JA Family Education Day 2013 Presentation by Dana Gerstbacher, MD (Lucile Packard Children's Hospital at Stanford)

1. Integrative Pediatric
Rheumatology:
How to help parents make the best
decisions for their children.
Dana Gerstbacher, MD
April 20, 2013

2. 2
Goals
 Define Complementary and Alternative
Medicine and Integrative Medicine
 Review specific therapies used in Pediatric
Rheumatology

3. 3
About Me
 Duke undergrad in Biology, Tufts University School
of Medicine
 LPCH Pediatric Residency
 LPCH Pediatric Rheumatology Fellowship
 University of Arizona Fellowship in Integrative
Medicine
 Joined Whole Child Wellness, as a part-time
integrative pediatrician in Oct 2010
 Part-time Pediatric Rheumatology at Stanford

4. What is Pediatric Rheumatology?
4

5. What is the immune system?
 The body’s defense against disease
causing organisms, malfunctioning cells,
and foreign particles
5

6. THE BOY WITH A THORN IN HIS
JOINTS
The New York Times Magazine
By SUSANNAH MEADOWS
Published: February 1, 2013

7. 7
Don’t Take Medical Advice From the
New York Times Magazine
The dangerous chemophobia behind its popular story
about childhood arthritis.
 Posted Thursday, Feb. 7, 2013, at 3:52 PM
 By Michelle Francl
 www.slate.com

8. 8
Chemophobia
 An irrational fear of chemicals
 “So here is my best advice to keep you from
succumbing to the chemophobia pandemic: One,
everything is a chemical. Two, don’t take medical
advice from a magazine writer, however impassioned
and well-intentioned, however popular her story is on
the New York Times’ “most read” list, who trusts a
massage therapist over medical experts. And three,
there are risks to all chemicals, even the ones with
friendly names like Montmorency cherry juice and
four-marvels powder.” - Michelle Francl

9. What is Integrative Pediatrics?
“Integrative Medicine is the practice of medicine that
reaffirms the importance of the relationship between
practitioner and patient, focuses on the whole person,
is informed by evidence, and makes use of all
appropriate therapeutic approaches, healthcare
professionals and disciplines to achieve optimal
health and healing”
Consortium of Academic Health Centers for Integrative
Medicine, May 2005

10. 5
 Complementary and Alternative medicine (CAM)
 A group of diverse medical and health care
systems, practices, and products
 Not considered part of conventional medicine
 Some scientific evidence exists regarding CAM
therapies
 For most, questions of safety and efficacy persist
 Integrative Medicine combines mainstream medical
therapies and CAM therapies for which there is some
high-quality scientific evidence of safety and
effectiveness.
http://nccam.nih.gov/health/whatiscam/

11. 7
Enhance the
mind’s capacity
to affect bodily
function and
symptoms
Chiropractice
Osteopathy
Massage
Alternative
medical
systems
Mind-body
interventions
manipulative
& body-based
methods
Energy
therapies
Homeopathic
Naturopathic
Traditional
Chinese Medicine
Ayurvedic Medicine
Dietary supplements
Herbs
Foods
Vitamins
Natural
substances
Biofield therapy
Bioelectro-
magnetic
therapy
Biologically
-based
therapies
http://nccam.nih.gov/

12. Modalities
• Functional Medicine
• Herbal Medicine
• Homeopathy
• Traditional Chinese Medicine
• Herbs and acupuncture/acupressure
• Essential Oils/Aromatherapy

13.  Toronto Sick Kids
 1) the prevalence of current use of CAM by children
with rheumatic disease
 2) the types of CAM currently used
 3) any differences in the reported use of CAM
between patients responding to a survey given in the
clinic compared to one sent to the home
 141 patients
 90 (64%) used one CAM therapy
 45 of the 90 (50%) used more then one therapy
Arthritis Rheum. 2003 Feb 15;49(1)

14.  Multiple studies show that the most popular CAM
treatments are vitamins, herbal medicines, and dietary
supplements
 Evidence is lacking even for the most popular and each
remedy needs to be individually studied
 Even where evidence is promising, most studies are in
adults
 However, the Institute of Medicine states: “the same
principles and standards of evidence of treatment
effectiveness apply to all treatments whether currently
labeled as conventional medicine or CAM”.
 Funding for research in CAM is growing but still
relatively small in total amount (NIH/NCCAM)

15. NHIS: PEDIATRIC SUB-GROUP
ANALYSIS
 Characteristics of pediatric CAM users
 More likely to take prescription medications
 At least one parent who used CAM
 Chronic conditions such as anxiety or stress,
musculoskeletal conditions, dermatologic conditions, or
sinusitis.
 Research is required to guide pediatricians in making
recommendations on CAM modalities for children
including potential risks and/or benefits and
interactions with conventional therapies
15

16. Functional Medicine/Holistic
Nutrition
What is Functional Medicine?
Functional medicine is a science-based field of health care that is
grounded in the following principles:
Biochemical individuality describes the importance of
individual variations in metabolic function that derive from
genetic and environmental differences among individuals.
Patient-centered medicine emphasizes "patient care" rather than
"disease care," following Sir William Osler’s admonition that "It
is more important to know what patient has the disease than to
know what disease the patient has."
Dynamic balance of internal and external factors.

