Complementary and Alternative Medicine Approaches for Pediatric Pain: A Review of the State-of-the-science

Efficacy and safety of pharmacological, physical, and psychological interventions for the management of chronic pain in children: a WHO systematic review and meta-analysis

ABSTRACT

Chronic pain in childhood is an international public health problem. We conducted a systematic review and meta-analysis to provide a summary of the published evidence of pharmacological, physical, and psychological therapies for children with chronic pain conditions. We searched CENTRAL, MEDLINE, EMBASE, and PsycINFO from inception to April 2020; clinical trial registries; and other sources for randomised controlled trials or comparative observational trials. We extracted critical outcomes of pain intensity, quality of life, physical functioning, role functioning, emotional functioning, sleep, and adverse events. We assessed studies for risk of bias and certainty of the evidence using GRADE. We included 34 pharmacological (4091 participants), 25 physical therapy (1470 participants), and 63 psychological trials (5025 participants). Participants reported a range of chronic pain conditions. Most studies were assessed to have unclear or high risk of bias across multiple domains. Pharmacological, physical, and psychological therapies showed some benefit for reducing pain, posttreatment, but only physical and psychological therapies improved physical functioning. We found no benefit of any treatment modality for health-related quality of life, role functioning, emotional functioning, or sleep. Adverse events were poorly reported, particularly for psychological and physical interventions. The largest evidence base for the management of chronic pain in children supports the use of psychological therapies, followed by pharmacological and physical therapies. However, we rated most outcomes as low or very low certainty, meaning further evidence is likely to change our confidence in the estimates of effects. This protocol was registered on PROSPERO (CRD42020172451).

myPainPal: Co-creation of a mHealth app for the management of chronic pain in young people

Chronic pain is common in young people aged 10-14 years. Interdisciplinary, clinician-delivered treatments, while effective, are often criticized for failing to be readily accessible. Mobile health applications (mHealth apps) have been proposed as effective treatment adjuncts that address these challenges, while meeting the needs of tech-savvy young people. The objectives of this study were to co-create a mHealth app with consumers and health care professionals and evaluate the acceptability and feasibility of the resulting mHealth app (myPainPal). A phased, qualitative approach within a consumer engagement framework was employed. Interviews with young people (n = 14), parents (n = 12) and health care professionals (n = 8) identified key health needs that formed the underlying structure of the myPainPal app. Testing showed that the app is an acceptable and feasible platform to facilitate young people's self-management of chronic pain. The myPainPal app has the potential to positively influence young people's experiences of chronic pain. Further testing in controlled settings is required.

Autonomically-mediated decrease in microvascular blood flow due to mental stress and pain in sickle cell disease: A target for neuromodulatory interventions

Pain and vaso-occlusive crises (VOC) are hallmark complications of sickle cell disease (SCD) and result in significant physical and psychosocial impairment. The variability in SCD pain frequency and triggers for the transition from steady state to VOC are not well understood. This paper summarizes the harmful physiological effects of pain and emotional stressors on autonomically-mediated vascular function in individuals with SCD and the effects of a cognitive, neuromodulatory intervention (i.e. hypnosis) on microvascular blood flow. We reviewed recent studies from the authors' vascular physiology laboratory that assessed microvascular responses to laboratory stressors in individuals with SCD. Results indicate that participants with SCD exhibit marked neurally mediated vascular reactivity in response to pain, pain-related fear, and mental stress. Further, pilot study results show that engagement in hypnosis may attenuate harmful microvascular responses to pain. The collective results demonstrate that autonomically-mediated vascular responses to pain and mental stress represent an important SCD intervention target. This ongoing work provides physiological justification for the inclusion of cognitive, neuromodulatory and complementary treatments in SCD disease management and may inform the development of targeted, integrative interventions that prevent the enhancement of autonomic vascular dysfunction in SCD.

Adverse events associated with paediatric massage therapy: a systematic review

INTRODUCTION

Massage therapy (MT) is frequently used in children. No study has systematically assessed its safety in children and adolescents. We systematically review adverse events (AEs) associated with paediatric MT.

METHODS

We searched seven electronic databases from inception to December 2018. We included studies if they (1) were primary studies published in a peer-reviewed journal, (2) involved children aged 0-18 years and (3) a type of MT was used for any indication. No restriction was applied to language, year of publication and study design. AEs were classified based on their severity and association to the intervention.

RESULTS

Literature searches identified 12 286 citations, of which 938 citations were retrieved for full-text evaluation and 60 studies were included. In the included studies, 31 (51.6%) did not report any information on AEs, 13 (21.6%) reported that no AE occurred and 16 studies (26.6%) reported at least one AE after MT. There were 20 mild events (grade 1) that resolved with minimal intervention, 26 moderate events (grades 2-3) that required medical intervention, and 18 cases of severe AEs (grades 4-5) that resulted in hospital admission or prolongation of hospital stay; of these, 17 AEs were volvulus in premature infants, four of which were ultimately fatal events.

CONCLUSION

We identified a range of AEs associated with MT use, from mild to severe. Unfortunately, the majority of included studies did not report if an AE occurred or not, leading to publication bias. This review reports an association between abdominal massage with volvulus without malrotation in preterm infants; it is still to be defined if this is casual or not, but our findings warrant caution in the use of abdominal massage in preterm infants.

Phytotherapeutic approaches to treatment and prophylaxis in pediatric practice

Medicinal plants, their extracts and herbal medicinal products occupy a growing share of medicines in the pharmacy worldwide.

Historically, the first medicines were products of plants, as well as some of the most important medicines still in use today. With the development of phytochemistry, as part of the pharmaceutical science, great progress has been made in the isolation and in determining the value of a number of biologically active substances (BAS).

Many plants have yielded pure substances (or natural products) that are applied in modern medical practice. Other compounds are potentially useful or have toxic effects.

Traditional medicine incorporating many herbal medicines remains an important (and in some cases, the only) form of treatment in some countries, with increasing use in medical practice.

On the other hand, the fact that in pediatric patients there is a limitation, mainly moral and ethical, of the number of medications to be administered due to the difficulty of conducting clinical trials in children, stimulates the use of herbal medicines of proven quality, effectiveness and safety among this group of patients.

