Complementary and alternative medicine use among children in the Washington, DC area.

OBJECTIVE: To determine the prevalence and reasons for complementary and alternative medicine (CAM) use among children in primary pediatric care practice in the Washington, DC area. DESIGN: Cross-sectional survey of parents at 4 Children's National Medical Center Pediatric Research Network (PRN) practices from July 1998 through November 1998. Survey information included demographics, child health problems, satisfaction with health care, and CAM use over the past year. RESULTS: Parents completed 348 surveys. Forty percent (138) of parents were CAM users themselves, whereas 21% (72) had treated their child with CAM over the past year. Factors positively associated with child CAM use included parents' use of CAM (P <.0001); greater parent age (P =.0005); greater child age (P =.001); and complaints of frequent respiratory illnesses, asthma, headaches, and nosebleeds. Ethnicity and parental education were not associated with child CAM use. Over 50% of pediatric CAM users reported specific vitamin supplementation, whereas 25% used other nutritional supplements or elimination diets, and over 40% used herbal therapies. Thirty-two percent of CAM users had visited a CAM practitioner; 81% of pediatric CAM users would have liked to discuss it with their pediatrician, but only 36% did so. CONCLUSION: Treatment of children with CAM is common and is frequently undertaken by parents without the knowledge or advice of their pediatrician.     

Don't Ask, Don't Tell: Parental Nondisclosure of Complementary and Alternative Medicine and Over-the-Counter Medication Use in Children's Asthma Management

INTRODUCTION: Parent-health care provider (HCP) communication is an important component of pediatric asthma management. Given the high prevalence of complementary and alternative medicine (CAM) and over-the-counter (OTC) medication use among this population, it is important to examine parental nondisclosure of these asthma management strategies. METHOD: One-time interview and 1-year retrospective medical record review with 228 parents of 5- to 12-year-old children with asthma enrolled from six pediatric primary care practices examining parental nondisclosure of CAM and OTC medication use, reasons for nondisclosure, medical record documentation of CAM usage, and association between parent-HCP relationship and nondisclosure. RESULTS: Seventy-one percent of parents reported using CAM and/or OTC medication for children's asthma management, and 54% of those parents did not disclose usage. Seventy-five percent "did not think" to discuss it. Better parent-HCP relationship led to decreased nondisclosure. DISCUSSION: HCPs can play an important role in creating an environment where parents feel comfortable sharing information about their children's asthma management strategies in order to arrive at a shared asthma management plan for the child, leading to improved asthma health outcomes.     

Concluding comments: maximizing good patient care and minimizing potential liability when considering complementary and alternative medicine

Our goal for this supplemental issue of Pediatrics was to consider what practitioners, parents, patients, institutions, and policy-makers need to take into account to make good decisions about using complementary and alternative medicine (CAM) to treat children and to develop guidelines for appropriate use. We began by explaining underlying concepts and principles in ethical, legal, and clinical reasoning and then used case scenarios to explore how they apply and identify gaps that remain in practice and policy. In this concluding article, we review our major findings, summarize our recommendations, and suggest further research. We focus on several key areas: practitioner and patient/parent relationships; decision-making; dispute resolution; standards of practice; hospital/health facility policies; patient safety; education; and research. Ethical principles, standards, and rules applicable when making decisions about conventional care for children apply to decision-making about CAM as well. The same is true of legal reasoning. Although CAM use has seldom led to litigation, general legal principles relied on in cases involving conventional medical care provide the starting point for analysis. Similarly, with respect to clinical decision-making, clinicians are guided by clinical judgment and the best interests of their patient. Whether a therapy is CAM or conventional, clinicians must weigh the relative risks and benefits of therapeutic options and take into account their patient's values, beliefs, and preferences. Consequently, many of our observations apply to conventional and CAM care and to both adult and pediatric patients.     