17. Homeopathy
 “Like Cures Like”
 An energy medicine
 Treats the unique individual
 Stimulates the innate healing capacity
 Administering and dosing the remedy
 What to Expect
 Safety
 Combination Remedies

18. Herbal Medicine
Natural ≠ Safe (necessarily)
 Herbs are natural drugs
 Contaminants
 Buy from a reputable manufacturer!
 Kan, Gaia, HerbPharm, Eclectic Kids, Herbs for Kids
 Side effects and toxicities
 Herb-drug interactions
 Herb-herb interactions

19. Acupressure
Loving touch
Effective means of symptom relief
Uses acupuncture points

20. Essential Oils
Direct stimulation of the brain
Many therapeutic actions
Use only natural and pure essential oils
 Elizabeth van Buren
Ways to use essential oils
 Diffused
 Inhaled
 In bath
 Massaged

21. JIA and Functional Medicine –
Reduce Inflammation
 Increase omega-3 fatty acids (EPA and DHA)
 Anti-inflammatory, Immune supporting, Lowers
triglycerides, Protects again heart disease, Stabilizes mood
 Wild salmon, cod liver oil/fish oil, pumpkin seeds, nuts
 www.epa.gov/fishadvisories/advice/
 Good oils – olive, avocado, walnut, grapeseed, flaxseed,
coconut, hempseed
 Increase GLA
 Anti-inflammatory omega-6 fatty acid
 Borage oil, black currant oil, evening primrose oil

22. JIA and Functional Medicine –
Reduce Inflammation
 Increase probiotics
 “good bacteria” – fermented foods, kefir, yogurt, miso
 Klaire, Metagenics, Pharmax, Jarrow, Natren, Udo’s Choice
 Support detoxification; support immune system; make
vitamins; antioxidant, anticancer, antimicrobial effects
 Increase antioxidant-rich foods
 Eat a “rainbow”
 Berries, broccoli, grapes, carrots, pomegranates, spinach,
garlic

23. Antioxidant-Rich Foods
Antioxidant Good Food Sources
Vitamin C Citrus fruits and their juices, berries, dark green vegetables
(spinach, asparagus, green peppers, brussel sprouts,
broccoli, watercress, other greens), red and yellow peppers,
tomatoes and tomato juice, pineapple, cantaloupe, mangos,
papaya and guava.
Vitamin E Vegetable oils such as olive, soybean, corn, cottonseed and
safflower, nuts and nut butters, seeds, whole grains, wheat,
wheat germ, brown rice, oatmeal, soybeans, sweet
potatoes, legumes (beans, lentils, split peas) and dark leafy
green vegetables.
Selenium Brazil nuts, brewer’s yeast, oatmeal, brown rice, chicken, eggs,
dairy products, garlic, molasses, onions, salmon, seafood,
tuna, wheat germ, whole grains, most vegetables.
Beta Carotene Variety of dark orange, red, yellow and green vegetables and
fruits such as broccoli, kale, spinach, sweet potatoes,
carrots, red and yellow peppers, apricots, cantaloupe and
mangos.

24. JA and Functional Medicine –
Reduce Inflammation
Reduce pro-inflammatory foods
 Reduce omega-6 fatty acids
 Saturated fats, beef, poultry
 Reduce gluten
 World’s Healthiest Foods “Eat Right for Your
Condition” (www.whfoods.com)
 Gluten  wheat, rye, barley, kamut, spelt, ?oats
 Non-gluten grains – buckwheat, quinoa, rice, corn,
millet, amaranth
 Reduce dairy

25. JA and Functional Medicine –
Reduce Inflammation
Reduce pro-inflammatory foods
 Reduce preservatives and additives
 Avoid nightshades
 Eggplant, tomatoes, bell peppers, white
potatoes
 Reduce insulinogenic carbohydrates
 Eliminate trans fats
 Institute of Medicine “NO safe level” for
trans fats

26. Food Allergy vs. Sensitivity
 Food allergy
 Ig-E reaction to protein  histamine  hives,
wheezing, diarrhea, life-threatening anaphylaxis
 Immediate reaction, within hours
 Not very common (<5% of the population)
 May be permanent
 Food sensitivity
 IgG reaction, not necessarily to protein
 Delayed reaction, up to 48-72 hours
 Very common  up to 25-50% of population
 Can be cured
 Underlying cause  LEAKY GUT

27. Food Allergies
 Most common food allergens
 Cow’s milk, wheat, soy, egg whites, shellfish,
fish, peanuts, tree nuts, chocolate, tomatoes,
citrus, corn, berries, sugar, food additives
 Least allergenic foods
 Apples, apricots, asparagus, avocados, barley,
beets, broccoli, carrots, cauliflower,
cranberries, dates, grapes, honey, lamb, lettuce,
mangoes, oats, papayas, peaches, pears,
raisins, rice, salmon, squash, sweet potatoes,
lamb
 www.askdrsears.com