Massage therapy for paediatric procedural pain: A rapid review

Background

Pain is a common paediatric problem, and procedural pain, in particular, can be difficult to manage. Complementary therapies are often sought for pain management, including massage therapy (MT). We assessed the evidence for use of MT for acute procedural pain management in children.

Methods

We searched five main databases for (i) primary studies in English, (ii) included children 0 to 18 years of age, (iii) compared MT for procedural pain management to standard care alone or placebo, and (iv) measured pain as the primary or secondary outcome. The data were extracted by one author and verified by a second author. Randomized controlled trials were evaluated using the Cochrane Risk of Bias tool.

Results

Eleven paediatric trials of procedural pain in neonatal, burn, and oncology populations, a total of 771 participants, were identified. Eight reported statistically significant reductions in pain after MT compared to standard care. Pain was measured using validated pain scales, or physiologic indicators. The studies were heterogeneous in population, techniques, and outcome measures used. No adverse events associated with MT were identified.

Conclusion

MT may be an effective nonpharmacologic adjunct for management of procedural pain in children.

Effect of acupressure on post tonsillectomy pain in adolescents: a randomized, single-blind, placebo-controlled trial study

Introduction Tonsillectomy is one of the most common pediatric surgeries in the world and pain control following tonsillectomy is very important. Objective The aim of this study is to investigate the effect of acupressure on the amount of pain following tonsillectomy in children. Method One hundred and forty-four children aged 5-12 years old were assigned into one of three groups: interventions, control and placebo. In the intervention group, acupressure was applied at three acupoints and in the placebo group, sham acupressure was applied. In the control group routine care only was applied. Results There was a significant difference between an average of changes in pain score before and after the intervention during the 3 time periods after the tonsillectomy operation in the acupressure group (p = 0.002). Conclusion The results showed that acupressure had a positive effect on pain reduction after tonsillectomy in children in the intervention group.

Social Media Content About Children's Pain and Sleep: Content and Network Analysis

BACKGROUND

Social media is often used for health communication and can facilitate fast information exchange. Despite its increasing use, little is known about child health information sharing and engagement over social media.

OBJECTIVE

The primary objectives of this study are to systematically describe the content of social media posts about child pain and sleep and identify the level of research evidence in these posts. The secondary objective is to examine user engagement with information shared over social media.

METHODS

Twitter, Instagram, and Facebook were searched by members of the research team over a 2-week period using a comprehensive search strategy. Codes were used to categorize the content of posts to identify the frequency of content categories shared over social media platforms. Posts were evaluated by content experts to determine the frequency of posts consistent with existing research evidence. User engagement was analyzed using Netlytic, a social network analysis program, to examine visual networks illustrating the level of user engagement.

RESULTS

From the 2-week period, nearly 1500 pain-related and 3800 sleep-related posts were identified and analyzed. Twitter was used most often to share knowledge about child pain (639/1133, 56.40% of posts), and personal experiences for child sleep (2255/3008, 75.00% of posts). For both topics, Instagram posts shared personal experiences (53/68, 78% pain; 413/478, 86.4% sleep), Facebook group posts shared personal experiences (30/49, 61% pain; 230/345, 66.7% sleep) and Facebook pages shared knowledge (68/198, 34.3% pain; 452/1026, 44.05% sleep). Across platforms, research evidence was shared in 21.96% (318/1448) of pain- and 9.16% (445/4857) of sleep-related posts; 5.38% (61/1133) of all pain posts and 2.82% (85/3008) of all sleep posts shared information inconsistent with the evidence, while the rest were absent of evidence. User interactions were indirect, with mostly one-way, rather than reciprocal conversations.

CONCLUSIONS

Social media is commonly used to discuss child health, yet the majority of posts do not contain research evidence, and user engagement is primarily one-way. These findings represent an opportunity to expand engagement through open conversations with credible sources. Research and health care communities can benefit from incorporating specific information about evidence within social media posts to improve communication with the public and empower users to distinguish evidence-based content better. Together, these findings have identified potential gaps in social media communication that may be informative targets to guide future strategies for improving the translation of child health evidence over social media.

Palliative Care for Children with Central Nervous System Malignancies

Children with central nervous system (CNS) malignancies often suffer from high symptom burden and risk of death. Pediatric palliative care is a medical specialty, provided by an interdisciplinary team, which focuses on enhancing quality of life and minimizing suffering for children with life-threatening or life-limiting disease, and their families. Primary palliative care skills, which include basic symptom management, facilitation of goals-of-care discussions, and transition to hospice, can and should be developed by all providers of neuro-oncology care. This chapter will review the fundamentals of providing primary pediatric palliative care.

Current Evidence-Based Interdisciplinary Treatment Options for Pediatric Musculoskeletal Pain

PURPOSE OF REVIEW

We review the prevalence of pediatric chronic musculoskeletal pain, the clinical need, the evidence for pharmacological, psychological, physical and, complementary approaches to pain management, and the possible future development of interdisciplinary and distance care.

RECENT FINDINGS

We summarize the Cochrane Systematic Reviews on pharmacological interventions, which show a lack of evidence to support or refute the use of all classes of medication for the management of pain. The trials for NSAIDs did not show any superiority over comparators, nor did those of anti-depressants, and there are no trials for paracetamol, or of opioid medications. There are studies of psychological interventions which show promise and increasing support for physical therapy. The optimal approach remains an intensive interdisciplinary programmatic treatment, although this service is not available to most.

SUMMARY

1. Given the absence of evidence, a program of trials is now urgently required to establish the evidence base for analgesics that are widely prescribed for children and adolescents with chronic musculoskeletal pain. 2. Until that evidence becomes available, medicine review is an essential task in this population. 3. We need more examples and efficacy evaluations of intensive interdisciplinary interventions for chronic pain management, described in detail so that researchers and clinicians can unpack possible active treatment components. 4. Online treatments are likely to be critical in the future. We need to determine which aspects of treatment for which children and adolescents can be effectively delivered in this way, which will help reduce the burden of the large number of patients needing support from a small number of experts.

