this report. However, the term “CAM” has been replaced increasingly with “holistic” or “integrative” medicine.
Holistic medicine refers to patient-centered care that includes consideration of biological, psychological, spiritual,
social, and environmental aspects of health. Integrative medicine is relationship-based care that combines main-
stream and complementary therapies for which there is some high-quality scientific evidence of safety and effec-
tiveness to promote health for the whole person in the context of his or her family and community.1 Integrative
medicine also reaffirms the importance of the relationship between the practitioner and the patient, emphasizes
wellness and the inherent drive toward healing, and focuses on the whole person, using all appropriate therapies to
achieve the patient’s goals for health and healing.6
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The AAP Provisional Section on Complementary, Ho-
statement from the AAP Committee on Children With
listic, and Integrative Medicine, established in 2005, also
Disabilities, “Counseling Families Who Choose Comple-
contributed extensively to this report.
mentary and Alternative Medicine for Their Child With
Chronic Illness or Disability,”43 recognized that the use of
Epidemiology
CAM is increasing and provides information and guid-
The use of CAM in Western medicine has grown dra-
ance for pediatricians when counseling families about
matically in recent decades. Many CAM therapies, such
CAM.
as herbal remedies, are mainstream or traditional in
many parts of the world. The World Health Organization
Patients’ Characteristics and Reasons for Using CAM
estimates that most of the world’s population regularly
Children who use CAM are more likely to be seeing their
uses “traditional medicine” such as traditional Chinese
pediatrician for an illness, take medication on a regular
medicine (TCM), Ayurvedic medicine, and Native Amer-
basis, and have ongoing medical problems.14 Approxi-
ican healing practices.
mately half of parents/caregivers of children who used
In the United States, more than one third of adults
CAM saw a CAM provider for themselves. The majority
have used CAM.7 The total number of visits to CAM
(66%) of parents/caregivers of CAM users had not in-
providers increased by 47.3%, from 420 million visits in
formed their child’s doctor of the use of CAM for their
1990 to 629 million visits in 1997.8 The number of visits
child.14 There has been no consistent connection be-
to CAM providers in 1997 exceeded the total number of
tween CAM use and parent income, children’s gender,
visits to primary care physicians in the same year.8 Esti-
or usual source of care,13,14,16–19,44 and there have been
mated expenditures for CAM services for adults in-
mixed findings connecting CAM use and parent educa-
creased by 45.2% between 1990 and 1997, with a con-
tion level, family ethnicity, insurance coverage, and
servative estimate of $21.2 billion spent in 1997. Of that
child’s age.13,16–19,44,45
total, out-of-pocket expenses were estimated to be $12.2
There are various reasons for the growing use of
billion. This figure exceeded the 1997 out-of-pocket ex-
CAM. Many users of CAM reported use “not so much as
penditures for all US hospitalizations.8 More recent stud-
a result of being dissatisfied with conventional medicine,
ies have described CAM use among adults as high as
but largely because they found these health care alter-
62%,9 with 41% of adults using 2 or more CAM thera-
natives to be more congruent with their own values,
pies in a 12-month period.10
beliefs, and philosophical orientations toward health and
Children and adolescents also are using CAM ther-
life.”46 Parents’ reasons for seeking care for their children
apies increasingly. Weighted estimates of the amount
from CAM providers included, in decreasing order of
paid for pediatric expenditures on CAM visits and
frequency, word of mouth, particular treatment was
remedies were $127 million and $22 million, respec-
considered effective, fear of drug adverse effects, dissat-
tively.11 An analysis of the 1996 US Medical Expendi-
isfaction with conventional medicine, and the need for
ture Panel Survey indicated that only 2% of the pe-
more personal attention.13 In addition, many cultural
diatric population uses CAM.12 However, an early
groups may use CAM because of cultural values and
study of Canadian children reported 11% use of pro-
beliefs.
fessionally provided CAM therapies, with chiropractic,
homeopathy, naturopathy, and acupuncture account-
ing for 84% of CAM use.13 Approximately 20% to
Insurance Coverage
40% of healthy children seen in outpatient pediatric
Many insurers offer coverage for CAM services. A 1996
clinics14–17 and more than 50% of children with
survey of managed care organizations reported that 70%
chronic, recurrent, and incurable conditions use CAM,
of surveyed plans have experienced an increased de-
almost
always
in
conjunction
with
mainstream
mand from members for CAM services and that 58%
care.18–20 The use of CAM is considerably higher in
intended to offer some services within the next 2 years.47
certain groups of children, including children with
A 2004 Kaiser Family Foundation employer survey re-
special health care needs21 and homeless adolescents,
vealed that 87% of covered employees had chiropractic
who have a reported use as high as 70%.22 Use tends
coverage, and 47% had acupuncture coverage.48 The
to be most common among patients with asthma,23–25 at-
Landmark Report II on Health Maintenance Organiza-
tention-deficit/hyperactivity disorder,26–28 autism,29–31 can-
tions and Alternative Care reported that 67% of health
cer,32–36 cerebral palsy,37 cystic fibrosis,38 inflammatory
maintenance organizations offer some type of alterna-
bowel disease,39,40 and juvenile rheumatoid arthritis.41
tive care.49 In addition, many Medicaid programs pay for
Presently, there is little research on the effectiveness of
the use of some CAM services. Of 46 reporting states, 36
most CAM therapies for many of these conditions.42 The
(78.3%) Medicaid programs provide coverage for at least
NCCAM funds various studies, but to date, they have not
1 alternative therapy,50 most commonly chiropractic
addressed the pediatric population as a priority focus
care (reimbursed by 33 programs), biofeedback (reim-
area for research.
bursed by 10 programs), acupuncture (reimbursed by 7
Most pediatric patients who receive complementary
programs), and hypnotherapy and naturopathy (reim-
therapies also receive conventional care.13 This fact un-
bursed by 5 programs each).50 Because state Medicaid
derscores the importance of pediatricians being aware of
benefits packages change frequently, pediatricians are
the necessity to have an open, respectful relationship
encouraged to become familiar with their state’s list of
and clear communication with families. A 2001 policy
covered services.
