Pediatric Pulmonology 46:530–544 (2011)

State of the Art

Complementary and Alternative Therapies:

Use in Pediatric Pulmonary Medicine
1 2
Youngran Chung, MD * and Robert C. Dumont, MD

Summary. With increased awareness of complementary/alternative medicine (CAM) and con-

cern of potential adverse effects or limited effectiveness of conventional medications, patients and
parents are looking to CAM approaches as either an alternative or as adjunct therapy, especially for
chronic diseases such as asthma or cystic fibrosis. It is important that practitioners have adequate
information so that patients and parents receive balanced and accurate information, especially
regarding safety and potential efficacy. This review provides an overview of some of the more
frequently used CAM therapies for children with chronic pulmonary disorders and summarizes
the basic principles of each modality, along with efficacy and safety data. Pediatr Pulmonol. 2011;
46:530–544. ß 2011 Wiley-Liss, Inc.

Key words: complementary medicine; alternative medicine; integrative medicine;

children; pulmonary disorders.

Funding source: none reported.

INTRODUCTION There are several reasons we should familiarize our-

selves with the various CAM modalities: (1) Respond to
Complementary and alternative medicine (CAM),
patients who seek CAM, and assist in monitoring for
‘‘defined as those interventions neither taught widely in
safety in a reasonable manner. (2) Find other options
medical schools nor generally available in US hospitals’’1
for patients who cannot tolerate or cannot find adequate
has shown a continued rise in the past few decades. In the
relief from conventional medicines. (3) Promote better
US, more than 50% of children with chronic medical
understanding and communication among CAM prac-
conditions use CAM almost always in conjunction with
titioners and physicians, thereby encouraging more
conventional care.2 One of the most commonly treated
well-designed clinical studies.
chronic diseases of our time, asthma, has a variable preva-
There are very few active clinical studies on the efficacy
lence rate of CAM use (33–89% in children).3 In one
of various CAM modalities for specific pulmonary
study, 71% of caregivers said they would consider using
CAM for their child in the future.4 We have seen a parallel
increase in the use of CAM among cystic fibrosis patients. 1
Division of Pulmonary Medicine, Children’s Memorial Hospital, North-
Many patients with cystic fibrosis who are followed at western University Feinberg School of Medicine, Chicago, Illinois.
accredited CF centers use CAM therapies in conjunction
with their standard conventional therapies. In one of the 2
Raby Institute for Integrative Medicine at Northwestern, LLC, Chicago,
earliest studies on the use of CAM therapies by CF patients Illinois.
at one center, at least one type of nonconventional treat-
*Correspondence to: Youngran Chung, MD, Division of Pulmonary
ment was used by 66% of their patients.5 There is a rising Medicine, Children’s Memorial Hospital, 2300 Children’s Plaza, Box 43,
parallel interest among healthcare providers to acquire Chicago, IL 60614-3394. E-mail: [email protected]
more knowledge regarding these therapies. This is
reflected in the inclusion of CAM topics or workshops Received 10 August 2010; Revised 15 December 2010; Accepted 16 Decem-
and symposiums at the North American Cystic Fibrosis ber 2010.
Conference, pediatric pulmonology conferences, as well DOI 10.1002/ppul.21426
as the American Academy of Pediatrics in the last Published online 18 February 2011 in Wiley Online Library
10 years. (wileyonlinelibrary.com).

ß 2011 Wiley-Liss, Inc.

 CAM Therapies in Pediatric Pulmonary Medicine 531
6
disorders such as cystic fibrosis or asthma. However, from medical conditions, including asthma. The World Health
the existing studies, historical use, and current experience Organization also lists many conditions treatable by acu-
with various CAM therapies, we can gain insight into puncture. Some of the conditions often treated by pulmo-
potential benefits for other pulmonary disorders. Due to nologists include allergic rhinitis (proved through
the vast array of CAM therapies, this review will only controlled trials to be an effective treatment); asthma,
focus on some of the more common therapies in use in whooping cough, insomnia (therapeutic effect exist but
the US, addressing (1) underlying principles, (2) efficacy, further proof is needed), and small airway obstruction
(3) safety, and (4) practicality. These include Acupunc- (only individual controlled trials reporting some thera-
ture, Herbs/supplements, Homeopathy, Mind–Body peutic effects).7
Medicine (MBM), and Bodywork therapies (e.g., chiro-
practics, massage).
Efficacy
ACUPUNCTURE AND CHINESE MEDICINE (CM) Literature on acupuncture treatment for medical dis-
orders is extensive, and there are a number of clinical
Background and Basic Theory
studies on asthma. Since asthma is a disease of chronic
Acupuncture’s first ‘‘text’’ was compiled over 2000 airway inflammation, some of these results may be
years ago and news of acupuncture was reported in Europe applicable to other respiratory diseases with similar symp-
in the sixteenth and seventeenth centuries from mission- toms and airway pathology. A 1996 comprehensive review
aries returning from China with stories of ‘‘miraculous of acupuncture studies in pulmonary disorders showed a
healing’’ with needles. Acupuncture is part of an ancient number of positive results for asthma as well as for chronic
and comprehensive Chinese medical system with a com- bronchitis and chronic obstructive pulmonary disease.8
plex theory of pathophysiology distinctly different from However, in the same year, a systematic review of 11
our Western view of human physiology and medicine. It is studies for acupuncture and asthma, authors concluded
often complemented by other therapeutic modalities such that there was insufficient evidence to support acupuncture
as herbal combinations, massage, dietary therapy, and for asthma, but acknowledged the need for further research
lifestyle modification. A basic concept of acupuncture because of the variability of acupuncture treatments in
is the flow of Qi through the body. The definition of Qi these studies.9 Many of these studies are inconclusive due
is elusive, but it could be defined as life force or vital to methodological problems such as difficulty in blinding,
energy that is the driving force behind bodily animation standardization of acupuncture points, and use of ‘‘sham’’
and function. Qi ‘‘flows through the body’’ via channels points for control (sham points can be active and adequate
(meridians), and it is thought that disease occurs when this inert placebo is almost impossible to obtain). Another
flow is disrupted. Acupuncture needles access these chan- caveat is that isolating acupuncture from other Chinese
nels to re-establish the flow of Qi. In present day, there are medicine (CM) therapies may be less effective because in
multiple styles and techniques of acupuncture including the practice of CM, Chinese herbs and other CM therapies
microsystems such as hand, ear, or scalp acupuncture. The (energy movement therapies such as Tai Chi, QiGong) are
National Center for Complementary and Alternative used synergistically along with needle acupuncture. It is
Medicine defines acupuncture as a family of procedures also important to know that acupuncture and other CM
involving stimulation of specific anatomic locations on the therapies require a regimen that is specifically tailored for
skin by a variety or techniques. Among these are needle- an individual for optimal results.
free acupuncture techniques using laser, magnetic or non- Acupuncture is used extensively in China to treat a
magnetic pellets, and other devices. variety of pulmonary diseases in addition to asthma
Acupressure is a technique stimulating acupuncture (e.g., viral pneumonia, pleural effusion, etc.). In cystic
points using manual pressure. In the US, the National fibrosis, there are no controlled clinical trials using acu-
Institute of Health Consensus Development Conference puncture. There is a single case report using acupuncture
on Acupuncture endorsed acupuncture in 1997 for many and Chinese herbs to treat a 10-year-old boy with cystic
fibrosis with lingering pulmonary exacerbation symp-
toms.10 Acupuncture and Chinese herbal treatment for
ABBREVIATIONS several weeks was associated with noticeable clinical
CAM complementary and alternative medicine improvement, including a chest CT which revealed no
CF cystic fibrosis mucus plugs 2 weeks following treatment. He remained
CM Chinese medicine healthy at 1 year follow-up.
FDA Food & Drug Administration A randomized-controlled trial involving patients with
MBM mind–body medicine non-CF bronchiectasis in adults who received standard
NIH National Institute of Health treatment (control) or standard treatment plus self-admin-
istered acupressure or sham acupressure was done to look
Pediatric Pulmonology
532 Chung and Dumont

