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(BQ) Part 2 book “Integrative pediatrics - Art, science, and clinical application” hass contents: Allergy and asthma, an integrative approach to preventive health, integrative intake, obesity and metabolic disease, conclusion, gastroenterology, dermatology,… and other contents.
14 An Integrative Approach to Preventive Health Time available for pediatric preventive care in clinical visits has become more and more constricted in the tightly controlled insurance reimbursement climate in the U.S However, despite the challenges, preventive care remains a major focus in pediatric integrative medicine In the U.S there are typically 32 well child visits, including the prenatal visit, with the majority occurring before the age of years These offer an important opportunity to reinforce a lifelong foundation of health The integrative medicine model can be used to enrich these visits by introducing more detailed information on nutrition, selected dietary supplements, stress management tools, physical activity, and sleep counseling and to harness emerging data on topics such as environmental health and the microbiome to maximize children’s wellbeing Once past the infant stage, an estimated 20% of pediatric office visits are due to behavioral or mental issues, highlighting the importance of addressing nurturing relationships, family and peer connections, self-regulation skills, self-efficacy, effective behavior change, and development of empathy and compassion for others—skills that are routinely taught in integrative medicine The Bright Futures resources through the American Academy of Pediatrics provides a foundation of rich resources on traditional pediatric health and health screening, and continues to serve as a classic blueprint for those caring for children and adolescents The Bright Futures guidelines were updated in 2014, with some of the biggest changes including recommendation for depression screening annually from age 11–21 Screening for dyslipidemia is now recommended for patients between and 11 years old, screening for HIV between 16 and 18 years old (Geoffrey et al 2014) This chapter includes a discussion and checklist of proposed integrative anticipatory guidance suggestions by age Ideally these guidelines would be introduced and consistently reinforced in an integrative medical home that supports child, family, and clinician health Some opportunities to influence the health of the newborn begin long before birth As in any practice of medicine, cultural considerations should be respected, and thoughtful assessment of the risk–benefit ratio of any therapy done prior to its use Immunizations The integrative approach in the model presented here fully supports the use of routine immunizations Despite historic and ongoing controversy, the protective benefits are enormous against illnesses that continue to be prevalent around the world Although a polarizing topic, no child is well served when adults take extreme positions in this 218 Integrative Pediatrics: Art, Science, and Clinical Application debate No family should be dismissed from a practice for refusing to vaccinate, just as no family should be encouraged to rely on “herd immunity,” relying on high vaccination rates on other children as a protective mechanism for their own children This places children who are too young to be vaccinated, those without access to medical care or unable to be vaccinated for medical reasons, or children who did not get a full immunologic response at real risk of exposure to serious illnesses (Buttenheim 2012) Some parents resist vaccinations on moral or religious grounds, or due to underestimation of real risk to their children Others fear triggering of autism or other serious neurological disease, or have deep skepticism that vaccines can actually prevent illnesses Of concern, vaccine refusal rates are increasing in the U.S which tracks with increasing prevalence of outbreaks of measles and pertussis (Omer et al 2009) One of the early spikes in anti-vaccination sentiment was caused by a now infamous article by Andrew Wakefield erroneously linking the measles-mumps-rubella (MMR) vaccine to autism The article was published in Lancet in 1998 and later retracted (Editors of The Lancet 2010) Author Wakefield and his two co-authors were charged with professional misconduct and falsifying research Wakefield was eventually banned from the practice of medicine Despite the serious professional fallout to Wakefield, the ripple effect from his erroneous work has been far reaching Rates of immunization remain impacted in the U.S and in other developed countries despite a range of large well-designed studies disproving the association between vaccines and any pattern of serious neurodevelopmental disease (Gilmour et al 2011; Demicheli et al 2012) Additional parental concerns involve the number and pacing of vaccines in the current schedule in the first 24 months of life Again, no established correlation between this schedule and serious neurodevelopmental or immunological outcome has been reported The American Academy of Pediatrics encourages practitioners to encourage open and respectful dialogue with parents about vaccines, and to work with the parents to be sure every child is fully vaccinated (Gilmour et al 2011) Although the term “alternate vaccine schedule” is popular, studies show that the majority of families using this approach are following informal recommendations from family, or picking and choosing vaccines based on input from friends A minority of 748 families in a study by Dempsey were working with their child’s medical provider to formulate a vaccine schedule (Dempsey et al 2011) Ideally, striking a balance between mutual respect, trust, flexibility, and collaboration and using evidence-based educational tools will help the parent–clinician team provide the best protection from what in many cases are 100% vaccine-preventable illnesses (Glanz, Kraus, and Daley 2015) Studies have shown that clinicians who are willing to listen, and who manifest openness with eye contact, receptive body language, and mindful presence in the room are most likely to connect successfully with parents and be able to fully understand their fears and concerns (Leask et al 2012) A newer term emerging in the global public health literature is vaccine hesitancy, described by the World Health Organization Strategic Advisory Group of Experts as being influenced by “complacency, convenience, and confidence.” Efforts are underway to improve educational approaches and resources and to support global efforts to best protect children from preventable illness (Kumar et al 2016) An Integrative Approach to Preventive Health 219 Lifestyle Foundations: Maternal Health Nutrition Maternal diet is important to fetal health, and accruing research offers more details on best approaches A “prudent” diet inclusive of vegetables, fruits, oils, whole grains, water as primary beverage, and fiber rich bread was shown to be associated with statistically significant reduced risk of preterm delivery in a population study of 66,000 pregnant women in Norway as compared to a “Western” diet that included salty and sweet snack foods, white bread, processed meats, and desserts The traditional diet in this study consisted of potatoes and fish and was also associated with reduction in risk of preterm delivery compared to a “Western” diet (Englund-Ogge et al 2014) Weight Management: Obesity Risks Maintenance of healthy weight throughout pregnancy has long-term implications for fetal and infant health The 2013 American College of Obstetricians and Gynecologists Committee Opinion No 549 on Obesity in Pregnancy recommends that preconception counseling should review the fetal risks of obesity in pregnancy which include: gestational diabetes, hypertension, preeclampsia, increased rate of cesarean delivery, and post-partum weight retention Fetal complications have also been widely reported and include: prematurity, stillbirth, higher rate of congenital anomalies—including neural tube defect, and large for gestational age which predisposes to childhood and adolescent obesity The report recommends that nutrition counseling and encouragement to begin an exercise program should be offered to all overweight or obese women Maternal obesity has also been shown to reduce initiation and success at breastfeeding (American College of Obstetricians and Gynecologists 2013) Dietary Supplements Similar to folate, docosahexaenoic acid (DHA) has an important role in fetal development DHA is integral in formation of the fetal brain and nervous system, especially during the third trimester when the fetal brain approximately doubles in size (Makrides 2013) DHA is also needed for development of the rods and cones of the retina, sperm, and testicles (De Giuseppe, Roggi, and Cena 2014) Adequate DHA has also shown a significant association with prolonging gestation and reducing the risk of preterm delivery at less than 34 weeks gestation in both low-risk and in high-risk pregnancies (Mozurkewich and Klemens 2012) Maternal consumption of omega-3 fatty acids during and post-pregnancy may also confer a protective effect against allergy by lowering allergen specific Th2 responses and elevated Th1 responses (D’Vaz et al 2012) Maternal DHA has also been shown to affect DNA methylation patterns, and research is active examining how this may impact fetal lipid metabolism and future development of lipid disorders (Khaire, Kale, and Joshi 2015) Although the optimal maternal level is not known, metabolic stores of DHA have been shown to reduce by half during pregnancy and may not return to pre-pregnancy levels until months postpartum Adequate levels of DHA can be attained through food, especially fish, but mercury contamination can be a concern, especially in pregnancy 220 Integrative Pediatrics: Art, Science, and Clinical Application The U.S EPA is one organization that provides useful resources on this issue (United States Environmental Protection Agency [a]; National Resources Defense Council) The recommended minimum DHA supplement dose for pregnant and lactating women is 200 mg per day according to the International Society for the Study