Complementary therapies in pediatrics: a legal perspective

Investigation of Herbal Therapy Methods Used by Parents of Children with Cancer for Symptom Management in Chemotherapy Process

INTRODUCTION

The number of types of cancer, which is the leading severe health problem and is frequently seen in childhood period, has steadily increased over the years. This descriptive and cross-sectional study was conducted to determine the herbal treatment methods used by parents of children with cancer during the chemotherapy process for symptom management.

METHODS

The study was carried out with the parents of 126 children diagnosed with cancer. The data were collected with a questionnaire form created in line with the literature and the form for the amount and frequency of use of herbal treatment methods used by parents. The data were evaluated with descriptive statistics and χ2 test.

RESULTS

The mean age of the children included in the study was 8.08 ± 3.15 (min = 3, max = 17) years, and the mean duration of diagnosis was 14.35 ± 13.22 (min = 6, max = 60) months. 78.6% (n = 99) of the parents included in the study stated that they used herbal treatment for the treatment of their child's disease. 79.4% (n = 100) of the parents thought that the herbal treatment they used was effective. The first reason (48.4%, n = 61) for using herbal treatment was "to do everything we could for the treatment."

CONCLUSION

It was determined that the use of herbal treatment methods was related to the mother's profession, the education level of the parents, and the place of residence. In particular, it is necessary to inform parents about herbal treatment methods through nurses with up-to-date information and to create the right attitude toward this issue.

Proportion of Over-The-Counter Medicines Containing a Plant Component and Those with Synthetic Substances Administered among Children in a Bulgarian Population

Over-the-counter medicines are intended to influence a number of symptoms and also to cure some human diseases without having to see the doctor. These medicines are used for self-medication and parents also give them to their children. The following fall within the scope of over-the-counter medicines: analgesics, antipyretics, antihistamines, decongestants, gastroprotectors, anti-cough medicines, and others. Their composition also includes one or a combination of medicinal plants. In addition to synthetic substances, some nonprescription medicines contain plant substances and their derivatives. Medicinal plants and their extracted derivatives are applicable in the therapies of a number of diseases. Considering the fact that over-the-counter medicines can be used among children from birth, the subject of our study is those whose composition includes biologically active plant substances. Within this study, we have established the number of nonprescription medicines containing a plant substance individually or in combination with another substance of the same kind and/or other substances, which have been included in a list published on the website of the Bulgarian Drug Agency. The objective of our study is to present the percentage of OTC medicines containing a plant substance intended to affect the symptoms of upper respiratory tract diseases and pain, which are used among children during different periods of their development. Some of these medicines also contain substances such as antihistamines (pheniramine maleate) and decongestants (pseudoephedrine, phenylephrine hydrochloride, dimetidine) that can cause various unwanted side effects. Considering the aforementioned aspects and also the peculiarities of childhood, we recommend that self-treatment be conducted only after consulting a health specialist.

What does the best interests principle of the convention on the rights of the child mean for paediatric healthcare?

The present review analyses the implications of the best interests of the child principle, which is one of the most widely discussed principles of medical ethics and human rights, for paediatric healthcare. As a starting point, it presents the interpretation of the best interests principle by the United Nations Committee on the Rights of the Child. On this basis, it points out possible fields of application of the best interests principle with regard to paediatric healthcare and discusses the potential difficulties in the application of the best interests principle. Based on this, it illustrates the implications of the best interests principle for paediatric healthcare through four case studies, which look at ethical dilemmas in paediatric gynaecology, end-of-life care, HIV care and genetic testing.   Conclusion: The best interests principle requires action, inter alia, by health policymakers, professional associations, hospital managers and medical teams to ensure children receive the best possible healthcare. Whilst the best interests principle does not provide a conclusive solution to all ethical dilemmas in paediatric healthcare (as illustrated by the case studies), it provides children, medical teams, parents and families, and clinical ethicists with an indispensable framework for health care centred on the rights of the child. What is Known: • The best interests principle is one of the most widely discussed principles of medical ethics and human rights and one of the four general principles of the Convention on the Rights of the Child. What is New: • The present review discusses possible fields of application and potential difficulties of the best interests principle with regard to paediatric healthcare. • Based on this, it illustrates the implications of the best interests principle for paediatric healthcare through four case studies, which look at ethical dilemmas in paediatric gynaecology, end-of-life care, HIV care and genetic testing.

Lessons for Employing Participatory Design When Developing Care for Young People with Cancer: A Qualitative Multiple-Case Study

Purpose: Participatory design (PD) is a collective creative design process involving designers and nondesigners. There is limited reporting on the experience of using PD for adolescent and young adult (AYA) care. This study summarizes lessons from employing PD to develop care for AYAs with cancer.

Methods: A qualitative multiple-case study method was conducted of three PD processes addressing food (FfC), intimacy and sexuality (I&S), and integrative medicine (IM) in caring for AYAs with cancer.

Results: Local key stakeholders, who were exposed to a problem and had not been successful at solving it individually, were recruited to “dream” together. Through this synergy, a shared understanding of the problem and a joint mission emerged to find a solution. PD tools were used to develop a problem definition. An open mind and explorative research helped to understand the problems, and stakeholders were managed such that idea-sharing and learning were enabled. Designers translated ideas into prototypes. The PD process was prolonged due to the hierarchical hospital environment, business considerations, and additionally required evidence. The FfC program produced an effective new food service for the whole hospital. The I&S initiative developed a podcast, two articles, and a prototype website. The IM project developed a pilot study.