at effects on symptoms that limited daily activity. The techniques (e.g., laser acupuncture or pellets used on
acupressure group resulted in better quality of life score hands or ears) make this even more acceptable especially
(P ¼ 0.01) compare to the control group but there was no in young children, though efficacy studies using these
difference in other parameters (6-min walk, sputum, dysp- techniques are lacking. To derive benefit from acupunc-
nea). The sham acupressure group showed improvement ture, a patient generally requires several or more treat-
(P ¼ 0.03) only in the sputum self-assessment score (sub- ments over a period. The time required for visits to the
ject’s sensation of effort to clear sputum).11 In a prospec- acupuncturists and insurance coverage may be an issue for
tive randomized study of chronic obstructive asthma some patients.
patients, there was improvement in quality of life
measures when acupuncture or acupressure was added HERBAL MEDICINE
to standard therapy.12 Background and Basic Theory
While acupuncture may not reverse the basic disorder of
a disease such as CF, it has the potential to alleviate Herbs have been widely popularized and are particu-
symptoms and can be effective for treating associated larly likely to be used by patients with chronic medical
chronic pain. Though not consistent in their findings, conditions such as asthma or cystic fibrosis. Unfortu-
recent systematic reviews suggest a possible positive nately, in the US herbal medicines do not go through
effect of acupuncture for specific pain conditions13–19 the same rigorous process as pharmaceuticals. Thus, there
which may also be seen in cystic fibrosis (e.g., low back are legitimate questions regarding the safety of herbal
pain, postoperative pain, osteoarthritis, and headache). A products. Otherwise, many herbal supplements have a
single pilot study on cystic fibrosis patients showed effec- written history spanning hundreds of years and some have
tiveness of acupuncture for diminishing pain with no side been in use for thousands of years. This historical infor-
effects or complications.20 mation gives important clues about safety and effective-
There is obviously a need for more studies on the use of ness. Of course, each herbal product must be judged on its
acupuncture for specific pulmonary conditions. However, own merit, based on documented historical information
based on some of the positive results seen in asthma, we and existing clinical studies. The amount of information
can see the potential applicability to other pulmonary available varies significantly from herb to herb. There are
conditions characterized by chronic airway obstruction four major herbal healing traditions: Chinese, Ayurvedic
and inflammation. Acupuncture is also routinely used to (India), European, and Native American. The use of herbal
maintain general health and support the immune system medicines may vary according to the principles of path-
and could be a useful adjunct to treating any chronic ophysiology practiced in a particular tradition. Chinese
pulmonary disease. Medicine practitioners use multiple herbs in combinations
based on a CM diagnosis and the individualized need of
the patient. Two patients with the same Western diagnosis
Safety and Practical Issues would not necessarily receive the same herbal preparation.
In skilled hands acupuncture is a very safe procedure. Earlier use of Western herbs was somewhat similar to CM
The needles are applied using a clean needle technique and with a goal to re-establish physiological balance and some
are almost always single use/disposable so infection is ‘‘herbalist’’ still practice with this goal. However, today
extremely rare. Mild side effects can include minor bleed- Western herbs are mostly practiced within the framework
ing and nausea. Syncope may occur in about 1% of of a conventional biomedical model based on their
patients, especially in the first treatment session and is pharmacologically active components. It is important to
preventable by treating the patient in a supine position.21 realize that herbal medicines differ from pharmaceuticals
An analysis by White which included 12 prospective in several ways: First, they are poly-pharmaceuticals often
studies that surveyed more than a million treatments containing a complex mixture of chemicals (e.g. >100
showed the estimated risk of a serious adverse event with chemicals have been identified in tea tree oil mixture23)
acupuncture to be 0.05 per 10,000 treatments, and 0.55 per thus they may have more than one pharmacological effect.
10,000 individual patients.22 While there are no absolute This could produce an independent effect (therapeutic or
contraindications to acupuncture, relative contraindica- harmful), a synergistic effect or a quenching effect (one
tions would include extreme frailty with concurrent febrile ingredient canceling out the adverse effect of another).
illness, early pregnancy, and bleeding disorders. Poten- Second, the quality of herbal products (active ingredients)
tially, deep needling of points on the thorax could cause a can be influenced by growing factors such as soil com-
pneumothorax in a very emaciated patient, but this serious position, weather, and time of harvest.
adverse effect is exceedingly rare. Acupuncture needles,
Efficacy
are generally painless as they are nonbeveled, therefore
noncutting thin needles and are well tolerated by all ages. While herbs may be one of the more commonly used
Nevertheless, the use of many noninvasive acupuncture therapies by CF patients, there are very few clinical trials
Pediatric Pulmonology
 CAM Therapies in Pediatric Pulmonary Medicine 533
38
of herbs for CF lung disease. Most interventions that might lung function. Curcumin, a yellow pigment in the spice
be used to treat CF are extrapolated from treatment of turmeric (curry powder), is probably the most recognized
other similar disease processes such as bronchitis or of herbs with potential use in CF, largely due to studies
asthma. Two systematic reviews, one of 17 randomized showing that it can open cystic fibrosis transmembrane
clinical trials24 and a more recent review of 26 trials,25 conductance regulator chloride channels.39 Over the
evaluated the use of herbal medicines for the treatment centuries its traditional use has emphasized its anti-
of asthma. Both reviews included CM and Ayurvedic inflammatory effects, which have recently been docu-
herbs. The first review concluded that there was no defini- mented. These immunomodulatory effects include
tive evidence for any of the herbal preparations in the down regulation of various proinflammatory cytokines.40
treatment of asthma, but several products showed promise: One factor that may limit its use is its poor bioavailability
Three of the CM herbal products resulted in significant as demonstrated in both animal and human studies.41
improvement in forced expiratory volume (FEV1) There is ongoing investigation in this area42 but clinical
(P < 0.05), and several traditional Indian (Ayurvedic) trials in humans are lacking. In general curcumin is
herbal products similarly showed either an increase in regarded as safe. Butterbur (Petastes hybridus), another
FEV1 (P < 0.05) or symptom relief. In the second review, herb mentioned for treatment of asthma appears to possess
Boswellia, Pycongenol1, Mai-men, Jia-Wei, and Tylo- anti-allergic properties reducing histamine and leuko-
phora were considered to have promise, improving lung triene levels in nasal fluids.43 There are two studies that
function (FEV1 and/or peak flow rates) based on few show promise. In an 8-week nonrandomized, open trial of
studies; in the same review, a single study showed adults and children with mild to moderate asthma,
Eucalyptol resulted in statistically significant decrease the group that took butterbur had decreased number,
in daily oral steroid intake. Both reviews noted that vari- duration, and severity of asthma attacks while peak flow,
ation in formulations of CM herbal preparations, poor FEV1, and all symptoms improved. More than 40% of
reporting, and the quality of studies made it difficult to patients reduced intake of their asthma medications.44
draw conclusions to strongly support use of these herbs for This study appears promising although limited by its
asthma. lack of blinding and small sample size. In the second
Several individual herbs with relevance to pulmonary small randomized placebo cross-over study, Butterbur
disease are of particular interest. as add-on therapy to asthmatic patients maintained
Boswellia serrata (frankincense), an Ayurvedic herb on inhaled corticosteroids showed improvements in
has traditionally been used for its anti-inflammatory inflammatory markers over the placebo group.45 Garlic
effects. Its pharmacologically active ingredients have (Allium sativum), commonly used as a natural ‘‘broad
been shown to inhibit pro-inflammatory processes by their spectrum antibiotic’’ may have useful effects on biofilm
effects on 5-lipoxygenase and cyclo-oxygenase and on the with in vitro studies demonstrating a quorum sensing
complement system. It has shown promise, though not yet inhibition of Pseudomonas aeruginosa biofilm.46 When
compelling evidence, for clinical effects in other inflam- introduced into a murine pulmonary infection model there
matory processes (inflammatory bowel disease, arthritis) was clearing of the pseudomonas organism.47 A recent
in past reviews.26–28 No significant adverse effects were randomized-controlled pilot study in cystic fibrosis
noted. In a double-blind, placebo-controlled clinical trial patients subjects assessed potential clinical effects of
of 40 adult asthmatic patients given B. serrata gum resin garlic capsules versus olive oil placebo capsules taken
for a period of 6 weeks, 70% of patients had decrease in for 8 weeks. Only a suggestion of improvement was noted
dyspnea, rhonchi, number of attacks, and increase in with no significant change in pulmonary function or
FEV1 (P < 0.0001), FVC, and PEFR as well as a decrease clinical parameters.48 Generally regarded as safe, there
in eosinophilic count and ESR.29 Tylophora indica (Indian are cautions for garlic in large amounts due to inhibition of
ipecac) is another Ayurvedic herb traditionally used platelet aggregation and enhanced fibrinolytic activity.
to treat asthma conditions. It is thought to have anti- Garlic may also cause gastrointestinal disturbance in some
inflammatory activity.30,31 Crude extract of the leaves people.
of Tylophora inhibited delayed hypersensitivity reaction Other Herbs traditionally used for asthma, including
to sheep red blood cells in rats, and suppressed cellular Lobelia, Sanguinaria, Grindelia camporum, Ginko biloba,
immune responses when administered at any stage during have little supportive evidence for efficacy. Ma Huang
the immune response.32 It may also increase endogenous (ephedra sinica), a classic Asian herbal remedy for asthma
steroid production.33 Of the five randomized clinical trials contains ephedra and may be present in other herbal
on Tylophora in the 1960s and 1970s, two showed remedies for asthma. Serious side adverse effects reported
improvement in asthma symptom scores,34,35 one had include dysrhythmias, hypertension, seizures, death, and
significant improvement in FEV1 as well as symptoms,36 for this reason the Food and Drug Administration (FDA)
another had improvement only in nocturnal dyspnea,37 recommends against its use in asthma. These warnings
and one study showed no change in symptom score or come from the use of ephedra in doses that are much larger
Pediatric Pulmonology
534 Chung and Dumont

