As a mother of six, I’ve always had an interest in pediatric healthcare. It has been hard to find a provider I trust for my own children, and even when I did, they rarely had any knowledge of complementary medicine, let alone functional medicine. I’ve had to do a lot of my own research and only more recently had I seriously considered extending my scope into this realm of healthcare. As I work towards that goal (January, 2019) and especially now that we’ve been blessed to add a family nurse practitioner, Debi Fehrman, to our team, I am eager to explore all the many ways we can support our clients.
Acupuncture & Kids
Acupuncture is a discipline of traditional Chinese medicine that has evolved over two millennia, and admittedly one that I am not super knowledgeable. I have certainly referred clients in my maternity practice and am aware of its positive contributions to healthcare, particularly in smoking cessation, turning the breech baby, post-date pregnancy, infertility, and nausea. It is widely practiced in the United States and as more and more of my colleagues become certified to extend this modality, I am interested in the supporting evidence for the various conditions our pediatric clientele might present. Acupuncture is an overwhelmingly safe intervention in the hands of a competent practitioner.
What I didn’t realize, and still need to investigate further, is that a specific criteria for training and demonstrating competency must be met within each state, and those criteria differ per state. California was the first state to make acupuncture a legal experimental procedure and in 1996, the FDA recognized acupuncture as safe and effective when used appropriately by licensed practitioners, so changed the status of acupuncture needles to Class II medical devices.
The theories of traditional Chinese medicine, as I understand, including acupuncture have evolved from thoughtful observation and explanation of the nature phenomena, including the concepts of “yin” and “yang” and the “five phases.” The concept of yin and yang is familiar to most, I imagine. They are co-dependent and exist in a constant state of dynamic balance. Yin is associated with rest, coldness, passivity, darkness, inwardness, and diminishment. Yang is associated with activity, hot, activity, brightness, outwardness, and augmentation. Optimal health requires a balance of yin and yang and diseases is characteristic of a disharmony in the two.
The theory of five phases is based on the concept that all phenomena in the universe are the products of the evolution of five elements: fire, earth, metal, water, and wood. These phases correspond with normal physiology and abnormal pathology. The five phases cycle through “sheng” and “ke” with sheng being the creation cycle and ke the more limiting or controlling cycle. Think of it this way, In the sheng cycle, earth is created from fire, metal is originated from earth, metal engenders water, water promotes wood to grow, and wood fuels the fire. In the ke cycle, the root of the wood can split the earth, earth can block water, water can extinguish fire, fire can melt the metal, and metal can cut the wood. The mutual generating and controlling relationship is the model for any yin and yang balance.
This balance allows for the flow of “Qi” which is pronounced “chee.” Familiar? Qi signifies power, movement, and a force similar to energy. It is described as functional and active, but not easily definable. This energy is between the earth and the heavens and can manifest at the physical and spiritual level. Those who work in traditional Chinese medicine refer to this as energy flowing through a complex system of meridians in the body which maintains life and health. Diseases and illnesses are byproducts of obstruction or inadequate flow of Qi through the meridians. The flow of Qi may be restored by the insertion of the acupuncture needles into acupuncture points.
When seeing an acupuncture clinician, they will typically take a detailed history and focus on the characteristic of one’s pulse and the manifestation of the tongue to best determine one’s balance of yin and yang. They may describe someone as having an imbalance in yin or yang, or being more external or internal, cold or hot, or deficient or in excess. The aim of course, is to restore deficiencies and address excess of Qi so optimal health can be achieved.
Science has attempted to understanding the complexity of acupuncture through a neurobiological perspective. Clearly there are sufficient cases of pain relief, even surgery performed when utilizing acupuncture, so that these effects are hard to deny. Interestingly, if one is injected with lidocaine at the puncture points the effects are not the same and an intact sensory afferent system has proven essential for the transmission of acupuncture signals. Acupuncture does release a neuromodulatory substance into the cerebral spinal fluid (Pomeranz, 1996; & Pomeranz & Chiu, 1976). Acupuncture and pain activate the hypothalamus-pituitary-adenocortical axis but at different nuclei of the hypothalamus and with the advancement of PET and fMRI, scientists have been able to study the central pathways of acupuncture non-invasively. They have identified a multitude of sites in the brain and within the connective tissue at the site of the needle that are stimulated by acupuncture which may contribute to its success.