Antrodia Cinnamomea Reduces Carbon Tetrachloride-induced Hepatotoxicity In Male Wister Rats

BACKGROUND/AIM

Antrodia cinnamomea is found with polysaccharides, lipids, vitamins, fibers and ash (minerals) and is well known in Taiwan as a traditional Chinese medicine. Its biological activities have been reported to have anti-inflammatory, anti-fatigue, anti-tumor and immunomodulatory effects, but its protective effects on liver function are still unclear.

MATERIALS AND METHODS

We determined if Antrodia cinnamomea was hepatoprotective against carbon tetrachloride (CCl₄) toxicity in Wistar rats. Six groups were used in the study: 1) control (no induction by CCl₄); 2) negative control (CCl₄-induction and no treatment); 3) positive control (silymarin treatment); 4) groups 4-6 were treated with CC1₄ and different concentrations (350 mg/kg, 1,400 mg/kg, 3,150 mg/kg) of Antrodia cinnamomea. Blood and liver samples of rats were harvested and then detected by biochemical and tissue histochemical analysis. Activity of the antioxidative enzymes glutathione peroxidase, superoxide dismutase and catalase in the liver were also monitored.

RESULTS

Only the high-dose treatment was able to decrease serum glutamic-oxaloacetic transaminase (GOT) and glutamic-pyruvic transaminase (GPT) levels and improve liver function. High and medium doses increased total liver protein and reduced hydroxyproline. It was also observed that the high dose treatment reduced lipid peroxidation. Liver sections of CC1₄ treated animals receiving Antrodia cinnamomea showed less fibrosis compared to the CCl₄ control group.

CONCLUSION

This finding suggested that Antrodia cinnamomea can either enhance liver recovering from CCl₄ damage or attenuate CCl₄ toxicity in rats.

Complementary and Alternative Medicine Use by Children With Pain in the United States

OBJECTIVE

Chronic pain is reported by 15% to 25% of children. Growing evidence from clinical samples suggests that complementary and alternative medicine (CAM) therapies are desired by families and may benefit some children with pain conditions. The objective of this study was to provide estimates of CAM use by children with pain in the United States.

METHODS

We analyzed data from the 2012 National Health Interview Survey (NHIS) to estimate patterns, predictors, and perceived benefits of CAM use among children 4 to 17 years of age with and without painful conditions in the United States. We used chi-square tests to compare the prevalence rates of CAM use among children with pain to CAM use among children without pain. Multivariable logistic regression was used to examine factors associated with CAM use within the group of children with pain conditions.

RESULTS

Parents reported that 26.6% of children had pain conditions (eg, headache, abdominal, musculoskeletal pain) in the past year; of these children, 21.3% used CAM. In contrast, only 8.1% of children without pain conditions used CAM (χ2, P < .001). CAM use among children with pain was associated with female sex (adjusted odds ratio [aOR] = 1.49, P = .005), higher income (aOR = 1.61, P = .027), and presence of 4+ comorbidities (aOR = 2.01, P = .013). Among children with pain who used CAM, the 2 most commonly used CAM modalities were biology-based therapies (47.3%) (eg, special diets and herbal supplements) and manipulative or body-based therapies (46.3%) (eg, chiropractic and massage).

CONCLUSIONS

CAM is frequently used by children with pain in the United States, and many parents report benefits for their child's symptoms.

Cytotoxic and apoptogenic effects of Bryonia aspera root extract against Hela and HN-5 cancer cell lines

OBJECTIVE

Bryonia aspera (Stev. ex Ledeb) is a plant that grows in northeast of Iran. In the present study, cytotoxic and apoptogenic properties of B. aspera root extract was determined against HN-5(head and neck squamous cell carcinoma) and Hela (cervix adenocarcinoma) cell lines.

MATERIALS AND METHODS

HN-5 and Hela cell lines were cultured in DMEM medium and incubated with different concentrations of B. aspera root extract. Cell viability was quantitated by MTT assay and the optical absorbance was measured at 570 nm (620 nm as the reference) by an ELISA reader, in each experiment. Apoptotic cells were assessed using PI staining of DNA fragmentation by flow cytometry (sub-G1 peak). The B. aspera inhibited 50% growth (IC50) of Hela and HN-5 cell lines at 100±28 μg/ml and 12.5±4 μg/ml, respectively after 48 hr of incubation.

RESULTS

Cell viability assay showed that inhibitory effects of B. aspera were time and dose-dependent in both cell lines, which were consistent with morphological changes, observed under light microscope. Apoptosis was investigated by flow cytometry in which percentage of apoptotic cells increased in a dose and time-dependent manner.

CONCLUSION

Based on our data, B. aspera has cytotoxic effects in which apoptosis played an important role. Further evaluations are needed to assess the possible anti-tumor properties of this plant.

Nonpharmacologic Treatment of Pain

Pain is a complex biopsychosocial experience that is influenced by neurological processes and psychosocial factors. Systematic reviews and meta-analyses of randomized controlled trials of psychological interventions have demonstrated evidence for psychological approaches in treating procedural pain and multiple types of chronic pain, including headaches, abdominal pain, and musculoskeletal pain. This article is directed toward clinicians and would provide an overview of cognitive-behavioral therapy, including specific cognitive-behavioral techniques for pediatric pain. A review is provided of preparation and psychoeducation, distraction, exposure and psychological desensitization, relaxation techniques, additional cognitive and behavioral therapy, exercise and alternative options, use of technology, multicomponent approaches, and final considerations in treating acute and chronic pain. It is important to consider multiple characteristics of the child when selecting an intervention for chronic pain, which are reviewed in the article.

The Role of Salivary Neuropeptides in Pediatrics: Potential Biomarkers for Integrated Therapies

INTRODUCTION

Objective measures of symptom response to integrated complementary approaches in pediatrics are evolving. The purpose of this study was to document the concentration range of salivary neuropeptides in healthy controls and in children with cancer, to explore correlations between serum and salivary measurements for Calcitonin Gene-Related Peptide (CGRP) and Vasoactive Intestinal Polypeptide (VIP), and to determine whether there is a change in these salivary neuropeptide levels in response to integrated mind-body therapies.

METHODS

A non-randomized pragmatic study with three phases: Phase 1- Healthy Control Saliva-10 healthy controls provided saliva samples; Phase 2- Cancer Diagnosis Serum-Saliva- 16 mixed-type cancer patients provided blood and saliva samples; Phase 3- Acute Lymphocytic Leukemia (ALL) Saliva Intervention- 12 patients with ALL provided pre- and post-complementary intervention saliva samples.