than those used for treatment of asthma in Traditional NUTRITIONAL SUPPLEMENTS

Chinese Medicine.3
Background and Basic Theory
The widespread use of Nutritional supplements has
Safety and Practical Issues
long generated concerns, which was best expressed over
Herbal medications are not regulated by the FDA in 12 years ago when Jane Brody of the New York Times
the US, but legal protection is provided under the wrote ‘‘Consumers are, in effect, volunteering for a vast
DSHEA (Dietary Supplement Health and Education largely unregulated experiment with substances that may
Act, 1994). This places the burden of proof of safety on be helpful, harmful, or simply ineffective.’’50 The situ-
the FDA, as the manufacturer does not have to provide ation is slowly changing as use of some supplements such
evidence for safety or efficacy, so care must be taken when as probiotics and Omega 3 fatty acids have been incorp-
choosing an herbal product. In general, many herbs are orated into conventional medicine practice based on main-
safe when used in appropriate dosages. However, herbal stream epidemiologic studies. The use of supplements by
products could potentially contain contaminants in the integrative medicine practitioners is based on the frame-
form of other herbs, heavy metals, or undesirable organic work of functional medicine, an approach designed to
compounds and they may contain unknown amounts of the reestablish balance to the various systems of the body
active ingredient. As pharmacologically active substan- (digestive, immune, inflammatory, oxidation-reduction,
ces, there can be herb–drug interactions. Some herbs can hormonal, etc.) that have been thrown into imbalance
induce or inhibit cytochrome p450 and can affect blood brought about by inappropriate diet, lifestyle, exposure
concentrations of other herbs or drugs concurrently taken. to pollutants, and (genetic and acquired) disease. Integral
Reputable companies follow strict standardized protocols to the functional medicine approach is lifestyle and dietary
(good manufacturing practice) ensuring quantifiable modification.
amounts of active ingredients and assurance of no con- There is lowered antioxidant activity and increased
tamination. Some companies submit their herbal products oxidative stress present in CF patients despite normal
to independent labs for certification of product quality. dietary antioxidant intake, suggesting that the immune
The Natural Standard (Cambridge, Mass) evaluates response might be a key factor causing oxidative
evidence using the criteria of Jadad et al.49 to indicate stress.51,52 These antioxidant levels decrease with age
methodological quality of information. When using herbal in the CF patient suggesting ongoing antioxidant
medicines, side effects, contraindications, and known depletion.53 Chronically stimulated immune cells as well
drug interactions should be examined. Children can be as invading pathogens are able to produce free radicals,
more susceptible than adults to the adverse effects of herbs thus increasing the free radical load. Nutritional supple-
due to the difference in their absorption, distribution, ments with anti-inflammatory and antioxidant properties
metabolism, and excretion of some substances. For would thus seem beneficial for chronic inflammatory
example, some herbs can be cathartic, or have powerful disorders such as asthma or CF. Several studies suggest
diuretic properties and may cause dehydration and electro- that intervention with antioxidant supplementation may
lytes disturbances more quickly in young children or improve pulmonary status. Whey, a supplement commonly
infants. There can also be allergic cross-reactivity such thought to improve muscle mass for athletic performance,
as ragweed allergy with Echinacea or Chamomile. may also enhance the antioxidant effect in CF. Rich in
Since self-administration is common with herbs, inappro- sulfated amino acids (primarily cysteine), important com-
priate use of herbs such as excessive doses or using ponents in the synthesis of glutathione (GSH), whey is a
inappropriate combinations could cause toxicity and is potent intracellular antioxidant. Studies have shown
more often the cause of adverse effects. Long-term increase in lymphocyte glutathione levels (46.6%
use may be required for some herbs to achieve expected increase) when whey protein isolate was administered
clinical effect before clinical benefit might be achieved. to CF patients for 3 months.54 Though no clinical changes
Raw herbs are sometimes recommended and preparation were seen in that study, a more recent study showed
can be time consuming. Most are available in liquid, improvement in FEV1 in children and a tendency to
tablets and concentrated drops, making them easier decreasing inflammatory marker in the majority of adults
to consume. In traditional Chinese Medicine approach, with CF. Both children and adults had enhanced nutri-
diet, acupuncture, and Chinese therapeutic massage are tional status based on body mass index.55 The later study
commonly used along with Chinese herbal medicines. utilized hyperbaric pressure-treated whey protein which is
This whole system multimodality approach may be thought to enhance availability of cysteine, increasing
important to achieve the greatest beneficial effect. lymphocytic glutathione.56 There may also be a relation-
CF patients who already take multiple drugs and do ship between asthma and low levels of antioxidants such as
other therapies may find it difficult to add herbs to their Vitamin C, which was found to be low in sputum levels of
regimen. asthmatic patients.57 A systematic review and meta-
Pediatric Pulmonology
 CAM Therapies in Pediatric Pulmonary Medicine 535

analysis showed that dietary vitamin C intake was signifi- Of the radical change in our diets for over the past 100
cantly lower in people with asthma compared to those years, one of the most significant is the tremendous
without asthma (mean differences
182 mg/day, 95% increase in omega 6 fatty acids with a decrease in omega
confidence interval
288 to
75; three studies) and in 3 fatty acids.68 This alteration of the Omega 3 to Omega 6
people with severe asthma versus mild asthma (mean ratio has pushed the western diet toward a pro-inflamma-
differences
344 mg/day; two studies). Lower quantile tory tendency. Correcting this imbalance by increasing
dietary intakes (odds ratio 1.12, 95% confidence interval omega-3 fatty acids may act to decrease the inflammatory
1.04–1.21; nine studies) and serum levels of vitamin C response by competitive inhibition of the proinflammatory
were also associated with an increased odds of asthma.58 effects of omega-6 dietary fats. Fish oils with their high
Whether or not supplementation can improve lung func- levels of the anti-inflammatory fatty acids (eicosapentae-
tion is uncertain. One systematic review revealed no sig- noic acid (EPA) and docosahexaenoic acid (DHA)) have
nificant relationship between dietary antioxidant intake been the most used in clinical trials. So far there is evi-
(vitamins C, E, and Beta-carotene) and lung function dence for its benefit in cancer, as well as in several chronic
except for a positive association between vitamin C and inflammatory diseases including cardiovascular diseases,
increase in FEV1.59 A Cochrane review of vitamin C inflammatory bowel disease and rheumatoid arthritis.69
supplementation and asthma could not recommend a For respiratory disease the evidence is not clear. A 2007
specific role for vitamin C in the treatment of asthma as Cochrane Database review of Omega 3 fatty acids and CF
larger randomized control trials were needed.60 Selenium came to the conclusion of promising effects but not
is well known as a component of GSH antioxidation. With enough evidence to suggest a definitive beneficial effect.70
low selenium levels in both CF and asthma populations, Similarly, there is yet no conclusive evidence for
supplementation would arguably make sense. In an 8- asthma.71,72 All three reviews call for larger and better
week randomized study of CF patients given antioxidant controlled randomized studies. A recent clinical trial of
supplement cocktail, there was a correlation between adult CF patients who receive low-dose supplements of
selenium and improvement in FEV1.61 In asthma, effects omega-3 and gammalinolenic fatty acids over 1 year
of selenium supplementation are not clear. In two random- appeared to improve pulmonary status and anthropometric
ized studies, one showed no significant improvement in measures with a decrease in inflammatory parameters.73
quality of life scores62 and the second study showed Magnesium is known to relax smooth muscle, and low
subjective clinical improvement.63 In neither study was magnesium levels have been shown to be associated with
there any objective improvement in lung status. A airway hyper-reactivity and wheezing.74 It also reduces
Cochrane Database review in 2004 concluded that inflammation through stabilization of T cells and inhi-
selenium supplementation could be a useful adjunct for bition of mast cell degranulation. It has been used intra-
chronic asthma but the data is limited.64 Aside from its role venously for acute treatment of asthma75 but it is unknown
as an antioxidant selenium may have a role as a modulator whether there is any benefit from routine oral Mg supple-
of immune function. Through its actions via a family of mentation for treatment of chronic asthma. Several studies
selenoproteins selenium may modulate the nuclear factor suggest that it may be beneficial with a reduction in
kappa-B (NF-kappaB) signaling pathway affecting the exacerbations and albuterol use in children; though no
inflammatory response (interleukin-6 and TNF-alpha pro- change in pulmonary function measurements were
duction).65 Though considered safe if supplemented found.76 Probiotics, long a mainstay in the alternative
within dietary guidelines, continued work is needed to medicine field are increasingly used in conventional medi-
unravel the relationship of selenium and airway disease. cine as therapeutic evidence accumulates for a variety of
Pycnogenol W (Horphag Research, Cointrin/GENEVA, medical problems such as antibiotic and viral-induced
Switzerland) is a proprietary extract of mixed bioflavo- diarrhea, atopy, irritable bowel syndrome, necrotizing
noids containing antioxidant and anti-inflammatory prop- enterocolitis, and a number of other acute and chronic
erties extracted from the French maritime pine (Pinus inflammatory and infectious gastrointestinal disorders.
pinater). Generally considered to be safe, it appears to Probiotics are packaged as either individual strains or
have very potent antioxidant properties, and has been as a mix of different species and strains usually composed
studied in two asthma clinical trials. Both were of various strains of lactobacilli and bifidobacteria. Indi-
placebo-controlled, one lasting 3 months in patients with vidual strains can have different metabolic effects, so the
mild to moderate asthma66 and the other a blinded cross- selection of appropriate strains is important. Intestinal
over design for patients with varying degrees of severity flora is responsible for the production of specific nutrients,
with 4 weeks for each limb of the trial.67 Both studies antioxidants, inhibition of potential pathogens, and
demonstrated a significant reduction in leukotrienes and enhancement of the immune system. There are several
improvement in symptoms. Pulmonary function and CF studies supporting a beneficial effect. Both reduction
asthma scores were significantly improved in the first of intestinal inflammatory markers77 and improvement in
study. It has not been studied in CF. Omega 3 Fatty Acids. bacterial overgrowth symptoms78 in CF children have
Pediatric Pulmonology
536 Chung and Dumont

been demonstrated. Whether probiotics can positively the physical properties but not chemical structure of water
influence pulmonary function was investigated. The first, by homeopathic dilutions has been suggested via studies
a placebo-controlled, cross-over study of 19 children utilizing thermoluminescence,85 calorimetry,86 and spec-
receiving lactobacillus or placebo (each arm for 6 troscopy.87,88 Further research is obviously needed in this
months). During treatment phase there was a reduction area. Physiologic effects induced by such ultramolecular
of pulmonary exacerbations and hospital admissions and dilutions have been demonstrated at the cellular level such
an improvement in FEV1 and body weight.79 In a smaller as the inhibition of human basophil degranulation by
6-month study using a (mixed) probiotic in 10 children homeopathic dilution of histamine.89 In a systematic
with CF, pulmonary exacerbation rates were reduced review of 67 in vitro homeopathic studies,90 75% of the
though PFT values were not changed.80 Probiotics have studies were positive, including studies with a high meth-
a status of ‘‘Generally Regarded As Safe’’ (GRAS) status odological standard. Most recently, an in vitro study
by the FDA in the US, but should not be given to critically showed preferential cytotoxic effect induced by homeo-
ill and immune compromised patients. Probiotics appear pathic medicines against two breast cancer lines while not
to be safe.81–84 affecting the normal breast cell line.91

