Published online July 2, 2007
PEDIATRICS
Vol. 120
No. 1
July 2007, pp.
e142-e146
(doi:10.1542/peds.2006-2648)
Frequency and Characteristics of Pediatric and Adolescent Visits in Naturopathic Medical Practice
Wendy Weber, ND, MPHa,
James A. Taylor, MDb,
Rachelle L. McCarty, ND, MPHa and
Amy Johnson-Grass, ND, MSNc
a School of Naturopathic Medicine, Bastyr University, Kenmore, Washington
b Child Health Institute, University of Washington and Children's Hospital and Regional Medical Center, Seattle, Washington
c Minnesota Consortium for CAM Clinical Research, University of Minnesota, Minneapolis, Minnesota
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ABSTRACT
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OBJECTIVES. This work sought to identify naturopathic physicians in Washington State who frequently provide pediatric care and to describe the conditions treated and therapies recommended for children.
PATIENTS AND METHODS. A mailed survey of licensed naturopathic physicians residing in Washington State collected demographic information and practice descriptions. For naturopathic physicians treating 
5 pediatric patients per week, data were collected on the conditions seen and treatments provided to children during a 2-week period.
RESULTS. Of 499 surveys delivered to providers, 251 surveys were returned (response rate: 50.3%). Among the 204 naturopathic physicians currently practicing, only 31 (15%) saw 5 children per week. For these pediatric naturopathic physicians, pediatric visits constituted 28% of their office practice. Pediatric naturopathic physicians were more likely to be licensed midwives (19.4% vs 0.6%) and treated significantly more patients per week (41.6 vs 20.2) than naturopathic physicians who provided less pediatric care. Eighteen of the 31 pediatric naturopathic physicians returned data on 354 pediatric visits; 30.5% of the visits were by children <2 years old, and 58.5% were by those <6 years old. The most common purpose for presentation included health supervision visits (27.4%), infectious disease (20.6%), and mental health conditions (12.7%). Pediatric naturopathic physicians provided immunizations during 18.6% of health supervision visits by children <2 years old and 27.3% of visits by children between the ages of 2 and 5 years.
CONCLUSIONS. Although most naturopathic physicians in Washington treat few children, a group of naturopathic physicians provide pediatric care as a substantial part of their practice. Based on the ages of children seen and the conditions treated, pediatric naturopathic physicians may provide the majority of care for some children. Efforts should be made to enhance collaboration between naturopathic physicians and conventional providers so that optimal care can be provided to children.
Key Words: naturopathic • complementary medicine • children and adolescents • infant • vaccines
Abbreviations: ND—naturopathic physician • ADHD—attention-deficit/hyperactivity disorder • pedsNDs—naturopathic physicians who treat 5 pediatric patients per week • nonpedsNDs—naturopathic physicians who treat <5 pediatric patients per week • URI—upper respiratory infection • CAM—complementary and alternative medicine
The practice of naturopathic medicine is licensed in 14 states in the United States, as well as the District of Columbia, Puerto Rico, and the US Virgin Islands. Under these licenses, naturopathic physicians provide care to infants, children, adolescents, and adults. Naturopathic physicians (NDs) are trained to treat the whole person with natural means, such as nutrition, exercise, lifestyle modification, vitamins, herbal medicines, nutritional supplements, and hydrotherapy.1 In addition to these modalities, in some states, licensed NDs can prescribe conventional medications, including antibiotics and vaccines. Licensing requires graduation from 1 of 5 accredited naturopathic medical schools in the United States or Canada (1 additional school is a candidate for accreditation). NDs receive a minimum of 4100 hours of education, including 1200 hours of clinical training.2
The majority of patients seen by NDs are adults, and most visits by adults are for the treatment of chronic conditions, such as fatigue, back symptoms, and headache.3 There are limited data on naturopathic medicine use by children.3–5 A survey of 15 NDs in Massachusetts reported that 19% of visits to an ND were by children and that, on average, 5 pediatric patients were seen per week.4 In another study, 99 NDs provided visit data on 20 consecutive patients; 10% to 12% of these visits were made by pediatric patients <15 years of age.3 Wilson et al5 summarized the chief complaints reported by 482 parents bringing their child in for naturopathic care at a large academic naturopathic clinic in Toronto, Ontario, Canada. The authors reported that 23% of pediatric patients presented with skin disorders, 17% with gastrointestinal complaints, and 15% with psychiatric or behavioral disorders.5 In a review of insurance claims data, Bellas et al6 found that 1% of children enrolled in 2 large insurance plans in Washington State had visited an ND. These reports provided few data on the care provided by NDs to children.
