Bent, S., Padula, A., Moore, D., Patterson, M., and Mehling, W. (2006). Valerian for sleep: a systematic review and meta-analysis. Am J Med , 119 (12), 1005 \200\2231012 . Laboratory investigations done to assess for anemia, infec- tion, thyroid dysfunction, and autoimmune diseases were all normal. Her RBC magnesium level was low at 3.5 mg/dL (normal 4 .7 \200\2237.0 mg/dL), homocysteine level high at 12 mol/L (normal <8 mol/L), 25-hydrox yvitamin D level low at 17 ng/ml (ideal 50 \200\22360 ng/ml), and coenzyme Q 10 level was l ow-normal at 0.6 mcg/ml (normal 0.5 \200\2231.5 mcg/ml). Bhatty, S.A., Shaikh, N.A., Irfan, M., Kashif, S. M., Vaswani, A. S., Sumbhai, A, et al . ( 2010). Vitamin D defi ciency in fi bromyalgia. J Pak Med Assoc , 60 (11), 949 \200\223951 . Bruijn, J., Duivenvoorden, H., Passchier, J., Locher, H., Dijkstra, N., and Arts, W. F. (20 10). Medium-dose ribofl avin as a prophylactic agent in children with migraine: a prelimina ry placebo-controlled, randomized, double- blind, cross-over trial Cephalalgia , 30 (12), 1 426 \200\2231434 . She was started on vitamin D 3 4000 IU daily, magnesium malate 500 mg twice daily, and CoQ 10 300 mg daily for the obvious defi - ciencies and for their known eff ects on headache pa in and myal- gias. She was also started on vitamin B-50 complex to provide the cofactors ne cessary for enzyme and energy production. She was encouraged to continue a healthy diet of lean meats, fresh fruits, and vegetables to provide other essential micronutrients. For sle ep and mood, she started 5-HTP 100 mg before bedtime to boost serotonin and melatonin produ ction, instructed on sleep hygiene strategies, encouraged to maintain a routine sleep/wake schedule every day, and asked to minimize naps to only 30 min a day. She was started on a l ow-intensity exercise program of stretching followed by walking 15 min day for the fi rst w eek. Th e time was increased only 5 min each week so as not to over-exert and trigger more fatigue/pain. Brzezinski, A. (1997). Melatonin in humans. N Engl J Med , 336 , 186 \200\223195 . Buckle, J. (1999). Use of aromatherapy as a complementary treatment for chronic pain. Altern Th er Health Med , 5 (5), 42 \200\22351 . Cady, R. K., Goldstein, J., Nett, R., Mitchell, R., Beach, M. E., and Browning, R. (2011). A double-blind placebo-controlled pilot study of sublingual feverfew and ginger (LipiGesic \204 M) in the treatment of migraine. Headache , 51 (7), 1078 \200\2231086 . Cerny, A. and Schmid, K. (1999). Tolerability and effi cacy of valerian/ lemon balm in heal thy volunteers: a double-blind, placebo-controlled, multicentre study. Fitoterapia , 70 (3) , 221 \200\223228 . Ciacci, C., Franceschi, F., Purchiaroni, F., Capone, P., Buccelletti, F., Iacomini, P., et al . (2011). Eff ect of beta-glucan, inositol and digestive enzymes in GI symptoms of patie nts with IBS. Eur Rev Med Pharmacol Sci , 15 (6), 637 \200\223643 . Clarke, N. M. and Page, J. E. (2012). Vitamin D defi ciency: a pediatric orthopedic perspective. Curr Opin Pediatr , 24 (1), 46 \200\22349 . Cond , M., Posar, A., Arbizzani, A., and Parmeggiani, A. (2009). Ribofl avin prophylaxis in pediatric and adolescent migraine. J Headache Pain , 10 (5), 361 \200\223365 . Suzanne returned for follow up 2 months later and was consid- erably better by her report. She was now sleeping consistently 10 CHAPTER 59 complementary drugs \200\224herbs, vitamins, and dietary supplements 621 Heuschkel, R., Afzal, N., and Wuerth, A. (2002). Complementary medicine use in children and young adults with infl ammatory bowel disease. Am J Gastroenterol , 97 (2), 382 \200\22338 8 Cordero, M. D., De Miguel, M., Moreno-Fern ndez, A. M., Carmona L pez, I. M., Garrido Maraver, J., Cot n, D., et al . (2010). Mitochondrial dysfunction and mitophagy activat ion in blood mononuclear cells of fi bromyalgia patients: implication in the pathogenesis o f the disease. Arthritis Res Th er , 12 , R17 . Hills, J. M. and Aaronson, P. I. (1991). Th e mechanism of action of peppermint oil in GI smooth muscle. Gastroenterology , 101 , 55 \200\22365 . Cordero, M. D., Alcocer-G mez, E., de Miguel, M., Cano-Garc a, F. J., Luque, C. M., F ern ndez-Riejo, P., et al . (2011). Coenzyme Q(10): a novel therapeutic approach for fi bromyalgia? Case series with 5 patients. Mitochondrion , 11 (4), 623 \200\223625 . Hormann, H. P. and Korting, H. C. (1994). Evidence for the effi cacy and safety of topical herbal drugs in dermatology: part I: anti-infl ammatory agents. Phytomedicine , 1 , 161 \200\223171 . Hoshino, K., Ogawa, K., Kitazawa, R., Nakamura, Y., and Uehara, R. (1998). Ionized magnesiu m level in whole blood of healthy Japanese children. Pediatrics International , 40 (2), 116 \200\223121 . Cordero, M. D., Cano-Garc a, F. J., Alcocer-G mez, E., De Miguel, M., and S nchez- Alc zar, J. A. (2012) Oxidative stress correlates with headache symptoms in fi bromyalgi a: coenzyme Q10 eff ect on clinical