Conclusions: For a PD process to successfully develop care for AYAs, one needs to use designers and skilled people, PD tools, and an open-ended approach to visualize and materialize new forms of care. Furthermore, recruitment and facilitation techniques help leverage knowledge and create a synergy in a democratic environment between stakeholders.

Phytotherapeutic approaches to treatment and prophylaxis in pediatric practice

Medicinal plants, their extracts and herbal medicinal products occupy a growing share of medicines in the pharmacy worldwide.

Historically, the first medicines were products of plants, as well as some of the most important medicines still in use today. With the development of phytochemistry, as part of the pharmaceutical science, great progress has been made in the isolation and in determining the value of a number of biologically active substances (BAS).

Many plants have yielded pure substances (or natural products) that are applied in modern medical practice. Other compounds are potentially useful or have toxic effects.

Traditional medicine incorporating many herbal medicines remains an important (and in some cases, the only) form of treatment in some countries, with increasing use in medical practice.

On the other hand, the fact that in pediatric patients there is a limitation, mainly moral and ethical, of the number of medications to be administered due to the difficulty of conducting clinical trials in children, stimulates the use of herbal medicines of proven quality, effectiveness and safety among this group of patients.

How do we improve men's mental health via primary care? An evaluation of the Atlas Men's Well-being Pilot Programme for stressed/distressed men

BACKGROUND

Over three-quarters of all suicides are men (England and Wales), this is despite higher levels of anxiety and depression being reported by women. This disparity may in part be explained by atypical presentations of distress in men, and gendered issues around help-seeking. Consequently, the Atlas Men's Well-being Programme was designed to engage stressed/distressed men who were patients at a London-based GP surgery. Atlas encouraged GPs to identify and refer men for counselling and/or acupuncture by raising their awareness of men's distress. The aim of this pilot study was to evaluate Atlas in terms of patients' characteristics, service utilisation, patient outcomes and cost implications.

METHODS

All patients using the Programme were asked to complete a questionnaire before and after their Atlas sessions. Outcome measures included the Hospital Anxiety and Depression scale, Perceived Stress Scale, Warwick-Edinburgh Mental Well-being Scale, a 11-point scale measuring physical health, and the Psychological Outcome Profiles (PSYCHLOPS), a patient-generated outcome measure. Additionally, for cost calculations, participants were asked about their employment, number of days off work due to illness, and their health and social care service use.

RESULTS

102 participants were recruited, 82 completed pre- and post-treatment questionnaires. Comparisons pre- and post-treatment revealed a statistically significant improvement in anxious mood (p <0.001), perceived stress (p < 0.001), positive well-being (p = <0.001), PSYCHLOPS (p = <0.001) and physical health (p = 0.001), though not depressed mood (p = 0.660). Additionally, reductions in costs related to lost employment and health and social care use, exceeded the cost of Atlas counselling and acupuncture sessions, with an average saving of nearly £700 per patient.

CONCLUSIONS

Atlas attendance was associated with improvements in patients' mental and physical health, and demonstrated likely cost savings. It is now important to understand patient and stakeholder perspectives. Further research could compare usual care with the Atlas approach, and investigate full cost-effectiveness.

Luoyutong Treatment Promotes Functional Recovery and Neuronal Plasticity after Cerebral Ischemia-Reperfusion Injury in Rats

Luoyutong (LYT) capsule has been used to treat cerebrovascular diseases clinically in China and is now patented and approved by the State Food and Drug Administration. In this retrospective validation study we investigated the ability of LYT to protect against cerebral ischemia-reperfusion injury in rats. Cerebral ischemia-reperfusion injury was induced by middle cerebral artery occlusion followed by reperfusion. Capsule containing LYT (high dose and medium dose) as treatment group and Citicoline Sodium as positive control treatment group were administered daily to rats 30 min after reperfusion. Treatment was continued for either 3 days or 14 days. A saline solution was administered to control animals. Behavior tests were performed after 3 and 14 days of treatment. Our findings revealed that LYT treatment improved the neurological outcome, decreased cerebral infarction volume, and reduced apoptosis. Additionally, LYT improved neural plasticity, as the expression of synaptophysin, microtubule associated protein, and myelin basic protein was upregulated by LYT treatment, while neurofilament 200 expression was reduced. Moreover, levels of brain derived neurotrophic factor and basic fibroblast growth factor were increased. Our results suggest that LYT treatment may protect against ischemic injury and improve neural plasticity.

Appraisal of clinical practice guidelines for ischemic stroke management in Chinese medicine with appraisal of guidelines for research and evaluation instrument: A systematic review

OBJECTIVE

To systematically review the clinical practice guidelines (CPGs) for ischemic stroke in Chinese medicine (CM) with the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument.

METHODS

CM CPGs for ischemic stroke were searched in 5 online databases and hand-searches in CPGrelated handbooks published from January 1990 to December 2012. The CPGs were categorized into evidence based (EB) guideline, consensus based with no explicit consideration of evidence based (CB-EB) guideline and consensus based (CB) guideline according to the development method. Three reviewers independently appraised the CPGs based on AGREE II instrument, and compared the CPGs' recommendations on CM pattern classification and treatment.

RESULTS

Five CM CPGs for ischemic stroke were identified and included. Among them, one CPG was EB guideline, two were CB guidelines and two were CB-EB guidelines. The quality score of the EB guideline was higher than those of the CB-EB and CB guidelines. Five CM patterns in the CPGs were recommended in the EB CPG. The comprehensive protocol of integrative Chinese and Western medicine recommended in the EB CPG was mostly recommended for ischemic stroke in the CPGs. The recommendations varied based on the CM patterns.

