The Tipping Point

Two new reports point to the increased use of complementary and alternative medical (CAM) therapies in children. Have we reached a tipping point?

Malcolm Gladwell’s book has re-popularized the concept of the Tipping Point – the point at which a phenomenon leaves the “early adopter phase” toward the “early majority.” From David Eisenberg’s Harvard studies in the 1990’s, we’ve known that CAM use reached the early majority stage among the vast public some time ago. But now, perhaps, two recently published reports documenting significant use in children will prompt the medical establishment to take notice.

1. December’s issue of Pediatrics features the long-awaited AAP Clinical Report titled, “The Use of Complementary and Alternative Medicine in Pediatrics.” Initiated by the AAP Task Force on CAM in 2000, the report was updated and finalized, at long last, by the Section on Complementary and Integrative Medicine, chaired by Dr. Kathi Kemper (and vice-chaired by yours truly). The highlights, according to a review in Medscape, include:

* CAM is used in 20% to 40% of healthy children and in more than 50% of children with chronic, recurrent, and incurable conditions, including asthma, attention-deficit/hyperactivity disorder, autism, cancer, cerebral palsy, cystic fibrosis, inflammatory bowel disease, and juvenile rheumatoid arthritis.

* 66% of caregivers did not tell their child’s clinician about CAM use.

* CAM research issues include the more likely publication of negative studies in well-known journals and positive studies in foreign-language journals, heterogeneous products and practices, need for more randomized controlled trials in children, few serious adverse effects in children, and lack of priority listing for children.

* Pediatric CAM training for providers and clinicians is variable or lacking.

* Clinicians should routinely ask about specific CAM therapies and stress management; respect the family’s values, perspectives, and cultural beliefs; reevaluate treatment if no or negative response; and maintain evidence-based knowledge about CAM therapies.

The true importance of the report is that it was finally published. Winds are blowing in our direction, and the timing of publication is not coincidental. Even within the AAP, there is greater recognition that CAM therapies are here to stay and that perhaps integrative medicine is a model worth paying attention to. We’ve come along way even in this decade; someone reminded me of this report from 2001 (“Pediatricians at AAP Meeting Warn Against Alternative Remedies“): “Reuters media reported that during a presentation given Oct. 23 at the American Academy of Pediatrics (AAP) meeting, pediatricians stated that giving children alternative medicines might be harmful. Physicians argued that nutritional supplements and herbal products have not been well tested in pediatric medicine and they may have dangerous consequences.” It’s worth noting that we’ve hosted sessions at the last few AAP National Conferences teaching pediatricians how to safely and effectively integrative CAM therapies in their practice. And these rooms are packed – the demand is at an all-time high.

2. NIH/NCCAM released their most recent survey of CAM use trends in the U.S. This was the first survey by the NIH that looked at use in children. The data comes from the 2007 National Health Interview Survey (NHIS) and are drawn from more than 23,300 interviews with American adults and more than 9,400 interviews with adults on behalf a child in their household. It’s the most substantial overview to date of CAM use in families. Highlights include:

* Overall, CAM use among children is nearly 12 percent, or about 1 in 9 children.

* Children are five times more likely to use CAM if a parent or other relative uses CAM.

* The most commonly used CAM therapies among children were a) Nonvitamin, nonmineral, natural products (3.9 percent), b) Chiropractic or osteopathic manipulation (2.8 percent), c) Deep breathing exercises (2.2 percent), and d) Yoga (2.1 percent).

I think 12% is an underestimate, especially when you consider how many children with special health care needs/chronic conditions. Most other surveys, as the AAP report notes, reveal a 20-40% use among well children in primary care settings and 50-90% in selected special needs population (with use among children with autism probably the highest). For anyone in practice who asks families specifically about use of botanicals, vitamins, special diets, homeopathy, mind-body practices, acupuncture, massage, spiritual practices, chiropractic, and so on, you will probably agree the numbers are closer to what’s noted in the AAP report. But regardless of quibbling over numbers, the fact is that more and more families are turning away from conventional medical treatments for their children, many whom have complex, chronic health care needs. And there is growing sentiment that the conventional health system is not addressing the needs of these children and their families. As I told Roni Rabin last week (December 11 N.Y. Times): “This is a wake-up call… The main thing pediatricians and patients need to recognize is that we all need to be talking about this. Parents need to be comfortable discussing it, and pediatricians need to feel comfortable bringing it up.”