Alternative asthma therapies: An evidence-based revie · ALTERNATIVE ASTHMA THERAPIES apies because they are frustrated with modern medicine’s inability to “cure” asthma or

S uppose you agree with theNational Heart, Lung, andBlood Institute (NHLBI) asth-

ma guidelines that patient educationis essential for good asthma man-agement. You start a class for familiesof school-age patients, and find your-self barraged by questions about com-plementary and alternative medical(CAM) therapies.n Should we start our child onherbs or vitamins to help decreasehis need for medications?n I’ve heard that the Chinese haveused ma huang for thousands ofyears, and my friend says vitamin Chas really helped her asthma. Arethese remedies safe?n Can you refer us to an acupunc-turist or homeopathic practitionerfor supplementary treatments?

How do you answer questionslike these? Should you warn fam-ilies off these far-out, “unscientific”approaches, or just go along on theassumption that since these rem-

edies are “natural,” they’re proba-bly harmless? Is it possible thatsome of them work? How can youtell?

This article will help you eval-uate the claims and the evidence,focusing on biochemical, lifestyle,and biomechanical and bioener-getic alternatives to standard ther-apies (Table 1). The article is notmeant to replace information onstandard medical care, as outlinedin Dr. Kemper’s article, “A practicalapproach to chronic asthma man-agement,” in the August 1997 issueof Contemporary Pediatrics.

Why patients choosealternative therapyAlternative therapy is not often dis-cussed with physicians, but it iswidely used these days—especiallyfor children with chronic diseaseslike asthma. An Australian survey ofasthmatic children from 1 to 6 yearsof age, for example, showed that55% used alternative therapy. TheCAM therapies most commonlyused for asthma are dietary changes,herbal remedies, meditation, andhomeopathy.1

Families may seek CAM ther-

162 CONTEMPORARY PEDIATRICS Vol. 16, No. 3

TABLE 1

Alternative therapiesfor asthma

Biochemical

Herbs

Vitamins

Other nutritional supplements

Lifestyle

Diet

Exercise

Environmental changes

Mind-body therapies

Biomechanical

Massage

Spinal adjustment

Bioenergetic

Acupuncture

Healing touch

Prayer

Homeopathy

DR. KEMPER is Director, Center for HolisticPediatric Education and Research, Children’sHospital, Boston, MA.

DR. LESTER is Clinical Director, Pediatric AsthmaCenter, Children’s Hospital, and Instructor inPediatrics, Harvard Medical School, Boston.

Alternative asthma therapies: An evidence-based reviewBy Kathi J. Kemper, MD, MPH, and Mitchell R. Lester, MD

From Ma huang to bee pollen, deep breathing to acupuncture, alternativeasthma therapy is in vogue. You need to know what your patients areusing, whether it’s safe, and how it works. Here’s the evidence.

Cover story

March 1999 CONTEMPORARY PEDIATRICS 163

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ALTERNATIVE ASTHMA THERAPIES

apies because they are frustratedwith modern medicine’s inability to“cure” asthma or because they fearthe adverse effects of steroids andother common asthma medica-

tions. Or they may prefer the tra-ditional practices of their ethnicgroup, or want therapies that seemmore “natural” than the medica-tions physicians prescribe, or be

unwilling to relinquish controlover their children’s health to so-called experts.

Whatever the reason for choos-ing CAM, the most commonly usedtherapies are herbs and other di-etary supplements. Whether theyare purified or raw, synthetic or nat-ural, modern or ancient, herbs andsupplements work biochemically—just as standard medications do.Their risks and benefits can be eval-uated in randomized, double-blind,placebo-controlled clinical trials,and there may be more such studiesthan you are aware of.