improvement. PLoS One , 7 (4), e35677 . Available at: < http://www.plosone.org>. Kakuda, T., Yanase, H., Utsunomiya, K., Nozawa, A., Unno, T., and Kataoka, K. (2000). Prote ctive eff ect of gamma-glutamylethylamide (theanine) on ischemic delayed neuronal death in gerbils. Neurosci Lett , 289 , 189 \200\223192 . Kemper, K. J., Vohra, S., and Walls, R. (2 008). Th e use of complementary and Demirkaya, S., Vural, O., Dora, B., and Top uo \237 lu, M. A. (2001). Effi cacy of intr avenous magnesium sulfate in the treatment of acute migraine attacks. Headache , 41 (2), 17 1 \200\223177 . alternative medicine in Pediatrics. Pediatrics , 122 , 1374 \200\2231386 . Di Rosa, G., Attina, S., Spano, M., Ingegneri, G., Sgr , D. L., Pustorino, G., et al . ( 2007). Effi cacy of folic acid in children with migraine, hyperhomocysteinemia and MTHFR po lymorphisms. Headache , 47 , 1342 \200\2231351 . Kennedy, D. O., Scholey, A. B., Tildesley, N.T, Perry, E. K., and Wesnes, K. A. (2002). Mod ulation of mood and cognitive performance following acute administration of Melissa offi ci nalis (lemon balm). Pharmacol Biochem Behav , 72 , 953 \200\223964 . Eisinger, J., Plantamura, A., and Ayavou, T. (1994). Glycolysis abnormalities Kline, R. M., Kline, J. J., Di Palma, J., and Barbero, G. (2001). Enteric coated, pH-depend ent peppermint oil capsules for the treatment of irritable bowel syndrome in children. J Pe diatr , 138 , 125 \200\223128 . in fi bromyalgia. J Am Coll Nutr , 13 (2), 144 \200\223148 . Eisinger, J. (1998). Alcohol, thiamin and fi bromyalgia. J Am Coll Nutr , 17 (3), 300 \200\223302 . Ko, W. C., Lei, C. B., Lin, Y. L., and Chen, C. F. (2001). Mechanisms of relaxant action of S-petasin and S-isopetasin, sesquiterpenes of Petasites formosanus, in isolated guinea pig trachea. Planta Med , 67 (3), 224 \200\223229 . Ellaway, C. M., Williams, K., Leonard, H., Higgins, G., Wilcken, B., and Christodoulou, J. (1999). Rett syndrome: randomized controlled trial of L-carnitine. J Child Neurol , 14 , 16 2 \200\223167 . Food and Drug Administration. (2012). Generally recognized as safe (GRAS) . Available at: < http://www.fda.gov/Food/IngredientsPackagingLabeling/ GRAS/ucm2006850.htm>. Kohnen, R. and Oswald, W. D. (1998). Th e eff ects of valerian, propranolol, and their comb ination on activation, performance, and mood of healthy volunteers under social stress cond itions. Pharmacopsychiatry , 21 (6), 447 \200\223448 . Francavilla, R., Miniello, V., Magist , A. M., De Canio, A., Bucci, N., Gagliardi, F., e t al . (2010). A randomized controlled trial of Lactobacillus GG in children with functiona l abdominal pain. Pediatrics , 126 (6), e1445 \200\2231452 . Langmead, L., Chitnis, M., and Rampton, D. (2000). Complementary therapies in GI patients: who uses them and why? Gut , 46 (Suppl. II), A22 (Abstract). Gaby, A. (2011). Migraine. In Nutritional Medicine , pp. 527 \200\223536 . Concord, Lee, D. K., Carstairs, I. J., Haggart, K., Jackson, C. M., Currie, G. P., and Lipworth, B. J. (2003). Butterbur, an herbal remedy, attenuates adenosine monophosphate induced nasal re sponsiveness in seasonal allergic rhinitis. Clin Exp Allergy , 33 , 882 \200\223886 . NH : Fritz Perlberg . Gallai,V., Sarchielli, P., Morucci, P., and Abbritti, G. (1993). Red blood cell magnesium levels in migraine patients. Cephalalgia , 13 , 94 \200\22398 . Lu, K., Gray, M. A., Oliver, C., Harrison, B. J., Bartholomeusz, C. F., Phan, K. L., et al . (2004). Th e acute eff ects of L-theanine in comparison with alprazolam on anticipatory a nxiety in humans. Hum Psychopharmacol , 19 , 457 \200\223465 . Ghadirian, A. M., Murphy, B. E., and Gendron, M. J. (1998). Effi cacy of light versus trypt ophan therapy in seasonal aff ective disorder. J Aff ect Disord , 50 (1), 23 \200\22327 . Grazzi, L., Andrasik, F., Usai, S., and Bussone, G. (2007). Magnesium as a preventive treat ment for pediatric episodic tension-type headache: results at 1-year follow-up. Neurol Sci , 28 (3), 148 \200\223150 . MacLennan, S. C., Wade, F. M., Forrest, K. M., Ratanayake, P. D., Fagan, E., and Antony, J. 2008). High-dose ribofl avin for migraine prophylaxis in children: a double-blind, randomi zed, placebo-controlled trial. J Child Neurol , 23 (11), 1300 \200\2231304 . Guandalini, S., Magazz , G., Chiaro, A., La Balestra, V., Di Nardo, G., Gopalan, S., et al . (2010). VSL#3 improves symptoms in children with irritable bowel syndrome: a multicent er, randomized, placebo- controlled, double- blind, crossover study. J Pediatr Gastroentero l Nutr , 51 (1), 24 \200\22330 . Mauskop, A., Altura, B. T., Cracco, R. Q., and Altura, B. M. (1996). Intravenous magnesium sulfate rapidly alleviates headaches of various types. Headache , 36 (3), 154 \200\223160 . Matthana, M. H. (2011). Th e relation between vitamin D defi ciency and Gupta, S., Nahas, S. J., and Peterlin, B. L. (2011). Chemical mediators of migraine: precli nical and clinical observations. Headache , 51 (6), 1029 \200\2231045 . fi bromyalgia syndrome in women. Saudi Med J , 32 (9), 925 \200\223929 . M ller, S. F. and Klement, S. (2006). A combination of valerian and lemon balm is eff ec tive in the treatment of restlessness and dyssomnia in children. Phytomedicine , 13 (6), 38 3 \200\223387 . Hagen, L. E., Schneider, R., Stephens, D., Modrusan, D., Feldman, B. M. (2003). Use of comp lementary and alternative medicine by pediatric rheumatology patients. Arthritis Rheum , 49 (1), 3 \200\2236 . Munoz-Hoyos, A., Sanchez-Forte, M., Molina-Carballo, A., Escames, G., Martin-Medina, E., Re iter, R. J., et al . (1998). Melatonin \200\231s role as an anticonvulsant and neuronal pro tector: experimental and clinical evidence. J Child Neurol , 13 , 501 \200\223509 . Hartmann, E. and Spinweber, C. L. (1979). Sleep induced by L-tryptophan. Eff ect of dosages within the normal dietary intake. J Nerv Ment Dis , 167 , 497 \200\223499 . Murphy, J. J., Heptinstall, S., and Mitchell, J. R. (1988). Randomized double- blind placeb o- controlled trial of feverfew in migraine prevention. Lancet , 2 (8604), 189 \200\223192 . Hawrelak, J. A. and Myers, S. P. (2010). Eff ects of two natural medicine formulations on i rritable bowel syndrome symptoms: a pilot study. J Altern Complement Med , 16 (10), 1065 \200\2231071 . Murray, M. T. (1995). Healing power of herbs . Rocklin, CA : Prima Hershey, A. D., Powers, S. W., Vockell, A. L., Lecates, S. L., Ellinor, P. L., Segers, A., et al . (2007). Coenzyme Q10 defi ciency and response to supplementation in pediatric and a dolescent migraine. Headache , 47 (1), 73 \200\22380 . Publishing . Natural Medicine Comprehensive Database. (2012). Available at: <http:// naturaldatabase.com>. SECTION 9 special topics 622 Srivastava, K. C. and Mustafa, T. (1989). Ginger (Zingiber offi cinale) and Nelson, K. B., Richardson, A. K., He, J., Lateef, T. M., Khoromi, S., and Merikangas, K. R. (2010). Headache and biomarkers predictive of vascular disease in a representative sample of US children. Arch Pediatr Adolesc Med , 164 (4), 358 \200\223362 . rheumatic disorders. Med Hypoth , 29 , 25 \200\22328 . Sumner, H., Salan, U., Knight, D. W., and Hoult, J. R. (1992). Inhibition of 5-lipoxygenase and cyclo-oxygenase in leukocytes by feverfew. Involvement of sesquiterpene lactones and o ther components. Biochem Pharmacol , 43 , 2313 \200\2232320 . Newall, C. A., Anderson, L. A., and Philpson, J. D. (1996). Herbal medicine: a guide for he althcare professionals . London : Th e Pharmaceutical Press . O \200\231Brien, H., Hershey, A. D., and Kabbouche, M. A.(2010). Prevalence of vitamin D among pediatric patients with r ecurrent headaches. Headache , 50 (Suppl.1), S23 . Sun, X., Chan, L. N., and Sucher, N. J. (2005). Magnesium as NMDA receptor blocker in the t raditional Chinese medicine Danshen. Phytomedicine , 12 (3), 173 \200\223177 . Sun-Edelstein, C. and Mauskop, A. (2009). Role of magnesium in the pathogenesis and treatme nt of migraine. Expert Rev Neurother , 9 (3), 369 \200\223379 . Oterino, A., Toriello, M., Valle, N., Castillo, J., Alonso-Arranz, A., Bravo, Y., et al . ( 2010). Th e relationship between homocysteine and genes of folate- related enzymes in migra ine patients. Headache , 50 (1), 99 \200\223168 . Th ys-Jacobs, S. (1994a). Alleviation of migraines with therapeutic vitamin D Pareek, A., Suthar, M., Rathore, G. S., and Bansal, V. (2011). Feverfew (Tanacetum partheni um L.): a systematic review. Pharmacogn Rev , 5 (9), 103 \200\223110 . and calcium. Headache , 34 (10), 590 \200\223592 . Th ys-Jacobs, S. (1994b). Vitamin D and calcium in menstrual migraine. Headache , 34 (9), 544 \200\223546 . Peres, M. F., Gon alves, A. L., and Krymchantowski, A. (2007). Migraine, tension-type he adache, and transformed migraine. Curr Pain Headache Rep , 11 (6), 449 \200\223453 . Tietjen, G. E., Herial, N. A., White, L., Utley, C., Kosmyna, J. M., Khuder, S. A. (2009). Migraine and biomarkers of endothelial activation in young women. Stroke , 40 (9), 2977 \200\2232982 . Perquin, C., Hazebroek-Kampschreur, A., Hunfeld, J., Bohnen, A. M., van Suijlekom-Smit, L. W., Passchier, J., et al . (2000). Pain in children and adolescents: a common experience. P ain , 87 , 51 \200\22358 . Tsao, J. C. I. and Zeltzer, L. K. (2005). Complementary and alternative medicine approaches for pediatric pain: a review of the state-of-the- science. eCAM , 2 (2), 149 \200\223159 . Pfeifer, M., Begerow, B., and Minne, H. W. (2002). Vitamin D and muscle function. Osteoporos Int , 13 (3), 187 \200\223194 . Turunen, M., Olsson, J., and Dallner, G. (2004). Metabolism and function of coenzyme Q. Biochimica et Biophysica Acta , 1660, 171 \200\223199 . Pieczenik, S. R. and Neustadt, J. (2007). Mitochondrial dysfunction and molecular pathways of disease. Exp Mol Pathol , 83 (1), 84 \200\22392 . van der Kuy, P. H., Merkus, F. W., Lohman, J. J., ter Berg, J. W., and Hooymans, P. M. (200 2). Hydroxocobalamin, a nitric oxide