Safety and Practical Issues Efficacy

Many nutritional supplements are considered generally There are a considerable number of clinical studies in
safe in the short-term but long-term effects are unknown in homeopathy. Independent systematic reviews that
many supplements. Caution is especially important for examined whether the effects of homeopathic medicines
chronic use in young children. Preparations mostly come are due to placebo showed a surprising number of positive
in the form of tablets and capsules, and some liquids. Many studies and conclusion that there was an effect beyond
dietitians emphasize the use of foods containing specific placebo.92 An analysis of studies that met the criteria of
nutrients as an alternative to preparations. Similarly, like double blind randomized, placebo-controlled, concluded
herbal medicines, supplements are not FDA regulated in that homeopathy can be efficacious for a number of con-
the US. ditions.93,94 Though one systematic review concluded no
difference between homeopathy and placebo,95 reanalysis
of the postpublication data did not support the conclusion
HOMEOPATHY
that homeopathy is a placebo effect.96 One study on
Background and Theory allergic rhinitis and another on allergic asthma (designed
by homeopathic physicians but implemented by pulmo-
Although homeopathy is one of the most widely used
nologists) led the authors to conclude that ‘‘homeopathy
form of complementary medicines worldwide, it is prob-
differs from placebo in an inexplicable but reproducible
ably one of the most controversial. Developed in the early
way.’’97,98 There is evidence from randomized, controlled
19th century by the German Physician Samuel Hahne-
trials that homeopathy may be more effective than placebo
mann, homeopathy competed with orthodox medicine in
for the treatment of influenza,99 postoperative ileus,100 and
the 19th century only to decline in the early part of the 20th
childhood diarrhea.101,102 While there are systematic
century. It has since undergone a revival in the past 30
reviews showing questionable results for asthma,103 this
years. It is based on the principle of ‘‘like cures like,’’ a
appeared to be due in part to variability of study design and
concept which dates back to Hippocrates. The premise is
form of homeopathy used. A prospective, randomized,
that a substance which may produce a particular constel-
double-blind, placebo-controlled study on intubated
lation of symptoms at a pharmacologic/toxic dose, will
chronic obstructive pulmonary disease patients to assess
‘‘cure’’ the same symptoms present in a patient when
the influence of homeopathic potassium dichromate on
administered in an ultra-diluted form. Since homeopathic
tenacious tracheal secretions showed significant decrease
medicines are often diluted beyond Avogadro’s number
in the amount of stringy tracheal secretions and earlier
(6.02  10
23) they may not even contain a molecule of
extubation in the treated group.104 There are no published
the original substance. Therefore, it would seem implau-
studies for homeopathy in CF.
sible that homeopathic therapy could have any effect over
placebo. However, the hypotheses for mechanism of
Safety and Practical Issues
action is not thought to be pharmacological but bio-
physical; that some form of information is transferred Unlike herbal and supplemental products, homeo-
from the substance to the water, possibly resulting in pathics have been FDA regulated in the US since 1939
rearrangement of the molecular structure of the water. and are available over-the-counter. The preparation
An explanation of the mechanism behind homeopathy process inherent to homeopathy eliminates any risk of
is not understood; the effect is thought to be biophysical pharmacological side effects and there are no interactions
rather than pharmacological. The theory that changes in with conventional drugs. Rarely, there are reports of
Pediatric Pulmonology
 CAM Therapies in Pediatric Pulmonary Medicine 537

‘‘aggravation,’’ which is a phenomenon of transient wor- treatment of irritable bowel syndrome, oral mucositis,
sening of symptoms before improvement.105 Based on temporomadibular disorders, and tension headaches.110
world literature search 1975–1995, the incidence of Self-hypnosis taught to children in one pulmonary center
adverse effects are very low, mostly minor and transi- showed improvement or resolution of symptoms such as
ent.105 Caution must be taken as some products are sold dyspnea, asthma, chest pain, and anxiety.111,112 There are
as ‘‘homeopathic’’ but may be combined with an herbal two studies utilizing self-hypnosis for cystic fibrosis. One
product. The homeopathic medicines are very convenient study in 1994 showed a significant increase in peak expir-
and easy to take as liquid, or more often in the form of atory flow rates immediately after self-hypnosis along
small tablets/beads (sugar beads that have been impreg- with improved aspects of psychological state.113 Forty-
nated with homeopathic dilutions, a manufacturing proc- nine cystic fibrosis patients successfully used self-hypno-
ess that creates a stable reliable vehicle for sublingual sis techniques for a variety of purposes including pain
absorption of the homeopathic solution). Although they relief associated with medical procedures, headache,
are available over the counter, homeopathic practitioners changing the taste of medications to make them more
feel that self-directed use is generally only effective for palatable and control of other symptoms associated with
treating acute and minor symptoms, as chronic conditions CF. Subjectively, success was achieved 86% of the time in
require more in depth evaluation for selection of the subjects with no worsening of symptoms from hypnother-
appropriate medicine. apy.114 A review of hypnosis and asthma concluded that
hypnosis likely helps with the behavioral/emotional com-
MIND/BODY MEDICINE ponent of asthma and shows promise decreasing severity
and relieving airway hyper-responsiveness.115
Background and Theory
Other frequently used forms of MBM include various
MBM includes a number of related techniques such as relaxation techniques, guided imagery, biofeedback, and
hypnosis, biofeedback, relaxation techniques, meditation, music therapy. The 1995 NIH Technology Assessment
breathing exercises, and may also include yoga, tai chi, qi Conference Panel on Relaxation and Behavioral
gong which involve some bodywork. These approaches Approaches for Chronic pain and Insomnia concluded
are based on the premise of a bidirectional influential that: ‘‘relaxation techniques’’ (e.g., deep and brief auto-
communication between mind and body. MBM is typi- genic training, meditation, progressive muscle relaxation)
cally used for symptom relief, preparation of surgery, and are effective for the treatment of a variety medical con-
as adjunctive treatment for a variety of medical conditions, ditions.110 Guided imagery or relaxation techniques have
particularly those which have a strong stress-related com- shown benefit in asthma.116 In CF patients, a positive
ponent. It is well documented that stress can enhance influence on lung function was observed after 4 months
airway inflammation in asthma by modulating immune of biofeedback assisted breathing retraining.117 A con-
cell function through neural and hormonal pathways.106–108 trolled study looking at benefits of music therapy for CF
In general, there exists a substantial body of clinical patients as an adjunct to chest physiotherapy showed that
evidence, demonstrating the effectiveness of mind/body music compiled by music therapist can be an aid when
techniques in many areas of medicine. However, most of doing chest physiotherapy for young children and their
these studies are small and there are obvious obstacles to parents.118
developing well-controlled studies. In patients with It is known that psychosocial stress may enhance airway
asthma and CF, there are studies which have shown that inflammation in asthma by modulating immune cell func-
these therapies, specifically relaxation and self-hypnosis tion through neural and hormonal pathways.107 There is
may minimize symptoms. Efficacy for several techniques growing evidence that mind–body techniques such as
is examined below. Hypnosis is the process of producing meditation, yoga, and other mind–body exercises when
an alternate state of awareness and alertness in which an practiced over time can reduce anxiety and may even help
individual is selectively focused, absorbed, and concen- with lung expansion. Some of these exercises incorporate
trating upon a particular idea or image (with or without regular breathing exercises. A Cochrane review concluded
relaxation), with a specific purpose of achieving some goal that yoga as well as other forms of breathing exercises
or realizing some potential.109 All clinical hypnosis is (Buteyko, diaphragmatic breathing) resulted in decreased
considered self-hypnosis, and the clinician’s role is as a use of beta-agonist medication and trend toward improve-
facilitator. In North America, clinical application of hyp- ment in quality of life although no improvement in lung
nosis emerged in the late 1950s, and has been shown to be function.119 Subsequently though, a number of studies on
efficacious for a wide spectrum of conditions from asthma, the effect of yoga breathing and asthma or chronic obstruc-
enuresis, encopresis to substance abuse.109 The NIH Tech- tive pulmonary disease showed benefit with some dem-
nology Assessment Conference Panel in 1995 found very onstrating improvement in pulmonary function, decreased
strong evidence for the efficacy of hypnosis in relieving airway hyper-responsiveness in addition to subjective
pain associated with cancer and moderate evidence for the measures.120–123 While most of these studies are on adults,
Pediatric Pulmonology
538 Chung and Dumont

