Ebook Integrative pediatrics - Art, science, and clinical application: Part 1

Integrative Pediatrics



Integrative Pediatrics
Art, Science, and Clinical Application
Hilary McClafferty, MD, FAAP
Associate Professor, Department of Medicine
Director, Pediatric Integrative Medicine in Residency
Co-Director, Fellowship in Integrative Medicine
University of Arizona Center for Integrative Medicine
University of Arizona College of Medicine
Tucson, Arizona


First published 2017
by Routledge
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and by Routledge
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Routledge is an imprint of the Taylor & Francis Group, an informa business
© 2017 Hilary McClafferty
The right of Hilary McClafferty to be identified as author of this work has been asserted by him/her in
accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988.
All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by
any electronic, mechanical, or other means, now known or hereafter invented, including photocopying
and recording, or in any information storage or retrieval system, without permission in writing from the
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Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used
only for identification and explanation without intent to infringe.

British Library Cataloguing-in-Publication Data
A catalogue record for this book is available from the British Library
ISBN: 978-1-4987-1671-0 (Hardback)
ISBN: 978-1-138-19607-0 (Paperback)
ISBN: 978-1-4987-1672-7 (Ebook)


To Kylie and Liam



Contents

Foreword by Andrew Weil
Foreword by James E. Dalen
About the Author
Acknowledgments

ix
xi
xii
xiii

PART 1

Integrative Medicine: A New Frontier in Pediatrics

1

1 Introduction to Pediatric Integrative Medicine

3

2 Self-Care: Cultivating Healthy Resilience

16

PART 2

Foundations of Health

29

3 Nutrition

31

4 Key Dietary Supplements: Omega-3 Fatty Acids, Vitamin D, and
Probiotics

50

5 Physical Activity

63

6 Mind–Body Therapies

76

7 Sleep

104

8 Environmental Health

122

PART 3

Complementary Approaches
9 Botanicals and Dietary Supplements

151
153

10 Manual Medicine

172

11 Aromatherapy

185


viii

Contents

12 Whole Medical Systems

192

13 Bioenergetic Therapies

207

PART 4

Clinical Application

215

14 An Integrative Approach to Preventive Health

217

15 Allergy and Asthma

242

16 Dermatology

263

17 Gastroenterology

283

18 Infectious Disease: Upper Respiratory Infections and Otitis Media

318

19 Mental Health: Toxic Stress, Peer Victimization (Bullying), Anxiety,
Depression
326
20 Neurodevelopmental Disorders: ADHD and Autism

359

21 Obesity and Metabolic Disease

377

22 Integrative Intake

413

23 Conclusion

421

Index

423


Foreword by Andrew Weil

With its focus on preventive health, engagement of the individual’s innate healing capacity, and goals of minimizing invasive procedures and use of prescription medications,

integrative medicine is a natural fit for pediatrics. Coming from the world of pediatric
emergency medicine, Hilary McClafferty would seem an unlikely champion for the
field, but, in fact, she has been a most effective one. I first met Hilary when she was a
Fellow in the University of Arizona Center for Integrative Medicine, Class of 2005. She
raised her hand during one of my lectures to ask about the use of integrative medicine
in children. I replied, “Pediatric integrative medicine is the way of the future,” knowing
very well that at the time the field was in its infancy and needed the efforts of committed pediatrician advocates to advance it.
She took this encouragement to heart and since completing the Fellowship has become
involved in local, national, and international initiatives to introduce research and clinical and educational programs on integrative pediatrics into mainstream medicine. One
of the most innovative she leads is the Pediatric Integrative Medicine in Residency
(PIMR) program at the University of Arizona Center for Integrative Medicine, which
has just completed a three-year pilot run involving more than 500 pediatric residents at
leading academic institutions. These residents received foundational training in integrative pediatrics embedded in their conventional medical training. The first initiative of
its kind in pediatrics, PIMR has grown to include other first-rate pediatric residencies
around the country and was recently launched at three children’s hospitals in Germany.
Hilary has also been a highly effective leader within the American Academy of
Pediatrics, where she is immediate past chair of the Section on Integrative Medicine, a
group with the ambitious mission of raising awareness about the field throughout the
66,000-member Academy. In this role, she also created an integrative medicine model
for physician self-care and wellbeing and led development of the first policy statement
on physician wellness for the Academy. She expects this work to catalyze an array of
educational initiatives that will continue to grow in scale and impact. Hilary is currently leading the update of the Academy’s Clinical Report on Pediatric Integrative
Medicine, an in-depth review of the literature in the field that serves as a guidepost for
the Academy and its diverse membership.
As a leader of the Fellowship in Integrative Medicine at the University of Arizona and
as a founding member of the American Board of Integrative Medicine, Hilary is known
and admired for her creativity and collaborative spirit and her commitment to mentoring upcoming faculty and students. What most people may not know about her is that
her passion for integrative pediatrics stems in part from deeply personal experiences in
the healthcare system, where as a mother who is also a physician she has lived firsthand