CONCLUSION

The quality of EB CPG was higher than those of CB and CB-EB CPGs in CM for ischemic stroke and integrative approaches were included in CPGs as major interventions.

Use of Complementary and Alternative Medicine in Children with Autism Spectrum Disorders: A Multicenter Study

INTRODUCTION

This study examined the prevalence of the use of different complementary and alternative medicine (CAM) strategies, families' attitudes and belief systems about the use of these strategies, and the economic burden of these strategies placed on family income in families of children with autism spectrum disorders (ASD).

METHOD

A questionnaire survey concerning the use of CAM in children with ASD was administered to parents in the five different geographic locations in Turkey.

RESULT

Of the 172 respondents, 56% had used at least one CAM therapy. The most frequently used CAM intervention was spiritual healing. Among the most reported reasons for seeking CAM were dissatisfaction with conventional interventions and a search for ways to enhance the effectiveness of conventional treatments. The most frequently reported source of recommendation for CAM was advice from family members. The mean economic burden of the CAM methods was a total of 4,005 Turkish lira ($2,670) in the sample using CAM. The CAM usage rate was lower in parents who suspected genetic/congenital factors for the development of ASD.

CONCLUSION

This study observed the importance of socioeconomic and cultural factors as well as parents' beliefs about the etiology of ASD in treatment decisions about CAM.

Complementary and alternative medicine in child and adolescent psychiatry: legal considerations

The rising popularity of complementary and alternative medicine (CAM) in child and adolescent psychiatry raises unique ethical and legal concerns for psychiatrists and other conventional health care providers. This article explores these concerns and provides clinical advice for promoting patient health and safety while minimizing the psychiatrist's risk. Although any departure from the conventional standard of care is a potential risk, the risk of malpractice liability for practicing integrative medicine in child and adolescent psychiatry is low. CAM is most safely recommended from a legal standpoint when there is some published evidence of safety and efficacy.

Use of complementary and alternative medicine by children in Europe: published data and expert perspectives

INTRODUCTION

Few data document the use of complementary and alternative medicine (CAM) in Europe, with even fewer investigating use by children.

METHODS

A narrative, non-systematic review of CAM use in Europe was performed by combining data from published surveys with expert perspectives. Limitations created by a lack of representative studies, varying definitions of CAM use, and what qualifies as CAM in different countries was partially overcome by integrating local experts to summarise information available only in the national language and provide their perspectives about CAM availability, quality, use and popularity in their countries using a semi-structured questionnaire. Local and international published surveys were summarised, and the prevalence of CAM use was extrapolated.

RESULTS

Data from 20 European countries were available, representing 69% of the European population. Some data about CAM use by the general population were available for 90% of the examined countries, whereas peer-reviewed published surveys were available for only 60%. We extrapolated that 56% (range: 10-90%, adjusted for population size) of the European population in general had used CAM at least once in the past year. Surveys in CAM use by children were available for 55% of the investigated countries. The extrapolated prevalence of CAM use by children in Europe was 52% (range: 5-90%, adjusted for population size). Paediatric CAM experts reported an increasing awareness for and use of CAM in healthcare institutions.

CONCLUSION

This precursor for further surveys indicates that CAM appears to be popular not only among adults in Europe, but also for children. Development of a pan-European definition of CAM use and CAM therapies are required to achieve surveys comparable between European countries. Additionally, more research investigating the efficacy and potential adverse effects of CAM therapies is needed because of increasing CAM use by children in Europe.

An investigation of the use of traditional chinese medicine in stroke patients in taiwan

Background. The use of complementary and alternative medicine in critical illness is increasing worldwide. This study investigates how traditional Chinese medicine (TCM) is used in stroke patients. Methods. Using Taiwan National Health Insurance reimbursement claims, we compared the annual use of TCM between stroke patients and general population, identifying 15,330 patients with a new onset of stroke in 2000-2009. The sociodemographic status and medical comorbidities between stroke patients receiving TCM services and those without using the service were compared. Results. The use of TCM was higher in stroke patients than in the general population, 27.9% versus 25.4% in 2000 and 32.7% versus 27.8% in 2009, respectively, and grew consistently from 2000 to 2009. Among stroke patients, women, younger patients, white-collar employees, higher-income residents, and those living in areas with more TCM physicians were more likely to use TCM. Stroke patients using rehabilitation services were more likely to have more TCM visits (OR = 2.28, 95% CI = 1.96-2.66) and higher expenditure on TCM (OR = 2.67, 95% CI = 2.29-3.12) compared with stroke patients without rehabilitation. Conclusion. TCM is popular and well accepted in Taiwan. Patients with stroke have a higher TCM utilization rate than people without stroke.

Pediatric integrative medicine: pediatrics' newest subspecialty?

BACKGROUND

Integrative medicine is defined as relationship-centered care that focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches, healthcare professionals and disciplines to achieve optimal health and healing, including evidence-based complementary and alternative medicine. Pediatric integrative medicine (PIM) develops and promotes this approach within the field of pediatrics. We conducted a survey to identify and describe PIM programs within academic children's hospitals across North America. Key barriers and opportunities were identified for the growth and development of academic PIM initiatives in the US and Canada.

METHODS

Academic PIM programs were identified by email and eligible for inclusion if they had each of educational, clinical, and research activities. Program directors were interviewed by telephone regarding their clinical, research, educational, and operational aspects.