scavenger, in the prophylaxis of migraine: an open, pi lot study. Cephalalgia , 22 (7), 513 \200\223519 . Pittler, M. H., Vogler, B. K., and Ernst, E. (2000). Feverfew for preventing migraine. Cochrane Database Syst Rev , 3 , CD002286 . Pothmann, R. and Danesch, U. (2005). Migraine prevention in children and adolescents: resul ts of an open study with a special butterbur root extract. Headache , 45 (3), 196 \200\2232 03 . van Geijlswijk, I. M., Korzilius, H. P., and Smits, M. G. (2010). Th e use of exogenous mel atonin in delayed sleep phase disorder: a meta-analysis. Sleep , 33 (12), 1605 \200\2231614 . Prabhala, A., Garg, R., and Dandona, P. (2000). Severe myopathy associated with vitamin D d efi ciency in western New York. Arch Intern Med , 160 (8), 1199 \200\2231203 . Vieth, R. (1999). Vitamin D supplementation, 25-hydroxyvitamin D concentrations, and safety. Am J Clin Nutr , 69 (5), 842 \200\223856 . Viola, H., Wasowski, C., Levi de Stein, M., Wolfman, C., Silveira, R., Dajas, F., et al . ( 1995). Apigenin, a component of matricaria recutita fl owers, is a central benzodiazepine r eceptors-ligand with anxiolytic eff ects. Planta Medica , 61 , 213 \200\223216 . Prakash, S. and Shah, N. D. (2009). Chronic tension-type headache with vitamin D defi cienc y: casual or causal association? Headache , 49 (8), 1214 \200\2231222 . Ranade, V. V. and Somberg, J.C. (2001). Bioavailability and pharmacokinetics of magnesium a ft er administration of magnesium salts to humans. Am J Th er , 8 (5), 345 \200\223357 . Wang, F., Van Den Eeden, S. K., Ackerson, L. M., Salk, S. E., Reince, R. H., and Elin, R. J . (2003). Oral magnesium oxide prophylaxis of frequent migrainous headache in children: a r andomized, double-blind, placebo- controlled trial. Headache , 43 (6), 601 \200\223610 . Robbers, J. E. and Tyler, V. E. (1999). Tyler \200\231s herbs of choice: the therapeutic us e of phytomedicinals New York : Th e Haworth Herbal Press . Weizman, Z., Alkrinawi, S., Goldfarb, D., and Bitran, C. (1993). Effi cacy of herbal tea pr eparation in infantile colic. J Pediatr , 122 (4), 650 \200\223652 . Weydert, J. A. (2012) Recurring abdominal pain in children. In D. Rakel (ed.) Integrative medicine: complementary therapeutics in medical practice (3rd edn), pp. 422 \200\223429 . Philadelphia, PA : Elsev ier/Saunders Company . Winter, T. A., O \200\231keefe, S. J., Callanan, M., and Marks, T. ( 2004). Impaired gastric acid and pancreatic enzyme secretion in patients with Crohn \200 \231s disease may be a consequence of a poor nutritional state. Infl amm Bowel Dis , 10 (5) , 618 \200\223625 . Rossini, M., Di Munno, O., Valentini, G., Bianchi, G., Biasi, G., Cacace, E., et al . (2007 ). Double-blind, multicenter trial comparing acetyl l-carnitine with placebo in the treatme nt of fi bromyalgia patients. Clin Exp Rheumatol , 25 (2), 182 \200\223188 . Russell, I. J., Michalek, J. E., Flechas, J. D., and Abraham, G. E. (1995). Treatment of fi bromyalgia syndrome with Super Malic: a randomized, double blind, placebo controlled, cros sover pilot study. J Rheumatol , 22, 953 \200\223958 . Sartor, R. B. (2011). Effi cacy of probiotics for the management of infl ammatory bowel disease. Gastroenterol Hepatol , 7 (9), 606 \200\223608 . Wong, A. H. C., Smith, M., and Boon, H. S. (1998). Herbal remedies in psychiatric practice. Arch Gen Psychiatry , 55 , 1033 \200\2231044 . Shimosawa, T., Takano, K., Ando, K., and Fujita, T. (2004). Magnesium inhibits norepinephri ne release by blocking N-type calcium channels at peripheral sympathetic nerve endings. Hyp ertention , 44 , 897 \200\223902 . Shrivastava, R., Pechadre, J. C., and John, G. W. (2006) . Tanacetum parthenium and Salix alba (Mig-RL) combination in migraine. Clin Drug Invest , 26 (5), 287 \200\223296 . Wu, K. L., Rayner, C. K., and Chuah, S. K. (2008). Eff ects of ginger on gastric emptying a nd motility in healthy humans. Eur J Gastroenterol Hepatol , 20 , 436 \200\223440 . Zick, S. M., Wright, B. D., Sen, A., and Arnedt, J. T. (2011). Preliminary examination of t he effi cacy and safety of a standardized chamomile extract for chronic primary insomnia: a randomized placebo-controlled pilot study. BMC Complement Altern Med , 22 (11), 78 . Soriani, S., Arnaldi, C., De Carlo, L., Mazzotta, D., Battistella, P. A., Sartori, S., et a l . (1995). Serum and red blood cell magnesium levels in juvenile migraine patients. Headac he , 35 , 14 \200\22316 . CHAPTER 60 Complementary therapy in pediatric pain Lonnie K. Zeltzer Summary Th ere is increasing pediatric use of complementary therapies (CTs), especially for pediatric pain. Th is chapter reviews the key literature on studies that pertain to CTs th at impact pain in children. Th e research is still in its infancy with few studies that hav e been well designed and replicated. Likely the strongest of the studies is in hypnotherapy , which will have its own chapter, and in biofeedback for headaches. Acupuncture