Lay Summary

What is asthma?
Asthma is a common chronic lung condition caused by inflammation, narrowing and spasms of the airways. Symptoms include coughing, wheezing, chest tightness, and difficulty breathing, some of which may be worse during the night. Although there are many causes of asthma attacks, common triggers for children include viral infections such as colds, airborne irritants such as cigarette smoke, allergies, exercise, weather or temperature changes, strong emotions and some medications. Asthma tends to run in families, especially those with allergic conditions.

How is asthma treated conventionally?
Conventional asthma therapies usually have two parts. The first part involves maintaining a healthy lifestyle that includes regular exercise and avoiding triggers (especially smoking). The second part of treatment uses medications to control symptoms and prevent or treat attacks. These medications work by decreasing airway inflammation and narrowing (corticosteroids or leukotriene modifiers) and by controlling airway spasms (bronchodilators).

What is Complementary and Alternative Medicine (CAM)?
Complementary and alternative medicine (CAM) is a group of diverse health care systems, practices and products that are not presently considered to be part of conventional medicine. (NCCAM. What is Complementary and Alternative Medicine. Health Information. 2002) Examples of CAM practices include massage therapy and acupuncture. Examples of CAM products (also known as natural health products) include Echinacea and St. John's wort.

What kinds of CAM are used to treat asthma?
There are many CAM therapies used to treat asthma. Many treatments have not been well studied in children, especially regarding effectiveness and safety. There are very few high-quality studies, and this can make it difficult to give good evidence-based advice. The information presented here is based on published research. In particular, randomized controlled trials (RCTs) of commonly used CAM and studies involving children were searched. For asthma, the focus will be on 8 kinds of CAM:
- Traditional Chinese Medicine (TCM)
- Acupuncture/acupressure
- Natural health products (NHPs)
- Homeopathy
- Massage therapy
- Chiropractic
- Osteopathy
- Mind and body interventions

Traditional Chinese Medicine (TCM)
TCM is an ancient Chinese system of medicine that includes meditation, herbal and nutritional therapy, restorative physical exercises, and acupuncture.

TCM herbs
The quality of studies identified was poor, and none of them involved children. In a review of adult studies, herbs that were reported to help were Ginkgo biloba, "Invigorating Kidney for Preventing Asthma" tablets, and Wenyang tonglulo mixture. Herbs that reportedly did not help were Ligusticum wallichii, "Strengthening body resistance" method and "Reinforcing kidney and invigorating spleen principle".

Safety of TCM
2 of the above studies reported side effects, but these were not described. Some herbal preparations from China have been found to be contaminated with toxins (i.e. heavy metals such as mercury or arsenic) and/or adulterated with prescription medications such as steroids. Reports of allergic reactions, and side effects involving blood, liver, heart and lungs after drinking Chinese teas are well documented.

Acupuncture
Developed in China over 2000 years ago, acupuncture uses a variety of techniques, such as thin needles, lasers and pressure, to stimulate specific anatomical points along meridians through which the body's vital energy, "qi", flows.

While several reviews found that acupuncture had no effect, one review found some benefit of acupuncture for asthma attacks. Most studies involved adults with a small number including children. 2 small studies of exercise-induced asthma in children had different results. The first study found that one laser acupuncture treatment had no benefit. The second study showed that exercise-induced asthma was prevented for 3 weeks by using needle acupuncture for 20 minutes, once a week during that period of time.

Safety of acupuncture
Acupuncture is very safe, with risk of complications estimated to be 0.05 per 10 000 treatments (5 in a million). The commonest side effects are needle pain, fatigue, and bleeding from the punctured area. Serious complications are rare, and include fainting, punctured lung (pneumothorax), injury to nerves and other tissues, and infections such as hepatitis.

Natural Health Products (NHPs)
NHPs are widely used for prevention and treatment of various conditions and to maintain health. Examples include herbals, homeopathic remedies, vitamins, minerals, probiotics, amino acids, and traditional medicines. Dosing and quality of products can vary significantly. More than 50 different herbs have been used to treat asthma.

Ivy leaf
Ivy leaf, the dried leaf of Hedera helix, is native to Europe and Asia. It is used for the treatment of coughs and other respiratory conditions. In three small studies involving children, one found some improvement on an asthma test (decreased airway resistance) in children given ivy leaf cough drops. The remaining two studies showed that ivy leaf as suppository and as syrup was as effective as ivy leaf cough drops.

