- *CARE Program, University of Alberta, Edmonton, Alberta, Canada.
- †Edmonton General Hospital, University of Alberta, Edmonton, Alberta, Canada.
Ms Surette has disclosed no financial relationships relevant to this article. Dr. Vohra has disclosed that she has grants as principal investigator or co-investigator from Health Canada, SERIN-ETD Acupuncture Research Fund, Alberta Innovates Health Solutions, Canadian Institutes of Health Research, Women & Children's Health Research Institute, National Health and Medical Research Council (Australia), EU Commission, Lotte & John Hecht Memorial Foundation, and Alberta Health Services. This commentary does contain a discussion of an unapproved/investigative use of a commercial product/device.
- autism spectrum disorder
- complementary and alternative medicine
Whether you believe in the effectiveness of complementary and alternative medicine (CAM) or not, some of your patients and their parents do. As you read this article, please note the number of patients who use CAM. Joseph A. Zenel, MD Editor-in-Chief
Health care professionals do not ask consistently about complementary, holistic, and integrative medicine use by their patients, yet it is important to do so because patients and families often pursue this course of therapy for specific medical conditions and do not volunteer this information.
No thorough assessment has been made of the literature on the use of pediatric complementary and alternative medicine (CAM) since 1999, when Ernst published a systematic review on this topic. (1) As part of its horizon scanning, the Complementary and Alternative Research and Education (CARE) program (www.care.ualberta.ca) tracks the use of CAM in the pediatric literature and, as of March 2011, has identified 160 English-language studies dating back to 1982. Utilization literature can be a valuable source of information for determining what CAM practices and products warrant further pediatric research. This article explores the 5 most studied pediatric specialty populations: oncology, asthma, autism spectrum disorder (ASD), gastrointestinal diseases (eg, inflammatory bowel disease and irritable bowel syndrome), and pediatric emergency care. The Table lists these studies, with references.
Thirty-one studies on the use of CAM by pediatric oncology patients were identified between 1977 and 2011 from the United States, Canada, Europe, the Middle East, Malaysia, Mexico, Singapore, the United Kingdom, Taiwan, and Australia. Sample sizes ranged from 15 to 1063 children; 19 studies had fewer than 100 participants. Rates of use ranged from a low of 6% reported in 1983 to a high of 84.5% reported in 2009. Only 5 studies reported rates below 20%. Spirituality/prayer, positive mental imagery, and natural health products were the most popular CAM interventions.
Of natural health products, multivitamins, megavitamins, and herbals were reported most often. Patients, parents, and families described perceived efficacy from 0% to 83% in the 16 articles that reported these data. Some of this variation appears to be related to the expectation of what the CAM therapy will accomplish, as families reported multiple goals, including reinforcing the immune system, supplementing conventional medicine, counteracting adverse effects of conventional medicine, alleviating symptoms, improving general well-being (psychological, emotional, and spiritual), and satisfaction that everything had been tried. Of concern, but perhaps not surprising, 11 studies also reported curing the cancer as one of the family’s goals.
Fourteen articles reported on adverse events, which varied from 0% to 28%, but few details were provided. Only 8 articles reported on disclosure of CAM use to health care practitioners, which varied from 0% to 89.9%. Eight studies included some discussion of costs of CAM, with families reporting spending US $0 to more than US $10,000. Two studies reported cost as a deterrent to CAM use for some families.
Twelve studies on pediatric asthma and CAM use have been identified from 1998 to 2010 from the United States, the United Kingdom, Australia, Turkey, Canada, Israel, and New Zealand. Sample sizes ranged from 48 to 2027 children. Statistics on use of CAM ranged from 13% to 89%, with 7 studies reporting rates higher than 50% and only 2 reporting rates below 20%. Concurrent use was reported commonly, but 2 studies described CAM as the primary treatment option by 27% and 44% of their respondents.
The most popular CAM therapies used in asthma were natural health products (eg, vitamins, minerals, herbals, oils, teas, and honey). Also common were prayer, homeopathy, and massage therapy. Five of the studies provided no description of how CAM was defined for the participants. Seven studies reported on perceived efficacy, which varied from 12.4% to 70%. Three studies discussed reasons for using CAM, which included avoiding or reducing the amount of conventional medicine used, believing that CAM was natural and not harmful, and for treating asthma symptoms. Only 3 studies reported on whether the participants had informed their physicians of their CAM use, which varied from 18% to 54%. Only 1 study reported on adverse events. One study reported a mean of US $66 (median, US $44) per month spent on various CAM modalities.
