Use of complementary and alternative medicine by pediatric rheumatology patients

Integration of Complementary and Alternative Medicine in a Major Pediatric Teaching Hospital: An Initial Overview

OBJECTIVE

To describe the establishment of a multidisciplinary team of complementary and alternative medicine (CAM) providers and educators in an urban pediatric hospital and affiliated medical school.

BACKGROUND

Pediatric CAM use is increasing. Physicians are interested in CAM-related education but few programs had been developed in pediatrics. In 1998, Children's Hospital Boston established the Center for Holistic Pediatric Education and Research (CHPER), a CAM multidisciplinary team providing clinical services, education, and research.

METHOD

A retrospective review describing data from patient consultation notes, CAM lectures, clinical practice guidelines, curriculum materials, team meeting minutes, and team member manuscripts and publications.

RESULTS

Over 5.5 years, CHPER staff provided over 2100 consults: acupuncture, massage, holistic pediatrician, relaxation therapies, biofeedback, hypnosis, and bio-pharmaceutics. Acupuncture and massage therapies were incorporated into a Clinical Practice Guideline. Formal education was delivered through didactic sessions, workshops, self-learning modules, clinical observation, and clinical practice. CHPER faculty published 1 book and 64 articles on CAM-related topics.

CONCLUSION

An interdisciplinary team of CAM clinicians and educators can be integrated into an urban pediatric teaching hospital to provide CAM medical education and clinical services.

Dietary supplement use is prevalent among children with a chronic illness

OBJECTIVE

To determine the nature and prevalence of dietary supplement use among chronically ill children.

DESIGN

This descriptive study used a self-report questionnaire.

SUBJECTS

A convenience sample of parents of 505 chronically ill children and adolescents seen in subspecialty medical clinics in Salt Lake City, UT. The medical conditions studied included asthma, cystic fibrosis, diabetes, cancer, liver and renal transplantations, seizures, and rheumatological and neurobehavioral disorders. Statistics Sample characteristics were described using frequencies, percentages, means, and standard deviations. chi 2 tests were used to compare sex, ethnicity, parental education level, and dietary supplement use variations among the various diagnostic categories. Analysis of variance with Bonferroni correction for multiple comparisons was used to determine differences among diagnosis groups for continuous variables, and the Kruskal-Wallis test was used to test categorical variables.

RESULTS

The population sampled was predominately white (88.5%), with a mean age of 9.9+/-5.3 years. Sixty-two percent of the population used dietary supplements, and 30% used nonprescribed supplements. Significant differences were noted among diagnosis groups, with the highest nonprescribed use reported in children with cancer (solid tumors=46%; leukemia=44%), cystic fibrosis (35%), neurobehavioral disorders (35%), and rheumatological disorders (34%). Only 20% of those using nonprescribed dietary supplements had discussed this use with the health care provider.

CONCLUSIONS

Dietary supplement use is prevalent among chronically ill children, especially among those with a poor prognosis or for whom there are limited medical treatments. Few pediatric health care providers are aware of their patients' use of nonprescribed supplements. This is a concern because of the unknown effects of many supplements on growth and development and the potential for adverse drug interactions.

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.

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.

Mast cells and mast cell mediators as targets of dietary supplements

OBJECTIVE

To review the increasing amount of data that support or dispel the use of dietary supplements in the treatment of inflammatory conditions that involve mast cells, such as allergies, arthritis, and chronic pelvic pain syndrome.

DATA SOURCES

A search was conducted in MEDLINE for natural substances, dietary supplements, flavonoids, and proteoglycans for their in vitro or in vivo effects on allergic and inflammatory conditions.

STUDY SELECTION

Studies were selected for inclusion because of the impact factor of the journal, the definitive nature of the findings, the soundness of the study design, and the expert opinion of the authors.

RESULTS

Dietary supplements include a large group of products, such as vitamins, minerals, plant, or animal extracts, as well as herbal preparations that are often called medicinal herbs. Many of the available dietary supplements contain a multitude of ingredients, the source and/or purity of which is seldom disclosed; some of these may have biologic effects of their own or may interact with other supplements or drugs, often leading to adverse effects. The most well-documented evidence published to date is on the inhibitory action of natural compounds, especially flavonoids, on mast cells and allergic symptoms. Some flavonoids have weak inhibitory activity, whereas others may have no benefit or may be detrimental. Sulfated proteoglycans could provide synergistic action but require formulations with increased absorption.

CONCLUSIONS

Combining the most active flavonoids with proteoglycans could be helpful in atopic and inflammatory conditions. However, a complete list of active ingredients and their source, purity, and exact concentration should be a requirement for nutraceuticals to standardize, compare, and promote their safe use.

Factors associated with the use of complementary and alternative medicine in juvenile idiopathic arthritis

OBJECTIVE

To describe the frequency of complementary and alternative medicine (CAM) use in patients with juvenile idiopathic arthritis (JIA) and to explore whether CAM was associated with patient-specific characteristics, parent-specific characteristics, and medical management factors.

METHODS

Parents of children with JIA completed questionnaires that addressed the use of CAM, adherence and perceived problems, parental distress, and coping with childhood illness. Clinical variables were abstracted from the patients' medical files.

RESULTS

One hundred-eighteen children with JIA, mean +/- SD age of 10.4 +/- 3.9 years and mean +/- SD disease duration of 4.5 +/- 3.5 years, participated in the study. Ever use of CAM was 33.9% and was higher in patients whose parents used CAM (odds ratio [OR] 5.1, 95% confidence interval [95% CI] 1.4-19.5) and among those who considered themselves as "Canadian" as opposed to belonging to a specific ethnic group (OR 10. 7, 95% CI 1.2-99.8). Adherence to conventional treatment was high for both users and nonusers of CAM.

CONCLUSION

Use of CAM is common among patients with JIA. CAM use is not related to any decrease in adherence to conventional medical treatment.

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.

Advances in paediatric rheumatology: beyond NSAIDs and joint replacement

Over the previous three decades there have been a number of dramatic changes in our understanding of both the pathogenesis and epidemiology of the rheumatic diseases of childhood. Improvements in the classification of paediatric-onset arthritides and international collaboration in terms of multicentre research have led to the development of new therapeutic agents and better methods of outcome assessment for these chronic and often disabling conditions. Fortunately for children with paediatric rheumatic diseases treatment regimes are now available that provide excellent disease control for many and remission induction for some. Challenges include clearer definition of the genetics and pathogenesis of the diseases, delineation of reliable biological markers for diagnosis and monitoring of disease activity. The future should also herald early identification of those with a poorer prognosis, together with the design of more powerful, safer and cheaper remission-inducing agents, given to the right patients at the right time.