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Some states require coverage for CAM services. In
Medicine urged the NCCAM to consider increasing their
1996, Blue Cross of Washington launched a plan called
priorities and funding for pediatric research, education,
AlternaPath in response to the passing of a Washington
and information dissemination (Harry Gewanter, MD,
state law in the same year mandating that all commercial
verbal communication).
health insurance companies cover the services provided
In 2000, the US President and Congress assembled
by every category of licensed provider.51 Currently, most
and mandated the White House Commission on Com-
states require coverage of chiropractic care, and more
plementary and Alternative Medicine Policy to make
than 50% of all health maintenance organizations cover
administrative and legislative recommendations to max-
these services.47 Although very few states mandate cov-
imize the benefits of CAM for Americans. Comprising 20
erage of acupuncture or massage therapy, these services
physicians and other clinicians, CAM providers, and
are quickly becoming part of many insurers’ benefit
other experts, the commission was charged with devel-
plans. The scope of services covered by insurers varies
oping a report to address the following:
considerably; most coverage is disease-treatment ori-
ented, with limited (either by scope or by number) visits
● education and training of clinicians;
allowed per diagnosis. Many plans offer a separate rider
● research to increase knowledge regarding CAM;
for purchase by either the employer or employee at an
● provision of reliable information to clinicians and the
additional cost, and other plans offer CAM coverage as
public; and
an embedded benefit to everyone in the program. An-
other type of program is an affinity discount network, in
● guidelines for appropriate access to and delivery of
which certain CAM providers are designated as members
CAM.
of the network. Members of the program pay providers
In March 2002, the commission issued its report,
directly at a discounted fee.52
which addressed these charges and examined the rele-
In a 1998 survey, the most common treatment mo-
vance of CAM to national efforts to promote health, and
dality covered by insurance plans was chiropractic care,
created a central coordinating office. The report included
with coverage ranging from 41% to 65%. By contrast,
29 recommendations and more than 100 action items
homeopathic treatments were covered by only 4% to
for federal agencies, Congress, state government, and
11% of all plans; acupuncture was covered by 9% to
other groups.54
19%; biofeedback was covered by 4% to 10%; and
In 2005, at the request of the NIH and the Agency for
massage therapy was covered by 6% to 10%.52
Healthcare Research and Quality, the Institute of Medi-
Despite the public’s increasing use of CAM therapies
cine released the report Complementary and Alternative
and willingness to pay out-of-pocket for these services,
Medicine in the United States. The report assessed what is
health insurers have had difficulty including them in
known about Americans’ reliance on CAM therapies and
their plans because of variation in credentialing, difficul-
assisted the NIH in developing research methods and
ties with accounting, and because there are so few Cur-
setting priorities for evaluating such products and ther-
rent Procedural Terminology (CPT) codes that cover these
apies.55
services.52 Although there are CPT codes that cover some
The US Food and Drug Administration (FDA) also has
CAM techniques, CAM providers may find them difficult
weighed in on CAM-related issues. The Dietary Supple-
to implement because of philosophical differences with a
ments Health and Education Act of 1994 (DSHEA)
system that singles out disease states or organs from the
amended previous FDA statutes to encompass dietary
whole person. Some CAM providers use a separate cod-
supplement–specific provisions, including the definition
ing system of more than 4000 codes for CAM procedures
of a “dietary supplement,” product safety, nutritional
and supplies, known as the alternative billing concept or
statements and claims, ingredient and nutritional label-
“ABC” codes.53
ing, good manufacturing procedures, and the classifica-
tion of “new” dietary ingredients.56
Government Response
Under the DSHEA, a dietary supplement is:
The Office of Alternative Medicine was established as
part of the NIH by congressional mandate in 1992. In
● a product (other than tobacco) intended to supple-
1998, the Office of Alternative Medicine became the
ment the diet that bears or contains 1 or more of the
NCCAM. The NCCAM has increased its fiscal-year ap-
following ingredients: a vitamin, a mineral, an herb or
propriations from $50 million in 1998 to an estimated
other botanical, or an amino acid;
$123 million in 2006.1 Total funding by all institutes and
centers of the NIH for research and training on CAM and
● intended for ingestion in pill, capsule, tablet, or liquid
the training of investigators to study CAM exceeded
form;
$225 million in 2006, with additional funding being
● not used as a conventional food or as the sole item of
provided by other agencies and philanthropic founda-
a meal or diet; and
tions.1 Of the approximately 360 NCCAM-funded re-
● labeled as a dietary supplement.
search projects in 2006, fewer than 5% were related to
pediatrics, including research on the effects of massage
This classification of dietary supplements is specifi-
for preterm infants, probiotics, omega-3 fatty acids, and
cally separate from food or drug categories and, as such,
food allergies.1 In 2007 and 2008, the AAP Provisional
lies outside the jurisdiction of many of the safety and
Section on Complementary, Holistic, and Integrative
regulatory rules that cover food and drugs.56
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According to the DSHEA, manufacturers bear the
TABLE 1
The Kemper Model of Holistic Care
burden of proof of ingredient safety of dietary supple-
Component
Example
ments. However, unlike pharmaceutical preparations,
Biochemical
Medications, dietary supplements, vitamins, minerals,
dietary supplements can be marketed without proven
herbal remedies
safety or efficacy. A manufacturer does not have to
Lifestyle
Nutrition; exercise/rest; environmental therapies such
provide the FDA with the evidence on which it relies to
as heat, ice, music, vibration, and light; mind-body
substantiate safety or effectiveness before or after it mar-
therapies (behavior management, meditation,
kets its products. For new ingredients, the manufacturer
hypnosis, biofeedback, counseling)
is only required to provide evidence to the FDA that the
Biomechanical
Massage and bodywork, chiropractic and osteopathic
product is “reasonably expected to be safe.”56
adjustments, surgery
Manufacturers of supplements are not required to
Bioenergetic
Acupuncture, radiation therapy, magnets, Reiki,
report any data on adverse events to the FDA. The FDA
healing touch, qi gong, therapeutic touch, prayer,
can demonstrate that a supplement is unsafe only after it
homeopathy
reaches the market. The FDA must prove that the prod-
uct is unsafe before it can restrict a product’s use or take
other legal action. The FDA largely relies on the Med-
A growing number of pediatric generalists and sub-
Watch voluntary reporting system to collect safety data
specialists have begun to offer complementary therapies
on dietary supplements.57
and advice as part of their practice. In addition, there is
The DSHEA also regulates third-party literature re-
a growing number of academic pediatric integrative
garding dietary supplements. Informational materials
medicine programs and new initiatives to promote sys-
(ie, articles, fact sheets, etc) may be displayed in com-
tematic sharing, support, and dissemination of informa-
mercial retail sites provided they are displayed separately
tion to improve collaborative and comprehensive care.