Of course before any procedure, medication or diagnostic test gains any credibility in Western medicine, we must have several random controlled trials to offer validity (except that is for maternity care because it is unethical for pregnant women to be subjects of research so technology and pharmaceuticals are introduced on theory alone which means not only do women and their children become naive subjects but their implementors assume the procedure and medication is safe and necessary without sound research then even after research identifies such as unnecessary or unsafe it is becomes part of the culture and remains). Acupuncture however, offers a few high-quality adult acupuncture clinical trials and a few specific to the pediatric population, although the majority on the younger ones are case reports.
Asthma has been addressed in the literature for the little ones, and for purposes of traditional Chinese medicine, it is differentiated into cold, heat, or yang deficiency patterns. A respiratory tract infection, stress or an allergy would create a cold pattern while the attack of wind-heat would be heat derived. The deficiency pattern is responsive to bronchodilators. Acupuncture points are used to help the client expel wind and tonify the lungs, invigorating the spleen and tonifying the kidneys. Although there are a few, quite small, studies, their results are somewhat conflicting. One random control trial offered one group laser acupuncture and probiotics and that group did have fewer respiratory exacerbations, but there wasn’t significant change in their expiration volume, need for additional medications, or even their quality of life (Stokert, Schneider, Porenta, & Rath et al., 2007).
Headache is another complaint acupuncture has addressed with children and the results here were much more significant. In traditional Chinese acupuncture theory, pain is understood as an obstruction of the qi so the intent with acupuncture is to release the blockage and restore the energy flow. As mentioned previously, an intact nervous system is necessary for the transmission of acupuncture signals and the release of endogenous opioids. Pintov, Lahat, Alstein, & Vogel et al. (2007) found after ten treatments, the frequency and intensity of migraines in children were significantly reduced. Another study found the same after four laser acupuncture treatments (Gottschling, Meyer, Gribova, Distler, & Bering et al., 2007).
Sadly, the evidence for smoking cessation in teens did not demonstrate effectiveness, but the literature for helping children who wet the bed was quite hopeful. Admittedly, one of our own had this issue until he was seven and then it rather spontaneously resolved. He tells us today that it was the diapers we put on him (whether cloth or disposable) because it seems quite clear to him that he had an allergy. It might have been the chiropractor adjustments or removing a fairly stressful variable that was previously part of his daily life, but no matter what it was, we are certainly grateful. I was quite honestly in the midst of researching acupuncture when his wetting began to stop, and although we did not utilize this modality, I would encourage you to try it if you have a bed wetter.
About 10% of 7-year-old children are wetting the bed and some of those will continue to do so through the age of 16. For many this causes a bit of distress. Capozza, Creti, De Gennaro & Minni, et al. (1991) and his colleagues performed a random control trial with 40 children and found acupuncture to be effective. A second random control trial found results of acupuncture similar to those utilizing pharmaceutical therapy (Radmayr, Schlage, Studen & Bartsch, 2001).
There is additional literature on the use of acupuncture for nausea associated with anesthesia, ridding the stridor after extubation, pain management, and allergic rhinitis. In one random control trial involving more than 60 children, those receiving acupuncture had fewer itchy and runny noses compared to those without, but their medication scores were not improved, nor were their blood work improved. Decreasing symptoms of rhinitis however, is significant and one would think, well worth the inconvenience of obtaining acupuncture.
While limited, there is a bit of data supporting the value of acupuncture and pediatric care. It would seem if a child were to seek out acupuncture care, they should be encouraged to maintain a symptom diary so treatment preferences, expectations, outcomes, and even safety and efficacy can be discerned.
