Complementary and alternative medicine (CAM) is greatly topical and plays an increasingly important role in pediatrics. Whereas up to half of general pediatric patients use CAM (1), rates of use in specialty populations are often much higher. A 2003 US study reported lifetime use of up to 76% in children with chronic health conditions and use in the past 6 months as 48% (2). A recent US study documented annual CAM use in specific pediatric populations at 47% for sickle cell disease, 51% for asthma, 59% for cancer, and 62% for epilepsy (3). CAM utilization has been more common among some pediatric populations than others, such as for pediatric gastrointestinal (GI) conditions.
Gastroesophageal reflux, gastritis, diarrhea, irritable bowel syndrome, and inflammatory bowel disease (IBD), such as ulcerative colitis and Crohn disease, are commonly encountered conditions seen in pediatric GI clinics. A 2002 Australian study found that 35.9% of pediatric patients with GI disorders at present or recently had used ≥1 type of CAM (4). A 2008 Dutch study reported similar findings, with 38% of pediatric patients with GI disorders describing CAM use in the past year, of which 60% was specifically aimed at treating their GI condition instead of for overall health (5). Some studies have specifically examined the use of CAM in patients with IBD and have reported utilization rates of up to 50% (6,7). Concurrent use of CAM with conventional care, including medications, is not uncommon (8,9) and raises concerns about the potential for interactions (10–12).
This article highlights the use of CAM products and practices at 2 outpatient pediatric GI clinics in Canada, and examines utilization patterns, patient and caregiver attitudes and beliefs, adverse effects, and concurrent use of CAM and conventional care.
This article describes a subset of a larger study that was carried out at 2 sites in Canada, the Children's Hospital of Eastern Ontario (CHEO, Ottawa, Ontario) and the Stollery Children's Hospital (Edmonton, Alberta). The pediatric subspecialty clinics chosen for the larger study included cardiology, GI, neurology, oncology, and respiratory and were chosen because they see many patients with chronic conditions who may use CAM products and/or therapies. Patients were surveyed in clinics at both locations.
Surveys were carried out in the waiting room of each participating clinic before the clinic appointment. All of the patients attending clinic during the time the research assistants were present were approached for participation. Children and/or their families were eligible for the study if they were <18 years of age, could read French or English, and had not completed a questionnaire for the present study.
Data were entered into an SPSS 11 database (SPSS, Chicago, IL). Descriptive statistics were tabulated as numbers and percentages for categorical variables and medians (interquartile range) or mean (standard deviation) for continuous variables. Participant variables, including demographics, general health and use of specific CAM products and therapies, satisfaction with care, and beliefs about CAM, were compared between the 2 centers (Stollery vs CHEO) using Wilcoxon tests, independent t tests, and χ2 tests as appropriate.
CAM use was compared between centers and modeled by univariate and multivariate logistic regression models. Variables predicting CAM use included child's age, child's sex, child's health status, time since diagnosis, family's use of CAM, family's CAM insurance, ethnicity, parent's education and income, and discussion of CAM with conventional medical practitioner. Regression diagnostics such as c-statistics, r2, and Hosmer-Lemeshow lack-of-fit statistics were carried out. Measures for detecting outliers and influential observations were also carried out.
The present study was approved by the research ethics boards at CHEO and the Stollery. For full methods, refer to the study by Adams et al (13).
A total of 214 completed surveys were obtained, 150 from Edmonton and 64 from Ottawa (5 surveys were refused in Edmonton and 4 in Ottawa). Data between sites were combined unless they were significantly different.
The mean patient age was 10.5 (±5.2) years, and 52.8% were boys. Ancestry was self-reported as white (55.9%), Canadian/French Canadian (28.4%), First Nations/Inuit/Metis (7.1%), South Asian (5.7%), black (3.3%), East Asian (2.4%), Middle Eastern/Arabic (1.9%), or Latin American/Hispanic (0.5%). The health status of most children was reported as good to excellent (87.1%). Half (51.7%) of the patients had received their diagnosis >12 months earlier, whereas 20.5% had received their diagnosis <3 months earlier. The incidence of use of CAM by the children differed significantly between sites (82.7% in Edmonton vs 35.9% in Ottawa, P < 0.001), with an overall rate of 68.7% (Table 1). Excluding patients who only used multivitamins, the rate of CAM use was 65.4% (77.3% in Edmonton and 35.9% in Ottawa, P < 0.001). Based on International Classification of Diseases-10 (ICD-10) classifications, one-third of patients presented to the clinic with noninfective enteritis or colitis (33.6%), whereas other patients presented with esophagus, stomach, or duodenal conditions (13.1%); liver disease, including hepatitis (9.8%); malabsorption (6.5%); and intestinal conditions such as irritable bowel syndrome or constipation (6.5%). CAM use based on condition ranged from 28% to 79% (Table 2).