Herbal remediesHerbal remedies are a mainstay ofethnobotanical medicine world-wide (Table 2). Cultural remediesthat are part of traditional Chinesemedicine (TCM), Kanpo (theJapanese indigenous medical sys-tem), Ayurvedic medicine (the tra-ditional medicine in India), andother traditional healing systemsrely heavily on herbs. Like medica-tions, herbs are believed to workthrough a variety of mechanisms.Some decrease inflammation(licorice root), while others sootheirritated airways (slippery elm barkand wild cherry bark), reduce an-xiety (kava kava), relieve bron-chospasm (ephedra), or dry secre-tions (Jimsonweed, also known asdatura). Herbs are used singly andin combination. The Puerto Ricanremedy, siete jarabes, is a combina-tion remedy, a honeyed syrup con-taining almond oil, castor oil, wildcherry, licorice, and cocillana.2

Many immigrants rely on tradi-tional therapies rather than main-


TABLE 2

An herbal ethnography

Culture Asthma remedies

Traditional Chinese medicine Shinpi-to

Licorice root (Glycyrrhiza glabra radix)

Ma huang (Ephedra sinica)

Gingko biloba

Kanpo (Japan) Saiboku-to

Sho-weiryu-to

Sho-saiko-to

Ayurvedic medicine (India) Coleus forskohlii

Tylophora indica

Mullein (Verbascum thapsus)

Hawaiian kahuna remedies Mamane (Sophora chrysopholla)

Kava kava (Piper methysticum)

Popolo (Solanum americanum)

Kukui (Aleurites molucana)

Puerto Rican Siete jarabes

Agua marvilla

Jarabe maguey

European Coffee and tea

Onions (Allium cepa)

Gingko biloba

Native American Evening primrose (Oenothera biennis)

Jimsonweed (Datura stramonium)

Licorice root

Mullein

Slippery elm bark (Ulmus flava)

Wild cherry bark (Prunus virginiana)


stream medications. To the extentthat herbs are not toxic and are animportant part of a patient’s culturalbelief system, they can be safely in-

corporated into a medical plan.The challenge for a mainstreamAmerican pediatrician is to knowwhich ones are safe and unlikely tointeract negatively with standardtreatments.

Coffee and tea. In the 1800s cof-fee was the treatment of choice forasthma. Epidemiologic data sup-port a relationship between coffeeintake and reduced respiratorysymptoms that may be mediatedthrough coffee’s xanthine content.Caffeine is chemically related totheophylline. Like theophylline, itincreases intracellular cyclic adeno-sine monophosphate (cAMP) andthereby relaxes bronchial smoothmuscles. In a large Italian study,adults who drank two to three cupsof coffee daily had about 25% lessasthma than adults who abstained.3

American data support a dose-effectassociation between coffee intakeand a reduced risk of asthmaticsymptoms. There are no recent,randomized controlled trials evalu-ating the effects of caffeine on

childhood asthma symptoms, noron the interaction between coffee,tea, colas, and modern asthmamedications.

Shinpi-to and saiboku-to.Clinical trials indicate somesteroid-sparing effects of the an-cient Chinese herbal combinationremedy, saiboku-to, reducing theneed for anti-inflammatory medica-tions in adult asthmatics taking itover several months. Saiboku-tocontains five herbs that slowsteroid breakdown, possibly in-creasing the risk of side effects (ordecreasing dosage requirements) inpatients dependent on oral steroids.Like the new asthma drug zileuton,saiboku-to and shinpi-to, anotherChinese herbal asthma remedy, in-hibit 5-lipoxygenase and thus thesynthesis of the pro-inflammatoryleukotrienes.4

Ma huang (Ephedra sinica). Thisherb has been an asthma remedyin China for over 5,000 years.Ephedrine, ma huang’s principle ac-tive ingredient, was included inmainstream medical therapies forpediatric asthma until the mid-1980s when it was replaced bymore specific b-agonist medicationsthat had fewer cardiovascular sideeffects. It continues to be a main-stay of natural herbal asthma reme-dies when used in combinationwith anti-inflammatory herbs suchas licorice root. Ephedra gained no-toriety in the 1990s as adolescentstried using it as a natural high. TheUS Food and Drug Administrationhas received over 600 complaints ofadverse effects, including 22 deaths,related to ephedra, a situation thathas led to tighter state regulations

on the availability and strength ofephedra-containing products aswell as a warning from the FDA.