INTERVENTIONS

20-minutes of structured touch or scripted relaxation breathing were administered to patients in Phase 3; Phase 1 and 2 patients did not receive this intervention.

OUTCOME MEASURES

cortisol, CGRP, VIP, State/Trait Anxiety Scale, visual analogue scale, vital signs.

RESULTS

Salivary CGRP and VIP were similar for children in Phases 1 and 2. There was a correlation between serum and salivary VIP in the mixed cancer group, though not between serum and salivary CGRP. In Phase 3 children, following a complementary intervention, salivary CGRP, heart rate, and systolic blood pressure decreased.

DISCUSSION/CONCLUSIONS

These data provide evidence of a decrease in sympathetic output after integrative/complementary therapy intervention in children with cancer. The study underscores the potential role of salivary neuropeptides as non-invasive biomarkers for integrated therapies in pediatrics.

[Non-pharmaceutical measures, topical analgesics and oral administration of glucose in pain management: Austrian interdisciplinary recommendations on pediatric perioperative pain management]

Non-pharmaceutical procedures are increasingly being used in pediatric pain therapy in addition to pharmaceutical procedures and have a supporting function. This article describes the non-pharmaceutical procedures which have an influence on perioperative and posttraumatic pain in children and adolescents. Prerequisites for every adequate pain therapy are affection, imparting a feeling of security, distraction and the creation of a child-oriented environment. Topical analgesics are indicated for application to intact skin for surface anesthesia. For a safe use consideration must be given to the duration of application, the dose and the maximum area of skin treated in an age-dependent manner. For simple but painful procedures in premature infants, neonates and infants, pain can be effectively reduced by the oral administration of glucose. The positive effect is guaranteed particularly for the use in a once only pain stimulation. Non-nutritive sucking, swaddling, facilitated tucking and kangaroo mother care, for example can be used as supportive measures during slightly painful procedures. There is insufficient evidence for a pain reducing effect in older infants and small children. Physical therapeutic procedures can be used as accompanying measures for acute pain and are individually adapted. However, the limited amount of currently available data is insufficient to make a critical scientific assessment of the individual measures. The effects can, however, be observed in the daily routine practice. Psychological methods can facilitate coping with pain. In situations with mental and psychiatric comorbidities or psychosocial impairment, a psychologist should be consulted. Acupuncture and hypnosis are also a meaningful addition within the framework of multimodal pain therapy.

Complementary and alternative medicine (CAM) use in an Italian cohort of pediatric headache patients: the tip of the iceberg

The use of complementary alternative medicine (CAM) in paediatric populations is considerably increased, especially for pain and chronic conditions, as demonstrated by epidemiological surveys both in Europe and in the USA. In our study, CAM was used in 76 % patients of a cohort of 124 children affected by headache (age 4-16 years; 67 % female; 70 % migraine without aura, 12 % migraine with aura, 18 % tensive headache according to IHS criteria) consecutively recruited at a Pediatric Headache University Center. CAM was used as preventive treatment in 80 % cases. The main reasons for seeking CAM were: the wish of avoiding chronic use of drugs with their related side effects, the desire of an integrated approach, the reported inefficacy of conventional medicine, and a more suitable children disposition to CAM than to pharmacological compound. Female gender, younger age, migraine without aura, parents' higher educational status, maternal use of CAM and other associated chronic conditions, correlated with CAM use (p < 0.05). 73 % patients chose CAM also to treat other diseases (i.e. allergies, colitis, asthma, insomnia, muscle-scheletric disorders and dysmenorrhoea). The most assumed CAM were: herbal remedies (64 %) such as Valeriana, Ginkgo biloba, Boswellia serrata, Vitex agnus-castus, passion flower, Linden tree; vitamins/minerals supplements (40 %) with magnesium, 5-Hydroxytryptophan, vitamin B6 or B12, Multivitamin compounds; Homeopathy (47 %) with Silicea, Ignatia Amara, Pulsatilla, Aconitum, Nux Vomica, Calcarea phosphorica; physical treatment (45 %) such as Ayurvedic massage, shiatsu, osteopathy; yoga (33 %); acupuncture (11 %). CAM-often integrated with conventional care-was auto-prescribed in 30 % of the cases, suggested by non-physician in 22 %, by the General Practitioner in 24 % and by paediatrician in 24 %. Both general practitioners and neurologists were mostly unaware of their patients' CAM use. In conclusion, neurologists should inquire for CAM use and be prepared to learn about CAM therapies or to directly interact with CAM trained experts, in order to coordinate an integrative approach to health, as especially required in paediatric headache patients and their parents. Further studies are required to investigate safety and efficacy of CAM in pediatric headache, as a possible side-medicine to conventional pharmacological approach.

Attitudes and practices of complementary and alternative medicine among adolescents in Saudi Arabia

The aim of this study was to investigate the attitudes and use of complementary and alternative medicine (CAM) among Saudi Arabian adolescents. A multistage stratified sampling method was used to select 736 adolescents (358 males, 378 females) aged 15–19 years from secondary schools. The study was carried out in Al-Khobar city, Eastern region of Saudi Arabia. The findings revealed that the use of CAM by adolescents in their lifetime ranged from 1.6% for acupuncture to 58.6% for honey treatment, with significant differences between genders, except in the use of dietary supplements, black cumin, and acupuncture therapies. Females were more likely to use CAM for treating abdominal pains, cold and flu, and cough than males (P < 0.000). Family members and friends (67.7%) were the main source of CAM usage, followed by television (10%), and Internet (8%). Religious and medicinal herb healers were the CAM healers most commonly visited by adolescents. Nearly 21–43% of adolescents had positive attitudes toward CAM, with some significant differences between males and females. It can be concluded that CAM is widely used by Saudi adolescents, but caution should be exercised for the safe usage of some CAM treatments. CAM should not be ignored; however there is an urgent need to establish regulations for CAM usage.

Treatment expectations among adolescents with chronic musculoskeletal pain and their parents before an initial pain clinic evaluation

OBJECTIVES

To understand expectations regarding treatment recommendations among treatment-seeking adolescents with chronic musculoskeletal pain and their parents.