x

Foreword by Andrew Weil

the challenges of advocating for a child and a family dealing with chronic disease. From
her years of navigating the healthcare system with a foot in both worlds and from her
early work in acute care, she has drawn rich lessons that inform her teaching every day.
Hilary tells me that her primary goals in writing this book are to document the progress that has occurred in this emerging field and to highlight areas where research gaps
remain. Her hope is that it will serve to guide integrative pediatrics to its rightful place
in the forefront of the day-to-day care of children of all ages.
Andrew Weil, MD
Lovell-Jones Endowed Chair in Integrative Rheumatology
Clinical Professor of Medicine
University of Arizona College of Medicine


Foreword by James E. Dalen

This is one of the rare textbooks with a single author, Dr. Hilary McClafferty, a very
experienced pediatrician and leader in the emergence of integrative medicine. She serves
as chair of the American Academy of Pediatrics Section on Integrative Medicine, and at
the University of Arizona Center for Integrative Medicine designed and directs an internationally distributed online integrative medicine curriculum for pediatric residents.
Integrative Pediatrics: Art, Science, and Clinical Application demonstrates how the
various aspects of integrative medicine can enhance pediatric care. It stresses prevention
by emphasis on nutrition, physical activity, mind–body medicine, sleep, and environmental health.
A very important section of the text is her evidence-based evaluation of complementary therapies, including dietary supplements, which may be helpful in pediatric care.
She carefully points out which of these therapies have been validated by appropriate
research, and which have not.
This text, by introducing the principles of integrative medicine, can enhance the clinical skills of practicing pediatricians and expand therapeutic options for children and

adolescents.
James E. Dalen, MD, MPH, ScD (hon)
Executive Director, Weil Foundation
Dean Emeritus, University of Arizona College of Medicine


About the Author

Hilary McClafferty is Board certified in pediatrics, pediatric emergency medicine,
and integrative medicine. She is Associate Professor in the Department of Medicine at
the University of Arizona College of Medicine in Tucson, Arizona, a founding Board
member of the American Board of Integrative Medicine, a leader of the Fellowship in
Integrative Medicine and Director of the international Pediatric Integrative Medicine
in Residency Program at the University of Arizona Center for Integrative Medicine.
She is certified in clinical hypnosis, trained in medical acupuncture, and speaks and
teaches internationally on integrative medicine topics including pediatrics, mind–body
medicine, environmental health, and physician wellness and resilience.


Acknowledgments

My sincere thanks and gratitude go out to all the children and families who have been
my great teachers through the years, and to my inspired colleagues in pediatric integrative medicine who are working together to improve the health and wellbeing of children
around the world. My thanks extend to Dr. Weil and my colleagues and students at the
University of Arizona Center for Integrative Medicine, Tucson, for their creative energy
and dedication to creating a paradigm shift in healthcare.



Part 1

Integrative Medicine: A New
Frontier in Pediatrics



1 Introduction to Pediatric
Integrative Medicine

Children are born with a natural capacity to thrive, ideally supported by parents who
provide food, shelter, companionship, education, and unconditional love. The clinician’s role has historically been that of trusted guide and dedicated child advocate
in the medical arena. Rapid changes in the business of medicine and an emphasis on
productivity over patient-centered care have stripped pediatric practice of some of its
richness, resulting in a lost sense of collaboration for many clinicians. Parents have
been similarly affected by the “commercialization” of medicine and seek a deeper connection with providers who can deliver more personalized care, expanded treatment
options, and accurate information about emerging therapies that may improve their
child’s health. Pediatric integrative medicine can serve to reconnect clinician, child, and
parent and can be defined as a modern approach to children’s health in that it respects
the strengths of conventional medicine while embracing emerging research in preventive
health and management of chronic illness. The field includes topics such as nutrition,
physical activity, sleep, stress management, mental health, environmental influences,
and social relationships across every stage of development. One of the newest concepts
in the field is inter-professionalism, which emphasizes the value of an interdisciplinary
team approach. The practice of pediatric integrative medicine has potential to bring
the heart back to pediatric practice by creating a child-centered model of care, infusing
the medical encounter with forward looking, evidence-based therapies, and prioritizing health across the lifespan.
Some of the principles of integrative medicine practice include:
•
•
•