a systematic review of studies on yoga for children also improvement.128 In a recent systematic review of chiro-
showed physiological benefits.124 However, not all studies practic therapy for asthma, chiropractic care showed
showed these benefits,125,126 and further investigative improvements in subjective measures and to a lesser
studies are needed to determine circumstances under degree objective measures, none of which were statisti-
which yoga could benefit in asthma or other chronic lung cally significant.129 In one CF center survey where 14% of
disease and to elucidate the mechanism by which this patients sought chiropractic care, 69% of users perceived
observed effect occurs. improvement in their pain, again showing only subjective
benefits.130
Safety and Practical Issues
Safety and Practical Issues
Used appropriately, hypnosis is safe109 but it is import-
ant to recognize psycho-emotional issues such as anxiety The issue of safety has always been a particular concern
or depression which may require psychotherapy or medi- of chiropractic manipulation. The major concerns have
cation. Promising long-term benefits of mind–body medi- been for (vertebral) arterial dissection or clot formation
cine techniques is the modification of behavioral patterns with a resultant cerebrovascular event, myelopathy,
of the child (and family); giving children effective tools to vertebral disc extrusion, epidural hematoma, and cauda
maintain health and deal with stress in a healthy and equine syndrome. From past safety review complications
effective manner. Used adjunctively with conventional range from 1 in 500,000 to 1 in 10,000,000 manipulations
therapies, mind–body modalities have the potential to with most agreeing on a complication rate of 1 CVAs per
benefit patients with a variety of disorders seen by pul- 1–3 million manipulations.131,132 A systematic review of
monologists including asthma, cystic fibrosis, and sleep adverse events examining the literature of the past 110
disorders. However, these techniques require active years revealed 11 cases of adverse events following spine
participation and a commitment by the patient, so each manipulation in children, 4 of which did not involve a
method must be evaluated with consideration of patient chiropractor. A more recent systematic review concluded
age and ability. no robust data concerning the incidence or prevalence of
adverse reactions after chiropractic manipulation.132
CHIROPRACTIC THERAPY Modifications are made by chiropractors when treating
pediatric patients133 and caution must be taken in cystic
Background and Theory
fibrosis patients as there is a high prevalence of osteopenia
Chiropractic care is one of the largest healthcare pro- and osteoporosis.134
fession in the US and is one of the most utilized CAM Patients who choose to seek chiropractic treatment as an
modalities. While it is primarily used to treat chronic alternative to conventional medicine especially for non-
musculoskeletal disorders and pain, it is also used by some musculoskeletal disorders such as asthma should be moni-
chiropractors for general well-being and treatment of a tored closely to avoid any delay in allopathic treatment,
wide variety of conditions such as asthma, GERD, chronic although chiropractic care for asthma is generally used for
constipation, sleep apnea, chronic otitis media, and enu- chronic maintenance.
resis. Chiropractics is based on the premise that proper
alignment of the spine is important for the nervous system
BODYWORK
to work properly. It is thought that subluxation of the spine
causes irritation of related neurological structures, affects Background and Theory
resting muscle tone, and disrupts blood flow to affected
This is a heterogeneous group of techniques, and theor-
structures leading to inflammation, pain, and organ dys-
etical approaches, which can be divided into several
function. The chiropractor employs various techniques to
groups: (1) manual therapy, (2) body movement or body
restore normal biomechanics to the articulations of the
re-education techniques, and (3) energy work. Theories
spine, cranium, and sometimes extremities to modulate
vary with the specific approach used. Generally, bodywork
neurological and physiological function.127 Patients with
techniques are used as an adjunct therapy for reduction of
CF and other respiratory disorders may turn to chiropractic
stress, and ‘‘holding patterns’’ in the body, improvement
care for chronic pain related to kyphosis and hypertrophic
of local circulation, and well-being. (1) Manual therapy
osteoarthropathy as well as specific respiratory problems,
implies physical contact from the therapist. This category
immune health, and general health maintenance.
would include Swedish massage, Rolfing, and Myofascial
Release releasing tension and muscular and fascial hold-
Efficacy
ing patterns as well as increasing circulation. (2) Body
While there are some studies showing benefits of chi- movement/education techniques such as Feldenkreis and
ropractic for management of pain syndromes, studies on Alexander technique re-educate the body giving improved
chiropractic for asthma have so far shown no objective balance, better alignment and a sense of well-being.
Pediatric Pulmonology
 CAM Therapies in Pediatric Pulmonary Medicine 539

(3) Energetic bodywork such as Reiki, Therapeutic Touch, biofield therapy and is most frequently used in pediatrics
and Polarity Therapy are considered healing practices for anxiety, subjective dyspnea related to asthma, pain,
influencing the body on an energetic level. The Chinese insomnia, and isolation. Many patients seek therapeutic
arts of Tai Chi Chuan and Qi Gong would fall into this last touch practitioners because they find they derive comfort
category. and benefit from them. Currently, there is no consensus
Massage is a very common technique that most people regarding the scientific mechanism of action involved.
associate with relaxation and feeling of well-being. How- There are numerous peer-reviewed articles indicating
ever, certain massage techniques are used adjunctively for patient perceived benefit as well as two meta-analysis
a variety of medical conditions and is increasingly being of therapeutic touch that concluded a positive effect on
employed in hospital settings for patients. Common to all physiological and psychologic variables.140 However, one
techniques is relaxation of the soft tissues, increased study in 1998 concluded that all therapeutic touch claims
circulation to the massaged area resulting in decreased were groundless.141 Subsequently, there have been at least
pain. There are other physiological and psychological four published papers critical of the procedures involved in
effects that can be therapeutic as well. For example, that study; that it violated the essential practice require-
massage is thought to activate the relaxation response ment of therapeutic touch and claim that this resulted in
and decrease respiratory rate, loosen tight respiratory inappropriate conclusions.142–145 A study on Reiki
muscles, and fascia which can help loosen and discharge showed significant reduction in anxiety, blood pressure,
phlegm. All forms of massage can be adapted for children. and increase in salivary IgA levels indicating stress
There are a few techniques that are specifically used in reduction response.146 But convincing research data on
children: infant massage, Ayurvedic (Indian), and Tui Na many of these therapeutic effects of these therapies are
(Chinese) massage for children. Some of these are also lacking at this time.
regarded as energy work as well. Qigong, literally meaning energy work, has many
different forms. Often with little body movement, the
Efficacy purpose is to move the ‘‘Qi’’ and enhance health. Medical
Qigong, is a branch of CM and Qigong exercises are
Few well-designed studies exist for manual bodywork.
prescribed for specific medical problems. One meta-
Most benefits such as the sense of well-being are subjective.
analysis review of past Qigong Random-controlled trials
However, massage therapy in premature infants has been
(26 trials) reports effects on a number of physiological
shown to promote a more stable response to stresses,
parameters including increased number of white cells,
increased weight gain and earlier discharge from the hos-
FVC, and FEV1.147 Tai Chi Chuan is also an energy
pital.135 Massage has been shown to benefit many different
(Qi) enhancement exercise contained within a martial
medical conditions such as insomnia, colic, as well as
art. There are two conflicting reviews of the effect of
chronic pulmonary disorders such as asthma and cystic
Tai chi exercises in adults: One meta-analysis with an
fibrosis. In two clinical studies on asthma and CF, parents
inclusion of seven trials concludes an increase in aerobic
were taught to do massage to their child while control group
capacity.148 The second review (five trials) found no con-
used relaxation technique only. Positive response to mas-
vincing evidence of an effect of Tai Chi on aerobic
sage therapy included reduction in anxiety, improvement in
capacity.149
mood, and increase in peak flows.136,137
Safety and Practical Issues
ENERGY WORK
The more gentle techniques of body movement or re-
The use of energy healing therapies has tripled between
education and energetic forms of bodywork are considered
1990 and 1997.138 Two types of energy fields are bioelec-
very safe. Manual massage is safe in almost all situations
tromagnetic based therapies: (1) use of magnetic fields
with the exception of acute febrile illness, local infection,
(generally used for pain syndromes) (2) biofield therapies
certain skin disorders, phlebitis, thrombosis, and bleeding
that are intended to affect the energy fields that surround
disorders. While massage can be provided at home by
and penetrate the human body and are not directly meas-
parents, a licensed massage therapist would be able to
urable; examples include therapeutic touch, Reiki, The
provide medical massage that is targeted towards a
goal of the latter is balancing the energy field in the body
particular therapeutic effect.
either through laying hands on or with nontouch inter-
ventions. These have in common the idea of facilitating the
CONCLUSION
body’s own natural healing ability. Spiritual healing or
prayer is amongst the oldest and most widespread inter- General concerns that arise when evaluating any poten-
ventions used, but the most recent Cochrane database tial new therapeutic approach are: safety, effectiveness,
reveals no evidence yet in support of prayer as an inter- and practical issues such as ease of administration and
vention.139 Therapeutic touch is a well known noninvasive cost. CAM modalities such as homeopathy, mind–body
Pediatric Pulmonology
540 Chung and Dumont

medicine, bodyworks, and acupuncture are generally prevalence, costs, and patterns of use. N Engl J Med 1993;
regarded as safe. Others, like herbs and supplements, 328:246–252.
may require more careful selection and monitoring due 2. Kemper JK, Vohra S, Walls R. The task force on complementary
medicine and alternative medicine and the provisional section on
to pharmacologic activity, product variability, and lack of complementary, holistic and alternative medicine. The use of
regulation. This is especially true for children as there is Complementary and Alternative Medicine in Pediatrics.
often less information and data in this age group. Pediatrics 2008;122:1374–1386.
While there is a lack of clinical studies in CAM for 3. Mark JD. Integrative medicine and asthma. Pediatr Clin N Am
many individual pulmonary diseases in children, the gen- 2007;54:1007–1023.
4. Ernst E. Use of complementary therapies in childhood asthma.
eral safety and efficacy data that do exist can help guide us Pediat Asthma Allergy Immunol 1998;12:29–32.
in its potential use or further investigation. It is recognized 5. Stern RC, Canda ER, Doershuk C. Use of nonmedical treatment
that research in CAM faces unique obstacles.150,151 For by cystic fibrosis patients. J Adolescent Health 1992;13:612–615.
example, there is difficulty finding true sham acupuncture; 6. Ramsay D, Bowman M, Greenman P, Jiang S, Kushi L, Leeman S,
blinding in mind–body studies; standardizing herbal and Lin K, Moerman D, Schnoll S, Walker M, et al. National Institute
of Health Consensus Development Conference Statement. Acu-
supplement products tested. With some therapies it is puncture 1997;15:1–34.
difficult to achieve the optimal effect when that modality 7. World Health Organization. Traditional Chinese Medicine and
is isolated from its accompanying synergistic therapies. Acupuncture Health Information Organization: acupuncture
Some question whether clinical studies in CAM should research: review and analysis of reports on controlled clinical
even be done using the standard methods that are used in trials. World Health Organization. 2003. www.tcm.health-info.org/
WHO-treatment-list.htm.
conventional medicine. This is evident in view of the fact 8. Jobst KA. Acupuncture in asthma and pulmonary disease: an
that many CAM therapies have to be tailored to the analysis of efficacy and safety. J Altern Complement Med
individual with the underlying premise that each individ- 1996;2:179–206.
ual has a different constitution and a unique reaction— 9. McCarney RW, Brinkhaus B, Lasserson TJ, Linde K. Acupunc-
‘‘one medicine does not fit all.’’ This is somewhat parallel ture for chronic asthma. Cochrane Database Syst Rev 2004;1:
CD000008.
to pharmacogenetics and the recognition of the variances 10. Fleischman GF. Possibilities for the treatment of cystic fibrosis
in individual response to drugs. with acupuncture and Chinese herbs: theory and case study. Am J
It should be noted that publication biases can affect our Acupunct 1996;24:135–142.
attitudes towards CAM therapies: negative studies in 11. Maa S, Tsou T, Wang K, Wang C, Lin H, Huang Y. Self admin-
CAM are more likely to be published in mainstream istered acupressure reduces the symptoms that limit daily activity
in bronchiectasis patients. J Clin Nurs 2007;16:794–804.
western journals, and positive studies more likely to be 12. Maa S, Sun M, Hsu K, Hung T, Chen H, Yu C, Wang C, Lin H.
published in foreign-language journals.152 Regardless, Effect of acupuncture or acupressure on quality of life of patients
there remains a great need for CAM therapies to undergo with chronic obstructive asthma: a pilot study. J Altern Comp-
rigorous clinical trials and investigations to elucidate the lement Med 2003;9:659–670.
mechanisms involved. It is understandable that this is 13. Manheimer E, Cheng K, Linde K, Lao L, Yoo J, Wieland S, van der
Windt DA, Berman BM, Bouter LM. Acupuncture for peripheral
needed in order for the practitioner to have a comfort joint osteoarthritis. Cochrane Database Syst Rev 2010;1:CD001977.
level when discussing CAM therapies with their patients 14. Lewis K, Abdi S. Acupuncture for lower back pain: a review. Clin
who may be seeking these treatment modalities. Open J Pain 2010;26:60–69.
dialogue with experienced CAM practitioners is essential 15. Lin JG, Chen WL. Review: acupuncture analgesia in clinical
for improved understanding and optimizing research. trials. Am J Chin Med 2009;37:1–18.
16. Selfe TK, Taylor AG. Acupuncture and osteoarthritis of the knee:
While many of us sit on the sidelines waiting for more a review of randomized, controlled trials. Fam Community Health
solid evidence-based data on CAM, patients have been 2008;31:247–254.
turning to many of these CAM therapies with or without 17. Madsen MV, Gøtzsche PC, Hróbjartsson A. Acupuncture treat-
their physicians’ participation. We need to develop a ment for pain: systematic review of randomised clinical trials with
knowledgeable understanding of these approaches and acupuncture, placebo acupuncture, and no acupuncture groups.
Br Med J 2009;338:a3115.
use the best available evidence along with safety and 18. Sun Y, Gan TJ. Acupuncture for the management of chronic head-
experiential profiles to assist in guiding our patients. ache: a systematic review. Anesth Analg 2008;107:2038–2047.
19. Sun Y, Gan TJ, Dubose JW, Habib AS. Acupuncture and related
techniques for postoperative pain: a systematic review of random-
ACKNOWLEDGMENTS ized controlled trials. Br J Anaesth 2008;101:151–160.
We gratefully acknowledge Susanna McColley, MD for 20. Lin YC, Ly H, Golianu B. Acupuncture pain management for
patients with cystic fibrosis: a pilot study. Am J Chin Med
her ideas and advice regarding this review. 2005;33:151–156.
21. Loo M. Acupuncture. In: Loo M, editor. Integrative medicine for
REFERENCES children. Saunders: Elsevier; 2009. p 81.
22. White A. A cumulative review of the range and incidence of
1. Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins DR, significant adverse events associated with acupuncture. Acupunct
Delbanco TL. Unconventional medicine in the United States: Med 2004;22:122–133.