The overall caregiver population had a mean age of 40.4 (±7.4) years and consisted mainly of mothers (85.2%). Almost all of the caregivers (94.7%) reported that they were aware of their child's use of CAM. The health status of most caregivers (97.6%) was reported as good to excellent; 56.7% had graduated from college or university, and 81.7% had an annual household income of ≥$40,000. Significantly more caregivers in Edmonton (77.6%) than in Ottawa (54.1%) used CAM (P < 0.001) (Table 1). Multivariate analyses determined that use of CAM by caregivers was a significant predictor variable of child CAM use, with increases of 17.1 times (P < 0.001, 95% confidence interval [CI] 6.2–47.2) for Edmonton and 7.2 times (P = 0.002, 95% CI 2.0–25.4) for Ottawa.
For the respondents who did not use CAM, the most common reasons reported were similar for patients and caregivers and included lack of knowledge about CAM (59.7%, 67.3%), not believing use of CAM was necessary (16.4%, 10.9%), and concerns about adverse effects from combining CAM with conventional care (7.5%, 12.7%).
The most commonly used CAM products being taken by the children were multivitamins (65.3%), calcium (34.7%), vitamin C (31.7%), probiotics (13.9%), and fish oil/omega-3 fatty acids (12.9%). The most common CAM practices used by the children were massage (43.2%), chiropractic (27.3%), faith healing (25.0%), and relaxation (18.2%). Lifetime use of CAM products and practices was generally reported as higher and showed similar trends as for the present study (Table 3). The most common reason given for use was general health (76%) instead of for the specific GI condition being treated.
Most products and practices were reported to be helpful by the majority of the patients. Cold remedies (72.7%), calcium (53.8%), and homeopathy (86.7%) were perceived as the most beneficial CAM products, whereas massage (80.6%) and chiropractic (70.6%) were considered the most beneficial CAM practices (Table 3).
Of 214 respondents, 20 (9.3%) reported 23 adverse effects associated with CAM. Of these, 13 were self-rated as minor in severity. Seven were reported as moderate, 2 each for probiotics and traditional Chinese medicine, and 1 each for cold remedy, colic remedy, and magnets. Three were reported as severe, 1 each for calcium, teething remedy, and naturopathy. Further details of the adverse effects were not provided by the respondents.
Whereas 7.7% of patients used CAM before trying conventional medicine, 10.3% (7.2% in Edmonton vs 25.0% in Ottawa, P = 0.032) used CAM after conventional medicine was not successful. Concurrent use of conventional medicine and CAM was reported by 65 (55.6%) patients. Most patients in Edmonton (61.7%), but only one-fourth of those in Ottawa (25.0%), used CAM at the same time as conventional medicine (P < 0.003).
Concurrent use of CAM with prescription medications, specifically, was reported by 89 (41.6%) respondents. Of the 89 concurrent medication/CAM users, 75 provided information about specific therapies, 24 (32.0%) of whom listed >1 category of CAM. Vitamins and minerals (70.7%), probiotics (34.7%), fish oils/omega-3s (21.3%), herbs (14.7%), and homeopathic remedies (6.7%) were the most common type of CAM products taken together with prescription medications (Table 4).
Classes of medications that patients with GI disorders commonly combined with CAM products included sulfa drugs (n = 33), immunosuppressants (n = 30), and antiulcer agents (n = 20). Of the 75 patients who provided details of their concurrent use, most were being treated for IBD, that is, Crohn disease (n = 25) and ulcerative colitis (n = 15). Of these 75 patients, 45.5% used >1 type of CAM product concurrently with their prescription medications. For example, of patients with IBD treated with a sulfa drug, 66.7% were also taking vitamins/minerals, 30.3% were taking probiotics, 12.1% were taking herbs, and 3.0% were taking homeopathy.
The majority (75.9%) of those who used CAM concurrently with prescription medications reported discussing this CAM use with their physician, whereas 52.0% reported seeking consultation from a pharmacist. Common sources of CAM information used by respondents included family (56.5%), their GI clinic (48.9%), pharmacies (33.6%), health food stores (32.1%), books or magazines (31.3%), and their health care provider (31.3%). Trust reported by respondents in the sources of CAM information was scored on a 10-point Likert scale, where 1 indicated no trust and 10 indicated complete trust. The most trusted sources were their GI clinic, other health care and CAM providers (8.2 each), followed by pharmacies, and family (7.7 each), whereas television and the Internet were rated as 6.0 and 4.8, respectively.
The majority of caregivers agreed or strongly agreed that they felt comfortable discussing their children's use of CAM in their GI clinic (79.3%), that they would appreciate more information on CAM from the clinic (63.2%), and that they would be more likely to use CAM products (56.1%) or practices (59.7%) if they were provided by their GI clinic.
The results of the present study demonstrate that more than two-thirds of pediatric patients with GI disorders surveyed use CAM, a value higher than those reported in studies investigating the same conditions (3), but in line with those reported in other pediatric populations experiencing chronic disease (2–6,14).