Licorice root (Glycyrrhiza glabraradix). Folk medicines around theworld use licorice root to treatcoughs. The herb’s active com-pounds, glycyrrhetinic acid and car-benoxolone, are potent inhibitors ofcortisol metabolism, thereby en-hancing endogenous and exoge-nous steroid benefits and sideeffects. As recently as the 1960s,licorice was used successfully byAmerican physicians to treat Addi-son’s disease. Because of its in-hibitory effects on steroid break-down, side effects of licorice in-clude fluid retention, peripheraledema, hypertension, headaches,hypokalemia, lethargy, and muscleweakness. Similar effects were seenwhen troleandomycin (TAO), amacrolide antibiotic, was used in

combination with methylpred-nisolone. TAO delayed steroidbreakdown and improved asthmasymptoms, but also enhancedsteroid side effects; this led mostclinicians to abandon TAO as anadjunct in asthma treatment. Nostudies have yet evaluated the risks


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and benefits of including licoriceroot in a standard pediatric treat-ment regimen for asthma. Patientsusing licorice should be closelymonitored for steroid-like side effects.

Coleus forskohlii. This herb isused in Ayurvedic medicine to treatasthma. Like theophylline, it in-creases intracellular cAMP and isan effective bronchodilator.5 AnotherAyurvedic herbal remedy, Tylophoraindica, has proven beneficial incontrolled, double-blind cross-overstudies, but the most effectivedosages and long-term effects onchildren are unknown.6

Gingko biloba. This is one of themost widely used herbal remediesin Europe. Standardized extract ofGingko biloba (EGb), is sold underseveral different brand names:Ginkgobil, Rokan, Tanakan, Tebonin,and Kaveri. Ginkgo’s active ingre-dient, ginkgolide, antagonizesplatelet activating factor (PAF), andmay decrease airway inflammation.Ginkgo is also a powerful antioxi-dant. Although Gingko biloba hasa long history and a reasonablebiochemical rationale, only onesmall pilot study has evaluated itseffectiveness as an asthma remedy.That study found it protectiveagainst exercise-induced bron-chospasm; it also decreased par-ticipants’ reactivity to house dust

mite antigen.7 Its long-term use isstill experimental.

Onions (Allium cepa). Nine dif-ferent compounds isolated fromthis common folk remedy inhibitleukotriene synthesis in vitro.Crude onion extracts reduce exper-imentally induced bronchocon-striction in guinea pigs.8 Onionsare extremely safe and well toleratedin normal diets. Hypersensitivity israre. Additional research is neededto determine the best dose and fre-quency of onion supplements forasthmatic children.

Bee pollen. This substance hasbeen widely touted as a naturalremedy for atopic diseases. Thereare no clinical trials evaluating itseffectiveness in treating childhoodasthma. Serious allergic reactionsand even fatalities have been re-ported. This is not a safe adjunctivetherapy for asthmatic patients.

Herbal products are not regulatedby the FDA. Consumers who relyon them must beware of the poten-tial for variations in purity and po-tency, and contamination with otherherbs, insects, pesticides, herbi-cides, heavy metals, and even med-ications. Consumers need to un-derstand that herbal products arenot necessarily safe (or organic)simply because they are natural.Evidence for the safety and efficacy



Herbal products are not regulated bythe FDA. Consumers must be awareof the potential for variation in purityand potency.

]Take-home message

educational supplement

Mailing with the May issue

Skin abnormalities in neonates

By these experts:

n Lawrence A. Schachner, MD

University of Miami School of Medicine

n Ronald C. Hansen, MD

University of Arizona, Tucson

n Anne W. Lucky, MD

University of CincinnatiCollege of Medicine

n Amy S. Paller, MD

Northwestern University School of Medicine

The supplement is based on a symposium held at the1999 Masters of Pediatricsmeeting and is made possible through an educational grant fromProcter & Gamble.

a Medical Economics Company publication

®

Continued on page 173


of herbal remedies for asthma issummarized in Table 3.

Nutritional supplementsThe vitamins and minerals mostcommonly recommended for asthma

include vitamin B6, vitamin C,magnesium, and selenium. Saltrestriction is also recommended.