research i s growing but there are few well designed studies in children compared to those in adults. Risks in CTs mostly relate to training of the practitioner and good clinical judgment (e.g. avoiding massage in children aversive to touch). Most are safe when used with clinical jud gment. usage of CTs has become more common and the science has moved forward. The National Center for Complementary and Alternative Medicine (NCCAM) at the National Inst itutes of Health has defi ned \200\230complementary therapies \200\231 as those interventi onal strategies used in conjunction with conventional medicine. \200\230Alternative therap ies \200\231 are defi ned as treatments used in place of conventional medicine. NCCAM has d ivided these complementary and alternative thera- pies into fi ve categories: biologically based therapies, manipulative and body-based therapies, energy therapies, mind \200\223body interven- tions, and alternative medical systems. Biologically based therapies include her bal remedies that employ plant preparations for thera- peutic eff ects, as well as vitamins and other dietary supplements. Manipulative and body-based methods include, for example, c hi- ropractic, osteopathic manipulations, and massage. Energy thera- pies include Reiki and the unconventional use of electromagnetic fi elds. Mind \200\223body interventions relate to techniques to increase the mind \200\231s capacity to enhance bodily function and reduce symptoms, such as hypnotherapy, biofeedback, meditation, prayer, and expres- sive therapie s such as music, art, or dance therapy. Alternative med- ical systems are built upon comple te systems of theory and practice and may make use of therapies from the biological, body-b ased, mind \200\223body, and energy modalities. Examples are homeopathic medicine, Ayervedi c healing, naturopathic medicine, and tradi- tional Chinese medicine (TCM). An individual c omplementary therapy may be used in isolation from its use within an alternative medical sy stem, such as acupuncture (TCM) and yoga (Ayervedic healing). Although CAM clearly encompas ses a variety of tech- niques from various schools of thought, this chapter will focus on C Ts that have been reported to have been used for acute or chronic pain in children. Introduction Th e biopsychosocial model for understanding and treating child- hood pain tak es into account the many facets of and contribu- tors to the pain experience and pain-relat ed functional disability. Increasingly, pediatric pain programs are incorporating com- plem entary therapy (CT) into their existing programs of pharmacological, physical, and psycholo gical pain management. Typically, this quadruple of treatments is called \200\230integrati ve pain management \200\231. A barrier to incorporating CTs into a more traditional approach to pain treatment in childr en is the relatively little published sci- ence to indicate which CTs are eff ective and sa fe and for what pain conditions. Th e implementation of many complementary practices is oft en not well described. Th e aim of this chapter is to present a state of the science on CTs in childhood pain, and how they would be applied to children in pain. A case of the use of complementary CTs for childhood pain is presented by an adolescent patient with discussion by the author about th e choice of therapies and the integration of CTs into the total treatment plan. Background Estimates of the use of CTs range from 2% in a healthy sample of children (Davis and Darden, 2003) to as high as 73% in children with cancer (Neuhouser et al., 2001), with fi gures pointing to sub- stantial increases across pediatric populations. Th e use of CTs in children is increasing internationally, but the reported preva- lence diff ers by count ry, methodology, and populations studied Th e various terms for CTs, typically known collectively as com- plementary and alternative medicine (CAM), have been used inconsistently in the literature. Not uncommonly, the terms \200\230com- plementary \200\231, \200\230alternative \200\231, \200\230holistic \200 \231, and \200\230integrative \200\231 have been used interchangeably. Over time there als o has been a blurring of boundaries between complementary and \200\230traditional \200\231 therapies, as SECTION 9 special topics 624 (Efe et al., 2013; Heath et al., 2012; Snyder and Brown, 2012). For example, the prevalence of CT use in the Netherlands in children with cancer was found to be about 40%, while it w as 11% in a Finnish study based on a national data set of over 6000 children. In the latter study, symptom reduction was the primary reason for parents seeking complementary therapie s (Singendonk et al., 2013; Siponen et al., 2012). CT use oft en goes unreported to physici ans; as many as half of all adults using CTs do so without consulting a practitioner (Eisen berg et al., 1993) and the fi gure may be even higher for children (Spigelblatt et al., 199 4). Th