To better characterize pediatric naturopathic care, we conducted a survey of NDs in Washington State. A main goal of the study was to identify NDs who provided care to a substantial number of children and to compare these practitioners to NDs who saw fewer pediatric patients. A second goal of the project was to describe the chief complaints from pediatric visits to NDs and the categories of treatments provided.
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METHODS
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In June 2004, the Department of Health in Washington State was contacted and provided the investigators with a list of NDs licensed in Washington. A cover letter and survey were mailed to all of the NDs with mailing addresses in the state of Washington in July 2004. A $1 incentive was included with each survey. For any survey returned as undeliverable, the online databases of the American Association of Naturopathic Physicians and the Washington Association of Naturopathic Physicians were searched in attempt to find an updated address for the ND (www.naturopathic.org and www.wanp.org). A second mailing was sent in November 2004 to all of the NDs who did not return the initial survey, along with another $1 incentive.
Contacted NDs were asked to complete a 1-page survey that included demographic items and questions about their practices. Demographic information included the age, gender, race, and ethnicity of the provider; information about other types of practitioners working in the office; an estimate of the average number of children or adolescents treated per week; and whether the provider's practice marketed for pediatric patients. NDs who reported an average of 5 pediatric patient visits per week were asked to record information including the age, gender, chief complaints, and treatment provided for each child <18 years old who was seen in the office during a 2-week time period. Surveys and visit data were collected from July 2004 to January 2005.
For the analysis, characteristics of NDs who estimated that they saw 5 pediatric patients per week were compared with those of respondents who saw fewer children. Differences in the number of years in practice, number of patients treated per week, and proportion of pediatric patients seen were assessed with t tests. 
2 tests were used to evaluate the significance of the differences between NDs who reported seeing substantial numbers of children in their practices and those who saw fewer children for types of additional degrees, types of providers sharing practices, and specific marketing for pediatric health care services. Differences were considered significant if the P value was <.05.
Data on patient visits were aggregated by age of the patient (<2, 2–5, 6–11, and 12–17 years old) and by primary diagnosis. Major diagnostic categories included health supervision visits (for visits characterized as "well-child examination" or "screening physical"), upper respiratory tract infections (cold, cough, and otitis media), allergies, eczema, attention-deficit/hyperactivity disorder (ADHD), and autism. Categories of treatments were further evaluated by specific diagnoses and within selected age groups.
This study was approved by the Bastyr University Institutional Review Board. Language was included in the cover letter stating that participation was voluntary, and consent was implied if the completed survey was returned.
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RESULTS
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The names and addresses of a total of 649 NDs were provided by the Washington State Department of Health. An out-of-state mailing address was listed for 136 of these NDs, excluding them from the study. Surveys were mailed to the remaining 513 licensed NDs residing in the state of Washington. Fourteen surveys (2.7%) were returned to sender as nondeliverable, and no correct forwarding address was available. Of the 499 surveys delivered to NDs, 251 completed surveys were returned (50.3%).
Returned surveys indicated that 18.7% of NDs were not actively in practice, and demographic data were not collected on these individuals. Of the 204 practicing NDs who completed the survey, 31 (15.2%) reported treating 5 pediatric patients per week (termed "pedsNDs"). In Table 1, the characteristics of these providers and their practices are compared with those of NDs who reported fewer visits with children (termed "nonpedsNDs"). Seven completed surveys did not indicate the number of pediatric patients treated per week; therefore, data from these surveys were not included in the comparative analysis between pedsNDs and nonpedsNDs. There were few significant differences in provider characteristics between pedsNDs and nonpedsNDs. However, although the overall proportion with additional degrees was similar, pedsNDs were more likely to also be licensed midwives (19.4% vs 0.6%; P < .001). In terms of their practices, pedsNDs reported significantly more visits per week and were more likely to specifically market pediatric health care services. Overall, 78.9% of all of the NDs reported sharing their office with other providers including the following: other NDs (65.2%), licensed acupuncturists (40.4%), massage therapists (40.4%), chiropractic doctors (18.0%), MDs (13.7%), PhDs (6.8%), counselors (6.2%), registered nurses (5.0%), licensed midwives (4.4%), and nutritionists (4.4%). PedsNDs were less likely to have shared their office with an acupuncturist (17.9% vs 44.6%; P < .01) and more likely to share their office with a licensed midwife (17.9% vs 1.4%; P < .001) than those who saw fewer children.