Pediatric Pulmonology
 CAM Therapies in Pediatric Pulmonary Medicine 541

23. Carson C, Riley T. Toxicity of the essential oil of Melaleuca hybridus in allergic rhinitis. Int Immunopharmacol 2002;
alternifolia or tea tree oil. J Toxicol Clin Toxicol 1995;33:193– 2:997–1006.
194. 44. Danesch UC. Petasites hybridus (Butterbur root) extract in the
24. Ernst H. Herbal medicines for asthma: a systematic review. treatment of asthma—an open trial. Alter Med Rev 2004;9:
Thorax 2000;55:925–929. 54–62.
25. Clark CE, Arnold E, Lasserson TJ, Wu T. Herbal interventions for 45. Lee DK, Haggart K, Robb FM, Lipworth BJ. Butterbur, a herbal
chronic asthma in adults and children: a systematic review and remedy, confers complementary anti-inflammatory activity in
meta-analysis. Prim Care Respir J 2010;19:307–314. pii: asthmatic patients receiving inhaled corticosteroids. Clin Exp
pcrj-2010- 04-0047. DOI: 10.4104/pcrj.2010.00041 [Epub ahead Allergy 2004;34:110–114.
of print]. Available on www.thepcrj.org. 46. Persson T, Hansen TH, Rasmussen TB, Skindersø ME, Givskov
26. Ammon HP. Boswellic acids in chronic inflammatory diseases. M, Nielsen J. Rational design and synthesis of new quorum-
Planta Med 2006;72:1100–1116. sensing inhibitors derived from acylated homoserine lactones
27. Ernst E. Frankincense: systematic review. Br Med J 2008; and natural products from garlic. Org Biomol Chem 2005;
337:1439–1441. 3:253–262.
28. Moussaieff A, Mechoulam R. Boswellia resin from religious 47. Bjarnsholt T, Jensen PÄ, Rasmussen TB, Christophersen L,
ceremonies to medical uses: a review of in-vitro, in-vivo and Calum H, Hentzer M, Hougen HP, Rygaard J, Moser C, Eberl
clinical trials. J Pharm Pharmacol 2009;61:1281–1293. L, Høiby N, Givskov M. Garlic blocks quorum sensing and
29. Gupta I, Gupta V, Parihar A, Gupta S, Ludtke R, Safayhi H, promotes rapid clearing of pulmonary Pseudomonas aeruginosa
Ammon HP. Effects of Boswellia serrata gum resin in patients infections. Microbiology 2005;151:3873–3880.
with bronchial asthma: results of a double-blind, placebo-con- 48. Smyth AR, Cifelli PM, Ortori CA, Righetti K, Lewis S, Erskine P,
trolled, 6 week clinical study. Eur J Med Res 1998;3:511–514. Holland ED, Givskov M, Williams P, Cámara M, Barrett DA,
30. Gopalakrishnan C, Shankaranarayan D, Kameswaran L, Natar- Knox A. Garlic as an inhibitor of Pseudomonas aeruginosa
ajan S. Pharmacological investigations of tylophorine, the major quorum sensing in cystic fibrosis—a pilot randomized controlled
alkaloid of Tylophora indica. Indian J Med Res 1979;69:513–520. trial. Pediatr Pulmonol 2010;45:356–362.
31. Gopalakrishnan C, Shankaranarayan D, Nazimudeen SK, 49. Jadad AR, Moore RA, Carroll D, Jenkinson C, Reynolds DJ,
Kameswaran L. Effect of tylophorine, a major alkaloid of Gavaghan DJ, McQuay HJ. Assessing the quality of reports of
Tylophora indica, on immunopathological and inflammatory randomized clinical trials: is blinding necessary? Control Clin
reactions. Indian J Med Res 1980;71:940–948. Trial 1996;17:1–12.
32. Ganguly T, Sainis KB. Inhibition of cellular immune responses 50. Jane Brody: vitamins and supplements. New York Times 1997.
by Tylophora indica in experimental models. Phytomedicine October 26.
2001;8:348–355. 51. Portal BC, Richard MJ, Faure HS, Hadjian AJ, Favier AE. Altered
33. Udupa AL, Udupa SL, Guruswamy MN. The possible site of anti- antioxidant status and increased lipid peroxidation in children
asthmatic action of Tylophora asthmatica on pituitary-adrenal with cystic fibrosis. Am J Clin Nutr 1995;61:843–847.
axis in albino rats. Planta Med 1991;57:409–413. 52. Wood LG, Fitzgerald DA, Gibson PG, Cooper DM, Collins CE,
34. Shivpuri DN, Menon MP, Prakash D. A crossover double-blind Garg ML. Oxidative stress in cystic fibrosis: dietary and meta-
study on Tylophora indica in the treatment of asthma and allergic bolic factors. J Am Coll Nutr 2001;20:157–165.
rhinitis. J Allergy 1969;43:145–150. 53. Back EI, Frindt C, Nohr D, Frank J, Ziebach R, Stern M, Ranke M,
35. Shivpuri DN, Singhal SC, Parkash D. Treatment of asthma with Biesalski HK. Antioxidant deficiency in cystic fibrosis: when is
an alcoholic extract of Tylophora indica: a crossover, double- the right time to take action? Am J Clin Nutr 2004;80:374–384.
blind study. Ann Allergy 1972;30:407–412. 54. Grey V, Mohammed SR, Smountas AA, Bahlool R, Lands LC.
36. Mathew KK, Shivpuri DN. Treatment of asthma with alkaloids of Improved glutathione status in young adult patients with cystic
Tylophora indica: a double-blind study. Aspects Allergy Appl fibrosis supplemented with whey protein. J Cyst Fibros 2003;
Immunol 1974;7:166–179. 2:195–198.
37. Thiruvengadam KV, Haranath K, Sudarsan S, Sekar TS, Raja- 55. Lands LC, Iskandar M, Beaudoin N, Meehan B, Dauletbaev N,
gopal KR, Zacharian MG, Devarajan TV. Tylophora indica in Berthiuame Y. Dietary supplementation with pressurized whey in
bronchial asthma. J Indian Med Assoc 1978;71:172–177. patients with cystic fibrosis. J Med Food 2010;13:77–82.
38. Gupta S, George P, Gupta V, Tandon VR, Sundaram KR. Tylo- 56. Zavorsky GS, Kubow S, Grey V, Riverin V, Lands LC. An open-
phora indica in bronchial asthma—a double-blind study. Indian J label dose-response study of lymphocyte glutathione levels in
Med Res 1979;69:981–989. healthy men and women receiving pressurized whey protein
39. Wang W, Bernard K, Li G, Kirk KL. Curcumin opens cystic isolate supplements. Int J Food Sci Nutr 2007;58:429–436.
fibrosis transmembrane conductance regulator channels by a 57. Kongerud J, Crissman K, Hatch G, Alexis N. Ascorbic acid is
novel mechanism that requires neither ATP binding nor dimeri- decreased in induced sputum of mild asthmatics. J Inhal Toxicol
zation of the nucleotide-binding domains. J Biol Chem 2007; 2003;15:101–109.
16:4533–4544. 58. Allen S, Britton JR, Leonardi-Bee JA. Association between anti-
40. Menon VP, Sudheer AR. Antioxidant and anti-inflammatory oxidant vitamins and asthma outcome measures: systematic
properties of curcumin. Adv Exp Med Biol 2007;595:105–125. review and meta-analysis. Thorax 2009;64:610–619.
41. Sharma RA, Steward WP, Gescher AJ. Pharmacokinetics and 59. Gao J, Gao X, Li W, Zhu Y, Thompson PJ. Observational studies
pharmacodynamics of curcumin. Adv Exp Med Biol 2007;595: on the effect of dietary antioxidants on asthma: a meta-analysis.
453–470. Respirology 2008;13:528–536.
42. Cartiera MS, Ferreira EC, Caputo C, Egan ME, Caplan MJ, 60. Kaur B, Rowe BH, Arnold E. Vitamin C supplementation for
Saltzman WM. Partial correction of cystic fibrosis defects with asthma. Cochrane Database Syst Rev 2009;21:CD000993.
PLGA nanoparticles encapsulating curcumin. Mol Pharm 61. Wood LG, Fitzgerald DA, Lee AK, Garg ML. Improved antiox-
2010;7:86–93. idant and fatty acid status of patients with cystic fibrosis after
43. Thomet OA, Schapowal A, Heinisch IV, Wiesmann UN, Simon antioxidant supplementation is linked to improved lung function.
HU. Anti-inflammatory activity of an extract of Petasites Am J Clin Nutr 2003;77:150–159.