Vitamins. In a double-blind,placebo-controlled study of steroid-dependent adult asthmatics, 300 mg

of pyridoxine (Vitamin B6) supple-ments taken daily significantly im-proved morning peak flow rates.There was no benefit on acutesymptoms. In a case series of adultasthmatics who had low serum


TABLE 3

Evidence on herbal remedies

Randomized Benefits Side effects/ PurportedHerb controlled trials demonstrated drug interactions mechanism

Coffee/tea None recently in Epidemiologic data Tachycardia, insomnia, Methylxanthineschildren suggest fewer jitters, decreased Increased intracellular cAMP

symptoms in appetite, potential Bronchodilatorcoffee drinkers interaction with b-agonist

Shinpi-to None in children Yes, in historical Unknown. Potential Inhibits 11 b-hydroxylasedata increase in steroid Blocks 5-lipooxygenase

side effectsInhibits platelet activating factor (PAF)

Ma huang Yes Yes Cardiovascular and b-agonist(Ephedra sinica) CNS toxicity Bronchodilator

Deaths reported

Potential interactionwith b-agonists

Licorice root No Case series Pseudohyperaldosteronism Inhibits 11 b-hydroxylase(Glycyrrhiza glabra suggests Hypertension and cortisol breakdownradix) steroid-sparing

Peripheral edemaeffectsPotential increase insteroid side effects

Coleus forskohlii No Yes, in case series Unknown Decreases cAMP metabolismin adults Bronchodilator

Tylophora indica Yes, in adults Yes Unknown Unknown

Gingko biloba No Yes, in pilot study Unknown PAF antagonist

Antioxidant

Onions (Allium cepa) No Yes, in vitro Hypersensitivity Blocks leukotriene synthesis

Animal data (rarely)

support use

Bee pollen No No Anaphylaxis Unknown



levels of pyridoxine, supplementa-tion led to fewer and less severewheezing episodes. Pyridoxinesupplements of 200 mg per day re-duced the number of asthma at-tacks, the severity of symptoms,and the need for medications in adouble-blind study of 76 asthmaticchildren.9 Side effects are rare withthese doses. Pyridoxine supple-ments may be particularly helpfulfor children whose serum levels ofpyridoxal phosphate have been de-pleted by chronic theophylline use.Antioxidant vitamins are commonlysuggested complementary ther-apies for asthma. Adults whosediets are naturally high in anti-oxidants such as vitamin C– andvitamin E–rich foods have thefewest pulmonary problems. Sixmonths of daily vitamin C (1 g perday) failed to reduce asthma symp-toms in one study, but did reduce

them in another double-blind compar-ison trial. In some children, 500 mg oforal vitamin C has a protective ef-fect against exercise-induced asth-ma.10 Taking 500 to 1,000 mg perday is probably safe for most chil-dren, although higher doses maylead to diarrhea. Additional studies

are necessary to determine the ef-fectiveness and optimal dosing, fre-quency, and duration of vitamin Csupplementation.

Magnesium. Dietary magnesiumintake is strongly correlated withasthma symptoms; the more mag-nesium, the fewer the symptoms.Intravenous magnesium has provenhelpful in treating pediatric statusasthmaticus. In a randomized, con-trolled, double-blind cross-overstudy of oral magnesium supple-mentation (400 mg daily) in adults,there was a statistically significantimprovement in asthma symptomsand a small reduction in bron-chodilator requirements, but nosignificant change in pulmonaryfunction tests during the threeweeks of treatment.11 Additionalprospective, controlled studies areneeded to evaluate the effectivenessand safety of oral magnesium sup-plements in preventing childhoodasthma episodes.

Selenium. Plasma and erythro-cyte levels of selenium and the ac-tivity of the selenium-dependentenzyme glutathione reductase arelower in asthmatic adults than innonasthmatics. However, no clin-ical trials document benefits to pe-diatric asthma patients from seleniumsupplements.

Salt restriction. While bronchialsensitivity to methacholine is in-creased by high salt intakes, a pe-diatric case control study found noassociation between levels of saltintake and asthma or exercise-induced bronchospasm. Studies arenot strong enough to suggest thatasthmatic children should severelyrestrict their salt intake.

Fatty acids. Omega-3 fatty acids(found in fish oils, canola oil, andflax seed oil) have been touted asimportant anti-inflammatory food

supplements. Omega-3 fatty acidslimit leukotriene synthesis byblocking arachidonic acid metabo-lism. Eating fresh oily fish (cod,mullet, orange roughy, salmon,tuna, mackerel, rainbow trout) isassociated with a significantly re-duced risk of asthma and improvedpulmonary function in large epi-demiologic studies in both adultsand children.12 In a long-term,double-blind trial of supplementa-tion with one g daily of fish oil inadult asthmatics, pulmonary func-tion tests did not improve until theninth month of treatment.13 Manyasthmatics may consider this toolong to wait. Canned fish and saladbar shrimp containing sulfitesshould be avoided in sensitiveasthmatics. However, fresh fish isgenerally well tolerated and can bereasonably recommended as part of alife-long healthy diet. Additional re-search is needed before recommend-ing routine supplementation withfish oil capsules for asthma. Evidencefor the safety and efficacy of nutri-


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tional supplements is summarized inTable 4.