METHODS

A total of 102 adolescent-parent dyads were recruited at the time of initial contact with a multidisciplinary pain management clinic. Each participant completed reports of adolescent pain intensity and disability, biopsychosocial perspective of pain, and treatment expectations related to recommendations and feedback for a vignette description of an adolescent presenting at an initial multidisciplinary pain clinic evaluation.

RESULTS

Descriptive findings for individual treatment expectations and adolescent-parent dyad agreement statistics were examined. Slight to fair levels of agreement occurred for 50% of the expectations assessed. The strongest shared expectations were for recommendations to return to school, pursue psychological counseling, and pursue PT/OT treatment. Stronger agreement occurred for items reflecting alternative, emotional, behavioral, and activity recommendations with weaker agreement for medical interventions (eg, medication and surgery). Correlations emerged between individual expectations and adolescent pain intensity, disability, with the greatest number of significant relationships found for adolescent and parent expectations and biopsychosocial perspectives of pain.

DISCUSSION

Our results document that adolescents and parents show modest levels of agreement on expectations for treatment at the time of an initial pain clinic evaluation. This may relate to expectations being internal perspectives not clearly expressed within families; thus, the initial treatment consultation may provide an important opportunity to create and align appropriate expectations. Implications of our findings are considered with respect to education, treatment, and future research to understand factors that contribute to treatment adherence and outcomes.

Investigation into the toxicity of traditional Uyghur medicine Quercus infectoria galls water extract

Objective

Quercus infectoria galls (QIG) is being widely used in Traditional Uyghur Medicine. To gather preclinical safety information for the aqueous extract of QIG, a toxicity study was performed.

Methods

Subject animals were randomized, and devided into exposure and control groups. In the acute toxicity phase, three different doses—5, 7.5, and 10 g/kg, respectively—were administered via enema to imprinting control region (ICR) mice. An experiment using the maximum tolerance dose (MTD) i.e.10 g/kg was also performed. Data were gathered for 14 days, and study parameters were clinical signs, body weight, general behavior, adverse effects and mortality. At the day 14, major organs of the subjects were examined histologically. Chronic toxicity was also evaluated in Wistar rats for over 180 consecutive days. The rats were divided into three groups with different doses of 0.2 g/kg, 0.8 g/kg, and 2 g/kg, QIG. Furthermore, observations were carried out in rabbits to investigate if there were signs of irritation.

Results

In comparison to control group, acute, chronic toxicity and mortality were not significantly increased in exposure group.

Conclusion

Study result suggests that the aqueous extract of QIG is unlikely to have significant toxicity and that clinical trials may proceed safely.

Non-medical use of prescription opioids and prescription opioid-related harms: why so markedly higher in North America compared to the rest of the world?

AIMS

This paper aims to identify possible system-level factors contributing to the marked differences in the levels of non-medical prescription opioid use (NMPOU) and prescription opioid (PO)-related harms in North America (i.e. the United States and Canada) compared to other global regions.

METHODS

Scientific literature and information related to relevant areas of health systems, policy and practice were reviewed and integrated.

RESULTS

We identified several but different factors contributing to the observed differences. First, North American health-care systems consume substantially more Pos-even when compared to other high-income countries-than any other global region, with dispensing levels associated strongly with levels of NMPOU and PO-related harms. Secondly, North American health-care systems, compared to other systems, appear to have lesser regulatory access restrictions for, and rely more upon, community-based dispensing mechanisms of POs, facilitating higher dissemination level and availability (e.g. through diversion) of POs implicated in NMPOU and harms. Thirdly, we note that the generally high levels of psychotrophic drug use, dynamics of medical-professional culture (including patient expectations for 'effective treatment'), as well as the more pronounced 'for-profit' orientation of key elements of health care (including pharmaceutical advertising), may have boosted the PO-related problems observed in North America.

CONCLUSIONS

Differences in the organization of health systems, prescription practices, dispensing and medical cultures and patient expectations appear to contribute to the observed inter-regional differences in non-medical prescription opioid use and prescription opioid-related harms, although consistent evidence and causal analyses are limited. Further comparative examination of these and other potential drivers is needed, and also for evidence-based intervention and policy development.

Complementary and conventional medicine use among youth with recurrent headaches

OBJECTIVE

To identify prevalence and patterns of complementary and alternative medicine (CAM) use among youth with recurrent headaches (HA) and evaluate associations with co-occurring health problems and limitations as well as with the use and expenditures for conventional medical care.

METHODS

Variables were constructed for youth aged 10 to 17 by using linked data from the 2007 National Health Interview Survey and the 2008 Medical Expenditures Panel Survey. Bivariate, logistic, and 2-part regression analyses were used.

RESULTS

Of the 10.6% of youth experiencing HA, 29.6% used CAM, rising to 41% for the many HA sufferers who also experienced difficulties with emotions, concentration, behavior, school attendance, or daily activities. Biologically based products (16.2%) and mind-body therapies (13.3%) were most commonly used, especially by the 86.4% of youth with HA experiencing at least 1 other chronic condition. Compared with non-CAM users, youth with HA who used CAM also had higher expenditures for and use of most types of conventional care.

CONCLUSIONS

CAM use is most common among youth with HA experiencing multiple chronic conditions and difficulties in daily functioning. Associations among CAM use, multiple chronic conditions, and higher use of conventional care highlight the need for medical providers to routinely ask about CAM use to meet the complex health needs of their patients and facilitate the optimal integration of care. Research is needed to identify models for coordinating complementary and conventional care within a medical home and to understand the health benefits or risks associated with CAM use in conjunction with conventional treatments for patients with HA.

Iyengar yoga and the use of props for pediatric chronic pain: a case study

Iyengar yoga uses postures and props to support the body so that practitioners can engage in poses that would otherwise be more difficult. This type of yoga may be useful in treating children and adolescents who have chronic pain and disability. In this case study, the authors discuss a 14-y-old girl who had two surgeries for gastro-esophageal reflux disease (GERD) and who had continued chest and abdominal pain, as well as vomiting, difficulty eating, weight loss, and anxiety. Having significantly impaired functioning, she was unable to attend school, sleep, socialize, or eat, and she had become wheelchair-bound. Despite evaluations and treatments by specialists over an extended period of time, her symptoms had not improved. This case history describes how the authors used a 4-mo treatment of Iyengar yoga to help the adolescent resume activities and re-engage with her environment. The authors intend this report to stimulate scientific study of this form of treatment for children and adolescents with chronic pain.