Pediatric Pulmonology
542 Chung and Dumont

62. Shaheen SO, Newson RB, Rayman MP, Wong AP, Tumilty MK, Kocis KC. Probiotic administration and the incidence of noso-
Phillips JM, Potts JF, Kelly FJ, White PT, Burney PG. Random- comial infection in pediatric intensive care: a randomized
ised double blind, placebo-controlled trial of selenium supple- placebo-controlled trial. Pediatr Crit Care Med 2007;8:452–
mentation in adult asthma. Thorax 2007;62:483–490. 458.
63. Hasselmark L, Malmgren R, Zetterstrom O, Unge G. Selenium 82. Whelan K, Myers CE. Safety of probiotics in patients receiving
supplementation in intrinsic asthma. Allergy 1998;48:30–36. nutritional support: a systematic review of case reports, random-
64. Allam MF, Lucance RA. Selenium supplementation for asthma. ized controlled trials, and nonrandomized trials. Am J Clin Nutr
Cochrane Database Syst Rev 2004;2:CD003538. 2010;91:687–703.
65. Duntas LH. Selenium F inflammation: underlying anti-inflam- 83. Liong MT. Safety of probiotics: translocation and infection. Nutr
matory mechanisms. Horm Metab Res 2009;41:443–447. Rev 2008;66:192–202.
66. Lau BH, Riesen SK, Truong KP, Lau EW, Rohdewald P, Barreta 84. Snydman DR. The safety of probiotics. Clin Infect Dis 2008;1:
RA. Pycnogenol as an adjunct in the management of childhood S104–S111.
asthma. J Asthma 2004;41:825–832. 85. Rey L. Thermoluminescence of ultra-high dilutions of lithium
67. Hosseini S, Pishnamazi S, Sadrzadeh SM, Farid F, Farid R, chloride and sodium chloride. Physica A 2003;323:67–74.
Watson RR. Pycnogenol1 in the management of asthma. 86. Elia V, Niccoli M. New physico-chemical properties of extremely
J Med Food 2001;4:201–209. diluted aqueous solutions. J Therm Anal Calorimetry 2004;75:
68. Simopoulos AP. Essential fatty acids in health and chronic dis- 815–836.
ease. Am J Clin Nutr 1999;70:560S–569S. 87. Roy R, Tiller WA, Bell IR, Hoover MR. The structure of liquid
69. Wall R, Ross RP, Fitzgerald GF, Stanton C. Fatty acids from fish: water; novel insights from materials research; potential relevance
the anti-inflammatory potential of long-chain omega-3 fatty to homeopathy. Mater Res Innov 2005;94:577–608.
acids. Nutr Rev 2010;68:280–289. 88. Rao ML, Roy R, Bell IR, Hoover R. The defining role of structure
70. McKarney C, Everard M, N’Diaye T. Omega-3 fatty acids (from (including epitaxy) in the plausibility of homeopathy. Homeo-
fish oils) for cystic fibrosis. Cochrane Database Syst Rev 2007; pathy 2007;96:175–182.
17:CD002201. 89. Belon P, Cumps J, Ennis M, Mannaioni PF, Sainte-Laudy J,
71. Reisman J, Schachter HM, Dales RE, Tran K, Kourad K, Barnes Roberfroid M, et al. Histamine dilutions modulate basophil
D, Sampson M, Morrison A, Gaboury I, Blackman J. Treating activity. Inflamm Res 2004;53:181–188.
asthma with omega-3 fatty acids: where is the evidence? A 90. Witt CM, Bluth M, Albrecht H, et al. The in vitro evidence for an
systematic review. BMC Complement Altern Med 2006;19:6–26. effect of high homeopathic potencies—a systematic review of the
72. Woods RK, Thien FC, Abramson MJ. Dietary marine fatty acids literature. Complement Ther Med 2007;15:128–138.
(fish oil) for asthma in adults and children. Cochrane Database 91. Frenkel M, Mishra BM, Sen S, Yang P, Pawlus A, Vence L,
Syst Rev 2002;3:CD001283. Leblanc A, Cohen L, Banerji P, Banerji P. Cytotoxic effects of
73. Olveira G, Olveira C, Acosta E, Espı́ldora F, Garrido-Sánchez L, ultra-diluted remedies on breast cancer cells. Int J Oncol
Garcı́a-Escobar E, Rojo-Martı́nez G, Gonzalo M, Soriguer F. 2010;36:395–403.
Fatty acid supplements improve respiratory, inflammatory and 92. Linde K, Clausius N, Ramirez G, Melchart D, Eitel F, Hedges LV,
nutritional parameters in adults with cystic fibrosis. Arch Bron- Jonas WB. Are the clinical effects of homeopathy placebo
coneumol 2010;46:70–77. effects? A meta-analysis of placebo-controlled trials. Lancet
74. Britton J, Pavord I, Richards K, Wisniewski A, Knox A, Lewis S, 1997;20:834–843.
Tattersfield A, Weiss S. Dietary magnesium, lung function, 93. Kleijnen J, Knipschild P, ter Riet G. Clinical trials of homeopathy.
wheezing and airway hyperreactivity in a random population Br Med J 1991;302:316–323.
sample. Lancet 1994;344:357–362. 94. Cucherat M, Haugh MC, Gooch M, Boissel JP. Evidence of
75. Rowe BH, Camargo CA, Jr. The role of magnesium sulfate in the clinical efficacy of homeopathy. A meta-analysis of clinical trials.
acute and chronic management of asthma. Curr Opin Pulm Med HMRAG. Homeopathic Medicines Research Advisory Group.
2008;14:70–76. Eur J Clin Pharmacol 2000;56:27–33.
76. Gontijo-Amaral C, Ribeiro MA, Gontijo LS, Condino-Neto A, 95. Shang A, Huwiler-Müntener K, Nartey L, Jüni P, Dörig S, Sterne
Ribeiro JD. Oral magnesium supplementation in asthmatic chil- JA, Pewsner D, Egger M. Are the clinical effects of homoeopathy
dren: a double-blind randomized placebo-controlled trial. Eur J placebo effects? Comparative study of placebo-controlled trials
Clin Nutr 2007;61:54–60. of homoeopathy and allopathy. Lancet 2005;2:726–732.
77. Bruzzese E, Raia V, Gaudiello G, Polito G, Buccigrossi V, For- 96. Rutten AL, Stolper CF. The 2005 meta-analysis of homeopathy:
micola V, Guarino A. Intestinal inflammation is a frequent feature the importance of post-publication data. Homeopathy 2008;97:
of cystic fibrosis and is reduced by probiotic administration. 169–177.
Aliment Pharmacol Ther 2004;20:813–819. 97. Reilly D, Taylor MA, McSharry C, Aitchison TC. Is homeopathy
78. Infante Pina D, Redecillas Ferreiro S, Torrent Vernetta A, Segarra a placebo response? Controlled trial of homeopathic potency,
Cantón O, Maldonado Smith M, Gartner Tizziano L, Hidalgo with pollen in hayfever as model. The Lancet 1986;344:881–886.
Albert E. Improvement of intestinal function in cystic fibrosis 98. Reilly D, Taylor MA, Beattie NG, Campbell JH, McSharry C,
patients using probiotics. An Pediatr (Barc) 2008;69:501–505. Aitchison TC, Carter R, Stevenson RD. Is evidence for homeo-
79. Bruzzese E, Raia V, Spagnuolo MI, Volpicelli M, De Marco G, pathy reproducible? The Lancet 1994;344:1601–1606.
Maiuri L, Guarino A. Effect of lactobacillus GG supplementation 99. Vickers AJ, Smith C. Homeopathic Oscillococcinum for prevent-
on pulmonary exacerbations in patients with cystic fibrosis: a pilot ing and treating influenza and influenza-like syndromes.
study. Clin Nutr 2007;26:322–328. Cochrane Database Syst Rev 2000;3:CD001957.
80. Weiss B, Bujanover Y, Yahav Y, Vilozni D, Fireman E, Efrati O. 100. Barnes J, Resch KL, Ernst E. Homeopathy for postoperative
Probiotic supplementation affects pulmonary exacerbations in ileus? A meta-analysis. J Clin Gastoenterol 1997;25:628–633.
patients with cystic fibrosis: a pilot study. Pediatr Pulmonol 101. Jacobs J, Jimenez LM, Gloyd SS, Gale JL, Crothers D. Treatment
2010;45:536–540. of acute childhood diarrhea with homeopathic medicine: a
81. Honeycutt TC, El Khashab M, Wardrop RM III, McNeal-Trice K, randomized clinical trial in Nicaragua. Pediatrics 1994;93:
Honeycutt AL, Christy CG, Mistry K, Harris BD, Meliones JN, 719–725.