from the product, do not contain false or misleading
These initiatives include the AAP Provisional Section on
information, and do not promote a specific brand of
Complementary, Holistic, and Integrative Medicine61;
supplement. Most important, the DSHEA regulates the
the International Pediatric Integrative Medicine Net-
labeling of dietary supplements. Under this provision,
work; and the Pediatric Complementary and Alternative
any claims to prevent, treat, or cure a specific disease are
Medicine Research and Education Network.62 However,
expressly prohibited (unless approved by the FDA). La-
these initiatives may be insufficient to ensure consistent,
bels can include statements describing the supplement’s
quality education across the spectrum of medical educa-
effects on the “structure and function” or general “well-
tion. Standardized curricula or content specifications for
being” of the body as long as they are truthful and bear
physician education on CAM therapies should be con-
the statement, “This statement has not been evaluated
sidered for medical school, residency, and continuing
by the Food and Drug Administration. This product is
medical education activities.
not intended to diagnose, treat, cure, or prevent any
disease.”56
COMMON CAM THERAPIES
Finally, like food products, dietary supplements are al-
As a means of understanding and integrating different
lowed to have suggested dosages on the label and must
modalities encompassing complementary and main-
bear nutritional labeling. The label must include the name
stream therapies, the Kemper model of holistic care (Ta-
and quantity of each dietary ingredient, and if the ingredi-
ble 1) has been widely accepted.63 This paradigm inte-
ent is botanical in origin, the label must state the part of the
grates complementary and mainstream therapies into a
plant from which the ingredient is derived.56
coherent construct of treatment options.63 Another
model for understanding CAM therapies has been de-
Physician Awareness, Attitude, and Perception
veloped by the NCCAM. This framework focuses on
In 1995, the American Medical Association passed a
CAM rather than integration of therapies. The most
resolution suggesting that its 300 000 members be-
common CAM therapies used by infants, children, and
come better informed regarding the practices and
adolescents within the NCCAM framework follow. A
techniques of CAM.57 Many primary care physicians,
complete description of all therapies and scientific evi-
including pediatricians, recommend and refer patients
dence regarding each of them is beyond the scope of this
for complementary therapies.58,59 In the 2001 AAP
report.
Periodic Survey 49, “Complementary and Alternative
Therapies in Pediatric Practice,” pediatricians reported
Biologically Based Practices (Use of Vitamins, Herbs, Other
that they recognize patients’ frequent use of CAM
Dietary Supplements, Diets, and Foods)
therapies and expressed a strong desire for additional
According to the NCCAM, biologically based practices
education on CAM topics.60 Topics of greatest imme-
include the use of botanicals, animal-derived extracts,
diate interest included herbs, dietary supplements,
vitamins, minerals, fatty acids, amino acids, proteins,
special diets, and exercise. More than one third of the
prebiotics and probiotics, whole diets, and functional
pediatricians reported that they or their families used
foods.1 Of these, multivitamins are the most frequently
some type of CAM therapy. Of those reporting CAM
used CAM products by children, with up to 41% re-
use, 70% used massage therapy, 21% received chiro-
ported usage.14,15 Among teenagers who use CAM,
practic care, 13.5% consulted a spiritual or religious
nearly 75% use herbs and other dietary supplements.64
healer, and 13% had used acupuncture.60
Controlled studies have investigated the use of dietary
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supplements for various conditions including asthma,
Massage is another common manipulative practice
upper respiratory infections, diarrhea, depression, anxi-
that is frequently provided at home by parents and by
ety, and attention-deficit/hyperactivity disorder.65–67
licensed massage therapists and nurses in clinical set-
Several studies are in progress, and the research litera-
tings. Massage is now routine practice in many NICUs to
ture is expanding rapidly. For example, the use of pro-
promote growth and development in preterm infants.2–4
biotics was considered complementary in the mid-1990s
Massage also has been demonstrated to be beneficial in
but has become mainstream practice in the 21st century
alleviating symptoms from asthma, insomnia, colic, cys-
as many gastroenterologists recommend and use them
tic fibrosis, and juvenile rheumatoid arthritis.87–92
in daily practice for patients with inflammatory bowel
disease.