Lifestyle therapiesLifestyle therapies that address theasthmatic child’s environment arecentral to the control and preven-tion of asthma symptoms in main-stream medicine. Unfortunately,there is no alternative therapy forhousecleaning, although manyCAM enthusiasts wish there were.

CAM lifestyle recommendations,in addition to environmental mea-sures, generally involve three ar-eas: diet, exercise, and mind-bodytherapies.

Diet. Many families blame foodallergies for asthmatic symptoms,even though only 2% to 3% of pa-tients react to double-blind, placebo-controlled food challenges. SomeCAM enthusiasts routinely adviseasthmatics to follow elimination diets

(restricting major allergenic foods),minimal diets (allowing only a verysmall number of foods), vegan di-ets, or diets excluding putative trig-gers (such as dairy products).14,15

Despite the lack of evidence fromfood challenge tests, recommend-ing dietary changes has a powerfuleffect. In a study of adult asthmat-ics, 79% of respondents who hadtried a restricted diet reported im-provement in their asthma symp-


TABLE 4

Evidence on nutritional supplements

Randomized Benefits Side effects/controlled trials demonstrated drug interactions Purported mechanism

Vitamin

Vitamin B6 Yes Yes, in mild disease Large doses may cause Tryptophan metabolism(pyroxidine) or if taken for at peripheral neuropathy

least 4 wk

Vitamin C Yes Mixed results Diarrhea with overdoses Antioxidant

Mineral

Magnesium Yes Yes, for acute High doses may cause Smooth muscle relaxantasthma when nausea, hypotension,given IV muscle weakness

Mixed data for oralsupplementation

Selenium No No Alopecia, liver disease, Antioxidantcardiomyopathy, fatigue,nail loss, nausea

Salt restriction No No. High salt intakes Hypertension Unknownassociated with with high salt intake increased symptoms in adults

Other

Fish oil (omega-3 Yes Mixed results Rare increased bleeding Leukotriene synthesisfatty acids) Up to 9 mo of

supplementationmay be needed

toms. While restricted diets may behelpful in a minority of patients,they should be strictly supervisedby a nutritionist and limited tobrief trials to prevent deficiencies.In the absence of documented foodallergies, there is no conclusive evi-dence that restricted diets are help-ful in reducing asthma symptoms.

Dairy products are often blamedfor inducing respiratory symptomsand restricted in the diet of patientswith asthma. However, amongadult asthmatic patients who be-lieved their symptoms were trig-gered by dairy foods, milk wasnot significantly more likely thanplacebo to trigger symptoms inrandomized, blinded challenges.16

Dairy restriction is potentially dan-gerous for children with steroid-dependent asthma, who need cal-cium’s protective effects to main-tain bone density. No controlledtrials indicate significant benefitsto eliminating dairy products fromthe diets of most children withasthma.

Exercise. Nearly 90% of asthmat-ics find that exercise, especially incold, dry air, triggers symptoms.Nevertheless, the benefits of cardio-vascular fitness are so importantthat children with asthma shouldbe encouraged to exercise. Asthmais easier to control in patients whoare physically well conditioned, andasthmatic symptoms triggered byexercise can be readily controlled.Many Olympic-caliber athletes haveasthma and have set world recordsfor athletic performance.

Despite theoretical concernsabout eliciting the diving reflex orchlorine-precipitated bronchospasm,

swimming is commonly recom-mended as beneficial exercise forasthmatic children. Studies of swim-ming programs have not demon-

strated that swimming is better thanother aerobic conditioning programs,but they generally indicate longitud-inal improvements in overall fitness,swimming ability, and self-esteem.Spa treatments (swimming in hotspring or mineral water) may beeven better. In a cohort study ofadults with severe, steroid-dependentasthma who received spa therapy,69% experienced significant clinicalimprovement; rates of improvementwere even higher among older pa-tients (41 to 60 years of age) andthose with more severe disease.17

Similar studies have not been done inchildren, nor are insurance compa-nies likely to race to reimburse thisform of therapy.