RESULTS

Sixteen programs were included. Most (75%) programs provided both inpatient and outpatient services. Seven programs operated with less than 1 FTE clinical personnel. Credentialing of complementary and alternative medicine (CAM) providers varied substantially across the programs and between inpatient and outpatient services. Almost all (94%) programs offered educational opportunities for residents in pediatrics and/or family medicine. One fifth (20%) of the educational programs were mandatory for medical students. Research was conducted in a range of topics, but half of the programs reported lack of research funding and/or time. Thirty-one percent of the programs relied on fee-for-service income.

CONCLUSIONS

Pediatric integrative medicine is emerging as a new subspecialty to better help address 21st century patient concerns.

Complementary and alternative health care in Israel

The paper explores the patterns of coexistence of alternative/complementary health care (CAM) and conventional medicine in Israel in the cultural, political, and social contexts of the society. The data are drawn from over ten years of sociological research on CAM in Israel, which included observation, survey research, and over one hundred in-depth interviews with a variety of CAM practitioners - many with bio-medical credentials - and with policy makers in the major medical institutions. The analysis considers the reasons for CAM use, number of practitioners, the frequency of CAM use and some of its correlates, and how CAM is regulated. The structure of the relationship between the conventional health care system and CAM is discussed in the public sector, which provides two-thirds of CAM services, and in the private sector, which provides about one-third. The history of the development of these structures and some of the dilemmas of their operation are discussed. A number of policy issues are considered against this background: regulation and licensing, CAM in primary care, reimbursement for CAM treatment, and the inclusion of CAM in education and training for the health professions.

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.

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.

Bridging the physician and CAM practitioner communication gap: suggested framework for communication between physicians and CAM practitioners based on a cross professional survey from Israel

OBJECTIVE

Our study aimed to develop a framework to improve communication between physicians and CAM practitioners regarding mutual patients.

METHODS

Following a modified Delphi process, we developed preliminary recommendations regarding communication between physicians and CAM practitioners. We then surveyed 473 physicians and 781 CAM practitioners regarding their opinions on these recommendations.

RESULTS

High reliability and validity of the survey were found among the physicians and CAM practitioners (Cronbach's alpha score of .94 and .83, respectively). Physicians and CAM practitioners considered communication regarding mutual patients important (80% and 97%, respectively; P<.001). A medical/referral letter was the preferred communication mode. Physicians and CAM practitioners concurred on four elements that should be included in such a referral letter: conventional-CAM diagnosis with coherent terminology, possible conventional-CAM treatment interactions, description of the treatment plan and its goals, and quality issues regarding CAM supplements.

CONCLUSIONS

A practical framework for advancing physician-CAM practitioner communication is feasible, and may be applied in daily medical care with the goal of bridging the patient-physician-CAM practitioner communication gap.

PRACTICE IMPLICATIONS

Communication between physicians and CAM practitioners regarding mutual patients is important. Establishing a framework for the mode and content of such communication is feasible.

Referrals and shared or collaborative care: managing relationships with complementary and alternative medicine practitioners

In this article we discuss steps that clinicians should take after deciding to include a complementary and alternative medicine (CAM) treatment that is beyond the clinician's expertise in a patient's treatment plan. We use the example of an adolescent patient with chronic recurrent headaches that have not been relieved by medication or other therapies and whose physician refers her to an acupuncturist for treatment. We focus on (1) circumstances under which referral is appropriate, (2) the nature of the relationship between the referring clinician and the practitioner to whom the referral is made (considering conventional health care and CAM, regulated and unregulated practitioners), and (3) considerations when undertaking shared or collaborative care with other health care practitioners (conventional health care or CAM). We also suggest best practices in managing such relationships.

Stakeholders' perspectives on the regulation and integration of complementary and alternative medicine products in Lebanon: a qualitative study

Background

The regulation of the markets for Complementary and Alternative Medicine (CAM) products presents a global challenge. There is a dearth of studies that have examined or evaluated the regulatory policies of CAM products in the Eastern Mediterranean Region (EMR). We investigate the regulatory frameworks and the barriers for the proper regulation and integration of CAM products in Lebanon, as an example of an EMR country with a weak public infrastructure.

Methods

We utilized a qualitative study design involving a series of semi-structured interviews with stakeholders of the CAM market in Lebanon. Snowball sampling was used to identify interviewees; interviews continued until the "saturation" point was reached. A total of 16 interviews were carried out with decision makers, representatives of professional associations, academic researchers, CAM product importers, policy makers and a media representative. Interviews were transcribed and thematic analysis of scripts was carried out.

Results

There was a consensus among all stakeholders that the regulation of the market for CAM products in Lebanon needs to be strengthened. Thematic analysis identified a number of impediments jeopardizing the safety of public consumption and hindering the integration of CAM therapies into mainstream medicine; including: weak infrastructure, poor regulation, ineffective policies and politics, weak CAM awareness and sub-optimal coordination and cooperation among stakeholders. With respect to policy instruments, voluntary instruments (self regulation) were deemed ineffective by stakeholders due to poor awareness of both users and providers on safe use of CAM products. Stakeholders' rather recommended the adoption of a combination of mixed (enhancing public awareness and integration of CAM into medical and nursing curricula) and compulsory (stricter governmental regulation) policy instruments for the regulation of the market for CAM products.