Safety of ivy leaf
In one of the studies described above, only one out of 26 children had a side effect (worsening of eczema). Ivy has been reported to cause nausea and vomiting. It should not be used in pregnant women. Direct contact with the leaf can sometimes cause an allergic skin rash (contact dermatitis).

Butterbur
Butterbur root, Petasites hybridus, is used to treat pain, stomach cramps and asthma. One study of adults and children who took Butterbur extract for 2-4 months found that asthma tests, asthma symptoms and asthma attacks improved, and patients were able to decrease the dose of conventional medications by almost half.

Safety of butterbur
In a study of 80 patients, 7 had side effects, including sneezing, itchy/watery eyes and nose, stomach pains and gas, bad breath, hair loss, cough, trouble breathing and severe depression. However, based on physician's ratings of causality, the authors felt that these symptoms were not due to butterbur. Butterbur is related to ragweed, so allergic persons should avoid it. It can also cause stomach upset, headache, fatigue, and liver and kidney problems.

Dietary fatty acid
Omega-3 fatty acids contribute to anti-inflammatory signals in the body and are thought to help asthma by reducing airway inflammation. Foods such as flax and oily fish, like salmon and herring, are rich in omega-3 fatty acids. In contrast, omega-6 fatty acids are suspected to increase asthma.

In one study, infants given dust-proof mattress covers and fatty acid supplements for about 3 years had less allergic coughing (by 10%) and less dust allergy (by 7.2%), but no difference in wheezing when compared to children who didn't take fatty acid supplements and slept on regular mattresses.

Safety of dietary fatty acid
Although fatty acid supplements are thought to be safe, dietary sources from fish should be consumed with caution because of the potential for mercury and other heavy metal contamination. The U.S. Food and Drug Administration (FDA) and U.S. Environmental Protection Agency (EPA) jointly recommend that children not eat larger species of fish including shark, swordfish, king mackerel, and tilefish because they generally contain high levels of mercury. Children are more vulnerable to side effects from mercury, which can cause neurologic symptoms. The decision to eat such fish must balance the benefits with the potential for side effects from mercury.

Homeopathy
The principle that "like cures like" means that substances that cause symptoms at normal or high doses can cure them when given in small, highly diluted amounts.

Because homeopathic preparations are often individualized, studies are difficult to compare and to apply to the general public. One study of 89 asthmatic children found no difference in quality of life or in an asthma test (peak expiratory flow rate), after half received homeopathy and the other half took placebo for a year. There were concerns about the quality of the study which potentially affected the interpretation of the results.

Safety of homeopathy
Homeopathy is considered to be very safe since the preparations are very dilute, but it may be possible to trigger a reaction in an allergic person. Temporary worsening of symptoms, called "aggravation", can last a few hours and happens in 10-20% of patients.

Massage therapy
A small study involving 32 asthmatic children showed benefits of massage therapy in a comparison between massage and relaxation therapy. Children received 20 minutes of treatment by their parents at bedtime for 30 days. Both groups had decreased anxiety and better asthma tests but the younger children (4-8 years old) seemed to improve more than the older children (8-14 years old) for unknown reasons.

Safety of massage therapy
Massage therapy is very safe. There are 2 cases of stroke reported in adults after shiatsu-type neck massage.

Chiropractic
The World Federation of Chiropractic (WFC) defines chiropractic care as the diagnosis, treatment and prevention of mechanical disorders of the musculoskeletal system, and the effects of these disorders on the function of the nervous system and general health. It uses manipulation of the spine, joints and soft tissues to treat various conditions and to maintain/restore health.

2 studies comparing asthmatic children who received true and false ("sham") manipulations showed no benefit of therapy, although there were concerns about the quality of both studies.

Safety of chiropractic
Safety of chiropractic therapy in children is not known due to limited research. Children's bodies and spines are immature and they are more vulnerable to potential injury from rapid and forceful manipulations, especially young children and infants. Less forceful techniques may be less likely to cause spinal injuries. Serious events requiring hospitalization or resulting in permanent loss of function seem to be rare. Financial costs may be a barrier for some families.

Osteopathy
The World Osteopathy Health Organization defines osteopathy as a health care system that relies on manual contact for diagnosis and treatment. Various manipulative techniques are generally less forceful than chiropractic. Osteopathy emphasizes the structural and functional integrity of the body and the body's intrinsic tendency for self-healing.

There are very few studies in children. One study had several limitations but showed some benefit in improvement on an asthma test (peak expiratory flow) after 3 separate osteopathic techniques: rib raising, muscle energy for ribs, and myofascial release.