of Fatty Acids and Lipids This dose can be reached with 1–2 portions of oily sea fish (such as herring, mackerel, salmon) per week Although environmental contamination pollutants remain an active concern as noted, the consensus statement reinforces the critical role of DHA in neural development and encourages intake of a variety of fish species and avoidance of regular intake of large predatory fish that have higher levels of contaminants (Koletzko et al 2007) Dietary supplements of DHA are a second option Products labeled “molecularly distilled” are presumed to be toxin free Physical Activity Aerobic exercise is accepted as safe and effective throughout pregnancy (depending on individual restrictions); for example, the fetal heart has been shown to adapt to exercise with positive changes in heart rate and heart rate variability and reduction in body fat (Domingues et al 2015) The effects of other types of maternal physical activity on fetal development and neonatal health is not well understood Studies are underway examining the effects of circuit training, resistance training, and aerobic training on maternal and fetal health, specifically on cardiovascular development and function (Moyer et al 2015) Sleep Sleep disturbance during pregnancy has been associated with stress and depression, and shown to upregulate the inflammatory cascade and negatively impact immune functioning Maternal sleep disturbance has been associated with increased risk for preterm birth and low birth weight (Okun et al 2013; Okun et al 2011) Sleep disordered breathing in pregnancy has also been associated with shortened fetal leukocyte telomere length as measured in cord blood (Salihu et al 2015) These studies highlight the importance of reinforcing the value of regular restorative maternal sleep in the prenatal period as a protective factor in fetal health Maternal Stress and Mind–Body Therapies Emerging studies on the effects of toxic maternal stress, also recognized as unremitting chronic stress, have shown a range of effects on the fetus, including upregulation of the inflammatory cascade, dysregulation of the hypothalamic-pituitary-adrenal axis, and imbalance of the immune system (Avitsur et al 2015) Epigenetic effects are also under active study Work by Shonkoff and colleagues has highlighted the negative effects of intergenerational stressors, and the need to buffer the unborn child from its effects (Shonkoff et al 2012) Although a 2011 Cochrane review noted that small study size and design variability limited broad recommendations for mind–body interventions for pregnant women (Marc et al 2011), a growing body of studies point to benefit with low risk to both An Integrative Approach to Preventive Health 221 mother and growing fetus Yoga and mindfulness are among the practices that have shown benefit in maternal stress reduction (Sheffield and Woods-Giscombe 2016) One randomized control trial of 64 Chinese maternal–fetal pairs also noted a statistically significant decrease in cord blood cortisol and infant salivary cortisol in infants of mothers who participated in six structured meditation sessions (Chan 2014) Both yoga and therapeutic massage were shown to decrease depressive symptoms in women with prenatal depression, and was also correlated with greater birth weight and longer gestational term than control group (Field et al 2012) Sufficient research exists to support the recommendation for discussion and intervention of chronic stressors in pregnancy and to encourage expectant mothers to take steps to address stress using non-pharmacologic evidence-based mind–body therapies that have a low incidence of adverse effects Environmental Health A wealth of information exists on the importance of minimizing or preventing exposures to all categories of pollutants and toxicants prenatally and after birth These topics are reviewed in more detail in Chapter 8, Environmental Health Accruing literature in the obstetrics-gynecology literature reinforces these concerns and highlights the educational programs for clinicians and patients that are under development in this area (Crighton et al 2016) Perinatal Health: Vaginal Versus Cesarean Delivery and the Role of the Microbiome Accruing research shows that the maternal microbiome, in both uterus and in breast milk, influences the fetal immune and inflammatory systems Although in the best-case scenario infants would be born vaginally with no exposure to unnecessary antibiotics and exclusively breastfed, in reality this is often not the case A caution with elective cesarean delivery is that the infant misses exposure to the rich microbiome of the birth canal and is colonized with the bacteria they are exposed to at birth; for example, microbes present in the operating room A decision to formula feed results in the infant missing the rich microbiota and prebiotics delivered in the breast milk, delaying normal colonization of the gut (Arrieta et al 2014) Consequences to these important decisions, vaginal versus cesarean delivery and breast versus bottle feeding, are areas of intense study Until more is known, clinicians who encourage expectant mothers to plan for a vaginal delivery and help set them up for a successful breastfeeding experience are taking important steps to support the infant’s health and wellbeing While legitimately needed in many cases, exposure to antibiotics peri- and postnatally also interrupt normal microbiome development in the newborn, possibly predisposing to future allergic, inflammatory, and atopic illnesses and their use should be limited whenever safely possible (Romano-Keeler and Weitkamp 2015) Summary: Maternal Lifestyle Foundations to Promote Fetal Health • • • Emphasize a varied, “prudent” whole food diet rich in vegetables and fruits, whole grains, olive oil, and lean proteins Encourage organic foods when available Maintain a healthy weight Ensure a daily minimum of 200 mg DHA to support fetal neural development 222 Integrative Pediatrics: Art, Science, and Clinical Application • • • • • • • • Normalize vitamin D levels Encourage enjoyable physical activity Emphasize the importance of restorative sleep Address chronic stress with non-pharmacologic approaches Explore mind–body techniques to encourage relaxation and self-regulation skills Support the choice of vaginal delivery if possible to promote healthy microbiome Support and encourage exclusive breastfeeding for first months of life Raise awareness about preventable environmental exposures pre- and postnatally Lifestyle Foundations: Newborn and Infant Nutrition Breastfeeding for the first months of life is the recommendation of both the World Health Organization and the American Academy of Pediatrics as the optimal nutrition for newborns and infants (Eidelman 2012), yet the 2014 CDC Breastfeeding Report Card shows that only about 19% of U.S babies breast feed exclusively at months and many women face significant obstacles to successful breastfeeding at home, on the job, and in the public domain (Centers for Disease Control and Prevention) Research on breast milk shows that it contains a rich reservoir of changing nutrients for the baby, including an important variety of immunoglobulins, leukocytes, a wide range of proteins, micronutrients, and peptides, fats, and fatty acids, including the anti-inflammatory omega-3 and the proinflammatory omega-6 fatty acids, another important reason to encourage lactating mothers to have adequate DHA intake either from diet or high-quality dietary supplement Bioactive components in the breast milk are highly varied and an area of active study They include substances such as stem cells, macrophages, cytokines, chemokines, growth factors including brain-derived neurotrophic factor and insulin-like growth factor, growth regulating hormones, adiponectin, oligosaccharides, and glycans The human milk oligosaccharides (HMOS) are large non-nutritive sugars—but serve as prebiotics to encourage the growth of beneficial probiotic organisms in the infant gut It has been shown that these remarkable compounds can also act as receptors of harmful pathogens, another area of active study (Ballard and Morrow 2013) Breastfeeding has been associated with a wide range of benefits to infant and child, including development of a healthy immune system, optimal gut microbiota, increased intelligence quotient (Smithers, Kramer, and Lynch 2015) and healthy body weight (Hunsberger et al 2013) A longitudinal study examining the impact of breast versus formula feeding in 8030 infants showed that infants who were primarily bottle fed for the first months of life were more than twice as likely to be obese at years of age compared to breastfed babies In this study population, early introduction of solids at months or earlier and putting the infant to bed with a bottle were also risk factors for obesity at years (Gibbs and Forste 2014) A source of ongoing controversy in the U.S is the distribution of infant formula discharge packs to new parents that typically contain samples, coupons, and a variety of marketing and advertising materials Advocacy efforts, especially renewed focus on the World Health Organization’s 1981 International Code of Marketing of Breast-milk Substitutes (World Health Organization), the Joint Commission Perinatal An Integrative Approach to Preventive Health 223 Core Measures that measure exclusive breastfeeding during perinatal hospitalization (Commission Specifications Manual for Joint Commission National Quality Measures (v2015A1)) and the Healthy People 2020 Maternal, Infant, and Child Health objectives (U.S Department of Health and Human Services) have helped reduce the prevalence of this practice from more than 70% of hospitals in 2007 to 32% in 2013 This downward trend is encouraging; however, the average of one in three hospitals per state continuing to distribute these marketing materials remains significant Artificial infant formula is a multimillion dollar industry in the U.S and a large part of the multibillion dollar global baby food market U.S retail sales for baby food, including infant formula, were nearly U.S.$37 billion in 2010 with estimated growth to U.S.