Conclusions

The current status quo with respect to the regulation of CAM products in Lebanon is not conducive to public safety, nor does it support the integration of CAM products into the healthcare system. The Ministry of Health indeed plays a dominant role in the regulation of these products through a combination of mixed and compulsory policy instruments. Yet, the proper implementation of these regulations requires political resolve coupled with the cooperation of all CAM stakeholders.

Triage and case presentations in a chiropractic pediatric clinic

OBJECTIVE

The use of triage in a chiropractic practice is to determine whether or not a patient who has presented to an office is in need of a referral to another health care provider. The objective of this article is to illustrate the use of triage skills in a primary care, chiropractic pediatric practice. This is examined both in the new patient setting and during visit-to-visit protocol.

METHOD

An analysis of the number of chiropractic triage visits during a 1-year period was performed on 48 new children or pregnant women and 1634 existing pediatric and pregnancy visits.

RESULTS

The average level of chiropractic triage for a new patient, whether pediatric or pregnant, was a limited level of concern (P3, green flag), with more than 85% of new patients falling into that category. Fifteen percent were at a cautionary (P2, yellow flag) level, and none were at the emergency (P1, red flag) level. Between 12% and 15% of the total of existing pediatric or pregnancy visits were at a P1 or P2 level of triage, and 11% of the total of pediatric triage visits were at the P1 level.

CONCLUSION

New patients rarely come to a chiropractic pediatric office in a P1-level crisis, whereas existing patients have a much higher likelihood of presenting during a P1 challenge. P2 triage levels are somewhat common, whereas P3 triage levels are the most frequent. Triage methods are a way to help place a patient in a category that can ensure an optimum, safe, and effective level of care.

Evidence-based neuroethics for neurodevelopmental disorders

Many neurodevelopmental disorders affect early brain development in ways that are still poorly understood; yet, these disorders can place an enormous toll on patients, families, and society as a whole and affect all aspects of daily living for patients and their families. We describe a pragmatic, evidence-based framework for engaging in empiric ethics inquiry for a large consortium of researchers in neurodevelopmental disorders and provide relevant case studies of pragmatic neuroethics. The 3 neurodevelopmental disorders that are at the focus of our research, cerebral palsy (CP), autism spectrum disorder (ASD), and fetal alcohol spectrum disorder (FASD), bring unique and intersecting challenges of translating ethically research into clinical care for children and neonates. We identify and discuss challenges related to health care delivery in CP; neonatal neurological decision making; alternative therapies; and identity, integrity, and personhood.

Patterns of medical pluralism among adults: results from the 2001 National Health Interview Survey in Taiwan

Background

Medical pluralism (MP) can be defined as the employment of more than one medical system or the use of both conventional and complementary and alternative medicine (CAM) for health and illness. A population-based survey and linkage with medical records was conducted to investigate MP amongst the Taiwanese population. Previous research suggests an increasing use of CAM worldwide.

Methods

We collected demographic data, socioeconomic information, and details about lifestyle and health behaviours from the 2001 Taiwan National Health Interview Survey. The medical records of interviewees were obtained from National Health Insurance claims data with informed consent. In this study, MP was defined as using both Western medicine and traditional Chinese medicine (TCM) services in 2001. The odds ratio (OR) and 95% confidence interval (CI) were estimated for factors associated with adopting MP in univariate and multiple logistic regression.

Results

Among 12,604 eligible participants, 32.5% adopted MP. Being female (OR = 1.44, 95% CI = 1.30 - 1.61) and young (OR = 1.38, 95% CI = 1.15 - 1.66) were factors associated with adopting MP in the multiple logistic regression. People with healthy lifestyles (OR = 1.35, 95% CI = 1.19 - 1.53) were more likely to adopt MP than those with unhealthy lifestyles. Compared with people who had not used folk therapy within the past month, people who used folk therapy were more likely to adopt MP. The OR of adopting MP was higher in people who lived in highly urbanised areas as compared with those living in areas with a low degree of urbanisation. Living in an area with a high density of TCM physicians (OR = 2.19, 95% CI = 1.69 - 2.84) was the strongest predictor for adopting MP.

Conclusion

MP is common in Taiwan. Sociodemographic factors, unhealthy lifestyle, use of folk therapy, and living in areas with a high density of TCM physicians are all associated with MP. People who had factors associated with the adoption of MP may be at risk for adverse health effects from interactions between TCM herbal medicine and WM pharmaceuticals.

Chiropractic approach to the management of children

BACKGROUND

Chiropractic (Greek: done by hand) is a health care profession concerned with the diagnosis, treatment and prevention of disorders of the neuromusculoskeletal system and the effects of these disorders on general health. There is an emphasis on manual techniques, including joint adjustment and/or manipulation, with a particular focus on joint subluxation (World Health Organization 2005) or mechanical lesion and restoring function. The chiropractor's role in wellness care, prevention and treatment of injury or illness is based on education in anatomy and physiology, nutrition, exercise and healthy lifestyle counseling as well as referral to other health practitioners. Depending on education, geographic location, scope of practice, as well as consumer preference, chiropractors may assume the role of primary care for families who are pursuing a more natural and holistic approach to health care for their families.

OBJECTIVE

To present a perspective on current management of the paediatric patient by members of the chiropractic profession and to make recommendations as to how the profession can safely and effectively manage the paediatric patient.

DISCUSSION

The chiropractic profession holds the responsibility of ethical and safe practice and requires the cultivation and mastery of both an academic foundation and clinical expertise that distinguishes chiropractic from other disciplines.Research into the effectiveness of chiropractic care for paediatric patients has lagged behind that of adult care, but this is being addressed through educational programs where research is now being incorporated into academic tracks to attain advanced chiropractic degrees.

