CAM in pediatrics: Use and potential dangers

Complementary and alternative medicine is defined by the National Center for Complementary and Alternative Medicine of the NIH as “a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional Western medicine.”

Many forms of complementary and alternative medicine (CAM) are available and used, and as evidence for efficacy slowly emerges for some therapies, the distinction between CAM and traditional medicine is constantly evolving. Categories of CAM can be listed as: 1) biologically based (eg, herbs, vitamins); 2) manipulative and body-based (eg, massage, chiropractic); 3) mind-body (eg, hypnosis, prayer); and 4) biofield (eg, acupuncture, homeopathy).

The reasons for use of CAM by adults and caregivers of children vary and include, among others, fear of adverse effects from conventional medications. Users of CAM may also consider some therapies to be safer (than traditional medicines), as they are more “natural.” One of the reasons that clinicians practicing traditional Western medicine may be hesitant to promote or recommend CAM is because of the many “unknowns” about its use, including efficacy and safety.

Recent evidence indicates that use of some CAM therapies may entail significant adverse effects. Although CAM has received increased attention and evaluation by Western medicine in recent years, few data from controlled clinical trials in children exist in the published medical literature. Caregivers of children or CAM practitioners may not consider this lack of data, and clinicians may not consider asking about CAM when taking histories from patients and when evaluating potential therapies for patient-specific medical conditions.

Use of CAM therapy among children and adolescents is not uncommon. Estimates of CAM use in the pediatric population vary from 2% to at least 50%. Studies of CAM use by children seen in ambulatory clinics have found usage rates of up to 40%. Children with recurrent conditions appear to use CAM more frequently, including children with autism, asthma, attention-deficit/hyperactivity disorder and other chronic disorders. Most of these children do not receive CAM alone, as they are concomitantly using traditionally prescribed therapies. The reasons for use of CAM by caregivers include personal and philosophical identification with CAM, availability of alternative treatment options, and concern of medication adverse effects, among others.

It is also important to note that several studies have documented that most caregivers do not disclose use of CAM for their children. One recent study of CAM and over-the-counter medication use in children with asthma seen in several primary care practices found that 54% of caregivers did not disclose usage to providers. Other studies have reported rates of non-disclosure as high as 66%.

CAM safety

Lim and colleagues recently sought to determine the types of adverse events associated with the use of CAM as seen by Australian pediatricians. Surveillance of various medical adverse events in children (birth–16 years of age) by use of monthly report cards was evaluated for 3 years (2001-2003). During this time, 46 reports of adverse events associated with CAM were made, with 39 cases further evaluated. Four fatalities were reported, which resulted from caregivers’ failure to use conventional medicine. One of the reported deaths was that of a 10-month infant whom succumbed from sepsis potentially related to use of homeopathic medicines and dietary restriction for chronic eczema.

Most cases were considered to be severe, life-threatening or fatal (64%) and either probably or definitely related to CAM (77%). Although these reports are limited by lack of more definitive data linking causation and CAM use, they provide reason for concern and further monitoring of the safety of CAM therapies and their associated use.

Although few data from controlled clinical trials are available to evaluate the safety profiles of CAM therapies, the literature includes other reports of adverse effects. Difficulties with evaluating the safety of CAM therapies, such as herbal therapy, include lack of regulation, standardization, and purification of herbal products. Adverse effects from a specific product may be caused by one of many herbal ingredients in the product, and because of less rigorous standardization regulations, products with similarly labeled ingredients may differ significantly in herb content and potency.

Numerous case reports of adverse effects and toxicities potentially caused by herbs and other CAM therapies have been reported, including seizures, hepatitis, cardiac arrhythmias and allergic reactions, among other effects. Some reports have documented contamination of several Asian CAM therapies with heavy metals (eg, lead, arsenic) and resultant toxicity. Other reports have shown that some herbal products can contain known pharmacotherapeutic agents. As shown in the study by Lim, and as documented in other studies, indirect adverse effects of CAM use includes dangers of withholding effective, conventional therapies in favor of CAM therapies.

Difficulties in assessing the safety and efficacy of some CAM therapies, such as herbal therapy, include differences in regulation and standardization of available products (as compared with conventionally used medications). Herbal products are considered to be “dietary supplements” by the FDA. With this designation, documented safety and efficacy before marketing and availability to the public is not required, as opposed to medications, which must be proved safe and effective before commercial public use. As well, manufacturers of herbal products are not required to report adverse effects of their products to the FDA, as is done with conventional medications. Vitamins are similarly classified as dietary supplements.

Additional information

As numerous CAM therapies are used, clinicians can benefit from dependable reference sources when evaluating specific treatments. The AAP has recently published two references on CAM use in children: 1) Counseling families who choose CAM for their child with chronic illness or disability (2001); and 2) The use of CAM in pediatrics (2008). An excellent Web-based resource for CAM is the National Center for Complementary and Alternative Medicine of the NIH (www.nccam.nih.gov). This Internet site lists CAM therapies, their common uses, evidence for efficacy, recently published studies and updated news on specific CAM therapies. An excellent book on various CAM therapies is the Natural Standard.

Conclusions

Numerous CAM therapies are available and are used by the pediatric population. Recent evidence indicates that some of these treatments may not be as safe as caregivers may assume them to be. Some CAM therapies may be effective, although few scientific data are available to support this efficacy. Important to the use of CAM by caregivers is the potential for lack of disclosure of use by caregivers when discussing past and current treatment options for a child with a clinician.

As several studies have shown, caregivers may not think to discuss CAM use, or they may be hesitant to admit to CAM use. It has been recommended that clinicians routinely ask about CAM therapies when obtaining medical histories. Asking patients and caregivers in a nonjudgmental manner about use of specific therapies (eg, use of herbs, vitamins, etc., instead of asking about complementary or alternative therapies in general) may allow a productive discussion to ensue about these therapies, including safety concerns and evidence for efficacy. Several readily available references on CAM use can help clinicians become more familiar with these therapies.

Edward A. Bell, PharmD, BCPS, is a Professor of Clinical Sciences at Drake University College of Pharmacy, Blank Children’s Hospital and Clinics in Des Moines, Iowa.

Disclosure: Bell reports no relevant financial disclosures.

For more information:

• AAP. Pediatrics. 2001;107:598-601.
• AAP. Pediatrics. 2008;122:1374-1386.
• Kruskal B. Acta Paediatrica. 2009;98:628-630.
• Lim A. Arch Dis Child. 2010;doi:10.1136/adc.2010.183152.
• Sidora-Arcoleo K. J Pediatr Health Care. 2008;22:221-229.
• Woolf AD. Pediatrics. 2003;112:240-246.