$55 billion by 2015, often making unsubstantiated health claims (Belamarich, Bochner, and Racine 2015; Nelson, Li, and Perrine 2015) For mothers unable to nurse, or who choose not to nurse for personal reasons, an option to consider is pasteurized human donor milk from a highly reputable source, a growing trend globally (Williams et al 2016) AAP recommendations include exclusive breastfeeding until ~age months with introduction of complementary solid foods accompanied by continued breastfeeding until 12 months (Klag et al 2015) Introduction of solid food types varies widely by culture and family traditions Longitudinal studies are lacking as to the optimal pediatric diet predictive of adult health; however, accruing evidence suggests health benefits of the Mediterranean type diet as a protective factor against overweight and obesity in children (Kaikkonen, Mikkila, and Raitakari 2014) and daily childhood consumption of fruits and vegetables has been independently associated with improved measures of cardiovascular fitness in adulthood (Aatola et al 2010; Kaikkonen et al 2013) Newborn: Dietary Supplements Docosahexaenoic Acid (DHA) Docosahexaenoic acid is passed from mother to infant in the breast milk, with DHA levels in breast milk showing good correlation with maternal DHA stores (Meldrum et al 2012) Postnatal supplementation of omega-3 fatty acids has been shown to increase infant omega-3 fatty acid levels and to balance the immune inflammatory response in randomized controlled studies (D’Vaz et al 2012) Although improvements in allergic response and in development of asthma have been demonstrated in some studies, conclusive recommendations not currently exist for infant DHA supplementation (Miles and Calder 2014) The Institute of Medicine (IOM) has set an acceptable macronutrient distribution range for total omega-3 fatty acid intake at 0.6–1.2 grams per day for ages and up pending further studies to determine conclusive recommendations (Minns et al 2010) Synthetic DHA has become an integral ingredient in many infant formulas to promote healthy brain development Despite marketing claims promising cognitive benefit, studies are lacking supporting the promise of improved cognition in children (Drover et al 2012) 224 Integrative Pediatrics: Art, Science, and Clinical Application Newborn Vitamin D Vitamin D is important in newborns as it has an array of important physiologic roles in addition to regulating calcium and phosphorus metabolism in bone health Reported associations include roles in autoimmune, inflammatory, cardiovascular, metabolic, and infectious diseases A 2015 expert position paper by Saggese and colleagues provides an excellent and detailed overview of the subject (Saggese et al 2015) Exclusively breastfed infants not receiving vitamin D supplementation are at high risk of vitamin D deficiency The 2012 American Academy of Pediatrics Breastfeeding Policy Statement recommends that all infants that are not consuming at least 500 mL (16 ounces) of vitamin D-fortified formula or milk be given a vitamin D supplement of 400 IU/day which should be started in the first few days of life The exact duration of vitamin D supplementation has not been determined (Mansbach, Ginde, and Camargo 2009) Newborn Toxic Stress As detailed in Chapter 19, Mental Health, the pattern of toxic stress often starts prenatally and has been shown to have lasting detrimental effect on a child’s health Exposure to stressors such as neglect, abuse, violence, poverty, and to chronic high caretaker stress has been shown to result in “biological embedding” with negative impact on the neuroendocrine-immune-inflammatory systems The lack of buffering from chronic stressors has been clearly associated with decreased immunity, and reduced resistance to disease as well as a predisposition to pro-inflammatory illnesses such as asthma, metabolic syndrome, obesity, and cardiovascular disease in children High-level chronic stressors are not limited to low socioeconomic groups All families should be screened for stressors at well child visits and referred accordingly Importantly, the presence of a stable source of a nurturing adult can mitigate the effects of chronic stress Significant work is ongoing in this area in the American Academy of Pediatrics and other national organizations dedicated to raise awareness and encourage clinicians caring for children to intervene and educate individuals, family members, and community organizations to help protect children from the long-term effects of chronic stressors In infants this involves creating a stable, nurturing environment that provides ample, on-demand nutrition, an organized sleep–wake cycle, and regular access to healthcare In families in need this may involve home visits and expanded social support (Johnson et al 2013; Garner 2013) Newborn Microbiome Research on the evolution and importance of the newborn gut microbiota is evolving rapidly and evidence is correlating a healthy gut microbiome with a protective effect against acute and chronic illness Contrary to traditional teaching, the uterus, amniotic fluid, and placenta have all been shown to contain bacteria in normal healthy pregnant women (Arrieta et al 2014) In newborns, early gut colonization is generally seen with strict anaerobes such as Bifidobacterium, Clostridium, and Bacteroides (Matamoros et al 2013) then begins to mimic maternal skin bacteria and vaginal microbiome (if not delivered by cesarean) Breast milk has also been shown to have a unique microbiota that plays a role An Integrative Approach to Preventive Health 225 in conjunction with human milk oligosaccharides to catalyze development of other microbes Bifidobacterium species are most prevalent during the next months of exclusive milk feeding and play the role of fermenting milk oligosaccharides The introduction of solid foods precipitates a change in the gut microbes and a decrease in Bifidobacterium and Enterobacteriaceae and over the first years of life the microbiome aligns with adult species The microbiome patterns of infants have been shown to vary by geographic location and by diet and have also been shown to be significantly affected by antibiotic exposure (Arrieta et al 2014) Conditions that have been associated with an altered microbiome that are under active study include: necrotizing enterocolitis, inflammatory bowel disease, obesity, malnutrition, asthma and atopy, and autism spectrum disorders (Cortese et al 2016) No current recommendations exist for pediatric probiotic supplementation; however, there is a growing literature suggesting a protective benefit to early exposure to a wide variety of bacteria in the natural environment One frequently cited example is the lower incidence of asthma seen in children raised on farms (Ege et al 2011) A counterargument to the push for increased time spent in nature is the concern about exposures to environmental toxicants, a real issue in many areas of the world The topic is complex and evolving and is covered in more detail in Chapter 8, Environmental Health In addition, large population studies are underway in protected rural living societies such as the Amish in the hope of better understanding the protective factors at play (von Mutius 2016) Treatment with probiotics is also an area of active study in some newborn conditions; for example, in acute gastroenteritis, where certain strains have been shown to reduce duration of diarrhea Both Lactobacillus rhamnosus GG and Saccharomyces boulardii have reduced duration of diarrhea, but have not been shown to consistently shorten hospital stay (Guarino et al 2014) Other strains have shown promise in studies in children with rotavirus including Bifidobacterium longum and Lactobacillus acidophilus (Lee et al 2015) Treatment of infant colic with specific strains of Lactobacillus reuteri has been evaluated in randomized controlled trials with mixed results (Lee et al 2015) A study by Sung and colleagues of 167 infants with colic who were either breast or bottle fed failed to find benefit of probiotic treatment and did not result in changes to infant gut microbiome diversity, E coli colonization, or calprotectin levels in this study population, although several variables were identified such as inclusion of infants on proton pump inhibitors and variability of formula in the bottle-fed group In contrast, a randomized controlled double-blind trial of the same strain of Lactobacillus reuteri (DSM 17938) by Chau and colleagues of 52 breastfed infants with colic showed a greater than 50% reduction in daily crying time and fussiness over control group with significance manifesting as early as week into treatment (Chau et al 2015) Large randomized trials are ongoing In the meantime standard recommendations for the use of probiotics in infant colic not exist (Sung et al 2014) Newborn Sleep Any new parent understands the importance of sleep in newborns Emerging research using electroencephalogram on healthy newborns shows that a well-developed sleep– wake cycle is present in the first 36 hours or sooner after birth and has an approximate ratio of 51% active sleep and 38% quiet sleep In infants delivered by elective cesarean 226 Integrative Pediatrics: Art, Science, and Clinical Application section, active sleep was longer and quiet sleep reduced in a study of 80 term infants This was hypothesized to reflect a lower level of stress than that experienced by infants delivered by vaginal delivery or by emergency cesarean, which may correlate with a lower level of “priming” of the stress response than that typically seen during the normal process of labor if the child is delivered emergently due to fetal distress Research is active in the study of newborn sleep architecture and its relation to cardiorespiratory markers that may be predictive of sudden infant death syndrome (SIDS) and other neurodevelopmental conditions (Korotchikova et al 2015) Chamomile tea (manzanilla) has historically been used to settle restless infants and to help colic as further discussed in Chapter 9, Botanicals While no published guidelines exist, a widely used practice of 2–3 ounces of cooled tea has been used in many countries throughout the world to soothe infants Daily volumes should not replace needed calories through breast milk or formula (Gardiner 2007) Infant Massage Infant massage is a non-pharmacological tool that may help infants equilibrate sympathetic and parasympathetic nervous systems Research has shown reduction in stress hormone secretion, decrease in heart rate variability, improved bone density, improved gastric motility, and increased overall weight gain in both preterm and term neonates receiving massage The mechanism for increased weight gain is not fully understood, but may be related to stimulation of the vagal nerve and increased release of insulin growth factor-1, an area of active study (Field, Diego, and Hernandez-Reif 2011) Other infant massage studies show how the modality may benefit the caregiver For example, in a small randomized controlled trial of 17 HIV-positive mother–infant pairs, mothers in the massage group reported increased confidence in reading their infant’s cues, and reduction in depression and feelings of parental distress Infants in the treatment group showed improved infant linear growth and weight gain in this pilot study (Oswalt and Biasini 2011) Aromatherapy Aromatherapy can be used in infant massage in the form of adding essential oils such as lavender to massage oil This has shown benefit in a small study on infant colic (Cetinkaya and Basbakkal 2012) Aromatherapy can also be used in aerosolized form to promote relaxation, or a few drops of essential oil placed on an infant’s blanket for the same reason A more detailed description of aromatherapy is covered in Chapter 11, Aromatherapy Essential oils should never be applied near an infants face or taken internally due to risk of aspiration Newborn Mind–Body and Bioenergetic Therapies The use of music therapy is one of the best studied mind–body therapies in infants For example, in NICU babies, music has been shown to be effective in calming behavior, stabilizing vital signs, and increasing weight gain (Standley 2012, Kemper and Hamilton 2008) The use of therapeutic touch has been evaluated in a small pilot study in preterm infants to see if it can buffer the stress of a simulated needle stick Infants who received 420 Integrative Pediatrics: Art, Science, and Clinical Application Complementary Approaches • • • • • Botanicals Manual medicine (massage, osteopathy, craniosacral, chiropractic) Aromatherapy Whole medical systems (homeopathy, naturopathy, Ayurveda, traditional Chinese medicine) Bioenergetics Motivational Interviewing Suggestions What to work on first, why, and how the patient can position themselves for success Practice Models Integrative clinicians use many practice models in both academic and community-based settings, therefore billing, coding, and malpractice models vary One common approach is to use the Evaluation and Management (E&M) codes to accurately represent time use, paired with typical International Classification of Disease (ICD) codes New codes are constantly evolving, for example the ICD 10 has a Z72 code labeled “Problems Related to Lifestyle” that includes lack of physical exercise, inappropriate diet and eating habits, sleep problems, and other similar categories A growing number of electronic medical records exist that can accommodate the integrative visit, yet modernization of insurance coding, billing, and reimbursement are still needed to prioritize fair reimbursement for time spent on preventive health and introduction of new skills The value of an integrative approach in pediatrics is reinforced by the potential for early development of healthy habits, reduction in use of prescription medications, and cultivation of resiliency and self-efficacy When introducing the integrative approach, the clinician may want to focus on the one or two areas in which they feel best prepared to counsel a patient to avoid overwhelming the patient Some clinicians may start with nutrition, or physical activity, and build on their strengths as they master other topics Others may feel more confident introducing mind–body therapies Momentum continues to build around the benefits of the inter-professional team approach that leverages the strengths of many disciplines and specialties, ideally in an integrative medical home where all services are available under one roof Clinician Self-Care Given the depth of an integrative intake visit, a few moments of personal reflection and mindfulness after each visit, or at the end of the clinic day, can be extremely helpful to review the high points, savor the personal connection with patients, and to replenish one’s well of energy 23 Conclusion The intent of the book has been to provide an overview of the emerging field of pediatric integrative medicine and to help the reader better understand which areas are supported by stronger research and where more data is needed The field has significant potential to improve the quality of preventive health in children, an urgent priority given the serious diseases reaching down into ever-younger age groups with significant emotional and financial costs Clinician self-care was added to reinforce emerging research that demonstrates how the health of the clinician impacts the health and wellbeing of their patient Burnout has reached epidemic proportions in clinicians worldwide and must be addressed in a coordinated fashion that involves the individual, the organization, and the overarching culture of medicine Integrative medicine provides a useful blueprint to craft a way forward, building on the unexpected blend of neuroscience and ancient meditation techniques that can help clinicians develop more skillful approaches to the daily stressors involved in authentic and caring patient interactions Foundations of health were covered with the goal of reviewing classic information and introducing emerging research in areas of nutrition science, selected dietary supplements, physical activity, mind–body therapies, sleep and environmental exposures, including how these foundational areas impact the prenatal environment and subsequently influence the child’s lifelong health The complementary approaches were covered with an eye to expanding the clinician’s worldview, if they were not already familiar with the fields, and to acknowledge the highly developed healing systems that exist throughout the world that can help enrich the practice of pediatrics in many ways Learning to assess benefit and risk of complementary therapies, and to understand the background and incorporate the training of a range of inter-professional colleagues is the next frontier of medicine The skillful clinician will appreciate this and move quickly to build strong collaborative interprofessional teams that will best serve the needs of the patient and their family Clinical applications were explored for a range of the most common pediatric conditions, yet still fall short on the distressing array of diseases faced by today’s children, including chronic pain The topics of allergy and asthma are among the most prevalent illnesses seen in children today; dermatologic conditions impact the child on levels that go far beyond the cosmetic; gut diseases similarly impact the child systemically, and emotionally, and require an approach that takes into account every element of a child’s life and lifestyle The upper respiratory illnesses are among the most common infectious diseases in the world, yet the conventional options to treat them in children can result in more harm than good Review of expanded integrative treatment options 422 Integrative Pediatrics: Art, Science, and Clinical Application for these common illnesses has the potential to keep a child out of danger’s way while they maximize their full inherent healing potential A significant focus of the book was to highlight the rising prevalence of mental health conditions in children and adolescents, and to help equip clinicians to offer these children more than just another prescription It is important for clinicians to be confident enough to move past the superficial in the mental health interview process so that they can fully understand the child’s situation and stressors Emerging research on the mental and physical implications of toxic stress means that clinicians must learn new approaches and be able to provide evidence-based counseling on stress reduction and self-regulation skills Pediatric clinicians are a lynchpin of the child’s care team, and as such must be ready to support the child’s progress and rally the family and community to their cause Review of the increasingly common neurodevelopmental conditions, ADHD and autism, updates the reader on new research, and also on which treatments are without merit so they may knowledgeably advise families who may be willing to try anything to alleviate their child’s suffering The chapter on obesity and metabolic syndrome offers both an overview of the serious state of the worldwide obesity epidemic, and introduces an innovative approach to modern preventive care that incorporates emerging research with a whole child approach to anticipatory guidance Finally, an example of an integrative intake is offered so that the clinician can begin to build new skills, or to deepen those already acquired, that will help them gain a multidimensional sense of the child and be ready to offer a full palate of evidence-based treatment options to help the child thrive Pediatric integrative medicine is a young field with incredible potential to help children and adolescents It is being carried forward by some of the best and brightest colleagues I have ever had the privilege to work with and it is my hope that significant shifts will occur in healthcare policy and insurance reimbursement that will support ongoing successes in the field Hilary McClafferty, MD, FAAP Index 5-HTP (5-hydroxytryptophan), 112, 162, 342 abdominal pain, chronic, 283, 289; see also functional abdominal pain; recurrent abdominal pain Academic Consortium for Integrative Medicine & Health, 12 acanthosis nigricans, 386–7, 402 acid suppressants, 303 acne, 272–7; predisposition to, 263; and tea tree oil, 187 ACOG (American College of Obstetrics and Gynecologists), 124 Activator Adjusting Instrument, 179–80 acupressure, 114, 176, 272; see also TCM acupuncture: and allergic rhinitis, 249; and anxiety, 345; and asthma, 