CONCLUSION

Studies in the United States show that over the last several decades, chiropractors are the most common complementary and alternative medicine providers visited by children and adolescents. Chiropractors continue to seek integration with other healthcare providers to provide the most appropriate care for their paediatric patients.In the interest of what is best for the paediatric population in the future, collaborative efforts for research into the effectiveness and safety of chiropractic care as an alternative healthcare approach for children should be negotiated and are welcomed.

Increasing health-care options: the perspectives of parents who use complementary and alternative medicines

AIM

To explore the relationship between conventional medicine and complementary and alternative medicine (CAM) with parents who use CAM, and to consider factors that may contribute to parent non-disclosure of CAM usage to their doctor.

METHODS

Thirty-three parents participated in one of seven focus groups. Transcripts were analysed using an iterative process of theme identification and testing against transcript data.

RESULTS

The participants believed they should trust their instincts as parents in caring for their child. It was important also to the participants that they understood why their child was ill, and a range of theories of health and illness were discussed. The use of CAM was attractive as it offered more options in health care than just relying on conventional medicine alone. The use of additional therapies was seen as a means to increase the likelihood that something would work. Many of the participants described bad experiences with doctors when they discussed CAM use previously so they had become more circumspect in mentioning it. The participants were most satisfied with medical care for their child when they felt the doctor respected their point of view and listened to them.

CONCLUSIONS

Doctors caring for children and their families should expect that many parents are using CAM to increase health-care options. Inquiries about CAM usage should be made in a non-judgmental and encouraging manner so parents feel comfortable in providing an honest answer. Advice to parents about CAM may need to be backed up with evidence to address differing parent understanding of illness.

Accidental intakes of remedies from complementary and alternative medicine in children--analysis of data from the Swiss Toxicological Information Centre

The use of complementary and alternative medicine (CAM) in Switzerland is rather high, and therefore, the occurrence of accidental intakes of CAM remedies by children and associated intoxications is to be expected. In the present study, the inquiries to the Swiss Toxicological Information Centre that took place from 1998 until 2007 and concerned accidental, unintended intakes of CAM remedies by children were analysed. Inquiries for information were performed by concerned care-givers, physicians, pharmacists and others in case of acute accidental intake of CAM remedies. Feedbacks from physicians about paediatric patients with acute intoxication possibly associated with the accidental ingestion of CAM remedies were as well considered. During the study period, 3,158 accidental intakes of CAM remedies (1,015 of herbal and 2,143 of homeopathic remedies) were reported, corresponding to 8.6% of all reported accidental intakes of pharmaceutical products by children. No significant increase of the yearly number of accidental intakes of CAM remedies was detected during the study period. There was no accidental intake of CAM remedies leading to severe signs or symptoms. Concerning the herbal remedies, three intoxications of moderate and 28 of minor severity were reported. Nine children with intoxication from homeopathic remedies were reported, with minor symptoms only. All other accidental intakes of CAM remedies did not lead to intoxications and evolved without manifestations. The data show that accidental, unintended intake of CAM remedies happened in children, but developed mostly harmlessly. Comparing herbal with homeopathic remedies, accidental intakes with homeopathic remedies were more common, but intoxications associated with manifestations were observed more frequently with herbal remedies.

Socioeconomic and Demographic Factors Associated With Health Care Choices in Taiwan

By using the data from the 2001 National Health Interview Survey and the National Heath Insurance database in Taiwan, this study aims at investigating the socioeconomic and demographic factors associated with different health care choices. This study incorporated hierarchical cluster analysis into multiple correspondent analysis to determine 5 attribute clusters of socioeconomic and demographic factors associated with different health care choices. This study found that older women with higher education levels were more likely to choose multiple sources of health care and that low- to middle-income people were more likely to use over-the-counter medications in pharmacies. In addition, people’s self-reported health care choices were inconsistent with their observed health care seeking behavior. The health policy authority may need to provide more health promotion education programs, especially for older women with higher educational levels, and funding incentives for quality of care provided rather than relying solely on reimbursements for episodic care.

Is Complementary and Alternative Healthcare Use Associated with Better Outcomes in Children with Juvenile Idiopathic Arthritis?

Objective.

The objectives of this study were (1) to examine the association between the use of complementary and alternative healthcare (CAHC) and subsequent health outcomes; and (2) to explore the association between CAHC use and adherence to conventional treatments in children with juvenile idiopathic arthritis (JIA).

Methods.

A cohort of children with JIA (n = 182, mean age 10 yrs) who attended outpatient clinics were followed for one year. We evaluated the use of CAHC, health-related quality of life (HRQOL), global health, physical functioning, pain, and disease severity at 3-month intervals. We also evaluated perceived adherence to treatments. General estimating equations were performed to determine the association between use of CAHC and subsequent outcomes while controlling for possible confounders.

Results.

CAHC was used by 36.4% of participants over the 12-month period. Use of CAHC was associated with subsequent lower global health and physical functioning despite higher adherence to prescribed medications as assessed by the rheumatologist (p < 0.05). Use of CAHC was not associated with subsequent improved HRQOL or decreased pain or disease severity.

Conclusion.

Children with JIA who use CAHC do not have improved outcomes, at least over the relatively short term. Nevertheless, they seem to be more adherent to conventional treatment according to the rheumatologist.

