Patterns in integrative medicine usage among pediatric patients in a disorders of gut–brain interaction clinic

Disorders of the gut–brain interaction (DGBI) comprise a wide array of diagnoses, including irritable bowel syndrome (IBS), functional dyspepsia (FD), abdominal migraine, and functional abdominal pain not otherwise specified (FAP-NOS) and non-pain predominant disorders (cyclic vomiting syndrome, functional constipation, and functional nausea/vomiting). In a US survey of mothers, about 25% of children and adolescents met Rome 4 criteria for a DGBI.1 DGBI are prevalent and associated with disability and reduced psychosocial functioning. In the pediatric population, this can be linked to long-term disability, school absenteeism, and anxiety/depression. Traditional pharmacologic management has been associated with suboptimal outcomes and a risk for adverse events. Thus, complimentary, alternative, and integrative medical (CAIM) therapies have been increasingly recognized. Integrative medicine (IM) is defined as holistic, patient-centered medical care that seeks to improve healing by recognizing the physical, psychological, and spiritual needs of patients. It incorporates both Western medicine and traditional Eastern medicine techniques. IM has been increasing in both demand and research on the past decade. In fact, trends in research output for IM have doubled in the past decade.2 According to the American Academy of Pediatrics, the desire for IM within the pediatric population is driven by increasing trends in children and adolescents with chronic diseases and a desire to decrease pharmacologic burden.4 IM has been promising in pediatric patients with chronic pain and disorders of gut-brain interaction.3 However, the exact trend in use of IM in pediatric DGBI patients is less well known. This study sought to explore trends in CAIM and IM usage in a pediatric DGBI clinic. After obtaining institutional review board approval (IRB# 2021-0844), electronic medical records including demographics and medical history of patients aged 6–21 years seen at the Cincinnati Children's Hospital Medical Center multidisciplinary DGBI clinic between 2017 and 2022 were reviewed. Patients who met the Rome IV criteria for a DGBI were included, while patients with organic GI disorders were excluded. The use of IM was evaluated by reviewing clinical documentation. The integrative treatments utilized were peppermint oil, caraway oil, nausea relief wristbands, herbal teas, acupressure, acupuncture, aromatherapy, and WebMAP, a digital pain-coping app.). We recorded the frequency of different integrative treatments used by patients, their demographics, diagnoses, and symptoms. Analysis was done with Chi-square and Fisher's exact test for categorical values and Wilcoxon rank-sum test for continuous data. The sample included 331 patients. The mean age was 15.6 ± 2.6 years. Eighty-eight percent of patients were aged 12–21. Seventy-nine percent of the patient population was female, while 21% was male. Eighty-nine percent of the patient population identified as Caucasian (Table S1). The most common symptoms were abdominal pain (92%) and nausea (73%) (Table S2). The most common comorbidities in the sample were anxiety (61%), sleep disturbance (36%), and depression (32%) (Table S3). The most common DGBI diagnoses in the study were FD (58%) and IBS (57.4%), with FAP-NOS being third most frequent 10.6%). Patients with FD were more likely to use IM therapy (Table S3). There was no statistically significant difference in IM usage between race and ethnicity (Table S4). In total, 59% of patients were receiving some form of integrative treatment, while 41% were not. Of the integrative treatments, peppermint oil was the most popular (45%), followed by caraway oil (37%), acupuncture (21%), WebMAP (18%), herbal tea (18%), aromatherapy (18%), acupressure (15%), and nausea wrist bands (10%) (Figure 1). Female patients were more likely to use caraway oil (p = 0.037) and acupressure than males (p = 0.047). Patients with lower abdominal pain (p = 0.009) and nausea (p = 0.03) were most likely to use a form of IM. Of DGBI patients who used integrative treatments, those with nausea were more likely to use caraway oil (p = 0.036), while patients with lower abdominal pain used peppermint oil (p = 0.0003) and the WebMAP app (p = 0.0039). DGBI patients with upper abdominal pain were most likely to use acupuncture (p = 0.049) or caraway oil (p = 0.013). Patients with early satiety were more likely to use nausea wrist bands (p = 0.039), while those with postprandial fullness preferred caraway