Essential oil enthusiasts are familiar with French chemist, Gattefosse, who in the early 1900s was burned in his lab and subsequently healed after applying lavender oil. He was then coined the first aromatherapist. Today we think of anything with a pleasant aroma as aromatherapy, but what we smell may not have anything what-s0-ever to do with the essential oils and some essential oils are quite unpleasant. As well, inhalation is not the only way one can utilize essential oils for healing and utilization of this healing modality is not one we should take lightly. There certainly are risks and a qualified provider should truly be sought when using these oils medicinally.
There really are a long history of healers utilizing essential oils and the practice of aromatherapy is part of the larger field of botanical medicine. Increasingly, healthcare providers are using these modalities within their healthcare practices and gaining real specialties. Local hospitals here in Central Indiana have began implementing them within their various units, including the maternity unit for labor support.
Essential oils are quite complex chemical mixtures of organic compounds and far from benign. In fact, they are quite potent and I feel that while it is exciting that the community has embraced them so openly, there seems to be a lack of appreciation for their potential. This particularly modality is a love of mine because it reminds me of Eden. I realized a few years ago that the Lord could have put us in a mansion or a castle or on a star, but he chose a garden and not just any garden but a garden upon a body of water, a moist, oil-filled garden where they breathed in the essential nature of the plants around them, depending on them for optimal health. I gained a new perspective of our very industrial environment and how this quite potentially impacts our lives today.
However, the garden of Eden is certainly not available to us today for harvesting into tiny little bottles and drops in our diffusers for fixing all our ailments. That seed to seal claim is a bit misleading and over simplified. Harvesting, distilling, extraction, expression, quality control, chemical analysis, gas chromatography, contamination, pesticides, fertilizers, organic cultivation, chemotype, origin, batch numbers, expiration dates, common names and botanical names, dilutions, blends, and proprietary information all add to the complexity of essential oils. That doesn’t even address administration, dosage, conditions treated, characteristics of the patient, age, co-morbidities, safety data, and professional practice parameters!
What should you know if using with your child? First, essential oils that would otherwise be used topically should be diluted even more for little ones. A concentration of 0.05-2% is recommended because their skin is more permeable and more susceptible to irritation (Buckle, 2003). Inhalation is often the preferred route however, especially for respiratory or sinus issues such as colds, sore throats, sinus infections, congestion or cough. If they are anxious, have tension, need to relax, are stressed, have insomnia or need to be more alert, inhalation is also the preferred method of administration. Simply adding a drop or two to a cotton ball is effective, and allowing the little one to smell it or using devices that can diffuse or vaporize are helpful. Steam inhalation is beneficial for treatment of colds and sinuses or upper respiratory tract issues.
Massage, foot baths, compresses, steaming and spray bottles are additional methods of administration. Simply adding a few drops to an ounce of water in a spray bottle, shaking immediately before spraying, can be effective for calming the kids in the car after school. Avoid spraying their eyes of course. Many mothers have benefited from essential oil compresses, or little ones with stomach cramps. Who hasn’t enjoyed a lovely foot soak?
Ingestion is a bit controversial, but is rather common in France where both oral and rectal doses of essential oils are prescribed by physicians (Battaglia, 2003). Most essential oil organizations do not endorse oral administration except by licensed providers, and rectal administration would be similar due to its high absorption rate. The vaginal route whether via douche, pessary, or soaked tampon is somewhat common as well (Buckle, 2003).
Understanding the purpose of essential oils in plants is not entirely understood, although they are thought to prevent and treat infections, heal wounds, repel animals and insects but how does that apply to the human eager to take advantage of their benefits? Certainly advocates of essential oils will attribute a large range of advantages, including analgesic, anti-inflammatory, antimicrobial, anti-septic, decongestant, digestive, insecticide, relaxant, and sedative properties (Battaglia, 2003 & Buckle, 2003).