Use of complementary and alternative medicine by patients presenting to a Paediatric Emergency Department

Although the popularity of complementary and alternative medicine (CAM) has risen in the last decade, information about its use by paediatric patients presenting to an Emergency Department is still sparse. We report here the results of a cross-sectional survey of paediatric patients presenting to an urban, tertiary paediatric Emergency Department between October 2006 and March 2007. In total, 1143 questionnaires (68% of those distributed) were completed and available for analysis. Of these, 58% (n = 665) of all respondents admitted that their child had received some form of CAM therapy, while 25% (n = 291) admitted that their child was receiving CAM for the present illness. In 31% of the respondents (n = 354), CAM had been prescribed by a physician, while 50% (n = 575) used CAM as self-medication. Patients presented to the Emergency Department mostly because of an infection (42% of total; 29% of these used CAM) or a trauma (38% of total; 19% of these used CAM). Parents of CAM-users were significantly older, more often born in Switzerland and had significantly higher school education than those of the non-users. Nearly two-thirds of the administered CAM therapies were not prescribed by a physician, and 50% of the families using CAM did not discuss this with their general practitioner. Parental requirements implied that medical professionals on a paediatric Emergency Department should know the effects and side-effects of CAM therapies and even be able to recommend them. The study population, even trauma patients, frequently used CAM. The use of CAM is characterised by a high rate of self-medication and the exclusion of the physicians from the decision-making process. The parents of paediatric patients frequently demand that CAM be considered as a possible treatment option and wish to have an open discussion with the medical professionals on this topic.

American Academy of Pediatrics. The use of complementary and alternative medicine in pediatrics

The American Academy of Pediatrics is dedicated to optimizing the well-being of children and advancing family-centered health care. Related to these goals, the American Academy of Pediatrics recognizes the increasing use of complementary and alternative medicine in children and, as a result, the need to provide information and support for pediatricians. From 2000 to 2002, the American Academy of Pediatrics convened and charged the Task Force on Complementary and Alternative Medicine to address issues related to the use of complementary and alternative medicine in children and to develop resources to educate physicians, patients, and families. One of these resources is this report describing complementary and alternative medicine services, current levels of utilization and financial expenditures, and associated legal and ethical considerations. The subject of complementary and alternative medicine is large and diverse, and consequently, an in-depth discussion of each method of complementary and alternative medicine is beyond the scope of this report. Instead, this report will define terms; describe epidemiology; outline common types of complementary and alternative medicine therapies; review medicolegal, ethical, and research implications; review education and training for complementary and alternative medicine providers; provide resources for learning more about complementary and alternative medicine; and suggest communication strategies to use when discussing complementary and alternative medicine with patients and families.

“Complementary and Alternative Medicine Treatments for Children with Autism Spectrum Disorders”

Complementary and alternative medical (CAM) treatments are commonly used for children with autism spectrum disorders. This review discusses the evidence supporting the most frequently used treatments, including categories of mind-body medicine, energy medicine, and biologically based, manipulative, and body-based practices, with the latter two treatments the most commonly selected by families. Clinical providers need to understand the evidence for efficacy (or lack thereof) and potential side effects. Some CAM practices have evidence to reject their use, such as secretin, whereas others have emerging evidence to support their use, such as melatonin. Most treatments have not been adequately studied and do not have evidence to support their use.

Ethics of complementary and alternative medicine use in children

Complementary and alternative medicine (CAM) has enjoyed tremendous public interest in North America in recent years. CAM is used most often by those who have serious, chronic, or recurrent illness, sometimes for symptom control and sometimes to combat the primary disease. Others use CAM to promote wellness or as a prophylaxis. CAM therapies are increasingly being offered in conventional medical settings and at various other centers and institutes. The relevant ethical commitments or values that must be considered are social commitment to public welfare, nonmaleficence, respect for patient autonomy/consumer choice, recognition of medical pluralism, and public accountability. This article explores the major ethical principles involved in pediatric CAM use and how they affect clinical care and research.

Integrative approaches to childhood constipation and encopresis

Constipation and encopresis (fecal soiling) are common childhood disorders that may lead to significant functional impairment. The etiology and course of constipation and encopresis are increasingly conceptualized from a broad biopsychosocial perspective, and therefore a holistic approach to assessment and treatment is indicated. Many children experience symptoms of chronic constipation and/or encopresis that are only partially responsive to conventional medical therapy. Complementary/alternative therapies can often help in the treatment of constipation/encopresis and are well accepted by patients and families.

Case report: skin discoloration following administration of colloidal silver in cystic fibrosis

PURPOSE OF REVIEW

Complementary and alternative medicine therapies are frequently combined with conventional medical treatment and can significantly affect patient care. In the following case, an adjunctive modality posed a significant health risk to the patient.

RECENT FINDINGS

An 11-year-old boy with cystic fibrosis reported a bluish skin color after he began ingesting a colloidal silver solution to facilitate mucus clearance. Serum silver level was elevated to more than twice the upper limit of normal. This finding is highly suggestive of argyria, a typically permanent discoloration of the skin due to dermal silver deposits. In this child, however, the discoloration was transient and the silver level normalized when the therapy was discontinued.

SUMMARY

Although a diagnosis of argyria was not formally made, this case reviews the known dangers associated with silver ingestion. Complementary and alternative medicine therapies are common and can both augment and interfere with the traditional standard of care. Informed providers who inquire about the use of these therapies can then discuss the risks and benefits of each utilized modality.

Factors influencing complementary and alternative medicine use in a multisite pediatric oncology practice

PURPOSE

Complementary and alternative medicine (CAM) use in children is common although estimates of prevalence vary widely. We studied CAM use in our multisite pediatric oncology practice and evaluated factors influencing CAM use.