oil (p = 0.042) (Table 1). This study identifies some unique trends in IM. In this population, most patients were either already using or started on some sort of IM therapy. This likely relates to the complex pathophysiology of DGBI. This is not to say that pharmacological therapy is not effective. However, it likely suggests that these are valuable complementary approaches to the management of DGBI. First, the most used therapeutic in this population was peppermint oil. Peppermint oil has been used for hundreds of years for gastrointestinal symptoms. Peppermint oil has several likely effects on the gastrointestinal (GI) tract. It is associated with calcium channel blockade in GI tract which can help with smooth muscle relaxation. Peppermint oil also is proposed to modulate visceral hypersensitivity which is a key pathophysiological etiology of DGBI and abdominal pain. It has implications for assisting with inflammation and psychosocial distress.5 Moreover, peppermint oil is safe and well tolerated.5 The next most used IM treatment was caraway oil. There is evidence on synergistic benefits of caraway oil in addition to peppermint oil.6 They share antispasmodic, prokinetic, and anti-inflammatory properties.6 Interestingly, caraway oil has been noted to have some antimicrobial properties and implicated to reduce fermentation in bowel. Gut fermentation is linked with gas and bloating symptoms in patients with IBS.6 Peppermint oil and caraway oil are well-established and well-tolerated options for patients with DGBI. They are relatively affordable and accessible over the counter. In our study population, peppermint oil was more commonly used in patients with lower abdominal pain compared to upper abdominal pain (where caraway oil is more commonly used). This may be related to peppermint oil's relative association with worsening in reflux symptoms.5 Next, there are non-ingested options for IM therapies that can be used and need more evidence. Acupuncture was used by 20.9% of the patients in this population. Acupuncture is a cornerstone of Traditional Chinese Medicine and has been used for over 2000 years. Yang et al. described how acupuncture can improve visceral hypersensitivity by modulating neurotransmitters in intestinal sensory endings, lowering peripheral sensation, and reducing pain-related neurotransmitter release. Acupuncture has additionally related to opioid release and balancing hypothalamic-pituitary-adrenal (HPA) axis hormones. These findings support acupuncture as a clinical adjuvant for IBS pain.7 Finally, this study shows that the use of other IM modalities (WebMAP, acupressure, nausea wristbands) are less commonly used. While this study does identify trends in IM strategies for management of DGBI, it is limited by retrospective design, so identifying use of many IM techniques may be underrepresented (ginger, L-glutamine, aloe vera, etc). These might have been used but were not reported or recorded in charts. Moreover, this study did not explore patient outcomes or perceived benefit of selected IM strategies. Future directions would include prospective studies and high-quality randomized controlled trials with a diverse patient population to evaluate the impact of IM therapies on outcomes and symptom burden. Socioeconomic analysis and differences could also be explored. IM is an emerging field in medicine, particularly in pediatrics. Children and adolescents with DGBI often experience disability, decreased functioning, and poor psychosocial outcomes. IM is a potential complementary option for these patients and helps to reduce pharmacologic burden and promotes holistic healing. Peppermint oil, caraway oil, and acupuncture were the most used in this practice. More evidence is needed to understand specific impacts of IM treatments on pediatric DGBI patients. Other, less frequently used, modalities may be potential targets of future research in pediatric DGBI. Dr. Santucci is funded by the NIDDK K23 grant # 1K23DK135797-01. Cincinnati Children's Gastroenterology and Nutrition Research Group: Kahleb Graham, Megan Miller, Jesse Li, Hanson Ton, Emily Romantic, and Kathryn Hitchcock. Dr. Neha Santucci: Key Opinion Leader for Kate Farms. This study strictly follows ethical guidelines as expected by the Cincinnati Children's Hospital Institutional Review Board. This study received IRB approval (IRB# 2021-0844). Informed consent was provided before participants were included in study and confidentiality was maintained through the study. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. 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