Each essential oil has its own profile and while they are all different, there is some overlap as well. Some essential oils are high in monoterpene alcohols or phenols which make them strong anti-bacterials, while others are high in esters and tend to be anti-spasmodics and calming (Battaglia, 2003; & Buckle, 2003). Their individual chemical compounds create their activity profile, and admittedly, I really enjoy saying monoterpene and sesquiterpenes. One of my favorite books on the topic is The Chemistry of Essential Oils by Stewart.
What does the data tell us? Most recommendations within the very lengthy essential oil guides are based on experimental data. There is very little human research on adults, and even less involving children. Those that do exist have very small sample sizes which offer little power to detect statistical differences. Often aromatherapy is combined with other therapies, such as breathing techniques or massage, making it hard to discern which technique offered the desired outcome. Studies often fail to provide both the chemical and botanical name, or even mention the presence or absence of adverse effects.
We have to consider how children respond to aromas as well, which may be very different from adults. Interesting, children prefer smells similar to their homes. In one study with young boys and girls, their preference was for lemon, sweet orange, spearmint, and peppermint, and not so much for ginger and lavender. Girls were more likely to report happy feelings when smelling sweet orange than boys, and male were more likely to describe peppermint as energetic. Overall though, the children were all willing to try aromatherapy and willing to try new aromas even if a previous one was not enjoyed (Fitzgerald, Culbert, Finkelstein, & Green et al., 2007).
Lavender, peppermint, rosemary, lemongrass, and Roman chamomile have all been reported as having analgesic effects. The mechanism is unclear but the inhibition of the nociceptive impulse or by activating the endogenous opioid system is thought to be at fault. The aromatherapy may also change pain perception by setting a more pleasant environment or distracting from the pain experience, and has even been recognized as altering memory of the event (Gedney, Glover, & Fillingim, 2004; Kerr & Casey 2004). Infants for example, provided either a familiar scent, an unfamiliar scent, or no scent demonstrated a faster decrease in pain behaviors in the familiar scent groups (Goubet, Rattan, Pierrot, Bullinger, & Lequien, 2003).
Adults exposed to essential oils during painful procedures did not rate the pain any less severe, but in hindsight did report less pain intensity and pain unpleasantness after treatment with lavender. Pleasant olfactory experiences may lead to more positive post-procedure appraisal (Gedney, Glover, & Fillingim, 2004), which could certainly be instituted with the newborn metabolic screen, frenotomy procedures, or blood draws.
Peppermint and eucalyptus oil mixture has demonstrated a positive impact on muscle-relaxation and on performance related activity and concentration, but sensitivity to pressure was not reduced. Irritable bowel, constipation and functional abdominal pain are often treated with Roman chamomile, sweet fennel, peppermint, and ginger, but the evidence has really only evaluated peppermint. These studies are riddled with issues, in that one, IBS is a complex condition that is not well understood or treated in any model of medicine. There is often lack of diagnostic criteria, and brief evaluation periods. There is one randomized controlled trial in children with IBS and in only two weeks, the IBS children showed significant improvement in the severity of pain but no real difference in distention, belching or gas. There were no reported adverse events, and so peppermint was thought to be a viable option (Kline, Kline, Di Palma & Barbero, 2001).
Other studies for dysmennorhea, functional dyspepsia (reflux), plantar warts, acne, head lice and pain management have been conducted and all had results supporting the use of essential oils (Han, Hur, Buckle, Choi & Lee, 2006; Forbes & Schmid, 2006; Battaglia, 2003; Bensouilah, 2002; Basset, Pannowitz, & Barnetson, 1990; Canyon & Speare, 2007; Audino, Vassena, Zerba, & Piccolo, 2007). Recommendations for use of essential oils for eczema though, should be given with caution. In one study, with a variety of applications, nighttime disturbance was increased for the aromatherapy group and the researchers felt the dermatitis was provoked by the essential oil (Anderson, Lis-Balchin, & Kirk-Smith, 2000).
