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PEDIATRIC PERSPECTIVE

A mainstream doctor finds a place for alternative medicine

The poor toddler had been hospitalized in the cardiac intensive-care unit for months for his heart defects, and neither his parents nor his doctors could help his irritability. He'd cry for hours at a time, and clutch his head in pain. Once in a while, the boy would smile, but then the headaches returned. Often, the on-call doctors gave him high doses of narcotics for the pain.

We needed help. At the parents' request, we consulted the ''alternative medicine" team at Children's Hospital. The recommendation: small magnets attached behind the toddler's ears. So on morning rounds, we discussed the size of his pulmonary arteries, surgical management, various cardiac parameters, metabolic needs, detailed medication orders -- and then the magnet therapy. A few eyebrows were raised, and sardonic looks exchanged. It seemed a little wishful, sticking some magnets to the child's head at one of the highest-technology units in the hospital.

There was no miracle cure: The child's parents thought the magnets helped a bit and were grateful the doctors had made an extra effort, but the headaches persisted and the narcotics continued.

The case made me wonder: Why do doctors and parents sometimes turn to alternative medicine for children? How should we feel about using these therapies?

As with our toddler's irritability, use of alternative therapy may indicate the lack of any better ideas. In other cases, their use reflects a lack of resources. For example, Masai children in Kenya (where I worked a few years ago) have unusual smiles, because they have some lower teeth ritually removed. The reason: Kids occasionally get tetanus, or ''lockjaw;" if the teeth are missinga straw can be pushed through the gap to allow feeding. Here, of course, we have tetanus vaccines.

Occasionally, a pediatrician's or parent's use of, say, acupuncture for asthma means they are ill-informed about current medical practice. Other times, alternative therapies reflect powerfully held cultural or generational beliefs (my mother, an Indian immigrant, subjected me mercilessly to menthol steam baths for any illness, just as her mother had done to her). Finally -- and most concerning -- a parent's refusal of pediatric vaccines or avoidance of well-child care, for example, sometimes means doctors failed to provide care they can understand.

Perhaps that's why a recent report in the Journal of the American Medical Association found that almost 42 percent of Americans use herbal or dietary supplements and visit alternative practitioners, at a cost of $27 billion per year. Many bemoan impersonal medical care and believe that herbal remedies or ancient treatments are more effective and less toxic;They point to the uses of foxglove for heart ailments, cinchona bark for malaria, and coca leaves for altitude sickness.

To evaluate its worth, one ultimately must define ''alternative" medicine. Some medical literature suggests, for example, that magnetic fields can help foot pain and bone healing. Are magnets now an alternative therapy or a modern pharmaceutical? The National Institutes of Health doesn't offer much help; it says ''alternative" means medicine that is not ''practiced by holders of M.D. [degrees] and by their allied health professionals." By this definition, anything a doctor does can't be ''alternative."

To frame this debate constructively, in 1998 the Journal of the American Medical Association editorialized, ''There is no alternative medicine. There is only scientifically proven, evidence-based medicine supported by scientific data or unproven medicine, for which scientific evidence is lacking. Whether a therapeutic practice is 'Eastern' or 'Western' [is] largely irrelevant."

Thus, the useful way to classify therapies is not alternative vs. conventional, but proven vs. unproven. This is a relatively new way of evaluating health care. The controlled clinical trial--where carefully selected patients are given novel medications and then compared to those who either take placebos or undergo the usual therapies--was not practiced until the mid-1900s. Without clinical trials, dangerous and useless practices flourish.

During a botanical research project in Kenya, I interviewed healers about treatments for chira, a common wasting disease. In an area with epidemic AIDS, tuberculosis, and parasitic infections -- which all cause weight loss -- chira was a catchall diagnosis. Different healers used varying doses of herbs, dissimilar methods of preparation, and an inconsistent nomenclature to identify plants. A systematic evaluation of the herbal remedies was impossible, but every healer reported perfect success. Until the advent of clinical trials, American medicine was much like this.

Well-informed physicians are usually open to, say, the clinical trial-supported use of St. John's Wort for mild depression or acupuncture for certain pain syndromes, but are suspicious of aura fluffing for cancer or magnets for headaches. Likewise, they endorse the proven use of penicillin for strep throat but don't support the unproven practice of treating viral respiratory infections with amoxicillin.

In addition to creating a misleading distinction between ''alternative" and ''modern" medicine, some people also advance the metaphysical notion that the root of disease is mental or spiritual weakness. People like best-selling author Dr. Andrew Weil think illness is largely within our control -- when we lose control of our lives, we get ill; when we pay close attention to our bodies, we can overcome most diseases. I spend most of my work life helping children who were born with deformed hearts, so I find this an odd notion.

Of course, mental well-being is critical to health. At its core, the popularity of unproven therapies arises from the need for hope and human connection. And this is where we doctors have a chance to improve care.

Though the holistic doctors at Children's Hospital may endorse unusual therapies, they also spend an extraordinary amount of time exploring the patient's belief system. They pull up a chair and don't look hurried. They enter the patient's world. Their reports often contain information other doctors never uncover -- fears about spirits, unusual beliefs about side effects, and more.

I remember how my father, who suffered from a terminal lung disease, once took me along for his acupuncture appointment. The man made us tea , and spent an hour talking with my father before inserting the thin needles. As he lay quietly, my father's face had a solemn peace that no doctor had ever produced.

Dr. Darshak Sanghavi, a clinical fellow at Children's Hospital and Harvard Medical School, can be reached at sanghavi@post.harvard.edu.  

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