Mind-Body Medicine
There are a number of excellent review articles on the
As defined by the NCCAM, mind-body medicine in-
use of herbal products in pediatric populations64–66,68,69 as
cludes diverse practices such as relaxation, visual imag-
well as data on potentially toxic herbal products and
ery, tai chi, qi gong, yoga, meditation, prayer, hypnosis,
herb-drug interactions.70–79 Because of regulations differ-
biofeedback, diaphragmatic breathing, progressive mus-
ing from those governing the use of pharmaceuticals,
cle relaxation, and cognitive-behavioral therapies. Many
there are concerns about the purity and potency of
of these practices, particularly prayer, are commonly
herbal products and other dietary supplements sold in
used among adults.11 In children, popular techniques
the United States. Product quality is influenced by many
include prayer, progressive relaxation exercises, medita-
factors, including which portion of the plant is used (ie,
tion, biofeedback, and hypnosis.14,15 Hypnotherapy en-
root, stem, leaves, flowers), the time of harvest (ie,
courages the child to use his or her imagination to im-
young versus old plants), the handling of the product,
prove health and health behaviors.
and proper identification of the plant. Furthermore, la-
Guided imagery, hypnosis, and biofeedback have
beling is often inaccurate.80–82 To conduct research, the
been shown to be effective adjuncts to medical therapy
quality of product must be guaranteed, and to compare
for such common conditions as chronic, acute, and re-
clinical trials, the similarity of product must be ensured.
current pain; anxiety and stress disorders; enuresis; en-
Dietary therapies such as the ketogenic diet in the
copresis; sleep disorders; autonomic nervous system dys-
treatment of seizure disorders83 have become an ac-
regulation; habitual disorders; attention and learning
cepted practice for some health conditions. However, the
disorders; asthma; cancer; and diabetes.5 These therapies
popularity of other diets has risen to a new level as the
generally have few or no adverse effects.5
prevalence of obesity and metabolic syndrome has in-
Spiritual healing includes prayer and is the most prev-
creased and traditional exercise and diet “prescriptions”
alent complementary therapy in the United States.9 Spir-
have failed. The macronutrient content of these popular
itual healing is sometimes included under the rubric of
diets varies widely.1
mind-body therapies and sometimes under the rubric
of biofield or bioenergetic therapies.1 Eighty-two per-
Manipulative and Body-Based Practices
cent of Americans believe in the healing power of
As defined by the NCCAM, manipulative and body-
personal prayer, 73% believe that praying for someone
based practices include chiropractic and osteopathic ma-
else can help cure their illness, and 77% believe that God
nipulation, massage therapy, reflexology, Rolfing, Bo-
sometimes intervenes to cure people who have a serious
wen technique, and Trager approach.1
illness.93 Prayer is used by up to two thirds of parents for
Chiropractic care is one of the most common profes-
their children.14,15
sionally provided CAM practices. It focuses on the rela-
Studies have suggested that spiritual/religious beliefs
tionship between body structure (primarily that of the
and practices may contribute to decreased stress and
spine) and bodily function and how that relationship
increased sense of well-being and enhanced immune
affects health. With more than 50 000 chiropractors li-
system functioning.93 RCTs of the clinical therapeutic
censed in the United States, the number of children
effects of prayers in pediatrics are lacking. Some states
visiting chiropractors is substantial and increasing.84 Re-
have pursued legal measures against parents seeking to
cent studies have confirmed that up to 14% of all chi-
use prayer or spiritual healing as an alternative to con-
ropractic visits were for pediatric patients14,15 and that
ventional medical therapy for children with serious
chiropractors were the most common CAM providers
medical problems such as cancer. However, most fami-
visited by children and adolescents.14 Few randomized,
lies view spiritual healing as a personal practice that is
controlled trials (RCTs) have demonstrated significant
complementary to medical care rather than a replace-
clinical benefits of chiropractic practices among pediatric
ment for it.
patients85; additional studies are needed, and parents
need to be cautioned not to rely on chiropractic care as
the primary treatment for serious conditions such as
Biofield Therapies
cancer. Although anecdotal data suggest that severe
According to the NCCAM, biofield therapies are “in-
complications are possible with chiropractic treatment of
tended to affect energy fields that purportedly surround
infants and children, such adverse effects seem to be
and penetrate the human body.” These therapies “ma-
rare.86 Further systematic studies are needed to deter-
nipulate biofields by applying pressure and/or manipu-
mine the costs, benefits, and safety of this widely used
lating the body by placing the hands in, or through,
practice.
these fields.”1 Biofield techniques include acupuncture,
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homeopathy, polarity therapy, magnet therapy, Japa-
edies, most often for respiratory problems, teething, oti-
nese Reiki and Johrei, Chinese qi gong, therapeutic
tis media, and other conditions related to the ears, neck,
touch, healing touch, and spiritual healing.
and throat.14,15
Perhaps the best known of the noninvasive biofield
therapies is therapeutic touch, which is taught in more
SPECIAL POPULATIONS
than 80 nursing schools and provided in numerous hos-
pitals in the United States. Therapeutic touch is a form of
Adolescents
energy medicine that has been developed by nurses on
Numerous reports have described the frequent use of
the basis of the premise that healing is promoted when
CAM by adolescents.44,102–106 In Seattle, Washington,
the body’s energies are in balance. Nurse-healers are
70% of homeless adolescents reported using some form
trained to identify and treat energy imbalances to im-
of CAM,22 and among 9th- and 12th-grade students in
prove the patient’s well-being.94
Massachusetts, herbal remedies were used by up to 20%
Studies on the effectiveness of biofield therapies in
of respondents.107 In a survey of New York teenagers, the
pediatric populations have been limited, but the thera-
most frequently used therapies were massage, prayer or
pies are generally safe.95,96
faith healing, herbs, vitamins, performance-enhancing
supplements, and special exercises.105 Many adolescents
use supplements to improve their body image or athletic
Acupuncture
performance. As many as 4.5% of boys and 0.8% of girls
Acupuncture has been one component of TCM, which
in secondary school used creatine108; of those, 73% were
also includes herbal remedies, diet, massage, and life-
student athletes.
style. Today, acupuncture describes a family of proce-
In general, adolescents seem to be more open than
dures involving stimulation of anatomic points on the
adults are to using CAM therapies, and adolescents are
body by a variety of techniques. American practices of
more inclined to use CAM if their parents also use these
acupuncture incorporate medical traditions from China,
therapies.103 Adolescence is characterized by increasing
Japan, Korea, and other countries. The acupuncture
cognition, independence, increased desire for privacy
technique that has been most studied scientifically in-
and autonomy, and higher incidence of risky behavior.
