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PEDIATRICS Vol. 111 No. 5 May 2003, pp. 981-985

Herbal Therapy Use in a Pediatric Emergency Department Population: Expect the Unexpected

Steven L. Lanski, MD*,{ddagger}, Michael Greenwald, MD*,{ddagger}, Amanda Perkins, RN{ddagger} and Harold K. Simon, MD*,{ddagger}

* Departments of Pediatrics and Emergency Medicine, Division of Pediatric Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia
{ddagger} Children’s Healthcare of Atlanta, Atlanta, Georgia

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   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 DESIGN/METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Background. In recent years investigators have reported widespread use of alternative medicine. Some herbal therapies have potentially harmful side effects as well as adverse interactions with medications. Data are lacking on the use in children and caregiver understanding of these products.

Objectives. To determine the reported use of herbal products among a pediatric emergency department population and to evaluate the caregivers’ understanding and source of information concerning these products.

Design/Methods. A convenience sampling of pediatric emergency department patients and their caregivers occurred during a 3-month period in 2001. The interview consisted of 18 questions regarding the types of non-Food and Drug Administration-regulated herbal products and home remedies used, general product knowledge and sources of information used by the child’s caregiver (including discussions with their child’s primary physician).

Results. One hundred forty-two (93%) of 153 families approached participated in the study. The mean patient age was 5.3 years (range: 3 weeks-18 years). Forty-five percent of caregivers reported giving their child an herbal product, and 88% of these caregivers had at least 1 year of college education. Of the children receiving these therapies, 53% had been given 1 type and 27% were given 3 or more in the past year. The most common therapies reportedly used were aloe plant/juice (44%), echinacea (33%), and sweet oil (25%). The most dangerous potential herbal and prescription medication combination reported was ephedra and albuterol in an adolescent with asthma. The most unusual products reportedly used included turpentine, pine needles, and cowchips. Of all people interviewed, 77% did not believe or were uncertain if herbal products had any side effects and only 27% could name a potential side effect. Sixty-six percent were unsure or thought that herbal products did not interact with other medications and only 2 people correctly named a drug interaction. Of the people who used these therapies, 80% reported either friends or relatives as their primary source of information. Only 45% of those giving their children herbal products report discussing the use with their child’s primary health care provider.

Conclusion. Herbal and home therapies are commonly used in this pediatric population. An unexpectedly wide variety of products were reportedly given to this patient population. Caregivers reported limited knowledge regarding potential adverse medication interactions and side effects. Limited discussions with the child’s primary health care provider were reported. It is therefore important for health care providers to have knowledge about herbal medications, to inquire about their use and to educate families about the risk/benefit as well as potential interactions these products may have with over-the-counter and prescription medications.

Key Words: alternative medicine • herbal therapy • pediatrics

Abbreviations: PED, pediatric emergency department • FDA, Food and Drug Administration


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
DESIGN/METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
In recent years, several investigators have reported widespread use of alternative medicine in North America. Alternative medicine is a poorly defined term that encompasses a wide spectrum of purported medicinal agents. Examples include such substances as herbal and homeopathic products as well as care provided by chiropractors, massage therapists, and homeopaths. Eisenberg et al1 showed an almost fivefold increase in adult use of herbal therapies in the United States between 1990 and 1997. In 2 adult studies, 1 in New York and 1 in California, 56% and 43%, respectively, of respondents reported using a form of alternative medicine.2,3 In 1994, a Canadian study reported 11% of patients seen at a pediatric outpatient department of a university-based hospital used some form of alternative therapy.4 A study in 1997 comparing the use of alternative therapies in children with cancer and children without chronic illness showed alternative therapy use of >50% in both groups.5 In 1999, Pitetti et al6 found the overall rate of alternative medicine use in their pediatric emergency department (PED) was 12% with almost half of those patients being given an herbal or homeopathic remedy. Although there are adult studies that report on the specific use patterns of herbal therapies, a paucity of data exists concerning the use of these products among pediatric patients.3

There exists some evidence to suggest that health care providers underestimate alternative medicine use in their patients. In a 1998 survey of Michigan pediatricians, the majority of the respondents reported that they believed few of their patients were being treated with alternative therapies and that most of the parents would tell them if they were exposing their child to these therapies.7 However, Eisenberg et al1 both in 1990 and 1997 reported that <40% of patients using herbal products discussed the use with their physician.