Survey of complementary and alternative medicine use at a tertiary children's hospital

OBJECTIVE: The use of complementary and alternative medicine (CAM) within the Australian community is common. The objective of this study was to determine the prevalence and pattern of CAM usage in children attending a tertiary children's hospital. METHODS: We conducted a cross-sectional survey of children attending the Royal Children's Hospital, Melbourne. Children were identified by consecutive acute admissions and attendance at outpatient clinics. A structured questionnaire with items about the use of CAM in the preceding year was administered by means of a face-to-face interview. RESULTS: Based on the 503 children surveyed, 51% reported CAM use in the preceding year. Forty-three percent had used at least one CAM medication. The most common medicinal CAM used were multivitamins, vitamin C, herbal remedies and homeopathic treatments. Non-medicinal CAM was used by 23% of the participants. The most commonly used therapies were chiropractic, naturopathy, aromatherapy, therapeutic massage and dietary restriction. The main reasons stated for CAM usage included promotion of general health and treatment of colds. Sixty-three percent of those reporting CAM use had not discussed this with their treating doctor. CONCLUSION: The use of CAM by children is common. Complementary and alternative medicine is particularly used for the treatment of common illnesses and conditions of childhood. Importantly, use is not always conveyed to treating physicians. Given the potential risk of adverse events associated with the use of CAM or interactions with conventional management, doctors should ask about their use as a part of routine history taking.     

Informed consent: advising patients and parents about complementary and alternative medicine therapies

Although research on complementary and alternative medicine (CAM) therapies is still limited, systematic reviews have revealed sufficient evidence to conclude that CAM can be effective for certain conditions. In this article we discuss clinicians' responsibilities to inform parents/patients about CAM alternatives and use the example of acupuncture for chemotherapy-induced nausea and vomiting. Chemotherapy-induced nausea and vomiting remain significant adverse effects of cancer therapy, and some patients cannot find relief with standard therapies. When making decisions for a child with a life-threatening illness, parents must consider all reasonable options and decide what is in the child's best interests. A physician's failure to provide parents with relevant information regarding therapies with the prospect of therapeutic benefit impedes their ability to make an informed decision. Physicians have the ethical duty of beneficence; they must be aware of current research in pain and symptom management and other aspects of care. A physician's duty of care does not necessarily include the obligation to provide information about therapies outside the range of conventional treatment or those not yet supported in the medical literature. However, as CAM therapies such as acupuncture become better studied and their safety and efficacy are established, the scope of disclosure required may expand to include them. The legal and ethical obligation to obtain informed consent to treatment requires disclosure and discussion of therapies when there is reliable evidence of potential therapeutic benefit. At the same time, the more limited state of knowledge regarding effects of a particular therapy in the pediatric population must be factored into decision-making when treating a child.     

Children's visits to providers of complementary and alternative medicine in San Diego.

OBJECTIVE: Increased attention has been focused on the growing use of complementary and alternative medicine (CAM); however, few studies have included children in the general US population. The present study investigated children's visits to CAM providers and factors associated with these visits. METHODS: Analysis of cross-sectional data from the 2001 United Way Outcomes and Community Impact Program telephone survey, a representative sample of households in San Diego County, California. We selected households with children younger than 19 years of age (N = 1104). Parents reported on children's CAM visits in the past year. RESULTS: Approximately 23% of parents reported that their child saw a CAM provider in the past 12 months. CAM care was sought for sick and routine care. Children of white parents had greater odds of having a CAM visit in the past year compared with children whose parents were Hispanic (adjusted odds ratio 1.71, 95% confidence interval [95% CI] 1.11-2.63). Children whose parents were college graduates had a greater likelihood of seeing a CAM provider than children of parents with high school education (adjusted odds ratio = 1.82, 95% CI 1.19-2.79). Children who were insured were also more likely to have CAM visits than uninsured children (adjusted odds ratio = 2.32, 95% CI 1.04-5.21). CONCLUSIONS: Visits to CAM providers were much more common among children in the general San Diego population compared with 1996 national estimates. Pediatric health care providers should remain aware that their patients may be using CAM so they can provide coordinated care.     

Use of complementary/alternative therapies among children in primary care pediatrics.

OBJECTIVES: To determine the prevalence of and factors associated with use of complementary/alternative therapies (CAM) by pediatric patients seeking primary care. DESIGN AND SETTING: A self-report questionnaire was administered to parents/caregivers in 6 general pediatric practices in urban and suburban Detroit from August 1999 to December 1999. RESULTS: A total of 1013 questionnaires were completed; 67.5% of the patients were 5 years of age or younger. The overall use of CAM was 12%. Factors in families associated with use of CAM were maternal age greater than 31 years (P =.001), religious affiliation (P =.001), parent/caretaker born outside of the United States (P =.04), and use of CAM by the parent/caretaker or his/her spouse (P =.001). Significant factors associated with the children who used CAM were age greater than 5 years (P =.001), pediatric visit for an illness (P =.05), regular medication use (P =.001), and having an ongoing medical problem (P =.001). The most common types of CAM used were herbs (41%), prayer healing (37%), high-dose vitamin therapy and other nutritional supplements (34.5%), folk/home remedies (28%), massage therapy (19%), and chiropractic (18%). The majority of CAM users (66%) did not report the use of CAM to their primary care physician. A logistic regression analysis revealed that use of CAM by parents/caretakers was the single best predictor of CAM use in a child. CONCLUSION: CAM use is significant among children who visit pediatric practices. Pediatricians should inquire about CAM use among patients, particularly those with ongoing medical problems and those with parents/caretakers who use CAM for themselves.     