volves penetrating the skin with thin, solid, metallic nee-
In addition, as they begin to take responsibility for their
dles that are manipulated by hand or by electrical stimu-
own health needs, adolescents also may use CAM ther-
lation.1 Variants of needle therapy include stimulation of
apies as self-treatment. The Internet is also becoming a
acupuncture points by vigorous massage (shiatsu), heat
larger influence on the lives of teenagers. Many dietary
(moxibustion), lasers, magnets, gentle massage or pressure
supplements are promoted on the Internet and promise
(acupressure), or electrical currents.
relief of adolescent concerns such as acne and obesity, or
Acupuncture is used by an increasing number of pe-
they promise enhanced energy and sports performance.
diatric patients. A meta-analysis of the use of acupunc-
Some pediatricians refer patients to CAM providers or
ture in the treatment of recurrent headaches suggested
provide complementary therapies themselves, integrat-
potential benefit.97 Additional applications for acupunc-
ing them into conventional medical practice.
ture may include nausea, pain, and allergy.98–101
Children With Chronic Illness or Disability
Whole or Traditional Medical Systems
Children with special health care needs are frequent
Whole medical systems involve complete systems of the-
users of CAM. The rate of CAM use for this population is
ory and practice that have evolved independently from
estimated to be 30% to 70%.21,29–41 In a recent survey of
or parallel to conventional Western medicine.1 They
families of children with developmental disabilities, fam-
include homeopathy, naturopathic medicine, TCM,
ilies wanted their clinicians to be able to counsel them
Ayurvedic medicine (India’s traditional system of med-
about CAM options.109 An overview of these issues and
icine), and healing systems of American Indian/Alaska
recommendations for counseling children with special
Native, African, Middle Eastern, Tibetan, and other in-
health care needs and their families is outlined in a 2001
digenous populations.
AAP Committee on Children With Disabilities state-
ment, “Counseling Families Who Choose Complemen-
Homeopathy
tary and Alternative Medicine for Their Child With
Developed by Samuel Hahnemann in 1790, homeopa-
Chronic Illness or Disability.”43
thy is based on the theory that “like cures like,” meaning
that small, highly diluted quantities of medicinal sub-
Ethnic and Cultural Groups
stances are given to cure symptoms, when the same
Use of CAM therapies varies among different ethnic and
substances given at higher or more concentrated doses
cultural groups. Excluding prayer, CAM is used less
would actually cause those symptoms.1 Unlike classic
commonly by Hispanic and black individuals than by
pharmacology, homeopathy follows the theory that the
white individuals, and its use by Hispanic and black
greater the dilution, the greater the potency of the prod-
people is less likely to be disclosed to clinicians.110 Fam-
uct. In the United States, an estimated 3000 clinicians,
ilies of different cultural backgrounds use different
including physicians, nurses, chiropractors, naturopaths,
herbs, over-the-counter remedies, and other items tra-
and dentists, use homeopathy in their practices.101 A
ditionally used for cooking as home remedies.111,112
range of 2% to 10% of children use homeopathic rem-
Many ethnic and cultural groups also use traditional
PEDIATRICS Volume 122, Number 6, December 2008
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healing practices such as TCM, Ayurvedic medicine, and
increase 88% between 1994 and 2010, compared with a
American Indian/Alaska Native healing practices, which
16% increase in the number of physicians. However,
can include a variety of diverse therapies and native
few CAM providers undergo extensive education or
healers within a coherent cultural belief system.113,114 Use
training specific to pediatric populations. For example,
of these remedies is often integrated with conventional
although chiropractic training typically lasts 4 years, pe-
medicine but may not be reported unless the clinician
diatric certification in chiropractic requires only a 10-
specifically inquires about them.110
module, 120-hour certification program.121 Naturopathic
training at the 4 US colleges also typically requires 2000
RESEARCH ISSUES
hours of training over 4 years, which includes clerkships
Although many CAM therapies have not yet been eval-
in dermatology, family medicine, psychiatry, medicine,
uated formally in children, a 2002 review identified
radiology, pediatrics, obstetrics and gynecology, neurol-
more than 1400 RCTs and 47 systematic reviews of
ogy, surgery, and ophthalmology.122 Some CAM training
pediatric CAM.115 Formal evaluation has suggested that
programs do not offer any specific training for diagnos-
the quality of RCTs of CAM is as good as that of RCTs of
ing or treating pediatric patients.
conventional medicine,116 and the quality of systematic
Many CAM providers seek additional training in
reviews of CAM exceeds that of systematic reviews of
pediatrics.123 Likewise, many physicians seek addi-
conventional medicine.117 It should be noted that publi-
cation bias in CAM research is opposite that of conven-
tional training in CAM. As of 1998, 64% of US medical
tional medicine; that is, negative studies are more likely
schools reported having CAM curricula,124 and 18 of
to be published in well-known journals, and positive
the 19 colleges of osteopathic medicine offered CAM
studies are more likely to be published in foreign-lan-
instruction.125 These programs have a wide range of
guage journals.118 Those interested in promoting an ev-
content and quality. Although many medical schools
idence-based approach to the use of CAM therapies must
and residency programs offer survey courses on
be cognizant of the bias created by applying language
CAM,126,127 the extent to which pediatric residencies
restrictions in their search strategy. Other approaches to
and postgraduate courses address educational needs
evidence-based
CAM
include
n-of-1
evaluation,
about CAM are unknown.128–131 However, there have
whereby methodologic rigor (eg, blinding, randomiza-
been significant gains in the growth of academic inte-
tion) is combined with an individualized approach fun-
grative medicine since the establishment of the Con-
damental to many CAM therapies.119
sortium for Academic Health Centers for Integrative
There are some unique considerations when examin-
Medicine in 2000. There are also well-established
ing the efficacy of CAM, including heterogeneity of both
training programs for physicians in specific modalities
products and practices. Lack of regulation of many com-
such as hypnosis and acupuncture.