It seems the body of evidence for using essential oils to combat pathologic organisms is growing. Tea tree oil for example, has been effective against staph and MRSA (Carson, Cookson, Farrelly, & Riley, 1995; Christoph, Stahl-Biskup, & Caulkers, 2001; May, Chan, King, Williams, & French, 2000; Sherry, Boeck, & Warnke, 2001). Oregano has also been found to treat a number of pathologic organisms, and lemongrass has also shown effectiveness for treatment of MRSA.
Motion sickness, nausea, insomnia, and cancer have all been addressed in the literature. Aromatherapy has been used to decrease apnea in neonates as well, with a 44% improved rate of apnea without bradycardia and 45% improvement with severe bradycardia (Marlier, Gaugler, & Messer, 2005). However, the big question is safety. Aromatherapy is considered safe, but there are risks with accidental ingestion and poisoning, skin irritation, allergic reactions, and phytotoxicity. Toxicity can be acute and chronic as well, or one large dose verses chronic exposure over time. The more toxic oils are pennyroyal, wormwood, and tansy. Tea tree and basil can also be dangerous in larger doses. Most all are safe in small doses and toxic levels for most exceed the quantity in a single bottle. However, severe reactions have been reported in as little as 5 to 15 mL of ingested essential oil (Tisserand & Balacs, 1995), and there are many cases of accidental ingestion among children age one to three years of age. In some cases death resulted (Battaglia, 2003; Buckle, 2003; Tisserand & Balacs, 1995; Wilkinson, 1991).
Essential oils should be treated like medications and keep out of the reach of young children. Bottles should have a drop dispenser to minimize ingesting in large amounts. Labels should offer all essential oils in a blend and in a carrier oil for dilution.
Chronic toxicity is more difficult to discern and most often results in nausea or headache, which can easily be contributed to other causes. Symptoms are typically minor, but if suspected use of the oil should be stopped and symptoms reevaluated. Interestingly, there is a report of three boys experiencing gynecomastia from lavender and tea tree oil, all of which resolved when use of the essential oil was discontinued (Henly, Lipson, Korach, and Bloch, 2007).
Patch testing should be offered to children to assure they won’t be irritated by topical application. A carrier oil to at least double the intended strength is recommended and applied to a small area of skin, possibly the foot. Observe for redness or other reactions. Avoid entirely the eyes and any mucous membrane. If these areas are exposed, use a carrier oil to rinse the area, and if not available, wash with soap and water. A mild hydrocortisone cream may be necessary if redness persists.
Allergic reactions can occur but are exceedingly rare. Sensitivities are more likely with lemongrass, lavender, may chang, and ylang yang essential oils. There may also be cross-sensitivity between essential oils of similar plants, for example Roman chamomile should not be used when a known allergy to plants from the Composite family (Battaglia, 2003). Bergamot, lime, cumin, and angelica are most likely to cause photophobia, but may also occur with lemon, bitter orange, and grapefruit (Guba, 1999).
There are a number of contraindications reported that aren’t supported in the literature. These may have stemmed from toxicity or from ingestion where topical application or aromatherapy would not have caused the same adverse reaction. Wintergreen, thuja, and camphor are described as hazardous essential oils not recommended for general use (Battaglia, 2003; Tisserand & Balacs, 1995). However, studies on pregnant women have been conducted and of 8,058 women in one particular study, only 1% reported side effects of the aromatherapy with nausea and vomiting, itching, watery eyes, and precipitous labor being the reported complaints (Burns, 2000).
Essential oils are safe and a gentle therapy for children; however, there are important cautions. Education is important. Keep in mind, there are no national certifications for aromatherapists in the United States. Individuals may complete a program of study that allows them to sit for an exam offered by the Aromatherapy Registration Council, and upon passing they may use the title “Registered Aromatherapist.” There are a number of programs of varying lengths and focus, and some are recognized by the National Association for Holistic Aromatherapy. Purdue offers rather extensive education in aromatherapy at the academic level. Web-based modules are also available for the public and the healthcare provider, look under the headings: Taking Charge of Your Health and Education.
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