Yoga for youth in pain: the UCLA pediatric pain program model

Children, adolescents, and young adults do not typically feature in clinics, studies, and mainstream notions of chronic pain. Yet many young people experience debilitating pain for extended periods of time. Chronic pain in these formative years may be especially important to treat in order for young patients to maintain life tasks and to prevent protracted disability. The Pediatric Pain Program at the University of California, Los Angeles, is a multidisciplinary treatment program designed for young people with chronic pain and their families. We offer both conventional and complementary medicine to treat the whole individual. This article describes the work undertaken in the clinic and our newly developed Yoga for Youth Research Program. The clinical and research programs fill a critical need to provide service to youth with chronic pain and to scientifically study one of the more popular complementary treatments we offer, Iyengar yoga.

Treatment Preferences for CAM in children with chronic pain

CAM therapies have become increasingly popular in pediatric populations. Yet, little is known about children's preferences for CAM. This study examined treatment preferences in chronic pediatric pain patients offered a choice of CAM therapies for their pain. Participants were 129 children (94 girls) (mean age = 14.5 years ± 2.4; range = 8–18 years) presenting at a multidisciplinary, tertiary clinic specializing in pediatric chronic pain. Bivariate and multivariate analyses were used to examine the relationships between CAM treatment preferences and patient's sociodemographic and clinical characteristics, as well as their self-reported level of functioning. Over 60% of patients elected to try at least one CAM approach for pain. The most popular CAM therapies were biofeedback, yoga and hypnosis; the least popular were art therapy and energy healing, with craniosacral, acupuncture and massage being intermediate. Patients with a diagnosis of fibromyalgia (80%) were the most likely to try CAM versus those with other pain diagnoses. In multivariate analyses, pain duration emerged as a significant predictor of CAM preferences. For mind-based approaches (i.e. hypnosis, biofeedback and art therapy), pain duration and limitations in family activities were both significant predictors. When given a choice of CAM therapies, this sample of children with chronic pain, irrespective of pain diagnosis, preferred non-invasive approaches that enhanced relaxation and increased somatic control. Longer duration of pain and greater impairment in functioning, particularly during family activities increased the likelihood that such patients agreed to engage in CAM treatments, especially those that were categorized as mind-based modalities.

Peer mentorship to promote effective pain management in adolescents: study protocol for a randomised controlled trial

Background

This protocol is for a study of a new program to improve outcomes in children suffering from chronic pain disorders, such as fibromyalgia, recurrent headache, or recurrent abdominal pain. Although teaching active pain self-management skills through cognitive-behavioral therapy (CBT) or a complementary program such as hypnotherapy or yoga has been shown to improve pain and functioning, children with low expectations of skill-building programs may lack motivation to comply with therapists' recommendations. This study will develop and test a new manualized peer-mentorship program which will provide modeling and reinforcement by peers to other adolescents with chronic pain (the mentored participants). The mentorship program will encourage mentored participants to engage in therapies that promote the learning of pain self-management skills and to support the mentored participants' practice of these skills. The study will examine the feasibility of this intervention for both mentors and mentored participants, and will assess the preliminary effectiveness of this program on mentored participants' pain and functional disability.

Methods

This protocol will recruit adolescents ages 12-17 with chronic pain and randomly assign them to either peer mentorship or a treatment-as-usual control group. Mentored participants will be matched with peer mentors of similar age (ages 14-18) who have actively participated in various treatment modalities through the UCLA Pediatric Pain Program and have learned to function successfully with a chronic pain disorder. The mentors will present information to mentored participants in a supervised and monitored telephone interaction for 2 months to encourage participation in skill-building programs. The control group will receive usual care but without the mentorship intervention. Mentored and control subjects' pain and functioning will be assessed at 2 months (end of intervention for mentored participants) and at 4 month follow-up to see if improvements persist. Measures of treatment adherence, pain, disability, and anxiety and depression will be assessed throughout study participation. Qualitative interviews for mentors, mentored participants, and control subjects will also be administered.

Trial registration

ClinicalTrials.gov NCT01118988.

Analyzing Cytotoxic and Apoptogenic Properties of Scutellaria litwinowii Root Extract on Cancer Cell Lines

The Scutellaria species (Lamiaceae) is used as a source of flavonoids to treat a variety of diseases in traditional medicine. In spite of many reports about the cytotoxic and antitumor effects of some species of this genus, anticancer researches on one of the Iranian species S. litwinowii have not yet been conducted. The cytotoxic properties of total methanol extract of S. litwinowii and its fractions were investigated on different cancer cell lines including AGS, HeLa, MCF-7, PC12 and NIH 3T3. Meanwhile, the role of apoptosis in this toxicity was explored. The cells were cultured in DMEM medium and incubated with different concentrations of herb plant extracts. Cell viability was quantitated by MTT assay. Apoptotic cells were determined using propidium iodide staining of DNA fragmentation by flow cytometry (sub-G1 peak). Scutellaria litwinowii inhibited the growth of malignant cells in a dose-dependent manner. Among solvent fractions of S. litwinowii, the methylene chloride fraction was found to be more toxic compared to other fractions. The IC₅₀ values of this fraction against AGS, HeLa, MCF-7 and PC12 cell lines after 24 h were determined, 121.2 ± 3.1, 40.9 ± 2.5, 115.9 ± 3.5 and 64.5 ± 3.4 μg/ml, respectively. Scutellaria litwinowii induced a sub-G1 peak in the flow cytometry histogram of treated cells compared to control cells indicating that apoptotic cell death is involved in S. litwinowii toxicity. Scutellaria litwinowii exerts cytotoxic and proapototic effects in a variety of malignant cell lines and could be considered as a potential chemotherapeutic agent in cancer treatment.