•
•
•
•

Emphasis on preventative health and lifestyle
Support of the individual’s innate healing response
Focus on the therapeutic relationship between patient, family, and clinician
Consideration of health in all dimensions (body, mind, and spirit)
Family-centered care
Cultural competency
Use of all appropriate evidence-based therapies
(Maizes, Rakel, and Niemiec 2009)

These principles are well aligned with the medical home model and will hopefully
pave the way for creation of an “integrative medical home,” a model that places whole
childcare squarely in the mainstream of healthcare.
Historically, expansion of the field of integrative medicine has been hampered by
those preying on the fears of parents willing to accept any therapy, no matter how


4

Integrative Pediatrics: Art, Science, and Clinical Application

unscientific, in the effort to help their child. A guiding principle of this book will be to
convey a balanced approach to the field and to stress the importance of evidence-based
therapies. The goal is to raise awareness about the field of integrative pediatrics and its
enormous potential to improve healthcare for children. The title of the book reflects
three important elements that together can help clinicians maximize whole child health.

These include: the art of medicine practiced with compassion and awareness, a firm
foundation of scientific evidence, and the skillful clinical application of all appropriate
therapies. When combined, these elements exceed the sum of their parts and describe a
modern approach to pediatrics that blends appropriate conventional and complementary therapies in a child-centered model with the potential to optimize children’s health
from preconception through adulthood.

What’s in a Name?
As the field of integrative medicine has evolved, the language used to define it has
adapted accordingly. Here the term integrative will be used to reflect an evidencebased blending of conventional and complementary approaches. Popularity of the term
complementary and alternative therapy (CAM) is waning as concerns have mounted
about the lack of evidence underpinning alternative therapies, defined as treatments
used in place of conventional medicine. This change is reflected in the name change of
the former National Center for Complementary and Alternative Medicine (NCCAM)
to the National Center for Complementary and Integrative Health (NCCIH) in 2014
(National Institutes of Health 2014; NCCIH 2014).
The following example compares conventional, complementary, integrative, and
alternative approaches in a child with migraine headache.
Examples of Treatment Approaches for an Adolescent with Migraine Headache
•
•

•

•

Conventional: Traditional history and physical by an MD or DO, prescription
medication as needed, comprehensive physical once per year, ‘sick’ visits as needed,
hospital admission if necessary.
Complementary: “Complements” conventional treatment. May include nutrition
counseling, judicious use of dietary supplements such as butterbur, vitamin D, and

omega-3 fatty acids, mind–body therapies such as guided imagery, yoga, clinical hypnosis, or biofeedback, probiotics, and bioenergetics treatments such as acupuncture.
Integrative: Emphasis on preventive health, conventional treatment as needed,
evidence-based complementary therapies as appropriate. In the integrative model,
complementary therapies might be appropriately used alone, but openness to
blending both conventional and evidence-based complementary therapies for the
highest benefit of the patient is the overarching theme. This approach might include
dietary review, possible symptom-driven elimination diet, stress management skills,
and counseling on sleep and environmental triggers. All evidence-based therapies
would be considered.
Alternative: Alternative medicine refers to use of non-evidence-based therapies in
place of conventional medicine. This approach will not be covered in this text.

Functional medicine is an emerging field primarily based on molecular biology and
metabolic pathways with an emphasis on laboratory testing and use of replacement


Introduction to Pediatric Integrative Medicine

5

Table 1.1 National Center for Complementary and Integrative Health Classifications
Practice

Examples

Whole medical systems

Homeopathy, naturopathy, Ayurveda, traditional
Chinese medicine

Mind–body medicine

Meditation, prayer, mental healing, creative therapy
(art, music, dance)