Hospitals and complementary and alternative medicine: managing responsibilities, risk, and potential liability

Patients and families increasingly press hospitals to facilitate provision of complementary and alternative medicine (CAM) therapies and products. At the same time, a growing number of hospitals and health care facilities have taken steps to integrate CAM and conventional care. In this article we consider institutional responsibilities when patients/parents use or are considering CAM. We (1) review hospitals' responsibilities to patients and parents, (2) explain how these principles apply in the case of CAM practitioners and products, (3) address institutional responsibilities for different models of service delivery, and (4) highlight issues that should be addressed when developing institutional policies to govern CAM use and propose ways to do so.     

Complementary/alternative medicine use in a pediatric oncology unit in Turkey

BACKGROUND: Important in the cancer therapy is the increasingly use of complementary/alternative medicine (CAM). The current study aims to establish the extent of use, the types of therapies employed, factors influencing, the reasons for choosing and the cost of CAM used in pediatric cancer patients in our clinic in Ankara, Turkey. PROCEDURE: A detailed questionnaire regarding demographic data and information about the use of CAM was completed by 95 patients who have attended the clinic between 1999 and 2000. RESULTS: Forty-nine patients (51.6%) had used one or more than one type of CAM. The most frequent (71.4%) was herbal medicine and biologic intake (stinging nettle, plant essence, honey of Anzer). The second one was religious therapy (40.8%). No correlation could be found between the use of CAM and parents education status, the level of income, number of siblings, the prognosis of the disease, the rate of satisfaction with the level of information given by the doctor at the time of diagnosis or the belief in the information given by the doctor about the prognosis (P > 0.05). All patients used CAM in addition to conventional therapy. CONCLUSIONS: More than half of the patients used CAM, with stinging nettle being the most common agent. Our patients place a high level of trust in their physicians and the conventional therapies offered by them; however, they also believe that the complementary therapies are harmless and, therefore, worth trying.     

Use of alternative and complementary therapies in children with cancer

BACKGROUND AND OBJECTIVES: The use of complementary and alternative medicines (CAM) is becoming increasingly popular. Although considered beneficial by users, the potential for interaction or substitution with conventional treatment should not be overlooked by health care professionals. It is therefore important to gain insight into the prevalence and the factors related to the use of CAM. To establish the prevalence of use of CAM among children with cancer treated in a large pediatric hospital, describe the profile of use and factors related with use. As a secondary objective we aimed at measuring quality of life of the children aged 5 or more and compare the scores between users and non-users. METHODS: The study is a cross-sectional survey of parents whose child was treated at the oncology clinic or ward of Sainte-Justine Hospital, a large pediatric hospital in Montreal. Data on socio-demographic variables, the use of CAM and the quality of life was collected through a self-administered questionnaire. Quality of life was measured with the Child Health Questionnaire CHQ-PF50, while clinical data was collected from medical records. RESULTS: A total of 115 patients were recruited and 92 parents completed and returned the questionnaire, resulting in a 80% response rate. According to this survey, 49% of the children used at least one type of CAM and 20% used herbal remedies/homeopathy/vitamins in the 2 months preceding the survey. Most popular CAM were spiritual/mental and physical strategies used by 35 and 33% of children under study, respectively. Only one parent reported having delayed a conventional treatment because of CAM. Although quality of life results must be interpreted with caution, they tend to favor non-users. CONCLUSIONS: CAM is likely to be used by a wide variety of people. In our study, we found that about half of the children with cancer has used CAM in the 2 preceding months. No specific profile of CAM users emerged from this study. The high prevalence of CAM warrants further studies to better understand the reasons and consequences of CAM use particularly on quality of life.     

Visits to complementary and alternative medicine providers by children and adolescents in the United States.

