The American Academy of Pediatrics (AAP) has an integrative medicine problem. It’s a wonderful organization, don’t get me wrong, and they do a lot of good work advocating for children and their families, and providing evidence-based guidelines for clinical care. In fact, they claim to be “committed to the optimal physical, mental, and social health and well-being for all infants, children, adolescents, and young adults”, and I have never really questioned this goal. But they have a huge biased blind spot when it comes to quackery.
The AAP Section on Integrative Medicine
The AAP, while often speaking as a unified voice, is also subdivided into 52 sections. These sections consist of different groups of members dedicated to one particular aspect of pediatric medicine or another, each with their own internal leadership hierarchy, and they are integral in helping to develop policy and in educating fellow AAP members as well as the public. One of them is the Section on Integrative Medicine (SOIM).
Since at least as far back as the late 1990s, the AAP has shown some interest in alternative therapies, in no small part because of the influence of Kathi Kemper, who refers to herself as “the holistic pediatrician” pretty much every chance she gets. She did essentially write the book on the subject after all. She was the founding chairman of the SOIM in addition to establishing the non-AAP affiliated Council on Bioenergetic Healing, which does not appear to have ever existed except on her CV (at least there is no trace of it online). The AAP evolved along with other proponents/PR departments over the years, officially referring to alternative medicine as “integrative medicine” with the establishment of the SOIM in 2005.
The SOIM then set out to establish an integrative medicine presence in pediatrics, complete with all the standard propaganda we have come to know and love. It encourages members to speak at conferences and gives grants for various endeavors that support the cause. It supports research into integrative medicine. It promotes educational resources for medical schools and residency programs and designs CME activities.
The SOIM strategic plan
In 2013, the AAP SOIM released their strategic plan, which unfortunately is only available to members. As I’ll explain in detail, it’s pretty much just integrative medicine boilerplate that occasionally mentions children. Their mission statement starts out okay, however. I mean, who wouldn’t support “optimal health and well-being for all children and families”? But it quickly goes the expected route, all the while making the assumption that their true mission is reasonable and even necessary:
The mission of the Section on Integrative Medicine (SOIM) is to promote optimal health and well‐being for all children and families through the promotion of high quality research, education and clinical care from the integrative perspective. To accomplish its mission, the section will promote a broad view of health and wellness involving patients, caregivers and providers; educate pediatricians and other pediatric providers on how to integrate evidence‐based, safe and effective integrative therapies into high quality pediatric practice; promote research on principles of integrative medicine; and respectfully collaborate with diverse health professionals dedicated to enhancing the health of infants, children, and adolescents.
High quality research you ask? This will come up again later in the post when I describe what such research looks like according to the SOIM. I’ll just tell you that it rhymes with shmanecdote for now. And what exactly is the integrative perspective? Let’s just say it involves two types of pie.
The rest of the SOIM strategic plan discusses their belief that the philosophy of integrative medicine is somehow different than what I do, for example, because it focuses on providing “high quality and patient-centered care that prioritizes patient and family wellness and planning”. Deep breath Dr. Jones, you’re a professional. They add that only through the addition of complementary therapies can every patient “flourish in the presence or absence of disease or disability”, and that physicians should be capable of competently discussing integrative medicine principles with patients and families. I agree with that last one, but the SOIM might not appreciate my approach.
The SOIM, according to its section on values, wants all medicine to be integrative because they believe it is required for the practice of “good medicine”. They call for all therapies to be judged on a level playing field “regardless of their origin”. They then list “nutrition, movement and exercise, mind-body connection, sleep, growth and spirituality, positive relationships and the physical environment” as being in their armamentarium for “enhancing wellness”. Physical environment? Do they mean earthing?
Their “Goals and Objectives” section spells out a desire to
indoctrinate educate pediatric residents with the implementation of standardized core competencies and the inclusion of integrative medicine questions on board examinations. They want to produce more educational opportunities for residents and AAP members, write policy statements for members to follow, link themselves to the NCCAM (now NCCIH), and “promote integrative medicine as a philosophy for caring for children”.
The SOIM Clinical Report
I’ve known about this issue for a long time. As part of SOIM educational outreach, for nearly ten years the AAP has provided “Complementary, Holistic, and Integrative Medicine” CME opportunities in the form of review articles in Pediatrics in Review. These invariably consist of cherry picked studies with weak methodology, biased assumptions, appeals to popularity, and calls for more research to prove what they already know is true, even after pointing out how weak the available data actually is.
But what inspired me to write about this topic today was the September publication in Pediatrics of an updated Pediatric Integrative Medicine Clinical Report from the SOIM, which is meant to guide AAP members in their approach to patient care. It’s pure propaganda with little actual substance and all the typical canards we’ve come to expect. You know something isn’t going to involve much critical thinking when it opens with “The National Center for Complementary and Integrative Health defines…”
The AAP, according to a press release announcing the publication, feels differently:
The report aims to raise awareness about this emerging field, improve pediatric preventive health and expand treatment options for children and adolescents living with a wide range of medical conditions.
They then employ a classic bait and switch and some serious question begging:
Children and adolescents face serious health challenges and stressors in today’s society. Integrative medicine seeks to promote a comprehensive approach to healthy nutrition, physical activity, stress management and coping skills, sleep and judicious use of complementary therapies that can help children and their families reduce risk of preventable chronic illness across the lifespan.
As we’ve discussed countless times on the pages of SBM, there is nothing alternative about recommendations on nutrition, exercise, stress management, or sleep. There is no “complementary therapy” that reduces the risk of preventable illness. This is historical revisionism that proponents need pediatricians and the public to buy into because any unique aspects of integrative medicine offer little if any benefit. Pediatricians (and family medicine providers) have been promoting these things for a long time without the help of recommendations from the SOIM.