is practice appears to occur despite the desire of many parents to discuss their chi ld \200\231s use of CTs with the family pediatrician (Sibinga et al., 2004). the experience acceptable (Kemper et al., 2000; Waterhouse et al., 2000; Zeltzer et al., 20 02). In treating pediatric pain, acupuncture therapy has been evalu- ated for its potential eff ectiveness in alleviating chronic headaches (Pintov et al., 1997; Pothmann et al., 2009), a cute pain (Wu et al., 2009) and surgical pain (Kim et al., 2006; Lin et al., 2009). A study investigating the effi cacy of laser acupuncture in 43 pediatric patients suff ering with chronic headaches, randomized children to an intervention group that used low-level laser f or individual- ized acupuncture or to a control condition of sham laser acupunc- ture. Th e intervention group had a signifi cant decrease in headache frequency, monthly headache hou rs, and headache pain intensity compared to baseline but not to the sham intervention. No a dverse events were observed in the study (Pothmann et al., 2009). In addition, a 2001 survey of 745 members of the American Academy of Pediatrics found that 87 % of pediatricians had been asked about CTs by a patient or a parent in the 3 months pri or to the survey (Sawni-Sikand et al., 2002; Yussman et al., 2004). Th e pediatricians were asked most oft en about herbs and dietary sup- plements (Wilson et al., 2006; Woolf, 2003) . Pintov et al. (1997) studied acupuncture for migraine treatment in children, with12 patient s randomly assigned to the true acupunc- ture group (TA) and ten assigned to the placebo ac upuncture group (PA). Th e PA group received a sham acupuncture treatment by the insertion of the same size needle into the stratum corneum. Both the TA and PA groups received ten we ekly sessions of intervention. Th e TA group had a signifi cant reduction in both frequency and intensity of migraines and a signifi cantly potentiated amount of panopioid activity a ft er the acupuncture compared to that found in the PA group. Th e 2007 National Health Interview Survey gathered informa- tion on CT use among more than 9000 children younger than 18 years (Barnes et al., 2008). Nearly 12% had used some form o f CTs during the past 12 months. CT use was much more likely among children whose parents a lso used CTs. Adolescents aged 12 to 17 years, children with multiple health conditions, an d those whose families delayed or did not use conventional medical care because of cost wer e also more likely to use CTs. Th e most common pain conditions for which CTs were used in the past 12 months included back or neck pain (8%), musculoskeletal con- ditions (4%), and abdominal pain (1%), with associated problems including anxiety/stress (5%), sleep problems (2%), and depres- sion (1%). Headaches were not included in the list but related sinusitis was 2% and \200\230other \200\231 was (8%). Chiropractic or osteopathic manipulations wer e used in 3% of children, deep breathing exer- cises in 3%, yoga in 2%, meditation and mass age in 1% each, and all other modalities were less than 1%. Integrative care including CTs is now included in major textbooks of pediatrics (Zeltzer and Krane, 2011). Th ese studies (Pintov et al., 1997; Pothmann et al., 2009) provide some evidence for acupu ncture eff ectiveness in treating chronic headaches in children, although limited by small sample sizes and the challenges of providing a sham treatment (such as the inability to dou ble blind). Th e Pintov study had a biased sample by exclud- ing children who were receivin g any headache medication. Yet, these early results are promising and more randomized contr olled trials (RCTs) are warranted. A non-randomized clinical trial (Wu et al., 2009) assessed two 10 to 15 min acupuncture ses sions in 11 hospitalized children with spi- nal fusion surgery and nine in intensive care ( PICU). Both groups had a general decrease in pain scores, heart rate and systolic blood pre ssure aft er acupuncture sessions. Th e non-PICU group 1 had a maximal decrease of morphine PCA usage 4 to 8 h aft er the fi rst acupuncture session and by the second session were pl aced on oral opioids. Th is study showed acceptance and tolerance for acupunc- ture for pos toperative pain management within a hospital setting, although effi cacy was not determined . Complementary therapies Acupuncture and related techniques Within TCM, there is a belief th at an energy force fl ows through the body, which, if blocked, causes imbalance and sicknes s. Diff erent traditions call this energy \200\230Qi \200\231 (pronounced \200\230chi \200\231), prana \200\231, and \200\230life force \200\231. Acupuncture is intended to res tore natural energy (Qi) through the insertion of needles into points along energy pathways (meridians) in the body. Th e needles help stimulate the energy fl ow. Usually, needles ar e inserted into the skin from to 1 inch deep. Th e patient oft en