Safety of osteopathy
Safety of osteopathic therapy in children is not known due to limited research. Adverse events have generally not been reported, but spinal manipulation may cause injury. Financial costs may be a barrier for some families.

Mind-Body techniques
Mind-body medicine focuses on connections between the mind, including emotional, mental, social, spiritual and behavioural aspects, and the body. These interactions are considered to affect health directly.

Studies of mind-body medicine for treatment of asthma are small and there are concerns about their quality.

Psychological treatment
A self-management program involving breathing exercises, behavioural techniques to better manage asthma, and imagery on managing an asthma attack led to improvements in children, and results were even better when relaxation techniques were added.

Biofeedback
A monitor is used to amplify and feed back physiological data to the user, who can then learn to regulate this information.

The Smetankin Method uses a combination of pursed-lip breathing, abdominal breathing, and relaxation to affect respiratory sinus arrhythmia (RSA). RSA is a normal physiological variation in heart rate during inhalation and exhalation. In a very small study of 20 asthmatic children who received 13-15 half-hour training sessions, this method did not make a significant difference to asthma tests. However, this study had several limitations.

Hypnosis
Hypnosis describes an artificially induced altered state of consciousness during which the person is more open to suggestions, and may appear asleep. Its use in the treatment of asthma is controversial since it has been associated with anxiety and panic, which can trigger asthma attacks.

A few studies in children have shown some benefits using relaxation-mental imagery (RMI) exercises, a kind of self-hypnosis, which did not improve asthma tests, but did improve asthma severity, amount of missed school, and number of visits to the doctor or emergency. Hypnosis was also found to help asthma attacks, with better asthma tests and decreased need for medications.

Safety of mind-body techniques:
There are no well-established tools to assess side effects of mind-body therapies, but studies suggest that 5-54% of people may experience some forms of anxiety, unpleasant sensations or thoughts, or muscle spasms. Factors associated with such experiences include fear of letting go or losing control, restlessness, and feelings of vulnerability. These side effects may cause some people to stop therapy. In other cases, the feelings are used to therapeutically to explore and cope with these fears. Adequate preparation and supervision of therapy may help minimize and prevent such effects.

Conclusions

There is research showing that CAM may help children with asthma. However, many of the studies have significant limitations that make it difficult to offer advice with confidence based on their conclusions, whether positive or negative. These limitations include lack of safety information (especially long-term side effects), flaws in methodology, and small numbers of patients recruited. Evidence from single studies of a particular therapy should encourage further study and confirmation of conclusions, and the use of such therapies supervised with caution by health care providers. Pediatric dosing is often unknown and the quality of some natural health products is unreliable, making safety a further concern. Adults respond to therapies in ways that children may not, therefore assumptions based on adult experience can be inaccurate or even harmful. Products given to prevent illness, rather than for treatment, are often given every day during susceptible periods. For asthma, this means that children may be taking NHPs for many weeks or months during the cold season. Some therapies and products can be costly and add financial stress for families.

The following figure shows how the evidence for each CAM can be organized according to safety and effectiveness.

Green
Butterbur
Massage
Mind-body therapies

Blue
Acupuncture
Ivy leaf
Dietary fatty acid (omega-3) supplements
Homeopathy
Osteopathy

Yellow
TCM
Chiropractic

The CAM therapies are organized into colour-coded categories for clarity. Conventional medications can also be categorized similarly. For instance, many over-the-counter medications would fall into the blue area, and many prescription medications would fall into the yellow area. Some pediatric health issues can be potentially serious, especially if the condition is chronic, or multiple therapies, NHPs and medications are used together. The decision to use CAM should be based on each child's health and include discussion with the child's physician.

Each child is unique, and families must weigh the risks and benefits of all interventions as objectively as possible. This is especially important for therapies and products in which good evidence is limited or unknown. The information provided here is intended to promote discussion among parents and health care providers of children with asthma and is not meant to replace medical advice. More rigorous studies are needed to guide recommendations about effectiveness and safety of CAM for treatment of asthma, and to assist caregivers and families in making informed decisions about treatment options.

Funding: Partial funding support for this review was received from Passeport Santé.

Lay summaries: For more information in French, please see Passeport Santé.

Clinician summaries: Full scientific review article will be published in Pediatrics in Review.

Disclaimer: The information available on this website is intended to provide general information about complementary and alternative medicine (CAM). This website does not provide specific medical advice and the information provided should not be used as a substitute for seeking medical advice from a registered health practitioner. The opinions expressed on this website are not necessarily reflective of the opinion of the Stollery Children's Hospital, Capital Health Authority,Passeport Santé or Pediatrics in Review.