256; and atopic dermatitis, 272; and autism, 371; as bioenergetic, 207–8; and IBS, 293; and inflammatory bowel disease, 298; licensing of, 202–3; prevalence of use, 201; research on, 202; and sleep, 114; see also TCM adenotonsillectomy, 116 ADHD (attention-deficit/hyperactivity disorder): and anxiety, 340; and atopic dermatitis, 266; and autism, 369; and Ayurveda, 200; and biofeedback, 84; clinical manifestation of, 360; comorbidities of, 360–1; conventional treatment of, 362–3; diagnostic criteria, 361–2; and environmental toxins, 126, 138–40; etiology of, 359–60; and food sensitivity, 41; and homeopathy, 195; integrative therapies for, 6, 363; and obesity, 386; and omega-3, 53–4; and osteopathy, 174; and physical activity, 68–9; prevalence of, 7–8, 359–60; progressive muscle relaxation for, 82; and sleep disorders, 113, 115, 162–3 adiponectin, 222, 393, 400 adolescents: and acne, 263; and depression, 8, 53; and EDCs, 124; foundations of health, 233–5; and migraine, 4, 196; mindfulness for, 88–9, 111; physical activity for, 68–70; and sleep, 106–10, 115 Affordable Care Act, 11, 392 air pollutants: and atopic dermatitis, 268; categories of, 126–7; clinical strategies for, 133–4; exposure routes, 127; impact on children, 125–6, 128 Air Quality Index, 126–7 ALA (alpha-linoleic acid), 37, 54, 229 alcohol abuse: among physicians, 16; and anxiety, 342 allergic march theory, 243 allergic rhinitis, 247–9; and atopic dermatitis, 264–5; and eosinophilic esophagitis, 43; etiology of, 131, 243–4, 247; prevalence of, 244, 247; and TCM, 202 allergies, 256–7; clinical manifestations of, 245; comorbidities of, 245; diagnostic criteria for, 246; etiology of, 243–4; prevalence of, 244; treatment of, 246–7; types of, 242; see also food allergy allostatic load, 76–7 aloe vera, 298 alternative therapies, see Complementary and Alternative Medicine (CAM) ambivalence, resolving, 71, 391 American Academy of Pediatrics (AAP): and antibiotics, 323; on beverages, 36; on breastfeeding, 32, 222–3; Council on Environmental Health, 124; on dextromethorphan, 321; and diabetes, 400, 402; on immunization, 218; on obesity, 379, 391; on pesticides, 138; on physical activity, 63, 66, 234; and screen time, 389; Section on Integrative Medicine, 12–13; on sleep, 115; Special Interest Group on Physician Health and Wellness, 13, 19; on spirituality, 92–3; and toxic stress, 330, 332–3; on vitamin D, 57, 58 amino acids, 38, 50, 275 amphetamine, 362 anaphylaxis, 41–2, 242, 244–5 anesthesia, 17, 27, 92, 175, 245 424 Index animal-assisted therapy, 80, 92, 371 antacids, 166, 303–4 antibiotics: and acne, 274; and obesity, 378–80, 394–6; and otitis media, 323; perinatal, 55, 221; and URI, 320 antidepressants, 39, 160–1, 286, 290, 342, 347–50 antihistamines, 193, 246, 248, 267–8, 320 antispasmodics, 154–6, 165, 290, 293 anxiety, 340–5; and abdominal pain, 284; and acne, 273; and ADHD, 361; and aromatherapy, 186, 188; and atopic dermatitis, 266; and autism, 370; and bacopa, 200; and bioenergetics, 207–8; and burnout, 17–18; complementary therapies for, 6; and IBS, 289; and massage, 177–8; and mind–body therapies, 21, 79–80, 82, 84, 86–91, 111; and physical activity, 68–9; pre-operative and procedural, 86, 116, 299, 345; and sleep, 106–7, 162 anxiety disorders, 340–1, 343; generalized, 109, 156 AP-FGIDS (abdominal pain-related functional gastrointestinal disorders), 283 apigenin, 113–14, 156 apolipoprotein, 383, 398 ARA (arachidonic acid), 53 aripiprazole, 370 aromatherapy, 185–9; and ADHD, 368; and anxiety, 343, 345; chamomile in, 155; for infants, 226 arsenic, 123, 127, 141 ASCH (American Society of Clinical Hypnosis), 87, 96 Asteraceae family, 114, 155–6, 159–60, 255 asthma, 249–57; and air pollution, 127–8, 130; and allergies, 42, 130, 243, 253; and atopic dermatitis, 265; and butterbur, 154–5; comorbidities of, 245, 251; and depression, 346; diagnostic criteria for, 246, 251; and homeopathy, 195–6; and massage, 178; and microbiome, 225; and obesity, 386; and physical activity, 63, 68; prevalence of, 7, 244; and progressive muscle relaxation, 82 atherosclerosis, 397–8, 400 atomoxetine, 363 atopic dermatitis, 263–72; and air pollution, 127, 131, 230; and allergies, 42, 243–4; and chamomile, 156; and homeopathy, 196; predisposition to, 263; and TCM, 202 atopic march theory, 243, 256, 264 ATSDR (Agency for Toxic Substances and Disease Registry), 124, 141 autism, 368–72; and air pollution, 131–2; and anxiety, 340; childhood prevalence of, 8; and environmental health, 122, 127; and melatonin, 113, 163; and microbiome, 225; and mind–body therapies, 89–90, 92; and vaccinations, 218 autism spectrum disorder (ASD), see autism autogenic training, 77, 80, 82–3, 95 autoimmune thyroid disorders, 308 Ayurveda, 199–200; curcumin in, 157; massage in, 176 azelaic acid, 274, 276 Bacopa monnieri, 200, 365 Bala Tantra, 199 bariatric surgery, 388 BEARS sleep evaluation tool, 106 bedtime routines, 109–10, 112–16, 230–1, 343, 351, 367 behavior change, 12, 70, 217, 227–8, 391–2, 418–19 belly breathing, 81, 334 beneficence, benzodiazepines, 39, 114, 157 bergamot, 188 Bifidobacterium: in newborn microbiome, 224–5; as probiotics, 55–6, 270, 310 bikes, stationary, 67 binge eating, 360, 379 bioenergetic therapies, 207–12, 226, 368 biofeedback, 76, 80, 82–5; and acne, 276; and atopic dermatitis, 268; and IBS, 292; resources for, 95 biological embedding, 224 birth defects: and air pollution, 126; and pesticides, 139 bitter gourd, 401 blood tests, 57, 123, 246, 284, 309 blue blocker, 110, 115, 367 BMI (body mass index): baseline for, 40; categories for children, 40; see also obesity bone strength, and physical activity, 68 BPA (bisphenol A), 123, 134–8, 140, 250, 359, 379, 394–8 breastfeeding, 222–3; and allergies, 244, 246; and healthy weight, 32; and music therapy, 91; and obesity, 394–5; toxin transfer through, 123, 137, 140 breath work, 76, 80–1; and ADHD, 368; and depression, 351; for mindful presence, 414; and sleep, 343 Bright Futures, 11, 217 bronchiolitis, 127, 131 bullying, 335–40; and ADHD, 361; and anxiety, 340; and autism, 370; and burnout, 16; and mind–body techniques, 79–80, 88, 232; and physical activity, 64; and sleep, 106; weight-based, 33, 387, 397–8 burnout: addressing, 18–22, 25; evaluating, 16, 23; factors contributing to, 16–17 Index butterbur, 4, 154–5; and allergic rhinitis, 249; and asthma, 255 bystander dynamics, 79, 335–9 caffeine: and abdominal pain, 287; and anxiety, 342; in energy drinks, 234; in green tea, 39; and obesity, 389; and sleep, 107–8 calcineurin inhibitors, 267 calories, average needs per day, 40, 41 Canada, health product regulation in, 51 cancer: and air pollution, 126–7, 132; childhood prevalence of, 8; see also pediatric oncology Cannon, Walter, 76 carbamazepine, 58, 155, 161 carbohydrates: hyperglycemic, 274; and IBS, 288; and nutrition, 34–5 carbon monoxide, 126–30, 129, 134 caretaker health, caretaker stress: and ADHD, 368; and autism, 372; and children’s stress, 224, 332; and inflammatory bowel disease, 299; and music therapy, 91; and obesity, 395–6; see also maternal stress; parental stress catechins, 39 CDRI 08, 200, 365 celiac disease, 43, 307–10; and atopic dermatitis, 269; and GERD, 304; and IBS, 289 cesarean delivery, 55, 219, 221, 224–6, 250, 378, 380 CFBAI (Children’s Food and Beverage Advertising Initiative), 379 CGMPs (Current Good Manufacturing Practices), 51 chamomile, 155–7; allergy to, 254; and anxiety, 344; for infants, 226; and sleep, 113–14 chest physiotherapy, 91 chia seeds, 54 child-centered care, 3–4 children with disabilities: bullying of, 335; caretakers of, 89, 390; and physical activity, 234; and sleep, 113 Chinese herbal medicine, 201–2; and allergic rhinitis, 249; and atopic dermatitis, 271; and lead, 153; and peanut allergy, 43; see also TCM CHIP (Children’s Health Insurance Program), 11 chiropractic, 179–82; inquiries about, 12; pediatric use of, 6; U.S licensing of, 10 cholesterol: and isoflavones, 39; and metabolic syndrome, 399; and obesity, 382–3, 385, 390, 397–8; and physical activity, 63, 69; and shift work, 20; and trans fats, 37 chronic illness: and depression, 346; and integrative medicine, 9; and mind–body 425 approaches, 234; pediatric, 3, 6–7; and sleep, 106 chronic pain: and depression, 347; and hypnosis, 86; and sleep, 106; and touch, 177, 210 chronic stress: and bullying, 330, 335; and burnout, 21–2; for caretakers, 89, 332, 372; maternal, 220, 222; mind–body skills for, 234, 334; newborn, 224; and obesity, 390; prenatal, 327; and systemic inflammation, 19 chrysanthemums, 156, 160, 344 cimetidine, 164, 304 cinnamon, 39, 401 circadian rhythms, 104, 107, 112, 162–3 cisapride, 303 climate change, 122, 242 clinicians, see physicians clopidogrel, 159 Clostridium difficile, 55, 292 coconut oil, 271 cognitive behavioral therapy, 9; and abdominal pain, 286, 291; and anxiety, 342–3; and depression, 351; and sleep, 111–12 commercialization of medicine, compassion, and empathy, 21–2 compassionate listening, 70, 418 compassion-based cognitive therapy, 22, 344 compassion-based meditation, 89, 95 compassion training, 16, 22 Complementary and Alternative Medicine (CAM): efficacy and safety of, 10; and inflammatory bowel disease, 296; pediatric use of, 6–7, 12–13; unethical promotion of, 9; use of term, Compositae family, 114, 254, 298 computerized tomography (CT), 248, 319 concussion, sports-related, 72 conduct disorders, 88, 126, 361 congenital heart defects, 127, 132 constipation: functional, 300–1; and GERD, 303–5; occult, 284 coping skills: and bullying, 336; and compassion fatigue, 22; and inflammatory bowel disease, 299; mind–body approaches to, 234, 335; and obesity, 395, 398; and positive stress, 326 CORD (Childhood Obesity Research Demonstration), 392 corticosteroids, 116, 246, 248, 295, 342 cough suppressants, 321–2 counseling: and ADHD, 363; and obesity, 391; see also nutrition counseling craniosacral technique, 173, 175–6 C-reactive protein, 107, 158, 285, 387, 400 criteria pollutants, 126–30, 129; health impacts of, 128; mechanisms of toxicity, 128 426 Index Crohn’s disease, 56, 58, 158, 294–9 culture of medicine, 17 curcumin, 157–9; and acne, 275; and inflammatory bowel disease, 298; and obesity, 393–4; as superfood, 39 Cushing’s syndrome, 273, 377 cyberbullying, 