OBJECTIVE: Determine the prevalence, patterns, costs, and predictors of visits to complementary and alternative medicine (CAM) providers and subsequent remedy use in a nationally representative pediatric sample. METHODS: The 1996 Medical Expenditure Panel Survey provided data on 7371 subjects < or =21 years of age. The primary outcome variable was CAM provider visits as defined by consulting a CAM provider "for health reasons." Predictors included sociodemographics, family resources, health status, parental CAM use, and perceptions and use of conventional medical care. Bivariate analyses and logistic regression determined independent factors associated with CAM use. RESULTS: Overall, 2.0% used CAM. Only 12.3% disclosed this use to their usual source of care (USC). The most common providers were chiropractors and clergy or spiritualists. The most common therapies were herbal remedies and spiritual healing. Mean amount spent per person on CAM visits was 73.40 US dollars and on remedies was 13.06 US dollars. Weighted estimates to the national pediatric population of annual expenditures on CAM visits and remedies were 127 million US dollars and 22 million US dollars, respectively. Significant factors independently associated with CAM visits were female gender, older age, good and very good perceived physical health as compared with excellent health, parental CAM use, and dissatisfaction with the quality of care received from the USC. CONCLUSIONS: Two percent of parents reported that their children consulted a CAM provider and rarely disclosed this use to their USC. While dissatisfaction with the quality of care by the USC and less good perceived physical health predicted CAM visits, parental CAM use was the most predictive.     

Communicating with pediatricians about complementary/alternative medicine: perspectives from parents of children with down syndrome.

OBJECTIVES: Barriers to communication about complementary/alternative medicine (CAM) between parents and pediatricians are frequently documented, yet the scope of these barriers remains poorly understood. Such barriers are especially troubling when they involve children with special health needs, among whom CAM use is especially common. This pilot study of parents of children with Down syndrome (DS) used qualitative methods to explore parents' perceptions of the extent and quality of communication about CAM with pediatricians, to elicit parents' recommendations for improvement, and to formulate new research questions. DESIGN: Semistructured interviews were conducted with parents from 30 families with children with DS. Data were audiotaped and analyzed with assistance from qualitative data analysis software. RESULTS: Parents described how they advocated vigorously with their pediatricians about biomedical concerns such as the American Academy of Pediatrics healthcare guidelines for DS, but often avoided discussion of nonbiomedical concerns such as CAM. Many parents looked to pediatricians to initiate conversations about CAM. DISCUSSION: Even parents who assertively advocate for biomedical concerns in their children's health care may be unlikely to disclose and discuss CAM use with their pediatricians. Attending to parents' experiences helps to illuminate the nature and scope of current communication barriers and poses new research questions for assessing and improving parent-physician collaboration about health-related issues that may be prioritized differently by parents and pediatricians.     

Parent-pediatrician communication about complementary and alternative medicine use for children

Anonymous self-report surveys of a convenience sample of caregivers accompanying children to the pediatrician for acute or well visits at 4 pediatric practices in the Washington, DC area from July through November 1998 were evaluated. Three hundred seventy-eight (85%) of 443 caregivers approached participated. The 348 surveys completed by parents (92%) were analyzed. As previously reported, in this sample 21% of parents used complementary and alternative medicine (CAM) for their child. Overall, 53% of parents expressed the desire to discuss CAM with their pediatrician, increasing to 75% (p<0.001) among those who used CAM themselves and 81% (p<0.01) among those who used CAM for their child. Among parents who used CAM for their child, 36% had discussed it with their pediatrician. Factors associated with increased disclosure to the pediatrician were CAM use in children younger than 6 years (p<0.05), "bioenergetic" CAM use (p<0.02), and parent CAM non-use (p<0.05). Despite parents' significant interest in discussion about CAM, few factors were associated with adequate parent-pediatrician communication.     

