Pediatric Integrative Medicine in Residency Program: Relationship between Lifestyle Behaviors and Burnout and Wellbeing Measures in First-Year Residents.

It is widely recognized that burnout is prevalent in medical culture and begins early in training. Studies show pediatricians and pediatric trainees experience burnout rates comparable to other specialties. Newly developed Accreditation Council for Graduate Medical Education (ACGME) core competencies in professionalism and personal development recognize the unacceptably high resident burnout rates and present an important opportunity for programs to improve residents experience throughout training. These competencies encourage healthy lifestyle practices and cultivation of self-awareness, self-regulation, empathy, mindfulness, and compassion—a paradigm shift from traditional medical training underpinned by a culture of unrealistic endurance and self-sacrifice. To date, few successful and sustainable programs in resident burnout prevention and wellness promotion have been described. The University of Arizona Center for Integrative Medicine Pediatric Integrative Medicine in Residency (PIMR) curriculum, developed in 2011, was designed in part to help pediatric programs meet new resident wellbeing requirements. The purpose of this paper is to detail levels of lifestyle behaviors, burnout, and wellbeing for the PIMR program’s first-year residents (N = 203), and to examine the impact of lifestyle behaviors on burnout and wellbeing. The potential of the PIMR to provide interventions addressing gaps in lifestyle behaviors with recognized association to burnout is discussed.

Pediatric Integrative Medicine.

The American Academy of Pediatrics is dedicated to optimizing the well-being of children and advancing family-centered health care. Related to this mission, the American Academy of Pediatrics recognizes the increasing use of complementary and integrative therapies for children and the subsequent need to provide reliable information and high-quality clinical resources to support pediatricians. This Clinical Report serves as an update to the original 2008 statement on complementary medicine. The range of complementary therapies is both extensive and diverse. Therefore, in-depth discussion of each therapy or product is beyond the scope of this report. Instead, our intentions are to define terms; describe epidemiology of use; outline common types of complementary therapies; review medicolegal, ethical, and research implications; review education and training for select providers of complementary therapies; provide educational resources; and suggest communication strategies for discussing complementary therapies with patients and families.

Pediatric Integrative Medicine in Residency (PIMR): Description of a New Online Educational Curriculum.

Use of integrative medicine (IM) is prevalent in children, yet availability of training opportunities is limited. The Pediatric Integrative Medicine in Residency (PIMR) program was designed to address this training gap. The PIMR program is a 100-hour online educational curriculum, modeled on the successful Integrative Medicine in Residency program in family medicine. Preliminary data on site characteristics, resident experience with and interest in IM, and residents' self-assessments of perceived knowledge and skills in IM are presented. The embedded multimodal evaluation is described. Less than one-third of residents had IM coursework in medical school or personal experience with IM. Yet most (66%) were interested in learning IM, and 71% were interested in applying IM after graduation. Less than half of the residents endorsed pre-existing IM knowledge/skills. Average score on IM medical knowledge exam was 51%. Sites endorsed 1-8 of 11 site characteristics, with most (80%) indicating they had an IM practitioner onsite and IM trained faculty. Preliminary results indicate that the PIMR online curriculum targets identified knowledge gaps. Residents had minimal prior IM exposure, yet expressed strong interest in IM education. PIMR training site surveys identified both strengths and areas needing further development to support successful PIMR program implementation.

Vitamin D in Children's Health.

Knowledge of vitamin D in the health of children has grown greatly over the years, extending past the importance for calcium homeostasis and bone growth. There is growing recognition of the role vitamin D plays in health impacting the innate immune system to prevent infections and the adaptive immune system to modulate autoimmunity. Other studies are starting to reveal the neurohormonal effects of vitamin D on brain development and behavior, with a link to mental health disorders. Many of these effects start well before the birth of the child, so it is important that each pregnant woman be assessed for vitamin D deficiency and supplemented for the best possible health outcome of the child. It is recommended that targeting a 25(OH)D level of 40-70 ng/mL for each individual would provide optimal health benefits and reduce health care costs. Current recommended doses of vitamin D supplementation fall short of what is needed to obtain ideal serum levels. A vitamin D supplementation program to prevent disease, much like the current vaccination program, could potentially have a dramatic impact on overall health worldwide.

Evaluation of guided imagery as treatment for recurrent abdominal pain in children: a randomized controlled trial.

BACKGROUND: Because of the paucity of effective evidence-based therapies for children with recurrent abdominal pain, we evaluated the therapeutic effect of guided imagery, a well-studied self-regulation technique. METHODS: 22 children, aged 5-18 years, were randomized to learn either breathing exercises alone or guided imagery with progressive muscle relaxation. Both groups had 4-weekly sessions with a therapist. Children reported the numbers of days with pain, the pain intensity, and missed activities due to abdominal pain using a daily pain diary collected at baseline and during the intervention. Monthly phone calls to the children reported the number of days with pain and the number of days of missed activities experienced during the month of and month following the intervention. Children with < or = 4 days of pain/month and no missed activities due to pain were defined as being healed. Depression, anxiety, and somatization were measured in both children and parents at baseline. RESULTS: At baseline the children who received guided imagery had more days of pain during the preceding month (23 vs. 14 days, P = 0.04). There were no differences in the intensity of painful episodes or any baseline psychological factors between the two groups. Children who learned guided imagery with progressive muscle relaxation had significantly greater decrease in the number of days with pain than those learning breathing exercises alone after one (67% vs. 21%, P = 0.05), and two (82% vs. 45%, P < 0.01) months and significantly greater decrease in days with missed activities at one (85% vs. 15%, P = 0.02) and two (95% vs. 77%. P = 0.05) months. During the two months of follow-up, more children who had learned guided imagery met the threshold of < or = 4 day of pain each month and no missed activities (RR = 7.3, 95%CI [1.1,48.6]) than children who learned only the breathing exercises. CONCLUSION: The therapeutic efficacy of guided imagery with progressive muscle relaxation found in this study is consistent with our present understanding of the pathophysiology of recurrent abdominal pain in children. Although unfamiliar to many pediatricians, guided imagery is a simple, noninvasive therapy with potential benefit for treating children with RAP.