28. What is a Healthy Gut?
Healthy small
intestine cells with
no leak between
them allow small
digested food
particles into the
bloodstream, but
keep larger
allergenic particles
out
With Permission, Patrick Hanaway, MD,
Genova Diagnostics

29. What is a Leaky Gut?
Damaged small
intestine cells with
leaks let larger
allergenic food
particles into
bloodstream and
don’t efficiently
allow digested
nutritious food
particles in
With Permission, Patrick Hanaway, MD,
Genova Diagnostics

30. Altered
Intestinal
Permeability
Poor Dietary Choices
Stress & Emotions
Infection
Celiac DiseaseCeliac Disease
Systemic Disease
Toxic Exposure – chemicals,
antibiotics, ?vaccines
Food Allergy
Malnutrition
Toxic Overload
Elevated Total
Toxic & Antigenic
Burden
Low Stomach Acid- Zantac
Systemic Disease –Systemic Disease –
Asthma, Eczema,Asthma, Eczema,
ADD/ADHD, Autism,ADD/ADHD, Autism,
Autoimmune illness,Autoimmune illness,
IBS/IBD, arthritis, CFIDSIBS/IBD, arthritis, CFIDS
AbnormalAbnormal
bacteria/yeast –bacteria/yeast –
antibiotic useantibiotic use
With Permission, Patrick Hanaway,
MD, Genova Diagnostics

31. Prevent Leaky Gut
 Avoid antibiotics – kill “bad” and “good”
bugs
 Avoid zantac – impairs digestive capacity
 Avoid chemicals – pesticides, additive,
preservatives, phenols, sulfites

32. What if I suspect my child has food
sensitivity allergies/sensitivities?
 Elimination diet
 http://www.askdrsears.com/html/4/T041800.asp
“Tracking Down Food Allergies”
 Food allergy testing
 Immediate (IgE) allergies
 RAST – lots of false negatives
 Skin test – lots of false positives
 Delayed (IgG) sensitivities
 Alletess IgG panel (www.foodallergy.com)
 Optimum Health Resource home testing kit (
www.optimumhealthresource.com)

33. What if I suspect my child has food
allergies/sensitivities?
 Healing the leaky gut
 Remove the allergenic food for 2-3 months
 Repair the leak
 Omega-3 essential fatty acids
 Probiotics
 Prebiotics
 chicory, Jerusalem artichoke, asparagus, garlic, arabinogalactan
 Glutamine
 N-acetylglucosamine
 Anti-inflammatory herbs
 Quercetin, ginger, turmeric, rosemary, marshmallow, slippery elm
 www.functionalmedicine.org

34. JIA and Herbal Medicine
 Boswellia
 Powerful anti-inflammatory effects
 Inhibits pro-inflammatory cytokines.
 Curcumin (Turmeric)
 Anti-inflammatory
 ‘Herbal Motrin’
 Quercetin
 Powerful phytochemical/anti-oxidant
 Anti-inflammatory
 Anti-histamine
 White Willow Bark
 Source of salicylic acid (aspirin)
 Rosemary
 Ginger
 Stinging nettle

35. JIA and Homeopathy
 Rhus toxicodendron
 “Creaky gate remedy”, stiffness and pain with first
movement, better with continued motion but worse
with overuse, better with heat
 Ledum palestre
 Cracking in joints, worse with warmth, better with
cold applications, affected area feels cold, esp ankles
 Bryonia alba
 Worse with any movement, better with deep
pressure, irritable (“grumpy bear remedy”)
 Arnica montana
 Bruised feeling, sore after overexertion, worse with
slightest touch or movement, wants to be left alone

36. JIA and Acupuncture
 Pain relief
 Different “local” points used depending on
location of pain/swelling
 Strengthen immune system
 Qi-tonifying points
 Relaxation

37. JIA and Essential Oils
 Lavender
 Anti-inflammatory, analgesic, calming
 Juniper
 Analgesic
 Rosemary
 Anti-inflammatory
 Stress Relief
 Ylang ylang
 Clary Sage
 Geranium
 Roman Chamomile
 Neroli

38. JIA and Lifestyle
 Exercise
 Reduce stress!
 Yoga
 Meditation
 Qi Gong

39. Arthritis Foundation response to
the NYT article
“We want to emphasize that comprehensive
medical care based on strong evidence is the
best and safest approach to the management
of children with Juvenile Arthritis.”
–Coleen Ryan and Dr Helen Emery
39

40.  Decision making can be generally placed in four
categories
 Safe and effective
 Safe but effectiveness unknown
 Unsafe but possibly effective
 Unsafe and likely ineffective
 “Why? What’s the evidence? How was it obtained? Is it
plausible? And above all, what are the risks?” - Michelle Francl

41. Contact Information
Dana Gerstbacher, MD
Elisa Song, MD
Donna Ruiz, MD
Whole Child Wellness, Inc.
1601 El Camino Real
Belmont, CA 94002
650-595-KIDS (5437)