Considering complementary and alternative medicine alternatives in cases of life-threatening illness: applying the best-interests test

In this article we explore decision-making about treatment when a child faces a life-threatening illness but conventional treatment presents substantial risk and uncertain benefit. When is it acceptable for parents to decide to use complementary and alternative medicine as an alternative, rather than a complement, to conventional care? We use the example of a young child suffering from progressive glycogen storage disease, for whom liver transplant offers the only prospect of a cure. Without a liver transplant, the disease usually results in death within a few years. However, experience using transplant to treat this illness has been limited, success is far from ensured, and the risks (including death and continued progression of the disease) are substantial. The child's parents, who are first-generation immigrants, consider the risks of the transplant unjustified because it still does not offer good prospects for a healthy future. They believe that traditional Chinese medicine could help remediate their daughter's disease. In the article we (1) review parents' obligation to make treatment decisions in the best interests of their child, (2) explain limits on parents' decision-making authority, (3) explore how "best interests" are determined, focusing on cases of serious illness for which conventional treatment is risky and benefit is possible but uncertain, (4) explain the standard of care that physicians must meet in advising about treatment, and (5) outline factors that clinicians and parents should take into account when making decisions.     

Complementary and alternative medicine in children attending gastroenterology clinics: usage patterns and reasons for use

Background: The use of complementary and alternative medicines (CAM) appears to be increasing. This cross‐sectional study aimed to assess the use of CAM in children, investigate factors influencing their use and attitudes towards them and to contrast to previous usage patterns. Methods: Parents of children attending gastroenterology outpatient clinics at a tertiary paediatric hospital completed a questionnaire providing details of CAM usage, awareness and attitudes. Results: Sixty‐nine percent of the 98 respondents were using or had used CAM (n= 66). Nutritional supplements (n= 37, 56% of CAM users) and probiotics (n= 33, 50%) were most commonly used. Most CAM users sought complementary therapy to help a chronic problem (n= 43, 69.4%) and had been referred by a friend or family member (n= 33, 53.2%). Self‐reported well‐being was associated with CAM use (P= 0.0009) and CAM were described as partially effective by 40 parents (67.8%). Forty‐six parents (75.4%) expressed that they would use CAM again. Seventy‐two respondents (80%) believed that doctors should support the use of CAM. Conclusion: Children attending this gastroenterology clinic are commonly given CAM. Awareness and acceptance of CAM by carers of children with gastroenterology conditions is high.     

Health care delivery: perspectives of young people with chronic illness and their parents

OBJECTIVE: To identify and compare perceptions of health care service delivery held by young people with chronic illness and their parents. METHODS: A convenience sample of young people with chronic illness and their parents were invited to complete a confidential self-report survey. The adolescents were aged 13-18 years inclusive and attended a specialist medical clinic. RESULTS: Participants comprised 53 young people (response rate 88%, 53/60) and 45 parents (response rate 75%, 45/60). Both young people and their parents rate honesty, confidentiality, having good medical knowledge and good listening skills as the most important qualities for a health care provider. Compared to the parent group, fewer young people report the presence of these desired qualities in their current health care provider. A quarter of young people (25%, 13/53) report they do not always trust health professionals to keep their information confidential, and 19% (10/53) of young people report having withheld information from a health professional due to a lack of trust. Some parents and young people would like to discuss a wider range of health topics, including mental health issues, than they currently do with their health provider. Young people and their parents report limited planning with their current health provider for transition to adult health services. CONCLUSIONS: Young people with chronic illnesses have significant levels of dissatisfaction with the health care they receive; this has the potential to impact on their use of health care services and their health outcomes. There is a need for increased provider awareness of the important qualities of health care service delivery to young people.     

Use of complementary and alternative therapies and probiotic agents by children attending gastroenterology outpatient clinics

OBJECTIVES: Complementary and alternative medicines (CAM) and probiotic therapies appear to be increasingly accepted and used. This questionnaire-based study aimed to ascertain the frequency of use and the acceptance of these therapies by children attending outpatient gastroenterology clinics. METHODS: Parents accompanying children to their appointments were asked to complete a questionnaire in order to determine usage of probiotic and alternative therapies. Questions also ascertained relevant background information and parental acceptance of alternative therapies. RESULTS: Ninety-two questionnaires were completed. The ages of the children varied from 6 months to 16 years (mean +/- SD; 6.5 +/- 4.3 years) and they had been prescribed an average of 1.7 +/- 1.3 (range 0-6) conventional medications. Thirty-three children (35.9%) were taking CAM and 98.6% of parents answered that they would be prepared to administer CAM to their child. Symptomatic improvements were attributed to CAM by the parents of 24 out of 33 children given these therapies. In addition, probiotic therapies were utilized by 23.8% of children, and 93.0% of parents would administer probiotic agents if recommended for their child's condition. CONCLUSION: Complementary and alternative medicines and probiotic therapies are used frequently by children attending gastroenterology clinics and are accepted widely by their parents.