Biologically based practices

Dietary supplements, botanical medicine

Manipulative and body-based
practices

Chiropractic, osteopathy, massage

Energy therapies

Biofield therapies (Qi gong, reiki, therapeutic touch),
Bioelectromagnetics (electromagnetic fields)

supplements. There is currently a relative paucity of evidence supporting this approach
in pediatrics, and for this reason functional medicine will not be covered in detail in
this work. Research is active in this field and will be important for pediatricians and
others caring for children to follow.
Many integrative therapies that have been gradually accepted into the Western biomedical model originated in long-established cultural healing traditions. A lack of
standardized definitions associated with this rich history can create challenges to clear
communication among conventionally trained health professionals. One approach
historically used is the NIH NCCIH classification developed by the former NCCAM
Advisory Board, noted in Table 1.1. This approach has recently been updated and
streamlined to include three main categories: mind and body practices, natural products,
and other complementary health approaches ( />

Organization and Overview
The main categories of integrative medicine discussed in the text include those with
the current strongest evidence in children. Part 1 includes an overview of the field, and
introduces the topic of clinician self-care and its important influence on patient outcome. Part 2 covers the foundations of healthy lifestyle habits in pediatrics including:
•
•
•
•
•
•

Nutrition
Selected dietary supplements
Physical activity
Mind–body therapies, spirituality in medicine
Sleep
Environmental health
Part 3 covers evidence-based complementary therapies including:

•
•
•
•

Botanicals
Manual medicine (therapeutic massage, osteopathy, craniosacral therapy)
Aromatherapy
Homeopathy

6

Integrative Pediatrics: Art, Science, and Clinical Application

•
•

Whole medical systems (traditional Chinese medicine, naturopathy)
Bioenergetic therapies (acupuncture, therapeutic touch, healing touch)

Part 4 covers integrative approaches to a variety of common pediatric conditions in
the areas of:
•
•
•
•
•
•
•
•
•

Preventive care
Allergy and asthma
Dermatology
Gastroenterology
Infectious disease (URI and otitis media)
Mental health
Neurodevelopmental disorders
Obesity and metabolic disorders

Integrative intake

Why Do Parents Use Integrative Medicine for their Children?
Reasons for the use of integrative medicine vary and can include a desire to support
the child’s natural healing process, a wish to explore all treatment options, preference
for less invasive treatments, and reduction of pain, stress, and suffering. An increased
range of cost-effective treatment options, cultural preference, and lack of access to
conventional care may be other important reasons. Integrative medicine holds special
potential to improve care in children by expanding treatment options, introducing new
approaches to chronic conditions and prioritizing health and wellness from preconception through adulthood.

Why is Pediatric Integrative Medicine Relevant to Modern Pediatric Practice?
The use of integrative therapies is high in children and in adolescents, requiring awareness on the part of all practitioners caring for these patients. Data from the 2012
National Health Interview Survey (NHIS) found that nearly 12% of children used
complementary therapies in the prior year (about one in nine), similar to the overall
prevalence recorded in the 2007 NHIS survey. Prevalence increases to approximately
50% in children living with a chronic illness (Black et al. 2015).
Dietary supplements (other than vitamins and minerals) were again the most commonly used approaches. The 2012 survey showed an increase from 3.9% in 2007 to
4.9% of children using dietary supplements, and a significant increase in pediatric use
of yoga, fish oil, and melatonin. Therapies used most frequently were reported as natural products (3.9%), chiropractic and osteopathic (2.8%), deep breathing (2.2%), yoga
(2.1%), homeopathy (1.3%), traditional healers (1.1%), massage (1.0%), diet-based
therapies (0.8%), and progressive relaxation (0.5%). Use remained higher in children
whose parents had also used complementary or alternative therapies, in children with
more than one health condition, and in children who did not use, or whose families
could not afford, conventional care. Fish oil was the most commonly used supplement
in 2012, as compared to echinacea in 2007. Melatonin was the second most commonly
used supplement in 2012.The conditions where complementary therapies were most
commonly used remained constant from 2007 and included back or neck pain (6.7%),

Introduction to Pediatric Integrative Medicine

7

head or chest cold (6.6%), anxiety/stress (4.8%), other types of musculoskeletal conditions (4.2%), ADHD (2.5%), and insomnia (1.8%) (Barnes, Bloom, and Nahin 2008;
NCCIH 2012).