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TABLE 1 Demographics of NDs in Active Clinical Practice Reporting That They Treat 5 Pediatric Patients per Week and Those Who Do Not
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Patient visit data were received from 18 (58%) of the 31 pedsNDs; information on 354 visits was collected. Of the patients seen by pedsNDs, 30.5% of the pediatric patients were under the age of 2 years; 28.0% of the patients were between 2 and 5 years of age; 22.6% were between 6 and 11 years of age; and 18.9% were between 12 and 18 years of age. The mean age of children and adolescents visiting pedsNDs was 5.8 years (SD: 5.4); the median age was 4 years. Nearly 45% of visits were by girls, and 55% of visits to pedsNDs were by boys.
The most common chief complaints recorded by pedsNDs for the patients' visits included health supervision visits (27.4%), upper respiratory infections (URIs) (18.4%; including URI [7.9%], otitis media [5.9%], and cough [4.5%]), allergies (6.2%), eczema (4.2%), ADHD (3.7%), and autism (2.5%). An estimated 24.0% (95% confidence interval: 19.7%–28.8%) of visits were for chronic conditions, including allergies, asthma, eczema, and mental health conditions. Table 2 provides details of the treatments recommended by the pedsNDs for each of the conditions listed above. Except for children with autism, pedsNDs recommended >1 category of treatment at 46% of visits.
Within each age group, the 5 most common reasons for visiting a pedsND included health supervision visits, upper respiratory tract infection, allergies, skin disorders, and mental health conditions (Table 3). In addition to the reasons noted above, 9.3% of visits by children <2 years old were for infant conditions (colic, teething, failure to thrive, or thrush). Immunizations were given during 18.6% of health supervision visits by children <2 years of age. Respiratory conditions (asthma or bronchitis) were recorded as the chief complaint for 6.1% of children ages 2 to 5 years. In this age group, immunizations were administered in 27.3% of health supervision visits. Oral antibacterial or antifungal prescriptions were prescribed in 6.1% of visits; however, no antibiotics were prescribed for children presenting with upper respiratory symptoms. Other reasons for visits in adolescents ages 12 to 18 years included 9% for gastrointestinal complaints (diarrhea or irritable bowel syndrome) and 7.5% for gynecologic disorders (amenorrhea, vaginitis, or premenstrual syndrome). Overall, no antibiotics were prescribed for any of the 65 children presenting with upper respiratory symptoms.
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DISCUSSION
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The results of this survey indicate that most NDs in Washington State see limited numbers of children in their practices. However, there is a distinct group of NDs, representing 15% of survey respondents, for whom pediatric care is a substantial part of their practice. These pedsNDs see almost 10 children per week in their offices, may specifically market the pediatric care they provide, and often partner with licensed midwives or provide midwifery care themselves.
Contrary to reports of adult use of complementary and alternative medicine (CAM), which consistently find that women are more likely to use CAM treatments, we found that nearly equal numbers of girls and boys were seen by NDs (45% and 55%, respectively).7,8 Similar to adults who are seen by NDs, 24% of the visits by pediatric patients to pedsNDs were for the treatment of chronic disorders, particularly those in which therapies provided by conventional practitioners are either controversial to some parents, such as with ADHD, or of limited benefit, as with autism. However, in our study, the 2 most common reasons for visits by children to pedsNDs were health supervision and URI symptoms. Preschool-aged children made most of these visits. Health supervision and URI symptoms are also the most common reasons that children see conventional providers.6 These data suggest that pedsNDs provide the majority of care for a group of pediatric patients.