But that’s just the press release. Unlike the SOIM strategic plan, their clinical report is available for everyone to read so I’ll simply discuss a few highlights that stood out to me. Not all of it is bad, but it adds very little to the discussion in my opinion, serving primarily as an attempt to justify an increasing presence of integrative pediatrics in medical schools, residency programs, and pediatric CME opportunities. Most of it comes across as a regurgitation of NCCIH talking points.
- They define integrative medicine as a combination of complementary and conventional therapies that are “evidence-informed” and patient-centered. This is code for lacking quality evidence and recommended or condoned because it seems to make the patient or their family happy. They say that complementary approaches may also serve as the primary treatment, but that we shouldn’t confuse this with alternative therapies, which are not evidence-based and not discussed in the report. Despite this, they do discuss herbal remedies, acupuncture, chiropractic, and biofield therapies, among many others, often implying benefit or the promise of future benefit once better studies are performed.
- They devote several paragraphs to the popularity of integrative medicine in pediatric populations, particularly children with chronic diseases, and claim that this justifies a need for more pediatric integrative medicine training programs. This is almost immediately followed up with the actual data showing that pediatric use has been stagnant based on NHIS data. They mention that the bulk of CAM use in pediatrics consists of things like supplements, exercise in the form of yoga, and chiropractic manipulation. Only the latter has any business being considered CAM. They also strongly imply that the use of CAM by children, again particularly by kids with chronic illness, is so common because of how helpful it is.
- They really want education/training in integrative medicine to be in all medical schools and pediatric residency programs, and they remind us that there is an actual board certification in integrative medicine through the American Board of Physician Specialties. They do not comment on the fact that the American Board of Pediatrics gives no such certification. 16 of 143 pediatric programs as of 2012 do offer integrative medicine training, however, so it’s likely going to come at some point.
- They claim that CAM research is as good as research into conventional medicine. Better even in the case of systematic reviews. According to the authors, publication bias is actually reversed with CAM, meaning that negative studies are more likely to be published in the better journals than positive studies. But, they add, because CAM can be ancient and challenging to study, “experiential evidence” and N-of-1 trials are “particularly useful”. So which is it?
- They are attempting to integrate a wide variety of CAM therapies into conventional medicine, and to make fundamental changes to the philosophy of patient care, yet they admit that the evidence stinks. The authors reveal that “to be comprehensive, high-quality data about both safety and effectiveness are needed…to inform policy and practice.”
- They mention the role of placebo effects almost in passing, essentially to plant the seed that it’s real, and it’s spectacular. You know, just in case you have any reservations about biofield therapies.
- They discuss DSHEA in detail but in such a way as to imply it’s doing a pretty good job.
- They discuss the ethics involved when a patient/family chooses CAM, and I actually agree in principle although I bet the authors and I would likely disagree in many specific cases. Providers should always assess the potential risks and benefits of any intervention. If there is significant risk without benefit, it would be appropriate to discourage the treatment. If it is determined to be effective and safe, we should obviously recommend it. Safe but ineffective, it would be reasonable to condone the approach. But if there is risk and only potential benefit, either monitoring the patient closely or discouraging the intervention could be the way to go. Easy, right?
- They actually provide almost no helpful information regarding specific interventions, mentioning only a handful by name, most of which aren’t CAM. Fish oil for ADHD isn’t CAM, nor is it very effective. Melatonin for sleep has similar issues. Probiotics are also fairly weak sauce. Herbal remedies are just dirty drugs, not CAM. Dietary interventions also are unfairly lumped into this report.
- They actually comment on the anti-vaccine tendencies of chiropractors who treat infants and children, and mention the lack of evidence supporting chiropractic for non-musculoskeletal complaints – but they stop short of saying outright that parents shouldn’t bring their baby to a chiropractor.
- They frequently mention how evidence of benefit for various therapies, such as acupuncture, is accruing or promising. Again, why are they calling for a fundamental shift in pediatric care prior to figuring out if these interventions actually work for anything?
- My final observation is again one that I agree with. Pediatricians in general don’t know much about CAM or integrative medicine. And what they do know is very likely wrong because it is based on information they get from resources such the SOIM. We don’t know about them and often we don’t ask about them. And patients and their families are often reluctant to share what unconventional therapies they are using with us. This can result in harm to patients.
Conclusion: Take the integrative out of the medicine
Yes, the AAP has an integrative medicine problem and, unfortunately, it only appears to be getting worse. For the time being, at least, it is sectioned off and we aren’t seeing recommendations for quackery being incorporated into general policy. There is nothing at all about this in the AAP five-year strategic plan, for instance. I still consider the majority of AAP resources to contain high quality information, but this report, and the existence of the SOIM, grants undeserved legitimacy to integrative medicine as a concept and to the individual CAM therapies that it is attempting to incorporate into pediatric medical practice.
(Here is a AAP endorsed lecture that Kathi Kemper gives. It provides a paper thin overview of the history of integrative pediatrics and includes a great deal of propaganda. In particular, she focuses on how popular these interventions are, then smoothly transitions into how to increase the presence of integrative medicine in pediatric training and medical care. We are apparently left to assume that there is solid evidence in support of this.
My favorite is the section on “Threats to Integrative Pediatric Care”, which includes “Misinformation on internet and media; negative press about CAM”. Here is another one, where she implies that critics of integrative medicine are equivalent to the KKK waving around a Confederate flag. Seriously. It’s in there.)