What do the Statistics Imply?
High prevalence of use of integrative and complementary therapies reinforces the need
for pediatricians and other practitioners caring for children to be current on research
in integrative medicine and familiar with reliable sources of information to best serve
the needs of their patients. The statistics also suggest that children and their families,
especially children living with chronic illness, may not be fully served in the conventional health model. Many turn to integrative therapies to fill the gap, citing concerns
about medication side effects and lack of access to care that is consistent with their
values (Birdee et al. 2010).
The relatively high use of integrative medicine in the pediatric population often goes
unrecognized, in part because of low disclosure rates (less than 50% in several studies) by parents who may fear a negative reaction from their child’s clinician (Kemper
et al. 2008).
Parents should be encouraged to discuss integrative therapies with their clinician,
especially to avoid unwanted drug–supplement interactions. Conversely clinicians
should feel comfortable discussing the subject and be able to offer accurate information and identify reliable resources to help guide parents.
As noted by Culbert and Olness (2009) in Integrative Pediatrics, other factors driving interest in pediatric integrative medicine reflect the sharp increase in the prevalence
of chronic illnesses reaching into progressively younger age groups, prescription drug
use, and the upturn in stress-related disorders in children.
Asthma
Asthma is the most prevalent chronic inflammatory pediatric illness in the U.S. and has
increased from a prevalence of 3.6 to 13.6 over the past 30 years, 1980–2010. Lifetime
prevalence of 13.6 in ages 18 and under in 2010 has increased from a prevalence of
3.6% in 1980 (Winer et al. 2012; NHIS National Health Interview Survey [NHIS] Data
2010; Centers for Disease Control and Prevention 2010).

Obesity
Childhood obesity has more than tripled in the past 30 years. In 2008 more than onethird of children and adolescents were overweight or obese, and one in six children aged
6–19 years were overweight or obese, a 45% increase in the past 10 years (Centers for
Disease Control and Prevention 2015).
Diabetes
The prevalence of type-2 diabetes has increased significantly in U.S. children, keeping
pace with increasing prevalence of obesity and showing an estimated tenfold increase
in the last decade, with higher rates in children of American Indian, African American,
Mexican American, and Pacific Islander descent (Mayer-Davis 2008).


8

Integrative Pediatrics: Art, Science, and Clinical Application

Attention-Deficit/Hyperactivity Disorder
Attention-deficit/hyperactivity disorder in children aged 5–17 years has increased in
prevalence from 6.9% to 9.0% in the periods from 1998–2000 through 2007–2009,
indicating that approximately 1 in 12 children have been diagnosed with ADHD, with
highest prevalence in lower socioeconomic groups and in the Midwest and Southern
United States (Akinbami et al. 2011).
Autism Spectrum Disorders
Autism spectrum disorders now affect 1 in approximately every 68 American children
(1 in 42 boys, 1 in 189 girls), a more than twenty-fold increase since the 1980s.
Despite numbers almost beyond comprehension, a clear etiology remains elusive
(Lee, Thomas, and Lee 2015; Section On Complementary and Integrative Medicine et
al. 2012).
Premature Birth
Premature birth (less than 37 weeks’ gestation) affects one in eight babies born in the
U.S. each year, contributing to one-third of all infant deaths. Premature births are

estimated to cost greater than $26 billion annually. The causes of premature birth are
multi-factorial and closely linked to prenatal care and poor maternal nutritional status
(Centers for Disease Control and Prevention 2012).
Cancer
The prevalence of leukemia and cancers of the brain and central nervous system make
cancer the leading cause of death by disease among U.S. children of 1–14 years of age.
The causes of childhood cancer remain unclear (National Cancer Institute 2014).
Mental Health Disorders
Mental health disorders in children are increasing and were estimated to impact 13%–
20% of U.S. children in a given year between 1994 and 2011 as reported by the U.S.
CDC.
Suicide was the second leading cause of death for ages 12–17 in 2010. On any given
day approximately 2% of school-aged children and about 8% of adolescents are estimated to meet criteria for major depression (Centers for Disease Control and Prevention
2005–2011).
Review of these statistics reflects startling shifts in a broad range of conditions, often
accompanied by a sharp uptick in prescription medicine use. For example, an estimated
2.8 million children under 19 years received stimulant medication in the U.S. in 2008,
a number that has increased steadily since 1996, primarily in the adolescent age group
(Zuvekas and Vitiello 2012).