Many herbal products are benign in nature; however, some of these therapies have potentially harmful side effects as well as adverse interactions with other medications. The regulation of herbal products falls under control of the Dietary Supplement Health and Education Act of 1994. According to this act, producers are required to ensure safety and appropriate labeling of a product. Manufacturers and distributors are not required to actually demonstrate safety or efficacy of the product before placing it on the market.8 The ambiguity of ensuring but not actually demonstrating safety potentially allows herbal products to enter the market without having to provide actual evidence of safety or efficacy. Regulation by the Food and Drug Administration (FDA) occurs only after reports appear of adverse effects related to products already in the marketplace. Recent examples of potentially harmful products include herbal fen-phen that contained both ephedra, which has been linked to cardiovascular problems, and L-tryptophan, which has been linked to eosinophilia myalgia syndrome.9–11 More recently the FDA has begun to focus on the relationship between kava kava use and possible hepatotoxicity.12 In light of the current regulatory situation, parents may incorrectly assume these products are adequately regulated and therefore safe.

This study set out to determine the reported use of specific types of herbal products among patients presenting to a PED and to evaluate the caregivers’ understanding of the potential for adverse effects with the use of these products. Furthermore, the study set out to describe the sources of information used by the caregivers and the extent to which the child’s primary health care provider was included in this process.


   DESIGN/METHODS
TOP
 ABSTRACT
 INTRODUCTION
 DESIGN/METHODS
RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
A convenience sampling of caregivers presenting to a PED at an urban tertiary care children’s hospital with annual patient census of 42 000 visits occurred during a 3-month period from October 2001–December 2001. Interviews were conducted during a representative sample of days, evenings, and weekends. After informed consent was obtained, a study investigator (S.L.L. or A.P.) verbally administered an 18-point questionnaire developed by the investigators (Table 1). The questions pertained to the types of herbal products both given to the child and used by the caregivers, concurrent medication administration, general product knowledge related to side effects, and medication interactions as well as sources of information used by the caregiver (including discussions with their child’s primary health care provider). Herbal products for the purposes of this study are defined as substances, used as health treatments, that are non-FDA-approved and not considered prescription or over-the-counter medications. Health care providers were considered the child’s primary care physicians or nurse practitioners. Initially, caregivers were asked "Has your child been given any herbal or natural remedies currently or in the past: week, 3 months, 6 months, or year?" If the caregiver requested clarification, the question was repeated with the additional statement "this includes anything used for health treatment that is not a prescription or over-the-counter medication." Later in the interview, a list of 17 herbal products (see Table 1, question 3) was given to the caregivers who were asked if their child had ever been given any of these products as well as any other products not specifically mentioned. All herbal products that were reported by the caregivers as being given to their children were recorded. The list, which was developed by the investigators before the initiation of the study, included products that had been reported as commonly sold in the United States as well as products the investigators thought were commonly given to children.13 This list was then compared with the products reportedly given to the children (Table 2). Families were excluded if the caregiver was unable to communicate in English and those patients who were critically ill so as not to delay patient care. Demographic information such as zip code, caregiver level of education, age, country of origin, and race of caregivers were recorded. Data were stored and analyzed using an Epi Info (Centers for Disease Control and Prevention, Atlanta, GA) 2002 database. {chi}2 analysis was used for categorical variables and analysis of variance for continuous variables. This study was approved by the Human Investigations Committee of Emory University.


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  		TABLE 1. Questions Related to Herbal Therapy Use Asked During the Interview

 

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  		TABLE 2. Herbal Products Caregivers Reportedly Gave to Their Child

 

   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 DESIGN/METHODS
 RESULTS
DISCUSSION
 CONCLUSIONS
 REFERENCES
 
One hundred forty-two (93%) of 153 families approached participated in the study. The 11 families that did not participate included 3 who left before the interview, 5 who declined the interview, and 3 who were excluded because they were non-English-speaking. The mean patient age was 5.3 years (range: 3 weeks-18 years). The mean caregiver age was 31 years. Sixty-four (45%) of 142 caregivers reported giving their child an herbal or home remedy within the last year. The overall racial composition of caregivers was representative of the typical population seen at this facility in that 88 (62%) of 142 were black, 46 (32%) were white, and 4 (3%) were Hispanic. There was no difference in the use of herbal products across the different racial groups, birth countries, or sex of child. There was, however, a difference between those who reported giving herbal therapies to their children and those who denied use, in educational background as well as age of caregiver and child. Of those who did report use, 56 (88%) of 64 had at least one year of college education compared with 51 (65%) of 78 in the group that denied giving these therapies to their children (P < .01). The mean age of caregivers giving herbal therapies to their children was 36 years (range: 26–52) compared with 28 years (range: 21–37) in the nonusers (P < .01). The mean age of children receiving herbal therapies was 7.3 years (range: 0.42–18) compared with 3.6 years (range: 0.06–16) in the group not receiving these therapies (P < .01; Table 3).