Methodological challenges to treatment trials for recurrent abdominal pain in children.

BACKGROUND: Studies evaluating the efficacy of treatments for recurrent abdominal pain (RAP) in children have used a wide range of methods, causing difficulty in the comparison of results. An expert panel on functional gastrointestinal disorders recently made recommendations regarding the standardization of study methods for childhood RAP, but many of their recommendations remain untested or lack supportive evidence. METHODS: During completion of a pilot study and randomized controlled trial for childhood RAP, baseline data were collected regarding the child and parent reports of abdominal pain frequency and intensity, type of abdominal pain, missed activities due to abdominal pain, psychological factors for the parent and child, parenting styles, and referral source (pediatric gastroenterologist vs general pediatrician). RESULTS: Children and parent pain reports showed good agreement in children younger than 13 years (weighted kappa, 0.77; 95% confidence interval [CI], 0.71-0.84), but only marginal agreement in children 13 years or older (weighted kappa, 0.37; 95% CI, 0.30-0.45). We found no significant differences in pain characteristics or psychological factors between children referred by pediatric gastroenterologists in a tertiary care center and those referred by community-based primary care pediatricians. However, children with symptoms consistent with nonspecific functional abdominal pain were reported by their parents to have less frequent pain (P=.003) and fewer missed activities (P=.003) than children with symptoms of irritable bowel syndrome or functional dyspepsia. CONCLUSIONS: Subjects referred by gastroenterologists and general pediatricians were similar, but the subtype of functional gastrointestinal disorder might be an important baseline characteristic of subjects in future RAP studies. We suggest that future interventional studies of childhood RAP measure 2 outcomes with pain reports obtained directly from children. Any child with fewer days of pain and missed activities due to pain after therapy would be considered improved, and those with no missed activities and 4 or fewer days of pain per month at follow-up would be considered healed.

A pilot study of the use of guided imagery for the treatment of recurrent abdominal pain in children.

Few effective therapies are available for children with recurrent abdominal pain (RAP). Relaxation and guided imagery have been shown to impact the autonomic nervous system, which is altered in patients with functional gastrointestinal disorders. Ten children with RAP were enrolled in the study after evaluation by a pediatric gastroenterologist. They were trained in relaxation and guided imagery during 4 weekly 50-minute sessions. Pain diaries were completed at 0, 1, and 2 months. Children and parents also completed psychological questionnaires at enrollment. Although refractory to conventional treatment by their physician and pediatric gastroenterologist, the children experienced a 67% decrease in pain during the therapy (chi-square for trend, p < 0.001). No baseline psychological characteristics impacted the response to therapy. The use of relaxation along with guided imagery is an effective and safe treatment for childhood RAP.

Systematic review of treatments for recurrent abdominal pain.

OBJECTIVE: To conduct a systematic review of evaluated treatments for recurrent abdominal pain (RAP) in children. METHODS: Online bibliographic databases were searched for the terms "recurrent abdominal pain," "functional abdominal pain," "children," or "alternative therapies" in articles classified as randomized controlled trials. The abstracts or full text of 57 relevant articles were examined; 10 of these met inclusion criteria. Inclusion criteria required that the study involve children aged 5 to 18 years, subjects have a diagnosis of RAP, and that subjects were allocated randomly to treatment or control groups. The methodology and findings of these articles were evaluated critically, and data were extracted from each article regarding study methods, specific interventions, outcomes measured, and results. RESULTS: Studies that evaluated famotidine, pizotifen, cognitive-behavioral therapy, biofeedback, and peppermint oil enteric-coated capsules showed a decrease in measured pain outcomes for those who received the interventions when compared with others in control groups. The studies that evaluated dietary interventions had conflicting results, in the case of fiber, or showed no efficacy, in the case of lactose avoidance. CONCLUSIONS: Evidence for efficacy of treatment of RAP in children was found for therapies that used famotidine, pizotifen, cognitive-behavioral therapy, biofeedback, and peppermint oil enteric-coated capsules. The effects of dietary fiber were less conclusive, and the use of a lactose-free diet showed no improvement. There seemed to be greater improvement when therapy (famotidine, pizotifen, peppermint oil) was targeted to the specific functional gastrointestinal disorder (dyspepsia, abdominal migraine, irritable bowel syndrome). The behavioral interventions seemed to have a general positive effect on children with nonspecific RAP. Many of these therapies have not been used widely as standard treatment for children with RAP. Although the mechanism of action for each effective therapy is not fully understood, each is believed to be safe for use in RAP.