Controlled breathing. Yoga, par-ticularly yogic breathing (pran-ayama), may help reduce the fre-quency of asthma attacks.18 Yogabreathing exercises emphasize slow,regular breaths in which the ratioof inhalation to exhalation is 1:2;inhaling hot, moist air can enhancethe benefits.19 Long-term (one tofour years) follow-up of asthmatic

adults indicated sustained improve-ment in pulmonary function andexercise tolerance and decreasedreliance on rescue medications fol-lowing a four-week yoga therapytraining program.20 A randomized,controlled trial of yoga training inyoung adult asthmatics resulted ingreater calm, improved attitudes,enhanced exercise tolerance, de-creased asthma symptoms, anddecreased use of asthma medications,but no changes in pulmonary func-tion tests.21 Additional studies areneeded to determine the most effec-tive components, duration, and fre-quency of training and practice, butthese exercises are safe for patientswho are interested in exploringalternative exercise programs.

Other types of breathing exercis-es frequently suggested for asthmacombine aspects of physical train-ing and mind-body interventions.Training may include voice lessonsto improve breath control andfunctioning of the diaphragmthrough relaxation and posturalchanges. In a randomized, con-trolled trial of German adults withmild asthma, breathing exercisessignificantly improved pulmonaryfunction. These long-term im-provements were comparable tothe short-term benefits of inhaledb-agonist medications.

A recent breathing exercise fadin the popular press and on theInternet is Buteyko breathing. Thistechnique is named after a Russianphysician, Konstantin Buteyko,who believed that “over-breathing”or deep breaths cause a number ofdiseases, including asthma, and thatto reduce asthma symptoms, pa-



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tients should be trained to “breatheless.”22 This is nonsense. Never-theless, since your patients are likelyto encounter moving testimonialsabout this technique, you should befamiliar with it. Information aboutButeyko is available on the web atwww.buteyko.com.

Environmental manipulation.While there is plenty of evidence tosupport reducing exposure to dustmites, cockroaches, animal dan-ders, and other allergens and sensi-tizers in the environment, claimsare being made for alternative de-vices that purport to purify the en-vironment. No studies support theuse of such devices as ozone or iongenerators, vaporizers, aromather-apy, magnets, or radionic devices.On the positive side, there are noknown adverse effects of thesetherapies, either.

Mind-body therapies. Childrenwith asthma are more likely tohave symptoms when they arestressed. Stress management cantake a variety of forms and may behelpful for both parents and chil-dren. Transcendental meditationhas proven helpful in improvingpulmonary function among adultasthmatics who practice it regu-larly. Progressive relaxation train-ing augments the benefits of acomprehensive asthma managementprogram for children. Autogenictraining (in which patients silentlyrepeat relaxing affirmations) canalso help manage stress and improvepulmonary function when practicedover several months. Just three ses-sions of systematic relaxation train-ing improved pulmonary functionsin asthmatic children more than

three sessions of simply sittingquietly.23

Hypnosis has proven useful inimproving symptoms and pul-monary function, enhancing pa-rental confidence in managingtheir children’s asthma, and reduc-ing the amount of medication andnumber of physician visits for asth-matic children, even preschoolers.24

Physicians experienced in usingclinical hypnosis may help patientsreduce reactivity to allergens, re-liance on oral steroids, and evenrates of hospitalization. Mostclaims are of modest symptomaticrelief, with few complete cures.Additional studies are needed toassess types of training, frequency,and duration, and the patients forwhom hypnosis is most likely tobe helpful.

Asthmatic children can learn toreduce air-flow resistance throughbiofeedback training. Regularlypracticing biofeedback can improveattitudes about asthma, reduceanxiety levels, reduce the frequency


The benefits ofcardiovascularfitness are soimportant thatchildren withasthma shouldbe encouragedto exercise.

]Take-home message

and severity of asthma symptoms,and lower medication use andemergency room visits.25 The types,duration, and frequency of biofeed-back training and patients mostlikely to benefit remain unknown.