Protocol for a randomized controlled study of Iyengar yoga for youth with irritable bowel syndrome

Introduction

Irritable bowel syndrome affects as many as 14% of high school-aged students. Symptoms include discomfort in the abdomen, along with diarrhea and/or constipation and other gastroenterological symptoms that can significantly impact quality of life and daily functioning. Emotional stress appears to exacerbate irritable bowel syndrome symptoms suggesting that mind-body interventions reducing arousal may prove beneficial. For many sufferers, symptoms can be traced to childhood and adolescence, making the early manifestation of irritable bowel syndrome important to understand. The current study will focus on young people aged 14-26 years with irritable bowel syndrome. The study will test the potential benefits of Iyengar yoga on clinical symptoms, psychospiritual functioning and visceral sensitivity. Yoga is thought to bring physical, psychological and spiritual benefits to practitioners and has been associated with reduced stress and pain. Through its focus on restoration and use of props, Iyengar yoga is especially designed to decrease arousal and promote psychospiritual resources in physically compromised individuals. An extensive and standardized teacher-training program support Iyengar yoga's reliability and safety. It is hypothesized that yoga will be feasible with less than 20% attrition; and the yoga group will demonstrate significantly improved outcomes compared to controls, with physiological and psychospiritual mechanisms contributing to improvements.

Methods/Design

Sixty irritable bowel syndrome patients aged 14-26 will be randomly assigned to a standardized 6-week twice weekly Iyengar yoga group-based program or a wait-list usual care control group. The groups will be compared on the primary clinical outcomes of irritable bowel syndrome symptoms, quality of life and global improvement at post-treatment and 2-month follow-up. Secondary outcomes will include visceral pain sensitivity assessed with a standardized laboratory task (water load task), functional disability and psychospiritual variables including catastrophizing, self-efficacy, mood, acceptance and mindfulness. Mechanisms of action involved in the proposed beneficial effects of yoga upon clinical outcomes will be explored, and include the mediating effects of visceral sensitivity, increased psychospiritual resources, regulated autonomic nervous system responses and regulated hormonal stress response assessed via salivary cortisol.

Trial registration

ClinicalTrials.gov NCT01107977.

Review of Pharmacological Effects of Antrodia camphorata and Its Bioactive Compounds

Antrodia camphorata is a unique mushroom of Taiwan, which has been used as a traditional medicine for protection of diverse health-related conditions. In an effort to translate this Eastern medicine into Western-accepted therapy, a great deal of work has been carried out on A. camphorata. This review discusses the biological activities of the crude extracts and the main bioactive compounds of A. camphorata. The list of bioactivities of crude extracts is huge, ranging from anti-cancer to vasorelaxation and others. Over 78 compounds consisting of terpenoids, benzenoids, lignans, benzoquinone derivatives, succinic and maleic derivatives, in addition to polysaccharides have been identified. Many of these compounds were evaluated for biological activity. Many activities of crude extracts and pure compounds of A. camphorata against some major diseases of our time, and thus, a current review is of great importance. It is concluded that A. camphorata can be considered as an efficient alternative phytotherapeutic agent or a synergizer in the treatment of cancer and other immune-related diseases. However, clinical trails of human on A. camphorata extracts are limited and those of pure compounds are absent. The next step is to produce some medicines from A. camphorata, however, the production may be hampered by problems related to mass production.

Uso de terapias complementares por mães em seus filhos: estudo em um hospital universitário

O objetivo deste estudo é avaliar a utilização de terapias complementares (TC) por mães em seus filhos. Trata-se de um estudo transversal, descritivo. Foram entrevistadas 202 mães de crianças assistidas em um hospital universitário. As variáveis analisadas foram: uso de terapias complementares/motivos para tal, tipos de terapias utilizadas, sua finalidade, seus efeitos, revelação ao médico/motivos para tal e reação do médico. A prevalência de uso de terapias complementares foi 87,6%. De 177 mães que utilizavam TC, muitas mencionaram mais de um tipo, sendo: chás (72,8%), benzimento (41%), simpatias (12,9%), remédios/xaropes caseiros (8,4%), oração/promessa (7,4%), homeopatia (4,0%), tratamento espiritual/parapsicológico (4,0%), mistura de substâncias desconhecidas/garrafada (3%), massagem (2%) e reiki/florais (1,5%). As ervas mais utilizadas foram erva-doce (16,7%), camomila (14,8%) e hortelã (10,9%); 57,6% das mães não informaram o uso ao médico. Dos 499 tratamentos empregados, houve percepção de melhora em 429 (86%) e relato de dois casos de efeitos adversos. A prevalência do uso de terapias complementares foi alta, sendo os chás a terapia mais utilizada e erva-doce, camomila e hortelã as ervas mais usadas. Houve percepção de melhora na maioria das terapias usadas.

International child health: state of the art

Many published articles and policies describe what should be state of the art in global child health, and there are dozens of large initiatives aimed at implementing these policies. We have knowledge of what should work, yet struggle to effectively implement that knowledge and improve child health outcomes in resource-poor settings, even at the most basic level of ensuring sufficient food and clean water for the world's children. This article highlights many smaller programs that are operational in the field, demonstrating excellence in global child health efforts, and may approach state of the art in actual implementation. The examples include a grass roots primary health care program, a home-based neonatal care program, kangaroo mother care, ready-to-use therapeutic food (RUTF), a vitamin A program, point-of-use water purification, disasters and children, a pain management program, and a developmental disabilities program. This article also discusses the importance of strengthening human resources for health by, for example, training child health professionals in low resource countries. These programs show what can be done and could be replicated in other communities to improve child health, given a few committed individuals and modest resources. Ultimately, truly state of the art health care for children must be defined locally and championed by each state or nation. Nevertheless, there are overarching components and supports that are the responsibility of the global community, particularly those needed to assure that the basic human rights of children, including health, are met throughout the world.