monly used practices exacerbates heterogeneity, making
treatment effect difficult to measure. The relative lack of
CAM expertise in conventional institutions results in
LICENSING
inadequate peer review and undue difficulties when
Licensure of CAM providers varies significantly from
attempting to obtain institutional review board approval
state to state. Licensing does not mean that CAM
to study CAM in children.
providers can practice medicine. In some states, CAM
Although CAM use is common in children, there
providers must have clients sign a form acknowledg-
have been few reports of serious adverse effects. Most
ing that they understand the provider is not a physi-
current safety data come from case reports. Some pop-
cian and not practicing medicine. As of the writing of
ulation-based surveillance studies to monitor adverse
this report, chiropractic medicine is licensed in all
events have been conducted in adults receiving acu-
states, acupuncture and massage therapy are licensed
puncture, and the resulting data are reassuring.120 The
in more than half of the states, and naturopathy and
need for rigorous safety evaluation is questioned by
homeopathy are licensed in less than one third of the
some who perceive “natural” to be equivalent to “safe.”
states. Lobbying efforts by CAM providers to win li-
More complete data about safety in children would re-
censure and expanded scopes of practice are ongoing
quire prospectively gathered, population-based studies,
in many states. It is essential for physicians to under-
which are expensive to conduct.
stand local and state statutes and regulations govern-
There are numerous challenges inherent in all clinical
research, and these difficulties are compounded when
ing specific therapeutic modalities. If a CAM provider
performing research in children and on therapies based
is unlicensed, then he or she may be engaged in the
on different cultural concepts of what causes or consti-
unauthorized practice of medicine, and if a physician
tutes disease and health. The NCCAM has identified
refers a patient to an unlicensed provider, the refer-
women and minority populations as priority groups for
ring physician may be liable for negligent referral. If a
federally funded research on CAM, but it has not yet
CAM provider is licensed, then he or she must be
added pediatrics to this priority listing.
practicing within his or her “scope of practice” as
defined by local and state statutes and regulatory
EDUCATION AND TRAINING
boards.132 Similar to physician licensing, licensing in-
The number of CAM providers is increasing. The num-
formation about other health care professionals is
ber of CAM providers in the United States is projected to
maintained by state licensing boards.
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MEDICOLEGAL AND ETHICAL CONSIDERATIONS
for Their Child With Chronic Illness or Disability” rec-
ommended that pediatricians seek information, evaluate
Medicolegal
the scientific merits of specific therapeutic approaches,
CAM poses a challenging risk-management issue with
and identify risks or potential harmful effects.43
the potential for either a medical malpractice lawsuit,
It is also prudent to apply common sense to balancing
disciplinary proceedings from state licensing boards, or
risks and benefits when making therapeutic decisions (see
fraud and abuse actions from federal or state regula-
Fig 1).142 The specific ethical questions in clinical practice
tors.133,134 The use of some types of CAM in adults has
vary in different clinical situations. If a therapy is both safe
been judicially held to be below the standard of care
and effective, the pediatrician is ethically obligated to rec-
constituting medical negligence135; that is, use of com-
ommend and encourage its use as he or she would for any
plementary therapies in and of themselves does not
other such therapy in conventional care.
constitute negligence. In terms of practicing within the
Factors to be included in a risk/benefit analysis when
standard of care, more clinicians are willing to offer
considering CAM therapies include the severity and
CAM, and more insurers are willing to pay for it.136
acuteness of illness; curability with conventional care;
Clinicians need to be aware of individual state laws relating
degree of invasiveness; toxicities and adverse effects of
to CAM, because medicine is regulated by state rather than
conventional treatment; quality of evidence for efficacy
federal laws.137 In its database of closed pediatric malpractice
and safety of the complementary therapy; and the fam-
claims from 1985–2005, the Physicians Insurers Association
ily’s understanding of the risks and benefits of CAM
of America reported that the average indemnity payment for
treatment, voluntary acceptance of those risks, and per-
all CAM claims was $358 333, which was 37.1% higher than
sistence of the family’s intention to use CAM therapy.139
the average for all pediatric claims ($261 321).138 A proposed
Thus, the level of evidence required for evaluating effi-
risk-management model limits liability for the use of CAM if
cacy can be small when there is little to no risk of harm
the physician is recommending, accepting, or avoiding CAM
from a therapy, especially when other therapies are
depending on availability of evidence relating to safety and/or
likely to be futile. Likewise, the level of evidence for
efficacy.139
efficacy required to endorse a particular complementary
Some CAM modalities may need to be included in
therapy would be quite high when that therapy is risky
discussions about informed consent for treatment. The
and safer, more effective therapies are available.
informed-consent process may potentially require a dis-
Situation-specific variables can also affect ethical decision-
cussion about possible risks of CAM, notwithstanding
making. Situation-specific variables include the patient’s and
the ability of a patient to acquire CAM without the
parents’ personal beliefs, cultural values and practices, and
involvement of the pediatrician (eg, dietary supplements
therapeutic goals; the type and severity of illness; and the lack
and their interaction with prescribed medication). Case
of efficacy and safety data in a specific patient. Even when
law has placed a burden on clinicians to at least discuss
such data are known for other populations, application of
viable options of treatment even though he or she may
population data to individual pediatric patients requires infer-
be unwilling to offer the therapy.140
ence and implies some degree of uncertainty. The tolerance of
Pediatricians need to be aware of the use of alterna-
the patient, family, and clinician for uncertainty varies from
tive therapies as a substitute for conventional medical
one situation to another.139
care for children with life-threatening conditions and
Finally, clinicians should be aware of the 4 basic princi-
whether they believe such treatment is reportable under
ples of biomedical ethics: (1) respect for patients’ auton-
state abuse and neglect laws. Another legal duty of pe-
omy; (2) nonmaleficence (avoiding harm); (3) beneficence
diatricians relates to the assurance that seeking reim-
(putting the patient’s interest and well-being first); and (4)
bursement for CAM therapy does not trigger a potential
justice (fairness in providing access to essential care).139
violation of fraud and abuse laws for therapy deemed
“medically unnecessary.” It is prudent to be cautious
about any representations or guarantees.