336 cyclosporine, 157, 161, 166 cystic fibrosis, 58, 87, 346 cytochrome P450 enzyme, 58, 157, 160, 350 cytokines, proinflammatory, 39, 68, 91, 157, 295, 298, 305, 310, 328, 379, 386, 401 daytime sleepiness, 107–9, 163, 385–6 DDT, 139 decongestants, 109, 193, 246, 248, 320, 322 delayed sleep phase disorder, 112–13, 162 dental caries, 36 depression, 345–51; and abdominal pain, 284; and acne, 273; and anxiety, 341; and atopic dermatitis, 266; and bullying, 337; and burnout, 16–17; and heart-rate variability, 85; and IBS, 289; maternal, 90, 284, 332; and obesity, 387; omega-3 in, 53; and physical activity, 68–9; and St John’s wort, 161; and toxic stress, 332 dermatitis: use of term, 263; see also atopic dermatitis dermatology, for children, 263 desks, sit-to-stand, 67 developing countries, air pollution in, 126 dextromethorphan, 321 DHA (docosahexaenoic acid), 52; and ADHD, 365; and depression, 349; and NALFD, 385; and obesity, 394, 396–7; plant-based sources of, 229; postpartum, 53, 222–3; in pregnancy, 52–3, 219–20 diabetes: childhood prevalence of, 7; and physical activity, 68; type-1, 32, 299, 308; type-2, 401–2; type-2 and nutrition, 33, 35, 38; type-2 and obesity, 381, 384; type-2 prevalence of, 7, 10 diarrhea: and abdominal pain, 286–7, 289, 295, 308; acute infectious, 55; and allergies, 245; and chamomile, 157; and ginger, 306; probiotics for, 225, 292; and proton pump inhibitors, 304; and URI, 319 DIDP (di-isodecyl phthalate), 137 dietary supplements: and ADHD, 364–5; for adolescents, 233–4; and anxiety, 342, 344; and asthma, 254; and autism, 371; botanical, 50, 153; and burnout, 19–20; for children, 40, 223–4, 231; and depression, 348–50; FDA definition of, 50–1; information resources on, 51–2; inquiries about, 12; in intake interview, 415; in pregnancy, 219–20; prevalence of use, 6, 50; regulation of, 51; and sleep, 112; in TCM, 202 diethylstilbestrol (DES), 134–5 dim light melatonin onset (DLMO), 163–4 Ding-chuan-tang, 202 DINP (di-isononyl phthalate), 137 disaster response medicine, 17 discrepancy, developing, 70, 391 diversified technique, 179–80 DNA methylation, 131, 134, 158, 219, 243–4 doctor–patient relationship, 93, 290 dogs, therapy, 92, 371 DSHEA (Dietary Supplement Health and Education Act), 51 dysfunctional voiding, 83–4, 87, 174 dyslipidemia, 217, 370, 382, 397–9, 402 dyspepsia: functional, 283, 301, 305; treatment for, 286 eating disorders, 233, 341, 361 echinacea, 159–60; allergy to, 254; Indian, 298; prevalence of use, 6, 153 eczema, see atopic dermatitis EDC (endocrine disrupting chemicals), 123–4, 134–5, 140; and ADHD, 368; adolescent exposure to, 234; health effects of, 135; and obesity, 379, 388, 394, 397–8; school-age children exposed to, 232; toddlers and preschoolers exposed to, 230 EEG, 92, 164, 362; neurofeedback, 84 EGCG (epigallocatechin-gallate), 39, 275, 277 elderberry, 323 electromyography, 83, 207 electronic medical records, 40, 366, 420 elimination diet: and eosinophilic esophagitis, 307; for food allergy, 43–4; for GERD, 304; and IBS, 291; six food, 44 E&M (Evaluation and Management) codes, 420 EMA (anti-endomysium), 309 emotional intelligence, 19, 22 emotional reactivity, 88, 331 empathic skills, 334, 339 empathy: and compassion, 21–2; and motivation, 70; for toddlers and preschoolers, 230 EMPOWER (Enabling Mothers to Prevent pediatric Obesity through Web-Based Education and Reciprocal Determinism), 399 Endocrine Society, on vitamin D, 57 energy drinks: adolescent use of, 234; and anxiety, 342; and dental caries, 36; and sleep, 107 enuresis, 84, 86, 180; nocturnal, 115, 202 environmental health: and ADHD, 368; for adolescents, 234; and burnout, 20–1; challenges in education, 125; in intake interview, 416–17; knowledge of, 11–13; Index and pediatric illness, 122–3; and pregnancy, 221; research and advocacy on, 124–5; for school-aged children, 232; for toddlers and preschoolers, 230 environmental pollution, and physicians, 141 environmental toxins: categories of, 125; children’s vulnerability to, 44, 123–4, 225; and newborns, 227; reducing exposure to, 11, 141–2; serious illness associated with, 122 eosinophilic infiltration, 43, 306 EPA (eicosapentaenoic acid), 52–3; and ADHD, 365; and depression, 349; plantbased sources of, 229 ephedra, 202 epigenetic regulation, 90, 158 epigenetics, and allergies, 243 equine-assisted therapy, 92 esophagitis: eosinophilic, 43, 306–7; erosive, 301, 303 essential oils, 185–6, 226 European Commission, 51 evening primrose oil, 270 evidence-based approach, 3–4 exercise: and anxiety, 343; and depression, 350; prescribing, 71–2; see also physical activity exergames, 70, 399 exhaust fumes, 126 eye contact, 218, 414 FAHF-2, 43 family education, 34; web-based, 399 fast food, 228–9, 269, 388, 395, 398 fat bias, 67 fats, and nutrition, 36–8 fatty acids, and nutrition, 37 FDA (Food and Drug Administration): on cough-cold medications, 320–1; and dietary supplements, 50–1, 153; and ephedra, 202; on essential oils, 185; and homeopathy, 192, 196–7 ferritin, 297, 360, 362, 364 fiber: and asthma, 252; and functional constipation, 301; and inflammation, 35 fibromyalgia, 210, 289 FICA Spiritual History Tool, 94 fight or flight response, 76, 326, 341 filaggrin, 243, 264 fish, DHA in, 219–20 fish oil: and acne, 276; and depression, 349; and inflammatory bowel disease, 296; prevalence of use, 6, 153; see also omega-3 fatty acids FITT (Frequency, Intensity, Type, Time), 71 flame retardants, 123, 134, 140 flatulence, 289, 300 flavonoids, 39, 156, 159, 305, 344, 401 flax, 37, 54, 229 427 FODMAP diet, 287–8, 290–1 folate, see vitamin B9 food addiction, 379–80 food advertisements, 32, 379 food allergy, 41–2: and ADHD, 364; and asthma, 42; and atopic dermatitis, 264–5; and autism, 370; and celiac disease, 309; diagnosis of, 42, 246; and immunizations, 244–5; prevalence of, 243–4; see also allergies food choices, parental modeling of, 396–8 food insecurity: and anxiety, 340; and obesity, 33, 378, 390; and stress, 327, 332 food sensitivity, 41 formaldehyde, 126, 131, 133 foundations of health, 11 fructose, 35–6, 288, 290, 389 functional abdominal pain, 283–8, 292, 305 functional medicine, 4–5 GABA (gamma-aminobutyric acid), 56, 114, 160, 344 galactans, 288, 290 gamma-linoleic acid (GLA), 270 gastroenteritis, 225; eosinophilic, 245 gastroenterology, 283 gastroesophageal reflux: and eosinophilic esophagitic, 43; etiology of, 302; and peppermint, 165–6; uncomplicated, 303 gastroesophageal reflux disease (GERD), 166, 251, 301–6 Gattefosse, Rene, 185 genistein, 39, 275 GERD, see gastroesophageal reflux disease ginger, 306 ginseng, 234, 342 glucocorticoid, 108, 328 gluten, sources of, 307–8 gluten-free diet, 43, 289–90, 309 gluten sensitivity, 43, 269, 307; non-celiac, 43–4, 289–90, 309 glycemic load, 35 glycyrrhetinic acid, 270 glyphosate, 123 green space, 232, 366 green tea, 39, 276–7 Growing Healthy study, 399 growth charts, 380–1, 395–8 guided imagery, 76, 80, 85–6; and anxiety, 343; and asthma, 255; for children, 230; and depression, 351; and obesity, 393; preoperative, 116; resources for, 95–6; and sleep, 112 gum, sugar-free, 303 gynecomastia, 186–7, 304 Hahnemann, Samuel, 193 hazardous air pollutants, 126 428 Index headache: and progressive muscle relaxation, 82; tension, 82–3, 166, 209; see also migraine headache healing touch, 207–8, 210–11; and anxiety, 345; and depression, 351 Health Promoting Schools (HPS), 66 healthy lifestyle: and ADHD, 363; in adolescence, 233; and anxiety, 345; and autism, 370; and IBD, 299; and obesity, 382; for physicians, 20, 22 healthy weight: maintaining in children, 34; for mothers, 219; as predictor of health, 31–3; in toddlers and preschoolers, 227–8; see also obesity heartburn, 165–6, 189, 293, 301–2, 306–7 heart rate variability monitoring, 84–5 herpes simplex, 266 histamine-2 receptor blockers, 166, 303–4 HIV-AIDS, 178, 209, 217, 226, 318 HLA (human leukocyte antigen), 43 HMBANA (Human Milk Banking Association of North America), 32 HMOS (human milk oligosaccharides), 222, 225 homeopathy, 192–7; and allergic rhinitis, 249; and atopic dermatitis, 271; as bioenergetic, 207; licensing, 10; and otitis media, 324; prevalence of use, 6; and URIs, 323 honey, 290, 322, 323 hops, 114 hospitals, environmental pollution in, 141 HPA (hypothalamic-pituitary-adrenal) axis, 56, 76, 220, 328, 333, 337, 340, 346 hygiene hypothesis, 244, 265 hypercalcemia, 59 hyperlipidemia, 107, 245 hypersensitivity, 43, 161, 284, 286 hypertension: and asthma, 245; and bullying, 337; and depression, 347; and obesity, 33, 219, 382, 384; and sleep disorders, 108 hypertriglyceridemia, 20, 54, 399, 401 hypervigilance, 78, 331, 340–1 hypnosis, 85–7; and abdominal pain, 291; and anxiety, 344; and asthma, 255; and depression, 351; and inflammatory bowel disease, 299; and obesity, 393; resources for, 96; and sleep, 111; steps in, 87; and toxic stress, 334 IgA, 308–9 IgE: and allergic rhinitis, 247–8; and atopic dermatitis, 263–5, 270; and eosinophilic esophagitis, 306; and food allergies, 41–2, 44, 243–4, 246, 285; and morin, 255 IGF-1, 275 IgG, 308–9, 363 immune system, and stress, 328–9 immunization, 217–18; and allergies, 244–5; in intake interview, 417; naturopaths opposed to, 198 immunotherapy, 247–9 INCA (Impact of Nutrition on Children with ADHD), 363 Incredible Years Series, 399 indoor air, 132–4, 138 infant formula, 53, 59, 123, 135–6, 222–3; and atopic dermatitis, 264 inflammation, systemic, 19–20, 348 inflammatory bowel disease, 294–9; and breast milk, 32; and curcumin, 39, 158–9; and depression, 346; and IBS, 289–90; and microbiome, 225; prevalence of, 10; and probiotics, 56 inflammatory diseases, and fiber, 35 inositol, 344 insomnia, 109; and anxiety, 343; complementary approaches to, 114; and melatonin, 163; see also sleep Institute of Medicine (IOM): “Best Care at Lower Cost” report, 11–12; on childhood obesity, 33; on vitamin D, 57 insulin resistance: and environmental pollutants, 136–7; and metabolic syndrome, 399–400; and omega-3, 52, 385, 393–4; and PCOS, 275, 384; and physical activity, 63; and vitamin D, 386; and yoga, 390 intake forms, 413–14 intake interview, 194, 413–19 integrative medicine: and burnout, 19; in clinical visit, 413; education about, 12–13; pediatric use of, 6–7; policy on, 10–12; practice models, 