A systematic review of the reporting of adverse events associated with medical herb use among children

Reporting of adverse effects of pomegranate in clinical studies: a systematic review

OBJECTIVES

Numerous studies have shown the pharmacological effects of pomegranate, such as: anti-cancer, cholesterol-lowering, anti-diabetic, and antihypertensive features. Pomegranate consumption has also revealed some adverse effects. This systematic review aimed to explore the adverse effects of pomegranate reported in clinical studies.

CONTENT

The keywords "pomegranate", "Punica granatum", "side effect", "clinical trial", and "case report or case series" were searched for in valid databases. Reports about adverse effects of pomegranate were also collected from several international registries.

SUMMARY

This systematic review included a total of 66 clinical articles. Eleven articles have reported side effects of pomegranate. Twenty-one articles have recorded no side effects in the pomegranate group while 34 articles have not mentioned any side effects for this plant. The study also included 7 case report studies. The most common side effects included gastrointestinal problems, flu-like symptoms, and urinary problems. In case report studies, the most significant reported side effect was allergic reaction.

OUTLOOK

In summary, pomegranate and its extract seem to be safe according to the reported adverse effects. Meanwhile, conducting more robust controlled trials with pomegranate products and documentation of any probable side effect is warranted.

Rationalising Optimal Dosing of Phytotherapeutics For Use In Children: Current Status - Potential Solutions - Actions Needed

"Children are not small adults with respect to the treatment with medicinal products." This statement of the WHO was the basis for the initiative of the European Commission for the establishment of a paediatric regulation in 2007 to improve the health of children by facilitating the development of medicines for children and adolescents. Seventeen years later, in the field of herbal medicinal products, results are still sobering. Therefore, the Foundation Plants for Health, Society for Medicinal Plants and Natural Products Research, and German Society for Phytotherapy organised a symposium to assess the status quo for the paediatric use of herbal medicinal products (HMPs), to analyse the causes of the current situation, and to discuss strategies for establishing the proof of safe and efficacious HMPs for children.The current situation for HMPs and their use in children is not fulfilling the requirements of legislation. HMPs in paediatrics are effective and safe, but considering the needs of children is necessary. In European countries, the use, registration, and marketing of HMPs are different, depending on the respective national regulations and specific traditions. EU herbal monographs are the best common denominator for such procedures. Emerging safety discussions must be considered. New approaches with real-world data might be a solution. The regulatory framework is to be adapted. Defining rationalised dosing for HMPs can be achieved by the extrapolation of data from adults, by using existing clinical data for children, and by using RWD. Therefore, a strong need for revising restrictions for the use of HMPs in children and rationalising defined dosage regimes is obvious.

Factors and Practices Associated with Self-Medicating Children among Mexican Parents

Background: Pediatric self-medication is based on the subjective interpretation of symptoms in children by the mother or an adult, the decision to self-medicate is made by a third party. The objective of this work is to provide information on the factors and practices associated with the self-medication of children among parents in Mexico. Methods: A cross-sectional and descriptive study was conducted between June 2020 and December 2021 on Mexican parents with children under 12 years of age. Online questionnaires were completed with sections on sociodemographic characteristics, use of medicines or medicinal plants and their treated symptoms, sources of collection, and their recommendation. Results: A total of 9905 online surveys were completed with representation from the 32 states of Mexico, and the prevalence of self-medication was 49.6% (n = 4908). Associated factors were age, having two or more children, children with chronic illnesses, medium educational level, unemployment or employment unrelated to health, medium and high socioeconomic level, and lack of medical security. Respondents self-medicated their children on the recommendation of a family member or friend (55.8%), and own initiative (28%). The most used medication was VapoRub (61.3%), followed by paracetamol (56.9%) and chamomile (33.1%), and the most prevalent symptoms were flu/flow (47.7%) followed by cough (34.2%). The main reasons were perceiving symptoms as not serious (69.9%) and reusing medications (51.9%). Conclusions: There is a high prevalence of self-medication in children in Mexico, mainly associated with children with chronic diseases and families with three or more children.