Pediatric palliative care: use of opioids for the management of pain

Pediatric palliative care (PPC) is provided to children experiencing life-limiting diseases (LLD) or life-threatening diseases (LTD). Sixty to 90% of children with LLD/LTD undergoing PPC receive opioids at the end of life. Analgesia is often insufficient. Reasons include a lack of knowledge concerning opioid prescribing and adjustment of opioid dose to changing requirements. The choice of first-line opioid is based on scientific evidence, pain pathophysiology, and available administration modes. Doses are calculated on a bodyweight basis up to a maximum absolute starting dose. Morphine remains the gold standard starting opioid in PPC. Long-term opioid choice and dose administration is determined by the pathology, analgesic effectiveness, and adverse effect profile. Slow-release oral morphine remains the dominant formulation for long-term use in PPC with hydromorphone slow-release preparations being the first rotation opioid when morphine shows severe adverse effects. The recently introduced fentanyl transdermal therapeutic system with a drug-release rate of 12.5 microg/hour matches the lower dose requirements of pediatric cancer pain control. Its use may be associated with less constipation compared with morphine use. Though oral transmucosal fentanyl citrate has reduced bioavailability (25%), it inherits potential for breakthrough pain management. However, the gold standard breakthrough opioid remains immediate-release morphine. Buprenorphine is of special clinical interest as a result of its different administration routes, long duration of action, and metabolism largely independent of renal function. Antihyperalgesic effects, induced through antagonism at the kappa-receptor, may contribute to its effectiveness in neuropathic pain. Methadone also has a long elimination half-life (19 [SD 14] hours) and NMDA receptor activity although dose administration is complicated by highly variable morphine equianalgesic equivalence (1 : 2.5-20). Opioid rotation to methadone requires special protocols that take this into account. Strategies to minimize adverse effects of long-term opioid treatment include dose reduction, symptomatic therapy, opioid rotation, and administration route change. Patient- or nurse-controlled analgesia devices are useful when pain is rapidly changing, or in terminal care where analgesic requirements may escalate. In this article, we present detailed pediatric pharmacokinetic and pharmacodynamic data for opioids, their indications and contraindications, as well as dose-administration regimens that include practical strategies for opioid switching and dose reduction. Additionally, we discuss the problem of hyperalgesia and the use of adjuvant drugs to support opioid therapy.

Effects of group music intervention on behavioral and psychological symptoms in patients with dementia: a pilot-controlled trial

We investigated the effects of group music intervention on behavioral and psychological symptoms in patients with dementia. Twenty patients were nonrandomly allocated to either a music-intervention group, or an usual care group. The music-intervention group received 50 minutes of music intervention 3 times per week for 5 consecutive weeks. After 15 sessions, the music-intervention group showed significant in improvement with regard to agitation, and the total scores of both patients and caregivers were lower, compared with the control group. These findings suggest that music can improve behavioral and psychological symptoms, especially in patients with dementia and their caregivers.

Nonpharmacological interventions for acute wound care distress in pediatric patients with burn injury: a systematic review

Acute wound care distress among burn-injured pediatric patients is of major clinical concern. This systematic review evaluates the benefits of nonpharmacological interventions to reduce this distress. MEDLINE, EMBASE, CINAHL, PsycINFO, ERIC, and the Cochrane Library databases were searched using appropriate search terms for articles reporting overall psychological effects of pediatric burn injury. Key references were hand-searched. Searches yielded approximately 900 unique citations. Two authors reviewed each abstract, and 198 articles were retrieved, of which 34 were selected for full review. Of these 34 articles, 12 focused on acute wound care distress and nonpharmacological interventions. Critical appraisal of individual studies was conducted using the methods of the US Preventive Services Task Force, with a particular focus on assessing nonrandomized controlled trial designs. Twelve articles were reviewed and categorized according to intervention types child mediated (CM), parent mediated (PM), and health care provider mediated (HCPM). Using the US Preventive Services Task Force criteria, 7 of the 12 articles were rated "fair" or "good" and five were rated as having "poor" internal validity. The HCPM and CM intervention categories reported patient benefit. The two PM studies were both rated "poor." Studies of nonpharmacological interventions to reduce pediatric burn distress were few, with a significant proportion (5/12) having concerns about internal validity. Patient benefit was reported for HCPM and CM interventions. Research designs incorporating control groups in studies that are adequately powered are needed. Additional research is required in the area of PM interventions in particular.

From the Ouchless Place to Comfort Central: the evolution of a concept

Although the past 20 years have yielded an outpouring of research on pain management in children, this information is often not applied uniformly to children in the hospital. To address this deficiency, we developed a systematic institution-wide program to reduce pain in all children in the hospital. Our goal was to create a setting in which attention to pain control and comfort measures would be inherent in all inpatient encounters. We labeled the inpatient unit in which this concept evolved as the "Ouchless Place" and described the program and its development in a 1997 Pediatrics article. In this article we describe the further evolution of that concept in light of the broader changes that have occurred in the field of pain management and in our community. The development of a new children's hospital allowed us to examine what we had learned from our previous experience and modify our program on the basis of that review. This new initiative was renamed "Comfort Central," recognizing that although no inpatient experience could be entirely "ouchless," we could still pledge to families that we were attentive to pain and would provide the most comfort that we could. Specific changes that were put in place in our model included the acquisition of administrative authority to mandate change; the extension of our program to the laboratory, outpatient clinics, and physician offices; the incorporation of newer, more active educational models; increased emphasis on collaboration with other services; increased visibility of pain-relief efforts; and development of an ongoing quality improvement program that monitors the efficacy of pain-relief initiatives in the institution. The elements of this program may be applicable to other health care systems that desire to develop a more cohesive system-wide approach to pain reduction in those for whom they provide care.

Dominican Children with HIV not Receiving Antiretrovirals: Massage Therapy Influences their Behavior and Development

Forty-eight children (M age = 4.8 years) infected with HIV/AIDS and living in the Dominican Republic were randomly assigned to a massage therapy or a play session control group. The children in the massage therapy group received two weekly 20-min massages for 12 weeks; the children in the control group participated in a play session (coloring, playing with blocks) for the same duration and length as the massage therapy group. Overall, the children in the massage therapy group improved in self-help abilities and communication, suggesting that massage therapy may enhance daily functioning for children with HIV/AIDS. Moreover, the HIV infected children who were six or older also showed a decrease in internalizing behaviors; specifically depressive/anxious behaviors and negative thoughts were reduced. Additionally, baseline assessments revealed IQ equivalence below normal functioning for 70% of the HIV infected children and very high incidences of mood problems (depression, withdrawn) for 40% of the children and anxiety problems for 20% of the children, suggesting the need for better monitoring and alternative interventions in countries with limited resources to improve cognition and the mental health status of children infected with HIV/AIDS.