PATIENTS AND METHODS

We conducted an anonymous cross-sectional survey of 274 parents of children treated at the combined Nemours oncology practice in Florida and Delaware. Prevalence of CAM use was determined and binary logistic regression was used to evaluate factors related to CAM use in children.

RESULTS

The prevalence of CAM use among children and parents was 24.5% and 66.7%, respectively. Intensity of parent's use of CAM and geographic region were significantly associated with CAM use in children. The odds of CAM use in children increased with increasing use among parents. When parents used 6 or more therapies children were 33 times more likely to use CAM compared with those whose parents did not use CAM (odds ratio=33.3; 95% confidence interval, 10.4-106.2, P<0.01). Children in Florida were more likely to use CAM compared with children in Delaware (odds ratio=3.0; 95% confidence interval, 1.6-5.8, P<0.01).

CONCLUSIONS

These results indicate that children's use of CAM is significantly related to the intensity of parent's use regardless of parent's race, sex, education, household income, or child's sex or age. Clinicians should consider parental use and intensity of CAM use. Assessing CAM use should include classifications established by the National Center for CAM and a standard format for inquiring about CAM use should be developed.

Use of complementary and alternative medicine by food-allergic patients

BACKGROUND

Interest in complementary and alternative medicine (CAM) is increasing. Use of CAM in food-allergic patients has not previously been evaluated.

OBJECTIVES

To determine the prevalence of CAM use, the types of CAM modalities used, and opinions about CAM in food-allergic patients.

METHODS

A questionnaire was distributed to attendees at a patient conference in 2002 and to patients at pediatric food allergy clinics in 2005.

RESULTS

Surveys were completed by 380 families. Respondents were mainly white, parents of children with multiple food allergies, and from the tri-state (New York, New Jersey, Connecticut) area. Diagnostic modalities considered unproven or disproven (such as serum IgG4, electrodermal skin testing, and kinesiology) were used by 22% of respondents; CAM therapies were used by 18%. Participants used several types of CAM practitioners, the most common being chiropractors, homeopaths, and acupuncturists. Only 49% of patients using CAM disclosed this to their physicians. Efficacy ratings for CAM were poor. Regarding participants' opinions, an herbal therapy of equal efficacy, safety, and cost was preferred to a pharmaceutical drug (37% vs 12%; P = .001), but most participants (51%) had no preference or were unsure.

CONCLUSION

Unproven or disproven diagnostic methods and CAM treatments were used by approximately 1 in 5 respondents. Those using CAM noted poor efficacy, but if given a choice, many would prefer herbal therapies to pharmaceutical drugs. Education regarding reliable testing for food allergy and further research on CAM therapies are warranted.

An interdisciplinary view of medical pluralism among Mexican-Americans

This article highlights the relationship between traditional, complementary, and alternative medicine (TCAM) and biomedicine, and the challenges this relationship poses to patients. Medical professionals tend to represent these systems dualistically - as mutually exclusive and in competition with one another. Patients, on the other hand, tend to make truly pluralistic health care decisions - moving freely between TCAM and biomedicine based on what they can access, what they can relate to, and what they believe works. Using their experience with Mexican immigrant and Mexican-American populations in Southwestern United States, the authors discuss strengths and weaknesses in both healthcare systems, and how medical dualism can be a significant barrier to effective healthcare. Recent literature on medical pluralism is discussed from the public health (i.e., community) and medical (i.e., provider) perspectives. These two disciplines are brought together in an attempt to deconstruct the notion that TCAM and biomedicine are diametrically opposed healthcare systems. Biomedically trained health care providers must understand, appreciate, and integrate into their practice how their patients make use of other healing practices and beliefs. Such integration is particularly essential when serving immigrant or minority populations as these groups are more likely to use a pluralistic approach in meeting their health needs.

Decision-making in pediatrics: a practical algorithm to evaluate complementary and alternative medicine for children

We herein present a preliminary practical algorithm for evaluating complementary and alternative medicine (CAM) for children which relies on basic bioethical principles and considers the influence of CAM on global child healthcare. CAM is currently involved in almost all sectors of pediatric care and frequently represents a challenge to the pediatrician. The aim of this article is to provide a decision-making tool to assist the physician, especially as it remains difficult to keep up-to-date with the latest developments in the field. The reasonable application of our algorithm together with common sense should enable the pediatrician to decide whether pediatric (P)-CAM represents potential harm to the patient, and allow ethically sound counseling. In conclusion, we propose a pragmatic algorithm designed to evaluate P-CAM, briefly explain the underlying rationale and give a concrete clinical example.

Legal and ethical issues relating to use of complementary therapies in pediatric hematology/oncology

Pediatricians increasingly are asked to advise pediatric patients and their families concerning integration into conventional care (including hematology and oncology) of complementary and alternative medical (CAM) therapies such as chiropractic, massage therapy, and herbal medicine. Inclusion of CAM therapies in pediatric oncology and hematology--as in any medical subspecialty--is not itself "unethical," clinically inadvisable, or legally risky; the danger comes from over-reliance on one or more CAM therapies (particularly those with evidence of danger and/or paltry evidence of success) to the exclusion of conventional care that is curative and imminently necessary. Pediatricians can help address potential malpractice liability issues by evaluating the level of clinical risk, engaging the patient in shared decision making and documenting this in the medical record, continuing to monitor conventionally, and being prepared to intervene conventionally when medically required.