Predictors for the use of herbal and dietary supplements in children and adolescents with kidney and urinary tract diseases

Complementary and alternative medicine are treatments administered alone or in combination with conventional medical treatments. Data on complementary and alternative medicine use in children with kidney and urinary tract diseases are limited. In this cross-sectional study, the frequency and preferred methods of complementary and alternative medicine use and factors associated with their use were evaluated in 201 patients (48% female; median age, 11 years; median disease duration, 5.1 years) with kidney and urinary tract diseases and 260 healthy (without chronic disease) controls. Data were collected through a questionnaire-based interview and patients' medical records. Herbal and dietary supplements, including fish oil, were the most commonly used complementary and alternative medicine agents in both groups. There was no difference in herbal and dietary supplement use between the groups when fish oil was excluded (29% vs. 28%; p = 0.88). Herbal and dietary supplements were mainly used to improve/mitigate renal disease (52%). Logistic regression analysis revealed that disease duration > 7 years (odds ratio (OR), 3.70; 95% confidence interval (CI), 1.48-9.20), current use of six or more drugs (OR, 5.6; 95% CI, 1.28-24.41), and recurrent urinary tract infection or nephrolithiasis (OR, 3.92; 95% CI, 1.02-15.09) were the independent risk factors for herbal and dietary supplement use, except fish oil. Middle socioeconomic status was associated with decreased herbal and dietary supplement use, except fish oil, compared with low socioeconomic status (OR, 0.30; 95% CI, 0.11-0.81). Herbal and dietary supplements were used by 78% patients, despite knowing that these products could have side effects; only 42% of the patients shared the information about herbal and dietary supplement use with their doctors.Conclusion: Herbal and dietary supplement use is frequent in children with kidney and urinary tract diseases. Educating health professionals regarding such use is mandatory for developing strategies to prevent critical consequences. What is Known: • Complementary and alternative medicine (CAM) practices are therapeutic approaches that do not have sufficient efficacy and safety evidence. • CAM is widely used in healthy children and in certain chronic diseases. What is New: • Herbal and dietary supplements (HDSs) were the most commonly used method in kidney and urinary tract diseases. • Duration of disease, number of drugs, and socioeconomic status are determinants of HDS use except fish oil.

Natural Health Product-Drug Interaction Causality Assessment in Pediatric Adverse Event Reports Associated with Attention-Deficit/Hyperactivity Disorder Medication

Background: Some pediatric patients with attention-deficit/hyperactivity disorder (ADHD) use natural health products (NHPs) such as herbal remedies. Although herbal remedies are generally considered to be safe when they are used appropriately, they may contain active components that can interact with medications being used concurrently, with potential for NHP-drug interactions leading to adverse events. Objectives: The objectives of this study were (1) to identify adverse event reports (AERs) involving commonly used herbal remedies and ADHD prescription medicines in children and adolescents; (2) to evaluate the quality of collected AERs; and (3) to assess whether NHP-drug interactions can be causally linked to reported adverse events. Methods: We systematically searched the FDAble database (FDAble.com) for herbal remedies commonly used by patients (4-18 years old) also taking ADHD drugs from 1997 to 2015. We assessed the completeness of the AERs and used three causality assessment tools modified for NHPs (Naranjo Adverse Drug Reaction Probability Scale, HORN Drug Interaction Probability Scale, and World Health Organization Uppsala Monitoring Centre Scale). Results: Of the 23 identified AERs involving both an herbal remedy and an ADHD prescription medication, most involved multiple (>3) substances with inadequate detail to assess multiple potential interactions. Following data extraction and evaluation of completeness, five AERs involving only one herbal remedy and one ADHD medication were evaluated for causality. An NHP-drug interaction was assessed to be probable in one case and to be possible in another. Both these reports involved a methylphenidate formulation and St. John's wort. Conclusions: Eighteen of the 23 identified AERs involving both an herbal remedy and an ADHD drug also involved other multiple ingredient products. The reporting quality was poor for the five AERs examined. Further research is needed to study the interaction between St. John's wort and methylphenidate.