Introduction to Pediatric Integrative Medicine

9

Strengths and Challenges of Integrative Medicine
Strengths
One of the main strengths of integrative medicine is its focus on preventive health. A
policy of incremental intervention while maximizing healthy lifestyle approaches has
the potential to reduce the need for prescription medications and to help lay a solid

foundation of health. Another strength of integrative medicine is its inherent flexibility
with the ability to tailor treatments to children of nearly any age, including those living
with chronic health conditions. The field promotes the child’s inherent capacity for selfregulation and healing (if not always cure), regardless of diagnosis. Other important
strengths emphasized in integrative medicine are cultivation of self-control, resiliency,
and self-efficacy, traits that have been shown to have significant impact on quality of
life and health outcomes. Caretaker health, including parents, family members, and
the medical team members has an important impact on health outcomes, and for this
reason is also considered a foundation of the integrative medicine approach.
Another strength of pediatric integrative medicine is that it can be practiced in
nearly any setting, from outpatient to the intensive and neonatal intensive care settings, including:
•
•
•
•
•
•
•
•
•

Pre-natal consults
Well child visits
Home setting
Acute care
Complex chronic illness
Behavioral and mental health issues
Inpatient medicine
Palliative care
Hospice care

Obstacles
In addition to the stigma related to a history of unethical promotion of alternative therapies to parents of ill children, other challenges include a lack of outcomes research,
inadequate insurance reimbursement, and disparate funding for child and maternal
preventive health. A lack of training opportunities for clinicians is another obstacle,
although this is gradually changing. Strongly skeptical colleagues and those complementary practitioners who take extreme positions (for example anti-vaccination) have
each polarized the field in different ways, slowing meaningful progress on research,
educational, and clinical fronts to benefit children’s healthcare.
Ethical and legal considerations are a critical concern in integrative medicine. The
guiding principles of beneficence (promote the wellbeing of the patient), nonmalfeasance (do no harm), and patient autonomy (does the patient have enough information to
make an informed decision) must be applied in every encounter (Gilmour et al. 2011a).
Variability in training, licensure, and credentialing is another challenge. It is paramount that clinicians (and parents) have a full understanding of the state of the evidence
surrounding individual therapies, an understanding of the qualifications of all practitioners, a clear understanding of the proposed treatment plan, and awareness of all
potential risks and benefits (Gilmour et al. 2011b).


10

Integrative Pediatrics: Art, Science, and Clinical Application

Table 1.2 Approach to CAM Therapies in Children Based on Efficacy and Safety
Efficacy

Safety

Yes

No

Yes

Recommend

Tolerate

No

Monitor closely or discourage

Discourage

In general, according to the National Center for Complementary and Integrative
Health, physicians may provide complementary therapies such as nutritional counseling, herbal medicine, biofeedback, and hypnotherapy because they are authorized by
state law to diagnose and treat disease. Psychologists are licensed in all states and commonly provide mind–body therapies and teach therapies such as biofeedback, guided
imagery, hypnosis, and stress management, including cognitive behavioral therapy,
mindfulness based stress reduction and others. However, states may or may not allow
other licensed clinicians, conventional or complementary, to provide such therapies,
or may not have laws addressing the question at all. Currently, four complementary
practices are widely licensed in the United States: acupuncture, naturopathy, massage,
chiropractic. A fifth, homeopathy, is licensed in only three states.
Difficulty in evaluating therapies for safety and efficacy is another important obstacle, especially with the lack of pediatric outcome studies available. One approach is to
use a hierarchy of evidence, which means the greater the potential harm, the better the
strength of evidence required before endorsement of the therapy can be made. Cohen
and Kemper have developed a useful model to assess efficacy and safety of individual
treatment approaches, shown in Table 1.2 (Kemper and Cohen 2004).

Policy
A paradigm change in priorities for national pediatric healthcare is needed to interrupt
the ineffective cycle that places millions of children at a staggering financial, physical,
mental, and emotional disadvantage often before they are even born. Research exists
to help us intelligently address critical time windows in early life that determine the

foundations of lifelong health. Clinicians caring for children must be the advocates
that translate this science into positive action. In addition, the prevalence of neurodevelopmental disorders, attention-deficit/hyperactivity disorder, obesity, type-2 diabetes,
metabolic syndrome, inflammatory bowel disease, asthma, and arthritis, premature
birth and other conditions has literally changed the landscape of pediatrics, impacting
millions of children, families, and clinicians. The old models of medical education and
insurance reimbursement are outdated and unable to keep pace with the realities of
pediatric practice. New approaches are urgently needed.
Given the complex realities of health policy, a thoughtful, informed, and wellcoordinated approach will be needed to move the field of pediatric integrative medicine
forward.
Medicine, and by association integrative medicine, is influenced by scientific advances,
healthcare economics, and strategically positioned policy makers. To be effective, clinicians who advocate for children must be present at the highest levels of the healthcare