Autistic Spectrum Disorder
Eight studies on the use of CAM by children with ASD were identified from 2003 to 2009. The studies were conducted in the United States, Canada, and China, and there was 1 international study. Sample sizes varied from 50 to 552 children, and rates of use ranged from 31.7% to 95%. Special diets, such as the gluten-free, casein-free, or Feingold diets, and vitamin and mineral supplements were the most common forms of CAM used. Four studies reported on perceptions of efficacy, which were positive more than 50% of the time. Two studies reported on reasons for use, which included following advice from family or medical practitioners, intending to treat general or specific symptoms to improve quality of life, or maintaining general health. One study reported users having high expectations, with 1 in 20 expecting the child to become healthy.
The 3 studies that discussed perceived efficacy all reported positive rates above 50%. Three studies reported on adverse events: 1 study described that “very few families reported that any therapy was actually harmful,” and 2 reported rates of adverse effects between 2.6% and 7.5%. Only 1 study reported on how many families or patients discussed their CAM use with their health care professionals (22%). Only 2 studies reported on costs: 1 study found that, on average, 44.7% of the families found the costs associated with some CAM therapies difficult to meet.
Seven studies were published from 2002 to 2010 on the use of CAM by pediatric patients with gastrointestinal diseases, primarily inflammatory bowel disease and irritable bowel syndrome, from the United States, United Kingdom, Europe, and Australia. Sample sizes ranged from 46 to 749 patients. The reported rates of use ranged from 36% to 72%. Six studies reported on CAM most commonly used by their study populations: herbal medicines, dietary supplements (vitamins, fish oils, and probiotics), and special diets (eg, dairy-free and gluten-free diets) were the most popular. Six studies included information on the perception of efficacy. Most studies reported rates of at least moderate satisfaction in perception of efficacy by more than half of the respondents. Reasons for using CAM included to feel better, to complement standard care, to address dissatisfaction with prescribed medications vis-à-vis adverse effects and efficacy, to follow advice from a trusted individual, and the belief that CAM is always natural and safe. Only 3 studies reported on the occurrence of adverse events related to CAM therapy, and none provided rates. Four studies reported whether families spoke with their physicians about their CAM use; disclosure rates ranged from 24% to 51%. Two studies reported on costs associated with CAM therapy, but they discussed only whether families found CAM expensive and not how much was spent.
Pediatric Emergency Care
Seven studies on the use of CAM by pediatric emergency patients have been identified from 2001 to 2010 in the United States, Canada, and Switzerland (the 2 from Switzerland used the same data set). Sample sizes ranged from 142 to 1804 patients. Published rates of use ranged from 7% to 58%. Homeopathy, naturopathy, and use of natural health products and dietary supplements (eg, vitamins, minerals, and oils) were the most commonly reported CAM therapies. Two studies reported on perceived efficacy: a positive perception occurred in 90% and 91% of respondents.
Four studies asked about adverse events: 2 reported none, whereas the other 2 provided few details. Six of the studies reported on whether patients discussed CAM use with their physicians and whether this practice meant that the emergency physicians or their family physicians were aware was not always clear. One study found that families reported CAM use only if they were asked. Reporting rates varied from 45% to 72%. No studies reported on how often physicians inquired about CAM use. Two studies reported on economic issues through the discussion of insurance coverage for CAM.
We have reaffirmed the heterogeneity in pediatric CAM use research identified by Ernst in 1999. (2) Although CAM use is common, the types of CAM used and patterns of use vary among specialty populations, as do the patients’ perceptions of effectiveness. Health care practitioners do not ask consistently about CAM use, but it is important to do so because patients and families often do not volunteer that information, and many want physicians to ask. The American Academy of Pediatrics Section on Integrative Medicine offers a comprehensive list of resources for health care professionals, including a parent education brochure and a How to Talk to Your Doctor poster. Health care practitioners also should inquire about reasons for use, perceptions of efficacy, adverse events, and cost. Contextualization of CAM use will allow better patient counseling.
Parent Resources from the AAP at HealthyChildren.org
- © American Academy of Pediatrics, 2014. All rights reserved.