reports light cramping , heaviness, distention, tin- gling, or electric sensation either around the needle or trav eling up or down the energy pathway. Although the precise analgesic mechanisms have not bee n identifi ed, it is likely that the body \200\231s nervous system, neurotransmitters, and endogenous substances are involved in needle stimulation (Ma 2004). Lin et al. (2009) randomized 66 children aged 2.2 1.4 years undergoing bilateral myringoto my/tympanostomy tube (BMT) placement into a post-anesthesia preoperative acupuncture or con trol condition without the acupuncture. Th e intervention group had signifi cantly lower pa in and agitation scores across the diff erent observed time points and a lower need for pos toperative acetami- nophen. No adverse events were observed. Long-term eff ects have yet to be determined. A study (Kim et al., 2006) of capsicum plaster placed at the Zusanli (Z:ST-36) points aft e r a unilateral hernia repair for post- operative pain control in 108 children (4 months to 9 years) ran- domly assigned patient to three groups. Th e intervention group (Z) received capsicum plaster at Z acupoints and placebo tape at a non-acupoint in the shoulder. Th e sh am group (S) received plaster at shoulder points and placebo tape at the Z acupoint. Th e c ontrol group (C) received placebo tape at both shoulder and Z points. Outcome measures were postoperative pain scores, as In adults, acupuncture is one of the most popular complemen- tary therapies, yet it is less oft en used in children (Barnes et al., 2008). Th e common assumption that most children a re fearful of needles may cause physicians to be averse to recommending acu- puncture; yet research has found that children and adolescents fi nd CHAPTER 60 complementary therapy in pediatric pain 625 well as the analgesic opioid requirements during the 24 h postop- erative time frame. A sig nifi cantly lower use of meperidine (the postoperative opioid used in the study) was found in group Th e Z group had less opioid use and lower pain scores compared to the other two g roups. No side eff ects from capsicum plaster were observed. (BFB-REL) intervention or a relaxation placebo (REL-PLAC) con- trol condition for ten sessi ons, two per week. Both groups had a 55% improvement in headache severity at the one month assessment, but only the BFB-REL group had improvement at the 6- and 12-month follow-ups, w ith an 85% improvement by the last assessment. Kroner-Herwig et al. (1998) randomized 40 children, ages 8 to 14 years, with tension-type o r combined headaches to an electro- myographic (EMG)-frontalis biofeedback or progressive r elaxation (PR) condition with and without parental involvement (PI) or to a wait list contr ol group. Th ere were12 bi-weekly sessions and the parent condition included three 1 h pare nt sessions. All four inter- vention groups had signifi cant main eff ects in all outcome d omains post-intervention. Yet, at the 6-month assessment, the biofeedback group without PI showing the greatest changes, followed by bio- feedback with PI, PR alone, PR with PI, and then the control group. Th e biofeedback group without PI had the highest mean eff ect size for headache outcomes. Adding parents did not appear to improve the intervention eff ects. Th ese studies (Kim et al., 2006; Lin et al., 2009) suggest a poten- tially safe complement ary therapy for reduction of opioid analgesic dosage for pediatric post-operative pain mana gement. Replication of the studies and improved study designs are warranted. Acupuncture practitioners are licensed and regulated health care professionals in about hal f the states in the US. In states that do not currently require licensing, the acupuncture practitioner should be asked if he/she is certifi ed by the National Commission for the Cer tifi cation of Acupuncturists. Th e acupuncturist should be asked to communicate with the c hild \200\231s pediatrician or pain specialist for optimal integrative care. Acupuncture in Canada developed in the late 1800 \200\231s primarily in Chinese communities but gradu- al ly spread to the communities until it was incorporated into the Governmental health care sy stem. For example, in the province of Ontario, it became part of the \200\230Traditional C hinese Medicine Act \200\231 in 2006 (Wang and Wu 2012). Across Asia, acupuncture has been accepted and used for hundreds of years. Th e governmental regula- tions for practicing acu puncture diff er by country worldwide but in most places few restrictions are in place. Grazzi et al. (1990) provided EMG biofeedback to ten children, ages 12 to 15 years, with te nsion headache twice weekly for 6 weeks. Pain Total Index collected with a headache diary a nd muscular ten- sion scores decreased in all patients from baseline to treatment completio n. Grazzi et al. (2001) provided an EMG biofeedback- assisted relaxation program in 54 chil dren, mean 12 years, with episodic tension-type