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  		TABLE 3. Comparison of People Who Reported Giving Herbal Therapies to Their Child With Those Who Reported Not Using Herbal Therapies

 
Of the 64 children receiving herbal therapies in the last year, 34 (53%) had been given 1 type and 17 (27%) were given 3 or more different herbal products. The highest number of products given to a single child in the last year was 11, reported by 2 separate families. The most commonly reported therapies given to the 64 children were: aloe plant/juice given to 28 children (44%), echinacea given to 21 children (33%), sweet oil given to 16 children (25%), eucalyptus given to 13 children (20%), ginkgo, ginseng, and goldenseal each given to 6 children (9%), and valerian root and ephedra each given to 3 children (5%) (Table 2). The most commonly reported reasons for use were: colds in 20 (31%), burns or cuts in 16 (25%), immune stimulation in 11 (17%), and relaxation in 10 (16%). Within the last 3 months, 14 (61%) of 23 of children on an herbal therapy were reportedly taking a prescription medication at the same time. The most dangerous potential combination reported was ephedra and albuterol in an adolescent with asthma. Echinacea was used to boost the immune system in a child with lupus who was taking steroids and an immunosuppressant. One child who was thought to have worms was given a turpentine rubdown and another child from a separate family was given a small amount of turpentine to drink for the same ailment. The youngest child reported to receive an herbal therapy was only 5 months old and received catnip tea for a cold. Interestingly, several children were receiving unusual therapies including pine needle and cowchip tea for colds. Overall, the most common reasons caregivers gave for using herbal products included the following: they were recommended by family or friends 29 (45%), they are natural and therefore more safe than traditional Western medications 19 (30%), and to avoid having to make an appointment to see a doctor 5 (8%).

Of all caregivers interviewed, 109 (77%) of 142 did not believe or were uncertain if herbal products had any side effects and only 9 (27%) of 33 believing side effect could occur were able to name a potential side effect of herbal products. Ninety-four (66%) of 142 caregivers were unsure or thought that herbal products did not interact with over-the-counter or prescription medications. Only 2 of the respondents that thought interactions could occur were able to correctly identified a potential medication interaction. Seven of the 64 people using herbal products (11%), stated the products were natural and therefore more safe than over-the-counter or prescription medications. Of the caregivers who gave herbal therapies to their children, 51 (80%) reportedly received their information from friends or relatives. Only 29 (45%) of caregivers giving their children herbal therapies report discussing the use with their child’s primary health care provider. The most common reasons reported by the 35 caregivers for giving herbal products but not discussing these products with their child’s health care provider were not remembering to ask 16 (46%) and not thinking it was important 9 (26%). Two separate caregivers who did try to discuss the use of herbal products with their child’s health care provider were reportedly told they were abusing their child by their child’s doctor. Of the caregivers who reported that they asked their child’s health care provider about using herbal products, 11 (38%) of 29 were told by their child’s health care provider that they were unfamiliar with the product in question.


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 DESIGN/METHODS
 RESULTS
 DISCUSSION
CONCLUSIONS
 REFERENCES
 
Herbal and home therapies are commonly used in this pediatric population with nearly half of the responding caregivers reportedly giving their child at least 1 product in the last year. Although caregiver race and country of origin did not correlate with use of these therapies, older individuals and college education was associated with higher rates of herbal product use. Not all the therapies given were generally marketed for health use, as we found several examples of home remedies using a variety of natural and household products. The spectrum of reportedly used herbal therapies/products was much wider than initially anticipated (Table 2). It included such unexpected substances as pine needles, cowchips, and turpentine.

Caregivers stated they give their child herbal therapies because they are natural and therefore more safe to use than traditional Western medicine. Although most of the products reportedly used are at present considered benign, several cases were identified in which products used could have detrimental effects on the health of the recipient. In this population the majority of caregivers did not believe these products had any side effects or potential medication interactions. Of those that did, few could name 1 specifically. The lack of awareness about potential adverse reactions underscores an important issue of which families may not be aware. These products do not require FDA approval before release in the marketplace. The lack of current regulatory control on these products highlights the heightened awareness consumers and medical personnel should have regarding the potential for adverse reactions/medication interactions. Without prompting families, health care providers may not be adequately informed about the actual use of these products. There is a need for health care providers to educate families about the lack of regulation on these products and that safety is not assured although these products are advertised as natural.

The majority of caregivers obtained their information about these products from friends or relatives. Reported discussions with health care providers remains low in this population. This contrasts with previously reported pediatricians’ views regarding communication with parents about alternative therapies.7 Several people who tried to discuss these products with a health care provider were not given helpful information enabling them to make an informed decision about the use of these products. Given the disparity between health care provider perception and the reported lay use of herbal products, it is important for health care providers to increase their awareness of the widespread use of herbal therapies and to fully discuss them with families.