Our finding that a group of children receive much of their care from NDs has implications for the health care provided to pediatric patients, as well as providing an opportunity for collaboration between conventional and alternative practitioners. The most striking example of this is immunizations. Despite reports that NDs are opposed to vaccination,4,9–11 we found that immunizations were administered at 18.6% of health supervision visits for children <2 years old and at 27.3% of health supervision visits for children 2 to 5 years old. Based on the recommended periodicity for health supervision visits to pediatricians and the current immunization schedule, it is likely that vaccines are provided at >50% of health supervision visits for children <2 years old to conventional providers.1,12 This suggests that there may be ambivalence regarding vaccinations among pedsNDs and/or the parents of their patients. In a previous survey, 1 of 15 NDs in Massachusetts opposed immunization, 3 of 15 actively recommended immunization, and the remainder did not actively make recommendations.4 It is likely that parents who oppose vaccination seek out pedsNDs as primary care providers for their children. Salmon et al13 found that parents of children who were exempted from school immunization requirements had significantly more negative beliefs about vaccines, and 11.5% received primary health care from an alternative provider versus 0.3% of those who were fully immunized. Currently, NDs are licensed to administer vaccines in a limited number of states, so children receiving care exclusively from NDs in unlicensed states may have limited access to immunization services.
Although NDs are licensed to prescribe antibiotics in Washington state, 0 of 65 children seen for URI symptoms by a pedsND were prescribed these medications. Because the upper limit of the 95% confidence interval for a point estimate of 0% with a sample of 65 children is 4.6%,14 our results suggest that <5% of pediatric patients presenting to the pedsNDs in this study with URI are prescribed antibiotics. This is in contrast to the experience of young children seen by pediatricians because of URI symptoms. In a study of community pediatricians in the Seattle, WA, area, 1 antibiotic was prescribed during 46% of visits by patients <3 years old who presented with cough and cold symptoms.15 It is possible that, by adopting some of the techniques used by the pedsNDs participating in our study, conventional practitioners might reduce the injudicious use of antibiotics in children with cold and cough symptoms.
The generalizability of the survey findings to NDs across the United States and internationally may be limited, because this survey was conducted in a licensed state. It is possible that the conditions and treatments reported by NDs in the survey may not be the same as those practicing in states where NDs are not licensed. Furthermore, Washington state law has required many insurance companies to reimburse for services provided by NDs.16 Cherkin et al3 reported that 50% of visits to Washington NDs were covered by insurance in 1998–1999. The results of a recent study analyzing Washington state insurance claims indicate that NDs see a similar spectrum of conditions as conventional practitioners.6 Lack of insurance coverage may change the reasons that parents bring their children in for treatment by NDs. For example, in states with a lower frequency of insurance reimbursement for ND care, parents may be less likely to pay out-of-pocket for a health supervision visit by an ND when it would be covered if performed by an MD. Thus, the results of this survey may only generalize to NDs practicing in licensed states with high levels of medical insurance reimbursement for this care.
Even in Washington, a state in which NDs are licensed, insurance coverage is available, and a naturopathic medical school is located, the results of this study indicate that pediatric care by most NDs is limited. However, in addition to adjunct care for chronic or complicated conditions, our results strongly suggest that there is a group of children for whom pedsNDs may be the sole health care providers. Some of these pedsNDs are providing immunizations to their patients, yet not at the same frequency as pediatricians. Research is needed to further elucidate the beliefs and recommendations of NDs regarding vaccines and the beliefs and preferences of the parents who bring their child to these providers. In addition, studies examining the practice of NDs in unlicensed states with limited or no insurance coverage are needed to determine whether these providers treat as many pediatric patients with similar conditions. Nationally, interest and use of CAM is increasing8; it is likely that the demand for NDs as pediatric primary care providers will also increase.
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ACKNOWLEDGMENTS
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This publication was made possible by National Center for Complementary and Alternative Medicine grants K23AT000929 and T32 AT000815 and a faculty seed grant from Bastyr University.
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FOOTNOTES
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Accepted Dec 12, 2006.
Address correspondence to Wendy Weber, ND, MPH, School of Naturopathic Medicine, Bastyr University, 14500 Juanita Dr NE, Kenmore, WA 98028. E-mail: wendyw{at}bastyr.edu
The contents of this article are solely the responsibility of the authors and do not necessarily represent the official views of the National Center for Complementary and Alternative Medicine or the National Institutes of Health.
The authors have indicated they have no financial relationships relevant to this article to disclose.
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ABSTRACT
METHODS