420; principles of, 3, 11; skills needed for, 23; strengths and challenges of, 8–10; treatment plan, 419–20; use of term, interleukin-6, 400–1 inter-professionalism, iberogast, 305 IBS (irritable bowel syndrome), 287–94; and AP-FGIDS, 283; and food sensitivity, 41; and hypnosis, 86; parental, 284; and peppermint, 165; and probiotics, 56, 287; and yoga, 287 IBS-constipation, 289–91, 300 ICD (International Classification of Disease), 338, 420 Kabat-Zinn, Jon, 21, 77 Kaumarabhritya, 199 Klein-Kemper model, 370–1 Krieger, Dolores, 208 Kunz, Dora, 208 Lactobacillus as probiotic, 55–6; and atopic dermatitis, 270; and functional constipation, 301; and IBS, 292; and Index inflammatory bowel disease, 297; and rotavirus, 225; and URI, 322 lactose, 285, 287–8, 290 lactulose/mannitol ratio, 292 land-based pollutants, 134–40 language, use of appropriate, 81 lavender oil, 186–8, 226 laxatives, 199, 290, 300–1 lead, 129, 132, 153 LEAP (Learning Early About Peanut Allergy), 42 lemon balm, 114, 156, 305, 344 leukotriene receptor antagonists, 116 licorice, 156, 270, 305 light, at night, 108, 112, 389 light therapy, 181, 274, 350 linoleic acid, 271 lipoproteins, 68, 382, 383, 398 listening, active, 414 listening skills, 413 locus of control, 18–19 low birth weight, 131, 133, 139, 220 L-tryptophan, 114 lupeol, 298 Lust, Benedict, 198 lymphoma, 32, 267, 308 magnesium, 304, 348, 360, 362, 364–5 manual medicine, 173 martial arts, 70, 390 massage: for infants, 177, 226–7; styles and techniques, 177 massage therapy, see therapeutic massage maternal distress, 329 maternal health, 219–22; see also pregnancy maternal obesity, 219, 378 maternal stress, 77, 220, 328–9, 359, 394 meal planning, 40, 361, 398–9, 415 measles-mumps-rubella (MMR) vaccine, 218, 245 media time, 229–30; see also screen time; television medical home, integrative, 3, 217, 348, 420 Mediterranean diet: and asthma, 252; and atopic dermatitis, 269; for children, 38, 40, 223, 228, 231, 233; and depression, 348; and metabolic syndrome, 400–1; and physicians, 20 MedWatch, 51 melatonin, 162–5; and autism, 371; and GERD, 306; prevalence of use, 6; and sleep, 112–13 mental health diseases: in children, 8, 326; and obesity, 387; prevalence of, 346 Mentgen, Janet, 210 menthol, 166, 322 metabolic syndrome, 63, 399–401; and corn syrup, 35; and curcumin, 158; and 429 depression, 347; and EDCs, 124; and NAFLD, 385; and obesity, 378–9, 381, 384; and sleep disorders, 108, 115; and toxic stress, 224, 331 methylphenidate, 362 metoclopramide, 303 microbiome: and allergies, 244; and asthma, 253; and depression, 346; and IBS, 288, 291; newborn, 224–5; and obesity, 378, 380; perinatal, 221; and probiotics, 55 migraine, abdominal, 283, 285 migraine headache: and anxiety, 341; and butterbur, 154–5; and homeopathy, 196; and IBS, 289; mind–body approaches to, 83; treatment approaches to, milk: cow’s, 44, 243–4, 264–5, 275, 307; human, 32; see also breastfeeding mind–body approaches: and abdominal pain, 287; and acne, 275–6; for adolescents, 234; appropriate language in, 81; and asthma, 255–6; and atopic dermatitis, 268–9; and burnout, 16, 21–2; for caretakers, 372; common therapies, 80; and depression, 351; history and physiology, 76–7; and IBS, 291–2; and inflammatory bowel disease, 298–9; in intake interview, 416; for migraine, 4; and obesity, 393; potential downsides, 78; in pregnancy, 220; psychologists providing, 9; research on, 77–8; resources for, 95–6; for school-age children, 232; for sleep, 111; for toddlers and preschoolers, 230; and toxic stress, 334–5 mindfulness, 87; and ADHD, 366–7; and anxiety, 343–4; and asthma, 255; capacity for, 24; and depression, 351; in pediatrics, 88; in pregnancy, 221; and resilience, 333; and toxic stress, 334 mindfulness-based stress reduction (MBSR), 87–9; and asthma, 255; and burnout, 21; and neuroplasticity, 77; and obesity, 393; and toxic stress, 334–5 mindfulness-based therapy for insomnia (MBTI), 111 mindfulness meditation: and burnout, 21; Kabat-Zinn’s introduction of, 77 mindful presence, 414 monoamine oxidase inhibitors, 39, 342 monounsaturated fats, 37 morin, 255 motivational interviewing: in integrative medicine, 23; and obesity, 391–2, 395–8; and physical activity, 65, 70–1 moxibustion, 201 MRE (magnetic resonance enterography), 295 MRI (magnetic resonance imaging), 164, 175, 319, 362 mucolytics, 320, 322 430 Index music therapy: and anxiety, 343, 345; and autism, 371; for infants, 226; as mind–body therapy, 80, 91 NALFD (non-alcoholic fatty liver disease), 384–5 narcolepsy, 105 nasal irrigation, 248–9, 322 NASH (nonalcoholic steatohepatitis), 385 National Health Interview Survey (NHIS): on acupuncture, 201; on bioenergetics, 207; on chiropractic, 179; and complementary therapies, 6, 172; on dietary supplements, 50, 52, 153; on melatonin, 162; on yoga, 89 naturopathy, 197–9 nausea: and anxiety, 341; and ginger, 306; and peppermint, 188 NCCIH (National Center for Complementary and Integrative Health), 4, 207; classifications of practices, 5; and naturopathy, 197 necrotizing enterocolitis, 32, 56, 225, 302, 304 Nei Yang Gong, 90 nervous system: parasympathetic, 226, 291, 334; sympathetic, 291 neurodevelopmental disorders: and melatonin, 113; prevalence of, 10; and sleep, 106 neurofeedback, 83–4, 367, 371 neuroplasticity: and anxiety, 340; and mindbody therapies, 77–8; and music therapy, 91; and toxic stress, 329 newborns: dietary supplements for, 50; foundations of health, 222–7; and menthol, 166; sleep times, 105; vitamin D for, 58; see also breastfeeding NHANES (National Health and Nutrition Examination Survey): and diabetes, 401; and obesity, 378, 382; on pesticides, 138–9, 359 NIAID (National Institute of Allergy and Infectious Disease), 41 nightmares, 79, 92, 331, 343 nitrogen oxides, 126, 128–32, 129, 266 nonmalfeasance, NSLP (National School Lunch Program), 38 nutrition: and acne, 274–5; and ADHD, 363–4; adolescent, 233; and asthma, 252; and atopic dermatitis, 269; challenges and obstacles, 31–2; and depression, 348; foundations of, 34–8; healthy pattern of, 38; and IBS, 290; and inflammatory bowel disease, 296–7; inquiries about, 12; in intake interview, 415; maternal, 219; newborn and infant, 222; practical integration, 40; for school-age children, 231; sound, 11, 31; for toddlers and preschoolers, 228 nutritional history, 40 nutrition counseling, 4, 9, 31, 34, 219, 382, 395–8, 400 obesity: and abdominal pain, 285; and ADHD, 360–1, 364; in adolescence, 233; and asthma, 253–4; and atopic dermatitis, 266, 268; and BPA, 136; and breastfeeding, 32; clinical manifestations of, 381–2; comorbidities of, 382–7; conventional treatment of, 387–91; coordination of care for, 391; and depression, 347; diagnostic criteria for, 380–1; and EDCs, 124; etiology of, 377–80; integrated treatment for, 392– 4; and microbiome, 225; policy changes on, 392; in pregnancy, 219; prevalence of, 7, 33–4, 377, 381; preventive measures, 392–9, 402; and sleep, 107 obesogenic home environment, 388 obsessive-compulsive disorder, 361–2 ointments, 185, 267 oligosaccharides, 55, 222, 225, 287, 290 omega-3 fatty acids: and acne, 275–6; and ADHD, 364–5; and asthma, 254; and atopic dermatitis, 270; in breast milk, 222; for children, 223, 229, 231; and depression, 348–9; and inflammatory bowel disease, 297–8; and obesity, 393; in pregnancy, 219 omega-6 fatty acids, 37, 52, 222, 275 online gaming, 346, 414 oppositional behavior disorders, 109, 361 oral food challenges, 42, 265 organochlorines, 54, 132, 139 organophosphates, 139, 368 OSA (obstructive sleep apnea), 105, 109, 115–16, 251, 385 osteopathy, 6, 172–5, 198 otitis media, 323–4; and breastfeeding, 32; and homeopathy, 194–5; and naturopathy, 198; and osteopathy, 174; and URI, 319 outdoor air, 126, 132–3, 230, 268 outdoor time: and air pollution, 133; and atopic dermatitis, 269; and sleep, 107, 110, 115 over-the-counter drugs, 137, 193, 308, 320–2 overweight children: and asthma, 245; and exercise, 68; stigmatization of, 67; see also obesity overweight trajectories, 33 ozone, 126, 128–31, 129 Paleolithic diet, 275 Palmer, Daniel David, 179 panchakarma, 199 PANDAS (pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections), 341 Index parasomnias, 105 parental stress: and obesity, 390, 395–8; see also maternal stress parenting programs, 363 “park prescription” movement, 366 particulate matter, 126–7, 130; and atopic dermatitis, 266; impact on children, 128, 131–2; toddlers and preschoolers exposed to, 230 patient autonomy, PCBs (polychlorinated biphenyls), 54, 132 PCOS (polycystic ovarian syndrome), 135–6, 234, 273, 275, 384, 402 peanut allergy, 42–4, 243–4, 264 Pediatric Academic Society, 124 Pediatric Environmental Health, 3rd Edition, 124 pediatric oncology: and massage, 178; and music therapy, 91 peer victimization, see bullying Pelargonium sidoides, 323 peppermint, 165–7, 188–9, 305 peppermint oil, 165–6, 185, 287, 293 perinatal health, 221 peroxisome proliferator-activated receptors (PPARs), 52, 254, 401 pesticides, 138–9; and ADHD, 359, 362, 368; as endocrine disruptors, 44, 134; phthalates in, 137; regulation of, 139; and VOCs, 133 petasins, 154, 255 PFCAs (perfluorocarboxylic acids), 227 phenobarbital, 58, 155 phenytoin, 58, 155, 159 phobias, 245, 248, 284, 340–1 phototoxicity, 186, 188 phthalates, 20, 44, 134, 137–8, 140; and asthma, 250; and cancer, 132 physical activity: and acne, 275; and ADHD, 366; for adolescents, 234; and asthma, 253; and atopic dermatitis, 268; and behavior change, 70; benefits of, 63–4; and burnout, 20; early steps in, 65–6; and IBS, 291; and inflammatory bowel disease, 299; in intake interview, 416; and obesity, 389–90, 395–8; obstacles to, 63, 72; in pediatric visit, 65; for physicians, 64–5; in pregnancy, 220; resources on, 72; role models for, 64–5; for school-age children, 231; in schools, 66–7; tailoring to needs, 67–8; for toddlers and preschoolers, 229 physical surroundings, safe, 11 physician coaching, 24–5 physician health, 23, 25, 217; see also burnout phytonutrients, 39 PIMR (Pediatric Integrative Medicine in Residency), 13 piperine, 158–9 431 plasma lipids, 382, 383, 398 plasticizers, 137, 368 plastics, environmental toxins in, 138 PNET (primitive neuroectodermal tumors), 132 pneumonia, deaths from, 318 PNFI (pediatric NALFD fibrosis