This study was limited by small numbers and represents a patient population from a single region. However, this is a representative sample from a large tertiary referral center. This study may have reporting bias as the data were collected by interview. However, if this bias exists one would expect caregivers would, if anything, underreport the use herbal products.


   CONCLUSIONS
TOP
 ABSTRACT
 INTRODUCTION
 DESIGN/METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
REFERENCES
 
In this pediatric population, caregivers reported giving a wide spectrum of various herbal products to their children. However, parental knowledge and communication about these products with their child’s health care provider is lacking. Certain therapies are known to have potential adverse effects alone or in combination with prescription and over-the-counter medications. Therefore, it is important for health care providers to have knowledge about herbal products, to inquire about their use, and to educate families about the risks and benefits these products may have. By using an open-minded approach based on available medical data, health care providers may improve physician-patient communication, which will hopefully translate into appropriate use of these products when medically indicated and in turn result in better care for our patients.


   ACKNOWLEDGMENTS
 
We thank the emergency department nursing staff at Children’s Healthcare of Atlanta for their assistance. We also thank Kevin Sullivan, PhD, MPH, for his invaluable suggestions over the course of this project.


   FOOTNOTES
 
Received for publication Jun 6, 2002; Accepted Oct 8, 2002.

Address correspondence to Steven L. Lanski, MD, Department of Pediatrics, Division of Pediatric Emergency Medicine, Emory University/Children’s Healthcare of Atlanta, 1405 Clifton Rd NE, Atlanta, GA 30322. E-mail: steve_lanski{at}oz.ped.emory.edu

Presented in part at the Society for Pediatric Research/Pediatric Academic Societies Meeting; May 4–7, 2002; Baltimore, MD; and at the Society for Academic Emergency Medicine Meeting; May 19–22, 2002; St Louis, MO.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 DESIGN/METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 

  1. Eisenberg DM, Davis RB, Ettner SL, et al. Trends in alternative medicine use in the United States, 1990–1997: results of a follow-up national survey. JAMA.1998; 280 :1569 –1575[Abstract/Free Full Text]
  2. Gulla MA, Singer AJ. Use of alternative therapies among emergency department patients. Ann Emerg Med.2000; 35 :226 –228[CrossRef][ISI][Medline]
  3. Weiss SJ, Takakuwa KM, Ernst AA. Use, understanding, and beliefs about complementary and alternative medicines among emergency department patients. Acad Emerg Med.2001; 8 :41 –47[ISI][Medline]
  4. Spigelblatt L, Laine-Ammara G, Pless BI, Guyver, A. The use of alternative medicine by children. Pediatrics.1994; 94 :811 –814[Abstract/Free Full Text]
  5. Friedman T, Slayton WB, Allen LS, et al. Use of alternative therapies for children with cancer. Pediatrics.1997; 100(6) . Available at: http://www.pediatrics.org/cgi/content/full/100/6/e1
  6. Pitetti R, Singh S, Hornyak D, et al. Complementary and alternative medicine use in children. Pediatr Emerg Care.2001; 17 :165 –169[CrossRef][ISI][Medline]
  7. Sikand A, Laken M. Pediatricians’ experience with and attitudes toward complementary/alternative medicine. Arch Pediatr Adolesc Med.1998; 152 :1059 –1064[Abstract/Free Full Text]
  8. United States Food and Drug Administration. Dietary Supplement Health and Education Act of 1994. Available at : http://vm.cfsan.fda.gov/~dms
  9. United States Food and Drug Administration. FDA warns against drug promotion of "herbal fen-phen." FDA Talk Paper. 1997. Available at: http://vm.cfsan.fda.gov/~lrd/tpfenphn.html
  10. Perrotta DM, Coody G, Culmo C. Adverse events associated with ephedrine-containing products Texas, December 1993-September 1995. MMWR Morb Mortal Wkly Rep.1996; 45 :689 –693[Medline]
  11. Belongia EA, Hedberg CW, Gleich GJ, et al. An investigation of the cause of the eosinophilia-myalgia syndrome associated with tryptophan use. N Engl J Med.1990; 323 :357 –365[Abstract]
  12. United States Food and Drug Administration. Kava-containing dietary supplements may be associated with severe liver injury. FDA CFSCAN Consumer Advisory. 2002. Available at: http://www.cfsan.fda.gov/~dms/ds-warn.html
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PEDIATRICS (ISSN 1098-4275). ©2003 by the American Academy of Pediatrics



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