Dietary Supplements in Children

High-quality systematic reviews of use of herbal or homeopathic remedies in children often suffer from design flaws, such as not following PRISMA guidelines, inconsistent outcome measurements, and paucity of high-quality studies. Herbal remedies have modest demonstrated benefits with insufficient evidence to recommend any particular supplement. Homeopathic remedies have no role in treatment of pediatric conditions, and have been associated with great harm in infants given homeopathic teething products. Two types of herbal supplements are associated with high risk in adolescents, energy drinks and adulterated weight-loss products. Parents should be counseled about risks of these products.

Salicylate Poisoning Potential of Topical Pain Relief Agents: From Age Old Remedies to Engineered Smart Patches

The pain relief capabilities of methyl salicylate are well established and a multitude of over-the-counter products populate pharmacy shelves. Over-application of the topical preparation containing the drug, or its accidental ingestion, invariably result in salicylate poisoning and in severe cases can be fatal. The drug has been a regular feature of the US National Poison Database Survey over the past decade and continues to pose a risk to children and adults alike. The aim of the review has been to cast a spotlight on the drug and assess why its use remains problematic, how technology could offer more efficacious delivery regimes, and minimise the possibility of accidental or intentional misuse.

Exogenous Cushing's syndrome due to a Chinese herbalist's prescription of ointment containing dexamethasone

Eczema in children is a chronic disabling condition. The impact of this condition on the lives of families is often underestimated by conventional physicians. As a consequence parents may investigate complementary treatment options. Close monitoring by a paediatrician is essential, considering that a variety of adverse effects can occur during the use of complementary treatment. We present a 5-year-old girl with eczema. She visited a Chinese herbalist who prescribed an ointment. The parents noticed that the eczema resolved fast, itching decreased and she was finally sleeping well. However, her behaviour changed and appetite increased. Undetectable levels of serum cortisol were found, which was indicative of exogenous Cushing's syndrome. Analysis of the ointment revealed the presence of dexamethasone. Hydrocortisone substitution and subsequently a reduction schedule were implemented, after which endogenous cortisol production recovered after 4 months. Physicians should be aware that unregistered herbal medicine can contain potent drugs such as glucocorticoids.

Spontaneously Reported Adverse Reactions for Herbal Medicinal Products and Natural Remedies in Sweden 2007-15: Report from the Medical Products Agency

Background

In relation to the extensive use of herbal medicinal products in self-care, the safety information is limited and there is a need for improvement. This study describes spontaneously reported adverse reactions related to herbal medicinal products and natural remedies in Sweden.

Objectives

To evaluate the characteristics and frequency of adverse events recorded by the Swedish Medical Products Agency, where herbal medicinal products and natural remedies were suspected as causative agents.

Methods

Adverse drug reactions reported to the Swedish Medical Product Agency during 2007–15 related to approved herbal medicinal products or natural remedies were included and analysed in the retrospective study. Reports had been assessed for causality when they were lodged and only reports that had been assessed as at least possible were included in the study.

Results

In total, 116 reports (concerning 259 adverse reactions) related to herbal medicinal products or natural remedies were found in the Swedish national pharmacovigilance database. The active ingredients most frequently suspected during the study period were black cohosh rhizome (15 reports), purple coneflower herb (14 reports) and a combination of extracts of pollen (13 reports). Adverse reactions related to skin and subcutaneous tissue were the most commonly reported reactions.

Conclusions

No previously unknown safety problems have been discovered in the present study. This finding could be explained by a thorough pre-approval assessment of medicinal products and the fact that most herbal preparations in medicinal products have been in clinical use for many years (for traditional herbal medicinal products, the requirements are ≥30 years), i.e. adverse reactions are acknowledged and assessed before approval.