Stress reduction and mind-bodytreatments work only when prac-ticed regularly, so families must becommitted and persistent in follow-ing these programs. Try to find outwhat kind of therapies appeal to

your patients, so that they choosetreatments they are likely to keepup. Additional studies are needed toassess the most effective types oftherapy for children of differentages. The pros and cons of these



TABLE 5

Evaluating lifestyle therapies

Therapy Benefits demonstrated Risk

Diet

Vegan, macrobiotic, vegetarian, Strong placebo effect Nutritional deficiencieselimination diets No controlled trials in children

Non-dairy diet Possible, in children with known allergy Nutritional deficiencies, especially calciumto dairy foods

Exercise

Swimming No proven asthma benefit compared Same as for children without asthmawith other conditioning programs

Improves general conditioning

Yoga breathing exercises Effective in adolescents and young adults None except time needed for practicein controlling asthma symptoms and improving pulmonary function

Other breathing exercises Helpful in adults None except time needed for practice

No studies in children

Environment

Avoiding triggers Yes Cost and inconvenience

Ion generators, ozone devices, No proven effectiveness in adults Costradionic devices, magnets, or childrenaromatherapy, vaporizers

Mind-body

Autogenic training Yes in adults Time for ongoing practice


Biofeedback Yes in children and adults Time for ongoing practice

Hypnosis/guided imagery Yes, even in very young children Time for ongoing practice

Meditation Yes in adults Time for ongoing practice


Progressive relaxation Yes in adults and children Time for ongoing practice



lifestyle therapies are summarizedin Table 5 on page 186.

Joints, muscles,and energy fieldsBiomechanical and bioenergetictherapies rely on manipulation ofthe patient’s body and of unseenenergy fields believed to influencehealth and disease.

Massage. This traditional thera-peutic modality not only feels goodbut has been shown to reduce stressand anxiety. In a recent random-ized, controlled trial, 20 minutes ofmassage given by parents at bed-time for a month helped improvechildren’s pulmonary function tests,even compared with standard re-laxation exercises.26 The necessaryfrequency, duration, and long-termbenefits of massage therapy remainunknown. However, when parentsdo the massage, costs and side ef-fects are minimal. You can safelyrecommend this complementarytherapy for families to try.

Chiropractic. Some chiropractorsclaim to benefit a variety of clinicalconditions, including asthma. Onlyone randomized clinical trial hasinvestigated this claim; it did notfind that real chiropractic therapyoffered any benefit beyond shamchiropractic. There is no scientificbasis for recommending chiro-practic therapy for the relief ofasthma symptoms in children. Itoffers no proven clinical benefit,and may—because of frequent vis-its and X-rays—increases health-care costs and dependence on healthprofessionals.

Acupuncture. All of the bioener-getic therapies rely on a belief in an

unseen vital or healing energy thataffects patients’ health and well-be-ing. Practitioners can affect theflow, amount, or intensity of thishealing energy through a variety oftechniques.

In acupuncture, the vital energy,known as qi or chi, flows throughchannels and can be balanced byproper placement and stimula-tion of acupuncture needles. Tra-ditional Chinese medical practi-

tioners claim that asthma is oneof the conditions most amenableto acupuncture, but data fromcontrolled trials offer conflictingresults. Most clinical trials havenot been methodologically rigor-ous but do support a modest rolefor acupuncture for adult asth-matics.27 In one case series,acupuncture was effective inaborting acute attacks if the needlesensation was felt strongly andneedles were left in place with fre-quent stimulation for 15 to 60minutes. In one controlled trial,true acupuncture performed 20minutes before exercise was moreeffective than sham needling in re-ducing exercise-induced asthma.28

Another study, on the contrary,found no benefits of acupuncture

in preventing exercise-inducedbronchospasm.

Adverse effects of acupunctureare exceedingly rare. A MedLinesearch for the years 1981 to 1994revealed a total of 193 patients withreported adverse events. These in-cluded several pneumothoraces,one of which led to death, and anadditional death from status asth-maticus. Although these side ef-fects are rare, they underscore theimportance of regarding acupunc-ture as an experimental, adjunctivetherapy and cautioning patientsagainst substituting acupuncturefor conventional medical care.