Ethics
There are several ethical challenges to integrating CAM
into mainstream pediatric practice. There is a lack of
systematic pediatric education about the safety and ef-
fectiveness of CAM therapies; uncertainty about the
scope of practice, licensing requirements, and credential-
ing of nonphysician CAM providers; concerns about pa-
tient safety and legal liability when recommending CAM
therapies or therapists; and uncertainty about how to
translate principles of medical ethics into CAM.141
The first guideline of ethical practice is to seek reli-
able, evidence-based information about the safety and
FIGURE 1
effectiveness of specific therapies and therapists. Indeed,
Guide to CAM treatment recommendations. (Reproduced with permission from Kemper
the 2001 AAP policy statement “Counseling Families
K, Cohen M. Ethics meet complementary and alternative medicine: new light on old
Who Choose Complementary and Alternative Medicine
principles. Contemp Pediatr. 2004;21:65.)
PEDIATRICS Volume 122, Number 6, December 2008
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CONCLUSIONS
to promote the best interests of the child is critical to the
Pediatricians and other clinicians who care for children have
integrity of the medical home.
the responsibility to advise and counsel patients and families
● Monitor the patient’s response to treatment and es-
about relevant, safe, effective, and age-appropriate health ser-
tablish measurable outcomes for evaluation. Measur-
vices and therapies regardless of whether they are considered
able outcomes such as specific goals for symptom relief
mainstream or CAM. In the 2001 AAP Periodic Survey of
can be established. The primum non noceri (“first do no
Fellows, 73% of pediatricians agreed that it is the role of
harm”) concept is central to all clinical practice. If
pediatricians to provide patients/families with information
there is a lack of response or untoward response, the
about all potential treatment options for the patient’s condi-
therapy needs to be reevaluated.
tion, and 54% agreed that pediatricians should consider the
use of all potential therapies, not just those of mainstream
● Maintain current knowledge of popular complementary
medicine, when treating patients.60 Because most families use
therapies and evidence-based resources about them. Be-
CAM services without spontaneously reporting this use to
come familiar with the definitions, terms, and uses of CAM
their clinician, pediatricians can best provide appropriate ad-
and learn about specific CAM therapies patients are using.
vice and counseling if they regularly inquire about all the
Pediatricians are encouraged to educate themselves about
therapies the family is using to help the child.143,144
the modalities and professionals that are available in their
Pediatricians should seek continued and updated
practice area. Provide evidence-based information about
knowledge about therapeutic options available to their
relevant therapies, available from the NCCAM, the Con-
patients, whether they are mainstream or CAM, and
sortium of Academic Health Centers for Integrative Medi-
about the specific services used by individual patients to
cine member institutions, and an increasing number of
ensure that issues of safety, appropriateness, and advis-
publications in peer-reviewed publications and professional
ability of CAM can be addressed. Only then can pedia-
review articles.
tricians appreciate the concerns of their patients and
families and offer them the thoughtful and knowledge-
TASK FORCE ON COMPLEMENTARY AND ALTERNATIVE MEDICINE, 2000–2002
able guidance they may require.
*Edward O. Cox, MD, Chairperson
Finally, if the pediatrician confirms that the patient is
Susan Baker, MD, PhD
seeing a CAM provider, the pediatrician can (with the
Timothy Culbert, MD
permission of the patient and family) include the CAM
Don Greydanus, MD
provider in overall care-coordination activities.
Eric David Kodish, MD
Godfrey Oakley, MD, MSPM
TIPS ON TALKING WITH PATIENTS
Adrian Sandler, MD
●
*Richard Walls, MD, PhD
Ask about the different therapies received by your patients.
Patients and parents often do not tell their clinicians about
CAM use, because many of them believe that it is not
LIAISONS
relevant or not within the clinician’s interest or exper-
Sunita Vohra, MD
tise.143,144 By asking routinely, pediatricians can learn
Canadian Paediatric Society
whether a child is receiving complementary therapies. This
Jerold Woodhead, MD
knowledge is essential for the pediatrician to evaluate and
Committee on Pediatric Workforce
counsel about potential adverse effects and to enhance the
probability of correctly attributing improvements or ad-
CONSULTANTS
verse effects to the specific intervention. Questions that
Kathi J. Kemper, MD, MPH
include examples are often helpful in jogging memories
Karen Olness, MD
and enhancing disclosure. Thus, rather than asking
whether a patient is using any “alternative” therapies, the
STAFF
pediatrician might ask whether the patient is using any
“vitamins, herbs, supplements, teas, home remedies, back
Junelle Speller
rubs, chiropractic, acupuncture, or other services to en-
hance health.” It is also often useful to ask how the patient
PROVISIONAL SECTION ON COMPLEMENTARY, HOLISTIC, AND
manages stress; examples here may include exercise,
INTEGRATIVE MEDICINE STEERING COMMITTEE, 2007–2008
prayer, music, or talking with friends or trusted adults.
*Kathi J. Kemper, MD, MPH, Chairperson
● Respect the family’s perspectives, values, and cultural
Lawrence Rosen, MD
beliefs in open, ongoing communication centered on the
*Sunita Vohra, MD
patient’s well-being. Recognize cultural or educational
Richard Walls, MD, PhD
differences. Demonstrate respect for families and their
Joy Weydert, MD
values. Work together with the parents as a team to
Susan Hyman, MD
consider and evaluate all appropriate treatments. This
may require discussing an array of treatment options. By
STAFF
actively listening to families and patients, pediatricians
Junelle Speller
can become important allies in examining all potential
treatment options for children. Maintaining a dialogue
*Lead authors
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ACKNOWLEDGMENTS
16. Loman DG. The use of complementary and alternative health
Robert Pendergrast, MD, Provisional Section on Com-
care practices among children. J Pediatr Health Care. 2003;
plementary, Holistic, and Integrative Medicine member-
17(2):58 – 63
at-large, and Hilary McClafferty, MD, Provisional Sec-
17. Ottolini MC, Hamburger EK, Loprieato JO, et al. Complemen-
tary and alternative medicine use among children in the
tion on Complementary, Holistic, and Integrative
Washington, DC area. Ambul Pediatr. 2001;1(2):122–125
Medicine editor, contributed extensively to this report.