Electronic supplementary material

The online version of this article (doi:10.1007/s40801-017-0104-y) contains supplementary material, which is available to authorized users.

A Critical Approach to Evaluating Clinical Efficacy, Adverse Events and Drug Interactions of Herbal Remedies

Systematic reviews and meta-analyses represent the uppermost ladders in the hierarchy of evidence. Systematic reviews/meta-analyses suggest preliminary or satisfactory clinical evidence for agnus castus (Vitex agnus castus) for premenstrual complaints, flaxseed (Linum usitatissimum) for hypertension, feverfew (Tanacetum partenium) for migraine prevention, ginger (Zingiber officinalis) for pregnancy-induced nausea, ginseng (Panax ginseng) for improving fasting glucose levels as well as phytoestrogens and St John's wort (Hypericum perforatum) for the relief of some symptoms in menopause. However, firm conclusions of efficacy cannot be generally drawn. On the other hand, inconclusive evidence of efficacy or contradictory results have been reported for Aloe vera in the treatment of psoriasis, cranberry (Vaccinium macrocarpon) in cystitis prevention, ginkgo (Ginkgo biloba) for tinnitus and intermittent claudication, echinacea (Echinacea spp.) for the prevention of common cold and pomegranate (Punica granatum) for the prevention/treatment of cardiovascular diseases. A critical evaluation of the clinical data regarding the adverse effects has shown that herbal remedies are generally better tolerated than synthetic medications. Nevertheless, potentially serious adverse events, including herb-drug interactions, have been described. This suggests the need to be vigilant when using herbal remedies, particularly in specific conditions, such as during pregnancy and in the paediatric population. Copyright © 2016 John Wiley & Sons, Ltd.

Emergency Department Visits for Adverse Events Related to Dietary Supplements

BACKGROUND

Dietary supplements, such as herbal or complementary nutritional products and micronutrients (vitamins and minerals), are commonly used in the United States, yet national data on adverse effects are limited.

METHODS

We used nationally representative surveillance data from 63 emergency departments obtained from 2004 through 2013 to describe visits to U.S. emergency departments because of adverse events related to dietary supplements.

RESULTS

On the basis of 3667 cases, we estimated that 23,005 (95% confidence interval [CI], 18,611 to 27,398) emergency department visits per year were attributed to adverse events related to dietary supplements. These visits resulted in an estimated 2154 hospitalizations (95% CI, 1342 to 2967) annually. Such visits frequently involved young adults between the ages of 20 and 34 years (28.0% of visits; 95% CI, 25.1 to 30.8) and unsupervised children (21.2% of visits; 95% CI, 18.4 to 24.0). After the exclusion of unsupervised ingestion of dietary supplements by children, 65.9% (95% CI, 63.2 to 68.5) of emergency department visits for single-supplement-related adverse events involved herbal or complementary nutritional products; 31.8% (95% CI, 29.2 to 34.3) involved micronutrients. Herbal or complementary nutritional products for weight loss (25.5%; 95% CI, 23.1 to 27.9) and increased energy (10.0%; 95% CI, 8.0 to 11.9) were commonly implicated. Weight-loss or energy products caused 71.8% (95% CI, 67.6 to 76.1) of supplement-related adverse events involving palpitations, chest pain, or tachycardia, and 58.0% (95% CI, 52.2 to 63.7) involved persons 20 to 34 years of age. Among adults 65 years of age or older, choking or pill-induced dysphagia or globus caused 37.6% (95% CI, 29.1 to 46.2) of all emergency department visits for supplement-related adverse events; micronutrients were implicated in 83.1% (95% CI, 73.3 to 92.9) of these visits.

CONCLUSIONS

An estimated 23,000 emergency department visits in the United States every year are attributed to adverse events related to dietary supplements. Such visits commonly involve cardiovascular manifestations from weight-loss or energy products among young adults and swallowing problems, often associated with micronutrients, among older adults. (Funded by the Department of Health and Human Services.).