index), 385 polycyclic aromatic hydrocarbons, 126, 132 polyethylene glycol, 300 polyunsaturated fats, 37, 52, 297 polyvinyl chloride, 137, 141 pomegranate, 276 positive stress, 78, 326 prayer, 80, 92–3, 255, 299, 371 prebiotics, 55, 221–2 pregnancy: phthalate exposure in, 137; probiotics in, 270; tobacco smoke during, 131; weight management in, 219 premature birth, 8, 177 preterm infants: and GERD, 302; healing touch for, 211; and massage, 177; and osteopathy, 174; and vitamin D, 58 preventive health: and integrative medicine, 8, 217; maternal, 9; pediatric, 10–11; for physicians, 19, 23 prioritization, 418 probiotics, 55–7; and acne, 277; and atopic dermatitis, 266, 269; and celiac disease, 310; and functional constipation, 301; and IBS, 292; and inflammatory bowel disease, 297; and NALFD, 385; in newborns, 225; prevalence of use, 52, 153; and URI, 322 problem-solving skills, 334, 338 procedural pain, 87, 91, 186 professionalism, 19 progressive muscle relaxation, 81–2; and ADHD, 368; and anxiety, 343; and asthma, 255; for children, 230; and depression, 351; and sleep, 110–11; and toxic stress, 334 prokinetics, 303 Propionibacterium acnes, 272, 276 propofol, 245 protein, and nutrition, 38 proton pump inhibitors (PPIs), 166, 225, 304 prudent diet pattern, 20, 38, 40, 219 pruritus, 187, 249, 264, 266–8, 272 psychobiotics, 56 PTQXT (Pei Tu Qing Xin Tang), 202 PTSD, 17–19, 23, 78, 85, 334 Puchalski, Christina, 94 pyridoxine, see vitamin B6 pyrrolizidine alkaloids, 154–5, 255 qi gong, 201–2, 207 RAGE (receptor of advanced glycation end products), 36 recurrent abdominal pain (RAP), 85, 283–7, 289, 291 432 Index reiki, 207–8, 211–12, 345, 371 relationships, stable responsible, 11 relaxation: autogenic, 99, 292; and inflammatory bowel disease, 299 relaxation response: and bioenergetics, 209; and massage, 177; and mind–body therapies, 77, 81; teaching, 334 REM (rapid eye movement), 104 renal disease, 58, 377, 386, 388 resilience: in integrative medicine, 11; for physicians, 13, 22, 24; and toxic stress, 233, 326, 328–9, 333–4 resistance training, 64, 220, 390, 408, 410–11 restless leg syndrome, 105, 109 retinoids, 274 rhubarb, 306 risperidone, 370 role models, 64, 72 Rome criteria, 283, 289, 301 rotavirus, 225, 292 Saccharomyces boulardii, 55, 225 St John’s wort, 160–2; and atopic dermatitis, 271–2; and depression, 350; and serotonin syndrome, 342 saline irrigation, nasal, see nasal irrigation SAMe, 342, 349 saturated fat, 34, 37, 40, 275 school-age children: and bullying, 106; depression in, 8; and environmental pollutants, 130; foundations of health, 231–2; and insomnia, 109–10; tai chi for, 90 school avoidance, 79, 331, 347 school belongingness, 338 Schultz, J H., 82 screen time: and autism, 370; and obesity, 388–9, 394–8; and physical activity, 63–6; and sleep, 227, 230–1, 343, 367; and toxic stress, 334 selenium, 271, 401 self-awareness, 19, 24, 89–90 self-blame, 337–8 self-care: modeling, 372; for physicians, 5, 21–2, 420–1 self-compassion, 22, 344 self-efficacy: in adolescence, 233; caretaker, 332; and exercise, 299; and guided imagery, 86; in integrative medicine, 9, 11, 23; mind–body techniques promoting, 80, 95, 111, 116, 255, 299; in motivational interviewing, 70–1; and physical activity, 69; and resilience, 333–4; and stress, 326 self-esteem: and bullying, 337; and mindfulness, 88; parental, 332 self-harm, 79, 336, 341 self-hypnosis, 86–7, 111, 276 self-regulation skills: for children, 11, 230, 232, 334; compassion as, 22; loss of, 107, 331; mind–body therapy as, 76, 88–9; and obesity, 399; for physicians, 19; and sleep, 109 sensory integration, 371 separation anxiety, 79, 109, 284, 330, 340, 343, 361 serotonin syndrome, 342, 349–50 sexual abuse, 329, 334, 361, 387 shame, 18, 23, 336–7 SIDS (sudden infant death syndrome), 32, 128, 133, 226 skin test, 44, 246, 248, 265 sleep: for adolescents, 234–5; age-specific recommendations, 110–11; caretaker impact on, 108; categories, 104; effects of reduced, 107; foundations of healthy, 109–10; herbal medicine for, 113–14; in intake interview, 416; in newborns, 225–6; normal times by age, 105; in pregnancy, 220; restorative, 20, 104; for school-age children, 232; for toddlers and preschoolers, 230; see also insomnia sleep disordered breathing, 107, 115, 220 sleep disorders: and anxiety, 343; in children, 104–5, 162; and depression, 347, 351; diagnosing, 105–6; metabolic symptoms of, 116 sleep hygiene: and ADHD, 367; and insomnia, 109, 113, 115 sleep latency, 113–14, 162–3, 371 sleep schedule, regular, 115, 227, 230, 232, 235, 394, 397 sleep screening, 106 slipped capital femoral epiphysis, 384 slow wave sleep, 104, 347, 351 smart phones, 32, 81, 108, 346, 367, 399 SNAP (Supplemental Nutrition Assistance Program), 38, 392 SNRIs (serotonin norepinephrine reuptake inhibitor), and anxiety, 342 social anxiety, 337, 340 social exclusion, 106, 337 social media: bullying on, 335; see also cyberbullying; food advertising on, 32, 233; and obesity prevention, 399; and sleep, 107 social skills, 67, 328, 335, 371 solid foods, introducing, 32, 223, 378, 395 soy isoflavones, 39 SPARK Physical Education program, 66 spirituality: in children, 94; in intake interview, 416; in integrative medicine, 12–13; as mind–body therapy, 80, 92–4; resources for, 96 sports massage, 177 SSRIs (selective serotonin reuptake inhibitors): and anxiety, 342; and St John’s wort, 161–2, 350; and sleep, 105, 109 Staphylococcus aureus, 187, 268, 271, 276 Index Steps to Growing Up Healthy, 392 stigma, and burnout, 17–19 Still, Andrew, 173, 175 stimulant medication: and ADHD, 359, 361–2, 365, 367; pediatric use of, 8; and sleep, 106, 109 Streptococcus spp.: as probiotics, 55; pneumoniae, 318; pyogenes, 323; thermophiles, 55–6 stress: behavioral markers of, 330–1; levels of, 78, 326; symptoms by age, 79; see also caretaker stress; chronic stress; toxic stress stress management: and abdominal pain, 287, 296; and asthma, 256; and atopic dermatitis, 268–9; and autogenics, 83; and obesity, 390–1, 395–8; and yoga, 90, 221, 256; see also mindfulness-based stress reduction stress response: and abuse, 78; priming of, 226 STRIP (Special Turku Coronary Risk Factor Intervention Project for Children), 400 substance abuse: and adolescence, 233; among physicians, 16; and anxiety, 341; and toxic stress, 331 sugar-sweetened beverages, 36, 334, 389, 392, 394–6 suicidal ideation: and acne, 273–4, 277; and ADHD, 361; among physicians, 16–17; and antidepressants, 342; and anxiety, 341; and asthma, 251; and bullying, 337; and depression, 345, 347; and toxic stress, 332, 337 suicide: and burnout, 17; as cause of death, 347; childhood prevalence of, 8; completed, 337, 341–2, 346–8, 351, 361, 387 sulfur oxides, 126–7, 129 sunflower oil, 37, 271 superfoods, 39 suprachiasmatic nuclei, 104, 162 Sutherland, W G., 175 Swedish massage, 177 synbiotics, 55 tai chi: as bioenergetic, 207; as mind–body therapy, 76, 80, 89–90; and obesity, 390; as physical activity, 67, 69; and sleep, 114; as TCM, 201–2 TCM (traditional Chinese medicine), 201–3 tea tree oil, 186–8, 276 television: and depression, 346; and overweight, 33, 136, 394; parents’ viewing habits, 64; and sleep, 108, 110, 227–8, 230 telomerase activity, increased, 21, 77 telomere length: and burnout, 20; and mind– body therapies, 77–8, 88–9; and omega-3, 52; and physical activity, 64; and sleep, 107 theophylline, 39, 159, 252 therapeutic massage, 176–9, 221, 345, 351, 368, 371 433 therapeutic touch, 207–10, 226–7, 345, 351, 368, 371 thermal biofeedback, 83 thyroid dysfunction, 135–6 tibia vara, 384 TNF-alpha, 310, 401 tobacco smoke: and allergies, 243; and asthma, 252; and atopic dermatitis, 266; health impacts of, 126–7, 131, 133 toddlers: and chamomile, 157; and environmental toxins, 127, 137; physical activity for, 65; and sleep, 105, 109 toddlers and preschoolers, foundations of health, 227–31 tolerable stress, 78, 326–7 toluene, 266 toxic stress, 78, 326–35; for adolescents, 233; for newborns, 224; prenatal, 327–8; research on, 11 trans fats, 37–8, 44, 275 tree nuts, 42–4, 244 tricyclic antidepressants, 161, 164 triglycerides, 20, 52–4, 68–9, 254, 298, 383, 385, 401 tTGA (anti-tissue transglutaminase), 309 typical day routine, 414 ulcerative colitis, 56, 158, 294–5, 297–9 United States Department of Agriculture: Healthy Eating Index, 31; Nutrition Guidelines, 34 URI (upper respiratory infections), 318– 23; allergies and asthma, 243; and breastfeeding, 32; and chiropractic, 182; clinical manifestation of, 319; and echinacea, 159; and homeopathy, 195 urinary tract infection, 300 Usui, Mikao, 211 vaccinations, see immunization valerian, 114, 344 Valnet, Jean, 185 VCUG (voiding cystourethography), 87 vesicoureteral reflux, 83, 300 vicarious traumatization, 17 violence: in media, 230; and toxic stress, 224, 329, 332 vitamin B6, 271, 276, 349, 364, 371 vitamin B9, 219, 348–9, 371 vitamin B12, 297, 304, 341, 349, 371 vitamin B complex: and autism, 371; and depression, 349 vitamin C, 254–5, 322, 350, 371 vitamin D: and acne, 276; and ADHD, 364–5; and allergies, 243; and asthma, 254–5; and atopic dermatitis, 269; for children, 224, 229, 231; and depression, 349; as dietary supplement, 52, 57–9; and 434 Index IBS, 293; and inflammatory bowel disease, 297; and obesity, 386, 394, 396–7 vitamin D2, 57, 59 vitamin D3, 57, 59 VOCs (volatile organic compounds), 131, 133–4, 141, 266 VSL#3, 56, 293, 297, 301 Wakefield, Andrew, 218 walnuts, 37, 54 warfarin, 39, 157, 159, 161 water pollution, 138, 140–1 weight stigmatization, 67 whey-based formulas, 264, 275 whole food approach, 38–9, 342 whole medical system, 192 WIC (Women, Infants, and Children), 11, 38, 378, 392 women physicians, 17 World Health Organization (WHO): growth curves, 33, 380; Health Promoting Schools, 66 yerba mate, 234 yoga: and abdominal pain, 287, 291; and ADHD, 366; and anxiety, 343; and asthma, 253, 256; and autism, 371; in Ayurveda, 200; breath work in, 81; and depression, 350; as mind–body therapy, 76–7, 89–90; and obesity, 390; as physical activity, 67, 69; in pregnancy, 221; and resilience, 333; and sleep, 114; and toxic stress, 334–5 zinc: and acne, 276; and ADHD, 360, 362, 364–5; and atopic dermatitis, 271; and depression, 350; and URI, 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