Detailed comparison of our findings with the 2 other published pediatric GI studies (4,5) and the 2 IBD-specific studies (6,7) is difficult because of variation in definition of CAM and whether authors reported lifetime versus present use. For example, Day (4) and Heuschkel et al (7) include vitamins, although Heuschkel et al exclude “once-a-day multivitamin supplements,” and yet other authors do not explicitly report whether vitamins are included in their definition of CAM. We included them in our survey because we wanted to assess how many patients used them and they are classified as natural health products (NHPs) by Health Canada. Although the popularity of multivitamins could exaggerate the rates of CAM use, in our study, <10% of patients used only multivitamins and the overall rate of CAM use did not decrease much when multivitamins were excluded from our analysis. As the most commonly used product, the potential for interactions between drugs and vitamins is an important issue that needs further exploration (10,11).
Our data also demonstrate that use of CAM by caregivers was the strongest predictor of child CAM use. This finding is consistent with earlier reports demonstrating parental CAM use as a major predictive factor for CAM use by children (15,16). Because caregiver CAM use was significantly higher in Edmonton than in Ottawa, it is not surprising that use by children at these sites also follows this pattern. Our data did not identify any other factors that would explain the difference in child use between sites.
A significant proportion (41.6%) of pediatric patients with GI disorders reported concurrent use of CAM with prescription drugs, especially multivitamins, herbs, and probiotics. Although this is keeping with earlier pediatric GI studies (7) and other pediatric studies on CAM use (17,18), concurrent use raises concerns of potential interactions, whether synergistic or antagonistic. For example, vitamins are known to interact with commonly used medications in this population, such as steroids, sulfa drugs, and omeprazole (10,11). The most commonly reported herb used in our study was echinacea, including by patients with IBD, which may be of potential concern because of its immunomodulating effects. Further studies are needed to evaluate potential benefits versus potential risks of taking NHPs with immunomodulating properties in patients with autoimmune conditions.
Caution also needs to be applied when mixing NHPs with narrow therapeutic index drugs (ie, those that must be monitored and maintained within a narrow band for optimal effectiveness, because too much can cause toxicity and too little can be associated with treatment failure). In our study, of the 30 patients who combined immunosuppressants with CAM, 1 severe and 2 moderate adverse effects were reported. Specific information about these reported adverse effects, however, is not available, and objective assessment is difficult.
Only 14% of patients reported use of probiotics, whereas emerging data about probiotics suggest they may be effective in children with GI disorders such as allergy and IBD (19,20), and in those who have been prescribed antibiotics through repopulation of microflora in the gut (21).
Similarly, although peppermint has been used historically to treat GI disorders (22), in our study it was used by only 11 of 214 patients. Peppermint is known to relax GI smooth muscle and affect motility by blocking the entry of calcium ions into GI smooth muscle cells (23,24). In a clinical trial, Hiki et al found that L-menthol sprayed on the gastric mucosa significantly suppressed peristalsis during endoscopy (25). Despite measurable effects of peppermint on GI motility, it seems to be underused for this effect.
From our data there appears to be a mismatch whereby patients are not necessarily using CAM therapies that may be optimal for their condition. In fact, most patients in our study reported using CAM for general health instead of to treat their specific GI condition. This likely reflects a lack of users’ awareness about the CAM therapy or discussion with health providers who are knowledgeable about the evidence profile of CAM therapies used in children. CAM therapies that have evidence of potential benefit may be underused because of lack of knowledge by pediatric health care providers (26). It would be helpful if pediatric GI clinic team members knew about and felt comfortable discussing the potential merits and harms of various CAM therapies so they can guide families that are searching for ways to augment their child's care. Table 5 provides a list of such resources.
In our study approximately one-fourth of the patients did not report their CAM use to their physician. Although not a new finding (7), the potential for adverse interactions mandates routine inquiry by providers about the patients’ CAM therapy use. This is further substantiated by the results of our study, in which patient/caregiver expressed a strong interest in discussing their CAM therapies with clinic physicians and staff. An open dialogue between a health care provider and patient/caregiver is imperative to ensure optimal patient care and safer outcomes while using CAM therapies concurrently with conventional therapies.
We are aware of the limitations on recall of past events, which may be exacerbated by use of a proxy response (ie, parent). It is routine medical practice, however, to ask parents about their child's health, including medication use, during clinic visits. Evidence suggests that recall of regularly consumed NHPs, as measured by a single questionnaire, is comparable to more detailed methods such as use of a diary (27). We chose to conduct our survey in English and French to meet the needs of the majority of patients in our participating clinics. We recognize, however, that CAM use may vary between ethnic groups (28–32) and that limiting the languages used may limit the generalizability of our findings.
The results of our study suggest that CAM use in the GI population is common, as is its concurrent use with prescription medications. We believe an open discussion about the potential benefits and harms associated with various CAM therapies would meet patient needs and enhance the relationship between health care providers and their patients. In an era of patient-centered care, pediatric gastroenterologists should be encouraged to learn about and participate in evidence-based dialogue about CAM use with their pediatric patients and families.
The authors thank Adam Gruszczynski (CHEO RA), Deepika Mittra (Edmonton RA), Samaneh Khanpour Ardestani, and Melba Baylon for their assistance in the study. The authors also thank the clinic directors and staff from participating clinics for their support of the study.
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