Healing touch and prayer. Theseare commonly used healing tech-niques in nearly every culture. Inhealing touch, reiki, and noncon-tact therapeutic touch, healerstransmit healing energy throughtheir beneficent intent, focusingthe flow of energy through theirhands. Prayer does not require theuse of hands or even the physicalpresence of the healer to intervenewith spiritual powers or unseenforces. We were able to find onlyone study that evaluated the effec-tiveness of healing touch or prayeron patients with asthma. In an un-controlled pilot study performed inGermany, 12 patients all receivedtreatments from a healer whoplaced his hand on the patients’chests for one to three minutes ofhealing; an average of 17 to 18treatments were given over an eight-week period. Most patients felt im-proved and several were able to re-duce their use of medication.29

Regardless of whether or not onebelieves in a healing energy, these


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types of treatments certainly appearto be safe as long as patients donot abandon mainstream medicaltherapies without consulting theirphysician.

Homeopathy. This mode of treat-ment is not based on classicalchemical or physical laws, but onthe two principles of “like cureslike” and the “law of dilutions.”The first principle means that aremedy is chosen because of itstendency to cause the same symp-toms patients experience as part oftheir illness. The second meansthat the remedy gains in potencythe more dilutions it undergoes;the most potent remedies are thosethat are diluted to the point atwhich they contain no moleculesof the therapeutic compound.Homeopathy fits into the bioener-

getic category because pracitionersbelieve that dilution imparts andamplifies healing energy or infor-mation from the original remedyto the diluted medication. Thathealing energy is then used by thepatient’s inner self to encouragehealing.

A 1994 placebo-controlled trialof homeopathy in the treatment ofadults with allergic asthma con-cluded that true homeopathy wassuperior to placebo in reducingasthmatic symptoms. Pulmonaryfunction tests showed no sig-nificant differences, however. Nostudies have evaluated the ef-fectiveness of homeopathy in treat-ing children with asthma. Home-opathic remedies may be assumedto be quite safe biochemically, andmay be a harmless, inexpensive,

and useful placebo. They cannotbe recommended as active ther-apy or replacement for standardtreatment, however. The evi-dence for effectiveness and risk ofthese biomechanical and bioener-getic therapies is summarized inTable 6.

Summing upthe evidenceComplementary and alternativemedical therapies are used fre-quently by children suffering fromchronic illnesses such as asthma.Many herbs and nutritional sup-plements are similar to or have be-come mainstream medical ther-apies. Combination herbs contain-ing anti-inflammatory compoundsmay reduce dosage requirementsfor standard medications, butcould potentiate the side effects oforal steroids. Herbal adrenergicstimulants run the risk of seriousside effects. Nutritional supple-ments such as vitamin B6, VitaminC, magnesium, and fish oil may behelpful but are no substitute for ahealthy diet. More research isneeded to ascertain how best to in-tegrate nutritional supplementsinto mainstream care for childrenwith asthma, both to promote ef-fectiveness and to reduce side ef-fects and costs. Safe recommenda-tions include a diet containingplenty of antioxidant-rich freshfruits, onions and other vegetables,and fatty fish.

Exercise, including yoga andbreathing exercises, should be en-couraged for children with asthma.Effective environmental therapiesstress avoidance of allergens and



TABLE 6

Evaluating biomechanical and bioenergetic therapies

Therapy Benefits demonstrated Risk

Biomechanical

Massage Yes, even in children when Noneprovided by trained parents

Spinal manipulation Anecdotal evidence only Cost, X-ray exposure

Bioenergetic

Acupuncture Conflicting data Cost; very rare needle

More studies needed breakage, pneumothorax, infection

Healing touch Positive results in one Nonecase series

No controlled trials in children

Prayer No controlled trials in children None

Homeopathy One study with minimal Nonepositive impact in adult asthmatics



other triggers. Stress management isimportant; a variety of techniquesmay be helpful, depending on pa-tient preferences. Massage therapyappears promising, at minimal costand little risk of side effects.Acupuncture cannot be routinelyrecommended without additionalresearch in children but need not bediscouraged. Prayer and healingtouch have not undergone rigorousstudy, but are safe ancillary thera-pies. Homeopathy may offer an in-expensive placebo, but has not beenadequately tested in children.

New fads are bound to comealong with extravagant claims foreffectiveness. While some alterna-tive treatments may offer modestbenefit for helping children withchronic asthma, none are recom-mended as a replacement forstandard medical therapies andnone should be the sole treatmentfor acute symptoms. Asthmamanagement plans should stressprompt medical care if symptomspersist or worsen on existingtreatments. □

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