18. Ball SD, Kertesz D, Moyer-Mileur LJ. Dietary supplement use
Kellie Waters, MD, FRCPC, of the Complementary and
is prevalent among children with a chronic illness. J Am Diet
Alternative Research and Education (CARE) Program
Assoc. 2005;105(1):78 – 84
(Department of Pediatrics, University of Alberta, Ed-
19. McCann LJ, Newell SJ. Survey of paediatric complementary
monton, Alberta, Canada) also contributed to this re-
and alternative medicine use in health and chronic illness.
port. The Committee on Medical Liability and Risk Man-
Arch Dis Child. 2006;91(2):173–174
agement developed the medicolegal text of the report.
20. Armishaw J, Grant CC. Use of complementary treatment by
Sunita Vohra, MD receives salary support from the Al-
those hospitalised with acute illness. Arch Dis Child. 1999;
berta Heritage Foundation for Medical Research and the
81(2):133–137
Canadian Institutes of Health Research.
21. Sanders H, Davis MF, Duncan B, Meaney FJ, Haynes J, Bar-
ton LL. Use of complementary and alternative medical ther-
apies among children with special health care needs in south-
REFERENCES
ern Arizona. Pediatrics. 2003;111(3):584 –587
1. National Institutes of Health. National Center for Comple-
22. Breuner CC, Barry PJ, Kemper KJ. Alternative medicine use
mentary and Alternative Medicine Web site. Available at:
by homeless youth. Arch Pediatr Adolesc Med. 1998;152(11):
http://nccam.nih.gov. Accessed November 29, 2006
1071–1075
2. Field TM, Schanberg SM, Scafidi F, et al. Tactile/kinesthetic
23. Braganza S, Ozuah PO, Sharif I. The use of complementary
stimulation effects on preterm neonates. Pediatrics. 1986;
therapies in inner-city asthmatic children. J Asthma. 2003;
77(5):654 – 658
40(7):823– 827
3. Vickers A, Ohlsson A, Lacy JB, Horsley A. Massage for pro-
24. Dinkevich E, Sass P, Pereira L, Asimolowo O, Glater L, Rao M.
moting growth and development of preterm and/or low birth-
Complementary and alternative medicine use by African-
weight infants. Cochrane Database Syst Rev. 2004;(2):CD000390
American and Caribbean-American children with asthma
4. Dieter JN, Field T, Hernandez-Reif M, Emory EK, Redzepi M.
[abstract 1068]. Pediatr Res. 2003;53(suppl):188A
Stable preterm infants gain more weight and sleep less after
25. Reznik M, Ozuah PO, Franco K, Cohen R, Motlow F. Use of
five days of massage therapy. J Pediatr Psychol. 2003;28(6):
complementary therapy by adolescents with asthma. Arch
403– 411
Pediatr Adolesc Med. 2002;156(10):1042–1044
5. Culbert T, Kajander RL, Reaney JB. Biofeedback with children
26. Cala S, Crimson ML, Baumgartner J. A survey of herbal use in
and adolescents: clinical observations and patient perspec-
children with attention-deficit-hyperactivity disorder or de-
tives. J Dev Behav Pediatr. 1996;17(5):342–350
pression. Pharmacotherapy. 2003;23(2):222–230
6. Consortium of Academic Health Centers for Integrative Med-
27. Chan E. The role of complementary and alternative medicine
icine Web site. Available at: www.imconsortium.org. Ac-
in attention-deficit hyperactivity disorder. J Dev Behav Pediatr.
cessed November 29, 2006
2002;23(1 suppl):S37–S45
7. Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins DR,
28. Sihna D, Efron D. Complementary and alternative medicine
Delbanco TL. Unconventional medicine in the United States:
use in children with attention-deficit hyperactivity disorder. J
prevalence, costs, and patterns of use. N Engl J Med. 1993;
Paediatr Child Health. 2005;41:23–26
328(4):246 –252
29. Levy SE, Mandell DS, Merhar S, Ittenbach RF, Pinto-Martin
8. Eisenberg DM, Davis RB, Ettner SL, et al. Trends in alternative
JA. Use of complementary and alternative medicine among
medicine use in the United States, 1990 –1997: results of a
follow-up national survey. JAMA. 1998;280(18):1569 –1175
children recently diagnosed with autistic spectrum disorder. J
9. Barnes PM, Powell-Griner E, McFann K, Nahin RL. Comple-
Dev Behav Pediatr. 2003;24(6):418 – 423
mentary and alternative medicine use among adults: United
30. Levy SE, Hyman SL. Use of complementary and alternative
States 2002. Adv Data. 2004;(343):1–19
treatments for children with autistic spectrum disorders is
10. Tindle HA, Davis RB, Phillips RS, Eisenberg DM. Trends in use
increasing. Pediatr Ann. 2003;32(10):685– 691
of complementary and alternative medicine by US adults:
31. Harrington JW, Rosen L, Garnecho A, Patrick PA. Parental
1997–2002. Altern Ther Health Med. 2005;11(1):42– 49
perceptions and use of complementary and alternative med-
11. Yussman SM, Ryan SA, Auinger P, Weitzman M. Visits to
icine practices for children with autistic spectrum disorders in
complementary and alternative medicine providers by chil-
private practice. J Dev Behav Pediatr. 2006;27(2 suppl):
dren and adolescents in the United States. Ambul Pediatr.
S156 –S161
2004;4(5):429 – 435
32.