Pediatric Pulmonology
 CAM Therapies in Pediatric Pulmonary Medicine 543

102. Jacobs J, Jonas WB, Jimenez-Perez M, Crothers D. Homeopathy 124. Galantino ML, Galbavy R, Quinn L. Therapeutic effects of yoga
for childhood diarrhea: combined results and meta-analysis from for children: a systematic review of the literature. Pediatr Phys
three randomized controlled trials. Pediatr Infect Dis 2003;22: Ther 2008;20:66–80.
229–234. 125. Sabina AB, Williams AL, Wall HK, Bansal S, Chupp G, Katz DL.
103. Linde K, Jobst KA. Homeopathy for chronic asthma. Cochrane Yoga intervention for adults with mild-to-moderate asthma:
Database Syst Rev 2000;1:CD000353. a pilot study. Ann Allergy Asthma Immunol 2005;94:543–
104. Frass M, Dielacher C, Linkesch M, et al. Influence of potassium 548.
dichromate on tracheal secretions in critically ill patients. Chest 126. Cooper S, Oborne J, Newton S, Harrison V, Thompson Coon J,
2005;127:936–941. Lewis S, Tattersfield A. Effect of two breathing exercises
105. Dantas F, Rampes H. Do homeopathic medicines provoke adverse (Buteyko and pranayama) in asthma: a randomised controlled
effects? A systematic review. Br Homeopath J 2000;89:235–238. trial. Thorax 2003;58:674–679.
106. Haczku A, Panettieri RA, Jr. Social stress and asthma: the 127. Haldeman S. Principles and practice of chiropractic. New York:
role of corticosteroid insensitivity. J Allergy Clin Immunol McGraw-Hill Professional; 2004. p. 755.
2010;125:550–558. 128. Bonfort G, Evans R, Kubic P, Filkin P. Chronic pediatric asthma
107. Chen E, Miller GE. Stress and inflammation in exacerbations of and chiropractic spinal manipulation: a prospective clinical series
asthma. Brain Behav Immun 2007;21:993–999. and randomized clinical pilot study. J Manipulative Physiol Ther
108. Chen E, Hanson M, Paterson L, et al. Socioeonomic status and 2001;24:369–377.
inflammatory processes in childhood asthma: the role of psycho- 129. Kaminskyj A, Frazier M, Johnstone K, Gleberzon J. Chiropractic
logical stress. J Allergy Clin Immunol 2006;117:1014–1020. care for patients with asthma: a systematic review of the literature.
109. Cohen DP. A pediatric perspective on mind-body medicine. In: J Can Chiropr Assoc 2010;54:24–32.
Culbert TP, Olness K, editors. Integrative Pediatrics. New York: 130. Stern RC, Canda ER, Doershuk CF. Use of nonmedical treat-
Oxford University Press; 2010. pp. 267–301. ment by cystic fibrosis patients. J Adolesc Health 1992;13:612–
110. NIH Technol Assess Statement. Integration of behavioral and 615.
relaxation approaches into the treatment of chronic pain and 131. Thiel HW, Bolton JE, Docherty S, Portlock JC. Safety of chiro-
insomnia. NIH Technol Assess Statement. 1995; October 16– practic manipulation of the cervical spine: a prospective national
18: 1-34. survey. Spine 2007;32:2375–2378.
111. Anbar R, Hummell K. Teamwork approach to clinical hypnosis at 132. Gouveia LO, Castanho P, Ferreira JJ. Safety of chiropractic
a pediatric pulmonary center. Am J Clin Hypn 2005;48:45–49. interventions: a systematic review. Spine 2009;15:E405–
112. Anbar RD. Self-hypnosis for management of chronic dyspnea in E413.
pediatric patients. Pediatrics 2001;107:E21. 133. Vohra S, Johston BC, Cramer K, Humphreys K. Adverse events
113. Belsky J, Khanna P. The effects of self-hypnosis for children with associated with pediatric spinal manipulation: a systematic
cystic fibrosis: a pilot study. Am J Clin Hypn 1994;36:282–292. review. Pediatrics 2007;119:275–283.
114. Anbar RD. Self-hypnosis for patients with cystic fibrosis. Pediatr 134. Paccou J, Zeboulon N, Combescure C, Gossec L, Cortet B. The
Pulmonol 2000;30:461–465. prevalence of osteoporosis, osteopenia, and fractures among
115. Brown D. Evidence-based hypnotherapy for asthma: a critical adults with cystic fibrosis: a systematic literature review with
review. Int J Clin Exp Hypn 2007;55:220–249. meta-analysis. Calcif Tissue Int 2010;86:1–7.
116. Lahmann C, Nickel M, Schuster T, Sauer N, Ronel J, Noll- 135. Field T, Hernandez-Reif M, Diego M, Figueiredo B, Schanberg S,
Hussong M, Tritt K, Nowak D, Rohricht F, Loew T. Functional Kuhn C. Prenatal cortisol, prematurity and low birthweight.
relaxation and guided imagery as complementary therapy in Infant Behav Dev 2006;29:268–275.
asthma: a randomized controlled clinical trial. Psychother Psy- 136. Hernandez-Reif M, Field T, Krasnegor J, Martinez E, Schwartz-
chosom 2009;78:233–239. man M, Mavanda K. Children with cystic fibrosis benefit
117. Delk KK, Gevirtz R, Hicks DA, Carden F, Rucker R. The effects from massage therapy. J Pediatr Psychol 1999;24:175–181.
of biofeedback assisted breathing retraining on lung functions in 137. Field T, Henteleff T, Hernandez-Reif M, et al. Children with
patients with cystic fibrosis. Chest 1994;105:23–28. asthma have improved pulmonary function after massage therapy.
118. Grasso M, Button BM, Allison DJ, Sawyer SM. Benefits of music J Pediatr 1998;132:854–858.
therapy as an adjunct to chest physiotherapy in infants and 138. Eisenberg DM, Davis RB, Ettner SL, Appel S, Wilkey S, Van
toddlers with cystic fibrosis. Pediatr Pulmonol 2000;29:371–381. Rompay M, Kessler RC. Trends in alternative medicine use in the
119. Holloway E, Ram F. Breathing exercises for asthma. Cochrane Unites States 1990–1997: results of a follow-up national survey.
Database Syst Rev 2004;1:CD001277. JAMA 1998;280:1569–1575.
120. Pomidori L, Campigotto F, Amatya TM, Bernardi L, Cogo A. 139. Roberts L, Ahmed I, Hall S, Davison A. Intercessory prayer
Efficacy and tolerability of yoga breathing in patients with for the alleviation of ill health. Cochrane Database Syst Rev
chronic obstructive pulmonary disease: a pilot study. 2009;2:CD000368.
J Cardiopulm Rehabil Prev 2009;29:133–137. 140. Ott MJ, Bossi I, Colbath J. A pediatric perspective on energy
121. Vempati R, Bijlani RL, Deepak KK. The efficacy of a compre- therapies. In: Culbert TP, Olness K, editors. Integrative pediatrics.
hensive lifestyle modification programme based on yoga in the New York: Oxford University Press; 2010. pp. 180–203.
management of bronchial asthma: a randomized controlled trial. 141. Rosa L, Rosa E, Sarner L, Barrett S. A close look at therapeutic
BMC Pulm Med 2009;30:37. touch. JAMA 1998;279:1005–1010.
122. Sodhi C, Singh S, Dandona PK. A study of the effect of yoga 142. Cox T. A nurse-statistician reanalyzes data from the Rosa thera-
training on pulmonary functions in patients with bronchial peutic touch study. Altern Ther Health Med 2003;9:58–64.
asthma. Indian J Physiol Pharmacol 2009;53:169–174. 143. Dossey L. Therapeutic touch at the crossroads: observations on
123. Donesky-Cuenco D, Nguyen HQ, Paul S, Carrieri-Kohlman V. the Rosa study. Altern Ther Health Med 2003;9:38–39.
Yoga therapy decreases dyspnea-related distress and improves 144. Achterberg J. Clearing the air in the therapeutic touch contro-
functional performance in people with chronic obstructive versy. Altern Ther 1998;4:100–101.
pulmonary disease: a pilot study. J Altern Complement Med 145. Leskowitz E. Un-debunking therapeutic touch. Altern Ther 1998;
2009;15:225–234. 4:101–102.

Pediatric Pulmonology
544 Chung and Dumont

146. Wardell D, Engebretson J. Biological correlates of Reiki Touch 150. Shekelle PG, Morton SC, Suttorp MJ, Buscemi N, Friesen C.
(sm) healing. J Adv Nurs 2001;33:439–445. Challenges in systematic reviews of complementary and
147. Ng BH, Tsang HW. Psychophysiological outcomes of health alternative medicine topics. Ann Intern Med 2005;142:1042–
qigong for chronic conditions: a systematic review. Psychophysi- 1047.
ology 2009;46:257–269. 151. Mason S, Tovey P, Long AF. Evaluating complementary medi-
148. Taylor-Piliae RE. The effectiveness of Tai Chi exercise in improv- cine: methodological challenges of randomised controlled trials.
ing aerobic capacity: an updated meta-analysis. Med Sport Sci Br Med J 2002;325:832–834.
2008;52:40–53. 152. Pham B, Klassen TP, Lawson ML, Moher D. Language of pub-
149. Lee MS, Lee EN, Ernst E. Is Tai Chi beneficial for improving lication restrictions in systematic reviews gave different results
aerobic capacity? A systematic review. Br J Sports Med 2009;43: depending on whether the intervention was conventional or
569–573. complementary. J Clin Epidemiol 2005;58:769–776.

Pediatric Pulmonology