headaches with two treatment sessions per w eek for 5 weeks. Pain Total Index via daily diaries were signifi - cant at treatment termin ation but not at the 1-year follow-up. At the 3-year assessment, 84% of the participants we re symptom-free. Given the lack of a control condition, the percentage of children who woul d have been headache free even without intervention at 3 years is unknown. Other study desi gn weaknesses limit strength of the fi ndings. Biofeedback Biofeedback uses a computer or other bodily feedback tool to help children to r educe pain or other symptoms by noticing and then learning strategies to control physiologi cal changes associated with the stress response. Th ese monitored changes (Evans and Zeltze r 2008) may include muscle tension, peripheral skin temperature, sweat gland response, brai n wave activity, or breathing rate, with the goal of increasing the body \200\231s relaxati on response. Using bio- feedback helps children learn about their body \200\231s responses to stress and become aware of their own abilities to alter those responses. Biofeedback is especially popular for the treatment of migraine and headaches in children (Evans and Zeltz er, 2008). Arndorfer and Allen (2001) conducted a within-subject, mul- tiple baseline, time-lagged stu dy to evaluate thermal biofeedback therapy in fi ve children, aged 8 to 14 years, with tens ion-type head- aches. Baseline data over 4 to 7 weeks were followed by six thermal biofeedb ack treatments. All participants showed clinical improve- ment via daily headache diaries a nd four of the fi ve were headache- free at 6 months. Lack of a control condition and small sample size limited the importance of the fi ndings. Biofeedback has been evaluated in its eff ectiveness for treating pediatric headaches (Arnd orfer and Allen, 2001; Bussone et al., 1998; Fentress et al., 1986; Grazzi et al., 1990, 20 01; Kroner-Herwig et al.1998; Scharff et al., 2002) and abdominal pain (Schurman et al., 20 10; Sowder et al., 2010). Fentress et al. (1986) randomized 18 children, ages 8 to 12 years , who had recurrent intermittent headaches and were not on preventive medication, to a biof eed- back with or without a relaxation response (RR) condition or to a control wait-list gr oup for seven weekly then two bi-weekly ses- sions. Headache diaries were evaluated through out the study and at a 1-year follow-up assessment. Outcome measures included frequency of headaches, total of hours of headache, and severity of headaches. Compared to control group , both treatment groups had improvement in their headache diary measures compared to baseli ne and at the end of the 15-week study period. However, no diff erences were found between baseline and the 1 year assessment. No diff erences in the RR groups were found with or wit hout bio- feedback. Th e study was limited by small sample size, no reporting of missing da ta, and other design problems. Scharff et al. \200\231s (2002) study randomized children (7 \200\22317 years) with migrain es to a stress management with thermal biofeedback (TB), hand-cooling biofeedback (HCB) wit hout stress manage- ment, and an assessment control condition to reduce pain, anxi- ety, an d depression. At the 6-week post-treatment assessment, no one in the control condition had headache improvement, while one child (10%) in the HCB and seven (54%) in TB group had sign ifi - cant reduction in headache severity. In a combined analysis, both treatment groups ha d reduced headache severity and frequency. No changes were in anxiety or depression measure s. Th e same fi nd- ings held for the 6-month follow-up. While this study is oft en cited a s evidence of thermal biofeedback for migraines in children and despite its promising title , caution is warranted because of the many confounds that limit generalizability of the fi ndings. Sowder et al. (2010) provided six sessions of heart rate vari- ability (HRV) biofeedback to restore vagal tone in 20 children, 5 to 17 years, with functional abdominal pain (FAP) and com- pared outcomes to ten children without FAP. Th e signifi cant decrease in low frequen cy/high frequency (LF/HF) ratio aft er Bussone et al. (1998) randomized 30 children, ages 11 to 15 years, with episodic tension-ty pe headache to either a biofeedback- relaxation SECTION 9 special topics 626 intervention suggested an improvement in cardiac vagal tone, along with a decrease in pain frequency and a signifi cant correla- tion between the decrease in LF/HF ratios and pain fr equency. Th is novel study of heart rate variability biofeedback in FAP was limited by the study design (no randomized trial with a control condition). pre- and postintervention eff ects, merging yoga groups including those who had yoga aft er being in the control condition found a signifi cant reduction in gastrointestinal symptoms . Th is study was limited by no monitoring for home practice adherence and small sample siz e.